INFO FOR THE WORKPLACE...

Reduce  Soft Tissue MSD Workplace Injuries & Costs

 Taking care of your AGING work force

MSD (back injury, tendinitis, carpal tunnel) are VERY costly.  MSD represents 55% of Worker Comp claims and 65% of Worker Comp costs.

BUT, we've seen hundreds of workplaces greatly reduce their MSD Worker Comp claims and costs.

Here's how they did it.

“NO-LOST-TIME” ...A PREVENTION PROGRAM THAT WORKS!!...

We have provided MSD prevention programs to over 600 workplaces throughout the US since 1980. These companies average a 72% reduction in lost work days for back-neck-arm MSD problems. Hundreds of therapists across the US have acquired this program to bring to employers.

See our workplace MSD Prevention site at  www.impacc.com

NO-LOST-TIME is not just an "Ergonomics Program".... It is an "Ergonomics Alternatives" Program.

The NO-LOST-TIME program has three components:

1. MSD Risk Analysis: more than an ergonomics analysis... examines each job to describe risks of ergonomics, worker behaviors and company policies that lead to injuries-claims-costs. A report suggesting corrections. Suggestions not limited to ergonomic re-design; rather, offers many no-cost low-cost alternatives to costly re-design. Gives you a written Action Plan to follow.

2. Manager-supervisor Training on the Upper Extremity MSD School or Back School: on what causes your injuries-claims-costs and how to reduce them... ergonomics, medical issues, attitudes & policy issues, return to work strategies, stretching, job rotation, posture control, and many other tactics. Builds commitment among supervisors to implement your ergonomics plan with cooperation, motivation, skill. No prevention program can succeed without that !! And employee training will not work unless supervisors-managers are trained first.

3. Employee Upper Extremity School or Back School for workers on reducing work fatigue-pain-injury... self-care and protection of the working aging body. Rather than focus on disease and symptoms, our tactic is fatigue-avoidance training! Employees must be trained to accept responsibility for the working, aging body.

Does it work?? The most critical factor in selecting a prevention program is TRACK RECORD !!

PREVENTION OUTCOMES

Lauren has evolved his MSD Prevention programs over the past 25 years. This is a list of outcomes from workplaces who have implemented various versions of Lauren's programs.

ELECTRONICS G, Maine: 757 lost days year before program; 9 days year after program, 98% reduction
ELECTRONICS G, NH: Year before program 67 lost days to MSD. After program 28 lost days, 60% decrease.
ELECTRONICS A, Maine: Before program 3 claims per month, affecting 30% of workers.
.......After program 30 months of no claims. Productivity increased from 85% of standard to 102% of standard.
ELECTRONICS E, Maine: Year before program 590 MSD lost days. Year after 75 lost days, a 89% decrease.
ELECTRONICS K, NH: 616 lost days year before program; 32 lost days year after program; 95% decrease.
ELECTRONICS R, Michigan; a 96% decrease in lost time after our programs.
ELECTRONICS H, Tennessee: 247 lost days for CTD before program; 20 year after 92% reduction.
...........Also 65% decrease in lost time MSD incident rate. Productivity improved; valuable workplace cultural changes.

FOOD MFG O, Georgia: Before program, 228 lost days to CTD. After program, 66 lost days, 72% decrease.
FOOD MFG B, Maine: Lost days to MSD was 338 days before program; 137 days after program. Lost time claims down 48%
.........Lost days down 60%. Reportables reduced 67%. Annual review classes led to lost time reduced 75%.
FOOD MFG V, Pennsylvania: Year before program 944 lost days. Year after program 272 lost days, 71% decrease.
FOOD MFG U, Missouri: prevention program led to a 54% decrease in lost days to MSD and back injury.
FOOD PROCESSOR T, Michigan; After 1991 program, 75% decrease in recordables for three years.
CANDY MFG W. Pennsylvania: Serious claims problems before program. 60% decrease in lost time a year later.

SHOE MFG N, Maine: Year before program 1499 MSD lost days. During program 392 lost days. Year after 16 lost days. 98% decrease.
SHOE MFG B, Maine: Had nine months of no lost time, 50% decrease for the year after program.
SHOE MFG W, Michigan; The year after program had 90% decrease in injury severity rate.
SHOE MFG S, Maine: Had a 50% decrease in CTD claims, with an increase in productivity after program.
SHOE MFG F, Maine: Before program 462 lost days. During program 94 lost days. After program 47 lost days.
...Review program Two years after program = 9 lost days. 97% decrease.
SHOE MFG D, Maine: Facility M = 201 lost days before program; 24 lost days after program. 88% decrease.
...Facility D = 1677 lost days before program; 319 year after program. 81% dreecase.
...Facility S = 298 lost days before program; 1 lost day year after program. 99% decrease.
...Company-wide = 82% decrease in lost days in year after program. Also: 9.3% increase in productivity.

FURNITURE MFG E, Vermont: After Back Program = 47% decrease in back lost days
FURNITURE MFG, Michigan: 300 employees went four years with no lost time MSD claims after program.
FURNITURE MFG T., Michigan: program led to our lowest medical costs in 25 years.

HOSPITAL S, Illinois: Claims reduced 50%; Lost time reduced 75% since program.
HOSPITAL S, Virginia: back injury costs before program $36,407; year after $3,693... a 91% decrease
HOSPITAL S, Iowa; claims down 54%; lost days down 68%; restricted duty days down 82%

WOOD PRODUCTS H, Maine: Claims down from 7 to I; restricted days down from 195 to 14, a 92% decrease.
GOVT OFFICES VA, Maine: MSD incident rate 3.0% before program; 0.3% after program. 90% decrease.
CITY PUBLIC WORKS DEPT. L, Maine: musculoskeletal injury costs reduced 80% after program
PUBLIC UTILITY B, Maine: Before program back injuries 40% of claims. After program back injury 17% of claims.
YACHT BUILDER, Michigan: Worker Comp bill was $500,000... year after program bill $50,000, a 90 % decrease
BRUSH MFG F, New Hampshire: 556 MSD lost days prior to program; 56 days after program, 91% decrease.
AUDIOTAPE MFG O, Maine: Program led to 75% decrease in lost days to MSD. Attitudes much improved.
PUMP MFG W, Maine: Had serious MSD and back claims problem. After program no claims for eight months.
LEATHER TANNERY P, Maine: MSD costs in worse dept. were $ 330,000. After program $ 9,000 a 97 % decrease
TEXTILE MFG G, Maine: Year before program 269 lost days to back injury. Year after 66 days, 75% reduction.
PAPER MFG S, Kansas: Year before program 191 lost days. Year after 45 lost days, a 73% decrease.
AMMUNITION MFG, Kansas: MSD illness rate 8.35 before program. After program rate 2.32, a 72% decrease
CONSTRUCTION B, Maine: Year before program back lost days = 468. Year after = 73 days 85% decrease.
MEDICAL SUPPLY S, Maine: Worker Compensation costs for MSD reduced 91% after program.
GOVT OFFICES VA, Maine: CTD incident rate 3.0% before program; 0.3% after program..
CITY PUBLIC WORKS DEPT. L, Maine: musculoskeletal injury costs reduced 80% after program
FOUNDRY C, Michigan; 1992 Worker Comp costs $382,000 after program, 1993 costs $41,000, an 89% decrease.
HYDRAULICS MFG, Iowa; Lost days down for 142 to 71, 50% reduction; Restricted days from 903 to 16,
PACKAGING PRINTING, Illinois: packaging printing plant of 275 employees saw a 75% reduction in claims.
PHARMACEUTICAL CORP HQ, NY; 54 claims per 1000 before program; 2 claims per 1000 after. 94% decrease

MEDICAL PRODUCTS MFG, ME, 2004 program, claims did not decline, but lost work days went from 130 to zero, plus Comp costs from MSD went from $240,000 to $23,000 the following year
PLUMBING CONSTRUCTION, ME: 2004 program, claims down 56%; lost days down 97%
SAWMILL, ME: 2004 program; claims down 71%, restricted duty down 85%

How do we get such ambitious numbers? Several critical reasons: We go beyond ergonomics to examine worker risk behaviors. We teach workers they have responsibility to properly use and take care of the working body. We do not train workers without first training their supervisors. We teach employers how to reduce the cost of claims with specific claims response tactics. We use sit-stand tactics, task rotation tactics, and some very unique stretching tactics. We address MSDs not as repetitive motion injuries but as sustained posture disorders. We consider tendinitis and carpal tunnel to be commonly aggravated by neck issues rather than exclusively wrist issues. We address back problems not as lifting injuries but as the result of bending and many other risks beyond lifting. We show employers how to succeed with light duty strategies to achieve NO LOST TIME. See our essays below for details on all these.

