Applied Ergonomics 1994 25(2) 111-115

Evaluation of occupational knee-joint stress using liquid crystal thermography: a case study
Daniel J. Habes*, Amit Bhattacharya' and Monica Milliron*
*US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Biomedical and Behavioral Science, Cincinnati, OH 45226, USA 'University of Cincinnati Medical School, Biomechanics-Ergonomics Laboratory, Cincinnati, OH 45267--0056, USA *Now at Converse, Inc., One Fordham Road, North Reading, MA 01864-2680, USA This paper describes a m e t h o d to detect knee stress using liquid crystal t h e r m o g r a p h y and presents the results of a case study in which the system was applied to two carpet installers. The m e t h o d involves placing heat-sensitive sheets of film on the knees of workers at various intervals during the work day. T h e thermographic sheets react to variations in heat by changing colour. T h e m e a s u r e m e n t s are taken with the worker's knee positioned in an illuminated, enclosed box. Once the patch stabilizes, the exhibited colours are recorded with an 8 m m video camera. The colour pattern, ranging from brown to blue, provides a thermal record of what is believed to be knee stress resulting from installing carpet. The thermographic records are stored in computer m e m o r y for subsequent analysis using an A T & T T A R G A 16 video board. Custom software allows computation of the area of each distinct eolour pattern as a percentage of total patch size. These records provide a characterization of knee response (inflammation) resulting from the biomechanical load sustained by the knee during the carpet installation task.

Keywords: carpet installers, liquid crystal thermography, biomechanical load, knee-joint stress

Introduction
Available morbidity data indicate that carpet installers, who represent 0.06% of the US workforce, file 6.2% of all workers' compensation claims for traumatic knee injury, a rate over 100 times that expected, and the highest rate of any occupation reporting such claims (NIOSH, 1990). This occupation is unusual in that biomechanical stress is imposed on the lower extremity through kneeling and, additionally, by using the knee to strike a tool that stretches carpet (Bhattacharya et al, 1985; Thun et al, 1987). Methods for assessing worker exposure to repetitive knee stress are needed as a first step towards reducing the incidence of knee disorders among carpet installers. The goal of this study was to develop a worksite 'dosimeter' to monitor worker exposure to repetitive
Mention of company names or products does not constitute endorsement by the National Institute for Occupational Safety and Health.

knee trauma. This dosimeter could be used to warn or signal workers to stop or modify their work patterns before injury to the knee occurred. To develop an effective work modification strategy, however, the relationship between the biomechanical load on the knee (dose) and physiological reaction (response) must first be determined. The purpose of this paper is to describe and illustrate the response portion of such a dosimeter: the development of a thermographic-based system for quantifying potential trauma-induced inflammatory reactions.

Materials and methods

Thermography is a technique for measuring the variations in heat emitted from the body. Unlike other evaluative methods, such as X-rays, thermography is non-invasive, painless, safe, and non-ionizing. Depending on the application, a thermogram can indicate an increase or decrease in body heat. The method has been used by clinicians to detect muscle 111

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Evaluation of occupational knee-joint stress: D.J. Habes et al

tissue response to back pain, to assess nerve root compression syndromes of the upper and lower extremities, and to evaluate soft tissue injuries (Dribbon, 1983; Pochaczevsky, 1983; Herrick and Herrick, 1987). We considered thermography to be a suitable measure for evaluating the effects of knee stress because of its convenience and simplicity, particularly in a field setting. Knee stress among carpet layers arises from the repeated contact and impact forces to the knee that take place during the installation process. Such mechanical stress can result in inflammation and increased joint heat due to increased blood flow. For this application, thermograms were obtained using flexible liquid crystal sheets. These elastic polymer sheets are embedded with cholesterol derivatives which selectively reflect polarized light in a narrow region of wavelengths. The result is a display of colours ranging from brown (coldest) to blue (hottest), depending on the temperature of the contact area. An individual thermographic sheet displays all colours within a range of 3 or 4 C. In order to perform the knee temperature assessments described in this paper, a collection of liquid crystal sheets enabling measurements from 22 C to 42 C was assembled.
Measurement procedure The intent of the thermographic measures was to show a progression of thermal responses due to physical activity; therefore several recordings were required at convenient intervals during the workday. In order to document the rise in knee temperatures resulting from the cumulative biomechanical load to the knee while installing carpet, five recordings were made at the following times: before work began, at mid-morning and mid-afternoon breaks, just before the lunch break, and at the end of the workday.

