CPD: a pain in the wrist – supporting work-related upper limb disorder

Work-related upper limb disorders can have a significant impact on the workplace, with women over the age of 45 at higher risk. But, with early intervention and appropriate occupational health and employer support, they can be managed and, as Victoria Keenan and Anne Harriss show, an employee may make a full recovery.

This article explores the management referral of a 57-year-old woman employed as a hospital administrator.

Diane (a pseudonym) was referred by her line manager for an occupational health (OH) opinion as a result of experiencing pain in her right wrist and forearm which were associated with a repetitive wrist movements which forms a work-related upper limb disorder (WRULD).

About the authors

Victoria Keenan is an occupational health nurse and Anne Harriss is professor in occupational health

WRULDs can have a significant impact on the workplace. In the UK in 2016/17 three million working days were lost because of WRULD. Females above the age of 45 are at higher risk of developing a work-related upper limb disorder than those under the age of 45 (HSE, 2017).

The condition Diane described is sometimes referred to as repetitive strain injury (RSI), a descriptive term for an overuse injury (Clarke, 2018). For a number of years RSI has been considered to be an inappropriate term. Aw et al (2007) note a lack of evidence supporting the term injury, and static muscle loading rather than repetitive movements may cause the disorder. Although repetitive movements led to Diane’s symptoms the term WRULD will be used within this case study.

WRULDs can involve joints, muscles, ligaments, tendons, nerves or other soft tissues with symptoms affecting the neck, shoulders, arms, wrists, hands and fingers. It is an umbrella term for a range of conditions, including tenosynovitis, De Quervain’s tenosynovitis, carpal tunnel syndrome, epicondylitis and peritendinitis crepitans (NHS Choices, 2016).

Each of which is associated with repetitive tasks and can be caused or exacerbated by work; prolonged or excessive force; uncomfortable working positions; carrying out tasks without suitable rest breaks and poor working environment (HSE, 2013). Micro-trauma occurs with resultant tenderness, aches and pain, stiffness, weakness, cramp, numbness and swelling (HSE, 2013). All or some of these symptoms may be present and they may be chronic, acute or recurrent (Aw et al, 2007).

Whenever muscles or tendons are over used, micro-tears can occur in the tissue leading to local inflammation as the body attempts to repair the damage. Thickening and scar tissue form over-damaged tissues and pain results. Normally, the body would repair the damage and the pain would resolve. However, with insufficient rest, tissues do not repair resulting in further damage (Clarke, 2018).

Nerve compression causing tingling in the hands is a feature of WRULDs. Damaged nerves can heal, but it can be an extremely slow process. Most cases of WRULDs involve the nerves running from the neck, down the arms, and into the wrists and hands. These nerves pass by other structures, most notably the discs and facet joints in the neck, and if they become damaged or tight, then the nerves cannot move freely in the arm. If these tight structures are then used repetitively they become sore and inflamed (Clarke, 2018).

Early intervention is key to a full recovery when recognising and treating WRULD (HSE, 2013). When acute it is relatively simple to assess and treat successfully, but not so when it develops into a chronic condition and this may lead to sufferers eventually developing a chronic pain syndrome affecting many aspects of their life. Recommended treatment options include analgesia, soft tissue massage, physiotherapy, wearing a brace or support and TENS therapy (NHS Choices, 2016).

Fitness to work framework and biopsychosocial flags

Thornbory (2013) highlights the role of the occupational health nurse (OHN) in case management is to assess a client’s fitness to work, so that beneficial advice and information can be given to both client and employer. A fitness to work framework can be used as a consistent, transparent method of assessing a client’s fitness to work. This case was managed using the fitness to work framework of Murugiah et al (2002) and the bio-psychosocial model of case management (Vivian, 2014).

The framework of Murugiah et al (2002) focuses on four specific areas: the personal aspect, legal aspects, the characteristic of work tasks, and the characteristics of the work environment. The personal aspects focus on the client assessment, is individual to the client and based around their work role (Murugiah et al, 2002). The assessment considers past occupations, skill levels, work technique and ability viewed in the light of the medical history.

