Understanding work-related upper extremity disorders: clinical findings in 485 computer users, musicians, and others.

Four hundred eighty five patients whose chief complaints were work related pain and other symptoms received a comprehensive upper-body clinical evaluation to determine the extent of their illness. The group had a mean age of 38.5 years. Sixty-three percent of patients were females. Seventy percent were computer users, 28% were musicians, and 2% were others engaged in repetitive work. The time between the onset of symptoms and our initial visit ranged from 2 weeks to over 17 years. A majority sought care within 30 months with the greatest number of them seeking care before 12 months. Fifty nine percent of subjects were still working when seen despite increasing pain and symptoms such as weakness, numbness, tingling, and stiffness. Following a history, a physical assessment utilizing commonly employed clinical tests were performed including evaluation of joint range of motion, hyperlaxity, muscle tenderness, pain, strength, and imbalance. Neurologic tests included Tinel's sign performed in wrist, elbow, tricipital sulcus, and neck and tests for thoracic out syndrome (TOS). Specific tests such as Finkelstein's test for deQuervain's tenosynovitis, Phalen's test for carpal tunnel syndrome and grip strengths were included in the examination protocol. Significant findings included postural misalignment with protracted shoulders (78%), head forward position (71%), neurogenic TOS (70%), cervical radiculopathy (0.03%), evidence of sympathetic dysfunction (20%), and complex regional pain syndrome (RSD) (0.6%). Hyperlaxity of fingers and elbows was found in over 50%, carpal tunnel syndrome in 8%, radial tunnel syndrome in 7%, cubital tunnel in 64%, shoulder impingement in 13%, medial epicondylitis in 60%, lateral epicondylitis in 33%, and peripheral muscle weakness in 70%. We conclude that despite initial presentation distally, work-related upper-extremity disorders are a diffuse neuromuscular illness with significant proximal upper-body findings that affect distal function. While neurogenic TOS remains a controversial diagnosis, the substantial number of patients with positive clinical findings in this study lends weight to the concept that posture related neurogenic TOS is a key factor in the cascading series of physical events that characterize this illness. A comprehensive upper-body examination produces findings that cannot be obtained through laboratory tests and surveys alone and lays the ground work for generating hypotheses about the etiology of work related upper-extremity disorders that can be tested in controlled investigations.

Training and retraining of office workers and musicians.

Both ergonomic and biomechanical principles must be applied to avoid and correct overuse syndromes. Equipment should be fitted to the user, but the user's interaction with the equipment should be examined, as well.

Soft-tissue injuries related to use of the computer keyboard. A clinical study of 53 severely injured persons.

We studied 53 disabled keyboard operators who complained of pain in the forearms, elbows, wrists, shoulders, and hands. Passive wrist flexion and dorsiflexion impairment to less than 70 degrees due to myofascial shortening associated with an increase in forearm muscle pain on palpation was a useful clinical indicator of injury. Isometric muscle testing was useful in detecting injury to specific muscles. Ligamentous hypermobility of finger joints (72%) and harmful inefficient keyboard styles (intrinsic ergonomic factors) were noted, videotaped, and analyzed. Changes in the workstation (extrinsic ergonomic factors) alone may not be adequate treatment. Individual intrinsic ergonomic factors must also be recognized, addressed, and corrected by a combination of physical therapy, conditioning, technique retraining, education, and counseling. A taxonomy of keyboard technique is proposed as an aid to recognizing potentially harmful postures.

Methadone maintenance patients in general medical practice. A preliminary report.

Medical maintenance is the treatment by primary care physicians of rehabilitated methadone maintenance patients who are stable, employed, not abusing drugs, and not in need of supportive services. In this research project, physicians with experience in drug abuse treatment provided both the pharmacologic treatment of addiction as well as therapy for other medical problems, as needed. Decisions regarding treatment were based on the individual needs of the patient and on currently accepted medical practice rather than on explicit regulations. We studied the first 40 former heroin addicts who were transferred to this program from more conventional methadone clinics. At a follow-up visit at 12 to 55 months, 33 (82.5%) of 40 patients had remained in treatment; five (12.5%) had been discharged because of cocaine abuse and two (5%) had been voluntarily discharged. Personal benefits of medical maintenance include the dignity of a standard professional atmosphere and a more flexible reporting schedule. This program has the potential for improving treatment of selected methadone maintenance patients.

Employee assistance: a business and community hospital partnership.

Employers are now providing a variety of healthcare services to combat health problems that affect productivity. These employee assistance programs are designed to improve work performance by providing an approach to the prevention, diagnosis, and treatment of such illnesses as alcoholism, drug dependence, mental illness and family, martial, financial, and legal difficulties common to all worksites. This article examines the concept, incentives, structure, obstacles, marketing, and cost containment factors that are part of the development of this new partnership between businesses and community hospitals.

Planning and developing a prehospital mobile intensive care system in an urban setting.

A suggested model for the development of an urban based prehospital emergency care system is described. Factors considered in the planning and development include: 1) demand for services, projected and actual; 2) analysis of costs; 3) design and maintenance of the delivery system; and 4) establishment of the evaluation mechanisms. Over one year's experience and 1,144 mobile intensive care unit (MICU) calls in a densely populated urban setting with over 500,000 persons are reported. During the peak 8-hour period, predetermined dispatch categories were employed to activate one MICU operating in conjunction with three conventional ambulances. This partial conversion imparted MICU capability to the entire system at an 11 per cent increase in the ambulance budget. MICU calls averaged 4.5 per 8-hour peak shift and took 45 minutes each.