Accommodation and Compliance Series:
Employees with Cumulative Trauma Disorders
JAN’s Accommodation and Compliance Series is designed to help employers determine effective accommodations and comply with Title I of the Americans with Disabilities Act (ADA). Each publication in the series addresses a specific medical condition and provides information about the condition, ADA information, accommodation ideas, and resources for additional information.
The Accommodation and Compliance Series is a starting point in the accommodation process and may not address every situation. Accommodations should be made on a case by case basis, considering each employee’s individual limitations and accommodation needs. Employers are encouraged to contact JAN to discuss specific situations in more detail.
For information on assistive technology and other accommodation ideas, visit JAN's Searchable Online Accommodation Resource (SOAR) at http://AskJAN.org/soar.
How prevalent are CTDs?
CTDs account for more than 50 percent of all occupational illnesses in the United States (Bureau of Labor Statistics, 2011). Among major disabling injuries and illnesses, carpal tunnel syndrome, a type of CTD, accounted for the greatest number of days away from work, surpassing fractures and amputations (Bureau of Labor Statistics, 2011). In addition, injuries caused by repetitive motion, such as grasping tools, scanning groceries, and typing, resulted in the longest absences from work (Bureau of Labor Statistics, 2004).
What are CTDs?
CTDs are disorders that are caused, precipitated, or aggravated by repeated exertions or movements of the body (National Institute for Occupational Safety and Health, 1997b). Continuous use or pressure over an extended period of time results in wear and tear on tendons, muscles, and sensitive nerve tissue. The most common parts of the body affected are the wrists, hands, shoulders, knees, eyes, back, and neck. CTDs are groups of disorders with similar characteristics and may be referred to as: repetitive trauma disorders, repetitive strain injuries, overuse syndromes, regional musculoskeletal disorders, and work-related disorders (National Institute for Occupational Safety and Health, 1997b). Examples (from About.com, 2011) of CTDs include:
- Bursitis is a condition where the bursal sac becomes irritated and painful
- Carpal Tunnel Syndrome (CTS):
- CTS is a condition that results from pinching of one of the nerves in the wrist and hand. This nerve, the median nerve, is compressed as it passes through the wrist, and because of this compression, the nerve does not function properly.
- Cubital Tunnel Syndrome:
- Cubital tunnel syndrome occurs when the ulnar nerve, one of the primary nerves supplying movement directions to the forearm muscles and sensory information from the hand, becomes compressed near the elbow.
- DeQuervain’s Disease:
- With DeQuervain’s Disease, pain comes from the tendons becoming inflamed on the side of the wrist and forearm just above the thumb.
- Lateral epicondylitis, sometimes referred to as tennis elbow, can result from excessive activities such as painting with a brush or roller, running a chain saw, and using many types of hand tools continuously. Medial epicondylitis, sometimes referred to as golfer's elbow, can result from activities such as chopping wood with an ax, running a chain saw, and using many types of hand tools continuously.
- Guyon’s Canal Syndrome:
- Guyon's canal syndrome occurs when there is compression of the ulnar nerve as it passes across the palm of the hand. Also called handlebar palsy, Guyons canal syndrome is similar to carpal tunnel syndrome in that it is caused by a pinched nerve.
- Impingement Syndrome:
- Also known as rotator cuff syndrome, impingement syndrome is a result of the lack of room between the acromion (upper part of shoulder blade bone) and the rotator cuff. Usually the tendons slide easily underneath the acromion as the arm is raised; however, each time the arm is raised, there is a bit of rubbing on the tendons and the bursa between the tendons and the acromion. This rubbing, or pinching action, is called impingement. Continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the arm can result in impingement syndrome.
- Radial Tunnel Syndrome:
- Radial tunnel syndrome, also called resistant tennis elbow, is an entrapment or compression of a nerve within the forearm. The symptoms of radial tunnel syndrome closely resemble tennis elbow, although the cause is different. Radial tunnel syndrome is caused when the nerve that operates several muscles around the wrist and hand (the posterior interosseous nerve) is compressed or pinched, causing weakness of the muscles supplied by the nerve and pain over the elbow where the compression takes place.
- Tendonitis is a common condition that can cause significant pain. Tendonitis occurs when there is inflammation of tendons at the point where a muscle attaches to the bone.
- Inflammation of the tendon sheaths that may follow trauma, overuse, or inflammatory conditions.
- Trigger Finger:
- Trigger finger is a common condition caused by inflammation of the flexor tendons in the hand.
