97-141 Musculoskeletal Disorders and Workplace Factors. A Critical Review of PDF

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Musculoskeletal Disorders and

Workplace Factors
A Critical Review of Epidemiologic Evidence for
Work-Related Musculoskeletal Disorders of the Neck,
Upper Extremity, and Low Back
Edited by:
Bruce P. Bernard, M.D., M.P.H.
Contributors:
Vern Putz-Anderson, Ph.D.
Bruce P. Bernard, M.D., M.P.H.
Susan E. Burt
Libby L. Cole, Ph.D.
Cheryl Fairfield-Estill
Lawrence J. Fine, M.D., Dr.P.H.
Katharyn A. Grant, Ph.D.
Christopher Gjessing
Lynn Jenkins
Joseph J. Hurrell Jr., Ph.D.
Nancy Nelson, Ph.D.
Donna Pfirman
Robert Roberts
Diana Stetson, Ph.D.
Marie Haring-Sweeney, Ph.D.
Shiro Tanaka, M.D.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
July 1997
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DISCLAIMER
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National Institute for Occupational Safety and Health.
This document is in the public domain and may be freely copied or reprinted.
Copies of this and other NIOSH documents are available from
National Institute for Occupational Safety and Health

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Please call (703) 4874650 and ask for PB97178628.
B 141
DHHS (NIOSH) Publication No. 97B
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FOREWORD
Musculoskeletal disorders (MSDs) were recognized as having occupational etiologic factors as early as
the beginning of the 18th century. However, it was not until the 1970s that occupational factors were
examined using epidemiologic methods, and the work-relatedness of these conditions began appearing
regularly in the international scientific literature. Since then the literature has increased dramatically;
more than six thousand scientific articles addressing ergonomics in the workplace have been published.
Yet, the relationship between MSDs and work-related factors remains the subject of considerable
debate.
Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence

for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back will
provide answers to many of the questions that have arisen on this topic over the last decade. This
document is the most comprehensive compilation to date of the epidemiologic research on the relation
between selected MSDs and exposure to physical factors at work. On the basis of our review of the
literature, NIOSH concludes that a large body of credible epidemiologic research exists that shows a
consistent relationship between MSDs and certain physical factors, especially at higher exposure levels.
This document, combined with other NIOSH efforts in this area, will assist us in our continued efforts to
address these inherently preventable disorders.
Linda Rosenstock, M.D., M.P.H.

Director, National Institute for
Occupational Safety and Health
Centers for Disease Control and Prevention
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NOTE TO THE READER

This second printing of Musculoskeletal Disorders and Workplace Factors: A Critical Review of
Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper
Extremity, and Low Back incorporates a number of editorial changes, including grammar, formatting,
and consistency issues that were identified in the first printing. In addition, the notation of Dr. Lawrence
Fine as co-editor was inadvertently omitted in the first printing and has been re-inserted.
The conclusions of the document in terms of decisions regarding the weight of the existing epidemiologic
evidence for the relationship between workplace factors and musculoskeletal disorders remain
unchanged. The following technical inconsistencies or errors were corrected:
Page 2-14: Text was corrected to reflect that five studies (as opposed to three) examined the
relationship between force and musculoskeletal disorders of the neck.
Page 2-28: For Viikari-Juntura [1994], the NR entry in the Risk Indicator column was replaced with
the value 3.0.
Page 2-34: Bergqvist [1995a] was changed to Bergqvist [1994]. The Risk Indicator entry for this
study was changed from 4.4 to 3.7 (both noted as statistically significant), the entry for Physical
Examination was changed from Yes to No, and the entry for Basis for Assessing Exposure was
changed from job titles or self-reports to observation or measurements.
Page 3-3: Text was corrected to reflect that four studies (as opposed to three) met all four evaluation
criteria. A description of Kilbom and Persson [1987] was moved forward in the chapter to this section
and includes a clarification that health outcome in their study was based on symptoms and physical
findings.
Page 3-32: The confidence interval depicted for Ohlsson [1994] was corrected to show a range from
3.5 to 5.9.
Page 3-69: Schibye et al. [1995] was added to Table 3-5.
Page 4-25: Dimberg [1989] was changed to Dimberg [1987].
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Page 5a-3: Text was corrected to reflect that nineteen studies (as opposed to fifteen) reported results
on the association between repetition and carpal tunnel syndrome (CTS). Text was also corrected to
reflect that five studies (as opposed to four) met the four evaluation criteria for addressing repetitiveness
and CTS. A description of Osorio et al. [1994] was moved forward in the chapter to this section.
Page 5a-15: Text was corrected to reflect that eleven studies (as opposed to ten) reported results on
the association between force and CTS and that four (as opposed to three) met all four evaluation
criteria. Descriptions of Moore and Garg [1994] and Osorio et al. [1994] were moved forward in the
chapter to this section.
Page 5a-19 : The discussion (strength of association, temporality, consistency of association, coherence
of evidence, and exposure-response relationship) of force and CTS was inadvertently omitted in the
first printing and has been re-inserted.
Page 5a-27: The Risk Indicator for Osorio et al. [1994] was changed from 4.6 to 6.7, and for Nathan
[1992], the No association entry under Risk Indicator was changed to a value of 1.0.
Page 5a-29: Stetson et al. [1993] was moved to the bottom of the table, and entries for Nathan
et al. [1992] and McCormack et al. [1990] were added.
Page 5a-31: This table was modified to more accurately reflect the text.
Page 5a-33: For Koskimies et al. [1990], the entry for Basis for Assessing Exposure was changed
from observation or measurements to job titles or self-reports.
Page 5b-1: Text was corrected to reflect that seven studies (as opposed to eight) are referenced on
Table 5b-1.
Page 5c-4: Text was corrected to reflect that five studies (as opposed to four) met three of the criteria.
A brief description of Kiveks et al. [1994] was added to this section.
A number of references were clarified, and full references for studies that were cited in the text of the
first printing but were inadvertently omitted from the reference list were added.
Appendix C was added to the document to provide a concise overview of the studies reviewed relative
to the evaluation criteria, risk factors addressed, and other issues.
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CONTENTS
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Note to the Reader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi
Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Scope and Magnitude of the Problem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-6
Defining Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-7
Exposure Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-8
Information Retrieval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-9
Selection of Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-9
Methods for Analyzing or Synthesizing Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-10
Criteria for Causality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-11
Categories Used to Classify the Evidence of Work-Relatedness . . . . . . . . . . . . . . 1-13
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-14
Description of Tables, Figures, and Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . 1-14
Chapter 2. Neck Musculoskeletal Disorders: Evidence for

Work-Relatedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-2
Repetition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-12
Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-16
Vibration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-21
Neck or Neck/Shoulder MSDs and the Role of Confounders . . . . . . . . . . . . . . . . 2-21
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-22
Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-24
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Chapter 3. Shoulder Musculoskeletal Disorders: Evidence for

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
Repetition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2
Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-9
Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-14
Vibration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-23
Role of Confounders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-25
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-25
Chapter 4. Elbow Musculoskeletal Disorders (Epicondylitis):

Evidence for Work-Relatedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-2
Repetition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-2
Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-16
Epicondylitis and the Role of Confounders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-17
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-18
Chapter 5. Hand/Wrist Musculoskeletal Disorders (Carpal Tunnel

Syndrome, Hand/Wrist Tendinitis, and Hand-Arm
Vibration Syndrome): Evidence for Work-Relatedness . . . . . . . . . . 5-1
Chapter 5a. Carpal Tunnel Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-1

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-1
Outcome and Exposure Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-2
Repetition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-3
Force and CTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-14
Posture and CTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-22
Vibration and CTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-25
Confounding and CTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-27
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-28
Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-29
Chapter 5b. Hand/Wrist Tendinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-1

