PMR PG Teaching

1. Work Related Shoulder Disorders
Dr. Sanjay Wadhwa
Professor,
Dept. of Physical Medicine and Rehabilitation,
AIIMS, New Delhi

2. • Why talk about it?
• What is it?
• Who gets it?
• When does it occur?
• Where does it occur?
• How can we manage it?
Work Related Shoulder Disorders

3. • Introduction
• Definition(s)
• Classification(s)
• Evaluation
• Prevention
• Management
Work Related Shoulder Disorders

4. • Work-related Musculoskeletal Disorders
(WMSDs) are common disorders.
• Economic costs are enormous.
• Considered by some as an ‘umbrella’ term.
• Also known as
repetitive motion disorders,
occupational overuse injuries,
repetitive strain injuries etc.
Work Related Shoulder Disorders

5. • Account for over 50% of all workers’
compensation claims in USA.
• Upper limb disorders are far more common
than lower limb disorders.
• The mainstay of management involves
ergonomic interventions.
Work Related Shoulder Disorders

6. WHO defines these disorders as multifactorial,
with work contributing significantly, though not
exclusively, to causing the disease.
The term disorder is more appropriate when
some of the outcomes are of uncertain
pathogenesis and may consist of symptoms
without clinical signs.
The term work related musculoskeletal disorders
has come to replace repetitive strain injuries or
cumulative trauma disorders.
Work Related Shoulder Disorders

7. Work-related musculoskeletal disorders are
MSDs that may be caused, aggravated, or
precipitated by intense, repeated, or sustained
work activities with insufficient recovery; they
generally develop over a period of weeks,
months, and years.
Work Related Shoulder Disorders

8. It follows that MSDs can be partially caused by
adverse work conditions, can be exacerbated by
work place exposure, and can impair work
capacity.
Work Related Shoulder Disorders

9. The diagnoses of WMSDs consist of
• Trapezial and parascapular myalgia,
• Rotator cuff and bicipital tendinitis,
• Impingement syndrome, and
• Subacromial and subdeltoid bursitis.
Work Related Shoulder Disorders

10. Sustained contractions result in increased
intramuscular pressure and decreased blood flow.
Ischemic conditions occur when intramuscular
pressure exceeds capillary closing pressure at
about 30 mm Hg.
The increased metabolic demands of the working
muscle and the relative ischemia caused by
increased intramuscular pressure can contribute
to derangements in intracellular pH, lactic acid,
calcium, potassium balance, PGE2 etc.
Work Related Shoulder Disorders

11. High levels of muscle enzymes, including creatine
phosphokinase and aldolase.
Work Related Shoulder Disorders

12. Work Related Shoulder Disorders

13. Work Related Shoulder Disorders

14. Work Related Shoulder Disorders

15. Different Systems of Grading/ Staging
• Japanese Grading System (Japanese
Association of Industrial Health)
• Australian Staging System (Occupational
Repetition Strain Advisory Committee in
Australia)
• Pathophysiologic Grading System (Luck and
Anderson)
Work Related Shoulder Disorders

16. Japanese Grading System
• Grade I
• Grade II
• Grade III
• Grade IV
• Grade V
Work Related Shoulder Disorders

17. Japanese Grading System
• Grade I
• Subjective complaints without clinical findings
Work Related Shoulder Disorders

18. Japanese Grading System
• Grade II
• Subjective complaints with induration and
tenderness of the neck, shoulder, and arm
muscles
Work Related Shoulder Disorders

19. Japanese Grading System
• Grade III
Includes grade II and any of the following:
• Increased tenderness or enlargement of
affected muscles
• Positive neurologic tests
• Paresthesia
• Decrease in muscle strength
• Tenderness of spinous processes of vertebrae
• Tenderness of the paravertebral muscles
Work Related Shoulder Disorders

20. Japanese Grading System
• Grade III contd.
• Tenderness of the nerve plexus
• Tremor of the hand or eyelid
• Cinesalgia of the neck, shoulder, and arm
• Functional disturbance of the peripheral
circulation
• Severe pain or subjective complaints of the
neck, shoulder, or upper extremity
Work Related Shoulder Disorders

21. Japanese Grading System
• Grade IV
• Type I
• Severe type of grade III
• Type 2
• Direct development from grade II without
passing through grade III, but having specific
findings as follows:
Work Related Shoulder Disorders

