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Technological diseases are diseases of the modern era. Some are caused by occupational exposures, and are marked with direct professional relation, or the action of harmful effects in the workplace. Due to the increasing incidence of these diseases on specific workplaces which may be caused by one or more causal factors present in the workplace today, these diseases are considered as professional diseases. Severity of technological disease usually responds to the level and duration of exposure, and usually occurs after many years of exposure to harmful factor. Technological diseases occur due to excessive work at the computer, or excessive use of keyboards and computer mice, especially the non-ergonomic ones. This paper deals with the diseases of the neck, shoulder, elbow and wrist (cervical radiculopathy, mouse shoulder and carpal tunnel syndrome), as is currently the most common diseases of technology in our country and abroad. These three diseases can be caused by long-term load and physical effort, and are tied to specific occupations, such as occupations associated with prolonged sitting, working at the computer and work related to the fixed telephone communication, as well as certain types of sports (tennis, golf and others). Key words: technological diseases, carpal tunnel syndrome, mouse shoulder, cervical pain syndrome.
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Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
ACTA INFORM MED. 2014 OCT 22(5): 333-340 / PROFESSIONAL PAPER
333
Occupational Overuse Syndrome (Technological
Diseases): Carpal Tunnel Syndrome, a Mouse
Shoulder, Cervical Pain Syndrome
Merita Tiric-Campara1, Ferid Krupic2, Mirza Biscevic3, Emina Spahic4, Kerima Maglajlija4, Zlatan Masic5, Lejla Zunic6, Izet Masic4
Neurology Clinic. Clinical Center of Sarajevo University. Sarajevo, Sarajevo, Bosnia and Herzegovina1
Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenbug, Sweden2
Orthopaedics and Traumatology Clinic. Clinical Center of Sarajevo University. Sarajevo, Bosnia and Herzegovina3
Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina4
XION Company, Vienna, Austria5
Faculty of Health Sciences, University of Zenica, Zenica, Bosnia and Herzegovina6
Corre sponding author: Mer itaTiric Camp ara, MD, PhD. Neurology Clinic. Clinical center of Univer sity of Saraj evo. Bol nicka 25. Sarajevo. E-mail: merita.tiric@ gmail .com
1. INTRODUCTION
Computers are considered as an integral part of everyday life
in today’s work and life (1-5). They are used in a wide variety
of professions from banking, health, communication to enter-
tainment and leisure time. “Thanks to the” great use of com-
puters, occurs the diseases of the modern era, which one of the
authors of this article named “Technological diseases” – Carpal
Tunnel Syndrome (CTS), a Mouse Shoulder (MS) and Cervical
Pain Syndrome (CPS). Within past a few decades rapidly in-
creased automation of oces and very few authors in the sci-
entific literature have reported about positive association be-
tween computer use and musculoskeletal symptoms as con-
sequences (6-10). Under term of “Technological diseases” we
mean the diseases caused by the harmful influence of the job
in the first place, the working position in which it is involved
excessive work on a computer, such as the banking sector, the
health sector and many others who are directly or indirectly
connected with the work on the computer and overuse of key-
board and computer mice, which are in large number of cases
of non-ergonomic, and inappropriate for a hand. It is therefore
recommended to use ergonomic computer mice. Using them
can prevent diseases of the modern era, technological diseases
associated with prolonged sitting and working on a computer
such as Carpal Tunnel Syndrome, Cervical syndrome, and cer-
tainly the most interesting for the many unknown, but not less
important disease, mouse shoulder an increasingly common
diagnosis in clinics of family medicine. These diseases are
described in more detail in this paper (11-20). In Bosnia and
Herzegovina to overuse injuries has not paid enough atten-
tion from the medical nor the social and economic aspects,
although it is evident that large amounts of funds are allocated
for treatment and rehabilitation of these diseases. In Clinical
Center University of Sarajevo in the cabinet for EMNG of
the Neurology clinic, monthly are diagnosed 10 cases with
carpal tunnel syndrome, while cases of cervical syndrome is
in a significant expansion during last 5 years which more and
more represent not only a medical but also social economic
problem (21-23).
2. CARPAL TUNNEL SYNDROME
Carpal tunnel syndrome (CTS) is the most common cana-
liculus syndrome resulting from pressure on the central nerve
(median nerve) in the carpal tunnel (lat. canalis carpi) and re-
flected in reduction of sensation, pain, paresthesia (numbness,
tingling), and muscle weakness in the hands and forearms .
