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Safeguard OSH Solutions - Thomson Reuters

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Safeguard Magazine

Prior knowledge

A woman whose life was shattered by musculoskeletal pain tells JACKIE BROWN-HAYSOM about her quest to understand her own condition and its causes.

Yes, the occupational physician told Anne Prior, computer work probably had caused the severe pain and loss of function in her arm and shoulder, but as she wasn’t actually suffering an injury ACC could not provide cover.

For Prior, a woman who had carved out a successful 20-year career as a judge’s associate, it was a shattering blow, as much because it offered no explanations or treatment options as because it excluded her from compensation.

Fortunately she had the determination and resourcefulness not to take this as the last word. Nine years later she is yet to convince ACC that its assessor made a misdiagnosis, but she has had a succession of more useful diagnoses from private treatment providers, and – after literally years of physiotherapy, exercises, deep tissue massage and an operation – her symptoms are now significantly reduced, and her arm function improved.

“I’ve been extremely lucky,” she says. “If I hadn’t found these people to tell me what was really wrong, and help with the things that could be sorted, I would have been an utter wreck.

“But I feel so sorry for others who’ve been told that nothing can be done about their symptoms. The only solution they’re offered is medication – yet there are procedures, including non-surgical ones, that do make a difference.”

BECOMING A RESEARCHER

Since she was forced to stop work, Prior has used the research skills picked up during her court career to study international literature on the pain conditions variously known as OOS, RSI, cumulative trauma, gradual process injury or, as she prefers to call them, work-related upper extremity musculoskeletal disorders (UEMSDs)

“Without a job I needed something to do,” she says. “I thought, well my body’s affected, but my mind’s still functioning, and after years of medical evidence I’m not frightened by scientific terminology. I’ll start looking at the overseas literature to see what I can learn.”

She set herself strict parameters – no gossip or blogs, just robust, peer-reviewed papers from established institutions.

“And blow me down, once you start looking for it, it’s all there.

“I’d always known it wasn’t just me, because there were quite a number of us at the High Court harbouring these aches and pains, but when I started looking into it I found a long line of research on computer users, going back to the 1970s.”

As someone accustomed to the New Zealand environment, where the accepted stance is that computer work, even at its most intense, lacks the force to cause physical injury, she was initially astonished to find reputable research linking a variety of UEMSD to work-related computer use. The source of the damage, the reports said, was not force but prolonged repetitive motion.

“In the US they’ve put huge resources into researching what’s causing these problems. They’ve done muscle biopsies and all sorts of analysis, so they really know what’s happening. They’ve even found a possible biomarker.”

It isn’t just scientists, she says – computer company websites also warn about conditions like epicondylitis.

Alongside the research papers – which, according to a recent international literature study, have risen significantly in both numbers and quality in recent years – there is also a major triennial international scientific conference, PREMUS, dedicated to MSD research and prevention, and a smaller but academically rigorous event, the Marconi Research Conference, where researchers and corporations pool their knowledge about ergonomic office design.

“Unfortunately,” Prior says, “none of this seems to be recognised here.”

Alongside her international research she follows ACC appeal decisions, and is disturbed that the medical evidence often contradicts international research. She points out that a NIOSH study in 1994 established the link between UEMSDs – mostly tendon and nerve injuries – and computer use, yet ACC appeals generally attribute computer users’ arm or shoulder pain to dysfunction rather than injury, or conclude that the condition could not have been caused by work because force was not involved.

“I haven’t found any evidence that the NIOSH research has ever been drawn to the attention of New Zealand judges, and it seems the District Court has now adopted the opinion that typing and mouse use cannot cause muscle or tendon damage because they aren’t forceful.”

DIAGNOSIS AND TREATMENT

Prior’s own path to diagnosis and treatment has been rugged. She worked as a judge’s associate in the High Court at Wellington, typing verbatim transcripts of court proceedings. At the start of her career manual typewriters meant witnesses had to pause regularly for typists to change paper. But after taking a few years off to study law, she returned to a fast paced world of word processors.

“We didn’t have adjustable desks back then,” she recalls. “The computer was just plonked on the surface and you had to fit yourself around it.”

She began to have acute pain in her right forearm in 1993, and by late 2005 it had become widespread and persistent. In 2007 she left both her job and the workforce.

“I didn’t want to accept that this was the end of my working life, but I couldn’t lift things, was struggling to hold anything with my right hand, and having great difficulty driving.”

An assessment by an ACC occupational physician the week after she finished work concluded that her symptoms, while associated with her job, were due to muscle tension pain, and not physical injury, making them ineligible for ACC cover – a decision that was a bitter disappointment.

“I’d assumed ACC was a centre of excellence for diagnosing and treating these types of symptoms,” she says, “I thought if I got cover, I’d tap into a body of expertise that would provide speedy rehabilitation, and a return to work.”

Too disabled by pain to cope on her own, she moved to Dunedin to live with her mother.

