Predictors of functional outcome after peripheral nerve injury and compression.

STUDY DESIGN: Retrospective cohort study. INTRODUCTION: Upper-extremity peripheral nerve injuries can impact long-term pain, work performance, and disability, yet there are few studies evaluating treatment outcomes for a large sample of patients with varying peripheral nerve pathology. PURPOSE OF THE STUDY: The purpose of this study was to identify outcomes of care and predictors of disability and health status in adults with peripheral nerve injuries. METHODS: We explored medical records from 364 patients treated by a plastic surgeon over a three-year period. Descriptive and inferential statistics compared the Disabilities of the Arm, Shoulder, and Hand, Short-Form 8, and routine intake data between baseline and discharge, diagnosis, and intervention group. Multivariate linear regression models predicted disability, work disability, and physical and mental health at discharge. RESULTS: We found significant improvements in disability, work disability, pain, depression, and stress. Health status changed minimally. Disability decreased most in patients who were working and who had symptoms fewer than six months. Outcomes were not statistically different between surgical and nonsurgical patients. Disability was the highest in patients with brachial plexus injuries. Multivariate models predicted 35 to 55% of the variance in the outcome measures. Factors that were highly predictive of functional outcomes included work status, household management, pain, depression, stress, and difficulty sleeping. CONCLUSIONS: Patients with peripheral nerve injuries experience improved pain and disability whether treated surgically or nonsurgically. Maintaining engagement in meaningful home and work roles may improve outcomes. Helping patients manage pain remains important, along with combatting stress, depression, and sleep deprivation.

Impact of Handedness on Disability After Unilateral Upper-Extremity Peripheral Nerve Disorder.

Background: Impairment of the dominant hand should lead to greater disability than impairment of the nondominant hand, but few studies have tested this directly, especially in the domain of upper-extremity peripheral nerve disorder. The aim of this study was to identify the association between hand dominance and standardized measures of disability and health status after upper-extremity peripheral nerve disorder. Methods: An existing database was reanalyzed to identify the relationship between affected-side (dominant vs nondominant) on individuals with unilateral upper-extremity peripheral nerve disorder (N = 400). Primary measure of disability was the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Results: We found no differences in standardized measures of disability or health status between patients with affected dominant hand and patients with an affected nondominant hand. However, a post hoc exploratory analysis revealed that patients with an affected dominant hand reported substantially reduced ability to perform 2 activities in the DASH questionnaire: "write" and "turn a key." Conclusions: Following unilateral upper-extremity peripheral nerve disorder, impairment of the dominant hand (compared with impairment of the nondominant hand) is associated with reduced ability to perform specific activities, but this reduced ability is not reflected in standardized measures of disability and health status. To adequately identify disability following unilateral impairment of the dominant hand with the DASH, individual items must be used instead of the total score. New or alternative measures are also recommended.

Predictors of Disability and Quality of Life With an Upper-Extremity Peripheral Nerve Disorder.

OBJECTIVE: We sought to understand the wide range of problems that patients with upper-extremity peripheral nerve disorders experience and to identify predictors of disability and quality of life (QOL). METHOD: Data from standardized assessments of disability and QOL, physical examination results, and intake surveys from 627 patients were analyzed using descriptive and inferential statistics. We compared results between groups and built multivariate models measuring disability, work disability, and physical and mental QOL. RESULTS: The sample demonstrated substantial disability and even greater work disability, which both closely correlated with poorer QOL. Work status was integral in predicting disability. Common predictors across models included problems with sleep and intimate relationships, deficits in work and household performance, and higher pain. CONCLUSION: To decrease disability and improve QOL, occupational therapy practitioners should help patients with upper-extremity peripheral nerve disorders identify strategies to maintain meaningful work and household roles, intimate relationships, and sleep, while continuing to address pain.

Foremen's intervention to prevent falls and increase safety communication at residential construction sites.

BACKGROUND: This research aimed to improve residential construction foremen's communication skills and safety behaviors of their crewmembers when working at heights. METHODS: Eighty-four residential construction foremen participated in the 8-hr fall prevention and safety communication training. We compared pre- and post-intervention surveys from foremen and their crewmembers to measure the effect of training. RESULTS: Foremen and crewmembers' ratings showed improvements in fall prevention knowledge, behaviors, and safety communication and were sustained 6-months post-training, with emphasized areas demonstrating larger increases. Ratings were similar between foremen and crewmembers, suggesting that the foremen effectively taught their crew and assigned accurate ratings. Based upon associations between safety behaviors and reported falls observed in prior research, we would expect a 16.6% decrease in the one year cumulative incidence of self-reported falls post-intervention. CONCLUSIONS: This intervention improved safety knowledge and behaviors of a large number of workers by training construction foremen in fall prevention and safety communication skills. Am. J. Ind. Med. 59:823-831, 2016. © 2016 Wiley Periodicals, Inc.