The median nerve in its course passes through the carpal
canal (Figure 1). The bones of the hand (lat. ossa carpi) make
gutter channels, and rectangular connection (lat. retinaculum
doi: 10.5455/aim.2014.22.333-340
ACTA INFORM MED. 2014 OCT 22(5): 333-340
Received: 12 September 2014 • Accepted: 25 October 2014
© AVICENA 2014
PROFESSIONAL PAPER
ABSTRACT
Technological diseases are diseases of the modern era. Some are caused by occupational exposures, and are marked with direct professional relation,
or the action of harmful eects in the workplace. Due to the increasing incidence of these diseases on specic workplaces which may be caused by one
or more causal factors present in the workplace today, these diseases are considered as professional diseases. Severity of technological disease usually
responds to the level and duration of exposure, and usually occurs aer many years of exposure to harmful factor. Technological diseases occur due to
excessive work at the computer, or excessive use of keyboards and computer mice, especially the non-ergonomic ones. This paper deals with the diseases
of the neck, shoulder, elbow and wrist (cervical radiculopathy, mouse shoulder and carpal tunnel syndrome), as is currently the most common diseases of
technology in our country and abroad. These three diseases can be caused by long-term load and physical eort, and are tied to specic occupations, such
as occupations associated with prolonged sitting, working at the computer and work related to the xed telephone communication, as well as certain types
of sports (tennis, golf and others).
Key words: technological diseases, carpal tunnel syndrome, mouse shoulder, cervical pain syndrome.
Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
PROFESSIONAL PAPER / ACTA INFORM MED. 2014 OCT 22(5): 333-340
334
flexorum) covers the channel. In the channel along with the
nerve are located tendon flexor muscle of fingers, m. pronator
teres, m. pronator quadrates, m. flexor carpi radialis, m. pal-
maris longus, m. flexor carpi ulnaris, m. flexor digitorum su-
perficialis et profundus and m. flexor policis longus. All these
muscles supplying the median nerve. Carpi ulnaris M.flexor
the inner half, m. Flexor digitorum profundus is innervated
by n. ulnaris.
Carpal tunnel syndrome (CTS) was first described in the
mid-1800 by James Paget’s (Figure 1). The world’s best known
as peripheral compressive neuropathy and one of the fastest
growing technology diseases in the United States. At least 1
out of 10 people develop this disorder or suering from the
symptoms of this syndrome. This is one of the most common
causes of absenteeism in the workplace and disability in the
United States (2)
Signs and symptoms are: a) pain in the palm of the hand, es-
pecially near the thumb and first two fingers; b) numbness and
tingling often occur in the thumb and first two fingers; and
c) weakness, usually thenar eminence (muscles at the base of
the thumb), can occur when a severe clinical picture (Figure
2) (3).
Compression of the nerve in the carpal tunnel (carpal
tunnel syndrome) is recognized as the impact of trauma and
attributed to tenosynovitis of the rheumatoid arthritis. Even
since 1954, Albert and his colleagues concluded that there are
numerous reports describing the spontaneous development of
carpal tunnel syndrome of unknown pathogenesis (4).
In case of a longer duration of illness and long-term nerve
compression, there is an unnecessary prolongation of the pa-
tient discomfort, severe nerve damage, prolonged recovery
time after surgery, and generally reduced chances for suc-
cessful surgical treatment. Thereby reducing the working
ability of the patient, leading both to the individual and to
the socioeconomic consequences.
At the Department of Orthopedic Surgery, Faculty of
Medicine, University of Zagreb, and Zagreb University Hos-
pital Center is conducted a retrospective study on 114 patients
and 154 hands with CTS that were surgically treated between
1999 and 2004. In this study, it was found that patients in only
52% of cases within one year since reporting to the physician
were referred to an orthopedist. In the period prior to surgical
treatment, 96.1% of patients were treated by physical therapy,
although all eventually underwent a surgical procedure, and
42% of patients in the same time period it was on sick leave,
usually from three to six months. The results demonstrate
that the timeliness of surgical treatment is essential to the suc-
cess of the outcome of the procedure, and that the time which
elapses from entering the patient’s health care system to the
surgical treatment of unnecessary cost.
This situation, besides being detrimental for the patient,
and leads to unnecessary economic losses include the expense
of physical therapy and absenteeism. The patients involved in
the study in question is estimated that these economic losses,
in the period prior to surgical treatment, for several hundred
thousand Euros higher than in the postoperative period.
From this stems the need for shortening the period of time
that has elapsed since entering the patient in the health care
system to its referral to an orthopedic clinic, so as to accelerate
the processing and diagnosis of the patient, i.e. shortened un-
necessarily long period of nonsurgical treatment. Accord-
ingly, physical therapy is helpful in the treatment (5).
In the diagnosis of CTS we also use provoking tests of
which we will mention four that are suitable for use in gen-
eral practice. These are the Tinel, Phalen, Bilic and Tourni-
quet test. Tinel’s test is positive if the percussion in the carpal
ligament is followed with occurrence of pain and/or pares-
thesia. Phalen’s test is performed so that the wrist is placed in
the second forced palmar flexion for 60 seconds, and is posi-
Figure 2. Sensory innervation of the median nerve in a hand
Figure 1. The muscles of the forearm.
