Relevant work assessments and tests created by the researchers will be listed in the essay so that therapists can have a better idea of what is needed to evaluate a worker and thus find a more specific treatment and return-to-work plan. Treatment and management strategies are focused on restoring function and self-management, and this will be discussed in the various self-explanatory ICF levels. Outcome measures have been listed in the last section of the essay to summarize the key points of management strategies, which are expected to help workers with knee OA.
Older workers are defined as those who are 55 years and above, and they are expected to increase by 3.5% to 4.5% per year from 2009 to 2020. This group of workers is said to have a longer work life and will be rejoining or staying on longer in the workforce. Foreign workers are known to take on the 3D jobs – dirty, dangerous, and difficult – and female workers are expected to take on a dual role as worker and family carer. These trends can only mean one thing: more physically and mentally demanding jobs in an environment that is fast-paced and rapidly changing to meet the demands of globalization.
Singapore has gained recognition in the field of occupational therapy, and the management of pain among the working population has been a well-discussed topic. According to Singapore’s Manpower 2020, there will be an increase in the number of older workers, female workers, and foreign workers in the Singapore workforce. This projects a changing landscape of work and worker demographics.
Understanding Knee Pain
The first step in managing knee pain in the workforce is by understanding the nature and the extent of the injury or the condition. This would involve knowing the history of the condition, symptoms (location and nature of pain), and knowing the triggering factors. An injury could have occurred in the past which is continuously troubling the individual, for example, an individual with a torn meniscus may not have had any initial treatment for it and the knee could be giving way recently. A sudden onset of pain could be an indication of an acute injury. Oftentimes, knee pain is only a symptom of an underlying condition. A patient with gout will have severe pain in the knees, but treating the gout will relieve the pain in the knees. Thus an individual with knee pain from gout must treat the condition at the same time as treating the knee. By understanding the cause of the knee pain, the patient will have a better idea of how to manage the pain in the long term.
The knee is one of the most common areas for injury, especially in the workplace. Knee pain can be the result of an acute injury, such as a torn ligament or a fracture. It can also be the result of chronic conditions. A common chronic condition that results in knee pain is arthritis. As we age, our bones begin to weaken and degenerate, and the constant load on the knees during our lifetime exacerbates this process. When the articular cartilage in the knee is worn away, the result is a form of arthritis known as osteoarthritis. Patellofemoral pain syndrome is a common knee condition in which there is an irritation between the patella and the groove on the femur. This condition results from the patella not tracking properly; it is often seen in adolescence and in older adults. All these conditions result in pain and discomfort to the patient. The location and severity of the pain may vary, but the function of the knee is often impaired by the damage to the structures in and around the knee.
Strategies for Managing Knee Pain at Work
It is emphasized that the less time spent doing painful activities, the more likely the individual is able to maintain both functional ability and work performance. Step one in minimizing time spent doing painful activities is to identify tasks that aggravate knee pain. This can be achieved by an analysis of the specific job or work environment. An understanding of the disease process will enable identification of how knee OA may affect job demands and potential restructuring of those demands. Task analysis can also be facilitated by focusing on symptom management and keeping a diary of pain occurrence and intensity, noting what tasks were being performed at the time. Ongoing observations and discussions with the employee may identify additional problem tasks as they arise.
The key to effectively managing knee pain at work is to modify the workstation and activities so that pain is minimized and functional ability is improved. This involves education on the nature of knee OA and possible effects on work, identification of aggravating factors, and development of strategies to avoid pain provocation, as well as ongoing reassessment and possible further modifications. A recent qualitative study of people with knee OA identified that in order to stay employed, individuals often had to change jobs or job tasks, effectively indicating that modifying current work demands was not sufficient to avoid pain and disability.
In strategizing for pain management at work, it is important to know about the disease process, identify aggravating activities, and develop self-management techniques for treating knee osteoarthritis. According to the American College of Rheumatology, osteoarthritis (OA) is the most common joint disorder, often resulting in pain and disability. Symptoms and progression of knee OA are exacerbated by certain activities and continued static postures. It is particularly complex to manage in people who are in their 40s and 50s and develop knee OA, as they are often still in the workforce and may have to continue working despite the pain.
Ergonomic Modifications
An alternate work method or job task change should be assessed to ensure that it does not simply overload the other knee or other joints. Potentially awkward postures which involve high load on the knee joint may also be eliminated with task modification. An example of this at the work site level is demonstrated by a recent project to improve ergonomics for electric cable jointers when taping the ends of high voltage cables. The modified work method demonstrated 42% less knee joint load and 51% less spinal load than the traditional method.
A change in work methods may require a change in the job task. For example, some builders or carpet layers may be able to take on a role as a supervisor, estimator, or trainer for a period of time to avoid retiring from the workforce, thereby reducing the load on the knee and delaying the need for joint replacement. An office worker whose knee pain precludes return to previous work as a teacher may need to consider retraining in an alternate profession. A job task change will involve vocational guidance and education regarding long-term implications of the knee injury and alternatives for the future.
Ergonomic modifications may be adapted at various levels, specifically work site, furniture, and equipment. At the work site level, changes are made to the physical features of the job. This is designed to reduce the amount of kneeling, squatting, stair climbing, and standing from a static position, which increases the amount of load transmitted through the knee joint. Specific to squatting and kneeling, modification may involve providing an alternate work method. For example, a mechanic may use a hoist to lift a motor to bench height rather than carrying it. A cleaner may use an extension handle on cleaning equipment or a reacher to reduce the amount of floor level work.
