A safer conversation: musculoskeletal disorders and ergonomics

What are the key elements in managing and, consequently, reducing the prevalence of MSDs?

Nigel: The elements are the same as they have always been: force, repetition, posture, lack of rest, stress and individual susceptibility, all of those things that Putz-Anderson described in the late ‘80s and early ‘90s. These are the key risk factors.

In terms of management, you basically manage the way people work, which elements of their job are going to expose them to the risk factors, to excessive force, to too much repetition, to poor posture and to lack of rest. And rest could mean taking an active break from excessively sedentary work. It might mean actually getting up and going to the printer and moving around, if you have a desk job. Clearly stress is another risk factor. As is luck.

There is a whole raft of evidence to say that unfortunately some people are simply more susceptible to MSDs than others. There is nothing that leads me to believe these six factors, which have been well understood and well described, are not the key factors.

I think there’s a second dimension, which is, if you’re going to apply a predictive model, you typically want to know what people do and how much exposure they have to these risk factors. So how often, how long and what sort of pressure are they under actually is the second dimension to whether those risk factors match or not. In other words, you can have really bad posture for a couple of minutes a day and it probably won’t matter. But if you have a really bad posture for eight hours a day you might be in big trouble. That is the sort of thing that organisations need to identify and manage.

Joanne: I agree. We also need to understand that most of us are going to get back pain at some point in our life. Something like 90% of us are going to get back pain, which we will recover from. But there’s different types of MSD – there’s the ones that are simpler and there are the much more complex ones. The key is early identification; early intervention, to identify if somebody has got a problem, or a particular group of workers have a problem.

As Nigel said, the information from the ‘90s still stands, and I think it’s how we’ve got all these risk assessment tools for manual handling. And for some reason we’re still struggling to prevent and reduce some of the upper limb disorders.

The Labour Force Survey 2013/14 reported over half a million cases of MSD, an increase on the 2011/12 figures, with 184,000 new cases. What could be the reasons for this?

Nigel: First of all, it’s worth reflecting that it’s self-reported illness and injury, so it’s not actually from the clinicians who have diagnosed and seen actual cases, it’s just people reporting themselves having an MSD. Now clearly, if you figure that over the previous period the UK has seen something of an economic downturn, there might be societal reasons for any increase in reporting.

There is also a change to the legal framework where the reforms to civil litigation means that if you’re going to get a claim in, it was better to get it in last year, not this year. So I think there has been an increase in advertising and putting pressure on people who are being told they have got an MSD.

It may simply be a statistical anomaly. MSDs have always been influenced by society.

Other factors might be things like zero-hour contracts, people holding multiple jobs, being constantly under stress, the stress caused by the permanent question of, “Have I got a job today, have I not got a job today?” That might also account for it.

There can be so many factors that impact both the perception of MSDs and their actual occurrence. So while we can speculate, I don’t know what the reason is for the increase.

Joanne: In the LFS report the data for the previous year is missing. The gap means you can’t actually see if there’s a potential trend yet or not, so it is really hard to say whether we are seeing an increase in cases of MSD.

Nigel: It would be interesting to see if this is the start of a trend, and I’d wait to see the reporting figures for the next three or four years to see whether it continues. And from my perspective, I think the previous reduction in the number of reported MSD cases has been a huge success and down to the initiatives of organisations such as the Health and Safety Executive (HSE). The fact that we have got it down is encouraging. Who knows whether this increase in 2013/14 is something we’re going to see in the future or whether it’s just a blip. And as Joanne said, it may well be that what we’ve actually got is two years’ data, or 18 months’ data, reported as a single year.

MSDs are usually linked to industries such as manufacturing and agriculture. Is there a trend of more office workers being affected and how should we deal with this?

Joanne: We have these issues here in the UK in our offices, and we’re trying to get the message across about the fact that we are sitting all day long. There are a number of important things. Have the risk assessments been done and the control measures been put in place? Because I’m forever telling people they really need to get up and move at least once an hour, but for whatever reason, people don’t do it. Most of the companies I’ve worked with say they don’t make employees sit at their desk all day.

I’d hope never to walk into a workplace where somebody’s tied to their desk. Because that’s got to change. I appreciate there are some industries that have a poor reputation with regard to the use of technology. But you’ve got the risk assessment mechanism, you’ve got the risk reduction mechanisms, which include training and awareness of the risks to anybody who’s using a computer.

