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You may need to set up systems to deal with any problems which may occur, to ensure an early response to them. You may be able to use benchmarking as a way of checking progress, eg between departments or with neighbouring businesses. This process should involve an ergonomics approach and should include the participation of workers.

Its objective is to optimise health, safety and productivity. An ergonomics approach is the most effective way of dealing with ULD problems. This is because it encourages you to take account of all the relevant parts of the work system and requires worker participation. Firstly managers and workers can look for any signs of problems or symptoms amongst the workforce. Secondly, you can observe work tasks themselves to see if risk factors for ULDs are present.

This can be done using a simple initial assessment of risks such as the risk filter approach found in Appendix 2. Sources of information that may help include expert advice, industry standards and legislative standards. Warning signs 48 Warning signs can indicate the presence of hazards relating to ULDs. Signs of existing ULD problems can include: n n n n n n n. Risk Filter 50 A detailed assessment of every job could be a major undertaking and might be an unnecessary effort.

To help identify situations where a detailed assessment is necessary, a Filter for an initial screening of tasks has been devised. Where the Filter identifies several risk factors in combination, the risk of ULDs is likely to be greater. A copy of the Risk Filter and instructions for use can be found in Appendix 2. ULD assessment worksheets that can assist in recognising and recording risk factors, can be found in Appendix 2.

The risk assessment process 52 A job often consists of series of tasks. Performing your risk assessment can be simplified by thinking in terms of these tasks and their subsidiary elements. To illustrate this point, Figure 4 describes the job of a process worker that consists of three different tasks on an assembly line: n station 1: attaching a handle; n station 2: grinding, and; n station 3: packing.

For example, in the case of the process worker the risk filter might identify the task of attaching a handle station 1 as posing a possible risk. The more detailed assessment using the worksheet would identify repeated use of a pinch grip when picking up and positioning the screws elements 1 and 2 , and awkward arm posture out to the side of the body when drilling element 3.

When considering the task in this way it is easier to link the risks to particular actions or operations, which then helps when considering risk reduction measures. Reducing the duration spent on the task and introducing more frequent breaks will reduce the risk associated with using the pinch grip.

Figure 4 The tasks and elements of a process workers role 56 Remember to consider whether workers perform a number of potentially risky tasks ie that have been highlighted by the risk filter , in a given shift. If this is the case, it is essential that your risk assessment considers the overall impact of performing the combination of tasks in your risk assessment.

In practice, this would usually mean that a separate filter and risk assessment worksheet would be filled out for each task, and that the completed worksheets would be considered in combination when deciding on the overall level of risk for those workers.

Detailed instructions for the risk filter and risk assessment worksheets can be found in Appendix 2. Engaging a competent person may be appropriate for more complex risk assessments. The principal ULD risk factors are:. For example, the task of gripping a heavy power tool with a large handle for six hours would result in an awkward, forceful gripping posture and exposure to vibration over a prolonged period. Therefore working postures, duration, force and working environment are all risk factors for injury in this task.

This is despite the fact that the risk factors of working postures; force and vibration are still present. However, one risk factor acting alone can create an unacceptable risk of injury if it is sufficiently great in magnitude, frequency or duration.

Repetition 63 Work is repetitive when it requires the same muscle groups to be used over and over again during the working day or when it requires frequent movements to be performed for prolonged periods. Repeated loading of soft tissues is also associated with inflammation, degeneration and microscopic changes.

Fast movements and acceleration require high muscle forces. Awkward postures 66 An awkward posture is where a part of the body eg a limb joint is used well beyond its neutral position. A neutral position is where the trunk and head are upright, the arms are by the side of the body, forearms are hanging straight or at a right angle to the upper arm, and the hand is in the handshake position. For example, when a persons arm is hanging straight down with the elbow by the side of the body, the shoulder is in a neutral position.

However, when employees are performing overhead work eg repairing equipment or accessing objects from a high shelf their shoulders are far from the neutral position. Resulting friction and compression of soft tissue structures can also lead to injury. Static postures 68 Static postures occur when a part of the body is held in a particular position for extended periods of time without the soft tissues being allowed to relax.

When holding a box, for example, it is likely that the hands and arms are in a static posture. Muscles held in static postures fatigue very quickly. As with all the risk factors for ULDs, the impact of the working posture needs to be understood in relation to other risk factors.

Force 71 Force can be applied to the muscles, tendons, nerves and joints of the upper limb by: n handling heavy objects when performing tasks, ie an external load; n fast movement or excessive force generated by the muscles of the body. Force in gripping 74 The need to grip raw materials, product or tools is a potential risk factor if excessive force is used. The amount of force required to grip can be influenced by the type of grip used, the posture of the wrist, exposure to cold and vibration and the effects of wearing gloves.

For example, a screwdriver handle with a flexible grip requires less force when being used than one with a harder handle. The size of the object being gripped can also affect the force required. For example, pliers with too wide or too narrow a span will be more difficult to grip. The strongest grip strength occurs when the wrist is close to the handshake position and is slightly bent upwards. Duration of exposure 77 Duration refers to the length of time for which a task is performed.

It includes the length of time that the task is undertaken in each shift, plus the number of working days the task is performed eg four hours per day, five days per week. Duration is an important concept in assessing the risk of musculoskeletal disorders. Therefore, when duration time is increased the risk of injury is increased. This is because when parts of the body undertake work for periods without rest, there may be insufficient time for recovery. Consequently, time for the individuals body to recover from a specific task or tasks is important.

