Strategies to tackle musculoskeletal disorders at work

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Lieven Eeckelaert, PREVENT, Belgium

Introduction

Several strategies can be taken to prevent musculoskeletal disorders that are primarily caused or aggravated by work and the work environment (work-related MSDs). These strategies range from technical and engineering measures, over more organisational approaches, to person-oriented interventions. As set out in the EU legislation, prevention of work-related MSDs should be based on the process of (participatory) risk assessment and should consider some general principles of prevention. Research indicates that an integrated, multidisciplinary and participatory approach is required in order to effectively tackle MSDs at the workplace.

Musculoskeletal disorders

Musculoskeletal disorders (MSDs) are impairments of body structures such as muscles, joints, tendons, ligaments, nerves, bones and the local blood circulation system. MSDs can occur in all parts of the body, although the back, neck, shoulders and upper limbs are the most commonly affected areas. When MSDs are primarily caused or aggravated by work and the work environment, they are called work-related MSDs.

Work-related MSDs are in general not caused by one specific, but by multiple risk factors. These include physical (e.g. manual handling of loads, working in awkward postures, repetitive work and working at high speed, exposure to vibrations) as well as psychosocial (work stress) demands.

Regulatory framework for MSD prevention

The EU Framework Directive of 12 June 1989 (Directive 89/391/EEC) sets out the EU regulatory framework for safety and health at work. Although it does not directly relate to the prevention of work-related MSDs, this Framework Directive contains basic obligations for employers and workers. It obliges employers to take appropriate preventive measures to make work safer and healthier, and introduces the principle of risk assessment as a key element in OSH prevention. It also stresses a hierarchy of preventive measures to be put in place after having assessed and evaluated the risks. These general prevention principles should also be taken into account when choosing strategies and preventive actions to tackle MSDs at the workplace.

Apart from the Framework Directive, the prevention of work-related MSDs is at EU level covered directly or indirectly by various other Directives: Directive 89/654/EEC on workplace requirements, Directive 89/655/EEC on use of work equipment, Directive 89/656/EEC on use of personal protective equipment, Directive 90/269/EEC on manual handling of loads, Directive 90/270/EEC on display screen equipment, Directive 2002/44/EC on vibration, Directive 2003/88/EC on working time, and the New Machinery Directive 2006/42/EC[1][2]. The Directives have been transposed by each Member State into national legislation.

In addition to these Directives, there exist European Guidelines, European Standards (EN, European Committee for Standardisation) and International Standards (ISO, International Standardisation Organisation) that relate to the prevention of work-related MSDs.

Levels and types of prevention

In order to tackle MSDs at work, several preventive strategies can be taken. Three different levels of prevention can be used to categorise these strategies:[2][3]

  1. primary prevention, includes the risk assessment process, and technical/ergonomic, organisational and person-oriented interventions
  2. secondary prevention involves the identification and health monitoring of workers at risks
  3. tertiary prevention comprises return-to-work actions.

Risk assessment

The risk assessment process forms the basis for the prevention of MSDs at the workplace. Risk assessment for MSDs can take place at two levels, as a primary or secondary prevention measure[3].

Ergonomic risk assessment is the systematic examination of all aspects of work, considering and evaluating the work-related and individual exposure of workers to physical and psychosocial risk factors for MSDs. The assessment also examines whether these risk factors can be eliminated and, if not, what preventive measures are, or should be, in place to control the risks. The risk assessment process allows to identify prevention priorities. Risk assessment should, if necessary, be supported by ergonomic experts.

In support of the risk assessment checklists can be used. Examples can be found on the EU-OSHA website [4][5][6][7]. Methods for assessing MSDs are usually focussed at assessing the physical workload using parameters such as the posture of the body parts, the force the worker exerts, time sequences etc. [8]. Methods that are commonly used include:

  • KIM - Key Indicator Methods [9];
  • NIOSH lifting equation, this method is also at the basis of standards EN 1005-2 and ISO 11228 [10] [11];
  • MAC - Manual Handling Assessment Chart [12];
  • ART - Assessment of Repetitive Tasks [13];
  • RULA - Rapid Upper Limb Assessment [14], also used in EN 1005-4;
  • OCRA – Occupational Repetitive Actions [15].

