A Medical and Legal Review of Repetitive Trauma in Workers' Compensation Cl

When Do Repetitive Activities = Repetitive Trauma? A Medical and Legal Review of Repetitive Trauma in Workers’ Compensation Claims

October 5, 2018

8:30 a.m. – 5:00 p.m.

St. Mary’s Hospital

Waterbury, CT

CT Bar Institute, Inc.

CT: 6.0 CLE Credits (General) NY: 6.5 CLE Credits (AOP)

No representation or warranty is made as to the accuracy of these materials. Readers should check primary sources where appropriate and use the traditional legal research techniques to make sure that the information has not been affected or changed by recent developments.Page 1 of 430 Lawyers’ Principles of Professionalism

As a lawyer I must strive to make our system of justice work fairly and Where consistent with my client's interests, I will communicate with efficiently. In order to carry out that responsibility, not only will I comply opposing counsel in an effort to avoid litigation and to resolve litigation with the letter and spirit of the disciplinary standards applicable to all that has actually commenced; lawyers, but I will also conduct myself in accordance with the following Principles of Professionalism when dealing with my client, opposing I will withdraw voluntarily claims or defense when it becomes apparent parties, their counsel, the courts and the general public. that they do not have merit or are superfluous;

Civility and courtesy are the hallmarks of professionalism and should not I will not file frivolous motions; be equated with weakness;

I will endeavor to be courteous and civil, both in oral and in written I will make every effort to agree with other counsel, as early as possible, on communications; a voluntary exchange of information and on a plan for discovery;

I will not knowingly make statements of fact or of law that are untrue; I will attempt to resolve, by agreement, my objections to matters contained in my opponent's pleadings and discovery requests; I will agree to reasonable requests for extensions of time or for waiver of procedural formalities when the legitimate interests of my client will not be In civil matters, I will stipulate to facts as to which there is no genuine adversely affected; dispute;

I will refrain from causing unreasonable delays; I will endeavor to be punctual in attending court hearings, conferences, meetings and depositions; I will endeavor to consult with opposing counsel before scheduling depositions and meetings and before rescheduling hearings, and I will I will at all times be candid with the court and its personnel; cooperate with opposing counsel when scheduling changes are requested; I will remember that, in addition to commitment to my client's cause, my When scheduled hearings or depositions have to be canceled, I will notify responsibilities as a lawyer include a devotion to the public good; opposing counsel, and if appropriate, the court (or other tribunal) as early as possible; I will endeavor to keep myself current in the areas in which I practice and when necessary, will associate with, or refer my client to, counsel Before dates for hearings or trials are set, or if that is not feasible, knowledgeable in another field of practice; immediately after such dates have been set, I will attempt to verify the availability of key participants and witnesses so that I can promptly notify I will be mindful of the fact that, as a member of a self-regulating the court (or other tribunal) and opposing counsel of any likely problem in profession, it is incumbent on me to report violations by fellow lawyers as that regard; required by the Rules of Professional Conduct;

I will refrain from utilizing litigation or any other course of conduct to I will be mindful of the need to protect the image of the legal profession in harass the opposing party; the eyes of the public and will be so guided when considering methods and content of advertising; I will refrain from engaging in excessive and abusive discovery, and I will comply with all reasonable discovery requests; I will be mindful that the law is a learned profession and that among its desirable goals are devotion to public service, improvement of In depositions and other proceedings, and in negotiations, I will conduct administration of justice, and the contribution of uncompensated time and myself with dignity, avoid making groundless objections and refrain from civic influence on behalf of those persons who cannot afford adequate legal engaging I acts of rudeness or disrespect; assistance;

I will not serve motions and pleadings on the other party or counsel at such I will endeavor to ensure that all persons, regardless of race, age, gender, time or in such manner as will unfairly limit the other party’s opportunity disability, national origin, religion, sexual orientation, color, or creed to respond; receive fair and equal treatment under the law, and will always conduct myself in such a way as to promote equality and justice for all. In business transactions I will not quarrel over matters of form or style, but will concentrate on matters of substance and content; It is understood that nothing in these Principles shall be deemed to supersede, supplement or in any way amend the Rules of Professional Conduct, alter existing standards of conduct against which lawyer conduct I will be a vigorous and zealous advocate on behalf of my client, while might be judged or become a basis for the imposition of civil liability of recognizing, as an officer of the court, that excessive zeal may be any kind. detrimental to my client’s interests as well as to the proper functioning of our system of justice; --Adopted by the Connecticut Bar Association House of Delegates on June 6, 1994 While I must consider my client’s decision concerning the objectives of the representation, I nevertheless will counsel my client that a willingness to initiate or engage in settlement discussions is consistent with zealous and effective representation;

Page 2 of 430 Table of Contents Agenda ...... 4 Faculty Biographies ...... 6 Repetitive Use Injuries of the Shoulder ...... 20 Repetitive Trauma in the Hand and Wrist: What Every Workers’ Compensation Attorney Should Know ...... 54 Repetitive Trauma in the Elbow: What Every Workers’ Compensation Attorney Should Know ...... 203 Legal Discussion about 31-299b ...... 278 Repetitive Trauma: Claimant’s Perspective ...... 280 Repetitive Trauma: Respondent’s Perspective ...... 281 Repetitive Stress Injuries in the Lumbar Spine ...... 283 Repetitive Work Trauma to Cervical Spine ...... 338 Occupational Disease in Connecticut, 2018 ...... 369 Who’s Who: Resources in Connecticut on Job Safety and Health ...... 422

Page 3 of 430

When Do Repetitive Activities = Repetitive Trauma? A Medical and Legal Review of Repetitive Trauma in Workers’ Compensation Claims

October 5, 2018

Schedule

8:00 a.m. – 8:30 a.m. Breakfast and Registration

8:30 a.m. – 8:45 a.m. Introductory Remarks Speakers: Chairman Stephen M. Morelli, State of Connecticut Workers’ Compensation Commission Dr. Michael E. Karnasiewicz, Neurosurgery Orthopaedics & Spine Specialists PC

8:45 a.m. – 9:30 a.m. Repetitive Use Injuries of the Shoulder Speaker: Dr. Frederick J. Watson, Neurosurgery Orthopaedics & Spine Specialists, PC

9:30 a.m. – 10:15 a.m. Repetitive Trauma in the Hand and Wrist: What Every Workers’ Compensation Attorney Should Know Speaker: Dr. Andrew J. Nelson, Neurosurgery Orthopaedics & Spine Specialists, PC

10:15 a.m. – 10:30 a.m. BREAK

10:30 a.m. – 11:15 a.m. Repetitive Trauma in the Elbow: What Every Workers’ Compensation Attorney Should Know Speaker: Dr. Richard L. Manzo, Neurosurgery Orthopaedics & Spine Specialists, PC

11:15 a.m. – 12:00 p.m. Q & A

12:00 p.m. – 1:00 p.m. Lunch

Page 4 of 430

1:00 p.m. – 1:30 p.m. Legal Discussion about 31-299b Speakers: Commissioner David W. Schoolcraft, State of Connecticut Workers’ Compensation Commission Scott A. Carta, Leighton Katz & Drapeau Elycia D. Solimene, Solimene & Secondo LLP

1:30 p.m. – 2:15 p.m. Repetitive Stress Injuries in the Lumbar Spine Speaker: Dr. David L. Forshaw, Neurosurgery Orthopaedics & Spine Specialists, PC

2:15 p.m. – 2:30 p.m. BREAK

2:30 p.m. – 3:15 p.m. Repetitive Work Trauma to Cervical Spine Speaker: Dr. Judith L. Gorelick, Neurosurgery Orthopaedics & Spine Specialists, PC

3:15 p.m. – 4:00 p.m. Medical Panel Speakers: Dr. Alisa H. Darling, Neurosurgery Orthopaedics & Spine Specialists PC Dr. David Forshaw, Neurosurgery Orthopaedics & Spine Specialists PC Dr. Judith L. Gorelick, Neurosurgery Orthopaedics & Spine Specialists PC Dr. Michael E. Karnasiewicz, Neurosurgery Orthopaedics & Spine Specialists PC Dr. Jarob N. Mushaweh, Neurosurgery Orthopaedics & Spine Specialists PC Dr. John G. Strugar, Neurosurgery Orthopaedics & Spine Specialists PC Dr. Glenn Taylor, Neurosurgery Orthopaedics & Spine Specialists PC Dr. Alan Waitze, Neurosurgery Orthopaedics & Spine Specialists PC

4:00 p.m. – 5:00 p.m. Cocktails/Reception

Page 5 of 430 Faculty Biographies

Chairman Stephen M. Morelli received his Bachelor of Arts degree from the University of Connecticut in 1983 and his law degree from the University of Connecticut School of Law in 1986. He is admitted to the practice of law in both Connecticut’s and California’s State and Federal Courts.

After graduating from law school he entered the Peace Corps as an ESL instructor in Thailand. Subsequent to that service he was admitted to practice law in California and worked for a private practice in California. In 1995 he returned to Connecticut, working in private practice, until his appointment as a Workers’ Compensation Commissioner, in August of 2012. Chairman Morelli has also served four terms on the Berlin Town Council and three terms as Deputy Mayor of the Town of Berlin. While his private practice in Connecticut was varied, the majority of Chairman Morelli’s experience was in the area of employment law. Prior to beginning his current role as the Workers’ Compensation Commission Chairman in May 2018, Chairman Morelli served in the New Britain, Norwich, Hartford, and Waterbury District Offices.

Commissioner David W. Schoolcraft grew up in Groton. He is a graduate of the University of Connecticut with degrees in History and French. Prior to attending law school he was a reporter for a daily newspaper in southeastern Connecticut.

After graduating from Western New England College School of Law in 1985, Commissioner Schoolcraft began practicing workers' compensation law in Willimantic, before moving to the greater Hartford area, where he was in private practice for 18 years. During that time his practice consisted largely of workers' compensation and related litigation. From early 2003 until his appointment to the Commission in May 2008, he practiced civil litigation with an insurance company’s staff counsel operation.

Originally assigned to the New Britain and Norwich Commission offices, since 2014 Commissioner Schoolcraft has been sitting in the Eighth District (Middletown) where, in addition to the usual caseload, he has been handling the Commission’s consolidated asbestos litigation docket.

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Scott A. Carta is a partner with the firm of Leighton, Katz & Drapeau with a principal office in Rockville, Connecticut. His practice consists almost exclusively of representing claimants/plaintiffs in workers’ compensation and personal injury cases. Mr. Carta is a Board Certified Workers’ Compensation Specialist.

Mr. Carta is a member of the Connecticut Bar Association and the Tolland County Bar Association. He is also a past chair of the Workers’ Compensation Section of the Connecticut Trial Lawyers Association, as well as a member of Executive Committee to the Connecticut Bar Association Workers’ Compensation Section. Mr. Carta also serves on the editorial board for Compensation Quarterly.

Mr. Carta received his B.A. from the University of Connecticut in 1996 and his J.D. from the University of Connecticut, School of Law in 1999. He was admitted to practice law in the State of Connecticut in 1999.

Page 7 of 430 Alisa H. Darling, M.D.

Board-Certified: American Board of Physical Medicine Rehabilitation; Sub-specialty Qualification in Sports Medicine; Certified in Integrative Health & Medicine Residency: Physical Medicine and Rehabilitation, New York University School of Medicine / Rusk Institute, New York, NY Internship: General Surgery, Stamford Hospital (affiliate of Columbia University), Stamford, CT MD: University of Connecticut School of Medicine, Farmington, CT BS: Environmental Biology, Yale University, New Haven, CT Hospital Affiliations: St. Mary’s Hospital, Waterbury Hospital Office location: Waterbury: 500 Chase Parkway Member: American Academy of Physical Medicine and Rehabilitation; Connecticut State Medical Society; Committee on the Medical Aspects of Sports

Dr. Alisa Darling is an experienced, board-certified physical medicine and rehabilitation specialist, or physiatrist. As a physiatrist, she focuses on providing nonsurgical care for musculoskeletal injuries and electrodiagnostic studies to evaluate and diagnose nerve injuries, including carpal tunnel syndrome, diabetic polyneuropathy and radiculopathy (nerve-root dysfunction that can result in pain, numbness, weakness or difficulty controlling certain muscles).

Dr. Darling is a compassionate person and physician dedicated to helping people through her skill, knowledge and friendly, patient-oriented approach. She is motivated by the opportunity to help people improve their quality of life and physical function and has a special interest in caring for sports injuries.

Page 8 of 430 David Forshaw, M.D.

Residency: Neurosurgery, New York University, New York, NY Internship: General Surgery, New York University, New York, NY MD: New York University, New York, NY BS: Neural Science, Magna Cum Laude, New York University, New York, NY Hospital Affiliations: St. Mary’s Hospital, Waterbury Hospital, Charlotte Hungerford Hospital, New Milford Hospital Member: American Association of Neurosurgeons, Congress of Neurological Surgeons, American College of Surgeons

Dr. David Forshaw is a compassionate and dedicated neurosurgeon with extensive experience in complex and minimally invasive spine procedures as well as with general neurosurgery. His areas of expertise include cervical spine disorders, chronic back and neck pain, spine diseases, degenerative conditions of the spine, spinal cord injuries and scoliosis. Dr. Forshaw’s training included neurosurgical oncology, in particular for brain tumors and skull-base tumors.

With his training and skill, Dr. Forshaw is an important part of NOSS’ multidisciplinary team devoted to the most advanced, comprehensive and effective spine, pain, nerve and musculoskeletal care in Greater Waterbury, Connecticut.

Page 9 of 430 Judith Gorelick, M.D.

Board-Certified: American Board of Neurological Surgery Residency: Neurosurgery, University of Michigan Hospitals, Ann Arbor, MI Internship: General Surgery, University of Michigan Hospitals, Ann Arbor, MI MD: New York University, New York, NY BS: Neuroscience, Cornell University, Ithaca, NY Leadership Positions: Section Chief of Neurosurgery, Griffin Hospital, Derby, CT; Medical Advisory Board, State of CT Worker’s Compensation Commission; Committee on Applicants, American College of Surgeons, CT Chapter Hospital Staff: Griffin Hospital, Yale-New Haven Hospital, Midstate Medical Center Member: Congress of Neurological Surgeons (CNS), fellow of the American Association of Neurological Surgeons (AANS), Alpha Omega Alpha Medical Honor Society (AOA), fellow of the American College of Surgeons (ACS), Women in Neurosurgery (WINS), Connecticut State Neurosurgical Society, Connecticut State Medical Society

Dr. Gorelick is one of the few female neurosurgeons in the state of CT and has nearly 15 years of clinical experience. Her practice focuses on the comprehensive treatment of degenerative cervical and lumbar spinal conditions, as well as the surgical treatment of brain and spinal tumors. Dr. Gorelick also has extensive expertise in stereotactic radiosurgery for the treatment of benign and malignant diseases of the nervous system.

Dr. Gorelick has published many scholarly articles, teaches spinal anatomy at the Yale School of Medicine, and actively lectures to both community and industry on a wide variety of neurosurgical topics. She is respected for her dedicated and compassionate approach to patient care as well as the extra effort she makes to educate her patients on the problem they are facing and the possible options for treatment. Dr. Gorelick stresses that a patient who understands their condition is in the best position to make informed choices about their care. She has been consistently recognized by her peers as one of Connecticut’s top doctors.

Page 10 of 430

Michael E. Karnasiewicz, M.D.

Board-Certified: American Board of Neurological Surgery Fellow: American Academy of Neurological Surgeons Fellowship: Neurosurgery, University of Connecticut School of Medicine, Farmington, CT Residency: Neurosurgery, Yale-New Haven Hospital, New Haven, CT Internship: General Surgery, Yale-New Haven Hospital, New Haven, CT MD: Case Western Reserve University, Cleveland, OH BA: Yale University, New Haven, CT Awards: Best Doctors in America (multiple years between 2003-2014) Leadership Positions: Former Board of Directors, Saint Mary’s Hospital Hospital Staff: Saint Mary’s Hospital, Waterbury Hospital Office location: Waterbury: 500 Chase Parkway Member: American Association of Neurological Surgeons, Congress of Neurological Surgeons, North American Spine Society, Connecticut Neurosurgical Society, Connecticut State Medical Society, New Haven County Medical Society, Waterbury Medical Association

Yale-trained, highly-credentialed and clinically accomplished with more than 30 years’ experience, Dr. Karnasiewicz is recognized as one of the leading neurological spine surgeons in the region. He is sought- after to treat the most challenging spine problems, including revision surgery. Dr. Karnasiewicz is also known for his direct, honest approach and dedication to finding the best treatment options — surgical and nonsurgical — for each individual.

During his notable career, Dr. Karnasiewicz has performed more than 6,000 spine surgeries. He has been named to Best Doctors in America in multiple years. Dr. Karnasiewicz is also recognized as a fair and expert case evaluator by Connecticut’s Workers’ Compensation Commission, for whom he has conducted thousands of exams. Dr. Karnasiewicz is a founding partner of NOSS and serves as the practice’s president and CEO.

Page 11 of 430 Richard L. Manzo, M.D.

Medical Certifications and Associations:

 Board Certified in Orthopaedic Surgery 2009  Subspecialty Certification in Hand and Upper Extremity Surgery administered by the American Board of Orthopedic Surgery 2011  Licensed by the State of Connecticut  Member American Academy of Orthopedic Surgeons (AAOS)  Member American Society for Surgery of the Hand (ASSH)  Member CT Orthopaedic Society

Honors and Awards:  CT Magazine Top Docs 2017  CT Magazine Top Docs 2016  CT Magazine Top Docs 2015  CT Magazine Top Docs 2014  Cavazos Award 2006; Most outstanding resident/teacher University of Connecticut Orthopaedic surgery residency

Education:  Bachelor of Arts in History, with Honors, Princeton University, Princeton, NJ  Medical Doctorate (M.D.) University of Connecticut School of Medicine, Farmington, CT  Surgical Internship, Hartford Hospital, Hartford, CT  Orthopedic Surgical Residency, University of Connecticut School of Medicine, Farmington, CT  Hand/Upper-extremity Fellowship, Tufts-New England Medical Center/New England Baptist Hospital, Boston, MA

Special Medical Interests:  Simple and Complex Hand and Wrist Trauma and Fractures  Open and Arthroscopic Surgery of the Shoulder  Open and Arthroscopic Surgery of the Elbow  Complex Fracture Care of the Upper and Lower Extremity

Page 12 of 430 Jarob N. Mushaweh, MD

Board-Certified: American Board of Neurological Surgery Residency: Neurosurgery, Wayne State University, Detroit, MI Residency: General Surgery, St. Francis Hospital & Connecticut Medical Center, Hartford, CT Internship: Bon Secours/Henry Ford Hospital, Detroit, MI; University of Connecticut, Hartford, CT MD: Aleppo University, Syria Hospital Affiliations: Waterbury Hospital, St. Mary’s Hospital, Waterbury, CT Office location: Waterbury: 500 Chase Parkway Member: Congress of Neurological Surgery; AANS/CNS Joint Section on Neurotrauma and Critical Care; Connecticut State Medical Society; New Haven County Medical Association; Waterbury Medical Association

A founding partner of NOSS, Dr. Mushaweh remains a core member of the spine care team. His broad knowledge and extensive spine microsurgery experience help NOSS provide the highest standard of spine care. A well-known, highly-respected and compassionate neurosurgeon, he is often consulted for workers’ compensation, independent medical evaluations and reviews of medical records.

Page 13 of 430 Andrew J. Nelson, M.D., FAAOS

Board Certification: American Board of Orthopaedic Surgery (ABOS) Fellow: American Academy of Orthopaedic Surgeons (AAOS) Certificate of Added Qualification (CAQ): American Association of the Hand (ASSH) Fellowship: Hand and Microvascular Surgery, Brown University/Rhode Island Hospital, Providence, RI Residency: Orthopaedic Surgery, Boston University, Boston, MA Internship: General Surgery, St. Elizabeth’s Hospital, Boston, MA MD: Boston University Medical School, Boston, MA BA: Biology and Biomedical Engineering, Brown University, Providence, RI Hospital Staff: St. Mary’s Hospital and Waterbury Hospital Hospital Affiliations: Waterbury Hospital; St. Mary’s Hospital, Waterbury, CT; Southington Surgery Center; Naugatuck Valley Surgical Center Office Location: 1320 West Main Street, Waterbury Member: American Association of the Hand (ASSH), American Academy of Orthopaedic Surgery (AAOS), Connecticut Orthopaedic Society, New Haven Medical Society. Awards: CT Magazine “Top Docs” for 2001, 2003, 2007, 2009 & 2010. Alpha Omega Alpha Medical Honor Society. Military Service: Lieutenant Commander, United States Navy, Charleston, SC Andrew J. Nelson, MD, specializes in hand and upper extremity surgery. With his advanced training, Dr. Nelson performs both simple and complex reconstruction of fingers, hand, wrist and elbow as well as microvascular surgery.

Dr. Nelson’s interests include: simple and complex hand and wrist trauma, wrist fractures, endoscopic (limited incision) carpal tunnel surgery, endoscopic cubital tunnel surgery, wrist arthroscopy and Dupuytren’s disease treated with needle aponeurotomy or Xiaflex enzyme injection or open surgery.

After more than 20 years of wide-ranging upper extremity experience, Dr. Nelson is a firm believer in providing both non-operative as well as operative solutions. Dr. Nelson is committed to the value of patient education in order to maximize each patient’s understanding of their condition or injury, their options and their overall health.

Dr. Nelson also provides expert services, including independent medical evaluations and medical record reviews.

Page 14 of 430 Elycia D. Solimene

Elycia D. Solimene is the managing partner at Solimene & Secondo, LLP. Her practice areas include the defense of workers’ compensation claims as well as general liability claims including premises liability and liquor liability. She has handled countless formal hearings and jury trials in the Connecticut State and Federal Courts. Attorney Solimene has also argued before the Connecticut Supreme Court, Appellate Court, and Compensation Review Board. Attorney Solimene was admitted to the Connecticut Bar in 2003, the New York Bar in 2004 and the United States District Court of Connecticut, the Southern District of New York and the Mohegan Tribal Gaming Disputes Court in 2005. She graduated from Ithaca College with a Bachelor of Arts in Political Science in 2000 and Quinnipiac University School of Law in 2003. Attorney Solimene was appointed to the Connecticut Bar Associations Workers’ Compensation Section, Executive Committee in 2016, 2017 and 2018. In 2012, she was nominated as a young leader in the law by the Connecticut Law Tribune. She has also been nominated for the last nine years as a Rising Star by the Connecticut Super Lawyers in 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2017, and 2018.

Page 15 of 430 John G. Strugar, MD

Board-Certified: American Board of Neurological Surgery Fellowship: Skull Base Surgery, George Washington University Medical Center, Washington, DC Residency: Neurosurgery, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT; Research Fellow: Angiogenesis & Brain Edema Research Laboratory, Yale University School of Medicine, New Haven, CT Internship: Surgery, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT MD: New York University, New York, NY BA: Chemistry, New York University, New York, NY Leadership Positions: Chief of Spine and Skull-Base Surgery, Yale-New Haven Hospital, New Haven, CT; Chief of Neurosurgery, Waterbury Hospital, Waterbury, CT Associated Clinical Professor: Neurosurgery, Yale University School of Medicine, New Haven, CT Hospital Staff: St. Mary’s Hospital, Waterbury Hospital, Yale-New Haven Hospital Office location: Waterbury: 500 Chase Parkway Member: Congress of Neurological Surgeons (CNS), CNS Educational Committee, CNS International Committee, American Medical Association, Connecticut State Neurosurgical Society, Connecticut Medical Society, North American Spine Society, Romanian Medical Society

Dr. Strugar’s areas of expertise as a neurosurgeon extend to spine tumors, cervical spine disorders and head and brain trauma. Fellowship-trained in skull base surgery, Dr. Strugar has deep expertise with intracranial injury. He is also extensively experienced in the surgical treatment of the spine, having performed numerous disc arthoplasties (artificial disc surgery) and minimally invasive spine surgeries, as well as combination arthroplasty and fusion surgery to treat complex spine disease.

Dr. Strugar has published and presented on a wide range of topics, including brain tumors, spine tumors, acute spinal cord injury and traumatic brain injury. A caring, dedicated and respected neurosurgeon, he is also highly experienced with independent medical evaluations and expert reviews of medical records.

Page 16 of 430 Glenn Taylor, MD, FAAOS

Board-Certified: American Board of Orthopaedic Surgery Fellow: American Academy of Orthopaedic Surgeons Residency: Orthopaedic Surgery, Yale-New Haven Hospital, New Haven, CT Internship: Surgery, Royal Hampshire County Hospital, Winchester, Hampshire, England Internship: Medicine, St. George’s Hospital, London, England MD: St. George’s Hospital Medical School, University of London, England BS: King’s College, University of London, England Leadership Positions: Former Chief of Staff, Waterbury Hospital Hospital Affiliations: Waterbury Hospital, Saint Mary’s Hospital, Waterbury, CT Office locations: Waterbury: 500 Chase Parkway Southbury: 2 Pomeraug Office Park, Ste 308 Member: American Academy of Orthopaedic Surgery, North American Spine Society

Dr. Glenn Taylor, a founding partner of NOSS, is a highly experienced orthopaedic surgeon. Dr. Taylor is certified by the American Board of Orthopaedic Surgery and is a Fellow of the American Academy of Orthopaedic Surgeons. He is a former chief of staff at Waterbury Hospital.

Dr. Taylor’s specialties within the field of orthopaedic surgery include complex and revision spine surgery, non-operative spinal care, trauma and general orthopaedics. Dr. Taylor performs Independent Medical Evaluations and Commissioner's Exams in addition to Medical Reviews. He is a compassionate person committed to providing the highest standards of care utilizing best medical evidence and best practices. After more than 35 years of wide-ranging orthopaedic experience, Dr. Taylor is a firm believer in the value of education in order to maximize each patient’s understanding of their condition or injury, their options and their overall health.

Dr. Taylor is Medical Director and Board Member of Teen Cancer America, a non-profit organization dedicated to improving the lives of teens and young adults afflicted with cancer.

Page 17 of 430 Alan S. Waitze, MD, FAANS

Board-Certified: American Board of Neurological Surgery Fellow: American Academy of Neurological Surgeons Fellowship: Neurosurgery, Emory University, Atlanta, GA Residency: Neurosurgery, Emory University, Atlanta, GA Internship: General Surgery, Emory University School of Medicine, Atlanta, GA MD: Hahnemann University School of Medicine, Philadelphia, PA BA: Biology, Brandeis University, Waltham, MA Awards: One of Connecticut’s Top Neurosurgeons, Connecticut Magazine Hospital Affiliations: St. Mary’s Hospital, Waterbury Hospital, Griffin Hospital Office location: Waterbury: 500 Chase Parkway Member: American Association of Neurological Surgeons, Congress of Neurological Surgeons, Connecticut State Medical Society, New Haven County Medical Society, North American Spine Society

Dr. Waitze is an experienced leader in neurosurgical spine care in Connecticut. He has extensive training in complex spine surgery and specializes in degenerative disease and trauma of the spine. He is recognized as an innovator who has helped bring the newest, most advanced techniques and treatments to Greater Waterbury, including lateral interbody fusion, for which he is among a select group of elite surgeons qualified to perform this procedure.