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-1
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-1
Repetition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-2
Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-9
Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-13
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-17
Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-18
Chapter 5c. Hand-Arm Vibration Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c-1

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c-1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c-1
Evidence for the Work-Relatedness of HAVS . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c-2
Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c-10
Chapter 6. Low-Back Musculoskeletal Disorders: Evidence for

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-2
Heavy Physical Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-4
Lifting and Forceful Movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-13
Bending and Twisting (Awkward Postures) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-21
Whole Body Vibration (WBV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-26
Static Work Postures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-34
Role of Confounders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-38
Chapter 7. Work-Related Musculoskeletal Disorders and

Psychosocial Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
Psychosocial Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
Upper-Extremity Disorders (Neck, Shoulder, Elbow, Hand, and Wrist) . . . . . . . . . 7-3
Back Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-7
Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R-1
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1
A. Epidemiologic Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1
B. Individual Factors Associated with Work-Related Musculoskeletal
Disorders (MSDs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1
C. Summary Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-1
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EXECUTIVE SUMMARY
The term musculoskeletal disorders (MSDs) refers to conditions that involve the nerves, tendons,
muscles, and supporting structures of the body. The purpose of this NIOSH document is to examine
the epidemiologic evidence of the relationship between selected MSDs of the upper extremity and the
low back and exposure to physical factors at work. Specific attention is given to analyzing the weight of
the evidence for the strength of the association between these disorders and work factors.
Because the relationship between exposure to physical work factors and the development and
prognosis of a particular disorder may be modified by psychosocial factors, the literature about
psychosocial factors and the presence of musculoskeletal symptoms or disorders is also reviewed.
Understanding these associations and relating them to the cause of disease is critical for identifying
exposures amenable to preventive and therapeutic interventions.
MAGNITUDE OF THE PROBLEM

The only routinely collected national source of information about occupational injuries and illnesses of
U.S. workers is the Annual Survey of Occupational Injuries and Illnesses conducted by the Bureau of
Labor Statistics (BLS) of the U.S. Department of Labor. The survey, which BLS has conducted for the
past 25 years, is a random sample of about 250,000 private sector establishments and provides
estimates of workplace injuries and illnesses on the basis of information provided by employers from
their OSHA Form 200 log of recordable injuries and illnesses.
For cases involving days away from work, BLS reports that in 1994 (the last year of data available at
the time this report was prepared), approximately 705,800 cases (32%) were the result of overexertion
or repetitive motion. Specifically, there were
C 367,424 injuries due to overexertion in lifting (65% affected the back); 93,325 injuries due to
overexertion in pushing or pulling objects (52% affected the back); 68,992 injuries due to
overexertion in holding, carrying, or turning objects (58% affected the back). Totaled across
these three categories, 47,861 disorders affected the shoulder.
C 83,483 injuries or illnesses in other and unspecified overexertion events.
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C 92,576 injuries or illnesses due to repetitive motion, including typing or key entry, repetitive use of
tools, and repetitive placing, grasping, or moving of objects other than tools. Of these injuries or
illnesses, 55% affected the wrist, 7% affected the shoulder, and 6% affected the back.
Data for 1992 to 1995 indicate that injuries and illnesses requiring days away from work declined 19%
for overexertion and 14% for repetitive motion. The incidence rate of overexertion (in lifting) declined
from 52.1 per 10,000 workers in 1992 to 41.1 in 1995; the incidence rate for repetitive motion
disorders declined from 11.8 per 10,000 workers in 1992 to 10.1 in 1995. These declines are similar
to those seen for cases involving days away from work from all causes of injury and illness.
The reasons for these declines are unclear but may include: a smaller number of disorders could be
occurring because of more intensive efforts to prevent them; more effective prevention and treatment
programs could be reducing days away from work; employers or employees may be more reluctant to
report or record disorders; or the criteria used by health care providers to diagnose these conditions
could be changing.
IDENTIFICATION AND SELECTION OF STUDIES

The goal of epidemiologic studies is to identify factors that are associated (positively or negatively) with
the development or recurrence of adverse medical conditions. This evaluation and summary of the
epidemiologic evidence focuses chiefly on disorders that affect the neck and the upper extremity,
including tension neck syndrome, shoulder tendinitis, epicondylitis, carpal tunnel syndrome, and hand-
arm vibration syndrome, which have been the most extensively studied in the epidemiologic literature.
The document also reviews studies that have dealt with work-related back pain and that address the
way work organizational and psychosocial factors influence the relationship between exposure to
physical factors and work-related MSDs. The literature about disorders of the lower extremity is
outside the scope of the present review.
A search strategy of bibliographic databases identified more than 2,000 studies. Because of the focus
on the epidemiology literature, studies that were laboratory-based or that focused on MSDs from a
biomechanical standpoint, dealt with clinical treatment of MSDs, or had other
nonepidemiologic orientation were eliminated from further consideration for this document. Over 600
studies were included in the detailed review process.
METHODS FOR SYNTHESIZING STUDIES

For the upper extremity studies included in this review, those which used specific diagnostic criteria,
including physical examination techniques, were given greater consideration than studies that used less
specific methods to define health outcomes. The review focused most strongly on observational studies
whose health outcomes were based on recognized symptoms and standard methods of clinical
examination. For completeness, those epidemiologic studies that based their health outcomes on
reported symptoms alone were also reviewed. For the low-back studies included in this review, those
which had objective exposure measurements were given greater consideration than those which used
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self-reports or other measures. For the psychosocial section, any studies which included measurement
or discussion of psychosocial factors and MSDs were included.
No single epidemiologic study will fulfill all criteria to answer the question of causality. However, results
from epidemiologic studies can contribute to the evidence of causality in the relationship between
workplace risk factors and MSDs. The framework for evaluating evidence for causality in this review
included strength of association, consistency, temporality, exposure-response relationship, and
coherence of evidence.
Using this framework, the evidence for a relationship between workplace factors and the development
of MSDs from epidemiologic studies is classified into one of the following categories:
Strong evidence of work-relatedness (+++). A causal relationship is shown to be very likely

between intense or long-duration exposure to the specific risk factor(s) and MSD when the
epidemiologic criteria of causality are used. A positive relationship has been observed between
exposure to the specific risk factor and MSD in studies in which chance, bias, and confounding
factors could be ruled out with reasonable confidence in at least several studies.
Evidence of work-relatedness (++). Some convincing epidemiologic evidence shows a causal

relationship when the epidemiologic criteria of causality for intense or long-duration exposure to
the specific risk factor(s) and MSD are used. A positive relationship has been observed between
exposure to the specific risk factor and MSD in studies in which chance, bias, and confounding
factors are not the likely explanation.
Insufficient evidence of work-relatedness (+/0). The available studies are of insufficient

number, quality, consistency, or statistical power to permit a conclusion regarding the presence or
absence of a causal association. Some studies suggest a relationship to specific risk factors, but
chance, bias, or confounding may explain the association.
Evidence of no effect of work factors (-). Adequate studies consistently show that the specific
workplace risk factor(s) is not related to development of MSD.
The classification of results in this review by body part and specific risk factor is summarized in
Table 1.
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Table 1. Evidence for causal relationship between physical work factors and MSDs
Strong Insufficient Evidence
Body part evidence Evidence evidence of no effect
Risk factor (+++) (++) (+/0) (-)
Neck and Neck/shoulder
Repetition T
Force T
Posture T
Vibration T
Shoulder
Posture T
Force T
Repetition T
Vibration T
Elbow
Repetition T
Force T
Posture T
Combination T
Hand/wrist
Carpal tunnel syndrome
Repetition T
Force T
Posture T
Vibration T
Combination T
Tendinitis
Repetition T
Force T
Posture T
Combination T
Hand-arm vibration syndrome

