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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