Musculoskeletal Disorder (MSD) Prevention

1. Musculoskeletal Disorder (MSD) Prevention Centre of Research Expertise for thePrevention of Musculoskeletal Disorders CRE-MSD www.cre-msd.uwaterloo.ca Presented by Richard Wells, Ph.D. CRE-MSD, IWH Presentation to the Minister of Labour’s Ergonomics Sub-Committee of the Manufacturing Panel , May 5th, 2005

2. MSDs are a problem in Ontario Reported MSDs greatly underestimate the burden MSDs have a substantial work component MSDs: The Problem

3. What are MSDs? “Musculoskeletal disorders (MSD) are injuries and disorders of the musculoskeletal system… …where exposure to various risk factors present in the workplace… …may have either contributed to the disorders' development, or aggravated a pre-existing condition” (OHSCO MSD Strategy Development Committee, 2005)

4. MSDs are a problem in Ontario • For the period 1996-2002, MSD accounted for: • (a) more than 40% of all lost time claims; • (b) more than 48% of all lost time claim related lost time days; and, • (c) more than 42% of all lost time benefit claim costs (averaged over the period). • Source: WSIB’s Information Warehouse and Prevention Strategy For Musculoskeletal Disorders (MSD) In Ontario

5. 15% 20% 22% 29% 51% 60% Reported MSDs greatly underestimate the burden in Ontario Office Environment. In the last year due to MSD… Lost days at work Pain > 12 times or > 7 days in last year, moderate intensity Reported to workplace Saw health practitioner Work aggravates pain to some extent Any neck or upper limb pain Polanyi et al 1997

6. Reported MSDs greatly underestimate the burden in Ontario • Not only is there a burden on the individual, but there is an decrease in their output • Amongst the 51% of office workers who reported that their neck and upper limb pain was aggravated by work: • 7% had difficulty sticking to their work routine or schedule • 9% had difficulty concentrating on work • 16% had difficulty using pens, computer keyboards etc. for at least half of the workday Polanyi et al 1997

7. MSDs Have a Substantial Work Related Component Risk factors for upper limb RSI/MSD in a large Canadian office Deadlines - weekly WORK ORGANIZATIONAL/ PSYCHOSOCIAL FACTORS Low social support High psychological demands Low skill utilization PHYSICAL FACTORS Time on keyboard (5h vs. 1.5h) Poor screen position INDIVIDUAL FACTORS Female vs. Male Relative Risk of Having ‘RSI’ Polanyi et al., (1998)

8. MSDs Have a Substantial Work Related Component • Risk factors for Low Back Pain in a Canadian auto assembly plant Self rated physical demands Physical Factors Cumulative disk compression Peak hand force Peak shear Job satisfaction Work Organizational/ Psychosocial Factors Social support Over-education Social environment Low job control Norman et al., 1998, Kerr et al., 2001 Hagberg et al (1995), Bernard (1997), NRC/IOM (2001)

9. OH&S System knows enough to prevent MSDs now; research frontiers continue to expand Ontario needs to consider physical and work organizational factors for prevention Different kinds of prevention activities needed at different stages of MSD Different organizations need different supports Guidelines and Regulations Why Participatory Ergonomics? Don’t reinvent the wheel! Programs to prevent MSD Prevention

10. We know enough to prevent MSDs now! Occupational risk factors can be addressed • Work organizational/ psychosocial AND physical factors are associated with high rates of MSDs THIS IS GOOD NEWS • We can change identified organizational and physical workplace factors • Individual factors are likely not as changeable

11. Example: Approaches to Prevention of Low Back MSD Many approaches are talked about… Back belts? Product redesign? Job enlargement? Rebalancing? Exercise programs? Lift Tables? Back school?Adjustable Platforms? Stretching programs? Job rotation? Adjustable furniture Hoists? Health promotion? Teams? Improved Tools?

12. Strategies to prevent low back MSD Eliminate/ Substitute Engineering Controls Administrative Controls Personal Protective Equipment Training Increase workers’ capacity Redesign (Product) Platforms, Hoists, Rebalancing (Process) Job enlargement, Job rotation, Teams, etc Back belts, etc Back school, etc Health Promotion, Exercise programs, Stretching programs, etc

13. One Root Cause of Low Back Pain High cumulative loads on the low back • Lifting/pushing/pulling of light to moderate loads many times per shift • Holding non-upright trunk postures for long duration x 500+ http://www.ahs.uwaterloo.ca/~wells/NAACL.ppt

14. Interventions for Low Back Pain • Re-position load (PRODUCT- PROCESS) • Reduce forces (PRODUCT –PROCESS) • Reduce proportion of cycle loaded or total time loaded (PRODUCT-PROCESS-ADMIN) • Reduce number of movements (PRODUCT-PROCESS-ADMIN) http://www.ahs.uwaterloo.ca/~wells/NAACL.ppt

