Richard P. Wells

Disability resulting from occupational low back pain. Part II : What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins

This is the second of two papers that systematically review available scientific evidence on the causes of disability from occupational low back pain, and the effectiveness of interventions to prevent it after its onset (secondary prevention). This paper reviews the national history of how back pain and the risk factors for its extension into chronic disability, followed by a critical summary of intervention studies attempting to reduce the duration of this disability, and to evaluate the results.

Errors in the use of isokinetic dynamometers

SummaryThe use of constant velocity dynamometers in functional testing and in exercise and therapy programs has been increasing in the past few years. For movements in the horizontal plane there are no gravitational errors. However, in vertical movements the limbs are not only working against the dynamometer but also are either aided or opposed by gravity. Far too often these gravitational forces have not been taken into account, and the error involved can be quite large.1.A study on four subjects using knee extension (against gravity) and flexion (with gravity) showed the error in mechanical work to vary from 26–43% in extension and from 55–510% in flexion.2.A relatively simple solution is offered to overcome the problem by compensating for the gravitational errors over the full range of movement. The time course of the error is such as to cause erroneous magnitudes of recorded moments which are a maximum at low level contractions and minimum at high level contractions.3.The effect of gravitational and other acceleration errors are such as to cause false early peaks in the muscle moment curves resulting in erroneous conclusions about muscle function.

Upper limb musculoskeletal disorders in highly repetitive industries : precise anatomical physical findings

Physical assessment of 146 female workers in highly repetitive jobs found 54% to have evidence of musculoskeletal disorders in the upper limb that are potentially work-related. Many workers had multiple problems, and many were affected bilaterally (33% of workers). Muscle pain and tenderness was the largest problem, both in the neck/shoulder area (31%) as expected and in the forearm/hand musculature (23%), a previously unreported site. Most forearm muscle problems were found on the extensor side. Carpal tunnel syndrome was the most common form of neuritis with 16 people affected (7 people affected bilaterally). De Quervains tenosynovitis and wrist flexor tendinitis were the most commonly found tendon disorders in the distal forearm (12 people affected for each diagnosis). The results suggest that exposure should be measured bilaterally. They also suggest that muscle tissue is highly vulnerable to overuse. Stressors that affect muscle tissue, such as static loading, should be studied in the forearm as well as in the shoulder.

Biomechanical analysis of peak and cumulative spinal loads during simulated patient-handling activities: a substudy of a randomized controlled trial to prevent lift and transfer injury of health care workers

Back injuries are a serious problem for nursing personnel who perform frequent patient-handling activities. Common prevention strategies include body mechanics education, technique training, and ergonomic interventions such as the introduction of assistive equipment. This investigation assessed and compared the effectiveness of two patient-handling approaches to reducing injury risk. One strategy involved using improved patient-handling technique with existing equipment, and the other approach aimed at eliminating manual patient handling through the use of additional mechanical and other assistive equipment. Both intervention arms received training in back care, patient assessment, and use of the equipment available on their particular wards. An analysis of compliance with interventions and the effects of patient-handling methods on both peak and cumulative spinal compression and shear during various tasks was conducted. Results showed greater compliance with interventions that incorporated new assistive patient-handling equipment, as opposed to those consisting of education and technique training alone. In several tasks, subjects who were untrained or non-compliant with interventions experienced significantly higher peak spinal loading. However, patient-handling tasks conducted with the aid of assistive equipment took substantially longer than those performed manually. This, along with variations in techniques, led to increases in cumulative spinal loading with the use of patient-handling equipment on some tasks. Thus, the use of mechanical assistive devices may not always be the best approach to reducing back injuries in all situations. No single intervention can be recommended; instead all patient-handling tasks should be examined separately to determine which methods maximize reductions in both peak and cumulative lumbar forces during a manoeuver.

Quantifying exposure in occupational manual tasks with cumulative trauma disorder potential

A method of describing the musculoskeletal loads in the hand and wrist during manual tasks is presented. A profile of twelve factors is used to quantify the exposure of applicable soft tissues to modes of loading suggested as being related to a number of chronic, work-related musculoskeletal disorders such as chronic muscle strain, tenosynovitis, and carpal tunnel syndrome. These factors include estimates of tendon loads and movement, frictional work done on the tendon sheaths, and muscle activation determined using electromyography. The response of these measures to changes of force, repetition, and posture was studied using eight conditions of a simulated task utilizing a pistol grip tool. Measures of tendon frictional work and dynamic electromyographic activity best paralleled the injury outcomes of an epidemiological study using similar task definitions (Silverstein et al. 1986). This field-usable system is being used currently to investigate the relationship between occupational exposure and musculoskeletal disorders.