Named by Connecticut Magazine as one of the state’s top neurosurgeons, Dr. Waitze today travels the world teaching advanced spine surgery techniques to other top-tier specialists. His care is marked by his unswerving commitment to delivering leading-edge care with a personal touch, spending the time to inform patients about their condition and options and always considering nonsurgical treatments first. Dr. Waitze brings to NOSS’ state-of-the-art capabilities his expertise in back and neck surgery, degenerative and traumatic disorders, spinal cord injuries and spine diseases. Dr. Waitze is also a recognized expert providing independent medical evaluations and medical record reviews.

Page 18 of 430 Frederick J. Watson, M.D.

Board-Certified: American Board of Orthopaedic Surgery Fellowship: Orthopaedic Sports Medicine, Boston University Medical Center, Boston, MA Residency: Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT MD: University of Massachusetts Medical School, Worcester, MA BS: Biology, Summa Cum Laude, Syracuse University, Syracuse, NY Hospital Staff: Waterbury Hospital, St. Mary’s Hospital, Southington Surgery Center Hospital Affiliations: Waterbury Hospital, St. Mary’s Hospital, Hospital of Central Connecticut, Naugatuck Valley Surgical Center, Southington Surgery Center Office locations: Waterbury: 500 Chase Parkway Southbury: 2 Pomeraug Office Park, Ste 308 Team Physician: Post University Athletics Member: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Orthopaedic Society for Sports Medicine, Connecticut Orthopaedic Society

Dr. Watson received his Bachelor’s degree from Syracuse University in 1994 and his Medical degree from The University of Massachusetts Medical School in 1998. He completed his Orthopaedic Residency at the University of Connecticut Health Center in 2003 and a Sports Medicine Fellowship at Boston University in 2004. A member of Tribury Orthopaedics/N.O.S.S. team since 2004, he specializes in Orthopaedic Sports Medicine with a particular focus in arthroscopic shoulder and knee surgery. He is the Team Physician for all intercollegiate athletics at Post University and also enjoys taking care of adolescent and high school athletes, the weekend warrior and “occupational athletes.” Arthroscopic techniques originally developed for the care of the most elite athletes are now commonly used to treat the conditions experienced by people of all ages and activity levels. Dr. Watson employs these techniques on his collegiate athletes and your injured workers.

Originally from the Boston area, Dr. Watson is an avid Boston sports fan and predicts a Red Sox World Series victory this year (and probably a New England Patriots Super Bowl win).

Page 19 of 430 Repetitive Use Injuries of the Shoulder

FREDERICK WATSON M.D. NEUROSURGERY, ORTHOPAEDICS & SPINE SPECIALISTS, P.C. WWW.NOSSMD.COM

OCTOBER 5, 2018

Page 20 of 430 Disclosures

 Speaker receives has no financial relationship with any commercial entity  Speaker claims no ownership or copyright rights to any images. All images are from public sites on the internet

Page 21 of 430 Overview

 Common Conditions  Rotator Cuff Impingement Syndrome/Bursitis  Rotator Cuff Tear  Biceps Tendonitis  Labrum Tears  Arthritis  Acromioclavicular Arthritis  Less Common/ ? Controversial  Frozen Shoulder  Thoracic Outlet

Page 22 of 430 Anatomy of the Shoulder

 Bones  Humeral head  Greater and lesser tuberosities  Clavicle  Acromion  Glenoid  Scapula  Musculature/Tendons  Rotator Cuff  Supraspinatus  Infraspinatus  Teres Minor  Subscapularis  Biceps (Long head)  Labrum/Capsule  Bursa

Page 23 of 430 Bony Anatomy

 Humerus  Humeral Head (articular surface)  Greater and Lesser Tuberosities  Bicipital Groove  Scapula  Glenoid (articular surface)  Acromion  Coracoid Process  Clavicle  Acromioclavicular Joint

Page 24 of 430 Rotator Cuff/Biceps Tendons

Page 25 of 430 Rotator Cuff Function

 Supraspinatus  Abduction  Infraspinatus and Teres Minor  External Rotation  Subscapularis  Internal Rotation

Page 26 of 430 Rotator Cuff Function

 Joint compression  Humeral head stabilization/depression

*Loss of cuff function leads to superior migration of humeral head

Page 27 of 430 Biceps Tendon Function

 Shoulder flexion  Humeral depression

* Long head of biceps tendon anchored on superior labrum (SLAP tears)

Page 28 of 430 Diagnostic Arthroscopy

Page 29 of 430 Rotator Cuff Problems

 Tendonitis/Bursitis  Impingement  Tears

Page 30 of 430 Rotator Cuff Tendonitis/Bursitis

 Tendon inflammation due to overhead use/repetitive use  Treatment  Rest  Avoidance of aggravating activity  NSAIDS  Physical Therapy  Corticosteroid injection

Page 31 of 430 Rotator Cuff Impingement

 Compression of rotator cuff tendon under acromion/CA arch/AC joint spurs (tight subacromial outlet)  Anterosuperior shoulder pain caused by repetitive overhead activity  Usually in patients over 40  Pt. younger than 40 with pain with overhead activity typically has excessive laxity than causes increased translation and cuff stretch which causes tendonitis, NOT impingement

Page 32 of 430 Rotator Cuff Impingement

 Pathology  Bursal surface abrasive changes and inflamed/hypertrophic bursa  Evaluation  Anterolateral shoulder pain  Worse with repetitive or forceful overhead activity  Night pain common  Painful arc of motion  Neer/Hawkin’s Impingement signs  Acromion shape  Diagnostic subacromial injection

Page 33 of 430 Rotator Cuff Impingement

Page 34 of 430 Rotator Cuff Impingement

 Treatment  Non-surgical  Avoidance  NSAIDs/ice  Physical Therapy  Subacromial corticosteroid injection  Surgical  Subacromial decompression

Page 35 of 430 Subacromial Decompression

Page 36 of 430 Rotator Cuff Tears

 Causes  Acute (trauma)  Chronic/Cumulative  Intrinsic degeneration due to overuse

Page 37 of 430 Rotator Cuff Tears

 Overuse leads to microtrauma  Poor blood flow impairs healing capacity  [Tendons undergo degenerative changes during normal aging]  Vicious cycle  Accumulation of degeneration and microtrauma leads to vicious cycle of cuff dysfunction, instability, impingement and injury to further dysfunction and eventually tearing

* Cuff tears usually a combination of mechanical impingement and intrinsic tendon degeneration from overuse

Page 38 of 430 Rotator Cuff Tears

 Evaluation  Symptoms similar to Impingement  Gradual onset  History of overuse without discrete injury  Night pain  Weakness (usually)  MRI  Tear Severity  Partial vs Full-thickness  Progression

Page 39 of 430 Partial-thickness Tears

 Non- full-thickness tear  Prevalence of RTC disease strongly associated with age  MRI study found 20% of ASYMPTOMATIC individuals had PTRCT  Highest (26%) in those over 60 and lowest (4%) in those under 40  PTRCTs tend to progress over time (30%)

Page 40 of 430 Full-thickness Cuff Tears

 Complete disruption of the tendon  Risk of complete tears  Progression of size  Retraction  Denervation  Muscle atrophy and fatty degeneration  Stiffness  Loss of elasticity

Page 41 of 430 Treatment of Rotator Cuff Tears

 Non-Operative  Activity modification  NSAIDs/Ice  Physical Therapy  Injection  Operative  After 3-6 months non-operative care  Partial RCTs > 30-50% and ? All full thickness RCTs  Arthroscopic debridement +/- SAD  Rotator Cuff Repair (open or arthroscopic)

Page 42 of 430 Arthroscopic Debridement

Page 43 of 430 Arthroscopic Rotator Cuff Repair

Page 44 of 430 Biceps Tendonitis

 Primary bicipital tenosynovitis  Wear and tear on tendon as it travels through tight bicipital groove  Often seen in workers with overhead work, especially supporting heavy loads  Most common cause may be subacromial impingement and rotator cuff disease  2003 study showed 96% of pts. with LHBT tears had SS tendon tear (i.e. often seen in conjunction with RTC tears)  Anterior shoulder pain radiating towards muscle belly

Page 45 of 430 Biceps Tendon Instability

 Subluxation/dislocation from bicipital groove  Damage to pulley system and/or subscapularis tendon tears  Patients report painful clicking or snapping with rotation of arm

Page 46 of 430 Biceps Treatment

 Tendonitis  Instability  Rehab/Physical Therapy  Surgery usually necessary  Address underlying RTC  pathology Tenotomy  NSAIDS  Corticosteroid injections  Surgery rare

 Tenodesis

Page 47 of 430 Biceps Treatment

Page 48 of 430 Acromioclavicular Arthritis

 Superior/anterosuperior shoulder pain  Exacerbated by cross-body adduction, forward flexion movements  AC arthritis is very common in asymptomatic elderly on xray and in most people on MRI – DO NOT OVERTREAT  Treat symptomatic AC joints  Pain with direct palpation  Diagnostic/Therapeutic injections  Physical Therapy  Distal clavicle resection (Mumford) with symptoms > 6 months and affecting ADLs

Page 49 of 430 Labrum Tears

 Most labrum tears are degenerative fraying due to humeral head translation during repetitive motions  Superior Labrum (SLAP) tears in overhead athletes (pitchers, tennis, volleyball)  Bankart (anteroinferior labrum) tears with traumatic dislocation

 Most degenerative labrum tears associated with other pathology (RTC tears)  Usually debrided along with treatment of the primary pathology

Page 50 of 430 Glenohumeral Arthritis

 Osteoarthritis – “wear & tear” arthritis related to years of repetitive heavy physical work (and recreation, and injuries, etc.)  Very slow developing, insidious- onset pain and stiffness leading to decreasing function  Treatment:  Non-surgical – (gentle) physical therapy, NSAIDS/Tylenol, corticosteroid/viscosupplementation injections  Surgical  Arthroscopic debridement  Biologic resurfacing  REPLACEMENT

Page 51 of 430 Frozen Shoulder/Adhesive Capsulitis

 Common condition (2-5% of general population)  Primary (idiopathic) or Secondary to other underlying cause (e.g. RCT)  Three Phases  Acute pain/Inflammation  Severe stiffness/Fibrosis  Gradual resolution  Insidious onset, pt. may report seemingly trivial injury (“strain”), severe pain then progressive stiffness, weakness  Treatment- analgesics, physical therapy, intraarticular injection, surgical

*Most cases resolve but may take 2-2.5 years (untreated). 50% of patients may have some residual pain and/or stiffness

Page 52 of 430 Thank you

Page 53 of 430 Dr. Andy Nelson Dr. Rich Manzo Dr. Eric Watson

When Do Repetitive Activities = Repetitive Trauma? A Medical and Legal Review of Repetitive Trauma in Workers’ Compensation Claims

Page 54 of 430 Waterbury, Southbury, Shelton, Litchfield, Cheshire

Page 55 of 430 Repetitive Trauma in the Hand and Wrist: What every workers compensation attorney should now.

I will discuss the causes and treatment of common repetitive trauma injuries to the hand and wrist.

Objectives:

1. Delve into the term “repetition”-its origin and use 2. Learn the causes and treatment of Carpal Tunnel Syndrome. 3. Learn the causes and treatment of De Quervain’s Tenosynovitis. 4. Learn the causes and treatment of Trigger Fingers.

Page 56 of 430 Mark Melhorn, MD Nationally Know “Guru” on WC

Page 57 of 430 1.Repetition Strain Injury‐Australia 2.Repetitive Trauma 3.Repetitive Strain/Stress Disorder 4.Cumulative Trauma 5.Overuse Syndrome

Page 58 of 430 How does the Public define Repetitive Stress or Repetitive Strain?

Page 59 of 430 Definition of repetitive strain injury

: any of various painful musculoskeletal disorders (such as carpal tunnel syndrome or tendinitis) caused by cumulative damage to muscles, tendons, ligaments, nerves, or joints (as of the hand or shoulder) from highly repetitive movements — called also repetitive stress injury

Page 60 of 430 What does OSHA define as Repetitive?

Page 61 of 430 Page 62 of 430 How do Hand Surgeons define Repetitive Stress or Repetitive Strain?

Page 63 of 430 1996 Journal of Hand Surgery

Page 64 of 430 982 pages!

Page 65 of 430 https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%20CPG_2.2 9.16.pdf

Page 222

“Computer work was significantly associated with increased risk of CTS by three moderate quality studies (Ali, 2006; Coggon, 2013; Eleftheriou, 2012). One study found an increased association with an average of greater than eight hours of computer use per day and more than four years of computer work (Ali, 2006). Another study found an association between an increased risk of CTS and working on a keyboard or mouse for more than four hours per day (Coggon, 2013). The third study found an association with a very high number of keystrokes typed per year and a higher risk of CTS (Eletheriou, 2012). There was one moderate quality study (Ali, 2006) evaluating internet use for leisure, which also found a significant result for increasing risk of CTS. “

Page 66 of 430 SO WHERE DID THESE WORDS WE USE COME FROM?

Page 67 of 430 Overuse Syndrome Umbrella

Australia USA Repetition Strain Injury Cumulative Trauma Disorder

Grab bag of both true physical disorders & non‐physical disorders

Page 68 of 430 Repetition Strain Injury and Australia

Page 69 of 430 Page 70 of 430 • Repetitive Strain Injury (RSI) was coined in 1981 by John Matthews, a non‐medical graduate and member of the Australian Council of Trade Unions and the Victorian Trades Hall Council • In 1982 the Australian National Health and Medical Research Council appropriated the term…and it is suggested that by promoting false beliefs that it became a vector in the Australian RSI epidemic • The Royal Australian College of Physicians stated there was ‘no scientific validity’ to the booklet • The term RSI came to be used as a descriptive for diffuse or less commonly localized arm symptoms with or without neck pain unaccompanied by any objective clinical, electrophysiological, laboratory or imaging abnormalities. • The New South Wales experience was largely reflected in an epidemiological study of Telecom Australia employees between 1981 and 1988 with 4891 RSI claims which peaked in March 1985, having increased 1000% from 1981. From 1985 to 1988 the numbers declined to pre‐epidemic levels. There was no evidence of a causal relationship between arm symptoms and ergonomic factors, keystroke rate or the use of new technology, nor were any factors identified which caused the decline in the epidemic.

Page 71 of 430 • Repetitive Strain Injury (RSI) was coined in 1981 by John Matthews, a non‐medical graduate and member of the Australian Council of Trade Unions and the Victorian Trades Hall Council • In 1982 the Australian National Health and Medical Research Council appropriated the term…and it is suggested that by promoting false beliefs that it became a vector in the Australian RSI epidemic • The Royal Australian College of Physicians stated there was ‘no scientific validity’ to the booklet • The term RSI came to be used as a descriptive for diffuse or less commonly localized arm symptoms with or without neck pain unaccompanied by any objective clinical, electrophysiological, laboratory or imaging abnormalities. • The New South Wales experience was largely reflected in an epidemiological study of Telecom Australia employees between 1981 and 1988 with 4891 RSI claims which peaked in March 1985, having increased 1000% from 1981. From 1985 to 1988 the numbers declined to pre‐epidemic levels. There was no evidence of a causal relationship between arm symptoms and ergonomic factors, keystroke rate or the use of new technology, nor were any factors identified which caused the decline in the epidemic.

Page 72 of 430 • Repetitive Strain Injury (RSI) was coined in 1981 by John Matthews, a non‐medical graduate and member of the Australian Council of Trade Unions and the Victorian Trades Hall Council • In 1982 the Australian National Health and Medical Research Council appropriated the term…and it is suggested that by promoting false beliefs that it became a vector in the Australian RSI epidemic • The Royal Australian College of Physicians stated there was ‘no scientific validity’ to the booklet • The term RSI came to be used as a descriptive for diffuse or less commonly localized arm symptoms with or without neck pain unaccompanied by any objective clinical, electrophysiological, laboratory or imaging abnormalities. • The New South Wales experience was largely reflected in an epidemiological study of Telecom Australia employees between 1981 and 1988 with 4891 RSI claims which peaked in March 1985, having increased 1000% from 1981. From 1985 to 1988 the numbers declined to pre‐epidemic levels. There was no evidence of a causal relationship between arm symptoms and ergonomic factors, keystroke rate or the use of new technology, nor were any factors identified which caused the decline in the epidemic.

Page 73 of 430 • Repetitive Strain Injury (RSI) was coined in 1981 by John Matthews, a non‐medical graduate and member of the Australian Council of Trade Unions and the Victorian Trades Hall Council • In 1982 the Australian National Health and Medical Research Council appropriated the term…and it is suggested that by promoting false beliefs that it became a vector in the Australian RSI epidemic • The Royal Australian College of Physicians stated there was ‘no scientific validity’ to the booklet • The term RSI came to be used as a descriptive for diffuse or less commonly localized arm symptoms with or without neck pain unaccompanied by any objective clinical, electrophysiological, laboratory or imaging abnormalities. • The New South Wales experience was largely reflected in an epidemiological study of Telecom Australia employees between 1981 and 1988 with 4891 RSI claims which peaked in March 1985, having increased 1000% from 1981. From 1985 to 1988 the numbers declined to pre‐epidemic levels. There was no evidence of a causal relationship between arm symptoms and ergonomic factors, keystroke rate or the use of new technology, nor were any factors identified which caused the decline in the epidemic.

Page 74 of 430 • Repetitive Strain Injury (RSI) was coined in 1981 by John Matthews, a non‐medical graduate and member of the Australian Council of Trade Unions and the Victorian Trades Hall Council • In 1982 the Australian National Health and Medical Research Council appropriated the term…and it is suggested that by promoting false beliefs that it became a vector in the Australian RSI epidemic • The Royal Australian College of Physicians stated there was ‘no scientific validity’ to the booklet • The term RSI came to be used as a descriptive for diffuse or less commonly localized arm symptoms with or without neck pain unaccompanied by any objective clinical, electrophysiological, laboratory or imaging abnormalities. • The New South Wales experience was largely reflected in an epidemiological study of Telecom Australia employees between 1981 and 1988 with 4891 RSI claims which peaked in March 1985, having increased 1000% from 1981. From 1985 to 1988 the numbers declined to pre‐epidemic levels. There was no evidence of a causal relationship between arm symptoms and ergonomic factors, keystroke rate or the use of new technology, nor were any factors identified which caused the decline in the epidemic.

Page 75 of 430 • Adverse psychosocial factors, psychological distress and depression are strongly associated with and predictive of the development of regional musculoskeletal pain including neck and arm pain in the absence of identifiable musculoskeletal conditions which might otherwise account for the pain.

• This paradigmatic shift resulted from the convergence of a number of variables: industrial, political, social, physical, psychological and iatrogenic. A new sociological dynamic was established, creating a milieu that captured the psychologically and the socially vulnerable and which proved irresistible to the disaffected and to the mendacious.

Page 76 of 430 • Adverse psychosocial factors, psychological distress and depression are strongly associated with and predictive of the development of regional musculoskeletal pain including neck and arm pain in the absence of identifiable musculoskeletal conditions which might otherwise account for the pain.

Page 77 of 430 Overuse Syndrome Umbrella

Australia USA Repetition Strain Injury Cumulative Trauma Disorder

Grab bag of both true physical disorders & non‐physical disorders

Page 78 of 430 Let us distinguish RSI/CTD from accepted overuse Syndromes • Rotator Cuff Tendonitis • Bicipital tendonitis • Lateral & medial epicondylitis • Olecrenon bursitis • DeQuervains tendonitis • Flexor tenosynovitis causing median nerve compression • Trigger finger/flexor tensosynovitis

These differ from RSI/CTD because 1. Clearly defined and distinguishable subjective symptoms 2. Reproducible subjective symptoms 3. Recognizable gross & microscopic path findings 4. Appropriate response to effective forms of treatment

Page 79 of 430 JHS 1995

Page 80 of 430 Hockings (‘87) studied the epidemiology of • Telecom Australia‐the national telecommunications monopoly • Highest RSI was 34% but had lowest keystrokes • Clerk RSI was 28% • Keyboard workers with highest key strokes had lowest incidence=3% ? protective

Page 81 of 430 RSI Characterisitics • Clinical presentation was vague and nonspecific pain • Pain was consistent with the patient but inconsistent patterns between patients • No response to PT • NSAIDS made worse

• RSI does not compare with Diagnoses that • Have a clearly defined & distinguishable symptoms • Have reproducible objective symptoms and exam • Have recognizable gross & microscopic pathology • Have appropriate response to effective forms of treatment • Eg: Rotator Cuff, Dequervains, Trigger Finger…

Page 82 of 430 RSI is

…a psychological symptom complex that has been described as a sociopolitical phenomenon…

Page 83 of 430 Recently…Similar Phenomenon have occurred throughout History • Occupational Cervicobrachial Disorder in the 1960’s: Japan, Switzerland and Sweden • Finland: Tenison Headache and Occupational Disorder • Germany: Occupational Complaint # 2101

Historically…With each advance in communication: the quill, the pen, the teleghaph, the keyboard the phone… • Ramazzi 1713: “Disease of clerks & scribes”=“continuous sitting, repeated use the the hand and strain of the mind.” • Sir Charles Bell 1833: “Writers cramp” • Robinson 1882: “Telegraphists cramp” deamed a nervous breakdown due to nervous instability and repeated fatigue

Page 84 of 430 RSI in Australia in the 1980’s is similar to CTD in the USA in the 1990’s in that it is…

…a non physical condition

Q: Are we dealing with a physical or non‐physical condition or a hybrid?

Eg. : different results of the same surgery in WC vs non‐WC— recovery from Carpal Tunnel Surgery

Page 85 of 430 QUESTION How can the same condition seemingly manifest so differently in different people?

Page 86 of 430 Some of these soldiers get blisters and stress fractures…and some don’t

And after conditioning, it is less

Page 87 of 430 We are inherently different • Some of us are younger • Some of us are in better shape • Some of us are healthier • Some of us have better genetics • Some of us have more grit

Page 88 of 430 The “Equation” Variables Physical Problem Work=Force x Repetition Psychology of Personal Resilience & Grit Family Genetics Personal Medical Health

Page 89 of 430 Larger Force x Repetition ______Physical = Problem Personal Resilience

Page 90 of 430 Force x Repetition Smaller ______Physical = Problem Personal Resilience

Page 91 of 430 Physical Problem =

Personal Force x Repetition Family ______X X Medical Genetics Personal Resilience Issues Or Grit

Page 92 of 430 Question: Does repetition equal cause?

Question: Does everything need a label‐to fall in line?

Question: What is the psychological power of labeling?

• Raise emotions • Intensify sympathy • Prevent otherwise spontaneous resolution

Page 93 of 430 A Division of

Page 94 of 430 CARPAL TUNNEL is pressure on a nerve causing numbness & pain DE QUERVAIN’S is pressure on a tendon causing pain TRIGGER FINGER is pressure on a tendon causing pain and locking

Page 95 of 430 Carpal Tunnel Syndrome

Page 96 of 430 Carpal Tunnel Syndrome

Too many people think that Carpal Tunnel Syndrome refers to anything that happens in the hand or wrist.

The highlight of CTS is . . .

Page 97 of 430 Carpal Tunnel Syndrome

Numbness

OR Tingling

OR “Pins and Needles” Feeling

OR Falling Asleep Sensation

Page 98 of 430 Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Page 99 of 430 Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is pressure on The Median Nerve at the wrist.

Page 100 of 430 Carpal Tunnel Syndrome

The Median Nerve at the Wrist

Page 101 of 430 Carpal Tunnel Syndrome

Nerves are tube‐like structures that carry electrical information.

You can compare them to household electrical wires or a garden hose —information flows through them.

Page 102 of 430 Carpal Tunnel Syndrome

The pressure on the nerve can decrease flow

Page 103 of 430 Carpal Tunnel Syndrome

Is there permanent damage from this pressure ?

Page 104 of 430 Carpal Tunnel Syndrome

What are the possible causes of increased pressure ? 1. Swelling of the synovial covering of tendons 2. Fluid in the Carpal Tunnel 3. Muscles, e.g. Lumbricles, in the tunnel

Page 105 of 430 Carpal Tunnel Syndrome

What causes swelling? 1. Reaction to friction-synovitis=tendons swell 1. Acute: will resolve 2. Chronic: will not resolve; ? accommodate 2. Trauma or infection 3. Systemic Dz: e.g., Rheumatoid Arthritis or Diabetes

Page 106 of 430 Carpal Tunnel Syndrome

Symptoms

What do people with CTS complain of ?

Page 107 of 430 Carpal Tunnel Syndrome Symptoms

• Numbness or tingling or “pins and Needles” or falling asleep of the fingers—not the small finger • Dropping objects • Clumsiness of the hand • Worsening handwriting • Pain • Visible loss of muscle in the hand

Page 108 of 430 Carpal Tunnel Syndrome Symptoms

Less Common Symptoms

• Pain or numbness in the forearm • Shoulder pain

Page 109 of 430 Carpal Tunnel Syndrome Symptoms

Page 110 of 430 Carpal Tunnel Syndrome Symptoms

Numbness or tingling or “pins and Needles” or falling asleep of the fingers—not the small finger

This usually begins to bother people at awakening and progresses to waking you out of your sleep and finally bothers you during some daytime activities

Page 111 of 430 Carpal Tunnel Syndrome Symptoms

Common Activities Associated with CTS • Sleeping • Blow drying hair • Driving • Protracted fine manipulation • +/‐ Typing

Page 112 of 430 Carpal Tunnel Syndrome Symptoms

The numbness classically involves the Thumb, Index, Middle and ½ of the Ring Fingers.

The Small Finger and other half of the Ring Finger are generally not involved in CTS.

Page 113 of 430 Carpal Tunnel Syndrome Symptoms

Page 114 of 430 Carpal Tunnel Syndrome Symptoms

Page 115 of 430 Carpal Tunnel Syndrome Symptoms

Many patients describe clumsiness and frustrations with:

•Buttons •Earrings •Zippers

Page 116 of 430 Carpal Tunnel Syndrome Symptoms

Page 117 of 430 Carpal Tunnel Syndrome Symptoms

Page 118 of 430 Carpal Tunnel Syndrome Symptoms

Squishing the nerve can be painful

Page 119 of 430 Carpal Tunnel Syndrome Symptoms

Page 120 of 430 Carpal Tunnel Syndrome

The Thumb muscles are called the “Thenar” muscles and they can become wasted or weak from this pressure.

Page 121 of 430 Carpal Tunnel Syndrome Symptoms

Carpal Tunnel Syndrome can become severe and cause weakness and atrophy to the thumb muscles.

This can cause a significant weakness of pinch.

Page 122 of 430 Carpal Tunnel Syndrome

The problem is the pressure on the Median Nerve.

Page 123 of 430 Diagnosis

How do you figure out if it is CTS?

Page 124 of 430 Carpal Tunnel Syndrome Diagnosis

• Determining if there is numbness and on which fingers • Excluding whether there may be a neck problem/source • Phalens test • Tinel test • Nerve conduction test

Page 125 of 430 Carpal Tunnel Syndrome Diagnosis

Determining if there is numbness and on which fingers

Can you tell which finger is numb ?

