INTRODUCTION TO

WORK-RELATED
MUSCULOSKELETAL
DISORDERS

DR. MIRTA WIDIA

 Learning Outcome
At the end of this topic, student should be able to:
▪ Define WRMSDs

▪ Explain in brief the risk factors of WRMSDs

▪ List the examples of WRMSDs

▪ Discuss the basics idea to manage the risk factors of

WRMSDs
MW
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Topic Outline
1. Introduction to WRMSDs

2. The causes of WRMSDs

3. Types of WRMSDs

4. The management of WRMSDs

MW
 Introduction to WRMSDs
• Work-related musculoskeletal disorders (WRMSDs)

• Interest to ergonomists
o Potential to cause musculoskeletal pain

o Cause injury

o Exacerbate (make worse) pain from existing MSDs

• Much evidence for the work relatedness of WRMSDs

comes from epidemiological studies

MW
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Work Related Musculoskeletal

Disorders (WRMSDs)
❑ Musculoskeletal disorders can affect muscles, joints and
tendons in all parts of the body.

❑ Most WRMSDs develop over time.

❑ They can be episodic or chronic in duration and can also

result from injury sustained in a work related accident

MW
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Work Related
Musculoskeletal Disorders
(WRMSDs)
2015
2014 (1123)
2013 (675)
2012 (517)
2011 (449)
2009
(268)
2006 (161)
(15)

Reported Cases to SOCSO MALAYSIA

(Year (case) )
MW
The Causes of WRMSDs

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Ergonomics at Workplace

Nawi et al (2016)

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Conceptual framework for WRMSDs Development

Oakman , MacDonald ad Wells (2014) MW

Armstrong et al. (1993) conceptual model for neck and upper limb musculoskeletal
disorders.

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Hagberg et al. (1995) generic model of WRMSDs prevention.

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Sauter and Swanson (1996) ecological model of WRMSDs for VDT work

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Feuerstein (1996) work style model of WRMSDs

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Carayon et al. (1999) model of job stress.

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Kumar (2001) multi-
variate interaction
theory of
musculoskeletal
injury precipitation.

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National Research Council/Institute of Medicine (2001) model WRMSDs
causation.

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Physical loads
• The physical demands of task performance are usually the
most obvious work-related cause of WRMSDs.
o Postures adopted (static and dynamic)

o Forces exerted during task performance, which in turn are

influenced by the design of workstations and tools,
characteristics of objects handled, such as their weight, size and
shape, and more general characteristics of the task itself.

MW
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Organisational factors
❑ Work is organised and how tasks are combined to create whole jobs.

❑ Work organisational hazards may include high workload, high work rates,

inadequate personal control or autonomy, role conflicts, lack of variety,

social isolation, inadequate rest breaks, excessively long working hours,

night shifts, and so on.

❑ Many of these factors can increase exposures to external loads and related

physical hazards as well as increasing the likelihood of workers experiencing

chronic fatigue and/or prolonged stress.

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Psychosocial Contexts
Factors related to job content, workload and
workplace, work schedule, control, organisational
culture and function, interpersonal relationships at
work, role in the organisation, career development
Type of WRMSDs
 Upper Body Injuries
 Most common hand-tool related injury = catastrophic, where the tool
suddenly strikes user

 Prevention: training in safe tool handling techniques

 Second = sprains (joint injury where fibers of supporting ligament

ruptured) or strains (over exercise or overexertion of muscle) resulting
from handling tool over long period of time

 Prevention = tool redesign, worker training in posture

 Third = injury to skin, blisters or “hot spots”, due to poor handle design

 Prevention: handle redesign

 Tissue Pathomechanics & WRMSDs
• Mechanism of WRMSDs thought to be repeated
microtrauma at cellular level where repair capacity
is exceeded due to lack of rest during day and
repeated daily exposure
• For loads <15% of muscle’s max voluntary
contraction humans have excellent endurance
• For loads >15% of this, rest periods needed to avoid
acute and chronic problems
 Tissue Pathomechanics & WRMSDs
• Cramp = pain due to accumulation of waste
products in muscle accompanied by muscle
weakness or spasm
• Common in jobs involving writing or typing,
especially where extreme postures held which
weaken muscle and joint systems
• Yeah Fountain Pens!!! They require less force during
handwriting than ballpoint pens.
 Tendon Pain
 Tendons connect bone to muscle. In fact, the tendon is just a
slow extension of muscle fibers that flow into the periosteum,
which is the external surface of bone. Do not think of these as
separate pieces. Muscle flow s to tendon, which flow to bone.
 Tendons are made of bundles of crosslinked collagen microfibrils
 Tendinitis = inflammation of the tendons and is caused by force,
posture, and or repetition
 Tendon Pain
 During repetition, the demanded increased blood supply to the
muscles “steals” blood from the nearby tendons
 Pain due to this known as “insertion syndromes”
 Impaired blood supply increases cell death rate
 Thought to provide site where calcium carbonate (chalk) is
deposited
 Static work positions also cause reduced blood supply to tendon
 Theory that an accumulation of dead blood cells in the tendons
can cause an inflammatory response in the tendon by the
immune system
 Tendon Pain
 Frequent mechanical loading can cause tendonitis or
inflammation of the cartilage surrounding a joint
 Extreme wrist positions can press flexor tendons of fingers against
bones in wrist, increasing friction in tendons
 Tenosynovitis = rapid, repetitive movements can cause sheaths
surrounding tendons to produce excess synovial (joint) fluid and
cause swelling, which impedes movement
 Repeated exposure can leave scar tissue, impeding movement,
and joint may be degraded bc of bony spurs formed around
damaged areas
 Trigger Finger
➢ Stiffness and “snapping” of fingers due to volitional flexion