Vibration T
Back
Lifting/forceful movement T
Awkward posture T
Heavy physical work T
Whole body vibration T
Static work posture T
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CONCLUSIONS
A substantial body of credible epidemiologic research provides strong evidence of an association
between MSDs and certain work-related physical factors when there are high levels of exposure and
especially in combination with exposure to more than one physical factor (e.g., repetitive lifting of heavy
objects in extreme or awkward postures [Table 1]).
The strength of the associations reported in the various studies for specific risk factors after adjustments
for other factors varies from modest to strong. The largest increases in risk are generally observed in
studies with a wide range of exposure conditions and careful observation or measurement of exposures.
The consistently positive findings from a large number of cross-sectional studies, strengthened by the
limited number of prospective studies, provides strong evidence (+++) for increased risk of work-
related MSDs for some body parts. This evidence can be seen from the strength of the associations,
lack of ambiguity in temporal relationships from the prospective studies, the consistency of the results in
these studies, and adequate control or adjustment for likely confounders. For some body parts and risk
factors, there is some epidemiologic evidence (++) for a causal relationship. For still other body parts
and risk factors, there is either an insufficient number of studies from which to draw conclusions or the
overall conclusion from the studies is equivocal. The absence of existing epidemiologic evidence should
not be interpreted to mean there is no association between work factors and MSDs.
In general, there is limited detailed quantitative information about exposure-disorder relationships

between risk factors and MSDs. The risk of each exposure depends on a variety of factors such as the
frequency, duration, and intensity of physical workplace exposures. Most of the specific exposures
associated with the strong evidence (+++) involved daily whole-shift exposure to the factors under
investigation.
Individual factors may also influence the degree of risk from specific exposures. There is evidence that
some individual risk factors influence the occurrence of MSDs (e.g., elevated body mass index and
carpal tunnel syndrome or a history of past back pain and current episodes of low-back pain). There is
little evidence, however, that these individual factors interact synergistically with physical factors. All of
these disorders can also be caused by nonwork exposures. The majority of epidemiologic studies
involve health outcomes that range in severity from mild (the workers reporting these disorders continue
to perform their routine duties) to more severe disorders (workers are absent from the workplace for
varying periods of time). The milder disorders are more common. A limited number of studies
investigate the natural history of these disorders and attempt to determine whether continued exposure
to physical factors alters their prognosis.
The number of jobs in which workers routinely lift heavy objects, are exposed on a daily basis to
whole-body vibration, routinely perform overhead work, work with their necks in chronic flexion
position, or perform repetitive forceful tasks is unknown. While these exposures do not occur in most
jobs, a large number of workers may indeed work under these conditions. The BLS data indicate that
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the total employment is over three million in the industries with the highest incidence rates of cases
involving days away from work from overexertion in lifting and repetitive motion. Within the highest risk
industries, however, it is likely that the range of risk is substantial depending on the specific nature of the
physical exposures experienced by workers in various occupations within that industry.
This critical review of the epidemiologic literature identified a number of specific physical exposures
strongly associated with specific MSDs when exposures are intense, prolonged, and particularly when
workers are exposed to several risk factors simultaneously. This scientific knowledge is being applied in
preventive programs in a number of diverse work settings. While this review has summarized an
impressive body of epidemiologic research, it is recognized that additional research would be quite
valuable. The MSD components of the National Occupational Research Agenda efforts are principally
directed toward stimulation of greater research on MSDs and occupational factors, both physical and
psychosocial. Research efforts can be guided by the existing literature, reviewed here, as well as by
data on the magnitude of various MSDs among U.S. workers.
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ACKNOWLEDGMENTS
In addition to the other contributors, the following staff members of the National Institute for
Occupational Safety and Health are acknowledged for their support, assistance, and advice in
preparing this document:
Penny Arthur Rose Hagedorn Marty Petersen

Vanessa Becks William Halperin, M.D., Sc.D. Donna Pfirman
Donna Biagini Anne Hamilton Linda Plybon
Jenise Brassell Denise Hill Faye Rice
Karen Brewer Suzanne Hogan Cindy Riddle
Carol Burnett Hongwei Hsiao, Ph.D. Kris Royer
Sue Cairelli Lore Jackson Walt Ruch
Dick Carlson Laurel Jones Steven Sauter, Ph.D.
Shirley Carr Susan Kaelin Lucy Schoolfield
Dave Case Sandy Kasper Mitch Singal, M.D.
Sharon Cheesman Aileen Kiel Paul Schulte
Alexander Cohen, Ph.D. Diana Kleinwachter Becky Spry
Marian Coleman Nina Lalich Anne Stirnkorb
Barb Cromer Leslie MacDonald Naomi Swanson, Ph.D.
Judy Curless Charlene Maloney Rodger Tatken
David Dankovic Diane Manning Allison Tepper, Ph.D.
John Diether James McGlothlin, Ph.D. Julie Tisdale
Clayton Doak Patricia McGraw Anne Votaw
Karen Dragon Alma McLemore David Votaw
Sue Feldmann Judy Meese Thomas Waters, Ph.D.
Jerry Flesch Matthew Miller Jane Weber
Larry Foster Kathleen Mitchell Joann Wess
Sean Gallagher Vivian Morgan Cindy Wheeler
Lytt Gardner, Ph.D. Leela Murthy Kellie Wilson
Pamela Graydon Rick Niemeier Ralph Zumwalde
Daniel Habes Andrea Okun
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We also thank the following reviewers for their thoughtful comments on an earlier draft of this
document:
Gunnar B.J. Andersson, M.D., Ph.D. Robert Harrison, M.D., M.P.H.

Rush-Presbyterian-St. Lukes University of California at San Francisco
Medical Center
Mohammed M. Ayoub, Ph.D., P.E., C.P.E. William S. Marras, Ph.D.

Texas Tech University The Ohio State University
Sidney J. Blair, M.D., F.A.C.S. J. Steven Moore, M.D., M.P.H., C.I.H., C.P.E.
Loyola Chicago University University of Texas Health Center at Tyler
Vance C. Calvez, M.S., C.P.E. Margareta Nordin, Dr. Med. Sc.

The Joyce Institute New York University
Don B. Chaffin, Ph.D. Donald C. Olsen, Jr., C.S.P., C.P.E.

University of Michigan ERGOSH
Jerome J. Congleton, Ph.D., P.E., C.P.E. Thomas Owens, C.I.H., P.E.

Texas A&M University IBM Corporation
Thomas Cook, Ph.D., P.T. Malcolm H. Pope, Dr. Med. Sc., Ph.D.
University of Iowa The University of Iowa
Theodore Courtney Laura Punnett, Sc.D.

Liberty Mutual University of Massachusetts
Michael Feuerstein, Ph.D. Robert G. Radwin, Ph.D.

Uniformed Services University University of Wisconsin-Madison
of the Health Sciences
Eric Frumin David Rempel, M.D.

Union of Needle Trades, Industrial, University of California, San Francisco
and Textile Employees (UNITE)
Michael Gauf Suzanne H. Rodgers, Ph.D.

CTD News Consultant in Ergonomics
Fred Gerr, M.D. C. Jivan Saran

Emory University Central Missouri State University
Lawrence P. Hanrahan, Ph.D., M.S. Scott Schneider, C.I.H.

Wisconsin Division of Health The Center to Protect Workers Rights
Barbara Silverstein, Ph.D., M.P.H., C.P.E.

