This case study concerns an individual suffering wrist pain at work. Michael Bowles and Anne Harriss demonstrate the use of an occupational health fitness to work framework and the biopsychosocial model to support a worker with a repetitive strain injury.
Thornbory (2013) suggests that the role of the occupational health advisor (OHA) has evolved considerably in recent years. Previously, for some, the role had been to offer health surveillance and provide a treatment service, a limited use of the skills of an OHA particularly as the aims of occupational health are to promote health at work and to prevent work related illnesses and injuries (Aw et al, 2007).
Many OHAs have developed a pivotal role in case management, receiving management referrals which was once the preserve of occupational physicians. This case study explores the management referral of Annette, a 56 year-old woman employed for the last eight years as a senior laboratory researcher in an internationally renowned research establishment. She has been experiencing pain associated with a repetitive strain injury (RSI).
The referral form included confirmation of the employee’s consent to the referral and detailed the employee’s work tasks and responsibilities, with questions about how the employee could be best supported, including work modifications.
If a condition falls under the Equality Act (2010) the manager must make reasonable adjustments to ensure that the employee is not being discriminated at as a result of their disability (Stationary Office, 2010).
Symptoms and impact on work
Upon meeting Annette the OHA introduced himself, explaining his role. The issue of consent was discussed and Annette confirmed her understanding of the OH service’s position on confidentiality and was happy to proceed.
She reported first experiencing symptoms consistent with that of an RSI one year previously. The frequency and severity of her symptoms had increased, she had self-managed her symptoms and had not consulted her GP. As a consequence a formal diagnosis of her condition had not been made.
Annette’s symptoms were triggered by laboratory work, specifically pipetting samples, a repetitive task involving the use of her right hand to operate a pipette (a laboratory tool commonly used to transport liquid).
Symptoms also occurred when lifting heavy objects with her right arm, particularly when moving equipment at work, lifting shopping at home or when playing tennis. Annette had been using an arm brace for support in the evenings and using topical ibuprofen gel for pain. These strategies were effective in managing her condition, but her symptoms were not improving.
Annette stated that as part of her role she has a degree of control over her work tasks. She had tried as far as possible to alternate tasks that she knew would trigger her symptoms and she delegated these where possible.
She undertakes this role on a full time basis and her working hours are 9-5 with a 40-minute lunch break. In her role Annette spends prolonged periods of time pipetting and handling samples, on average between two to four or more hours every day. She reported that her manager has generally been supportive.
In addition to her laboratory procedures, Annette also undertakes computer-based tasks that have not significantly exacerbated her condition. She had not yet taken sick leave as a result of this condition.
When asked about current medication and past medical history she reported she has been taking a maintenance dose of 2.5 mg of Ramipril daily for hypertension for 10 years and is regularly monitored by her GP. She reports that her hypertension is well controlled.
Aside from this, Annette used topical ibuprofen gel for pain relief when required. Annette reported no significant or relevant past medical history.
Annette lives with her husband, is a non-smoker and drinks alcohol occasionally, about one glass of wine at the weekend. She indicated that she is normally very active, playing tennis twice a week and attending the gym two to three times a week. Her condition has recently prevented her playing sports.
She reports normally being independent in relation to activities of daily living but has noticed the condition beginning to affect this and her recent pain and inability to undertake household tasks as before have begun to lower her mood.
Definition of repetitive strain injury
Repetitive strain injury (RSI) as defined by Aw et al (2007) was originally a term used to refer to a nonspecific pain in the upper limbs as a result of work tasks that involved repetitive movement. Aw et al report that as time progressed the term RSI has widened to involve similar effects in the lower limbs.
The terms repetitive motion injuries, cumulative trauma injury, occupational over use syndrome, work related repetitive movement disorder and work related upper limb disorders are all synonyms for repetitive strain Injury and can be used interchangeably.
Aw et al (2007) highlight that the term RSI may not always be appropriate as there is a lack of evidence to support the word injury and that static muscle loading without repetitive movements can cause conditions of this nature.
RSI is an umbrella term for a range of different clinical conditions all of which are caused by or made worse by repetitive movements. These are tenosynovitis, De Quervain’s tenosynovitis, peritendinitis crepitans, carpal tunnel syndrome and epicondylitis.