Lifestyle factors impacting on the client’s work performance should also be explored. As illnesses and injuries may have psychological effects individual, their psychological state should also be addressed (Murugiah et al, 2002).

The legal aspects of the Murugiah framework relate to the duties of employers to their employees as required by the Health and Safety at Work etc. Act (1974) and the Equality Act (2010) and the advice given by the OHN must be based on sound legal principles (Murugiah et al, 2002).

In terms of the characteristics of work, OHNs require a thorough knowledge of the job specification and the client’s required skill-set. The employee’s symptoms and health should be viewed in the light of their job role. Factors for consideration include job demand, the specific type, intensity, duration and schedule (Murugiah et al, 2002).

The workplace environment relates to environmental risks that may affect those with an illness or disability. Although able-bodied individuals may be able to undertake a task without issue, those returning to work following illness or impairment may pose a hazard to themselves or others.

The holistic biopsychosocial approach to assessing clients and flag system was used in the assessment as these flags can help identify barriers to work (Vivian, 2014). Each flag represents a different element: red flags focusing on biological issues; yellow with psychological factors; blue with social factors; and black with factors outside the client’s control, such as financial issues.

Schultz, et al (2012) highlight symptoms of WRULD can be persistent affecting many aspects of the individual’s life; therefore it is important to carry out a holistic assessment to provide an effective management plan.

The assessment

At the beginning of the appointment the OHN introduced herself and explained the referral process. Diane gave written consent to participate in this assessment and for a report to be sent to her manager. The Data Protection Act requires that consent is obtained before personal information is collected.

Diane confirmed understanding the reason for her manager’s referral and of the referral process clarified. In line with requirements of the Nursing and Midwifery Council (NMC, 2015) the consultation was confidential and it was confirmed that the response to management would only be shared with Diane and her manager who might subsequently share it with HR. Diane confirmed her readiness to proceed.

The manager’s referral confirmed Diane’s consent to the referral and included a brief outline of her job description. Her manager posed specific questions regarding how her condition affected her work role and whether any adjustments would support her in the workplace.

Diane had been employed as a clinical administrator for the past five years, working 37.5 hours a week from 9am to 5pm. Her main duties involved typing reports that had been dictated by medical staff, emailing and using the telephone. Approximately five hours of her working day involved using a keyboard and mouse. She could take a 10-minute break in the morning and afternoon and a 30-minute lunch break.

Diane had worked in various administrative roles involving typing and paperwork since the age of 17. Details of her past medical history and any medication she was taking were recorded. She disclosed two well-managed conditions: hypercholesterolemia treated with Simvastatin, and asthma, requiring the occasional use of Salbutamol inhalers.

Diane reported no previous history of musculoskeletal conditions but described experiencing symptoms consistent with WRULD for the past three months, including pain in her wrist and arm with occasional tingling and numbness in her hand and fingers.

She self-managed her symptoms using over-the-counter analgesia. Her symptoms were increasing in frequency and severity and she treatment from her GP who prescribed stronger analgesia and referred her for nerve conduction studies to exclude carpal tunnel syndrome. Test results were negative and the consultant considered her symptoms resulted from acute WRULD. Although not having taken any sickness absence she had disclosed her condition to her manager who then made the OH referral.

Diane’s symptoms occurred predominantly when undertaking keyboard and mouse-focused tasks for long periods. She experienced discomfort when holding the telephone handset and lifting heavy boxes of files. Symptoms occurred at home when lifting shopping bags, her young grandson or pursuing her hobby of cross-stitch. Despite wearing a wrist support whilst at work and self-treating with analgesia, her symptoms had not improved.

A social history was taken as part of the assessment. Diane lived with her husband. Her two adult children lived nearby and she occasionally cared for her three-year-old grandson. She drank two to three glasses of wine at weekends and was a non-smoker. She was fairly active, walking her dog and swimming for exercise. However, the pain she experienced had recently prevented her from swimming and precluded her continuing her hobby of needlework.

