Industrial Medicine and Acute Musculoskeletal Rehabilitation. 3. Work-Related Musculoskeletal Conditions: The Role for Physical Therapy, Occupational Therapy, Bracing, and Modalities

3.1 Clinical Activity: To assess the efficacy of modalities and splinting to guide treatment of a 40-year-old home improvement warehouse worker with plantar heel pain 

A 2003 COCHRANE REVIEW1 examined the effectiveness of various treatments for plantar heel pain. Nineteen randomized trials involving 1626 participants met the inclusion criteria for analysis. Trial quality was generally considered poor and data from the various studies could not be pooled. All trials measured heel pain as the primary outcome. The reviewers found limited evidence that stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than 8 hours a day. There was some evidence that orthotic devices were not as effective as corticosteroid injections. Evidence for topical corticosteroids administered by iontophoresis was limited. Based upon conflicting evidence for low energy extra corporeal shock wave therapy (ECSWT) in reducing pain in the short term (6 and 12wk), its effectiveness remains equivocal. No evidence was found supporting the effectiveness of therapeutic ultrasound, low-intensity laser therapy, or insoles with magnetic foil. In people with chronic (>6mo) plantar heel pain, there was limited evidence that dorsiflexion night splints reduce pain. Overall, the reviewers concluded that further research studies (eg, well-designed, randomized trials) are needed.

Since the 2003 Cochrane review, a more-recent, prospective, randomized study2 evaluated the effectiveness of 2 different types of stretching programs in 101 patients with chronic plantar fasciitis (at least 10mo). Researchers compared a program of non-weight-bearing stretching exercises specific to the plantar fascia versus a standard program of weight-bearing stretching exercises for the Achilles’ tendon. They concluded that stretching the plantar fascia under non-weight-bearing conditions provides significantly better outcomes in terms of pain relief, activity limitations, and patient satisfaction. The authors also provided all patients with prefabricated soft insoles and 3 weeks of nonsteroidal anti-inflammatory drugs (NSAIDs), and concluded that these treatments (especially when combined with non-weight-bearing stretching of the plantar fascia) can be very helpful nonsurgical treatments for patients with chronic, disabling plantar heel pain.2

3.2 Clinical Activity: To evaluate the use of soft cervical orthoses (“collars”) and modalities for a state Department of Transportation employee with neck pain following a rear-end automobile collision 

Frequently, soft cervical orthoses are prescribed to patients with whiplash, although recent studies question this approach. Crawford et al3 prospectively studied 108 consecutive patients with soft tissue cervical injuries from automobile collisions. Patients were randomized to either early mobilization using an exercise regime or 3 weeks in a soft cervical orthosis followed by the same exercise regime. Results found no differences between the 2 groups for improvements in pain, range of movement, or activities of daily living at any of the follow up intervals (3, 12, and 52wk). Patients treated with a collar took significantly longer to return to work after injury than those treated with early mobilization (34d vs 17d, P<.05). Overall, treatment with a soft cervical orthosis had no obvious benefit and was adversely associated with prolonged time out of work.3 Similarly, Gennis et al4 found that collars do not influence the duration or degree of persistent pain.

In 2001, the Philadelphia Panel for Evidence Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Neck Pain5 analyzed randomized controlled trials (RCTs) and observational studies, regarding treatments for neck pain. The panel used methods defined by the Cochrane Collaboration, using a systematic approach to literature search, study selection, data extraction, and data synthesis. The panel concluded that for patients with neck pain, therapeutic exercises including both proprioceptive and traditional therapeutic exercises were the only intervention with clinically important benefits. Benefits included pain relief, functional improvement, and improved patient global assessment compared with controls. There was a lack of evidence regarding whether to include or exclude the use of thermotherapy, massage, electromyographic biofeedback, mechanical cervical traction, ultrasound, electric stimulation, and combined rehabilitation interventions for acute and chronic neck pain.5

3.3 Clinical Activity: To review the use of counterforce bracing (forearm straps), modalities, and exercise in the case of a secretary with lateral epicondylitis 

Counterforce bracing is frequently prescribed for patients with lateral epicondylitis. The brace is a nonelastic strap that is curved for better fit and support of the conical shape of the forearm. The orthosis decreases intrinsic muscular forces on sensitive or vulnerable areas such as the wrist extensor origins at the lateral epicondyle. Nirschl6 demonstrated improvement in wrist extension and grip strength with counterforce bracing. However, some other investigators have not found benefit from it. Wuori et al7 compared 50 patients who used 2 commercially available braces versus a placebo strap; that investigation found no significant difference in pain-free grip.

A nationwide occupational medicine network that cares for approximately 7% of U.S. workers’ compensation patients recently retrospectively studied the efficacy of splinting for epicondylitis. Among 4000 patients, those given splints had higher rates of limited-duty work, more medical visits, higher charges, and longer treatment durations than patients treated without splints. Logistic regression was used to minimize the confounding variable of whether more severe cases were more likely to have been splinted. Other limitations of this study included no standardization of the splinted site (forearm vs wrist), type of splinting used, or site of epicondylitis (medial vs lateral).8

Svernlov and Adolfson9 studied 38 patients with lateral epicondylitis who were randomly allocated to 2 treatment groups: a contract-relax stretching program and an isotonic eccentric exercise program. Reduced pain and increased grip strength were seen more frequently in the eccentric exercise group (71%), than in the stretching group (39%) (P=.09). The eccentric training regimen seemed more effective at reducing symptoms in a majority of the patients, regardless of symptom duration, and was superior to conventional stretching.9

In a systematic review and meta-analysis Bisset et al10 examined 76 RCTs on physical modalities for lateral epicondylalgia. They found a lack of evidence for long-term benefit of physical interventions in general. Evidence suggested that ECSWT is not beneficial. Meanwhile, a Cochrane review of ECSWT included 2 trials that yielded conflicting results.11

Haahr and Andersen12 studied a cohort of 266 consecutive new lateral epicondylitis cases and found that after 1 year, 83% of cases showed overall improvement. Poor overall improvement was associated with employment in manual jobs, high level of physical strain at work, and a high level of baseline pain. Other studies13, 14 had similar findings of poor prognosis among patients who reported neuropathic symptoms, keyboarding, or highly repetitive monotonous work. These findings may imply that physiatrists should place a greater focus on workplace modifications in order to reduce physical demands during recovery from lateral epicondylitis.

