Work related rheumatoid complaints

work related rheumatoid complaints

Introduction

The physical demands of work and exercise can make existing rheumatic problems worse. However, work can sometimes cause a rheumatic problem, particularly if your physical working methods suddenly change. These conditions are often known as work-related or occupational disorders. The term ‘repetitive strain injury’ (RSI) is less likely to be used nowadays. In sports medicine the term ‘overuse injury’ is used. If your particular sport or DIY activity strains the same parts of the body that you also use at work, you may be more prone to rheumatic symptoms.

Other work and home demands can also make existing problems worse, or can add to symptoms occur ring in the workplace. These might include, in the home, such things as stress or depression. In the workplace causes of stress might include bullying and jobs in which people have little or no control over their work pattern.

However, even if pain occurs in association with your job it does not necessarily mean there is any serious damage to your body. Often it will get better on its own with little or no medical treatment once the activity is stopped. Staying active generally will help you get better faster and prevent more trouble occurring.

This booklet explains how some common problems can arise and how to recognise them. It also gives advice on simple remedies you might try yourself. Technical words, like tendon, are explained in the glossary at the back of the booklet. They appear in italics when they are first used.

What problems can happen in the arms and shoulders?

Tenosynovitis is an inflammation of one of the tendons that work the fingers or thumb. The tendon that pulls the thumb backwards is often involved (this is called de Quervain’s tenosynovitis). If the symptoms start at the same time as you start doing something which involves that particular movement of the thumb, and if resting the thumb from that movement relieves the symptoms, it is possible that the problem is work-related. However, it is unusual to get tenosynovitis in one finger as a result of using a computer keyboard, as this activity distributes the work fairly evenly across all ten fingers.

Carpal tunnel syndrome occurs when the median nerve is compressed (squeezed) in the carpal tunnel on the underside of the wrist. The main symptoms are pins and needles in the hand, and weakness of grip. Conditions that cause swelling of parts of the wrist which might squeeze the tunnel, such as rheumatoid arthritis or thyroid deficiency, can cause carpal tunnel syndrome. It can also occur if you are going through the menopause or if you are very overweight or diabetic. If symptoms coincide with a change in job (for example, if you start using a vibrating drill), or if you hold your wrist for a long time in a position that kinks the median nerve or stretches it, the problem may be work-related. (See arc booklet ‘Carpal Tunnel Syndrome’.)

Epicondylitis is a mild inflammation of the epicondyle (the site where the forearm muscles are joined to the bones of the elbow). It is much more common on the outer side of the elbow, where it is known as ‘tennis elbow’. (See arc booklet ‘Tennis Elbow‘.) Some cases are probably caused by work. Repetitive movements that put particular strain on the forearm muscles, such as using a screwdriver or prolonged and repeated gripping, can lead to this problem.

Shoulder problems Some shoulder problems are also probably caused by work, especially if you work above shoulder height. More generalised shoulder conditions (‘frozen shoulder’ or ‘adhesive capsulitis‘) are more likely to have natural causes, although they may feel worse because of work. This also applies to the neck. (See arc booklets ‘The Painful Shoulder‘ and ‘Pain in the Neck‘.)

Non-specific work-related upper-limb disorder Sometimes symptoms occur over a wide area. For this situation we use the term ‘non-specific work-related upper-limb disorder’. This can be difficult to diagnose, as the source of the pain still has to be identified. As these disorders are not often seen in self-employed people it has been suggested that psychological factors may also be important, although it is possible that the greater control the self-employed have over work means they can avoid damaging patterns of work. The Arthritis Research Campaign (arc) continues to support research work in this area.

What about other parts of the body?

The low back is particularly likely to cause pain as you get older, as a result of what doctors may describe as ‘degenerative changes’. Symptoms may be made worse by work, particularly if the job involves heavy manual work. This also applies to the hip. At the knee, pain may be caused by jobs that involve lifting, particularly from a squatting position. If a conveyor belt is positioned so that more strain is taken on one knee than the other, and if this is the first or only knee to show symptoms, this is probably a work-related symptom.

Situations that may cause symptoms at work

Here are some examples of situations that may cause pain at work.

A sudden change in working conditions is often the most important clue. If you use a computer keyboard, then a change in its position, or a sudden increase in the number of keystrokes, or a change involving the use of one hand more than the other, may cause symptoms to appear. For example, a school secretary who typed manuscripts for the teachers throughout the term, but in the holiday used only her right hand to do the school accounts, always developed symptoms of pain in the right hand a few days after she started each batch of accounts.

Factory workers tend to adapt to changing conditions, but there are some problems. The rush before Christmas in factories that process turkeys usually takes its toll. For example, in a year when managers needed deep-frozen (rather than cold) turkeys to be stuffed, the injuries increased because of the extra effort needed to work with a frozen carcass.

As mentioned, stressful work situations may also make symptoms more likely to occur. There are many causes of workplace stress – bullying, job insecurity and tight schedules would all be included here.

