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2	WORK-RELATED MUSCULO-SKELETAL DISORDERS (WRMSD): Overview & Epidemiology Clinical & Compensation aspects
3	Overview OVERVIEW & EPIDEMIOLOGY History Legal Definitions Models of causation Risk factors CLINICAL & COMPENSATION ASPECTS Classification Specific clinical conditions Compensation
4	OVERVIEW & EPIDEMIOLOGY History Legal Definitions Models of causation Risk factors
5	The most important skill you need… COMMON SENSE
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7	Case study: Clinical signs Crepitus (crackling sound in subcutaneous tissue) Muscle spasm Muscle weakness Reduction of range movement Swelling Tender trigger points in muscles Tenderness
8	Case study: Progression of disease I STAGE 1 Pain, aching & tiredness of limb during work Improve overnight Most often reversible with rest alone Sometimes guided exercise and treatment is required
9	Case study: Progression of disease II STAGE 2 Recurrent pain, aching and tiredness earlier in day Persist at night and may disturb sleep Physical signs (e.g. swelling) may be visible
10	Case study: State progression of disease III STAGE 3 Persistent pain, aching, weakness and fatigue even if not been working for some time Sleep is often disturbed This can be irreversible if it is not treated appropriately
11	So what…. De Quervain’s syndrome and Carpal Tunnel Syndromes were diagnosed during the past 2 years She received steroid injections into the relevant tendon sheaths Twice surgery Only little improvement And now it is “all in the mind”…
12	Stupid… R40,000 later (pain & suffering & loss of income excluded) Nobody ever asked her “WHAT ARE YOU DOING AT WORK?” … !!!@#$%^&*()!@#$%^&&?!!! Typical doctor / specialist …???!!!
13	WHO Definition of work-related musculoskeletal disorders 1: Results from a number of factors where the work environment and the performance of the work contribute significantly, but in varying magnitude, to the causation of the disease. Some of the disorders have well defined signs and symptoms E.g. rotator cuff tendinitis, carpal tunnel syndrome and acute prolapsed inter-vertebral disc.
14	WHO Definition of work-related musculoskeletal disorders 2: Many others are less well defined: E.g. myalgic conditions involving pain, discomfort, numbness and tingling sensations throughout the neck shoulders, upper limbs and lower back. These types of disorder, that are sometimes called non-specific WMSDs, often cannot be diagnosed with respect to a clinical pathology but they may still result in physical impairment and disability.
15	WHO Definition of work-related musculoskeletal disorders 3: WMSDs therefore, cover a wide range of inflammatory and degenerative diseases of the locomotor system. They include: Inflammations / degenerations of tendons (tendinosis, tendinitis and tenosynovitis), especially in the forearm-wrist, elbow and shoulder, evident in occupations involving prolonged periods of repetitive and static work; myalgias, i.e. pain and functional impairments of muscles, occurring predominantly in the shoulder-neck region, that occur in occupations with large static-work demands;
16	WHO Definition of work-related musculoskeletal disorders 4: compression of nerves – entrapment syndromes – occurring especially in the wrist and forearm; degenerative disorders occurring in the spine, usually in the neck or lower back, especially in those performing manual handling or heavy physical work. However, they may also occur in the hip or knee joints. These disorders are chronic, and symptoms usually occur only after exposure to work-related risk factors for a period of time.
17	Draft amendment of Schedule 3 of COID Act (130 0f 1993) – 7 Nov 2003 2.3. Occupational musculo-skeletal disorders 2.3.1 Musculo-skeletal diseases caused by specific work activities or work environment where particular risk factors are present. Examples of such activities or environment include: (a) rapid or repetitive motion (b) forceful exertion (c) excessive mechanical force concentration (d) awkward or non-neutral postures (e) vibration
18	Definition: Work-related Upper Limb Disorder (WRULDs) (CI 180) WRULDs is a collective term for a group of occupational diseases that consist of musculo-skeletal disorders caused by exposure in the workplace affecting tissues (muscles, tendons, nerves, blood vessels, joints and bursas) of the hand, wrist, arm and shoulder.