Many people use different types of technology – laptops, phones, tablets – and we don’t know quite yet how those are going to impact on workers’ health. There have been reports about the posture you have when you’re using your iPhone or your tablet, but we’re exposing ourselves to other things as well. So it’s not just at work, it is at home, everywhere.

We need to think about the way we’re using this technology. We need to skill people into how to set up workstations, use the technology and get up and move. I’m just as bad as everyone else. I’ll sit there for hours. To be frank, we all do this but we need to get people moving; it is stated in the DSE Regulations that every 55 to 60 minutes is a good interval for having a screen break. Just stand up, stretch, move.

Nigel: It’s worth saying it isn’t actually new, it’s a classic RSI [repetitive strain injury] for somebody with a desk job. I’m not sure that MSDs have just been associated with manual workers. I do think that we have known for a long time that people with sedentary jobs, mainly in Europe, have lots of conditions, and that maybe there is huge under reporting, maybe we prefer not to report it. I completely agree with Joanne that the challenge now is not just the fact that the plethora of ways of sitting for long periods of time has increased; you have your phone, your laptop, your iPad, your TV.

And if you look at the latest research you see now that young employees are entering the workforce with what are presenting themselves as early signs of MSD; they are becoming more prevalent in young people. Research in Sweden and Switzerland looking at kids as young as 13 to 15 is saying that they are starting to show the symptoms of things that might become MSDs.

For me, it is a knowledge thing and the notion that you wouldn’t think sitting down can hurt you. And that is a real challenge.

Can we say that self-management of MSDs is the future, as suggested by the NHS mandate?

Nigel: Well, let’s be clear, I can see why the NHS would mandate it. They’re strapped for cash, they’re strapped for time. It is much easier to give everything a self-management route. Treatment of MSDs is improving and at its heart is self-management. We know that using drugs such paracetamol for back pain does not work; instead we recommend people do exercise. We know that the best way to manage MSDs is for people to do some sort of activity, some sort of exercise. And that only has to be very gentle – you go for a walk or a swim, you stretch.

Joanne: I think it depends on the particular problem, but if you’ve got somebody with rheumatoid arthritis, that’s something for which they’re going to be under a consulting physician anyway. But if you think that your problem has been caused by work it can be something problematic, unless you’ve got an occupational health service or a very sympathetic GP. Working with your employer can be problematic in some cases, because it’s something that we all get; people get aches and pains, we can all get uncomfortable. But when it becomes something more chronic, something that’s going to disrupt your working life and your home life then that’s something that you may need support to manage.

Nigel: If you look at Scotland, there were a series of initiatives around back pain. It was found that fast treatment of back pain was incredibly effective, it was really cost-effective and really great. It was so obvious it was a good idea that the NHS said, “Well actually, business who benefits from this ought to pay for it”. The minute the NHS stopped paying for it, business stopped paying for it and we slipped back into our old position.

So it seems to me that we do need the NHS or some other government-funded organisation to feed funds, and to provide the framework, and then persuade individuals to do some exercise. Any physiotherapist will tell you the fundamental problem with physiotherapy is the physio will give the patient 20 exercises to do and the patient will do none of them. And then they will re-present with exactly the same condition, saying, “I’m not getting any better, physiotherapy isn’t working for me”.

I think you need a grown-up to supervise the management of MSDs, but it is absolutely down to changing behaviour, and affecting behaviours of people is incredibly hard and challenging. I think if we can crack that we would be a wiser and better society.

The NHS should not step away. I think it is, unfortunately, a question of time and behaviour change, and that’s harder; it’s probably harder for clinicians to cost-benefit. If you can see someone for 10 minutes, give them paracetamol, give them Nurofen, give them whatever, you see them, they’re out of the door, job’s a good one.

If you’ve actually got to go, “Here are three exercises that I’d like you to do, I’d like you to do them five minutes a day,” then a week later, “Have you done them? What’s the effect? What can we do to encourage you?” that’s a much harder thing for clinicians and physicians to do.

Poor physical health and MSDs have a negative impact on an individual’s stress levels, but are generally not assessed as an interconnected phenomena. What is the impact of MSDs on workers’ mental health?

Joanne: We know there’s an association. I’m not clear yet in which direction it goes, it could be you get a physical problem which increases your stress levels. Or you’re getting stressed at work and you’re just tensing up. I know that when people have deadlines they often feel themselves tensing up.