Specialist occupations

We can learn more about work-related rheumatic complaints from certain groups of people. Overuse symptoms are well recognised in athletes by doctors specialising in sports medicine. Long-distance runners are particularly at risk, but any athlete who trains year in, year out is susceptible. Top athletes whose bodies are well adapted to their events may avoid these problems. Even then, however, overuse injuries can still happen.

Professional musicians often suffer from overuse symptoms as they have to play at the speed indicated by the composer. Wind players and keyboard players may have problems in both hands, whereas string players usually develop shoulder problems in the bowing arm and tendon problems that affect the fingers in the other arm.

Dancers have even more problems. They have to perform at the level of a high-class athlete, using all parts of the body, but also have to follow the choreography at a speed set by the music.

What are the causes of work-related rheumatic complaints?

To diagnose a particular condition your doctor needs to look at the work you do, examine you, and take account of your medical history. We know that jobs that require high rates of repetition or involve lifting large weights are more likely to cause problems. Sometimes the origin of the pain is clear, e.g. carpal tunnel syndrome. Sometimes it is less clear, as in non-specific work-related upper-limb disorder. Some of the areas on which research is concentrated are as follows:

Nerves

Nerves that slide from side to side easily may be at particular risk from the movements imposed on them. This includes the median nerve that passes through the carpal tunnel. Tension in nerves may be a cause of symptoms in the neck and shoulders.

Muscles

In non-specific work-related upper-limb disorder, samples of muscle tissue, muscle enzymes, and the overall structure of the muscles are all normal. However, muscle that is working too hard builds up lactic acid, which can cause pain and tiredness. This or other chemicals which build up in the muscles may be a contributing factor in rheumatic problems in the workplace.

Compartment syndrome

Muscles are protected by covers (known as sheaths). If the sheath is relatively inelastic and cannot stretch, the muscle can swell during exercise and cause cramping pain known as a ‘compartment syndrome’. These syndromes are common in athletes and dancers, and sometimes need surgery to divide the sheath and prevent the swelling and pain. Similar injuries may be more common than realised in some people who work.

Double-jointedness

People who are born with particularly supple joints in the fingers seem more prone to work-related upper-limb disorders than others. This may be because of the greater mechanical effort needed to keep the joints properly in line if they are naturally looser (more supple) than normal.

Psychosocial factors

As mentioned previously, symptoms in the arm or neck may become more noticeable and more troublesome in people who are under stress from whatever cause. Research into these factors is currently under way in several large UK workforces and in people attending rheumatology clinics.

Is there a link with reflex sympathetic dystrophy (RSD)?

In long-lasting work-related upper-limb disorder, some of the symptoms are like a mild form of a condition called reflex sympathetic dystrophy (RSD). Most changes in reflex sympathetic dystrophy are thought to arise from an abnormality of part of the body’s nervous system known as the sympathetic nervous system. Although there may be some similarity, the two are not the same condition. (See arc booklet ‘Reflex Sympathetic Dystrophy’.)

How can I recognise a work-related problem?

Your symptoms may vary depending on whether a muscle, nerve, tendon or joint is involved. Common symptoms are:

  • Pain
  • Cramp
  • Weakness and dropping things
  • Pins and needles
  • Clumsiness
  • Burning and other unpleasant sensations

Whatever your symptom, it may be related to a particular job, movement or action. Normally you will not develop symptoms until you have repeated the action a certain number of times. You feel better when you have had a rest but the symptoms return once you start the repetitive action again. Any action that is particularly ‘unnatural’, involves a heavy weight or is repeated many times in quick succession is more likely to produce symptoms quickly. On the other hand, if you merely sit for long periods in an unnatural position you may not have symptoms for several hours or even for days or weeks.

How can I treat myself?

Think carefully about the movements and actions you performed before the symptoms appeared. It is often possible to recognise a new pattern of activity that has caused the trouble. The symptoms will disappear if you can avoid that particular action. If it is part of your job this may not be possible, but perhaps you can change your style of working to alter the speed or the angle at which you have to hold any heavy object.

If symptoms start after 15 minutes of repetitive activity you could stop the task after 12 minutes and rest for 3 minutes to relieve the aches or pains. On the other hand, if you get back strain after sitting in one position for 3 hours, a 5-minute walk around every 21/2 hours may prevent it happening.

If you work as part of a team you could discuss your problems with the factory nurse or with the company’s doctor who specialises in occupational health. Changes to the way you work may be possible, particularly if a large section of the workforce is affected.

Regular exercise and staying fit will help your general health and help you cope with the pain. This will help you get on with your life and do the things you want to do.

Physical therapy

Physical methods of treatment may be helpful and some of these may be things you can do yourself, without needing to see a work physiotherapist. You may be able to rest a painful joint enough by wearing a firm bandage or a lightweight support while you work. Warmth may also help if the site is tender. Out of work you could relax your hands in a bowl of warm water or your whole body in the bath, or use a hot-water bottle or heated wheat bag.

The symptoms sometimes respond better to cold than heat. If this is the case try wrapping a packet of frozen peas (wrapped in a damp towel) around the affected area. Let them thaw for a few minutes first. Only use it for 15 minutes at the start.

