Work-related conditions

Work-related conditions are injuries or illnesses caused, aggravated, or exacerbated by workplace events or hazards. Conditions include musculoskeletal injuries, respiratory diseases, infectious diseases, poisoning, hearing loss, and burnout syndrome. High-risk occupations include manufacturing, cleaning, construction, animal handling, agriculture, and health care. Patients with new or worsening health conditions should be screened for possible occupational causes. If screening is positive, a detailed occupational history is required. Management involves removing patients at risk of severe injury from their work environment, modifying activities for those with less severe injuries, initiating specific treatment, and education on PPE use. Consultation with occupational health specialists may be necessary. Always follow local protocols for reporting work-related injuries or illnesses.

For skin diseases contracted from exposure in the workplace, see “Occupational skin diseases.”

General principles ^[1][2][3]

There are few clinical practice guidelines for the initial management of work-related injuries; recommendations are based on common sense and limited data.

• Screen all patients for an occupational source of injury or illness.
• Perform a focused work-related assessment if a screening question is positive.
• Initiate initial treatment of work-related conditions.
• Consider occupational medicine consultation for:
  • Obtaining a more detailed history (e.g., review of material safety data sheets)
  • Further diagnostic testing
  • Determining work restrictions and fitness for return to work

Screening for occupational injury ^[2][3]

Screening questions quickly indicate the possibility that an injury or illness has work-related causes.

• What type of work do you do?
• Are you exposed to chemicals, animals, radiation, fumes, and/or dust at work?
• Are your symptoms worse at work and/or better at home?
• Do you think your health condition is related to work?

Focused history for work-related conditions ^[2][3]

• Job title and/or description of activities
  • Type of industry, e.g., agriculture, construction, chemical, military, health care
  • Specific job responsibilities, e.g., use of cleaning solvents
• Length of employment and any recent changes in duties
• Accidents or unusual events at work
• Exposure to dust, animals, chemicals, metals, radiation, extreme heat or cold, and/or mechanical factors (e.g., lifting, vibration, repetitive motion)
• Other employees with similar symptoms
• Protective equipment used
• Exposures outside of the workplace that may mimic or exacerbate work-related conditions (e.g., tobacco use, prior military service, pets)

Red flags for occupational injury ^[1][2][4]

• High-risk industries (e.g., agriculture, mining, manufacturing, petrochemical)
• Multiple workers with similar symptoms in the same location
• Symptom onset after a job change
• Worsening of symptoms during the workday or workweek
• Atypical symptoms for the individual
• No identifiable cause for atypical symptoms

Initial treatment of work-related conditions ^[5]

• Remove individuals from life-threatening exposures (e.g., solvents, heavy metals).
• Initiate symptom-specific or disease-specific management.
• Modify patient activity as needed.
• Provide activity recommendations for a safe return, including:
  • Description of current physical capabilities
  • Restrictions to prevent exacerbation
  • Use of assistance devices (e.g., splints)
  • Duration of restrictions
• Counsel on prevention and expected recovery timeline.
• Consult occupational medicine specialist for complex or chronic cases.

Early return to work with restrictions improves outcomes compared to prolonged time off work, e.g., reduced morbidity and minimized lost wages and productivity.

Documentation and common evaluations

Most patients with suspected work-related conditions do not require hospitalization but many require expert consultation for specific evaluations. ^[6]

• Functional capacity evaluation ^[5]
  • Assesses a patient's physical ability to perform essential job-related activities
  • Typically performed by a physical therapist or occupational therapist using validated tools
• Fitness for duty evaluation ^[1]
  • Medical evaluation performed at the request of an employer
  • Determines whether an individual is physically, mentally, and emotionally competent for a specific job
  • May be a legal requirement for certain occupations, e.g., pilot, truck driver
• Independent medical evaluation ^[7]
  • An examination by a physician other than the patient's primary provider to evaluate the cause of a disability
  • Requested by disability insurers, employers, and/or lawyers if a work-related injury is severe or may lead to litigation

Etiology ^[8]

• Extremely forceful motions
• Repetitive tasks
• Poor ergonomics (e.g., sustained and/or awkward positions)
• Vibration exposure
• Contact stress from localized pressure on a body part (e.g., resting forearms on a desk, kneeling on hard surfaces)
• Cold working environment

Overview of occupational musculoskeletal injuries

Neck and shoulder injuries ^[9]

