4. MUSCULOSKELETAL DISORDERS
4.2 Work-Related Upper Limb Disorders (WRULD)
4.2.1 The Nature and Causes of WRULD/Repetitive Strain
The phrase “work-related upper limb musculoskeletal disorders” includes a variety of upper limb degenerative and inflammatory diseases and disorders, which result in pain and functional impairment. Affected areas typically include the neck, shoulders, elbows, forearms, wrists and hands (Buckle &
Devereux, 2002). Names for these types of disorders include: cumulative trauma disorder (CTD), repetitive strain disorder (RSI), occupational cervico- brachial disease (OCD), occupational overuse syndrome (OOS) and more commonly work related upper limb disorder (WRULD).
These types of occupational injuries have been well known over history, examples of occupations include tailors, shoe makers, milk maids; and more recently VDU workers involved with repetitive data entry and vibration induced hand and wrist disorders, such as jack hammer operators.
Colombini et al. (2002) state that the incidence of occupational illnesses of the upper limbs has been constantly increasing and that in 1990, „cumulative trauma disorder‟ accounted for over 60% of all occupational illnesses in the USA.
For the disorder to be work-related, work tasks and conditions must exacerbate or cause the disorder. This sounds straightforward, but of course it is not. Earlier in this section we examined the evidence for musculoskeletal disorder risk factors from the meta-analysis by Bernard et al (1997) for NIOSH. Outlined in Table 4.3 is the particular evidence for upper limb disorders.
Table 4.3 – Evidence for Risk Factors for WRULD Risk Factor/
Body Part Repetition Force Posture Vibration Combination Neck &
Neck/shoulder
Shoulder
Elbow
Hand/Wrist Carpal Tunnel
Syndrome
Tendinitis
Hand-arm vibration
syndrome
Strong Evidence
Evidence
Insufficient Evidence
(Source: UOW – adapted from Bernard et al, 1997)
From the evidence it is clear that posture is a definite risk factor for the neck and shoulder, while a combination of factors are a risk for the elbow and wrist/hand.
Use of our upper limbs in functional activity, whether at work or at home usually involves static loading of the postural muscles and active use of the dynamic muscles for task completion. For example, when typing on a keyboard, the shoulder, neck and scapular musculature is stabilising the arms for dynamic work of the hands and forearms. However, using the evidence such as the findings of Bernard, allow us to determine whether or not manual tasks involving the upper limbs pose a risk to musculoskeletal health for workers.
To add to the complexity of WRULD, other research into the causes of WRULD indicates that age, gender (female), psychosocial factors and work organisational factors are also significant. A summary of the known risk factors for WRULD is outlined in Table 4.4.
Table 4.4 - Summary of Known Risk Factors for WRULD
Physical Risk
Factors Psychosocial Risk Factors Individual Risk Factors
Repetition Job demands Age
Force Job control Gender
Posture Social relations at work Socioeconomic status
Vibration Pre-existing musculoskeletal
disorders
As outlined in Section 4.1, the causes of manual handling injury relates to demands exceeding tissue tolerances. In WRULD, the link between cause and effect is more difficult to tease out. The nexus between the physical risk factors, psychosocial factors, and individual risk factors is complex.
Figure 4.11 below, adapted from Bongers et al, (2002) is a useful model for understanding the interaction, where it can be seen that individual factors interact with psychosocial load, physical load and physiological response to produce chronic musculoskeletal symptoms.
(Source: UOW - adapted from Bongers et al 2002)
Figure 4.11 - Interaction between Psychosocial Load, Physical Load and Individual Factors and Symptoms and Signs of Shoulder, Arm or
Wrist Injury
a) The Upper Limb
Let us now examine the structure of the upper limb; it comprises of the hand, wrist, forearm, upper arm and shoulder. The hand is comprised of 19 bones with a further eight in the wrist. It is highly flexible but also delicate and has evolved to manipulate and feel small items with a great degree of sensitivity and skill. It does not have intrinsic strength or mechanical power as the muscles of the hand are very small and are adapted to fine movements and precision.
Physical Load
Psycho -social Load
Stress Response
Physiological Response
Chronic Musculo- Skeletal Symptoms
Individual factors, such as coping, personality, perception, functional capacity Physical
Load
Psycho -social Load
Stress Response
-
Individual factors, such as coping, personality, perception, functional capacity Signs &
Symptoms of Shoulder, Arm or Wrist Injury
(Source: Mosby‟s Medical Encyclopedia)
Figure 4.12 – Bony Structure of the Hand
Some mechanical power, however, can be achieved through the larger forearm muscles acting on the fingers and through body leverage.
Therefore the hand can perform two different types of grasp - the pinch or precision grip and the palmar or power grasps.
(Source: McPhee, 2005 – reproduced with permission)
Figure 4.13 – Precision or Pinch Grip
Both require the forearm and particularly the hand to be stabilised. This is achieved by forearm, upper arm, shoulder and trunk muscles which for the most part are working statically.
