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Musculoskeletal Disorders at work: Using evidence to guide practice

Article · October 2013

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Wendy Macdonald Jodi Oakman

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Musculoskeletal Disorders at work: over 40 percent of all compensation
claims for serious work-related injuries or
Using evidence to guide practice diseases (Safe Work Australia, 2012), and
a similar situation prevails in Europe (Eu-
Wendy Macdonald1 and Jodi Oakman1 ropean Agency for Safety and Health at
Work, 2010). Clearly, work-related MSDs
Abstract present a major challenge to occupational
Work-related musculoskeletal injuries and disorders (MSDs) present a major problem health and safety (OHS) professionals
throughout the world. Strategies to control this risk typically focus on re-design throughout the world – particularly to
of tasks, workstations or equipment to reduce the biomechanical loads that people occupational ergonomists who are seen as
experience during work performance. Training workers in “safe” manual handling specialists in this field.
techniques is another popular strategy, despite strong evidence that it is ineffective.
In fact, it is now evident that to focus workplace risk management strategies only on Current risk management
workstation design and people’s physical actions during task performance is not the practices
optimal way to reduce MSD risk. This articles outlines research evidence identifying Little published information is available
key work-related causes of MSDs and requirements for effective interventions. concerning ‘real world’ MSD risk
Examples of current approaches to MSD risk management are described, including management practices. Research in the
progress on two projects currently being conducted under the auspices of the workplaces of four large Melbourne
International Ergonomics Association (IEA). companies found a strong focus on
controlling risk from hazards associated
with ‘manual handling’ (Macdonald et al.,
2007). In two of these four workplaces
Nature and extent of the there was particular emphasis on training
problem workers in ‘safe’ movement techniques
Musculoskeletal disorders (MSDs) are despite strong research evidence that this
a diverse group of injuries and disorders typically does not reduce WMSD risk
which in a workplace context are (Hignett, 2003). Similar findings have
sometimes referred to as repetitive strain been reported from the UK (Whysall,
injuries, cumulative trauma disorders, 2004), where consultant ergonomists
or occupational overuse syndrome were found to focus on assessing and
(Australian Safety and Compensation controlling risk from manual handling
Council, 2006). According to the World hazards. This situation is not surprising
Health Organisation (2003): in light of the strong orientation of
Standards, Codes of Practice and
Musculoskeletal disorders are the Associated Guidance Materials in a wide
most frequent causes of physi- range of countries towards identifying,
CITE THIS ARTICLE AS: cal disability, at least in developed assessing and controlling risk from this
Macdonald, W. & Oakman, J. (2013), countries. As mortality from infec- type of hazard (Macdonald et al., 2003).
Musculoskeletal Disorders at work: tious diseases reduces worldwide, In light of this situation it is not surprising
Using evidence to guide practice, J Health the global population is ageing and that workplace risk management strategies
& Safety Research & Practice, 5(2), 7-12 the numbers of people in the old- typically focus on designing work tasks,
est age groups are increasing. As the workstations and associated equipment to
KEY WORDS: prevalence of many musculoskele- reduce the biomechanical loads that people
work-related; musculoskeletal; risk tal disorders increases with age, the experience during work performance.
management; toolkit; physical; likely result is that there will be a However, there is now strong evidence
psychosocial growth in the number of people with that to focus workplace risk management
chronic disabling disorders. strategies only on workstation design
CORRESPONDENCE: and people’s physical actions during task
Centre for Ergonomics & Human Factors It has been estimated that “37 percent performance is not the optimal way to
School of Public Health & Human of all back pain worldwide is attributable reduce MSD risk, as described below.
Biosciences, La Trobe University to work, resulting in an estimated
Melbourne, Australia 800,000 DALYs lost, a significant loss Work-related factors influencing
Email: [email protected] of time from work, at a high economic MSD risk
cost”(Nelson et al., 2005). In Australia, One of the most extensive reviews of re-
1 La Trobe University work-related MSDs are responsible for search evidence on this topic was by an