there until the colour stabilized. This usually took about 15 s. Small weights were attached to each corner of the sheet to ensure good contact with the skin. The initial patch in our pilot study was one that began changing colours at 25.6 C. The highest knee temperature detected was 30.1 C; thus all measurements were well within the range of thermography sheets at our disposal. When the patch ceased changing colour, the knee colour patterns were recorded for about 15 s using a video camera (Sony CCD V8AF) mounted inside the box, which was located 61 cm from the liquid crystal sheet (Figure 1). Following the initial measurement, the worker placed his heel on a footrest mounted at the rear of the box to obtain a temperature profile of the ground contact (prepatellar) portion of the knee (below the kneecap). The same prgeedure with the liquid crystal patch and video camer~t was followed. When all measurements were completed, the worker removed his leg from the box. After similar procedures and measures had been repeated for the left leg, the workers proceeded with their normal work routine. The measurements for both knees were completed in less than 10 min.
Data-analysis procedures The videotapes of the liquid crystal sheets were returned to the laboratory for analysis, An AT&T Truevision Advanced Raster Graphics Adapter (TARGA) 16 video capture-and-display board was used to digitize the taped images in real time. Before

All thermography measurements were conducted in a draught-free room. To minimize the effects of any difference between the ambient temperature of the work area and that of the measuring room, each knee was swabbed with a cool, wet cloth. To ensure that no fever existed, the worker's body temperature was measured with a Feverscan forehead thermometer. When the skin was dry, the worker sat on an adjustable chair and placed his right knee into the opening of a box. The box was a 76 cm x 76 cm table with black material wrapped around it to exclude ambient light. Two 20 W incandescent/fluorescent light bars (Sylvania Model F20T12/1F) were mounted inside the box for illumination. This light arrangement combined the full colour-spectrum display capabilities of incandescent light with the low-temperature illumination properties of fluorescent light. Before taking the measure, all overhead lights were turned off. To begin the thermography assessment a liquid crystal sheet was selected and placed on the suprapatellar portion of the knee (above the kneecap). If the patch of material remained dark, a sheet with a lower temperature range was selected. Similarly, if the patch immediately turned green or blue, a sheet with a higher temperature range was used. When the appropriate liquid crystal sheet was identified, it was placed on the knee and left 112

Max. height
62 crn

69 cm

Figure t The table and video camera arrangement used to collect the thermograms. During a measurement, the camera, viewing window and open side of the box are covered with black cloth to screen out ambient light
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Evaluation of occupational knee-joint stress: D.J. Habes et al

saving the records in computer memory, a previously saved file of a colour-calibration chart was displayed on the computer monitor so that the colours could be adjusted to match those of the same chart held in the analyst's hand. Commercial software, Truevision Image Processing Software (TIPS), allowed this colour calibration to be made easily and accurately. A custom program by Scientific Computer Technology, Inc. (Cincinnati, Ohio) enabled the size of different colour areas on each liquid crystal patch to be computed as a percentage of total patch area. In order for the program to make these calculations, the analyst must outline the area of each colour pattern and the perimeter of the patch with a mouse. The thermogram is completed by assigning temperatures to the outlined colour areas using a reference chart supplied by the thermographic patch manufacturer. The sequence of analyses is shown in Figure 2. With this method, the temperature profile of each knee was captured, consisting of the relative areas of the possible colours for each thermography patch.
Intra- and inter-rater reliability o f the method

Case

study description and

results

The thermography system was tested at the site of a local hotel undergoing renovation. Two carpet-installer tradesmen volunteered to undergo a day of testing in accordance with the measurement schedule described above. Both were experienced workers, with 10 and 11 years as carpet installers, respectively. Owing to time constraints at the worksite, only the right (kicking) knee was evaluated for the two study participants. The two tradesmen were asked to go about their typical work activities, which included a mix of unloading rolls of carpet from the delivery truck, cutting carpet and pads to size, laying tack strip and moulding, and stretching carpet (Figure 3). The workers were not observed during their work, nor were attempts made to quantify the time distribution of these activities during the workday. However, based on previous job analyses on other carpet installers, it was estimated that the two volunteer carpet installers spent about 75% of the workday on their knees (Bhattacharya et al, 1985). The individual and combined results for the upper knee (suprapatellar) only of the two workers over the course of the day are presented in Figure 4 (a), (b) and (c). The extent of knee temperature increase during the day differed between the two carpet installers, but the direction of change was generally the same for each of them. The hottest temperatures (green and blue) increased steadily during the workday, whereas the cooler temperatures (brown and tan) decreased. The only exception to this trend was the before-lunch measure for worker 1 and the end of work measure for worker 2. In each case, the percentage of hottest temperatures decreased slightly from that of the previous measure. For the averaged data (Figure 4 (c)), the distribution of hottest temperatures increased for each measure taken. One notable finding for both subjects was that for the measures taken at the end of the day, green and blue 'hotspots' seemed to be concentrated primarily on a

