Job History
A lifetime job history, including employer names, dates of employment, job titles and major job duties, serves as the framework for assessing occupational exposures and the risk of illness. For job duties that appear relevant to the patient's current symptoms, additional details should be elucidated. Ask the patient to describe what he/she does in a typical workday including non-routine tasks and any recent changes. Additionly, query second jobs, hobbies, household exposures, and military service as these represent their own unique exposures.
Exposures
Occupational exposures come in many forms: chemical, biological, physical and psychosocial. Physical hazards are most likely to cause WMSD. All major exposures should be listed for each job in the job history. Examples of physical exposures include,
- Excessive noise
- Temperature extremes
- Recent change in duties
- Repetitive movements
- Hand-arm vibration
- Non-neutral, extreme, or static postures
- Forceful movements
- Fast work pace
- Restricted tasks or low task variation
A worker in a meat processing plant uses a clipping machine to separate individual sausage links. Note that although this task may not be especially hand intensive, it is made so by the cold temperatures (less than 10 degrees Celsius)
Image Source: Victoria Squissato
Brick layers often have to carry heavy objects with poor grips. Here the worker is carrying a cinder block. Note that the block is held away from the body, placing strain on the lumbar spine and trunk extensors. Also note the poor wrist posture (extreme ulnar deviation and wrist extension) that is adopted to compensate for poor grip (unable to oppose finger and thumb for maximum grip with least amount of strain).
Image Source: Victoria Squissato
Character
All aspects of the patient’s workplace should be investigated as this can be useful in developing an understanding of the ergonomic stressors faced by the patient. The physician should obtain a description and/or demonstration of the movements performed by the patient during his/her work duties, including the patient's posture, particularly the position of both upper extremities. A description of the workstation should be obtained, for example the adjustability of an office chair, anti-fatigue matting, the most frequently used tools, etc. In regards to tools ask about the movements required to manipulate the tool, how well the tool fits the patient’s hand, a subjective estimate of the force required for operation, and if there is any vibration. Furthermore, a description of the work pace or the presence of piece rate work or productivity requirements is necessary because treatment may require slowing of work pace or initiation of rest breaks and the presence of such factors may affect treatment plans.
A worker uses an impact screwdriver to attach flashing to an exterior faςade. Note the non-neutral posture: extreme truncal flexion (lateral and forward), winging arm to operate tool, and the extreme radial deviation of the hand holding the flashing.
Image Source: Victoria Squissato
Duration and Frequency
The physician needs to know how long and how often have the worker has been exposed to potential hazards in order to assess the total exopsure level. The history should include the number of hours per day spent performing relevant activities. Determining exposure level allows for the evaluation of latency issues and whether or not the exposure of concern represents an acute or chronic event. In addition, other factors to consider are the rate at which movements are performed as well as the frequency and duration of rest breaks.
Temporality
Determine whether symptoms are worse at work or home. The temporal relationship between exposure and a patient's symptoms helps in the evaluation of the relevance of potential exposures. Do the symptoms occur or are exacerbated at work and improve when not at work? For example, a patient with CTS is more likely to have occupationally related disease if her symptoms resolve when she is away from work. Furthermore, it may be possible to link symptoms to a specific duty, tool, or other occupational condition. However, it is important to recognize that as many job-related illnesses progress, symptoms become continuous and the clear cause and effect relationship between occupational exposures and symptoms may be lost. The clinician should also consider any recent changes in duties, workstation design or work pace in relation to symptom onset.
Workplace Incidence
When asked, patients with occupational illness commonly report others who are similarly affected. The probability that work is contributing to an illness is strengthened if the patient's co-workers who have similar duties are also experiencing similar symptoms.