What’s interesting is that, for psychosocial risks and stress, and for upper limb disorders and manual handling, you have to make a risk assessment. There’s a requirement as an employer to risk assess for those and I suspect that most risk assessments are carried out independently. But this is something that we need to link together more, because still there’s a relationship going on, so how do we take that forward in practice?

Nigel: I think you have to look at the civil claims around MSDs and how often, when you read them, you think that some shouldn’t be an MSD claim, they should be stress claims; it is very clear that the psychosocial issues absolutely impact on physical health. And certainly, it’s sometimes harder to report because if the interaction is complex you can’t report the fact that, “I’m stressed to hell and it is affecting my back”. You either have a bad back or you are stressed, it is argued.

But we know from all the research that the key predictor of whether someone gets an MSD is the interaction between lots of factors. And certainly, in this multi-causal model of MSD, you absolutely see stress as being an incredibly powerful predictor as to whether somebody will get an MSD or not. If you look at organisations that run so-called stress surveys, you will find that where people report excessive stressors rather than stress then they are more prone to have MSDs.

I think it is still easier to report a back problem or a wrist problem or a neck problem than to report a stress problem, and this adds to the individual’s stress. It is clear that the two phenomena are connected, and if an organisation launches a stress campaign then it’s almost like people have an excuse to be stressed. Whereas, if they launch a managing MSDs campaign then they have an excuse to have a MSD. What is missing is the holistic view that says it is about your system, it is about understanding that these things are absolutely linked together, they are almost indistinguishable and you have to manage them both.

But we like to put things into boxes. It’s very easy; we have got the Display Screen Regulations and Manual Handling Regulations and we have the Management Standards for work- related stress from HSE. There are clearly viewed as three separate issues, when in reality it is what people do at work and what factors are present that might expose them to harm. That kind of systems thinking and approach is a big challenge for organisations that hate systemic approaches. Organisations use silos, because you can manage a silo, you can identify it and sort it out

And yet, the real challenge is to recognise that most of these issues come where silos interact or where issues actually lie outside the silos. But it might not be as simple as a single factor such as somebody sitting in a broken chair, or somebody who is having to work 10 hours a day. It’s the fact that they’re working 10 hours a day, they’ve got an incredibly pressing deadline, they’re moving house or they’re going through a divorce, they’re basically having to deal with all sorts of problems outside of work. At work they’re not treated sympathetically, they’re under a lot of pressure, maybe people are losing their jobs all around them.

And all of those factors combine to give somebody a problem of, if it’s acceptable, stress; if it’s not acceptable, an MSD. Or if neither of these are acceptable, they wait until their acute injury becomes chronic, they then go off work permanently and they then end up suing their employer. The real challenge for organisations is to get a big picture view. It’s not about single factors, these are not independent variables that we can treat in isolation as if they are actually the source of the problem. It is a far more complex picture than that.

Joanne: You mentioned the risk assessment and in the risk assessment even the regulatory structure separates them, when it’s really both.

Nigel: Systems thinking is hard thinking, otherwise everybody would do it. If it was intuitive and easy it would be done, we wouldn’t have failures. And that’s not just in terms of health and safety, it’s in terms of business failures, bank failures. All organisations struggle with systemic thinking.

If you take it completely outside of MSDs, if you look at what was revolutionary about the Turnbull Report [Internal Control: Guidance for Directors on the Combined Code, 1999], the big idea was, “Actually, risk is something that organisations as a whole have and they don’t have models to manage”.

And I still think most MSDs are a risk, people suffer them; organisations are shocked that their employees are working 10-hour days, are working in kind of Dickensian conditions, that their employees do have MSDs that they choose not to report for fear until they become really bad. All of those things are absolutely hard for organisations to tackle.

The UK (and Europe) is facing the challenge of an ageing workforce. What is the role of ergonomics and its professionals in this context?

Nigel: The fundamental role of ergonomics is to design a job to fit the person that is going to do it. It doesn’t matter whether you’re 20 or 70, the role of ergonomics is to make sure that people have jobs that are suited to them. It seems to me we have to design jobs that fit older people and other jobs that fit younger people. There are clearly some challenges that we’ve already met. We already design jobs for people who have partial sight, partial hearing, partial mobility, and it is simply saying, that these people, whether old or young, are not actually suffering from a disease. You don’t treat these factors as an illness. In the same way that if you have a pregnant worker you don’t treat her as if she’s ill, she has a physical condition that you manage by adapting work to suit her.