Volume 5 Issue 2 • September 2013  JOURNAL OF HEALTH AND SAFETY, RESEARCH AND PRACTICE 7
expert committee of the USA National general characteristics of the task itself
Research Council and Institute of Med- (e.g. requirement for percussive force or Social context: psychosocial hazards
icine (NRC) (2001). The committee static posture). Other physical hazards The term ‘psychosocial hazard’ is often
grouped work-related hazards for MSDs influencing MSD risk include vibration used to include the organisational factors
into three categories as described below, (e.g. from a hand tool affecting just the described in section B above, particular-
and depicted in the conceptual model de- hand and arm, or a vehicle causing whole- ly in relation to risk of psychological in-
veloped by that committee, shown in Fig. body vibration) and environmental factors juries and mental disorders. However,
1. The model shows that hazards within such as low temperatures. for MSD risk management it is useful to
all three categories interact with each distinguish effects of work organization
other, and affect both processes internal Organisational factors: hazards arising and job design factors from effects of
to the individual (internal biomechanical from work organization and job design work’s social context, including the at-
loading, physiological responses) and MSD risk is influenced by how work is titudes and behaviours of managers, su-
personal outcomes (discomfort, pain, organised and how tasks are combined pervisors and co-workers. Psychosocial
impairment, disability). to create whole jobs. Hazards of this type hazards are categorized in different ways
include highly repetitive movements, high based on different theoretical frameworks.
External or physical loads experienced workload, high work rates, inadequate According to the European Framework for
during task performance personal control or autonomy, role Psychosocial Risk Management (Leka &
The physical demands of task performance conflicts, lack of variety, social isolation, Cox, 2008), these include factors related
are usually the most obvious work-related inadequate rest breaks, excessively to: Job content, Workload and workpace,
cause of MSDs. Hazards of this type are long working hours, night shifts, and so Work schedule, Control, Organisation-
task-specific, stemming from the postures on. Many of these factors can increase al culture and function, Interpersonal re-
adopted and forces exerted during task exposures to external loads and related lationships at work, Role in organisation,
performance, which in turn are influenced physical hazards (section A above), Career development, and Home-work
by the design of workstations and tools, as well as increasing the likelihood of interface.
characteristics of objects handled such workers experiencing chronic fatigue and/
as their weight, size and shape, and more or prolonged stress. Role of work-related psychological
stress in MSD causation
FIGURE 1. In the report outlined above (Nation-
Conceptual model of factors influencing MSD risk [10, p.353] al Research Council, 2001) the impor-
tance of psychological stress and its
The Workplace The Person physiological and behavioural correlates
in MSD aetiology was clearly acknowl-
Biomechanical Loading edged. Although stress is not mentioned
Internal in Fig. 1, it is implicit there within
Loads ‘physiological responses’. As described
External Loads by Cox (1978), the individual’s ‘stress
response’ is multidimensional, including
Physiological a complex physiological dimension along
Responses
with behavioural, cognitive and affective
dimensions. Consistent with this, a 1995
Internal Tolerances model of work-related determinants of
MSD risk included a ‘patho-physiology’
Mechanical
component within which was “Distress
Individual Factors

Organisational Strain
Factors with hormonal, endocrine and immune sys-
tem response” (Kuorinka & Forcier, 1995),
Fatigue and more recent research has confirmed the
important role of stress in MSD aetiology
(Marras, 2008; Marras et al., 2009).
Stress is sometimes presented as a
Pain psychosocial hazard affecting the risk
Social Discomfort of various occupational health problems
Context including MSDs. However, at workplace
Impairment level where a key goal is to identify
Disability and control risk from work-related
hazards, it is arguably more useful to

