The management of musculoskeletal disorders in the workplace




Abstract


Musculoskeletal disorders are a major cause of suffering and disability among working-age adults. Although working in ergonomically unsound jobs may lead to the development of certain musculoskeletal disorders, it is increasingly recognised that well-designed work is generally good for health and individuals with musculoskeletal disorders generally benefit from working. This chapter explores how health-care professionals should assess patients’ fitness for work, what factors should be considered and how the results should be communicated and to whom. Of necessity, this chapter describes current United Kingdom (UK) schemes and systems. Nevertheless, the principles described can be extended to most countries but the reader is advised to familiarise themselves with the detail of the equivalent national services in their own practice. The new UK Fit for Work service is explained together with advice on how best to use a fit note to optimise patients’ short- and long-term health. We detail what benefits are available to those who are unable to work because of poor health and how health professionals can achieve an optimum balance between supporting those who are genuinely unfit to work through benefits from a welfare state and encouraging and facilitating those who can earn an independent living to do so.


Introduction


Work is important to individuals and their families. It enables people to define their self-identity and build their self-esteem as well as providing monetary income. A major review concluded that, on balance, well-designed work carries net health benefits . Conversely, poorly designed work and unemployment are major social determinants of health inequalities . It therefore follows that health professionals need to consider the impact of their patients’ medical disorders on their work. Patients with musculoskeletal disorders (MSDs) often have disabling symptoms, which may or may not limit the type or duration of work that they are able to do. In some cases, a patient’s work may have contributed to the development of their MSD or may lead to deterioration in their disorder. However, health-care professionals must be mindful that work can also have a therapeutic role in helping patients to maintain function.




Work as a cause of MSDs


Broadly speaking, physical factors at work such as frequent or prolonged work in awkward postures or exposure to vibration may result in specific MSDs, for example, osteoarthritis of the hips in certain groups of farmers. Non-specific disorders, such as diffuse arm pain, are much less likely to be caused by physical factors at work. Care must be taken before attributing work as the cause of an MSD; causation is usually multifactorial and work may not be the only or even the main cause. Moreover, work, as a causative factor in the development and progression of MSDs and the resultant disability, is complex. Many factors come into play, including physical and psychological aspects of the job, relationships with managers and peers and the worker’s perceptions of organisational justice . Specific associations between occupational exposures and the development of MSDs will be explored in depth in other chapters.


A health-care professional managing a patient with an MSD should take a careful occupational history to understand the details of relevant physical and psychosocial workplace exposures, both past and present. In some cases, exposure throughout one’s working lifetime may be relevant (e.g., exposure to hand-transmitted vibration in a patient presenting with Raynaud’s phenomenon). In some workplaces, mechanical aids may be used to reduce physical stressors on the body and exposure to vibration can be reduced through engineering of tools or vehicles. If a health-care professional considers that work has contributed to, or aggravated, a patient’s disease or disorder, they have a duty to try to ensure that other workers in the same environment are not further exposed to the same risk (primary prevention). If their patient is to return to the same working environment, they should endeavour to ensure that exposure to an ongoing hazard is minimised (secondary prevention). Health-care professionals may not normally consider this within their remit, but it is imperative that remedial action is taken to prevent on-going exposure of their patient and other workers to risks that are potentially harmful to their health. If the patient works for an organisation that has access to an occupational health (OH) service, the best approach would be to contact the service and explain your concerns (provided your patient consents to you doing this). The OH service should liaise with the patient’s employer and advise on risk reduction through elimination of tasks, job rotation or engineering. If your patient does not have access to OH advice, the employee has the choice to speak to their line manager, employer, health and safety or trade union representative. A supporting letter from a medical professional expressing concern that exposure at work may be contributing to their medical problem may help. If the employer fails to act, or if they are in breach of health and safety laws, the worker can contact the Health and Safety Executive. The Health and Safety Executive’s website has a section on ‘how to raise a concern’ .


