Upper-Extremity Issues Take the Lead
A perspective on industrial workplace injuries.
As physical therapists who have a primary focus in industrial on-site injury prevention and early intervention for discomfort, we have seen a change in the body areas workers and employers are concerned with. During the past 3 to 5 years, there has been a gradual decrease in employee reports of lower and upper back discomfort with a simultaneous increase in reports of discomfort involving the upper extremities. Our practices are located in different geographic areas of the country, but the trend is apparent in each location. We have responded with appropriate action, and although some of the solutions are similar between back and upper-extremity problem resolution, the equipment and products used to treat these cases differ.
What has caused the decrease? One possibility is added awareness among workers of safe lifting habits and work techniques that reduce exposure to potential back injuries. In contrast, upper-extremity overuse or “ergonomic” injuries in particular have logged an increase and sparked concern about determining their causes and developing strategies for prevention. Some of these issues stem from highly repetitive tasks requiring control, dexterity, and force.
The National Safety Council (NSC) Injury Facts 2011 Edition reports costs of work-related musculoskeletal disorders (MSDs) from 2007-’08 data. The documented average cost of lower back injury was $37,154. Average cost of a shoulder injury was $34,789 and a hand/finger/wrist injury was $18,104. The NSC also has indicated that upper-extremity disorders related to the use of computer keyboards are the second most common reason for work-related disability after back pain. According to the Occupational Safety and Health Administration (OSHA), the average direct cost of carpal tunnel syndrome (CTS) is $28,647, while the indirect costs associated with CTS can more than double this cost.
The solution for these types of injuries does not lie solely in just addressing matters related to workers’ equipment; it is also through early intervention. In getting on-site to meet with a worker, we can become involved at the early stages of a problem and analyze how a task is completed. This enables us to make suggestions that target improved postures and ergonomic processes, or recommendations for better tools. Additionally, it can allow us to provide first aid support for the worker.
Keeping Little Problems Little
Outcomes are better when an injury or symptom can be addressed at the onset. When we see a person with concerns that began 6 months prior, complicating factors such as substitution, protective muscle guarding, and movement dysfunction often occur. These problems are not as prevalent when we intervene in the first days of onset. The Early Intervention (EI) model provides workers access to the expertise and knowledge of a therapist who is present on-site at the employer’s location. We are able to improve comfort through education and by increasing a worker’s awareness of neutral work positions, optimization of blood flow through alternating postures, and making suggestions for better tool application. These strategies are often summarized as “Job Coaching.”
All of our initial interventions are designed to be first aid in nature by the OSHA guideline definition. Significant information is available through OSHA’s website under the first aid standard, best accessed by entering 1904.7 into the search function. Heat and ice can provide basic control of discomfort or swelling. Over-the-counter medications must be used per dosing on the label. Directing a worker to take more is not appropriate and will create OSHA recordability if the issue is work-related.
When splinting, nonrigid splints should be used to stay within guidelines for first aid. Some of the models we use are the ProFlex line from St Paul, Minn-based company Ergodyne for the wrist; Norco Neoprene Thumb Supports from North Coast Medical, Gilroy, Calif; and Aircast tennis elbow splint available through AliMed, headquartered in Dedham, Mass. Padding and protection for trigger finger symptoms can be address with the TFS Trigger Finger Solution, available through North Cost Medical. These are inexpensive options that can help control and reduce symptoms through support of a joint or decreased strain on tissue.
Proactive Versus Reactive Intervention
It is our experience that the EI model is a better response to a
worker’s concern than waiting until the problem requires formal medical attention. Identifying ergonomic stressors and correcting them before they result in soft-tissue damage or postural strain is the best approach to avoiding injury. Being at the production line or workbench with
the worker provides many opportunities to identify and correct issues that may lead to a musculoskeletal disorder. The worker can be the best “ergonomist” in this type of evaluation strategy. They indicate where they feel pain symptoms, identify which tools are better than others for performing certain tasks, and specify which product they
dread building because their role in its production is inefficient or
By listening to and engaging workers in this process, they are able to help identify solutions, take ownership of their own safety, and more readily accept the corrective actions. Administrative controls that are “forced” on the workforce by supervisors or engineers are often met with resistance by the workers. Workers may comment that they feel the supervisor or engineer “doesn’t know the job” or “has never actually performed the job,” which typically leads to more frustration and negativity.
You are Not Solely Responsible for fixing Everything
Most therapists are not experts in all ergonomic tools available to improve a situation. When we collaborate with the worker, supervisor, engineering, and purchasing professionals, we develop stronger solutions. It is important to practice the phrase, “know what you know and what you don’t know.”
As therapists, we know the proper anatomical neutral postures, causes of soft-tissue and joint strain, and how to treat musculoskeletal problems. Identifying a MSD stressor may be our only contribution to the process. We point out a poor posture, use of excessive force, or highly repetitive tasks. Solutions to these issues may come from someone else on the team who is familiar with a better tool or process.
In one case, the idea for such an improvement came from an engineer who worked with a power driver. This driver reduced the force of using a hand torque wrench and decreased tact time in reaching to obtain and replace the original tool. These solutions are often more costly than alternatives such as task rotation, postural changes, or use of a splint. Other tool variations may require vibration-dampening strategies. A good “quick fix” solution for reducing vibration can be achieved with a Viscolas tool wrap or a Proflex glove, both available through AliMed.
Keeping Healthy Workers Healthy
Workplace wellness continues to be a popular topic; from weight-loss challenges, to walking programs, striving for five fruit and vegetable servings per day, and smoking-cessation programs. Part of our successful wellness initiatives have included simple warm-up stretches at the beginning of the shift and after the meal break to improve blood flow, create postural balance, and provide some control for worker comfort.
Commercial turnkey programs are available, such as “Stretch It Out!” The program’s success arises from accountability of stretch teams led by a trained coach, a fun atmosphere, and the realization that there are no magic stretches—just the need to improve circulation and create postural balance.
Therapists have the skills and knowledge required to support employers and employees in the prevention and management of work-related injuries. Our “formal” therapist education programs do not typically focus attention on how to work on-site with an employer, how to perform a job or task analysis, or provide significant information about ergonomics. Continuing education programs are critical for the development of proficiency and comfort in these new work environments.
The DSI Work Solutions Job Function Matching program provides training and tools for success in on-site and clinic-based injury prevention and management. Learning proper process for job analysis, functional testing, and legal guidelines surrounding this employer service will develop a business line to complement clinic-based services.
Upper-extremity and back injuries are not going away. As therapists, we must continue to focus attention on lifting activities, encourage proper techniques for material handling, and implement tools to improve task efficiency and safety. PTP
Curt DeWeese, PT, is COO of DSI Work Solutions Inc, Bowling Green, Ky, and president of Work Injury Solutions, Rochester, NY. DeWeese works with many employers using Job Function Matching for workplace injury prevention and management. He also provides therapists education and training in working on-site with industry. For more information, visit PTPEditor@nullallied360.com.
Scott Ege, PT, MS, is president of Ege WorkSmart Solutions PC. His expertise includes ergonomics, early intervention, job function matching, injury management, and education/training. He is the author of the “Stretch It Out!” workplace stretching program. For more information, visit