Ergonomics Engineering and Administrative Controls

PRINCIPLES AND APPLICATIONS
IN ENGINEERING SERIES
OCCUPATIONAL
ERGONOMICS
Engineering and
Administrative Controls
PRINCIPLES AND APPLICATIONS

IN ENGINEERING SERIES
OCCUPATIONAL
ERGONOMICS
Engineering and
Administrative Controls
EDITED BY
Waldemar Karwowski
University of Louisville
Louisville, Kentucky
William S.Marras
The Ohio State University
Columbus, Ohio
CRC PRESS
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Library of Congress Cataloging-in-Publication Data

Occupational ergonomics: engineering and administrative controls/edited by Walidemar
Karwowski, William S.Marras.
p. cm.(Principles and applications in engineering; 14)
Includes bibliographical references and index.
ISBN 0-8493-1800-9
1. Human engineering. 2. Musculoskeletal systemWounds and injuriesPrevention.
3. Industrial hygiene. I. Karwowski, Waldemar. II. Marras, William S. (William Steven),
1952- III. Series.
TA166.O257 2003
620.8'2dc21
2002041399
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The Editors
Waldemar Karwowski, Ph.D., P.E., C.P.E., is Professor of

Industrial Engineering and Director of the Center for Industrial
Ergonomics at the University of Louisville, Kentucky. He holds
an M.S. (1978) in production management from Technical
University of Wroclaw, Poland, and a Ph.D. (1982) in Industrial
Engineering from Texas Tech University. His research, teaching,
and consulting activities focus on prevention of low back injury
and cumulative trauma disorders, human and safety aspects of
advanced manufacturing, fuzzy sets and systems, and theoretical
aspects of ergonomics.
Dr. Karwowski served as President (20002003) of the
International Ergonomics Association. He is editor of many
international journals, including Human Factors and Ergonomics
in Manufacturing, and Theoretical Issues in Ergonomics Science, and consulting editor of
Ergonomics. He is the author or co-author of more than 200 scientific publications, including
25 books.
Dr. Karwowski is founder and chairman of the International Conference on Human Aspects
of Advanced Manufacturing and Hybrid Automation. He was the recipient of the Outstanding
Young Engineer of the Year Award, given by the Institute of Industrial Engineering. He was
also a Fulbright Scholar at Tampere University of Technology in Finland. He received the
Presidents Award for Outstanding Scholarship, Research, and Creative Activity in the category
of Basic and Applied Science at the University of Louisville.
William S.Marras, Ph.D., C.P.E., holds the Honda Endowed
Chair in Transportation in the Department of Industrial,
Welding, and Systems Engineering at The Ohio State University,
Columbus. He is also the director of the biodynamics laboratory
and holds appointments in the departments of physical medicine
and biomedical engineering. Professor Marras is also the codirector of the Ohio State University Institute for Ergonomics.
Dr. Marras received his Ph.D. in bioengineering and
ergonomics from Wayne State University in Detroit, Michigan.
His research centers around biomechanical epidemiologic
studies, laboratory biomechanic studies, mathematical
modeling, and clinical studies of the back and wrist.
His findings have been published in more than 100 refereed
journal articles and 12 book chapters, and he holds two patents, including one for the lumbar
motion monitor (LMM). His work has also attracted national and international recognition.
He has won the prestigious Swedish Volvo Award for Low Back Pain Research and Austrias
Vienna Award for Physical Medicine.
v
Contributors
Elsayed Abdel-Moty
Department of Industrial
Engineering
University of Miami
Coral Gables, Florida
Patrick G.Dempsey
Liberty Mutual Research
Center for Safety and Health
Hopkinton, Massachusetts
W.Gary Allread
Columbus, Ohio
Bradley Evanoff
School of Medicine
Washington University
St. Louis, Missouri
Charles K.Anderson
Advanced Ergonomics, Inc.
Dallas, Texas
Paul Gaddie
Gunnar B.J.Andersson
Department of Orthopedic
Surgery
St. Lukes Medical Center
Chicago, Illinois
Katharyn A.Grant
Robert A.Taft Laboratories
National Institute for
Occupational Safety and
Health
Cincinnati, Ohio
Michele C.Batti
Department of Orthopaedics
University of Washington
Seattle, Washington
Patricia Bertsche
Columbus, Ohio
Ram Bishu
IMSE Department
University of Nebraska
Lincoln, Nebraska
A.Kim Burton
Department of Clinical
Biomechanics
Huddersfield Polytechnic
Huddersfield, England
Don B.Chaffin
Center for Ergonomics
University of Michigan
Ann Arbor, Michigan
Thomas Hales
Health
Cincinnati, Ohio
Simon M.Hsiang
Renliu Jang
Waldemar Karwowski
Engineering
Glenda L.Key
Key Functional Assessments
Minneapolis, Minnesota
Tarek M.Khalil
Engineering
University of Miami
Jung-Yong Kim
Engineering
Hanyang University
Ansan, Korea
Stephan Konz
Department of IMSE
Kansas State University
Manhattan, Kansas
Steven A.Lavender
Department of Orthopedic
Surgery
St. Lukes Medical Center
Chicago, Illinois
Wook Gee Lee
Chris J.Main
Department of Behavioural
Medicine
Hope Hospital
Salford, England
Richard W.Marklin
Department of Mechanical and
Industrial Engineering
Marquette University
Milwaukee, Wisconsin
William S.Marras
ISE Department
Columbus, Ohio
vii
Stuart M.McGill
University of Waterloo
Waterloo, Ontario, Canada
Raymond M.McGorry
Donald R.McIntyre
Interlogics
Hillsborough, North Carolina
Stephen J.Morrissey
State of Oregon
OSHA
Portland, Oregon
A.Muralidhar
University of Nebraska
Lincoln, Nebraska
Robert W.Norman
Department of Kinesiology
Ewa Nowak
Department of Ergonomics
Research
Institute of Industrial Design
Warsaw, Poland
Mohamad Parnianpour
Department of ISE
Columbus, Ohio
Malcolm H.Pope
Department of Orthopaedic
Surgery
Iowa Spine Research Center
University of Iowa
Iowa City, Iowa
Vern Putz-Anderson
Applied Psychology and
Ergonomics
Health
Cincinnati, Ohio
Renee Steele-Rosomoff
Comprehensive Pain and
Rehabilitation Center
University of Miami
Aboulfazl Shirazi-Adl
cole Polytechnique
Montreal, Quebec, Canada
Carolyn M.Sommerich
ISE Department
Columbus, Ohio
Robert G.Radwin
Engineering
University of Wisconsin
Madison, Wisconsin
Leon M.Straker
Curtin University of
Technology
Shenton Park, Australia
David Rempel
University of California
San Francisco, California
Carol Stuart-Buttle
Stuart-Buttle Ergonomics
Philadelphia, Pennsylvania
Valerie J.Rice
U.S. Army Research Institute of
Environmental Medicine
Occupational Physiology
Division
Natick, Massachusetts
Eira Viikari-Juntura
Department of Physiology
Finnish Institute of
Occupational Health
Topeliuksenkatu, Finland
Richard G.Ried
Columbus, Ohio
Stephen N.Robinovitch
San Francisco General Hospital
San Francisco, California
Hubert L.Rosomoff
Comprehensive Pain and
Rehabilitation Center
University of Miami
Thomas R.Waters
Occupational
Safety and Health
Cincinnati, Ohio
Richard Wells
Department of Kinesiology
Contents
Preface
xiii
PART I MUSCULOSKELETAL DISORDERS
SECTION I Disorders of the Extremities
Epidemiology of Upper Extremity Disorders Bradley Evanoff and David Rempel
1-1
Integrated Analysis of Upper Extremity Disorders
2-1
Biomechanical Aspects of CTDs Richard W.Marklin
3-1
Occupational Risk Factors for Shoulder Disorders Eira Viikari-Juntura
4-1
Hand Tools: Design and Evaluation Robert G.Radwin
5-1
Gloves Ram Bishu and A.Muralidhar
6-1
Industrial Mats Jung-Yong Kim
7-1
Ergonomic Principles Applied to the Prevention of Injuries to the

Lower Extremity Steven A.Lavender and Gunnar B.J.Andersson
8-1
Ergonomics of the Foot
9-1
Richard Wells
Stephan Konz
SECTION II Low Back Disorders
10
Epidemiology of Back Pain in Industry Gunnar B.J.Andersson
10-1
11
Static Biomechanical Modeling in Manual Lifting Don B.Chaffin
11-1
ix
12
Dynamic Low Back Models: Theory and Relevance in Assisting the

Ergonomist to Reduce the Risk of Low Back Injury Stuart M.McGill
12-1
Selection of 2-D and 3-D Biomechanical Spine Models: Issues for

Consideration by the Ergonomist Robert W.Norman and Stuart M.McGill
13-1
Quantitative Assessment of Trunk Performance Mohamad Parnianpour and

14-1
15
Perspective on Industrial Low Back Pain Malcolm H.Pope and Donald R.McIntyre
15-1
16
Revised NIOSH Lifting Equation
16-1
17
A Population-Based Load Threshold Limit (LTL) for Manual Lifting Tasks

Performed by Males and Females Waldemar Karwowski, Paul Gaddie,
Renliu Jang, and Wook Gee Lee
17-1
Occupational Low Back Disorder Risk Assessment Using the Lumbar Motion
Monitor William S.Marras, W.Gary Allread, and Richard G.Ried
18-1
Prevention of Musculoskeletal Disorders: Psychophysical Basis

Patrick G.Dempsey
19-1
The Relative Importance of Biomechanical and Psychosocial Factors

in Low Back Injuries A.Kim Burton, Michele C.Batti, and Chris J.Main
20-1
21
Fall-Related Occupational Injuries Stephen N.Robinovitch
21-1
22
Low Back Pain (LBP) Glossary: A Reference for Engineers and Ergonomists
Simon M.Hsiang and Raymond M.McGorry
22-1
13
14
18
19
20
Thomas R.Waters and Vern Putz-Anderson
PART II ADMINISTRATIVE CONTROLS

SECTION I Ergonomics Surveillance
23
24
Fundamentals of Surveillance for Work-Related Musculoskeletal Disorders

Vern Putz-Anderson and Katharyn A.Grant
23-1
Injury Surveillance Database Systems Carol Stuart-Buttle
24-1
25
OSHA Recordkeeping
26
Body Discomfort Assessment Tools
Stephen J.Morrissey
25-1
Leon M.Straker
26-1
SECTION II Medical Management Prevention
27
Medical Management of Work-Related Musculoskeletal Disorders

Thomas Hales and Patricia Bertsche
27-1
Ergonomic Programs in Post-Injury Management Tarek M.Khalil,

Elsayed Abdel-Moty, Renee Steele-Rosomoff, and Hubert L.Rosomoff
28-1
29
Physical Ability Testing for Employment Decision Purposes Charles K.Anderson
29-1
30
Preplacement Strength Screening Valerie J.Rice
30-1
31
Assessment of Worker Functional Capacities
31-1
32
Ergonomics and Rehabilitation Ewa Nowak
32-1
33
Update on the Use of Back Belts in Industry: More DataSame Conclusion

Stuart M.McGill
33-1
The Influence of Psychosocial Factors on Sickness Absence Chris J.Main,

A.Kim Burton, and Michele C.Batti
34-1
Back Pain in the Workplace: Implications of Injury and Biopsychosocial

Models Michele C.Batti, Chris J.Main, and A.Kim Burton
35-1
Upper Extremity Support Carolyn M.Sommerich
36-1
28
34
35
36
Index
Glenda L.Key
I-1
xi
Preface
Ergonomics (or human factors) is defined by the International Ergonomics Association

(www.iea.cc) as the scientific discipline concerned with the understanding of interactions
among humans and other elements of a system, and the profession that applies theory,
principles, data and methods to design in order to optimize human well-being and overall
system performance. Ergonomists contribute to the design and evaluation of tasks, jobs,
products, environments, and systems in order to make them compatible with the needs, abilities,
and limitations of people.
Currently, there is substantial and convincing evidence that the proficient application of
ergonomics knowledge, in a system context, will help to improve system effectiveness and
reliability, increase productivity, reduce employee healthcare costs, and improve the quality
of work processes, products and working life for all employees. As ergonomics promotes a
holistic approach in which considerations of physical, cognitive, social, organizational,
environmental and other relevant factors are taken into account, the professional ergonomists
should have a broad understanding of the full scope of the discipline. Development of this
book was motivated by the quest to facilitate a wider acceptance of ergonomics as an effective
methodology for work-system design aimed at improving the overall quality of life for millions
of workers with a variety of needs and expectations.
This book focuses on prevention of work-related musculoskeletal disorders with emphasis
on engineering and administrative controls. This volume contains a total of 36 chapters divided
into two parts, each of which is divided into two sections.
Part I focuses on engineering factors relevant to management of work-related
musculoskeletal disorders. Section I provides knowledge about risk factors for upper and
lower extremities at work, while Section II concentrates on risk factors for work-related low
back disorders. The knowledge presented in Section I includes epidemiology, biomechanics,
and analysis of upper extremity disorders. This section also includes discussion of occupational
risk factors, shoulder, design and evaluation of handtools, gloves, and industrial mats. In
addition, information about injuries to the foot and leg is provided. The section on low back
disorders includes knowledge on epidemiology of back pain in industry, static and dynamic
low back biomechanical modeling, quantitative assessment of trunk performance, revised
NIOSH equation, and population-based limits for manual lifting. In addition, this section
discusses psychophysical basis and psychosocial factors in preventing musculoskeletal disorders.
It also includes a method for assessment of risk of occupational low back disorders,
occupational injuries due to falls, and provides a useful glossary of low back pain terminology.
Part II focuses on administrative controls in prevention and management of musculoskeletal
disorders. Section I discusses fundamentals of surveillance of such disorders, requirements
for surveillance database systems, OSHA record keeping system, and surveillance methods
xiii
based on assessment of body discomfort. Section II focuses on medical management of workrelated musculoskeletal disorders, including programs for post-injury management, testing
of physical ability for employment decisions, assessment of worker strength and other
functional capacities, and applications of ergonomics knowledge in rehabilitation.
The use of back belts and supporting devices for upper extremities is also considered.
Finally, the influence of psychosocial factors and implications of back pain in the workplace
is provided.
We hope that this volume will be useful to a large number of professionals, students, and
practitioners who strive to improve product and process quality, worker health and safety,
and productivity in a variety of industries and businesses. We trust the knowledge presented
in this volume will help the reader learn and apply the principles of ergonomics in prevention
of work-related musculoskeletal disorders.
Waldemar Karwowski
WIlliam S.Marras
xiv
Part I
Musculoskeletal
Disorders
Section I
Disorders of the
Extremities
1
Epidemiology of Upper
Extremity Disorders
Bradley Evanoff
Washington University School
of Medicine
David Rempel
University of California
San Francisco
1.1
1.2
1.3
1.4
1.5
Frequency, Rates, and Costs

Disorder Types and their Natural History
Individual Factors
Work-Related Factors
Summary
11
12
13
14
17
This chapter summarizes findings from epidemiologic studies that address workplace and individual
factors associated with upper extremity musculoskeletal disorders. These disorders are not new: epidemics
and clinical case series of work-related upper extremity problems were reported throughout the 1800s
and early 1900s (Conn, 1931; Thompson et al., 1951). Although there are almost no prospective studies
in this area, within the last 20 years a number of well-designed, cross-sectional studies have focused on
disorders of the hand, wrist, and elbow as related to work. These studies point to the multifactorial
nature of work-related upper extremity disorders. The severity of these disorders is influenced not only
by biomechanical factors, but also by other work organizational factors, the workers perception of the
work environment, and medical management.
From an epidemiologic point of view, this topic is problematic because there are many specific disorders
that can occur in the hand, arm, and shoulder, ranging from arthritis to nerve entrapments. To complicate the
matter further, there are few accepted criteria for case definitions for these many disorders. In their early
stages, these disorders usually present with nonspecific symptoms without physical examination or laboratory
findings. In fact, the only laboratory tests consistently of value in diagnosing these disorders are nerve conduction
studies for nerve entrapment disorders and radiographs for osteoarthritis. Finally, symptoms at the hand or
wrist may be due to nerve compression or vascular pathology in the neck or shoulder.
1.1 Frequency, Rates, and Costs

Rates of hand and wrist symptoms and associated disability among working adults were assessed by a
1988 national interview survey of 44,000 randomly selected U.S. adults (National Health Interview
Survey) (Park et al., 1993). Of those who had worked anytime in the past 12 months, 22% reported
some finger, hand, or wrist discomfort that fit the category pain, burning, stiffness, numbness, or
tingling for one or more days in the past 12 months. Only one-quarter were due to an acute injury such
as a cut, sprain, or broken bone. Nine percent reported having prolonged hand discomfort that was not
due to an acute injury; that is, discomfort of 20 or more days or 7 or more consecutive days during the
last 12 months. Of those with prolonged hand discomfort, 6% changed work activities and 5% changed
jobs due to the hand discomfort.
0-8493-1800-9/03/$0.00+$1.50
1-1
1-2
Occupational Ergonomics: Engineering and Administrative Controls

TABLE 1.1 Examples of Disorders of the Hand, Wrist, and Elbow
Observed in Workplace Studies
Elbow pain and epicondylitis are common in working populations. Symptoms of elbow pain are
reported by 7 to 21% of workers in industrial populations (Chiang et al., 1993; Ohlsson, 1989; Buckle,
1987). Epicondylitis is seen in 0.7 to 2.0% of workers in jobs with low levels of physical demands to the
arms and hands, and in 2 to 33% of worker groups with high levels of demands.
In the U.S., hand and wrist disorders account for 55% of all work-related repeated motion disorders
reported by U.S. private employers (Bureau of Labor Statistics, 1993). This category excludes low back
pain. A similar percentage is also reported in industrial (McCormack et al., 1990) and other national
studies (Kivi, 1984). A similar rise in work-related hand/forearm problems has been observed in other
countries such as Finland (Kivi, 1984), Australia (Bammer, 1987), and Japan (Ohara et al., 1976).
Costs for work-related musculoskeletal disorders are difficult to estimate reliably. Webster and Snook
(1994) analyzed 1989 insurance claims data from 45 states, restricting their analysis to upper extremity
claims classified as cumulative trauma disorders. They estimated that the total compensable cost for
upper extremity cumulative trauma disorders in the U.S. was $563 million in 1989. The National Institute
for Occupational Safety and Health has estimated that the annual workers compensation costs for neck
and upper extremity disorders is $2.1 billion, plus $90 million in indirect costs (NIOSH, 1996).
1.2 Disorder Types and their Natural History

Table 1.1 lists the most common workplace hand, wrist, and elbow problems. Nonspecific hand/wrist
pain is the most common problem, followed by tendinitis, ganglion cysts, and carpal tunnel syndrome.
(Silverstein et al., 1987; McCormack et al., 1990; Hales et al., 1994). In many workplace studies, rates
of nonspecific symptoms, tendinitis, and CTS appear to track each other, that is, a number of specific
disorders typically occur together. For example, in a pork processing plant, the rank order of hand and
wrist problems, as a percentage of all morbidity, was: nonspecific hand/wrist pain (39%), CTS (26%),
trigger finger (23%), trigger thumb (17%), and DeQuervains tenosynovitis (17%) (Moore and Garg,
1994). Similar ratios of disorders have been observed in manufacturing (Armstrong et al., 1982; Silverstein
et al., 1986; McCormack et al., 1990), food processors (Kurppa et al., 1991; Luopajrvi et al., 1979),
and among computer operators (Hales et al., 1994; Bernard et al., 1993).
Tendinitis is the most common specific, work-related hand disorder (McCormack, 1990; Luopajarvi,
1979). For the purposes of this chapter tendinitis will include hand, wrist, and distal forearm tendinitis
or tenosynovitis, and trigger finger. Tendinitis occurs at discrete locations; the most common site is the
first extensor compartment (De Quervains Disease), followed by the five other pulley sites on the extensor
side of the hand and three on the flexor side. The diagnosis is based on history, symptom location, and
palpation and provocative maneuvers on physical exam. There has been no association of tendinitis
with age or gender, but work-related tendinitis is higher among workers with less than 3 years of
employment (McCormack et al., 1990).
Lateral epicondylitis is the most common specific elbow disorder; medial epicondylitis is less common.
The diagnosis is based on pain and tenderness over the lateral or medial elbow and pain on movement
of the wrist or fingers against resistance. Other disorders of the elbow which may be related to occupational
activities include olecranon bursitis, triceps tendinitis, and osteoarthritis.
Epidemiology of Upper Extremity Disorders
1-3
Studies of carpal tunnel syndrome have generated considerable controversy. While there is agreement
that this disorder results from compression of the median nerve at the wrist, there are no universally
accepted diagnostic criteria for carpal tunnel syndrome. Some consider an abnormal nerve conduction
study a gold standard (Katz et al., 1991; Nathan et al., 1992; Heller et al., 1986). However, relying
exclusively on nerve conduction studies can lead to reporting very high prevalence rates28% (Nathan
et al., 1992) and 19% (Barnhart et al., 1991) in low-risk working populations. A case definition
incorporating typical symptoms and signs has been proposed by NIOSH for surveillance purposes (CDC,
1989); however, the usual signs have relatively poor sensitivities and specificities (Katz et al., 1991;
Heller et al., 1986; Franzblau et al., 1993). Therefore, this definition may have limited value in
distinguishing CTS from other hand disorders. Hand diagrams completed by patients are reproducible
and sensitive, but may lack specificity (Katz et al., 1990; Franzblau et al., 1994). Only in the later stages
are weakness and thenar atrophy a noticeable feature. In approximately 25% of cases, CTS is accompanied
by other disorders of the hand or wrist (Phalen, 1966).
Few studies have evaluated the work-relatedness of osteoarthritis of the hand and wrist (Hadler et
al., 1978; Williams et al., 1987). Hadler et al. (1978) assessed the hands of 67 workers at a textile plant
in Virginia. Significant differences in finger and wrist joint range of motion, joint swelling, and X-ray
patterns of degenerative joint disease were observed between three different hand intensive jobs; the
observed differences matched the pattern of hand usage.
Hand arm vibration syndrome or Vibration White Finger disease occurs in occupations involving
many years of exposure to vibrating hand tools (NIOSH, 1989). This is a disorder of the small vessels
and nerves in the fingers and hands presenting as localized blanching at the fingertips with numbness on
exposure to cold or vibration. The symptoms are largely self-limited if vibration exposure is eliminated
at an early stage (Ekenvall and Carlsson, 1987; Futatsukal and Ueno, 1986).
Hypothenar hammer syndrome or occlusion of the superficial palmar branch of the ulnar artery has
been associated in clinical series and case-control studies with habitually using the hand for hammering
(Little and Ferguson, 1972; Nilsson et al., 1989) and with exposure to vibrating hand tools (Kaji et al.,
1993). The mean years of exposure before presentation were 20 to 30 years.
Small case-control studies or clinical series have described factors associated with less common disorders
such as Gamekeepers thumb (Campbell, 1955; Newland, 1992), digital neuritis, and ulnar neuropathy
at the wrist (Silverstein et al., 1986).
1.3 Individual Factors

Some data on individual risk factors, such as age and gender, are available for carpal tunnel syndrome
but not for other disorders of the hand and wrist. The risk of CTS increases with age (Stevens et al.,
1988), but in a cross-sectional study of an industrial cohort, age explained only 3% of the variability in
median nerve latency (Nathan et al., 1992). Although CTS is more common among women in the
general population, in workplace studies, when employees perform similar hand activities, the ratio of
female to male rates is close to 1.2:1 (Franklin et al., 1991; Nathan et al., 1992; Silverstein et al., 1986).
Certain female-specific factors, such as pregnancy (Eckman-Ordeberg et al., 1987) are clearly associated
with CTS; however, the role of other female factors such oophorectomy, hysterectomy (Cannon et al.,
1981; Bjorkquist et al., 1977; de Krom et al., 1990), or use of oral contraceptives (Sabour, 1970), is less
certain. Other individual factors have strong associations with carpal tunnel syndrome based on multiple
studies: diabetes mellitus (Phalen, 1966; Yamaguchi et al., 1965; Stevens et al., 1987), rheumatoid
arthritis (Phalen, 1966; Yamaguchi et al., 1965; Stevens et al., 1987), and obesity (Nathan et al., 1992;
de Krom et al., 1990; Falck and Aarnio, 1983; Vessey et al., 1990; Werner et al., 1994). For some
putative risk factors, the associations are based on single studies on studies presenting conflicting results:
thyroid disorders (Phalen, 1966; Hales et al., 1994), vitamin B6 deficiency (Amadio, 1985; Ellis et al.,
1982; McCann, 1978), wrist size and shape (Johnson et al., 1983; Armstrong and Chaffin, 1979; Bleeker
1-4

TABLE 1.2 Work-Related Factors Associated with
Disorders of the Hands and Wrists
TABLE 1.3 Controlled Epidemiologic Workplace Studies Evaluating the Association between Work and Wrist,
Hand or Distal Forearm Tendinitis*
* Case criteria are based on history and physical examination.

1
significant difference from control
2
adjusted for age, sex, and plant
3
analysis includes other disorders, although tendinitis was most common
4
cohort study with 31-month follow-up
5
all exposed and control subjects are female
From Rempel, D. and Punnet, L., Epidemiology of wrist and hand disorders, in Musculoskeletal Disorders in the
Workplace: Principles and Practice, eds. M.Nordin et al., Mosby-Year Book, Inc., St. Louis, Missouri, 1997. With
permission.
et al., 1985), and general de-conditioning (Nathan et al., 1988, 1992).
1.4 Work-Related Factors

Table 1.2 summarizes the characteristics of work that have been associated with elevated rates of upper
extremity symptoms and specific disorders, including carpal tunnel syndrome and tendinitis. These
associations have been observed in multiple studies and in different population groups, while doseresponse trends have been seen in several studies. Most studies have been cross-sectional in design,
limiting our ability to draw conclusions about causation. The preponderance of evidence, however,
suggests strongly that there is a causal relationship between work exposures and upper extremity disorders.
Carpal tunnel syndrome and hand-wrist tendinitis have been the best studied; several recent reviews
have evaluated the work-relatedness of these disorders and concluded that there is a causal relationship
(Stock, 1991; Hagberg et al., 1992; Kuorinka and Forcier, 1995). Tables 1.3, 1.4, and 1.5 summarize
selected studies of wrist and hand tendinitis, carpal tunnel syndrome, and epicondylitis.
Studies using crude measures of exposure have reported associations between repetition and hand/
wrist pain and disorders. In a study relying exclusively on nerve conduction measurements, median
nerve slowing occurred at a higher rate among assembly line workers than among administrative controls
1-5
TABLE 1.4 Selected Controlled Epidemiologic Workplace Studies Evaluating the Association between Work and
Carpal Tunnel Syndrome*
* Diagnosis based on history and physical exam or nerve conduction study.

1
significantly different from control group
2
control for age, gender, years on job
3
control for age and gender
4
low participation rate and limited exposure assessment
From Rempel, D. and Punnet, L., Epidemiology of wrist and hand disorders, in Musculoskeletal Disorders in the
Workplace: Principles and Practice, eds. M.Nordin et al., Mosby-Year Book, Inc., St. Louis, Missouri, 1997. With
permission.
TABLE 1.5 Selected Epidemiologic Workplace Studies Evaluating the Association between Work and Epicondylitis*
* Diagnosis based on history and physical exam.

1
prospective cohort study: rates are incidence of epicondylitis per 100 workers/yr
2
cross-sectional study: rates are prevalence of epicondylitis observed in active workers
1-6
(Nathan et al., 1992; Hagberg et al., 1992). Although no systematic assessment of exposure was carried
out, the assembly line work was considered more repetitive than the control group. Rate of persistent
wrist and hand pain was higher in garment workers performing repetitive hand tasks than in the control
group, hospital employees (Punnett et al., 1985). Persistent wrist pain, or that lasting most of the day for
at least one month in the last year, occurred in 17% of garment workers and 4% of hospital controls,
while persistent hand pain occurred in 27% of garment workers and 10% of controls. Others have
observed a similar link between high hand/wrist repetition and carpal tunnel syndrome (Chiang et al.,
1990; Barnhart et al., 1991) and tendinitis (Kurppa et al., 1991). The link to repetition may be that
these are jobs that require high velocity or accelerations of the wrist (Marras and Schoenmarklin, 1993).
Rates of wrist tendinitis among scissors makers was compared to shop attendants in department stores
in Finland. Examinations and histories were systematized and performed by one person. The rates between
the groups were not significantly different; however, among the scissors makers the rate of tendinitis
increased with increasing number of scissors handled (Kuorinka and Koskinen, 1979). Luopajrvi et al.
(1979) compared packers in a bread factory to the same control group. The packers work involved
repetitive gripping, up to 25,000 cycles per day, with maximum extension of thumb and fingers to handle
wide bread packages. Approximately half of the packers had wrist/hand tenosynovitis compared to 14%
among the controls. The most common disorder of the hand or wrist was thumb tenosynovitis followed by
finger/wrist extensor tenosynovitis. CTS was diagnosed in four packers and no controls.
The force applied to a tool or materials during repeated or sustained gripping are also predictors of
risk for tendinitis and carpal tunnel syndrome. For example, in a study of the textile industry the risk of
hand and wrist tendinitis was 3.9 times higher among packaging and folding workers than among
knitters (McCormack et al., 1990). The packing and folding workers were considered to be performing
physically demanding work compared to the knitting workers. Armstrong et al. (1979) observed that
women with carpal tunnel syndrome applied more pinch force during production sewing than did their
job- and sex-matched controls. It is possible that those with carpal tunnel syndrome altered their working
style as the carpal tunnel syndrome progressed; however, it is unlikely that they would increase the pinch
force because this would also trigger symptoms. In a study by Moore et al. (1994) at a pork processing
plant, the jobs that involved high grip force or long grip durations, such as Wizard knife operator,
snipper, feeder, scaler, bagger, packer, hanger, and stuffer, affected almost every employee. Others have
observed a similar relationship with work involving sustained or high-force grip in grinders (Nathan et
al., 1992), meatpackers and butchers (Kurppa et al., 1991; Falck and Aarnio, 1983), and other industrial
workers (Thompson et al., 1951; Welch, 1972).
The most comprehensive study of the combined factors of repetition and force was a cross-sectional
study of 574 industrial workers by Silverstein et al. (1986, 1987; Armstrong, 1982). Disorders were
assessed by physical exam and history and were primarily tendinitis followed by carpal tunnel syndrome,
Guyon tunnel syndrome, and digital neuritis. Subjects were classified into four exposure groups based
on force and repetition. The high-force work was that requiring a grip force on average of more than
4 kg-force, while low-force work required less than 1 kg of grip force. The high-repetition work
involved a repetitive task in which either the cycle time was less than 30 seconds (greater than 900 times
in a work day) or more than 50% of cycle time was spent performing the same kind of fundamental
movements. The high-risk groups were compared to the low-risk group after adjusting for plant, age,
gender, and years on the job. The odds ratio of all hand/wrist disorders for just high force was 4.9, and
it increased to 30 for jobs which required both high-force and high-repetition. The identical analysis of
just carpal tunnel syndrome revealed an odds ratio of 1.8 for force and 14 for the combined high-force
and high-repetition group. A meta-analysis of Silversteins data and Luopajrvi study concluded that for
high-force and high-repetition work the common odds ratio for carpal tunnel syndrome was 15.5 (95%
C.I. 1.7141) and for hand/wrist tendinitis it was 9.1 (95% C.I. 516) (Stock, 1991). Estimates of the
percentage of CTS cases among workers who perform repetitive or forceful hand activity that can be
attributed to work range from 50 to 90% (Hagberg et al., 1992; Cummins, 1992; Tanaka et al., 1994).
With regard to epicondylitis, the individual roles played by force and repetition are less clear. One
cohort study and six cross-sectional studies have evaluated the incidence or prevalence of epicondylitis
1-7
in relation to specific jobs, which were characterized by high force, high repetition, or both. Kurppa et
al. (1991) found a relative risk of 6.4 for epicondylitis in jobs with high repetition, some of which also
involved high force. One cross-sectional study found a significantly elevated risk of epicondylitis only
among recently employed workers in high-repetition or high-repetition/high-force jobs (Chiang et al.,
1993). Another cross-sectional study found an odds ratio of 6.9 epicondylitis in a high-repetition, highforce job (Roto and Kivi, 1984). This odds ratio was not statistically significant. Four other crosssectional studies found little or no increase in risk for epicondylitis in workers involved in jobs characterized
by high force and/or high repetition (McCormack et al., 1990; Luopajrvi et al., 1979).
Work involving increased wrist deviation from a neutral posture in either the extension, flexion or
ulnar, radial direction has been associated with carpal tunnel syndrome and other hand and wrist problems
(Thompson et al., 1951; Hoffman et al., 1981; Tichauer, 1966). De Krom et al. (1990) conducted a
case-control study of 156 subjects with carpal tunnel syndrome compared to 473 controls randomly
sampled from the hospital and population registers in a region of the Netherlands. After adjusting for
age and sex, a dose-response relationship was observed for increasing hours of work with the wrist in
extension or flexion. No risk was observed for increasing hours performing a pinch grasp or typing.
Some studies of computer operators have linked awkward wrist postures to severity of hand symptoms
(Faucett and Rempel, 1994), risk of tendinitis or carpal tunnel syndrome (Seligman et al., 1986), arm
and hand discomfort (Sauter et al., 1991; Duncan and Ferguson, 1974; Hunting et al., 1981).
Prolonged exposure to vibrating hand tools, such as chain saws, has been linked in prospective
studies to Hand Arm Vibration Syndrome (Ekenvall and Carlsson, 1987; Futatsuka and Ueno, 1986).
The risks are primarily vibration acceleration amplitude, frequency, hand coupling to tool, hours per
day of exposure, and years of exposure. However, based on existing studies, there is no clear vibration
acceleration/frequency/duration threshold that would protect most workers. Therefore, medical
surveillance is recommended to identify cases early while the disease can still be reversed (NIOSH,
1989). Use of vibrating hand tools may also increase the risk of CTS (Seppalainen, 1970; Cannon et al.,
1981) indirectly by increasing applied grip force through a reflex pathway (Radwin et al., 1987).
Prolonged or high-load localized mechanical stress over tendons or nerves from tools or resting the
hand on hard objects have been associated with tendinitis (Tichauer, 1966) and nerve entrapments
(Phalen, 1966; Hoffman and Hoffman, 1985) in case studies.
The average total hours per day that a task is repeated or sustained has been a factor in predicting hand
problems (Margolis, 1987; Macdonald, 1988). Among computer operators increasing self-reported hours
of computer use has been a predictor of symptom intensity or disorder rate in all (Faucett and Rempel,
1994; Burt et al., 1990; Bernard et al., 1993; Oxenburgh et al., 1985; Maeda et al., 1982; Hunting et al.,
1981). De Krom et al. (1990) did not observe a relationship between CTS and hours of computer use.
Work organizational (work structure, decision control, work load, deadline work, supervision) and
psychosocial factors (job satisfaction, social support, relationship with supervisor) appear to have some
influence on hand and wrist symptoms among computer users. Among newspaper reporters and editors,
work organizational factors modified the expected relationship between workstation design and hand
and wrist symptoms. Symptom intensity increased as keyboard height increased among those with low
decision latitude but not among those with high decision latitude (Faucett and Rempel, 1994). In another
study of newspaper employees, the risk of hand and wrist symptoms was increased among those with
increasing hours on deadline work and less support from the immediate supervisor (Bernard et al.,
1993). Among directory assistance operators at a telephone company, high information processing
demands were associated with an elevated rate of hand and wrist disorders (Hales et al., 1994). On the
other hand, in the industrial setting, Silverstein et al. (1986) observed no effect on job satisfaction.
1.5 Summary
The lack of prospective studies and an uncertainty about the precise pathophysiologic mechanisms
involved limits our ability to definitively identify causative factors. Nonetheless, current studies point to
1-8
a multifactorial relationship between work exposures and disorders of the hand, wrist, and elbow.
Symptom severity and disorder rate appear to be influenced by work organizational factors, such as
decision latitude and cognitive demands. Some disorders, such as tendinitis and carpal tunnel syndrome,
are clearly associated with work involving repetitive and forceful use of the hands. It seems likely that
there is a causal relationship between some work exposures and these disorders. For other disorders,
such as epicondylitis and osteoarthritis, the relationship to work exposures is less clear, although current
data are suggestive. Carpal tunnel syndrome has been linked to individual factors in population-based
studies and in clinical case series. However, in workplace studies where workplace exposures are adequately
quantified, individual factors play a limited role relative to workplace factors (Cannon et al., 1981;
Silverstein et al., 1987; Armstrong and Chaffin, 1979; Franklin et al., 1991; Faucett and Rempel, 1994;
Hales et al., 1994).
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2
Integrated Analysis of
Upper Extremity
Disorders
2.1 Introduction
2.2 Site and Types of Upper Limb Work-Related
Musculoskeletal Disorders
2.3 Risk Factors for Upper Limb Work-Related
2-1
2-2
2-2
Time as an Integral Part of Risk Factor Description Posture

as a Risk Factor Force as a Risk Factor
2.4 Integrated Approach to Evaluate Potential for Upper

Limb WMSD
2-5
Approaches to Investigating Tendon Disorders Approaches

to Investigating Nerve Disorders Methodological
Approaches to Predicting Muscle Disorders in the Upper Limb
2.5 Workplace Assessment Tools

Richard Wells
2-9
Scope of Workplace Assessment Tools Reviewed
2.6 Summary
2-18
2.1 Introduction
Work and activity-related musculoskeletal disorders (WMSD) have a complex multifactorial etiology
including not only the physical aspects of the activities that people perform but also the psychosocial
aspects. These disorders may involve muscular, tendinous, ligamentous, nervous tissues and include
both acute (overexertion) as well as chronic (overuse) onset. A number of sources of information ranging
from biomechanics, epidemiology, and clinical case series have identified a number of major risk factors
associated with the development of upper limb musculoskeletal disorders. (For reviews, see Stock, 1992
or Hagberg et al., 1995.) These include forcefulness, adverse posture, repetition or continuous activity,
angular velocity and acceleration, or joints and duration of exposure. Plausible biological mechanisms
by which these risk factors may result in disorders of the musculoskeletal system have been proposed.
Despite this, our best evidence points to a complex interaction of physical, psychosocial, and individual
factors in the development of musculoskeletal disorders at work.
An integrated approach to the causation of WMSD helps us understand the many simultaneous and
interacting physical stressors which act on the upper limb during activity. These approaches help form a
bridge between the performance of work and the cellular and other descriptions of the degenerative/
inflammatory processes involved in work and activity-related musculoskeletal disorders. An integrated approach
0-8493-1800-9/03/$0.00+$1.50
2-1
2-2
also guides us in the construction and evaluation of workplace assessment tools. In the sections which
follow, concepts important to the assessment of the risk factors of force and posture are reviewed prior
to analyzing the features of a number of assessment tools.
2.2 Site and Types of Upper Limb Work-Related Musculoskeletal

Disorders
Terminology describing work-related musculoskeletal disorders (WMSD) has become extremely
convoluted; for example, in the U.S., where the term of preference is cumulative trauma disorders (CTD),
disorders in visual display terminal (VDT) operators are called repetitive strain injuries (RSI). In this
chapter WMSD refers to all disorders of the musculoskeletal system (both upper extremity and low
back and limbs) both to specific tissue as well as nonspecific symptoms and syndromes where associations
with work have been found (cf. Hagberg et al., 1995).
An examination of Figure 2.1 reveals that a large number of types of tissues have been identified as
being affected by work: tendon, muscle, nerve, and joint. The disorders identified are found in a wide
variety of locations in the hand, forearm, arm, shoulder, and neck. How can we possibly devise methods
which will allow us to predict injury risk in such a wide variety of sites and tissues? Fortunately,
quantification of the external loads applied to the upper limb and its posture have been successful in
describing the differences between jobs and tasks with high versus low risks of developing WMSD.
Technically this is known as a low specificity of effect; a specific work factor can cause a number of
different musculoskeletal disorders in a number of anatomic sites (Hagberg et al., 1995). This is likely so
because increasing the external demand, in terms of increased force or frequency of exertion, increases
the demands on most of the tissues (internal) of the arm and shoulder. While this makes the development
of workplace assessment tools simpler, it makes it more difficult to examine causation and the mechanisms
of disorders.
2.3 Risk Factors for Upper Limb Work-Related

Sources of information ranging from biomechanics, epidemiology and clinical case series have identified
a number of major extrinsic (external) risk factors associated with the development of upper limb
musculoskeletal disorders. These include forcefulness, adverse posture, repetition or continuous activity,
joint angular velocity and acceleration, and duration of exposure. In addition, there are a number of
potentiating factors which are commonly mentioned including, cold, vibration, and use of gloves (Hagberg
et al., 1995). The following sections explore some concepts useful in the quantification of time and
posture.
Time as an Integral Part of Risk Factor Description

The time or frequency characteristics of tasks have typically been described by the term repetitiveness.
Unfortunately, this word is so often used and overused as to make such terms as repetitive job and
highly repetitive almost meaningless. No clear definition of the term is usually offered, which compounds
the lack of clarity.
In general the word is used in three main ways. First, it is used as a qualitative term to describe both
the high frequency of actions as well as the sameness or monotony of the job. Second, it has been used
to describe fast manual work with little apparent rest between movements. Third, repetitive work can be
quantified by the number of parts, efforts, keystrokes or wrist movements/per unit time. Perhaps the
most widely used operational definition of repetitive is that of Silverstein and colleagues: work with a
cycle time of less than 30 seconds or having a repeated sub-cycle lasting more than 50% of the main
2-3
FIGURE 2.1 Schematic of the upper limb showing examples of the sites and tissues potentially involved in work-and
activity-related musculoskeletal disorders: {T} = tendon-related disorders; {N} = nerve-related disorders; {M} = musclerelated disorders; {V} = vascular disorders.
2-4
cycle was categorized as being highly repetitive (Silverstein et al., 1986). Marras and colleagues have
developed approaches to quantifying the time-varying nature of body motions using angular velocity
and acceleration of both the wrist and trunk which have also been shown to be related to risk of injury
(Marras and Schoenmarklin, 1993; Marras et al., 1993; Schoenmarklin et al., 1994).
It can be noted that many of these definitions rate the frequency of both motions and force generation;
in general, each risk factor has an associated time variation. In addition, the phrase, repetitive job,
ignores the various functions of the different parts of the body. For example, a keyboard data entry task is
thought of as repetitive; true, the fingers have a high frequency of movement; however, the forearms,
shoulders, and back have almost constant and unchanging (static) posture and muscle activity. Westgaard
and Winkel have argued that each risk factor should be described by its intensity, time variation, and its
duration (Westgaard and Winkel, 1994; Winkel and Mathiassen, 1994). Ideally, the time dimension should
allow the effects of different work organizations to be predicted: the effects of micropauses, of different
work/rest ratios, of different break schedules, of rotation and work enlargement. At this time our knowledge
does not permit us to deal with this important dimension at more than a rudimentary level. This argues for
research into better ways of characterizing the time-varying nature of the major risk factors.
In the assessment of injury risk, tools must account for one more aspect of time. The estimation of
risk factors which relate either to the highest demand or to some measure of cumulative or average
loading. Despite the common notion that WMSDs are related to the accumulated exposure over months
or years, i.e., cumulative trauma disorders, there are surprisingly few examples where cumulative exposureresponse relationships have been demonstrated; most associations found are between exposure intensity
and WMSD. For example, Stenlund et al. (1992) found relationships between the cumulative load lifted
and arthrosis of the acromioclavicular joint in the shoulder, and Kumar (1990) found that workers with
back pain had higher cumulative loads on the spine. In a similar manner, long periods in non-neutral
postures have been associated with back pain (Punnett et al., 1991). Relationships have also been found
for maximum loads; for example, one of the stronger predictors found by Marras et al. (1993) for low
back pain was from maximum hand load.
Posture as a Risk Factor

Postures of the limbs and trunk have a long history in characterizing tasks because, unlike many other
risk factors, they are often observable and quantifiable without instrumentation. Posture is an important
element of task analysis because it can be related to a number of injury mechanisms. In general, posture
can give information about four kinds of stressors on the musculoskeletal system. First, if a limb segment
is inclined with respect to the line of gravity a joint moment of force is required about the proximal end
with the necessity for muscular or ligamentous forces to support it. Second, a joint angle close to the end
range of motion (extreme posture) will load ligaments and may compress blood vessels and nerves.
Third, joint angles away from the joints optimal working range will change the geometry of the muscles
crossing the joint, possibly impairing the optimal functioning of joints or tendons around the joint.
Fourth and last, the change (or lack of change) in posture may be used to characterize the frequency
(repetitiveness) or the static nature of the task.
Posture as a Predictor of Joint Moment of Force

As the previous section illustrated, the joint moment of force gives important insights into tissue loads.
As body segments deviate from the vertical, the ever-present force of gravity acts on the mass of the body
segment: the hidden load of the arm mass about the shoulder and particularly the trunk mass about
the low back are important, especially in sedentary tasks where the posture may be maintained for
substantial periods of time. This is frequently termed postural load. If weights are held in the hand, a
moment is usually created by the load in non-neutral postures.
Extreme Posture as a Predictor of Soft Tissue Loads

Usually the extremes of a joints motion are constrained by ligaments: use of extreme posture during
work may not be desirable. For example, in the low back during stoop lifts, flexion of the lumbar
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spine creates tension in the posterior ligaments of the spine, and in many people a flexion relaxation
phenomenon is seen whereby the extensor muscles of the spine become inactive and the ligaments
support the moment (McGill and Norman, 1993). The drawback and potential risk in this for low back
injury is that if there are unexpected loads or slipping, the only structures which can support the extra
loads are the ligaments. If the posture is held for long periods of time, for example in steel reinforcement
workers or gardeners, creep of the spinal ligaments and a change in the stability of the spine may result.
Joint Posture and Optimal Musculoskeletal Geometry

For each joint there is a range of posture which minimizes possible adverse features of work and which
allows effective force application with minimum fatigue and injury potential. Even before an extreme
posture is reached, there are changes in the function of the musculoskeletal system which usually make
the postures less than optimal and which may elevate tissue loads.
For example, at the wrist, extension of greater than about 30 degrees increases intracarpal pressure,
even in normal people, above 30 mmHg (Rempel et al., 1995). This pressure, if maintained for substantial
periods of time, likely decreases microcirculation of the structures in the tunnel, including the median
nerve. This may be one of the mechanisms by which work activities cause carpal tunnel syndrome.
Another example at the wrist involves grasping a small object with the wrist in flexion. This can require
large effort, and forcing the wrist into maximal flexion will usually cause the object to be dropped. This
is the basis of a number of actions in self-defense. This example shows that nonoptimal postures require
higher efforts to perform a given task. Large deviation from approximately neutral postures can also
affect blood supply: looking upward, as during the picking of fruit, can compromise cerebral blood flow
especially if coupled with neck twist (Sakakibara et al., 1987).
Each joint has an optimal position for different work activities; it is often near the midpoint of the
range of motion, but this rule has sufficient exceptions to make it unreliable. For example, the knee
functions very well close to the extreme straight position during most locomotor tasks.
Change of Posture
Work involves changes in posture, and the changes can be used to quantify the frequency of movements.
Frequency of activity is described further in a later section. If postures do not change for long periods of
time, such as shoulder and trunk posture during computer (VDT) work, the task may be called static.
Force as a Risk Factor

Despite the existence of a large number of external risk factors (Figure 2.2), it can be argued that the
final common pathway by which work causes or contributes to the development of WMSD is force.
External loads and postures give rise to internal exposures in the tissues of the upper limb. Thus a
fingertip force may give rise to tensile force in the finger flexor tendons; simultaneous wrist flexion
stretches the wrist and finger extensors, increasing their passive tensile force (Keir et al., 1996); the wrist
flexion also increases the hydrostatic pressure in the carpal canal. These forces have a different effect on
each tissue which will be discussed in more detail shortly.
Externally we may wish to measure the force required or the force exerted by the hand (which may be
considerably more, depending on the friction and size of the object). We may wish to measure the
absolute force or the force relative to an individuals capacity.
It can be seen that posture is most frequently a modifier of or a predictor of the loads experienced by
the tissue. The foregoing shows why posture is such a valuable measure of workplace risks: only when
external loads are applied is it of limited use in workplace evaluation. The internal exposure to force,
however, remains central; other risk factors affect this directly or indirectly.
2.4 Integrated Approach to Evaluate Potential for Upper Limb WMSD

Figure 2.2 illustrates an integrated approach to evaluate the potential for upper limb WMSD: the
external factors of force, posture, time variation (repetitiveness), and duration of exposure act on the
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FIGURE 2.2 Illustration of the distinction between external exposures to the body and internal exposures to
individual tissues. Under each tissue some of the measures for evaluating the potential for developing work-related
musculoskeletal disorders are listed.
musculoskeletal system. These create internal exposures to the tissues of the body. It is these internal
exposures which stress the individual tissues and which must be resisted: it is at this level which injury
mechanisms can be tested using histological, physiological, or electrophysiological techniques. For
example, through the use of external forces (An et al., 1987) and limb accelerations (Marras and
Schoenmarklin, 1993) moments of force at the elbow during work can be predicted. Because the
musculoskeletal system is mechanically indeterminate, i.e., there are more force-producing structures
than equations of equilibrium to describe the system, analysis to predict the load in the individual tissues
demands either that assumptions be made concerning how muscles are recruited be made or some
criterion measure is minimized through optimization approaches (An et al., 1987; Wells et al., 1995). In
addition, through the incorporation of the biological materials properties the response of the tissue to
load can be grossly predicted. The models available to study activity-related musculoskeletal disorders
are in preliminary stages of development. This is complicated by the lack of a good animal model of
these disorders and the delicate balance of physical strain and restorative responses.
In general these internal exposures are the subject of laboratory-based research rather than workplace
assessment, but they are important because they help us conceptualize the best external variables to
measure and the best way in which to evaluate them. For example, in the depiction of manual material
handling tasks to elucidate the link between work and low back pain, one could describe the load lifted
by a person, and separately, the distance away from the body of this mass. It has been found more useful
to compute the joint moment; the product of the force and the distance (Marras et al., 1993). This is
done based on a biomechanical model which demonstrates that tissue loads (internal exposures) are
better reflected by moment than either load or posture separately. Similar arguments can be made at the
shoulder.
Figure 2.3 depicts a conceptual model of the factors influencing the development of work-related
carpal tunnel syndrome. The pathways indicated a way in which the multiple demands of work may
combine to reduce or elevate potential for trauma to the tissue. Take, for example, work in the cold with
a vibrating tool; gloves will also likely be worn. The diagram illustrates how the presence of gloves may
increase grip force; the presence of cold and vibration may decrease tactile sensation and further increase
grip force.
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FIGURE 2.3 Conceptual model of the relationship between external risk factors and the development of carpal
tunnel syndrome due to both compression of the median nerve by the flexor tendons and changes in carpal tunnel
geometry due to posture alone. Across the center are listed the major (external) risk factors of force, posture and
time. Below are listed risk factors which may elevate the effect of these primary factors, and above are noted possible
pathways by which the external exposures (risk factors) create internal exposures that could plausibly lead to the
development or aggravation of CTS. Many additional factors can alter the forces in the flexor tendons such as the
grip type, number of digits used, and the angular acceleration of the wrist. Lack of skill may lead to poorer postures,
higher grip forces, or increased coactivation of muscles, more movements to perform a given task, or jerkier (higher
acceleration) motions.
Building on this concept, Moore et al. (1991) described an integrated approach using biomechanical
modeling to predict internal exposure variables likely related to injury. This is achieved by the synthesis
of posture, force, movement, and muscle loading data. The model produced a profile of measures for
use in industrial settings, that reflect the loading on the different tissues affected by WMSD (nerves,
tendons, muscles) and the different loading mechanisms (e.g., highly static postures, repeated extreme
postures, dynamic movements). The measures involve continuous monitoring of hand/wrist postures,
forces, and muscle activations (electromyographic signals) over the duration of the task both in the arms
and shoulders. Using the previously described measures as input to a biomechanical model of the forearm
and hand, a profile of 12 risk factors was created which characterized the demand of the task on the
distal upper limb. The 12 variables were: peak tendon force, cumulative tendon force, cumulative tendon
excursion, peak tendon excursion velocity, average pressure on the flexor retinaculum (and thus the
median nerve), peak pressure on the flexor retinaculum, cumulative pressure on the flexor retinaculum,
cumulative frictional work on the flexor tendons, peak frictional power, and three measures of the
flexor myographic signal, the 10th or static, 50th, and 90th percentiles of the amplitude probability
distribution function (APDF).
The models above integrated information from anatomical, biomechanical, and epidemiological studies
to produce a profile of measures to characterize tasks and which reflected injury mechanisms for different
tissue types. These will now be briefly reviewed.
Approaches to Investigating Tendon Disorders

Etiologically, reduced lubrication between tendons and tendon sheaths due to excess relative movement
has been suggested in tenosynovitis (Rowe, 1987) while high peak loads and cumulative strain have been
suggested for tendinitis (Goldstein et al., 1987). Norman and Wells (1990) have proposed a model for
assessment of tenosynovitis which was operationalized by Moore et al. (1991). This is seen in Figure 2.4.
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FIGURE 2.4 Conceptual model of the relationship between external risk factors and the development of tenosynovitis.
Across the center are listed the major risk factors of force and posture. Below are listed risk factors which may
elevate the effect of these primary factors, and above are noted possible pathways by which the external exposures
(risk factors) create internal exposures that could plausibly lead to the development or aggravation of tenosynovitis.
Many additional factors can alter the forces in the flexor tendons, such as the grip type, number of digits used, and
the angular acceleration of the wrist. (Adapted from Norman, R.K. and Wells, R.P. 1990. Biomechanical aspects of
occupational injury, Proceedings of the 23rd Annual Conference of the Human Factors Association of Canada. With
permission.)
In this approach the frictional work done by the tendon sliding through its sheath is calculated. One
type of frictional work is present due to a belt-pulley interaction when the wrist deviates from a
straight position (Armstrong and Chaffin, 1979). In addition to this type of frictional work, it is suggested
that a non-negligible resistance to movement is present to move the tendons through the carpal tunnel
even in the straight position. Estimates from the work of Goldstein et al. (1987) and Smutz et al. (1995)
put this resistance at around 5N in the neutral position. Excursion of the tendons at the wrist (caused by
finger and wrist movement) in both deviated, and straight postures will therefore create an energy input,
possibly beyond the recovery capability of the tissue.
Approaches to Investigating Nerve Disorders

Insult to the median nerve, whether due to increased hydrostatic pressures in the carpal canal (Rempel et al.,
1995) or due to mechanical insult upon the nerve by overlying tendon (Keir and Wells, 1995), has often been
suggested as a likely mechanism of work-induced carpal tunnel syndrome. More controversially, it may be
caused by hypertrophy or edema of the synovial sheaths and thus be secondary to tenosynovitis.
Mechanical stress to the median nerve can be predicted by modified belt-pulley models of the wrist
and is an output of a biomechanical model (Moore et al., 1991). Hydrostatic pressures are measurable
using in vivo and in vitro techniques (Keir and Wells, 1995).
Methodological Approaches to Predicting Muscle Disorders in the Upper Limb

Recent clinical findings have suggested that forearm muscle pain may be an overlooked problem in
studying work-related chronic musculoskeletal injuries (Ranney et al., 1995). While work-related muscle
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pain is well accepted in the shoulder area (e.g., Veiersted et al., 1993), pain in the forearm is usually
attributed to tendinitis or epicondylitis. The major approach to investigating muscle-related occupational
disorders is electromyography. Jonsson (1982) described a technique in which the frequency of any
particular level of EMG occurring is calculated. From this, an amplitude probability curve is developed.
The static level describes the ability of the muscle to rest at least 10% of the time and appears important
in the development of chronic work-related muscle problems. If the value is greater than zero, the
muscle is not given a chance to completely rest at least 10% of the time during a task. While this is a
useful technique for quantifying muscle usage throughout the duration of a task, it gives no indication
of the duration of each rest pause, i.e., whether the rests came as numerous pauses or one big pause.
Veiersted et al. (1990, 1993) addressed this by using a gaps analysis. This analysis looks at the number
of times the muscle is turned off (an EMG gap is defined as a muscle activation of less than 0.5%
MVC lasting for more than 0.2 seconds), and it appeared that people with pain had fewer gaps. More
recently it has been shown that workers likely to require neck/shoulder sick leave can be predicted from
measures of gap frequency (Veiersted et al., 1993).
2.5 Workplace Assessment Tools

Scope of Workplace Assessment Tools Reviewed
The previous sections have described some of the main risk factors which increase the risk of developing
upper limb musculoskeletal disorders and how these risk factors may produce internal exposures to
tissues of the body potentially leading to premature fatigue or WMSD. It falls to this section to describe
and review some of the tools in the literature which have been developed to assess workplace risk of
WMSD. Tools included met two conditions: (1) the tool or method not only recorded risk factors but
rated them and (2) rated the injury risk to the upper limbs or the intervention priority.
The workplace assessment tools reviewed fell into two main categories: those using mainly
observational methods to identify, rate, and combine a number of risk factors to produce an estimate of
risk for upper limb musculoskeletal disorders (e.g., Strain Index) or intervention priority (e.g., RULA)
and which are often suggested as screening tools, and those which measured (sometimes called technical
methods) the time course of a more complex risk factor (e.g., the trapezius electromyogram) and produced
an estimate of risk. The tools are described in Table 2.1 and evaluated on a number of criteria which are
important either from a conceptual, measurement, or usability viewpoint. The following sections describe
these criteria.
Stated Purpose
The tools can only be reviewed on the basis of the stated purpose; this purpose differed between the
tools. For example, the RULA output is in terms of an intervention priority, whereas trapezius EMG has
been associated with neck/shoulder musculoskeletal sick leave. Some tools were designed for screening
purposes whereas others were intended to produce more definitive analyses. The precise area of the
body for which the tool predicts risk also differs between tools and methods; for example, RULA has
upper limb and trunk scores and defines an intervention priority based upon the combined whole body
score, whereas the Strain Index is specific to the distal upper limb.
Input Variables
As noted in the previous sections, there is a wide range of potential stressors for the upper limb; how
many there are and how they are measured is important information concerning the potential
generalizability of the method. The handling of the time-varying nature of the risk factors is, to this
author, of prime importance both for its usefulness and its ability to answer the frequently asked questions
concerning line balancing, job rotation, and break schedules. The inputs are described by the forces and
postures adopted, the characterization of their time course, as well as the treatment of other risk factors.
TABLE 2.1 Comparison of Workplace Assessment Tools in the Literature which Have Been Developed to Assess Workplace Risk of WMSD and Priority for Intervention
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TABLE 2.1 (continued) Comparison of Workplace Assessment Tools in the Literature which Have Been Developed to Assess Workplace Risk of WMSD and Priority for Intervention
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TABLE 2.1 (continued) Comparison of Workplace Assessment Tools in the Literature which Have Been Developed to Assess Workplace Risk of WMSD and Priority for Intervention
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The tools differed considerably in their treatment of the time course of the input variables; some used
only a single instant while others used mathematical or electronic processing to extract information
about the time variation of the risk factor.
Rating of Individual Risk Factors

As previously noted, only tools which evaluated the size of the risk factor(s) have been reviewed here;
how this is done and the quality of this assessment is key to the usefulness of the tool. It is difficult to
imagine any work without some risk factors present and one can quickly fall into the mindset that work
is inherently dangerous and the observation of a bent wrist during work implies hazard. A distinction is
made in industrial hygiene between toxicity and hazard. Benzene is highly toxic, yet if used infrequently
where the concentration is small (a persons exposure is low), the hazard is small. Similarly, even for
wrist flexion close to an individuals range of motion (ROM), the risk is also low if the motion is
infrequent. In fact the adoption of extreme postures for short periods of time is probably beneficial;
they are called stretch breaks.
A number of approaches are seen ranging from statistical treatments based on epidemiological studies
to expert and consensus judgments. For single risk factors epidemiological approaches are possible;
however, some element of expert judgment becomes necessary to fill-in the holes in the epidemiological
literature.
Combination of Risk Factors

Very few epidemiological studies allow the interactions of a number of risk factors to be examined. For
example, Silverstein and colleagues did study a simple 2 2 interaction of force and repetitiveness
(Silverstein et al., 1986), while the psychophysical approach allows combinations of multiple dimensions
to be rated. These studies are not common and so the majority of studies combine rating of the individual
risk factors with additive or multiplicative models to arrive at a risk estimate.
The combination of risk factors to produce an estimate of risk is perhaps the most difficult issue in
workplace evaluation and tool construction. Should the individual risk factor ratings be added or
multiplied or even considered completely separately? For example, in evaluating the risk of low back
pain on a job one could measure the risk factor of posture and load separately. Does one add the
posture and load score or multiply them? Biomechanical models indicate that multiplying the load
and its moment arm about the low back (in effect, posture) gives the low back moment of force (or
torque). This has been found to give the best single prediction of low back pain risk (Marras et al.,
1993). Clearly the integrated approach advocated here uses biological and mechanical arguments to
help in this decision.
In industrial hygiene exposure levels are considered separately except when the agent of interest has
the same target organ or pathway. For example, in a given job there is exposure to work overhead and
hand/arm vibration from a hand tool. Does this mean the job has two risk factors which need improvement
or is there more risk than if either of these exposures occurred separately? The first approach is supported
by different target organs, the shoulder and forearm, while the low specificity of effect (Hagberg et
al., 1995) could argue for the second interpretation.
Based on the discussion of the importance of time as a descriptor of risk factors, it would appear that
time must be considered along with the primary risk factor, force. In some cases both force and posture
are considered and in these cases, both force and posture may be considered with their time variation. In
some cases posture may be used as a surrogate of force and in such cases its time variation must be
considered. In all these cases, this may be done additively or, more commonly, multiplicatively (cf.
NIOSH, 1981; Moore and Garg, 1995).
Definitive answers to the above conceptual issues are not available, and so the magnitude of the total
score calculated and its relation to risk must be cautiously interpreted. In the case of tools whose purpose
is to calculate intervention priority, these questions are not as critical because the scores are used as a
summary of the size of the individual risk factors and their number combined.
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Equipment Required
The equipment required is important in the choice of a tool; some methods utilize observations of work,
while others use various technical methods, such as electromyography or goniometry, in the
measurement process. This obviously affects the time and cost of the assessment. While it is sometimes
heard that ergonomics assessments must be simple and cheap, the value of more costly yet precise
technical measures with epidemiologically determined relationships to risk must not be undervalued.
The time, training required, and cost of using the tools are rarely reported.
Measurement Characteristics
The tools developer can arrive at an estimate of risk in a large number of ways; what is important,
however, is the quality of the tools predictions. This can be assessed in terms of the measurement
characteristics and validity. The measurement characteristics refer to such qualities as intra-observer
reliability (or test-retest reliability) as well as inter-observer agreement or reliability. A tool with poor
reliability will be of limited usefulness. It may still, however, be able to distinguish jobs with many risk
factors and high risks from those with few risk factors and low risks, but it may not reliably distinguish
between jobs with less extreme contrasts. Good measurement characteristics become of even greater
concern if the tool is used for guidelines or legislative purposes.
Validity
The term validity can be used in a number of senses. Content validity refers to the completeness of the
assessment. Questions such as are all important risk factors rated are asked here. Most tools reviewed,
however, used some variant of criterion-related validity. The output of the tool was compared to some
health-related output on jobs or individuals. The stated purpose is important here in evaluating the
appropriate comparisons.
Study Base/Generalizability
It is not possible to test a tool under all possible conditions; the range of workplaces used to develop and
test the tool are useful in judging the applicability of the tool to a given target workplace. For example,
it is likely problematic to use a tool developed in an office environment to apply to a construction site.
Proposed Limit of Guideline Level?

Although not universal, many of the tools produced some recommendations or guidelines in terms of
the score or output of the tool. A number of tools have screening as their stated purpose. In this case a
two-(or more) step process is assumed, and those jobs exceeding some criterion score are further analyzed.
In this case a high sensitivity is desirable; a moderate number of false positive findings are accepted so
as not to miss potentially risky jobs in the first step.
For those tools whose purpose is to define risk, it is unreasonable to imagine that a single threshold
divides risky jobs from non-risky ones. Where the risk of developing various WMSDs has been produced
against a continuous exposure measure, it has been found that the risk increases steadily from the
nonexposed state, i.e., there is no obvious step or threshold evident (e.g., Punnett et al., 1991). The
threshold chosen is then dependent on the increased risk which is to be accepted (a societal judgment).
While a guideline value can be useful in the interpretation of an instruments score, the measurement
characteristics (the validity and the generalizability) of the tool must be of high quality before reliance
can be placed on these recommendations.
Information for Intervention

The assessment of risk is but one step in process of workplace improvement; a good tool provides
direction on which risk factors need addressing and also provides material and suggestions for solutions.
Ideally, it might also allow what if scenarios to be explored and predict what the level of risk will be
for the new combination of risk factors.
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Limitations
No tool is perfect; the limitations of a given tool need to be understood, however, so that undue reliance
on the output is not made where the tools predictions are likely not to be of high quality. Each tool
could have a large number of limitations; the focus of this section is on major areas where the predictive
power of the tool is suspect or untested.
2.6 Summary
This chapter has reviewed some concepts important in the measurement and evaluation of the major
risk factors for the development of WMSDs in the upper extremity. An integrative approach is followed
whereby anatomical, physiological, and biomechanical information is used to conceptualize upper limb
function and as a possible means to learn how work might cause WMSDs. These concepts are then used
to inform a review of some of the major upper limb workplace evaluation tools; each has different
purposes, strengths, and weaknesses. As these tools are further developed, the framework used in this
chapter should provide a springboard from which the reader can assess existing and new tools in the
light of their needs and available resources.
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3
Biomechanical Aspects
of CTDs
3.1 Introduction
3.2 Anatomy of the Upper Extremity
3-1
3-1
Skeletal System Muscular System Connective Tissue

and Carpal Tunnel Nervous System
3.3 Work-Related Muscle Disorders

3.4 Biomechanical Aspects of Muscle-Tendon
Disorders
3.5 Work-Related CTDs Involving the
Muscle-Tendon Unit
3-9
3-11
3-17
Tendinitis Lateral Epicondylitis

(Tennis Elbow) Supraspinatus Tendinitis
(Rotator Cuff Syndrome) Tenosynovitis
DeQuervains Tenosynovitis Trigger Finger
3.6 Biomechanical Aspects of Nerve Compression

Disorders
3.7 Work-Related CTDs Involving the Nerve
Richard W.Marklin
Marquette University
3-25
3-27
Carpal Tunnel Syndrome Occupational Sources of Median

Nerve Compression in CTS Thoracic Outlet Syndrome
3.8 Summary
3-31
3.1 Introduction
The purpose of this chapter is to explain the biomechanical etiology of cumulative trauma disorders
(CTDs) that affect the hand, wrist, elbow, and shoulder. The assumption that these CTDs are caused, in
part, by work-related activity is based on biomechanical mechanisms that are consistent with
epidemiological findings. CTDs affect the soft tissues in the body, namely tendons, ligaments, muscles,
and nerves, and in general not bone tissue. Although some authors include bone tissue within the umbrella
of CTDs (Kuorinka and Forcier, 1995), this chapter will focus only on those CTDs affecting soft tissue.
A brief description of the anatomy of the upper extremity will be provided to familiarize the reader with
anatomical terms. Then the three major classes of CTDs, namely those involving muscle, the muscletendon unit, and nerve compression, will be discussed.
3.2 Anatomy of the Upper Extremity

Skeletal System
The bones of the upper extremity, which are illustrated in Figure 3.1, are of two types, long and short
bones. The long bones connecting the shoulder to the elbow (humerus), the elbow to the wrist (radius
0-8493-1800-9/03/$0.00+$1.50
3-1
3-2
FIGURE 3.1 The long and short bones of the right upper extremity. (From Basmajian, J.V. 1982. Primary Anatomy,
8th edition, p. 57, Williams and Wilkins, Inc. With permission.)
and ulna), and the wrist to the fingers (metacarpals and phalanges) are adapted for weight bearing and
for sweeping, speedy movements that allow the hand to move in space and grasp and touch objects
(Rasch, 1989). The movement of the radius (thumb side) around the ulna (little finger side) in the
forearm permits the hand to be turned up (supination) or down (pronation), as illustrated in Figure 3.2.
The proximal and distal parts of the long bones display flared ends that act as attachment points for
other bones and for connective tissue, such as tendons and ligaments.
The cluster of small cubical bones comprising the wrist are the eight carpal bones, which are categorized
as short bones (Rasch, 1989). The carpal bones move with respect to each other to flex (palm side) and
extend (back side of hand) the wrist joint, while also allowing the wrist to move side to side, from a neutral
position to radial deviation (thumb side) and to ulnar deviation (little finger side), as shown in Figure 3.3.
Muscular System
The muscles of the body are the generators of internal force that convert energy chemically stored in the
body into mechanical work (Rasch, 1989). Skeletal muscle, also called striated muscle, is composed of
longitudinal fibers that follow the direction in which a muscle exerts a force, as seen in Figure 3.4. A
muscle is like a rope in that it can only pull or exert a force in tension, and it cannot push or exert a
weight-bearing force (compression force). As shown in Figure 3.5, a muscle exerts a tensile force by
contracting its thread-like fibers, which shortens the length of the muscle and in fusiform muscles creates
a bulge at its center.
Biomechanical Aspects of CTDs
3-3
FIGURE 3.2 The forearm in a pronated and supinated posture. (From Marklin, R.W. original artwork. With
permission.)
FIGURE 3.3 Postures of the wrist in the flexion-extension and radial-ulnar planes. (From Putz-Anderson, V. 1988.
Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs, p. 54, Taylor & Francis.
With permission.)
3-4
FIGURE 3.4 A photograph of the left shoulder muscles from a cadaver, as seen from the side. (From McMinn,
R.M.H. and Hutchings, R.T. 1977. Color Atlas of Human Anatomy, p. 113, Year Book Medical Publishers, Inc.,
Chicago, IL. With permission.)
FIGURE 3.5 The shortening of a muscle as it contracts, generating a pulling force. (From Basmajian, J.V. 1982.
Primary Anatomy, 8th edition, p. 113, Williams and Wilkins, Inc. With permission.)
The muscles that flex and extend the elbow, which are shown in Figure 3.6, are the biceps and
triceps. The group of muscles that flex and extend the wrist are the forearm flexors and extensors, as
shown in Figure 3.7. The flexors and extensors located on the thumb side of the forearm also radially
deviate the wrist; likewise, the forearm flexors and extensors on the little finger side of the forearm
ulnarly deviate the wrist. The muscles in the forearm, which are the primary generators of hand pinch
and grasp forces, are called extrinsic muscles, while the much smaller muscles located within the hand
are called intrinsic muscles. One of the main functions of the intrinsic muscles in the hand is to cooperate
with the extrinsic muscles to generate hand movements that require dexterity and fine motor control.
A) Front of Right Arm
3-5
B) Back of Right Arm
FIGURE 3.6 The muscles that flex (a) and extend (b) the elbow. Figures (a) and (b) are the front and back views of
the right arm, respectively. (From Van de Graaff, K.M. and Rhees, R.W. 1987. Human Anatomy and Physiology, p.
107, Schaums Outline Series, McGraw-Hill Book Co. With permission.)
Connective Tissue and Carpal Tunnel

As shown in Figure 3.7, the extrinsic muscles of the forearm are attached to the fingers with strong cordlike collagen structures called tendons. The tendons attached to the flexor and extensor forearm muscles
are constrained within the wrist area by thick bands called the flexor retinaculum and extensor retinaculum,
as illustrated in Figure 3.8. The flexor and extensor retinacula are ligaments that attach carpal bones on
one side of the wrist to bones on the other side. The flexor retinaculum and carpal bones form a canal
called the carpal tunnel, through which nine tendons from the forearm flexor muscles and the median
nerve pass, as shown in Figure 3.8. As the flexor tendons course through the carpal tunnel on their way to
the fingers, they travel through a network of synovial sheaths, as shown in Figures 3.9 and 3.10. These
sheaths reduce the friction between the tendons and their adjacent structures as they wrap around tendons
in articulating joints of the wrist and fingers. The structure of a synovial sheath is an elongated and doublewalled bursa that contains synovial fluid, as illustrated in Figures 3.11 and 3.12. The inner wall of the
sheath is attached to the tendon, and the outer wall is attached to a fibrous sheath moored to a bone or
ligament. The inside surfaces of the sheaths inner and outer walls are lined with synovial fluid, which acts
as a lubricant as the tendon traverses inside the tunnel formed by the fibrous sheath.
Nervous System
The primary purposes of the peripheral nervous system (PNS), which serves voluntary skeletal muscles
of the extremities, head, neck, and torso, are first, to receive sensory information from outlying parts of
the body and relay this information to the central nervous system (CNS), which consists of the brain and
spinal cord. The second major purpose of the peripheral nervous system is to send motor signals that
activate muscles in the outlying area(s) in response to the sensory input. Of the several nerves traveling
through the arm, the nerve most often associated with CTDs is the median nerve. As shown in Figure
3-6
FIGURE 3.7 The muscles that flex (a) and extend (b) the wrist. Figures (a) and (b) are the front and rear views of the
right arm, respectively. (From Van de Graaff, K.M. and Rhees, R.W. 1987. Human Anatomy and Physiology, p. 109,
Schaums Outline Series, McGraw-Hill Book Co. With permission.)
FIGURE 3.8 Cross-sectional anatomy of the wrist. The area highlighted is the carpal tunnel. (From Chaffin, D.B.
and Andersson, G.B.J. 1991. Occupational Biomechanics, 2nd edition, p. 240, John Wiley & Sons Publishers. With
permission.)
3-7
FIGURE 3.9 The system of synovial sheaths that lubricate the flexor tendons as they bend around the wrist and
finger joints (palmar view of the right hand). (From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p. 158,
Williams and Wilkins, Inc. With permission.)
FIGURE 3.10 A magnified end view of a muscle, tendon, sheath, and bony attachment point. (From Putz-Anderson,
V. 1988. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs, p. 12, Taylor
& Francis. With permission.)
3-8
FIGURE 3.11 Structure of a synovial sheath. An area of the sheath has been cutaway to expose its double-walled
structure. Synovial fluid lines the inside of the sheaths inner and outer walls and reduces friction as the tendon
moves within its tunnel. Note: normally the tendon fits snugly in its tunnel, but is shown having a loose fit in this
figure for illustration purposes. (From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p. 119, Williams and
Wilkins, Inc. With permission.)
FIGURE 3.12 A bursa, which is a collapsed bag of connective tissue filled with synovial fluid, forms whenever a
tendon rubs against a hard structure, such as a bone. (From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p.
118, Williams and Wilkins, Inc. With permission.)
3.13a, the median nerve starts at the shoulder, provides motor inputs to muscles in the forearm and
thumb region, and provides sensory feedback from the palm region and from the thumb to the center of
the ring finger. The median nerve is the nerve of precision because it supplies motor function to the
extrinsic muscles in the forearm that flex the fingers and the intrinsic muscles in the thumb that exert a
precision grip (Feldman et al., 1983). Figure 3.14 indicates the sensory regions of the hand served by the
median nerve and the radial and ulnar nerves, which travel down the radial and ulnar sides of the
forearm, respectively, as illustrated in Figures 3.13b and 3.13c. The radial nerve is the nerve of stability
because it innervates the forearm extensor muscles that oppose and stabilize the precision and power
muscles on the forearms flexor side. The ulnar nerve is the nerve of power because it innervates the
muscles that provide wrist flexor power, but little precision (Feldman et al., 1983).
3-9
FIGURE 3.13 a) Front view of the paths of the median nerve as it travels down the right upper extremity. b) Rear
view of the paths of the radial nerve. c) Front view of the paths of the ulnar nerve. (From Basmajian, J.V. 1982.
Primary Anatomy, 8th edition, p. 340, Williams and Wilkins, Inc. With permission.)
3.3 Work-Related Muscle Disorders

After frequent or prolonged contractions, a muscle can feel painful for a relatively short period of time
and recover to full function, or it could develop a more serious chronic condition. If the pain disappears
after a relatively short period of time, the cause was probably temporary fatigue of the muscular tissues.
However, if the pain persists, the worker could have developed a muscle CTD.
The medical term describing muscle pain is myalgia, which includes a few specific muscle pain syndromes.
Myalgia can occur after vigorous or unaccustomed exercise, and also from work-related activity. A worker
can develop a myopathy called myofascial syndrome, which is characterized by the presence of one or
more discrete areas (or trigger points) that are tender and hypersensitive and from which pain may radiate
when pressure is applied (Kuorinka and Forcier, 1995, p. 81). Myofascial syndrome could be associated
with work-related activity, and a common work-related myofascial syndrome is tension neck syndrome
(also called shoulder-neck myofascial syndrome). Tension neck syndrome is a myofascial syndrome localized
3-10
FIGURE 3.13 (continued)
FIGURE 3.14 Sensory regions of the right hand served by the median, radial, and ulnar nerves. (From Basmajian,
J.V. 1982. Primary Anatomy, 8th edition, p. 341, Williams and Wilkins, Inc. With permission.)
3-11
FIGURE 3.15 A typical stress-strain curve of a tendon. (From Abrahams, M. 1967. Mechanical analysis of tendon
in vitro: A preliminary report, Med Biol Eng, Vol. 5, p. 435. With permission.)
in the shoulder and neck region with tenderness descending into the trapezius muscle. Occupational
groups cited in the literature that have been associated with high rates of tension neck syndrome are
those requiring repetitive arm movements and constrained postures (Kuorinka and Forcier, 1995).
The pathogenesis of myofascial syndromes is unknown; however, several hypotheses have been offered
in the literature, which include a lower capillary-to-fiber ratio for the slow twitch fibers (Type I), severe
depletion of ATP in the muscle, and dysfunctional energy metabolism (Kuorinka and Forcier, 1995). For a
more thorough discussion of muscle CTDs, the reader is referred to Kuorinkas and Forciers (1995) book,
which has a comprehensive description and discussion of biomechanical mechanisms of muscle CTDs.
3.4 Biomechanical Aspects of Muscle-Tendon Disorders

As a muscle shortens during contraction and lengthens during stretching, its tendon acts like a rope and
transmits the muscle force to the bony attachment site. As a tendon moves with a muscle, the length of the
tendon does not necessarily stay constant. A tendon has elastic properties and is analogous to a rubber
band. The muscle force applied to the tendon is a tensile force, which is commonly converted to the units
of stress (force divided by cross-sectional area of tendon). As the tensile force increases, the tendon elongates,
which is measured by strain (the percentage of change in length). Figure 3.15 shows a typical stress-strain
curve of a tendon with its three characteristic regions (Abrahams, 1967). In Region 1, the crumpled collagen
fibers of a relaxed tendon merely straighten under negligible loads. Then, as the tensile force increases, the
tendon passes through the toe region (region 2), and then has a linear relationship between stress and
strain in region 3. Although the tendon can elongate up to 5% strain before onset of failure, normal
tendon strain is below 3% (Abrahams, 1967; Elliott, 1965; Rigby et al., 1959).
The loading and unloading of a tendon can change its elastic properties depending on whether the
tensile force is increasing or decreasing. As shown in Figure 3.16, the amount of stress required to
elongate a tendon to a specific strain level is greater when a tendon is loaded (increase in tensile load)
then when it is unloaded (decrease in tensile load). This change in stress-strain curve is called hysteresis,
which results from a loss of energy, probably as heat, during the unloading phase (Moore, 1992).
Several CTDs reported in the literature occur at sites where a tendon wraps around a deviated joint.
As a muscle contracts and moves its tendon accordingly, the tendon can rub against its adjacent surface,
3-12
FIGURE 3.16 The stress-stress curve of a tendon depends on whether the tensile force is increasing or decreasing.
The difference in the stress-strain curves is called hysteresis. The units of stress and strain are N/mm2 and % elongation,
respectively. (From Moore, J.S. 1992. Function, structure, and responses of components of the muscle-tendon unit,
in State of the Art Reviews in Occupational Medicine, Vol. 7, No. 4, p. 721. With permission.)
usually a bone or ligament, as a rope rubs against a nonrotating pulley. Likewise, when the muscle
lengthens, the tendon moves in the opposite direction against its adjacent structures. In the wrist area,
the repetitive rubbing of the tendons against the carpal bones and flexor retinaculum can cause CTDs
known as tendinitis and tenosynovitis, which are inflammation of the tendon and its sheath, respectively.
Based on Landsmeers (1962) model, Armstrong and Chaffin (1979) developed a static model of a
tendon wrapping around a joint. Figure 3.17 depicts Landsmeers model of a tendon, which is analogous
to a rope bent around a nonrotating pulley, and Figure 3.18 illustrates the Armstrong and Chaffin
(1979) model as a reasonable representation of Landsmeers model. When the wrist is flexed, the flexor
tendons bend around the flexor retinaculum that is assumed to have a constant radius. When the wrist
is extended, the flexor tendons are supported on the dorsal side by the carpal bones that are assumed to
have a constant radius. Armstrong and Chaffin (1978) found that the radius in a flexed posture is larger
than in an extended posture.
The arc length of the tendon wrapping around the pulley is defined in Equation (3.1).
(3.1)
where
X = tendon arc length around pulley (mm)
R = radius of curvature of supporting tissues (mm)
G = angle of deviation of wrist from neutral (in radians)
The reaction forces acting normal to the tendon are shown in Figure 3.18 and defined in Equation (3.2).
(3.2)
where
Fn = normal supporting force per unit of arc length (N/mm)
Ft = average tendon force in tension (N)
3-13
FIGURE 3.17 Landsmeers (1962) model of a tendon wrapping around a joint. (From Chao, Y.S., An, K.N., Cooney,
W.P, and Linscheid, R.L. 1982. Biomechanics of the Hand: A Basic Research Study, p. 15, Biomechanics Laboratory,
Department of Orthopaedic Surgery, Mayo Clinic/Mayo Foundation, Rochester, MN. With permission.)
= coefficient of friction between tendon and supporting synovia

G = wrist deviation angle (radians)
R = radius of curvature of supporting tissues (mm)
Since is considered small (approximately 0.0032 [Fung, 1981]), it can be approximated by zero. This
changes Equation (3.2) to Equation (3.3).
Fn = Ft/R
(3.3)
Equation (3) reveals Fn is a function of the tendon force and radius of curvature. As the radius of
curvature decreases, the normal supporting force per unit of arc length increases. The normal supporting
force for women would be greater than for men because women have smaller wrists. Also, as the tendon
force increases, the normal supporting force increases.
The total supporting force Fr in Figure 3.18 is the force of the ligaments, bones, and median nerve in
the carpal tunnel acting on the flexor tendons. Fr is defined in Equation (3.4).
(3.4)
where
Fr = resultant force exerted by adjacent wrist structures on the flexor tendons (N)
Ft = tendon force (N)
G = wrist deviation angle (in radians)
Equation (4) indicates that Fr is a function of the tendon force and wrist deviation angle, but is independent
of radius of curvature. Figure 3.19 illustrates this relationship in that as the tendon force and wrist angle
increase, the resultant force Fr increases linearly.
The significance of Fn and Fr is based on the theory that increased normal forces place greater stress
on the tendon and its surrounding structures. The increase in normal force could cause the tendon and
its sheath or the fibrous sheath moored to bone or ligament to hypertrophy or inflame. If these structures
3-14
FIGURE 3.18 Armstrongs and Chaffins (1979) biomechanical model of a flexor tendon wrapping around the
flexor retinaculum. Ft is the tendon force, and Fr is the resultant reaction force exerted against the tendon. (From
Chaffin, D.B. and Andersson, G.B.J. 1991. Occupational Biomechanics, 2nd edition, p. 243, John Wiley & Sons
Publishers. With permission.)
were to hypertrophy or inflame, then the coefficient of friction ( in Equation (3.2)) would increase,
thereby placing even greater Fn on the tendons.
Dynamic movements that accelerate and decelerate the tendons around a nonrotating pulley could
exacerbate the trauma imposed on the tendons. Schoenmarklin and Marras (1990) developed a dynamic
model of a flexor tendon bent around the carpal bones or flexor retinaculum, taking into account the
acceleration and deceleration of a tendons movements. This model analyzes the effects of peak angular
acceleration on the resultant reaction force that the wrist bones and ligaments exert on tendons and
their sheaths in the flexion/extension plane. Like the Landsmeer (1962) and Armstrong and Chaffin
(1979) models, Schoenmarklin and Marras (1990) model the tendon as a rope bent around a fixed
pulley.
The quantitative effects of the wrists peak angular acceleration on resultant reaction forces were
based on the free body diagram (FBD) and massacceleration diagram (MAD) approach in engineering
dynamics (Meriam and Kraige, 1986). Figure 3.20 illustrates the FBD and MAD approach applied to a
wrist and hand in midposition (neither pronated or supinated). There is no externally applied load in
the hand. The hand is rotated in the horizontal plane around a vertical z axis, so the effects of gravity do
not play a role in this example. All the flexor tendons are grouped together as one tendon force vector
in order to maintain static determinacy. The hand is assumed to accelerate from a stationary posture, so
the angular velocity is theoretically zero, resulting in zero centripetal force.
3-15
FIGURE 3.19 The resultant reaction force (Fr), as modeled by Armstrong and Chaffin (1979), that is exerted against
the flexor tendons as a function of wrist angle and tendon force. (From Chaffin, D.B. and Andersson, G.B.J. 1991.
Occupational Biomechanics, 2nd edition, p. 247, John Wiley & Sons Publishers. With permission.)
The maximum tendon force (Ft-max) was computed as a function of five peak angular accelerations
(? = 3000, 6000, 9000, 12000, and 15000/sec2). Based on empirical data from normal subjects,
15000/sec2 was found to be about 50% of peak wrist acceleration in the flexion/extension plane
(Schoenmarklin and Marras, 1993). The Ft-max isdepicted in Figure 3.21 and is derived from Equation
(3.5) (LeVeau, 1977).
(3.5)
where
Ft-max = maximum force in flexor tendons, which is the force that the extrinsic flexor muscles in the
forearm exert on their tendons (N)
Ft-min = minimum force in flexor tendons, which is the force that the flexor tendons transmit to the
hand and fingers (N)
= coefficient of friction between tendons and their sheaths
G = wrist deviation angle (radians)
Since the coefficient of friction for human synovial joints bones is estimated to be very low (0.0032
according to Fung, 1981), then the calculation of the Ft-max force is very close to Ft-min. The Fr depicted
in Figure 3.21 and expressed in Equation (3.4) was calculated as the resultant force necessary to resist
Ft-max and Ft-min.
3-16
FIGURE 3.20 The free body diagram (FBD) and mass acceleration diagram (MAD) approach used by Schoenmarklin
and Marras (1990) to calculate the peak reaction force (Fr in Figures 3.21 and 3.22) on the wrist when the wrist is
accelerated (in the flexion direction) at an extension angle of ?. (From Schoenmarklin, R.W. and Marras, W.S. 1990.
In Proceedings of the 34th Meeting of the Human Factors Society, p. 807. With permission.)
As shown in Figure 3.22, Fr increases approximately linearly as wrist angle or angular acceleration
increases, resulting in a curved plane that signifies an interactive effect between wrist angle and angular
acceleration. The greatest Fr occurs when the wrist is accelerated at a deviated wrist posture. The large
peak reaction forces exerted on the flexor tendons and their sheaths are due solely to wrist motion
without any externally applied load in the hand. If loads were applied in the hand (e.g., power grip or
pinch grip) while the hand was accelerated in deviated postures, then Fr would increase even more,
resulting in even more stress on flexor tendon tissue. The large peak Fr in Figure 3.22 could possibly
cause the tendon and its sheath or the fibrous sheath moored to bone or ligament to hypertrophy or
inflame, which could result in tendinitis or tenosynovitis. The occurrence of either tendinitis or
tenosynovitis would most likely increase in Equation (3.5), thereby increasing Ft-max and Fr even more
(refer to Figure 3.21 and Equation (3.4)).
The large resultant reaction forces on the tendons from wrist deviation and accelerations could
possibly explain the findings of Armstrong et al. (1984), who investigated the histological changes in the
flexor tendons as they pass through the carpal tunnel. These investigators found hypertrophy and increased
density in the synovial tissue in the carpal tunnel area. These authors suggested that biomechanical
factors, such as repeated exertions with a flexed or extended wrist posture, could have partially caused
degenerative changes in tendon tissue. In addition to reaction forces from supporting structures, the
hypertrophy of the tendon tissue could have been caused by differences in strain within a tendon. In an
investigation of the viscoelastic properties of tendons and their sheaths, Goldstein et al. (1987) found
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FIGURE 3.21 Relationship between the maximum (Ft-max) and minimum (Ft-min) forces of a tendon and the resultant
reaction force (Fr). Ft-max is the force emanating from the forearm flexor muscles, and Ft-min is the force transmitted to
the hand. The flexor tendon is wrapped around the wrists carpal bones. Ft-max and Ft-min are the maximum and
minimum tendon forces in Schoenmarklins and Marrass (1990) dynamic model of a flexor tendon passing through
the wrist joint. The equation for Ft-max and Ft-min is from Leveau (1977). (From Schoenmarklin, R.W. and Marras,
W.S. 1990. In Proceedings of the 34th Meeting of the Human Factors Society, p. 807. With permission.)
that flexion/extension wrist angle increased the shear traction forces between tendons, their sheaths,
and bones and ligaments that form the anatomical pulley. As depicted in Figure 3.23, when the wrist is
extended approximately 10, the strain in the flexor digitorum profundus (FDP) tendons, which pass
through the carpal tunnel and move the fingers, is approximately 10% to 15% lower on the side distal
(hand side) to the flexor retinaculum than the proximal side (forearm side). This difference in strain
within a tendon creates shear traction forces, which are magnified when the wrist angle is deviated to
65 flexion or extension.
3.5 Work-Related CTDs Involving the Muscle-Tendon Unit

The pathogenesis of the most frequently studied CTDs involving the muscle-tendon unit will be discussed
below.
Tendinitis
Although tendinitis is defined as inflammation of the tendon, Moore (1992) contends there is scant
scientific evidence that the collagenous fibers that comprise the tendon actually inflame. According to
Moore (1992), tendinitis is often used as a term that implies soreness localized to a muscle-tendon unit
that increases with tensile load from either muscle contraction or passive stretch. Moore (1992) further
states that these clinical findings of soreness may represent no more than a normal pattern to varying
degrees of use, rather than inflammation. Because clinicians do not have sensitive diagnostic tools to
differentiate between tendinitis and tenosynovitis (inflammation of the tendons sheath), soreness in
joints where the tendons do not have sheaths, such as in the elbow and shoulder, is usually diagnosed as
tendinitis, whereas soreness in joints with sheathed tendons is commonly diagnosed as tenosynovitis.
One theory of the pathogenesis of tendinitis is the physical disruption of a small number of collagen
fibers within a tendon and the ensuing repair process. According to Moore (1992), the body responds to
this disruption in a manner similar to that of a partial tendon laceration, which is the partial cutting or
severing of a tendon. The healing process of the tendon occurs in three stages: inflammatory stage,
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FIGURE 3.22 The resultant reaction force (Fr) exerted by the carpal bones or flexor retinaculum against a flexor
tendon and its sheath as a function of wrist angle and acceleration. (From Schoenmarklin, R.W. and Marras, W.S.
1990. In Proceedings of the 34th Meeting of the Human Factors Society, p. 809. With permission.)
reparative or collagen-production stage, and a remodeling stage (Gelberman et al., 1988). As the body
rebuilds its tendon tissue, the collagen content increases and the tendon could hypertrophy, or increase
in size. In addition, the body may not repair all of the disrupted fibers, resulting in permanent fraying of
the tendon. Due to hypertrophy and fraying, the tendon may be biomechanically different, possibly
deficient, after the bodys attempt to completely restore the disrupted tissues.
Moore (1992) relates the effects of partial tendon laceration to CTDs in that when a joint is deviated
from a neutral position, the tendons could react to resulting reaction forces from the joint structures (Fr
in Equation (3.4) and Figures 3.21 and 3.22) in a manner similar to a partial tendon laceration. As
shown by Armstrong and Chaffins (1979) static model, as the wrist deviates, the resulting reaction
forces from the flexor retinaculum or carpal bones could cause physical disruption to the tendons, much
like the effects of partial tendon laceration. Theoretically, physical disruption of the tendon tissue would
be exacerbated by even greater reaction forces if the wrist were accelerated or decelerated, particularly at
extreme wrist deviation angles (Schoenmarklin and Marras, 1990). If the wrist and fingers were deviated
excessively in repetitive motions, hypertrophy of the tendons from the healing process or permanent
fraying of the tendons could cause soreness at the wrist. Depending on the specific tendon, this soreness
may be diagnosed as tendinitis or tenosynovitis. Soreness in the wrist flexor muscles tendons (flexor
carpi radialis and ulnaris) would probably be diagnosed as tendinitis because these tendons do not have
sheaths, whereas soreness in tendons passing through the carpal tunnel (flexor digitorum superficialis
and profundus) would commonly be diagnosed as tenosynovitis because these tendons are sheathed.
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FIGURE 3.23 The difference in strain within the flexor digitorum profundus tendon between measurements taken
proximal and distal to the flexor retinaculum. Even at an extended wrist angle of 10, there is a 10% to 15%
difference in strain between the FDP tendon proximal and distal to the flexor retinaculum. The difference in strain
is magnified as wrist deviation angle increases. (From Goldstein, S.A., Armstrong, T.J., Chaffin, D.B., and Matthews,
L.S. 1987. Analysis of cumulative strain in tendons and tendon sheaths. J. Biomed, 20, p. 4. With permission.)
Lateral Epicondylitis (Tennis Elbow)

Lateral epicondylitis, which is also called tennis elbow in lay parlance, is tendinitis of the forearm
extensor and supinator muscles at the lateral epicondyle of the elbow. The lateral epicondyle is the small
bony attachment point on the outside of the elbow where the group of forearm extensor and supinator
muscles originate. The extrinsic extensor and supinator muscles fuse into an aponeurosis, or a broad,
flat tendon, which is attached to the lateral epicondyle in the elbow. Soreness and pain occur at the point
where the aponeurosis of the extensor and supinator muscles pull on the lateral epicondyle. The small
size of the lateral epicondyle and the relatively large mass of extensor and supinator muscles create high
stresses on the lateral epicondyle and its attached aponeurosis. Patients who have lateral epicondylitis
report their pain is particularly acute when they extend their wrist or supinate the forearm against
resistance, which occurs when one is hitting a tennis ball with a backhand stroke.
Lateral epicondylitis is a CTD in that it is directly related to the motions that tense the wrists extensor
and supinator muscles (Nirschl, 1983). In a study of 113 patients, Goldie (1964) found that repeated
wrist extensions or alternating pronating and supinating movements of the forearm were causal factors
in 83 of the cases.
Review of the medical literature reveals several hypotheses regarding the pathogenesis of lateral
epicondylitis, although all of them do agree that the basic mechanism is deterioration of the aponeurotic
tendinous tissue at the lateral epicondyle. Cyriax (1936), who treated 20 patients with lateral epicondylitis,
concluded it is caused by a tear between the tendinous origin of the extensor muscles and the periosteum
of the lateral epicondyle. Goldie (1964) suggested that lateral epicondylitis is due to a buildup of lesions
in a space under the tendon and distal to the epicondyle. Microscopically, Nirschl (1985) found that the
affected tendon in lateral epicondylitis had a characteristic appearance of hypertrophy that was grayish,
edematous, and friable. Nirschl (1985) interpreted this medical description as a thick unhappy gray
tendon, weeping with edema. A normal tendon has collagen fibers that run parallel, but the tendons
afflicted with lateral epicondylitis look coarse and granular.
Often, a patient with lateral epicondylitis will wear a brace around the forearm near the elbow
(Froimson, 1971; Moore, 1992), as is often seen on tennis players. Although it has not been validated
experimentally, one of the theories of why the forearm brace is beneficial is based on biomechanics.
Figure 3.24 shows a free body diagram of the elbow as viewed from the head position. The tendons of
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the forearm extensor and supinator muscles are modeled as a single vector. When tightened, the brace
may keep the aponeurosis from vibrating against underlying bony tissue during repeated extending or
supinating exertions. In addition, when the forearm brace is tightened it compresses the aponeurosis
against the underlying structures, thereby creating a frictional force that resists, albeit partially, the pull
of the forearm extensor and supinator muscles. Theoretically, this frictional force would relieve the
lateral epicondyle of carrying the full tensile load of the aponeurosis. However, because the coefficient of
friction among the musculoskeletal tissues underlying the brace is probably very low, the reduction in
tensile load on the lateral epicondyle may be small and negligible or it may be large enough to retard
lateral epicondylitis. Experimental research is needed to determine whether this biomechanical theory
can explain the efficacy of forearm braces.
Supraspinatus Tendinitis (Rotator Cuff Syndrome)

Supraspinatus tendinitis, which is often called rotator cuff syndrome, is tendinitis of the muscle that
elevates the shoulder. Elevation of the shoulder in the frontal plane is called shoulder abduction. Pain is
felt on the acromion process, or bony top of the shoulder, when one abducts the shoulder, particularly
when the arm is holding a load or exerting a pushing force.
The pathogenesis of supraspinatus tendinitis is impingement of the bursa and supraspinatus tendon
as the shoulder is abducted. The superficial and deep muscles of the shoulder are shown in Figure 3.25.
The deltoid muscle, which covers the outside of the shoulder, and the supraspinatus muscle, which is a
smaller muscle under the deltoid and trapezius muscles and acromion, are the major abductors of the
shoulder. As shown in Figures 3.26a and 3.26b, abduction of the shoulder compresses the acromion
downward, thereby pinching the underlying bursa and supraspinatus tendon (Chaffin and Andersson,
1991). As illustrated in Figure 3.12, the bursa is a tubular synovial sheath whose purpose is to lubricate
the contact between the deltoid muscle and acromion and the supraspinatus tendon. However, if the
shoulder is abducted repeatedly, and particularly under heavy loads, the resulting impingement could
damage the bursa and supraspinatus tendon fibrils and produce fraying of the tendon. The relative
avascular nature of the supraspinatus tendon diminishes its capability to repair itself, thereby leading to
degeneration, as shown in Figure 3.26c (Moore, 1992). In addition, intramuscular pressure from muscle
fibers attached to the tendon can also diminish the reparative process of the tendon.
Tenosynovitis
Although tenosynovitis is defined as inflammation of the tendon sheath (Stedman, 1982), any tendon sheath
disorder is called tenosynovitis, regardless of the presence or absence of inflammation (Moore, 1992). As
shown in Figures 3.9 and 3.10, the tendon sheath is a tubular structure that wraps around a tendon and
contains synovial fluid to provide lubrication, protection, and repair assistance for the surrounded tendon
(Moore, 1992). Tenosynovitis is diagnosed only where tendons are sheathed, whereas tendinitis could occur
in a tendon regardless of whether it is sheathed. Usually, soreness in a sheathed tendon area is diagnosed as
tenosynovitis, whereas soreness in a tendon without sheathing is diagnosed as tendinitis.
DeQuervains Tenosynovitis
DeQuervains disease is the stenosing tenosynovitis of the tendons that abduct and extend the thumb
(abductor pollicis longus [APL] and extensor pollicis brevis [EPB]) (Williams and Ward, 1983). This
disease was named after a Swiss surgeon who observed the condition in 1895. The practical importance
of the muscles that flex, extend, and abduct the thumb cannot be overestimated. According to Bunnel
(1956), a hand without a thumb is no more than a hook. The APL and EPB are two of the thumbs
muscles that are necessary for dexterity and fine manipulations.
As shown in Figure 3.27, the tendons of the APL and EPB pass underneath the extensor retinaculum
of the wrist, and then they share the same synovial sheath on their way to the dorsal and lateral side of
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FIGURE 3.24 Free body diagram (FBD) analysis of the forearm extensor and supinator muscles and their tendinous
attachment (aponeurosis) to the lateral epicondyle. The view of the elbow is from the head looking down, with the
forearm in midposition (neither supinated or pronated). a) FBD of the elbow without a forearm brace. The force the
aponeurosis has to exert, Ft1, is equal to the tensile pull of the extensor and supinator muscles, Fm. b) The tightening
of the forearm brace around the forearm creates a frictional force, Ff, that opposes Fm, thereby lessening the force on
the aponeurosis, Ft2. (From Marklin, R.W. original artwork. With permission.)
the thumb (Lamphier, 1965). The APLs and EPBs common sheath, which is about 5 cm long, passes
over a bony depression called the radial styloid.
The APL and EPB tendons and their common sheath are subject to cumulative trauma because of their
position in the bony groove in the radial styloid. DeQuervains disease is caused by the friction of the two
tendons rubbing against each and against the long bony groove (Lamphier et al., 1965). DeQuer-vains
disease is a stenosing tenosynovitis in that the common synovial sheath thickens (refer to Figure 3.27),
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FIGURE 3.25 a) Superficial muscles of the shoulder complex. The deltoid muscle is a major shoulder abductor. b)
Deep muscles of the shoulder complex. The supraspinatus muscle is responsible for initiating abduction of the
shoulder, after which the deltoid provides most of the abduction force. (From Basmajian, J.V. 1982. Primary Anatomy,
8th edition, p. 141, Williams and Wilkins, Inc. With permission.)
FIGURE 3.26 a) Normal shoulder structure with the arm hanging at the side. Bursa separates the deltoid muscle and
acromion from the supraspinatus tendon (rotator cuff tendon). b) When the shoulder is abducted, bursa and
supraspinatus tendon are pinched between the acromion and humerus bone (arm bone). c) With repeated abductions,
both the bursa and tendon could swell and degenerate and the tendon could fray. (From Chaffin, D.B. and Andersson,
G.B.J. 1991. Occupational Biomechanics, 2nd edition, p. 381, John Wiley & Sons Publishers. With permission.)
thereby increasing the friction between the APL and EPB tendons within their common sheath. In his
review of the medical literature, Moore (1992) described the pathogenesis of DeQuervains disease. In
mild cases, the synovial layer within the synovial sheath thickens up to twice the normal thickness. However,
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FIGURE 3.27 Abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons as they proceed under the
extensor retinaculum and through their common synovial sheath. DeQuervains disease is stenosing tenosynovitis of
the APL and EPB in their common sheath. (From Lamphier, T.A., Crooker, C., and Crooker, J.L. 1965. DeQuervains
disease. Industrial Medicine and Surgery, p. 848. With permission.)
FIGURE 3.28 A) Cross-section of a normal fibroosseus canal as it passes over the radial styloid. The tendon (a) and
its synovial sheaths (b) are moored to the radius bone (d) with a fibrous ligamentous sheath (c). B) Cross-section of
a fibroosseus canal with stenosing tenosynovitis. The tendons (a) are flattened, the synovial sheath (b) is thinned,
and the fibrous ligamentous sheath (c) is thickened. (From Finkelstein, H. 1930. Stenosing tendovaginitis at the
radial styloid process. J. Bone Jt Surg, Vol. 12, p. 515. With permission.)
at the point of constriction where the tendons rub against the radial styloid, the synovial sheath of the APL
and EPB tendons thin and the tendons flatten (Finkelstein, 1930), as illustrated in Figure 3.28. The thinning
of the tendon sheath and flattening of the tendons is caused by hypertrophy of the fibrous ligamentous
sheath, namely the extensor retinaculum, that holds the APB and EPB tendons and their common sheath
to the radial styloid bone. In severe cases, the fibrous ligamentous sheath thickens three to four times
(Lamphier et al., 1965), and the tendon could swell, forming a bulbous shape adjacent to the site of
constriction, as illustrated in Figure 3.29. This bulbous swelling could cause popping of the APL and EPB
tendons as the wrist is ulnarly deviated with the thumb flexed inside the palm.
Trigger Finger
Trigger finger is stenosing tenosynovitis of the tendons that flex the fingers and is manifested by painful
locking of the finger during finger flexion. As illustrated in Figure 3.30, the finger flexor tendons and
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FIGURE 3.29 A) Longitudinal section of a normal fibroosseus canal. The tendon (a) is covered by it sheath (b). The
fibrous ligamentous sheath (c) forms a canal through which the tendon can travel unimpeded. B) Longitudinal
section of a fibroosseus canal with stenosing tenosynovitis. The tendon (a) and its synovial sheath (b) are thinned by
a thickened fibrous ligamentous sheath (c), forming a nodule in the tendon (d). (From Finkelstein, H. 1930. Stenosing
tendovaginitis at the radial styloid process. J Bone Jt Surg, Vol. 12, pp. 514 and 515. With permission.)
FIGURE 3.30 A finger flexor tendon as it traverses from the knuckle (left) to the tip (right). Fibrous ligamentous
sheaths comprise the five annular pulleys (A1-A5) and three cruciate pulleys (C1-C3). These pulleys hold the tendons
close to the finger joints to avoid bowstringing during finger flexion. (From Doyle, J.R. 1989. Anatomy of the finger
flexor tendon sheath and pulley system: A current review. J Hand Surg, 14A, p. 350. With permission.)
their synovial sheaths are moored to the bones of the finger with fibrous ligamentous sheaths to avoid
bowstringing during finger flexion. These fibrous ligamentous sheaths are called pulleys, of which there
are two types: annular (A1-A5) and cruciate (C1-C3). Repetitive and forceful flexing of the fingers
could cause trigger finger, whose pathogenesis is related to that of DeQuervains disease. As depicted in
Figure 3.29A, a normal fibroosseus canal allows the tendon to glide with no obstruction. However, in
the case of trigger finger, bulbous swellings, such as those shown in Figure 3.29B, will restrict the finger
flexor tendons from traversing through their fibrous ligamentous sheaths. If large enough, the bulbous
swellings could immobilize the tendon, thereby locking the finger in a fixed flexed position. In order to
unlock the finger, the bulbous swelling has to snap to move beyond the constriction in the fibroosseus
canal. External aid from the other hand may be required to extend the finger back to a straight, neutral
position (Rowe, 1985).
Although trigger finger tends to occur at the creases of the finger (Caillet, 1984), it occurs most
frequently near the knuckle (metacarpophalangeal joint) (Quinnel, 1980). The middle and ring fingers
are the predominant sites of trigger finger in the dominant hand, accounting for over 40% of the cases
in Quinnels (1980) study.
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3.6 Biomechanical Aspects of Nerve Compression Disorders

Nerve compression disorders are a group of disorders in which a peripheral nerve is compressed or
pinched, causing trauma to the immediate area served by the nerve and sometimes distal to the site of
impingement. The effects from the trauma could be temporary or long term. An example of a widely
known nerve disorder is sciatica, which is compression of the sciatic nerve in the lower back but whose
pain is felt throughout the areas of the lower leg served by the sciatic nerve.
Nerve compression disorders of the upper extremity can affect all three major nerves of the upper
extremity, namely the radial, ulnar, and median nerves (refer to Figure 3.13a). The most widely publicized
nerve compression disorder of the upper extremity is carpal tunnel syndrome, which is compression of
the median nerve at the site where it passes through the carpal tunnel in the wrist. Examples of lesser
known nerve compression disorders of the upper extremity are cubital tunnel syndrome and posterior
interosseous nerve syndrome, which are caused by compression of the ulnar and radial nerves, respectively.
The anatomy of a neuron is illustrated in Figure 3.31. Although neurons vary in size and shape, they
generally consist of a cell body (soma), dendrites, and an axon. The axon is the shaft of the nerve
through which electrical impulses travel. When the impulse reaches the axon terminal, it then crosses
over to the dendrites of an adjacent neuron. As shown in Figure 3.31, there are small gaps, called the
nodes of Ranvier, between segments of the axon. These segments are covered with a myelin sheath and
neurilemma (or Schwann cells), which insulate the nerve fibers from adjacent cellular compartments and
allow the electrical impulse to travel from node to node (Van de Graaf and Rhees, 1987). The speed of
an impulse traveling through a neuron is called conduction velocity. A cross-sectional view of the axon
of a neuron reveals three layers of connective tissue that hold the nerve fibers together and protect them.
As illustrated in Figure 3.32, the epineurium is the most external layer, holding together several fasciculi.
Several fasciculi surrounded by epineurium is called a single nerve (Spence, 1986). The perineurium,
which consists of fibrous collagen, surrounds each fasciculus or bundle of nerve fibers. The endoneurium
is the connective tissue within each fasciculus and forms a tube-like membrane around each nerve fiber
(Szabo and Gelberman, 1987).
Although the pathogenesis of nerve entrapment syndromes is controversial, two prominent theories
have been hypothesized (Moore, 1992). These two theories are first, mechanical compression of the
nerve, and second, inadequate blood supply serving the nerve. The first theory, mechanical compression,
is described in detail in Feldman et al. (1983) and Szabo and Gelberman (1987) and is summarized
below. Any physical disturbance to the nerve can cause motor or sensory dysfunction. An impingement
upon the efferent portion of the nervecarrying impulses to the peripheral nervous system from the
brain and spinal cordcan result in loss of muscular strength. Likewise a disturbance to the afferent
portioncarrying impulses to the central nervous system from receptors located throughout the body
can decrease sensory feedback. Myelinated nerves are more susceptible to the effects of pressure than
unmyelinated nerves. Since motor nerves consist predominantly of thick myelinated fibers, the motor
nerves are theoretically more susceptible to the effects of compression than sensory cutaneous nerves
(Feldman et al., 1983). However, based on clinical observations of nerve entrapment syndromes, the
sensory function appears to show decrements before motor function (Szabo and Gelberman, 1987). The
pathogenesis of why sensory decrements are manifested before motor decrements is still unclear.
Compression can cause neural dysfunction in the following manner. First, compression causes bulbous
swellings on the fibers (Aguayo, 1975), which can block conduction of electrical impulses. If compression
continues, the myelin between nodes on the nerve becomes thinner, and the fibers start to segmentally
demyelinate, which can further decrease the conduction velocity of nerve impulses (Feldman et al., 1983).
The second prominent theory posed to explain the pathogenesis of nerve entrapment syndromes is
insufficient blood supply to the nerves (Moore, 1992). Ischemia, or inadequate circulation due to mechanical
obstruction in the nerves path, can cause symptoms typical of nerve entrapment syndromes, such as
paresthesia or acute pain and possibly a reduction in conduction velocity. The mechanical obstruction
could take the form of pinching or entrapment of the nerve as the nerve travels around tendons, ligaments,
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FIGURE 3.31 Structure of a typical motor neuron. (From Spence, A.P. 1986. Basic Human Anatomy, The Benjamin
Cummings Publishing, Inc., p. 348. With permission.)
or bones in a joint. Vascular deficiencies and changes in blood pressure could account for the variation
in symptoms noted in patients with approximately equal levels of nerve conduction delay (Shivde et al.,
1981; Moore, 1992). In one study, vascular sclerosis was observed in 98% of the carpal tunnel cases
(Fuchs et al., 1991).
The nerve fiber distal to the site of compression or physical trauma, whether by compression or
inadequate blood supply, can also be detrimentally affected. Wallerian degeneration is the deterioration
of the myelin sheath distal to the site of trauma and can lead to atrophy and destruction of a neuron.
Wallerian degeneration is caused by impaired flow of electrical impulses down the nerves axon and
ischemia (Feldman et al., 1983). Ogata and Naito (1986) investigated the effects of compression and
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FIGURE 3.32 Cross section of a single peripheral nerve, which is composed of several fasciculi wrapped in epineurium
connective tissue. The perineurium wraps each fasciculus, and the endoneurium encases each single nerve fiber.
(From Spence, A.P. 1986. Basic Human Anatomy, The Benjamin Cummings Publishing, Inc., p. 353. With permission.)
stretching of nerves, and they found that compression and stretching do restrict blood flow to the
nerves, even to the point of arresting blood flow. In addition to Wallerian degeneration, compression of
a nerve can impede nerve conduction and lower conduction velocity distal to the site of trauma, resulting
in decreased motor and sensory function such as muscle atrophy and paresthesia, respectively (Feldman
et al., 1983).
In the upper extremity, peripheral nerves can be compressed at any point along its path, ranging from
the wrist (carpal tunnel syndrome) to the shoulder (thoracic outlet syndrome). These two syndromes are
described and discussed below.
3.7 Work-Related CTDs Involving the Nerve

Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a nerve entrapment disorder arising from compression of the median
nerve at the site where it travels through the carpal tunnel in the wrist. Although CTS was first recognized
by Sir James Paget more than a century ago (1860), the name CTS was not uniformly applied to
compression of the median nerve until the late 1950s (Phalen, 1981). Prior to and through the early
1950s, CTS was referred to with long, clumsy names, such as spontaneous compression of the median
nerve in the carpal tunnel and compression secondary to trauma, tumor, or systemic disease. The
much shorter, more facile name, carpal tunnel syndrome, started to gain acceptance in the late 1950s
to include all conditions that might cause compression of the median nerve, regardless of the source of
compression. In 1957, Phalen and Kendrick stated, The term carpal tunnel syndrome is now used to
describe all cases of compression neuropathy of the median nerve at the wrist (Moore, 1992).
The symptoms of CTS involve the motor, sensory, and autonomic functions of the median nerve
(Armstrong, 1983):
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1. Motor nerve impairment: reduced motor control and atrophy of the abductor pollicis brevis, a
major thumb abductor located at the base of the thumb, and weakness in precision grip (Feldman
et al., 1983). A patient with severe and long-standing CTS may show a severely diminished
musculature at the thenar eminence, which is the protruding area at the base of the thumb.
2. Sensory nerve impairment: paresthesia (burning, prickling, and tingling) and hypesthesia
(diminished sensitivity to stimulation) in the thumb and fore, middle, and one half of the ring
fingers and in the thenar eminence on the palmar side; paresthesia and hypesthesia on the distal
phalanges of the thumb and same fingers on the dorsal side of the hand (refer to Figure 3.14).
3. Autonomic nerve impairment: diminished sweat function, resulting in dry and shiny skin in areas
noted in sensory nerve impairment.
Of all the tissues that pass through the carpal tunnel at the wrist, the median nerve is the softest and
most vulnerable to pressure. As illustrated in Figure 3.8, the median nerve along with nine forearm
flexor tendons pass through the carpal tunnel, which is formed by the carpal bones on the dorsal side of
the hand and the flexor retinaculum on the palmar side. In 1963, Robbins conducted a systematic study,
considered by some to be the most thorough, of the anatomy of the carpal tunnel (Moore, 1992). He
analyzed cross sections of cadaveric wrists dissected at distances 2 to 4 cm proximal and distal to the
wrist crease. Among Robbinss (1963) major findings were:
1. The cross-sectional area of the carpal tunnel decreases from its proximal entrance to a point 2 cm
distal from its origin. He said the effect is to have a canal with a slightly narrowed waist.
2. All the structures are crowded in the canal, and in 6 of the 7 specimens, the median nerve was
flattened and directly beneath the flexor retinaculum.
3. When the wrist was in a neutral position in the cadaveric specimens, Robbins (1963) inserted
and withdrew a piece of rubber easily underneath the flexor retinaculum. However, when the
wrist was flexed or extended, the resistance increased concomitantly with the angle of deviation.
Considerable force was required to withdraw the rubber proximally in either of the extreme
flexed or extended positions. Robbins (1963) concluded the volume of the carpal tunnel decreases
as the wrist is deviated in either flexion or extension.
Patients with CTS show a significant elevation of pressure in the carpal tunnel. At a neutral posture,
Gelberman et al. (1981) found that the mean pressure in the carpal tunnel of patients with CTS was 32
mmHg, compared to 2.5 mmHg for control subjects. These researchers also showed that 90 of wrist
flexion and extension increased the pressure precipitously to approximately 100 mmHg and 32 mmHg
for the CTS patients and healthy subjects, respectively.
Although the pathophysiology of CTS is unknown, researchers have postulated thickening of the
flexor tendon sheaths in CTS patients as contributing to the increase in pressure in the carpal tunnel. In
a study of 212 wrists surgically treated for CTS, Phalen (1966) observed thickening or fibrosis of the
flexor synovium in 203 of the cases. Biopsy specimens of the flexor synovium from 181 of the 212
wrists revealed chronic fibrosis or thickening in 91 specimens, chronic inflammation compatible with
symptoms of rheumatoid arthritis in 64, and no pathologic change in 26. Yamaguchi et al. (1965)
observed microscopically an aging effect on the flexor tendon sheaths, manifested by fibrous thickening
of the sheaths. They compared the sheath anatomy of CTS patients vs. healthy controls, and they found
that almost 90% of the patients exhibited a greater increase in thickening and fibrosis of the sheaths
than the healthy control subjects. Kerr et al. (1992) observed hypertrophy of the synovium of the flexor
tendons, with little or no evidence of inflammation, in patients with CTS. Schuind et al. (1990) observed
fibrous hypertrophy and necrotic lesions in flexor synovium typical of a connective tissue undergoing
degeneration under repeated mechanical stresses. The experimental findings of Armstrong et al. (1984)
support Schuinds (1990) association between degeneration of tendon tissue and mechanical stress.
Synovial hypertrophy and the mean densities of subsynovium and adjacent connective tissue were
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significantly greater at the wrist crease as compared to locations proximal and distal to the crease.
Armstrong et al. (1984) concluded that repeated exertions with a flexed or extended wrist are an important
factor in the etiology of the degeneration and hypertrophy of tissue surrounding the tendon.
Occupational Sources of Median Nerve Compression in CTS

The three main occupational risk factors of CTS (wrist repetition, deviated wrist angle, and tendon
force), along with the basic anatomical structure of the wrist, can increase the pressure in the carpal
tunnel, compress the median nerve, and result in the following:
1. Increase in carpal tunnel pressure at deviated wrist angles due to reduction in tunnel volume.
According to Robbins (1963), extreme flexion and extension of the wrist reduced the volume of
the carpal tunnel, thereby augmenting the pressure on the median nerve. This increase in tunnel
pressure would, theoretically, affect the median nerve first because it is the softest and most
vulnerable tissue in the carpal tunnel.
2. General increase in tunnel pressure from wrist deviation. Deviation of the wrist in the flexion/
extension plane has been shown repeatedly in the anatomical and physiological literature to
increase the pressure in the carpal canal (Phalen, 1966; Smith et al., 1977). In a flexed or extended
wrist posture, the median nerve is squeezed between the flexor retinaculum and the overlying
flexor tendons, thereby exposing a worker to CTS. Recently, Rempel et al. (1994) measured the
carpal tunnel pressure of subjects typing on a computer keyboard elevated at various slopes to
extend the wrist at five different angles. As shown in Figure 3.33, these researchers found that the
pressure in the carpal tunnel was lowest at a neutral position compared to postures up to 50
extension and 20 flexion. The approximately 100 mmHg maximum pressures Rempel et al.
(1994) measured were in the same range as in Gelbermans et al. (1981) study. In addition to the
flexion/extension plane, carpal tunnel pressure has been shown to increase as the wrist radially
and ulnarly deviates from a neutral posture. Sommerich (1994) measured the carpal tunnel
pressures of four subjects typing on a standard QWERTY computer keyboard and an alternative
keyboard split and angled to reduce ulnar deviation. She found that all subjects showed a decrease
in carpal tunnel pressure with a concomitant decrease in ulnar deviation. The maximum carpal
tunnel pressures of 80 mmHg measured in Sommerichs (1994) study were similar to those
measured in the studies of Gelberman et al. (1981) and Rempel et al. (1994).
3. Thickening and fibrosis of synovium and hypertrophy of synovial sheaths. The well-documented
reporting of thickening of the flexor sheaths and synovium in the carpal tunnel (Phalen, 1966;
Yamaguchi et al., 1965; Armstrong et al., 1984; Schuind et al., 1990; and Kerr et al., 1992) could
possibly be explained by the biomechanical models of Armstrong and Chaffin (1979) and
Schoenmarklin and Marras (1990). The resultant reaction force on the flexor tendons and the
median nerve passing through the carpal tunnel increases concomitantly, not only with deviation
angle (Fr in Figures 3.18 and 3.19 from Armstrong and Chaffin [1979]), but also with acceleration
of the wrist (Fr in Figures 3.21 and 3.22 from Schoenmarklin and Marras [1990]). Wrist deviation
and acceleration are the static and dynamic components of repetitive movements of the wrist,
which have been associated with CTS.
In order to accelerate the wrist, the extrinsic muscles in the forearm have to exert force which is transmitted
to the tendons. As modeled by Schoenmarklin and Marras (1990), some of the force transmitted through
the tendon is lost to friction against the ligaments and bones that form the carpal tunnel (refer to Figure
3.21). This frictional force could irritate the tendons and their sheaths and possibly cause the synovitis
and hypertrophy found experimentally in the carpal tunnel. Armstrong et al. (1984) found sizeable
increases in synovium and synovial density in the carpal tunnel area, which they attributed to repeated
flexion/extension exertions. From a modeling point of view, Tanaka and McGlothlin (1989) hypothesized
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FIGURE 3.33 Carpal tunnel pressure in one subjects wrist while typing on a computer keyboard set at different
wrist extension angles. (From Rempel, D. and Horie, S. 1994. Effect of wrist posture during typing on carpal tunnel
pressure. In Proceedings of Working With Display Units: Fourth International Scientific Conference, Milan, Italy, p.
C27. With permission.)
that the friction between tendons and adjacent structures is a major cause of CTDs and CTS, and Moore
and Wells (1989) and Moore et al. (1991) showed that the frictional work generated in the carpal tunnel
supported Silversteins et al. (1986, 1987) dose-response relationship between repetition and CTD risk.
In theory, the deleterious effects of frictional work generated between the tendons and their sheaths
or supporting structures is exacerbated by coactivation of the forearm extensor muscles during movements
of the wrist and hand. In order for the hand to maintain the same flexor torque or power/pinch force,
the flexor muscles have to exert more force to overcome the extensor force. Greater forces in the flexor
muscles will generate, in theory, increased frictional work between the flexor tendons and their adjacent
structures, thereby exposing workers to an increased risk of CTS.
Coactivation of antagonist muscles during static and dynamic contractions of the agonist muscles
have been found experimentally and modeled (Schoenmarklin and Marras, 1992; Marras and Sommerich,
1991a,b; Marras, 1992). With regard to hand grip exertions, Grant et al. (1992) measured the
electromyographic (EMG) signal of the forearm flexor and extensor musculature while subjects gripped
various diameters of handle, and these researchers found contractions of the extensor muscles (which
act as antagonists in this case) up to 30 % maximum valuntary contraction (MVC). Coactivation of the
extensors stabilizes the wrist during flexion movements (and vice versa, coactivation of the flexors
stabilizes the wrist during extension movements), and coactivation of the extensors also helps guide and
stabilize the hand while it exerts a power or pinch force.
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FIGURE 3.34 Abduction of the shoulder causes the neurovascular bundle, containing the brachial plexus nerve and
subclavian artery, to be stretched under the pectoral muscles. Hypertrophy of the pectoral muscles would impinge
the neurovascular bundle, thereby causing deficiencies in the neural and circulatory systems of the upper extremity.
(From Putz-Anderson, V. 1988. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper
Limbs, p. 20, Taylor & Francis. With permission.)
Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a neurovascular disorder that affects the bundle carrying nerves,
arteries, and veins from the neck through the shoulder and into the arm, as illustrated in Figure 3.34.
This neurovascular bundle, which contains the brachial plexus nerve and the subclavian artery and vein,
could be compressed by adjacent muscles in the shoulder region, such as the scalene, subclavius, or
pectoralis minor, or the bones forming the thoracic outlet in the shoulder. The motions and tasks that
are associated with TOS are repetitive shoulder abduction and adduction, carrying heavy loads on the
shoulder, and working overhead (Feldman et al., 1983).
The pathogenesis of TOS is hypertrophy of the subclavius or pectoral muscles, which can pinch the
neurovascular bundle and produce symptoms in the neural and circulatory system throughout the arm.
Compression of the brachial plexus, which branches out into the median and ulnar nerves, can cause
numbness or paresthesia in the lower parts of arm and hand served by the median and ulnar nerves. An
impinged subclavian artery, which is the major artery supplying the upper extremity (refer to Figure
3.35), will result in ischemia, a reduction of blood flow to shoulder and arm (Basmajian, 1982). This
diminished blood flow will reduce the amount of oxygen and nutrients available for dynamic arm
movements and exacerbate the fatiguing effect from static (anaerobic) contractions by reducing the
amount of blood needed to carry away lactate and metabolites.
3.8 Summary
In this chapter, major CTDs that affect the soft tissues of the body and have been associated with workrelated activity are categorized into three groups: CTDs affecting muscle, the muscle-tendon unit, and
nerve. The anatomy of the upper extremitys musculoskeletal system was described, followed by a
discussion of biomechanical mechanism(s) that theoretically explain, in part, the epidemiological
associations between respective categories of CTD and work-related activity. In addition, each CTDs is
described in detail along with its pathogenesis.
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FIGURE 3.35 The subclavian artery, which branches off into several arteries, is the major artery that serves the
upper extremity. Compression of the subclavian artery can cause ischemia and paresthesia in the arm and hand.
(From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p. 274, Williams and Wilkins, Inc. With permission.)
Defining Terms
Abduct (abduction): Literally means to to lead away from. In anatomical parlance, abduction is
moving a joint away from the center of the body. Shoulder abduction is elevating the arm in the
frontal plane.
Acromion process: The bony top of the shoulder. The acromion is actually the highest part of the
scapula bone, which spans the back of the shoulder.
Adduct (adduction): Literally means to lead towards. Adduction of a joint is moving the joint toward
the center of the body. Shoulder adduction is moving the shoulder towards the side of the torso.
Afferent nerves: Nerves that travel from the peripheral nervous system to the central nervous system,
namely the brain and spinal cord.
Agonist muscle: Muscle that initiates and carries out motion (Chaffin and Andersson, 1991).
Antagonist muscle: Muscle that opposes the action of the agonist muscle (Chaffin and Andersson,
1991).
Aponeurosis: A broad, flat tendon. An aponeurosis usually occurs at the point where the tendons from
several muscles fuse and connect to a bone.
Atrophy: A wasting of tissues or organs. A severe case of carpal tunnel syndrome will show atrophy of
the muscles in the thenar eminence.
Autonomic: Relating to the autonomic nervous system, which is part of the efferent division of the
peripheral nervous system. The autonomic nervous system is the involuntary system functioning
below the conscious level, that controls the heart, organs, and glands of the body (Spence, 1982).
Patients with carpal tunnel syndrome may display dry and shiny palms, resulting from insufficient
activity of the sweat glands in the hand, which are controlled by the autonomic nervous system.
Avascular: Nonvascular; without blood vessels (Stedman, 1982).
Axon: The shaft of a neuron that transmits electrical impulses (Spencer, 1986).
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Bursa: A structure resembling a collapsed bag with cellophane-thin walls whose inner surfaces are
extremely smooth, moist, and slippery. A bursa usually forms where a tendon rubs back and forth
on a hard structure. For example, rotator cuff syndrome is the deterioration of the bursa that lubricates
the shoulder bone from a tendon whose muscle raises the shoulder (Basmajian, 1982).
Carpal tunnel: The tunnel formed by eight small bones of the wrist and the transverse carpal ligament
(flexor retinaculum). The tendons that connect the forearm flexor muscles to the fingers pass through
the carpal tunnel.
Carpal tunnel syndrome: Compression of the median nerve as it passes through the carpal tunnel.
Central nervous system (CNS): The nervous system consisting of the brain and spinal cord. The CNS is
the integrative and control center of the body. The CNS receives sensory input from the peripheral
nervous system (PNS) and develops response strategies to the input (Spence, 1986).
Conduction velocity: The velocity at which an electrical impulse travels through a nerve. Conduction
velocity, which for a motor nerve is normally 50 to 60 m/s (Johnson, 1989). When the impulse
reaches muscle fiber, its conduction velocity slows down to about 3 to 6 m/s (Basmajian and DeLuca,
1985).
Cumulative trauma disorders (CTDs): Any of a class of pathologies affecting soft tissues (muscles,
tendons, and nerves) created from excessively frequent use of a particular joint or tissue, especially
in combination with awkward positioning, inadequate or no rest periods, or excessive loads. Also
called repetitive strain injury (RSI), repetitive stress injury, repetitive motion injury, and overuse
syndrome (Stramler, 1993).
Dendrites: Thin extensions emanating from the cell body of a neuron that receive electrical impulses
from adjoining neurons (Spence, 1986).
DeQuervains tenosynovitis: A narrowing of the passage (stenosing tenosynovitis) of the tendons and
their sheaths that extend the thumb in the palmar plane.
Disease: Illness, sickness, or cessation of bodily functions, systems, or organs. A disease is characterized
usually by at least two of the following criteria: a recognized causal agent(s), an identifiable group of
signs and symptoms, or consistent anatomical alterations (Stedman, 1982). Compare to Syndrome
and Disorder.
Distal: Located away from the center of the body or point of origin. For example, the wrist is distal to
the elbow, and the elbow is distal to the shoulder (Stedman, 1982).
Disorder: A disturbance of the functions, structure, or both resulting from a failure in development or
from external factors such as physical contact, injury, or disease (Stedman, 1982). Compare to
Disease and Syndrome.
Dorsal: Pertaining to the back of an anatomical structure, as in the dorsal (back) side of the hand.
Edema: An accumulation of an excessive amount of watery fluid in cells, tissues, or cavities (Stedman,
1982).
Efferent nerves: Nerves that travel from the brain and spinal cord in the central nervous system to the
outlying areas in the peripheral nervous system.
Endoneurium: Thin connective-tissue sheath that wraps each individual nerve fiber (Spence, 1986).
Epicondyle: A projection from a long bone above an articulating joint.
Epineurium: Connective-tissue sheath that surrounds several fasciculi in a nerve. Several fasciculi
surrounded by epineurium constitute a single nerve (Spence, 1986).
Etiology: The science and study of the causes of disease and their mode of operation (Stedman, 1982).
Compare to Pathogenesis.
Extend (extension): Movement of a body part that increases the angle of its adjacent joint. For example,
moving your hand away from your shoulder requires elbow extension.
Extensor retinaculum: A strong fibrous ligament that stretches across the back of the hand at the wrist.
The extensor retinaculum holds the forearm extensor tendons close to the carpal bones of the wrist.
Extrinsic muscles: Flexor and extensor muscles in the forearm that generate much of the movement and
force production of the hand and fingers. The extrinsic muscles can also be recruited for hand
movements and forces requiring fine motor control.
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Fasciculus (fasciculi): A bundle of nerve fibers surrounded by connective tissue (perineurium) (Spence,
1986).
Fibroosseus canal: A canal formed by a fibrous ligamentous sheath and an underlying bone. DeQuervains disease and trigger finger are thickening of the fibrous ligamentous sheath, resulting in a
thinning of the tendon and its synovial sheath that pass through the canal.
Flex (flexion): Movement of a body part that decreases the angle of its adjacent joint. For example,
moving your hand toward your shoulder requires elbow flexion.
Flexor retinaculum: The transverse carpal ligament that stretches across the palmar side of the wrist.
The flexor retinaculum, which forms the top of the carpal tunnel, holds the flexor tendons and their
sheaths inside the wrist.
Frictional force: A force that impedes impending motion.
Frontal plane: The plane of the body that travels through the chest and arms. The frontal plane shows
the front of the body. Also called coronal plane.
Humerus: The arm bone connecting the shoulder to the elbow.
Hypertrophy: General increase in the bulk of a part or organ that is not due to tumor formation (Stedman,
1982). Compare to Inflame.
Hypesthesia (hypoesthesia): An abnormal sensation characterized by diminished sensitivity to stimulation
(Stedman, 1982).
Hysteresis: The difference in the stress-strain response of a material to an increasing load or decreasing
load. With tendons, the stress required to maintain a certain amount of strain is less when the force
is decreasing than when increasing.
Innervate: To supply nerve function to a specific muscle group.
Insert (insertion): The distal attachment point of a muscle to bone, via a tendon.
Inflame: Pathologic process consisting of a histologic reaction to affected blood vessels and adjacent
tissues in response to an injury or abnormal stimulation caused by a physical, chemical, or biologic
agent (Stedman, 1982). Compare to Hypertrophy.
Intrinsic muscles: The small muscles located within the hand that move the thumb and fingers. The
intrinsic muscles, which are much smaller than the extrinsic muscles in the forearm, are used primarily
for motions and forces requiring dexterity and fine motor control.
Ischemia: Inadequate circulation of the blood due to mechanical obstruction, mainly arterial narrowing
(Stedman, 1982).
Lateral epicondyle: A bony protrusion located on the lateral side of the elbow. Viewed from the side, the
lateral epicondyle is located close to the pivot point of the elbow as it flexes and extends.
Lateral epicondylitis (tennis elbow): Tendinitis of the forearm extensor and supinator muscles at the
lateral epicondyle of the elbow. Lateral epicondylitis is colloquially dubbed tennis elbow because
patients with lateral epicondylitis report pain when the wrist is extended and supinateda movement
similar to that of a back stroke in tennis.
Ligament: Connective tissue resembling a tendon except a ligament attaches bone to bone (Basmajian,
1982).
Median nerve: The great flexor nerve of the upper extremity. It supplies motor function to the forearm
flexor muscles and the thumbs (thenar) muscles and sensory function to the palm and the digits
from the thumb to the center of the ring finger (Basmajian, 1982).
Morbidity: A diseased state (Stedman, 1982).
Muscle: A contractile organ of the body that moves various body parts and internal organs. A muscle
can only pull (tensile force) and not push (compression force). The origin of a muscle is the end that
is more fixed and the insertion of a muscle is the end that is more movable. For example, the flexor
muscles of the forearm originate at the elbow and insert at the wrist and fingers (Stedman, 1982).
Myalgia: Muscular pain.
Myelin sheath: A sheath that surrounds the axon of a neuron. The purpose of the myelin sheath is to
insulate the neuron from adjacent cellular fluids so an electrical impulse can travel down the axon
jumping from one node of Ranvier to the next.
3-35
Myofascial syndrome: Term referring to regional muscle pain syndromes (Kuorinka and Forcier, 1995).
Myopathy: Term for measurable pathological changes in a muscle with or without symptoms (Kuorinka
and Forcier, 1995).
Nerve: A collection of nerve fibers in the peripheral nervous system (Spence, 1986).
Nerve fiber: Any long process of a neuron. The term usually refers to axons, but also includes the
peripheral processes of sensory neurons (Spence, 1986).
Neurilemma: The thin membrane between the myelin and connective tissue (endoneurium) in a neuron.
Neurilemma is also called the sheath of Schwann (Spence, 1986).
Neuron: A nerve cell (Spence, 1986).
Neurovascular: Pertaining to the nervous and circulatory systems of the body.
Nociceptor: A peripheral nerve organ or mechanism that senses pain or injurious stimuli and transmits
them (Stedman, 1982).
Nodes of Ranvier: Gaps in the myelin sheath and neurilemma of a neurons axon. Electrical impulses
known as potentials travel down the axon from one node to the next, which is called saltatory
conduction. (The etymology of saltatory is from the Latin word saltare, meaning to dance.)
Origin (originate): The proximal attachment point of a muscle to bone, via a tendon.
Paresthesia: An abnormal sensation, such as of burning, prickling, tickling, or tingling (Stedman, 1982).
Pathogenesis: The mode of origin or development of any disease or morbid process (Stedman, 1982).
Compare to Etiology.
Periosteum: Thick fibrous membrane covering the surface of a bone (Stedman, 1982).
Peripheral nervous system: All nervous structures located outside the central nervous system (CNS),
which consists of the brain and spinal cord. The PNS consists of nerves that connect the outlying
parts of the body and their receptors with the brain and spinal cord (Spence, 1986).
Phalanx (phalanges): One of the long bones of the fingers (Stedman, 1982). A finger has three phalanges:
distal (tip), middle, and proximal (connected to the knuckle).
Proximal: Located toward the center of the body or point of origin. For example, elbow is proximal to
the wrist, and the shoulder is proximal to the elbow (Stedman, 1982).
Radial deviation: Rotation of the wrist joint toward the radius bone or thumb side. Sometimes radial
deviation is referred to as abduction of the wrist joint.
Sclerosis: The process of becoming hard or firm. In the case of arteriosclerosis, the walls of the arteries
harden and become less elastic. The blood vessels are unable to expand and recoil in response to
pressure changes, thereby elevating ones maximum blood pressure (Spence, 1986).
Shoulder-neck myofascial syndrome: See Tension neck syndrome.
Stenosing tenosynovitis: A narrowing of the canal through which a tendon and its sheath pass.
Striated muscle: Muscle that appears striped with dark and light bands under a microscope. Also called
skeletal muscle, which are the muscles that move the limbs, head, neck, and torso.
Supraspinatus tendinitis (rotator cuff syndrome): Tendinitis of the supraspinatus muscle, which abducts
the shoulder from the side of the trunk. Supraspinatus tendinitis is often called rotator cuff
syndrome.
Syndrome: The collection of signs and symptoms associated with any disease process and constituting
the picture of the disease (Stedman, 1982). Compare to Disease and Disorder.
Synovial fluid: A clear fluid whose purpose is to lubricate a tendon within a sheath or a joint (Stedman,
1982).
Synovial sheath: An elongated and double-walled tubular structure (bursa) that surrounds a tendon and
allows the tendon to travel with little friction. Synovial sheaths are located where tendons move
around joints, such as in the wrist (Basmajian, 1982).
Tendon: Connective tissue resembling a tough cord or band and always part of a muscle, usually forming
an attachment of muscle to bone (Basmajian, 1982).
Tendinitis (also spelled tendonitis): Inflammation of a tendon (Stedman, 1982).
Tenosynovitis: Inflammation of a tendons sheath (Stedman, 1982). Clinically, any tendon sheath disorder
is called tenosynovitis, regardless of the presence or absence of inflammation (Moore, 1992).
3-36
Tension neck syndrome (TNS): Myalgia in the shoulder-neck region of the body. TNS is synonymous
with shoulder-neck myofascial syndrome, and TNS is defined by symptoms of pain in the shoulderneck region with simultaneous findings of tenderness over the shoulder-neck muscles (Kuorinka and
Forcier, 1995).
Thenar eminence: The area at the base of the thumb that is raised above the general level of the palm.
The thenar eminence contains the intrinsic musculature that controls the thumb.
Thoracic outlet syndrome: A neurovascular disorder that affects the brachial plexus nerve and the
subclavian artery and vein as they traverse through the thoracic outlet in the shoulder. The early
symptoms of thoracic outlet syndrome are found in the areas in the forearm and hand served by the
median and ulnar nerves.
Trigger finger: Painful locking of a finger caused by narrowing of the canal through which a finger
flexor tendon and its sheath pass.
Ulnar deviation: Rotation of the wrist joint toward the ulna bone or little finger side. Sometimes ulnar
deviation is referred to as adduction of the wrist joint.
Wallerian degeneration: Degeneration of the myelin sheath of a neurons axon caused by compression of
the nerve and ischemia. Wallerian degeneration leads to the atrophy and destruction of the neuron
(Stedman, 1982).
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Schoenmarklin, R.W. and Marras, W.S. An EMG-assisted biomechanical model of the wrist joint.
Advances in Industrial Ergonomics and Safety IV, edited by Kumar, S., 777781, Taylor & Francis
Publishers, 1992.
Schivde, A.J., Dreizen I., and Fisher, M.A. The carpal tunnel syndrome: A clinical-electrodiagnostic
analysis. Electromyogr Clin Neurophysiol, 21, 143153, 1981.
Schuind, P.F., Garcia-Elias, M., Cooney, W.P., and An, K.N. Flexor tendon forces: In vivo measurements.
Journal of Hand Surgery, 17A(2), 291298, 1992.
Silverstein, B.A., Fine, L.J., and Armstrong, T.J. Hand wrist cumulative trauma disorders in industry.
British Journal of Industrial Medicine, 43, 779784, 1986.
Silverstein, B.A., Fine, L.J., and Armstrong, T.J. Occupational factors and carpal tunnel syndrome.
American Journal of Industrial Medicine, 11, 343358, 1987.
Smith, E.M., Sonstegard, D.A., and Anderson, W.H. Contribution of flexor tendons to the carpal tunnel
syndrome. Archives of Physical Medicine and Medical Rehabilitation, 58, 379385, 1977.
Sommerich, C.M. Carpal tunnel pressure during typing: Effects of wrist posture and typing speed, in
Proceedings of the Human Factors and Ergonomics Society 38th Annual Meeting, 611615, 1994.
Spence, A.P. Basic Human Anatomy, Second Edition, The Benjamin/Cummings Publishing Co., 1986.
Stedman, T.L. Stedmans Medical Dictionary, 24th edition, Williams and Wilkins, 1982.
Stramler, J.H. The Dictionary for Human Factors and Ergonomics, CRC Press, 1993.
Szabo, R.M. and Gelberman, R.H. The pathophysiology of nerve entrapment syndromes. The Journal
of Hand Surgery, 12A(5), 880884, 1987.
Tanaka, S. and McGlothlin, J.D. A conceptual model to assess musculoskeletal stress of manual work for
establishment of quantitative guidelines to prevent hand and wrist cumulative trauma disorders (CTDs),
in Advances in Industrial Ergonomics and Safety I, Mital, A., editor, 419426, Taylor & Francis, 1989.
Van de Graaff, K.M. and Rhees, R.W. Human Anatomy and Physiology, Schaums Outline Series in
Biology, McGraw-Hill Book Co., 1987.
Williams, H.J. and Ward, J.R. Musculoskeletal occupational syndromes. Chapter 29 in Environmental
and Occupational Medicine, Little, Brown, & Co., 1983.
Yamaguchi, D.M., Lipscomb, P.R., and Soule, E.H. Carpal tunnel syndrome. Minn Med, 2223, Jan. 1965.
For Further Information

Although replete with medical terminology, an excellent reference for the biomechanical pathogenesis of
cumulative trauma disorders of the upper extremity are chapters on the muscle-tendon unit and
carpal tunnel syndrome in J.S.Moores and A.Gargs State of the Art Reviews: Ergonomics: LowBack Pain, Carpal Tunnel Syndrome, and Upper Extremity Disorders in the Workplace.
A good discussion of biomechanical models of the wrist is presented in Section 6.5.2 of Occupational
Biomechanics, 2nd Edition by Don B.Chaffin and Gunnar B.J.Andersson. This book also has a
chapter on handtool design (Chapter 5).
Basmajians Primary Anatomy, 8th edition provides easy-to-read and well-illustrated depictions of the
bodys soft tissues (muscles, nerves, and tendons) and their structures and functions.
The Clinical Mechanics of the Hand by Paul W.Brand is particularly helpful in describing the function of
specific muscles and tendons in the hand and forearm and how these interact to configure the hand
in common pinch and grip postures.
The Work-Related Musculoskeletal Disorders (WMSDs): A Reference Book for Prevention (edited by
Kuorinka and Forcier) is an excellent book that describes specific WMSDs and provides evidence
for the association between work-related activity and each respective WMSD.
4
Occupational Risk
Factors for Shoulder
Disorders
4.1 Introduction
4.2 Structure and Function of the Shoulder
4-1
4-2
Bony Structures Muscles and Tendons Nerves and Vessels

Around the Shoulder Movements of the
Shoulder Loading of Shoulder Muscles in Different
Activities Mechanisms of Injury in the Shoulder
4.3
Eira Viikari-Juntura
Finnish Institute of Occupational
Health
Occupational Risk Factors

Heavy Physical Work Manual Handling Elevated Postures
of the Arm Nonneutral Trunk Postures Static
Work Repetitive Work Work-Rest Schedule: Lack of
Pauses Vibration Draft Work Organizational
Factors Summary of Occupational Risk Factors
4-4
4.1 Introduction
This chapter deals with occupational risk factors of shoulder disorders. The shoulder is structurally and
functionally intimately linked with the neck, and often neck-shoulder disorders have been dealt with as
one group of disorders. In this chapter, the main emphasis is on the disorders of shoulder structures,
although some overlap to the neck area cannot be avoided.
The shoulder is a complex system of bones, muscles, tendons, and ligaments that attach the upper
extremity to the torso. The glenohumeral joint is the joint with the largest range of motion in the human
body, allowing large mobility for the upper extremity and enabling the body to reach far in all directions.
The primary function of the shoulder is to direct and support the hand in its activities.
Because of its supporting function, high forces are imposed on the shoulder, especially if the
hand is holding a heavy object. Due to the long moment arm of the extended upper arm, fairly light
objects, weighing about 1 kg, impose high mechanical stress on the shoulder. To be able to withstand
such forces great stability is demanded of the structures of the shoulder. On the other hand, the long
moment arm of the upper arm and the large mobility and relatively poor protection of the shoulder
joint render various tissues liable to injuries associated with falls and other sudden movements.
Such injuries may heal only partially and decrease the strength and stability of the structures
permanently.
Physical load factors occurring at work associated with various shoulder disorders include manually
strenuous activities, postural factors of the arm and torso, static work, repetitive work, lack of rest pauses,
vibration from handheld tools, environmental factors, and work organizational factors. Only a small
amount of data exist on which to base any reference values for acceptable load intensities, frequencies, and
durations of such factors. Because of the great liability of the shoulder to acute injuries, nonoccupational
0-8493-1800-9/03/$0.00+$1.50
4-1
4-2
FIGURE 4.1 Bony structures in the shoulder, front view.
activities, especially hand-intensive sports, should be considered when investigating the etiology of shoulder
pain in individual workers.
Due to the complexity of the shoulder, it has long been difficult to estimate the stresses to the different
parts in the shoulder complex when exposed to various physical load factors. Recent advances in
biomechanical modeling have markedly increased our knowledge of the stresses on the different structures
of the shoulder and also of the capacity of shoulder structures.
4.2 Structure and Function of the Shoulder

Bony Structures
The most important bones in the shoulder are the shoulder blade (scapula), the humerus, and the clavicle
(Figure 4.1). The humerus is attached to the scapula by the glenohumeral joint at the lateral aspect. It is
in this joint that the primary motion occurs during movements of the arm. The clavicle is attached to the
acromion in the upper lateral aspect of the shoulder, and the other end attaches to the sternum. The
scapula covers part of the dorsal aspect of the rib cage.
Muscles and Tendons

The prime movers of the shoulder are the deltoid and four so-called rotator cuff muscles. The deltoid
has its origin at the lateral part of the clavicle, the acromion process of the scapula, and the back of the
scapula and inserts at the lateral aspect of the humerus. The rotator cuff muscles have their origin in the
scapula and insert at the head of the humerus. Before the insertion, their tendons merge around the head
of the humerus, thereby forming the rotator cuff (Figure 4.2). The trapezius is a flat muscle on the
surface that has its origin at the occiput, neck, and thoracic vertebrae and inserts at the clavicle, acromion
process of the scapula and spine of the scapula.
Occupational Risk Factors for Shoulder Disorders
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FIGURE 4.2 Insertion of rotator cuff tendons at the head of humerus, front view.
Nerves and Vessels Around the Shoulder

In addition to the nerves and vessels that supply the shoulder muscles and bones, all vessels and nerves
supplying the arm and hand pass by the shoulder, forming a neurovascular bundle at the so-called
thoracic outlet area. Due to postural factors, structural anomalies, and tight bands of the muscles at the
thoracic outlet, the course of these latter nerves and vessels may be interfered with.
Movements of the Shoulder

The upper arm has a wide range of motion in all three planes: sagittal, transversal, and horizontal. The
movement in the sagittal plane is the flexionextension movement, the movement in the transversal
plane is the abduction-adduction movement; and the movement in the horizontal plane is the horizontal
abduction and adduction (Figure 4.3). Moreover, the arm has a wide range of rotation around its
longitudinal axis. Most work activities demand varying degrees of flexion and abduction of the shoulder,
often with the forearm in flexion at the elbow.
Loading of Shoulder Muscles in Different Activities

Shoulder muscle loading may be estimated by recording the electrical activity of the muscles by
electromyography and measuring the intramuscular pressure. The trapezius, deltoid, supraspinatus, and
infraspinatus muscles have been measured most commonly. The abduction movement in the plane of the
scapula creates more loading than the flexion movement, especially for the supraspinatus muscle. The
intramuscular pressure shows a linear increase with increasing abduction or flexion angle. In the
supraspinatus, a flexion or abduction angle of 30 is enough to raise the intramuscular pressure above
the level where muscle blood flow is impeded. Adding hand load increases the intramuscular pressure
markedly. The increase is somewhat higher in shoulder abduction than in flexion. Flexing the elbow by
90 reduces the intramuscular pressure by about 30% in shoulder abduction.
Mechanisms of Injury in the Shoulder

Shoulder disorders may have their pathological process in the muscles, tendons, nerves, or joints. Commonly
painful muscles are the trapezius, especially the descending part, supra- and infraspinatus, and the levator
scapulae. Tendinitis of the rotator cuff tendons (e.g., supraspinatous or infraspinatous tendinitis) is the
most common tendon disorder at the shoulder. In the thoracic outlet syndrome, the nerves and/or vessels
of the neurovascular bundle are compressed at the thoracic outlet. The joints of the shoulder differ as to
how prone they are to degenerative changes. In the glenohumeral joint, degenerative changes are uncommon,
whereas in the acromioclavicular joint, such changes occur much more frequently.
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FIGURE 4.3 Movements of the shoulder in the three planes.
As described above, flexion and abduction of the arm increase the intramuscular pressure, which in
turn interferes with blood circulation and may produce local ischemia and cause muscle pain. Other
possible mechanisms for muscle pain are disturbances in energy metabolism and mechanical failure,
especially after heavy physical exercise.
Rotator cuff tendinitis is usually associated with degenerative changes in the tendons of the rotator
cuff. Such changes may be caused by impaired circulation in the tendon due to high tension in the
muscle. When the hand is exposed to local low-frequency vibration, the muscles of the arm contract
involuntarily as a consequence of the tonic vibration reflex. The tendons of the rotator cuff may also be
mechanically injured due to compression under the acromion and the coracoacromial arch. The tendons
may also be injured in falls and other accidents. A degenerated tendon is more likely to tear in an
accident than is a healthy tendon.
4.3 Occupational Risk Factors

Knowledge of occupational risk factors for shoulder disorders is based on epidemiological studies in the
field and experimental studies in the laboratory. Epidemiological studies have investigated the associations
between physical load factors and clinically defined shoulder tendinitis, radiographically assessed
degenerative joint disease, or reported shoulder pain. In many epidemiological studies, certain occupations
have been selected to represent a certain type of work, e.g., welders for overhead work. In some other
studies, exposure assessment has been based on self-assessment. Only rarely has the validity of such selfassessment been investigated. This means that the information on physical load factors in the
epidemiological studies is usually crude and may have considerable inaccuracy and even bias. Only
exceptionally have direct measurements been carried out.
4-5
In experimental studies, the intensity, frequency, and duration of the exposure can be determined and
measured with high precision, but the outcome is different from that in the epidemiological studies. In
addition to subjectively assessed discomfort, various physiological responses have been measured, such as
myoelectrical activity of muscles, intramuscular pressure, and blood metabolites. Only some data exist on
the associations between different types of physiological responses and the development of shoulder disorders.
Based on epidemiological and experimental evidence, ten work-related risk factors may be recognized:
Heavy physical work
Manual handling
Elevated postures of the arm
Nonneutral trunk postures
Static postures
Repetitive work
Lack of pauses
Vibration
Draft
Work organizational factors
Each of these risk factors will be discussed below. A compilation of selected epidemiological studies
(Table 4.1), studies in which various physiological responses have been measured during real or simulated
work (Table 4.2), and studies that have measured various physiological responses during basic movements
and loading situations of the shoulder in the laboratory (Table 4.3) serve as a source of original data for
the text. In all studies, various physical load factors (exposure) have been the independent variables
under study. The outcome or health effect has usually been more long term by nature in the epidemiologic
studies and a short-term response in the experimental studies.
Heavy Physical Work

Several studies have shown an association between heavy physical work and shoulder problems. The
association has been found for shoulder tendinitis (Stenlund et al., 1993), radiographically defined
acromioclavicular arthrosis (Stenlund et al., 1992), and reported shoulder pain (Viikari-Juntura et al.,
1993). An increased risk of acromioclavicular arthrosis was observed for 10 to 28 years of manual
work, and an even higher risk for more than 28 years of manual work, i.e., an exposure-response
relationship was observed for cumulative exposure to manual work. Examples of occupational groups
are rockblasters, bricklayers, and various jobs in forestry.
Heavy physical work may involve manual handling of heavy loads, nonneutral trunk postures, and
elevated postures of the arm. Such work may also be associated with repeated minor traumas and a risk
of major trauma.
Manual Handling
Manual handling of loads has been associated with shoulder disorders in some studies. Wells et al. (1983)
found a higher prevalence (13%) of recurrent shoulder pain for letter carriers than for meter readers (7%)
and postal clerks (5%). The maximum bag weight of the letter carriers was 11.4 kg. Letter carriers whose
maximum bag weight had been increased by 4.4 kg had a prevalence of 23% of recurrent shoulder pain.
Stenlund et al. (1992) determined life-long lifting as lifted tonnes, and found an increased risk of radiographically
assessed osteoarthrosis of the acromioclavicular joint for 710 to 26,000 tonnes, and an even higher risk for
more than 26,000 tonnes. This means that an exposure-response relationship was also found for lifted load
and acromioclavicular joint arthrosis. Unfortunately, it is not known whether intensive lifting for a short
period is associated with a different risk than less intensive lifting for a longer period. It should also be noted
that the data on lifting were based on questionnaires and interviews with no assessment of validity.
TABLE 4.1 Selection of Epidemiological Studies on Shoulder Disorders
4-6
4-7
TABLE 4.1 (continued) Selection of Epidemiological Studies on Shoulder Disorders
4-8
TABLE 4.2 Selected studies on Physiological Responses During Real or Simulated Work Tasks Involving Activation of Shoulder Muscles

4-9
* Activity figures from different studies, given as % of maximal activity, can be compared only roughly, due to different calibration procedures in different studies.
TABLE 4.2 (continued) Selected studies on Physiological Responses During Real or Simulated Work Tasks Involving Activation of Shoulder Muscles
4-10
TABLE 4.3 Selected Studies on Physiological Responses Associated with Controlled Postures and Loading of the Shoulder Muscles in the Laboratory

4-11
* Activity figures from different studies, given as % of maximal activity, can be compared only roughly, due to different calibration procedures in different studies.
TABLE 4.3 (continued) Selected Studies on Physiological Responses Associated with Controlled Postures and Loading of the Shoulder Muscles in the Laboratory
4-12
4-13
Manual handling activities impose high loads on probably all shoulder structures of which the rotator
cuff muscles and the deltoid have been the most investigated (Sigholm et al., 1984; Jrvholm et al., 1988).
Hand load has a strong effect on shoulder muscle activity, especially in the rotator cuff muscles, and on
intramuscular pressure in the supraspinatus. Manual handling activities may also run a risk of trauma.
Elevated Postures of the Arm

There is some epidemiological evidence to support an association between elevated postures of the arm
and shoulder pain (Bjelle et al., 1979; Sakakibara et al., 1995) as well as supraspinatus tendinitis (Herberts
et al., 1981). The occupations involved in the studies have been shipyard welders and orchard farmers.
Experimental studies have shown that the activity of shoulder muscles increases with increasing elevation
(flexion and abduction) of the arm (Sigholm et al., 1984). A flexion angle of =30 without hand load
raises the intramuscular pressure at a level where blood circulation is disturbed (Sigholm et al., 1984;
Jrvholm et al., 1988). After longer periods of intensive shoulder muscle exercise, cardiovascular and
neuromuscular recovery may be incomplete for hours (Mathiassen, 1993). Elevated arm postures may
also be associated with mechanical irritation of the rotator cuff tendons under the acromion and
coracoacromial arch.
The loads imposed on shoulder structures in various activities with elevated arms may be decreased
by suspending the arms. The results from the simulated work of welders showed that arm suspension
reduced shoulder muscle load, but the intramuscular pressure of the supraspinatus remained at a level
where muscle blood flow would still be compromised (Jrvholm et al., 1991).
Nonneutral Trunk Postures

In sedentary work, the workplace layout largely determines the posture of the torso, neck, and limbs.
Schldt et al. (1987) investigated the myoelectrical activity of several neck and shoulder muscles in different
postures during simulated soldering work in the laboratory. Sitting with the spine slightly tilted backward
and the cervical spine vertical was associated with the lowest activity. The posture with the whole spine
straight and vertical resulted in a higher myoelectrical activity, and the posture with the whole spine flexed
was associated with the highest activity. In the latter experiment, the work object was horizontal in the
whole-spine-flexed posture, tilted 35 in the whole-spine-straight-and-vertical posture, and tilted 75 in
the posture with the spine tilted backward and neck vertical. As stated by these authors, a backward
inclination of the spine generally requires that the work object should be tilted from the horizontal plane.
Static Work
According to epidemiological studies, shipyard welders (Herberts et al., 1981), orchard harvesters
(Sakakibara et al., 1995), packers (Luopajrvi et al., 1979), garment workers (Punnett et al., 1985),
workers in light assembly tasks (Kvarnstrm, 1983), and office workers with intensive use of the mouse
(Hagberg and Karlqvist, 1994) have shown a high risk for shoulder disorders. Common to the tasks in
these occupations is static exertion of shoulder muscles with or without elevation of the arm.
Measurements of myoelectrical activity in the field and simulated work in the laboratory have shown
static activity levels ranging from 4 to 17% of maximal activity in different shoulder muscles (Christensen,
1986; Sundelin and Hagberg, 1992), the upper range being far above the 2 to 5% of maximal activity
recommended by Jonsson (Jonsson, 1982). A simulation of cash register operation in the laboratory
(Lannersten and Harms-Ringdahl, 1990) and word processing operations, both with spontaneous and
forced pauses (Hagberg and Sundelin, 1986), was associated with a lower static load of 2 to 5% of
maximal activity.
Measurements of various keyboard activities in the field showed activity in the trapezius also at times
when no activity was performed by the forearm (Onishi et al., 1982). The importance of interruptions
of activity was shown in a follow-up of workers at a chocolate manufacturing plant. The workers who
4-14
had a smaller number of short unconscious interruptions of electromyographic activity (so-called emggaps) had a higher risk of contracting trapezius myalgia than those with a higher number of emg-gaps
during a follow-up time of six months (Veiersted et al., 1993).
The load of the shoulder muscles may be reduced by arm support or arm suspension in activities
involving static exertion of shoulder and arm muscles. A laboratory experiment of simulated soldering
work in different postures of the trunk and neck suggested that arm suspension might be more efficient
than arm support in the posture with the trunk slightly inclined backward. Arm support might be more
effective than arm suspension in the whole-spine-flexed posture. This latter posture, however, showed
generally high myoelectrical activities and should not be adopted for longer periods of work (Schldt et
al., 1987).
Repetitive Work
A typical pattern of repetitive work is that the fingers perform quick movements while the shoulder
muscles perform mostly static exertions to fulfil their primary task in supporting the arms. Word
processing, packing, and light assembly tasks are examples of such repetitive work, and high risk for
shoulder disorders has been shown in these tasks. In a simulation of assembly work in the laboratory,
the introduction of a one-minute pause with dynamic lifting activity every 6th minute resulted in less
pronounced myoelectrical signs of fatigue in the shoulder muscles, suggesting that dynamic activity
might be effective in counteracting the effects of static loading of shoulder muscles (Sundelin, 1993). No
difference was seen in discomfort ratings, however.
Certain work tasks may demand repetitive movements of the upper arm, but the health effects of
repetitive arm flexions or abductions are not well known. In an experimental study in which six healthy
students performed repetitive shoulder flexions with a frequency of 15/min for 60 minutes with loads
varying from 0 to 3.1 kg, all subjects had tenderness in the descending part of the trapezius and
supraspinatus, and two of them also had other signs of supraspinatus tendinitis after two days (Hagberg,
1981). A study among electronics assembly workers showed that the duration of mild upper arm flexion
was associated with shoulder disorders, but the number of upper arm flexions was inversely related to
shoulder disorders (Kilbom et al., 1986). This suggests that a more dynamic working style decreases the
risk of shoulder disorders.
An experimental study used the psychophysical approach to investigate the effects of various repetition
rates, forces, tool weights, and reach heights on work durations until a given degree of subjectively rated
fatigue was achieved in repeated arm flexions. The repetition rate was the prime determinant for work
duration, followed by force, height of upper target, and tool weight. Repetition rate and force showed
an interaction, so that increases in each variable led to a slight attenuation of the other variables effect
(Putz-Anderson and Galinsky, 1993). This study is among the few sources of data on which reference
values for the frequencies of shoulder elevations with given loads and elevation angles may be established.
Work-Rest Schedule: Lack of Pauses

It is conceivable that the frequency, duration, and quality of pauses are crucial determinants for the
development of fatigue in the muscles during forceful, repetitive, or static exertions. Work-rest schedules
have been investigated in some studies in the field (Hagberg and Sundelin, 1986) and in the laboratory.
In the aforementioned simulation of light industrial work in the laboratory, an MTM-110 pacing without
pauses was compared with an MTM-132 pacing with one-minute pause every 6th minute, consisting of
the dynamic lifting activity, the production rate of the task itself being equal in both schemes. As mentioned,
electromyographic signs of fatigue were less pronounced with pause activities than without, despite the
higher repetition rate and extra work of lifting during the pauses (Sundelin, 1993). In another experimental
study, a range of physiological responses was measured when holding the arm continuously and
intermittently in the horizontal plane at 60 to the sagittal plane. Duty cycle had a more pronounced
effect on the various physiological responses than cycle time. A ranking of the protocols with different
4-15
combinations of cycle time and duty cycle differed according to which physiological response was used
(Mathiassen, 1993).
In conclusion, while the need for pauses is evident in tasks demanding forceful, repetitive, or static
shoulder activities, only few data exist upon which to base any recommendation. Moreover, the
recommendations will differ depending on what kind of physiological criterion is used. Sometimes
objective and subjective criteria seem to contradict each other.
Vibration
Vibration from hand-held tools has been shown to be associated with both radiographically assessed
arthrosis of the acromioclavicular joint (Stenlund et al., 1992) and shoulder tendinitis (Stenlund et al.,
1993). For both conditions, an exposure-response relationship between cumulative exposure to vibration
and the disease have been observed. The assessment of cumulative exposure took into consideration the
hours that each vibrating tool had been used and the energy emission from the tool.
Draft
High air velocities in the work environment are perceived as draft and traditionally considered to increase
neck and shoulder discomfort. Only some epidemiological evidence exists for the association of draft
with neck and shoulder pain (Tola et al., 1988). The behavior of shoulder muscles was studied in an
experiment with different air velocities in the office environment. The myoelectrical activity changes
suggested increased recruitment of motor units in some muscles, and a possible cooling effect in others
associated with increasing air velocity (Sundelin and Hagberg, 1992).
Work Organizational Factors

Demands, control, and social support are work organizational factors that have been most often
investigated in association with shoulder disorders. An association between high job demands such as
time pressure, high concentration, high work load and shoulder disorders has been shown in many
studies. Also low control and little autonomy has been associated with shoulder disorders, but the
results concerning social support are conflicting (Bongers et al., 1993). In a follow-up study, mental
overload (difficult phases at work, the need to hurry to get work done) was associated with the persistence
of severe shoulder pain but not with the incidence of pain, indicating that work organizational factors
might have a greater role in the prognosis than in the genesis of shoulder disorders (Viikari-Juntura et
al., 1993).
Summary of Occupational Risk Factors

The text above deals with individual occupational risk factors for shoulder disorders. In real work
situations, many risk factors are present simultaneously and may have combined effects on the risk of
shoulder disorders. In dynamic work, the overall risk of shoulder disorders is probably a function of
arm posture, weight of load, and frequency of repetitions of arm movements. There is evidence that a
high cumulative exposure of heavy work increases the risk of shoulder disorders, but whether a certain
duration of heavy work per day could be tolerated for longer times is not known. Traumas to the
shoulder may increase the risk of shoulder disorders in heavy work. There is convincing evidence of
harmful effects of low-frequency vibration from handheld tools to the shoulder. Therefore, low-frequency
vibration from tools should be eliminated or kept to the minimum.
In static work tasks with lower force demands, the elevation angle of the arm, the overall posture of
the body, and the rest pauses largely determine the loading pattern of shoulder muscles. In this kind of
work, optimal body and arm postures should be enabled by proper workplace layout and possibilities
to support or suspend the arm according to the preference of the worker.
4-16
Work organizational factors may have an effect on the risk of shoulder disorders by influencing the
intensity, frequency, or duration of physical load factors. They may also affect the reporting of the
disorders or the recovery from them.
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Schldt, K., Ekholm, J., Harms-Ringdahl, K., Nmeth, G., and Arborelius, U.P. 1986. Effects of changes
in sitting work posture on static neck and shoulder muscle activity. Ergonomics 29(12):15251537.
Schldt, K., Ekholm, J., Harms-Ringdahl, K., Nmeth, G., and Arborelius, U.P. 1987. Effects of arm
support or suspension on neck and shoulder muscle activity during sedentary work. Scand. J. Rehab.
Med. 19(2):7784.
4-17
Sigholm, G., Herberts, P., Almstrm, C., and Kadefors, R. 1984. Electromyographic analysis of shoulder
muscle load. J. Orthop. Res. 1(4):379386.
Stenlund, B., Goldie, I., Hagberg, M., and Hogstedt, C. 1993. Shoulder tendinitis and its relation to
heavy manual work and exposure to vibration. Scand. J. Work Environ. Health 19(1):4349.
Stenlund, B., Goldie, I., Hagberg, M., Hogstedt, C., and Marions, O. 1992. Radiographic osteoarthrosis
in the acromioclavicular joint resulting from manual work or exposure to vibration. Br. J. Ind. Med.
49(8):588593.
Sundelin, G. 1993. Patterns of electromyographic shoulder muscle fatigue during MTM-paced repetitive
arm work with and without pauses. Int. Arch. Occup. Environ. Health 64(7):485493.
Sundelin, G. and Hagberg, M. 1992. Electromyographic signs of shoulder muscle fatigue in repetitive
arm work paced by the Methods-Time-Measurement system. Scand. J. Work Environ. Health
18(4):262268.
Sundelin, G., and Hagberg, M. Effects of exposure to excessive drafts on myoelectric activity in shoulder
muscles. J. Electromyogr. Kinesiol. 2:3641.
Tola, S., Riihimki, H., Videman, T., Viikari-Juntura, E., and Hnninen, K. 1988. Neck and shoulder
symptoms among men in machine operating, dynamic physical work and sedentary work. Scand. J.
Work Environ. Health 14(5):299305.
Veiersted, K.B., Westgaard, R., and Andersen, P. 1993. Electromyographic evaluation of muscular work
pattern as a predictor of trapezius myalgia. Scand. J. Work Environ. Health 19:284290.
Viikari-Juntura, E., Riihimki, H., Takala, E.-P., Rauas, S., Leppnen, A., Malmivaara, A., Grnqvist,
R., Hrm, M., Martikainen, R., Saarenmaa, K., and Kuosma, E. 1993. Niska-hartiaseudun ja
ylraajan oireita ennustavat tekijt metsteollisuudessa (Factors predicting pain in the neck, shoulders,
and upper limbs in forestry work). Ty ja ihminen 7(4):233253 (in Finnish with English summary).
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25(11):814820.