- Thoracic Outlet Syndrome:
- Thoracic outlet syndrome is a condition characterized by pain in the neck, shoulders, and fingers and weakening of the grip.
What are the symptoms of CTDs?
The symptoms of CTDs are aching, tenderness, swelling, pain, crackling, tingling, numbness, weakness, loss of joint movement, and decreased coordination in the affected area (National Institute for Occupational Safety and Health, 1997a). The most common body parts affected by CTDs are the fingers, hands, wrists, elbows, arms, shoulders, back, and neck; however, other areas can be affected. Symptoms may appear in any order and at any stage in the development of an injury. A serious injury can develop only weeks after symptoms appear or it may take years.
What causes CTDs?
There could be one or several causes of CTDs. The repetition of small, rapid movements; working in a static and/or awkward posture for long periods of time; insufficient recovery time (too few rest breaks); improper workstation setup; forceful movements; excessive grasping; and poor work techniques may contribute to injury. Some conditions associated with CTDs are: broken or dislocated bones, arthritis, thyroid gland imbalance, diabetes, hormonal changes from menopause, and pregnancy (National Institute for Occupational Safety and Health, 1997b).
How are CTDs treated?
Treatments for CTDs vary; exercising alleviates some individuals’ symptoms, while other individuals need surgery. The first recommendation is usually to rest the affected area. Vitamin B6 therapy, anti-inflammatory medication, ibuprofen, steroid injections, contrast baths (hot and cold), surgery, and work habit alteration are also treatment options (Carpal tunnel . . . , 1998).
Is a CTD a disability under the ADA?
The ADA does not contain a list of medical conditions that constitute disabilities. Instead, the ADA has a general definition of disability that each person must meet (EEOC Regulations . . ., 2011). Therefore, some people with CTDs will have a disability under the ADA and some will not.
A person has a disability if he/she has a physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or is regarded as having an impairment (EEOC Regulations . . . , 2011). For more information about how to determine whether a person has a disability under the ADA, visit http://AskJAN.org/corner/vol05iss04.htm.
When requesting an accommodation, do employees with CTDs have to tell their employers that they have a CTD?
Under the ADA, when an employee requests an accommodation, an employer can require sufficient medical documentation to determine whether the employee has a disability and needs the requested accommodation. According to the Equal Employment Opportunity Commission (EEOC), sufficient medical documentation can include the name of the medical condition. The employee may want to begin by giving a more general description of the condition, such as saying “I have a cumulative trauma disorder,” and see if that suffices. However, such a limited description does not tell the employer that the individual has an impairment that substantially limits a major life activity because it is vague.
To increase the chance that the employer will settle for the use of a vague term, the employee may want to provide a letter from his/her doctor that confirms the existence of a "cumulative trauma disorder,” but then goes on to give concrete information about how the condition substantially limits a major life activity. The inclusion of concrete information may satisfy the employer. However, if the employer insists on knowing the diagnosis and the individual refuses to divulge it, the employer probably has a valid reason to refuse to provide the requested accommodation.
Note: People with CTDs may develop some of the limitations discussed below, but seldom develop all of them. Also, the degree of limitation will vary among individuals. Be aware that not all people with CTDs will need accommodations to perform their jobs and many others may only need a few accommodations. The following is only a sample of the possibilities available. Numerous other accommodation solutions may exist.
Questions to Consider:
- What limitations is the employee with the CTD experiencing?
- How do these limitations affect the employee and the employee’s job performance?
- What specific job tasks are problematic as a result of these limitations?
- What accommodations are available to reduce or eliminate these problems? Are all possible resources being used to determine possible accommodations?
- Has the employee with the CTD been consulted regarding possible accommodations?
- Once accommodations are in place, would it be useful to meet with the employee with the CTD to evaluate the effectiveness of the accommodations and to determine whether additional accommodations are needed?
- Do supervisory personnel and employees need training regarding CTDs?