State of Washington Department of Labor
and Industries
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CHAPTER 1
Introduction
PURPOSE The goal of epidemiologic studies is to identify
This document examines the epidemiologic factors (such as physical, work organizational,
evidence that associates selected psychosocial, individual, and sociocultural
musculoskeletal disorders (MSDs) of the upper factors) that are associated positively or
extremity and the low back with exposure to negatively with the development or recurrence
physical factors at work. The authors have paid of adverse medical conditions. This document
particular attention to analyzing the strength of addresses and evaluates the literature with
the association between MSDs and work regard to these issues for work-related MSDs.
factors. Because the development of an MSD
may be modified by psychosocial factors, the This document reviews the epidemiologic
authors have also reviewed the literature on the evidence regarding the role of physical factors
relationship of these factors to the presence of in the development of MSDs for the following
musculoskeletal symptoms or disorders. body areas: the neck, shoulder, elbow,
Understanding these associations and relating hand/wrist, and back. The document also
them to disease etiology is critical to identifying addresses the influence of work organizational
workplace exposures that can be reduced or and psychosocial factors on the association of
prevented. physical factors with work-related MSDs. This
evaluation and summary of the epidemiologic
BACKGROUND evidence focuses chiefly on disorders affecting
The World Health Organization has the neck and the upper extremityincluding
characterized work-related diseases as tension neck syndrome, shoulder tendinitis,
multifactorial to indicate that a number of risk epicondylitis, carpal tunnel syndrome, and
factors (e.g., physical, work organizational, hand-arm vibration syndrome, which have been
psychosocial, individual, and sociocultural) the most extensively studied in the
contribute to causing these diseases [WHO epidemiologic literature. This document also
1985]. One important reason for the concentrates on studies that have dealt with the
controversy surrounding work-related MSDs is issue of work-related back pain and sciatica.
their multifactorial nature. The disagreement The literature on disorders of the lower
centers on the relative importance of multiple extremities is beyond the scope of this review.
and individual factors in the development of
disease. The same controversy has been an SCOPE AND MAGNITUDE OF THE
issue with other medical conditions such as PROBLEM
certain cancers and lung disordersboth of The only routinely published, national source of
which have multiple causal factors information about occupational injuries and
(occupational and nonoccupational). illnesses in U.S. workers is the Annual Survey
of Occupational Injuries and Illnesses (ASOII)
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conducted by the Bureau of Labor Statistics number of cases decreased by 7% to 308,000

(BLS) of the U.S. Department of Labor. This reported cases; but this number still exceeds the
survey is a random sample of about 250,000 number of cases in any year before 1994.
private-sector establishments, but it excludes
self-employed workers, farms with fewer than Because these summary data did not
11 employees, private households, and all adequately describe the nature of occupational
government agencies. The ASOII provides injuries and illnesses and the related risk
estimates of workplace injuries and illnesses factors, the ASOII was redesigned in 1992 to
from information that employers provide to capture more detailed information about injury
BLS from their OSHA Form 200 log of and illness cases requiring days away from
recordable injuries and illnesses. work. This redesigned survey captures
demographic information about injured workers
BLS has conducted this annual survey since as well as the following characteristics of the
1972 and has thus provided basic information injury or illness: (1) the employers description
about cases of occupational injury or illness that of the nature of the injury or illness, such as
required more than first-aid (including medical sprain or carpal tunnel syndrome; (2) the part
treatment, restricted work activity, or days of the body affected by the specified
away from work). This information includes the condition, such as back or wrist; (3) the source
total number of cases categorized on the of the injury or illness that directly produced
OSHA Form 200 log as either an injury or an the disabling condition, such as a crate, heavy
illness. The illness data are separated into six box, or a nursing home patient; and (4) the
subcategories; the category that contains most event or exposure that describes the manner in
(but not all) musculoskeletal conditions is which the injury or illness was inflicted, such as
disorders associated with repeated trauma. overexertion during lifting or repetitive motion.
This illness category also includes illnesses The BLS data are based on information
associated with noise-induced hearing loss, provided by employers from their records of
but MSDs account for the largest proportion of work-related injuries and illnesses and then
these cases, especially in recent years. All back coded into these categories.
disorders or injuries are placed in the single,
broad injury category, which also includes all For injury and illness cases involving days away
other types of injuries such as lacerations, from work, BLS reports that in 1994 (the last
fractures, and burns. year for which the detailed data were complete
when this report was prepared), approximately
From this part of the ASOII, BLS reports that 705,800 cases (32%) resulted from
in 1995, 308,000 (or 62%) of all illness cases overexertion or repetitive motion. Specifically:
were due to disorders associated with repeated C 367,424 injuries were due to overexertion in
trauma (excluding low-back disorders, which lifting; 65% affected the back. Another
are listed as injuries). The number of repeated 93,325 injuries were due to overexertion in
trauma cases increased dramatically, rising pushing or pulling objects; 52% affected the
steadily from 23,800 in 1972 to 332,000 in back. In addition, 68,992 injuries were due
1994a 14-fold increase. In 1995, the to overexertion in holding, carrying, or turning
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objects; 58% affected the back. Totaled boys work clothes, and hats, caps, and
across these three categories, 47,861 millinery; these industries also include
disorders affected the shoulder. The median manufacturing sectors such as textile bags,
time away from work from overexertion potato chip and similar snacks, motor vehicles,
injuries was 6 days for lifting, 7 days for and meat packing plants (Table 12). These
pushing/pulling, and industries have IRs that are more than eight
6 days for holding/carrying/turning. times the rate for all private industry.
C 83,483 injuries or illnesses occurred in other Not all workers in these high-risk industries are
and unspecified overexertion events. exposed to the working conditions associated
with these clearly elevated rates of illnesses and
C 92,576 injuries or illnesses occurred as a injuries from overexertion and repetitive
result of repetitive motion, including typing or motion; however, smaller proportions of
key entry, repetitive use of tools, and workers in other industries may be similarly
repetitive placing, grasping, or moving of exposed. For example, trucking and courier
objects other than tools. Of these repetitive services, an industry employing over 1.6 million
motion injuries, 55% affected the wrist, 7% people, had IRs for overexertion disorders that
affected the shoulder, and 6% affected the were almost three times higher than the average
back. The median time away from work was rate for all private industries. Thus, these
18 days as a result of injury or illness from employment estimates provide a conservative
repetitive motion. approximation of the number of workers with
heavy exposures to high-risk conditions.
The highest incidence rates (IRs) of work-
related injuries and illnesses from overexertion The BLS data are surveillance information that
occur among workers in nursing and personal might contain misclassifications of both
care facilities, scheduled air transportation, and exposure and health outcomes. However, some
manufacturing of travel trailers and campers. As industries have notably and consistently
Table 11 indicates, these industries have rates elevated rates of musculoskeletal injuries and
of overexertion disorders four times higher than disorders that are not likely to be attributable to
the average rate for all private industry. More data collection or coding. Note that decisions
than 2 million workers are employed in the about the event or exposure that resulted in an
three highest-risk industries alone. However, injury or illness are associations rather than
rates are not available by occupation within causal inferences. Nevertheless, they provide
these industries, and not all workers within a some perspective on the magnitude of work-
high-risk industry will be at equal risk of related MSDs.
developing a work-related MSD.
Industries with the highest IRs of work-related