A recent scientific review on occupational risk factors of soft tissue disorders of the shoulder is presented
by Sommerich, McGlothlin, and Marras in Ergonomics (1993, 36:697717).
An extensive overview of the work-relatedness of shoulder disorders as well as other disorders of the
neck and upper limbs with a practical approach to prevention is presented in Hagberg, Silverstein, Wells
et al.s Work-Related Musculoskeletal Disorders (WMSDs): A Handbook for Prevention, Taylor &
Francis, 1995.
Results on extensive investigations using electromyographic recordings in simulated sedentary work
in different postures have been presented in a supplement (No. 19, 1988) of Scandinavian Journal of
Rehabilitation Medicine by Kristina Schldt On Neck Muscle Activity and Load Reduction in Sitting
Postures.
Basic biomechanics of the shoulder are included in Occupational Biomechanics by Chaffin and
Andersson (John Wiley & Sons, Inc., 1991).
5
Hand Tools:
Design and Evaluation
Robert G.Radwin
University of Wisconsin-Madison
5.1
5.2
5.3
5.4
5.5
5.6
Introduction
Power Tool Triggers and Grip Force
Handle Size and Grip Force
Static Hand Force
Dynamic Reaction Force
Vibration
5-1
5-2
5-3
5-5
5-8
5-11
5.1 Introduction
This chapter describes specific hand tool design features that help minimize physical stress and maximize
task performance in jobs involving the continuous or repetitive use of hand tools. An important objective
of ergonomics in the design, selection, installation, and use of hand tools is the reduction of muscle
fatigue onset and the prevention of musculoskeletal disorders of the upper limb. It is not just the tool
design, but how a tool is used for a specific task and workstation that imparts physical stress upon the
tool operator. Consequently, there is no ergonomic hand tool per se. What makes sense in one situation
can produce unnecessary stress in another.
It is generally agreed that physical stress, fatigue, and musculoskeletal disorders can be reduced and
prevented by selecting the proper tool for the task. Tools used so that physical stress factors are minimized,
such as reducing stress concentrations in the fingers and hands, producing low force demands on the
operator, or minimizing shock, recoil, and vibration are usually the best tools for the job. Control of
these factors depends on the tool and the specific tool application. Selection of tools should, therefore,
be viewed within the context of the specific job being performed.
Tool selection should be based on (1) process engineering requirements, (2) human operator limitations,
and (3) workstation and task factors. Some factors considered for each of these requirements are
summarized in Table 5.1. A detailed description of each of these factors is contained in Radwin and
Haney (1996). Manufacturing engineers often specify the process requirements with little regard for the
operator and the workstation. Hand tool selection should therefore consider how the particular task
and workstation relate to the capabilities and limitations of the human operator for a particular tool
design. The process is not always simple and often involves an iterative approach, considering individual
tool design features and their role in augmenting and mitigating physical stress. This chapter will describe
some hand tool design features and the research leading to an understanding of how tool design can
help reduce physical stress in hand tool operation.
0-8493-1800-9/03/$0.00+$1.50
5-1
5-2
TABLE 5.1 Requirements for Ergonomic Hand Tool Selection
5.2 Power Tool Triggers and Grip Force

Extended-length triggers (see Figure 5.1) that distribute force among two or more fingers are often
suggested for minimizing stress concentrations at the volar aspects of the fingers (Lindquist et al., 1986;
Putz-Anderson, 1988). The rationale is that the force for squeezing the trigger and grasping the handle
will be distributed among several fingers to reduce the stress in the index finger. Following is a description
of a study that investigated how this particular design feature affects the force in the hands.
In order to directly measure finger and hand force exerted during actual tool operation, an apparatus
was constructed for simulating a functioning pistol grip pneumatic nutrunner (Oh and Radwin, 1993).
Strain gages were installed in two aluminum bars that were used as the handle for measuring force
exerted against the fingers and palm. The instrumented bars were constructed so they were insensitive to
the point of force application and linearly summed force applied along the length of the handle (Pronk
and Niesing, 1981; Radwin et al., 1991). This was accomplished by measuring shearing stress acting in
the cross section of the beam. Strain gages were mounted on a thin web that was machined into the
central longitudinal plane and aligned at 45 with respect to the long axis. The effect of bending stresses
were completely removed from the strain gages by selecting a measurement point at the neutral axis of
the beam, so that all the strain at the measurement point is strictly due to shear stress. Shear strain is
totally independent of the point of application.
The strain gage instrumented handle was mounted on a rigid frame and attached perpendicular to a
modified in-line pneumatic nutrunner motor in a configuration resembling a pistol-grip power tool (see
Figure 5.2). The two dynamometers were mounted in parallel on a track so the handle span could be
continuously adjusted. The apparatus was completely functional. The air motor contained an automatic
air shut-off torque control mechanism and was operated at a 6.8 Nm target torque setting.
FIGURE 5.1 A conventional trigger and an extended-length trigger on pistol grip power hand tools. (Reprinted with
permission from Human Factors, 35, 3, 1993. Copyright 1993 by the Human Factors and Ergonomics Society.)
Hand Tools: Design and Evaluation
5-3
FIGURE 5.2 Dynamometer used for measuring finger and palm forces exerted when operating a completely functional
simulation of a pistol-grip pneumatic power hand tool. (Reprinted with permission from Human Factors, 35, 3,
1993. Copyright 1993 by the Human Factors and Ergonomics Society.)
Plastic caps were formed and attached to each end of the dynamometer so the contours resembled a
power tool handle. The handle circumference was 12 cm for a 4-cm span, measured between two points
tangent to the handle contact surfaces. The handle circumference increased an additional 2 cm as the
handle span was increased by 1 cm. A trigger was mounted on the finger side cap (see Figure 5.2), and
a contact switch was installed inside the trigger. A leaf spring was used for controlling trigger tension.
When the trigger was squeezed, the switch tripped a relay and a solenoid valve for supplying air to the
pneumatic power tool motor.
Two different trigger types were tested. One was a conventional power tool trigger, activated using
only the index finger. The second was longer than the conventional trigger and was activated using both
the index and middle fingers (see Figure 5.1). The conventional trigger was 21 mm long and the extended
trigger was 48 mm long. The conventional trigger required 8 N, and the extended trigger required 11 N
for activation.
Use of the extended trigger was found beneficial for reducing grip force and exertion levels during
tool operation. Average peak finger and palm forces were, respectively, 9% and 8% less for the extended
trigger than for the conventional trigger. Eleven of eighteen subjects (61%) indicated that they preferred
using the handle with the extended trigger after just an hour of use in the laboratory. The average finger
and palmar holding force was 65% and 48%, respectively, less for the extended trigger, than for the
conventional trigger. Since subjects spent 65% to 76% of the operating time holding the tool, using an
extended trigger may have an important effect on reducing exposure to forceful exertions in the hand
during power hand tool operation.
5.3 Handle Size and Grip Force

Research on handle design has typically focused on finding the optimal handle dimensions. Grip strength
is affected through the biomechanics of grip from the relative position of the joints of the hand and by
the position and length of the muscles involved. Consequently, grip strength is affected by the handle
size. Recommendations for handle size are usually based on the span that maximizes grip strength, or
the span that minimizes fatigue.
Hertzberg (1955), in an early Air Force study, reported that a handle span of 6.4 cm maximized
power grip strength. Greenberg and Chaffin (1975) recommended that a tool handle span should be in
the range between 6.4 cm and 8.9 cm in order to achieve high grip forces. Ayoub and Lo Presti (1971)
found that a 3.8 cm diameter was optimum for a cylindrical handle. This was based on maximizing the
ratio between strength and EMG activity, and on the number of work cycles before onset of fatigue.
Another study by Petrofsky et al. (1980) showed that the greatest grip strength occurred at a handle
span between 5 cm and 6 cm.
Grip strength is affected by hand size. Fitzhugh (1973) showed that the handle span resulting in
maximum grip strength for a 95 percentile male hand length is larger than the handle span for a 50
5-4
FIGURE 5.3 Average grip strength plotted against handle span for three hand size categories. Error bars represent
standard error of the mean. (Reprinted with permission from Human Factors, 35, 3, 1993. Copyright 1993 by the
Human Factors and Ergonomics Society.)
percentile female. Consequently, a person with a small hand might benefit from using a smaller handle,
and a person with a large hand might benefit from using a larger one.
Grip strength data often used for handle design are based on population measurements made using
instruments like the Jamar or Smedley dynamometers (Schmidt and Toews, 1970; Young et al., 1989) rather
than using handle dimensions representative of an actual tool. In most cases, only one dimension (handle
span) has been controlled, while the other handle dimensions were not necessarily similar to a tool handle.
A power hand tool manufacturer considered offering a power hand tool that provided a handle that
was adjustable in size. An investigation of grip strength using handle dimensions similar to power hand
tool handles was conducted in order to explore the differences against published grip strength data (Oh
and Radwin, 1993). Hand length up to 17 cm was classified as small, between 17 cm and 19 cm as
medium, and greater than 19 cm as large. Average grip strength is plotted against handle span and hand
size in Figure 5.3. Grip strength increased as hand length increased. Large hand subjects produced their
maximum grip strength (mean = 463 N, SD = 128 N) for a handle span of 6 cm, while medium hand
(mean = 280 N, SD = 122 N) and small hand (mean = 203 N, SD = 51 N) subjects produced their
maximum strength for a handle span of 5 cm.
The span resulting in maximum grip strength agreed with the findings of previous strength studies.
Hertzberg (1955) found that subjects exerted more force at a 6.4 cm span than among 3.8 cm, 6.4 cm,
10.2 cm, and 12.7 cm handle spans. Petrofsky et al. (1980) reported that on the average, subjects
produced maximum grip force for a handle span between 5 cm and 6 cm.
Although the span resulting in maximum grip strength and the grip strength function agreed with
previous findings, the maximum grip strength for both student and industrial worker subjects was
markedly less than what has been previously reported in the literature. Schmidt and Toews (1970)
collected grip strength data from 1,128 male and 80 female Kaiser Steel Corporation employee applicants,
using a Jamar dynamometer. They reported for a handle span of 3.8 cm, an average of 499 N for the
dominant male hand and 308 N for the dominant female hand. Swanson et al. (1970) measured the grip
strength of 50 females and 50 males using a Jamar dynamometer. Among these subjects, 36 were light
manual workers, 16 were sedentary workers, and 48 were manual workers. They reported for a handle
span of 6.4 cm, 467 N for the male dominant hand and 241 N for the female dominant hand. These all
exceeded the strength levels observed (see Figure 5.3).
A major difference between grip strength measured for tool handles by Oh and Radwin (1993) and
previously reported strength data is in the handle dimensions. The Jamar and Smedely dynamometers have
smaller circumferences and narrower widths than the tool handle used in this study. The tool handle curvature
was also straight while the Jamar dynamometer has a curved surface at the grip center. The handle used in this
study closely represented an actual tool handle in circumference and width. These size and curvature differences
5-5
FIGURE 5.4 Preferred handle span plotted against hand length. (Reprinted with permission from Human Factors,
35, 3, 1993. Copyright 1993 by the Human Factors and Ergonomics Society.)
can affect the position of the fingers and grip posture. These dimensional differences must be considered
when designing handles based on strength using published grip strength data.
The investigation also found a difference in grip strength between student subjects and industrial
workers. Grip strength, averaged over handle span, was 279 N (SD = 133 N) for the students and 327
N (SD = 90 N) for the workers. No significant grip strength differences, however, between the student
and worker groups were observed within each hand size.
The underlying assumption in designing handles based on maximum strength is that the actual force
exerted is independent of handle size. Exertion level is the ratio of the actual grip force used, to the
maximum voluntary force generating capacity. If the grip force used during tool operation is the same
for all handle sizes, then the handle span associated with the greatest grip strength should result in the
lowest exertion level. If grip force, however is affected by handle size, then the handle span associated
with the greatest grip strength may not be the handle span resulting in the minimum exertion level.
A series of experiments were performed using the pistol grip power hand tool with strain gage
instrumented handles and an adjustable handle span as described above. Handle span affected peak finger
and palmar force. Peak finger force increased 24% for a student subject group, and 30% for an industrial
worker group, as handle span increased from 4 cm to 7 cm. Similarly, peak palmar force increased 21% for
the student group and 22% for the worker group, as handle span increased from 4 cm to 7 cm. Handle
span also influenced finger and palmar holding forces. Finger holding force increased 20%, and palmar
holding force increased 16%, as handle span increased from 4 cm to 7 cm for the student subjects.
The study found that hand size was proportional to the handle span operators preferred when offered
the opportunity to adjust the handle size to any size they desired. Operators with larger hand sizes
reported they preferred using a tool with a larger handle. Preferred handle span is plotted against hand
length in Figure 5.4 for both trigger types. There was no difference between the preferred handle span
for the conventional trigger and the preferred handle span for the extended trigger. No anthropometric
measurements, however, were related to the span resulting in the minimum peak exertion level. Exertion
level when holding the tool was less for the large size hands than for the small size hands. Holding
exertion level for the large hands was maximum for the 4 cm handle span, while holding exertion level
for the small hands was maximum for the 7 cm handle span. In addition, the tendency for large hand
subjects to prefer larger handle spans suggests that selectable size handles may be more desirable than
having only a single size handle for power hand tools.
5.4 Static Hand Force

Safe power hand tool operation requires that an operator possess the ability to adequately support the
tool in a particular position, apply the necessary forces, while reacting against the forces generated by
5-6
the tool. Force demands that exceed an operators strength capabilities can cause loss of control, resulting
in an accident or an injury. Design and selection of power hand tools that minimize static grip and hand
force will help reduce muscle fatigue and prevent upper limb disorders.
The force necessary for supporting a power hand tool depends on the tool weight, its center of
gravity, the length of the tool, and air hose attachments. Power hand tools should be well balanced with
all attachments installed. As a general rule, a hand tool center of gravity should be aligned with the
center of the grasping hand so the hand does not have to overcome moments that cause the tool to rotate
the operators wrist and arm (Greenberg and Chaffin, 1977).
Psychophysical experiments have provided some insight into the load that power tool operators
prefer. When experienced hand tool operators were asked to rate the mass of the power tools they
operated, tools weighing 0.9 to 1.75 kg mass were rated just right (Armstrong et al. 1989). Other
psychophysical experiments showed that perceived exertion for a tool mass of 1 kg was significantly less
than for tools with a mass of 2 kg and 3 kg (Ulin and Armstrong, 1992).
There is a tradeoff between selecting a light tool and the benefit of the added weight for performing
operations that require high feed force. The power available for a grinding task increases with increasing
mass of the grinder. Reducing the weight of the grinder can increase the feed force the operator must
provide and may increase the amount of time necessary for accomplishing the task, consequently subjecting
the operator to more stressful work and greater vibration exposure. Heavy grinding tasks should be
performed on horizontal surfaces so the weight of the tool does not have to be supported by the operator.
Heavy power tools should be suspended using counterbalancing accessories.
In addition to supporting the tool load, power hand tool operators often have to exert push or feed
force, or act against reaction forces. Feed force is necessary for starting a threaded fastener, advancing a
bit, or keeping a bit or socket engaged during the securing cycle. Feed force is affected by the work
material and design of the tool, bit, or fastener. Large feed forces are sometimes needed when operating
power tools such as drills and screwdrivers. Repetitive or sustained exertions associated with these
operations should be minimized. Drill feed force is affected by the drill power and speed, bit type,
material, and diameter of the hole drilled. Power screwdriver feed force may be affected by the fastener
head and screw tip used. Feed force for a slotted or Phillips head screw generally requires more feed
force than for a torx head screw. Self-tapping screws require more force than screws tightened through
pre-tapped holes. Material hardness is also a factor for self-tapping screws and drilling. Feed force
requirements also increase as torque level increases for cross recess screws.
Power hand tools such as screwdrivers or nutrunners, used for tightening threaded fasteners, are
commonly configured as (1) in-line, (2) pistol grip, and (3) right angle. A mechanical model of a nutrunner
was developed for static equilibrium (no movement) conditions (Radwin et al., 1995). Hand force,
reaction force from the workpiece, tool orientation, weight, and output torque were included in this
model. This chapter will describe the model developed for pistol grip nutrunners.
The model uses a Cartesian coordinate system relative to the orientation of the handle grasped in the
hand using a power grip. This coordinate system has the x-axis perpendicular to the axial direction of
the handle; the y-axis is parallel to the long axis of the handle; and the z-axis is parallel to the tool
spindle. The origin is the end of the tool bit or socket. Hand forces are described in relation to these
coordinate axes. To simplify the model, an initial assumption is that orthogonal forces can be applied
along the handle without producing coupling moments. This assumption allows force to be considered
as having a single point of application. The resultant hand force FH at the grip center is the vector sum
of the three orthogonal force components
(5.1)
where the hand force magnitude is:
(5.2)
5-7
FIGURE 5.5 Free body diagram and orthogonal force components considered in the pistol grip force model.
FIGURE 5.6 Power hand tool geometry and variables in the hand tool static force model.
and i, j, k are the unit vectors. The coordinates and respective force components are illustrated
inFigure 5.5.
Consider the free-body diagram for the pistol grip nutrunner in Figure 5.6. The torque, Ts, acts in
reaction to torque, T, applied by the tool to the fastener. The tool operator has to oppose this equal and
opposite reaction torque in the counter-clockwise direction by producing a reaction force, FHx. That is
not the only force, however, that the operator has to produce. A force acting in the z direction, FHz,
provides feed force and produces an equal and opposite reaction force, FRz. In addition, the operator has
to react against the tool weight in order to support and position the tool by providing a vertical force
component, FHy. The tool weight, WT, and push force, FHz, tend to produce a clockwise moment about
the tool spindle in the yz-plane which is countered by this vertical support force.
When a body is in static equilibrium, the sum of the external forces and the sum of the moments are
equal to zero. Using that relationship, the following system of equations was developed for the pistolgrip nutrunner to describe these static forces:
(5.3)
5-8
FIGURE 5.7 Comparison of predicted hand forces for four different tool configurations performing the same task
for one-hand tool operation.
Assuming one-hand operation, resultant hand force magnitude was predicted using the model for the
four different tools and plotted as a function of torque in Figure 5.7. Hand force was determined for
both low feed force (1 N) and high feed force (50 N) conditions, when operating these tools against a
vertical surface. When feed force was small, the resultant hand force was mostly affected by torque
reaction force, which increased as torque increased for all four tools. Since the greatest force component
in this case was torque reaction force, Tools 3 and 4 had the least resultant hand force since they both
had the longest handles. Tool 3, however, had a considerably greater resultant hand force when feed
force was high. This effect was not observed for Tool 4, which also had a similar handle, but contained
a spindle extension shaft.
5.5 Dynamic Reaction Force

Whereas manual hand tools rely on the human operator for generating forces, power hand tools operate
from an external energy source (i.e., electric, pneumatic, and hydraulic) for doing work. The tool operator
provides static force for supporting the tool and for producing feed force, and must react against the forces
generated by the power hand tool. Power hand tools such as nutrunners produce rapidly building torque
reaction forces which the operator must react against in order to maintain full control of the tool.
Nutrunner reaction torque is produced by spindle rotation and is affected primarily by the spindle
torque output and tool size. Nutrunner spindle torque can range from less than 0.8 Newton-meters
(Nm) to more than 700 Nm. This torque is transmitted to the operator as a reaction force through the
moment arm created by the tool and tool handle. A tool operator opposes reaction torque while supporting
the tool and preventing it from losing control.
The three major operating modes for nutrunners include (1) mechanical clutch, (2) stall, or (3)
automatic shut-off. When a stall tool is used, maximum reaction torque time is directly under operator
control by releasing the throttle, which can last as long as several seconds. Stall tools tend to expose an
operator to reaction torque the longest. Although clutch tools limit reaction torque exposure, ratcheting
clutch tools can expose workers to significant levels of vibration if used frequently (Radwin and Armstrong,
1985). The speed of the shut-off mechanism controls exposure to peak reaction force for automatic
shut-off tools. Consequently, automatic shut-off tools have the shortest torque reaction time because
these tools cease operating immediately after the desired peak torque is achieved.
As torque is applied to a threaded fastener, it rotates at a relatively low spindle torque until the
clamped pieces come into intimate contact. This torque can approach zero with free running nuts or can
be rather significant as in the case where locking nuts, thread interference bolts, or thread-forming type
5-9
fasteners are used. After the fastener brings the clamped members of the joint into initial intimate contact,
it continues to draw the parts together until they form a solid joint. When the joint becomes solid,
continued turning of the nut results in a proportionally increasing torque. This is the elastic portion of
the cycle and is the time when reaction torque forces are produced. Torque build-up, and consequently
torque reaction force, continues rising at a fixed rate until peak torque is achieved, which is the clamping
force of the joint. Forearm muscle reflex responses when operating automatic air shut-off right angle
nutrunners during the torque-reaction phase was more than four times greater than the muscle activity
used for holding the tool and two times greater than the run-down phase (Radwin et al., 1989). Flexor
EMG activity during the torque-reaction phase increased for tools having increasing peak spindle torque.
Threaded fastener joints are classified as soft or hard depending on the relationship between
torque build-up and spindle angle. The International Standardization Organization (ISO) specifies that
a hard joint has an angular displacement less than 30 degrees when torque increases from 50% to 100%
of target torque, and a soft joint has an angular displacement greater than 360 degrees (ISO-6544).
Nutrunner torque reaction force is a function of several factors including target torque, spindle speed,
joint hardness, and torque build-up time. Some of these factors are interdependent. Faster spindle speed
results in shorter torque build-up time, and softer joints are related to longer build-up times. The duration
of exertion is directly related to torque build-up time rather than just the speed of the tool or joint hardness.
Studies have shown that torque build-up time as well as the magnitude of torque reaction force has
a significant influence on human operators during power nutrunner use. Kihlberg et al. (1995) studied
right angle nutrunners having different shut-off mechanisms (fast, slow, and delayed) and found a strong
correlation between perceived discomfort, handle displacement, and reaction forces. Radwin et al. (1989)
investigated the effects of target torque and torque build-up time using right-angle pneumatic nutrunners
and found that average flexor rms electromyography (EMG) activity scaled for grip force increased
from 372 N for a low target torque (30 Nm) to 449 N for a high target torque (100 Nm), and that
average grip force was 390 N for a long build-up time (2 s), and increased to 440 N for a medium buildup time (0.5 s). They also reported that EMG latency between tool torque onset and peak flexor rms
EMG for the long torque build-up time (2 s) was 294 ms and decreased to 161 ms for the short buildup time (0.5 s). The findings suggested that torque reaction force can affect extrinsic hand muscles in the
forearm, and hence grip exertions, by way of a reflex response. Johnson and Childress (1988) showed
that low torque was associated with less muscular activity and reduced subjective evaluations of exertion.
Representative torque reaction force, handle kinematics, and EMG muscle activity are illustrated in
Figure 5.8. Since torque builds up in a clockwise direction, the reaction torque has a tendency to rotate the
tool counterclockwise with respect to the operator. When the operator has sufficient strength to react
against the reaction torque, the tool remains stationary or rotates clockwise and the operator exerts concentric
muscle contractions against the tool (positive work). However, when the tool overpowers the operator, it
tends to move in a counterclockwise direction and the operator exerts eccentric muscle contractions against
the tool (negative work). Therefore, measures of handle movement that occur (handle velocity and
displacement) and the direction of rotation can indicate relative tool controllability. Handle movement
direction was defined as positive when the handle moved in the direction of tool reaction torque (see
Figure 5.1). If handle velocity increases after shutoff, it means that the tool and hand are unstable. The
work done on the tool-hand system and the power involved in doing work during torque build-up were
also assessed. If the operator has the capacity to successfully react against the torque build-up (positive
work), then the tool is considered stable. This occurs when handle displacement and velocity were less
than zero. If the handle become unstable and the net handle displacement occurs in the direction of torque
reaction away from the operator, then work and power are negative.
A computer-controlled right angle nutrunner was used to study power hand tool reaction forces (Oh
and Radwin, 1997). A torque transducer and an angle encoder were integrated into the tool spindle
head which outputted analog torque and digital angular rotation signals. A threaded fastener joint
simulator that could be oriented horizontally or vertically was mounted on a height adjustable platform.
The longitudinal axis of the joint head was oriented perpendicular to the ground for the horizontal
work-station setting, and oriented parallel to the ground for the vertical workstation setting.
5-10
FIGURE 5.8 Representative torque reaction force, handle kinematics and EMG muscle activity for different torque
build-up times.
The study showed that workstation orientation and tool dynamics (torque reaction force and torque
build-up time) influenced operator muscular exertion and handle stability. In general, handle instability
increased when the tool was operated on a vertical workstation (rather than a horizontal workstation),
when torque reaction force was high (88.3 and 114.6 N), and for a 150 ms torque build-up time,
regardless of torque reaction force.
As torque reaction force increased from 52.1 N to 114.6 N, peak hand velocity 89%, and peak hand
displacement increased 113%. Peak hand velocity was greatest for a 150 ms build-up time and the least
for a 900 ms build-up time. The effect of target torque was consistent with previous studies that showed
that target torque was related to muscular exertion, subjective perceived exertion, and handle instability
(Johnson and Childress, 1988; Lindqvist, 1993; Oh and Radwin, 1994; Radwin et al., 1989). As torque
reaction force increased from 52.1 N to 114.6 N, the magnitude of negative work increased by 35%,
and the magnitude of average power against the operator increased by 30%. Under these conditions,
perceived exertion also increased from 2.7 to 4.3 (as rated on Borgs 10-point scale), and task acceptance
rate decreased from 73% to 28%. When the tool was operated on a horizontal workstation, average
finger flexor EMG was significantly influenced by torque reaction force. As torque reaction force increased
from 52.1 N to 114.6 N, the average flexor EMG increased by 14%.
The effect of torque build-up time on power hand tool operators has been studied in terms of perceived
exertion, muscular activity, and handle stability (Armstrong et al., 1994; Freivalds and Eklund, 1991;
Lindqvist et al., 1986; Oh and Radwin, 1994; Radwin et al., 1989). Torque build-up time is a concern
because it is directly related to assembly time and exertion duration. Increased duration may lead to
earlier fatigue onset. Although longer build-up time results in longer duration exertions and increases
the operation cycle time, it may provide an opportunity for better tool control since it gives the operator
a longer time to react.
Peak hand velocity was 5.7% less for horizontal workstations (mean = 0.46 m/s, SD = 0.26 m/s) than
for vertical workstations (mean = 0.67 m/s, SD = 0.34 m/s). A similar trend was observed for peak hand
displacement. Peak hand displacement for horizontal workstations (mean = 4.0 cm, SD = 2.2 cm) was
90.2% less than peak hand displacement for vertical workstations (mean = 7.6 cm, SD = 4.6 cm).
Previous findings agree that a horizontal workstation is preferable for right angle tool use. Ulin et al.
(1992) showed that average subjective ratings of perceived exertion were significantly less when the tool
5-11
was operated on horizontal workstations rather than vertical workstations. Also, 88% more negative
work and 58% more power against the operator were recorded while the tool was operated on a vertical
workstation. However, subjective ratings of perceived exertion and task acceptance rates did not differ
between horizontal and vertical workstations. This might come from the fact that the torque levels in
the current study were much greater than the torque level used for the Ulin et al. study (1992).
Although perceived exertion was less and task acceptance rate was greater for a 35 ms build-up time
than for longer build-up times, the operator might not have sufficient time to voluntarily react against
torque build-up with the 35 ms build-up time. On the average, the onset of the EMG burst occurred 40
ms after the onset of torque build-up for the 35 ms build-up time. This indicated that the muscles were
not activated until a significant amount of torque had built up for the 35 ms build-up time. Lack of
muscular contraction during torque build-up might explain why the peak handle velocity was higher for
short build-up times. Without muscular contractions, the inertia of the tool and hand had to absorb all
of the reaction force. Short exertion duration and lack of muscular contractions due to EMG latencies
might contribute to lower subjective ratings of perceived exertion for the 35 ms build-up.
The larger torque variance that occurred for the 35 ms build-up time indicated that even though
subjective perceived exertion was less, this condition might result in more target torque error. Also, the
probability of increased handle instability after shutoff was significantly greater for the 35 ms build-up
time. This suggests that even after shutoff, operators did not have sufficient capacity to control the tool
reaction torque. Therefore, the 35 ms build-up time increased handle stability in terms of peak handle
displacement and negative work, and reduced subjective perceived exertion, however, the lack of muscular
contraction during torque build-up reduced tightening quality.
Methods for limiting reaction force include (1) use of torque reaction bars, (2) installing torque absorbing
suspension balancers, (3) providing tool mounted nut holding devices, and (4) using tool support reaction
arms. A torque reaction bar sometimes can be used to transfer loads back to the work piece. Tools that can
be equipped with a stationary reaction bar adapted to a specific operation so reaction force can be absorbed
by a convenient solid object can completely eliminate reaction torque from the operators hand. These bars
can be installed on in-line and pistol-grip tools. Right angle tools can react against a solid object instead of
relying on the hand and arm. Reaction devices (1) remove reaction forces from the operator, (2) permit
pistol-grip and in-line reaction bar tools to be operated using two hands, (3) free the operator from restricting
postures, (4) provide weight improvements over right angle nutrunners, and (5) improve tool fastening
performance. The disadvantages are that reaction bars must be custom made for each operation, and the
combination of several attachments for one tool can be difficult. Torque reaction bars may also add weight
to the tool and can make the tool more cumbersome to handle.
5.6 Vibration
Vibration can be a by-product of power hand tool operation, or it can even be the desired action as is the
case with abrasive tools like sanders or grinders. Vibration levels depend on tool size, weight, method of
propulsion, and the tool drive mechanism. It is affected by work material properties, disk abrasives, and
abrasive surface area. Continuous vibration is inherent in reciprocating and rotary power tools. Impulsive
vibration is produced by tools operating by shock and impact action, such as impact wrenches or chippers.
The tool power source, such as air power, electricity, or hydraulics can also affect vibration. Vibration is
also generated at the tool-material interface by cutting, grinding, drilling, or other actions.
Pneumatic hammer recoil was observed producing a stretch reflex and muscular contractions in the
elbow and wrist flexors (Carls and Mayr, 1974). Studies of the short-term neuromuscular effects of
hand tool vibration have demonstrated that hand tool vibration can introduce disturbances in neuromuscular force control resulting in excessive grip exertions when holding a vibrating handle (Radwin et
al., 1987). The results of these studies demonstrated that grip exertions increased with tool vibration.
Average grip force increased for low frequencies (40 Hz) vibration but did not change for higher frequencies
(160 Hz) vibration. Since forceful exertions are a commonly cited factor for chronic upper extremity
5-12
muscle, tendon, and nerve disorders, vibrating hand tool operation may increase the risk of CTDs
through increased grip force.
Vibration has also been shown to produce temporary sensory impairments (Streeter, 1970; Radwin
et al., 1989). Recovery is exponential and can require more than 20 minutes (Kume et al., 1984).
Workers often sand or grind surfaces and periodically inspect their work using tactile inspection to
determine if the surface was sanded to the desired level of smoothness. Diminished tactility may result in
a surface feeling smoother than it actually is, resulting in a rougher surface than is actually desired.
Vibration has not been shown to be significantly reduced by using resilient mounts on handles.
Vibration isolation techniques have been generally unsuccessful for limiting vibration transmission from
power tools to the hands and arms. Isolation has been particularly difficult for vibration frequencies less
than 100 Hz. This is because attenuation only occurs when the vibration spectrum falls above the
resonant frequency of the isolation system or material. When the vibration frequency is less than the
resonant frequency of the isolating material, the handle acts as a rigid body and no vibration is attenuated.
Grinding tools typically run at speeds near 6000 rpm (100 Hz) making it difficult to have a resilient
vibration isolating handle. Furthermore, if the vibration frequency is approximately equivalent to the
isolator resonant frequency, the system will actually intensify vibration levels. Weaker suspension systems
have lower resonant frequencies, but are often impractical because such a system is usually too flexible
for the heavily loaded handles of tools like grinders. Handles loaded with high forces must be very rigid.
References
Armstrong, T.J., Bir, C., Finsen, L., Foulke, J., Martin, B., Sjgaard, G., and Tseng, K. 1994. Muscle
responses to torques of hand held power tools, Journal of Biomechanics, 26(6): 711718.
Ayoub, M.M. and Lo Presti, P. 1971. The determination of an optimum size cylindrical handle by use of
electromyography. Ergonomics, 14(4): 509518.
Fitzhugh, F.E. 1973. Dynamic Aspects of Grip Strength. (Tech Report). Department of Industrial &
Operations Engineering, Ann Arbor: The University of Michigan.
Freivalds, A. and Eklund, J. 1991. Subjective ratings of stress levels while using powered nutrunners, in
W.Karwowski and J.W.Yates (Eds.), Advances in Industrial Ergonomics and Safety III, New York:
Taylor & Francis, 379386.
Greenberg, L. and Chaffin, D.B. 1975. Workers and Their Tools: A Guide to the Ergonomic Design of
Hand Tools and Small Presses. Midland, MI: Pendell.
Hertzberg, H.T.E. 1955. Some contributions of applied physical anthropology to human engineering.
Annals of NY Academy of Science, 63(4): 616629.
International Organization for Standardization 1981. Hand-held Pneumatic Assembly Tools for Installing
Threaded FastenersReaction Torque Reaction Force and Torque Reaction Force Impulse
Measurements. ISO-6544.
Johnson, S.L. and Childress, L.J. 1988. Powered screwdriver design and use: tool, task, and operator
effects, International Journal of Industrial Ergonomics, 2:183191.
Kihlberg, S., Kjellberg, A., and Lindbeck, L. 1995. Discomfort from pneumatic tool torque reaction
force reaction: acceptability limits, International Journal of Industrial Ergonomics, 15:417426.
Lindqvist, B. 1993. Torque reaction force reaction in angled nutrunners, Applied Ergonomics, 24(3):
174180.
Lindquist, B., Ahlberg, E., and Skogsberg, L. 1986. Ergonomic Tools in Our Time. Atlas Copco Tools,
Stockholm.
Oh, S. and Radwin, R.G. 1993. Pistol grip power tool handle and trigger size effects on grip exertions
and operator preference, Human Factors, 35(3): 551569.
Oh, S. and Radwin, R.G., 1994, Dynamics of power hand tools on operator hand and arm stability, in
Proceedings of the Human Factors and Ergonomics Society 38th Annual Meeting, 602606, Santa
Monica, CA: Human Factors and Ergonomics Society.
5-13
Oh, S. and Radwin, R.G. 1998. The influence of target torque and torque build-up time on physical
stress in right angle nutrunner operation, Ergonomics, 41(2): 188206.
Petrofsky, J.S., Williams, C., Kamen, G., and Lind, A.R. 1980. The effect of handgrip span on isometric
exercise performance, Ergonomics, 23(12): 11291135.
Pronk, C.N.A. and Niesing, R. 1981. Measuring hand grip force using an application of strain gages,
Medical, Biological Engineering and Computing, 19:127128.
Putz-Anderson, V. 1988. Cumulative Trauma Disorders. New York: Taylor & Francis.
Radwin, R.G., Masters, G., and Lupton, F.W. 1991. A linear force summing hand dynamometer
independent of point of application, Applied Ergonomics, 22(5): 339345, 1991.
Radwin, R.G. and Haney, J.T. 1996. An Ergonomics Guide to Hand Tools, Fairfax, VA: American
Industrial Hygiene Association.
Radwin, R.G., VanBergeijk, E., and Armstrong, T.J. 1989. Muscle response to pneumatic hand tool
torque reaction force reaction forces, Ergonomics, 32(6): 655673.
Radwin, R.G., Oh, S., and Fronczak. 1995. A mechanical model of hand force in power hand tool
operation, Proceedings of the Human Factors and Ergonomics Society 39th Annual Meeting, Santa
Monica: Human Factors and Ergonomics Society: 348352.
Schmidt, R.T. and Toews, J.V. 1970. Grip strength as measured by the Jamar dynamometer, Archives of
Physical Medicine & Rehabilitation, 51(6): 321327.
Swanson, A.B., Matev, I.B., and Groot, G. 1970. The strength of the hand, Bulletin of Prosthetics
Research, Fall: 145153.
Ulin, S.S., Snook, S.H., Armstrong, T.J., and Herrin, G.D. 1992. Preferred tool shapes for various
horizontal and vertical work locations, Applied Occupational and Environmental Hygiene, 7(5):
327337.
Young, V.L., Pin, P., Kraemer, B.A., Gould, R.B., Nemergut, L., and Pellowski, M. 1989. Fluctuation in
grip and pinch strength among normal subjects, The Journal of Hand Surgery, 14A(1): 125129.
6
Gloves
Ram Bishu
University of Nebraska-Lincoln
A.Muralidhar
University of Nebraska-Lincoln
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
Importance of the Hand

Prehensile Capabilities of Hand
eed for Protection of the Hand
Types of Gloves
Glove Effect on Strength
Glove Effect on Dexterity
Glove Effect on Tactility
Liners
Glove Attributes
Challenges of Glove Design
Glove Evaluation Protocol
Glove Standards
Conclusion
6-1
6-1
6-2
6-2
6-3
6-4
6-5
6-7
6-8
6-8
6-9
6-10
6-10
6.1 Importance of the Hand

The hand is probably the most complex of all anatomical structures in the human body. Along with the
brain, it is the most important organ for accomplishing the tasks of exploration, prehension, perception,
and manipulation, unique to humans. The importance of the hand to human culture is emphasized by
its depiction in art and sculpture, its reference frequency in vocabulary and phraseology, and its importance
in communication and expression (Chao et al., 1989). The human hand is distinguished from that of the
primates by the presence of a strong opposable thumb, which enables humans to accomplish tasks
requiring precision and fine control. The hand provides humans with both mechanical and sensory
capabilities.
6.2 Prehensile Capabilities of the Hand

Napier (1956) divides hand movements into two main groupsprehensile movements, in which an
object is seized and held partly or wholly within the compass of the hand, and nonprehensile movements,
where no grasping and seizing is involved but by which objects can be manipulated by pushing or lifting
motions of the hand as a whole or of the digits individually.
Landsmeer (1962) further classifies human grasping capabilities as power grip, where a dynamic initial
phase can be distinguished from a static terminal phase, and precision handling, where there is no static
terminal phase. The dynamic phase as defined by Landsmeer includes the opening of the hand, positioning
of the fingers, and the grasping of the object. Westling and Johansson (1984) state that the factors that
influence force control during precision grip are friction, weight, and a safety margin factor related to the
individual subject. They also found that in multiple trials, the frictional conditions during a previous trial
could affect the grip force. They also showed that the grip employed when holding small objects stationary
in space was critically balanced such that neither accidental slipping between the skin and the object
0-8493-1800-9/03/$0.00+$1.50
6-1
6-2

TABLE 6.1 Comparison of Bare Hand-Gloved Hand
Capabilities
occurred, nor did the grip force reach exceedingly high values. This sense of critical balance as to the
amount of force applied while gripping is important, as too firm a grip could result in the destruction of a
fragile object, causing possible injury to the hand, or lead to muscle fatigue and interfere with further
manipulative activity imposed upon the hand. Sensory perception in the hand is due to the presence of
mechanoreceptors distributed all over the palmar area, especially at the tips of the fingers.
Thus, feedback from the hand is a critical component of the gripping task enabling the amount of
force to be controlled. Anything that blocks the transmission of impulses from the hand interferes with
the feedback cycle and affects grip force control. Gloves do affect the feedback cycle.
6.3 Need for Protection of the Hand

The hand, which provides humans with both mechanical and sensory capabilities, needs to be protected
from the environment. Protection is needed from mechanical trauma (abrasions, cuts, pinches, punctures,
crush injuries), thermal extremes (heat and cold), radiation (nuclear, ultraviolet, X-ray, and thermal),
chemical hazards, blood-borne pathogens, electrical energy, and vibration.
There exist several forms of hand protection, which can be used as stand-alone protection, or in
combination with other personal protective equipment. The commonly available hand protection are
gloves, mittens, finger cots, and gauntlets made of several materials such as leather, cotton, rubber,
nylon, latex, metal, and in combinations of the same, to provide maximum protection against the specific
condition being guarded against. The use of gloves, although a necessity in many workplaces, has some
associated disadvantages. Gloves have been found to affect hand performance adversely, and the
performance parameters affected are dexterity, task time, grip strength, and range of motion. Table 6.1
provides a summary of bare hand and gloved hand capabilities.
Facilitation of these activities, with simultaneous protection from the hazards of the work environment,
are often conflicting objectives of glove design. The conflicts associated with providing primary hand
protection through the use of a glove while permitting adequate hand functioning has been widely recognized.
It will be relevant to give a brief description of a variety of gloves that are available today. It will also
be relevant to discuss performance effects of gloves, before detailing the challenges of glove design.
6.4 Types of Gloves

There are a wide variety of gloves available today. Starting from a garden glove at 50 cents a pair from
the local grocery store to the custom-fit shuttle gloves donned by astronauts for extra vehicular activities
Gloves
6-3
(EVA), which cost a few hundred thousand dollars a pair, the variety among gloves can be so overwhelming
as to defy easy categorization. Gloves can be categorized along a number of dimensions, such as materials,
design, and location of use. According to the National Safety Council (1975, 1976), hand protection
can be job-rated or general purpose. Job-rated hand protection is designed to protect against the hazards
of specific operations, while general purpose gloves protect against many hazards. Materials used in
gloves are cotton, nylon, duck, jersey, canvas, terry, flannel, lisle, leather, rubber, synthetic rubber, wire
mesh, aluminized fabric, asbestos, plastic and synthetic coatings, impregnated fabrics, polyvinyl chloride,
nitrile, neoprene, and many man-made fibers with identifiable brand names (Dionne, 1979; Riley and
Cochran, 1988). Glove styles include liners, reversibles, open back, gloves or mittens with reinforced
nubby palms and fingers, and double-thumb gloves. Certain tasks may need double or more gloves. For
example, shuttle gloves are an assemblage of three layers of gloves, while latex-sensitive people in the
medical community wear an inner liner with an outer shell. The length of glove may be wrist-, elbow-,
or shoulder-length with exact dimensions depending on the manufacturer. In summary, the gloves range
from easily available general purpose ones to highly task-specific and job-rated ones.
6.5 Glove Effect on Strength

Grip strength: Published evidence exists for glove effect on grip strength, grasp strength, pinch strength,
grasp at submaximal levels of exertion, torque capabilities, and on endurance time. Reduction in grip and
grasp force when gloves are donned has been reported by a number of investigators (Hertzberg, 1955;
Lyman and Groth, 1958; Cochran et al. 1986; Wang et al. 1987; and Sudhakar et al. 1988). Hertzberg
(1955), using a Smedley hand dynamometer, determined that grip strength was reduced by about 20%
among gloved airplane pilots. Reduction in strength may be as much as 30% or more, according to Lyman
and Groth (1958). Cochran et al. (1986) performed an experiment which examined the differences in
grasp force degradation among five different types of commercially available gloves as compared to a barehanded condition. The results indicated that the no glove condition was significantly higher in grasp
force than any of the glove conditions. Wang et al. (1987) performed an experiment on strength decrements
with three different types of gloves. The results of the study showed that there was a reduction in grip
strength when comparing gloved performance to bare-handed performance. Bishu et al. (1995a, b) studied
the effects of EVA gloves at different pressures on human hand capabilities. A factorial experiment was
performed in which three types of EVA gloves were tested at five pressure differentials. The independent
variables tested in this experiment were gender, glove type, pressure differential, and glove make. Six
subjects participated in an experiment where a number of performance measures, namely grip strength,
pinch strength, time to tie a rope, and the time to assemble a nut and bolt, were recorded. Tactile sensitivity
was also measured through a two-point discrimination test. The salient results were that with EVA gloves
strength is reduced by nearly 50%, and that performance decrements increase with increasing pressure
differential. McMullin and Hallbeck (1991) studied the effect of wrist position, age, and glove type on the
maximal power grasp force, and their findings indicate that a single-layer glove is better than several
layers, as the bunching of glove material at the joints could cause strength decrement. More recently
Muralidhar et al. (1999) evaluated two prototype gloves (contour and laminated) with a single layer and
a double layered glove. Bare-hand performance was measured to assess the exact glove effect. Considerable
reduction in grip strength with gloves was found. Figure 6.1 shows the effect of gloves on grip strength.
Similar results were also reported by Bronkema and Bishu (1996).
In summary, most of the research evidence on gloves indicates that gloves reduce grip and grasp
capabilities.
Torque strength: A number of studies have reported an increase in strength capabilities with gloves.
Riley et al. (1985) examined forward handle pull, backward handle pull, maximum wrist flexion torque,
and maximum wrist extension torque while using no-glove, one-glove, and double-glove conditions.
The results of this study showed that the one-glove condition was superior to both the no-glove and
two-glove conditions. Similar results have been reported by Adams and Peterson (1988), who investigated
the effects of two types of gloves on torque capabilities. In this study, a two-layer work glove and a
6-4
FIGURE 6.1 Gloves vs. grip strength.
threelayer chemical defense glove were found to enhance tightening performance, while only the work
glove aided the loosening performance. Mital et al. (1994) have reported an increase in peak torquing
exertion capabilities when gloves are donned, with the extent of increase being dependent on the type of
gloves donned. In contrast, Cochran et al. (1988) found that gloves reduce torquing force. They had
subjects perform a flexion torque task using four sizes of cylindrical handles (7 cm, 9 cm, 11 cm, and 13
cm) while wearing three types of gloves (cotton smooth leather, and suede leather). Using cotton gloves
yielded the lowest torquing force, while bare-handed had the highest, and the two leather gloves were in
between and were not significantly different from each other. These results are supported by Chen et al.
(1989), who found the forces generated using cotton gloves of all sizes were significantly lower than the
leather or deerskin gloves of different sizes in a similar torquing task. The effect of gloves on torque
capabilities is far less clear. However, it is reasonable to assume that gloves would aid torquing tasks.
Pinch strength: As compared to grip or grasp capabilities, studies on glove effect on pinch strength
are few and far between. Kamal et al. (1992) report that gloves do not affect lateral pinch capabilities.
Hallbeck and McMullin (1991, 1993) found similar results for three jaw chuck pinch. Overall, gloves
do not affect pinch strength.
Endurance time: Almost all activities with a gloved hand involve certain levels of hand exertions for
periods of time. Therefore, two issues are relevant here: the extent of exertion and the time of exertion.
Most of the published studies on gloves have addressed the issue of extent of exertion. Bishu et al. (1995b)
addressed the question of how long a person can sustain a level of exertion in the gloved-hand condition.
This deals with muscular fatigue and related issues. They reported that the endurance time at any exertion
level depended, not on the glove, but just on the level of exertion expressed as a percentage of maximum
exertion possible at that condition. There is, however, a glove effect for the maximum exertion. Figure 6.2
shows the plot of the exertion level effect on the endurance time, across all glove and pressure configurations.
The endurance time is least at 100% exertion level, while it is greatest at 25% exertion level.
6.6 Glove Effect on Dexterity

Bradley (1969) showed that control operation time was affected while wearing gloves. Banks and Goehring
(1979), while studying the effects of degraded visual and tactile information in diver performance, found
that the use of gloves increased task time by 50 to 60%. McGinnis et al. (1973) investigated the effect of
six different hand conditions on dexterity and torque capability. They used bare hand, leather glove,
leather glove with inserts, impermeable glove, impermeable glove with inserts, and an impermeable glove
with built-in insulation. They found that under dry conditions, the impermeable glove had the best torque
capability, and that the bare-handed dexterity performance was superior to that of gloved-hand performance.
Plummer et al. (1985) studied the effects of nine glove combinations (six double and three single) on
Gloves
6-5
FIGURE 6.2 Endurance time.
performance of the Bennett Hand Tool Dexterity Test apparatus. Results of the study indicated that
subjects, with gloves donned, took longer to complete the task, with the double glove causing longer
completion times. Cochran and Riley (1986) found that gloves generally reduce dexterity and force
capability. Bensel (1993) conducted an experiment in which the effects of three thicknesses (0.18 mm,
0.36 mm, and 0.64 mm) of chemical protective gloves on five dexterity tests (the Minnesota rate of
manipulation-turning; the OConnor finger dexterity test; a cord and cylinder manipulation; the Bennet
hand-tool dexterity test; and a rifle disassembly/assembly task) were investigated. Mean performance
times were shortest for the bare-handed condition and longest for the thickest (0.64 mm) glove. Nelson
and Mital (1995) found no appreciable differences in dexterity and tactility among latex gloves of five
different thicknesses: 0.2083 mm; 0.5131 mm; 0.6452 mm; 0.7569 mm; and 0.8280 mm. The authors
found the thickest latex glove (0.8280 mm) to be puncture resistant, with no loss in dexterity and
tactility as compared to the thinner gloves. Bellinger and Slocum (1993) investigated the effect of protective
gloves on hand movement and found that gloves decreased the range of motion in adduction/abduction
and supination/pronation, while extension/flexion was not affected. Their findings suggest that there is
an overall reduction in the kinematic abilities of the hand while wearing gloves. More recently Muralidhar
et al. (1999) evaluated two prototype gloves (contour and laminated) with a single layer, and a doublelayered glove. Bare-hand performance was measured to assess the exact glove effect. A battery of tests
consisted of the Pennsylvania Bi-Manual Worksample Assembly Test (PBWAT), Minnesota Rate of
Manipulation Test-Turning (MRMTT), a rope-tying task to evaluate dexterity for flexible object
manipulation, and a manipulability test. Figure 6.3 shows the glove effect on MRMTT. Figure 6.4
shows the plot of the glove effect on PBWAT. Figure 6.5 shows the glove effect on the rope tying time,
while Figure 6.6 shows the glove effect on the manipulation time. It is seen that gloves reduce dexterity.
The reduction in gloved performance is seen consistently in all the measures.
Overall, gloves reduce finger dexterity, and manipulability.
6.7 Glove Effect on Tactility

Although intuitively most obvious, the effect of gloves on tactile sensitivity has not been well documented.
The evidence on this matter is somewhat confusing mainly due to inadequacies of measures and inadequacies
of instruments. The monofilament test (Weinstein, 1993) is by far the most popular to assess tactile sensitivity.
Used in clinical testing, filaments with predetermined force are pressed against the fingers of the subjects by
the experimenter until the sensation of touch is felt. The force is recorded as the tactile sensitivity. The twopoint discrimination test used by OHara et al. (1988) and by Bishu and Klute (1995a) failed to give a clear
indication of loss of tactile sensitivity. Bronkema et al. (1994) have used grasp force degradation at
submaximal levels of exertion with gloves as a measure of the loss of tactility. Their results indicate that
6-6
FIGURE 6.3 Gloves vs. pegboard time.
FIGURE 6.4 Gloves vs. number of assemblies.
FIGURE 6.5 Gloves vs. rope knotting time.
Gloves
6-7
FIGURE 6.6 Gloves vs. blocks manipulation time.
FIGURE 6.7 Glove effect on tactility.
gloves do reduce tactile sensitivity. Desai and Konz (1983) studied the effect of gloves on tactile inspection
performance and found that gloves had no significant effect on the inspection performance. In fact, they
recommend that gloves be worn during tactile inspection tasks to protect the inspectors hands from
abrasion and to help in the detection of small surface irregularities. Nelson and Mital (1995) found no
appreciable differences in dexterity and tactility among latex gloves of five different thicknesses. In
summary, the effect of gloves on tactility has not been clearly understood and should be the focus of
glove research in the future.
6.8 Liners
Today there is a growing trend toward the use of inner gloves or glove liners. For example, health care
professionals often tend to use glove liners to prevent outer glove/skin interaction. Similarly, meat
processors usually wear glove liners, while astronauts use multiple layers of liners. Almost all of the
research efforts on gloves has focused on the outer glove, while liners have drawn little research attention.
Using a standardized glove testing protocol, Bishu and Chin (1998) investigated the effect of a number
of glove liners.
The study compared three types of liners: liners made from PTFE, cotton, and latex. A battery of
evaluation tests, comprising some standardized tests and certain functional tests, was designed. The tests
assessed the following capabilities: tactile sensitivity, dexterity, manipulability, strength, and effect of
continuous use. The actual tests performed were the pinch test, finger strength test, monofilament test,
6-8
FIGURE 6.8 Glove effect on overall fatigue.
pain threshold test, rope-tying test, peg board test, and fatigue test. In the fatigue test the effect of
continuous use of gloves was measured with Borgs RPE scale. Continuous use was simulated by making
the subjects perform keyboard tasks and peg board tasks alternately for an hour. Discomfort measures
were recorded every 10 minutes. Important findings were (a) liners made a distinct contribution to the
performance decrements with gloves, and (b) liners had a significant effect on the overall comfort
(discomfort) during extended periods of glove usage. Figure 6.7 shows the graph of effect of liners on
tactility as measured with monofilament test. Figure 6.8 shows the liner effect on overall fatigue.
6.9 Glove Attributes

Bradley (1969) also investigated dexterity as a function of glove attributes such as snugness of fit,
tenacity, and suppleness in a wide variety of 18 industrial gloves. The conclusions reached are that
various glove attributes influence dexterity performance to varying extents. Bishu et al. (1987) found
that glove attributes and the task performed had a significant effect on the force exertion. Wang et al.
(1987) concluded that altered feedback from a gloved hand caused strength degradation. Batra et al.
(1994) found grip strength reduction to be significantly correlated with glove thickness and subjective
rating discomfort, and suggest that glove thickness should be minimized, while increasing the tenacity.
In spite of these studies, no comprehensive model linking performance degradation with glove
characteristics exists.
6.10 Challenges of Glove Design

In summary, gloves do reduce performance, but provide a vital protective function. Facilitation of
performance, with simultaneous protection from the hazards of the work environment, are often
conflicting objectives of glove design. The conflicts associated with providing primary hand protection
through the use of a glove while permitting adequate hand functioning has been widely recognized.
Looking at the glove attributes that cause performance differences, attributes or level of attributes that
facilitate performance deteriorates safety function. This conflict poses certain challenges for the glove
designer. Before attempting to design any kind of protection for the hand, it is necessary to first identify
what it needs to be protected against. Human capability is limited to a narrow bandwidth of acceptable
environmental conditions in which performance is not affected. There are a number of environmental
hazards, often in combination, that are likely to pose a threat to the hands of workers interfacing with
their workplace.
Glove material is often fixed by the environment. Environments that expose the worker to radiation,
electrical, biological, fire, chemical, and extreme thermal hazards warrant that specific materials be
incorporated into the hand protection, irrespective of the design. The hazard-specificity of such materials
Gloves
6-9
TABLE 6.2 Glove Attributes as a Function of Design Parameters
also poses a problem for the glove designer, because the minimum thickness of the material required to
provide adequate protection is usually a fixed value, limiting the designers choice of variable parameters.
For example, a glove designed for use in an operating room or by a dental hygienist has to be capable
of being sterilized either by steam or chemical disinfectants, impermeable to any potentially dangerous
fluids, and of sufficient thickness and strength to maintain its integrity for a reasonable period of time.
However, in spite of the inflexibility in the materials parameters, the glove is expected to enable the
user to function without significant loss of desirable hand functions like grip strength, dexterity, range
of motion, and tactile feedback. When these requirements are combined with multiple hazard condition
protection requirements, glove design becomes a complex task. Table 6.2 shows the glove attributes as
a function of design parameters. Muralidhar et al. (1999) suggest an ergonomic approach for glove
design. Basing on published literature on force distribution in the hand during any task, they recommend
that gloves should have variable thickness, with more thickness in regions where more force is exerted
and less thickness in regions where force exertion is minimal. They argue that such an approach would
yield gloves with minimal performance degradation and maximal protection.
6.11 Glove Evaluation Protocol

The question of how to evaluate a glove has always interested the designer, manufacturer, and the user
of gloves. Standard evaluation protocols do not generally exist. Even in cases where they do exist, as in
cases of rubber gloves used by utility people or fire fighters gloves, the protocols are inadequate. It is
recommended that a typical glove evaluation protocol include the following:
1. Strength tests including grip and pinch tests.
2. A battery of standardized tests to assess dexterity, tactility, and manipulability. Typical standard
tests for these include Pennsylvania Bi-Manual Worksample Assembly Test (PBWAT), Minnesota
Rate of Manipulation Test-Turning (MRMTT), Purdue peg board test, OConnor dexterity test,
and Monofilament test.
3. A battery of functional tests. This is what most of the existing glove evaluation protocols lack.
Functional tests are task specific and should be appropriately designed to simulate actual tasks to
be performed with the concerned gloves.
Evaluation protocols similar to one listed above have been used by OHara et al. (1988) and Bishu and
Klute (1995a) in the evaluation of EVA gloves. Similar protocols have been used for evaluating liners by
Bishu and Chin (1998).
6-10
6.12 Glove Standards

Existing glove standards are of three types. The standards generally describe protective requirements as
in some of the U.S. Occupational Safety and Health Administration standards; or describe the protection
the gloves must provide for safety as in gloves in the chemical industry or for the utility personnel; or
specifically describe glove testing requirements.
6.13 Conclusion
In summary, the following statements can be made with regards to gloves.
1. Gloves protect the hand from the environment, but affect the performance.
2. Gloves range widely in size, type, and cost. They range from general purpose gloves to highly
specialized task-specific gloves.
3. Gloves reduce grip or grasp strength capabilities, while they do not affect torque or pinch
capabilities.
4. Glove reduce hand dexterity, tactility, and manipulability.
5. Providing protection without compromising performance is a continuous challenge for glove
designers.
References
Adams, S.K. and Peterson, P.J. (1988). Maximum voluntary hand grip torque for circular electrical
connectors. Human Factors, 30 (6), pp. 733745.
Banks, W.W. and Goehring, G.S. (1979). The effects of degraded visual and tactile information on diver
work performance. Human Factors, 21 (4), pp. 409415.
Batra, S., Bronkema, L.A., Wang, M., and Bishu, R.R. (1994). Glove attributes: can they predict
performance? International Journal of Industrial Ergonomics, 14, pp. 201209.
Bellingar, T.A. and Slocum, A.C. (1993). Effect of protective gloves on hand movement: An exploratory
study. Applied Ergonomics, 24 (4), pp. 244250.
Bensel, C.K. (1993). The effects of various thicknesses of chemical protective gloves on manual dexterity.
Ergonomics, 36 (6), pp. 687696.
Bishu, R.R., Batra, S., Cochran, D.J., and Riley, M.W. (1987). Glove effect on strength: an investigation
of glove attributes. Proceedings of the 31st Annual Meeting of the Human Factors Society, pp. 901
905.
Bishu, R.R. and Chin, A. (1998). Inner gloves: How good are they? Advances in Occupational Ergonomics
and Safety 1998 (Editor S.Kumar) IDS Press, Ohio, 347400.
Bishu, R.R. and Klute, G. (1995a). The effects of extra vehicular activity gloves on human performance.
International Journal of Industrial Ergonomics, 16, pp. 165174.
Bishu, R.R., Klute, G., and Kim, B. (1995b). Force endurance relationship: does it matter if gloves are
donned? Applied Ergonomics, 26(3), pp. 179185.
Bradley, J.V. (1969). Effect of gloves on control operation time. Human Factors, 11(1), pp. 1320.
Bronkema, L. and Bishu R.R. (1996). The effects of glove frictional characteristics and load on grasp
force and grasp control. Proceedings of the 40th Annual Meeting of the Human Factors and Ergonomic
Society, Philadelphia, PA., pp. 702706.
Bronkema, L., Bishu, R.R., Garcia, D., Klute, G., and Rajulu, S. (1994). Tactility as a function of grasp
force: the effect of glove, pressure and load. Advances in Ergonomics and Safety VI (Editor:
Aghazadeh), Taylor & Francis Ltd., London, pp. 627632.
Chao, E.Y.S., An, K.N., Cooney, W.P., and Linschied, R.L. (1989). Biomechanics of the HandA Basic
Research Study, World Scientific, Singapore.
Gloves
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Chen, Y., Cochran, D.J., Bishu, R.R., and Riley, M.W. (1989). Glove size and material effect on task
performance. Proceedings of the 33rd Annual Meeting of the Human Factors Society, Denver,
Colorado, pp. 708712.
Cochran, D.J. and Riley, M. (1986). The effects of handle shape and size on exerted forces. Human
Factors, 28 (3), pp. 253265.
Cochran, D.J., Albin, T.J., Bishu, R.R., and Riley, M.W. (1986). An analysis of grasp force degradation
with commercially available gloves. Proceedings of the 30th Annual Meeting of the Human Factors
Society, pp. 852855.
Cochran, D.J., Batra, S., Bishu, R.R., and Riley, M.W. (1988). The effects of gloves and handle size on
maximum torque. Proceedings of the 10th Congress of the International Ergonomics Association,
pp. 254256.
Desai, S. and Konz, S. (1983). Tactile inspection performance with and without gloves. Proceedings of
the Human Factors Society, pp. 782785.
Dionne, E.D. (1979). How to select proper hand protection. National Safety News, 119, pp. 4453.
Hallbeck, M.S. and McMullin, D.L. (1993). Maximal power grasp and three jaw chuck pinch as a
function of wrist position, age and glove type. International Journal of Industrial Ergonomics,
11(3), pp. 195206.
Hallbeck, M.S. and McMullin D.L. (1991). The effect of gloves, wrist position, and age on peak threejaw chuck pinch force: a pilot study. Proceedings of the Human Factors Society, 35th Annual Meeting,
pp. 753757.
Hertzberg, T. (1955). Some contributions of applied physical anthropometry to human engineering.
Annals of New York Academy of Sciences, 63, pp. 621623.
Kamal, A.H., Moore, B.J., and Hallbeck, M.S. (1992). The effects of wrist position/glove type on maximal
peak lateral pinch force. Advances in Industrial Ergonomics and Safety IV (Editor S. Kumar) London:
Taylor & Francis, pp. 701708.
Landsmeer, J.M.F. (1962). Power grip and precision handling. Annals of Rheumatic Disease, 21, pp.
164169.
Lyman, J. and Groth, H. (1958). Prehension force as measure of psychomotor skill for bare and gloved
hands. Journal of Applied Psychology, 42:1, pp. 1821.
McGinnis, J.S., Bensel, C.K., and Lockhar, J.M. (1973). Dexterity Afforded by CB Protective Gloves.
U.S. Army Natick Laboratories, Natick, Massachusetts, Report No. 7335-PR.
McMullin, D.L. and Hallbeck, M.S. (1991). Maximal power grasp force as a function of wrist position,
age, and glove type: A pilot study. Proceedings of Human Factors Society 35th Annual Meeting, pp.
733737.
Mital, A., Kuo, T., and Faard, H.F. (1994). A quantitative evaluation of gloves used with non-powered
hand tools in routine maintenance tasks. Ergonomics, 37, (2), pp. 333343.
Muralidhar, A. and Bishu, R.R., (1994) Glove evaluation: a lesson from impaired hand testing.
Advances in Industrial Ergonomics and Safety VI, Editor F.Aghazadeh. Taylor & Francis. pp.
619625.
Muralidhar, A., Bishu, R.R., and Hallbeck, M.S. (1999). The development and evaluation of an ergonomic
glove. Applied Ergonomics, 30:6, pp. 555563.
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National Safety Council, (1976). Keeping hands safe. National Safety News, 119, pp. 4453.
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Surgery, 38B, pp. 902913.
Nelson, J.B. and Mital, A., (1995). An ergonomic evaluation of dexterity and tactility with increase in
examination/surgical glove thickness. Ergonomics, 38(4), pp. 723733.
OHara, J.M., Briganti, M., Cleland, J., and Winfield, D. (1988). Extravehicular activities limitations
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6-12
Plummer, R., Stobbe, T., Ronk, R., Myers, W., Kim, H., and Jaraiedi, M. (1985). Manual dexterity
evaluation of gloves used in handling hazardous materials. Proceedings of the 29th Annual Meeting
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Riley, M.W. and Cochran, D.J. (1988). Ergonomic aspects of gloves: design and use. International
Reviews of Ergonomics, 2, Editor David J.Oborne, Taylor & Francis, pp. 233250.
Riley, M.W., Cochran, D.J., and Schanbacher, C.A. (1985). Force capability differences due to gloves.
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muscle activity. Proceedings of the 32nd Annual Meeting of the Human Factors Society, pp. 647
650.
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Experimental Brain Research, 53, pp. 277284.
7
Industrial Mats
7.1
7.2
7.3
7.4
7.5
7.6
7.7
Introduction
Psychophysical Approach
Physiological Approach
Postural Approach
Biomechanical Approach
Characteristics of Tested Mats
A Standardized Protocol
7-1
7-1
7-2
7-2
7-3
7-3
7-3
Jung-Yong Kim
7.8
Standardized Compressibility Measure

Foot Wear Conditions
7-5
Hanyang University
7.9 Suggestions for the Ergonomist
7-5
7.1 Introduction
Prolonged standing on ones feet is very common in the workplace. Workers who are exposed to prolonged
standing often experience fatigue, discomfort, and swelling of the legs and feet (Winkel, 1981; Rys and
Konz, 1989). Ryan (1989) showed that supermarket cashiers, who stood 90% of their working hours,
experienced discomfort mostly in the lower back area. Redfern and Chaffin (1988) reported a significant
level of fatigue and discomfort in various areas of the body after prolonged standing.
Many studies have shown that the lack of venous return in the lower extremities increased discomfort
during prolonged standing (Brantingham et al., 1970; Winkel and Jorgensen, 1986; Konz et al., 1990).
Local muscle fatigue in the lower back area has also been observed after two hours of standing (Kim et
al., 1994). Likewise, the cause of discomfort and fatigue can be different depending upon the related
body parts.
In industry, floor mats have been widely distributed as a quick remedy to help reduce the discomfort
and fatigue of workers. However, there is no documented guideline to choose the proper matting for an
individuals working condition. This made it difficult for ergonomists or safety managers to objectively
evaluate mats for their own workplaces. Therefore, in this chapter, various studies are introduced and
compared to help readers understand different approaches and testing methods. Furthermore, a few tips
or guidelines in the selection of a proper mat are summarized based upon the results of these studies.
7.2 Psychophysical Approach

A subjective rating technique for postural discomfort (Corlett and Bishop, 1976) has been employed to
examine the level of discomfort in various body parts after prolonged standing. In this technique, workers
can score the level of discomfort by using a body diagram, even though it only provides subjective opinions.
Redfern and Chaffin (1988) used this technique to examine the overall body fatigue and leg fatigue in nine
different floor conditions at the end of the workday. They asked about the discomfort level of the feet,
ankle, shank, knee, thigh, hips, lower back, and upper back. They found that all thebody parts except for
0-8493-1800-9/03/$0.00+$1.50
7-1
7-2
the legs and hips indicated significant differences in a discomfort rating with achange in the floor conditions.
In their study, the feet showed the highest discomfort rating followed bythe ankle and shank. Regarding
the floor conditions, the relatively soft mats consistently showed lessdiscomfort than the concrete floor or
the hard mat. However, the uneven soft surface showed a relativelyhigher rating of tiredness despite its
softness. No quantitative data were reported to specify the propercompressibility of mats in this study. It
was concluded that the different hardness and depth, as well asthe viscoelastic property of the mat are the
main factors in determining the effectiveness of the mat.
Konz et al. (1990) investigated three different mats and a concrete surface. Twenty college students stood
on mats for 90 minutes, and discomfort levels were examined from the neck, shoulder, upper back, mid
back, lower back, buttocks, upper leg, lower leg, ankle, hind foot, mid foot, and fore foot. As a result, all
of the lower parts of the body from the buttocks down were significantly affected by the floor surfaces. All
three mats in this study showed a significant reduction of discomfort compared to the concrete surface.
Importantly, the compressibility of the mats was quantitatively reported based upon the technique developed
by Konz and Subramanian (1989). In this study, the comfort level was inversely related to the mat
compressibility. In other words, the harder the mat was, the more effective it was in reducing discomfort,
which was the reverse outcome compared to the previous study by Redfern and Chaffin (1988).
Hinnen and Konz (1994) tested five different mats by using a compressibility measure (Konz and
Subramanian, 1989). They tested 16 female subjects standing an entire shift for 2 days. Each hour they
measured the discomfort levels of nine body regions. After they compared five mats in terms of discomfort
level and compressibility, they found that there was an optimal range of thickness and compressibility of
the mats to maximize the reduction of discomfort. They concluded that the most comfort can be provided
when the mat is at least 1/2 inch thick and 3 to 4% compressible.
From the results of these studies, it was found that the discomfort level increased with time and
appeared to be the greatest at the feet, and became progressively less and less from the feet up. Also, the
surface type, thickness, and compressibility of the mat have been recognized as important factors in
determining the anti-fatiguing effect during prolonged standing.
7.3 Physiological Approach

During a period of prolonged standing or sitting, the hampered venous and arterial circulation of the
lower leg (Basmajian, 1979; Brantingham, 1970; Winkel and Jorgensen, 1986) can cause foot swelling
or skin temperature change, which are signs of discomfort and tiredness of the leg.
Changes in foot dimension and skin temperature were measured by Rys and Konz (1989) and Konz
et al. (1990). They examined the changes in foot length, width, thickness, and ankle thickness after
standing for 90 minutes and found no significant differences with a variety of floor surfaces. The calf
circumference was also measured by Kuorinka et al. (1978) after one hour of standing. The result
showed 3.5 to 1 mm increase in calf circumference in an hour, but the increase somewhat leveled off
toward the end of the session for half of the participants. Eventually, no difference in calf circumference
was found on the three surfaces.
Skin temperature was measured from the calf and instep by Konz et al. (1990). They observed that the
calf skin temperature had increased by 0.3 C for the concrete surface, while small or negative increases
were recorded for the mat. Conversely, Rys and Konz (1989) reported that the calf skin temperature
measured on the concrete was significantly lower, by 1.5 and 1.9 C, compared to the rubber mat after an
hour of standing. No skin temperature change was found in the instep as the floor surface varied.
7.4 Postural Approach

The frequency of posture shifting was observed by a video recorder, and the center of gravity of body
sway was measured by force platform by (Zhang et al., 1991). They found that the frequency of posture
shift is a sensitive measure to show the effect of prolonged hours of standing, but it is a poor indicator
Industrial Mats
7-3
of showing the difference in floor types. Kuorinka et al. (1978) also measured the frequency of a postural
sway at the beginning and the end of one hour of standing. An increase of frequency was found at the
end of the session, but no difference was found between the three different surfaces.
7.5 Biomechanical Approach

An electromyographic (EMG) study (Basmajian 1979) showed that the standing posture can be maintained
by muscle activities in the solius, iliopsoas, sacrospinalis, and neck extensor. Kuorinka et al. (1978)
examined the EMG signals of the solius muscle and showed a slight trend for the integrated EMG
(IEMG) to rise on a concrete surface, although the initial IEMG was the lowest. Zhang et al. (1991)
measured EMG from the tibialis anterior and gastrocnemius muscles during and after two hours of
standing and found no differences in the fatigue level as the thickness of the floor changed.
Marras (1992) pointed out that the processed EMG used in previous studies simply indicated the
level of muscle contraction that could be a very weak indicator of muscle fatigue during static standing.
He suggested that the EMG power spectrum could be a more effective tool for detecting the localized
muscle fatigue after prolonged standing than the processed EMG. LeVeau and Andersson (1992) used a
spectral analysis to derive EMG power frequency distribution that is the second-order information of an
IEMG signal. They showed that the shift of mean or median value of a frequency distribution could be
used as a sign of local muscle fatigue.
Kim et al. (1994) studied muscle fatigue after a period of two hours of standing by using the EMG
power spectrum. The erector spinae muscle as well as tibialis anterior and gastrocnemius muscle were
examined. Three floor conditions including concrete, thin mat, and thick mat were tested. The
compressibility of the mat was also quantified based on the method used by Konz and Subramanian
(1989). The Kin/Com dynamometer was used to measure the 75% of maximum voluntary contraction
(MVC) before and after prolonged standing. The IEMG immediately recorded after two hours of standing
and the median frequency shift of the EMG power spectrum was computed. In the study, a more local
muscle fatigue in the erector spinae muscle rather than the lower leg muscles was found. The significant
increase of the processed IEMG signal was also observed in the leg muscles, however, that was not
necessarily the sign of local muscle fatigue. It was stated that the decreased discomfort on the softer mat
could be due to the active venous return following lower leg contraction on a soft surface.
7.6 Characteristics of Tested Mats

Various types of mats have been tested in different studies. Currently, individual mats cannot be
quantitatively compared to each other because test protocols are not yet standardized for the studies. In
spite of this, test results in different studies are summarized in Table 7.1. The comfort score in this table
should not be used for direct comparison between mats.
7.7 A Standardized Protocol

A standardized protocol needs to be developed to quantitatively evaluate mats. The protocol is expected to
specify the method and apparatus to measure the thickness and compressibility of material. The material
can be further specified in terms of resiliency and elasticity if an apparatus such as an Instron machine is
available. Moreover, surface type can be specified in terms of the shape and friction coefficient. In general,
the standing period needs to be longer than an hour to see signs of discomfort. Since the standing posture
may change the result greatly, the posture needs to be standardized and strictly instructed during the test.
Standardized Compressibility Measure

Konz and Subramanian (1989) computed an average foot pressure based upon the average male body
weight of 170 lb. (77.3 kg), which is 0.35 kg/cm2. If one uses a 7 7 cm mat specimen, 17.15 kg of force
n/a: not available.

1
The absolute amount of compressed part under the given pressure (Equation 1)
2
The amount of compressed part relative to the original depth of mat
TABLE 7.1 Characteristics of Various Mats
7-4
Industrial Mats
7-5
should be applied to generate the same average foot pressure on the specimen. In actual testing, 18 kg
instead of 17.15 kg was used to record the compressibility of the mat. The duration of compression
should be short enough (about a second) to simulate the actual foot-stepping situation. The equation
computing the average adult foot pressure (Konz and Subramanian, 1989) is as follows:
(7.1)
A proper press machine should be used to control the pressure level precisely. The following are examples
of devices used in previous studies:
1. Instron machine (Redfern and Chaffin, 1988), Instron model 1122 universal testing machine
(Konz et al., 1990).
2. MTS Bionix 858 servo hydraulic materials testing system (Kim et al., 1994)
7.8 Foot Wear Conditions

The discomfort level can be greatly affected by footwear as well as the characteristics of the mat itself.
That is, the standardized test also needs to be specified in terms of footwear conditions, and the results
should be interpreted accordingly. The following are examples of the various footwear used in previous
studies.
1.
2.
3.
4.
5.
Working shoes (Redfern and Chaffin, 1988)

Thin-soled sneakers (Kuorinka et al., 1978)
Dress shoes with hard insole and sneaker with soft insole (Zhang et al., 1991)
Cotton socks and slippers (Konz et al., 1990)
Cotton socks without shoes (Kim et al., 1994)
Moreover, the final selection of mats should be made after considering the interactive effect between
shoes and mats. The right combination of the two materials not only increases the comfort level but can
also prevent slips and falls in the workplace. To quantitatively assess the interaction between shoes and
mats, Redfern and Bidanda (1994) measured the friction level in terms of proper parameters including
dynamic coefficient of friction. Leclercq et al. (1995) also suggested the use of reference conditions
including lubricant, floor surface and footwear model to accurately measure the slipping resistance.
7.9 Suggestions for the Ergonomist

Selecting the best mat is not a simple task. Commercialized mats sometimes use materials with different
compressibility for each foot. This type of mat may be able to stimulate the venous circulation of one leg
better than the other. However, it has not been adequately studied to determine how effective those specially
designed mats are. Presently, the simple and safe way of selecting a mat is to choose one that is not too
hard, not too soft. For example, workers who stand and walk around may need a good hard and even
surface to minimize unnecessary ankle action to balance their posture. At the same time, the softness of the
mat helps the blood pumping mechanism while standing quietly to reduce the discomfort level. Therefore,
the combination of solid surface and a soft padding may meet the needs of workers who both walk and
stand. In summary, the surface shape, softness, thickness, kind of padding, and material should be carefully
considered in selecting the right mat to meet the specific requirements of an individuals workplace.
Further research should be conducted under the standardized protocol to acquire information on the
anti-fatiguing and anti-slipping effect of various mats. Then, a quantitative ergonomic guideline can be
developed based upon the standardized data. Eventually, such guidelines will help ergonomists and
safety managers select the best mat for the individual worker.
7-6
References
Basmajian, J.V. and DeLuca, C. 1979. Their functions revealed by electromyography, in Muscle Alive.
Williams & Wilkins, Baltimore, MD.
Brantingham, C.R., Beekman, B.E., Moss, C.N., and Gorden, R.B. 1970. Enhanced venous blood pump
activity as a result of standing on a varied terrain floor surface. Journal of Occupational Medicine,
12:164169.
Corlett, E.N. and Bishop, R.P. 1976. A technique for assessing postural discomfort. Ergonomics, 19(2):
175182.
Hinnen, P. and Konz, S. 1994. Fatigue mats. Advances in Industrial Ergonomics and Safety VI, Taylor
& Francis. 323327.
Kim, J.Y., Stuart-Buttle, C., and Marras, W.S. 1994. The effects of mats on back and leg fatigue. Applied
Ergonomics, 25(1): 2934.
Konz, S., Bandla, V., Rys, M., and Sambasivan, J. 1990. Standing on concrete vs. floor mats. Advances
in Industrial Ergonomics and Safety II, Taylor & Francis. 991998.
Konz, S. and Subramanian, V. 1989. Footprints. Advances in Industrial Ergonomics and Safety I, Taylor
& Francis. 203205.
Kuorinka, I., Hakkanen, S., Nieminen, K., and Saari, J. 1978. Comparison of floor surfaces for standing
work. Biomechanics VI-B, 207211.
Leclercq, S., Tisserand, M., and Saulnier, H. 1995. Assessment of slipping resistance of footwear and
floor surfaces. influence of manufacture and utilization of the products. Ergonomics, 38(2): 209
219.
LeVeau B. and Andersson, G. 1992. Output forms: data analysis and applications. Interpretation of
electromyographic signals. Selected Topics in Surface Electromyography for Use in the Occupational
Setting: Expert Perspectives. U.S. Department of Health and Human Services. 70102.
Marras, W.S. 1992. Applications of electromyography in ergonomics. Selected Topics in Surface
Electromyography for Use in the Occupational Setting: Expert Perspectives. U.S. Department of
Health and Human Services. 122143.
Redfern, M.S. and Bidanda, B. 1994. Slip resistance of the shoe-floor interface under biomechanicallyrelevant conditions. Ergonomics, 37(3): 511524.
Redfern, M.S. and Chaffin, D.B. 1988. The effect of floor types on standing tolerance in industry.
Trends in Ergonomics/Human Factors V, (Ed.) F. Aghazadeh, Elsevier Science Pub.
Ryan, G.A. 1989. The prevalence of musculoskeletal symptoms in supermarket workers. Ergonomics,
32: 359371.
Rys, M.J. and Konz, S. 1989. Standing with one foot forward. Advances in Industrial Ergonomics and
Safety I, (Ed.) A. Mital, Taylor & Francis.
Rys, M.J. and Konz, S. 1989. An evaluation of floor surfaces. Proceedings of the Human Factors Society
33rd Annual Meeting. 517520.
Rys, M. and Konz, S. 1990. Floor surfaces. Proceedings of the Human Factors Society 34th Annual
Meeting. 575579.
Winkel, J. 1981. Swelling of the lower leg in sedentary workpilot study. Journal of Human Ergology,
10:139149.
Winkel, J. and Jorgensen, K. 1986. Evaluation of foot swelling and lower-limb temperature in relation
to leg activity during long-term seated office work. Ergonomics, 29(2): 313328.
Zhang, L. Drury, C.G., and Woollet, S.M. 1991. Constrained standing: evaluation of the foot/floor
interface. Ergonomics, 34:175192.
8
Ergonomic Principles
Applied to the
Prevention of Injuries to
the Lower Extremity
Steven A.Lavender
Rush-Presbyterian-St. Lukes
Medical Center
Medical Centers
8.1 Lower Extremity Injuries: Is There an

Occupational Problem?
8.2 Preventing Injury: Types of Ergonomic Controls
81
84
Floor Mats Shoe Insoles The Foot-Floor

Interface Stair Design Help for Those in
Kneeling Postures
8.3 Summary
88
Most of the ergonomics literature dealing with the prevention and control of musculoskeletal disorders
in the workplace has focused on the upper extremity and the back. Comparatively little attention has
been given to lower extremity musculoskeletal disorders which occur in the workplace. One could argue
that since the lower extremity problems are not well documented in ergonomic journals, the problems
may not be of much practical significance. The first objective of this chapter is to review the current
literature regarding occupational musculoskeletal disorders affecting the lower extremities and to
demonstrate the significance of the problem. The second objective is to describe what types of intervention
strategies are available to minimize the likelihood of future or recurrent injuries to the feet, ankles,
knees, and hips.
8.1 Lower Extremity Injuries: Is There an Occupational Problem?

The sports medicine literature is full of lower extremity overuse injuries in athletes. All too often we
have seen athletes relegated to the sidelines following some sort of soft tissue injury that is likely to be
the effect of not just a single incidence, but rather a cumulative loading pattern during practice and
competition. Luckily, in most occupational environments the intensity of the exercise is greatly diminished,
however, the cumulative exposure problem still persists. Recent studies have begun to report the
relationship between occupational factors and knee, hip, and foot trauma.
Lindberg and Axmacher (1988) reported the prevalence of coxarthosis in the hip to be greater in
male farmers than in an age-matched group of urban dwellers. Vingard et al. (1991) classified bluecollar occupations as to whether static or dynamic forces could be expected to act on the lower extremity.
The authors found that those employed in occupations that experienced greater loads on the lower
extremity, namely farmers, construction workers, firefighters, grain mill workers, butchers, and meat
0-8493-1800-9/03/$0.00+$1.50
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preparation workers, had an increased risk of osteoarthrosis of the hip. Similarly, Vingard et al. (1992)
found that disability pensions for hip osteoarthrosis were significantly more likely to be received by
males employed as farmers, forest workers, and construction workers.
Lindberg and Montgomery (1987) reported that knee gonarthrosis (osteoarthritis), as defined by a
narrowing of the joint space with a loss of distance between the tibia and the femur in one compartment,
of one-half or more of the distance in the other compartment of the same knee joint or the same
compartment of the other knee, or less than 3 mm, was more common in those who had performed
jobs that required heavy physical labor for a long time. Kohatsu and Schurman (1990) found that,
relative to controls, the individuals with severe OA were two to three times more likely to have worked
in occupations requiring moderate to heavy physical work. Anderson and Felson (1988) reported a
relationship between the frequency of knee bending required in a respondents occupation and
osteoarthritis in the older working population (55 to 64 years). Moreover, these same authors have
shown that the strength demands of the job were predictive of knee OA in the women from this older
age group (Anderson and Felson, 1988). The authors suggest that the increased OA in those with long
exposure to occupational tasks is indicative of the role of repetitive occupational exposure. Further
supporting the link between material handling jobs and knee problems is the finding by McGlothlin
(1996), who recently reported that beverage delivery personnel were experiencing discomfort in the
knees, in addition to the anticipated discomfort in the back and shoulders. It should be recognized,
though, that personal risk factors for osteoarthrosis of the knee include obesity and significant knee
injury (Kohatsu and Schurman, 1990). These same authors found no relationship between leisure time
activities and knee OA.
Torner et al. (1990) reported that chronic prepatellar bursitis was the predominant knee disorder in
120 fishermen who underwent an orthopedic physical examination. Forty-eight percent of the men
examined showed this disorder. Interestingly, the finding was as common among younger men as in
older men. The authors believe that this disorder is a secondary effect of the boats motion. The knees
are used to stabilize the body by pressing against gunwales or machinery as tasks are performed with the
upper extremities. Furthermore, just standing in mild sea conditions (maximum roll angles of 8 degrees)
has been shown to considerably elevate the moments at the knees as the motion in the lower extremities
and the trunk are the primary means for counteracting a ships motions (Torner et al., 1991).
The etiology of beat knee was described by Sharrard (1963). He reported on the examination of
579 coal miners. Forty percent of those examined were symptomatic or had previously experienced
symptoms. Most of the injuries could be characterized as acute simple bursitis or chronic simple bursitis.
The majority of the affected miners were colliers whose job requires constant kneeling at the mine face.
There was a strong relationship between the coal seam height (directly related to roof height in a mine)
and the incidence of beat knee. The incidence rates were much higher in mines with a roof height under
four feet as compared with those with greater roof heights. Obviously, this factor greatly affects the
work posture of the miners. With higher roof heights miners can alternate between stooped and kneeling
postures, but when seams are one meter or less, the stooped posture is no longer an alternative. Gallagher
and Unger (1990), for example, present recommendations for weight limits of handled materials in
underground mines. Below 1.02 m these are based on miners in kneeling postures. Sharrard (1963) also
speculated on the individual factors attributable to the disorder and found a higher incidence among
younger men. However, this may be due to the healthy worker effect (Andersson, 1991) in which
older miners with severe beat knee have left the mining occupation.
Tanaka et al. (1982) reported that the occupational morbidity ratios for workers compensation
claims of knee-joint inflammation among carpet installers was twice that found in tile setters and floor
layers, and was over 13 times greater than that of carpenters, sheet metal workers, and tinsmiths. Others
have shown the knees of those involved with carpet and flooring installation were more likely to have
fluid collections in the superficial infrapatellar bursa, have a subcutaneous thickening in the anterior
wall of the superficial infrapatellar bursa, and have an increased thickness in the subcutaneous prepatellar
region (Myllymaki et al., 1993).
Ergonomic Principles Applied to the Prevention of Injuries to the Lower Extremity
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Thun et al. (1987) determined the incidence of repetitive knee trauma in the flooring installation
professions. While all flooring installers spend a large amount of time kneeling, the authors divided the
154 survey respondents into two groups, tilesetters and floor layers, based on their use of a kneekicker. This device is used to stretch the carpet during the installation process. These respondents were
compared with a group of millwrights and brick layers whose jobs did not require extended kneeling
and/or the use of a knee kicker. Of the 112 floor layers (those who used the knee kicker) the prevalence
rate of bursitis was approximately twice that found in the 42 tilesetters, and over three times that found
in the 243 millwrights and brick layers. However, the prevalence in both groups of flooring workers of
having required needle aspiration of the knee was almost five times that of millwrights and bricklayers.
These results suggest that long durations of occupational kneeling is related to fluid accumulation, yet
the bursitis is due to the repetitive trauma endured by the floor layers using the knee kicker. Village et al.
(1991) found that the peak impulse forces generated in the knees of carpet-layers when using the kneekicker were on the order of 3000 N. The opposite knee which was supporting the body during this
action had an average peak force of 893 N. Bhattacharya et al. (1985) reported knee impact forces of
2469 N (about three times body weight) for a light kick and 3019 N (or about four times body weight)
for a hard kick. These light and hard kicks resulted in impact decelerations of 12.3 g and 20 g, respectively.
The authors observed that the knee kicking action during flooring installation occurred at a rate of 141
kicks per hour. Putting the knee injuries in perspective, pain was reported by 22% of questionnaire
respondents in the tufting job at a carpet manufacturer. However, knees were only listed in 2.4% of the
accident records. Thus, the knee is frequently the site of discomfort, although there may be few lost days
associated with knee pain (Tellier and Montreuil, 1991).
Cumulative trauma injuries can take the form of stress or fatigue fractures. Linenger and Shwayhat
(1992) reported training-related injuries to the foot occurred in military personnel undergoing basic
training at a rate of three new injuries per 1,000 recruit days. These authors found that stress fractures
to the foot, ankle sprains, and achilles tendinitis accounted for the bulk of the injuries. Anderson (1990)
found the stress fractures to be most common in the distal second and third metatarsal bones but could
occur in any of the bones in the foot. Giladi et al.s (1985) findings indicated that 71% of the stress
fractures in their sample of military recruits occurred in the tibia and 25% in the femoral shaft. Moreover,
they found the fractures to occur later in the training process than reported by others. Jordaan and
Schwellnus (1994) reported that overuse injuries, when normalized according to training hours per
week, decreased from week 1 to week 4, showed a resurgence in week 5, and a large peak in the final
week of training. The injury rates corresponded to the weeks in which there was increased marching and
less field training.
With regard to the overuse injuries found in military recruits, some investigators have looked into
aspects of lower limb morphology that may indicate which individuals will be more susceptible to injury
while performing the tasks associated with military training. Giladi et al. (1991) reported the influence
of individual factors on the incidence of fatigue fractures, specifically, they found that individuals with
narrow tibiae, and/or a greater external rotation of the hip were more likely to experience fatigue fractures.
Cowan and colleagues (1996) reported the relative risk of overuse injuries was significantly higher in
military recruits with the most valgus knees. In addition, these authors showed that the Q angle,
which defines the degree of deviation in the patellar tendon from the line of pull on the patella by the
quadriceps muscles, was shown to be predictive of stress fractures.
In summary, several occupational risk factors have been identified which place an employee at increased
risk for disorders in the lower extremity. The literature has shown that heavy physical labor and frequent
knee bending are factors, especially in the older component of the work force, thereby suggesting an
interaction between the age degenerative processes and cumulative work experience. In other occupations
the risk of lower extremity disorders is increased through poor footing conditions. And clearly, the role
of direct cumulative trauma in those employees who must maintain kneeling postures and use their
knees to strike objects (knee kicker) cannot be overlooked when considering preventive measures.
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8.2 Preventing Injury: Types of Ergonomic Controls

Several types of control mechanisms to prevent or accommodate lower extremity disorders are available.
This section will focus on the techniques whereby the foot-floor interface can be optimized. This includes
measures to prevent slips and falls, stress fractures, as well as improving circulation and comfort in the
lower extremities for those who remain in relatively static work postures throughout the day.
Floor Mats
Floor mats are often used for local slip protection. While inexpensive, they create a possible trip hazard,
interfere with operations or cleanliness, and wear excessively (Andres et al., 1992). Several investigators
have looked into the use of floor mats to reduce the fatigue effects observed in jobs that require prolonged
standing. The subjects tested by Kuorinka et al. (1978) indicated through subjective ratings that they
preferred to work on softer surfaces as opposed to harder surfaces. A foam plastic surface was rated the
best and concrete the worst. These authors reported a moderate correlation between the subjective
comfort ratings of the five surfaces tested and the order of surface hardness. However, integrated
electromyographic (EMG) signals, median frequency of the EMG, measures of postural sway, and measures
of calf circumference did not show any significant difference due to the floor covering. Hinnen and
Konz (1994) asked employees in a distribution center to stand for two 8-hour shifts on each of five mats
tested in the study. Approximately every hour the employees rated their comfort in several body regions
including the upper leg, lower leg, ankle, and back. A scale of 0 (no discomfort at all) to 10 (extreme
discomfort) was used. While these workers experienced relatively little discomfort, the mats with
compressibility between 3 and 4% did best in the upper leg discomfort rankings as well as subject
preference rankings. Marginally significant changes in the discomfort ratings were reported for the
ankle. The ratings of lower leg and back discomfort showed no significant differences.
Rys and Konz (1989,1990) reported on several anthropometric and physiological measures including
changes in foot size and skin temperature at the instep and the calf. In general, the mats included in this
study were significantly different from concrete in that there was greater skin temperature at both measured
locations and greater comfort ratings, These authors report that the comfort was inversely related to
mat compressibility.
Cook et al. (1993) used surface EMG to study the recruitment of the anterior tibialis and paraspinal
muscles when standing on linoleum-covered concrete vs. an expanded vinyl 9.5 mm-thick surgical mat.
After subjects stood for two sessions, of two-hour duration, on the mat and on the linoleum, it was
concluded that there were no significant changes in the mean of the rectified EMG signals in either
muscle due to the mats. As in the studies above, subjective data support the use of the mat.
Kim et al. (1994) tested two types of floor mats and a control condition in which subjects stood on
concrete. While these authors observed muscular fatigue, as determined by a shift in the EMG median
frequencies in the gastrocnemius and anterior tibialis muscle, the EMG median frequencies in these
muscles were not affected by the use of floor mats. The median frequency shift in the erector spinae was
reduced when subjects stood on the thinner and more compressible mat. The authors hypothesized that
greater compressibility would have made for a less stable base of support, thereby, requiring more
frequent postural changes in the trunk to overcome the destabilization associated with postural sway.
Thus, the dynamic use of erector spinae muscles to correct for postural sway would facilitate the oxygen
delivery and the removal of contractile by-products through increased blood flow. A further test of this
hypothesis would evaluate whether this motion occurred only in the trunk, or if it occurred in the lower
extremities which did not show the spectral shift due to the floor condition.
Shoe Insoles
It is widely recognized that shoe design plays a critical role in the development of overuse syndromes in
runners (Lehman, 1984; McKenzie et al., 1985; Pinshaw et al., 1984). Moreover, the role of the shoe in
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controlling lower extremity kinematics has been reviewed by Frederick (1986) and discussed by McKenzie
et al. (1985). Similarly, the use of wedged insoles has been shown to alter the static posture of the lower
extremity (Yasuda and Sasaki, 1987). Sasaki and Yasuda (1987) have shown the use of wedged insoles
to be a good conservative treatment for medial osteoarthritis of the knee in the early stages. These
authors reported that patients with early radiographic stages of osteoarthritis and who were provided a
wedged insole had reduced pain and improved walking ability relative to controls without the insole.
Clearly, the lower extremity disorders reported by runners represent extreme overuse, however, the
treatment and prevention mechanisms may be applicable to occupational settings where employees
must stand, walk, run, or even jump during their normal work activities. Padded insoles have been
investigated for the shock-abating effects on the skeletal system. Loy and Voloshin (1991) used lightweight
accelerometers for measuring the shock waves as subjects walked, ascended and descended stairs, and
jumped off platforms of a fixed height. The peak magnitude of the shock waves during jumping activities
were approximately eight times that seen during normal walking. The results indicated that the insoles
reduced the amplitude of the shock wave by between 9 and 41% depending upon the activity performed.
The insoles were most effective at reducing heel strike impacts and had the largest effect with the jumping
activities.
Milgrom et al. (1985) tested the effects of shock attenuation on the incidence of overuse injuries in
infantry recruits. Earlier studies conducted by fixing accelerometers to the tibial tubercle showed that
soldiers wearing modified basketball shoes had mean accelerations that were 19% less than soldiers
wearing lightweight infantry boots. These authors also found that over the 14 weeks of basic training
the modified basketball shoes reduced the metatarsal stress fractures. However, the tibial and femoral
stress fractures were not affected by the shoes worn. Gardner et al. (1988) compared viscoelastic polymer
insole and a standard mesh insole that were issued by platoon to over 3,000 marine recruits. While the
polymer insole had good shock absorbing properties, the incidence of lower extremity stress injuries
over the 12-week basic training program were unaffected by the insole used.
Several studies have been conducted to evaluate variations in insole materials. Leber and Evanski
(1986) describe the characteristics of the following seven insole materials: Plastazote, Latex foam,
Dynafoam, Ortho felt, Spenco, Molo, and PPT. These authors measured the plantar pressures in 26
patients with forefoot pain. All insole materials reduced the plantar pressure by between 28 and 53%
relative to a control condition. However, PPT, Plastazote, and Spenco were the superior products. Viscolas
and Poron were found to have the best shock absorbency of the five insole materials tested by Pratt et al.
(1986). Maximum plantar pressures were found to be significantly reduced in the forefoot region with
PPT, Spenco, and Viscolas, although the three materials were not significantly different (McPoil and
Cornwall, 1992). In the rear foot region, however, McPoil and Cornwall (1992) report that only the
PPT and the Spenco reduced the maximum plantar pressure relative to the barefoot condition. The
plantar pressure in the rearfoot region was not significantly reduced with the Viscolas. Interestingly,
based on the shock absorbency data from Pratts (1988) 30-day durability test, the resilience of Viscolas,
PPT, and Plastazote could be described as excellent, good, and poor, respectively. Sanfilippo et al. (1992)
also reported the change in foot-to-ground contact area as a function of insole material. Plastazote,
Spenco, and PPT led to a significantly greater contact area than the other materials tested.
In summary, insoles appear to be effective at modifying the lower extremity kinematics and reducing
the peak plantar pressures, although their effectiveness is dependent upon the material used. Additional
research is needed to clarify the effectiveness of insoles in controlling lower extremity stress injuries.
Based on the previous discussion it should be clear that the effectiveness of this control strategy will be
dependent upon shock absorbing capacity, the pressure dispersion, and the durability properties of the
insole materials selected.
The Foot-Floor Interface

Controlling slip and fall injuries requires a multifaceted approach. The foot-floor interface is analogous
to the four-legged stool shown in Figure 8.1. To optimize the postural stability all four legs need to be in
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FIGURE 8.1 The four-legged stool showing the interdependence of the factors affecting postural stability at the footfloor interface.
place and of equal length. The obvious legs are the flooring material and the shoe tread material and
design. The environmental conditions represent the third leg as these affect the coefficient of friction
between the shoe and the floor. And the fourth leg of the stool pertains to the behavior of the individual
wearing the shoe. This behavioral component includes an individuals locomotion pattern, perception
of environmental conditions, and allocation of the attentional resources necessary for adaptive behavior.
If any of the four primary components are missing, at least to some degree, a leg of the stool is cut off by
some random amount. For example, if the environmental conditions result in an oil film on the floor
surface, the stool may still stand on the three remaining legs provided the shoe design and the floor
material are adequate, and that the individual perceives the environmental conditions and adapts his or
her behavior accordingly. Thus, the stool remains standing, although precariously, in spite of a shortened
leg. If the individual did not attend to the environmental conditions the psychomotor leg would have
been shortened, thereby making it unlikely that the stool will remain standing. In summary, the prevention
of lower extremity injuries due to slips and falls requires attention be paid to each component or leg of
the stool responsible for maintaining the bodys stability.
In considering slip and trip prevention it is the dynamic friction of the interface, as opposed to static
friction, which is considered more critical in determining slip potential as most slips occur when the heal
initially contacts the ground (Redfern et al., 1992; Strandberg, 1983). Gronqvist et al. (1992) has
quantified slip resistance by determining the coefftcient of friction between the interacting surfaces and
possible contaminants. These authors reported that the important counter measures against floor
slipperiness are the microscopic porosity and roughness of floor coverings. Flooring materials which
have rough, unglazed, raised patterns, or are made from porous ceramic tiles are best for reducing
slipping hazards in areas which must maintain very high standards for hygiene. In environments where
the hygiene standards can be relaxed, very rough epoxy or acrylic resin floor materials should be used.
Floor surface issues become even more critical on ramps and other inclined work surfaces. Redfern and
McVay (1993) reported that when walking down ramps, the required coefficient of friction increased in
a nearly linear fashion as ramp angle increased. This was due to the high shear forces encountered
during heal strike as an individual walks down a ramp.
Gronqvist and Hirvonen (1994) studied slip resistance properties of footwear on iced surfaces. They
found that the shoe material significantly affected the slip resistance. Shoe heels and soles constructed
from thermoplastic rubber with a large cleated area were best for dry ice conditions (-10 C). Very few
of the shoes tested functioned well on wet ice (0 C) where there is a boundary layer of water on top of
the ice. In fact, the shoes which worked best for dry ice conditions were among the worst when tested in
the wet ice condition. Shoes with the sharpest cleats yielded the greatest friction readings under this
condition. Hardness of the heel and sole material was not a significant factor on wet ice.
Little consensus is found in sole hardness data, and what differences exist are not of practical
significance (Leclercq, 1994). In general, microcellular PU (polyurethane) heels and soles are
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recommended, although footwear showed less of an effect on the kinetic coefficient of friction than did
variations in floor surfaces (Gronqvist et al., 1992). Relative to rubber soles and heels, Manning et al.
(1985) reported that boots with microcellular polyurethane (PU) soles and heels better resisted polishing
caused by smooth, wet, or oily floors; had a longer life; and had a greater average coefficient of friction.
The COF of the PU improved over time, indicating that the initial smooth surface of the boots should be
roughened prior to use. Tisserand (1985) recommends avoiding the use of micro-treads or small
bumps. However, tread design and material are not independent factors when it comes to the coefficient
of dynamic friction. Leclercq et al. (1994) stress that the ridges in the tread need to be as sharp as
possible to wipe away contaminants on the surface. In addition, these authors point out that the tread
design needs to provide channels for the surface contaminants to flow through. Slipping risk is greatest
at heel-strike, and therefore, the heel of the shoe requires considerable attention. There is controversy
regarding whether the use of a bevelled heel to increase contact surface area is superior to the use of a
small contact surface that would result in high contact pressure (Leclercq et al., 1994).
Tisserand (1985) has promoted the concept of a mental model whereby an individual has constant
input as to the friction available from the surface being walked upon. The model is updated as new
information is received indicating a change in the surface conditions. Slips occur where there is a
discrepancy between the mental model of the surface and the actual conditions. Thus, as Tisserand
(1985) points out: The risk of slipping lies more in the gradient of the friction coefficient of the surface
than in its absolute value: such as when in a car, a small patch of ground with a low coefficient (an
isolated patch of ice, for example, on a large surface with a high coefficient of friction) is more dangerous
than a surface with a medium but constant coefficient of friction (pp. 1039).
Swensen assessed the subjective judgments of surface slipperiness by having groups of iron workers
and students walk across steel beams. The subjects were asked to rank the slipperiness of four types of
steel coatings and four levels of surface contaminant: none, water, clay, plastic covering oil. Static coefficient
of friction (COF) values ranged between .98 and .20. For the experienced and inexperienced subjects the
correlation between the subjective surface ratings and the actual COF measured following the test were
.75 and .90, respectively. The subjects exposed to the very slippery conditions (COF=.20) created by the
oil and plastic compensated by shortening their stride length, thereby lessening the foot velocity and
shear forces, and maintained the bodys center of gravity within the smaller region of stability. Thus,
people can detect the COF and adapt their gait accordingly. When this adaptation fails to take place, an
individual is much more likely to slip and possibly fall.
Ideally, with the perfect shoe-floor interface, one with no environmental contaminants, the individuals
behavior would be not be a factor. But in few cases would this exist, and then, even a small fluctuation
in the environment would be enough to disrupt the balance of the now three-legged stool. Therefore,
administrative control measures need to be considered as a means for maintaining the behavior necessary
for stable work postures. Employees should be trained to recognize where slippery conditions are likely
within a facility, and that they be alert to changing environmental conditions. Further, employees should
be encouraged to report maintenance problems with machines that affect the flooring conditions.
Stair Design
Pauls (1985) reports that only 6% of stair accidents entail slips, more often accidents are due to overstepping. This author suggests that the overstepping occurs because the individual descending the
stairs does not accurately perceive the stair width (also known as tread length). Thus, the foot is placed
too far forward on the step. This scenario accounts for 19% of all stair accidents. This work highlights
the interplay between engineering design factors (stair size) and behavioral factors. Research has suggested
that stairs should have risers no higher than 178 mm (7 inches) and treads no shorter than 279 mm (11
inches).
A secondary issue in stair design is the complex effect of visual distractions. Pauls (1985) reported
that when visual distractions were present people actually focused harder on descending the stairs.
When no distractions were present people exhibited less caution. Similarly, patients commonly reported
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that their falls leading to femoral neck fractures were initiated with missing a step down, for example,
unexpectedly stepping off a curb (Citron et al., 1985). This suggests that when the brain recognizes the
potential distractions attention resources are allocated to the task at hand, whereas without some overt
distraction the brain may allocate adequate attentional resources, or it may not. Archea (1985) has
stressed that an older population that may not have the perceptual and motor capabilities found in
younger individuals are more vulnerable to accidents on stairs. These findings suggest that the effects of
distractions around stairs changes through the aging process.
Help for Those in Kneeling Postures

Sharrard (1963) reported that there was no relationship between the type of knee pads used and the
incidence of beat knee in miners. This author recorded peak pressures on the order 35.7 kg per square
cm as simulated mining tasks were performed. These compression forces were shown to vary widely
throughout the 2.5 second cycle time for a shoveling task. Unfortunately, the author had no
instrumentation capable of determining the shear forces and the torsional moments placed on the knee
during the simulated tasks. At the time of Sharrards paper a bursa pad had been designed that
allowed perspiration to escape, pushed coal particles away from the skin, and provided satisfactory
cushioning. Although no control group was used, the author reported that of the 24 previously affected
men selected to test the pad under working conditions only two reported a recurrence of beat knee after
a 12-month period.
Ringen et al. (1995) reported on a new tool to reduce the knee and back trauma in those who tie
rebar rods together in preparation for pouring concrete. No longer will concrete workers need to kneel
or stoop for extended periods to interconnect the iron rods as this tool allows the operator to work in a
standing posture.
Powered carpet stretching tools are available to remove the repeated trauma experienced by carpet
layers. However, their widespread implementation depends upon educating flooring workers on the
trade-offs between the additional time necessary to operate the tool and the knee disorders associated
with the conventional technique.
8.3 Summary
Ergonomic texts historically have focused relatively little attention on the prevention of lower extremity
disorders or the accommodation of individuals returning to work who have experienced a lower extremity
disorder. In part this may be due to an underappreciation of the frequency and severity of occupational
lower extremity disorders. Unlike many back or upper extremity disorders which have their origins in
the repeated stresses placed on muscular, tendinous, and ligamentous tissues, many of the occupational
lower extremity disorders occur through direct compression of the body tissues by a surface in the
environment. As a result, the occupational lower extremity disorders often involve cartilaginous tissue
and bone. Therefore, accommodation and prevention of these disorders occurs primarily through the
optimizing the bodys contact with surfaces in the environment. This chapter has illustrated some of the
key ways in which this can be accomplished.
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9
9.1 Foot/Leg
9.2
9.3
Anatomy Physiology Dimensions

Activities of the Foot
Standing Walking Running Stepping
Accidents
Falls Causes of Falls Solutions for Falls
9.4 Fatigue/Comfort
Stephan Konz
Kansas State University
9.5
Walking Standing
Foot Controls
Pedals Switches
91
95
96
910
912
This chapter is divided into five sections. Section 1 (Foot/Leg) gives the anatomy, physiology, and
dimensions of the foot. Section 2 (Activities) describes the activities of standing, walking, running, and
stepping. Section 3 (Accidents) discusses falls, their causes and solutions. Section 4 (Fatigue/Comfort)
discusses walking and standing. Section 5 (Foot Controls) briefly describes pedals and switches.
9.1 Foot/Leg
Anatomy
Figure 9.1 shows the bones of the foot and ankle. The toes (foot fingers) are divided into metatarsals
and three phalanges (except for the big toe, which only has two phalanges). In supporting the body, the
calcaneus (heel) supports 50% of the weight, the 1st and 2nd metatarsal 25%, and the 3rd, 4th, and 5th
metatarsal 25%. In between are two arches: (1) the medial arch (calcaneus, the talus, the navicular, the
cuneiform bones, and the 1st, 2nd, and 3rd metatarsals) and (2) the lateral arch (calcaneus, talus,
cuboid, and the 4th and 5th metatarsals).
Under the heel (calcaneus) is a very important shock absorber, the heel pad (about 1.8 cm thick). The
bottom of the calcaneus is not spherical but has two small mountains; the pad reduces the pressure on
these mountains, and thus on the ankle, knee, and back.
The foot is connected to the ankle with a mortise and tenon joint. The vertical leg of the mortise is
short on the outside (lateral side); in addition, the ligaments holding the bottom of the fibula (lateral
malleolus) to the talus and calcaneus are relatively weak. In contrast, the vertical leg of the inside (medial)
mortise is longer, and the ligaments holding the bottom of the tibia (medial malleolus) to the talus are
relatively strong.
Inward rotation (inversion) of the foot tends to pull the ligaments from the bone; with proper treatment,
healing is usually complete in about 3 weeks. There is a danger that the injured person may not seek
medical advice even with a complete tear of the ligaments (connecting either the malleolus and the talus
or the tibia and fibula). Then there would be need for surgical repair and rigid fixation in a cast for 2 to
3 months.
0-8493-1800-9/03/$0.00+$1.50
9-1
9-2
FIGURE 9.1 The foot and ankle. The right foot is viewed from below (top left) and the outside (top right); the left
ankle (bottom) is viewed from the front.
External rotation (eversion) of the foot tends to break one of the malleoli bones (vertical part of the
mortise). These serious injuries tend to be recognized and the injured person goes to a physician.
Approximately 80% of all foot fractures involve the toes; almost all of them could be prevented by
safety shoes since they lie within the area protected by the metal toe cap (Rowe, 1985).
Three venous systems drain the lower limbs: (1) a deep central system drains the muscles, (2) a
superficial system drains the foot and the skin of the leg, and (3) a perforating system connects the deep
and superficial systems.
Physiology
The veins are the bodys blood storage location. If the legs dont move, the blood from the heart tends
to go down to the legs and stay there (venous pooling). This causes more work for the heart, as, for a
constant supply of blood, when there is a lower ml of blood per beat, then there must be more beats.
Venous pooling causes swelling of the legs (edema) and varicose veins. The foot swelling during stationary
seated desk work can be overcome by modest leg activity (such as rolling the chair about the workstation)
(Winkel and Jorgensen, 1986).
Venous pressure in the ankle of sedentary people is approximately equal to hydrostatic pressure from
the right auricle. Pollack and Wood (1949) gave a mean ankle venous pressure of 56 mmHg for sitting
and 87 for standing. Nodeland et al. (1983) gave 48 for sitting and 80 for standing. Pollack and Wood
reported walking drops ankle venous pressure to about 23 mmHg (Nodeland et al. reported 21) in
9-3
TABLE 9.1 Selected Dimensions (cm) of Nude U.S. Adult Civilians
The percentages show the dimension as a percent of stature height.

Shoes add 25 mm height for males and 15 mm for females. Shoes add
.9 kg to body weight.
Source: Konz, S. 1995. Work Design: Industrial Ergonomics, 4th
ed., p. 111. Publishing Horizons, Scottsdale, AZ. With permission.
about ten steps. The fall occurs as the calf muscles contract in taking the next step before venous filling
has been completed; thus additional blood is pumped out of the leg, causing a further drop in pressure
when the calf muscles relax. The drop stabilizes in about ten steps when the incoming flow to the vein
from the capillaries equals the flow out of the leg. Thus, walking can partially compensate for posture;
for example, Nodeland et al. reported standing bench work (i.e., with occasional steps around the area)
had ankle pressure approximately equal to sitting at a desk (48 mmHg).
Because of vasoconstriction, foot skin temperature (without shoes) usually is the lowest body skin
temperature. Normal skin foot temperature = 33.3C for males but 31.2 for females (Oleson and
Fanger, 1973).
Dimensions
Table 9.1 gives some dimensions for U.S. adults. A large portion of the variation in human stature is in
leg length; the torso is relatively constant in height. Figure 9.2 shows the mean difference, when standing,
between the inside of the two feet is about 107 mm. The distance between foot centerlines is about 107
+ 90 = 197 mm (200 mm in round numbers). The distance between outside edges is 107 + 90 + 89 = 286
(300 mm in round numbers). Yet mean height for males is 1756 mm! Thus there is a base of only 200 to
300 mm for a structure of 1756 mm.
The mean pressure (Rys and Konz, 1994) on the feet can be estimated from:
(9.1)
where
MP = mean pressure, kg/cm2
WT = body weight, kg
Thus a 70 kg person would have an MP = .33 kg/cm2. But the peak pressure could be much higher (say
10 kg/cm2). Diabetics (who may have neuropathic feet) can have pressures of 20 to 30 kg/cm2, leading to
recurrent ulceration and eventual amputation (Boulton et al., 1984).
There is no significant difference between the left and right foot. However, for specific individuals, there
often is considerable difference between the left and right footespecially in width (see Figure 9.3.)
The technical name for differences in leg length in the same person is leg length discrepancy (LLD).
Contreras et al. (1993), summarizing studies with N = 2377, reported that 40% of people had LLD 5
mm, 30% had LLD 9 mm, 20% had LLD 11 mm, and 10% had LLD 14 mm.
Weight of leg segments (Clauser et al., 1969), as a percent of body weight, are: 1.47 for foot, 4.35 for
calf, and 10.27 for thigh; a total leg is 16.10 and both legs are 32.2. For example, the weight of both legs
for a 70 kg person would average 70 (.322) = 22.5 kg.
9-4
FIGURE 9.2 Footprint dimensions in mm (males above line; females below line); areas in mm2; angles in degrees
(Rys and Konz, 1994). Toe area is 10% of contact area. They stood with the right foot slightly (68 mm) ahead of the
left foot. The left foot (for males) averaged 7.3 to the left of the medial plane; the right foot averaged 9.1 to the
right.
FIGURE 9.3 Distributions of left/right percentage of 84 Americans for foot length, width, circumference and volume
(Rys and Konz, 1994). Although the mean of the left does not differ significantly from the right (i.e., the ratio does
not differ from 100), for an individual the left can differ from the right.
9-5
When people stand at a work surface, there needs to be an indentation for their toes so they can stand
close to the worksurface. Rys and Konz (1994) recommend a space at least 150 mm deep, 150 mm high,
and 500 mm wide.
9.2 Activities of the Foot

Standing
During standing, the legs will generally move occasionally. Satzler et al. (1993) recorded foot movements
for 120 min of standing; people moved a foot approximately every 90 s.
Walking
When walking, the activity of one leg has a shorter swing phase (when the foot is being passed forward)
and a longer support (stepping, contact) phase (when the foot is on the ground). The support phase
starts at heel strike and ends at toe-off; it has an early, passive section and a later active (propulsion)
section (Davis, 1983).
At heel strike, the forward-moving heel hits the ground (causing deceleration). Continued forward
motion of the body results in the forefoot contacting the ground; propulsion (acceleration) begins. The
heel rises and the foot is pushed backward under the body. This tendency is resisted by friction under the
sole; the body is propelled forward. The foot is everted, increasing forefoot contact area on the inner
side, until only the skin around the big toe is in ground contact. Finally, contact ceases and the cycle
repeats. At heel strike, horizontal velocity decreases from about 450 cm/s to 20 cm/s; heel angle to the
floor changes from about 20 prior to heel contact to 0 at 100 ms after contact (Redfern and Rhoades,
1996). During a slip, instead of stopping, the heel continues to move and the leading foot moves out in
front of the body.
Since the swing phase is shorter than the support phase, heel strike of the opposite limb occurs during
the propulsion section of the support phase.
The length of stride (L) divided by stature height (h) varies linearly with velocity; L/h = .67 at v = .8
m/s and L/h = .9 at 1.7 m/s (Alexander, 1984).
Running
Walking changes to running, for normal size adults, at about 2.5 m/s (6 miles/h) (Alexander, 1984) since
it uses less energy (for the same speed). Running differs from walking in that both feet are off the ground
for part of the stride. In addition, the heel strike should be renamed the foot strike, since the initial
contact probably will be forward of the heel. Peak force is about 3body weight at about .1 s after
contact. For walking, heel touchdown to toe push-off is .48 s, while, for running, the average contact
duration is .29 s (Scanton and McMaster, 1976). After foot strike (usually on the outside edge of the
foot), the foot rolls inward and flattens out (pronation). Then the foot rolls through the ball and rotates
outward (supination).
Stepping
Descending stairs demands a gait quite different from ascent (Templer, 1992). For descent, the leading
foot swings forward over the nosing edge and stops its forward motion when it is directly over the tread
below; the toe is pointed downward. Meanwhile the heel of the rear foot begins to rise, starting a
controlled fall downward toward the tread. The heel of the forward foot then is lowered and the weight
transferred to the forward foot. The rear foot then begins to swing forward. We tend to hold our center
of gravity as far back as possible by leaning backward. Problems are overstepping the nosing with the
forward foot, catching the toe of the forward foot, and snagging the heel of the rear foot on the nosing
as it swings past. Falls tend to be down the stairs.
9-6
For ascent, the leading foot has a toe-off, swing, and first contact with the upper step. The foot is
roughly horizontal. The ball of the foot is well forward on the tread; the heel may or may not be on the
tread. The rear foot then rises on tiptoe, pushing down and back. The rear leg then begins the swing
phase. The primary problem is catching the toe, foot, or heel of either foot on the stair nosing. Another
problem is slipping by the rear foot when it pushes backward. Falls tend to be upward.
9.3 Accidents
Falls
The annual death rate from falls in the United States is about 11,700; about 6,500 of these are in the
home (especially affecting elderly women). About 15% of the population will have hospital treatment in
their lifetime because of injuries from a stair accident (Pauls, 1985). Occupational exposures result in
about 1,500 deaths and 300,000 injuries (Leamon, 1992). In industrial fatalities, falls account for about
12%, which is greater than the total for electrical current, fires, burns, and poisons of all types (Leamon,
1992). Of workers injured in falls from heights, about 20% die (Eisma, 1990).
Not all underfoot accidents result in falls, and not all falls result in a lost-time injury. Some falls result
in no lost time, some result in sprains and strains, some in broken bones, and some in death. In addition,
falls often are not recorded by accident recording procedures (Leamon, 1992). Thus the accident reports
tend to drastically underestimate the number of falls. It needs to be emphasized that the risk of a fall
varies very much with occupation; all people do not have a dry, level indoor floor. Construction workers,
cleaning personnel, transportation workers, and restaurant serving personnel have higher risks (Chaffin
et al., 1992).
Andersson and Lagerlof (1983) analyzed 121,000 occupational accidents resulting in injuries; 20,600
had a fall. Falls on the same level were 2/3 and falls between levels were 1/3. For the same level, the main
preevents were slipping (55%) and tripping (19%). (Manning et al. (1988) reported, for falls on the
same level, 62% for slips and 17% for trips.) For falls to a lower level (e.g., from stairs, ladders, roofs,
vehicles), the main pre-events were loss of support of underlying surface (28%), slipping (28%), and
stepping-on-air (8%). The lower-level problem is focused in job trades such as roofers, painters, and
maintenance workers. Since the fall has a greater distance, the body velocity and resulting deceleration
become greater.
Falls which occur when the person is carrying something are especially dangerous. The object carried
decreases stability as a function of the torque above the ankle (weightobject height above ankle). Other
problems are that the arms cannot be used for balance (to prevent a fall), to grab a railing, or to break
the fall impact.
Causes of Falls
Falls can occur from slips (unexpected horizontal foot movement), trips (restriction of foot movement),
and stepping-on-air (unexpected vertical foot movement). Loss of balance and falls can occur without a
slip, trip, or stepping-on-air. Examples would be from alcohol or drugs, fainting, etc. Or, people who fall
may have blood pressure problems or foot problems (Gabel et al., 1985).
The elderly may be more likely to fall because of deterioration in postural control mechanisms and
decrements in visual acuity, strength, endurance, reaction time, and motor control. Furthermore, on falling,
the elderly are more likely to sustain a bone fracture (due to osteoporosis) (Maki and Fernie, 1990).
Slips
Slips primarily occur during foot pushoff and heel strike. During pushoff, the person falls forward (less
common and less dangerous). In addition, during pushoff, most of the weight has already been transferred
to the other foot. If a slip occurs during heel strike, the person falls backward. The critical time is .05 to
.1 s after heel strike. Leamon (1992) defines a microslip as a slip less than 2 cm, a slip as 8 to 10 cm, and
a slide as uncontrolled movement of the heel. Microslips occur very often and normally are not perceived
9-7
TABLE 9.2 Minimizing Slips and Slip Effects
by the person. A slip is perceived and the person typically jerks the upper body, moves the arms, etc.
but does not fall. A slide involves loss of control and usually a fall.
During a slip, there normally is a lubricant (water, oil, grease, dust, ice, snow) either on the surface
or on the shoe heel (Leclercq et al., 1994).
Slips can also occur, with stationary feet, during pushing and pulling. Although the feet slip, there
does not tend to be a fall and injury.
Slips also can occur when the ground slopes (front to back or side to side). Examples are ramps
and ladder rungs. When moving a cart up or down a ramp, stay above the cart to prevent injury from the
cart if it gets loose. Outdoor walkways often are sloped, have poor illumination, and have water and
ice as lubricants.
In the special outdoor circumstances of snow and ice, slipping can be very common; in Finland,
slipping outdoors is 10 times more common in winter (Gronqvist and Hirvonen, 1995). The most
danger occurs when the ice is wet (i.e., close to the freezing point) as the water is a lubricant. For this
situation, the best shoes have a soft heel/sole (Shore A hardness <60) made of thermoplastic rubber and
exhibiting a large apparent contact area (good tread). Cleats (spikes, studs) are effective if they can
penetrate the ice (i.e., if ice is close to the freezing point); if they cannot penetrate (i.e., ice is too hard (say
at -10 C), then shoes with spikes are very slippery. Strewing sand on ice is effective on wet ice (i.e., close
to freezing) but has relatively little effect on dry ice. Adding salt to melt ice may work if the temperature
is close to freezing; if the water then evaporates, this is good, but if the result is just a lubricant added to
the ice, the result is bad.
Table 9.2 summarizes how to reduce slips.
Trips
Trips occur during swing. As the foot swings forward, it hits an obstacle and the person falls forward.
Thus, in contrast to slips where the problem is excessive horizontal leg movement, with trips the problem
is lack of leg movement. Outdoor trips often occur from uneven surfaces (walkways, parking lots)
which the person expects to be even. Indoor trips tend to be from objects on the floor or stairs. Usually
there is a visual problem.
9-8
Stepping-On-Air
Stepping-on-air occurs when the foot has unexpected vertical movement. This can occur on steps when
the distance between stairs is unequal; it can occur when there is a hole in the ground; it can occur when
there is no ground (i.e., cliff, edge-of-scaffold, unexpected step, step on spiral stairs, unexpected curb
or ramp). Very commonly, stepping-on-air occurs with single steps (small changes in elevation) such
as curbs or one-step changes in floor level. Steps descending from large trucks and off-road vehicles
often present problems. On steps, the fall usually occurs when descending; the fall can be for a considerable
distance.
In some cases, the surface is there initially but breaks or moves (step breaks, floor mat slides, a chair
used as a stepstool moves). Ladder feet need to be non-slip as slipping of the ladder base is the most
common pre-event for portable ladder accidents (Alexsson and Carter, 1995). Often stepping-on-air has
a visual cause.
Solutions for Falls

The goals are to: (1) prevent the fall and (2) reduce the consequences of the fall.
Prevent the Fall

Scaffolds and work platforms should have a waist-high (107 cm) guardrail as well as a 10 cm high
toeboard (reduces slips over the edge as well as reducing falling objects). The top of the guardrail should
discourage sitting.
Since the primary problem on stairs is overstepping (Pauls, 1985), for safe stairs: (1) have easily
visible steps, (2) provide treads that are long enough, and (3) provide handrails that are both within
reach and graspable.
Visual solutions consider both the quantity of light and the quality of light. Note that not everyones
vision is perfect. For example, consider people not wearing their glasses, vision of elderly, the out of
focus of steps when people wearing bifocals descend stairs, etc.
The quantity of light typically is increased with fixed sources (ceiling lights, street lights, etc). But
lamps fail; the resulting lack of light is especially critical for stairs. One solution is to have two lamps
illuminate critical areas. Portable sources such as flashlights are a temporary solution. Too much light
causes glare; solutions include nonreflecting surfaces and glare shields for both natural and artificial
illumination.
The quality of light is also important. Ideally, the light should give moderate shadows because shadows
aid depth perception. Depth perception is improved by using multiple sources and considering the
orientation (direction) of the light. Camouflage consists in obliterating contrasts; we are concerned with
anticamouflage. Contrast is especially important on steps.
Because walking is automatic, attention must be drawn to steps, especially if the step is camouflaged
so there is an ambush. Do not distract attention from a stairs by providing a view as a person
begins the descent. Call attention to steps by changing the color of the floor (e.g., red carpet on stairs vs.
green carpet on approaches), having a handrail (especially for one-step stairs), changing wall color on
stair walls (e.g., paint changes color and descends at the angle of the stairs), having the handrail color
contrast with the wall and stair, and avoiding carpet patterns which confuse depth perception (e.g.,
narrow strips with strong contrast).
For stairs, the key for friction is the nosing, not the tread. Thus, have a high coefficient of friction for
the nosing. Outdoor stairs often are lubricated by rain and snow. Such stairs should have a wash (slope
of less than 1:60) to permit water to drain. Perhaps a roof is feasibleeven if it doesnt give 100%
protection. Prevent water (from the ground or a building) from draining onto the stairs.
Handrails on stairs help prevent falls. The handrail should permit a power grip (11 to 13 cm
circumference), have a clearance from the wall of about 3.8 cm, and be 89 to 97 cm above the stair
9-9
(Konz, 1994). A handrail must be within reaching distance; at a minimum there should be a handrail on
the right side descending. For detailed information on stair design, see Templer (1992) and NFPA (1991).
For mounting/dismounting vehicles, use the three-contact rule (at each phase of mounting/dismounting,
at least three limbs should maintain contact with steps or handles at the same time).
Ramps for people should have a maximum angle of about 5. If handtrucks are pushed up the ramp,
there should be a landing at least every 3 m in elevation. Have a nonskid surface in the center of each
lane. Ramps should have handrails and, if used by vehicles, heavy curbs. If vehicles use a ramp exposed
to rain or snow, have a 60 cm strip of abrasive metal plate in the track of each wheel; attach it to the
concrete with countersunk holes and flat-head expansion screws. Maximum ramp angles for vehicles
are 3 for a power-operated hand truck, 7 for a powered platform truck, 10 for a low-lift pallet-skid
truck, 10 for an electric fork truck, and 15 for a gasoline fork truck (Konz, 1994).
Dont use the hands to carry objects while on ladders and stairs.
If a person knows the surface is slippery, walking behavior can be changed. A short stride length
reduces foot velocity, gives smaller foot shear force at the heel/ground interface, and keeps the body
center of gravity between the feet. Leaning forward helps keep the center of gravity between the feet and,
if you fall, it will be forward instead of backward. Sun et al. (1996) report that, when walking down a
ramp, people over age 35 decrease stride length and steps/min.
Reduce the Consequences of the Fall

The solution depends upon the task and environment. For example, for workers on a scaffold or roof,
use a full-body harness attached to an anchorage point. Another choice is safety nets.
A fall down some stairs is comparable to falling into a hole with jagged rocks at the bottom. For falls
on stairs or on the same level, carpet can reduce peak body deceleration on the hip by 20% over hard
floors (Makie and Fernie, 1990). (Of course, in addition, carpets have high coefficients of friction and
thus have very few slips.) Stair landings reduce the distance of a fall. To minimize impact injuries, stairs,
handrails, and balustrading should be free from hostile elements such as projecting elements, sharp
edges, and corners.
Box 1 discusses hard surface floors.
Box 1
Hard Surface Floors
Concrete floors can either be: (1) the wearing surface itself or (2) a base for other materials (e.g.,
terrazzo, plastic tiles or sheeting, or carpet).
If concrete is the wearing surface, it must be durable, have satisfactory slip resistance, and be
easily cleaned.
Concrete typically is poured in slabs with joints. There are two types of joints: (1) contraction
joints (5 to 10 mm wide) and (2) expansion (isolation) joints (about 20 mm wide, filled with
compressible material). The expansion joints are not very necessary in a temperature-controlled
building and are potential trip hazards as the slab shifts. Good design is to minimize contraction
joints in a building. In addition, a horizontal reinforcing dowel between slabs will reduce slab
tilting and thus trip hazards.
If tile or plastic is placed on concrete, the problem tends to be slips rather than trips.
If liquids are used or stored in an area, there will be spills. Install drains and slope the floor
appropriately.
9-10
9.4 Fatigue/Comfort
The discussion is divided into walking and standing.
Walking
The primary problem is the shock of heel strike being transmitted up the foot, leg and back. For shoe
solutions, see Box 2.
The energy cost of walking depends upon the terrain, with a hard surface giving the minimum cost
(Pandolf et al., 1976):
(9.2)
where
WLKMET = Walking metabolism, W/kg of body weight
C = Terrain coefficient
= 1.0 for treadmill, blacktop road
= 1.1 for dirt road
= 1.2 for light brush
= 1.3 for hard-packed snow; C = 1.3 + .082 (foot depression, cm)
= .5 for heavy brush
= 1.8 for swamp
= 2.1 for sand
v = velocity, m/s (for v > .7 m/s (2.5 km/h))
Box 2
Shoes
Athletic shoes are divided into running shoes (designed for forward movement) and court shoes
(designed for quick side to side movement).
For running, the main problem is the shock of foot strike, yielding arthritis of the knee and
hip, Achilles tendonitis, low back pain, and shin splints. Overpronation gives knee pain.
For walking, heel strike is less forceful (1.5body weight) so cushioning is less critical (but still
desirable); flexibility in the sole allows the normal heel-to-toe roll. For walking, deceleration
properties of the cushioning material is important; for standing, time is not as critical and material
stiffness and maximum compression is relevant to comfort (Goonetilleke and Himmelsbach, 1992).
At a given walking speed, the energy expenditure values increase by .7 to 1.0% per additional
100 g shoe weight; this increase in energy consumption is approximately 5 times higher than the
same weight on the upper body (Smolander et al., 1989). Legg and Mahanty (1986) found it took
6.4 times as much energy to carry a kilogram on the feet as on the back.
Feet often swell so, for fit, buy shoes when your feet are swollen (late in the day). In addition,
your left and right foot might vary slightly. Thus buy shoes with at least four pairs of eyelets as
they increase the adjustment possibilities.
People with low arches (footprint has a broad connection of two areas) will be more comfortable
with shoes with a straighter inner line (difficult to distinguish left from right shoe).
Boots support the ankle and calf as well as increasing insulation; they are especially useful for
side support, such as when walking outdoors. Boots also protect against chemicals and animal
products (such as fats and oils); some boot materials have a better life than others.
For impact protection, use a steel-toe shoe; in some industries (such as mining), metatarsal
guards are also used.
9-11
Standing
Problems can occur with floor temperature and static electricity. However, the primary problem is lack
of circulation in the leg and static loading of the muscles.
When wearing normal shoes, 23 C is optimal comfort for floors for standing and walking people;
use 25 C for sedentary people (ASHRAE, 1993). Heavy carpet will save about 1% of the total energy
used to heat the building (Hager, 1977).
Static electricity is a problem in industries such as electronics. Some solutions are: (1) raise humidity
in the air above 40%, (2) use conductive carpets (e.g., with carbon fibers), (3) use an antistatic floor
mat, (4) connect the operator to ground with a static-bleed wrist strap, (5) use shoes with static-dissipating
soles.
Teitelman et al. (1990) reported preterm births occurred more often (7.7%) when women had jobs
with prolonged standing; the rate for sedentary jobs was 4.2% and for active jobs was 2.8%.
Avoid static standing by sitting, by walking, and by shifting posture while standing. If static standing
is required, consider a cushioned floor or a footrest (Whistance et al., 1995).
Sitting
Perhaps the person can sit instead of stand. Sitting does tend to restrict movement of the shoulders and
thus reach distance. A compromise is a sit-stand seat, such as that used by post office workers sorting
mail into boxes. Nijboer and Dul (1987) reported a sit-stand seat was beneficial for upholstery workers
even though they could use the seat for only part of the work cycle. Another technique for supporting
part of the body weight is to have something to lean ontypically a counter. Another possibility is to sit
part of the time. For example, service personnel often are required by management to stand when
serving customers; they should be provided chairs for times when there are no customers. Seats should
be available for factory personnel during breaks. One firm used swing-down benches on the wall of an
aisle; during work they were up against the wall but during worker breaks they were pivoted into sitting
position.
Walking
As mentioned earlier, blood circulation in the foot can be brought to normal in as few as ten steps. Thus
design the job so there is occasional walking (such as to get supplies, dispose of materials).
Shifting Posture
It also is possible to shift the posture while standingremember the bar rail. Bar rails are designed to
improve the comfort of those standing at the bar. Satzler et al. (1993) studied four conditions: (1)
standing with one foot on a 100 mm high, flat platform, (2) standing with one foot on a 100 mm 15
angled platform, (3) standing with one foot on a 100 mm high, 50 mm diameter bar, and (4) standing
with both feet flat on a concrete floor. The three standing aids were preferred over no aid; the two
platforms were better than the bar. Note that bar patrons not only support their feet on bar rails but lean
on the bar.
Cushioned Floor
The entire floor can be cushioned (carpeted) or the floor can be cushioned locally with a mat. Mats can
also be used to raise the feet off the floor (raise above liquid) and act as a frictional surface (avoid slips).
Brantigham et al. (1970) studied a varied terrain floor mat with nonuniform resilience density;
each placement of the foot caused a slight change in horizontal angle of the foot during weight-bearing.
The concept is that many foot problems are due to the over flat nature of the built environment. The
varied terrain mat enhanced circulation in the lower extremities (reduced venous pressure) and increased
skin temperature of the calf .3 to 1.0 C (improved circulation to the surface); about 2/3 of the subjects
reported they were less tired when using the special mat.
Additional studies have been done on floor mats (Kuorinka et al., 1978; Rys and Konz, 1988; Redfern
and Chaffin, 1988; Rys and Konz, 1989; Rys and Konz, 1990; Konz et al., 1990; Zhang et al., 1990;
Stuart-Buttle et al., 1993; Redfern, 1995). Summarizing:
9-12
Floor mats improve comfort (over hard-surfaced floors). Comfort may be increased in the back as
well as the legs.
Mats should compress but not too much. Optimum is about 6% under the feet of a 70 kg adult.
Mats should have beveled edges to reduce tripping and falling.
Mats should have a nonslip surface; drain holes may be useful to aid drainage of fluids. In addition,
the mat should not slip on the floor.
Mats may have to be cleaned periodically (e.g., in food service environments). In these cases, large
mats are difficult to handle.
If a raised work platform is used to stand on, the surface should be resilient rather than rigid (i.e.,
wood or plastic, not steel). The platform also should have a high ratio of surface to holes (i.e., you
are not standing on knives).
9.5 Foot Controls

Although most controls are operated by the hands, some controls are operated by the foot. The foot
does not have the dexterity of the hand, but it is connected to the leg instead of the arm so it can exert
more force. A leg has approximately 3 times the strength of an arm. A foot control also reduces use of
the hand/arm.
Foot controls can be divided into pedals and switches.
Pedals
Pedals can be used for power and control. Power generation can be continuous (bicycle) or discrete
(nonpowered automobile brake pedal). For information on continuous power, see Whitt and Wilson
(1982) and Brooks et al. (1986).
Discrete power generally is applied by one leg; there does not seem to be any advantage to using the
left or right leg. Force using both feet is about 10% higher than using just one foot (Van Buseck, 1965).
A control example is an auto accelerator pedal.
Switches
A foot switch can actuate a machine (such as a punch press). Generally the foot remains on the switch so
the time and effort of moving the foot/leg is not important.
On-off controls (such as faucets, clamping fixtures) can be actuated by lateral motion of the knee as
well as vertical motion of the foot. The knee should not have to move more than 75 to 100 mm; force
requirements should be light. Hospitals use knee switches to actuate faucets to improve germ control on
the hands.
Avoid foot pedals/switches which must be operated while standing, because they tend to distort
posture and cause back problems.
Defining Terms
Calcaneus: The heel bone; see Figure 9.1.
Edema: Swelling of legs due to fluid retention.
Eversion: External rotation of the foot.
Inversion: Inward rotation of the foot.
Metatarsals: Bones in the foot; see Figure 9.1.
Mortise and tenon joint: A type of joint; see Figure 9.1.
Lateral: The outside (side farthest from the centerline).
Leg length discrepancy: Differences in leg length (in the same person).
Medial: The inside (side closest to the centerline).
Phalanges: Bones in the foot; see Figure 9.1.
Pronation: Rolling inward (toward the centerline) of the foot.
9-13
Supination: Rolling outward (away from centerline) of the foot.

Three-contact-rule: Rule used on ladders and steps. At least three limbs should be in contact with steps
or handles at all times.
Venous pooling: Pooling of blood in the veins of the legs.
References
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ASHRAE, 1993. Handbook of Fundamentals, ed., Parsons, R. Am. Society of Heating, Refrigeration
and Air Conditioning Engineers, Atlanta, GA.
Boulton, A., Franks, C., Betts, R., Duckworth, T., and Ward, J. 1984. Reduction of abnormal foot
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Chaffin, D., Woldstad, J., and Trujillo, A. 1992. Floor/shoe slip resistance measurement. American
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Work, eds. W. Marras, W. Karwowski, and L. Pacholski, 199202, Taylor & Francis, London.
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Eisma, T. 1990. Rules changes, worker training help simplify fall prevention. Occupational Health and
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Gabell, A., Simons, M., and Nayak, U. 1985. Falls in the healthy elderly: predisposing causes. Ergonomics,
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Hager, N. 1977. Energy conservation and floor covering materials. ASHRAE Journal, 3439, September.
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Van Buseck, C. 1965. Excerpts from maximal brake pedal forces produced by male and female drivers.
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Konz, S. 1995. Work Design: Industrial Ergonomics, 4th edition, Holcomb Hathaway, Scottsdale AZ.
This popular textbook concisely summarizes many aspects of job design and gives detailed design
guidelines.
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AZ. Gives many details and design recommendations for design and arrangement of industrial
facilities.
Ergonomics. This journal, published in England, publishes articles on ergonomics from authors around
the world.
Section II
Low Back Disorders
10
Epidemiology of Back
Pain in Industry
10.1
10.2
10.3
10.4
10.5
Medical Center
Introduction
The Magnitude of the Problem
National Studies
United States United Kingdom Sweden Canada
Cross-Sectional Studies
United States Scandinavia Israel The
Netherlands Belgium Hospitalizations and
Operations Chronic Back Pain
Occupational Risk Factors
Heavy Physical Work Static Work Postures Frequent
Bending and Twisting Lifting, Pushing, and
Pulling Repetitive Work Vibrations Psychological
and Psychosocial Work Factors
101
101
102
103
1010
10.1 Introduction
Epidemiologic research in low back pain (LBP) has been, and still is, hampered by methodologic problems
in definition, classification, and diagnosis. Objective evidence of existing low back pain is often lacking,
and peoples recall of previous episodes is poor. The intermittent nature of low back pain complicates
prevalence studies, and studies of disability due to LBP are influenced by legal and socioeconomic
factors. Methodologic problems also exist in the quantification of physical exposures that might be of
etiologic importance.
In general, data about back pain may be obtained from official health registers or by retrospective,
prospective, or cross-sectional surveys of general populations or of specific industrial populations. Such
data are useful in defining the magnitude of the problem. Care must be taken when interpreting these
data, however. As mentioned above there is no consensus on classification and diagnosis, making it
difficult to rely on insurance and hospital data (Wood and Badley, 1987). Sickness absence and disability
data are heavily influenced by work conditions and the legal and socioeconomic situation, and there is
a poor correlation between tissue injury and disability.
Data from workers compensation claims are affected by several inherent biases (Abenhaim and
Suissa, 1987): (a) all workers are not covered by worker compensation programs; (b) the claims data are
mainly administrative and therefore, while accurate on absence and cost, lack validity on symptoms and
diagnosis; (c) all workers with back pain do not file a claim, and many do not stay away from work.
10.2 The Magnitude of the Problem

The magnitude of any health problem is measured by prevalence and incidence. In a prevalence study,
the presence of LBP and other important variables is determined at one point in time (point prevalence)
0-8493-1800-9/03/$0.00+$1.50
10-1
10-2
or during one period of time (period prevalence) for each member of the population studied or for a
representative sample. Incidence may be defined as the number of people who develop LBP over a
specified time period, such as their lifetimes (lifetime incidence, which is synonymous with lifetime
prevalence) or in a single year (annual incidence). In short, prevalence means all cases of LBP, whereas
incidence means all new cases of LBP.
10.3 National Studies

Information obtained from different countries is considered separately because the differing socioeconomic
factors of these populations may influence the results. This is particularly true for disability data, which
are significantly determined by local legal, social, and economic factors.
United States
Between 10 and 17% of adults in the U.S. have a back pain episode in a given year (Cunningham and
Kelsey, 1984; Deyo and Tsui-Wu, 1987; Praemer et al. 1992). In about one-third of these the pain is
severe and chronic. In a large National Health Survey performed from 1985 through 1988, about 4.1
million persons per year reported a disc disorder, and another 4.6 million a back strain (Praemer,
1992). Other epidemiologic data show that back pain is the most frequent cause of activity limitation in
people below age 45, the second most common reason for patient visits (over 14% of new visits are for
back pain), the fifth ranking reason for hospitalization, and the third most common reason for surgical
procedures (Praemer et al., 1992; Taylor et al., 1994; Hart et al., 1995; Andersson, 1997). About 2% of
the U.S. workforce (500,000 workers), report compensation back injuries each year (National Safety
Council, 1991). The frequency of surgical procedures for back related conditions has risen dramatically
in the U.S. over the past two decades. In fact, it has more than doubled from 1979 to 1990. In that later
year, 279,000 back operations were performed on adults; 232,500 without fusion and 46,500 fusions
(Taylor et al., 1994).
United Kingdom
British surveys place low back pain at the top of the list of medical conditions as well. In 199293 there
were 81 million certified back-related sick days, and about 7 million visits to general practitioners for
back pain (National Back Pain Association, 1994). During the same period there were 33,000 workrelated back injuries. Frank (1993) reported that back pain was the single largest cause of sick leave in
198889, responsible for 12.5% of all sickness absence days.
Sweden
Swedish national insurance data show a consistent sickness absence in percent of all annual sickness
absence from the early sixties to the late eighties. In the 1961 to 1971 period, the average absence was
12.5% or 1% of all workdays (Helander, 1973). In 1983 the percent was 10.9, and in 1987, 13.5%
(Nachemson, 1991). Unfortunately, the number of sickness absence days rose dramatically during that
period so that the percent of insured sick listed for back pain rose from 1% of the working population
in 1970 to 8% in 1987, the number of days per absence rose similarly from 20 to 34 days per year, and
the cost in terms of lost production increased 16-fold (Table 10.1). Retirement and disability pensions
caused by back pain rose by 6000% from 1952 to 1987.
During 1983 and 1984, a prospective Swedish study analyzed all patients who were sicklisted for
LBP in a district of Gothenburg containing 49,000 subjects from 20 to 65 years of age (Choler et al.
1985). A total of 7,526 sickness absence episodes for LBP were reported over an 18-month period.
Fifty-seven percent of patients recovered in 1 week, 90% in 6 weeks, and 95% after 12 weeks. At the
end of a year 1.2% remained work disabled. Those with sciatica were out of work for longer periods of
time than were patients who had back pain only. Recurrent pain and disability occurred in 12% over the
18-month period of observation.
Epidemiology of Back Pain in Industry
10-3
TABLE 10.1 Estimated Sicklisting for LBP and Associated

Cost Due to Loss of Production in Sweden
4.7 million
Based on 1987 wages and social costs.
3
Assuming $1 = 6 Sw. Cr.
Adapted from Nachemson AL (1991): Back Pain. Causes,
diagnosis and treatment. The Swedish Council of Technology
Assessment in Health Care. Stockholm.
2
Canada
Lee et al. (1985) analyzed data on musculoskeletal complaints based on the 1978 to 1979 Canada
Health Survey. A prevalence of 4.4% with serious back and spine problems was calculated. The total
number of disability days exceeded 21 million, and the average sickness absence period was 21.4 days.
There was no difference in prevalence between men and women.
10.4 Cross-Sectional Studies

A cross-sectional epidemiologic study is one in which a population is studied at a single point in time, or
over a defined period, in an attempt to evaluate all members of that population. In the past decades
several cross-sectional studies have been performed. Table 10.2 presents the prevalence and lifetime
incidence of LBP, as determined by some of these studies. The prevalence rates vary from a low of 12.0%
to a high of 35.0%. Some authors report a higher prevalence in females, but others found no difference.
The lifetime incidence rates are higher and range from 48.8% to 69.9%.
United States
In 1973, Nagi, Riley, and Newby determined the prevalence rates of persistent back pain of persons
between 18 and 64 years residing in Columbus, Ohio (Nagi et al., 1973). A random sample of 1,135
subjects was studied, of whom 203 (18%) reported often being bothered with pain in the back. Of
those with back problems, 62% had had a spine radiograph; 26% had worn a back support; and 4%
had had back operations.
Frymoyer et al. (1980, 1983) performed a retrospective and cross-sectional analysis of 1,221 males
18 to 55 years of age who had enrolled in a family practice facility from 1975 to 1978. Almost 70% had
had LBP. When the data from that study were extrapolated to the 50 million working American males
in the age group 18 to 55, it was calculated that 38.5 million workdays are lost annually. Patients with
severe LBP had significantly more leg complaints, sought more medical care and treatment for LBP, and
had lost more time from work for this reason when compared to subjects with no or moderate LBP.
Sciatica-like symptoms were present in 28.9% of the males with moderate LBP and 54.5% of the males
with severe LBP. Objective reports of numbness were present in 14.0% of the males with moderate LBP
and 37.4% of those with severe LBP, while weakness was reported by 17.9% of those with moderate
LBP and 44.0% with severe LBP.
10-4
TABLE 10.2 Prevalence and Lifetime Incidence of LBP in Difference Cross-Sectional Studies
Andersson GBJ (1997): The epidemiology of spinal disorders, in The Adult Spine: Principles and Practice, 2nd
edition, J.W.Frymoyer, Ed. Lippincott-Raven, Philadelphia, pp. 93141.
Studies by Kelsey (1975a,b) and Kelsey and Hardy (1975) sampled 20- to 64-year-olds residing in the
New Haven (Connecticut) area who had lumbar X-rays taken over a two-year period for suspected herniated
nucleus pulposus. The researchers divided the sample into those with surgically confirmed herniated discs
and those who had probable or possible herniated discs based on clinical signs and symptoms. She was
able to define a variety of risk factors related to the diagnosis of herniated lumbar disc; including sedentary
occupations, driving of motor vehicles, chronic cough and bronchitis, lack of physical exercise, participants
in certain sports (baseball, golf, and bowling), suburban residence, and pregnancy.
Kelsey et al. (1984a,b) and Kelsey and Golden (1988) later performed another case-control study in
Connecticut from 1979 to 1981 with minor methodologic modifications. The study population was 20to 64-year-old women and men who had had X-rays and myelograms at various health centers in New
Haven and Hartford. As in the previous study, they were divided into those with surgically confirmed
disc herniations and those with probable or possible disc herniations. A control group of nonback
patients admitted for in-hospital services was matched for sex and age. A number of possible risk factors
were studied and odds ratios determined. Frequent lifting and twisting were both significant risk factors,
as were driving and smoking.
The prevalence of low back pain in elderly people (over age 65) was determined in a survey of 3,097
persons living in rural parts of Iowa (Lavsky-Shulan et al., 1985). Twenty-four percent of the women
and 18% of the men had low back pain in the year preceding the survey, and 40% had back pain at the
time of the interview. Five percent of the population had been operated on.
Scandinavia
A number of studies have been performed in the city of Gteborg, Sweden (about 450,000 inhabitants).
Four are reviewed here. Hirsch, Jonsson, and Lewin (1969) interviewed 692 women (15 to 72 years of
age), selected at random to represent the adult Swedish female population. The lifetime incidence of LBP
was 48.8% and increased with age up to 55 years, after which no further increase was noted. Horal
(1969) and Westrin (1970, 1973) studied a random sample of subjects who in 1964 had been sicklisted
for LBP by physicians in Gteborg, Sweden. They were compared to a control group matched with
respect to sex, age, and sickness benefit but not previously sicklisted for LBP. Of the total group, Horal
studied 212 pairs of probands and controls, and shortly thereafter Westrin studied 214 (78% of the
10-5
TABLE 10.3 Data on Prevalence and Use of Medical Services from

Two Retrospective Cross-Sectional Surveys in Gteborg, Sweden
Adapted from Svensson HO, Andersson GBJ (1983): Low back

pain in forty to forty-seven year old men: Work history and work
environment factors. Spine 8:272276. and Svensson HO, Andersson
GBJ (1989): The relationship of low-back pain, work history, work
environment, and stress: A retrospective cross-sectional study of 38to 64-year-old women. Spine 14:517522.
base material). Ninety-five percent (95%) of the probands had had LBP in the preceding 3 to 4 years,
and 52% had ongoing pain at the time of the interview. In the control group, the corresponding figures
were 49% and 27%, respectively. This means that sickness absence statistics severely underestimate the
true frequency of low back pain.
Svensson and Andersson (Andersson et al., 1983; Svensson, 1982; Svensson and Andersson, 1982,
1983; Svensson et al., 1983) studied a randomized sample of 940 40- to 47-year-old men in Gteborg,
Sweden. Seven hundred and sixteen men were interviewed, and information about the remaining 234
was obtained from the Swedish National Health Insurance Office. Thirty-three percent of all sickness
absence episodes experienced during their working life were spine related, constituting 47% of all sickness
absence days; 3.6% were totally disabled and 4% had been off work more than 3 months because of
LBP in the 3 years preceding the study. Forty percent had consulted a physician, 3.5% had been admitted
to a hospital, and 0.8% had been operated on because of their LBP (Table 10.3).
The same study design was later used to survey 1,640 38-to 64-year-old women (Svensson et al.,
1988; Svensson and Andersson, 1989). Of these, 19% had been off work because of LBP in the preceding
three-year period, 3.5% for 3 months or longer. About 2.6% of 38- to 49-year-old women had significant
work disability, whereas the corresponding percentage among 50-to 64-year-olds was 5.9.
Biering-Sorensen (1982) sampled 82% of all 30- to 60-year-old inhabitants in Glostrup, Denmark.
There were 449 men and 479 women. An extensive questionnaire regarding low back problems was
administered along with objective measurements of spine function. Twelve months after the examination
99% of the study population completed a follow-up questionnaire on LBP occurring in the intervening
period. The lifetime prevalence/incidence of LBP appears in Figure 10.1 along with the one-year period
and point prevalence data. In general, increasing age was associated with increasing episodes of LBP.
Work absence at some time was reported by 22.5% of those who had LBP, 10% had needed some job
adjustment, and 63% had changed their jobs because of back pain. Of those who had experienced LBP,
60% had consulted a physician, 25% a specialist, and 15% a chiropractor (Biering-Sorenson, 1983).
About 30% had had radiographs taken of the lumbar spine, 4.5% had been admitted to a hospital, and
1% had been operated on because of LBP.
The prevalence rate of sciatica and its impact on Finnish society was estimated by Heliovaara 1988
(see also Heliovaara et al., 1987), based on a sample of 8,000 persons representative of the Finnish
population aged 30 or over. Sciatica was present in 5.3% of men and 3.7% of women. In both genders
the prevalence rates were highest in the 45- to 64-year-old group. The prevalence of definite herniated
discs was 1.9% for men and 1.3% for women. Low back syndrome other than sciatica was present in
12.5% of men and 17% of women. Disability due to lumbar disc syndrome was estimated at 3.5% in
men, 4.5% in women.
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FIGURE 10.1 Top: Prevalence rates of low back trouble by age and sex. (Redrawn from Biering-Sorensen F
(1982): Low back trouble in a general population of 30-, 40-, 50-, and 60-year-old men and women. Study design,
representativeness, and basic results. Dan Med Bull 29:289.) Bottom: Incidence of low back trouble over one year
in a general population. (From Biering-Sorensen F (1982): Low back trouble in a general population of 30-, 40-, 50, and 60-year-old men and women. Study design, representativeness, and basic results. Dan Med Bull 29:289. With
permission.)
Israel
Magora and Taustein (1969) studies a random sample of 3,316 individuals taken at random. Present
and past LBP was determined. Four hundred twenty-nine (12.9%) were found to suffer from LBP at the
time of the survey (point prevalence), and 92% (394) of those had pain on and off from 6 months to 11
years or more before the investigation. The majority of the subjects with LBP did not take sick leave
(57.8%) and, of those who did, 29.4% had absence periods from 1 to 10 days.
The Netherlands
A study of 3,091 men and 3,493 women 20 years of age and older was performed by Valkenburg and
Haanen (1982) in 1975 through 1978 in the Dutch city of Zoetermeer. A questionnaire, physical
examination, and radiographs were obtained. The prevalence of LBP in men and women increased
slightly with age up to 65 years, and thereafter decreased (Table 10.4). Disc prolapse, defined by clinical
signs and symptoms, was found in 1.9% of men and 2.2% of women. Considerable disability was
attributed to LBP: 85% had recurrences; 30% had LBP for more than 3 months, and 30% had become
bedridden at some point by their symptoms. Nearly half of the men and one-third of the women reported
that they had been unfit to work because of LBP at some time, and 8% of the men as well as 4% of the
women had changed their jobs because of these complaints. Twenty-eight percent of the men and 42%
of the women had consulted a physician for LBP.
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TABLE 10.4 Low Back Complaints and Work Incapacity in the Zoetermeer Study
*Rel % refers to proportion among those with a lifetime history of low back pain.
TABLE 10.5 Rates of Selected Back Operations in the United States per
100,000 of General Population
Deyo RA, Cherwin D, Conrad D, Volinn E (1991): Cost,

controversy, crisis: Low Back Pain and the Health of the Public. Ann
Rev Publ Health 12:14156.
FIGURE 10.2 Low back surgery rates per 100,000 adults, by age, 19791990. (Adapted from Taylor VM, Deyo RA,
Cherkin DC, Kreuter W (1994): Low back pain hospitalization. Recent United States Trends and Regional Variations.
Spine 19:12071213.)
Belgium
About 4,000 individuals were studied to explore the influence of sociocultural and employment variables
on back pain (Skovron et al., 1994). The lifetime incidence of back pain was 59%, and 33% had
ongoing back pain (point prevalence). Age (OR = odds ratio, 2.0) and female gender (OR = 1.42) were
associated with an increased risk of a LBP history. Sociocultural factors influenced the risk of first-time
back pain episodes, but not of disability or severity.
Hospitalizations and Operations

Volinn et al. (1994) examined the National Hospital Discharge Survey for time trends (19791987),
and for geographic variations (1987). The U.S. rate of lower back surgery increased 49% over the time
period reviewed, while the rate of nonsurgical low back pain hospitalization decreased by 33%. Table
10.5 illustrates the dramatic increase in back operations in the U.S. and breaks it down into actual
procedures (Deyo et al., 1991). A comparatively larger increase occurred in fusions than in laminectomies
or discectomies. Volinnet al. (1994) also report large regional variation in hospitalization, surgical rates,
10-8

TABLE 10.6 Hospitalizations in the U.S. for Back Conditions in 1988, Based on First Listed
Diagnosis by ICD.9.CM.Code
From National Hospital Discharge Survey, 1988.
FIGURE 10.3 Ratios of back surgery rates in 11 countries or Canadian provinces compared to the back surgery rate
in the U.S. (19881989). Adapted from Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G (1994): An international
comparison of back surgery rates. Spine 19:12011206.)
and length of stay. They found that in 1987 the rate of surgery ranged from 77/100,000 adults in the
Northeast region to 146/100,000 in the South region. Variations in surgical rates exist between areas of
each region as well. Thus, among counties in the State of Washington rates of surgery for low back pain
varied from 11.5/100,000 to 172/100,000, an almost 1.5-fold difference (Volinn, 1992). This indicates
that cultural differences and practice patterns have a major influence on hospitalizations and procedures.
Taylor et al. (1994) further analyzed the National Hospital Survey Data from 1979 through 1990. The
increase in the number of surgical procedures continued from 1987 to 1990. Over the 11-year time
period surveyed, adult low back operations increased by 55% from 147,500 (1979) to 279,000 (1990).
This corresponds to an increase from 102 to 158 per 100,000 adults. The rise was particularly great for
fusions which increased by 100% from 13 to 26/100,000. In 1990, there were 46,500 lumbar fusions
and 232,500 low back pain operations without fusion. The upward trends occurred among all age
groups, but were particularly great for patients aged 60 and older (Figure 10.2). Nonsurgical
hospitalizations, on the other hand, decreased from 402/100,000 in 1979 to 150/100,000 in 1990.
Table 10.6 shows the hospitalizations for back conditions in 1988.
There are marked international variations in rates of back surgery (Deyo et al., 1991, Cherkin et al.,
1994). Nachemson (1991) has reported that the number of operative procedures for herniated nucleus
pulposus (HNP) in Sweden has remained stable at 200/million inhabitants/year from the mid-1950s
through the 1980s. The corresponding numbers in Finland (19671977) were 350 (Heliovaara, 1988)
and in Great Britain 100 (Benn and Wood, 1975; Wood and Badley, 1987). The number of people
operated on for HNP per million/year in the U.S. has been assessed in the past as ranging between 450
to 900 (Kane, 1980; Frymoyer, 1988; Kelsey and White, 1980). In 1990, it was 1310 (Taylor et al.
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TABLE 10.7 Prevalence of Back and Spine Impairments in

the United States, 1988
Adapted from Praemer A, Furnes S, Rice DP (1992):

Musculoskeletal conditions in the United States. Amer Acad
Orthopaed Surg, Park Ridge, IL pp. 1199. Based on the
National Health Interview Survey 198588.
1994). A recent study compares the back surgery rates of thirteen countries and provinces revealing that
in the United States, it is at least 40% higher than in any other country, and more than five times higher
than in Scotland and England (Figure 10.3). Differences in the underlying prevalence of back pain was
not felt to explain the differences in surgical rates. Cultural differences, differences in practice patterns,
and availability are more likely explanations.
Chronic Back Pain

Limited data is available about the prevalence of chronic back pain. The NHANES II data suggest that
33.7% of those reporting back pain lasting for at least 2 weeks had pain for 6 months or longer. This
percentage is similar to the one reported by Valkenburg and Haanen for a Dutch population, where
34% of those with back pain had a duration of 3 months or longer (14.3% of all males, 19.6% of all
females). Praemer et al. (1992) used the 1988 National Health Interview Survey (19851988) to determine
the frequency of impairment in the U.S. Impairment in the survey was defined as a chronic or permanent
defect representing a decrease or loss of ability to perform various functions. Musculoskeletal impairment
was the most prevalent impairment in people up to age 65, and back and spine impairments the most
frequently reported subcategory of musculoskeletal (51.7%). The annual rates vary significantly by
gender and age group (Table 10.7). Back and spine impairments were more common in females (70.3/
1,000) than males (57.4/1,000), and more common among whites (68.7/1,000) than blacks (38.7/1,000).
In 1988, back and spine impairments resulted in over 185 million restricted activity days (21.0/
impairment), including 83 million bed days (5.4/impairment) (Table 10.8). About 56% of restricted
activity days occurred among women.
Rossignol et al. (1988) (see also Abenhaim et al., 1988) followed a cohort of 2,341 cases, randomly
sampled to represent occupational back compensated individuals in the state of Quebec (Canada) in
1981. From the initial injury date, 6.7% of compensated workers were still absent from work after 6
months, accounting for 68% of work days lost and 76% of the total compensation cost for low back
pain. When the cumulative absence was calculated over the three years, 9.7% of workers were absent
for 6 months or longer. This increase illustrates the recurrent nature of back pain. A logistic regression
model was used to calculate risk factors associated with absences of 6 months or more. Age and site of
symptoms were the two most important variables. An increase in age of 23 years doubled the odds of
accumulating at least 6 months of absence and lumbar symptoms were 2.86 times more likely than
thoracic symptoms to become chronic. The odds ratio for gender and occupation was not statistically
10-10

TABLE 10.8 Restricted Activity Days and Bed Days/
Impairment for Back or Spine Disorders in 1988 by Major
Population Subgroup
Adapted from Praemer A, Furnes S, Rice DP (1992):

Musculoskeletal conditions in the United States. Amer
Acad Orthopaed Surg, Park Ridge, IL pp. 1199.
significant. When occupation was eliminated, sex achieved statistical significance, however (OR 1.92;
95% CI = 1.193.11).
van Doorn (1995) studied a self-employed subset of Dutch dentists, veterinarians, physicians, and
physical therapists. Twenty-three percent of claims lasted longer than 6 months or were considered
chronic (van Doorn 1995). The risk for chronicity increased with advancing age. Using a predictive
coxregression model, van Doorn found that specific diagnosis, older age, previous back pain, and
psychosocial problems were all factors negatively influencing recovery.
10.5 Occupational Risk Factors

The relationship between occupational factors and low back pain is difficult to determine because exposure
is usually difficult and sometimes impossible to quantify. Using job titles alone is not appropriate. Healthy
workers may well stay in the same occupation and job, while workers with low back pain may leave a
job and move to a less taxing one. The result is a shift in prevalence of back pain from heavy to light
jobs. Another problem is the definition of what is heavy and what is light. Traditionally, heavy physical
jobs have been defined as jobs with high energy demand, and light as jobs with low energy demand.
Many low energy jobs are static in nature, however, which as such can be a risk factor for LBP. Burdorf
(1992) reviewed 81 original epidemiologic articles to determine how well they assessed exposure to
postural loading. In 58% there was no exposure data, while in the remaining subjects, exposure was
based on questionnaire in 33%, observation in 9%, and direct measurement in 5% only. Throughout,
it was felt that the quality of exposure data was poor.
The recall of exposure is even worse than the recall of previous pain and disability, and is often
influenced by the insurance system. Subjects will tend to relate LBP to an injury or particular exposure
if this results in compensation. Kelsey (1975a) found, for example, that 70.9% of men receiving
compensation associated the onset of their problem with a specific event, compared to 35.5% of men
not receiving compensation. Swedish and Canadian injury statistics would suggest the same.
Further complicating the situation is the fact that exposure to several occupational risk factors often
occurs in the same job. For example, a truck driver may have to load and unload his truck (lifting), sit
for many hours in an unchanged posture (static loading), and be exposed to whole-body vibration.
The seven most frequently discussed occupational risk factors are listed in Table 10.9. Among them,
the first six are all physical risk factors which have been experimentally associated with the development
of injuries in spinal tissues. Because they often occur together, the relative importance of each is difficult
to determine. The seventh, psychological and psychosocial work factors, is probably more related to
disability claims than to occurrence of a specific pathology.
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TABLE 10.9 The Seven Most Frequently

Discussed Risk Factors for Lower Back Pain
Heavy Physical Work

Several investigations indicate an increase in sickness absence due to low back pain, and also an increase
in low back symptoms in individuals performing physically heavy work (Andersson, 1981, 1997; Snook,
1982). A few will be discussed here. Magora (1970) found prevalence to vary greatly between occupations.
Uyttendaele et al. (1981) found that university and hospital employees with occupations demanding
high physical strains were absent from work significantly more often due to LBP than those with light
physical work. Unskilled laborers had the highest prevalence rate for disc prolapse and lumbago in the
Dutch study by Valkenburg and Haanen (1982). Svensson and Andersson (1983) found heavy physical
work to be strongly associated with the occurrence of low back pain; and the highest prevalence of low
back pain in their first cross-sectional study, which included men only, was in men with physically heavy
professions (Table 10.9). In a subsequent study in women, however, Svensson and Andersson (1989)
found only psychological variables, such as dissatisfaction with the work environment and the work
itself, and fatigue and worry at the end of the work day to be directly associated with low back pain.
Forward bending, lifting, standing, and monotonous work correlated to LBP, but in the univariate
analysis.
Klein et al. (1984) found the highest rates of back sprain/strains among workers in physically heavy
industries and with physically heavy occupations, as did Behrens et al. (1994). Lloyd et al. (1986) report
a higher lifetime prevalence and three-month prevalence in miners than in office workers. Finnish
employees in the metal industry were followed over a 10-year period (Leino et al., 1987). Low back pain
was more common among blue collar workers than among white collar workers. Among blue collar
workers, however, only weak associations were found between morbidity and indices of physical work
load.
Mitchell (1985) surveyed low back pain occurring in RAF (Royal Air Force) ground trades personnel.
The male prevalence was 9.1% overall, and increased with the severity of the job grade. In all job
grades, the prevalence was highest in the 40- to 49-year age group. Both sickness absence and frequency
of employment restriction increased with the severity of the job grade. Herrin et al. (1986) analyzed
musculoskeletal injury rates among 6,900 workers in 55 industrial jobs with almost 3,000 different
manual tasks. The manual exertion requirements were determined using various job stress indices, and
2-year retrospective as well as 1-year prospective medical reports were gathered. Musculoskeletal problems
were twice as common if predicted peak lumbosacral disc compression forces exceeded 6,800 N (1,500
lb.). Back problems were about 2.5 times higher in workers with high physical performance requirements.
Using the U.S. Quality of Employment Survey for 19721973, Leigh and Sheetz (1989) found physically
heavy work to be associated with back pain, particularly farming (OR = 5.17). A cross-sectional survey
at a U.S. oil company employing 10,350 full-time regular employees found the relative risk for a lowback injury to be 1.57 in physically demanding jobs (Tsai et al., 1992).
Similar to LBP, sciatica also has an increased prevalence in physically heavy occupations. Wickstrom
et al. (1978) found a higher prevalence of sciatica in concrete reinforcement workers than in computer
technicians, and higher rates of HNP have been reported in physically demanding occupations by Hrubec
and Nashold (1975), Kelsey et al. (1984), and Videman et al. (1984). Riihimaki (1985) found higher
prevalances of sciatica among concrete reinforcement workers compared to house painters. Hrubec and
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TABLE 10.10 Annual Prevalence of Back Sprains/Strains (BS) and
Unspecified Back Injuries (BI) in Selected Studies
TABLE 10.11 Prevalence of LBP in Studies Comparing Physically Heavy and Light Work
Source: Rowe ML (1963): Preliminary statistical study of low back pain. J Occup
Med 5(7): 336341; Rowe ML (1969): Low back pain in industry. A position paper. J
Occup Med 11(4): 161169.
Nashold (1975) found a negative association between HNP and clerical work, while craftsmen and
foremen had a significantly higher than average risk. Heliovaara (1987), in a large Finnish study, found
that men had a significantly higher probability of being hospitalized for HNP if they were blue collar
workers or motor vehicle drivers. A lesser difference between occupations was present in women.
All these studies would seem to support the idea that heavy physical work increases the risk of low
back pain. Confounding factors may exist, however, and the level at which physical work load becomes
a risk factor is not determined. Other studies are less clear. Lockshin et al. (1969), Sairanen et al. (1981),
Porter (1987), and Bigos and Batti (1992) did not find any differences in prevalence between heavy and
light work. And occupational factors did not predict the incidence of LBP over a 1-year follow-up
period in a Danish cross-sectional sample (Biering-Sorensen and Thomsen, 1986). It is not surprising in
epidemiologic studies of this type that some studies will be negative. The association between work load
and LBP is relevant in time order, strong based on the majority of studies, dose-related (Heliovaara et
al., 1991; Burdorf et al., 1991; Kumar, 1990; Punnett et al., 1989), consistent, and biologically coherent.
Table 10.10 summarizes the annual rates per 100 workers reported by different investigators among
different worker samples, using injury reports, registry statistics, questionnaires, and interviews. Although
differences in research methods make data difficult to compare directly, the average prevalence rates
range from a low of 0.75 to a high of 4.5, i.e., large injury rates are reported everywhere. Prevalence
rates are higher for workers in physically demanding jobs (Table 10.11). This reflects not only the risk,
but also the diffkiculty of performing a heavy job with a painful lower back. It is obvious from the data,
however, that back pain is very frequent in physically light jobs as well. A change in the work environment,
therefore, cannot be expected to solve the back injury problem completely.
10-13
Static Work Postures