See our workplace MSD Prevention web site at  www.impacc.com

This web site describes to industry what we do in the workplace

WHAT DOES NO-LOST-TIME COST? ...a comprehensive MSD Prevention program costs about $30-40 per employee. These costs are recovered if NO-LOST-TIME prevents only 2-3 MSD claims for a typical workplace, or perhaps a 10 percent decrease in lost time claims or days Thereafter, the investment turns a profit. We actually average 70% reduction in MSD lost days.

DO BACK SCHOOLS WORK??... Some studies suggest no... other studies say yes.  So, what is the answer? The reason we see conflicting study findings is one study uses one type of Back School approach, while another uses a different approach. We have provided 2000 Back School classes for about 500 workplaces. We have learned what works and what does not. Back Schools work very well IF certain rules are followed... 1. It is taught by a valid qualified expert in the eyes of the workers... 2. Training goes beyond lifting to address other often more important factors... 3. Up-to-date techniques are taught (some schools teach ineffective methods)... 3. Training is customized to match the specific demands of the workers being trained... 4. There is actual practice of techniques as a part of training... 5. Supervisors are trained first to address attitudes, policies and workplace politics (this perhaps most important). When these rules are followed, results are good. Back School training typically costs about $30-40 per employee and typically reduces lost days and costs about 70%, for about a 10 to 1 return on investment in one year. YES, BACK SCHOOL DO WORK.

WHAT ABOUT NECK-ARM MSD SCHOOLS?? ..We have provided Neck-Arm Schools to reduce carpal tunnel and tendinitis for about 500 companies and have seen EXCELLENT results. This not simply an "ergonomics" training process. Ergonomics is not that effective when applied alone. This School goes beyond ergonomics to also address work behaviors, posture habits, flexibility, self-care, job rotation, seating tactics, and a unique tactic of micro-stretching exercises. We see an average 70% reduction in lost work days and injury costs. And with improved productivity.

These are ergo-injury risks. But, company policies, workplace politics, supervisor attitudes are the primary causes of runaway Worker Comp costs. These can be fixed without raising costs or reducing production. NO-LOST-TIME identifies and corrects these critical issues. Our experience at over 600 workplaces has taught us how to handle these issues without disruption of the workplace, often with improved production and employee relations.

WORKPLACE POLITICS DETERMINES COST PER CLAIM:

The number one factor determining the cost of a claim is... supervisor attitudes and company policies toward injury claims management.   These have a far greater effect on costs than do injury severity or poor medical care!  Workplace POLITICS is the root of the Worker Comp costs problem!  If you want to reduce Comp costs, you MUST address supervisor attitudes and company policies (before attempting ergonomics or employee training). THIS IS THE SECRET TO A SUCCESSFUL PREVENTION PROGRAM.

WHAT ABOUT TREATMENT OF INJURED WORKERS?

You should designate a network of good health care providers... physicians and physical therapists.  Some physicians have their own physical therapy clinics.  But beware... some physician-owned PT clinics tend to over-prescribe PT and over-treat patients just to generate revenues.  This is a widespread problem in some areas.  You should check this out yourself.  Check your records or data from your insurance company to determine the average number of PT visits per patient for the clinics you use.  National average for PT is 12 visits per patient.  But some clinics average to 30 or 40.  That is a problem.   Other PT clinics average less than 10 visits.  That reflects good care and, thus, reasonable cost per case.  You should demand good care at reasonable costs.  

Many employers in our area demand their injured employees go to SmartCare... because SmartCare averages 6 visits, with excellent treatment outcomes... because SmartCare is so experienced on work injury care... plus an injured employee can get in to SmartCare within 24 hours, sometimes even within a few hours.   SmartCare will examine the jobs so that restricted duty can be more precisely recommended and treatment can be provided to match the demands of the job.   You -- the employer -- can specify SmartCare as YOUR physical therapy resource.   This is the type of PT clinic employers should seek.

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MORE ESSAYS TO MAKE YOU THINK:

LIFTING is often NOT the primary cause of BACK INJURY... Injury occurs during lifting often to a back that is already screwed up, usually from gradual wear damage.   Bending, not lifting, is the leading stress, along with tight hamstrings, poor lifting habits, excessive sitting, standing, etc. that all gradually damage microscopic amounts of ligaments, muscle, joints and discs. This damage heals with scar tissue that is not as strong or elastic as the tissues it tries to heal... leaving those tissues weaker and stiffer, more vulnerable to a major injury from a relatively light load.  Prevention training must address the wider collection of risk factors: new lifting techniques, new micro-stretching techniques, worker behavior modification, ergonomics, etc.

Back injury prevention must go beyond lifting to address the more common and significant risks of bending stresses, flexibility risks, sitting, fitness for work. Injury occurs to a back that is often already stressed by many other risk factors.

Consider ergonomic improvements in posture, bending, lifting requirements... PLUS address worker lifting techniques, stretch breaks, posture variety and flexibility. 

Back Schools DO work IF done correctly!

REPETITIVE MOTION is often NOT the cause most CARPAL TUNNEL & TENDINITIS...

CTS and tendinitis are generally not caused by the friction of repetitive motion.  These tissues tolerate repeated motions quite well, as long as they are getting enough blood supply.  And that is the key!!   The ability of those tissues to tolerate work demands is determined by the NUTRIENT PATHWAY.  This is the ability of working tissues to obtain oxygen and nutrients, delivered by the blood supply.  But this is often reduced by tight neck muscles from prolonged posture. If the worker has poor posture, is tense, has tight neck muscles, poor flexibility, this slows the flow of blood to working tissues at the shoulder, elbow, wrist, causing them to break down.  One could say these are more of a ‘static posture disorder’ than a ‘repetitive motion injury’.  Prevention must address ergonomics, task rotation, sit-stand options, micro-stretching techniques.  And it is easier to fix posture stresses than it is to fix repetitive motion !!

Sustained posture is the more significant MSD risk, more so than is repetitive motion. Posture risks are easier to address than are repetitive motion risks.

But we must go beyond injury prevention, to address political, policy, and attitude issues in order to reduce Worker Comp costs.

The biggest MSD risk factor is ignorance, and that can be fixed... workers will take better care of the working aging body once they become experts on this.

Ergonomics vs. Alternatives to Ergonomics... Can't afford the cost of re-tooling the workplace?? That's OK. You may not need to. Job re-design has had only limited success. Ergonomics seeks to reduce external demands on the body due to work design. But most injuries are not the result of faulty job design. Rather, they are caused more by faulty worker behaviors and poor fitness-for work. Ergonomic design has little effect on worker behaviors, posture habits, improper lifting, poor flexibility, fitness for work. Ergonomics is one important contributor to injuries, but it is not the entire definition of the problem! It is the responsibility of management to provide a safe workplace (ergonomics). BUT it is the responsibility of workers to properly use and care for the working body!!

And jobs with poor ergonomics may have no re-design alternatives. So what to do?.. job rotation reduces workers' time exposure to critical work stresses by providing variety of posture and movements. Rotate jobs every 1-2-4 hours, depending on severity of risks. It costs nothing. Production often increases due to reduced fatigue. A version of this is sit-stand option: switch frequently between sitting and standing at the job. Another alternative is stretching programs... see next essay to follow...

 ergonomics-design problem:  

While some injuries are due to poor ergonomics , most are due to risky worker behavior. Ergonomics may be fixed with better job design, if design alternatives exist. But behaviors are fixed only by effective worker training.

