Research Article Physiotherapy International Journal of Pharma and Bio Sciences ISSN 0975-6299 EFFECTS OF EXERCISES ON REPETITIVE STRAIN INJURIES OF HAND IN MILKMEN PROF.TUSHAR J PALEKAR *1, ANIRUDHA VAIDYA 2 AND SOUMIKBASU 3 1,2,3 Padmashree Dr. D.Y. Patil College of Physiotherapy, Dr. D.Y. Patil Vidyapeeth, Pune, India. ABSTRACT Repetitive strain injury (RSI) is a common and serious occupational health problem worldwide. About 60% of all occupational injuries are caused by repetitive strain.41 milkmen were taken from Indian dairy farm Pimpri, Pune found symptomatic for RSI, and 9 asymptomatic milkmen were taken. All 50 milkmen were treated with exercise protocol for 3 weeks. Disabilities of the Arm, Shoulder and Hand(DASH )questionnaire and VAS Scale were given to fill up (Pre-rehabilitation) and data collected and analyzed. After 3 weeks of hand strengthening exercises for 20-25 mins daily, all 50 milkmen were assessed with same DASH questionnaire and VAS, and were statistically analyzed. The incidence of the repetitive strain injuries of hand in milkmen was 82%. The decided exercise protocol showed significant improvement in DASH score and VAS score. KEY WORDS: Repetitive Strain Injuries, Milkmen, Strengthening Exercises, Disabilities of the Arm, Shoulder and Hand questionnaire, VAS. PROF.TUSHAR J PALEKAR Padmashree Dr. D.Y. Patil College of Physiotherapy, Dr. D.Y. Patil Vidyapeeth, Pune, India. *Corresponding Author B - 47
INTRODUCTION Repetitive strain injury or RSI, also known as repetitive stress injury, repetitive motion injuries, repetitive motion disorder (RMD), cumulative trauma disorder (CTD), occupational overuse syndrome, overuse syndrome, Work Related Upper Limb Disorders or WRULDS. 1 Repetitive strain injury (RSI) is a common and serious occupational health problem. About 60% of all occupational injuries are caused by repetitive strain. 2 The injury is characterized by discomfort or persistent pain in muscles, tendons, and other soft tissues. 1 Repetitive strain injuries are caused by repetitive movement, sustained or constrained postures, and forceful movements as well as stress and unfavorable working conditions. In RSI, the repetition of movements does not allow muscles, tendons, or ligaments sufficient time to recover and thus can damage these structures. In these occupational injuries, the holding of the upper limb in a certain position for prolonged periods of time induces local ischemia in the muscles and accumulation of lactic acid. Tissue micro trauma occurs as a consequence of repetitive tasks and such injury leads to inflammation, followed by fibrotic and other structural tissue changes. Posture can increase pressure on nerves at entrapment sites or can shorten muscles to cause an adaptive shortening and secondary nerve compression. Muscles can be elongated into a weakened position with certain prolonged postures. This leads to overuse of other muscles and ultimately contributes to muscle imbalance and secondary nerve compression. Recent studies show that rapid, nearly simultaneous, stereotypical repetitive fine motor movements can degrade the sensory representation of the hand and lead to a loss of normal motor control of a targeted task, commonly referred to as occupational hand cramps or focal hand dystonia. 2 Repetitive strain injury is an occupational disease that imposes a considerable impact on workers lives and has significant socioeconomic repercussions. According to the 1995 United States Bureau of Labor Statistics, approximately 60% of all occupational injuries were caused by repetitive strain. 3, 5. Repetitive Strain Injury (RSI) is a serious condition that according to the Health and Safety Executive (HSE) affects up to 500,000 workers each year - with 81,000 new cases in 2007/08 alone. RSI covers a wide range of injuries to muscles, tendons and nerves. Usually hands, wrists, elbows or shoulders are affected. RSI s must be treated at an early stage or a permanent disability could be caused. Repetitive strain injuries (RSI) can be defined as injuries caused or aggravated by repetitive or sustained sub maximal exertion of the body s soft tissue structures including muscles, tendons, ligaments, and nerves of particular concern is the increasing prevalence of RSI in the workplace. 