Page 126 of 430 Carpal Tunnel Syndrome Diagnosis

• Determining if there is numbness and on which fingers • Excluding whether there may be a neck problem/source • Phalens test • Tinel test • Nerve conduction test

Page 127 of 430 Carpal Tunnel Syndrome Diagnosis

Excluding whether there may be a neck problem/source

C6 Nerve Root

Page 128 of 430 Carpal Tunnel Syndrome Diagnosis

• Determining if there is numbness and on which fingers • Excluding whether there may be a neck problem/source • Phalen’s test • Tinel test • Nerve conduction test

Page 129 of 430 Carpal Tunnel Syndrome Diagnosis Phalen’s test

Page 130 of 430 Carpal Tunnel Syndrome Diagnosis

• Determining if there is numbness and on which fingers • Excluding whether there may be a neck problem/source • Phalens test • Tinel test • Nerve conduction test

Page 131 of 430 Carpal Tunnel Syndrome Diagnosis Tinel test

Page 132 of 430 Carpal Tunnel Syndrome Diagnosis

• Determining if there is numbness and on which fingers • Excluding whether there may be a neck problem/source • Phalens test • Tinel test • Nerve conduction test

Page 133 of 430 Carpal Tunnel Syndrome Diagnosis

Nerve conduction test/EMG

A B

Page 134 of 430 Treatment

What can be done?

Page 135 of 430 Carpal Tunnel Syndrome Treatment

There is a ladder of treatment and we need to begin on the bottom rung.

Page 136 of 430 Carpal Tunnel Syndrome Treatment

Activity Modification The first rung on the ladder is to do less of the things you KNOW bother you…or at least in smaller portions.

If you are gardening and this bothers you, then 1 break up your tasks.

If you are splitting wood, do small batches at a time.

Page 137 of 430 Carpal Tunnel Syndrome Treatment

Splinting or Bracing Using a wrist splint at sleep time can rest the Median Nerve and prevent you from waking up at Night.

Page 138 of 430 Carpal Tunnel Syndrome Treatment

Steroid Injections I believe that steroid injections are an important step.

3 If you already have CONSTANT numbness or thenar atrophy they are of little help.

Page 139 of 430 Carpal Tunnel Syndrome Treatment

Steroid Injections They are best suited for those patients who are: • Less than 40 yo 3 • Do not have Diabetes or thyroid conditions • Have symptoms for less than 9 mo

Page 140 of 430 Carpal Tunnel Syndrome Treatment

Steroid Injections Although many people do not fit those criteria I still use an injection.

3 They are effective in 80‐100% of people but may be long lasting in 22%

Page 141 of 430 Carpal Tunnel Syndrome Treatment Steroid Injections

+ Celestone is in the “cortisone” family

Page 142 of 430 Carpal Tunnel Syndrome Treatment

Other forms of treatment that have not been scientifically proven but may help

• NSAIDS eg, Motrin, Naprosyn, etc • Vitamin B6 • Chiropractic Treatment • Acupuncture • Yoga • Physical therapy • “Cold Laser”

Page 143 of 430 Carpal Tunnel Syndrome Treatment

Surgery Surgery is considered only when all other steps have failed AND… SURGERY You wish to proceed.

3 2 You decide—unless there are constant 1 (24/7) symptoms or loss of the thumb muscles.

Page 144 of 430 Carpal Tunnel Syndrome Treatment

Surgery

Page 145 of 430 Carpal Tunnel Syndrome Treatment

Surgery—Take the pressure OFF!

SURGERY

3 2 1

Page 146 of 430 Carpal Tunnel Syndrome Treatment

TIGHT

OPEN

Page 147 of 430 Carpal Tunnel Syndrome Treatment

Page 148 of 430 Carpal Tunnel Syndrome Treatment

Surgery

Open Carpal Tunnel Release

Endoscopic Carpal Tunnel Release

“Plan B”

5 out of 1000

Page 149 of 430 Carpal Tunnel Syndrome Treatment

Endoscopic Carpal Tunnel Release

Page 150 of 430 Carpal Tunnel Syndrome Treatment

Endoscopic Carpal Tunnel Release

Page 151 of 430 Carpal Tunnel Syndrome Surgery

Page 152 of 430 Which would you Prefer?

Page 153 of 430 Carpal Tunnel Syndrome Recovery

• Many people use NO medication or just 2‐3 pills total • The night of surgery you can perform light activities such as eating and dressing • Many people can go back to work the NEXT day with reasonable and paced activities

Page 154 of 430 Carpal Tunnel Syndrome Recovery

• It takes up to 3‐4 weeks to perform • Forceful grasping • Pushing out of a chair • Extended writing or typing

• Everything in moderation !

Page 155 of 430 Carpal Tunnel Syndrome Recovery

A roofer 6 weeks post op

Page 156 of 430 Movie for Endoscopic CTR

Page 157 of 430 A Division of

Page 158 of 430 De Quervains Tenosynovitis

Page 159 of 430 De Quervains

The formal name is Stenosing tenosynovitis of the first dorsal compartment.

Page 160 of 430 De Quervain’s Definition The wrist tendons move by way of a rope‐like tendon that passes like a train through a tunnel.

Page 161 of 430 De Quervain’s Definition When the rope‐like tendon swells it is like a train with a fat caboose where the caboose gets stuck in the tunnel.

Page 162 of 430 Swelling in a normal tunnel

Page 163 of 430 Symptoms

What do people complain of ?

Page 164 of 430 De Quervain’s Symptoms • Pain and Swelling on the thumb side of the wrist • Weakness of grasp

Page 165 of 430 De Quervain’s Symptoms • Pain and Swelling on the thumb side of the wrist • Weakness of grasp

Page 166 of 430 Demographics

Who gets De Quervains?

Page 167 of 430 De Quervains Demographics

• Anybody • New Mothers or Grandmothers • Direct trauma • Diabetic patients • Rheumatoid arthritis patients • Repetitive wrist motion • Patients over 40

Page 168 of 430 De Quervains Demographics The common thread is swelling of the rope‐like tendon in a fixed tunnel.

Page 169 of 430 Treatment

What can be done?

Page 170 of 430 De Quervains Treatment • Activity Changes—less wrist motion, especially hammer like motion • Steroid Injections • Motrin‐like medications • Splinting • Surgery

Page 171 of 430 De Quervains Treatment Steroid injections

Page 172 of 430 De Quervains Treatment • Activity Changes—less wrist motion, especially hammer like motion • Steroid Injections • Motrin‐like medications • Splinting • Surgery

Page 173 of 430 De Quervains Treatment

Arthritis Medication

Page 174 of 430 De Quervains Treatment • Activity Changes—less wrist motion, especially hammer like motion • Steroid Injections • Motrin‐like medications • Splinting • Surgery

Page 175 of 430 De Quervains Treatment Surgery

Page 176 of 430 De Quervains Recovery

Page 177 of 430 A Division of

Page 178 of 430 Trigger Fingers

Page 179 of 430 Trigger Fingers The formal name is Stenosing tenosynovitis.

Page 180 of 430 Trigger Fingers Definition The fingers move by way of a rope‐like tendon that passes like a train through a tunnel.

Page 181 of 430 Trigger Fingers Definition

When the rope‐like tendon swells it is like a train with a fat caboose where the caboose gets stuck in the tunnel.

Page 182 of 430 Trigger Fingers

Page 183 of 430 Swelling in a normal tunnel

Page 184 of 430 Symptoms

What do people complain of ?

Page 185 of 430 Trigger Fingers Symptoms

• Catching or locking of the finger or thumb • Pain in the palm of the hand—opposite of the knuckle • Weakness • Morning symptoms more than daytime symptoms

Page 186 of 430 Trigger Fingers Symptoms

• Catching or locking of the finger or thumb • Pain in the palm of the hand—opposite of the knuckle • Weakness • Morning symptoms more than daytime symptoms

Page 187 of 430 Trigger Fingers Symptoms

• Catching or locking of the finger or thumb • Pain in the palm of the hand—opposite of the knuckle • Weakness • Morning symptoms more than daytime symptoms

Page 188 of 430 Trigger Fingers Symptoms

• Catching or locking of the finger or thumb • Pain in the palm of the hand—opposite of the knuckle • Weakness • Morning symptoms more than daytime symptoms

Page 189 of 430 Demographics

Who gets Trigger Fingers ?

Page 190 of 430 Trigger Fingers Demographics

• Anybody • Diabetic patients • Rheumatoid arthritis patients • Repetitive pinching or grasping • Patients over 40

Page 191 of 430 Trigger Fingers Demographics The common thread is swelling of the rope‐like tendon in a fixed tunnel.

Page 192 of 430 Treatment

What can be done?

Page 193 of 430 Trigger Fingers Treatment • Activity Changes—less pinching and grasping • Finger Extension Splinting • Motrin‐like medications • Steroid injections • Surgery

Page 194 of 430 Trigger Fingers Treatment • Activity Changes—less pinching and grasping • Finger Extension Splinting • Motrin‐like medications • Steroid injections • Surgery

Page 195 of 430 Trigger Fingers Treatment • Activity Changes—less pinching and grasping • Finger Extension Splinting • Motrin‐like medications • Steroid injections • Surgery

Page 196 of 430 Trigger Fingers Treatment • Activity Changes—less pinching and grasping • Finger Extension Splinting • Motrin‐like medications • Steroid injections‐1 or 2 injections cure about 70‐80% • Surgery

Page 197 of 430 Trigger Fingers Treatment Steroid injections

Page 198 of 430 Trigger Fingers Treatment • Activity Changes—less pinching and grasping • Finger Extension Splinting • Motrin‐like medications • Steroid injections • Surgery‐IS NOW DONE IN THE OFFICE UNDER LOCAL‐ONLY and takes 20 minutes or less • WALANT=Wide Awake Local Anesthesia No Tourniquet

Page 199 of 430 Trigger Fingers Treatment

Surgery

Page 200 of 430 Trigger Finger Surgery Recovery

Page 201 of 430 Dr. Andy Nelson Dr. Rich Manzo Dr. Eric Watson

Thank You

Page 202 of 430 REPETITIVE TRAUMA AND THE UPPER EXTREMITY: All You Ever Wanted to Know And More

Richard L. Manzo, MD

Page 203 of 430 OUTLINE

• Lateral Epicondylitis • Anatomy • Etiology • Role of Repetitive Trauma • Treatment • Medial Epicondylitis • Anatomy • Etiology • Role of Repetitive Trauma • Treatment • Cubital Tunnel Sydrome

Page 204 of 430 LATERAL EPICONDYLTIS • “Doc, why does my elbow hurt so mucn”

• “My elbow is KILLING ME…..

Page 205 of 430 LATERAL EPICONDYLITIS

• Lawn “tennis-elbow” first described in 1873 • Common • 1-3% of general population • 15% of workers in “at- risk” professions • Most common in 35- 50 age group

Page 206 of 430 ELBOW PAIN: TENNIS ELBOW

• Most common cause of lateral elbow pain • Over 50% of people on earth • “But I don’t play tennis”

Page 207 of 430 ELBOW PAIN: TENNIS ELBOW

• Usually occurs spontaneously • Can be very painful • Good News! • Self-limiting condition • BAD news.. • 9-12 months!! • Seriously….

Page 208 of 430 ELBOW PAIN: TENNIS ELBOW • Symptoms: • Lateral elbow pain with grip • Can’t use a mouse • Can’t twist a doorknob • Can’t grip a wrench • No strength • Dropping things • Burning pain

Page 209 of 430 ELBOW PAIN: TENNIS ELBOW

• Why does it occur? • Unknown……. • Lot of stress • Poor blood supply • Poor Healing capacity • Rotator cuff • Achilles tendon • Proximal Biceps • Quadriceps tendon

Page 210 of 430 ETIOLOGY • Degenerative tendinopathy primarily affecting the ECRB origin • EDC in 30% • Rarely ECRL/ECU • Related to overuse • ECRB active (Funk et al., 1987) • Flexion • Extension • Varus • Valgus

Page 211 of 430 REPETITIVE ACTIVITIES AND TENNIS ELBOW

• How long must one do this before elbows hurt?

Page 212 of 430 LATERAL EPICONDYL-ITIS?

• Repetitive microtrauma • Especially palm down activities! • Chronic degeneration • Hypovascularity Oww..my ECRB!! • Granulation tissue • Few inflammatory cells

Page 213 of 430 HISTOLOGY

• Normal tendon • Highly organized • Parallel collagen bundles • Hypocellular

Page 214 of 430 PATHOLOGY

• Granulation-like tissue • Disorganized matrix • Immature fibroblasts • Non-functional vasculature • Angiofibroblastic hyperplasia

Page 215 of 430 HYPOVASCULARITY (BALES ET AL, 2007)

• Relative avascularity

Page 216 of 430 PERFECT STORM:

• Lots of use • ECRB fires with virtually any gripping activity

• Poor healing capacity • Tendon origin tears and cannot heal

Page 217 of 430 ANGIOFIBROBLASTIC DEGENERATION (NIRSCHL, 1988) • Cellular response to microtears • 4 stages • Stage 1: Inflammatory faze; muscle soreness; usually resolves • Stage 2: Fibroblastic infiltration; degeneration • Stage 3: Pathologic change; tendinosis; structural failure • Stage 4: Chronic degeneration; calcifications

Page 218 of 430 ELBOW PAIN: TENNIS ELBOW

• My job: • Make the patient comfortable while the body heals ITSELF • Strategies: • Therapy • Bracing • Wrist splints better • Injections

Page 219 of 430 TREATMENT

• Conservative measures • Physical therapy • Counter-force braces • Wrist splints

• 80-90% success • Injections

Page 220 of 430 ELBOW PAIN: TENNIS ELBOW

• What about these injections? • Steroid • PRP • “I’m here for an injection..” • Bottom line: • They DO NOT make you heal faster or better • They CAN make you more comfortable while your body heals ITSELF • They are a helpful tool

but NOT a cure. Page 221 of 430 ALTERNATIVE TREATMENTS

• Acupuncture • Prolotherapy • Autologous blood injections • Platelet injections • ESWT treatments • Cold laser

Page 222 of 430 ELBOW PAIN: TENNIS ELBOW

• Surgery! • Last Resort: REALLY.. • 6 months of minimal relief • Surgically excise pathologic tissue • Mini-open • Arthroscopic • Percutaneous

Page 223 of 430 OPERATIVE TREATMENT

• Many techniques • Open excision +/- repair • Arthroscopic debridement • 6 week recovery • 70-98% success rate • Nirschl series • 98% overall improvement • 85% return to full activity • Is all this really necessary?

Page 224 of 430 THE PERCUTANEOUS APPROACH

• Limited ECRB tenotomy • Relieves tension • Introduces sufficient injury to stimulate healing • Office procedure • Less cost/risk to the patient

Page 225 of 430 PERCUTANEOUS RELEASE

• Knife inserted distal to lateral epicondyle • Above mid-point of radio- capitellar joint • Humeral template • Knife directed upward • No releasing posterior to “equator”

Page 226 of 430 PROCEDURE

ECRB ECRL

EDC

Page 227 of 430 THE PERCUTANEOUS RELEASE

Page 228 of 430 PERCUTANEOUS RELEASE

• Small skin incision • Substantial release of ECRB

Page 229 of 430 POST-OP

• Wound irrigated • Steri-strip closure • Soft-dressing applied • Wrist splint for comfort 4 weeks • Immediate return to activity as tolerated

Page 230 of 430 THE PERCUTANEOUS TECHNIQUE

• A simple technique • Appropriate patient • Results equivalent to open and arthroscopic techniques • Less risk to the patient?

Page 231 of 430 MEDIAL ELBOW PAIN: GOLFER’S ELBOW

• “Doc, but I don’t play golf….”

Page 232 of 430 MEDIAL EPIDONDYLITIS

• Similar pathophysiology to Lateral Epidondylitis • “Golfer’s Elbow” • Tendinopathy of the Flexor/Pronator Origin • Muscles that flex your wrist and fingers • Turn your hand Palm-Down

Page 233 of 430 MEDIAL EPICONDYLITIS

• Golfer’s elbow • Less common than tennis elbow • Similar, often LONG course • Self-limiting • 95% resolves spontaneously • Seriously • I’m not joking…

Page 234 of 430 MEDIAL EPICONDYLITIS

• Treatment is generally conservative • Therapy • Eccentric loading • Splinting • Counterforce brace • Wrist Splint • Activity Modification • Avoidance of firm grasp

Page 235 of 430 MEDIAL EPICONDYLITIS

• Open surgery

Page 236 of 430 MEDIAL EPICONDYLITIS SURGERY

• Recovery: • Begin ROM in 7-10 days • Back to full-duty 4-6 weeks

Page 237 of 430 ROLE OF REPETITIVE TRAUMA

• Both conditions can be the result of a traumatic blow • RARE • It is a repetitive tendinosis that takes time to develop • At risk professions(Occ/envir med 2013) • 1200 patients • 700 w/o elbow complaints • 36 months; 6.9% developed lateral/medial epicondylitis

Page 238 of 430 REPETITIVE MICROTRAUMA

• Strong correlation with wrist bending/twisting and forearm twisting/rotating/screwing motion • How much in enough? • Unknown • Work restrictions?

Page 239 of 430

CUBITAL TUNNEL SYNDROME

Page 240 of 430 MY FINGERS TINGLE

• Ring and middle fingers • Medial Forearm • Funny bone sensation • Fingers feel cold

Page 241 of 430 ANATOMY

• The Ulnar nerve is the issue…..

Page 242 of 430 Page 243 of 430 SYMPTOMS

Page 244 of 430 CUBITAL TUNNEL SYNDROME

• Ulnar nerve function: • Sensation to ring and small fingers • Funny bone feeling • At times painful • Power to most muscles in the hand • Intrinsic atrophy/ wasting

Page 245 of 430 CUBITAL TUNNEL: INTRINSIC ATROPHY

The hand looks “hollow”

When we see this level atrophy…it is pretty far gone Page 246 of 430 CUBITAL TUNNEL: INTRINSIC ATROPHY

The hand looks “hollow”

When we see this level atrophy…it is pretty far gone Page 247 of 430 CUBITAL TUNNEL: INTRINSIC ATROPHY

The hand looks “hollow”

When we see this level atrophy…it is pretty far gone Page 248 of 430 CUBITAL TUNNEL: INTRINSIC ATROPHY

The hand looks “hollow”

When we see this level atrophy…it is pretty far gone Page 249 of 430 • Direct blow to the inside elbow CAUSES • Persistent pressure on the inside elbow • Persistent flexed elbow postures • Previous elbow fracture with malunion • Subluxating ulnar nerve • Co-morbidities • Diabetes • Obesity • Thyroid

Page 250 of 430 CUBITAL TUNNEL SYNDROME

• Vibration

• Prolonged or repetitive positioning of a tool in space (SJEM, 2004)

Page 251 of 430 Bending the elbow SQUEEZES the nerve

Page 252 of 430 RULE OUT OTHER DIAGNOSES

• C8-T1 nerve root issues • Lower trunk brachial plexus issues • Thoracic outlet • Guyon’s canal

Page 253 of 430 C8-T1

Page 254 of 430 LOWER TRUNK BRACHIAL PLEXUS

TUMOR

Page 255 of 430 GUYON’S CANAL SYNDROME

Page 256 of 430 KEYBOARD USE AND NUMB HANDS

• Poor ergonomics • Direct pressure on the Ulnar nerve at Guyon’s canal

Page 257 of 430 PHYSICAL EXAM • Neck – nerve root compression exam • Thoracic outlet exam • Guyon’s canal palpation • Elbow Flexion Test • Elbow Tinnel • Ulnar intrinsic testing: 1st Dorsal Interossei, Abductor digiti quinti, Cross Finger test • Clawing or intrinsic atrophy

Page 258 of 430 CLAWING

Page 259 of 430 NON-OPERATIVE TREATMENT • Prevent pressure on inside elbow—chairs, workspaces • Ergonomic optimization • Avoid vibration • Change habits to extend elbows- • Tough to do • Nightime elbow extension brace • +/- Cubital tunnel injection • +/- therapy if there is a TO component

Page 260 of 430 Time

Page 261 of 430 Elbow extension

Bulk on the front of the elbow

Page 262 of 430 Cubital Tunnel Steroid Injection

Page 263 of 430 OPERATIVE TREATMENT

DECREASE PRESSURE AND/OR

DECREASE TRACTION ON THE NERVE

Page 264 of 430 OPERATIVE TREATMENT CHOICES

• Medial Epicondylectomy • In-situ decompression • Subcutaneous ulnar nerve transposition • Submuscular ulnar nerve transposition • Intermuscular ulnar nerve transposition • Endoscopic decompression • Revision with nerve wrap/sapheous vein

Page 265 of 430 MEDIAL EPICONDYLECTOMY

Page 266 of 430 IN-SITU DECOMPRESSION

Page 267 of 430 SUBCUTANEOUS

Page 268 of 430 SUBMUSCULAR

Page 269 of 430 INTERMUSCULAR

Page 270 of 430 ENDOSCOPIC CUBITAL TUNNEL RELEASE

Page 271 of 430 5 areas that can be compressed

10-12 cm

Page 272 of 430 Beginning the Dissection with Illuminated Speculum

Partial Division of Osborne‘s Ligament Division of Osborne‘s Ligament Dividing the Fascia

Separating the FCU-Muscle Dissection of the 1st fibrous Arcade Cubital Tunnel Release Page 273 of 430 NERVE

Page 274 of 430 CUBITAL TUNNEL RELEASE Which would you Prefer?

• Outcomes are equivalent • Anatomic factors • Body habitus • Nerve instability • Medial epicondylitis

Page 275 of 430 SUMMARY

• Repetitive trauma clearly plays an important role in the development of elbow problems • Firm grasping • Twisting • Impacting • Vibration • Temperature extremes

• White collar risk factors • Work-station ergonomics • Prolonged elbow flexion

Page 276 of 430 THANK YOU

Page 277 of 430 Sec. 31-299b | Workers’ Compensation Act as amended to January 1, 2007 https://wcc.state.ct.us/law/wc-act/2007/31-299b.htm

Workers’ Compensation Act as amended to January 1, 2007

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Sec. 31-299b. Initial liability of last employer. Reimbursement. If an employee suffers an injury or disease for which compensation is found by the commissioner to be payable according to the provisions of this chapter, the employer who last employed the claimant prior to the filing of the claim, or the employer’s insurer, shall be initially liable for the payment of such compensation. The commissioner shall, within a reasonable period of time after issuing an award, on the basis of the record of the hearing, determine whether prior employers, or their insurers, are liable for a portion of such compensation and the extent of their liability. If prior employers are found to be so liable, the commissioner shall order such employers or their insurers to reimburse the initially liable employer or insurer according to the proportion of their liability. Reimbursement shall be made within ten days of the commissioner’s order with interest, from the date of the initial payment, at twelve per cent per annum. If no appeal from the commissioner’s order is taken by any employer or insurer within twenty days, the order shall be final and may be enforced in the same manner as a judgment of the Superior Court. For purposes of this section, the Second Injury Fund shall not be deemed an employer or an insurer and shall be exempt from any liability. The amount of any compensation for which the Second Injury Fund would be liable except for the exemption provided under this section shall be reallocated among any other employers, or their insurers, who are liable for such compensation according to a ratio, the numerator of which is the percentage of the total compensation for which an employer, or its insurer, is liable and the denominator of which is the total percentage of liability of all employers, or their insurers, excluding the percentage that would have been attributable to the Second Injury Fund, for such compensation.

(P.A. 81-155, S. 1; P.A. 01-22, S. 2; P.A. 05-199, S. 1.)

History: P.A. 01-22 increased time for taking an appeal from order of commissioner from 10 to 20 days; P.A. 05-199 provided that Second Injury Fund not be deemed an employer or insurer and be exempt from liability under section, and that compensation otherwise attributable to fund be reallocated among any other liable employers or insurers according to ratio, effective July 1, 2006.

Page 278 of 430

1 of 2 9/21/2018, 2:03 PM Sec. 31-299b | Workers’ Compensation Act as amended to January 1, 2007 https://wcc.state.ct.us/law/wc-act/2007/31-299b.htm

Cited. 231 C. 469. Cited. 232 C. 758. Cited. 241 C. 282. Application is limited to cases of ongoing repetitive trauma or occupational disease. 263 C. 279. Cited. 33 CA 695; judgment reversed, see 231 C. 469.

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State of Connecticut Workers’ Compensation Commission Page last revised: June 24, 2014 Page URL: http://wcc.state.ct.us/law/wc-act/2007/31-299b.htm

Workers’ Compensation Commission Disclaimer, Privacy Policy and Website Accessibility

Page 279 of 430

2 of 2 9/21/2018, 2:03 PM

Repetitive Trauma: Claimant’s Perspective

A. Types of injuries: Most common include CTS and hearing loss

B. Other types: 1) Back from repetitive lifting 2) Neck from constant position of head doing inspection/computer work 3) Shoulder from repetitive overhead activities

C. Intake: 1) Obtain as much information as possible regarding the exact physical motions the claimant does at work with attention to frequency, amount of weight, and height. 2) Also, ask them to bring a resume or other documentation to the intake to identify all past employers.

D. Date of injury: 1) Generally, it’s the date of last injurious exposure. However, do not just assume the last date of work, as the claimant may have been doing a different activity that day, weeks or months leading up to that date. 2) Also, often times there is medical treatment for the injury prior to the date of last injurious exposure, therefore try to use a date as early as you can with regards to the statute of limitations to encompass as much of the treatment as possible.

E. Causation: 1) When asking the doctor for a causation opinion give as much information as possible regarding the claimant’s work activities. 2) If you can, obtain a job description for the doctor; otherwise have the claimant write up a detailed description of the work activities.

F. 31-299b: 1) This statute puts the onus of administering the claim onto the last employer and/or insurance carrier, which makes it easy to know who to make the claim against. 2) However, the problem from a claimant’s perspective is that at times the last employer or carrier has a very small period of exposure. If this is the case you can run into resistance which will delay the acceptance of the claim. Therefore, find out from the claimant at intake what companies they have worked for in the past doing the same repetitive activity. Also, check the WC website on the coverage verification section to find out the carrier names and periods of coverage. This way you will have information to provide to the last carrier to expedite the apportionment search and know who to have cited into the hearings. 3) To be even more proactive, if you have clearly defined periods of employment with different employers, you could ask the treating physician to comment on apportionment. 4) The biggest obstacle I find in these apportionment cases is for settlement. Usually you are dealing with 5 to 6 carriers all trying to agree on 1) the ultimate value of the case and 2) what percent of exposure they have. I had a case recently that settled for just over $10,000 and required 8 hearings to be finally approved, after the commissioner gave us a number. 5) From the claimant’s point of view, being more proactive in the beginning of the claim and providing as much information as possible identifying past employers and carriers and medical evidence regarding apportionment, could certainly make your and your client’s life much easier.

{A0493903-1} Page 280 of 430 Repetitive Trauma: Respondent’s Perspective

1. Determine whether the employer/insurer is going to (1) accept that an injury occurred and (2) accept that it is work related. Next, the employer/insurer needs to decide if they (3) agree that the injury is a repetitive trauma vs. a specific incident. If the respondent is not going to accept the repetitive trauma, they are going to need a medical opinion and/or some factual evidence to support their argument.