Figure 3. EMNG median nerve recording procedure
Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
ACTA INFORM MED. 2014 OCT 22(5): 333-340 / PROFESSIONAL PAPER
335
tive if within this time span occurs pain and/or parasthesias
(Figure 2). Compression of median nerve in this position with
carpal tunnel syndrome causes the characteristic symptoms of
burning and tingling (6).
Bilic test is performed in palmar flexion of the wrist by 45
degrees by pressing above the median nerve in the d istal ridges
and mid wrist for 30 seconds. The test is positive if within this
time span occurs pain and/or paresthesia. Tourniquet test is
performed so that the cu pressure gauge is mounted on the
upper arm and inflated above the systolic pressure value. The
test is positive during 60 seconds occurs pain and/or pares-
thesia in the innervation area of median nerve.
Alongside this symptom, electrical neurophysiological
diagnostic is the “gold standard” in the diagnosis of carpal
tunnel syndrome, in order to determine the exact location of
nerve compression, and in order to set the indication for sur-
gical treatment (Figure, 3, 4, 5) (6).
In the case of known primary disease that caused Carpal
tunnel syndrome the primary disease is treated first. The
conservative methods of treatment include immobilization,
local application of corticosteroids and avoidance of chronic,
repeated trauma. If the cause of the syndrome is mechanical
compression, the treatment is surgical (cutting of retinaculum
flexorum).
In Turkey was conducted a study that suggests that treat-
ment with vitamin B6 improves clinical symptoms as well as
sensory and electro diagnostic results in patients with carpal
tunnel syndrome, and therefore it is advisable to treat carpal
tunnel syndrome with vitamin B6 (7).
Another study in Turkey was carried out at the Institute of
Neurology in cooperation with the Clinic for Physiotherapy
in which patients were included with carpal tunnel syndrome.
They are divided into two groups, one in the treatment arm
used immobilization and massages, while the other control
group used only immobilized arm.
The study results showed that the massage of the painful
area only in patients with carpal tunnel syndrome is sucient
for mild cases.
This was also one of the biggest studies with massage treat-
ment in patients with car pal tunnel syndrome. The researchers
recommend self-administration of massage methods, and this
would reduce the time to go to the doctor and rehabilitation
centers, and thereby save money, both for health funds, and
patients (8).
Manipulation (eeurage): Thirty seconds smoothing the
skin’s surface, from distal to proximal forearm. Friction:
sixty seconds, massaging the deep tissues from the distal to
proximal. (8)
3. CERVICAL PAIN SYNDROME
Cervical pain syndrome (CPS) refers to a range of disorders
caused by changes in the cervical spine and soft tissue sur-
rounding it, with pain as the predominant symptom. Neck
pain is a common problem for a large portion of today’s pop-
ulation.
Factors contributing to this problem are the modern way of
life, prolonged sitting and inadequate, fixed or artificial posi-
tions. The root of these problems is found in the mechanical
disorders of the cervical spine, poor posture and quick move-
ments of the body (9).
Figure 4. EMNG: Motor Conduction Velocity of nervus medianus
Figure 5. EMNG: Sensory Conduction Velocity of nervus medianus
Figure 5. EMNG: Sensory Conduction Velocity of nervus medianus
3. CERVICAL PAIN SYNDROME
Figure 6. Example of cervical syndrome caused by disc herniation with
reduction of liquor space (Source: I.M.)
Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
PROFESSIONAL PAPER / ACTA INFORM MED. 2014 OCT 22(5): 333-340
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Anatomical specificity of the cervical spinal column are:
a small side vertebral joints that cervical spine provide great
mobility, transversaria foramina through which the verte-
bral artery (C6-C2) and the spinal cord enters in the vertebral
canal.
Cervical radiculopathy causes symptoms that radiate from
the neck. Although the problem is in the spine, the symptoms
can be felt in the shoulder or arm. Symptoms will be felt in the
area where the nerve is in its path.
By clinical examination of the spine the specialist can usu-
ally determine which nerve is involved. Symptoms include
pain, stiness and weakness. Reflexes on the upper arm may
be aected. (10).
Risk factors for radiculopathy are activities that put exces-
sive or repetitive load on the spine. Patients involved in heavy
work or are in contact sports, are more prone to the develop-
ment of those with radiculopathy more sedentary. A family
history of radiculopathy or other spine disorders also increase
the risk of developing radiculopathy (Figure 6) (11).
In the younger population, cervical radiculopathy is the
result of disc herniation or acute injury. In the older popu-
lation, cervical radiculopathy is often the result of foramen
narrowing and the formation of osteophytes then reduced the
amount of disk and degenerative changes in the joints (12).
Cervical syndrome classification:
CERVICAL SYNDROME patients complain of pain in
the neck that occurs gradually or abruptly, after taking a cer-
tain position, rapid or uncontrolled movements of the neck
or cool ing.