This can occur after return to work from holidays or with an increase in work pace. Working environment 80 Working environment refers to aspects of the physical work environment that can increase the risk of ULDs. This includes factors such as vibration, cold and lighting.

Vibration can increase the risk of ULDs and is known to cause vibration white finger and carpal tunnel syndrome, loss of sense of touch or temperature, painful joints and loss of grip strength. Information about the dose ie vibration magnitude and exposure time of vibration is needed in order to accurately assess the risk.

Cold 82 Working in cold temperatures, handling cold products or having cold air blowing on parts of the body can place additional demands on the body as well as possibly requiring the use of personal protective equipment which can compound the risk by requiring additional force to grip.

Exposure to cold can result in decreased blood flow to the hands and upper limbs, decreased sensation and dexterity, decreased maximum grip strength and increased muscle activity which is part of the bodys natural response to being cold. Lighting 83 The visual demands of the task are an important consideration, since a workers posture can be largely dictated by what they need to see. Dim light, shadow, glare or flickering light can encourage workers to adopt a bent neck and poor shoulder postures in order to see their work, thereby exacerbating the effects of other risk factors.

Further information on lighting can be found in Lighting at work. Psychosocial factors 84 Physical risk factors exert their harmful influence through physiological and biomechanical loading of the upper limb. Of equal importance is the large body of work showing that a workers psychological response to work and workplace conditions has an important influence on health in general and musculoskeletal health in particular; that is, work as experienced by workers.

These are referred to as psychosocial risk factors. They include the design, organisation and management of work and the overall social environment in general the context of work and also the specific impact of job factors the content of work. It is very likely that physical and psychosocial risk factors combine and that the greatest benefit will be achieved when both are identified and controlled.

Many of the effects of these psychosocial factors occur via stress-related processes which include direct biochemical and physiological changes. Also included are instances where individuals try to cope with stressful demands with behaviours that, in the long term, may be detrimental to health.

An example would be where an individual, because of high workload or deadlines, foregoes the rest breaks to which they are entitled. Important aspects of work design include the amount of control people have in their jobs, the level of work demands, the variety of tasks that they have to carry out and the support they receive from supervisors and Upper limb disorders in the workplace Page 22 of Many jobs are not well designed and include some or all of the following undesirable features where: n workers have little control over their work and work methods including.

As with physical risk factors, psychosocial issues are best addressed with full consultation and involvement of the workforce. Individual differences 86 All individuals are different and for biological reasons there may be some people who are more or less likely to develop an ULD.

Individual differences may also have implications for employees reporting ULD type conditions. Where an ergonomic approach is followed, this should ensure that tasks are within the capabilities of the entire workforce. Some factors may increase the risk of developing symptoms and should be considered in the management programme. This can lead to. Firstly, consider if it is reasonably practicable to eliminate the hazard, eg by redesign of the work task, by substitution or replacement of tools or components, or through automation of the task.

In some cases it may be possible to isolate the risks at source by engineering controls or protective measures, eg by shielding the worker from draughts or by preventing exposure to vibration. Where these are not viable, the lowest order in the hierarchy of controls is to minimise risk by designing suitable systems of work, using PPE if appropriate and to provide training.

A participative approach to solution finding is considered to be the most effective method for intervention development. Research has shown that interventions that take account of all these aspects are more effective in reducing risk: n Changes to the work task s may include redesign of the workstation. It may include the provision of appropriate furniture, equipment or tools that have been matched to the needs of the workers and the task.

Job rotation or automation may be beneficial in reducing ULD risks. Changes to influence psychosocial factors may be required. A review of the work organisation and structure such as reduction of work hours or changes to scheduling of breaks, or modifying pacing or incentive schemes may also be helpful. Some helpful principles are: n great benefit often results from simple and low cost interventions eg. Even sound ergonomic solutions may not be successful if they are imposed.

Involving workers in problem solving and the implementation processes, gives an enhanced sense of ownership of the solutions and may create a greater commitment to their effective implementation; in large, geographically spread organisations, incorporate short-term local initiatives into the companys overall health and safety strategy; refer to case studies from other sources, eg from trade associations or the Internet, for ideas concerning best practice solutions.

There is no scientifically valid screening test which can predict the future development of ULDs in an individual. Placement procedures should take account of the risk assessment, job requirements and the individual differences outlined in the previous section. This works best, for example, by only working for a limited time per day at production speed, increasing as appropriate.

Introducing newcomers at a slower pace enables them to develop good work practices before having to concentrate on working fast and helps them to assimilate training more effectively: ideally, early training should be done off-line. Regulation 12 in the Management of Health and Safety at Work Regulations details requirements concerning new employees. This includes guidance based on case studies33, 34 as well as some that is industry-specific. Information can also be found on the HSE, and some other websites.

See further information for sources. Upper limb disorders in the workplace Page 25 of Keep abreast of new developments eg when new machinery or staff are introduced into the workplace or when other alternative risk control measures are developed. Monitoring and reviewing are explained in paragraphs Educate and inform your workforce n Have you educated and informed your workforce to help prevention?

Informing staff about signs and symptoms of ULDs, risk factors, control measures and the need for early reporting and action will improve the overall effectiveness of your programme and will encourage employees to become actively involved in identifying and controlling ULD risks. Influencing the way workers perform tasks through training is an essential part of risk control, but relying on this alone has been shown to have limited success in prevention.

