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New Approaches to Musculoskeletal Health at Work

Wendy Chalmers Mill and Liz Simpson explain
November 2004

Organisations which run on lean staffing levels cannot afford long-term injury or ill health. Yet musculoskeletal ill health remains a major financial drain on industry and we are a long way from eliminating this problem. It is becoming apparent that diffuse upper limb disorders in particular represent a more complex problem than first thought, involving both physical and psycho-social factors.

One difficulty in rehabilitating these injuries is that most individuals do not present for treatment until they are no longer able to work and the problem has become chronic. This article discusses the benefits of introducing a corporate health culture which encourages open reporting and adopts a strategy for the proactive management of musculoskeletal injuries, looking at diffuse upper limb disorders in particular.

Managing musculoskeletal ill health

Recent health and safety legislation has required a more proactive approach involving the analysis of risk in the workplace and staff training, a process which will raise awareness of musculoskeletal ill health. This is the ideal time for organisations to introduce policies, which encourage early reporting of injuries and rehabilitation procedures.

For the last three years, Interact Consulting has been running health surveys in organisations. Our data suggests that between 70 and 80 per cent of staff working on computers are experiencing some form of musculoskeletal discomfort. These symptoms may not necessarily result in absenteeism, but will obviously affect staff motivation and performance. They may also be the precursor to ill health and injury.

Conflicting information

The incidence of work-related upper limb disorders can cover a wide range of conditions, which are often poorly understood. This may be due to inaccurate medical diagnosis and conflicting information from both the media and medical specialists. For the purpose of this article, we have divided upper limb disorders into two groups:

1. local soft tissue lesions; and
2. diffuse pain syndromes

Local soft tissue lesions

The disorders which fall into this category are recognised and have accurate diagnostic criteria, e.g., tendonitis, carpal tunnel syndrome. Treatment of these conditions is generally well understood and widely available. All these conditions respond well to treatment in the early stages but can become chronic if ignored.

Diffuse pain syndromes

This group of disorders has been the subject of much controversy. A large percentage of upper limb disorder cases present with pain as the major symptom. Often, the absence of any defining pathology has presented problems for medical and legal professionals when dealing with these cases.

It should be recognised that in many cases of lower back pain, there is often little clear pathology and pain is the main factor. However, back pain is more readily accepted as a legitimate condition. It is therefore helpful to look to research and clinical knowledge regarding occupational low back pain to gain insight into improved management of diffuse upper limb pain conditions.

Currently, diffuse upper limb disorders tend to be the most ineffectively managed group of injuries and often the most costly to organisations. There is also evidence to suggest that diffuse pain syndrome is more common than localised soft tissue lesions amongst individuals working on computers.

Data collected from The Body Garage, Interact Consulting's occupational injuries treatment centre, looked at a sample of 160 individuals involved in computer work, presenting for treatment of upper limb disorders. Over half of the sample (53 per cent) reported diffuse upper limb pain.

Chronic Pain

The most common type of musculoskeletal injury we are seeing in relation to working with computers involves diffuse pattern of pain in the upper limb, which is often bilateral. Pain may spread throughout the arm or move from one area to another. The level of pain can vary, according to physical activity or emotional mood. Once individuals have developed diffuse work-related upper limb pains, there also appears to be a strong tendency for the pain to become chronic.

A change in health culture

Let us begin by looking at the well-established risk factors associated with diffuse upper limb pain in the modern office. Risk factors are physical with regard to environment, equipment or furniture and work task. The importance of good work position with equipment appropriate to the task has been well documented in terms of minimising static muscle loading, repetition and awkward postures.

In addition, new research suggests that psycho-social factors - the stress element - also play an important role. For the purpose of this article, we have taken the definition of psycho-social factors to be the non-physical aspects of the job.

Psycho-social factors - the stress element

There is no dispute that stress and anxiety increase the risk of injury. However, the exact mechanism behind this is as yet unknown. Previously, the link between these psycho-social factors and musculoskeletal disorders was thought to be due to the increased muscle tension associated with stress. However, it now appears that the relationship is a more complex interaction between: musculoskeletal (muscle tension), chemical (adrenaline), behavioural (motivation) and psychological (perception) factors.