19	Historical Perspective Alternative Names Repetitive Strain Injury (RSI) – Australia Cumulative Trauma Disorder (CTD) – USA Occupational Cervicobrachial Disorder – Japan & Sweden Work-related upper limb disorder (WRULD) – E.U.
20	Historical Perspective I Not a new problem 1713: Ramazzini – serious disease caused violent and irregular motions and unnatural postures of the body". Scrivener's Palsy – incessant driving of pewn over paper causes intense fatigue of hand & arm because of continuous strain of the muscles & tendons
21	Historical Perspective II 1830s: Sir Charles Bell writer’s cramp in male clerks in British Civil Service steel nibs vs goose-quill pens Late 19^th Century: musicians, telegraphists, cowherds, hammersmiths, seamstresses, bricklayers, etc.
22	Historical Perspective III Telegraphist’s cramp Hop picker’s gout Fisherwoman’s finger Upholsterer’s hand Gamekeeper’s thumb Cotton-twister’s hand Tennis elbow Pizza-cutter’s wrist Nintendonitis (Nintendo^® play station – ‘computer game wrist’ in children)
23	Historical Perspective IV OCD Epidemic (Japan) 1960 - 1980 Keypunch operators 16-28% Typists 13% Cash register operators 11-16% Packing machine operators 12% Assembly line workers 16%
24	Historical Perspective V 1964 Ministry of Labour Guidelines (Japan) Work maximum of 5 hours/day Take 10 minutes rest / hour Do less than 40,000 keystrokes / day Job Rotation
25	Historical Perspective VI Mid 1980’s – Australian RSI Epidemic Data processors g all screen-based operators 1978/9 = 762 cases 1981/2 = 2263 cases (h 297%)
26	Historical Perspective VII Telecom Australia 1981 - 1985 90,000 employees 3976 cases of RSI Cost $15,5 million $1,8 million medical cost (excluding common law claims)
27	Historical Perspective VIII RSI Definition Collective term - range of conditions characterised by discomfort or persistent pain in muscles, tendons and other soft tissues, with or without physical manifestations Usually caused or aggravated by work, thought to be associated with repetitive movements, sustained or constrained postures and/or forceful movements Psychosocial factors, including stress in the working environment, may be important in the development of RSI National Occupational Health & Safety Commission (1986)
28	Historical Perspective IX Who developed RSI? Young (±40 years) Women with children at home Stomach-related stress conditions Smokers Progressive glasses and/or bifocals Did not exercise Poor social conditions Monotonous work Lack of job control Recent increase in workload
29	Historical Perspective XI RSI controversy A psychosomatic symptom complex (epidemic of mass hysteria) Socio-political phenomenon vs. medical condition
30	Historical Perspective XIII Supreme Court of Australia Cooper vs. Commonwealth (1987) Employer not guilty of negligence Plaintiff had no injury Awarded all costs against the plaintiff
31	Historical Perspective XIV Australian Hand Surgery Society Resolution (1985) RSI = an occupational neurosis Not associated with localised pathology Reversible with normal use No residual, permanent disability
32	WRULDs – Historical Perspective XV Medical Journal of Australia (1986) Editorial decision to publish articles that emphasised the non-physical nature of RSI
33	Historical Perspective XVI CTD Epidemic in USA (1990s) Vague definition Epidemic spread Treatment unsuccessful Self-employed unaffected Repetitive, monotonous tasks Low job satisfaction
34	Historical Perspective XVII WRULD – UK & Europe Regional Pain Syndrome Work-related and non-occupational risk factors E.g. carpal tunnel syndrome
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36	Cost of WRULDs II European Union WRULDs cost Nordic Countries –0,5% GNP Netherlands – 2% GNP UK £1.25 billion per year Sources: HSE (1996) EU Agency for Safety & Health at work (1990)
37	Cost of WRULDs III South Africa Limited data – need research WRULDs expected to be higher than industrially developed countries – h excessive physical demands made on workers SAMOSA (SA Musculoskeletal Surveillance Action Group)
38	Cost of WRULDs IV Direct & indirect costs
39	WRMSD - Models of causation 1 1. Biomechanical Excessive loads, force, repetition Abnormal postures ê Compression. Ischaemia. Microtears. Muscle fatigue. Metabolic changes. Inflammation. 2. Psychosocial Somatising disorders (e.g. work stress, depression) Industrial relations conflict changing nature of work medicalised via workers' compensation
40	WRMSD - Models of causation 2 3. latropenic-(Hadler) High background rate of aches and pains Misattribution to work as primary cause 4. Technological Automation, specialisation, electronic data processing
