A different approach

using a new tact has helped transform the approach to musculoskeletal disorders
at Clifford Chance.  By Lucia

Clifford Chance, managing staff with musculoskeletal disorders (MSDs) accounted
for a large proportion of the occupational health department’s time. We were
seeing a general improvement in symptoms of staff with back and neck pain, but
this was not the case with upper-limb pain.

having workstation assessments for all employees, appropriate training,
specialist referrals and copious amounts of physiotherapy, upper limb pain
accounted for a significant proportion of sickness absence and permanent health
insurance (PHI) claims. Some individuals could be absent from work for anything
up to five years. Factors such as poor work quality and output, staff turnover,
and problems with recruitment and compensation claims were also likely to be

became embroiled in the whole claims procedure, where the aim was often to
support a claim by gathering evidence from specialists; this reinforced the
individual’s belief in their inability to work. Individuals soon became deeply
ingrained in the medical model, which reinforced the ‘victim’ mentality of ‘I
have been made ill by my work’. This placed OH in the unenviable position of
neither satisfying worker or employer.

OH relied upon referral to GPs and specialists, usually rheumatologists, for a
specific diagnosis, but these were often ambiguous labels such as ‘RSI’,
fibromyalgia, work-related upper limb disorder (WRULD), tenosynovitis etc.
Despite these labels, the treatment remained the same: rest, non-steroidal
anti-inflammatory drugs, and occasionally, surgery (which in our experience
carried a fairly poor success rate).

of the reasons for this was to fulfil the criteria for the Reporting of
Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).2 However,
the written guidelines and advice were ambiguous. According to Macfarlane, Hunt
& Silman, the term ‘RSI’ should be avoided when diagnosing upper-limb pain as
it can ‘imply a single and uniform cause’ and be misleading.3 There is also a
lack of a widely agreed definition of RSI.4 Based on this information we, as a
department, have chosen to use the term upper-limb pain to describe any
presentation of pain in the upper limb(s), including referred symptoms from the
cervical and thoracic spine, and have deliberately avoided pre-fixing the
phrase with the term ‘work-related’, as this is almost impossible to prove –
even by an experienced specialist. This also avoids ‘victim’ labelling, and
subsequent detrimental behaviour.

focus of employees’ health and well-being appeared to have become obscured by
the medicalisation, potentially litigious and political nature of the problem,
with far-reaching effects on the individual, family and friends.


to popular belief, there seems to be a lower incidence of upper-limb pain in
the working population than the non-working population. It could be argued that
employment can actually reduce the chances of acquiring upper-limb pain.5

suggests that musculoskeletal conditions in low-risk environments such as an
office can also be caused by non-work exposure and individual factors, such as
poor posture, an elevated body mass index, or a history of past back pain.6
Genetic predisposing factors – hypermobility syndrome, for example – can be
exacerbated by poor postural habits, insufficient recovery time between
activities, excessive force and frequent repetitive movements without a break,
both in the workplace and the home.

most common symptoms include aches, pains and movement difficulties. Typical
conditions include tennis elbow, golfers elbow, frozen shoulder, trigger
finger, arthritis, de Quervain’s tenosynovitis and carpal tunnel syndrome.

to recent articles, psychosocial factors can account for as much as 70 per cent
of perceived MSDs. Factors such as the level of support from colleagues/
managers and the degree of control an employee has over their work have been
found to influence the onset of upper-limb pain. Increased risks were
associated with high levels of psychosocial distress.

example of the complex psychosocial phenomenon was Australia’s ‘RSI epidemic’
in the 1980s. Reported cases in New South Wales alone grew from less than 1,000
in 1981 to 7,000 by 1985, followed by a decline, whereby ‘the injury theory of
RSI could not account for the epidemiology of the disorder’.7

interesting piece of research was the recovery rates of whiplash due to
personal error, or whiplash due to a third party. It was found that after a
six-week period, the recovery rate for those who sustained injuries as a result
of personal error was 46 per cent, compared with just 6 per cent for those who perceived
that they were ‘victims’ of an accident.

on the above evidence, the Hanasaari conceptual model for OH and subjective
observation, a new management process was formulated.

management approach

focus was shifted from whether upper limb pain was ‘work-related’ to how to
improve the health and well being of individuals with these problems. The aims
were to:

Ensure early referral to occupational health and safety (OH&S) departments

Contain the problem – using internal support structures rather than spreading
the problem outside where the firm has little or no control

Improve awareness of the root cause, with education and effective
self-management in a supportive environment

Empower the individual to take ownership of their problem

Improve communication between OH&S, HR, manager, employee and GP (where

Stop fear-avoidance behaviour, ‘victim’ perception and mental detachment from
their symptoms.


process was fairly straightforward to implement because we actually had the
necessary skills under one roof. We needed to improve communication and liaison
between OH and the risk assessors (RAs). OH, the RAs and our physiotherapist
agreed upon a protocol which sped up the process from reporting to intervention,
and avoided any unnecessary GP/ specialist referrals outside of the firm.

decided that every symptomatic employee would attend the posture course as a
first line of physiotherapy intervention, rather than going down the route of
‘hands-on’ passive therapy. All risk assessors attended this course to gain
insight into the process, and to enable them to differentiate between an
ergonomic and a postural cause.

