Tackling work-related upper-limb disorders
Chris Dyer reviews new HSE advice on the prevention and management of upper-limb disorders.
Musculoskeletal disorders are the most common work-related ailment afflicting the population in Britain, accounting for more than half of all self-reported occupational ill health. A 1995 household survey estimated that 44% of this group - approximately 506,000 cases - were suffering from "upper-limb disorders" (ULDs). The HSE estimates that work-related ULDs caused the loss of 4.2 million working days that year, with each employee affected taking an average of 13 days off work, at an overall cost to employers of at least £200 million.
The HSE defines "upper limbs" as the part of the body, from the tips of the fingers to the shoulder, extending into the neck and including the tissues involved, the soft tissues, muscles, tendons and ligaments, the bony structures, skin, circulatory and nerve supply to the limb. "Disorder" refers to the clinical effects produced by underlying changes in the tissues. These include symptoms, such as pain, and signs of abnormalities. Clinical effects are accompanied by functional changes, such as a reduction in use of the affected part of the limb and an associated restriction in speed or movement. Clinical and functional effects are confined to the limb itself, but their presence often makes the sufferer feel less healthy in general, leading to a reduction in the quality of their life. The phrase "repetitive strain injury" is sometimes used to describe the same conditions, but is misleading because of the many factors that can contribute to the onset of the conditions.
Management cycle
As part of its strategy to cut the incidence of work-related ULDs, the HSE has revised its 10-year-old guidance on their prevention and management.1 The guidance uses a framework for managing ULDs that is based on a seven-stage management cycle:
understand the issues and commit to action;
create the right organisational environment;
assess the risks of ULDs in the workplace;
reduce the risk of ULDs;
educate and inform the workforce;
manage any episodes of ULDs; and
carry out regular checks on programme effectiveness.
Each stage of the framework (see box below) is considered in a separate section of the guidance. There are four appendices that:
provide real-life examples where the risks of ULDs have been managed;
offer practical advice on risk assessment, a risk assessment filter and worksheets and suggestions for reducing the risk;
give background information on medical aspects of ULDs; and
set out the legal duties on the prevention of ULDs.
Risk factors
ULDs are not confined to any one particular group of workers or industrial activity and are widespread in the workforce. High levels of arm pain have been reported, however, in some jobs that share recognised risk factors (see box below). These risk factors are task-related, environment-related and worker-related.
Task-related factors include:
repetition, where the same muscle groups are used over and over again during the working day, or frequent movements are performed for a long period;
working postures that are awkward or static;
force, which if excessive can lead to fatigue and, if sustained, to injury. The need to grip raw materials, product or tools is particularly significant; and
duration of exposure - many types of ULD are cumulative in nature, with the risk of injury decreasing with duration time.
Environment-related factors include:
vibration, particularly resulting from hand-held or guided power tools or the need to hold the item being worked when using fixed equipment;
cold, which decreases blood-flow, dexterity, sensation and maximum grip strength, as well as increasing muscle activity;
lighting, since workers' posture can be largely dictated by what they need to see; and
psychosocial factors, such as the design, organisation and management of work.
Worker-related factors arise from the fact that all individuals are different and that there may be some people who are more, and some less, likely to develop a ULD.
Adopting an ergonomic approach should ensure that tasks are within the capabilities of the entire workforce. Ergonomics is concerned with ensuring work is designed to take account of people, their capabilities and limitations.
Risk assessment and management
Employers can use two approaches to identify ULD problems in the workforce, by seeking signs of problems and symptoms, or by examining the work tasks themselves to see if risk factors for ULDs are present.
A detailed assessment of every job could be a major undertaking and might be an unnecessary effort. To help identify situations where a detailed assessment is necessary, the HSE has devised, and included in the guidance, a filter to screen tasks. Where the filter identifies several risk factors in combination, the risk of ULDs is likely to be greater. (The TUC has recently urged union safety representatives to use the filter in their workplace.)
Once an employer has identified tasks that create a risk of ULDs, it should conduct a more detailed risk assessment, involving managers and workers, in order to ascertain the likelihood and severity of risk. Where it identifies risks, it should adopt a hierarchical approach to reduction, with priority given to eliminating risks at source. Worker participation is particularly important here.
Adequate control of risk factors will go a long way to prevent the occurrence of ULDs. But individual differences in the body's response to stresses mean it is not possible to prevent all ULDs. Employers therefore need a system to manage any reports or cases of ULDs, and to maintain a climate that encourages early reporting. Where symptoms are such that continuing work does not make them worse, it may be enough to provide the worker with reassurance, advice on risk factors and to review the individual's work tasks with them. Where continuing to work exacerbates the symptoms, further advice should be sought from a health professional. Access to an occupational health service will allow the worker and the manager to obtain appropriate advice with minimal delay.
Confirmation of a ULD case should prompt consideration of the adequacy of existing risk assessments and controls. Where individuals have to take time off work, the exact timing of any return will depend on medical advice. It is often possible for an individual to return to work before symptoms have been cleared up - in some cases, this may be advantageous.
Targets
The HSC's strategy for reducing musculoskeletal disorders, including ULDs, adopts the principles set out in Securing health together: a long-term occupational health strategy for England and Wales (Healthy at work, healthy for life: HSC/E goes holistic), which is an integral part of the Government's Revitalising health and safety initiative (Employers face major health and safety at work shake-up).
Musculoskeletal disorders, including ULDs, are one of eight priority areas where most improvement is needed to enable the targets for occupational health and safety to be met: the HSC has set a target to cut musculoskeletal disorders by 20% and to reduce working days lost by 30% by 2010. The priority programme aims to improve compliance with the law, to promote continuous improvement, and to develop the necessary knowledge, skills and support systems to achieve the MSD targets. The new guidance forms one strand of the support for employers, employees and those who advise them. It should ensure that they have the right information and advice to prevent and manage ULDs in the workplace.
1"Upper-limb disorders in the workplace", HSG60 (rev), HSE Books, ISBN 0 7176 1978 8, £9.50.
