Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and one of the most commonly reported occupational diseases. Sandra Ghiasse and Anne Harriss examine the impact of CTS on the performance of an employee during a fitness for work assessment.
The carpal tunnel, a narrow, rigid passageway of ligament and bones in the wrist, houses the median nerve and tendons. Swelling of structures within this tunnel causes median nerve compression and carpal tunnel syndrome (CTS) results. It is characterised by pain, weakness and numbness in the wrist and hand.
Symptom onset is usually gradual, starting with discomfort, tingling, or numbness in the hand, thumb, index, middle and ring fingers, subsequently limiting manual dexterity causing difficulty in grasping small objects. If left untreated, chronicity develops, which includes muscle wastage at the base of the thumb.
Anatomical factors can be key, as the carpal tunnel may be smaller in some people, particularly women, who are therefore more likely to develop CTS than men. Other factors contributing to symptom development include metabolic disorders such as: hypothyroidism and diabetes; obesity; trauma; rheumatoid arthritis and using vibrating tools (National Institute of Neurological Disorders and Stroke (NINDS), 2015).
Early diagnosis and treatment is vital in avoiding irreversible median nerve damage. Assessment of the hands and arms involves noting discoloration, swelling, warmth and tenderness as these may indicate CTS. Sensation and finger strength is assessed, as is the presence/absence of atrophy of the muscle at the base of the thumb.
Two standard tests in the diagnosis of CTS include Tinel and Phalen’s. The Tinel test involves the clinician percussing the median nerve in the patient’s wrist. Tingling in the fingers or the occurrence of shock-like sensations indicate a positive result. Phalen’s test invo-lves the patient pressing the back of the hands together, with the fingers pointing downwards for 60 seconds. Tingling or numbness suggests CTS, and this can be confirmed by nerve conduction studies. Abnormal median nerve size may be identified using an ultrasound (NINDS, 2015).
Carpal tunnel syndrome case study
Mrs Brown, a 55-year-old cleaner, was seen by an OH adviser as a management referral following her repeated short-term absences associated with a three-month history of wrist pain. She had been in her employment full-time for 10 years and work tasks included extensive repetitive, manual labour. Brown reported mild to moderate hand pain with weakness in the right thumb, paraesthesia in the digits and that she was dropping weightier objects. Her hand discomfort resulted in occasional sleep disturbances.
Brown had been prescribed hormone replacement therapy in 2013 by her GP, which she took for 12 months with good effect. Her consultation with her GP resulted in a diagnosis of CTS, based on positive Phalen’s and Tinel tests. Her GP recommended a wrist splint to be worn at night and prescribed the non-steroidal anti-inflammatory drug (NSAID) ibuprofen. Brown reported a slight improvement in symptoms following this regime.
The GP instigated investigative blood tests that eliminated inflammatory disease, hypothyroidism and diabetes. Brown reported no trauma or relevant past medical history, but she was noted to be overweight (with a body mass index (BMI) of 35). A non-smoker, she drank alcohol moderately and enjo-yed her social life and work. Her only regular exercise was a 30-minute walk to and from the bus stop during her commute.
Pathological and bio-psychosocial aspects
Her GP prescribed ibuprofen, with good effect. NSAIDs reduced swelling by blocking the production of prostaglandins normally released in response to illness and injury. Their analgesic effects are realised soon after a dose is taken; but their anti-inflammatory effects take longer (Drugs.com, 2015).
Using a biopsychosocial model, Goodson et al (2014) suggest low job satisfaction is significantly related to the presence of CTS. Obesity, repetitious work, poor physical health and lack of exercise are factors related to the development of CTS, according to the same report.
Hammond and Harriss (2012), refer to psychosocial factors decreasing the effectiveness of treatment and increasing the experience of pain. Burt et al (2013) suggest that individual risk factors and workplace factors can contribute to the risk of developing CTS. Time spent engaging in forceful activities poses a greater risk than obesity, where there is a high degree of exposure.
