Presentation by Kurt Hegmann, Medical College of Wisconsin
DR. EVANOFF: Now I want to introduce Dr. Kurt Hegmann. Becky did a very nice job of covering two ends of medical management: the front in the surveillance, picking things up early; and then the back end, case management. Filling out the middle will be Dr. Hegmann who, in addition to being a fan of the Green Bay Packers, which you may be able to tell by his tie, is a Professor at the Medical College of Wisconsin and the Medical Director of Master Lock.
Dr. Hegmann.
DR. HEGMANN: Initially, this paper will review background information so it is understood why I believe that medical aspects of ergonomics are very important, just as the design aspects are important. When clear hazards are present, they need to be addressed as best as can be done. However, once that is done, there are going to be residual cases. No matter how much modification of the job is done, there still will be residual cases reported due to the development of chronic disease processes. Thus, the medical aspects are very important.
Background
The first graph is from the sensor data from Wisconsin covering carpal tunnel syndrome. What is apparent is that the incidence of the disorder climbs with age, with the exception of the perimenopausal flip in women indicating the probable hormonal aspects of some of the epidemic curve there is not a decrease in cases in the age category of 65 and up, rather, the incidence continues to rise.
Back pain rises with age. The problem with reported data on back pain cumulative incidence is that there appears to be a lower recollection of back pain in the over 65 year category, yet it is not possible to have a decline in your cumulative lifetime incidence. That's not possible. That is probably unreliable data. Also, if all causes of back pain are combined, including lumbar sprains, strains, degenerative intervertebral disc problems, sciatica, and spinal stenosis, it is likely that the combined problems would rise relentlessly with age.
Shoulder problems including suprospiratus tendinitis, rotator cuff tendinitis, subacromial bursitis and impingement syndrome also rise with age in a relentless manner. If anything, the slope of that epidemic curve rises faster beyond retirement. Further shoulder problems are the second greatest workers' compensation problem after back disorders.
This information does not refute that there are work-related aspects, but it implies that there are non-work-related degenerative aspects of these problems, and it is very hard to sort those things out.
If the postulate is accepted that these problems are all work-related, perhaps they would rise after some latency period and then they would decline after retirement. Although, perhaps there is a fixed defect that occurs. In such an event, the epidemic curves should rise and then plateau. However, that is not what is observed as rise relentlessly with age. Thus regardless of ergonomic design issues, a number of these cases will occur in a plant's population.
With this knowledge in mind, several things have been done at the Master Lock Company. This paper will focus only on the medical aspects, rather than design changes.
The Plant Site
The Master Lock Company is in Milwaukee. There are about 1,400 workers at one plant. There is another small plant in Alabama; that plant manufactures door hardware. This paper only deals with the Milwaukee location. It is a stable work force, largely unionized (UAW).
The basic job functions vary. Materials are brought in, and handled by Material Handlers. Most of these parts are small in size. It is light in weight, except when it is bulk. Then there are some heavy material handling tasks by truckers. There is some die casting of parts that is done. There is a small electroplating area. Most of the workers, however, are employed in assembly tasks. Mostly these tasks are light assembly, but can be highly repetitive. Shops support the manufacturing plant. There are office workers as well.
While some areas, tasks or jobs have been automated, it is not practical to automate everything. Some products do not have enough volume to warrant it.
The Medical Facilities
Medical facilities consist of an on-site clinic. There are three full-time nurses. The nurses cover the first and the second shift with some overlap with the third shift, 7:00 A.M. to midnight. There are two part-time physicians working about three half-days a week. Contracted-out services include part-time physical therapy and occupational therapy. The therapists and nurses have not held any turnover for a number of years. Thus, they know a lot of the workers, and the supervisors, as well as being very familiar with the worksite, all of which is quite helpful.
The clinic has two examination rooms, as well as treatment areas and a waiting room.
Estimates of the patient mix are comparable with what most people see in diverse manufacturing settings. Most problems are neuromusculoskeletal, mostly upper extremity problems, then back related problems, then shoulder pain, followed by neck issues, and then a mixture of minor things. Treatments provided include acute injury care, chronic care, and follow-up care. Patients will be treated for six months. As long as better results cannot be obtained out of the clinic, then they are treated on site; it provides significant savings, as well as early diagnosis and treatment.
Nonoccupational issues and return-to-work examinations are also addressed. In the event that a patient has been off work for a month or two, an appointment will be scheduled with me. Currently, these nonoccupational issues are not managed as much as the occupational injuries, and supporting data are presented.
Ergonomic evaluations are done by both the therapist and me. The evaluations that the therapists do are important, particularly as the therapists are the ones who evaluate the jobs to accommodate the light duty restrictions. They are critical medical aspects of this ergonomics program. The other critical aspect is having a knowledgeable nurse who knows the patients, and performs the case management functions on day one, rather than on day seven, or day thirty.
Personal Protective Equipment
Patients desiring an elastic wrist support may obtain them without a prescription. It is dubious that there will be a significant alteration in force or posture. These are mainly a comfort measure, as it is dubious that there is any preventive aspect.