CERVICOCEPHALIC SYNDROME usually develops
as a result of irritation or compression of the nerve roots C1-
C3. The main symptom is headache of varying character and
intensity. Headache is localized in the neck with a tendency to
spread to the shoulders, the face, orbital or auricular region.
CERVOCOBRACHIAL SYNDROME result is irrita-
tion or compression of the nerve roots C4-C8, mostly due
to prolapse of the intervertebral discus, severe degenerative
changes or injury.
VERTEBROBASILAR SYNDROME occurs as a result
of irritation of the last cervical sympathetic with fiber mesh
wrap vertebral artery, causing reflex vascular disorders in the
vertebrobasilar basin.
Irritation commonly caused by degenerative changes in the
cervical spine: spondylosis (osteophytes), uncarthrosis, spon-
dylosis. Atherosclerosis can worsen symptoms (13).
The typical clinical presentation of patients with cervical
syndrome is characterized by the presence of pain and sensi-
tivity in the muscles back of the neck with the spread of pain
in the back of the head, shoulders or scapular region (Figure
6). The sensitivity of the muscle can occur during execution
of one or more movements, and the headache is a common
symptom.
Symptoms and signs are: a) pain in the neck, which may be
sharp or blunt; b) the tension in the neck; c) painful and lim-
ited mobility; d) inability to perform daily duties due to sti-
ness in the neck; e) pain in the shoulders and arms associated
with pain in the neck; f) fainting; g) dizziness; h) tinnitus;
i) blurred vision; j) headache; k) diplopia; l) weakness; m)
feeling of heaviness, tenderness and paresthesia in the upper
extremities; n) impaired concentration and memory, etc. (13).
Diagnostic imaging such as magnetic resonance imaging,
computerized tomography, or myelography should be used as
a strategy for assessment. Electromyography is useful in dif-
ferentiating between the various entities when distinguishing
clinical diagnosis. Treatment of this disorder has not been
studied systematically in a controlled manner. However,
using a variety of treatments, radiculopathy usually improves
without the need for surgery. Indications for surgery were
persistent pain, increased weakness, or new or progressive
process. Future studies evaluating dierent treatment options
will be helpful in guiding practitioners towards optimal eco-
nomic evaluation (13).
The goal of treatment is absolutely the same as for any other
illness. Always seeks the same goal, or cure, and if this is not
possible, at least alleviate symptoms and apply palliative care.
Since we are talking about a technological disease that aects
more and more to older and younger people should therefore
work on the prevention of disease. It is very important to ad-
vise patients about lifestyle, how to maintain mobility and
that despite the dicult situation improve the quality of life.
Treatment without medicationshould be: a) massage hot/
cold; b) rest; c) exercises with light stretching (gently stretch
your neck to one, then the other aside and keep 30 seconds); d)
exercises for neck recommended by physiologists; e) transcu-
taneous electrical stimulation (TENS); f) short-term immo-
bilization; g) surgical treatment; h) acupuncture; i) traction
(enlargement of the intervertebral space), j ) medicamentous
treatment:
Early and adequate treatment with analgesics, anti-inflam-
matory drugs, muscle relaxants and help with sleep problems
are carriers of pharmacological treatment in patients with
neck pain (14).
Performed is a study on how the steroid injections aect the
reduction of pain in patients with cervical syndrome, who are
waiting for surgery discus, and whether the possible suspen-
sion of surgical treatment.
Transforaminal injection of steroids has gained popularity
with the explanation that the inflammation of nerve roots
causing radicular pain, and because steroids are placed on the
local level should relieve symptoms.
Prospective–cohort study indicates a decrease in the need
for surgical treatment because of treatment-injection steroid
injections. The clinical eect is measurable and statistically
significant improvement registered radicular pain (14).
Another in a series of studies on the treatment of cervical
syndrome confirmed the eectiveness of acupuncture in the
cervical region of patients with radicular symptoms. Favor-
able results have been seen in almost 90% of cases. These re-
sults indicate that treatment of acupuncture cervical region
can be eective as the conservative therapy for the treatment
of cervical radiculopathy (15).
4. MOUSE SHOULDER
Computers are considered as an integral part of everyday
life. They are used in education, health and medicine, science,
banking, recreation and entertainment, politically engaged
people (16). Approximately 75% of jobs are dependent on the
work on the computer (17, 18).
Chen and colleagues examined the eect of five computer
mice made at dierent angles in 12 respondents employed in
Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
ACTA INFORM MED. 2014 OCT 22(5): 333-340 / PROFESSIONAL PAPER
337
the business sector in Taiwan. They concluded that too fre-
quent use of non ergonomic computer mice causes extreme
discomfort in the muscle and tendon system of the hand along
with various manifest symptoms in the shoulder and forearm.
