Workplace-based rehabilitation with garment workers: A multiple case study

Abstract

BACKGROUND:

Garment workers are at risk of developing work-related upper limb disorders (WRULD) due to the highly repetitive nature of their work. Workplace-based rehabilitation (WBR) facilitates improvement in work performance by providing intervention at the worker’s place of work.

OBJECTIVE:

This study aims to determine the documented outcomes of workplace-based occupational therapy rehabilitation of garment workers with upper limb conditions.

METHODS:

A multiple case study design was used through a retrospective record review. All garment workers with upper limb conditions who were treated at a student occupational therapy practice in Cape Town, South Africa, with pre- and post-intervention outcome assessment, were included in the study (n = 7). Data were extracted from occupational therapy and medical files.

RESULTS:

70% of the cases (n = 5) improved after WBR while 30% of cases showed no improvement or deterioration. Participants received 3– 5 individual WBR sessions of approximately 30 minutes each, over a period of 4 to 6 weeks. Interventions included workstation adaptations, job rotation, psychoeducation, work task modification, assistive technology and exercise programmes. Outcome measures most commonly used were the RULA, DASH, Boston Carpal Tunnel Questionnaire and pain intensity using the VAS.

CONCLUSION:

Workplace-based occupational therapy can be effective at improving upper limb function, pain and ergonomic risk amongst garment workers with upper limb conditions.

Keywords

Occupational therapy return to work sewing machine operators textile workers upper limb

1 Introduction

Upper limb conditions rank among the most significant causes of illness and disability within the workplace [1]. Disability and injury to the hand directly affects one’s ability to work and earn an income [2]. Work-related ill health can result in reduced worker productivity and quality of work, increased absenteeism and a greater demand for worker retraining and replacement [1]. Garment workers may be at particular risk of work-related upper limb disorders (WRULD) due to the repetitive upper limb movements, high frequency of monotonous tasks, sustained and awkward postures required of these workers [3 –5].

The clothing industry is known to have one of the highest incidence rates for WRULD in the USA [6]. A study conducted in 2004 with Asian immigrant garment workers working in California found that 99% of the workers experienced musculoskeletal pain [6]. Similarly, a study conducted amongst a group of garment workers in India in 2012 found that 55% of participants from the stitching section reported experiencing severe musculoskeletal pain [7]. Hossain et al. analysed the prevalence of WRULD amongst Bangladeshi garment workers, and found that garment workers are exposed to various risk factors of WRULD [8]. Some of these factors include extended stationary work tasks, repetitive movements, manual labour, forceful actions, vibration and unusual postures [8]. In addition to this, a study conducted with garment workers in Brazil found that clothing factories are marked by physically demanding tasks executed in a sustained sitting position, usually with awkward postures in non-ergonomic stools [9]. Work-related factors such as exposure to high frequency vibrations from machines, lack of ergonomic adaptations to workstations, repetitive and forceful hand tasks and unusual work postures or hand positions place garment workers at risk of developing musculoskeletal conditions [10, 11].

Poor workstation design (improper seating and table height, low light quality, inappropriately sized machinery for the garment worker population and the uncomfortable placement of foot pedals) and poor workplace conditions have been indicated to reduce the work output and general health of garment workers in California [6]. The most common problems reported were nonadjustable chairs, awkward positions/ movements and fabric dust causing breathing problems. Stress, working at a high frequency for sustained periods, and poor ventilation are several other factors affecting worker health [6]. In a Botswanan textile manufacturing company in 2009, researchers sought to identify ergonomic limitations of garment workers’ workstation designs [12]. They found that workstations were too high, forcing workers to adopt poor postures with excessive trunk flexion, increasing the risk of work-related back conditions [12].

