EXERCISE FOR OPTIMIZATION OF WORK PERFORMANCE AND OCCUPATIONAL REHABILITATION

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EXERCISE FOR OPTIMIZATION OF WORK PERFORMANCE
AND OCCUPATIONAL REHABILITATION
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WORK DEMANDS
Physical Task Demands
Work Content
Mental Task Demands
Required Qualification Processor
Physical Environment Demands
Work Context
Non-physical Environment Demands
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Work Demands
Workers Qualification
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Seating Standing Walking Kneeling Squatting One-le
gged Crouching Crawling Climbing Others
Extremity postural Demands
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Repetitive work
Body segment Force and Posture
Static work
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Seating Standing Walking Kneeling Squatting One-le
gged Crouching Crawling Climbing Others
Dynamic work
Extremity postural Demands
Static
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Aerobic
Energy System
Anaerobic
Circulatory Function
Cardiorespiratory System
Heart Function
Respiratory Function
ROM
Physical Fitness
Flexibility
Joint
Tissue
Muscular
Neuromuscular System
Neural
Fat Mass
Body Composition
Fat-free Mass
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Biomechanical Physiological Psychological

• Stress Strain

Disorders
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TISSUE RESPONSES TO PHYSICAL STRESSORS
Load
Response
Symptoms
Adaptation
Impairment
Disability
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TYPICAL PHYSICAL WORK DEMANDS OF TEACHER

• Standing

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WORK RISK FACTORS OF PROLONGED STANDING

• Circulation
• Muscle fatigue
• Joint compression

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• Develop and improve
• Strength
• Endurance
• Cardiovascular fitness
• Mobility
• Flexibility
• Stability
• Co-ordination, balance and functional skills

Work Demands
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LOW BACK DISORDERS AS AN EXAMPLE FOR PHYSICAL
ACTIVITIES
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Introduction

• Low back pain is the most common work-related
  msuculoskeletal disorders, and cause most
  socio-economical burden.
• LBP claims account for 16 of all workers
  compensation claims and 33 of total claims costs
  (Bernard et al., 1997)

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Definition

• Prevalence
• percentage of people in a certain population who
  suffer from the condition concerned
• Point Prevalence
• percentage who are found to be suffering at a
  certain moment in time ( i.e. when the survey is
  conducted)

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LBP Prevalence

• About 70 of people will suffer from one or more
  episodes of LBP at some time or another during
  their lives
• Bernard 1997

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PREVALENCE OF LOW BACK DISORDERS

• Local
• 39 in general population (Lau et al., 1995)
• 58 in a group of manual handling workers

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LBP Natural History

• Most episodes of LBP are relatively short-lived
  (subsided within 6 weeks).
• Recurrent rate is very high (60)
• Biering-Sroenson 1983

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Sickness Absence

• 6 months absence likelihood of returning to
  work fall to about 50
• After 1 year absence 25
• After 2 years absence virtually nil

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Work-Related Risk Factors

• Physical Factors
• Heavy physical work
• Lifting and forceful movements
• Bending and twisting
• Whole body vibration
• Static work postures
• Non-physical factors
• Psychosocial factors
• Bernard 1997

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EFFECTS OF PHYSICAL ACTIVITIES IN THE PREVENTION
OF LBP

• Strong evidence that PA has a primary preventive
  effect on LBP

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EFFECTS OF PA IN SECONDARY PREVENTION (Van Tulder
et al., 2000)

• Acute LBP - strong evidence that exercise therapy
  is NOT more effective than inactive treatments or
  other active treatments.
• Low stress aerobic activity during the first 2
  weeks is indicative to improve recovery and
  lessen disability.

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• Chronic LBP strong evidence that exercise
  therapy and conventional physiotherapy are
  equally effective and exercise therapy is more
  effective than usual care by GP
• Strong evidence that strengthening exercises are
  more effective than other types of exercise.
• Strong evidence that exercise diminishes the
  musculoskeletal and cardiorespiratory effects

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TYPES OF EXERCISE AND TRAINING PRINCIPLES

• FITT
• TYPES STRENGTHENING
• STABILIZER
• ENDURANCE
• STRENGTH
• TYPES MOBILIZING

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EXERCISE TO IMPROVE LIFTING CAPACITIES
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RATIONALE

• Relationship between the probability of injury
  and percentage of strength capacity used by the
  worker at work. (Chaffin 1973)
• Relationship between the incidence of firefighter
  back injuries and level of physical fitness. 7.1
  least fit, 3.2 moderate, 0.8 most fit (Candy et
  al., 1979)

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EFFECTS OF A FOUR-WEEK MUSCLE STRENGTHENING
PROGRAM ON MAXIMUM ACCEPTABLE LIFTING LOAD

• Yeung SS. et al., 1998

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METHOD

• Subjects university students (N19)
• Isokinetic measurements of back extensors, knee
  extensors, shoulder abductors, and elb. Flexors.
• Maximal acceptable lifting load (psychophysical
  approach)