4 Not only are these injuries associated with personal morbidity and direct costs to the health care system, but considerable loss of productivity and disability claims are associated with substantial indirect costs to society. Types of RSI: Many health care professionals refer to RSI as ULD (upper limb disorder) because it frequently involves the forearm, elbow, wrist or hands. RSI often affects the neck as well. There are two main types of RSI: Type 1 RSI - It usually caused by repetitive tasks, but not always; some people who do not perform repetitive tasks may have Type 1 RSI. The muscles and tendons swell. Examples are Carpal tunnel syndrome, Tendinitis (tendonitis), Tenosynovitis. 1 Type 2 RSI - There is a feeling of pain but no obvious inflammation or swelling in the area where symptoms are felt. Often referred to as when a person s symptoms do not fit into one of the (above listed) conditions, also called non-specific pain syndrome. 1 Symptoms of RSI vary. They include 1. Pain in the fingers, wrists, arms and shoulders 2. tenderness, 3. heaviness in the arms and wrists 4. swelling, 5. a tingling sensation in the fingertips 6. numbness 7. restriction of the joints 8. loss of sensation and whiteness on the fingers 4 The actual pain itself can have a weakening affect however, depending on the type and severity of the Repetitive strain injuries; it can B - 48
also affect sleeping patterns. In the early stages of an RSI it is common to have one or two symptoms during the type of activity that brings on the pain, but once the activity has ceased, the symptoms will also disappear. MATERIALS AND METHODS A pre-post experimental study was conducted on 50 milkmen. After ethical approval, study was done in Diary Farm, Pimpri, Pune, India. Inclusion criteria included only milkmen aged 25 55years. Exclusion criteria were any disease affecting hand function, peripheral neuropathies and radiculopathies. Outcome measures were DASH and VAS scale. Materials used were gripping exercise ball, pen and newspaper. All milkmen were explained the nature of the study and a written consent was taken, and then DASH questionnaire and VAS Scale were given to fill up (Pre-rehabilitation) and data collected and analyzed. Then positive findings milkmen were treated by decided exercise protocol for 3 weeks, after that assessed them with the same DASH questionnaire and VAS Scale (Post-rehabilitation) and on the basis of that, data was collected and statistically analyzed. 41 milkmen were found suffering from RSI of hand, 9 were found potential of suffering from RSI in future so, they were also included into the study as prophylactic measures. EXERCISE PROTOCOL A) Warm up exercises for hand 1. Imaginary Tabletop - Make a tabletop with your fingers by keeping your wrists and your fingers straight. Bend only at the knuckles 10 times. 2) Knuckle Bend - Keep your knuckles and wrist straight. Bend and straighten your fingers 10 times. B - 49
3) Make a Fist - Make a fist, being sure each joint is bending as much as possible and Straighten your fingers as much as possible 10 times. 5) Make O s - Make an O by touching your thumb to your fingertips, one at a time. Open your hand wide after touching each finger 10 times. 6) Table Spread - Rest your hand on the table with the palm down. Spread your fingers wide apart and bring them together again 10 times. B - 50
B) Active hand range of motion exercises - Int J Pharm Bio Sci 2015 Jan; 6(1): (B) 47-59 1. Flexion: Gently try to bend your wrist forward. Hold for 5 seconds. Repeat 10 times. 2. Extension: Gently bend your wrist backward. Hold this position for 5 seconds. Repeat 10 times. 3. Side to side: Gently move your wrist from side to side, holding 5 seconds at each end. Repeat 10 times. C) Stretching exercises- Thumb stretch Extensor stretch Flexor stretch Thumb stretch - Using your other hand, pull the thumb back into the hitch-hike position. You should feel a nice stretch in the muscles at the base of the thumb. Push from the base of the thumb where it meets the palm. Do not pull from the thumb tip. This can hyper-extend the tip or the middle thumb joint. Extensor stretch - 1. Hold your arm straight at waist height, palm down. 2. Gently bend your wrist by pressing your hand down. 3. Hold for 15 to 30 seconds. 4. Repeat 2 to 4 times. 5. Repeat on the other arm. B - 51