➢ Cause thought to be thickening of fibro-osseous canal through

which the finger flexors pass

➢ High prevalence in certain meatpacking jobs that require static

grasping of powered knives w/ triggers

➢ Nonoccupational factors such as thyroid disease, diabetes, and

arthritis are usually the cause

➢ As well as gymnastics!!!
Trigger Finger

Trigger finger is a common problem that causes

pain and snapping of the tendons in the fingers.
The problem that occurs in a patient who has
trigger finger is due to the tendons of the fingers,
and the sheath in which these tendons live.
Trigger Finger
 De
Quervain’sTenosynovitis
• Pain on thumb side of wrist
• Impaired thumb function
• Most common in dominant hand so
theory assumes due to activity
• Avoid ulnar deviation in task and tool
design
Ulnar Deviation
 Bursitis
• Bursa = Greek word for wine skin and related to
English word for purse
• ~150 bursa in body acting like cushions
protecting muscles and tendons from rubbing
against bones during movement
• Overexertion can cause inflammation
• Bunions are form of Bursitis and due to bad
shoes
• Pain is dull and aching (tendonitis is sharper)
Bursitis (Bunion)
 Neuritis
 Damage to nerves due to repeated or prolonged
exertion of related / nearby muscles
 Especially in awkward postures at extreme ranges of motion by this preloads
tendons and ligaments and stretches muscles and nerves
 Impaired never function
 Destroyed fibers
 Reduced nerve conduction velocity
 Pins and needles sensation
 Overexertion can cause increased pressure in muscle
due to edema or scar tissue
 Pressure threshold limit for nerve viability is 40-50 mm Hg
 Blood flow in nerve ceases at 60 mm Hg
 2 h compression at 40 mm Hg cause severely reduced
blood flow in segment for up to 7 days
 No awkward postures and or pressure
Neuritis
 Peripheral Neuropathies
&Nonlocalized Arm Pain
❑ The peripheral nervous system is used by the brain to communicate with
the rest of the body, including the nerves of the head and the nerves
supplying the internal organs, muscles, skin, and other areas.
❑ Peripheral neuropathy (also called peripheral neuritis) is a problem with
the functioning of these nerves outside of the spinal cord and brain.
❑ Sometimes this involves the breakdown of the nerve endings (axons)
which send sensations to the brain.
❑ Sometimes, the damage affects the coating of nerve fibers (myelin),
interfering with the transmission of pain signals to the brain.
❑ Peripheral neuropathy can be a mild nuisance, or it can be disabling.
 Peripheral Neuropathies
&Nonlocalized Arm Pain
• Nerves make up 2% of body weight yet consume 20% of
oxygen in blood
• Nervous system most extended and connected system
in body
• This means nerves accommodate postural movements
o Speculated that postural deviations can predisposed
people to pain through mechanism of neural tension
 Peripheral Neuropathies
&Nonlocalized Arm Pain
 Nonlocalized arm pain may have vascular origins
 Research has shown that much of this pain is as a
result of restricted blood supply to the muscles
 Butler’s “activity specific mechanosensitivity”
Hypothesized that during particular movement a
small region of scarred nerve tissue moves in a
particular direction against a damaged or
pathological surface such as bony outgrowth
Explains why you can have pain a specific task
but not in a related one
 Bones and Joints
• Repeated, heavy loading is essential for proper
formation and maintenance of bone