The use of ergonomic mice custom hand shape, thanks to the
dierent corners of the obliquity have less adverse eect on
the activity of the forearm and shoulder. (19)
The shoulder belt is common, even among the most fre-
quent localization of musculoskeletal pain after pain in the
back and knees (20).
The long-term work at the computer leads to inflamma-
tion of tendons and exchanges shoulder joint, and in severe
cases can lead to tearing of tendons and muscles “rotator
cu”. If inflammation persists, the capsule and ligaments of
the shoulder joint becomes stier and limited mobility. Inap-
propriate placement of computers may have adverse eects on
posture in children (21).
Limited and painful mobility is especially pronounced
when raising your arms above your head or behind your back.
Long-term pain becomes stronger and leads to the develop-
ment of muscle weakness areas of the shoulder belt through a
series of hands, and preventing further activities.
Symptoms of pain in the shoulder dierently vary from in-
tense that it can spread to other parts of the body, to moderate
that lingers on the shoulder belt, but still hinder the function
of the hinge, and can even lead to sleep disorders.
The anatomy of the shoulder is a specific because the
shoulder joint consists of primary, secondary and ancillary
wrist joints. The anatomical structure makes the most com-
plex joint of the body. Joints shoulders: glenohumeral joint
(shoulder joint primary), Scapulothoracic joint (secondary
shoulder joint), and sternoclavicular joint (extra joints).
Muscle groups that may be a potential source of pain are ro-
tator cu (responsible for balance of the glenohumeral joint),
stabilizing the scapula (responsible for the position of the
scapula) the primary drivers (responsible for the strong move-
ments).
For the diagnosis of mouse shoulder, the most important is
detailed history with regard to occupation and profession of
the patient and physical review. We should not forget to ex-
amine whether the patient has in the past had a shoulder in-
jury, or some localized inflammation in the same.
Information about the character, pain intensity and direc-
tions of its expansion are of great importance. In fact it is nec-
essary to establish that the primary cause of shoulder pain,
and that the anatomical structure of the shoulder is aected.
It is known that the pain can be transmitted from the adjacent
region to the shoulders, for example. The cervical region, or
by visceral fibers of the heart.
In equivocal cases, x-rays of the shoulder joint may help in
dierentiating existing inflammation of the joints and struc-
ture surrounding joint of a possible slight shoulder disloca-
tion.
The primary method for the treatment of mouse shoulder
in a timely manner to reduce the strain on shoulders, mostly
working with computer mouse.
If the patient is in question, and cannot make a break, they
definitely need the to replace old with new ergonomic com-
puter mouse that is adapted to grip and allows the natural po-
sition of the hand during mouse use.
NSAIDs are the first drugs of choice. In the long-term in-
tractable pain states and may prescribe therapy application of
corticosteroid injections in the shoulder joint. An indispens-
able aspect of therapy is physical therapy. Physical therapy is
appropriate in the chronic phase of the disease, which aims to
stabilize and strengthen the muscles of the shoulder belt, and
the resultant reduction in pain.
Jan C. Winters and colleagues came to the conclusion that
only 50% of patients with newly diagnosed painful condition
experience a full recovery within the first 6 months. This per-
centage rises to 60% in the first year of the onset of pain. They
also proved that speaking to the long-term treatment, at the
end of treatment, there was no dierence in eect between
the corticosteroid and physical therapy (22).
Onyebeke LC investigated the eects of props during the
use of the mouse on the palm, forearm and upper extremities,
and came to the result that 90% of respondents who have used
the support arm had less pain in the shoulder girdles of those
who are not used to. The use of any support results in less ten-
sion, and less applied force to a computer mouse during op-
eration, and therefore less hassle and pain in the shoulder (23).
5. PHYSICAL REHABILITATION AND PREVENTION OF
TECHNOLOGICAL DISEASES
5.1. The role and organization of the Centers for Physical
Rehabilitation (CBR)
If the patient required outpatient treatment, family doctor
referred him Physiotherapy in CBR (Community based reha-
bilitation) i.e. the center for rehabilitation in the community.
CBR’s are organized within the framework of primary health
care and are located within the health centers. CBR–rehabili-
tation in the community–the definition of a Joint Paper, ILO,
UNESCO, WHO, in 1994.
Community rehabilitation strategy based on community
development for the rehabilitation, equalization of opportu-
nities and social integration of people with disabilities, their
families and communities and the appropriate health of edu-
cational, professional and social services.
Community rehabilitation allows people with disabilities
Figure 7. Recommended proper position of the neck, torso, arms and legs
when working at a computer
Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
PROFESSIONAL PAPER / ACTA INFORM MED. 2014 OCT 22(5): 333-340
338
to take initiative and improve their own lives, and to con-
tribute to the community, and not just use the funds and re-
sources that are available. Thus, the entire community and all
its members are winners.