8 JOURNAL OF HEALTH AND SAFETY, RESEARCH AND PRACTICE Volume 5 Issue 2 • September 2013

view stress as a product of such hazards Some of this variability is undoubtedly This work has recently been extended to
which, in combination with individual due to differences between studies in three organizations within the healthcare
factors, partially mediates the effects of the particular hazards assessed and the sector, and results to date are similar to
workplace hazards on MSD risk (Eatough measures used to quantify them. those found previously. Employees from
et al., 2012). Job satisfaction, which has Furthermore, considering the huge two hospital networks and from a large
also been shown to influence MSD risk variety of work undertaken and the organisation of paramedics were surveyed
(Schoenfisch & Lipscomb, 2009), can associated hazards and risks it is reasonable and results from each organization were
be seen to play a similar role – although to expect that variations will be large. analysed using hierarchical logistic
reducing rather than increasing risk. A current Australian research program is regressions with age and gender entered
comparing the influence on MSD risk of a first, followed by scores on the physical
Relative importance of different wide range of physical and organisational/ hazards and organisational/psychosocial
types of hazards psychosocial hazards in workplaces across hazards scales used previously. Beta values
There is wide variability in the relative several industry sectors. for these two scales are shown in Table 1;
influence of the above factors on MSD The first phase involved four workplaces it can be seen that in all three organizations
risk, but the evidence is clear that – two in the manufacturing sector and two the physical hazards score accounted for
organisational and psychosocial hazards in warehousing – were assessed using a more variance than the organisational/
can have a large impact on risk that is of- common set of survey items to quantify all psychosocial hazards score, with the
ten of comparable magnitude with that of types of hazard. MSD risk was quantified difference between the two being much
physical hazards (Macdonald & Evans, using a Discomfort/Pain score derived greater for hospital network B. The reason
2006). Following an extensive review of from the rating scales shown in Fig. 2; total for this hospital network being different
epidemiological studies by Marras et al. score (out of 60) was the sum of scores out from the other two organizations may
(2009), they reported: of 12 for each of five body regions (each lie in the different occupations included
such score was the product of discomfort/ within the samples: the network B sample
between 11% and 80% of low-back pain frequency rating on a scale from zero had a smaller proportion of professionally
injuries and 11–95% of extremi- to 4 and severity rating on a scale from 1 qualified staff than the other two. Clearly
ty injuries, are attributable to work- to 3). Results from hierarchical multiple there is a need for further investigation of
place physical factors, whereas, be- regression analyses to identify the main occupational differences in the relative
tween 14% and 63% of injuries to predictors of MSD risk demonstrated influence of physical versus organisational/
the low back and between 28% and that the contributions of physical and psychosocial hazards. Nevertheless, in all
84% of injuries of the upper extrem- organisational/psychosocial hazard scores seven of the workplaces investigated to date,
ity are attributable to psychosocial were of similar magnitude to each other, the organisational/psychosocial hazards
factors ... (p.16) and that this held true separately for each score accounted for a very substantial
workplace (Macdonald, et al., 2007). proportion of variance in MSD risk.
FIGURE 2.
Rating scales used to create a Discomfort/Pain score out of 60 (from [6])

How Often For each body area where there’s been some
discomfort or pain (i.e. marked as 1 or higher)
Never Occasionally Sometimes Often Almost always circle a number below to show HOW BAD
Neck, Shoulders Neck, Shoulders Mild 1
0 1 2 3 4 Moderate 2
Severe discomfort 3
Hands, Fingers Hands, Fingers Mild 1
0 1 2 3 4 Moderate 2
Severe discomfort 3
Arms Arms Mild 1
Moderate 2
0 1 2 3 4
Severe discomfort 3
Middle to lower Middle to lower Mild 1
Back Back
Moderate 2
0 1 2 3 4
Severe discomfort 3

Hips, Hips,
Bottom, Mild 1
0 1 2 3 4 Bottom,
Legs, Legs, Moderate 2
Feet Feet Severe discomfort 3