Risk assessment can also be applied as a secondary prevention approach, by identifying workers at risk, ensuring the systematic monitoring of their health and investigate work-related causal factors. This should allow early intervention actions and prevent the chronification of acute MSDs.


Technical interventions

Technical interventions at the workplace (also referred to as ergonomic or engineering interventions) aim to reduce the physical workload and thus also decrease the risk for MSDs in workers. These interventions can amongst others focus on the elimination or reduction of risks related to manual handling of loads, working in awkward postures, repetitive work and hand-arm tasks, etc.

The following types of technical interventions can be distinguished:[2][3]

  • Automation or mechanisation: decisions to automate certain work processes, to implement powered or mechanical transportation or handling equipment such as conveyor belts, lift trucks, electric hoists, patient lifting devices, etc.
  • Ergonomic workplace (re)design: design and optimisation of the (physical) work environment to enable working in a comfortable, strainless posture. Ergonomic design should amongst others take the principles of anthropometry into account. Examples are changes in office lay-out, modification of lighting in offices, the adjustment of working heights, etc.
  • Ergonomic work equipment and tools: introduction or redesign of ergonomic work equipment and tools. Examples are ergonomic chairs and alternative keyboards and pointing devices in office settings, ergonomic hand tools, etc.
  • Protective equipment: imposed on a group of workers, such as back belt (lumbar supports), wrist splints, and knee protectors.

Even though the positive impact of ergonomic tools and workplace adjustment on the physical workload and worker comfort can be demonstrated clearly, systematic reviews of evidence-based research studies (Randomised Control Trials, RCT) in this field generally fail to reveal a direct and strong relation between these ergonomic measures, as a single intervention, and a reduction of MSDs symptoms[2][3][16]. Findings from non-controlled and experimental studies ('grey literature') tend to be more positive in this regard[3].

Research on the use of back belts indicates some strong evidence that these lumbar supports are not effective as a primary prevention measure. The secondary preventive effects however appear to be stronger. However, as a second preventive measure they appear to be more effective[2][3] but it remains unclear if lumbar supports are more effective than no or other interventions for the treatment of low-back pain van [17]. There appears to be insufficient evidence for the efficacy of wrist splints.


Organisational interventions

Interventions at the organisational level can focus specifically on the improvement of:

The aim of these types of interventions is often to reduce the exposure time to high physical load and/or increase recovery time. These organisational measures are generally adopted in tasks whose exposure level cannot be lowered due to the characteristics of the job or through technical measures [18].

Person-oriented interventions

Two main categories of person-oriented interventions can be distinguished: education and exercises[3].

Education comprises the classic 'back or neck schools' and other ergonomic-related guidance and training programmes. These types of interventions are focused on raising more awareness among workers and attempting to change their working behaviour.

  • Back or neck schools train people in the adoption of good working postures, the use of correct lifting/handling techniques, and strengthening exercises[1][2].
  • There are (in-company) training programmes that give training and guidance on proper working methods and practices with the aim to reduce physical strain in workers. These trainings may focus on manual handling, including training in lifting/handling techniques, or focus on group training and counselling on the topic of office ergonomics.
  • Education in the prevention of work-related MSDs can also include the dissemination of written information, for example through brochures or leaflets on ergonomics-related topics.

Physical exercises (physical training), for example encouraged through workplace health promotion programmes, aim to increase the worker's physical capacity and thus reduce the discrepancy between the workload[2].

There is clear evidence from research that (intensive) physical exercise programmes reduce low back pain occurrence. In particular exercises in muscle strengthening appear to play an important role[3]. Also in exercise programmes to reduce work-related upper limb disorders show beneficial results [19]. The primary preventive effect of educational strategies (back or neck schools and other training programmes) on work-related low back pain and other MSDs is less apparent - if these are used as the only preventive measure[2][3].

Participatory approach

A participatory approach to ergonomics, also called participatory ergonomics (PE), relies on actively involving the workers in planning and controlling a significant amount of their own work activities, and implementing ergonomic knowledge, procedures and changes with the intention to improve working conditions, safety, productivity, quality and comfort. There is evidence that PE interventions may reduce work-related MSDs[20].