Working in predominantly one posture, such as prolonged sitting, seems to carry an increased risk for
back pain. But there is considerable disagreement. While many studies indicate an increased risk of low
back pain in subjects with predominantly sitting work postures (Hult 1954; Kroemer and Robinette,
1969; Lawrence, 1955; Magora, 1972; Partridge, 1969), others do not (Bergquist-Ullman, 1977; Braun,
1969; Frymoyer et al., 1983; Damkot et al., 1984; Heliovaara, 1987; Riihimaki, 1989; Svensson and
Andersson, 1983, 1989; Westrin, 1973). Kelsey (1975, 1978) and Kelsey and Hardy (1979) found that
men who spend more than half their workday in a car have threefold increased risk of disc herniation.
This could be due to the combined effect of sitting and vehicle vibration. Magora (1972) found that
those who either sat or stood during most of the workday had an increased risk of low back pain.
Frequent changes in posture were also found to increase the risk of back pain, however.
Frequent Bending and Twisting

The association between low back symptoms and frequent bending and twisting is difficult to evaluate
as a separate activity because lifting is usually also involved. A large number of studies report an association
between these movements in general and low back pain (Bergquist-Ullman and Larsson, 1977; Brown,
1975; Damkot et al., 1984; Daniel et al., 1980; Frymoyer et al., 1983; Frymoyer et al., 1980; Lloyd et
al., 1986; Maeda et al., 1980; Troup, 1984; Troup et al., 1970; Wickstrom et al., 1978).
Magora (1973) established a connection between both excessive bending and occasional bending on
the one hand and low back pain on the other, and a similar finding was made by Chaffin and Park
(1973). Keyserling et al. (1988) found low back pain to be related to asymmetric postures in an automobile
assembly plant, and Riihimaki et al. (1989) report a relationship between sciatica and twisting and
bending work postures not only in physically heavy jobs, but in office workers as well. Further analysis
of the data from the automobile assembly plant (Punnett et al., 1991) revealed the following odds ratios
(OR) and confidence intervals (CI); mild trunk flexion (OR 4.9, CI 1.417.4), severe trunk flexion (OR
5.7, CI 1.620.4), and trunk twist or lateral bend (OR 5.9, CI 1.621.4). The risk increased with
exposure to multiple postures and with increasing duration of exposure. Thus, a combination of mild
flexion and twisting produced an OR of 7.4 (CI 1.829.4).
Lifting, Pushing, and Pulling

It has been clearly established that back pain can be triggered by lifting, but the frequency at which
lifting is the main cause of back pain varies between studies (Bergquist-Ullman and Larsson, 1977; Bigos
et al., 1986; Hult, 1954; Ikata, 1965; Kelsey, 1975; Klein et al., 1984; Lloyd et al., 1986; Magora, 1970,
1972). Sudden unexpected maximal efforts were found by Magora (1972) to be particularly harmful,
and Glover (1960), Tichauer (1965), and Troup et al. (1970) express the same opinion about lifting in
combination with lateral bending and twisting.
Chaffin and Park (1973) found that workers involved in heavy manual lifting had about eight times
the number of lower back injuries as those with a more sedentary work situation. Svensson and Andersson
(1983) found a direct association between occurrence of low back pain and frequent lifting, as did
Frymoyer et al. (1980, 1983) and Hult (1954). Snook (1982) found that a worker was three times more
susceptible to compensable low back injury if exposed to excessive manual handling tasks. The National
Institute of Occupational Safety and Health (NIOSH) estimated in 1981 that one third of the U.S.
workforce lifted in excess of what was considered acceptable, and that lifting was a major cause of low
back pain. They also concluded that the severity of injury rate while lifting was proportional to the
weight of the object, the bulk of the object, the location of the object at the start of the lift, and the
frequency of lifting.
Kelsey (1975), on the other hand, in her first study found no indication that workers with herniated
discs did more lifting on the job than workers without such symptoms. Further, there was no indication
in that study that jobs requiring pushing, pulling, or carrying either increased or decreased the risk of
herniated discs. In the second study, however, (Kelsey et al., 1984b) frequent lifting was identified as a
10-14
risk factor for HNP, the risk increasing the heavier the weight lifted and the more frequent the lifts.
Lifting while twisting increased the risk even further. The odds ratio for HNP in subjects performing
frequent lifting of heavy weights while twisting was 3.4.
Troup et al. (1981) followed 802 workers over a 2-year period. Half of all episodes of LBP were
associated with a back injury and of those, 1 of 3 occurred from manual material handling. A
crosssectional survey in a small market town in the south of England correlated the life-time occupational
history of 545 adults with the prevalence of low back pain (Walsh et al., 1989). The strongest associations
were for lifting and moving weights over 25Kg (RR 2.0, CI 1.13.7). When considering those individuals
with severe unremitting back pain, the risk ratio for lifting increased to 5.3 among the men, and 2.9
among the women.
Repetitive Work
Repetitive work increases, in general, the sickness absence rate. Low back pain seems to be no exception
in this respect. This may explain, in part, why assembly line industries have a higher incidence of low
back pain among their manual workers than among their office employees (Bergquist-Ullman and Larsson,
1977).
Duration of employment may also be associated with back pain, although the healthy worker effect
makes this difficult to evaluate. Magora (1970) found an association with back pain among workers
doing heavy work, and Astrand (1987) reports a direct relationship between back pain and time of
employment among 391 male employees in a Swedish pulp and paper industry.
Vibrations
There are several studies suggesting an increasing risk of low back pain in drivers of tractors (Christ,
1973, 1974; Christ and Dupuis, 1966; Christ and Dupuis, 1968; Damlund et al., 1986; Dupuis and
Christ, 1966; Dupuis et al., 1972; Dupuis and Zerlett, 1986; Hulshof and van Zanten, 1987; Rosegger
and Rosegger, 1960; Seidel et al., 1986; Seidel and Heide, 1986), of trucks (Gruber, 1976; Kelsey and
Hardy, 1975; Kristen et al., 1981; Wilder et al., 1982; Behrens et al., 1994), of buses (Gruber and
Ziperman, 1974; Kelsey and Hardy, 1975), and of airplanes (Fitzgerald and Crotty, 1972; SchulteWintrop and Knoche, 1978). These studies also suggest that low back pain occurs at an earlier age in
subjects exposed to vibration.
Kelsey and Hardy (1975) found that truck driving increased the risk of disc herniation by a factor of
four, while tractor driving and car commuting (20 miles or more per day) increased the risk by a factor
of two. In a later study, the risk of HNP was related to the type of vehicle, indicating significant differences
between different brands of cars (Kelsey et al., 1984a).
Hulshof and van Zanten (1987) have reviewed the epidemiologic data supporting a relationship
between whole-body vibration and low back pain. They concluded that vibration was a probable risk
factor in helicopter pilots, tractor drivers, construction machine operators, and transportation workers.
They were critical of the data, however, concluding that none of the many studies reviewed was adequate
in terms of the quality of exposure data, effect data, study design, and methodology. Most studies did
not control for confounding variables, and only a few had control populations.
Dupuis and Zerlett (1986), in a 10-year prospective study (1961 to 1971), describe an increased
incidence of backache reports from 47% to 58% among tractor drivers, while Hilfert et al. (1981)
reported that 70% of 352 construction machine operators had periodic LBP compared to 54% in an
unexposed control group. Gruber and Zipermann (1974) compared 1,448 male interstate bus drivers to
three control groups. Experienced drivers had a higher prevalence of spinal disorders than controls. A
significant correlation was found between prevalence rates and exposure level. In a later study Gruber
(1976) found significantly higher back pain prevalence rates among 3,205 interstate truck drivers
compared to 1,137 air traffic controllers. Behrens et al. (1994) found the highest prevalence estimates
for back injuries among U.S. occupational groups to occur among truck drivers. In a Danish study,
2,045 full-time male bus drivers in the three largest cities in Denmark were compared to 195 motormen
10-15
(Netterstrom and Juel, 1989). The prevalence of low back pain was 57% vs. 40%. Burdorf and Zondervan
(1990) found an odds ratio of 3.6 for low back pain among crane operators compared to controls.
Buckle et al. (1980), Frymoyer et al. (1980), Backman (1983), Damkot et al. (1984), Walsh et al.
(1989), and Biering-Sorensen and Thomsen (1986) all report an association between automobile use
and low back pain. The risk of being hospitalized because of HNP was high among motor vehicle
drivers in the Finnish Study by Heliovaara (1987), and Pentinnen (1987) and Riihimaki et al. (1989)
report an increased risk of sciatica with motor vehicle driving in other Finnish studies.
Studies of vibration-exposed populations have also indicated that radiographic changes occur in the
spines of these subjects (Dupuis and Zerlett, 1986). These studies are retrospective and usually limited
to selected subject groups. It is therefore difficult to make cause-effect conclusions. Further, the radiographic findings are diverse and cannot all be explained by mechanical theory. Nonetheless the prevalence
rates of radiographic changes are very high.
Psychological and Psychosocial Work Factors

Several psychological work factors, including monotony at work, work dissatisfaction, and poor relationship to co-workers have been found to increase the risk of complaining of low back pain and report
workers compensation claims. (Astrand, 1987; Battie, 1989; Cunningham and Kelsey, 1984; Deyo and
Tsui-Wu, 1987; Bergquist-Ullman and Larsson, 1977; Bigos et al., 1996; Bigos and Spengler et al.,
1986; Damkot et al., 1984; Svensson and Andersson, 1983 1989, 1988). Monotony had a direct
relationship to low back pain in the study by Svensson and Andersson (1983), while Bergquist-Ullman
and Larsson (1977) found that workers with monotonous jobs, requiring less concentration, had a
longer sickness absence following low back pain than the others. Diminished work satisfaction has also
been found to be related to an increased risk of low back pain by Westrin (1970), Magora (1973), and
Svensson et al. (1983). Bergenudd and Nilsson (1988) found that middle-aged workers had an increased
prevalence of back pain if they had physically heavy jobs and that the association increased further
when the workers were dissatisfied with their work. Individuals with back pain had been less successful
in a childhood intelligence test, and on average had a shorter education. Kelsey and Golden (1988) point
out that since most of the studies are retrospective it is difficult to determine whether psychological
factors are ante-cedents or consequences of pain. Bigos et al. (1986) and Battie et al. (1992) prospective
studies concluded, however, that psychological work factors were more important than physical work
factors as risk indi-caters of low back pain.
Acknowledgment
This manuscript is in part based on Chapter 7, The epidemiology of spinal disorders, by G.B.J.Andersson,
in The Adult Spine (Ed. J.W.Frymoyer), Lippincott-Raven Publishers, Philadelphia, pp. 93141, 1997.
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11
Static Biomechanical
Modeling in
Manual Lifting
11.1
11.2
11.3
11.4
Don B.Chaffin
The University of Michigan
11.5
Introduction
Development of Static Strength Prediction
Programs
Computerization of Strength Prediction and
Back Force Prediction Models
Validation of Strength and Back Force Prediction
Models
Final Comments
111
112
117
1110
1110
11.1 Introduction
Though most manual tasks in industry involve significant body motions, it continues to be very helpful
to evaluate specific exertions within a manual task by performing a static biomechanical analysis. Such
analyses are normally performed by combining the postural information (body angles) obtained from a
stopped frame video image (or photograph) of a worker, and measured forces exerted at the hands. The
latter is often obtained with a simple handheld force gauge.
What follows is a description of a computerized static biomechanical model which has been developed
and used over the last 25 years to predict:
1. The percentage of men and women who would be capable of exerting specified hand forces in
various work postures, and
2. The forces acting on various spinal motion segments.
Since these two different output predictions have specific criterion values referenced in the NIOSH
Lifting Guideline, they are often used by professional ergonomists to determine the relative risk of injury
associated with the performance of a manual exertion of interest (Chaffin, 1988). It also should be
noted, that the prediction of the percent of the population capable of performing a specific exertion
required on a job is often crucial to the determination of a job-specific strength test score for preemployment and return to work purposes (Chaffin, 1996a). Finally, because the biomechanical population
strengths and low back stresses are predicted by a computerized model which runs on common personal
computer platforms, this has meant that job and product designers and engineers have been able to
simulate various expected high exertion tasks during the early part of the design process, and thus avoid
costly prototype evaluations and retrofits when the products and/or processes become operational
(Chaffin, 1996b). It is this latter application of the biomechanical static strength prediction programs
that provide perhaps the greatest potential benefit over other common job evaluation methods. Many
other methods require a person to be observed and measured, sometimes with expensive instrumentation.
0-8493-1800-9/03/$0.00+$1.50
11-1
11-2
FIGURE 11.1 Biomechanical logic used to predict whole-body static exertion capabilities for given postures, hand
force directions, and anthropometric groups.
This precludes the use of these empirical methods for use in proscriptive job design, wherein the job
exists only on paper or in a computer-rendered drawing of the workspace. By interfacing a computerized
biomechanical model of a person (as described in the following) into a computerized rendering of the
workspace, the designer can quickly perform a large number of simulated exertions to determine the
human consequences of altering a proposed job design, much like that being done to accommodate
various sized individuals using computerized anthropometric manikins.
What follows is a brief description of the development of a static biomechanical strength modeling
technology, including illustrations of how it has been used to evaluate various manual lifting situations.
11.2 Development of Static Strength Prediction Programs

The general logic used to predict population static strengths in various jobs is depicted in Figure 11.1. In
this model specific muscle group strength data and spinal vertebrae failure data are used as the limiting
values for the reactive moments at various body joints created when a person of a designated stature and
body weight attempts an exertion (i.e., lifts, pushes, or pulls in a specific direction with one or both
hands while maintaining a known posture).
This logic has been well described for a sagittal, coplanar static strength analysis in Chaffin and
Andersson (1991). When wishing to perform an analysis in three dimensions, the body is represented as
a set of links with known mass, as depicted in Figure 11.2. The load moments Mj are computed by the
cross products of the unit distance vectors to each joint and body segment weights and hand forces.
The static moment equilibrium equations for the elbow and shoulder in this linkage can be
defined as:
(11.1)
where
is the Right Hand Force with X, Y, Z unit vector (i, j, k) components for each,
FRX: X component of R Hand Force,
FRY: Y component of R Hand Force, and
FRZ: Z component of R Hand Force.
(11.2)
Static Biomechanical Modeling in Manual Lifting
11-3
FIGURE 11.2 Three-D distance, force, and moment vectors used in 12 link biomechanical model for strength
prediction. From Chaffin, D.B. and Erig, M. 1991. Three-dimensional biomechanical static strength prediction
model sensitivity to postural and anthropometric inaccuracies. IIE Trans. 23(3):216227. With permission.)
11-4
where
is the Forearm Length with Link unit Vectors,
V1x: X component of Forearm Unit Vector,
V1y: Y component of Forearm Unit Vector,
V1z: Z component of Forearm Unit Vector, and
Lelink: Magnitude of Forearm Length from Anthropometric Data.
(11.3)
where
V1cg is the cg distance from elbow to Forearm Center of Gravity Vector expressed in unit vector form,
multiplied by the cglink, which is the magnitude of proximal distance to cg of forearm from anthropometric
data.
(11.4)
where
is the Elbow Resultant Moment with X, Y, Z unit vector components,
M1x: Elbow Moment about X axis,
M1y: Elbow Moment about Y axis,
M1z: Elbow Moment about Z axis,
and
(11.5)
where
(which is Forearm Weight Vector),
and
(11.6)
where
is the Elbow Joint Reaction Force Vector with X, Y, Z unit vector components,
and
(11.7)
11-5
where
is the Right Shoulder Resultant Moment with:
Upperarm Center of Gravity Vector,
Upperarm Link Vector,
Upperarm Weight Vector.
and
(11.8)
where
Shoulder Moment about X axis,
M2y: Shoulder Moment about Y axis,
M2z: Shoulder Moment about Z axis.
A recursive computational procedure is used to continue the analysis to compute external load moments
and forces at the elbow and shoulder of the arm or arms doing the exertion, the lumbosacral joint, hip
joints and knee and ankle joints.
The size and mass of the person (linkage) size is most often specified as a select strata of the population
(i.e., a percentile of specific anthropometric dimensions is selected from population surveys). Thus, a
small, medium, or large man or woman can be specified, or specific link anthropometry can be used if
available. Link length-to-stature ratios from Drillis and Contini (1966) and link mass-to-bodyweight
ratios from Dempster (1955) and Clauser et al. (1969) are used to simplify this procedure, if specific
anthropometry is not available on a subject. Most often an average male or female anthropometry is
chosen for assessing the strength requirements of a given task in industry.
The strength moment values used as population limit values in the program were measured by Stobbe
(1982) for 25 men and 22 women employed in manual jobs in three different industries. These values
have been combined with the earlier values from Chaffin and Baker (1970) and Schanne (1972) to form
the statistical data for the population joint moment limits.
Once the size of the person has been specified or selected from a known anthropometric data source,
the posture is entered with reference to either photographs or videos (or by manipulating a computergenerated hominoid) and then the hand forces of interest are keyed in. The program then computes the
load moments at each joint of the linkage, and compares each to the corresponding strength moment
capability obtained from the previously measured populations. This provides a prediction of the percent
of the population that is capable of producing the necessary strength moments at each joint. The logic
for computing the lumbar motion segment compression force is shown in Figure 11.3.
The logic assumes that once the lumbar moment is computed (as described in the preceding), torso
muscles contract to stabilize the column. In the 2D Sagittal Plane logic a single torso muscle equivalent
contraction force is included. When the necessary reactive torso muscle force is added to body segment
weights and hand forces (with a minor adjustment for abdominal pressure effects) a prediction of the
compression force on the L5/S1 disc results, as shown in Figure 11.4.
When an asymmetric exertion (e.g., one-handed force, or twisted or laterally bent torso) is being
analyzed, many different torso muscle actions and passive supporting tissue reactions need to be
considered. The first step in such a procedure requires that the position, orientation, cross-sectional size,
and length of the various connective tissues be modeled at the lumbar spinal level. A geometric torso
11-6
FIGURE 11.3 Logic for computing L5/S1 compression forces in 2D and 3D Static Strength Prediction Programs.
FIGURE 11.4 Simple low-back model of lifting for static coplanar lifting analyses. The load on the hands LH and
torso and arm weights BW act to create moments at the L5/S1 disc of the spine. The moments are resisted primarily
by the back muscles. The high muscle forces required in such a task cause high disc compression forces. (From
Chaffin, D.B. and Andersson, G.B.J. 1991. Occupational Biomechanics, 2nd ed. John Wiley & Sons, Inc., NY. With
permission.)
model proposed by Nussbaum and Chaffin (1996) for this purpose is shown in Figure 11.5. This model
includes estimates of specific tissue geometry acquired from various CT scans (Tracy et al., 1989; Moga
et al., 1993; Chaffin et al., 1990), along with passive tissue reaction forces estimated by McCully and
Faulkner, (1983), Nachemson et al. (1979), Miller et al. (1986), and others.
The most important predictors of spinal column stress, however, are the muscle reaction forces required
to stabilize the spine to external load moments. In the 3D torso models various approaches have been
used to predict the required reactive muscle forces. Perhaps the most commonly cited torso biomechanical
model for 3D Static Analysis is that developed by Schultz and Andersson (1981). It is depicted in Figure
11.6. A revised version of this model has been developed by Bean et al. (1988). This latter model
11-7
FIGURE 11.5 Muscle geometry illustrated for a 50th percentile male. Muscles are treated as pointwise connections
from origin to insertion (see text). An imaginary cutting plane which bisects the L3/L4 motion segment is also shown.
(From Nussbaum, M.A. and Chaffin, D.B. 1996. Development and evaluation of a scalable and deformable geometric
model of the human torso. Clin. Biomech. 11(1):2534. With permission.)
provides a more efficient computational method for solving the linear programs used to simultaneously
minimize the torso muscle contraction intensities and motion segment compression forces. The present
model predicts the minimum muscle force contractile intensities required to meet the moment equilibrium
requirements about the three orthogonal axis-of-rotation of the motion segment. Given a set of optimal
forces so computed, the model further seeks to minimize the disc compression forces. Because such an
approach attempts to minimize both muscle intensity requirements and disc compression forces
simultaneously, it is referred to as a double linear optimization approach.
More recently Hughes and Chaffin (1995) proposed that a nonlinear objective function be used as
the basis for selecting the various muscle reaction forces during a given exertion. They referred to this as
the sum of the cubed muscle intensity objective. Nussbaum et al. (1996) also have proposed a neural
network model to predict torso muscle actions. And most recently, Raschke and Chaffin (1996) have
proposed that the external moment is normally distributed about the torso, and activates several muscles
simultaneously depending on the direction and magnitude of the external moment.
11.3 Computerization of Strength Prediction and Back Force Prediction

Models
It should be clear from the preceding descriptions that the biomechanical models used for population
strength and spinal motion segment force prediction are computationally intense, especially in the
3-dimensional form. For this reason a number of faculty, staff, and students associated with the Center
11-8
FIGURE 11.6 Schematic of 10 muscle model developed by Schultz and Andersson (1981).
for Ergonomics at the University of Michigan have worked to provide user friendly, computer programs
of the models. These are referred to as the 2-dimensional and 3-dimensional Static Strength Prediction
Programs (i.e., 2DSSPP and 3DSSPP). Over 2,500 licenses for use of these programs have been
granted by the University of Michigans, IPO Software Group over the last 13 years.
The main screen of the 2DSSPP program is depicted in Figure 11.7. The input values, (i.e., body
link angles, hand forces, and anthropometry) are shown in the upper left quadrant. A stick figure
depicting the body posture, the hand location, and the hand force direction used as inputs is depicted in
the upper right quadrant. The predicted percent of the male and female population having sufficient
strength to perform the designated exertion (in this case lifting a 44-pound stock reel) is shown in
tabular and graphical form in the lower left quadrant. The back compression force predictions for a
man and women performing the 44-pound lift is shown in the lower right quadrant. From inspection of
the percent capable predictions (left bottom) it is obvious that hip strengths are the most limiting muscle
group strength (only 66% of women and only 87% of men have sufficient hip strength to lift the 44pound reel). These values are below those recommended by NIOSH, which believes that jobs should
accommodate 99% of mens and 75% of womens strength (or 90% of a mixed gender population). It
also is shown in the right bottom quadrant that the L5/S1 compression forces of 924 and 845 pounds
are above that recommended by NIOSH of 760 pounds.
The 3DSSPP program requires more input data than the 2D version depicted in Figure 11.7. Threedimensional exertions often involve two hand forces which can act in any direction. Also, a model of the
human body in 3D has 12 body links (some with three postural angles). Two types of input presentations
are used to assist in assuring the correct input data are used for 3D analyses. One presentation has three
orthogonal views of a stick figure, and the other presents a shaded, enfleshed hominoid, which can be
viewed from any direction. Figure 11.8 depicts these two presentations. The use of the 3D hominoid
was found by Beck and Chaffin (1992) to allow postures viewed on a video or photograph to be accurately
represented in a computer. An inverse kinematic model with preferred postural prediction capability is
included to allow the user to easily manipulate the figure into the posture to be analyzed. The output
screens are similar to that shown in Figure 11.7 for the 2DSSPP. These depict both percent capable
strength predictions (for 21 muscle functions) and lumbar compression forces; the latter can include 3D
predictions of a large number of individual muscle and spinal forces.
11-9
FIGURE 11.7 Main screen from the University of Michigan 2D Static Strength Prediction Program for personal
computers. (From the University of Michigan, IPO Software, Ann Arbor, MI 48109.)
FIGURE 11.8 Input screen used in 3DSSPP to assure postural data are correct. (With permission, University of
Michigan Regents.)
11-10
11.4 Validation of Strength and Back Force Prediction Models

The validation of the static strength predictions from the 2D and 3D strength models has been
accomplished in three different studies. All three validations required using the models to simulate
whole-body exertions and compare the percent capable predictions with the mean, 10, and 90 percentile
strengths of a group of volunteers who performed the same tasks.
In the first validation Garg and Chaffin (1975) had 71 male Air Force personnel perform 38 different
maximum arm exertions (i.e., lifts, pushes, pulls, etc.) in a variety of arm/torso postures while seated.
They found the predicted strengths were highly correlated with the group strengths when performing
the 38 upper body tasks (r = 0.93 to 0.97). Chaffin et al. (1987) simulated 15 different whole-body
exertions in the sagittal plane which were also performed by both men and women from a variety of
industries. In some of these tests over 1,000 people performed the exertions, though on average about
200 people performed each one. Comparison with the 2DSSPP program with the group strength data
revealed a very high correlation (r = 0.92). This same study also included simulations with the 3DSSPP
program of 72 different one-arm exertions performed by five male Army personnel. The correlations
ranged from r = 0.71 to 0.83. Unfortunately, in this latter comparison, exact postural and bracing
conditions were not available to use in the simulations. This may have contributed to the lower
correlations.
The last validation involved simulations of 56 one- and two-handed, whole-body exertions in 14
different symmetric, bent, and twisted-torso postures (Chaffin and Erig, 1991). The simulation results
were compared with the group strengths of 29 young males. Photographs from several views were
available to assist in replicating the postures used by these subjects. The results indicated that if care is
taken to assure that the postures used in the model simulation is the same as that chosen by people
performing the exertions, the prediction error standard deviation will be less than 6%.
In conclusion, it appears that the strength prediction models and population norms used in the
present models are accurate in predicting the percent of the population capable of performing a large
variety of different types of maximal static exertions. One caution should be noted, however. At present
the strength norms used as limits in the models are based on male and female populations who are
relatively young (i.e., 18 to 49 years). To improve the models further, strength values are currently being
gathered on older populations by these investigators. In this regard, one comparison involving 98 men
and women with a mean age of 73 years, showed a major decrease in strength performance in certain
muscle functions. When these decreases were included in the 3DSSPP population database, it was found
that some exertions that could easily be performed by younger people were predicted to be impossible to
perform by most older people (Chaffin et al., 1994).
Validation of the low back biomechanical model has been largely dependent on EMG estimates of
muscle reactions in subjects performing controlled torso exertions. Hughes et al. (1994) discusses this
procedure, and the results of comparisons with four different optimization procedures used to predict
torso muscle responses to different external torso moment loads. Generally speaking, relatively high
correlation (r > 0.8) is achieved when loading the torso approximately in the sagittal plane. With greater
asymmetric or sudden loading, more complex muscle patterns result, sometimes with a 10 to 30%
antagonistic type of muscle response. These complex responses are often not well predicted (r = 0.6) by
existing models. Thus it is expected that existing models may underpredict the muscle-induced compression
and shear forces on the spinal motion segments by as much as 30% during sudden (i.e., jerking) motions
or lateral, asymmetric exertions. The newer neural network and/or geometric moment distribution models
are yet to be thoroughly tested under complex loading conditions. They may be less sensitive to this
cocontraction phenomenon than existing optimization models.
11.5 Final Comments

The development of biomechanically based, static strength and low back force prediction models provide
powerful tools for performing ergonomic assessments of high physical effort jobs. With the advent of
11-11
FIGURE 11.9 Comparison of two different postures used to lift 25- and 50-pound objects from the floor close to feet
using the Michigan 3DSSPP.
faster personal computers these models are gaining popularity not only as a means to evaluate existing
manual tasks, but also to aid in the design of new workplaces and equipment, as well as in the specification
of personnel selection and training programs.
The inclusion of inverse kinematics, behaviorally based posture prediction methods, improved human
form graphics, and direct human image video input data, have made the use of these models relatively
easy for the ergonomics practitioner. By simply clicking and pointing to parts of the body, one can adjust
postures and have a comprehensive biomechanical assessment of a specific exertion (such as depicted in
Figure 11.9).
With the widely recognized need to design workplaces right the first time, computerized
biomechanical strength prediction models will become even more useful. It is hoped that this presentation
assists those interested in knowing more about both the scientific basis for this rapidly expanding
technology, and the potential benefits and limitations inherent in it.
Acknowledgment
I wish to acknowledge NIH Grant AR-39599 for partial support for some of the work described in this
presentation.
References
Bean, J.C., Chaffin, D.B., and Schultz A.B. 1988. Biomechanical model calculation muscle contraction
forces: a double linear programming method. J. Biomech. 21(1):5966.
Beck, D.J. and Chaffin, D.B. 1992. An evaluation of inverse kinematics models for posture prediction.
Proceedings of CAES 1992, Tampere, Finland. Center for Ergonomics, The University of Michigan,
Ann Arbor, MI.
Chaffin, D.B. 1996a. Ergonomic basis for job-related strength testing, in Disability Evaluations, Eds.
S.L. Demeter, G.B.J.Andersson, and G.M.Smith, p. 159167. American Medical Association, Mosby,
St. Louis, MO.
Chaffin, D.B. 1997. Biomechanical aspects of workplace design, in Handbook of Human Factors, Ed.
G. Salvendy. Wiley & Sons, Inc., New York, NY.
11-12
Chaffin, D.B. 1988. A biomechanical strength model for use in industry. Appl. Ind. Hyg. 3(3):7986.
Chaffin, D.B. 1988. Biomechanical modelling of the low back during load lifting. Ergonomics 31(5):685
697.
Chaffin, D.B. and Andersson, G.B.J. 1991. Occupational Biomechanics, 2nd ed. John Wiley & Sons,
Inc., NY.
Chaffin, D.B. and Baker, W.H. 1970. A biomechanical model for analysis of symmetric sagittal plane
lifting. AIIE Trans. 2(1):1627.
Chaffin, D.B. and Erig, M. 1991. Three-dimensional biomechanical static strength prediction model
sensitivity to postural and anthropometric inaccuracies. IIE Trans. 23(3):216227.
Chaffin, D.B., Redfern, M.S., Erig, M., and Goldstein, S.A. 1990. Lumbar muscle size and location
measurements from CT scans of 96 older women. Clin. Biomech. 5(1):916.
Chaffin, D.B., Freivalds, A., and Evans, S.M. 1987. On the validity of an isometric biomechanical
model of worker strengths. IIE Trans. 19(3):280288.
Chaffin, D.B., Woolley, C.B., Buhr, T., and Verbrugge, L. 1994. Age effects in biomechanical modeling
of static lifting strengths. Proceedings of Human Factors Society, Nashville, TN.
Clauser, C.E., McConville, J.T., and Young, J.W. 1969. Weight, volume and center of mass of segments
of the human body. AMRL-TR-6970, Aerospace Med. Res. Labs., OH.
Dempster, W.T. 1955. Space requirements of the seated operator. WADC-TR-55159, Aerospace Med.
Res. Lab. Wright-Patterson AFB, OH.
Drillis, R. and Contini, R. 1966. Body Segment Parameters. BP174945, Tech. Rep. No. 1166.03, S. of
Engnrg. and Sci., NYU, NY.
Garg, A.D. and Chaffin, D.B. 1975. A biomechanic computerized simulation of human strength. AIIE
Trans. 14:272280.
Hughes, R.E. and Chaffin, D.B. 1995. The effect of strict muscle stress limits on abdominal muscle force
predictions for combined torsion and extension loadings. J. Biomech. 28(5):527533.
Hughes, R.E., Chaffin, D.B., Lavender, S.A., and Andersson, G.B.J. 1994. Evaluation of muscle force
prediction models of the lumbar trunk using surface electromyography. J. Orthop. Res. 12:689698.
Miller, J.A.A., Schultz, A.B., Warwick, D.N., and Spencer, D.L. 1986. Mechanical properties of lumbar
spine motion segments under large loads. J. Biomech. 19:7984.
Moga, P.J., Erig, M., Chaffin, D.B., and Nussbaum, M.A. 1993. Torso muscle moment arms at
intervertebral levels T10 through L5 from CT scans on eleven male and eight female subjects. Spine.
18(15):23052309.
McCully, K.K. and Faulkner, J.A. 1983. Length-tension relationship of mammalian diaphragm muscles.
J. Appl. Physiol. 54:16811686.
Nachemson, A.L., Schultz, A.B., and Berkson, M.H. 1979. Mechanical properties of human lumbar
spine motion segments: influences of age, sex, disc level, and degeneration. Spine. 4:18.
Nussbaum, M.A. and Chaffin, D.B. 1996. Development and evaluation of a scalable and deformable
geometric model of the human torso. Clin. Biomech. 11(1):2534.
Nussbaum, M.A., Chaffin, D.B., and Martin, B.J. 1996. A back-propagation neural network model of
lumbar muscle recruitment during moderate static exertions. J. Biomech. 28(9):10151024.
Raschke, U. and Chaffin, D.B. 1996. Trunk and hip muscle recruitment in response to external anterior
lumbosacral shear and moment loads. Clin. Biomech. 11 (3): 145152.
Schanne, F.T. 1972. Three dimensional hand force capability model for a seated person. An unpublished
Ph.D. dissertation, University of Michigan, Ann Arbor, MI.
Schultz, A.B. and Andersson, B.J.G. 1981. Analysis of loads on the lumbar spine. Spine. 6(1):7682.
Stobbe, T.J. 1982. The development of a practical strength testing program in industry. An unpublished
Ph.D. dissertation, University of Michigan, Ann Arbor, MI.
Tracy, M.F., Gibson, M.J., Szypryt, E.P. et al. 1989. The geometry of the muscles of the lumbar spine
determined by magnetic resonance imaging. Spine. 14:186193.
12
Dynamic Low Back
Models: Theory and
Relevance in Assisting
the Ergonomist to
Reduce the Risk of Low
Back Injury
12.1
12.2
12.3
12.4
Stuart M.McGill
0-8493-1800-9/03/$0.00+$1.50
12.5
Introduction
Issues Relevant for Complex Model Interpretation
122
122
The Asset of Anatomical Complexity The Problem of

Indeterminacy Estimating Deep (and Inaccessible) Muscle
Forces Dynamic Models to Assess Movement Over Long
Durations A Brief Description of a Dynamic, 3-Dimensional,
Anatomically Complex, Biologically Driven, Modeling
Approach
Application of Complex Dynamic Models to
Reduce the Risk of Low Back Injury
128
Should One Avoid End Range of Spine Motion During
Exertion? Should One Lift or Perform Extreme Torso
Bending Shortly After Rising from Bed? Should One Lift
Immediately Following Prolonged Flexion Postures?
Should Intraabdominal Pressure Be Increased While
Lifting? Should Abdominal Belts Be Prescribed to Manual
Materials Handlers? Should Workers Adopt a Lifting
Strategy to Recruit the Lumbodorsal Fascia? Should the
Trunk Musculature Be Cocontracted to Stabilize the
Spine? How Do People Hurt Their Backs Picking Up a
Pencil? Are Twisting Lifts Particularly Dangerous? Is
Lifting Smoothly and Not Jerking the Load Always
Best? Is Sedentary-Seated Work Harmful?
Tentative Risk Reduction Guidelines for

Occupational Injury
1215
Recommendations for Safer WorkA Tentative List

Future Directions
1216
12-1
12-2
12.1 Introduction
This chapter will address some issues associated with complex models and highlight how ergonomists
can take advantage of these special tools to reduce the risk of low back injury. Throughout the course of
daily activity, the low back system is subjected to loading from external forces, and from forces produced
by the internal tissues needed to create movement and maintain static postures. The fact that injury to
the low back can only be caused by excessive loading of any given tissue cannot be easily dismissed. This
overloading may occur during strenuous exertion or during prolonged postures; sitting may be such an
example. On the other hand, too little tissue loading also leads to higher injury risk from atrophied
tissues, detrained motor control systems and physiological impairment. Prevention of injury requires
knowledge of the tissue loads during activity, which also enable testing of hypotheses designed to reduce
the risk of injury. Because direct measurement of tissue loads in vivo is not feasible, the only tenable
option for predicting tissue loads is to utilize modeling approaches.
Biomechanical models have been used to estimate loads in the low back tissues and identify high-risk
jobs for approximately three decades. Several approaches to model development have been employed
with each approach having a specific objective, and corresponding assets and liabilities. For example,
some models were intended to reveal spine function and low back injury mechanisms which is background
knowledge required to devise injury avoidance strategies in industry. Other model approaches were
intended as simple tools for health and safety personnel to provide an approximate index of injury risk
on the plant floor. The main issue boils down to the purpose, and necessary complexity, of the model.
Complex models are required to reveal how tissues function inside a worker and to identify specific (and
often subtle) injury mechanisms, while simpler models are needed to broaden utility of use and reduce
the more overt risks on the plant floor. But the better simple models need the complex models to
assess the many simplifying assumptions which affect accuracy and validity of output, depending on the
type of application. Further, in most workplaces, the most blatant or overt ergonomic injury risks have
been addressed, and only the more subtle and sometimes sublime risks remain. Ergonomists need simple
models but also must be conversant with the more complex models which will assist in rectifying the
more subtle injury risks, and assist in developing more effective intervention strategies.
The intent of this chapter is to first examine some issues associated with the development, interpretation,
and application of complex models, then briefly describe a complex model, and finally apply the
complex model to real occupational injury issues. Specifically, data and model output will be integrated
into the formulation of a set of guidelines intended to reduce the risk of low back injury in a wide variety
of occupational situations, ranging from heavy lifting to sedentary activities. Since some of these guidelines
are based on recent research findings, they remain tentative until their efficacy under clinical trial is
proven or disproven. While some may think it prudent to wait for the definitive study, ergonomists have
not always the luxury of time to deal with injury issues, thus the intention in listing the tentative guidelines
here is to provoke discussion and debate, and motivate the initiation of experiments to test their viability.
12.2 Issues Relevant for Complex Model Interpretation

Having made clear the need for complex models in the previous section, the ergonomist must understand
the limitations, and conversely the most appropriate applications, associated with complex models. The
issues of anatomical complexity and how tissue loading is determined will be discussed here. Simple and
static models are described elsewhere in this handbook, together with a discussion of the static vs.
dynamic modeling issue and when two-dimensional analysis or three-dimensional analysis is required
(e.g., Chapter 13.).
The Asset of Anatomical Complexity

There is no doubt that the most overt violations of biomechanical injury risk reduction principles can be
addressed by quite simple models. However, if the purpose of a biomechanical model is to provide
Dynamic Low Back Models
12-3
insight into the functional role of various tissues and how they become injured, it is necessary that the
model represent the structure of the anatomy as closely as possible. Unfortunately, some researchers
have worked beyond the anatomical limitations of the simple models and have made erroneous and
unjustified conclusions about the best choice of injury risk reduction strategy. Examples of questionable
anatomical/mechanical simplification are as follows:
1. Muscle areas used in some models were obtained from cadavers. Dimensions obtained in this
way are difficult to justify for use in models of healthy, young, and working individuals when
atrophy and distortion from fluids would greatly under-predict the force potential of the
musculature. These underestimations of muscle area, and force-producing potential, have been
pointed out with CT scan data of younger, ambulatory adults presented by Nemeth and Ohlsen
(1986), Reid and Costigan (1985), and McGill et al. (1988, 1993, 1997). Models for ergonomic
application must give proper credit to the musculature to most accurately estimate the risk of
injury for a given work load.
2. Muscles in the trunk do not pull in straight lines as represented in many lumbar spine models.
Several important muscles within the trunk act around pulley systems of bone, other muscle
bulk, and pressurized viscera, which alters length, force, and vector direction properties together
with the resultant joint loading (cf. McGill and Norman, 1987; McGill, 1996).
3. Models which assume the extensor musculature can be represented by a single equivalent force
vector acting parallel to the compressive axis produce controversial output. Excellent work by
Langenberg (1970) and Macintosh and Bogduk (1987) provides clear descriptions of the
connections for the prime extensors of longissimus thoracic pars thoracic and pars lumborum,
iliocostalis lumborum pars thoracic and pars lumborum, and multifidus. Very few of these fibers
run parallel to the axis of spinal compression, demonstrating that they exert both compression
and shear forces on the spine (Figure 12.1). In addition, the laminated architecture of the muscle
fascicles provides for a much larger muscle cross-sectional area to contribute to extensor moment
production than would be observed in a single transverse section of the torso. For this reason, an
estimate of extensor moment potential from a transverse scan at a single level of the spine would
result in large error as only a small portion of the musculature would be measured. The relatively
large bulk of thoracic fibers (shown in Figure 12.2) is often neglected as an important contributor
to extension as the fibers produce extensor forces over the full lumbar spine through a moment
arm often exceeding 10 cm.
4. The extensor and torsional potential of latissimus dorsi is often neglected, yet it has the largest
moment arm length of all of the posterior trunk muscles. Its association with the lumbodorsal
fascia as a spine extensor is a contentious issue (cf. Tesh et al., 1987; McGill and Norman, 1988).
5. The passive force contributions of the supraspinous and interspinous ligaments are often modeled
with a single equivalent element. However, interspinous fibers run obliquely to the supraspinous
ligament, thus creating nonparallel forces (Figure 12.1a, vectors a,b,c). In fact, the interspinous
acts to generate a shear force on the joint. However, the fiber direction of this ligament complex
as depicted in most anatomical texts (e.g., Grays Anatomy (1980)), is in error as pointed out by
Heylings (1978). Instead, the interspinous ligament has been shown to contribute significant
anterior not posterior, shear forces which increase, rather than reduce, facet load during large
degrees of flexion (see Figure 12.1) (Shirazi-Adl and Drouin, 1987; McGill, 1988).
6. The diaphragm area and shape is fundamental to the calculation of the potential assistance provided
by intra-abdominal pressure. It is suspected that the size of diaphragms that have been used in
the past (up to 465 cm2) is a gross overestimate; the normal surface area on which pressure is
exerted is probably closer to 243 cm2 (McGill and Norman, 1987), 276 cm2 (Schultz et al.,
1982), or 299 cm2 (Troup et al., 1983).
7. The psoas complex has long been considered and described in the textbooks as a flexor of the
lumbar spine. Recent work has shown that while it is a flexor of the hip, its moment arm to flex
the spine is extremely limited (Thorstensson et al., 1989; Santaguida and McGill, 1995), and its
neural activation is not correlated with moments acting on the lumbar spine but rather with hip
flexion moments (McGill et al., 1996).
12-4
FIGURE 12.1 (Left panel) Pars lumborum fibers of iliocostalis lumborum and longissimus thoracis create a posterior
shear force on the superior vertebra compared to the compressive axis (C), (right panel) while the interspinous
ligament imposes an anterior shear when strained in flexion. The general oblique line of action of the muscle and
ligament which causes shear loading, is shown compared to the compressive axis (C). (From Heylings, D.J.A. (1978)
Supraspinous and interspinous ligaments of the human lumbar spine. J. Anat. 123:127131. With permission.)
The Problem of Indeterminacy

Pain and disability have been documented to result from damage to ligaments, discs, vertebral end
plates, vertebral bodies themselves, facet joints, various muscles, and to several other tissues. While
investigation of these injuries requires a modeling approach that incorporates sufficient anatomical
detail, a method is needed to solve for the inherent indeterminacy from so many unknown muscle,
ligament, and bone forces. Because people differ in the way they perform work, causing only some of
them to become injured, the modeling method should also be sensitive to the many different ways that
individual people utilize their muscles and various ligaments to perform tasks. Historically, two basic
approaches have been used to partition the supporting duties among the many components of the trunk
musculature and ligamentous systemoptimization approaches and biological approaches that utilize
biological signals obtained from each subject (for example, measurements of muscle EMG and spine
kinematics). The optimization approach attempts to satisfy the reaction moment requirements needed
to support a posture by recruiting the various muscles based on an optimization criterion such as the
minimization of joint compression and shear load (e.g., Gracovetsky et al., 1981), or first minimization
of muscle contraction intensity and then spine compression load (e.g., Bean et al., 1988). Generally
optimization assumes that the motor control system operates to fulfill objectives that can be mathematically
defined and in so doing ignores individual variability and predicts the same tissue load distribution for
all subjects performing a certain task. Furthermore, most currently reported optimization approaches
are very poor at predicting patterns of muscle cocontraction so characteristic of three-dimensional spine
motion (cf. Hughes et al., 1994, 1995) and for predicting muscle activity in other areas of the body (e.g.,
Collins, 1995). It may turn out in the future that more robust and comprehensive optimization cost
functions, yet to be defined, will prove more effective in predicting patterns of muscle activation and
their resulting forces.
On the other hand, a modeling approach that uses biological signals obtained directly from each
subject is inherently sensitive to the individual ways that people load their low back tissues and, hence
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FIGURE 12.2 A bundle of fibers of longissimus thoracis has been dissected and the tendon isolated to show the
insertion on the sixth and seventh thoracic (T6 and T7) ribs and sacral origin (a). Hence, these muscles create an
extensor moment over the full length of the lumbar spine and minimize the compressive penalty due to their mechanical
advantage. Longissimus thoracis bulk in a developed weight lifter (b). (From McGill, 1990. With permission.)
are better suited to investigations of injury. For example, McGill and Norman (1986) and Marras and
Sommerich (1991) have proposed dynamic models of the lumbar spine that attempted to determine the
significant forces in many muscles in the low back based in part on their neural activation measured
through calibrated surface EMG and in the passive structures based on estimates of strain from directly
measured spine kinematics. The major asset of the biologically based approach is that muscle cocontraction
is fully accommodated together with the approach being sensitive to the differences in the way individuals
perform a movement. However, estimations of muscle force, based in part on myoelectric signals, are
problematic because the force potential per muscle cross-sectional area must be assumed, together with
other variables that are known to modulate muscle force production. Furthermore, one must rely on
anatomical accuracy to satisfy the moment requirements about all three joint axes and about several
joints simultaneously so that errors in achieving moment equilibrium remain. Nonetheless, the ability to
predict measured moments from biologically driven models adds some degree of validity to the modeling
approach. In addition, animal studies involving the direct measurement of tendon forces compared with
predictions of tendon forces, from EMG-based models, appear encouraging (see the work of Komi,
1990; Gregor et al., 1987; Norman et al., 1988). Recent work by Cholewicki et al. (1995) compared the
assets and liabilities of an EMG and spine kinematics approach with an optimization approach to
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obtain tissue force distribution profiles and concluded that the biological-EMG-based approach was
more suitable for investigation of injury mechanisms.
Estimating Deep (and Inaccessible) Muscle Forces

A major drawback of the EMG-based approach using surface electrodes is the myoelectric inaccessibility
of the deeper torso muscles (e.g., psoas, quadratus lumborum, three layers of the abdominal wall). In an
attempt to address this criticism, recent work by McGill et al. (1996) utilized in-dwelling intramuscular
electrodes with simultaneous surface electrode sites to evaluate the possibility, and validity, of using
surface activity profiles as surrogates to activate deeper muscles over a wide variety of tasks and exercises
common in industry and in rehabilitation programs (e.g., situps, curlups, leg raises, pushups, some spine
extensor tasks, and lateral bending and twisting tasks). Prediction of these deeper muscles is possible
from well-chosen surface electrodes within an error criterion of 15% of MVC (RMS difference), or less.
Dynamic Models to Assess Movement Over Long Durations

Analysis of prolonged tasks requires assessment of tissue loads throughout the performance rather than
trying to select a single event in time for analysis. Low back tissues are not always under static loading
during static work, nor used in repeatable patterns during prolonged work (Potvin and Norman, 1992).
For example, subtle shifts in tissue load distribution during the performance of lighter loading tasks, but
of longer duration, can lead to situations where loads in a single tissue may rise to unreasonable levels
(for example, during prolonged sitting or flexion where ligamentous creep transfers more load and
strain to the posterior anulus). Once again, anatomical complexity is required to evaluate the interplay
between muscle and passive tissues, but also a biologically driven model is required that is sensitive to
subtle changes in spinal posture (and therefore sharing of ligament and disc loads) and sensitive to shifts
in muscle activity (either between muscles or between muscles and passive tissues).
A Brief Description of a Dynamic, 3-Dimensional, Anatomically Complex, Biologically

Driven, Modeling Approach
While two groups (the Marras Group, e.g., Granata and Marras, 1993, and the McGill Group) have
devoted much effort to the development of biologically driven models, the McGill model will be described
here, given its familiarity to the author.
Individual tissue loads have been predicted from a laboratory technique and model developed over
the past 14 years. The model is composed of two distinct parts. First, a three-dimensional linked segment
representation of the body was constructed using the dynamic load in the hands as input, and working
through the arm and trunk linkage, reaction forces and moments about a joint in the low back (usually
L4/L5) are computed (previously described in McGill and Norman, 1985) (see Figure 12.3). Joint
displacements are recorded on two or more video cameras at 30 Hz to reconstruct the joints and body
segments in three dimensions. This first model produces the three reaction forces and corresponding
moments about the three orthopedic axes of the low back (flexion-extension, lateral bend, axial twist).
The second anatomically detailed model enables the partitioning of the reaction moment obtained from
the link segment model into the substantial restorative moment components (supporting tissues) using
an anatomically detailed three-dimensional representation of the skeleton, muscles, ligaments, nonlinear
elastic intervertebral discs, etc. This part of the model was first described in McGill and Norman (1986),
with full three-dimensional methods described in McGill (1992) and the most recent update provided
by Cholewicki and McGill (1996) where 90 low back and torso muscles are represented in total. Very
briefly, first the passive tissue forces are predicted by assuming stress-strain or load deformation
relationships for the individual passive tissues and calibrated for the differences in flexibility of each
subject by normalizing the stress-strain curves to the passive range of motion of the subject, which is
detected by electromagnetic instrumentation which monitors the relative lumbar angles in three
dimensions. Then the remaining moment is partitioned among the many laminae of muscle based on
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FIGURE 12.3 The tissue load prediction approach required two models: (A) the first is a dynamic, 3D linked
segment model to obtain the three reaction moments about the low back; (B) the second model partitions the
moments into tissue forces (muscle forces 118), ligaments 1926, and moment contributions from deformed disc,
gut, and skin in bending etc.).
FIGURE 12.4 Subject monitored with EMG electrodes and electromagnetic instrumentation to directly measure 3D
lumbar kinematics and muscle activity (left panel). The modeled spine (partially reconstructed for illustration purposes)
moves in accordance with the subjects spine, whose muscles are activated by the subject.
their myoelectric profile, their physiological cross-sectional area, and modulated with known relationships
for instantaneous muscle length and of either shortening or lengthening velocity. Most recent improvements
of the force velocity relationship have been described in Sutarno and McGill (1995). In this way, the
modeled spine moves according to the movements of the subjects spine, and the virtual muscles are
activated according to the activation measured directly from the subject (see Figure 12.4). This method
of using biological signals to solve the indeterminacy of multiple load bearing tissues facilitates the
assessment of the many ways that we choose to support loads, an objective that is necessary for evaluation
of injury mechanisms and the formulation of injury avoidance initiatives.
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12.3 Application of Complex Dynamic Models to Reduce the Risk of Low

Back Injury
In the previous section a case was made, and hopefully justified, for the need for representing the
musculature and ligaments as accurately as possible in spine models. Such models have enabled
reassessment of many mechanical issues that pertain to spine function. The following section constitutes
a discussion of some recent research findings as they relate to the issue of formulating guidelines for
manual exertion for task assessment and implementation by the ergonomist. While not all issues were
borne from the use of complex dynamic models, they were listed here to act as source material for the
ergonomist.
Should One Avoid End Range of Spine Motion During Exertion?

It is recognized that very few lifting tasks in industry can be accomplished by bending the knees and
not the back. Furthermore, most workers rarely adhere to this technique when repetitive lifts are
requireda fact which is quite probably due to the increased physiologic cost of squatting compared
with stooping (Garg and Herrin, 1979). However, a case can be formulated for the preservation of
neutral lumbar spine curvature while lifting (specifically avoiding end range limits of spine motion
about any of the three axes). This is a different concept than trunk angle, as the posture of the lumbar
spine can be maintained independent of thigh and trunk angles. Specifically, there has been much confusion
in the literature between trunk angle or inclination, and the amount flexion in the lumbar spine. Bending
over is accomplished by either hip flexion or spine flexion or both. It is the issue of specific lumbar spine
flexion that is of importance here. Normal lordosis can be considered to be the curvature of the lumbar
spine associated with the upright standing posture.
Using the tissue load distribution perspective, the following example demonstrates the shifts in tissue
loading, predicted from our modeling approach, which has quite dramatic affects on shear loading of
the intervertebral column and lends insight into the stoop-squat issue. First, the dominant direction of
the pars lumborum fibers of longissimus thoracis and iliocostalis lumborum are noted to act obliquely
to the compressive axis of the lumbar spine, producing a posterior shear force on the superior vertebra.
In contrast, the interspinous ligament complex acts with the opposite obliquity to impose an anterior
shear force on the superior vertebra (see Figure 12.1). Lets observe one example where spine posture
determines the interplay between passive tissues and muscles which ultimately modulates the risk of
several types of injury. For example, if a subject holds a load in the hands with the spine fully flexed
sufficient to achieve myoelectric silence in the extensor muscles (reducing their tension), and with all
joints held still so that the low back moment remains the same, then the recruited ligaments will add to
the anterior shear to levels well over 1000 N, which is of great concern from an injury risk viewpoint
(see Figure 12.5). However, when a more neutral lordotic posture is adopted, the extensor musculature
is responsible for creating the extensor moment and at the same time will support the anterior shearing
action of gravity on the upper body and handheld load. Disabling the ligaments by avoiding full flexion
greatly reduced shear loading. Full flexion postures have injury implications on strained posterior tissues
and also on structures affected by large shear loads (e.g., facet joints, neural arch, or conditions of
spondylolisthesis).
Using knowledge of tissue loads, one could take the position that the important issue is not whether
it is better to stoop lift or to squat lift but rather the emphasis should be to place the load close to the
body to reduce the reaction moment (and the subsequent extensor forces and resultant compressive
joint loading) and to avoid a fully flexed spine (i.e., maintain some lordosis) to minimize shear loading.
In fact, sometimes it may be better to squat to achieve this, or in cases where the object is too large to fit
between the knees, it may be better to stoop, flexing at the hips but always avoiding full lumbar flexion
to minimize posterior ligamentous involvement. (For a more comprehensive discussion, see McGill and
Norman, 1987; Potvin et al., 1991; McGill and Kippers, 1994.)
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FIGURE 12.5 The fully flexed spine is associated with myoelectric silence in the back extensors and loaded posterior
passive tissues, and high shearing forces on the lumbar spine (these are computer digitized images). A more neutral
posture recruits the shear supporting pars lumborum extensors, disables the interspinous ligaments minimizing their
shear producing forces, and reduces the net shear (Shrs) on the spine. Compression (CMP) remains essentially
unchanged.
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The scientific evidence appears to point to the following positive effects if one lifts while avoiding full
lumbar flexion: conscious control of lumbar musculature is retained, reducing shear load on the facet
joints and providing neurological protection not present if one depends on passive tissue to support the
load; the disc is loaded more uniformly permitting all of the annular fibers to share the stress rather than
disabling some.
Should One Lift or Perform Extreme Torso Bending Shortly

After Rising from Bed?
The diurnal variation in spine length together with the ability to flex forward has been well documented.
Losses in sitting height over a day have been measured up to 19 mm by Reilly et al. (1984), who also
noted that approximately 54% of this loss occurred in the first 30 minutes after rising. Over the course
of a day, hydrostatic pressures cause a net fluid outflow from the disc, resulting in the narrowing of the
space between the vertebrae, which in turn reduces tension in the ligaments. When lying down at night,
osmotic pressures exceed the hydrostatic pressure, causing the disc to expand. Adams et al. (1987)
noted that the range of lumbar flexion increased by 5 throughout the day. The increased fluid content
caused the lumbar spine to be more resistant to bending, while the musculature does not appear to
compensate by restricting the bending range. They estimated that disc bending stresses increased by
300% and ligament stresses by 80% and concluded there is an increased risk of injury to these tissues
when bending forward early in the morning.
Should One Lift Immediately Following Prolonged Flexion Postures?

For a number of years, it has been proposed that the nucleus within the annulus migrates anteriorly
during spinal extension and posteriorly during flexion (McKenzie, 1979). McKenzies program of passive
extension of the lumbar spine (which is presently popular in physical therapy) was based on the supposition
that an anterior movement of the nucleus would decrease pressure on the posterior portions of the
annulus, which is the most potentially problematic site of herniation. Due to viscous properties of the
nuclear material, such repositioning of the nucleus is not immediate upon a postural change, but rather
takes time. Krag et al. (1987) demonstrated anterior movement, albeit quite minute, from an elaborate
experiment that placed radio-opaque markers in the nucleus of cadaveric lumbar motion segments.
Whether this observation was due only to a redistribution of the centroid of the wedge-shaped nuclear
cavity moving forward with flexion, or to a migration of the whole nucleus, remains to be seen.
Nonetheless, hydraulic theory would suggest lower bulging forces on the posterior annulus if the nuclear
centroid moved anteriorly during extension. If compressive forces are applied to a disc where the nuclear
material is still posterior (as in lifting immediately after a prolonged period of flexion), then a concentration
of stress will occur on the posterior annulus.
While this specific area of research needs more development, there does appear to be a time constant
associated with this redistribution of nuclear material. If this is so, it would be unwise to lift an object
immediately following prolonged flexionsuch as sitting or stooping, as would a stooped gardener
who may stand erect and lift a heavy object. Furthermore, it was suggested by Adams and Hutton
(1988) that prolonged full flexion may cause the posterior ligaments to creep, which may allow damaging
flexion postures to go unchecked if lordosis is not controlled during subsequent lifts. The data of McGill
and Brown (1992), in a study of posterior passive tissue creep while slouching forward in a seated
posture, showed that even after 2 minutes following 20 minutes of full flexion, subjects only regained
half of their intervertebral joint stiffness, while even after 30 minutes of rest some residual joint laxity
remained. This is of particular importance for those individuals whose work or movement patterns are
characterized by cyclic bouts of full end range of motion postures followed by exertion.
These data suggest that the spine has a memory, since the mechanics of the joints are modulated by
previous loading history. Before lifting, following a stooped posture, or after prolonged sitting, a case
could be made for standing or even consciously extending the spine for a short period. Allowing the
nuclear material to equilibrate or move anteriorly to a position associated with normal lordosis may
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decrease forces on the posterior nucleus. However, further research is required to assess this potentially
important possibility.
Should Intraabdominal Pressure Be Increased While Lifting?

It has been claimed for many years that intra-abdominal pressure (IAP) plays an important role in
support of the lumbar spine, especially during strenuous lifting. This issue has been considered in lifting
mechanics for years and, for some, has formed a cornerstone for prescription of abdominal belts to
industrial workers and also has motivated various abdominal strengthening programs. Many have
advocated the use of intra-abdominal pressure as a mechanism to reduce lumbar spine compression
(Cyron et al., 1979; Troup et al., 1983; Thomson, 1988).
However, some have indicated that they believe the role of IAP in reducing spinal loads has been
overemphasized (e.g., Bearn, 1961; Grew, 1980; Ekholm et al., 1982). In fact, some experimental evidence
suggests that somehow, in the process of building up IAP, the net compressive load on the spine is
increased! During squat lifts, it appears that the net effect of the involvement of the abdominal musculature
and IAP is to increase compression rather than alleviate joint load (McGill and Norman, 1987). The size
of the cross-sectional area of the diaphragm and the moment arm used to estimate force and moment
produced by IAP had a major effect on conclusions reached about the role of IAP (see McGill and
Norman, 1987). The diaphragm surface area was 243 cm2 and the centroid of this area was 3.8 cm.
anterior to the center of the T12 disc (compare with a 511 cm2 pelvic floor and 465 cm2 diaphragm
together with moment arm distances [up to 11.4 cm] used in other studies). While these results were
obtained with complex models, others have noted increased low back EMG activity with higher IAP
during voluntary valsalva maneuvers (Krag and coworkers, 1986). Nachemson and Morris (1964) and
Nachemson et al. (1986) showed an increase in intradiscal pressure during a valsalva maneuver indicating
a net increase in spine compression with an increase in IAP, presumably a result of abdominal wall
musculature activity.
The generation of appreciable IAP during load handling tasks is well documented; the role of IAP is
not. Farfan (1973) has suggested that IAP creates a pressurized visceral cavity to maintain the hoop-like
geometry of the abdominals. Recent work which measured the distance of the abdominals to the spine
(their moment arms) was unable to confirm substantial changes in abdominal geometry when activated
in a standing posture (McGill et al., 1996). However, the compression penalty of abdominal activity
cannot be discounted. It appears that the spine prefers to sustain increased compression loads if intrinsic
stability is increased. An unstabilized spine buckles under extremely low compressive load (e.g.,
approximately 20N, Lucas and Bresler, 1961). The geometry of the musculature suggests that individual
components exert lateral and anterior-posterior forces on the spine, which perhaps can be thought of as
guy wires on a mast to prevent bending and compressive buckling (Cholewicki et al., 1996). As well,
activated abdominals create a rigid cylinder of the trunk resulting in a stiffer structure. Thus it appears
that increased IAP, commonly observed during many activities including lifting, as well as in those
people experiencing back pain, does not have a direct role to reduce spinal compression but rather is an
agent used to stiffen the trunk and prevent tissue strain or failure from buckling.
Should Abdominal Belts Be Prescribed to Manual Materials Handlers?

This topic is addressed in Chapter 33 of this volume.
Should Workers Adopt a Lifting Strategy to Recruit the Lumbodorsal Fascia?

Studies have attributed various mechanical roles to the lumbodorsal fascia (LDF). In fact there have
been some attempts to recommend lifting postures based on LDF hypotheses. Suggestions were originally
made (Gracovetsky et al., 1981) that lateral forces generated by internal oblique and transverse abdominis
are transmitted to the LDF via their attachments to the lateral border. This lateral tension was hypothesized
to increase longitudinal tension, from Poissons effect, pulling in the direction of the posterior midline of
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the lumbar spine, causing the posterior spinous processes to move together resulting in lumbar extension.
This proposed sequence of events formed an attractive proposition because the LDF has the largest
moment arm of all extensor tissues. As a result, any extensor forces within the LDF would impose the
smallest compressive penalty to vertebral components of the spine.
However, this hypothesis was examined by three studies which used quite different methods, all
published about the same time, and which, collectively, questioned its viability: Tesh et al. (1987), who
performed mechanical tests on cadaveric material; Macintosh et al. (1987), who recognized anatomical
inconsistencies with the abdominal activation; McGill and Norman (1988), who tested the viability of
LDF involvement with latissimus dorsi as well as with the abdominals using a dynamic modeling approach.
Regardless of the choice of LDF activation strategy, the LDF contribution to the restorative extension
moment was negligible compared with the much larger low back reaction moment required to support
the load in the hands. Although the LDF does not appear itself to be a significant active extensor of the
spine, it is a strong tissue with a well-developed lattice of collagen fibers. Its function may be that of an
extensor muscle retinaculum (Bogduk and Macintosh, 1984). The tendons of longissimus thoracis and
iliocostalis lumborum pass under the LDF to their sacral and ilium attachments. Perhaps the LDF provides
a form of strapping for the low back musculature. Hukins et al. (1990), on theoretical grounds only
at this time, have proposed that the LDF acts to increase the force per unit cross-sectional area that
muscle can produce by up to 30%. They suggest that it does this by constraining bulging of the muscles
when they shorten. This contention remains to be proven. Tesh et al. (1987) have suggested that the
LDF may be more important for supporting lateral bending. No doubt, this notion will be pursued in
the future. Given the confused state of knowledge about the role, if any, of the LDF, the promotion of
lifting strategies based on intentional LDF involvement cannot be justified at this time.
Should the Trunk Musculature Be Cocontracted to Stabilize the Spine?

The ability of the joints of the lumbar spine to bend in any direction is accomplished with large amounts
of muscle coactivation. Such coactivation patterns are counter productive to generating the torque
necessary to support the applied load in a way that minimizes the load penalty imposed on the spine
from muscle contraction. Several ideas have been postulated to explain muscular coactivation: the
abdominals are involved in the generation of intra-abdominal pressure (Davis, 1959), or in providing
support forces to the lumbar spine via the lumbodorsal fascia (e.g., Gracovetsky et al., 1981); however,
these ideas have not been without opposition (see previous sections).
It appears that another explanation for muscular co-activation is tenable. As noted above, ligamentous
spine (one in which muscles are removed) will fail under compressive loading in a buckling mode, at
very low forces of only about 20N (Lucas and Bresler, 1961). The spine can be likened to a flexible rod
where under compressive loading it will buckle. However, if the rod has guy wires connected to it, like
the rigging on a ships mast, more compression is ultimately experienced by the rod, but it is able to bear
much more compressive load as it is stiffened and more resistant to buckling. The cocontracting
musculature of the lumbar spine can perform the role of stabilizing guy wires to each lumbar vertebrae
bracing against buckling. Work by Crisco and Panjabi (1990) and Cholewicki and McGill (1996) has
begun to quantify the influence of muscle architecture and the necessary coactivation on stability of the
lumbar spine. The architecture of the lumbar erector spinae is especially suited for this role (see Macintosh
and Bogduk [1987] and McGill and Norman [1987]). In order to invoke this antibuckling and stabilizing
mechanism when lifting, one could justify lightly cocontracting the musculature to both minimize the
potential of buckling and remove the possibility of any tissue having to bear a surprise load.
How Do People Hurt Their Backs Picking Up a Pencil?

While injury from large exertions is understandable, explanation of how people injure their backs
performing rather benign-appearing tasks is more difficultbut the following is worth considering by
the ergonomist. Continuing the considerations about stabilization from the previous sectiona number
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FIGURE 12.6 While injury from high loading tasks is easier to rationalize, injury from low loading tasks appears to
reduce spine stability and increase the possibility of injury from errors in motor control, and the resulting joint
displacement and tissue overload. (From Cholewicki, J. and McGill, S.M. (1996) Mechanical stability of the in vivo
lumbar spine: Implications for injury and chronic low back pain, Clin. Biomech. 11(1):115. With permission.)
of years ago, we were investigating the mechanics of power lifters spines while they lifted extremely
heavy loads, using video fluoroscopy for a sagittal view of the lumbar spine (Cholewicki and McGill,
1992). The range of motion of the power lifters spines was calibrated and normalized to full flexion by
first asking them to flex at the waist and support the upper body against gravity with no load in the
hands. During their lifts, although they outwardly appeared to have a very flexed spine, in fact, the
lumbar joints were all two to three degrees per joint from full flexion, explaining how they could lift
such huge loads (up to 210 kg) without sustaining the injuries suspected to be linked with full lumbar
flexion. However, during the execution of a lift, one lifter reported discomfort and pain. Upon examination
of the video fluoroscopy records, one of the lumbar joints (specifically, the L4/L5 joint) reached the full
flexion calibrated angle, while all other joints maintained their static position (2 to 3 degrees from full
flexion). This is the first observation that we know of reported in the scientific literature documenting
proportionately more rotation occurring at a single lumbar joint than at the other joints, and it would
appear that this unique occurrence was due to an inappropriate sequencing of muscle forces (or a
temporary loss of the normal motor control pattern). This motivated the work of our colleague, Dr.
Jacek Cholewicki, to investigate and continuously quantify stability of the lumbar spine throughout a
reasonably wide variety of loading tasks (Cholewicki and McGill, 1996). Generally speaking, it appears
that the occurrence of a motor control error which results in a temporary reduction in activation to one
of the intersegmental muscles, perhaps for example a laminae of multifidus, could allow rotation at just
a single joint to the point where passive tissue or other muscle tissue could become irritated or injured.
Dr. Cholewicki noted that the risk of such an event was greatest when there are high forces in the large
muscles with simultaneous low forces in the small intersegmental muscles (a possibility with our power
lifter) or when all muscle forces are low, such as during a low-level exertion. Thus, a mechanism is
proposed, based on motor control error resulting in temporary inappropriate neural activation, that
explains how injury might occur during extremely low load situations, for example, picking a pencil up
from the floor following a long day at work performing a very demanding job (see Figure 12.6).
Are Twisting Lifts Particularly Dangerous?

Twisting of the trunk has been identified as a factor in the incidence of occupational low back pain
(Frymoyer et al., 1983; Troup et al., 1981), but the mechanisms of risk require some explanation. Some
hypotheses have been based on an inertia argument in that twisting at speed will impose dangerous axial
torques upon braking the axial rotation of the trunk at the end range of motion. Farfan and colleagues
(1970) proposed that twisting of the disc is the only way to damage the collagenous fibers in the annulus
leading to failure. They reported that distortions of the neural arch permitted such injurious rotations.
More detailed analyses of the annulus under twist were conducted by Shirazi-Adl et al. (1986b) who
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supported Farfans contention that twisting indeed can damage the annulus but also noted that twisting
is not the sole mechanism of annulus failure. In contrast, some research has suggested that twisting in
vivo is not dangerous to the disc as the facet in compression forms a mechanical stop to rotation well
before the elastic limit of the disc is reached, and thus the facet is the first structure to sustain torsional
failure (Adams and Hutton, 1981). Ligament involvement during twisting was studied by Ueno and Liu
(1987), who concluded that the ligaments were under only negligible strain during a full physiological
twist. However, an analysis of the L4/L5 joint by McGill and Hoodless (1990) suggested that posterior
ligaments may become involved if the joint is fully flexed prior to twisting.
Certainly the mechanisms of injury from torsional loads applied under twisting conditions remain
inconclusive. However, it is clear that the increase in compressive load on the spine is dramatic if a
comparatively small amount of axial twist torque is required in addition to the dominant extensor
torque. Using data from a combination of our previous studies, to support 50 N.m in extension imposes
about 800 N of spinal compression, but 50 N.m in axial twist would impose over 2500 N, while 50
N.m of lateral bend imposes 1400 N of compression. These differences result from the difference in
coactivation of the trunk musculature, combined with small moment arms in many cases, to generate
the moments of force required. It appears that the joint pays dearly in order to support even small axial
torques when extending during the lifting of a load.
Is Lifting Smoothly and Not Jerking the Load Always Best?

We have all heard that a load should be lifted smoothly and not jerked. This recommendation was
most likely rationalized on the basis that accelerating a load upwards increases its effective mass by
virtue of an additional inertial force acting downward together with the gravitational vector. However,
this may not always be the case as it is possible to lift a load by transferring momentum from an already
moving segment. The concept of momentum transfer during lifting has been referred to by Troup and
Chapman (1969) and by Grieve (1975), who coined the term kinetic lift. Later, McGill and Norman
(1985) documented that smaller low back moments were possible in certain cases compared to moments
during static lifts in the same posture using skillful transfer of momentum. For example, if a load is
awkwardly placed, perhaps placed on a worktable at a distance of 75 cm from the worker, a slowsmooth lift would necessitate the generation of a large lumbar extensor torque for a lengthy duration of
timea situation that is most strenuous on the back. However, this load could be lifted with a very low
lumbar extensor moment or quite possibly no moment at all. For example, if the worker leaned forward
and placed his hands on the load, with bent elbows, the elbow extensors and shoulder musculature
could thrust upward initiating upward motion of the trunk to create both linear and angular momentum
in the upper body (note that the load has not yet moved). As the arms straighten, coupling takes place
between the load and the large trunk mass (as the hands then start to apply upward force on the load)
transferring some, or all, of the body momentum to the load causing it to be lifted with a jerk. This
highly skilled inertial technique is observed quite frequently throughout industry and in some athletic
events such as competitive weight lifting, but it must be stressed that such lifts are conducted by highly
practiced and skilled individuals. In most cases, acceleration of loads to decrease low back stress in the
manner described is not suitable for the lay individual when conducting the lifting chores of daily
living.
The momentumtransfer technique is a skilled movement that requires practice, is only feasible for
awkwardly placed lighter loads, and could not be justified for heavy lifts. However, there may be another
mechanical variable to be integrated into the analysis of a dynamic technique. The tissue property of
viscoelasticity enables tissues to sustain higher loads when loaded at rate (Burstein and Frankel, 1968).
Troup (1977) suggested that the margin of safety for spine injury may be increased during a higher
strain rate but cautioned that incorporation of this principle into lifting technique depends on the rate of
increase in spinal stress, the magnitude of peak stress, and its duration. The lifting instruction to always
lift a load smoothly may not invariably result in the least risk of injury. Indeed, it is possible to
skillfully transfer momentum to an awkwardly placed object to position the load as close to the body
12-15
quickly and minimize the extensor torque required to support the load. There can be no argument that
reduction of the extensor moment required to support the hand load is paramount in reducing the risk
of injury and that this is best accomplished by keeping the load as close to the body as possible.
Is Sedentary-Seated Work Harmful?

Epidemiological evidence presented by Videman et al. (1990) documented the increased risk of disc
herniation for those who perform sedentary jobs characterized by sitting. Known mechanical changes
associated with the seated posture include the increase in intradiscal pressure when compared to standing
postures (Andersson et al., 1975), increases in posterior annulus strain (Pope et al., 1977), creep in
posterior passive tissues (McGill and Brown, 1992) which decreases anterior-posterior stiffness and
increases shearing movement (Schultz et al., 1979), and posterior migration of the mechanical fulcrum
(Wilder et al., 1988) which reduces the mechanical advantage of the extensor musculature (resulting in
increased compressive loading). This has motivated occupational biomechanists to consider the duration
of sitting as a risk factor when designing seated work in the interest of reducing the risk of injury. A
recently proposed guideline has suggested a sitting limit of 50 minutes without a break, although this
proposal will be tested and evaluated in the future.
12.4 Tentative Risk Reduction Guidelines for Occupational Injury

The following recommendations have been summarized from the biomechanical rationale developed in
the previous section. Some are consistent with what has been advocated for years, while others contradict
longstanding notions that were based on flawed, or unavailable, biomechanical understanding. They
are more versatile and widely applicable than the commonly used instruction of bend the knees, not
the back to reduce lifting stresses. However, they have not been subjected to rigorous scientific challenge
and clinical trial. Due to the lack of conclusive evidence to support these recommendations, and
acknowledging that the definitive studies will probably not occur in the near future, they are listed in the
following form to provoke thought, stimulate discussion and generate research interest. Perhaps it is
overly optimistic to expect that these recommendations will withstand time and remain intact. However,
these recommendations may have the potential to reduce tissue loads during the performance of a wide
range of industrial exertion tasks and they are able to accommodate all tasks including those outside the
sagittal plane. Furthermore, the exact instructions issued to a specific worker should not be taken verbatim
from the following list, but rather the biomechanical principle should be explained in a language and
terminology which is familiar to the worker. In addition, often successful job incumbents have developed
personal strategies for working that assist them in avoiding fatigue and injury. Their insights are the
result of thousands of hours of performing the task, and they can be very perceptiveattempts should
be made to accommodate them.
Recommendations for Safer WorkA Tentative List

1. Avoid a fully flexed or bent spine and rotate trunk using hips.
Strain in the annular fibers is equalized (Hickey and Hukins, 1980; Shirazi-Adl et al., 1986a)
Posterior ligaments are not strained and cannot be injured (McGill, 1988).
Facets are in contact and can bear some load (e.g., Nachemson, 1960).
The anterior shearing effect from ligament involvement is minimized, and the posterior supporting
shear of the musculature is maximized (McGill, 1989).
Compressive testing of lumbar motion units has shown increases in tolerance with partial flexion
but decreased ability to withstand compressive load at full flexion (Adams and Hutton, 1988).
2. Choose a posture to minimize the reaction moment on low back so long as #1 is not compromised.
Neutral lordosis is still maintained but sometimes the load can be brought closer to the spine
12-16
with bent knees (squat lift) or relatively straight knees (stoop lift). The key is to reduce the
moment which has been shown to be a dominant risk factor (Marras et al., 1995).
3. Allow time for the disc nucleus to equilibrate and ligaments to regain stiffness after prolonged
flexion.
After prolonged sitting or stooping, spend time standing to allow the nuclear material within the
disc to equilibrate and equalize the stress on the annulus, and allow the ligaments to regain their
rest length and provide protective stiffness to the lumbar spine (McGill and Brown, 1992).
4. Avoid lifting shortly after rising from bed.
Forward bending stresses on the disc and ligaments are higher in the early morning compared
with later in the day (Adams et al., 1987).
5. Prestress system even during light tasks.
Lightly cocontract the stabilizing musculature to remove the slack from the system and stiffen the
spine, even during light tasks such as picking up a pencil (Cholewicki and McGill, 1996).
Cocontraction and the corresponding increase in stability increases the margin of safety of material
failure of the column under axial load (Crisco and Panjabi, 1990)
In this way, no tissue will have to bear a surprise load
6. Avoid twisting.
Twisting reduces the intrinsic strength of the annulus by disabling some of its supporting fibers
while increasing the stress in the remaining fibers under load (Shirazi-Adl et al., 1986b)
Since there is no muscle designed to produce only axial torque, the collective ability of the muscles
to resist axial torque is limited and may not be able to protect the spine in certain postures
(McGill, 1991)
The additional compressive burden on the spine is substantial for even a low amount of axial
torque production (McGill and Hoodless, 1990).
7. Exploit the acceleration profile of the load.
This is only for highly skilled individuals performing repetitive tasks.
Dangerous for heavy loads and should not be attempted.
It is possible that a transfer of momentum from the upper trunk to the load can start moving an
awkwardly placed load without undue low back load (Grieve, 1975; Troup, 1977). Possibly, the
viscoelastic property of biological material will safely absorb a momentary high load required to
bring the load close to the trunk, which reduces the reaction moment.
8. Avoid prolonged sitting.
Prolonged sitting is associated with disc herniation (Videman et al., 1990).
When required to sit for long periods, adjust posture often, stand up, at least every 50 minutes,
and extend spine and/or walk for a few minutes.
Organize work to break up bouts of prolonged sitting into shorter periods that are better tolerated
by the spine.
9. Consider the best rest break strategies
Workers engaged in sedentary work would be best served by frequent, dynamic breaks to reduce
tissue stress accumulation (Adams and Dolan, 1995) and migrate tissue load bearing (McGill,
1997).
Workers engaged in dynamic work may be better served with longer and more restful breaks.
12.5 Future Directions

The recent advances in low back research and ergonomic model sophistication has increased general
understanding of lumbar mechanics, injury mechanisms, and planning injury avoidance strategies.
However, the reader of this chapter becomes aware, quite quickly, that many issues pertaining to reducing
the risk of industrial low back injury, and to the recommendation of injury risk reduction guidelines
remain unsolved. The future of ergonomics and spinal biomechanics must address a range of issues that
will demand the utmost effort in creating models that capture biological fidelity. Continued effort must
be directed toward obtaining more sophisticated anatomy for model components, for it is the fine
details that unlock the secrets of force generation, transmission, and sharing strategies among tissues.
12-17
Tissue properties such as strength, viscoelasticity, and fatiguability must be better understood. The
knowledge base of biomaterials is still in the developmental stage. Static behavior has been quite well
documented for some tissues although not all. However, with the recent development of quite involved
dynamic models, dynamic tissue behavior is desperately required. The property of viscoelasticity is
paramount in the determination of dynamic tissue load due to its time and loading rate dependency.
Examination of movement, particularly rapid movements of the trunk and limbs, is hindered by inadequate
dynamic tissue information.
Muscle cocontraction and interplay with the passive tissues is far more prevalent under complex
motion conditions which enforces the need to measure the activity of individual tissues. Both EMG
techniques and optimization strategies to partition tissue loads require basic research to improve
predictions of the cocontracting muscle forces. Perhaps major developments in artificial intelligence will
provide the required interface with motor control in the future. However, at present only the mind is
capable of such sophisticated processing, and research efforts would appear to be best directed toward
the improvement of EMG techniques and the appropriate processing to obtain muscle force predictions.
Work must continue to determine which muscles to monitor, where to place electrodes, and improve
processing techniques to increase EMG reliability. Some international effort is ongoing, with the continual
reporting of some quite impressive predictions of individual muscle force measures in animal preparations,
from processed EMG.
Analysis of the single task, with no provision for repeated movements, has dominated the literature.
However, most tasks in industry and those that are part of mundane daily events are repeated and
prolonged. The effect of fatigue on the body system, intervertebral joints, muscles, and ligaments demand
investigation. For example, at present the frequency of task repetition can only be recommended on the
psychophysical criterion of what the individual thinks is appropriate. Data on repeated tissue loads is
extremely scarce, although is appearing in the literature with greater frequency. Tissue fatigue must also
be considered in the context of static holds that may occur in activities such as stooping for long periods
of time while gardening. While ergonomic design of the workplace is of utmost importance in facilitating
work postures that minimize joint loads, much basic research remains to test and refine low back
hypotheses and related issues such as reducing the risk of low back injury for workers. Finally, there is
a commonly held notion among ergonomists that minimal tissue loading is best. This is untrue. Biological
tissues require repeated loading to be healthy. The trick is to develop a wise rest break strategy to
facilitate optimal tissue adaption. The most healthy combination of work and rest will be achieved
through first understanding the biomechanical, physiological, and psychological parameters of injury
and human performance, followed with thoughtful application of this wisdom.
Acknowledgment
The author wishes to acknowledge the many colleagues who have made intellectual contributions to the
series of works documented in this chapter and who have made the journey such a joy: Jacek Cholewicki,
Ph.D., John Sequin, M.D., Lina Santaguida, M.Sc., Chrisanto Sutarno, M.Sc., Daniel Juker, M.D., Michael
Sharratt, Ph.D. and, in particular, Robert Norman, Ph.D.
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13
Selection of 2-D and 3-D
Biomechanical Spine
Models: Issues for
Consideration by the
Ergonomist
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8
13.9
13.10
Robert W.Norman
Stuart M.McGill
13.11
Introduction
The Biomechanical Approach to Assessment and
Reduction of Risk of Back Injury
Have Biomechanical Spine Model Outputs Been
Shown to Be Related to Injury Risk?
Are All Spine Models the Same?
Have Spine Models Been Validated?
How Much Anatomical Detail in the Model is
Necessary for Adequate Content Validity?
Is a Model Needed that Will Allow Dynamic
Analysis of Tasks or Are Static Models Acceptable?
Are Single Plane (2-Dimensional) Models Useful or
Must 3-Dimensional Analyses Always be Performed?
A Simple 2-Dimensional, Quasidynamic Model for
Risk Assessment and Job Design (2DWATBAK)
If a 3-Dimensional Model is Needed, How Does the
Model Estimate Forces on Joints and How Are They
Interpreted: An Example of a 3-Dimensional
Industrial Risk Assessment Model (3DWATBAK)
Are There Any Spine Models that Reflect the Effects
of Prolonged Loading?
131
132
133
135
135
136
137
138
138
1310
1315
13.1 Introduction
The usefulness and interpretation of complex biomechanical models have been explained in another
chapter (McGill, 1999). Biomechanists continue to debate many contentious questions, such as whether
there is a need for high levels of accuracy in the anatomical representation of spinal structures in a spine
model, and whether the mathematical method used to solve large numbers of equations in these models
reflects known physiological patterns of muscle activation in human movements. These authors believe
that the answer to both of these questions is yes. However, the focus of this chapter is on simpler models
0-8493-1800-9/03/$0.00+$1.50
13-1
13-2
intended for relatively easy use in workplace settings for the assessment of risk of back injury; but
simplification raises another set of questions that ergonomists should ask before purchasing a
biomechanical software package.
Some of the most pertinent questions are: How do biomechanists approach the assessment of level of
risk of back injury in the workplace? Have biomechanical spine model estimates of risk factors (typically
low back moments of force, spinal compression and shear forces are outputs from these models), been
shown to be related to increased risk of injury? Are all spine models the same? Have spine models been
validated, i.e., how close to reality are the model estimates of moments of force, spinal compression, and
shear? How much anatomical detail in the model is necessary for adequate content validity? Is a model
that will allow dynamic analysis of tasks always needed or are static models acceptable? Are single plane
(2-D) assessments still useful or must 3-dimensional analyses always be performed? If a 3-dimensional
model is needed, how does the model estimate forces on joints and how are the forces and moments
interpreted? Are there any spine models that produce outputs that reflect the effects of prolonged loading?
This chapter will address these issues and will then describe a family of 2- and 3-dimensional models
into which the authors have attempted to incorporate as many important biological features as they
could within the constraints of producing a method to assess low back injury risk that is practical for
workplace use by ergonomists. The chapter is not a critical, comparative review of commercially available
spine models suitable for ergonomic use, although several interesting models have been described in the
past decade by spinal biomechanists (e.g., Chaffin et al., 1989; Marras and Sommerich, 1991).
13.2 The Biomechanical Approach to Assessment and Reduction of Risk of

Back Injury
Biomechanists generally operate under the concept that a tissue will become irritated or will fail when
the forces to which it is exposed at a particular point in time are greater than the tolerance of that tissue
to force at that point in time. Both the size of the force acting on a tissue and the tolerance of tissue to
force change with time. The forces on tissues change with changing demands of a task or with the way
in which the worker does the same task from time to time; the tolerance of the tissue to force (or other
mechanical input) varies with factors such as state of repair from previous injury, conditioning or
deconditioning, age, gender, disease, and inherited individual differences in factors such as the crosssectional area of tissues.
Typically, the biomechanics approach to injury risk assessment is to represent the body of the worker
as a system of individual body segments linked at the joints (linked segment model). An external force
acting on the linkage, for example the force of a weight held in the hand, requires the production of
forces in muscles and in other tissues at all joints in the linkage to prevent the linkage from collapsing or
to cause it to move in a desired direction. At the level of the lumbar spine these reaction forces and
reaction moments of force are produced by some combination of muscles, ligaments, discs, bones in
contact with each other, and by other body tissues, depending upon what the posture is and where in the
joint range of motion each body segment is at each instant in time throughout the movement. The
reaction forces in the supporting tissues can become very large for even relatively light loads held in the
hands because the weights of body parts are very large (head, arms, and trunk above the pelvis are about
one half body weight), and the mechanical advantage of body tissues in producing moments of force is
very poor. If the forces in tissues gets too large, the tissues are damaged.
In all biomechanical spine models, reaction moments are produced by simplified representations of the
real anatomical structures that actually produce the reaction moments that have to support the weight of
the force on the hands and of the body parts and any inertial forces caused by accelerations of these
masses, for example by combining forces of some or many small muscles to make one force vector. Some
models are much more simplified anatomically and physiologically than others leading to the question
as to whether they are over-simplified and produce unrealistic estimates of exposure variables; the reverse
question can also be asked. Are some models more complex than is necessary for ergonomic use?
Selection of 2-D and 3-D Biomechanical Spine Models
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The forces calculated in these supporting structures are the measures of exposure used to estimate
injury risk. For spinal models, typically the reaction (or support) moment about the lumbar spine required
to support the load moment, and the consequent compressive and shear forces acting on the lumbar
spine at the L4/L5 or L5/S1 level are calculated. Quantifying the risk of injury usually involves comparing
these estimates of supporting tissue forces with estimates of the failure tolerance of these tissues (e.g.,
compressive or shear strength of the spinal tissues) or reaction moments of forces with back extension
strength under the knowledge that operating at or near a persons strength limits is getting close to tissue
fatigue limits, if not failure limits. Simply, as a force applied to a tissue approaches its capacity to bear
force, the risk of injury increases to the point where the limit of force tolerance is reached and injury
(tissue damage) occurs. More recently, epidemiological studies have appeared in which injury or pain
reporting odds ratios have been calculated for high vs. low exposure to biomechanical variables such as
trunk angle (Punnett et al., 1991; Marras et al., 1993), back extension moment of force (Marras et al.,
1993), and peak and prolonged spine compression and shear soon to be published from work of our
own group and colleagues from the Institute for Work & Health (Toronto). The establishment of target
values for these variables to reduce risk epidemiologically is promising.
The advantages of the biomechanical approach are several: from a good model, any task should be
analyzablelifting, lowering, pushing, pulling, while interacting with any material, tool or machine; the
analysis should be individualizable for gender, height, weight, strength etc.; and, in principle, any region
of the body may be considered. The critical issue for the ergonomist is the ability to analyze the demands
of a job using reasonably simple methods, to assess the risk of injury, and to redesign jobs in a way that
can be shown to actually reduce forces on vulnerable tissues to levels below injury threshold.
13.3 Have Biomechanical Spine Model Outputs Been Shown to Be Related

to Injury Risk?
Both biomechanical and epidemiological evidence show clearly that high moments of force about the
lumbar spine which, in turn, are highly related to large compressive or shear forces on lumbar motion
units, increase risk of injury. Biomechanical models that output lumbar moments of force, compression
and shear, therefore, are useful as tools for measuring exposure to risk of injury.
Many studies on cadavers and on animal tissue in the laboratory have shown that excessive compressive
or shear forces on the spine will result in failure of various tissues including the cartilaginous end plate
of the vertebral body, the laminae of the annulus fibrosis of the intervertebral discs, muscles, ligaments,
facet joints, and other structures. Original data and excellent compilations of many years of experimental
results on the compressive tolerance of spinal motion units (two vertebral bodies and a disc) can be
found in papers by Brinckmann et al. (1989) and Jager et al. (1991). The compilation by Jager et al.
shows that older spines and female spines are weaker in compressive loading than younger spines and,
for the same age, male spines on average but with large individual differences in tolerance to load. Figure
13.1 is an adaptation of data from regression equations presented by Jager et al. (1991).
Cripton et al. (1994) have shown failure of spinal motion units exposed to anterior shear forces of
about 2000 N. Troup and Chapman (1969) reported maximum trunk extension moments of force
(back strength) of 485 N.m for 98 men aged 18 to 39 years and 302 N.m for 132 women aged 18 to 23
years. Although people can produce maximum effort muscular contractions without injury, particularly
well-conditioned people, well-motivated maximum muscular contractions, particularly in eccentric (active
muscle lengthening) efforts, are approaching tissue tolerance levels. It is also well known that maximum
muscular efforts can be maintained for only a few seconds before fatigue results in continual drops in
force with efforts to sustain or repeat the contraction. Muscular fatigue may be a protective mechanism
for active tissue, but it causes changes in the ways people perform tasks, in some cases loading tissues
that would normally not be used in that task and that should not be used because of a lower injury
tolerance (Potvin and Norman, 1992).
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FIGURE 13.1 Lumbar spine compressive strength data compiled by Jager et al. (1991). Means by age and sex
calculated from their regression equation.
As noted earlier, not only is there biomechanical justification for assessing risk using biomechanical
spine models, there is an increasing body of epidemiological studies that support this notion. Marras et
al. (1993) showed, in an epidemiological study of 403 lifting jobs in 40 different industries, that those
workers exposed to high average or peak lumbar moments of force were 4 to 5 times more likely to be
in a high injury risk group than those exposed to low moments. Punnett et al. (1991), in a study of 219
auto assemblers, showed that those who spent more than 10% of the cycle time with the trunk flexed
more than 20 degrees were 6 times more likely to report a back injury than those who worked in a more
upright posture. If they spent more than 10% of the time flexed more than 45 degrees, the risk was 9
times higher than those who could work in an upright posture with less than 20 degrees of flexion. A
flexed trunk increases the moment of force because of the weight of the head, arms, and trunk alone,
even without loads in the hands.
In a recent study (unpublished) from our own group we showed, in data from 235 auto workers, that
the correlation of trunk moment of force with L4/L5 compression was 0.98 and with reaction shear was
0.88. The 105 auto workers who were in the back pain group had peak moments of force of 182 N.m
compared with 141 N.m for 130 control workers who reported no back pain, peak spinal compression
of 3402 N vs. 2740 N and peak spinal shear of 462 N vs. 353 N, respectively. All of these differences
were highly significant statistically (p<0.0001). These values were obtained from video analysis of all
workers in the study while they worked combined with a quasidynamic, two-dimensional, biomechanical
spine model (2DWATBAK to be discussed later). Interestingly, the mean spinal compression forces of
the back pain group were very close to the Action Limit for spinal compression (3434 N) proposed as a
limit by NIOSH (1981), below which most people are expected to have nominal risk of back injury. As
noted earlier, high compressive forces, in the absence of impacts, are produced primarily because of very
large forces in torso muscles, particularly back extensor muscles, which have relatively poor mechanical
advantage but are required to support or produce the sizable moments of force required to do some
tasks. The independent odds ratios on three biomechanical variables, over the spread in observed responses
for the 25% of random control subjects (no reports of back pain) who had the highest exposures
compared to the 25% with the lowest exposures, showed that there was a 232% greater risk of being a
low back pain case (those who reported back pain to plant medical personnel) if the shear forces on the
spine were high, 189% greater risk if the usual force on the hands was high, and 170% greater risk if
the average degrees of torso flexion were high. If all three of these variables were high, the risk of being
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a case was 750% higher than if the exposures were low. The univariable odds ratio for peak spinal
compression was 1.86 and for accumulated compression over a shift, 1.33.
While it is infrequent to see spinal motion unit failure associated with reported occupational low
back pain, high spinal compression almost invariably indicates high forces on spinal muscles and, if the
torso is flexed, laterally bent or twisted to very near the extremes of the range of motion, on ligaments
and other spinal structures.
13.4 Are All Spine Models the Same?

All spine models are not the same. Several different models which implicitly or explicitly contain different
assumptions regarding function and dramatically different levels of anatomical realism, have been
presented in the literature. An earlier chapter by McGill (1999) (Chapter 53) addressed generic functional
differences among complex, EMG-assisted spine models (e.g., McGill and Norman, 1986; Marras and
Sommerich, 1991), optimization models (e.g., Gracovetsky et al., 1981; Schultz et al., 1982; Bean et al.,
1988), and single muscle equivalent models (e.g., Frievalds et al., 1984; Norman et al., 1994). Cholewicki
et al. (1995) argue that outputs from current optimization spine models are not physiologically realistic
in that they do not account for the simultaneous activation of antagonistic muscles (cocontraction),
such as those of the low back and abdomen, that is observed when people handle loads. Cocontraction
of trunk muscles is extreme when a trunk twist moment of force is present, for example when one bends
forward and lifts a garage door or some other load with one hand. In this case, spinal compression
would be considerably underestimated by optimization models or other types of models that do not
account for cocontraction of antagonistic torso muscles.
Not only are there differences in the physiological behavior of different spine models because of
differences in how the models are activated (e.g., EMG vs. optimization), there are structural differences
in the anatomical representation of the models. It is well known that the low back muscles, when
activated, produce force in a slightly backward as well as downward direction (with respect to the spine)
during a lift. The backward (posterior) component of their force reduces the shear forces acting on the
facet joints and other structures but not the compressive force (Potvin et al., 1991). Excessive shear is a
risk factor. It is also well known that if the normal curvature (curve seen when standing upright) of the
low back is lost during a lift, the low back muscles reduce their contribution to the support moment and
with extreme spine flexion these muscles may shut off completely. This causes the moment to be supported
entirely by passive structures such as ligaments, and the shear force reducing contribution of the muscles
is lost. Ligament injury is more serious than muscle strain, and shear forces can irritate facet joints
without causing tissue damage if the joints are sensitive or result in severe damage to facet joints and
other parts of the vertebral body if the forces are excessive.
It is possible to build these structural and functional features of spinal mechanics into even relatively
simple models. Biomechanical spine models intended for the assessment of back injury risk in industry
should include these known phenomena to increase the number of known injury mechanisms to which
they are sensitive. Not all of them do this; therefore all spine models are not the same.
13.5 Have Spine Models Been Validated?

It is important to ask the question as to how close to reality the spine model estimates of exposure
measure are, the measures that will be compared with tolerance levels (the lumbar moments of force,
spine compression, and shear). The fact is that none of the spine models referred to above has been
directly validated, although one has come close. The authors of some of the models claim that their
model has been validated, but their claims are, at best, based on correlations of estimates of muscle
forces from the model output with EMG recordings. This is only an indirect and not entirely convincing
validation.
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To be assured that outputs from models are reasonably accurate, direct validation is necessary.
Therefore, if a model is to predict a muscle force or spine compression force in Newtons (N), direct
validation requires that measurement of muscle forces or spine compression (N) must be made against
which to compare the predictions. Technically it is not possible to directly measure spine muscle forces
in living, active humans. Therefore, direct validation of spinal models has not been reported, except for
the work of Schultz et al. (1982).
Schultz et al. claimed validation of a 22-muscle optimization model on the grounds that the disc
compression force (N) predicted by the model was close to the pressure (mmHg) that was directly
measured from a pressure transducer inserted into the lumbar discs of humans while they performed
quite light, static tasks. This is a reasonable approach to validating the disc compression prediction part
of the model although even in this study, Newtons of force were plotted against mmHg of disc pressure.
These authors also recorded EMG amplitude activity observed during static efforts and correlated
these static amplitudes with the muscle forces predicted by the model. The correlations were far from
perfect but were encouraging. However, EMG is not a direct measure of muscle force and consequently
the validation of the distribution of muscle forces in this, and in all other models, particularly during
asymmetric tasks, is still in question.
As noted above, correlating predictions of muscle forces in Newtons with electrical activity from
muscle in microvolts is, at best, indirect. If some in the scientific community consider this type of validation
of spine, or other models to be acceptable, then the EMG-assisted models are inherently valid because
they use the electrical activity on a trial-to-trial and instant-to-instant basis. They do not predict it.
Direct validation of predicted forces against directly measured forces acting on most spinal tissues is
virtually impossible. Therefore, content validity in the form of realistic representation of anatomical
structures together with biological recruitment of passive tissues and simultaneous activation
(cocontraction) of both agonist and antagonist muscles is important. The ergonomist or other users of
commercially available spine models should take claims of validation of these models skeptically, demand
detailed descriptions of the anatomical structures built into the models, and clear statements of the
implicit and explicit assumptions and limitations of the model before purchasing it.
13.6 How Much Anatomical Detail in the Model is Necessary for Adequate
Content Validity?
As much biological realism as possible should be incorporated into simple/industrial models so that
content validity is at least present, even if direct validation of predicted forces in low back tissues is not
possible. For example, the architecture of the extensor muscles and ligaments of the low back, and their
dramatic effect on low back shear loads were explained briefly above and in detail in Chapter 12 (McGill,
1999). These features should be incorporated into industrial low back models. Another issue concerns
the representation of contraction of the many muscles acting about the torso. For example, cocontraction
of antagonistic torso muscles is commonly observed even during sagittal plane load handling and is
particularly dominant in 3-dimensional tasks. Cocontraction of antagonistic muscles results in higher
muscle forces to satisfy the required moment, and in turn, higher spine compressive forces, than would
be the case if there were no cocontractions (McGill and Norman, 1986; Marras and Granata, 1995).
This effect can be easily incorporated into 2-dimensional models by simply reducing the effective moment
arm lengths of single equivalent muscles from anatomical dimensions observed from CT and MRI
(McGill et al., 1988, 1993) to more physiologically effective lengths (McGill, 1991, McGill and Norman,
1992). Table 13.1 shows this comparison. It is highly desirable to incorporate this phenomenon into
any 2- or 3-dimensional model of the lumbar spine because the cocontraction can have a dramatic effect
on the sizes of forces acting on other structures within the system.
However, the problem of incorporating the effects of muscular cocontractions into 3-dimensional spinal
models is not trivial and is particularly problematic if a relatively simple model must be developed. In the
opinion of the authors, optimization does not solve the problem. Indeed, one of the biggest weaknesses in
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TABLE 13.1 Approximate moment arms (cm) of equivalent force generators based on measurements of muscle
geometry and also estimated from an anatomically detailed, myoelectrically driven model that attempted to
accommodate measured muscular cocontraction. Cocontraction has the effect of decreasing the mechanical advantage
of an equivalent force generator and imposes higher compressive loads on the spine.
current spine optimization models is that they are poor at predicting patterns of cocontractions of antagonistic
muscles (Hughes et al., 1995; Cholewicki et al., 1995) particularly in complex 3-D tasks. Anatomically
complex models are available (and described in Chapter 53) that have biological and mechanical content
validity and can produce estimates of forces on tissues during dynamic three-dimensional tasks (e.g.,
McGill and Norman, 1986; Marras and Sommerich, 1991; McGill, 1992). Unfortunately, these models
require the use of multichannel electromyography and direct measurement of spine kinematics and, thus,
are too complex for ready application in industry although they are extremely useful in laboratory
experiments in formulating and testing hypotheses designed to reduce low back injury.
In order to facilitate industrial application, anatomically simplified 3-dimensional models have been
reported in which the torso musculature is represented by a system of single equivalent force-moment
generators (e.g., Schultz et al., 1982; Chaffin et al., 1989; Norman et al., 1994). During the generation
of pure moment about any one axis, the single moment generators can be designed to quite closely
predict the output from the detailed biomechanical models. The problem lies in tasks in which two or
more moments must be satisfied. Should the three moment generators be activated separately, in spite of
the fact that the human musculature does not work this way, or should they form a relationship that
recognizes muscle coupling and allows the muscles to work together to satisfy the moments? One solution
is to estimate spinal compression using a regression equation that relates compression, estimated from a
complex EMG-assisted model, with the 3-dimensional low back moments that resulted in the compression.
while subjects performed dynamic, asymmetrical, 3-dimensional tasks. An equation was proposed by
McGill et al. (1996) that retained as much anatomical and physiological content validity as they could
and, in particular, preserved the effects of antagonistic muscle cocontraction since it was based on
subjects performing dynamic, asymmetrical, 3-dimensional tasks. This is described in the 3DWATBAK
section of this chapter.
13.7 Is a Model Needed that Will Allow Dynamic Analysis of Tasks or Are
Static Models Acceptable?
A model is needed that will at least allow accounting of the inertial forces on the hands (the live loads)
during lifts and lowers, pushes and pulls, not just the static load weights of objects held in the hands.
Some static models can provide this versatility and a quasidynamic analysis of human lifting tasks is
often a reasonable approach to estimating the size of the moments of force, joint reaction forces, and
lumbar compression and shear forces of tasks which, in reality, are dynamic. The extent to which an
entirely static model is acceptable depends upon the size of the inertial forces in a dynamic lift compared
with the static load and body segment weights which create forces and moments. For example, heavy
loads may be analyzed statically in many cases, simply because the lifters are incapable of appreciably
accelerating the load. An exception from the athletic world is the competitive snatch or clean and
jerk of a heavy load, which contains periods of very high accelerations and decelerations and
corresponding high and low inertial forces. While a static analysis would be inappropriate in these
cases, most heavy loads in industry are not lifted with a technique characterized by high accelerations.
Of course, to analyze pushes or pulls, knowledge of the size and direction of forces acting on the hands
is essential.
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Freivalds et al. (1984) estimated that accelerations of loads lifted by their subjects could increase the
static load by as much as 40% of its weight. The loads lifted were maximum loads the subjects were willing
to lift repeatedly according to their own feelings of exertion and fatigue (not single maximum lifts). They
varied from about 10 kg to 66 kg depending upon the subject and conditions of the awkward lifts. The
authors of this chapter reported that dynamic analysis of lifts of 20 kg masses resulted in lumbar moments
19% higher on average than those statically determined by zeroing all accelerations of the body segments
and load in the hands. Individual trials were up to 50% higher, but one skilled subject showed slightly
lower dynamic than static moments on two trials. He exploited trunk accelerations which were transferred
to the load to assist in the lift. A subsequent reanalysis of the data, in which only the load weight acceleration
but not the body segment accelerations were accounted for, showed that this quasi-dynamic moment
overestimated the actual dynamic moment by about 25% (McGill and Norman, 1985).
These studies indicated that caution must be exercised in interpreting statically determined moments
from simple industrial models and all other static models in the context of lifts which are highly dynamic.
On the other hand, if one knows the actual dynamic load weight in the posture analyzed, from an
instrumented handle on the load for example, using this instantaneous value (or live load) as a hand
force, instead of the static load weight, will usually give a liberal estimate of the actual dynamic joint
moment. This is an error on the safe side as far as estimating demands of the lift on the low back, or
other joints is concerned, avoids the complexity of a fully dynamic analysis for the ergonomist, and
allows some accounting for dynamic tasks in methods suitable for workplace use. To reiterate, a model
which cannot account for varying sizes and directions of forces acting on the hands cannot be used to
analyze pushes or pulls.
13.8 Are Single Plane (2-D) Models Useful or Must 3-Dimensional Analyses
Always be Performed?
Many industrial tasks are dominated by joint loading in one plane even though there may be components
of forces in other planesthe posture may be asymmetric but the loading is essentially planar and most
often the dominant moment is in the flexion/extension (sagittal plane) of trunk movement. For many
tasks, therefore, a 2-dimensional model is satisfactory and many load handling postures that appear to
be 3-dimensional do not result in large twisting moments around the long axis of the trunk. On the
other hand, some efforts that do not appear as trunk twists around its long axis in fact have a substantial
moment about this axis or the lateral bend axis; handling loads with one hand but with no actual torso
twist or lateral bend displacement are examples. Sensitivity analyses have demonstrated that joint moments
and low back compression estimated from a 2-dimensional model are less than 10% different from
those estimated from a 3-dimensional model for two-handed lifts in which the load is placed toward the
side of the body up to 30 degrees away from the midline (Bone et al., 1990). This posture looks far more
twisted than calculation of torsional moments reveals (Figure 13.2). This is a far smaller difference than
the trigonometry would explain and is the result of movement toward the side of the body to reach the
load that was accomplished by shifting the position of the legs, pelvis, and torso together, even though
the feet were constrained to remain facing forward. These small errors can be further reduced by orienting
the camera axis orthogonal to the dominant loading plane and a 2-dimensional analysis would not be
out of the question. An example of the use of a 2- and 3-dimensional, quasidynamic spine model developed
in our own laboratories and suitable for use in the workplace follows. Several models that have been
reported in the literature by other authors were cited earlier.
13.9 A Simple 2-Dimensional, Quasidynamic Model for Risk Assessment

and Job Design (2DWATBAK)
The objective of this model, called 2DWATBAK, is to facilitate rather routine injury risk assessment of
industrial tasks, but in a way that incorporates as much biological detail and content validity as possible,
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FIGURE 13.2 (Top panel) Illustration of two of the lifting postures performed with the load positioned in the
sagittal plane and 90 from the sagittal plane; (middle and bottom panels) Differences in L4/L5 extensor moment
predicted by a 2-D model and the 3-D model, expressed as a percentage of the 3-D model prediction.
consistent with a method that is usable in the workplace. This model uses joint position data, obtained
from a single frame of film, a slide or video, or from a manikin that the operator can move on the
computer screen. The gender, body weight, and height of the worker and the sizes and directions of the
static or dynamic forces acting on the hands must be input for the model to estimate moments of force
about the elbows, shoulders, hips, knees, ankles, and the L4L5 level of the low back. The compression
and two shear forces, the reaction shear and the joint shear, acting at the L4/L5 level of the lumbar spine
are then calculated.
To assess risk, the moments at all of the joints can be compared with strength data obtained from the
literature or from the worker if measured, and the compression (e.g., Figure 13.1) and shear forces can
be compared with tolerance data obtained on cadavers.
Several features are incorporated into 2DWATBAK in an attempt to increase biological content validity
and to facilitate use:
1. Spinal posture (lordotic curvature) is monitored and entered by the operator to improve the
accuracy of low back shear force predictions. Shear force injury risk has been underestimated in
the past. For example, the size of the shear force supported by spinal structures depends upon
whether the workers lumbar spine is in a neutral posture (the curve observed during upright
standing) or is flexed. A neutral posture requires erector spinae muscle activation to supply the
supporting moment when the torso is inclined forward by rotating about the hips. When the
posterior muscles are activated, they reduce the shear forces acting on the spinal motion unit
joints (joint shear) below the level of anterior reaction shear. When the spine is severely flexed,
the erector spinae muscles can be deactivated (flexion relaxation) and the moment has to be
supported by ligaments and other passive tissues. When stretched, the interspinous ligament
(Figure 13.3, force vectors 2a-d), described by Heylings (1978), adds undesirably to the anterior
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shearing force produced by the weight of the head, arms, and trunk and forces in the hands; it
does not offset this shearing force.
While most lumbar spines will tolerate 2000N of anterior shear (Cripton et al., 1994), one could
argue for a workplace guideline of 1000N, half the average value, to provide a margin of safety
for those in the bottom half of the shear strength distribution. Large individual differences typify
tissue tolerance data.
2. Guidelines for interpreting low back compression values are improved with adjustment factors
for gender differences and the effects of age (20, 40, 60 years) from data compiled by Jager et al.
(1991).
3. Moments of force at each joint can be compared to joint strength data obtained from the literature
(or from the worker) to identify joints at risk other than the low back (Figure 13.4).
4. The posture of a manikin can be altered on the computer screen by moving the body segment
with the arrow keys. 2DWATBAK then automatically recalculates the various exposure variable
values to allow assessment of the redesigned task (Figure 13.5).
13.10 If a 3-Dimensional Model is Needed, How Does the Model Estimate

Forces on Joints and How Are They Interpreted: An Example of a
3-Dimensional Industrial Risk Assessment Model (3DWATBAK)
While many occupational tasks are performed essentially in the sagittal plane and can be reasonably
analyzed using two-dimensional biomechanical models, many other tasks require three-dimensional
analysis for approximation of the actual demands. However, obtaining input data for a 3-dimensional
model is a problem for industrial use in the absence of very expensive image reconstruction equipment
or the need to use an often oversimplified look-up table of many possible 3-dimensional postures.
3DWATBAK will take digitized x,y,z coordinates if the user has a 3-dimensional image reconstruction
system. An alternative to this expensive equipment for obtaining the necessary input coordinates of the
body joints has been provided by means of a manipulable manikin on the computer screen.
First, a worker is captured in a frame of a video image or photograph. Then, 3DWATBAK provides
three views (top, side, front) of a manikin which appears on the computer screen (Figure 13.6). The
posture of the manikin is altered to approximate that of the worker by using a mouse. The body segments
of any one of these views are moved one at a time. Movement of a segment in one view automatically
moves the manikin in the other two views. When the posture of concern has been produced on the
screen to the satisfaction of the analyst, the 3-dimensional coordinates of the end points (body joints) of
the manikin segments are automatically generated, scaled, and stored.
As for 2DWATBAK, the model can be individualized for a particular worker by providing data on
height, weight, gender, and user-defined or standard anthropometrics. Control of anthropometrics (e.g.,
mass of thigh or any other segment) allows alteration of a body segment mass or location of mass center
if necessary, for example to add the mass of a tool belt or to accommodate analysis of an amputee. Size
and direction of forces acting on each hand are defined as a push, pull, lift, lower, or as a load mass.
Anatomical detail has inherently been incorporated through the development of a regression equation
to enhance biological fidelity in estimations of low back compressive load, and, in particular, attempt
to account for the cocontracting musculature. This regression equation was based on the data of three
subjects, performing a variety of tasks which produced various combinations of 3-dimensional moments
about the low back. Compression was calculated using the anatomically detailed laboratory model
which accommodated patterns of muscle/ligament interplay and muscle cocontraction measured in
each subject-trial (see Chapter 12). The specific regression equation is as follows (R-square 0.936);
the shape of the spinal compression/moment surface, from which the equation was derived, is seen
in Figure 13.7.
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FIGURE 13.3 WATBAK allows the user to indicate the spine curvature (top panel), accommodates muscle and
passive tissue load sharing (middle panel), and calculates the joint shear forcenot only the reaction shear force
(bottom panel). The joint shear force is the index of shear injury risk.
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FIGURE 13.4 Calculated joint moments from require by the task are compared with gender specific joint strength
data from the literature. The average moment +/- 1 standard deviation at the joint angle reported in the studies cited
are found under the selected strength data column. Data from a 50 kg woman holding a 20 kg load mass in front
of her in a semi-squat with her torso inclined forward about 45.
FIGURE 13.5 A manikin figure is moved into position in the sagittal plane, using arrow keys, which automatically
creates posture data for joint loads. This method of data entry also facilitates rapid analysis of effects of redesign of
tasks.
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FIGURE 13.6 Input to 3DWATBAK can be obtained by manually moving a 3-D manikin with a mouse into position
to represent the posture of a worker seen on videotape (top panel). The manikin is automatically digitized and
processed through the 3-D computations to produce 3-D output.
(13.1)
where
C = compression (N)
F = flexion-extension moment where negative values correspond to flexion (N.m)
B = lateral bending moment where bending to the right is positive (N.m)
T = axial twisting moment where CCW twist is positive (N.m)
13-14
FIGURE 13.7 Compression as a function of three moments (flexion-extension, lateral bend, axial twist) is predicted
using a 4-D regression equation. Since only three dimensions can be plotted at one time, two plots are shown,
compression (top panel) as a function of flexion-extension moment (x) and lateral bending moment (y), compression
(bottom panel) as a function of flexion-extension moment (x) and axial twist moment (y).
13-15
TABLE 13.2 Low back loads and some examples of 3-D joint moments produced
during the barrel holding task shown in Figure 13.6. Typical moments about the xy-z axes are automatically transformed into orthopedic orientations for each joint
for functional interpretation.
Total compression: 3482 N

Anterior-posterior joint shear: 288 N
Anterior-posterior reaction shear: 534 N
Lateral reaction shear: 0 N
An example of the utility of 3DWATBAK is provided in Figure 13.6, where the real lifting task is
observed and the ergonomist positions the manikin with the computer mouse to represent the posture,
then 3DWATBAK uses linked segments to calculate the reaction moments (x, y, z), and then transforms
the moments into specific joint axes (in this case flexion-extension, lateral bend, axial twist) and supports
the moments with muscle and ligament forces (using the regression equation) to compute low back
compression (Table 13.2).
It is interesting to compare the compressive cost of producing moments about the 3 lumbar axes. For
example, a pure extensor moment of approximately 160 N.m results in a compression load close to
3000 N. On the other hand, an extensor moment of 100 N.m coupled with 50 N.m of left lateral bend
and 50 Nm of CW axial twist produces the same level of compression. The spine pays dearly for supporting
combinations of moments, particularly for those outside the sagittal plane.
In summary, the way in which 3DWATBAK represents the anatomy and biological muscle recruitment,
represents a compromise between the relative simplicity that is needed in models for assessing the risk of
injury in industry, and a rigorous and methodologically complex modeling approach that inherently
contains quite high levels of biological fidelity in predicting low back loads but is impractical for industrial
use. However, the equations within 3DWATBAK are based on model output that gives full credit to
muscle cocontractions and also recognizes biological muscle coupling which occurs in three-dimensional
spine loading. This method seems a reasonable way to examine risk of low back injury for threedimensional occupational tasks.
13.11 Are There Any Spine Models that Reflect the Effects of Prolonged
Loading?
Some experimental methods are under development but not yet routinely available to ergonomists. It is
true that current biomechanical spine models provide an assessment of exposure to injury risk at a single
13-16
FIGURE 13.8 (A) Linear envelope and accompanying APDF of short cycle job (1 min.); (B) Long cycle job (5 min.);
(C) Noncyclic job illustrating conversion of extensor muscle EMG to Newtons of estimated compression during
prolonged monitoring of jobs (Compression Normalized EMG). Interpretation in text.
instant in time. Our work with the complex, EMG-assisted model has shown a high correlation of back
muscle EMG with spinal compression in load-handling tasks that do not have a dominant axial twist
component. Modern data loggers permit the collection of EMG for long periods of time. The question
then arose as to whether it was possible to estimate spinal compression continuously as a person worked
13-17
by using an electronically processed version of the EMG signal calibrated against the spine compression
observed when a worker held a load statically in a standard posture and the back muscle EMG recorded
during that calibration effort. In other words, could we approximate the compression estimate that a
biomechanical model would yield if it were applied 100 times per second for periods of work of several
hours by normalizing the EMG to Newtons of compression from the calibration effort? Without going
into detail, the answer was yes, as long as the job did not involve a large part of the total time in which
the dominant torso moment was spinal twisting. The method did not work well for pure torso twisting.
Most jobs that we have observed in our field research do not have large periods of time in which
torso twist predominates. Even in asymmetrical tasks, if the worker is bent over to some degree, the
dominant support moment is trunk extension. This method seems to work well in this case. The most
useful presentation of data obtained from this so-called compression normalized EMG is in the form
of a (compression) amplitude probability distribution function. Figure 13.8 shows compression normalized
APDF curves recorded from three different auto workers, one worker (A) who did a short cycle assembly
job (1 minute), one worker (B) who did a longer job cycle (5 minutes), and a third worker (C) whose job
was highly varied over a 2-hour period. These workers were monitored for 17, 86, and 100 minutes,
respectively. If one uses the 90% level as the estimate of peak compressive loading (90% of the cycle
time the compression was below this level and above this level for only 10% of the time), a range from
about 1800 to 3000 N for the three workers is observed. The median level of compression, representing
50% of the work cycle time, ranged from about 800 to 1800N during the period of observation, and the
compression never dropped below 400 N (level at 10% on the normalized time axis). Standing upright
with no muscular activity the compression on the L4/L5 motion unit is about one half body weight.
This method, based upon spine model output, has considerable potential for monitoring spinal loading
over prolonged periods of time, but the limitations of the method need further exploration. The percentages
of the work cycle time at various levels of compression can be compared with data on spine tolerance to
acute loading. It would be helpful if epidemiological data could be obtained on the risk associated with
lower level accumulated loads as well. This would extend the utility of this type of monitoring of
exposure to back injury risk.
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14
Quantitative
Assessment of Trunk
Performance
14.1
14.2
Introduction
Principles
141
142
14.4
Impairment, Disability, and Handicap Muscle Action and

Performance Quantification
Low Back Pain and Trunk Performance
144
Maximal and Submaximal Protocols
Static and Dynamic Strength Measurements of Isolated
Trunk Muscles Static and Dynamic Trunk Muscle
Endurance Lifting Strength Testing Inverse and
Direct Dynamics Comparison of Task Demands
and Performance Capacity
Clinical Applications
1417
cole Polytechnique, Montreal
14.5
Conclusions
14.3
Mohamad Parnianpour
1418
14.1 Introduction
As early as 1700, Bernardino Ramazzini, one of the founders of occupational medicine, had associated
certain physical activities with musculoskeletal disorders (MSD). He postulated that certain violent and
irregular motions and unnatural postures of the body impair the internal structure (Snook et al., 1988;
NIOSH, 1997). Presently, much effort is directed toward a better understanding of work-related
musculoskeletal disorders involving the back, cervical spine, and upper extremities (Parnianpour et al.,
1990). The World Health Organization (WHO) has defined occupational diseases as those work-related
diseases where the relationship to specific causative factors at work has been fully established (WHO,
1985). Obtaining the occupational history is crucial to proper diagnosis and appropriate treatment of
work-related disorders. The occupational physician must consider the conditions of both the workplace
and the worker in the evaluation of the injured workers. Biomechanic and ergonomic evaluations have
developed a series of techniques for quantification of the task demands and evaluation of the stresses in
the workplace. Functional capacity evaluation has also been advanced to quantify the maximum
performance capability of the workers. The motto of ergonomics is to avoid the mismatch between the
task demand and the functional capacity of individuals. A multidisciplinary group of clinicians and
engineers constitutes the rehabilitation team that will work together to implement the prevention measures.
Through proper workplace design, workplace stressors and risk factors could be minimized. It is expected
that one third of the compensable low back pain in industry could be prevented by proper ergonomic
workplace or task design. In addition to reducing the probability of both the initial and recurring
episodes, proper ergonomic design allows earlier return of injured workers by keeping the task demands
at a lower level. Unfortunately, ergonomists are often asked to redesign the task or the workplace after
0-8493-1800-9/03/$0.00+$1.50
14-1
14-2
a high incidence of injuries has already been experienced. The next preventive measure that has been
suggested is preplacement of workers based on the medical history, strength, and physical examinations
(Parnianpour et al., 1987; Snook et al., 1988; Parnianpour and Engin, 1994).
Title I of the Americans with Disabilities Act (ADA, 1990) prohibits discrimination in regard to any
aspect of the employment process. Thus, the development of preplacement tests has been impeded by
the possibility of discrimination against individuals based on gender, age, or medical conditions. The
ADA requires physical tests to simulate the essential functions of the task. In addition, one must be
aware of reasonable accommodations, such as lifting aids, that may make an otherwise infeasible task
possible for a disabled applicant to perform. Health care providers who perform physical examinations
and provide recommendations for job applicants must consider the rights of disabled applicants. It is
extremely crucial to quantify the specific physical requirements of the job to be performed, and to
examine an applicants capabilities to perform those specific tasks, taking into account any reasonable
accommodations that may be provided. Hence, task analysis and functional capacity assessment are
truly intertwined.
This chapter is intended to illustrate the application of some principles and practices of human
performance engineering, especially quantification of human performance. The problem of low back
pain has been selected to illustrate a series of concepts that are essential to evaluation of both the worker
and the workplace, while realizing the importance of the disorders of the neck and upper extremities. By
inference and generalization, most of these concepts can be extended to these situations. Manual material
handling tasks have been the focus of our attention due to their prevalence in industry. In addition, the
trunk muscles and spine were selected for the most detailed investigation due to the observation that a
large proportion of ADA cases involve low back disability (Khalaf et al., 1997a).
14.2 Principles
Assessment of function across various dimensions of performance (i.e., strength, speed, endurance, and
coordination) has provided the basis for a rational approach to clinical assessment, rehabilitation strategies,
and determination of return to work potential for injured employees (Kondraske, 1990). To understand
the complex problem of trunk performance evaluation of (low back pain) LBP patients, the terminology
of muscle exertion must first be defined. However, it should be noted that a number of excellent reviews
of trunk muscle function have been performed (Andersson, 1991; Beimborn and Morrissey, 1988; Newton
and Waddell, 1993; Pope, 1992). We do not intend to reproduce this extensive literature here, as our
motive is to provide a critical analysis that will lead the reader toward an understanding of the future of
functional assessment techniques. A more extensive clinical application is presented elsewhere
(Parnianpour and Tan, 1993; Parnianpour, 1995; Szpalski and Parnianpour, 1996).
Impairment, Disability, and Handicap

The tremendous human suffering and economic costs of disability present a formidable medical, social,
and political challenge in the midst of growing health care costs and scarcity of resources. The WHO
(1980) distinguished among impairment, disability, and handicap. Impairment is any loss or abnormality
of psychological, physiological, or anatomical structure or functionimpairment reflects disturbances
at the organ level. Disability is any restriction or lack (resulting from impairment) of ability to perform
an activity in the manner or within the range considered normal for a human beingdisability reflects
disturbances at the level of person. Handicap is a disadvantage for a given individual, resulting from an
impairment or a disability, that limits or prevents the fulfillment of a role that is normal (depending on
age, sex, and social and cultural factors) for that individual. As disability is the objectification of an
impairment, handicap represents the socialization of an impairment or disability. Despite the immense
improvement presented by the International Classification of Impairments, Disabilities, and Handicaps
(ICIDH), it is limited from an industrial medicine or rehabilitation perspective. The hierarchical
Quantitative Assessment of Trunk Performance
14-3
organization lacks the specificity required for evaluating the functional state of an individual with respect
to task demands.
Kondraske (1990) has suggested an alternative approach, using the principles of resource economics.
The resource economics paradigm is reflective of the principal goal of ergonomics: fitting the demands
of the task to the functional capability of the worker. The Elemental Resource Model (ERM) is based on
the application of general performance theory that is to present a unified theory for measurement,
analysis, and modeling of human performance across all different aspects of performance, across all
human subsystems, and at any hierarchical level. This approach uses the same bases to describe both the
fundamental dimensions of performance capacity and task demand (available and utilized resources) of
each functional unit involved in performance of the high-level tasks. The elegance of the ERM is due to
its hierarchical organization, allowing causal models to be generated based on assessment of the task
demands and performance capabilities across the same dimensions of performance (Kondraske, 1990).
Muscle Action and Performance Quantification

The details of the complex processes of muscle contraction in terms of the bioelectrical, biochemical,
and biophysical interactions are under intense research. Muscle tension is a function of muscle length
and its rate of change, and can be scaled by the level of neural excitation. These relationships are called
the length-tension and velocity-tension relationships. From a physiological point of view, the measured
force or torque applied at the interface is a function of: (a) the individuals motivation (magnitude of the
neural drive for excitation and activation processes); (b) environmental conditions (muscle length, rate
of change of muscle length, nature of the external load, metabolic conditions, pH level, temperature,
and so forth); (c) prior history of activation (fatigue); (d) instruction and descriptions of the tasks given
to the subject; (e) the control strategies and motor programs employed to satisfy the demands of the
task; and (f) the biophysical state of the muscles and fitness (fiber composition, physiological crosssectional area of the muscle, cardiovascular capability). It cannot be overemphasized that these processes
are complex and interrelated (Kroemer et al., 1994). Other factors that may affect the performance of
the patients are: misunderstanding of the degree of effort needed in maximal testing, test anxiety,
depression, nociception, fear of pain and re-injury, as well as unconscious and conscious symptom
magnification.
In the following sections we review some methods to quantify performance and lifting capability of
isolated trunk muscles during a multilink coordinated manual material handling task. Relevant factors
that influence the static and dynamic strength and endurance measures of trunk muscles will be addressed,
and the clinical applications of these assessment techniques will be illustrated.
The central nervous system (CNS) appropriately excites the muscle, and the generated tension is
transferred to the skeletal system by the tendon to cause motion, stabilize the joint, and/or resist the
effect of external forces on the body. Hence, the functional evaluation of muscles cannot be performed
without the characterization of the interfaced mechanical environment. The four fundamental types of
muscle exertion or action are isometric, isokinetic, isotonic, and isoinertial. In isometric exertion, the
muscle length is kept constant and there is no movement. Although mechanical work is not achieved,
physiological work, i.e., static work, is performed and energy is consumed. When the internal force
exerted by the muscle is greater than the external force offered by the resistance, then concentric, i.e.,
shortening, muscle action occurs; whereas if the muscle is already activated and the external force exceeds
the internal force of the muscle, then eccentric, i.e., lengthening, muscle action occurs. When the muscle
moves, either concentrically or eccentrically, dynamic work is performed. If the rate of shortening or
lengthening of the muscle is constant, the exertion is called isokinetic. When the muscle acts on a constant
inertial mass, the exertion is called isoinertial. Isotonic action occurs when the muscle tension is constant
throughout the range of motion.
These definitions are very clear when dealing with isolated muscles during physiological investigations.
However, terminologies employed in the literature of strength evaluation are imprecise. The terms are
intended to refer to the state of muscles, but they actually refer to the state of the mechanical interface,
14-4
i.e., the dynamometer. Isotonic exertion, as defined, is not as realizable physiologically because muscular
tensions change as its lever arm changes despite the constancy of external loads. Special designs may
vary the resistance level in order to account for changes in mechanical efficiency of the muscles. In
addition, the rate of muscle length change may not remain constant even when the joint angular velocity
is regulated by the dynamometer during isokinetic exertions. During isoinertial action, the net external
resistance is not only a function of the mass (inertia) but is also a function of the acceleration. The
acceleration, however, is a function of the input energy to the mass. Hence, to fully characterize the net
external resistance we need to have both the acceleration and the inertial parameters (mass and moment
of inertia) of the load and body parts. Future research should better quantify the inertial effects of the
dynamometers particularly during nonisometric and nonisokinetic exertions.
For any joint or joint complex, muscle performance can be quantified in terms of the basic dimensions
of performance: strength, speed, endurance, steadiness, and coordination. Muscle strength is the capacity
to produce torque or work by voluntary activation of the muscles, whereas muscle endurance is the
ability to maintain a predetermined level of motor outpute.g., torque, velocity, range of motion,
work, or energyover a period of time. Fatigue is considered to be a process under which the capability
of muscles diminishes. However, neuromuscular adjustments take place to meet the task demands (i.e.,
increase in neural excitation) until there is final performance breakdownendurance time. Coordination,
in this context, is the temporal and spatial organization of movement and the recruitment patterns of
the muscle synergies.
Despite the proliferation of various technologies for measurement, basic questions such as: What
needs to be measured and how can it best be measured? are still being investigated. However, there is
a consensus on the need to measure objectively the performance capability along the following dimensions:
range of motion, strength, endurance, coordination, speed, acceleration, etc. Strength is one of the most
fundamental dimensions of human performance and has been the focus of many investigations. Despite
the general consensus about the abstract definition of strength, there is no direct method for measurement
of muscle tension in vivo. Strength has often been measured at the interface of a joint (or joints) with the
mechanical environment. A dynamometer, which is an external apparatus onto which the body exerts
force, is used to measure strength indirectly.
Different modes of strength testing have evolved based on different levels of technological
sophistication. The practical implication of contextual dependencies on the provided mechanical
environment of the strength measures must be considered during the selection of the appropriate mode
of measurement (Khalaf et al., 1997a). In this regard, equipment that can measure strength in different
modes is more efficient in terms of both initial capital investment, required floor space in the clinics or
laboratories, and the amount of time it takes to get the person in and out of the dynamometer.
14.3 Low Back Pain and Trunk Performance

The problem of LBP is selected to present important models that could be utilized by the entire
multidisciplinary rehabilitation team for the measurement, modeling, and analysis of human performance
(Kondraske, 1990). The inability to relate low back pain (LBP) to anatomical findings and the difficulties
in quantifying pain have directed much effort toward quantification of spinal performance. The problem
is made even more complex by the increasing demand of the health care system to quantify the level of
impairment of patients reporting back pain without objective findings. Indeed some studies have indicated
that a precise cause of nociception cannot be recognized in more than 80% of patients with low back
pain complaints. However, work-related disorders of upper extremity, unlike low back disorders, can
better be related to specific anatomical sites such as a tendon or compressed nerve. Examples of the
growing number of cumulative trauma disorders of the upper extremities and the neck are: carpal
tunnel syndrome (CTS), DeQuervains disease, trigger finger, lateral epicondylitis (tennis elbow), rotator
cuff tendinitis, thoracic outlet syndrome, and tension neck syndrome (Kroemer et al., 1994).
14-5
There are three basic impairment evaluation systems, each having its merits and shortcomings: (1)
anatomic, based on physical examination findings;)2) diagnostic, based on pathology; and (3) functional,
based on performance or work capacity (Luck and Florence, 1988). The earlier systems were anatomical,
based on amputation and ankylosis. Although this approach may be more applicable to the hand, it is
very inappropriate for the spine. The diagnostic-based systems suffer from lack of correspondence between
the degree of impairment for a given diagnosis and the resultant disability and even more from the lack
of a clear diagnosis. A large percentage of symptom-free individuals have anatomical findings detectable
by the imaging technologies, while some LBP patients have no structural anomalies.
The function-based systems are more desirable from an occupational medicine perspective for the
following reasons. They allow the rehabilitation team to rationally evaluate the prospect for return to
light duty work and the type of reasonable accommodations needed (such as assistive devices) that
could reduce the task demand below the functional capability of the individual. By focusing on remaining
ability and transferable skills rather than the disability or structural impairment of the injured worker,
the set of feasible jobs can be identified. These points are extremely important, given the natural history
of work disability after a single low back pain episode causing loss of work time: 40% to 50% of
workers return to work by 2 weeks, 60% to 80% return by 4 weeks, and 85% to 90% return by 12
weeks. The small portion of disabled workers who become chronic are responsible for the majority of
the economic cost of LBP. It is therefore the primary goal of the rehabilitation team to prevent the LBP,
which is self correcting in most cases no matter what kind of therapy is used, from becoming a chronic
disabling predicament. Injured workers should neither be returned to work too early nor too late, as
both could complicate the prognosis. The results of functional capacity evaluation and task demand
quantification should guide the timing for returning to work. It is clear that psycho-socioeconomic
factors become more important than physical factors as the disability progresses into chronicity
syndrome and play a major role in defining the evolution of a low back disability claim. Future research
should further establish the reliability and reproducibility of performance assessment tools to expedite
their widespread use (Luck and Florence, 1988; Newton and Waddell, 1993; Parnianpour et al., 1989a,b).
Maximal and Submaximal Protocols

Biomechanical strength models of the trunk are usually based on static maximal strength measurement.
In real-life work situations, individuals rarely exert lengthy or maximum static effort. In most clinical
situations, submaximal protocols are recommended, especially in patients with pain or with cardiovascular
problems. Also, submaximal testing is less susceptible to fatigue and injury. The activity of daily living
also has a great deal of submaximal efforts at the self-selected pace (Kim et al., 1996). Hence, it has been
argued that testing at the preferred rate may be complementary to the maximal effort protocols. The
preferred motion can be solicited by instructing the subject to perform repetitive movement at a pace
and through the range of motion at which he/she feels the most comfortable. It has been shown that low
back pain patients and normals have different resisted preferred flexion/extension motion characteristics.
Having the subject perform against resistance is based on the hypothesis that, at higher resistance levels,
the separation between the performance levels of patients and normal subjects becomes more evident. It
has been shown, for example, that functional impairment of trunk extensors in LBP patients with respect
to the normal population is larger at higher velocities during isokinetic trunk extension. However, the
proponents of unconstrained testing have argued that separation of these groups can be performed
based on the position, velocity, and acceleration profiles of the trunk during self-selected flexion/extension
tasks. They have noted that pain and fear of re-injury may become the limiting factors. The sudden
surge in acquiring performance measures of LBP patients during the initial rehabilitation process also
underscores the validity of this concept.
Static and Dynamic Strength Measurements of Isolated Trunk Muscles

Weakness of the trunk extensor and abdominal muscles in patients with low back pain was demonstrated
using the cable tensiometer to measure isometric strength. The disadvantage of the cable tensiometer
14-6
(which records applied force) is that it neglects to measure the lever arm distance from the center of
trunk motion. It is also recommended that the cable tensiometer be used to determine peak isometric
torques rather than the stable average torque exerted over a 3-second period. Dynamometers used for
testing dynamic muscle performances contain either hydraulic or servo motor systems to provide constant
velocity (e.g., isokinetic devices) or constant resistance (e.g., isoinertial devices) The isokinetic devices
can be further categorized into passive and active types. The robotics-based dynamometers can actively
apply force on the body and hence allow eccentric muscle performance assessments, while only concentric
exertions can be measured by the passive devices. Eccentric muscle action can simulate the lowering
phase of a manual material handling task. Based on sport medicine literature, eccentric action has been
implicated for its significant role in the muscle injury mechanism. Using isokinetic dynamometers, the
isometric and isokinetic strength of trunk extensor and abdominal muscles were shown to be weaker in
low back pain patients compared to healthy individuals. Dedicated trunk testing systems have become
the cornerstone of objective functional evaluation and have been incorporated in the rehabilitation
programs in many centers.
Two issues of importance for future research are the role of pelvic restraints and the significance of
using newly developed triaxial dynamometers as opposed to more traditional uniaxial dynamometers.
Studies on healthy volunteers have shown that trunk motions occur in more than one planelateral
bending accompanies the primary motion of axial rotation. Numerous attempts have been made to
measure the segmental range of motion three dimensionally in the lumbar spine with the purpose of
quantifying abnormal coupling and diagnosing instabilities.
The effect of posture on the maximum strength capability can be described based on the lengthtension relationship of muscle action and the changes in the moment arm of trunk muscles (Parnianpour
et al., 1991; Parnianpour et al., 1993; Khalaf et al., 1997a). Marras and Mirka (1989) studied the effect
of trunk postural asymmetry, flexion angle, and trunk velocity (eccentric, isometric, and concentric) on
maximal trunk torque production. It was shown that trunk torque decreased by about 8.5% of the
maximum for every 15 of asymmetric trunk angle. At higher trunk flexion angles, extensor strength
increased. Complex, significant interaction effects of velocity, asymmetry, and sagittal posture were
detected. The range of velocity studies were more limited (30/second) than those used customarily in
spinal evaluation.
Tan et al. (1993) tested 31 healthy males for the effects of standing trunk-flexion positions (0, 15, 35
degrees) on triaxial torques and electromyogram (EMG) of ten trunk muscles during isometric trunk
extension at 30%, 50%, 70%, and 100% of maximum voluntary exertions (MVE). Trunk muscle
strength was significantly increased at a more flexed position. But the accessory torques in the transverse
and coronal planes were not affected by trunk postures. The recorded lateral bending and rotation
accessory torques were less than 5% and 16% of the primary extension torque, respectively. The rectus
abdominus were inactive during all the tests. The EMG of erector spinae varied linearly with higher
values of MVE, while the latissimus dorsi had a nonlinear behavior. The obliques were coactivated only
during 100% MVE. The neuromuscular efficiency ratio (NMER) was constructed as the ratio of the
extension torque over the processed (RMS) EMG of the extensor muscles. It was hoped that NMER
could be used in a clinical setting where generation of the maximum exertion is not indicated. However,
the NMER proved to have a limited clinical utility because it was significantly affected by both exertion
level and posture. The NMER of the extensor muscles increased at more flexed position. Studies that
have combined the EMG activities and dynamometric evaluations have the potential of discovering the
neuromuscular adaptation during different phases of injury and rehabilitation processes.
Khalaf et al. (1997a) measured concentric trunk isokinetic extension/flexion strength for 20 male
and female healthy volunteers in the range of upright to 40 degrees of trunk flexion at six levels of
angular velocity (10, 20, 40, 60, 80, and 100 degrees/sec). Results indicated that trunk strength is
significantly influenced by trunk angular position, trunk angular velocity, gender, direction, as well as
the interaction between trunk angular position and velocity. Three-dimensional surfaces of trunk strength
in response to trunk angular position and velocity were constructed for each subject per direction. Such
data presentation is more accurate and gives better insight about an individuals strength profile as
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FIGURE 14.1 Trunk extension strength of a healthy female volunteer.
compared to the traditional use of a single strength value (Figure 14.1). In addition, when comparing
the task demands of a particular MMH task and maximum strength capacity of an individual subject,
the contextual dependencies of fit or lack of it in terms of workplace design can better be illustrated. The
workplace factors affect the required trunk speed, the muscular torque, and the range of motion of the
worker. Concept of dynamic utilization ratio will be presented in the following section.
Static and Dynamic Trunk Muscle Endurance

The high percentage of type I fibers in the back muscles, in addition to the better vascularization of these
muscle groups, contributes to their superior endurance (Parnianpour et al., 1987a,b; Zhu et al., 1989).
Physiological studies indicate that at higher muscle utilization ratios (relative muscle loads), fatigue is
detected earlier. Isometric endurance tests have been used to compute the median frequency (MF) of the
myoelectrical activities of trunk muscles in both normal and LBP populations. The expected decline of
the median frequency with fatigue is parameterized by the intercept (initial MF) and the slope of the fall.
It has been shown that trunk range of motion (ROM) and isometric strength suffered from lower specificity
and sensitivity than spectral parameters. Trunk muscle endurance does differ between healthy subjects
and those reporting LBP. During isometric endurance testing, trunk flexors develop fatigue faster than
extensors in symptom-free subjects. The flexor fatiguability appeared significantly higher in patients
with low back pain as compared to controls. Chronicity also influences trunk muscle endurance. Chronic
LBP patients showed reduced abdominal as well as back muscle endurance as compared to the healthy
controls, and lower back muscle endurance as compared to the intermittent LBP group. Individuals
with a history of debilitating low back pain demonstrated less isometric trunk extensor endurance than
either normal individuals or patients with history of lesser low back pain.
We have developed the following testing protocols for the quantification of trunk muscle endurance
during diverse sets of fatiguing isometric submaximal tasks: (a) constant torque isometric exertions
(Sparto et al., 1997b); (b) sustained varying torque isometric exertions (Sparto et al., 1997c; 1998).
These isometric submaximal extension exertions are analyzed by novel modeling approaches to quantify
the state of muscular fatigue using spectral analysis of trunk muscle activity (EMG). In addition, new
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TABLE 14.1 Decline in Median Frequency of Power
Spectrum of Erector Spinae (ES) at Five Different Locations
During the Performance of a Static Endurance Test
EMG-driven models predicted the forces developed in the muscles during these tests so that the severity
of spinal loading could be quantified. The safety of the proposed protocols can be assessed by comparing
the developed disc compression and shear forces with tissue tolerances in the literature. A detailed finite
element model of the spine has been developed that quantifies the stress and strain in the highly innervated
tissues such as the annulus fibers, ligaments, and vertebral end plates (Wang et al., 1997a,b,c; 1998).
While quantifying the trunk muscle recruitment during the isometric tasks, it was observed that as
the subjects fatigued, muscles other than the primary trunk extensors became more active. The implication
of this finding is that if a worker has a deficit in either the primary or secondary muscles, risk of injury
may increase. We have found that more caudal and medial muscles fatigue the most (Table 14.1). Hence,
if experimental resources are limited, based on our results, we have identified the medial erector spinae
muscle at the level of L5 to be the location of choice for quantifying trunk fatigue (Sparto et al., 1997b).
Soft tissues subjected to repetitive loading, due to their viscoelastic properties, demonstrate creep and
load relaxation (Wang et al. 1997b,c; 1998). The loss of precision, speed, and control of the neuromuscular
system induced by fatigue reduces the ability of muscles to protect the weakened passive structure,
which may explain many industrial, clinical, and recreational injury mechanisms. These results further
indicate the necessity of relating clinical protocols to the job and show how short-duration maximal
isometric testing alone cannot provide the complex functional interaction of strength, endurance, control,
and coordination (Parnianpour et al., 1988; Sparto et al., 1997c).
Parnianpour et al. (1988) studied the effect of isoinertial fatiguing of flexion and extension trunk
movements on the movement pattern (angular position and velocity profile) and the motor output
(torque) of the trunk. They showed that, with fatigue, there is a reduction of the functional capacity in
the main sagittal plane. There is also a loss of motor control, enabling a greater range of motion in the
transverse and coronal planes while performing the primary sagittal task. Association of sagittal with
coronal and transverse movements is considered more likely to induce back injuries; thus the effect of
fatigue and reduction of motor control and coordination may be an important risk factor leading to
injury-prone working postures. The endurance limit is a more useful predictor of incidence and recurrence
of low back disorders than the absolute strength values. Although physiological criteria used in the
National Institute for Occupational Safety and Health Lifting Guide (NIOSH, 1981) considered
cardiovascular demands of dynamic repetitive lifting tasks, the limits of muscular endurance were not
explicitly addressed. Future research should fill this gap, since the maximum strength measures should
not guide the design decisions. Maximum level of performance can only be maintained for short periods
of time, and muscular fatigue should be avoided to prevent the development of MSD. This caveat
should be applied to all dimensions of performance capability (Kondraske, 1990; Parnianpour, 1995).
Other dynamic endurance protocols use repetitive isoinertial and isokinetic lifting tasks (Sparto et
al., 1997c; 1998b). These two variations provide low stress to the musculoskeletal system and high
stress to the cardiovascular system, and vice versa. Decreased knee and hip motion and increased spine
flexion were evident in these studies, during repetitive sagittal lifting and lowering tasks, suggesting that
the effects of fatigue may increase the loading of the passive tissues of the spine (Sparto et al., 1997c,d;
1998b). The changes in the phase angles of hip and spine motion between the rested and fatigued states
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FIGURE 14.2 Change in the phase angles from the start to the end of the repetitive lifting test for one subject. The
phase angles are shown for the hip and lumbar spine.
during a repetitive lifting task are shown in Figure 14.2. The implications of this altered coordination
should be investigated further in future research. Additional analyses have demonstrated a decrease in
the postural stability of subjects performing these tasks (Sparto et al., 1997d). The validation of the
LIDOlift simulator was originally presented in Sparto et al. (1995).
Sparto and Parnianpour (1997) studied endurance of trunk extensors during repetitive submaximal
trunk isokinetic extension. Trunk muscle electromyography (EMG) and torque output were measured
in 16 healthy men [mean (s.d.) 23 (3) yrs, 178 (5) cm, 79 (9) kg] as they performed repetitive trunk
extension exertions at 15 degrees/sec. A factorial design consisting of two load levels (35% and 70% of
the maximum dynamic trunk extension torque) and two repetition rates (5 and 10 reps per minute) was
implemented in order to cause different rates of fatigue. Each of the four load/rep combinations was
tested during a single session, with at least one week in between. After the subjects stretched, bipolar
surface electrodes were applied to the skin. Three bilateral trunk extensor muscles were sampled
latissimus dorsi (LAT), erector spinae (ERS), and posterior internal obliques (PINO)as well as three
trunk flexorsrectus abdomini (RAB), external obliques (EOB), and anterior internal obliques (AINO).
The pelvis and lower extremities of the subjects were restrained within a trunk dynamometer. Maximal
voluntary isometric exertions in each of the six cardinal directions were performed at 17.5 degrees of
forward flexion to measure the maximum electromyographic activity of each muscle. The average of
three dynamic maximal voluntary contractions (DMVC) in trunk extension was obtained, in order to
measure the initial maximum torque-generating capability. During the dynamic exertions, subjects
extended their trunks from a forward flexion posture of 35 degrees to upright standing, at a constant
velocity of 15 degrees per second. The torque was measured using a load cell and knowing the distance
from the point of force application to the center of rotation of the trunk. Two minutes of rest was
provided between all maximum exertions.
During the repetitive endurance test, trunk extension was performed at 15 deg/sec while subjects
controlled their torque output at 35% or 70% of the initial DMVC, by using visual feedback displayed
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FIGURE 14.3 (Top) Decline in maximum dynamic torque generating capability during an endurance test performed
at 35% MVC, 10 reps/minute. A 35% decline in torque is indicated by the dashed line. (Bottom) The normalized
EMG of the left latissimus dorsi during the same test.
on a computer monitor. The exertion rate, 5 or 10 reps per minute, was regulated by an audible tone.
Once per minute, a DMVC was performed, to quantify the reduction in the maximal torque-generating
capability (fatigue). The exertions continued until a 35% reduction in the MVC occurred, the subject
could no longer continue, or 30 minutes elapsed.
The raw EMG from each exertion was sampled at 1536 Hz, rectified, and low pass filtered at 3 Hz.
After normalizing with the maximum EMG obtained from the isometric MVCs, the root-mean-square
(rms) value of the EMG between the trunk angles of 25 and 10 degrees of flexion was computed. From
the exertions whose rms torque was within 5% of the designated load level, the change in EMG with
time, or SLOPE, was quantified using linear regression. In order to obtain an estimate of the slope for
each muscle group, the slopes were averaged for the right and left muscle pairs. The effect of the load
magnitude and repetition rate on the slope was tested using repeated measures multiple analysis of
variance (MANOVA).
The effect of the repetitive endurance test on the decline in maximum torque-generating capability
and change in muscle activation are shown in Figure 14.3. For this test, the maximum torque declined
by 35% in about 4 minutes, during which the EMG of the left latissimus dorsi muscle increased by
10%. The endurance time (point at which the predicted maximum torque declined by 35%) for each of
the load/reps combinations is shown in Table 14.2. The effect of load, repetition rate, and their interaction
on the endurance time were all highly significant (p<.001), indicating the study design was effective at
eliciting different rates of fatigue. It can be seen that doubling the repetition rate from 5 to 10 reps/min
had a greater effect in causing fatigue than doubling the load magnitude.
The results of the MANOVA indicated that as a group, the slopes of all muscles were significantly
affected by the effects of load, repetition rate, and their interaction (p<.005). Furthermore, Table 14.3
demonstrates that significant differences in slope were found in each of the trunk extensor muscles
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TABLE 14.2 Mean (s.d.) Endurance Time, in

Minutes, for the 4 Load/Reps Endurance Tests
TABLE 14.3 P-values from the Univariate

ANOVA, Testing the Effect of Load, Repetition
Rate, and Interaction on the Slope
FIGURE 14.4 Increase in slope of the regression between the normalized EMG of the latissimus dorsi and time, due
to the interaction between the load and repetition rate.
(LAT, ERS, PINO). Figure 14.4 shows the mean slope as a result of the interaction between load and
repetition rate for the latissimus dorsi. The other extensor muscles display a common pattern.
Because of the ambiguity in relating the amplitude of the processed EMG to muscle tension, one
cannot speculate if the increase in activation resulted in greater muscle force, or represented a decreased
efficiency in EMG/force production due to fatigue. Furthermore, it is not known if the function of the
increased activation of the secondary trunk extensors (LAT and PINO), is to provide greater stability, or
augment the torque generation. The increased and altered trunk extensor muscle activation due to
fatigue requires further investigation to determine its effect on the spinal loading. EMG-driven models
accounting for muscle fatigue have been developed to address these issues (Sparto, 1998).
In addition, models are being developed that are attempting to predict the endurance time based on
parameters obtained from the noninvasive surface EMG of the trunk extensor muscles. Both short-time
Fourier transform and wavelet transform techniques are being used to process the EMG (Sparto et al.,
1997a). The use of the wavelet transform is more promising than the short-time Fourier transform
because it does not depend on stationarity of the signal, the bases of analysis are not restricted to
sinusoids, and it is not limited by the time-frequency resolution tradeoff. Furthermore, the analysis
techniques can be incorporated into digital signal processing hardware that can be used to monitor the
extent of back muscle fatigue in real time. The real time displays will allow the biofeedback application
as well in the retraining of muscle endurance so essential in the conservative treatment of low back pain
patients with spinal instability.
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Lifting Strength Testing

The National Institute for Occupational Safety and Health (NIOSH, 1981) recommended static, i.e.,
isometric, strength measurement as its standard for lifting tasks. This was based on the evidence that
associated low back pain with inadequate isometric strength. The incidence of an individuals sustaining
an on-the-job back injury increases threefold when the task-lifting requirements approach or exceed the
individuals strength capacity. However, lifting strength is not a true measure of trunk function but is a
global measure taking into account arm, shoulder, and leg strength as well as the individuals lifting
technique and overall fitness. It has been shown that strength tests were more valid and predictive of risk
of low back disorders if they simulated the demands of the job. The clinicians must be aided with easyto-use and validated instruments or questionnaires to gather information about the task demands in
order to decide what testing protocol best simulates the applicants spinal loading conditions.
Static strength measurements have been reported to underestimate significantly the loads on the
spine during dynamic lifts. Comparing static and dynamic biomechanical models of the trunk, the predicted
spinal loads under static conditions were 33% to 60% less than those under dynamic conditions,
depending on the lifting technique. The recruitment patterns of trunk muscles (and thus the internal
loading of the spine) are significantly different under isometric and dynamic conditions. General manual
material handling tasks require a coordinated multilink activity which can be simulated using classical
psycho-physical techniques or the robotics-based lift task simulators. Various lifting tests, including
static, dynamic, maximal, and submaximal, are currently available. The experimental results of
correlational studies have confirmed the theoretical prediction that strength will be dependent upon the
measurement technique (Balague et al., 1993; Parnianpour et al., 1987b; Parnianpour et al., 1993).
Since muscle action requires external resistance, the effect of muscle action will depend on the nature of
the resistance. These results refute the implicit assumption that a generic strength test exists that can be
used for preplacing workers (pre-employment) and predicting the risk of injury or future occurrence of
low back pain. The psychometric properties of isokinetic and isoresistive modes of strength testing were
recently addressed. The quantification of the surface response of strength as function of joint angle and
velocity was only possible for isokinetic testing, while isoresistive tests yielded a very sparse data set
(Parnianpour, 1995).
The widely conflicting results found in the literature regarding the relationship of an individuals
strength to the risk of developing LBP may be due to inappropriate modes of strength measurements,
i.e., lack of job specificity (Parnianpour, 1995; Szpalski and Parnianpour, 1996; Parnianpour et al.,
1977b). Isometric strength testing of the trunk is still widely used, especially in large-scale industrial or
epidemiological studies, because it has been standardized and studied prospectively in industry. Compared
to trunk dynamic strength testing protocols, the trunk isometric strength testing protocols are simpler
and less expensive.
One outstanding issue during dynamic testing is the unresolved problem of how the wealth of
information can be presented in a succinct and informative fashion. One approach has been to compare
the statistical features of the data with the existing normal databases. This is particularly crucial because
we do not have the option of comparing the results to the contralateral asymptomatic joint, as we
have with lower or upper extremity joints. Given the large differences between individuals, we recommend
comparison be made to job-specific databases (Parnianpour et al., 1991; Parnianpour et al., 1994). For
example, it is more appropriate for the trunk strength of an injured construction worker to be compared
to age- and gender-controlled healthy construction workers than to data from healthy college graduate
students or office workers. However, given the scarcity of such data, we argue for comparison of
performance capacity with job demand based on task analysis. The performance capacity evaluation is
once again linked to task demand quantification (Parnianpour, 1995).
In evaluating any manual material handling (MMH) tasks such as lifting, the quantification of the
various generated parameters (kinetic, kinematic, and electromyographic) is essential to assessing
functional capacity and development of a biomechanical profile of task demands. We have developed a
methodology for representing and quantifying performance data variability of the kinematic and kinetic
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TABLE 14.4 P-values of MANOVA to Test the Effect of Load

(L), Mode (M), Speed (S), and Their Interactions on the
Extracted Features (Coefficients) of the Joint Torque Profiles
NS: Not Significant
motion profiles as a function of the different lift characteristics (load, mode, and speed) during MMH
tasks (Khalaf et al., 1997b,c). Using a database of motion profiles from a manual lifting experiment, the
Karhunen-Loeve Expansion (KLE) was shown to be quite effective for representing the various motion
profiles, where the number of basis vectors (eigenvectors) and coefficients needed to accurately represent
the data were substantially smaller than the original data set resulting in lower order space or dimension.
The factorial lifting experiment required subjects to lift two masses (6.8 and 13.6 kg), at three different
speeds (2, 4, 6 seconds per lifting/lowering cycle), using three modes of lift (preferred, straight leg, bent
leg). Table 14.4 demonstrates how the lift characteristics affect the extracted features of the joint torque
profiles. We can see that the main effects of load (L), mode (M), and speed (S) significantly affect the
torque profiles (Khalaf et al., 1997). Further inspection of the data revealed that the 13.6 kg load
resulted in greater peak lumbosacral (L5/S1) torques; the greater speeds of lift resulted in greater peak
lumbosacral torque; and that the preferred mode of lift was a compromise between the straight leg and
bent leg modes, in terms of the peak lumbosacral torque. The following analysis also revealed that the
patterns of joint movement was invariant with respect to the level of load and speed tested in this
experiment (Khalaf et al., 1997c).
The effects of lift characteristics were also investigated using analysis of variance techniques which
recognize the vectorial constitution of the waveforms as opposed to the traditional descriptive statistics
representing the data over the lifting cycle (Khalaf et al., 1997). The application of these techniques will
enhance the ability to document the effect of intervening measures such as education or physical training/
exercise on the kinematic and kinetic patterns of performance (Parnianpour et al., 1987). In addition,
the ADA-related applications are significant since this will aid in the assessment of the feasibility of task
performance as a function of existing impairments, and assessment of limitations on functional capacity,
allowing appropriate task assignment based on a workers capabilities. Furthermore, the differential
influence of lift characteristics on the variability of performance during different phases of lifting and
lowering may provide added resolution in the analysis of MMH tasks. The most effective workplace
modifications can be recommended based on the preceding results.
Inverse and Direct Dynamics

A major task of biomechanics has been to estimate the internal loading of musculoskeletal structure and
establish the physiological loading during various daily activities. Kinematics studies deal with joint
movement with no emphasis on the forces involved. However, kinetic studies address the effect of forces
that generate such movements. Using sophisticated experimental and theoretical stress/strain analyses,
hazardous/failure levels of loads have been determined. The estimated forces and stresses are used to
estimate the level of deformation in the tissues. This technique allows us to assess the risk of over-exertion
injury associated with any physical activity. Given repetitive motions and exertion levels much lower than
the ultimate strength of the tissues, an alternative injury mechanism, the cumulative trauma model, has
been used to describe much of the musculoskeletal disorders of the upper extremities (Wang et al., 1997a,b,c).
The experimental data on the joint trajectories are differentiated to obtain the angular velocity and
acceleration. Appropriate inertial properties of the limb segments are used to compute the net external
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moments about each joint. This mapping from joint kinematics to net moments is called inverse dynamics.
Direct dynamics refers to studies that simulate the motion based on known actuator torques at each joint.
The key issue in these investigations is understanding the control strategies underlying the trajectory planning
and performance of purposeful motion. A highly multidisciplinary field has emerged to address these
unsolved questions [see Berme and Cappozzo (1990) for a comprehensive treatment of these issues].
It should be pointed out that determination of the external moments about different joints during
manual material handling tasks is based on the well-established laws of physics. However, the
determination of human performance and assessment of functional capacity are based on other disciplines,
e.g., psychophysics, that are not as exact or well developed. We can describe the job demand, in terms of
the required moments about each joint, easily by analyzing the workers performing the tasks. However,
we are unable to predict the ability to perform an arbitrary task based on our incomplete knowledge of
functional capacities at the joint levels. A task is easily decomposed to its demands at the joint level,
however, we cannot compose (construct) the set of feasible tasks based on our functional capacity
knowledge. The mapping from high-level task demands to the joint-level functional capacity for a given
performance trial is unique. However, the mapping from joint-level functional capacity to the high-level
task demand is one to many (not unique). The challenge to the human performance research community
is to establish this missing link. Much of the integration of ergonomics and functional analysis depends
upon the removal of this obstacle. The question of whether a subject can perform a task based on the
knowledge of his/her functional capacity at the joint level remains an area of open research. When
ergonomists or occupational physicians evaluate the fitness of task demands and worker capability, the
following clinical questions will be presented: (1) Which space should be explored for determining
normalcy, fit, or equivalence? (2) Should we consider the performance of the multilink system in the
joint space or end-effector (cartesian work space)? These issues have profound effects on both the
development of new technologies and evaluation of trunk or lifting performance (Sparto et al., 1995).
The enormous degree of freedom existing in the neuromusculoskeletal system provides the control
centers for both the kinematic and actuator redundancies. The redundancies provide optimization
possibility. Since we can lift an object from point A to point B with infinite postural possibilities, it can
be suggested that certain physical parameters may be optimized for the learned movements. The possible
candidates for objective function to be optimized are: movement time, energy, smoothness, muscular
activities, etc. This approach, though still in its early stage, may be very important for spine functional
assessment. We could compare the given performance to the optimal performance that is predicted by
the model. This approach provides specific goals and gives biofeedback with respect to the individuals
performance.
Biomechanical Models
To complement the trunk strength and endurance testing protocols, a number of biomechanical simulation
models have been developed which will be briefly discussed in the following section: (a) simulation of
trunk strength based on anatomical cross-sectional area of muscles, line of action, and their lever arms
(Parnianpour et al., 1997b); (b) simulation of trunk motion for healthy and impaired low back patients
(Parnianpour et al., 1997a); (c) simulation of lifting tasks considering the strength and range of motion
of each joint based on the load characteristics: initial and final load position, load magnitude, duration
of lift (Khalaf et al., 1996).
Figure 14.5 represents the three-dimensional trunk strength boundaries based on the anatomical
data of Hughes et al. (1995). Any task that requires moments that are interior to the surface are considered
feasible, while those on the outside of the boundary are infeasible. These models can utilize the readily
available CT scan or MRI data that the patients may already have. Any conceivable MMH task can be
reduced to the three components of moment that it requires from the trunk muscles to keep it in
equilibrium. Hence, the model is not limited to any specific task (pushing, lifting etc.), which is highly
desirable. The preceding strength model can quickly identify the tasks that cannot be performed without
any ergonomic modifications. It can easily be interfaced with the databases that may have been developed
based on biomechanical analyses of the task in question (Parnianpour, 1995; Khalaf et al., 1997a).
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FIGURE 14.5 Three-dimensional boundaries for trunk strength, assuming muscle geometry from Hughes et al.
(1995).
FIGURE 14.6 Effect of minimizing different cost functions (energy, work, peak torque) on the optimized trunk
trajectory during simulation of trunk extension and flexion movements. The movement time has been specified at 1
second.
Figure 14.6 shows the simulated trajectory of flexion and extension of the trunk using a number of
candidate cost functions in the range of upright to 60 degrees of flexion. The simulation models require
specification of initial and final angular position, velocity and acceleration of the trunk and the subjects
trunk flexion/extension strength. The movement time could be specified or kept as another free parameter.
This model can indicate whether a task is feasible within the desired movement time or could provide a
physical basis for real-time feedback to individual during the training. To simulate the impairment, we
have limited the trunk extension strength to 200 Nm, and report the simulated trajectories for flexion
task in Figure 14.7. It is clear that the imposed limitation on strength reduces the variability of predicted
trunk trajectory (Parnianpour et al., 1997a). Although we may not be able to ever verify the cost function
being used or whether CNS uses the optimization algorithms, the ability to simulate trajectories of
movement is still invaluable. The numerical simulations may allow us to estimate the bounds on the
required functional capacity or changes in the workplace to make the task feasible.
Biomechanical simulation models provide a time- and cost-effective tool for answering what if
types of questions. In the light of the ADA, this is of great value in predicting the consequences of task
modifications and/or workstation alterations without subjecting an injured worker or a disabled individual
to unnecessary testing. Consequently, a computer-based simulation program of multilink coordinated
lifting that predicts the optimum motion pattern(s) required to perform a wide range of lifting tasks
subjected to constraints based on experimental strength profiles has been developed (Khalaf et al.,
1996). The model uses nonlinear optimization techniques to investigate the feasibility of task performance
as a function of existing impairments, and limitations on functional capacity such as the range of motion,
strength, and speed of lifting.
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FIGURE 14.7 Effect of limiting trunk extension strength to 200 Nm on the optimized trunk flexion trajectory. The
movement time has been specified at 1 second to allow comparison with unconstrained strength simulation presented
in Figure 14.6.
FIGURE 14.8 Comparison between the simulated and experimental motion patterns for the five joints during a
lifting simulation (6.8 kg mass).
The models sensitivity to various types of strength constraints was studied such as upper and lower
bounds of joint strength, joint strength as a function of joint position, and dynamic joint strength as a
function of joint position and velocity (based on the previously obtained experimental strength profiles).
The simulation was validated by comparing the predicted motion patterns with the experimental data
generated for a similar lifting task (Figure 14.8). The results could be used as a biofeedback tool for
training injured workers during rehabilitation, return to work assessment, as well as workplace
modifications or reasonable accommodations as dictated by the ADA. The proper choice of a cost
function remains an open area of research. Present work includes further experimental validation for a
diverse set of loading conditions. In addition, we are in the process of implementing a nonlinear feedback
control scheme to enhance the model by providing stability.
Comparison of Task Demands and Performance Capacity

The regression analysis was used to model the dynamic torque, velocity, and power output as a function
of resistance level during isoresistive flexion and extension using the B-200 Isostation (Parnianpour et
al., 1990). Results indicated that the measured torque was not a good discriminator of the 10th, 50th,
and 90th percentile populations. However, velocity and power were shown to effectively discriminate
the three populations. Based on these data, it was suggested that during clinical testing, sagittal plane
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resistance should not be set at higher than about 80 Nm in order to minimize the internal loading of
spine while taxing trunk functional capacity. This presentation of data may be useful to the physician or
ergonomist in evaluating the functional capacity requirements of workplace manual material handling
tasks. For example, a manual material handling task that requires about 80 Nm (61 ft-lbs) of trunk
extensor strength could be performed by 90% of the population in the normal database if the required
average trunk velocity does not exceed 40/sec, while only 50% could perform the task if the velocity
requirement exceeds 70/sec; but more importantly, only the top 10th percentile population could perform
the task if the velocity requirement approaches 105/sec (Parnianpour et al., 1990). A few versions of
lumbar motion monitors that can record the triaxial motion in the workplace have been used to provide
the trunk movement requirements. The following example also illustrates the importance of having the
same bases for evaluation of both task and the functional capability of the worker.
Lifting Utilization Ratio

The utilization ratio provides a joint-specific unified scalar quantity representing the task demand
normalized by an individuals maximum capacity. It would indicate whether a subject is capable of
performing the task and how much of his/her maximum capacity is taxed by a given physical activity
such as lifting. To illustrate this concept, Khalaf et al. (1997a) combined the trunk strength surface
responses and the results of the task demand profiles of a lifting task performed by a typical female
subject (Khalaf et al., 1997b). Very different results were predicted depending on whether the denominator
of the utilization ratio was based on a single isometric strength value measured in upright position,
posture dependent, or a function of both posture and trunk velocity. One of the reasons for the poor
results of many epidemiological investigations for prediction of future low back injury based on isometric
strength is shown here. To increase the predictive power, it has been suggested that the measured strength
must simulate the essential functions of the task as closely as possible. The results of this analysis indicated
that accurate estimation of the utilization ratio requires both the dynamic measurements of the external
moment and strength in the range of joint positions being experienced during the performance of the
lifting task. Moreover, the dynamic characteristics of the task should be considered. It is clear that the
higher magnitudes of the dynamics components increase the task demand and reduce the maximum
functional capacity, hence increasing the utilization ratio. The dynamic utilization ratio is computed
considering the strength dependence on both the angular position and velocity. At the faster rate of lift,
the numerator of the utilization ratio (task demand) is increased due to the increased acceleration. On
the other hand, the denominator (maximum strength capacity) is decreased since the tension is inversely
proportional to a muscles speed of shortening (Hills tension-velocity relationship). Hence, the utilization
ratio approaches unity even for lifts that are only a fraction of the maximum lifting capacity. Moreover,
the higher muscular activities (including higher coactivation) experienced at the faster lifting tasks may
augment the risk of injury due to higher spinal loading (Ross et al., 1993).
14.4 Clinical Applications

Clinical studies have utilized quantitative human performance, i.e., strength and endurance measures, to
predict the first incidence or recurrence of LBP, disability outcome, and also as a prognosis measure
during the rehabilitation process. Training programs to enhance the endurance and strength of workers
have been implemented in some industries. A prospective randomized study among employees in a
geriatric hospital showed that exercising during work hours to improve back muscle strength, endurance,
and coordination proved cost effective in preventing back symptoms and absence from work (Gundewall
et al., 1993). Every hour spent by the physiotherapist on the exercise group reduced the work absence
by 1.3 days. In this study both training and testing equipment were very modest. More studies on
effectiveness of these programs are needed (Nordin et al., 1987; Kahanovitz et al., 1987). It can be
hypothesized that these programs complement the stress management programs to enhance both worker
satisfaction and coping strategies with regard to physical and nonphysical stressors at the workplace.
14-18
Functional-based impairment evaluation schemes have traditionally used spinal mobility (Buchalter
et al., 1998; Elnaggar et al., 1991). Given the poor reliability of range of motion (ROM), its large
variability among individuals, and the static psychometric nature of ROM, the use of continuous dynamic
profiles of motion with the higher order derivatives has been suggested (Marras et al., 1993). Dynamic
performances of 281 consecutive patients from the Impairment Evaluation Center at Mayo Clinic were
used (Sharafeddin et al., 1996). As part of the comprehensive physical and psychological evaluation,
281 consecutive LBP patients underwent isometric and dynamic trunk testing using the B200 Isostation.
Feature Extraction and Cluster Analysis techniques were used to find the main profiles in dynamic
patient performances. The middle three cycles of movements were interpolated and averaged into 128
data points; thus the data were normalized with respect to cycle time. This allowed for comparison
between individuals. The LBP patients in this study were shown to be heterogeneous with respect to
their movement profile (Sharafeddin et al., 1996). Uniform treatment of these patients is questionable,
and rehabilitation programs should consider their specific impairments. Future research should incorporate
the clinical profiles with these movement profiles to further delineate the heterogeneity of low back
patients (Parnianpour et al., 1994; Szpalski and Parnianpour, 1996).
Marras et al. (1993) used similar feature extraction techniques to characterize the movement profiles
of 510 subjects belonging to normal (N = 339) and ten LBP patient groups (N = 171). Subjects were
asked to perform flexion/extension trunk movement at five levels of asymmetry, while the threedimensional movement of the spine was monitored by the Lumbar Motion Monitor (an exoskeleton
goniometer developed at the Biodynamics Lab of The Ohio State University). Trunk motions were
performed against no resistance, and no pelvic stabilization was required. The quadratic discriminant
analysis was able to correctly classify over 80% of the subjects. The same technology was used to
develop logistic regression models to identify the high-risk jobs in industrial workplaces. Hence, principles
of human performance can successfully be applied to the worker and the task to avoid the mismatch
between performance capability and task demand. A more detailed clinical implication of quantitative
assessment of trunk performance is presented in Szpalski and Parnianpour (1996).
14.5 Conclusions
The outcome of trunk performance is affected by the many neural, mechanical, and environmental
factors which must be considered during quantitative assessment. The objective evaluation of the critical
dimensions of functional capacity and its comparison with the task demands is crucial to the decisionmaking processes in the different stages of the ergonomic prevention and rehabilitation process. Knowing
the tissue tolerance limits from biomechanical studies, task demands from ergonomic analysis, and
function capacities from performance evaluation, the rehabilitation team will optimize the changes to
the workplace or the task that will maximize the functional reserves (unutilized resources) to reduce the
occurrence of fatigue or overexertion. This will enhance worker satisfaction and productivity, while
reducing the risk of MSD.
Based on ergonomic and motor control literature, the testing protocols that best simulate the loading
conditions of the task will yield more valid results and better predictive ability. Ergonomic principles
indicate that the ratio of the functional capacity to the task demand (utilization ratio) is critical to the
development of muscular fatigue which may lead to more injurious muscle recruitment patterns and
movement profiles due to loss of motor control and coordination. However, large prospective studies
are still needed to verify this. The most promising application for these quantitative measures is to be
used as a benchmark for the safe return to work of injured workers, given the enormous variations
within the normal population.
The ability to identify subgroups of patients or high-risk individuals based on their functional
performance will remain an open area of research to interested biomedical engineers within the
multidisciplinary group of experts addressing neuromusculoskeletal occupational disorders. With the
advent of technologies to monitor trunk performance in the workplace, we can obtain estimates of the
14-19
injurious levels of task demands (kinematics and kinetic parameters) which can be used to guide our
preplacement and rehabilitation strategies. The more functional the clinical tests become, the more
clinicians need a complex interpretation scheme. An increasingly complex interpretation scheme opens
the possibility of using mathematical modeling with intelligent computer interfaces.
The integration of complex biomechanical modeling of viscoelastic elements of spine, EMG-driven
models quantifying the muscular activity, and realistic anatomical models with the well-controlled
experimental designs motivated by the task demand analyses in the workplace is crucial to further
understanding of low back disorders and their work-related risk factors. We need to accelerate our
research efforts toward understanding the stabilization role of muscles in spine and the consequences of
various neuro-control strategies by applying detailed biomechanical models to quantify the tissue stresses
and strains (Parnianpour, 1991; Parnianpour et al., 1997b; Shirazi-Adl and Parnianpour, 1993, 1996a,b,
1998; Kiefer et al., 1997) during physical exertions.
Acknowledgment
The authors acknowledge the support from OSURF and NIDRR H133E30009. The authors would like
to thank, for their invaluable comments and contributions, George V.Kondraske, Margareta Nordin,
Victor H.Frankel, Elen Ross, Jackson Tan, Robert R.Crowell, William Marras, Sheldon R.Simon, Ali
Sheikhzadeh, Jung Yong Kim, Patrick Sparto, Kinda Khalaf, Jaw L.Wang, Alexander Kiefer, Marek
Szpalski, and Sue Ferguson.
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15
Perspective on Industrial
Low Back Pain
15.1
15.2
Malcolm H.Pope
15.3
University of Iowa
Donald R.McIntyre
Interlogics
15.4
Introduction
Manual Materials Handling (MMH) Postural
Demands Whole Body Vibration (WBV) Slipping
and Tripping Psychosocial factors
An Ergonomics and Injury Evaluation System
Baselining or Pre-Injury Phase Post-Injury Analysis
Case Study
Injury Incidence/Severity Analysis Job Analysis
Task Analysis Recommendations Baseline Testing
Clinical Evaluation
Conclusions
151
154
159
1511
15.1 Introduction
The first recorded case of occupational low back pain (LBP) was during the building of the pyramids.
Although there is an extensive literature supporting a positive relationship between LBP and workplace
factors (see reviews by Andersson et al., 1991; Garg and Moore, 1992; Kelsey and Hochberg, 1988;
Riihimaki, 1995), recent publications have claimed that psychosocial factors are much more important
(Nachemson, 1991; Bigos et al., 1991; Hadler, 1994). This paper will address the important ergonomic
principles.
The industrial risk factors that have been identified are:
1.
2.
3.
4.
5.
6.
Manual materials handling (both frequent and heavy lifting)

Awkward postures
Fixed postures (including sitting)
Whole body vibration
Slipping and tripping
Psychosocial factors
There is a lengthy epidemiological literature dealing with the relationship of these risk factors with LBP.
The epidemiological studies have several generic limitations:
1. Exposure data is generally limited (job title alone reduces risk toward null effects)
2. Confounding factors are often present
3. A definitive diagnosis is often absent
Manual Materials Handling (MMH)

Numerous studies have found a positive relationship between MMH and LBP. Helivaara (1987) found
that the odds ration (OR) for herniated nucleus pulposus (HNP) for heavy MMH was 2.5 to 4.6.
0-8493-1800-9/03/$0.00+$1.50
15-1
15-2
Riihimki (1995) summarized reviews of the relationship of LBP and MMH. Of 26 studies since 1950
only two found no relationship. However, all of the studies were cross sectional rather than prospective
and used job title as a surrogate of exposure.
Biomechanical studies, as summarized by Pope et al. (1991), show that a large load or one held at a
distance from the body leads to extremely high forces in the disc due to contraction of the erector spinae.
Likewise, flexion of the trunk increases compression forces. A simple means of addressing the issue of
the allowable lift is to use the NIOSH lifting formula (Waters et al., 1993).
1. Recommended Weight Limit (RWL)
(15.1)
where
LC = Load constant
HM = Horizontal multiplier
VM = Vertical multiplier
AM = Asymmetric multiplier
CM = Coupling multiplier
FM = Frequency multiplier
The six multipliers are the penalties for deviating from the ideal lifting situation. The ideal lifting situation
is defined as lifting from a 30 in. (75 cm) height, to a distance of up to 10 in. (25 cm), with hands close
to the body (up to 10 in. [25 cm] from the ankles), with no twisting, with good grasp, a lifting frequency
of once every 5 minutes or less, and with the lifting duration not exceeding 1 hour.
Thus, the load constant (LC) is the maximum weight allowed to be lifted. Since the six multipliers are
penalties, none of them can be more than 1. In other words, under ideal conditions, when all six multipliers
are 1, the RWL = LC.
2. Lifting Index (LI)
The LI gives the ratio of the weight to be lifted to the recommended weight limit.
(15.2)
A convenient means of assessing the NIOSH lifting risk is via a tool such as Video Works (see example).
The data can be digitized directly from the video into the NIOSH equations and the effects of ergonomic
changes assessed.
Control of the risk can include reducing the:
1.
2.
3.
4.
5.
Postural demands
Burden
Size of the load
Repetitions
Twisting
Other control strategies can include the use of:

1. Lifting equipment
2. Parts delivered at waist height
3. Two-man lift
Perspective on Industrial Low Back Pain
15-3
A logical control technique would appear to be matching the worker to the task. Chaffin (1974) found
that a mismatch increased the injury risk. Liles et al. (1984) found that the incidence of injury was
related to the job severity index (JSI). The JSI is the weight of a lift divided by the acceptable weight of
a lift as defined by the worker. A JSI of 0.6 increasing to 2.0 increases the risk of injury by 4.5 times.
Repetitive lifting of greater than 5 kg increases the risk twofold.
Testing of workers to assess lifting ability is limited in the United States under the provisions of the
ADA unless the lifting represents an essential function of the job.
Postural Demands
The literature contains numerous papers relating severe postural demands to LBP and HNP. These
postural demands are often linked together with MMH. An exception is the static awkward postures
normally associated with sedentary work. Punnett (1991), while studying auto workers, found that LBP
was associated with awkward postures. Mild flexion has an OR = 4.9, high flexion 5.7 and twist or
lateral bend 5.9. Pope et al. (1986) showed there is a higher level of antagonistic muscle activity in
twisted postures, leading to high muscle and disc forces. This was supported by Kelsey et al. (1984) who
found an OR of 3.0 between lifting while twisting and HNP. Adams and Hutton (1985), in laboratory
studies, showed that loading a cadaver disc in a flexed, twisted orientation leads to an HNP.
Controls mean a redesign of the workplace to prevent high kinematic demands such as reaching,
bending, and twisting. Conveyor belts, adjustable tables, and delivery of goods at waist height are some
of the solutions that have been employed.
Whole Body Vibration (WBV)

There is considerable literature relating exposure to WBV through driving vehicles to LBP and HND.
Hulshof and Van Zanton (1987) found OR to range from 1.6 to 7.0. Kelsey and Hardy (1975) found
that spending over half the day in a car gives an OR of 3.0 for HND.
Studies of the occupational environment reveal that many vehicles subject the worker to levels of
vibration greater than that recommended by the International Standards Organization (ISO, 1978). The
human spinal system has a characteristic response to vibration in a seated posture. The first resonance
occurs within a band of 4.5 to 5.5 Hz. Similar, but less tightly defined resonances, are also in the 9.4 to
13.1 Hz range (Pope et al., 1986, 1987, 1989). The resonance is markedly affected by the pelvis-buttocks
system. The response of the human is due to a combination of a vertical subsystem and a rotational
subsystem. The latter is by rocking of the pelvis.
The back muscle response with respect to the vibration stimulus was studied by Seroussi et al. (1989).
The muscles are not able to protect the spine from adverse loads. At many frequencies, the muscle
response is so far out of phase that muscle forces are added to those of the stimulus. The fatigue that was
found in muscles, after vehicular vibration, is indicative of the loads in the muscles. Exposure of the
seated subject to whole body vibrations of 5 Hz, in a position that ensured back muscle activity, increased
the rate of development of fatigue in the erector spinae muscles, as compared to the same conditions
without vibrations. After WBV, there is an increased latency in muscle recruitment (Wilder et al., 1996).
This may be due to the fatigue inherent in WBV exposure. This suggests that if a worker unloads a
vehicle after exposure to WBV this could present a problem for the back.
Many ergonomic interventions are possible. WBV should be attenuated at the cab or seat to comply
with ISO 2631. The layout of the vehicle cab should be optimized to prevent awkward postures. This
is particularly true for tractor and forklift drivers. Excessive driving shifts should be avoided and
frequent stretch breaks encouraged. Lifting directly after driving should be avoided. The psychological
environment should not be ignored and good health (i.e., aerobic strength, trunk strength, and
endurance) encouraged.
15-4
Slipping and Tripping

It is reported in some studies that as much as 50% of LBP injuries occur in conjunction with slipping and
tripping (Pope et al., 1991). In the absence of blunt trauma, the slip may cause a sudden load to be applied
to the ligamentous spine or may cause the muscles to contract with high force (Wilder et al., 1996).
Psychosocial factors
Many studies support a positive relationship between LBP report or disability and psychosocial stressors.
These stressors include:
1.
2.
3.
4.
5.
6.
Monotonous work
Poor social support
High work pressure
Lack of control
Job dissatisfaction
Mutual dislike of boss and/or co-workers
In the Boeing study, Bigos et al. (1991) found the OR for LBP disability was 1.7. Magnusson et al.
(1996) found that mechanical stressors lead to LBP, but psychosocial factors are responsible for low
back pain disability.
The challenge would seem to be to separate the issues of LBP and disability since the solutions may
be different. Clearly, a systematic method needs to be employed to deal with this difficult problem.
15.2 An Ergonomics and Injury Evaluation System

With this in mind, we developed a systems approach to the ergonomics and injury evaluation. The
overall system is shown in Figure 15.1. It will be noted that the usually disparate functions of the
industrial and medical facilities now overlap, leading to vastly improved communications and efficiencies.
The system can be thought of as having both baselining, or pre-injury phases and post-injury components.
With the emphasis on evaluating and treating both the worker and workplace, the baselining or preinjury phase includes task analysis, task screening, and training, baseline testing of the worker, ergonomics
intervention/reengineering, while the post-injury phase includes testing of both the worker and workplace.
The system is operated by Interlogics, Hillsborough, NC.
Baselining or Pre-Injury Phase

Software has been developed to download information from the standard OSHA 2000 or other customized
databases in order to determine the incidence, nature, and severity of musculoskeletal-related injuries.
These data are transferred to a central processing facility to identify jobs, activities, or sub populations
with an increased injury risk (high-priority jobs). A typical data collection screen for a given injured
worker is shown in Figure 15.2.
Task Analysis
The system for ergonomics assessment and intervention includes task analysis. Once the high-priority
jobs have been identified, trained technicians travel to the workplace where they use novel portable
measurement devices for data collection. Data are initially collected at the workplace using a pentop
computer (Figure 15.3). The collection system is based on a time and motion analysis and identifies the
essential functions of the job and selects tasks and workplace hazards leading to a higher risk of injury.
This process also provides detailed job descriptions of the jobs analyzed. Specific job data include:
Posture data, including sustained postures, improper sitting positions, and documentation of the
orientation of the ankles, hips, lower back, shoulders, wrists, neck, and elbows
Lifting hazards data
15-5
FIGURE 15.1 Overview of the system used to evaluate, reduce, and manage job-related injuries.
FIGURE 15.2 Injury incidence and severity data collection screen.
Pushing/pulling hazards data

Repetition hazards data, including constant work cycles, lack of stretching, and heavy duty cycles
Fatigue hazards data, including abnormal speech patterns and worker behavior changes, such as
looking for resting places and rubbing body parts used in performing a task
Environmental hazards data, including flagging for hot or cold extremes, wetness, slippery
conditions, sharp edges, noise, and obstructions
15-6
FIGURE 15.3 Example screen used during the process of collecting job description and job hazard
information.
Tool/equipment hazards data
Desk job hazard data, including ergonomic risks for workstations, excessive reaching for tools
and/or equipment, VDT height and distance violations, excessive low or high positions of chairs,
and cluttering of desktop work spaces
Time-based summary data for the Dictionary of Occupational Titles (1987) jobs performed
Time-based summary data for lifting, carrying, placing, pushing/pulling, vibrations, precision
work, desk work, locomotion (walking), and rest
Correlation data of perceived pain vs. actual joint stresses observed, including Genaidy and
Karwowski (1993) Joint Stress Tables, Nordic Questionnaire (Dickenson et al., 1992), and extreme
posture flags
Following this the data are transmitted to the centralized facility where professional ergonomists will
make recommendations and generate reports focusing on potentially injurious task characteristics.
At this stage trained technicians would then be instructed to quantify the potentially hazardous
aspects of a given job. If the job is not repetitive or stereotyped, this may mean that measurements
should occur throughout the working day.
For example, InterLogics B-Tracker is used to measure the functional characteristics of low-back
movement. At the central processing facility, professional ergonomists analyze the data to precisely
define awkward and prolonged trunk postures and repetitive trunk movements. (An illustration of this
application of the B-Tracker in the workplace is shown in Figure 15.4.)
The report generated by the professional ergonomist with the help of the technicians would then
make recommendations for workplace modification to reduce ergonomic risk or to hasten return to
work for an injured worker.
Task Screening and Training

The same data transmitted to the central processing facility to define potentially injurious task
characteristics can also be used to generate a task-specific protocol to test job candidates. Candidates
15-7
FIGURE 15.4 Example of a proprietary measurement tool used to collect task specific functional information at the
worksite.
can be screened post-offer and pre-placement, using the task-specific protocol to determine whether
they can perform the extreme characteristics required of the task. This screening process, which is based
on the actual demands of a particular job, complies with the Americans with Disabilities Act of 1990.
A typical screening test, allowable under the ADA, would be to have the prospective worker lift a
load repetitively from the floor to a shelf across the room.
Task analysis information can also be used to create task-specific training programs. The actions of
the expert worker can often be used as a model for a videotape. Risks of injury can therefore be
reduced by ergonomic intervention and training program implementation, for example, by correcting
hazardous lifting techniques, encouraging other productive noninjurious workplace behaviors, and
teaching workers how to recognize and respond to potentially hazardous situations. To determine the
effectiveness of ergonomics intervention and training, workers are subsequently analyzed performing
their tasks.
Baseline Testing
Baseline testing of the worker, if economically feasible, can be a very useful tool for following a worker
if he or she subsequently becomes injured. However, typically once injury incidence and severity data
have been collected and analyzed, regardless of whether task-specific screening has occurred, testing can
be conducted to generate baseline data for the identified at risk population. For instance, low-back
baseline assessments are accomplished by using the B-Tracker, a portable stabilization system, and a
standardized protocol consisting of software directed movements in all cardinal planes, circumductions,
and stimulated sagittal plane lifts. (The testing set-up is shown in Figure 15.5.) These baseline data serve
as a record of the functional characteristics of the healthy workers low back. Each workers data are
subsequently compared to healthy and low-back problem population profiles, and a certainty of group
membership in either of those populations is assigned. Current work employs a neural network to refine
this population.
Baseline data are gathered in the event a worker later becomes injured. The comparison of baseline
and post-injury clinical data enables a determination of the precise nature and extent of changes in the
15-8
FIGURE 15.5 Testing set-up used for baselining healthy workers and for injury evaluations. (Photo by Dan Crawford
1996.)
workers functional status, which in turn leads to the assignment of an appropriate treatment path.
Baseline data also inform the clinician when a worker has recovered to his or her pre-injury functional
status.
Post-Injury Analysis
The Worker
After an injury, the workers functional status is assessed using the same protocols and devices used at
baseline. In the case of a low-back injury, for instance, additional information is also collected, including
a pain discomfort rating and a measure of nonorganic physical signs. This and the protocol data are
transmitted to the central processing facility for analysis and report generation. The report identifies the
functional status of the injured worker with respect to healthy and low-back problem populations, and
it assigns a degree of certainty for the injured workers membership in the low-back problem population.
Work is under way to develop an expert system using neural networks that can learn to improve and
refine its characterization. These data, especially the changes with time, will be helpful to the clinician in
optimizing return to work and early activation while avoiding chronicity.
Comparing a workers healthy baseline functional status with that derived from the clinical evaluation
shows the extent of loss of functional ability. Subsequent testing of the injured worker can be used to
track the recovery process.
Before release to return-to-work status, the injured worker can be screened for functional ability to
perform specific task characteristics of his or her job. This is accomplished by using the task-specific
screening protocol previously created from data collected at the work site. If the injured worker is found
to be functionally unable to perform the specific task characteristics, the analyzed data are used to
assign different job tasks suitable to the injured worker based on an analysis of the essential functions of
alternative jobs.
In an effort to return injured workers to the workplace as soon as possible, separate programs are
implemented for managing acute or chronic injuries. The acute low-back program is based on the clinical
15-9
practice guidelines for acute low-back problems in adults as described by the Agency for Health Care
Policy and Research (1994). The chronic low-back pain management program was created and validated
by the Iowa Spinal Research Center. An objective of the software-driven program for managing acutely
injured patients is to begin the appropriate treatment regimens as early as possible in an effort to prevent
any injuries from becoming chronic. The treatment costs are contained by selecting appropriate treatment
protocols, maintaining contact with the injured worker, accurately tracking recovery progress, and
objectively documenting the workers return to pre-injury status.
15.3 Case Study

In many cases it would be helpful to evaluate the workplace (see task analysis) to assess whether ergonomic
changes can be made to hasten return to work and prevent reinjury.
Injury Incidence/Severity Analysis

Bandy Boxing Groups OSHA Logs for the 6-month period Jan-Jun 1996 were input into the OCM
software. The resulting injury incidence and severity report shows the Stacker job has the highest incidence/
severity rate. (Table 15.1) The incidence rate was found to be 19%. This represents the number of
injuries per 100 full-time workers. The industry incidence rate for the same time period is 6%. The high
incidence rate at Bandy Boxing Group compared to the industry incidence rate indicates further
investigation is warranted.
Severity is the number of average lost workdays per total lost workday cases. On average injured
workers missed 5 days of work due to injury. Industry severity for the same time period is 5.4. In general
it is desirable to reduce the number of days of missed work, i.e., assign alternate duties to keep workers
at work.
Job Analysis
An ergonomist does an on-site analysis of the tasks associated with the Stacker job, using a pentop
computer running TCM software. The resulting Job Analysis report pinpoints for further analysis the
specific task that puts the Stacker at risk: the lifting task. The ergonomists analysis of the Stacker job
and related jobs at Bandy Boxing provides the data composing several job description reports (Tables
15.2AC).
Task Analysis
A videotaped performance of the Stackers lifting task generates a VideoWorks report, documenting the
tasks high lifting index. Simultaneous use of the B-Tracker provides data for the B-Tracker Job Analysis
report, which shows the Stacker repetitively using extreme flexion and extreme lateral bending postures
(Tables 15.2AE).
Recommendations
All reports are analyzed by the ergonomic experts at InterLogics Central Processing Facility, yielding an
Ergonomic Recommendations report with the following recommendations:
Engineering Re-design
Ergonomic Intervention
Education and Training
Screening
Baseline Testing
(See Table 15.4.)
15-10
TABLE 15.1
Baseline Testing
All stackers at Bandy Boxing are baseline tested to provide benchmark data about the current functional
status of their low backs. The resulting Baseline Testing reports indicate that all but one of the Stackers
achieved scores that place them in the healthy low-back population (Tables 15.5, 15.6AB, and 15.7AD).
Clinical Evaluation
An injury to the Stacker Bobby Carrera immediately initiates a B-Tracker clinical evaluation, precisely
the same protocol that was used during baseline testing. The Clinical Evaluation report score places
Bobby Carrera in the problem low-back population, and also provides information about the relative
extent of the injury. The attending physician prescribes a rehabilitation program and returns Bobby to
work with alternative work duties, assigned on the basis of the Job Description reports previously
compiled. Treatment and a subsequent Clinical Evaluation report show Bobby Carreras improved
functional status.
15-11
TABLE 15.2A
At this point the physician, in conjunction with InterLogics, has Bobby return to work at full capacity as
a Stacker. A later Baseline Testing report shows that Bobby Carrera is at or near pre-injury low-back
functional status (Table 15.8).
15.4 Conclusions
The cost and disability associated with LBP remain very high. The vast majority of studies show causality
between mechanical loading factors and LBP. It is evident that psychosocial factors have an important
role in the disability from LBP.
The ergonomics and injury evaluation system works well in practice and represents a novel,
comprehensive system for health care cost containment. This program links the industrial and clinical
15-12
TABLE 15.2B
arenas to promote an integrated injury prevention and injury management program which effectively
reduces injuries and more quickly returns injured workers to their jobs, all with the benefit of reduced
expense. Injury prevention proceeds by initially identifying the causes of industrys job-related injuries
and the at-risk worker populations; this then leads to baselining and screening procedures, to ergonomic
intervention, or to training programs. On the clinical side, injury management proceeds by use of the
information gathered at the workplace and by further evaluation with the same portable assessment
tools. By use of such functional capability information, the injured worker can be placed in the chronic
or acute treatment program, and his or her rehabilitation efficiently managed to expedite a speedy
return-to- workplacement in a functionally appropriate job.
15-13
TABLE 15.2C
The cost of injuries in the workplace will continue to be expensive, but the costs can be effectively
contained. Integrating injury prevention and injury management programs reduces health care costs by
reducing initial injuries, speeding recovery, and leveraging professional expertise via a central processing
facility.
Defining Terms
Accelerometer: Instrument that measures acceleration.
Biomechanics: The application of principles of mechanics to the human body.
15-14
TABLE 15.3A
Electromyograph: Recording of electrical output of the contraction of a muscle.

