A 14% drop in the incidence of carpal tunnel syndrome (CTS) anchors the latest Bureau of Labor Statistics data that reflects an overall drop in reported cases of repetitive strain injuries (RSI). The figure hints at a trend welcomed by private industry, yet with more than 43,000 cases recorded in those statistics, RSIs persist in harassing both workers and business.
And as the aggregate costs of treatment and lost productivity related to some CTS cases near $100,000 per incident, the value of ergonomic interventions as countermeasures to workplace injuries takes a new appeal.
“Employers have a lot to lose,” Joanette Alpert, PT, MS, CPE, says, outlining the expansive course of treatment some RSIs can follow, including surgery, hospital care, a complete rehabilitation program, and follow-up.
“Bottom line: It’s very expensive,” she says.
Since 1990, Alpert’s Brea, Calif, consulting firm, Ergonomics Focus, has designed ergonomic injury-prevention programs to help firms battle the colossal expenses RSIs can generate.
“At a minimum an ergonomic injury prevention program can reduce the severity of a workers’ compensation case,” Alpert says, and in Southern California, where Alpert’s firm is based, surgical treatment for a single CTS case at some hospitals can reach $30,000.
Alpert works not only to prevent the impairment with which RSIs often leave the affected worker, but also to design systems that ultimately will reduce the number of workers’ compensation claims made against an employer.
“And it is absolutely doable,” Alpert says. “Possible, been doing it, happens every time.”
JOB ANALYSIS IS JOB ONE
In the 1980s, Alpert observed a peculiar routine: Injured workers would enter a clinic and restore function through a successful rehab, only to return to work and perform the same task in the same way. Some of those workers would soon find themselves returning to Alpert’s care with an encore of the original injury.
Alpert wondered if something fundamental was overlooked.
“It made no sense to me at all; there was a huge piece missing,” she recalls. Alpert became frustrated at watching the cycle, and in 1990 she left a job as a therapist to become a consultant to private industry, for whom, according to government reports, RSIs had been costing billions of dollars.
She discovered that the key to halting the cycle she had witnessed as a therapist lay in a strategy of prevention. And prevention, Alpert reasoned, could best be underwritten by understanding the causes of injuries.
“Analysis is the biggest piece of my business,” she says. “You have to figure out why someone is suffering an injury, so job analysis is absolutely critical—then training, then education.”
While Alpert includes employee education and training as important components of her programs, she says a truly effective intervention can only be created when the root cause of an injury is fully understood.
“Identifying the risk factor is the easy part, but you have to figure out the ‘why,’ ” she says.
The number of variables that can trigger an RSI can make pinpointing the cause of injury difficult. Workplace RSIs can be set in motion by the design of a task, the design of furniture and tools used for the task, or the physical capacities and limitations of a worker.
“If you get in there and find out the ‘why,’ you’ll be effective,” Alpert says.
“Effective,” by Alpert’s definition, hinges on crafting a program that reduces the number of workers’ compensation claims an employer might otherwise face. The cost savings such a program might generate can be sufficient to alter a firm’s bottom line.
“And that’s even after they’ve paid for our services,” she adds.
The revolving door through which workers strode in and out and back into therapy continued to swing long after Alpert left clinic work. The phenomenon caught the notice of Miriam Wedemeyer, OT, MS, who in 1999 was working part-time at Long Beach Memorial Medical Center and Miller Children’s Hospital, Long Beach, Calif, doing on-site evaluations for firms in private industry.
That year, the hospital’s care staff had become so affected by RSIs that Wedemeyer and others began to consider the impact of an internal injury-prevention program. Administrators at the hospital realized the revenues Wedemeyer generated working for outside firms would be dwarfed in comparison to the savings she could provide to the hospital if an effective, internal program could stem the tide of workers’ compensation claims and lost productivity within their own walls.
“A typical employer would pay $350 for an ergonomics assessment,” Wedemeyer says, adding that many private firms were reluctant even to pay that figure. “I saw opportunities to build an internal program that would be relevant from the standpoint of prevention and also net a considerable savings for the hospital.”
Wedemeyer created the Zero Manual Patient Lift (ZMPL) program—which she now directs—at a cost of $252,000. The money saved on rehabilitation services that would have been spent to treat injured hospital employees allowed Long Beach Memorial Medical Center to recover the total start-up costs for ZMPL in less than 1 year. The dividend to workers’ health was reflected in hospital data that shows in 2001, before ZMPL, workers in the hospital’s rehabilitation center reported an injury every 2 weeks. In the 4 years following the program’s start, only a single injury has been reported at the center.
FINDING WHAT WORKS
The capital outlay required to implement an ergonomics program sometimes draws resistance from the executive level, which Wedemeyer and Alpert both say rarely surprises them. Wedemeyer, however, says she is periodically rebuffed by the very people she is assigned to help.
“What I will hear from certain employees is: ‘I’ve been doing this for 20 years, and I can’t change the way I do things.’ ”
After years of working to educate employees about the risk of injury they face at their jobs, Wedemeyer says she has found workers reluctant to alter their long-standing habits. “Many times, it takes severe pain to motivate them to change anything,” she says. “Otherwise, they simply do not believe in what you’re telling them.”
Wedemeyer says workers respond best to the education component of ZMPL when she is able to give demonstrations to very small groups of workers. Several areas are available inside Long Beach Memorial Medical Center for employees to sit down and experience ergonomically designed work areas. “Unless they can see, feel, and try an appropriate setup, they can’t comprehend the differences,” Wedemeyer says.
