A case study sheds light on how to manage carpal tunnel syndrome at work, explain Julie Gormley and Anne Harriss.
Musculoskeletal disorders (MSD) are the most common work-related illnesses in the UK, accounting for almost half (49%) of all self-reported occupational health conditions (HSE, 2009). In 2008/09, of the 538,000 self-reported MSD work-related illnesses, 40% (215,000) related to upper limb and neck disorders (HSE, 2009).
Upper limb disorders (ULD) include conditions involving “muscles, tendons, ligaments, nerves or other soft tissues and joints and include the neck, shoulders, arms, wrists, hands and fingers” (HSE, 2002). The HSE estimates that in 2008/09, MSDs affecting upper limbs and necks either “caused or made worse by work accounted for the loss of 3.8 million working days” (HSE, 2010).
Carpal tunnel syndrome (CTS) is a ULD caused by compression of the median nerve as it passes through the carpal tunnel at the front of the wrist (Patient UK, 2008).
CTS is considered the most common peripheral nerve entrapment syndrome (Ryder & Bird, 2007). Its prevalence in the general population is estimated to be between 2.7% and 5.8% (Hobby, 2008), and is more common in women (Bupa, 2008), and manual worker occupational groups (Hobby, 2008; Atroshi et al, 1999). Sunderland (1991, p.135) proposes that this compression trauma can be related to the position in which the hand and wrist are habitually held. Symptoms include pain, paresthesia, sensory loss and muscle weakness to the fingers and thumbs.
This article examines the impact CTS had on a healthcare worker’s fitness to undertake the duties of her role, the variables used to assess fitness for work and the role the occupational health service (OHS) played in facilitating employment of the individual. It also explores the implications of the pathophysiology of CTS including inflammatory processes in relation to the impact on functional ability.
Subject of the case study
Jane (pseudonym), a 37-year-old nurse, attended the occupational health department (OHD) following a management referral for an assessment of her fitness for work. The employee had been experiencing pain, paresthesia, weakness and loss of sensitivity in her fingers and thumbs. Her role required a high degree of repetitive, fine manual dexterity and hand/finger manipulation.
Jane had worked within the same fast-paced technical department for 15 years. Her hobbies included gardening and she had no significant underlying medical conditions. Jane’s post included working three 12.5-hour shifts per week in a role requiring a high degree of repetitive, intricate manual dexterity. Tasks included: complex cannulation procedures using sensory palpation techniques; fine digital dexterity movements of gripping, twisting, “pincer and clamping” motions; and applying digital pressure to prevent haemorrhage.
Initially, Jane experienced dull, aching pains and paresthesia in her hands, affecting manual dexterity and fine manipulation and adversely impacting on work performance. Her GP diagnosed CTS and Jane then informed her line manager, who referred her to the OH department.
Nerve ischaemia
It used to be thought that the pain experienced in CTS was a result of nerve deformity due to compression, resulting in demyelination of the A fibres. However, Sunderland (1991, p.338) argued that the pain is due to nerve ischaemia secondary to the physical trauma of nerve compression, eliciting an acute inflammatory response, and chemical stimulation of the nociceptors. Jane’s pain may initially have been from acute inflammatory responses, causing release of chemical mediators stimulating nociceptors. Symptoms of sensory loss are thought to be due to the more chronic aspects of the compression injury (Sunderland, 1991, p.142).
However, Sunderland (1991, p.142) also states that acute nutritional impairment results in nerve fibres becoming hyper-excitable and discharging spontaneously. This causes intermittent pain, paresthesia and the aching associated with prolonged use of the hand.
This explanation is consistent with the symptoms Jane experienced, which were exacerbated by the manual dexterity tasks of her role such as pincer and clamping movements, and applying digital pressure. Jane’s symptoms affected the functional ability required for the job.
Jane was assessed by an occupational health nurse (OHN) using the fitness-for-work model of Murugiah et al (2002) to identify her fitness to perform her role tasks. The assessment focused on four main variables: personal aspects; work characteristics; work environment; and legal aspects. The OHN discussed with Jane the difficulties that affected the specific activities of daily living and her work role. Gauging the client’s “out-of-work” limitations facilitates the OHN in making an assessment regarding the impact in the workplace.
Time limits
Jane indicated that she had to limit the time she undertook manual dexterity tasks, especially in relation to her hobby of gardening. She experienced hand pain and weakness when holding and gripping objects and while applying digital pressure. She also experienced a decreased sense of touch in her fingertips, describing her hands as feeling “clumsy”. These symptoms directly affected her ability to carry out her job tasks safely.
