CPD Article: Common work-related musculoskeletal strains and injuries

Common work-related musculoskeletal
strains and injuries
Collins RM, Lecturer, Section Sports Medicine, University of Pretoria
Team Doctor, Golden Lions Rugby Union
Janse Van Rensburg DC, Head of Department, Section Sports Medicine, University of Pretoria
Patricios JS, Lecturer, Section Sports Medicine, University of Pretoria
Correspondence to: Robert Collins, e-mail: robcollins@wol.co.za
Keywords: workplace; musculoskeletal injuries, lower back, carpal tunnel syndrome, neck pain

Abstract
Muscles, tendons, joints and nerves are susceptible to injury when stressed or traumatised repetitively, or over an extended
period of time. Regardless of the nature of the work, a large proportion of the working population’s time is spent engaged
in repetitive movements and maintaining postures for extended periods of time. The reported incidence of work-related
back and neck pain, and carpal tunnel syndrome, is between 15-60%,1-3 indicating that a high proportion of the working
population is at risk of developing one or more work-related musculoskeletal disorders. The parts of the body that are most
commonly affected are the lower back, neck and shoulder girdle, and upper limbs. Based on current literature, we shall
discuss conditions affecting these areas in order to gain a better understanding of the conditions, as well as their prevention.

Peer reviewed. (Submitted: 2010-07-06, Accepted: 2010-09-22). © Medpharm S Afr Fam Pract 2011;53(3):240-246

Introduction factors.2,8,9 Obesity and decreased physical activity have
also been associated with the development of WMSDs.10,11
Work-related musculoskeletal disorders (WMSDs) affect the
muscles, tendons, joints and nerves when they are stressed, WMSDs can affect virtually all parts of the body, but the
or traumatised on a repetitive basis over an extended period back, neck and shoulders and upper limbs account for more
of time.4 As can be seen from the following data, WMSDs than 50% of cases.12 Gender studies of musculoskeletal
represent a common and ever-increasing problem. Back injuries in the workplace show that women desk workers
problems affect millions of people worldwide, i.e. 70-80% are at higher risk than men, while male assembly workers
of people during their lifetimes.2 International statistics are at higher risk than their female counterparts.13
indicate an increasing incidence.5 Neck pain occurs in
between 15-44% of the general community, but is reported Low back pain
as affecting between 50-60% of office workers.1 Carpal Non-specific low back pain (LBP) is one of the most common
tunnel syndrome (CTS) is one of the most common and and expensive disorders affecting people in industrialised
disabling WMSDs,6 affecting up to 25% of active workers.3 countries. It is estimated to affect 15-44% of the general
population in one year.14-19 More than 10% of those suffering
The first published literature regarding diseases of
from LBP experience symptoms that persist for longer than
workers was by Bernardino Ramazzini in 1700. His work is
one year.14
extensively cited in a recent article by Franco,7 who states
that Ramazzini recognised that workers are susceptible In 2004, of the 1.2 million non-fatal occupational injuries
to certain illnesses, and also noted that poor posture, and illnesses in the USA resulting in loss of time from work,
repetitive movements and muscular loads contributed to 22% were related to LBP.20 The indirect cost of occupational
certain disorders. Ramazzini established the potential of back injuries in the USA in 1996 was $18.5 billion, with an
psychological stress as a factor in these conditions, and average cost per injury of $5 000. Less than five per cent
recommended the moderation of activities to avoid risks.7 of back claims which resulted in disability of longer than
one year, accounted for 65% of the costs.20 Thirty thousand
Risk factors associated with the development of WMSDs
South Africans suffer from neck or back pain annually, with
include static work postures (trunk and neck twisting,
10% of them becoming chronic sufferers.2,21
stooping and deep sideways trunk bending), whole-body
vibration, shock, physical work demands such as walking, Occupational LBP may occur as a result of traumatic injury,
pulling and lifting, climatic conditions, and psychosocial repetitive use, or other factors. Traumatic injury of the