2. If your employer/insurer accepts that there was an injury that is work related and accepts it as a repetitive trauma, the next thing to determine is who the 299b carrier/last insurance carrier on the risk is. That carrier will be responsible for the initial payment of all benefits that will later be reimbursable per §31-299b.

3. The alleged date of injury, making a respondent the 299b carrier, is important in the initial stages. However, that date is not necessarily set in stone. The individual facts and medical opinions of each case can, at times, change the date of injury for purposes of determining the 299b carrier. If a respondent doesn’t agree to accept their status as 299b carrier or contests that the injury is due to a repetitive trauma/occupational disease, they will need to get a medical opinion to support this (RME/records review) and/or take some depositions.

4. If a respondent is the 299b carrier, but only has a small amount of exposure, you can see if the insurance carrier with the largest share wants to administer the claim. If you are the carrier with the largest share, and it is a high exposure case, it may make sense to control the progress of the claim. This varies case by case and largely depends on the desires of each employer/insurer. If a carrier has a small amount of exposure, you can also try to get a medical opinion that indicates your carrier does not have any exposure at all. However, this is not always a cost-effective option.

5. If you are investigating an apportionment/occupational disease claim, it is always a good idea to speak with the employer directly to determine the claimant’s specific job duties at your location. You can then present that information to a doctor to try to get a medical opinion that is more favorable to your client.

6. If you are not sure if your employer/insurer is going to be the 299b carrier and there is a sense of urgency regarding the claim, your carrier can decided to commence the payment of medical or indemnity benefits without prejudice, while these issues are sorted out.

Concerns with doing this before the legal exposure is sorted out:

a. Will your carrier get any or all of its money back if your insurer/employer ultimately has zero exposure? Yes, the Commissioner has the power to order this if that is the ultimate conclusion.

b. What if your carrier has some exposure but you are not sure how much and you don’t want to overpay while it is being sorted out? Again, the Commissioner can fix this at a formal hearing if the individual carriers will not agree to do this on their own.

Page 281 of 430 c. What if your carrier doesn’t want to pay without prejudice because they don’t want to pay the legal expense related to getting your money back? This depends on your case and the individual carrier as well as your anticipated exposure. You can also attempt to reach an agreement, in writing, with the other counsel involved, if this is something you are considering and concerned about.

Apportionment Steps When You Are the 31-299b Carrier

1. Obtain a medical causation report from a doctor that says the condition is (1) repetitive trauma or occupational disease. The medical report will need to detail the time frame for apportionment or the time frame over which the repetitive trauma/occupational disease occurred.

2. Once you have a medical opinion, you need to consider how strong your case is before deciding whether it is finically worth it for your client to try and get their money back (balancing the legal expenses with the recovery and the facts of your case). As an example, are there any prior specific injuries to consider in your fact pattern that may shorten or limit the apportionment period?

3. Information you are going to need: All medical records past and present. Get an employment/work history from the claimant if you can by way of a written statement or a deposition. The statement/deposition needs to include with detail, the claimant’s specific job duties. If there is more than one employer, social security records will be very important in determining additional exposures and other employers/insurers that will need to be cited in.

4. Obtain insurance coverage cards to determine the employers/carriers on the risk for your apportionment period as supported by your medical report. Get this from the Connecticut Insurance Statistical Division. Also check the date of hire on the first report of injury and determine last day the claimant worked.

5. Obtain a payment history for all medical and indemnity benefits paid to date.

6. Prepare an apportionment chart detailing the proposed responsibility of each carrier/employer.

7. Prepare an apportionment package for distribution to other employers/carriers. Include your apportionment chart, all medical records, voluntary agreements, the print out of med/indemnity benefits paid to date, depo transcript(s) or social security wage statement and insurance cards.

8. Request an informal hearing on the issue of apportionment pursuant to 31-299b and cite in all appropriate employers and carriers.

9. Doing all the above before you request a hearing will significantly reduce the amount of hearings that are needed and the number of supplemental requests coming in from counsel.

Page 282 of 430 Lumbar Spine Repetitive Stress Injury David Forshaw MD FAANS

Page 283 of 430 “Everything we hear is an opinion, not a fact. Everything we see is a perspective, not the truth”

–Marcus Aurelius

Page 284 of 430 What is an RSI

• RSI refers to wide variety of problems. An RSI can affect almost any moveable part of the human body.

• RSIs are associated with repetitive tasks, forceful exertions, vibrations, mechanical compression or awkward positions.

• Other names include repetitive motion injuries, repetitive motion disorder (RMD), cumulative trauma disorder (CTD), occupational overuse syndrome, overuse syndrome, and regional musculoskeletal disorder.

Page 285 of 430 Occupational Activity

• Cyclic Activity- A job that has repetitive cycles many times a day. Labor specialization has resulted in fewer different tasks per job and is a contributing factor

• Vibration-especially over long periods, has long been shown to be a factor in increasing the risk of injuries to the back and wrist

Page 286 of 430 Schematic for work related MSK disorders

Page 287 of 430 RSI and Psychological Factors

• Psychological and social factors affect repetitive strain injury complaints.

• Psychological stresses in large amounts have been associated with doubled risk of the reported pain. Similarly job demands, poor support from colleagues, and work dissatisfaction have also been shown to increase pain

Page 288 of 430 Who is at Risk?

• A review of 57 surveillance studies that looked at the most investigated personal risk factors for LBDs.

• The strength of these risk factors is mild at best.

Page 289 of 430 Pathophysiology of RSI

• Tissues take time to adapt to the stresses placed on them. A tissue could be subjected to various stresses like shear, tension, compression, impingement, vibration and contraction.

• If tissues do not get time to adapt to repeated forces acting on them, mechanical fatigue and failure can result.

• Thus rate of injury > rate of adaptation and healing of the tissue.

Page 290 of 430 Tissue chemical changes

• Tissues subjected with repetitive stress have altered levels of prostaglandin E2 and nitric oxide.

• Alterations in the regulation of genes within tendons undergoing overuse have been shown in experimental animals. Suggesting that overuse may cause a morphological alteration in the tissue.

• Cavanaugh et al [1997] showed cellular and neural mechanisms that lead to facet pain, discogenic pain and sciatica. They identified nerve fibers in the joint capsule and the annulus and how moderate pressure on the DRG can lead to sciatica. Confirmed by Bogduk [1995]

Page 291 of 430 Biomechanical Logic

A-when a load exceeds a tolerance injury occurs. B-cumulative trauma due to variable loading C-explanation of cumulative trauma due to tolerance reduction

Page 292 of 430 Degenerative Pathway

This process represents the beginning of cumulative trauma to the spine and can result in disc protrusions, disc herniation and instability of the spinal system.

Lotz et al. [1998] demonstrated how disc compression can initiate harmful disc responses that respond according to a dose±response relationship, thus providing further evidence of a cumulative trauma to the spine.

Page 293 of 430 Clinical presentation

• The symptoms of overuse injury of RSI depend on the region involved and the forces involved.

• Major complaints are pain and stiffness

• There are activities that worsen the pain, flexion/extension, prolonged standing, axial loads.

• Patients may complain of weakness and lack of endurance

• Radicular symptoms such as numbness, tingling, or pain are possible from chemical or physical irritation of the nerve roots

Page 294 of 430 History

• A detailed inquiry about work place conditions, job activities, specific hobbies or training methods.

• A history of popping, clicking, rubbing, erythema or swelling should she be asked about

Page 295 of 430 Differential Diagnosis

• Acute injuries

• Infection

• Inflammatory Diseases

Page 296 of 430 Work-up

• Lab studies to exclude other potential etiologies

• CBC, ESR, CRP, ANA, Vit B12 levels, TSH, BMP, LFTs

• Imaging

• X-rays- possibly normal, or showing degenerative changes, loss of disc height, foraminal stenosis, listhesis, osteophytes, or pars fractures

• MRI- loss of disc hydration, high intensity annular zones, disc herniations, facet hypertrophy, modic changes

Page 297 of 430 Multiple Traumas

• With multiple discrete traumas there are separate events separated by time and potentially different mechanisms that can lead increasing degrees of dysfunction, with or without a return to baseline. • Patients who are working in physically demanding jobs are more likely to encounter multiple discrete traumas, and it may not be clear as to the ultimate causal etiology.

Page 298 of 430 CDC/NIOSH

• Published critical review of epidemiological evidence for work related MSD of Neck, UE and Low back in 1997

• In 1994 last data year prior to publication there were 705,800 cases of overexertion or repetitive motion.

• Over 40 articles were used as evidence for the generation of the relationship between occupational exposure and low-back disorder

Page 299 of 430 CDC continued

• 4 categories of evidence

• Strong evidence-“a causal relationship is shown to be very likely between intense or long duration exposure tom a specific task”

• Evidence- “some convincing epidemiological evidence shows a causal relationship…”

• Insufficient evidence- “the available studies are of insufficient number, quality, consistency or statistical power to permit a conclusion”

• Evidence of no effect of work factors-“Adequate studies consistently show that the specific workplace risk factor is not related”

Page 300 of 430 CDC continued

Back Strong Evidence Insufficient No effect

Lifting/forceful movements x

Awkward posture x

Heavy Physical work x

Whole body vibration x

Static work posture x

Page 301 of 430 CDC Continued

• “This critical review of the epidemiological literature identified a number of specific physical exposures strongly associated with specific MSDs when exposures are intense, prolonged, and particularly when workers are exposed to several risk factors simultaneously.”

Page 302 of 430 Heavy work

• Heavy Physical Work was defined as work that has high energy demands or requires some measure of physical strength.

• 18 studies looked at this exposure. Only 3 had defined health outcomes using both symptoms and medical exam criteria, only 2 assessed exposure independent of self reporting.

• 14/18 studies did not asses the temporal response between work and injury

• 9/18 showed a positive response between exposure and outcome and all were in the positive direction. Conversely 9/18 showed no response

Page 303 of 430 Heavy Work

• Videman et al. [1990] study of cadavers addressed two aspects of the causal chain linking exposure of heavy physical work and low back disorder

• It showed an association between subjective health outcomes and objective measures with significant spinal pathology

• Second it showed an association of objective measures of the disorder with heavy work exposures, (increased disc degeneration, vertebral osteophytes, and facet osteoarthritis)

Page 304 of 430 Heavy Work

• Heliovaara et al [1991] looked at a cross sectional analysis of chronic low back syndrome, sciatica and LBP. They interviewed and examined patients and assessed work place exposure and created a “sum index of occupational and physical stress”

• A dose response was observed for sciatica and the physical stress score and for low ack syndrome and physical stress.

• Strengths were a high response rate, objective measures of health outcomes and multivariate adjustment for covariates.

Page 305 of 430 Heavy Work

Page 306 of 430 Heavy Work

• In all 18 studies the authors stated that “heavy physical effort or work” was a risk factor of interest, the actual estimates of the exposures varied from job title assumptions to self reported scores. In no case were measured physical loads used as independent variables.

Page 307 of 430 Heavy Work

• In summary despite the fact that across the studies they defined disorders and assessed exposures in a heterogenous way. All studies that did demonstrate significant associations between exposure and outcome did so in a positive way. While there may have been some misclassification of exposure status this might have caused a dampening effect of risk estimates. This may have accounted for some of the lower OR in some of the studies.

Page 308 of 430 Lifting and Forceful Movement

• Lifting is moving or bringing something from a lower level to a higher one. And forceful movements include pushing, pulling or other efforts.

• 18 studies examined relationships between back disorders and lifting or forceful movements.

• 1 study met all 4 evaluation criteria Punnett et al. 1991 case controlled study of auto workers.

Page 309 of 430 Punnett et al.

• Case controlled study involving 95 auto workers with back pain, controls of auto workers without pain.

• Jobs video taped and work cycles were reviewed using posture analysis system.

• Exposures included time spent in awkward positions. When multivariate analysis was performed they showed that adjusted for age, gender, length of employment, recreational activities and medical history that time in non-neutral positions was strongly associated with back disorder. OR of 8.09 (95% CI from 1.4-44)

• When the subset with physical medical findings was examined the associations were even more pronounced.

• They also demonstrated a strong increase in risk with both the intensity and the duration of the exposure.

Page 310 of 430 Lifting

• During lifting three types of stress are transmitted through the spinal tissues of the low back; compressive force, shear force, and torsional force. [Waters et al. 1993]

• It is suggested that disc compression is responsible for end plate fracture, disc herniation and nerve root irritation. [Chaffin and Anderson 1984]

Page 311 of 430 Lifting and Forceful Movements

• 8 studies examined exposure response relationships

• 4 found dose-response relationships between low back disorder and objective measures of lifting.

• 1 found a dose response between sudden maximal efforts and low back disorder [Magora]

• 1 found an association between low back disorder and length of employment [Undeutsch]

• 2 found no no dose relationship

Page 312 of 430 Lifting and Forceful Movements

Page 313 of 430 Lifting and Forceful Movements

• “There is strong evidence that low back disorders are associated with work related lifting and forceful movements.” -CDC

• The 5 studies without an association were of poorer design and more subjective.

• For the most part higher OR were observed in high exposure populations

Page 314 of 430 Bending and Twisting (awkward posture)

• Bending is defined as flexion of the trunk, usually in the forward or lateral direction, twisting refers to trunk rotation.

• Awkward postures consist of non- neutral trunk postures in extreme positions or at extreme angles

• Risk is likely related to speed or changes and degree of deviation from neutral

Page 315 of 430 Bending and twisting

• 12 studies looked at the relationship between low back disorder and bending/twisting (awkward posture)

• Outcomes included low back and sciatic pain, lumbar disc herniation, and back injury reports

• 4 studies used both symptoms and medical reports

Page 316 of 430 Bending and Twisting

• Burdof et al [1991] loved at back pain symptoms in a cross sectional study of male concrete fabrication workers and a reference group of maintenance workers.

• They evaluated exposures using the Ovako Working Posture Analysis System which asses posture for the back and lower limbs and lifting load. The concrete workers had an OR of 2.8 compared to the control.

• They also found associations between back pain and posture index, with the highest incidence in steel benders who also had the highest rates of time in bent postures

Page 317 of 430 Bending and Lifting

• Marras et al [1995] looked at the relationship between low back disorders and spinal load during occupational activities.

• 403 jobs across 48 different manufacturing companies were assessed for risk of low back injuries using medical reports.

• Jobs were in 3 categories according to risk for position, velocity, and acceleration of movements using electrogoniometric techniques.

Page 318 of 430 Bending and Lifting

• Marras cont’ 5 factors distinguished between high and low risk jobs

• Lifting frequency, load moment, trunk lateral velocity, trunk twisting velocity, and trunk sagittal angle

• The highest combo had an OR of 10.7 compared to the lowest

Page 319 of 430 Bending and Lifting

Page 320 of 430 Whole Body Vibration

• WBV refers to mechanical energy oscillation which are transferred to the body as a whole, usually through a supporting system such as a seat or platform.

• Typical exposures are through driving trucks or operating industrial vehicles

Page 321 of 430 WBV

• 19 studies reviewed, Health outcomes were symptom report or LBP, sciatica, lumbago, sick leave or disability retirement due to back disorders and herniated discs.

• 5/19 used similar methodologies

Page 322 of 430 WBV

• Bovenzi and Betta [1994] examined the relationship between WBV and back disorder in male tractor drivers. It was a cross sectional study comparing them with revenue inspectors and administration workers

• Vibration measures were taken from a sample of tractors and linked to individual hours driven yearly.

• Tractor drivers had an OR of 3.22 of lifetime LBP. The one year exposure OR was 2.39

• In multivariate analysis LBP showed a dose response with total vibration dose and the duration of exposure.

Page 323 of 430 WBV

• Bovenzi and Zadini [1992] looked at bus drivers controlled with maintenance employees.

• Again cumulative vibration exposure demonstrated higher OR of LBP

• Across three escalating dose categories the OR of 1.67, 2.63, and 3.46

Page 324 of 430 WBV

• 4/5 studies using quantitative exposure assessments demonstrated positive associations between back disorders and vibration exposure. The 5th found no association however it did find them is associated sub groups (suggesting a biased population).

• The data for WBV goes back to the 1960s and there were many more studies in the 80s and an NIH study that found male truck drivers had a RR of 2.0 compared to all male workers for LBD

Page 325 of 430 Lab evidence of WBV

• Wilder and Pope [1996] showed in a lab the WBV causes physical spine changes, including fatigue of the paraspinal muscles and ligaments, lumbar disc flattening, disc annular fiber strain, intradiscal pressure increases, disc herniations and micro fractures in end plates.

• Wikstrom et al [1994] showed that high exposure to vibration causes degeneration and fracturing of the vertebral end plates.

• He also showed that vibrations causes EMG changes in the paraspinal muscles of the low back, leading to muscle exhaustion predisposing to further low back injuries.

Page 326 of 430 WBV

Page 327 of 430 Static Work Positions

• Static work positions include isometric positions where very little movement occurs, along with cramped or inactive postures. These include sedentary work.

• 10 studies looked at the association between lap and static work postures, 6/10 found no association between sedentary work and LBP, the others found at best small to modest increases in risk.

• The studies show poor consistency in estimation of the risk of static work with LBP

Page 328 of 430 Static Work Posture

Page 329 of 430 The Case for Cumulative Trauma

• Cumulative trauma is a common element found in many reports of low back pain associated in the work place. Others argue that these disorders are idiopathic and a normal life experience due to progressive ‘wear and tear” of the spine structures and tissues.

Page 330 of 430 Cumulative trauma

The observational literature suggests that cumulative exposure might explain at least part of the low back pain picture. However, epidemiological studies are limited in that they are often not specific enough in their measures to assess the precise dose–response trends associated with work.

Page 331 of 430 Cumulative trauma At the heart of the logic of cumulative trauma plausibility is the relationship between loads imposed on a structure and the tolerance of that structure.

This concept is at the core of biomechanical analyses and suggests that when the loads experienced by a structure exceed the tolerance of a structure, damage occurs, whereas if the imposed load magnitude is below that of the structural tolerance, the loading is safe.

In classical mechanical terms “damage” would indicate structural change, which has been demonstrated to occur in the spine for human and animal models as a result of cumulative trauma. Callaghan et al. [2001] Page 332 of 430 Cumulative tauma

• The tolerance of a tissue may change over time with repetitive loads. Material science show us that materials fatigue during repetitive loads and are subject to damage, ie a paperclip will change, the material will heat up and become more brittle and fail.

• Similar processed are at work for biologic materials. Hip joints wear down with excessive use and athletes develop shin splints with excessive activities.

• There is cadaveric evidence that spines are compromised at low levels of forces when exposed to repetitive loading. Brinkman et al [1998]

Page 333 of 430 Cumulative trauma

• Studies have also shown that psychosocial factors have an interactive effect with biomechanics loading. David et al [2000]

• And individual factors, such as personality, can explain some of the variance in the magnitude of the loading forces experienced across individuals. Marras et al [2000]

Page 334 of 430 Cumulative trauma

• Relationship between workplace biomechanics forces and personality factors which accounts for the observed “J’ relationship of risk and intensity. Videman et al [1990]

Page 335 of 430 Cumulative Trauma The evidence suggests that cumulative exposure to loads when combined with other risk factors can contribute to low back disorders above and beyond the influence of aging or genetics alone.

Therefore, instead of asking whether cumulative trauma exists, the question shifts to, how big a role can cumulative exposure to biomechanical loads play in the causation of low back disorders when considered in context along with the effects of the other risk factors?

Page 336 of 430 Thank You

Page 337 of 430 Page 338 of 430 Page 339 of 430 Page 340 of 430 Page 341 of 430 Page 342 of 430 Page 343 of 430 Page 344 of 430 Page 345 of 430 Page 346 of 430 Page 347 of 430 Page 348 of 430 Page 349 of 430 Page 350 of 430 Page 351 of 430 Page 352 of 430 Page 353 of 430 Page 354 of 430 Page 355 of 430 Page 356 of 430 Page 357 of 430 Page 358 of 430 Page 359 of 430 Page 360 of 430 Page 361 of 430 Page 362 of 430 Page 363 of 430 Page 364 of 430 Page 365 of 430 Page 366 of 430 Page 367 of 430 Page 368 of 430 Occupational Disease in Connecticut, 2018

This report covers data for 2016 and was prepared under contract for the State of Connecticut Workers’ Compensation Commission, Stephen M. Morelli, Chairman, as part of the Occupational Disease Surveillance Program, operated in cooperation with the Connecticut Department of Labor and the Connecticut Department of Public Health

by Tim Morse, PhD, Professor Emeritus Division of Occupational and Environmental Medicine and Department of Community Medicine UConn Health Farmington, CT 06030 [email protected]

September 2018

Page 369 of 430 Table of Contents

List of Tables ...... 3 List of Figures ...... 4 A. Executive Summary ...... 5 Map of rates of illness by town…………………………………………………………...7 B. Summary of Diseases ...... 8 C. Bureau of Labor Statistics/Connecticut OSHA Surveys ...... 10 Occupational Illnesses in 2016...... 10 Illnesses by Industry...... 12 Lost-Time Illnesses...... 12 D. Workers’ Compensation First Report of Injury Data ...... 15 Illnesses by Town/Municipality ...... 19 Musculoskeletal Disorders ...... 20 Infectious Diseases ...... 22 Respiratory Illness and Poisonings ...... 23 Chronic Lung Conditions ...... 24 Skin Conditions ...... 25 Stress and Heart Conditions ...... 25 Other Occupational Diseases ...... 27 E. Occupational Illness Surveillance System: Physicians’ Reports ...... 28 Musculoskeletal Disorders ...... 31 Skin Conditions ...... 33 Lung/Respiratory Diseases and Poisonings ...... 33 Lead Poisoning ...... 34 Infectious and Other Diseases ...... 35 F. Appendix 1: Databases and Methods ...... 37 G. Appendix 2: Occupational Disease Detail by Type and Year ...... 39 H. Appendix 3: Internet Resources for Job Safety and Health ...... 41 I. Appendix 4: Who’s Who: Resources in Connecticut on Job Safety and Health ...... 45

2 Page 370 of 430 Tables

Table A-1 Summary of Occupational Diseases Reported by Systems, 2013 - 2016 ...... 5 Table B-1 Matched, Unique, and Estimated Total Cases of Occupational Illness, CT, 2016 .... 9 Table C-1 Occupational Disease by Type, BLS/Conn-OSHA 2015 - 2016 ...... 10 Table C-2 Illness Rates per 10,000 Workers by Industry and Type of Illness, CT, 2016 ...... 12 Table C-3 Illnesses involving Repetitive Motion by Type 2015 - 2016 ...... 14 Table D-1 Occupational Disease by Type, WCC, 2015 - 2016 ...... 15 Table D-2 Occupational Illness by Age, 2016 ...... 16 Table D-3 Cases of Occupational Disease by Major Industry Sector, WCC, 2016 ...... 17 Table D-4 Type of Disease by Industry Sector, WCC, 2016 ...... 17 Table D-5 Specific Industry Sectors with over 25 Cases of Occupational Disease, 2016 ...... 18 Table D-6 Illnesses by Town/Municipality, WCC, 2016 ...... 19 Table D-7 Musculoskeletal Disorders by Type, WCC, 2015 - 2016 ...... 21 Table D-8 Musculoskeletal Disorders by Part of Body, WCC, 2016 ...... 21 Table D-9 Musculoskeletal Disorders (MSD) with Identified Cause, WCC, 2016 ...... 23 Table D-10 Infectious Disease and Exposures by Type, WCC, 2015 - 2016 ...... 23 Table D-11 Respiratory Conditions and Poisonings by Cause, WCC, 2015-16 ...... 24 Table D-12 Chronic Lung Diseases by Type, WCC, 2015 - 2016 ...... 25 Table D-13 Skin Diseases by Cause, WCC, 2015 - 2016 ...... 25 Table D-14 Heart and Hypertension Conditions by Type, WCC, 2015 - 2016...... 26 Table D-15 Stress Conditions by Cause, WCC, 2016...... 26 Table D-16 Other Occupational Illnesses, WCC, 2015 - 2016 ...... 27 Table E-1 Occupational Disease Case Reports by Type, OIISS and ABLES, 2007-2016 ...... 28 Table E-2 Type of Illness by Industry Sector (NAICS), OIISS, 2016 ...... 30 Table E-3 Musculoskeletal Disorders by Type, OIISS, 2015- 2016 ...... 31 Table E-4 Common Causes of MSD, OIISS, 2016...... 32 Table E-5 Skin Conditions by Type, OIISS, 2015- 2016 ...... 33 Table E-6 Respiratory Diseases and Poisonings by Type, OIISS, 2015- 2016 ...... 33 Table E-7 Lead Cases by Level of Blood Lead, CT ABLES, 2015-2016...... 34 Table E-8 Infectious and Other Illnesses, 2015- 2016 ...... 35 Table G-1 Cases of Occupational Disease, by Type, BLS/Conn-OSHA, 1979 - 2016 ...... 39 Table G-2 Rate per 10,000 Workers of Occupational Disease, by Type, BLS/Conn-OSHA, 1979 - 2016...... 40

3 Page 371 of 430 Figures

Figure A-1 Map of Occupational Illness Rates by Town, 2016 ...... 7 Figure B-1 Summary of Diseases Reported by System, 2016 ...... 8 Figure B-2 Trend in Occupational Disease Reports by Reporting System, 1997-2016 ...... 9 Figure C-1 Rates of Occupational Illness by Type, US and CT, 2016 ...... 11 Figure C-2 Rates of Occupational Disease by Type and Year, CT, 2002 - 2016 ...... 11 Figure C-3 Rates of Musculoskeletal Disorders, CT and US, 2004 - 2016 ...... 13 Figure C-4 Rates of Lost-time Carpal Tunnel (CTS) and Tendonitis, US & CT, 2016 ...... 13 Figure D-1 Percent of Women by Disease Type, WCC, 2016 ...... 15 Figure D-2 Occupational Illness Cases by Industry, WCC, 2016 ...... 16 Figure D-3 Rate per 10,000 Employees (20 cases or more), by Town ...... 21 Figure E-1 Occupational Disease Case Reports by Type, OIISS and ABLES, 1998-2016 ...... 28 Figure E-2 Occupational Disease by Age, OIISS, 2016 ...... 29 Figure E-3 Occupational Disease by Industry Sector, OIISS, 2016 ...... 30 Figure E-4 Musculoskeletal Disorders by Industry Sector, OIISS, 2016 ...... 32 Figure E-5 Lead Cases 2003-2016 ...... 34

4 Page 372 of 430 A. Executive Summary This report focuses on occupational disease reports for 2016 and recent trends in reported cases. It does not address traumatic occupational injuries; data for Connecticut injuries can be found at the national Bureau of Labor Statistics at https://www.bls.gov/iif/oshstate.htm. Occupational diseases are typically harder to detect than injuries, since they often occur over longer periods of time, and can have multiple (including non- occupational) risks. Therefore, this report uses data from three primary sources as a way of establishing a more complete picture of occupational disease: Workers’ Compensation First Report of Injury cases (WCC), physicians’ reports under the Occupational Illnesses and Injury Surveillance System (OIISS), and the Bureau of Labor Statistics/Conn-OSHA Annual Survey (BLS).