• Tension neck syndrome ^[8][10][11]
  • Nonradiating pain and/or discomfort in the neck and shoulder muscles
  • Risk factors
    • Prolonged sitting
    • Holding the neck in a forward and downward position (e.g., working on a computer or mobile device)
    • Poor ergonomics (e.g., inappropriately placed keyboard)
    • Sedentary work
  • Prevention
    • Stretching and strengthening exercises
    • Improved ergonomics (e.g., more functional keyboard placement, forearm support)
    • Breaks from positions that aggravate the injury
  • Differential diagnoses: cervical osteoarthritis, cervical nerve root compression
• Shoulder injuries most commonly occur with heavy overhead lifting or sports-related repetitive overhead movements, e.g., swimming and baseball.
  • Subacromial impingement syndrome
  • Rotator cuff tendinopathy
  • Rotator cuff tear
  • Biceps tendon tear
  • Biceps tendinopathy
  • Thoracic outlet syndrome

Elbow injuries ^[12]

Elbow injuries are most commonly caused by low-demand repetitive wrist movements and/or forearm supination-pronation.

• Lateral epicondylitis
  • Mechanism: wrist extension and/or repetitive forearm supination-pronation with the elbow extended
  • Common inciting activities: office work, sewing, gardening, racket sports
• Medial epicondylitis
  • Mechanism: repeated wrist flexion and forearm pronation
  • Common inciting activities: golf, baseball, woodwork

Hand and wrist injuries

• Carpal tunnel syndrome ^[13]
  • Mechanisms
    • Prolonged exposure to hand-transmitted vibration (e.g., construction)
    • Awkward and/or repetitive wrist movements (e.g., data entry)
    • Forceful handgrip and/or pinching motion (e.g., auto repair, agricultural work)
  • See “Carpal tunnel syndrome” for details.
• Hand-arm vibration syndrome ^[14]
  • Mechanism: prolonged exposure to vibration (e.g., vibrating power tools)
  • Clinical features: paresthesias, sensory loss, decreased grip strength, and/or peripheral vasospasm
  • Complications: osteoporosis, joint damage, muscle necrosis
  • Management
    • Early identification and exposure avoidance
    • Alpha blockers, calcium channel blockers, and prostaglandins are occasionally used, but their efficacy for this condition is uncertain.
• Hypothenar hammer syndrome ^[15][16]
  • A rare condition caused by injury to the ulnar artery as it exits the Guyon canal
  • Mechanism: repetitive trauma to hypothenar eminence (e.g., from vibrating tools, mountain biking, volleyball, baseball)
  • Clinical features: pain over the hypothenar eminence, ulnar nerve paresthesia, cold sensitivity, pallor of fingers
  • Treatment: thrombolysis, embolectomy, and/or revascularization

Back injuries

• Degenerative disc disease
  • Displacement of disc fragments causing nerve or spinal cord impingement
  • Mechanisms: prolonged sitting (e.g., office work, long-haul driving), heavy lifting, and/or repetitive bending and twisting
• Clay-shoveler fracture ^[17]
  • Avulsion fracture of a spinous process in the lower cervical or upper thoracic spine
  • Mechanism: forceful flexion or rotation of the cervical spine

Knee injuries

Knee injuries are common in occupations requiring prolonged kneeling, repetitive stair climbing, and/or use of ladders.

• Meniscus tear
• Anterior cruciate ligament injury
• Posterior cruciate ligament injury
• Osteoarthritis of the knee

Additional work-related injuries

• Tendinitis and tenosynovitis
• Osteoarthritis
• Inguinal hernia

Clinical evaluation

• Obtain a focused history for work-related conditions.
• Perform a focused musculoskeletal examination.

Diagnostics

Diagnostic testing is condition-specific.

• X-rays
• CT or MRI
• Electromyography

Management

• Begin initial treatment of work-related conditions.
• Initiate acute pain management.
• Use the POLICE principle for acute musculoskeletal injury.
• Provide injury-specific treatment.