Flexor Stretch 1. Hold your arm straight at waist height, palm up. 2. Gently bend your wrist by pressing your hand down. 3. Hold for 15 to 30 seconds. 4. Repeat 2 to 4 times. 5. Repeat on the other arm. D) HAND EXERCISES Grip strengthening: Squeeze a yellow smiley ball and hold for 5 seconds. Repeat 20 times. Finger And Hand Muscles strengthening: i. Paper squeezing: Squeeze the full page of newspaper with hand 5 times each hand B - 52
ii. Standing Push-ups across the wall 15 pushups in standing with both hands fingers against the wall. Advice and Suggestions 1. Take Regular Breaks It has been suggested that, for RSI prevention purposes, you should take a 10 minute break after every 20 or 30 minutes of continuous activity. 2. Sit Up Straight And Adjust Your Seat Bad posture is a primary risk factor in RSI. Choose and adjust your seat so that you sit up straight, rather than leaning forward. 3. Warm Up Daily Before Milking Procedure Always do warm up exercises before to start the milking procedure. 4. Take Hot Water Bath Bathing with warm water will give relaxation of the joints, tendons, and muscle tissue. At the same time, Warm water can treat pain in muscles and joints caused by arthritis, muscle tear, and fatigue. Warmth will stimulate circulation and blood flow. Although no permanent cure, a five-minute warm baths can reduce pain, stimulate healing and reduce inflammation. 5. Stretch Hand and Forearm Frequently While At Milking Procedure. RESULTS Statistical analysis was done by using descriptive and inferential statistics using student s paired t test and Pearson s Correlation Coefficient. The software used in the analysis was SPSS 17.0 and Graph Pad Prism 5.0 and p<0.05 is considered as level of significance Table 1 Incidence of DASH score DASH Score No. of patients Percentage(%) Positive 41 82.00 Negative 9 18.00 Total 50 100.00 DASH score was positive in 41 patients out of 50 so the incidence of DASH score was 82%. B - 53
Graph 1 Incidence of DASH score Table 2 Age wise distribution of patients Age Group(Years) No of patients Percentage (%) 25-34 10 24.39 35-44 26 63.41 45-54 5 12.20 Total 41 100.00 Mean 37.43 yrs SD 5.40 Range 26-47 Distribution of patients according to their age in years shows that 24.39% of the patients were belonging to the age of 25-34 years, 63.41% in the age of 35-44 years and only 12.20% were belonging to the age of 45-54 respectively. The mean age of the patients was 37.43±5.40 years. Graph 2 Age wise distribution of patients B - 54
Table 3 Comparison of DASH score at pre and post rehabilitation Paired Differences Mean Table 3.1 Descriptive Statistics Mean N Std. Deviation Std. Error Mean Pre Rehabilitation 23.58 41 7.31 1.14 Post Rehabilitation 10.78 41 4.87 0.76 Std. Deviatio n Std. Error Mean Table 3.2 Student s paired t test 95% Confidence Interval of the Difference Lower Upper 12.80 3.87 0.60 11.58 14.02 21.16 40 t df p-value 0.000 S,p<0.05 Mean DASH score at pre rehabilitation was 23.58±7.31 and at post rehabilitation it was 10.78±4.87. By using student s paired t-test statistically significant difference was found in DASH score at pre and post rehabilitation (t=21.16, p-value=0.000). Graph 3 Comparison of DASH score at pre and post test Table 4 Distribution of patients according to duration of milking Duration of milking No of patients Percentage(%) Up to 10 5 12.20 11-20 27 65.85 21-30 9 21.95 Total 41 100.00 Mean 16.60 SD 4.47 Range 9-25 Distribution of patients according to their duration of milking shows that 12.20% of them, had duration up to 10 years, 65.85% had up to 11-20 years and 21.95% of them had duration of milking between 21-30 years. Mean duration of milking was 16.60±4.47 years. B - 55
