Haven't Got Time for the Pain

Manage the cumulative impact of cumulative trauma by focusing on medical care coordination and return to work concurrently.

CARLY Simon's hit song "Haven't Got Time for the Pain" is nearly 30 years old, but it certainly describes today's business environment. The constant demands of business--complicated by rising health care costs, an economic recession, layoffs, and an aging workforce--make it difficult to focus on preventable injuries plaguing workers and businesses.Yet, these injuries annually rack up billions of dollars in worker's compensation claims and productivity costs.

Repetitive motion injuries. Cumulative trauma disorders. Repetitive stress injuries. There are many classifying terms for this group of painful and prevalent injuries that are taking a costly toll on American workers. Certainly, the physical pain for employees with these disorders, which can range from tendonitis to bursitis to carpal tunnel syndrome, is significant. But employers experience a different kind of pain: In addition to medical costs, the unpredictable time off and indirect expenses associated with lost time can significantly affect the balance between productivity and the bottom line.

High Frequency and High Cost
By decreasing the variety of tasks and motions performed, workplace automation and specialization have contributed to an increase in job tasks that are repetitive. Awkward or fixed postures, force, and repetitive exertions over time can lead to inflamed tendons and nerves, along with strained muscles in the back, hand, wrist, or forearm, to name a few. Eventually, workers can begin to experience pain, numbness, and a reduction in or loss of function. Without intervention and treatment, employees can suffer permanent disability.

How significant is the pain? The Bureau of Labor Statistics reports disorders associated with cumulative trauma account for approximately 60 percent of all occupational injuries or illnesses. Each year, 600,000 new cases of cumulative trauma disorder that result in lost work time are recorded and contribute to $100 billion in associated costs, according to OSHA estimates. The direct medical costs alone total $20 billion per year. Estimated indirect costs--including overtime, training, and lost production--are five times higher than direct costs.

One type of cumulative trauma, carpal tunnel syndrome, has garnered a lot of attention in the past few years. This is not surprising, considering the following:

  • Carpal tunnel syndrome accounts for nearly 58 percent of injuries with more than 20 lost work days. (OSHA--Best Review, November 2000, Vol. 101, Issue 7, page 85)
  • The median lost time for carpal tunnel is 27 days, according to the BLS data for 2000, the highest among all work-related injury or illnesses. Even fractures (20) and amputations (18) fall behind carpal tunnel syndrome in lost work days.

Repetitive motion injuries, another type of cumulative trauma, produce the longest absences of other leading events or exposures. Repetitive tasks such as scanning groceries and keyboarding are among the types of repetitive tasks that drive a high median of 17 days away from work (DOL data 1999).

Fortunately, it is possible to reduce the incidence and costs of cumulative trauma. Effective management that focuses on medical care coordination and return to work concurrently is a win-win situation for employer and employee.

Step One: Prevention and Planning
Successful management can be broken down into three primary steps:

1. Prevention and planning

2. Recovery and return-to-work management starting the first day of disability

3. Setting expectations

To manage cumulative trauma disorders, preparation and planning are key before the injury occurs. These preventive steps should include an analysis of the company's experience and risk; risk mitigation including ergonomic intervention, training, and education; and contingency plans that start the first day of disability for management of medical recovery and return to work.

The first step toward preventing cumulative trauma disorder is understanding the company's specific risks and setting priorities to manage those risks. This can be accomplished with an analysis of the frequency, location, job classification, and cost of cumulative trauma disorders to determine the company's specific experience and to set priorities. For example, a company might find only 15 percent of its injuries are carpal tunnel, but those claims contribute to 60 percent of the company's medical costs. Or a company might find 60 to 70 percent of the risks driving costs are in a small number of job classifications. Once these high-loss areas are identified, injury prevention and contingency planning can begin.

Many cumulative trauma injuries are preventable if their triggers are identified and addressed. A work-site survey will provide an overall assessment of biomechanical risk factors contributing to injury, as well as recommendations for targeted intervention. Trained ergonomic professionals can evaluate individuals in their work environment, assessing the employees' physical characteristics as well as their job tasks and functional requirements. These professionals should recommend work changes that will significantly reduce the risk of injury. Many times, simple, inexpensive changes in the ways a task is performed can result in dramatic improvement. Examples include raising or lowering the height of a workstation, changing the width on tool handles to better fit workers, changing the work flow to offer more variability in tasks over time, and rearranging a workstation to make better use of lighting.

Employees need to be motivated and empowered to take an active role in eliminating cumulative trauma risks. Safe work performance training builds awareness among employees by providing information on the causes and effects of cumulative trauma. Employees also should be encouraged to report any symptoms of injuries as soon as they are recognized. Early reporting enables immediate management of necessary medical treatment and job accommodations to prevent additional injury.