Diane was asked about her daily living activities, including dressing, and domestic tasks such as cooking. She reported being independent with most of these tasks but had noticed an exacerbation of symptoms if she vacuumed or ironed for long periods and she experienced difficulties lifting heavy saucepans in her right hand whilst cooking.

Her husband assisted her with some domestic tasks including carrying heavy items. Diane described the impact of her symptoms on her daily activities and highlighted that this was affecting her mood. Analgesia and the use of a wrist support had been ineffective for symptom reduction.

Red flags for Diane were the impact of work tasks that might have contributed to the symptoms she was experiencing, specifically typing. She used her right hand for most of her work tasks, including the use of the telephone, keyboard and mouse and had experienced pain in her right wrist and forearm for the past six months.

If left to progress this could have significant consequences on her job role. A numerical rating scale was used to determine Diane’s level of pain. She was asked to rate her pain on a scale of 0-10, with 0 meaning no pain at all and 10 being the worst pain they have ever experienced or could imagine (Swift, 2015).

Diane described her pain intensity as variable, when not at work her pain level decreased significantly to around 2/10. Following a day at work it could reach 9/10. Specific tasks including typing, and the use of the computer, mouse and telephone triggered symptoms predominantly in the right hand and wrist.

Sharp, stabbing pain

However, over the past six weeks it had radiated to the forearm. She described experiencing a constant dull ache developing to a sharp, stabbing pain when typing. She described weakness, numbness and tingling in her fingers. A grip assessment of her right hand performed by the OHN confirmed slightly reduced grip strength compared to her left hand.

Diane had initially self-treated her pain with paracetamol although this proved ineffective. She then applied a topical anti-inflammatory gel onto the affected areas with little effect, a treatment option recommended by NHS Choices (2016).

The yellow flag for Diane was her belief that her symptoms would improve over time with the correct treatment. She had been proactive in trying to self-manage her symptoms and when this was ineffective she had sought treatment by her GP. She was generally feeling positive that her condition would improve but frustrated regarding the impact it was having on her daily living activities, including cleaning and shopping and on her mood. She was also worried of the effect on her job role if her symptoms did not improve soon.

Pain can be a barrier to work resulting from low mood, leading to feelings of anxiety or stress. Stress in turn can exacerbate WRULD symptoms because of constant muscle tensing (Devereux et al, 2004). Diane expressed coping well with her low mood because of support from her family and colleagues. She did not appear low in mood during the consultation, maintained good eye contact and engaged well in conversation. She did not participate in any unhealthy coping strategies such as increased alcohol intake or smoking

Blue biopsychosocial flags represent social factors impacting work. No social issues impacting on work were disclosed, so there did not appear to be any barriers. Diane enjoyed her role and no conflict issues were evident in the workplace. Black biopsychosocial flags represent financial and legal issues.

Diane had not taken any sickness absence from work and was receiving her full salary. She explained that her husband was medically retired making her the sole earner. She was concerned how her condition might impact her financially if her job was affected. Her manager had reassured her that if she did need to be absent then the company sick policy would cover her for a period of time. As Diane was hoping to see an improvement in her symptoms with the correct treatment and workplace adjustments, it was determined that financial issues were not a barrier to her recovery.

Recommendations

Following the consultation, it was determined that Diane was fit to remain in work with some advice to manage her condition, subject to a display screen equipment (DSE) risk assessment followed by recommendations of workplace adjustments for her manager to consider.

The aim of the DSE risk assessment was to discount or rectify poor working positions that may underpin the pain Diane had experienced. Particularly important considerations included her use of arm positions that did not maintain neutral positions and holding items, including the telephone in the same place for a period of time.

The assessment took various factors into account, such as the position, height and layout of the workstation and the provision of ergonomic equipment (HSE, 2013). It was suggested Diane might benefit from the use of a wireless vertical mouse, a split keyboard and a screen raiser. Further suggestions included a hands free telephone headset and a new chair which would better support her upper spine.