Although every PE intervention is different (there does not exist 'a best way'), six elements of success for implementing PE interventions in the workplace can be identified:[21][22][23]

  • management and worker support
  • adequate resources committed to the programme
  • appropriate ergonomics training provided to those involved
  • a team with the right people involved (workers, supervisors and (internal or external) ergonomic specialist(s)) who understand their responsibilities (problem identification, solution development, and implementation of change) and make decisions in a consultative way (workers are involved in decision making in the risk assessment process while senior management has control over resources and implementation issues)
  • good communication between team members, management and team, and between the team and individuals in the workplace
  • training in how the organisation works so the team functions well to identify and make necessary changes.

Cost-effectiveness of interventions

Beside the knowledge on the effectiveness of interventions to tackle MSDs at the workplace, information on their financial implications is of great importance for OSH management decision-making in organisations. A systematic review of workplace ergonomic interventions containing economic analyses [24] tried to find evidence for the financial merits of investment in ergonomic interventions. Only few (16) published intervention studies that included a cost-benefit analysis were retained. The review concludes that there is strong evidence for financial benefits from MSDs prevention interventions in the manufacturing and warehousing sector (mainly participatory, technical interventions), moderate evidence in the administrative and support services sector (investment in office equipment and ergonomic training for office workers) and health care sector (participatory ergonomics and introduction of mechanical patient lifts), and limited evidence in the transportation sector (training programmes on back injury prevention).

Return-to-work

From a tertiary prevention perspective, actions can be taken to support the reintegration (return-to-work, RTW) of workers being absent from work due to a subacute or chronic MSDs. RTW interventions should be initiated as early as possible (in the clinical stage of rehabilitation). A multidisciplinary and coordinated approach is required and can comprise measures for the evaluation and (ergonomic) adaptation of the work process or workplace, and individual support, training and psychomental education[1][25][3].

Integrated approach

Findings from several systematic reviews indicate that successful ergonomic approaches are not about single intervention programmes (specific implementation of technical, organisational or training measures). Conversely, there is more evidence for the effectiveness of integrated implementation strategies, comprising a combination of preventive measures (multi-component interventions) [2][3][26][27][28] There is for example no clear evidence for the positive impact of preventive measures such as work station adjustments (technical), rest breaks (organisational), or ergonomic training (behavioural) on work-related MSDs [29]. When these specific interventions are on the other hand included in a combined approach, they become more effective. The same holds true for office work, where ergonomic training and guidance in proper adjustments of the workstation and the adoption of good working postures have proven to be effective, especially when good quality and adjustable office equipment and furniture are available [22]. The following key features of successful and effective ergonomic programmes can be distinguished [22]:

  • being supported by an organisational policy;
  • making available the appropriate technology to the workers enabling them to perform the work healthy and safely;
  • being implemented by means of broad-based and tailored ergonomic trainings (covering more than trainings on how to use properly a tool or technique).

Emphasis is placed on the great importance of a prevention-oriented organizational culture [3] since there is increased evidence of the impact of psychosocial risk factors on the development of MSDs. A strong preventive culture requires a clear management commitment, a proactive organisational strategy to manage the health and safety of the workforce, the willingness of the employer to implement innovative strategies in work organisation and personnel development, a strong emphasis on communication and reporting, the development of leadership qualities of (line) managers and a participatory approach enabling active worker engagement in occupational safety and health. Such an integrated approach also means that MSDs strategies should be part of the main management processes. Bringing ergonomics and MSDs prevention into an organisations' management system can add to its success [30].



Conclusion

As work-related MSDs arise from multiple risk factors of biomechanical, biobehavioural, psychosocial and organisational nature, an integrated, holistic preventive approach is needed. Preventive strategies need to be taken at three levels: primary prevention with a combined focus on the risk assessment process and implementation of technical, organisational and person-oriented measures; secondary prevention targeting early identification and intervention; and tertiary prevention aiming to stimulate and facilitate the (multidisciplinary) return-to-work process of workers being absent from work due to a MSDs problem. This integrated approach can be successful if it is embedded in a participatory environment and a strong prevention-oriented corporate culture.

