March 2006

Preventing Injuries

By Stephen Krcmar

Examining common workplace injuries, their treatment and prevention.

Although about a third of the patients seen by the 17 physical therapists at the University of Pittsburgh Center for Sports Medicine (UPMC), have sports-related injuries, the staff there says the nonsporting population would do well to take a page from athletes.

“America today: typically, we’re pretty sedentary,” says Brian Hagen, MS, PT, OCS, FAAOMP, facility director and program administrator, that sedentary lifestyle, as well as aging and health issues, has only served to increase the instances of work-related injuries. According to statistics released by the US Department of Labor in 2004, an estimated total of 4.3 million nonfatal injuries and illnesses were reported in private industry workplaces. That number was down only slightly from 4.4 million in 2003. More than half of the injuries and illnesses required days away from work, job transfer, restricted work duties, or a combination of those.

The UPMC has a team of therapists who are sent out into the field to do on-site analysis of various work settings. They often find workstations that are not conducive to good body mechanics. Since good body mechanics can be taught, center employees conduct lectures at schools as well as job sites. With each company they will look at the business’ concentration and make specific suggestions. For a business that includes a lot of lifting, they will demonstrate the correct and incorrect way to lift an object. They will do this slowly; like a Pilates instructor walking a client through a workout, therapists encourage the workers to be mindful of their motions and to use the proper muscles for the task. Although some workplaces have posters that offer instructions on proper lifting, many workers do not apply them.

According to Hagen, improper lifting results in the majority of spine injuries. Once an injury does occur, rehabilitation professionals at the center employ manual therapy, as well as joint mobilization/manipulation. They use passive modalities early on if necessary and also are using lasers with “guarded optimism.” The treatment is focused at getting at the problem, fixing it, and making sure it does not repeat. This philosophy stems from research that the center has conducted, which has found that active treatment and early intervention are the most successful way to avoid chronic conditions. Exercise balls and bands are also given to many patients so they can work on rehabilitation outside of the center. “That’s really the key to getting them to continue after they leave therapy,” says Hagen.

The center has also found success with de-weighting—a procedure that reduces the weight put on a body. Similar to use of a swimming pool, a client can exercise without having to support 100% of their weight. But de-weighting allows more fine-tuning. Therapists can adjust the amount of weight a client works with. As the patient progresses, they can carry an increasingly larger percentage of their own weight, until their ankle or knee has fully recovered.

WEIGHING IN ON THE PROBLEM

Paul Fontana, OTR, FAOTA, owner and president of the Center for Work Rehabilitation Inc at The Fontana Center (with locations in Lafayette, La, and Houston), believes that excess weight is also becoming a problem among workers, causing not only heart problems, but shoulder, back, and knee problems—for starters. “They are getting older and heavier,” according to Fontana, who regularly sees refinery employees weighing more than 300 pounds. Their jobs require them to be at computer terminals 85% of the day. But, during the 15% of the time when they have to move around the plant and go up and down stairs, they are having problems. In these cases he tries to get them on a path of healthy eating and exercise.

With his centers not far from the Gulf of Mexico, Fontana regularly works with businesses involved with oil and gas drilling exploration, as well as production and service companies that service them. Instead of just analyzing a job site, he will visit a work site and quantify the physical demands of the job, recording how much an employee has to sit, stand, stoop, squat, bend, pull, push, carry, climb, jump, and work in various postures. Data in hand, he returns to one of his offices and simulates the work. He has a variety of spaces that include a 7,000-square-foot area where he simulates a variety of jobs. And simulation means just that: swinging hammers, pulling hoses, climbing structures—whatever the job necessitates. “From the injury prevention side, we have a protocol that tests individual jobs from the senior manager guy to the entry level guy,” Fontana says.

Fontana’s practice gives him a unique perspective on how doctors and physical therapists around the country view rehabilitation. The rigging business attracts employees from around America. They travel to the Gulf of Mexico to work for a month and then return home. When on-the-job injuries occur, workers are taken off the rig and sent home for rehab. When their therapists feel that the employee is ready to return to work, they send them back to the Gulf of Mexico.

Companies that work with Fontana have seen their on-the-job injuries drop dramatically. One drilling company was spending almost 80% of their injury dollars, about $11 million, on employees who had worked less than 2 weeks. Last year, after working extensively with Fontana, they did not have a single injury or one return-to-modified-duty during the first 4 months of employment. “The process is working. The stuff that we’re doing in addition to the new recruiting techniques is reducing injuries,” Fontana says.

One of Fontana’s favorite items for back and knee injuries is a customized programmable knee brace that features resistance modules built into both hinges of the orthosis and its ability to alleviate back problems by focusing on knee-tracking problems. This brace is a good example of Fontana’s view that therapy goes beyond the problem area to the whole body, “The biggest thing we’re finding is to not just look at the injured part,” he says.

CHRONIC PAIN MODALITIES

By the time that most patients with chronic pain make it through the doors of the Rehabilitation Center of Chicago (RIC), they have been suffering for more than 6 months, and have already tried a myriad of modalities. Recently named in US News & World Report as the “Best Rehabilitation Hospital in America” for the 15th consecutive year, RIC is a last chance for many patients to find effective treatment modalities for their work injuries.