Functional Measures Developed for Clinical Populations Identified Impairment Among Active Workers with Upper Extremity Disorders.

PURPOSE: Few studies have explored measures of function across a range of health outcomes in a general working population. Using four upper extremity (UE) case definitions from the scientific literature, we described the performance of functional measures of work, activities of daily living, and overall health. METHODS: A sample of 573 workers completed several functional measures: modified recall versions of the QuickDASH, Levine Functional Status Scale (FSS), DASH Work module (DASH-W), and standard SF-8 physical component score. We determined case status based on four UE case definitions: (1) UE symptoms, (2) UE musculoskeletal disorders (MSD), (3) carpal tunnel syndrome (CTS), and (4) work limitations due to UE symptoms. We calculated effect sizes for each case definition to show the magnitude of the differences that were detected between cases and non-cases for each case definition on each functional measure. Sensitivity and specificity analyses showed how well each measure identified functional impairments across the UE case definitions. RESULTS: All measures discriminated between cases and non-cases for each case definition with the largest effect sizes for CTS and work limitations, particularly for the modified FSS and DASH-W measures. Specificity was high and sensitivity was low for outcomes of UE symptoms and UE MSD in all measures. Sensitivity was high for CTS and work limitations. CONCLUSIONS: Functional measures developed specifically for use in clinical, treatment-seeking populations may identify mild levels of impairment in relatively healthy, active working populations, but measures performed better among workers with CTS or those reporting limitations at work.

Toolbox Talks: Insights for Improvement.

Tool box talks (TBTs) have the potential to improve communication, empower workers, reduce injuries and improve safety; however, they can also be "missed opportunities" for providing important safety messages in construction. The goal of this paper is to share the results from two research projects designed to improve the frequency, delivery, participation, and outcomes of TBTs. The results of these projects provide suggestions for planning and delivering TBTs in construction. Methods: In the first project, 86 residential carpentry foremen from 8 different residential contractors in the St. Louis region participated in training for delivering TBTs as part of an 8-hour fall prevention and safety communication intervention. We compared baseline measures of safety behavior and fall prevention knowledge items to follow-up between participating foremen and their crewmembers. Concurrently, surveys of 300 apprentice carpenters were collected to describe the frequency and delivery methods of TBT and to serve as a comparison group for the TBT intervention. In the second project, we evaluated the utility of ergonomics TBTs delivered by a safety representative to 36 carpenters and laborers. Workers rated their perceptions of topic relevance, delivery method, similarities to traditional TBTs, and intent to change behaviors. The safety representative provided feedback regarding the TBTs and reported their observations of improved worker use of ergonomics in work tasks post-training. Discussion / Conclusions: Both interventions described in this paper improved workplace safety. The interventions demonstrate how to simply shift from non-collaborative TBTs to participatory, context-driven TBTs by using a pre-printed TBT template, modified to address the hazards present at the worksite. Delivery suggestions relate the information to the workers, and include workers in the identification of problems and safety-related solutions. These participatory methods for preparing and delivering TBTs have the potential to improve construction workplace safety practices.

Revisiting Pneumatic Nail Gun Trigger Recommendations.

Use of a pneumatic nail gun with a sequential actuation trigger (SAT) significantly diminishes the risk for acute traumatic injury compared to use of a contact actuation trigger (CAT) nail gun. A theoretically-based increased risk of work-related musculoskeletal disorders from use of a SAT nail gun, relative to CAT, appears unlikely and remains unproven. Based on current knowledge, the use of CAT nail guns cannot be justified as a safe alternative to SAT nail guns. This letter provides a perspective of ergonomists and occupational safety researchers recommending the use of the sequential actuation trigger for all nail gun tasks in the construction industry.

Social impact of peripheral nerve injuries.