A 1996 survey amongst Californian clothing firms found 96% of firms to have health and safety issues, with 72% being cited for serious violations such as electrical and fire hazards, tripping risks and lack of disease and disability prevention programs [6]. Other issues included ergonomic risk factors not being assessed [6]. According to the Clean Clothes Campaign, garment workers are vulnerable to exploitation on an international scale, being exposed to poor working conditions [10]. Sealetsa and Thatcher’s research in Botswana found that the general poor conditions in which garment workers operate predispose them to health risks [10]. Some of the most frequent health complaints of this client population besides musculoskeletal pain were headaches, poor eyesight, swollen legs and allergies [6]. In addition to musculoskeletal pain, garment workers in Jaipur, India, reported experiencing headaches, respiratory problems, skin irritations, hearing difficulties and visual impairments [7]. Infringements on minimum wage laws is also a common issue within the clothing industry [6]. Most garment workers are female and are the primary breadwinners for their families [6 , 10]. Thus, equitable treatment of and advocacy for garment workers is of utmost importance as most workers are responsible for not only protecting their own livelihoods but also for meeting the needs of their dependents [6 , 10].

Work rehabilitation can be defined as a structured therapeutic program aimed at improving work performance that may be negatively affected by disability or ill health [2]. Occupational therapy contributes significantly to the process of work rehabilitation through assessment and rehabilitation of workers who have difficulty returning to or sustaining work because of an injury or disability [13]. Workplace-based rehabilitation may have particular benefits over traditional clinic-based rehabilitation, including earlier access to treatment, reduced time off work, targeted interventions and collaboration with workplace supervisors and onsite occupational health practitioners [1 , 14]. Worksite interventions may include ergonomic modifications to the workplace or job, or strategies to successfully transition workers back to full productivity, such as “light duty”, graded work exposure and work trials [14]. These strategies facilitate return to work and aim to reduce recurrence of WRULD [14]. Workplace-based rehabilitation is supported within a variety of employment settings [1, 3]. It has been found to be more effective than conventional clinic-based work rehabilitation programs at reducing pain and disability as well as improving functional capabilities and preventing further work disability [3].

A randomised controlled trial conducted by Edries et al. in 2013 (n = 80) analysed the short-term advantages of a wellness program on garment workers’ Health Related Quality of Life (HRQoL) [15]. The study included 80 participants from three clothing manufacturing companies in South Africa. The experimental group, who received Cognitive Behavioural Therapy (CBT) and weekly exercises as part of the wellness program, had higher HRQoL scores after the intervention than the control group, who received educational pamphlets and a once off health promotion talk. However, no significant changes were identified at 6 weeks post-intervention [15].

A systematic review by Amini evaluated 36 studies that focused on occupational therapy interventions for work related conditions and injuries of the forearm, wrist and hand [16]. The following interventions were utilised by the included studies: workplace interventions, massage, early mobilization, silicone gel sheeting, low-level laser therapy, splinting, exercise, ultrasound, thermal modalities, gloves, pain control techniques and diverse interventions including biopsychosocial treatment, sensory re- education, function-based activities, conservative treatments, measurement of functional outcomes and treatment of writer’s cramp [16]. Amini concluded that further investigation was needed to determine the effectiveness of these interventions [16].

Case study can be used as a research methodology that allows for the understanding of complex phenomena, such as the activities people perform in their daily work [17]. The case study design can be understood as an investigation of a phenomenon within a real-life context. It is explained as being a bounded system in which many factors and components within the case act together to formulate the particular case [17]. Case studies can also be understood as a pre-experimental design that can be used as a method for exploring a phenomenon that is complex in nature and is made up of various relevant components [18]. These components are specific to the relevant studies and each study should define the specific parameters within the protocol of the research study [17]. While randomised controlled trials (RCTs) are generally considered to provide the highest level of effectiveness evidence [19], these may not be easily attainable in real-life workplaces and rehabilitation settings. Multiple case studies present contextual, real-world informed evidence that can provide a foundation for future higher level effectiveness research [19]. This multiple case study thus aims to determine the documented outcomes of workplace-based student-led occupational therapy rehabilitation of garment workers with upper limb conditions.