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TRAINING PROTOCOL

• 4 WEEKS OF TRAINING
• LOAD 80 PEAK TORQUE
• WEEKLY ADJUSTMENT BY 5

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RESULTS

• Significant training effect on MALL and back
  extensors

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EFFECTS OF SQUAT LIFT TRAINING AND FREE WEIGHT
MUSCLE TRAINING ON MAXIMUM LIFTING LOAD AND
ISOKINETIC PEAK TORQUE OF YOUNG ADULTSWITHOUT
IMPAIRMENTS

• Yeung SS., Ng GYF 2000

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METHOD

• 36 University Students
• Training approach
• 1. free weight muscle strengthening program
• 2. Task specific training programme and
• 3. Control

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RESULTS

• Significant improvement in MALL and back
  extensors
• No significant differences between the training
  protocol

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LOW BACK EXERCISES FOR LOW BACK DISORDERS

• McGill 1998

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OBJECTIVES

• To stress both damaged tissue and healthy tissues
  for tissue repair but avoid excessive loading
• Exercises that challenge muscle but impose
  minimal joint loads

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EXERCISE PRINCIPLES

• Frequency most beneficial when performed daily
• No pain No gain ?
• General conditioning exercise is important
• Endurance more protective value than strength
• Flexibility (mobilizing) should best be performed
  at unloaded position
• No fixed recipes, exercise should be tailored made

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BACK EXTENSORS
1 leg ext 1 leg/arm prone ½ supp
RA 3.3 4.0 4.7 3.1
EO 8.4 16.2 4.3 3.7
IO 12.0 15.6 12.1 12.7
LD 8.1 12.0 11.2 6.5
TES 5.7 11.5 66.1 45.4
LES 19.7 28.4 59.2 57.8
MF 21.9 31.5 51.9 47.5
Compression 2.3 3.2 4.3 4.3
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BACK EXTENSOR EXERCISE

• Pr lying arch back
• ½ support back extension
• Single leg extension with hand and knee support

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ABDOMINAL EXERCISES
ex QL PS EO IO TA RA RF ES
Sit-up (st) 24 44 15 11 48 16 4
Sit-up (kn bent) 12 28 43 16 10 55 14 6
Curl up (kn) 11 10 19 14 12 62 8 6
SLR 9 33 26 9 6 37 23 7
Side support 54 12 43 36 39 22 11 24
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ABDOMINAL EXERCISE

• No single abdominal exercise challenges all of
  the abdominal musculature
• Curl-up challenges mainly RA
• Sit-ups (leg straight or knee bent) high psoas
  activation and disc compression
• Leg raises causes even higher activation and
  compression
• Isometric side support for QL

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OCCUPATIONAL REHABILITATION

• To facilitate a return to work or ensure an
  employee remains at work, ideally in his or her
  original job
• Different terminologywork, industrial,
  vocational rehabilitation

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DISABILITY MANAGEMENT
Injury
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FUNCTIONAL CAPACITY EVALUATION

• Functional Meaningful, useful and
  purposeful
• Capacity maximum ability and capability
• Evaluation Systematic approach including
  observation, measurement, reasoning and
  conclusion

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FUNCTIONAL CAPACITY EVALUATION

• Systematic, comprehensive approach
• Objective and valid measurements to predict a
  persons ability to perform work related tasks.

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FUNCTIONAL CAPACITY EVALUATION

• Generic - Baseline Capacity Evaluation
• Usually based on physical demands of DOT
• Job oriented Job capacity Evaluation
• Focus on the match of the workers ability to the
  work demands of specific job
• Worker oriented Work capacity Evaluation
• Determine workers capabilities to the basic
  demands of earning occupation

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APPLICATION

• Ensure workers health and safety in job
  placement (OSHA)
• Identify an individuals physical abilities and
  limitations (ADA)
• Determine an injured worker wage-earning
  potential and return to work abilities (Insurance
  company and legal profession)

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EVALUATION SYSTEM COMMONLY USED IN HONG KONG
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FCEs

• ARCON
• BLANKENSHIPS
• TRACKER
• BTE
• ERIC
• MVE Battery Tests
• Non-computerized system

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TYPICAL COMPONENTS OF FCES

• Interview patient information
• Job analysis (questionnaire)
• Behavioural profile
• Physical measures/muscuoskeletal evaluation
• Physiological measures
• Functional measures
• Comparison of testing with job requirements

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FUNCTIONAL MEASURES

• Isometric strength test (6 positions)
• Material handling test (3 positions)
• Frequency of manual handling Occasional (0-33),
  frequent (34-66), and constant (67-100) manual
  handling
• Hand function hand and pinch grip
• Fine hand dexterity
• Non-materials handling test
• Positional tolerance test

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ISOMETRIC STRENGTH TEST

• Arm Lift
• Torso Lift
• Leg Lift
• High Far Lift
• Floor Lift
• High Near Lift

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OCCASIONAL MATERIAL HANDLING TESTS

• 0-33 of the working day, lt32 repetitions
• Psychophysical approach
• Floor to knuckle
• Shoulder lift
• Overhead lift
• Carrying - 30 ft.
• Pushing/Pulling - 30 ft.