There the long process of diagnosis and treatment began, with referral to a musculoskeletal doctor who identified that her shoulder was out of alignment, the upper trapezius muscle in her back massively enlarged, and her diaphragm not functioning, causing her shoulder to drop and impinge the tendons.

“I’d spent years of my life hunched over a hot keyboard, so with hindsight it was all blindingly obvious. He gave me exercises – which were hugely painful – to restore the function of my diaphragm, and referred me to a shoulder specialist.”

This meant more exercises – “equally painful” – and referral to a private massage clinic, where she underwent months of deep tissue massage to break up fibrosis [scarring] and adhesions in her trapezius muscle, and supervised gym work to strengthen her damaged muscles.

“They were always checking my shoulder because as soon as I got tired my trapezius muscles would take over. That was the pattern that had developed over the years – as my small muscles tired, the larger muscle would kick in to take the load – so I had to retrain my over-active trapezius to stop firing all the time.”

It took two years of hard work, but by the end of it her previously hunched posture had straightened, her breathing was normal, and her shoulder problems had largely resolved. Her forearm and hand, however, were still troublesome, sending shooting pains down her forearm when she tried to grasp and lift.

KEY SURGICAL INTERVENTION

Her GP suspected peripheral nerve damage and recommended surgery, so she tracked down a surgeon in Auckland.

“When I saw him it was very impressive – he put his fingers on exactly the point where the pain was, and gave me a preliminary diagnosis of radial tunnel syndrome.”

Conclusive diagnosis required an injection of local anaesthetic into the nerve.

“I couldn’t use my arm for about eight hours – but more importantly I was pain-free for the first time in years.”

The absence of pain proved the diagnosis, and Prior underwent surgery in 2012. Her surgeon later reported he was satisfied that the venous plexis – anomalous growth of blood vessels – that he removed from her radial nerve had formed in response to work-related damage. He also saw evidence of tendonosis – untreatable tendon damage associated with repetitive motion.

For Prior the surgery was a major step forward.

“I got my arm back. It was fantastic. I’ve regained the muscle use, and I’m not getting the shooting pains any more.”

This happy outcome has only fuelled her doubts about accepted diagnostic practices, as at an ACC assessment in 2010 the examining doctor concluded her problem was a regional pain syndrome.

“I asked him what further medical investigations I needed to find out what was wrong, and he assured me there was no tissue damage, no further investigations were required, and all he could suggest was pain management through psychological counselling.”

BATTLING FOR OTHERS

With her own problems finally at manageable levels, Prior is troubled that the accepted diagnostic approach means others must face the same battles.

A 2015 ACC appeal decision, in which a hairdresser was denied cover for elbow injury on the grounds that her work was, in the words of an occupational physician, “at the less forceful end of the physical spectrum”, prompted her to get involved.

“I was appalled, so I wrote to her lawyer suggesting the poor woman consult a hand specialist. She did, and was given a preliminary diagnosis of radial tunnel syndrome. She lodged a fresh ACC claim on that basis, and has now been given cover for her surgery costs.”

For Prior an ideal world would have specialist musculoskeletal treatment centres, where people could seek advice and treatment at the first symptoms.

“It would be much more cost effective to involve someone who knows how to treat them right at the start. If you intervene early enough they may never need surgery.”

For her part, she believes she’s reached the end of her treatment options, and is content to live with her remaining limitations.

“I function in a way that I couldn’t before, although I’ve had to learn to balance what I do.

“I might clip the roses for half an hour, then stop and not go back to it for a couple of days. It’s just a matter of being sensible.”

She’s still awaiting an ACC appeal hearing to consider the work-relatedness of her radial tunnel syndrome, after an occupational physician dismissed the likelihood of any link.

“If it fails will I give up?” She laughs. “I don’t know. I’ve written a very detailed analysis for my lawyer, so maybe we’ll keep going. I can see why people lose heart and give up, but if by speaking up and challenging the system I can help just one other person, it’s worth doing.”

Recent research

There is both good and bad news among the recent research findings. A number of literature reviews cast doubt on traditional prevention strategies for UEMSDs, with a Malaysian study finding little evidence that swapping to a better mouse will prevent harm.

A Canadian study concluded that workstation adjustments on their own are of no value. However such adjustments may have some benefit when combined with ergonomics training, new chairs and rest breaks. Several studies found limited evidence that chair arm rests could be beneficial.

In November a major study involving Canadian, American, Dutch and Scottish researchers, analysed 30 different interventions used by 9900 people, and found strong evidence of a positive preventive effect for only one – resistance training.

The evidence was good enough for it to recommend implementation of workplace-based resistance training as a means of both preventing and managing upper extremity MSDs.

A Korean study, also published late last year, measured the effect of tailored interventions on the duration, frequency and intensity of pain associated with a range of diagnosed conditions. It found significant improvements in at least one indicator for all the conditions, but much less improvement across all indicators for those with severe, rather than mild, pain.

JACKIE BROWN-HAYSOM

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