References

  1. 1.0 1.1 1.2 EU-OSHA - European Agency for Safety and Health at Work, Work-related musculoskeletal disorders: Back to work report, Publications Office of the European Union, Luxembourg, 2007, pp. 100. Available at: [1].
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 EU-OSHA - European Agency for Safety and Health and Work, Work-related musculoskeletal disorders: prevention report, Publications Office of the European Union, Luxembourg, 2008, pp. 106. Available at: [2].
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Michaelis, M., IPP-aMSE - Identification and prioritisation of relevant prevention issues for work-related musculoskeletal disorders (MSD) - Work package 4 - Prevention approaches: evidence-based effects and prioritised national strategies in other countries, Bergische Universität Wuppertal, 2009, pp. 72 Available at: www.dguv.de/content/prevention/campaigns/msd/review/ap_4_e.pdf.
  4. EU-OSHA - European Agency for Safety and Health at Work, E-fact 45 - Checklist for preventing bad working postures, Available at: [3]
  5. EU-OSHA - European Agency for Safety and Health at Work, E-fact 44 - Checklist for the prevention of manual handling risks, Available at: [4]
  6. EU-OSHA - European Agency for Safety and Health at Work, E-fact 43 - Checklist for preventing WRULDs, Available at: [5]
  7. EU-OSHA - European Agency for Safety and Health at Work, E-fact 42 - Checklist for prevention of lower limb disorders, Available at: [6]
  8. Roman-liu, D., 'Comparison of concepts in easy-to-use methods for MSD risk assessment', Applied Ergonomics, 2014, 45, pp. 420-427
  9. Steinberg, U., 'New tools in Germany: development and appliance of the first two KIM ("lifting, holding and carrying" and "pulling and pushing") and practical use of these methods', Work: A Journal of Prevention, Assessment and Rehabilitation, 2012, 41, pp. 3990-3996
  10. Gezondheidsraad, Tillen tijdens werk, 2012. Available at [7]
  11. [12] HSE – Health and Safety Executive, Prospective evaluation of the 1991 NIOSH Lifting Equation, Research Report, RR 901, 2011. Available at: [8]
  12. HSE – Health and Safety Executive, Manual handling assessment chart (MAC) tool, 2014. Available at: [9]
  13. HSE – Health and Safety Executive, Assessment of Repetitive Tasks (ART) tool. Available at: [10]
  14. McAtamney, L., Corlett, E. N., ‘RULA: a survey method for the investigation of work-related upper limb disorders’, Applied Ergonomics, 1993, vol. 24, pp. 91-99. Available at: [11]
  15. Occhipinti, E., Colombini, D., 'OCRA Index and OCRA Checklist', Handbook of Human Factors and Ergonomics Methods, 15-1–15-14, 2004
  16. Driessen, M., Proper, K., van Tulder, M., Anema, J., Bongers, P., and van der Beek, A., 'The effectiveness of physical and organisational ergonomic interventions on low back pain and neck pain: a systematic review', Occupational and Environmental Medicine, 2010, 67, 4, pp. 277-85.
  17. Duijvenbode, I., Jellema, P., van Poppel, M., van Tulder, M., 'Lumbar supports for prevention and treatment of low back pain', Cochrane Library, 2008, Available at: [12]
  18. Comper, M., Padula, R., 'The effectiveness of job rotation to prevent work-related musculoskeletal disorders: protocol of a cluster randomized clinical trial', BMC Musculoskeletal Disorders, 2014, 15:170. Available at: [13]
  19. Rasotto, C., Bergamin, M., Simonetti, A., Maso, S., Bartolucci, G., Ermolao, A., Zaccaria, M., 'Tailored exercise program reduces symptoms of upper limb work-related musculoskeletal disorders in a group of metalworkers: A randomized controlled trial', Manual Therapy, 2014, Available at: [14]
  20. Rivilis, I., Van Eerd, D., Cullen, K., Cole, D.C., Irvin, E., Tyson, J., and Mahood, Q., 'Effectiveness of participatory ergonomics interventions: A systematic review', Applied Ergonomics, 2008, 39, 3, pp. 342-58.
  21. Amick, B.C., Brewer, S., Tullar, J.M., Van Eerd, D., Cole, D.C. and Tompa, E., 'Musculoskeletal Disorders: Examining Best Practices for Prevention', Professional Safety, March 2009, pp. 24-8.
  22. 22.0 22.1 22.2 IWH - Institute for Work & Health, Reducing MSD hazards in the workplace - A guide to successful participatory ergonomics programs, 2009, pp. 11. Available at: [15].
  23. van Eerd, D., Cole, D., Irvin, E., Mahood, Q., Keown, K., Theberge, N., Village, J., St Vincent, M., and Cullen, K., 'Process and implementation of participatory ergonomic interventions: a systematic review', Ergonomics, 53, 10, 2010, pp. 1153-66.
  24. Tompa, E., Dolinschi, R., de Oliveira, C., Amick, B., Irvin, E., 'A Systematic Review of Workplace Ergonomic Interventions with Economic Analyses', Journal of Occupational Rehabilitation, 20, 2010, pp. 220-34.
  25. Tompa, E., Dolinschi, R., Irvin, E., 'A systematic review of disability management interventions with economic evaluations', Journal of Occupational Rehabilitation, 18, 1, 2008, pp. 16-26.
  26. National Research Council, Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Panel on Musculoskeletal Disorders and the Workplace, Commission on Behavioral and Social Sciences and Education, 2001, Available at: [16]
  27. Wijk, K. Mathiassen, S., 'Explicit and implicit theories of change when designing and implementing preventive ergonomics interventions - a systematic literature review', Scandinavian Journal of Work, Environment & Health, 2011, vol. 37(5), pp. 363-375
  28. Montano, D., Hoven, H., Siegrist, J., 'Effects of organisational-level interventions at work on employees’ health: a systematic review', BMC Public Health, 2014, vol. 14:135. Available at: [17].
  29. Hoe, V., Urquhart, D., Kelsall, H., Sim, M., 'Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults (Review)', Cochrane Database of Systematic Reviews, 2012, Issue 8. Available at: [18]
  30. Yazdani, A., Neumann, W., Imbeau, D., Bigelow, P., Pagell, M., Wells, R., 'Prevention of musculoskeletal disorders within management systems: A scoping review of practices, approaches and techniques', Applied Ergonomics, 2015, vol. 51, pp. 255 – 265.