BOTH ergonomics and worker behaviors must be considered for claims prevention to be effective.

IS THE PHYSICAL THERAPIST QUALIFIED AS AN ERGONOMICS CONSULTANT ??

.... Absolutely yes. No one in our society is more highly trained on musculo-skeletal structure, work, function, injury, disease, treatment, and prevention than the physical therapist. No one.  ...6 or more years of university education and internships focusing on musculoskeletal movement function and dysfunction injury mechanics.

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controversy... STRETCHING EXERCISES ON THE JOB... Yes or No ??

The question of the value of workplace stretching exercises is one of the hottest debates going in the world of ergonomics and MSD prevention. This is an excellent debate to examine.

Detractors include most engineering-based ergonomists and OSHA regulators. Supporters include physical therapists and occupational therapists who treat workers with MSD problems. Each side presents strong opinions. But that is exactly the point. The scope of workplace MSD prevention strategies is almost totally founded on OPINIONS. Very little is actually "proven" by sound, controlled scientific research. Our recommendations what we see has worked for our 600+ client workplaces.

Exercise opponents fear workplace managers will turn to stretching rather than invest in ergonomic improvements in workplace design to reduce work stresses. They fear stretching may become a cheap way to avoid spending money on improved job design. This is a valid concern.

Another big reason to avoid stretching, according to these detractors, is workplace stretching is not supported by controlled scientific studies.  This is a correct observation, to a point.  BUT...neither is the value of ergonomic job re-design supported by controlled studies!  One study that was attempted showed exercises do not work... but they were the wrong exercises!   Another very large study that we are preparing for publication involves 4200 workers at 11 workplaces in 5 states, using our micro-stretching exercise protocol (takes 2 minutes done every two hours) clearly shows lost time claims reduced 59% and lost days reduced 78%.   The right exercises DO work.

None of the various strategies for MSD prevention in the workplace (engineering-ergonomics controls or administrative controls or work performance controls) have had their value firmly measured by controlled studies. Us experts are all basing our prevention recommendations on our learned OPINIONS, supported by our professional scientific education and experience.

The nature of all these prevention strategies does not lend itself to investigation by double blind research design. We are limited to anecdotal observation and analysis of what seems to work or not work at various workplaces. There are numerous discussions of the effects of several approaches to workplace exercises in various publications, some supportive and others not, based on the bias of the author (yes, me included).

When we look at large numbers of workplaces that have tried various workplace exercise programs, we see a wide range of outcomes. We do not see a near-unanimous trend of favorable versus unfavorable effects. Some famously succeed while others miserably fail. This is important. We must consider why some failed while others succeeded. There are lessons to be learned here.

This is the issue I have focused on in my 25 years of workplace MSD prevention consulting at more than 600 workplaces nationwide. I have seen several critical trends.   This led us to develop our micro-stretching protocol that ties together repetitive task demands at the hand with posture stresses at the neck.  If stretching is done right... using the right stretches... with good training to motivate workers... with proper commitment and leadership from management... then... stretches become extremely effective for virtually every type of job.

These are just two examples of a typical set of 8 or 9 micro-stretches customized to the job.  BUT employees MUST be effectively trained to select and do these properly for this strategy to work.   Success is based on effective training (both management and workers).

HERE IS THE BASIS FOR WORKPLACE STRETCHING...

MSD problems are the result of reduced circulatory perfusion (blood supply) to muscles, tendons and joint structures. Muscle contraction, tendon tension and joint compression all create mechanical pressures that inhibit circulatory perfusion pressures of these working tissues. Work then shifts to anaerobic metabolism, resulting in excessive accumulation of metabolic waste products in working tissues. These chemicals irritate and damage the musculoskeletal tissues.

MSD is a NUTRIENT PATHWAY DISORDER. It is critical to understand this. We prevent MSD by restoring, maintaining and enhancing the nutrient pathway to working musculoskeletal tissues.

This is accomplished by designing jobs to minimize mechanical compression or tension of posture and movement work that inhibit tissue perfusion. This defines the purpose of engineering controls.

Or we accomplish that objective by administrative controls such as job rotation or switching between sitting and standing to provide posture and movement work variety.

Or we may accomplish that objective with specific targeted stretching techniques that reduce neuro-muscular tension and unload compressed tissues. This is a critical definition of workplace stretching.

The term "stretching" is incorrect. Stretching implies lengthening of a shortened muscle-tendon unit. But this may not be the appropriate or safe objective. Lengthening requires a stretch to be held for 30 seconds. Research implies this is the threshold for optimal lengthening effect. But that is not what we are after. Besides, that calls for stretches that are too time consuming for the workplace to tolerate and too hazardous to teach to large numbers of individuals with individual complications.

What we seek for MSD prevention are exercises that relax neuro-muscular tension in the muscle-tendon units that are deprived of nutrient pathway. A gentle passive stretch for ten seconds can stimulate the Golgi Tendon Organs, nerve endings located within tendons that can reduce motor nerve input to working muscles. The result is decreased muscle tone resulting in increased muscle, tendon and joint surface perfusion. Exercises must target those muscle-tendon units involved in grip, pinch, reach or other loading demands of work.

Another critical issue consideration of the neck region. Repetitive motion problems occur in the upper extremity while the worker is sustained sitting or standing at the workstation. Static posture often leads to forward head posture and a protracted shoulder girdle. This encourages a degree of thoracic outlet compression, where tight lateral neck muscles compress the nerves and vessels running to and from the working upper extremity. This is a major source of reduced nutrient pathway to the brachial plexus nerves to the carpal tunnel, radial tunnel and cubital tunnel. There is also obstruction of vein and lymphatic drainage of the upper extremity in this posture, creating tissue fluid backup throughout the upper extremity. This reduces nutrients feeding working tissue. We, therefore, seek to gently stretch the scaleni at the lateral neck to reduce neck compression of nerves and vessels to the working upper extremity.

There are many bad exercises employed in the workplace and a few good exercises. One cannot judge the value of workplace exercises without specifying which exercises are employed. Potentially hazardous and generally worthless exercises must be eliminated from the discussion. We have consistently seen excellent reductions in MSD problems at hundreds of workplaces where the correct exercises are employed.

Workplace stretching is not a cure-all. It is certainly not an excuse to defer ergonomic improvements. But it is extremely valuable as an added effort to accomplish maximum reduction in MSD problems. It is especially valuable for jobs where ergonomics modifications are just not available.

Another consideration is to address MSD problems not caused by ergonomics hazards. We find that many workers develop MSD not because the job is poorly designed but. Rather, because the worker has poor posture habits, bad body mechanics, poor flexibility or vulnerabilities presented by health issues (pregnancy, diabetes, thyroid dysfunction, etc.). These at-risk workers could benefit from stretching to build their margin of work tolerance.

Workplace Stretching Programs..Yes, they do work!!!.... if you follow certain rules. Over 300 workplaces have implemented our stretching program...with consistently great success. But only if certain criteria are met. Studies showing poor results with stretching programs violated these criteria. Stretches must address the neck to reduce wrist-hand problems (tight neck muscles squeezing blood supply to wrist-arm tendons). Stretches must be designed by a professional therapist and be customized to the workplace. Workers must be educated as to how and why, and checked on their accuracy of doing them. Management must have the courage to ENFORCE exercises (supervisors must be trained in this and REQUIRED to cooperate). Our program requires only two minutes of total stretch time, done every hour or two. And productivity does NOT go down... it INCREASES according to our client workplaces that track piecework productivity, due to reduced fatigue. Stretching is especially valuable for stressful jobs but have no ergo re-design alternatives.

Re-defining workplace "stretching" exercises

We are guilty of incorrect terminology. We have long been advocating a specific method of workplace "stretching" exercises for the prevention of common MSD problems. We have consistently enjoyed exceptional success with these, contrary to the writings of other ergonomics experts. Why have they been so resistive while we have been so successful?