CBR became the backbone of the carrier non-institutional
organization of the program in physical medicine and reha-
bilitation of persons with disabilities as well as a large number
of chronically ill patients in the prevention of disability.
5.2. The forms of work in the CBR
Rehabilitation system reaches into every community reha-
bilitation team becomes more flexible and actively participate
in all aspects of rehabilitation. Rehabilitation includes all age
groups.
Treatment in the community increases the accessibility and
quality of services for people with disabilities and their fami-
lies.
Services include primary treatment damage and disability
in the center and at home, as well as patient education, health
promotion and prevention of disease and disability.
CBR Team composition: a) 1 medical doctor specialist in
physical medicine and rehabilitation; b) 1 physiotherapist; c) 1
occupational therapist; d) 2 medical technicians–physiother-
apist; e) Medical technician–general direction; f) 0.5 Social
Worker; g) 0.4 special education teacher-speech therapist.
5.3. The most common reasons for referral of patients in the CBR
The most common reasons due to which family physician
refers patients to the ambulance treatment in rehabilitation
centers in the community are:
Adult patients: a) Cervical pain syndrome; b) Lumbar pain
syndrome; c) Rheumatic diseases; d) Rehabilitation after
stroke. Children and young people: a) Neurorisk children; b)
Deformities of the spinal column; c) Deformities of the lower
extremities; d) Rehabilitation after injuries of the locomotor
apparatus
6. ACCREDITATION STANDARDS RELATED TO
PHYSICAL REHABILITATION
Standard 5I: Center/Service for Physical Rehabilita-
tion
Health Center promotes the concept of active participation
of disabled people and their families in identifying needs and
resources in rehabilitation develop a shared vision of their life
in society, the implementation of the vision and the moni-
toring and evaluation of implementation.
Criteria
5I.295 Within the health center there is a center for the re-
habilitation of disabled persons (CBR) with support groups
and self-help.
5I.296 center is managed by the appointed specialist in
physical medicine and rehabilitation.
5I.297 Depending on the systematization of jobs, the
Centre employed physiotherapy technicians, occupational
therapists, nurses, general direction.
5I.298 Physical therapists adhere to the Code Company
physiotherapists with permission to work in practice.
5I.299 specialist in physical medicine and rehabilitation
therapists are members professional organizations that pro-
vide guidance on continuing professional development.
5I.300 All employed sta in service has a documented plan
for ongoing personal professional development that includes
measurable goals for learning.
5I.301 There is evidence in writing of actions taken on the
permanent professional development that reflects the plan.
5I.302 There are dated, documented criteria for refer-
ring patients to physical therapy. The criteria are written/re-
viewed in the past three years.
5I.303 There are dated, documented procedures on
granting new cases to team members for physical therapy.
The procedure is written/rewritten in the past three years.
Instructions: Cases should be awarded according to the skills
and experience required for the indicated treatment, together
with the need for equitable distribution of the number of
cases.
5I.304 There are documented procedures on the regulation
of proper completion of the treatment of patients having im-
plemented the rehabilitation plan. The procedure is written/
rewritten in the past three years.
5I.305 estimated needs of the patient/user for the physical
treatment by physical examination which receives measurable
data for evaluation.
5I.306 Each patient was referred to physical therapy has an
individual rehabilitation plan for the implementation of phys-
ical therapy.
5I.307 Before each procedure/treatment is carried out risk
assessments. Note: This includes risk assessment, contraindi-
cations to treatment and precautions. Also, include the verifi-
cation of hazards such as wet floors, and the provision of suit-
able clothing and shoes worn by therapists and patients/users.
5I.308 rehabilitation program undertaken only after the
results of the risk assessment.
5I.309 risks associated with the use of electrical equipment
reduces the use of safety switches.
5I.310 Before using the apparatus and its application to a
patient, is made visual and physical verification of security
equipment.
5I.311 There is plenty of space and are available partitions/
curtains in the room/rooms for physiotherapy treatment that
patients provide visual privacy when using the equipment.
5I.312 equipment is kept in a place where not to interfere
with access to fire exits, entrances, hallways and other equip-
ment.
5I.313 Health Centre organizes regular meetings for
people with disabilities and their family members, performs
basic assessment of their needs and implements early educa-
tion and basic rehabilitation programs under the guidance of
an appropriate therapist.
