Workplace Related Pain
Original Edit> or - Elvira Muhic
- 1 Introduction
- 2 Most Common Pain Conditions related to Work
- 3 Physiotherapy and/or Ergonomic Interventions
- 4 Clinical Bottom Line
- 5 References
Community reintegration is a broad term encompassing the process of returning home and re-establishing life following an event. Dijkers (1998) provides this definition:
”Community (re-)integration (after/with (physical) impairment or disability) is acquiring/resuming age-/gender-/culture appropriate roles/statuses/activities, including independence/interdependence in decision making, and productive behaviours performed as part of multi-varied relationships with family, friends, and others in natural community settings”.
This definition fits well with the International Classification of Functioning, Disability and Health (ICF) when used as a biopsychosocial framework to consider the interaction between health, function and participation and the contextual impact of the person and their environment (World Health Organisation, 2002). The term ‘environment’ encapsulates both physical factors (such as the built environment) and social factors (such as attitudes within society) that may influence a person’s ability to function.
When returning home following an injury, individuals will be in contact with a range of health professionals who will be involved in their ongoing rehabilitation. Physiotherapists, occupational therapists, clinical psychologists, nurses and vocational rehabilitation providers work with individuals in the months and early years post-injury, with the focus shifting to community reintegration for the individual to resume activities, leisure pursuits and work (Hay-Smith et al, 2013; Kendall et al, 2003). The process of reintegrating back to their local community is usually difficult and challenging (Gargaro et al, 2013).
Retirement can no longer be conceptualized as disengagement, as the end of a person’s career, as it is in the life-span, life-space theory. Increasingly, retirees are returning to work, in paid and unpaid positions, in a part-time or full-time capacity, as an act of re-engagement. Vocational psychology theories are yet to adequately conceptualize the phenomenon of retirees’ re-engagement in work. The ability to make this transition and manage one’s own health and physical needs is important.
Self-management is defined as having the self-efficacy to be able to take responsibility for managing the day-to-day aspect of one’s own long-term condition (Lorig and Holman 2003). Self-efficacy is described as the belief in oneself to be able to accomplish a task and self-esteem as the belief in oneself per se (Geyh et al 2012, Bandura 1977).
Pain in the upper limb is frequent among employees with repetitive and forceful job tasks. Pain may originate from activation of peripheral nociceptors due to tissue damage. However, when the perception of pain for some reason persists beyond the expected time for tissue healing, chronicity has occurred. The subjective experience of chronic pain is the result of the transduction, transmission and modulation of sensory information, signifying the involvement of central mechanisms in the perception of pain. Hence, general hyperalgesia, evidenced by reduced pressure pain threshold (PPT) in a non-painful part of the body, is present in many variants of chronic pain including carpal tunnel syndrome, fibromyalgia, chronic low back pain, and trapezius myalgia. Work-related upper limb disorder (WRULD), repetitive strain injury (RSI), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as those associated with operating vibrating tools. However, evidence of a central component to work related chronic pain in the upper limb is lacking. Work related chronic pain is often accompanied by an escalating imbalance between work demands and individual resources, consequently affecting work ability. In line with this, workers exposed to highly repetitive and forceful exertion, lack of sufficient recovery, and awkward postures have an elevated risk of both impaired work ability and musculoskeletal disorders. Additionally, impaired work ability has been associated with loss of productivity, sickness absence, early retirement and all-cause mortality.
Musculoskeletal disorders represent the most common occupational diseases in the European Union. Besides the direct effect on employee health and work disability, work-related musculoskeletal disorders impose a major socioeconomic burden due to extensive use of health care services, sickness absence, disability pension and loss of productivity. The prevalence of work-related musculoskeletal disorders, especially in the shoulder, neck and upper extremity is higher in occupations involving a high rate of repetitive movements compared with less repetitive job settings. In 2005 about 23% of European workers reported that their work negatively affected their health in the form of significant pain in the shoulder, neck, and/or upper/lower limbs.