Melanie Swan, OTR/L, clinical manager at the RIC’s Chronic Pain Care Center, favors modalities that the patient can perform with minimal risk of self-injury like TENS and hot and cold therapies, which use heat to relax the muscles and increase the circulation and cold to decrease pain or reduce inflammation. “With proper education and compliance, these modalities can be independently used by the patients, allowing them to take an active part in the management of their pain,” she says.

Swan says that other patients prefer techniques like relaxation, pacing their activities, or changing their posture or body mechanics—using modalities in flare-up situations only. In patients with chronic pain, therapists try to get them to that point where they are managing most of their daily activities, without flaring up and needing additional pain medication or treatment.

According to Swan, “TENS can be a great adjunct, if patients can be educated to use it properly and if they can be compliant with using it properly.” This modality must be used appropriately.

“If you’re finding that compliance is there, we’ll typically try to wean the patients off of TENS and utilize the other techniques. So they’re really paying more attention to what their bodies are telling them in terms of activities,” she says.

Swan says that many of her patients who suffer from chronic pain due to work injury become strong advocates for ergonomics and proper posture. Those who are injured often return to their workplaces and tell their coworkers about what they learned in physical therapy and how injury can be prevented. When talking to office workers, she finds that chairs are frequently discussed, as are ergonomic keyboards and mouse options. Swan tailors each response to the individual worker. “Just because the facility has the bells and whistles doesn’t mean that the worker knows how to use all them,” she says.

The importance of options is most visible when it comes to chairs. A “tech geek” who loves finding out about equipment may want a chair with lots of levers and knobs because he will actually use them. Swan often recommends a high-back ergonomic chair for these folks. Workers who want something simpler will probably want to go with a different chair. Some OTs suggest that the choice of chair should not be one of the first things that are dealt with. For one, they are expensive. And, unlike other equipment, most chairs are not returnable. Swan says that many office managers also have a misconception concerning the cost of workstation changes. They do not have to be expensive, she says, and equipment can often be modified to keep costs down.

One of the newest populations that Swan has been serving? School-aged kids. As more and more learning institutions become computer-based, the patients with chronic pain are getting younger and younger.

TAKING AN ACTIVE PREVENTIVE ROLE

Maureen Ziegler, OTR/L, is a clinical occupational therapist at RIC’s Spine and Sports Rehabilitation Center. She does not focus on modality use. Although she educates patients on the use of heat and ice to help manage symptoms, she prefers that patients take a more active role in the management of their pain, such as stretching, posture, and taking breaks. Ziegler says that minimizing modality use takes the worker out of the “sick” role and gives them more control over their care, rather than relying on the therapist to make them better.

Ziegler sees a lot of pain caused by computer use: patients complain of pain in the upper trapezius, lateral epicondylitis, and back pain as well as headaches. She also visits local businesses to educate workers about prevention. She says that healthy employees do not listen until it is too late. “A lot of times you get employees that don’t really value the idea of prevention…after they get hurt, they’re willing to do anything to get rid of that pain.”

This was a surprise for the therapist, “It was eye-opening for me. They don’t value it as much as people who do have pain and realize how valuable [prevention] is.” She has suggestions for prevention of carpal tunnel syndrome that can be implemented for free, like typing with floating hands. “You don’t ever see a piano player with their wrists on the piano,” Ziegler says. “It takes the person out of a neutral wrist position, which puts a lot of stress on the carpal tunnel and extensor tendons; eventually, it can injure the elbow.” Ziegler is also seeing younger and younger patients. One thing she recommends to all ages is frequent movement—at least hourly. “The trick is to get people to move before they have pain. Keep the wolves at bay, so to speak,” Ziegler says. That way even constricted blood vessels, which cause impediments like carpal tunnel syndrome, get a chance to relax.

Carpal tunnel treatments vary. Some PTs still use injections, but for the needle-shy, iontophoresis (commonly referred to as “pain patches”) is the way to go. Through this technique, electrodes are used to move the molecules of the medication through the skin down into the carpal tunnel.

“[Iontophoresis] works well with tendons that are inflamed and close to the surface of the skin,” says Patrick Zerr, PT, of Summit Physical Therapy in Tempe, Ariz. Even though it is not well reimbursed, he has been using the modality for more than 9 years, almost the entire length of his career.

In addition to iontophoresis, the FDA recently approved cold laser therapy for the treatment of carpal tunnel syndrome and pain management. Steven Shoshany, DC, CCEP, has been using laser therapy at his Manhattan practice for more than 8 months. Although he recommends its use primarily on the extremities, he reports great success using the modality to treat the carpal tunnel, carpal area, shoulders, and knees, as well as treating heel spurs and fibromyalgia.

Shoshany says, “[Cold laser therapy] works really well with chronic, inflammatory conditions, and on those with acute spasms.” The chiropractor will often conduct a 3- to 4-minute laser session before an adjustment and it will make the manipulation easier. In addition, he has combined it with other treatments like spinal decompression therapies.

“I’m finding more and more uses for it every day,” he says.

Stephen Krcmar is associate editor of Rehab Management.

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