2 Methods

A multiple case study design was employed, using retrospective record review from case files at an occupational therapy practice in Cape Town, South Africa. This practice primarily offers work rehabilitation services to garment workers, usually at their workplaces. A part-time clinical occupational therapist supervises occupational therapy students from Stellenbosch University –the practice thus mostly runs through student services offered on an individual basis to garment workers during the student clinical placements. Students keep detailed clinical notes and write case studies on all clients. Prior to intervention, all clients give consent for their case data to be utilised for research. Ethical approval for this study was received from Stellenbosch University Health Research Ethics Committee (U20/02/059, March 2020). Consent was also obtained from the clinical occupational therapist at the practice. The study was conducted according to the guidelines of the Declaration of Helsinki.

Total population sampling was used to identify all cases meeting the following inclusion criteria from inception of the practice in 2012 until data collection in 2020:

Garment workers with upper limb conditions who participated in individual rehabilitation offered by student occupational therapists via the Stellenbosch University / Clothing Industry Healthcare Fund occupational therapy service;

Cases with complete records of the same outcome measures administered pre- and post-intervention (with a duration of 4 –6 weeks in between assessments), to allow for comparison of outcomes. Outcome measures could include the Disability of Arm, Shoulder and Hand Questionnaire (DASH) [20]; Pain Visual Analogue Scale [21]; Dallas Pain Questionnaire [22]; Boston Carpal Tunnel Questionnaire (BCTQ) [23]; Rapid Upper Limb Assessment (RULA) [24]; grip strength assessment using a dynamometer or range of motion assessment.

No exclusion criteria were added as the inclusion criteria met all the specifications required. Data were collected from case files by two researchers (NM and HJVR). All past case files in the practice were searched to identify cases meeting the inclusion criteria. Once the sample was identified, data were extracted from the occupational therapy case files by one researcher and cross-checked by the second researcher to ensure accuracy. All data were anonymised by allocating pseudonyms, saved electronically on an Excel spreadsheet and password-protected before allowing access to the remaining researchers for data analysis.

Data were analysed by three researchers (FB, TT and NBC) with the assistance of a biostatistician using SPSS. Scores on pre- and post-intervention outcome measures, namely the DASH, RULA, BCTQ and Pain Visual Analogue Scale (VAS), were compared for each case, as well as across cases. Demographic information and details about the amount and type of intervention for each case were represented diagrammatically in tables and graphs. As far as possible, the researchers compared data on factors that could have contributed to any change in outcomes after intervention, changes in outcomes and common factors across cases.

3 Results

Approximately 200 case files were present in the practice, of which seven met the inclusion criteria. Most of the cases had pre-intervention outcomes assessment included within the file; however, many files did not include post-intervention assessments. A lack of consistent outcomes assessment and poor record keeping at the clinical site became evident during the data collection process. Some of the cases had undated assessments or no information on the administrator – the researchers could thus not determine whether or not this was a student-administered assessment, and these cases were excluded.

3.1 Demographic information

All seven cases were female with a mean age of 41 years [minimum (36), maximum (46)]. Three had one child, another three had two children and one had four children. Five of the garment workers were married and the other two were single. The majority of the garment workers lived in formal houses (six cases) while one lived in an informal structure.

3.2 Job descriptions

The seven included cases held the jobs of sewing machinist, textile cutter, data capturer, garment finisher and examiner (Table 1).

Table 1
Job descriptions

Case (pseudonym) Job title Work posture Physical demand level according to task demands¹

Nikita Examiner Sitting or standing Light work requiring 2.2–3.5 METS

Jacqueline Cutter Sitting Light work requiring 2.2–3.5 METS

Karen Finisher Standing Medium work requiring 3.6–6.3 METS

Gloria Data capturer Sitting Sedentary work requiring 1.5–2.1 METS

Felicia Sewing machinist Sitting Light work requiring 2.2–3.5 METS

Phiona Sewing machinist Sitting Light work requiring 2.2–3.5 METS

Cynthia Examiner Sitting or standing Light work requiring 2.2–3.5 METS

Case (pseudonym)	Job title	Work posture	Physical demand level according to task demands¹
Nikita	Examiner	Sitting or standing	Light work requiring 2.2–3.5 METS
Jacqueline	Cutter	Sitting	Light work requiring 2.2–3.5 METS
Karen	Finisher	Standing	Medium work requiring 3.6–6.3 METS
Gloria	Data capturer	Sitting	Sedentary work requiring 1.5–2.1 METS
Felicia	Sewing machinist	Sitting	Light work requiring 2.2–3.5 METS
Phiona	Sewing machinist	Sitting	Light work requiring 2.2–3.5 METS
Cynthia	Examiner	Sitting or standing	Light work requiring 2.2–3.5 METS

¹METS –Metabolic equivalents of tasks. US Department of Labor Dictionary of Occupational Titles [20].