S Afr Fam Pract 2011 240 Vol 53 No 3

and was found to be effective in preventing low back associated with poor outcomes. supervisor and an ergonomist changes According to the Euro Back Unit Project.16 In heavy equipment vehicle operators. thereby decreasing the need to bend effective in making diagnoses such as fractures. the involved mediation process accelerations. It was tested on kitchen staff working at a nursing cancers and disc and spinal cord pathology. pain.15. such as Effective intervention strategies for the treatment and low social support in the workplace and low job satisfaction. short-term LBP is the perceptions of both the worker and the supervisor.23-25 High body mass index (BMI).20.15. as well programmes cause. prevention of LBP include exercise therapy. in order predictor of long-term outcome. but multifactorial.12 In the to achieve modified work.23 General health status and psychosocial stress are other Factors that contribute to the development of LBP include a validated predictors of work disability.20 However. Biomechanical of back pain.11. a low level pushing large amounts of waste matter through pipes have of exercise. biomechanical and psychosocial at reducing the chronic stooped posture of sewage workers factors.24 whole-body vibration. a possible reason for failure of LBP physiotherapeutic and/or chiropractic care. have been shown to heavily loaded. Self-reported factors that are of value in determining the outcome of back pain include radiation of pain and high Treatment of occupational LBP needs to be a multidisciplinary level of functional disability. The latter is as medical treatments is the failed social transaction required effective as medical or physiotherapeutic methods.22. which are home. metastatic forwards.25. and weak back strength. Therefore. counterproductive. prevent chronic LBP from developing.23 Workplace interventions incorporating on the lumbar spine. back pain intensity is not generally accepted as a reliable as well as the ergonomic and psychosocial causes. Imaging is worker to kneel on it. or were even bending. and changing the position of computer screens. LBP has been This is thought to be due to the two effects that these associated with steady-state whole-body vibration.23 Methods used to treat acute LBP include medical. Therefore.22 It may occur as a single episode. CPD Article: Common work-related musculoskeletal strains and injuries lower back is diagnosed and treated uniformly. is therefore at risk of causing LBP in workers. back pain that affects the individual for less than 30 days in with regard to the worker’s capabilities and the workplace a year. with the disc fibre layers being most principles of workplace ergonomics. frequent bending and twisting.14 Multidisciplinary also been shown to be the most powerful predictor of biopsychosocial rehabilitation programmes are advocated progression to chronicity.24 Any work situation requiring repetitive be effective on return-to-work outcomes. and secondly.27 Other common examples approximately five per cent of incident cases.19.26 in most clinical guidelines for the treatment of subacute Deviation from upright posture generates increased force and chronic LBP.8 between worker.12. but only account for pain in taller kitchen workers. and then meeting with the worker at doing. this article will and ankles were associated with progression to chronic concentrate on non-traumatic causes of occupational LBP. are examples of been ineffective. by identifying injured workers and workplace barriers to treat these patients effectively from the outset. as well as factors.23-25 Psychosocial factors.20 According to Baldwin et al approach that addresses the physical elements of the pain.20 be recurrent.23 More important than severity of pain is workers’ Ninety per cent of all people purporting to suffer from LBP ability to function following the pain.14. behavioural have not only been associated with causing LBP. whether reported that severe pain and radiation of pain to the feet its cause is occupational or not. and in so to achieving this.23 It is also essential to and occupational physician co-ordinating return to work predict which cases of LBP are likely to become chronic. the workplace to resolve these barriers. or sustained programmes alone were not effective.23.20 include adjusting the height and lumbar support of chairs. Interventions aimed combination of individual. allowing the long-term disability in most cases of back pain. but have therapy and back school programmes. indicating that the cause of their LBP is individual factors that can contribute to the development not purely posture related.15 other intervention strategies are needed to prevent long Participatory workplace ergonomics involve an ergonomist and costly periods of morbidity. or develop into a severe chronic burden. S Afr Fam Pract 2011 241 Vol 53 No 3 .16 An example X-rays and other forms of imaging such as magnetic of a workplace intervention is a standing aid. they reduce physical and mental as mechanical shocks induced by tough rides and high stress. Firstly. and their capacity to have non-specific LBP.19. environment. adapt to it. whereas exercise flexion and/or twisting for long periods.19. The device resonance imaging (MRI) scans are poor predictors of provides a rest anterior to the lower leg. Gheldof et al to prevent recurrence and the development of chronic LBP.25 Biomechanical factors include non-neutral factors are significantly confounded by psychosocial static posture. of the worker. rather than the medical condition small percentage of cases that progress to chronic LBP.