The answer lies with our faulty terminology and assumptions. First, the other experts decry workplace stretching because it tends to direct attention away from correcting faulty workplace ergonomic design. This is a valid concern. But we refuse to implement workplace exercises in the absence of a workplace ergonomics analysis and corrections efforts. We insist on this as a pre-requisite. Our workplace exercises are an adjunct to that and serve as a rescue vehicle where work demands are stressful but ergonomics alternatives are unavailable.

My concern is our faulty terminology of calling our exercise protocol a "stretching" program. These are not, in strict physical therapy definition, true "stretching" exercises. Stretching exercises are intended to maximize muscle flexibility. That is not the objective of our exercise protocol. Our objective is to restore muscle and tendon perfusion. These is a significant difference between improving flexibility and improving perfusion.

Stretching to restore flexibility calls for a minimum 30 seconds of passive or dynamic stretching of the target muscles. This is time-consuming (thus costly to production) and requires specific individualized worker training to assure safe and correct technique. That is not our objective.

We seek, instead, to restore circulatory perfusion to the working tissues. Muscle contraction and its tendon tension forms a barrier to blood supply for these working tissues. Too much contraction and tissue tension can shift metabolism from aerobic work to anaerobic work. This greatly increase accumulation of metabolic waste chemicals in these tissues. These serve as an irritant than can lead to inflammation. Our exercises are designed to specifically target this process. Prolonged postures and repetitive motion cycles can greatly increase muscle-tendon tension, leading to this process.

Our exercises call for a brief, gentle, ten second passive stretch across the target tissues. This is not enough stretch duration to restore flexibility and that is not our aim. This is a stimulus to golgi tendon organs and other mechanoreceptor nerve endings that respond by inhibiting muscle tension and increasing relaxation. This then allows circulation to be increased, restoring a predominance of aerobic metabolism and irrigation of metabolic wastes from the working tissues. That is our objective.

This protocol of ten-second stretches to key muscle-tendon regions seeks to relax these structures through neurological inhibitory reflexes. Relaxation of the contractile units allows circulatory perfusion to be restored, thus reversing risks for inflammation and improving repair. This is a protocol that is time-efficient so as to avoid impairing production demands. We have, in fact, observed increases in productivity when workers take a minute or two of exercise time every hour, apparently due to reduced worker fatigue and improved output capabilities.

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Wrist-rests for keyboards...Yes or No?...

Some ergonomists worry about wrist positions with wrist rests. But they miss the point. Wrist position may not be as important as NECK posture. Neck muscles work to posture the head, neck, and working arms to control fingers on the keyboard. This posture work causes neck muscles to compress nerves and blood vessels passing through the neck on their way to the arm and wrist, risking CTS and tendinitis. The purpose of wrist rests is to ease neck-shoulder posture holding stress. This is far more important than wrist position. No matter what wrist position is used, some wrist structures will be stressed. Finding and staying with an ideal wrist position will not prevent CTS or tendinitis. Wrist position variety is far more important than wrist position perfection. Worrying about wrist position is not as important as is neck posture stress relief... the purpose of wrist rests. Arms rest lightly and intermittently on the padded wrist rest, not sustained there requiring awkward finger reaching. The object is to interrupt sustained neck-arm posture muscle holding with brief pauses for upper extremity weightbearing.

Use of wrist rests greatly reduces neck muscle holding tension that typically squeezes blood vessels that feed the working wrist.  Neck muscles relax with wrist rests and allows better blood supply to working tendons at wrist

 

PROPER COMPUTER SETUP:

*Chair height-adjustable, forward tilt seat pan, lumbar support; change adjustments frequently for posture variety. *Monitor squarely in front, not to side; monitor height places vision angled down 5 to 15 degrees below horizontal. *Desk height places elbows at 90 degrees with fingers on keys. *Push equipment back to give space in front of keyboard for padded arm rest. *Paperwork on document holder near midline to avoid turning head. Vary this position for posture variety. *Mouse pushed in to allow arm to rest on surface. Perhaps switch often between mouse and trackball or touchpad for variety. *Shade to cut reflected glare. *Hourly chime from clock to remind to stop to do stretches at neck-arm-standing backbends at low back. *Telephone headset replaces handset if much phone work. *Pen-pencil padded to reduce pinch stress. *Stand to stretch often!!

See our publication PERSONAL ERGO GUIDE FOR COMPUTER WORK

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analyzing your jobs for MSD risks...

ERGONOMIC MSD RISKS CHECKLIST: (OK to copy and use)

MSD RISKS ANALYSIS CHECKLIST...

Job _________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

code R = repetitive S = sustained F = forceful A = awkward X = present
____ Standing
____ Standing on ____ cement, ____ metal, ____vibrating surface
____ Foot switch operation
____ Holds _____ neck or ____ back in a ____ bent or ____ twisted posture
____ Kneeling or ____ squatting
____ Sitting
____ Poor chair design and/or: ____ Improper chair adjustment
____ Minimal variety of work postures; movement patterns; tasks

____ Forward head, rounded-shoulders, slouching posture
____ Lack of upper extremity weight bearing support
____ Keyboard, mouse or other data input
____ Shoulder elevation repeated or sustained
____ Elbows bent more than 90 degrees
____ Forearm supination
____ Loading across wrist (tennis elbow loading)
____ Wrist flexion or ____ wrist deviation
____ Grip ___________________________________________________________________________
____ Pinch __________________________________________________________________________
____ Combined thumb pinch with wrist deviation (deQuervain's risk)
____ Repeating same motion or cycle of motions every few seconds
Repetitions described__________________________________________________________________

____ Contact stress (edge or pressure or impact with hand or knee) ___________________________
____ Vibration ____during sitting _____during standing _____ in hand during grip
____ Improper tool selection and-or use __________________________________________________

Materials handling ____ lifting ____ carrying ____ pushing ____ pulling
Handling what _________________________________________________________________
____ Heavy.. wt = ______ average and ______ peak maximum
____ Frequent. frequency of lifts = ______ per hr; or ______ per day
____ Height lifted low est ht = ______ highest ht = ______
____ Reach with load at _____ from body
____ Twisting with load ____ degrees twisted
____ Lifting/carrying across obstructions _________________________________________________
____ With difficult grip or _____ cumbersome shape
____ Workers using unsafe lifting techniques
____ Pushing or pulling _______________________________________________________________
Worker demographics ________________________________________________________________
Production demands _________________________________________________________________
Politics ____________________________________________________________________________
Claims Hx _________________________________________________________________________
Notes:

This leads to suggesting corrective actions; selected from these prevention categories...

Ergonomics-Engineering ..Re-design work to reduce the required stresses of work. This works if design is faulty and if alternative design is available and it is affordable. Seeks to dilute stresses to a less toxic level. (Lifting example: reduce weight or frequency or lowest height or highest height or horizontal distance or arc twisted or cumbersomeness of load, all to dilute severity of lifting requirements)

Time Exposure Reduction... Reduce time exposure to work stress that cannot otherwise be re-designed: job rotation, job enlargement to increase task variety, sit-stand option to switch between standing and sitting, switching between alternative methods or movement patterns doing the job. (Lifting example: lifting work limited to 1-2 hours, then switch to non-lifting tasks for 1-2 hrs)

Micro-Stretching.. Specific stretches that restore perfusion to overworked tissues; politically difficult but very effective if done right and enforced by mgt. Great protection on jobs that are stressful but no redesign available. See our essay on this. (Lifting example: Hourly standing back-bends and hams stretches)

Training & Education.. None of these work unless all parties are educated, not on what to do, but on why to do it. That is our Back School and Upper Extremity MSD School.

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OSHA 300 LOG ANALYSIS....

What are the important metrics and what do they mean?

1.  MSD claims.... raw number does not mean much.  Zero claims may mean under-reporting; employees told to put MSD claims through on their health insurance plans (potential fraud here!)

2.  How many MSD claims become lost time claims?  This metric should be less than 20%.  More than that reflects a problem... pain being reported too late in the disease process (are employees hassled over claims so they delay claim?.... too tough a work ethic for people to acknowledge pain?).... doctors who routinely take people out of work with MSD rather than utilize restricted duty (not acceptable medical care)... company policy of no restricted duty; no work unless 100% capable (a very poor costly policy that many consider incompetent and improper).   Reduce lost time claims with early reporting of pain while it is easier to fix; aggressive use of restricted duty; effective doctors and therapists; no hassles by managers-supervisors or coworkers toward those with problems.