• Under repeated loading stress fractures can occur

• This is a process, rather than an event, like many

WMSDs

• Repeated loads below acute fracture threshold

damage bone, and coupled with muscle fatigue, can
lead to fracture
 Bones and Joints
Mechanical trauma contributing
factor to OA (osteoarthritis)
Most common joint disorder
Noninflammatory
Degeneration of cartilage
Hypertrophy of bone
Changes to synovial
membrane, which causes
stiffness and pain in joints
Higher prevalence in come
occupations as compared to
others (e.g. more in retired dock
workers and farmers than office
workers)
 Bones and Joints
When muscle/joint system is place in extreme posture,
muscles on one side of joint lengthened and other
side (antagonist) shortened
Results in strength imbalance in antagonistic pair
Ability of muscles to protect joint against external
forces degenerated
Joint more easily damaged, esp. with high forces
Analysis of joint posture particularly important
when evaluating design of hand tools, particularly
in heavy work where the joints may be exposed
to high forces
 Neck Disorders
 Evidence of Work Relatedness
 Relationships btwn neck pain and work postures in:
◼ Neck flexion
◼ Arm force
◼ Arm posture
◼ Duration of sitting
◼ Twisting or bending of trunk
◼ Hand-arm vibration
◼ Workplace design
 History of neck injury (such as car accident in past 6 months) may show
pain IS NOT work related or increase pain severity of work related pain /
injury
 Older workers more susceptible to occupationally induced symptoms by of
degenerative changes already occurring in neck (and other tissues)
 Neck Disorders
 Evidence of Work Relatedness
 Jonsson et al. (1988)
◼ Investigated cervicobrachial disorders in female workers in electronics
industry
◼ Severe symptoms in 11% of subjects initially and 24% after 1 year
◼ Predictors of deterioration
◼ Symptoms increased in workers stayed in same work
◼ Previous heavy work, high productivity, previous sick leave
◼ Predictors of remaining healthy
◼ Satisfaction with work
◼ No shoulder elevation
◼ Predictors of improvement
◼ Change in work
◼ Spare time in physical activities
 Neck Disorders
 Possible Causal Pathways
 Cervical spine has several functions
◼ Support weight of head
◼ Provide conduit for nerves
◼ Attachment for muscles controlling head position
 Head balanced on top of cervical spine with fulcrum directly above the
first cervical vertebra, eyes forward
◼ Head must be held erect by postural posterior neck muscle
contractions
◼ Postural muscles refer to those that are essential for erect posture
and constantly contracting to prevent head falling due to gravity
Neck Disorders
 Neck Disorders
 Control of neck problems at work
 HEAD AND NECK SHOULD NOT BE FLEXED FORWARD MORE THAN 15
degrees TO AVOID UNDUE POSTURAL STRESS
 Exacerbated when flexion accompanied by
◼ Rotation of head
◼ Shoulders and arms elevated
 Designs/Re-designs
◼ Sloping work surfaces encourage neutral spine
◼ Desk top or document / book holder
◼ Elbow rests take load off should musculature and lumbar spine
◼ Monitor height should not be 15-25 degrees below eye height but
middle of monitor should be at eye height when in neutral
 Carpal Tunnel Syndrome
(CTS)
 Evidence for Work Relatedness
 Combined stressors such as extreme postures, repetition, and vibration of
hand and wrist associated with CTS
 6 occupational risk factors for CTS
◼ Exertion of force over 1 kg
◼ Length of shortest elementary operation <10s
◼ Lack of a change in tasks
◼ Lack of break for >15% of day
◼ Manual supply of parts and equipment to workstations
◼ Lack of job rotation
 One personal risk factor for CTS
◼ Women with >3 children
 Carpal Tunnel Syndrome
(CTS)
 Possible Causal Pathways
 Muscles that flex fingers are in forearm and have long
tendons that pass through a narrow opening, called
carpal tunnel, in wrist before inserting into fingers
 Nerves and blood vessels also pass through carpal
tunnel
 Symptoms are numbness and tingling in palm and
fingers
 CTS caused by pressure increase in carpal tunnel if
pressure affects median nerve or reduces blood
supply
 CTS-like symptoms can come from referred pain due
to degenerative changes in cervical spine interfering
with spinal cord and nerve roots, leading to
misdiagnosis
 Carpal Tunnel Syndrome
(CTS)
Possible Causal Pathways
▪ Nathan et al. (1992) found that the health
of the median nerve is linked to the health
of the rest of the body and median
neuropathy is closely related to lifestyle
and only peripherally to work activities
▪ You et al. (2004) compared personal and
work-related CTS risk-factors
▪ Work-related: high pinch grip forces and
highly repetitive motions
▪ Personal: competitive, female, older
Carpal Tunnel Syndrome
(CTS)
 Tennis Elbow
(Epicondylitis)
 Evidence for work relatedness
 Overexertion of wrist extensor muscles can
lead to “tennis elbow” or lateral humeral
epicondylitis
 Muscles and tendon can separate from bone
 Risk factors
◼ Activities requiring large grasping forces
◼ Combined stressors (e.g., force and
posture)
◼ Common in mechanics, butchers,
construction workers
◼ Non-neutral hand/arm postures
◼ Use of heavy tools
 Tennis Elbow
(Epicondylitis)
Possible causal pathways

o Activities that require a strong grip for extended periods

places a high load on the elbow joint and associated
structures

o Tennis elbow can come about by performing any number

of repetitive gripping, grasping, squeezing or lifting tasks.