Erector spinae: Back muscles that extend the spine.
Ergonomics: Science that seeks to adapt working conditions to suit the worker.
Extensor: Any muscle that performs extension.
Flexor: Any muscle that flexes a joint.
Intervertebral: Situated between two adjacent vertebrae of the spine.
Isometric: A type of muscle contraction in which the length of the muscle remains constant.
Kinematics: Science of motion, including movements of body.
Nucleus pulposus: The central, more viscous portion of the intervertebral disc.
15-15
TABLE 15.3B
Static Dynamic Task: Characterized by both static and nonrepetitive low-back movements which show
no obvious repeated pattern.
Repetitive/Excursion Task: Characterized by cyclical movement pattern where no posture is held
continuously and the changes in trunk orientation are predictable.
Excursion: A continuous movement in a single direction with defined position end points (its length in
degrees defines a range of motion for one or more axial movements).
Oscillation Angle: The angle which describes the symmetry of the excursion with respect to the subjectss
neutral posture.
Repetitive/Excursion Parameters: Number of excursions, movement range (range of motion), velocity,
oscillation angle, successive excursions (repetitions).
15-16
TABLE 15.3C
Graphical Regions: Class 1: denotes normal velocities, oscillation angles, and ranges of motion for
which no ergonomic/safety action is required (within 31% of mean values for each direction for
each axis). Class 2: denotes velocities, oscillation angles, and ranges of motion for which postures
need consideration in the near future (between 31% and 62% of mean values for each direction for
each axis). Class 3: denotes velocities, oscillation angles, and ranges of motion for which postures
need consideration immediately and job-redesign may be required (beyond 62% of mean values for
each direction for each axis).
15-17
TABLE 15.3D
15-18
TABLE 15.3E
15-19
TABLE 15.4
15-20
TABLE 15.5
15-21
TABLE 15.6A
15-22
TABLE 15.6B
15-23
TABLE 15.7A
15-24
TABLE 15.7B
15-25
TABLE 15.7C
15-26
The B-Tracker BackAbility Baseline Protocol is used for testing subjects who have no low-back problem.
Specific directions are provided about placement of the B-Tracker and use of a stabilization platform. The
formalized protocol requires that the clinician demonstrate each baseline movement immediately preceding
its performance. The following three movements compose the protocol:
Flexibility
two repetitions of movements for each axis (flexion/extension, lateral bending, rotation). Subjects
are instructed to move as far as possible.
Free Dynamic Movement
seven repetitions of movements for each axis (flexion/extension, lateral bending, rotation). Subjects
are instructed to move as far as feels comfortable at their preferred pace.
Circumduction
four circumductions to the right, then four to the left. Subjects are instructed to move as far as is
comfortable at their preferred pace.
The Baseline Score

The purpose of the baseline score is to confirmby degrees of certainlythe subjects low-back health and
to establish for future reference a quantifiable benchmark. There are four levels to which individuals are
assigned on the basis of their B-Tracker baseline score:
Level I
Level II
Level III
Level IV
95100
7094
669
15
Use of the Baseline Report

In the event of injury, the subjects baseline data will serve as the goal to which recovery should be directed
in order to achieve pre-injury functional status and return-to-work readiness. Categorization by level also
enables recommendations which can assist individuals improve or maintain their low-back status. Of course,
the recommendations should be tailored towards the functional demands placed on an individuals low back
due to specific job requirements.
Level I
Level II
a special medical intervention is necessary to determine if a low-back problem exists

a low-back exercise program is strongly recommended
correct lifting techniques should be used; heavy Lifting and prolonged and/or awkward trunk
postures should be avoided
performance of job tasks and work environment may be evaluated for potential improvement
baseline testing should be repeated in 6 months
Level III
a low-back exercise program is recommended
correct lifting techniques should be used; heavy lifting and prolonged and/or awkward trunk
postures should be avoided
performance of job tasks and work environment may be evaluated for potential improvement
baseline testing should be repeated in 12 months
Level IV
current low-back exercise should be maintained
correct lifting techniques should be continued; avoidance of heavy lifting and prolonged and/or
awkward trunk postures should persist
TABLE 15.7D
15-27
The B-Tracker Low-Back Clinical protocol is used when the patient asserts he/she has a low-back problem.
The protocol comprises the following three parts:
Waddell Signs Test
VAS (Visual Analog Scale) Test
B-Tracker movement exercises.
The Waddell Signs Test is administered in accordance with procedures documented by Waddell, et at. in
Spine (5:2, 1980), Nonorganic Physical Signs in Low-Back Pain.
The VAS requires patients to rate their pain just prior to beginning the B-Tracker movement exercises. As
patients view a scale whose only markings are 0 and None at one end and 100 and Unbearable at the
other end, they are asked to respond to the following question: Mark on the scale from 0 to 100 your level of
pain discomfort, with 0 being None and 100 being Unbearable.
The B-Tracker movement exercises are performed in strict order with specific directions. Further assuring
consistent testing are specific directions about placement of the B-Tracker and use of a stabilization platform.
The protocol also requires that the clinician demonstrate each exercise immediately preceding its
performance. The following three exercises compose the protocols movement exercises:
Flexibility
two repetitions of movements for each axis (flexion/extension, lateral bending, rotation). Patients
are instructed to move as far as possible.
Free Dynamic Movement
seven repetitions of movements for each axis (flexion/extension, lateral bending, rotation. Patients
are instructed to move as far as feels comfortable at their preferred pace.
Circumduction
four circumductions to the right, then four to the left. Patients are instructed to move as far as is
comfortable at their preferred pace.
The Clinical Report Score

The purpose of the resulting B-Tracker score is to confirmby degrees of certaintythe patients assertion
that he/she is experiencing a low-back problem without a specific diagnosis. To this end, there is a range of
scores (6100) which confirms a patients low-back problem. A score falling in the range 05 suggests the
patients claim of a low-back problem should be further tested.
The Clinical Report score provides the means to make decisions regarding treatment paths. Consider
the following two scenarios: confirmation can be used to initiate a treatment path involving exercise and other
non-surgical procedures; or, confirmation can be used to initiate surgical intervention. In the first case, the
treatment is conservative and in the second, aggressive. When considering an aggressive treatment path,
greater certainty is desired.
An example may serve to illustrate: Consider a patient who obtains a score of 20. The score is sufficient
to initiate a treatment path involving rehabilitation/exercise. However, the score may not be sufficient as the
basis for consideration of surgical intervention due to the consequences associated with treatment if, in fact,
the individual was not a member of the low-back problem population.
Use of the Low-Back Clinical Report

The B-Tracker Low-Back Clinical Report, when compared to a patients earlier Low-Back Baseline Report,
objectively documents the precise extent of low-back functional loss. The B-Tracker Low-Back Clinical Report
further provides means to ensure a patient is directed to an appropriate patient management program.
Subsequent assessments with the Low-Back Clinical protocol objectively indicate the patients level of
functional improvement, when a patient has returned to his/her pre-injury functional status, and the patients
return-to-work readiness.
TABLE 15.8
15-28
References
Adams, M.A., Hutton, W.C. 1985. Gradual disc prolapse. Spine. 10:524531.
Andersson, G.B.J., Chaffin, D.B., Pope, M.H. 1991. Occupational biomechanics of the lumbar spine, in
Occupational Low Back Pain, Mosby-Year Book, Inc., St. Louis, MO.
Bigos, S.J., Batti, M.C., Spengler, D.M. et al. 1991. A prospective study of work perceptions and
psychosocial factors affecting the report of back injury. Spine. 16:16.
Dickenson, C.E. et al. 1992. Questionnaire development: an examination of the Nordic musculoskeletal
questionnaire. Applied Ergonomics. 23:197201.
Dictionary of Occupational Titles. 1977. U.S. Department of Labor Employment and Training
Administration, Washington, D.C.
Chaffin, D.B. 1974. Human strength capability and low-back pain. J. Occup. Med. 16(4).
Garg A., Moore, S.J. 1992. Epidemiology of low-back pain in industry, in Occupational Medicine, State
of the Art Reviews: Ergonomics: Low-back Pain, Carpal Tunnel Syndrome, and Upper Extremity
Disorders in the Workplace, Eds. J.Moore and A.Garg, p. 599608. Hanley & Belfus, Inc.,
Philadelphia, PA.
Genaidy, A.M., Karwowski, W. 1993. The effects of neutral posture deviations on perceived joint
discomfort ratings in sitting and standing postures. Ergonomics. 36:785792.
Hadler, N.M. 1994. Backache and work incapacity in Japan. J. Occup. Med. 36(10):11101114.
Helivaara, M., Knekt, P., Aromaa, A. 1987. Incidence and risk factors of herniated lumbar intervertebral
disc or sciatica leading to hospitalization. J. Chronic Dis. 40:251258.
Hulsof, C., Veldhuizen van Zantan, B. 1987. Whole-body vibration and low-back pain: A review of
epidemiologic studies. International Archives of Occupational and Environmental Health. 59:205
220.
ISO: Evaluation of human response to whole body vibration. Intl. Org. for Standardization Ref. No:
2631 (E), 1978.
Kelsey, J.L., Hochberg, M.C. 1988. Epidemiology of chronic musculoskeletal disorders. Ann. Rev. Public
Health. 9:379401.
Kelsey, J.L., Githens, P.B., White, A.A. III et al. 1984. An epidemiologic study of lifting and twisting on
the job and risk factors for acute prolapsed lumbar intervertebral disc. J. Orthop. Research. 2:61.
Kelsey, J.L., Hardy, R.J. 1975. Driving of motor vehicles as a risk factor for acute herniated lumbar
intervertebral disc. Am. J. Epidemiology. 102(1):6373.
Liles, D.H., Deivanayagam, S., Ayoub, M.M., Mahajan, P. 1984. A job severity index for the evaluation
and control of lifting injury. Human Factors. 26:683694.
Magnusson, M.L., Pope, M.H., Wilder, D.G., Areskoug, B. 1996. Are occupational drivers at an increased
risk for developing musculo-skeletal disorders? Spine. 21(6):710717.
Nachemson, A.L. 1991. Spinal disorders: overall impact in society and the need for orthopaedic resources.
Acta Orthop. Scand. Suppl. 241:1722.
Pope, M.H., Frymoyer, J.W., Andersson, G.B.J., Chaffin, D. 1991. Occupational Low Back Pain:
Assessment, Treatment and Prevention, 2nd ed. Mosby Press, St. Louis, MO.
Pope, M.H., Andersson, G.B.J., Broman, H., Svensson, M., Zetterberg, C. 1986. Electromyographic
studies of the lumbar trunk musculature during the development of axial torques. J. Ortho. Res.
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Pope, M.H., Wilder, D.G., Jorneus, L., Broman, H., Svensson, M., Andersson, G.B.J. 1987. The response
of the seated human to sinusoidal vibration and impact. J. Biomech. Eng. 109:279284.
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Contact Interlogics, 328 Elizabeth Brady Rd., Hillsborough, NC 27278.
16
Revised NIOSH Lifting
Equation
16.1
16.2
16.3
16.4
Thomas R.Waters
Occupational
Safety and Health
16.5
Vern Putz-Anderson
16.6

Occupational
Safety and Health
Introduction
Definition of Terms
Recommended Weight Limit (RWL Measurement
Requirements Lifting Index (LI) Miscellaneous Terms
Limitations of Equation
Obtaining and Using the Data
Horizontal Component Vertical Component Distance
Component Asymmetry Component Frequency
Component Coupling Component
Procedures
Step 1: Collect Data Step 2: Single-Task Procedure
Step 2: Multitask Procedure
Applying the Equations
Using the RWL and LI to Guide Ergonomic
Design Rationale and Limitations for LI Job-Related
Intervention Strategy Example Problems
161
162
166
166
1613
1619
16.1 Introduction
This chapter provides information about a revised equation for assessing the physical demands of certain
two-handed manual lifting tasks that was developed by the National Institute for Occupational Safety
and Health (NIOSH) and described earlier in an article by Waters et al.1 We discuss what factors need to
be measured, how they should be measured, what procedures should be used, and how the results can
be used to ergonomically design new jobs or make decisions about redesigning existing jobs that may be
hazardous. We define all pertinent terms and present the mathematical formulas and procedures needed
to properly apply the NIOSH lifting equation. Several example problems are also provided to demonstrate
how the equations should be used. An expanded version of this chapter is contained in a NIOSH
document.2
Historically, NIOSH has recognized the problem of work-related back injuries and published the
Work Practices Guide for Manual Lifting (WPG) in 1981.3 The WPG contained a summary of the
lifting-related literature up to 1981; analytical procedures and a lifting equation for calculating a
recommended weight for specified two-handed, symmetrical lifting tasks; and an approach for controlling
the hazards of low back injury from manual lifting. The approach to hazard control was coupled to the
action limit (AL), a term that denoted the recommended weight derived from the lifting equation.
0-8493-1800-9/03/$0.00+$1.50
16-1
16-2
In 1985, NIOSH convened an ad hoc committee of experts who reviewed the current literature on
lifting, including the NIOSH WPG.* The literature review was summarized in a document containing
updated information on the physiological, biomechanical, psychophysical, and epidemiological aspects
of manual lifting.4 Based on the results of the literature review, the ad hoc committee recommended
criteria for defining the lifting capacity of healthy workers. The committee used the criteria to formulate
the revised lifting equation.** Subsequently, NIOSH staff developed the documentation for the equation
and played a prominent role in recommending methods for interpreting the results of the lifting equation.
The revised lifting equation reflects new findings and provides methods for evaluating asymmetrical
lifting tasks, and lifts of objects with less than optimal couplings between the object and the workers
hands. The revised lifting equation also provides guidelines for a more diverse range of lifting tasks than
the earlier equation.3
The rationale and criterion for the development of the revised NIOSH lifting equation are provided
in a journal article by Waters et al.1 We suggest that those users who wish to achieve a better understanding
of the data and decisions that were made in formulating the revised equation consult that article. It
provides an explanation of the selection of the biomechanical, physiological, and psychophysical criterion
as well as a description of the derivation of the individual components of the revised lifting equation.
For those individuals, however, who are primarily concerned with the use and application of the revised
lifting equation, this chapter provides a more complete description of the method and limitations.
Although the revised lifting equation has not been fully validated, the recommended weight limits
derived from the revised equation are consistent with, or lower than, those generally reported in the
literature. Moreover, the proper application of the revised equation is more likely to protect healthy
workers for a wider variety of lifting tasks than methods that rely only on a single task factor or single
criterion.
Finally, it should be stressed that the NIOSH lifting equation is only one tool in a comprehensive
effort to prevent work-related low back pain and disability. Some examples of other approaches are
described elsewhere.5 Moreover, lifting is only one of the causes of work-related low back pain and
disability. Other causes that have been hypothesized or established as risk factors include whole body
vibration, static postures, prolonged sitting, and direct trauma to the back. Psychosocial factors,
appropriate medical treatment, and job demands may also be particularly important in influencing the
transition of acute low back pain to chronic disabling pain.
16.2 Definition of Terms

This section provides the basic technical information needed to properly use the revised lifting equation
to evaluate a variety of two-handed manual lifting tasks. Definitions and data requirements for the
revised lifting equation are also provided.
Recommended Weight Limit (RWL)

The recommended weight limit (RWL) is the principal product of the revised NIOSH lifting equation.
The RWL is defined for a specific set of task conditions as the weight of the load that nearly all healthy
workers could perform over a substantial period of time (e.g., up to 8 h) without an increased risk of
developing lifting-related low back pain (LBP). By healthy workers we mean workers who are free of
adverse health conditions that would increase their risk of musculoskeletal injury.
*
The ad hoc 1991 NIOSH Lifting Committee members included: M.M.Ayoub, Donald B.Chaffin, Colin G.Drury,
Arun Garg, and Suzanne Rodgers. NIOSH representatives included Vern Putz-Anderson and Thomas R.Waters.
**
For this document, the revised 1991 NIOSH lifting equation will be identified simply as the revised lifting
equation.1,2 The abbreviation WPG will continue tobe used as the reference to the earlier NIOSH lifting equation,
which was documented in a publication entitled Work Practices Guide for Manual Lifting.3
16-3
The concept behind the revised NIOSH lifting equation is to start with a recommended weight that
is considered safe for an ideal lift (i.e., load constant equal to 51 lb) and then reduce the weight as the
task becomes more stressful (i.e., as the task-related factors become less favorable). The precise formulation
of the revised lifting equation for calculating the RWL is based on a multiplicative model that provides
a weighting (multiplier) for each of six task variables:
1. Horizontal distance of the load from the worker (H)
2. Vertical height of the lift (V)
3. Vertical displacement during the lift (D)
4. Angle of asymmetry (A)
5. Frequency (F) and duration of lifting
6. Quality of the hand-to-object coupling (C)
The weightings are expressed as coefficients that serve to decrease the load constant, which represents
the maximum recommended load weight to be lifted under ideal conditions. For example, as the horizontal
distance between the load and the worker increases from 10 in, the recommended weight limit for that
task would be reduced from the ideal starting weight.
The recommended weight limit (RWL) is defined as
RWL=LCHMVMDMAMFMCM
where
METRIC
U.S. CUSTOMARY
LC =
HM =
VM =
Load Constant
Horizontal Multiplier
Vertical Multiplier
=
=
=
23 kg
(25/H)
1-(.003V-75)
51 lb
(10/H)
1-(.0075V-30)
DM
AM
FM
CM
Distance Multiplier
Asymmetric Multiplier
Frequency Multiplier
Coupling Multiplier
=
=
=
=
.82+(4.5/D)
1-(.0032A)
From Table 16.5
From Table 16.7
.82+(1.8/D)
1-(.0032A)
From Table 16.5
From Table 16.7
=
=
=
=
The term task variables refers to the measurable task-related measurements that are used as input data
for the formula (i.e., H, V, D, A, F, and C); whereas, the term multipliers refers to the reduction coefficients
in the equation (i.e., HM, VM, DM, AM, FM, and CM).
Measurement Requirements
The following list briefly describes the measurements required to use the revised NIOSH lifting equation.
Details for each of the variables are presented later in this chapter.
H = horizontal location of hands from midpoint between the inner ankle bones. Measure at the origin
and the destination of the lift (cm or in).
V = vertical location of the hands from the floor. Measure at the origin and destination of the lift (cm or
in).
D = vertical travel distance between the origin and the destination of the lift (cm or in).
A = angle of asymmetry or angular displacement of the load from the workers sagittal plane. Measure
at the origin and destination of the lift (degrees).
F = average frequency rate of lifting measured in lifts/min. Duration is defined to be = 1 h; = 2 h; or =
8 h assuming appropriate recovery allowances (see Table 16.5).
C = quality of hand-to-object coupling (quality of interface between the worker and the load being
lifted). The quality of the coupling is categorized as good, fair, or poor, depending upon the type
and location of the coupling, the physical characteristics of load, and the vertical height of the lift.
16-4
FIGURE 16.1 Graphic representation of hand location.
Lifting Index (LI)

The lifting index (LI) is a term that provides a relative estimate of the level of physical stress associated
with a particular manual lifting task. The estimate of the level of physical stress is defined by the
relationship between the weight of the load lifted and the recommended weight limit. The LI is defined
by the equation
where Load Weight (L) = weight of the object lifted (lbs or kg).
Miscellaneous Terms
Lifting task The act of manually grasping an object of definable size and mass with two hands, and
vertically moving the object without mechanical assistance.
Load weight (L) Weight of the object to be lifted, in pounds or kilograms, including the container.
Horizontal location (H) Distance of the hands away from the midpoint between the ankles, in inches or
centimeters (measure at the origin and destination of lift). See Figure 16.1.
Vertical location (V) Distance of the hands above the floor, in inches or centimeters (measure at the
origin and destination of lift). See Figure 16.1.
16-5
FIGURE 16.2 Graphic representation of angle of asymmetry (A).
Vertical travel distance (D) Absolute value of the difference between the vertical heights at the destination
and origin of the lift, in inches or centimeters.
Angle of asymmetry (A) Angular measure of how far the object is displaced from the front (midsagittal
plane) of the workers body at the beginning or end of the lift, in degrees (measure at the origin and
destination of lift). See Figure 16.2. The asymmetry angle is defined by the location of the load
relative to the workers midsagittal plane, as defined by the neutral body posture, rather than the
position of the feet or the extent of body twist.
Neutral body position Position of the body when the hands are directly in front of the body and there is
minimal twisting at the legs, torso, or shoulders.
Frequency of lifting (F) Average number of lifts per minute over a 15-minute period.
Duration of lifting Three-tiered classification of lifting duration specified by the distribution of worktime and recovery-time (work pattern). Duration is classified as either short (1 h), moderate (1 to 2
h), or long (2 to 8 h), depending on the work pattern.
Coupling classification Classification of the quality of the hand-to-object coupling (e.g., handle, cutout, or grip). Coupling quality is classified as good, fair, or poor.
Significant control A condition requiring precision placement of the load at the destination of the lift.
This is usually the case when (1) the worker has to regrasp the load near the destination of the lift,
or (2) the worker has to momentarily hold the object at the destination, or (3) the worker has to
carefully position or guide the load at the destination.
16-6
16.3 Limitations of Equation

The lifting equation is a tool for assessing the physical stress of two-handed manual lifting tasks. As
with any tool, its application is limited to those conditions for which it was designed. Specifically, the
lifting equation was designed to meet specific lifting-related criteria that encompass biomechanical,
physiological, and psychophysical assumptions and data used to develop the equation. To the extent
that a given lifting task accurately reflects these underlying conditions and criteria, this lifting equation
may be appropriately applied.
The following list identifies a set of work conditions in which the application of the lifting equation
could either under- or overestimate the extent of physical stress associated with a particular workrelated activity. Each of the following task limitations also highlights research topics in need of further
research to extend the application of the lifting equation to a greater range of real-world lifting tasks.
The revised NIOSH Lifting Equation does not apply if any of the following occur:
Lifting/lowering with one hand
Lifting/lowering for over 8 hours
Lifting/lowering while seated or kneeling
Lifting/lowering in a restricted work space
Lifting/lowering unstable objects
Lifting/lowering while carrying, pushing, or pulling
Lifting/lowering with wheelbarrows or shovels
Lifting/lowering with high speed motion (faster than about 30 in./second)
Lifting/lowering with unreasonable foot/floor coupling (<0.4 coefficient of friction between the sole
and the floor)
Lifting/lowering in an unfavorable environment (temperature significantly outside 66 to 79F [19 to
26C] range; relative humidity outside 35 to 50% range)
16.4 Obtaining and Using the Data

Horizontal Component
Definition and Measurement
Horizontal location (H) is measured from the midpoint of the line joining the inner ankle bones to a
point projected on the floor directly below the midpoint of the hand grasps (i.e., load center), as defined
by the large middle knuckle of the hand (Figure 16.1). Typically, the workers feet are not aligned with
the midsagittal plane, as shown in Figure 16.1, but may be rotated inward or outward. If this is the case,
then the midsagittal plane is defined by the workers neutral body posture as defined above. If significant
control is required at the destination (i.e., precision placement), then H should be measured at both the
origin and destination of the lift.
Horizontal distance (H) should be measured. In those situations where the H value cannot be measured,
then H may be approximated from the following equations:
Metric
(All distances in cm)
U.S. Customary
(All distances in inches)
H = 20 + W/2
for V 25 cm
H = 8 + W/2
for V 10 in.
H = 25 + W/2
for V < 25 cm
H = 10 + W/2
for V < 10 in.
where W is the width of the container in the sagittal plane and V is the vertical location of the handsfrom
the floor.
16-7
TABLE 16.1 Horizontal Multiplier

H
in
Hm
cm
Hm
=10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
>25
1.00
.91
.83
.77
.71
.67
.63
.59
.56
.53
.50
.48
.46
.44
.42
.40
.00
=25
28
30
32
34
36
38
40
42
44
46
48
50
52
54
56
58
60
63
>63
1.00
.89
.83
.78
.74
.69
.66
.63
.60
.57
.54
.52
.50
.48
.46
.45
.43
.42
.40
.00
Horizontal Restrictions
If the horizontal distance is less than 10 in. (25 cm), then H is set to 10 in. (25 cm). Although objects can
be carried or held closer than 10 in. from the ankles, most objects that are closer than this cannot be
lifted without encountering interference from the abdomen or hyperextending the shoulders. Although
25 in. (63 cm) was chosen as the maximum value for H, it is probably too great a distance for shorter
workers, particularly when lifting asymmetrically. Furthermore, objects at a distance of more than 25
in. from the ankles normally cannot be lifted vertically without some loss of balance.
Horizontal Multiplier
The horizontal multiplier (HM) is 10/H for H measured in inches and 25/H for H measured in centimeters.
If H is less than or equal to 10 in. (25 cm), the multiplier is 1.0. HM decreases with an increase in H
value. The multiplier for H is reduced to 0.4 when H is 25 in. (63 cm). If H is greater than 25 in., then
HM=0. The HM value can be computed directly or determined from Table 16.1.
Vertical Component
Vertical location (V) is defined as the vertical height of the hands above the floor. V is measured vertically
from the floor to the midpoint between the hand grasps, as defined by the large middle knuckle. The
coordinate system is illustrated in Figure 16.1.
Vertical Restrictions
The vertical location (V) is limited by the floor surface and the upper limit of vertical reach for lifting
(i.e., 70 in. or 175 cm). The vertical location should be measured at the origin and the destination of the
lift.
Vertical Multiplier
To determine the vertical multiplier (VM), the absolute value or deviation of V from an optimum height
of 30 in. (75 cm) is calculated. A height of 30 in. above floor level is considered knuckle height for a
16-8
TABLE 16.2 Vertical Multiplier

V
in
VM
cm
VM
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
>70
.78
.81
.85
.89
.93
.96
1.00
.96
.93
.89
.85
.81
.78
.74
.70
.00
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
175
>175
.78
.81
.84
.87
.90
.93
.96
.99
.99
.96
.93
.90
.87
.84
.81
.78
.75
.75
.70
.00
worker of average height (66 in. or 165 cm). The vertical multiplier (VM) is (1-(.0075V-30)) for V
measured in inches, and VM is (1-(.003V-75)), for V measured in centimeters.
When V is at 30 in. (75 cm), the vertical multiplier (VM) is 1.0. The value of VM decreases linearly
with an increase or decrease in height from this position. At floor level, VM = 0.78, and at 70 in. (175
cm) height, VM = 0.7. If V is greater than 70 in., then VM = 0. The VM value can be computed directly
or determined from Table 16.2.
Distance Component
The distance variable (D) is defined as the vertical travel distance of the hands between the origin and
destination of the lift. For lifting, D can be computed by subtracting the vertical location (V) at the
origin of the lift from the corresponding V at the destination of the lift (i.e., D is equal to V at the
destination minus V at the origin). For a lowering task, D is equal to V at the origin minus V at the
destination.
Distance Restrictions
The distance variable (D) is assumed to be at least 10 in. (25 cm), and no greater than 70 in. (175 cm).
If the vertical travel distance is less than 10 in. (25 cm), then D should be set to the minimum distance of
10 in. (25 cm).
Distance Multiplier
The distance multiplier (DM) is (.82 + (1.8/D)) for D measured in inches and (.82 + (4.5/D)) for D
measured in centimeters. For D less than 10 in. (25 cm) D is assumed to be 10 in. (25 cm), and DM is
1.0. The distance multiplier, therefore, decreases gradually with an increase in travel distance. The DM
= 1.0 when D is set at 10 in., (25 cm); DM = 0.85 when D is 70 in. (175 cm). Thus, DM ranges from 1.0
to 0.85 as the D varies from 0 in. (0 cm) to 70 in. (175 cm). The DM value can be computed directly or
determined from Table 16.3.
16-9
TABLE 16.3 Distance Multiplier
D
=10
DM
cm
DM
=10
15
20
25
30
35
40
45
50
55
60
70
>70
1.00
.94
.91
.89
.88
.87
.87
.86
.86
.85
.85
.85
.00
=25
40
55
70
85
100
115
130
145
160
175
>175
1.00
.93
.90
.88
.87
.87
.86
.86
.85
.85
.85
.00
Asymmetry Component
Asymmetry refers to a lift that begins or ends outside the midsagittal plane (See Figure 16.2). In general,
asymmetric lifting should be avoided. If asymmetric lifting cannot be avoided, however, the recommended
weight limits are significantly less than those used for symmetrical lifting.*
An asymmetric lift may be required under the following task or workplace conditions:
1. The origin and destination of the lift are oriented at an angle to each other.
2. The lifting motion is across the body, such as occurs in swinging bags or boxes from one location to
another.
3. The lifting is done to maintain body balance in obstructed workplaces, on rough terrain, or on
littered floors.
4. Productivity standards require reduced time per lift.
The asymmetric angle (A), which is depicted graphically in Figure 16.2, is operationally defined as the
angle between the asymmetry line and the midsagittal line. The asymmetry line is defined as the line that
joins the midpoint between the inner ankle bones and the point projected on the floor directly below the
midpoint of the hand grasps, as defined by the large middle knuckle. The sagittal line is defined as the
line passing through the midpoint between the inner ankle bones and lying in the midsagittal plane, as
defined by the neutral body position (i.e., hands directly in front of the body, with no twisting at the
legs, torso, or shoulders). Note: The asymmetry angle is not defined by foot position or the angle of
torso twist, but by the location of the load relative to the workers midsagittal plane.
In many cases of asymmetric lifting, the worker will pivot or use a step turn to complete the lift.
Because this may vary significantly between workers and between lifts, we have assumed that no pivoting
or stepping occurs. Although this assumption may overestimate the reduction in acceptable load weight,
it will provide the greatest protection for the worker.
*
It may not always be clear if asymmetry is an intrinsic element of the task or just a personal characteristic of the
workers lifting style. Regardless of the reason for the asymmetry, any observed asymmetric lifting should be considered
an intrinsic element of the job design and should be considered in the assessment and subsequent redesign. Moreover,
the design of the task should not rely on worker compliance, but rather the design should discourage or eliminate the
need for asymmetric lifting.
16-10

TABLE 16.4 Asymmetric Multiplier
A
deg
0
15
30
45
60
75
90
105
120
135
>135
AM
1.00
.95
.90
.86
.81
.76
.71
.66
.62
.57
.00
The asymmetry angle (A) must always be measured at the origin of the lift. If significant control is
required at the destination, however, then angle A should be measured at both the origin and the
destination of the lift.
Asymmetry Restrictions
The angle A is limited to the range from 0 to 135. If A > 135, then AM is set equal to zero, which
results in an RWL of zero, or no load.
Asymmetric Multiplier
The asymmetric multiplier (AM) is 1-(.0032A). AM has a maximum value of 1.0 when the load is lifted
directly in front of the body and decreases linearly as the angle of asymmetry (A) increases. The range is
from a value of 0.57 at 135 of asymmetry to a value of 1.0 at 0 of asymmetry (i.e., symmetric lift). If
A is greater than 135, then AM = 0, and the RWL = 0.0. The AM value can be computed directly or
Frequency Component
The frequency multiplier is defined by (1) the number of lifts per minute (frequency), (2) the amount of
time engaged in the lifting activity (duration), and (3) the vertical height of the lift from the floor. Lifting
frequency (F) refers to the average number of lifts made per minute, as measured over a 15-minute
period. Because of the potential variation in work patterns, analysts may have difficulty obtaining an
accurate or representative 15-minute work sample for computing F. If significant variation exists in the
frequency of lifting over the course of the day, analysts should employ standard work sampling techniques
to obtain a representative work sample for determining the number of lifts per minute. For those jobs
where the frequency varies from session to session, each session should be analyzed separately, but the
overall work pattern must still be considered. For more information, most standard industrial engineering
or ergonomics texts provide guidance for establishing a representative job sampling strategy (e.g., Eastman
Kodak Company).6
Lifting Duration
Lifting duration is classified into three categories based on the pattern of continuous work time and
recovery time (i.e., light work) periods. A continuous work time (WT) period is defined as a period of
uninterrupted work. Recovery time (RT) is defined as the duration of light work activity following a
period of continuous lifting. Examples of light work include activities such as sitting at a desk or table,
monitoring operations, light assembly work, etc. The three categories are short duration, moderate
duration, and long duration.
16-11
TABLE 16.5 Frequency Multiplier (FM)
Values of V are in inches.
For lifting less frequently than once per 5 minutes, set F = .2 lifts/minute.
Short Duration. Short duration lifting tasks are those that have a work duration of 1 h or less, followed
by a recovery time equal to 1.2 times the work time (i.e., at least a 1.2 recovery-time to work-time ratio
[RT/WT]). For example, to be classified as short-duration, a 45-minute lifting job must be followed by
at least a 54-minute recovery period prior to initiating a subsequent lifting session. If the required
recovery time is not met for a job of one hour or less, and a subsequent lifting session is required, then
the total lifting time must be combined to correctly determine the duration category. Moreover, if the
recovery period does not meet the time requirement, it is disregarded for purposes of determining the
appropriate duration category.
As another example, assume a worker lifts continuously for 30 min, then performs a light work task
for 10 min, and then lifts for an additional 45-minute period. In this case, the recovery time between
lifting sessions (10 min) is less than 1.2 times the initial 30-minute work time (36 min). Thus, the two
work times (30 min and 45 min) must be added together to determine the duration. Since the total work
time (75 min) exceeds 1 hour, the job is classified as moderate duration. On the other hand, if the
recovery period between lifting sessions was increased to 36 min, then the short duration category
would apply, which would result in a larger FM value.
A special procedure has been developed for determining the appropriate lifting frequency (F) for
certain repetitive lifting tasks in which workers do not lift continuously during the 15-minute sampling
period. This occurs when the work pattern is such that the worker lifts repetitively for a short time and
then performs light work for a short time before starting another cycle. For work patterns such as this,
F may be determined as follows, as long as the actual lifting frequency does not exceed 15 lifts/min:
1. Compute the total number of lifts performed for the 15-minute period (i.e., lift rate times work
time).
2. Divide the total number of lifts by 15.
3. Use the resulting value as the frequency (F) to determine the frequency multiplier (FM) from
Table 16.5.
For example, if the work pattern for a job consists of a series of cyclic sessions requiring 8 min of lifting
followed by 7 min of light work, and the lifting rate during the work sessions is 10 lifts/min, then the
16-12
frequency rate (F) that is used to determine the frequency multiplier for this job is equal to (10 8)/15
or 5.33 lifts/min. If the worker lifted continuously for more than 15 min, however, then the actual lifting
frequency (10 lifts/min) would be used.
When using this special procedure, the duration category is based on the magnitude of the recovery
periods between work sessions, not within work sessions. In other words, if the work pattern is intermittent
and the special procedure applies, then the intermittent recovery periods that occur during the 15-minute
sampling period are not considered as recovery periods for purposes of determining the duration category.
For example, if the work pattern for a manual lifting job was composed of repetitive cycles consisting of 1
min of continuous lifting at a rate of 10 lifts/min, followed by 2 minutes of recovery, the correct procedure
would be to adjust the frequency according to the special procedure [i.e., F = (10 lifts/min 5 min)/15 min
= 50/15 = 3.4 lifts/min]. The 2-minute recovery periods would not count toward the RT/WT ratio, however,
and additional recovery periods would have to be provided as described above.
Moderate Duration. Moderate duration lifting tasks are those that have a duration of more than 1 h
but not more than 2 h, followed by a recovery period of at least 0.3 times the work time [i.e., at least a
0.3 recovery time to work time ratio (RT/WT)].
For example, a worker who continuously lifts for 2 h would need at least a 36-minute recovery
period before initiating a subsequent lifting session. If the recovery time requirement is not met, and a
subsequent lifting session is required, then the total work time must be added together. If the total work
time exceeds 2 h, then the job must be classified as a long duration lifting task.
Long Duration. Long duration lifting tasks are those that have a duration of between 2 and 8 h, with
standard industrial rest allowances (e.g., morning, lunch, and afternoon rest breaks). Note: No weight
limits are provided for more than 8 h of work.
The difference in the required RT/WT ratio for the short (<1 hour) duration category, which is 1.2,
and the moderate (1 to 2 h) duration category, which is 0.3, is due to the difference in the magnitudes of
the frequency multiplier values associated with each of the duration categories. Since the moderate
category results in larger reductions in the RWL than the short category, there is less need for a recovery
period between sessions than for the short duration category. In other words, the short duration category
would result in higher weight limits than the moderate duration category, so larger recovery periods
would be needed.
Frequency Restrictions
Lifting frequency (F) for repetitive lifting may range from 0.2 lifts/min to a maximum frequency that is
dependent on the vertical location of the object (V) and the duration of lifting (Table 16.5). Lifting
above the maximum frequency results in an RWL of 0.0 (except for the special case of discontinuous
lifting discussed above, where the maximum frequency is 15 lifts/min).
Frequency Multiplier
The FM value depends upon the average number of lifts/min (F), the vertical location (V) of the hands
at the origin, and the duration of continuous lifting. For lifting tasks with a frequency less than 0.2 lifts/
min, set the frequency equal to 0.2 lifts/minute. Otherwise, the FM is determined from Table 16.5.
Coupling Component
The nature of the hand-to-object coupling or gripping method can affect not only the maximum force a
worker can or must exert on the object, but also the vertical location of the hands during the lift. A
good coupling will reduce the maximum grasp forces required and increase the acceptable weight for
lifting, while a poor coupling will generally require higher maximum grasp forces and decrease the
acceptable weight for lifting.
The effectiveness of the coupling is not static, but may vary with the distance of the object from the
ground, so that a good coupling could become a poor coupling during a single lift. The entire range of
16-13
TABLE 16.6 Hand-to-Container Coupling Classification
1.
2.
3.
4.
5.
6.
An optimal handle design has .75 to 1.5 inches (1.9 to 3.8 cm) diameter, =4.5 inches (11.5 cm) length, 2 inches
(5 cm) clearance, cylindrical shape, and a smooth, nonslip surface.
An optimal hand-hold cut-out has the following approximate characteristics: =1.5 inch (3.8 cm) height, 4.5 inch
(11.5 cm) length, semi-oval shape, =2 inch (5 cm) clearance, smooth nonslip surface, and = 0.25 inches (0.60
cm) container thickness (e.g., double thickness cardboard).
An optimal container design has =16 inches (40 cm) frontal length, =12 inches (30 cm) height, and a smooth
nonslip surface.
A worker should be capable of clamping the fingers at nearly 90 under the container, such as required when
lifting a cardboard box from the floor.
A container is considered less than optimal if it has a frontal length >16 inches (40 cm), height >12 inches (30 cm),
rough or slippery surfaces, sharp edges, asymmetric center of mass, unstable contents, or requires the use of gloves.
A worker should be able to comfortably wrap the hand around the object without causing excessive wrist
deviations or awkward postures, and the grip should not require excessive force.
the lift should be considered when classifying hand-to-object couplings, with classification based on
overall effectiveness. The analyst must classify the coupling as good, fair, or poor. The three categories
are defined in Table 16.6. If there is any doubt about classifying a particular coupling design, the more
stressful classification should be selected.
The decision tree shown in Figure 16.3 may be helpful in classifying the hand-to-object coupling.
Limitations
There are no limitations for classifying the coupling, but both hands must be observed when assessing
the coupling. If one hand is predominately used to lift the load, and the fingers are flexed at 90 under
the load, then the coupling should be rated as fair, regardless of the position of the other hand.
Coupling Multiplier
Based on the coupling classification and vertical location of the lift, the Coupling Multiplier (CM) is
16.5 Procedures
Prior to data collection, the analyst must decide (1) if the job should be analyzed as a single-task or
multitask manual lifting job, and (2) if significant control is required at the destination of the lift. This
is necessary because the procedures differ according to the type of analysis required.
A manual lifting job may be analyzed as a single-task job if the task variables do not differ from task
to task, or if only one task is of interest (e.g., single most stressful task). This may be the case if one of the
tasks clearly has a dominant effect on strength demands, localized muscle fatigue, or whole-body fatigue.
16-14
FIGURE 16.3 Decision tree for coupling quality.
TABLE 16.7 Coupling Multiplier
On the other hand, if the task variables differ significantly between tasks, it may be more appropriate to
analyze a job as a multitask manual lifting job. A multitask analysis is more difficult to perform than a
single-task analysis because additional data and computations are required. The multitask approach,
however, will provide more detailed information about specific strength and physiological demands.
For many lifting jobs, it may be acceptable to use either the single- or multitask approach. The singletask analysis should be used when possible, but when a job consists of more than one task and detailed
information is needed to specify engineering modifications, then the multitask approach provides a
reasonable method of assessing the overall physical demands. The multitask procedure is more complicated
than the single-task procedure, and requires a greater understanding of assessment terminology and
mathematical concepts. Therefore, the decision to use the single- or multitask approach should be based
on: (1) the need for detailed information about all facets of the multitask lifting job, (2) the need for
accuracy and completeness of data regarding assessment of the physiological demands of the task, and
(3) the analysts level of understanding of the assessment procedures.
The decision about control at the destination is important because the physical demands on the
worker may be greater at the destination of the lift than at the origin, especially when significant control
is required. When significant control is required at the destination, for example, the physical stress is
increased because the load will have to be accelerated upward to slow down its descent. This acceleration
16-15
FIGURE 16.4 Single task job analysis worksheet.
may be as great as the acceleration at the origin of the lift and may create high loads on the spine.
Therefore, if significant control is required, then the RWL and LI should be determined at both locations
and the lower of the two values will specify the overall level of physical demand.
To perform a lifting analysis using the revised lifting equation, two steps are undertaken: (1) data are
collected at the worksite as described in step 1 below; and, (2) the recommended weight limit and lifting
index values are computed using the single-task or multitask analysis procedure described in step 2 below.
Step 1: Collect Data

The relevant task variables must be carefully measured and clearly recorded in a concise format. As
mentioned previously, these variables include the horizontal location of the hands (H), vertical location
of the hands (V), vertical displacement (D), asymmetric angle (A), lifting frequency (F), and coupling
quality (C). A job analysis worksheet, as shown in Figure 16.4 for single-task jobs or Figure 16.5 for
multitask jobs, provides a simple form for recording the task variables and the data needed to calculate
the RWL and the LI values. A thorough job analysis is required to identify and catalog each independent
lifting task in the workers complete job. For multitask jobs, data must be collected for each task.
Step 2: Single-Task Procedure

For a single-task analysis, step 2 consists of computing the recommended weight limit (RWL) and the
lifting index (LI). This is accomplished as follows.
Calculate the RWL at the origin for each lift. For lifting tasks that require significant control at the
destination, calculate the RWL at both the origin and the destination of the lift. The latter procedure is
required if (1) the worker has to regrasp the load near the destination of the lift, (2) the worker has to
momentarily hold the object at the destination, or (3) the worker has to position or guide the load at the
FIGURE 16.5 Multitask job analysis worksheet.
16-16
16-17
destination. The purpose of calculating the RWL at both the origin and destination of the lift is to
identify the most stressful location of the lift. Therefore, the lower of the RWL values at the origin or
destination should be used to compute the LI for the task, as this value would represent the limiting set
of conditions.
The assessment is completed on the single-task worksheet by determining the LI for the task of
interest. This is accomplished by comparing the actual weight of the load (L) lifted with the RWL value
obtained from the lifting equation.
Step 2: Multitask Procedure

For a multitask analysis, step 2 comprises three steps:
1. Compute the frequency-independent recommended weight limit (FIRWL) and single-task
recommended weight limit (STRWL) for each task.
2. Compute the frequency-independent lifting index (FILI) and single-task lifting index (STLI) for
each task.
3. Compute the composite lifting index (CLI) for the overall job.
Compute the Frequency-Independent Recommended Weight Limits (FIRWLs). Compute the FIRWL
value for each task by using the respective task variables and setting the frequency multiplier (FM) to a
value of 1.0. The FIRWL for each task reflects the compressive force and muscle strength demands for
a single repetition of that task. If significant control is required at the destination for any individual task,
the FIRWL must be computed at both the origin and the destination of the lift, as described above for a
single-task analysis.
Compute the Single-Task Recommended Weight Limit (STRWL). Compute the STRWL for each
task by multiplying its FIRWL by its appropriate FM value. The STRWL for a task reflects the overall
demands of that task, assuming it was the only task being performed. Note: This value does not reflect
the overall demands of the task when the other tasks are considered. Nevertheless, it is helpful in
determining the extent of excessive physical stress for an individual task.
Compute the Frequency-Independent Lifting Index (FILI). The FILI is computed for each task by
dividing the maximum load weight (L) for that task by the respective FIRWL. The maximum weight is
used to compute the FILI because the maximum weight determines the maximum biomechanical loads
to which the body will be exposed, regardless of the frequency of occurrence. Thus, the FILI can identify
individual tasks with potential strength problems for infrequent lifts. If any of the FILI values exceed a
value of 1.0, then job design changes may be needed to decrease the strength demands.
Compute the Single-Task Lifting Index (STLI). The STLI is computed for each task by dividing the
average load weight (L) for that task by the respective STRWL. The average weight is used to compute
the STLI because the average weight provides a better representation of the metabolic demands, which
are distributed across the tasks, rather than being dependent on individual tasks. The STLI can be used
to identify individual tasks with excessive physical demands (i.e., tasks that would result in fatigue). The
STLI values do not indicate the relative stress of the individual tasks in the context of the whole job, but
they can be used to prioritize the individual tasks according to the magnitude of their physical stress.
Thus, if any of the STLI values exceed a value of 1.0, then ergonomic changes may be needed to decrease
the overall physical demands of the task. Note: It may be possible to have a job in which all of the
individual tasks have an STLI less than 1.0 and yet is physically demanding due to the combined demands
of the tasks. In cases where the FILI exceeds the STLI for any task, the maximum weights may represent
a significant problem and careful evaluation is necessary.
Compute the Composite Lifting Index (CLI). The assessment is completed on the multitask worksheet
by determining the composite lifting index (CLI) for the overall job. The CLI is computed as follows:
1. The tasks are renumbered in order of decreasing physical stress, from the task with the greatest STLI
down to the task with the smallest STLI. The tasks are renumbered in this way so that the more
difficult tasks are considered first.
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TABLE 16.8 Computations from Multitask Example
2.
The CLI for the job is then computed according to the following formula:
where:
Note: (1) The numbers in the subscripts refer to the new task numbers; and, (2) the FM values are
determined from Table 16.5, based on the sum of the frequencies for the tasks listed in the subscripts.
An Example. The following example is provided to demonstrate this step of the multitask procedure.
Assume that an analysis of a typical three-task job provided the results shown in Table 16.8.
To compute the Composite Lifting Index (CLI) for this job, the tasks are renumbered in order of
decreasing physical stress, beginning with the task with the greatest STLI. In this case, as shown in Table
16.8, the task numbers do not change. Next, the CLI is computed according to the formula shown
above. The task with the greatest CLI is Task 1 (STLI = 1.6). The sum of the frequencies for Tasks 1 and
2 is 1 + 2, or 3, and the sum of the frequencies for Tasks 1, 2 and 3 is 1 + 2 + 4, or 7. Then, from Table
16.5, FM1 is 0.94, FM1,2 is 0.88, and FM1,2,3 is 0.70. Finally, the CLI = 1.6 + 1.0(1/.88 - 1/.94) + .67(1/
.70 - 1/.88) = 1.6 + .07 + .20 = 1.9. Note: The FM values were based on the sum of the frequencies for
the subscripts, the vertical height, and the duration of lifting.
16-19
16.6 Applying the Equations

Using the RWL and LI to Guide Ergonomic Design
The recommended weight limit (RWL) and lifting index (LI) can be used to guide ergonomic design in
several ways.
1. The individual multipliers can be used to identify specific job-related problems. The relative magnitude
of each multiplier indicates the relative contribution of each task factor (e.g., horizontal, vertical,
frequency, etc.).
2. The RWL can be used to guide the redesign of existing manual lifting jobs or to design new manual
lifting jobs. For example, if the task variables are fixed, then the maximum weight of the load could
be selected so the RWL is not exceeded; if the weight is fixed, then the task variables could be
optimized so that the weight does not exceed the RWL.
3. The LI can be used to estimate the relative magnitude of physical stress for a task or job. The greater
the LI, the smaller the fraction of workers capable of safely sustaining the level of activity. Thus, two
or more job designs could be compared.
4. The LI can be used to prioritize ergonomic redesign. For example, a series of suspected hazardous
jobs could be rank ordered according to the LI and a control strategy could be developed according
to the rank ordering (i.e., jobs with lifting indices above 1.0 or higher would benefit the most from
redesign).
Rationale and Limitations for LI

The NIOSH recommended weight limit (RWL) and lifting index (LI) equations are based on the concept
that the risk of lifting-related low back pain increases as the demands of the lifting task increase. In other
words, as the magnitude of the LI increases, (1) the level of the risk for a given worker would be
increased and (2) a greater percentage of the workforce is likely to be at risk for developing liftingrelated low back pain. The shape of the risk function, however, is not known. Without additional data
showing the relationship between low back pain and the LI, it is impossible to predict the magnitude of
the risk for a given individual or the exact percent of the work population who would be at an elevated
risk for low back pain.
To gain a better understanding of the rationale for the development of the RWL and LI, consult
Waters et al.,1 which provides a discussion of the criteria underlying the lifting equation and of the
individual multipliers and identifies both the assumptions and uncertainties in the scientific studies that
associate manual lifting and low back injuries.
Job-Related Intervention Strategy

The lifting index may be used to identify potentially hazardous lifting jobs or to compare the relative
severity of two jobs for the purpose of evaluating and redesigning them. From the NIOSH perspective,
it is likely that lifting tasks with an LI > 1.0 pose an increased risk for lifting-related low back pain for
some fraction of the workforce.1 Hence, to the extent possible, lifting jobs should be designed to achieve
an LI of 1.0 or less.
Some experts believe, however, that worker selection criteria may be used to identify workers who
can perform potentially stressful lifting tasks (i.e., lifting tasks that would exceed an LI of 1.0) without
significantly increasing their risk of work-related injury above the baseline level.6,7 Those who endorse
the use of selection criteria believe that the criteria must be based on research studies, empirical
observations, or theoretical considerations that include job-related strength testing and/or aerobic capacity
testing. Even these experts agree, however, that many workers will be at a significant risk of a workrelated injury when performing highly stressful lifting tasks (i.e., lifting tasks that would exceed an LI of
16-20

TABLE 16.9 General Design/Redesign Suggestions
3.0). Also, informal or natural selection of workers may occur in many jobs that require repetitive
lifting tasks. According to some experts, this may result in a unique workforce that may be able to work
above a lifting index of 1.0, at least in theory, without substantially increasing their risk of low back
injuries above the baseline rate of injury.
Example Problems
Two example problems are provided to demonstrate the proper application of the lifting equation and
procedures. The procedures provide a method for determining the level of physical stress associated
with a specific set of lifting conditions and assist in identifying the contribution of each job-related
factor. The examples also provide guidance in developing an ergonomic redesign strategy. Specifically,
for each example, a job description, job analysis, hazard assessment, redesign suggestion, illustration,
and completed worksheet are provided.
A series of general design/redesign suggestions for each job-related risk factor are provided in Table
16.9. These suggestions can be used to develop a practical ergonomic design/redesign strategy.
Loading Bags Into A Hopper, Example 1

Job Description. The worker positions himself midway between the handtruck and the mixing hopper,
as illustrated in Figure 16.6. Without moving his feet, he twists to the right and picks up a bag off the
handtruck. In one continuous motion he then twists to his left to place the bag on the rim of the hopper.
A sharp-edged blade within the hopper cuts open the bag to allow the contents to fall into the hopper.
This task is done infrequently (i.e., 1 to 12 times per shift) with large recovery periods between lifts (i.e.,
> 1.2 Recovery Time/Work Time ratio). In observing the worker perform the job, it was determined that
the nonlifting activities could be disregarded because they require minimal force and energy expenditure.
Significant control is not required at the destination, but the worker twists at the origin and destination
of the lift. Although several bags are stacked on the hand truck, the highest risk of overexertion injury
is associated with the bag on the bottom of the stack; therefore, only the lifting of the bottom bag will
be examined. Note, however, that the frequency multiplier is based on the overall frequency of lifting for
all of the bags.
Job Analysis. The task variable data are measured and recorded on the job analysis worksheet (Figure
16.7). The vertical location of the hands is 15 inches at the origin and 36 inches at the destination. The
horizontal location of the hands is 18 inches at the origin and 10 inches at the destination. The asymmetric
angle is 45 at the origin and 45 at the destination of the lift, and the frequency is less than .2 lifts/min
for less than 1 hour (see Table 16.5).
Using Table 16.6, the coupling is classified as fair because the worker can flex the fingers about 90
and the bags are semi-rigid (i.e., they do not sag in the middle). Significant control of the object is not
16-21
FIGURE 16.6 Loading bags into hopper, example 1.
FIGURE 16.7 Job analysis worksheet, example 1.
required at the destination of the lift so the RWL is computed only at the origin. The multipliers are
computed from the lifting equation or determined from the multiplier tables (Tables 16.1 to 16.5, and
Table 16.7). As shown in Figure 16.7, the RWL for this activity is 18.9 lbs.
Hazard Assessment. The weight to be lifted (40 lbs) is greater than the RWL (18.9 lbs). Therefore,
the LI is 40/18.9 or 2.1. This job would be physically stressful for many industrial workers.
16-22
FIGURE 16.8 Warehouse order filling, example 2.
Redesign Suggestions. The worksheet shows that the smallest multipliers (i.e., the greatest penalties) are
.56 for the HM, .86 for the AM, and .89 for the VM. Using Table 16.8, the following job modifications
are suggested:
1. Bring the load closer to the worker to increase the HM.
2. Reduce the angle of asymmetry to increase AM. This could be accomplished either by moving the
origin and destination points closer together or farther apart.
3. Raise the height at the origin to increase the VM.
If the worker could get closer to the bag before lifting, the H value could be decreased to 10 inches,
which would increase the HM to 1.0, the RWL would be increased to 33.7 lbs, and the LI would be
decreased to 1.2 (i.e., 40/33.7).
Comments. This example demonstrates that certain lifting jobs may be evaluated as a single-task or
multitask job. In this case, only the most stressful component of the job was evaluated. For repetitive
lifting jobs, the multitask approach may be more appropriate.
Warehouse Order Filling, Example 2

Job Description. A worker lifts cartons of various sizes from supply shelves onto a cart as illustrated in
Figure 16.8. There are three box sizes (i.e., A, B, and C) of various weights. These lifting tasks are typical
in warehousing, shipping, and receiving activities in which loads of varying weights and sizes are lifted
at different frequencies. Assume that the following observations were made: (1) control of the load is
not required at the destination of any lift; (2) the worker does not twist when picking up and putting
down the cartons; (3) the worker can get close to each carton; and, (4) walking and carrying are minimized
by keeping the cart close to the shelves.
Job Analysis. Since the job consists of more than one distinct task and the task variables often
change, the multitask lifting analysis procedure should be used. This job can be divided into three tasks
represented by cartons A, B, and C. The following measurements were made and recorded on the job
analysis worksheet (Figure 16.9):
1. The horizontal locations (H) for each task at the origin and destination are as follows: Box A, 16
inches; Box B, 12 inches; and, Box C, 8 inches.
2. The vertical locations (V) at the origin are taken to be the position of the hands under the cartons as
follows: Box A, 0 inches; Box B, 0 inches; and, Box C, 30 inches.
16-23
FIGURE 16.9 Job analysis worksheet, example 2.
3. The vertical locations (V) at the destination are the vertical position on the cart as follows: Box A,
30 inches; Box B, 6 inches; and, Box C, 39 inches.
4. The average weights lifted for each task are as follows: Box A, 22 lbs; Box B, 33 lbs; and, Box C,
11 lbs.
5. The maximum weights lifted for each task are as follows: Box A, 33 lbs; Box B, 44 lbs; and, Box C,
22 lbs.
6. No asymmetric lifting is involved (i.e., A = 0).
7. The lifting frequency rates for each task are as follows: Box A, 1 lift/min; Box B, 2 lifts/min; and Box
C, 5 lifts/min.
8. The lifting duration for the job is 8 hours, however, the maximum weights are lifted infrequently
(i.e., less than or equal to once every 5 minutes for 8 hours).
9. Using Table 16.6, the couplings are classified as fair.
The multitask lifting analysis consists of the following three steps:
1. Compute the frequency-independent-RWL (FIRWL) and frequency-independent-lifting index (FILI)
values for each task using a default FM of 1.0.
2. Compute the single-task-RWL (STRWL) and single-task-lifting index (STLI) for each task.
3. Renumber the tasks in order of decreasing physical stress, as determined from the STLI value, starting
with the task with the largest STLI.
Step 1Compute the FIRWL and FILI values for each task using a default FM of 1.0. The other multipliers
are computed from the lifting equation or determined from the multiplier tables (Tables 16.1 to 16.5,
and Table 16.7). Recall, that the FILI is computed for each task by dividing the maximum weight of that
task by its FIRWL.
16-24
These results indicate that some of the tasks requires excessive strength. Remember, however, that these
results do not take the frequency of lifting into consideration.
Step 2Compute the STRWL and STLI values for each task, where the STRWL for a task is equivalent
to the product of the FIRWL and the FM for that task. Recall, that the STILI is computed for each task
by dividing the average weight of that task by its STRWL. The appropriate FM values are determined
from Table 16.5.
These results indicate that Tasks 1 and 2 would be stressful for some workers, if performed individually.
Note, however, that these values do not consider the combined effects of all of the tasks.
Step 3Renumber the tasks, starting with the task with the largest STLI value, and ending with the task
with the smallest STLI value. If more than one task has the same STLI value, assign the lower task
number to the task with the highest frequency.
Hazard Assessment. Compute the composite-lifting index (CLI) using the renumbered tasks. As shown
in Figure 16.9, the CLI for this job is 3.6, which indicates that this job would be physically stressful for
nearly all workers. Analysis of the results suggests that the combined effects of the three tasks are
significantly more stressful than any individual task.
Redesign Suggestions. Developing a redesign strategy for a job depends on tangible and intangible
factors that may be difficult to evaluate, including costs/benefits, feasibility, and practicality. No preferred
procedure has been developed and tested. Therefore, the following suggestions represent only one approach
to ergonomic job modification.
In this example, the magnitude of the FILI, STLI, and CLI values indicate that both strength and
endurance would be a problem for many workers. Therefore, the redesign should attempt to decrease
the physical demands by modifying the job layout and decrease the physiological demands by reducing
the frequency rate or duration of continuous lifting. If the maximum weights were eliminated from the
job, then the CLI would be significantly reduced, the job would be less stressful, and more workers
could perform the job than before.
Those lifts with strength problems should be evaluated for specific engineering changes, such as (1)
decreasing carton size or removing barriers to reduce the horizontal distance; (2) raising or lowering the
origin of the lift; (3) reducing the vertical distance of the lift; improving carton couplings, and (4)
decreasing the weight to be lifted. The redesign priority for this example is based on identifying
interventions that provide the largest increase in the FIRWL for each task (Step 2 on worksheet). For
example, the maximum weight lifted for carton A is unacceptable; however, if the carton at the origin
were on the upper shelf, then the FIRWL for Task 1 would increase from 21.0 lbs to 27.0 lbs. The
maximum weight lifted still exceeds the FIRWL, but lifts of average weight are now below the FIRWL.
Additionally, providing handles, decreasing box size, or reducing the load to be lifted will decrease the
stress of manual lifting.
Comments. This example demonstrates the complexity of analyzing multitask lifting jobs. Errors
resulting from averaging, and errors introduced by ignoring other factors (e.g., walking, carrying, holding,
pushing and pulling activities, and environmental stressors), can only be resolved with detailed
biomechanical, metabolic, cardiovascular, and psychophysical evaluations.
16-25
Several important application principles are illustrated in this example:

1. The horizontal distance (H) for Task 3 was less than the 10.0 inches minimum. Therefore, H was set
equal to 10 inches (i.e., multipliers must be less than or equal to 1.0).
2. The vertical travel distance (D) in Task 2 was less than the 10 inches minimum. Therefore, D was set
equal to 10 inches.
References
1. Waters, T.R., Putz-Anderson, V., Garg, A., and Fine, L.J., 1993, Revised NIOSH equation for the
design and evaluation of manual lifting tasks. Ergonomics. Vol. 36(7), 749776.
2. Waters, T.R., Putz-Anderson, V., and Garg, A., 1994, Applications Manual for the Revised NIOSH
Lifting Equation. National Institute for Occupational Safety and Health, Technical Report.
DHHS(NIOSH) Pub. No. 94110. Available from the National Technical Information Service (NTIS).
NTIS document number PB94176930 (1800553-NTIS).
3. NIOSH, 1981, Work Practices Guide for Manual Lifting, NIOSH Technical Report No. 81122
(U.S. Department of Health and Human Services, National Institute for Occupational Safety and
Health, Cincinnati, OH).
4. NIOSH, 1991, Scientific Support Documentation for the Revised 1991 NIOSH Lifting Equation:
Technical Contract Reports, May 8, 1991 (U.S. Department of Health and Human Services, National
Institute for Occupational Safety and Health, Cincinnati, OH). Available from the National Technical
Information Service (NTIS No. PB-91226274).
5. ASPH/NIOSH, 1986, Proposed National Strategies for the Prevention of Leading Work-Related
Diseases and Injuries: Part 1. Published by the Association of Schools of Public Health under a
cooperative agreement with the National Institute for Occupational Safety and Health.
6. Eastman Kodak, 1986, Ergonomic Design for People at Work, Vol. 2, Van Nostrand Reinhold,
New York.
7. Ayoub, M.M. and Mital, A. 1989, Manual Materials Handling, Taylor & Francis, London.
8. Chaffin, D.B. and Andersson, G.B.J. 1984, Occupational Biomechanics, John Wiley & Sons, New
York.
17
A Population-Based
Load Threshold Limit
(LTL) for Manual Lifting
Tasks Performed by
Males and Females
17.1
17.2
17.3
17.4
Waldemar Karwowski
17.5
Paul Gaddie
Renliu Jang
Wook Gee Lee
17.6
17.7
17.8
Introduction
Threshold RWL Values
The 1991 Revised NIOSH Lifting Equation
Computer Simulation of the NIOSH (1991)
Lifting Equation
Summary of Simulated Characteristics of Lifting
Factors and Multipliers
Horizontal Factor Vertical Height Factor Distance
Multiplier Asymmetry Factor Work Duration
Factor Frequency Factor Coupling Multiplier
Results of Simulation: Threshold Values of RWL
Development of the Population-Based Design
Load Threshold Limits
The LTL Model Application
171
172
172
173
173
175
175
177
17.1 Introduction
In order to reduce the risk of low back pain and injuries due to manual lifting tasks, we need guidelines
for load limits with respect to different percentiles of capable industrial population that are simple to
understand by the practitioners, and easy to apply in practical settings. Unfortunately, the revised NIOSH
(1991) method, which aims to protect 99% of males and 75% of females of the U.S. population, is quite
cumbersome to use, and by design very restrictive in setting the acceptable load limits. This chapter
introduces population-based load threshold limits (LTL) for evaluation of manual lifting tasks performed
by males and females. The proposed limits are based on the simulation of the revised (1991) NIOSH
lifting equation, and application of the threshold lifting index (scaling factors) developed in reference to
the comprehensive database for manual lifting tasks reported by Snook and Ciriello (1991).
As described in Chapter 16 of this handbook, the National Institute for Occupational Safety and
Health proposed the recommended weight limit (RWL) as the guide for evaluating manual tasks in industry
(Waters et al., 1993). The revised lifting equation (RLE) and its predecessor (NIOSH, 1981) aim to
0-8493-1800-9/03/$0.00+$1.50
17-1
17-2
simultaneously satisfy the biomechanical, physiological, and psychophysical criteria for setting limits in manual
lifting tasks (Waters et al., 1993; Dempsey, 1998). The 1991 equation expands the previous guidelines, and
it is claimed that it can be applied to a larger percentage of lifting tasks (Waters et al., 1993).
Because the RWL is intended to protect 90% of the mixed industrial working population (99%
males and 75% females), it is designed for the least physically capable percent of the industrial workforce.
Given that more capable populations may be available at the workplace to perform physically demanding
lifting tasks (for example strong young males and females), the application of the RWL-based limits that
accommodate the majority of mixed male/female population may result in some work inefficiency. As
discussed by Waters et al. (1993), a critical point concerning the 1991 RLE concept is that the NIOSH
perspective was very conservative in nature. Furthermore, as demonstrated by Karwowski (1992), an
application of the 1991 RLE model leads to a fairly narrow range of RWL values.
According to Waters and Putz-Anderson (1998), the lifting index (LI) may be used to identify potentially
hazardous lifting jobs. NIOSH believes that jobs with LI smaller than 1.0 would pose an increased risk
for lifting-related injury to less than 25% of female and 1% of male industrial workers. However, it was
also recognized, that worker selection criteria may be used to identify workers who can perform lifting
tasks that would exceed an LI = 1.0 without significantly increasing their risk of work-related injury
above the baseline level. It was also noted that the said selection criteria must be based on research
studies, job-related strength testing, and/or aerobic capacity (Waters and Putz-Anderson, 1998). Although
the risk function representing the relationship between the lifting index and probability of injury is
mostly unknown today (for some preliminary data see Karwowski et al., 1994), some experts hypothesize
that many workers would be at significant risk of a work-related injury when performing lifting jobs
with the LI values above 3.0, which are classified as highly stressful tasks (Waters et al., 1993; Waters
and Putz-Anderson, 1998). Such assumption is yet to be validated in the field.
17.2 Threshold RWL Values

Given the above discussion, until comprehensive epidemiological data that relate the LI values to the
risk of lifting-related injury are developed, the paradigm of protecting most of the population represented
by the RLE concept seems a plausible and desirable strategy. There is also, however, a pressing need, at
least for some of the industrial applications, to identify lifting limits and the population of capable
workers (both males and females), who are able to handle physically demanding jobs with a lifting index
above 1.0 (but below 3.0). Such data could be developed with respect to the simulated threshold RWL
(TRWL) values corresponding to different levels of lifting index.
The threshold RWL values were defined by Karwowski and Gaddie (1995) as those limiting values of
RWL (corresponding to LI = 1.0) that would be expected to represent at least 99.5% of all of the potential
industrial jobs. In other words, these values mean that only in 0.5% of all possible cases (lifting tasks), the
expected recommended weight limit would exceed the specific threshold RWL value. From the practical
standpoint that means that for the majority of industrial jobs (99.5%), the expected RWL would be at or
below the specific TRWL value. This implies that when LI is set to 1.0 for task design or evaluation
purposes, it can be expected that only half of one percent of the plausible industrial lifting tasks would
have the recommended weight greater than the specific TRWL value. Assuming that the 0.5% is the
additional safety factor, the TRWL indicates the maximum values of RWL that one would expect to get
when using the RLE model for evaluating any of the real lifting jobs encountered in industry.
17.3 The 1991 Revised NIOSH Lifting Equation

Detailed description of the relevant terms utilized by the RLE (1991) is provided in Chapter 16. For the
purpose of this discussion, it is noted that the recommended weight limit (RWL) is the product of the
load constant (LC) and six multipliers (M) which account for seven risk factors, i.e., RWL (Kg) = LC *
Population-Based Load Threshold Limit (LTL) for Manual Lifting
17-3
HM * VM * DM * AM * FM * CM. The multipliers are defined in terms of the related risk factors,
including the horizontal location (H), vertical location (V), vertical travel distance (D), frequency of lift
(F), asymmetry angle (A), and coupling (C). The multipliers for frequency and coupling are defined
using relevant tables. In addition to lifting frequency, the work duration and vertical distance factors are
used to compute the frequency multiplier.
17.4 Computer Simulation of the NIOSH (1991) Lifting Equation

One way to investigate the practical implications of the RLE (1991) for industry is to determine the
likely results of the equation when applying a realistic and practical range of values for the risk factors
(Karwowski, 1992). Karwowski and Gaddie (1995) introduced a computer simulation modeling approach
to derive the threshold RWL values for 90% of the mixed male/female population (i.e., 99% of male
and 75% of female industrial workers). Shortly, a computer simulation was written in SLAM II, a
Simulation Language for Alternative Modeling (Pritsker, 1986). The NIOSH 1991 Lifting Equation was
modeled as the product of factor multipliers represented as attributes of an entity flowing through the
network. The developed model is a sequence of operations which draws random values from each of the
relevant factor distributions and tables, and then calculates the corresponding RWL values.
17.5 Summary of Simulated Characteristics of Lifting Factors and Multipliers

As much as possible, the probability distributions for the risk factors utilized by the RLE (1991) were
designed to be representative of the real industrial workplaces (Ciriello et al., 1990; Brokaw, 1992;
Karwowski and Brokaw, 1992; Marras et al., 1995). Except for the vertical travel distance factor, coupling
and asymmetry multipliers, all factors were defined using lognormal or normal distributions. For all the
factors defined as having lognormal distributions, the following procedure was used to adjust for the
required range of real values whenever necessary. After the given distribution was generated, it was then
adjusted for the range, i.e., truncated for values below the lower limit and above the upper limit.
Specifically, the values outside the range were removed, and the new values that would fall within the
desired range were generated. This process normalized the derived distributions to the area of 1.0.
Horizontal Factor
The horizontal factor (H) represents the distance of the hands from the midpoint of the ankles, measured
in centimeters at the origin and the destination of lift. This horizontal distance was assumed to be the
maximum of the two positions, and that no intermediate position was greater than this maximum. The
range of horizontal distance as specified by NIOSH (Waters et al., 1993) is from 25 cm to 63 cm, and is
used to define the horizontal multiplier (HM). A lognormal distribution for H (mean value of 44 cm,
standard deviation of 6 cm) was used to generate random values within the required range. These values
were chosen because H = 44 cm is the midpoint of the range from 25 cm to 63 cm, and the standard
deviation of 6 cm allows almost all the values generated to fall within this range. It should be noted that
the lognormal distribution gives greater weight to the values which are located near the mean.
Vertical Height Factor

The vertical height factor (V) indicates the vertical distance of the hands from the floor, with the range
from the floor position (of 0 cm at a minimum) to the upper limit of vertical reach of 175 cm (Waters
et al., 1993). This factor was defined using a lognormal distribution (mean = 100 cm, std = 25 cm). It
should be noted that the vertical height factor is also used as an independent variable in the definition of
vertical multiplier (VM), the coupling multiplier (CM), and the frequency multiplier (FM).
17-4
Distance Multiplier
The vertical travel distance factor (D), i.e., the difference between the origin and destination of the lift,
is used by NIOSH (Waters et al., 1993) to define the distance multiplier (DM). For the purpose of this
simulation, the vertical travel distance (D) was assumed uniform over the interval of (0, [175-V]). Since
the vertical distance traveled is the difference between the origin and the destination heights, this distance
can be no greater than the one defined by the origin of lift and the maximum vertical reach limit. A
variable called the maximum vertical distance (MAVED) was created based on the vertical factor (V).
The travel distance factor (D) was then drawn from a uniform distribution ranging from 0 to MAVED.
The MAVED variable was then modified in order to reset all values of D which were less than 25 cm to
25 cm. This procedure guaranteed that the DM was set at 1.0 for such D values.
Asymmetry Factor
The asymmetry factor is defined for the (0135 degrees) range of the upper body twisting angle. This factor
was modeled using a lognormal distribution (45, 15), i.e., the mean of 45 and a standard deviation of 15.
This mean and standard deviation provide a natural range from 0 to 90 of twist for the underlying distribution.
The mean of 45 degrees was chosen based on the conservative assumption that in most of the industrial
lifting tasks the upper body twisting does not exceed 90 degrees. The standard deviation was chosen to
ensure that almost all the lifting posture asymmetry values will fall within the NIOSH-specified range limit.
Work Duration Factor

The work duration factor is used to define the frequency multiplier (FM). For the purpose of this
simulation, the work duration was conservatively modeled as a normal variable with the mean of 2.0
hours and standard deviation of 2.0 hours. This distribution was then adjusted for the range, i.e.,
truncated for values of work duration of zero or less, and those which were greater than 8 hours. For the
purpose of simulation, the values outside the range of work duration were removed, and the new values
that would fall within the desired range were generated. This process normalized the derived distribution
to the area of 1.0. These random values were then used in the selection of the frequency multiplier from
the NIOSH table for FM (Waters et al., 1993).
Frequency Factor
The frequency variable F (lifts/minute), for the range of lifting frequency from 0.2 lifts/min to 15 lifts/
min, is used in the definition of the frequency multiplier (FM). The frequency multipliers (FMs) were
selected from the NIOSH table based on randomization of three factors: (1) the frequency of lift, (2)
work duration, and (3) vertical height (V). Due to the discrete nature of the values for frequency of lift,
the probability distribution function for this factor was generated using normal distribution. The
parameters for this distribution were defined as follows: a mean of 4.7 lifts/min, and a standard deviation
1.75 lifts/min. These values were derived based on the information provided by results of industrial
surveys of manual lifting tasks. For example, Ciriello et al. (1990) reported that 94% of industrial lifting
tasks are performed at frequencies of 4.3 lifts/min or slower. Brokaw (1992) analyzed 31 industrial
lifting tasks and reported that in about 80% of these tasks the observed frequency was lower than 5
lifts/min. For the purpose of this simulation, however, it was decided that better representation of the
higher lifting frequencies is warranted by the fact that such frequencies of lifting tasks are common
today in the service industry, and by the attention given to such tasks by NIOSH (1993), as reflected by
their inclusion in the frequency multiplier table. The randomly generated values of the frequency of lift
which were less than or equal to zero were eliminated, and the truncated normal distribution was
renormalized to equate the area under the curve to 1.0. The resulting distribution was used to generate
the probability density function values for entries from the frequency of lift table.
17-5
Coupling Multiplier
Coupling describes the quality of coupling between the hand and the load. This quality has three linguistic
values, i.e., good, fair and poor. The discrete values for the coupling multiplier (CM) were chosen based
on the results of an industrial survey of 31 manual lifting tasks performed in three different companies
reported by Brokaw (1992). This survey showed that slightly less than 10% of the observed lifting tasks
had good couplings, about 64% had fair couplings, while about 26% had poor couplings. Due to the
limited sample size of the above study, it was decided to allow for more liberal coupling assumption for
the simulation purposes. Therefore, the probability of good hand-to-container coupling was set at 0.3,
for fair coupling at 0.5, and the probability for poor coupling was set at 0.2.
17.6 Results of Simulation: Threshold Values of RWL

The results showed that overall, in conditions studied (represented by 100,000 randomly generated lifting
task scenarios), the threshold RWL values (the RWL values which account for 99.5% of all simulated
lifting tasks) were equal to or lower than: (1) 13.0 kg (or 28.6 lbs) for up to 1 hour of lifting, (2) 12.5 kg
(or 26.4 lbs) for less than 2 hours of exposure, and (3) 10.5 kg (or 23.1 lbs) for lifting over an 8-hour shift.
The above results indicate that under most of the examined lifting conditions (99.5% of the simulated
cases), one can reasonably expect that an implementation of the RLE (1991) model at the level of Lifting
Index of 1.0, which is designed to protect 90% of the mixed industrial working population, would necessitate
redesign of those manual lifting tasks for which the load lifted exceeds the TRWL values reported above.
From a practical point of view, these results define the threshold RWL values that can be used by practitioners
for the purpose of immediate risk assessment of manual lifting tasks performed in industry.
17.7 Development of the Population-Based Design Load Threshold Limits

The next step in development of the population-based design load threshold limits (LTL) for manual
lifting tasks was to define the threshold lifting index (TLI) values for different percentiles of capable
male and female populations. This was done by using the scaling factors derived from the psychophysical
data reported by Snook and Ciriello (1991), which account for different percentiles of the capable
U.S. population. The scaling factors were defined in reference to 90% of male and 75% of female
populations, at which their values were equated to 1.0 (e.g., LI = 1.0). These scaling factors (see Table
17.1) were derived based on the ratios between the 10th, 50th, and 90th percentile values of the
maximum acceptable weights of lift (MAWL) under frequency of 1 lift per minute (box width
TABLE 17.1 Values of Threshold Lifting Index (TLI)
for Male and Female Populations
V = vertical height of lift (cm)

SR = shoulder-to-reach height
17-6
of 34 cm), assuming normal distribution of these values. Three lifting conditions with vertical heights of
lift, i.e., (1) V < 75 cm, (2) V > 75 cm, and the shoulder-to-reach, were adopted for the purpose of
calculating the scaling factors for males and females based on the appropriate percentile distribution
values (Snook and Ciriello, 1991).
The derived scaling factors were defined as the threshold lifting index (TLI) values (see Table 17.1).
It should be noted that all of the TLI values are less than 3. For comparison purposes, the results of the
field study of 24 lifting jobs (Karwowski et al., 1994) revealed the value of lifting index of 4.1 (at lift
destination), which corresponds to the lumbar compressive strength of 4100 N (with one standard
deviation) for 40-year-old males, as proposed by Jager and Luttman (1992).
The population-based load threshold limits (LTL) corresponding to different percentiles of capable
workers were defined as follows:
The derived distributions of load threshold limits are illustrated in Figures 17.1 and 17.2, for males and
females, respectively. Furthermore, Tables 17.2 and 17.3 show the LTL values as the function of work
exposure and vertical lifting height. These values range from the most capable population of workers
(10% value) to the least capable (90% value), and are expressed as a function of: (1) task exposure (up
to one hour, one-to-two hours, and eight hours of work), and (2) vertical location of the load, i.e., the
vertical height of the hands above the floor (V < 75 cm and V > 75 cm). In addition, the LTL values for
lifting from shoulder-to-reach (SR) are also given. It should be remembered that the LTL values represent
the threshold RWLs which apply to 99.5% of all possible simulated cases based on the NIOSH (1991)
RLE model, and, therefore, represent the largest variation of all possible lifting tasks that can be
encountered in industry today.
TABLE 17.2 Load Threshold Limits (LTL) for Male Population (kg) at Different Work Exposures

TABLE 17.3 Load Threshold Limits (LTL) for Female Population (kg) at Different Work Exposures
17-7
FIGURE 17.1 (a) Distributions of load threshold limits (LTL) for males (V < 75 cm).
17.8 The LTL Model Application

The population-based load threshold limits could be very useful for immediate risk assessment of manual
lifting tasks performed in industry at large. Such values of lifted loads, if exceeded, provide an indication
of the need for a more thorough examination of the manual lifting tasks performed in a given industrial
setting, and, if appropriate, evaluation of the physical capacity of the exposed workers. It should be noted
that the developed model does not imply that the LTL values are safe for any given individual performing
a specific manual lifting task. Rather, these data should be used a guide for design and evaluation of
manual lifting tasks performed in different types of industry by a given percentile of capable workers,
17-8
FIGURE 17.1 (continued) (b) Distributions of load threshold limits (LTL) for males (V > 75 cm).
until more objective epidemiological evidence regarding the causal relationship between the loads lifted
on the job and related risk of low-back injury is available (Dempsey, 1998; Karwowski et al., 1998).
It should be remembered that the LTL data apply to 99.5% of the expected cases (i.e., potential
lifting tasks that can be expected to occur in real industrial environments), and would be somewhat
greater for 0.5% of the remaining cases. Since the TRWL concept, which integrates all aspects of the
NIOSH revised lifting equation (1991), was used as the basis for development of the population-based
design limits, the proposed LTL approach is applicable to a large variety of possible lifting task conditions
as it integrates all lifting factors considered by the RLE model. Finally, the developed threshold load
limit approach extends application of the original RWL concept to different percentiles of capable male
and female populations, making it much more relevant and applicable to the real life situations.
FIGURE 17.2 (a) Distributions of load threshold limits (LTL) for females (V < 75 cm).
17-9
17-10
FIGURE 17.2 (continued) (b) Distributions of load threshold limits (LTL) for females (V > 75 cm).
17-11
References
Ayoub, M.M., Dempsey, P.G., and Karwowski, W. 1997, Manual materials handling, in Handbook of
Human Factors & Ergonomics, G.Salvendy, Ed., John Wiley & Sons, New York, pp. 10851123.
Brokaw, N. 1992, Implications of the Revised NIOSH Lifting Guide of 1991: A Field Study. Unpublished
M.S. Thesis, Department of Industrial Engineering, University of Louisville, Louisville, Kentucky.
Dempsey, P. 1998, A critical review of biomechanical, epidemiological, physiological and psychophysical
criteria for designing manual materials handling tasks. Ergonomics, 41 (1) 7388.
Jager, M. and Luttman, A. 1992, The load on the lumbar spine during asymmetrical bi-manual materials
handling. Ergonomics, 35 (7/8), 783805.
Karwowski, W. and Brokaw, N. 1992, Implications of the Proposed Revisions in a Draft of the Revised
NIOSH Lifting Guide (1991) for Job Redesign: A Field Study, Proceedings of the 36th Annual
Meeting of the Human Factors Society, Santa Monica, California, pp. 659663.
Karwowski, W. 1992, Comments on the assumption of multiplicity of risk factors in the draft revisions
to NIOSH Lifting Guide, in S. Kumar (Ed.), Advances in Industrial Ergonomics and Safety IV,
Taylor & Francis, London, pp. 905910.
Karwowski, W., Caldwell, M., and Gaddie, P. 1994, Relationship between the NIOSH lifting index,
compressive and shear forces on the lumbosacral joint, and low back injury incidence rate based on
industrial field study, in Proceedings of the 36th Annual Meeting of the Human Factors Society,
Santa Monica, California, pp. 654659.
Karwowski, W., Lee, W.G., Jamaldin, B., Gaddie, P., and Jang, R. 1998, Beyond psychophysics: a need
for cognitive modeling approach to setting limits in manual lifting tasks, Ergonomics, in press.
Marras, W.S., Lavender, S.A., Leurgans, S.E., Fathallah, F.A., Ferguson, S.A., Allread, W.G., and Rajulu,
S.L. 1995, Biomechanical risk factors for occupationally related low back disorders. Ergonomics,
38, 377410.
Snook, S.H. and Ciriello, V.M. 1991, The design of manual handling tasks: Revised tables of maximum
acceptable weights and forces. Ergonomics, 34 (9), 11971213.
Waters, T.R., Putz-Anderson, V., Garg, A., and Fine, L.J. 1993, Revised NIOSH equation for the design
and evaluation of manual lifting tasks, Ergonomics, 36, 749776.
Waters, T.R. and Putz-Anderson, V. 1998, Revised NIOSH Lifting Equation, in W.Karwowski and W.S.
Marras (Eds.), Handbook of Occupational Ergonomics, CRC Press, Boca Raton.
18
Occupational Low Back
Disorder Risk
Assessment Using the
Lumbar Motion
Monitor
18.1
18.2
William S.Marras
18.3
18.4
W.Gary Allread
Richard G.Ried
Background
Occupational Back Injuries Tools for Analyzing Low
Back Injury Risk
Development of the Lumbar Motion Monitor
Physical Description Calibration and
Validation Development of the LBD Risk Model
Benefits of the LMM and the LBD Risk Model
Applications: How to Use the LMM and LBD
Risk Model
Recommended Equipment Selecting the Job(s) to
Monitor Defining the Major Components of the Job
through a Task Analysis Collecting and Recording
Workplace Data for Risk Assessment Setting Up the LMM
for Data Collection Collecting the Data Analyzing and
Interpreting the LMM Data
181
182
1817
1818
18.1 Background
Occupational Back Injuries
Low back disorders (LBD) are among the most common occupationally related injuries. According to
Andersson (1997), LBDs affect an estimated 80% of the population during their working career. The
National Center for Health Statistics (1977) has documented that LBDs are the prime reason for activity
limitation for those under 45 years of age. Cats-Baril (1996) has shown that LBDs cost society up to 100
billion dollars annually. Despite the prevalence and cost of these injuries, there are relatively few accurate
methods available to predict the risk of occupationally related LBDs.
Tools for Analyzing Low Back Injury Risk

There is a host of tools available to evaluate LBD risk in industrial jobs. These tools vary widely in their
assumptions and complexity. When choosing an analysis technique it is important to match the capabilities
of tool to the characteristics of the job being evaluated.
0-8493-1800-9/03/$0.00+$1.50
18-1
18-2
Two- and three-dimensional static models are easy to apply but assume that motion is not a significant
factor in LBD risk. The 1981 and 1991 NIOSH lifting equations are also easy to apply but assume that
all movements are slow and smooth. Within their limitations, these methods can provide insight on LBD
risk. However, recent research has suggested that motion may play a role in LBD risk.
Numerous epidemiologic studies have specifically indicated that the risk of LBD increases when
dynamic lifting occurs. Data from a retrospective study of 4,645 injuries by Bigos et al. (1986) suggest
that there were greater reports of LBD with dynamic tasks relative to awkward static tasks. Magora
(1973) concluded that lateral bending and twisting were only significant risk factors when they occurred
simultaneously with sudden (quick) movements. Punnett et al. (1991) studied non-neutral postures in
automobile assembly plants and reported that postural stress to the back was more dynamic than static.
All of these studies have indicated that the risk of LBD increases with dynamic activity, especially when
the body moves asymmetrically. Therefore, if the job has a dynamic component it is important to choose
an analysis method that accounts for the additional risk that motion imparts.
Video-based motion analysis systems offer one way to study the dynamic component of a job, but they
have several drawbacks when used in an industrial setting. Video assessments must take place in a calibrated
space of usually no more than 2 to 3 cubic meters. Cameras must be carefully placed to obtain data for all
three planes of motion, and time-consuming analysis is necessary to obtain usable data. In industrial
environments, tasks often involve movement outside the calibrated space, work areas limit camera placement,
and a great deal of labor must be expended to analyze a few minutes of usable data. These limitations often
make video-based systems impractical for routinely evaluating a large number of industrial jobs.
18.2 Development of the Lumbar Motion Monitor

Physical Description
The Lumbar Motion Monitor (LMM) (Figure 18.1) was developed in the Biodynamics Laboratory at
The Ohio State University in response to the need for a practical method of assessing the dynamic
component of occupationally related LBD risk in industrial settings. The patented LMM is a triaxial
electrogoniometer that acts as a lightweight exoskeleton of the lumbar spine. It is positioned on the back
of a subject directly in line with the spine and attached by harnesses at the pelvis and thorax. Four
potentiometers at the base of the LMM measure the instantaneous position of the spine (as a unit) in
three-dimensional space relative to the pelvis. Position data from the potentiometers are recorded at 60
Hz, transmitted to an analog-to-digital (A/D) converter, and then recorded on a microcomputer. The
data are then processed to calculate the position, velocity, and acceleration of the spine in each of the
three planes of motion as a function of time.
Calibration and Validation

During data collection and analysis, each LMM is used with its matching calibration file. Before its first
use, each LMM is calibrated individually, using a specially designed reference frame (Figure 18.2). During
the calibration process the LMM is positioned on the calibration frame at 225 different positions in
three-dimensional space and the voltage outputs recorded. The calibration process eliminates any
individual variability in each LMM.
The LMM was validated to ensure its accuracy and sensitivity with a video-based motion analysis
system (Marras et al., 1992). During the validation process the predicted velocities and accelerations of the
LMM were compared relatively (to position accuracy) against the predicted values of the motion analysis
system. The results of the validation process (Table 18.1) show high correlation coefficient values and
significance levels (r > .95, p < 0.0001) for all three planes of motion. An independent group has also
determined that the reproducibility of the LMM is suitably high for range of motion and velocity for the
device to be used for evaluation in a clinical and research setting (Gill and Callaghan, 1996).
Occupational Low Back Disorder Risk Assessment Using the Lumbar Motion Monitor
18-3
FIGURE 18.1 The Lumbar Motion Monitor (LMM) compared to an anatomical model of the spine.
Development of the LBD Risk Model

An in vivo study was undertaken to determine quantitatively whether dynamic trunk motions in
combination with workplace and environmental factors may better describe the risk of LBD in repetitive
manual materials handling (MMH) tasks.
Approach
The study involved an industrial surveillance of the trunk motions and workplace factors involved in highand low-risk repetitive MMH jobs. The approach used in this phase of the project was to (1) identify
industries involved with repetitive MMH work; (2) examine the company medical records as well as the
health and safety records to identify those repetitive MMH jobs that were associated, historically, with
either a high or low risk of occupationally related LBD; (3) quantitatively monitor the trunk motions and
workplace factors associated with each of these jobs; and (4) evaluate the data to determine which
combination of trunk motion and workplace factors was most closely associated with LBD risk.
18-4
FIGURE 18.2 The three-dimensional reference frame.

TABLE 18.1 Correlations of the Velocities and
Accelerations of the Motion Analysis System in
the Three Planes of Motion with the Velocities
and Accelerations of the LMM
* p < 0.0001
Study Design
This study was a cross-sectional study of 403 industrial jobs from 48 manufacturing companies throughout
the midwestern United States. Only repetitive jobs without job rotation were examined in this study.
This was necessary to prevent the confounding effects created by alternate jobs. Jobs examined in this
study were divided into two groups, high and low risk of LBD, based on examination of the injury and
medical records. Whenever possible, company medical reports were used to categorize risk. In some
cases only injury logs (OSHA 200 logs) were available. All medical reports, injury records and logs were
scrutinized to ensure they were as accurate as possible. The outcome measure (LBD risk) derived from
these medical and injury records consisted of the normalized rate of reported occupationally related
LBD. Incidence of reported LBD was considered regardless of whether there was any restricted or lost
time associated with the incident.
Thus, the dependent variable in this study consisted of two levels of job-related LBD risk categories.
Low-risk group jobs were defined as those jobs with at least 3 years of records showing no injuries and
18-5
no turnover. Turnover is defined as the average number of employees who left a job per year. High-risk
group jobs were those jobs associated with at least 12 injuries per 200,000 hours of exposure (average
of 26/200,000 hours). The high-risk group category incidence rate corresponds to the 75th percentile
value of risk for the 403 jobs examined. Of the 403 jobs examined, 124 of the jobs were categorized as
low-risk and 111 were categorized as high-risk. The remainder of the jobs (168) were categorized as
medium-risk and were not used in this particular analysis.
The independent variables in this study consisted of workplace, individual, and trunk motion characteristics
that were indicative of each job. The workplace and individual characteristics consisted of variables typically
considered in current workplace guidelines for materials handling (NIOSH, 1981; Putz-Anderson and Waters,
1991). Specifically, these variables were: (1) the maximum horizontal distance of the load from the spine; (2)
the weight of the object lifted; (3) the height of the load at the origin of the lift; (4) the height of the load at the
destination of the lift; (5) the frequency of lifting (lift rate); (6) the asymmetric angle of the lift (as defined by
NIOSH, 1981); (7) employee anthropometry (12 measures); (8) employee injury history; (9) employee
satisfaction; and (10) trunk motion. Trunk motion characteristics were those variables obtained using the
LMM. These variables consisted of the trunk angular position, velocity, and acceleration characteristics (i.e.,
means, ranges, maximums, minimums, etc.) in each of the cardinal planes. Selected trunk motion factors
along with selected workplace factors were used to develop a quantitative model of occupational risk factors.
Data Collection
Initially, data about employee health, employment history, and anthropometry were collected. Next, the
employee was fitted with an LMM. A baseline reading from the LMM was then taken, while the individual
stood erect and rigid. The employee then was asked to return to work and wore the LMM for at least ten
job cycles. Thus, the length of time the employee wore the monitor depended upon the cycle time of the
job. Monitoring of back motion was initiated as the employee began the MMH task and concluded when
the employee completed the task. Extraneous activities not involving MMH were not monitored. Signals
from the LMM were sampled at 60 Hz via an analog-to-digital converter and stored on a portable
microcomputer. The data were further processed in the laboratory to determine position, velocity, and
acceleration of the trunk as a function of time in the sagittal, lateral, and axial twisting planes of the body.
Analysis
The data were initially examined to determine whether the trunk motions were repeatable. This analysis
indicated that more than half of the variation was attributable to the job. Hence, trunk motions were
dictated largely by the design of the task, and repetitive trials resulted in motions that were fairly similar.
The various personal, environmental, and workplace factors from the database were analyzed using
logistic regression techniques to determine if any single factor could distinguish jobs associated with
high-risk group membership from those that were not. The most powerful single variable was maximum
moment, which yielded an odds ratio of 5.17. Overall, however, the odds ratios were low, indicating
that few of the individual variables discriminate well between high- and low-risk jobs. Of the trunk
motion factors, the velocity variables generally produced greater odds ratios than maximum or minimum
position, range of motion, or acceleration. Table 18.2 shows the descriptive statistics of the workplace
and trunk motion factors for the high- and low-risk groups.
Next, multiple logistic regression was used to predict the probability of high-risk group membership
as a function of the values of several workplace and trunk motion factors. A five-variable model
incorporating the trunk motion and workplace factors was developed and further refined after examining
a series of stepwise logistic regression models (containing different variables, e.g., velocity, acceleration)
fitted to several intermediate data sets. A combination of five variables (moment, frequency of lift,
sagittal flexion, twisting velocity, and lateral velocity) was found to have the greatest odds of predicting
high-risk group membership. This combination of workplace and trunk motion factors forms the basis
of the LBD Risk Model. The model was selected for the statistical importance of the predictors and for
biomechanical plausibility. The model variables remained consistent when tested with the various
intermediate
18-6
TABLE 18.2 Descriptive Statistics of the Workplace and Trunk Motion Factors in Each of the Risk Groups
data sets. The empirical stability of the model was checked by predicting the classification of 100 jobs
based on the preliminary model. This model resulted in an odds ratio of 10.6.
By averaging individual probability values for moment, frequency of lift, sagittal flexion, twisting
velocity, and lateral velocity, the LBD Risk Model is able to predict the probability of high-risk group
membership (LBD risk) for any repetitive job (Figure 18.3). It is important to understand that the
predictive power of the model is a result of the interaction of these five variables. Individually, each of
these factors is unable to reliably distinguish between a high-risk and a low-risk situation, but when they
are considered in combination the predictive power increases tenfold.
The LBD Risk Model is currently being validated in a longitudinal study. Jobs are prospectively
tracked (over time) to determine if changes in injury rates after the implementation of ergonomic changes
correspond with predicted value changes in the LBD Risk Model. Preliminary results indicate the changes
18-7
FIGURE 18.3 The LBD Risk Model showing the five risk variables scaled relative to risk. The arrow points to the
overall probability of high risk of LBD group membership for a particular job.
in LMM probability of risk corresponds well with an observed change in actual injury rates after changes
have been made to the work environment.
18.3 Benefits of the LMM and the LBD Risk Model

Use of the LMM and its computation of risk provides several advantages to the ergonomist studying
injury risk for material handling activities. First, the LMM allows one to determine the instantaneous
three-dimensional position of the trunk while individuals perform their actual job tasks, not work
simulated instead in a laboratory. This ability eliminates the question of whether a material handling
study conducted in an artificial setting can be generalized to the workplace. Also, the LMM data are
gathered objectively. Resulting calculations of injury risk are determined irrespective of an investigators
(perhaps unintentionally biased) view of the work.
A second advantage of using the LMM system is that material handling jobs can be assessed relative
to a large database covering jobs from diverse manufacturing environments and with different levels of
risk. This enables the ergonomist to determine if a job has a high probability of injuring employees who
perform that job. It also allows one to rank several jobs, based on their risk values, and to study solutions
for those having the greatest chance of producing injury.
Third, the probability model enables the ergonomist to quantitatively assess and compare each task
within a job. Specific factors that contribute to a tasks probability are identified, as are the tasks that
most contribute to the jobs overall risk. This information pinpoints the specific tasks and the factors
therein that must be addressed during job redesign to reduce the jobs injury risk potential. This method
of identifying and changing only those components that contribute to risk eliminates the need to change
the entire job. This quantitative assessment permits the ergonomist to make decisions about what level
of risk is acceptable for a job. It is not possible to totally reduce a jobs risk to zero. However, the LBD
Risk Model allows one to determine if a jobs risk is above a criteria of acceptance set by the company
or the ergonomist.
A fourth benefit of this LBD Risk Model is the assistance it can provide to the ergonomic intervention
process. Modified jobs can be re-monitored using the LMM, and the effects of those changes can be
quantified and compared with those values determined prior to the intervention. Traditionally, the
18-8
effects of job changes on the numbers of related musculoskeletal strains (the jobs incident rate) may
take several years to appear. The LMM can produce more timely feedback to the ergonomist regarding
anticipated returns on the redesign investmentactually, just the time needed to analyze the data. For
jobs that produce minimal reductions in risk due to redesign efforts, further improvements can be
attempted sooner. In other words, this risk model can assist in determining whether or not an ergonomic
intervention has produced enough of an improvement in the job.
18.4 Applications: How to Use the LMM and LBD Risk Model
Recommended Equipment
It is important to make sure that all equipment used in LMM data collection is available before going to
a job site. The following list of items represents the essential equipment needed.
Lumbar Motion Monitors

Two sizes of LMMs are available commercially, large and small. These LMMs differ only in their length;
the large LMM is suitable for taller individuals or individuals of moderate height who must bend forward
extremely far in their work. The small LMM is more appropriate for shorter individuals or those of
moderate height who do little forward bending.
LMM Harnesses
Elastic waist and shoulder harnesses are supplied with the commercial LMMs and consist of three sizes:
large, medium, and small. The large harnesses are for taller or heavier people, the medium harnesses are
for those with average body builds, and the small harnesses are for shorter individuals or those with
slighter builds. All harnesses have adjustable Velcro straps to allow for individual differences. The shoulder
harness is fitted over ones torso before the waist harness and LMM are attached. The waist harness
attaches to the LMM before it is placed on the individual.
Laptop/Notebook Computer
The LMM software requires a PC-based operating system. (The software will be discussed in a later
section.) The computer should have, as a minimum, a 486 processor. However, the faster the processing
speed of the computer used, the more efficiently data will be collected and stored. Most industrial
environments will have 110-volt outlets for computers, though battery-operated laptops may make data
collection more flexible. Be aware of the length of battery life before recharge, however.
LMM/Computer Connections
A cable that connects the LMMs to the computer is supplied with the LMMs. This cable transmits
information regarding trunk positions from the LMM to the computer for storage. It is important that
this cable be in good working order, since data collection in an industrial environment can often put
heavy wear on equipment. Also available is a digital telemetry system. This wireless system consists of
a transmitter and battery pack, worn on the waist harness, and a receiver unit, placed alongside the
computer. Both systems (the cable and the telemetry unit) provide the same information. The telemetry
system, however, allows data to be collected without the cable connection between the monitored
individual and the computer, providing greater freedom of movement.
Other Equipment
The LMM provides data regarding the trunk motions required of a job. However, other information is
important and needs to be collected at the job site to fully assess the jobs risk. Listed below is additional
equipment that should be part of the LMM gear.
Scale and Push/Pull GaugeIt is critical to record the weights of items handled by individuals during
data collection. A heavy-duty scale is needed, one that is capable of reading object weights from 1 to 100
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pounds. Occasionally, during material handing, objects are not lifted but are pushed or pulled instead.
A gauge capable of recording these forces also is important to have. Both devices are available commercially.
Tape MeasureA heavy-duty tape measure is needed to record the reach distance and the vertical
and horizontal locations of objects that are handled at the job site. The size of the objects themselves
also may be of importance and can be measured using a tape.
Extension Cord/Outlet StripPower outlets in industry are not always conveniently located near
where data collection is to take place. An extension cord permits greater flexibility in locating the
computer closer to the job site and in full view of the individual being monitored. An outlet strip also
allows the use of other electronic devices such as video recorders and battery chargers.
Wheeled CartCollapsible carts are useful to move equipment into the job site, and from one site to
another, if multiple sites are to be monitored.
Selecting the Job(s) to Monitor

The LMM can be used to monitor the positions, velocities, and accelerations of the trunk in the three
cardinal planes for any job in which trunk movements are required. This type of information can be
important when one needs to describe the motion characteristics required of a job or activity. The LBD
Risk Model is composed of five workplace factors that, when combined, assess a jobs probability of
having a high number of LBDs. This model is also useful for establishing relative comparisons between
several tasks that comprise a job.
The industrial jobs used to develop the risk model had MMH frequencies ranging from approximately
6 to 1500 lifting tasks required per hour. Thus, the tasks to be assessed using this risk model should fall
within this scope of lifting rates. Most MMH jobs fit this profile. For example, in automobile assembly,
job cycles are repeated every one to two minutes, and the parts themselves often are standard in size and
weight. Palletizing jobs may require very different types of objects to be handled, but the task of continual
lifting from one storage area to another remains the same. These types of jobs are very consistent with
those used to develop the risk model database, and the jobs LBD risk can be easily assessed with the
LMMs software.
Some jobs are less repetitive or have more job variation than assembly or palletizing tasks. However,
the LBD risk model still can be used to make relative comparisons between the tasks that comprise the job.
For jobs that require a larger number of tasks, the risk model is helpful in comparing the factors that make
up the model. This will allow for the ergonomist to assess trade-offs between such factors as lifting frequency,
object weights handled, and the trunk motions required for the different tasks. It should be noted that
there is inherent variability in the way an individual may perform the same task repeatedly. Because of this
difference, a minimum of five repetitions should be collected of any given task.
Another issue to be considered is job rotation. Employers often use a variety of rotation schemes for
job processes. If the job to be monitored requires no rotation (employees perform the same job every
day/week/month), then the risk assessment can be directly related to the tasks observed. Jobs in which
individuals rotate regularly between a few work areas also may be used in assessing LBD risk, if this
rotation schedule is fixed. When the job rotation requires employees to do completely different jobs on
an hourly or weekly basis, it becomes difficult to relate a tasks risk values to the overall job risk, since
many tasks could contribute to the risk assessment. This issue is key to determining a jobs suitability for
LBD risk assessment. That is, does the jobs work structure enable one to define the job in terms of a few
repeatable, consistently performed tasks?
There may be some jobs that fit within the LBD Risk Model profile but still should not be monitored.
Seated jobs may require repetitive activities, but they usually are not ones that require significant material
handling. In any event, the LMM may rub against a chairs back or the waist harness will shift from its
position on the hips during seated work, and erroneous LMM output will result. Also, jobs that require
close contact of the LMM with a finished product could produce scratches on the product, and the
employer may not want to risk product damage. Finally, exposure to water or other liquids may damage
the LMM or its components.
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FIGURE 18.4 The three tasks of the frozen food packager job: (a) place two packages in box; (b) record date/time of
packaging; (c) load full box onto pallet.
TABLE 18.3 Task Analysis of One Cycle of the Frozen Food Packager Job
Defining the Major Components of the Job through a Task Analysis

It is very important to properly define all relevant tasks that make up the job under investigation. These
tasks should encompass the range of materials handling work that is required of the jobespecially
those that may present a risk of LBD. The tasks also should be defined so they are meaningful to those
who will be interested in the LMM results. One way to define these job tasks is through a task analysis.
A task analysis defines the discrete events of a job.
Take, for example, a job performed in a food processing plant (shown in Figure 18.4). An employee
places twelve frozen food packages, two at a time, into a box (a), records the date and time of the
packaging (b), then loads the packed box onto a pallet (c). A simple task analysis of this job is shown in
Table 18.3. Two of the three tasks identified would qualify as material handling tasks for this job
loading the individual packages and placing the full box onto the pallet. Recording the date and time of
the packaging would not be considered relevant material handling since low forces and exertions are
required. Any trunk movement related to this task would not be considered in further analyses. However,
trunk kinematics and the probability of risk could be determined for the two relevant MMH tasks
identified.
It may be convenient to subdivide and redefine a task that is similar in all work dimensions except for
one. For instance, in the above example, a fully loaded pallet may contain many boxes stacked several
layers high. Tasks could be defined separately as Place box on Layer 1, Place box on Layer 2, etc.
This may assist data interpretation. That is, differences in trunk kinematics could be interpreted not
only as a function of the defined job tasks, but further in terms of workplace factors such as a boxs
location on a pallet.
Collecting and Recording Workplace Data for Risk Assessment

The trunk motion information that is used in the LBD Risk Model is automatically stored in the data
collection software. Trunk motions include the position, the velocity of movement, and the related
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acceleration of the trunk in all three directions of motion during a taskthe lateral (side-bending)
plane, the sagittal (forward bending) plane, and the rotational (twisting) plane. Two other components,
lift rate and maximum moment, must be determined and input manually.
Lift Rate
Lift rate is defined as the total number of MMH actions that a job requires per hour. This number is
related to the lifts for all tasks combined; it does not change from one task to another in a job. As the
task analysis in Table 18.2 found, on average, one box is fully prepared and loaded onto the pallet per
minute. Assuming this rate represents an average job cycle across the work shift, the packaging task
alone would require 360 lifts per hour, since the product is placed in each of the 60 boxes six times (two
packages per lift). For the palletizing task, 60 lifts are required per hour, for each fully packed box. Both
tasks combine for a total of 420 lifts required per hour for this job. The non-MMH date/time recording
task would not influence the lifting frequency of the job.
Because the lift rate value is directly input into the LBD Risk Model, it is very important to get an
accurate estimate of the lifting frequency. It may be necessary to confirm the task analysis results by
questioning employees familiar with the job or the job supervisor.
Maximum Moment
Maximum moment is defined as the external moment generated about the spine. A moment is composed
of two factors, the weight of the object being handled and the horizontal distance from the spine at
which it is handled.
WeightEach object handled on a job must be weighed and recorded in the software or noted
manually and input during data analysis. If objects of varying weights are handled, then each must be
weighed individually and recorded. This often occurs in mail and freight delivery operations. In the
aforementioned food processing example, the weights are constant for each task. The combined weight
of the two food packages lifted together needs to be recorded, as should the weight of a fully packed box
that is palletized.
Horizontal DistanceA tape measure is needed to determine how far from the spine objects are
being handled for each task. With the tape measure held horizontally, one must measure the distance
from the spine at the lumbosacral joint (near the top of the hips) to the center of the hands when the task
is being performed. Obviously, as individuals handle objects, this distance changes as the object is moved.
It is important to determine at what point during the task the distance is the greatest (i.e., generating the
greatest moment about the spine) and to record this length. An ergonomist correctly measuring the
horizontal distance is shown in Figure 18.5a. Here, the tape measure is kept level to determine the length
from the individuals L5/S1 joint to the center of the hands. The incorrect approach is being used in
Figure 18.5b, since the distance being measured is not horizontal.
For some MMH jobs, perhaps those on an assembly line, work requirements can be very repetitive
and the employees actions and movements rather consistent. In these cases, the horizontal distances
may not vary much as identical objects are handled on each cycle. For other jobs, such as when pallets
are loaded or unloaded, each cycle can produce very different trunk motions, since objects are being
handled from different areas. This will likely change the horizontal distance at which an employee
handles the load. Because the maximum moment value, a combination of an objects weight and its
horizontal distance from the spine, is directly input into the LBD Risk Model, it is important that these
distances be accurately measured and that changes in the distances for each task cycle being monitored
by the LMM are recorded.
The measurement of these horizontal distances should not interfere with the work being done by the
employee. The ergonomist who measures these distances should stand close enough to the individual to
get accurate readings, but far enough away to not disturb the work. It is important that the individual be
able to move naturally at the job site. A monitored employee being crowded by an investigator will
move differently, change his/her trunk motions, and give erroneous information via the LMM.
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FIGURE 18.5 The correct (a) and incorrect (b) methods of measuring the distance a load is held from the L5/S1 joint.
FIGURE 18.6 Flow chart of the LMM set-up procedure.
Setting Up the LMM for Data Collection

After the job to be monitored has been selected, the tasks identified, and basic workplace information
has been gathered, the data collection process can start. To begin, the proper LMM and harnesses need
to be chosen and prepared for use. This process is depicted in a flow chart in Figure 18.6 and is described
below.
Selecting the Correct LMM

The standing height of the individual to be monitored is usually the best indicator of which LMM to use.
As shown in Figure 18.7a, a small LMM placed on a taller individual will restrict his/her range of motion.
A large LMM put on a shorter person will cause the LMM to buckle and give erroneous readings
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FIGURE 18.7 LMM sizing- (a) the small LMM incorrectly placed on a tall individual; (b) a large LMM incorrectly
put on a small individual; (c) properly sized LMM for the individual.
(Figure 18.7b). Both situations could damage the LMM. A properly sized LMM (Figure 18.7c) will
enable an individual to stand upright without the LMM pulling him/her backward or buckling due to
the waist and shoulder harnesses being too close to one another. The shoulder harness also can be
adjusted to create a proper fit.
Adjusting the LMM

LMMs are individually calibrated during their manufacture, and there is a specific position designated
as its neutral position. During normal usage, this neutral position may change slightly and must be
readjusted (through the software) before every subsequent use. To adjust the LMM, choose which
LMM is to be used, but keep it in the LMM case. Attach the cable from the computer to the LMM (or
use the telemetry device), and adjust the voltage offsets using the supplied LMM software. Every LMM
should be adjusted in this manner before it is placed on an individual. Without disconnecting the LMM,
use the software to monitor the LMMs three motion traces. Take the LMM out of the case and move
the top of the LMM while keeping the bottom in place. The three traces on the computer screen should
show realistic position values.
Putting the LMM on the Employee

After the LMM has been checked to be working properly, it is ready to be placed on an employee. When
handling the LMM, note that it should never be bent into extreme angles; damage to the LMM could
result. The following steps, diagrammed in Figure 18.6, will ensure proper placement.
Select the Shoulder HarnessThe shoulder harness should fit snugly when worn but still enable the
individual to breath normally. Its important that most of the Velcro strap that crosses the chest be
overlapped during wear, so that it and the LMM remain in place during data collection. Place the
harness on the individual to be monitored.
Attach LMM on Waist HarnessThree sets of harnesses are available. Select the size that will fit on
the individual with the greatest amount of Velcro that will overlap when worn. Place the base of the
LMM evenly on the waist harness and secure tightly.
Place Waist Harness/LMM on IndividualFirst slide the top of the LMM into place on the shoulder
harness. Then, fit the waist harness over the hips and momentarily secure the harness with the Velcro
strap. The base of the LMM (at the lowest t-section) should be aligned with the lumbosacral joint (L5/
S1) of the trunk. This position can be found by first locating the tops of the hips (the iliac crest) with the
fingers, then placing the thumbs about an inch lower than the fingers. See Figure 18.8 for proper LMM
alignment on an individual. When the LMM base has been positioned, check that the LMMs t-sections
are aligned vertically. If not, one or both of the following adjustments can be made:
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FIGURE 18.8 Proper placement of the LMM on the torso. The base of the LMM is located slightly below the top of
the hips, and the LMM t-sections are aligned vertically.
1. The waist harness can be moved to the left or right.

2. The shoulder harness can be loosened and shifted. It can be adjusted by shortening or lengthening
the Velcro straps that cross over the shoulders.
Once the LMM is properly positioned, securely tighten the Velcro strap on the waist harness, and insert
each leg strap through the buckle. It is important to always use these leg straps. They prevent the LMM
from moving up on the hips, which otherwise would move the base of the LMM from its L5/S1 location
and result in erroneous data.
Collecting the Data

After the LMM is properly placed on an individual and is correctly hooked to the computer, the investigator
is ready to gather job data. It is suggested that the individual be given some time (a few job cycles, for
example) to become accustomed to the LMM before collecting data.
If not already done, the company, job, task, and employee data need to be entered into the LMM
software. Follow the software instructions for this procedure. Examples of the job profile set-up screens
for the Chattanooga DOS and Windows software are shown in Appendix A-18.1. After the task data
are input and the data collection screen is open and showing the three traces (for the lateral, sagittal, and
twisting planes of motion), data collection can begin.
The main goal of data collection is to gather information on trunk motions that is representative of
all the work required of the job. For example, if the job requires handling objects of widely varying
weights or from different locations (on a pallet, for example), then the data should be gathered of each
of these tasks. The more data that are collected, the more it is likely to represent the requirements of the
job. The amount of data collected should be reflective of the job and how it is structured. For example,
if 80% of the job requires doing Task A and only 20% doing Task B, then a majority of the data should
be of the employee performing Task A. In other words, data collection should be proportional to the job
being studied. Example LMM data collection screens for DOS and Windows software packages are
shown in Appendix A-18.2. Notice that only the motions associated with the designated tasks are
marked using the computer keyboards function keys.
There is no set number of job cycles that indicates when enough data have been collected. It is
dependent on the nature of the tasks. Jobs that are highly consistent in their activities usually require
fewer numbers of collected cycles than those with more widely varying requirements. The authors suggest,
though, that a minimum of seven to ten cycles of any task be collected.
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TABLE 18.4 Example Data Collection Form
Its extremely important to keep a record of the weights handled and the measured horizontal lifting
distances for each task cycle collected, so that these data are matched with the corresponding trunk
motion data for that cycle. An example form is shown in Table 18.4. The ergonomist may wish to
develop a customized data collection form beforehand to keep track of this information.
Analyzing and Interpreting the LMM Data

By following the guidelines in the previous sections of this chapter, data analysis and interpretation will
be made easier. Tasks of a job that are carefully chosen will assist in the jobs interpretation of its risk
probability and lead to results having more practical significance. The software used to collect and
analyze LMM data provides trunk kinematic information and risk probability charts for each task
defined for a job and for each employee who was monitored. It is beyond the scope of this chapter to
provide LMM software documentation. Instead, explanations of how these software outputs can be
interpreted will be discussed.
Trunk Kinematic Information

Information on the specific trunk motions produced by employees during each task can be obtained
from the software. This includes the trunk positions and the velocities and accelerations produced by
the trunk for each plane of motion for those cycles of a task chosen by the ergonomist. This information
can be useful for general descriptions of the material handling or for comparisons with other tasks or
jobs. Use of these data can be valuable for investigators who have formed hypotheses about, for example,
what tasks require more trunk motions than others.
Output from the frozen foods example job is shown in Table 18.5. As the header shows, these data
include trials of data collected for the food packaging task of this job. Information includes minimum
and maximum trunk positions, average and maximum velocities, and maximum accelerations and
decelerations for each plane of motion. From these data, average motions over the six trials could be
computed, as could the range of movement required and the amount of variation for each kinematic
parameter.
Probability of High Risk Group Membership (LBD Risk)

The software will produce information that compares the job tasks of interest with a database of jobs
previously determined to be at a high or low risk in terms of low back injury. The interpretation of
data is best described through continued use of the food packager example.
TABLE 18.5 Output Data Showing Low-Back Kinematics for Six Trials of One Job Task
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18-17
In the food packaging job, two tasks were defined. The first task involved placing individual frozen
food packages into a box (12 in all), and the second task involved loading the filled box of packages
onto a pallet. Risk probability charts are shown for each task in Figure 18.9. In Figure 18.9a, The
package loading task was found to have a risk probability of 40%. (Probability values are calculated by
averaging the individual logits from each of the five risk factorsin Figure 18.9a,
(99%+30%+3%+23%+45%)/5 = 40%.) The risk charts for this first task that were produced using the
DOS and Windows LMM software are shown in Appendix A-18.3. The probability value for the
palletizing task (Figure 18.9b) was calculated to be 64%, clearly the task more similar to those considered
high risk. These two probability values are to be used only for comparison purposes. It is the chart in
Figure 18.9c that reflects the true risk value for the entire job. This chart summarizes the largest values
for each risk factor across both tasks making up this job. The value shown on this chart, and thus the
risk for this material handling job, is 66%.
A closer examination of the top two charts in Figure 18.9 shows which factors most contributed to
the job summary values in Figure 18.9c. Each of the five factors is discussed separately.
Lift RateThe lifting frequency for the entire job was 420 lifts/hour. Because this variable is composed
of the total number of lifts from both tasks, this value is shown to be the same on all charts in Figure
18.9. As indicated by the length of the lift rate bar on the charts, this rate is very rapid and is comparable
to some of the highest frequency material handling jobs found in industry.
Average Twisting VelocityThe amount of twisting velocity required for package loading was fairly
low, but it was moderately high for the palletizing task, as indicated by the length of the bars on these
charts in Figure 18.9. The greater value of the two is used in the job summary chart in Figure 18.9c,
which was taken from the palletizing task.
Maximum MomentAs shown on the charts in Figure 18.9, the moment values were very low for
both tasks comprising this job. The low weight of the individual packages (each at one pound) and the
fully packed box being palletized (12 pounds) generated low maximum moment values. The greater
moment value from the palletizing task was used in the job summary chart.
Maximum Sagittal FlexionThe package loading task was performed while employees were in
relatively upright postures. This is reflected in Figure 18.9a by a short sagittal flexion bar on the chart.
However, during box palletizing, those boxes placed on the lower layers of the stack required much
forward trunk flexion. Figure 18.9b depicts these higher angles by the long bar for this factor. Subsequently,
this higher value of the two tasks resulted in it being used in the job summary chart in Figure 18.9c.
Maximum Lateral VelocityThe LMM determined that lateral velocities generated during the package
loading task actually were higher than found during box palletizing. While the values for the previous
factors all were larger during handling of the full box, and thus were used in the job summary chart, it
is the lateral velocity value from the package loading task that must be used in the job summary, since it
is the greater of the two tasks analyzed.
It is the job summary value of 66% (taken from the chart in Figure 18.9c) that represents the LBD
risk for this example food processing job. The value indicates that, on the continuum of low-risk jobs
(0%) to high-risk jobs (100%), this particular job has a 66% likelihood of being considered high
risk. As stated earlier in this chapter, a high-risk job was defined as one having twelve or more (with an
average of 26.4) low back strains per 200,000 hours (or 100 workers/year) of employee exposure.
Results here could be interpreted as indicating that this particular job has a moderately high chance of
producing a large number of low back strain injuries among individuals who do this job.
The primary goal of the LMM analysis could be simply to determine whether or not a job presents a
risk of low back strain to its employees. This can be determined by calculating the LBD risk value from
a job summary. As Figure 18.10 shows, there is some overlap in risk values among jobs defined as low
and high risk. However, our analyses (Marras et al., 1993) found that those jobs with fairly low probability
values (below 30%, for example) were much more likely to be low-risk jobs. Similarly, very few jobs
having a risk value over 50% were defined as low risk, and no low-risk jobs had risk values over
70%. That is, jobs with probability values above 60% are virtually assured to have some low back
injury risk associated with them.
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FIGURE 18.9 Risk value charts for the frozen food packager job: (a) Place Two Food Packages in Box task; (b)
Load Full Box onto Pallet task; and (c) summary of all job tasks.
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FIGURE 18.10 Distributions of the LBD risk values for jobs defined as low risk and those defined as high risk
in Marras et al. (1993).
A second goal of the analysis may be to compare one job task with another, to determine which
one(s) require more back motions and external moments about the trunk. This exercise can assist in
learning which task(s) should be the focus of redesign efforts. Introducing ergonomic modifications to
tasks already found to have low risk values probably will have little real impact on improving the job
overall. However, making changes to tasks whose individual factors contribute most to the jobs summary
risk probability will reduce the probability for the entire job.
A third goal of the analysis may be to determine, for specific tasks, which individual components are
most responsible for its composite probability value. This type of analysis provides direct information
regarding how the jobs requirements may affect those factors used in this probability model. Examples
of ergonomic improvements that can be made on a job to affect each component are listed below. These
examples should not be considered an exhaustive list of possible changes that can be implemented to
improve working conditions.
Lift RateThe total number of material handling actions required of the job affects this risk factor. Thus,
reducing this rate will reduce the overall risk value. This type of change is not usually favored by management,
since it will likely reduce productivity. However, there are ways to redesign jobs to reduce lifting frequency:
1. Rearrange Job TasksFor jobs in which a number of tasks comprise the job, one method is to
rearrange tasks with those of other jobs. This may more evenly distribute the lifting frequencies
of several jobs, some of which may be considerably lower than the job monitored.
2. Rotate JobsRotating employees between a job having a high lifting frequency with one having
a much lower frequency also will reduce the rate for the job of interest. The effects of the job(s)
into which employees are rotated must also be considered, however. It should be cautioned that
this and the previous approach are most beneficial if the jobs that are rearranged or included in
the rotation allow employees to use different muscle groups to perform the job. Rotating individuals
into jobs that require the same muscles be used likely will have either no benefit or could produce
greater musculoskeletal stress.
3. Add EmployeesDividing the job so that added personnel are available to perform the job will
distribute the work across more people and lower the jobs required lift rate. Of course, the cost
of the additional employee(s) must be compared with the benefits of reduced low back strains
and their related costs.
4. AutomateIt may be possible that some job tasks can be automated through new equipment or
robotics. This method of assisting the material handler will undoubtedly reduce the lifting frequency
of the job and the overall job requirements.
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Average Twisting VelocityRapid twisting of the trunk can result from a number of situations. If a
work area is designed such that material transfer from point A to point B is difficult or if these two
locations are not convenient to one another, a high twisting velocity may result. High velocities often
result because work areas do not allow employees to move their feet to handle goods. As a result, a
turning action an employee would normally do that included movement of the trunk, hips, legs, and
ankles is more concentrated in the trunk, and higher twisting velocities can occur. It would be difficult
to reduce the speed at which individuals twist simply by instructing them to slow down. However,
engineering controls that can reduce twisting velocity include:
1. Place Work in Front of Material HandlerMove the locations of point A relative to point B, so
that they are more convenient to one another. In other words, create a workplace in which the
material transfer requires moving in as few planes of motion as possible, thus allowing the employee
to remain in a more neutral posture
2. Spread Out Congested Work AreasMaterial handling areas that allow employees to walk or
take at least one step between handling points A and B often reduces the twisting velocity of the
job. This occurs because the added movement allows one to get into a position in which the
entire body can assist in the transfer, rather than just the trunk.
3. Raise Working HeightsDepending on the location of goods to be handled, lower levels of work
that require a great deal of sagittal flexion also may require additional trunk twisting. This is
often the case when the work requires asymmetric lifting. By raising the work heights, not only
will forward flexion be reduced, but twisting velocity can decrease because the handling distances
are more appropriately located.
Maximum MomentBecause an external moment is the product of an objects weight and the distance
from the body at which it is handled, reducing either of these two factors will reduce the moment.
Various examples are described below.
1. Reduce Weight RequirementsSome work situations allow employees to handle as many units
or as much weight as they feel is acceptable. However, to work faster, some employees may
handle more goods at one time than is physically safe. A limit on the numbers/weights of objects
handled in any given time can reduce Maximum Moment values. In some environments, raw
materials handled are received from a supplier in bulk quantities. The weights of these materials
may produce excessive moment values. By working with these suppliers, an arrangement may be
possible to package materials in smaller, lower-weight containers. The weight changes just described
likely will increase the lifting frequency of the job, however, so this trade-off in the risk model
should be examined.
2. Install Material Handing AidsFor goods that are of uniform shape or size, several types of
lifting aids are commercially available to provide handling assistance. These can be adapted to a
wide range of work environments. Handling aids, such as lifting hoists, when incorporated
successfully, greatly reduce the loading forces on the spine and result in much lower moment
values. The device should be considered carefully, since a handling aid that is difficult to use or
greatly slows the job process will likely be abandoned by the employees. In addition, some material
handling aids can reduce the distance at which objects are handled. For example, lift/tilt tables
are available commercially and able to be adapted to specific needs. These devices can raise or
angle objects or bins of goods so that they can be more easily accessed. This can result in reduced
horizontal reach distances.
3. Evaluate the Transfer LocationsThe distance from the body at which individuals handle goods
often is greatest during the initial or final contact with the product. This is often true during
palletizing operations, in which cases need to be placed properly on a skid to ensure the loads
stability. During carrying, for example, people tend to bring the product closer to their bodies.
An evaluation of these locations may detect workplace arrangements that cause individuals to
reach farther than is necessary to handle objects.
18-21
Maximum Sagittal FlexionThe more that individuals work in upright positions during material
handling, the lower their trunk flexion will be. This reduces subsequent risk probabilities for jobs.
Reducing sagittal flexion can be accomplished by eliminating tasks that, for example, require loads
below knee level to be handled. Several interventions can prevent these situations.
1. Raise the Heights of Loads Placed near the FloorObjects can be raised from the floor during
material handling work a number of different ways. For palletizing tasks, stacking a skid
underneath the pallet will raise the height of the bottom-most objects. Lift tables and self-raising
devices placed underneath objects also will raise objects higher off the floor and reduce sagittal
flexion. These changes should be evaluated for safety considerations and to ensure that objects at
the top of the pallet can still be accessed. Other tables are available commercially that tilt or
swivel objects, such as those on pallets, that bring the loads closer to the material handlers.
2. Adjust Working Heights Relative to an Individuals Standing HeightWork areas that are
adjustable to accommodate those performing the work also can reduce trunk flexion. Work
tables can be constructed or purchased that move vertically to a position most comfortable to the
user. On assembly lines, conveyors can be adjusted that raise or lower objects depending on the
work being performed at a specific location. Alternately, work areas alongside the lines, under
the employees themselves, can be raised or lowered to produce the correct working height.
3. Train Employees on Proper Lifting TechniquesFor some work situations, vertical adjustability
may not be technically or economically feasible. In these cases, employees can be educated on proper
lifting techniques aimed to reduce back strain and reduce the amount of sagittal flexion required.
Maximum Lateral VelocityHigh lateral velocity values on the risk charts indicate that the material handling
work requires rapid sideways bending. This motion may be difficult to visualize, but it usually indicates that
work is not being performed in front of ones body, but asymmetrically instead. Workplace modifications
that more conveniently locate or raise the work relative to the material handler (as already noted above) can
assist in reducing this factor on the probability charts. A case study conducted by Stuart-Buttle (1995) found
that reductions in lateral velocities and sagittal flexion can be achieved through workplace interventions in
MMH tasks using lift tables. This paper also illustrated the importance of testing the impact of workplace
modifications. The initial installation of this table actually produced higher LMM risk values and more
employee dissatisfaction. The LMM analysis identified the problems with the new system and provided
feedback about how the workplace needed to be further changed to produce actual risk reduction.
From the example job modifications just discussed, it is important to understand that these five workplace
factors are interrelated. None of these factors responds independently from the others. For instance, adding
a lift table to palletizing work may reduce sagittal flexion, because the load is being raised. However, is also
can lower the maximum moment and average twisting velocity values, because the load may be held closer
to the body during handling and be more easily accessed. If the work is self-paced, lift rate actually could
increase since the work may be less physically demanding and those affected may be capable and willing to
handle more material. This example illustrates the trade-offs that must be considered when evaluating the
probability of risk for a job and implementing ergonomic interventions.
Interpreting Results from Several Individuals

Casual observation of any material handling activity will show that different people usually perform the
same job slightly differently. Employees inherently vary in how they do manual work, and this will likely
produce different trunk motions. To account for these differences, the ergonomist may wish to use the
LMM to monitor several employees who perform the same job and then analyze and interpret the
results in terms of average probabilities across these individuals. The authors know of no literature that
specifies how many employees must be monitored to account for all variability in a job. This process is
task-dependent, and the ergonomist should study the amount of variability of the job tasks and work
layout before deciding how many employees to monitor. Assembly-line or machine-paced operations
may limit the freedom employees have in performing job tasks in comparison with self-paced material
handling work. The ergonomist may want to adjust the number of individuals monitored accordingly.
18-22

TABLE 18.6 Computational Example for Assessing LBD Risk
from Three Employees Performing the Frozen Packager Job
If the LMM data collection and analysis software does not assess the average risk probability across
employees doing the same tasks, then these values can be calculated manually, by following the steps
listed below. A computational example of the results from three employees monitored who performed
the frozen food packager job is shown in Table 18.6.
1. For Task 1, the average probabilities range from 36.0% to 41.0% for these three individuals. For
Task 2, the range is 64.0% to 67.0%. To find the probability average for each of these tasks,
average the values of each factor used in the model across all employees. That is, add the lift rate,
average twisting velocity, maximum moment, maximum sagittal flexion, and maximum lateral
velocity values separately and divide that number by the total number of employees monitored.
Do this calculation for each job task. In Table 18.6, the right-most column shows the average
values for each risk factor for the two material handling tasks of this job.
2. Compute the average probability for each task. To do this, sum the individual factor probabilities
and divide by five. This value will be the average probability across employees. In the right-most
column, Table 18.6 shows that the average probability for Task 1 is 39.0%, and it is 65% for
Task 2. Also note that, due to individual differences in how the job is done, risk values vary from
employee to employee.
3. Determine the job risk probability by reviewing all averaged task probabilities (again, those in
the right-most column of Table 6 for Task 1 and Task 2). Find the highest probability value for
each of the five factors and record it. This must be done for each employee and overall, to find
the average risk for the job. As Table 18.6 shows, the largest average values for all five factors but
maximum lateral velocity come from Task 2. These are shown in the bottom section of this table.
Averaging these five values generates a job risk of 65.8%. This represents the risk for the entire
job, averaged across all employees monitored.
18-23
References
Andersson, GBJ, The Adult Spine. Principles and Practice, 2nd ed. Raven, New York, 1997.
Andersson GBJ, Epidemiologic aspects on low back pain in industry. Spine, 6(1):5360, 1981.
Bigos SJ, Spengler DM, Martin NA, Zeh J, Fisher L, Nachemson A, and Wang MH, Back injuries in
industry: A retrospective study. II. Injury factors. Spine, 11(3):246251, 1986.
Cats-Baril WL and Frymoyer JW, The economics of spinal disorders, in Frymoyer JW, Ducker TB,
Hadlet NM, Kostuik JP, Weinstein JW, and TS Whitecloud III (Eds.): The Adult Spine: Principles
and Practice. Raven Press, New York, 85105, 1991.
Gill, KP, and Callaghan MJ, Intratester and intertester reproducibility of the lumbar motion monitor as
a measure of range, velocity and acceleration of the thoracolumbar spine. Clinical Biomechanics,
11(7):418421, 1996.
Magora A, Investigation of the relation between low back pain and occupation. 4. Physical requirements:
Bending, rotation, reaching and sudden maximal effort. Scand J Rehab Med, 5(4): 186190, 1973.
Marras, WS, Fathallah FA, Miller RJ, Davis SW, and Mirka GA, Accuracy of a three dimensional
lumbar motion monitor for recording dynamic trunk motion characteristics. International Journal
of Industrial Ergonomics, 9(1):7587, 1992.
Marras WS, Lavender SA, Leurgans SE, Rajulu SL, Allread WG, Fathallah FA, and Ferguson SA, The
role of dynamic three-dimensional motion in occupationally-related low back disorders. Spine,
18(5):617628, 1993.
National Center for Health Statistics, Prevalence of Selected Impairments, United States Government
Printing Office, Series 10, No. 134, 1977.
National Institute for Occupational Safety and Health (NIOSH): Work practices guide for manual lifting.
Department of Health and Human Services (DHHS), National Institute for Occupational Safety and
Health (NIOSH), Publication No. 81122, 1981.
Putz-Anderson V and Waters TR. Revisions in NIOSH guide to manual lifting. Paper presented at
national conference entitled A national strategy for occupational musculoskeletal injury prevention
Implementation issues and research needs. Ann Arbor, MI, University of Michigan, 1991.
Punnett L, Fine LJ, Keyserling WM, Herrin GD, and Chaffin DB. Back disorders and nonneutral trunk
postures of automobile assembly workers. Scand J Work Environ Health, 17:337346, 1991.
Stuart-Buttle C, A case study of factors influencing the effectiveness of scissor lifts for box palletizing.
American Industrial Hygiene Association Journal, 56:11271132, 1995.
18-24
APPENDIX A-18.1 Example job profile selection screens for Chattanooga software; (a) DOS version; (b) Windows
version
18-25
APPENDIX A-18.2 Example data collection screens for Chattanooga software; (a) DOS version; (b) Windows
version.
18-26
APPENDIX A-18.3 Example OSU Model screens for Chattanooga software; (a) DOS version; (b) Windows version.
19
Prevention of
Musculoskeletal
Disorders:
Psychophysical Basis
19.1
19.2
19.3
Patrick G.Dempsey
19.4
Liberty Mutual Research Center for

Safety & Health
19.5
Introduction
Chapter Goal and Outline Introduction to
Psychophysics The Current State of Psychophysical Data
The Psychophysical Approach to Designing
Manual Materials Handling Tasks
Setting Weight and Force Limits Task and Workplace Design
The Psychophysical Approach to Designing
Upper Extremity Tasks
Setting Acceptable Force and Frequency Limits Tool and
Workplace Design
Advantages and Disadvantages of the
Psychophysical Approach
Conclusions
191
193
1921
1923
1924
19.1 Introduction
Occupational ergonomics is a discipline that seeks to maximize the performance of systems found in
diverse settings such as production work, service industries, and health care. In this context, the system
consists of the personnel, the equipment, the organizational and ambient environments, and the tasks
required to produce a good or service. System performance refers to the ratio between system outputs
(goods and services) and inputs to the system (personnel, capital, etc.). Not only is productivity at
individual workstations important, but so is preventing injuries and illnesses associated with the tasks
performed. A detriment to system performance in many settings in which manual work is performed is
musculoskeletal disorders.
The direct costs (medical and indemnity payments) associated with work-related musculoskeletal
disorders (WRMSDs) represent a significant source of financial losses. These losses have a direct economic
impact on employers and insurers, which in turn are passed on to the customer. For example, customers
who buy goods or services from an organization must bear the additional costs of the WRMSDs associated
with producing those goods or providing those services.
An often overlooked aspect of WRMSDs is the negative impact of indirect costs (lost production time,
training new workers, litigation, etc.) on system performance. For WRMSDs that develop over a period of
time, there may be a gradual reduction in individual productivity. Once a disorder (whether it be the
0-8493-1800-9/03/$0.00+$1.50
19-1
19-2
result of cumulative trauma or the direct result of a single overexertion) progresses to the point that the
individual cannot continue to perform a job, there are additional indirect costs associated with lost
production, replacing the individual, as well as potential performance decrements until the replacement
worker becomes proficient at the task. The extent of indirect costs is partially a function of the injured
individuals function in the system.
One approach to the prevention of WRMSDs is the psychophysical approach. This approach seeks
to provide limits and guidelines for manual work that represent maximum acceptable work loads
that minimize the injury potential of the work. To some extent, it is unknown if the psychophysical
approach achieves this goal, as will be discussed in more detail later. In general, the extent to which
many ergonomic criteria represent optimal limits with respect to optimizing the performance of systems
comprised of manual work is unknown. Work loads and physical stresses have to be at or below levels
which protect workers, but at the same time permit output levels which are economically sound. The
psychophysical approach is an approach that seeks a balance between productivity and health and
safety concerns.
Chapter Goal and Outline

The goal of this chapter is to provide the reader with information concerning basic theory behind the
psychophysical approach, the availability of data for designing manual tasks, the methods of applying
the data, and the limitations of the data. The primary focus will be on the application of psychophysical
techniques rather than on empirical methodologies or a literature review of the theoretical underpinnings
of the psychophysical approach. Where necessary, theoretical and empirical results will be used to justify
specific application techniques or to explain caveats of psychophysical data. Manual materials handling
(MMH) and upper-extremity intensive (UEI) tasks have been the focus of psychophysical research, and
each will be considered separately due to the disparity in application methodologies.
Readers interested in the empirical and theoretical aspects of the psychophysical approach to MMH
task design are referred to Snook1,2 and Ayoub and Mital3 for further reading. For specific information
on the comparisons of the psychophysical approach to the biomechanical and physiological approaches
to MMH task design, the reader should consult Ayoub,4 Mital et al.,5 and Nicholson.6 Less thorough
information on the empirical and theoretical aspects of the psychophysical approach to UEI task design
is available. However, there are useful discussions in Kim et al.7 and Fernandez et al.8
Introduction to Psychophysics
Psychophysics is a branch of psychology dealing with the relationships between stimuli and sensations.
These relationships can be best described by the psychophysical power law. The psychological magnitude
(sensation) ? grows as a power function of the physical magnitude (stimulus) in the following manner:9
The value of the constant k depends on the units of measure, while the exponent n has a value that varies
for different sensations. The value of n may be lower than 1 for stimuli such as smell and brightness, or
as high as 3.5 for electric shock.9 Ljungberg et al.10 found a value of n = 1.86 for a simulated brewery
lifting task, whereas Gamberale et al.11 found a value of 2.43 for a similar task. Gamberale et al. attributed
the larger value in the latter study to more demanding lifting cycles.
In MMH experiments, the subject adjusts the magnitude of the stimulus (weight, force, or frequency)
to correspond to a sensation which is dictated by the instructions given by the experimenter, i.e.,
without straining yourself, or becoming unusually tired, weakened, overheated, or out of breath.12
Adaptations of these instructions have been used to study UIE tasks. For UEI tasks, the instructions are
directed at having subjects select work loads that do not result in unusual discomfort in the hands,
wrists, or forearms.13 Subjects are also monitored during experimentation for signs of soreness, stiffness,
and numbness.
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The Current State of Psychophysical Data

Psychophysical data are currently available for designing MMH tasks as well as UEI tasks. For MMH
tasks, there are fairly extensive data available for maximum acceptable weights and forces for lifting,
lowering, pushing, pulling, holding, and carrying tasks. Research of the psychophysical approach to
MMH task design has spanned approximately three decades, and current work continues to expand the
range of task conditions for which psychophysical data are available.
For UEI tasks, data are available for maximum acceptable frequencies and forces for a variety of
tasks. It should be noted that there are considerably more data available for designing MMH tasks than
UEI tasks. The increased attention to cumulative trauma disorders (CTDs) in the past decade or so led
researchers to adapt psychophysical techniques used in MMH research to the study of UEI tasks. In
part, this was done because of the lack of quantitative guidelines for forces, durations, and postures
associated with UEI work. Although there are not extensive data, there are data that can be used to
design manual work involving the upper extremities.
19.2 The Psychophysical Approach to Designing Manual Materials

Handling Tasks
One of the first approaches to the control of MMH injuries through specifying task limits was the
psychophysical approach. Applications in the military which relied on subjective estimates of load handling
limits14,15 were followed by the psychophysical approach being utilized to set industrial materials handling
limits.16 The methodologies and database developed by Snook and his colleagues1,1618,19 at the Liberty
Mutual Research Center have been used by researchers and practitioners for the past several decades.
This has resulted in the availability of a wide range of data available for designing MMH tasks (e.g.,
References 5, 1922).
Setting Weight and Force Limits

The application of the psychophysical approach to MMH task design is performed by using databases
in the literature which provide limits specific to task conditions such as frequency, pushing or pulling
distance, and load dimensions. Figure 19.1 presents a general model of the procedures associated with
applying psychophysical data.
To use a database, the user records the relevant task parameters, then finds the value in the database
applicable to the specific task. Since it is impossible to collect data for all combinations of tasks, one can
either use interpolation to find the appropriate value, or one can use the closest value. In the latter case,
the user should use the lower of the values in between which the task parameters fall. Next, the analyst
determines if a task is acceptable. At a minimum, an MMH task should be designed to accommodate
75% of the population:1 however, one should strive to accommodate at least 90% of the population
whenever possible. If females perform the task, then the design should be based upon accommodating
the female workers.
When a task does not accommodate at least 75% of the population, or if the task does accommodate
75% of the population and minor changes can be made to increase the acceptability of the task at little or
no cost, then the task and/or workplace should be redesigned to accommodate at least 90% of the population.
Options to increase the acceptability of a task will be described in more detail later. If a task cannot be
redesigned to accommodate at least 75% of the population, then preplacement testing should be considered.
Psychophysical Data
Most psychophysical databases present maximum acceptable weights or forces. There is limited
information available on maximum acceptable frequencies.2325 The data described in detail here are all
related to force and weight data.
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FIGURE 19.1 General model of the psychophysical approach to analyzing manual tasks.
The largest and most comprehensive single database for designing MMH tasks is that of Snook and
Ciriello.19 The data were collected from industrial subjects. The database includes maximum acceptable
weights for lifting and lowering tasks, maximum acceptable initial and sustained forces for pushing and
pulling tasks, and maximum acceptable weights for carrying tasks. The database provides values for males
and females, as well as values that accommodate 10, 25, 50, 75, and 90% of the respective populations.
An expanded computerized version of the database which covers a wider range of task conditions is
available which performs analyses for both single- and multiple-component jobs (CompuTask *).
For lifting and lowering tasks, Snook and Ciriellos19 database accommodates frequencies between
one lift/lower every eight hours and 12 lifts/lowers per minute. Box dimensions in the sagittal plane
between 34 and 75 cm are accommodated, as are lifts and lowers with vertical distances between 25 and
76 cm. Finally, data for floor to knuckle height, knuckle to shoulder height, and shoulder height to arm
reach ranges of lift/lower are available.
Snook and Ciriello19 presented maximum acceptable forces for pushing and pulling tasks, including forces
required to start an object in motion (initial force) and forces required to keep an object in motion (sustained
forces). Vertical handle heights between 57 and 135 cm are accommodated by the data. Frequencies for
pushing/pulling are the same as those for lifting. The push/pull distances range between 2.1 m and 61.0 m.
Finally, Snook and Ciriellos19 database also contains maximum acceptable weight of carry values for
the same frequencies as the other MMH tasks mentioned above. Carry distances of 2.1 m, 4.3 m, and
8.5 m are available with vertical heights of 79 and 111 cm for males and 72 and 105 cm for females.
Snook and Ciriellos19 data are presented in Tables 19.1 through 19.9.
Modified Psychophysical Databases

Mital et al.5 modified Snook and Ciriellos19 database to conform with biomechanical, physiological, and
epidemiological criteria. Mital et al. also present data from other sources for additional types of MMH
tasks. Snook and Ciriellos19 database was modified to satisfy the following criteria: spinal compression
*Registered trademark of Liberty Mutual Insurance Group, Boston, Massachusetts
19-5
limits of 2689 and 3920 N for females and males, respectively, in consideration of the results of Liles et
al.;26 an intra-abdominal pressure limit of 90 mmHg; and an energy expenditure limit of 21 to 23% of
treadmill aerobic capacity or 28 to 29% of bicycle aerobic capacity. Mital et al.5 also present maximum
acceptable frequencies of lift for one-handed lifting, acceptable holding time data, and maximum
acceptable forces and weights of lift for MMH tasks performed in nonstandard postures such as lying
down and kneeling. In order to extend the range of applicability of the modified data, Mital et al.5
presented seven multipliers to adjust the data for the following factors: work duration, limited headroom,
asymmetrical lifting, load asymmetry, couplings, load placement clearance, and heat stress.
Mital27 found that psychophysical data collected in short periods (i.e., 20 to 25 min.) assuming a
longer work period (8 to 12 hours) should be reduced. Subsequently, Mital21 presented psychophysical
data for males and females performing lifting tasks for 8-hour work shifts based on the adjustments
determined in the earlier study. The data were collected from 37 males and 37 females experienced in
manual lifting. Mital21 also presented a modified database representing the combined data from his
study, Snooks1 data, and data collected by Ayoub et al.20 Although the modified database only
accommodates lifting tasks, the combined sample size is considerable. Similarly, Mital22 presented a
psychophysical database for lifting tasks for males and females working 12-hour shifts. The database
represents values valid for 12 hours based on adjustments of 8-hour data.
Data for Nonstandard MMH Tasks

One advantage of the psychophysical approach is that it allows for the realistic simulation of many
types of materials handling tasks. Several such examples will be provided to illustrate how psychophysics
has been used to develop guidelines for specific applications.
Smith et al.28 presented a psychophysical database for evaluating MMH tasks performed in unusual
postures. Maximum acceptable weight data for 99 different tasks were presented, including data for
one-and two-handed lifting and lowering tasks performed in postures such as lifting on one knee, lifting
on two knees, lifting while lying down, etc. These data are particularly appropriate for occasional
maintenance tasks which impose postural constraints on the operator.
Like maintenance, mining is comprised of many activities for which standard psychophysical data
are not applicable. Mining tasks are often performed under postural constraints, such as limited headroom.
Gallagher29 collected psychophysical data to address tasks performed under restricted headroom conditions
and provided guidelines for tasks performed in low-seam coal mines requiring lifting while kneeling.
Mining also requires handling of a variety of materials. Gallagher and Hamrick30 provided psychophysical
guidelines for the handling of rock dust bags, ventilation stopping blocks, and crib blocks.
Assessment of Multiple Component MMH Tasks

More often than not, workers who perform MMH tasks perform a number of tasks, often in sequence.
For example, a common combination task in industry is where a worker lifts material, carries it for
some distance, then lowers the material. In such situations, all of the tasks should be evaluated.
Snook and Ciriello19 recommend using the weight or force limit for the task with lowest percentage
of the population accommodated as the design criterion for multiple component tasks. This
recommendation was based upon the findings of Ciriello et al.17,18 Thus, for a combination where the
worker lifts materials, carries materials, and then lowers material, the limiting component task would be
the lift. Snook and Ciriello19 do caution that this method of analysis may result in violation of
recommended energy expenditure criteria for some multiple component tasks.
Straker et al.31 disagree with the multiple component methodology described in the preceding
paragraph, stating that combination tasks should probably be assessed as whole entities and not separated
into components for analysis. However, Straker et al.31 recommend no alternative methodology to
assess multiple component tasks as whole entities. Ciriello et al.17,18 did evaluate combination tasks as
whole entities using psychophysics, and as stated above, there is typically one component that is the
limiting component. In general, the design and evaluation of multiple component MMH jobs is one of
the more underdeveloped areas of MMH research and practice.
TABLE 19.1 Maximum acceptable weight of lift for males (kg).
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Box width (the dimension away from the body) (cm).