There is an association between “repetitive and forceful” exposure to work and CTS (National Institute of Occupational Safety and Health, 1997). Wahlstrom (2005) links two categories of factors: work organisation, psychological factors, and mental stress; and physical demands and physical load. Several factors may have contributed to Brown’s CTS, including being overweight and taking little physical exercise outside of work. Her work enjoyment also discounted job dissatisfaction as a contributory factor.
Assessment of fitness to work
OH advisers help employers and employees understand “what good work looks like”, assessing fitness to work in contributing to the evidence base for the employee capabilities needed in delivering their job role (Harrison, 2015). Palmer et al (2013) suggest three components key to an OH assessment:
- the employee’s strengths/weaknesses;
- job demands and the workplace; and
- employee and employer expectations re the outcome.
The adviser has a key role in assessing fitness for work and recommending effective return-to-work strategies, which incorporate reasonable adjustments.
Key aspects of the assessment included: consideration of her physical and psychological attributes; and understanding her work tasks and her working environment. Working with the employee and their manager throughout was instrumental in developing mutually acceptable solutions to any health, wellbeing and occupational concerns.
Following an assessment of Brown’s health status and precipitating factors, a return-to-work plan was developed to facilitate a safe workplace and healthy employee. Interventions should be constantly evaluated to confirm the achievement of desired outcomes for the employee and employer. Adjustments to the plan may be necessary.
The Murugiah et al framework (2002) cited by Hammond and Harriss (2012) was used in this case to assess Brown’s fitness to work, incorporating:
- Personal attributes (including work ethic, lifestyle and hobbies).
- Physical/psychological assessment (her feelings toward her work environment and the effects of CTS). This included a functional assessment of which aspects of her job description that Brown was able/unable to fulfil.
- Understanding her work characteristics and job description.
- Her work environment and required or current reasonable adjustments.
Brown consented to the sharing of this information with management in order to agree a way forward and continue the understanding for all parties in dealing with her abilities and needs at work.
From a functional perspective, her day-to-day job was physically demanding, especially on her hands due to her cleaning role. Having CTS, when particularly painful, limited her abilities at work, requiring her to take regular breaks to ease the strain on her right hand and wrist. She managed to fulfil her job description, however her efficiency was reduced. Her high workload completing physically demanding tasks had exacerbated her symptoms.
Psychologically she did not feel isolated from her colleagues, but occasionally found it difficult to maintain a positive attitude, given the required work pace and duties she sometimes had to pass to colleagues; physically her pain concerned her.
The prescribed NSAIDs controlled her pain and inflammation but she was concerned about possible long-term effects; in terms of her work characteristics and environment, she reported good relationships with her line manager and colleagues.
However, a high turnover of staff in her department resulted in her being unfamiliar with many colleagues and this was challenging when she worked at a reduced pace. From the above assessments, Brown’s symptoms were well controlled and, as she had not required surgery, there was no need for rehabilitative interventions. This may change in the future depending on the outcome of her discussion with her GP. Her line manager was informed of this, serving as an early alert to any future workplace adjustments.
Her physical pain and psychological characteristics at the time of the assessment raised no concerns that drastic adjustments to work would be required. Providing Brown with support and reassurance at this early stage aimed to prevent a worsening of her feelings towards work.
Recommended interventions included regular updates for her line manager and adjustment of her schedule incorporating: regular changes of task; careful scheduling of breaks; and no heavy lifting for the foreseeable future.
Her manager was advised to perform a risk assessment with Brown in compliance with Regulation 3 of the Management of Health and Safety at Work Regulations (1999) and the Health and Safety at Work etc Act (1974).
Brown was advised to follow her GP’s advice to take her NSAID medication and wear her wrist splint. Consideration should be given regarding infection control issues if wearing her splint in the workplace. Direction on safe moving and handling of equipment and gentle exercises were given, however her need for refresher training on manual handling and possibly physiotherapy was noted and management were advised of this.
Flag assessment
In relation to OH, the adviser established relevant “flags”, which are essentially areas of particular concern related to different areas of work. Black flags relate to organisational obstacles; and blue and yellow flags to psychosocial barriers (Kendall et al, 2009). A black flag relating to workplace issues comprising a heavy physical workload was identified in this case. This was discussed with Brown and her manager was advised accordingly.