Volume 5 Issue 2 • September 2013  JOURNAL OF HEALTH AND SAFETY, RESEARCH AND PRACTICE 9
TABLE 1. hazard management – identifying hazards, Benefits of a participative approach in
Relative contribution of physical assessing risk from each identified hazard, MSD risk management have also been
versus organisational/psychosocial and taking any necessary steps to control demonstrated in a systematic review
hazards to MSD risk in three different risk from each hazard separately. This evaluating ‘participative ergonomics’
organisations, as indicated by Beta approach is appropriate for hazard-specific approaches (Cole et al., 2005).
values from hierarchical multiple diseases and disorders such as noise- Participative ergonomics has been defined
regression analyses. induced hearing loss, or mesothelioma due (Wilson & Haines, 1997) as
to asbestos exposure. However, a more
β value: β value:
Physical Organisation- holistic approach is required to achieve The involvement of people in plan-
Organisation
Hazards al/Psychosocial effective control of diseases and disorders ning and controlling a significant
Score Hazards Score
for which risk is determined by multiple, amount of their own work activities,
Hospital network
A (n = 252)
.30 .26 diverse hazards – as is the case for MSDs. with sufficient knowledge and pow-
Hospital network For example, a particular posture might be er to influence both processes and
.42 .19
B (n = 160) rated as low risk if considered alone, but outcomes in order to achieve desir-
Paramedic service the risk could be higher for workers who able goals.
.34 .26
(n = 957)
are chronically fatigued or stressed due
to long working hours, tight production Its practical manifestation can vary
Importance of interactions schedules with few rest breaks, and considerably (Haines et al., 2002), but
between hazards supervisors perceived as unsupportive. most workplace interventions entail the
For occupational health outcomes arising In other words, risk management must be formation of a project team which includes
primarily from just one type of hazard, based on assessment of risk from the com- representatives of all key stakeholders.
risk can be estimated in terms of the bined effects of the hazards identified as Clearly, some such process is likely
severity of the hazard and the extent of most relevant in the particular situation, to be necessary in order to customise
exposure to it. For example, risk from taking account of the hazards’ additive interventions to local needs ... bearing in
hazardous chemicals is generally a direct and possibly interacting effects. minds that ‘local needs’ include those of
function of the extent of exposure to the For the above reasons, a key the workers themselves.
particular chemical. In contrast, MSD risk requirement for effective MSD risk
is influenced by a large and diverse range management is a multidisciplinary, ho- Development of a Toolkit to
of hazards as described above. Further, it listic approach that assesses and controls support MSD Risk Management
has been shown that interactions between risk from the particular combination of A review by Macdonald & Evans (2006) of
a number of hazards and related factors workplace causal factors found to be rele- the methods available for assessing MSD
can substantially affect MSD risk (Ber- vant in a given situation. In addition to its risk concluded that none of the existing
nard, 1997; Marras, 2008; National Re- basis in research evidence of the causes of tools provided comprehensive coverage
search Council, 2001) Consequently, work-related MSDs, this requirement was of all the main MSD hazards. The toolkit
the extent of exposure to a particular also identified by the European Agency project described below should help to
hazard, if considered independently of for Safety and Health at Work (European address this problem.
other exposures, is not necessarily a good Agency for Safety & Health at Work, The International Ergonomics
indicator of overall MSD risk. 2008) in a review of research evidence Association (IEA) is a member of the World
Importantly, this means that MSD risk concerning the effectiveness of workplace Health Organisation (WHO) network of
cannot be adequately assessed simply interventions to reduce MSD risk. Their Collaborating Centres in Occupational
by assessing the severity of each hazard report stated that: Health, and as part of its contribution to this
in isolation from the other hazards network it is currently supporting a project
present – which further implies that … interventions that are based on sin- to formulate, implement and evaluate a
the output of many existing methods gle measures are unlikely to prevent toolkit to support more effective MSD risk
for assessing risk related to adverse MSDs, but … a combination of sev- management. At a meeting during the 2009
postures or biomechanical load should be eral kinds of interventions (multidis- IEA Congress in Beijing it was agreed
understood as an indication of the severity ciplinary approach) is needed, includ- that prescriptive guidance focusing on
or ‘riskiness’ of the particular hazard, ing organisational, technical and per- risks from single hazards, out of context,
rather than as an indicator of overall sonal/individual measures. It is not is inappropriate, and that the WHO con-
MSD risk. known how such measures should be cept of such a toolkit was applicable here.
combined for optimal results. (p.34) That is, it should be practicable and user-
Requirements for effective MSD friendly advice for non-experts to apply in
risk management The report concluded that strategies ordinary workplaces, without expert assis-
The conventional approach to OHS needed to be tailored and participative in tance; required training or guidance mate-
risk management has been to focus on their approach to maximise effectiveness. rials should be included within the toolkit.

10 JOURNAL OF HEALTH AND SAFETY, RESEARCH AND PRACTICE Volume 5 Issue 2 • September 2013

It should explain basic MSD risk manage- tools (e.g. OCRA Checklist, RULA, etc) evaluate the success of interventions
ment requirements and the general pro- should be included via links to web- and identify potential barriers to
cesses to be followed, based on a specified based resources, or when necessary in an implementation of controls.
conceptual model grounded in current re- appendix.
search evidence. Such an approach – focusing on Acknowledgements
Among the most important intended users principles and general processes rather Support for the Australian research
of such a toolkit are people in emerging than on details regarding specific tools or program outlined in Section IV has been
economies and developing nations, and interventions – is particularly important in provided by SafeWork Australia and in
those in small and medium enterprises. the case of MSD risk management, given part by funding of a Development Grant
The toolkit should assist such users to the need to consider a very wide range from WorkSafe Victoria and the Transport
work through the full risk management of potential hazards for each of which Accident Commission (TAC), through the
cycle within their own workplace, as the potential means of reducing risk are Institute for Safety, Compensation and
shown in Fig. 3. It can be seen there that likely to depend on the specific workplace Recovery Research (ISCRR).
worker involvement is central to the risk context.
management process – consistent with a For example, a current IEA References
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