Vertical distance of lift (cm).
Percentage of industrial population.
Italicized values exceed 8 h physiological criteria.
From Snook, S.H. and Ciriello, V.M., The design of manual handling tasks: revised tables of maximum acceptable
weights and forces, Ergonomics, 34, 1197, 1991. With permission.

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TABLE 19.2 Maximum acceptable weight of lift for females (kg).
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Vertical distance of lower (cm).

19-9
TABLE 19.3 Maximum acceptable weight of lower for males (kg).
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TABLE 19.4 Maximum acceptable weight of lower for females (kg).
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Vertical distance from floor to hands (cm).

The force required to get an object in motion.
*The force required to keep an object in motion.
TABLE 19.5 Maximum acceptable forces of push for males (kg).
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TABLE 19.6 Maximum acceptable forces of push for females (kg).

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TABLE 19.7 Maximum acceptable forces of pull for males (kg).
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TABLE 19.8 Maximum acceptable forces of pull for females (kg).

19-17

Italicized values exceed 8 h physiological criteria (see text).
TABLE 19.9 Maximum acceptable weight of carry (kg).
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The only other method for multitask assessment that incorporates MMH tasks in addition to lifting
that the author was able to find was the method presented by Mital.32 The data used with this methodology
are from Mital et al.,5 which are modified psychophysical data as described earlier. The method is similar
to that developed by Jiang and Mital,33 except that capacity is predicted using more contemporary data.
In general, this method requires that each MMH task is analyzed, and data regarding work duration,
etc., are also needed. The analyst then determines the percentage of the population that the design
should accommodate, which should be 75 or 90%. The next step involves calculating the recommended
work rate (kg-m/min) for the percentage of the population being analyzed using the Mital et al.5 data.
The actual work rate is divided by the recommended work rate, which yields the risk potential. Any risk
potential values greater than 1 signal the need for task redesign. This method focuses on the individual
components that are unacceptable, as with the Snook and Ciriello19 method.
Example
An example of Snook and Ciriellos19 multicomponent task assessment will be used to illustrate how
psychophysical data are used to analyze MMH tasks. The analysis was performed with the CompuTask
computer program. The set of tasks is fairly simple and includes a worker bending over and lifting a
box, carrying the box 5 feet, and lowering the box to the floor. The set of tasks is performed three times
per minute for 8 hours. The relevant data that need to be collected as well as the analysis are shown in
Figure 19.2. Aside from psychophysical results, physiological analyses and NIOSH lifting equation
computations (STRWL = single task recommended weight limit, FIRWL = frequency independent
recommended weight limit, STLI = single task lifting index, FILI = frequency independent lifting index)
are provided by the software.
The task with the lowest percentage of the population accommodated is the lifting task. This task
accommodates 75% of the male population and <10% of the female population. Thus, the set of tasks is
marginally acceptable for males and unacceptable for females. Also, the overall physiological evaluation
shows that the task is not acceptable for eight hours. As was discussed earlier, the method of analysis being
used may result in violation of energy expenditure criterion. Redesign efforts would be focused on eliminating
the tasks through materials handling devices or a conveyor, or eliminating the need to lift and lower the
boxes by increasing the vertical origin and destination of the lifting and lowering tasks, respectively.
Task and Workplace Design

An often overlooked use of psychophysical data is workplace design. In situations where unacceptable
tasks cannot be eliminated, or loads, frequencies, or forces cannot be reduced to acceptable levels,
psychophysical results can be used to suggest workplace design changes to increase the percentage of the
population that a task or job will accommodate. For example, a common problem is that the dimensions
and/or weight of the load cannot be reduced. In situations such as this, the task and/or workplace can be
redesigned to decrease the physical demands of the task.
The following list provides several examples of task and workplace redesign principles to reduce
physical demands when altering the material being handled is infeasible or mechanical aids cannot
alleviate the need to handle materials manually. Application of these principles will increase the percentage
of the population a task will accommodate.
1. For lifting or lowering tasks, bring the load closer to the body.
2. When lifting low loads, bring the vertical origin of the load as close to knuckle height as possible.
Alternately, when lowering loads, the destination should be as close to knuckle height as possible.
This principle will reduce bending. In general, try to avoid lifting or lowering to or from high and
low locations.
3. Decrease the vertical distance that loads must be lifted/lowered and the distance which loads
must be pushed, pulled, or carried.
4. Decrease the frequency of the task or increase the number or workers performing the task.
FIGURE 19.2 Example of psychophysical analysis of a multiple-component MMH job using CompuTask.
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19-21
5. For pushing and pulling tasks, provide equipment that provides the least resistance so that initial
forces required to overcome inertia are as low as possible. Maintenance of mechanical assists is
very important with regard to this principle.
6. For all MMH tasks, provide good hand-to-object coupling when possible, i.e., tote boxes with
handles, carts with handle bars, etc.
7. Decrease the duration over which the task is performed.
8. Change pulling tasks to pushing tasks.
19.3 The Psychophysical Approach to Designing Upper Extremity Tasks

The primary risk factors for WRMSDs of the upper extremity are fairly well known.34 Task-related risk
factors include posture, force, and repetition. Vibration and cold are task-related risk factors for some
disorders such as carpal tunnel syndrome. Duration of the task and rest periods are also important since
these factors affect the acceptability of task. Altering work-rest relationships can alter the acceptability
of a particular combination of posture, force, and repetition.
There are few quantitative guidelines for limits of posture, force, and repetition. Although general
guidelines suggest maintaining a neutral wrist posture and reducing the force requirements and frequency
of a task, these guidelines do not indicate acceptable levels of the variables. Once ergonomic analyses
and task redesign are done, a decision as to the acceptability of a task is difficult.
The application of the psychophysical approach to the design of UEI tasks was a response to the need
for establishing quantitative guidelines with which to assess tasks. Currently, quantitative dose-response
relationships developed with epidemiological techniques that provide relationships between individual
risk factors and their interactions and the risk of upper-extremity WRMSDs do not exist. In the absence
of such relationships, psychophysical data will continue to be one option of setting task limits. The
remainder of this section will provide an overview of the current state of psychophysical data as well as
discussion of how these data are applied in the workplace.
One advantage of the psychophysical approach is that data can be developed that incorporate force,
posture, and repetition into the development of data for different durations. This is important in that
this approach allows for trade-offs between variables, i.e., for some tasks, it is not always possible to
modify all factors.
Setting Acceptable Force and Frequency Limits

Fernandez and his colleagues have collected maximum acceptable frequency data for several types of
tasks include drilling,3538 riveting,39,40 and tasks requiring pinch and power grasps.41,42 In these studies,
factors such as wrist posture and duration were incorporated into the experimental protocol to provide
frequency limits for a variety of UEI tasks. In a similar study, Abu-Ali et al.43 had subjects control the
length of rest periods for task combinations of varying wrist postures, exertion periods, and power grip
forces.
In order to use these data, one would record relevant task parameters, find the data relevant for a
particular task in the database, and determine if the task is acceptable to the majority of the population,
just as with MMH data. If the task is not acceptable, then the frequency would need to be reduced, the
duration would need to be reduced, or factors such as wrist deviation would need to be modified to
increase the acceptability of a task.
While Fernandez and his colleagues chose frequency as the variable that subjects manipulate, Snook
et al.13 chose force as the manipulated variable. Also, Snook et al.13 used a 7-hour adjustment period
which was much longer than the shorter (20 to 25 min.) period used in the studies cited above. Snook et
al.13 studied tasks requiring wrist flexion with a power grasp, wrist flexion with a pinch grip, and
extension with a power grasp. Frequencies between 2 and 20 repetitive motions per minute were studied.
Female subjects adjusted wrist torque during the experiment by manipulating the resistance offered by
19-22

TABLE 19.10 Maximum acceptable forces for female wrist
flexion (power grip) (N).
From Snook, S.H., Vaillancourt, D.R., Ciriello, V.M., and

Webster, B.S., Psychophysical studies of repetitive wrist flexion
and extension, Ergonomics, 38, 1488, 1995. With permission.
flexion (pinch grip) (N).

Webster, B.S., Psychophysical studies of repetitive wrist
flexion and extension, Ergonomics, 38, 1488, 1995. With
permission.
extension (power grip) (N).

Webster, B.S., Psychophysical studies of repetitive wrist flexion
and extension, Ergonomics, 38, 1488, 1995. With permission.
a magnetic particle brake. Aside from reporting the torques, forces were also reported which were
computed by dividing the torques by the moment arms. The forces are reported in Tables 19.10 through
19.12. Currently, studies are being conducted that address other motions such as ulnar deviation, etc.
Snook et al.s13 data would be applied in a manner similar to that described earlier in this section.
However, these data are more generic than some of the data collected by Fernandez and his colleagues.
For example, the data collected by Snook et al.13 do not apply only to specific tasks such as drilling, as
do some of the data from other studies mentioned.3538
Krawczyk et al.14 presented preferred weights for manual transfer tasks for transfer distances of 0.5
and 1.0 m. and frequencies between 10 and 30 transfers per minute for an 8-hour work duration. Thus,
depending on the situation, one could adjust frequency or transfer distance for a particular weight of
object being transferred.
19-23
Tool and Workplace Design

Up to this point, the psychophysical results discussed have all involved experimentation where subjects
control a variable. Another approach to the study of manual work using psychophysics is to elicit
perceived exertion or discomfort ratings from subjects performing specific tasks. The results can then be
used to select the task conditions with the lowest perceived exertion or discomfort.
Ulin et al.4547 utilized perceived exertions to study tool masses, tool shapes, and horizontal and
vertical work locations. A very general summary of the results indicates that 114 cm was the preferred
vertical height for driving screws with a variety of tools. At that height, a pistol-shaped tool was the
most preferred. The ratings of perceived exertion with respect to the horizontal distance of the workpiece
from the body indicated that the workpiece should not be greater than 38 cm from the front of the
worker. The optimal workpiece location was a vertical height of 114 cm and a horizontal distance of 13
cm. Likewise, increasing the tool mass increased the ratings, as would be expected.
In general, the following recommendations are examples of means to increase the psychophysical
acceptability of a UEI task:
1.
2.
3.
4.
Maintain a neutral wrist posture.

Decrease the force requirements of a task.
Decrease the duration over which a task is performed. Worker rotation can be very helpful.
Decrease the frequency at which the task is performed. This will increase recovery time between
exertions and help to prevent fatigue and possible CTDs.
5. Reduce the horizontal distance between the workpiece and the worker.
6. For work with hand tools performed while the operator is standing, position the workpiece at a
vertical height of approximately 114 cm. Ideally, the location of the workpiece should be adjustable
to accommodate different operators.
19.4 Advantage dvantages of the Psychophysical Approach

Like any approach to setting limits for manual work, there are advantages and disadvantages of the
psychophysical approach. This approach is only one of several approaches available for designing MMH
and UEI tasks, and the advantages and disadvantages of each approach should be examined to determine
the best fit for a particular situation. The advantages and disadvantages of the psychophysical approach
to the design of MMH and UEI tasks are given below. When necessary, a distinction is made if the
advantage or disadvantage is specific to MMH or UEI tasks.
The advantages of the psychophysical approach include:
Psychophysics allows for the realistic simulation of industrial work.2

Currently, there is a considerable amount of psychophysical data for MMH tasks available that
were collected from industrial workers. Many physiological models were developed from limited
samples of university students. Likewise, the representativeness of cadaver data used to set certain
biomechanical criteria such as lumbosacral compression limits is questionable.
Psychophysical results are consistent with the industrial engineering concept of a fair days
work for a fair days pay.2
Psychophysics can be used to study intermittent MMH tasks which are common in industry.2
Such tasks are not amenable to physiological analyses.
Psychophysical results are very reproducible.2
For MMH tasks, psychophysical judgments take into account the whole job, and integrate
biomechanical and physiological factors.48,49
Psychophysical results for MMH tasks appear to be related to low-back pain.1,2,26
19-24

For MMH tasks, psychophysical data apply to a wider array of tasks than either the biomechanical
or physiological approach.
For MMH tasks that must necessarily be performed under postural restrictions (i.e., maintenance
work and mining), psychophysics is one technique that can be used to develop handling limits
specific to the tasks being examined.
The psychophysical approach is less costly and time consuming to apply in industry than many
of the biomechanical and physiological techniques.
Currently, psychophysical data represent one of the only quantitative guides for the design of
force limits for UEI work. In the absence of objective biomechanical or physiological criteria,
psychophysics may be used to elicit acceptable task parameters for UEI work.7
The disadvantages and limitations of the psychophysical approach include:

Psychophysics is a subjective method.2
The assumption that the subjective work loads selected by subjects are below the threshold for
injury has not been validated.50 There is not extensive epidemiological support for psychophysical
data for MMH tasks and no epidemiological support for using psychophysical data for the
design of UEI data. However, the same is true of most of the other criteria currently in use for
designing manual work.
Psychophysical results for high-frequency MMH tasks exceed energy expenditure criteria.2
Some psychophysical values for MMH tasks may violate the biomechanical spinal compression
criterion of 3400 N.51 However, this assumes that the spinal compression criterion of 3400 N is
correct, for which there is not much support.
Psychophysics does not appear to be sensitive to bending and twisting while performing MMH
tasks, both of which have been related to compensable low-back pain cases.2
The range of data for designing UEI tasks is somewhat limited at this time.
19.5 Conclusions
Psychophysical data are one option available to the ergonomist for designing manual tasks and assessing
whether or not a task or set of tasks needs to be redesigned. These data have been applied in the
workplace for many years with considerable success. As with any assessment tool, there are advantages
and limitations associated with psychophysics as discussed in the previous section. When used properly,
psychophysical data provide the analyst with a tool applicable to a diverse set of tasks involving manual
work.
References
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2.
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4.
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Ayoub, M.M., Problems and solutions in manual materials handling: the state of the art, Ergonomics,
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5. Mital, A., Nicholson, A.S., and Ayoub, M.M., A Guide to Manual Materials Handling, Taylor &
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Ergonomics, 32, 1125, 1989.
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extremities with the psychophysical approach, in Proceedings of the 3rd Pan Pacific Conference on
Occupational Ergonomics, 1994, 312.
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8. Fernandez, J.E., Fredericks, T.K., and Marley, R.J., The psychophysical approach in upper extremities
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responses, Ergonomics, 25, 741, 1982.
11. Gamberale, F., Ljungberg, A.S., Annwall, G., and Kilbom, A., An experimental evaluation of
psychophysical criteria for repetitive lifting work, Applied Ergonomics, 18, 311, 1987.
12. Snook, S.H. and Ciriello, V.M., Maximum weights and work loads acceptable to female workers,
Journal of Occupational Medicine, 16, 527, 1974.
13. Snook, S.H., Vaillancourt, D.R., Ciriello, V.M., and Webster, B.S., Psychophysical studies of repetitive
wrist flexion and extension, Ergonomics, 38, 1488, 1995.
14. Emanuel, I., Chaffee, J.W., and Wing, J., A study of human weight lifting capabilities for loading
ammunition into the F-86H aircraft, WADC Technical Report 56367, Wright Air Development
Center, Wright-Patterson Air Force Base, Ohio, 1956.
15. Switzer, S.A., Weight-Lifting Capabilities of a Selected Sample of Human Subjects, Technical Document
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Force Base, Ohio, 1962.
16. Snook, S.H. and Irvine, C.H., The evaluation of physical tasks in industry, American Industrial
Hygiene Association Journal, 27, 228, 1966.
17. Ciriello, V.M., Snook, S.H., and Hughes, G.J., Further studies of psychophysically determined
maximum acceptable weights and forces, Human Factors, 35, 175, 1993.
18. Ciriello, V.M., Snook, S.H., Blick, A.C., and Wilkinson, P.L., The effects of task duration on
psychophysically-determined maximum acceptable weights and forces, Ergonomics, 33, 187, 1990.
19. Snook, S.H. and Ciriello, V.M., The design of manual handling tasks: revised tables of maximum
acceptable weights and forces, Ergonomics, 34, 1197, 1991.
20. Ayoub, M.M., Bethea, N., Deivanayagam, S., Asfour, S., Bakken, G., Liles, D., Selan, J., and Sherif,
M., Determination and modeling of lifting capacity, Final Report, HEW (NIOSH) Grant No.
5R010H0054502, 1978.
21. Mital, A., Comprehensive maximum acceptable weight of lift database for regular 8-hour work
shifts, Ergonomics, 27, 1127, 1984a.
22. Mital, A., Maximum weights of lift acceptable to male and female industrial workers for extended
work shifts, Ergonomics, 27, 1115, 1984b.
23. Fox, R.R., A psychophysical study of high-frequency lifting, Unpublished doctoral dissertation,
Texas Tech University, Lubbock, Texas, 1993.
24. Nicholson, L.M. and Legg, S.J., A psychophysical study of the effects of load and frequency upon
selection of work load in repetitive lifting, Ergonomics, 29, 903, 1986.
25. Snook, S.H. and Irvine, C.H., Maximum frequency of lift acceptable to male industrial workers,
American Industrial Hygiene Association Journal, 29, 531, 1968.
26. Liles, D.H., Deivanayagam, S., Ayoub, M.M., and Mahajan, P., A job severity index for the evaluation
and control of lifting injury, Human Factors, 26, 683, 1984.
27. Mital, A., The psychophysical approach in manual liftinga verification study, Human Factors, 25,
485, 1983.
28 Smith, J.L., Ayoub, M.M., and McDaniel, J.W., Manual materials handling capabilities in nonstandard postures, Ergonomics, 35, 807, 1992.
29. Gallagher, S., Acceptable weights and physiological costs of performing combined manual handling
tasks in restricted postures, Ergonomics, 34, 939, 1991.
30. Gallagher, S. and Hamrick, C.A., Acceptable work loads for three common mining materials,
Ergonomics, 35, 1013, 1992.
31. Straker, L.M., Stevenson, M.G., and Twomey, L.T., A comparison of risk assessment of single and
combination manual handling tasks: 1. Maximum acceptable weight measures, Ergonomics, 39,
128, 1996.
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32. Mital, A., Using A Guide to Manual Materials Handling for designing/evaluating multiple activity
manual materials handling tasks, in Proceedings of the IEA World Conference on Ergonomic Design,
Interfaces, Products, and Information, 1995, 550.
33. Jiang, B.C. and Mital, A., A Procedure for designing/evaluating manual materials handling tasks,
Int J Prod Res, 24, 913, 1986.
34. Putz-Anderson, V. (Ed.), Cumulative Trauma Disorders: A Manual for Musculoskeletal Disorders
of the Upper Limb, Taylor & Francis, London, 1988.
35. Davis, P.J. and Fernandez, J.E., Maximum acceptable frequencies for females performing a drilling
task in different wrist postures, J Human Ergol, 23, 81, 1994.
36. Fernandez, J.E., Dahalan, J.B., and Klein, M.G., Using the psychophysical approach in hand-wrist
work, in Proceedings of the M.M. Ayoub Occupational Ergonomics Symposium, Institute for
Ergonomics Research, Lubbock, Texas, 1993, 63.
37. Kim, C.H. and Fernandez, J.E., Psychophysical frequency for a drilling task, International Journal
of Industrial Ergonomics, 12, 209, 1993.
38. Vaidyanathan, V. and Fernandez, J.E., MAF for males performing drilling tasks, in Proceedings of
the Human Factors Society 36th Annual Meeting, Human Factors Society, Santa Monica, 1992,
692.
39. Fredericks, T.K., The effect of vibration on maximum acceptable frequency for a riveting task,
Unpublished doctoral dissertation, The Wichita State University, Wichita, Kansas, 1995.
40. Fredericks, T.K. and Fernandez, J.E., The effect of vibration on maximum acceptable frequency for
a riveting task, in Proceedings of the Konz/Purswell Occupational Ergonomics Symposium, Institute
for Ergonomics Research, Lubbock, Texas, 1995, 27.
41. Dahalan, J.B. and Fernandez, J.E., Psychophysical frequency for a gripping task, International Journal
of Industrial Ergonomics, 12, 219, 1993.
42. Klein, M.G. and Fernandez, J.E., The effects of posture, duration, and force on pinching frequency,
International Journal of Industrial Ergonomics, 20, 267, 1997.
43. Abu-Ali, M., Purswell, J.L., and Schlegel, R.E., Psychophysically determined work-cycle parameters
for repetitive hand gripping, International Journal of Industrial Ergonomics, 17, 35, 1996.
44. Krawczyk, S., Armstrong, T.J., and Snook, S.H., Preferred weights for hand transfer tasks for an
eight hour day, in Proceedings of International Scientific Conference on Prevention of Work-related
Musculoskeletal Disorders, Hagberg, M., and Kilbom, A., Eds., 1992, 157.
45. Ulin, S.S., Armstrong, T.J., Snook, S.H., and Franzblau, A., Effect of tool shape and work location
on perceived exertion for work on horizontal surfaces, Am Ind Hyg Assoc J, 54, 383, 1993a.
46. Ulin, S.S., Armstrong, T.J., Snook, S.H., and Keyserling, W.M., Examination of the effect of tool
mass and work postures on perceived exertion for a screw driving task, International Journal of
Industrial Ergonomics, 12, 105, 1993b.
47. Ulin, S.S., Snook, S.H., Armstrong, T.J., and Herrin, G.D., Preferred tool shapes for various horizontal
and vertical work locations, Appl Occup Environ Hyg, 7, 327, 1992.
48. Haslegrave, C.M. and Corlett, E.N., Evaluating work conditions for risk of injurytechniques for
field surveys, in Evaluation of Human Work, 2nd. ed., Wilson, J.R., and Corlett, E.N., Eds., Taylor
& Francis, London, 1995, 892.
49. Karwowski, W. and Ayoub, M.M., Fuzzy modelling of stresses in manual lifting tasks, Ergonomics,
27, 641, 1984.
50. Gamberale, F. and Kilbom, A., An experimental evaluation of psychophysically determined maximum
acceptable work load for repetitive lifting work, in Ergonomics International 88, A.S.Adams,
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51. Chaffin, D.B. and Page, G.B., Postural effects on biomechanical and psychophysical weight-lifting
limits, Ergonomics, 37, 663, 1994.
20
The Relative
Importance of
Biomechanical and
Psychosocial Factors in
Low Back Injuries
A.Kim Burton
University of Huddersfield
Michele C.Batti
University of Alberta
Chris J.Main
University of Manchester
20.1
20.2
20.3
20.4
20.5
20.6
20.7
Introduction
Background
Spinal Damage
Injury, Recurrence and Work Loss
Effectiveness of Ergonomic Intervention
Concluding Remarks
Summary
20-1
20-2
20-3
20-4
20-7
20-8
20-8
20.1 Introduction
That low back trouble (LBT) is an increasing problem in industrialized society has become obvious. The
realization that this increase is occurring despite the best efforts of ergonomists, clinicians, and legislators
has not gone unnoticed (Nachemson, 1996; Waddell, 1992; Bigos and Batti, 1990; Winkel and
Westgaard, 1996). Arguably the field of ergonomics has been thrown a little off balance by developments
in the clinical arena over recent years. On the one hand, ergonomists and biomechanists strive to reduce
physical stress at the workplace with the intent of lowering the risk of musculoskeletal problems. On the
other hand, the clinicians and psychologists are suggesting that rehabilitation of the back-injured worker
should involve not only activity but physical challenges to the musculoskeletal system (Kohles et al.,
1990; Bendix et al., 1995). This apparent dichotomy cannot readily be dismissed; to understand how it
has arisen requires an exploration of reports from the various fields of endeavor involved.
This chapter will attempt to bring together, from a variety of perspectives, evidence on the development,
recurrence, and persistence of work-related low back trouble. Some of the issues raised are covered in
detail elsewhere in this book; the intention here is to provide a rationale which links the considerations
of ergonomics/biomechanics with those psychosocial aspects discussed in the two following chapters.
Rather than present a systematic review, or attempt a meta-analysis, the starting point is the commonly
held tenet that physically demanding work is detrimental to the back, i.e., it will cause injury leading to
low back pain and consequent disability. From this it would follow logically that management of workrelated low back disorders can best be achieved by reduction of occupational spinal stressors.
0-8493-1800-9/03/$0.00+$1.50
20-1
20-2
The basic injury/damage model can be expressed as one where exposure to mechanical overload,
whether a single event or cumulative stress, results in some form of damage to spinal tissues, and that
further exposure leads to further damage and/or lack of recovery, which in turn leads to disabling
consequences. On the face of it, this model would appear to be intuitively reasonable and valid. What
follows is a selective exploration of the literature focusing on evidence which challenges the basic premise
that ergonomic intervention is the key to reducing the burden of occupational back pain, and highlights
the emergent role of psychosocial influences.
20.2 Background
There is no shortage of epidemiological reports that link heavy, strenuous work (physical stress) with back
pain (Suadicani et al., 1994; Riihimaki, 1989), but this link is not universally reported (Burton et al., 1989;
Spengler et al., 1986; Riihimaki et al., 1994); seemingly much depends on definitions for back pain and
workload. Similarly, reports of an association between heavy work and absenteeism (Riihimaki et al., 1989;
Andersson et al., 1983), are not entirely consistent (Lindstrom et al., 1994). Physical spinal stress from whole
body vibration (WBV) also has been associated with an increased risk of occupational back injury (Wikstrom
et al., 1994), and has been linked specifically with symptoms (Burton and Sandover, 1987), but a dose
response relationship has not been confirmed. There is certainly some experimental biomechanical evidence
suggesting that strenuous work environments are likely to be detrimental; in vitro experiments, simulating
physiological occupational loads, can result in fatigue damage of numerous spinal soft tissues (Adams and
Dolan, 1995) and to the end plates of the vertebral bodies (Brinckmann et al., 1988).
The injury model suggests that if occupational loads are reduced there should be a concomitant
reduction in occupational back trouble. It is highly likely that occupational physical stressors on workers
spines have progressively reduced over the last 20 years or so, due to the combined effects of increasing
mechanization and ergonomics-driven legislative procedures. However, there is no evidence that back
pain has decreased, and in fact the disability due to LBT continues to grow exponentially (Clinical
Standards Advisory Group, 1994).
It might, at this point, be helpful to put the work-relatedness of LBT into perspective. Occupational low
back trouble must be viewed in the light of a high prevalence of LBT in the general population, at least in
the industrialized nations. The background prevalence is often quoted as 80% or more, but a more realistic
figure for what might be termed notable back trouble (i.e., that which results in care-seeking or a period
of disability, as opposed to the transient twinges suffered by most) is probably an average of around 60%
(Papageorgiou et al., 1995). The lifetime prevalence is similar among males and females, but does seem to
vary with age. Few adults can recall trouble before the age of 18 years (Burton, 1987), but then the
prevalence rises through working years (from ~50% to ~65%), but does not increase thereafter
(Papageorgiou et al., 1995). The 1-month prevalence rate amounts to 39% on average among adults
(Papageorgiou et al., 1995), while the point prevalence rate is of the order of 14 to 30% (Clinical Standards
Advisory Group. 1994). Such figures are derived from cross-sectional studies and are at the mercy of
reporting errors; for instance it has been found that some will deny ever having back trouble despite the
fact that previously they have been sick listed for the condition (Svennson and Andersson, 1982).
Longitudinal studies of school children and adolescents have reported a surprisingly high lifetime prevalence
of over 50% by 16 years of age (Burton et al., 1996b; Balagu et al., 1995). Undoubtedly back pain is a
common life experience virtually irrespective of age, but adolescent back pain differs markedly from the
adult experience in that, while a recurrent phenomenon, it is rarely disabling (Burton et al., 1996b).
Recent epidemiological studies have revealed that LBT can be as prevalent among sedentary workers as
among manual workers (Hemmingway et al., 1994) but heavy jobs do seem to be associated with an
increased work loss due to LBT (Riihimaki et al., 1989), though that increase may be due to longer spells
rather than more spells (Andersson et al., 1983). However, the association between heavy work and absence
rates is not a consistent finding (Lindstrom et al., 1994). A study of construction workers did find a
Biomechanical and Psychosocial Factors in Low Back Injuries
20-3
dose-response relationship between severe low back pain and stooping and kneeling, but back pain in
general was associated more with a range of psychosocial parameters (Holmstrom et al., 1992).
The identification of risk factors for a condition with such a high background prevalence has long been
recognized as problematic (Troup and Edwards, 1985). The etiology is clearly multifactorial (Troup and
Videman, 1989) so it is exceedingly difficult to be certain that a particular job is involved in causation in
individual cases. The problem may have arisen even if the individual had not been employed, there may have
been a non-work etiology, or it may have resulted from a previous job. The high prevalence in adolescents,
coupled with the fact that only 3 to 10% of episodes in adults are brought to medical attention (Wells, 1985),
is a fair indication that much back pain is relatively benign and can be considered a normal life experience.
It should be remembered that LBT usually occurs simply as a complaint of pain (in back and/or leg,
with or without sensory symptoms); very rarely is it possible to determine a physical reason for the
symptoms; i.e., there is no objective evidence of tissue damage. A consequence of the symptoms is an
inability (or reluctance) to perform activities of daily living, including work activities. In essence, LBT is
a symptomatic complaint (usually) without evidence of specific tissue or structural damage, which may
be associated with some degree of dysfunction; it is well recognized that there is poor correlation between
the degree of symptoms and the extent of purported physical stress prior to onset.
Work-related LBT has to be viewed against this high background level of reporting, in the general
population, of a symptom which has an undetermined pathology, a propensity for recurrence, and a
variable tendency to progress to disability. It is the link between these features (damage, reporting/
recurrence, and disability) which is the focus of the following discussion.
20.3 Spinal Damage

The structure presumed at greatest risk for damage from heavy work (including WBV) is the intervertebral
disc, and this has been the major subject of investigation. While it has been indicated that heavy work is
associated with lumbar disc degeneration (Riihimaki et al., 1990), much may depend on the measurement
methods, imaging techniques, and the population studied. For instance, a review on this subject (Troup
and Edwards, 1985) noted that reports of severe disc degeneration occurring in miners are not entirely
consistent; numerous studies support the link, but at least one found that it was osteophytes rather than
discal changes that were related to duration of mining work (Caplan et al., 1966). This association has
been noticed in another mining population (authors unpublished data). Interestingly, Olympic weight
lifters do not seem to show an excess of radiological changes (Hult, 1954). Assuming a link between work
and disc degeneration, it might reasonably be assumed that disc degeneration will have an adverse effect on
spine function (e.g., flexibility), and thus exposure to physical stressors (via occupation or leisure) will
result in diminished flexibility. However, it would seem that lumbar flexibility, while being somewhat
related to disc height, is not substantially influenced by either degeneration or exposure to physical stressors
(Burton et al., 1996a). Recent investigation involving multivariable statistical techniques has confirmed
that disc degenerationas measured from magnetic resonance images (MRI)is influenced only modestly
by work history; the greatest proportion of the explained variances in degeneration score can be accounted
for by genetic influences, though age did have some expected influence (Batti et al., 1995).
Disc herniations (as opposed to generalized degenerative changes) are not apparently associated with
heavy work (Kelsey, 1975), but sitting work, particularly involving driving, may carry an increased risk
(Kelsey et al., 1984). However, it should be borne in mind that the presence of herniations is poorly
correlated with symptoms (Boos et al., 1995). Disc herniations were found in 76% of an asymptomatic
control group (matched for age, sex, and work-related factors) compared with 96% in a symptomatic
group; the presence of symptoms was related to neural compromise and psychosocial aspects of work,
but not to the exposure to physical stressors (Boos et al., 1995).
Certainly we would expect to find, based on in vitro studies, signs of damage to the discs and vertebral
bodies from exposure to mechanical overload (Brinckmann et al., 1988), but this has yet to be confirmed.
20-4
Perhaps the level of physical stressors commonly encountered in workers is simply below the threshold
needed to create the predicted damage, or it may be that the measurement techniques currently available
are insufficiently precise to identify it. Alternatively, it may be that the normal biological repair processes
obscure the evidence (Brinckmann, 1985). A new method for quantifying overload damage from
radiographs has become available (Brinckmann et al., 1994), by which it is possible to compare
radiographs from cohorts exposed to heavy work or WBV with those exposed to light or sedentary
work. Overload damage has only been detected in cohorts exposed to extremely heavy work, or to
undamped vehicular vibration; cohorts performing strenuous work within current ergonomic guidelines
did not show overload damage (Brinckmann et al, 1998). Also, certain strenuous sports activities have
been shown to induce disc disruption (e.g., fast bowlers in cricket [Elliott et al., 1993]).
Severe trauma leading to vertebral body fractures, such as can happen in parachute landing (MurrayLeslie et al., 1977) or ejection from military aircraft (Laurell and Nachemson, 1963), may present few if
any symptoms. Even when symptoms do ensue, recovery is relatively swift with no lasting disability or
reduced effectiveness (Laurell and Nachemson, 1963).
Structures other than vertebrae and discs (i.e., muscles and ligaments) may, of course, be damaged
(Adams and Dolan, 1995), but for the most part we do not have objective means for detecting such
damage. Experience in areas other than the low back indicate that muscle and ligament injuries (in the
absence of complete rupture) have a healing time of the order of 4 to 8 weeks. Perhaps 85% of those
taking time off work with back trouble will have returned to work during that time (Clinical Standards
Advisory Group. 1994), but that leaves a sizeable number for whom an obvious physiological explanation
for the persisting disability is lacking.
Current knowledge is insufficient, in the vast majority of cases of LBT, for accurate identification of
the structure or structures that are injured, or the extent to which they might be injured. Some measure
of strain to the soft tissues supporting the spine (possibly involving neuromuscular control mechanisms)
are the most likely candidates. New modeling techniques are suggesting that spine stability is closely
related to muscle activity. Deficient intrinsic spine muscles or a lack of motor control seem to reduce the
mechanical stability of the spine which could increase the risk of straining muscles or ligaments (Cholewicki
and McGill, 1996). The question remains whether back strains are most often the result of some specific
element of work or the result of other circumstances in life. The evidence shows that the back can
certainly be injured in various ways, but the injury model can be seen to be lacking explanatory power
where prolonged disability is concerned.
Irrespective of whether damage to spinal structures can be identified or quantified, there is no doubt that
workers do get painful backs and some will believe it is their work which is to blame. In a general survey of
workers, 61% stated their back disorder was caused by their work, and 39% felt it was made worse by their
work; workers report back disorders twice as frequently as any other disorder (Clinical Standards Advisory
Group. 1994). A study, of sicklisted blue collar workers found that 60% of patients believed that work
demands had caused their back trouble, but neither an assessment of workload (e.g., lifting, bending) nor
calculated compression loads predicted the rate of return to work or sick leave during follow-up (Lindstrom
et al., 1994). Low back pain attributed to work has been reported to be more common in female nurses than
female teachers, but non-occupationally attributed back pain had the same prevalence in both groups (Cust
et al., 1972). The finding that worker ratings of job-required physical abilities are correlated with back injury
rates is interesting (Skovron et al., 1991) but, because both parameters are subject to possible reporting bias,
the relationship may, in part, represent subjective attribution. Confounding of physical workload with
psychosocial workload has been found among various branches of agricultural work with differing prevalence
rates, rendering clear identification of risk factors difficult (Hildebrandt, 1995).
20.4 Injury, Recurrence, and Work Loss

The biomechanical approach to identification of occupational risk factors for LBT has shifted from
static models of spinal loading to dynamic models which use accelerations and velocity to estimate
20-5
forces acting on the spine (Halpern, 1992), while the more sophisticated approaches are advocating
methods which incorporate muscle synergy and cocontraction patterns (Cholewicki et al., 1995). This
sort of modeling fits better with the epidemiology. Some data suggest that the risk of LBT is associated
with dynamic lifting (Bigos et al., 1986), and this parameter has been studied in detail by Marras and
colleagues (Marras et al., 1993). This latter study was the first to link epidemiological findings with
quantitative biomechanical findings in a large working population. A multiple logistic regression model
revealed that a combination of five trunk motion and workplace factors distinguished between high and
low risk; the factors were lifting frequency, load moment, trunk lateral velocity, trunk twisting velocity,
and trunk sagittal angle. The outcome variable (risk of LBT) was derived from medical and injury
records, which admittedly suffer from confounding effects of reporting bias and inadequate information
about previous trouble. While a causative link was not proved, the association between biomechanical
factors and risk was clear. When looking at worker-rated job demands (including ratings of dynamic
components) and back injury rates, it is apparent that high-risk jobs can have quite diverse demands,
i.e., not all jobs with high injury rates require the same physical abilities (Halpern, 1992). A study of
1800 nurses in Belgium and The Netherlands, using a quasi-objective rating system for task demands,
showed a significantly lower prevalence of back trouble (and other musculoskeletal complaints) in the
Dutch nurses despite the fact that their average workload was substantially greater than their Belgian
counterparts. Overall, symptoms and work loss in the previous 12 months were not related to workload,
nor was attribution that work was causative. It transpired that the Dutch nurses differed strikingly from
the Belgian nurses on a range of psychosocial variables; they reported less depressive symptoms and
were significantly more positive about pain, work, and activity (Burton et al. 1997).
It is known that a previous history of back pain is highly predictive of future episodes (Troup et al.,
1987; Burton et al., 1989; Bigos et al., 1991), so it might be more illuminating to investigate the relationship
between occupational physical stressors and first-time back injury rather than with prevalence rates
(i.e., study of workers without any back trouble history). Because of methodological difficulties, reports
of such studies are rare. Videman and colleagues (Videman et al., 1984) studied nursing aides and
trained nurses. They found that young nursing aides (with high work loads but low likelihood of previous
LBT history) had a higher prevalence than the trained nurses who did less manual handling, suggesting
that skill and training may be important. But it was also noted that the aides tended to have children at
an earlier age, thus domestic spinal loading was possibly a confounding influence. While the annual
incidence rate of LBT in nurses has been found to be higher than in teachers, the annual prevalence and
point prevalence rates were the same (Leighton and Reilly, 1995), though first-onset at a younger age in
nursing aides compared with teachers has been reported (Cust et al., 1972). It has been shown that
experienced industrial workers do show a reduced risk for LBT compared with inexperienced workers,
but this is not necessarily because they experience reduced spinal loads, rather, their smoother motions
may be related to muscular coordination aiding spinal stability (Granata et al., 1996).
A large general population study (Croft et al., 1995) has found that new episodes of LBT are more
likely for those who are psychologically distressed; a relationship that held true even for first onsets. In
the large prospective study at the Boeing plant (Bigos et al., 1991) it was found that reported first
injuries were not related specifically to job demands, rather to psychosocial factors (i.e., low job satisfaction
and an elevated hysteria scale on the Minnesota Multiphasic Personality Inventory); the workers at
Boeing, though, worked in an environment where job tasks were not particularly stressful for the back.
Some clarification of the issue could emerge from study of first-onsets in workers exposed to the same
substantial physical stressors over long periods; police officers in Northern Ireland have proved to be a
useful group for study (Burton et al., 1996c). They compulsorily wear body armor (weighing >8 kg) for
up to 12 hours per day; they do so irrespective of rank, and they return to the same work on recovery
from back trouble. This police force was compared with an English police force which did not wear
armor. It was found that the physical stress of wearing body armor reduced the survival time to firstonset, and there was a slight increase in the hazard over time. It was also found that spending longer
than two hours per day in vehicles comprised a separate risk for first-onset of LBT, but this hazard did
20-6
not increase; it is interesting to note that the effect of exposure to armor and vehicles was not additive.
Surprisingly, the proportion of officers with persistent (chronic) back complaints did not depend on the
length of exposure (to the same stressors) since first-onset, rather chronicity was associated with
psychosocial factors (distress and blaming work) (Burton et al., 1996c).
Physical stress on the spine may actually be beneficial. It has been reported that a physical fitness
program improved cardiovascular performance, strength, and flexibility, and was associated with reduced
workers compensation costs for back injuries (Cady et al., 1979), though this finding has not been
confirmed by others (Batti et al., 1989). Porter has suggested that heavy manual work (in miners) may
benefit the spine by developing ligamentous and annular strength, thus restraining encroachment of a
disc protrusion into the spinal vertebral canal (Porter, 1987). A later cadaveric study gave some support
to this notion; the compressive strength of the spines from young men who had been physically active
tended to be greater than those who had been less active (Porter et al., 1989).
There may, of course, be factors other than task-induced stress that could be important in respect of
causation. In a large prospective study of employees in various industries, Troup and colleagues (Troup et al.,
1981) found that the current attack of back pain arose with no evidence of injury in over 50%. For those
with an injury, two thirds were truly accidental, i.e., they occurred in association with some identifiable
event. Falls were actually as common a cause as handling injuries, and there was no indication that those
currently injured by handling were more likely to have had a previous handling injury. Falls were also associated
with longer periods of sick leave and a greater propensity for recurrence. Overall, recurrence was found to be
common; a figure of 44% in the first year dropped to 31% in the second year, suggesting recurrence rates
may be more a feature of the natural history of the disorder than a reflection of continued exposure to the
work environment (Troup et al., 1981). Support for this notion has come from other studies, involving
multivariable analyses, which have found little relationship between recurrence and work demands (Troup et
al., 1987; Burton et al., 1989; Bigos et al., 1991). As mentioned above, the best predictor of future trouble
seems to be a previous history, with perception of work demands being more important than objective
measurement (Troup et al., 1987), and dissatisfaction with work being a significant factor; the term re-injury
may be a misnomer (Bigos et al., 1991). More recently, an enhanced instrument, the Psychosocial Aspects of
Work questionnaire, has been described which separately evaluates job satisfaction, social support, and
mental stress (Symonds et al., 1996). It has been possible to show that workers with current LBT have a
lower score for job satisfaction and social support but, surprisingly, absenteeism (Symonds et al., 1996) and
work heaviness (Burton et al., 1997) were not related to these parameters.
While absenteeism may not be related to attitudes about work itself, other attitudes and beliefs do
seem to be relevant. Psychosocial factors such as negative beliefs about the inevitable consequences of
LBT (measured by the Back Beliefs Questionnaire [Symonds et al., 1996]), inadequate pain control
strategies (Symonds et al., 1996), fear-avoidance beliefs (Waddell et al., 1993) and belief that work was
causative (Burton et al., 1996c) have all been found to relate to absenteeism. The relationship between
attribution of cause, job satisfaction, and pain perception is complex and, in part, related to job level;
issues related to attribution are important factors for compliance with intervention strategies (Linton
and Warg, 1993). Accordingly, it has been found that a simple educational intervention program
(comprising workplace broadcasting of a pamphlet stressing the benign nature of LBT, the importance
of activity and desirability of early work return) is capable of creating a positive shift in beliefs with a
concomitant reduction in extended absence (Symonds et al., 1995).
The question of when and how to return workers with LBT to their job has attracted considerable
attention. It has been popularly held that too early a return to the same task would risk recurrence of
symptoms (or do further damage). Indeed back injured workers may perceive their back problem as
lifelong trouble, and believe that their back injury has made them more vulnerable to reinjury and
disability (Tarasuk and Eakin, 1994). There is accumulating evidence that this belief is not only false,
but detrimental. The use of work restrictions does not necessarily correlate with reduced symptoms
following return to work. A 3-year follow-up of reported occupational musculoskeletal injuries (including
LBT) found that those whose workloads had been reduced did not report fewer problems (Kemmlert et
20-7
al., 1993). A 1-year follow-up report concerning the use of restrictions for nonspecific back pain found
that restrictions were associated with a reduced probability of returning to the original work; they did
not reduce work absence, and they did not significantly reduce recurrences (Skovron et al., 1997). In
fact, a successful rehabilitation program for patients with subchronic back pain has advocated early
return to unrestricted duties as part of a combined graded activity/behavioral therapy approach (Lindstrom
et al., 1992). Prospective study of even the most severe chronic disabling spinal disorder workers
compensation patients who completed a functional restoration program and returned to work, found
that they were at relatively low risk for recurrence (Garcy et al., 1996). When looking at predictors for
chronicity, using multivariable analyses in a mixed population of workers, occupation was not found to
be significant, rather chronicity was related to age and to the duration of the first spell (Burton et al.,
1989). The study of working police officers revealed that change of duties after developing LBT was
rare, and persistence of symptoms was found to be unrelated to the length of exposure (to the same
physical stressors at work) following first-onset (Burton et al., 1996c).
Even when there is known damage to lumbar structures, activity restriction seems not to be necessary.
A prospective study of 50 patients operated for lumbar disc herniation, who were urged to return to full
activity as soon as possible, showed the following features: mean return to work time was 1.7 weeks with
25% returning within 1 to 2 days; 97% returned to their previous job and had returned to full work by 8
weeks; no patient changed jobs because of symptoms; only 6% had a recurrence (follow-up averaged 3.8
years) (Carragee et al., 1996). Clinical studies in workers compensation back pain patients have found
that delayed functional recovery was associated with psychosocial factors more than with perceived task
demand (Hadler et al., 1995), and that longer spells off work were associated with a poor outcome (Lancourt
and Kettelhut, 1992). In compensation cases, settlement of the claim, interestingly, does not result in a
reduction in morbidity (Greenough and Fraser, 1989). Generally it would seem that workers over 50 years
old return to work faster than younger ones; neither gender nor length of employment influenced recovery
rates, but a lower hourly wage was associated with a longer return to work period (Reid et al., 1996).
The reluctance to confront normal physical challenges seen in back-disabled workers has been termed
activity intolerance, which is variously linked to individual response to pain, the belief that a specific
injury must be the cause of the pain, and behavioral roles such as suffering. This has led to the proposal
that treatment and benefits should not, in general, be (pain) complaint-contingent but time-contingent
such that there is a clear incentive to return to work within an allotted time (IASP, 1995).
The question obviously arises as to the origin of the various relevant psychosocial traitsdo they
develop before or after onset of symptoms? This issue will be addressed in the following chapters, but
there is clinical evidence that psychological profiles predictive of chronicity are present early in the
course of the back pain experience (within the first three weeks) (Burton et al., 1995) and will even
precede it in a few people (Mannion et al., 1996). The profiles identified clinically (coping strategies and
individual beliefs, as opposed to job satisfaction) are in the same domain as those found to be related to
work loss (Symonds et al., 1996).
20.5 Effectiveness of Ergonomic Intervention

Most ergonomic interventions will focus on strategies to reduce spinal loading and have been discussed
elsewhere in this book. What reports there are to support the belief that ergonomic intervention will
reduce the impact of occupational low back pain have been considered largely anecdotal (Smedley and
Coggon, 1994), and there are significant risks of ergonomics being confounded with rationalization
leading to an ergonomic pitfall (Winkel and Westgaard, 1996). The only intervention which has been
formally evaluated is worker training in manual handling techniques; while lifting techniques can be
improved, the effect on injury rates has not been clearly demonstrated (Smedley and Coggon, 1994).
Rigorous controlled trials of ergonomic intervention programs, with morbidity as the outcome, remain
to be conducted. Meanwhile, there is evidence that personnel issues may be more important than physical
20-8
ergonomics. A large industrial study has found that ergonomic solutions failed to reduce lost workdays,
and that reliance on case monitoring and wellness orientation actually increased work loss. However,
diligent safety programs and an emphasis on systematic return-to-work programs did reduce lost workdays
(Hunt and Habeck, 1993). Similarly, a comparison of a personnel program (designed to increase
communication between claimants and their employer, their doctor and the Workers Compensation
Board) with a back program (designed to reduce back injuries through intensive feed-back training)
found that it was the personnel program which was by far the most effective (Wood, 1987).
20.6 Concluding Remarks

There is now sufficient evidence to seriously challenge the power of the injury/damage model to explain
the current phenomenon of occupational back trouble. Although epidemiological studies can link the
incidence (first recalled onset) of back pain with certain physical stressors (notably spinal loading and
vehicle use [Burton et al., 1996c]), the fact remains that these injuries should, by virtue of known physiological
processes, resolve within the natural healing time of 4 to 8 weeks. Doubtless many such injuries do resolve
naturally, but the problem (for science as well as society) is that a considerable number recur or progress to
chronic disability. There is strong evidence that recurrence and disability are not generally related to physical
stressors, rather they may be mediated by psychosocial phenomena. Biomechanics may help to explain
initial injury mechanisms, but currently offers little in the way of explanation for persisting trouble.
It can be accepted that much work is physically demanding, and may (frequently) lead to some discomfort
and pain. These transient symptoms may be a normal consequence of life, but if the worker believes that the
job is to blame there is the potential for psychosocial factors to intervene. A proportion of back injured
workers having inappropriate beliefs about the nature of their problem, and its relationship to work, will
develop fear-avoidance behaviors because of inadequate pain coping strategies. They then begin to function
in a disadvantageous way and drift into chronic disability. Once a worker has developed back trouble, it
would seem that therapeutic programs combining physical challenges to the back with operant conditioning
are more successful than traditional approaches involving rest. Just as bed rest is known to be detrimental to
recovery from an episode of back trouble (Malmivaara et al., 1995), it may be that the same principle applies
to prolonged work absence. Certainly, undue rest can be expected to result in the deficient motor control
mechanisms which heighten biomechanical susceptibility to injury or reinjury (Cholewicki and McGill, 1996).
20.7 Summary
On balance, there is evidence to support the notion that biomechanics-based ergonomic improvements to
the workplace may have some potential to limit first-time back injury; therefore they should be deployed
where practicable. The possible role of ergonomics for reducing recurrence rates seems at best equivocal,
but there is no convincing evidence that continuance of work is detrimental in respect of disability. Because
it is likely that much back pain is only work-related inasmuch as people of working age get painful backs,
it is becoming clear that reducing spinal loads or awkward postures is likely to have only a small impact on
the overall pattern of back pain. Non-biomechanical approaches (organizational and psychosocial) seemingly
are more effective in maintaining workability. Primary prevention may be an unrealistic goal, but reducing
the costly burden of chronic disability may well be possible; strategies which involve psychosocial advice
to overcome activity intolerance (IASP, 1995), reduce fear avoidance, and promote activity (along with
therapeutic motor-control training) may well transpire to be effective.
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21
Fall-Related
Occupational Injuries
21.1
21.2
21.3
21.4
Stephen N.Robinovitch
San Francisco General Hospital
21.5
Introduction
General Considerations
Epidemiology
Fatal Injuries Nonfatal Injuries
Biomechanics
Fall Initiation Fall Descent Kinematics Impact
Mechanics
Prevention
211
211
213
215
2110
21.1 Introduction
In the United States, falls account for approximately one third of all injury-related hospitalizations and
one tenth of all injury-related deaths, making them the leading cause of accidental injury and second
leading cause of traumatic death (Rice, 1989; Public Health Service, 1993). The annual cost associated
with such injuries has been estimated at a staggering $37.3 billion, over one third of which involves direct
medical expenses (Rice, 1989). Therefore, in terms of both frequency and cost, falls closely rival motor
vehicle accidents (MVA) as a leading cause of injury. However, aside perhaps for the problem of fall-related
hip fractures in the elderly (which represent approximately one quarter of all fall-related injury costs
[Praemar, 1992]), they have received considerably less attention from injury prevention experts.
To design effective strategies for preventing fall-related injuries, we must consider two sets of risk
factors: those which lead to an increased incidence of falls, and those which increase risk for injury in
the event of a fall. Research tools for identifying such risk factors generally fall under the categories of
epidemiology and biomechanics. The former (discussed in Section 21.3 of this chapter) provides important
information on the circumstances surrounding fall injuries, thereby identifying host and environmental
targets for intervention. The latter (discussed in Section 21.4) complements epidemiological data by
identifying, through the analysis of experimental or mathematical models of the injury-causing
environment, how injury risk is influenced by factors such as motor control, Newtonian dynamics, and
mechanical properties of biological tissues. Prevention strategies (discussed in Section 21.5) with the
highest likelihood for success are often those derived from, and therefore compatible with, a combined
epidemiological and biomechanical perspective.
21.2 General Considerations

Three general groups of individuals are at high risk for fall-related injuries: the elderly over age 65,
children between ages 6 to 10, and individuals whose occupation requires them to work at heights
(Figure 21.1). For each of these, injury results from the transfer of gravitational potential energy to
0-8493-1800-9/03/$0.00+$1.50
21-1
21-2
FIGURE 21.1 Overview of factors influencing injury risk during typical falls in the elderly individual, child, and
construction worker.
tissue strain energy (and the corresponding generation of mechanical stresses and strains) that exceeds
the tissues energy-absorbing capacity. However, among the three groups, important differences exist in
risk factors for fall-related injury. In particular, injury risk in the elderly is generally dominated by host
factors such as balance, strength, reaction time, vision, and bone strength (Tinetti, 1994), while injury
risk in the workplace is generally dominated by environmental factors such as poor lighting, slippery
surfaces, workplace clutter, or lack of adequate fall prevention equipment (McVittie, 1995). Consequently,
ergonomic or human factors-based strategies are likely to be highly effective in preventing fall-related
injuries in the workplace, while this has, as yet, been untrue for the elderly (Fleming, 1993; Parker,
1996; Tinetti, 1993; Waller, 1978).
Fall-Related Occupational Injuries
21-3
TABLE 21.1 Annual Fall-Related Occupational Injuries and Deaths in the United States, by Occupation
Source: Bureau of Labor Statistics, U.S. Department of Labor, Census of Fatal Occupational Injuries, 1995.
Source: Bureau of Labor Statistics U.S. Department of Labor, Survey of Occupational Illnesses and Injuries,
1994. Data reflect a sum of injuries due to falls to a lower level and falls to the same level.
b
21.3 Epidemiology
Fatal Injuries
Incidence. In 1995, falls accounted for 10% of fatal work-related injuries in the United States (653 of
6210 total deaths), ranking them alongside MVA, violent assault, and being struck by an object as a
leading cause of accidental work-related death (Bureau of Labor Statistics, 1996a). As shown in Table
21.1, approximately one half of these deaths occurred in the construction industry, where falls accounted
for 32% of work-related fatalities, more than any other cause (Bureau of Labor Statistics, 1996a; National
Safety Council, 1994; McVittie, 1995; Ore, 1996). Construction-related occupations with the highest
risk for fall-related fatality include roofers, structural metal workers, carpenters, and painters. In each
of these, falls account for about one half or more of total fatalities (Bureau of Labor Statistics, 1996a;
Sorock, 1993; Suruda, 1992).
Circumstances. Not surprisingly, over 95% of fall fatalities in the workplace involve falls from elevation
(Bureau of Labor Statistics, 1996c), and accordingly, working at elevation is the single greatest risk factor
for a fatal fall in the workplace. A review of 63 fatal falls in the Quebec construction industry between
1989 and 1992 (McVittie, 1995) found that the most common working surfaces from which falls occurred
were skeletal structures such as building frameworks and roof trusses (25%), unfinished floors (24%),
scaffolds (24%), roofs (18%), and ladders (6%). OSHA reported slightly different results in the analysis of
1148 fall-related deaths in the U.S. construction industry between 1985 and 1989 (Occupational Safety
and Health Administration, 1992), citing roofs as the most common working surface (26%), followed by
scaffolds (21%), skeletal structures (14%), unfinished floors (10%), and ladders (6%).
A second important class of risk factors for fall fatalities is lack of proper protective equipment.
Indeed, several investigators have observed that the vast majority of fall-related fatalities involve the
absence or improper use of fall restraint equipment, and noncompliance with recommended equipment
and job site standards. For example, in McVitties study of fall-related injuries in the Ontario construction
industry (McVittie, 1995), no obvious fall risk existed in 84% of deaths, which apparently could have
been prevented with proper use of safety equipment. In such cases, safety harnesses were often available
but not being used. In another 13% of cases, falls occurred through poorly guarded floor openings.
Only one case resulted from failure of a fall restraint system, and this involved the worker fastening his
safety harness to a hoisting line rather than a lifeline. Similarly, in Surudas study of fatal falls to
construction painters (Suruda, 1992), over one half involved falls from scaffolds, and the vast majority
of these (88%) involved the painter falling off the scaffold, as opposed to the scaffold collapsing. In
74% of cases, OSHA issued safety violations, commonly citing the lack of scaffold guardrails, nets,
lifelines, and safety belts. Indeed, the single most common cause of death was failure to connect a safety
belt to a lifeline.
21-4

TABLE 21.2 Incidence Rates (Injuries per 10,000 Worker-Years)
for Fall-Related Nonfatal Injury by Nature of Injury and Body
Part Affected, 1994
Source: Bureau of Labor Statistics, U.S. Department of Labor,

Survey of Occupational Illnesses and Injuries, 1994.
Nonfatal Injuries
Incidence. According to the Bureau of Labor Statistics, falls were the cause of 18% of all work-related
injuries in 1994, trailing only overexertion and being struck by an object as a leading cause of injury
(Bureau of Labor Statistics, 1996b). Between 1992 and 1994, the overall frequency for disabling fallrelated injuries was fairly constant at 49 per 10,000 person-years. Sectors with the greatest number of
fall-related injuries were the service and trade industries (Table 21.1). However, incidence rates were
highest for the construction, transportation, agriculture, and mining industries, with respective risks of
96, 73, 64, and 62 injuries per 10,000 worker-years.
In contrast to fall fatalities, over two thirds of nonfatal fall injuries were due to falls onto the same
level (Bureau of Labor Statistics, 1996b). However, we might generally expect that, the higher the fall
height, the greater the injury severity, and indeed, lost workdays were considerably higher for injuries
caused by falls to a lower level (10 days vs. 6 days for falls on the same level). As shown in Table 21.2,
the most frequent types of injury were strains and sprains, followed by fractures and contusions, and the
body part most affected was the trunk (including back and shoulders), followed by the lower extremity,
upper extremity, and head. While a useful reflection of overall injury trends, Table 21.2 fails to show
that falls represent the leading cause of work-related spinal cord injury (Rosenberg, 1993) and brain
injury (Heyer, 1994), surely among the most devastating of injuries. Not surprisingly, workers in
construction and agriculture are at greatest risk for these injuries.
Circumstances. When compared to fall fatalities, risk factors for nonfatal falls in the workplace are
considerably more diverse, as reflected by the small variation among industries in injury incidence (Table
21.1). McVittie (McVittie, 1995) found that risk factors for falls in the construction industry generally
fell under two categories: in-transit activities and poor housekeeping. Risk-factors associated with the
former included uneven terrain and the use of steps and ladders, while those associated with the latter
included the presence of waste materials, debris, clutter, poor lighting, and slippery surfaces.
21-5
21.4 Biomechanics
In considering the biomechanics of falls and fall-related injuries, it is useful to consider falls as having
three stages (Hayes, 1993): (1) an initiation stage, involving a slip, trip, or loss of balance, and potential
attempts to regain upright posture; (2) a descent stage, where movements may be attempted in preparation
for landing; and (3) a contact stage, where impact occurs between the body parts and the ground,
resulting in the generation of reaction forces and dissipation of the bodys kinetic energy.
Fall Initiation
Numerous studies have been conducted on the control of balance, involving application of destabilizing
perturbations to the feet or trunk (see reviews by Alexander, 1994; Prieto, 1993; Winter, 1990). Most
have focused on balance correction through sway, or standing balance maneuvers (Alexander, 1992; Era,
1995; Kuo, 1993; Maki, 1987; Romick-Allen, 1988; Stelmach, 1989), which involves activation of lower
extremity muscles in either a proximal-to-distal sequence (hip strategy), or distal-to-proximal sequence
(ankle strategy) (Manchester, 1989; Woollacott, 1993). However, several investigators have observed that
sway-based recovery is feasible only for small perturbations to posture (i.e., small displacements of the
bodys center-of-gravity from the base-of-support formed by the feet), such as those occurring during
normal walking and standing. Consequently, in the event of a slip or trip, stepping emerges as the
primary means for balance recovery (Maki, 1996; Nashner, 1980; Thelen, 1997; Wolfson, 1986).
To assess the factors which influence balance recovery by stepping after a slip, we recently measured
body movements as subjects (aged 22 to 35 years) stood barefoot on a large gymnasium mat and attempted
to prevent falls after the mattress was made to unexpectedly translate (Hsiao, 1998). Throughout the
testing session, we randomly varied both the direction of the perturbation (by having the subject stand
forward, backward, or sideways to the perturbation direction), and the strength of the perturbation
(randomized between 4 acceleration levels). To evoke natural responses, no practice trials were allowed,
and subjects were only instructed that (1) in the event of platform movement, they should try to
prevent themselves from falling, and (2) prior to platform movement, they should maintain their gaze
directed forward and at eye level. In each trial, a three-dimensional motion measurement system acquired
the positions of 20 skin surface markers located throughout the extremities and trunk.
As expected, stepping was the predominant balance recovery technique; only a single trial involved
stabilization of posture through sway (Figure 21.2). However, the effectiveness of stepping in preventing
a fall was highly directional-dependent, with subjects being more than twice as likely to fall when the
perturbation was directed posteriorly (i.e., the mattress translated in the anterior direction), as opposed
to anteriorly or laterally. Furthermore, falls due to posterior perturbations commonly involved trunk
and/or pelvis impact, while this was rare in falls due to anterior or lateral perturbations (in these trials,
impact was almost always restricted to the hands and/or knees). Finally, females were twice as likely to
fall as males, and in all but one fall trial, a failed attempt at balance recovery by stepping was observed
(Figure 21.3).
Implicit in the observation that stepping represents the primary means for balance recovery after a
slip or trip is the suggestion that fall risk is inherently greater on scaffolds and ladders, since the small
surface area of these environments nearly eliminates ones ability to recover balance by stepping. This
highlights the importance of educating workers to correctly perceive this difference in fall risk, and the
importance of utilizing fall restraint devices when working in such environments.
Fall Descent Kinematics

Even in a fall from standing height, sufficient energy exists to fracture the wrist (Chiu, 1996; Myers,
1993) or hip (Courtney, 1994; Robinovitch, 1991). However, only a small percentage of such falls
actually result in serious injury (Melton, 1988). This suggests that highly effective movement strategies
21-6
FIGURE 21.2 Balance recovery and falling responses during simulated slipping experiments. Seventy-seven percent
of trials involved balance recovery through one or more steps. During anterior and lateral perturbations, loss-ofbalance was more likely to lead to a partial fall (defined as contact to one or both knees and/or wrists) than a
fall (defined as contact to the pelvis and trunk), while the reverse was true for posterior perturbations. (From
Hsiao ET, Kearns M, Robinovitch SN. 1998. Analysis of movement strategies during unexpected falls. J Biomechanics,
31:19. With permission.)
FIGURE 21.3 Stick-figure (oblique view) image of a typical fall from a posterior perturbation. Note the failed
attempt to recover balance by stepping at approximately t = 0.45 s, the initial upward and then downward movement
of the upper extremity, the small degree of trunk rotation during descent, and the near-simultaneous impact to the
wrist and pelvis at approximately t = 0.75 s. (From Hsiao ET, Kearns M, Robinovitch SN. 1998. Analysis of
movement strategies during unexpected falls. J Biomechanics, 31:19. With permission.)
exist for preventing injury during a fall, and that injury risk may indeed be governed by impairment of
such responses due to host or environmental factors.
To assess the nature of protective responses during falls, we analyzed body movements during the 28
falls occurring during the slipping experiments described in the previous section (Hsiao, 1997). Our
results confirmed our suspicion that, rather than being random and unpredictable, body segment
kinematics during falls are organized into specific movement sequences which facilitate safe landing.
These could be classified into two major types. The first was a complex yet highly repeatable sequence
of upper extremity movements which allowed subjects to impact their wrist at nearly the same instant as
the pelvis (average time interval between contacts = 38 ms; Figure 21.4). This involved an immediate
upward movement of the upper extremity (perhaps reflecting a startle response), followed by a rapid
downward movement, and finally a second upward acceleration just prior to impact (Figure 21.3). This
last deceleration substantially decreased the vertical velocity of the wrist at contact velocity, which
21-7
FIGURE 21.4 Vertical velocity of the pelvis at the moment of impact as a function of the time interval between wrist
and pelvis contacts. Positive x-axis values reflect the wrist impacting before the pelvis, and negative values on the yaxis reflect downward movement. In approximately 70% of trials, the time difference between hip and wrist impacts
was less than 50 ms (gray band), suggesting a sharing of impact energy between the two body regions. (From Hsiao
ET, Kearns M, Robinovitch SN. 1998. Analysis of movement strategies during unexpected falls. J Biomechanics,
31:19. With permission.)
averaged 2.6 m/s, or 66% of its peak downward velocity during descent. Impact to both wrists was
observed in 26 of the 28 falls, with an average interval of 70 ms between contacts. Average vertical pelvis
velocity at impact was 2.5 m/s, or 83% of its peak downward velocity during descent. Head impact was
observed in only five falls, three of which involved the same subject.
These results suggest (as does common experience) that the upper extremity plays a major role in
allowing safe landing during a fall. For example, it is reasonable to assume that without the occurrence
of upper extremity impact, all cases of failed balance recovery would have resulted in impact to the head
and trunk. Therefore, braking the fall with the outstretched hand allowed for complete avoidance of
upper body impact in anterior trials, and reduced the incidence of upper body impact by over fourfold
in lateral trials. Second, over two thirds of falls involved wrist contact within 50 ms of pelvis contact
(Figure 21.4), and previous studies have shown that approximately 50 ms is required to reach peak
force during a fall on the hip (Robinovitch, 1991) or wrist (Chiu, 1996). This suggests that impact
configurations are chosen to allow sharing of impact energy between these body parts, and a subsequent
reduction in localized impact forces and injury risk.
The second class of protective response observed in these trials was marked trunk rotation in falls
due to lateral (but not anterior or posterior) perturbations (Figure 21.5). This commenced late in the
descent stage of the fall, and resulted in impact with the body anteriorly facing the contact surface. This,
in turn, allowed subjects to contact the impact surface with both right and left upper extremities, and
avoid impact to the lateral aspect of the hip (thereby decreasing ones risk for hip fracture [Greenspan,
1994; Nevitt, 1993]). In posterior perturbations, subjects apparently sensed the infeasibility of a 180degree trunk rotation to anteriorly face the impact surface, and instead focused on safe landing on the
buttocks and wrists.
Impact Mechanics
During a fall, the risk for injury to a specific anatomical structure depends on the ratio of the force
applied to the structure divided by the force required to cause failure. To estimate failure forces of
anatomical structures, cadaveric materials may be loaded to failure in a mechanical testing system which
simulates the fall impact environment. Such studies have measured failure loads for the distal radius,
21-8
FIGURE 21.5 Stick figure image of a typical side fall. Note that trunk rotation about an inferior-superior axis
allowed for impact to the anterior-lateral aspect of the pelvis rather than the hip, at nearly the same instant that
contact occurred to the wrist. (From Hsiao ET, Kearns M, Robinovitch SN. 1998. Analysis of movement strategies
during unexpected falls. J Biomechanics, 31:19. With permission.)
which average 1800 700 N (Myers, 1993; Spadaro, 1994), and the hip, which average 4200 1600
(S.D.) N (Courtney, 1994; Weber, 1992).
In order to estimate fall impact forces, consider the mechanics of a simple mass-spring representation
of the body, as shown in Figure 21.6. In configuration (a), the system is stationary at height h (measured
in units of m), possessing zero kinetic energy and a gravitational potential energy of mgh, where m is the
mass in kg, and g is the gravitational constant, 9.81 m/s2. Configuration (b) represents the beginning of
the impact phase. The system has descended a height h, and the spring just contacts the ground but has
not yet undergone compression. Therefore, the system has zero potential energy and a kinetic energy of
mv2/2, where v is the downward velocity in m/s. By equating total energy between configurations (a)
and (b), it is readily observed that
(recall that free-fall velocity is dependent only on descent
height, and not system mass). Finally, in configuration (c), the spring has compressed maximally (by an
amount x, measured in m), and is about to rebound upward. Therefore, the system has zero downward
velocity and kinetic energy, and (neglecting the difference in gravitational potential energy between
configurations (b) and (c)) a potential energy of kx2/2 = F2/(2k). Equating this to the total energy in
configurations (a) or (b), the peak impact force on the system is:
(21.1)
Equation (21.1) illustrates that the main requirement in determining impact force is to derive reasonable
estimates for the systems effective mass m and stiffness k. In previous studies, we estimated such values
based on the measured response of human subjects during safe, simulated falls on the hip (Robinovitch,
1991) and outstretched hand (Chiu, 1996). Average values for m and k during falls onto the hip were 35
kg and 71 kN/m, respectively, while those for falls on the outstretched hand were 29 kg and 8.7 kN/m.
Figure 21.7 shows resulting estimates of peak contact force when floor stiffness is infinitely stiff, and
primary contact occurs to either the upper extremity (filled circles) or hip (filled squares). Under such
conditions, hip contact force is over threefold greater than upper extremity contact force, due to the
substantially higher effective stiffness of the body during a fall on the hip. Also shown in Figure 21.7 are
peak contact forces for falls onto a rather soft surface, possessing a stiffness of 10 kN/m. These were
calculated by replacing k in Equation (21.1) with the equivalent series stiffness kkf/(k + kf). Note that,
21-9
FIGURE 21.6 Idealized spring-mass model of impact during a fall. Simple energy considerations imply that contact
force scales with the square-root of descent height, effective mass, and effective stiffness.
FIGURE 21.7 Effect of fall height and ground stiffness on estimated contact forces during falls. Contact force is
based on
(see Figure 21.6), where keq = kkf/(k + kf) is the effective series stiffness (in kN/m) of the body
spring k and ground spring kf, m is the effective mass of the body (in m), g = 9.81 m/s2, and h is descent height (in m).
Estimated values for m and k are 35 kg and 71 kN/m for impact to the hip (Robinovitch, 1991) and 29 kg and 8.7
kN/m for impact to the outstretched hand (Chiu, 1996). Note that, during impact to an infinitely stiff surface (kf =
; filled symbols), the much stiffer hip region experiences contact forces threefold higher than those generated
during a fall on the upper extremity. However, during impact to a soft surface (kf = 10 kN/m; open symbols), the
series stiffness governing hip impact is greatly reduced, and peak hip impact forces exceed upper extremity forces by
only 1.5-fold.
under this scenario, hip contact force is reduced 65%, while upper extremity force is reduced by only
27%. Consequently, a soft impact surface substantially reduces ones risk for hip fracture during a fall
(or injury to other stiff body parts, such as the head or back), but offers considerably less protection
against upper extremity injury.
21-10
21.5 Prevention
The single most effective means for lowering the incidence of serious fall-related injuries in the workplace
is to ensure appropriate use of personal fall protection equipment. This follows from the following facts
discussed in Section 21.3: (1) that the vast majority of serious fall injuries and fatalities involve descents
from high elevation; (2) that in the majority of cases, fall protection equipment was not being used at the
time of the injury; and (3) that few fall-related deaths result from restraint system failure.
A major challenge for ergonomics researchers is to therefore engineer systems which ensure usage of
fall protection equipment in high-risk environments. This requires the conversion of fall protection
systems from an active form of protection, which relies on workers choice in utilizing it, to an automatic
(or passive) form of protection, in which user choice, and thus risk for noncompliance, is eliminated
(Committee on Trauma Research, 1985). To illustrate the point here, consider the role of seatbelts in
preventing injury during motor vehicle accidents. While it is well-established that seatbelts reduce injury
risk, the existence of a seatbelt in itself provides no actual protection, unless the occupant chooses to use
it (active protection). In contrast, an automobile designed so the transmission operates only when seatbelts
are engaged (passive protection) is likely to be inherently safer, since it removes user choice as a variable.
An analogous system for work at high elevation is, for example, one which prevents workers from
ascending to elevated workspaces without the use of an effective fall protection system.
Simultaneous with efforts to develop such systems, improvements should be undertaken in job training
and work site inspection for fall hazards. Equipment should be regularly tested for structural integrity,
and inspected for evidence of wear or damage. Risk factors for standing height falls should also be
minimized, with special attention to proper lighting, and the elimination of clutter and slippery surfaces.
Workers and supervisors should also be alert to intrinsic risk factors for falls, such as alcohol or medication
use, and impairments in vision, balance, strength, and joint range-of-motion.
Education should focus on the principles of load-transfer and load-sharing among restraint system
components, and the need to ensure that the load-bearing capacity of each component (e.g., anchoring
sites, belts, lifeline attachment fixtures, ropes) meet appropriate factors of safety. Workers should also
be educated regarding the importance of short lifelines, since the loads imposed on a tethering system
increase with descent height. In using scaffolding, attention should be paid to manufacturer
recommendations on the use of counterweights, safety brakes, tie-off of support devices, and floor load
capacity. Different anchor points should be used to support scaffolding and harness or body belt lifelines.
Workers should also be trained on proper use of ladders, including reaching practices, use of three-point
contact, avoidance of unstable surfaces, and limitations on ladder inclination and ascent height.
Education on fall mechanics may also promote safe work practices, and eliminate misconceptions
regarding risk for falls and fall-related injuries. For example, workers should be instructed on the
relationship between injury tolerance limits and fall descent height, and be made aware that postural
stability is inherently lower in the constrained environment of a scaffold or ladder, since reduced surface
area impairs ones ability to recover balance by stepping.
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22
Low Back Pain (LBP)
Glossary: A Reference
for Engineers and
Ergonomists
Simon M.Hsiang
Liberty Mutual Research Center
for Safety and Health
Raymond M.McGorry
Liberty Mutual Research Center
for Safety and Health
22.1
22.2
22.3
Foreword
Introduction
Terms and Definitions
221
221
222
22.1 Foreword
Low back pain (LBP) is a pervasive problem in many societies and low back pain disability (LBPD) is the
most expensive and pervasive health and safety problem arising in industry (Spengler et al., 1986a;
Webster and Snook, 1990). However, there is no clear definition, well-accepted pathology, diagnostic
scheme or treatment protocol for the problem. With occurrences both in and out of the workplace and
in both the presence and absence of biomechanical stressors arising from work, the problem is regarded
as belonging to several academic domains. Consequently, ergonomists, sociologists, psychologists, and
engineers are attempting to determine the relevant approaches from their individual disciplines. The
large volume of LBP research papers produced by widely divergent disciplines is indicative of the scope,
and the urgent need to control the problem.
In attempting to deal with the immense and sometimes controversial literature, many ergonomists
and engineers interested or involved in the studies of LBP are often exposed to documents replete with
medical vocabularies and unfamiliar theories.
For the benefit of these professionals, in their review of the literature, this glossary of LBP terminology
and research has been compiled. The reader should be aware of the complexity and the subjective nature
of the large volume of LBP literature. This document is not meant to substitute for a medical dictionary,
or for review of the current literature, but rather as a desk reference for those requiring assistance with
terms or hypotheses encountered during an article review.
22.2 Introduction
The terms compiled in this glossary can be classified into six highly interrelated categories. They are:
anatomy of the vertebral column, the mechanism of disease process, diagnosis, diagnostic tools, treatment
plans based on diagnosis, and terms specific to low back pain (see Figures 22.1 and 22.2).
0-8493-1800-9/03/$0.00+$1.50
22-1
22-2
FIGURE 22.1 Schematic of the six categories of terms of low back pain.
Anatomy deals with terms that are descriptive of and specific to the structure and physical properties of
the vertebrae, the intervertebral disc, the spinal cord and its nerve roots, and the muscles and ligaments
that attach to it.
Mechanism describes the normal and abnormal function (physiology) of the anatomy, providing insight
into the effect of disease process on the mechanics of the spinal column.
Diagnostic tools have been developed to provide insight into the anatomy and function to aid the
medical practitioner in developing an appropriate diagnosis and subsequent treatment plan.
Diagnosis is a medical judgment based on the qualitative and quantitative findings produced by the
diagnostic tools. Development of the appropriate diagnosis provides insight into the disease process
and as a result provides goals and direction to the treatment plan.
Treatment covers a spectrum of techniques and procedures, performed by a wide array of medical
professionals, based on any number of philosophies.
Low back pain is a category that encompasses terms related to the cause, nature, and description of the
pain.
Two cases are provided to demonstrate the interrelationships that exist between the terms included in
this glossary. In these cases the terms are linked to illustrate two different pathways from activity to the
mechanism and finally the diagnosis and medical management of LBP. Consider the case where lifting
and activities of daily living (ADL) create compressive and torsional forces acting on the spine. These
forces are borne by both the anterior (disc) and posterior (apophysis) portion of the vertebral column.
Case 1, as shown in Figure 22.3, uses the apophyseal (facet) joint as an example to trace the low back
pain pathway for the posterior aspect of the spine. Case 2, as shown in Figure 22.4, uses the disc to trace
the same pathway for the anterior spine. Note that both examples are for illustrative purposes only.
They are not all-inclusive and are not intended as suggested limitations to the use of diagnostic tool or
treatment protocols.
22.3 Terms and Definitions

Acupuncturebased on Chinese medicine techniques. Involves insertion of thin needles of various length
through the skin at sites believed (1) to relieve symptoms, (2) to induce surgical anesthesia, and (3)
to promote healing. Sometimes used to relieve low back pain.
Analgesic(1) insensitive to pain, (2) relieving pain, and (3) an agent whose intended action is to
alleviate pain (see pharmacological agents for low back pain).
22-3
Anaphylaxis (Anaphylactic)a manifestation of sudden allergic reaction (see antigen).

Ankylosisimmobility or abnormal fixation of a joint. May be congenital, hereditary, or resulting from
disease, injury, aging process (Sampson and Davis, 1988), or induced artificially by surgical fixation
or fusion. Ankylosis reduces spinal segment range of motion, and often is painful. It can sometimes
be asymptomatic.
Ankylosing spondylitisinflammation of the spine that leads to stiffening or fusion of the vertebral joints.
Annulusa ring or ring-like structure.
Annulus fibrosusThe fibrous outer ring-like portion of the intervertebral disc (Bogduk, 1983, 1991;
Brinckmann, 1986; Hickey and Hukins, 1983).
Anatomy
Can be classified into the inner portion and the outer portion. The inner portion of the annulus
is mainly type II collagen (fibrocartilaginous). These collagen fibers are attached to the vertebral
endplate, forming an internal capsule surrounding the nucleus pulposus. The outer portion is
largely type I collagen (fibroelastic) and spans the rims of the vertebral bodies.
The annulus fibrosis is comprised of 16 to 20 layers called lamellae. Collagen fibers in a single
lamella of the annulus fibrosus have the same orientation. They are typically oriented at an angle
of 65 to the long axis of the vertebral column. The orientation of the fibers alternates from 65
to -65 in successive lamellae.
Mechanism
Both apophyseal joints and annulus fibrosus can resist shear force. The apophyseal joints have
facets oriented to block forward translation by bony contact. The annulus fibrosus acts as a
substantial ligament capable of resisting shear due to its high density of collagen.
The orientation of collagen fibers may be biomechanically essential for the annulus to withstand:
(1) the tensile force due to trunk flexion; (2) the radial load due to axial loading; (3) the torsional
stress due to trunk rotation; (4) the shear stress due to anterior or posterior translation of the
vertebrae; (5) or the combination of these forces.
Failure
The annulus fibrosis can fail under conditions of low magnitude cyclic loading when exposed to
a combined pattern of flexion and rotation (Gordon et al., 1991).
The annulus may creep in time under compression with buckling and bulging of the annulus fibrosus
and narrowing of the disc space. Creeping may become symptomatic as a result of foraminal or
canal stenosis. In some cases of annular disruption, CT scan and discography provocation have
demonstrated good correlation (Vanharanta et al., 1988b) (see creep and stenosis).
The annulus fibrosus may creep due to the shear force when the mechanism of apophyseal joints
is disabled by spondylolysis. Creeping may cause the upper vertebrae in the segment to slide
progressively forward, as the condition progresses to spondylolisthesis (see spondylolysis and
spondylolisthesis).
Anterior longitudinal ligamentthe broad, strong band of longitudinal fibers that extends along the
anterior surface of the vertebral bodies. It extends from the cervical spine to the sacrum (see ligament,
and spinal ligament).
Antigenany substance that the body regards as foreign and potentially dangerous and against which it
initiates a specific immune response.
Apophyseal joint of the spinecommonly used as a synonym for the zygapophyseal or facet joint
between adjacent vertebrae. The function of the apophyseal joint is to allow limited movement
between vertebrae and to protect the disc from excessive shear forces, flexion, and axial rotation
(Adams and Hutton, 1983b; Oxland et al., 1992). Excessive loading of this joint stretches the joint
capsule and can itself be a cause of low back pain (Yang and King, 1984a). These joints contain
rudimentary menisci which have been suspected of causing pain in entrapment disorders and may
respond to treatment with manipulation (Bogduk and Engle, 1984).
22-4
FIGURE 22.2 Compilation of glossary terms in each of the six categories.
Apophysisprojection or swelling from a bone.

Arachnoidresembling a spiders web in consistency.
Arachnoid membranethe middle of the three membranes (meninges) covering the spinal cord and
brain (see meninges).
Arachnoiditisinflammation of the arachnoid membrane; can progress to fibrosis or scarring that binds
the nerve roots of the cauda equina (see cauda equina, sciatica).
22-5
FIGURE 22.2 (continued)
Arthritisinflammation of a joint (see osteoarthritis, rheumatoid arthritis).

Arthropathydisease affecting a joint.
Autoimmunitya condition characterized by an immune response directed against the bodys own
tissues.
Avulsionthe tearing or forcible separation of part of a structure.
Back schoola patient education program usually administered by health care professionals with the
goal of achieving the greatest functional level for the patient. This usually includes education about
the anatomy of the spine, mechanisms of back pain, proper body mechanics for lifting and in activities
of daily living (ADLs), and safe exercise techniques (Saal and Saal, 1989).
Bed rest for low back painrestriction of movement and activity during the acute phase of an LBP
episode. Current medical management suggests bed rest for only a brief period (two days or less)
(Deyo et al., 1986; Nachemson, 1985).
Biofeedbackthe process of providing audio, visual, or tactile feedback of some physiological measure
(e.g., skin temperature, heart rate, EMG, blood pressure) to the patient. The goal is to teach the
patient self modulation or voluntary control of the measures, often with a resultant reduction or
cessation of the associated symptoms (Asfour et al., 1989).
22-6
FIGURE 22.3 Schematic of Case 1: Facet joint.
Bone scanan imaging technique during which a radioactively tagged metabolite is injected into the
body and becomes incorporated into the skeletal system of the individual. Regions of increased
metabolic activity and increased blood supply (e.g., inflammation, healing fractures, cancerous
growths) can be visualized using nuclear medicine imaging techniques.
Cancellouslattice like; applied to the bony tissue laid down by osteoblasts during development of
bone and in the consolidation stage of fracture repair.
Caudaltoward the tail, opposite to cephalad.
Cauda equinaLatin for mares tail. The terminus of the spinal cord in the lower lumbar spine
forming an array of nerve roots and occupying the vertebral canal below the cord.
Cephaladtoward the head, opposite to caudal.
Chemonucleolysis (CNL)dissolution of the nucleus pulposus of an intervertebral disc by injection of
a proteolytic agent (see chymopapain). Can be effective in the treatment of herniation of a disc
(Farfan, 1985). Some of the complications or side effects of this procedure can be severe allergic
reactions, migration of the enzyme to surrounding tissues, tissue destruction, postoperative LBP and
spasm, and a slowing of nerve conduction (Wehling et al., 1989; Bromley et al., 1984; Fager, 1984;
Agre et al., 1984).
Chymopapainan enzyme that dissolves soft tissue, especially the intervertebral disc nucleus. The
mechanism of the injection of chymopapain is the hydrolysis of proteoglycans resulting in a decrease
in intradiscal pressure, and subsequent dissolution of disc components. A temporary change in the
mechanical properties of the disc may result from the injection (Spencer et al., 1985; Nordby, 1983)
(see chemonucleolysis).
22-7
FIGURE 22.4 Schematic of Case 2: HNP.
Claudication (neurogenic)pain due to neurologic or vascular compromise.
Neurogenic claudicationpain of a neurologic origin occurring in the back, buttocks, and legs.
It increases with walking or other weight-bearing activities (Dong and Porter, 1989) (see straight
leg raise test).
Vascular claudicationleg pain secondary to a circulatory insufficiency. No pain in a limb when
at rest. The pain starts after walking has begun. Intensification of the pain will not occur without
activity. Pain stops after a period of rest.
Coccyxcommonly known as the tail bone; the last four bones of the spine, generally fused.
Cohorta group of individuals who share a common exposure or experience.
Collagena group of fibrous proteins that are major constituents of connective tissues (e.g., skin, tendon,
bone, cartilage).
22-8
Compression loading of the discthe load applied along the long axis of the vertebral column (Marras
et al., 1984). It is the force vector normal to the body of the disc. Several mutually dependent factors
can contribute to compressive loading of the intervertebral disc (Barnes et al., 1989; Dillard et al.,
1991; Dolan et al., 1988; Marras and Reilly, 1988; Schultz, 1986): (1) weight of the body; (2) forces
due to external loading; (3) forces secondary to muscular contraction (Bogduk et al., 1992; Cartas
et al., 1992; Goel et al., 1993; Ladin et al., 1989; Poulsen, 1981; Schultz and Andersson, 1981;
Schultz et al., 1981); (4) restorative forces of the spinal ligaments; (5) forces secondary to intraabdominal pressure (Davis, 1981; Gracovetsky et al., 1981; rtengren et al., 1981; Bogduk and
Macintosh, 1984). It may be that the L3/L4 lumbar disc is exposed to greater compressive loading
than the L5/S1 disc. This is due to the greater mechanical advantage provided by the more pronounced
L5 spinous process which serves as the attachment for ligaments and extensor muscles (Gracovetsky
et al., 1977; Gracovetsky and Farfan, 1986).
Capacity
The forces required to produce failure purely by compression alone are quite large, on the order
of 10 kN. Such forces are not incurred under normal circumstances (Hutton and Adams, 1982).
There are studies suggesting that the maximal compressive force on the L5/S1 disc could be used
to predict incidence rates of LBP (Chaffin and Park, 1973; Herrin et al., 1986). However, LBP
due to annulus rupture from acute strain on the tissue appears improbable, and the ultimate
compressive strength is not a reliable measure since it varies over a wide range.
There is some evidence that an individuals level of physical activity may positively influence the
compressive strength of the lumbar disc and vertebral body (Porter et al., 1989).
Mechanism (Lin et al., 1978)
The annulus can passively transmit weight (compressive loads) between consecutive vertebral
bodies because the sheer mass of its fibers renders them effective space fillers.
Weight bearing between two vertebrae thus requires the cooperative action of both the nucleus
pulposus and the annulus fibrosus.
Failure
Sudden large magnitude compressive forces tend to cause anterior disc prolapse, while smaller
magnitude cyclic compressive loading tends to result in bulging of the lamella of the posterior
annulus (Adams and Hutton, 1985; Lavender et al., 1993; McNally et al., 1993).
When a spinal joint is under compressive loading or flexed beyond its normal range, failure may
result due to microfracture of a vertebral endplate (Adams and Hutton, 1982) and/or excessive
strain on the underlying vertebra (Brinckmann et al., 1983).
Interdependency has been documented between the surface area of the endplate and the density
of the vertebral body (Brinckmann et al., 1989). Likewise, an interdependence has been reported
between the vertebral bone density and the mechanical properties of the disc (Keller et al., 1989).
Repeated microfractures and scarring of the bone underlying the vertebral endplates may induce
a spot deterioration of the disc (Horst and Brinckmann, 1981). Uneven pressure gradients due
to the spot deterioration propagate unrecoverable disc bulge. Deterioration is due to fluid loss
and resultant change in viscoelastic properties. The mechanical failure of the endplate is highly
dependent on the rigidity of the endplate and the underlying trabecular bone (Holmes et al.,
1993). The consequences are decreased disc height and destabilization of the motion segments.
The deterioration may continue with herniation of nuclear material into the vertebral canal,
where it irritates or compresses nerve roots.
Under compressive loading the facet joints are the foremost structure to yield at the limit of
torsion. When compression of the disc is combined with torsion, the probability of failure
increases.
22-9
Computer assisted tomography (CT or CAT) scanan imaging technique involving a series of sequential
X-ray exposures (slices) taken at discrete space intervals. The resultant tissue density information
can be manipulated and stored by the computer. These data can be digitally enhanced to provide
clinically useful information (Dvorak et al., 1987). The integration of a series of these exposures can
be used to create three-dimensional images. CT images can provide evidence of soft tissue
encroachment, such as disc herniation (Ninomiya et al., 1992); however, MRI has become the gold
standard for identifying disc herniation except in some cases where CT with myelography is needed.
MRI provides greater resolution of soft tissues and has become more widely used in the imaging and
diagnosis of spinal pathology where soft tissue involvement is suspected (see MRI).
Congenitalreferring to a condition present at the time of birth.
Coronal planerelating to the plane that bisects the body into anterior and posterior sections.
Corsetsan orthopedic device that encircles and supports a part, as worn in certain spinal injuries or
deformities (Lantz and Schultz, 1986a, 1986b) (see orthosis).
Creepincreasing strain (elongation) due to constant loading under the elastic limit of the material over
a long period of time
Creep of the intervertebral discUnder experimental conditions, the disc with its nucleus removed
initially exhibits the same compressive stiffness as an intact disc (Adams and Hutton, 1983a). The
problem with an isolated annulus fibrosus is that, in time, it will creep; its lamellae buckle inward
and outward, and the disc space is decreased (Adams et al., 1987; Panjabi et al., 1984; Shirazi-Adl
et al., 1984). Prolonged sitting or standing postures, and exposure to whole body vibration may
cause creep detectable as a temporary decrease in stature (Brinckmann and Grootenboer, 1991).
Diagnosis of Low Back PainDiagnostic Terminology for LBP based on Fardon et al., (1993):
22-10
Diagnostic techniques/tools for low back pain (Wiesel et al., 1984; Nachemson, 1985; Hadler, 1984;
Haig, 1992)
History, physical exam, and self report;

Imaging techniquesX-rays (Panjabi et al., 1992a; Scavone et al., 1981), CT scan, MRI (Bernhardt
et al., 1992), Thermograph (Mills et al., 1986);
Enhanced imagingdiscography, myelography, bone scan;
Electrophysiologic testingEMG (electromyography), NCV (nerve conduction velocity), and
SEP (somatosensory evoked potentials) (Tonzola and Ackil, 1981; Haldeman, 1984; Eisen and
Hoirch, 1983).
DiscThe intervertebral disc is intimately connected to two adjacent vertebral bodies. Composed of
soft tissue, the disc serves to transmit loads down the vertebral column, as well as provide an energy
absorptive capacity. Due to its flexibility and its interposition between the vertebrae, it allows for
greater range of motion of the spine.
Gross anatomy (Inoue, 1981; Markolf and Morris, 1974)
The disc consists of three parts: (1) a semifluid nucleus pulposus, consisting of water bound by a
matrix of proteoglycans and collagen; (2) an annulus fibrosus, consisting of some 16 to 20
lamellae of collagen fibers surrounding the nucleus pulposus; and (3) vertebral endplates, covering
the top and bottom surfaces of the disc and connecting it to the vertebral bodies.
Neuroanatomy (Bogduk et al., 1981; Goren et al., 1990; Panjabi et al., 1988b; Yoshizawa et al.,
1980)
Nerve fibers (including nociceptors) exist within the outer third of the annulus. The middle third
of the annulus fibrosus may or may not be innervated. The inner third is not innervated (Bogduk,
1983, 1991).
The sources of nerve fibers in the annulus fibrosus are the sinuvertebral nerves posteriorly, from
the ventral rami posterolaterally, and from the gray rami communicants anteriorly and laterally
(Bogduk et al., 1992).
Disc degenerationa term describing the physical deterioration resulting from an injury to the disc
(Thompson et al., 1990) or from the gradual wear and tear associated with the aging process (Hickey
et al., 1986) and gender (Hsu et al., 1990; Kim et al., 1991; Miller et al., 1988; Pedrini-Mille et al.,
1990; Tanaka et al., 1993; Vanharanta et al., 1989).
22-11
Mechanical property alterations

The structural deterioration results in a change in viscoelastic properties (from resilient, with a
high water concentration, to nonresilient, with a low water concentration) of the disc (Horst and
Brinckmann, 1981; Panagiotacopulos et al., 1987; Hukins et al., 1990; McNally et al., 1992).
The nucleus pulposus loses fluid and becomes less elastic (Adams and Hutton, 1983a).
The normally firm and compact annulus fibrosis becomes fragmented and can surrender its
structural integrity (Hickey and Hukins, 1982).
The bone of the vertebral bodies adjacent to a degenerated disc exhibits a decrease in mechanical
properties under compressive loading (Hansson et al., 1987). Relatively greater degeneration in
the lumbar discs of cadavers occurs at lower spinal levels (Panjabi, 1988).
Diagnosis
Measurement of disc height from radiographic studies has been found to be a poor method of
detecting early, potentially symptomatic, degenerative changes (Vanharanta et al., 1988a).
A relationship has been described between disc degeneration and osteoarthritis of the facet joint.
It is believed that arthritis follows disc degeneration because of changes in the loading of the facet
(Butler et al., 1990; Noren et al., 1991).
Disc disruptiondegradation of the nucleus pulposus and inner annulus fibrosus without change in
contour or size of the disc. There is a resultant degradation of the mechanical properties of the disc
(Bogduk, 1983; Bogduk, 1991).
Mechanism of disc disruption
Nuclear degradation may progress to involve erosion of the annulus fibrosus and fissures in the
radial directions.
The annulus fibrosus may be left to bear weight alone, because the bracing effect of the nucleus
on the annulus fibrosus is reduced.
The nerve endings in the annulus fibrosus can be sensitized by substances produced during the
inflammatory response at thresholds lower than would be anticipated if the mechanical process
operated alone (McCarron et al., 1987).
Physical evidence
Very little physical evidence of disc disruption can be found directly. Since the outer perimeter
(boundary) of the disc remains intact and normal in contour, no element of disc bulge or herniation
is observed. Discography is required for definitive diagnosis (Sachs et al., 1987).
Symptoms (without frank herniation of the nucleus)
Pain may be due to the chemical nociception and would be aggravated by any movement that
mechanically stressed the affected disc.
Inflammatory cells penetrate the annulus fibrosus of disrupted discs, whereupon chemical
mediators may trigger nociceptive nerve endings.
Nerve endings in the annulus fibrosus may be exposed to enzymes and breakdown products
involved in the degradative process of the disc.
Diagnosis
No abnormal neurologic signs will be present because the disc disruption does not involve nerve
root irritation or compression.
CT scans and myelography are usually normal because the outer perimeter of the disc is intact.
Discectomysurgical removal or excision of all or part of the disc (Spengler, 1982a; Eismont and Currier,
1989). There is a change in disc contour and size following discectomy (Brinckmann and Horst, 1985).
Disc height, radial bulging, and intradiscal pressure all decrease following discectomy (Brinckmann and
Grootenboer, 1991). The inflammatory focus and the source of mechanical pain is often eliminated with
excision of the problematic disc (see micro-discectomy). Total disc excision may destabilize the motion
segment, and surgical fusion may be required (Goel et al., 1985, 1986; Frymoyer, 1981).
22-12
Disc prolapse or disc herniationextrusion of the nucleus pulposus of an intervertebral disc. The extruded
material may be mixed elements of the annulus fibrosus and nucleus pulposus (see HNP).
Discitisinflammatory disease of the disc.
Discogenic painpain caused by derangement of an intervertebral disc.
Discographyan imaging technique for direct visualization of disc structure and pathology. This
procedure involves X-ray photography of an intervertebral disc after direct injection of an absorbable
radiopaque contrast medium (Sachs et al., 1987).
Pain provocation
Discography pain provocation is usually conducted on the suspected disc and at least one adjacent
disc (Weinstein et al., 1988a; Calhoun et al., 1988; Friedman and Goldner, 1955). During the
procedure the patient is asked to distinguish between the painful and pain-free discs (Vanharanta
et al., 1987).
Patients undergoing discography sometimes suffer reproduction of their back pain.
Application
Some clinicians and researchers question if discography provides information that cannot be
obtained by other methods (Mooney et al., 1988; Nachemson, 1989). Others question the reliability
and utility of the technique (Nachemson, 1989; Holt, 1968).
Test specificity is reported to be markedly improved by combining analysis of the discographic
image with information acquired during provocation (Walsh et al., 1990).
A combined analysis using computed tomography (CT scan) and discography is reported to
provide better documentation of the site and size of a prolapsed disc (Ninomiya et al., 1992;
Anntti-Poika et al., 1990).
Discography, like any invasive procedure, is not without its risks. One serious complication is
discitis secondary to infection (Fraser et al., 1987).
Diurnal changes (in the disc)It is hypothesized that the daily cyclic change in stature is due to
expungement and reabsorbtion of fluid by the disc (Adams et al., 1986). This is thought to be
related to the change of compressive loading of the disc associated with standing and sleep positioning
(Tyrrell et al., 1985; Krag et al., 1990). Research indicates that the greatest rate of shrinkage or
swelling occurs during the first hour of standing or lying, respectively. However, disc height
measurements can vary greatly (Andersson et al., 1981; Adams and Hutton, 1983a; Adams et al.,
1987; Adams et al., 1990; Adams and Dolan, 1991).
Dorsal(1) related to the back; (2) posterior; a position more toward the back surface.
Dura materthe tough outermost of the three membranes (meninges) covering the spine and brain (see
epidural).
Ectopicmisplaced, occurring in an unnatural location, especially if congenital.
Edema (oedema)excessive accumulation of fluid in the intercellular tissue spaces.
EMASendorphin mediated analgesia system (see endorphin).
Electromyography (EMG)the measurement of the electrochemical potential produced during: (1) rest;
(2) voluntary contraction; and (3) electrical stimulation of the skeletal muscle. Although EMG is
used to estimate muscular exertion force, the limits of its accuracy and precision have not yet been
clearly defined. EMG can also be used as an indirect measure of the function of the motor nerves
which control the tested muscle (Schultz et al., 1982b; Khatri et al., 1984).
Endogenousoriginating or produced within the organism.
Endorphina neurotransmitter produced in the central nervous system that acts as an analgesic (see EMAS).
Endplate fracture or disruptionrefers to fissuring or loss of continuity of the cartilage interface between
the disc and adjacent vertebral bodies. An endplate fracture may heal and cause no further problems.
It is possible for an endplate fracture to set into motion a series of sequelae that manifest as pain and
a variety of end stages. These symptoms may be demonstrated by pain provocation during discography
(see discography) (Hsu et al., 1988).
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Enthesis(1) the junction of tendon and bone; (2) the use of a man-made substance as a substitute for
lost or removed tissue.
Enthesopathyany rheumatic disease resulting in inflammation of enthesis.
Epidemiology of low back painEpidemiology is the science concerned with the study of the factors
influencing the frequency and distribution of disease or injury in human populations. Epidemiologic
studies of low back pain have been limited due to the difficulty in defining exposures and outcomes.
Three domains of risk factors for the epidemiology of low back pain have been established (Allan
and Waddell, 1989; Bigos et al., 1986a, 1986b; Damkot et al., 1984; Frymoyer and Gordon, 1989;
Nachemson et al., 1991; Sandover, 1988; Skovron, 1992).
Task factors (Pearcy et al., 1985; Troup et al., 1981)
Vibration (Althoff et al., 1991; Kelsey, 1975; Kelsey et al., 1984b; Weinstein et al., 1988b; Wilder
et al., 1982).
Lifting (Kelsey et al., 1984b; Mirka and Marras, 1993; Mundt et al., 1993; Svensson and
Andersson, 1983).
Monotonous work (Magnusson et al., 1990; Svensson and Andersson, 1983).
Work load (Sairanen et al., 1981; Stubbs, 1981; Videman et al., 1984).
Environmental factors
Job satisfaction (Bigos et al., 1991a).
Prolonged sitting/Sedentary jobs (Kelsey, 1975; Svensson and Andersson, 1983; Videman et al.,
1990; Williams et al., 1991).
Individual factors (Bigos et al., 1991c)
Cigarette smoking (Batti et al., 1989b; Kelsey et al., 1984a).
Physical characteristics.
Cardiovascular conditioning (Batti et al., 1989b).
Age and gender (Videman et al., 1990; Videman et al., 1984).
Pregnancy and menstruation (Ostgaard et al., 1993; Svensson et al., 1990; Videman et al., 1984).
Strength (Batti et al., 1989b; Troup, 1991b).
Psychological characteristics (Bigos et al., 1991b; Ostgaard et al., 1991).
Psychosocial status (Troup, 1991a).
Epidural (extradural)on or over the dura mater; often used in reference to the space outside the dura,
a common site for administration of anesthetics (see dura mater).
Erector spinaelarge rope-like muscle mass made up of many small, segmental muscles that run parallel
to the spine. They act in concert to extend the trunk, creating an extension moment and compressive
forces within the vertebral column (Schultz et al., 1982a; Macintosh and Bogduk, 1987, 1991;
McGill, 1991). The extensor moment created by the erector spinae muscle force is a function of
trunk position since the muscle moment arm varies with flexion angle (Cartas et al., 1992; Goel et
al., 1993; Macinstosh et al., 1993; Tan et al., 1993; Triano and Schultz, 1987).
Etiology of low back painEtiology is the study of the factors and causes of disease. The potential
causes of LBP can be categorized into mechanical, chemical, biological, infectious, genetic,
degenerative, and psychosocial causes (Spengler, 1982b, 1983; Spengler and Freeman, 1979).
Exercise treatment for low back painusually prescribed to improve flexibility of the spine and
strengthening of the trunk musculature. This may involve flexion or extension exercises, or both
(Saal and Saal, 1989; Elnaggar et al., 1991; Nachemson, 1985).
Exogenousoriginating or produced externally.
Facet joints of the spinethe paired synovial (moveable) joints between adjacent vertebrae, located on
the apophyseal protuberances on the posterolateral aspect of the vertebral body. Its integrity and
proper function depend on support from surrounding structures such as the joint capsule, ligaments,
the intervertebral disc, and the muscles that cross the joint (Carrera, 1980a, 1980b; Davis and
Carragee, 1993; Panjabi et al., 1992b, 1993; Van Schaik et al., 1985; Shirazi-Adl et al., 1987; Yang
and King, 1984b).
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Facetectomysurgical excision of the articular facet of the spine (Wiltse, 1977). This procedure can be
performed for correction of severe scoliosis. A major concern following this type of surgery is the
stability of the spinal segment (Abumi et al., 1989b).
Fibrosisformation of fibrous tissue, as in repair of or replacement of parenchymotous (organic, nonframework, non-supporting) material; pl. fibrosus.
Fissure of the disca channel, cleft, or groove through the annulus which forms secondary to injury.
Degradation of the nuclear matrix destroys its cohesiveness. This may allow the nucleus to extrude
through the fissure. Formation of a fissure is a prerequisite phenomenon for HNP to occur (see HNP).
Foramenan opening or passage (Panjabi et al., 1983).
Ganglionan aggregation of nerve cells.
Gate control theorya theory on the modulation of pain perception by the central nervous system first
proposed by Melzak and Wall (Melzack and Wall, 1965; Wall and Melzack, 1994). The main
hypothesis of this theory is that sensory neurons trigger central control systems which inhibit or
facilitate the input of nociceptors and their transmission pathways.
Herniated nucleus pulposus (HNP)commonly known as a slipped disc or herniated disc, or
more technically as a prolapsed disc. Extrusion of material from the nucleus pulposus mixed with
elements of the annulus fibrosus (Haig et al., 1993).
Failure mechanism
Antecedent injury may damage the nucleus and produce a passageway through the annulus
fibrosus. Heavy load lifting or long-term exposure to excessive vibration may be contributing
factors to development of HNP (Wilder et al., 1982; McCarron et al., 1987).
HNP may start when a radial fissure completely erodes the annulus. Spinal nerve roots may be
compressed mechanically by the prolapsed material (Spencer et al., 1984; Adams and Hutton,
1985). The prolapsed material may elicit an inflammatory response that secondarily caused edema
of the nerve roots. The blood vessels which supply the nerve may be compressed either mechanically
or as a result of the edema, thereby rendering the nerve root ischemic.
Recent research supports the idea that the annulus has a limited capacity for healing. Surgically
created defects in the lumbar discs of dogs seem to show that large lesions can heal by filling with
a solid plug of fibrous tissue and prevent leakage of nuclear fluid. Small wounds (comparable to
a radial fissure), tend to heal more slowly, and continue to leak (Hampton et al., 1989). Other
researchers have reported on the spontaneous resolution of extruded disc material over time
without surgery (Saal and Saal, 1989).
Disc herniations are categorized based on the degree of displacement of the nuclear material. The
four levels ranked in order of increasing severity are (Spengler, 1982a):
1. Intraspongy herniation (herniation through the endplate into the underlying cancellous, or
spongy, bone of the vertebral body),
2. Protrusion (displacement beyond a line drawn between the margin of two adjacent vertebral
bodies),
3. Extrusion (displacement into the foramina or canal),
4. Sequestration (separation of the extruded material).
Symptoms
HNP is present in a small percentage of incidence of low back pain, and conversely not all
instances of HNP produce low back pain and neurologic symptoms. It is hypothesized that
chemical nociception starts when a radial fissure reaches the middle and outer thirds of the
annulus fibrosus and encounters nerve endings (Mooney, 1987). It may be that a combination of
pressure and chemical irritation is necessary for HNP to produce pain.
HNP patients often present with lancinating pain in the lower limb, severely limited straight-leg
raising, and objective neurologic signs of numbness or weakness in the distribution of the affected
nerve root.
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Stenosis of the disc space occurs when there is prolapse into the spinal canal or near the nerve roots.
This can cause pressure and can become symptomatic if it compromises a spinal nerve, the spinal
cord, or its roots. Pressure can be applied to the nerve root by a disc protrusion without direct
compression of the nerve against the posterior elements of the foramen (Spencer et al., 1983).
Diagnosis
Clinical examination can reliably identify HNP. Additional investigations, such as
electromyography and radiology, are not essential for the purpose of diagnosis. Computed
tomographic (CT) scans, magnetic resonance imaging (MRI), and myelography are of value in
determining the exact site and extent of the prolapse (Morris et al., 1986).
Treatment
The objectives of treatment are: (1) relieving pain; (2) increasing mobility; and (3) minimizing the
impairment and disability associated with LBP.
For a small percentage of patients with HNP, surgical intervention may be necessary. The surgical
intervention can include chemonucleolysis, percutaneous discectomy, microdiscectomy, open
laminotomy, and laminectomy.
Hypochondriasisa mental disorder characterized by morbid anxiety about health, body function, and
sensations.
Iatrogenicdescribing a disease or dysfunction that has resulted from treatment. Iatrogenic discitis is an
intensely painful condition, resulting from a disc infected by bacteria introduced by needles used for
discography.
Idiopathicof unknown origin.
Innervationthe nerve supply for a body part.
Intra-abdominal pressure (IAP)pressure that develops within the abdominal cavity secondary to forces
produced by the diaphragm, chest wall, and abdominal musculature.
Mechanism
A great deal of controversy exists whether IAP directly or indirectly produces a reactive force
counter to the compressive forces developed in the vertebral column during lifting (Gracovetsky
et al., 1995). Some research supports a contrary opinion that IAP under some conditions and
postures may actually increase compressive loading (Nachemson et al., 1986).
IAP can be generated by other means as well, such as the Valsalva maneuver. This occurs when
the breath is held while bearing down as if one were to move ones bowels.
The use of back belts during lifting activities is often recommended as an ergonomic intervention.
Wearing a back belt while lifting constrains expansion of the abdomen. In theory this should
result in an increase in IAP and a subsequent decrease in the compressive load upon the lumbar
disc. The efficacy of a back belt is quite controversial at present, and the exact mechanism of IAP
development is not clear.
Ischemiainsufficient blood flow or inadequate blood supply.
-itissuffix meaning inflammation of.
Kyphosisa convex or posterior curvature of the spine; the normal curvature of the thoracic spine.
Laminaa thin bony plate; part of the dorsal region of a vertebra.
Laminectomysurgical excision of the posterior arch (lamina) of the vertebrae. This procedure is
performed to relieve spinal or nerve root pressure secondary to a space occupying lesion (e.g., herniated
disc). Laminectomy is a futile intervention for disc disruption, because the lesion lies within an
otherwise intact disc (Wiltse, 1977).
Laminotomydivision of lamina of a vertebra without removal or excision of the arch. The rationale
for this procedure is the same as for laminectomy or for exploration of the intervertebral space.
Lancinating painsharp stabbing or cutting pain.
Lifting (manual lifting) and low back painThe current theory of the relationship between LBP and
lifting is based on three assumptions (Buseck et al., 1988; Jager and Luttmann, 1989):
22-16

Manual lifting poses a risk of LBP to many workers (Bigos et al., 1986a). The risks vary due to
postural characteristics, repetition rates, and the load of the specific task (Nordin et al., 1984).
LBP is more likely to occur when workers lift loads that exceed their physical capacities (Batti et
al., 1989a; Poulsen, 1981; Herrin et al., 1986).
The physical capacities of workers vary substantially (Kishino et al., 1985).
The implications of these three assumptions are:
LBP is a potential outcome of various activities. Lifting may be one of them.

Manual lifting can be evaluated as a risk factor for LBD. The measurement of the exposure
includes type (e.g., lifting or other activities) and virulence (e.g., lifting over the physical capacity).
Each individual has his or her own physical capacity, and such capacity can be approximated by
statistics (percentile), such as,
The maximal permissible compressive forces on the spine (Chaffin and Park, 1973),
The maximal acceptable weight of load (Troup et al., 1987; Snook and Ciriello, 1991).
The maximal permissible energy expenditure,
The deviation of physical capacities among individuals can be identified and measured.
Lifting technique and low back painseveral variables have been reported to be important in the
evaluation of the spinal loading of various lifting techniques (Hart et al., 1987).
Initial position of the load (Marras et al., 1993).

Initial posture (stoop vs. squat) (Omino and Hayashi, 1992).
Foot position (straddle vs. parallel) (Anderson and Chaffin, 1986).
Velocity and acceleration of lift (Marras et al., 1993).
Muscular recruitment and fatigue (Trafimow et al., 1992; Lavender et al., 1992; Schultz et al.,
1982b).
Compound movements (e.g., flexion with torsion) (Kelsey et al., 1984b; Markolf, 1972; Marras
et al., 1993; Omino and Hayashi, 1992).
Lumbodorsal curvature (lordotic vs. kyphotic) (Panjabi and White, 1980)Controversy exists
as to the role of lumbar lordosis in lifting. One theory is that preservation of the lordosis in
conjunction with intra-abdominal pressure (IAP) strengthens the spine and is critical to prevention
of injury during lifting (Aspden, 1989). To the contrary, another theory states that decreased
lordosis may increase the tension in the posterior spinal ligaments thus decreasing the muscular
forces required and subsequently decreasing the resultant compressive forces on the spine
(Gracovetsky et al., 1989, 1990). The risk of injury may be influenced more by the degree of
flexion than the choice of lifting posture (stoop vs. squat) (Potvin et al., 1991). The mechanical
advantage provided the trunk muscles is also dependent on the assumed posture (Schultz et al.,
1984).
Ligamenta band of strong, fibrous connective tissue that attaches bone to bone and serves to provide
stability, transmit loads, and restrict motion (Yamamoto et al., 1990; Panjabi and White, 1980).
The posterior ligaments of the vertebral column act passively to assist in lifting (Gracovetsky et
al., 1981). The spinal ligaments have different biochemical composition and fiber density and
orientation based on their specific function within the spinal column (Hukins et al., 1990) (see
spinal ligament).
Ligamentum flavumconnects the laminae of adjacent vertebrae (see ligament, spinal ligament).
Lordosisthe inward curvature of the spine; the normal curvature of the cervical and lumbar spine
(Gracovetsky and Farfan, 1986, Gracovetsky et al., 1987).
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Different postures result in different loading patterns of the passive tissues, such as the ligaments
and fascia. In some circumstances these structures can contribute significantly to the development
of axial torque (McGill, 1992).
Posture can directly influence the amount of curvature. The height of the heel has been shown to
change the curvature of the lumbar spine (Bendix et al., 1984).
The degree of lumbar lordosis has not been directly correlated to low back pain (Hansson et al.,
1985).
Low back pain (LBP)a symptom of any one of several pathologies of the lumbosacral spine, with
varying terminology, etiology, evaluation and medical management techniques (Cavanaugh and
Weinstein, 1994; Ghosh, 1988; Hadler, 1987; Loeser, 1980; Troup, 1981; Waddell et al., 1980;
White and Gordon, 1982).
Low back pain researchThere are many different hypotheses as to the origin of LBP. In general the
potential causes of LBP may be categorized as mechanical, chemical, biological, infectious, genetic,
and degenerative (Boden et al., 1991; Carr et al., 1985; Ghosh, 1988). Ergonomists and engineers
have focused on the mechanical basis of LBP since the variables in that domain are more readily
defined and manipulated. Good scientific method dictates that research must build upon the
knowledge at each of the levels below it in the critical path (Pope, 1990; Weinstein, 1988a; Zohn,
1988):
Level I:
Level II:
Level III:
Level IV:
The painIs the pain of spinal origin, and is it real? Usually based on medical history,
self reporting, standardized pain questionnaires, and physical exam.
The anatomyCan the pain signal be transmitted? Is the presence of pain receptors
consistent with the present understanding of the anatomy?
The autopsy and mechanical testingWhat are the internal and external forces needed
to cause sufficient injury to stimulate the pain receptors? The techniques used in cadaver
lumbar motion segment studies have not been standardized, making prediction based on
this body of research difficult (Keller et al., 1990).
Biomechanical modelingCan the forces required to cause damage as determined from
mechanical testing, be generated in a person during work activities?
Low back pain impairment (LBPI)refers to the physical limitations in movement, strength and function
of an individual due to LBP (Waddell et al., 1984; Mayer et al., 1988; Deyo, 1988).
Low back pain disability (LBPD)refers to the loss of capacity or time for an individual to function at
work or in activities of daily living. It is not synonymous with LBPI, since impaired individuals may
be able to function normally, and conversely an individual with minimal measurable impairment
may be significantly disabled with respect to work and/or activity of daily living. This dichotomy is
secondary to psychosocial factors, socioeconomic factors and specific job requirements (Andersson
et al., 1983; Bigos et al., 1992; Deyo and Diehl, 1983; Barnes et al., 1989; Polatin et al., 1989;
Rowe, 1971; Spengler et al., 1986a, 1986b, 1986c; Waddell et al., 1984; Waddell and Main, 1984).
Lumbosacral sprain/strainone of the more common diagnoses associated with an episode of low back
pain often related to a memorable injury of moderate severity. An imprecise diagnosis, it is often
used prior to ruling out other, more specific diagnoses.
Manipulation/Mobilization/Chiropractic practices for low back painmanual techniques involving
movement of spinal segments for the purpose of adjusting spinal alignment, improving ROM, or
decreasing pain (Cassidy and Kirkaldy-Willis, 1988; Hadler et al., 1987; Haldeman, 1980; Khalil et
al., 1992).
Mechanical tractionthe application of a tensile load along the long axis of the spine with the goal of
promoting relaxation of the back musculature and decompressing the spine.
Mechanoreceptora specialized nerve ending that is stimulated by mechanical pressure, pressure changes,
oscillation or movement.
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Medical management of low back painthe goals of intervention are the reduction of symptoms and
the restoration of functional levels. The outcome of treatment for LBP is very variable, with a portion
of the population typically becoming chronic (Gatchel et al., 1992; Wiesel et al., 1984; Spitzer et al.,
1987; Deyo, 1983).
Activity modification: (see bed rest, back school, and pain clinics).
Oral medication (see pharmacological agents).
Physical medicine: (see acupuncture, biofeedback, corsets/orthotics, exercise, mobilization/
manipulation/chiropractic, mechanical traction, physical modalities, work hardening).
Meningesthe three membranes that cover the spinal cord and brain. They are the dura mater, pia
mater, and arachnoid membrane.
Meniscusa dense fibrocartilage pad present in some synovial joints (e.g., knee, facet) which acts to
protect the cartilage surfaces of the joint and to distribute the load between the articular surfaces. A
meniscus is typically attached at one end to the joint capsule and/or ligaments and thus receives
some degree of vascular supply and innervation.
Micro-discectomythe use of microsurgical techniques and a small incision to perform a partial removal
of a herniated disc. The smaller incision and decreased disruption to surrounding tissues allows for
a more rapid recovery phase.
Morbiditystate of being diseased. Morbidity ratethe number of instances of a disease over a specified
period of time per unit of population. It is usually expressed as x cases per year per 1,000, 10,000,
or 100,000 of population.
Morphologythe science of forms and structures of organisms.
Myelographya radiographic imaging technique for visualization of the spinal cord, involving the
injection of a radiopaque dye into the area around the meninges of the spinal cord. It is particularly
useful in detecting impingement on the spinal canal and nerve roots.
MRI (magnetic resonance imaging)a noninvasive imaging technique using electromagnetic radiation
particularly useful for visualization of soft (non-radio-opaque) tissues. The MRI provides greater
resolution of intrinsic disc abnormality than a CT scan due to its ability to detect water content in
the disc (Bernhardt et al., 1992; Hickey et al., 1986; Panagiotacopulos et al. 1987a 1987b) (see CT
scan).
NCV (nerve conduction velocity)a direct measure of the conductivity of motor nerves in the region
being tested. Often performed in conjunction with EMG testing.
Necrosisdeath of one or more cells.
Neoplasmnew growth of cells or tissues, may be benign or malignant (cancerous).
Neurological deficita defect or dysfunction of the central or peripheral nervous system, such as
diminished deep tendon reflexes or decreased sensation.
Nociceptora specialized peripheral nerve ending which senses painful stimuli.
Nucleus pulposusthe central, more viscous portion of the disc.
Anatomy
A semifluid mass of proteoglycans in a collagen fiber matrix.
The nucleus is intrinsically cohesive and resists herniation, even under experimental conditions
when a posterior channel is cut into the annulus fibrosus.
Immunological basis of spinal pain syndromes
The nucleus pulposis lacks a blood supply and is never exposed to the circulation. In a disc that
suffers an endplate fracture, proteoglycans may be exposed to the bodys immune system for the
first time, triggering an inflammatory response (Pennington et al., 1988). The gelatinous matrix
of the nucleus has not been studied according to contemporary standards of immunology, but
available evidence suggests that the matrix does have antigenic properties.
Prolapsed nuclear material elicits an inflammatory response if it enters the epidural space or the
22-19
vertebra spongiosa in the case of traumatic Schmorls nodes. Patients exhibit changes in lymphocyte
migration and antibody profiles consistent with an antigenic response.
Mechanism
The main function of the nucleus pulposis is to transmit loads from one vertebra to another.
Functioning as a volume of fluid within an enclosed space, the nucleus is incompressible. The
attempted expansion of the nucleus pulposus effectively braces the annulus fibrosus from within,
preventing it from buckling.
When exposed to a compression load, the nucleus deforms by attempting to spread in a radial
direction, but this displacement is arrested by the annulus fibrosus. Tension develops in the
annulus fibrosus to resist radial expansion of the nucleus pulposus.
Orthosisorthopedic device for assisting the function of part of the body without replacing it (see
corset).
-osissuffix meaning disease of.
Ossificationthe formation of bone.
Osteoarthritiscommonly described as a wear and tear disease of the joints. Chronic, degenerative
disease particularly of weight-bearing joints characterized by erosion of the cartilage and bony
overgrowth.
Osteomalaciaa softening of the bone related to demineralization of the matrix, often associated with
a deficiency of vitamin D.
Osteopenialoss of bone mass.
Osteophytea bony or osseous outgrowth or excrescence (tumor).
Osteoporosisa decrease in bone mass, often related to prolonged bed rest, post-menopausal endocrine
changes, and prolonged periods of weightlessness among astronauts. It is often treated with hormone
therapy and dietary supplements in post-menopausal women. Weight-bearing activities are
recommended for cases resulting from prolonged bed rest, as bone remodels in response to the
stresses imposed on it.
Pain clinics and low back painspecialized facilities utilizing a multidisciplinary approach to the treatment
of pain. Emphasis is placed on improving functional levels, using activity and behavior modification,
and pain management techniques rather than treatment of symptoms (Aronoff, 1982, 1983).
Percutaneousthrough the skin.
Pharmacological agents for low back painthe medical intervention for low back pain may involve the
use of pharmacological agents. These drugs, prescribed for several reasons, are classified into three
major categories:
Analgesica category of drugs whose main action is reduction of pain. They can be narcotic
(morphine based, and by prescription only) or non-narcotic. They may be prescription (e.g.,
Darvonpropoxyphene hydrochloride) or over the counter (e.g., Tylenolacetaminophen,
aspirin).
Anti-inflammatorya category of drugs whose main action is reduction of the inflammatory
response with a secondary effect of pain reduction. These drugs are further divided into two
subcategories based on their pharmacology:
Steroidalthese are typically prescription corticosteroids or their derivatives which are analogs
of the hormones produced by the adrenal cortex (i.e., prednisone). Their action is to directly
modulate the inflammatory response via the endocrine system. There use is usually limited
to severe episodes due to the significant number and severity of side effects.
Nonsteroidal anti-inflammatory drug (NSAID)a category of prescription such as Feldene
piroxicam, Voltarendiclofene, Naprosynnaproxen and nonprescription such as
Motrin, Advilibuprofen. The action of this class of drugs is to inhibit the inflammatory
response. The side effects of NSAIDs tend to be less severe than steroids.
Muscle relaxantsa category of drugs whose action is to decrease muscle spasm, thereby reducing
associated muscle pain (e.g., Flexeril, Soma, Robaxin).
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Physical exam and history of low back pain (Hadler, 1984; Haig, 1992; McCombe et al., 1989; Roland
and Morris, 1983a 1983b)
Patient self report

Medical History (Bigos et al., 1992). Pain questionnairedeveloped to assess the nature of
the pain as well as its psychological and psychosocial impact (Herron and Pheasant, 1982;
Waddell et al., 1980).
Pain diagrampatient drawing of pain type and distribution.Visual analog scalesubjective
patient report of pain level using a calibrated scale.
Referral pain/trigger pointpalpation (probing by touch) of the muscles in or around the location
of pain, for local tenderness.
Range of motion (ROM)a measure of the freedom of movement of a joint (Keeley et al., 1986;
Pope et al., 1985). A relationship between decreased lumbar ROM and a previous history of LBP
is reported to exist, but no significant predictive value for future LBP has been demonstrated
(Batti et al., 1990).
Straight leg raise test (see straight leg raise test, SLR).
Neurologic/reflex evaluationassessment of sensory and motor function, including deep tendon
reflexes (i.e., knee jerk), muscle strength. Provides an indication of the function of the nerves
controlling the tested area.
Physical modalitiesthe application of physical agents with the goal of decreasing pain, decreasing
inflammation, increasing local circulation to promote healing, and/or increasing flexibility. These
include: electrical stimulation, heat or ice applications, and ultrasound (Kane and Taub, 1975).
Pia materthe innermost of the three meninges (membranes) covering the spinal cord and brain.
Plexusnetwork of nerves or blood vessels.
Posterior longitudinal ligamentthe ligament extending along the posterior surface of the vertebral
body (within the spinal canal) from the cervical spine to the sacrum (see ligament, spinal ligament).
Proteoglycanssubstance found in the matrix of connective tissues and in synovial fluid, vitreous humor
of the eye, and mucous secretions.
Radiculopathyany disease of the motor or sensory root of a spinal nerve. Distribution of symptoms
and findings is characteristic for each spinal segment. There are mono- and polyradiculopathies
(Saal and Saal, 1989).
Radiopaqueimpenetrable by X-ray.
Ramus (rami pl.)branch.
Rheumatoid arthritischronic systemic disease characterized by inflammation of the joint linings, bony
changes and eventually deformity usually involving multiple joints.
Sacrumthe five fused vertebrae between the lumbar vertebrae and the coccyx. They comprise the
posterior aspect of the pelvis.
Sagittal planethe plane through the body which bisects it into left and right parts.
Scarificationmaking a number of superficial incisions in the skin or other tissue.
Schmorls nodesdisc protrusions through the endplate and into the vertebral body (Hansson and
Ross, 1983). They are reported to be healed fractures of the vertebral endplates (Farfan et al., 1972).
Sciatic nervelongest nerve of the body formed from lower lumbar and sacral nerve roots and running
deep in the posterior aspect of the thigh. It is responsible for sensation of the posterolateral thigh,
calf, and parts of the foot, as well as motor control of some of the muscles of the foot and calf.
Sciaticacommon terminology for the pain and sensory changes along the distribution of the sciatic
nerve, usually resulting from compression or trauma to the nerve or the nerve roots that form it
(Heliovaara et al., 1986; Allan and Waddell, 1989).
Scoliosisabnormal curvature of the spine. This can be an accentuation or decrease of the normal
regional curvatures, or rotation or curvature of the spine in an abnormal plane or direction.
Sequela (sequelae pl.)disorder due to a preceding disease or accident.
Shear loading of the discthe component of the resultant force acting on the disc which is perpendicular
22-21
to the long axis of the spinal segment. It is the complement of the compressive force. All the factors
contributing to disc compression may also contribute to shear loading. The magnitude of shear
loading depends on the orientation of the disc and body posture. Because there is little dynamic
information about trunk muscles and their orientation to the disc, for biomechanical modeling
straight line representation of the muscle force perpendicular to the disc is assumed. As a result,
shear loading may be underestimated.
Somatotypethe classification of persons by body shape or type (morphology). The categories are:
ectomorph (thin, wiry), mesomorph (well proportioned), endomorph (soft, rotund).
Somatosensory evoked potentials (SEP)an electrodiagnostic procedure used to assess sensory neurons
in peripheral and spinal cord pathways. This technique is sometimes used to evaluate stenosis.
Somatizationconversion of anxiety into physical symptoms.
Spasminvoluntary muscular contraction.
Spinal fusionthe surgical fixation of two or more adjacent vertebrae to provide structural stability or
maintain normal disc space (Abumi et al., 1989a). Fusion is indicated in the presence of clinical
instability of one or more lumbar motion segments (Farfan and Gracovetsky, 1984). Fusion provides
no significant advantage over laminectomy alone in the case of the simple herniated disc (White et
al., 1987). The mechanics of spinal fusion are complex, and the procedure can produce adverse
effects, such as higher stresses at the adjacent vertebrae (Goel et al., 1988). Likewise, clinical research
has not yet demonstrated what degree of stability is necessary for optimal healing and progression
to solid fusion (Panjabi, 1988; Panjabi et al., 1988a).
Anterior interbody fusiona transabdominal spinal fusion interferes little with the integrity of
the lumbar spine as compared to the posterior approach. There are some advantages of this
procedure: back muscles are not disabled, the posterior elements remain intact, and the contents
of the vertebral canal are not exposed. This latter advantage avoids the potential complication of
arachnoiditis and preserves the sinuvertebral nerves, avoiding the risk of neuroma formation
(tumor of the nerve fiber).
Posterior interbody fusionspinal fusion surgery involving access to the vertebrae through the
back musculature and ligaments.
Spinal ligamentssee ligament, anterior longitudinal ligament, posterior longitudinal ligament,

ligamentum flavum, and supraspinous ligament (Panjabi et al., 1982; Ratcliffe, 1980).
Supraspinous ligamentthe strong, fibrous cord joining the spinous processes from the seventh cervical
vertebrae to the sacrum (see ligament).
Spinal nerve rootsthe nerve trunks that exit and enter the spinal cord at the intervertebral space
(Bogduk, 1983).
Spinal surgerysurgical intervention for the treatment of severe pain, spinal instability, and/or neurologic
involvement (Pope and Panjabi, 1985; Posner et al., 1982). Surgery is usually the treatment of last
resort, when conservative therapies have failed.
Spondylitisinflammation of one or more vertebrae.
Spondylolisthesisa condition of forward slippage of a lumbar vertebrae which may or may not be
associated with instability (Grobler et al., 1993a, 1993b). It can be categorized as follows (Pearcy
and Shepherd, 1985):
Isthmic spondylolisthesisthe slippage is due to loss of the constraint by the neural arch, secondary
to a spondylolysis, most commonly occurring in the last lumbar vertebrae (Grobler et al., 1993a).
Degenerative/pseudo spondylolisthesisforward slippage, typically at L4 and L5 levels due to a
degenerative process, without any defect in the neural arch. This may also be due to a developmental
disposition related to the orientation of the facet joint (Grobler et al., 1993b).
Retrospondylolisthesismisalignment of one vertebra relative to the adjacent vertebra
characterized by backward displacement.
Displastic, traumatic, and pathologic spondylolisthesis are less common diagnoses.
22-22
Spondylolysisa defect in the neural arch, typically at L5 and commonly believed to be due to repetitive
low-grade trauma over prolonged periods. Short duration exposures may be of little clinical
significance (Semon and Spengler, 1981; Crock, 1981).
Spondylosisankylotic state or fusion of the vertebrae. Disease of the spine often associated with disc
degeneration. There is a spectrum of changes effecting one or multiple levels, initially signified
radiologically by loss of disc height, osteophytes arising from the margins of the vertebral bodies,
and osteoarthritic changes in the apophyseal joints (Edwards and LaRocca, 1985).
Spongiosaspongy. The sustantia spongiosa ossium is the thin bony matrix that makes up the center of
the intervertebral body.
Stenosis, spinalnarrowing of the spinal canal, nerve root canals, or tunnels of the intervertebral foramina.
The narrowing not only reduces the anteroposterior and lateral diameters, but also alters the crosssectional configuration of the spinal canal (Schonstrom et al., 1985; Spengler 1983). Decreased
cross-sectional area causes an associated increase in local pressure, with a resultant effect on local
nerve function (Schonstrom and Hansson, 1988; Grabias, 1980; Crock, 1981).
When the spinal canal and lateral nerve root canal are narrowed, a relatively small disc herniation
can produce clinically significant symptoms, such as sciatica, which would not have occurred if
the canal had been of adequate dimensions. A nerve root may be compromised in a stenotic canal
even during normal movement patterns (Panjabi et al., 1984).
Stenosis may result from occupational factors or trauma, or from non-occupational factors such
as malnutrition or genetic predisposition (Clark et al., 1985).
There are gender related differences in the dimensions of the canal (Vanharanta et al., 1985).
Steroida lipid-based organic compound. Steroidal hormones are synthesized by the sex glands (e.g.,
estrogen, testosterone) and the adrenal cortex (corticosteroids, e.g., cortisone). There are a number
of synthetic analogs which also have physiologic activity. Corticosteroids are potent anti-inflammatory
agents, and in some cases may be given orally or by direct injection to the target site.
Straight leg raise (SLR) testa clinical evaluation technique where the thigh with the knee extended
straight is gradually bent (flexed) at the hip. Onset or aggravation of low back pain or sciatica
during the maneuver is considered a positive test result and may be indicative of lumbar disc disease
(Troup, 1981).
Subluxationpartial dislocation of a joint; bone ends are misaligned but still in contact.
Taxonomythe science dealing with the identification, naming, and classification of organisms.
Thermographyan imaging technique currently being investigated as an indirect measure of autonomic
nervous system function. It is a measure of skin surface temperature using the infrared spectrum.
Torsional loading of the disctorque resulting from rotation about or near the long axis of the spinal
column (Bogduk, 1991; Farfan, 1984). Torsional loading occurs frequently in common activities
such as the rotation of the pelvis during walking, and rotation of the trunk when throwing a ball
(Farfan et al., 1970; Farfan and Gracovetsky, 1984; Gracovetsky and Farfan, 1986; Marras and
Mirka, 1992; Miller et al., 1988).
Mechanism (Panjabi and White, 1980)
The rotational range of motion of a lumbar segment is limited to less than three degrees by the
blocking of the apophyseal joint (Adams and Hutton, 1981). Both the disc and the apophyseal
joint provide resistance to rotation. (Gunzburg et al., 1991a).
When the apophyseal joint fails, the range of rotational movement increases. This occurs at the
expense of increased axial torque and lateral shear forces on the disc itself (Adams and Hutton,
1981). Fracture or dislocation of this joint is a rare occurrence (Kramer and Levine, 1990).
An isolated disc can tolerate only three degrees of axial rotation before the collagen fibers of the
annulus suffer injury. For a given direction of rotation, only half of the collagen fibers in the
annulus fibrosus are appropriately oriented to resist the rotation.
22-23
Failure
Torsion injury to the annulus fibrosus is increased if axial rotation occurs in combination with
flexion. Flexion prestresses the posterior annulus fibrosus. Consequently, far less axial rotation is
required to strain collagen fibers beyond their physical limit.
In flexion, the articular processes of the apophyseal joints are subluxated, and the apophyseal
joints afford less resistance to axial rotation. As a result, during flexion-rotation, the annulus
fibrosus is maximally stressed while least protected by the posterior elements (Miller et al., 1983).
Trunk rotation ROM is decreased while the trunk is flexed (Gunzburg et al., 1991a, 1991b).
Torsion is more recurrent and more detrimental than a compressive force. After injury, if the joint
never heals fully, it is more likely to fail with repeated torsion. When torsion of the disc is combined
with compression, the probability of failure increases.
Torsional injury may include a rupture of ligamentous tissue, the annulus, and associated damage
to the facet.
Under continued rotation beyond three degrees, disc failure occurs with avulsion of the laminae
of the annulus from the endplate. The nucleus and endplate remain intact. Gradually, the annulus
develops radial fissures and the lumbar segment may become unstable. Furthermore, the torsional
deformity can cause the neural elements in the intervertebral canal to displace to one side, stretching
the nerve roots.
Diagnosis/Imaging
Neurologic examination, CT scans, myelography, and MRI are normal because the lesion is
restricted to the annulus fibrosus and does not involve nerve root compression.
During discography, contrast medium and local anesthetic are injected into the painful site. If
pain is relieved by the local anesthetic, and if the contrast medium is confined to the annulus
fibrosus, the source of pain is assumed to be the annulus fibrosus.
Symptoms
The pain will be aggravated by any movements that stress the annulus fibrosus, particularly
flexion and rotation in the same direction that produced the lesion. Healing may require several
months of protection from reinjury coupled with gradual and gentle reintroduction and restoration
of function.
Trabeculaany of the bands of tissue that pass from the outer part of an organ to its interior, dividing
it into separate chambers.
Trabecular bonespongy bone.
Transverse planethe cross-sectional plane through the body perpendicular to the long axis.
Trigger pointsmall, focal region of a muscle which is tender to touch. This sensitivity is assumed to be
related or in reaction to regional pain.
Ventralpertaining to the anterior or frontal surface of the body.
Work hardeninga therapeutic approach to functional training for return to work. This involves reduction
of the patients work tasks to component parts, progressive training in these components, followed
by recombination of the work task and progression to maximum functional work level.
X-ray (radiography)an imaging technique in which a body part is placed between an X-ray source and
a photographic film plate. The X-rays are absorbed by the body part in direct proportion to the
density of the tissue in its path. The radiograph (a photographic negative) is therefore a map of
tissue density. Bone and mineralized tissue are well defined, while less dense substances such as body
fluids and muscle are poorly imaged. X-ray can be used to estimate the dimension of vertebrae with
adequate accuracy (Malmivaara et al., 1986).
Zygapophysealpertaining to an articular process of a vertebra.
22-24
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185247.
Part II
Administrative
Controls
Section I
Ergonomics
Surveillance
23
Fundamentals of
Surveillance for
Work-Related
Musculoskeletal
Disorders
23.1
23.2
Vern Putz-Anderson
U.S. Department of Health and
Human Services
23.3
Katharyn A.Grant
U.S. Department of Health and
Human Services
23.4
Introduction
Scope Purpose
Collecting, Analyzing, Intervening
Establishing Definitions and Criteria Implementing
Standardized Reporting Procedures Calculating Rates and
Percentages Interpreting Incidence, Prevalence, and
Severity Establishing Priorities for Intervention
Data Sources
Existing Records Worker Surveys Hazard (Risk Factor)
Surveys
Conclusions
231
232
235
2310
23.1 Introduction
Scope
This chapter will address occupational surveillance* as it relates to the practice of industrial ergonomics
and the prevention of work-related musculoskeletal disorders. Surveillance is a continuous analysis,
interpretation, and feedback of systematically collected data, generally using methods distinguished by
their practicality, uniformity, and frequently their rapidity, rather than by their accuracy or completeness
(Last, 1995). Occupational surveillance provides the data needed to identify, control, and prevent workrelated injuries and illnesses. Epidemiologists also use surveillance data to study the distribution and
determinants of health-related states or events in defined populations. Methods for conducting
occupational surveillance programs are well documented, and reviews of surveillance concepts and
methods have been presented elsewhere (Baker et al., 1989; Baker and Matte, 1994; Greife et al., 1995).
This chapter will limit the discussion of surveillance to those issues that affect the work of the industrial
ergonomist and the prevention of musculoskeletal disorders.
*This chapter contains a glossary of the terms in bold type.
0-8493-1800-9/03/$0.00+$1.50
23-1
23-2
Purpose
The purpose of occupational surveillance is to track patterns of health and disease in groups of workers
and to identify risk factors that influence these trends. Ultimately, this information should be used to direct
the implementation of measures to prevent and/or control work-related disorders. Surveillance can answer
questions such as, Is there a problem? or Is there still a problem? Establishing surveillance procedures
is generally the first step in establishing an industrial ergonomics program. Surveillance serves to stimulate
and focus prevention efforts and provides a method to assess the impact of corrective action.
23.2 Collecting, Analyzing, Intervening

Effective surveillance systems include the following components: (1) data collection, (2) analysis of the
data, i.e., a mechanism to evaluate the meaning of the health/injury or hazard data, and (3) some action
or response to ensure that surveillance activities are translated into preventive action. The response
action may be directed toward individuals (e.g., providing medical treatment for symptomatic workers),
or toward groups of workers (e.g., eliminating hazardous workplace conditions).
Several factors govern the strategy for collecting, analyzing, and acting upon surveillance data. These
factors include the scope and urgency of the perceived problem, the resources available to the investigators,
and the types of information systems already set in place. Many surveillance programs begin with efforts
to document the number of work-related musculoskeletal disorders that have occurred in recent history
(i.e., establish a baseline). Data for this effort can be obtained from a review of existing records. If
existing records are incomplete or are unreliable as sources of surveillance information, or if additional
information about current (rather than historical) conditions is needed, questionnaires or worker surveys
may be used to determine how many workers are experiencing symptoms that could be caused by work
activities. Additionally, because prevention of work-related musculoskeletal disorders depends on the
identification and elimination of hazardous working conditions, hazard surveys or simple checklists can
be used to identify jobs where risk factors for musculoskeletal disorders may be present.
For example, during an annual review of the OSHA 200 logs, an occupational nurse notices there
has been a sudden increase in the number of workers reporting severe back strains on a new job. The
surveillance plan would likely call for an immediate inspection of the worksite, along with interviews of
workers and the supervisors to assist in identifying hazards. Once hazard control techniques had been
identified and implemented, worker and hazard surveys would be administered at periodic intervals to
determine the long-term effectiveness of the intervention.
Additional information about each of these data sources (existing records, worker surveys, and hazard
surveys) will be provided later in this chapter.
Establishing Definitions and Criteria

Before data can be collected and analyzed, it must be defined. An obvious (and unfortunately common)
problem in the surveillance of work-related musculoskeletal disorders is the lack of consistency or
standardization in the way these disorders are defined. The resulting confusion can lead to inaccuracies
or inconsistencies in the data that make comparisons between locations and over time difficult if not
impossible.
Defining what is meant by terms like musculoskeletal disorder or ergonomic hazard can be
especially difficult. Musculoskeletal disorders encompass a broad spectrum of illnesses; in a recent
review, NIOSH (1993) listed more than 160 different musculoskeletal conditions that can be caused or
aggravated by various work activities. Diagnosis of these conditions is often complicated since many of
these disorders have nonspecific symptom patterns, long latency periods and complex etiologies
(Schierhout and Myers, 1996). For surveillance purposes, work-related musculoskeletal disorders have
been defined from self-reported symptoms, clinical signs, specialized medical tests, impairment, or
disability.
23-3
TABLE 23.1 Examples of Case Definitions Used in Studies of Work-Related Musculoskeletal Disorders
Examples of case definitions used in various studies are found in Table 23.1. Two important considerations
in the selection of a case definition are its sensitivity and specificity. The sensitivity of a case definition is
the likelihood that the definition will identify diseased individuals. The specificity of a case definition is
the probability that it will not label healthy individuals as diseased. In general, case definitions based
solely on symptoms (e.g., pain, tingling in a particular body part) tend to be more sensitive but less
specific than definitions that rely on physical findings or diagnostic tests; however, for surveillance
purposes, it may be preferable to use definitions that are more inclusive or sensitive (Katz et al., 1991).
In the face of uncertainty, the use of sensitive definitions will encourage investigators to examine suspect
jobs and begin interventions at the earliest indication of a problem.
Implementing Standardized Reporting Procedures

Providing information in an accessible and usable format is critical to the success of a surveillance effort.
Unfortunately, the data needed for surveillance are usually not centralized in a single location. Performing
a comprehensive analysis of costs associated with absenteeism, turnover, injury morbidity, compensation,
lost productivity, and poor quality can require a search of numerous record systems, many of which
employ their own coding procedures. Although relational database management systems can greatly
simplify this process, their success depends on the establishment of common linkages between record
systems. One approach employed by some plant medical departments and occupational health clinics is
to use the coding system provided in the International Classification of Diseases (ICD). Such a coding
system should lead to greater consistency in collecting, analyzing, and reporting health data.
23-4
Calculating Rates and Percentages

Surveillance data are often reported as rates or percentages. Expressing the occurrence of injuries, illnesses,
symptoms, complaints, etc. as a rate or percentage allows investigators to compare the occurrence across
jobs/departments/plants that employ different numbers of workers and across periods of fluctuating
employment. When the surveillance goal is to identify high-risk jobs that need attention, rates are most
useful when they are computed for individual departments or even on similar jobs within a department.
The incidence rate is the rate of work-related musculoskeletal disorders appearing for the first time
during a specific period (usually a year). The value commonly used in occupational health is the number
of illnesses per 100 full-time workers per year and is calculated as follows:
The information needed to compute the denominators for the rates can usually be obtained from
personnel or payroll records. The assumption is that each employee works 2000 hours per year (8 hours
a day, 5 days a week, 50 weeks a year). If the number of hours worked in the past 12 months is not
known, it can be estimated by multiplying the number of full-time equivalent workers employed in the
job, department, or plant by 2000 hours.
The prevalence rate is the percentage of all cases of disease/symptoms/complaints at a specific instance
in time, regardless of when they first appeared. It is calculated as follows:
The severity index uses the number of lost or restricted workdays due to illness as a surrogate for the
seriousness of the disorder. The severity index is calculated as follows:
The magnitude of the severity index can be influenced by medical treatment practices, the health
benefits available to employees, and the opportunity for transfer to jobs that are less stressful. The
severity index can be skewed by unusually long illnesses suffered by a few employees.
Interpreting Incidence, Prevalence, and Severity

Although closely related, incidence and prevalence rates convey somewhat different information.
Prevalence depends on the incidence and the duration of the disease from its onset to its resolution. For
example, if the incidence of back pain is low, but recovery is slow, the prevalence will be high relative to
the incidence. Conversely, if the incidence of musculoskeletal disorders among workers is high, the
prevalence may be low relative to the incidence if workers recover quickly, or if they leave the workforce
because of their condition (Hennekens and Buring, 1987).
From a surveillance perspective, incidence and prevalence rates serve as valuable prevention tools for
guiding interventions to mitigate hazardous workplace conditions. Incidence and prevalence rates,
however, are also being used as management tools to gauge the performance of supervisors and health
and safety staff who are held responsible for workplace injuries and illnesses. Such measures, when used
as an indicator of performance or compliance, can inadvertently penalize employers or safety and health
personnel who have recently introduced an ergonomics program. Typically, the incidence and prevalence
rates will initially increase in organizations in which ergonomics programs are implemented. This is
often due to an increase in training-related awareness by the employees of the work-relatedness of their
conditions and represents better reporting rather than a true increase in the disorders. Moreover, the
23-5
goal of an ergonomics program is to encourage employees to report problems early to allow immediate
treatment and intervention, and thus reduce lost time and the risk of permanent injury. This goal may be
undermined when incidence and prevalence rates are used as the sole measure to evaluate the effectiveness
of an ergonomics program. For this purpose, the severity index may provide a more appropriate yardstick,
since it reflects failures in early detection and prevention that represent real costs to the company. These
failures are evident in the records of workers whose injuries have gone undetected, unrecognized, or
unreported until the injuries reach a level of severity where restricted duty or lost time result.
Establishing Priorities for Intervention

Ultimately, surveillance should direct the allocation of resources toward groups at highest risk for
musculoskeletal injury. A common question that arises in discussions of surveillance is When does
surveillance data become compelling? i.e., when is there enough information to warrant intervention?
Some suggest that even a single reported musculoskeletal disorder should be sufficient cause to trigger
more focused evaluations of workplace conditions (ANSI, 1996). This recommendation is based on the
recognition that formal surveillance activities usually detect only a small proportion of the musculoskeletal
problems and that one reported case may lead to several times as many unreported cases.
If multiple problem areas are identified and resources are constrained, it is often necessary to rank
order jobs for further analysis and intervention. Jobs can be ranked by incidence, prevalence, or
hazard severity; many survey instruments are designed to provide guidance for directing intervention
efforts. For example, a checklist developed for the automobile industry uses a series of questions and
a three-level scale to rate the postural stress associated with a specific job (Keyserling et al., 1992;
1993). Jobs that receive one or more stars (indicating significant exposure to postural stress) are
considered to have priority for additional investigation. Giving precedence to jobs that employ many
people, or jobs where major changes are already planned, can also be a sensible and cost-effective
approach.
23.3 Data Sources

Data sources for conducting occupational surveillance can be conveniently grouped into three
classifications: (1) existing records, (2) worker surveys, and (3) hazard surveys.
Existing Records
Record-based surveillance involves reviewing and analyzing existing records or data systems for evidence
of work-related musculoskeletal disorders. Because of its availability, these data can provide an initial
gauge of the status of workers health without a substantial investment of time or labor. Potential
information sources include Occupational Safety and Health Administration (OSHA) 200 logs, on- and
off-site medical records, workers compensation records, and insurance claim data. Other records that
can provide helpful information include absentee records, job transfer applications, employee grievances,
or job satisfaction surveys. Although this information has been described as passive surveillance data
(Fine et al., 1984), this description is not meant to minimize the importance of reviewing available
records. Record reviewing is far from a passive endeavor, requiring great diligence in interpreting and
coding the information in a consistent manner. Rather, the term serves to differentiate record reviewing
from the active process of generating data of interest using targeted surveys.
OSHA Records. OSHA requires most employers to maintain records of work-related injuries and
illnesses. Since 1978, the standard form for keeping these records has been the Log and Summary of
Occupational Injuries and Illnesses (OSHA No. 200). In February 1996, OSHA proposed changes in
record keeping requirements, including replacement of the OSHA 200 form with a new recording form,
known as OSHA No. 300. These changes had not been adopted at the time of this writing. Whether or
23-6
not new requirements are enacted, OSHA-required records should be maintained at each facility or
establishment where work activities are performed.
Under OSHA record keeping guidelines, musculoskeletal disorders must be recorded if (1) they were
caused or exacerbated by work activities, and (2a) there is at least one physical finding (e.g., positive
Tinels or Phalens test, swelling, loss of motion), or (2b) there is at least one subjective symptom (e.g.,
pain, numbness, burning) that resulted in medical treatment, lost or restricted workdays, or transfer/
rotation to another job (OSHA, 1990). Determination of these conditions may be made by a physician,
nurse, or other health care provider. Musculoskeletal conditions are generally recorded on the existing
OSHA 200 form as an occupational illness under column 7f (disorders associated with repeated
trauma). These disorders are caused, aggravated, or precipitated by repeated motion, vibration, or
pressure.
A review of OSHA logs will generally yield a count of the number of musculoskeletal disorders
recorded within a given time frame. Although almost all worksites keep an OSHA log, its utility for
musculoskeletal disorder surveillance can be limited. The form does not require a detailed description of
the workers job or the disorder, making it difficult to determine the exact cause and nature of the injury.
Also, because most musculoskeletal problems tend to develop over time (i.e., do not result from a
specific event), workers or medical personnel may not realize that these disorders are work-related, and
hence, recordable.
The OSHA logs do provide a convenient basis for making internal comparisons within a company.
The rates of injuries and illnesses can be compared over time and at different sites to assist in determining
trends in injuries and illnesses. An industry can also use the data to compare itself against a national
benchmark, such as the experience of other companies in the same Standard Industrial Classification
(SIC).
For example, Company XYZ, a nursing home provider, employed 250 workers in 1991. This same
year, workers reported 20 injuries and illnesses that resulted in a total of 100 lost workdays. Using
payroll records, the company determined that employees had worked 450,000 hours during this period.
They calculated an injury severity rate of 42.1 lost workdays per 100 full-time employees. Although the
severity rate is high, this rate is less than the national severity rate of 61.2 for companies in SIC 805,
individual and family services.
To find the national rate for the companys SIC code, refer to the Department of Labors Occupational
Injuries and Illnesses in the United States by Industry, available from the U.S. Government Printing
Office each spring.
On-and Off-Site Medical Records. Some companies maintain an onsite health clinic; others contract
with external medical providers to provide care to workers injured at the job site. In either case, reports
from these services, whether they are first-aid reports, dispensary logs, or employee medical records may
provide useful information about potential work-related musculoskeletal disorders. At a minimum,
these records may supplement information contained in the OSHA log.
For example, a review of the dispensary records at a poultry processing plant revealed no OSHA
recordable injuries among workers on the trimming line in the previous year. However, the first aid
medical reports showed that several employees who worked on that line on a daily basis requested
antiinflammatory medications and ice packs.
The utility of medical records for surveillance purposes can varythey may or may not describe the
reason for the visit or the condition underlying the prescribed treatment. Also, unless the information is
routinely summarized, reviewing many medical records can be highly inefficient. Because medical records
can contain sensitive information about employees, their contents must be treated confidentially. Routine
access should be limited to health care personnel and public health agencies. Others should not have
access without consent of the affected individuals.
Workers Compensation Records. In many states, companies are required to obtain workers
compensation insurance to cover the medical and indemnity costs of employees who sustain injuries
arising out of, and in the course and scope of their work. Where they exist, workers compensation
records can provide valuable information about the direct costs (medical and indemnity) associated
23-7
with work-related musculoskeletal disorders. These costs include (1) payments made to outside hospitals,
clinics, physicians, and other licensed medical personnel for the diagnosis, treatment (including surgery),
and rehabilitation of the injury, (2) payments made to the injured worker as compensation for lost work
time, and (3) payments made as a lump sum settlement for permanent disability. The actual cost of
musculoskeletal disorders is often higher than those covered by workers compensation insurance. For
example, the cost of medical treatments rendered directly by the employer or charged to the employees
health plan is not included. As a result, the total financial burden of these disorders to a companys
balance sheet often goes unrecognized and unaddressed.
Workers compensation claims are filed under specific rules and regulations that vary from state to
state. Each workers compensation law specifies what, how, and when work-related injuries and illnesses
must be reported. To be covered, the worker must first choose to report the injury. Once the worker files
a claim, there are issues of eligibility that govern whether the worker will receive benefits. Surveillance
data based on the number of claims filed will differ from those based on the number of claims paid. As
a result, workers compensation data will often underestimate the true rates of work-related injuries and
illnesses (Schwartz, 1987).
Misclassification and coding errors are also serious problems in using workers compensation data. In
an examination of workers compensation data in Washington State, Franklin et al. (1991) found that
only 72% of claims for carpal tunnel surgery were given an ICD code compatible with carpal tunnel
syndrome.
Despite these limitations, workers compensation data provide some significant advantages as a source
of surveillance information. First, all records in the data set relate to conditions of suspected occupational
origin. Also, workers compensation records usually describe the circumstances of the disorder in a way
that provides an understanding of the cause of the condition (Baker and Matte, 1994). If case identification
leads to improvement of workplace conditions, the cost of compensation should be greatly reduced in
future years.
Payroll Records. Payroll records are useful from two standpoints. First, payroll records can be used
to determine the number of hours worked by employees on a particular job. This value is often used as
a crude measure of employees exposures to job hazards and is required for the incidence/prevalence/
severity rate calculations described previously in this chapter. Second, payroll records can be used to
identify jobs or departments where absenteeism or turnover is high. Although high turnover can result
from several causes, physical stress is a common reason for leaving a job. If less stressful jobs are available,
workers may choose to quit or bid out of their present, more stressful jobs. In a study by Lavender and
Marras (1994), high rates of job turnover were identified as a useful indicator of jobs that posed a risk
of overexertion injury leading to low back disorders. Although turnover can be affected by factors
beyond the physical hazards posed by the job (e.g., the availability of higher paying positions, psychosocial
factors), the results suggest that the sensitivity of surveillance programs based on existing records can be
improved by using turnover rates to supplement injury rate data.
Summary. The quality and utility of existing record systems for surveillance purposes can vary.
Musculoskeletal disorders often go unreported, and depending on the data source, striking differences
in the incidence of work-related musculoskeletal disorders can be found (CDC, 1989). Even when
records are complete, a lag will often exist between the appearance of a hazard and the onset of injury;
therefore, records may not give an accurate picture of the current situation. Finally, linking injury/
disease data with exposure to a hazard can be especially challenging. Job titles are often poor indicators
of exposure to risk factors for musculoskeletal disorders. Additional data needed to link disorders to
specific tasks or job processes may not exist.
Worker Surveys
Most work-related musculoskeletal disorders produce symptoms of pain or discomfort. Likewise, workers
can provide valuable information about job attributes that cause fatigue or pain. Therefore, one of the
most direct and effective methods for collecting surveillance data is to administer questionnaires or
23-8
other surveys to workers. These techniques are sometimes called active surveillance measures because
the investigator plays an active role in soliciting and collecting information specifically for surveillance
purposes. (In traditional public health surveillance, e.g., for infectious diseases such as tuberculosis,
active surveillance means going out to hospitals and clinics to review patient records to detect cases.
To avoid confusion, we do not use the term active surveillance here.)
Worker surveys can take several forms. They can be lengthy or quite short; they can be oral (i.e.,
administered by an interviewer) or written; and they may rely heavily on pictures or charts. Examples of
worker surveys include the body part discomfort scale (Corlett and Bishop, 1976), the Nordic
Musculoskeletal Questionnaire (Kuorinka et al., 1987), the NIOSH Health Hazard Upper Extremity
Questionnaire (Hales et al., 1992), and the computerized discomfort assessment system (Saldana et
al., 1994). Common features of surveys include the following:
Use of body part diagrams, where workers can indicate the location of pain or other symptoms;
Questions about the onset and duration of the symptoms;
Questions about the nature of job activities;
Use of numerical rating scales to indicate the severity of pain, fatigue, or discomfort.
Worker surveys are sometimes underrated as useful sources of surveillance data. A main reason stems
from concerns that workers either may under- or over-report their symptoms. Inaccurate reporting may
be more of an indication of a poorly worded survey, a lack of understanding, fear of job loss or
recrimination, or simply a stoic attitude about discomfort. In situations in which worker surveys yield
evidence of over-reporting of an occupational problem, investigators should not dismiss the findings
until they are certain they understand the reason for their findings. In such cases organizational problems
may be intertwined with safety and health problems (Schierhout and Myers, 1996).
To avoid concerns about reporting biases in worker surveys, some investigators have combined
questionnaires with physical examinations of workers to identify musculoskeletal conditions (Bernard
et al., 1994; Hales et al., 1994). These studies show that while symptoms of discomfort or pain may not
always reflect an underlying pathology, the vast majority of employees with moderate to severe
musculoskeletal symptoms have at least one positive physical finding on a concurrent physical examination
(Baron et al., 1992).
Worker surveys should be conducted (1) when there is evidence from any data source of increased
musculoskeletal injury or illness in the facility, (2) when new jobs or tasks are begun, or (3) when
employees change jobs. The latter two surveys provide useful baseline data for determining the impact
of the change on employee health. For example, one method to evaluate the effectiveness of a redesigned
workstation would be to compare the pattern of shoulder, neck, and back discomfort recorded before
the intervention with the pattern of discomfort for those same body segments after the improvements
have been installed.
The advantages of using worker surveys as a source of information include the following: (1) The
investigator can exert more control over the data collected. Once the investigator has decided what
questions need to be answered, he or she can select the survey items that will elicit the most complete
information that is needed. Because the investigator has control over the survey, there is also less chance
that the information will change or become biased between administrations of the survey. (2) Surveys
are easy to administer in the fieldworkers can complete the surveys at their convenience, and responses
can be kept anonymous. These features can encourage high participation rates and candid responses,
although the opportunities for follow-up surveillance are more limited. (3) Worker surveys can be
readministered periodically to allow for early recognition of musculoskeletal disorders.
Worker surveys also have some inherent limitations. First, the time and resources required to develop
and administer surveys may make them more costly than surveillance activities that rely on existing
records. Second, the survey information may be unreliable if there is a lack of trust between management
and workers. Third, the design of the questionnaire can have a dramatic effect on the quality of the
responses and the number of workers who complete the survey. Key design issues include the length of
the questionnaire, the phrasing of the questions, and method of administration. In a diverse or
23-9
multilanguage workforce, translating the questionnaires into several languages may be necessary. Finally,
responses can be influenced by the workers expectations about how much effort is required to perform
a certain job. For example, a young warehouse worker may rate his job as only moderately strenuous,
whereas an older worker using the same scale in a busy office environment may perceive his work to be
very stressful in terms of work demands.
Hazard (Risk Factor) Surveys

Ideally, actions to prevent work-related musculoskeletal disorders should proceed before injuries and/or
symptoms develop. In the last decade, a significant amount of research has been undertaken to improve
our understanding of the risk factors that lead to the development of work-related musculoskeletal
disorders (Gerr et al., 1991; Rempel et al., 1992). The process of examining jobs for these risk factors is
known as hazard surveillance. Even without clear medical evidence that musculoskeletal problems exist,
hazard surveillance activities can provide the data needed to begin an effective primary prevention
program.
Because surveillance for ergonomic hazards is a relatively new notion, few industries maintain records
that explicitly identify hazards for each job. However, many companies maintain job descriptions that
identify the skills or abilities required to perform jobs in their facilities. In recent years, many industries
have updated their job descriptions to include statements defining Essential Job Functions to comply
with the Americans with Disabilities Act (ADA). According to the ADA, the descriptions should identify
essential functions, or fundamental job duties, and the physical and mental abilities needed to perform
these functions. If functional job descriptions are available, they can provide useful information for
identifying potentially stressful jobs or jobs requiring unique skills or special endurance.
For example, a job description in a large assembly plant may list the ability to perform manual lifts,
assemble parts, and use an impact wrench as requirements. Based on this description, an investigator
could infer that the job might require high force exertions, awkward postures, repetitive hand movements,
and exposure to segmental hand vibration.
Whether or not job descriptions exist, hazard surveillance efforts depend heavily on walk-through
surveys. Investigators need to observe job activities, speak with workers and supervisors to obtain job
information not apparent from observation, and use checklists to score job features against a listing of
risk factors. The walk-through survey is differentiated from more formalized job analysis efforts by the
amount of detailed information collected. The purpose of the walk- through is to identify risk factors
that might otherwise go unnoticed and provide additional basis for prioritizing jobs for further evaluation.
Examples of checklists that might be used for hazard surveillance are provided in Tables 23.2, 23.3,
and 23.4. Although most of the checklists are designed for use by non-experts, some minimal level of
training is usually needed to use checklists properly. Hazard checklists can vary in length and in scope.
At one extreme, there are generic checklists that are widely applicable, i.e., for use on nearly all jobs
in all industries (OSHA, 1995). These checklists can be contrasted with more focused checklists, designed
to evaluate a specific job or industry, e.g., carpenters or nurses aides (Bhattacharya, 1992; Engkvist et
al., 1995). While some checklists are intended to serve primarily as mnemonics (i.e., to remind users to
evaluate a particular job characteristic), other checklists incorporate a scoring system for indicating the
risk associated with a particular job or process. Attempts to validate various checklists as scoring
instruments have yielded mixed results (Lifshitz and Armstrong, 1986; Keyserling et al., 1992; 1993;
Shierhout et al., 1994; Kemmlert, 1995).
Hazard surveys should be administered (1) whenever a job, task, or process is changed substantially,
(2) when new jobs are introduced, and (3) periodically (especially after new cases of musculoskeletal
disorders are reported) to detect whether trends exist across jobs that use similar equipment, tools, or
processes (ANSI, 1996). Hazard surveys can also be incorporated into regular safety and health inspections
at the facility, expanding the scope of these inspections to include identification of musculoskeletal
23-10
TABLE 23.2 Ergonomic Hazard Identification Checklist*
*Developed by Grant, Habes, Fernandez, and Putz-Anderson, NIOSH, Cincinnati, Ohio, 1994.
Any response of: Usually to Questions 114 = Potential Risk Present: Follow-up
disorder risk factors.
23.4 Conclusions
Surveillance is essential to the prevention/control of musculoskeletal disorders in the workplace.
Unfortunately, surveillance efforts will ultimately be wasteful and ineffective if there are major breakdowns
in any of the three major components: data, analysis, or intervention. In general, no single data source
provides enough information to direct a program for preventing work-related musculoskeletal disorders.
Therefore, effective surveillance programs make use of multiple data sources to identify problem areas
and determine intervention priorities. Even in the absence of health data, hazard surveys conducted in
workplaces where there are significant or well-defined hazards can provide the data needed to mount an
effective primary prevention program for work-related musculoskeletal disorders.
Once established, surveillance should become an ongoing process. As corrective actions are taken,
23-11
TABLE 23.3 Manual Material Handling Checklist for Lifting, Carrying, Pushing, or Pulling*
Comment: Yes responses are indicative of conditions that pose a risk of developing low back pain.
The larger the percentage of yes responses, the greater the possible risk.
* Developed by Thomas Waters, Ph.D., CPE, NIOSH, Cincinnati, Ohio, 1994.
TABLE 23.4 Physical Exertion Questionnaire
The purpose of this questionnaire is to assess the amount of exertion you use in your job. Exertion is defined
by (1) force, (2) repetitive motion, and (3) whole-body activity. The following pages contain three lists of
activities, one for force, one for repetition, and one for whole-body activity. Use the activities in these lists to
estimate the amount of exertion you use in your job.
To complete the questionnaire, read the activities on each page. Then compare the amount of force, wholebody activity, or repetitive motion (according to the particular list) the activities require, with the amount of
force, whole-body activity, or repetition your work activities require. If you dont spend much work time doing
exactly these activities, you may spend time doing activities that require about the same amount of
exertion as the activities in the lists. Read the activities and think about an average workday. Then, in the boxes
beside the activities, write in the number of hours and minutes during a typical workday, on the average, you
spend doing activities that require about the same amount of exertion as those at each intensity level. The
total amount of time on each page should add up to about the length of your average workday.
Some of the intensity levels do not have activities to describe them. These levels stand for an amount of
exertion that is halfway between the activities above and below. Write in the amount of time on those lines also.
Think carefully about the amount of time you spend in low intensity activities, which may be more difficult to
remember than high intensity activities.
As an example of completing the questionnaire, how much time during an average workday do you spend in
activities that require about the same amount of whole-body activity as running up stairs? If you usually spend
about 4 hours and 30 minutes during an average day, write this in the box beside the activity. Then estimate the
amount of time you spend doing activities at the other intensity levels and write the time in the boxes. Please do
not leave any of the boxes empty. Put a 0 in the box if you dont spend time doing activities at that intensity
level.
Remember The activities are only examples of amounts of exertion. The question is Do you use the
same amount of exertion as required by the different activities and not whether you perform the activities
listed. The activities are only a guide for you to help you estimate your level of exertion, relative to the listed
activity.
Whole-Body Activity Scale
On this page, you will indicate how much whole-body activity your job requires. Whole-body activity is any activity
that increases heart rate and breathing, and involves movement mostly of the legs, such as pedaling a bicycle, or
movement of the entire body. The activities below require whole-body activity; those near the top of the list
require more whole-body activity than those near the bottom.
23-12
TABLE 23.4 (continued) Physical Exertion Questionnaire

Compare your work activities to the activities below in terms of how much whole-body activity your job requires.
Then decide how much time on the average, you spend doing activities that require about the same amount of wholebody activity as those at each intensity level. To help you estimate the intensity of your whole-body activity, think about how
your body feels when you perform the activities in the scale, and compare this to the way your body feels when you perform your
work activities.
Remember: The activities below are only examples of amounts of whole-body activity for you to compare with
your work activities. We are NOT interested in whether you perform the specific activities listed in the scale. Also, think
only about the amount of whole-body activity used to perform these activities, and not about the amount of force or
repetitive motion the activities require.
The total number of hours and minutes in the table should equal about the length of your average workday.
Repetitive Motion Scale

In this table, we are interested in how much repetitive motion your job requires. Repetitive motion is movement that
requires use of the same muscles and body parts to perform the same movements or sequence of movements over
and over.
The activities below require repetitive motion. Those near the top of the list require more repetitive motion,
meaning that the movements or sequence of movements take only a short time to complete before being repeated.
Activities near the bottom of the list require less repetitive motion, and it takes longer before the same movement is
repeated.
Please read the activities below and think about your average workday. Then write in the number of hours and
minutes during a typical workday, on the average, you spend doing work activities that require about the same
amount of repetitive motion as those at each intensity level. Please remember: The activities below are only examples
of repetitive motion to be compared with your work activities. We are NOT interested in whether you perform the
specific activities listed in the scale. Also, think only about the amount of repetitive motion used to perform these
activities, and not about the amount of whole-body activity or force the activities require.
The total number of hours and minutes in the table should equal about the length of your average workday.
23-13
TABLE 23.4 (continued) Physical Exertion Questionnaire
Force Scale
On this page, you will indicate how much muscle force your job requires. In the boxes below enter the number of hours and
minutes during a typical workday, on the average, you spend doing activities that require about the same amount of force as those
at each intensity level.
The activities near the top of the list require more force, and activities near the bottom of the list require less force.
To help you estimate the amount of force you use in your job, think about how your body feels when you perform the activities in the scale,
and compare this to the way your body feels when you perform your work activities. Remember: The activities are only examples of
amounts of force. We are NOT interested in whether you perform the specific activities listed in the scale. Also, think only about
the amount of force used to perform these activities, and not about the amount of whole-body activity or repetitive motion the
activities require.
The total number of hours and minutes in this table should equal about the length of our average workday.
Cole, L.L. (1996). Construction and Validation of a Musculoskeletal Risk Questionnaire. Unpublished doctoral
dissertation, University of Cincinnati, Cincinnati, Ohio.
surveillance data can provide the information needed to show the beneficial effects of these efforts. By
integrating surveillance efforts with existing quality assurance and cost containment programs, their
utilization and success will be maximized.
Defining Terms
Case definition: Set of decision-making criteria, intended to assist health care providers in identifying work-related
injuries and illnesses so that further investigation and preventive activities can be initiated.
Existing records: Records created for other purposes that may be useful in surveillance efforts. These records can
include OSHA 200 logs, medical or health care records, workers compensation claims, payroll records, sickness
and accident reports, etc.
Hazard surveys: Assessments of jobs, workplaces, or processes for the purpose of identifying risk factors (e.g.,
biomechanical stress, vibration) that can lead to development of musculoskeletal disorders. Can be used to
identify intervention targets before injuries or diseases have occurred.
Incidence rate: The rate of work-related musculoskeletal disorders appearing for the first time during a specific
period.
Prevalence rate: The percentage of all cases of disease/symptoms/complaints at a given point in time.
Sensitivity: The probability that a case definition or screening procedure will identify individuals with the condition
(disease) of interest.
23-14
Severity index: The rate of lost or restricted workdays due to musculoskeletal illness occurring within a specific
period.
Specificity: The probability that a case definition or screening procedure will not label a healthy individual as
diseased.
Surveillance: The continuous analysis, interpretation, and feedback of systematically collected data, essential to the
planning, implementation and evaluation of occupational safety and health programs. Surveillance methods are
often distinguished by their practicality, uniformity, and rapidity, rather than by their accuracy or completeness.
Worker surveys: Questionnaires and interview procedures developed to solicit information about signs, symptoms,
and risk factors for musculoskeletal disorders from workers.
References
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Extremities (Working Draft, January 1, 1996). National Safety Council, Itasca, Illinois.
Baker, E.L., Honchar, P.A., and Fine, L.J. 1989. Surveillance in occupational illness and injury: concepts
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Baker, E.L. and Matte, T.P. 1994. Surveillance for occupational hazards and disease, in Textbook of
Clinical Occupational and Environmental Medicine, Eds. L.Rosenstock and M.R.Cullen, p. 6167.
W.B. Saunders Company, Philadelphia.
Baron, S., Hales, T., and Fine, L. 1992. Evaluation of a questionnaire to assess the prevalence of workrelated musculoskeletal disorders. Arbete Och Halsa 17:3941.
Bhattacharya, A. 1992. Walkthrough Ergonomics Checklist for Carpentry Tasks. Greater Cincinnati
Occupational Health Center, Cincinnati, Ohio.
Bernard, B., Sauter, S., Fine, L., Petersen, M., and Hales, T. 1994. Job task and psychosocial risk factors
for work-related musculoskeletal disorders among newspaper reporters. Scand. J. Work Environ.
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Centers for Disease Control, 1989. Occupational disease surveillancecarpal tunnel syndrome. MMWR
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Corlett, E.N. and Bishop, R.P. 1976. A technique for assessing postural discomfort. Ergonomics
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Engkvist, I.L., Hagberg, M., Wigaeus-Hjelm, E., Menckel, E., and Ekenvall, L. 1995. Interview protocols
and ergonomics checklist for analyzing overexertion back accidents among nursing personnel. Appl.
Ergonom. 26(3):213220.
Fine, L.J., Silverstein, B.A., Armstrong, T.J., Anderson, C.A., and Sugano, D.S. 1986. Detection of
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Franklin, G.M., Haug, J., Heyer, N., Checkoway, H., and Peck, N. 1991. Occupational carpal tunnel
syndrome in Washington State, 19841988. Am. J. Public Health 81:741746.
Gerr, F., Letz, R., and Landrigan, P.J. 1991. Upper-extremity musculoskeletal disorders of occupational
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Greife, A., Halperin, W., Groce, D., OBrien, D., Pedersen, D., Myers, J.R., and Jenkins, L. 1995. Hazard
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Hales, T., Sauter, S., Peterson, M., Fine, L., Putz-Anderson, V., Schleifer, L., Ochs, T., and Bernard, B.
1994. Musculoskeletal disorders among visual display terminal users in a telecommunications
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Hennekens, C.H. and Buring, J.E. 1987. Epidemiology in Medicine. Little, Brown and Company, Boston.
Katz, J.N., Larson, M.G., Fossel, A.H., and Liang, M.H. 1991. Validation of a surveillance case definition
of carpal tunnel syndrome. Am. J. Public Health 81:189193.
Kemmlert, K. 1995. A method assigned for the identification of ergonomic hazardsPLIBEL. Appl.
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Keyserling, W.M., Brouwer, M., and Silverstein, B.A. 1992. A checklist for evaluating risk factors
resulting from awkward postures of the legs, trunk and neck. International J. of Industrial
Keyserling, W.M., Stetson, D.S., Silverstein, B.A., and Brouwer, M.L. 1993. A checklist for evaluating
ergonomic risk factors associated with upper extremity cumulative trauma disorders. Ergonomics
36(7):807831.
Kuorinka, L., Jonsson, B., Kilbom, A., Vinterberg, H., Biering-Sorensen, F., Andersson, G., and Jorgensen,
K. 1987. Standardized Nordic questionnaire for the analysis of musculoskeletal symptoms. Appl.
Ergonom. 18(3):233237.
Last, J.M. (Ed.) 1995. A Dictionary of Epidemiology, 3rd ed. Oxford University Press, New York.
Lifshitz, Y. and Armstrong, T.J. 1986. A design checklist for control and prediction of cumulative trauma
disorders in intensive manual jobs. Proceedings of the Human Factors Society, 30th Annual Meeting.
Human Factors Society, Santa Monica, pp. 837841.
Margolis, W. and Kraus, J.F. 1987. The prevalence of carpal tunnel syndrome symptoms in female
supermarket cashiers. J. Occup. Med. 29(12):953956.
NIOSH, 1993. Comments from the National Institute for Occupational Safety and Health on the
Occupational Safety and Health Administration Proposed Rule on Ergonomic Safety and Health
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OSHA, 1990. Ergonomics Program Management Guidelines for Meatpacking Plants. U.S. Department
of Labor, Occupational Safety and Health Administration, Washington, D.C.
OSHA, 1995. OSHA Draft Proposed Ergonomic Protection Standard: Summaries, Explanations,
Regulatory Text, Appendices A and B, March 20, 1995. Occupational Safety and Health Reporter
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Rempel, D.M., Harrison, R.J., and Barnhart, S. 1992. Work-related cumulative trauma disorders of the
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Saldana, N., Herrin, G.D., Armstrong, T.J., and Franzblau, A. 1994. A computerized method for
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Schierhout, G.H., Myers, J.E., and Bridger, R.S. 1993. Musculoskeletal pain and workplace ergonomic
stressors in manufacturing industry in South Africa. Int J. Ind. Ergon. 12:311.
Schierhout, G.H. and Myers, J.E. 1996 Is self-reported pain an appropriate outcome measure in
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30(6):488492.
24
Injury Surveillance
Database Systems
24.1
24.2
Introduction
Injury Surveillance
24.3
Sources of Primary Injury Surveillance Data
241
242
History Goals and Objectives
243
Injury Data Job Descriptions Worker Tracking
24.4
Benefits of an Injury Surveillance Database System
246
Cost Benefit Analysis of Database Investment Integration

of Database Systems
24.5
Ergonomics and Injury Surveillance
248
Ergonomics Process Ergonomics Module of a Database

System
24.6
Early Databases
2410
Challenges that Were Met
24.7
Defining the Database Model
2411
Designing the System and Defining Components .