Table A-1: Summary of Diseases Reported by Systems, 2014-2016 Type of Disease BLS/Conn-OSHA WCC OIISS (Physicians) Unique Cases* 2014 2015 2016 2014 2015 2016 2014 2015 2016 2014 2015 2016 Lung & poisonings 200 200 200 520 364 315 171 178 133 660 511 431 Lead ** 379 425 330 Skin 400 400 500 230 178 193 140 166 158 343 310 313 Musculoskeletal*** *** *** *** 3,028 2,831 2,916 774 734 633 3,610 3,403 3,430 Infectious 1,287 1,045 1,155 1500 1390 1513 2,572 2,262 2,408 Hearing loss 300 200 300 138 84 105 12 17 12 147 99 115 Other*** 1,400 1,500 1,300 765 788 770 172 178 238 925 940 978 Total 2,400 2,300 2,300 5,968 5,290 5,454 3,148 3,088 3,017 8,257 7,525 7,675 Sources: BLS: Bureau of Labor Statistics/Conn-OSHA survey; WCC: CT Workers’ Compensation Commission (First Report of Injury) OIISS: Occupational Illnesses and Injury Surveillance System (physician reports) *Unique cases are the combined total of workers’ compensation cases and physician reports, adjusted for cases reported to both systems **Laboratory reports of adult blood lead levels are from the Connecticut Adult Blood Lead Epidemiology and Surveillance program *** Musculoskeletal Disorders (MSD) definitions vary somewhat between systems. MSD is included in the “other” category for BLS/Conn-OSHA data

Table A-1 summarizes the data from the three different sources for the last 3 years. The BLS survey rounds to the nearest 100, so the subcategories do not always sum exactly to the total and yearly changes should be viewed with caution. The OIISS draws from physician reports for known or suspected occupational illnesses and are required of all physicians but in practice are mostly from the network of occupational health clinics (and therefore are likely to over-represent illnesses from those hospitals).

Approximately 2,300 cases of occupational diseases were reported under the BLS/Conn-OSHA survey, 5,454 through the workers’ compensation first report of injuries and 3,017 for OIISS (including lead reports) for 2016. The number of reports in 2016 stayed the same as 2015 in the BLS system, increased by 3% for workers’ compensation, and decreased 2% for physicians’ reports. Reports from workers’ compensation and physicians combined (adjusting for matching cases reported to both systems) totaled 7,675 unique reports (excluding the 330 lead poisoning cases), an increase of 2% from the previous year. Statistically adjusting for estimated unreported cases produces an estimate of approximately 31,500 cases of occupational illnesses in Connecticut for 2016 (Table B1).

Musculoskeletal disorders (MSD) such as Carpal Tunnel Syndrome and tendonitis dominated the workers’ compensation reports, accounting for 53% of reports (21% of the physician reports). MSD has not been broken out by BLS since 2002, but MSD cases are presumed to be the main portion of the “other illness” category, which is by far the largest BLS category. Respiratory diseases and poisonings, which include respiratory conditions and lung disease such as asthma, as well as poisonings such as from carbon monoxide and lead, accounted for 6% of cases for workers’ compensation and 4% of physician reports. Infectious diseases, which 5 Page 373 of 430 include bloodborne diseases such as HIV and hepatitis, Tb, scabies, Lyme disease (and including exposures as well as diagnosed disease) accounted for 21% in workers’ compensation but 50% of physician reports (infectious disease is categorized under “other disease” in BLS; also, needlesticks and other bloodborne exposures with lost time are counted under injuries rather than illness in BLS). “Other diseases”, which includes infectious diseases and MSD in BLS, physical hazards such as heat and cold exposures, allergies, cancer, and others in Workers’ Compensation and physician reports, accounted for 14% (WC) and 8% (physicians). Skin conditions accounted for 4% (WC) and 5% (physicians). Lead poisoning is tracked separately and is based on laboratory reports to the Connecticut Department of Public Health; very few of those cases are reported to the other systems.

There was an overall illness rate of 17.4 cases per 10,000 workers based on the BLS survey, 2% lower than the previous year. The CT rate was 6% higher than the average national rate of 16.4. The highest specific sector rate was State Government with 41.8, with the highest rates for skin conditions (17.7) and lung conditions (7.9). Local Government was second with 32.1, and Utilities third highest rate with 31.8.

Overall (based on Workers’ Compensation reports), approximately 49% were for women, but this varied by type of case, with women accounting for 66% of infectious cases. Based on workers’ compensation reports, occupational illnesses occurred more in older workers, with almost half involving workers between 40 and 59 years old. Based on physician reports where race and ethnicity were known, 16% of cases were black and 8% Hispanic.

The most common specific diagnoses for musculoskeletal disorders reported by physicians were epicondylitis (tennis elbow) with 17% of the cases, tenosynovitis (14%), and carpal tunnel syndrome (12%). The most common specific causes (aside from the commonly used terms “repetition” or “cumulative”) for MSD in workers’ compensation reports were lifting, pushing or pulling, tool use (including references specifically to pneumatic tools or vibration exposure), and computing and clerical tasks.

Nonspecific respiratory illnesses were the most common type of physician-reported lung condition, with 53% of reports, followed by asthma or reactive airways dysfunction syndrome (RADS) with 11%. Exposures associated with respiratory conditions included lead fumes, other fumes (including gas or carbon monoxide), chemicals (including solvents, cleaning chemicals, and oil), mold or indoor air quality, and smoke.

Infectious disease and exposures were reported primarily through workers’ compensation. There were 872 reports of potential exposure to bloodborne pathogens (including reports of exposure to HIV/AIDS and Hepatitis C), accounting for 75% of all infectious disease reports. There were 75 reports of exposure to meningitis in health care settings. There were 57 reports of tick bites, rashes from tick bites and/or a diagnosis of Lyme disease attributed to occupational exposures. There were 47 cases of tuberculosis infection, usually determined by PPD conversion (which is a skin test based on immune response) or based on exposure to patients or clients with TB.

Rates of illness varied widely by municipality based on workers’ compensation reports. Often the highest rates appear to be related to having large employers in high rate industries. The overall state mean (average) was 33.3 cases per 10,000 employees. There were 62 towns and cities with at least 25 cases of occupational disease. Of those, Farmington had the highest rate at 126 cases per 10,000 employees, almost 4 times the rate as the state average. Farmington was followed by Hartford (89 cases per 10,000), Cromwell (89), Groton (85), Westbrook (84), Windsor Locks (73), East Windsor (63), Cheshire (61), Stratford (60) and Middletown (58). Figure A-1, a map of the rates by town is below, with rates listed in Table D-6. The map is based on 25 or more cases (prepared by Connie Cox Cantor at the Center for Population Health of UConn Health).

6 Page 374 of 430 Figure A-1: Map of Occupational Illness Rates by Town, 2016 (map prepared by Connie Cox Cantor, Center for Population Health, UConn Health

7 Page 375 of 430 B. Summary of Diseases Figure B-1 shows the totals by disease category for 2016 for three reporting systems: the Bureau of Labor Statistics/Conn-OSHA (BLS) survey; Workers’ Compensation (WC) First Reports of Injury; and the Occupational Illnesses and Injury Surveillance System (OIISS) which are physician reports. Categories have been combined to make comparisons as close as possible; however, differences in the three systems’ definitions make comparisons incomplete. For example, Workers’ Compensation only requires reporting for lost-time or restricted duty cases, while the other two reporting systems require all occupational illnesses to be reported. Although all physicians are legally required to report occupational disease, only a minority report, usually from the occupational health clinic network. Lead reports from the laboratory reporting system are combined into “lung and poisoning” for the OIISS. The BLS/Conn-OSHA system discontinued collecting “repetitive trauma” as a category in 2002, so MSD has been estimated based on the proportion of “other illness” in the 2001 dataset, which was 85%. See Appendix 1 for a complete description of methods.

Figure B-1: Summary of Diseases Reported by System, 2016 3500

3000 2916

2500

2000 BLS

1513 WC 1500 OIISS

1155 1105 1000 875

633 463 500 495 500 315 250 200 193 158

0 Lung & Poisoning Skin Infectious MSD Other

Notes: BLS=Bureau of Labor Statistics/ConnOSHA survey; WC=Workers’ Compensation First Report of Injury Database; OIISS= Physicians reports from the Occupational Illnesses and Injury Surveillance System combined with laboratory reports of lead poisoning. MSD for the BLS database was estimated using prior proportions from “other” (85%) since they are no longer broken out by BLS.

The Workers’ Compensation database showed the highest number of cases, with 5,454 cases reported, followed by the physicians’ reporting/laboratory database with 3,109 cases, and by the BLS survey with 2,300. There is a low amount of overlap between these systems, so total cases are higher than these figures might indicate (see section below on case matching estimates).

Longer term trends in number of reports are complex (Figure B2), with BLS trends generally declining; Workers’ Compensation data generally slightly declining since 2008 (the Workers’ Compensation database appears incomplete in 2003 and 2005-2007); and Physician reports fluctuating but decreasing the last 3 years after 5 years of increases. 8 Page 376 of 430 Case Matching and Total of Unique and Estimated Cases of Occupational Illness There is a fairly low number of cases that are reported to both workers’ compensation and by physicians. In order to get a better estimate of the total number of cases of occupational illness in Connecticut, cases were matched by name, employer, and type of illness for the WC and OIISS reports (Table B-1). This allows a sum of unique cases that were reported to at least one of the two systems and an estimate of cases that were not reported to either. Individual level BLS/ConnOSHA data from their survey was not available for matching, and lab-based lead reports did not have enough detail to match, so lead reports are not included in Table B-1.

Table B-1: Matched, Unique, and Estimated Total Cases of Occupational Illness, CT, 2016 OIISS WC Unique Estimated Estimated Illness Type Matched Only Only Cases Unreported Total Infectious 260 1,253 895 2,408 4,313 6,721 Lung 17 116 298 431 2,033 2,464 MSD 119 514 2,797 3,430 12,081 15,511 Other 30 208 740 978 5,131 6,109 Skin 38 120 155 313 489 802 Hearing loss 2 10 103 115 515 630 Total 466 2,221 4,988 7,675 23,773* 31,448 *Total is different than the sum of the categories due to rounding errors

There was a total of 466 cases that were reported to both workers’ compensation (WC) and by physicians; 2,221 cases were reported only to the physician report system, and an additional 4,988 cases were reported only to the workers’ compensation system. This gives a total of 7,675 unique cases that were reported to at least one of the two systems, with approximately 2,400 infectious cases, 400 lung cases, 3,400 musculoskeletal (MSD) cases, 300 skin conditions, 100 hearing loss cases, and 1,000 “other” cases. Using a statistical method called “capture-recapture” analysis, an estimate was made of the unreported cases (cases not reported to either workers’ compensation nor by physicians), which was about 24,000 cases. When combined with the unique cases, this provides an estimate of approximately 31,500 occupational illness cases in Connecticut for 2016.

Figure B-2: Trend in Occupational Disease Reports by Reporting System, 1997-2016 7,000

6,000

5,000

4,000 BLS* 3,000 WCC

2,000 OIISS

1,000

19… 19… 19… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20… 20…

Notes: BLS= Bureau of Labor Statistics/Conn-OSHA survey; WCC= Workers’ Compensation First Report of Injury; OIISS= Occupational Illness and Injury Surveillance System (physician reports). *Notes: BLS figures starting in 2002 not comparable to prior years due to changes in data collection. WCC data was not complete for 2003 and 2005-2007. OIISS was not complete for 2010 and did not include most bloodborne infectious diseases/exposures in 2011. 9 Page 377 of 430 C. Bureau of Labor Statistics/Connecticut Occupational Safety and Health Administration Surveys

In cooperation with the U.S. Bureau of Labor Statistics (BLS), Conn-OSHA conducts an annual survey of employers for job-related injuries and illnesses; data on injuries in Connecticut can be accessed through the national Bureau of Labor Statistics website at https://www.bls.gov/iif/oshstate.htm. Our report focuses on illnesses and includes data from Conn-OSHA that is not published in that report. Since these statistics are based on a survey rather than a census, numbers and rates are estimated and rounded. The Connecticut Department of Labor acknowledges that the BLS/Conn-OSHA survey under-counts occupational diseases, particularly chronic diseases, since these are frequently not recognized nor reported.

Occupational Illnesses in 2016 There were approximately 2,300 reported cases of occupational illnesses in 2016 (Table C-1 and Figure C-1) with an overall rate of 17.4 per 10,000 workers, approximately the same as the prior year.

Table C-1: Occupational Disease by Type, BLS/Conn-OSHA 2015-2016 2015 2016 % Change Cases Rates Cases Rates in Rate Respiratory 200 1.5 200 1.3 -13% Skin 400 3.0 500 3.9 30% Hearing Loss 200 1.7 300 2.2 29% Poisonings 0.2 Other* 1,500 11.3 1,300 10.0 -12% Total 2,300 17.7 2,300 17.4 -2% Source: BLS/Conn-OSHA; Rates are per 10,000 workers, adjusted for hours worked. The data includes public sector. Blanks indicate numbers that are too small or unreliable to publish. Total Illnesses may differ from sum due to rounding errors. *Musculoskeletal disorders (MSD) is categorized under the “Other” category by BLS.

Overall rates for Connecticut in 2016 were higher than the U.S., driven primarily by higher rates of skin disease and hearing loss (Figure C-1). The overall Connecticut rate (17.4 cases per 10,000 workers) was 6% higher than the U.S. rate of 16.4. Rates decreased in 2016 for both Connecticut and the U.S.

Connecticut’s illness rate ranked 15th highest out of 41 states with publishable data (fourteen states had higher rates and 26 had lower rates). Maine had the highest rate of 38.8 and Texas had the lowest at 9.8. Private sector rates for occupational illness were 15.0 in Connecticut and 14.1 nationally. Connecticut’s public sector rate was 35.7; the U.S. public sector rate was 31.6.

In Connecticut, the rate of illnesses increased slightly from 2002-2005, then generally decreased through 2016 with the exception of 2011 (Figure C-2).

10 Page 378 of 430 Figure C-1: Rates of Occupational Illness by Type, US and CT, 2016

17.4 18.0 16.4 16.0

14.0

12.0 10.5 10.0 10.0 US 8.0 CT 6.0 3.9 4.0 2.6 2.2 1.4 1.3 1.7 2.0 0.2 0.0 Skin Poisonings Respiratory Hearing loss Other Total Illnesses

Source: BLS and Conn-OSHA. Rates per 10,000 workers, adjusted for hours worked.

Figure C-2: Rates of Occupational Disease by Type and Year, CT, 2002-2016

25 24.0 22.1 23.3 Other 23.7 20 Hearing 18.8 18.2 15.4 16.8 Poison 15 15.0 13.1 Respir 12.0 10 0.2 3.6 2.8 12.4 0.6 3.8 0.3 Skin 2.4 2.7 3.6 3.4 2.7 11.0 3.3 3.5 11.3 10.0 5 0.3 0.2 1.0 2.5 2.5 2.7 2.2 2.6 6.2 6.9 6.4 1.8 2.3 2.1 2.0 6.3 2.6 2.2 0 4.3 4.7 5.1 0.2 2.1 4.7 5.1 6.3 2.0 1.9 1.7 2.2 2002 0.2 1.3 20032004 4.6 1.5 2005 2006 3.5 3.4 2007 2008 3.0 3.9 2009 2010 2011 2012 2013 2014 2015 2016

Source: BLS and Conn-OSHA. Rates per 10,000 workers, adjusted for hours worked.

11 Page 379 of 430 Illnesses by Industry Numbers and rates by industry sector for 2016 are presented in Table C-2. Overall, the adjusted rate was 17.4 cases of occupational illness per 10,000 CT workers, 2% lower than the 2015 rate of 17.7 (though the number of cases remained even at 2,300, since there was an increase in employment). The overall private sector rate was 15.0, with a government rate of 35.7 (more than double the private sector rate).

Table C-2: Illness Rates per 10,000 Workers by Industry and Type of Illness, CT, 2016 Total Skin Respiratory Poison Hearing Other Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. All industries including state and local government 17.4 2.3 3.9 0.5 1.3 0.2 -- -- 2.2 0.3 10.0 1.3 Private industry 15.0 1.7 2.7 0.3 0.8 0.1 -- -- 2.4 0.3 9.1 1.1 Goods-producing 24.9 0.5 4.2 0.1 1.0 ------12.1 0.3 7.7 0.2 Natural resources and mining ------Agriculture, forestry, fishing and hunting ------Mining, quarrying, and oil and gas extraction ------Construction ------Manufacturing 31.2 0.5 5.3 0.1 ------16.5 0.3 8.8 0.1 Service-providing 12.7 1.2 2.3 0.2 0.7 0.1 ------9.5 0.9 Trade, transportation, and utilities 11.5 0.3 ------9.8 0.2 Wholesale trade 7.5 ------5.4 -- Retail trade 10.2 0.1 ------9.3 0.1 Transportation and warehousing 19.1 0.1 ------16.3 0.1 Utilities 31.8 ------Information ------Finance, insurance, and real estate 2.2 ------2.0 -- Finance and insurance ------Real estate and rental and leasing ------Professional and business services 5.5 0.1 1.8 ------3.2 0.1 Management of companies and enterprises ------Administrative, support, waste management serv. 6.0 -- 5.2 ------Educational and health services 25.9 0.6 3.0 0.1 1.9 ------20.8 0.5 Educational services 6.4 ------Health care and social assistance 30.8 0.6 3.6 0.1 1.6 ------25.3 0.5 Leisure, entertainment, and hospitality 14.9 0.1 9.3 0.1 ------Arts, entertainment, and recreation 10.2 ------Accommodation and food services 16.7 0.1 11.0 0.1 ------Other services (except public administration) 5.7 ------State and local government 35.7 0.5 13.5 0.2 4.9 0.1 ------16.8 0.3 State government 41.8 0.2 17.7 0.1 7.9 ------15.8 0.1 Local government 32.1 0.3 11.0 0.1 3.2 ------17.4 0.2 Source: Conn-OSHA; Rates are adjusted for hours worked and are per 10,000 full-time workers. Blanks indicate too little data for reliable estimates.

The highest specific sector rate was State Government with 41.8, with the highest rates for skin conditions (17.7) and lung conditions (7.9). Local Government was second with 32.1, and Utilities third highest rate with 31.8.

12 Page 380 of 430 Lost-Time Illnesses BLS obtains additional data for the subset of cases that result in lost worktime and provides additional detail on specific conditions and causes. The following draws from this data for conditions that are more chronic in nature (usually classified as occupational illness). Restricted work cases are not included in this data, which is about half again the number of lost worktime cases.

Musculoskeletal Conditions The rate of musculoskeletal disorders (MSD) with lost time was 1% lower than the previous year at 50.0 cases per 10,000 workers (Figure C-3). The Connecticut rate is 60% higher than the national MSD rate of 31.2. MSD rates in Connecticut have generally decreased over the last five years. National rates for all private and public employees have only been available since 2008.

Musculoskeletal conditions are the most common category of specific injury and illness conditions and is a category that includes both chronic conditions and sprains and strains from overexertion. BLS defines this fairly complex category as “includes cases where the nature of the injury or illness is pinched nerve; herniated disc; meniscus tear; sprains, strains, tears; hernia (traumatic and non-traumatic); pain, swelling, and numbness; carpal or tarsal tunnel syndrome; Raynaud's syndrome or phenomenon; musculoskeletal system and connective tissue diseases and disorders, when the event or exposure leading to the injury or illness is overexertion and bodily reaction, unspecified; overexertion involving outside sources; repetitive motion involving microtasks; other and multiple exertions or bodily reactions; and rubbed, abraded, or jarred by vibration.”

Figure C-3: Rates of Musculoskeletal Disorders, CT and US, 2004-2016

70 60.1 56.6 56.2 57.9 60 54.9 53.9 55.4 54.6 51.6 51.1 50.6 50 47.6 50 38.5 37.8 35.8 40 35 34.3 33.8 33 32.2 31.2 CT 30 US

0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Source: U.S. Bureau of Labor Statistics (Customized Tables); http://data.bls.gov Rates are cases per 10,000 full time employees, public and private

Tendonitis was the most common specific illness in CT, with a rate of 2.7 cases per 10,000 workers in 2016 (Figure C-4), and 1.4 cases per 10,000 of Carpal Tunnel Syndrome (CTS). The rate of tendonitis in CT was 350% higher than the national rate, and 133% higher for CTS. CTS had a very high number of lost work days, with a median of 20 days of lost time per case (compared to 8 days for all cases of injury and illness) in CT. Tendonitis (and related soft-tissue disorders) was also high at 14 days.

13 Page 381 of 430 Figure C-4: Rates of Lost-time Carpal Tunnel (CTS) and Tendonitis, US & CT, 2016

2.7 3

2.5

2 1.4 1.5

0.6 0.6 1

0.5

0 CT US CT US

CTS Tendonitis & Related

Source: BLS Website http://www.bls.gov customized tables, private and public, cases per 10,000 full time employees.

Connecticut lost time cases coded as “repetitive motion” for cause decreased to 3.3 cases per 10,000 workers from 3.9 in the previous year. Computer tasks was the largest specific cause of repetitive motion (Table C-3). The CT rate was 57% higher than the national rate of 2.1. Repetitive motion lost time cases in CT had a median of 18 days away from work.

Table C-3: Illnesses involving Repetitive Motion by Type, 2015-2016 Repetitive Motion Injuries 2015 2016 Microtasks (unspecified) 0.9 1.1 Typing and computer 1.1 0.7 Tools 0.5 0.4 Grasping, placing, moving 0.6 0.6 Hand use (not tools) 0.4 0.1 Multiple types of repetitive motions 0.1 0.2 Other microtasks 0.3 All repetitive with microtasks (total) 3.9 3.3

14 Page 382 of 430 D. Workers’ Compensation First Report of Injury Data There was a total of 5,454 reports in the Workers’ Compensation First Report of Injury Database for 2016 (Table D-1), a 3% increase from 2015, with a 11% increase in infectious diseases, an 8% increase in skin disorders, a 13% decrease in lung disorders, and a 3% increase in musculoskeletal disorders (MSD).

Over half (53%) of reports were due to chronic musculoskeletal disorders (MSD) such as carpal tunnel syndrome and tendonitis. Infectious diseases accounted for 21% of the cases, lung diseases (including nonspecific respiratory illness and chronic lung conditions such as asthma and asbestos-related illnesses and exposures) 6%, skin disorders 4%, and “Other Illnesses” (which includes heart conditions, stress cases, noise- induced hearing loss, and other conditions), 16%.

Table D-1: Occupational Disease by Type, WCC, 2015-2016 2015 2016 Illness type Cases Cases % of total % Change Musculoskeletal Disorders (MS) 2,831 2,916 53% 3% Infectious Disease 1,045 1,155 21% 11% Lung Disorders 364 315 6% -13% Skin Disorders 178 193 4% 8% Other Illnesses 872 875 16% 0% Total 5,290 5,454 100% 3%

Overall, 49% of reports were for women, but this varied by type of case, with a higher proportion than average for infectious diseases (66% women) but equal or lower for all other types of illness (Figure D-1).

Figure D-1: Percent of Women by Disease Type, WCC, 2016 70% 66%

60%

49% 50% 47% 43%

40% 35% 36%

30%

20%

10%

0% infect lung msd other skin total

Reported occupational illnesses occurred more in older workers, with almost half involving workers between 40 and 59 years old (Table D-2), with 19% involving workers in their 30’s, and 17% in their 20’s.

15 Page 383 of 430

Table D-2: Occupational Illness by Age, 2016 Age Range Cases Percent Under 20 66 1% 20-29 899 17% 30-39 1,048 19% 40-49 1,159 21% 50-59 1,507 28% 60-69 691 13% 70+ 76 1% Total 5,446 100%

Numbers and rates of occupational illnesses by industry sector are presented by major North American Industry Classification System (NAICS) classifications in Figure D-2 and Table D-3. Ninety-eight percent (98%) of reported cases were able to be coded for major industry sector. The largest sectors in terms of overall numbers were Government (34%), Manufacturing (16%), Education/Health (14% of all cases; there are also health and education cases classified under government, such as employees in public schools), and Trade (13%).

Figure D-2: Occupational Illness Cases by Industry, WCC, CT, 2016 Construction/Agriculture /Mining, 3%

Manufacturing, 16%

Government, 34%

Trade, 13%

Transportation/Utilities, 2% Business Information Services, 1% Leisure/Other Services, Services, Education/Health, Finance/Insurance/Real 5% 7% 14% Estate, 2%

The number of illnesses by industry may be compared to the size of employment in those industries to understand which industries are at higher risk for illness. Table D-3 shows these figures, excluding cases where the industry was unknown. Overall, the rate of illness is 32.7 cases per 10,000 workers, an increase of 3% from the 31.8 cases per 10,000 in 2015. The highest rates by industry sector were for Government (80.5, 146% higher than the overall rate) and Manufacturing (54.6 or 67% higher), with other sectors below the average rate.

16 Page 384 of 430 Table D-3: Cases of Occupational Disease by Major Industry Sector, WCC, 2016 NAICS Sector Cases % Employment % Rate Construction/Agriculture/Mining 146 3% 64,397 4% 22.7 Manufacturing 865 16% 158,431 10% 54.6 Trade 731 13% 247,143 15% 29.6 Transportation/Utilities 129 2% 50,295 3% 25.6 Information Services 53 1% 32,336 2% 16.4 Finance/Insurance/Real Estate 118 2% 127,758 8% 9.2 Business Services 403 7% 218,177 13% 18.5 Education/Health 768 14% 321,743 19% 23.9 Leisure/Other Services 271 5% 216,921 13% 12.5 Government 1,860 34% 231,034 14% 80.5 Unknown 110 2% Total 5,454 100% 1,666,580 100% 32.7 Notes: Employment is adjusted for hours worked. A small number of reports that could not be coded for industry are categorized as unknown. Rates are illnesses per 10,000 workers. *Government sector includes cases that could alternately be classified under health and education.

Table D-4 provides the detail of industry sector by type of condition. Patterns of illness by industry differed by the type of illness, although Government was relatively high in all categories. Table D-4 is based on numbers of cases and not rates, so they are not adjusted for employment size in the different sectors (rates are shown in Tables D-3 and D-5).

Government dominated in all categories of illnesses. Infectious diseases were concentrated in Government (59%) and Education/Health (29%). Lung diseases were concentrated in Government (52%) and Manufacturing (13%). Musculoskeletal disorders (MSD) were most prevalent in Manufacturing (23%), Government (21%), Trade (19%), and Education/Health (11%). Skin disorders were spread across Government (42%), Manufacturing (14%), Business Services (13%), and Education/Health (13%). “Other” illnesses, including heart and hypertension, stress, and hearing loss cases (see below) were most common in Government (40%), Manufacturing (15%) and Trade (14%).