Before prescribing opiates for chronic pain, assess side effects, work status, driving ability, and whether the patient operates machinery. ^[18][19]

Work-related hearing conditions can be caused by hazardous noise (≥ 85 dB) and/or ototoxic chemicals (e.g., solvents, metals, asphyxiants). In the US, approximately 22 million workers are exposed to hazardous noise annually, and about 10 million workers are exposed to ototoxic agents (e.g., from the manufacture of paint, pharmaceuticals, rubber, footwear). Occupational noise is a major cause of hearing loss in the US (approximately 24% of all cases). ^[20]

Noise-induced hearing loss (NIHL)

• Definition: hearing loss due to continuous exposure to sounds > 85 dB (e.g., during construction work, mining, welding) or a single exposure to sounds > 120 dB (e.g., gunshots, jet engines, fireworks)
• Pathophysiology
  • Repeated or constant exposure to noise > 85 dB → cumulative microtrauma and irreversible damage to the stereocilia of hair cells of the organ of Corti → sensorineural hearing loss
  • Sudden noise > 120 dB → tympanic membrane rupture → conductive hearing loss
• Clinical features
  • Slowly progressive hearing loss, beginning with loss of high-frequency hearing
  • Difficulty hearing in noisy, crowded environments
  • Difficulty hearing high-pitched voices (e.g., children's) occurs as the condition progresses.
• Treatment
  • There is no definitive treatment.
  • Hearing aids or cochlear implants
• Prevention: hearing protection (i.e., earplugs or earmuffs)

Tinnitus

See “Tinnitus” for more information.

Lung diseases are considered work-related if they are caused, exacerbated, or permanently worsened by substances in the workplace. They may be obstructive, restrictive, and/or neoplastic. ^[21]

Overview of occupational respiratory diseases ^[22][23][24]

• Acute
  • Inhalational injury
  • Hypersensitivity pneumonitis
  • Pneumonia
  • Inhalational anthrax
  • Irritant and asphyxiant exposure
  • Radiation pneumonitis
• Chronic or acute-on-chronic
  • COPD and acute exacerbation of COPD
  • Occupational asthma
  • Allergic asthma
  • Pneumoconioses (e.g., coal workers' pneumoconiosis, silicosis, berylliosis)
  • Asbestos-related diseases (e.g., asbestosis, mesothelioma)
  • Lung cancer
  • Granulomatosis disease (e.g., tuberculosis)
  • Bronchiolitis obliterans: a chronic disease of the small airways, usually caused by repeated cycles of inflammation and scarring
    • Chronic scarring causes obstructive lung disease.
    • Exposure to toxic fumes (e.g., nitrogen oxides) is the most common workplace-related cause; other causes include severe adenovirus pneumonia.

Clinical evaluation ^[22][23][24]

A thorough occupational history is crucial for identifying work-related respiratory disease, as diagnostic tests and physical examinations often cannot distinguish between occupational and nonoccupational causes.

• Obtain a focused history for work-related conditions.
• Perform a detailed inhalational exposure history (often specific to the type of occupation).
  • Irritants and asphyxiants: industrial workers, cleaning workers, painters, agricultural workers, military personnel
  • Allergens: e.g., pollen (agricultural workers), animal dander (animal handlers), grain dust (bakers), exposure to humidifiers
  • Microbes: e.g., agricultural pathogens , mold, spores
  • Minerals
    • Silica: miners, workers who mill or grind countertops, boiler workers
    • Beryllium: individuals working with electronics, ceramics, metal alloys; aerospace workers
    • Asbestos: auto mechanics; miners; and workers installing insulation, roofing, or pipes
    • Lead: painters, construction workers (especially if working on older structures), battery manufacturers
• Inquire about respiratory PPE usage.
• Document past medical history and family history of respiratory conditions.

The latency between exposure and symptom appearance is highly variable; it can be as long as 25 years for some interstitial lung diseases. ^[23]

Diagnostics ^[23][25]

• CXR
• PFTs: Consider testing before and after the work shift in patients with obstructive lung disease.
• CT chest: especially for interstitial lung disease, granulomatosis
• Disease-specific tests: e.g., allergy testing, serology, bronchoalveolar lavage

Management ^[24][25]

• Begin initial treatment of work-related conditions.
• Initiate treatment for dyspnea in patients with respiratory distress.
• Obtain initial diagnostic testing.
• Begin disease-specific treatment (e.g., antibiotics, treatment of acute asthma exacerbation).
• Include exposure reduction and PPE recommendations in activity modifications.
• Refer for expert consultation (e.g., pulmonology, infectious diseases, oncology).
• Counsel the patient on prevention (e.g., adherence to respiratory PPE).