Company Size Onsite or Offsite Medical and Surveillance
Services Types of Database Models Confidentiality .
Data Entry Computerization
24.8
Carol Stuart-Buttle
Stuart-Buttle Ergonomics
Statistical Treatment of Data
2416
Report Generation
24.9
24.10
Choosing a Commercial Injury Surveillance Database 2418

Summary
2419
24.1 Introduction
A database is a collection of organized, related data typically in electronic form that can be accessed and
manipulated by computer software. When the interface between the data and user is developed beyond
just managing the data, but with a particular function in mind, a database system evolves. Features of
the interface may include data dictionaries, data security, statistical and graphical capabilities, and report
writing.
Injury surveillance database systems focus on the collection of data that are pertinent to injuries and
illnesses, the management of that data, and data interpretation. The goals of interpretation may include
determining trends, promoting prompt treatment and directing prevention strategies. The general use of
the term injury refers to all types of injuries and illnesses. Conducting epidemiological studies or other
research that attempts to find causal relationships of injuries may be practical with large organizations
but not for most of industry; therefore research use of databases are not discussed in this chapter. Injury
surveillance databases and the relationship of surveillance to ergonomics are addressed from the practicing
industrial safety and health professionals perspective.
0-8493-1800-9/03/$0.00+$1.50
24-1
24-2
Surveillance of the workplace for injuries and potential injuries is an important aspect of the ergonomics
process as injuries are an indicator of poor design. Often, the effectiveness of ergonomic processes are
measured by the rates of injury and lost workdays. Most employers are required to record work-related
injuries and illnesses in accordance with the Occupational Safety and Health (OSH) Act (OSHA, 1970).
As personal computers (PCs) have become commonplace in industry, the most basic information pertaining
to the OSH Act can be easily computerized; in other words, a company database can be established.
Considerable time and effort can be saved in the update and analysis of the data with the right software
interface.
The rate of change and growth in the computer software market is so great that for many industries
the task of exploring, evaluating, and choosing a database system for the company is formidable. This
chapter does not attempt to predict the future of information systems, nor does it try to summarize the
existing safety and health software since such information rapidly changes. However, some safety and
health software directories are provided. The main points and discussion of this chapter focus on the
fundamental components of injury surveillance as they relate to ergonomics and tips on how to assess
commercial injury surveillance database systems. A section touches on the development of an injury
surveillance database only to provide an opportunity to understand injury surveillance in the context of
system development.
24.2 Injury Surveillance

History
Surveillance is the ongoing and systematic collection, analysis, and interpretation of data related to
health. (Baker, 1989a). Surveillance historically began in the public health setting, as a method of
watching out for certain serious diseases or illnesses such as syphilis and smallpox, so that isolation
could be instituted at the first signs of symptoms. Since 1950 the term surveillance was formally
applied to the systematic collection of relevant disease data with the purpose to improve the control of
specific diseases. During the 1960s, surveillance in the U.S. expanded such that it applied not only to
communicable diseases but also to noninfectious diseases including environmental and occupational
hazards (Langmuir, 1976).
During the 1960s, some states developed reporting requirements for selected occupational diseases
or used data from the workers compensation system for surveillance. Not until the federal OSH Act of
1970 was there a standardized scheme to monitor injuries and illnesses (Wegman, 1985). It was not
surprising that the chemical industry was a pioneering group in developing occupational surveillance
systems, since there was much potential for disease. Hazard surveillance, as a means of predicting workrelated health problems in the chemical industry, was developed to complement the basic surveillance of
recording injuries and illnesses required by the OSH Act. Many companies then started hazard profiles
that included information such as industry demographics (employment size in the geographic area), use
of chemicals in the workplace, levels of the chemicals to which workers were exposed, and data on the
dose-response relationship for each chemical (Froines, 1986).
The hazard surveillance model has been applied to ergonomics-related issues in the workplace. One
problem in applying such a model to ergonomics is that suspected risk factors for musculoskeletal
disorders are treated discretely without taking into account the interactions of the risk factors. The
effects of the interactions and the dose-response relationships are still being discovered.
Monitoring is another term that refers to the methods to anticipate a disease or medical disorder
before it occurs (Yodaiken, 1986). Monitoring complements medical surveillance in a way similar to
that of hazard surveillance. The difference lies in semantics and the use of the word hazard which
implies that the dose-response is known. As stated above, it is difficult to determine when one or more
risk factors are hazardous for musculoskeletal disorders.
Monitoring may be considered as a more general term, one that refers to looking at the workplace in
Injury Surveillance Database Systems
24-3
order to anticipate problems and prevent their occurrence. An illustration of the practical difference
between medical surveillance and monitoring is the distinction between a symptom survey and discomfort
survey (Stuart-Buttle, 1994). A symptom survey identifies the employees with physical problems through
the collection of detailed information about symptoms. On the other hand, a discomfort survey attempts
to find out the discomfort that employees are experiencing while performing their jobs. Discomfort
indicates a physical stress at performing the job, not necessarily an active medical problem. The implication
of a discomfort survey is that discomfort could be a precursor to injury, hence a discomfort survey is a
monitoring method for determining where to focus prevention efforts.
Another common distinction of the term surveillance is whether it is passive or active (BNA,
1993a). Passive surveillance is the analysis of data from existing databases, such as the Occupational
Safety and Health Administration (OSHA) 200 logs that record work-related injuries and illnesses, or
workers compensation records. Active surveillance is collecting data to actively seek information,
such as using surveys to determine the physical conditions that individuals have not reported, or defining
aspects of the jobs that may be risk factors for injury. The distinction between passive and active
surveillance is almost the same as that between surveillance and monitoring, or medical surveillance and
hazard surveillance.
Goals and Objectives

Injury surveillance should entail both active and passive surveillance. Existing injury data as well as
additional information collected about the workers and their jobs must be analyzed. The goals of a
surveillance system include the prevention of occupational disease (injuries) through control of the
causative agents (Sundin, 1986). Surveillance helps to direct the prevention programs to control or
eliminate preventable disorders (Baker, 1989b).
The objectives to fulfill the goals of surveillance are to locate and monitor groups of workers who are
exposed to risk, to determine the risk factors and take corrective action, or reduce exposure to those
factors. Discovering the relationships between exposure and the injury is a research domain which may
be undertaken by some corporations with substantial databases or as state or university projects. The
interaction and dosage of risk factors for musculoskeletal disorders are not yet known, but industry can
take action based on the best knowledge to date and refine the decisions as research progresses. Gerard
Scannell, president of the National Safety Council asks, How do you direct your safety and health
program if you dont know what is happening in your workplace? The proper analysis of recorded
injuries and illnesses will drive the programs (Smith, 1995). In addition, surveillance is the primary
method of assessing the efficacy of prevention measures that are instituted to control the identified
problems (Hanrahan, 1989). Therefore, a company benefits from collecting the data that are useful in
reducing the risk of injuries and improving job performance.
24.3 Sources of Primary Injury Surveillance Data

Injury Data
There are several primary sources of injury data that companies either keep or to which they have access
without having to survey the workforce.
Injury logs that are mandated by OSHA

Workers compensation records
Medical records
Accident records
24-4
OSHA Recordkeeping
Since the OSH Act of 1970 companies have had to keep a record of their injuries. In 1981 OSHA began to
look at the log data as indicators for an inspection. Industry responded to this new focus in one of two
ways. They either improved the safety and health in the facility or became more selective in what was
recorded on the logs. OSHA began to discover significant under-reporting on companies logs, and stronger
enforcement action was instituted in 1986 (Tyson, 1991). Total penalties have become so substantial that
companies now pay much more attention to keeping accurate records (BNA, 1993b, 1994). However,
some of the difficulties of accurate recordkeeping have come to light and influence injury surveillance.
The increase in cumulative trauma disorders in the workplace highlights the difficulty of keeping the
records up to date. As a medical condition progresses, the diagnosis sometimes changes, but the OSHA
records may not reflect the new diagnosis. For example, if an injury originally recorded as a strained
wrist eventually led to carpal tunnel syndrome, the diagnosis is typically not changed in the logs. This
may be a common oversight if the records are kept by nonmedical personnel or if there is poor
communication with the health care professional (HCP). Computerized databases can help a company,
even if there is no medical department, as the system could be designed to prompt for confirmation of
diagnosis while a case is open.
Despite guidelines on recordkeeping (BLS, 1986), there remains considerable confusion among
employers about when and how to record occupational injuries and illnesses. The ambiguity of some of
the requirements has been a point of litigation, and one company issued a digest of official interpretations
of the recordkeeping guidelines primarily based on legal decisions in enforcement cases or in the courts
(Duvall, 1996). OSHA proposed revised recordkeeping requirements and a new guidebook on how to
interpret the requirements (OSHA, 1996). The proposal suggested significant improvements that included
new versions of the OSHA 200 and 101 forms and simpler recording requirements.
In addition to recording injuries, OSHA and other government and state agencies mandate that
several types of records be kept by the person or people responsible for safety and health. Records
pertaining to hearing conservation, tracking of and training in the use of personal protective equipment
(PPE), and compliance with confined space are just a few examples of the requirements. These records
may be easily tracked and integrated into the safety and health database system.
Workers Compensation Data

Small industries commonly rely on workers compensation data supplied by the companys insurance
carrier as an injury surveillance system. The benefit of this practice is the convenience of the data,
especially if the insurance carriers summarize the information. There are several downsides to using only
these data. Not all injuries become workers compensation cases, and therefore the injury profile is only
partial. By the time a claim is processed and appears on a summary, a considerable length of time has
passed during which preventative action could have been initiated. However, the claims on the workers
compensation insurance originate in the company, so that the company can have immediate access to
the information if good records are kept. But, if the workers compensation data can be tracked effectively
by the company, then so can the accident data that might not become workers compensation. The
company would have richer data on which to base prevention and improvements.
The cost of injuries is one type of information that workers compensation data do provide that is
difficult to obtain any other way. Cost data are very useful for calculating cost benefit equations for
improvements. Since workers compensation databases are often large, they can be used effectively for
major epidemiological studies or to complement large-scale surveillance (Seligman, 1986).
Medical Records
Medical records can be the most reliable source of injury data since there is no interpretation required
for recording as there is for the OSHA logs and workers compensation filing. As discussed later in this
chapter, a difficulty that can arise is access to the medical records. Very few workplaces have onsite
medical services, and medical records can reflect both work- and nonwork-related injuries which can
confuse data collection for injury surveillance.
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First aid treatment is often recorded by a company but may not be entered in an employees medical
record. Although by definition the incidents are minor, there may be indication of a design problem. For
example, it is not uncommon to find frequent treatment for grazed knuckles. If this is happening to the
same employee or to a group of employees under the same circumstances, it could be a clearance or
access issue.
Accident Records
Accident reports are filled out by many companies and are the earliest records of an injury within a
companys safety and health process. Not all injuries from accidents are recorded on the OSHA forms or
claimed on workers compensation, so that accident reports potentially provide the most comprehensive
record of injuries, although maybe without medical detail. If good root cause analyses are conducted
and recorded on the accident reports there may be valuable information indicating job redesign.
Job Descriptions
Job information is useful from many standpoints. The causes of injuries need to be identified in order to
prevent them. Although the causes for musculoskeletal injuries are not well defined, identifying risk
factors of the job can be helpful. For example, risk factors for cumulative trauma disorders include
extreme postures, high forces, high repetitions, inadequate recovery times and excessive duration. Some
of the reasons to consider building a database of job descriptions are to:
Have a list of risk factors present in each job

Track employees exposure
Aid in the initial placement of employees
Determine a job rotation system to create a balance of the job demands
Provide information to the HCPs to help them with decisions regarding the work-relatedness of
conditions
Provide the context for functional capacity evaluations or to tailor workhardening or conditioning
programs
Guide appropriate placement of employees returning to work and to determine temporary
alternative jobs or jobs that could be modified
Help determine jobs that may be modified for accommodating a person under the Americans
with Disabilities Act (ADA) (EEOC, 1990).
The downside of developing a job description database is the expense of establishing it and keeping it up
to date. Such costs will vary considerably according to the type and size of industry. Some industries
change their processes frequently, perhaps seasonally. To keep job descriptions current in a rapidly
changing environment may not be practical.
Computerized injury surveillance database systems could provide a tremendous benefit for a small
company that is communicating with offsite services. If an electronic network is established, the records
can be efficiently updated. Information about the jobs could be on-line for the medical service to access,
including formats such as computer-captured video.
Worker Tracking
Keeping up with job descriptions may be a challenge for some industries, as is tracking the worker.
Many of the companies that developed computerized databases early on stated that tracking the workers
was the most complex and difficult task (Sugano, 1982; Hagstrom, 1982; Smith, 1982; Kuritz, 1982).
Effective tracking required frequent updating of employee assignments including the length of time at
the job in the specific area. In addition, each job in every area required a profile so that there was a
history of exposure. The job profiles or descriptions also needed to be kept up to date by periodic job
analyses or audits.
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Employee tracking remains worthwhile, except that the experience of the companies that were in the
forefront of developing surveillance databases, found that not only was employee tracking difficult but
also very costly to implement. Therefore, each company must assess the importance of worker tracking,
that is, to determine the type and extent of the hazards of the industry and to develop surveillance that
is the most reasonable, practical, and cost effective. The trade-offs to consider with the four basic
qualities of an employee tracking system follow (Sugano, 1982):
Uniformity within the exposure group. Are the exposures the same across many jobs, and if so,
may some of the descriptions be combined?
Accuracy of tracking the worker. What are the means for communicating when an employee
moves area or job? How does job rotation affect exposure? What differences are there between
plants?
Adequacy of job and location description. How often does the job change, and how frequently
should the database be updated? Is environmental monitoring conducted regularly? How difficult
is it to keep the physical, environmental, and material descriptions up to date?
Cost effectiveness. How much money and manpower is needed to develop and maintain the
database? Is too much data being collected and too often?
At present, worker tracking for exposure to risk factors for musculoskeletal injuries remains an area of
research. There is no model by which to analyze the data and to provide an answer to the question how
much exposure to each risk factor or combination of factors is too much. Risk models that do exist are
based on task analyses rather than monitoring the worker throughout a shift.
24.4 Benefits of an Injury Surveillance Database System

A complete and standardized reporting system for occupational injuries does not exist in the U.S. (Brewer,
1990). Almost all employers with more than 11 employees are mandated by OSHA to keep a current
record of injuries and illnesses and details of how the injury occurred. The government forms may be
substituted by ones that are equivalent. Exposure information, such as the demands of the job, a history
of the different jobs the employee has held, or the job characteristics such as the state of the environment
or the presence of chemicals, is typically not included. However, even without the enhanced job
information, the two mandated OSHA forms contain considerable amounts of data that are not easily
analyzed by hand. Computerization of only the OSHA forms can be helpful. What is important to
remember is that the quality of the data depends on the information that is entered. The OSHA forms,
filled thoroughly and thoughtfully, provide a better company database. A basic computerized injury
surveillance database system can have the following benefits:
Standardized and accurate recordkeeping, improving the quality of health records, and compliance
with OSHA
Efficient handling of data, reducing paper work and data re-entry
Easy and effective reporting system
Quick statistical analyses for the evaluation of potential problems and the measurement of
effectiveness of interventions
Enhanced tracking ability, particularly of employees job exposures, and such tracking also
facilitates epidemiological studies
Quick verification in disability and compensation cases
Potential for integration with other data, e.g., those used by the safety or industrial hygiene
professional
Ease of cost tracking for cost benefit analyses
Efficient corporate response to litigation, community complaints, and public relations requirements.
There are many commercial software packages available for computerizing the OSHA forms combined
with basic surveillance functions. The sophistication of the available programs vary considerably, from
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large database systems with an injury surveillance module combined with advanced statistical analyses,
to simple OSHA form recording and tracking. A few software directories that are regularly updated are
listed in For Further Information.
Cost Benefit Analysis of Database Investment

A cost benefit analysis for investing in an injury surveillance database system is not easy to conduct
(Wrench, 1990). Some of the benefits are listed above but assigning a dollar value can be difficult. At the
planning stage the time saved can only be anticipated; however, software vendors can sometimes provide
a percentage figure of time saved by their systems. Wrench (1990) listed some cost aspects to consider in
the cost benefit equation.
Direct costs
Initial costs that include the stages of development, such as needs and requirements analysis,
systems analysis and design, programming and software development, hardware, software,
installation, training, and system implementation.
Operating costs that include personnel to use and maintain the system, backup systems, training,
and supplies. In addition there are costs related to updating the system as software changes, or
when regulations alter, which affect decision algorithms, data entry, and form outputs of a
database.
Indirect costs
Space requirements may increase with purchase; air-conditioning may be needed for larger
systems; security measures and additional insurance may be necessary.
Integration of Database Systems

The data collection mandated by OSHA may be useful, but, most industries would benefit from a
broader collection of data and greater integration with other company functions (Finucane, 1982;
Committee Report, 1992; Holzner, 1993; Dieterly, 1995). Early on, during the development of surveillance
within the chemical industry it was realized that exposure measures were needed to interpret the medical
findings, thus integrating medical surveillance programs with industrial hygiene surveillance (Parkinson,
1986). A survey conducted by OSHA also found medical surveillance programs were most effective
when they were integrated into a comprehensive and systematic approach for identifying and addressing
workplace hazards (BNA, 1991, 1993c). A comprehensive approach requires the involvement of different
expertise within a company and hence involves more than one discipline.
Injury surveillance can be incorporated into comprehensive safety and health programs. The Occupational
Medical Practice Committee (OMPC) of the American College of Occupational and Environmental Medicine
(ACOEM) provided guidelines for the scope of occupational and environmental health programs. The
committee identified 14 essential components of a program (Committee Report, 1992).
1. Health and evaluation of employees.
2. Diagnosis and treatment of occupational and environmental injuries or illnesses, including
rehabilitation.
3. Emergency treatment of nonoccupational injury or illness.
4. Education of employees in jobs where potential occupational hazards exist, including job-specific
instruction, instruction on methods of prevention, and recognition of possible adverse health
effects.
5. Implementation of programs for the use of indicated personal protective devicesear protection
(plugs, muffs), safety spectacles, respirators, etc.
6. Evaluation, inspection, and abatement of workplace hazards.
7. Toxicological assessments, including advice on chemical substances that have not had adequate
toxicological testing.
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8. Biostatistics and epidemiology assessments.

9. Maintenance of occupational medical records.
10. Immunization against possible occupational infections.
11. Medical interpretation and participation in development of governmental health and safety
regulations.
12. Periodic evaluation of the occupational or environmental health program.
13. Disaster preparedness planning for the workplace and the community.
14. Assistance in rehabilitation of alcohol and drug-dependent employees or those with emotional
disorders.
Many of these items can be addressed by other professionals such as those in industrial hygiene, safety,
or ergonomics. The OMPC stressed that the practitioner in occupational medicine should understand
how to enlist and collaborate with the skills of colleagues from the many other professions involved
with industry. The above list is a useful one for a company to consider. Some elements will be more
important than others, depending on the industry. If many services are contracted offsite, the overall
program may not be managed by an HCP but perhaps by another professional, for example in safety or
industrial hygiene.
24.5 Ergonomics and Injury Surveillance

Injury surveillance is of interest to several professions in industry such as safety, industrial hygiene,
medicine, and risk management, as well as ergonomics. The different disciplines may have a part in
contributing to the database, or one department may be responsible for it overall, while others access it.
Different professions may develop their own interface or module with the same database so as to
manipulate and interpret the data as they wish. If a person wears the hats of several job functions, for
example all aspects of safety and health, he or she they might work with a number of discrete modules,
such as safety, industrial hygiene, and ergonomics. However, a small company may choose to integrate
the modules to a basic safety and health one. The scale of module for each discipline depends on the
level of detail desired or degree of expertise of the person using the system. If expertise is outsourced,
then an in-house module in that field may not be needed.
Many injuries are related to poor design of the workplace or jobs, which is the domain of ergonomics.
In particular, musculoskeletal injuries such as low back disorders and cumulative trauma disorders have
become informally termed ergonomics-related disorders. This is a limited view as other injuries can
occur due to poor design; for example, accidents can arise because of inadequate accessibility or because
of an error provoked by poor layout and labeling of controls and displays. However, there is considerable
focus on musculoskeletal injuries as they are one of the 10 leading work-related health problems affecting
workers in the U.S. and such injuries are the leading cause of disability of people in their working years.
The cost, based on lost earnings and workers compensation, exceeds that of any single health disorder
(NIOSH, 1986). The most common source of injury and illness for lost workday cases in manufacturing
was reported to be the worker motion or position. Overexertion was the primary event causing injury
and illness across all the divisions of industry (Synergist, 1995). Injury surveillance, therefore, is an
important method to determine indicators of poor job design and the need for ergonomics intervention.
The data are also important as an effectiveness measure of interventions in an ergonomics process.
Ergonomics Process
An ergonomics process in a company commonly has components of medical management which includes
injury surveillance; worksite analysis which is active surveillance for risk factors; prevention and control
which also entails measures of effectiveness of the controls; and training and education (OSHA, 1990).
Good injury surveillance promotes prompt treatment and directs the prevention programs. The greater
the understanding of the causes of the injuries, the more proactive can be the prevention. If prevention
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measures are not taken, then the system consists only of treatment and remains reactive to the occurrences
of the workplace. Surveillance systems that are set up from only a medical standpoint can be weak on
the prevention aspect, even if there are good data. The who, what, when, and where (Garrett, 1982)
of injuries can often be captured on the accident reports and on the OSHA forms or equivalent if they
are thoroughly completed. Typically, the how and why of an injury are not well reported and are
dependent upon the quality of the accident investigation and whether it includes an ergonomics perspective.
Some caution is needed in relying upon a medical focus for improving the workplace. The workplace
system may suffer if workstation changes are in the form of accommodation or excessive tailoring on a
case by case basis, as a response to medical injuries. A balance must be kept between appropriate design
of workstations and the overall function of the system, including organizational design aspects.
Involvement of an interdisciplinary team helps to ensure the work system is addressed. Disciplines such
as professionals in safety, engineering, management, health care, industrial hygiene, and ergonomics, as
well as the operators often participate in the teams.
Responsibility has to be assigned to an individual or a group within the company to apply the results
of the surveillance data by looking at the workplace, identifying the problems and root causes, and
developing potential solutions. The process does not stop there, as interventions have to be implemented
and then followed to ensure effectiveness. It is more likely that prevention measures will not be taken
when the medical facilities are offsite, which is the case for the majority of workplaces. It is the companys
responsibility to bridge the communication gap between the company and offsite services. Assigning a
company contact person often helps in promoting communication.
Ergonomics Module of a Database System

An ergonomics module that interfaces with an injury surveillance database system has its own list of
needs to fulfill the ergonomics function. The main tasks are:
Collecting data, apart from injury data, that indicate ergonomics intervention or help with the
interpretation of injury surveillance data
Interpretation of the data, for example, prioritization methods and graphical trends or statistical
analysis of surveys
Tracking of information such as, project status, timelines, workplace changes, effectiveness, and
training
To accomplish data collection and interpretation in the context of task analyses, an ergonomics module
may also interface with technical software such as the National Institute of Occupational Safety and
Health (NIOSH) Lifting Index. Job profiles may be generated from job analyses or analyses results
added to profiles that may have been developed by another department, such as human resources. Data
that can be gathered apart from injuries include:
Turnover rates
Absenteeism rates
Productivity rates and quotas
Quality-related figures
Workers compensation costs
Job profiles or descriptions
Employees jobs record or work history
Discomfort survey results
Ergonomics audit results
Employee suggestions or reports of problems
Ergonomic analyses results
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FIGURE 24.1 A fundamental model of an injury surveillance database system and possible user groups. Listings
under People, Places, and Things are examples of database information of common interest to the users. (Adapted
from Hillman, G. 1982. ECHOES: IBMs environmental, chemical and occupational evaluation system, in Medical
Information Systems Roundtable. p. 827835. JOM 24(10) Supplement.)
A simple way to categorize most of this information is by using three groups: People, Places and
Things as illustrated in Figure 24.1. An ergonomics module would add ergonomics software tools of
choice, statistical analysis programs, analyses and survey results, and tracking systems. Specific
customization will be required to interface the desired software of an ergonomics module to an injury
surveillance database, whether that database is company developed or a commercial package. The degree
of software tailoring and the extent of the companys capabilities and resources will determine how
much would be in an ergonomics module. It may be practical to keep some components independent
such as the ergonomics tools.
24.6 Early Databases

The earliest computerized surveillance databases were purchased or developed during the 1970s primarily
by the chemicals and petroleum industry. Computer-based information systems became a necessity to
manage the data growth more effectively. Manual data systems in large corporations were hand-written
and paper-based, lacked consistency and standardization and could not adequately capture the data on
important monitoring aspects such as job history and workplace exposures (Finucane, 1982). The models
that were conceived were comprehensive and sophisticated, and many currently continue their
development (Holzner, 1993). The focus of the systems were occupational health and, at a minimum,
incorporated (Finucane, 1982):
Detailed worker and job histories and demographic data

An inventory of potential exposures and associated adverse health effects related to specific workplace location
Worksite exposure data
Employee medical information collected throughout the workers career
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These extensive models depended on effective interaction between the departments and the readily
available retrieval and analysis of the information. Wolkonsky (1982) described the following information
as necessary for a health data system at Amoco:
Employeejob history, location codes, sickness, and disability

Claimsworkers compensation payments, death certificates, internal cost reports
Medicalpersonal and family history, physical examination, laboratory results, immunizations
Industrial Hygienepersonal samples, area samples, potential exposures by location, exposure
levels
Toxicologyanimal research, materials safety data sheets
Safetyaccident data, physical conditions, supervisor data, DOT data
These early medical surveillance database systems remain but are continually up-graded and developed
as computer hardware and software change, regulations alter, and knowledge about exposures and risk
assessment models progress through research.
Challenges that Were Met

Descriptions of the early computerized systems highlighted many difficulties in establishing comprehensive
database systems. Of the large and sophisticated models being developed by the major corporations in
the country, none were the same. Those who attempted to purchase anothers system ended up making
significant modifications and customizations to fit the needs of the company (Joiner, 1982). However,
despite the individuality of the systems there were some common factors that made them successful. The
common factors of the systems were: flexibility, interaction, user friendliness, modular design, valid
databases, economy, innovation, key staff, commitment, and phased approach.
One of the first difficult decisions for the developers was whether to develop a system in-house or
buy a commercial system and modify it to the meet the companys needs. Building the system gradually
by modules was a common approach, but the modules of the database systems varied considerably
between companies. On a basic level, the modules can be summarized as People, Places, and Things
(Hillman, 1982). Deciding how much information about each area was needed and was cost effective,
and what hardware to accomplish the goal varied according to company philosophy and existing computer
experience or investments.
Early developers reported some modules as challenging to design. In particular, tracking workers was
the most complex and difficult task (Sugano, 1982; Hagstrom, 1982; Smith, 1982; Kuritz, 1982).
Centralization of information, such as personnel data, was another issue for a few companies. Despite
the large corporate size, not all systems, such as the personnel system, were consistent or centralized
across facilities (Hagstrom, 1982). Privacy and confidentiality of medical information were of general
concern and were resolved in different ways. Some companies encrypted information in case it was
routed to the wrong terminal, while others limited access and used passwords. Many of the issues and
difficulties that were met by those who developed the early medical surveillance systems are pertinent
today. Some of these issues are further addressed in the context of developing or choosing an injury
surveillance database system.
24.7 Defining the Database Model

For a company to define the model of an injury surveillance database system to be developed or purchased
requires more than a clear understanding of the goals and objectives of the system. Development of a
system must be a team effort (Wrench, 1990). The computer software professionals need to work closely
with the safety and health professionals.
An assessment of the company itself is necessary to ensure that the goals of the surveillance system
integrate with the companys needs, vision, and resources. There are common phases of development
for a computerized health surveillance program. Designing the system and defining the components are
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just one stage (Joiner, 1982). If commercial software packages are being deliberated, take particular care
to consider them in context of the overall system because the result can be a different program for each
departmental function. If later the decision is to combine the programs, it may be technically too difficult
to do so and efficiency is lost in the long run. The following program development phases are also
pertinent for defining programs to purchase:
Feasibility study
Planning and identifying potential users
Designing the system and defining components (system development and modification)
Implementing
Operating
Maintaining
Upgrading the system
Designing the System and Defining Components

The step of designing the system and defining the components requires particular comment because it is
important for determining the scope of an injury surveillance system. Deciding whether injury surveillance
should be part of a larger system or if it should be a small discrete system may not be an easy task for a
company. This step of program development is especially useful also for the decision process necessary
prior to purchasing a program.
1. Define the present injury surveillance system in the company, however manual that may be, and
critique for aspects that you wish to maintain and determine areas of improvements.
2. Define the basic components of the injury surveillance database system that you would like to
have. Keep in mind the primary goal of an injury surveillance database system; that is, determining
the who, what, where, when of employee exposure (Garrett, 1982) and using that information to
guide prevention. As a database, this may be organized conceptually as three subsets: People,
Places, Things (Hillman, 1982) (Figure 24.1).
3. Determine the functions or modules of the groups that could utilize the database and compare to
the needs of the company; e.g., an industrial hygiene function is possible but may not be needed
as a full module by the company.
4. Compare the present surveillance system in the company with the defined database model. Prioritize
the development of the modules.
5. Assess the status of computerization in the company. Allocate which modules warrant
computerization now vs. in the future. Not all aspects of a system need to be computerized. Some
aspects may not be cost effective to develop, depending on the size of the company, the number of
people using the information, and the criticality of the information to risk exposure for the
workers in the industry. However, allow for growth in both software and hardware.
Company Size
The size of a company influences the models and decisions about injury surveillance database systems.
In the past, database systems utilized mainframes and analyzed volumes of data, putting them on a scale
and at a cost prohibitive to smaller industries. With the advent of powerful personal computers (PC)
and easy networking, computerization is available to most companies. Despite the availability, many
companies have not devoted resources to developing injury surveillance database systems despite the
time-saving advantages. One possible reason is that the system is not developed in a manual form in
those companies. Basic recordkeeping that entails filling out the OSHA forms does not constitute a
simple injury surveillance system, unless there is some analysis of the data and preventive action is
taken. Another possible reason that resources have not been devoted to surveillance is that a company
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experiences so few recordable injuries that attention to injury surveillance is deemed unwarranted. A
third reason may be that improving the efficiency of surveillance is not a top priority relative to other
company improvements. It is important to remember, however, that computerization only recently has
been so available and relatively affordable.
Large Companies
Large corporations were the first to develop injury surveillance database systems. This is not surprising
for several reasons. There was a large volume of data due to the size of the company. The companies had
a number of potential exposures from chemicals and the environment, and they had the resources for
epidemiological studies.
Small and Medium Companies

Establishment sizes of 50 to 249 employees incur the highest injury incidence rates (per 100 full-time
workers). Often, less than 100 employees is considered a small company and up to 1000 employees is
medium-sized. The Small Business Administration (SBA), however, defines small as typically less than or
equal to 500 employees (Stuart-Buttle, 1996). Regardless of definition, companies of about 50 to 500
employees in size should be particularly vigilant of their injury statistics. Despite national statistics,
there will be some small companies with such low injury prevalence that a formal injury surveillance
system is not necessary (other than mandated recordkeeping).
Some of the characteristics of a small industry indicate that conducting injury surveillance may be
difficult (Stuart-Buttle, 1996). The main common characteristics are:
Less formality
Responsibility for several positions
Greater responsiveness
Less specific knowledge
More management involvement
Less data-oriented approach
However, it is precisely some of these characteristics, such as the responsibility for several positions, that
would make an investment in an injury surveillance database system such an aid. The system could
provide the benefits listed earlier and enhance an individuals and the companys efficiency.
Onsite or Offsite Medical and Surveillance Services

Only 6.3% of U.S. workplaces provide onsite medical surveillance that includes treatment and recording
of occupational injuries (BNA, 1995). These facilities are large corporations and medium-sized companies
with a sufficient number of employees or injuries or both for an onsite medical department to be costeffective. The remainder of the workplaces use offsite treatment services that may or may not track data
for the company. Usually a company employee, typically a person without medical knowledge, fulfills
the basic clerical duty of recording the OSHA logs and filling out workers compensation forms.
If the OSHA logs and accident records are the minimum data for surveillance tracking, the quality of
the information is very important if it is to be useful. The questionable quality of offsite surveillance has
been raised by NIOSH. Murthy of NIOSH suggested that physicians away from the worksite were less
likely to probe a patient about work history and often had very little occupational medicine training to
assess work-related conditions effectively (BNA, 1995). Although the company is dependent upon the
HCP for accuracy and detail of diagnosis, the designated contact person for the company can exert some
control by communicating the requirements of the company to the medical service (Stuart-Buttle, 1996).
Close communication between the medical service and company is needed for all injury cases to keep the
information accurate and up to date.
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Brewer et al. (1990) described a clinic-based occupational injury surveillance system that served
many industries. The system connected several clinics that treated employees for even minor injuries. All
injuries, regardless of whether they were compensable or recordable on the OSHA log, were recorded.
Statistical analyses were routinely conducted and results provided to the companies. The companies
learned what type of injuries were occurring, the frequency, part of the body, severity, and how the
injury was caused. Of all the cases analyzed within the system, 78.4% of the patients received care for
minor traumas which were classified as cuts or lacerations, sprains, strains, or contusions. Such analyses
showed that collecting data of first aid treatment is beneficial and that a company could reduce costs by
preventing the occurrence of minor trauma. The study by Brewer et al. also demonstrated the feasibility
of clinic-based occupational injury surveillance as a means of assisting employers with the control of
work-related conditions.
Medical screening is often used to complement environmental control measures (Baker, 1990). The
purpose of screening is to detect disorders early and implement appropriate intervention. Screening also
serves as a monitor of the effectiveness of prevention measures already instituted. Many medical screening
functions, such as auditory testing and pulmonary function screening, can be conducted and supported
by an offsite contract service. Tracking and time tabling the routine screening of employees is easily
performed by a database.
Types of Database Models

An injury surveillance database system can be developed anywhere along the continuum of simple to
sophisticated. It may be a system that is customized, commercially purchased, or contracted as an offsite
service. Whichever type of system is chosen, it is most likely to be modular. The most basic injury
surveillance database model fulfills the recordkeeping function and provides some descriptive statistics
of the data. Many PC packets provide the interface to enter the information required for the OSHA
forms, analyze the data, and produce summary graphs by department, for the month, quarter, or year
and sometimes across years. Printouts of the filled forms are also commonly available.
Beyond a recordkeeping level, the fundamental model can be represented by the three interacting
modules of Hillman (1982): Places, People, Things (Figure 24.1). This still could be kept simple: Places
includes a basic coding of the areas or jobs, possibly with a description; People includes demographics
(gender, age, date of hire, job), and health data, both evaluations and incidents; and Things includes
information files of chemicals or materials that are in the company. A small company may have very
little information in the Places and Things files. A large corporation could expand this model with
considerable databases of information under all three modules.
With this concept, potentially there may be many users of the database, depending what data is
entered in the first place. Human resources, safety, medical, industrial hygiene, ergonomics, and risk
management are some of the possible parties interested in an injury surveillance database system. Each
group interfaces with the system from its own perspective, using its own programs to extract appropriate
data, perform statistical functions and risk assessments as required, and present data in the format
desired and appropriate for the users job function. Injury surveillance is dependent upon someone
being responsible for looking at the data of the injury reports that has been entered into the system. The
responsibility may be almost any one of the users indicated, as the job function depends on the company
size and structure. Each interface of a user group is a module that could be developed as the system
evolves according to the companys needs.
Confidentiality
A database that is shared between many users raises concern about confidentiality and the need to limit
access to certain information. Systems with distinct modules for each user group typically make each
module a limited access to a defined group of people, usually by use of a password. A network can be
designed to monitor passwords and terminal identification. Medical data are particularly sensitive
24-15
information. Joyner and Pack (1982) described the Shell Oil Companys system that encrypts the data
and stores it centrally. Decryption programs were installed in the medical department to decode output
to the terminal, therefore precluding disclosure of confidential information in the event the output
inadvertently arrived at another terminal. Another technique that has been adopted to ensure
confidentiality is the scrambling of social security numbers (Hillman, 1982; Wolkonsky, 1982).
Data Entry
Many of the early large and sophisticated systems were invested with efficient methods of data entry.
For example, the Amoco occupational health system recorded a patients medical history and examination
on mark-sense forms that were computer input sheets that were entered by optical scanner. This eliminated
any possible error from transcription (Wolkonsky, 1982). Questionnaires or surveys can be efficiently
collected in a similar way. An overall benefit of a database, however, is the reduced re-entry of data.
Personnel data, in particular, is typically entered many times if there is no network to a personnel
database.
Computerization
There are many commercial software programs which can suit a variety of companies. (See For Further
Information for software directories.) However, some industries choose to develop their own injury
surveillance database system. The level of computerization that already exists in the company influences
the choice of a customized program. Often there are many programs that already exist in a company, for
example, production and quality control systems, payroll, accounting, and maintenance department
systems. With the increase of computers in the workplace many companies have invested in management
information system (MIS) departments to develop and maintain the hardware and software. Older
systems were originally written for mainframes and minicomputers, and most newer systems are written
for PCs. If an additional system is intended to be added to a network, it is sometimes easier to develop
it rather than purchase a program that may be difficult to make compatible and to support in the future.
The compatibility of commercial software to an existing system is influenced by the age of the system
and to what extent the software language has been updated. Therefore, companies with relatively new
computer systems are more likely to be able to take advantage of the large commercial market, tailor the
packages with fewer technical problems, and support the systems with in-house personnel. Considering
the available choices of sophisticated programs, purchase of a system can save considerable design and
development costs. The choice of system also depends upon the level of computer skill of the users or
resources of the company. The Centers for Disease Control and Prevention (CDC) developed Epi
Info, a series of public-domain PC software programs in IBM-compatible format (DOS) for word
processing, database, and statistics work in public health. (See For Further Information.) The programs
are designed to be easily modified to meet company needs but still require some computer knowledge,
especially since many computer users are only familiar with the Microsoft Windows operating system.
In addition, before modifying the program, the user must clearly define the functions desired of Epi Info
which requires knowledge of injury surveillance. Despite being in the public domain and having excellent
technical support, the programs may not be compatible with some companies.
Not every company has extensive computerization or a network. Some may have computerization
but choose to have an independent safety and health system. As stated above, the majority of workplaces
do not have onsite medical services or extensive exposure issues, so the companys needs are primarily to
track and analyze first aid logs, OSHA logs, and accident-related records. Job descriptions would be
beneficial for injury analysis, but, as previously discussed, they can be difficult to maintain for some
industries. Many commercial software programs are available that provide a recordkeeping function
with OSHA log entry and analysis. (See For Further Information.) There are several safety or industrial
hygiene functions that could be efficient to computerize depending on the company size, and for which
there is available software, for example, maintaining Material Safety Data Sheets (MSDS), tracking PPE,
and tracking employee training (Johnson, 1996).
24-16
An expanding area of computers is internet capability. The internet provides a source of information
for data such as MSDSs, as well as updates on regulations. As more professional associations have
representation on the world wide web, the internet may serve to help resolve technical questions.
24.8 Statistical Treatment of Data

A computer can perform sophisticated data analyses only if specifically instructed to do so. A good
understanding of statistical methods is required to develop a data analysis program, and if necessary, a
statistician should be consulted. There are commercial statistical packages that may be interfaced with a
database system, and some of the packages guide a user in interpreting data. There is potential for a vast
array of analyses of the data in an injury surveillance database, depending on the extent and sophistication
of the overall system. For example, if there is a focus on industrial hygiene issues, numerous calculations
may be required to interpret data from workplace monitoring. The safety and health professional needs
some knowledge of statistics to interpret data beyond the OSHA logs. The commercial software market
is rapidly responding to demand by producing programs specifically for industrial hygienists, such as
those that assist with industrial hygiene formulae (Cameron, 1996). There are other programs on the
market designed to meet the technical needs of the ergonomist and safety professional.
The majority of workplaces are small businesses in which those responsible for safety and health
often do not have a background in statistics. In addition, they may not know what to look for in the
basic data collected from OSHA logs and accident records. Some fundamental information is, what
volume and type of injuries are occurring, to which parts of the body, while performing which jobs or
tasks. Most of these questions can be answered by descriptive statistics. The commercial market offers
many programs that focus on OSHA recordkeeping and provide basic data analysis with graphic output.
After careful assessment of these programs there is likely to be a software package that meets the companys
needs. However, even more useful information can be obtained if data collection and analysis extend
beyond the minimum requirements for compliance. The following are a few points that will help to
make the data more useful. The points may also help when assessing software programs.
Convert the number of injuries into an incidence rate as described in OSHAs recordkeeping
guideline (BLS, 1986). This provides a figure that has a common denominator with other companies
and national statistics. The national injury incidence rate calculated by the Bureau of Labor
Statistics (BLS) or the rate for the companys Standard Industrial Classification (SIC) code can
serve as benchmarks for the company. Incidence rate can be calculated for groups of types of
injuries and also for departments. Direct comparison between departments can be made when
the numbers are expressed as incidence rates.
The number of lost workdays is usually considered an indication of severity of the injury. An
incident rate can also be calculated for the lost workdays. At times a given incidence may be so
severe that it accounts for most of the recorded lost workdays. In such situations the incidence
rate should be calculated with and without that particular case. The proposed recordkeeping
revision does not require the number of restricted days to be recorded, however, a company may
find it useful to record them (OSHA, 1996). When injuries begin to be detected early and undergo
conservative treatment, then lost workdays are less likely. However, an increase in restricted
workdays is more probable. Recording the restricted workdays provides some measure of progress,
especially if the number of restricted workdays are then improved.
Record the side of the body that was injured. This is not often recorded yet it can be useful to
know. If the information is related to a record of the employees dominant hand a useful picture
of the stresses and injuries at the job begin to be built, which helps with job analyses and prevention
strategies.
Look at the incidence rate by age, gender, length of time on the job, and whether the employees
are full-time or part-time. All of these analyses will help to determine if a certain group is susceptible.
Those who are very new on the job are typically suffering from lack of conditioning. If this is
24-17
found to be the case, strategies can be implemented to gradually introduce the worker to the job.
For example, orientation sessions could be scheduled throughout the first week rather than in the
first couple of days.
Look at the injury rate by supervisor or line leader if these are different groupings from the
department or area. This can be very useful in determining if a certain team has a problem and
suggests there may be some administrative issues to investigate. Similarly, data should be compared
between shifts. Often any differences are related to management.
Incorporate workers compensation costs into the database and determine the mean for type of
injury and cause and for each area or job. This helps with cost benefit analyses and prioritizing
areas to be improved. Sometimes the incidence rate in a plant has increased, but the workers
compensation costs decreased. This may indicate that more people are reporting before the
condition is severe and more expensive to treat.
Track the work status of all those injured, whether they are off work on workers compensation
or on work restrictions. Develop a list on a regular basis, such as once a week, to ensure that each
case is kept up to date and progressed toward full return to work, preferably at the previous job.
It is not unusual for an employee to fall between the cracks and be on workers compensation
for a period of time without any functional change or decision about the case.
Identify the causes and mechanisms of injuries based on the accident record, and in particular,
relate the findings to the areas of high incidence rates.
Look at the data to see if there are patterns according to time of day, days of the week, the month,
quarter, or year. Compare across the years as well.
If possible, collect first aid data as well as the data mandated by OSHA. Treating minor cuts and
bruises takes time and there can also be an associated loss of productivity. If this information is
collected and analyzed similar to the logs, there may be some useful emerging patterns that can
help with identifying the causes and lead to prevention measures. Examples of common problems
are blunt tools that cause the user to slip, or inadequate clearance around equipment that provokes
bruising.
More sophisticated analyses can be conducted on data from OSHA forms. However, some understanding
of statistics is needed to make use of such features in a software program, even if the interface is user
friendly. A larger company may benefit from a data analysis that indicates when the occurrence of
injuries is out of control relative to a determined baseline. Boyd (1988) presented one approach based
on injury costs per exposure hour. Goldberg, (1993) describes an injury surveillance database with some
useful, advanced analysis features. A description of some of these features follows.
Actual exposure hours were collected from payroll to calculate the incidence rate. This allowed
for a better picture of incidence rate related to overtime hours, especially since overtime was
inconsistent and potentially a reason for increased injuries.
Regression analysis helped determine the factors leading to lost and restricted workdays. The
software interface displayed a list of independent variables and interactions from which to choose.
For example, the number of restricted workdays could be looked at by gender, age, and length of
employment. Regression analysis could also be used to predict the number of expected lost or
restricted workdays for an injured employee, and this helped management plan for the situation.
Time series modeling provided insight as to whether there were certain periods of higher incidence
rates. Accidents are sometimes based on cyclical seasonal weather change, employment
relationships, or perhaps rapid expansion.
A forecasting feature smoothed the data to remove known cyclical fluctuations and provided
indication of the data trend, whether the incidence rate was increasing or decreasing.
Inclusion of cost and billing information was used to generate cost/benefit analyses.
24-18
Report Generation
Except for mandated government forms, reports are primarily for company use, (e.g., OSHA forms).
The reports are not generally required for scientific presentations but rather analysis and communication.
Two levels of reports are needed: one for the professional to explore and interpret the data, and another
that summarizes the findings for presentation to management. The system needs to be flexible enough
such that a summary report can be focused on specific findings.
The maxim pictures speak a thousand words is true when it comes to concise presentation. Good
graphic presentation straight from the software program saves considerable time, especially when the
alternative is transporting the data to another program. However, it is possible to set up standard links
to a program that produces charts and graphs, so that graphs can be routinely produced.
24.9 Choosing a Commercial Injury Surveillance Database

One size does not fit all when it comes to setting up an injury surveillance database system (Wrench,
1990). If a commercial program is purchased, it will require professional tailoring to fit the needs of the
company. For example, along with social security numbers, company identification numbers are commonly
used for personnel tracking, yet every company has a different numbering system which requires
modification of that data field. Likewise, the job coding system is different in every company.
Involve the employees as much as possible in decisions about a database. The employees know the
information needed for their jobs and can contribute significantly to the needs assessment and system
design and to evaluating existing programs. In addition, the success of a system is dependent upon their
acceptance of it.
The following are some aspects to consider when choosing a commercial software program (Menzel,
1994).
Evaluating needs and resources
Identify data management goals and objectives.

Define requirements. (This may be accomplished by mapping out the existing manual system.)
Include anticipated growth and potential new functions.
Define company constraints, such as type of hardware system, technical equipment, and the
characteristics of other company databases.
Assess company resources (personnel, budget, hardware, and software).
Develop a list of criteria, based on the needs and resources evaluation, by which to assess the
software programs. There may not be a program that satisfies each criterion so developing a
spreadsheet can be useful for deciding the trade-offs for a final selection. A scoring system could
also be used to determine several final contenders.
Finding the software
Use directories that may be available through professional safety and health associations (see For
Further Information).
Research articles on software in safety and health magazines.
Respond to software advertisements in occupational safety and health magazines.
Ask colleagues about the software they use and their experience with it.
Request demonstration disks and onsite demonstrations.
Evaluating the software
Assess the basic features of the programs against the criteria. This will narrow the selection for
more critical view.
Evaluate for qualities such as:
ease of use
provision of high quality, onsite training
24-19
variety and quality of reports

ability to transfer data from other programs
potential degree of customization
presence of security systems to safeguard confidentiality and data integrity
reasonable initial and continuing cost
Select a few final contenders based on the extent to which criteria are satisfied.
With program specifications attached to the proposal, request price proposals with details of
features, service, and renewal fees.
Request names of current users that can be contacted.
Assess the responsiveness and quality of the support available.
Review the length of time each company has been in operation.
Assess their financial stability and long-term viability. (This is not easy but the number of clients
being supported may give an indication.)
Selecting the vendor
Negotiate the price

Negotiate the extent of customization and support
Negotiate for additional features such as training
Evaluating the effectiveness
Ensure that the program is thoroughly reviewed before the first anniversary (when maintenance
fees usually begin).
If necessary, negotiate for modifications before paying maintenance fees.
When implementing computerization of a system ensure that parallel systems are run for at least a
month after full installation, even if the computerized system is off-the-shelf (Bonnett, 1982). The accuracy
of the system must be checked before abandoning the old methods. If there are software modifications
or connections made to an existing network, it is better to assure that the system is running smoothly
before relying upon it. New hardware should be tried also before being relied upon.
24.10 Summary
The cost benefits of injury surveillance database systems are becoming more apparent since there has
been greater focus on accurate recordkeeping, and as computerization has become more affordable.
There are several benefits including standardized and accurate recordkeeping, time saving and efficient
data entry and analysis, enhanced tracking abilities, and effective guidance to prevention strategies.
Considerable and careful thought should be given by a company to the design of the injury surveillance
database system. The design is dependent upon the companys needs, size, constraints, potential growth,
and resources. An assessment of the companys needs prevents a quick purchase of a commercial system
that might not have the growth potential, adequate support and customization services to make the
program a successful addition to the company.
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Brewer, R.D., Oleske, D.M., Hahn, J., and Leibold, M. 1990. A model for occupational injury surveillance
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25
OSHA Recordkeeping
Stephen J.Morrissey
Oregon OSHA Consultative Services
25.1
25.2
25.3
25.4
25.5
25.6
25.7
25.8
25.9
25.10
25.11
Introduction
Who Must Keep Records
Which Employers Do Not Have to Keep Records
What is An Employer? An Employee?
What Records Have to be Kept, Should be Kept?
Posting Requirements
Essential Definitions and Concepts for Recordkeeping
Recording Data on OSHA Forms
Proposed Changes in OSHA Recordkeeping
Specific Changes in Recordkeeping Requirements
Summary and Conclusions
251
252
252
253
254
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255
257
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258
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25.1 Introduction
The history of occupational safety has been recorded as progress primarily initiated by injury, loss, and
disaster. Despite many well-meaning efforts at controlling the human and social-economic losses in the
workplace, it was not until the passage of the Occupational Safety and Health Act of 1970 that a
comprehensive, integrated safety and health program at the national level was present in the United
States. The OSHA Act, while safety and health oriented, has clear social and economic goals in its basic
philosophy as reflected in the enabling legislation which in part states that the purpose of the Act was
to assure so far as possible every working man and woman in the Nation safe and healthful working
conditions and to preserve our human resources.
Over the years the regulatory aspects of OSHA have become more complicated and widespread with
changing industries and job demands, public pressures for changes in safety law, and as the work
environments have become better understood. This increased regulatory presence has not been without
industry complaint. However, since OSHA has been in existence there have been clear drops in the
numbers of workers injured, killed, and suffering adverse health effects, all of which translate into lower
costs of doing business (Gray and Scholz, 1993; U.S. Department of Labor, 1995, 1997).
Fundamental to the effective control of job-related injuries and illnesses has been the development of
a comprehensive safety and health recordkeeping standard. The Occupational Safety and Health Act of
1970 gave OSHA the authority to develop such a program, and in 1971 the occupational injury and
illness recordkeeping regulations, 29 CFR Part 1904, were published. These regulations set comprehensive
and mandatory requirements for reporting job-related injuries and illnesses. The basic goals of OSHA
recordkeeping are to establish the risks present in the work environment; to direct employer attention to
tasks and areas that need attention or which have unacceptable injury-illness levels; and to help guide
research and enforcement activities to better serve industry and the employee.
0-8493-1800-9/03/$0.00+$1.50
25-1
25-2
However, despite the breadth and detail of these recordkeeping goals, the overall recordkeeping
requirements have been kept limited to reduce the burden on employers and to help safety and health
professionals identify and then respond to high-risk industries and workplaces. Over the years, OSHA
has set forth and enforced the recordkeeping regulations. The Bureau of Labor Statistics (BLS) has
prepared survey and recordkeeping forms and information and conducted the Annual Survey of
Occupational Injuries and Illnesses. Information from this survey is used by OSHA to identify industries
with high injury rates. In 1990, the duties performed by the BLS were transferred to OSHA.
This chapter will discuss the basics of occupational safety and health recordkeeping as mandated by
OSHA. It will not discuss the parallel systems used by workers compensation systems, as these systems
differ widely by state and many major changes in compensation systems are being undertaken or planned.
There are also major changes proposed in the actual mechanics of OSHA recordkeeping and in definitions
of critical factors that are used to record data. At the time of writing, only preliminary proposals have
been presented for these changes, and these proposed changes in recordkeeping will be identified and
discussed later in this paper. To obtain the most current information, the interested reader is encouraged
to contact his or her local or regional OSHA office or access the OSHA world wide web site at: http://
www.osha.gov or http://www.osha-slc.gov.
25.2 Who Must Keep Records

Compliance with OSHA recordkeeping is required of private sector employers in the 50 States, the
District of Columbia, Puerto Rico, the Virgin Islands, American Samoa, Guam, and the Trust Territories
of the Pacific Islands. In general, employers who employed at least 11 or more employees at any time in
the previous calendar year must comply with OSHA recordkeeping regulations. If employers have more
than one establishment or place of business, it is the combined total number of employees at all places of
work that is considered in determining the number of employees in the previous calendar year. If this
number is 11 or more at any time in the previous calendar year, then the company must comply with
OSHA recordkeeping requirements, and records must be kept at each individual place of employment.
Employers with fewer than 11 employees at any one time in the previous calendar year are generally
exempt from recordkeeping, as are the self-employed, partners with no employees, those that employ
domestic help in their private residences, and employers engaged in religious activities, services, or rites.
However, on occasion, the Bureau of Labor Statistics (BLS) will require companies with fewer than 11
employees or in other generally noncovered occupations to keep records in order to develop more
accurate hazard data for their Annual Survey of Occupational Injuries and Illnesses.
Employers who are required to keep records must do so at each of their establishments, regardless of
the number of employees at the site, but they do not have to keep records for employees of other firms,
independent contractors, or companies temporarily present on the worksite. If an injury or illness occurs
to the employees of the other firms on the worksite, these injuries or illnesses must be recorded on the
records of the company for which the injured employee works, or that of the company which has the
most immediate control and supervision of work activities. Thus, if the employer is using temporary or
leased workers, and has immediate control of their day-to-day work activities, then the employer must
record any injuries or illness on the employers own records. Employers must also present copies of the
OSHA 200 and 101 upon request of OSHA inspectors and may, under the direction of other codes, have
to provide these data to employees or their legal representatives.
25.3 Which Employers Do Not Have to Keep Records

Despite the apparent simplicity of the recordkeeping rule of 11 or more employees, not all industries or
occupations are required to follow OSHA recordkeeping requirements. Most manufacturing, agricultural,
construction, and service industries are required to keep records if they have the required number of
employees. However, OSHA recordkeeping is generally not required for employers in what are considered
OSHA Recordkeeping
25-3
low-risk occupations. These low-risk industries or occupations include the retail trade, finance, insurance,
real estate, and various service industries in the Standard Industrial Codes (SIC) 5289. However, there
are some employers within this group who must follow recordkeeping regulations. These covered
industries are building materials and garden supplies, SIC 52; general merchandise and food stores, SIC
53 and 54; hotels and other lodging places, SIC 70; repair services, SIC 75 and 76; amusement and
recreation services, SIC 79; and health services, SIC 80. Also exempt from recordkeeping requirements
are those industries which have an average lost workdays cases injury rate over a three-year recording
period that is at or below 75% of the U.S. private sector injury rate. Even though these industries are
exempt from general federal recordkeeping requirements, they may be subject to state recordkeeping
requirements, must comply with all other safety and health requirements set by OSHA, and as noted
above, may be required by the BLS to participate in special studies to establish injury and illness rates.
Employers who do not have to keep formal OSHA records either because of the number of employees
or by virtue of their SIC code still must meet reporting and recordkeeping requirements in the event of
the death of an employee or if multiple employees are hospitalized as a result of a work-related incident
or exposure. Basically these requirements are to notify the local OSHA office within eight hours in the
event of an employee death or within eight hours in the event of an incident that results in the
hospitalization of three or more individuals.
Employers who are subject to other federal government safety and health regulations must also comply
with basic OSHA recordkeeping requirements. However, these employers can use modified reporting forms
as long as they are equivalent to the required OSHA 200 and 101 forms discussed later in this paper.
Churches or other religious organizations or their affiliated operations do not have to comply with
recordkeeping requirements for those individuals who perform religious rites or activities. However, churches
or other religious organizations must comply with OSHA recordkeeping requirements for those individuals
not engaged in performance of religious rites or activities. In some cases, volunteers who are not clergy or
direct participants in religious services, may be covered by recordkeeping requirements.
Charitable and non-profit organizations, if they meet the number of employees criteria, must comply
with recordkeeping requirements.
More detailed information on specific employers, industries, and SIC codes that are required to keep
records, and to what extent, is available in the two primary documents on recordkeeping (U.S. Department
of Labor, 1986 a,b).
It must be noted again that this discussion applies only to OSHA mandated recordkeeping. Recordkeeping requirements mandated by insurance or workers compensation laws are often separate and
different from those of OSHA, and employers should consult with their own state to determine applicable
laws and codes.
25.4 What is An Employer? An Employee?

A critical aspect of recordkeeping is the determination of who is an employer, an employee, or what is a
place of employment. In Section 3(5) of the Act, an employer is defined as a person or persons
engaged in business that directly or indirectly affects commerce and has one or more employees and who
is not the United States or any State or political subdivision of a State.
An employee is any individual who receives compensation of any form from the employer for services.
This also applies to part-time, temporary workers or leased workers or employees. Volunteers are exempt
from recordkeeping if they serve of their own free will and do not receive any compensation for their
efforts. Temporary workers are a particular issue these days as more and more employers use them to fill
staffing needs. Despite common views, work-related injuries and illness experienced by temporary
employees are reported on the records of the employer who has the most immediate supervision, direction,
or control of them. This is almost always the employer who is using the temporary worker. Eventual
liability for any citable violations of safety and health codes may, however, be distributed between both
the immediate employer and the temporary worker supplier.
25-4
There are many more highly specific questions that can be raised that relate to the role and definitions
of an employer and employee, and many of these are discussed in the recordkeeping reference, Recordkeeping Guidelines for Occupational Injuries and Illnesses (U.S. Department of Labor, 1986b). These
documents are available from the U.S. Government Printing Office, local and regional OSHA offices,
and from OSHAs world wide web sites (http://www.osha.gov; http://www.osha-slc.gov).
A place of employment is any location at which services or industrial operations are performed or
where employees report to work, work at, or where they are paid. Records have to be kept for each
individual workplace.
25.5 What Records Have to be Kept, Should be Kept?

While the regulatory coverage under OSHA is extensive and sometimes complicated, the recordkeeping
is relatively simple, with only two forms required. These two forms are:
OSHA 200: Log and Summary of Occupational Injuries and Illnesses: The OSHA 200 form is
widely available and will not be reproduced here because of its large size (11 inches by 17 inches). The
OSHA 200 is used to record and classify all recordable injuries and illness and contains three basic
sections. Section I records information on the date of the injury, who was injured, how, and where
(Columns A-F). Section II records the nature and severity of the injury/illness, how much time was lost,
and whether the injury resulted in a fatality (Columns 16). The third section (Columns 713) contains
information on occupational illnesses experienced by the employee. Section 7 has seven subsections (a
to g) that further define the nature of the occupational illness.
Data for any injury or illness must be filled in within six days after the incident is discovered and, in
the case of a fatality or multiple hospitalizations (three or more workers), the local OSHA office must be
notified within eight hours. At the end of each calendar year, the data on this form are totaled at the
bottom, signed, and dated. The summary sections describing overall lost workdays (Columns 16) must
be posted in a conspicuous location at each work location for the entire month of February in the
following calendar year. The completed forms must be kept at each work location for the next five
calendar years, even if an establishment changes owners. If, in years subsequent to the one in which an
injury or illness is recorded, there need to be changes in a recorded entry based on new information, then
the original entry must be lined out (not erased) and a corrected entry made. If errors in recording are
discovered, or if unreported cases are identified, these need to be entered.
Conversely, if it is later found that an entry is a nonreportable entry, it should be lined out but not
erased. While only recordable injuries have to be entered on the OSHA 200, many companies enter all
injuries and illnesses on the form to help identification, understanding, and control of hazards that may
be present in the workplace.
OSHA 101, Supplemental Record of Occupational Injuries and Illnesses: For every recordable event
entered on the OSHA 200 log, it is necessary to record additional information on the OSHA 101 form or
its equivalent. This form gives additional information that describes how the accident or illness occurred,
the work processes involved, substances or exposures present, and more detail on the worker and the exact
nature of the injuries or illnesses experienced. This form is also commonly used by workers compensation
carriers and various state organizations for filing and evaluating claims. In general, entries on the OSHA
101 must be completed within six working days of the date the employer received information on the
event. A major problem with the OSHA 101 and 200 forms is that the data from these forms are not
always properly interrelated, or even related to information describing the actual accident. This lack of
correspondence can complicate or slow down understanding and control or elimination of hazards.
25.6 Posting Requirements

Employers who are required to keep records must keep OSHA 101 and 200 forms for each physical
location where work is performed. If an employer has multiple locations, then separate sets of records
OSHA Recordkeeping
25-5
must be kept for each distinct location. Further, if within a physical work location distinctly different or
separate activities are performed, separate records must be kept for each area. As noted earlier, the
OSHA 200 must be summarized and posted for the entire month of February in a place that is used by
all employees.
Failure to keep proper records can lead to substantial fines from OSHA. Over the past few years,
some recordkeeping penalties have approached a million dollars, so the consequences can be substantial
from a regulatory aspect. The more real penalties that occur from improper recordkeeping are the loss
of control of the economics of production. Studies have found that companies that keep good records
have good safety and health programs, lower overall production costs, and higher profitability (Gray
and Scholz, 1993). The changes in OSHA regulations proposed at the time of the writing of this chapter
all support a reduction in penalties or enforcement schedules for companies that have a well-developed
safety and health program. OSHA considers careful recordkeeping and tracking of progress made in
addressing accidents, injuries, and illness as the cornerstone of any such program.
25.7 Essential Definitions and Concepts for Recordkeeping

Recordable Injury/Illness: By OSHA definition, a recordable event is any work-related death and
illness, and those work-related injuries which result in: Loss of consciousness, restriction of work or
motion, transfer to another job, or require medical treatment beyond first aid. (U.S. Department of
Labor, 1986a). It is important to understand that a case being recordable does not necessarily mean that
the employer is at fault, has violated any OSHA standards, that the worker is at fault, or that any
injuries are of a compensable nature. Recording an event only means that the consequences to the
worker meet the legal definitions for being recorded. Once a case is determined to be recordable, it must
be recorded in the correct columns on the OSHA 200 and 101 forms or their equivalent.
Other tests to define the recordability of an injury or illness are that an injury or illness is recordable if
it results in any of the following: (1) the inability of the worker to perform all parts of the normal work
assignments with the same ability as before the incident; (2) transfer of the worker, even temporarily to
another job; (3) physical damage to the structures of the body, such as fractures, cuts requiring stitches,
burns and bruises requiring repeated visits to a health care provider, and continuing infections; (4) loss of
consciousness; or (5) an illness or injury that requires treatment by licensed medical personnel or physicians.
Work Related: An injury or illness is considered to be work-related if it resulted from a single or
cumulative exposure or event in the work environment. The work environment is the immediate workplace and any and all locations where employees are engaged in work-related activities, or have to be
present at, as part of their normal work activities. When workers normally have to travel between
different worksites as part of work or to perform a work duty, the transportation may also be considered
as a work activity, and injuries that occur during this transportation may be recordable. With many
types of injuries and illnesses, determination of work-relatedness can be complicated, and the interested
reader is referred to either of the documents on recordkeeping (U.S. Department of Labor, 1986 a,b) for
more detailed information. Determination of work-relatedness is usually easier for injuries than for
illnesses, particularly for those illnesses whose symptoms only appear after long exposures or long
latency periods after a critical exposure.
First Aid: With respect to OSHA, first aid is any one-time treatment, and any follow up visit for
the purpose of observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily
require medical care. Such one-time treatment and follow up visits are considered as first aid, even
though provided by a physician or registered professional personnel.
The critical distinction between medical treatment (a recordable case) and first aid treatment (a
nonrecordable case) depends not only on what treatment is provided but also on the severity of the
injury involved. A brief listing of different types of injuries and whether they classify as being first aid or
as medical treatment is presented as Table 25.1 and further discussion of the recordability of injuries and
illnesses is given in the two basic documents on recordkeeping (U.S. Department of Labor, 1986 a,b).
25-6
TABLE 25.1 Determining an Injurys Recordability
Injury: Is any injury or disorder such as a cut, fracture, sprain/strain, etc, that results from a work
accident or from a single, instantaneous exposure to the work environment. This includes exposures to
all work processes, insects, animals, and chemical or toxic agents.
Illness: Is any abnormal condition or disorder other than an injury that is a consequence of exposure
to environmental factors related to work and the work environment. This includes cumulative, acute
and chronic illness or diseases resulting from any exposure to agents in the work environment by
inhalation, absorption, ingestion, direct contact, or direct exposure. There are seven different categories
of occupational illness which are recorded on the OSHA 200 form. These illness categories are:
Occupational skin diseases or disorders; dust disease of the lungs; respiratory conditions due to toxic
agents; poisoning (systematic effects of toxic materials); disorders due to physical agents other than
toxic materials; disorders associated with repeated trauma (noise-induced hearing loss, vibration-related
OSHA Recordkeeping
25-7
injuries such as Raynauds phenomenon, and other conditions arising from repetitive motion such as
bursitis, synovitis, tenosynovitis); and, all other occupational illnesses.
Criteria to identify and evaluate the work-relatedness of injuries or illnesses related to repeated trauma
(cumulative trauma), such as tendinitis, synovitis, bursitis, back injuries, and carpal tunnel syndrome,
are more fully developed in the Ergonomics Program Management Guidelines for Meatpacking Plants
(U.S. Department of Labor, 1993). This document, which is available on OSHAs world wide web
servers or from OSHA centers, describes the stages in developing an ergonomics program to reduce the
losses associated with ergonomics injuries.
Restricted Work or Motion: A work or motion restriction occurs when, as a consequence of a workrelated injury or illness, the employee cannot perform any part of, or all of, the normal job assignments
during any part of, or all of, a workday or workshift. The common practice of having someone move to
another job for a while to rest up thus constitutes a work restriction and requires the accident or illness
to be recorded. The key point to understand is that if, as a consequence of a work-related accident, the
employee cannot do the same job or work assignments at the same rate as before the accident, then the
accident is recordable.
25.8 Recording Data on OSHA Forms

Once an injury or illness is determined to be recordable it must be evaluated to determine its type and
outcomes. There are three types of recordable cases: Fatalities; accidents resulting in lost workdays; and
cases that are recordable but do not result in lost workdays. Each case must be entered into the correct
columns on the OSHA 200 form.
For fatalities, the entry is obvious, but determination of what is to be entered for lost workdays can
be more complicated. Lost workdays occur either because the worker could not be at work due to the
injury or illness, was unable to perform the normal job duties for a period of time, or the worker was
assigned to another job until he or she recovered (light duty, modified duty, restricted work). In all cases,
the total number of days to be recorded is the total number of days that worker was not present due to
the injury or illness not including the initial day of injury/illness, or any days that the worker would not
have normally worked (holidays, weekends, special days off, vacations) as a result of the injury or
illness. If the workers injury extends into another year, the amount of time that will be lost in the next
year must be estimated and entered for the year in which the injury occurred.
Once the total number of days missed is correctly entered, it becomes important to properly and fully
detail the remainder of the OSHA 200 and 101 to facilitate tracking of problems in the workplace as well
as to meet recordkeeping requirements. While the various columns on the OSHA 200 form are selfevident, a common error is to incorrectly or too briefly describe the events that led to the accident. As
much as possible, the physical location where an accident occurred (loading dock station 3; not receiving),
actual job title of the individual involved in the accident (assistant press operator, machine #3; not machine
operator), and a clear description of the injury (laceration to top of left hand; not cut hand) should be
included on the 200 form to facilitate tracking of accidents, injuries, illnesses, and losses.
Data Developed From OSHA 200 Form: There are several statistics that are developed from the
OSHA 200 form to describe the relative and absolute injury and illness experience for a particular
facility, company, or industry. These data are used by OSHA to direct inspections and research and by
insurance providers in rate setting.
All OSHA statistics are based on an Incidence Rate statistic (Equation 25.1) that is the number of
injuries, illness, or lost workdays normalized to reflect a worksite with 100 full-time employees. As all
employers who must comply with OSHA must use the same basic criteria for recordkeeping, this allows
direct comparison of individual company loss experience with respect to the respective industry or
region, across time, or even within a company. The statistic that is most commonly used by OSHA to
direct inspections, define research needs and also by insurers to set and adjust rates is the Lost Workdays
Case Incident Rate (LWDCIR). The LWDCIR is calculated by entering the appropriate date into the
following equation:
25-8

(25.1)
where
N
HW
= total number of recordable injuries, illnesses, or lost workdays (sum of Columns 2 and 9)
= total number of hours worked by all full-time and part-time employees during the
previous calendar year as derived from payroll data
200,000 = the normalizing factor to correct data to a 100 full-time employee workforce that works
40 hours a week, 50 weeks a year
25.9 Proposed Changes in OSHA Recordkeeping

Over the past 10 years, numerous criticisms have been leveled against OSHAs recordkeeping requirements
by industry, government, and academic policy and study groups. Some of the most common criticisms
included that the current system was too complicated, particularly with respect to definition of injury
and illness classifications; that the current system encouraged under-reporting or misreporting of injuries
and illnesses; tracking of changes in the system was hard to follow; difficulty of the forms to facilitate
good accident investigation; and, the difficulty of establishing work-relatedness of injuries and illnesses.
In February of 1996, OSHA published its proposed modifications to recordkeeping, 29 CFR Parts
1904 and 1952: Occupational Injury and Illness Recording and Reporting Requirements; Proposed
Rule for comment in the February 2, 1996, Federal Register. This proposal, which will be debated and
discussed for the next year or so, involves major changes in several aspects of recordkeeping. Important
definitions and criteria that are being proposed for change are briefly described in the following paragraphs.
In addition to changed definitions, the recording forms would be changed to the OSHA 300 (replacing
the OSHA 200) and the OSHA 301 (replacing the OSHA 101). These proposed forms (from the Federal
Register of February 2, 1996) are shown as Figures 25.1 and 25.2. Bearing in mind that this legislation
is being discussed and changed at the time of publication of this book, the interested reader should
consult the Federal Register or a local OSHA office for more information.
OSHA 300 and 301 Forms: The new OSHA 300 form (Figure 25.1) is designed to fit on standard 8
inch by 11 inch paper and is significantly streamlined in definitions and instructions for use as well as
providing a column for the employers use. Some of these improvements are described in the following
sections and are designed to make recordkeeping easier and more consistent. The use of computerized
equivalents is specifically allowed in the proposed regulations to increase speed and accuracy of recordkeeping
as well as to facilitate better database manipulation and study. Similarly, the OSHA 301 (Figure 25.2), has
been redesigned to facilitate ease and consistency of data entry and linking to other reports.
25.10 Specific Changes in Recordkeeping Requirements

All employers must maintain an OSHA 300 log or its equivalent at each establishment. Employers with
multiple establishments may maintain a consolidated log for establishments with no more than 20
employees. Recordable injuries or illness must be recorded within seven calendar days of receiving
information that a recordable injury or illness has occurred. The employer will also maintain an Injury
and Illness Incidence Record, OSHA 301 or its equivalent, and it must be updated within seven calendar
days of receiving information that a recordable injury or illness has occurred.
Before the end of January of each calendar year, the employer will post a year-end summary of all
occupational injuries and illness for each establishment for the previous year. This form will remain
posted for the entire year and be updated as new information is determined. This form must be signed
by a responsible company official indicating that they have examined the summary log and that the
year-end summary is true, accurate, and complete. Records must be kept for three years following the
calendar year they represent rather than the current five-year period. During this retention period, the
OSHA 300 and 301 must be updated if new information is discovered.
FIGURE 25.1 Proposed OSHA 300 form that will replace OSHA 200. (From Federal Register, Friday, February 2, 1996; 29 CFR Parts
1904 and 1952: Occupational Injury and Illness Recording and Reporting Requirements; Proposed Rule; pages 40304067.)
OSHA Recordkeeping
25-9
FIGURE 25.2 Proposed OSHA 301 form that will replace OSHA 101. (From Federal Register, Friday, February 2, 1996; 29 CFR Parts
1904 and 1952: Occupational Injury and Illness Recording and Reporting Requirements; Proposed Rule; pages 40304067.)
25-10
OSHA Recordkeeping
25-11
If an establishment changes hands, the new owners are responsible for recording only those injuries
and illnesses that occur after the purchase date. They still have to keep the previous owners records for
the required period of time.
Access to Records: The employer must, upon request by a government representative, provide copies
of OSHA Forms 300 and 301 or their legal equivalents, year-end summaries for their own employees,
and injury and illness records for subcontractor employees. When the request for records is in person,
the information must be provided in hard copy within four hours. If the request is in writing, the
information must be made available within 21 days unless requested otherwise.
Upon request, employees, former employees, and/or their representatives may see the OSHA 300 and
301 forms or their legal equivalents. These forms must be made available for viewing by the close of
business on the next scheduled workday. An individual or his or her representative may also request to
see the OSHA 301 form for his or her own injury or illness.
Days Away from Work (Lost Workdays): is defined as the total number of days the employee could
have worked but did not because of the injury/illness. These days do not include the day the worker was
injured or days the employee would not have normally worked because of holidays or weekends. The
maximum number of days away from work will be entered as 180 or 180+ in the days lost column.
For injuries that last into the next calendar year, the number of days lost should be estimated and
entered into the days lost column for the year in which the injury/illness occurred. The 180 or 180+ days
lost limits still apply.
Employee: an employee is any full-time, part-time, temporary, leased, limited service, independent
contractor subject to day-to-day supervision, and those corporate officials who receive compensation
of any form. Day-to-day supervision is defined as specifying how all aspects of output, production, and
work processes are done. This definition now formally includes temporary or leased workers, independent
contractors, or migrant laborers.
First Aid: refers to any treatment in the following comprehensive list that is provided by any heath
care provider for a work-related injury or illness:
1.
2.
3.
4.
5.
6.
7.
8.
Visit(s) to health care provider limited to observation.

Diagnostic procedures including use of prescription medicines solely for diagnostic purposes.
Use of nonprescription medications, including antiseptics.
Simple administration of oxygen.
Administration of tetanus or diphtheria shot(s) or booster(s).
Cleansing, flushing, or soaking wounds on skin surface.
Use of wound coverings such as bandages, gauze pads, etc.
Use of any hot/cold therapy for local relief, except for musculoskeletal disorders. (Musculoskeletal
disorders are covered in a special section, Appendix B, in the Proposed Rules.)
9. Use of any totally non-rigid, non-immobilizing means of support, such as elastic bandages.
10. Drilling of a nail to relieve pressure for subungual hematoma.
11. Use of eye patches.
12. Removal of foreign bodies not embedded in the eye, if only irrigation or removal with a cotton
swab is needed.
13. Removal of splinters or foreign material from areas other than the eyes by irrigation, tweezers,
cotton swabs, or other simple means.
Any procedure other than those listed above is considered as being medical treatment, and thus defines
the injury or illness as recordable.
Injury or Illness: is any sign, symptom, or laboratory abnormality which indicates an adverse change
in an employees anatomical, biochemical, physiological, functional, or psychological condition.
Work-Related: is still a very complicated question, but under the proposed rules, an injury or illness
is work-related if an event or exposure in the work environment either caused or contributed to the
resulting condition or aggravated a pre-existing condition. The events or exposures must occur at the
employers establishment or as a consequence of a work activity performed as a condition of employment.
25-12
More detailed descriptions of the criteria for work-relatedness are given in Appendix A of the Proposed
Rules.
Restricted Work Activity: means that the employee is not capable of performing his or her normal
work activities or the activity he or she was performing at the time of the injury or illness, at full
capacity, for a full workshift.
Recordable Injury or Illness: a recordable injury or illness is one that meets all of the following four
criteria:
1. An injury or illness, as defined above, exists.
2. The injury or illness is work related.
3. The injury or illness is new. A new injury or illness does not result from the recurrence of a preexisting condition if no new or additional workplace incident or exposure or occurs.
4. The injury or illness meets one or more of the following conditions:
a. results in death or loss of consciousness,
b. results in day(s) away from work, restricted work activity or job transfer,
c. requires medical treatment beyond first aid,
d. is a recordable condition as listed in Appendix B of the proposed rules.
Only if an injury or illness meets all of these tests is it recordable.
25.11 Summary and Conclusions

The recordkeeping requirements developed by OSHA set the basic criteria for controlling economic and
human loses in the workplace. While recordkeeping may seem to be a nonproductive, time-consuming
task, it is the law, and when properly used, will result in a more profitable organization.
References
Gray, W. and Scholz, J., Does regulatory enforcement work? Law and Society Review, July, 1993.
U.S. Department of Labor, Bureau of Labor Statistics (BLS), 1997. Workplace Injuries and Illnesses in
1995. Statistical Report from the Bureau of Labor Statistics, Safety and Health Statistics, March 12,
1997.
U.S. Department of Labor, Bureau of Labor Statistics. A Brief Guide to Recordkeeping Requirements
for Occupational Injuries and Illnesses. June, 1986a. U.S. Government Printing Office.
U.S. Department of Labor, Bureau of Labor Statistics. Recordkeeping Guidelines for Occupational
Injuries and Illnesses. September, 1986b. U.S. Government Printing Office.
U.S. Department of Labor, Occupational Safety and Health Administration, 1995. The Cumulative
Impact of Current Congressional Reform on American Working Men and Women. Special Report
prepared for presentation by Robert B.Reich, Secretary of Labor, August, 1995.
U.S. Department of Labor, Occupational Safety and Health Administration. Ergonomics Program
Management Guidelines for Meatpacking Plants (OSHA 3123). 1993 (reprinted). U.S. Government
Printing Office.
26
Body Discomfort
Assessment Tools
Leon M.Straker
Curtin University of Technology
26.1
26.2
Overview
Fundamental Concepts
26.3
The Discomfort Phenomenon/Construct The Description

of Discomfort Intensity Quality Location
Temporal Pattern Summary of Important Fundament als
of Discomfort Measurement
ApplicationExamples of Discomfort Tools
26.4
261
262
Used in Ergonomics
268
Whole Body Discomfort Scales Body Part Discomfort

Location and Intensity Scales Temporal Pattern Criteria
for Selection of an Appropriate Tool
Conclusion and Recommendations
2613
26.1 Overview
This chapter reviews various body discomfort assessment tools that can be used in industry for the
purpose of preventing work-related musculoskeletal disorders. Prior to describing the various tools
available the theoretical background to discomfort assessment is reviewed to assist the ergonomics
practitioner with decisions about when to use discomfort as a measure and which tool to use.
The aim of ergonomics is to provide a match between the person and the environment. In order to
evaluate the success of any ergonomics input or intervention, tools are required which provide information
on the degree of match or mismatch.
One aspect of the match between people and their environment that has become increasingly important
is the physical aspect. An important reason for this is that it has been claimed that the high rates of
work-related musculoskeletal disorders (such as work-related back problems and work-related neck
and upper limb disorders) are at least partially attributable to physical mismatches.
Unfortunately, the etiology of these work-related musculoskeletal disorders is complex and
controversial. This lack of etiology clarity makes an assessment of risk difficult. However, it is widely
believed that discomfort is a useful risk indicator.
Conceptually, discomfort is an attractive risk indicator as it uses the bodys own feedback system to
detect possible problems.
Possible sources of discomfort resulting from musculoskeletal stress include: tension in muscles,
nerves, blood vessels, ligaments, and joint capsules; compression of the same body tissues; local
chemical changes associated with muscle fatigue; local chemical changes related to restricted blood
flow and partial ischemia; disruption of nerve conduction resulting from pressure; and secondary
inflammation.
As mechanical stress on tissue and local chemical changes are both thought to be sources of tissue
damage and pathology, the potential utility of discomfort as a risk indicator is clear.
0-8493-1800-9/03/$0.00+$1.50
26-1
26-2
However, discomfort may also be influenced by psychological and social factors. This is seen by some
as a major disadvantage, but perhaps it should not be seen as a disadvantage as the level of disability a
certain pathology creates is also related to psychological and social factors.
Discomfort is thought to be especially useful for assessing situations where the impact of physical
mismatch may be greatest on small muscles and where static muscle activity is required. This is beneficial,
because small muscle problems are not detected well with other common risk assessment tools, such as
biomechanical modeling, and gross physiological indicators, such as heart rate and body temperature.
The following section reviews some concepts fundamental to the use of discomfort as an indicator of
risk of musculoskeletal disorder.
26.2 Fundamental Concepts

The Discomfort Phenomenon/Construct
There has been little ergonomics research and discussion reported about the phenomenon of discomfort.
Therefore, many of the fundamental concepts of discomfort measurement discussed here are drawn
from the extensive research on the measurement of pain.
One of the important issues from pain measurement research is the specificity of terms. Pain researchers
have found that different people interpret terms differently. This has important implications for discomfort
measurement in ergonomics as the ergonomics literature has not been very specific about the use of the
term discomfort. For example, some authors have considered pain and discomfort as synonymous.
However, the error of this assumption is well illustrated in a study by Bates et al. (1989).
The study by Bates et al. was mainly aimed at investigating the effect of arm posture on worker
performance at a computer task. They therefore had their 32 subjects perform a computer-based
choice reaction time task for 8 minutes while working in both a good arm posture (no shoulder
flexion) and apoor arm posture (45 shoulder flexion). However, they were also interested in the
possible interactions of discomfort (from poor posture) and performance. The ergonomics literature
available at the time of their study used discomfort and pain interchangeably; however, their
understanding of the pain literature suggested this was not valid. To investigate the interchangeability
assumption, their subjects were asked to rate both their shoulder discomfort and their shoulder pain,
with a balanced order of recording.
Figure 26.1 shows the relationship between the discomfort and pain intensities recorded by Bates et
al. It is clear that discomfort intensity tended to increase before pain did, suggesting discomfort is more
sensitive at lower noxious stimuli levels.
However, Figure 26.1 also shows that the relationship between discomfort and pain was a nonlinear
relationship. This suggests that different subjects interpreted the two terms, pain and discomfort,
differently. The implication of this is that scales which use multiple nouns may not be valid.
Figure 26.2 shows the visual analog scale intensity ratings of discomfort and pain at the end of
working in the 45 shoulder posture. The significant difference (38mm, t31 = -6.04, p = .0001) confirms
that discomfort is a more sensitive scale than pain, although they may both be accessing the same
feelings. This study also confirmed the utility of discomfort in gathering early information about possible
physical ergonomics mismatches.
Another example of possibly invalid discomfort measurement scales is where some authors have
considered discomfort and comfort to be on the same continuum. However, there is little evidence to
suggest that this is true and some ergonomists have suggested that perhaps comfort is a separate entity
which is more (or less?) than just the absence of discomfort. Branton (1969) illustrates this with the
analogy that the absence of pain does not necessitate the presence of pleasure.
A final point about the importance of terminology in scales is that the interpretation of terms is likely to
not only vary between individuals, but also between cultural groups. Thus, multiple term scales which may
be valid in one culture may not be valid in another culture. With many modern societies being comprised of
individuals from varied ethnic and cultural backgrounds, the clear implication for ergonomics is that widely
26-3
FIGURE 26.1 Relationship between discomfort and pain.
FIGURE 26.2 Pain and discomfort ratings (mean and standard deviation) after working in 45 shoulder flexion for
8 minutes.
applicable discomfort assessment tools should restrict the number of terms (nouns) used to ensure more
consistent use of the tool across cultural groups.
The Description of Discomfort

To adequately describe discomfort four aspects need to be coveredintensity, quality, location, and
temporal pattern. For example, sitting on a hard chair for several hours may result in discomfort which
could be described as a numb, cold feeling in the areas extending approximately 15 cm out from each
ischial tuberosity which is of low to moderate intensity and which began after about 15 minutes of
sitting and increased to the end of the first hour then remained at a constant level until arising from the
chair, when the discomfort subsided to minimal intensity after 5 minutes. The following sections describe
how the different attributes of discomfort can be measured.
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Intensity
Measurement of the intensity of discomfort has usually been attempted by asking the worker to rate the
intensity on a scale commonly termed a subjective scale. Although there is a large number of possible
subjective scales, they can be grouped into: verbal rating scales; visual analog scales; numeric rating scales;
and graphic rating scales. There have also been a number of attempts to try to use a more objective
measure of intensity. Thus, discomfort intensity is inferred from changes in behavior (using a behavior
rating scale), or changes in correlated biomechanical and physiological entities. Examples of possibly
suitable correlates are: estimates of static muscle tension (using biomechanical modeling); and estimates of
muscle fatigue (using amplitude and frequency shifts in power spectrums of muscle electrical activity). The
various types of scales and their relative advantages and disadvantages are described below.
Biomechanical and Physiological Correlates

If discomfort is thought to arise from mechanical loads around joints, then it is reasonable to estimate
those loads using position data and biomechanical modeling. Some studies have demonstrated a good
correlation between joint load and discomfort ratings (Boussenna, Corlett, and Pheasant 1982). Similarly,
if discomfort is thought to be due to sustained or high-magnitude muscle activity, then electromyography
can provide an objective measure. Other physiological correlates which could be used are heart rate,
blood pressure, respiratory rate, skin conductance, sweat rate, and skin temperature.
The advantage of these measures is their lack of reliance on worker reports.
However, it should always be remembered that it is not discomfort which is being measured. Rather,
a correlation is assumed between the measure taken and discomfort. Another disadvantage is the
potentially culture-specific nature of any correlation. For example, people in some cultures understand
comfort to equate to dynamic balance (and resultant moderate muscle activity) and not the lack of
muscle activity commonly accepted as comfort by people in Western cultures.
Behavior Rating Scales

Some ergonomists have suggested measuring discomfort intensity by using observation of behavior
thought to be indicative of discomfort reaching a certain intensity, such as fidgeting. For example,
Branton (1969) suggested sitting was for a purpose and that discomfort can be seen as an interference
which, when it reaches a sufficient intensity, results in changes to sitting posture. Thus, an increased
number of postural changes would be considered to indicate an increase in discomfort intensity.
Shackel et al. (1969) considered the use of time-sampling of posture changes and duration as an
objective measure of discomfort. However, the labor intensive nature of such observation was not thought
to be feasible for their purposes. However, with newer technologies of electrogoniometry and digital
motion analysis this may now be more feasible.
Corlett and Bishop (1976) recorded machine use and machine idle times for two weeks before and
after ergonomic intervention. The increased overall percentage of work vs. idle time and the increased
length of work periods were interpreted as suggesting a decrease in physical stress. That is, a reduction
of discomfort allowed the workers to work productively for longer periods which increased overall
production. It was also used to argue the cost-benefit of the changes as the cost of the machine changes
were paid for in a few days of higher productivity.
One advantage of behavioral scale assessment is that it is independent of a workers capacity and
willingness to verbalize feelings. It also provides task interference information and thus can be more
readily used in productivity-based justifications for ergonomic interventions. A major disadvantage is
the assumption that the postural movements are due to discomfort reaching a certain intensity. For
example, frequent movements could be the result of a good work habit of not maintaining static postures,
and be a desirable characteristic to be encouraged in any ergonomic intervention.
Verbal Rating Scales

There are two types of verbal rating scale: one in which a single noun is used to describe the construct (in
this case discomfort) and multiple adjectives are used to indicate changes in intensity, and another in
which different nouns are used.
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FIGURE 26.3 Single noun verbal rating scale for discomfort intensity.
FIGURE 26.4 Multiple noun verbal rating scale for discomfort intensity.
FIGURE 26.5 Visual analog discomfort scale.
Figure 26.3 shows a single noun, multiple adjective verbal rating scale for discomfort which uses
no, minimal, moderate, severe, and maximal to indicate increasing intensities of discomfort. Commonly
five or seven categories are used.
Figure 26.4 shows an example of a multiple noun scale where the terms relaxed, comfortable,
neutral, uncomfortable, and painful are used to indicate increasing intensities of discomfort.
For both types of verbal rating scale a rating of discomfort intensity is collected from the worker
either by their circling a descriptor or their verbally reporting a descriptor. Analysis of these data is by
frequency distributions and rank order nonparametric statistics.
The advantages of verbal rating scales are that they are relatively straightforward and easy for workers
to understand.
One disadvantage of verbal rating scales is the relatively small number of points on the scale,
resulting in only gross changes in the intensity of discomfort being detected. Another disadvantage is
the assumption that feelings like discomfort can be verbalized (which has led some ergonomists to
trial cross modality matching and suggest behavioral scales). Multiple noun scales have the added
disadvantage of introducing error from different interpretations of the different nouns. For example,
one worker may consider numb to equate to a higher intensity of discomfort than stiff, while
another worker may interpret them in the opposite order. Such errors will hinder the evaluation of
ergonomic interventions because an improvement post intervention may not be detected due to the
different uses of the scale by workers.
Visual Analog Scales

Visual analog scales consist of a line, usually 100 mm in length, with a label at each end (often termed
anchors). Figure 26.5 shows a Visual Analog Discomfort Scale which uses the anchors no discomfort
and extreme discomfort to indicate the ends of the continuum. Another common anchor for the high
intensity end is discomfort as bad as it could be. Both vertical and horizontal lines can be used.
To indicate the level of discomfort, a worker places a mark on the line to indicate the intensity. The
intensity rated is then measured as the distance from the left-hand end of the line to the mark placed by
the worker. When the measuring is recorded in mm, the scale effectively has 101 levels of discomfort.
Robust parametric statistics, such as analysis of variance, are often used for analysis, although the data
are strictly not interval data and may be skewed (for example, if most workers record very low or no
discomfort).
The advantages of visual analog discomfort scales include their ease of administration, sensitivity,
and amenability to statistical analysis.
Pain measurement research has suggested that a possible disadvantage of visual analog scales is that
some workers may have difficulty conceptualizing how to indicate perceptions of discomfort intensity
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FIGURE 26.6 Visual numeric rating scale.
FIGURE 26.7 Graphic rating scales.
on a line. Groups thought to have greater difficulty are older people and those without formal education
(those who may be less familiar with abstracting concepts).
Numeric Rating Scales

Numeric rating scales are similar to visual analog scales except they have a discrete number of categories
and can be either visual or verbal. Common examples use 0 to 10 in one-unit intervals to give an 11-unit
scale or 0 to 100 in one-unit intervals to give a 101 unit scale. The scale has anchors similar to analog
scales. Figure 26.6 shows a visual numeric rating scale with 11 levels of intensity.
Workers rate their discomfort intensity either by marking a number or verbally reporting a number.
Data collected are less parametric than visual analog scale ratings so nonparametric statistical analysis
should be used.
Advantages of numeric rating scales include that they are simple to administer and the verbal scale
can be used during a manual task without interference with posture.
Disadvantages include that the 0 to 10 point scale has limited sensitivity, and workers often tend to
clump ratings on the 1 to 100 scale around deciles.
Graphic Rating Scales

Graphic rating scales are a mixture of a visual analog scale and either a numeric or verbal rating scale.
The scale thus consists of a vertical or horizontal line with anchors (as for a visual analog scale) with the
addition of either numbers or adjectives along the line. Figure 26.7 shows examples of both types.
Workers place a mark on the line to represent their rating of discomfort intensity. Nonparametric
statistical tests should be used.
An advantage of graphic rating scales is that the extra labels may assist a worker having difficulty
using a visual analog scale.
However, it has been demonstrated that there is a problem with clustering of results around the
labels along the line.
Quality
The quality of discomfort can probably only be assessed by allowing different nouns to be used by the
worker. Different qualities of discomfort may include: tingling; burning; searing; numbness; coldness;
stiffness; heat; cramping; prickling; stabbing; and gnawing. Although quality of pain is widely used in
health assessment, quality of discomfort has not been regularly used by ergonomists. Perhaps this is
because the implications of the different possible qualities are unclear, whereas the implications of intensity,
location, and temporal pattern are usually clear.
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FIGURE 26.8 Body map for reporting discomfort location.
Location
The location of discomfort is commonly collected either through the use of a body map or by specific
reference to a body part. Thus, where only the discomfort of a specific body part is of interest, it is usually
made clear to the worker that the other information collected about discomfort (intensity, quality, and
temporal pattern) is just related to that body part. However, when discomfort at a number or sites, or at
any site, is of interest, the worker is usually asked to indicate where each and every discomfort is felt.
Workers can indicate the body parts either by shading on a body map or by reporting the name or number
of a body part. Figure 26.8 shows an example of a body map which separates the body into 13 parts.
Temporal Pattern
The temporal pattern of discomfort is often measured by collecting information about discomfort at
different times. Depending on the reason for investigating discomfort, the time between collections may
vary from a number of minutes (presumably for quite severe or intense tasks), to a number of hours (if
a daily fluctuation is of interest), to a number of days or longer. Multiple recording of aspects of discomfort
can be achieved by either using separate data collection sheets for each time (thus keeping the worker
blind to previous recordings), or by recording on the same data collection sheet (enabling the worker to
compare with previous recordings).
Another issue related to assessing the temporal pattern of discomfort is the importance of the period
between worker experience and data collection. Branton (1969) suggested that because post-experience
discomfort reporting relies on kinesthetic memory, discomfort information should be collected while the
worker is experiencing the discomfort. Pain research has clearly demonstrated the importance of
immediacy for best validity.
Summary of Important Fundamentals of Discomfort Measurement

Based on the discussion above, the following fundamentals of discomfort measurement can be distilled:
Discomfort measurement is likely to be useful in the assessment of information about physical

matches and mismatches.
Consistent use of the sole noun discomfort will assist the validity of assessment.
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Discomfort is a subjective experience and can therefore only be measured by worker report.
Intensity, location and temporal pattern are important attributes of discomfort.
A Visual Analog Discomfort Scale is probably the most widely applicable discomfort intensity
scale.
The following section provides examples of how discomfort tools have been used in ergonomics research
and practice.
26.3 ApplicationExamples of Discomfort Tools Used in Ergonomics

Some examples of the use of discomfort tools in ergonomics are described below. A list of other reports
of discomfort tool use is provided in the Further Reading section.
Whole Body Discomfort Scales

Shackel et al. (1969) used a multiple noun graphic rating scale, which they called a General Comfort
Scale, to measure the discomfort caused by different chair designs. The rating scale had 11 items
arranged at 10 mm intervals on a vertical line as shown in Figure 26.9. Chair raters were asked to place
a mark on the vertical line to express their rating. Scoring was achieved by rounding the mark to the
nearest 5 mm, giving a 0 to 20 scale. Using nonparametric statistics, Shackel et al. were able to rank
chairs for discomfort and compare user ratings with expert opinion.
Although the scale appeared to work reasonably well for the purposes of the study, the earlier discussion
presented in this chapter suggests that a single noun scale would have been more valid, and may have
allowed better differentiation of the chairs.
Corlett and Bishop (1976) evaluated ergonomic changes to pedestal spot welder machines by measuring
discomfort before and after machine modifications using an Overall Comfort Scale. Three operators
were asked to rate the intensity of their overall comfort using a seven-point graphic rating scale with end
labels extremely comfortable and extremely uncomfortable. Coding of intensity was achieved by
dividing each scale interval into 2 to give 14 measurement units. Prior to modification, one machine
resulted in mean operator ratings of around 12, which was reduced to around 7.5 after modification.
From the earlier discussion, use of a continuum from extreme comfort to extremely uncomfortable may
not be valid because comfort may be a separate state.
Bhatnager et al. (1985) used a slightly different approach to assessing whole body discomfort. They
used Drury and Courys (1982) Body Part Discomfort Frequency (total number of body parts with
non-zero discomfort) and Body Part Discomfort Severity (mean severity of body parts with non-zero
discomfort) to gain an indicator of overall body discomfort. Their fascinating study showed a negative
relationship between discomfort and productivity at an inspection task. There has been some discussion
FIGURE 26.9 General Comfort Scale. (From Shackel, B., Chidsey, K.D., and Shipley, P. (1969). The assessment of
chair comfort. Ergonomics, 12 (2), 269306. With permission.)
26-9
in the ergonomics literature about whether it is the number of body parts experiencing discomfort, or
the average severity of discomfort in various body parts, or the peak severity of discomfort in one body
part which determines overall ratings of discomfort. Until this issue is resolved, it is probably useful to
use a tool which collects the specific information required so that no unproven assumptions are needed.
Visser and Straker (1994) collected general body discomfort intensity ratings using a General Body
Visual Analog Discomfort Scale. The written instructions to workers were to Place a dash (/) at a
point along the line that best corresponds to your present feeling of overall discomfort. The scale was
the same as shown in Figure 26.5. The tool was easy to use as was demonstrated by the remarkably high
compliance rate for the study. (Other details of this study are described below.)
Body Part Discomfort Location and Intensity Scales

Besides collecting whole body discomfort, Shackel et al. (1969) also collected body part discomfort
data. Chair raters were shown a body map divided into 15 numbered body parts. Alongside the map
were 5 boxes, the first of which was marked 3 most comfortable and the last marked 3 most
uncomfortable. Chair raters were asked to identify the 3 most comfortable body parts and note these
in the first box and then cross them off on the body map. They were then to identify the next 3 most
comfortable and record the numbers for those body parts in the next box and cross them off the body
map. This was continued until all body parts were noted. Chair raters were also allowed to rate the 3
most comfortable then the 3 most uncomfortable at each successive round of rating, if that was found
easier. Shackel et al. tried to rank chairs by various body part discomforts, but as the buttocks experienced
the most discomfort for each chair the differences between chairs were not able to be detected. The
authors also reported the technique to be extremely laborious. The difficulty of use, lengthy procedure,
and lack of sensitivity were disadvantages of this assessment tool.
Corlett and Bishop (1976) also collected body part discomfort data. Their method was to ask operators
to identify the body part with the most discomfort, then the body part with the next most discomfort,
and so on until all body parts had been ranked. The data was used to compare the locations of discomfort
experienced when using 2 different machines. A machine which required considerable right foot force
showed asymmetry in discomfort and greater lower limb discomfort compared with a machine which
required a much smaller foot force. The data were therefore useful in assisting to identify the features of
the machinery which contributed to a physical mismatch with the worker. The assessment tool was
easier to use and quicker than that of Shackel et al., though it still lacked some sensitivity.
Straker et al. (1997b) collected ratings of body part discomfort from manual handlers performing a
range of tasks. The data collection form used a body part map for location information and multiple
visual analog scales for intensity information. Figure 26.10 shows the form used.
Besides statistical analysis of the information, Straker et al. used graphic representation to facilitate
comparison of the location and intensity of discomfort between different tasks. For example, the body
diagram on the left side of Figure 26.11 shows the group average intensity for each of 13 body parts
during a task requiring box carrying at shoulder height (high carry). The areas of highest discomfort are
the shoulders and wrists/hands. This can be compared to the body on the right side in Figure 26.11
which summarizes the group discomfort data for a task requiring box carrying in a stooped posture
(low carry). The change of highest discomfort areas to low back, pelvis, and thighs in the low carry task
is consistent with biomechanical modeling of areas of greatest stress. This assessment tool was easy and
quick to administer and provided a high level of sensitivity.
Temporal Pattern
Visser and Straker (1994) used a General Body Visual Analog Discomfort Scale to collect ratings from
56 dental workers at 6 different times over a working day (on arrival, morning break, prior to lunch
break, upon returning from lunch break, mid afternoon, and on completion of work). Figure 26.12
shows some of the results of Visser and Strakers study and clearly indicates both the trend for increasing
discomfort as the workday progressed and the ameliorative effect of the lunch break.
FIGURE 26.10 Body part discomfort location and intensity form.
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26-11
FIGURE 26.11 Body part discomfort for high and low carry tasks.
FIGURE 26.12 Mean general body discomfort of dental professionals for 6 different times of day.
Visser and Straker also compared the differences in the development of whole body discomfort when
dental workers where provided with a specially designed chair which incorporated an arm rest. Figure
26.13 clearly shows the benefit of the introduction of an arm rest in reducing discomfort in the afternoon.
Straker et al. (1997a) conducted a study to further investigate the relationship between arm posture
and discomfort and computer operator performance, as begun by Bates et al. They were interested in the
changes in discomfort over a 20-minute task. A verbal Numeric Rating Scale-101 was used which
allowed the operators to verbally report the intensity of the discomfort they were experiencing without
needing to change postures. Straker et al.s scale was an adaptation of the scale recommended by Jensen
et al. (1986) for pain. Operators were verbally instructed to Indicate to me the number between 0 and
100 that best describes your right shoulder discomfort. A 0 would mean no discomfort and a 100
would mean discomfort as bad as it could be at your right shoulder. These ratings were collected every
5 minutes from 21 female operators working in either no shoulder flexion or 30 shoulder flexion.
Figure 26.14 shows how the data collected was able to clearly show a more rapid rise in discomfort in
the poorer posture.
26-12
FIGURE 26.13 Comparison of mean general body discomfort of dental professionals across the day with and
without an armrest.
FIGURE 26.14 Changes in shoulder discomfort intensity while working in 0 and 30 shoulder flexion.
These examples have shown that a wide range of discomfort tools have been used in ergonomics
research and practice to provide information about the physical match between workers and their
environment.
To assist ergonomists in the decision of which discomfort assessment tool to use, a number of criteria
are presented.
Criteria for Selection of an Appropriate Tool

A discomfort assessment tool should have high utility, validity, and sensitivity. Utility can be considered
in two phases, data collection and data analysis. High utility in data collection requires the tool to be
easy for workers to use correctly, quick to administer, and with minimal interference with workers
performance of their tasks. One aspect of widespread ease of use is that the tool should require minimal
language skills. Thus, a tool used in an English-speaking country should require little English competence
so that the tool can be used across workgroups without difficulty and without jeopardizing validity.
Ease of use will improve the quality of collected data by minimizing errors.
High utility in data analysis requires the data to be readily amenable to statistical analysis and graphical
representation. Numerical data with either nonparametric characteristics or close to parametric characteristics
will facilitate easy statistical analysis. Currently, parametric analysis of complex statistical models tends to
be easier, giving an advantage to a tool which collects parametric-like data. Graphical representation of
data is important for the communication of ergonomics findings to managers and workers.
26-13
Validity is critical, as no validity means the data are of no value. As previously mentioned, the only
valid measure of a persons experience is the report of that person. Although there is little discomfortspecific
research on tool validity, pain measurement research has produced considerable evidence on the validity
of certain tools, such as the visual analog scale for intensity assessment.
However, because discomfort is commonly used in ergonomics to imply a problem in the physical
match between worker and work, the strong correlation of discomfort to biomechanical and physiological
risk indicators such as joint torque and electromyograph power spectral shifts provides corroboratory
evidence of the validity of discomfort.
Reliability is an important corequisite of validity. Van der Grinten (1991) provides evidence of
reasonable reliability of a discomfort assessment tool, and this was the only study of discomfort tool
reliability found.
Finally, a discomfort assessment tool needs to have sensitivity appropriate to the workers capacities
for discrimination and the assessment purpose. It is unlikely that workers can reliably differentiate 1000
levels of discomfort intensity, and even 100 levels may be ambitious. However, 10 levels are often not
sensitive enough for comparisons between work situations unless radical ergonomic interventions have
occurred.
26.4 Conclusion and Recommendations

To help ergonomists choose and use an appropriate assessment tool, this chapter has provided a concise
review of the fundamental concepts, provided examples of how discomfort assessment tools have been
used, and provided criteria to select an appropriate assessment tool.
Discomfort is a valuable variable for ergonomists to use to assess the physical match between workers
and their work. Several decades of practical experience by ergonomists and research in the area of pain,
has resulted in the development of easy-to-use, valid, and sensitive discomfort assessment tools.
This author recommends the use of a Visual Analog Discomfort Scale or Verbal Numerical Rating
Scale for assessment of intensity; body map or specific instructions for assessment of discomfort location;
and repeated measurements for the assessment of the temporal pattern of discomfort.
Acknowledgments
The author would like to thank past students, Grace Szeto, Michael Bates, Marshall Stockden, Mark
Petrich, Jodie Visser, and Jean Mangharam for stimulating the conceptualization of this chapter.
References/Further Reading
Studies Cited in Chapter
Bates, M., Petrich, M., and Stockden, M. (1989). Posture, pathology, pain and performance. Bachelor
of Applied Science Research Report, Curtin University of Technology, Perth Australia.
Bhatnager, V., Drury, C.G., and Schiro, S.G. (1985). Posture, postural discomfort and performance.
Human Factors, 27 (2), 189199.
Boussenna, M., Corlett, E.N., and Pheasant, S.T. (1982). The relation between discomfort and postural
loading at the joints. Ergonomics, 25 (4), 315322.
Branton, P. (1969). Behaviour, body mechanics and discomfort. Ergonomics, 12, 316327.
Corlett, E.N. and Bishop, R.P. (1976). A technique for assessing postural discomfort. Ergonomics, 19
(2), 175182.
Drury, C.G. and Coury, B.G. (1982). A methodology for chair evaluation. Applied Ergonomics, 13 (3),
195202.
Jensen, M.P., Karoly, P., and Braver, S. (1986). The measurement of clinical pain intensity: a comparison
of six methods. Pain, 27, 117126.
26-14
Shackel, B., Chidsey, K.D., and Shipley, P. (1969). The assessment of chair comfort. Ergonomics, 12 (2),
269306.
Straker, L.M., Pollock, C.M., and Mangharam, J. (1997a). The effect of shoulder posture on performance,
discomfort and muscle fatigue while working on a Visual Display Unit. International Journal of
Industrial Ergonomics, 20, 110.
Straker, L.M., Stevenson, M.G., and Twomey, L.T. (1997b). A comparison of single and combination
manual handling tasks risk assessment: 2. discomfort, rating of perceived exertion and heart rate
measures. Ergonomics, 40 (6), 656669.
van der Grinten, M.P. (1991). Test-retest reliability of a practical method for measuring body part
discomfort, in Y.Quennec and R.Daniellou (Eds.), Designing for Everyone. Proceedings of the 11th
Congress of the International Ergonomics Association, (pp. 5456). Paris: Taylor & Francis.
Visser, J.L. and Straker, L.M. (1994). An investigation of discomfort experienced by dental therapists
and assistants at work. Australian Dental Journal, 39 (1), 3944.
Further Reading
Cameron, J.A. (1996). Assessing work-related body-part discomfort: Current strategies and a behaviorally
oriented assessment tool. International Journal of Industrial Ergonomics, 18, 389398.
Chapman, C.R., Casey, K.L., Dubner, R., Foley, K.M., Gracely, R.H., and Reading, A.E. (1985). Pain
measurement: An overview. Pain, 22, 131.
Hagberg, M., and Sundelin, G. (1986). Discomfort and load on the upper trapezius muscle when operating
a wordprocessor. Ergonomics, 29 (12), 16371645.
Life, M.A. and Pheasant, S.T. (1984). An integrated approach to the study of posture in keyboard
operation. Applied Ergonomics, 15 (2), 8390.
Marley, R.J. and Kumar, N. (1994). An improved musculoskeletal discomfort assessment tool, in
F.Aghazadeh (Ed.). Advances in Industrial Ergonomics and Safety VI (pp. 4552). London: Taylor
& Francis.
Scott, J., and Huskisson, E.C. (1976). Graphic representation of pain. Pain, 2, 175184.
Van der Grinten, M.P. and Smitt, P. (1992). Development of a practical method for measuring body part
discomfort, in F.Adhazadeh (Ed.), Advances in Industrial Ergonomics and Safety IV (pp. 311318).
London: Taylor & Francis.
Section II
Medical Management
Prevention
27
Medical Management of
Work-Related
Musculoskeletal
Disorders
27.1
27.2
27.3
27.4
27.5
27.6
27.7
Thomas Hales
National Institute for Occupational
Safety and Health (NIOSH)
Patricia Bertsche
27.8
27.9
Introduction
Terminology
Selection of a Health Care Provider (HCP)
Early Reporting of Symptoms and Access to
Health Care Providers
Health Care Providers Familiarity with
Employees Job
Evaluation of the Employee
Treatment of the Employee
Resting the Symptomatic Area Thermal (more frequently
cold) Therapy Oral Medications Stretching and
Strengthening Hot Wax Steroid Injections Surgery
Follow-up and Return to Work
Follow-up Return to Work
Screening
27.10 Conclusion
271
272
272
274
274
275
276
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2712
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27.1 Introduction
The Bureau of Labor Statistics (BLS) reports that in 1994 nearly two thirds of the workplace illnesses
were disorders associated with repeated trauma (one category of musculoskeletal disorders) (BLS, 1995).
These figures do not include low back disorders associated with overexertion, which accounted for
380,000 lost time cases in 1993. The number of repeated trauma cases reported in 1994 was 332,000,
a 10% increase from the 1993 figure. In fact, since 1982, the number of reported disorders associated
with repeated trauma has been increasing each year (BLS, 1995). Not surprisingly, many health care
providers (HCPs) find evaluating and treating these employees consumes an increasing proportion of
their time and energy.
To prevent or reduce symptoms, signs, impairment, or disability associated with work-related
musculoskeletal disorders (WRMSDs), employers, in collaboration with HCPs, should develop a medical
management program which is outlined in Figure 27.1. This chapter provides assistance to employers
setting up a medical management program and to HCPs managing these cases in two waysfirst, by
outlining the general principles and listing the components of a program needed to adequately evaluate
0-8493-1800-9/03/$0.00+$1.50
27-1
27-2
FIGURE 27.1 Overview of a medical management program (MMP).
and treat affected employees; second, by providing HCPs with practical guidance and forms to collect
the appropriate information. These forms can then be incorporated into the employees medical record.
27.2 Terminology
Before addressing the various components of a medical management program, the term musculoskeletal
disorder must be defined. MSDs are disorders of the muscles, tendons, peripheral nerves, or vascular
system not directly resulting from an acute or instantaneous event (e.g., slips or falls). These disorders
are considered to be work-related when the work environment and the performance of work contribute
significantly, but as one of a number of factors, to the causation of a multifactorial disease (WHO,
1985). Physical risk factors that cause or aggravate MSDs and that may be present at the workplace
include, but are not limited to: repetitive, forceful, or prolonged exertions; frequent or heavy lifting;
pushing, pulling, or carrying of heavy objects; fixed or awkward work postures; contact stress; localized
or whole-body vibration; cold temperatures; and poor lighting leading to awkward postures. These
workplace risk factors can be intensified by work organization characteristics, such as inadequate workrest cycles, excessive work pace and/or duration, unaccustomed work, lack of task variability, machinepaced work, and piece rate.
27.3 Selection of a Health Care Provider (HCP)

An HCP is a practitioner operating within the scope of his or her license, registration, certification, or
legally authorized practice. The evaluation and treatment of employees with WRMSDs should be
performed by an HCP with experience and/or training in managing these disorders. Many HCPs are
capable of providing these services, including physicians, occupational health nurses, physical therapists,
occupational therapists, and hand therapists. Employers and employees may be more familiar with the
services of physicians, therefore Table 27.1 provides information regarding some of the other HCPs
who might be directly providing the care or coordinating the care of employees with WRMSDs.
Considerations for the employer to use in selecting an HCP include:
Specialized training and experience in ergonomics and the treatment of work-related

musculoskeletal disorders
Current working knowledge of the worksite and the specific industry
Willingness to periodically tour the worksite
TABLE 27.1 Non-Physician Health Care Providers Who Might Be Involved in the Medical Management of Work-Related Musculoskeletal Disorders (Not intended to be allinclusive)

27-3
27-4
Willingness to communicate with the employer and employees (Louis, 1987; Haig et al., 1990)
Experience in the case management of work-related musculoskeletal disorders
Willingness to consider conservative therapy prior to surgery
History of successful treatment of work-related musculoskeletal disorders
27.4 Early Reporting of Symptoms and Access

to Health Care Providers
The case management process begins with an employee informing his or her employer of the presence of
musculoskeletal symptoms or signs. Generally, the earlier that symptoms are identified, an evaluation
completed, and treatment initiated, the likelihood of a significant disorder developing is reduced. Early
treatment of many MSDs has been shown to reduce their severity, duration of treatment, and ultimate
disability (Haig et al., 1990; Wood, 1987; Wiesel et al., 1984; Mayer et al., 1987). There can be various
workplace situations influencing an employees decision to report symptoms. These situations can result
in employees over-reporting, or under-reporting, symptoms. In either case, to prevent severe disorders
from occurring, employees must not be subject to reprisals or discrimination based on reporting symptoms
to their supervisors.
Supervisors and foremen are not trained to evaluate and assess MSDs. To prevent supervisors or
other plant personnel from performing triage, employees reporting persistent musculoskeletal
symptoms (e.g., symptoms lasting seven days from onset, or symptoms that interfere with the
employees ability to perform the job) should have the opportunity for a prompt HCP evaluation. If
an HCP is available at the workplace, this initial assessment should be offered when the employee
reports symptoms or at least within two days. If the HCP is offsite, the employer should make
available an assessment to the employee promptly, but no later than a week after the signs or
symptoms are reported. This is not meant to imply that employers should wait seven days from
onset of all employees symptoms before referring the employee to an HCP. There are foreseeable
circumstances where immediate evaluation by an HCP would be warranted. For example, an employee
who reports to the supervisor that he/she is experiencing severe low back pain with numbness and
tingling radiating down his/her leg, an inability to sleep due to the pain, and obvious difficulty
walking should immediately be referred to the HCP.
27.5 Health Care Providers Familiarity with Employees Job

HCPs who evaluate employees, determine an employees functional capabilities, and prepare opinions
regarding work-relatedness and work-readiness, must be familiar with employee jobs and job tasks.
Being familiar with employee jobs not only assists HCPs in making informed case management decisions,
but also demonstrates to employers and employees the importance HCPs place on making informed
decisions, assists with the identification of workplace hazards that cause or aggravate MSDs, assists
with the identification of alternate duty jobs, and can help establish the proper diagnosis for the employees
condition.
Critical to this process is open lines of communication with the employer, employee, and the HCP.
The employer should appoint a contact person who is familiar with plant jobs and workplace risk
factors to communicate and coordinate with the HCP. In addition, HCPs should perform a plant walkthrough. Once familiar with plant operations and job tasks, the HCP can periodically revisit the facility
to remain knowledgeable about working conditions. Other approaches to become familiar with jobs
and job tasks include review of job analysis reports, job surveys or risk factor checklists, detailed job
descriptions, job safety analyses, photographs and/or videotapes accompanied by narrative or written
descriptions, and interviewing the employee.
27-5
27.6 Evaluation of the Employee

The HCP evaluation of the symptomatic employee should contain a relevant occupational and health
history, a physical examination, laboratory tests appropriate to the reported signs or symptoms, and
conclude with an initial assessment/diagnosis. If the HCP providing the initial evaluation does not have
the training or experience to make a preliminary assessment or diagnosis, the employee should be referred
to an HCP with such training and experience. The content of the evaluation is outlined below with a
recording form available (see Form 1).
1. Characterize the symptoms and history
Onset (date; circumstance; abrupt vs. gradual, etc.)

Duration and frequency
Quality (pain; tingling; numbness; swelling; tenderness, etc.)
Intensity (mild; moderate; severe; other rating scales)
Location
Radiation
Exacerbating and/or relieving factors or activities (both on-the-job and off-the-job)
Prior treatments
2. Relevant considerations:
Demographics (e.g., age; gender; hand dominance)
Past medical history (e.g., prior injuries or disorders related to the affected body part)
Recreational activities, hobbies, household activities
Occupational history with emphasis on the (a) job the employee was performing when the
symptoms were first noticed, (b) prior job if the employee recently changed jobs, (c) amount of
time spent on that job, and (d) whether the employee was working any other moonlighting or
part-time jobs.
3. Characterize the job:
Becoming familiar with an employees job is a critical component of the HCP evaluation and
treatment process. In addition to collecting the information from the plant contact person and
plant walk-through (described above), employees should be interviewed regarding their work
activities. The employee should be asked to describe their required job tasks with respect to
known workplace risk factors for MSDs and the duration of exposure such as hours per day,
days per week and shift work. Workplace risk factors for MSDs include repetitive, forceful, or
prolonged exertions; frequent or heavy lifting or lifting in awkward postures (e.g., twisting,
trunk flexion, or lateral bending); pushing, pulling, or carrying of heavy objects; fixed or awkward
work postures; contact stress; localized or whole-body vibration; cold temperatures; and others.
The employee should also be asked if there has been any recent changes in their job, such as
longer hours, increased pace, new tasks or equipment, or new work methods which may have
caused or contributed to the current illness.
4. Physical examination:
The physical examination should be targeted to the presenting symptoms and history.
Components of the exam include inspection (redness, swelling, deformities, atrophy, etc.),
range of motion, palpation, sensory and motor function (including functional assessment),
and appropriate maneuvers (e.g., Finkelsteins). It is important to note that clinical
examinations may not identify the specific structure affected, nor find classic signs of
inflammation (e.g., redness, warmth, swelling). This should not be surprising since the role
of inflammation in the pathophysiology of these disorders is unclear (Nirschl, 1990). For
further information on the content of an appropriate exam, or the technique to perform the
exam, please consult the following references: AHCPR, 1994; ASSH, 1990; Hoppenfield,
1976; Tubiana et al., 1984.
27-6
5. Assessment and diagnosis:

For each employee referred for an assessment, the HCP should make a specific diagnosis
consistent with the current International Classification of Diseases, or the HCP should summarize
the findings of his or her assessment. Terms such as repetitive motion disorders (RMDs), repetitive
strain injury (RSI), overuse syndrome, cumulative trauma disorders (CTDs), and work-related
musculoskeletal disorder (WRMSD) are not ICD diagnoses and, although useful as general terms,
should not be used as medical diagnoses. Given the difficulty in establishing the specific structure
affected, many diagnoses should describe the anatomic location of the symptoms without a specific
structure diagnosis (e.g., unspecified neck symptoms or disorders should be listed as ICD-9 723.9;
unspecified disorders of the soft tissues should be listed as ICD-9 729.9). When a specific anatomical
structure can be ascertained, most of these conditions involve the muscles or tendons (unspecified
disorders of muscle, ligament, and fascia should be listed at ICD-9 728.9; unspecified disorders
of synovium, tendon, and bursa should be listed as ICD-8 727.9). Table 27.2 provides a listing of
ICD-9 codes.
The HCP should assist in determining whether occupational risk factors are suspected to have caused,
contributed to, or exacerbated the condition. Factors helpful in making this determination are:
Is the medical condition known to be associated with work?
Does the job involve risk factors (based on job surveys or job analysis information) associated
with the presenting symptoms?
Is the employees degree of exposure consistent with those reported in the literature?
Are there other relevant considerations (e.g., unaccustomed work, overtime, etc.)?
27.7 Treatment of the Employee

Before initiating treatment, the HCP should document the specific treatment goals (e.g., symptom
resolution or restoring of functional capacity), expected duration of treatment, dates for follow-up
evaluations, and time frames for achieving the treatment goals. Resting the symptomatic area, and
treatment of soft tissue and tendon disorders are the mainstays of conservative treatment. Despite the
wide application of some therapeutic modalities, many are untested in controlled clinical trials.
Resting the Symptomatic Area

Reducing or eliminating employee exposure to musculoskeletal risk factors through engineering and
administrative controls in the workplace is the most effective way to rest the symptomatic area while
allowing employees to remain productive members of the workforce (Upfal, 1994). Until effective controls
are installed, employee exposure to workplace risk factors can be reduced through restricted duty and/
or temporary job transfer. The specific amount of work reduction for employees on restricted duty must
be individualized; however, the following principles apply: the degree of restriction should be proportional
to the condition severity and to the frequency and duration of exposure to relevant risk factors involved
in the original job. HCPs are responsible for determining the physical capabilities and work restrictions
of the affected worker. The employer is responsible for finding a job consistent with these temporary
restrictions. The employers contact person (who is knowledgeable about the employees job requirements
and their associated risk factors) is critically important to this process. The contact person should
communicate and collaborate with the HCP so that appropriate job placement of the employee occurs
during the recovery period. Written return-to-work plans ensure that the HCP, the employee, and the
employer all understand the steps recommended to promote recovery, and ensure that the employer
understands what his or her responsibility is for returning the employee to work. A form is included to
collect and distribute this written plan (Form 2). The HCP is also responsible for employee follow-up to
document a reduction in symptoms during the recovery period.
FORM 2Musculoskeletal Disorder Management Plan
27-7
TABLE 27.2 Specific ICD-9 Diagnoses Referred to as

Musculoskeletal Disorders by ICD-9 Numbers
Tendon, synovium, and bursa disorders
Trigger finger (acquired)
Radial styloid tenosynovitis (deQuervains)
Other tenosynovitis of hand and wrist
Specific bursitides often of occupational origin
Unspecified disorder of synovium, tendon, and bursa
Peripheral enthesopathies
Rotator cuff syndrome, supraspinatus syndrome
Bicipital tenosynovitis
Medial epicondylitis
Lateral epicondylitis (tennis elbow)
Unspecified enthesopathy
Disorders of muscle, ligament, and fascia
Game-Keepers thumb
Muscle spasm
Unspecified disorder of muscle, ligament, and fascia
Other disorders of soft tissues
Myalgia, myositis, fibromyositis
Swelling of limb
Cramp
Unspecified disorders of soft tissue
Osteoarthritis
Mononeuritis of upper limb
Carpal tunnel syndrome (median nerve entrapment)
Cubital tunnel syndrome
Tardy ulnar nerve palsy
Lesions of the radial nerve
Unspecified mononeuritis of upper limb
Peripheral vascular disease
Raynauds syndrome
Hand-Arm Vibration Syndrome
Vibration White Finger
Arterial embolism and thrombosis
Hypothenar hammer syndrome
Ulnar artery thrombosis
Nerve root and plexus disorders
Brachial plexus lesions
Cervical rib syndrome
Costoclavicular syndrome
Scalenus anticus syndrome
Thoracic outlet syndrome
Unspecified nerve root and plexus disorder
Spondylosis (inflammation of the vertebrae)
Cervical without myelopathy
Cervical with myelopathy
Thoracic without myelopathy
Lumbarsacral without myelopathy
Thoracic or lumbar with myelopathy
Intervertebral disc disorders
Displacement of cervical disc
Displacement of thoracic or lumbar disc
Degeneration of the cervical disc
Degeneration of the thoracic or lumbar disc
Intervertebral disc disorder with myelopathy
Disorders of the cervical region
Cervicalgia (pain in neck)
Cervicobrachial syndrome (diffuse)
Unspecified neck symptoms or disorders
Unspecified Disorders of the Back
Low back pain
727
727.03
727.04
727.05
727.2
727.9
726
726.10
726.12
726.31
726.32
726.9
728
728.8
728.85
728.9
729
729.1
729.81
729.82
729.9
715
354
354.0
354.2
354.2
354.3
354.9
443
443.0
443.0
443.0
444
444.2
444.21
353
353.0
353.0
353.0
353.0
353.0
353.9
721
721.0
721.1
721.2
721.3
721.4
722
722.0
722.1
722.4
722.5
722.17
723
723.1
723.3
723.9
724
724.2
27-8

FORM 1Occupational and Health History Recording Form for Musculoskeletal Disorders

FORM 2Musculoskeletal Disorder Management Plan
27-9
27-10
Complete removal from the work environment should be avoided unless the employer is unable to
accommodate the prescribed work restrictions. Research has documented that the longer the employee
is off work, the less likely he/she will return to work (Vallfors, 1985). In these cases, the employers
contact person and the employee should be in day-to-day contact, and the employee can be encouraged
to participate in a fitness program that does not involve the injured anatomical area.
Wrist immobilization devices, such as wrist splints or supports, can help rest the symptomatic area in
some cases. These devices are especially effective off the job, particularly during sleep. They should be
dispensed to individuals with MSDs only by HCPs with the training and experience in the positive and
potentially negative aspects of these devices. Wrist splints, typically worn by patients with possible
carpal tunnel syndrome, should not be worn at work unless the HCP determines that the employees job
tasks do not require wrist deviation or bending. Struggling against a splint can exacerbate the medical
condition due to the increased force needed to overcome the splint. Splinting may also cause other joint
areas (elbows or shoulders) to become symptomatic as work technique is altered. Recommended periods
of immobilization vary from several weeks to months depending on the nature and severity of the
disorder. Immobilization should be prescribed judiciously and monitored carefully to prevent iatrogenic
complications (e.g., disuse muscle atrophy).
The prophylactic use of immobilization devices worn on or attached to the wrist or back is not
recommended. Research indicates wrist splints have not been found to prevent distal upper extremity
musculoskeletal disorders (Rempel, 1994). Likewise, there is no rigorous scientific evidence that back
belts or back supports prevent injury, and their use is not recommended for prevention of low back
problems (NIOSH, 1994; Mitchell et al., 1994). Where the employee is allowed to use a device that is
worn on or attached to the wrist or back, the employer, in conjunction with a HCP, should inform each
employee of the risks and potential health effects associated with their use in the workplace, and train
each employee in the appropriate use of these devices. (McGill, 1993)
The HCP should advise affected employees about the potential risk of continuing non-modified
work, or spending significant amounts of time on hobbies, recreational activities, and other personal
habits that may adversely affect their condition (e.g., requires the use of the injured body part). However,
as mentioned above, the employee should engage in a fitness program designed for exercise and aerobic
conditioning that does not involve the injured anatomical area.
Thermal (more frequently cold) Therapy

Such treatment is generally considered useful in the acute phase of some MSDs. Cold therapy may be
contraindicated for other conditions (e.g., neurovascular).
Oral Medications
Aspirin or other nonsteroidal anti-inflammatory agents (NSAIA) are useful in reducing the severity of
symptoms either through their analgesic or anti-inflammatory properties. Their gastrointestinal and
renal side effects, however, make their prophylactic use among asymptomatic employees inappropriate,
and may limit their usefulness among employees with chronic symptoms. In short, NSAIAs should not
be used prophylactically.
It must be noted that the effectiveness of Vitamin B-6 for treatment of musculoskeletal disorders has
not been established (Amadio, 1985; Stransky et al., 1989; Spooner et al., 1993). Additionally, at this
time there is no scientifically valid research that establishes the effectiveness of Vitamin B-6 for preventing
the occurrence of musculoskeletal disorders.
Stretching and Strengthening

A valuable adjunct in individual cases, this approach should be under the guidance of an appropriately
trained HCP (e.g., physiatrists, physical and occupational therapists). Exercises that involve stressful
motions or an extreme range of motions, or that reduce rest periods may be harmful.
27-11
Hot Wax
At this time there is no scientific evidence regarding the effectiveness of hot wax treatments as a preventative
measure or as a therapeutic modality.
Steroid Injections
For some disorders resistant to conservative treatment, local injection of a corticosteroid by an experienced
physician may be indicated. The addition of a local anesthetic agent to the injection can provide valuable
diagnostic information.
Surgery
With an effective ergonomics and medical management program, surgery for work-related MSDs should be
needed rarely. Surgical intervention should be used for objective medical conditions and should have proven
effectiveness. While the indications for prompt or emergency surgical intervention may still be present (e.g.,
ulnar artery thrombosis), surgery should be reserved for severe cases (e.g., very high levels of pain resulting in
significant functional limitations) not responding to an adequate trial of conservative therapy.
27.8 Follow-up and Return to Work

Follow-up
Many, if not most, WRMSDs improve with conservative measures. HCPs should follow up the
symptomatic employee to document improvement, or to reevaluate employees who have not improved.
The time frame for this follow-up depends on the symptom type, duration, and severity. A clinical exam
or telephone contact with the employee should be made once a week, followed by a complete reevaluation
within ten days from the last examination if the employees symptoms are not improving. Where HCPs
are available at the workplace, monitoring the symptomatic employee should occur every 3 to 5 working
days depending on the clinical severity of the disorder (Wiesel et al., 1984; Wiesel et al., 1994).
In reassessing employees who have not improved, the following should be considered:
Is the diagnosis correct?

Are the treatment goals appropriate?
Have the MSD risk factors on and off the job been addressed?
Is referral appropriate?
If the jobs relevant risk factors have been eliminated but the employees symptoms persist, it is important
for the HCP to realize that employee reactions to pain and functional limitations may prolong the
recovery period. Strategies to help the employee cope with the pain and stress associated with these
disorders should be incorporated into the employees treatment plan. The time frames for considering
referral depends on the primary HCPs training and expertise, in addition to the type, duration, and
severity of the condition. In general, severe symptoms with objective physical examination findings
interfering with an employees ability to perform his/her job should be referred to an appropriate HCP
specialist sooner than milder symptoms without objective findings.
Return to Work
If an employees treatment plan required time away from work, the next step is to return the employee
to work in a manner that will minimize the chance for re-injury. Employees returning to the same job
without a modification of the work environment are at risk for a recurrence. Key to the return to work
process is open communication among the employee, the HCPs, and management. This will allow: (1)
27-12
prompt treatment, (2) an expedient return to work consistent with the employees health status and job
requirements, and (3) regular follow-up to manage symptoms and modify work restrictions as appropriate.
The principles guiding the return to work determination include the type of MSD condition, the severity
of the MSD condition, and the MSD risk factors present on the job.
Employees with MSDs who have diffkiculty remaining at work or returning to work in the expected
timeframes are candidates for rehabilitation therapy. Rehabilitation refers to the process in which an
injured worker follows a specific program that promotes healing and helps him or her return to work.
During the rehabilitation process, psychosocial factors (factors present both on the job, and off the job,
that can compromise an individuals ability to cope with symptoms, physical disorders, and functional
limitations) should be addressed.
27.9 Screening
Currently there is no scientific evidence that validates the use of preassignment medical examinations,
job simulation tests, or other screening tests as a valid predictor of which employees are likely to develop
MSDs (Frymoyer, 1992; Werner et al., 1994; Cohen et al., 1994). Literature findings are mixed on the
use of preplacement strength testing as a valid predictor of back injury.
27.10 Conclusion
The financial and human costs of work-related musculoskeletal disorders to our society are staggering.
This chapter on the medical management of these disorders should help employers and HCPs wishing to
prevent or reduce the severity of these disorders, resulting in a healthier, more productive workplace.
Acknowledgments/Disclaimer
We would like to thank the individuals and professional associations who contributed to the draft ANSI
Z-365 standard, and the draft OSHA Ergonomic Protection Standard. Ms. Bertsches contribution to this
chapter occurred while a visiting scientist at the National Institute for Occupational Safety and Health
(NIOSH), from the U.S. Department of Labor Occupational Safety and Health Administration (OSHA).
This chapter represents the views of the authors and does not constitute official policy of NIOSH.
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and Human Services, Public Health Service, Agency for Health Care Policy and Research. Rockville,
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Amadio PC (1985). Pyridoxine as an adjunct in the treatment of carpal tunnel syndrome. J Hand Surg;
10A:237241.
ANSI (1995). ANSI Z-365 Control of Work-Related Cumulative Trauma Disorders Part 1: Upper
Extremities. American National Standards Institute. Chicago, IL: Working draft 4/17/95.
ASSH (1990). The Hand: Examination and Diagnosis, 3rd ed. American Society for Surgery of the
Hand. New York, NY; Churchill Livingstone.
BLS (1995). Workplace injuries and illnesses in 1994. U.S. Department of Labor, Bureau of Labor
Statistics. Washington, D.C.
Bongers PM, De Winter CR, Kompier MA, Hildebranndt VH (1993). Psychosocial factors at work and
musculoskeletal disease. Scand J Work Environ Health; 19:297312.
Cohen JE, Goel V, Frank JW, Gibson ES (1994). Predicting risk of back injuries, absenteeism, and
chronic disability. J Occup Med; 36(10):10931099.
27-13
Day DE (1987). Prevention and return to work aspects of cumulative trauma disorders in the workplace.
Seminars in Occup Med; 2(l):5763.
Frymoyer JW (1992). Can low back pain disability be prevented? Baillieres Clinical Rheumatology;
6(3):595607.
Haig A, Linton P, McIntosh M, Moneta L, Mead P (1990). Aggressive early medical management by a
specialist in physical medicine and rehabilitation: effect on lost time due to injuries in hospital
employees. J Occup Med; 32(3):241244.
Hoppenfield S (1976). Physical Examination of the Spine and Extremities. Norwalk, CT: Appleton
Century Crofts.
Kiefhaber TR, Stern PH (1992). Upper extremity tendinitis and overuse syndromes in the athlete. Clinics
in Sports Med; 11(1):3955.
Louis DS (1987). Cumulative trauma disorders. J Hand Surg; 12A(5):823825.
Mayer TG, Gatchel RJ, Hayer H et al. (1987). A prospective two-year study of functional restoration in
industrial low back injury: an objective assessment procedure. JAMA; 258:17631767.
McGill SM (1993). Abdominal belts in industry: A position paper on their assets, liabilities, and use.
Am Indust Hygiene Assoc; 54(12):752554.
Mitchell LV, Lawler FH, Bowen D, Mote W, Ajundi P, Purswell J (1994). Effectiveness and costeffectiveness of employer issued back belts in areas of high risk for back injury. J Occup Med;
36(1):9094.
NIOSH (1994). Workplace use of back belts. Review and recommendations. U.S. Department of Health
and Human Services, Public Health Service, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health. Cincinnati, OH; Publication No. 94122.
Nirschl RP (1990). Patterns of failed healing in tendon injury, in Leadbetter WB, Buckwalter JA, Gordon
SL (eds). Sports-Induced Inflammation. Park Ridge, IL: American Orthopaedic Society, pp 577
585.
OSHA (1995). Draft Ergonomics Protection Standard. U.S. Department of Labor, Occupational Safety
and Health Administration. Washington, D.C. March, 1995
Ranney D (1993). Work-related chronic injuries of the forearm and hand: Their specific diagnosis and
management. Ergonomics; 36(8):871880.
Rempel D, Manejlovic R, Levinsohn DG, Bloom T, Gordon L (1994). The effect of wearing a flexible
wrist splint on carpal tunnel pressure during repetitive hand activity. J Hand Surg; 19(1):106110.
Spooner GR, Desai HB, Angel JF, Reeder BA, Donat JR (1993). Using pyridoxine to treat carpal tunnel
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Stransky M, Rabin A, Leva NS, Lazaro RP (1989). Treatment of carpal tunnel syndrome with vitamin
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Spine; 12:7782.
28
Ergonomic Programs in
Post-Injury Management
28.1
28.2
28.3
28.4
28.5
28.6
28.7
28.8
28.9
Introduction
Workplace Injuries
Ergonomics Disorders
Causes of Workplace Injuries/Illnesses
Prevention of Workplace InjuriesThe
Ergonomic Approach
Primary Prevention of Workplace Injuries
Post-Injury ManagementPrevention of
Disability
Tarek M.Khalil
Elsayed Abdel-Moty
University of Miami
Renee Steele-Rosomoff
University of Miami
Hubert L. Rosomoff
University of Miami
0-8493-1800-9/03/$0.00+$1.50
284
284
285
The Role of the Medical Community in Post-Injury

Management The Role of the Clinical Ergonomist in Injury
Management
Ergonomic Interventions in Post-Injury
Management
287
Evaluation of Physical, Functional, and Work

Capacities
288
Components of the Human Performance Profile

28.10 Scientific Determination of Patients Daily
Treatment Goals
University of Miami
282
282
282
283
289
28.11 Electrically Assisted Methods (EMG, Biofeedback,

Muscle Reeducation, and Functional Electric
Stimulation)
2810
Functional Electric Stimulation Electromyography and

Biofeedback Work Conditioning and Job Simulation
Workplace Design Job Site Analysis Biomechanical
Analysis, Motion Analysis Patient Education Applied
Clinical Research: Innovations in Problem Solving
28.12 Ergonomics and the ADA
2816
28.13 Post-Injury Management of the Aging

Population
28.14 Ergonomic Interventions Post-Rehabilitation
(Prevention of Reinjury)
28.15 Who Should Do Ergonomics in Post-Injury
Management Programs?
28.16 Who Pays for Ergonomics Service in a Clinical
Setting?
28.17 Summary
2817
2818
2818
2818
2818
28-1
28-2
28.1 Introduction
The management of work-related injuries and illnesses continues to be a challenge to ergonomists and
health and safety professionals. This chapter outlines a selected number of ergonomic contributions in
rehabilitation and disability prevention. The rationale, concepts, and methods developed for patient
evaluation, work conditioning and job simulation, workplace design, worksite analysis, neuromuscular
conditioning, and other topics are presented. Many of these intervention techniques were developed and
tested by the ergonomics team at the University of Miami Comprehensive Pain and Rehabilitation Center
(CPRC), and have proven valuable to post-injury management and return to work. It is difficult to
provide detailed descriptions of the various ergonomic interventions in post-injury management in a
few pages. Therefore, the authors have included an expanded list of references that may help the reader
get more detailed information about the approaches used.
28.2 Workplace Injuries

Injuries or pain happen either due to specific accidents (trauma or a single stress of high magnitude) or
cumulative events (a series of repeated stressors or micro traumas). If the resulting effects of an injury
extend beyond three months, an acute injury is classified as a chronic condition (Pain Commission, 1987).
Injuries in the workplace often occur due to inadequate design of work environments, tools, and
tasks. Workplace inadequacy also means that environments, tools, and tasks are designed without
consideration for the people who must use them. Injuries can also develop due to a variety of causes
including unsafe acts or human errors. These can also be dealt with through ergonomic interventions.
According to the Bureau of Labor Statistics, there were approximately 6,252,000 occupational injuries
and 514,000 occupational illnesses in 1994 (Safety Management, 1996). These figures translate into a
total rate of 8.4 occupational injuries or illnesses per 100 full-time workers. There are certainly many
more injuries and ergonomic disorders in the nonoccupational environment.
28.3 Ergonomics Disorders

Poor ergonomic design of tasks, equipment, or workplaces have resulted in a newly recognized group of
injuries recently called ergonomic disorders. These are disorders of the musculoskeletal and nervous
systems occurring in upper or lower extremities. They may be caused by repetitive motions, forceful
exertions, vibration, sustained or awkward postures, and/or mechanical compression. Among ergonomic
disorders are: low back pain, soft tissue injuries, eye fatigue and strain, sensitivity to light, blurred
vision, changes in color perception, numbness of fingertips, headache, neck strain, skin problems, stress,
and cumulative trauma disorders (also known as repetitive motion injuries, overuse disorders, or motion
strain.)
Musculoskeletal injuries are the most common workplace injuries with back pain leading the charts
in terms of incidence, cost, and suffering. Backaches can strike almost anyone. Although the exact
incidence of low back pain is unknown, it is obviously high. It has been estimated that 70 to 80% of the
population will develop some form of back pain during their life time. Annual estimates of the new cases
of low back pain (LBP) have ranged from 10 to 15% of the United States population. LBP accounts for
25% of all disabling injuries (Rosomoff and Rosomoff, 1991). It has been reported to consume about
80% of total health care expenditures associated with musculoskeletal injuries.
Impairments of the back are the most frequent cause of activity limitation in persons under the age of
45, and they rank as the third most common cause of disability after heart and arthritic conditions in
people age 45 years and over. The National Institute for Occupational Safety and Health (NIOSH) cited
that back injuries account for about 20% of all injuries and illnesses in the workplace and that these
injuries cost the nation an estimated $20 to 50 billion per year (NIOSH, 1991).
Ergonomic Programs in Post-Injury Management
28-3
Cumulative trauma disorders (CTD) have been identified as the industrial disease of the information
age and the work-related disease of the 1980s and 1990s. CTDs are the most frequently reported
on-the-job ailment. Millions of Americans have been afflicted by this family of disorders. It has been
estimated that by the year 2000, over half the workforce could be vulnerable.
The latest federal statistics put the number of work-related ergonomic CTD injury cases at 514,000,
up from just 30,000 in the mid-1980s (Safety Management, 1996). Carpal tunnel syndrome (CTS) is a
frequently reported work illness. CTS is a special case of CTDs. It refers to injury to the median nerve of
the wrist. Associated symptoms include numbness, tingling, burning sensations in the fingers, pain and
wasting of muscles at the base of the thumb, dry or shiny palms, and clumsiness. CTS develops when the
effective cross section of the carpal tunnel in the wrist is decreased or there is an increase in the volume
and pressure within the tunnel due to inflammation or edema. While there is an increasing number of
CTS cases which have been associated with workplace factors, some believe that the majority of CTS
cases are not occupationally related and that certainly not all wrist problems are necessarily CTS.
The staggering statistics make rehabilitation and effective management of low back pain, cumulative
trauma disorders, and all types of musculoskeletal or soft tissue injury a challenge to health care
professionals and ergonomists.
28.4 Causes of Workplace Injuries/Illnesses

Workplace injuries can be caused by a host of factors. Musculoskeletal work injuries afflict people who
perform light tasks (sedentary) and those involved in heavy labor. The magnitude of the stressor is an
important factor, however a common characteristic among injury profiles is that job tasks require excessive
bending, twisting, reaching, and deviation from neutral postures.
Most ergonomic disorders have been associated with injuries to the soft tissues in the human body.
Soft tissue injury (for example: tension, sprain, spasms, weakness, strain, contracture, and inflammation)
is the most common cause of pain (Quebec Study, 1987).
Soft tissue injury (STI) can result from activities such as lifting heavy objects, slipping and falling,
bending and twisting, driving, accidents, and the manner by which work activities are carried out (also
known as body mechanics). Soft tissue injuries can also develop gradually due to unknown causes and
due to disuse and muscle weakness (Abdel-Moty et al., 1992a). In one study, we have shown that 20%
of a sample of 200 patients with LBP were not able to attribute their painful condition to a specific
incident, indicating that pain developed gradually (Abdel-Moty et al., 1990a).
STI can also develop gradually as a result of the wear and tear when activities are done with
forceful muscular exertion, awkward postures, fast actions, sustained activity, and/or with frequent
repetitive motion (case of CTDs) (Abdel-Moty et al., 1991b). Several human activities and job tasks are,
therefore, more likely to result in STIs. Examples are: checkout scanning in supermarket, keypunching,
working at an assembly line, manufacturing, meat processing, butchers, hairdressers, sewing and knitting,
packing, stapling, tight grasping at the steering wheel, polishing and buffing, surface grinding, painters,
dentists, interpreters, postal workers, milking cows, use of a spray gun, and sports activities.
Work-related injuries can also develop due to medical conditions and dysfunction of body structures
and systems (e.g., infections, congenital disorders, neurological factors) (Khalil et al., 1993a).
In particular, computers have been blamed for causing or contributing to workplace injuries. Computers
are becoming a household item in millions of offices, business, and homes for the purpose of increasing
productivity. However, the effects on health have been negative. Prolonged keypunching, constant
switching of the eyes from the document to the computer screen, improper combination of computer
tasks and other activities, and inadequate visual attributes of the operator are but some of the conditions
that have resulted in disabling physical and psychological conditions of the workplace user.
Numerous guidelines have been recommended to deal with workplace and ergonomic injuries. These
will be discussed throughout this chapter.
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FIGURE 28.1 The premise of the ergonomic approach to injury/reinjury prevention is matching human abilities to
task demands. When task demands exceed human abilities (T>1), human safety is at risk. There is a need, then, to
improve human abilities through conditioning, exercise, and rehabilitation. When human abilities meet or exceed
task demands (T = 2 or T<3), human safety is improved. Task demands can be decreased through ergonomic,
engineering, and management controls.
28.5 Prevention of Workplace InjuriesThe Ergonomic Approach

The thrust of the ergonomic approach to injury prevention is matching human abilities/limitation to the
demands of the task (Figure 28.1). In doing so, ergonomists utilize knowledge of engineering, health,
behavioral, physical, and management sciences in an integrated fashion for analyzing, designing, testing,
and evaluating systems to improve human performance, reduce risk, improve productivity, and reduce
workers compensation costs.
Ergonomic contributions to injury prevention can be identified under three stages:
1. Primary prevention stagewhere the prevention of the onset of injury becomes a priority and a
desired goal for the avoidance of subsequent disability and lost workdays.
2. Secondary prevention stagewhere the goal is the prevention of disability, quick functional
restoration, and an expeditious return to work and productive life style of the injured worker.
3. Tertiary prevention stagewhere prevention of re-injury becomes essential in order to ensure no
recurrence of the injury-disability cycle.
Ergonomics contributions at each level of injury prevention are discussed below with emphasis on
secondary and tertiary prevention approaches, herewith referred to as post-injury management.
28.6 Primary Prevention of Workplace Injuries

By far, this is considered to be the most effective approach to curing the problem of work injuries and
illnesses. However, despite the increasing efforts to make workplaces safer, injuries still happen at an
alarming rate. In response to the problem, several government, academic, commercial, and industrial
entities have devoted tremendous resources toward injury prevention. The underlying approach has been
early identification and recognition of the problem. This is important especially if done at a stage that
allows prevention of injury through ergonomic work reorganization and work redesign (Kroemer, 1994).
To enhance efforts associated with primary prevention of injury, several bills, regulations, and standards
have been issued by local, state, and federal agencies. In 1990, OSHA introduced its OSHA Program
Management Guidelines which emphasize the need for:
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1. Routine worksite analysis to recognize, identify, and correct ergonomic hazards including review
and analysis of injury and illness records.
2. Hazard prevention and control through design measures to prevent or control hazards; engineering
controls for workplace design; work practice controls such as work rest schedule; use of personal
protective equipment; and administrative controls.
3. Medical management; injury/illness recordkeeping; early recognition and reporting; systematic
evaluation and referral; treatment and return to work; systematic monitoring; and adequate
staffing and facilities.
4. Training and education (both general and job specific) of the supervisors, managers, and engineers
and maintenance personnel.
Also, NIOSH declared that the most effective way to prevent back injury is to implement an ergonomic
program that focuses on redesigning the work environment and work tasks to reduce the hazards. One
such effort was the introduction of the lifting equation and guidelines for manual material handling.
Repetitive material handling has been considered to increase vulnerability to injuries/claims involving
the back. NIOSH, therefore, developed its Work Practice Guide which has undergone two revisions
since 1981. The guide provided direction as to the amount of weight to be handled under various
conditions. Obviously, this biomechanical approach has its practical limitations. Employee capabilities,
skills, past injuries, stress, and similar factors should be considered together with this mathematical
determination of lifting limits. Additionally, guidelines alone are not an effective substitute for employee
training in safety, a well-engineered workplace, and a fit worker.
The American National Standards Institute (ANSI) is another agency which advocates human factors
in workplace design for health and safety. ANSI published technical standards for implementation of
human factors engineering principles and practices in the design of visual display terminals (VDT),
associated furniture, and the office environment in which they are placed (ANSI, 1988).
28.7 Post-Injury ManagementPrevention of Disability

The primary objective of ergonomic contributions in this stage is to design effective intervention strategies
for the restoration of functional abilities and immediate return to work and productive life style.
Another objective is deterrence of further aggravation of an existing condition or injury.
This philosophy was adopted by the University of Miami Comprehensive Pain and Rehabilitation
Center as early as 1982 when ergonomics was first introduced in a multidisciplinary pain management
team. This marked the beginning of a new era for ergonomics research and application in health care
systems and pain treatment in particular. The basis for introducing ergonomics in post-injury management
is demonstrated in Figure 28.2. In this model, injury management according to the traditional medical
approach alone may be effective in treating the symptoms of pain, but it may fail to address and correct
the cause of the injury. Through the use of a rehabilitation through technology approach, ergonomists
assist in effective treatment as well as returning the patient to a modified work environment with improved
safety and better ergonomic design. Therefore, the potential for reinjury is greatly reduced or eliminated.
Since its introduction in pain management, ergonomics has gained wide acceptance, and its contributions
have proved vital in addressing issues of primary importance. Working with other health care professionals
who are usually involved in musculoskeletal and low back pain rehabilitation, ergonomists have played
equally important roles in the successful rehabilitation and management of injuries.
The Role of the Medical Community in Post-Injury Management

Several medical treatment approaches have been advocated by different care providers to deal with
musculoskeletal injuries; especially low back pain problems. Successful rehabilitation and management of
musculoskeletal injuries should integrate the different medical treatment disciplines in order to accomplish
such goals as: restoration of function; pain reduction; and, consequently, increasing productivity and
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FIGURE 28.2 (A) Injury occurs as a result of a faulty human-machine system. (B&C) Medical management attempts
to resolve acute injuries in order to return the injured worker to the same job. Since no measures are taken to change
the cause of injury, the worker is at a risk of reinjury. (D) Acute injuries may develop into chronic conditions if left
untreated or when mismanaged. (E&F) The medical-ergonomic management of both acute and chronic injuries or
illnesses will assist the injured individual to return to a productive life style. (G) The inclusion of ergonomics in the
post-rehabilitation stage will ensure the individuals return to an ergonomically correct human machine system, thus
minimizing the potential of reinjury.
FIGURE 28.3 Comprehensive pain and rehabilitation programs employ a multidisciplinary approach. In this
model, ergonomists work jointly with other health care providers to address patient issues and needs for full
restoration.
reducing rising disability costs. The health care professions that are usually involved in dealing with an
important problem such as low back pain rehabilitation include: the physician(s), physical therapists,
occupational therapists, nurses, vocational counselors, psychologists, and psychiatrists. Another profession
which has shown to be equally important in a successful low back pain rehabilitation effort is ergonomics
(Figure 28.3) (Khalil et al., 1993a).
The Role of the Clinical Ergonomist in Injury Management

The application of ergonomics principles and methods to the injured population is far from simple. A
major difficulty often encountered in applying ergonomic methods in a clinical setting is that these
methods are developed for the healthy population, representing military personnel, industrial workers,
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FIGURE 28.4 Listing of ergonomic contributions to post-injury management in the various areas.
and volunteers. Therefore, it becomes important to bridge the gap between traditional ergonomic research
and its application in health care systems. This requires a thorough understanding of the type of injury,
the specifics of the population at hand, and of medical, social, and legal issues (Khalil et al., 1991b;
Khalil et al., 1992b). For example, in ergonomic research, the evaluation of muscle strength has been
based on the use of maximum voluntary exertion protocols where subjects are asked to increase their
efforts to a maximum level. Applying this protocol to patients with back injury may be detrimental to
their health and their safety, may be psychologically unacceptable to the patient, or may result in irreversible
damage leading to medical as well as legal complications. In this case, it becomes necessary to develop
methods of strength testing which are more appropriate and specific to the type of injury such as the
acceptable maximum effort procedures developed by Khalil et al. (1987). Conversely, and as their
awareness of the role of ergonomics is increased, the medical staff will begin to redefine their roles and
contributions in order to make use of available ergonomic approaches not previously known to them.
28.8 Ergonomic Interventions in Post-Injury Management

Ergonomic contributions to injury management can be classified under the following categories in the
order of their application (Abdel-Moty et al., 1990b; Khalil et al., 1993b) (Figure 28.4):
1.
2.
3.
4.
5.
6.
7.
Physical, functional, and work capacity assessments.

Determination of patients daily treatment goals.
Electrically assisted methods to improve neuromuscular functioning.
Work conditioning and job simulation.
Workplace design and analysis including job site visits.
Biomechanical analysis of human motion (gait, sway, kinetics, and kinematics).
Patient education (safety, body mechanics, ergonomics).
28-8
8. Applied clinical research to develop innovative solutions to clinical problems (electronic

goniometry, stretching, traction, outcome).
The methods used in each area have been successfully implemented at the University of Miami
Comprehensive Pain and Rehabilitation Center (CPRC) at South Shore Hospital in Miami Beach, Florida
and are discussed in more detail below.
28.9 Evaluation of Physical, Functional, and Work Capacities

Objective evaluation of human performance is a step in an ergonomic program aimed at matching people
to their environments, machines, and tasks. In a rehabilitation setting, evaluations are used in order to:
1. Assess the current level of function and the degree of the loss of function due to injury or illness.
This helps the patient understand the degree of their functional loss and the clinician to establish
a baseline for evaluation of treatment efficacy
2. Evaluate and monitor patients progress during rehabilitation to ensure that treatment goals are
met and that the patient is part of the therapeutic plan of care
3. Direct treatment to address problem areas and focus on functional restoration
4. Evaluate treatment outcome following rehabilitation
5. Examine the patients ability to re-enter a productive life style
Also, objective assessment of functional capacities can be a useful tool in making administrative, clinical,
and legal decisions regarding work readiness.
Components of the Human Performance Profile

The patients performance profile may consist of one or more of the following measures (Abdel-Moty et
al., 1991c; Abdel-Moty et al., 1992b; Fishbain et al., 1994, 1995):
a. Measures of physical capacities such as isometric and dynamic strength, flexibility, mobility,
posture, sway and balance, psychomotor abilities, and gait.
b. Measures of physiological capacities such as muscular endurance and cardiovascular endurance.
c. Measures of functional capacities such as tolerance to sitting, standing, walking, climbing, lifting,
carrying, pushing, pulling, driving, stooping, crouching, and squatting.
d. Measures of work capacities specific to the patients ability to perform job demands.
Measurements of the human performance profile are reported relative to basic scores upon initiation of
treatment, progress from beginning to final scores, and in comparison to norms. Behaviors during
evaluation are observed and recorded with respect to cooperation, consistency, effort, motivation, patient
comments, and pain behavior. At the CPRC, this profile is established for each patient at three intervals:
upon admission to the rehabilitation program (inpatient or outpatient); two weeks into the program;
and at the end of the 4-week treatment program. The profile can also be compared to the physical
demands dictated by the job thus assisting in job placement for the prevention of further injury.
The issues surrounding patient evaluation are numerous and can be found in Abdel-Moty et al.
(1996). Among these are:
1. Operational definitions with respect to the types of evaluations (physical capacity evaluation vs.
functional capacity assessment, work-related assessments)
2. Patients issues (pain, perceptions, behaviors, motivation, effort, secondary gains, use of
medications, prior exposure to similar testing, contraindications, use of assistive devices)
3. Relationship to the Americans with Disabilities Act (ADA)the ADA requires that employment/
post-hire evaluations using functional capacity assessment (FCA) to be job specific and task
oriented (Abdel-Moty et al., 1993a)
4. Administrative issues of insurance, authorization, referrals, and scheduling
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5. Evaluators issues (bias, objectivity, training, experience, qualifications)

6. Methodological issues (patient safety, testing equipment, protocols, instructions, sequence of
testing)
7. Statistical issues (validity, reliability, sensitivity)
8. Other issues (testing environment, presence of third-party, such as attorneys, during testing,
reporting of results)
By accurately establishing performance parameters of the patients, it is possible to chart their course of
treatment through the use of the concept of daily goals.
28.10 Scientific Determination of Patients Daily Treatment Goals

Restoration of functional abilities of patients requires knowledge about patients baseline level of
performance as well as target goals. Baseline values represent the levels of functional abilities at which
patients enter the rehabilitation process. Typically, baseline values are determined for categories of muscle
strength, ranges of motion, tolerances, mobility, and soft-tissue factors, as well as a host of behavioral
and vocational variables. Treatment goals are usually determined based on vocational and/or avocational
objectives as well as on expected levels of functional abilities representing norms for healthy subjects
(e.g., the expected angle for lumbar flexion is 90 degrees).
The objective of rehabilitation is to treat, condition, and build the patients functional abilities in
order for them to achieve the desired levels of performance constituting their treatment goals.
In most rehabilitation settings, the progression from the initial (admission) levels to the final goals
(i.e., daily achievement during treatment) is determined through subjective clinical judgment of the
patients current status. Additionally, in some instances patients progression may be seen as tied to the
length of hospitalization or rehabilitation.
In todays atmosphere of health care management awareness, cost effectiveness, and health reforms,
optimization of treatment approaches and maximization of service delivery becomes a priority. Using a
daily goal model can help maximize treatment plans and determine optimal pathways patients should
follow during rehabilitation. A prediction modeling approach provides the treating team, as well as the
patient, with scientific tools for determining, realistically and objectively, patients daily performance
achievement during treatment. It also enables effective utilization of resources, and hence cost effectiveness,
for both the patient and the health care delivery system.
At the CPRC, ergonomists developed a novel approach to maximizing patients progress during
rehabilitation through the use of computerized modeling and optimization approaches. Named the
computerized daily goals (CDG) model, it was developed to determine optimal pathways a patient
should follow during chronic low back pain rehabilitation. The model utilizes statistical projection
methods which take into consideration the patients initial performance level and the desired goals
(Abdel-Moty et al. 1993b) (Figure 28.5).
This nonlinear model derives its coefficients from retrospective data collected on over 1000 patients
with chronic pain who were admitted for treatment at the CPRC, successfully completed the 4-week
rehabilitation program, and returned to a productive life style. All patients underwent evaluations of
functional abilities at three points during treatment: upon admission, after 2 weeks, and at the end of
the 4-week treatment program. Patients were evaluated and their performance was analyzed in the
following categories:
1. Tolerances (sitting, standing, walking, squatting, kneeling, stair climbing).
2. Strength (lifting, carrying, reaching, pulling, pushing).
3. Flexibility (trunk, cervical).
The purpose of this type of classification was to determine quantitative trajectories of progress in the
various categories as a result of the intervention protocols. Following necessary testing and validation,
a model was constructed and implemented on a personal microcomputer. Currently, once initial levels of
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FIGURE 28.5 The scientific determination of patients daily projected goals and clinical pathways requires accurate
determination of a patients initial performance levels as well as knowledge of a desired. Projections are then made
over the length of the patients treatment. The range of projection allows for flexibility in order to accommodate
individual patients.
performance have been measured and treatment goals have been determined, the daily goals program is
used to provide a personalized print-out of the expected daily performance in the different categories.
Final goals are reached just prior to patients discharge from the program. The daily goals program
predicts daily increments and corresponding dosage of patients therapeutic activities. Optimal progression
from initial tolerances to final goals is then printed and used by the patient and the medical staff to
determine activities needed to achieve desired daily performance in the various categories throughout
treatment.
In order to demonstrate its usefulness, a sample of 200 patients who completed the treatment program
was analyzed. About 82% of patients who were studied followed the projected levels, with another 9%
exceeding projections and showing improvements at rates higher than expected. In about 3% of the
cases examined, the printed goals were lowered due to unexpected changes in the patients medical
condition. In another 5% of the cases the projected goals were modified (mostly decreased) due to
changes in return-to-work plans.
28.11 Electrically Assisted Methods (EMG, Biofeedback, Muscle

Reeducation, and Functional Electric Stimulation)
Soft tissue injury and the resulting pain often produce compensatory changes in posture and in the
manner by which patients perform daily activities. The failure to treat chronic pain patients effectively
is, in part, due to an inability to identify and pinpoint the source of these altered motor patterns affecting
functional abilities. In order to assist the patient and the medical team with treatment goals, several
technology-based methods and intervention protocols were developed by clinical ergonomists. Among
these are protocols for biofeedback, neuromuscular reeducation, and functional electrical stimulation.
One method was developed to identify and effectively treat motor dysfunction in patients with chronic
pain conditions. This innovative multidisciplinary evaluation/treatment approach is based on the use of
on-line computerized electromyographic (EMG) methods to study multiple muscles involved in a chain
of precise activities specific to recruiting these muscles. The EMG signals of the various muscles are
examined for: baseline activity, symmetry, magnitude, frequency contents, synchrony, timing, and patterns.
28-11
Patients behaviors are also observed. EMG findings are then compared to relevant clinical findings. The
team of medical and ergonomics professionals discusses the significance of the findings, composes
interpretations, and recommends treatment plans or addresses outcomes as applicable. Patient-specific,
as well as condition-specific, multidisciplinary approaches are then generated to deal with the problems
during daily treatment. The overall objective is to decrease pain and improve function. This is accomplished
through using EMG and other electrically assisted methods to increase sensory perception (of muscles
and joints); increase neuromuscular recruitment; increase strength and endurance; and reestablish
synchrony, symmetry, pattern, and synergy of muscle activity to increase functional capacities. These
protocols are incorporated into patients daily treatment and clinical pathways. These treatment
approaches fall under the categories of functional electric stimulation, biofeedback, and neuromuscular
reeducation.
Functional Electric Stimulation

Functional electric stimulation (FES) is used when minimal muscle recruitment or reduced voluntary
control is detected upon medical or ergonomic testing. FES is a good example of an approach for
muscular conditioning and strengthening through which muscles can be strengthened passively without
placing excessive demands on the patient especially in the presence of pain. FES is the process of applying
an external electrical stimulus to a muscle or muscle groups in order to induce muscle contraction. FES
found many applications in rehabilitation, physical therapy, sports medicine, and recently in physical
fitness. Its usefulness ranged from increasing local blood flow to strengthening weak and healthy muscles
and enabling paraplegics to walk. We have also used FES successfully to treat conversion-disorders-type
paralysis, for electric testing of motor responses, and as a motor dysfunction treatment method. The
strength of FES arises from its ability to induce maximal muscular contraction without any voluntary
effort on the part of the treated individual. This later aspect is of value for patients with chronic pain
whose pain is often aggravated through regular exercise or who are unable to initiate the voluntary
effort necessary for muscular conditioning due to disuse.
The use of FES as a muscle strengthening alternative proved useful and shows great potential in the
rehabilitation and physical restoration of muscles weakened by disuse or pain. The current technology
has allowed for the development of electrical stimulation units that are safe for use with minimal adverse
effects. Studies on FES indicate that this passive intervention strategy is quite effective in numerous cases
(Khalil et al., 1991a; Abdel-Moty et al., 1994). The use of FES may be less effective in some cases due to
such reasons as fear of electricity, impaired sensory perception, skin conditions, lesions, muscles of the
chest wall, and cervical paraspinals.
It should be emphasized here that FES is not a substitute for regular exercise. FES is used to jump
start the neuromuscular system function. Once the patient has gained sufficient power to initiate
voluntary movement comfortably, he or she is to engage in active exercises of strengthening, flexibility,
and endurance training. In this regard recent advertisements which market muscle stimulators so you
never have to do sit-ups again and the cellulite breakthroughs must be evaluated objectively and
scientifically, especially with respect to patients perception of such products.
Electromyography and Biofeedback

Another electrically assisted tool for improving functional abilities of injured individuals is the use of
electromyography (EMG). Recently there has been a renewed interest in the use of surface
electromyographic (EMG) recording for the assessment and evaluation of patients with chronic pain. In
general, a carefully processed EMG signal can be a useful tool in the quantitative measurement of
muscular performance. In chronic low back pain rehabilitation, we found EMG to be valuable in the
study of muscle dynamics, for purposes of muscle reeducation and biofeedback, and in the evaluation of
patients response to specific treatments (Khalil et al., 1991a). In earlier reports, it has been shown that
the initial EMG levels of pain patients upon admission to the rehabilitation program were low and
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increased following muscle reeducation and physical restoration (Khalil et al., 1993a). The significant
increase in EMG was associated with significant increase in strength and reduction of pain.
Biofeedback (biological feedback) is the process of using specialized instruments to give people
information about their biological systems (temperature, heart rate, muscle activity, etc.). It is a set of
treatment/training techniques used to increase awareness and voluntary control of biological conditions
and relate them to human physical and emotional well being. Biofeedback (BF) is useful in the relief of
stress, tension, headaches, muscular dysfunction, and for improvement of muscle strength (Khalil et al.,
1987; Asfour et al., 1990).
Using EMG biofeedback, patients perform therapeutic maneuvers while affected muscles are monitored.
Muscles are then compared bilaterally, and the information is used to facilitate the patients awareness
of muscular performance. Patients are also evaluated without the use of feedback to determine carryover and awareness level. Ergonomists contribute in this area by making the technology and measurement
methods available to clinicians. The developed methods can then be used to improve the patients ability
to coordinate muscle activity, re-establish proper reciprocal inhibition, re-establish functional synergy
including appropriate force couples and sequential contractions, decrease the need for inappropriate
muscular or postural compensations, and achieve recruitment levels and baseline activity.
Work Conditioning and Job Simulation

The concepts of job simulation and work conditioning are important to effective return-to-work strategies.
The objective here is to improve the physical and functional abilities of post-injury individuals while
practicing job tasks. It is important to raise the individuals tolerances to adequate levels in order to
maximize his or her potential for return to work. This is accomplished through exercise, training, work
conditioning, and job simulation. In clinical settings, the ergonomists assist the health care delivery team
in developing realistic job simulations within the rehabilitation establishment to permit patients to
perform critical job tasks, preferably under medical supervision. An individual or a patient is taught to
perform his or her job task properly, which assures them that he or she is capable of carrying them out.
This also allows the treating physician to certify that the patient has been physically rehabilitated to
handle task demands.
During this activity, the ergonomist evaluates motions, time, and forces required to perform the
various tasks and relates these demands to the functional abilities of the individual. For this purpose, it
is not possible, nor necessary, to replicate jobs. It is also not necessary to simulate a full workday unless
a work tolerance evaluation is requested.
Work conditioning programs are highly structured, task focused, goal oriented, individualized, and
multidisciplinary/interdisciplinary in nature. The following are factors which affect the design of a work
conditioning program:
1. Intensity (the level of exertion at which a patient is expected to perform). The amount of weight
to be carried, distance to be covered, and other physical demands are a function of, not only the
patients status during treatment, but also his or her projected goal. The ergonomist seeks input
from the rehabilitation team regarding the patients medical status in order to determine work
intensity in job simulation.
2. Environment (actual or simulated). In many instances the rehabilitation team may decide that it
is necessary to observe the patient performing work tasks on the job. This gives an insight into
work behaviors, ability to manage stress on the job, and helps develop realistic treatment plans
and ergonomic recommendations.
3. Personnel involved (medical, ergonomic). In most cases, the ergonomist designs and conducts
work conditioning activities with input from the multidisciplinary team. It is not unusual to find
a team of the ergonomist, the occupational therapist, physical therapist, the vocational counselor,
the biofeedback specialist, and a psychologist working simultaneously with a patient during job
simulation. Each professional brings to this process a unique input and perspective and assists in
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immediate problem solving. The degree of involvement of each discipline depends on the activities
required.
4. Approach (progressive nature of work simulation sessions). A patient who is deconditioned and
who has a physically demanding job to return to (e.g., heavy work), will need a different approach
to work conditioning than a patient who will return to a sedentary job. For example, at the
CPRC, the objective of rehabilitation and ergonomic interventions is to raise the patients abilities
to maximum attainable physical and functional abilities. The inclusion of work demands in these
abilities will modify the approach to development of the plan of care for the patient. The plan of
care also includes essential goals (or prerequisites) to be achieved before work conditioning activities
begin. These are:
a.
b.
c.
d.
e.
f.
g.
Increase patients awareness of posture and body mechanics.