Clinically these conditions present with pain or discomfort in the muscles, soft tissues or tendons in a limb. There can be swelling, tenderness and other signs of inflammation. There can also be changes in sensations, numbness and weakness in the limb, and this is more pronounced if there is accompanying nerve involvement (Aw et al 2007).
These symptoms can be chronic, acute or recurrent. The Health and Safety Executive (HSE, 2013) highlights that employers have a duty under the Health and Safety at Work etc Act (1974) and the Management of Health Safety at Work Regulations (1999) to manage and control the risks associated with repetitive strain injuries.
The HSE (2016) states that females above the age of 45 are statistically at higher risks of developing a work-related upper limb disorder (WRULD) than those under the age of 45. The HSE (2016) highlights that around 4,112,000 days were lost in 2015 as a result of a WRULD and this on average equated to 18 days lost per case.
Occupational health role
The OHA’s role is to assess the client’s fitness to work. This is done so that effective advice and information that is beneficial to both the client and employer can be given.
This case was managed using the fitness for work framework of Murugiah, Thornbory and Harriss (2002) and the bio-psychosocial model of case management.
The fitness to work framework Murugiah et al (2002) facilitates a consistent, transparent method of assessing client’s fitness to work. There are four specific areas integral to this model: the personal aspect, legal aspects, the characteristics of work tasks and of the workplace environment:
- The personal aspect relates to the assessment of the client, it highlights that the assessment must be individual to the client and must be based around the client’s work role.
- The legal aspect highlights that the advice given by the OHA has been used by industrial tribunals in the past and that information and advice given must be based on sound principals that are legal and clear.
- Characteristics of work highlight that when assessing clients the employee’s symptoms and health should be compared and contrasted against the work the employee does. This involves the OHA having a thorough understanding of the employee’s role and their required skill set.
- The workplace environment highlights that although able-bodied people may be able to carry out a task without issue, those returning to work following illness or impairment may become a hazard to themselves or others.
The bio-psychosocial model is a holistic approach to assessing patients (Vivian, 2014). It utilises a flag system with each flag representing a different holistic area: red flags deal with the biological issues; yellow with psychological factors; blue with social factors; and black with financial issues.
This provides a systematic framework to identify barriers to work. RSI symptoms can be very pervasive and affect multiple aspects of a person’s life, therefore a psychological and holistic assessment is important in creating an effective health management plan (Schultz et al, 2012).
The consultation commenced with a discussion regarding what the client knows about OH and confidentiality and consent. Without consent the OHA cannot continue the consultation (Richards and Edwards, 2008).
OH sits between HR, the client and the manager, therefore confidentiality should be discussed and the client made aware that their information is kept confidential as this is a requirement of the Nursing and Midwifery Code (NMC, 2015).
Developing a rapport with the client is essential as without this they may not divulge all the information required to make the proper recommendations. The issues of confidentiality were explained and Annette was happy to have the consultation.
A full history was taken. The red flags for Annette were that work tasks may be associated with hand and wrist pain and weakness. If left to progress this could have long-term health effects impacting on her working in her current role.
The PQRST Pain Assessment Method was used to accurately assess Annette’s pain. The acronym PQRST stands for Provocation/Palliation, Quality of the pain, Region/Radiation, Severity Scale and Timing as reported by Krohn (2002).
The method indicated that specific tasks triggered her symptoms. The steps she has taken to alleviate her symptoms have not been totally effective in remedying the problem.
Pain relief had been partially effective. The pain was focused predominately in the hand and wrist, but had recently radiated to the forearm and upper arm around the deltoid region. She reported that her pain on a scale oscillated between two out of ten but when symptoms flared up this increased to eight out of ten.
She described her pain as generally a dull ache with sharp shooting pains when lifting or undertaking specific tasks including pipetting. Annette stated that initially her pain presented predominately in the evening following significant amounts of pipetting but that this now occurred when performing any pipetting task.
She had less pain at weekends and in the morning. She self-medicated with topical ibuprofen gel (5% strength) when necessary. This non-steroidal anti-inflammatory drug is recommended as a possible treatment by NHS Choices (2016).