Work-related infectious diseases are caused or exacerbated by exposure to biological agents, e.g., bacteria, viruses, parasites, or fungi. ^[26][27]

Etiology ^[26][28]

• Disease factors
  • High transmission risk (e.g., influenza)
  • Novel pathogens (e.g., ebola virus)
• Workplace factors
  • Environmental (e.g., exposure to fungus, ticks)
  • Engineering limitations (e.g., poor air quality)
• Individual factors
  • Immunocompromised status
  • Socioeconomic status (e.g., limited access to vaccinations)

High-risk occupations ^[26][28]

• Health care workers
• Military personnel
• Livestock and dairy workers, veterinarians
• Slaughterhouse workers
• Agricultural, garden, and forestry workers

Overview of occupational infectious diseases

Management ^[29]

• Begin initial treatment of work-related conditions.
• Initiate measures to prevent the spread of disease (e.g., isolation precautions, droplet precautions).
• Start disease-specific treatment.
• Follow local protocols for reportable diseases.
• Consider infectious diseases consult.
• Counsel the patient on prevention (e.g., adherence to respiratory PPE).

Work-related exposure to hazardous chemicals leads to thousands of deaths and millions of injuries annually. ^[30]

Common exposures ^[4][30]

• Cleaning and antimicrobial solutions
• Solvents
• Gases (e.g., engine and diesel engine emissions, asphyxiants, carbon monoxide)
• Metals (e.g., lead, cadmium, mercury)
• Dusts (e.g., wood, nanoparticles)
• Pesticides
• Epoxy resins

At-risk occupations ^[31]

• Construction
• Manual workers in professional, scientific, and technical services (e.g., research, engineering)
• Real estate, rental, leasing
• Manufacturing
• Manual workers in wholesale trade (e.g., furniture fabrication, warehouse workers)
• Military personnel (e.g., burn pit exposure)
• Firefighters (e.g., exposure to burning plastics)

Management ^[4]

• Use the ABCDE approach in poisoning.
• Perform a focused history for work-related conditions.
• Obtain relevant material safety data sheets.
• Order exposure-specific diagnostics.
• Begin initial treatment of work-related conditions.
• Start exposure-specific treatment as quickly as possible; see:
  • “Overview of poisoning”
  • “Detergent poisoning” and “Caustic agents”
  • “Cyanides” and “Carbon monoxide”
  • “Organophosphates”
  • “Metal toxicity”
  • “Irritants and asphyxiants”
  • “Gulf War syndrome”
• Consider expert consultation.
• Notify the employer of potential exposure.
• Follow local protocols for reporting to appropriate regulatory agencies, e.g.:
  • Local health department
  • Occupational Safety and Health Administration

Don PPE when caring for patients with suspected hazardous chemical exposure.

Definition

Burnout is a psychological syndrome caused by chronic work-related stress and characterized by three dimensions. ^[32][33][34]

• Emotional exhaustion
• Cynicism, negativism, depersonalization
• Reduced feelings of personal achievement, job satisfaction, and/or productivity

Epidemiology

Work-related conditions are more common in female individuals than males. ^[35]

• Less decision-making authority
• More work-family conflicts

Etiology ^[33][34]

• Organizational factors
  • Mismatched work demands and resources
  • Lack of worker autonomy and influence
  • Lack of community or social support
  • Perceived injustice (e.g., unfair treatment, moral conflict)
• Individual factors
  • Inadequate coping mechanisms
  • External locus of control

Clinical features ^[34]

• Mild
  • Physical symptoms (e.g., headache, appetite change)
  • Reduced productivity
• Moderate
  • Concentration deficits, progressive loss of motivation
  • Exhaustion, fatigue, insomnia
  • Apathy, frustration, personal negativity
• Severe
  • Absenteeism, desire to leave the occupation
  • Alcohol, psychotropic drug misuse
• Extreme
  • Depression, suicidal ideation
  • Extreme behaviors (e.g., isolation, aggression)

Diagnosis

• Mental health screening for adults
• Standardized tools for burnout (e.g., Maslach burnout inventory manual) ^[36]

Differential diagnoses

• Major depressive disorder
• Anxiety disorder
• Trauma- and stressor-related disorders

Complications

• Worker: impaired physical and mental well-being, substance misuse, depression, loss of employment
• Employer: reduced productivity and quality of work, increased employee turnover and absenteeism

Management ^[34]

• Organization-focused strategies
  • Reduction of work stressors and increase in organizational resources (e.g., reduced workload)
  • Often more effective than employee-focused strategies ^[37]
• Employee-focused strategies: interventions that enhance employees' personal resources
  • Organization-initiated interventions: mindfulness, stress management, and/or communication training
  • Individual-initiated interventions: exercise, cognitive therapy, lifestyle changes