the employee reported mild symptoms specifically related to poor ergonomics,
the RAs would implement change and review things a week later. If the issue had
been resolved, no further action was needed. If symptoms were persistent and
moderate to severe – for example, tingling, swelling, spasms, continuous pain,
headaches and/or dizziness – the RA would refer to OH immediately for

would assess the employee and advise them and their line manager on any
necessary and reasonable adjustments to their workplace, hours, and job
content. They would also be advised of any immediate self-treatment, including
anti-inflammatories, ice-packs, and rest. If the symptoms were inconsistent
with a mechanical musculoskeletal condition, the employee would be referred to
their GP or appropriate specialist.

all other mechanical musculoskeletal presentations, staff were referred to the
in-house postural re-education workshop, where the physiotherapist would make
an assessment and relay the outcome to OH. Further specialist referral is
available if needed.

flowcharts compare the old system with the new one (see above and flow chart on
page 20):

re-education course

physiotherapist specialises in the re-education of posture and habitual poor
patterns of movement and behaviour. She has a background in using the
principles of the Alexander Technique to educate and treat clients, alongside
the science of physiotherapy. This skill mix enabled the issues of behavioural
and physical patterns of misuse to be treated side-by-side. It was noted that
individuals with upper limb pain typically had the following symptoms:

Detachment and disassociation of the pain from the rest of their body

Over-protection of the ‘injured’ limb, rather like a wounded animal

Perception of irreversible degenerative disease, reinforced by the medical
model (‘crumbling spine syndrome’).

behavioural patterns appeared to be founded by fear due to lack of knowledge,
understanding and control.

relation to personality types, they tended to be either driven characters,
speed-walking their way through life both at work and at home, or personalities
who suppress their feelings; but both types seemed unable to ‘let go’,
physically or mentally.  

Posture Re-education Workshop was devised with the intention of keeping
rehabilitation in-house. Historically, outside referral appeared to have spread
the problem, leading to breakdowns in communication. The advantages of the
in-house workshop were that the physiotherapist and the OH&S departments
work very closely together with mutual respect, and an understanding of the
organisational culture.

course is goal-orientated and run over a number of weeks. Individuals are made
aware of how poor patterns of posture, movement and behaviour have negative
impacts on the body and mind. With a little motivation, they can acquire the
necessary skills to improve this in functional settings both at work and at
home. It is our first and preferred method of medical intervention.  

dynamics are important and operate well, with individuals feeling supported and
empowered. Some employees (especially those seconded from overseas) can feel
isolated, but this is also an excellent opportunity for them to feel involved
and to make friends.

scheme has been successful because it is a holistic approach to a multi-faceted
problem, and one which is functional and relevant. By giving individuals the
choice to behave differently, they take ownership of their well-being.

necessary, further one-to-one treatment is offered with the physiotherapist,
and specialist referrals are available where necessary – but this has been in
the vast minority. Psychosocial problems are also addressed, and where
necessary workers are referred to the employee assistance line.

one year on

No private or NHS GP referrals for upper-limb pain

In 2002, 85 upper limb pain cases were seen (an average of seven a month). The
new management structure was applied to 100 per cent of upper-limb pain cases;
94 per cent were successfully managed. The remaining 6 per cent were referred
to our insurers, which had all been managed under the old method

The highest percentage of upper limb pain cases were found among legal support
secretaries (38 per cent), lawyers (22 per cent), and support staff (14 per
cent). Of the secretaries and lawyers, the majority of cases reported were in
the 25-29-year-old age bracket. Of the support staff, most were aged between 40
to 44. A very small percentage were aged 45 to 64. This is contrary to what you
would expect for physiological ‘wear and tear’ symptoms, and this could
highlight the importance of the psychosocial factors.


approach is a holistic one, which encompasses psycho-social issues. Emphasis on
past cases has been purely on ergonomics, which reinforces the myth that work
is to blame for the problem.  Staff are
empowered with the right focus on education and self-management, allowing them
to take control. Change in behaviour both at work and at home is also the key.
Our attitude, as is the case with stress management, is that musculoskeletal
pain will affect a person at work, whatever the cause. And therefore they will
need to be supported and adjustments will have to be made.

avoiding unhelpful and potentially damaging labelling, we have prevented a
complex but manageable condition from becoming disabling. The majority of cases
need not be medicalised, as we know that the treatment is often unsuccessful in
the long-term.

appears that we have successfully managed reported cases of upper-limb pain by
adopting the new management process. We appear to be spending less on manual
therapy, specialist referrals and time away from work for appointments and
sickness absence. Interestingly, our permanent health insurance premiums are
also reducing significantly. In addition, there has been a marked improvement
in communication and relationships between staff, their manager, HR and

has also been a change in the blame culture, with individuals now asking what
they can do to help themselves. The shift is in managing an acute, rather than
a chronic condition, which carries a better prognosis.

than being seen as an employer who could potentially exacerbate or cause
musculoskeletal problems, our ultimate goal is to promote ourselves as an
employer that has strategies in place to improve our employees’ health.

Walker, OHN BSc manager of Clifford Chance LLP Wellness Centre


Work-related ULD – guide to prevention, HSE 1990

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, HSE 1995

RSI is an overused misnomer, OH Review, Nov/Dec 2000, p12

Psychosocial risks increase physical burden, OH Review, May/June 2002

Work-related upper limb disorders: diagnosis and treatment options’ Repetitive
Strain Injury practical workplace management conference – Burke, F, 2002,
Butterworths Tolley in association with OH Review.

A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal
Disorders of the Neck, Upper Extremity, and Low Back, DHHS (NIOSH) Publication,
1997, No.97-141



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