3.  How many lost work days on average per lost time MSD claim?   This should average lass than 12 days.   More than that reflects lack of restricted duty availability; inadequate physician or therapist care; hostile relations between workplace and physicians; hostile employee relations over injury.

4.  How many restricted duty claims?  Restricted duty claims should be replacing your lost time claims.  Use of restricted duty is good, if done right.

5.   How many restricted duty days are being used?  These should average 12 days per case.  More than that reflects injuries that have been reported too late; physicians or therapists not progressing restricted duty adequately; employer not overseeing restricted duty adequately (put on restricted duty then forgotten about).  Restricted duty is a hassle, no matter how good you manage it.  That is reality.  But it should be implemented immediately... plus upgraded weekly (not monthly).  Doctors and therapists must see the jobs so they can prescribe it properly.  Hostile relations over injuries or other labor issues can lead to abuse of this.

6.   Do not expect any of these to improve without first implementing and effective injury prevention program (such as No-Lost-Time) so that you have overall fewer cases to deal with.  Then address your injury treatment and recovery issues.  Too many companies seek to establish restricted duty programs and medical provider arrangements first.  Prevention is the better first step before these.

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REDUCING COMP COSTS  and LOST WORK DAYS

HOW TO ACHIEVE "NO LOST TIME"

an employer's action plan

1. ... Establish good working relations with your local health care providers.

Set up preferred provider arrangements with good physicians and physical therapists (specialists in treating musculoskeletal disorders). Guide your injured workers to those who provide good care at reasonable cost and are motivated to keep the worker working during recovery. Make sure the doctors and therapists come see your jobs, because that is the only way they can give valid opinions on whether the injury is work-related, set work restrictions, and determine work readiness. The employer and the health care providers must be partners in injury recovery. If they are adversaries, everyone loses!

Ask local your physical therapists or chiropractors what is their average number of treatment sessions per patient. Do they get workers better and back to work quickly (6-8 visits), or do they drag it out for 15-30 visits? Do they encourage restricted duty to keep the worker working? Do they discourage chronic pain disability behaviors (or do they, instead, enable dependence on ongoing treatment that does not end?). Some health care providers make a living by getting people better quickly; but others try to sell as much treatment as they can get away with.

2. ... Arrange with a local PT clinic to see injured workers the SAME DAY the worker reports a problem...

This is a very valuable alternative to sending workers to the emergency room where you will pay hundreds of dollars and the worker may be taken out of work unnecessarily. The ER is for emergencies; not for occupational health care. The PT can be your most valuable point of immediate care for MSD claims. Arrange for immediate same-day PT examination and recommendation (much like the trainer for a sports team immediately examines an injury to determine what is needed). The PT starts treatment, may refer to a particular doctor if needed, and can advise on work modification. This can result in remarkably lower Worker Comp costs due to quick care that requires very little expense and no lost time. This can save thousands of dollars per claim!! See our new study on cost effectiveness of this elsewhere in this web site (in the section on INFO FOR PHYSICAL THERAPISTS).

3. ... Implement a Restricted Duty program!!!

The cost savings is enormous (but you have to do it right). Telling workers not to return to work until they are 100% recovered is very costly. But setting up Restricted Duty policies is not easy. Recruit an experienced PT, OT, or occupational health nurse to help you set up policies and job assignments that fit restricted duty needs. Requiring light duty also discourages frivolous claims by unethical workers seeking time off. This often requires some supervisor training and attitude adjustment, plus new collaboration with health care providers. All parties must cooperate. See essay on how to set up restricted duty, later in this section.

4. ... Arrange for a physical therapist to regularly visit your workplace

...for consults with workers having early pain problems. Workers can speak with the visiting therapist to discuss how to resolve their minor pain problems or offer their ergo suggestions, without making an injury claim. Often these early problems can be fixed with some simple self-care advice, without any reportable claim being made (because this is a first aid visit, unless the pain problem needs ongoing care)). The on-site PT can also do ergonomic consults, light duty advice, injury claims review, new employee screening, prevention training, stretching programs. You can avoid many very expensive claims with this tactic.

5. ... Arrange for screening of new hires

(actually screen all workers) by the PT to identify weaknesses or flexibility or body mechanics or other problems that may risk injury. Now, you cannot refuse to hire the worker on this basis. That risks legal action. But the PT can educate the worker on their injury risk and show them what they need to do to correct their deficits, and the employer may avoid placing the worker on certain high-risk jobs.

6. ... Encourage early reporting of pain problems.

Do not discourage pain reporting with hostile responses. Early pain reporting, with appropriate response, good treatment, immediate job risk correction will result in much reduced lost days and Worker Comp costs. It works!! This is key to NO LOST TIME.

7. ... Implement an MSD prevention program

Our prevention program that has reduced lost work days an average 72%. Employs a set of effective prevention tactics including ergonomics, job rotation, stretching, sit-stand options, employee Work-Smart training, supervisor skills training, return-to-work strategies, and much more. Very effective. Also improves productivity in many settings.

8. ... Bottom line prerequisite... train managers-supervisors to be MSD experts

All prevention and injury control programs require managers & supervisors to be trained to as experts on the realities of back injury, tendinitis, carpal tunnel claims to eliminate the ignorance and erroneous assumptions about these MSD's that lead to hostile expensive mis-management of MSD claims. It is the attitude and education of managers-supervisors about MSD that determine the cost of Worker Comp claims. Ignorance leads to mis-management and excessive Worker Comp costs!! Provide a training seminar on this topic by an expert PT-OT-RN specializing in this topic. This will create the policies and politics that will save you tons of $$.

NOTE: SmartCare averages only 5 treatment sessions per work injury (about a third the national average) ..has set up restricted duty programs for many companies ...does on-site visits to advise on job design and pain problems ...offers screening for new hires ...and offers same-day injury examination & treatment for injured workers. ....and has provided MSD control seminars to over 400 workplaces nationwide.

Workplaces save big $$ with SmartCare's NO LOST TIME program. Call for details on how to do this for your workplace

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SPECIFIC M.S.D. DISEASES-INJURIES defined...

CARPAL TUNNEL SYNDROME (CTS): Pinched median nerve at wrist, affecting digits 1-2-3. Numbness, pain, loss of coordination, weakness in thumb side of hand. Extreme cases may need surgery, if EMG tests says damage is severe. CTS is often caused by or made worse by neck posture and stiffness problems, rather than by repetitive motion at the wrist. Median nerve passes through lateral neck muscles on its way to the wrist-hand. Tightness in these squeezes median nerve, causing it to swell all the way to the wrist where it gets pinched at carpal tunnel (double crush mechanism).

ROTATOR CUFF: Tendinitis of tendons that move and hold shoulder. Tendons run under end of collar bone and outer corner of shoulder blade to get to shoulder. This is narrow passage. Holding or moving shoulder elevated (reach) stresses tendons in this narrow track causing pressure, swelling, friction damage.

TENNIS ELBOW; GOLFERS ELBOW; EPICONDYLITIS: Muscle that work the wrist originate near elbow. Loads worked across wrist (grip, pull, lift at wrist-hand) will pull on these tendons where they originate near elbow, causing them to break down here.

DEQUERVAIN'S TENDINITIS: tendons that move thumb pass across wrist at base of thumb, passing through pulleys of ligament. They get worn here, causing tendinitis.

BACK STRAIN: Spine's bones connect at FACET JOINTS... are spaced by DISCS... all held together by LIGAMENTS, and are moved or held upright by MUSCLES. Many sensitive NERVES run through tight spaces between bones and discs, where they are vulnerable to pinching.
BENDING is leading cause of problems: it pulls on ligaments; it pulls on edges of discs; and weakens muscles that protect these structures.
TWISTING pinches edges of joints together and rips at edges of discs.
SITTING is major cause, as it is identical to bending, usually for hours.
STANDING leads to fatigue which allows spine to sag on its ligaments.
LIFTING just magnifies the stresses of bending, since most lifting is done with bending.
TIGHT HAMSTRINGS upsets mechanics between hips and low back during bending, stressing low back

NOTE: NONE of the above problems can be seen on x-rays !

