Musculoskeletal disorders and workplace absence

Over the last 10 years or more the conversation relating to absence has shifted to discussions relating to mental health, with very little mention of musculoskeletal disorders (MSDs).

Professor A. D. Woolf wrote many articles on how MSDs were being ignored, mostly he believed because they were rarely a threatening illness, but they were, and still are, life changing conditions that severely impact quality of life, and not just in the short term: they can significantly impact retirement years, or Quality Adjusted Life Years. The references below are a snapshot of his work.

The incidence of MSDs from an absence perspective, however, is still significant. After a combination of short-term minor illnesses, MSDs are normally the highest incidence each year, and the highest prevalence over several years, for episodes of absence. Whilst short-term absence may be less than one week, the average length of absence is normally 14 days (or 10 working days). However, the number of long-term absence cases is also significant, and those requiring surgery can easily be absent for 3 to 6 months, dependent on the severity of the surgery, the age and gender of the person, their work, and their psychosocial factors, which is outlined below.

This compares with mental health, which is normally ranked as the highest reason for the number of days lost per year, with an average of circa 28 days (20 working days). Mental health has also been the subject of much publicity in recent times, and continues to be the case. The reasons for this are numerous, and will be referred to separately.

MSDs were often thought to be mostly related to those individuals involved in "manual" type work. Whilst this is true, as this can lead to a faster rate of degeneration, there appears to be insufficient data which measures the combination of risk factors that can lead to this state, or which can reduce the risk of the process and indeed "slow" the rate of degeneration. An example of these, and there are many, is the research that reviews the findings on an MRI scan and reviews the clinical condition, for example a disc bulge, and whether the person has pain or no pain.

MSDs are also often the highest reason for claims on private healthcare schemes. Many healthcare plans, however, are offered to management and not blue-collar workers, so this suggests that MSDs are prevalent in the broader population. Yet the incidence, prevalence and cost of MSDs from an insurance perspective is not discussed in grey literature in the same way as mental health, suggesting that Woolf's concerns in the noughties and beyond still hold true today.

Factors ignored or not understood by the healthcare industry

There are several factors at play that are ignored or not understood by the healthcare industry. These include:

• The importance of the psychosocial factors: these have been recognised since 1977, when George Engel suggested that the medical model needed to evolve, as diagnosing and treating a physical condition such as an MSD was not enough to effect a cure. (Engel, G.L. (1977 & 1989). The need for a new medical model: A challenge for biomedicine. Science. 196:129-136 (1977) and Holistic Medicine. 4(1). 37-53 (1989).)
• The continuation of the "siloed" approach to medicine, which in general does not assess the presence of the psychosocial factors, even though these are recognised as Clinical Flags and are categorised by Red (serious physical pathology), Orange (serious psychiatric condition), Yellow (attitudes, beliefs, fears, emotions, pain behaviour, coping strategies), Blue (work-related factors associated with the factors being the cause of harm, mostly outlined in the Management Standards) and Black (work-related factors including such as manual work with no opportunity to modify, conflict with insurance such as Group Income Protection, over solicitous family, friends and healthcare staff, legislation restricting options for a return to work, and those where there is a financial incentive to remain ill, which can be an "unconscious" or "conscious" factor). (Kendall, N.A.S., Linton, S.J. & Main, C.J. (1997). Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Wellington. Accident Compensation Corporation and the New Zealand Guidelines Group. Kendall, N.A.S., Burton, A.K., Main, C.J. & Watson, P. (2009). Tackling musculoskeletal problems: a guide for clinic and workplace, identifying obstacles using the psychosocial flags framework. London. TSO.)
• The impact of personal risk factors, including age, gender and ethnicity, but more importantly levels of activity and purposeful exercise, including strength and conditioning, excess weight and obesity, sub-optimal nutrition, poor sleep, alcohol and drug use, financial problems, and relationship stressors at work, at home and socially. (Engel, G.L. (1980). The clinical application of the biopsychosocial model. Annals Psychiatric Association. Vol. 137. 5. 535-544.) Plus numerous research articles on the impact of these risk factors on our skeletal muscle system.
• Poor knowledge by the public on what happens to our skeletal muscle system if we fail to undertake regular exercise, and how the deterioration can be slowed to preserve lean muscle mass with exercise. Research published in 2011 presented images of a 74-year-old athlete who had the same lean muscle mass as a 40-year-old athlete, compared to a 74-year-old sedentary male whose thigh (quadriceps) was mostly fat and had significantly reduced muscle mass. (Wroblewski, A.P., Amati, F., Goodpaster, B. & Wright, V. (2011). Chronic exercise preserves lean muscle mass in masters athletes. Physician and Sportsmedicine. 39(3) 172-8.)
• Expectations that private healthcare is better than NHS care, and that early intervention, including diagnostics such as an MRI scan, is necessary to diagnose and then receive a "cure". Information gained from grey literature and discussions with case and claims managers and supporting clinicians.
• Little understanding that circa 80% of MSDs can be self-managed and do not need a clinical intervention. This is information the author has gained from 150,000 cases actively managed over several years, plus research articles.

How these factors interplay

These factors interplay with each other and result in:

• Increase in absence episodes, especially as an employee ages.
• Increase in private healthcare claims for those covered by a plan.
• Belief that ageing and work are responsible, and that "interventions" are needed.
• Reduced activity in the belief that this will also cause harm.
• Deterioration in the skeletal muscle system, leading to possibly early retirement on health grounds, a claim on Group Income Protection, and possibly Employers' Liability.
• Dramatic reduction in quality of life for the individual, unless the underlying issues are assessed and addressed.

The figures cited in this article are the author's own, drawn from her prior professional work, and are not ORIGIN data.