Training should ideally complement other higher order controls that have already been implemented ie redesign of the work task, substitution or replacement of tools or components, isolating the risk at the source etc. It can be very beneficial to involve employees in the development and presentation of training.

Education should also extend to purchasing staff, engineers, maintenance and support staff, particularly where they are involved in specifying, designing or modifying work equipment in order to increase their awareness of ergonomic issues and ULD risk factors. Such training should include a review of risk factors related to tasks and safe working methods for that particular task. Any specific control measures associated with the job, including personal protective equipment should also be covered.

When attempting to alter worker behaviour, programmes will need to consider: n n n n n n. This is fundamental to the success of any training programme. Employers should promote participation by encouraging discussion, asking employees for suggestions and comments on training issues and, where appropriate, involving employees in the presentation of training material; the role of safety representatives in promoting safe working practices and reinforcing training messages; the need to provide opportunities for immediate practice and feedback so as to correct performance and to ensure that skill levels can be maintained following training.

Principles covered in training sessions should be reinforced by supervisors, safety representatives and peers on a regular basis; the need for periodic refresher training for all employees. Employees should be involved in this process, particularly safety representatives and supervisors, who can assess the impact and effectiveness of the training offered. Training should also be reviewed when there are changes in: n workplace layouts, task design or work organisation or the introduction of.

Manage any episodes of ULDs n Have you implemented and supported a system for early reporting of. Due to individual differences in the bodys response to stresses it is not possible to ensure that every possible episode of ULDs will always be prevented. It is necessary, therefore, to have a system in place to manage any reports or cases of ULDs that arise in the workforce. The approach to managing these complaints is broadly similar whether they are thought to have been caused by work activity, been made worse by the work or are largely unrelated to particular work tasks.

It is important to maintain a climate in which early reporting of symptoms is regarded positively and this will be encouraged if managers and safety representatives both emphasise the benefits of such early detection of possible harm. Education on possible symptoms and signs, who to see in the company and what help to expect should be provided to all employees where there is a residual risk of ULDs.

Employees should be advised to have any relevant symptoms recorded in the company accident book. Any first aid provided should also be documented. A diagnostic support aid for ULDs has been developed and is likely to be of benefit to General Practitioners GPs and other health professionals.

This can prevent the need for sickness absence and allow for recovery time before return to their normal duties. Appendix 3 contains more information on the scope of occupational health provision and how to access this. Access to an occupational health service will usually allow both the worker and their manager to be given appropriate advice with minimal delay. The individual will be advised on the nature of their complaint and any appropriate treatment.

Appendix 3 lists a number of specific medical diagnoses to look out for if you are concerned about complaints of ULDs. However, any such communication has to comply with the principles detailed in the Access to Medical Reports Act, Appendix 4 provides further details. Individuals diagnosed with such disorders should be advised that they might be entitled to benefit under the Industrial Injuries Scheme.

This is especially important if there are other previously reported cases. It is often possible to return to work before symptoms have resolved, and, in some cases this may be advantageous. This is particularly important in work where there is already existing evidence of upper limb complaints. The Approved Code of Practice for the Management of Health and Safety at Work Regulations20 recommends that health surveillance is undertaken where certain criteria are met.

One of these is access to a valid means of detecting the disease or condition of concern. At present it is not considered that valid techniques exist for the detection of changes which reliably indicate the early onset of specific upper limb disorders. It is good practice to put in place systems which allow individuals to make early reports of upper limb complaints.

Where appropriate these can be supplemented by regular surveys of symptoms. Further information can be found in Health surveillance at work. Carry out regular checks on programme effectiveness n Do you have systems in place to monitor and review your controls for. These checks can be considered at two levels: n monitoring: which is the ongoing and regular appraisal of the procedures.

Monitoring generally involves recording trends in ULD symptoms and risk factors over time in order to assess the performance of existing control measures and to plan and implement new interventions. The scale and extent of monitoring required will depend on the degree of risk and the relative costs and benefits of available methods. It is important that there is consultation with employees so that they are fully aware of the monitoring procedures which are in place.

Table 1 compares the general features of each approach. Passive Uses existing information sources and methods Usually inexpensive Usually undertaken first. Active Active seeking of information about signs, symptoms, risk factors Generally involves additional costs Usually undertaken as a follow-up to passive monitoring but may be the first line approach where there is a significant ULD risk.

In depth data coding and analysis require specialist assistance. Non-clinical and clinical indicators included Recommended when faced with an outbreak of ULDs. Data coding and analysis is usually simple Non-clinical Readily established as information sources usually designed for other administrative purposes. Consultation with employees is particularly important since there are ethical considerations relating to the handling of personal health information.

Examples of passive and active monitoring Some examples of passive and active monitoring methods are given in Table 2. Where practicable, comparing your experiences with other companies in your sector may also assist in evaluating the performance of your control measures. Employees should be advised of the situation and any appropriate medical management made available.

Further monitoring will determine if these revised measures have been effective. Appendix 1: Case studies These case studies have been divided into the stages presented in the management model shown in Figure 1. This has been done retrospectively so all stages of the model are not always fully represented. Case study A: Easter egg and chocolate box packing Background A large factory identified a number of tasks that created a risk of ULDs: n Task 1: Easter egg packing For packing Easter eggs, eight separate.