41	WRULDs - Risk Factors 1 WRULDs are caused, aggravated or precipitated by one or more of the following risk factors, singly or in combination: Task-related factors highly repetitive upper limb movements awkward and/or static working postures Movements at the extremes of reach Contact stress (e.g. uncomfortable gripping and twisting, sharp edges to hand tools, desk edges, etc.) high force requirements duration of exposure to tasks
42	WRULDs - Risk Factors 2 Environmental-related factors Vibration Low temperatures (Cold) Lighting Work organisation (e.g. rotation, hours, shifts, high task pressure, conveyor belt))
43	WRULDs - Risk Factors 3 Psychosocial factors 1 Job dissatisfaction: + Monotonous work: ++ Perceived intensified work load: ++ Lack of job control: ++ Lack of job clarity: ++ Job stress leading to excessive pressure such as high job demands, time pressures and lack of control;
44	WRULDs - Risk Factors 4 Psychosocial factors 2 Depression / burn out / affirmative action Lack of social support from supervisors or co-workers; tasks requiring high levels of attention and concentration are related to increased muscle tension, changing thresholds for the perception of pain and fatigue. “compensitis”
45	WRULDs - Risk Factors 5 Individual differences All individuals are different and for biological reasons there may be some people who are more or less likely to develop an WRULDS. Individual differences may also have implications for employees reporting WRULDS type conditions. Genetic predisposition new employees - time to acquire the necessary work skills and/or rate of work; difference in competence and skills;
46	WRULDs - Risk Factors 6 Individual differences cont… Anthropometry - workers of varying body sizes, ie height, reach etc.; vulnerable groups, eg older, younger workers and new or expectant mothers; Gender health status and disability; individual attitudes or characteristics that may affect compliance with safe working practices or reporting of symptoms . Smoking: Some association with LBP
47	LOWER BACK PAIN -RISK FACTORS Occupational Heavy manual labour Lifting, twisting, awkward motions Sitting Driving, whole body vibration Shorter duration of employment ? Psychosocial: monotonous work, low motivation, lower rating by supervisor
48	LOWER BACK PAIN -RISK FACTORS Non-occupational Smoking Taller More births Heavy alcohol
49	Work-relatedness of MSD: Physical work risk factors 1
50	Work-relatedness of MSD: Physical work risk factors 2
51	Work-relatedness of MSD: Physical work risk factors 3
52	Work-relatedness of MSD: Physical work risk factors 4
53	Work-relatedness of MSD: Physical work risk factors 5
54	Work-relatedness of MSD: Physical work risk factors 6
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56	CLINICAL & COMPENSATION ASPECTS Classification Specific clinical conditions Compensation
57	Classification Types of WRULDS 1 TYPE 1 Well-defined musculo-skeletal conditions & nerve entrapment syndromes affecting the upper limbs Carpal Tunnel Syndrome, De Quervain’s Relatively clear cut characteristics & established treatment methods
58	Classification Types of WRULDS 2 TYPE 2 Regional Pain Syndrome Widespread dissemination of symptoms between neck & hand Regional allodynia & hyperalgesia g neural sensitisation & pain
59	Classification According to affect on specific tissue Tendon-related disorders Nerve-related disorders Bursa-related disorders Blood vessel disorders Other
60	Classification Tendon-related disorders I Tendonitis Confusion with terminology Rare condition Inflammation of tendon & tendon muscle (e.g. Achilles tendon in conjunction with tendinosis) Promote collagen production & reduce paratendon inflammation
61	Classification Tendon-related disorders II Tendinosis - common Sports Medicine Intratendinous collagen degeneration due to Aging Microtrauma (chronic overuse repetitive movements) Vascular compromise Examples: epicondylitis, rotator cuff syndrome
62	Classification Tendon-related disorders III Treatment of tendinosis Combat collagen breakdown Relative rest for reasonable period Strengthening and graduated loading of tendon (eccentric) Facilitate collagen production & maturation gnormal strength
63	Classification Tendon-related disorders IV Tenosynovitis Rapid repetitive movements especially of hands and fingers g Inflammation of synovial lining of the tendon sheath g swelling g pain g restricted movement of tendon in sheath Repeated exposure g hscar tissue g h pain g imobility g istrength Examples: Trigger Finger, De Quervain’s
64	Classification Nerve-Related Disorders I Nerves need to undergo mechanical changes (compression, elongation, cross-sectional changes, etc.) for normal functioning â mechanical changes g physiological changes (âaxoplasmic flow, etc.)