5I.314 health center, or CBR, is developing a multi-sec-
toral cooperation and contracts with appropriate institutions
for labor and social policy, education, institutes Employment,
sports institutions, etc. Panel evidence-based clinical practice
guidelines on musculoskeletal rehabilitation interventions,
7. DISCUSSION AND RECCOMENDATIONS ON
THERAPEUTIC MODALITIES
Several studies have reported possitive or negative asso-
ciation between computer use and musculosceletal symp-
toms (24-26). The prevalence of Computer Carpal Syndrome
(CTS) among computer professionals based on clinical signs
Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
ACTA INFORM MED. 2014 OCT 22(5): 333-340 / PROFESSIONAL PAPER
339
and sympoms is approximately 13,1% and almost 1 out of
every computer professional suers from this condition. Very
few data published about this topic – studies about CTS prev-
alence based on clinical signs and symptoms, according to Ali
KM and Sathiyasekaran BWC, ranging from 3 to 6 %b only,
but we think real situation is much worse. Postural stress due
to inadeqauate workstation ergonomics (inappropriate lo-
cation of monitor, keyboard or mouse) discussed as cause of
all mentioned technological diseases in this text (Figure 7).
Aydan Oral et al. Had written paper about Evidence Based
Physical Medicine and Rehabilitation strategies for patients
with cervical radiculopathy due to disc herniation. They re-
ported that neck pain aected 4,82% of the world population
in 2010, ranks second after low back pain among musculo-
skeletal disorders as one of the leading causes of years lived
with disability, with contribution of 33,6 million years (26).
Physical medicine and rehabilitation interventions in radic-
ular neck pain and their evidence based are: a) educational
interventions; b) exercise; c) workplace interventions/ergo-
nomics; d) phyasical agents (TENS, therapeutic ultrasound,
low-level laser therapy) pulsed electromagnetic field therapy,
non-invasive brain stimulation techniques, etc); e) injection
therapy (epidural steroids, botulinum toxin, ozone); f) cer-
vical collars; g) traction; manual therapies (massage, manip-
ulation and mobilization (commonly used in the manage-
ment of discogenic neck pain); complementary and alterna-
tive medicine treatments (acupuncture, herbal medicine, etc.).
Much research eorts have been spent and several risk fac-
tors such as heavy lifting, lifestyle, psichosocial factors iden-
tified, but the etiology of technological diseases are still or
not enough unclear. Recurrences and functional limitations
can be minimized limitations with appropriate conservative
management, including medications, physical therapy, exer-
cise and patient education. But, these subgroup of developing
chronic and disabling symptoms generating large social costs
(26).
According to the Panel evidence-based clinical practice
guidelines on musculoskeletal rehabilitation interventions the
key points to clinicians are (23) (Table 1 and 2):
The Philadelphia Panel recommends continued normal ac-
tivities for acute, uncomplicated low back pain and thera-
peutic exercise for chronic, subacute, and postsurgical low
back pain.
The Philadelphia Panel also recommends transcutaneous
electrical nerve stimulation and
exercise for knee osteoarthritis.
For chronic neck pain, the Philadelphia Panel recommends
proprioceptive and thera-peutic exercise.
The Philadelphia Panel found evidence to sup-port the use
of therapeutic ultrasound in thetreatment of calcific ten-
donitis of the shoulder.
The main diculty in determining the eec-tiveness of re-
habilitation interventions is the lack of well-designed, pro-
spective, random-ized, controlled trials.
Acute neck pain is often associated with injury or accident,
whereas chronic neck pain is related to repetitive injury. Neck
pain is commonly managed with analgesics and rest, but re-
ferrals to rehabilitation are increasing. The Philadelphia Panel
sought to improve the appropriate use of rehabilitation inter-
ventions for neck pain by providing evidence-based guide-
lines. A summary of the Panel’s recommendations can be
found in Table 2.
Rehabilitation specialists oer several conservative inter-
ventions for the management of shoulder pain. There are few
published guidelines for the management of shoulder pain.
8. CONCLUSION
Thanks to the high use of computers, resulting diseases
of the modern era, known as the “Technological disease.”
Under this term we mean the diseases caused by the harmful
influence of the job in the first place, the working position in
which it is involved excessive work for a computer, such as
the banking sector, the health sector and many others who are
directly or indirectly connected with the work on the com-
puter and overuse keyboards and computer mice, which are
in a number of cases of non-ergonomic, and inappropriate for
a handful. Establishing the diagnosis of diseases of technology
is an interdisciplinary process that requires special knowledge
in medicine and related fields related to health and safety at
work. Determining the causes and diagnosis of occupational
diseases is carried out according to the criteria of modern
medicine work.
First, we identify the clinical picture of the disease on the
one hand and identification in the working process on the
other side, and their immediate connections. Medical his-
tory is the gold standard, because without it, it would be pos-
sible to find information on working conditions and the dura-
tion and intensity of exposure to a particular hazard from the
workplace. The intensity and length of exposure to harmful
factor must be that level that is known and proven scientific
Therapy Calcific tendinitis Capsulitis, bursitis, ten-
dinitis, nonspecific pain
Ultrasound A C
Exercise ID ID
TENS ID ID
Massage ID ID
Thermotherapy ID ID
EMG biofeedback ID ID
Electrical stimulation ID ID
Combined rehabilitation
modalities ID ID
Table 2. Summary grid of shoulder pain guidelines. *Adapted from the
Philadelphia Panel Members and Ottawa Methods Group.1A, benefit
demonstrated; C, no benefit demonstrated; EMG, electromyographic; ID,
insucient or no data; TENS, transcutaneous electrical nerve stimulation.
