SCIENTIFIC REVIEW

Repetitive Movement on Shoulder and

Shoulder Disorders

dr. Agustiany, MKK

1806263760

LECTURER:
DR. dr. Astrid W. Sulistomo, MPH, Sp.Ok.
Dr. Suryo Wibowo, Sp.Ok.

FACULTY OF MEDICINE UNIVERSITY OF INDONESIA

OCCUPATIONAL MEDICINE EDUCATION PROGRAM
JAKARTA, NOVEMBER 2018
APPROVAL OF THE LECTURER

Lecturer : Dr.dr. Astrid Sulistomo, MPH, Sp.Ok

Department : Occupational Medicine Studies Department of Community Medicine

Title of the article : Shoulder Pain and Repetitive Movement on Shoulder

The paper has been completed and approved by the Lecturer

Jakarta, November 2018

Dr.dr. Astrid Sulistomo, MPH, SpOk

Lecturer
STATEMENT OF ORIGINALITY

I signed below by actually stated that the this paper was written without action of
plagiarism in accordance with the regulations at the Universitas Indonesia. If later on it turns
out I did the Act of plagiarism, I will be fully responsible for and ready to receive adequate
sanctions determined by Universitas Indonesia.

Jakarta, December 2018

Dr. Agustiany, MKK

 CHAPTER 1

INTRODUCTION

1.1 Background
According to population surveys, shoulder pain affects 18-26% of adults at any point in time,
making it one of the most common regional pain syndromes. Symptoms can be persistent and
disabling in terms of an individual’s ability to carry out daily activities both at home and in
the workplace [5,6]. There are also substantial economic costs involved, with increased
demands on health care, impaired work performance, substantial sickness absence, and early
retirement or job loss [7–10].

Shoulder pain is the result of a concerted action of many factors, including individual factors,
physical work load factors, and the psychosocial work environment. Several authors have
proposed multifactorial models to explain the aetiology of musculoskeletal problems, and
more specifically shoulder pain. Increased levels of muscle activity with few periods of low
activity (micropauses) during awkward and static postures, and during repetitive movements,
may result in shoulder pain. Psychosocial factors seem to be important in both the
development and maintenance of subacute and chronic problems.

A number of workplace physical exposures have been implicated in the causation or

exacerbation of shoulder disorders [56]. Important occupational exposures include: manual
handling (heavy lifting, pushing, pulling, holding, carrying [63,64]); working above shoulder
height [65]; repetitive work [66,67]; vibration; and working in awkward postures [46].
Interestingly, another review that explored risk factors for specific shoulder disorders and not
shoulder pain, reported similar work exposures as important: handling of loads frequently or
with high force, highly repetitive work, working in awkward postures and also high
psychosocial job demand.

Repetitive work is one of the causes of shoulder pain. Many studies have reported the strong
relationship between shoulder pain and repetitive movements (intech). Some studies mention
work that is at risk of being exposed to repetitive movements including farmers, dentists,
miners, carriers, iron foundry workers, heavy workers and civil servants (0026).
1.2. Problem Statement
Repetitive movements on shoulders are suspected of increasing the risk of shoulder disorders.
It is very important to review the association between repetitive movement on shoulder and
shoulder disorders based on the available evidences in order to diagnosed occupational
disease

1.3. Objective
The objectives of this scientific review is to give a better understanding about shoulder
disorders and to identify the association between the repetitive movement and shoulder
disorders.
 CHAPTER 2
LITERATURE REVIEW

2.1. Anatomy of the Shoulder

2.2. Shoulders Disorders

According to the multidisciplinary consensus on the terminology and classification of
complaints of the arm, neck and/or shoulder (CANS), complaints at the shoulder classified as
specific CANS were: subacromial impingement syndrome (SIS), tendinitis of the biceps
tendon, rotator cuff tears, bursitis around the shoulder are difficult to differentiate but can be
identified as a group. Scand J Work Environ Health 2010, vol 36, no 3.