Most of these components arrived as flat-packs which then had to be folded and bent into the correct shape. The operators on this task were paid piecework rates dependent upon the number of eggs they assembled in a workday. The boxes were presented to the operator on a moving conveyor, and, as they went past, different operators had to put different components the chocolates, the mouldings in which they sit, the cardboard pad, and information leaflets into the boxes in a flow assembly operation.

With the permission of the employees concerned, management had become aware of ULD referrals and had directed action on the issue. Create the right organisational environment The company doctor, the operations manager and the industrial engineer for the site worked with employees throughout the process of assessment. Trials of solutions to reduce the risks were also done in a participative manner. Assess the risk of ULDs in your workplace A risk assessment of task, environment and individual factors for ULDs identified the following risk factors:.

Task 1: Easter egg packing Task-related factors Repetition: This task was highly repetitive with workers performing the same finger, wrist, arm and shoulder movements many times per minute. The task required many movements of the hand and wrist, eg sideways bending and bending the wrists up and down while folding the cardboard and snapping a plastic cover over the eggs.

The elbow was often held and moved in positions away from the body. Snapping of the plastic cover over the eggs required force with pinch grip. Workers conducted this task for prolonged periods each day. Workers were paid on a piecework basis which may have encouraged them to push themselves beyond the point at which they experienced discomfort. Task 2: Chocolate box packing Task-related factors Repetition: This task was highly repetitive with workers performing the same upper limb movements many times per minute.

The operators work rate was determined by the conveyor speed. The box design made it difficult to place the components accurately in the boxes when the conveyor was moving quickly. This meant that workers assumed awkward postures of the shoulder and wrist. Workers undertook this task for prolonged periods each day.

If workers were rotating between the two tasks, they may have been at an increased risk of ULDs. Both tasks present very similar risk factors for ULDs repetition of similar upper limb postures for long periods and in combination, further increase the risk of ULDs. This example highlights the importance of looking at the risk assessments of tasks in combination where workers are performing multiple tasks during the shift.

Reduce the risk of ULDs After the assessment was completed it was determined that certain elements needed to be redesigned: n the packing operation was redesigned to remove the risk element of. This reduced the number of uncomfortable wrist and hand movements; n the pay structure was changed from piecework to salaried work; n for chocolate box assembly, engineers developed a mock-up workstation to trial with operators in which the rate of completion of the task was determined by the operator, not by the conveyor;.

Carry out regular checks on programme effectiveness For Easter egg packing: n fewer cases of wrist and hand problems are now reported to medical. The company has benefited in both production efficiency and staff well being and health by recognising risks within the task, and investing in ergonomic changes to the tasks and packaging materials.

Case study B: Computer use in news media organisation The work covered by this case study was subject to the Display Screen Equipment Regulations. This case study shows how the structured approach in the guidance can help comply with the Regulations in an unusual situation with complex challenges. Background 11 For many years a large news media organisation had used a computer-based system to store and transfer news stories.

This was gradually becoming outdated and required upgrading due to developments in the electronic transfer of stories and the need for a faster more efficient system. Some adaptations were made for the current organisation and it was installed in the newsroom and elsewhere.

Accompanying the rollout was a programme of change management that included advice on implementation, installation and training for users including workstation adjustment and posture. Understand the issues and commit to action 13 The use of the new system led to unanticipated consequences because it was being used for a task for which it was not designed the preparation of sometimes lengthy, in-depth news stories rather than short bulletin-style pieces.

There then followed a rapid surge in new cases in the order of a three to four fold increase over the previous years. Create the right organisational environment 15 Right from the beginning an open-minded policy was adopted so that all staff could be kept fully informed of the extent of the problem and its progress.

Assess the risk of ULDs in your workplace 16 Assessment of task, environment and individual factors for ULDs revealed that the software did not cope with page breaks, spell checking, cut-and-paste editing facilities and the need for the news organisation to cope with nonEnglish material. The task of text input and editing against constant deadlines was now much more onerous than with a standard word processing style package. Unfortunately the implementation of this new system coincided with the outbreak of a major international news event necessitating an enormous increase in workload.

In addition, organisational changes were being made to the business infrastructure in common with those being made elsewhere at the time. This inevitably led to uncertainty about the future, insecurity on the part of the workforce, and to higher levels of stress. Wrist postures were also problematic for some workers. Text input and editing tasks were performed for prolonged periods each day. The outbreak of the major ongoing news event meant that many workers were working longer hours.

Environment-related factors Psychosocial factors: Organisational changes, strict deadlines and workload associated with the major news event were all identified as psychosocial risk factors. Reduce the risk of ULDs 18 Controls to reduce the risk of ULDs were implemented as follows: n computer related equipment which included hardware, software and. This rectified any adverse work practices and included control over work quality and deadlines.

These controls focused on the risk factors of duration and psychosocial factors. Manage any episodes of ULDs 19 Early reporting of individual cases to the occupational health department was encouraged so that steps could be taken by managers to minimise the impact of symptoms.

Three main routes of management were drawn up: n a self-help route including a range of physical therapies and relaxation. Background 22 A large manufacturing company with several factory sites produces and packs a wide range of cosmetic and skin care products. These often have short packing run times, and some product lines are difficult to automate. The company recognised that the highly manual packaging tasks presented a risk of ULDs and took measures to tackle these.

