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Musculoskeletal disorders and work Professor Karen Walker-Bone Director Arthritis Research UK/MRC Centre for Musculoskeletal Health and Work

Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

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Page 1: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Musculoskeletal disorders and work

Professor Karen Walker-BoneDirector Arthritis Research UK/MRC Centre

for Musculoskeletal Health and Work

Page 2: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Plan

• Work and health

Changes in modern workplaces

Work and musculoskeletal health

• A case presentation

• The retrospectoscope

• Results of a recent trial of treatment of ARM pain

• What are the future questions for researchers in this area?

Page 3: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Plan

• Work and health

Changes in modern workplaces

Work and musculoskeletal health

• A case presentation

• The retrospectoscope

• Results of a recent trial of treatment of ARM pain

• What are the future questions for researchers in this area?

Page 4: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Work and health

• Work is central to human existence • It is the motive force for all economies

and provides structure and meaning to individuals and societies

• Good for health & well-being

• Good for financial health & prosperity

• Good for families

• Socially inclusive & a right

Page 5: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

The effects of unemployment on health

• Higher mortality : 5-10 years earlier mortality

• Poor general health

• 2-3 fold higher risk of chronic disease

• Poorer mental health

• 3-fold risk of psychiatric morbidity

• Higher medical consultation and hospital admission rates

Page 6: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Unemployment

Mental illness

Worklessness

High personal debt

Suicide x2Self harm x10

Page 7: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect
Page 8: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Is ALL work good..?

Page 9: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect
Page 10: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect
Page 11: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Occupational research matters..

• ‘Hazards’ in the workplace are

expensive

• The public tolerate hazards from work less well than those arising from personal lifestyle choices

• Occupational hazards often more amenable to public health measures and controls

Page 12: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Prevention of serious hazards• Occupational medicine first

emerged as scientific discipline in response to chemical, physical and biological hazards

• Based on managing adverse effects by assessing risk related to each hazard

• Measures to eliminate, substitute, reduce, protect against or manage risk

• Monitoring to ensure control

• Much occupational mortality and morbidity prevented, at least in the developed world

Page 13: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect
Page 14: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect
Page 15: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Health and work today

• The workplace has changed!

• Many major hazards identified

• Health & Safety Executive

• Legislation

• Most of the ‘new’ causes of occupational ill-health are not diseases only found in the workplace…

AsbestosisPhossy jawBerylliosis

Silicosis

Neck painLow back pain

‘Repetitive Strain Injury’Osteoarthritis

AsthmaLung cancer

Stress

Page 16: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Plan

• Work and health

Changes in modern workplaces

Work and musculoskeletal health

• A case presentation

• The retrospectoscope

• Results of a recent trial of treatment of ARM pain

• What are the future questions for researchers in this area?

Page 17: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Source: OECD (2014), Mental Health and Work: United Kingdom, Paris: OECD Publishing. Courtesy Shruti Singh

New UK disability claims are among the highest in the OECDNew claims per 1,000 of the working-age population (inflow rates),

latest year available

0

2

4

6

8

10

12

OECD

average

UK: Disability burden and the benefit system

Earlier intervention could

improve this

Page 18: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

In developed world, TWO main causes of work disability..

• Mental health

• Musculoskeletal disorders

Page 19: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Work and musculoskeletal health

• Many of the 21st Century work and health issues affect the musculoskeletal system

– Back and neck pain, shoulder and knee pain

– Osteoarthritis

• 5 of the top 6 problems that impact work productivity are musculoskeletal or musculoskeletal-related (fatigue /depression)

• Responsible for 10 million days lost per year and £7billion societal costs

Page 20: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Musculoskeletal disorders become increasingly common with age

….and developed economies need people to work to

older ages..