The repeatability of the method of computing the size of the various colour areas was considered. An experienced member of our laboratory team, who used the computer method to analyse more than 60 thermography patches for a different project, re-analysed 15 randomly selected patches that contained 44 colour spots. The computed correlation coefficient for the 44 pairs of numbers was greater than 0.99, and the coefficient of variation was 7.4%. One of the authors of this paper (DJH) analysed five of the same patches that the laboratory staff member had reanalysed, which contained 12 colour areas. The correlation coefficient for the twelve pairs of numbers was 0.99 and the coefficient of variation was 9.0%. In neither of the two analyses was there any disagreement in the colour or the number of spots on the thermography sheets; variability was due exclusively to differences in the size of the traces outlined by the analysts.

Figure 2 Computer analysis sequence of the captured video images: (a) the raw thermogram; (b) each eolour traced and coded into the computer (1 = green, 2 -- tan, 3 = blue); (c) summary sheet provided by the area-computation program
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Evaluation of occupational knee-joint stress." D.J. Habes et al

Figure 3 The main activities of a carpet installer: (a) attaching base strip; (b) nailing tack strip to the floor; (c) gluing the pad to the floor; (d) bringing carpet rolls into the room: (e) unrolling carpet; (f) stretching carpet into place

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114

The results of the case study indicate that the use of contact thermography, in conjunction with the analytical methods described above, may be an effective and expedient means of obtaining quantitative nmmures of knee temperature patterns in response to work involving the knee. While the increase in size ofaae 'hotspots' on the knees of the two volunteer carpet installers was steady and consistent over the course of the day, the exact cause of the inflammatory response cannot be ascertained from analysis of the thermographic records alone. Proper cause-and-effect interpretation of the

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Evaluation of occupational knee-joint stress: D.J. Habes et ai

results must be made in conjunction with several important considerations: for example, whether the observed inflammatory response was due to the work that was performed on the day of testing, or to a preexisting knee inflammation that each worker had developed over the course of their 10-year careers. Other questions that are raised from this initial study include whether or not recovery to the workers' knees would occur overnight, and whether workers would demonstrate similar patterns of increases in knee temperature while performing knee-intensive activities other than carpet installing, such as walking, stair climbing, or crouching with bended knee. To address some of these concerns, a larger study is planned. Based on the present limited data, three conclusions were drawn. 1 Knee temperatures appear to increase consistently as cumulative biomechanieal loading increases, and the trend is not noticeably affected by rest and lunch breaks. 2 Contact thermography is able to detect these temperature changes. 3 The thermographic system developed for use in this field study provides a feasible means of measuring knee temperature at the worksite. The effective use of thermography in preventing injury to carpet layers' knees depends on performing the type of research described above, and on devising a mechanism for measuring the biomechanical load sustained by the worker so that a dosimeter can be developed. After

establishing a dose-response relationship between the biomechanical loading factors and the physiological response, the decision rules for the implementation of preventive work practices can be formulated. Examples of these work practices are the proper scheduling of rest breaks, rotating to less knee-intensive aspects of carpet installing, and increased use of available mechanized tools to install carpeting, such as a power stretcher.

Acknowledgement
The authors would like to thank Dr Katharyn A. Grant for her assistance in drawing figures for this paper.

References
Bhattaeharya, A, Mueiler, M and Putz.Anderson, V 1985 'Traumatogenic factors affecting the knees of carpet installers' Appl Ergon 16 (4), 243--250 Dribbon, B S 1983 'Application and value of liquid crystal thermography' J A m Podiatry AsSoc 7 (8), 400--404 Herrick, R T and .Herrick, S K 1987 'Thermography in the detection of carpal tunnel syndrome and other compressive neuropathies' J Hand Surg 12A (5, part 2), 943-949 Pochaczevsky, R 1983 'Assessment of back pain by contact thermography of extremity dermatomes' Orthop Rev 12

(1), 45-58
NIOSH 1990 'Preventing knee injuries and disorders in carpet layers' USDHHS (NIOSH) Alert Publication 90-104, May Thun, M, Tanaka, S, Smith, A B, llalperin, W E, Lee, S T, Luggen, M E and Hess, Evelyn E 1987 'Morbidity from repetitive knee trauma in carpet and floor layers' Br J lnd Med 44, 611--620

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