In some eligible cases, English law provides for payment of no fault compensation (industrial injuries disablement benefit) to people who are ill or disabled from an accident or disease caused by work . If your patient has had an accident at work, which leads to disablement, they should contact their union representative or local job centre for advice on their eligibility for compensation ( https://www.gov.uk/expenses-benefits-compensation-injuries-at-work ). If they have developed disablement because of a disease acquired due to work, they should ascertain if they are eligible for industrial injuries disablement benefit. The payment is only available to those who are suffering from defined diseases contracted in the course of certain types of employment or whilst working on an approved employment training scheme or course. These diseases are referred to as ‘prescribed diseases’. A disease is prescribed when it is caused by a risk arising from a person’s occupation and not a risk common to everybody. To be eligible for payment, the individual must have worked in the job stated and they will need to apply for the benefit. They must meet specific criteria, which vary depending upon the nature of the condition/injury. The MSDs, which are prescribed, and the associated jobs are listed in Table 1 . If you think that your patient has a prescribed occupational disease you should advise them to contact their local job centre for further advice. Advisers working on behalf of the Department for Work and Pensions will assess their application.



Table 1

Prescribed musculoskeletal diseases and their associated prescribed occupations .




























Prescribed disease Prescribed occupation
Task-specific focal dystonia of the hand or forearm. For example, writer’s cramp Any job involving prolonged periods of handwriting, typing or other repetitive movements of the fingers, hand or arm.
Bursitis or subcutaneous cellulitis arising at or about the knee due to severe or prolonged external friction or pressure at or about the knee. For example, housemaid’s knee Manual labour causing severe or prolonged external friction or pressure at or about the knee. For example, workers who kneel a lot.
Bursitis or subcutaneous cellulitis arising at or about the elbow due to severe or prolonged external friction or pressure at or about the elbow. Manual labour causing severe or prolonged external friction or pressure at or about the elbow. For example, jobs involving continuous rubbing or pressure on the elbow.
Traumatic inflammation of the tendons of the hand or forearm, or of the associated tendon sheaths. Tenosynovitis Manual labour, or frequent or repeated movements of the hand or wrist. For example, routine assembly workers.
Carpal tunnel syndrome

  • a)

    The use, at the time the symptoms first develop, of handheld powered tools whose internal parts vibrate so as to transmit that vibration to the hand, but excluding those tools that are solely powered by hand; or


  • (b)

    repeated palmar flexion and dorsiflexion of the wrist for at least 20 h per week for a period or periods amounting in aggregate to at least 12 months in the 24 months prior to the onset of symptoms. We use ‘repeated’ to mean once or more often in every 30 s.

Osteoarthritis of the hip Work in agriculture as a farmer or farm worker for a period of, or periods amounting in aggregate to, ≥10 years.
Osteoarthritis of the knee Work underground in a coal mine for a period of, or periods amounting in aggregate to, at least 10 years in any one or more of the following occupations:

  • (a)

    before 1 January 1986 as a coal miner; or (b) on or after 1 January 1986 as a:



    • (i)

      face worker working on a non-mechanised coal face,


    • (ii)

      development worker,


    • (iii)

      face salvage worker,


    • (iv)

      conveyor belt cleaner or


    • (v)

      conveyor belt attendant.


A ‘non-mechanised coal face’ means a coal face without either powered roof supports or a power loader machine, which simultaneously cuts and loads the coal, or without both.
Work wholly or mainly fitting or laying carpets or floors (other than concrete floors) for a period of, or periods amounting in aggregate to, ≥20 years.




Work as a cause of MSDs


Broadly speaking, physical factors at work such as frequent or prolonged work in awkward postures or exposure to vibration may result in specific MSDs, for example, osteoarthritis of the hips in certain groups of farmers. Non-specific disorders, such as diffuse arm pain, are much less likely to be caused by physical factors at work. Care must be taken before attributing work as the cause of an MSD; causation is usually multifactorial and work may not be the only or even the main cause. Moreover, work, as a causative factor in the development and progression of MSDs and the resultant disability, is complex. Many factors come into play, including physical and psychological aspects of the job, relationships with managers and peers and the worker’s perceptions of organisational justice . Specific associations between occupational exposures and the development of MSDs will be explored in depth in other chapters.