Nikita and Cynthia were clothing examiners who completed fine motor tasks on a table at waist level while alternating between sitting and standing. Felicia and Phiona were sewing machinists who engaged in precision work while operating sewing machines in a seated position. Jacqueline was responsible for cutting garments, which required dexterity of the upper limbs while seated. Karen was a finisher who completed work requiring medium physical demands in standing. Lastly, Gloria was responsible for capturing data on a computer while seated.

Sedentary work includes activities that are typically performed in sitting that have minimal additional movements. Therefore, sedentary work has a low energy requirement. Light work requires between 40 and 55% of one’s maximum heart rate. This activity has a higher energy requirement compared to sedentary work; however, it does not cause an observable change in one’s breathing rate. Medium work requires 55 –70% of one’s maximum heart rate. METS is an abbreviation for Metabolic Equivalents which refers to the level of energy required to execute an activity. One MET is equivalent to the amount of energy required at rest or when sitting still, therefore medium work requires 3.6 - 6.3 times the energy required to sit still or be at rest [25, 26].

All of the cases had jobs of a repetitive nature that, when conducted over a prolonged period in a seated or standing position, place strain on the upper limbs [12]. Nikita and Cynthia were therefore advantaged by the fact that they alternated work positions throughout the day.

3.3 Diagnosis and symptoms

Three cases presented with undiagnosed upper limb pain. In the remaining four cases, diagnoses ranged between undifferentiated arthritis, carpal tunnel syndrome (CTS), de Quervain’s tenosynovitis (dQt) and osteoarthritis. Four cases experienced symptoms in both upper limbs while the other three cases presented with symptoms in their dominant, right upper limbs only. Symptoms varied as two cases presented with pain and inflammation in the right wrist, another two experienced general pain, and the remaining cases reported symptoms including limited range of motion, pain, numbness, weakness in both hands (CTS), deep pain in joints and upper limbs, and pain at night. Comorbidities included hypertension, hypercholesterolaemia, spondylosis, cancer, sleep disorder and arthritis.

3.4 Treatment

3.4.1 Prior treatment

All seven cases had received prescribed oral pain medication prior to WBR. Other interventions, each received by a different case, included physiotherapy, surgery, chemotherapy, and chiropractic adjustment.

3.4.2 Workplace-based rehabilitation

All WBR interventions were offered by student occupational therapy clinicians at the clients’ workplaces. Each case had three to five individual WBR sessions of approximately 30 minutes each over a period of 4 –6 weeks. Interventions included psychoeducation, cognitive behavioural therapy (CBT), workstation adaptations, job rotation, work task modification, assistive technology and exercises. A summary of treatment for each case can be seen in Table 2.

Table 2
Case summaries (n = 7)

Main diagnosis Job title Outcome measure Pre-intervention outcome Intervention Number of sessions Post-intervention outcome Summary of intervention outcomes regarding UL functioning

Nikita Carpal tunnel syndrome Examiner BCTQ 30/55 (Moderate impairment) Workstation adaptations, psychoeducation/ CBT 3 12 / 55 (Mild impairment) Improvement with reduced carpal tunnel symptoms

Jacqueline De Quervain’s tenosynovitis Cutter Pain assessment form 10/10 (pain intensity) Work task modification, psychoeducation/ CBT, exercises 5 3/10 (pain intensity) Improvement with reduced pain intensity