Upper limb work-related musculoskeletal disorders among newspaper employees: Cross-sectional survey results

At a metropolitan newspaper office in Canada with extensive video display terminal (VDT) use, researchers carried out a survey (n = 1,007, 84% response) to establish baseline prevalence of work-related musculoskeletal disorders (WMSDs) and to identify demographic, postural, task, and psychosocial factors associated with WMSD symptoms. One-fifth of the respondents reported moderate or worse upper limb pain recurring at least monthly or lasting more than a week over the previous year. Logistic regression showed that employees who faced frequent deadlines and high psychological demands (fast work pace and conflicting demands), had low skill discretion and social support, spent more time keyboarding, or who had their screen in a non-optimal position were more likely to report moderate to severe symptoms. Women reported significantly higher levels of symptoms than men.

Musculoskeletal symptoms among mobile hand-held device users and their relationship to device use: A preliminary study in a Canadian university population

The study aims were, in a population of university students, staff, and faculty (n = 140), to: 1) determine the distribution of seven measures of mobile device use; 2) determine the distribution of musculoskeletal symptoms of the upper extremity, upper back and neck; and 3) assess the relationship between device use and symptoms. 137 of 140 participants (98%) reported using a mobile device. Most participants (84%) reported pain in at least one body part. Right hand pain was most common at the base of the thumb. Significant associations found included time spent internet browsing and pain in the base of the right thumb (odds ratio 2.21, 95% confidence interval 1.02-4.78), and total time spent using a mobile device and pain in the right shoulder (2.55, 1.25-5.21) and neck (2.72, 1.24-5.96). Although this research is preliminary, the observed associations, together with the rising use of these devices, raise concern for heavy users.

A work-energy approach to determine individual joint contributions to vertical jump performance

SummaryA work-energy approach was used to determine the contributions of the muscles crossing the hip, knee and ankle joints to the total positive work done during maximal vertical jumps. It was found that the average relative contributions of the ankle and hip muscles were approximately 23 and 28% respectively, with the remaining 49% of the work being done by the muscles acting at the knee joint. The efficiency of jumping, i.e. the ratio of potential energy gained to the net mechanical work done by the muscles acting at the three lower limb joints was nearly 1.0. These results stress the importance of all three major leg extensor muscle groups to the performance of an explosive activity such as vertical jumping. It is suggested that the work-energy approach supplies useful information concerning joint contributions without the problems associated with other techniques.

The effects of job rotation on the risk of reporting low back pain

Job rotation has been widely recommended as an administrative control to reduce the risk of developing work-related musculoskeletal disorders. However, evidence of its benefits are hard to find in the literature. The effect of job rotation on predictions for the risk of reporting low back pain was estimated using Low Back Pain Reporting (LBPR) and Time Weighted Average (TWA) approaches. Index scores calculated using the peak hand force, the peak L4/L5 shear force and the L4/L5 moment cumulated over the entire shift were used to estimate the effects of job rotation on the probability of reporting low back pain. Simulations of realistic rotations between two jobs showed that workers in low demand jobs who rotate into higher demand jobs experience a linear increase in reporting probability using the TWA approach. With the LBPR approach a step increase in reporting probability occurred because of the immediate exposure to the peak loading parameters associated with the more demanding job. With a 50-50 rotation the TWA and LBPR index scores increased by 39% and 57%, respectively. With the LBPR approach the redistribution of risk was not uniform with job rotation. The increase was greater for those who rotated into the demanding job compared to the reduction experienced by those who rotated out of the demanding job. The effects of job rotation are not easily estimated because of the complex effect that mixing jobs has on peak and cumulative tissue loading.

Assessment of physical work load in epidemiologic studies: common measurement metrics for exposure assessment

There are many possible means of determining exposure ranging from self-reports of physical exposure to measures of muscle activations and estimated spinal loads. In epidemiologic studies, issues of validity make instrumented measures preferable, however issues of cost and practicability tend to force investigators to less costly but less valid and less reliable measures of exposure, such as self-report questionnaires. This paper presents a method by which estimates of exposure from self-report questionnaires, expert observers, work sampling, video analysis and electromyograms can be reported in a common metric, Newtons of force on a tissue, and show, as an example of its application, estimation of spinal compression on auto workers. A common metric allows a flexible approach to selection of measurement methods in occupational settings: no matter which instrument is used the results can be combined to provide an overall picture of exposure. This approach to exposure assessment for the low back allows for comparability across studies and settings.