Musculoskeletal disorders and work
Professor Karen Walker-BoneDirector Arthritis Research UK/MRC Centre
for Musculoskeletal Health and Work
Plan
• Work and health
Changes in modern workplaces
Work and musculoskeletal health
• A case presentation
• The retrospectoscope
• Results of a recent trial of treatment of ARM pain
• What are the future questions for researchers in this area?
Plan
• Work and health
Changes in modern workplaces
Work and musculoskeletal health
• A case presentation
• The retrospectoscope
• Results of a recent trial of treatment of ARM pain
• What are the future questions for researchers in this area?
Work and health
• Work is central to human existence • It is the motive force for all economies
and provides structure and meaning to individuals and societies
• Good for health & well-being
• Good for financial health & prosperity
• Good for families
• Socially inclusive & a right
The effects of unemployment on health
• Higher mortality : 5-10 years earlier mortality
• Poor general health
• 2-3 fold higher risk of chronic disease
• Poorer mental health
• 3-fold risk of psychiatric morbidity
• Higher medical consultation and hospital admission rates
Unemployment
Mental illness
Worklessness
High personal debt
Suicide x2Self harm x10
Is ALL work good..?
Occupational research matters..
• ‘Hazards’ in the workplace are
expensive
• The public tolerate hazards from work less well than those arising from personal lifestyle choices
• Occupational hazards often more amenable to public health measures and controls
Prevention of serious hazards• Occupational medicine first
emerged as scientific discipline in response to chemical, physical and biological hazards
• Based on managing adverse effects by assessing risk related to each hazard
• Measures to eliminate, substitute, reduce, protect against or manage risk
• Monitoring to ensure control
• Much occupational mortality and morbidity prevented, at least in the developed world
Health and work today
• The workplace has changed!
• Many major hazards identified
• Health & Safety Executive
• Legislation
• Most of the ‘new’ causes of occupational ill-health are not diseases only found in the workplace…
AsbestosisPhossy jawBerylliosis
Silicosis
Neck painLow back pain
‘Repetitive Strain Injury’Osteoarthritis
AsthmaLung cancer
Stress
Plan
• Work and health
Changes in modern workplaces
Work and musculoskeletal health
• A case presentation
• The retrospectoscope
• Results of a recent trial of treatment of ARM pain
• What are the future questions for researchers in this area?
Source: OECD (2014), Mental Health and Work: United Kingdom, Paris: OECD Publishing. Courtesy Shruti Singh
New UK disability claims are among the highest in the OECDNew claims per 1,000 of the working-age population (inflow rates),
latest year available
0
2
4
6
8
10
12
OECD
average
UK: Disability burden and the benefit system
Earlier intervention could
improve this
In developed world, TWO main causes of work disability..
• Mental health
• Musculoskeletal disorders
Work and musculoskeletal health
• Many of the 21st Century work and health issues affect the musculoskeletal system
– Back and neck pain, shoulder and knee pain
– Osteoarthritis
• 5 of the top 6 problems that impact work productivity are musculoskeletal or musculoskeletal-related (fatigue /depression)
• Responsible for 10 million days lost per year and £7billion societal costs
Musculoskeletal disorders become increasingly common with age
….and developed economies need people to work to
older ages..
