A different approach
Despite having workstation assessments for all employees, appropriate training, specialist referrals and copious amounts of physiotherapy, upper limb pain accounted for a significant proportion of sickness absence and permanent health insurance (PHI) claims. Some individuals could be absent from work for anything up to five years. Factors such as poor work quality and output, staff turnover, and problems with recruitment and compensation claims were also likely to be present.1
OH became embroiled in the whole claims procedure, where the aim was often to support a claim by gathering evidence from specialists; this reinforced the individual's belief in their inability to work. Individuals soon became deeply ingrained in the medical model, which reinforced the 'victim' mentality of 'I have been made ill by my work'. This placed OH in the unenviable position of neither satisfying worker or employer.
Traditionally, OH relied upon referral to GPs and specialists, usually rheumatologists, for a specific diagnosis, but these were often ambiguous labels such as 'RSI', fibromyalgia, work-related upper limb disorder (WRULD), tenosynovitis etc. Despite these labels, the treatment remained the same: rest, non-steroidal anti-inflammatory drugs, and occasionally, surgery (which in our experience carried a fairly poor success rate).
One of the reasons for this was to fulfil the criteria for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).2 However, the written guidelines and advice were ambiguous. According to Macfarlane, Hunt & Silman, the term 'RSI' should be avoided when diagnosing upper-limb pain as it can 'imply a single and uniform cause' and be misleading.3 There is also a lack of a widely agreed definition of RSI.4 Based on this information we, as a department, have chosen to use the term upper-limb pain to describe any presentation of pain in the upper limb(s), including referred symptoms from the cervical and thoracic spine, and have deliberately avoided pre-fixing the phrase with the term 'work-related', as this is almost impossible to prove - even by an experienced specialist. This also avoids 'victim' labelling, and subsequent detrimental behaviour.
The focus of employees' health and well-being appeared to have become obscured by the medicalisation, potentially litigious and political nature of the problem, with far-reaching effects on the individual, family and friends.
Evidence
Contrary to popular belief, there seems to be a lower incidence of upper-limb pain in the working population than the non-working population. It could be argued that employment can actually reduce the chances of acquiring upper-limb pain.5
Evidence suggests that musculoskeletal conditions in low-risk environments such as an office can also be caused by non-work exposure and individual factors, such as poor posture, an elevated body mass index, or a history of past back pain.6 Genetic predisposing factors - hypermobility syndrome, for example - can be exacerbated by poor postural habits, insufficient recovery time between activities, excessive force and frequent repetitive movements without a break, both in the workplace and the home.
The most common symptoms include aches, pains and movement difficulties. Typical conditions include tennis elbow, golfers elbow, frozen shoulder, trigger finger, arthritis, de Quervain's tenosynovitis and carpal tunnel syndrome.
According to recent articles, psychosocial factors can account for as much as 70 per cent of perceived MSDs. Factors such as the level of support from colleagues/ managers and the degree of control an employee has over their work have been found to influence the onset of upper-limb pain. Increased risks were associated with high levels of psychosocial distress.
One example of the complex psychosocial phenomenon was Australia's 'RSI epidemic' in the 1980s. Reported cases in New South Wales alone grew from less than 1,000 in 1981 to 7,000 by 1985, followed by a decline, whereby 'the injury theory of RSI could not account for the epidemiology of the disorder'.7
Another interesting piece of research was the recovery rates of whiplash due to personal error, or whiplash due to a third party. It was found that after a six-week period, the recovery rate for those who sustained injuries as a result of personal error was 46 per cent, compared with just 6 per cent for those who perceived that they were 'victims' of an accident.
Based on the above evidence, the Hanasaari conceptual model for OH and subjective observation, a new management process was formulated.
New management approach
The focus was shifted from whether upper limb pain was 'work-related' to how to improve the health and well being of individuals with these problems. The aims were to:
- Ensure early referral to occupational health and safety (OH&S) departments
- Contain the problem - using internal support structures rather than spreading the problem outside where the firm has little or no control
- Improve awareness of the root cause, with education and effective self-management in a supportive environment
- Empower the individual to take ownership of their problem
- Improve communication between OH&S, HR, manager, employee and GP (where appropriate)
- Stop fear-avoidance behaviour, 'victim' perception and mental detachment from their symptoms.
Implementation
This process was fairly straightforward to implement because we actually had the necessary skills under one roof. We needed to improve communication and liaison between OH and the risk assessors (RAs). OH, the RAs and our physiotherapist agreed upon a protocol which sped up the process from reporting to intervention, and avoided any unnecessary GP/ specialist referrals outside of the firm.
OH decided that every symptomatic employee would attend the posture course as a first line of physiotherapy intervention, rather than going down the route of 'hands-on' passive therapy. All risk assessors attended this course to gain insight into the process, and to enable them to differentiate between an ergonomic and a postural cause.
If the employee reported mild symptoms specifically related to poor ergonomics, the RAs would implement change and review things a week later. If the issue had been resolved, no further action was needed. If symptoms were persistent and moderate to severe - for example, tingling, swelling, spasms, continuous pain, headaches and/or dizziness - the RA would refer to OH immediately for assessment.