Karen Osteoarthritis Finisher RULA 7 (left and right) Psychoeducation/ CBT, assistive technology, workstation adaptations 5 3 (left and right) Improvement with reduced ergonomic risk

Gloria Upper limb pain Data capturer RULA 7 (left and right) Workstation adaptations, psychoeducation/ CBT 4 3 (left and right) Improvement with reduced ergonomic risk

Felicia Upper limb pain Sewing machinist DASH 17.86 Job rotation 3 9.17 Improvement in ability to perform functional activities

Phiona Upper limb pain Sewing machinist DASH 52.5 Psychoeducation/ CBT, exercises 5 52.5 No change in ability to perform functional activities

Cynthia Arthritis (unspecified) Examiner DASH 6.67 Psychoeducation/ CBT, exercises 5 23.15 Deterioration in ability to perform functional activities

	Main diagnosis	Job title	Outcome measure	Pre-intervention outcome	Intervention	Number of sessions	Post-intervention outcome	Summary of intervention outcomes regarding UL functioning
Nikita	Carpal tunnel syndrome	Examiner	BCTQ	30/55 (Moderate impairment)	Workstation adaptations, psychoeducation/ CBT	3	12 / 55 (Mild impairment)	Improvement with reduced carpal tunnel symptoms
Jacqueline	De Quervain’s tenosynovitis	Cutter	Pain assessment form	10/10 (pain intensity)	Work task modification, psychoeducation/ CBT, exercises	5	3/10 (pain intensity)	Improvement with reduced pain intensity
Karen	Osteoarthritis	Finisher	RULA	7 (left and right)	Psychoeducation/ CBT, assistive technology, workstation adaptations	5	3 (left and right)	Improvement with reduced ergonomic risk
Gloria	Upper limb pain	Data capturer	RULA	7 (left and right)	Workstation adaptations, psychoeducation/ CBT	4	3 (left and right)	Improvement with reduced ergonomic risk
Felicia	Upper limb pain	Sewing machinist	DASH	17.86	Job rotation	3	9.17	Improvement in ability to perform functional activities
Phiona	Upper limb pain	Sewing machinist	DASH	52.5	Psychoeducation/ CBT, exercises	5	52.5	No change in ability to perform functional activities
Cynthia	Arthritis (unspecified)	Examiner	DASH	6.67	Psychoeducation/ CBT, exercises	5	23.15	Deterioration in ability to perform functional activities

3.5 Outcomes

A variety of outcome measures were used pre- and post- WBR to assess improvement after intervention. The Rapid Upper Limb Assessment (RULA) was used with two cases, the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) was used with three cases and the Boston Carpal Tunnel Questionnaire and Pain Intensity Assessment (VAS) were used for another two cases. Five cases showed improvement in the outcome assessed, one showed no change, and one case showed deterioration.

Nikita presented with carpal tunnel syndrome (CTS). Her intervention included workstation adaptations and psychoeducation over a period of 3 sessions. Her disability score on the BCTQ improved from moderate (30/55) disability before WBR to mild (12/55) disability after WBR.

Jacqueline, with a diagnosis of de Quervain’s tenosynovitis (dQT), received pain medication and WBR in the form of work task modification, psychoeducation/CBT and exercises over a period of 5 sessions, after which her pain had reduced from a 10/10 (maximum intensity) to 3/10 (mild intensity) on the VAS.

Karen had a diagnosis of osteoarthritis and her treatment prior to WBR included pain medication, physiotherapy and occupational therapy. Before WBR, Karen scored a 7 on the RULA, the maximum score on this scale, which indicates high risk of developing a WRULD. After receiving psychoeducation, assistive technology and workstation adaptations over a duration of 5 sessions, Karen’s RULA score decreased to a 3, marking an improvement in her ergonomic risk at work.

Gloria, Felicia and Phiona all experienced undiagnosed pain for which they received pain medication. Gloria and Phiona received previous occupational therapy intervention whereas Felicia was unsure about her previous exposure to occupational therapy services. Gloria had seen a chiropractor, Felicia received chemotherapy and Phiona had surgery prior to student-led OT WBR.