CONSERVATIVE TREATMENT:

REST: Soft tissue problems need a balance between rest to allow repair, plus continued use & activity so that repair is strong enough to tolerate return to work. Rest is accomplished by restricted duty, careful use of splints, balanced with restricted duty work.

MEDICATIONS: Some reduce the chemical irritation of inflammation; some reduce muscle spasm; some reduce pain.

SPLINTS: Must be carefully and skillfully selected to get the right one used right. Sometimes it is only a badge that says "I work hard" (and that may be OK). Valuable for short term recovery.

EXERCISE: a most important treatment to restore flexibility and strength and even circulation to injured parts. Can even correct bulging or ruptured discs. But must be very skillfully designed and progressed to re-build function. But worker must comply !!!

MANIPULATION: Several types of manipulation (gentle joint mobilization, aggressive joint manipulation, soft tissue mobilization). Should be done by skilled professional. Should not be done over and over for lots of sessions or else risks more damage. But often very effective.

ELECTRIC STIMULATION, ULTRASOUND, COLD LASER, ACUPUNCTURE All can reduce pain very well, but does not restore strength and flexibility. IONTOPHORESIS is an electric stimulator that can drive cortisone into inflamed tendons or carpal tunnel.

EDUCATION: Worker must become an expert on their problem to learn how to overcome it, then how to avoid re-injury (some of these problems have a 90% re-injury risk!)
TREATMENT is typically provided 2-3 visits per week for 2-4 weeks, with worker working restricted duty that protects injury but keeps worker active.

WORK-RELATEDNESS CONTROVERSY... It is often asked, "when someone claims a work-related MSD, could it not be their hobbies or crafts or their thyroid problem or their diabetes or normal aging or smoking or arthritis or simply being female, rather than work-related?" The answer almost always is there is no one single risk factor that causes the onset of symptoms. Any of the above-mentioned risk factors will increase one's vulnerability to an MSD. But any of these alone is rarely the single cause of the MSD. Workers who are female, diabetic, thyroid, smokers, pregnant, menopausal, stressed, poor diet, over 50 or under 25 are more vulnerable to MSD's. If their job adds sustained postures and repetitive motions, this exposure often then leads to the onset of symptoms. That makes the problem work-related. For most MSD claims there is a huge grey area between totally caused by the job and totally not work related. That makes the issue of work-related MSD's controversial, especially to those supervisors who want to see a specific single incident as the cause to the MSD claim. They will not usually find such a single incident. Worker Comp covers problems caused by, or significantly aggravated by the job.

WHAT'S THE DIAGNOSIS?... WHEN WILL THEY BE CURED? ... Employers want to know exactly what is wrong with their injured employee. They want to know exactly what they should allow or not allow for restricted duty work. But the employer is often frustrated by vague diagnosis, vague advice on work restrictions, and vague estimates on recovery and return to work. The employer's frustration is justified. When we deal with musculo-skeletal problems (back or neck pain, tendinitis, carpal tunnel, or other over-use pain), even the top experts are guessing at exactly what is wrong and how it will respond to care. Precise diagnosis of exactly what is injured and how badly is just not possible. These problems do not show up on x-ray or MRI like a fracture or tumor. Diagnosis is an educated guess based on history, how pain responds to specific movement tests and manual touch exam. We can be reasonably accurate but not always precise. And we usually find more than one problem. Carpal tunnel syndrome, for example, usually has some neck problems that predispose symptoms. The same is true with treatment, setting work restrictions, and identifying when to expect a cure. Treatment is usually a process of trial-and-error. How the patient will respond to treatment is highly unpredictable. Some people are cured in a week. Others with the same condition still suffer after months of treatment. Setting work restrictions is just as difficult. There are no tests that will clearly determine exactly what the worker can or cannot do at work. Health care professionals are giving their best guess as to what the worker might tolerate for work duties. And the injured worker may not have the same work tolerance from one day to the next. Who am I to tell you this? I am not expressing the opinions of a novice. I am a Board-Certified Orthopedic Physical Therapist with 28 years of advanced experience specializing in work injury. You will find my colleagues rather universally agree with this.

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OSHA's ERGONOMICS RULE defeated in 2000; may return with a new administration... However, Smart employers realize that OSHA Ergo Rules are not needed once employers realize the money they spend on MSD Worker Comp costs are far greater than OSHA fines would have been. Complying with OSHA is the LAST reason to implement an ergonomics program... reducing Worker Comp costs is the best reason. The defeat of the OSHA Rule will allow employers far greater flexibility to implement what works for each workplace. Proof: look at the outcomes of the NLT program.

Think about this.

Complying with OSHA is the LAST reason to consider an ergonomics-prevention program. Saving a ton of Worker Comp costs is the real reason. A reasonable ergo program can GREATLY reduce Worker Comp costs, lost work days, and improve productivity.

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Essay... Do Back Supports Help Prevent Back Injury?

Back supports have always been controversial. Many of us have told people NOT to wear them, as they encourage false sense of security or encourages stiffness-weakness in the torso. BUT this is now being challenged!! The Home Depot study showed a 34% decrease in back injuries among 36,000 workers, among young and old, new and experienced, high intensity lifting and low intensity lifting workers. Kraus, Jess, et al: "Reduction of Acute Low Back Injuries by Use of Back Supports," INTL J OCCUP & ENVIR HLTH, Oct-Dec 1996, Vol. 2 (3).    OSHA countered with the WalMart Study that did not find any reductions. However, the back supports were not enforced at WalMart but strictly enforced at Home Depot.    One of the best papers describing back support biomechanics and potential benefits is "Effects of Soft Lumbar Support Belt on Abdominal Oblique Muscle Activity in Non-impaired Adults During Squat Lifting" by L. Warren, et al, J ORTHOP SPORTS PHYS THER, June, 2001; 31. This offers great biomechanical description and cites many other related studies.

We often recommend back supports for those with spinal instability, do repeated or heavy lifting, wear the support loosely until the lift is about to occur, must be committed to proper lifting methods and regularly do their corrective back exercises. In this situation, back supports may make the critical difference between success and failure.

APPROACHES TO RESTRICTED DUTY: (OK to copy and use this!)

Restricted duty is to provide workers affected by MSD a sequence of controlled, graduated work assignments to facilitate maximum recovery of work tolerance with minimal risk of recurrence. Restricted duty is to gradually "harden" the recovering injured worker to tolerate normal work demands. The emotional and psychological advantages are widely accepted, as is the process of physical reconditioning presented by continued work. Reductions in lost work days and cost-per claim can have profound financial advantages. as do employee relations.

What is remarkable is the RANGE of average cost per claim for the same type of MSD disorder, varying from one workplace to another. Company A may average 8 lost days and $500 per claim, while Company B averages 50 lost days and $15,000 per claim. Differences between workplaces can be huge. Why? One of the most common and most costly weaknesses in an employer's Worker Comp management procedures is the lack of an effective Restricted Duty Program. Some employers tell injured workers to stay home until they are 100% work-capable. This 100% Rule is perhaps the most expensive Worker Comp policy we have ever encountered.

Employers have an opportunity to do something very positive to speed recovery and reduce Worker Comp costs by making this process meaningful and recovery-directed. Some call this Transitional Work, a structured progressive process of assigning work duties to facilitate reconditioning the injured worker quickly to full work tolerance. The OSHA terminology is Restricted Duty.

Restricted Duty saves employers lots of money. It gets people back to work and back to normal life. It saves immeasurable human and corporate suffering. Telling workers they cannot return to work until they are 100% recovered is financially foolish. But to succeed with restricted duty, the employer must be deliberate and organized and prepared. Bring in a PT, OT or occupational health nurse experienced with work injury management to advise you how to avoid failure and frustration. This will be a politically difficult challenge, especially where work injury has been handled with conflict and harsh feelings. your local health care providers must be skilled and cooperative; and so must the employer.

