Slide 1

WORK-RELATED
MUSCULO-SKELETAL DISORDERS
(WRMSD):
 
Overview & Epidemiology
Clinical & Compensation aspects

Overview

	OVERVIEW & EPIDEMIOLOGY
	History
	Legal Definitions
	Models of causation
	Risk factors
	CLINICAL & COMPENSATION ASPECTS
	Classification
	Specific clinical conditions
	Compensation

OVERVIEW & EPIDEMIOLOGY

	History
	Legal Definitions
	Models of causation
	Risk factors

The most important skill you need…

	COMMON SENSE

Slide 6

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

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

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

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

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”…

Stupid…

	R40,000 later (pain & suffering & loss of income excluded)
	Nobody ever asked her “WHAT ARE YOU DOING AT WORK?” …
	!!!@#$%^&*()!@#$%^&&?!!!
	Typical doctor / specialist …???!!!

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.

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.

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;

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.

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

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.

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.

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

Historical Perspective II

	1830s: Sir Charles Bell
		writer’s cramp in male clerks in British Civil Service
		steel nibs vs goose-quill pens
	Late 19th Century:
		musicians, telegraphists, cowherds, hammersmiths, seamstresses, bricklayers, etc.

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)

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%

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

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%)

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)

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)

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

Historical Perspective XI
RSI controversy

	A psychosomatic symptom complex (epidemic of mass hysteria)
	Socio-political phenomenon vs. medical condition

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

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

WRULDs – Historical Perspective XV
Medical Journal of Australia (1986)

	Editorial decision to publish articles that emphasised the non-physical nature of RSI

Historical Perspective XVI
CTD Epidemic in USA (1990s)

	Vague definition
	Epidemic spread
	Treatment unsuccessful
	Self-employed unaffected
	Repetitive, monotonous tasks
	Low job satisfaction

Historical Perspective XVII
WRULD – UK & Europe

	Regional Pain Syndrome
	Work-related and non-occupational risk factors
		E.g. carpal tunnel syndrome

Slide 35

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)

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)

Cost of WRULDs IV
Direct & indirect costs

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

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

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

WRULDs - Risk Factors 2

		Environmental-related factors
		Vibration
		Low temperatures (Cold)
		Lighting
		Work organisation (e.g. rotation, hours, shifts, high task pressure, conveyor belt))

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;

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”

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;

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

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

LOWER BACK PAIN -RISK FACTORS Non-occupational

	Smoking
	Taller
	More births
	Heavy alcohol

Work-relatedness of MSD:
Physical work risk factors 1

Work-relatedness of MSD:
Physical work risk factors 2

Work-relatedness of MSD:
Physical work risk factors 3

Work-relatedness of MSD:
Physical work risk factors 4

Work-relatedness of MSD:
Physical work risk factors 5

Work-relatedness of MSD:
Physical work risk factors 6

Slide 55

CLINICAL &
COMPENSATION ASPECTS

	Classification
	Specific clinical conditions
	Compensation

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

Classification
Types of WRULDS 2

	TYPE 2
	Regional Pain Syndrome
	Widespread dissemination of symptoms between neck & hand
	Regional allodynia & hyperalgesia g neural sensitisation & pain

Classification
According to affect on specific tissue

	Tendon-related disorders
	Nerve-related disorders
	Bursa-related disorders
	Blood vessel disorders
	Other

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

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

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

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

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.)

Classification
Nerve-Related Disorders II

	Dysfunctional nerve g
		Pain
		Paraesthesia
		Sensory changes
		in areas supplied by nerve

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.

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

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

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.

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

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.

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” -  70o to 120o  abduction

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

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.

Elbow
Lateral Epicondylitis I

	“Tennis Elbow” - Pain at epicondyle

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.

Elbow
Medial Epicondylitis (“Golfer’s Elbow”)

	Overuse of
		finger flexors
		wrist flexors / pronators

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

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

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).

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).

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.

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

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

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.

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.

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

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

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.

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

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.

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

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.

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

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.

Slide 96

Diagnosis
Symptoms

	Burning sensation
	Fatiguability
	Loss of grip strength
	Loss of normal sensation
	Muscle spasm
	Muscle weakness
	Pain
	Paraesthesia (tingling)
	Sensation of cold
	Swelling

Diagnosis
Clinical signs

	Crepitus (crackling sound in subcutaneous tissue)
	Muscle spasm
	Muscle weakness
	Reduction of range movement
	Swelling
	Tender trigger points in muscles
	Tenderness

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

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

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

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

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

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

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

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

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

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

Treatment
Biokinetic and ergonomic strategies I

	Initial treatment may include rest
	Compression and elevation
	Temporary job change

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

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.

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)

Treatment
Psychology & Surgery

	Pscychological evaluation
	Surgery
		where indicated as last resort

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

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)

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.

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.

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

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

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

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

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.

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.

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

Reporting to Labour / DME

Reporting to Labour / DME

Reporting to Labour / DME

Slide 128