Gloria’s RULA score decreased from 7 to 3 after receiving WBR in the form of workstation adaptations and psychoeducation/ CBT over a period of 4 sessions, reducing her exposure to potentially harmful WRULD-related ergonomic factors.

Felicia had 3 sessions of WBR including job rotation, after which her DASH disability score improved from 17.86/100 to 9.17/100.

Phiona made no documented improvement after 5 sessions of WBR, which consisted of psychoeducation/CBT and exercises. Her DASH score remained unchanged at 52.5/ 100.

Cynthia was diagnosed with arthritis and her prior intervention included pain intervention and occupational therapy. After 5 sessions of WBR, which included psychoeducation/CBT and exercises, her DASH disability score increased from 6.67/ 100 to 23.15/ 100.

4 Discussion

This multiple case study aimed to determine the documented outcomes of workplace-based student-led occupational therapy rehabilitation of garment workers with upper limb conditions. While poor record keeping practices at the clinical site limited the number of cases that could be included in this study, seven cases were found to be eligible for inclusion. 70% of these cases showed improvement after WBR led by student occupational therapists. Despite the limited amount of cases included, this multiple case study provides several insights that parallel with, and differ from, international research on garment workers. A systematic review of systematic reviews on workplace interventions similarly found that exercise, ergonomic modifications and education can have positive effects on pain and other symptoms [27]. Also similarly to existing research, this study found that all included cases were female and significant breadwinners in their families [6 , 10]. This has important implications for workplace health, including WRULD. Garment workers who are the main breadwinners in their families, with the added responsibility of traditional female family and home-making roles, may be less likely and able to take time off work to rest and relieve some of their WRULD related symptoms.

In contrast to the definition of garment work suggested by Feuerstein et al. [28], which limited garment work to the operation of sewing machines from a seated position, researchers found garment work to include a variety of job descriptions and work positions, including data capturing, garment finishing, examining and textile cutting machine setting from either a seated and/ or standing position. These cases’ job demands caused them to be exposed to repetitive, awkward and strenuous postures that predisposed them to WRULD, just like many other garment workers across the globe [12].

From what was observed in this study, most WRULD were characterised by symptoms of pain and inflammation in either both upper limbs or in the dominant upper limb. Additionally, all cases presented with comorbidities, with the most common being musculoskeletal pain, arthritis, and hypertension. This poses a risk not only to the garment workers’ health, but to their productivity and work quality [1, 29]. However, despite this limitation, most cases had a good prognosis with the opportunity for improved work function after WBR.

Each case was exposed to a different combination of WBR interventions. Five of the cases with WRULD received WBR in the form of workstation adaptations and psychoeducation. Two of the cases received exercises as therapeutic input, making this the second most popular WBR intervention for this client population. Other interventions included job rotation, work task modification and the use of assistive technology. Ergonomic modifications and job- related modifications such as modified work tasks have been shown to reduce the incidence of WRULD [2].

As seen in Table 2, post-intervention results indicated that most cases made improvement in their upper limb functioning after WBR including work-related modifications (work task modification, workstation adaptations, job rotation and assistive technology). While statistical significance could not be calculated, these improvements were clinically important. In contrast, the cases that made no improvement in their post-intervention results were those who only received psychoeducation and exercises. This can be seen with Phiona’s case as she made no improvement in her DASH score. Similarly, Cynthia who also received psychoeducation and exercises without work related modifications had a worse post-intervention DASH score. Considering that a WRULD is caused mostly by physical rather than psychological strain, it can be understood through clinical reasoning that providing intervention on a purely psychological and cognitive level is not sufficient to improve a garment worker’s upper limb functioning. A combination of psychoeducation and exercises performed in the absence of work-related modifications may be ineffective at addressing the causative repetitive and strenuous tasks linked to WRULD. However, psychoeducation and exercises can result in an improved perception of workers’ health state and encourage them to change health related behaviours [15]. Therefore, a combination of psychoeducation, exercises and work-related modifications are recommended by the researchers in order to provide a holistic intervention. This is supported by Pieper et al’s findings that multicomponent workplace interventions were found to have positive effects [27]. According to Désiron et al., occupational therapy intervention should have a client-centred and holistic approach that incorporates a rehabilitation program that specifically sets goals to address a worker’s needs [30]. We suggest that WBR similarly needs to be client-centred and holistic in order to be effective.