Table D-4: Type of Disease by Industry Sector, WCC, 2016 Other Lung Infectious MSD Skin Total Construction/Agric/Mining 21 2% 8 3% 4 0% 110 4% 3 2% 146 3% Manufacturing 130 15% 41 13% 7 1% 661 23% 26 14% 865 16% Trade 123 14% 29 9% 26 2% 538 19% 15 8% 731 14% Transport/Utilities 15 2% 4 1% 5 0% 105 4% 0% 129 2% Information Services 4 0% 3 1% 2 0% 43 2% 1 1% 53 1% Finance/Insurance/Real Es. 16 2% 8 3% 1 0% 93 3% 0% 118 2% Business Services 55 6% 19 6% 74 6% 231 8% 24 13% 403 8% Education/Health 74 9% 25 8% 331 29% 313 11% 25 13% 768 14% Leisure/Other Services 72 8% 12 4% 16 1% 155 5% 16 8% 271 5% Government 344 40% 163 52% 679 59% 594 21% 80 42% 1,860 35% Subtotal 854 100% 312 100% 1,145 100% 2,843 100% 190 100% 5,344 100% Unknown 21 3 10 73 3 110 Total 875 315 1,155 2,916 193 5,454

17 Page 385 of 430 Table D-5 shows those specific industry (3-digit NAICS code) sectors that reported 25 or more cases of occupational illness in 2016, ordered by the rate of illness. Local Government and State Government do not show detailed sector (such as Education or Health) since the data did not provide reliable detail. The highest rates were in Beverage and Tobacco Product Manufacturing (170 cases per 10,000 workers), Computer and Electronic Product Manufacturing (131), Primary Metal Manufacturing (112), and State government (103). The next highest rates were Local Government (81), Transportation Equipment Manufacturing (59), Electrical Equipment Manufacturing (57), and Miscellaneous Retail Stores (51). Although all of the specific sectors in the table had over 25 cases reported, 18 of them were at or below the average overall rate of 32.7 per 10,000 workers (primarily because they are sectors that employ relatively large numbers of workers).

Table D-5: Specific Industry Sectors with over 25 Cases of Occupational Disease, WCC, 2016 NAICS Cases Employt Rate Specific Industry Sector Code Beverage and Tobacco Product Manufacturing 312 29 1,703 170.3 Computer and Electronic Product Manufacturing 334 153 11,644 131.4 Primary Metal Manufacturing 331 41 3,662 112.0 State Government 658 64,029 102.8 Local Government 1,202 149,164 80.6 Transportation Equipment Manufacturing 336 248 41,756 59.4 Electrical Equipment, Appliance, and Component Mfg. 335 47 8,253 56.9 Misc. Retail Stores 453 48 9,380 51.2 Fabricated Metal Product Manufacturing 332 142 29,183 48.7 Hospitals 622 268 58,371 45.9 Food Products 311 35 7,803 44.9 Chemical Manufacturing 325 33 7,597 43.4 Health and Personal Care Stores 446 58 13,384 43.3 Couriers and Messengers 492 28 7,231 38.7 Merchant Wholesalers, Nondurable Goods 424 70 19,624 35.7 Motor Vehicle Dealers 441 74 21,434 34.5 Administrative and Support Services 561 284 82,502 34.4 Merchant Wholesalers, Durable Goods 423 100 29,119 34.3 General Merchandise Stores 452 97 29,010 33.4 Telecommunications 517 29 8,764 33.1 Food and Beverage Stores 445 139 44,025 31.6 Nursing and Residential Care Facilities 623 181 62,686 28.9 General Purpose Machinery Manufacturing 333 39 13,543 28.8 Accommodation 721 33 11,660 28.3 Transit and Ground Passenger Transport 485 36 14,601 24.7 Non-residential Construction 236 27 11,143 24.2 Physician Offices 621 204 88,681 23.0 Specialty Trade Contractors 238 91 41,501 21.9

18 Page 386 of 430 Membership Associations and Organizations 813 32 15,083 21.2 Clothing and clothing accessories 448 35 17,650 19.8 Credit Intermediation and Related Activities (Banks) 522 36 24,888 14.5 Amusement, Gambling, and Recreation Industries 713 29 20,932 13.9 Personal and Laundry Services 812 26 21,576 12.1 Educational Services 611 59 56,912 10.4 Professional, Scientific, and Technical Services 541 99 96,911 10.2 Food Services and Drinking Places 722 112 114,876 9.7 Social Assistance 624 53 55,093 9.6 Insurance Carriers and Related Activities 524 32 56,813 5.6

Illnesses by Town/Municipality Occupational illnesses were coded by the town where the illness occurred (typically the town where the employer is located). Table D-6 and Figure D-3 shows the rates of illness per 10,000 employees per town (based on total employment by town of employment, provided by the CT Labor Department) for all towns and municipalities with at least 25 cases of occupational illness reported in 2016; the table is ordered by rates. The lower the rank, the higher the rate of illness. Rates of illness varied widely by municipality; often these appear to be related to large employers in high rate industries. The overall state mean (average) was 32.7 cases per 10,000 employees. For towns with at least 25 cases, Farmington had the highest rate at 126 cases per 10,000 employees, almost four times the average rate. Farmington was followed by Hartford (89), Cromwell (89), Groton (85), Westbrook (84), Windsor Locks (73), East Windsor (63), Cheshire (61), Stratford (60), and Middletown (58).

Table D-6: Illnesses by Town/Municipality, 25 or more cases, WCC, 2016 Town Employment Cases Rate per 10,000 Rank Connecticut 1,666,580 5,544 33.3 State Average Farmington 13,531 171 126.4 1 Hartford 48,474 433 89.3 2 Cromwell 7,559 67 88.6 3 Groton 17,571 150 85.4 4 Westbrook 3,461 29 83.8 5 Windsor Locks 7,007 51 72.8 6 East Windsor 6,176 39 63.1 7 Cheshire 14,993 91 60.7 8 Stratford 26,022 156 59.9 9 Middletown 24,668 143 58.0 10 South Windsor 13,405 76 56.7 11 Mansfield 11,972 65 54.3 12 Rocky Hill 10,943 58 53.0 13 Stafford 6,423 34 52.9 14 Bloomfield 10,767 56 52.0 15 Old Saybrook 4,858 25 51.5 16 Windsor 15,670 79 50.4 17 Killingly 8,996 42 46.7 18 Westport 12,257 53 43.2 19 North Haven 12,752 55 43.1 20 New London 11,148 47 42.2 21 Berlin 11,182 47 42.0 22 New Haven 59,934 249 41.5 23 19 Page 387 of 430 Montville 8,833 36 40.8 24 Southbury 8,364 32 38.3 25 Darien 8,310 30 36.1 26 Suffield 7,214 26 36.0 27 Waterford 9,674 33 34.1 28 Stonington 9,201 31 33.7 29 Shelton 21,086 71 33.7 30 East Lyme 8,389 28 33.4 31 Wilton 8,225 27 32.8 32 Southington 23,242 76 32.7 33 Danbury 45,470 148 32.5 34 New Canaan 8,101 26 32.1 35 East Hartford 25,487 79 31.0 36 Enfield 21,860 67 30.6 37 Norwich 19,031 58 30.5 38 Manchester 30,976 94 30.3 39 Trumbull 17,422 52 29.8 40 Torrington 18,261 54 29.6 41 New Milford 14,751 39 26.4 42 West Hartford 32,789 86 26.2 43 Waterbury 46,545 122 26.2 44 Windham 11,544 28 24.3 45 Bristol 30,944 75 24.2 46 Greenwich 27,845 67 24.1 47 Guilford 12,406 29 23.4 48 Glastonbury 18,171 42 23.1 49 Milford 28,612 65 22.7 50 Wethersfield 13,336 30 22.5 51 Wallingford 24,996 56 22.4 52 Vernon 16,138 36 22.3 53 Newtown 13,728 29 21.1 54 Meriden 30,019 63 21.0 55 New Britain 33,844 70 20.7 56 Norwalk 48,484 99 20.4 57 Bridgeport 65,505 130 19.8 58 Simsbury 12,697 25 19.7 59 Stamford 67,069 82 12.2 60 Fairfield 28,018 34 12.1 61 Hamden 33,428 29 8.7 62 *Lower rank indicates higher rates of illness (i.e. the town ranked first has the highest rate of illness). Ranks are based on the towns with at least 25 cases of illness reported in either year. Employment figures are based on the town of employment.

Musculoskeletal Disorders (MSD) “Musculoskeletal disorders” is the currently-used term for conditions also known as cumulative trauma disorders or repetitive strain injuries. There were 2,916 cases of MSD reported to Workers’ Compensation in 2016, a 3% increase from 2015 (Table D-7). MSD accounted for just over half (53%) of the reported occupational diseases to Workers’ Compensation. MSD do not include cases for conditions determined to be injuries caused from sudden events. Most cases for the lower back are not included, unless they specifically noted that they were due to repetitive exposures (since the descriptions of back conditions are typically insufficient to be able to distinguish between acute injuries and cumulative back injuries that result in disease).

20 Page 388 of 430 Strains and sprains (which does not include acute strains or sprains such as those from single events/accidents) was the most common category of MSD, with 73% of reports (Table D-7) coded for that general category. Carpal Tunnel Syndrome (CTS), which is a very debilitating pinching of the median nerve at the wrist, accounted for 9% of total MSD reports. Other nerve-related problems (with descriptions of numbness or tingling) accounted for an additional 4% of cases. Tendon-related problems included tendonitis and tenosynovitis, epicondylitis (“tennis elbow” or “golfer’s elbow”), trigger finger, and rotator cuff, combining for 4% of cases. A large number of cases did not have a specific description other than inflammation, swelling, pain or no specific description.

Table D-7: Musculoskeletal Disorders (MSD) by Type, WCC, 2015-2016 2015 2016 MSD Type Cases Cases % Change Sprain/strain 2,070 2,140 73% 3% Carpal Tunnel Syndrome 347 260 9% -25% Numbness 98 112 4% 14% Tendonitis/tenosynovitis 40 38 1% -5% Trigger finger 20 29 1% 45% Ganglion cyst 12 17 1% 42% Epicondylitis 20 16 1% -20% Rotator cuff 22 11 0% -50% Arthritis/bursitis 10 6 0% -40% Other/Unknown 192 287 10% 49% Total 2,831 2,916 100% 3%

Table D-8: Musculoskeletal Disorders by Part of Body, WCC, 2016 Part of body Cases Percent Lower Arm, Wrist, Hand 1,179 40% Upper Arm, Shoulder, Upper Extremity 616 21% Legs, Knees, and Feet 430 15% Elbow 230 8% Neck and Upper Back 125 4% Trunk 84 3% Multiple 237 8% Other/Unknown 15 1% 2,916 100%

Over two-thirds (69%) of the cases of MSD were in the upper limbs of the body such as hands, arms, elbows, and shoulders (Table D-8). Another 15% were for the lower extremity (legs, knees and feet), and 7% for the

21 Page 389 of 430 neck, upper back, and torso (note that lower back cases were excluded from these figures unless they explicitly indicated they were due to cumulative exposures).

Causes of conditions were often incomplete, overlapping, and not consistently coded nor described. Approximately 80% of MSD cases had enough description to show some cause. Of the MSD that could be classified (Table D-9), the most frequently mentioned cause was the broad category of “repetitive” (26% of cases). This term is often used as a general description to describe any chronic musculoskeletal problem. Repetitive cause was followed by lifting and carrying (20%), pushing or pulling (14%), tool use (including references specifically to pneumatic tools or vibration exposure; 9%), and computing and clerical tasks (8%).

Table D-9: Musculoskeletal Disorders (MSD) with Identified Cause, WCC, 2016 Cause of MSD Reports % Repetitive 604 25.8% Lifting/carrying 467 19.9% Push/Pull 330 14.1% Tools/vibration 207 8.8% Computer/clerical 176 7.5% Reaching 95 4.1% Twisting 55 2.3% Bending/kneeling/crawling 53 2.3% Patient care 41 1.8% Walking/running/moving 42 1.8% Cleaning/mopping/sweeping 41 1.8% Driving 40 1.7% Assembly 33 1.4% Sitting/standing 33 1.4% Grasping/gripping/squeezing 30 1.3% Climbing 29 1.2% Machine 28 1.2% Shoveling 14 0.6% Overhead 10 0.4% Selecting/sorting/inspecting/packing 8 0.3% Scanning/cashier 5 0.2% Sub-Total 2,341 100.0% Unknown/other 575 Total 2,916

Infectious Diseases There were 1,155 reports of infectious diseases or exposures in the database for 2016 (Table D-10), a 10% increase from the previous year. Infectious disease reports include both actual disease and exposure to infectious agents. There were 872 reports of exposure to bloodborne pathogens (including reports of exposure to HIV/AIDS and Hepatitis C), accounting for 75% of all infectious disease reports. These included 290 needlestick injuries or cuts from sharps or surgical instruments that may have resulted in exposure to a patient’s blood, 406 reports of exposures to human bites (cases were excluded if they specifically indicated the skin was not broken), and 176 reports of skin or eye exposure to blood or bodily fluids. There were additional reports of exposure to “spit” or “sputum” that are not reported here, since risks tend to be extremely low from such 22 Page 390 of 430 exposures. Diseases that can be contracted through blood and body fluid exposures include hepatitis B, C and HIV. Human bites are considered to be relatively low risk exposures in terms of bloodborne disease transmission. Exposure to blood and fluids are somewhat higher risk (especially if the worker has open wounds or sores). Sharps (i.e. scalpels) and needlesticks are considered the highest risk (especially if they are deep cuts or injections). Incidents concerning prisoners or clients (including special needs students) accounted for the vast majority of human bites as well as some of the other bloodborne exposures. The data does not have consistent information on whether the source patient is known to be infected with a bloodborne illness such as HIV or hepatitis, so many of these reported incidents will have little or no actual risk of disease transmission. However, preventive efforts focus on universal precautions, so it is important to reduce these incidents regardless of whether patients/clients are known to be infected.

Table D-10: Infectious Diseases and Exposures by Type, WCC, 2015-2016 2015 2016 Illness Cases % Cases % Change Bloodborne: Human bite 365 35% 406 35% 11% Bloodborne: Sharp and needlestick exposures 316 30% 290 25% -8% Bloodborne: Blood/body fluids 155 15% 176 15% 14% Meningitis exposure 17 2% 75 6% 341% Lyme Disease/Tick bite 75 7% 57 5% -24% TB/ppd conversion/exposure 37 4% 47 4% 27% Scabies/lice 22 2% 20 2% -9% MRSA/staph/strep 4 0% 20 2% 400% Rabies 3 0% 12 1% 300% Chicken pox, measles, whooping cough 7 1% 7 1% 0% Other infectious 46 4% 45 4% -2% Total 1,047 100% 1,155 100% 10%

There were 75 reports of meningitis exposure or illness, a large increase from 2015. There were 57 reports of tick bites, rashes from tick bites and/or a diagnosis of Lyme disease attributed to occupational exposures. There were 47 cases of tuberculosis infection, usually determined by PPD conversion (which is a skin test based on immune response) or based on exposure to clients with TB. This was an increase of 27% from 2015. In addition, there were 20 cases of scabies or lice exposures/illnesses, 20 reports of exposure or cases of MRSA (Methicillin-resistant Staphylococcus aureus, or staph infection that responds poorly to antibiotics) or other staph or strep infections, 12 cases of exposure to rabies, and 7 cases of chicken pox, measles or whooping cough.

Court decisions have broadened the definition of compensable disease under Workers’ Compensation to include exposures, particularly where exposure requires medical treatment such as prophylactic treatments for tuberculosis (TB) and AIDS (HIV) exposures. It is often difficult to determine whether the first report of injury was actual disease or only exposure (for example, actual Lyme disease or only a report of a tick bite).

Respiratory Illness and Poisonings Chronic lung disease such as asbestos-related illnesses, asthma, and lung cancer are addressed in the following section. In addition to these chronic conditions, there were 159 cases of respiratory illnesses (mostly nonspecific respiratory illness from relatively acute chemical or biological exposures) for 2016 (Table D-11), a 30% decrease from 2015. There were 21 cases of poisonings from carbon monoxide, other gases, mercury, or lead, roughly the same as the previous year.

23 Page 391 of 430 Chemical exposures were the most common cause of respiratory illness, (42% of cases) followed by smoke or fire (23%), general indoor air quality (IAQ) or mold (13%), and dust or fumes (9%). There were 17 cases of poisoning from exposure to carbon monoxide or other gases and fumes, and no Workers’ Compensation reports of lead or mercury poisoning or exposure in 2016.

In addition to the more general categories of smoke and mold, specific substances were reported as connected to the respiratory cases: Carpet removal (2), glaze carpet freshener, battery acid, toner dust, PCB’s (2), oven cleaner, sewage fumes, laminator, fire extinguisher (3), isocyanates, spor-klenz, bio-solv, cut-thru cleaner, bug spray fogger (2), paint, varnish, magna may lacquer, epoxy (2), butyl acetate, disinfectant (2), dishwasher disinfectant, bleach (2), chlorine (2), Lysol wipes, metal fumes, pesticides, and acetone.

Table D-11: Respiratory Conditions and Poisonings by Cause, WCC, 2015-2016 Cause 2015 2016 Respiratory Cases % Cases % Change Chemical Exposure 79 35% 66 42% -16% Smoke, Fire 56 25% 37 23% -34% IAQ/mold/odor 41 18% 21 13% -49% Dust/fumes 27 12% 14 9% -48% Other Respiratory 23 10% 21 13% -9% Respiratory subtotal 226 100% 159 100% -30%

Poisoning Carbon monoxide/gas 14 70% 17 81% 21% Lead 1 5% 0 0% Other Poisoning 5 25% 4 19% -20% Poisoning Subtotal 20 100% 21 100% 5% Total Respiratory and Poisoning 246 100% 180 100% -27%

Chronic Lung Conditions There were 143 cases of chronic lung conditions in 2016, a 13% increase from the previous year (Table D-12). These included asbestos-related diseases and exposures, occupational asthma, and other chronic lung diseases. Acute respiratory illnesses are classified under respiratory conditions and poisonings (above).

Asbestos There were 33 reports of asbestos-related disease or exposures in 2016. The descriptions of the cases often make it difficult to determine whether the cases are actual disease or current exposure to asbestos; the notations may be either describing historic exposures that contributed to current disease, or current exposures that raise the risk of future disease. Cancers, including those caused by asbestos, are noted below (under “other illnesses”).

Asbestos exposure is known to increase the risk of lung disease and cancer. If disease occurs as a result, it often appears between 10-40 years after exposure. Asbestos disease may be under-reported by traditional surveillance sources such as Workers’ Compensation. The main industry for asbestos conditions was transportation equipment manufacturing (10 cases).

24 Page 392 of 430 Table D-12: Chronic Lung Diseases by Type, WCC, 2015-16 Illness 2015 2016 Change Asthma/bronchitis 32 33 3% Asbestos-related 30 33 10% Allergies 14 13 -7% Other chronic lung 43 56 30% Total 119 135 13%

Other Chronic Lung Conditions There were 33 occupational asthma cases reported in 2016 (essentially unchanged from the prior year), 13 lung- related allergies, and 56 other chronic lung conditions. The causes mentioned for asthma and other chronic lung conditions were mold, pigeon droppings, rubble, cat dander, perfume (3), wallpaper removal, peanuts, kerosene, dog dander, coolant, diesel fumes, ammonia bicarbonate, floor stripping chemicals, Ben-gay, adhesive remover, latex, bleach, painting (2), fire extinguishers, and disinfectant.

Skin Conditions There were 193 skin conditions in the database in 2016 (Table D-13), an increase of 8% over the previous year. These included 70 cases of contact dermatitis from poison ivy or other plants (36% of all skin cases). There were 30 cases of skin conditions caused by chemicals, as well as 15 additional cases attributed specifically to cleaning chemicals. There were 9 cases caused by allergic reactions to clothing, gloves, or latex, and 13 other allergic skin conditions. There were 56 cases of poorly defined skin conditions, frequently just described as rashes.

In addition to cleaning chemicals and latex, specific substances associated with skin conditions included Loctite (2), dish cleaner, dishwasher chemicals, de-burring and grinding fluids (2), coolant (2), fiberglass, a grease stripping agent, bleach, paint thinner (2), boxes, soap and hand cleaners (4), oven cleaner, brush cleaner, hair coloring, plating chemicals, glue, ceiling tile dust, medical files, oils, and “Primer C”.

Table D-13: Skin Diseases by Cause, WCC, 2015-2016 Category 2015 2016 % Change Poison Ivy/plants 78 70 36% -10% Chemical 28 30 16% 7% Soap/Cleaning 19 15 8% -21% Allergic 10 13 7% 30% Gloves/Latex/clothing 10 9 5% -10% Rash/Other/Unknown 34 56 29% 65% Total 179 193 100% 8%

Stress and Heart Conditions Heart and Hypertension There were 263 cases involving heart conditions, stroke, chest pain, hypertension, or stress in the database for 2016 (Table D-14), a 9% decrease from the previous year. Reports noted 144 cases of heart attacks, myocardial infarctions or acute heart events and 12 reported strokes or blood clots, often associated with emergency care at a hospital. There were 17 cases that described the condition as hypertension or “heart and hypertension” (the usual legal term for heart or hypertension cases that are covered under workers’ compensation for police and fire fighters).

25 Page 393 of 430 Approximately one-half of the heart cases appeared to involve police or firefighters or other municipal and state employees who are frequently covered under heart and hypertension laws that consider those conditions to be work-related for Workers’ Compensation purposes. Though not generally well described, causes of the heart cases included exertion (including shoveling, lifting or custodial work, 14 cases), firefighting, live fire training, or smoke (4), a car accident, raccoon attack, driving (3), working with a customer/client (6), police/EMT response (5), stress (2), monitoring students (3), and working out (2)

Table D-14: Heart and Hypertension Conditions by Type, WCC, 2015-2016 Category 2015 2016 % Change Heart attack/severe symptoms 139 144 55% 4% Hypertension 20 17 6% -15% Stroke/clots 15 12 5% -20% Stress/anxiety/depression 116 90 34% -22% Total 290 263 100% -9%

Mental Stress There was a total of 90 stress-related claims in the database in 2016, a 22% decrease over the previous year. Approximately one third (34%) of the cases where cause was noted referred to violence or post-traumatic stress disorders after violence (Table D-15), and 9 cited either harassment or a hostile work environment.

Table D-15: Stress Conditions by Cause, WCC, 2016 Sources of Stress Conditions 2016 % Violence/robbery/trauma 31 34% Harassment/hostile environment 9 10% Supervisor/co-worker 5 6% Excessive work demands 5 6% Motor vehicle accident 4 4% Unknown/other 36 40% Total 90 100%

Stress cases included a observing a student dying in the cafeteria, a police dispatcher in contact with a police shooting, a driver who injured a technician trying to repair the vehicle, a clinician who was stressed from counseling students who were victims of trauma, trying to revive a person who was choking but who died (2 people), a co-worker having an affair with the worker’s spouse, changes at the workplace, occupational title changes, hitting a pedestrian with a bus, breaking up arguments between students (2 cases), sexual assault at work, an auto accident, a patient’s sexual exhibitionism, physical and verbal abuse by a violent student, being stalked by a patient’s ex-boyfriend, a witness to a suicide with a failed attempt to revive the person, a dismissal from the workplace, a panic attack after a phone conversation (2 cases), a first responder to a fatal car accident involving a 4-year old child, verbal threats from a student, physical assault by a client (2 cases), job demands as a police officer, an investigator on an officer-involved shooting, PTSD from a car accident (2 cases), a robbery where the worker had a gun placed against his neck, rescuing a teenager from the railing of a bridge where the teenager was about to commit suicide, a police officer who shot an emotionally disturbed person, verbal abuse and harassment, sexual harassment and retaliation, an unexpected loud noise, an argument with supervisor during termination, a student threatening to shoot the worker, a robbery with a suspect stating he had a knife and came behind counter, discovering a supervisor had attempted suicide in the worker’s office, having a rifle blow up while testing the gun, and verbal confrontation with a customer. 26 Page 394 of 430 Stress-related claims that are not also associated with a physical injury are typically not compensable under the Workers’ Compensation statute, so it is likely that there are additional unreported (non-compensable) cases. It should be noted that this report is based on First Reports of Injury for compensation, and the number of cases that were ultimately awarded compensation was not determined.

Other Occupational Diseases Hearing Loss There were 105 reports of hearing loss in 2016 (Table D-16), 25% more than the previous year. Of these cases, 24 appeared to be caused by acute (single incident) noises or injuries such an air horn, loss of hearing protection while shooting guns at a range, a phone slammed in employee’s ear, firing a cannon, dive training, fast loss of air pressure, batteries exploding, a nearby fire alarm, a patient screaming in employee’s ear, an unexpected trombone sound near the ear, and sudden air from a vacuum cleaner. Of all the hearing loss cases, most were from manufacturing (61 cases), in particular transportation equipment manufacturing (53 cases), as well as schools/police/firefighting/government (17 cases).

Table D-16: Other Occupational Illnesses, WCC, 2015-2016 Type of illness 2015 2016 % Change Dizziness/passing out/seizure 80 122 20% 53% Hearing loss 84 105 17% 25% Chemicals in eye 99 97 16% -2% Cold/heat related conditions 79 65 11% -18% Allergic 63 47 8% -25% Cancer 9 10 2% 11% Other conditions 171 163 27% -5% Total 585 609 100% 4%

Other Disease Conditions There were 122 reports of workers becoming dizzy, fainting, or similar conditions such as seizures, a 53% increase. There were 97 reports of eye exposures to chemicals (this does not include other physical acute eye injuries such as particles or dust), a 25% increase. Some of these are likely from pre-existing conditions that occurred while at work (such as epilepsy or diabetes) and some of which were accompanied by an injury from a fall; some may reflect more serious conditions such as heart attacks but are just described based on initial symptoms. There were 65 reports of temperature-related problems from heat or cold, an 18% decrease from the previous year.

There were 47 cases of allergic reactions reported in addition to those noted above under respiratory and skin conditions, a 25% decrease. There were 10 cases of cancer reported, which included asbestos-related cancers. There were 163 “other” conditions that were difficult to classify, usually due to incomplete information.

27 Page 395 of 430 E. Occupational Illnesses and Injury Surveillance System (OIISS)

Physicians are required to report known and suspected occupational disease to the Occupational Illnesses and Injury Surveillance System (OIISS) that is maintained by the Department of Public Health. Although all physicians are required to report, most reports are received from Connecticut’s occupational health clinics and industrial medicine programs. Information on blood lead level laboratory reports are taken from the Connecticut Adult Blood Lead Epidemiology and Surveillance (ABLES) program. Data for lead and infectious diseases were incomplete for certain years prior to 2012 (as noted for the table and figure below), so comparisons for total disease with earlier years should be made cautiously.

Table E-1: Occupational Disease Case Reports by Type, OIISS and ABLES, 2007-2016 % Category 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 change 2015-16 MSD 838 827 411 208 616 580 666 774 734 633 -14% Skin 273 302 193 102 183 180 174 140 166 158 -5% Lung 59 142 140 56 101 146 120 171 178 133 -25% Other 58 31 59 33 96 164 159 184 195 250 28% Infectious* 20 66 939 347 103 443 973 1500 1,390 1,513 9% Sub-total 1,248 1,368 1,742 746 1,099 1,513 2,092 2,769 2,663 2,687 1% Lead (Lab) 363 364 304 443 345 283 327 379 425 330 -22% Total 1,611 1,732 2,046 1,189 1,444 1,796 2,419 3,148 3,088 3,017 -2% *Infectious did not include most bloodborne pathogen exposures up to 2008, and again in 2011

Figure E-1: Occupational Disease Case Reports by Type, OIISS and ABLES, 1998-2016 3500

3000

2500

2000

1500

1000 Cumulative Total Cases 500

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

MSD Skin Lung Other Infectious* Lead (Lab)

*Infectious category did not include most bloodborne pathogen exposures up to 2008, and again in 2011. ** Lead values for 1998-99 did not include cases in the blood lead level range of 10-19 micrograms per deciliter (ug/dl).

