Alison Hammond and Anne Harriss discuss what to do when dealing with one of the most common musculoskeletal disorders in the workplace.
Musculoskeletal disorders (MSDs) account for the majority of occupational-related absence and illness in the UK (Gormley and Harriss, 2010).
Although Health and Safety Executive (HSE) statistics for 2010/11 show a 10-year downward trend for MSDs in the workplace, they account for 7.6 million working days lost, with more than 40% of this number attributable specifically to upper limb disorders (ULD).
Carpel tunnel syndrome (CTS) is the most common neurological disorder of nerve entrapment in the wrist (Schoen, 2002). It results from compression or traumatisation of the median nerve where it routes through the carpal tunnel in the wrist (National Institute of Neurological Disorders and Stroke, 2012).
CTS affects approximately 60 to 120 people per 100,000 of the population, and is more prevalent in women than in men (NHS, 2012).
Carpel tunnel syndrome results from compression or traumatisation of the median nerve where it routes through the carpal tunnel in the wrist”
Werner (2006) suggests that CTS cannot be attributed to work alone, but shows there is a greater prevalence of CTS in the industrial versus the general population. Health workers in hospital settings had among the highest population rates for ULD in 2010/11 (HSE, 2011).
Three factors indicating that an individual is at a high risk of developing CTS are the use of vibrating tools, work requiring high hand exertion forces or heavy manual repetitive tasks (Werner, 2006; Ohnari et al, 2007; Barcenilla et al, 2012).
Psychosocial attributes also affect CTS by increasing the patient’s experience of pain and decreasing the effectiveness of treatment outcomes (Werner, 2006).
Social deprivation has an impact on prevalence (Jenkins et al, 2012), and personal factors such as obesity and inactivity have been cited as risk factors for CTS – especially for women under the age of 63 (Bland, 2005; Moghtaderi et al, 2005).
Other risk factors include genetics, pregnancy and disorders such as rheumatoid arthritis, diabetes and hypothyroidism (Werner, 2006; Ohnari et al, 2007).
The following case study examines how CTS can affect work performance and the assessment that can establish the client’s fitness to return to work. It gives an overview of the pathophysiology of pain and inflammatory processes associated with CTS, and the ways these can affect the client’s ability to perform work duties. It also looks at the OH care that should be provided.
Jodie, a 21-year-old healthcare assistant, was experiencing wrist pain that interfered with activities involving gripping or holding objects. She was referred to the OH service regarding her fitness for work on the busy acute cardiac ward where she had been working for the past two years. She said she enjoyed her job, but had been sent home due to her inability to perform her tasks.
Prior to this post, Jodie had worked in a factory packing poultry. She reported a two-year history of bilateral wrist pain affecting her ability to perform manual tasks, which had resulted in a diagnosis of CTS. The diagnosis resulted in three episodes of sickness over the past two years.
Jodie’s symptoms prevented her from undertaking a range of tasks including carrying food trays, gripping washing bowls full of water and removing blood pressure cuffs.”
Jodie was prescribed non-steroidal anti-inflammatory drugs before the time of the OH referral. She drinks between 14 and 20 units of alcohol per week, is a non-smoker and physically inactive, with a body mass index of greater than 30. There is a family history of CTS in her mother and grandmother. Jodie’s age is not a predisposing factor to CTS, but her job includes the risk factors of repetitive tasks requiring manipulation of hand and fingers and she feels that tasks involving repetitive gripping or holding triggered her symptoms.
She has sensory abnormality in both her index finger and thumb, and reports swelling and tenderness on both wrists, as well as pain radiating from the wrists up the forearm. Jodie has experienced paraesthesia and weakness in her hands that worsens at night, and these symptoms can cause her to drop heavier items.
A positive Tinel’s sign, Phalen test, diagnostic test for CTS, and nerve conduction and electromyography had led to the diagnosis of CTS. Jodie’s symptoms prevented her from undertaking a range of tasks including carrying food trays, gripping washing bowls full of water and removing blood pressure cuffs.
Jodie’s social situation is complex – she lives with her mother and three brothers, and is the sole breadwinner. Jodie is also a carer for her mother, who has a disability that limits her functional ability and movement, which means she cannot perform many of the activities of daily living such as dressing and preparing family meals. Two of Jodie’s brothers have developmental disabilities and behavioural difficulties. When asked about her psychological state, Jodie denies being under any stress but reported feeling tired.
Assessment of fitness to work
The management referral to OH was late, which delayed a timely rehabilitation programme being developed – Jodie had been experiencing symptoms for the past two years.
The OH referral letter detailed previous absences associated with this condition that assisted the assessment process.
Jodie’s confirmation that she had consented to the referral was of paramount importance, both legally and ethically (NMC, 2008; Kloss, 2010).