The management of this return to work depended on collaboration between many professionals, involving the OH adviser, line manager, HR and her GP.
Moving forward it will be likely that a physiotherapist will also be in the team for the management of this particular case. Open and continuous dialogue between all parties, including Brown herself, has been, and will continue to be, key in the ongoing positive management and the reduction in her work absence. A multi-professional approach will continue to underpin her OH care so that her condition does not worsen in future by virtue of her workload or obligations.
There were several strengths and positive aspects to this case, which include:
- Brown was cooperative and open to disclosing information throughout the process. Similarly, employer and employee were responsive to OH advice, including changes to work practices.
- Management were similarly co-operative and proactive in supporting the employee in managing her CTS. The OH referral was carried out at a reasonably early stage of the employee’s condition, enabling her to reduce work absence and limit the likelihood of her CTS worsening.
- Employee follow-up was positive, her symptoms have reduced and ongoing dialogues between OH, her GP, and management have been positively established.
In terms of weaknesses, there was some initial difficulty in co-ordinating and receiving information from the employee’s GP and HR. This was overcome due to early intervention. Once rectified, no further barriers were reported.
Initially, it became clear that when the symptoms of CTS first occurred, Brown did not report them to her line manager as she lacked confidence in the process and outcomes of doing so. This was sensitively raised with her manager, which resulted in more open and transparent relationships between managers and employees.
The employee’s lifestyle factors around weight and exercise had not been fully addressed prior to her
OH assessment. Healthy weight and lifestyle were therefore discussed with Brown and a referral was made to her local gym via her employer’s subsidised gym membership scheme. Information on BMI, healthy eating and exercise was discussed, with the aim of improving her general health and wellbeing.
A recommendation made to management was that, should future employees develop health complaints affecting their work, early intervention and establishment of a management team should be initiated, mitigating feelings of isolation from the employee and supporting them at work. This reduces the risk of employee absence and a worsening of their condition.
Continuing dialogues between the employee and OH and then reflecting on both practice and outcomes are key to reaching positive and ongoing progress from the management plan. Explaining and justifying to the employee their fitness (or otherwise) for work supports them in feeling that they are informed about their condition.
In this case, should Brown’s condition worsen, she will need surgical intervention resulting in sickness absence, which will require a rehabilitation plan in preparation for her return to work. This was discussed with Brown and her manager, informing them that the decision regarding a surgical intervention will rest with her GP and surgeon. Educating the employee and the employer on the implications of a health condition and the workplace implications of it are key roles of the OH adviser. This will help all concerned understand the reciprocal effect of health on the workplace.
References
Burt S (2013). “A prospective study of carpal tunnel syndrome: workplace and individual risk factors”, Occup Environ Med; 70, pp.568-574.
Drugs.com (2015). Ibuprofen Side Effects, accessed 24 August 2015.
Goodson JT et al (2014). “Occupational and biopsychosocial risk factors for carpal tunnel syndrome”, Journal of Occupational & Environmental Medicine; 56(9), pp.965-972, September 2014.
Hammond A and Harriss A (2012). Impact of carpal tunnel syndrome, Occupational Health, 14 December 2012.
Harrison J (2015). “Planning the future: delivering a vision of occupational health and its workforce for the UK for the next 5-20 years.
Kendall et al (2009). “Flags in detail“. Accessed 25 August 2015
Murugiah et al (2002). Cited by Hammond A; Harriss A, (2012). Impact of Carpal Tunnel Syndrome, Occupational Health 14 December 2012, accessed 25 August 2015.
Palmer K et al (2013). Fitness for Work, 5th ed. Oxford: FOM. 274.
Roberts A (2008). “Carpal tunnel syndrome – synopsis of causation“. Accessed 24 August 2015
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US National Institute of Neurological Disorders and Stroke [USNINDAS] (April 2015), accessed 24 August 2015.
Wahlstrom J (2005). “Ergonomics, musculoskeletal disorders and computer work”, Occupational Medicine 2005; 55, pp.168-176.