The effectiveness of physical conditioning as part of a return to work strategy in reducing sick leave for workers with back pain, compared to usual care or exercise therapy, remains uncertain. For workers with acute back pain, physical conditioning may have no effect on sickness absence duration. There is conflicting evidence regarding the reduction of sickness absence duration with intense physical conditioning versus usual care for workers with subacute back pain. It may be that including workplace visits or execution of the intervention at the workplace is the component that renders a physical conditioning programme effective. For workers with chronic back pain physical conditioning has a small effect on reducing sick leave compared to care as usual after 12 months follow-up.
It is intuitive that disability caused by illness should be reflected in illness severity. For example, there may be numerous reasons why persons with fibromyalgia (FM) may have poor sustainability in the workforce. Studies have pointed to work disability being associated with higher ratings of pain and symptom severity, increased physical demands of the job or alternately more sedentary work, and workplace stressors. Whereas continued work is promoted by individual strategies such as the ability to handle symptoms, work day, and long-term work life, as well as social support from colleagues and employers. Measurement of function in FM is also fraught with challenge, with a patient’s report of functional impairment often greater than objective observation, and self-report of physical activity showing poor agreement with objective measurement by accelerometry. To better understand factors that may be contributing to work disability, examiners examined patients with FM currently working compared with those unemployed for non-FM reasons, and those receiving disability payments for illness identified as FM. The prevalence of disability caused by FM was 30.8%. With the exception of measures for anxiety and depression, all measurements for disease severity differed significantly among the groups, with greater severity reported for the disabled group, which used more medications and participated less in physical activity. Disabled patients were more likely previously employed in manual professions or the service industry, whereas employed patients were more commonly working in non-manual jobs that included clerical, managerial, or professional occupations.
Upper Trapezius Muscle Activity
Patterns of cervical muscle activity may contribute to overuse injuries in office workers. The purpose of this investigation was to characterise patterns of upper trapezius muscle activity in pain-free office workers using traditional occupational exposure measures and a modified Active Amplitude Probability Distribution Function (APDF), which considers only periods of active muscle contraction. Upper trapezius muscle activity was characterised in a large cohort of pain-free workers using electromyographic recordings from office environments. Dominant muscles demonstrated higher activity and less rest than non-dominant, and women demonstrated less rest than men. Results may be used to identify atypical trapezius muscle activity in office workers.
Chronic Upper Limb Pain
Other study investigated biopsychosocial differences, with specific focus on rate of force development (RFD) and work ability, between workers with and without chronic upper limb pain. Chronically painful upper limb muscles demonstrated impaired rapid force capacity and neural activation compared to non-painful muscles. Further, workers with chronic pain showed impaired work ability, work disability and general health compared to pain-free controls.
Generally, there were very low-quality evidence indicating that pain, recovery, disability and sick leave are similar after exercises when compared with no treatment, with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm, neck or shoulder. Low-quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up.
Physiotherapy and/or Ergonomic Interventions
Lowering the physical exposure through participatory ergonomic interventions may represent a strategy to reduce musculoskeletal loading intensity and/or rehabilitate musculoskeletal pain. A review by Rvilis et al. found partial to moderate evidence that participatory ergonomic interventions are effective in improving different health outcomes. The main reason for not finding full evidential support was due to the low number of methodologically sound studies available in the literature. Many examiners found moderate-quality evidence to suggest that the use of arm support with alternative mouse may reduce the incidence of neck/shoulder MSDs, but not right upper limb MSDs. Moreover, they found moderate-quality evidence to suggest that the incidence of neck/shoulder and right upper limb MSDs is not reduced when comparing alternative and conventional mouse with and without arm support. However, given there were multiple comparisons made involving a number of interventions and outcomes, high-quality evidence is needed to determine the effectiveness of these interventions clearly. While they found very-low- to low-quality evidence to suggest that other ergonomic interventions do not prevent work-related MSDs of the upper limb and neck, that was limited by the paucity and heterogeneity of available studies.