We do the same for older people; we simply need to know their capabilities, and how can we make sure the job matches their capabilities, rather than carry on doing things as before. It is about the requirements of the job, what the people are capable of, and match the two together. And it is important to recognise that older people are absolutely ideally suited for quite a lot of things. There is no reason for an older worker to not do almost any job, even manual handling jobs, if you design them correctly.

If you’ve got a manual handling job which is predominantly using mechanical handling aids, it doesn’t matter whether you’re 16 or 76, you should still be able to do that job. As a society we have become incredibly adept at making work easier by giving people aids. We have automation, we have mechanical equipment, we have all sorts of things designed to make jobs better and easier. And that should be true whether somebody is a youngster or whether somebody is old. It shouldn’t matter.

Joanne: I would say that what we need to do is actually get that evidence out there into practice. Because there’s so much stereotyping about our older workforce; the media don’t always help calling them ‘silver surfers’ and all sorts of terms they use. As ergonomists we should get the message out as well that we design work to fit people.

When we’re doing risk assessments we should include issues such as diversity and age. When you go back to the ‘70s and ‘80s, a lot of manufacturing workplaces were designed for men, not both genders. And that’s changed. I think we need to get research into practice. Let’s not forget our younger workers who are just coming into the workforce, and may already have issues. They’re the guys who are going to have to work the longest ever, so we’ve got to protect them. If we’re considering workplace design, a lot of it’s designed to fit all. But the changes we make with good workplace design for older workers are hopefully going to be beneficial to the whole workforce.

The self-management of chronic MSDs and employment report (2014) recommend the government ensure work is considered a clinical outcome by healthcare professionals. Is it possible?

Nigel: If we go back to the days when people reported bad backs to the doctor, the doctor would say, “Take to your bed, put a board underneath your bed or get a door and sleep on a door,” and that’s basically what you did. And we realise now that was extremely poor advice, that people who had an acute injury very rapidly would be tipped into chronic injury.

If you look at companies like DuPont for example, which is an incredibly profitable capitalist company, if you have an injury at work or at home the first thing they do is get you back to work, because they recognise the best place for a worker is work. And we know the longer they are off work the less likely they are ever to re-enter the workforce. For more than 20 years every single study has said that if you have a worker who’s off work for a couple of months it is likely they will not work again. Once you’re extending it to nine months to a year, pretty much 100% of people will never re-enter the workforce.

So actually, it is important to get into the mindset that is not about getting them back to work doing the old job, but get them back to work doing something that is constructive and useful. Let’s do a functional capability assessment of them, and work out what they can do, get them back to work: it seems to me to be a much kinder thing for everybody and much more likely to get really good outcomes.

Joanne: We have seen this change happening with the introduction of fit notes, which is already getting the general practitioners focused on work as the outcome. And we’ve now got the Fit for Work service, which I appreciate hasn’t been evaluated yet, but the focus has changed; general practitioners and employers can use that service too. It’s something that is coming, but it’s really important.

We know that good work is good for you, not just necessarily work but good work. You want to define what good work is: it is an important part of being well, being a member of society. Getting people back to work is vital. The cultural change we are talking about it’s going to take a few more years yet, hopefully not too many.

Nigel: I agree. If you go back to the really early studies of motivational theory, like Maslow and Herzberg, you find all the evidence showing that work is good for you if it is a good job. If you actually design a job that people do, and they remain in that job, there are hugely good outcomes in terms of their physical health, mental health and the feeling of self-worth.

It is widely accepted that prevention is the key, but competing needs of efficiency and heavier workloads make it difficult to ensure. Is it always possible to prevent?

Nigel: First of all we’ve got to accept that prevention isn’t always possible, that there will be always an underlying issue of people getting MSDs, no matter what we’re doing. So the first thing to say is, prevention is good and it’s what we should be aiming for but recognise that we’re not going to get there always. And therefore, the single most important thing is giving people a framework for earlier reporting. Because we know that if somebody reports a condition straightaway we’ve got two massive advantages: we can have a good stab at what it is that led to that condition occurring, and secondly we’ll have a good stab at sorting it out and physically rehabilitating them.