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FREQUENT MATERIAL HANDLING TESTS

• 33-66 of working day or 32-200 repetition per
  day.
• 4 lifts in 20 seconds

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HAND TESTS

• Maximum Grip Strength Test - Jamar
• 5-position Grip Test
• Rapid Exchange Grip Test

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NON MATERIAL HANDLING ACTIVITIES

• Sitting
• Standing
• Walking
• Bending
• Reaching
• Squatting
• Kneeling

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NON MATERIAL HANDLING ACTIVITIES

• Crawling
• Climbing
• Balancing
• Arm Controls / Leg Controls

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ARCON SYSTEM
Blankenship Valpar Jmed
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ACRON

• Interview
• Physical measures/muscuoskeletal evaluation
• Physiological measures
• Functional measures
• Comparison of testing with job requirements

• Standardized format
• Hand Strength Testing System
• Pinch Strength Testing System
• Electronic Goniometer
• Lifting platform
• Methods-Time Measurement

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OCCUPATIONAL REHABILITATION

• Initial Occupational Assessment
• Functional assessment
• Advice or assistance in vocational re-education
• Advice or assistance in job-seeking
• Work Conditioning

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OCCUPATIONAL REHABILITATION

• Occupational Rehabilitation Counselling
• Functional Education
• Workplace Analysis
• Vocational Assessment
• Vocational Re-education

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TEAM APPROACH

• Injured worker (workers family)
• Physician
• Therapist
• Psychologist
• Vocational specialist
• Ergonomist

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RETURN TO WORK

• How much can this injured work perform?
• Suitability of job
• job demand
• restrictions / limitation
• how to imposed

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RETURN TO WORK PROGRAM

• Initial Occupational Rehabilitation Assessment
• Functional Assessment
• Vocational Re-education
• Assistance in Job seeking
• Working Conditioning

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Seating Standing Walking Kneeling Squatting One-le
gged Crouching Crawling Climbing Others
Dynamic work
Extremity postural Demands
Static
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WORK CONDITIONING AND HARDENING

• A structured, goal-oriented, individualised
  program
• To improve the biomechanical, neuromuscular,
  cardiovascular/metabolic, behaviour and
  vocational function
• Education of injury prevention
• Work-risk identification

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WORK CONDITIONING

• Training should be based on job requirement (job
  analysis) and work functional limitation (FCE)

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Typical work conditioning program

• Warm-up and stretching exercise
• Cardiovascular training ergometer, treadmill,
  stair-stepper
• Lumber stabilization training therapeutic balls
• Strength endurance training circuit training
  (multi-gym), dead wt, isokinetic training)
• Balance BAPS, therapeutic balls
• Functional activities MMH
• Work simulation activities
• Dexterity training hand or upper limbs injury
  (e.g. Perdue peg board, Valpar)
• Education pain management

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WORK HARDENING

• Interdisciplinary
• use real or simulated work activities in a
  relevant work environment and conditioning tasks.
• Address patients physical, behavioural and
  vocational needs
• Daily sessions 4-8 hrs/day

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Difference between work conditioning and health
related conditioning

• Exercise prescription based on job requirement
  and FCE (job goal oriented)
• Identifiable outcome measure (work nature that
  can be performed)
• Multiple components involves education components
  related to work

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Seating Standing Walking Kneeling Squatting One-le
gged Crouching Crawling Climbing Others
Dynamic work
Extremity postural Demands
Static
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WORK CONDITIONING AND HARDENING

• Potential client
• Chronic injured worker
• Poor physical conditioning
• Compromised cardiovascular status
• Pain on activities
• Psychosocial dysfunction

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Conditioning
Work conditioning
Work Hardening
Strength Endurance Cardiovascular
fitness Flexibility Mobility Stability Co-ordinati
on
Job simulation Education Training
Vocational Rehabilitation Psychosocial
Rehabilitation
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REFERENCES

• Key GL. (1995) Industrial Therapy, Mosby-
  YearBook Inc., Chapter 14-15, 21.
• Isernhagen JS. (1997) Industrial Physical Therapy
  In Orthopaedic and Sports Physical therapy. Ed.
  Malone TR, McPoil T. Nitz AJ. 3rd edition,
  Mosby.
• Yeung, S.S., Chan, M.C., Leung, D.C., Ma, M.S.,
  Tsang, S.Y., 1998, The effects of a four-week
  muscle strengthening program on maximum
  acceptable lifting load, Journal of Occupational
  Rehabilitation, 8(4) 265-272.
• Yeung, S.S., Ng, G.Y.F., 2000 Effects of
  Functional Lifting Training and Free Weight
  Muscle Training on Maximum Acceptable Lifting
  Load and Isokinetic Peak Torque of Normal Young
  Adults. Physical Therapy, 80570-577.

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• McGill SM. 1998, Low back Exercise Evidence for
  improving exercise regimens. Physical therapy 78
  754-765.