injuries and illnesses from repetitive motion
include a number of garment manufacturing
sectors such as knit underwear mills, mens and
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Table 1-1. Private sector industries with the highest incidence rates of injuries and illnesses
from overexertion resulting in days away from work, 1994
1994 annual
average Incidence rate 95% confidence
employment (per 10,000 interval
Industry* SIC code (in thousands) workers) (rate per 10,000) Number of cases
Nursing and personal care facilities 805 1,648 318.0 (286, 350) 41,884
Air transportation, scheduled 451 607 306.7 (276, 337) 16,309
Travel trailers and campers (manufacturing) 3792 22 303.7 (206, 401) 635
Food products machinery (manufacturing) 3556 24 260.1 (142, 378) 620
Bottled and canned soft drinks (manufacturing) 2086 95 255.6 (224, 287) 2,512
Beer, wine, and distilled beverages (wholesale) 518 150 254.6 (189, 321) 3,750
Coal mining 12 112 235.6 not available 2,609
Mattresses and bedsprings (manufacturing) 2515 31 233.5 (172, 295) 719
Comparison Industries:
All manufacturing 2, 3 18,319 83.00 (81.4, 84.6) 151,794
All private industry 94,146 76.00 (75.7, 76.3) 613,251
Finance, insurance, and real estate 6 6,707 17.90 (16.5, 19.3) 11,191
Source: Bureau of Labor Statistics, U.S. Department of Labor, Annual Survey of Occupational Injuries and Illnesses, 1994 Case and Demographic Resource Tables
(ftp://stats.bls.gov/pub/special.requests/ocwc/osh/c_d_data).
*
High rate industries were those having an incidence rate greater than three times the rate for all private industry, at the most detailed or lowest SIC level at which rates are published.
Generally, manufacturing industries are published at the 4-digit code level and the remaining industries at the 3-digit level.
Standard Industrial Classification Manual, 1987 edition.
Annual average employment from the BLS Covered Employment and Wages (ES-202) Survey.
Excludes farms with fewer than 11 employees.
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Table 1-2. Private sector industries with the highest incidence rates of injuries and illnesses
from repetitive motion resulting in days away from work, 1994
1994 annual
average Incidence rate 95% confidence
SIC employment (per 10,000 interval
Industry* code (in thousands) workers) (rate per 10,000) Number of cases
Knit underwear mills (manufacturing) 2254 25 165.6 (145, 187) 370
3
House slippers (manufacturing) 3142 146.3 (92, 201) 48
Mens and boys work clothes (manufacturing) 2326 42 117.2 (97, 137) 463
Textile bags (manufacturing) 2393 11 115.7 (60, 171) 117
Potato chips and similar snacks (manufacturing) 2096 35 115.2 (95, 135) 406
Motor vehicles and car bodies (manufacturing) 3711 335 113.9 (99, 129) 4,058
Hats, caps, and millinery (manufacturing) 235 21 103.9 (79, 129) 202
Meat packing plants (manufacturing) 2011 138 98.5 (76, 121) 1,402
Bras, girdles, and allied garments (manufacturing) 2342 12 96.2 (73, 119) 111
Wood products, not elsewhere classified (manufacturing) 2499 58 92.8 (69, 117) 515
Mens and boys suits and coats (manufacturing) 231 40 89.1 (74, 104) 320
Electronic coils and transfers (manufacturing) 3677 17 87.0 (52, 122) 142
Mens footwear (excluding athletic) 3143 28 84.9 (64, 106) 221
Comparison Industries:
All manufacturing 2, 3 18,319 27.0 (26.4, 27.6) 49,278
All private industry 94,146 11.5 (11.4, 11.6) 92,576
Finance, insurance, and real estate 6 6,707 8.1 (7.4, 8.8) 5,046
Source: Bureau of Labor Statistics, U.S. Department of Labor, Annual Survey of Occupational Injuries and Illnesses, 1994 Case and Demographic Resource Tables
(ftp://stats.bls.gov/pub/special.requests/ocwc/osh/c_d_data).
*
High rate industries were those having an incidence rate greater than three times the rate for all manufacturing workers at the most detailed or lowest SIC level at which rates are published.
Generally, manufacturing industries are published at the 4-digit code level and the remaining industries at the 3-digit level.
Standard Industrial Classification Manual, 1987 edition.
Annual average employment from the BLS Covered Employment and Wages (ES-202) Survey.
Excludes farms with fewer than 11 employees.
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The large number of work-related low-back COST

injuries or illnesses reported in the BLS data is The precise cost of occupational MSDs is not
consistent with the results of two representative known. Estimates vary depending on the
surveillance studies in the United States and method used. A conservative estimate
Ontario. In the U.S. study, about 52% of the previously published by NIOSH is
back pain reports were attributed by the $13 billion annually [NIOSH 1996]. Others
worker to repetitive events at work, and an have estimated the cost at $20 billion annually
additional 16% were attributed to discrete, [AFL-CIO 1997]. Regardless of the estimate
acute events at work; 33% were associated used, the problem is large both in health and
with both types of exposures [Guo et al. 1995]. economic terms.
Although workers often consider MSDs to be Work-related MSDs are a major component of
work-related, their reports of back pain do not the cost of work-related illness in the United
appear to affect the reliability of their self States. The California Workers Compensation
reports about exposure to physical work. In the Institute (a non-profit research institute)
Ontario study [Liira et al. 1996], 24% of the estimates that upper-extremity MSD claims by
long-term back disorders were related to workers average $21,453 each [CWCI 1993].
bending and lifting, working with vibrating Back pain is by far the most prevalent and
machines, and working in awkward postures. costly MSD among U.S. industries today.
Interestingly, 8% of the population were Recent analysis of the 1988 Occupational
exposed to at least two of these three factors, Health Supplement of the National Health
and an additional 3% were exposed to all three. Interview Survey (an ongoing household-based
survey) shows that the overall prevalence of
The impact of work-relatedness is self-reported back pain from repeated activities
demonstrated by the elevated MSD rates for on the most recent job was 4.5%, or 4.75
certain industries in workers compensation million U.S. workers [Behrens et al. 1994]. The
data as well as the BLS data. For example, in mean cost per case of compensable low-back
the State of Washington workers pain was reported to be $8,321 in 1989
compensation system, the overall IR of work- [Webster and Snook 1994b].
related MSDs was 3.87/100 workers in 1992,
3.72 in 1993, and 3.52 in 1994. Work-related Webster and Snook [1994a] estimated that the
MSDs in this study were defined as injuries and mean compensation cost per case of upper-
illnesses involving sprains/strains, joint extremity, work-related MSD was $8,070 in
inflammation, low-back pain, and nerve- 1993; the total U.S. compensable cost for
compression syndromes. Four industries had upper extremity, work-related MSDs was
rates at least four times the 199294 average $563 million in 1993. For example, the State of
rate: wallboard installation (23.6/100 workers Washington averaged 44,648 work-related
per year), temporary help-assembly (23.6), MSD claims, with an average total cost of
roofing (19.9), and moving companies (18) $166.8 million/year for the period 199294.
[Washington State Department of Labor and The State of Washington has a working
Industries 1996]. population that is 2% that of the U.S.
workforce. The compensable cost is limited to
the medical expenses and indemnity costs (lost
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wages). When other expenses such as the full processsuch as incipient disease or residual
lost wages, lost production, cost of recruiting signs of a MSD that was once clinically
and training replacement workers, cost of apparent. Because of the multifactorial nature
rehabilitating the affected workers, etc. are of MSDs, it has been necessary to look at a
considered, the total cost to the national broad spectrum of outcome measures to assess
economy becomes much greater. the effects of these factors.
DEFINING HEALTH OUTCOMES Certain authors have noted the scarcity of