65	Classification Nerve-Related Disorders II Dysfunctional nerve g Pain Paraesthesia Sensory changes in areas supplied by nerve
66	Classification Nerve-Related Disorders III Carpal Tunnel Syndrome Pronator Teres Syndrome Cubital Tunnel Syndrome Guyon tunnel Syndrome Radial Tunnel Syndrome Anterior Interosseous Nerve Syndrome Posterior Interosseous Nerve Entrapment, etc.
67	Classification Bursa-related disorders Fluid-filled sacks that protect muscles, tendons & skin from friction against bones during joint movement Overexertion g inflammation (bursitis) g swelling & dull, aching pain Examples: Olecranon bursitis (beat elbow) Subacromial burisits Subdeltoid bursitis
68	Classification Blood-vessel disorders Usually due to vibration or hammering g vasospasm & i circulation Excessive exposure g i circulation + neurological findings (i motor function of hand and arm) Examples: Raynaud’s Phenomenon Hand Arm Vibration Syndrome Hypothenar Hammer Syndrome
69	Classification Other Disorders Effect on muscles and joints Problematic to prove objectively Controversial Static loading Occurs proximally when repetitive movement occurs distally Static loading g muscle imbalances & trigger points g pain Examples: Tension neck syndrome, myalgia, strains, etc.
70	Shoulder Rotator Cuff Syndrome I Bicipital tendinosis Infraspinatus tendinosis Partial tear of the rotator cuff Subacromial bursitis Subdeltoid bursitis Subscapularis tendinosis Supraspinatus tendinosis Tendinosis of the shoulder
71	Shoulder Rotator Cuff Syndrome II Executing repetitive overhead movements, static loading and/or sustained postures. Prone to develop bursal side tears secondary to impingement Sign of rotator cuff lesions = pain exacerbated by abduction against resistance.
72	Shoulder Rotator Cuff Syndrome III Limited by pain towards the end of the active range of movement Passive range of motion ± normal Acute rotator cuff tendinosis ≤12 weeks duration. Chronic rotator cuff rupture = marked difficulty initiating abduction with weakness and limitation of movement “painful arc” - 70^o to 120^o abduction
73	Shoulder Job activities and tasks typically associated with rotator cuff syndrome Belt conveyor assembly Carrying load on shoulders Construction work Electrical work Lifting Overhead assembly Overhead painting Overhead welding Packing Punch press operation Reaching Work with the arms away from the body
74	Shoulder Other work-related shoulder conditions Rupture of the long head of the biceps Pectoralis major strains Levator scapulae syndrome Fractures around the shoulder joint.
75	Elbow Lateral Epicondylitis I “Tennis Elbow” - Pain at epicondyle
76	Elbow Lateral Epicondylitis II Often starts as an acute direct injury to the site of the muscle origin which progresses to an epicondylitis Work action: Unusual forces (power grasp), Repetition Forceful gripping Repeated supination and pronation.