OH would assess the employee and advise them and their line manager on any necessary and reasonable adjustments to their workplace, hours, and job content. They would also be advised of any immediate self-treatment, including anti-inflammatories, ice-packs, and rest. If the symptoms were inconsistent with a mechanical musculoskeletal condition, the employee would be referred to their GP or appropriate specialist.
For all other mechanical musculoskeletal presentations, staff were referred to the in-house postural re-education workshop, where the physiotherapist would make an assessment and relay the outcome to OH. Further specialist referral is available if needed.
The flowcharts compare the old system with the new one (see above and flow chart on page 20):
Posture re-education course
Our physiotherapist specialises in the re-education of posture and habitual poor patterns of movement and behaviour. She has a background in using the principles of the Alexander Technique to educate and treat clients, alongside the science of physiotherapy. This skill mix enabled the issues of behavioural and physical patterns of misuse to be treated side-by-side. It was noted that individuals with upper limb pain typically had the following symptoms:
- Detachment and disassociation of the pain from the rest of their body
- Over-protection of the 'injured' limb, rather like a wounded animal
- Perception of irreversible degenerative disease, reinforced by the medical model ('crumbling spine syndrome').
These behavioural patterns appeared to be founded by fear due to lack of knowledge, understanding and control.
In relation to personality types, they tended to be either driven characters, speed-walking their way through life both at work and at home, or personalities who suppress their feelings; but both types seemed unable to 'let go', physically or mentally.
The Posture Re-education Workshop was devised with the intention of keeping rehabilitation in-house. Historically, outside referral appeared to have spread the problem, leading to breakdowns in communication. The advantages of the in-house workshop were that the physiotherapist and the OH&S departments work very closely together with mutual respect, and an understanding of the organisational culture.
The course is goal-orientated and run over a number of weeks. Individuals are made aware of how poor patterns of posture, movement and behaviour have negative impacts on the body and mind. With a little motivation, they can acquire the necessary skills to improve this in functional settings both at work and at home. It is our first and preferred method of medical intervention.
Group dynamics are important and operate well, with individuals feeling supported and empowered. Some employees (especially those seconded from overseas) can feel isolated, but this is also an excellent opportunity for them to feel involved and to make friends.
The scheme has been successful because it is a holistic approach to a multi-faceted problem, and one which is functional and relevant. By giving individuals the choice to behave differently, they take ownership of their well-being.
Where necessary, further one-to-one treatment is offered with the physiotherapist, and specialist referrals are available where necessary - but this has been in the vast minority. Psychosocial problems are also addressed, and where necessary workers are referred to the employee assistance line.
Results one year on
- No private or NHS GP referrals for upper-limb pain
- In 2002, 85 upper limb pain cases were seen (an average of seven a month). The new management structure was applied to 100 per cent of upper-limb pain cases; 94 per cent were successfully managed. The remaining 6 per cent were referred to our insurers, which had all been managed under the old method
- The highest percentage of upper limb pain cases were found among legal support secretaries (38 per cent), lawyers (22 per cent), and support staff (14 per cent). Of the secretaries and lawyers, the majority of cases reported were in the 25-29-year-old age bracket. Of the support staff, most were aged between 40 to 44. A very small percentage were aged 45 to 64. This is contrary to what you would expect for physiological 'wear and tear' symptoms, and this could highlight the importance of the psychosocial factors.
Conclusion
Our approach is a holistic one, which encompasses psycho-social issues. Emphasis on past cases has been purely on ergonomics, which reinforces the myth that work is to blame for the problem.Staff are empowered with the right focus on education and self-management, allowing them to take control. Change in behaviour both at work and at home is also the key. Our attitude, as is the case with stress management, is that musculoskeletal pain will affect a person at work, whatever the cause. And therefore they will need to be supported and adjustments will have to be made.
By avoiding unhelpful and potentially damaging labelling, we have prevented a complex but manageable condition from becoming disabling. The majority of cases need not be medicalised, as we know that the treatment is often unsuccessful in the long-term.
It appears that we have successfully managed reported cases of upper-limb pain by adopting the new management process. We appear to be spending less on manual therapy, specialist referrals and time away from work for appointments and sickness absence. Interestingly, our permanent health insurance premiums are also reducing significantly. In addition, there has been a marked improvement in communication and relationships between staff, their manager, HR and OH&S.
There has also been a change in the blame culture, with individuals now asking what they can do to help themselves. The shift is in managing an acute, rather than a chronic condition, which carries a better prognosis.
Rather than being seen as an employer who could potentially exacerbate or cause musculoskeletal problems, our ultimate goal is to promote ourselves as an employer that has strategies in place to improve our employees' health.
1.
Work-related ULD - guide to prevention,
2. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, HSE 1995
3. RSI is an overused misnomer, OH Review, Nov/Dec 2000, p12
4. Psychosocial risks increase physical burden, OH Review, May/June 2002
5. Work-related upper limb disorders: diagnosis and treatment options' Repetitive Strain Injury practical workplace management conference - Burke, F, 2002, Butterworths Tolley in association with OH Review.
6. A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back, DHHS (NIOSH) Publication, 1997, No.97-141
7.
http://members.ozemail.com.au/~lucire/