The employer may need a consulting PT-OT-nurse to audit the available job tasks to identify what tasks would fit workers with what problems. They must also audit policies and procedures to re-write them to facilitate efficient success with restricted duty. They may also need to provide reality training to managers and supervisors and perhaps even to employees to break down hostilities that will block success. Local health care providers will also need to be educated and committed to this, and that may require some re-building of relations. Everyone at the workplace must become skilled and committed. It is not easy. But it can save you tons of money.

Example of how restricted duty may be applied...

1. Alternative job assignment: An alternative job assignment is best designed to be varied in activities, postures and motions. Sustained postures, highly repeated motions, heavy efforts and extremes of mobility are to be avoided. The alternative assignment must avoid stresses that would likely increase the damage of the problem. Consider the risk factors for back injury to be the stresses to avoid for workers with back problems, as well as the risk factors for neck and upper extremity CTD to be the stresses to avoid for workers wit these problems. Refer to the following chart of risks to avoid per problem area.

2. Restricted duty within the confines of the regular job (but at restricted hours): This is for the employer who has no alternative jobs for light duty. Light duty can often be confined to the regular job normally worked by the employee, but at abbreviated hours (such as four hours per day at three days per week, more or less as indicated). Two or more light duty workers may even share a regular job part-time to fill full-time hours for that job. This is good for settings with minimal variety of jobs available to choose from. This could be the least disruptive approach for many situations, assuming the regular job can be made safe and tolerable simply by reducing the worker's time exposure to it. The worker may work the regular job at reduced hours, or may rotate between the regular job and an alternative job assignment. If the regular job is too stressful even at reduced hours, then an alternative job must be developed.

3. Progression of restricted duty: Restricted duty is a dynamic process, continually moving the worker toward their regular job duties. Restricted duty should gradually add progressive doses of work stresses to harden the individual to tolerate them. The restricted duty job should, at first, protect the injured body parts from further strain while providing physical conditioning. Work progresses toward increasing demands that progressively stress recovering body parts. Injured structures are exposed to graduated doses of work demands that build strength and endurance as tolerated. A recovering injured worker may ideally graduate from one restricted duty job assignment to another more challenging assignment on their way toward full return to regular work duties. Typical progression is made weekly.

RESTRICTED DUTY CHART OF RISKS TO AVOID:

1. Low Back Risks
.......a. Heavy, frequent, low, high, cumbersome lifting
.......b. Forward bending that is low, frequent, prolonged
.......c. Overhead work that is high, frequent, prolonged
.......d. Twisting (especially combined with bending or with a load)
.......e. Prolonged standing (especially on cement or steel or vibrating floor)
.......f. Prolonged sitting (especially on chair of poor design, adjustability, or vibration)

Preferences:
.......a. Frequently switch between sitting and standing
.......b. Walking about
.......c. Anti-fatigue floor mat or insoles; ergonomically correct and adjustable chair
.......d. Variety of activities
.......e. Frequent stretch breaks

2. Neck Risks
.......a. Overhead work
.......b. Twisting-torsion: frequent, sustained, extreme
.......c. Low-positioned work creating sustained and-or extreme neck flexion
.......d. Prolonged arm activity
.......e. Arm activity whereby arms cannot rest on work surface

Preferences:
.......a. Ergonomically correct seating
.......b. Frequently switch between sitting and standing
.......c. Head positioning in neutral anatomical position
......d. Frequent stretch breaks

3. Upper Extremity Risks:
.......a. Shoulder: reaching high, forward, or to side: frequent, sustained, loaded
.......b. Elbow: lifting or holding loads in the hand, loading the extensor carpi radialis
.......c. Wrist: Grip, pinch, vibration; wrist flexion, deviation (forceful, sustained, repeated, extreme)
.......d. Thumb: Pinch with wrist deviation, thumb push, repeated thumb motions or extremes of position

4. Lower Extremity Risks:
.......a. Sustained standing
.......b. Standing predominantly on one foot, as in operating a foot switch (piriformis problems)
.......c. Excessive walking
.......d. Climbing stairs or ladders
.......e. Cement or steel or vibrating floor
.......f. Poor footwear

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EXAMPLE.... Company SR's Worker Comp Control Program...

Company SR's Human Resources Department has operated an aggressive Worker Comp costs control process for the past two years. This involves a number of well-coordinated tactics. There are...

1. Soft tissue injury & ergonomics Risks Analysis.
A certified industrial physical therapist examines jobs with claims history or injury risk to identify risk factors and recommend prevention actions. This presents several injury prevention suggestions for ergonomics modifications, job task rotation, seating design, stretching exercises and other customized suggestions.

2. Stretching programs for at-risk employees.
The physical therapist customizes specific stretches to meet specific job physical demands, with aggressive supervisor enforcement and detailed employee training.

3. Training of supervisors on injury prevention and restricted duty management.
Supervisors undergo training on injury avoidance, ergonomics, and how to properly manage restricted duty to maximize recovery with minimal lost time.

4. Earliest intervention pain complaint response.
Employees are aggressively encouraged to report pain problems early, for immediate early intervention to avoid lost time and minimize costs. SmartCare PT clinic provides same-day intake for evaluation, initiate treatment (emphasizing self-care), and establish work restrictions. SmartCare determines whether physician involvement is needed, thus avoiding more expensive medical care when not needed. Early application of restricted duty greatly hastens recovery and avoids lost time. The result is minimal lost time and extremely low cost-per case.

5. On-site PT Clinic .... Physical Therapist is on-site at the workplace two afternoons per week during the busy season when worker populations and work demands are very high, for early intervention evaluation and treatment, thus avoiding travel time and costs.

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A STUDY AWAITING PUBLICATION... ( Using the Physical Therapist as the primary provider for MSD claims)

DIRECT ACCESS PT CARE OF INJURED WORKERS VS. PHYSICIAN REFERRAL TO PT: COMPARISON OF COSTS & OUTCOMES

.......Injured workers are traditionally referred to physical therapy by physicians, as is often dictated by law. Many states have liberalized laws to allow patients direct access to PT without being referred by a physician. The basis of these changes assumes physical therapists are adequately trained to evaluate patients to design safe and effective treatment. Another consideration is direct access may reduce health care costs and disability due to quicker access to PT care earlier in the disease process.

.......SmartCare enjoys an arrangement with workplaces whereby employers may refer workers complaining of musculoskeletal problems directly for PT care. The arrangement calls for early reporting of problems by employees, with SmartCare providing evaluation and intervention within 24 hours of referral by the employer. The physical therapist performs evaluation and initiates treatment, unless evaluation indicates need for physician referral. The clinic also treats injured workers referred by physicians. This presents an opportunity to compare employer referral to PT versus physician referral for treatment visits, costs, outcomes.

.......Both groups of workers in this study originated from a variety of workplaces and suffered similar musculoskeletal problems. Workplaces included sawmills, furniture manufacturers, wood-turning, paper manufacturers, ski resort housekeeping and maintenance departments, public works, office settings, construction, and others. Work injuries included non-fracture non-surgical sprains, strains, and cumulative trauma disorders of the extremities and spine. Workers in each group were treated by the same physical therapist utilizing the same treatment protocols. Treatment protocols included restorative exercises, manual therapy, electrotherapy modalities, risk factor education, and restricted duty work assignments.

RESULTS: Workers referred directly to PT by their employer needed 60 percent fewer treatment visits than workers who saw a physician before referral to PT. 132 physician-referred injured workers utilized 911 physical therapy visits, averaging 6.90 visits per worker at $607 cost per case. 137 workplace-referred injured workers utilized 566 physical therapy visits, averaging 4.13 visits per worker at $363 cost per case. 87% of employer-referred patients achieved successful outcome. 79% of physician-referred patients achieved successful outcome. These are high rates of outcomes success that may be attributable to early PT referral by both employers and physicians, plus workplaces that are skilled and cooperative at providing restricted duty work assignments to injured workers.