BACKGROUND: Disorders involving the peripheral nervous system can have devastating impacts on patients' daily functions and routines. There is a lack of consideration of the impact of injury on social/emotional well-being and function. METHODS: We performed a retrospective database and chart review of adult patients presenting between 2010 and 2012 with peripheral nerve compression, brachial plexus injury, thoracic outlet syndrome (TOS), or neuromas. At the initial assessment, patients completed a questionnaire used to obtain demographic and psychosocial variable data including the (1) average level of pain over the last month, (2) self-perceived depression, (3) how much pain impacts quality of life (QoL), (4) current level of stress, and (5) ability to cope with stress. Statistical analyses were used to assess the differences between the dependent variables and diagnostic and demographic groups. RESULTS: This study included 490 patients (mean age 50 ± 15 years); the most common diagnosis was single nerve compression (n = 171). Impact on QoL was significantly greater in patients with TOS, cutaneous peroneal compressions, and neuroma versus single site nerve compressions. Average pain, impact on QoL, and stress at home were significantly higher in females versus males. Impact on QoL was correlated with average pain, depression, stress at home, and ability to cope with stress at home. CONCLUSIONS: Our study demonstrates that patients with single site nerve compression neuropathies experience fewer negative psychosocial effects compared to patients with more proximal upper extremity peripheral nerve disorders and neuromas. The impact on QoL was strongly correlated with pain and depression, where patients with neuromas and painful peroneal nerve entrapments reported greater detriments to QoL.

Responsiveness of a 1-Year Recall Modified DASH Work Module in Active Workers with Upper Extremity Musculoskeletal Symptoms.

OBJECTIVES: To evaluate the responsiveness to change of a modified version of the Work module of the Disabilities of the Arm, Shoulder, and Hand (DASH-W) in a prospective, longitudinal cohort study of active workers. METHODS: We compared change on a 1-year recall modified DASH-W to change on work ability, work productivity, and symptom severity, according to predetermined hypotheses following the Consensus-based standards for the selection of health measurement instruments (COSMIN). We evaluated concordance in the direction of change, and magnitude of change using Spearman rank correlations, effect sizes (ES), standardized response means (SRM), and area under the receiver operating characteristic curves (AUC). RESULTS: In a sample of 551 workers, change in 1-year recall modified DASH-W scores showed moderate correlations with changes in work ability, work productivity, and symptom severity (r = 0.47, 0.44, and 0.36, respectively). ES and SRM were moderate for 1-year recall modified DASH-W scores in workers whose work ability (ES = -0.58, SRM = -0.52) and work productivity improved (ES = -0.59, SRM = -0.56), and larger for workers whose work ability (ES = 1.24, SRM = 0.68) and work productivity worsened (ES = 1.02, SRM = 0.61). ES and SRM were small for 1-year recall modified DASH-W scores of workers whose symptom severity improved (-0.32 and -0.29, respectively). Responsiveness of the 1-year recall modified DASH-W was moderate for those whose symptom severity worsened (ES = 0.77, SRM = 0.50). AUC met responsiveness criteria for work ability and work productivity. CONCLUSIONS: The 1-year recall modified DASH-W is responsive to changes in work ability and work productivity in active workers with upper extremity symptoms.

Weak grip strength does not predict upper extremity musculoskeletal symptoms or injuries among new workers.

PURPOSE: Grip strength is often tested during post-offer pre-placement screening for workers in hand-intensive jobs. The purpose of this study was to evaluate the association between grip strength and upper extremity symptoms, work disability, and upper extremity musculoskeletal disorders (UE MSDs) in a group of workers newly employed in both high and low hand intensive work. METHODS: 1,107 recently-hired workers completed physical examinations including grip strength measurements. Repeated surveys obtained over 3 years described the presence of upper extremity symptoms, report of physician-diagnosed musculoskeletal disorders (MSDs), and job titles. Baseline measured grip values were used in analytic models as continuous and categorized values to predict upper extremity symptoms, work disability, or UE MSD diagnosis. RESULTS: Twenty-six percent of males and 20 % of females had low baseline hand strength compared to normative data. Multivariate logistic regression analyses showed no consistent associations between grip strength and three health outcomes (UE symptoms, work disability, and MSDs) in this young cohort (mean age 30 years). Past MSD and work type were significant predictors of these outcomes. CONCLUSIONS: Physical hand strength testing was not useful for identifying workers at risk for developing UE MSDs, and may be an inappropriate measure for post-offer job screens.

Fall prevention and safety communication training for foremen: report of a pilot project designed to improve residential construction safety.