Exercise and Stretching
Exercise and stretching are an important part of knee pain management. Strong quadriceps can absorb some of the shock when the knee bears the weight of your body. Strong hamstrings can also help to reduce the load on the knee when you are moving around. A stretching program can help to maintain or even increase the range of motion in the knee. Motion is necessary for the nourishment of knee cartilage. Some people with knee arthritis avoid bending their knees in an attempt to minimize pain and prevent further damage to the joint. However, this can cause the quadriceps to weaken and atrophy. When the quadriceps become weak, it makes the knee less stable and more prone to pain and further injury. This can create a vicious cycle of knee pain and quadriceps atrophy. To prevent this, exercises can be done to strengthen the quadriceps without causing any further damage to the knee. A stationary bike is an excellent tool for this purpose. In addition to being easy on the knee, biking is a great way to improve cardiovascular conditioning. Other exercises that can strengthen the quadriceps include limited use of a leg extension machine, supported knee bends, and straight leg raises. These exercises should be done without pain and with high repetitions. If any exercise causes pain that persists for more than 2 hours after the exercise, it is probably doing more harm than good. It is common to see young, healthy individuals loading enormous amounts of weight on a leg press machine in the gym and banging their knees together. However, this is not an appropriate exercise for someone with knee pain. Instead, exercises that strengthen the adductor muscles are recommended. One simple and effective exercise for this purpose is a wall slide. To perform this exercise, stand with your back against the wall, slide down until both your hips and knees are bent at a 90-degree angle, then slide up and repeat. Hamstring exercises should be done in a way that reduces stress on the knee. Using a prone or seated knee curl machine is not appropriate for someone with knee pain. Instead, a low resistance and high repetition exercise such as a lying or seated hamstring curl is a better option. Straight leg raises and hip extension exercises can also work the hamstrings in a way that is easy on the knee. It is important not to overexert the muscles of the thigh even during painless exercises. These muscles can tighten up quickly and cause pain in the front of the knee. To prevent this, it is recommended to ice the knee for 10-15 minutes after working out. Stretching should be done after exercising and during breaks at work. It should be pain-free and each stretch should be held for at least 30 seconds. The goal is to maintain or increase the current range of motion in the knee. If there is a high amount of pain or swelling in the 2 hours following exercise, it is a sign that the exercise is either too much or it is being done too soon. It is important to be patient and take the knee step by step.
Pain Management Techniques
Joint protection involves the conservation of energy and the use of the body in such a way as to reduce stress on joints, and avoid positions that cause increased pain and risk of joint damage. Use larger or stronger joints to carry objects. This principle is useful for avoiding carrying objects in your hands by using a backpack, carrying two bags at once, or pushing an object with your shoulder or leg. Use the strongest and largest joints of the hand to hold objects. An example includes carrying a bag with the forearms instead of the hands. Implement levers or assistive devices to reduce the amount of force and stress on a joint. An example of this principle is using a long-handled shoehorn to put on shoes or using a trolley to carry heavy objects. Try to avoid staying in one position for too long. Change positions frequently and shift the weight from one joint to another. This principle is seen in the frequent changing of crossed legs. This technique is not always appropriate and there are some disadvantages of avoidance of certain hand positions. Always use the most comfortable and less stressful way to do an activity.
Pacing activities involves altering the way you do a task to expend less energy and decrease stress on painful joints. Determine the most important components of an activity and allocate the most time to these. Avoid tasks that really are not necessary. Save your energy for enjoyable activities. Alter the steps of an activity to make it less tiring and stressful on your joints. For example, spread the task over several days or weeks. Change timing, frequency, duration or intensity of an activity. Measure your current ability level for a specific activity and then increase or decrease the time spent at this activity by 25%. Although pacing activities is a useful tool, there is a fine line between pacing and avoiding activity. Some people mistakenly stop doing an activity altogether and this can lead to increased pain and stiffness and weakened muscles.
Learning a variety of pain management techniques can be useful in the workplace. Specific techniques have different effects on pain. Not every technique is appropriate for each individual. Techniques include: pacing activities, using joint protection, applying physical agents, taking oral medications, and using assistive devices.
In conclusion, work-related knee pain is usually an overuse syndrome which is mechanical in nature. Therefore, relieving and preventing further exacerbation of the pain would require mechanical solutions. Though pain relief from modalities and medications can be achieved, the true resolution lies in simplifying task performance and reducing patellofemoral joint stress. This can be achieved with education on proper posturing, ergonomics, stretches and exercises. By applying these principles, patients can experience significant results in a relatively short period of time. Postural correction and activity modification has to be incorporated into the patient’s work and daily life. Failure to do so will result in the recurrence of PFPS. In severe cases of patients working in physically demanding jobs, a change in job and an ergonomically correct work hardening program may be the best solution. A step towards any of these mechanical solutions will be a step towards complete resolution of patellofemoral pain. Occupational therapists play an important role in identifying the course of the disease, which occurs when the mechanical provocation exceeds the biological healing response. With their knowledge of ergonomics and analysis of the work tasks, they can help improve the condition of their client or even prevent further degeneration of the knee.