This was met through the development of a company ULD policy. A company ergonomist was also recruited to develop and facilitate an ergonomics programme. Upper limb disorders in the workplace Page 39 of Create the right organisational environment 24 Managers and operators had been aware of reported symptoms of ULDs and were supportive of measures to reduce these.

From the start the ergonomist worked closely with occupational health staff and management. Assess the risk of ULDs in the workplace 26 A three-stage risk assessment process was set up: n detailed risk assessments of the packaging tasks were undertaken.

These formed the basis for prioritising risk reduction recommendations; n senior team members regularly assess the risk of ULDs during routine risk assessments of their packing lines. They are encouraged to identify and implement risk reduction measures and can seek advice from the company ergonomist; n when a new product is to be introduced to a line, a change control assessment is undertaken to identify any specific problems which may relate to the packing of that product, and possible solutions.

An example of a task identified during a packing trial risk assessment as posing a ULD risk was sealing a two-piece glass jar using a wire metal clasp. The task required repetitive activity and the application of force to close the clasp. There was also the risk of pressure points on the palm from the wire.

The risk of ULDs associated with the task was reduced by encouraging operators to stand rather than sit to make it easier to apply force; providing a leather palm protector; ensuring two people undertook the task to reduce duration of exposure and increase recovery time; and providing guidance on task procedure.

After implementation, no ULD symptoms were reported from this packing operation. Reduce the risk of ULDs 27 The following measures apply to all packing lines: n all packing employees rotate to a different task every 30 minutes.

Educate and inform your workforce 28 A leaflet on ULDs, covering causes of ULDs, how to identify signs and symptoms, and what to do if these are experienced, was issued to all staff with a follow-up issue after 18 months. Manage any episodes of ULDs 30 The company policy requires employees to report any ULD symptoms to their team leader who refers them to the occupational health service. Their workstation and tasks are assessed in light of the problems experienced and appropriate recommendations given.

The team leader reviews the situation weekly, and occupational health staff regularly monitor the employees symptoms. Carry out regular checks on programme effectiveness 31 Regular health and safety group meetings involving senior management, occupational health staff, the company ergonomist, factory engineers and safety representatives review risk management issues and the impact of risk reduction measures taken.

They also provide effective routes of communication between staff involved. This was followed by a steady reduction in referral rate over the following two years. When the leaflet was re-issued the anticipated increase in referrals was not experienced. Background 34 A leading bookmakers group with over 11 staff and 2 shops planned to roll-out a radically new design of electronic point-of-sales EPOS system and associated counter. Prevention of ULD risks was a major consideration in the selection of equipment, design of the counter, furniture and software.

The new design and management programme had to accommodate a range of shop environments, staff regularly moving between premises and different cashier workstations. The EPOS system involves some computer work keyboard and mouse use to handle and process bets. Understand the issues and commit to action 36 Management recognised that ULD risk factors were present in the cashiers task eg repetitively reaching to the counter top and awkward stretches to reach equipment.

Senior management was supportive of the plan to introduce new counter design guidelines and recognised the potential impact on occupational health. Create the right organisational environment 37 It was agreed that the new counter design and layout should be based on ergonomics criteria. Management also recognised that providing information to employees and having a means of identifying any health problems was essential in managing occupational health.

A project team was assembled. Assess the risk of ULDs in the workplace 38 A risk assessment identified that certain movements and tasks would be required reaching to counter top, cash drawer, handling money etc which contained the ULD risk factors of repetition, reaching and awkward posture. This enabled ergonomics criteria to be specified for the counter design. Educate and inform your workforce 40 Information on setting up the workstation and chair adjustment was provided on the company intranet to which all cashiers have access.

In addition, on an ongoing basis employees are prompted to complete an on-line assessment of their workstation after a certain number of log-ons. This also directs staff to relevant guidance documentation. Manage any episodes of ULDs 41 Most health problems are identified in the on-line assessment or through the absence management system.

Any problems identified are reported to the employees line manager, and to the safety manager, and it is the line managers responsibility to action change eg replace faulty equipment. Where a problem has been identified the employee completes an on-line assessment 21 days after the initial report.

If the problem has not been resolved it is reported to a higher level of manager, and a re-assessment is completed after a further 21 days. Continuing problems are reported to a director of the company. This provides an incentive for reported problems to be dealt with rapidly and ensures that awareness is raised among all staff. Ongoing monitoring of occupational health data continues. Further investigation is taking place into the design of betting slips to allow more electronic recognition of options ie using tick boxes so that the amount of mouse use by cashiers dealing with transactions can be reduced.

Background 44 A large poultry processing company with a number of different sites wanted to systematically tackle their ULD problems. Understand the issues and commit to action 45 The company had received guidance from their industry federation and was aware of the extent of ULD problems in the sector. There had also been a significant number of referrals to their occupational health department and claims for ULDs, which acted as a motivator to tackle these issues.

Although managers had been aware of the issues, attitudes changed significantly when the cost of placing people with ULDs onto lighter duties was calculated, and found to be considerable. Create the right organisational environment 46 Following a review of their health and safety management systems, the company established a programme for the prevention of ULDs.

Policies were written, arrangements and procedures put in place, and roles and responsibilities clarified. Teams were given an ergonomics training programme to raise awareness of the issues and identify ways of reducing the risks. In addition, the companys occupational health nurses were given a more proactive role in managing ULDs and worked closely with first line managers.