Increase flexibility and mobility.
Increase strength and endurance.
Improve stress management skills.
Improve pain control, safety, and preventive medicine techniques.
Modify behaviors toward work, employment, and return to work.
Involve patient in work conditioning activities early in the treatment program.
The ergonomist provides direct supervision during the work conditioning sessions as well as
encouragement, support, and reinforcement to the patient while monitoring behaviors.
Workplace Design
This type of ergonomic intervention aims at assessing the relationship between human characteristics (e.g.,
posture, body mechanics) and musculoskeletal stresses with emphasis on work issues. This is a rather complex
process due to the large number of human and environmental factors involved (Khalil et al., 1990). The
ergonomic premise here is that awkward postures and poor body mechanics can result in a multitude of
health problems. With patients who already have an injury or illness, the aches and pains are magnified. The
task of the ergonomist is to assist the patient or employer to design/modify the workstation to ensure:
1. Proper engineering design from an ergonomic point of view.
2. Proper posture of the workplace user.
3. Good body mechanics when performing job tasks.
These issues are also interrelated. For example, poor workplace design can result in poor work habits by
not allowing good posture and proper body mechanics. Additionally, proper design does not guarantee
stress-free environment if good posture and proper body mechanics are not practiced.
The process of workplace design within a clinical setting consists of the following components:
1. Preliminary data collection of patients information, job-related information, and a self description
of a typical workday.
2. Initial evaluation. This is a session of simulated activities during which essential job tasks are
conducted, recorded, and analyzed. Emphasis is on posture, body mechanics, and muscular work
during repetitive activities. This evaluation aims at identifying tasks as potentially stressful. During
this session, no feedback or suggestions for modifications or adjustments are given. Observations
and analysis of video graphic data are used to isolate the critical risk factors with respect to the
worker, the tools, the furniture, and other workplace parameters.
3. Intervention phase. Once risk factors are identified, the ergonomist begins to develop the
interventions specific to reducing/resolving the risk factors. Once more, the interventions usually
address the engineering design of the workplace as well as the posture, body mechanics, and
patients ability to follow through (learning). Engineering measures aim at adjusting, modifying,
changing, and/or replacing current heights, layout, equipment, tools, and design characteristics.
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It is important at this stage to explain to the patient the rationale behind the recommendations in
order to increase his or her awareness and ability to generalize to situations outside work. It is
also not necessary to always make recommendations for new equipment or assistive technologies
(e.g., cushions, ergonomic chairs, etc.). In most cases, workplaces can be reasonably accommodated
to meet ergonomic needs. An essential ergonomic rationale is that people may not have the ideal
ergonomically correct setup wherever they go. It is, therefore, the responsibility of the ergonomist
to teach patients methods of improving safety and comfort without the need for expensive
adjustments.
A tool we have used to aid in the process of analyzing and recommending workplace adjustments
and modifications is SWAD (sitting workplace analysis and design) (Abdel-Moty and Khalil,
1991). SWAD is a computer program resembling artificial intelligence. The inputs to the program
are workplace users demographics, 16 anthropometric dimensions, workplace dimensions, work
tools, and the priority and frequency of use of each work element. SWAD then combines this
information with a knowledge base of ergonomic principles and guidelines and a set of inference
procedures. The output of SWAD is the recommended workplace dimensions, heights, reaches,
foot rest, chair parameters, VDT parameters, and optimal placement of all work tools. SWAD
packages anthropometric data and ergonomic principles into a software available to the medical
community and to workplace users. It enables customization of workstation adjustment without
trial and error.
Also, in this intervention phase, patients posture and body mechanics are corrected and the
effect on reduced muscle activity is demonstrated through the use of EMG. Patients are shown
how to correct movements, minimize awkward postures, and refine their body mechanics. In
most instances, patients can now perform the same job tasks with minimum discomfort.
4. Follow-up evaluation. In order to document the effectiveness of the interventions, a follow-up
evaluation is performed which consists of the patient performing the same simulated activities
performed during the initial evaluation. Also, during this session, no feedback is given. Data are
then analyzed and results are compared to baseline information. In all cases, significant resolution
in the risk factors are observed, muscle activity is decreased reflecting improved economy of
motions and less stress, and patients are able to perform essential work functions with no increase
in pain or discomfort.
Job Site Analysis

The analysis of worksites can be extremely helpful and should follow a systematic method. The process
starts with a data collection phase during which health records are examined in order to identify
priority problem areas/tasks. Data collection also includes photographing work areas, recording
postures and motions, measuring forces and vibration data, and documenting repetitiveness and
frequencies of job cycles.
The data collected are then analyzed and examined to determine the risk factors specific to motion
economy, postures, and body mechanics. Quantitative data are also analyzed to determine if, for example,
forces and vibration data are within exposure ranges.
Recommendations can then be offered to improve working conditions and/or reduce repetitiveness,
vibration, forces, etc. For example, in order to reduce vibration the ergonomists may recommend the
use of dampen technology, reduce contact surface area, reduce exposure to driving force, isolate vibration
or use material that absorbs vibration. Another common risk factor that usually requires ergonomic
intervention is task repetitiveness. Common recommendations to reduce the exposure to high-frequency
activities can be: reducing the number of cycles, augmenting human activities with machines through
automation and mechanization (e.g., use of scanners), enlarging jobs (e.g., providing help to workers),
and when possible alternating use of extremities and job rotation.
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Recommendations often include workers training in proper posture and body mechanics for
performing job tasks. Workers are either taught to maintain the neutral postures of their body joints or
are provided with technological aides to minimize awkward deviations of joints.
In order to reduce muscle force, the ergonomists may recommend using machines to replace human
effort, improving quality of tools to reduce force, changing tool design to allow use of stronger muscles
(e.g., the thumb is stronger than any single finger), modifying design to use multiple muscle groups (e.g.,
group fingers are stronger than the thumb), distributing force over a larger area (e.g., using trigger
strips), reducing force by having a slip prevention design in handheld tools, improving tool balance, use
of proper gloves (e.g., not too tight at the wrist), and utilizing spring action in tools such as scissors and
clippers.
A useful tool in data collection is the use of ergonomic checklists. These are specially designed forms
that facilitate problem identification and documentation. While it may be possible to prepare a generic
checklist, job environments are not alike, thus necessitating customized checklists. An ergonomic checklist
should be designed to focus on the human component of the workplace rather than the workplace itself.
For example, it should be asked Does work surface height permit satisfactory postures of the arms?
rather than What is work surface height?
Biomechanical Analysis, Motion Analysis

Biomechanics is the discipline dedicated to the study of the living body as a structure which can function
properly only within the confines of both the laws of Newtonian mechanics and the biological laws of
life. Occupational biomechanics deals with understanding the complex mechanisms of human interaction
with the industrial environment. A number of biomechanical models have been developed which allow
the prediction of tissue load indices. Some of these mathematical models deal with evaluating the muscle
force and joint reactions for different static postures or during motion. Other models of the lumbosacral
region are used to study the combined stresses and strains on the local ligaments, muscles, and disc
tissue (Khalil and Ramadan, 1987; Andersson and Chaffin, 1986; Adams et al., 1994; Hindle et al.,
1990; McGill and Norman, 1987).
Biomechanical models use different criteria for the evaluation of the muscle and joint forces necessary
for maintaining the human bodys equilibrium during various activities. Some researchers use such
models for the design of manual handling tasks and for the development of a physical job evaluation
methodology. Biomechanical models are usually validated mathematically, experimentally, or through
the use of EMG. The use of biomechanical models in post-injury management is helpful for patient
education and for worksite analysis.
Patient Education
Another task of the clinical ergonomist is to develop patient education programs and materials based on
ergonomics concepts. Patient education is an essential component in the comprehensive rehabilitation
process. This is especially important with chronic pain patients who have been treated and evaluated in
many facilities and have failed various rehabilitation efforts. In addition to the education on pain,
myofascial syndrome, health, diet, relaxation, dealing with flare-ups, activities of daily living, and stress
management issues, patients are educated in workplace/home safety. Patient education takes many forms:
lecture type, group discussions, and hands-on training.
Applied Clinical Research: Innovations in Problem Solving

In the area of applied clinical research, ergonomists evaluate the effectiveness of treatment regimens
upon the restoration of functional abilities and upon the reduction of pain, thus providing objective
rationalization and justification of treatment. Research is also performed to develop and evaluate devices
useful in diagnosis and treatment. Quantitative methods based on recognized approaches are used to
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assist medical professionals in identifying the usefulness of tools and equipment often prescribed for use
in pain management (Zaki et al., 1990).
Another type of research has been necessitated by todays health care environment. This is clinical
outcome research. This involves the development of a computerized program evaluation system to manage
and analyze data regarding patient treatment, satisfaction, and the effectiveness of rehabilitation (Zaki
et al., 1992). Data collection instruments and questionnaires are developed to assess patients self-report
of pain and functional status upon admission to the program, at the conclusion of treatment, and at
regular intervals following discharge (3 months, 6 months, and 1 year). Data are used, not only to
evaluate program effectiveness, but also to measure and improve the quality of care. Ergonomists provide
the research methods, computer expertise, and statistical approach to manage this type of information.
28.12 Ergonomics and the ADA

The Americans with Disabilities Act (ADA, 1992) is a civil rights protection act that provides
comprehensive protection to individuals with disabilities. The ADA addresses disability issues in relation
to employment, public accommodation, transportation, and telecommunication. The application of
ergonomics methods to individuals with disabilities necessitates complete knowledge of the ADA and its
provisions. A review of the ADA is beyond the scope of this chapter; however, a selected number of
relevant issues are discussed here.
According to the ADA, an individual with a disability is (ADA, 1992):
1. A person who has a physical or mental impairment that substantially limits one or more major
life activities
2. Person who has a record of physical or mental impairment that substantially limits one or more
major life activities
3. A person who is regarded as having such an impairment
The ADA prohibits discrimination in all employment practices, including job application procedures,
hiring, firing, advancement, compensation, and training. It applies to recruitment, advertising, tenure,
layoff, leave, fringe benefits, and all other employment-related activities. An employer may not make a
pre-employment inquiry on an application form or in an interview as to whether, or to what extent, an
individual is disabled. The employer may ask a job applicant whether he or she can perform particular
job functions. If the applicant has a disability known to the employer, the employer may ask how he or
she can perform job functions that the employer considers difficult or impossible to perform because of
the disability, and whether an accommodation would be needed. A job offer may be conditioned on the
results of a medical examination, provided that the examination is required for all entering employees in
the same job category regardless of disability, and that information obtained is handled according to
confidentiality requirements specified in the ADA. After an employee enters duty, all medical examinations
and inquiries must be job related and necessary for the conduct of the employers business. The
employment provision of the ADA will, therefore, govern the ergonomists approach to assisting an
employer in designing job applications, job descriptions, and employment offers. It also affects the
approach to functional capacity assessment since evaluations have to be job specific. This, in turn,
means that the use of computerized testing equipment for the evaluation of generic functional abilities
may no longer be valid. Evaluation setting should simulate the work situation. Testing protocols will
need to be changed and modified to meet compliance. The ergonomist can also assist the employer in
developing practical post-offer screening tools in order to test the applicants ability to perform essential
job functions (with or without reasonable accommodations).
The ADA expressly permits employers to establish qualification standards that will exclude individuals
who pose a direct threati.e., a significant riskto the health and safety of others, if that risk cannot be
lowered to an acceptable level by reasonable accommodation. However, an employer may not simply
assume that a threat exists; the employer must establish through objective, medically supportable methods
28-17
that there is genuine risk that substantial harm could occur in the workplace. By requiring employers to
make individualized judgments based on reliable medical evidence rather than on generalizations,
ignorance, fear, patronizing attitudes, or stereotypes, the ADA recognizes the need to balance the interests
of people with disabilities against the legitimate interests of employers in maintaining a safe workplace.
The ergonomist can assist in this area by establishing workplace safety criteria in relation to human
factors while taking medical information into account.
Another core issue in the ADA is reasonable accommodation. Reasonable accommodation is any
modification or adjustment to a job or the work environment which should be made to enable a qualified
applicant or employee with a disability to perform essential job functions. This is another area of primary
relevance to ergonomics. Examples of reasonable accommodation include making existing facilities used by
employees readily accessible to and usable by an individual with a disability; restructuring a job; modifying
work schedules; acquiring or modifying equipment; providing qualified readers or interpreters; or appropriately
modifying examinations, training, or other programs. Reasonable accommodation also may include reassigning
a current employee to a vacant position for which the individual is qualified, if the person becomes disabled
and is unable to do the original job. An employer, however, is not required to make an accommodation if it
would impose an undue hardship on the operation of the employers business.
28.13 Post-Injury Management of the Aging Population

Another population which requires special ergonomic attention is the injured elderly. One of the most
pressing needs in the 1990s is to develop effective ways to serve an increasingly aging population.
In the coming decades the greatest growth is projected for the population aged 55 and over. In fact
between the years 1990 and 2000 this group will increase by 11.5%, a gain of over 6 million persons. Within
this group the greatest growth will be among persons 75 and over, an increase of 26.2% (U.S. Bureau of the
Census, 1988). A question of major policy and fiscal importance is how well will the large population of
elderly be able to live and function independently? It is well established that age-related changes in functional
capacities affect the ability of older individuals to successfully complete daily living activities.
Many elderly persons reside in nursing homes and need some type of assistance to perform basic activities
of daily living. Many others have difficulty functioning well at home and experience a high rate of accidents.
The most frequent types of accidents are falls associated with stairs and steps, floors and floor coverings,
bathtubs and showers, and ladders (Consumer Product Safety Commission, 1985). Many of the accidents
could be prevented with the implementation of appropriate ergonomic intervention strategies. A wide variety
of remedial techniques is already available for hazard reduction. The role of the ergonomist is to provide the
information and products regarding older individuals to caregivers and medical professionals. Currently
there are more than 15,000 assistive products on the market and a number of home safety catalogs available;
however, most elderly home care providers and health care specialists are unaware of their existence. The
ergonomist assists with the training and education. Not only must older people be aware of assistive tools
and safety strategies, they must also understand how to use them. Elderly people must also be aware of safety
issues in the living environment and must learn how to deal with them. Certainly, technological aids are not
effective without appropriate training. Furthermore, this training needs to be directed at the health care
specialist, designers of homes for the elderly, as well as potential users.
Understanding the human factors-related changes in performing daily activities for the aged population
is one of the major aims of the ergonomist (Khalil et al., 1992b). Application of this knowledge to the
design of tasks, equipment, and the home environment in which the elderly live contributes to the
enhancement of their quality of life.
The ergonomic approach in this case will consist of:
1. Studying and understanding accident and hazardous environments of the elderly population
(e.g., stairs and steps, bathtubs and showers, use of tools and appliances)
2. Identifying appropriate hazard intervention strategies
28-18
3. Developing and evaluating education and safety training material to ensure successful
implementation of the hazard interventions
4. Developing techniques to educate and train relevant individuals caring for the elderly
28.14 Ergonomic Interventions Post-Rehabilitation (Prevention of Reinjury)

The continuous spectrum of including ergonomics in injury prevention goes beyond the clinical setting
into post-rehabilitation. The thrust of the ergonomic approach continues to follow up on the worker
once on the job or at home. Strategies used in the post-rehabilitation stage may include:
1.
2.
3.
4.
Immediate matching of the worker to the work.

Job modification based on the recommendations of the clinical ergonomist.
Ongoing screening of workers capabilities.
Development of effective health maintenance programs including onsite stretching and home
exercise programs.
5. Continuity of care through follow-up questionnaires at predetermined intervals. (This is a
requirement of the Commission on the Accreditation of Rehabilitation Facilities, CARF.)
6. Potential involvement with the employer to extend the ergonomic safety interventions to other
workers.
28.15 Who Should Do Ergonomics in Post-Injury Management Programs?

This is by no means a rhetorical question. It represents the reality of practicing ergonomics in clinical
settings. The dilemma facing the ergonomics professions recently has been that anyone can say he or she
is an ergonomist after attending brief training seminars. The field has become attractive to unqualified
individuals who claim association to the profession regardless of education or experience. Recently,
efforts have been made to address this issue. However, more needs to be done to combat the problem of
unqualified individuals presenting themselves as ergonomists.
28.16 Who Pays for Ergonomics Service in a Clinical Setting?

Rehabilitation settings and hospital facilities follow a stringent system of reimbursement through different
types of insurance (e.g., self-insurance, third-party insurance). In most states, workers compensation
provisions allow for reimbursement of necessary and justifiable ergonomic services. There must be a physician
referral for the service, and authorization must be obtained in advance. Charges are then posted according
to specific codes describing the procedure(s) performed, the length of the session, work performed, patients
interactions, and outcome data. In doing so, the ergonomist follows the hospital/rehabilitation facilitys
policies and procedures regarding documentation, reporting, and billing systems.
28.17 Summary
Ergonomics is the missing piece of the puzzle in post-injury management programs. Since 1982, the
University of Miami Comprehensive Pain and Rehabilitation Center realized the importance of including
ergonomics rationale, expertise, personnel, and resources in the day-to-day struggle to return injured
individuals to a productive life style.
The clinical ergonomists have demonstrated that it is possible to return the disabled individual to full
function with a properly designed multidisciplinary therapeutic rehabilitation program. The contribution
of ergonomics to post-injury management has proved to be quite valuable. At the CPRC, ergonomists
28-19
interact with patients as well as other members of the health care team to restore function to the patient.
The involvement of ergonomists in activities of patient evaluation, job simulations, body mechanics
teachings, patient education, and rehabilitation research should be an integral part of pain management
settings.
The capacity to utilize ergonomics in a clinical setting extends beyond treatment to optimization of
the treatment and prognosis of treatment outcome. It also extends to the post-rehabilitation stage where
re-injury can be avoided without the need for expensive technology to solve workplace problems.
It remains the responsibility of the ergonomics profession, its organizations, and governing bodies to
protect the field from less qualified individuals who encroach on the practice of ergonomics in general,
and in clinical settings in particular.
In order to be involved in post-injury management, ergonomists will need to become familiar with
health care trends, reforms, and language. They will require training in and exposure to a host of
rehabilitation and medical issues ranging from hospital policies to documentation and health insurance.
Above all, they will need to adapt to the clinical setting and develop interactive ties with other health
care providers. The reward of helping patients overcome their disability and restore their identity not
only justifies but compels the inclusion of the science and practice of ergonomics in rehabilitation and
all phases of post-injury management.

The book Ergonomics in Back Pain: A Guide to Prevention and Rehabilitation (Van Nostrand Reinhold,
NY, 1993) provides detailed descriptions of the methods and approaches presented in this chapter.
Questions
For specific questions, call Elsayed Abdel-Moty, Ph.D., at (305) 5327246, or write to the Ergonomics
Division, University of Miami Comprehensive Pain and Rehabilitation Center, 600 Alton Road, Miami
Beach, Florida 33139 USA.
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Safety IV, Ed. S.Kumar, p. 11791186, Taylor & Francis, New York.
29
Physical Ability Testing
for Employment
Decision Purposes
Charles K.Anderson
Advanced Ergonomics, Inc.
29.1
29.2
Introduction
Implementation
291
292
29.3
Job Analysis Test Battery Design Validation

Ongoing Practices
295
29.4
Equal Treatment Prior Experience

Summary
296
29.1 Introduction
Much of ergonomic activity is focused on designing or altering the demands of the job so that there is
better match with the capabilities of the workforce. Sometimes, this approach reaches a point where
further change in the job is either cost-prohibitive or technically infeasible at the moment. An alternative
approach is to consider matching workers to the job demands on the basis of their physical abilities. For
instance, if the job requires individuals lift cases weighing 60 pounds and there is no way to reduce the
case weight, one approach would be to assess job candidates ability to lift 60 pounds as part of the
process of determining whether the individual is able to perform the job.
A number of studies have documented the effectiveness of physical ability testing as a means of
identifying individuals who will be able to safely perform a given job (Anderson et al., 1980; Anderson
et al., 1987; Anderson, 1989a,b; Anderson, 1992a,b; Arnold et al., 1982; Ayoub 1983; Cady et al.,
1979; Chaffin et al., 1977; Herrin et al., 1982; Jackson et al., 1984; Jackson et al., 1991a,b; Jackson et
al., 1992; Keyserling 1979; Keyserling et al., 1980a,b; Laughery et al., 1984; Laughery et al., 1988; Liles
et al., 1984; Reilly et al., 1979). The experience of the author is that injury rates for new hires typically
fall 20 to 40% with the implementation of testing (Anderson, 1996).
There are numerous issues that need to be considered when implementing a physical ability test
battery to assure that it will be effective. One of the first concerns is to assure that the test battery will
truly assess what is intended to be assessedthe individuals ability to perform the job. This means that
a thorough job analysis must be performed, tests carefully chosen, and efforts taken to validate that the
battery truly predicts job performance. Without this foundation, the employer may find that the battery
provides no useful information while being a source of additional hiring cost and time delay.
In many countries, including the United States, there is a legal mandate that test batteries be valid
predictors of job performance, particularly if it can be anticipated that protected groups, such as females
and older individuals, will be less likely to pass the battery. In the United States, lack of compliance with
the various pieces of legislation addressing employment testing can result in a company having to pay
back wages to all individuals denied employment on the basis of the test, being required to offer those
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individuals employment, and perhaps in being liable for punitive damages of up to $300,000. Hence,
there are moral, financial, and legal considerations when implementing a physical ability test battery.
The courts prefer that the emphasis be on the ability to perform the job rather than the risk of an
injury or illness that may occur sometime in the future. The basis for this preference is the observation
that employers have sometimes decided not to hire individuals with particular health conditions, such as
a bad back, because of the employers perception that the individual is at increased risk of injury. If
the basis for establishing the battery is risk of injury, the technical assistance manual for Title I of the
Americans with Disabilities Act, which deals with employment discrimination, emphasizes that injury
must be expected to occur in the near future, be severe, and have a significantly higher likelihood in the
population to be denied employment than the risk in the general population (EEOC, 1992).
All of these considerations can be met with a carefully constructed implementation and ongoing
management practice. The implementation consists of the job analysis, test battery design, and validation.
Ongoing practices refer to the steps taken to assure that all individuals are given equal consideration and
the manner in which other information, such as prior experience on a similar job, is integrated in the
decision-making process.
29.2 Implementation
Job Analysis
One of the most critical aspects of the job analysis is to identify the essential functions of the job. These
are the functions that define the purpose of the job and are typically the elements that have to be
performed in order for an employee to be considered satisfactory. In most cases, the essential functions
are the ones that are performed frequently, though there may be situations where a function that is
performed infrequently is still considered essential. For example, the essential function of a warehouse
selector is to lift cases from storage racks to a pallet that will be shipped to a client. A second essential
function is to drive a motorized vehicle that transports the pallet throughout the warehouse. These tasks
comprise the bulk of the selectors activity over the course of the shift. As a counter-example, one of the
essential functions of a firefighter is to respond to emergencies. The amount of time actually spent in
emergency response may be small, but it is essential that the firefighter be able to perform these duties.
An example of a nonessential function for the warehouse selector would be the task of cleaning up
broken cases since selectors rarely need to perform that task and it is an essential function of the janitor.
When developing a physical ability test battery, the degree to which it can be anticipated that there
will be a substantial portion of individuals who will be unable to perform the task is also an important
consideration. If the task can be performed by virtually everyone, then there is little economic justification
for testing applicants since virtually everyone would pass the test.
The cost/benefit analysis can be quantified by calculating the cost of not being able to perform the
task and the probability of an individual not being able to perform the task, and then balancing these
against the cost of testing all applicants for the ability to perform the task. For instance, consider a
situation where 100 employees are hired per year. If there is a 1% probability that an individual could
not perform the task, and the inability to perform the task results in a $2,000 loss associated with hiring
and training the individual, then there is an expected cost of $2,000 per year for not using the test (100
new-hires1% chance of not being able to perform the job$2,000 cost). If the cost of the test is $30 per
applicant and 101 applicants must be tested to find 100 who pass (99% pass rate), the expected cost of
testing would be $3,030 per year. Hence, in this example, it is less costly to not test and accept the risk
that 1% of all the workers will not be able to perform the job (expected cost of $2,000 per year) rather
than test all candidates ($3,030 per year). In contrast, if it can be anticipated that only 80% of new-hires
truly have the ability to perform the job, then the cost of not testing rises to $40,000 per year (100 newhires20% chance of not being able to perform$2,000 cost). The cost of testing would now be $3,750
($30 per test125 applicants tested to find 100 who pass). Under this scenario there is better than a 10to-1 benefit/cost ratio for implementation of testing ($40,000 without testing vs. $3,750 with testing).
Physical Ability Testing for Employment Decision Purposes
29-3
A third consideration during the job analysis is whether the essential functions that are potentially
difficult for a substantial portion of the population can be modified through some form of ergonomic
intervention (i.e., reasonable accommodation). For instance, wholesale grocery delivery drivers have to lift
cases weighing up to 60 pounds on a routine basis. In addition, to access the cases, they must raise the rear
door on their trailer. When brand-new trailers arrive from the manufacturer, virtually no force is required
to open the door. However, the door track can become bent from forklifts running into the track while
loading pallets onto the trailer. This can lead to a situation where a force of up to 200 pounds has to be
exerted to open the door. Obviously, an essential function of the drivers job is to open the trailer door, but
is it reasonable to design a test that assesses the drivers ability to exert 200 pounds to open a jammed
door? An alternative is to require preventative maintenance rather than require the driver to exert 200
pounds. This would reduce the demand for this essential function back into the region where it can be
anticipated that virtually all candidates will be able to perform the task. Hence, in this example, the critical
task for the purposes of test battery design for these drivers would be the ability to lift 60-pound cases.
Test Battery Design

It has already been mentioned that tests should be included only for those essential functions that will be
difficult for a substantial portion (5 to 10% or more) of the applicant population. There are three
additional considerations in designing the test battery.
Job-Relatedness
First, it is critical that the tests bear a high degree of job-relatedness to the essential functions of the job that
are used as the basis for the test battery design. For instance, when testing the ability of an individual to lift
a 60-pound case, the most job-related test would be to have the individual literally demonstrate the ability
to lift a 60-pound case by having him or her move the case through the region (for example, floor to table
level) that is found on the job. In contrast, having the applicant perform a series of exercises such as pushups, chin-ups, and sit-ups would not be a job-related test of the ability to lift a 60-pound case.
Basis for Establishing the Cutoff Score

The second consideration in test selection is the ease with which the cutoff score can be determined. The
cutoff score is the level of test performance required in order to be considered as having demonstrated
the ability to perform the job. Ideally, there is a clear relationship between the cutoff score and the
performance of the job. For instance, if the test for the ability to lift a 60-pound case consists of lifting
a case from floor level to table level, the most job-related cutoff for weight lifted would be 60 pounds.
In contrast, an alternative method is to use normative data. For example, some companies strap the
applicant into a fixture that isolates his or her movement to flexion and extension about the low back.
The test consists of measuring the moment, or torque, that the applicant can then generate with these
muscles. It is difficult to directly measure the moment about the low back required for a given individual
to lift a 60-pound case, since the moment will be a function of the posture used, how rapidly the
individual lifts the case, the anthropometry of the individual, and a host of other factors. The only
alternative is to measure the moment created by a number of incumbents and develop a distribution of
their scores. Conceivably, one could then choose the lowest score of the incumbents and require that the
applicant at least demonstrate the ability to demonstrate that level of strength. A problem with this
approach is that there is no guarantee that the scores demonstrated by the incumbents have a bearing on
what the job requires. For instance, if all of the incumbents are regular participants in heavy weight
training, their strength may be a reflection of the weight training rather than the job requirement.
A second example illustrating the problem of using cutoff scores based on normative data comes
from test batteries used for evaluating police officer candidates. Some batteries for police officers require
that applicants perform a run over a short distance to simulate the essential function of chasing suspects
fleeing on foot. The score for the test is the time taken to cover the distance. The question becomes
How fast must an applicant complete the distance in order to be able to perform the job? One
29-4
approach that has been used is to determine whether the applicants time is above the median for
individuals of their sex and age. The justification has been that one would want their police officers to
be at least as fit as an average person of their sex and age. Unfortunately, this does not speak to whether
the officer can perform the essential function of the job.
Most jobs lend themselves to determining the cutoff scores directly from the job requirements, as
described in the first example given in this sectionhandling 60-pound cases. Likewise, there typically
are testing formats available that will allow the test administrator to assess the ability at issue in a
manner that can be directly compared to the job requirement. Hence, the problems that arise with
utilizing the normative data approach can generally be avoided once the issue is recognized.
Accuracy, Reliability, and Safety

The third consideration is that the tests have a high degree of accuracy, reliability and safety. An accurate
test is one that precisely measures the attribute it purports to measure. A reliable test is one that yields the
same results when it is repeated over time and by different test administrators. Reliability is enhanced
when objective test measures are used rather than subjective assessments or opinions of the test administrator.
Safety is an important consideration, particularly if maximal strength tests are being used. Typically,
steps can be taken to reduce the risk of injury during the test. For instance, an alternative to having the
participant demonstrate the maximum amount of weight they can lift is to ask them to only demonstrate
the ability to lift the weight required by the job. A second safety modification would be to have the
participant first demonstrate the lift with an empty case, and then add weight to the box in fixed
increments so that there is the chance to detect inability to lift the required weight without actually
having the individual attempt the lift with the full weight required on their first effort.
Validation
Statistical Validation Studies
The strongest form of validation is a prospective statistical analysis. The typical form of this type of
analysis involves administering the test to a group of individuals who are about to be hired into the
position in question, although the test scores are not used as part of the hiring decision. The performance
of these individuals is then tracked over the course of their employment. Measures of performance
might be productivity, retention, injury rate, or supervisor evaluation. Care must be taken when selecting
a measure that it reflect the important aspects of job performance and be reliable. Performance for
individuals who pass the test would then be compared to performance for individuals who fail. As an
example, Figure 29.1 shows the worker compensation injury rate for new-hires who failed a physical
test battery compared to the injury rate for their peers who passed the battery designed for grocery
warehouse selectors (Anderson, 1989a). The injury rate for those who failed the test was about double
the rate for those who passed.
The effectiveness of the battery can be projected by comparing the performance of the entire group of
new-hires, which reflects the performance anticipated without implementation of the battery, to the performance
of those individuals who passed the battery. This latter group reflects the performance that would be expected
with implementation of the battery. Table 29.1 summarizes the results calculated in this manner for three
prospective statistical studies performed by the author (Anderson, 1989b; Anderson, 1992a,b).
A less strong form of statistical validation is to compare performance for new-hires who began
employment in time periods prior to and after implementation of the battery. The primary shortfall of
this approach is that there is no control for factors that did not stay constant between the two time
periods, such as work load, job structure, or management policies. The benefit of this type of analysis is
that there is at least some indication of the effectiveness of implementing the battery when it is technically
or economically infeasible to perform a prospective validation study. As noted earlier, the author has
found that worker compensation incidence rates for new-hires typically fall 20 to 40% with
implementation of a well-designed test battery (Anderson, 1996).
29-5
FIGURE 29.1 Worker compensation incidence rate by pass/fail status.

TABLE 29.1 Summary of Expected Impact of Test Battery Implementation
n/adata not available for all locations in the study
Content Validation Studies

The alternative to a statistical validation is a content validation. A content validation study consists of
demonstrating that the content of the job is reflected in the content of the test battery, and that the
cutoffs on the tests reflect the job demands. It is valuable to be able to also make reference to any
statistical validation studies in similar industries that further support the content validity of the battery
at issue.
In the United States, the Equal Employment Opportunity Commission states that a content validation
is acceptable when a statistical validation is technically infeasible (EEOC, 1978). For example, this
could be the case when there is a small number of new-hires on which to base the study, or the job
demands are not homogeneous.
29.3 Ongoing Practices

It is critical to not only carefully construct the test battery, but also the management policies that surround
its use. Four aspects are particularly crucial to assure that the manner in which the test battery is used is
fair to all applicants.
29-6
Equal Treatment
The fundamental consideration is that all applicants must be treated equally. For instance, all applicants
for the job for which the test battery has been designed must be given the same opportunity to test. It is
not considered appropriate to only give the battery to females, individuals over the age of 40, or those
considered disabled under the premise that these are individuals who are most likely to be unable to
perform the job. Furthermore, they should all be given the same information prior to the test. This
information might include instructions to wear loose-fitting clothes, avoid a heavy meal prior to the test,
and have adequate rest the night prior to their appointment.
Another dimension of equal treatment is that the same scoring process must be used for all individuals.
It is generally recommended that the same cutoff be used for all individuals without exception. Problems
arise when managers attempt to factor in their own judgment by allowing some individuals who fall
below the cutoff to be employed, particularly when the decision as to who shall benefit is arbitrary.
Finally, all individuals who fail should be given the same opportunity to be reconsidered. This
opportunity could be structured on the basis of their performance, but must be equally applied. For
instance, all individuals who score within 95% of the cutoff might be offered the chance to retest
immediately. Those who score between 80 and 95% might be allowed to retest after four weeks, whereas
those who score less than 80% have to wait at least eight weeks to retest. There should be a valid basis
for the time periods, such as the percent of improvement in performance that could be expected at
particular points in time with a well-designed physical conditioning program.
Prior Experience
There is only one exception to the policy of rigid interpretation of the cutoff score which occurs when an
individual who fails the test has demonstrated the ability to perform the job during prior experience in
similar employment. It is important to remember that the best indicator of an individuals ability to
perform a job is actual demonstration of that performance. Lacking direct evidence of ability to perform
the job, one might consider performance on a test battery designed to provide information about that
ability. The test battery is not necessarily a perfect indicator, so it is possible that an individual who can
perform the job might fail the battery. Clearly, the battery should be designed so that this possibility is
minimized. This is the reason for selecting tests that bear the closest resemblance to the way the job is
actually performed, carefully selecting the cutoff score and taking all possible steps to assure that the test
scores are valid predictors of job performance.
In the circumstance where there is additional information available about an individuals ability to
perform the job, such as prior experience, this information can be used to override a failing test result.
It is critical, though, that all individuals in similar circumstances be treated the same way. This can be
promoted by establishing clear definitions of what would be considered adequate previous experience
that can be consistently applied in each case that arises. For instance, if an individual applying for a
warehouse selector position has previous experience as a selector yet fails the battery, the manager might
ascertain if the previous experience involved handling cases of similar weight at a similar pace for a
similar shift length using similar equipment (e.g., manual lifting vs. picking full pallets with a forklift). If
all aspects of the previous job and the job at issue are similar, then the prior experience could be used as
a legitimate basis for hiring the individual in spite of the failing test results.
29.4 Summary
Physical ability testing can be an effective way to improve the match between job demands and worker
ability, thereby enhancing performance and reducing the risk of injury. Thorough job analysis is required
to guarantee that the test battery selected is a valid predictor of the ability to perform the essential
functions of the job. Furthermore, it is important to assure that the management policies related to the
utilization of the battery guarantee equal application of its use and interpretation. This includes to
29-7
whom the battery is administered, the information that applicants are given prior to the test, the way
their results are interpreted, and the opportunity for retesting that is extended to those who fail the test.
When the test battery is designed with these factors in mind, it can meet the legal requirements and be an
effective management tool. Results from a wide range of applications indicate that there typically is a 20
to 40% reduction in worker compensation injuries associated with implementation of a well-designed
test battery.
References
Anderson, C.K. Strength and endurance testing for pre-employment placement. K.Kroemer, Ed. Manual
Material Handling: Understanding and Preventing Back Trauma, American Industrial Hygiene
Association, Akron, 1989a.
Anderson, C.K. Impact of physical ability screening for grocery warehousing. Technical Report, Advanced
Ergonomics, Inc., 1989b.
Anderson, C.K. Impact of physical ability testing on injuries and retention for the Coca-Cola Bottlers
Association Technical Report, Advanced Ergonomics, Inc., 1992a.
Anderson, C.K. Impact of physical ability testing on workers compensation injury rate and severity:
target distribution centers. Technical Report, Advanced Ergonomics, Inc., 1992b.
Anderson, C.K. The advanced ergonomics physical ability testing program: a seven year review. Technical
Report, Advanced Ergonomics, Inc., 1996.
Anderson, C.K.; Catterall, M.J. The impact of physical ability testing on incidence rate, severity rate and
productivity. S.S.Asfour, Ed. Trends in Ergonomics/Human Factors IV, Elsevier Science Publishers,
North Holland, 1987.
Anderson, C.K.; Herrin, G.D. Validation study of pre-employment strength testing at Dayton Tire and
Rubber Company. Technical Report, University of Michigan Center for Ergonomics, 1980.
Arnold, J.D.; Rauschenberger, J.M.; Soubel, W.G.; Guion, R.M. Validation and utility of a strength test
for selecting steel workers. Journal of Applied Psychology, 67(5): 588604, 1982.
Ayoub, M.A. Design of a pre-employment screening program. Kvalseth, T.O., Ed. Ergonomics of Workstation Design, Butterworths & Co. London, 1983.
Cady, L.D.; Bischoff, D.P.; OConnell, E.R.; Thomas, P.C.; Allan, J.H. Strength and fitness and subsequent
back injuries in fire fighters. Journal of Occupational Medicine, 21(4): 269272, 1979.
Chaffin, D.B.; Herrin, G.D.; Keyserling, W.M.; Foulke, J.A. Pre-Employment Strength Testing in Selecting
Workers for Materials Handling Jobs. Cincinnati, OH, NIOSH Physiology and Ergonomics Branch.
Contract No. CDC 997462, 1977.
Equal Employment Opportunity Commission (EEOC). Title I of the Americans with Disabilities Act:
EEOCs Technical Assistance Manual 1992.
Equal Employment Opportunity Commission (EEOC). Uniform Guidelines on Employee Selection
Procedures. Title 29, CFR, Part 1607, 1978.
Herrin, G.D.; Kochkin, S.; Scott, V. Development of an employee strength assessment program for
United Airlines. Technical Report, The University of Michigan Center for Ergonomics, 1982.
Jackson, A.S.; Osburn, H.G.; Laughery, K.R. Validity of isometric strength tests for predicting performance
in physically demanding tasks. Proceedings of the Human Factors Society 28th Annual Meeting,
452454, 1984.
Jackson, A.S.; Osburn, H.G.; Laughery, K.R. Validity of isometric strength tests for predicting endurance
work tasks of coal miners. Proceedings of the Human Factors Society 35th Annual Meeting, 753
767, 1991a.
Jackson, A.S.; Osburn, H.G.; Laughery, K.R.; Vaubel, K.P. Strength demands of chemical plant work
tasks. Proceedings of the Human Factors Society 35th Annual Meeting, 758762, 1991b.
Jackson, A.S.; Osburn, H.G.; Laughery, K.R.; Vaubel, K.P. Validity of isometric strength tests for predicting
the capacity to crack, open, and close industrial valves. Proceedings of the Human Factors Society
36th Annual Meeting, 688691, 1992.
29-8
Keyserling, W.M. Isometric Strength Testing in Selecting Workers for Strenuous Jobs. Ph.D. Dissertation,
University of Michigan, Center for Ergonomics, 1979.
Keyserling, W.M.; Herrin, G.D.; Chaffin, D.B. Isometric strength testing as a means of controlling medical
incidents on strenuous jobs. Journal of Occupational Medicine, 22(5): 332336, 1980a.
Keyserling, W.M.; Herrin, G.D.; Chaffin, D.B.; Armstrong, T.A.; Foss, M.L. Establishing an industrial
strength testing program. American Industrial Hygiene Association Journal, 41:730736, 1980b.
Laughery, K.R.; Jackson, A.S. Pre-employment physical test development for roustabout jobs on offshore
platforms. Technical Report, Kerr McGee Corporation, 1984.
Laughery, K.R.; Jackson, A.S.; Fontenelle, G.A. Isometric strength tests: Predicting performance in
physically demanding transport tasks. Proceedings of the Human Factors Society 32nd Annual
Meeting, pp. 695699, 1988.
Liles, D.H.; Deivanayagam, S.; Ayoub, M.M.; Mahajin, P. A job severity index for the evaluation and
control of lifting injury. Human Factors, 26(6):683693, 1984.
Reilly, R.R.; Zedeck, S.; Tenopyr, M.L. Validity and fairness of physical ability tests for predicting
performance in craft jobs. Journal of Applied Psychology, 64(3): 262274, 1979.
30
Preplacement
Strength Screening
30.1
30.2
Valerie J.Rice
30.3
U.S. Army Research Institute of

Environmental Medicine
30.4
Introduction
Literature Review
Predicting Job Performance from Preplacement
Screening Using Preplacement Screening to Predict
Injury Rates
Establishing a Preplacement Screening
Program
Summary
301
302
3014
3015
According to federal employment laws, it is illegal to disqualify an employee for reasons of race, color,
religion, gender, national origin, or disability status. Accordingly, employers are using preplacement
screening tests to determine an individuals ability to safely perform job tasks. This chapter reviews the
pertinent literature related to preplacement screening and derives guidelines for developing job-specific
screening. Both management and workers benefit from the increased productivity and safety resulting
from a well-constructed preplacement screening process.
30.1 Introduction
When hiring new personnel, management has a vested interest in having workers succeed in their jobs.
Workers who will have an acceptable level of productivity and will perform the job safely are needed to
run an efficient operation. In physically demanding jobs, there is a concern that smaller, weaker individuals
may be at greater risk for injury and may be less productive. Job redesign, worker selection, and training
are used in an attempt to ensure safe execution of job requirements. Of these approaches, it is preferred
to design the equipment, job, or task so the majority of workers can perform the task safely and efficiently.
In this way, the risks of injury are controlled by reducing the probability of occurrence. If the task or
tools cannot be redesigned, then selection procedures can be used to identify personnel who meet the
physical requirements of the job. For example, the tasks of fire fighters, police, rescue workers, and
soldiers cannot always be anticipated or redesigned in order to permit persons with lower levels of
physical fitness and strength to complete them. Instead, worker selection procedures are used to select
personnel for these physically demanding jobs.
Pre-employment and preplacement screening refer to the process of administering a test or set of tests
to job applicants in order to discern whether they can safely perform the job in question. Three assumptions
must be accepted before a strength-based screening program is introduced. First, it is assumed the job
and job tasks have been evaluated to determine whether ergonomic redesign was appropriate and any
necessary redesign is complete. Second, the individuals designing the preplacement strength testing program
must believe that they can accurately test a persons physical performance in some manner and use those
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test results to predict successful job performance. Third, it is assumed that an inverse relationship exists
between injury risk and an individuals ability to meet the physical requirements of a job, and that this
relationship can be demonstrated objectively.
The ergonomist must also be acutely aware of the legal issues involved in preplacement strength
screening. The majority of screening programs have the appearance of inherent bias for age, gender, and
disability classification. Therefore, legislation has been enacted in an attempt to eliminate these biases
and provide guidance to base personnel selection criteria on sound business and ethical considerations.
30.2 Literature Review

A number of researchers have examined methods of determining and/or predicting a persons ability to
perform a job or task. Static strength tests (Chaffin et al., 1978; McMahan, 1988) dynamic strength
tests (Kroemer, 1983; Menon and Freivalds, 1985; Pytel and Kamon, 1981), work simulations (Arnold
et al., 1982), calisthenics (Sharkey, 1981), aerobic capacity (Sharp et al., 1980), body composition and
anthropometrics (Misner et al., 1987), and other physical performance measures (Reilly et al., 1979)
have been suggested as evidence of ability to perform physically demanding work. The research is limited,
however, as many of the predictions have centered on simple lifting capacity, rather than multistep
complex tasks such as those involved in most jobs.
For example, Pytel and Kamon (1981) examined the relationship between several dynamic strength
measures (lift, back and arm strength) and a one repetition maximum (1-RM) lift from the floor to a
113 cm height with a psychophysical assessment of a maximal acceptable lift to the same height at a rate
of 6 lifts/min. A prediction equation was developed using dynamic lift strength and gender, accounting
for 94% of the variance. The authors concluded the study demonstrated the usefulness of a simple,
portable isokinetic dynamic strength measuring device; however, it is unknown whether the same
device can be used to predict actual job performance. Teves et al. (1985) examined the use of body
composition and various strength measures to predict a one repetition maximum lift to 132 cm for
military soldiers. This is similar to lifting a box onto the bed of a 2 ton truck. They found that lean
body mass and a lift to a height of 183 cm, using an incremental dynamic lift device, were the best
predictors (R2 = 0.47). They predicted the ability to complete one lift, and no task analysis was mentioned;
therefore, it is unknown whether this was an essential task for the military. Similar difficulties are seen
in other studies predicting individual (Kumar, 1995; Mital and Ayoub, 1980) and team lifting capacities
(Fox, 1982; Karwowski, 1988; Rice et al., 1995).
At face value, perhaps the best measure of job performance is to have the applicant perform the job.
However, having each applicant work at the job, even for a short period, is time consuming, costly, and
may put the applicant at undue risk of injury. Instead, criterion tasks, in the form of work simulations
or task components, are used to predict job performance. It is assumed that testing applicants on an
aspect of job performance that is critical to job success is a valid approach, as it seems to satisfy content
requirements (Wigdor et al., 1991). It also appears to ensure the constructs of job performance are
represented and as long as characteristic samples of each critical element of a job are included, the
validity should be axiomatic (Wigdor et al., 1991, p. 59). In addition to using work simulations to
predict work performance, many screenings use work simulations as the performance to be predicted. In
other words, instead of being on the predictor side of the equation, the work simulation is on the
criterion side of the equation as the standard against which the preplacement screening measures will be
tested. In these cases, various constructs such as strength or aerobic capacity are used to predict
performance on simulated tasks.
The use of isometric strength tests to predict performance is appealing because they are relatively
easy to administer, standardized procedures have been established, test-retest reliability has been established
(Hershenson, 1979; Keyserling et al., 1980a), and they have been shown to be safe in a series of industrial
studies (Chaffin, 1974; Hershenson, 1979; Kamon and Goldfuss, 1978). They have also been found to
be predictive of performance on dynamic tasks (Aghazadeh and Ayoub, 1985; Ayoub et al., 1980;
Preplacement Strength Screening
30-3
Kamon et al., 1982; Kroemer, 1982; Kroemer, 1983; McDaniel et al., 1983). However, accurate predictions
of dynamic tasks from isometric strength tests are not always found, as the differences in mechanical
and physiological processes that occur during static and dynamic strength testing make prediction difficult
(Kroemer, 1970). In addition, strength in one working posture is not necessarily correlated with strength
in another posture (Hershenson, 1979), and maximal isometric lifting strength is not necessarily a predictor
of psychophysically acceptable levels of lifting (Garg et al., 1980).
Predicting Job Performance from Preplacement Screening

Simulated job performance. A review of over 21 research studies designed to predict work performance
revealed the use of static (isometric), dynamic (isotonic), and combined strength tests (task simulations)
to predict job performance, with varying degrees of success (see Table 30.1 at end of chapter). Predictions
accounted for anywhere from 12 to 90% of the variance. The most successful predictions, those that
accounted for 60% of the variance or more demonstrated several consistencies (Arnold et al., 1982;
Celentano et al., 1984; Davis et al., 1982; Jackson et al, 1984; Rice and Sharp, 1994; Robertson, 1982;
Robertson and Trent, 1985; Schonfeld et al., 1990; Sharkey, 1981; Stalhammar et al., 1992; Wilmore
and Davis, 1979). All performed a well-constructed job analysis, with a breakdown of job tasks into
component parts, using multiple assessment techniques: interviews with ratings of key tasks for frequency,
duration, and difficulty; direct observation, videotaping, measurements of masses moved and forces
exerted; and identification of pace and frequency. As a result, all of the highly successful evaluations
examined multiple constructs determined from the job analysis.
Sharkey (1981) (Table 30.1) found that unless the full complement of pertinent measures (with a
combination of constructs) was used, screening did not guarantee positive results. The inclusion of
multiple factors increases the predictive ability, due to correctly identifying essential components of the
task. For example, Rice and Sharp (1994) evaluated seven strength measures, three Army Physical Fitness
Test scores, and three physical descriptors for their ability to predict performance on two stretcher-carry
tasks (Table 30.1). The best predictors for repeated short distance stretcher-carrying were 2-mile run
time (aerobic factor) and peak handgrip (strength factor) (R2 range from 0.74 to 0.78). For a continuous
carry, a sustained mean grip strength was the best predictor of performance (R2 range from 0.74 to
0.78). The results illustrate the necessity for tailoring preplacement tests to accurately reflect job demands,
as different predictors were selected for each type of stretcher-carrying task.
It also appears that use of consolidated or summed scores either as the dependent or independent
variable may strengthen the predictive ability of a model. This procedure has been used with an isometric
test battery administered to coal miners (Laughery et al., 1986), roughneck and roustabout positions in
oil drilling and production operations (Jackson, 1984), and operator positions in refining and chemical
manufacturing (Jackson, 1986 as cited in Jackson, 1994). In their study of oil drilling operations, Jackson
et al. (1984) used three strength tests and one arm endurance test to predict performance in several work
simulations (Table 30.1). A composite score for the strength battery was used, resulting in correlations
between the isometric strength tests and work sample tests ranging from 0.67 to 0.93, with equal validity
for men and women. In another study by the same authors (Jackson et al., 1991) (Table 30.1), a composite
of the isometric strength tests was found to be a valid predictor of endurance work tasks, again with the
measure being valid for both men and women (accounting for up to 87% of the variance, Table 30.1).
Other studies have also used this technique with positive results (Laughery et al., 1988), with one study
concluding that task performance was dependent on strength rather than gender, and the higher the sum
of an individuals isometric strength, the greater the probability of success on work simulations (Jackson
et al., 1991). The commonalities in the studies conducted by these authors are their meticulous attention
to task analysis, inclusion on all pertinent performance constructs, and the use of a composite score to
predict performance on job simulations. However, since the use of a composite score can artificially
raise the R2 value, it is debatable whether its use adds or detracts from a prediction. Arnold et al. (1982)
used a composite score on the other side of the equation (Table 30.1). General physical abilities thought
to be required for work simulations of moving/carrying, lifting, wheelbarrowing, and shoveling were
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used as a test battery to predict a composite score derived from several work simulations. Each of the
simulations was evaluated by observers and objective measures were used for as many tasks as possible
(strength, number of objects moved during a timed session). The best single predictor was the strength
measure attained with the arm dynamometer, accounting for 67% to 72% of the variance of a composite
score.
On-the-job performance. Table 30.1 also contains studies that examine the ability to predict
performance and productivity while in training or on the job (Anderson, 1988; Anderson and Catterall,
1989; Arnold et al., 1982; Bernauer and Bonanno, 1975; Doolittle et al., 1988; Hogan, 1985; Reilly et
al., 1979). Certainly attrition is one aspect of productivity, since retraining is required following most
job changes. In one study of transfers from jobs with heavy demands vs. jobs with light demands, it was
found that men left the heavy demand jobs at a rate almost double to those with light demands (34% vs.
57%), and womens transfers from heavy jobs were more than triple those from light jobs (23% vs.
75%, Kowal, 1983). Robertson (1992) discussed the idea that personnel whose strength capacity
marginally meets the strength requirements of a task may fatigue at a significantly faster rate. For jobs
requiring repeated heavy strength exertions, it can be assumed individuals with lower strength will be
put at a performance disadvantage and increased risk of injury.
However, results of other studies do not support the relationship between worker strength and
productivity. The job demands and loads on the lumbosacral spine of National Guard mechanics
were compared to static strength physical capacity testing of the same workers (arm lift, back lift, and
floor lift) (Pedersen et al., 1989). Results indicated up to a 38% job mismatch between requirements
and capabilities; however, it was not clear how the workers were able to perform the job with such a
mismatch. They were currently working (and presumably performing successfully) in those jobs,
although they reported a high incidence of low back pain. It is possible they completed their work
through development of alternate methods for task completion or through informal selection (letting
the stronger individuals perform the heavier jobs), but the usefulness of the study results are questionable
without this information. General physical fitness has not been found to be predictive of successful
job performance. Wilmore and Davis (1979) found no difference in general physical fitness levels
between California Highway Patrol officers who received high vs. low supervisory ratings. Nor did
they find differences in the physical fitness of police officers compared with other researchers results
for the general public.
Researchers have also examined the ability to predict success during training. Bernauer and Bonanno
(1975) investigated applicants for pole climbing jobs using body fat, arm strength, trunk strength,
cardiovascular fitness, response time, and body balance. The mean scores for the step test and balance
were found to differ for successful and unsuccessful applicants. Hogan (1985) also evaluated successful
training completion (Table 30.1), using a test battery of 23 measures and five widely recognized physical
fitness batteries. Performance results were compared with receiving either a pass or fail, and with nine
performance rating scales (completed by three independent instructors). Multiple regression revealed
that cardiovascular fitness, muscular endurance, and flexibility were highly related to program completion
and overall potential ratings (Table 30.1). Results from the five physical fitness batteries yielded multiple
Rs ranging from 0.38 to 0.60 for prediction of final outcome (pass/fail). Although a comparison with
actual job performance might be preferable, these results indicate that models can be developed for
predicting training attrition.
Few studies have gone the extra distance to try and predict actual job performance. Instead many
researchers assume that being able to complete a task simulation of the most demanding portion of the
job is indicative of an individuals ability to perform the job. This may be accurate, but becomes
questionable if a one-time administration of a task is used as the criterion, when repeated performances
are required on the job. Those research evaluations that have included this last step to ensure that their
measure is predictive of successful job performance appear more persuasive for court challenges of
preplacement testing.
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Anderson and Catterall (1989) studied job productivity and turnover of initial applicants (Table
30.1). They conducted a prospective validation involving grocery warehousemen and demonstrated
that use of a screening battery decreased turnover and increased productivity. It was also demonstrated
that the more stringent the cutoff criteria, the greater the productivity. The test battery consisted of two
isometric strength tests and a step test, based on a thorough job analysis. Criteria were established based
on the heaviest cases to be moved (60 to 100 lbs) and an estimated aerobic capacity three times the
average metabolic requirement of the job (15 kcal/min).
Considerations in predicting performance. One difficulty in reviewing the literature is that researchers
vary in the methods they use and how they report their data. For example, several authors did not report
the r values or used correlations without any regression analysis. Although a correlation or prediction
may be significant (p < 0.05), if it only accounts for 30% of the variance, the model may be questionable
in court challenges of its ability to foretell job performance.
Another challenge is where to place the cutoff criterion. It would appear that determining the cutoff
criterion by the exact job requirements would be the ideal. For example, if the job requires a 75-lb. lift,
then have the job applicant perform a 75-lb. lift.
The more challenging position comes with tasks requiring repetitive heavy physical demands, as it is
unlikely that preplacement testing could incorporate four lifts per minute for a full day due to time,
financial constraints, and safety concerns. Instead, if some examiners observe an applicant straining, out
of breath, or demonstrating a high heart rate and slow recovery, they report that information to the
physician for consideration in the final medical report. Should an applicant be denied a particular
position based on this analysis and challenge the medical and preplacement screening, the problem will
be in demonstrating that although the person could perform the basic task, these observations would
indeed indicate an inability to do the job or increased risk to themselves or others.
A better procedure would be to establish a rigorous statistical model that is predictive of performance.
For example, Anderson and Catterall (1989) demonstrated the more stringent the pass cutoff score, the
more likely personnel were to stay for 8 weeks and the more productive they were.
Ayoub (1982) introduced a method to determine cut scores for exercise intensity relative to the
individual. He suggested that cutoff scores for heart rate be based on a percentage of their heart rate
maximum. He suggested that cutoff scores for heart rate as those falling below 75% are acceptable,
those between 75% and 80% are marginal, and those above 80% are unacceptable. For strength, he
suggests a cutoff of 50% of a persons maximum strength; applicants falling below 50% are acceptable,
those between 50% and 60% are marginal, and those above 60% are unacceptable.
Dr. Ayoub noted the rationale for pre-employment screening, and these cutoff scores are explainable,
integrative (consider all aspects of the physical and physiological properties of human work capacity),
and can be used for jobs characterized by brief exertions as well as sustained performance. However, his
recommendations are conservative and appear more focused on sustained activity rather than brief
periods of high activity.
Caution should be used if assessing personnel who are currently performing the job to establish
cutoff criteria. This could lead to misleading conclusions, as these persons have developed the skills,
strength, and knowledge regarding task requirements. Use of a cutoff score that allows for improvement
through a training program could be one solution.
The military services accept the fact that physical strength will be necessary and include physical
training as part of a soldiers entry level instruction, job requirements, and performance assessment.
Civilian counterparts may be less likely to invest the time and funding in such an effort, instead
recommending that persons who are unable to qualify for a given position may be able to train on their
own and reapply for a position.
TABLE 30.1 Prediction of Performance
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TABLE 30.1 (continued) Prediction of Performance
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= predicted
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Using Preplacement Screening to Predict Injury Rates

There is some evidence for an association between physically demanding jobs and injury rates, which
could lead to the assumption that workers who are better able to meet the physical demands are less
prone to injury. Physical fitness was found to be predictive of back injuries for fire fighters; however, the
injuries sustained by the fit group were more severe than those of the unfit group (Cady et al., 1979).
Load transportation in narrow spaces was found to be associated with musculoskeletal (especially spinal)
injury (Stalhammar et al., 1992), and increased incidence and severity of low back pain has been found
in people who work in jobs requiring lifting and moving of heavy loads (Wickstrom, 1978; Kosiak et al.,
1968; Rowe, 1969). Although most individuals with back problems cannot associate the onset of their
symptoms with an accident or unusual activity, those who can cite a specific event, cite lifting (Cady et
al., 1979; Snook et al., 1978). In a retrospective review of back injuries, it was demonstrated that the
most common event associated with back injury claims was manual materials handling, and improper
lifting was most frequently listed as the cause (Bigos et al., 1986).
A previous history of back pain (Biering-Sorensen, 1984; Bigos et al., 1986) and/or a change of
occupation to heavier work (Nordgren et al., 1980) have been suggested as potential predictors of
consequent back pain. Persons experiencing back pain within the last 6 months have been found to have
a higher incidence of subsequent back problems (Batti et al., 1989), which is consistent with the idea
that recurrences (of back injury) are more likely in the 2 to 3 years following an injury. However,
Venning et al. (1987) found work-related factors such as the job category and exposure levels have
greater contributions to back injury than did a previous history of back pain.
Table 30.2 contains a synopsis of studies relating preplacement screenings with injuries. Strength has
been identified as a potential risk factor for back injuries by a number of researchers (Biering-Sorensen,
1984; Cady et al., 1979; Chaffin et al., 1978; Doolittle and Kaiala, 1986; Keyserling et al., 1980a; Nachemson
and Lindh, 1969). In fact, it has been over 20 years since researchers identified an association between an
increased chance of injury with strength capabilities of workers (Chaffin, 1974; Chaffin, 1971; Rowe,
1971). However, Hagberg et al. (1995) reviewed 25 articles dealing with preplacement or pre-employment
screening and concluded that at present there is no scientific evidence to support the use of pre-employment
or preplacement screening tests to predict the development of work-related musculoskeletal disorders, nor
are they justified from an ethical and, in some countries, legal point of view (p. 336).
Several articles provide direct support for this viewpoint. Batti et al. (1989) examined isometric
lifting strength as a predictor of industrial back pain. During a 4-year follow-up, those with greater
isometric strength were found to be at greater risk for injury than were weaker workers. However, after
controlling for age, no significant difference was seen. These researchers concluded that isometric lifting
strength testing was ineffective in identifying individuals at risk for industrial back problems. Anecdotally,
in military operations, it has been suggested that natural selection occurs with stronger workers executing
the heavier work more often. Dueker et al. (1994) measured isokinetic trunk flexion and extension, as
well as repetitive isotonic lifting (Table 30.2), and monitored the workers for 6 years. No difference was
found between any isokinetic scores of injured vs. non-injured workers. Mostardi et al. (1992) used an
isokinetic (Cybex) lifting device to measure lifting capacity of nurses. After following the workers for 2
years, the authors concluded that isokinetic lifting strength was not related to occupational back injury.
Several elements were missing from these studies. The design of the strength measures was not based on
a precise task analysis (at least none was reported), and no other constructs (aerobic capacity, movement
quality) were included.
Several studies have demonstrated the positive effect of an individuals strength capacity meeting or
exceeding job requirements (Chaffin, 1974; Chaffin et al., 1978). In Chaffins seminal work, he examined
subjects maximal acceptable isometric lifting capacity and compared it with job requirements. The hypothesis
was that those with higher job strength ratios (job lift requirements average acceptable lift) would be
more likely to experience low back pain. The hypothesis was upheld, as a sharp increase in the mean low
back pain incidence rates was found for those jobs populated by persons without strength equal to or
exceeding that required by the job. The medical incidence rate of workers with insufficient strength to
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meet job demands was nearly three times the rate of workers who were matched to their jobs (Chaffin,
1974). Three subsequent prospective studies used isometric tests that were similar to job requirements and
compared those results with the job requirements (Chaffin et al., 1978; Keyserling et al., 1980a; Keyserling
et al., 1980b). Results revealed greater injury rates when the job demands approached or exceeded the
persons abilities. The authors concluded that workers whose strength abilities were less than job
requirements suffered higher incidence rates in general than workers whose strength matched or exceeded
job demands. However, excess strength was not found to be of protective value. Anderson (1988) found
incidence rates were 34% greater for persons who did not meet job strength requirements (below criteria)
compared with those who met or exceeded the requirements. He also noted that workers below criteria
had more lost duty time and higher worker compensation costs (although the data were not statistically
analyzed), and workers above criteria were more productive. The authors suggested the use of a screening
battery could result in an increase in productivity and a reduction of back injuries, over-exertion injuries,
incurred compensation costs, and lost time. Although the results demonstrated that workers who met the
criteria were less likely to report back or over-exertion injuries, this was not true for all five jobs studied,
even though they were considered physically demanding.
Other methods of decreasing injuries in the workplace have been suggested in early reports by Snook
et al. (1978) and later by Doolittle and Daniel (1989). Their suggestions focused on limiting the
requirements of the task. For Snook et al. (1978) the limitations were based on his research using
maximal acceptable strength tasks, while Doolittle and Daniels limitations used the NIOSH lifting
formula and previous research by Ayoub et al. (1984). Snook et al. (1978) determined that a worker is
three times more susceptible to low back injury if exposed to manual handling tasks that less than 75%
of the population find acceptable and, therefore, that 67% of the injuries could be avoided through
ergonomic design. Troup et al. (1987) also found that lifting capability, expressed as a rating of acceptable
load, was related to the development of future low back pain of bakery workers. The physically demanding
tasks were compared with the 1981 NIOSH lifting guide, and the authors recommended preassignment
screening to select workers who are physically capable of performing the job in order to prevent injuries.
They further recommended that workers not exceed 75% of maximum capability based on Ayoubs
recommendations (Ayoub, 1982). Rather than a pure cutoff score, they suggested ranking candidates
into four performance levels: below minimum (applicant taxed at more than 40% maximum aerobic
capacity and more than 95% strength capacity), marginal (40% aerobic capacity and 85% strength),
acceptable (33% to 40% aerobic and 75% strength), and better qualified (<33% maximum aerobic
capacity and <65% strength). Similar procedures were used for screening fire fighters (Doolittle and
Kaiyala, 1987) and for identifying physically demanding jobs for line workers (Doolittle et al., 1988);
however, neither article included research to demonstrate that their method actually reduced injuries of
workers.
One of the more convincing reports was published in a recent study by Karwowski et al. (1994)
(Table 30.2). They examined the relationship between the NIOSH 1991 Lifting Index, estimated
compressive and shear forces on L5/S1, and back injury incidence rates. Strong, positive correlations
were found between the maximum compressive forces and the maximum lifting index for the job (r =
0.88, p = 0.05), with similar findings between the average compressive forces and the average lifting
index. Strong correlations were also found between the average recommended weight limit (RWL) and
the maximum incidence rate of low back injury (r = .97, p = 0.004), and between the Lifting Index (ratio
between the actual load lifted and the RWL) and incidence rate for 1992 (r = .94, p = 0.1) and 1993 (r
= .97, p = 0.007). Although no prediction equations were used, Reimer et al. (1994) found that use of a
worker fitness evaluation, based on job-related lifting and trunk function, reduced injury rates over a 4year follow-up period.
It appears that there is a relationship between preplacement strength measures and injuries, but the
associations were not as strong or as consistent with those found between preplacement testing and
performance. Once again, it appears that basing the criterion tasks on a well-designed task analysis is
essential. Although not as obvious, it also appears beneficial for other constructs such as aerobic capacity
to be included in the assessment. Certainly, additional rigorous evaluation of this assumption is warranted.
TABLE 30.2 Prediction of Injury
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30.3 Establishing a Preplacement Screening Program

The goal of a preplacement program is to match the job requirements with a workers capacity in order
to ensure productivity and safety. As stated by Keyserling et al. (1980b), preplacement testing should be
safe, reliable, quantitative, practical (time, equipment, financial expenses, supervision/manpower-ease
of administration, availability), related to job requirements, and predictive of job performance and/or
risk of future illness or injury. Preplacement screening may result in fewer older individuals, women, and
persons with disabilities being hired for certain jobs. As long as the assessment batteries are carefully
developed, validated, and alternate methods of completing a task are considered so that it is evident the
preplacement screening is based on the job requirements, this should not be an issue of undue concern.
The steps in developing a preplacement screening program are in outline form in Appendix A (preceding
the Reference list for this chapter). During the job analysis, it is important to consider the skill levels and
degree of competency required in each job. In order to do this, ergonomists must be directly involved in the
job analysis. They should interview the subject matter experts (i.e., the workers, supervisors, administrators,
and safety personnel; consult training manuals), observe, and conduct careful assessments of the job to
include frequency, duration, and difficulty, measurements of masses moved and forces exerted; and
identification of pace, frequency, and postural constraints. The ergonomist should also be aware of
confounding factors such as noise and calibration of equipment. It is important to reiterate that each
preplacement test will most likely differ for distinct jobs, all of which may be physically demanding. No
studies have shown that the same preplacement/prescreening evaluations have been predictive of job
performance or injury rates in multiple physically demanding jobs. Instead, the more successful reports
have come from authors who tailored their assessments to the jobs in question (Jackson, 1994).
From the job analysis, an accurate description of the task requirements (essential job functions) with
limiters should be identified. Every essential function does not need to become part of the preplacement
evaluation. For example, if one of the essential functions requires the worker to lift a 40-lb. box, carry
it 15 ft, and place it on a 4-ft. shelf and a second essential function requires the worker to lift a 30-lb.
box to 2 ft, it can be assumed that an applicant who can complete the former task, can also complete the
latter task. The first task (lift and carry) is a limiter Once a task analysis is complete, the description
of the tasks should be presented to the company subject matter experts and revised as necessary. The
preplacement job simulations and test battery should then be derived from the task descriptions of the
essential functions, and the model of evaluation and criterion measures should be identified.
Kroemer et al. (1988) described various models to identify limiting factors, such as a linear anatomical
model of the long bones, joints, and muscles to describe volume, mass, and muscle strength; physiological
models using oxygen consumption, energy expenditure, and circulatory demands; orthopedic models
using a prediction of musculoskeletal injuries; biomechanical models which may use anatomical,
anthropometric, and orthopedic measures; and psychophysical models which evaluate synergistic mental
and physical functions. One of these models, or a combination of them, must be selected for use in
developing a preplacement screening evaluation.
The type of model selected will determine the test measures that will be used. For example, a medical
examination may be used when employing an orthopedic model, and a lumbar motion monitor may be used
to assess biomechanical limitations, such as the load-bearing capacities of the spine (Marras et al., 1992;
Marras et al., 1995). Hogan (1991) conducted a review of literature and a series of evaluations on the
physical requirements of tasks as reflected in job analysis. As a result of these evaluations, Hogan suggested
that the structure of physical performance has three major components: strength, endurance, and movement
quality. Hogan concluded that all occupational task performances fit within these three constructs. Although
examination of specific subcomponents may be necessary, Hogan (1991) suggests using this taxonomy to
organize worker selection procedures, and hence the test measures, for physically demanding jobs. Each
model and test measure has its own strengths and weaknesses and its own proponents and adversaries.
Generally, it may be easier to develop a job simulation and consequently identify subelements that
can then be used in a test battery. Many researchers prefer the use of a test battery, rather than task
simulations in their preplacement screening. Test batteries are repeatable, require less skill from the
30-15
participants (and often from the evaluators), can be used in a variety of locations, and require less
equipment compared with task simulations. Of course, task simulations have greater face validity. Once
the job simulation and test batteries have been developed, they should be compared using statistical
analysis to determine whether one is representative of the other. If they are closely related, then only one
need be used to predict on-the-job performance. Although the ADA and EEOC requirements do not
include validation studies per se, it behooves those conducting the preplacement screening to be aware
of the predictive ability of their simulations and test batteries. If possible, it would be wise to conduct a
validation study in which either the job simulation, the test battery, or both are statistically examined
for their relationship (association and predictive ability) with on-the-job performance. Thus, the
ergonomist can establish that the preplacement testing does what it purports to do, and potentially, the
results will be more defensible.
Once a job simulation or test battery is selected and implemented, it is desirable to conduct a followup analysis on the effectiveness of the preplacement screening through the evaluation of both productivity
and injury data. Although the investigators can select any amount of time for a follow-up period, it is
recommended that it be a minimum of 18 months to attempt to eliminate a placebo effect.
As mentioned previously, the preplacement tests should be reliable (giving the same evaluation at
different times should yield the same result), and the safety of the applicants should be of utmost
importance. Isometric strength tests have exhibited test-retest coefficients-of-variation ranging between
5% and 15% (Hershenson, 1979, Keyserling et al., 1980b), and have been shown to be safe in a series
of industrial studies (Hershenson, 1979; Chaffin, 1974; Kamon et al., 1978). For task simulations, testretest reliability evaluations may become part of the validation process. Simulations must also be fair. If
they are too complex, learning and skill development can contaminate the assessment capabilities.
It will not always be possible to include each of the steps in Appendix A, due to funding or contract
restraints of the hiring company. It is imperative that the researcher/ergonomist developing the
preplacement screening evaluation be comfortable with the level and stringency of the particular program.
It is possible that both the hiring company and the involved contractor could be questioned, should an
applicant decide to challenge the validity of the preplacement process. The developer of the preplacement
screening evaluation is not relieved of the duty to meet test validation requirements, even if the test user
(hiring company) did not request the test be validated or asked for a lesser standard.
An inordinate amount of testing is undesirable due to time and funding costs, and the use of validation
testing should assist in honing the preplacement evaluation. A direct relationship between the preplacement
evaluation and task demands should be unequivocal. However, the requirement for business necessity
may be more lenient if there is a high degree of risk to the job or if all or substantially all, women would
be unable to perform the job safely and efficiently because of the strenuous manual labor required. For
this reason, a validation of injury potential should be just as rigorous as the validation of the prediction
of work performance.
30.4 Summary
According to federal employment laws, it is illegal to disqualify an employee for reasons of race, color,
religion, gender, national origin, or disability status. Accordingly, employers are using preplacement
screening tests to determine an individuals ability to safely and effectively perform a job. To date, there
have been successful challenges to preplacement screening which failed to test important job actions
(Jackson, 1994). Using a well-defined, scientific approach, it is possible to design a preplacement screening
battery that is directly related to (and predictive of) job performance. It is also possible to use the
preplacement screening to prospectively determine its impact on injuries, workers compensation, lost
workdays, and turnover. Following the evaluation and completion of ergonomic design alterations, a
preplacement screening program should be the next step in ensuring a match between work demands
and worker abilities for physically demanding positions. Both management and workers will benefit
from the resulting increases in productivity and safety.
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Appendix A
I.
Job Analysis
A. Job descriptions
B. Observation/Videotaping
C. Interview/Survey (subject matter experts, management/workers)
1. Difficulty
2. Frequency
3. Importance
4. Other means to accomplish tasks
D. Direct measurement
1. Heights
2. Weights
3. Distances
4. Frequency
5. Pace
E. Develop task list/description of essential functions
II. Presentation and Alteration

A. Present to company
1. Officials
2. Supervisors
3. Workers
B. Modify task list, as needed
C. Suggest uses of task list
1. Preplacement screening
2. Return to work of injured employees
3. Graded introduction to task demands for new workers
4. Americans with Disabilities Act compliant job advertisements
III. Preplacement Test Development
A. Develop simulation (criterion tasks with standards of performance) and may include task
limiters
1. Lifting, carrying, pushing/pulling, digging, or climbing,
a. Single
b. Repetitive
c. Location of beginning/ending object placement
d. Object description (handles, size, mass, etc.)
e. Posture requirements
f. Distance
2. Aerobic demands
3. Other
B. Identify task elements from task simulation
1. Range of motion
2. Strength
3. Endurance
4. Coordination
5. Positioning/posture
C. Development of preplacement test battery from task elements
D. Development of necessary instrumentation
IV. Test new (avoid cumulative injury confounds) and current workers
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A. On job task simulations

B. On preplacement test battery
V. Validation of task simulation, test battery, and on-the-job performance
A. Compare scores on task simulation and test battery
1. Multiple correlations
2. Regression equations
3. Other statistical methods as needed
B. Validation of task simulation and test battery with on-the-job work performance
1. Follow workers for specified period of time and record on-the-job data
a. Descriptive data (age, weight, job, etc.)
b. Work performance (productivity, supervisor ratings)
c. Lost duty time
d. Turnover/retention
2. Record potential confounding factors, such as pertinent changes at company
a. New safety programs
b. Reorganization
c. Other
3. Compare scores on task simulations and test battery with on-the-job work performance
a. Multiple correlations
b. Regression equations
c. Other methods as needed
VI. Validation studies of test battery and task simulation with injury data
A. Follow-up study for specified period of time (suggested minimum of 18 months)
1. Tabulate data of new and current workers
a. Descriptive data (age, weight, job, etc.)
b. Injury rates (categorized by type of injury/illness)
c. Lost duty time due to injuries
d. Turnover/retention
2. Record potential confounding factors, such as pertinent changes at company
a. New safety programs
b. Reorganization
c. Other
B. Compare test battery and task simulation with injury data
1. Multiple correlation
2. Regression
3. Other methods as needed
VII. Report findings to company management
VIII. Revise preplacement strength test battery and/or simulation in accordance with findings
IX. Repeat steps IV-X, as necessary
30-18
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31
Assessment of Worker
Functional Capacities
31.1
31.2
Introduction
Worker Assessments
31.3
Definitions Components Standardization Worker

Assessment Principles Assessment Reports
The Provider of Worker Assessments
317
31.4
Outcomes
317
31.5
JPA Outcomes
After the Assessment Results Are In
319
31.6
Diversification Options
319
31.7
Mobile Assessments Mobile Occupational Health

Clinic Onsite Services
Conclusion
3111
Glenda L.Key
KEY Method
311
311
31.1 Introduction
There are nearly 500,000 U.S. workers each year who, as a result of injury, are unable to resume their
jobs for long periods of time. Low back pain will afflict roughly 80% of the population at some time in
their lives (Wheeler and Hanley, 1995). Workers compensation costs have reached $70 billion per year,
tripling since 1980. The direct cost of the situation is staggering and in each case the degree of loss is
unpredictable.
The knowledge of what a workers functional capabilities are, is one of the most valuable pieces of
information that a professional can have for reducing workers compensation costs and prevention of
injury in the workplace today. There are two occasions in the employment of a worker when it is critical
to know just what the physical work capability of that worker is. One occurs during the decision to hire,
and the other is upon return to work of an injured employee. The focus of this chapter will be on these
two occasions as highlighted in Figure 31.1, the Worker Care Spectrum representing assessment of
worker functional capabilities.
31.2 Worker Assessments

Definitions
Functional Capacity Assessment
The functional capacity assessment (FCA) is a return-to-work testing process that determines an individuals
physical functional work-related capabilities through measuring, recording, and analyzing data gathered
during a standardized physical testing procedure. There are many different formats of functional capacity
0-8493-1800-9/03/$0.00+$1.50
31-1
31-2
FIGURE 31.1 Industrial therapy worker care spectrum.
assessments and almost as many names for them. The term used may be physical capacity assessment,
functional capacity evaluation, work capacity evaluation, or work assessment. For the purposes of this
chapter, the term functional capacity assessment is used.
The activities of an FCA include materials handling functions of lifting, carrying, pushing, and pulling.
It also includes tolerances of posture such as standing, sitting, kneeling, crawling, and activities of
walking and stair climbing (Key, 1995a).
Simulation of the movements and postures during the weighted activities and standardizing for
consistency of instruction, weight loading protocols, and determining termination points are primary
issues that need to be considered in a functional capacity assessment. An FCA allows for the testing of
the individual to confirm meeting or not meeting the minimum physical requirements of the job.
As quickly as possible, the workers should be returned to their jobs and workplaceseven if they are
unable to be fully productive. Athletes do not wait until they are fully recovered before they start back
in practice or training. They work their bodies to the point where they still maintain safety and will not
reinjure themselves. Their capabilities are built up gradually until they are back in their game. It does
not mean that they play without pain. It does not mean that they can do everything as well as or in the
same manner as before. This approach applies to the injured worker as it does to the athlete.
Job Placement Assessment

The job placement assessment (JPA) provides data prior to hiring that assists managers in making decisions
resulting in significantly decreased incident rates in the future. When armed with the information of the
requirements of the job as provided through a job analysis and job description, and the physical abilities
of the individual as provided through a job placement assessment, it is relatively easy to determine
whether persons should be hired into a specific job or not. If they meet the requirements of the job, the
answer is Yes. If they do not meet the requirements of the job, the answer is No.
The job placement assessment is a series of specific, objective, and standardized protocols followed
in a consistent progression to allow for objective, accurate, and repeatable results (Frey, 1995). These
results identify the prospective employees work capabilities in the areas of lifting, carrying, pushing,
pulling, and other job-specific activities.
31-3
The continuous and significant increase cost of health care and workers compensation has added to
the already inherent need to have healthy, productive employees. This process begins with hiring individuals
who are able to physically perform the requirements of the job. How can employers tell if their next hire
will be their best employee or become their worst workers compensation and litigation nightmare?
The employee has the most to gain and lose if decisions are made based on anything other than
accurate data. At the time of hire, the prospective employee has the right to be judged through a
nondiscriminatory process. Generally, his or her personal need is to be employed and be a productive
part of society. The expectation is that the hiring process will be fair and that the job activity will not be
a precursor of an injury. Once injured, whether on the job or not, the worker relies on the medical
system and those individuals carrying out company policies to establish the return-to-work process. The
desire to be productive, the fear of reinjury, the unfamiliar role of patient, and the acceptability of not
working can all be contributors to the complex course of action. It is of substantial importance that the
match of the worker to the work be accurate to prevent any reinjury yet place the worker in the highest
level of productivity possiblefor economic and social reasons.
At these two points in the Worker Care Spectrum, the employee is especially vulnerable to the decisions
of others. Employees often report that their experience in a worker assessment, JPA or FCA, is the first
time that decisions are being made based on their actual participation, with themselves and their activities
in control of the end points. To have their capabilities objectively tested in a participatory manner is
important to them.
Components
Recommendations of an individuals physical work ability are made based on assessing components in
the following three categories.
1. Weighted capabilities
2. Tolerance and endurance parameters
3. Validity of participation determinants
Weighted Capabilities
These tests include analyzing an individuals ability to perform specific work-related materials handling
functions such as lifting at three standard heights, carrying, pushing, and pulling. A detailed list of
components is found in Figure 31.2. Cardiac responses, kinesiological changes and repetition of posture
and posture changes are documented and included in the formulas of decision of the individuals
capabilities. This further confirms cardiovascular and body mechanics safety of the employee or
prospective employee at that level of physical activity. Important questions are answered through these
thorough testing techniques. For example, can the employee lift the 48 lbs. that are required for the job?
How can one know unless the worker is tested?
Tolerances and Endurance

Testing includes and recommendations are given in the categories of standing tolerance, sitting tolerance,
and workday tolerance. Kneeling, crawling, and activities such as walking and stair climbing are also
covered. A detailed list of components is found in Figure 31.2. For example, can your employee return
to an eight hour workday or is he or she limited to a lesser amount? And if so, what is the safe limitation
of a workday?
Validity of Participation Determinants

It is important to objectively, scientifically, and statistically determine and demonstrate when individuals are
not being forthright in the representation of their capabilities (Grossman, 1985; Osterweis et al., 1987). It is
known that some individuals will demonstrate less than their full capability. They may be attempting to
prolong their time off work or may be attempting to falsely maximize their case closure settlement.
31-4
FIGURE 31.2
The percentage of people participating in this kind of exaggeration and falsification is less than the
public generally perceives it to be. Figure 31.3 presents the percentages in each category of participation
determinant based on a sample of 43,000 injured clients (Worker Data Bank, 19941997).
It is important to the valid participators to have their honest attempts proven to be full effort
demonstrations. The injustice is not only when the conscious and deceptive low participator is not
revealed, but also when the honest, full effort, low capability level participator is misjudged.
Validity of participation determinants have been developed by one vendor of FCA equipment and protocols
(Gilliand et al., 1986; Personnel Decisions, Inc., 1994). The individuals level of participation is determined
through the use of algorithms and decision science objectively identifying the degree of an individuals
consistency or inconsistency. The formula includes data from a database made up of over 100,000 cases of
this standardized, protocolized, FCA (Worker Data Bank, 19941997). These data have provided valuable
correlations, one of which is between the amount someone can lift at specific heights and how much they can
push and pull. Scientific literature and the same database have provided statistics on certain vital signs, such
as heart rate, which respond predictively as the individual approaches and reaches exertion level (Astrand
and Rhyming, 1954; Gilliand et al., 1986; Worker Data Bank, 19941997).
The delineations of performance levels as introduced by KEY Method in Minneapolis, Minnesota
are (Gilliand et al., 1986; Key, 1984; Worker Data Bank, 19941997):
1. Valid participation. This determinant means that the individual participated with full effort and
the results and recommendations reflect safe capabilities.
2. Invalid participation. This as a determinant means that the participant consciously and intentionally
provided less than full effort. The numbers produced by this individual reflect less than full
capability. The results can be used in addressing the issue directly with the participant or, if
necessary, in litigation.
3. Conditionally valid participation. An individual with this determinant has demonstrated less
than full capability. The results reflect their perception of capability even though they can physically
do more. The numbers and capabilities are, therefore, safe, but may also reflect an unconscious
psychological barrier.
4. Conditionally invalid participation. The individual with this determinant has demonstrated work
levels that are beyond what would be considered full, safe levels for extended work periods.
When left to their own end point determinations of work activity, they exceed the safe levels.
31-5
FIGURE 31.3 Functional capacity assessment validity determinants.
TABLE 31.1 Consistency of KEY Method Assessment Results
Freidman two-way analysis of variance by ranks. Region by participation (%)

k = 4, n = 4; X2 = 7.5 Xr2 + .9
The importance of standardization, statistical analysis of data, and carrying the level of data in a
database to produce determinants of participation is paramount.
Standardization
When looking for an assessment, standardization and validity of participation determinants are of
consummate importance. They are the primary elements of defense against the occurrence of litigation
and the primary elements of defense should the case eventually go to court. One of the standardized
systems maintains a complete data bank of all assessments performed (Worker Data Bank, 19941997).
To be assured of such level of standardization, studies should be provided to those using the assessment
that demonstrate reliability and consistency. The consistency of the KEY Method assessment results was
analyzed and is represented in Table 31.1. Analysis using 2-way analysis by ranks found no differences
in providers results across the United States. Statistically, any differences were found to be extremely
not significant (Aitken, 1996; Portney and Watkins, 1993, Worker Data Bank, 19941997).
31-6
FIGURE 31.4 Descriptive summary validity.
Another analysis demonstrating consistency in the assessment results, representing standardization,

is the graph in Figure 31.4. This confirms the consistency of the results of the assessment when administered
in three different countries: the United States, Canada, and Australia.
Worker Assessment Principles

Principles to look for in selecting a functional capacity assessment include:
1. The assessment must contain standards for identifying validity of participation of the individual
being tested
2. The methodology administered must be consistent from tester to tester and test to test
3. Standardized equipment must be used and the same procedure followed with each assessment
4. The administrator of the assessment must be thoroughly trained and objective
5. The processing of the information gathered during testing must be standardized
The psychology of the individual needs to recognized in the assessment as well as the kinesiology of the
activities (Schmidt et al., 1989). There is a growing body of literature supporting the theory that a
statistical relationship does exist between low back pain and an individuals psychological factors as
tested by the Minnesota Multiphasic Personality Inventory (MMPI) (Block et al., 1996). The MMPI has
also been able to predict the occurrence of job-related low back pain or when poor response to surgery
would be the outcome (Bigos et al., 1991; Blair et al., 1994; Block et al., 1996; Keller and Butcher, 1991;
Schmidt et al., 1989).
Assessment Reports
A report should provide details of the results of the assessment and then compare those results with the
physical demands of the job. Through this matching exercise, the decision maker can make an informed,
unbiased, and defensible decision relating to the return to work of a previously injured employee.
It is also helpful to receive a visual display of the major highlights of the results, as in Figure 31.5.
Graphic displays of these major areas can be most helpful in assisting the decision-making process for
rehire or case management. The individuals assessment results are compared with the same profile of
individual in the data bank. They also may be compared with the job requirements. Another option is
to compare norms from the injured database with similar profiles of individuals in the uninjured
database.
31-7
FIGURE 31.5 Injured worker FCA results compared to job requirements and data bank norms.
31.3 The Provider of Worker Assessments

The provider of these assessments can be instrumental in increasing return-to-work percentages, reducing
reinjury rates, decreasing lost workdays, and yielding other short and long-term cost reductions.
Physical and occupational therapists are the primary providers of worker assessments, job placement
assessments, and return-to-work functional capacity assessments. The motive for providing quality results
in functional assessments lies primarily in the accuracy of the results and the defensibility in the courts.
The therapist needs to provide the most objective, unbiased data. These data are then used as an assist
in the hiring and returning-to-work decisions. As a result, therapists need to be able to support their
method with objectivity, standardized equipment, and consistent protocols and procedures.
31.4 Outcomes
Outcome surveys or studies should be available for review for one to trust the results and the legitimacy
of the recommendations of a worker assessment (Dobrzykowski, 1995; Key, 1995b). The predictive
ability of an FCA needs to be demonstrated based on a track record of return-to-work without reinjury.
The primary outcomes that one should be looking for include:
1. Decreased reinjury rates
2. Decrease lapse of time from date of injury to date of return to work
3. Decrease incidents and cost of litigation
The State of Colorado studied the impact of FCAs on shortening the amount of time required for
vocational evaluation of injured workers. H.D.Waite found that the inclusion of the KEY Method FCA
31-8
FIGURE 31.6 (a) Lost work days. (b) Workers compensation costs.
resulted in a median of 18 fewer days of rehabilitation. This would save the State of Colorado over
$200,000 annually (Waite, 1987).
JPA Outcomes
Having the data and using them to safely match workers capability levels to the job demands, or being
in a position to know the modifications necessary to facilitate a match results in fewer injuries and
subsequent lower health care costs, lower workers compensation complications, preserved productivity,
worker morale, and job satisfaction. These issues along with that of the assessments predictive capabilities
regarding future injuries are the primary issues in outcome reports. Examples assist in demonstrating
the effects (Karwowski and Salvendy, 1998).
OutcomeCase A
In 1988 a paper manufacturer in Minnesota instituted job placement assessments to help stem the costs
related to workers compensation claims and lost workdays. In analysis two years later, the experiences
of 70 employees hired before the use of JPAs were compared to 70 hired after the initiation of administering
JPAs. Use of the JPAs lowered both lost workdays and workers compensation costs (see Figure 31.6)
(Frey, 1995).
OutcomeCase B
A state transportation authority discovered that job placement assessments enable them to predict if an
employee is at risk of injury. Of the 36 employees injured from 1985 to 1992, 75% had been categorized
as at risk by JPAs performed when they were hired. Fourteen providers across the state administered
the same system of JPA. Personnel Decisions, Inc. reports, While the analysis is based on a relatively
few cases, the results are statistically significant. The chi square for this cross-tabulation is 15.4, which
is significant at p = .00045 (Personnel Decisions, Inc., 1994).
31-9
FIGURE 31.7
OutcomeCase C
A major trucking firm used the JPA for two separate hiring locations over a continuous eighteen-month
period. Since implementing the administration of the JPA on each candidate and hiring based on the
results, there were no new injuries (Worker Data Bank, 19941997).
31.5 After the Assessment Results Are In

The results of job placement assessments and functional capacity assessments offer options for pathways
to follow, depending on the data assembled. The decision tree layout of Figures 31.7 and 31.8 demonstrate
optional pathways available.
31.6 Diversification Options

As change occurs in industry so will industrys approach to minimizing work-related injuries. To meet
these changing needs medical providers are diversifying the services they now offer to industry and the
mode of delivery of those services. Todays marketplace offers some examples of successful diversification.
Mobile Assessments
For those who offer functional capacity assessments or job placement assessments, a beneficial adaptation
has been to perform these assessments at the job site rather than in a clinic. This is done by utilizing a
mobile testing unit that uses the same standardized test procedures as those which are practiced in the
clinical setting. By having the JPAs performed onsite, the individual responsible for the hire/no-hire
decision has immediate access to the assessment results. Because of this, no administrative or production
31-10
FIGURE 31.8
time is lost waiting for reports. They can be printed up immediately upon completion of the JPA. With
todays tight economic issues and tight worker market it is important that the hire be made quickly.
Onsite JPAs provide a system by which many employees can test through and begin work the same day.
Having the return-to-work assessment, the FCAs, performed onsite promotes the bond between the
injured worker and the workplace. It assists in the process of employee acceptance, co-worker to coworker. Management and nonmanagement observe that the individual is indeed participating in the
return-to-work program. Bringing the worker back to the site for testing also allows the employee to
reunite with other colleagues and co-workers.
Additionally, therapists are able to develop a closer working relationship with management and
thereby better understand and meet the companys needs.
Mobile Occupational Health Clinic

Taking this idea a step further, some have adapted large vans or buses to house a mobile occupational health
clinic. This includes facilities for examinations and physicals, functional capacity assessments, job placement
assessments, job analysis, ongoing treatment, and educational materials, as well as facilities for drug, hearing,
and vision screenings. This mobility presents industry with a broad offering for delivery of services. One such
mobile unit travels up to 200 miles to deliver such services to hundreds of industries in a rural region.
Onsite Services
Onsite industrial therapist services are becoming a very cost-effective way for industries to more thoroughly
meet the needs of their company. When the provider of services shows up for work every day at the plant
site, there is a deepened knowledge level of the problems and a quicker pathway to the solutions.
Services onsite may be delivered by contracting with a local clinic or therapist. It may be to the companys
advantage to have the individual or individuals be employees of the company.
31-11
Onsite services can vary from full-time positions to a few hours per week depending on the size of the
company and the workers risk for injury. This approach requires that the company designate space for
the medical provider to assess and treat workers. The most apparent benefits of onsite therapy services
are the immediacy of services and the decreased worker down time. Musculoskeletal injuries (i.e., repetitive
motion injuries, back injuries, sprain/strain injuries) receive treatment faster and therefore allow the
patient to return to work faster.
Prompt treatment is the key to returning the worker to work as quickly as possible. In addition to
helping the worker overcome injuries, prompt treatment can also impact the bottom line by cutting the
costs of finding a replacement worker and reducing workers compensation premiums. An intangible
benefit of onsite services is the therapists ability to effectively communicate the workers situations to
administration. This independent opinion can alleviate tensions which often develop between injured
workers and their supervisors. It is these tensions that can lead to exaggerated symptoms and litigation.
The services that can be provided to industry and the worker through this approach are limited only
by the willingness of the parties involved. Most services offered in a medical clinic can be offered at the
plant site. The number of employees and the incident rate usually dictate the choice of services brought
in-house.
The entire Worker Care Spectrum as represented in Figure 31.1 can be provided along with drug,
hearing and vision screening, medical physicals, ergonomics consulting, fitness and wellness programs,
inoculations, and traditional general medical treatment. The company also experiences economic benefits
through the immediacy of evaluation and treatment of resultant earlier return-to-work, less time off
work, and maintaining the bond between the worker and the worksite. Diversification can take many
forms. These are but a few examples which are being offered to industry in todays market and demonstrate
insight of how challenges will be met in the future.
31.7 Conclusion
Financial reward for losses as result of work activities is evidenced as far back as Greek warriors and
pirates. More that 2000 years ago, the families of warriors who lost their lives in battle were compensated.
Pirates were also provided a scheduled award for loss of a limb, but only after a successful attack and
after the captain had taken his share of the recovered booty. Todays workers compensation system is
much more complicated. In 1986, Liberty Mutual reported $6807 as the mean cost per case for low
back pain. In 1989, this cost had risen to $8321. This 1989 amount is more than twice the amount for
the average workers compensation claim which was $4075 (Webster and Snook, 1990). Liberty estimates
the cost of time lost by injured workers to be $18.7 billion. Liberty also reports the cost of disability for
corporations to be 6 to 12 percent of their corporate payroll. In 1993, 8.5 million people had disabling
injuries (Liberty Mutual, 1998). It has been shown that the majority of costs incurred when an employee
is injured comes from nonmedical costs (Quebec Task Force, 1987). A 1987 study revealed that only
14% of the total cost incurred was direct medical. The remaining 86% was attributed to indirect costs
including the costs surrounding the replacement of an employee. Considering that industry directly pays
for lost time, it is incumbent that industry know what an individuals capability is upon hiring and upon
return-to-work from an injury.
Armed with accurate data, the human resource department can be sure that potential employees who
do not have the capacity for the work will not be hired. Also, when an injured worker returns to work,
it will be as soon as they are able to do so without risk of reinjury.
The employer needs increasingly more objective determination of job requirements and of worker
capabilities to defensibly support their decisions of hire and of return-to-work once injured. By focusing
on what the worker can do, job placement assessments and functional capacity assessments can trigger
a more accurate and proactive response from the employer. This includes proper placement upon hiring
and easier placement and accommodation, if necessary, once injured (Key, 1995a).
31-12
References
Aitken MJ, Creighton University School of Pharmacy and Allied Health, Department of Occupational
Therapy, Omaha, Nebraska June, 1996.
Astrand PO, Ryhming I, A nomogram for calculation of aerobic capacity from pulse rate during submaximal work, J of Applied Physiology 7:218221, 1954.
Bigos SJ, Batti MC, Spengler DM, et al. A prospective study of work perceptions and psychosocial
factors affecting the report of back injury. Spine 16:16, 1991.
Blair JA, Blair RS, Rueckert P, Pre-injury emotional trauma and chronic back painan unexpected
finding. Spine, 19:10, May 15, 1994.
Block AR, Vanharanta H, et al. Discogenic pain report, influence of psychological factors, Spine 21(3):334
338, February 1996.
Dobrzykowski E, Data collection and use in industrial therapy, in Industrial Therapy, Key GL (Ed.) St.
Louis, Mosby, 1995, p 4260.
Frey DH, Job placement assessments and pre-employment screening, in Industrial Therapy, Key, GL
(Ed.) St. Louis, Mosby, 1995, pp 110122.
Gilliand RG, Sevy BA, Ahlgren A, A Study of Statistical Relationships Among Physical Ability Measures
of Injured Workers Undergoing KEY Functional Assessments, Minneapolis, Minnesota 1986.
Grossman P, Respiration, stress, and cardiovascular function, Psychophysiology 20(33):284300, 1983.
Karwowski E, Salvendy G, Ed. Ergonomics and Manufacturing: Raising Productivity Through Work
Place Improvement, Society of Manufacturing Engineers, 1998.
Keller LS, Butcher JN, Assessment of Chronic Pain Patients with the MMPI-2. Minneapolis, MN:
University of Minnesota Press, 1991.
Key GL, Functional capacity assessment, in Industrial Therapy, Key GL (Ed.) St. Louis, Mosby, 1995a.
Key GL, The impact and outcomes of industrial therapy, in Industrial Therapy, Key GL (Ed.) St. Louis,
Mosby, 1995b, p 220254.
Key GL, Key Functional Assessment Policy and Procedures Manual and Training and Resource Manual,
Minneapolis, MN, 1984.
Liberty Mutual, For Your Employees: Workers Compensation, available at: www.libertymutual.com/
business/workcomp.html, accessed 10698.
Osterweis M, Kleinman A, Mechanic D, Pain and Disability, Clinical, Behavioral, and Public Policy
Perspectives, Washington, DC, National Academy Press, 1987.
Personnel Decisions Inc. Key Functional Assessment Pre-employment Screening Battery as a Predictor
of Job Related Injuries, Minneapolis, MN, January, 1994.
Portney LG, Watkins MP, Foundations of Clinical Research, Norwalk, Conn., Appleton & Lange,
1993.
Quebec Task Force Study: Scientific approach to the assessment and management of activity-related
spine disorders, Spine, 12:7S, 1987.
Schmidt AJM, Gierlings EH, Madelon LP, Environmental and interoceptive influences on chronic low
back pain behavior. Pain 38:13743, 1989.
Waite HD, Use of a New Physical Capacities Assessment Method to Assist in Vocational Rehabilitation
of Injured Workers, University of Colorado, Thesis, 1987.
Webster BS, Snook, SH, The cost of compensable low back pain, J Occup Med, 32:1315, 1990.
Wheeler AH, Hanley EN, Spine update: nonoperative treatment for low back painrest to restoration,
Spine, 20(3): 375378, February 1, 1995.
Worker Data Bank, KEY Method, Minneapolis, Minnesota. 1994, 1995, 1996, 1997.
32
Ergonomics and
Rehabilitation
Ewa Nowak
Institute of Industrial Design
32.1
32.2
Introduction
Ergonomics and Equalization of Opportunities
32.3
Somatic Characteristics of the Disabled as a Determinant of

Spatial Structures Hand Characteristics as the Basis for
Designing Objects of Everyday Use Elements of
Ergonomics in Clothing Design
Ergonomic Methods for the Needs of
Rehabilitation
321
323
3214
32.1 Introduction
Based on a criterion of body efficiency, the human population can be divided into three main groups:
People of the highest (extreme) efficiency

People of an average efficiency (within normal range)
People of efficiency below normal rangethese are the disabled
Efficiency undergoes changes during ontogenesis. It is determined genetically, but can also change (within
the limits of so-called reaction standard) depending on the environmental, social, material, cultural, and
other conditions. Body efficiency can be improved through physical exercises, better nutrition, and a
more hygienic way of life. In the case of the disabled, rehabilitation is in charge of this question.
Disability, according to International Classification posed by WHO (1980) is defined as follows: A
restriction or lack of ability (resulting from impairment) to perform an activity in the manner or within
the range considered normal for a human being.
Rehabilitation (after Kumar, 1989) is defined as a science of systematic multidimensional study of
disordered human neuropsychosocial and/or musculoskeletal function(s) and its/their remediation by
physicochemical and/or psychosocial means. Rehabilitation can be treated as a process that, by making
use of the latest medical, technical, and social sciences achievements, restores, within the optimum
limits, the efficiency of impaired or handicapped organs. The aim, and at the same time the result, of
rehabilitation is enabling the man to come back to normal life in society. Two steps can be distinguished
in this process. At the same time they constitute two basic aims accepted by the World Health Organization
in the World Program of Action (1984) (Figure 32.1).
The first step is rehabilitation. As a result of rehabilitation, the disabled person regains the optimum
level of mental, physical, and social functioning. Of course, the process, in addition to being enabling,
also strives to reduce pain and suffering. The second step is equalization of opportunities for disabled
people. This involves a process through which physical environment, housing and transportation, social
and health services, educational and work opportunities, cultural and social life, including sports and
recreational facilities, are made accessible to all (Kumar, 1992).
0-8493-1800-9/03/$0.00+$1.50
32-1
32-2
FIGURE 32.1 Activities of the World Program of Action.
FIGURE 32.2 Correlation of ergonomics and rehabilitation in home and work environments.
Particularly helpful in this second step is ergonomics. While rehabilitation improves the efficiency of
the body, ergonomics, through adjusting and optimizing external environmental factors to the capabilities
of the person, enhances work comfort and increases its efficiency and effectiveness. Investigations of
Canadian scientists (Kumar, 1992) as well as my own observations confirm the fact that rehabilitation
and ergonomics applied together considerably intensify and advance both the progress of the rehabilitation
process and the return to normal life.
Exercises, as well as medical treatment, supported by properly constructed workstands and objects
of everyday use, intensify significantly the effect of rehabilitation. Under the influence of cumulated
factors an impaired organ or function attain their initial capabilities to a higher degree. Ergonomics is of
extreme importance in attaining equal chances. This is of assistance in the process of integrating the
disabled into society. It helps to achieve the goal of the World Health Organization, i.e., full participation
of the disabled in social life and development. Figure 32.2 illustrates interrelation between ergonomics
and rehabilitation in work and home environments.
It seems that ergonomics and its possibilities are not sufficiently used for the needs of the disabled.
Several methods and measuring techniques applied in ergonomics can be used, e.g., in rehabilitation.
Some of these should be completed, partially changed, and adapted. It is necessary to develop closer
cooperation between designers and specialists from the fields of ergonomics and rehabilitation.
Even at the present moment there appears a new direction of ergonomics aimed at the needs of
disabled people. This is rehabilitation ergonomics (Kumar, 1992; Nowak, 1993). This can be roughly
defined as an interdisciplinary field of science that aims at adjusting tools, machines, equipment, and
technologies as well as material work and life environments including objects of daily use and rehabilitation
equipment to the psychophysical needs of the disabled. Rehabilitation ergonomics takes part both in the
rehabilitation process and in equalizing chances. This chapter presents ergonomic possibilities and their
achievements in these spheres.
Ergonomics and Rehabilitation
32-3
32.2 Ergonomics and Equalization of Opportunities

Somatic Characteristics of the Disabled as a Determinant of Spatial Structures
Defining the possibilities and necessities of the disabled is a necessary condition for designing the material
work and life environment for this population. Data that characterize somatic structure constitute basic
information. The influence of disabilities on shaping the body structure was studied by numerous
anthropologists (Floyd et al., 1966; Pheasant, 1986; Boussena and Davis, 1987; Goswami et al., 1987, 1994;
Laubach et al., 1981; Molenbroek, 1987; Nowak, 1988, 1989, 1994; Samsonowska-Kreczmer, 1988; Jarosz,
1996; Miesowicz, 1990; Luczak et al., 1993; Das and Kozey, 1994; Lebiedowska et al., 1994).
The largest disproportions between the healthy and the disabled population can be found in a group
of people with motor dysfunction. This is understandable since the dysfunction results from the past or
currently developing diseases that lead to joint disturbances of the osseous, ligament and joint, muscular,
and nervous systems. These disturbances lead to deformities and somatic changes of particular parts of
the body, and this affects the final shape and dimensions of the body and its motorics.
Other factors that restrain the development and growth of the body including restriction of motion
activities, neglected nursing, improper or lack of rehabilitation, as well as stresses connected with pain,
frequent stays in hospitals and rehabilitation centers etc., accompany the pathological process. Descriptions
of investigations of people with lower extremity dysfunction are usually found in the literature, and they
usually are wheelchair users. It should be realized, however, that this group embraces people with various
degrees of motor efficiency limitations. This depends not only on a type and stage of a disease but also
on the time of its appearance. Therefore, researchers dealing with this problem face great difficulties in
selecting subjects and in describing results scientifically. This may be the cause of the small number of
studies undertaken in this field. This particularly concerns studies, the results of which are to provide
data for designing.
It turns out, that height measurements are measured in relation to various reference bases. This fact
creates a difficulty not only for comparison purposes, but also creates a difficulty for designers who
would like to utilize investigation results. A synthesis of existing data was done for design purposes.
Table 32.1 comprises height measurements measured in relation to the seat plane (Bs), and Table
32.2 to the floor level (B). Anthropometric data differ significantly regardless of the fact that these
concern various populations. The influence of diseases resulting in the necessity of using the wheelchair
affects shaping the body. Pheasant (1986) indicates that the body proportions of wheelchair users resemble
those of elderly people above age 65. This was confirmed by the results of investigations carried out by
Molenbroek (1987).
Not only anthropometric measurements of the disabled are important for the needs of design but
also differences between the disabled and healthy population. The majority of authors indicate that the
body structure of disabled men and women differs significantly from the able-bodied population (Pheasant,
1986; Samsonowska-Kreczmer, 1988; Nowak, 1988, 1989; Jarosz, 1996; Das and Kozey 1994). This
problem was illustrated by the example of data on the Polish population (Jarosz, 1996). Using the
threshold values of the 5th percentile, a linear anthropometric model of disabled women in the sitting
position was drawn. This model was compared to the model of the 5th percentile of the able-bodied
(Figure 32.3).
It appears that the above measurements show smaller values for the disabled than for healthy people.
The differences are significant and amount to 110 mm for the seated stature (Bs-V), for eye level (Bsen)
to 113 mm, for shoulder height (Bs-a) to 126 mm, and for elbow height (Bs-r) to 57 mm. For arm reach
measurements the differences amount for arm reach forward (Bs-phIII) to 204 mm, and to 90 mm for
arm overhead reach (Bsd-phIII). Similar results were obtained by Nowak (1988, 1989) by comparing
the population of disabled young people aged 15 to 18 with the lower extremity dysfunction, with
young of the same age representing the Polish population (Nowak, 1988).
Floyd (1966) and Bouisset and Moynot (1985) indicate that the smaller seated stature (Bs-v) measurements
of the disabled can result from the deformities of the osseous system as well as from the fact that, as a result of
32-4
TABLE 32.1 Structural Anthropometric Data for Males and Females with Respect to the Seat
* measured from the acromiale point

x
measured from the acromiale point
TABLE 32.2 Reported Anthropometric Data of Disabled People with

Respect to the Floor
back muscle paralysis, difficulties with maintaining the straight position of the body appear. This problem
seems to be very serious for paraplegics. A similar interpretation can be accepted for reach measurements.
According to Pheasant (1986) the same analogies of changes in body proportions occur in wheelchair
users and in elderly people. In old age, similarly to people with motor organ dysfunction, deficient muscular
tonicity of the chest and belly appears. This results in pectoral kyphosis increasing. At the same time, the
32-5
FIGURE 32.3 Anthropometric model 5th percentile of disabled and standard women (in the sitting position), where
1,1Arm overhead reach; 2,2Stature; 3,3Eye height; 4,4Shoulder height; 5,5Elbow height; 6,6Popliteal
height; 7,7Arm reach forward; 8,8Popliteal depth. (From Dr. Emilia Jarosz. With permission.)
processes of intervertebral cartilage flattening and of the back shortening occur. This leads to the C shape
of the spine (Nowak, 1980, 1988). Samsonowska-Kreczmer (1988) indicated that the stooping back and
sunken chest occur in young people with motor organ dysfunction. Another reason for diminishing the
seated stature measurements is that the buttock and thigh muscles atrophy, resulting from immobility of
the back and the lower extremities. Studies conducted by Jarosz (1993) indicate that for 55% men and
65% women thigh thickness measurement is below the lower limit of the healthy population standard.
Similar results concerning adults were obtained by Goswami et al. (1987), and concerning the young by
Nowak (1988,1989) and Miesowicz (1990). In comparison with the stature and reach characteristics,
shoulder breadth characteristics (a-a) appear different. Most scientists confirm the fact that the value of
this characteristic is higher for wheelchair users than for the healthy population (Goswami et al., 1987;
Boussena and Davies, 1987; Nowak, 1989; Jarosz, 1996). Wezyk (1989) and Miesowicz (1990) point out
that children with cerebral palsy have larger shoulder breadth values in comparison to those of healthy
children. Without exploring the reason for this phenomenon, this is, without doubt, important information
for clothes designers. This question will be discussed in a later section.
Essential characteristics exerting an influence on workspace shaping are functional characteristics of
the upper extremities, i.e., reaches. Values observed in these characteristics (Tables 32.1 and 32.2) are
significantly lower in persons with lower extremity dysfunction, although their upper extremities are qualified
as efficient. Lower reach values result not only from lower values of the arm and forearm length, but
also from limitations in shoulder and elbow joints. In connection with the above, the disabled have difficulty
in performing the movements of abduction and extension (Nowak, 1988). Grabowska et al. (1986) found
that in the case of persons suffering from rheumatoid arthritis, workspace of the upper extremity is 7 to
10% lower if a shoulder joint is constrained and 25 to 33% lower when there is a constraint of the elbow
joint movements. It is obvious that disorders of these two joints increase the limitation of the upper
extremity movements, and thus the efficient workspace is significantly reduced. This is confirmed by
investigations conducted by Nowak (1988, 1989) and Jarosz (1996). It should be pointed out that particular
values of reach of the disabled refer to the straight position of the body. Thus, they can be increased
through trunk movements forward and lateral. Floyds investigations (1966) proved that the difference
32-6
FIGURE 32.4 Maximum transverse reach for the all-Polish population (MTR) and the disabled population (MTR),
where R,Rreach radius; P,Phypothetical axis of rotation; N,Nreach forward.
FIGURE 32.5 Maximum sagittal reach for the all-Polish population (MSR) and the disabled population (MSR),
where R,Rreach radius; P,Phypothetical axis of rotation; N,Nreach forward.
between reach forward of disabled women in the straight position of the body and the same reach in the
position of maximum bend forward amounted to 142 mm, and in case of the lateral reach with the
trunk lateral bend135 mm. Reaches forward of the disabled are limited by the foot-rest of the wheelchair.
The difference between the point of reach of disabled women investigated and the beginning of the
wheelchair amounted to 242 mm. That is, it exceeded the difference between reaches in the straight
position and reaches in the bend forward stated by Floyd. That means that the wheelchair user is not
able to reach any devices in the frontal position if there is not enough space for the wheelchair under the
working plane.
Nowak (1989), based on the Das and Gradys method (1983), developed a simple method of defining
workspace for arms. This space was determined for disabled young people with dysfunction of the lower
extremities, using the wheelchair. Figures 32.4 and 32.5 show the graphic way to determine this space in
the sagittal plane (maximum sagittal reachMSR) and in the transverse plane (maximum transverse reach
MTR). These figures show the difference for both reaches between disabled and healthy young people.
Differences in maximum reach measurements were significant and amounted for the 5th percentile to 300
mm. Results of the study were used for ergonomic analysis of schools and for designing school workshops,
laboratories, and rehabilitation centers. This method can be recommended for work-space design for the
disabled. It is simple and easy to use. Using only five anthropometric characteristics, one can obtain the
graphic representation of workspace of any population or an individual person.
While designing the functional space for the paraplegic, one should bear in mind that they have
difficulty with the stability of position, and they can easily fall out of the wheelchair if they bend forward
too much (Przybylski, 1979). Upper extremities moving forward disturb the balance of the body, which
is more difficult to redress because of the paralysis of the muscles of the spine and pelvis, stabilizing the
body in the sitting position (Bouisset and Moynot, 1985).
32-7
Molenbroeks investigations (1987) provide data determining the values of reach of the elderly.
Limitation of the movement range of particular joints and decrease in the values of reach increase as
age increases. Molenbroek (1987) proved that differences between the values of the arm reach overhead
for 50-year-old and 95-year-old Dutchmen amount (for the value of the 5th percentile) to approximately
300 mm. These are the directions for designing living interiors meant for the elderly. It is important
for determining the ability to reach the top shelf of a wardrobe, the highest buttons in a lift, or a
window handle. These data prove that while designing for people aged 50 to 110, one should place all
kinds of switches at the height not exceeding 1474 mm. Above this height, the elderly have difficulty
operating them.
According to Pheasant (1986), a wheelchair user (whose upper extremities are unimpaired) can reach
a zone from around 600 to 1500 mm in a sideways approach, but considerably less head on. It may
well be that the location of fittings within this limited zone will prove entirely acceptable for the ambulant
users of the building, but in case of working surface heights no such easy compromise is possible.
Another task is determining appropriate steps and handrails adjusted to the dimensions of the disabled,
who can move without aid. Petzal (1993) recommends installing a handrail at the height of 900 mm
above the floor. Based on the investigations of different step variants, he suggests the height of a step
within 150 to 200 mm and the width from 250 to 300 mm.
The above author, on the basis of anthropometric data, research tests, and observations, determined
placement of handrails in a bus adjusted to the needs of ambulant disabled people, as well as the size of
seats and the distance from one to another.
As the review of investigations has proved, the body structure of disabled men and women differs
considerably from that of the healthy population. Ergonomics, providing data concerning the body
structure of disabled people, makes it possible to adjust designs of products and spatial structures to the
abilities and predispositions of this group of users.
Hand Characteristics as the Basis for Designing Objects of Everyday Use

Statistics of many countries report that a significant proportion of the population with disabilities requires
help from family, friends, volunteers, or paid care-givers. Almost one half (45.6%) of all disabled people
require assistance with heavy household work, and 22.4% with daily housework (Kumar, 1995). In terms
of the cost, though the figures were not given, it is surmised that it is significant. Many able-bodied people
have to spend their time to assist. The cost of this time along with the cost of the paid health care worker
can add up to a significant magnitude. It may be useful to point out that the larger cost for these people is
not medical but maintenance, attendant care, nursing home, and home care expenses on top of the loss of
productivity due to inability to work. Environment modification and assistive devices may offer disabled
people a chance to decrease these costs and be productive members of society.
Therefore, the problem of making daily life more efficient for the disabled is of extreme importance
from the point of view of economics. The possibility of designing objects of every day use with the help
of ergonomics can play a significant part in this field. One of the basic aims of ergonomics is to define
the needs and capabilities of the user. These capabilities, in comparison with the able bodied, are usually
limited and result from dysfunction of a particular organ. The dysfunction of performing manual functions
is felt most acute during everyday activities. The hand is a unique organ, adjusted to performing
manipulation activities. Efficiency of performing these activities depends on the grasping capabilities of
the hand. The grasping function is one of the most important functions allowing a person to perform
daily activities. Dysfunction in grasping makes it impossible for a person to perform the majority of
activities, including such fundamental ones as eating and drinking. Figure 32.6 shows the types of hand
grips used (Nowak, 1993). The possibility of performing particular grips depends on the type and
degree of hand dysfunction. Thus, it is important to know handgrip capabilities of the disabled user, and
these capabilities should be taken into consideration by a designer while designing an object. Stabilization
of an object in the disabled hand should be secured by the grip, that at the same time allows an object to
be manipulated. Normally this is attained by adjusting the shape and size of an object or its handle to
32-8
FIGURE 32.6 Hand grips classification. (From Nowak, E. 1993. Hand grip classification, in the catalogue Human
DimensionErgonomics and Design, Institute of Industrial Design, Warsaw: 30 [in Polish]. With permission.)
the capabilities of the deformed hand. Investigations that define the contact area of the hand and the
object or its handle, depending on its shape and size, are quite popular in this field. Figure 32.7 (Frejlich,
1993) shows pictures of the contact area of the hand and the handle with the shape of a circle cross
section that depends on diameter measurements of the handle. The larger cross section, the larger the
contact area. Frejlich proved (1983) that handles with square, rectangular, and triangle cross sections
attain smaller contact areas in comparison to handles with circle cross sections. This is important
information for designers, since the shape and size of handles are of great significance for an object to be
held, stabilized, and manipulated. This was confirmed by Benktzons investigations (1993). The most
important for her was to define the appropriate contact between the hand and a handle. Benktzon, with
the cooperation of numerous specialists from the Ergonomi Design Gruppen (Benktzon, 1993), analyzed
objects of everyday use and offered new solutions for these objects. These can be used both by the
elderly and the disabled. Several of these objects were presented by the Ergonomi Design Gruppen at the
exhibition Design and Ergonomics, organized in Warsaw in 1993. Figure 32.8 presents a new solution
for a walking stick. The design was developed basing on a keen analysis of the manner of gripping by the
disabled with hand dysfunction. The contact area between the hand and the new anatomical handle has
increased considerably, thus providing much better support. In practice, seemingly small differences can
be of vital importance for function, safety, and comfort.
The new design (Fenix) is characterized by:
32-9
FIGURE 32.7 Pictures of contact area of the hand with the handle of a circular cross section. (From Frejlich, C.
1993. Analysis of the active contact surface of the hand with a handle depending on its cross-section shape and size,
in the catalogue Human DimensionErgonomics and Design, Institute of Industrial Design, Warsaw: 100 [in Polish].
With permission.)
FIGURE 32.8 The walking stick handles; made by RFSU, Sweden, designed by Ergonomi Design Gruppen. (From
Catalogue of the exhibition Human DimensionDesign and Ergonomics. 1993. Institute of Industrial Design,
Warsaw. With permission.)
Larger load-bearing areas for the hand, without the usual consequence of the thumb being pushed
out of place
The stick being positioned at the back of the handle which allows the fingers to be flexed together
Good friction and soft grip surface to enhance comfort
The angle of the handle being adjustable to each individual by means of a ball-and-socket joint
32-10
FIGURE 32.9 Cutlery for the disabled using one hand; made by RFSU, Sweden, designed by Ergonomi Design
Gruppen. (From Catalogue of the exhibition Human DimensionDesign and Ergonomics. 1993. Institute of
Industrial Design, Warsaw. With permission.)
Figure 32.9 presents a design developed by the same group. This is a set of cutlery for people using
only one hand. The fork has small prongs, and the spoon has a serrated edge that allows cutting of food.
There is also a range of cutlery designed to accommodate many special needs, along with a goblet and
a curved rimmed plate. All these designs demonstrate the goal of integrating style and special needs
design; people should be not stigmatized because their needs can be classed as special.
Elements of Ergonomics in Clothing Design

Clothes for the disabled constitute a social problem of particular importance. A person suffering from
disability or permanent illness should get such clothing that makes his or her life easier, is functional,
meets his or her emotional needs, and, at the same time, is adjusted to the limitations caused by a
disability. People with motion dysfunction have the most problems with clothes. Clothing designed for
this group of people should assure appropriate physiohygienic properties, heat comfort, as well as ease
of manipulation. Concepts of model-constructions solutions should take into account not only the
usefulness of products, but also the economic effect. Designs must be simple in construction and easy to
manufacture. The form of clothing is to integrate the group of the disabled with society, to conceal a
disability, and to give the feeling of satisfaction at possessing clothes appropriate to needs and expectations.
Basing on ergonomic criteria, we can determine two main types of clothing:
Clothing for totally inefficient people, who are attended by other persons
Clothing for people able to self-service
In both these cases ergonomic investigation are helpful.

Determination of the somatic characteristic of the disabled is the starting point for clothing design.
Figure 32.10 (a,b) shows the measurements that determine the necessary dimensions of a working suit.
As was proved earlier, disability and the motion limitations connected with it result in changes in the
shape, dimensions, and proportions of the body.
Investigations of 15- to 18-year-olds (Nowak, 1988, 1989) with motor dysfunction of the lower
extremities proved that the body dimensions of this group differ considerably from those of the healthy
population of the same age. Their body weight and height are lower. This was confirmed by other
scientists investigations (Malinowski, 1975; Pheasant, 1986; Samsonowska-Kreczmer, 1990; Jarosz,
32-11
FIGURE 32.10 Examples of anthropometric characteristics defining clothes dimensions. (a) At maximum backward
trunk bending; (b) at maximum lateral trunk bending. (From Batogowska, A. 1993. Selected maximum measurements
for the needs of clothing design. In the catalog Human DimensionErgonomics and Design, Institute of Industrial
Design, Warsaw: 64 (in Polish). With permission.)
1993). On the other hand, it was proved that this group of people has considerably higher values of
shoulder breadth characteristic. Walking with the help of crutches and walking sticks, or driving a
wheelchair is performed thanks to the work of the upper extremities and the trunk muscles. It is also
supposed that intensive physical training of these muscles during rehabilitation can stimulate the growth
of the clavicles in length. This results in the considerable increase in the shoulder breadth characteristic
values. In addition to the body dimensions, determination of motor abilities is of vital importance.
Figure 32.11 shows the measurement of the upper extremity movement range (Nowak, 1978). Basing
on ergonomic investigations, assumptions for clothing design are determined. For example, clothing for
the wheelchair user must fulfill (among others) the following requirements: (1) appropriate clearance
allowing the hands to move easily up and forward and appropriately larger shoulder breadth. This is
ensured by the special construction of sleeve and armpit cut; (2) increased transverse dimensions related
to the enlarged, muscular chest; (3) widened sleeve finish related to the considerably enlarged biceps and
triceps; (4) adjustment of the bottom part of clothing length and cut (in case of a blouse, shirt, and vest)
to the sitting position of its user. This is attained through the removal of excess fabric in front. Figures
32.12, 32.13, and 32.14 show example solutions of the upper and lower parts of clothing for a wheelchair
user. The projects were designed in the clothing department of the Institute of Industrial Design in
Warsaw (Dabrowska-Kielek; Szymanska-Petrykowska, 1991).
Interesting ergonomic investigations for the needs of clothing design for the disabled were conducted
by Sperling and Karlsson (1989). They determined demands on clothing fasteners for long-term care
patients:
Functional Demands
The clothing fastener should:
Be located in the patients optimum grip area (Figure 32.3)

Be easy to understand and identify, visually as well as tactally
Be possible to handle with one hand
Be easy to grip and hold
Not demand more grip strength or precision handling than the patient is able to produce
Stand body movements without opening
Have dimensions suitable for handling as well as clothing construction
32-12
FIGURE 32.11 Measurement of upper extremity movements range performed in working clothes.
FIGURE 32.12 Exemplary solution of the upper part of clothes for men using a wheelchair; designed by Jolanta
Szymanska-Petrykowska, made by the Institute of Industrial Design. (From Dabrowska-Kielek, J., Szymanska-Petrykowska, J. 1991. Clothes and shoes. Designers VademecumProblems of the Disabled, Vol. 5 (in Polish). With
permission.)
Comfort and Safety Demands

The closure should:
Not scratch or rub

Not cause such a pressure against the skin that might lead to pressure-sores
32-13
FIGURE 32.13 Design of trousers for men and women using a wheelchair; designed by Jolanta Szymanska-Petrykowska, made by the Institute of Industrial Design. (From Dabrowska-Kielek, J., Szymanska-Petrykowska, J.
1991. Clothes and shoes. Designers VademecumProblems of the Disabled, Vol. 5 (in Polish). With permission.)
FIGURE 32.14 Design of a skirt for women using a wheelchair; designed by Jolanta Szymanska-Petrykowska, made
by the Institute of Industrial Design. (From Dabrowska-Kielek, J., Szymanska-Petrykowska, J. 1991. Clothes and
shoes. Designers VademecumProblems of the Disabled, Vol. 5 (in Polish). With permission.)
Sewing and Maintenance Demands

The closure should:
Be easy to fasten
Be lasting and easy to replace
Stand washing (chemicals, high temperature)
Be inexpensive
The aim of this study was to facilitate a more independent daily life for long-term care patients. For this
group of people it is of great importance to be able to dress and undress without assistance. The design
and position of clothing fasteners often lead to a restriction of the functional capacity of the patient.
Three different types of fasteners were evaluated:
32-14

Oval asymmetric button for a horizontal buttonhole (2519 mm)
Oval symmetric button for a vertical buttonhole (2819 mm)
A finger strap, which was designed to be handled with one hand and nonprehensile movements
(3614 mm)
In a subsequent study, an adapted oval button and a finger strap alternative to hook-and-eye were
designed and evaluated, together with a standard button. The oval button in combination with a vertical
buttonhole improved the function for most patients, and the front position for the fasteners was superior
to a diagonal or lateral position on the chest. The finger strap was of advantage to patients with hemiplegia
and joint complaints but was difficult for many of the subjects to understand, being a technical innovation.
Many investigators and designers of clothing for the elderly and the disabled (Benktzon, 1980;
Dabrowska-Kielek; Szymanska-Petrykowska, 1991; Nowak, 1996) underline the fact that in the process
of clothing design they are governed by the idea that clothing, in addition to its functional characteristics,
should give its user physical comfort. The disabled want to live and work among healthy people. Therefore,
they have to accept the clothes they wear. Clothing should not deform the shape of the body, but just the
opposite, it should cover anatomical defects.
32.3 Ergonomic Methods for the Needs of Rehabilitation

Rehabilitation is a complex and complicated process. It consists of restoring, to a maximum possible
degree, motor efficiency of the human body. Rehabilitation employs many means and research techniques
used in various fields of science, such as medicine, sociology, psychology, mechanics, and biology. It
would seem that rehabilitation processes could also benefit from drawing more freely on achievements
of anthropometry. An objective of this subsection is to present methods of dynamic anthropometry used
in ergonomics, and to put forward proposals for suitable modification of those methods to satisfy the
requirements of rehabilitation processes.
Anthropometry can be particularly useful in diagnosing and assessing the motor efficiency of the
human body. Rheumatic diseases and mechanical injuries result in pathological changes in joints,
ligaments, tendons, muscles, and lead to considerably restricted movement ranges. Thus, the assessment
of motor efficiency of the affected joints is essential for monitoring the rehabilitation processes.
The simplest way of assessing motor efficiency is by comparing a restricted motion range of an
affected joint with its initial range of motion, i.e., before injury or disease. Unfortunately, after injury or
disease has already prevailed, it is impossible to determine what the initial motion range was in the
healthy patient. Also, it may hardly be expected that a rehabilitated patient had his initial motion ranges
measured just before the injury.
Thus, motor efficiency of a rehabilitated patient can only be assessed based upon the data of the healthy
population. A method based upon this kind of data and allowing the quantitative assessment of rehabilitation
progress was developed by Nowak (1992). The results of investigations conducted for the needs of
ergonomics were used. The investigations comprised ranges of motion of arm, leg, hand, foot, and head.
The following maximal movements were measured:
Flexion and extension of the arm and leg

Flexion and extension, adduction and abduction, supination, and pronation of the extended
hand
Flexion and extension, supination, and pronation of the grasping hand
Flexion and extension, adduction, and abduction of the foot
Flexion and extension, bending to the right and left, right and left turning of the head
Motion ranges for these movements were measured by means of a set of measuring devices. The
investigations embraced 355 men and 215 women aged 18 to 65. The results of the investigations were
used to calculate standards, i.e., biological bases of reference for particular motion ranges. Standards
were developed for three age categories and adequate subordinate classes of movements.
32-15
These are:
Age Groups
Motion Classes
1. 18 up to 30 years
1. Wide range of motion (W)

2. Average range of motion (A)
3. Small range of motion (S)
The following formulae were used to calculate the ranges of motion in three classes (Batogowska, 1977):
(32.1)
Values of for i = 0, 1, 2, 3, 4 were found from equations:
(32.2)
where
P5 = value of the 5th percentile
P95 = value of the 95th percentile
x = average value
s = standard deviation
Angular values of the hand grasping characteristic are shown in Table 32.3. It includes the values attained
by a healthy population of adults aged 18 to 65. The values of movement ranges are grouped in three
motion classes, i.e., from the maximum to the minimum valueclasses W, A, and S. In each class, minimum
and maximum extreme values are given, calculated according to formulae given earlier. Three age categories
are subordinated to the classes of movement shown. The youngest persons, aged 18 to 30, belong to class
W, characterized by the maximum values. Class A includes adults aged 31 to 40, and class S includes the
eldest subjects, aged 41 to 65, whose movement range in particular joints has the smallest values.
TABLE 32.3 Movement Ranges of the Grasping Hand for Three Classes of Motion:
Wide (W), Average, (A), and Small (S) for Polish Population 1865 Years
32-16
The values of movement ranges for particular classes shown in the table can be practically applied in
the rehabilitation process. If the age of a patient is known, one can read from the table the value of a
range of movement in a given joint that can be attained by the joint, i.e., the range of movement that it
should have had prior to the injury. The maximum value is particularly significant in our case. It shows
the angular value that should be aimed at in the rehabilitation process. The maximum value of range
movement provides a basis for the evaluation of rehabilitation progress in a selected age group and is
expressed by .
After assessing the value , the value of the range of movement of a subject investigated before the
rehabilitation process should be defined. This state is denoted by the symbol and is indicated by
measurement, using a suitable protractor.
The final step is to define the decrease in the movement range. Knowing the values and one can
calculate the absolute decrease in the movement range (Ar), and a percentage decrease in the movement
range (Pr) using the following formula:
(32.3)
(32.4)
The value of a percentage decrease in movement range (Pr) is inversely proportional to the ability of
movement (Ab) which can be defined by the equation:
Ab=100Pr%
(32.5)
The above values Ar, Pr, and Ab provide a basis for a direct evaluation of the progress of the rehabilitation
process. Based upon the above, the motion ability can be assessed in many various stages of rehabilitation.
This assessment may be employed in:
Diagnosing a disease
Evaluating progress and monitoring the rehabilitation process
Determining a permanent decrease in movement ranges
The assessment may be either continuous or administered at random, depending upon the requirements.
The application of the method described above is presented in a graph (Figure 32.15) which shows
the rehabilitation process of a wrist joint. A considerable movement restriction was caused by injury of
the hand in the wrist joint and surgery that followed the injury. Results of systematically taken
measurements of hand flexion (a) and extension (b) shown in Figure 32.15, illustrate a process of
gradual improvement. Percentage of angular decrease in the range of hand flexion was 14.6% and hand
extension 30.8%. Thus, the post-injury efficiency of the wrist joint can be determined as 85.4% during
flexion and 69.2% during extension.
Motion efficiency of individual movements can be assessed using different scales, depending upon
requirements, disease and general mobility. The scale is also dependent upon the individual preferences
of the assessor. Scales of three, five, or ten grades may be used in assessing the motion efficiency. A fivegrade scale may be considered optimal after Zeyland-Malawka et al. (1968):
Very good: decrease up to 20%efficiency from 80%

Good: decrease up to 40%efficiency from 60%
Poor: decrease up to 60%efficiency from 40%
Very poor: decrease more than 60%efficiency less than 40%
The above proposal does not preclude applications of other assessment scales, which may be found
convenient.
32-17
FIGURE 32.15 An example of the wrist joint rehabilitation at the movements of hand flexion
The measurement of force is, besides motion ranges, one of the parameters determining the efficiency
of the person. Ergonomics studies the amount of force exerted by the hand or the foot. The results of
investigations are used in designing hand- or foot-operated control devices. Some of the results can be
used in rehabilitation for the assessment of the efficiency of an impaired organ or organ with dysfunction
resulting from a disease. The assessment is based, as in the case of motion ranges, on the standards of
force range, developed with the use of data concerning the healthy population. These standards make
biological bases of reference to be strived for by a person increasing the efficiency of an impaired organ.
Investigations conducted by many scientists confirm the fact that there is a correlation between the
exerted force and circumferential measurements as well as body weight (Laubach, 1966; Hunsicker,
1970; Malinowski, 1975; Jarosz, 1993; Luczak et al., 1993; Batogowska, 1993).
Persons with motor dysfunction, as it was proved in an earlier section, have lower values of somatic
characteristicsthe same concerns children and young people. Rehabilitation makes it possible to increase
the efficiency of particular motor organs and activate respective groups of muscles. Measurement of
force can be an excellent indicator of the rehabilitation progress. Following this line of thought, the
measuring stand to test the hand efficiency was developed in the Institute of Industrial Design in Warsaw
(Nowak, 1995). This efficiency is determined, among others, by measurement of force exerted by the
hand grasping a cylindrical grip. Figure 32.16 shows the schematic diagram of the measuring stand. The
principle of measurement is based upon the hydraulic system. The measuring system cooperates with a
computer unit. The appropriate program makes it possible to calculate and visualize tested parameters.
The subject can watch the effect of measurement on the monitor. This can increase motivation to achieve
better results when the stand is used as a rehabilitation device, creating natural biofeedback. In the case
of children, rehabilitation progress can be stimulated by games. There is a special computer program
developed for this purpose.
The increase of motor efficiency is an important factor in the rehabilitation of children with cerebral
palsy. Myszkowski and Stezala (1989) put forward a proposal of an interesting testing stand. It consists
of the set of control devicesmanipulators using the handgrip function to perform repeated movements.
The set of manipulators and the respective psychomotor computer tests allow the investigation and
rehabilitation of children regardless of the degree of motor dysfunction of the hands.
The examples reported in this subsection prove that methods used in ergonomics are useful in the
rehabilitation process. These methods, as well as the results of investigations, can be used for assessing
an impaired or injured organ. Measuring stands can serve as rehabilitation devices.
32-18
FIGURE 32.16 Schematic diagram of measuring stand for estimation of hand capabilities.
Defining Terms
Anthropometry: (anthroposa man, metreoI measure). A set of techniques used in anthropological
investigations, it embraces methods of physical measurements of the man.
Rehabilitation: A science of systematic multidimensional study of disordered human neuropsychosocial
and/or musculoskeletal function(s) and its (their) remediation by physicochemical and/or psychosocial
means.
Impairment: Any loss or abnormality of psychological and anatomical structure or function (WHO,
1980).
Disability: A restriction or lack of ability (resulting from impairment) to perform an activity in the
manner or within the range considered normal for a human being (WHO, 1980).
Handicap: A disadvantage for a given individual, resulting from an impairment or disability that limits
or prevents the fulfillment of role that is normal (depending on age, sex, and social and cultural
factors) for that individual.
Rehabilitation ergonomics: An interdisciplinary field of science aiming at adjusting material work and
life environment, including articles of everyday use and rehabilitation equipment, to the psychophysical
requirements of the disabled. Rehabilitation ergonomics assists the rehabilitation process, accelerating
integration of the disabled into society.
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33
Update on the Use of
Back Belts in Industry:
More DataSame
Conclusion
Stuart M.McGill
33.1
33.2
33.3
33.4
33.5
Field Trials
Biomechanical Studies
Physiological Studies
Psychophysical Studies
Back Belt Prescription
332
333
334
335
335
The use of abdominal belts in industrial settings continues to be the topic of lively debate. The
premier question still remains Should abdominal belts be prescribed to workers in industry to
perform manual materials handling tasks? In a paper published a few years ago (McGill, 1993), I
reviewed the available scientific literature pertaining to the use of back belts in industry with the
objective of formulating a policy for belt prescription. The intent was not to take a position, either
unconditionally for or against belt usage, but rather weigh the potential assets and liabilities for the
development of belt prescription guidelines. The purpose of this chapter is to briefly review the
literature previously reported, together with the most recent scientific data to see if our position on
belt prescription has changed.
Abdominal belts and lumbar supports continue to be sold to industry in the absence of a regulatory
requirement to conduct controlled clinical trials similar to that required of drugs and other medical
devices. Many claims have been made as to how abdominal belts could reduce injury. For example,
some have suggested that the belts remind people to lift properly. Some have suggested that belts may
possibly support shear loading on the spine that results from the effect of gravity acting on the handheld
load and mass of the upper body when the trunk is flexed. Compressive loading of the lumbar spine has
been suggested to be reduced through the hydraulic action of increased intra-abdominal pressure associated
with belt wearing. Belts have been suspected of acting as a splint, reducing the range of motion, and
thereby decreasing the risk of injury. Still other hypotheses as to how belts may affect workers include
(1) providing warmth to the lumbar region, (2) enhancing proprioception via pressure to increase the
perception of stability, and (3) reducing muscular fatigue. These issues, together with others, will be
addressed in this chapter.
A recent publication from NIOSH (1994) entitled Workplace Use of Back Belts contained critical
reviews of a substantial number of scientific reports evaluating back belts and concluded that back belts
do not prevent injuries among uninjured workers nor do they consider back belts to be personal protective
equipment. While this is generally consistent with our position stated in 1993, my personal position for
belt prescription is somewhat more moderate.
0-8493-1800-9/03/$0.00+$1.50
33-1
33-2
The following sections have subdivided the scientific studies into clinical trials and those that examined
biomechanical, psychophysical, and physiological changes from belt wearing. Finally, based on the
evidence, guidelines are recommended for the prescription and usage of belts in industry.
33.1 Field Trials

Many clinical trials that were reported in the literature were fraught with methodological problems and
suffered from the absence of a matched control group, no post-trial follow-up, limited trial duration,
and insufficient sample size. While the extreme diffkiculty in executing a clinical trial is acknowledged,
only a few trials will be reviewed in this chapter.
The first trial reviewed here was reported by Walsh and Schwartz (1990), in which 81 male warehouse
workers were divided into three groups: a control group (n = 27); a group that received a half-hour
training session on lifting mechanics (n = 27); and a group that received the one-hour training session
and wore low back orthoses while at work for the subsequent six months (n = 27). Instead of using more
common types of abdominal belts, this research group used orthoses with hard plates that were heat
molded to the low back region of each individual. Given the concern that belt wearing was hypothesized
to cause the abdominals to weaken, the abdominal flexion strength of the workers was measured both
before and after the clinical trial. The control group and the training-only group showed no changes in
abdominal flexor strength nor any change in lost time from work. The third group, which received both
training and wore the belts, showed no changes in abdominal flexor strength or accident rate, but did
show a decrease in lost time. However, it appears that the increased benefit was only to those workers
who had a previous low back injury.
In a larger clinical trial reported by Reddell (1992) and colleagues, 642 baggage handlers who worked
for a major airline were divided into 4 treatment groups: a control group (n = 248); a group that received
only a belt (n = 57); a group that received only a one-hour back education session (n = 122); and a group
that received both a belt and a one-hour education session (n = 57). The trial lasted eight months and the
belt used was a fabric weight lifting belt, 15 cm wide posteriorly and approximately 10 cm wide anteriorly.
There were no significant differences between treatment groups for total lumbar injury incident rate, lost
workdays, or workers compensation rates. While the lack of compliance by a significant number of
subjects in the experimental group was cause for consideration, those who began wearing belts but
discontinued their use had a higher lost-day case injury incident rate. In fact, 58% of workers belonging to
the belt-wearing groups discontinued wearing belts before the end of the eight-month trial. Further, there
was an increase in the number and severity of lumbar injuries following the trial of belt wearing.
The clinical trial reported by Mitchell and colleagues (1994) was a retrospective study administered
to 1,316 workers that performed lifting activities in the military. While this study relied on self-reported
physical exposure and injury data over six years prior to the study, the authors did note that the costs of
a back injury that occurred while wearing a belt were substantially higher than if injured otherwise.
A most recent study, reported by Kraus and colleagues (1996), surveilled the low back injury rates of
nearly 36,000 employees of the Home Depot Stores in California from 1989 to 1994. As reported, the
company implemented a mandatory back belt use policy. Although the authors claim that belt wearing
reduced the incidence of low back injury, analysis of the data and methodology suggests a much more
cautious interpretation may be warranted. The concern is based on two issues: the lack of a robust effect
and co-interventions (in addition to belts). The data suggest that the beneficial effect was limited to men
with 1 to 3 years of employment (but not for longer or shorter lengths of employment) and for women
employed 1 to 2 yearsthis is a very narrow band of affected employees. However, of greatest concern
is the lack of scientific control over co-interventions to ferret out the true belt wearing effectthere was
no comparable non-belt wearing group, which is critical given that the belt wearing policy was not the
sole intervention at Home Depot. For example, over the period of the study, the company increased the
use of pallets and forklifts (changing physical demands), installed mats for cashiers, implemented postaccident drug testing, and enhanced worker training. In fact, the company made a conscious attempt to
enhance safety in the corporate culture. This was a large study and the authors deserve credit for the
33-3
massive data reduction and logistics. However, despite the title and claims that back belts reduce low
back injury, this uncontrolled study cannot answer the question about the effectiveness of belts.
In summary, difficulties in executing a clinical trial are acknowledged: the placebo effect is a concern, as
it is difficult to present a true double-blind paradigm to workers since those who receive belts certainly
know so; and there are logistical constraints on duration, diversity in occupations, and sample size. However,
the data reported in the better-executed clinical trials cannot support the notion of universal prescription
of belts to all workers involved in manual handling of materials to reduce the risk of low back injury. There
is weak evidence to suggest that those already injured may benefit from belts (or molded orthoses) with a
reduced risk of injury recurrence. However, there does not appear to be support for uninjured workers
wearing belts to reduce the risk of injury, and in fact, there appears to be an increased risk of injury during
the period following a trial of belt wearing. Finally, there appears to be some evidence to suggest that cost
per back injury may be higher if the worker was wearing a belt than if injured otherwise.
33.2 Biomechanical Studies

Biomechanical studies have examined changes in low back kinematics, posture, and issues of specific
tissue loading. Two studies in particular have suggested that wearing an abdominal belt can increase the
margin of safety during repetitive lifting: Lander et al. (1992) and Harman et al. (1989). Both of these
papers reported ground reaction force and measured intra-abdominal pressure while subjects performed
repeated lifting of barbells. Both reports observed an increase in intra-abdominal pressure when abdominal
belts were worn. These researchers assumed that intra-abdominal pressure is a good indicator of spinal
forces, which is highly contentious. Nonetheless, they assumed the higher recordings of intra-abdominal
pressure indicated an increase in low back support which, in their view, justified wearing belts. Spinal
loads were not directly measured or calculated in these studies.
Several studies have questioned the hypothesized link between elevated intra-abdominal pressure
and reduction in low back load. For example, using an analytical model and data collected from three
subjects lifting various magnitudes of loads, McGill and Norman (1987) noted that a build-up of intraabdominal pressure required additional activation of the musculature in the abdominal wall, resulting
in a net increase in low back compressive load and not a net reduction of load as had been previously
thought. In addition, Nachemson et al. (1986) published some experimental results that directly measured
intra-discal pressure during the performance of valsalva maneuvers documenting that an increase in
intra-abdominal pressure increased, not decreased, the low back compressive load. Therefore, it would
seem erroneous to conclude that an increase in intra-abdominal pressure due to belt wearing reduces
compressive load on the spine. In fact, it may have no effect or may even increase the load on the spine.
In another study McGill, Norman, and Sharratt (1990) examined intra-abdominal pressure and
myo-electric activity in the trunk musculature while six male subjects performed various types of lifts
both wearing and not wearing an abdominal belt (a stretch belt with lumbar support stays, Velcro tabs
for cinching, and suspenders for when subjects were not lifting). Wearing the belt increased intraabdominal pressure by approximately 20%. Further, it was hypothesized that if belts were able to help
support some of the low back extensor moment, one would expect to measure a reduction in extensor
muscle activity. There was no change in activation levels of the low back extensors nor in any of the
abdominal muscles (rectus abdominis or obliques).
In a recent study that examined the affect of belts on muscle function, Reyna and colleagues (1995)
examined 22 subjects for isometric low back extensor strength and found belts provided no enhancement
of function (although this study was only a four-day trial and did not examine the affects over a longer
duration). Ciriello and Snook (1995) examined 13 men over a four-week period lifting 29 metric tonnes
in four hours twice a week both with and without a belt. Median frequencies of the low back
electromyographic signal (which is sensitive to local muscle fatigue) were not modified by the presence
or absence of a back belt, strengthening the notion that belts do not significantly alleviate the loading of
back extensor muscles. Once again this trial was not conducted over a very long period of time.
33-4
In 1986, Lantz and Schultz observed the kinematic range of gross body motions while subjects wore
low back orthoses. While they studied corsets and braces rather than abdominal belts, they did report
restrictions in the range of motion, although the restricted motion was minimal in the flexion plane. In
a more recent study McGill et al. (1994) tested flexibility and stiffness of the lumbar torsos of 20 male
and 15 female adult subjects, both while they wore and did not wear a 10 cm leather abdominal belt.
The stiffness of the torso was significantly increased about the lateral bend and axial twist axes but not
when subjects were rotated into full flexion. Thus, it would appear from these studies that abdominal
belts assist to restrict the range of motion about the lateral bend and axial twist axes but do not have the
same effect when the torso is forced in flexion, as in an industrial lifting situation. Posture of the lumbar
spine is an important issue in injury prevention for several reasons, but in particular Adams and Hutton
(1988) have shown that the compressive strength of the lumbar spine decreases when the end range of
motion in flexion is approached. Therefore, if belts restrict the end range of motion one would expect
the risk of injury to be correspondingly decreased. While, the splinting and stiffening action of belts
occurs about the lateral bend and axial twist axes, stiffening about the flexion-extension axes appears to
be less. A most recent data set presented by Granata et al. (1997) supports the notion that some belt
styles are better in stiffening the torso in the manner described above, namely the taller elastic belts
which span the pelvis to the rib cage. Furthermore, they also documented that a rigid orthopedic belt
generally increased the lifting moment, while the elastic belt generally reduced spinal load, but a wide
variety in subject response was noted (some subjects experienced increased spinal loading with the
elastic belt). However, even in well-controlled studies, it appears that belts can modulate lifting mechanics
in some positive ways in some people and in negative ways in others.
33.3 Physiological Studies

Blood pressure and heart rate were monitored by Hunter and colleagues (1989) while five males and
one female subject performed dead lifts, bicycle riding, and one-armed bench presses, while wearing and
not wearing a 10-cm weight belt. A load of 40% of each subjects maximum weight in the dead lift was
held in a lifting posture for two minutes. The subjects were required to breathe throughout the duration
so that no valsalva effect occurred. During the lifting exercise blood pressure was significantly higher
(up to 15 mmHg), while heart rate also was higher when the belt was worn. Given the relationship
between elevated systolic blood pressure and an increased risk of stroke, Hunter et al. (1989) concluded
that individuals who may have cardiovascular system compromise are probably at greater risk when
undertaking exercise while wearing back supports.
Recent work conducted in our own laboratory (Rafacz and McGill, 1996) investigated the blood
pressure of 20 young men performing sedentary and very mild activities both with and without a belt
(the belt was the elastic type with suspenders and Velcro tabs for cinching at the front). Wearing this
type of industrial back belt significantly increased diastolic blood pressure for quiet sitting and standing
both with and without a handheld weight, during a trunk rotation task, and during a squat lifting task.
There is increasing evidence to suggest belts increase blood pressure!
Over the past three or four years I have been asked to deliver lectures and participate in academic
debate on the back belt issue. On several occasions, occupational medicine personnel have approached
me after hearing the effects of belts on blood pressure and intra-abdominal pressure, and have expressed
suspicions that long-term belt wearing at their particular workplace may possibly be linked with higher
incidents of varicose veins in the testicles, hemorrhoids, and hernias. At this point in time, there has been
no scientific and systematic investigation of the validity of these claims and concerns. Rather than wait
for strong scientific data to either lend support to these conditions or dismiss them, it may be prudent to
simply state concern. This will motivate studies in the future to track the incidents and prevalence of
these pressure-related concerns to assess whether they are indeed linked to belt wearing.
33-5
33.4 Psychophysical Studies

Studies based on the psychophysical paradigm allow workers to select weights that they can lift repeatedly
using their own subjective perceptions of physical exertion. McCoy et al. (1988) examined 12 male college
students while they repetitively lifted loads from floor to knuckle height at the rate of 3 lifts per minute for
a duration of 45 minutes. They repeated this lifting bout three times, once without a belt and once each
with two different types of abdominal belts (a belt with a pump and air bladder posteriorly, and the elastic
stretch belt previously described in the McGill, Norman, and Sharratt [1990] study). After examining the
various magnitudes of loads that subjects had self-selected to lift in the three conditions, it was noted that
wearing belts increased the load that subjects were willing to lift by approximately 19%. There has been
some concern that wearing belts fosters an increased sense of security, which may or may not be warranted.
This evidence may lend some support to this criticism of wearing abdominal belts.
33.5 Back Belt Prescription

My earlier report (McGill, 1993) presented data and evidence that neither completely supported nor
condemned the wearing of abdominal belts for industrial workers. Definitive laboratory studies that
describe how belts affect tissue loading and physiological and biomechanical function have yet to be
performed. In addition, clinical trials of sufficient scientific rigor to comprehensively evaluate the
epidemiological risks and benefits from exposure to belts must be done. The challenge remains to arrive
at the best strategy for wearing belts. Therefore, the available literature will be interpreted and given
placement, and also combined with common sense to derive the most sensible position on prescription.
Given the available literature, it would appear the universal prescription of belts (i.e., providing belts to all
workers in a given industrial operation) is not in the best interest of globally reducing both the risk of injury
and compensation costs. Uninjured workers do not appear to enjoy any additional benefit from belt wearing
and in fact may be exposing themselves to the risk of a more severe injury if they were to become injured and
may have to confront the problem of weaning themselves from the belt. However, if some individual workers
perceive a benefit from belt wearing, then they may be allowed to conditionally wear a belt, but only on trial.
The mandatory conditions for prescription (for which there should be no exception) are as follows:
1. Given the concerns regarding increased blood pressure and heart rate, and issues of liability, all
those who are candidates for belt wearing should be screened for cardiovascular risk by medical
personnel.
2. Given the concern that belt wearing may provide a false sense of security, belt wearers must receive
education on lifting mechanics (back school). All too often belts are being promoted to industry as
a quick fix to the injury problem. Promotion of belts conducted in this way is detrimental to the
goal of reducing injury as it redirects the focus from the cause of the injury. Education programs
should include information on how tissues become injured, techniques to minimize musculo-skeletal
loading, and what to do about feelings of discomfort to avoid disabling injury.
3. No belts will be prescribed until a full ergonomic assessment has been conducted of the individuals
job. The ergonomic approach will examine, and attempt to correct, the cause of the musculoskeletal
overload and will provide solutions to reduce the excessive loads. In this way, belts should only
be used as a supplement for a few individuals while a greater plant-wide emphasis is placed on
the development of a comprehensive ergonomics program.
4. Belts should not be considered for long-term use. The objective of any small-scale belt program
should be to wean workers from the belts by insisting on mandatory participation in comprehensive
fitness programs and education on lifting mechanics, combined with ergonomic assessment.
Furthermore, it would appear wise to continue vigilance in monitoring former belt wearers for a
period of time following belt wearing, given that this period appears to be characterized by
elevated risk of injury.
33-6
References
Adams, M.A. and Hutton, W.C. Mechanics of the intervertebral disc, in The Biology of the Intervertebral
Disc, Ed. P.Ghosh, Boca Raton, FL: CRC Press (1988).
Ciriello, V.M. and Snook, S.H. The effect of back belts on lumbar muscle fatigue. Spine 20(11): 1271
1278 (1995).
Granata, K.P., Marras, W.S., and Davis, K.G. Biomechanical assessment of lifting dynamics, muscle
activity and spinal loads while using three different style lifting belts, Clin. Biomech. 12(2): 107
115 (1997).
Harman, E.A., Rosenstein, R.M., Frykman, P.N., and Nigro, G.A. Effects of a belt on intra-abdominal
pressure during weight lifting. Med. Sci. Sports Exercise 2(12): 186- 190 (1989).
Hunter, G.R., McGuirk, J., Mitrano, N., Pearman, P., Thomas, B., and Arrington, R. The effects of a
weight training belt on blood pressure during exercise. J. Appl. Sport Sci. Res. 3(1): 1318 (1989).
Kraus, J.F., Brown, K.A., McArthur, D.L., Peek-Asa, C., Samaniego, L., and Kraus, C. Reduction of
acute low back injuries by use of back supports. Int. J. Occup. Environ. Health 2:264273 (1996).
Lander, J.E., Hundley, J.R., and Simonton, R.L. The effectiveness of weight belts during multiple repetitions
of the squat exercise. Med. Sci. Sports Exercise 24(5):603609 (1992).
Lantz, S.A. and Schultz, A.B. Lumbar spine orthosis wearing. I. Restriction of gross body motion. Spine
11(8):834837 (1986).
McCoy, M.A., Congleton, J.J., Johnston, W.L., and Jiang, B.C. The role of lifting belts in manual lifting.
Int. J. Ind. Ergonomics 2:259266(1988).
McGill, S.M. Abdominal belts in industry: A position paper on their assets, liabilities and use. Am. Ind.
Hyg. Assoc. J. 54(12):752754 (1993).
McGill, S.M. and Norman, R.W. Reassessment of the role of intra-abdominal pressure in spinal
compression. Ergonomics 30(11):15651588 (1987).
McGill, S., Norman, R.W., and Sharratt, M.T. The effect of an abdominal belt on trunk muscle activity
and intra-abdominal pressure during squat lifts. Ergonomics 33(2): 147160 (1990).
McGill, S.M., Seguin, J.P., and Bennett, G. Passive stiffness of the lumbar torso in flexion, extension,
lateral bend and axial twist: The effect of belt wearing and breath holding. Spine 19(6):696704
(1994).
Mitchell, L.V., Lawler, F.H., Bowen, D., Mote, W., Asundi, P. and Purswell, J. Effectiveness and costeffectiveness of employer-issued back belts in areas of high risk for back injury. J. Occup. Med.
36(1):9094 (1994).
Nachemson, A.L., Andersson, G.B.J., and Schultz, A.B. Valsalva maneuver biomechanics. Effects on
lumbar trunk loads of elevated intra-abdominal pressures. Spine 11(5):476479 (1986).
NIOSH, Workplace use of back belts, U.S. Department of Health and Human Services, Centres for
Disease Control and Prevention. National Institute for Occupational Safety and Health. July, 1994.
Rafacz, W. and McGill, S.M. Abdominal belts increase diastolic blood pressure. J. Occup. Environ.
Med. 38(9):925927 (1996).
Reddell, C.R., Congleton, J.J., Huchinson R.D., and Mongomery J.F. An evaluation of a weightlifting
belt and back injury prevention training class for airline baggage handlers. Appl. Ergonomics
23(5):319329 (1992).
Reyna, J.R., Leggett, S.H., Kenney, K., Holmes, B., and Mooney, V. The effect of lumbar belts on
isolated lumbar muscle. Spine 20(1):6873 (1995).
Walsh, N.E. and Schwartz, R.K. The influence of prophylactic orthoses on abdominal strength and low
back injury in the workplace. Am. J. Phys. Med. Rehab. 69(5):245250 (1990).
34
The Influence of
Psychosocial Factors on
Sickness Absence
Chris J.Main
Hope Hospital, Salford, U.K.
A.Kim Burton
Michele C.Batti
34.1
34.1 Introduction
341
34.2 Workloss and Suboptimal Work Functioning:
The Extent of the Problem
342
Influence of Psychological Factors on Accidents and
Reinjury Costs and Effects of Long-Term Disability
34.3 Models of Incapacity
343
Injury and Incapacity: A Dynamic Model
34.4 Psychological Factors and Pain
344
Nature of Psychological Factors Clinical Perspectives on
Pain and Disability Conclusion Determinants of
Chronicity in Clinical Settings Mechanisms of Chronic
Incapacity Conclusions from Clinical Studies
34.5 Psychological Aspects of Work
3410
Difficulties in the Identification of Work-Related Stress
Approaches to the Definition and Study of Work Stress
Coping with Occupational Stress Predictors of Chronic
Incapacity in Occupational Settings
34.6 Socioeconomic and Medicolegal
Dimensions
3413
34.7 Return to Work: Prevention of Chronic
Incapacity
3413
The Role of Education Physical Therapy Functional
Restoration (Sports Medicine Approach) Specific
Psychological Approaches Conclusion
34.8 Implications
3415
Reappraisal of the Nature of Work-Related Incapacity
Solutions for the Individual Worker Solutions for a Sick
Workplace
34.9 Conclusion
3417
Introduction
Despite increasing advances in medical technology, the cost of musculoskeletal incapacity, particularly
low back pain, in terms of sickness benefits, invalidity benefits, and associated allowances has led to a
fundamental reconsideration of the nature of chronic incapacity. Recent reports from the United Kingdom
(CSAG, 1994), the United States (Bigos et al., 1994), and New Zealand (ACC and the National Health
Committee, 1997) in their recommendations for a comprehensive multidisciplinary assessment for patients
still symptomatic at six weeks, are based on the clear assumption that a significant proportion of chronic
0-8493-1800-9/03/$0.00+$1.50
34-1
34-2
incapacity is preventable. Such a proposition represents a fundamental challenge to much of current

medical practice.
Incapacity, as defined clinically is seen as the result of a series of processes in which nature of injury, rate
of recovery, and extent of recovery are significantly intermeshed with the nature of medical management and
patients beliefs about the nature of their injury, confusion about the nature of hurting and harming, and
mistaken beliefs that physical activity will lead to further damage. Such beliefs may also be the product of the
organizational culture in which they work and affected by workplace practices in which persistence of incapacity
is viewed with suspicion and conditions of service dictate that 100% recovery is required before the
employer is willing to undertake the risks of permitting an injured employee to return to work.
There has been a tendency also to predicate beliefs about incapacity on an incorrect and outmoded
view of the relationships among physical and psychological factors in the context of injury. In simple
terms, the mind and the body have become divorced. Psychological influences are viewed with suspicion
either as a sign of mental infirmity or as malingering. The adoption in particular of a blue-collar macho
culture has made it difficult to admit that there are many factors affecting successful recovery, and these
are not simply confined to the parameters of medical treatment and associated rehabilitative efforts.
The costs of incapacity have led to a considerable financial commitment to the investigation and
amelioration of risk factors for chronicity. It has been argued in the previous chapter that the concept of
risk has been confined almost entirely to biomechanical and ergonomic perspectives. Psychosocial factors,
similarly, have been investigated principally as aspects of stress, a multifaceted concept which has
incorporated a wide range of perspectives including management style, cognitive demands of tasks,
fatigue, the social climate of work (whether supportive or antagonistic), and the recognition of stress
responses in individuals. A wide-ranging survey of the literature has revealed direct relevance to the
interaction of occupational and clinical factors in recovery from injury and return to work.
It is the intention of this chapter to address such issues from the perspective specifically of psychological
obstacles to rehabilitation. An attempt will be made to offer a new conceptual framework and suggest a
set of specific procedures and guidelines which may be of assistance in considering afresh the problem of
occupational incapacity, using pain-associated incapacity (and back pain in particular) as an example.
34.2
Workloss and Suboptimal Work Functioning:

The Extent of the Problem
The extent of the problem has been addressed in our previous chapter, and the issue will be addressed
here specifically only to the extent that a specific psychosocial perspective is relevant.
Influence of Psychological Factors on Accidents and Reinjury

Psychological factors have been implicated in the occurrence of accidents, both in terms of their frequency
and in the actual nature of the accidents. Accident-proneness has been appraised from both the
statistical and the psychological or physiological points of view. A number of specific psychological
characteristics have been associated with the occurrence of accidents. These can be conceptualized first
in terms of central nervous system dysfunction in terms of the processing of information, and second in
terms of performance or execution of tasks.
Apparent accident-proneness may be indicative of or may result from some sort of impaired function
in the interpretation or execution of tasks (Porter, 1988). Fatigue and mood disturbance can affect
concentration. Difficulties in concentration in turn can affect the accurate coding and decoding of
information., which may lead to misinterpretation of information with associated performance
compromise. She concludes that individuals do appear to differ in their propensity toward minor accidents,
and this is most likely the result of an attention deficit, which is itself a consequence of stress. Such an
effect may be particularly noticeable in complex tasks or tasks requiring sustained vigilance. The
complexity of the task also appears to be important rather than the intelligence of the subject.
The Influence of Psychosocial Factors on Sickness Absence
34-3
Execution of tasks can also be affected by impaired neuromuscular coordination as a result of fatigue
or disturbances to muscle control. Possibly mediated by sympathetic over-activity such as heightened
muscle tension or tremor. The specific importance of such factors, over and above central processing
effects, on accident-proneness does not seem specifically to have been evaluated.
Whatever the scientific basis for the term accident-proneness, it would appear to be the case,
however, that some individuals believe themselves to be more prone to accidents, and as such engage in
a variety of superstitious behaviors designed to reduce the likelihood of accidents. Such behaviors may
range from relatively benign rituals to marked avoidance of a range of situations. To the extent that
normal functioning is not compromised, such behavior can be viewed as harmless eccentricity, but
where it develops a compulsive quality and interferes significantly with effective functioning or
psychological well-being then it may constitute a clinical disorder necessitating treatment. Attempts to
return to work may be hindered by such beliefs.
More common, however, are specific fears of hurting and harming when engaging in specific activities
rather than worries about unforeseen accidents. Such fears can either be about the activity being painful
or about the dangers of further damage or reinjury. Such fears may lead to excessive caution in the
execution of tasks, disturbances to normal biomechanical rhythm, and thereby increased the actual risks
of accident or re-injury. (The evaluation of the nature and significance of such beliefs and fears is discussed
further below.)
Costs and Effects of Long-Term Disability