Graph 4 Distribution of patients according to duration of milking Table 5 Correlation of duration of milking with pre and post rehabilitation score Mean Std. Deviation N Correlation r p-value Duration of milking 16.60 4.47 41 - - Pre Rehabilitation Score 23.58 7.31 41 0.61 0.000 S,p<0.05 Post Rehabilitation 0.006 10.78 4.87 41 0.42 Score S,p<0.05 Significant positive correlation was found between duration of milking and pre rehabilitation DASH score (r=0.61,p-alue=0.000) and post rehabilitation DASH score(r=0.42, p-value=0.006). It reveals that as duration of milking is more pre and post rehabilitation score increases significantly. Graph 5.1 Correlation of duration of milking with pre rehabilitation DASH score B - 56
Graph 5.2 Correlation of duration of milking with post rehabilitation DASH score Table 6 Chi-square test for VAS score at pre and post rehabilitation The Chi-square test applied on VAS Scale and the distribution of data is as follows, Expected Frequency Pre-Rehab Post-Rehab Total < Median 19 37 56 = Median 31 13 44 Total 50 50 100 Pre-Rehabilitation Post-Rehabilitation 28 28 28 22 P Value 0.001755626 Pre-median VAS score is 6 and post-median VAS score is 3, pain is reduced about 50%, the quantitive analysis was supported by χ2 = 9.8, which is statistically significant. The ratio of the samples increase in the category of the less than median score and the rest also support the findings by the reducing the number of patient. Hence, we may conclude that there is effect of exercises in Repetitive strain injuries of hand in milkmen on VAS Scale. Graph 6 Comparison of VAS score at pre and post test B - 57
Table 7 Comparison of pre and post vas score Pre-vas Score Post- vas Score 6 3 Graph 7 Comparison of pre and post vas score DISCUSSION During this study, when questions on dash questionnaire, such as to open a tight or new jar and to carry a heavy object (over 10 lbs) was put forward maximum number of milkmen said that, they had moderate and severe pain during that activity. This was because during the activity of opening a tight or new jar, maximum stress is created on the wrist joint, its muscles and tendons and soft tissues in and around hand. These are the clinical features of repetitive strain injuries of hand. So, these two questions are sensitive points of DASH questionnaire in relation to the repetitive strain injuries of hand in milkmen.study conducted by Barbara A. O Neil on chronic occupational repetitive strain injuries shows that, repetitive strain injury continues to be an important health problem and the epidemic shows no signs of slowing down. It causes a dilemma for physicians and the general public because rising social and financial costs are associated with RSI.Preventing these injuries by ensuring ergonomically sound work environments and adequate time away from work is important for decreasing incidence. 5 This is very true, as there were positive effects of daily exercise and frequent breaks between their continuous work schedules.practitioners of obstetrics and gynecological, ultrasound worldwide shows that, operator-dependent factors except gender, had little correction with symptoms suffered, whilst the number of days worked per week, not taking regular breaks each day, reveled positive correction. 6 Continuous work without taking frequent breaks and forceful repetitive work of hand are major risk factors of development of repetitive strain injuries of hand. The exercise protocol showed good result in repetitive strain injuries of hand in milkmen, as the pain was reduced about 50% on VAS scale but more research could help to delineate the relationship between different types of interventions and repetitive strain injuries of hand. CONCLUSION In this study50 milkmen were treated for RSI of hand.41 were treated for RSI,9 were given preventive measures.3weeks of exercise were given 20-25 mins everyday, at the end significant improvement were seen in VAS and DASH scale. B - 58
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