2.2.1. Subacromial Impingement Syndrome (SIS)

SIS is the generic term for shoulder-area disorders that include rotator cuff syndrome,
bursitis, and tendinitis of the musculus infraspinatus, supraspinatus and subscapularis. SIS is
the most common disorder of the shoulder, accounting for 44–60% of all complaints of
shoulder pain during a physician office visit (7, 8). SIS is characterized by shoulder pain that
is aggravated by arm elevation and overhead activities (8, 9). In occupational settings, the
prevalence of rotator cuff tendinitis ranged from 1% among data entry operators to 69%
among industrial workers working above shoulder height (10). Pooling the OR of
occupational groups with work tasks at shoulder level results in an overall OR of 11 (95% CI
2.7–48) (10). Silverstein et al reported a claim incidence rate of 19.9 per 10 000 fulltime
equivalents per year for rotator cuff syndrome (3).

2.2.2. Tendinitis of Biceps Tendon

Tendinitis of the biceps tendon is an inflammation or irritation of the long head of the biceps
brachii, which results in pain and decreased force in the upper arm. In specific occupations, a
high prevalence of tendinitis of the biceps tendon has been reported [eg, 7.7% among fish-
processing workers, 9.0% among assembly-line packers, and 9.2% among female workers in
the laminate industry (11–13)]. Information on the occurrence of tendinitis of the biceps
tendon in the general working population remains scarce.

2.2.3. Rotator Cuff Tears

A tear in one of the rotator cuff muscles (musculus supraspinatus, infraspinatus, and
subscapularis or musculus teres minor) can be caused, for example, by a chronic irritation.
Tears of the rotator cuff tendons are one of the most common causes of pain and disability in
the upper extremity (14). However, no detailed information is available on the occurrence of
rotator cuff tears in working populations.

2.2.4. Suprascapular Nerve Compression

Suprascapular nerve compression is a relatively rare neuropathy and accounts for roughly 1–
2% of the total number of pathological conditions causing shoulder girdle pain and
dysfunction (15); however, a prevalence of 16.7% has been reported in newsreel cameramen
(16). The suprascapular nerve travels from the spine over the top of the scapulae to the back
of the scapulae. Entrapment of this nerve results in pain around the shoulder that radiates to
the upper arm. This disorder can be caused by direct injury, traction, and repetitive activities
leading to overuse of the upper limb (17).

2.3. Repetitive Movement

 CHAPTER 3
JOURNAL REVIEW

3.1 Methods
Search strategy and data abstraction. We searched PubMed and scopus to find all published
observational studies evaluating the relationship between repetitive movement on shoulder
and shoulder disorders using free the free text and Medical Subject Headings (MeSH) terms
“repetitive movement”, or “repetitive movement on shoulder” and “shouder disorders”.
Inclusion criteria of this searching is cross sectional, case control, cohort, systematic review,
and RCT. The searching period was from 26th of November till 10th of December.

Tabel 1. Searching strategy by using database from PubMed and Scopus

Database Searching Strategy Found Selected
PubMed (("repetitive movement"[Title/Abstract] OR 10 3
"repetitive movement on
shoulder"[Title/Abstract]) AND "shoulder
disorders"[Title/Abstract])
Scopus TITLE-ABS-KEY ( Metal Dust OR Metal 20 3
Fume AND Carcinoma OR Lung
Tumor ( LIMIT-
TO ( PUBYEAR , 2004 ) OR LIMIT-
TO ( PUBYEAR , 2003 ) OR LIMIT-
TO ( PUBYEAR , 2000 ) )

3.2 Critical Appraisal

From the selection anf filtration, five articles qualified for further assessment. these

articles were appraised and considered to have a good validity and relevance.

Tabel 1. Critical appraisal of the useful articles based on criteria by Oxford Centre for
Evidence-Based Medicine 2011

Levels of Evidence

Articles

Validity Relevance

Result

Level of

Evidence

Study Design
Numb er of

Patient

Randomization

Similarity

Treatment and

Control

Blinding

Comparable

Treatment

Intention to Treat

Domain

Determinant

Measurement of

outcome

Mateen FJ, et al + 2402 - - - - - + + + A 2A

Karakulak UN, et

al

+ 112 - - - - - + + + B 3B

Ameer SS, et al ? 225 + - ? - - + + + C 3B

Letta C, et al ? 114 - - ? - - + + + D 3B

Kuo CC, et al ? 237 - - - 3A

Note: + stated clearly in the article; - not being done; ? not stated clearly

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3.3 Journal Review

Journal I

Title : Chronic arsenic exposure and risk of carotid artery disease: The Strong

Heart Study
Author : Farrah J. Mateen, Maria Grau-Perez, Jonathan S. Pollak, Katherine A.