An alternative strategy to reduce or prevent work-related musculoskeletal pain may be achieved by increasing the workers physical capacity through strength training interventions.Sundstrup E, Jakobsen MD, Andersen CH, et al. Participatory ergonomic intervention versus strength training on chronic pain and work disability in slaughterhouse workers: study protocol for a single-blind, randomized controlled trial. BMC Musculoskeletal Disorders. Implementation of strength training at the workplace prevents deterioration of work ability among manual workers with chronic pain and disability exposed to forceful and repetitive job tasks. Thus, strength training performed at the workplace may in fact be regarded as a complex biopsychosocial intervention modality that reaches further than the specific physiological benefits of training per se.
Barriers and facilitators to community reintegration can change over time. What may not be a barrier initially may become more of an issue later. For example, while pain was not a strong theme in the qualitative studies reviewed in study Community reintegration following spinal cord injury: Insights for health professionals in community rehabilitation services in New Zealand, it has been identified as a significant factor impacting community reintegration in other studies, becoming more prevalent as an issue with time following SCI (Donnelly and Eng 2005, Gargaro et al 2013). Therefore, health professionals need to re-evaluate a client’s situation on a regular basis.
Clinical Bottom Line
Knowledge of factors associated with chronic pain is necessary for preventive strategies. The environment and personal factors predominate, with maintenance of health, accessibility to the built environment and health services, re-establishing self and community connections being strong facilitators to reintegration. The challenge for health professionals working in the community with individuals with pain is to be client-centred and ensure the individual’s needs are suitably met to support them to re-connect with their work and community life.
- Dwyer KJ, Mulligan H (2015) Community reintegration following spinal cord injury: Insights for health professionals in community rehabilitation services in New Zealand. New Zealand Journal of Physiotherapy 43(3): 75-85. doi 10.15619/NZJP/43.3.02
- Luke J, McIlveen P, Perera HN. A Thematic Analysis of Career Adaptability in Retirees Who Return to Work. Frontiers in Psychology. 2016;7:193. doi:10.3389/fpsyg.2016.00193.
- Verhagen AP, Bierma-Zeinstra SMA, Burdorf A, Stynes SM, de Vet HCW, Koes BW. Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD008742. DOI: 10.1002/14651858.CD008742.pub2.
- Sundstrup E, Jakobsen MD, Brandt M, Jay K, Aagaard P, Andersen LL. Associations between biopsychosocial factors and chronic upper limb pain among slaughterhouse workers: cross sectional study. BMC Musculoskeletal Disorders. 2016;17:104. doi:10.1186/s12891-016-0953-7.
- Sundstrup E, Jakobsen MD, Brandt M, Jay K, Persson R, Aagaard P, Andersen LL. Workplace strength training prevents deterioration of work ability among workers with chronic pain and work disability: a randomized controlled trial. Scand J Work Environ Health 2014; 40(3):244-251 doi:10.5271/sjweh.3419
- Schaafsma FG, Whelan K, van der Beek AJ, van der Es-Lambeek LC, Ojajärvi A, Verbeek JH. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD001822. DOI: 10.1002/14651858.CD001822.pub3.
- Disability in Fibromyalgia Associates with Symptom Severity and Occupation Characteristics. Mary-Ann Fitzcharles, Peter A. Ste-Marie, Emmanouil Rampakakis, John S. Sampalis, and Yoram Shir RJ. Rheumatol published online before print March 15, 2016, doi:10.3899/jrheum.151041
- Ergonomics. 2016 Feb 28:1-10. [Epub ahead of print] Upper trapezius muscle activity in healthy office workers: reliability and sensitivity of occupational exposure measures to differences in sex and hand dominance. Marker RJ, Balter JE, Nofsinger ML, Anton D, Fethke NB, Maluf KS.
- Hoe VCW, Urquhart DM, Kelsall HL, Sim MR. Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD008570. DOI: 10.1002/14651858.CD008570.pub2.