PROBLEM: Falls from heights account for 64% of residential construction worker fatalities and 20% of missed work days. We hypothesized that worker safety would improve with foremen training in fall prevention and safety communication. METHOD: Training priorities identified through foreman and apprentice focus groups and surveys were integrated into an 8-hour training. We piloted the training with ten foremen employed by a residential builder. Carpenter trainers contrasted proper methods to protect workers from falls with methods observed at the foremen's worksites. Trainers presented methods to deliver toolbox talks and safety messages. Results from worksite observational audits (n=29) and foremen/crewmember surveys (n=97) administered before and after training were compared. RESULTS: We found that inexperienced workers are exposed to many fall hazards that they are often not prepared to negotiate. Fall protection is used inconsistently and worksite mentorship is often inadequate. Foremen feel pressured to meet productivity demands and some are unsure of the fall protection requirements. After the training, the frequency of daily mentoring and toolbox talks increased, and these talks became more interactive and focused on hazardous daily work tasks. Foremen observed their worksites for fall hazards more often. We observed increased compliance with fall protection and decreased unsafe behaviors during worksite audits. DISCUSSION: Designing the training to meet both foremen's and crewmembers' needs ensured the training was learner-centered and contextually-relevant. This pilot suggests that training residential foremen can increase use of fall protection, improve safety behaviors, and enhance on-the-job training and safety communication at their worksites. IMPACT ON INDUSTRY: Construction workers' training should target safety communication and mentoring skills with workers who will lead work crews. Interventions at multiple levels are necessary to increase safety compliance in residential construction and decrease falls from heights.

The impact of flexor tendon rehabilitation restrictions on individuals' independence with daily activities: implications for hand therapists.

STUDY DESIGN: Descriptive, grounded theory. PURPOSE: This study identified activity limitations which individuals with flexor tendon lacerations experience post-repair and explored methods they used to support participation in life roles. The role of hand therapy during the period of restricted hand use is discussed. METHODS: Standardized interviews with 19 individuals 6-12 months after flexor tendon repair (FTR) were recorded and thematic analysis was performed. Descriptive and nonparametric statistics were used to analyze quantitative data generated through these interviews. RESULTS: Patients struggled to fulfill life roles during the period of restricted hand use following FTR. Most participants asked other individuals for assistance; however, 59% of the participants removed their injured fingers from the orthosis in order to use their hand to perform activities. All of the participants' hand therapists instructed them in orthotic wear and activity restrictions and most addressed pain management, but few addressed how to perform meaningful activities and participate in life roles during the period of restricted hand use. Participants who did receive these types of interventions perceived that they were very useful. CONCLUSIONS: During the phase of restricted hand use following FTR, it is important for hand therapists to address activity performance and participation in meaningful life roles, in addition to ensuring the integrity and function of the healing tendon. This can include instruction in one-handed methods, use of adaptive equipment, and exploration of accommodations needed at work. LEVEL OF EVIDENCE: III.

Outcomes of a revised apprentice carpenter fall prevention training curriculum.

Falls from heights are a leading cause of morbidity and mortality among construction workers, especially inexperienced workers and those performing residential construction. This research reports changes in fall prevention behaviors following revision of fall prevention training in a union-based carpenters' apprenticeship program. We used a comprehensive needs assessment to identify gaps in apprentice carpenters' preparation to work at heights, used these results to guide a school-based fall prevention curriculum to fill these gaps, and measured the effects of the revised curriculum on knowledge, beliefs, and fall prevention behaviors.

Changes in fall prevention training for apprentice carpenters based on a comprehensive needs assessment.

PROBLEM: Falls from heights in residential construction are common, especially among inexperienced workers. METHODS: We conducted a comprehensive needs assessment to determine gaps in the school-based apprentice carpenters' fall prevention training. A team of carpenter instructors and researchers revised the fall prevention training to fill these gaps. Apprentice evaluation and feedback guided ongoing curricular improvements. RESULTS: Most apprentice carpenters performed work tasks at heights prior to training and fall protection techniques were not commonly used at residential construction sites. Priorities of the revised school-based training included safe ladder habits, truss setting, scaffold use, guarding floor openings, and using personal fall arrest systems. New apprentices were targeted to ensure training prior to exposure at the workplace. We used adult learning principles to emphasize hands-on experiences. A framed portion of a residential construction site was fabricated to practice fall protection behaviors in a realistic setting. The revised curriculum has been delivered consistently and apprentice feedback has been very favorable. CONCLUSIONS: Integration of needs assessment results was invaluable in revising the school-based carpenters apprentice fall prevention curriculum. Working closely with the instructors to tailor learning experiences has provided preliminary positive results. IMPACT ON INDUSTRY: The fall safety of the residential construction industry continues to lag behind commercial construction and industrial settings. The National Occupational Research Agenda includes a Strategic Goal to strengthen and extend the reach of quality training and education in the construction industry via mechanisms such as construction safety and health training needs assessments. This study demonstrates how a structured process can be used to identify and remedy gaps and improve training effectiveness. We encourage others to take steps to assess and increase the impact of training efforts directed at all residential construction professionals; including both union and non-union workers. The implications are even greater in the non-union sector where most U.S. residential work is done.