77	Elbow Medial Epicondylitis (“Golfer’s Elbow”) Overuse of finger flexors wrist flexors / pronators
78	Elbow Cubital Tunnel Syndrome Resting forearm near elbow on a hard surface Resting forearm near elbow on sharp edge Resting forearm near elbow while reaching over obstruction Repetitive or static elbow flexion
79	Forearm, Wrist & Fingers De Quervain’s Tenosynovitis I Stenosing tenosynovitis of the abductor pollices longus and extensor pollices brevis tendons Tendons of the forearm are stretched and rub against the radial styloid g inflammation of tendon sheath
80	Forearm, Wrist & Fingers De Quervain’s Tenosynovitis II Presents with pain & localised swelling over styloid process of radius Common variant : localised swelling at base of the thumb & thickening of fibrous sheath (extensor retinaculum).
81	Forearm, Wrist & Fingers De Quervain’s Tenosynovitis III De Quervain’s can results from overuse of the thumb such as in the repetitive grasping of a straight handled tool (e.g. screwdriver, endo files of dentist).
82	Forearm, Wrist & Fingers De Quervain’s Tenosynovitis IV Diagnostic criteria Pain and tenderness localised to the radial aspect of the wrist PLUS positive Finkelsteins's test Sometimes a palpable nodule in course of Abd. pollicis longus & Ext. pollicis brevis.
83	Forearm, Wrist & Fingers De Quervain’s Tenosynovitis V Differential Diagnoses Degenerative arthritis of trapeziometacarpal joint Grind Test Painful in degenerative arthritis No, little pain in De Quervain's
84	Forearm, Wrist & Fingers De Quervain’s Tenosynovitis VI Differential Diagnoses Degenerative arthritis of trapeziometacarpal joint Post-partum women Intersection Syndrome Wartenberg's Syndrome Radial sensory nerve entrapment causing significant pain in the lower third of the forearm
85	Forearm, Wrist & Fingers Trigger Finger / Thumb I Stenosing tenosynovitis and/or tendinosis of flexor tendons Inability to move fingers or thumb smoothly Locking of affected digit, with or without pain.
86	Forearm, Wrist & Fingers Trigger Finger / Thumb II Hand tools that have sharp edges pressing into the tissue Hand tools whose handles are too far apart for user. Repetitive movements with repeated or prolonged gripping or pinching can also cause operating trigger finger. Investigate concomitant diseases and/or other reasons for trigger finger rheumatoid arthritis diabetes, etc.
87	Forearm, Wrist & Fingers Carpal Tunnel Syndrome I Condition which results from direct or indirect pressure on nerves Common ailment affecting the wrist and hand Majority of cases not caused by work
88	Forearm, Wrist & Fingers Carpal Tunnel Syndrome II Specific occupations where wrists are in abnormal positions for prolonged periods with highly repetitive movements â Tenosynovitis of flexor tendons â Pressure on the median nerve in the carpal tunnel Buffing Grinding Prehensile task especially in extremes of flexion, extension and ulnar deviation Assembly work Typing Packing Scrubbing Hammering Repetitive or forceful grip VDT work Polishing Sanding
89	Forearm, Wrist & Fingers Carpal Tunnel Syndrome III SYMPTOMS Symptoms start with a gradual onset of tingling and numbness in the fingers Can progress to pain Clumsiness muscle atrophy in the hand.
90	Forearm, Wrist & Fingers Carpal Tunnel Syndrome IV CLINICAL DIAGNOSIS Positive Tinel’s Sign pain, numbness, or tingling in the median nerve distribution resulting from tapping over the proximal wrist crease PLUS Positive Phalen’s sign or reverse Phalen’s sign pain, numbness, or tingling in the median nerve distribution resulting from complete palmar flexion and dorsiflexion respectively, of the wrist for 60 seconds
91	Forearm, Wrist & Fingers Carpal Tunnel Syndrome V CARPAL TUNNEL AS INJURY Direct injury to the wrist area Acutely haematoma g pressure on the nerve More sub acutely like a fracture g swelling / deformity.