Work-related MSDs are defined differently in objective measures (including physical
different studies; thus, it is not surprising that examination techniques) to define work-related
controversy has arisen about the relative MSDs, and the lack of standardized criteria for
importance of various risk factors in the defining MSD cases. Such insufficiencies
etiology of these disorders. Some investigators sometimes make study comparisons difficult
restrict themselves to case definitions based on [Gerr et al. 1991; Moore 1992; Frank et al.
clinical pathology, some to the presence of 1995; Riihimki 1995; Hadler 1997]. It would
symptoms, some to objectively demonstrable be useful to have a concise pathophysiological
pathological processes, and some to work definition and corresponding objective clinical
disability (such as lost work-time status). test for each work-related MSD to translate the
degree of tissue damage or dysfunction into an
The most common health outcome has been the estimate of current or future disability and
occurrence of pain, which is assumed to be the prognosis. Such definitions and tests do not yet
precursor of more severe disease [Riihimki exist. Clinically defined work-related MSDs
1995] or (as in the case of back pain) the often have no clearly delineated
disorder itself. Different MSD health outcomes pathophysiological mechanisms for pathological
have been assessed by investigators depending processes. In cases where some criteria exist
on the particular concern or nature of the study. (such as carpal tunnel syndrome [CTS]), the
The specific health outcomes studied vary standard of accuracy is relatively expensive,
depending on (a) the purpose of the study, (b) elaborate, and subject to interpretation. For
the composition of the study population, (c) the example, the overlap between symptoms and
rarity or prevalence of the health outcome in the presence of abnormalities in nerve conduction
population, (d) the need to limit specific biases, studies is not great [Stetson et al. 1993];
and (e) the decisions of the investigators. furthermore, abnormalities in nerve conduction
studies cannot be reliably used to predict the
Different epidemiologic measures and time future onset of CTS symptoms [Werner et al.
scales have also been used to quantify MSDs in 1997]. Thus, in the interest of feasibility,
groups of people (lifetime prevalence, period expense, and utility, simpler tests and less
prevalence, point prevalence, IR, incidence specific case definitions may have been used in
ratio, etc.). Similarly, some studies have some studies, thereby introducing some risk of
included chronic cases, whereas others have misclassification for specific
studied acute or subacute cases or both.
Cross-sectional studies usually employ case diagnostic entities.
definitions that take into account prevalent
cases at different stages of the disease For upper-extremity studies in this review,
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those with specific diagnostic criteria (including assessment of physical workload by the study
physical examination techniques) were given subjects.
greater consideration than studies that used
less-specific methods to define health The accuracy of such self-assessment has been
outcomes. The review focused on observational debated (both for under-estimation and over-
studies whose health outcomes were based on estimation). Uhl et al. [1987] found that
the constellation of recognized symptoms and workers reported performing more physical
standard methods of clinical examination. For work than observational data could support.
completeness, those epidemiologic studies that Armstrong et al. [1989] found that workers can
based their health outcomes on reported (on average) distinguish among levels of
symptoms alone were also reviewed. exposure, but workers ratings may not
correspond with objective measurements.
Therefore, this document focuses on the upper- Bernard et al. [1994] found that video display
extremity MSDs that have commonly used terminal (VDT) operators (those with and those
diagnostic symptoms and physical examination without symptoms of work-related MSDs)
abnormality criteria. Specifically, these MSDs reported that the average time they spent typing
are (1) tension-neck syndrome, (2) rotator cuff daily in the last year was twice that noted by
tendinitis and impingement syndrome in the independent observers in a single work day
shoulder, (3) epicondylitis in the elbow, (4) (although the 1-day observation period may
CTS, have been insufficient to capture an average
(5) wrist tendinitis, and (6) hand-arm vibration day of typing time). Similarly, Stubbs [1986]
(HAV) syndrome. Generally, the physical found large and significant differences between
examination techniques used to define these subjective and observed estimates of time spent
MSD cases of the upper extremity have been working in specified postures. Fransson-Hall et
similar from study to study and involve standard al. [1995], on the other hand, found that
examination techniques recognized by the
workers tended to underestimate their
American Academy of Orthopedic Surgeons,
the American College of Physicians, or the exposures to contact stress of the hand
International Labor Organization compared with observation. This
Musculoskeletal Task Force (thus increasing underestimation may be because workers tend
the reliability of comparisons between studies). to monitor discomfort from direct contact
Although physical examination techniques have pressurenot the time spent with direct
not been commonly used in epidemiologic contact. Katz et al. [1996] found evidence of
studies of low-back disorders, this document the validity of self-reported symptoms and
also reviews those epidemiologic studies that
functional status, and analysis of their data
address low-back pain.
yielded evidence that variability in self-reports
EXPOSURE MEASUREMENTS is not influenced by potential secondary gain.
Exposure measurements used in work-related
MSD studies range from very crude As Riihimki [1995] pointed out, it is difficult to
assess current exposure, but it is even more
measures (e.g., occupational title) to complex difficult to assess cumulative past exposure
analytical techniques (e.g., spectral analysis of retrospectively. Accurate retrospective data are
electrogoniometer measurements of joint usually not available; thus the exposure
motions). Some studies have relied on self- assessment is often based on self-reports, and
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the assessment may incur information bias. injury, repetitive strain injury, epidemiology,
etiology, cumulative trauma disorders, MSDs
A few studies have used observational methods (neck, tension neck syndrome, shoulder,
to estimate exposures to workplace physical rotator cuff, elbow, epicondylitis, tendinitis,
hazards more accurately and reliably. Because tenosynovitis, carpal tunnel, de Quervain's,
studies that directly observe or assess physical nerve entrapment syndrome, vibration, back
exposure factors are less likely to misclassify pain and sciatica, manual materials handling).
exposure status, these studies are given greater Bibliographies of relevant articles were
weight in this review. reviewed. Relevant foreign literature citations in
English and included in the databases were
Despite the noted limitations, occupations included in this review along with literature from
classified as high-risk in several studies share the personal files of the contributors. This
a number of workplace exposures associated search strategy identified more than 2,000
with work-related MSDs. These workplace studies. Because of the focus on the
exposures occur in various combinations epidemiology literature, a number of these
(singly, simultaneously, or sequentially) at studies that were laboratory-based or focused
different levels for different durations. These on MSDs from a biomechanical standpoint that
exposures have not been routinely broken dealt with clinical treatment of MSDs or other
down into task variables and quantified, with non-epidemiologic orientations were eliminated
the mechanical or physiological loads defined from further consideration for the present
and measured. document. Over 600 studies were included in
the detailed review process.
INFORMATION RETRIEVAL
This document examines scientific peer- SELECTION OF STUDIES
reviewed epidemiologic journal articles, The studies that were chosen for more detailed
including recent publications addressing MSD review specifically concerned the work-
risk factors, conference proceedings, and relatedness of MSDs, musculoskeletal
abstracts dealing with upper-extremity or back problems of the neck, upper limbs, or back,
MSDs, recent textbooks, internally reviewed and/or occupational and nonoccupational risk
government reports or studies conducted by factors. The following inclusion criteria were
NIOSH, and other documents. Reports of used to select studies for the review:
epidemiologic studies were acquired using both
CD-ROM and online commercial and Population: Studies were included if the
governmental databases. Searches were exposed and referent populations were well
carried out on computer-based bibliographic defined.
databases: Grateful Med (which includes
Medline and Toxline), NIOSHTIC (a Health outcome: Studies were included if they
NIOSH database), and CIS (the International involved neck, upper-extremity, and low-back
Labour Organization occupational health MSDs measured by well-defined, explicit
database). The search strategy included the criteria determined before the study. Studies
following key terms: occupation, repetition, whose primary outcomes were clinically
force, posture, vibration, cold, psychosocial, relevant diagnostic entities generally had less
psychological, physiological, repetition strain misclassification and were likely to involve
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more severe cases. Studies whose primary 4. The joint under discussion was subjected
outcomes were the reporting of symptoms to an independent exposure assessment,
generally had more misclassification of health with characterization of the independent
status and a wider spectrum of severity. variable of interest (such as repetition or
repetitive work). This criterion indicates
Exposure: Studies were included if they whether the exposure assessment was
evaluated exposure so that some inference conducted on the joint of interest and
could be drawn regarding repetition, force, involved the type of exposure being
extreme joint position, static loading or examined such as repetitive work,
vibration, and lifting tasks. Studies in which forceful exertion, extreme posture, or
exposure was measured or observed and vibration. This criterion indicates whether
recorded for the body part of concern were the exposure was measured
considered superior to studies that used self- independently or in combination with
reports or occupational/job titles as surrogates other types of exposures. Exposure was
for exposure. also characterized by the method used to
measure the level of exposure. Studies
Study design: Population-based studies of that used either direct observation or
MSDs, case-control studies, cross-sectional actual measurements of exposure were
studies, longitudinal cohort studies, and case considered to have a more accurate
series were included. exposure classification scheme, whereas
studies that exclusively used job titles,
METHODS FOR ANALYZING OR interviews, or questionnaire information
SYNTHESIZING STUDIES were assumed to have less accurate
The first step in the analytical process was to exposure information.
classify the epidemiologic studies by the
following criteria: During review of the studies, the greatest
qualitative weight was given to studies that had
1. The participation rate was $70%. This objective exposure assessments, high
criterion limits the degree of selection bias participation rates, physical examinations, and
in the study. blinded assessment of health and exposure
status. The chapters dealing with the different
2. The health outcome was defined by body regionsneck (including neck-shoulder),
symptoms and physical examination. This shoulder, elbow, hand/wrist, and low-
criterion reflects the preference of most backsummarize these characteristics for each
reviewers to have health outcomes that study reviewed on the criteria table.
are defined by objective criteria.
The second step of the analytical process was