Low back pain

Knee osteoarthritis

Page 21: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Case history

• A 45 year old female ambidextrous employee in a bank

• Full-time employee for > 12 years

• Recruited to do office administration including work with machines which sorted and organised envelopes

• Work described as requiring precision but not physically taxing

Page 22: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Changes in the workplace

• Over 5-6 years, two staff members retired and were not replaced

• Job description altered to include more office work as well as machine work

• Hand sorting letters became part of the workload

• Initially 1300 letters/day

Page 23: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Changes in the workplace (2)

• Gradual but steady increase in workload

• 1500 letters/day increased up to 13,000 some days

• All had to be sorted by 2.30pm by hand

• Machine work still needed to be completed daily

• Increased demands, deadlines tight and felt ‘pressured’

Page 24: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Onset upper limb symptoms

• 2008, developed discomfort in her left thumb

• Progressed quickly over two days such that within 2 days, she had acute locking of thumb joint

• Pain radiated proximally to elbow and upper arm

Page 25: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Symptom progression

• First day after the locking occurred, went to work as usual and reported pain and symptoms to Line Manager

• Sent home to rest. Repeated the same pattern for 13 days then Occupational Health team called in

• Advised that she must not work, must go off sick and report to her GP for assessment

Page 26: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Assessment in primary care

• GP prescribed NSAIDs, wrist support and arranged physiotherapy

• Despite these, steady progression of symptoms

• Hand painful continuously, focussed around thumb, radial border of hand and forearm and gradually over 6 months, started to radiate proximally towards elbow

Page 27: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Assessment in secondary care

• I personally assessed this lady 2 years after onset of symptoms

• By this time, made redundant from Bank, taking statutory sick pay and attending job centre

• Symptoms now involving hand, forearm, shoulder and neck

• Chronic unrelenting pain, 7-8/10, marked disability despite co-codamol and regular NSAIDs

Page 28: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

On examination

• Anxious lady, distressed and in pain• Pain behaviour• Poor posture: Exaggerated cervical lordosis and

thoracic kyphosis• Restricted cervical lateral rotation to the left• Restricted range of motion in left shoulder:

active and passive, abduction and external rotation and internal rotation (capsular pattern)

• Crepitus in IPJ of left thumb• Chronic thickening of common extensor origin

but not acute de Quervain's and provocation tests unconvincing

Page 29: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Impression

• 2 years of chronic non-specific arm pain

• ?Work-related

• Now secondary effects on shoulder and cervical spine (regional pain syndrome)

• At risk for chronic widespread pain

• Psychological impact of two years’ sickness absence

Page 30: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Proportion of people who will return to work in relation to duration of sickness absence

83.3

50

30

10

0

10

20

30

40

50

60

70

80

90

1.5 6 12 24

Duration sickness absence (weeks)

%

Page 31: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Plan

• Work and health

Changes in modern workplaces

Work and musculoskeletal health

• A case presentation

• The retrospectoscope

• Results of a recent trial of treatment of ARM pain

• What are the future questions for researchers in this area?

Page 32: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

What would have made a difference?

• Changes in work organisation factors:

• Staffing

• Job demands

• Control over workload minimal

• Support in work reduced

Page 33: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

What else would have made a difference?

• Occupational advice was to GO HOME and NOT return until better!!

• Employee felt unvalued and created expectation that she could not work until 100% recovered

• Task rotation?

• Re-deployment elsewhere?

• Amended duties

• Maintenance of regular support and contact with work and co-workers

• Fit note: what COULD she still do?

Page 34: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

What else would have made a difference?

• Excellent primary care management (by the book) but

• Delays built into the system

• Primary care does not have WORK as an outcome!

• Developed shoulder-hand syndrome because of enforced rest and fear of movement

• Medicalised symptoms and developed pain behaviour

• Forced towards disability/benefit and worse long-term health

Page 35: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Prevention of MSK disability

• Policy to prevent exposures that are excessive or repetitive and accidents

• Promote leisure-time activity /fitness

• Good line management:

• Know the role of each employee

• Be mindful of changes which are impacting upon individuals and their workload

• Show interest

• Rotate tasks /share tasks /listen to employees – what would help them?

• Demand-control-support

• Train managers!! Support managers!!

Page 36: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Once MSK pain has started..

• Take them and their symptoms seriously –with concern – LISTEN!

• Try to keep them in the workplace if at all possible

• If impossible, maintain regular (weekly) contact but NOT in an interrogatory fashion – supportive, friendly, compassionate

• Actively engage with GP through the fit note – tell GP what is required in the job and if temporary adjustments or changes are possible

• If employee waiting for NHS treatment – is that in your business’ best interests?

• Support

• Expectation of return to work

Page 37: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

If employee making a return to work

• Active and supportive engagement

• ‘Smooth’ them back to work

• Try visits for social contact first

• Reduced hours

• Reduced responsibilities

• Take account of full role and responsibilities and adjust what needs adjustment: mechanisation, rotation of tasks, enhance job control and flexibility, peer support

• Maintain interest in their health

Page 38: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

If employee forced to leave on health grounds

• The organisation has FAILED!