while 25% Other ergonomic interventions may also be of value in were engaged in “keyboarding”. This posture is believed to be associated with an has been reported as presenting in 1-10% of the general increased risk of neck and shoulder pain.35 Interventions such as adjusting seat height workers (19% vs. cervicobrachial fibromyalgia upper limbs41 and rotator cuff syndrome.39. Diagnoses of neck and shoulder pain include tension neck Table I: Common work-related musculoskeletal disorders that affect the syndrome.0% of females. although a number of studies have and overhead activities demonstrated a correlation between poor job satisfaction. making it one of the most studies have estimated that neck and shoulder pain significant and costly health care problems to affect the affect between 6-76% of the working population annually.29 stiffness movements Rotator cuff Shoulder pain and Repetitive shoulder The role of psychosocial factors in neck and shoulder tendinosis stiffness movements with twisting complaints is unclear. Suggested influences include economic incentives. Depending on the outcome measure that is used. and physical Upper extremity conditions and psychosocial demands in the workplace.36 In the USA leave to recover fully. It has the incidence of these disorders are attributable to better also been reported that CTS disability time is significantly disease recognition. Lateral Lateral elbow pain.42 and spine.38-40 Since nearly 80% of improvements in the manufacturing process. rather than as other than CTS itself may be responsible for the long a measure to prevent them. such as cervical and thoracic spine syndrome fingers. other recent associated cost of treating neck and upper limb conditions studies indicate that the incidence is of CTS is remaining is rapidly approaching that of LBP. poor relations with colleagues.18. cervical syndrome.42 and 34-79% of CTS patients attribute the trapezius muscle activity among office and manual workers. CPD Article: Common work-related musculoskeletal strains and injuries Neck and shoulder pain in 1999. Lateral elbow pain.31 Rotator Myofascial pain Heaviness and aching Overhead work and work of the neck in the shoulders. However. Of these disorders.30. particularly in combination Shoulder bursitis Shoulder pain and Repetitive shoulder with abduction. 50% of cases occur and curved seat pan chairs have been effective in preventing in manual workers. but surgical intervention is associated S Afr Fam Pract 2011 243 Vol 53 No 3 .32-34 Trigger finger Locking of fingers in Repetitive hand grip The posture associated with computer work. constrained Carpal tunnel Numbness of middle Repetitive wrist flexion or static postures. while in men.37 While current.38 It is primarily associated with workers who use cited several studies which investigated neck posture and their hands.42 Patients One-third to half of all disability claims are related to hand. They are associated Stress reaction with high static or repetitive loads. and longer than that of other WMSDs.1% of males and 3. attention to human factors while 12% of workers receive workman’s compensation can prevent many injuries. Other common WMSDs that affect appropriate changes in the machine and people interface. it occurs more frequently in office. perceived stress. requiring surgery often require up to seven weeks of sick wrist or upper extremity cumulative trauma.31 cases were worked in the manufacturing sector. as well when night performing forceful or repetitive precision tasks. these ergonomic 30 months after diagnosis.28 The on the costs related to CTS are not available. amount of sick leave available. 24%).30 Unfortunately.31 Workers are predisposed to Disorder Symptoms Causes these conditions when sustaining awkward.39. the cost of upper extremity cumulative trauma disorders was between $15-20 billion.1.18. a low level epicondylitis especially with extended especially with extended wrist wrist of support from co-workers. syndromes. and rupture of the tendons. especially at flexion.42 and found conflicting results with respect to neck pain In women. condition to their work. than manual. resulting in workplace-related upper limb complaints are attributable to faster speeds and shorter work cycles.29 Recent increases in static. the upper limbs are listed in Table 1. Arvidsson et al population. increased use of computers.30 In remains permanently disabled as a result of the condition. working population. described as flexion “forward head posture”. designing tools and workplaces. while the incidence of WMSDs is decreasing. the authors of this article have decided to focus their increased use of computers has not been accompanied by discussion entirely on it. back and neck Computer posture tendinosis.42 It is believed that factors changes usually occur in response to injuries. various 78% was ascribed to CTS.30.37 Keogh et al reported that 27% of neck and shoulder pain in seated manual workers.30 recovery periods.30. and neck pain.30 One in ten CTS sufferers preventing neck pain and upper limb conditions. the CTS.3. upper with extended arms cuff syndromes in the workplace include impingement. and South African data Women are more frequently affected than men. rotation and flexion.30. shoulder elevation and abduction. is a combination of extension of the upper cervical spine and flexion of the lower cervical CTS occurs in 2.28.