3. The investigators were blinded to health to divide the studies into those with statistically
or exposure status when assessing health significant associations between exposures and
or exposure status. This criterion limits health outcomes and those without statistically
observer bias in classifying exposure or significant associations. The associations were
disease. then examined to determine whether they were
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likely to be substantially influenced by viewed individually (taking into account good

confounding or other selection bias (such as epidemiologic principles) but together as a
survivor bias or other epidemiologic pitfalls that body of evidence for making broader
might have a major influence on the interpretations about epidemiologic causality.
interpretation of the findings). These include the Many investigators did not examine each risk
absence of nonrespondent bias and factor separately but selected study and
comparability of study and comparison groups. comparison groups based on combinations of
There are also tables that summarize risk factors (such as workers in jobs involving
information about confounders and high force and repetition compared with
epidemiologic pitfalls for each study reviewed workers having no exposure to high force and
at the end of each body region chapter. repetition).
The third step of the analytical process was to CRITERIA FOR CAUSALITY
review and summarize studies with regard to No single epidemiologic study will fulfill all
strength of association, consistency in criteria for causality. However, the results of
association, temporal association, and many epidemiologic studies can contribute to
exposure-response relationship. Each of these the evidence of causality in the relationship
factors is discussed in greater detail in the next between workplace risk factors and MSDs.
section (Criteria for Causality). Each study Rothman [1986] defined a cause as an event,
examined (those with negative, positive, or condition, or characteristic that plays an
equivocal findings) contributed to the pool of essential role in producing an occurrence of the
data for determining the strength of disease.
work-relatedness using causal inference. The
exposures examined for the neck and upper This document uses the following framework of
extremity were repetition, force, extreme criteria to evaluate evidence for causality. The
posture, and segmental vibration. The framework was proposed by Hill [1966; 1971]
exposures examined for the low back were and modified by Susser [1991] and Rothman
heavy physical work, lifting, bending/twisting, [1986].
whole-body vibration, and static postures.
Strength of Association
Care should be taken when interpreting some The ORs and prevalence rate ratios (PRRs)
study results regarding individual workplace from the reviewed studies were used to
factors of repetition, force, extreme or static examine the strength of the association between
postures, and vibration. As Kilbom [1994] exposure to workplace risk factors and MSDs,
stated, these factors occur simultaneously or with the higher values indicating stronger
during alternating tasks association. The greater the magnitude of the
relative risk (RR) or the
within the same work, and their effects concur
and interact. A single odds ratio (OR) for an OR, the less likely the association is to be
individual risk factor may not accurately reflect spurious [Cornfield et al. 1959; Bross 1966;
the actual association, as not all of the studies Schlesselman 1978]. Weaker associations are
derived ORs for simultaneously occurring more likely to be explained by undetected
factors. Thus these studies were not only biases.
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Debate is ongoing in the epidemiologic Rothman [1986] referred to specificity of effect

literature about studies with small sample sizes as useless and misleading as a criterion for
that find increased ORs or PRRs but have causality.
confidence intervals (CIs) that include 1.0. The
question is whether such studies simply show Temporality
no significant association or can be seen as Temporality refers to documentation that the
useful estimates of associated risk. cause precedes the effect in time. Prospectively
Nonetheless, it is useful to identify trends across designed studies ensure that this criterion is
such studies and consider whether they have strictly adhered tothat is, that exposure
valuable information after taking into account precedes adverse health outcome. But cross-
other epidemiologic principles. If the studies sectional studies are not designed to allow strict
with and without significant findings both have adherence to this criterion because both
similarly elevated ORs or PRRs, this exposure information and adverse health
information is useful in estimating the overall outcome are obtained at the same point in time.
level of risk associated with exposure.
Even though the cross-sectional study design
Consistency precludes strict establishment of cause and
Consistency refers to the repeated observation effect, additional information can be used to
of an association in independent studies. make reasonable assumptions that exposure
Multiple studies yielding similar associations preceded the health effectparticularly when
support the plausibility of a causal the relationship between physical exposures is
interpretation. Finding the same association measured by observation or direct
with different and valid ways of measuring measurement and by MSD-related health
exposure and disease may show that the outcomes. If the exposure was directly
association is not dependent on measurement measured or observed, it is also unlikely that
tools. Similar studies that yield diverse results the measurement was influenced by the
weaken a causal interpretation. presence or absence of the MSD in the
employee. Rothman [1986] stated that it is
Specificity of Effect or Association important to realize that cause and effect in an
This criterion refers to the association of a epidemiologic study or epidemiologic data
single risk factor with a specific health effect. cannot be evaluated without making some
We have not emphasized this criterion because assumptions (explicit or implicit) about the
of the different views of its utility in determining timing between exposure and disease. For
causality. If this criterion is interpreted to mean example, from a cross-sectional study of
that a single stressor can be related to a specific hand/wrist tendinitis and highly forceful,
outcome (e.g., that forceful exertion alone can repetitive jobs, a researcher can determine
be related to hand/wrist tendinitis) it becomes when exposure began from recorded work
an important criterion for MSDs. However, this histories or from interviews. The researcher can
criterion can be interpreted and applied too also reasonably determine the time of tendinitis
simplistically. Schlesselman [1982] noted that onset by interviews. Kleinbaum et al. [1982]
the concept of specificity is that is generally too said that in cross-sectional studies, risk factors
simplistic and that multiple causes and effects and prognostic factors cannot be distinguished
were more often the rule than the exception. empirically without additional information.
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With additional information (e.g., laboratory THE EVIDENCE OF WORK-

