Work-related Carpal Tunnel Syndrome 王賢和 MD.PhD 職業醫學科.

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1 Work-related Carpal Tunnel Syndrome 王賢和 MD.PhD 職業醫學科

2 Case - M/48 季 xx CC: referral here under the impression of work related carpal tunnel syndrome.

3 職業病的診斷原則 1. 疾病的證據 2. 職業暴露的證據 3. 符合時序性 4. 符合人類流行病學已知的證據 5. 排除其他可能的致病因素 3

4 罹病的證據 1.Symptoms 2.Signs 3.Tests

5 SYMPTOMS 1.Numbness, 2.Tingling pain in the volar aspects of hands 3.Weakness in left hand gripping 4.Especially noted after work or at night 5.Shaking hands to relieve the pains No sleep disturbance yet

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7 Signs 1.Tinel's sign (+/-): tapping over the median nerve at the wrist causes paresthesias or pain radiating from the wrist to the thumb and the index, the middle and half the ring fingers. 2.Phalen‘s test (+/-): bending the wrist forward all the way for 60 seconds results in numbness, tingling, or weakness in a median nerve distribution Atrophy of the thenar muscles (-)

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9 Present illness 1.Numbness, tingling pain and weakness of hands for 3 years 2.Pain could temporarily relieved by the analgesics, traditional massages, herb medicines and local steroid injection. 3.Carpal tunnel syndrome was diagnosed at the 賢德 hospital on 2011/01/07. 4.Referral under the impression of work related disease.

10 Motor Nerve Conduction Study 1.Normal amplitude 2.Delayed distal latencies of bilateral median nerves. 3.Prolong F latencies of bilateral median nerves in F wave study 4.Normal results of ulnar, peroneal and tibial nerves.

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12 F wave study Supra-maximal stimulation Ortho-dromic stimulus  M wave: muscle contraction. Anti-dromic stimulus  the motor neuron cell bodies  backfire down towards the muscle  small F wave.

13 F-wave study D = the length from the stimulation (wrist crease) to the spine (C7) (for median nerve). F-M = the latency difference between mean F and M Delay = 1 millisecond Conduction velocity = 2D/(F- M-1).

14 Sensory Conduction Study 1.Slowing in the palm-wrist conduction of bilateral median nerves 2.Normal results of ulnar and sural nerves.

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17 Nerve Conduction Study (NCS) Motor NCS Sensory NCS F-wave study (initially recorded in the foot muscles) H(Hoffmann)-reflex study

18 F-wave study vs. Motor and Sensory coduction studies The F-wave latency can be used to derive the conduction velocity of nerve between the limb and spine, whereas the motor and sensory nerve conduction studies evaluate conduction in the segment of the limb. F-wave study is not a reflex.

19 H reflex monosynaptic reflex electrically stimulating the tibial nerve (Ia afferents from muscle spindles), generally in the popliteal fossa, recording from the gastrocnemius-soleus muscle similar to the Achilles reflex, except that the neuromuscular spindles are bypassed.

20 Hoffmann reflex 1.Square-wave current of short duration and small amplitude 2. Early response on EMG: M-wave 3.Later responses: H-wave (reflected). 4.As the stimulus increases, the M-wave increases and the H-wave decreases. 5.At supramaximal stimulus, alpha fibers involved, the H- wave disappears and the F-wave appears.

21 NCV Reports Slowing at wrist conduction of bilateral median nerves. Diagnosis: carpal tunnel syndrome (CTS)

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23 Tests Nerve conduction velocity: positive Therapeutic and diagnostic challenge test: possibly positive. Wrist X-rays: negative Electromyography: nil.

24 Electromyography (EMG) 1.surface EMG 2.intramuscular (needle and fine- wire) EMG. Resting and contracting

25 Occupational CTS (OCTS)

26 職業病的診斷原則 1. 疾病的證據 2. 職業暴露的證據 3. 符合時序性 4. 符合人類流行病學已知的證據 5. 排除其他可能的致病因素 26

27 工作史１ 1980-1984 友聯鞋業之裁剪作業員 1988-1992 偉仲製帽之裁剪作業員 工作時, 需使用油壓機器將牛皮裁成鞋底或帽 子。 油壓機上的裁刀常會卡於機台上, 需用手腕施 力直接拔出或拿鐵鎚 (5 磅重 ) 用力鎚打敲鬆再 拔出. 鎚打的頻率約 20 秒一次，每天持續 8 小 時。

28 工作史 -2 1992-2001 群國工程之營造工人 2001-now 無固定雇主之營造工人 動鑽打洞, 植筋, 砌磚, 敲磚, 扛鐵和粉刷等. 每天需重覆地扛起 20-30 公斤的鐵條並以手 腕用力綑綁, 約 6-7 小時. 或使用電動鑽打洞約 6 小時, 每 1-2 秒震動一次.

29 暴露之證據 過去擔任皮革裁剪作業員時, 以及擔任營 造勞力工作時, 皆需經常重覆地以手腕用 力地扭轉或接觸高頻震動等. 工作場所評估： 目前無固定雇主及工作場所. 其中一次的工作現場照片如下：

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32 職業病的診斷原則 1. 疾病的證據 2. 職業暴露的證據 3. 符合時序性 4. 符合人類流行病學已知的證據 5. 排除其他可能的致病因素 32

33 時序性 1980-1992 裁剪皮革 1992–now 營造工作, 砌磚, 粉刷, 鋼筋組合, 植筋, 敲磚和電動鑽打洞等。 於 2008 年開始出現雙手腕酸痛、無力和 麻的情形

34 職業病的診斷原則 1. 疾病的證據 2. 職業暴露的證據 3. 符合時序性 4. 符合人類流行病學已知的證據 5. 排除其他可能的致病因素 34

35 Reviews 1.The median nerve is formed from parts of the medial and lateral cords of the brachial plexus. 2.It continues down the arm to enter the forearm with the brachial artery. 3.It originates from the brachial plexus with roots from C5, C6, C7, C8, & T1.