However, regarding other "personal protective equipment", a diagnosis is required. They are evaluated, examined and diagnosed. A record is made of the issues at that time. The problems with not following this are that they may wear a brace inappropriately, or may not recognize that problems can arise from wearing braces at work. Also, they may not accurately recall the inciting circumstances at a later date.
Mainly, the volar reinforced wrist spints are used on a nocturnal basis, because they are principally used for those with carpal tunnel symptoms. They are not used as a preventive measure.
Thumb spica splints are used mainly to treat deQuervain's tenosynovitis. They are used in the daytime. They also are not used as a preventive measure. Lumbar supports are not prescribed and they are not available.
Medical Evaluation and Treatment Goals
The first goal is early reporting; this is believed to be very important. With early reporting and early identification of symptoms, people are generally easier to treat. They also will tend to come to the clinic much earlier than they will go to their own doctor because of the convenience issue. Treatment and restrictions are applied early. Also, should a physician not be available on-site, the nurse will place the patient on light duty until the next appointment. They are gradually returned to regular work as available. When a clinic is on site, and therapy is also on site, one of the hazards is to over-utilize it. This may occur because of the shift in patients towards the mild spectrum. Time off of work is another incentive. Thus, judicious use of therapy must be utilized.
Nonoccupational Vs. Occupational Issues
What patients need and desire are accurate diagnoses and appropriate treatment. It is also important to facilitate return to work for nonoccupational, as well as the occupational problems. This de-emphasis on the difference between occupational and nonoccupational disorders then also reduces incentives to misrepresent facts such as when or where the problem began. Unfortunately, differentiation is forced, when a problem does not resolve due to medicolegal or fiscal reasons.
Encouraging accommodation for all injuries is recommended, regardless of apparent etiology.
If there are early attempts to differentiate nonoccupational from occupational problems, the incentives are likely to increase the probability that patients will not accurately report or record the inciting information. It increases the probability that they will report back pain with doing a lifting task with previously reported excess induction of back pain problems, rather than from a motor vehicle accident, for example.
Information is also provided to the primary care physician that she/he does not know. For example, what are the job tasks, and forces are involved. These pieces of information, in conjunction with proposed light duty restrictions that are able to be accommodated often resolve conflicts.
Restrictions to be Accommodated
These are the key restrictions to accommodate. If a plant/employer can accommodate these restrictions, there are very few problems that will be resolved. The prioritization may differ based upon in terms of which one is most important to a given work force. If there are much heavy materials handling tasks, then the accommodation of restrictions should take precedence over the others, for example.
First, completely one-handed work should be accommodated. Second, no lifting more than ten pounds, no bending, and alternating sitting and standing as needed for those with back problems is a common restriction. Third, forward flexion or abduction more than 45 degrees and no lifting more than ten pounds for the shoulder are frequent restrictions. Lastly, no highly repetitive work is sometimes needed. Less frequently, but usually more easily accommodated are completely seated tasks for lower extremity problems, knee sprains and ankle sprains. If these restrictions can be accommodated, an employer can accommodate almost anybody.
Implementation of a Medical Ergonomics Program - The Results
With about the same number of injuries (occupational versus nonoccupational), the number of days the workers are off of work is about 16 percent as many days for the occupational in comparison with the nonoccupational problems. These results are the opposite of the results previously and widely reported. There is no management of the nonoccupational problems. Nevertheless, it is clear that managing the occupational injuries with application of and accommodation of restrictions has resulted in a marked improvement.
After implementation, the number of employees on lost time is typically one or two at any time. Previously there were approximately a dozen. Only at the end of a three year period of time did these results become somewhat less impressive. The primary reasons for that dealt with running out of work because of orders slowing down and the slow down in production.
Light duty is light duty, largely as a spinoff of the main manufacturing processes. Workers work on the main manufacturing processes until they run out of that type of work. At such time, they too begin to do some of the light duty jobs and these are no longer available for the accommodation of injured workers.
Likewise, workers' compensation costs, medical plus indemnity, from 1993 to 1996, fell from three-quarters of a million dollars annually, down to about a quarter million. Why did it go up in late 1996? It went up again because of lack of accommodation of light duty due to the aforementioned problem.
Conclusions
The impacts of a medical ergonomics program include a marked reduction in lost time and a marked reduction in workers' compensation costs. The patients are basically very happy, in part because they do recognize that we know a lot about these disorders and how to treat them. The usual relationship of occupational lost time for back problems being greater than nonoccupational lost time has been completely inverted.
Lastly, it is suspected that there was little, if any, impact on total numbers of neuromusculoskeletal disorders. Encouraging early reporting is likely to augment numbers. Alternating accurately recording the inciting event information may lower the numbers. Regardless, the concentration cannot be on numbers of people recorded on the OSHA 200 log. The attention should be directed toward severity of cases, impairment, and disability; cost issues are a reasonable index of such a problem.