General risk assessments are done by trained risk assessors under the guidance of the line manager of the department. The assessment considers a range of risks and uses specific checklists for ULDs, manual handling and ergonomics issues. If these identify a potential ULD risk, a person trained in ergonomics or an occupational health nurse undertakes a more detailed assessment.

Reduce the risk of ULDs 49 Because staff on the shop floor have had ergonomics training they have been able to generate many workplace improvements themselves. It is primarily through the empowerment and commitment of the first line managers that the process has been successful.

Chicken hang on One of the poultry processing activities involves hanging chilled whole birds onto moving shackle lines so that they can be cut into chicken portions by a machine. The task requires individual birds to be picked from a hopper situated in front of the operator and the legs of the bird placed in the shackle on a suspended conveyor. The operators carrying out this task work in teams of three, at a rate of 70 birds per minute.

A decision was taken to replace the cut up machines and, as a part of that project, to redesign the hang-on workstation to reduce the ULD risk and the wasteful handling involved in the existing process. A detailed assessment revealed the following: Task related risk factors Repetition: The task was highly repetitive with up to 25 cycles per minute. The task was also machine paced. Workers had to reach forward and down to pick up the birds, then up to place them in the shackle.

Positioning the bird to align with the shackle also required awkward postures. Some force was required to place birds in the shackle; Birds weigh up to 2 kgs. Environment related risk factors Working environment: Psychosocial factors: Low workroom temperature 12 C and low temperature of product 3 C The work was machine paced. A two-phase re-design was implemented to reduce, and ultimately eliminate, the risk.

Phase 1 Redesigned workstation reduced height of shackle on conveyor; repositioned bird delivery hopper so the reach distances required were reduced; redesigned shackle to make attachment easier. Employees were consulted and involved in the design of the revised workplace. Phase 2 Direct feed of birds from another shackle line, to the shackle line on the automatic cut up machine, thus eliminating the need to manually hang birds. Outcomes include: Significant reduction in ergonomic risk; reduction of reported ULDs from the activity; reduction in number of employees on lighter duties from this operation; a marked improvement in productivity.

Educate and inform your workforce 50 All staff receive induction training which covers the risk of ULDs, control measures and reporting procedures. Further information and training are given on the job. The profile of ULDs has been raised within the company and there is open communication about the issue. Manage any episodes of ULDs 51 If an employee experiences ULD symptoms they are referred through their line manager to the occupational health department who will assess their condition and work, and make recommendations concerning appropriate action workplace or task modifications, rest, lighter duties.

Occupational health staff undertake on-going surveillance of those with problems. A physiotherapist is available on site to treat and advise those with ULDs. Carry out regular checks on programme effectiveness 52 The company undertakes a six monthly audit of the ULD programme to review the management system and procedures, their effectiveness and the impact they have had, and to identify any further improvements.

Following the ergonomics programme, in the same sample week in only 16 staff 0. In direct labour costs alone the company estimate that this reduction equates to a saving of The guidelines in the Risk Filter and Worksheets are provided as an aid to risk assessment.

They have been developed from the scientific literature and from expert opinion. As such, they are not precise exposure limits, but are intended to help you to identify the potential risks and possible measures to reduce them. Other methods of assessment are available and may be equally appropriate in assessing the level of risk of ULDs.

Overview Together the Risk Filter and Risk Assessment Worksheets provide a twostage assessment process, which may be photocopied for use: n Stage one: Use the Risk Filter to help identify situations where a more. Please note that certain risk factors have been purposely omitted in the filter in order to provide a useable, first stage, screening tool.

In order for your assessment to be effective you should: n involve your workforce in the assessment and control process to take. Equipment that may be useful includes: n stopwatch or timer to measure cycle times; n video camera to allow for more detailed analysis of movement cycles, and. Duration: A consideration of duration, or exposure time, as a risk factor for ULDs would include both the length of time that a task is performed in a typical working day as well as how often it is repeated eg daily, weekly or less often.

Building such a complex factor into a simple risk filter and worksheet is difficult. Consecutive in this context means the task or similar groups of tasks are repeated successively throughout the 2 hour period. It must be emphasised that the 2 hour period is not a limit and should be applied pragmatically. For example, if a task was performed for 1 hour and 40 minutes, followed by a 10 minute break, then for another 1 hour and 40 minutes, followed by another break, and so on, throughout an 8 hour workday, the worker has not strictly worked more than 2 consecutive hours.

The duration of exposure for this task, however, is certainly high and would be of concern if the other risk factors for ULD were also present. Conversely, if the task requirements are exceptionally demanding, a duration of less than 2 consecutive hours may present an unacceptable risk. Completing the Filter involves: n recording the basic details of the task such as the date, name of the task,.

Examples may include repeated hand press operations, repeated triggering operations, repeated cutting actions, repeated handling etc. A Cycle refers to a sequence of actions of relatively short duration that is repeated over and over, and is almost always the same.

They are not necessarily associated with one single joint movement, such as the elbow , but with movements of one or more parts of the limb such as reaching, manipulating and placing an object. Cycles are not always clear-cut, and in such cases observers should look for similar actions that are repeated. A simple task may consist of a sequence of movements which would be repeated and therefore form the cycle. A more complex task may consist of elements as described in paragraph 53 some or all of which may be distinct cycles.