92	Forearm, Wrist & Fingers Flexor/Extensor tendinosis/tenosynovitis Punch press operation Assembly work Wiring Packaging Use of pliers Buffing Grinding Polishing Sanding Punch press operation Sawing Cutting Use of pliers “Turning” controls such as on motorcycle Inserting screws in holes Forceful hand wringing
93	Forearm, Wrist & Fingers Other work-related hand and wrist conditions Radial Tunnel Syndrome Guyon (Ulnar) Tunnel Syndrome Pronator Teres Syndrome Anterior & posterior Interosseous Syndrome Intersection Syndrome.
94	Diagnosis Principles of diagnosis I Medical assessment Medical history The employee’s current medical history: site and distribution of the symptoms quality (type, character) severity (intensity, frequency, duration) progression of the symptoms. Physical examination Special investigations
95	Diagnosis Principles of diagnosis II Functional capacity evaluation E.g. the employee is able to type, but develops symptoms after continuous typing for 30 minutes.) This might be simple and straightforward … in complicated cases a formal occupational therapy and / or physiotherapy assessment Job analysis / Ergonomic assessment Assess the employee’s working environment(s) for human and environmental risk factors.
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97	Diagnosis Symptoms Burning sensation Fatiguability Loss of grip strength Loss of normal sensation Muscle spasm Muscle weakness Pain Paraesthesia (tingling) Sensation of cold Swelling
98	Diagnosis Clinical signs Crepitus (crackling sound in subcutaneous tissue) Muscle spasm Muscle weakness Reduction of range movement Swelling Tender trigger points in muscles Tenderness
99	Diagnosis PLEASE NOTE THAT… Symptoms may not always be accompanied by objective signs Any one symptom or sign is not indicative of WRULDs and some may be common with normal function Very few sufferers experience all the symptoms The symptoms do not appear in any particular order
100	Diagnosis State progression of disease I STAGE 1 Pain, aching & tiredness of limb during work Improve overnight Most often reversible with rest alone Sometimes guided exercise and treatment is required
101	Diagnosis State progression of disease II STAGE 2 Recurrent pain, aching and tiredness earlier in day Persist at night and may disturb sleep Physical signs (e.g. swelling) may be visible Refer for physiotherapy and ergonomic assessment to prevent recurrence
102	Diagnosis State progression of disease III STAGE 3 Persistent pain, aching, weakness and fatigue even if not been working for some time Sleep is often disturbed This can be irreversible if it is not treated appropriately
103	Diagnosis History of occupational exposure I Require summary of work environment work process work actions If necessary, photos, diagrams and/or extra reports to explain the employee’s work actions may be very helpful
104	Diagnosis History of occupational exposure I RISK FACTORS Repetitive actions with short cycles Forceful movements Static loading of muscles Any postures held for a long time, especially awkward postures. Forceful gripping and twisting Poor work organisation – low level of control over work rate and no breaks
105	Diagnosis History of occupational exposure II RISK FACTORS Psychosocial stress at work and fatigue Cold environment or handling chilled or frozen products Vibration Overhead working postures or jobs with minimal movement and non-optimal sustained postures. High-risk jobs - Combination of repetitive, forceful movements, awkward postures, static loading
106	Diagnosis Special investigations Perform special investigations if it is essential for the accurate diagnosis and treatment of the disorder to investigate and eliminate other causes Examples X-rays strength testing range of motion testing electromyography (EMG) analysis isokinetic dynamometry Get prior authorisation for MRI scans
107	Treatment Employee Education OHP: explain pathology of tendinosis Most vulnerable employees Those with symptoms of short duration and still able to work Should they continue without Rx g exacerbate condition
108	Treatment Anti-inflammatory Strategies Cryotherapy (ice) Electrotherapeutic modalities (Physiotherapy) Non-steroid anti-inflammatory drugs (e.g. Voltaren) Infiltration with corticosteroids Inhibits collagen repair g avoid
109	Treatment Biokinetic and ergonomic strategies I Initial treatment may include rest Compression and elevation Temporary job change
110	Treatment Biokinetic and ergonomic strategies II Biomechanical deloading Collagen degeneration & mechanical overload g tendinosis Mechanical overload due to Work environment Work tasks (repetition, force, posture, vibration, etc.) Individual biomechanics (trigger points, muscle imbalances) Correct biomechanics Movement patterns muscle imbalances Equipment used / environment
111	Treatment Biokinetic and ergonomic strategies III Immobilise – Splintage (occupational therapy) Load-decreasing devices imechanical load on collagen Splints Braces Supports Examples Tenosynovitis of forearm, wrist, fingers, etc.