Low back pain
Knee osteoarthritis
Case history
• A 45 year old female ambidextrous employee in a bank
• Full-time employee for > 12 years
• Recruited to do office administration including work with machines which sorted and organised envelopes
• Work described as requiring precision but not physically taxing
Changes in the workplace
• Over 5-6 years, two staff members retired and were not replaced
• Job description altered to include more office work as well as machine work
• Hand sorting letters became part of the workload
• Initially 1300 letters/day
Changes in the workplace (2)
• Gradual but steady increase in workload
• 1500 letters/day increased up to 13,000 some days
• All had to be sorted by 2.30pm by hand
• Machine work still needed to be completed daily
• Increased demands, deadlines tight and felt ‘pressured’
Onset upper limb symptoms
• 2008, developed discomfort in her left thumb
• Progressed quickly over two days such that within 2 days, she had acute locking of thumb joint
• Pain radiated proximally to elbow and upper arm
Symptom progression
• First day after the locking occurred, went to work as usual and reported pain and symptoms to Line Manager
• Sent home to rest. Repeated the same pattern for 13 days then Occupational Health team called in
• Advised that she must not work, must go off sick and report to her GP for assessment
Assessment in primary care
• GP prescribed NSAIDs, wrist support and arranged physiotherapy
• Despite these, steady progression of symptoms
• Hand painful continuously, focussed around thumb, radial border of hand and forearm and gradually over 6 months, started to radiate proximally towards elbow
Assessment in secondary care
• I personally assessed this lady 2 years after onset of symptoms
• By this time, made redundant from Bank, taking statutory sick pay and attending job centre
• Symptoms now involving hand, forearm, shoulder and neck
• Chronic unrelenting pain, 7-8/10, marked disability despite co-codamol and regular NSAIDs
On examination
• Anxious lady, distressed and in pain• Pain behaviour• Poor posture: Exaggerated cervical lordosis and
thoracic kyphosis• Restricted cervical lateral rotation to the left• Restricted range of motion in left shoulder:
active and passive, abduction and external rotation and internal rotation (capsular pattern)
• Crepitus in IPJ of left thumb• Chronic thickening of common extensor origin
but not acute de Quervain's and provocation tests unconvincing
Impression
• 2 years of chronic non-specific arm pain
• ?Work-related
• Now secondary effects on shoulder and cervical spine (regional pain syndrome)
• At risk for chronic widespread pain
• Psychological impact of two years’ sickness absence
Proportion of people who will return to work in relation to duration of sickness absence
83.3
50
30
10
0
10
20
30
40
50
60
70
80
90
1.5 6 12 24
Duration sickness absence (weeks)
%
Plan
• Work and health
Changes in modern workplaces
Work and musculoskeletal health
• A case presentation
• The retrospectoscope
• Results of a recent trial of treatment of ARM pain
• What are the future questions for researchers in this area?
What would have made a difference?
• Changes in work organisation factors:
• Staffing
• Job demands
• Control over workload minimal
• Support in work reduced
What else would have made a difference?
• Occupational advice was to GO HOME and NOT return until better!!
• Employee felt unvalued and created expectation that she could not work until 100% recovered
• Task rotation?
• Re-deployment elsewhere?
• Amended duties
• Maintenance of regular support and contact with work and co-workers
• Fit note: what COULD she still do?
What else would have made a difference?
• Excellent primary care management (by the book) but
• Delays built into the system
• Primary care does not have WORK as an outcome!
• Developed shoulder-hand syndrome because of enforced rest and fear of movement
• Medicalised symptoms and developed pain behaviour
• Forced towards disability/benefit and worse long-term health
Prevention of MSK disability
• Policy to prevent exposures that are excessive or repetitive and accidents
• Promote leisure-time activity /fitness
• Good line management:
• Know the role of each employee
• Be mindful of changes which are impacting upon individuals and their workload
• Show interest
• Rotate tasks /share tasks /listen to employees – what would help them?
• Demand-control-support
• Train managers!! Support managers!!
Once MSK pain has started..
• Take them and their symptoms seriously –with concern – LISTEN!
• Try to keep them in the workplace if at all possible
• If impossible, maintain regular (weekly) contact but NOT in an interrogatory fashion – supportive, friendly, compassionate
• Actively engage with GP through the fit note – tell GP what is required in the job and if temporary adjustments or changes are possible
• If employee waiting for NHS treatment – is that in your business’ best interests?
• Support
• Expectation of return to work
If employee making a return to work
• Active and supportive engagement
• ‘Smooth’ them back to work
• Try visits for social contact first
• Reduced hours
• Reduced responsibilities
• Take account of full role and responsibilities and adjust what needs adjustment: mechanisation, rotation of tasks, enhance job control and flexibility, peer support
• Maintain interest in their health
If employee forced to leave on health grounds
• The organisation has FAILED!