CONCLUSIONS: Injured workers referred to physical therapy directly by the employer, without first seeing a physician, underwent fewer treatment visits, expended less Worker Compensation costs and enjoyed higher outcomes success. Possible explanations for these findings are:

(1) Direct referral to PT by employers allows injured workers earlier access to PT before deconditioning or other deteriorative effects can impair recovery. This may reduce Worker Compensation costs and disability.

(2) Employers utilizing direct referral may be more pro-active with other injury management strategies such as early reporting of pain problems, effective use of restricted duty, attention to ergonomics, and training programs such as Back School and CTD School which may contribute to favorable outcomes.

(3) Injured workers referred by the physicians may have been more severely affected, with their less severely affected workers having recovered prior to physical therapy referral. This could account for some of the differences between the two patient groups.

IMPLICATIONS TO PHYSICAL THERAPY: These findings may present an example of the intent and advantage of direct access, versus physician referral requirements. This further suggests an opportunity for physical therapists to market to employers early intervention treatment services on an early-intervention preferred-provider direct-access basis, with an objective of reduced Worker Compensation costs and more rapid recovery. Such arrangements would require direct access be allowed by law and-or standing orders arrangements with company physicians to comply with existing law.

OTHER STUDIES PARALLEL THIS: Our study closely resembles the findings of Mitchell, J.: "A comparison of Resource Use and Cost in Direct Access Versus Physician Referral Episodes of Physical Therapy" PHYSICAL THERAPY, Vol. 77, No. 1, Jan 1997. Mitchell found physician referrals to PT averaged 12.2 visits at $2236 per patient, while direct access to PT averaged 7.6 visits at $1004 per patient from Maryland Blue Cross data. Plus the study: Zigenfus GC, Yin J, Giang GM, Fogarty WT, "Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders" J Occup Environ Med. 2000;42:35-39, which says: Patients referred to physical therapy at day one or day two of back pain onset needed fewer treatment visits and had fewer lost work days than those referred later than day two. PT Magazine quoted the trade journal "Business Insurance" profile of the PT direct referral program at Tex Tech clothing mfg in Maine whereby costs averaged $4124 per case before PT direct referral, but only $908 per case the year after implementing direct referral to PT.

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ANOTHER STUDY AWAITING PUBLICATION

“Implementation of a “Micro-Stretching” Program for MSD Prevention in Manufacturing Work Settings:  A Multi-Case Report”

Lauren Hebert, PT, DPT, OCS

Study Design:   Multiple-case report

Background and Purpose:  Worker Compensation claims for musculoskeletal disorders (MSD) are widespread in today’s workplace, resulting in extensive human suffering, costs and lost workdays.  Despite controversy over effectiveness, workplace stretching exercises is one intervention utilized by many workplaces.  This report describes a “micro-stretching” program encompassing 4200 manufacturing workers at 11 workplaces provided by four physical therapists in five states and the implications of the outcomes.

Case Description:  11 manufacturing workplaces experiencing high rates of MSD claims and lost workdays employed physical therapists to introduce a structured stretching program seeking to reduce incidence, severity and costs of work-related MSD.  These workplaces had a predominance of jobs requiring repetitive tasks performed in fixed postures (sustained standing or sitting).  It was assumed that these work demands led to high rates of claims for MSD.

Intervention:   Physical therapists designed a “micro-stretching” program of brief but frequent stretching to neuromusculoskeletal structures at the neck, upper extremity and lower back.  This program was implemented via a structured training process provided first to company leadership to gain implementation commitment, followed by employee training on how and why to perform these exercises.   Micro-stretching was performed over a two-minute period every two hours during the workday, seeking to restore nutrient pathway and perfusion to neuromusculoskeletal tissues under posture, movement and loading demands.

Outcomes:   MSD claims and lost days were measured from workplace injury records for the year prior to implementation and compared to the year following implementation.  MSD claims declined 37 percent.  Lost-time claims declined 59 percent.  Lost workdays declined 78 percent.

Discussion:  Preventive stretching in the workplace is a controversial issue.  Although evidence is lacking, stretching offers potential value to MSD prevention, particularly where ergonomics controls may not be viable options.  Key prerequisites to an effective preventive stretching program include proper exercise design by qualified experts such as physical therapists who understand pathomechanics of MSD, management commitment to making the exercises happen, and effective employee education to foster motivation and skills to perform the stretching exercises.

Keywords:  workplace stretching exercises, MSD prevention

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Proposed

Invite us to a day of examination of your MSD claims and costs issues, leading to a proposed action plan to address the root causes of these problems.

We examine OSHA logs to identify trends and implications; analyze past efforts that have succeeded or failed; explore policies and practices that affect costs and outcomes; examine selected high-claims work areas to identify sometimes subtle but critical injury risk factors; explore claims response, treatment and controls, including health care provider interactions and restricted duty processes.

This analysis leads us to produce a comprehensive action plan. This may include manager training to build enlightened decision-making; supervisor training to build commitment-cooperation-attitudes; claims response procedures; build health care provider cooperation and communications; suggest ergonomics actions that are affordable and practical; suggest alternatives to ergonomics that effectively reduce claims; suggest restricted duty processes and more, customized to your workplace needs.

If interested.... Call us at SmartCare 562-8048

We can provide an on-site MSD claims-costs Risk Analysis that details your problems and what are the options available to correct them

We can then provide a seminar for your supervisors and managers to educate them about our findings and what they can do to implement a corrective action plan.

We can then provide a WorkingSmart employee training program teaching employees what they can do to take care of the working-aging body, how to avoid MSDs and personal ergonomics techniques, all customized to their workplace.

We can train your in-house ergonomics team on advanced problem-solving strategies.

A GREAT EXAMPLE...

No-Lost-Time Program for the XYZ Corp mill..

They initially presented with a virtual epidemic of MSD problems of the upper extremity and low back. We started with an MSD Risk Analysis to identify risk factors in: (1) work demands and ergonomics, (2) worker behaviors and body mechanics, (3) employee relations, (4) injury response policies and attitudes. This presented a suggested Action Plan to address these.

This was quickly followed by a Manager-Supervisor MSD School seminar to educate and enlighten them on their problems and how to fix them. Policies, practices, and attitudes are corrected with education about the underlying issues of MSD injuries-claims-costs. This launched a committed effort to correct risk factors.

This was quickly followed by Employee Back School and Upper Extremity School sessions to build employee commitment to self-care of the working body, plus personal ergonomics skills. This built cooperation with the planned corrective changes and prevention actions.

This launched a series of policies implementing Job Rotations, frequent Micro-Stretching, and Ergonomics improvements, with strong commitment by supervisors and managers.

We provided a manager-supervisor Restricted Duty seminar and helped establish restricted duty policies and job assignments.

Company uses us as their Preferred PT Provider, with direct access for non-emergency MSD problems. Early reporting of MSD symptoms is emphasized (with a supportive, non-punitive response attitude by supervisors). Employees are seen the same day as the injury onset or report of pain problem. We would set up a part-time On-Site PT Clinic, except they are already located next door to our clinic.

All new employees undergo a Musculo-Skeletal Risks Screening. When they have hired 10 or more new employees, they undergo the employee MSD School.

The physical therapist provides a bi-monthly factory walk-through to seek employee suggestions for ongoing risks and possible improvements, plus early pain complaints that may be addressed with first aid self care advice.

We provide annual review MSD School classes for supervisors and employees. We also provide focused MSD Risk Analysis, MSD School., and other custom prevention interventions for work areas where new MSD claims begin to appear or where there have been new jobs created or re-designed.

The initial prevention program (MSD Risk Analysis, supervisor and employee MSD Schools) resulted in a 70 percent reduction in MSD lost days. The follow-up services then led to a 50 percent reduction in costs per MSD claim.

MSD Risk Analysis, MSD Schools, monthly walk-through tours, pre-placement screening, restricted duty consulting are all billed directly to the factory at a standard rate of $200/hour (later reduced as part of a large preferred client deal). All treatment services are billed to the Worker Compensation insurer at the standard Worker Compensation fee schedule.

This relationship has led to prevention programs and consulting for several of their other facilities in US and Canada.

Moxie Gorge

See much more on this topic at our MSD prevention web site  www.impacc.com