A health-care professional managing a patient with an MSD should take a careful occupational history to understand the details of relevant physical and psychosocial workplace exposures, both past and present. In some cases, exposure throughout one’s working lifetime may be relevant (e.g., exposure to hand-transmitted vibration in a patient presenting with Raynaud’s phenomenon). In some workplaces, mechanical aids may be used to reduce physical stressors on the body and exposure to vibration can be reduced through engineering of tools or vehicles. If a health-care professional considers that work has contributed to, or aggravated, a patient’s disease or disorder, they have a duty to try to ensure that other workers in the same environment are not further exposed to the same risk (primary prevention). If their patient is to return to the same working environment, they should endeavour to ensure that exposure to an ongoing hazard is minimised (secondary prevention). Health-care professionals may not normally consider this within their remit, but it is imperative that remedial action is taken to prevent on-going exposure of their patient and other workers to risks that are potentially harmful to their health. If the patient works for an organisation that has access to an occupational health (OH) service, the best approach would be to contact the service and explain your concerns (provided your patient consents to you doing this). The OH service should liaise with the patient’s employer and advise on risk reduction through elimination of tasks, job rotation or engineering. If your patient does not have access to OH advice, the employee has the choice to speak to their line manager, employer, health and safety or trade union representative. A supporting letter from a medical professional expressing concern that exposure at work may be contributing to their medical problem may help. If the employer fails to act, or if they are in breach of health and safety laws, the worker can contact the Health and Safety Executive. The Health and Safety Executive’s website has a section on ‘how to raise a concern’ .


In some eligible cases, English law provides for payment of no fault compensation (industrial injuries disablement benefit) to people who are ill or disabled from an accident or disease caused by work . If your patient has had an accident at work, which leads to disablement, they should contact their union representative or local job centre for advice on their eligibility for compensation ( https://www.gov.uk/expenses-benefits-compensation-injuries-at-work ). If they have developed disablement because of a disease acquired due to work, they should ascertain if they are eligible for industrial injuries disablement benefit. The payment is only available to those who are suffering from defined diseases contracted in the course of certain types of employment or whilst working on an approved employment training scheme or course. These diseases are referred to as ‘prescribed diseases’. A disease is prescribed when it is caused by a risk arising from a person’s occupation and not a risk common to everybody. To be eligible for payment, the individual must have worked in the job stated and they will need to apply for the benefit. They must meet specific criteria, which vary depending upon the nature of the condition/injury. The MSDs, which are prescribed, and the associated jobs are listed in Table 1 . If you think that your patient has a prescribed occupational disease you should advise them to contact their local job centre for further advice. Advisers working on behalf of the Department for Work and Pensions will assess their application.



Table 1

Prescribed musculoskeletal diseases and their associated prescribed occupations .




























Prescribed disease Prescribed occupation
Task-specific focal dystonia of the hand or forearm. For example, writer’s cramp Any job involving prolonged periods of handwriting, typing or other repetitive movements of the fingers, hand or arm.
Bursitis or subcutaneous cellulitis arising at or about the knee due to severe or prolonged external friction or pressure at or about the knee. For example, housemaid’s knee Manual labour causing severe or prolonged external friction or pressure at or about the knee. For example, workers who kneel a lot.
Bursitis or subcutaneous cellulitis arising at or about the elbow due to severe or prolonged external friction or pressure at or about the elbow. Manual labour causing severe or prolonged external friction or pressure at or about the elbow. For example, jobs involving continuous rubbing or pressure on the elbow.
Traumatic inflammation of the tendons of the hand or forearm, or of the associated tendon sheaths. Tenosynovitis Manual labour, or frequent or repeated movements of the hand or wrist. For example, routine assembly workers.
Carpal tunnel syndrome

  • a)

    The use, at the time the symptoms first develop, of handheld powered tools whose internal parts vibrate so as to transmit that vibration to the hand, but excluding those tools that are solely powered by hand; or


  • (b)

    repeated palmar flexion and dorsiflexion of the wrist for at least 20 h per week for a period or periods amounting in aggregate to at least 12 months in the 24 months prior to the onset of symptoms. We use ‘repeated’ to mean once or more often in every 30 s.

Osteoarthritis of the hip Work in agriculture as a farmer or farm worker for a period of, or periods amounting in aggregate to, ≥10 years.
Osteoarthritis of the knee Work underground in a coal mine for a period of, or periods amounting in aggregate to, at least 10 years in any one or more of the following occupations:

  • (a)

    before 1 January 1986 as a coal miner; or (b) on or after 1 January 1986 as a:



    • (i)

      face worker working on a non-mechanised coal face,


    • (ii)

      development worker,


    • (iii)

      face salvage worker,


    • (iv)

      conveyor belt cleaner or


    • (v)

      conveyor belt attendant.


A ‘non-mechanised coal face’ means a coal face without either powered roof supports or a power loader machine, which simultaneously cuts and loads the coal, or without both.
Work wholly or mainly fitting or laying carpets or floors (other than concrete floors) for a period of, or periods amounting in aggregate to, ≥20 years.

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Nov 10, 2017 | Posted by in RHEUMATOLOGY | Comments Off on The management of musculoskeletal disorders in the workplace

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