• Learn lessons

• Listen to staff

• What would have allowed successful return to work

• Systems

• Skills

• Availability of appropriate advice /guidance

Page 39: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect
Page 40: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Plan

• Work and health

Changes in modern workplaces

Work and musculoskeletal health

• A case presentation

• The retrospectoscope

• Results of a recent trial of treatment of ARM pain

• What are the future questions for researchers in this area?

Page 41: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

The ARM pain trial: An RCT

Maintained physical activity and physiotherapy in the management of distal arm pain

Aberdeen

SouthamptonBrighton

Bath

Cambridge

Page 42: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Physiotherapy

referral

Advice to

remain activeFast-track

physiotherapy

Advice to

rest

Pre-trial

assessment

Physiotherapy

(optional)

Follow-up

6, 13 and 26 wks

Fast-track

physiotherapy

Physiotherapy

(optional)

Advice to remain

activeAdvice to rest

Page 43: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

ARM pain trial: the results

• 539 patients recruited

• Randomised evenly to three groups

• Mean age 49 years (SD 13.6)

• 54.5% female

• 87.6% right-handed

• Equal distribution of pain in elbow, hand/wrist or both

• Pain most common in dominant arm (45.5%) or bilateral (24.7%)

Page 44: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Proportion with full recovery

Page 45: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Plan

• Work and health

Changes in modern workplaces

Work and musculoskeletal health

• A case presentation

• The retrospectoscope

• Results of a recent trial of treatment of ARM pain

• What are the future questions for researchers in this area?

Page 46: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

What are the other important research questions?

• Is retirement good for our health (or bad)?

• What impact on health will there be from policy changes making pension age >65 years?

• Can we get people back to work earlier after elective orthopaedic surgery?

• Can employers create workplaces with ‘good’ musculoskeletal health?

• Can we enhance the EARLY management of sickness absence?

• Can we make WORK PARTICIPATION a health outcome?

Page 47: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

.. AND What else?

• What is the impact of MSDs like osteoarthritis and osteoporosis in the workplace?

• Can we enhance the EARLY management of sickness absence?

• Can we make WORK PARTICIPATION a health outcome?

• Can we de-medicalise musculoskeletal pain in terms of attitudes and behaviours of the population?

• …etc…etc…etc..

Page 48: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Conclusion

• Fascinating time to be involved with work and health research

• Lots of really important research questions that affect us all

• We can make (quick) differences

• Researchers need to work closely with industry to respond to the ‘real’ issues in the workplace

• Please let us know how we can help YOU!

Page 49: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect
Page 50: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

• Prof Nigel Arden

• Ms Fani Avgoustaki

• Dr Neil Basu

• Prof Steve Bevan

• Prof Marijn de Bruin

• Prof Anthony Bull

• Prof Kim Burton

• Prof Susan Cartwright

• Prof David Coggon

• Prof Cyrus Cooper

• Ms Stefania D’Angelo

• Dr Linda Dean

• Mr Maciek Dobras

• Mr Stephen Duffield

• Prof Rob Moots

• Ms LaKrista Morton

• Dr Fehmidah Munir

• Ms Georgia Ntani

• Dr Enrica Papi

• Prof Katherine Payne

• Prof Keith Palmer

• Dr Yeliz Prior

• Dr Rudresh Shukla

• Dr Julia Smedley

• Dr Mike Smith

• Prof Deborah Symmons

• Dr Suzan Verstappen

• Dr Elaine Wainwright

• Mr Daniel Whibley

• Dr Gwen Wynne-Jones

• Prof John Goodacre

• Dr Nicky Goodson

• Prof Alison Hammond

• Dr Clare Harris

• Prof Elaine Hay

• Prof Markus Heller

• Dr Paula Holland

• Dr Kassim Javaid

• Ms Cheryl Jones

• Dr Gareth Jones

• Dr Cathy Linaker

• Prof Gary Macfarlane

• Dr Ira Madan

• Dr Jane Martindale

• Prof Alison Macgregor

Page 51: Musculoskeletal disorders and work - energynetworks.org · •Musculoskeletal disorders. Work and musculoskeletal health •Many of the 21st Century work and health issues affect

Thank you