Unlike acute injuries, cumulative trauma occurs over time. Preventive measures can often arrest and even reverse the injury's progression. However, prevention alone will not minimize the physical impact and lost time associated with cumulative trauma disorders. To this end, contingency planning can prove invaluable.

By establishing return-to-work options before an employee is injured, transitional duties for at-risk positions can be identified and available immediately after the injury is reported. In addition, job analysis of critical positions is key in the early determination of work suitability for usual duty. This information--preferably in a database format that gives the employer the ability to match employee capabilities with job requirements--is ideal and can be prepared and sent to the physician as early as the day of injury.

Recovery and Return-to-Work Management
When an injury or illness does occur, most employers have a process in place to handle the notice of injury and get recovery and return to work under way. The question is, does this process expedite medical recovery and at the same time facilitate safe return to work? If the answer is no, opportunities for process improvements abound.

Following the report of injury on a cumulative trauma case, the objective should be to initiate appropriate medical intervention and to determine work suitability. If pre-loss identification of job requirements, accommodations, or transitional work options are in place, then the process of securing appropriate medical treatment and obtaining physician approval for the identified suitable duty is simplified and shortened. If the pre-loss identification does not exist, the work suitability evaluation must be initiated on that first day in order to minimize unnecessary lost time.

In determining work suitability, the best practice model would first assess whether the employee will be able to return to the tasks of the pre-injury job. If these tasks are temporarily unsuitable, then job accommodation should be considered. The benefits of having employees perform their usual job, even with accommodation, are the retention of skills and ensuring productivity, elimination of the need for a replacement worker, and the benefit to the workers of continuing their level of contribution to the workplace.

However, if neither the original job nor a job accommodation is an option, transitional duty is the next step. Transitional duty differs from accommodated duty in that transitional duty is temporary. Although it may or may not be related to the employee's pre-injury work, transitional duty should still be a viable job task for the company. Transitional duty is best managed if it is task-specific. For example, if an employee can perform two of the three essential functions of her usual job, it is best to have her perform those two essential functions and to replace the third with a transitional duty task.

Recovery from cumulative trauma is incremental. Therefore, when a well-coordinated effort between medical treatment and return to work exists, the transitional duty options can become more flexible as the injured worker recovers. This coordination of transitional duty minimizes lost work days and maximizes the employee's continuation of employment.

Set the Expectation with Communication
The physician clearly has an important role in the effectiveness of the return-to- work process after a cumulative trauma injury is reported. Selecting an appropriate medical professional and then making sure the physician has accurate information about the transitional work are two important details often overlooked.

In a study conducted by the Integrated Benefits Institute, 90 percent of the more than 300 physicians surveyed said that if employers provided a list of jobs and their functional requirements, they would release the employee to appropriate work. The two resources the physicians requested most were direct input from employers on job descriptions and return-to-work options, and cooperation from the employer in the return-to-work process.

The importance of communication is not isolated to the interaction with the physician. Communication between the injured employee and his or her employer--and the employer's treatment of the employee--greatly affect the employee's return to work. Building a return-to-work environment begins with communicating to a healthy workforce the company's commitment to their well-being and the impact they have on the bottom line. By communicating the process and the employer's expectations before an injury or disability occurs, the employer should expect better return-to-work results should a cumulative trauma injury occur.

In addition to setting the stage before the injury occurs, communication once the medical and return-to-work process begins is critical. A 2001 survey of employees who lost time from work because of an injury or illness, conducted by the Gallup Organization, showed a strong correlation between employee satisfaction and return to work. Employees who felt satisfied with the disability process and with their employers' treatment of them while they were out of work came back to work in approximately half the time of their disenfranchised counterparts: 63 days compared to 125 days. Survey respondents who were contacted two or three times during their absence reported greater satisfaction with the disability process than those who were contacted only once. Although communication may take time, in the end it should reduce the pain of having the employee away from work.

Worth Repeating
Cumulative trauma is a cost driver for many employers. Lost productivity, high medical costs, and even costly litigation are real threats to the bottom line.

It is sometimes difficult for employers to focus on these "quiet costs" when they are bombarded with the larger, more evident issues that affect daily business. But in this challenging economic environment, employers cannot ignore the pain and impact of "one of the most significant occupational health problems in the United States," according to the National Institute for Occupational Safety and Health.

By identifying and mitigating stressors, it is possible to prevent or reduce the impact of cumulative trauma disorders in an organization. Early deployment of ergonomics, appropriate case management to facilitate recovery, a strong return-to-work program, and effective communication pay off in reduced residual disability and minimized lost time--and in more satisfied, more productive, and safer employees.

This article originally appeared in the June 2003 issue of Occupational Health & Safety.

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