Therapy Acute Chronic
Exercise/neuro-muscular reeducation ID A
Traction C C
Ultrasound ID C
TENS ID ID
Massage ID ID
Thermotherapy ID ID
Electrical stimulation ID ID
EMG biofeedback ID ID
Combined rehabilitation interventions ID ID
Table 1. Summary grid of neck pain guidelines. *Adapted from the
Philadelphia Panel Members and Ottawa Methods Group.2. A, benefit
demonstrated; C, no benefit demonstrated; EMG, electromyographic; ID,
insucient or no data; TENS, transcutaneous electrical nerve stimulation
Occupational Overuse Syndrome (Technological Diseases): Carpal Tunnel Syndrome, a Mouse Shoulder, Cervical Pain Syndrome
PROFESSIONAL PAPER / ACTA INFORM MED. 2014 OCT 22(5): 333-340
340
research that can damage health. Prevention would involve,
educate employees by computers to ensure better and more
regular position of the spine and shoulder while working at
the computer, as well as the use of stylish ergonomic mice in
hand. Of course, adequate work breaks are required, in order
to avoid fatigue and exhaustion syndrome, but today it is dif-
ficult to appreciate the extent and speed of work. No less im-
portant and ecient are exercises to strengthen the shoulder
belt, as well as exercises for posture.
CONFLICT OF INT ERE ST: NONE DECLARED.
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CONFLICT OF INTEREST: NONE DECLARED Neck pain syndrome is described as: Pain in the neck affects at least once in a lifetime every second person, and also 10 % of adult population suffers from chronic pain in this area. It is more often among women. A constant increase of incidence in the industrialized countries is noticed. It is also the leading cause of referral to physical rehabilitation. It is causing huge financial costs in the health care system. There is no consensus regarding Neck pain syndrome management, but many therapeutic modalities are applied: a) to isolate (or manage) rare, but potentially dangerous states that can cause neck pain; b) identify and treat each co morbid state and risk factors; c) provide resources and information’s, especially about regarding use computers in dayly practice. Physical and manual treatments can be: a) physical therapy can assist to achieve early mobilization and return to daily activities; b) active physical therapy , mobilization, manipulation and exercises can assure short time relief of neck pain; c) home based exercises, as shown by this research, can significantly prolong the pain free period, in case of patients with the chronic syndrome; d) Medications, combined with the exercise program and ergonomic improvements can be effective solution for the chronic or recurrent neck pain. Intensive treatments in Neck pain syndrome are: a) Surgical and other intensive treatment (rarely indicated); b) invasive treatments includes and percutaneous radiofrequent neurotomy and cervical epidural analgesis.
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When neck pain is accompanied with radiating arm pain in addition to motor, sensory, or reflex changes resulting from nerve root compression or irritation, it is defined as cervical radiculopathy. The aim of this narrative review is to overview recent evidence regarding the effectiveness of physical medicine and rehabilitation strategies with a holistic approach in the management patients with cervical radiculopathy resulting from disc herniation and to provide evidence-based recommendations on the management. © 2014 by Turkish Society of Physical Medicine and Rehabilitation.
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Purpose: Carpal tunnel syndrome (CTS) refers to a cluster of signs and symptoms that stems from compression of the median nerve traveling through carpal tunnel. Surgery is a definite treatment for CTS; however, many conservative therapies have been proposed. The present study set out to assess the effect of vitamin B6 in patients with CTS. Methods: Forty patients (67 hands) with mild-moderate CTS were initially selected and randomly assigned into two groups as follows: 1) Case group with 20 subjects (32 affected hands) receiving vitamin B6 (120 mg/day for 3 months) and splinting. 2) Control group with 19 subjects (35 affected hands) only received splinting. One subject from the control group dispensed with continuing participation in the research. Daily symptoms and electrodiagnostic (NCV-EMG) results were assessed at baseline and after 3 months. Results: Nocturnal awakening frequency due to pain, daily pain, daily pain frequency, daily pain persistence, hand numbness, hand weakness, hand tingling, severity of nocturnal numbness and tingling, nocturnal awakening frequency owing to hand numbness and tingling, and clumsiness in handling objects improved significantly in the vitamin B6-treated patients; even so, only problem with opening a jam bottle and handling phone significantly reduced in the control group. The median nerve sensory latency mean decreased following the treatment; and the median nerve sensory amplitude mean and sensory conduction velocity mean increased. Conclusion: The present study suggests that vitamin B6 treatment improves clinical symptoms and sensory electrodiagnostic results in CTS patients, and thus is recommended for CTS treatment.
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