Fall prevention among apprentice carpenters.

OBJECTIVES: Falls from heights are a leading cause of mortality and morbidity in the construction industry, especially among inexperienced workers. We surveyed apprentice carpenters to identify individual and organizational factors associated with falls from heights. METHODS: We developed a 72-item survey on fall prevention with multiple domains including fall experience, fall-prevention knowledge, risk perceptions, confidence in ability to prevent falls, training experience, and perceptions of the safety climate and crew safety behaviors. We administered the questionnaire to apprentice carpenters in this cross-sectional study. RESULTS: Of the 1025 respondents, 51% knew someone who had fallen from a height at work and 16% had personally fallen in the past year, with ladders accounting for most of the falls. Despite participation in school-based and on-the-job training, fall-prevention knowledge was poor. Ladders were perceived as low risk and ladder training was rare. Apprentices reported high levels of unsafe, fall-related behaviors on their work crews. Apprentices in residential construction were more likely to fall than those in commercial construction, as were apprentices working on crews with fewer senior carpenters to provide mentorship, and those reporting more unsafe behaviors among fellow workers. CONCLUSIONS: Despite participation in a formal apprenticeship program, many apprentices work at heights without adequate preparation and subsequently experience falls. Apprenticeship programs can improve the timing and content of fall-prevention training. This study suggests that organizational changes in building practices, mentorship, and safety practices are also necessary to decrease worker falls from heights.

Effect of upper extremity nerve damage on activity participation, pain, depression, and quality of life.

PURPOSE: To explore the relationship between upper extremity nerve damage and activity participation, pain, depression, and perceived quality of life. METHODS: A total of 49 patients with upper extremity nerve damage completed standardized measures of activity participation, pain, depression, and quality of life. We analyzed scores for all subjects and for 2 diagnostic groups: patients with compressive neuropathy and patients with nerve injury (laceration, tumor, and brachial plexus injury), and explored predictors of overall quality of life. RESULTS: Participants had given up 21% of their previous daily activities; greater activity loss was reported in patients with nerve injury. Pain was moderate and 39% had signs of clinical depression. Physical and psychological quality of life ratings were below the norms. Activity loss was strongly associated with higher levels of depression and lower physical and psychological quality of life. Higher depression scores correlated strongly with lower overall quality of life. Greater pain correlated moderately with higher depression scores and weakly with quality of life; no statistical relationship was found between pain and physical quality of life. Activity participation and depression predicted 61% of the variance in overall quality of life in patients with nerve damage. CONCLUSIONS: The results of this study suggest that hand surgeons and therapists caring for patients with nerve compression and nerve injury should discuss strategies to improve activity participation, and decrease pain and depression, to improve overall effect on quality of life throughout the recovery process. Depression screening and referral when indicated should be included in the overall treatment plan for patients with upper extremity nerve damage. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Fall hazard control observed on residential construction sites.

BACKGROUND: Falls are a leading cause of mortality and morbidity in the construction industry. This study measured fall hazards at residential construction sites. METHODS: Trained carpenters administered the St. Louis Audit of Fall Risks and interviewed carpenters. The prevalence of fall prevention practices meeting safety criteria was counted and correlations explored. RESULTS: We identified a high prevalence of fall hazards at the 197 residential sites audited. Roof sheathing met safety criteria most consistently (81%) and truss setting least consistently (28%). Use of personal fall arrest and monitoring of unguarded floor openings were rare. Safer performance on several scales was correlated. Construction sites of large-sized contractors were generally safer than smaller contractors. Apprentice carpenters were less familiar with their employers' fall prevention plan than experienced workers. CONCLUSIONS: Safety could be improved with consistent use of recognized fall prevention practices at residential construction sites.

Development of the St. Louis audit of fall risks at residential construction sites.

We describe the development and pilot testing of the St. Louis Assessment of Fall Risks, a worksite audit to assess fall prevention safety practices on residential construction sites. Surveillance data and feedback from carpenters and safety instructors regarding work tasks associated with falls from heights were used to develop the audit instrument. The audit focuses on the framing process, including general safety climate/housekeeping, floor joist/sub-floor installation, walking surfaces/edges, wall openings, truss setting, roof sheathing, ladders, scaffolds, and personal fall arrest equipment. The audit was tested at sixteen residential construction sites, documenting excellent inter-rater reliability (kappa = 0.93). Results suggest that the audit has good face and content validity and is a reliable instrument for measuring fall safety risks at residential construction sites. It is practical, easy, and safe to administer, making it a potentially useful instrument for field research as well as regular safety monitoring by foremen and crew.