22. Japanese Grading System
• Grade IV Type 2
• Orthopaedic diagnosis of the neck-shoulder-
arm syndrome
• Organic disturbances such as tendinitis or
tenosynovitis
• Autonomic nervous disturbances such as
Raynaud’s phenomenon, passive hyperemia,
or disequilibrium
• Mental disturbance such as anxiety,
sleeplessness, thinking dysfunction, hysteria,
or depression
Work Related Shoulder Disorders

23. Japanese Grading System
• Grade V
• Disturbance at work and in daily life
Work Related Shoulder Disorders

24. Australian Staging System
• Stage I
• Stage II
• Stage III
Work Related Shoulder Disorders

25. Australian Staging System
• Stage I
• Aching and tiredness of the affected limb that
occurs during the work shift but subsides
overnight and during days off work.
• There is no significant reduction in work
performance, and there are no physical signs.
• This condition can persist for months and is
reversible.
Work Related Shoulder Disorders

26. Australian Staging System
• Stage II
• Symptoms fail to settle overnight, cause a
sleep disturbance, and are associated with a
reduced capacity for repetitive work.
• Physical signs may be present.
• The condition usually persists for months.
Work Related Shoulder Disorders

27. Australian Staging System
• Stage III
• Symptoms persist at rest.
• Sleep is disturbed, and pain occurs with
nonrepetitive movement.
• The person is unable to perform light duties
and has difficulty with nonoccupational tasks.
• Physical signs are present.
• The condition may persist for months to years.
Work Related Shoulder Disorders

28. Pathophysiologic Grading System
• Grade I (mild)
• Grade II (moderate)
• Grade III (severe)
Work Related Shoulder Disorders

29. Pathophysiologic Grading System
• Grade I (mild)
• Shoulder girdle muscle pain that occurs during
work or similar activities and resolves a few
hours later
• No findings on physical examination
Work Related Shoulder Disorders

30. Pathophysiologic Grading System
• Grade II (moderate)
• Shoulder girdle muscle pain that persists for
several days after work
• Muscle belly and insertional tenderness on
examination
Work Related Shoulder Disorders

31. Pathophysiologic Grading System
• Grade III (severe)
• Shoulder girdle muscle pain that is constant for
weeks or longer
• Multiple tender areas
• Palpable induration indicating muscle fibrosis
• Muscle belly contracture
• Reduced range of motion of myogenic origin
Work Related Shoulder Disorders

32. Internal stress due to exposure to environmental
and organizational risk factors in the workplace:
• Poor lighting
• High background noise
• Cramped working conditions
• Inadequate work breaks
• Job dissatisfaction
• Excessive productivity demands
Work Related Shoulder Disorders

33. • Symptoms are common.
• Diagnosis is essentially clinical.
• Investigations have some role to play.
• Recurrence is common if treatment is not
comprehensive.
Work Related Shoulder Disorders

34. Dentists seem to be particularly susceptible to
work related shoulder disorder as a result of
sustained static loads while maintaining the
shoulder in a position of flexion and abduction
with elevation of the scapula.
Work Related Shoulder Disorders

35. In a Finnish study that included 40 dentists,
Katevuo and coworkers found that 46% had
radiographic evidence of osteoarthritis and 44%
had bilateral disease. In contrast, only 13% in the
control group- 82 farmers presumably unexposed
to static load- had findings consistent with
osteoarthritis.
Work Related Shoulder Disorders

36. Other groups:
• Musicians
• Healthcare workers
• Factory workers
• Sheet metal workers
• Garment workers
• Electricians
• Fish industry
Work Related Shoulder Disorders

37. Work Related Shoulder Disorders

38. • According to the WHO approved ICF model
OSDs are structural and functional body
impairments.
• A disability occurs when various activities are
limited.
Work Related Shoulder Disorders

39. Management is best carried out by a
multidisciplinary team.
The team includes:
• clinical psychologist,
• physical therapist,
• occupational therapist,
• physical education teacher,
• vocational counselor,
• physician (physiatrist), and
• nurse.
Work Related Shoulder Disorders

40. Management includes
• Ice/ Heat
• Exercises
• NSAIDs
• Tricyclic antidepressants
• Local interventions (steroids)
• Stress management
• Ergonomic interventions
Work Related Shoulder Disorders

41. Conclusion
• A very big challenge for India
• ‘Make in India’
• Rehabilitation
• Prevention
Work Related Shoulder Disorders

42. Work Related Shoulder Disorders
THANK YOU