Murugiah et al (2002) recommend that OH nurses be aware of the essential and desirable qualities relating to the job specification. The assessment of Jane’s work characteristics included the pace, repetitive nature and duration of the workload. Jane’s working conditions exacerbated her symptoms of pain, paresthesia and aching. Jane was referred for medical OH assessment, which included baseline neurological assessment, confirming Jane had symptoms of CTS. Consent was gained to liaise with her GP who, following investigations, diagnosed Jane with bilateral CTS resulting in a further referral for a surgical assessment. It was recommended to Jane’s manager that she be temporarily redeployed to a non-clinical role until she recovered from her planned surgery.
Whittaker and Baranski (2001) suggest the OHN is skilled and knowledgeable in disease and injury prevention, and well placed to advise on risk assessment and modification of duties ensuring safe systems of working. The NHS Confederation (2005) further acknowledges that for OH staff to make recommendations facilitating a return to work or redeployment, they “need to be in possession of all the facts”. This is supported by Whittaker and Baranski (2001), who advise “collaboration with the occupation health physician may be necessary in many circumstances”. Although the OHN had the skills to identify, assess and plan interventions in relation to recommending modified duties, it was considered that, as Jane would require substantial modifications and/or redeployment, a formal medical report would be required.
Under s.7(a) of the Health and Safety at Work Act (HSWA) 1974, employees have a duty to “take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions at work”. Jane also has a duty of care under the Nursing and Midwifery Council (2008) Standards of Conduct, Performance and Ethics for Nurses and Midwives, which states that nurses must “act without delay if you believe that you may be putting someone at risk”. It can be argued that Jane complied with both pieces of legislation and also with her professional duty by raising her concerns regarding her functional ability with her manager.
Employers have a legal duty of care under s.2 of the HSWA 1974, which is “to ensure, so far as is reasonably practicable the health, safety and welfare at work of its employees” and s.6 of the Disability Discrimination Act (DDA) 1995 (now included in the Equality Act 2010), which stipulates that it is the “duty of the employer to make reasonable adjustments” in relation to an employee with a disability.
OH practitioners have a contractual obligation to their employer and responsibilities towards the employee relating to the “law of tort”, where an individual can “foresee” that his actions or omissions will cause harm (Kloss, 2006). A medical report from the OH physician may indicate whether the employee is likely, or unlikely, to be considered disabled within the DDA 1995. CTS is also listed in the World Health Organisation (WHO) (2010) International classification of diseases.
Under common law, an employer has a higher duty of care to employees with a known pre-existing medical condition, shown in the 1951 case of Paris v Stepney Borough Council (Kloss, 2006). As Jane was successfully redeployed to a suitable alternative post, it is suggested that the organisation acted in Jane’s best interests and in accordance with legislation.
Assessing the situation
All four variables suggested by Murugiah et al (2002) in assessing fitness for work were considered. The OH assessment highlighted the implications of CTS on Jane’s functional capabilities and role requirements. It considered the impact of her work environment and the elements of work tasks causing her difficulties and the legal implications.
Murugiah et al (2002) advise that “illness or disorders, which result in disability, normally leave psychological scars”. There was no specific evidence that the psychological impact of Jane’s disability and redeployment had been assessed. It is therefore recommended that the psychological state of the employee be assessed, as well as their physical state, especially in cases of disability and/or redeployment.
As CTS can be related to the position in which a hand and wrist are habitually held (Sunderland, 1991), it is recommended that the OH nurse provides health pro-motion and awareness-raising activities regarding the risks of poor posture. This is especially important in a fast paced work environment that demands high levels of repetitive manual dexterity, and where long shifts are worked. It is further recommended that during post em-ployment assessments staff whose role requires repetitive work with hands and arms, are educated regarding the risks of poor posture.
Conclusion
A positive outcome is more likely if information is provided regarding the results of both a risk assessment and a job description. Murugiah et al (2002) recommend using the fitness for work framework to ensure that documentation is appropriate to support the decision-making process. This also supports transparency and a defensible position. It should be acknowledged however, that following the OH assessments, the medical report was completed by the OH physician, which according to Murugiah et al (2002), would be viewed more favourably by an employment tribunal should there be conflicting medical opinions.
Finally, Jane was able to continue with employment and patients were not put at risk from a practitioner who, due to CTS, was unable to safely fulfil the duties of her post.
Julie Gormley is an occupational health adviser and Anne Harriss is course director, occupational health courses, reader in educational development, London South Bank University.
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