WBR does not come without challenges. In the WBR service where the study was conducted, sessions needed to be limited to 30 minutes in order to reduce interference with the production line. However, the workers included in these interventions would otherwise need to take much more time off work in order to access rehabilitation outside of the workplace –resulting in either a larger impact to the production line, or reduced access to intervention. It is likely that in areas where WBR is not offered, workers tend to delay intervention until WRULD are more serious or chronic. This is in contrast to the better outcomes that are achievable with early referral to rehabilitation.

4.1 Strengths of the study

The use of a multiple case study allowed for researchers to explore the variety of components which could contribute to each cases’ outcomes, in depth. This approach is reflective of rehabilitation philosophy, which emphasises the importance of holistic and client-centred assessment and intervention according to personal, occupational, and environmental factors.

The researchers had no direct contact with the cases included in the study, thus reducing the risk of bias and subjectivity when analysing and reporting results during the research process.

4.2 Limitations of the study

The retrospective nature of the study limited the ability to control for confounding variables such as concurrent interventions, medication, weather and strenuous activities performed outside of the workplace. Case files had limited information on these variables, thus the relevant data could not be gathered on the variables that could have potentially had a facilitating or inhibiting effect on intervention outcomes.

Another limitation of this study was the small sample size and study design, which limits the generalisability of results.

4.3 Recommendations for practice

In order to optimise intervention outcomes, a combination of psychoeducation, exercises, and work-related modifications should be considered with each client.

WBR should be considered as an intervention that can be effective at improving upper limb function, pain and ergonomic risk. It may facilitate early intervention, reduced time off work and reduced costs, with minimal impact to productivity.

Consistent documentation is an important basis for developing evidence-based practice and practice-based evidence. The importance of thorough and detailed documentation should thus be emphasised with all students and clinicians [31].

The consistent use of the same sensitive outcome measures before and after intervention is valuable for documenting changes during intervention. In this clinical setting, the DASH and RULA were found to be broadly applicable and useful outcome measures.

4.4 Recommendations for research

It is recommended that higher-level effectiveness studies such as cohort studies are conducted in this and similar settings to determine and document the effectiveness of WBR [19].

Studies with larger sample sizes need to be conducted in order to improve the generalisability of results. This is needed to further establish WBR as an evidence-based intervention.

To improve the accuracy and consistency of case data as well as the quality of research, researchers should partner with clinicians to conduct experimental research.

5 Conclusions

Overall, 70% of cases showed improvement after WBR in post-intervention outcome measures, whereas 30% of cases made no improvement. These improvements included improved upper limb function, reduced pain intensity, reduced ergonomic risk and improved ability to perform functional activities. There was limited information on potential confounding variables –thus the impact of other factors on the studied outcomes is not fully understood.

While this study showed improved outcomes after WBR in the majority of cases, the sample size was small as a result of poor record keeping practices and the absence of post-intervention assessments. This limited the generalisability of the research findings. The study findings point towards the benefit of holistic intervention rather than intervention focussed only on psychoeducation and exercise. Intervention should address intrinsic factors such as physical and psychological components, as well as extrinsic factors within garment workers’ occupation and environment, including work modifications and job rotation.

6 Author contributions

This study was completed in partial fulfillment of the degree “Bachelor of Occupational Therapy” at Stellenbosch University. Conceptualisation, all authors; Data collection, NM and HJVR; Data analysis, TT, FB and NBC; Funding acquisition, FB; Supervision, MH; Writing, review and editing, all authors. All authors have read and agreed to the published version of the manuscript.

Conflict of interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Data availability

Data supporting the reported results can be obtained from the corresponding author upon reasonable request.

Funding

This research was funded by Stellenbosch University, Faculty of Medicine and Health Sciences, Undergraduate Research Office.

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