There were 2,687 occupational illness reports received from physicians for 2016 (Table E-1). Physician reports increased slightly (1%) in 2016 compared to the year before. Infectious disease (such as bloodborne diseases and exposure) was the largest category of reports, accounting for 56% of the reports, followed by

28 Page 396 of 430 musculoskeletal conditions (MSD) such as tendonitis and carpal tunnel syndrome (24%). Skin disorders (including poison ivy and chemicals as causes), lung conditions (including respiratory conditions, asthma, and other lung diseases) comprised 5% of physician reports. “Other” conditions (including heart disease, stress, noise-induced hearing loss) accounted for 9%. There were 330 reports of blood lead levels in adults of 10 micrograms per deciliter (ug/dl) or greater (a 22% decrease) from laboratory reports, giving a total of 3,017 occupational illnesses reported by physicians or laboratories in 2016.

In 2016, 108 physicians from 16 clinics (at 23 locations) reported at least one case to the OIISS. Twenty-nine of the physicians reported 20 or more cases and accounted for 86% of the reports; six reported 100 or more cases and accounted for 35% of reports. Eight clinic networks reported 100 or more cases and contributed 94% of the cases.

Many workers with occupationally-related illness seek care from their primary care providers. Although it is a state law that known and suspected occupational diseases diagnosed by any physician in the state must be reported to CT Departments of Labor and Public Health (CGS § 31-40a), the majority of reporters are from the academic occupational health clinics and auxiliary occupational health clinics that are funded under the state occupational disease surveillance network. Therefore, these reports should be viewed as a small portion of physician-diagnosed occupational diseases in Connecticut.

Eighty-seven percent (87%) of the cases were classed as “high certainty” for being an occupationally-related disease, 9% were “moderate certainty,” and 3% “low certainty”, where certainty was reported. There was a fairly low amount of reporting on whether exposure was continuing or if others are likely to be exposed, but 12% of those reported that the exposure that caused the illness was continuing, and 7% reported other workers were likely to be exposed to the same hazard.

Of the 1,738 reports where race was known, 273 (16%) were identified as black, and 188 (of 2,496 or 8%) were identified as Hispanic (where ethnicity was known).

Figure E-2: Occupational Disease by Age, OIISS, 2016

665 700 639 578 600 529

500

400 269 300

200

100 3 0 <20 20-29 30-39 40-49 50-59 60+

Figure E-2 shows the age distribution of reported cases (where data was available). There were similar proportions (between 20%-25%) for workers in their 20’s, 30’s, 40’s and 50’s. Only 10% were 60 or older, and only 4 cases were reported in workers less than 20 years of age.

29 Page 397 of 430 The Education and Health sector had the most cases (68%), followed by Government (10%), Manufacturing (7%), and Trade (5%); see Figure E-3 and Table E-2. It should be noted that the Education and Health sector also includes many government workers, such as teachers and nurses who work for government (the workers’ compensation data includes most of these under the government sector, so the two numbers aren’t exactly comparable).

Figure E-3: Occupational Disease by Industry Sector, OIISS, 2016

Const, Agric., 2% Manuf, 7% Trade, 5% Service , 2% Govt, Trans/Utility, 2% 10% Info, 0% Fin/Insur/RE, 1% Business Serv, 3%

Educ/Health, 68%

Industry distribution was somewhat different by condition (Table E-2), although Education and Health led all the categories of illness. Infectious disease was highly concentrated in Education and Health (88%), with Government contributing another 6%. MSD were primarily from Education and Health (40%), Manufacturing (18%), Trade (12%), and Government (10%). Dermatitis (skin disorders) was primarily from Education and Health (42%), Government (18%), and Manufacturing (15%). Respiratory cases (“Lung”) were primarily from Education and Health (47%) and Government (23%).

Table E-2: Type of Illness by Industry Sector (NAICS*), OIISS, 2016 Industry All Infectious Lung MSD Other Skin Cases % Cases % Cases % Cases % Cases % Cases % Construction/ Agriculture 52 2% 7 0% 7 5% 21 3% 10 4% 7 4% Manufacturing 194 7% 5 0% 10 8% 116 18% 39 16% 24 15% Trade 129 5% 12 1% 6 5% 79 12% 27 11% 5 3% Transport/Utilities 58 2% 6 0% 5 4% 40 6% 3 1% 4 3% Information Services 5 0% 0% 0% 4 1% 1 0% 0% Finance/Insur/Real Estate 26 1% 13 1% 2 2% 6 1% 2 1% 3 2% Business Service 87 3% 30 2% 4 3% 29 5% 11 4% 13 8% Education/Health 1,818 68% 1,333 88% 63 47% 255 40% 101 40% 66 42% Other Services 53 2% 12 1% 4 3% 20 3% 10 4% 7 4% Government 260 10% 93 6% 31 23% 62 10% 45 18% 29 18% Unknown 5 0% 2 0% 1 1% 1 0% 1 0% 0% Total 2,687 100% 1,513 100% 133 100% 633 100% 250 100% 158 100% *The North American Industry Classification System 30 Page 398 of 430 Musculoskeletal Disorders (MSD) There was a total of 633 reports of musculoskeletal disorders (MSD) in 2016, a decrease of 14% from the previous year (Table E-3). This table excludes lower back diagnoses unless specifically defined as caused by cumulative strain and does not include MSD caused by acute incidents such as falls or individual lifts. The most common specific diagnoses for musculoskeletal disorders were epicondylitis (tennis elbow) with 17% of the cases, tenosynovitis (14%), and carpal tunnel syndrome (12%).

Table E-3: Musculoskeletal Disorders (MSD) by Type, OIISS, 2015-2016 Illness 2015 2016 Percent Change Epicondylitis 143 108 17% -24% Tenosynovitis 114 89 14% -22% Carpal Tunnel Syndrome (CTS) 87 76 12% -13% Tendonitis 64 47 7% -27% Bursitis/Arthritis 69 46 7% -33% Other Neuropathy (nerve disorder) 43 37 6% -14% Trigger Finger 27 18 3% -33% Ganglion 14 15 2% 7% Strain/Sprain 105 13 2% -88% Plantar fasciitis 20 10 2% -50% Rotator Cuff 24 5 1% -79% Other MSD 24 169 27% 604% Total 734 633 100% -14%

Musculoskeletal disorders (also referred to as cumulative trauma disorders or repetitive strain injuries) include tendon-related conditions, nerve problems, circulatory, as well as combined conditions.

Tendon Disorders • Tendonitis: swelling of the tendons • Epicondylitis: tendon irritation in the elbow area, including “golfer’s elbow” and “tennis elbow” • Rotator Cuff Syndrome: tendonitis in the shoulder area • Tenosynovitis: inflammation of the tendon sheaths, lubricated covers that surround the tendons, particularly in the hand • DeQuervain’s Syndrome: tendon sheath disorder of side of wrist and base of thumb • Trigger Finger: a bump on the tendon that catches on the tendon sheath that makes the finger or thumb difficult to move • Ganglion Cysts: swelling of the tendon sheaths from excess lubricating fluid • Bursitis: inflammation of the fluid-filled sacs around ligaments and tendons

Nerve Disorders • Carpal Tunnel Syndrome: pinching of the median nerve in the wrist, usually by swollen tendons that pass through the carpal tunnel (the median nerve can also be pinched in the elbow, shoulder, or neck areas)

Circulatory/Combined/Other • Thoracic Outlet Syndrome: pinching of the nerves and blood vessels in the neck/ shoulder area

31 Page 399 of 430 Figure E-4: Musculoskeletal Disorders by Industry Sector, OIISS, 2016

Const, Ag 3%

Serv Other Govt 3% 10%

Manuf 18%

Trade 13%

Educ/Health 40%

Trans/Util Info 6% 1% Bus Service Fin/Insur/RE 5% 1%

The largest number of MSD’s were in Education and Health (255 cases), followed by Manufacturing (116), Trade (79), and Government (62); see Figure E-4 and Table E-2.

Table E-4: Common causes of MSD, OIISS, 2016 Cause Cases Lifting 78 Repetitive 53 Push/pull 49 Tools & Vibration 27 Computer/clerical 25 Gripping/grasping 17 Patient-related 14 Standing/walking/running 14 Assembly 9 Kneeling 6 Climbing 3 Other 25

32 Page 400 of 430 Causes for MSD are difficult to classify since they are frequently described differently by the various people recording the case, and most case reports do not describe cause. The most common specific cause noted for MSD (Table E-4) was lifting (78 cases) and followed by pushing or pulling (49), tools and/or vibration (27), and computer use and data entry (25). An additional 53 cases were attributed to the general description of “repetitive”.

Skin Conditions There were 158 reports of skin disorders in 2016 (Table E-5), a 5% decrease from the previous year. The largest single cause was poison ivy or other plant exposures (34% of all cases). Other causes included chemicals (28 cases), latex or clothing (12 cases), and cleaning or cleaning chemicals (7 cases).

Table E-5: Skin Conditions by Type, OIISS, 2015-2016 Illness 2015 2016 Percent Change Dermatitis 116 86 54% -26% Poison ivy & other plants 40 54 34% 35% Other skin conditions 10 18 11% 80% Total 166 158 100% -5%

Skin conditions (Figure E-5) occurred most commonly in Education and Health (42%), State and Local Government (18%), and Manufacturing (15%).

Lung/Respiratory Diseases and Poisonings There were 133 cases of respiratory and other lung diseases and poisonings reported by physicians in 2016 (Table E-6), a decrease of 25% from the previous year. Nonspecific respiratory illnesses were the most common type of condition, with 53% of reports, followed by poisoning (such as carbon monoxide or metals) with 18%, and asthma or reactive airways dysfunction syndrome (RADS) with 11%. In addition to asbestos (some of the asbestos cases appeared to be reports of asbestos exposures rather than asbestos-related disease) noted in Table E-6, exposures associated with respiratory conditions included lead fumes (23 cases), other fumes (including gas or carbon monoxide) (16 cases), chemicals (including solvents, cleaning chemicals, and oil; 27 cases), mold or indoor air quality (7 cases), and smoke (5 cases).

Table E-6: Respiratory Diseases and Poisoning by Type, OIISS, 2015-2016 Illness 2015 2016 Percent Change Respiratory 72 71 53% -1% Poisoning 10 24 18% 140% Asthma/RADS 25 14 11% -44% Rhinitis 15 4 3% -73% Asbestos exposure/disease 3 4 3% 33% Bronchitis 10 0% Other Lung 43 16 12% -63% Total 178 133 100% -25%

Respiratory disease and poisoning cases mainly occurred in Education and Health (47% of cases) and Government (23%).

33 Page 401 of 430 Lead Poisoning (Laboratory Reports) Connecticut requires laboratories to report all blood lead tests of 10 micrograms per deciliter (ug/dl) of whole blood or greater to the Connecticut Department of Public Health (CGS § 19a-110). These cases are classified into childhood (less than 16 years of age) and adult cases (only adult cases are reported here), with the majority of adult cases being attributed to an individual’s occupation (although some cases occur in individuals engaged in hobbies such as home improvement or target shooting). Up to a third or more of cases in recent years are related to the use of gun firing ranges. The numbers are based on the highest level measured for each individual during the calendar year; they do not include multiple tests on the same individual. OSHA medical removal protections apply at the level of 50 ug/dl of whole blood or above (and require a reduction to 40 ug/dl to return to work). Lead can have neurological and other negative effects on health at much lower levels of exposure.

The total number of lead poisoning reports in 2016 (330 cases) decreased 22% from the previous year. The lowest category (10-24 ug/dl) of recorded elevated lead levels accounted for 78% of all cases (Table E-7). There was a decrease in all categories of lead levels except the 50-59 micrograms per deciliter group. Almost all of the reported lead poisoning cases (94% of cases where gender was known) occurred in men; there were only 20 reports for women. Thirty-eight percent (38%) were under 40 years old and 25% were age 60 or older.

Table E-7: Lead Cases by Level of Blood Lead, CT ABLES, 2015-2016 Blood lead level* 2015 2016 Percent Change 10-24 351 257 78% -27% 25-39 57 56 17% -2% 40-49 12 9 3% -25% 50-59 2 7 2% 250% >=60 3 1 0% -67% Total 425 330 100% -22% Source: Connecticut Adult Blood Lead Epidemiology and Surveillance (ABLES program) * micrograms per deciliter (ug/dl) of whole blood. Number of individuals with elevated lead levels (multiple tests for individuals were eliminated.)

Figure E-5: Lead Cases 2003-2016

500 450 400 350 300 250 40+ 200 Total cases 150 100

0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Overall, lead cases have fluctuated over the previous 12 years, from 400 in 2003 to 330 in 2016, with a high of 465 cases in 2006 and a low of 283 cases in 2012. Cases at or above the OSHA level of 40 ug/dl have stayed

34 Page 402 of 430 relatively constant at 15 to 20 cases since 2004 (Figure E-7). Fluctuations in the past have been observed due to lead screening programs and special bridge maintenance projects involving the removal of lead paint.

Infectious and Other Diseases Infectious diseases increased 9% to 1,513 cases in 2016. Bloodborne pathogen exposures (to needlesticks, blood, body fluids or human bites) or diseases (such as HIV or Hepatitis) were the most common infectious diseases reported, with 1,226 reports in 2016, a 7% increase over 2015. Bloodborne exposures are of most concern when there is a needlestick or other sharp injury, particularly if there is an injection of blood into the caregiver’s body. These reports do not generally specify whether the source patient/client was infected with a bloodborne illness such as HIV or Hepatitis B or C. Of the bloodborne exposures where cause was noted, 50% were due to a needlestick or sharps injury, despite OSHA regulations that require safe needle devices where available. Thirty-four percent (34%) of the reports were due to blood or body fluid exposures. Exposure to saliva is not included in these numbers, since the risk of disease transmission is very low in those cases. Finally, 17% were from a human bite; often there is not a description on whether these bites penetrated the skin.

There was an increase in reports of potential exposure to tuberculosis (TB) or positive PPD tests for Tb, with 63 cases in 2016 compared to 28 cases reported in 2015. In addition to bloodborne disease/exposures and TB exposures, there were 93 reports related to meningitis, 41 cases of scabies, 21 cases of Lyme disease or tick bites, and 15 cases of Brucella (not specifically tracked in the prior year) reported. Most of the “Other Infectious” cases were not well-defined in the database and may include some of the more common reports (such as bloodborne or Tb).

Table E-8: Infectious and Other Illnesses, 2015-2016 Illness 2015 2016 % Change Bloodborne 1,144 1,226 7% Meningitis 52 93 79% TB/PPD 28 63 125% Scabies 22 41 86% Lyme/tick bite 7 21 200% Brucella 15 Measles/chickenpox 5 4 -20% Rabies 7 5 -29% MRSA 0 2 Conjunctivitis 46 0 Other infectious 79 43 -46% Subtotal: Infectious 1,390 1,513 9% Chemicals in eyes 33 75 127% Headache/dizzy 36 25 -31% Allergic 7 22 214% Stress/heart 11 18 64% Hearing loss 17 12 -29% Heat/cold 4 10 150% Other 87 88 1% Subtotal: Other 195 250 28% Total 1,585 1,763 11%

35 Page 403 of 430 In addition to the infectious diseases, there were 250 other occupational illnesses reported by physicians in 2016 (Table E-8), an increase of 28%. This included 75 cases of chemical exposures to the eyes, 25 cases of headache, dizziness, or similar symptoms, 22 cases of allergic reactions to substances or foods, 18 cases of either heart or stress-related conditions, 12 cases of hearing loss and 10 cases of over-exposures to heat or cold.

36 Page 404 of 430 F. Appendix 1: Databases and Methods

Determining the incidence of occupational illness in Connecticut is difficult. The problem is two-fold: 1) occupationally-related illness is not consistently recognized as work-related; and 2) the cases reported to either the Department of Labor and/or the Occupational Health Surveillance Division of the Department of Public Health are not complete. Consequently, this assessment of occupational disease reviews a number of sources of information: the Workers’ Compensation Commission’s First Report of Injury database, the Bureau of Labor Statistics/Connecticut Occupational Safety and Health Administration Survey of Occupational Injuries and Illnesses, the Occupational Illnesses and Injury Surveillance System, and the Connecticut Adult Blood Level Epidemiology Surveillance Program. The Workers’ Compensation database was provided in electronic form from the CT Workers’ Compensation Commission and the physicians’ reports from the CT Department of Public Health. The BLS/Conn-OSHA survey data was provided in table form from the Connecticut Department of Labor. Assumptions and Conventions The Workers’ Compensation Commission’s First Reports of Injury database and the Occupational Illnesses and Injury Surveillance System (OIISS, referred to as Physicians’ Reports) were reviewed in depth. A rationale for the data review was developed to differentiate occupational illnesses from injuries and to classify the workplace reports by nature and cause of the illness. Each entry was reviewed for internal consistency and reasonableness. Specifically, the process employed the following steps:

1) Clear acute injuries were eliminated. In assessing the Workers’ Compensation First Reports of Injury, a line by line review of injury descriptions, nature descriptions and codes, listed causes, and part of body were used to differentiate whether an injury or illness was described. The determination relied most heavily on the text description and then on the other data fields in the order listed above.

The Physicians’ Reports are organized differently. Numerical “Nature of Injury or Illness” codes from the Bureau of Labor Statistics Occupational Injury and Illness Classification System (ANSI Z16.2-1995, American National Standard for Information Management for Occupational Safety and Health) were used as the primary indicator to evaluate the records. Cause, certainty, diagnosis, ICD codes, suspected agent and symptom fields were also reviewed in determining illness or injury. Categories that were eliminated included all burns, eye problems such as conjunctivitis or chemical exposures, lower back problems (including sciatica), hernias, infected wounds or burns, insect and animal bites (with the exception of tick bites because of the relationship with Lyme disease), and electrical shocks.

2) Validity of remaining records was determined. Records were reviewed to be sure that the coding of types of disease was consistent with other information in the record. In addition, diseases were categorized by type of disease.

3) Fields were either revised or added to the databases: Illness Type and Nature of Illness. The Nature of Illness was based on the information in the databases, research, and general information about the illnesses. Then each entry was categorized by Illness Type. The specific nature categories were grouped into broader categories to support graphic representation. For the Workers’ Compensation database, the description of injury was used as the key description of the illness if it disagreed with the coding for other variables.

4) Employers were coded for industry utilizing a comprehensive list of Connecticut employers from the CT Department of Labor and coded based on the NAICS (North American Industry 37 Page 405 of 430 Classification System) for the BLS and workers’ compensation data. Rates were calculated using employment figures from the Occupational Safety and Health Statistics Division of the CT Labor Dept.

5) Data was cleaned, tabulated and put into presentation form using Microsoft Access, Excel, and Word software.

6) The report is reviewed by the Connecticut Workers’ Compensation Commission prior to publication.

38 Page 406 of 430 G. Appendix 2: Occupational Disease Detail by Type and Year

Table G-1: Cases of Occupational Disease, by Type, Bureau of Labor Statistics/Conn-OSHA, 1979 – 2016 Employ.* All Ill Skin MSD Lung-dust Respir. Poison Physical Other 1979 1,358 3,322 1,716 471 25 317 175 250 368 1980 1,394 3,066 1,586 513 88 214 66 199 400 1981 1,409 3,214 1,509 701 38 290 89 192 395 1982 1,400 2,549 1,130 580 31 223 31 216 323 1983 1,419 2,930 1,236 665 20 154 152 176 519 1984 1,490 2,735 1,109 665 24 273 65 162 432 1985 1,528 2,809 928 727 44 233 51 130 693 1986 1,567 2,719 808 761 39 274 65 235 538 1987 1,607 4,643 1,352 1,430 31 300 62 704 754 1988 1,637 4,364 1,257 405 35 332 56 405 733 1989 1,634 5,844 1,248 2,629 57 277 74 468 1,087 1990 1,593 5,307 1,032 2,535 93 457 54 496 641 1991 1,518 6,094 946 3,454 62 422 113 501 591 1992 1,483 6,458 1,084 3,852 37 471 53 349 612 1993 1,487 8369 965 5526 52 512 166 346 802 1994 1,502 7,319 957 4,482 74 410 97 313 986 1995 1,520 6,787 884 4,220 80 323 35 349 896 1996 1,538 6,021 827 3,711 40 418 34 235 756 1997 1,570 5,419 620 3,335 21 287 70 150 936 1998 1,597 5,510 989 3,398 10 459 45 92 517 1999 1,630 5,513 793 3,306 20 386 71 265 671 2000 1,653 6,396 897 3,827 65 438 29 137 1,003 2001 1,572 5,514 916 3,220 10 630 29 118 591 Employ.* All Ill Skin Respir. Poison Hearing Other 2002 1,602 4,387 831 320 78 3,159 2003 1,605 4,559 903 490 32 3,132 2004 1,603 4,572 832 354 35 466 2,886 2005 1,614 4,850 848 480 8 381 3,134 2006 1,636 3,787 575 235 38 439 2,500 2007 1,667 3,904 624 358 22 457 2,443 2008 1,675 3,562 690 293 130 360 2,088 2009 1,629 3,400 600 300 -- 500 2,000 2010 1,629 3,000 700 300 -- 300 1,700 2011 1,578 3,500 800 300 -- 300 2,100 2012 1,628 2,800 600 300 -- 300 1,500 2013 1,640 2,600 500 300 -- 300 1,600 2014 1,653 2,400 400 200 -- 300 1,400 2015 1,663 2,300 400 200 -- 200 1,500 2016 2,300 500 200 -- 300 1,300 Source: BLS/Conn-OSHA. Data collection methods and categories changed in 2002 and are not comparable to prior years. Employment in thousands. Since this data is based on a weighted survey, some of these numbers (particularly the smaller numbers) are not reliable.

39 Page 407 of 430 Table G-2: Rate per 10,000 Workers of Occupational Disease, by Type, Bureau of Labor Statistics/Conn-OSHA, 1979-2016 Employ.* All Ill Skin MSD Lung-dust Respir. Poison Physical Other 1979 1,358 3,322 1,716 471 25 317 175 250 368 1980 1,394 3,066 1,586 513 88 214 66 199 400 1981 1,409 3,214 1,509 701 38 290 89 192 395 1982 1,400 2,549 1,130 580 31 223 31 216 323 1983 1,419 2,930 1,236 665 20 154 152 176 519 1984 1,490 2,735 1,109 665 24 273 65 162 432 1985 1,528 2,809 928 727 44 233 51 130 693 1986 1,567 2,719 808 761 39 274 65 235 538 1987 1,607 4,643 1,352 1,430 31 300 62 704 754 1988 1,637 4,364 1,257 405 35 332 56 405 733 1989 1,634 5,844 1,248 2,629 57 277 74 468 1,087 1990 1,593 5,307 1,032 2,535 93 457 54 496 641 1991 1,518 6,094 946 3,454 62 422 113 501 591 1992 1,483 6,458 1,084 3,852 37 471 53 349 612 1993 1,487 8369 965 5526 52 512 166 346 802 1994 1,502 7,319 957 4,482 74 410 97 313 986 1995 1,520 6,787 884 4,220 80 323 35 349 896 1996 1,538 6,021 827 3,711 40 418 34 235 756 1997 1,570 5,419 620 3,335 21 287 70 150 936 1998 1,597 5,510 989 3,398 10 459 45 92 517 1999 1,630 5,513 793 3,306 20 386 71 265 671 2000 1,653 6,396 897 3,827 65 438 29 137 1,003 2001 1,572 5,514 916 3,220 10 630 29 118 591 Employ.* All Ill Skin Respir. Poison Hearing Other 2002 1,602 4,387 831 320 78 3,159 2003 1,605 4,559 903 490 32 3,132 2004 1,603 4,572 832 354 35 466 2,886 2005 1,614 4,850 848 480 8 381 3,134 2006 1,636 3,787 575 235 38 439 2,500 2007 1,667 3,904 624 358 22 457 2,443 2008 1,675 3,562 690 293 130 360 2,088 2009 1,629 3,400 600 300 -- 500 2,000 2010 1,629 3,000 700 300 -- 300 1,700 2011 1,578 3,500 800 300 -- 300 2,100 2012 1,628 2,800 600 300 -- 300 1,500 2013 1,640 2,600 500 300 -- 300 1,600 2014 1,653 2,400 400 200 -- 300 1,400 2015 1,663 2,300 400 200 -- 200 1,500 2016 2,300 500 200 -- 300 1,300 Source: BLS/Conn-OSHA *Data collection methods and categories changed in 2002 and are not comparable to prior years. “Other” includes the pre-2002 categories of MSD, Physical, Lung-dust, and Other.

40 Page 408 of 430 H. Appendix 3: Internet Resources for Job Safety and Health; 2016

General Health and Safety Sites

One of the best sources of information for job health and safety on the internet is the OSHA (Occupational Safety and Health Administration) homepage, which includes an ergonomics homepage, a searchable index of standards, and many other resources. http://www.osha.gov To look up OSHA citations by company or industry: http://www.osha.gov/pls/imis/establishment.html

The Bureau of Labor Statistics tracks occupational injuries and illnesses https://www.bls.gov/iif/

NIOSH (the National Institute for Occupational Safety and Health) is another good general source. A searchable section on diseases and injuries briefly describes conditions with updates on current research and guidance on prevention. http://www.cdc.gov/niosh/homepage.html http://www.cdc.gov/niosh/topics/diseases.html

EPA (the Environmental Protection Agency) has a number of sites relevant to occupational health on indoor air quality, office and school environments, and other topics. www.epa.gov www.epa.gov/iaq/

The North Carolina Occupational Safety and Health Education and Research Center is the home for the occupational health forum (formerly based at Duke), directed particularly to health care professionals, with a good set of technical links to other occupational health resources. http://www.occhealthnews.net

The Canadian Centre for Occupational Health and Safety has hundreds of resources on their health and safety internet resource list. Start at their home page, then choose “Free Resources” (on the side bar). http://www.ccohs.ca

New Jersey Department of Health has 1,600 excellent chemical hazard factsheets that are free, independently researched, and clearly written (900 in Spanish) on hundreds of substances. http://web.doh.state.nj.us/rtkhsfs/indexfs.aspx

Vermont Safety Information Resources, Inc. has a database of material safety data sheets (MSDS) from a large number of chemical companies. http://hazard.com

Several safety organizations have useful websites: www.nsc.org The National Safety Council www.aiha.org The American Industrial Hygiene Association www.asse.org American Society of Safety Engineers www.nfpa.org National Fire Protection Association www.safetycentral.org International Safety Equipment Association

For a labor perspective, the national AFL-CIO includes a health and safety page. http://www.aflcio.org/Issues/Job-Safety,

COSH (Coalitions for Occupational Safety and Health) are labor-oriented nonprofit groups based in many states, with information on a variety of hazards. They can all be accessed through the National Coalition for Occupational Safety and Health http://www.coshnetwork.org 41 Page 409 of 430

The Connecticut Business and Industry Association has a health and safety page that helps businesses understand what OSHA laws apply to them and provides information on upcoming conferences and events. https://www.cbia.com/resources/category/hr-safety

The Environmental Defense Fund has a “pollution information site” called Scorecard with information about 11,200 chemicals and their recognized and suspected health effects. The site offers information with an interactive data based on the 2002 Toxics Release Inventory and is currently working on providing an update. http://www.scorecard.org/

The Cal-OSHA Reporter carries current stories on job health and safety. http://www.cal-osha.com.