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37 Carpal Tunnel Syndrome 1.Median nerve compression at the wrist is the most common peripheral nerve entrapment disorder. 2.Constellation of specific symptoms and signs, described as CTS. 3.Annual incidence in the general population = 1/1000

38 Epidemiology of CTS 1.most often in people 30 to 60 years old 2.more common in women than men. 3.common in people who perform repetitive motions of the hand and wrist.

39 Repetitive motions of the hand and wrist Typing on a computer keyboard Sewing Driving Assembly line work Painting Writing Use of hand tools that vibrate Sports such as racquetball or handball Playing some musical instruments

40 Work-related CTS most often associated with activities requiring extensive, forceful, repeated, or prolonged use of the hands and wrists, 1.(NIOSH Publication no. 97–141.US Department of Health and Human Services, 1997) 2.(Palmer KT et al.Occup Environ Med 2007; 57:57–66) 。

41 職業性腕隧道症候群 工作時, 手腕必須 1. 經常反覆地動作, 2. 經常持續地以一種不自然的姿勢工作, 3. 或經常用力地作出扭轉的動作等 長時間累積的傷害造成  手腕部軟組織的病變或功能異常,  以及造成附近肌腱的發炎和週邊神經之壓 迫.

42 Occupational Carpal Tunnel Syndrome (OCTS) 1.Forceful hand use, particularly if repeated for prolonged periods 2.Constant firm gripping of objects 3.Moving or using the hand and wrist against resistance or with force 4.Exposing the hand and wrist to strong regular vibrations 5.Regular or intermittent pressure on the wrist

43 Work Exposures and the Probability of Work-Relatedness ExposureExamples of types of jobsProbability of work- relatedness Combinations of high force with high repetition and awkward posture; regular strong vibrations Seafood, fruit, or meat processing or canning, carpentry, roofing, dry- wall installation, boat building, book binding High, Relative risk > 4 Medium-high force, high repetition or awkward posture alone, on a nearly continuous basis Dental hygienists, wood products production Medium, Relative risk 2-4 Low force or medium-low repetition alone, on an intermittent basis Computer or keyboard use Low, Relative risk < 2

44 職業病的診斷原則 1. 疾病的證據 2. 職業暴露的證據 3. 符合時序性 4. 符合人類流行病學已知的證據 5. 排除其他可能的致病因素 44

45 過去病史 1. 過去無手部的重大外傷、痛風、甲狀腺 疾病、痛風、自體免疫疾病糖尿病和關 節炎等可能會造成腕隧道症候群之相關 病史。 2. 2011 年曾由鷹架跌落，胸部挫傷，但 未傷及手部。

46 Risk factors for CTS 1.inflammatory or non-inflammatory arthropathies, 2.recent or remote wrist trauma or fractures, 3.diabetes mellitus, 4.obesity, 5.hypothyroidism, 6.pregnancy, 7.genetic factors.

47 Medical problems associated with CTS Fracturesand arthritis of the wrist Acromegaly Diabetes Alcoholism Hypothyroidism Kidney failure and dialysis Pregnancy Infections Obesity Rheumatoid arthritis, systemic lupus erythematosus (SLE), and slceroderma

48 OCUPATIONAL DISEASE on a more probably than not basis (greater than 50%) that the workplace activities (exposure) in an individual case contributed to the development or worsening of the condition (outcome).

49 Summary Dx; 臨床徵狀及神經傳導檢查皆符合腕隧道症候群的診斷 認定基準 Exposure: 過往至今的工作 (repeated and forceful works), 皆明顯地增加罹患腕隧道症候群的機會 Time sequence: 1980 起工作 30 年, 於 2008 年開始出現雙 手腕酸痛, 無力和麻的情形, 合乎危害暴露在前, 發病在 後之時序性。 可合理地排除其他非職業因素造成之腕隧道症候群之可 能。 Thus, 此疾病由職業引起之可能性大於 50 ﹪。

50 診斷基準 勞工保險職業病種類表之 3.4 壓迫 造成之神經麻痺：包括職業性腕 道症候群等。 診斷： work related carpal tunnel syndrome, bilateral ( 雙側職業性 腕隧道症候群 )

51 後續處理 個案因經濟上之需求, 目前仍需持續 地工作. 1. 衛教 2. 職能治療 3. 藥物 4. 手術

52 Education 1.Avoid sleeping on wrists. 2.Hot and cold compresses 3.Take frequent breaks when typing and always stop if tingling or pain. 4.Avoid or reduce the number of repetitive wrist movements whenever possible.

53 Occupational Therapy 1.Wearing a neutral position wrist splint at night 2.Wearing a splint intermittently during work 3.Ergonomic aids, such as split keyboards, keyboard drawers, cushioned mouse pads, and wrist braces. 4.Job modification 5.Forearm/wrist stretching home exercise 6.Referral to an occupational therapist

54 MEDICATIONS Cyclo-oxygenase (COX) inhibitors 1.Nonselective : ibuprofen or naproxen. 2.COX-2 selective: celecoxib Local steroid injections into the carpal tunnel for short term relief.

55 Prognosis Symptoms often improve with treatment, but more than 50% of cases eventually require surgery. Surgery is often successful, but full healing can take months

56 SURGERY Carpal tunnel release 1.Release of the transverse carpal ligament 2.Open or endoscopic approach 3.Decompression of the median nerve at the wrist Revision after 6 months if worsening

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59 Possible Complications If untreated, the nerve can be damaged, causing permanent weakness, numbness, and tingling.

60 The END

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