Murugiah et al’s (2002) framework for assessing fitness to work has four aspects:
- personal attributes;
- physical/psychological attributes;
- work characteristics; and
- work environment.
This model underpinned the OH assessment, helping to ensure that a holistic, balanced approach was used to meet the needs of both the employer and the worker.
Jodie had consented to an OH report being submitted to management. In line with best practice, she had previously discussed the referral with her line manager and had received a copy of the referral letter prior to her OH attendance.
During the initial assessment, Jodie signed a consent form allowing information about her to be shared with other professionals. As a safeguard in the event of future litigation, the OH records were signed by Jodie confirming an accurate representation of her account (Palmer et al, 2007).
Under the Equality Act 2010, CTS can be considered a disability as it is a physical impairment resulting in long-term substantial adverse effects on day-to-day activities (Office for Disability Issues, 2010). The OH assessment notes documented the family history of CTS, wrist and forearm pain and paraesthesia for the two previous years.
Work characteristics were identified from Jodie’s job description and a discussion of her job requirements. Jodie’s eagerness to return to work was noted, as well as the complex situation of her home life. Jodie cared for her mother and brothers, which implied she needed support in her carer’s role.
The yellow flags – which indicate psychosocial, workplace and other factors that increase the risk of developing disability – in Jodie’s psychosocial and occupational risk factors had been identified. Addressing these were essential, as they could delay recovery. The length of time she had been suffering from the condition could also have resulted in depression, especially as there is a family history of the illness.
As Murugiah et al (2002) suggest, the OH practitioner must examine the finer details of the client’s job specification, including essential and desirable aspects in relation to work characteristics.
The OH assessment explored load, activity level and duration, establishing that the conditions of Jodie’s work were exacerbating symptoms of paraesthesia, pain and hand weakness.
The OH practitioner must examine the finer details of the client’s job specification, including essential and desirable aspects in relation to work characteristics.”
As Jodie’s condition had deteriorated, a GP referral for a surgical assessment was made. Jodie’s manager was advised that redeployment to a non-clinical role would be advisable until post-surgical intervention, which was particularly important as Jodie was likely to be considered as disabled under the Equality Act 2010.
Evidence was recorded about Jodie’s inability to carry heavy objects and her difficulties in performing many manual tasks due to pain and/or a loss in sensitivity and strength within her hands. Details of her previous roles and tasks at the poultry factory were also documented, as were the manual tasks required in her carer role.
There is a heightened duty for employers under common law from the “eggshell skull” principle, meaning that you should take into account further harm to workers with pre-existing conditions (Kloss, 2010). “Law of tort” also applies to OH professionals where they can anticipate that certain actions will cause harm (Kloss, 2010). These legal principles guided joint decision-making and collaborative working, resulting in the advice that Jodie was given temporary redeployment, non-clinical tasks and an extended, phased return to work.
Dame Carole Black promotes collaborative working and argues it is integral to the role of OH (Department of Health, 2005; 2008). The severity of Jodie’s condition and concomitant need for redeployment resulted in collaboration with an OH physician and orthopaedic specialist.
Jodie was admitted as a day case for release of her carpal ligament and given a minimum of four weeks post-operative rehabilitation before return to work was considered.
Post-operative medication included dihydrocodeine and naproxen. A discussion about dose and the possible effects of medication had been had with Jodie to ensure that the drugs’ effects neither disguised further injury nor affected her safety at work.
Psychological and social assessment included evaluating and documenting the impact of the pain and weaknesses in Jodie’s hands both pre- and post-operatively on her mood, behaviour and speech pattern. Jodie had reported functional difficulties associated with the activities of daily living including washing, food preparation, lifting a kettle and driving. The OH team noted that her role as the family carer could also affect her recovery post-operatively by delaying healing time. The impact of these factors on Jodie’s work tasks and environment were evaluated as part of her ongoing OH assessment (Whittaker and Baranski, 2001; Gormley and Harriss, 2010).
During her rehabilitation, contact was maintained with Jodie from OH, her manager and colleagues to help prevent feelings of isolation. Prior to planning a phased return to work, there was liaison with physio-therapy to assess her functionality. HR and her manager discussed Jodie’s phased return with her and set a date for an OH review. Non-clinical tasks were initially allocated gradually, progressing up to the full healthcare assistant remit.
Jodie returned to work six weeks after her operation. A graded return to her full role took a further six weeks.
The assessment of fitness to work for Jodie by the OH practitioner examined all four aspects within Murugiah et al’s model (2002). Considerable time had elapsed from when Jodie first experienced problems to the initial OH referral. The need for education and training for managers about the optimal referral process to OH was identified, in conjunction with HR and policy and processes implemented for prompt sickness absence referral.
Jodie returned to her role in her original workplace content and able to deliver the full remit of her job.”