• Learn lessons
• Listen to staff
• What would have allowed successful return to work
• Systems
• Skills
• Availability of appropriate advice /guidance
Plan
• Work and health
Changes in modern workplaces
Work and musculoskeletal health
• A case presentation
• The retrospectoscope
• Results of a recent trial of treatment of ARM pain
• What are the future questions for researchers in this area?
The ARM pain trial: An RCT
Maintained physical activity and physiotherapy in the management of distal arm pain
Aberdeen
SouthamptonBrighton
Bath
Cambridge
Physiotherapy
referral
Advice to
remain activeFast-track
physiotherapy
Advice to
rest
Pre-trial
assessment
Physiotherapy
(optional)
Follow-up
6, 13 and 26 wks
Fast-track
physiotherapy
Physiotherapy
(optional)
Advice to remain
activeAdvice to rest
ARM pain trial: the results
• 539 patients recruited
• Randomised evenly to three groups
• Mean age 49 years (SD 13.6)
• 54.5% female
• 87.6% right-handed
• Equal distribution of pain in elbow, hand/wrist or both
• Pain most common in dominant arm (45.5%) or bilateral (24.7%)
Proportion with full recovery
Plan
• Work and health
Changes in modern workplaces
Work and musculoskeletal health
• A case presentation
• The retrospectoscope
• Results of a recent trial of treatment of ARM pain
• What are the future questions for researchers in this area?
What are the other important research questions?
• Is retirement good for our health (or bad)?
• What impact on health will there be from policy changes making pension age >65 years?
• Can we get people back to work earlier after elective orthopaedic surgery?
• Can employers create workplaces with ‘good’ musculoskeletal health?
• Can we enhance the EARLY management of sickness absence?
• Can we make WORK PARTICIPATION a health outcome?
.. AND What else?
• What is the impact of MSDs like osteoarthritis and osteoporosis in the workplace?
• Can we enhance the EARLY management of sickness absence?
• Can we make WORK PARTICIPATION a health outcome?
• Can we de-medicalise musculoskeletal pain in terms of attitudes and behaviours of the population?
• …etc…etc…etc..
Conclusion
• Fascinating time to be involved with work and health research
• Lots of really important research questions that affect us all
• We can make (quick) differences
• Researchers need to work closely with industry to respond to the ‘real’ issues in the workplace
• Please let us know how we can help YOU!
• Prof Nigel Arden
• Ms Fani Avgoustaki
• Dr Neil Basu
• Prof Steve Bevan
• Prof Marijn de Bruin
• Prof Anthony Bull
• Prof Kim Burton
• Prof Susan Cartwright
• Prof David Coggon
• Prof Cyrus Cooper
• Ms Stefania D’Angelo
• Dr Linda Dean
• Mr Maciek Dobras
• Mr Stephen Duffield
• Prof Rob Moots
• Ms LaKrista Morton
• Dr Fehmidah Munir
• Ms Georgia Ntani
• Dr Enrica Papi
• Prof Katherine Payne
• Prof Keith Palmer
• Dr Yeliz Prior
• Dr Rudresh Shukla
• Dr Julia Smedley
• Dr Mike Smith
• Prof Deborah Symmons
• Dr Suzan Verstappen
• Dr Elaine Wainwright
• Mr Daniel Whibley
• Dr Gwen Wynne-Jones
• Prof John Goodacre
• Dr Nicky Goodson
• Prof Alison Hammond
• Dr Clare Harris
• Prof Elaine Hay
• Prof Markus Heller
• Dr Paula Holland
• Dr Kassim Javaid
• Ms Cheryl Jones
• Dr Gareth Jones
• Dr Cathy Linaker
• Prof Gary Macfarlane
• Dr Ira Madan
• Dr Jane Martindale
• Prof Alison Macgregor
Thank you
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