Links for future reading

EU-OSHA - European Agency for Safety and Health and Work, Musculoskeletal Disorders (no publishing date available). Retrieved on 17 June 2015, from: [19]

EU-OSHA - European Agency for Safety and Health and Work, OSH in figures: Work-related musculoskeletal disorders in the EU - Facts and figures, Publications Office of the European Union, Luxembourg, 2010, pp. 179. Available at: [20]

EU-OSHA - European Agency for Safety and Health and Work, Work-related musculoskeletal disorders: prevention report, Publications Office of the European Union, Luxembourg, 2008, pp. 106 Available at: [21]

EU-OSHA - European Agency for Safety and Health at Work, Work-related musculoskeletal disorders: Back to work report, Publications Office of the European Union, Luxembourg, 2007, pp. 100. Available at: [22]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 39 - Cleaners and musculoskeletal disorders, 2008. Available at: [23]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 28 - Patient handling techniques to prevent MSDs in health care, 2008. Available at: [24]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 24 - Musculoskeletal disorders (MSDs) in HORECA, 2008. Available at: [25]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 19 - Prevention of vibration risks in the construction sector, 2007. Available at: [26]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 17 - The prevention of work-related neck and upper limb disorders (WRULDs) in construction, 2007. Available at: [27]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 13 - Office ergonomics, 2007. Available at: [28]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 12 - Work related musculoskeletal disorders in the service and retail sectors, 2007. Available at: [29]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 1 - Musculoskeletal disorders in construction, 2004. Available at: [30] EU-OSHA - European Agency for Safety and Health at Work, The human-machine interface as an emerging risk, Available at: [31]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 45 - Checklist for preventing bad working postures, Available at: [32]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 44 - Checklist for the prevention of manual handling risks, Available at: [33]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 43 - Checklist for preventing WRULDs, Available at: [34]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 42 - Checklist for prevention of lower limb disorders, Available at: [35]


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