Allowances for Jodie’s social situation were made through a phased return to work. The psychological aspects were addressed verbally with Jodie and subjective recording of her behaviour and mood state to evaluate the impact of CTS, work and home life on her mental health. Jodie was engaged throughout the assessment, there was a clear audit trail of signatures of agreement and consent for report release with collaborative working evidenced from joint working with OH, physiotherapists, orthopaedic specialists, GP, HR and her manager.
Despite delays in referral to OH and lengthy treatment and rehabilitation periods, effective measures ensured that Jodie returned to her role in her original workplace content and able to deliver the full remit of her job.
Alison Hammond RN BSc (Hons) sport science, MPhil exercise physiology, graduate CIPD is an occupational health adviser.
Anne Harriss MSc BEd RGN OHNC RSCPHN CMIOSH is course director for occupational health nursing and workplace health management programmes at London South Bank University.
Barcenilla A, March LM, Chen JS, Sambrook PN (2012). “Carpal tunnel syndrome and its relationship to occupation: a meta-analysis”. Rheumatology; vol.51, issue 2, pp.250-261.
Bland JD (2005). “The relationship of obesity, age, and carpal tunnel syndrome: more complex than was thought?” Muscle Nerve; vol.32 issue 4, pp.527-532.
Department of Health (2005). “Health, work and wellbeing – caring for our future”. London: HMSO.
Department of Health (2008). “Working for a healthier tomorrow: Dame Carol Black’s review of the health of Britain’s working-age population”. London. TSO.
Gormley J, Harriss A (2010). Assessment exposed. Occupational Health; vol.62, issue 11.
Health and Safety Executive (2011). “Musculoskeletal Disorders”. Suffolk.
Health and Safety Executive (2012). “Health and Safety Executive annual statistics report”. Suffolk.
Jenkins PJ, Watts AC, Duckworth AD, McEachan JE (2012). “Socioeconomic deprivation and the epidemiology of carpal tunnel syndrome”. The Journal of Hand Surgery; vol.37, issue 2, pp.123-129.
Kloss D (2010). Occupational Health Law (5th edition). Chichester: Wiley-Blackwell.
Lewis J, Thornbory G (2010). Employment Law and Occupational Health: A Practical Handbook. Oxford: Wiley-Blackwell.
McArdle WD, Katch FI, Katch VL (2010). Exercise Physiology: Energy, Nutrition and Human Performance (5th edition). Philadelphia: Lippincott, Williams and Wilkins.
McNamara B (2003). “Clinical anatomy of the median nerve”. Advances in Clinical Neuroscience and Rehabilitation; vol.2, issue 6, pp.19-20.
Moghtaderi A, Izadi S, Sharafadinzadeh N (2005). “An evaluation of gender, body-mass index, wrist circumference and wrist ratio as independent risk factors for carpal tunnel syndrome”. Acta Neurologica Scandinavica; vol.112, issue 6, pp.375-379.
Murugiah S, Thornbory G, Harriss A (2002). “Assessment of fitness”. Occupational Health; vol.54, issue 4, pp.26-30.
National Institute of Neurological Disorders and Stroke (2012). Carpel tunnel factsheet.
NHS (2012). Treating carpel tunnel syndrome.
Nursing and Midwifery Council (2008). The code: standards of conduct, performance and ethics for nurses and midwives. London.
Office for Disability Issues (2010). “Equality Act 2010 guidance: guidance on matters to be taken into account in determining questions relating to the definition of disability”. London: Crown Copyright.
Ohnari K, Uozumi T, Tsuji S (2007). “Occupation and carpal tunnel syndrome”. Brain Nerve; vol.59, issue 11, pp.1,247-1,252.
Palmer KT, Cox RAF, Brown I (2007). Fitness for Work: The Medical Aspects (4th edition). Oxford: Oxford University Press.
Porth C (2011). Essentials of Pathophysiology (3rd edition). Philadelphia: Lippincott Williams and Wilkins.
Schoen DC (2002). “Upper extremity nerve entrapments”. Orthopaedic Nursing; vol.21, issue 2.
Sunderland SG (1991). Nerve Injuries and Their Repair: A Critical Appraisal. Edinburgh: Churchill Livingstone.
Werner RA, Andary M (2002). “Carpal tunnel syndrome: pathophysiology and clinical neurophysiology”. Clinical Neurophysiology; vol.113, pp.1,373-1,381.
Werner RA (2006). “Evaluation of work-related carpal tunnel syndrome”. Journal of Occupational Rehabilitation; issue 16, pp.207-222.
Whittaker S, Baranski B (2001). “The role of the occupational health nurse in workplace health management”. Copenhagen: World Health Organisation.
WorkCoverSA (2010). Carpal tunnel syndrome.