The economic costs of pain-associated incapacity have been discussed in earlier chapters. In addition to
the costs to industry of lost productivity and wage-replacement, there is of course a cost to the injured
worker and his/her family. This cost has to be understood not only in financial terms but also in terms
of its psychological effects. In addition to the pain and limitations on everyday living, absence from
work can be demoralizing. Boredom, loss of identity, and diminished self worth can create stress and
depression, which can have a major impact on the individual and the family. Major psychological effects
may not be evident until the worker has been off work for some time and faces the prospect of losing his/
her job. Persistence of pain, disturbance to normal activities (particularly sleep) and routines of daily
living, and concerns about their recovery and satisfactory return to work can produce frustration and
irritability even in the short term. In order to understand the complex interaction between medical,
psychological, and occupational factors, it is necessary to reconsider the nature of incapacity and its
relationship with sickness absence from work.
34.3
Models of Incapacity
The evidence for and against biomechanical and ergonomic models has been reviewed in our related
chapter (Burton et al., 1997). Any workplace will have its own culture or zeitgeist concerning the nature
of injury and the specific role of ergonomic and biomechanical factors. These maxims may be
enshrined in specific documents concerning work practices or be the subject of health and safety
training or procedures required by the organization to reduce the risk of injury. As mentioned, the actual
evidence for the efficacy of primary prevention is in fact weak, and whether workers understand, adhere
to, or even accept the assumptions behind such regulations is unknown. To the extent that workers do
form a view about the nature of injury and the process of recovery, it seems likely that they would adopt
a biomechanical or ergonomic view of causation rather than a more complex biopsychosocial
formulation.
If a clearly identified injury has occurred, and this has resulted in a medical assessment, then the
person may have been offered a diagnosis implying a structural basis to their complaint. It may be
implied that some sort of permanent damage might have occurred and a series of impressive hightechnology investigations may be recommended. Even if no permanent physical impairment in terms of
34-4
structural damage to bone or nerves is identified, the notion of a significant weakness and therefore
occupational vulnerability may be promulgated. Either of these views may of course have substance if a
significant trauma has occurred, but usually have not. Even in the context of minor injury, it may be
implied that the work accident (or incident) simply has been the straw that broke the camels back. It
may be implied that there has been a cumulative impact of work leading finally to tissue breakdown.
Osteoarthritic changes on X-ray may be adduced as evidence of this, despite the fact that only agerelated changes may be apparent.
A worker may thus come to believe that his or her problem can only be understood in straightforward
biomechanical, ergonomic, or medical terms. The worker may believe that the nature of the injury
has specific implications for the nature of treatment and rehabilitation. His or her understanding of
these issues concerning causality may make it difficult to accept the worth of and indeed necessity for, a
speedy return to normal work. He may be resistant to rehabilitative efforts based on a self-help approach
and may resist vigorously the suggestion that successful return to work may be hindered or indeed be
prevented by psychosocial factors.
It is, in our view, necessary to consider disability from a wider perspective. Research into the nature
of disability in clinical settings has suggested the need for a wider perspective on pain-associated
incapacity than the traditional medical model. In formulating the biopsychosocial model of disability
(Waddell, 1992), Waddell and his colleagues demonstrated that level of disability could by adequately
understood only if consideration was given to psychological and social as well as physical factors. In an
earlier publication (Waddell et al., 1984), they critically compared the influence of a large number of
psychological factors on reported disability. They found that patients current level of distress and
behavioral responses to pain were far more important as predictors of disability than general
personality traits, specific hypochondriachal fears, or generalized beliefs about patients perceived
degree of control over their lives. The biopsychosocial model, as it came to be known, was later further
refined by the incorporation of beliefs about pain into a dynamic model addressing the transition from
acute to chronic incapacity (Waddell et al., 1993). The relative importance of specific psychological
factors is described in the next section. Recently it has been suggested (Main and Watson, 1996) that it
may be helpful to consider incapacity as a developing process rather than as some sort of end-state.
Most injuries seem to be over-reliant on concepts of tissue-healing time, where it is assumed that after
about six weeks tissue should have healed and by implication the physical status should have
returned to its preinjury status. This perception has the unfortunate concept that pain and painassociated incapacity persisting beyond that time may be viewed with suspicion. Clearly a proportion of
patients remain incapacitated after injury and theoretical models are needed which address the process
of chronicity.
Injury and Incapacity: A Dynamic Model

Such perspectives of chronic incapacity as a dynamic process have not to date been integrated adequately
into the psychology of return-to-work after injury. Before addressing occupational factors specifically, it
is necessary from the psychological point of view to consider further the nature and influence of
psychological factors in relation to pain and incapacity.
34.4
Psychological Factors and Pain
Nature of Psychological Factors

During the last 15 years, the role of psychological factors in the genesis and maintenance of pain problems
has been increasingly recognized (Main and Spanswick, 1991). Early research into personality traits and
identifiable psychiatric illness has been followed by investigation of more specific psychological
characteristics such as psychological distress, pain behavior, beliefs about pain, and pain coping strategies.
A range of psychometric tests, behavioral measures, and more general tools assessing function or impact
34-5
of pain have been developed both for the assessment of pain and the investigation of specific psychological
dimensions and mechanisms.
Clinical Perspectives on Pain and Disability

There is a wide range of psychological tests available. For the purpose of this review, psychological
aspects of pain will be considered under a number of headings. The focus of this review will be primarily
on clinical and occupational applications. A comprehensive analysis of the relative merits of objective
and subjective measures in chronic pain from a methodological point of view is presented elsewhere
(Dworkin and Whitney, 1992).
Evaluation of Pain
There is no simple relationship between the amount of tissue damage and the sensation of pain since the
experience of pain is affected by a number of physiological and psychological factors. It cannot therefore
be assessed as simply, for example, as temperature since it has both sensory and emotional components.
Pain has been defined as: An unpleasant sensory and emotional experience associated with actual or
potential damage, or described in terms of such damagepain is always subjective (International
Association for the Study of Pain, 1979). The emotional content can be appraised by investigation of the
vocabulary patients use to describe their pain (Melzack, 1987; Melzack and Katz, 1992) or the way they
complete pain drawings (Ransford et al., 1975; Parker et al., 1995). Thus, while the assessment of pain
may appear to be fairly straightforward, an understanding of its significance requires a more
comprehensive assessment of the pain patient.
Influence of General Psychological Characteristics

In general clinical practice there is a range of goals for psychological assessment including influences on
pain perception, adjustment to pain, selection for particular types of treatment, and the design of treatment
interventions. Methods of assessment include administration of questionnaires, psychodiagnostic clinical
interviews, videotape analysis, and behavioral observation. No single assessment tool or indeed method
of assessment is suitable for all purposes. The use of interviews and self-report inventories in the evaluation
of pain patients is reviewed comprehensively elsewhere (Bradley et al., 1992). The focus of many of
these studies has been on the nature of pain perception. For the purpose of this review, specific attention
will be directed toward influences on incapacity, recovery from injury, and obstacles to rehabilitation.
It is important to consider how patients react to the whole treatment process, and the establishment
of a successful therapeutic alliance between doctor and patient is extremely important (Hazard et al.,
1994). With regard to pain patients in particular they considered that this was best achieved by setting
mutually agreed goals concerning pain relief, improved functional capacity, and occupational
reengagement. Mayer and his colleagues (Mayer and Gatchel, 1988) have consistently advocated
functional restoration as the primary goal for rehabilitation for pain-associated incapacity. While
acknowledging the tremendous value and importance of functional restoration in treatment of the
chronically incapacitated patient, a degree of preselection is involved in all treatment programs and the
noncommitted might feel that it cannot be assumed that all psychological obstacles can necessarily be
dissolved or rendered inert by a robust functional restoration approach. Nonetheless, the functional
restoration approach has been hugely important in shifting emphasis from psychopathology to function.
Although the more psychiatrically derived and complex psychological dimensions have been as yet of
only limited value in the prediction of outcome of treatment, it would appear that simpler measures of
the individuals response to pain and incapacity are helpful.
In back-associated disability, patients level of distress, in the form of heightened somatic awareness
and depressive symptomatology, has been shown to be more closely associated with reports of disability
than general personality characteristics or hypochondriacal fears (Main and Waddell, 1987). The two
distress questionnaires later were combined into the Distress Risk Assessment Method or DRAM (Main
34-6
et al., 1992), which yields a fourfold classification of patients in terms of their level of distress. Although
the test does not offer an evaluation specifically of the relationship between distress and incapacity,
scores on this test have been shown to be predictive of the development and continuation of chronic
incapacity in patients with back pain (Burton et al., 1995). The relationship between generalized distress
and more specific fears of hurting and harming (see below) may merit further investigation.
Pain Behavior
Although it is not possible to experience anothers pain, people can communicate their pain either verbally
or nonverbally. During the last 30 years, the importance of pain behavior has been increasingly recognized
(Fordyce, 1976). It is important to recognize that the explanation for a pain behavior is not necessarily
immediately apparent. Indeed a clear formulation is usually considered to require a detailed functional
behavior analysis to identify the precise circumstances in which the behavior is occurring. The type of
analysis will depend on the behavior in question. Typical pain behaviors might include verbalized pain
responses, nonverbalized pain behaviors, patterns of activity, or health care usage (e.g., medication use).
The behavioral view has been hugely influential as an alternative to the disease-dominated medical
model and has led to significant changes in the manner and content of health care delivery (as evidenced by
the development of pain management programs and functional restoration programs).
Pain behavior may be assessed in a number of ways, and a variety of methods have been devised for
use in different settings. Clinical approaches have included assessment of pain behavior during clinical
examination (Waddell et al., 1980; Waddell et al., 1984) and use of videotaped ratings of pain behavior
during a standardized sequence of movements (Keefe and Hill, 1985), but simpler rating scales have also
been devised (Richards et al., 1982).
Although the interpretation of pain behavior is not without controversy, it should form an important
aspect of assessment following injury and may contain important features indicative of obstacles to
successful rehabilitation. Only the most committed of behavioral theorists would probably now argue
that pain behavior can be adequately understood without an evaluation of specific beliefs, fears, and
coping strategies. Nonetheless, in many contexts, self-report may be insufficiently informative, and an
adequate crystallization of the problem may require a systematic behavioral analysis.
Cognitive Factors in Pain

The study of cognition has become increasingly complex, but it is possible in general to subdivide the
field into three distinct fields of enquiry: beliefs or appraisal; cognitive processes; and coping strategies.
Such perspectives have led to the investigation of cognitive factors in pain, adjustment to pain, and in
the development of chronic incapacity. The complexity of these interrelationships is indicated in the
following quotation:
Patients who believe they can control their pain, who avoid catastrophizing about their condition;
and who believe they are not severely disabled appear to function better than those who do not. Such
beliefs may mediate some of the relationships between pain severity and adjustment (Jensen et al.,
1991, p. 249).
Specific Beliefs About the Nature of Pain

There are a number of different types of belief or appraisal about the nature of pain, and the development
of new tests assessing different aspects of beliefs has become something of a growth industry. A
comprehensive review of the field is presented elsewhere (DeGood and Schutty, 1992). While many of
these tests seem to be of value, there is clearly much conceptual overlap among them and further research
is needed to determine the precise value of each of these tests for particular purposes and contexts. For
this review, a number of tests will be chosen to illustrate the types of belief which have been found in the
literature to be of relevance in the assessment of the psychological impact of pain.
In the psychological literature there has long been interest in the extent to which individuals believe
they can control or gain control over aspects of their life. Researchers have assessed specific beliefs about
health (Wallston et al., 1978). The same scale was then adapted for the study of pain by simple substitution
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of pain for health throughout the questionnaire (Toomey et al., 1991; Crisson and Keefe, 1988).
Other pain locus of control scales have been developed (Main and Waddell, 1991) and used specifically
in occupational settings. In one study, negative pain locus of control beliefs were significantly associated
with absence from work (Symonds et al., 1996), but in a related study, the introduction of educational
leaflets produced increased optimism about the control of pain (Symonds et al., 1995).
Locus of control beliefs would seem to have some influence on response to treatment and return to
work, but the relationship of such beliefs to other beliefs merits further examination, and a critical
comparison of these questionnaires in a wider range of occupational contexts is needed. Their specific
value in occupational rehabilitation has yet to be demonstrated.
Specific Beliefs About Outcome of Treatment

Specific beliefs about treatment outcome can also be investigated. Such beliefs are often referred to as
self-efficacy beliefs. Self-efficacy has been defined in terms of the belief that one was capable of
producing a behavior which was necessary to achieve a certain outcome (Bandura, 1977). This general
idea has been investigated in terms of the relationship between such beliefs and resultant behavior in
relation to treatment outcome.
According to DeGood and Shutty (1992), These concepts suggest that pain patients who perceive
themselves lacking the capacity to acquire self-management skills might be less persistent, more prone to
frustration, and more apt to be noncompliant with treatment recommendations. Hence, some patients
might demonstrate adequate understanding of particular treatment rationale, yet be noncompliant due
to their perceived inability to produce the behavior necessary to follow treatment recommendations
(DeGood and Shutty, 1992, p. 221).
The Self-Efficacy Questionnaire or SEQ (Nicholas et al., 1992) is a 10-item scale yielding a single score
giving a measure of the patients confidence in the outcome of pain management (or rehabilitation in
which they have to play an active part). This questionnaire seems promising but requires further scientific
evaluation. Such beliefs would also seem to be important in the context of occupational rehabilitation. It
has been shown, for example, that patients beliefs about whether or not they would be able to return to
work were the best predictor of return to work after rehabilitation (Sandstrom and Esbjornsson, 1986).
There are as yet few questionnaires specifically validated for the assessment of self-efficacy beliefs in
occupational settings. Recently one such questionnaire has been developed specifically to investigate
beliefs about back pain. Unlike the previous measures it has been used primarily in occupational settings.
The Back Beliefs Questionnaire or BBQ (Symonds et al., 1996) includes scales specifically concerning
the perceived inevitability of back pain and its future course. They found that workers with a previous
history of back pain were more likely to believe their backs would be problematic in the future. More
pessimistic beliefs about the controllability of pain and less willingness to take responsibility for it were
associated with a higher number of spells of back pain and more back-associated work loss in the past.
Specific Fears of Hurting, Harming, and Further Injury

It is crucial to recognize the role of fear and avoidance as obstacles to rehabilitation following injury. Behavioral
theorists such as Fordyce (1976) explained the development of avoidance learning where successful avoidance
of pain established a behavioral pattern which was successful in reducing pain but with the cost of maintaining
the disability. Letham et al. (1983) and Slade et al. (1983) incorporated these ideas into a fear avoidance
model of exaggerated pain perception in chronic low back pain. In their view, such beliefs were central in the
development of pain avoidance behavior. Letham et al. (1983) described patients as confronters or avoiders,
and it has been observed (Waddell et al., 1993) that fear and avoidance of pain can become more disabling
than pain itself, since although avoidance at early stages may reduce nociception, the avoidance behaviors
may persist in anticipation of pain rather than simply as a response to it.
Fear, specifically of movement and reinjury, may also become established. If an injured worker
mistakenly believes that resumption of a particular activity will actually lead to an increase in pain or
produce further damage, this obstacle to rehabilitation will have to be removed if the worker is to be
rehabilitated. The genesis of such fears has also been investigated. Vlaeyen et al. (1995a) found that fear
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of movement and reinjury was more related to depressive symptoms and catastrophizing than to pain
itself. Finally, in a study of 300 patients attending their family doctor with acute back pain, fear-avoidance
beliefs predicted outcome at two and twelve months (Klenerman et al. 1995). The importance of addressing
such beliefs and associated psychological mechanisms within a reactivation framework would seem to
be compelling, but development of accurate assessment instruments is still at an early stage.
The Fear-Avoidance Beliefs Questionnaire or F.A.B.Q (Waddell et al., 1993) has two scales. The first
(physical activity scale) assesses beliefs about the influence of physical activity on pain, while the second
(work scale) examines specifically beliefs about the influence of work on pain. The Tampa Scale of
Kinesophobia or T.S.K. (Miller et al., 1991) has also been recently developed. A recent study (Vlaeyen et
al., 1995b) has shown that fear of movement may have a major impact on behavioral performance. This
topic would seem to merit further investigation.
Coping Strategies
Coping can be considered in terms of what people do to try to diminish the occurrence or impact of
unpleasant events of various sorts. Patients may employ a wide range of behavioral and coping strategies
in order to limit the effects of pain. Choice of strategies will depend on patients beliefs about pain, on
their confidence in being able to influence events, and of course on their repertoire of coping behaviors.
In addition to differentiating behavioral from cognitive coping strategies, researchers have also described
coping behaviors in terms of their appropriateness and effectiveness, specifically in relation to pain and
adjustment. Thus, Brown and Nicassio (1987) made the important distinction between active and passive
coping strategies. Perhaps the most widely used questionnaire is the Coping Strategies Questionnaire or
CSQ (Rosenstiel and Keefe, 1983). The 50 items give scores of six cognitive scales (diverting attention,
reinterpreting pain sensation, coping self-statements, ignoring pain sensations, passive praying, or hoping
and catastrophizing), two behavioral coping scales (increasing activity level and increasing pain behaviors),
and two single items concerning perceived control over pain.
The questionnaire offers a general evaluation of the relative use of effective (or appropriate) coping
strategies and ineffective (or inappropriate) coping strategies. Several studies have shown that negative
or ineffective coping strategies such as catastrophizing (fearing the worst) are associated with higher
levels of self-reported disability or adjustment (Jensen et al., 1991; Keefe et al., 1989; Main and Waddell,
1991). The catastrophizing scale has also shown impressive predictive value in outcome of treatment,
particularly in patients with acute pain (Burton et al., 1995). Brandtstadter (1992) distinguished two
fundamentally different ways of coping with chronic pain: assimilative coping, involving active attempts
to alter circumstances in line with personal preferences and accommodative coping or downgrading
of goals or expectations when goals are seen to be unattainable through active coping efforts. Two
scales: Tenacious Goal Pursuit (TGF) and Flexible Goal Adjustment (or FGA) have been developed to
measure these aspects of coping (Brandstadter and Renner, 1990). In a recent study of coping style and
pain-associated distress, it was concluded accommodative coping functions as a protective resource by
preventing global losses in the psychological functioning of chronic pain patients and maintaining a
positive life perspective. Most important, the ability to flexibly adjust personal goals attenuated the
negative impact of the pain experience (pain intensity, pain-related disability) on psychological wellbeing (depression). Furthermore, pain-related coping strategies led to a reduction of disability only
when accompanied by a high degree of flexible goal adjustment (Schmitz et al., 1996; p. 41).
These research findings are consistent with early work by demonstrating that depression is primarily
a function of pain-associated incapacity (or interference with life) rather than a direct result of pain itself
(Rudy et al., 1988)). These findings suggest that, in the design of a return-to-work rehabilitation program
for the injured worker, a degree of flexibility should be seriously considered.
Conclusion
There is now wide evidence that psychological factors influence pain perception, level of incapacity,
adjustment to disability, and response to treatment in clinical settings. A number of key psychological
dimensions have been identified. Such factors are important not only for understanding the impact of
34-9
pain on the individual but also for understanding the nature of pain-associated incapacity and recovery
from injury. A number of recent studies have suggested that a number of these psychological factors are
also predictive of the development of chronic incapacity and as such can be considered as risk factors for
chronicity.
Determinants of Chronicity in Clinical Settings

Psychological factors, however, need to be understood not only in terms of their influence on pain
perception and on response to treatment, but also on the process of chronicity (or conversely, recovery
from incapacity).
Several studies have compared the relative importance of physical and psychological factors on the
prediction of outcome of treatment As has been stated elsewhere, most treatment and intervention is
based on concepts of tissue damage and amelioration of biomechanical dysfunction following injury.
Many studies have tried to identify the importance of all sorts of anthropomorphic, clinical, and
biomechanical factors in terms of risk of injury, or risk of continued incapacity (Halpern, 1992).
Multivariable analyses of such data suggest that the relative contribution of the different classes of
variable to prediction of chronicity is particularly complex (Burton and Tillotson, 1991). In general,
however, it may be the (clinical) historical and psychosocial information rather than the socio-occupational
or biomechanical variables that are associated with lack of recovery (Burton et al., 1999).
In chronic back pain patients, levels of distress at time of initial assessment were found to be as
important as known risk factors (such as previous lumbar surgery) in outcome from conservative treatment
2 to 4 years later (Main et al., 1992). The particular importance of psychological factors in chronic pain
patients may not be particularly surprising, but recent studies on patients with acute pain have come up
with similar findings. In a one-year follow-up cohort study of patients with back pain attending for
osteopathic treatment, cognitive factors (specifically negative or inappropriate coping strategies) were
found to be by far the most powerful predictors of outcome; particularly in the subgroup of patients
with acute back pain in which it was possible to explain 47% of variance in outcome from negative
cognitive coping strategies alone (Burton et al., 1995). In another study (Main et al., submitted)
psychological factors had a powerful influence on outcome of treatment in patients with acute back
pain, whether treated by McKenzie physiotherapy or by a nonsteroidal anti-inflammatory drug, both
immediately following treatment and at one-year follow-up.
Such factors have not been investigated as yet with sufficient precision in the context of occupational
rehabilitation, but seem to merit investigation. It would appear, nonetheless, that levels of distress or
dysfunctional thoughts may be important factors in the development of chronicity and thus represent
psychological obstacles to recovery which need to be addressed as part of the rehabilitative process.
Mechanisms of Chronic Incapacity

The importance of psychological factors has been clearly shown, but most of the above studies have
been either cross sectional in nature or involved analysis of outcome of treatment and have not addressed,
therefore, the possible mechanisms involved. The original Gate Control Theory or GCT (Melzack and
Wall, 1965) postulated an interaction between nociception and central psychological factors, but most
research studies have treated physical and psychological factors as if they were quite independent. The
relationship between emotion and physiological activity has been shown however in a series of
investigations of peripheral and central physiological responses to experimental stimuli. (Flor et al.,
1989). In an early experiment (Flor et al., 1985) they had shown heightened levels of muscle activity in
the paraspinal muscles to personally relevant stressors in patients with low back pain.
Although there is some evidence for differences in resting levels of SEMG between back pain patients
(Ahern et al., 1988), guarded movements of various sorts, while protective during the acute stages of
recovery from injury, are clearly evident in many chronic pain patients. Guarded movements can be
investigated using surface electromyography (SEMG) from the lumbar muscles, and recently a specific
34-10
measure of the guarded movement during forward flexion the Flexion Relaxation Ratio (FRR) has been
developed and validated for use with low back pain patients (Watson et al., 1997a). In a further study
using the FRR, the relationship between muscle activity and response to treatment was investigated
(Watson et al., 1997b).
A significant correlation was found initially between fear avoidance beliefs and abnormalities of
muscle action prior to treatment (a three-week pain management program). Following the pain
management program there were significant correlations between changes in the muscular abnormalities
and changes in fear avoidance beliefs as well as between changes in self efficacy beliefs and changes in
muscular abnormalities. The results raise the possibility that following injury, or a significantly painful
episode, some people develop persistent abnormalities in muscle electrical activity suggestive of a persistent
physiological abnormality around the painful site.
They conclude:
The extent to which these abnormalities are mediated by fears of hurting and harming is not yet
entirely clear, but changes in SEMG patterns towards the normal following pain management are
associated with reductions in fear of hurting and harming and increase in self-confidence as measured
by self-efficacy beliefs.
Conclusions from Clinical Studies

It would seem, therefore, that several conclusions can be reached from the above research findings.
1. Psychological factors are implicated in the perception of pain.
2. Reactions to pain, in terms of distress, specific beliefs, coping strategies and the development of
pain behavior, seem likely to be more influential than more widespread psychological constructs
or perspectives.
3. It has been possible to identify specific psychological factors which place individuals at risk of the
development of both the persistence of and the development of chronic incapacity.
4. It would appear that these psychological factors are more important than clinical history or
physical examination factors in the prediction of outcome.
5. Psychologically oriented pain management program can reduce these risk factors.
6. Laboratory investigations have shown than reduction in specific fears of hurting and harming
are associated with physiological changes in electrical activity in muscle.
7. It would appear that future research might usefully be directed at secondary prevention in patients
in whom chronic incapacity has not yet become established.
34.5
Psychological Aspects of Work
Difficulties in the Identification of Work-Related Stress

The complex sociopsychological characteristics of organizations has made the investigation of workrelated stress extremely difficult. Most of the studies have tended to focus on specific features of the
organization or particular job characteristics. Kasl (1992) identifies, for example: organizational size
and structure, cumbersome or arbitrary procedures and practices, and role-related issues. Cox (1993)
discusses the significance of role ambiguity, role conflict, and role insufficiency as aspects of the latter.
Responsibility for people (Leiter, 1991), lack of job security, and failure to realize job expectations are
among other factors considered to be of importance. A number of recent studies have examined the
nature of work stress (Schaefer and Moos, 1993; Crum et al., 1995; Alliger and Williams, 1993). Other
studies have examined more specific aspects, such as job satisfaction (Medcof and Hausdorf, 1995), job
opportunity/frustration (Noack, 1994), and job predictability and turnover (Pearson, 1995).
Organizational stressors therefore can be identified, and certain characteristics of the working
environment constitute risk factors in their own right. The extent to which an individual copes with such
risk factors will influence job satisfaction, morale, and psychological well-being. Extended absence from
34-11
work, however, can have a marked effect on the perception of the work environment. Interpersonal
relationships at work for example may be an important determinant of successful return to work. Good
relationships with colleagues, a sense of being valued, and worry about letting ones colleagues down may
act as important incentives to return to work after injury. An unpleasant or difficult interpersonal
environment may represent a significant obstacle to return to work. Appraisal of such factors, combined
with a loss of self-confidence and anxiety about not being able to perform satisfactorily on return to work
may also represent a specific hindrance. According to Bigos et al. (1990) once an individual is off work,
perceptions about symptoms, about the safety of return to work, and about the impact of return to work
on ones personal life can affect recovery even in the most well-meaning worker, (p. 854; Bigos italics).
Approaches to the Definition and Study of Work Stress

For the purpose of this chapter an attempt will be made to examine the nature of work stress from a
general perspective, derived from Cox (1993). Finally, it has to be recognized that although it is possible
to identify work stress, there may be an interdependence with other life stresses. Long working hours,
for example, can significantly interfere with family life.
There have been three different but overlapping approaches to the definition and study of stress
(Cox, 1993). According to the engineering model, stress is conceptualized as an aversive or noxious
characteristic of the work environment and is construed essentially as an environmental cause of ill
health. The model has been criticized on the grounds of oversimplicity, since specific stimuli such as
noise may be stressful or beneficial depending on a number of other factors. Furthermore, according to
Douglas (1992), perception of risk and risk-related behavior are not adequately explained by the natural
science of objective risk and are strongly determined by group and cultural biases.
In the physiological model, stress is defined in terms of the common physiological effects of a wide
range of aversive and noxious stimuli; i.e., stress is the physiological response to a threatening or dangerous
environment. The model has been criticized because differences in physiological responses to the same
stressor, and difficulties in identifying unambiguously physiological responses which are specifically
stress responses. According to Cox (1993), there are subtle but important differences so that noradrenaline
activation may be more related to the physical activity inherent in various tasks, while adrenaline activation
may be more related to feelings of effort and stress.
More fundamentally, both models have been criticized for their reliance on an over simplistic
stimulusresponse paradigm, while ignoring individual differences in the cognitive and perceptual processing
of information; ignoring the interactions between the individual and his/her environment; and in their lack
of a systems-based approach, ignore the psychosocial and organizational contexts of work stress.
The third model, the psychological model, conceptualizes stress in terms of the dynamic interaction
between the person and the work environment. Interactional models focus on the structural features of
the persons interaction with the work environment, while transactional models are concerned principally
with psychological mechanisms such as cognitive appraisal and coping which underpin the interactions.
The Person-Environment Fit or P-E fit model (French et al., 1974) identifies two aspects of fit:
1. The degree to which an employers attitudes and abilities meet the demands of the job, and
2. The extent to which the job environment meets the workers needs.
Lack of fit, whether defined objectively or subjectively (in terms of the individuals perceptions), has
been recognized as a potential stress. Job demands and job decision latitude have also been identified as
powerful factors in psychological reaction to work (Karasek, 1979).
According to transactional models, stress involves elements of both cognition, such as appraisal, and
emotion. According to Lazarus and Folkman (1984), primary appraisal involves monitoring the situation
and may lead to identification of a problem. such problem recognition may be accompanied by unpleasant
emotions or general discomfort. Secondary appraisal, following after recognition of the problem, involves
attempts to generate a set of coping strategies. According to Cox (1993): The experience of stress is
therefore defined, first, by the realization that they are having difficulties in coping with demands and
34-12
threats to their well being and, second, that coping is important and the difficulty in coping depresses or
worries them (p. 17).
Finally, the appraisal process may be thought of in five stages, beginning with no more than a hazy
recognition of the existence of a problem, and leading via an on going process of interaction between
coping strategies, reappraisal, and redefinition of the problem.
Coping with Occupational Stress

A wide range of coping strategies has been identified. They have been differentiated, for example, into
task-focused or emotion-focused (Dewe, 1987) and into strategies changing meaning or managing stress
symptoms (Pearlin and Schooler, 1978). Individual characteristics such as informational styles (blunters
and monitors) have been identified (Miller et al., 1988), and concepts of vulnerability or job hardiness
(Kobasa, 1979; Kobasa et al., 1981) have also been considered. Finally, individual differences have been
investigated both as components of the appraisal process, or as moderators of the stress-health relationship
(Payne, 1988).
Behavioral characteristics such as Type A behavior (Friedman and Rosenman, 1974) were identified
originally as risk factors for coronary heart disease. Since then concepts such as work commitment and
time-urgency have become an integral part of the psychology or work. Gaining control is an important
coping strategy in dealing with work difficulties. If as a coping strategy it is ineffective and the problem
persists, frustration or anger can result in significant work stress, deterioration in health, and absence
from work.
Predictors of Chronic Incapacity in Occupational Settings

Cats-Baril and Frymoyer (1991), in a study of employees with between 2 and 6 weeks incapacity,
identified four main risk factors for long-term disability. These included job characteristics (work status
at time of the survey, work history, and type of occupation); job satisfaction factors (including
preretirement policies and benefits; perception about whether the injury was compensable; who was at
fault and whether a lawyer had been contacted); past hospitalizations; and educational level. The utility
of their predictive model, however, was criticized on methodological grounds specifically because of
their failure to control for duration of disability, and because of the likely influence of psychological
factors in terms of expectation.
The population of patients who have already incurred two weeks of off-work time secondary to
low back trouble probably are anticipating long-term disability, and, perhaps more importantly, so are
their health care providers, employers, and insurers. These expectations may trigger illness behaviors
that help establish long-term disability (Lehmann et al., 1993, p. 1110).
In a recent review of risk factors in industrial low back pain, four major types of risk factors have
been implicated in industrial low back pain (Bigos et al., 1990). These were individual factors (mainly
demographic and anthropomorphic), physical findings (mainly radiographic), workplace factors (including
various work characteristics), and psychological factors (determined from psychological tests or evidence
of substance abuse). In their view, however, methodological problems significantly compromised accurate
evaluation of these factors.
According to a recent review, Monotonous work, high perceived work load, and time pressure are
related to musculoskeletal symptoms. The data also suggest that low control on the job and lack of
support by colleagues are positively associated with musculoskeletal disease. Perceived stress may be an
intermediary in the process (Bongers et al., 1993, p. 297). Specific psychological features have been
found in a number of prospective studies. Carosella et al. (1994) found that patients with low return-towork expectations, heightened perceived disability, pain, and somatic focus had problems complying
with an intensive work rehabilitation program. Haazen et al. (1994) have shown that change in distorted
pain cognitions, workers compensation status, and use of medication were the most important predictors
in behavioral rehabilitation of low back pain. (They were, however, pessimistic about the overall level of
34-13
prediction achieved.) Bigos and colleagues (1991) found that psychological distress, low job satisfaction,
and a history of back trouble were the strongest predictors of the report of back pain in the future. The
above studies, although tantalizing, do not identify the putative psychological factors with sufficient
degree of accuracy to evaluate their specific importance. There is a need for the development of
psychometrically sound occupationally focused instruments to assess aspects of job satisfaction; perception
of safety; and the perceived consequences of sickness absence for job security and financial stability. In
addition to investigation of the employee, it may be necessary furthermore to consider characteristics of
the organization.
In the clinical assessment of low back pain, the lack of a simple relationship between physical signs
and resulting incapacity is well recognized and different sorts of factors have been adduced to explain
the apparent mismatch. Recent clinical studies into the outcome of treatment for low back pain have
however offered a more specific evaluation of the role of different sorts of psychological variables in the
prediction of chronic incapacity (as determined by self-reported disability) than is currently available in
most occupational studies. The findings of such studies for our understanding of the nature and
development of chronic incapacity may have relevance also to secondary prevention in occupational
settings and so some of these studies will now be reviewed.
In a study of attitudes, beliefs, and absenteeism among workers in a biscuit manufacturing factory,
Symonds et al. (1996) showed that workers who had taken in excess of one weeks absence due to low
back trouble had significantly more negative attitudes and beliefs (when compared with workers who
had taken shorter absences, or with those who reported no history of back trouble). Beliefs about the
inevitability of back pain, fears of hurting or harming, and perceived disability were significantly associated
with absenteeism. In an associated study (Symonds et al., 1995), introduction of a psychosocial pamphlet,
designed to correct mistaken beliefs about back pain (e.g., confusing hurting with harming) and reduce
avoidance behavior, successfully reduced extended sickness absence resulting from low back trouble.
34.6
Socioeconomic and Medicolegal Dimensions
Since the turn of the century, the nature of chronic incapacity has been considered in the medicolegal
literature, but little systematic research into the role of socioeconomic factors has emerged. The
dichotomous view of pain as either physical or psychological has prevailed. The persistence of pain
without a clear and unambiguous physical lesion has been considered either as a manifestation of
psychiatric disorder or as evidence of simulation (malingering). The conceptual confusion evident in the
investigation of pain and incapacity in the legal system is reviewed elsewhere (Main and Spanswick,
1995). For the purpose of this chapter, it can be stated that in occupational rehabilitation, the specific
influence of socioeconomic factors in general, and of medicolegal factors in particular awaits further
research; both in terms of their specific influence and in terms of their possible interactions with physical
and psychological factors.
34.7
Return to Work: Prevention of Chronic Incapacity
The Role of Education

Results of back schools based mainly on medical and ergonomic principles have been somewhat
disappointing. As far as primary prevention is concerned, according to Nordin et al. (1992) there is little
evidence for sole efficacy of back schools, but they may be beneficial within the wider context of a
company-wide effort (Wood et al., 1987) where management and unions participate and the program is
geared to the needs of the employee (Versloot et al., 1992). Yet somewhat surprisingly, in a recent U.K.
study carried out in a light industrial environment, mere distribution of a simple educational pamphlet
designed specifically to reduce fear-avoidance beliefs, produced a substantial reduction in extended
absence associated with LBT (Symonds et al., 1995). As far as secondary prevention is concerned, the
34-14
picture is somewhat confused, perhaps because of the variety of approaches adopted. Bergquist-Ullman
and Larsson (1977), in a randomized controlled trial, showed that back school was superior to physical
therapy treatment or placebo; but recent studies (Berwick et al., 1989; Stankovic and Johnell, 1990)
have failed to replicate the findings. Methodological difficulties in the evaluation of their efficacy are
presented elsewhere (Schlapbach and Gerber, 1991). According to Scheer et al. (1995, p. 970): Although
an ergonomic education for recently injured workers makes inherent sense, there is not incontrovertible
published evidence that back school is more efficacious than placebo for acute LBP.
Physical Therapy
Physical therapists employ a wide range of techniques ranging from passive modalities such as heat
treatment, ice packs, interferential stimulation, and a range of manipulative techniques. The approaches
are detailed elsewhere (Tan et al., 1992; Ottenbacher and Fabio, 1985). As far as return to work is
concerned, the evidence for efficacy is unproven, perhaps because there is no requirement for the individual
to be actively involved in the treatment process.
Functional Restoration (Sports Medicine Approach)

Functional restoration programs (FRP) place a particular emphasis on the restoration of strength and
the development of fitness. As such, they are more appropriate for the chronically incapacitated worker
in whom a disuse syndrome may have developed, than for a secondary prevention approach in the
more recently incapacitated worker. They do have an advantage over the individualized physical therapy
approach, however, in that they require a specific Functional Capacity Evaluation or FCE (Mayer and
Gatchel, 1988) which can be more closely matched with specific occupational requirements than a more
generalized and less focused clinical approach.
Specific Psychological Approaches

A number of individual approaches to the management of pain are available (Gatchel and Turk, 1996)
and may be offered as part of routine pain management following injury. As far as return to work is
concerned, there is no more evidence for individualized psychological therapy such as psychotherapy or
stress reduction as a single treatment approach than for individualized physical therapies. The recent
development of graded activity programs with a behavioral therapy approach, however, has shown
much more promise (Lindstrom et al., 1992). In the latter study, patients were randomized to either
traditional physiotherapeutic care or to a graded activity program with a behavioral therapy approach.
The graded activity program proved to be a successful method of restoring occupational function and
facilitating return to work in subacute low back patients.
Conclusion
It would seem that the traditional content of workplace education concerning injury, pain, and
rehabilitation needs radical revision. Ergonomic interventions alone may be insufficient to prevent the
development and/or persistence of musculoskeletal problems (Burton et al., 1997b). It is clear that the
problem of return to work is multifaceted. It seems that to enable successful return to work, occupational
rehabilitation requires a multidisciplinary perspective with an integrated model of work disability such
as the Rochester model (Feuerstein, 1991). This highlights the potential interaction of a patients
medical condition and ability to meet physical and psychological demands at work. It also emphasizes
the importance of psychological factors (such as fear of reinjury, expectations of return to work, perception
of disability, illness behavior, and pain and stress coping skills) in rehabilitation efforts directed at RTW
(Feuerstein and Zastowny, 1996, p. 463).
34.8
34-15
Implications
Reappraisal of the Nature of Work-Related Incapacity

In this chapter we have attempted specifically to consider the psychological influences of injury on
absenteeism and return to work. They have been considered from a biopsychosocial framework,
recognizing the interactions among physical, psychological, and socio-occupational factors. It is considered
that models of incapacity constructed solely from biomechanical and ergonomic principles are inherently
limited since they are based on a partial understanding of the nature of absenteeism (Burton et al.,
1997b). It follows from the above that the concept of risk analysis merits fundamental reconsideration.
If an individual has no interest, for whatever reason, in successful and satisfactory return to work,
then consideration of psychological obstacles to return to work is an irrelevance. It is important to
distinguish generalized occupational stress from specific injury-associated distress. While both may present
obstacles to return to work, they require different solutions. Furthermore, it is important to recognize
that in the well-intentioned worker psychologically mediated work incapacity should not be confused
with irredeemable work incapacity. It has been shown that lengths of absence from work are associated
both with characteristics of the individual and features of the working situation. It is necessary therefore
to consider absenteeism both from a system and an individual perspective (Versloot et al., 1992).
Solutions for the Individual Worker

In general it is not in any workers interests to become chronically incapacitated. Although most workers
recover from injury, unnecessary delay in return to work is costly and potentially psychologically damaging.
Once an individual has become injured, the assessment of the risk of chronic incapacity needs to
considered. Such risks need to be understood not only from the biomechanical and ergonomic perspectives,
but also from the psychological perspective. Clinical studies have identified early psychosocial risk factors
for chronicity. Consideration should be given to a system of routine evaluation of such risks if the
worker does not make a speedy recovery.
Assessment of the individual worker cannot be undertaken without consideration of the context of
assessment. Whether or not an individual becomes chronically incapacitated depends not only on his/
her actual and perceived clinical status, but also on the socioeconomic system. Differences in social
policy, in remuneration for sickness, and in industrial agreements regarding the protection of the injured
worker will all have a profound effect on sickness absence and chronicity (I.A.S.P., 1995). The importance
of the socioeconomic implications of continued incapacity should not be underestimated.
Features of the occupational environment can be more or less conducive to return to work. The issue of
whether it is right to expect someone to be fully fit merits some discussion. From an employers perspective,
in terms of job performance this is clearly desirable, since it obviates the need for special consideration,
discussion of temporary restricted work, with the associated problem of preventing such arrangements
being viewed adversely by workmates. The increase in all sorts of litigation in industrial society is a matter
of fact, irrespective of ones political stance on it. The issue is increasingly seen as a risk management issue.
The easiest way to eliminate all risk simply would be to refuse to employ or reemploy anyone who has had
any sort of injury. Such a solution however, in a skilled workforce with a relatively high rate of minor jobassociated injury, could be extremely expensive as well as socially unacceptable. On the other hand,
identification of specific role conflicts likely to follow injury and subsequent absence from work could, at
relatively low cost, be specifically addressed in a time-limited workplace rehabilitation program for patients
with specific musculoskeletal rehabilitation needs. Success of such an endeavor would of necessity have to
take into consideration reaction of managers, their management style, and the reaction of workmates as
well as specific task functioning and general job performance.
Given the costs of extended absenteeism, specific attention might be given to a number of the other
risk factors for occupational stress (discussed above). While accepting that a fully comprehensive
psychological evaluation is not a practical proposition, specific attention might be directed at the
assessment of changes in the perception of the work environment by the injured worker in terms of:
34-16
a.
b.
c.
d.

Job satisfaction
Job stress (including relationships with colleagues)
Specific requirements regarding job performance
Perceived role conflict
In fact a new instrument has been recently developed specifically for use in occupational settings. The
Psychosocial Aspects of Work (PAW) questionnaire measures three different types of attitude about
work. It contains a 7-item job satisfaction scale, a 4-item social support scale, and a 4-item mental stress
scale (Symonds et al., 1996). Although at an early stage of development, this questionnaire would seem
to have some potential as a general screening instrument.
The identification of specific psychological obstacles to work requires specific evaluation. Since such
obstacles are probably evident soon after injury, they may be perhaps best tackled close to the work
environment immediately after injury during the phase of active treatment. Since most musculoskeletal
injury, however, if managed properly, should resolve successfully, provision of front-line treatment
within occupational health settings has an obvious appeal, and many employers have employed physical
therapists from various professional disciplines for this purpose. Such an approach, provided it is not
seen as a thinly disguised management ploy to reduce costs or identify malingerers, has an intuitive
appeal in that it is preventing the distancing between the injured worker and his/her worksite.
Unfortunately, since such workplace-based treatment has been offered primarily with an ergonomic or
biomechanical emphasis, specific psychological obstacles to return to work have not usually been
incorporated into the format of the rehabilitation program.
Although a number of clinical measurement tools (as identified above) are now available, further
research is needed into specific occupational applications. The following clinical dimensions would
seem to be of particular importance and perhaps should be incorporated routinely when a worker has
been off for more than a few days, or where occupational records indicate a pattern of increasing spells
of work absence with nonspecific musculoskeletal complaints.
1.
2.
3.
4.
General level of distress.

Specific beliefs and fears about pain and rehabilitation
Pain coping strategies
Fear of physical activity
Solutions for a Sick Workplace

There is an urgent need to develop sound measurement instruments for the perception of work. In
development of new tests, however, it should be remembered that jobs differ significantly in their
psychological characteristics and so occupationally sensitive instruments with adequate normative data
will be required.
Assessment of Psychological Risk Factors

Traditionally, assessment of risk in occupational settings has tended to focus on environmental
characteristics, such as safety, or on ergonomic dangers, such as poor lifting and handling techniques. In
this chapter it has been argued that the concept of psychological risk must be recognized. The reduction
of unnecessary absenteeism needs to be considered both from an occupational and a clinical perspective.
Reduction of Occupational Stress

It would seem likely on a simple intuitive level that perceived occupational stress will delay return to
work after injury. While the widespread introduction of mental health promotion (Kasl, 1992) in industry
as an answer to occupational stress in industry is perhaps more of a pious hope than a realistic possibility,
specific attention to the company ethos regarding injury and pain-associated incapacity might merit
consideration. It has recently been recommended that stress management programs which encourage
individuals to change workplace factors through innovation would be a useful addition to interventions
that emphasize individual adaptation to stressful work environments (Bunce and West, 1994). According
34-17
to Cox and Griffiths (1995), The challenge for the late 1990s is a practical one: to develop effective
systems for assessing and managing the problem in organizations, and then to educate those organizations
in using those systems (p. 3). It is being suggested that workplace rehabilitation after injury also should
incorporate such perspectives.
Establishment of a Work-Based Rehabilitation Policy

Identification of possible changes to working practices necessary prior to full recovery and development
of a clear work-based rehabilitation policy will reduce anxiety about return to work. Working practices
clearly are job specific, but it is known that certain occupations carry higher risks for back injury, even
though the physical demands may differ (Halpern, 1992). Functional Capacity Evaluation is an integral
part of the sports medicine approach (Mayer and Gatchell, 1988), but the emphasis is very much on
the capacity of the individual. Traditionally, graded work practices have taken place in rehabilitation
settings, but it may be possible to establish closer integration between rehabilitation and occupational
health in the design of work-based graded return to work, as has been evident in Scandinavia. While a
clear understanding of the biomechanical demands and ergonomic features of the jobs concerned is
essential, such considerations have to be located within an appropriate model of rehabilitation (Feuerstein,
1991; Feuerstein and Zastowny, 1996).
Management Style and Conditions of Employment

Return to work is affected first and foremost by conditions of employment which may have a specific
influence on rate of return to work irrespective of severity of injury. Management style is a key ingredient
of both job satisfaction and job stress (Cox, 1993). Specific attention to the management of return to
work may pay dividends. In one North American study (Wood, 1987), for example, a simple telephone
call from a line manager offering good wishes and expressing concern for the absentees welfare
significantly increased rate of return-to-work.
The Design of Context-Sensitive Interventions

A recent review of RCTs of early intervention in industrial low back pain was pessimistic (Scheer et al.,
1995), but frequently the design of such interventions has been inappropriate in that they have been
over-reliant on biomechanical and ergonomic principles (Burton et al., 1997). A number of recent studies
have suggested that specifically designed and appropriately targeted interventions may be effective. Such
interventions have ranged in complexity from the introduction of educational pamphlets designed to
change beliefs (Symonds et al., 1995) and telephone calls (Wood, 1987); via graded exercise programs
(Lindstrom et al., 1992) and occupationally specific secondary prevention programs (Linton et al.), to
major tertiary rehabilitation programs (Mayer and Gatchell, 1988).
34.9
Conclusion
The rising costs of back-associated incapacity has led to a number of reports which have offered solutions
to the problem of long-term incapacity (CSAG, 1994; Bigos et al., 1994; ACC and the National Health
Committee, 1997). These reports essentially have addressed the problems of secondary incapacity rather
than primary prevention, and made a number of clinical recommendations involving assessment and
management. A recent report by the International Association for the Study of Pain (IASP, 1995) has
offered a radical solution to work absence from nonspecific back pain. It sees long-term absenteeism
primarily as a consequence of the over-medicalization of pain. It recommends that after six weeks
work absence, such patients be redefined as activity-intolerant. The incapacity is then no longer
defined as a medical problem. Whatever economic advantages such a solution may offer in answer to
the increasing costs of back-pain associated incapacity (which has to be addressed), the report has not
met with universal support. It has been criticized mainly on the grounds that it seems to rest on oldfashioned concepts of tissue-healing time and does not offer either an adequate clinical or an adequate
occupational answer to the problem of persistent incapacity (Turk and Main, 1997).
34-18
Traditionally, clinical treatment has in general been considered in complete isolation of the occupational
context. Conversely, the psychological aspects of return to work, if considered at all, have tended to
omit consideration of such clinical factors. In terms of psychological mechanisms, however, it is clear
that an effective rehabilitation program has to address both perspectives. In this chapter an attempt has
been made to identify the sorts of psychological factors which influence return to work following injury.
It would appear that the traditional separation into clinical and occupational factors needs to be
reconsidered. The cost of unnecessary absenteeism is considerable. Adequate attention to the psychological
risk factors highlighted in this chapter might be of considerable economic benefit in the reduction of
unnecessary absence from work. The development of context-sensitive interventions, while recognizing
the powerful influence of psychosocial risk factors within an overall disability management framework,
may offer a better way forward than the narrow biomechanical and ergonomic-based approaches, or
the fairly drastic social policy solutions offered by Pain in the Workplace (IASP, 1995).
Acknowledgments
Sincere thanks to Dr. Ana-Paola Viera for assistance with the background literature.
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35
Back Pain in the
Workplace: Implications
of Injury and
Biopsychosocial Models
Michele C.Batti
Chris J.Main
Hope Hospital, Salford, U.K.7
A.Kim Burton
35.1 Back Pain in the Workplace: An Injury Model
352
The Influence of Physical Loading Perceptions of

Fault Back Pain the the Workers Compensation System
35.2 Back Pain in the Workplace: A Biopsychosocial Model
356
Sociocultural Influences Work-Related Disability

Management Interventions Practical Considerations for
Workplace-Based Management of Low Back Problems
35.3 Summary
3511
The growth of back pain complaints and associated long-term disability in the industrial insurance
system defies simple explanations based on concomitant changes in physical environments, work demands,
or increases in degenerative or pathological changes to the spine. As has been eloquently chronicled in
an historical overview by Allen and Waddell (1989), back symptoms have been present throughout the
ages. What appears to have changed dramatically in many societies is public perception of back pain as
an injury or medical problem, and its effect on work and life in terms of disability.
Long-term disability from low back pain is a relatively new phenomenon in the history of Western
civilization, and its dramatic growth in the last half century suggests that factors other than physical
pathology may be influencing its development. This is not to say that back pain is not genuinely
experienced by large numbers of people, or that severe symptoms do not occasionally cause physical
limitations of some duration. On the contrary, numerous health surveys indicate that back symptoms
are extremely common in both developed and third-world countries (Waddell, 1987; Anderson, 1984;
Honeyman and Jacobs, 1996; Nyha et al., 1991; Bierine-Srensen, 1984; Troup, 1987; Videman,
1989), and that they begin at an earlier age than once thought (Balague et al., 1988; Burton et al., 1996;
Salminen et al., 1995). Yet, only a small percentage of persons experiencing back symptoms each year
file industrial injury claims or seek medical care.
Back injury reporting and disability are clearly influenced by other factors than purely the presence
of pain. For example, the severity of symptoms and the physical demands of the workplace are likely to
interact to affect reporting and absenteeism. While an individual with light physical job demands may
be able to continue work through an episode of back pain, the same condition may be sufficiently
exacerbated by heavy loading or work in awkward postures, such that the individual is unable to continue
with normal work tasks during recovery. In addition to the effects of symptom severity and job demands,
other factors of likely importance to the onset and persistence of disability are cultural norms (Anderson,
1984; Waddell, 1987; Honeyman and Jacobs, 1996), socioeconomic conditions (Volinn et al., 1988;
Volinn, 1991) and opportunities for compensation (Loeser et al., in press; Leavitt, 1992), attitudes and
0-8493-1800-9/03/$0.00+$1.50
35-1
35-2
beliefs about back problems (Symonds et al., 1995, 1996), emotional distress (Bigos et al., 1992; Klitzman
et al., 1990), and job satisfaction and the social work environment (Bigos et al., 1992; Linton et al.,
1989; Linton and Kamwendo, 1989; Linton, 1990). Fears that continuing work activities will cause
further harm also may influence the decision to file a complaint or miss work. Innumerable factors
could affect the response to back symptoms, many relating to perceptions of the problem and the perceived
benefits and costs of various options available in the social systems and cultural norms in which the
person lives and works.
Considering the factors noted above, a biomedical model, focusing purely on physical pathology, has
long been recognized as inadequate to explain back pain disability or formulate a sufficient management
strategy to combat it. Focusing simply on physical pathology and biomechanical causes and solutions to
the problem would appear to be a gross, and occasionally misleading, oversimplification of the back pain
experience in the developed countries of the world. While such factors should not be ignored, a broader
perspective is needed if growth in work-related back pain disability is to be curbed. Some suggest that
biopsychosocial (Waddell, 1987) or biocultural models (Honeyman and Jacobs, 1996) may provide better
frameworks for, and insights into, the development and management of this growing problem. In this
chapter we will examine the industrial injury model and explore the shift in paradigms over the past
decade toward biopsychosocial and sociocultural models of back pain disability and their implications.
35.1
Back Pain in the Workplace: An Injury Model
As more is learned about the epidemiology and natural history of back symptoms, that they are endemic
and episodic in nature, the more difficult it becomes to apply a simple injury model. The challenges of
applying such a model in the working environment were demonstrated by Robertson and Keeve (1983),
who reported on the results of efforts to prevent industrial back injury claims by minimizing physical
hazards at the workplace through establishing and enforcing safety and health regulations. Although
these efforts led to a decrease in objectively verifiable injuries, such as fractures and lacerations, more
subjective injury reports, including back strains, were unaffected.
Most back symptoms are of gradual onset, and are not associated with a traumatic accident or
unusual activity (Videman et al., 1989; Rowe, 1969; Vlfors, 1985). Therefore, it may be inappropriate
to refer to all back symptoms occurring in the workplace as injuries, a common practice to meet the
demands of the industrial insurance system. Among first-year nurses, who often have relatively high and
unpredictable loading conditions in patient handling, symptoms were found to be of sudden onset with
or without a specific inciting event in only 28% of cases cited (Videman et al., 1989). The great majority
of back pain episodes were of gradual onset. Thus, it may be more appropriate to reserve the term
injury, and the images that the term elicits, for back symptoms of sudden onset following a specific
inciting event, such as a fall, when direct trauma is more likely. As Allen and Waddell outline in their
historical review of back pain, this condition has not always been viewed in an injury context (Allen and
Waddell, 1989).
Hadler noted that once an inguinal herniation was termed a rupture and then considered an
injury, and a ruptured disc was accepted as a source of back symptoms in the 1930s, back pain also
received injury status in the workers compensation system (Hadler, 1995). He goes on to note that since
that time much of what is costly and contentious in workers compensation systems relates to back
injuries. Furthermore, Americans, in general, have come to perceive musculoskeletal discomfort in an
injury context. As will be further discussed in later sections, the injury model has other consequences.
The Influence of Physical Loading

If we followed the paradigm that back pain and resultant disability are consequences of injury caused by
mechanical overload, to be prevented by lessening loads on the spine, then it would follow that populations
with heavier loads would have a higher incidence of back pain and subsequent disability. This clearly is
Back Pain in the Workplace: Implications of Injury and Biopsychosocial Models
35-3
FIGURE 35.1 The graph displays the percentage of variability in disc degeneration in the T12L4 and L4S1 spinal
regions explained by specific occupational and leisure physical loading variables relative to that explained by familial
aggregation which represents a combination of genetic and shared childhood environmental influences (beyond that
explained by age). (Adapted from Batti MC, Videman T, Gibbons LE et al.: Determinants of lumbar disc degeneration.
Spine 1995; 20:26012612.)
not the case, however, as has been discussed previously in Chapter 20 (Burton et al.). It is puzzling that
instead, back pain complaints and disability are highest in countries with generally less extreme
occupational physical loading conditions and high utilization of medical services.
Volinn (1997) studied the point prevalence of low back pain in low and middle income countries,
where a far greater portion of the population is engaged in heavy labor, and often into old age, as
compared to relatively high income countries. He hypothesized that if back pain were caused by heavy
physical loading, that low income countries with substantially more heavy labor would have a higher
point prevalence. Instead, a considerably lower back pain prevalence was found among populations of
low income farmers as compared to wealthy populations of Northern European countries that had two
to three times higher prevalences. He concluded that hard physical labor itself is not necessarily related
to LBP. He did, however, find that workers from low income countries working in urban enclosed
work-shops, such as sewing machine operators, had the highest prevalence of back pain.
As we discussed in Chapter 20 (Burton et al.), even when physical loading is investigated in the
etiology of degenerative changes in the lumbar spine, its effects are seldom clear. In a recent study of
determinants of disc degeneration (Batti et al., 1995), occupational and leisure time physical loading
exposures in adulthood were found to have a minor influence on degree of degenerative findings,
particularly when compared to familial aggregation, which represented a combination of genetic and
childhood environmental influences (Figure 35.1). It was suggested that this relatively modest influence
of physical loading may explain the mixed results of earlier studies of the effects of physical loading on
degenerative findings. The investigators concluded, that disc degeneration may result primarily from a
combination of genetic influences, childhood exposures, and unidentified factors, which may include
complex, unpredictable interactions.
While the role of occupational physical loading may be modest in terms of accelerating disc
degeneration, certainly some physical activities may aggravate back symptoms, and ergonomic
interventions may make it easier for someone experiencing back problems to continue work or return
sooner following an acute or recurrent episode. Appropriate interventions may include accommodations
35-4
to the work environment or task that minimize extreme loads or awkward postures. It is important,
however, to keep the role of ergonomic interventions in perspective when developing more comprehensive
management strategies.
Perceptions of Fault
The common view of back pain as an industrial injury may lead to the perception that fault lies with the
work tasks or environment, particularly if symptoms occur during the course of normal work activities.
Furthermore, affected workers may feel as though their injuries are the result of negligence on the
part of their supervisors or employers for placing them in hazardous situations. It has been hypothesized
that such perceptions of fault may influence the attitudes and expectations of workers experiencing
back symptoms. Placing blame on external sources also may influence the affected workers sense of
responsibility in promoting the recovery process (Bigos and Batti, 1987).
DeGood and Kiernan (1996) were interested in investigating the influence of perceptions of fault on
expectations of recovery, psychological distress, and behavioral disturbances. When they grouped
patients under their care for chronic pain according to whether they believed that their employer,
another (primarily doctors or another driver from a MVA), or that no one was really responsible for
their pain, they found the groups were similar with respect to current pain intensity and level of activity
limitations. However, those who blamed their employer for their current pain problems were
significantly more likely to be unemployed, to report negative responses from past treatments and
expect the same from future therapy, to perceive that they had been treated unfairly by their employer
before and after the onset of their pain, and to exhibit greater psychological distress than those who felt
that no one was to blame. The retrospective nature of this study limits the conclusions, but the findings
do support the hypothesis that perceptions of fault may influence pain behavior, psychological
disturbances, and poor expectations of recovery.
It also has been suggested that individuals who report back injuries may be more inclined to forget
having had minor back symptoms related to performing common activities prior to their injury,
which may reinforce perceptions that the injury is responsible for any subsequent back symptoms (Fagan,
1995).
Back Pain in the Workers Compensation System

When a person experiences what is believed to be work-related back symptoms and chooses to file an
injury claim he or she enters the workers compensation paradigm. This paradigm defines work tasks as
causal, infers structural damage, and requires medical testimony of injury. Unfortunately, conditions
that are identified primarily through symptom complaints, where medicine has yet to clearly identify the
underlying pathology, do not fit well into this paradigm. Affected individuals often find themselves in
the position of having to demonstrate to health care providers and insurance adjusters that they are
indeed injured and worthy of receiving the benefits awarded to such a designation. This situation can
place the worker in an adversarial position where his or her integrity is questioned, such that an appropriate
response is to demonstrate that the health problem is serious enough for acceptance by the system. Such
patients are sometimes viewed with suspicion, and as Leavitt (1992) once stated, The unfortunate
problem is that stereotypes have consequences. Doubts raised by labels often shape evaluation and
treatment of industrial workers in problematic ways to the extent that their integrity and status as
patients are challenged. This is counter-productive to recovery.
Several studies have suggested poorer outcomes in patients receiving workers compensation. Studies
have found patients on compensation were less likely to benefit from lumbar interbody fusion for
degenerative disc disease as compared to patients not receiving compensation (Flynn and Hoque,
1979). Compensation also has been associated with residual back pain following surgery (Hanley and
Shapiro, 1989) and delayed recovery from conservative treatment (Greenough and Frazer, 1989). Leavitt
35-5
(1992) pointed out, however, that researchers typically do not account for the influence of physical
labor on the outcome of return to work, and that compensation and noncompensation groups usually
differ on occupational physical job demands. In a study designed to determine the effects of compensation
on work loss while controlling for differences in occupational physical demands, he determined that
irrespective of the job performed work-related back pain was associated with prolonged disability duration
(Leavitt, 1992).
A later study of 1,366 self-referred patients with back pain of less than 8 weeks duration was
conducted to investigate whether workers with acute low back pain were better served if they were
insured through a workers compensation insurance policy (Hadler et al., 1995). Those with and without
workers compensation insurance were deemed to be similar in clinical status and demographic variables
at entry. Yet, while most in both groups returned to full function and work activities rapidly, those with
workers compensation insurance returned to work less convinced that they had recovered to the level
of health experienced before the onset of their back pain episode. This perception of compromised
health remained even after perceived job characteristics were controlled, diminishing the chances that
this finding could be due to differences in work-related physical demands.
Loeser et al. (1995) note that discussions around the future of workers compensation insurance
programs center around understanding: (1) personal and social factors that lead an individual to injury
or illness reporting and the adoption of a sick role, with its associated disability and health care utilization,
and (2) factors that influence the behavior of workers in a compensation system. They proceeded to
conduct a comprehensive review looking at the effects of wage replacement levels on claims behavior. As
part of the review, they conducted some reanalyses of previously reported data in an effort to control for
possible confounding factors that may have influenced the original interpretation of results. They included
24 studies that directly addressed the relationship between wage replacement level and workers
compensation claims incidence and duration.
In their synthesis of the literature Loeser at al. (1995) conclude that, when other factors are held
constant, both the incidence and duration of industrial injury claims in the workers compensation
system are associated with the level of wage replacement benefits. The effect on duration appears to be
somewhat larger than that for incidence. The methodologically stronger studies provided estimates of a
1.83 to 11.28% increase in claim duration as a result of a 10% increase in workers compensation
benefits. Evidence was mixed with respect to a relationship to underlying injury rates. The challenge
would appear to be finding the appropriate balance between financially supporting an injured worker
to prevent major financial hardship during recovery, while providing financial incentive for timely return
to work and discouraging unnecessarily extended disability.
Hadler et al. (1995) urge an examination of whether or not regional backache belongs in the workers
compensation paradigm, under the injury rubric. They suggest that the industrial injury distinction
received by back symptoms has not led to a safer, healthier workplace, nor has it forwarded the
understanding or management of this problem. Over past decades the frequency of workplace injuries
has been relatively constant, but their consequences for workers have grown dramatically. As evidence,
Hadler et al. note that disability from work-related injuries has steadily climbed, as measured through
workdays lost. In addition, the cost of workers compensation in the United States in the two decades
following 1971 increased 12-fold, and went from 0.5% to 2.5% of the national payroll. Such increases
are not exclusive to the United States; similar growth in back-related disability has been noted in other
Western countries as well.
A controversial discussion document, Back Pain in the Workplace: Management of Disability in
Non-specific Conditions (1995), reached similar conclusions to those discussed above. Yet,
reconstructing a more successful and humane system of dealing with disability or work incapacity
associated with non-specific symptom complaints faces many challenges. Hopefully, such documents as
Back Pain in the Workplace, while stirring controversies, will also advance the discussion of
constructive reforms in the medical management and social systems that have been dismally inadequate
in dealing with this problem.
35-6
35.2
Back Pain in the Workplace: A Biopsychosocial Model
A decade ago, in a Volvo Award winning paper, Waddell (1987) presented a strong argument for the
adoption of a biopsychosocial model of illness for the management of low back problems. At the core of
this model is the acknowledgment and integration of physical, psychological, and social aspects of
illness. Such a model demands a broad approach to considering factors influencing illness and recovery.
Since the time Waddell encouraged the use of a biopsychosocial model, evidence supporting the importance
of psychosocial factors in back pain reporting and disability has steadily grown. Much of this evidence
has been presented in the previous chapters.
Most studies of back problems and suspected risk factors have been retrospective or cross-sectional in
design and have been quite limited with respect to inferences regarding risk. Currently, a number of
prospective cohort studies specifically investigating predictors of work-related back pain complaints have
been reported (Batti et al., 1989a; Batti et al., 1989b; Batti et al., 1990; Bigos et al., 1992; Cady et al.,
1979; Chaffin and Park, 1973; Dueker et al., 1994; Mostardi et al., 1992; Ready et al., 1993; Rossignol et
al., 1993; Venning, 1987). Most of these studies have focused on the effects of individual physical factors
and medical history. One of the most comprehensive prospective studies of predictors of work-related
back pain complaints and disability was conducted among Boeing employees (Bigos, 1992). This study
demonstrated that the role of psychosocial factors in risk of future injury complaints and disability was
greater than that of individual physical factors, such as lifting strength, aerobic capacity, and range of
motion which proved to be very poor predictors (Batti et al., 1989a, 1989b, 1990), findings that have
been supported by subsequent prospective cohort studies (Mostardi et al., 1992; Ready et al., 1993;
Dueker et al., 1994). Specifically, emotional distress, as determined from the Minnesota Multiphasic
Personality Inventory, and poorer job task enjoyment and co-worker relationships were implicated in risk
of reporting work-related back problems. A later analysis looking at perceptions of the work environment
in a broader context of work-related injury and illness reporting revealed that lower job task enjoyment
and co-worker relations had a similar influence on the reporting of other types of injuries, as well (Batti
et al., 1993). Thus, there is no indication from the Boeing study that workers who file back injury claims
differ significantly from workers claiming other types of injuries with respect to these work perceptions. It
should be emphasized, however, that such workplace perceptions, while associated with a higher risk of
reporting, are poor predictors of precisely who will and will not report a future industrial injury. While
most studies that have included factors related to job satisfaction have found associations with back pain
reporting and work loss (Bigos et al., 1992; Ready et al., 1993; Magnusson et al., 1996), all have not
(Symonds et al., 1996). The inconsistency may be partly due to differences in question presentation and
partly to differing philosophies among occupational groups; these issues require further study.
As was discussed in the previous chapter, other perceptions or beliefs have been linked to the
development of long-term disability. The fear-avoidance model was first proposed by Lethem et al. in
1983 to explain exaggerated pain perception and behavior resulting from relatively minor nociception
and underlying pathology. Fear of pain is the central concept of the model, with the two extreme responses
being confrontation or avoidance. Confrontation results in resumed social and physical activities which
regularly tests the pain relative to activities and allows the individual to calibrate a response, such that
activity and pain level remain in synchrony. On the other hand, avoidance leads to withdrawal of normal
activities and an increased likelihood of encountering and adapting to various positive and negative
reinforcers of chronic pain. They hypothesized and provided data to support that confrontation or
avoidance responses depend on the psychosocial context (stressful life events, personal pain history,
personal coping strategies, and personal characteristics) in which the symptoms originate and management
occurs (Lethem et al., 1983; Slade et al., 1983). Philips (1987) later hypothesized that avoiding
stimulation plays an active part in reducing the sufferers sense of control over pain, and in increasing
his or her expectation that exposure will increase pain. These cognitive changes encourage further
withdrawal from normal activities and a growing intolerance of stimulation. Over the past decade the
fearavoidance model has been studied and supported as having an important role in the development
of chronic pain (Klenerman et al., 1995).
35-7
Szpalski et al. (1995) conducted a population-based survey in Belgium that revealed that health
beliefs related to whether back problems experienced would be lifelong or not was significantly associated
with current health behaviors and history of health care utilization. Another study examining beliefs
about back problems among British office and manufacturing workers found those who had missed
more than one week of work due to low back problems, as compared to those with less time loss or no
reported back problems, were significantly more likely to have negative attitudes and beliefs (Symonds
et al., 1996). Specifically, they were more likely to believe that negative consequences of back pain were
inevitable and to feel less control and responsibility over pain. It is not clear, however, from such a
retrospective study design whether such beliefs influenced the time loss or whether the episodes that led
to greater time loss led to more negative beliefs. However, a prospective study designed to change negative
beliefs about back problems suggests that such a change may positively influence subsequent backrelated work loss, strengthening the hypothesis that beliefs about back problems may directly influence
illness behavior (Symonds et al., 1995).
Sociocultural Influences
It is generally accepted that back pain is common in populations throughout the world, yet the
interpretation of the experience and associated behaviors differ significantly depending upon cultural
norms. When studying health problems in rural Nepal, Anderson (1984) reported that although back
symptoms were very common, virtually no one sought care for the symptoms when medical services
were made available. It appeared that back pain problems were not perceived as a medical problem, but
rather a common consequence of normal living and aging. Later, Waddell (1987) reported that before
the introduction of Western medicine in Oman, extended disability for back pain problems was virtually
nonexistent. Similar to the experience in Nepal, while persons were crippled by such diseases as polio or
tuberculosis and injuries involving spinal fractures, they did not stop daily life or become permanently
disabled from idiopathic back pain problems. Back pain reportedly was, however, a very common
condition there, as is the case in Western countries.
In a study of back pain in an Australian Aboriginal community (Honeyman and Jacobs, 1996),
nearly one third of men and half of women reported problems with long-term low back pain when
privately questioned. However, the Aboriginals did not perceive back pain as a health issue, and
consequently did not report such symptoms openly, display pain-related behaviors, or seek medical
care. The result of this study led Honeyman and Jacobs to suggest that cultural beliefs and practices
influence how people respond to back pain in themselves and in others, including how and whether they
present to health professionals or seek involvement of others.
Sanders et al. (1992) investigated cross-cultural similarities and differences in Sickness Impact Profile
scores of patients seeking help for back pain problems at pain clinics in the United States, Japan, Mexico,
Columbia, Italy, and New Zealand. They found levels of psychosocial, vocational, and avocational
impairment to be greatest in the Americans, followed by the New Zealanders and Italians. The authors
note that many sociocultural factors could be responsible for these differences, such as work ethic,
social support and acceptance, economic stability and entitlement issues, beliefs and coping strategies,
to name a few. The numbers of representative patients included in the study were small, however, and
further work will be needed to more clearly establish differences in chronic low back pain patients
between these cultures and to explore the causes of such differences.
Similarly, an earlier study found more interference with social, sexual, recreational, and vocational
activities in Americans attending a pain clinic for chronic low back pain than their counterparts in New
Zealand (Carron et al., 1985). The study investigators hypothesized that substantial differences in the
disability systems, rather than inherent cultural differences, may have accounted for the differences between
patient groups. The studys limitations, however, make such inference speculative. Interestingly, while a
similar percentage of patients from each group attributed the onset of their pain to a specific incident (74%
vs. 71%), patients in the United States were three times as likely to cite a work-related accident, whereas
New Zealanders, with a no fault insurance system were just as likely to cite a non-work-related incident.
35-8
Work-Related Disability Management Interventions

There have been several interventions designed to minimize disability from back problems that appear
promising and worthy of further examination. They are based on a biopsychosocial model and the
belief that psychosocial factors, as well as physical factors, influence response to injury and illness,
particularly return to work. The interventions have several commonalities; they are employer-based,
involve changing attitudes and responses to back symptom complaints, and focus on decreasing the
negative consequences of back problems once reported. They concentrate on improving the quality and
quantity of communication with the injured worker and other parties involved, and support temporary
work modifications, if necessary.
Two reports in the mid 1980s described a program designed to mitigate the negative consequences of
back problems among employees of a shoe-parts manufacturer (Fitzler and Berger, 1982, 1983). The
employer previously had been active in ongoing safety training and enforcing adherence to regulations
and had redesigned work tasks to eliminate unnecessary or frequent heavy exertions, but continued to
have significant problems with back injury complaints and subsequent disability. Therefore, the company
began a new strategy that emphasized changing attitudes and responses of management personnel toward
back pain reporting and encouraging prompt, appropriate medical attention. Management training
emphasized that back pain symptoms are very common in the adult population and that malingering is
rare. Recognizing employee needs also was emphasized, along with responding empathetically. To meet
the goal of prompt medical attention, symptom relief agents were provided onsite through the employers
medical service. The affected employee also was provided with education in back care, including treatment
and recovery expectations and a discussion of any activity restrictions. If in-house care was deemed
insufficient, referral was made to an outside physician. Attempts were made to modify work activities,
if needed, to allow the employee to continue working or return to work more quickly during recovery.
There was a dramatic and sustained decrease in workers compensation costs for the three years
following the implementation of the program, as compared to the three prior years. Workers compensation
costs decreased during the first year of the program to approximately 20% of what they had been in
each of the prior three years, and further decreased to 10% during the second year. This decrease was
sustained during the third year of the program. Because the efforts of the program were determined
simply by examining the experiences with back problems within the company before and after the
program was implemented, it is possible that other changes occurring at the same time may have been
partly responsible for the apparent effects of the program. There is also the Hawthorne effect to consider,
employee behavior may have been affected temporarily simply in response to a change in the system.
Yet, there are several points in support of the effect being due to the intervention. First, there was a
substantial decrease in related work loss and medical and indemnity costs, but not in the rate of back
symptom reporting. This result supports the specific intent of the program to minimize the negative
consequences of back problems once reported, and not to influence reporting. Second, the apparent
effects of the program endured over the three years of observation following implementation.
Subsequently, Batti reported on an intervention with several similar traits conducted in a long-term
health care facility (Batti, 1994). The goal was to investigate the effects of an intervention designed to
create a more supportive and accommodating work environment following injury reporting. The
intervention focused on improved communication and provisions for temporary accommodations in
work activities, if needed, to allow an earlier return to the workplace. A system was put in place to
ensure regular contact was maintained with employees throughout recovery. The contacts were made by
either the employees supervisor or the safety and health representative, and expressed concern for the
employees well-being, offered assistance, and let the employee know that he or she was missed. A
special training session was held for all supervisors to improve their understanding of back problems
and encourage empathetic attitudes and responses to back symptom complaints. There was a 77%
reduction in the mean back injury claim cost during the intervention year, as compared to the claims
filed in the prior three years. Furthermore, none of the back injury claims filed were over $5,000, as
compared to 14% of claims filed in the prior three years at the intervention site or among other longterm health care facilities in the region during the year of intervention. This intervention was of a short
35-9
duration (only one year) and results may be due, in part, to the normal fluctuations commonly experienced
in injury rates and costs. It is interesting to note, however, that similar to the previously reported experience
in the shoe-parts manufacturing company, the incidence of back injury claims appeared unaffected
during the intervention. It was primarily work loss and associated costs that decreased, which were the
outcomes specifically targeted by the intervention.
In contrast, Greenwood et al. (1990) reported on an early intervention program among coal miners,
initiated by the West Virginia Workers Compensation Fund that involved early case management by an
independent rehabilitation firm that acted as an advocate for the patient. Unlike employer-based disability
management approaches, the intervention failed to lower medical costs or prevent extended disability. It
would appear that the support of the workplace may be of critical importance in the success of disability
management approaches that rely on such elements as improved communication and the availability of
modified work duties, when needed.
Wood (1987) also reported on the effects of an intervention in a group of long-term health care
facilities designed to decrease the duration of wage loss claims, similar to the subsequent study by Batti
(1994), which was described previously. The personnel program, as it was called, focused on improving
communications between all the parties involved in the recovery of the affected employee, including: the
employee, his or her doctors, the Workers Compensation Board, and the hospital personnel. A hospital
representative immediately contacted the employee and the workers compensation representative after
the report of back symptoms. The employee then was contacted regularly. The tone of the communications
was empathetic and helpful, and included the message, You are a vital part of the hospital team. Your
work is important and your job is waiting. The hospital representative served as a liaison between the
various parties involved. After the adoption of the personnel program, the proportion of high timeloss claims significantly decreased, as compared with the prior period (7.1 vs. 1.7%). There also was a
reversal in the trend of increasing claims rates over the prior years.
Wood also examined the effects of a training program to improve work practices. Although the
training program was popular among the staff, no added benefit beyond that received from the personnel
program could be determined based on quantitative data. In general, despite its popularity, there has
been little evidence to suggest that educational approaches presenting biomedical and ergonomic principles
alone are effective in primary prevention of back symptom reports and disability (Scheer et al., 1995).
There have been reports of other approaches to education, however, that appear more promising. They
are based on a biopsychosocial model of the problem.
Symonds et al. (1995) implemented an education program among workers in a British biscuit
manufacturing factory involving the distribution of written information aimed at changing common
misconceptions about back problems. The information was based on the fear-avoidance model and
aimed at enforcing active coping strategies, rather than passive, avoidance behavior. When comparing
the employee group receiving the educational information to a control group, a decrease in incidence of
back pain reports requiring brief absences was observed in both groups during the follow-up period, but
the intervention group had significantly less extended sickness absence resulting from low back trouble.
Another educational program with encouraging results was reported by Versloot et al. (1992). The
findings of the longitudinal field study in a Dutch bus company provided some evidence to support a
decrease in overall length of absenteeism related to the program, although the incidence of time loss
episodes was unaffected. The program emphasized psychosocial factors, including responsibility of ones
own health, interactions between mind and body in relation to illness, managing stress and coping
strategies, as well as ergonomic advice specifically tailored to work and leisure activities.
Recognizing that back problems are most often recurrent in nature, several worksite programs have
aimed to decrease subsequent problems in employees with back problem histories by encouraging regular
exercise. Although the benefits of exercise in the prevention and treatment of back problems can be
debated, and appear to vary depending upon the stage of symptoms (Fass, 1996), several workplace
exercise interventions targeting employees with previous back problems report positive effects (Donchin
et al., 1990; Kellett et al., 1991; Gundewall et al., 1993). The various exercise programs were offered
through sessions at the workplace during regularly scheduled work time. In two of the programs, exercise
35-10
compliance and greater gains in fitness outcomes were found along with fewer symptoms and work
loss (Donchin et al., 1990; Gundewall et al., 1993). However, another study reporting significantly less
work loss attributable to program participation did not find a concomitant change in fitness measures
(Kellett et al., 1991). This raises questions about whether physical or psychosocial aspects of the program
were most responsible for the observed decrease in subsequent work loss. These interventions suggest
that employer-supported activity programs specifically for employees with a history of back problems
may decrease subsequent problems and be cost-effective. Whether apparent benefits are due to the
physiological effects of exercise or the many possible psychosocial effects of the programs, including a
more positive attitude toward the employer, is unclear.
Other interventions to control disability from work-related back problems have aimed at improving
the quality of medical care through the use of quality-based, standardized diagnostic and treatment
protocols. Among the motivations for developing such protocols was to minimize apparently haphazard
variations in care. Wiesel and his coworkers (1984) were among the first to develop and investigate the
effects of using such a system for the medical management of industrial back incident reports. They
demonstrated a significant and sustained decrease in lost workdays and medical and compensation costs
following the implementation of the program. Interestingly, fewer back injury incident reports also were
reported, an unexpected finding given that the intervention was designed to improve care once back
problems were reported. Since Wiesel et al. presented their approach, other similar models have been
developed in an effort to improve worker/patient outcomes (Wiesel et al., 1985, 1994; Lonstein and
Wiesel, 1988; Tufo et al., 1991), but not all have achieved similar findings (Batti et al., 1995). One
aspect of the intervention reported by Wiesel et al. that may have significantly influenced the success of
their program was their strong working relationship with the employers of the intervention sites. They
worked closely with the employers and had support and cooperation when, for example, temporary
work accommodations were needed to encourage earlier return to work.
Practical Considerations for Workplace-Based Management of Low Back Problems

Judging the effectiveness of workplace interventions is challenging. There can be difficulties in selecting
adequate control or comparison groups and good results often observed during short-term follow-up
may be simply a brief manifestation of the Hawthorne effect. The many unpredictable changes that
can occur in the work environment related to labormanagement relations, administrative processes in
the industrial insurance system, as well as the imposition of other safety and health initiatives, to name
just a few, further complicate the evaluation of specific interventions. Yet the examples mentioned above
do warrant further attention and point to several practical considerations for safety and health
professionals involved in workplace-based interventions to minimize back-related disability.
First they suggest the need to adopt the broader perspective of a biopsychosocial model in developing
injury management strategies. Such a model recognizes that a variety of psychological and sociocultural
factors, as well as physical factors, can influence back problems and related work loss. Several specific
considerations follow.
1. Improve the quality and quantity of communication between the workplace and the employee
following an injury report. Early contact should express genuine concern and offer assistance, if
possible. Contact should be maintained with employees throughout recovery to let them know
they are missed and will be welcomed back when well enough to return (Wood, 1987; Batti,
1994). Management training may be a necessary step toward changing negative attitudes and
beliefs about back injury claimants to create a more responsive environment of trust and employee
advocacy (Fitzler and Berger, 1982, 1983; Batti, 1994).
2. The importance of maintaining as normal a life style as possible during recovery should be stressed.
Recent randomized clinical trials have demonstrated that even in the acute stages of back problems,
advising the patient not to fear activity, but rather to maintain as much normal activity as tolerated
is more effective in promoting recovery than prescribing specific exercises or other common treatment
3.
4.
5.
6.
35.3
35-11
approaches (Fass, 1996; Malmivaara, 1995). Along the same line, temporary work modifications
should be made when possible to allow an employee to return to activities in the workplace as soon
as medically advisable (Fitzler and Berger, 1982, 1983; Wood, 1987; Batti, 1994).
Educational approaches should include messages that promote realistic, positive attitudes and
beliefs about back problems and their consequences. In particular, consider promoting positive
coping strategies and an active approach to confronting and managing symptoms to discourage
fear-avoidance reactions and maladaptive responses (Versloot et al., 1992; Symonds et al., 1995).
Information on biomechanics and ergonomic advice should be practical and tailored specifically
to the employees work and leisure activities.
If health promotion programs involving exercise are being considered, it may be most costeffective to target individuals with a history of recent or recurrent back problems (Keller et al.,
1991; Gundewall et al., 1993). While the employee may be expected to do some exercise on his
or her own time, having some sessions during work hours, or offering other types of employer
support, may send a powerful message about the employers commitment to employee wellbeing.
Consider ways of bolstering employees perceptions of the workplace and their personal resources
to discourage maladaptive approaches to handling problems. Management style and labormanagement relations would appear to be important aspects of such perceptions, influencing
both job satisfaction and stress (Cox, 1993).
Implement any new intervention in such a way that its effects can be evaluated. The interventions
discussed earlier, while promising, are in need of further study to verify their effects in other
environments and to better understand the specific mechanisms through which they influence
back-related disability and work loss. There are many examples of approaches that have reported
significant positive results in some environments, but have not been successful when duplicated
in others.
Summary
The aim of this chapter was to highlight some of the apparent strengths and shortcomings of two
competing models of back problems in the workplace, rather than offering an extensive literature review.
We have had greater than a half-century of experience using the injury model, stressing the role of
biomechanical factors in the etiology and management of back problems, and it has been an unequivocal
failure. This is not to say that biomechanical considerations and ergonomic interventions have no value
in the management of back problems in the workplace, but rather that they are insufficient in preventing
the development and persistence of long-term work incapacity. It is time for a new paradigm. Many
psychosocial and cultural factors influence the response to back symptoms, in terms of reporting and
disability. Many of the factors appear to relate to attitudes and beliefs about back problems and the
perceived costs and benefits of the various options available in the sociocultural systems in which we live
and work. In this broader perspective of the problem lie opportunities to develop more effective approaches
to curbing the impact of back problems in the workplace.
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36
Upper
Extremity Support
36.1 Introduction
36.2 Fundamentals
361
361
Splinting and Bracing as Medical Treatment Arm Supports

as Ergonomic Modifications to a Workstation
36.3 Applications
Carolyn M.Sommerich
North Carolina State University
36.1
364
Splinting and Bracing Arm Supports as Ergonomic

Modifications to a Workstation
36.4 Summary
369
Introduction
A concise review of the literature on upper extremity supports is presented in this chapter. Broadly
speaking, there are two categories of upper extremity supports. One category contains devices that are
used as medical treatment to relieve symptoms or improve functionality. For example, wrist splints and
elbow braces are commonly prescribed in the conservative treatment of carpal tunnel syndrome and
lateral epicondylitis (tennis elbow), respectively. The other category contains items that are used as
workstation modification in order to minimize joint and soft tissue loading or to reduce effects of
physiologic tremor on precision tasks. Arm rests on chairs and palm rests on newer computer keyboards
theoretically provide users with opportunities to reduce loads on postural muscles in the shoulder and
forearm. Both aspects of upper extremity support, as medical treatment and as workstation modification,
are discussed in this chapter. Situations wherein usage overlaps, such as wearing wrist splints during
work, are discussed as well. Additionally, the use of arm supports for some specific work activities,
including keyboarding and microsurgery, are discussed in some detail. Where sufficient evidence exists,
recommendations are provided for circumstance-specific use of upper extremity supports.
36.2
Fundamentals
In this section, basic theories of upper extremity support are explored, including the ways in which
various designs provide support, and under what circumstances they may be employed.
Splinting and Bracing as Medical Treatment

Wrist Splints. In the treatment of fractures, splinting had long been known to provide rest and relief
from pain and disability. By analogy, splinting has been applied to arthritis (Ehrlich, 1968), where the
treatment is typically prescribed to relieve pain and inflammation, but may also be prescribed to prevent
deformities (contracture), or increase function (Spoorenberg et al., 1994). Wrist splinting is also used in
conservative treatment of carpal tunnel syndrome (CTS). When CTS is attributed to pregnancy or to
work which is highly repetitive or requires sustained non-neutral wrist postures, splinting may reduce
0-8493-1800-9/03/$0.00+$1.50
36-1
36-2
pain and paraesthesia (Ditmars, 1993). Symptoms would not be expected to respond to splinting when
CTS is due to vibration exposure, lumbrical muscles entering the distal carpal tunnel during pinch grips,
pathologic encroachment (carpal bone fracture or dislocation), or external pressure applied to the palm
(from hand tools with sharp edges or short handles, or from repetitive activation of palm buttons).
Splinting the wrist in extension (using a cock-up splint) is a common practice. This practice is based
on studies of wrist position during common activities, which have shown the centroid of motion for
most common tasks to be an extended position (Palmer et al., 1985). However, minimum pressure in the
carpal canal, and therefore on the median nerve, has been shown to occur when the wrist is in a neutral
orientation (in both flexion-extension and radial-ulnar axes) (Weiss et al., 1995). Splinting the wrist in
extension may be effective for treating early stage (fully reversible inflammatory) lateral epicondylitis
(Nirschl, 1985). Passive extension of the wrist relieves tensile stress at the common origin of the wrist
and finger extensor muscles, the loci of pain in epicondylitis.
Splints are categorized as either rigid or flexible. Rigid splints do not permit any wrist motion, while
flexible splints permit a limited range of motion, thereby preserving more hand function. Rigid splints
may also be referred to as immobilizing, resting, or static splints. Flexible splints are also referred to as
activity or working splints, or wrist supports. Splints usually have a plate or bar in or across the palmar
region which may interfere with grasping activities. Both prefabricated and custom-made splints are
used in treatment protocols, depending on the preference of the medical provider. Wearing
recommendations may be for night use, usage during painful activity, or continuous usage, depending
on the protocol recommended by the medical provider.
Elbow Bracing. A variety of occupations and tasks have been associated with tennis elbow, including
meat processing, carpentry, plumbing, short cycle repetitive tasks, typing, and writing (Nirschl, 1985).
Pain associated with tennis elbow (medial or lateral epicondylitis) may be relieved by wearing a support
band just distal to the elbow, that covers the upper part of the forearm. Typically, about 5 cm in width,
the band inhibits maximum contraction of the extrinsic wrist and finger muscles, which reduces tensile
stress at the origins of those muscles (the tendons, aponeuroses, and epicondyles thought to be the sites
of involvement). A band may be prescribed for use only during strenuous activity or throughout the day
(Froimson, 1971; Valle-Jones and Hopkin-Richards, 1990).
Arm Supports as Ergonomic Modifications to a Workstation

Work in constrained postures is an acknowledged risk factor for neck and shoulder disorders (Hagberg,
1984), particularly when joint angles deviate significantly from neutral (resting) orientations. In reviewing
numerous studies of the role of posture in neck and upper limb disorders, Wallace and Buckle (1987)
concluded that posture may not always be a sufficient cause, but may interact with or add to other
physical or psychosocial risk factors. Constrained postures impose continuous loads (stress) on muscles,
tendons, ligaments, and joints. When they are of sufficient duration, even low levels of stress can lead to
adverse health outcomes. Aars (1994) reported a significant reduction in lost time associated with
musculoskeletal illness at an electronics assembly facility when static loads on workers trapezius muscles
were reduced from levels of 4 to 6% of maximum voluntary contraction (% MVC) to below levels of
2% MVC, through workstation modification. For reference, simply positioning the arm for typing
(upper arm vertical, elbow bent 90 degrees) has been estimated to require trapezius muscle activation of
3% MVC (Hagberg and Sundelin, 1986).
Potential pathologic reactions from sustained work-related stress on various musculoskeletal elements
in the neck and shoulder include degenerative joint disease; tendon disorders, including degeneration
and tendinitis; and problems with muscles, including myofascial syndrome (Hagberg, 1984). Development
of localized muscular fatigue may be an immediate consequence of sustained muscle loading. Symptoms
of fatigue may include discomfort or pain, reduced strength capacity, increased time for hand-eye
coordination, increased hand tremor, and, when severe, difficulties in hand positioning (Chaffin, 1973).
Low level muscle contractions (5% MVC) sustained for one hour have been shown to result in a 12%
reduction in MVC, and shifts in the spectral frequency of the electromyographic (EMG) signal that are
Upper Extremity Support
36-3
associated with localized muscle fatigue (Jrgensen et al., 1988). Considering typical work break schedules
(morning and afternoon work blocks, each four hr in length and each interrupted by a single 15 min
break), maintaining a work posture for an hour would not be extraordinary, especially for individuals
performing precise, hand-intensive work, or work requiring intense concentration.
Working with the upper arm unsupported and out of the vertical plane has been associated with
symptoms of musculoskeletal disorders in the neck and shoulder region, with duration of exposure a
key element (Melin, 1987; Jonsson et al., 1988). Ergonomic hazard surveillance tools assign penalties
for arms positioned out of the vertical or not supported (McAtamney and Corlett, 1993). Working with
arms unsupported, significant levels of static activity have been recorded from muscles in the shoulder
and forearm of typists performing typical keyboard operations (Onishi et al., 1982; Sommerich et al.,
1995). Positioning an unsupported arm or arm segment in any posture away from vertical requires
activation of shoulder and arm muscles in order to oppose gravitational forces. Concomitant tensile
loads are imposed on ligaments and tendons in the upper extremity, including the shoulder. These active
and passive internal loads contribute, along with any external loads at the hand, to compressive and
shear loading of the joints of the upper extremity. However, it is important to recognize that joint
posture is not the sole factor affecting muscle activity requirements. Joint posture interacts with arm
segment weight and the weight of any handheld objects. Specifically, it is the moments that result from
these interactions that directly determine muscle activity requirements. These levels of muscle contraction,
and associated soft tissue and joint loads, are necessary in order for an individual to accommodate the
physical conditions of his or her work, including work space layout and tools. However, levels of muscle
activity that exceed physical work requirements are not uncommon, and may occur due to operator
training or technique, environmental conditions, task complexity, or personality (Lundervold, 1958;
Westgaard and Bjrklund, 1987; Goldstein, 1964).
Joint and Soft Tissue Stress Reduction. The use of arm supports may be an effective method for
reducing muscle activity requirements imposed by physical work conditions. Effectively, arm supports
reduce arm segment weight. This reduces joint moments due to external forces, which, in turn, reduces
moments required from muscles and may reduce stress on other soft tissues. Frequently supporting
hands and arms on the work surface was found to be associated with lower incidence of pain in the
neck, shoulder, and arms in groups of professional keyboard operators performing different types of
keyboarding tasks (Hnting et al., 1981). In a laboratory-based study where subjects performed a
simulated soldering task, Schldt et al. (1987) demonstrated that supporting the upper extremity through
suspending the elbow or resting the elbow on a support resulted in marked reductions in shoulder
muscle activity. Muscle activity was reduced whether subjects sat upright or sat with trunks flexed over
the work surface. Sitting in a slightly reclined position reduced muscle activity so significantly that arm
support did not provide further reductions in activity in that condition.
Based on force plate measurements, Occhipinti et al. (1985) found that 4 to 7% of body weight was
supported through resting wrists on the keyboard support surface, while 7 to 14% was supported when
resting forearms on the same surface. Ranges reflect differences due to changes in unsupported trunk
postures. Based on biomechanical modeling, they estimated reductions in spinal loading at the level of
the third lumbar vertebra (L3) ranging from approximately 25 to 100 kg, depending upon type of arm
support and trunk posture. In a related study, Colombini et al. (1986) reported 6.6% of body weight
supported through a forearm support when the back was also supported.
Methods of Supports. There are many ways to provide direct support for the upper extremity, and
many points at which a support can contact the upper extremity including the elbow, along the forearm,
at the wrist, or at the base of the palm. Objective effectiveness and user acceptance are both important
issues in determining which methods may be appropriate for a particular situation. For example, as
mentioned above, researchers have demonstrated reductions in shoulder muscle activity when the elbow
was supported via suspension, or through fixed support located directly under the elbow during a
soldering task (Schldt et al., 1987). Chaffin (1973) demonstrated that time to fatigue was extended by
2 to 4 times with the use of an elbow support. Alternative keyboards are now available with built-in
wrist rests. In an early study of alternative keyboards, subjects tended to prefer a split keyboard with a
36-4
large built-in forearm-wrist support over both a split keyboard with a small built-in support and a
traditional keyboard with a large support (Nakaseko et al., 1985). Subjects were found to exert about
twice as much force on the large support (about 35 N), compared to the small one (about 17 N),
meaning that more upper body weight was supported by the larger support. Efficacy and preference for
various types of supports will be examined in more detail in the Applications section of this chapter.
Influence of Support on Posture. Supports may be useful in helping muscles to maintain or improve
the position of the supported limb. However, other body parts may be impacted by support, as well. For
example, during a series of six 10-minute long typing periods, Weber et al. (1983) found arm abduction
was greater when trained typists keyed with a forearmwrist support, when compared to unsupported
keying. Subjects also sat nearer to the keyboard support surface when arms were supported.
In theory, one effect of wrist pad usage should be a reduction of wrist extension (if the pad is positioned
appropriately). However, in a study of 12 office employees, Paul and Menon (1994) reported wrist
extension ranging from 29 to 41 degrees when subjects used five different wrist pads that varied in
shape, width, and compressiveness. However, no unsupported condition was provided to show whether
extension with any of the pads was different from extension when no pad was used.
36.3
Applications
The theoretical benefits of various upper extremity supports were discussed in the previous section.
Results from numerous studies are summarized in this section in order to demonstrate how and under
what circumstances various types of upper extremity supports have been shown to be effective.
Splinting and Bracing

Effectiveness as Medical Treatment
Wrist splints for disorders affecting the wrist. There is a consensus that usage of a splint should be based
on a medical opinion, and that the usage should be supervised by a medical provider (Falkenburg,
1987). However, usage protocols and treatment effectiveness seem to vary widely across providers.
Results of several studies of various protocols are provided in the following paragraphs.
Use of a working splint for one week, at night and during stressful activities, was found to reduce,
at the end of the week, subjective assessments of pain, numbness, and tingling in a group of CTS
patients with abnormal nerve conduction study results, when compared with symptoms in a similar
group of patients who did not receive splints (Dolhanty, 1986). Wrists were splinted at 0 to 5 degrees
of flexion.
The efficacy of conservative treatment of CTS based on steroid injection followed by continuous use
of a neutral position, rigid splint for four weeks was tested prospectively by Weiss et al. (1994). No
patients with advanced CTS or associated medical conditions (such as diabetes, pregnancy, or arthritis)
were admitted to the study. The authors found that only 13% of the treated hands were cured (defined
as symptom free) at final follow-up, which occurred between 6 and 18 months after the injection.
A similar success rate (17%) was achieved by Banta (1994), with a regime of ibuprofen and three
weeks of continuous, neutral positioned, wrist immobilization for 23 hands with early-mild CTS. A
second stage treatment consisting of one week of iontophoresis and splinting followed by two more
weeks of continuous splinting resulted in an improvement in 58% of the remaining hands. The authors
overall success rate was 65%, based upon absence of symptoms at six months follow-up.
From a retrospective review of 105 CTS patients treated with a neutral angle rigid splint designed to
permit hand function, Kruger et al. (1991) determined that 67% of the patients received symptom relief
attributable to the splint. There was a significant decrease in the median sensory latency group average
between pre- and post-treatment measurements. Splinting seemed to be most effective for patients who
had experienced symptoms for a short period of time (1 to 3 months). Patients were told to wear the
splints at night and during the day as much as possible, however, the authors were not able to confirm
36-5
the wearing patterns of the patients. Though no lower limit was provided for post-treatment measurements,
some occurred as long as 17 months after receiving the splint.
Based on a review of 363 hands with CTS, Kaplan et al. (1990) identified five factors which were
related to the successful medical management of CTS. The five factors were age over 50 years, symptom
duration exceeding 10 months, constant paresthesia, stenosing flexor tenosynovitis, and a positive Phalens
test in less than 30 s. Treatment success was defined as a patient remaining symptom free for six months
following conservative treatment with a rigid wrist splint (neutral wrist position; worn at night and
during the day when symptomatic) and anti-inflammatory medication. Follow-up averaged 15.4 months,
but ranged from 6 to 48 months. Although their overall success rate was only 18.4%, there was a
66.7% success rate in the subgroup of patients who did not have any of the five factors. In the subgroup
of patients who had one of the five factors, the success rate dropped to 40.4%; in the group with two,
the rate was 16.7%, and was only 6.8% in the group with three factors. No patients with more than
three factors were successfully treated.
Splinting may be specifically prescribed to relieve nocturnal CTS symptoms. This is based on the
theory that patients sleep with wrists curled (flexed), which results in elevated pressure on the median
nerve. Luchetti et al. (1994) found no statistically significant differences in carpal tunnel pressure (CTP)
due to splinting, either during the day or throughout the night, between two groups of CTS patients
(one splinted in 20 deg of extension, and the other not splinted). It is not known whether splinting
would have had an effect if splints had maintained the wrists in neutral rather than extended postures.
The question of appropriate splint angle was addressed in a clinical trial in which patients subjective
responses indicated that a two-week regime of splinting in a neutral position was more effective in
relieving CTS symptoms than was splinting in 20 degrees of extension (Burke et al., 1994). Both splint
designs appeared to be more effective for relief of nocturnal symptoms than daytime symptoms. Also of
interest was the finding that only 8% of patients who continued to use their splints for two months
experienced further symptom relief.
Compliance is an important part of any medical treatment. In their study of splint usage in the
treatment of rheumatoid arthritis, Spoorenberg et al. (1994) found that patients were less likely to
adhere to wearing advice for an immobilization splint than for an activity splint, although none of the
patients who were told to wear their splints at night did so. Only 17% of the patients with immobilization
splints who rested often (and therefore had the opportunity to wear the splint often) did so. In contrast,
57% of the patients with activity splints wore them often. This is, undoubtedly, at least partly due to
patients perceptions of the splints. While 96% of the rheumatologist responding to the survey prescribed
both immobilization and activity splints for reduction of pain, only 44% of patients with immobilization
splints found they relieved pain, and only 26% found they improved hand function. Seventy-eight
percent of those patients found the rigid splints both unwieldy and ugly. In contrast, 75% of the patients
with activity splints found they relieved pain and improved hand function. Only 29% thought they were
ugly, but 63% found even the activity splints to be unwieldy.
Wrist splints for tennis elbow. As in the case with most musculoskeletal disorders and their associated
risk factors, unless exposure to the risk factors associated with tennis elbow are reduced or eliminated,
after immobilization treatment pain returns once a patient resumes the activities that lead to the
development of tennis elbow (Nirschl, 1985). Therefore, Nirschl (1985) advocated for alteration or
elimination of abusive activity rather than for immobilization of either the elbow or wrist joint. He
cautioned that rigid immobilization could result in muscle atrophy. He also recommended changes in
training techniques and equipment, along with counterforce bracing once activities were resumed. Little
(1984) did not find splints to be effective in the treatment of tennis elbow. In two groups of subjects who
both received cortisone and ultrasound treatment for tennis elbow, he found essentially no difference in
recovery time (time when subjects became symptom-free) though the patients in one group were given
splints and told to rest, while members of the other group were told to continue their normal activities.
Elbow bracing. Chen (1977) found reduced pain in patients with tennis elbow who used an elbow
brace. Patients were reported to be able to perform many normal activities without experiencing symptoms,
and were even able to participate in racquet sports. Apparently, however, an elbow brace may not
36-6
provide instant relief from tennis elbow pain. Wadsworth et al. (1989) were not able to demonstrate a
statistically significant reduction in pain in a group of patients with tennis elbow who performed grip
and extension strength tests, with and without an armband, although patients reported feeling more
comfortable with the brace. For the arm affected by tennis elbow, patients demonstrated a significant
increase in wrist extension strength, and a lesser increase in grip strength when wearing the armband.
No such increases occurred in the unaffected (control) arm.
Use on the Job. The science of ergonomics seeks to match workplace requirements with human
capabilities and limitations. The preferred method of matching is through engineering controls, by
which the work or work environment is altered to fit the worker. Use of wrist splints on the job is,
instead, a method of altering the worker. Falkenburg (1987) described wrist splinting as an industrial
treatment to keep the employee on a job. She specifically mentioned, however, that splinting interferes
with hand grasp, thereby reducing hand strength and interfering with holding or grasping tasks. Such
functionality problems are documented in some of the splint research studies that are summarized in the
following paragraphs. Most of the research on splints has been conducted in laboratory settings using
healthy subjects, so results are only suggestive of what may occur in actual employment situations.
In an early field study of splinting as an intervention for CTS, results from a battery of objective and
performance-based tests demonstrated that CTS was actually aggravated by the use of a rigid splint
during work (Armstrong, 1981). In contrast, time off and light duty were found to be effective intervention
methods.
One reason splints might be thought to be useful on the job for patients with CTS would be to reduce
pressure on the median nerve by restricting patients from deviating wrists too far from a neutral posture.
However, in a laboratory-based study using only healthy subjects, Rempel et al. (1994) were not able to
demonstrate any difference in carpal tunnel pressure during a hand-intensive task between conditions
when subjects wore a flexible wrist splint and when they did not, even though wrist motion, in both
flexion-extension and radial-ulnar directions, was restricted by the splint. Rempel, Manojlovic et al.
(1994) did find, however, that simply putting on the splint significantly raised CTP in each subject.
Perez-Balke and Buchholz (1995) also observed reduced wrist motion in subjects performing a repetitive
pick and place task while wearing a rigid splint (with a malleable metal bar across the forearm, wrist,
and palm), compared to performing the same task without the splint. They found reductions in peak
grip force when subjects were splinted. Female subjects were particularly handicapped by the splint.
When wearing the splint, their grip strength was reduced by a greater percentage than the males in the
study (Perez-Balke and Buchholz, 1994; 1995). Their results might be explained, at least in part, by the
work of Fransson-Hall and Kilbom (1993), who recorded significantly lower hand pain threshold
tolerances and shorter times to experience pain in female subjects who experienced pressure applied to
various points over the palm, fingers, and thumb, compared with results from male subjects who
experienced the same test protocol. Another important finding from Perez-Balke and Buchholz (1995)
was the increase in activity in the deltoid muscle and forearm flexor muscle group during the pick and
place task when the splint was worn. In other words, subjects were less efficient when wearing the splint
(more input for the same output).
In another task-based study using healthy subjects, Carlson and Trombly (1983) found that wearing
a rigid splint slowed the performance of several manual tasks. Increased performance times were recorded
for each of seven different tasks in the Jebsen Hand Function Test (which includes writing, manipulating
small and medium-sized objects, picking up heavy cans, and feeding) when subjects wore a rigid splint,
compared to when no splint was worn. The authors suggested that increased task performance times
would be particularly problematic for an employee wearing a splint on a job with speed requirements
(such as a highly repetitive assembly task), or for an employee who fatigued easily. They also made note
of remarks of fatigue in the shoulder and upper trunk from several subjects, following task performance
with the splint. Obviously, whether or not a person is wearing a wrist splint, the hand still needs to be in
the same spatial location to perform a given task. If the wrist is not able to position the hand, the
positioning task falls to the more proximal joints (elbow, shoulder, spine), and the muscles that control
those joints. This is another example of the worker adapting to the workplace.
36-7
Stern et al. (1994) also employed the Jebsen Hand Function Test to evaluate the impact on performance
due to splint usage in a group of healthy subjects. In contrast to the previous study, these authors tested
several styles of commercial, nonrigid splints, which they referred to as static wrist extensor orthoses,
devices designed to support rather than immobilize the wrist. Only in manipulating small objects was
there a significant difference in performance between the splinted and free hand conditions. In the other
six tests, performance when wearing at least one of the five test splints did not differ from performance
in the free hand condition, though it was not the same commercial splint which matched barehanded
performance in each test. Subjects also wore each splint for a day, and reported differences in subjective
experiences among the different splints. Splints differed in terms of the types of daily tasks with which
they interfered (such as hygiene, housekeeping, or driving). Splints also differed in terms of comfort,
temperature, and pain experienced by the subjects.
Possible Adverse Results. No reports were found in the literature which associated wrist splint usage
with accidental injury. However, one report described a fracture of the distal radius in a gymnast
wearing a standard gymnasts wrist support, which caught while he worked on the high bar. This
experience should cause workers, employers, and medical providers to consider whether a wrist
support could pose a danger in some situations. Wearing a splint might increase the chances of an
employee becoming caught in rotating machinery, either directly by catching the splint, or indirectly by
restricting the employees movements and thereby restricting his or her ability to avoid contact with the
equipment.
Arm Supports as Ergonomic Modifications to a Workstation

Arm support is typically considered for work that requires steady positioning of the hands for some
period of time, such as electronics assembly, keyboarding, or surgery. One brief, but interesting mention
was made by Jex and Magdaleno (1978) regarding their efforts to model the potential vibration damping
effects of elbow rests for pilots flying high-performance aircraft. As in the case of wrist splints, few
intervention studies have been performed to examine the effects of arm support on the job. Most of the
research has been conducted in laboratories, on healthy subjects with limited exposure to each test
condition, making it difficult to predict either short- or long-term effects from use of the various types of
arm support. Results of many of those studies are summarized below.
Support During Specific Work Tasks

Assembly work. Eighteen months after installing arm suspension devices at an electronics plant, HarmsRingdahl and Arborelius (1987) found that workers continued to choose to use the devices, which may
have been due to the reductions in shoulder and neck discomfort experienced by the workers. Compared
to before the suspension was introduced, average discomfort intensity was reduced by one-half to twothirds. Before the suspension was introduced, about 40% of the workers rated their afternoon shoulder
and neck discomfort greater than 50 on a scale of 0 to 100, whereas after 18 months of suspension use,
only about 14% rated their discomfort that high.
In making ergonomic modifications to several workstations in an electronics assembly plant, Aars
(1994) recognized the importance of reducing shoulder load moments in workers. They achieved this
through a number of engineering controls, including the provision of arm rests, either positioned on the
chair or work surface, for any tasks carried out above elbow height.
Keyboarding. When given an opportunity to work at an adjustable workstation, either with or without
a forearm-wrist support, two-thirds of a sample of 67 keyboard operators preferred the support
(Grandjean et al., 1983). Seventy-eight percent of that sample did not find the support hindered their
work on the keyboard. Based on observations of the operators, when the forearm-wrist support was
present 80% of the subjects used the support. When no formal support was present, 50% of the subjects
still rested their forearms or wrists on the keyboard support surface. A recent cross-sectional
epidemiological study of VDT work seemed to objectively confirm the importance of arm supports for
keyboard operators. Bergqvist et al. (1995) found neck/shoulder discomfort in a group of VDT operators
36-8
was associated with a combination of three factors: more than 20 hr per week of VDT work, limited rest
break opportunity, and working with the lower arm unsupported.
In a study of the effects of palm rest height and profile, 40 typists were each allowed to work with
nine different palm rests during a one-week period, and were asked to use the one they preferred for at
least half a day (Parsons, 1991). Though it is unclear how the supports compared physically, unlike the
outcome of the study by Grandjean et al. (1983), in this study only four of the 40 typists found the rests
to be useful, while seven commented about increased discomfort. Several operators suggested that arm
rests on their chairs might have been more comfortable because they would have provided support
while enabling freedom of wrist and hand movement.
Relying on objective electromyographic data, two studies have demonstrated reduced activity in
forearm extensor muscles with use of one particular alternative keyboard with a built-in wrist support
(Smith and Cronin, 1993; Gerard et al., 1994), although a portion of that reduction was apparently due
to reductions in typing speed which occurred with the alternative keyboard. However, palm rests were
not shown to reduce activity in any of the forearm, shoulder, or back muscles studied by Fernstrm et al.
(1994). The authors discussed a couple of important limitations of their study which may have impacted
their results: none of their subjects had prior experience with palm rests; and both practice (10 to 20
min) and testing (5 min) times in the study were limited. The authors suggested that people unfamiliar
with palm rests tend to avoid using them (which may be important to remember when evaluating other
support studies, or when introducing supports into the workplace).
Bendix and Jessen (1986) also found that forearm muscle activity (extensor carpi radialis) was not
affected by the use of a wrist support, in a situation wherein subjects typed on electric typewriters,
although trapezius muscle activity actually increased somewhat with use of the support. Both performance
and subjective assessments of conditions with and without the support were similar. All subjects in the
study were professional secretaries who had experienced discomfort in the neck and shoulder or elbow
region for a substantial portion of the twelve-month period preceding the study. Prior to data collection,
subjects had been allotted two weeks to adapt to the wrist support. In spite of the lack of objective or
subjective beneficial effects of the support, nine of the twelve subjects wanted to keep the support once
the study was completed.
Unlike wrist pads which are fixed relative to the keyboard, full motion forearm supports are fixed
relative to the users forearms. They are designed specifically to facilitate unrestricted motion of the arm
and hand in a fixed horizontal plane, while maintaining support of the forearm and hand. Nonetheless,
Powers et al. (1992) found that subjects, described as office workers with substantial computer
experience, using full motion forearm supports thought that the supports slowed their typing and
increased their errors, although objective measurements showed this not to be the case. The authors did
not find any postural benefits to using this type of support, based on a limited assessment of wrist and
elbow postures.
Erdelyi et al. (1988) studied the effects of fixed arm supports and arm suspension on experienced
keyboard operators, some of whom were experiencing shoulder and neck pain. Both support methods
were effective in reducing trapezius activity in the group with pain. In contrast, the group of healthy
subjects experienced either no reduction in muscle activity, or, in some conditions, an increase in activity
with the supports. In each condition, pain sufferers tended to display higher levels of muscle activity
than did healthy subjects. Neither group preferred working with the supports. Compared to these findings
with experienced keyboard operators, Sihovonen et al. (1989) found a significant reduction in trapezius
activity with the use of moveable arm supports in a group of healthy, novice word processors.
Medical procedures. Several different wrist and forearm supports have been designed for use during
microsurgical, plastic, and ophthalmic surgical procedures (Halliday, 1988; Bustillo, 1968). The common
objectives of each are to provide fatigue relief for shoulder and back muscles during procedures that
require surgeons to remain almost immobile for long periods of time, as well as to provide a steady base
of support for control of postural tremor. Unfortunately, there are other restrictions in an operating
room which may diminish the impact of arm supports, including the adjustability and height requirements
of the surgical microscopes and the height and thickness of the patient support surface.
36-9
An electromyographic study of dentists performing a variety of procedures on patients revealed fairly

high levels of activity in the trapezius and extensor carpi radialis muscles (Milerad et al., 1991) A second
study was performed in order to determine the effect of several factors on muscle activity during dental
procedures, including different types of upper extremity support (Milerad and Ericson, 1994). Compared
to a no-support condition, arm support provided at the elbow significantly decreased muscle activity in
the deltoid and trapezius muscles. Support at the elbow appeared to be more effective than support
applied at the hand in reducing shoulder muscle activity. Whether such a support would be acceptable in
practice is not clear from this study, since dentists were not used as subjects.
Possible Adverse Results. Most concerns are for the effects of localized pressure at contact sites
between the support and the users body. Direct pressure applied to the base of the palm was shown to
raise the pressure in the carpal tunnel in cadaver specimens (Cobb et al., 1995), with point of application
appearing to be the crucial factor. A 1 kg force applied just proximal to the distal wrist crease resulted in
a mean increase in carpal tunnel pressure of 9 mmHg (median value of 1 mmHg), whereas that same
force applied just distal to the distal wrist crease resulted in a mean pressure of 77 mmHg (median value
of 29 mmHg) (Cobb et al., 1995). Pressure in the range of 20 to 30 mmHg begins to impact nervous and
circulatory function and performance. In vivo, CTP has also been shown to increase when typing while
resting the wrist, either on a wrist rest or on the keyboard support surface, in comparison to unsupported
typing (Horie et al., 1994). However, those authors did not report wrist posture in the three test conditions.
If changes in wrist extension occurred between those three conditions, it would be difficult to determine
whether the pressure change was due to external pressure on the wrist or change in wrist extension.
Pressure is also a concern at the elbow. Working with continuously flexed elbows, especially if supported
at the elbow such that the ulnar nerve is compressed, may result in the development of cubital tunnel
syndrome (compression of the ulnar nerve at the cubital tunnel) (McPherson and Meals, 1992).
36.4 Summary
In reviewing the literature there seems to be little consensus on the effectiveness or acceptance of upper
extremity supports. However, some summary statements and recommendations can still be made.
Wrist splints and elbow braces are forms of medical treatment. As such, usage is an issue which
should be decided between a medical provider and patient. Individuals should not self-prescribe these
devices. If an individuals symptoms are the result of physical exposures, either in the workplace or
outside of work, there is no reason to believe the symptoms will not return if the individual continues to
be exposed to the same risk factors. Wrist splints may, in fact, cause a disorder to migrate to a more
proximal joint that is forced to compensate for the reduced functionality imposed on the injured wrist
by the splint. As such, the use of wrist splints at work should not be encouraged.
Wrist splints used at work would, at best, be considered an administrative control measure. However,
nowhere are splints categorized as personal protective equipment (PPE), and they may actually make
hand-intensive tasks more difficult to perform. The decision to wear a splint on the job should be made
by an occupational health professional who has firsthand knowledge of the patients workstation, tools,
and tasks. Wrist splints may treat symptoms, but they do not address the root cause of an individuals
discomfort. Thoughtful engineering controls are the most effective method for reducing an individuals
exposure to physical risk factors associated with work-related upper extremity symptoms and disorders,
such as carpal tunnel syndrome.
Wrist pads, forearm supports, and arm rests can all be categorized as engineering controls. Yet, based
on the literature, their presence does not guarantee benefits or even usage. First, a workers need for
support must be balanced with the need for freedom of movement of the upper extremity. Continuous
support methods would be appropriate if arms and hands are maintained in the same spatial location
for extended periods of time. However, if movement is required, then the need is for a support that
provides a resting point during mini-breaks (a few seconds in length) and longer pauses in activity. This
resting support should not hinder the individual during work periods. Additionally, the workers preference
36-10
must be considered. For example, in modifying VDT workstations, once chair, monitor, and keyboard
heights have all been established, operators should be provided with a variety of support options from
which to choose. They should receive proper instructions in the ways the various supports should be
used. Operators should also be encouraged to try out the supports at their own workstations.
There are a myriad of commercially available ergonomic support devices for keyboard workstations.
The key to evaluating the efficacy of these products is to determine how and where the support is
delivered, what postural changes might occur when using the device, and whether operators will find
the support interferes with task performance. Based on the information in this chapter and some trialand-error user-testing effective support devices may be found for those operators interested in utilizing
them. For industrial settings, appropriate commercial supports may not exist. However, with some basic
ergonomics training engineers, maintenance personnel, and operators may be able to devise unique
support systems tailored to particular workstations or operators.
The goal of any upper extremity support is to aid an individual in achieving or maintaining a desired
posture with less effort or less discomfort. Given that joints are designed to move, and most tasks
require motion, there is often a conflict between the desire for support and the need for motion. Identifying
a support which will provide support without interfering with motion requirements is important for the
successful employment of upper extremity supports.
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Index
A
Abdel-Moty, Steele-Rosomoff, and
Rosomoff, Khalil,
studies, 28-1 to 19
Abdominal muscles, 12-11, 14-5 to 6,
see also Intraabdominal
pressure
Acceleration, 13-7 to 8, see also
Momentum
Accident records, 24-5
Accidents
foot, 9-6 to 9
psychosocial factors, 34-2 to 3
stairs, 8-8
ADA, see Americans with Disabilities
Act (ADA)
Administrative controls, xv to xvi,
see also Ergonomics
surveillance;
Medical management
prevention
Aging population
back pain, 10-4, 10-8
ergonomic strategy
ineffectiveness, 21-2
post-injury management,
28-17 to 18
stairs accident vulnerability, 8-8
Air movement, see Draft (air)
Allread, and Ried, Marras, studies,
18-1 to 22
American National Standards
Institute (ANSI), 28-5
Americans with Disabilities Act
(ADA), 14-2, 14-13,
14-16, 28-16 to 17, 29-2
Amplitude probability distribution
function, 2-7
Anatomical complexity, 12-2 to 4
Anatomy
carpal tunnel, 3-5
connective tissue, 3-5
foot, 9-1 to 2
muscular system, 3-2 to 5
nervous system, 3-5 to 9
shoulders, 4-2 to 3
skeletal system, 3-1 to 2
Anderson studies, 29-1 to 7
Andersson, Lavender and, studies,
8-1 to 8
Andersson studies, 10-1 to 15
Arms
elevation, 4-13
posture study, 26-11
strength, 9-12
supports, 4-14, 36-2 to
4, 36-7 to 9, 36-9 to 10
Assembly work, arm supports, 36-7
Assessment tools
body discomfort, 26-1 to 13
low back injury risk, 18-1 to 2
lumbar motion monitor, 18-1
to 22
workplace, 2-9, 2-16 to 18
Asymmetry factor, 16-9 to 10, 17-4
Average twisting velocity, 18-17,
18-20
B
Back belts, 27-10, 33-1 to 5
Back force prediction, 11-7 to 10
Back injuries, 12-12 to 13, 12-16,
18-1
Back pain, industry, see also
Industrial low back pain
basics, 10-1
Belgium, 10-7
bending, 10-13
Canada, 10-3
chronic back pain, 10-9 to 10
cross-sectional studies, 10-3 to 10
heavy physical work, 10-11 to 12
hospitalizations and operations,
10-7 to 9
Israel, 10-6
lifting, 10-13
magnitude, 10-1 to 2
national studies, 10-2 to 3
The Netherlands, 10-6 to 7
occupational risk factors, 10-10
to 15
psychological work factors, 10-15
psychosocial work factors, 10-15
pulling and pushing, 10-13 to 14
repetitive work, 10-14
Scandinavia, 10-4 to 6
static work postures, 10-13
Sweden, 10-2 to 3
twisting, 10-13
United Kingdom, 10-2
United States, 10-2, 10-3 to 4
vibrations, 10-14 to 15
Back pain, workplace

basics, 35-1 to 2, 35-11
biopsychosocial model,
35-6 to 11
disability management
interventions, 35-8 to
10
fault perceptions, 35-4
injury model, 35-2 to 5
low back problems, 35-10 to 11
physical loading, 35-2 to 4
sociocultural influences, 35-7
Workers Compensation
system, 35-4 to 5
Baselining phase, 15-4 to 8, 15-10
Batti, and Main, Burton, studies,
20-1 to 8
Batti, Main, and Burton, studies,
35-1 to 11
Batti, Main, Burton and, studies,
34-1 to 18
Beat knee, 8-2, 8-8
Behavior rating scales, 26-4
Belgium, 10-7
Beliefs, 34-6 to 8, 34-13
Belt-pulley interaction, 2-8
Bending, 10-13, 12-10, 12-16
Bertsche, Hales and, studies, 27-1
to 12
Biofeedback, 28-11 to 12
Biomechanical and psychosocial
factors, low back
injuries
background, 20-2 to 3
basics, 20-1 to 2, 20-8
ergonomic intervention
effectiveness, 20-7 to 8
recurring injury, 20-4 to 7
spinal damage, 20-3 to 4
work loss, 20-4 to 7
Biomechanical approaches
back belts, 33-3 to 4
industrial mats, 7-3
post-injury management, 28-15
spine models, 13-2 to 3
trunk performance modeling,
14-14 to 16
Bishu and Muralidhar studies, 6-1
to 10
B-200 Isostation, 14-16
Body discomfort assessment tools
basics, 26-1 to 2, 26-13
behavior rating scales, 26-4
I-1
I-2
body part scales, 26-9

description, 26-3
discomfort
phenomenon/construct,
26-2 to 3
graphic rating scales, 26-6
intensity, 26-4 to 6, 26-9
location, 26-7, 26-9
measurement fundamentals,
26-7 to 8
numeric rating scales, 26-6
quality, 26-6
selection criteria, 26-12 to 13
temporal pattern, 26-7, 26-9
to 12
verbal rating scales, 26-4 to 5
visual analog scales, 26-5 to 6
whole-body scales, 26-8 to 9
Body part scales, 26-9
Bony structures, shoulder, 4-2
Braces
tennis elbow, 3-19 to 20
upper extremities, 36-1 to 2,
36-4 to 7, 36-9 to 10
B-Tracker (Interlogics), 15-6, 15-9,
15-10
Bursitis, chronic prepatellar, 8-2
Burton, and Batti, Main, studies,
34-1 to 18
Burton, Batti, and Main studies,
20-1 to 8
Burton, Batti, Main and, studies,
35-1 to 11
C
Cable tensiometer, 14-5 to 6
Canada, 10-3
Capacity evaluations, 28-8 to 9
Carpal tunnel anatomy, 3-5
Carpal tunnel syndrome, see also
Wrists
basics, 3-27 to 29, 14-4
conceptual model, 2-6 to 7
individual factors, 1-3
deviated wrist angles, 3-29
natural history, 1-3
nonneutral wrist position, 1-7
repetitive use, 1-7
work factors, 1-4, 1-8
Carpet installers, 8-2 to 3, 8-8
Chaffin studies, 11-1 to 11
Chronicity, determinants of, 34-9
Clothing design, 32-10 to 14
Company size, injury surveillance,
24-12 to 13
Computers, see Keyboarding;
Models
Confidentiality, database systems,
24-14 to 15
Connective tissue, 3-5
Context-sensitive interventions,
34-17
Controls, foot-operated, 9-12
Coping strategies, 34-8
Costs
back injuries, 18-1
disability, long-term, 34-3
low back pain, 31-11
physical ability test, 29-2
upper extremity disorder, 1-1 to 2
worker tracking database, 24-6,
24-7
work-related musculoskeletal
disorders, 19-1
Coupling multiplier, 16-12 to 13,
17-5, see also Grip
force and strength
Cross-sectional studies
back pain, 10-3 to 10
reporting errors, 20-2
CTDs, see Cumulative trauma
disorders (CTDs)
Cumulative trauma disorders (CTDs)
basics, 3-1, 3-31
carpal tunnel, 3-5, 3-27 to 29
connective tissue, 3-5
DeQuervains disease, 3-20 to 23
fatigue fractures, 8-3
industrial disease of the
information age, 28-3
lateral epicondylitis, 3-19 to 20
median nerve compression, 3-29
to 30
muscle disorders, 3-9 to 11
muscle-tendon disorders, 3-11
to 24
muscular system, 3-2 to 5
nerve compression disorders,
3-25 to 31
nervous system, 3-5 to 9
rotator cuff syndrome, 3-20
stress fractures, 8-3
supraspinatus tendinitis, 3-20
skeletal system, 3-1 to 2
tendinitis, 3-17 to 19
tennis elbow, 3-19 to 20
tenosynovitis, 3-20
thoracic outlet syndrome, 3-31
trigger finger, 3-23 to 24
upper extremity anatomy, 3-1
to 9
work-related muscle disorders,
3-9 to 11
D
Data, statistical treatment, 24-16 to
18
Database systems, injury surveillance,
see also Injuries

accident records, 24-5
basics, 24-1 to 2, 24-19
benefits, 24-6 to 8
categories of data, 24-10
company size, 24-12 to 13
components, 24-12
computerization, 24-15 to 16
confidentiality, 24-14 to 15
cost benefit analysis, 24-7
data, treatment of, 24-10, 24-16
to 18
data entry, 24-15
data sources, 24-3 to 6
early databases, 24-10 to 11
ergonomics, 24-8 to 10
history, 24-2 to 3, 24-10 to 11
integration, 24-7 to 8
job descriptions, 24-5
medical records, 24-4 to 5
medical services, 24-13 to 14
model, defining, 24-11 to 16
modules, 24-10, 24-11
OSHA records, 24-4
report generation, 24-18
selecting, 24-18 to 19
types, 24-14
Workers Compensation
records, 24-4
worker tracking, 24-5 to 6
Data entry, 24-15
Data sources
database systems, injury
surveillance, 24-3 to 6
musculoskeletal disorders,
OSHA recordkeeping, 23-5 to 6
Dempsey studies, 19-1 to 24
DeQuervains disease, 1-2, 3-20 to
23, 14-4
Determinants of chronicity, 34-9
Dexterity, 6-4 to 5
Diaphragm, models, 12-3
Direct dynamics, 14-13 to 16
Disabilities
ADA, 28-16 to 17
cost and effects, 34-3
ergonomics and rehabilitation,
32-3 to 7
interventions, 35-8 to 10
prevention, 28-5 to 7
trunk performance, assessment,
14-2 to 3
Disc herniations, 20-3, see also Spine
Discomfort phenomenon/construct,
26-2 to 3
Distance multiplier, 16-8 to 9, 17-4
Draft (air), 4-15
Dynamic modeling, 12-1 to 1, 13-7
to 8
Dynamic reaction force, 5-8 to 11
Index
I-3
Dynomometers, 14-6
E
Education
fall prevention, 21-10
incapacity prevention, 34-13
to 14
Elbows, see also Lateral epicondylitis
bracing, 36-2, 36-5 to 6
disorder types, 1-2 to 3
symptom frequency, 1-2
Electrically assisted treatment
methods, 28-10 to 16
Electromyogram (EMG)-based
models and approaches
indeterminacy, 12-4 to 5
muscle forces, 12-6
to 12
prolonged loading, 13-16 to 17
trunk muscles, 14-6, 14-10 to 11
Elemental resource model (ERM),
14-3
Employees
evaluations, medical
management, 27-5 to 6
medical management treatment,
27-6, 27-10 to 11
OSHA criteria, 25-3 to 4, 25-11
physical ability testing, 29-6
Endurance
glove effect, 6-4
14-7 to 11
worker functional capacities, 31-3
Epidemiology, back pain in industry
basics, 10-1
Belgium, 10-7
bending, 10-13
Canada, 10-3
chronic back pain, 10-9 to 10
cross-sectional studies, 10-3 to 10
heavy physical work, 10-11 to 12
hospitalizations and operations,
10-7 to 9
Israel, 10-6
lifting, 10-13
magnitude, 10-1 to 2
national studies, 10-2 to 3
occupational risk factors, 10-10
to 15
psychological work factors, 10-15
psychosocial work factors, 10-15
pulling and pushing, 10-13 to 14
static work postures, 10-13
Sweden, 10-2 to 3
twisting, 10-13
United States, 10-2, 10-3 to 4
vibrations, 10-14 to 15
Epidemiology, upper extremities
basics, 1-1, 1-7 to 8
costs, 1-1 to 2
factors, 1-3 to 7
frequency, 1-1 to 2
individual factors, 1-3 to 4
rates, 1-1 to 2
work-related factors, 1-4 to 7
Equipment, 2-17
Ergonomic design, NIOSH lifting
equation, 16-19
Ergonomic interventions
effectiveness, low back injuries,
20-7 to 8
to 8
whole body vibration, 14-3
Ergonomics
basics, xv
database systems, injury
to 3
post-injury management
programs, 28-1 to 19
Ergonomics and rehabilitation
basics, 32-1 to 2
clothing design, 32-10 to 14
disabilities, 32-3 to 7
hand characteristics, 32-7 to 10
methods, 32-14 to 18
opportunity equalization, 32-3
to 14
Ergonomics surveillance
body discomfort assessment
tools, 26-1 to 13
database systems, injuries, 24-1
to 19
work-related, 23-1 to 14
OSHA recordkeeping, 25-1 to 12
Ergonomists, qualifications, 28-18
ERM, see Elemental resource model
(ERM)
Evaluation
gloves, 6-9
impairments, 14-4 to 5, 14-18
low back pain, industrial
perspective, 15-4 to 9,
15-10 to 11
upper extremities, integrated
analysis, 2-5 to 9
Evanoff and Rempel studies, 1-1 to 8
Everyday use objects, ergonomics
and rehabilitation, 327 to 10

Exercises, 32-5, see also Ergonomics
and rehabilitation
Existing records, surveillance, 23-5
to 7
Extremity disorders
cumulative trauma disorder, 3-1
to 32
foot, 9-1 to 13
gloves, 6-1 to 10
handtools, 5-1 to 12
industrial mats, 7-1 to 5
lower extremities, injury
shoulders, 4-1 to 16
upper extremities, 1-1 to 18,
2-1 to 18
F
Factors, see Biomechanical and
psychosocial factors,
low back injuries; Risk
factors
Factors and multipliers, 16-6 to 13,
17-3 to 5
Fall-related injuries, occupational
risk factors
basics, 21-1
biomechanics, 21-5 to 9
considerations, 21-1 to 2
epidemiology, 21-3 to 4
fall descent kinematics, 21-5 to 7
fall initiation, 21-5
fatal injuries, 21-3
impact mechanics, 21-7 to 9
nonfatal injuries, 21-4
prevention, 21-10
protective responses, 21-6 to 7
Falls
causes, 9-6 to 8
foot accidents, 9-6
slips, 9-6 to 7
solutions, 9-8 to 9
stepping-on-air, 9-8
trips, 9-7
Fatal injuries, 21-3
Fatigue, 8-3, 9-10 to 12
Fault perceptions, 35-4
Finland, 1-6
First aid, 25-5, 25-11
Flexion postures, 2-4 to 5, 12-10 to
11, 12-16
Floor mats, 8-4, 9-11 to 12, see also
Industrial mats
Follow-up evaluations, 27-11, 28-14
Foot, see also Foot wear; Leg; Shoes
accidents, 9-6 to 9
activities, 9-5 to 6
anatomy, 9-1 to 2
I-4
comfort, 9-10 to 12
controls, foot-operated, 9-12
dimensions, 9-3 to 5
fatigue, 9-10 to 12
hard surface floors, 9-9
physiology, 9-2 to 3
shoes, 9-10
Foot-floor interface, 8-5 to 7
Foot wear, 7-5, see also Foot; Shoes
Force factor limits, 19-21 to 22
Forearm muscle pain, 2-8 to 9
Forms, OSHA recordkeeping, 25-4,
25-7 to 8
Frequency factor, see also Lift rate
limits, 19-21 to 22
manual lifting, threshold limit,
17-4
NIOSH lifting equation, 16-10
to 12
repetitiveness, 2-2 to 4
upper extremities, 1-1 to 2
Functional electric stimulation,
28-11
G
Gaddie, Jang, and Lee, Karwowski,
studies, 17-1 to 10
Gaps analysis, 2-9
Generalizability, workplace
assessment tools, 2-17
Glossary, low back pain, 22-1 to 23
Gloves, see also Hand
attributes, 6-8
design challenges, 6-8 to 9
dexterity, effect on, 6-4 to 5
evaluation, 6-9
feedback cycle, 6-2
liners, 6-7 to 8
standards, 6-10
strength, effect on, 6-3 to 4
tactility, effect on, 6-5 to 7
types, 6-2 to 3
Grant, Putz-Anderson and, studies,
23-1 to 14
Graphic rating scales, 26-6
Grip force and strength, 5-2 to 5, 6-3,
see also Coupling
multiplier
H
Hales and Bertsche studies, 27-1 to 12
Hand, see also Gloves; Hand tools
design of objects, 32-7 to 10
frequency of symptoms, 1-1, 1-2
grip strength, 5-3
hand importance, 6-1
need for protection, 6-2
prehensile capabilities, 6-1 to 2

vibration, 1-7
Handicap, trunk performance, 14-2
to 3
Handle size, 5-3 to 5
Hand tools
basics, 5-1 to 2
dynamic reaction force, 5-8 to 11
grip force, 5-2 to 5
handle size, 5-3 to 5
power tool triggers, 5-2 to 3
static hand force, 5-5 to 8
vibration, 1-7, 5-11 to 12
Hard surface floors, 9-9
Harness, lumbar motion monitor,
18-13 to 14
Hazard surveys, 23-2, 23-9 to 10
Health care providers, 27-2 to 6,
27-10
Heavy physical work, 4-5, 10-11 to 12
High risk group membership, 18
15 to 21
Horizontal factor
to 12
17-3
NIOSH lifting equation, 16-6 to 7
Hospitalizations and operations,
10-7 to 9
Hot wax, 27-11
Hsiang and McGorry studies, 22-1
to 23
Hypothenar hammer syndrome, 1-3
I
Illness, see also Sickness absence,
psychosocial factors
causes, 28-3
gap frequency prediction, 2-9
OSHA criteria, 25-6 to 7, 25-11
Impairment, 14-2 to 3, 14-4 to 5,
14-18
Incapacity, see Sickness absence,
psychosocial factors
Incidence, surveillance, 23-4 to 5
Indeterminacy, 12-4 to 5
Individual risk factors, 1-3 to 4, 2-16
Industrial low back pain, see also
Back pain, industry
baselining phase, 15-4 to 8, 15-10
basics, 15-1 to 4, 15-11 to 13
case study, 15-9 to 11
clinical evaluation, 15-10 to 11
evaluation, 15-4 to 9
injury incidence, 15-9
job analysis, 15-9
manual materials handling,
15-1 to 3
post injury analysis, 15-8 to 9
postural demands, 15-3
psychosocial factors, 15-4

recommendations, 15-9
severity analysis, 15-9
slipping, 15-4
task analysis, 15-9
tripping, 15-4
Industrial mats
basics, 7-1
biomechanical approach, 7-3
characteristics, 7-3
foot wear conditions, 7-5
physiological approach, 7-2
postural approach, 7-2 to 3
psychophysical approach, 7-1 to 2
selection, 7-5
standards, 7-3 to 5
Infraspinatous tendinitis, 4-3
Injuries, see also Database systems,
injury surveillance
causes, 28-3
decreasing, 30-11
incidence, 15-9
OSHA criteria, 25-6, 25-11
prediction, 30-10 to 11
recurring, 20-4 to 7
shoulders, 4-3 to 4
sickness absence, psychosocial
factors, 34-2 to 3
workplace, 28-2, 35-1 to 11
Interspinous ligament, 12-3
Intervention information
context-sensitive, 34-17
workplace assessment tools, 2-17
Intraabdominal pressure, 12-11
Inverse dynamics, 14-13 to 16
Ischemia, 3-25, 4-4
Israel, 10-6
J
Jang, and Lee, Karwowski, Gaddie,
studies, 17-1 to 10
Jebsen Hand Function Test, 36-6 to 7
Jerking, 12-14
Job analysis, see also Occupational
risk factors; Work
conditioning; Workrelated disorders
perspective, 15-9
medical management, 27-4
on-the-job performance, 30-4
to 5
physical ability testing, 29-2 to 5
post-injury management, 28
14 to 15
preplacement strength
screening, 30-3 to 5
simulation, 28-12 to 13, 30-3
to 4, 31-2
Index
I-5
splints and braces, 36-6 to 7

Job descriptions, 24-5
Job placement assessment, 31-2 to
3, 31-8 to 9, 31-9 to
10
Job-related intervention strategy,
16-19 to 20
Joints, 2-4, 36-3
K
Karwowski, Gaddie, Jang, and Lee
studies, 17-1 to 10
Keyboarding
ergonomic support, 36-7 to 8,
36-10
workplace injuries, 28-3
Key studies, 31-1 to 11
Khalil, Abdel-Moty, Steele-Rosomoff,
and Rosomoff studies,
28-1 to 19
Kim studies, 7-1 to 5
Knee gonarthrosis, 8-2
Kneeling postures, 8-8
Konz studies, 9-1 to 13
L
Lateral epicondylitis, see also Elbows
to 20, 14-4
forearm muscle pain, 2-9
repetitive use, 1-6 to 7, 1-8
Lateral velocity, maximum, 18-17,
18-21
Latissimus dorsi, 12-3
Lavender and Andersson studies, 8-1
to 8
Lee, Karwowski, Gaddie, Jang and,
studies, 17-1 to 10
Leg, 9-2 to 3, 9-12, see also Foot;
Standing
Lifting
back pain, 10-13
duration, 16-10 to 12
flexion postures, 12-10 to 11
intraabdominal pressure, 12-11
lumbodorsal fascia, 12-11 to 12
modeling, 11-1 to 11
momentum, 12-14, 12-16
multitask approach, 16-14,
16-17 to 18
single-task approach, 16-14,
16-15 to 17
smooth movement, 12-14
trunk performance, 14-12 to
13, 14-17
twisting simultaneously, 12-13
to 14, 12-16
utilization ratio, 14-17

Lifting equation, NIOSH
applications, 16-19 to 25
asymmetry component, 16-9
to 10
basics, 16-1 to 5
computer simulation, 17-3, 17-5
coupling component, 16-12 to 13
distance component, 16-8 to 9
ergonomic design, 16-19
examples, 16-20
frequency component, 16-10
to 12
horizontal component, 16-6 to 7
job-related intervention
strategy, 16-19 to 20
lifting index, 16-4
limitations, 16-6, 16-19
loading bags, 16-20 to 22
measurement requirements,
16-3
obtaining data, 16-6 to 13
procedures, 16-13 to 18
rationale, 16-19
recommended weight limit,
16-2 to 3, 17-2
revised, 1991, 17-2 to 3
using data, 16-6 to 13
vertical component, 16-7 to 8
warehouse order filling, 16-22
to 25
Lifting index, 16-4, 16-19, 17-5 to 7
Lift rate, 18-17, 18-19, see also
Frequency factor
Ligaments, 12-3, 13-5
Limitations, workplace assessment
tools, 2-18
Liners, gloves, 6-7 to 8
Loading
acceleration, 13-7 to 8
back pain, workplace, 35-2 to 4
intraabdominal pressure, 12-11
prolonged, spine models, 13-15
to 17
shoulders, 4-1, 4-3
soft tissue, 2-4 to 5
tendons, 3-11 to 17
tissue, modeling, 12-6, 12-8
Loading bags (example), 16-20 to 22
Low back disorders
back pain, epidemiology, 10-1
to 15
biomechanical models, 13-1 to
17
dynamic models, 12-1 to 17
fall-related occupational
injuries, 21-1 to 10
industrial low back pain, 15-1
to 27
low back pain glossary, 22-1
to 13

to 22
manual lifting, static
biomechanical
modeling, 11-1 to 11
17-1 to 10
to 25
prevention, psychophysical
basis, 19-1 to 24
14-1 to 19
Low back injuries
basics, 20-1 to 2, 20-8
ergonomic intervention
effectiveness, 20-7 to 8
recurring injury, 20-4 to 7
risk factors, 18-1 to 2
spinal damage, 20-3 to 4
work loss, 20-4 to 7
Low back modeling
basics, 12-2, 12-6 to 7
future directions, 12-16 to 17
issues, 12-2 to 7
occupational injuries, 12-15 to 16
risk reduction, 12-8 to 16
Low back pain
basics, 22-1
categories, 22-1 to 2
glossary, 22-2 to 13
14-4 to 17
Workers Compensation cost,
31-11
workplace, 35-10 to 11
Low back pain, industrial perspective
baselining phase, 15-4 to 8, 15-10
basics, 15-1 to 4, 15-11 to 13
case study, 15-9 to 11
clinical evaluation, 15-10 to 11
injury incidence, 15-9
job analysis, 15-9
manual materials handling,
15-1 to 3
post injury analysis, 15-8 to 9
postural demands, 15-3
psychosocial factors, 15-4
recommendations, 15-9
severity analysis, 15-9
slipping, 15-4
task analysis, 15-9
tripping, 15-4
Lower extremities, injury prevention
basics, 8-1, 8-8
ergonomic controls, 8-4 to 8
floor mats, 8-4
foot-floor interface, 8-5 to 7
I-6
kneeling postures, 8-8

occupational relationship, 8-1
to 3
shoe insoles, 8-4 to 5
stair design, 8-7 to 8
Lumbar motion monitor
benefits, 18-7 to 8
calibration, 18-2
data, 18-10 to 22
development, 18-2 to 7
equipment, 18-8 to 9
individual results, 18-21 to 22
job selection, 18-9
physical description, 18-2
risk model, 18-3 to 7
task analysis, 18-10
validation, 18-2
Lumbodorsal fascia, 12-3, 12-11 to 12
M
Main, and Burton, Batti studies,
35-1 to 11
Main, Burton, and Batti studies,
34-1 to 18
Main, Burton, Batti and, studies,
20-1 to 8
MANOVA, see Multiple analysis of
variance (MANOVA)
Manual lifting, modeling
basics, 11-1 to 2, 11-10 to 11
computer models, 11-7 to 9
strength prediction programs,
11-2 to 7
validation, 11-10
Manual lifting, threshold limit
basics, 17-1 to 2
factors and multipliers, 17-3 to 5
lifting index, 17-5 to 7
model application, 17-7 to 8
simulation results, 17-5
threshold values, 17-2
Manual materials handling,
see also Back belts
herniated nucleus pulposus,
15-1 to 2
perspective, 15-1 to 3
musculoskeletal disorders, 19-3
to 5, 19-19 to 21
nonstandard, 19-5
occupational risk factors,
shoulders, 4-5, 4-13
quantification evaluation, 14-12
to 13
Marklin studies, 3-1 to 32
Marras, Allread, and Ried studies,
18-1 to 22
Mats, see Industrial mats
Maximal protocols, 14-5
Maximum lateral velocity, 18-17 to
19, 18-21
Maximum moment, 18-11, 18-17,
18-20
Maximum sagittal flexion, 18-17,
18-21
McGill, Norman and, studies, 13-1
to 17
McGill studies, 12-1 to 17, 33-1 to 5
McGorry, Hsiang and, studies, 22-1
to 23
McIntyre, Pope and, studies, 15-1
to 27
Median nerve, 2-8, 3-29 to 30, 28-3,
see also Carpal tunnel
syndrome
Medical management prevention
back belts, 33-1 to 5
biopsychosocial models, 35-1
to 11
ergonomics and rehabilitation,
32-1 to 18
to 12
physical ability testing, 29-1
to 7
to 19
preplacement strength
screening, 30-1 to 17
influence, 34-1 to 18
rehabilitation, ergonomics
and, 32-1 to 18
sickness absence, 34-1 to 18
upper extremity support, 36-1
to 10
worker functional capacities,
assessment, 31-1 to 11
Medical procedures, arm supports,
36-8 to 9
Medical records, 23-6, 24-4 to 5
Medical services, 24-13 to 14
Medicolegal dimensions, 34-13
Miners, see Beat knee
Models
back pain, injury, 35-2 to 5
biomechanical simulation, 14-15
to 16
biopsychosocial, 35-1 to 11
injury surveillance database
systems, 24-11 to 16
low back, 12-1 to 17
manual lifting, 11-1 to 11
17-3, 17-5, 17-7 to 8
quasidynamic models, 13-8 to 15
sickness absence, 34-3 to 4
spine, 13-1 to 17
trunk performance, 14-14
to 16
Momentum, 12-14, 12-16
Monitoring, see Ergonomics
surveillance
Morrisey studies, 25-1 to 12
Motion analysis, 28-15
Movement, 4-3, 12-6, see also
Frequency factor
Multiple analysis of variance
(MANOVA), 14-10
Muralidhar, Bishu and, studies, 6-1
to 10
Muscle disorders, CTDs, 3-9 to 11
Muscles
back belt effect, 33-3
forces, 12-6
performance quantification,
14-3 to 4
shoulder structure, 4-2 to 3
trunk performance, 14-7 to 11
Muscle-tendon disorders, 3-11 to 24
Muscular system anatomy, 3-2 to 5
Musculoskeletal disorders, xv, 2-2
to 5, 19-1 to 24,
see also Extremity
disorders; Low back
disorders
Musculoskeletal disorders, medical
management
basics, 27-1 to 2, 27-12
early reporting, 27-4
employee evaluation, 27-5 to 6
follow-up, 27-11
health care provider selection,
27-2 to 4
hot wax, 27-11
job familiarity, 27-4
oral medications, 27-10
resting, 27-6, 27-10
return to work, 27-11 to 12
screening, 27-12
steroid injections, 27-11
strengthening, 27-10
stretching, 27-10
surgery, 27-11
thermal therapy, 27-10
treatment of employee, 27-6,
27-10 to 11
Musculoskeletal disorders,
surveillance
analyzing, 23-2 to 5
basics, 23-1 to 2, 23-10
collecting, 23-2 to 5
data sources, 23-5 to 10
existing records, 23-5 to 7
hazard surveys, 23-2, 23-9 to
10
incidence, 23-4 to 5
intervening, 23-2 to 5
Index
prevalence, 23-4 to 5
rates and percentages, 23-4
reporting procedures, 23-3
severity, 23-4 to 5
worker surveys, 23-2, 23-7
to 9
Myalgia, 3-9
Myofacial syndrome, 3-9 to 11
N
National studies, back pain, 10-2 to 3
Nerve of power (ulnar nerve), 3-8
Nerve of stability (radial nerve), 3-8
Nerves
compression disorders, 3-25
to 27, 3-39 to 30
to 31
disorders, 2-8
shoulders, 4-3
Nervous system, 3-5 to 9, 14-3
NIOSH lifting equation
asymmetry component, 16-9
to 10
basics, 16-1 to 5
computer simulation,17-3, 17-5
coupling component, 16-12 to 13
distance component, 16-8 to 9
ergonomic design, 16-19
examples, 16-20
frequency component, 16-10
to 12
horizontal component, 16-6 to 7
job-related intervention
strategy, 16-19 to 20
lifting index, 16-4
limitations, 16-6, 16-19
loading bags, 16-20 to 22
17-2 to 3
measurement requirements,
16-3
obtaining data, 16-6 to 13
procedures, 16-13 to 18
rationale, 16-19
recommended weight limit,
16-2 to 3, 17-2
revised, 1991, 17-2 to 3
using data, 16-6 to 13
vertical component, 16-7 to 8
warehouse order filling, 16-22
to 25
Nonfatal injuries, 21-4
Norman and McGill studies, 13-1
to 17
Nowak studies, 32-1 to 18
Numeric rating scales, 26-6
Nutrunner torque reaction, 5-8 to 9
O
I-7
Occupational risk factors, see also
Job analysis; Workrelated risk factors
low back injuries, 12-15 to
16, 20-2
lower extremities, 8-1 to 3
Occupational risk factors, fall-related
injuries
basics, 21-1
biomechanics, 21-5 to 9
considerations, 21-1 to 2
epidemiology, 21-3 to 4
fall descent kinematics, 21-5 to 7
fall initiation, 21-5
fatal injuries, 21-3
impact mechanics, 21-7 to 9
nonfatal injuries, 21-4
prevention, 21-10
Occupational risk factors, shoulders
arm elevation, 4-13
basics, 4-1 to 2
draft, 4-15
heavy physical work, 4-5
manual handling, 4-5, 4-13
nonneutral trunk postures, 4-13
pauses, lack of, 4-14 to 15
static work, 4-13 to 14
structure and function, 4-2 to 4
vibration, 4-15
work organizational factors, 4-15
work-rest schedule, 4-14 to
15, 12-16
Opportunity equalization, 32-3 to 14
Oral medications, 27-10
OSHA recordkeeping
basics, 25-1 to 2, 25-12
concepts, 25-5 to 7
data source, 23-5 to 6
employer requirements, 25-2
to 4
forms, 25-4, 25-7 to 8
systems, 24-4
posting requirements, 25-4 to 5
proposed changes, 25-8
specific changes, 25-8 to 12
temporary employees, 25-3
Osteoarthritis, 1-3, 1-8, 8-2
P
Pain, clinical perspectives, 34-4 to
10, see also specific
type of pain
Paraplegic workspace design, 32-6
Parnianpour and Shirazi-Adl studies,
14-1 to 19
Pauses, lack of, 4-14 to 15
Payroll records, 23-7
Peak angular acceleration, 3-14
to 17
Pedals, 9-12
Pelvic restraints, 14-6
Percentages, surveillance, 23-4
Physical ability testing,
see also Preplacement
strength screening;
Screening; Test battery
design
basics, 29-1 to 2, 29-6 to 7
implementation, 29-2 to 5
ongoing practices, 29-5 to 6
Physical loading, 4-1, 4-5, 35-2 to 4
Physical therapy, 34-14
Physiological approaches, 7-2, 33-4
Pinch strength, 6-4, 19-21
Pope and McIntyre studies, 15-1 to
27
Population-based load threshold
limit
basics, 17-1 to 2
factors and multipliers, 17-3 to 5
Post-injury analysis, 15-8 to 9
Post-injury management
ADA, 28-16 to 17
aging population, 28-17 to 18
applied clinical research, 28-15
to 16
basics, 28-2, 28-18 to 19
biofeedback, 28-11 to 12
biomechanical analysis, 28-15
capacity evaluations, 28-8 to 9
causes of illness and injury,
28-3
disability prevention, 28-5 to 7
education, 28-15
electrically assisted methods,
28-10 to 16
electromyography, 28-11 to
12
ergonomic interventions, 28-7
to 8
ergonomics disorders, 28-2 to
3
functional electric stimulation,
28-11
job simulation, 28-12 to 13
job site analysis, 28-14 to 15
motion analysis, 28-15
post-rehabilitation, 28-18
qualifications of ergonomists,
28-18
reimbursement, 28-18
treatment goals, 28-9 to 10
I-8
work conditioning, 28-12 to 13
workplace design, 28-13 to 14
workplace injuries, 28-2
Post-rehabilitation injury
management, 28-18
Posture, see also Static positions
changing, 2-5, 7-2 to 3, 9-11
extreme, 2-16
industrial mats, 7-2 to 3
joint moment of force, 2-4
kneeling, 8-8
low back pain, 15-3
nonneutral trunk position, 4-13
optimal, 2-5
soft tissue loads, 2-4 to 5
splints and braces, 36-4
stretch breaks, 2-16
Power nerve (ulnar nerve), 3-8
Power tool triggers, 5-2 to 3
Prediction of strength, 11-2 to 7
Pre-injury phase, 15-4 to 8, 15-10
Preplacement strength screening,
see also Physical ability
testing; Screening; Test
battery design
basics, 30-1 to 2, 30-15
injury rate prediction, 30-10
to 11
job performance prediction,
30-3 to 5
literature review, 30-2 to 5,
30-10 to 11
program establishment, 30-14
to 15, 30-16 to 17
Prestress system, 12-12 to 13, 12-16
Prevalence, surveillance, 23-4 to 5
Prolonged loading, 13-15 to 17
Psoas complex, 12-3
Psychological approaches and
factors, 10-15, 34-14
Psychophysical approaches, 7-1 to
2, 33-5
Psychophysical basis, musculoskeletal
disorders
approach analysis, 19-23 to 24
basics, 19-1 to 3, 19-24
force limits, 19-21 to 22
frequency limits, 19-21 to 22
manual material handling, 19-3
to 5, 19-19 to 21
task design, 19-19 to 21
tool design, 19-23
upper extremity tasks, 19-21
to 23
weight limits, 19-3 to 5, 19-19
workplace design, 19-19 to
21, 19-23
Psychosocial factors, 10-15, 15-4,
20-5 to 6, see also

Biomechanical and
low back injuries
Pulling, 10-13 to 14
Pushing, 10-13 to 14
Putz-Anderson, Waters and,
studies, 16-1 to 25
Putz-Anderson and Grant studies,
23-1 to 14
Q
Quasidynamic models, 13-8 to 15
R
Radial nerve (nerve of stability), 3-8
Radwin studies, 5-1 to 12
Rates, 1-1 to 2, 23-4
Reasonable accommodation, ADA,
28-17
Recommended weight limit, 16-2
to 3, 17-2
Recordable injury or illness, 25-5,
25-12
Recordkeeping, see OSHA
recordkeeping
Recurring injury, 20-4 to 7
Rehabilitation, 34-17,
see also Ergonomics
and rehabilitation
Reimbursement, 28-18
Rempel, Evanoff and, studies, 1-1 to 8
Repetitive work
back pain, 10-14
hand/wrist pain and disorders,
1-4, 1-7
lower extremity disorders, 8-1
to 3
occupational risk factors,
shoulders, 4-14
studies, 1-6
time or frequency characteristics,
2-2 to 4
Reporting
systems, 24-18
medical management, 27-4
disorders, 23-3
Restricted work or motion, 25-7,
25-12
Rest schedule
gaps analysis, 2-9
low back, 12-16
medical management, 27-6,
27-10
shoulders, 4-14 to 15, 12-16
Returning to work
low back pain, 20-6 to 7
medical management,
27-11 to 12
post injury analysis, 15-8
Rice studies, 30-1 to 17
Ried, Marras, Allread and, studies,
18-1 to 22
Risk factors
combination, 2-16
force, 2-5
individual, 1-3 to 4
posture, 2-4 to 5
shoulder disorders, 4-1 to 16
surveys, surveillance, 23-9 to 10
time, 2-2 to 4
upper extremities, 1-3 to 7, 2-2
to 5
work-related, 1-4 to 7
Risk factors reduction guidelines,
12-15 to 16
Robinovitch studies, 21-1 to 10
Rosomoff, Khalil, Abdel-Moty,
Steele-Rosomoff and,
studies, 28-1 to 19
Rotator cuff syndrome, 3-20, 4-3
to 4, 14-4
Running, 8-5, 9-5
S
Sagittal flexion, maximum, 18-17,
18-21
Screening, see also Physical ability
testing; Preplacement
strength screening; Test
battery design
evaluation systems, 15-7
medical, 24-14, 27-12
post injury analysis, 15-8
Sedentary-seated work, 12-15, 12-16
Severity analysis, low back pain, 15-9
Severity index, 23-4 to 5
Shirazi-Adl, Parnianpour and,
studies, 14-1 to 19
Shoes, 8-4 to 5, 9-10, see also Foot;
Foot wear
Shoulder harness, lumbar motion
monitor, 18-13 to 14
Shoulders, 2-9, 4-2 to 4, see also
Occupational risk
factors, shoulders
Sickness absence, psychosocial
factors, see also Illness
accidents and reinjury, 34-2 to 3
basics, 34-1 to 2
context-sensitive interventions,
34-17
coping strategies, 34-8
determinants of chronicity, 34-9
disability cost and effects, 34-3
education, 34-13 to 14
implications, 34-15 to 17
Index
incapacity, 34-3 to 4, 34-9 to
10, 34-12 to 13, 34-13
to 14, 34-15
medicolegal dimensions, 34-13
models, 34-3 to 4
pain, 34-4 to 10
physical therapy, 34-14
psychological approaches, 34-14
rehabilitation policy, 34-17
socioeconomic dimensions,
34-13
sports medicine approach, 34-14
stress, 34-10 to 12, 34-16 to 17
suboptimal work functioning,
34-2 to 3
workloss, 34-2 to 3
Sick workplace, 34-16 to 17
Sitting
fatigue and comfort, 9-11
sedentary-seated work, 12-15,
12-16
time limit, 12-15
Skeletal system anatomy, 3-1 to 2
Slipping
foot activity, 9-6 to 7
foot-floor interface, 8-5 to 7
perspective, 15-4
Snook and Ciriellos database, 19-3
to 5, 19-6
Sociocultural influences, 35-7
Socioeconomic dimensions, 34-13
Socks, see Foot wear
Soft tissue loads
CTDs, 3-1
posture, 2-4 to 5
repetitiveness, 14-8
splints and braces, 36-3
Sommerich studies, 36-1 to 10
Spine
damage, low back injuries,
20-3 to 4
disc herniations, 20-3
diurnal variation, 12-10
end range of motion, 12-8 to
10
physical stress benefit, 20-6
trunk musculature, 12-12
Spine models
anatomical detail, 13-6 to 7
basics, 13-1 to 2
biomechanical approach, 13-2
to 3
2D compared to 3D analyses,
13-8
2DWATBAK, 13-8 to 10
dynamic compared to static
analyses, 13-7 to 8
model differences, 13-5
model outputs relationship,
I-9
13-3 to 5
prolonged loading, 13-15 to 17
validation, 13-5 to 6
Splints
during sleep, 27-10
wrists, 36-1 to 2, 36-4 to 7,
36-9 to 10
Sports medicine, 8-1, 34-14
Stability nerve (radial nerve), 3-8
Stairs, 8-7 to 8, 9-5 to 6, 9-8 to 9
Standing, 7-1, 9-5, 9-11 to 12
Static positions, see also Posture
back pain, 10-13
hand force, 5-5 to 8
manual lifting, modeling, 10-13
strength measurements, 14-12
Static spine models, 13-7 to 8
Steele-Rosomoff, and Rosomoff,
Khalil, Abdel-Moty,
studies, 28-1 to 19
Stenosing tenosynovitis, 3-20 to 24
Stepping, 9-5 to 6
Stepping-on-air, 9-8
Steroid injections, 27-11
Straker studies, 26-1 to 12
Strength
gloves, 6-3 to 4
prediction modeling programs,
11-2 to 7
trunk performance, 14-5 to 7
Stress
coping strategies, 34-10 to 12,
34-16 to 17
on spine, 20-6
Stress fractures, 8-3
Stretching, 2-16, 27-10
Stuart-Buttle studies, 24-1 to 19
Submaximal protocols, 14-5
Suboptimal work functioning, 34-2
to 3
Supraspinatus ligament, 12-3
Supraspinatus tendinitis, 3-20, 4-3
to 4
Surgery, 27-11
Surveillance, see Ergonomics
surveillance
Surveys, 23-2, 23-7 to 10
Sweden, 10-2 to 3
Switches, 9-12
T
Tactility, 6-5 to 7
Tasks, see also Workplace
analysis, 15-9
demands, 14-16 to 17
design, 19-19 to 21
Temporal pattern, 26-7, 26-9 to 12
Tendinitis
cumulative trauma disorder,

3-12, 3-17 to 19, 14-4
forearm muscle pain, 2-9
injury mechanism, 4-3
investigative approaches, 2-7 to 8
repetitive use, 1-7
wrists, 1-6
Tendons
biomechanical aspects, 3-11 to 17
disorders, investigative
approaches, 2-7 to 8
shoulder structure, 4-2 to 3
Tennis elbow, see Elbows; Lateral
epicondylitis
Tenosynovitis, 2-7 to 8, 3-12, 3-20
Tension neck syndrome, 14-4
Test battery design, 29-3 to 4, see
also Physical ability
testing; Screening
Thermal therapy, 27-10
Thoracic outlet syndrome, 3-31, 14-4
3D Static Strength Prediction
Program, 11-8
Threshold limits, manual lifting
basics, 17-1 to 2
factors and multipliers, 17-3
to 5
Time or frequency factors, 2-2 to 4
Tools, 19-23, see also Assessment
tools; Hand tools
Torque, 5-8 to 11, 6-3 to 4
Treatment goals, 28-9 to 10
Triaxial dynomometers, 14-6
Trigger finger, 3-23 to 24, 14-4
Tripping, 9-7, 15-4
Trunk
hidden load, 2-4
kinematic information, 18-15
muscle modeling, 12-3
nonneutral posture, 4-13
spine stabilization, 12-12
weakness, 14-5 to 6
Trunk performance, assessment
basics, 14-1 to 2, 14-18 to 19
clinical applications, 14-17 to 18
disability, 14-2 to 3
endurance, 14-7 to 11
handicap, 14-2 to 3
impairment, 14-2 to 3
inverse and direct dynamics,
14-13 to 16
lifting strength, 14-12 to 13
low back pain, 14-4 to 17
maximal and submaximal
I-10
protocols, 14-5
muscle action, 14-3 to 4
performance capacity, 14-16 to 17
strength measurements, 14-5 to 7
task demands, 14-16 to 17
Twisting
back pain, 10-13
lifting simultaneously, 12-13
to 14, 12-16
lumbar motion monitor, 18
17, 18-20
2D Static Strength Prediction
Program, 11-8
Type A behavior, 34-12
U
Ulnar nerve (nerve of power), 3-8
United States, 10-2, 10-3 to 4, 29-1
to 2
Upper extremities
anatomy, 3-1 to 9
fall, protective response, 21-7
tasks, musculoskeletal
disorders, 19-21 to 23
Upper extremities, epidemiology
basics, 1-1, 1-7 to 8
costs, 1-1 to 2
factors, 1-3 to 7
frequency, 1-1 to 2
individual factors, 1-3 to 4
rates, 1-1 to 2
work-related factors, 1-4 to 7
Upper extremities, integrated
analysis
basics, 2-1 to 2, 2-18
sites, 2-2
types, 2-2
workplace assessment tools,
2-9, 2-16 to 18
disorders, 2-2 to 5
Upper extremities, support
adverse results, 36-7, 36-9
arm supports, 36-2 to 4, 36-7
to 9, 36-9 to 10
basics, 36-1, 36-9 to 10
splinting and bracing, 36-1 to
2, 36-4 to 7, 36-9 to 10
Upper limb muscle disorders, 2-8 to 9
V
Validation
body discomfort assessment,
26-13
manual lifting, modeling, 11-10
participation determinants,
31-3 to 5
physical ability testing, 29-4 to 5
Verbal rating scales, 26-4 to 5
Vertebrae, 20-4, see also Spine
Vertical factor, 16-7 to 8, 17-3
Vessels, 4-3
Vibration
hand tools, 1-7, 5-11 to 12
Vibration White Finger
disease, 1-3
whole body, 15-3
Viikari-Juntura studies, 4-1 to 16
Visual analog scales, 26-5 to 6
W
Waist harness, 18-13 to 14
Walking, 9-5, 9-10, 9-11
Wallerian degeneration, 3-26 to 27
Warehouse order filling (example),
16-22 to 25
Waters and Putz-Anderson studies,
16-1 to 25
Weight
limits, 19-3 to 5, 19-19
to 3
Wells studies, 2-1 to 18
Wheelchairs, workspace design, 32-3
to 7
Whole-body scales, 26-8 to 9
Work conditioning, 28-12 to 13,
see also Job analysis
Work duration factor, 17-4
Worker functional capacities
assessment, 31-1 to 7
basics, 31-1, 31-11
diversification options, 31-9
to 11
endurance, 31-3
job placement, 31-2 to 3
mobile assessments, 31-9 to 10
mobile occupational health
clinic, 31-10
onsite services, 31-10 to 11
outcomes, 31-7 to 9
provider of assessments, 31-7
reports, 31-6 to 7
representation validity, 31-3
to 5
standardization, 31-5 to 6
tolerances, 31-3
weighted capacities, 31-3
Workers Compensation system
data source, 23-6 to 7, 24-4
financial costs, 31-11
Worker surveys, 23-2, 23-7 to 9
Worker tracking, 24-5 to 6
Work factors, see specific factor
Work loss, 20-4 to 7, 34-2 to 3
Work organizational factors, 1-7,
4-15
Workplace, see also Tasks
assessment tools, 2-9, 2-16 to 18
back pain, 10-1 to 15, 35-1 to 11
design, 11-11, 19-19 to 21,
19-23, 28-13 to 14
sick, 34-16 to 17
Work-related disorders, 2-2 to 5,
3-9 to 11, see also Job
analysis
Work-related risk factors, 1-4 to 7,
12-15, 12-16,
see also Occupational
risk factors
Work-rest schedule
alteration, 19-21
low back, 12-16
shoulders, 4-14 to 15, 12-16
World Health Organization, 14-1
Wrists, see also Carpal tunnel
syndrome
falls, 21-7
intracarpal pressure, 2-5
median nerve, 28-3
nonneutral position, 3-29
peak angular acceleration, 3
14 to 17
splints and braces, 27-10, 36
1 to 2, 36-4 to 5, 36-9
to 10
symptom frequency, 1-1, 1-2
tendinitis, 1-6

Ergonomics Engineering and Administrative Controls

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What are some of the assessment methods mentioned for evaluating worker performance and capacities?

What are some of the assessment methods mentioned for evaluating worker performance and capacities?

PRINCIPLES AND APPLICATIONS

PRINCIPLES AND APPLICATIONS

This edition published in the Taylor & Francis e-Library, 2005.

Library of Congress Cataloging-in-Publication Data

Visit the CRC Press Web site at www.crcpress.com

ISBN 0-203-58848-7 (Adobe eReader Format)

Waldemar Karwowski, Ph.D., P.E., C.P.E., is Professor of

PART I MUSCULOSKELETAL DISORDERS

SECTION I Disorders of the Extremities

Epidemiology of Upper Extremity Disorders Bradley Evanoff and David Rempel

Integrated Analysis of Upper Extremity Disorders

Biomechanical Aspects of CTDs Richard W.Marklin

Occupational Risk Factors for Shoulder Disorders Eira Viikari-Juntura

Hand Tools: Design and Evaluation Robert G.Radwin

Gloves Ram Bishu and A.Muralidhar

Industrial Mats Jung-Yong Kim

Ergonomic Principles Applied to the Prevention of Injuries to the

Ergonomics of the Foot

SECTION II Low Back Disorders

Epidemiology of Back Pain in Industry Gunnar B.J.Andersson

Static Biomechanical Modeling in Manual Lifting Don B.Chaffin

Dynamic Low Back Models: Theory and Relevance in Assisting the

Selection of 2-D and 3-D Biomechanical Spine Models: Issues for

Quantitative Assessment of Trunk Performance Mohamad Parnianpour and

Revised NIOSH Lifting Equation

A Population-Based Load Threshold Limit (LTL) for Manual Lifting Tasks

Prevention of Musculoskeletal Disorders: Psychophysical Basis

The Relative Importance of Biomechanical and Psychosocial Factors

Fall-Related Occupational Injuries Stephen N.Robinovitch

Thomas R.Waters and Vern Putz-Anderson

PART II ADMINISTRATIVE CONTROLS

Fundamentals of Surveillance for Work-Related Musculoskeletal Disorders

Injury Surveillance Database Systems Carol Stuart-Buttle

Body Discomfort Assessment Tools

SECTION II Medical Management Prevention

Medical Management of Work-Related Musculoskeletal Disorders

Ergonomic Programs in Post-Injury Management Tarek M.Khalil,

Physical Ability Testing for Employment Decision Purposes Charles K.Anderson

Preplacement Strength Screening Valerie J.Rice

Assessment of Worker Functional Capacities

Ergonomics and Rehabilitation Ewa Nowak

Update on the Use of Back Belts in Industry: More DataSame Conclusion

The Influence of Psychosocial Factors on Sickness Absence Chris J.Main,

Back Pain in the Workplace: Implications of Injury and Biopsychosocial

Upper Extremity Support Carolyn M.Sommerich

Ergonomics (or human factors) is defined by the International Ergonomics Association

Frequency, Rates, and Costs

1.1 Frequency, Rates, and Costs

Occupational Ergonomics: Engineering and Administrative Controls

1.2 Disorder Types and their Natural History

Epidemiology of Upper Extremity Disorders

1.3 Individual Factors

Occupational Ergonomics: Engineering and Administrative Controls

* Case criteria are based on history and physical examination.

et al., 1985), and general de-conditioning (Nathan et al., 1988, 1992).

1.4 Work-Related Factors