- Reduce or eliminate physical exertion and workplace stress
- Schedule periodic rest breaks away from the workstation
- Allow a flexible work schedule and flexible use of leave time
- Allow work from home
- Fine Motor Impairment:
- Implement ergonomic workstation design
- Provide alternative computer and telephone access
- Provide arm supports
- Provide writing and grip aids
- Provide a page turner and a book holder
- Provide a note taker
- Provide ergonomic tools and other adaptations
- Gross Motor Impairment:
- Modify the work-site to make it accessible
- Provide parking close to the work-site
- Provide an accessible entrance
- Install automatic door openers
- Modify the workstation to make it accessible
- Make sure materials and equipment are within reach range
- Move workstation close to other work areas, office equipment, and break rooms
- Provide carts and lifting devices
- Temperature Sensitivity:
- Modify work-site temperature
- Modify dress code
- Use fan/air-conditioner or heater at the workstation
- Allow flexible scheduling and flexible use of leave time
- Allow work from home during extremely hot or cold weather
- Maintain the ventilation system
- Redirect air conditioning and heating vents
- Provide an office with separate temperature control
- Administrative Considerations:
- Provide training on ergonomic principles, including proper lifting techniques, adequate maintenance, awkward postures, and correct use of equipment.
Situations and Solutions:
A journalist with bilateral carpal tunnel syndrome was limited to two hours of typing and writing per day. His employer purchased a digital tape recorder, writing aids, and an alternative keyboard; installed speech recognition software; allowed him to take breaks throughout the day; and provided him with office equipment to rearrange his workstation.
An assembly line worker with bursitis in his knee was limited in his ability to stand. His employer gave him a stand/lean stool, provided him with anti-fatigue matting, and purchased vibration dampening shoe inserts.
A sales clerk with cubital tunnel syndrome lost the ability to move her right hand. The individual needed to use the computer to create reports. Her employer purchased a left-handed keyboard, foot mouse, forearm supports, an articulating keyboard and mouse tray, and an ergonomic chair.
A construction worker with DeQuervain’s disease had severe inflammation of the wrist and forearm after prolonged use of handtools. The employer provided him with lightweight and pneumatic tools; anti-vibration tool wraps and gloves; and tool balancers/positioners for stationary work.
A switch board operator with myofacial pain syndrome (TMJ) was having difficulty using the phone and taking messages. The employer gave her a headset, speech recognition software, an adjustable telephone holder, writing aids, and an angled writing surface.
A truck driver with thoracic outlet syndrome was having difficulty driving for long periods of time and unloading bags at his delivery destination. The employer installed a small crane in the back of the trailer and provided him with a lightweight aluminum hand truck to help him unload materials. The employer also provided the employee a steering wheel spinner knob to eliminate prolonged grasping of the steering wheel and an anti-vibration seat to cut down on fatigue.
A clerical worker who stamped paperwork for several hours a day was limited in pinching and gripping due to carpal tunnel syndrome. The individual was accommodated with adapted stamp handles. Anti-vibration wrap was placed around the stamp handles. In addition, tennis balls were cut and placed over the wrapped handles to eliminate fine motor pinching and gripping.
A maintenance worker with rotator cuff syndrome was having difficulty reaching cleaning areas and moving cleaning supplies. The employer replaced his tools with long-handled, pneumatic, and lightweight tools. The employer also provided him an electric cart.
There are numerous products that can be used to accommodate people with limitations. JAN's Searchable Online Accommodation Resource (SOAR) at http://AskJAN.org/soar is designed to let users explore various accommodation options. Many product vendor lists are accessible through this system; however, upon request JAN provides these lists and many more that are not available on the Web site. Contact JAN directly if you have specific accommodation situations, are looking for products, need vendor information, or are seeking a referral.
About.com. (2011). Dictionary for common terms [Electronic database]. Retrieved December 28, 2011, from http://about.com
Bureau of Labor Statistics. (2011). Lost-worktime injuries and illnesses: characteristics and resulting time away from work, 2010. Retrieved December 28, 2011, from http://www.bls.gov/news.release/osh2.nr0.htm
Bureau of Labor Statistics. (2004). Repetitive motion results in longest work absences. Retrieved December 28, 2011, from http://www.bls.gov/opub/ted/2004/mar/wk5/art02.htm
Carpal tunnel syndrome. (2011). Typing injury FAQ and the RSI network newsletter. Retrieved December 28, 2011, from http://www.tifaq.org/
EEOC Regulations To Implement the Equal Employment Provisions of the Americans With Disabilities Act, as Amended, 29 C.F.R. § 1630 (2011).
National Institute for Occupational Safety and Health. (1997a). Musculoskeletal disorders (MSDs) and workplace factors. Retrieved December 28, 2011, from http://www.cdc.gov/niosh/docs/97-141/
National Institute for Occupational Safety and Health. (1997b). Work-related musculoskeletal disorders. Retrieved December 28, 2011, from http://www.cdc.gov/niosh/topics/ergonomics/