3.4 Clinical Activity: To review the use of bracing, modalities, and exercise in an assembly-line worker who has carpal tunnel syndrome 

A Cochrane review15 of nonsurgical interventions for carpal tunnel syndrome (CTS) found moderate evidence for short-term benefit from oral steroids; limited evidence for short-term benefit from splinting, ultrasound, yoga, and carpal bone mobilization; and no clear evidence for other nonsurgical treatments. Among these, oral steroids are a simple, inexpensive treatment, but side effects may be a concern.

Werner et al16 found that autoworkers with symptoms consistent with CTS benefited from a 6-week nocturnal splinting trial and the benefits were still evident at the 1-year follow-up. The splinted group’s hand discomfort improved regardless of degree of median nerve impairment, whereas the controls showed improvement only among subjects with normal median nerve function. Results suggest that a short course of nocturnal splinting may reduce wrist, hand, and/or finger discomfort among active workers with CTS symptoms.16

Walker et al17 found that CTS patients who were instructed to wear neutral splints full-time had superior motor and sensory distal latency improvements compared to subjects instructed to wear splints only at night. Function and symptom severity were also improved. Walker17 concluded that neutral wrist splints are efficacious for CTS, particularly when worn as much as possible.

3.5 Educational Activity: To educate a workers’ compensation nurse case manager regarding the use of lumbosacral supports and directional-based exercises for a loading dock worker with low back pain 

A recent Cochrane back review18 systematically examined 5 randomized and 2 nonrandomized preventative trials, and 6 randomized therapeutic trials. Only 4 of 13 studies were of high quality. There was moderate evidence that lumbosacral supports are ineffective for primary low back pain (LBP) prevention. No evidence supported the use of these supports for secondary LBP prevention. There was limited evidence that lumbosacral supports are more effective than no treatment, but was unclear whether they are more effective than other treatments for LBP. An essential issue to address in future trials is compliance with wearing the device.18

Petersen et al19 did an RCT with an 8-month follow-up period on 260 consecutive patients with LBP for longer than 8 weeks. One subgroup was treated with the McKenzie method and another subgroup was treated with intensive dynamic strengthening training. The outpatient treatment period for both groups was 8 weeks, followed by 2 months of self training at home. Petersen found no significant differences in pain reduction at any time and no significant differences in disability. Petersen19 concluded that the McKenzie method and intensive dynamic strength training were equally effective treatments for subacute or chronic LBP.

In a study of patient-specific exercises for LBP,20 312 patients underwent a standardized mechanical assessment classifying them by their pain responses, specifically eliciting a “directional preference.” The patient’s directional preference was identified and thus defined by an immediate, lasting improvement in pain in a particular vector via repeated lumbar flexion, extension, or side-glide or rotation tests. Subjects were randomized to 10 directional exercises that either “matched” their preferred direction, were “opposite” to it, or were “nondirectional” relative to their preferred direction. Outcome measures included pain intensity, location, disability, medication use, degree of recovery, depression, and work interference. Results showed that a directional preference was elicited in 74% (230) of subjects. One third of the subjects treated with the “opposite” exercises and one third of subjects treated with and the “nondirectional” exercises withdrew within 2 weeks because of no improvement or worsening symptoms. No subjects whose exercises matched their directional preference withdrew. Significantly greater improvements occurred in subjects performing exercises that matched their directional preference compared with both other treatment groups in every outcome (P<.001), including a 3-fold decrease in medication use. They concluded that standardized mechanical assessment identified a large subgroup of LBP patients with a directional preference. Regardless of subjects’ direction of preference, exercise that matched their directional preference significantly and rapidly decreased pain and medication use and improved all other outcomes. Results suggest that patient-specific therapeutic exercises are more effective than nonspecific exercises. This may explain the previously reported lack of efficacy of exercise and physical therapy for LBP treatment.

3.6 Educational Activity: To critique the literature regarding modalities and exercise as treatment for Achilles’ tendinosis in a 45-year-old tree trimmer 

A Cochrane review for Achilles’ tendinosis found 9 trials (N=697) that met the inclusion criteria for review.21 They found weak evidence of benefit from oral NSAIDs, but weak evidence of no benefit for heel pads, topical laser therapy, heparin injection, or peritendinous steroid injections. Heat, cold, and ultrasonography are anecdotally beneficial for Achilles’ tendinosis, but well-designed research supporting their use is somewhat sparse.

Eccentrically loading the Achilles’ tendon via calf muscle training is a well-supported treatment for Achilles’ tendinosis. It is favorably associated with reduction in abnormal Achilles’ tendon thickness, decreased pain, restoration of normal tendon architecture,22 and decreased abnormal neovascularization of the tendon.23 A prospective study of 15 patients with chronic Achilles’ tendinosis showed that 12 weeks of this therapy, using eccentric heavy loading, resulted in full recovery to preinjury functional levels, including running, while all patients in a control group had persistent pain and underwent surgical treatment.24