If they wait a couple of weeks it gets harder. If they wait several months then what you end up doing is managing chronic pain. And once you get into chronic pain and chronic conditions then, basically, what we end up managing is the time between episodes. You look at all the evidence around this: if you have a chronic back condition and you have been off work for a substantial period of time, then we know you will be off work about every five years for a substantial period of time. Put this as a worst case scenario: if you are a 35 year old in work who’s going to have to work another 35 years, you’re going to have seven episodes of back pain, and each one will be between two and three months long. So you’re going to be off work for almost two working years in your lifetime.

Whereas if we pick the condition up really quickly we’ll put you into intensive physio; we’ll monitor your work; we’ll make sure that you’re not doing certain things. This not only prevents chronicity but we also prevents recurrence, or hopefully, if recurrence occurs, it’s much more minor. Let’s recognise prevention is really important, but let’s also recognise that a really important outcome for businesses is to have incredibly good ways of managing conditions as they occur.

Companies like Carlsberg in the brewing industry have fast-track physio programme and you also see it in other organisations doing proactive risk assessments and good effective control.

Joanne: It’s about early reporting, having a sympathetic reporting system, so that, if you report it, something will be done. But it’s not going to end up as a result of a threat to you and your work. And that’s something I think some companies have a way to go to build. Some companies are doing excellent jobs but others don’t. And certainly, not all MSDs are preventable.

MSDs affect 10m workers in Europe (EU-OSHA). Is a broader, official and institutionalised policy across Europe the best way to deal with it or should it be left to national governments or companies?

Nigel: We already have it – we already have the Framework Directive and the various regulations and directives around MSDs in terms of display screen equipment (DSE) and manual handling. But we also know that when organisations are asked to self-govern and self-do, things don’t happen; I think that unless you have a pan-European approach it doesn’t work.

We also know that we can’t afford to let health and safety be a competitive advantage. Let’s say that you are a company operating in Greece and actually you don’t have a requirement to manage MSDs, and if somebody becomes ill you sack them. Or if you go to the extreme, let’s just say you’ve got a female worker and she becomes pregnant and you sack her because she’s pregnant, then treating workers badly suddenly becomes a competitive advantage. You can save money by giving people poor chairs and when they’re ill and unable to work simply throw the injured people back into society, and society picks up the tab.

If you take that approach then what you see is that the big multinationals will naturally migrate to countries that have weaker health and safety regulations.

Fundamentally, if we don’t take a European approach then what we will have is we will have poor quality McJobs moving south, moving into countries where workers are really poorly-protected. We will have a system of, essentially, attrition of health and safety standards. And it worries the hell out of me that there is this perception in the UK that we have too much health and safety, that there’s health and safety that prevents us from doing business when all the evidence, even the internal government evidence, says that actually, getting health and safety right is a huge competitive advantage. It’s like the whole thing about tax – many companies go to the country that offers the cheapest tax and don’t bother about anything else.

Joanne: Having worked in various European countries I can say it’s an opportunity to share best practice, knowledge and information. It’s really important that we stay as part of that. We all do risk assessments, and they may be slightly different across different nation states but the principles are there with the Framework Directive. Having access to research across Europe helps us make the argument to continue to think about job design and worker protection. So certainly, I think having European level policies is great and I think it’s been good for us.

Nigel: At a European level we actually have a view that workers’ health matters. Joanne made a really good point; we’re quite keen on an evidence-based approach to health and safety. And one of the nice things about some of the European initiatives is that they enable us to gather quite large data sets and to look at it and analyse it.

It is interesting that now it is possible to have chartered ergonomists it might actually help organisations up their game. I think it’s the idea that says we’re starting to recognise that ergonomics is a skillset that is not trivial, not easy to acquire, and I think the Institute of Human Factors and Ergonomics has done a great job in getting chartership. Because if you look at health and safety, once you become a chartered safety practitioner, that has driven up standards of health and safety without doubt in the UK. And I’m hoping to see the same thing from the chartership around ergonomics, because if you have an ergonomics problem it’s generally worth speaking to somebody who actually has a clue as to what they’re talking about, rather than somebody who’s a self-proclaimed expert on it.

Many safety professionals can do a lot of the basic work and that’s really great, but there are some of the more intractable problems, like MSDs, where actually you probably do need somebody who knows about it. Having people who can become chartered ergonomists seems to me to be a really nice step in the right direction if you want to understand what a good ergonomist would look like and work with them.