15. Research shows we can prevent MSDs now • Mechanical lift-assists installed in acute and chronic care facilities • Earlier return to work when lift assists used • Newer ceiling lifts likely to produce even larger reductions Evanoff et al 2003, Engst et al 2005

16. Ontario needs to consider physical and work organizational factors Because there are both physical and work environment (psychosocial) factors that contribute to disability: • Physical: e.g., Forces, postures repetition • Work Environment: e.g., Job Control, Supervisor Support Ontario needs to consider physical and work organizational factors in prevention activities NRC/IOM (2001)

17. Need to consider physical and work organizational factors Example: Garage mechanics • Injured mechanics are told to change working techniques and use lifting equipment • Mechanics coped best when they were supported by managers and supervisors • Achieving positive results from MSD prevention activities requires that organizations create positive attitudes towards work modifications. TORP, et al 1999

18. Primary, Secondary and Tertiary Prevention of MSDs • "...provide workplaces that are comfortable when we are well and accommodating when we are ill."(Morken et al 2002) • Combining primary and secondary preventive interventions can yield greater impact than the sum of impacts from separately implemented interventions. (Frank et al 2005) • "...clinical management + ergonomic modification best combination..."(Loisel et al 1997 Sherbrooke Model of Workplace Disability Prevention)

19. Primary, Secondary and Tertiary Prevention of MSDs Primary Secondary Tertiary Secondary Reduce MSD risk factors to prevent creation or aggravation of MSD and permit the largest possible workforce to perform job… work smarter not harder Monitoring and reporting schemes to detect MSD and initiate abatement of risk factors and restoration of health Disability resulting in Lost Time triggering abatement of risk factors, accommo-dation to disability, restoration of musculoskeletal health and early and safe return to work Monitoring and reporting schemes to detect MSD and initiate abatement of risk factors and restoration of health Symptoms/ Disability At work, little disability or limitations At work, some disability and limitations Off work, substantial disability and limitations At work, some disability and limitations ? Time, weeks

20. Primary, Secondary and Tertiary Prevention of MSDs Address all three prevention strategies simultaneously It may not be helpful to think only in terms of these three classic types of prevention activities: • MSDs tend to have a variable history • A large proportion of the population will have an MSD at some point in their life (especially low back pain)

21. Who benefits from (1°, 2°, 3°) prevention initiatives? • Workers whose symptoms developed as a direct result of current work • Workers who have cumulative damage from previous work experiences • Workers who develop back pain after a weekend’s yard work or caring for their small children… they have responsibilities outside work. • Workers who have age related changes

22. Effective Prevention… Effective prevention of MSDs requires that workplaces need to be simultaneously performing activities that: • Detect MSD’s • Reduce risk factors, • Accommodate disability, • Facilitate restoration of musculoskeletal health • Participate in early and safe return to work

23. You don’t have to reinvent the wheel! MSD prevention builds on the same foundations as other workplace health and safety prevention programs… • Leadership • Participation • Policy • Training • Hazard Identification • Hazard Control • Resources

24. You don’t have to reinvent the wheel! Examples: A) Reducing vibration for LBP & HAVS B) Improving manual materials handling for slips and falls C) Maintaining adequate lighting for tasks D) Improving social support for accommodation E) Designing for lower forces and improved postures ____________________ F) Adding stretching exercises for flexibility Safety Occupational Hygiene Production Engineering C B A MSD Prevention Program E D F Health Promotion Stress Prevention

25. Different organizations need different approaches to facilitate prevention Inspections? Guidance? Recognition? Organizations’ Readiness to Change

26. Guidelines and Regulation: Issues Specification or Performance/Process “Trigger” for Action Cases of MSD Identified Hazard Cal OSHA BC Specification Performance CEN/ISO 1005-3 CSA Office Ergonomics Forces in Machinery Hierarchy of Controls None Hierarchy Identified

27. Guidelines and Regulation: Issues Assessment of Hazard/Risk Single Risk Factors Multiple Risk Factors Weight NIOSH equation Participation None Specified Full Participation Size Large Single-Site Small Multi-Site Auto Assembly Residential Construction Scope Sectoral “Universal” Forestry, Manufacturing Office, Manual Handling

28. Specification Heights, Weights moved Force Angles, Time, … Performance Who participates Stages and checkpoints Training …. Specification or Performance?