The manipulative ability of the hand is improved by the full range mobility of the shoulder joint, the hinge action of the elbow and by the rotation of the forearm at the elbow and wrist.
(Source: McPhee, 2005 – reproduced with permission)
Figure 4.14 – Power or Palmar Grasp
(Source: McPhee, 2005 – reproduced with permission)
Figure 4.15 – Shoulder Function/Range of Movement
b) Injury Mechanisms
The hand is a delicate and highly complex machine at the end of a highly flexible lever on a mobile body but its ability to perform depends to some extent on the rest of the body. Where the shoulder or the trunk cannot be positioned for optimum movement of the hand all three areas may suffer strain. This possibility must be considered in relation to the physical layout of work or the demands of the task.
Similarly where joints are in their outer or inner positions (away from neutral position) repeatedly or long periods, all structures – capsules (connective tissue around a joint), ligaments (strengthening tissue in a capsule), tendons (joining muscles to bones) and muscles – may be stressed. For most people such positions are held for short periods and are desirable intermittently. They are not difficult or damaging unless maintained for long periods or repeated many times. Sitting, reading or sewing with the neck bent is an extreme posture and may lead to considerable discomfort if continued over any length of time.
Work that requires the human body to adopt fixed postures and to repeat movements has become common over the last two to three hundred years. In such jobs the body must work in a way that it was never evolved to do. Repeated movements, be they light or forceful, and fixed work postures, such as at a computer terminal, a work bench or conveyor line put mechanical stress on the body. This cumulative loading on muscles, their capsules and ligaments sooner or later results in fatigue and perhaps strain, and eventually WRULD.
When considering work activities and potential risk for WRULD, it is useful to consider the postural clues that can be observed. Ranney (1997, p. 54,55) provides a list of risks to look for in work tasks for the shoulder, and then the hand and forearm. He notes that the potential damage these risk factors may cause is dependent upon exposure.
Possible risk signals outlined by Colombini et al (2002) have also been included in Tables 4.5 and 4.6 outlined below:
Table 4.5 - Risk Factors for the Shoulder
Risk Factors for the Shoulder
High moments at the shoulder Hands far from body, especially if with load
Arms out from body or above mid-torso (weight of arms alone ~ 4 kg.)
Static load on the shoulder
(NB continuous low loads can be just as fatiguing and lead to injury as infrequent high loads
Arms held out from body continuously without support
Shoulder girdle elevated Tools held continuously
Awkward shoulder posture Working above shoulder height (eg:
painting)
Working with arm behind the trunk (eg: reversing machinery)
No time for tissue recovery Continuous repetition of same activity More than 1/3 strength required for 1/3
of task time. This may lead to incomplete recovery
(Source: UOW - adapted from Ranney 1997 & Colombini et al. 2002)
Table 4.6 - Risk Factors for the Hand and Forearm
Risk Factors for the Hand and Forearm
High forces and very repetitive work Cycle time of up to 15 seconds for at least 4 hours within a shift
Little „rest‟ time between cycles (arms in constant movement)
High forces required by task Use of fine grips rather than gross grips Fine grip required to lift object > 900g Individual fingers used for task
(eg: pressing action) Fingers in hyperextension
Gloves used for task (increases grip requirements due to fit issues) Lifting activity with palm down
(pronation)
Handling of objects > 2.5 kg
Risk Factors for the Hand and Forearm
Non-optimal postures
(extreme, end of range) Sustained flexion/extension > 30º Rapid, continual wrist movements Sustained ulnar or radial deviation Jerky, flicking or tossing movements of
the wrist
Sustained full pronation
Static loads Use of gloves for task
Activity requires wrist to remain in extension
Continuously holding an object Power tools used
High vibration
High torques/poor torques
„Kickback‟ observed from power tool Vibration – leads to mechanical injury of
tissue and may lead to nerve damage Sharp edges and hard surface Contact with sharp/hard surfaces by
fingers or palm
Hitting/hammering trim or parts with palm of hand
High precision placement requirements
Increases time
Increases static loading Increases force requirements
Holding parts to fit together
Sustained awkward posture to assemble parts
(Source: UOW - adapted from Ranney 1997 & Colombini et al. 2002)
The following illustrations and photographs demonstrate potentially
„unsafe‟ postures of limbs and joints.
(Source: ASCC, 2007 – reproduced with permission)
Figure 4.16 – Prolonged sitting at desk with flexed neck & trunk posture
(Source: ASCC, 2007 – reproduced with permission)
Figure 4.17 – Repetitive movements of the fingers is required to open pliers because the tool has no return spring. Repetitive use of pliers requires awkward movements and postures of the hands
(Source: BP International Limited – reproduced with permission)
Figure 4.18 – Working above head height with shoulder at extreme range of movement