Check fingers, wrists, hands, arms, shoulders and necks. Remember: The more the joints deviate from their neutral position, the greater the risk. Step 4: Force: Check for sustained or repeated application of force. Step 5: Vibration: Make a note of the type of vibrating tools or equipment such as grinders, polishers etc. You should also be aware that psychosocial and working environment factors such as high job demands and lack of control, cold and lighting could further increase the risk of ULDs.

These factors are expanded in the full risk assessment. Complaints of aches and pains? Improvised changes to work equipment, furniture or tools? Are any of these present? Step 2: Repetition Are there repetitive elements such as: Repeating the same motions every few seconds? A sequence of movements repeated more than twice per minute? For more than 2 hours total per shift? Step 3: Working postures Are there any working postures such as: Large range of joint movement such as side to side or up and down?

Awkward or extreme joint positions? Joints held in fixed positions? Stretching to reach items or controls? Twisting or rotating items or controls? Working overhead? Step 4: Force Are there any forces applied such as: Pushing, pulling, moving things including with the fingers or thumb? Pinch grips ie holding or grasping objects between thumb and finger? Steadying or supporting items or work pieces?

Objects creating localised pressure on any part of the upper limb? Step 5: Vibration Do workers use any powered hand-held or hand-guided tools or equipment or do they hand-feed work pieces to vibrating equipment? Regularly ie at some point during most shifts? Ensure you have read Assess the risks of ULDs in your workplace see paragraphs and the general guidance at the beginning of this Appendix prior to undertaking your assessment.

The risk factor of duration is addressed within the guidance values for other risk factors and therefore does not have a heading in its own right. An example task description is: a worker reaches for screws, places them in position at head height, then uses counterbalanced drill to fix screws. The finished product is then pushed across the body to the next station ; going through each risk factor in turn, observing the task s in relation to the appropriate guidelines to see if a risk of ULDs is present; recording which aspects of the task s present the risk; noting down possible control options; identifying those tasks with the most risk factors to help in prioritising tasks for a programme of control the more yes ticks the greater the risk.

Some control options are listed in the final column, these are explained in further detail in Appendix 2: Suggestions for reducing the risk. The controls listed represent some options only and are not an exhaustive list. Identify tasks with the highest number of Yes ticks. Tasks with a higher number of Yes ticks may require more immediate action; where you have established that there are diagnosed cases of ULDs or complaints of discomfort etc.

For 2 consecutive hours per work day: A Cycle is a sequence of actions of relatively short duration that is 1. Describe any problem s Describe any risk Control options and probable cause s : control options you have not exhaustive list Describe what the person identified is doing eg. Performed 3 hours per day, five days per week. Fingers, hands and wrist 2.

Remember: the greater the deviation from a neutral position, the greater the risk. Describe any problem s Describe any risk Control options and probable cause s : control options you have not exhaustive list Note problem postures and identified identify parts of the upper limb involved. Static gripping posture used for up to 2 hours at a time, wrists repetitively bent sideways when drilling objects. Arms and shoulders 3.

Shoulder held in fixed position with elbow out to the side for up to 2 hours at a time. This is due to the work height. Awkward reaching behind the body? Awkward reaching across the body? Yes No. Head and neck 4. Optimise working posture: Ensure visual requirements are not too demanding Provide visual aids Ensure lighting is suitable Reposition items that workers are required to look at.

Describe any problem s and probable cause s : eg. Drill handle is too small resulting in increased gripping force for up to 4 hours per day. Also high force applied to screws. For example, pinching an unsupported object weighing 0. Optimise working posture: Reduce forces necessary Use power tools Can the function be achieved differently?

Use jigs to hold items Reduce weight of items Present items differently Increase mechanical advantage After task to use stronger muscles Use foot pedals If gloves used check that they are appropriate Maintain tools Ensure tools are suitable for task Improve handles Use light weight tools Use tool counterbalances Ensure tool handles fit workers comfortably. Describe any problem s Describe any risk Control options and probable cause s : control options you have not exhaustive list eg.

Workers exposed to identified hand vibration from drill up to 4 hours per day. Workers have cold air blowing on hands from exhaust. Yes 6. Sensitivity may be required Yes No. Workers are on identified piecework system. Support from supervision and co-workers is low. Reduce force: Reduce monotony Ensure reasonable workload and deadlines Ensure good communication and reporting of problems Encourage teamwork Monitor and control overtime and shiftwork Reduce or monitor productivity relatedness of pay systems Provide appropriate training.

Describe any risk Control options control options you have not exhaustive list identified Improve the working environment: Allow for a gradual build up to full production speed Provide suitable training to develop the skills required Seek advice on special requirements.

Innovative ideas for controlling risks are often devised by workers or those familiar with the task. Reducing repetition Generally Automation and mechanisation Tools Job. Limit the duration of continuous work or restructure work methods to provide greater variety. Can machinery do the highly repetitive functions more varied jobs for the workers Take care to avoid creating repetitive, boring and monotonous tasks to feed the machinery with work. Avoid pacing of the work. Automated machinery and team working can all act to increase the work rate.

Aim to allow people to control their own pace of work. Use power tools in place of manual tools. Use manual tools with ratchet devices to reduce the number of movements required, eg screwdrivers or spanners see also Tools. Break up long periods of frequent repetitions and static inactivity or spread repetitions across both hands.

Share repetitive work through teamwork or job rotation. Distribute the workload over different muscle groups and joints. Consider adding extra activities to the job to provide variety in posture and speed of work. Job enlargement Rest Job breaks. Breaks, before the onset of fatigue, are important. Consultation with workers may help to set an adequate work rest ratio or alternatively allocate times when workers should rotate from a specific task.