There were no co-morbidities that would have an impact on her symptoms. She reported reduced grip strength in her right hand and this was confirmed when she gripped the hand of the OHN.
The yellow flag for Annette was her belief that her condition would improve over time. She had initiated proactive steps including using a hand/wrist brace and alternating tasks.
She had not consulted her GP as securing an appointment had been difficult and she believed her symptoms would dissipate in time. This is a barrier to work: without appropriate treatment the symptoms were worsening, culminating with her being unable to continue with her work.
Psychologically, Annette generally reported good mood but described frustration with the impact of her pain on her carrying out activities of daily living, such as lifting shopping, washing and driving for long periods which proved painful and difficult.
This can also be seen as a work barrier as pain is known to cause negative mental health issues and can exacerbate or lead to feelings of stress and anxiety resulting in lowered self-esteem, Devereux et al (2004) state that stress and strain can help bring on the emergence of RSI symptoms and can exacerbate these due to constant muscle tensing.
Annette reported good coping strategies to manage this, including meditation, and good social support from friends and family. Annette did not report any unhealthy coping mechanisms such as smoking or high alcohol intake. During the consultation Annette appeared well groomed and dressed and maintained good eye contact throughout.
As Annette had a good locus of control in her work and had few barriers to work that fall within the blue flag category or social issues. Annette did not highlight any issues regarding colleagues and indicated that she enjoyed her role.
Schultz et al (2012) highlight that employees experiencing burnout symptoms at work are more likely to present with RSI symptoms compared to those who are highly engaged.
Annette did indicate that she sees her manager infrequently and this could be seen as a barrier to work in that there may be fewer opportunities for the manager and Annette to discuss and review how she is progressing.
The black flag represents financial and legal issues. Annette was still able to work and there were no direct financial ramifications. Therefore there did not appear to be any barriers to work within this category.
Advice given by OHAs should be clear, based on the employee in question and implementable in the work place. It is for the manager and the courts to indicate what is feasible, reasonable and practical and as Palmer (2013) reports the role of the OHA is to provide impartial advice/recommendations.
Annette was considered fit for work and could continue to work with suitable adjustments including careful task rotation and discontinuing the use of a manual pipette.
Recommendations to OH client and her manager
The following recommendations were suggested to Annette and her manager:
- A referral to an occupational physiotherapist as recommended by Aw et al (2007) and Keller et al (1998). With early intervention a good prognosis is expected.
- A further risk assessment was indicated and consideration of providing an electronic pipetting device. Implementing new technology within the workplace may help in the management of Annette’s health and also prevent others from developing similar symptoms.
- Undertaking pipetting for short periods with frequent alternating tasks. Short breaks while at work would minimise the strain on her hand. As part of her role Annette must avoid tasks that may exacerbate her symptoms such as manual pipetting and possibly tasks involving the use of display screen equipment (DSE). Voice activated software was a further consideration in relation to reducing keyboard tasks. Aw et al (2007) advise that job rotation and short break periods are ways of preventing and managing RSI conditions at work.
- Annette was advised to consult her GP for a diagnosis, a review of the analgesia she was taking and consideration of a referral for other treatment such as physiotherapy. As RSI is a heading under which many conditions falls an accurate diagnosis of the condition allows for more specific and effective treatment (Helliwell and Taylor, 2004).
- It was recommended that Annette and her manager arrange regular meetings to review her progress.
Annette was emailed a copy of the report and was happy for the recommendations to be released to her manager and HR. As her manager implemented all the recommendations, the case was closed with the proviso that Annette could self refer or the manager could refer her for a further OH review should her symptoms not resolve.
In conclusion, RSI’s affect: the employer through lost time from work, and loss of productivity: the employee, in loss of earnings, pain and a reduction in quality of life.
Without proper treatment and advice there was a high probability that Annette would have been unable to carry on her role. The employer has a legal responsibility to try to alleviate and reduce health and safety issues to employees under the Health and Safety at Work etc Act (1974) and the Management of Health and Safety at Work Regulations (HSE 2013).
Michael Bowles RGN, BSc (Hons), SCPHN (OH) is a specialist practitioner in occupational health. Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, NTF, PFHEA, CMIOSH, FRCN is Professor in occupational health, London South Bank University.
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