Diane’s job required her to occasionally lift heavy boxes of paperwork that put excessive force on her upper limbs. It was recommended that she avoid carrying out such tasks where possible by reducing the weight of the boxes or delegating such tasks to another colleague. Diane was advised to carry out task rotation where possible taking regular breaks away from her workstation breaking up prolonged work periods involving repetition as repetitive work using the same muscles over and over, is associated with the development of an upper limb disorder (HSE, 2013).

An in-house physiotherapy referral was arranged. Diane was shown a series of exercises and provided with an information sheet detailing exercises she could undertake at her desk. Research suggests that regular stretching and exercise can be effective in reducing musculoskeletal discomfort in computer users (Fenety & Walker, 2002). The report that would be sent to her manager was discussed with Diane and a copy retained in her OH records.

This case study has explored the OH management referral of an employee with an acute WRULD highlighting the impact on the workplace. A fitness to work framework and biopsychosocial flag system underpinned the holistic assessment of the client.

A DSE assessment coupled with task rotation, regular breaks and avoidance of heavy lifting were recommended to her manager. A physiotherapy referral aimed to assist with muscle strengthening exercises. It was decided that a review appointment was unnecessary but her manager could re-refer her should her condition deteriorate or there were workplace concerns.

These workplace adjustments, along with appropriate medical and physiotherapy treatment, were successful in Diane’s full recovery.

References

References

Aw, T C, Gardiner, K, Harrington, J M, Whitaker, S, Jackson, C A, Ahmed, S M and Hitchins, J. (2007) Pocket consultant: occupational health. 5th ed. Oxford Blackwell Publishing Ltd.

Clarke, A. (2018) Repetitive Strain Injury, Physio Works. Available from: https://physioworks.com.au/injuries-conditions-1/rsi-repetitive-strain-injury/

Devereux, J. Rydstedt, L, Kelly, V, Weston, P and Buckle, P. (2004) The role of work stress and psychological factors in the development of musculoskeletal disorders. London: Health and Safety Executive.

Fenety, A and Walker, J. (2002) Short-Term Effects of Workstation Exercises on Musculoskeletal Discomfort and Postural Changes in Seated Video Display Unit Workers. Physical Therapy, 82 (6), pp. 578-589.

Health and Safety Executive (2013) Managing upper limb disorders in the workplace. Available from: http://www.hse.gov.uk/pubns/indg171.pdf

Health and Safety Executive (2017) Work-related Musculoskeletal Disorders (WRMSDs) Statistics in Great Britain. Available from: http://www.hse.gov.uk/statistics/causdis/musculoskeletal/msd.pdf

Murugiah, S, Thornbory, G and Harriss, A. (2002) Assessment of fitness, Personnel Today. Available From: https://www.personneltoday.com/hr/assessment-of-fitness/

NHS Choices (2016) Repetitive strain injury (RSI) -Treatment. Available From: http://www.nhs.uk/Conditions/Repetitive-strain-injury/Pages/Treatment.aspx

Nursing and Midwifery Council (2015). The Code, Professional standards of practice and behaviour for nurses and midwives. Available From: http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmc-code.pdf

Schultz, G, Mostert, K and Rothmann, I. (2012) Repetitive strain injury among South African Employees: The relationship with burnout and work engagement. International Journal of Industrial Ergonomics, 42 (5), pp. 449-456.

Swift, A. (2015) Pain management 3: the importance of assessing pain in adults. Nursing Times, 11 (41), pp. 12-17.

Thornbory, G. (2013) Contemporary Occupational Health Nursing. Oxford: Routledge.

Vivian, C. (2014) Biopsychosocial incapacity assessments: a survey of occupational physicians’ opinions. Available From: https://academic.oup.com/occmed/article/64/5/337/1437207/Biopsychosocial-incapacity-assessments-a-survey-of

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