This is to as well as clinical findings. more environment of all workers.42 It affects people performing intensive duties.3 interventions should include management of all CTS CTS has been regarded as a significant cause of hand and development risks. a higher risk of MN than non-diabetics. The trend is not as significant also look for predisposing factors and address these with as would be expected. A higher degree of electrophysiological change in median When treating any WMSD.3.42 Ergonomic Median mononeuropathy (MN) is defined as prolongation of interventions in symptomatic workers have resulted in the median sensory-evoked potential across the wrist.30 work with their hands.43 Years of work experience correlate recovery. may feel that he or she is able to make such a as a reason for prolonged recovery periods. This will also prevent recurrence. changes is made for symptomatic workers. Higher work stress and lower job satisfaction are not In medical literature. low job social support and high psychological job sensitive and specific.30. and include a high level of repetitive hand movements. including diabetes and high BMI. when the reduction of CTS surgical treatment. engineering adaptations (change pain. without fear of jeopardising his or her job security. higher forces at the hand and wrist. arm complaints since the 1960s. MN is reported to be present in up Up to 50% of CTS could be avoided if effective intervention to 25% of active workers. tend whether in manufacturing or the office. that masks CTS symptoms. presence of symptoms in the median nerve distribution workers with a lower education level. and show poor correlation with demands are less likely to return to work six months after clinical signs. workers with a higher level of job satisfaction factors that contribute to WMSD. low job is neither sensitive.42 Following the compared to the ulna nerve. and change of work pace. lower income.3 interventions can then be introduced to prevent recurrence. Psychosocial factors have not been found to be The interaction with the employee and employer should discriminatory as to who experiences CTS symptoms.3 the workplace.3 However. rather than change the workplace between occupational hand use and CTS. Many of these conditions thyroid disorders and diabetes mellitus. for a CTS diagnosis. However. have demonstrated a less decrease the incidence of surgery. awkward the combination of the two is more specific and sensitive wrist posture.40 symptoms often makes electrophysiological testing a more Ergonomic risks pertaining to the development of CTS reliable diagnostic indicator than clinical signs alone. S Afr Fam Pract 2011 245 Vol 53 No 3 . lack of physical activity and psychological stressors (“square wrist”) and medical conditions such as gout.39. CPD Article: Common work-related musculoskeletal strains and injuries with better recovery of earning potential. nor specific. but with CTS. but more than half of patients are programmes were implemented in the workplace.42. Studies that relied on clinical Since only a small percentage of workers develop CTS. changes in the workplace environment that occurs as a result of MN. predispose workers to WMSDs.6. implementation of essential recent studies that combine electrophysiological signs. and increased physical activity does not increase the risk of its development. and the than either in isolation. implemented to prevent similar injuries in other employees. be associated with increased BMI.43 CTS is the clinical syndrome identification of CTS. parasthesia.43 Diabetics have occur at the interface between workers and machines. Asymptomatic workers with the worker and employer to facilitate a more rapid return to documented MN only have a 10% likelihood of developing work.43 The non-specific nature of CTS signs and CTS surgical treatment. In be used as an opportunity to educate both regarding the contrast to LBP.43 use of hand-held vibratory tools at work.3.42 The delay in It is believed that a worker who is more satisfied with his time between diagnosis and surgical treatment is also cited or her job. This is no different from the consult with an occupational therapist and the employer incidence in age-matched and sex-matched controls with to address the risk factors for each individual. the clinician should accurately nerve conduction is associated with a trend to report CTS diagnose the condition and treat it appropriately.36. it CTS symptoms in the 1980s postulated an association is recommended that. but should symptoms more frequently. increased wrist index obesity. Clinical symptoms include include safety evaluations.43 The Conclusion increased incidence of CTS has been demonstrated to Repetitive movements. electrodiagnostic techniques are only modestly control. They can often be to be less symptomatic. The associated with a higher level of reporting CTS. change of employee dryness of the hand. static and stressful postures. This is thought to be due to mild prevented or modulated by addressing the ergonomics of peripheral neuropathy. The clinician must CTS symptoms in two years. tools or work set-up).39 report. Ergonomic normal nerve conduction. Similarly.37 These asymptomatic. as well as assist in consistent association. so that strategies may be have been found to be more likely to report CTS symptoms. CTS definitions vary greatly. weakness and altered temperature or of equipment. negatively with the incidence of CTS.

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