Perception of the injury

Recent research from TNO Institute of Preventative Health Care in the Netherlands has called attention to the cognitive process, which occurs in an individual between a mechanical overload and a musculoskeletal injury. This cognitive process relates to the detection of symptoms, their attribution, labelling and the perception of the injury.

It is thought that the cognitive processing of information regarding symptoms could mean the difference between the individual experiencing a transient ache and a chronic pain condition.

Cycle of pain and anxiety

The occurrence of work-related arm pain is itself a source of stress, which will affect all of the above processes. If we examine some of the common perceptions of work-related upper limb symptoms, it is easy to see why some people become caught in a cycle of pain and anxiety - 'I will be unable to do my job.' 'I could be permanently disabled.' 'I will experience severe pain.' 'There is no treatment available.'

It is therefore important to understand that the way an organisation manages upper limb disorders in the work force, will have an effect on this aspect of psycho-social risk.

Insurance policies

For most companies, management of work-related musculoskeletal problems begins and ends with insurance. Policies are available to pay out for a legal claim and company health policies will cover the cost of a specialist's appointment and physiotherapy. Unfortunately, in practice, both these schemes only come into play after an injury has become established and a staff member has been off work for a length of time.

By this time, the individual will have been exposed to a number of factors, which will affect his or her perception of the symptoms. Conflicting medical advice and diagnosis and anecdotal information from friends and work colleagues can all lead to fear regarding the injury and anxiety regarding return to work.

Return to work?

Once these perceptions and fears have been established, it is more difficult to introduce a work rehabilitation programme. Clinical evidence and our own experience suggest that the sooner a musculoskeletal problem is dealt with, the easier it is to cure, and of course, the less time off work is required.

Furthermore, it now appears that not only the speed with which treatment is started, but the attitude of the organisation, the medical practitioners and obviously the individual towards his or her symptoms, may also affect the development of a long-term injury.

Open reporting

For some years now, industry has been moving towards an open safety culture to encourage accident and injury reporting. Yet, this kind of policy remains rare within office-based organisations. Open reporting would help create a 'no-blame' culture where musculoskeletal problems are reported and treated quickly.

The psycho-social risk factor can be reduced by developing policies which facilitate positive response to any reported incidents, and limiting any negative cognitive processes associated with the development of work-related musculoskeletal symptoms. In this way, there is far less chance of the individual developing a chronic pain condition.

Appropriate treatment

Once an organisation has decided to seek advice or treatment for staff reporting work-related upper limb symptoms, they then need to select the most appropriate treatment. Until recently, treatment has been along the lines of traditional medicine, rest and drug therapy, all passive forms of treatment. No single form of treatment has proved to be particularly successful. We are now looking to the experience of chronic back pain for some answers. Research in this field shows that physical exercise-based rehabilitation employing a behavioural pain management approach, is more effective than passive treatments, including manipulation. An active form of treatment is more likely to increase the rate of return to work and reduce health care usage.

Active rather than passive

All the indicators suggest that treatment for diffuse pain syndromes should be active rather than passive. Individuals should be involved in their treatment programmes. Work conditioning and rehabilitation programmes should be run for any staff off work or currently on light duties. In addition, therapists should have an understanding of the psychological aspects of these disorders and adopt a behavioural approach to pain management.

There are now a few specialised occupational health treatment centres, which run work rehabilitation and conditioning programmes for staff.

Treatment is most effective if individuals are given assessment and advise immediately after reporting symptoms. Treatment programmes should be started within a week. In most cases, staff should be encouraged to remain at work rather than being advised to take time off and rest.

A more cost-effective approach

An approach, which encourages early reporting of symptoms, will significantly reduce the likelihood of individuals developing chronic pain resulting in prolonged absence from work. Surely this approach is far more cost-effective than a system which may actually contribute to long-term sickness absence?

Wendy Chalmers has published and lectured widely on work related ill health.