o Incorrect posture and arm/hand placement while typing

can produce a repetitive strain.

o Sometimes the position your wrist is in while sleeping can

be a cause of this pain.
 Shoulder Disorders
• Evidence for work relatedness
o Risk factors
• Should abduction and or flexion more than 90 degrees
• Highly repetitive or static shoulder postures
• Duration of employment
• Length of workday
• Age
• Participation in sports confound occupational factors
• NOT VIBRATION AND FORCE!
 Shoulder Disorders
 Possible causal pathways
• Shoulder structure makes it especially mobile yet susceptible
to injury (especially above horizontal) Designs / Redesigns

DESIGN AND REDESIGN:

✓ Provide support for arm weight to shoulder muscles can relax
• Armrests
• Slings
✓ Lighten loads
✓ Reduce repetitive nature of motions
Shoulder Disorders
 Lower Limbs
 Main occupational causes of lower limb injury
excluding falls
 Walking while carrying heavy loads
 Jobs that require excessive use of knees
 Examples
 Blisters
 Foot pain
 Ankle and knee strain
 Foot swelling
 Hip and thigh pain
 Metatarsal stress fracture
 Lower Limbs
• Risk Factors
o Smoking
o Age
o Heavy physical work
o Excessive squatting
o Genetics
o REMEMBER: Hip and similar problems take time to
develop, so workers may be retired / out of workforce by
time symptoms appear / treatment is sought
 WRMSD Management
 Posture of shoulders, elbows, wrists and their relations to
pathological musculoskeletal changes of particular
interest
 Control of finger movements rely on numerous small
muscles that become fatigued during prolonged work w/
inadequate rest and poorly designed tools
 Many women now in previously male dominated fields
 The workers change, but not the tools
 Males and females benefit from re-designs
 Risk Assessment for
WRMSDs
• Many tools developed for WRMSD risk assessment
o Some based on visual observation

o Some require measurement

 Work vs. Exercise
 In physical training, goal is to cause tissue damage
 Body responds by building tissue back up stronger and
increasing size of contractile elements
 This requires ~48 hours of rest for the muscle to repair itself

 In work, the tissue is damaged, but a rest period is not

taken
 Daily damage to muscle tissue may exceed the repair
capability leading to a decrease in strength or endurance and
increase in myalgia
 Work vs. Exercise
 Chronic pain theories:
▪ Tissue change responsible for pain, in the absence of
inflammation, is due to buildup of tissue in extracellular
matrix
▪ Matrix is a barrier to nutrients and contains pain receptors

▪ May be in increase in collagen in muscles, which causes an

increase in muscle stiffness
 End result of chronic pain = loss of strength,
endurance, and ability to absorb shock or vibration
 Handle Design
 >5 cm diameter = strength deteriorates
 Diameter should allow slight overlap of thumb and
fingers
 Finger grooves can cause hot spots and blistering, so
smooth handle best
 Account for gloves
 For neutral wrist, axis of handle 100-110 degrees from
forearm
 “pistol grip” rather than traditional straight grip
 For work on horizontal surface, perpendicular grip best
 :: ehs::

Easy handling..

Example of low cost ergonomics solution

 Ergonomic Keyboard
Design
❑ Have separate key banks, one for each hand

❑ Have keys slop at 20 degrees to the horizontal

❑ Increase auditory feedback for key compression to

keep typists from depressing keys w/ excessive
force

❑ Can you think of any other designs?

 Ergonomic Tools and WMSDs
 Plenty of epidemiological evidence to show that tasks
requiring the following may increase risk of MDS
 Excessive force

 Poor posture

 High repetition

 Long duration

 And stressful tasks

 Ergonomic methods to asses and decrease risk needed

 Training to Prevent
WRMSDs
 Training programs to increase capacity/decrease
WMSDs have been given little attention in HF&E field
 Although regarded as fundamental in sports science to avoid the same
(W)MSDs

 Research shows ergonomic training for new workers

results in reductions in leave for WRMSDs and illness
related absences
 Research shows ergonomics training effects not as strong for experienced
works
◼ Perhaps due to built up established motion patterns
 Summary
• Despite, or because of, automization and
computerization of work, WRMSDs are still prevalent

• Repetitive work common

• Individual characteristics (age, gender, size) can

negatively interact w/ tools or tasks and place
undue stress on musculoskeletal system
Thank You