Alpert believes that education is important but subordinate to task analysis. Her client portfolio is lined with firms that have employee populations that range from several hundred to several thousand. The substantial numbers drive her to develop infrastructure built on a company’s own human and financial resources that leave a program in place that is self-sustaining. She trains personnel throughout an enterprise to perform simple workstation evaluations, order equipment, arrange installation, and conduct follow-up.
“Up to 90% of the program can be taken care of by the company’s own people. They can call me in for the tough stuff, but my objective is to work myself right out of there,” Alpert says.
“And that’s the philosophy of a PT anyway: Let me help you help yourself.”
WHAT YOU DON’T KNOW CAN HURT YOU
Anterior cruciate ligament injuries are identified with athletes the way atherosclerosis is identified with couch potatoes. In the workplace, CTS is frequently considered the defining RSI, but despite its prevalence, Wedemeyer asserts CTS is the most overdiagnosed and misdiagnosed of all ergonomics injuries.
Alpert agrees, and says tendinitis, not CTS, is the most common musculoskeletal disorder that results from overuse. She also points out that CTS can be caused by conditions that have nothing to do with repetitive motion, such as pregnancy.
Symptoms sometimes mistaken for CTS, Alpert explains, can originate from a more proximal area such as the neck or shoulder. “CTS is compression of the median nerve at the wrist, and symptoms would only be from the wrist down. Anything causing symptoms up the arm has pretty much stepped out of the CTS box.”
A missed diagnosis can mean a patient also misses appropriate care and their condition is allowed to worsen. In cases for RSIs that do not resolve themselves, Alpert says, a patient can undergo surgery as the ultimate treatment.
“So you certainly don’t want to misdiagnose it,” she says.
Though the direct impact of an office-borne condition such as CTS is hardly life-threatening, its potential to wreak quiet destruction should never be underestimated.
GOING TO COURT
“For an employer, the consequences of RSIs can be catastrophic,” attorney Kevin Duffis says.
Duffis, who once worked as a registered nurse, is a shareholder in the California law firm of Cotkins and Collins, where his practice focuses on medical malpractice defense. His experience as a front-line care worker gives him an overlapping awareness of the medical and legal jeopardy posed by RSIs.
“I have seen cases where people, especially those who do typing, have become so damaged they lose the productivity in their hand,” Duffis says.
The cost of such extreme disability claims can dig deep at an employer’s resources. Duffis explains that while many employers are at least casually aware of the financial havoc an RSI claim can wreak, he says others fail to appreciate the threat posed by cases that can be built around a worker’s lifetime lost earning potential.
“Let’s say you had a secretary who lost her office skills as a result of an RSI, and now she has to work as a receptionist. She has the right to claim she could have made $10,000 more a year over her working life,” Duffis explains.
“Those kinds of numbers become significant.”
The decision a worker makes whether to pursue a claim for an RSI may also be influenced by the size of the employer, Duffis says. Workers in larger companies can be more aware of the potential for liability and, thus, more likely to perceive the firm as a deep-pocket target. Workers in smaller firms who may feel a sense of loyalty to their employer may be more reluctant to pursue a claim.
“Sometimes smaller companies will gamble,” Duffis says. “They’ll make the choice to forgo the cost of an injury-prevention program by reasoning that low-level employees who become injured will not have the resources to bring litigation.
“And oftentimes that proves to be true,” he adds.
Even if a prevention program fails to completely avert an RSI, it can still offer a measure of defense to an employer should an injured worker move forward with a claim. Duffis says a solid prevention program can show substantial evidence of good faith and non-negligence on behalf of the employer.
“There is an obligation by a worker to mitigate their own damages,” Duffis explains. “If you know an activity is damaging you, you can’t just sit at a desk and continue to do it year after year until you become so crippled you have to go on total disability.”
WHEN THE DUST SETTLES
The success of Wedemeyer’s ZMPL program is measured primarily by workers’ compensation statistics, with lost time on the job and the cost of replacement workers considered as secondary factors. Assessing how well the standards of her programs are enforced becomes a murky matter for Wedemeyer, who says she has no mechanism to truly gauge compliance.
“There is no enforcement beyond safety regulations,” Wedemeyer says, “OSHA will hold the manager responsible if they’re not ensuring safe work habits, but a lot of it depends on the employee.”
Alpert says once she turns a program over to her client, the lack of control she subsequently feels can be frustrating. “You want to do follow-up and observe things over time, but as an outside consultant I have to be paid to come back. I have to be invited.”
Though she has no way to monitor her programs directly once they have been put in place, Alpert says some clients will provide her with data that reflect trends such as a drop in workers’ compensation costs—an indication that her system has achieved its desired result.
“Still, ergonomics programs are significantly undervalued,” Alpert says. “People are better educated about what ergonomics is and how it can help them because there is more awareness of ‘ergonomics’ in the public discourse.”
Though she believes there is room for improvement in the perceived value of ergonomic injury-prevention programs, she acknowledges that getting decision-makers to embrace those programs is easier now than when she rolled out her first plan 17 years ago.
“I’d like to think employers are more easily making that buy-in now because they see it’s the prudent thing to do,” she says.
Frank Long is the associate editor for Rehab Management. For more information, contact