112	Treatment Biokinetic and ergonomic strategies IV Mobilise – manual therapy (physiotherapy) Mobilise – exercise therapy to appropriately strengthen the tendons and muscles. Graded loading of tendon g improved collagen alignment & cross linkage g improved strength Eccentric training drills g stimulate mechanoreceptors in tenocytes g hcollagen production Collagen production key to tendinosis recovery Re-introduction to the workplace (Work hardening and ergonomics adjustments)
113	Treatment Psychology & Surgery Pscychological evaluation Surgery where indicated as last resort
114	Treatment Coordinated effort Interaction with the therapist OMP, OHN, employee, employer, physiotherapist, occupational therapist, biokinethesist, ergonomist, medical specialist g Similar understanding of tendinosis pathology Coordinated approach Realistic time frame for rehab (months, not weeks) Short duration symptoms ~ resolve fully in 2-3 months Chronic symptoms ~ 4-6 months
115	Treatment Algorithms For the OHN as primary contact For the OMP to work up the case Reporting to the Compensation Commissioner (OMP) Reporting to Dept Labour / DME (Employer)
116	Compensation of WRULDs A reportable occupational disease to the Compensation Commissioner Inspectorate of the nearest Dept of Labour Minerals and Energy An occupational medicine practitioner should preferably do the notification.
117	Circular Instruction 180 Occupational Disease vs. Occupational Injury Occupational Disease = WRULD caused by repetitive movements (¹ injury ) Occupational Injury = Complication of initial occupational injury Example: Fracture of the forearm Ú Tenosynovitis (because no work hardening) Here WRULD should be reported to Compensation Commissioner on the Progress Medical Reports i.t.o. occupational injury.
118	Circular Instruction 180 Compensation & Prevention (COIDA & OHSA/MHSA) Report to the Compensation Commissioner so that payment of medical costs, sick leave and compensation could be considered in terms of the COID Act. Prevention: Report to Provincial Executive Manager of Labour / Regional Principal Inspector of Mines
119	Reporting to the Compensation Commissioner 1 W. Cl. 1 Employer’s Report of an Occupational Disease W. Cl. 14 Notice of an Occupational Disease and Claim for Compensation W. Cl. 110 Occupational Exposure
120	Reporting to the Compensation Commissioner 2 W. Cl. 301 First Medical Report in respect of a Work-Related Upper Limb Disorder (WRULD) W. Cl. 301 must be used instead of the usual W. Cl. 22 All other reports that may be relevant
121	Reporting to the Compensation Commissioner 3 W. Cl. 6 Monthly Resumption Report W. Cl. 302 Progress/Final Medical Report in respect of a Work-Related Upper Limb Disorder (WRULD) Progress medical reports - monthly W. Cl. 302 must be used instead of the usual W. Cl. 26
122	Evaluation of Impairment Description of residual impairment by the treating doctor (W. Cl. 302) Most employees will recover and return to work only a small percentage will suffer any permanent residual impairment.
123	Permanent impairment will be assessed after (I): Medical treatment Vocational rehabilitation, which includes Optimising the person’s functional ability through rehabilitation that includes work hardening, work conditioning, etc.
124	Permanent impairment will be assessed after (II): Addressing problem areas identified in the job analysis / ergonomic assessment by allowing alterations in the way in which work is performed through reasonable accommodation: workplace environment adaptation tool and equipment adaptation workstation redesign job task modification retraining and reassignment work schedule modifications
125	Reporting to Labour / DME
126	Reporting to Labour / DME
127	Reporting to Labour / DME
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