Talk to your doctor

If the simple measures mentioned above do not improve your symptoms you should talk to your family doctor. You may need a period of total rest from the activity that is causing your problems. Your family doctor may be able to help by prescribing tablets to relieve your pain or inflammation and, in the case of tenosynovitis or epicondylitis, may be willing to give a local steroid injection – one given at the site of the problem. This may help the condition, particularly if it is done in the early stages.

What specialist help is available?

Family doctors have varying amounts of experience of treating work-related rheumatic problems. If you need to be referred to a specialist you may want to discuss with your doctor whether you should see a rheumatologist or orthopaedic surgeon in a hospital, or even the occupational doctor in your workplace.

The hospital may also have physiotherapists with experience in rheumatology who will be able to carry out more complicated therapy than your family doctor.

Occupational therapists, particularly those working from hospitals, often have a lot of experience and may recommend changes in the way you do your job that might ease the strain on your muscles at work.

Many large firms have separate departments of occupational health where doctors are experts in treating these conditions, sometimes working with physiotherapists and occupational therapists. If you are struggling at
work, your local Disability Employment Adviser (contacted via the local Jobcentre) can arrange work assessment so that help can be given to you in the workplace.

What about treatment with drugs?

Drugs may be helpful. This section describes drugs that you can buy yourself from a chemist (although if these do not help you should talk to your doctor, who may prescribe alternative or perhaps stronger drugs).

If the problem is pain and discomfort, you could try paracetamol. The usual recommended dose is two tablets (500 mg each) every 4 hours. Paracetamol usually starts to work within 20 minutes and works for up to 4 hours. You should take the tablets about 1 hour before doing any action that is likely to cause pain. Try to use paracetamol only at the times of day when you have discomfort. You can get other painkillers (e.g. co-proxamol) from your doctor.

If there is swelling as well as pain, ibuprofen (e.g. Nurofen) may work better. The tablet strength is 200 mg. It is likely to start working within 20 minutes and often wears off after 2–3 hours. Try to take one at least 1/2 hour before you expect the symptom to start and ‘top up’ as necessary during the day. Make sure that you do not have more than eight tablets a day. Ibuprofen is not suitable for everyone – check the packaging and contact your doctor if in doubt.

How long will recovery take?

With so many different conditions recovery varies considerably, so you should probably discuss this question with your doctor.

In general, the less time you have had the pain when you take some action to deal with it, the faster it will improve. Acute (short-lasting) tenosynovitis or epicondylitis normally gets better as a result of an injection within a week, or on its own within a few weeks. If it is not possible to take time off work this time period is at least doubled.

Problems that take longer to develop tend to take longer to improve. Pain getting worse over 2–3 months will probably take 6–12 months to get better. Once a work-related upper-limb disorder has become established the period to recovery may be even longer, particularly if the symptoms are similar to reflex sympathetic dystrophy, such as persistent and severe pain (see arc booklet ‘Reflex Sympathetic Dystrophy’). Although some cases improve within 6 months others can last for years. The average time to recover for a severe case of work-related upper-limb disorder seems to be 3–4 years.

What about prevention?

As research progresses, the conditions in which work-related disorders occur become better known and steps can be taken to avoid them. In the workplace, if the business is of sufficient size, there will be an ergonomist to check each job task and the working environment and to recommend necessary changes to the management. Certain recommendations have already been incorporated into law and can be seen in the publications of the Health & Safety Executive. Most of the larger industries are now much safer places to work than they were.

Legal aspects

Employees sometimes ask if they have a legal claim for damages against their employer. In some cases they do. However, changes required by the Health & Safety Executive tend to be more carefully followed by employers nowadays than they once were. Employers recognise the need for risk assessments to make sure that their employees take regular breaks or change activity regularly.

To make a successful claim, the employee has to prove that s/he has a case. This can be a very long-drawn-out process. It is necessary to prove that a medical condition exists, that it exists because of the job, and that the employer was negligent in not taking enough precautions to prevent the condition. Proving that the condition is caused by work is the biggest problem. The employee’s medical records will have to be examined to confirm that similar injuries have never happened in the past, and proof will be needed that the employee has no hobbies or activities outside the workplace that might have contributed to the injury.

Glossary

Carpal tunnel – the passageway within the wrist through which the median nerve and flexor tendons pass. The flexor tendons bend the fingers. The tendons which straighten the fingers, the extensor tendons, do not pass through the carpal tunnel but across the back of the hand.

Median nerve – the nerve which controls movement of the thumb and carries information back to the brain about sensations felt in the thumb and fingers.

Rheumatoid arthritis – a common inflammatory disease affecting the joints, mainly starting in the smaller joints in a symmetrical pattern (that is, for example, both hands or both wrists at once). See the arc booklet ‘Rheumatoid Arthritis‘.

Tendons – strong fibrous cords or ‘guiders’ that anchor muscles to bone, and through which fingers or other parts of the body are moved.

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