January/February 2004

MSI'S TOP CHRONIC CONDITION

By Astrid Van den Broek

WHO, the World Health Organization, is no stranger to dealing with global health crises — think AIDS or SARS. And while musculoskeletal injuries (MSIs) may lack the immediate drama of some other conditions, WHO says their impact is often underestimated despite touching the lives of millions of people around the globe. Experts from WHO and the Bone and Joint Decade, a global, non-profit organization, have worked since the beginning of the millennium to raise awareness of MSIs and pin down costs. The tab for MSIs — roughly 150 related diseases, syndromes and conditions that include rheumatoid arthritis, carpal tunnel syndrome (CTS) and low-back pain — in developed countries is estimated at $100 billion (US).

In a report released last October, WHO noted a need for more accurate data with respect to MSIs, agreed definitions of individual conditions for use in studies, and guidelines for the uniform collection of data.

Some would argue that, in the past, MSIs often took a back seat to more traumatic and deadly conditions. But low-back pain, for example, has grown to “epidemic proportions”, being reported by about 80 per cent of people at some time in their lives, WHO reports.

So, do worldwide statistics reflect the experience in Canadian workplaces? The Canadian Community Health Survey, conducted by Statistics Canada in 2000-2001, says MSIs ranked highest, 29.8 per cent, in overall prevalence of chronic conditions in this country. More than four million Canadians suffer from these disorders, 90 per cent of which relate specifically to osteoarthritis, says information from the Institute of Musculoskeletal Health and Arthritis (IMHA). Not surprisingly, IMHA notes, these disorders are increasing as our population ages. Five per cent of Canadians between 25 and 35 suffer from MSIs compared with 50 per cent of people older than 75.

Cam Mustard, scientific director and president of the Institute for Work & Health (IWH) in Toronto, says there’s been an important reduction in traumatic injuries and Canadian workplaces have become much safer over the last 20 years. “But against that benefit has been a persistent, enduring appearance of work-related musculoskeletal disorders. So while the decline in traumatic injuries is really important, the piece we have to solve now is how to minimize exposures in workplaces causing or contributing to causing these non- traumatic musculoskeletal disorders,” says Mustard.

Of these, osteoarthritis is a key concern. “Once we hit 40, a lot of us get some form of osteoarthritis. It’s wear-and-tear in the joints as opposed to an inflammatory condition,” says Hazel Wood, a therapist with Toronto-based Rehab Results, and a consultant helping to roll out Bone and Joint Decade efforts in Canada.

Following osteoarthritis, Wood says, low-back conditions are probably the most prevalent. Mustard points out that, in non-specific musculoskeletal disorders, “age doesn’t particularly relate to the distribution of these syndromes. You’re almost as likely to have a disabling episode of low-back pain if you’re 25 as when you’re 55.” The best advice a doctor can give a patient with low-back pain, Mustard suggests, is to tell him or her to use muscle relaxants and pain relievers, keep mobile, don’t stay in bed, and don’t get X-rays or intensive physiotherapy. “Just let them heal it. That’s not a very profound clinical intervention. So there’s a set of controversies that arise around the management of these conditions, both the classification and definition and diagnosis,” he says.

Management of employee health has also been raised in the context of company size. Some would argue that smaller firms are not as aware as their larger counterparts. Shelly Wiseman, director of provincial affairs for the Manitoba arm of the Canadian Federation of Independent Business (CFIB), counters there have been changes both in terms of awareness and with respect to the money spent to prevent MSIs in the first place. “We’re starting to see more employers bring in preventive measures, whether it be keyboards or chairs or safety equipment,” Wiseman says. There’s a trend of small firms having safety budgets, “as opposed to spending on it if there’s any money left over.” Some also call for a shift in dollars spent on prevention, which may positively influence return to work. “If you nip it in the bud, then people tend to get back to full employment relatively quickly,” says Wood of Rehab Results. Research has found the longer someone with a back condition is off, for example, the less likely he or she will return to full employment, she says.

With something like CTS, Wood adds, once it “gets to the point of numbness and tingling, you’re looking at longer time off work, possibly surgery. Early intervention makes good business sense.”

A stumbling block to dealing with MSIs may be that there is often no visible sign of injury, sometimes requiring that an employer rely on a worker’s say. “There still is a reasonably vigorous debate about the legitimacy of these conditions,” says the IWH’s Mustard, adding there’s no definitive diagnostic procedure for establishing the pain. “Clinicians are in a difficult spot because they’re asked by employers and compensation authorities to rule if someone has a medical condition underlying their disability and was it caused by work? So the clinical dilemma is quite profound and we don’t have a strong tool kit for managing the rehabilitation of these conditions,” Mustard says.

Diagnostic procedure is expected to be a focus of future efforts to identify how to alleviate these work-related conditions. Another point will likely be to establish national consistency in the regulatory requirements that currently exist.

Dave Bennett, national director of health, safety and environment for the Canadian Labour Congress in Ottawa, says the solution is to establish a Canadian national standard for ergonomics. British Columbia and Saskatchewan have their own ergonomics requirements, Bennett says, and Manitoba seems to be heading in that direction. “And we’ve just started the process in the federal jurisdiction under Part II of the Canada Labour Code,” he adds.

“We do recognize things like carpal tunnel and repetitive strain are issues,” says the CFIB’s Wiseman. However, she adds, “when you bring in regulations that are far too rigid and prescriptive, you actually end up doing more harm than good.”

This type of regulation, Wiseman maintains, would make it virtually impossible for an employer to accommodate each employee with a specialized chair, for example. Oftentimes, when regulations and legislation take effect, “employers simply follow that and don’t look at it in a broader sense because that’s what they’re legally required to do,” Wiseman says. “But what you really want is to take a more general look and assess where a situation may be harmful in one situation and be less harmful in another and how one could accommodate it.”

It is known that work is an important source of harmful exposures, Mustard says, adding that strong information exists that ergonomics and biomechanics can reduce these exposures. “But we have a set of gaps in our current practice in North America inhibiting the ability of this knowledge base to be used by workplaces,” he says.

One such gap revolves around work process design, says Mustard, whether that be mice and keyboards in white-collar work, patient handling in institutional health care settings, or manufacturing processes. Another hole, he suggests, exists because “engineering sciences in this country do not train engineers well in human factors.”

The challenge, with regard to controlling adverse biomechanical exposures, is to “figure out ways to make it more actionable in the thousands and thousands of Canadian workplaces,” says Mustard. “There are simply not enough efforts on translating this evidence into forms that workplaces can use.”

Wood suggests that “the more that employers know the downside and what they can do to minimize the effects, the more likely they are to change.”

The WHO report, Mustard believes, will help bring MSI issues into the spotlight. “In the developed countries, this is a dominant source of disability in working-age populations. This is the right time to be putting this flag on the flagpole.”

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