29. PRO Know better when in/ not in compliance Know when problem is fixed CON could limit intervention flexibility may not apply well to our situation Sector specific rules may be needed… may not have enough data? TLV may be too high or too low Promotes approach of “just achieving compliance”? Can be used to argue that if workplace below TLV, injuries not work- related Specification Standard

30. PRO Harder to tell if in/ not in compliance Harder to enforce? Harder to tell if the problem has been fixed CON Process oriented Matches business approaches Flexible; can handle many sectors, firm sizes, complexity of jobs etc Does not require so many details of limits, hazard controls etc There are many ways to fix hazards… this approach allows flexibility Performance Standard

31. Participatory Ergonomics “The involvement of people in planning and controlling a significant amount of their own work activities, with sufficient knowledge and power to influence both processes and outcomes in order to achieve desirable goals.” (Haines et al., 2001)

32. Why Participatory Ergonomics? Participation of workers and managers makes sense and is effective in making change (Cole et al., 2005) Ergonomics involves the relationships between people and the (work) environment... workers experience this interaction directly and thus are experts about its strengths and weaknesses ...conversely, managers are responsible for resource allocation.

33. Prevention Programs • Awareness... MSDs are real, cost a lot of money, MSD risk factors exist in Ontario workplaces, but something can be done • Making the case for prevention... businesses in “your” sector can and are making changes to prevent MSDs • Programs to use... here are some approaches that are incorporated into organizations • Regulations... this is what must be done as a minimum

34. Programs To Prevent MSD • Hazard Identification • Hazard Evaluation • Control Strategy • Engineering • Administrative • Personal Protective Equipment • Training and Education • Participation

35. OH&S System knows enough to prevent MSDs now; research frontiers continue to expand Ontario needs to consider physical and work organizational factors for prevention Different kinds of prevention activities needed at different stages of MSD Different organizations need different supports Guidelines and Regulations Why Participatory Ergonomics? Don’t reinvent the wheel! Programs to prevent MSD Prevention

36. Sources Cited • Cole DC, Rivilis I, Van Eerd D, Cullen K, Irvin E, Kramer D. Effectiveness of Participatory Ergonomic Interventions, a Systematic Review. A report to the Ontario Workplace Safety and Insurance Board. January, 2005 • Engst, C., Chokar, R., Miller, A., Tate, R.B., Yassi, A   Effectiveness of Overload Lifting Devices in Reducing the Risk of Injury to Care Staff in Extended Care Facility Ergonomics 48 : 48(2):187-199 2005. • Evanoff, B., Wolf, L., Aton, E., Canos, J., Collins, J. Reduction in Injury Rates in Nursing Personnel through Introduction of Mechanical Lifts in the Workplace, American Journal of Industrial Medicine 44(5): 451 – 457, 2003 • Haines • Frank, F., Cullen, K., IWH Ad Hoc Working Group* Preventing Injury, Illness and Disability at Work: The View from Canada, IWH Working Paper • Kerr, M.S., Frank, S.W., Shannon, H.S., Norman, R.W., Wells, R.P., Neumann, W.P., and Bombardier, C. and the OUBPS group. Biomechanical and psychosocial risk factors for low-back pain at work. American Journal of Public Health, 91:1069-1075, 2001. • Loisel P, Abenhaim L, Durand P, Esdaile JM, Suissa S, Gosselin L et al. A population-based, randomized • clinical trial on back pain management. Spine 1997; 22(24):2911-2918. • Morken, T., et al. Effects of a Training Program to Improve Musculoskeletal Health among Industrial Workers - Effects of Supervisor's Role in the Intervention International Journal of Industrial Ergonomics 30(2):115-12, 2002. • National Research Council /Institute of Medicine, Musculoskeletal disorders and the workplace, National Academy Press, Washington, DC, 2001. • Norman, R., Wells, R., Neumann, P*., Frank, J., Shannon, H. and Kerr, M. A Comparison of Peak vs Cumulative Physical Loading Factors for Reported Low Back Pain in the Automobile Industry, Clinical Biomechanics, 13(8): 561-573, 1998.

37. Sources Cited • OHSCO MSD Strategy Development Committee. PREVENTION STRATEGY FOR MUSCULOSKELETAL DISORDERS (MSD) IN ONTARIO. February, 2005 • Polanyi, M., Cole, D., Beaton, D., Chung, J*., Wells, R., Abdolell, M., Beech-Hawley, L*., Ferrier, S., Mondlock, M.., Sheilds, S., Smith. J. and Shannon, H. Upper-limb Work Related Musculoskeletal Disorders Among Newspaper Employees: Cross-sectional Survey Results. American Journal of Industrial Medicine, 1997, (32):620-628. • Torp, S., Riise, T., Moen, B.E. How the Psychosocial Work Environment of Motor Vehicle Mechanics May Influence Coping with Musculoskeletal Symptoms Work and Stress 13(3):193 - 203,1999