Increase the frequency of breaks. Frequent short breaks are preferable to a few long ones. Rotate the worker to perform other tasks, which varies body part action and speed. Remember that rotating to a task that utilises the same parts of the body and presents the same risk factors for injury as the original task will not provide rest periods for the parts of the body that are at risk of ULDs see also Job rotation in Reducing duration.

Place a limit on or monitor overtime and provide sufficient rest breaks to account for prolonged exposure. Page 60 of Optimising work postures Poor workstation and equipment design is usually responsible for postural problems leading to ULDs. There are a number of methods for reducing postural problems. Generally Enable work to be done with the joints at about the mid points of their range of motion.

Avoid using static postures for prolonged periods. Consider the location, angles and height of equipment, controls or work pieces in relation to the operator. Modify to improve posture. Ensure workplaces and work equipment are designed or selected to account for difference in size, shape and strength of workers. Alter tool design to improve wrist posture.

Can changes be made upstream of the job? Can the sequence be changed to make the task less awkward? Consider position of the work, and the use of fixtures and jigs to angle and hold work in more accessible positions. Consider how the body will interface with the equipment.

Are there objects or attachments that act as obstacles and lead to poor posture? Ensure seats are adjustable. Ensure that there is sufficient space to enable workers to make effective use of the adjustable features of their chairs.

Do workers know how to adjust their chairs? Ensure that there is sufficient leg space for the worker to stretch and make changes in leg and foot posture. Confined leg space can constrain overall body posture. Workstation and tool design Work organisation and job design. Place equipment and materials within primary reach zones keeping repetitive reaching as close as possible to the body and always within mm of the front of the operator.

The condition has subsequently borne his name, De Quervain tenosynovitis. The two tendons concerned are the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles, which run side by side, have almost the same function: the movement of the thumb away from the hand in the plane of the hand—so called radial abduction as opposed to movement of the thumb away from the hand, out of the plane of the hand -palmar abduction.

The tendons run, as do all of the tendons passing the wrist, in synovial sheaths, which contain them and allow them to exercise their function whatever the position of the wrist. Evaluation of histological specimens shows a thickening and myxoid degeneration consistent with a chronic degenerative process. The pathology is identical in de Quervain seen in new mothers. De Quervain is potentially more common in women; the speculative rationale for this is that women have a greater styloid process angle of the radius.

Patients with De Quervain tenosynovitis note pain resulting from thumb and wrist motion, along with tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarely noted. The first dorsal compartment over the radial styloid becomes thickened and feels bone hard; the area becomes tender. Usually, the compartment's thickening so distorts the sparsely padded skin in this area that a visible fusiform mass is created.

Finkelstein's test is used to diagnose de Quervain syndrome in people who have wrist pain. To perform the test, the examining physician grasps the thumb and the hand is ulnar deviated sharply. If sharp pain occurs during Finkelstein test along the distal radius top of forearm, about an in inch below the wrist , De Quervain's syndrome is likely. Tenderness is absent over the muscle bellies proximal to the first dorsal compartment.

Tenderness and pain on axial loading are absent at the carpometacarpal CMC joint unless the patient has arthritis in that joint. Radiographs are negative and are not necessary for routine diagnosis. However, it should be emphasized that radiographs should be obtained to rule out other conditions that may be responsible for the patient's pain. Radiographs may be helpful in differentiating the patient who has de Quervain tenosynovitis from one who has osteoarthritis at the thumb carpometacarpal CMC joint or who is suffering from both conditions.

Rest, ice and NSAIDs may provide relief and reversal of this condition, especially if it is caught early enough. Splinting with a thumb-spica splint may be necessary to reduce the movement of the wrist and lower joints of the thumb. If these interventions do not work, then a cortisone shot into the irritated area may be the next course of action.

Physical therapy may also be used to retrain movements to avoid or change the method of those daily actions that caused the inflammation. The final step, if all other interventions fail, is surgery to release the tendons and provide more space for them to move. Following the surgery physical therapy may still be required to retrain the movements that caused the injury. Surgery may be recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment covering to make more room for the irritated tendons.

Although de Quervain tenosynovitis features a simple tendon entrapment and the treatment is quick and straightforward, complications can be profound and permanent. Careful attention to surgical technique at the initial release is paramount to avoiding complications. Superficial radial nerve injury is the most irksome complication.

Sharp injury, traction injury, or adhesions in the scar can cause neuritis in this high-contact area, greatly limiting hand and wrist function. This complication is best avoided through careful blunt dissection of the subcutaneous tissue and gentle traction. Persistent entrapment symptoms are possible if the tendon slips of the abductor pollicis longus are mistaken for the tendons of the abductor pollicis longus and the extensor pollicis brevis.

In such a case, the extensor pollicis brevis tendon may remain entrapped within the septated first dorsal compartment. Should repeat cortisone injections fail to relieve symptoms, careful surgical re-exploration may allow a previously overlooked tendon to be released. Subluxation of released tendons is possible. With wrist flexion and extension, the tendons of a widely released first dorsal compartment snap over the radial styloid. This complication is best avoided by carefully limiting the release to the thickest mid — 2 cm of the first dorsal compartment or by reconstructing a loose roof to the released sheath.

Reconstruction of the sheath with a slip of local tissue may relieve symptoms.

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