Moon, Barbara V. Howard, Jason G. Umans, Lyle G. Best, Kevin A.

Francesconi, Walter Groessler, Ciprian Crainiceanu, Eliseo Guallar,

Richard B. Devereux, Mary J. Roman, Ana Navas, Acien.

Publication : Departement of Environmental Health Services, Columbia University

Maiman School of Public Health, United States. Available online 26 May

2017.

Objective : To examine the prospective association of arsenic exposure with

carotid intima media thickness (CIMT) and atherosclerotic plaque in the

Strong Heart Study (SHS) cohort of American Indians from the

Southwestern and Central USA.

Method :

study population

The SHS study begun in the 1980s, targeted enrolment was 4549

participants, ages 45-74 years old, Thirteen tribes were included. Each

participant underwent a structured interview, physical examination

(1989-1992), anthropometric measurements, and collection of blood

and urine specimens.

For the present study, the follow up was until study visit three (1998-1999)

when 88% of all surviving cohort participants were re-examined, including

ultrasound measurements. Included 3974 participants with sufficient urine

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available for arsenic measurement. Excluded 1494 participants without

available carotid ultrasound data due to death. After further excluding 78

additional participants due to missing data on other covariates of interest, the

final sample size for this study was 2402. Participants in the SHS were followed

for vascular events, as defined previously, ending in 2008.

Arsenic measurements

Spot urine arsenic level was measured at the baseline study, from one urine

sample, they used as proxy for arsenic exposure and arsenic internal dose.

Urine was collected in polypropylene tubes, frozen within 1-2h, and

transported on dry ice to long term storage at -70°C. urinary concentrations of

inorganic arsenic (arsenite, arsenate), monomethylarsonate (MMA),

dimethylarseninate (DMA) and arsenobetaine and other arsenic cations were

measured using high-performance liquid chromatography inductively coupled

plasma-mass spectrometry.

Other risk factors

• Smoking (current, past, or never)

• Alcohol use (regularly, past)

• Body mass index (kg/m2)

• Hypertension (systolic blood pressure ³140 mmHg,

diastolic blood pressure ³ 90 mmHg, and/or the use of

antihypertensive medications to treat blood pressure)

• Diabetes (fasting glucose ³ 126mg/dL, post oral glucose

challenge glucose measurement of ³ 200 mg/dL, the use

17

of oral hypoglycemic medications or insulin to treat

diabetes and/or glycated hemoglobin ³ 6.5%)

• Serum high density lipoprotein (HDL), cholesterol and

triglycerides

• Plasma creatinine was measured by an alkaline-picrate

rate method.

Carotid ultrasonography

Imaging of the extracranial carotid arteries was performed using standardized

protocols with centralized training of field sonographers. Three vascular

measurement were assessed in this study:

1. The presence of atherosclerotic plaque in the common carotid artery,

which was defined as focal carotid arterial wall thickening >50% compared to

the thickness of the surrounding wall.

2. A carotid plaque score, which was calculated by the number of

segments containing plaque, combining left and right common carotid, carotid

bulb, and external and internal carotid arteries. Carotid palque scores ranged

from zero ( no plaque in any segment in either artery) to eight affected

segments.

3. Thickness of the far wall of the common carotid artery (CIMT), which

was measured at end-diastole using electronic calipers, on several cycles and

averaged. Wall thickness was not measured at the level of a plaque. Left and

right wall thicknesses were averaged and the mean thickness of the two (in

mm) was calculated.

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Result : 2402 participants (mean age 55.3 years, 63.1% female, mean body

mass index 31.0 kg/m2 , diabetes 45.7%, hypertension 34.2%) had a

median (interquintile range) urine arsenic concentration of 9.2 (5.00,

17.06) μg/g creatinine. The mean CIMT was 0.75 mm. 64.7% had

carotid artery plaque ( 3% with > 50% stenosis). In fully adjusted models

comparing participants in the 80th vs 20th percentile in arsenic

concentrations, the mean difference in CIMT was 0.01 ( 95% CI:

0.99,1.09), and the geometric mean ratio of plaque score was 1.05

(95% CI: 1.01, 1.09).

Conclusion : Urine arsenic was positively associated wit CIMT and increased plaque

score later in life although the association was small. The relationship
between urinary arsenic and the presence of plaque was not

statistically significant when adjusted for other risk factors. Arsenic

exposure may play a role in increasing the severity of carotid vascular

disease.