Some blogs carry job health and safety news and commentary. Jordan Barab has a labor perspective on OSHA and job health and safety http://jordanbarab.com/confinedspace The USMWF United Support and Memorial for Workplace Fatalities posts current stories about workers who have been killed on the job and their families https://www.facebook.com/USMWF or www.usmwf.org The Pump Handle connects to Facebook and Twitter, written by Celeste Monforton http://scienceblogs.com/thepumphandle/. Workers’ compensation issues are covered at http://workerscompinsider.com.

The Toxic Use Reduction Institute at UMass Lowell has extensive resources on safer alternatives to toxic substances, including a database on alternatives to solvents. http://www.turi.org. UMass-Lowell’s Center for Sustainable Production has information on changing chemical policies. http://www.sustainableproduction.org/

The Health and Safety Executive of Great Britain has extensive information on the new European Union’s REACH (Registration, Evaluation, and Authorization of Chemicals). http://www.hse.gov.uk/reach/index.htm http://www.hse.gov.uk/index.htm

OSHA has a discussion of the US program that responds to the International Globally Harmonized System for Hazard Communication. http://www.osha.gov/dsg/hazcom/global.html.

State of Connecticut and Select Other Resources

The Connecticut Workers’ Compensation Commission has an excellent website, including information on the locations of offices, a searchable version of the workers’ compensation statutes, new decisions, and other information. http://wcc.state.ct.us

The Connecticut (CT) website allows access to all branches of state government including agencies. http://www.state.ct.us

The CT Department of Public Health includes a site for the occupational health program, including Occupational Health Fast Facts, Health Alerts and Fact Sheets.

42 Page 410 of 430 http://www.ct.gov/dph/occupationalhealth

The CT Department of Labor includes an occupational health services site, which includes information on their free consultation program and a great set of links to other health and safety sites. CONN-OSHA offers a variety of consulting services to both public and private employers in Connecticut, available at no charge. http://www.ctdol.state.ct.us/osha/osha.htm http://www.ctdol.state.ct.us/osha/consulti.htm

The Connecticut General Assembly website lets you search for any bill being considered or get information about relevant committees such as Labor and Public Employees or Public Health. http://www.cga.ct.gov

You can track national bills on the National Library of Congress site. https://www.congress.gov/

You can search the medical literature at US National Library of Medicine PubMed. http://www.ncbi.nlm.nih.gov/pubmed/

You can search general academic literature through Google Scholar. http://scholar.google.com/schhp?tab=ws .

UConn Health’s Division of Occupational and Environmental Medicine has information and links on job health and safety. http://health.uconn.edu/occupational-environmental

The Center for the Promotion of Health in the New England Workplace (CPH-NEW) is a research-to- practice initiative led by investigators from the UMASS Lowell and UCONN HEALTH. http://health.uconn.edu/occupational-environmental/academics-and-research/cph-new/

The UCONN HEALTH’s Center for Indoor Environments and Health provides guidance on environmental exposures in indoor settings including schools and office buildings http://health.uconn.edu/occupational-environmental/consultation-and-outreach/cieh/

Ergonomic Sites and Links Ergoweb has good factsheets, documents, and news. https://ergoweb.com/

Tom Bernard’s website at University of South Florida has many of the standards and excellent free electronic ergonomic analysis tools such as the NIOSH lifting equation. http://personal.health.usf.edu/tbernard/ergotools/index.html.

Tom Armstrong at the University of Michigan runs one of the most respected university training programs for ergonomics, and has extensive information, tools, and lectures. http://www-personal.umich.edu/~tja

Cornell University’s Alan Hedge has an active ergonomics program, with reports posted on graduate student projects and evaluation of ergonomic products. http://ergo.human.cornell.edu

The University of Virginia has ergonomics training and resources. http://ehs.virginia.edu/Ergonomics.html

43 Page 411 of 430 Human Factors and Ergonomics Society is the main professional association in ergonomics. http://www.hfes.org

Since 1994, the National Ergonomics Conference & Ergo Expo has provided a forum on ergonomics, safety and wellness programs. http://www.ergoexpo.com

The Typing Injury FAQ has links and information on repetitive strain injuries from user and injured workers groups. http://www.tifaq.org

The National Health Service/UK has information about repetitive strain injuries/RSI http://www.nhs.uk/conditions/Repetitive-strain-injury/Pages/Introduction.aspx

Paul Landsbergis has a good website on job stress. http://unhealthywork.org/about-us/team/paul-a-landsbergis

The European Agency for Health and Safety at Work’s Job Stress Network web page is dedicated to increasing communication among researchers and others interested in job stress and its impact on health https://osha.europa.eu/data/links/795

Internet Resources for Job Safety and Health is compiled by Tim Morse, Ph.D., at UConn Health. To update or add a listing, please contact Tim at [email protected].

44 Page 412 of 430 I. Appendix 4: Who's Who: Resources in Connecticut on Job Safety and Health

Academic Programs and Courses

Central Connecticut State University, School of Technology Type of Degree: Certificate Program in Environmental and Occupational Safety Faculty contact: Ravindra Thamma, Department Chair Address: Copernicus Hall - Room 2120900, CCSU, 1615 Stanley Rd., New Britain, CT 06050 Phone: 860-832-3516 e-mail: [email protected] Web: http://www.ccsu.edu/mcm/environmentalOccupationalSafetyOCP.html

UConn College of Agriculture, Health and Natural Resources, Department of Allied Health Sciences Type of Degree and Program: Bachelor in Allied Health Sciences with an Occupational Environmental Health Sciences Concentration; and an Online Occupational Safety and Health Post-Baccalaureate Certificate Program Faculty contact: Paul Bureau, MS MS CIH Address: Koons Hall Room 306, 358 Mansfield Road, Unit 1101, Storrs, CT 06269-1101 Phone: (860) 486-0040 e-mail: [email protected] Web: http://www.alliedhealth.uconn.edu/majors/oshConcentration.php and http://osh.uconn.edu

UConn Health, Department of Community Medicine Type of Degree: Masters in Public Health program with ergonomic/occupational health courses Director: David Gregorio, PhD Address: UCONN Health, 263 Farmington Ave., Farmington, CT 06030-6325 Phone: (860) 679-5480 Fax: (860) 679-1581 e-mail: [email protected] Web: http://commed.uchc.edu/education/mph/index.html

UConn Health, Department of Community Medicine Type of Degree: Ph.D. in Public Health with courses in Occupational and Environmental Health Sciences Faculty Contact: Helen Swede, Ph.D. Address: UCONN Health, 263 Farmington Ave., Farmington, CT 06030-6210 Phone: (860) 679-5568 Fax: (860-679-5463 e-mail: [email protected] Web: http://health.uconn.edu/community-medicine/ph-d-in-public-health

45 Page 413 of 430 OSHA

Connecticut Department of Labor's Division of Occupational Safety and Health/CONN-OSHA: CONN- OSHA enforces state occupational safety and health regulations as they apply to state and municipal employees, and offers free consultations to public agencies, school districts and private companies. Director: Kenneth C. Tucker III Address: 38 Wolcott Hill Rd., Wethersfield, CT 06109 Phone: (860) 263-6900 Fax: (860) 263-6940 Web: http://www.ctdol.state.ct.us/osha/osha.htm Publications: ConnOSHA Quarterly https://www.ctdol.state.ct.us/osha/Quarterly/coqtrly.htm

OSHA (Occupational Safety and Health Administration): Federal OSHA inspects workplaces in the private sector for violations of standards, and also has information and pamphlets. National Website: https://www.osha.gov

OSHA Bridgeport Office (Fairfield, New Haven, and Middlesex counties). Area Director (Acting until August 2017): Steve Biasi Address: 915 Lafayette Blvd, Room 309, Bridgeport, Connecticut 06604 Phone: (203) 579-5581; National Hotline after hours, etc.: (800) 321-OSHA (6742) Fax: (203) 579-5516

OSHA Hartford Office Director: Dale Varney Address: 135 High Street, Suite 361, Hartford, CT 06103 Phone: (860) 240-3152; National Hotline after hours, etc.: (800) 321-OSHA (6742) Fax: (860) 240-3155

Academic Occupational Health Clinics

UConn Occupational and Environmental Medicine Clinic Clinic Director: George W. Moore, M.D., M.Sc., FACPM, FACOEM Address: UCONN Health, 263 Farmington Ave, Farmington, CT 06032-8077 Clinic address: UCONN Main Building (Hospital Entrance), Room CG228 Phone: (860) 679-2893 Fax: (860) 679-4587 e-mail: [email protected] Web: http://health.uconn.edu/occupational-environmental/clinical-services/

Yale Occupational and Environmental Medicine Program Director: Carrie A Redlich, MD, MPH Address: 367 Cedar Street, ESHA 2nd Floor, New Haven, CT 06510 Clinic address: 135 College St. Rm. 366, New Haven, CT 06510 Phone: (203) 785-4197 Fax: (203) 785-7391 e-mail: [email protected] Web: http://medicine.yale.edu/intmed/occmed/

46 Page 414 of 430 Occupational Health Clinics

Concentra Medical Director: David Feinstein, MD Address: 701 Main Street, East Hartford, CT 06108 Phone: (860) 289-5561 Fax: (860) 291-1895 e-mail: [email protected] Web: http://www.concentra.com/employers/occupational-health/ Other Offices: 972 West Main Street, New Britain (860) 827-0745 1080 Day Hill Road, Windsor (860) 298-8442 8 South Commons Rd, Waterbury (203) 759-1229 333 Kennedy Drive, Torrington (860) 482-4552 900 Northrup Rd, Wallingford (203) 949-1534 370 James Street, New Haven (203) 503-0482 60 Watson Blvd, Stratford (203) 380-5945 15 Commerce Road, 3rd Floor, Stamford, (203) 324-9100 10 Connecticut Avenue, Norwich, (860) 859-5100

Connecticut Occupational Medicine Partners, St. Francis Hospital and Medical Center President, CEO and Administrative Director: Derrick Amato Address (corporate): 675 Tower Avenue, Suite 404B, Hartford, CT 06112 Phone: (860) 714-6188 Fax: (860) 714-2775 Web: http://compllc.org/ Clinics: St Francis; 1000 Asylum Ave, Ste 4320, Hartford, 860-714-4270; 1598 East Main St, Torrington, (860) 482- 3467; 100 Deerfield Road, Windsor, 860-714-9444 ECHN Corporate Care; 2800 Tamarack Ave., Suite 001, South Windsor, CT 06074, (860) 647-4796 MedWorks of Bristol Hospital; 975 Farmington Ave. Bristol (860) 589-0114 MedWorks; 375 East Cedar St., Newington (860) 667-4418 Johnson Memorial Medical Center: Director, Clinical Services: Kathy Heim, RN, MSN 155 Hazard Ave., Suite 6. Enfield, CT 06082, (860) 763-7668

Griffin Hospital Occupational Medicine Center Director: Myra Odenwaelder, DPT Address: 10 Progress Drive. Shelton, CT 06484 Phone: (203) 944-3718 Fax: (203) 929-3068 e-mail: [email protected] Web: http://www.griffinhealth.org/locations/shelton/griffin-hospital-occupational-medicine-center

Hartford Medical Group—Occupational Medicine Business Development Director: Peter Kowalski Address: 1025 Silas Deane Highway, Wethersfield, CT 06109 Phone: (800) 557-8389 e-mail: [email protected] Web: https://hartfordhealthcaremedicalgroup.org/specialties/primary-care/occupational-medicine

47 Page 415 of 430 Other Offices; 324 Flanders Rd, East Lyme, CT 06333 (860) 739-6953; 80 Norwich-New London Tnpk, Montville, 06353, (860) 898-1297; 440 New Britain Ave, Plainville 06062 (860) 747-944; 445 South Main Street, West Hartford, (860) 696-2200.

Middlesex Hospital Occupational Medicine Director: Matthew Lundquist, MD, MPH Address: 534 Saybrook Rd., Middletown, CT 06457 Phone: (860) 358-2750 Fax: (860) 348-2757 e-mail: mailto:[email protected] Web: http://middlesexhospital.org/occmed Other Office: Essex Medical Building, 252 Westbrook Road, Essex (860) 358-3840

St. Mary’s Hospital Occupational Health and Diagnostic Center Medical Director: Erica Martinucci, MD Address: 1312 West Main Street, Waterbury, CT Phone: (203) 709-3740 Fax: (203) 709-3741 Email: [email protected] Web: http://www.stmh.org/occupational-medicine-2892

Yale-New Haven Health Systems Manager for Clinical Operations (St. Raphael campus): Andrea Santerre, RN Address: 175 Sherman Avenue, New Haven, CT 06511 Phone: (203) 789-6216 Fax: (203) 789-5174 e-mail: [email protected] Web: https://www.ynhh.org/services/occupational-health.aspx Other Offices: 2080 Whitney Ave., Suite 150, Hamden (203) 789-6242 Greenwich Hospital, 5 Perry Ridge Rd, (203) 863-3483 Bridgeport Hospital, (203) 988-2551 20 York St., New Haven, 203-688-4242

Lawrence and Memorial Occupational Health Center Medical Director: Saima Khalid, MD Address: 52 Hazelnut Hill Rd., Groton, CT 06340 Phone: (860) 446-8265 x7074 Fax: (860) 448-6961 Web: https://www.lmhospital.org/services/occupational-health.aspx

48 Page 416 of 430 Organizations American Lung Association (ALA) in Connecticut The ALA is a non-profit association geared towards preventing lung disease, including occupational lung disease. Director, Health Promotions: Michelle Caul Connecticut Address: 45 Ash St., East Hartford, CT 06108 Phone: (860)838.4370 e-mail: [email protected] Web: Lung.org

Coalition for a Safe and Healthy Connecticut This is a community-based coalition of environmental, public health, and labor organizations providing resources and advocacy for reducing the use of toxic chemicals through substitution of safer alternatives. Coordinator: Anne B. Hulick, RN MS JD Address: c/o Clean Water Action, 2074 Park Street, Suite 308, Hartford, CT, 06106 Phone: (860) 232-6232 Fax: (860) 232-6334 e-mail: [email protected] Web: https://safehealthyct.wordpress.com

Connecticut Safety Council/Safety Roundtable The Safety Council is associated with the Connecticut Business and Industry Association and offers seminars, training courses, consulting, and policy discussions on safety and regulations. Contact: Phillip Montgomery Address: 350 Church St. Hartford, CT 06103-1126 Phone: (860) 244-1900 e-mail: [email protected] Web: https://www.cbia.com/resources/hr-safety/hr-safety-councils/safety-health-roundtable

ConnectiCOSH (The Connecticut Council for Occupational Safety and Health) CTCOSH is a union-based non-profit organization for education and political action on job safety and health. They have conferences, fact sheets, and speakers. Director: Mike Fitts Address: 683 No. Mountain Rd, Newington, CT 06111 Phone: (860) 953-COSH (2674) Fax: (860) 953-1038 e-mail: [email protected] Web: http://connecticosh.org

The Center for the Promotion of Health in the New England Workplace (CPH-NEW) CPH-NEW is a NIOSH-funded center for scientific research and education, based in participatory action research, integrating occupational health and safety with worksite health that is administered jointly by UMASS Lowell and UCONN Health. Director: Martin Cherniack, MD, MPH Address: 263 Farmington Ave, Farmington, CT 06030-8077 Phone: (860) 679-4916 Fax: (860) 679-1349 e-mail: [email protected] Web: http://health.uconn.edu/occupational-environmental/academics-and-research/cph-new/

49 Page 417 of 430 The Ergonomic Technology Center (ErgoCenter) at UCONN Health The ErgoCenter is a center for prevention of repetitive strain injuries based at UCONN Health, which does training, research, consulting, and clinical care. Contact: Jennifer Garza, ScD, Ergonomist Address: 263 Farmington Ave, Farmington, CT 06030-8077 Phone: (860) 679-4916 Fax: (860) 679-1349 Phone: 860-679-5418 Email: [email protected] Web: https://health.uconn.edu/occupational-environmental/consultation-and-outreach/ergonomics-consultation/

UConn Health- Center for Indoor Environments and Health (CIEH) The CIEH at the University of Connecticut Health Center works with public health agencies, companies, clinics and individuals to promote indoor environments which protect the health of building occupants and provide productive, creative spaces for learning and work. The website on hurricane health (below) provides educational materials on protecting workers from exposures when addressing flooded buildings after severe wet weather. Director: Paula Schenck, MPH Address: 263 Farmington Ave, Farmington, CT 06030-8077, Phone: (860) 679-2368 Fax: (860) 679-1349 e-mail: schenck@ uchc.edu Web: http://health.uconn.edu/occupational-environmental/consultation-and-outreach/cieh/ http://hurricane-weather-health.doem.uconn.edu

Professional Associations

American Industrial Hygiene Association (AIHA), Connecticut River Valley Section AIHA is a professional association for industrial hygienists. Contact: Brian Bethel, CIH Phone: (203) 232-9993 e-mail: [email protected] Web: http://www.crvaiha.wildapricot.org

Connecticut Safety Society This society is a professional association for safety inspectors President: Larry French Phone: (910) 322-5092 e-mail: [email protected] Web: http://www.ctsafety.org

American Society of Safety Engineers (ASSE) ASSE is a non-profit association for enhancing the competence and knowledge of the safety profession. Connecticut Valley Chapter (Northern CT) Address: Box 106, 1131-0 Tolland Turnpike, Manchester, CT 06040 President: Maryanne Steele e-mail: [email protected] Web: http://ctvalley.asse.org

50 Page 418 of 430 Air & Waste Management Association (AWMA), Connecticut Chapter AWMA provides training, information, and networking opportunities to environmental professionals. The Connecticut Chapter, New England Section, provides periodic forums for discussion and sponsors an annual student scholarship. Chair: David Krochko Phone: (888) 265-8969 e-mail: [email protected] Web: http://www.awmanewengland.org/connecticut_chapter.htm

Connecticut Trial Lawyers Association, Workers' Compensation Committee This is an association of attorneys specializing in workers' compensation, mostly for claimants. Executive Director: Joan D. Maloney Workers’ Compensation Section Chair: Lukas Watson Address: 150 Trumbull Street, 2nd Floor, Hartford, CT 06103 Phone: (860) 522-4345 Fax: (860) 522-1027 e-mail: [email protected] Web: https://www.cttriallawyers.org

Connecticut Bar Association, Workers' Compensation Section This is a professional association of attorneys who concentrate in workers' compensation. Chair: Francis “Bud” Drapeau Phone: (860) 875-7000 E-mail: [email protected] Web: http://ctinjurylawyers.com/

New England College of Occupational and Environmental Medicine/NECOEM NECOEM is an association for occupational medicine doctors. Executive Director: Dianne Plantamura, MSW Address: 22 Mill Street, Groveland, MA 01834 Phone: (978) 373-5597 e-mail: [email protected] Web: http://www.necoem.org/

Northeast Association of Occupational Health Nurses /NEAOHN NEAOHN is an association of occupational health nurses, including most of the nurses working in industry. CT Director: Richard Sandrib, BSN, MS, APRN e-mail: [email protected] Address: 5 Research Pkwy, Wallingford, CT 06492 Phone: (203) 677-6441 Web: http://www.neaohn.org/

51 Page 419 of 430 Connecticut State Agencies

Department of Public Health (DPH), Occupational Health Unit This unit investigates clusters of occupational diseases. Programs for radon, asbestos, AIDS, lead, asthma, CT Schools Environmental Resource Team, TB control and infectious disease are also at the DPH. Director: Thomas St. Louis, MSPH Address: DPH/ OHP, 410 Capitol Ave, MS #11EOH, PO Box 340308, Hartford, CT 06134-0308 Phone: 860) 509-7740 Fax: (860) 509-7785 e-mail: [email protected] Web: http://www.ct.gov/dph/cwp/view.asp?a=3140&q=387472&dphNav_GID=1828

State Department of Emergency Services and Public Protection Public Information Officer: Scott Devico Phone: (860) 685-8230; (203) 525-6959 (cell) Fax: (860) 685-8902 e-mail: [email protected] Web: http://www.ct.gov/demhs/site/default.asp

State Emergency Response Commission, Department of Energy and Environmental Protection This commission oversees plans for response to chemical accidents and collects chemical information for the public under Community Right to Know. Chairman: Gerard P. Goudreau Address: 79 Elm St, Hartford, CT 06106-5127 Phone: (860) 424-3373 Fax: (860) 424-4062 e-mail: [email protected] Web: http://www.ct.gov/serc

Connecticut Fire Academy, Commission on Fire Prevention & Control Safety training & standards compliance. Training Director: Bill Higgins Address: 34 Perimeter Road, Windsor Locks, CT 06096-1069 Phone: 860-264-9272 or toll free (877) 5CT-FIRE (only in CT) Fax: (860) 654-1889 Email: [email protected] Web: http://www.ct.gov/cfpc/site/default.asp

Connecticut Department of Environmental Protection, Radiation Safety Unit Director: Jeff Semancik Phone: (860) 424-4190; (860) 424-3333 24/7 Emergency Fax: (860) 706-5339 e-mail: [email protected] Web: http://www.ct.gov/deep/cwp/view.asp?a=2713&q=324824&deepNav_GID=1639

52 Page 420 of 430 Workers' Compensation Commission Chairman's Office and Compensation Review Board The Workers’ Compensation Commission (WCC) administers the workers’ compensation laws of the State of Connecticut with the ultimate goal of ensuring that workers injured on the job receive prompt payment of lost work time benefits and attendant medical expenses. To this end, the Commission holds hearings on disputed matters, facilitates voluntary agreements, makes findings and awards, hears and rules on appeals, and closes out cases through full and final stipulated settlements.

The WCC Safety & Health Services unit assists employers with implementation of the workers’ compensation regulations regarding “Establishment and Administration of Safety and Health Committees at Work Sites.”

Chairman: Stephen M. Morelli Address: 21 Oak St., 4th Floor, Hartford, CT 06106-8011 Phone: (860) 493-1500 Information: (800) 223-WORK (9675) Fax: (860) 247-1361 e-mail: [email protected] Web: http://wcc.state.ct.us/

Workers' Compensation District Offices 1. 999 Asylum Ave., Hartford, CT 06105; (860) 566-4154; Fax: (860) 566-6137 2. 55 Main St., Norwich, CT 06360; (860) 823-3900; Fax: (860) 823-1725 3. 700 State St., New Haven, CT 06511; (203) 789-7512; Fax: (203) 789-7168 4. 350 Fairfield Ave., 2nd Floor, Bridgeport, CT 06604; (203) 382-5600; Fax: (203) 335-8760 5. 55 West Main St., Waterbury, CT 06702; (203) 596-4207; Fax: (203) 805-6501 6. 233 Main St., New Britain, CT 06051; (860) 827-7180; Fax: (860) 827-7913 7. 111 High Ridge Rd., Stamford, CT 06905-5111; (203) 325-3881; Fax: (203) 967-7264 8. 90 Court St., Middletown, CT 06457; (860) 344-7453; Fax: (860) 344-7487

The Who’s Who is compiled by Tim Morse, Ph.D., at UConn Health. To update or add a listing, please contact Tim at [email protected].

53 Page 421 of 430 Who's Who: Resources in Connecticut on Job Safety and Health

Academic Programs and Courses

Page 422 of 430 OSHA

OSHA Hartford Office Director: Dale Varney Address: 135 High Street, Suite 361, Hartford, CT 06103 Phone: (860) 240-3152; National Hotline after hours, etc.: (800) 321-OSHA (6742) Fax: (860) 240-3155

Academic Occupational Health Clinics

Occupational Health Clinics

Page 423 of 430

Other Offices; 324 Flanders Rd, East Lyme, CT 06333 (860) 739-6953; 80 Norwich-New London Tnpk, Montville, 06353, (860) 898-1297; 440 New Britain Ave, Plainville 06062 (860) 747-944; 445 South Main Street, West Hartford, (860) 696-2200.

Page 424 of 430 Middlesex Hospital Occupational Medicine Director: Matthew Lundquist, MD, MPH Address: 534 Saybrook Rd., Middletown, CT 06457 Phone: (860) 358-2750 Fax: (860) 348-2757 e-mail: mailto:[email protected] Web: http://middlesexhospital.org/occmed Other Office: Essex Medical Building, 252 Westbrook Road, Essex (860) 358-3840

Page 425 of 430 Organizations American Lung Association (ALA) in Connecticut The ALA is a non-profit association geared towards preventing lung disease, including occupational lung disease. Director, Health Promotions: Michelle Caul Connecticut Address: 45 Ash St., East Hartford, CT 06108 Phone: (860)838.4370 e-mail: [email protected] Web: Lung.org

The Ergonomic Technology Center (ErgoCenter) at UCONN Health

Page 426 of 430 The ErgoCenter is a center for prevention of repetitive strain injuries based at UCONN Health, which does training, research, consulting, and clinical care. Contact: Jennifer Garza, ScD, Ergonomist Address: 263 Farmington Ave, Farmington, CT 06030-8077 Phone: (860) 679-4916 Fax: (860) 679-1349 Phone: 860-679-5418 Email: [email protected] Web: https://health.uconn.edu/occupational-environmental/consultation-and-outreach/ergonomics-consultation/

Professional Associations

Connecticut Safety Society This society is a professional association for safety inspectors President: Larry French Phone: (910) 322-5092 e-mail: [email protected] Web: http://www.ctsafety.org

Air & Waste Management Association (AWMA), Connecticut Chapter AWMA provides training, information, and networking opportunities to environmental professionals. The Page 427 of 430 Connecticut Chapter, New England Section, provides periodic forums for discussion and sponsors an annual student scholarship. Chair: David Krochko Phone: (888) 265-8969 e-mail: [email protected] Web: http://www.awmanewengland.org/connecticut_chapter.htm

Page 428 of 430 Connecticut State Agencies

Page 429 of 430 Workers' Compensation Commission Chairman's Office and Compensation Review Board The Workers’ Compensation Commission (WCC) administers the workers’ compensation laws of the State of Connecticut with the ultimate goal of ensuring that workers injured on the job receive prompt payment of lost work time benefits and attendant medical expenses. To this end, the Commission holds hearings on disputed matters, facilitates voluntary agreements, makes findings and awards, hears and rules on appeals, and closes out cases through full and final stipulated settlements.

The Who’s Who is compiled by Tim Morse, Ph.D., at UConn Health. To update or add a listing, please contact Tim at [email protected].

Page 430 of 430