experiments or biomechanical findings), an RELATEDNESS
investigator can deduce that the adverse health After assessing the quality of individual
outcome followed exposure. For example, epidemiologic studies, NIOSH investigators
taking other confounders into account, it is judged whether the evidence was strong
unreasonable to deduce that persons with enough to relate the risk factor to the MSD. In
hand/wrist tendinitis are likely to seek making this judgement, the investigators
employment in jobs that require highly forceful, considered the criteria for causality. Studies
repetitive exertion of the hand/wrist area. which met all four evaluation criteria were given
more weight than those which met at least one
Exposure-Response Relationship of the criteria.
The exposure-response relationship relates
disease occurrence with the intensity, The evidence of work-relatedness from
frequency, or duration of an exposure (or a epidemiologic studies is classified into one of
combination of these factors). For example, if the following categories: strong evidence of
long-duration, forceful, repetitive work using work-relatedness (+++), evidence of work-
the hands and wrists is associated with an relatedness (++), inadequate evidence of
increased prevalence of hand/wrist tendinitis, work-relatedness (+/0), and evidence of no
this association would tend to support a causal effect of work factors (-).
interpretation. Some have challenged the
importance of physical factors as causal agents, Strong Evidence of Work-
but prospective studies have shown that Relatedness (+++)
reduced exposures result in a decreased A causal relationship is very likely between
disease [Bigos et al. 1991b]. In occupational intense and/or long duration exposure to a
health, important and effective preventive specific risk factor(s) and an MSD when using
actions have been initiated without prospective the epidemiologic criteria of causality. A
demonstration that reduced exposure decreases positive relationship has been observed
the incidence of disease. between exposure to the risk factor and the
MSD in at least several studies in which
Coherence of Evidence chance, bias, and confounding could be ruled
Coherence of evidence means that an out with reasonable confidence.
association is consistent with the natural history
and biology of disease. For example, an Evidence of Work-Relatedness (++)
observed association between repetitive wrist Some convincing epidemiolgic evidence exists
motion and CTS (defined by nerve conduction for a causal relationship using the epidemiologic
criteria) must be supported by biological criteria of causality for
plausibility: repeated wrist movement can cause intense and/or long-duration exposure to a
swelling of tissue in the carpal tunnel, resulting specific risk factor(s) and an MSD. A positive
in injury to nerves. It is important to remember, relationship has been observed between
however, that epidemiologic studies can identify exposure to the risk factor and the MSD in
new associations for further study. studies in which chance, bias, and confounding
are not the likely explanation.
CATEGORIES USED TO CLASSIFY
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Insufficient Evidence of Work- agency reports that have undergone peer

Relatedness (+/0) review and are widely available.
The available studies are of insufficient quality,
consistency, or statistical power to permit a DESCRIPTION OF TABLES,
conclusion regarding the presence or absence FIGURES, AND APPENDICES
of a causal association. Some studies suggest a In each chapter on neck, shoulder, elbow,
relationship to specific risk factors but chance, hand/wrist, and low back disorders, there are
bias, or confounding may explain the tables summarizing the risk indicators and
association. epidemiologic criteria used in examining studies
relevant to each body part. For each of these
Evidence of No Effect of criteria tables there are corresponding figures
Work Factors (-) which depict ORs, PRRs, or IRs, along with
Adequate studies consistently and strongly their associated CIs, if available.
show that the specific risk factor is not related
to MSDs. In a separate table for each chapter, more
extensive descriptions of studies, whether or
SUMMARY not they contributed to decisions regarding
This document critically reviews the evidence causal inference, are provided for each body
regarding work-related risk factors and their part. These tables include information from
relationship to MSDs of the neck, shoulder, each study about their design, population,
elbow, hand/wrist, and low back. The outcome, and exposure measures, as well as
document represents a first step in assessing the reported MSD prevalence. Some studies are
work-relatedness of MSDs. This step involves included in the tables that may not be
examination of relevant epidemiologic mentioned in the text. These additional studies
information to assess the strength of the are for information purposes only.
available evidence that, under certain conditions
of exposure, specific risk factors could increase Appendix A, Epidemiologic Review, is a brief
the risk of MSDs or increase the likelihood of primer on occupational epidemiologic methods.
impairment or disability from MSDs. The Appendix B, Individual Factors Associated
second step would involve quantitative risk with Work-Related Mus-culoskeletal
estimates that are beyond the purpose and Disorders (MSDs), discusses individual factors
scope of this document. This review of the (age, gender, etc.) and their association with
epidemiologic literature may assist national and work-related MSDs. Appendix C, Summary
international authorities, academics, and policy Tables, provides a concise overview of the
makers in assessing risk and studies reviewed relative to the evaluation
formulating decisions about future research or criteria, risk factors addressed, and other
necessary preventive measures. issues.
This document does not necessarily cite all of

the literature on a particular MSD. Included are
articles considered relevant by NIOSH
investigators and internal and external reviewers
of the draft document. Only reports that have
been published or accepted for publication in
the openly available scientific literature have
been reviewed by the authors. In certain
instances, they have included government
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CHAPTER 2
Neck Musculoskeletal Disorders: Evidence
for Work-Relatedness
SUMMARY
Over 40 epidemiologic studies have examined physical workplace factors and their relationship to neck and
neck/shoulder musculoskeletal disorders (MSDs). Among these studies are those which fulfill rigorous
epidemiologic criteria and appropriately address important issues so that causal inferences can be made.
The majority of studies involved working groups with a combination of interacting work factors, but certain
studies assessed specific work factors. Each of the studies we examined (those with negative, positive, or
equivocal findings) contributed to the overall pool of data for us to use in assessing the strength of the work-
relatedness using causal inference.
There is evidence for a causal relationship between highly repetitive work and neck and neck/shoulder
MSDs. Most of the epidemiologic studies reviewed defined repetitive work for the neck as work activities
which involve continuous arm or hand movements which affect the neck/shoulder musculature and generate
loads on the neck/shoulder area; fewer studies examined relationships based on actual repetitive neck
movements. The two studies which measured repetitive neck movements by measuring head position
(using frequency and duration of movements) fulfilled the most stringent epidemiologic criteria, showing
strong associations with neck/shoulder MSDs. In those studies defining repetitive work involving continuous
arm or hand movements affecting the neck/shoulder, nine studies were statistically significant and had
odds ratios (ORs) greater than 3.0.; eight studies fulfilled all the epidemiologic criteria except the
exposure criteria, and measured repetition for the hand/wrist and not for the neck. Of these, three
were statistically significant and had ORs greater than 3, five had nonsignificant ORs, all under 2.0.
There is also evidence for forceful exertion and the occurrence of neck MSDs in the epidemiologic
literature. Most of the epidemiologic studies reviewed defined forceful work for the neck/shoulder as work
activities which involve forceful arm or hand movements, which generate loads to the neck/shoulder area; no
study examined a relationship based on actual forceful neck movements. Of the 17 studies addressing
force as one of the exposure factors, five studies found statistically significant associations, but did not
derive ORs; two studies found ORs greater than 3.0, seven studies from 1 to 3.0, and two studies with ORs
less than 1.0. Many of the studies relating measured force (as workload, etc.) to MSDs are in the
biomechanical and ergonomic literature.
There is strong evidence that working groups with high levels of static contraction, prolonged static loads,
or extreme working postures involving the neck/shoulder muscles are at increased risk for neck/shoulder
MSDs. Consistently high ORs were found (twelve statistically significant studies with ORs over 3.0)
providing evidence linking tension-neck syndrome with static postures or static loads.
The epidemiologic data were insufficient to provide support for the relationship of vibration to neck
disorders. At this time, further studies must be done before a decision regarding causal inference is made.
The few prospective studies which have included interventions to decrease workplace exposures that
include decreasing repetitive work and less extreme working postures showed a decrease in the incidence
of neck MSDs and an improvement in symptoms among affected workers. The data on intervention provide
additional evidence that these disorders are related to workplace risk factors.
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INTRODUCTION symptoms has ranged from approximately 50%

Studies from the United States have generally (Silverstein et al. [1987]; Blder et al. [1991];
classified neck disorders separately from Bernard et al. [1993]; Hales et al. 1994]) to
shoulder disorders when evaluating work- about 85% (Andersen and Gaardboe
related risk factors. Scandinavian studies [1993b]). Forty-seven of the listed studies
examining work-related factors, on the other referenced included physical examination
hand, have often combined neck and shoulder findings in their health outcome assessment
MSDs into one health outcome variable. This criteria.
was based on the concept that several muscles
act on both the shoulder girdle and the upper Many of the neck and neck/shoulder MSD
spine together. We have divided our reviews of studies referenced in the tables were part of
the neck and shoulder MSDs into two larger studies that inquired about
chapters: Chapter 2 addresses neck and musculoskeletal symptoms and physical findings
neck/shoulder MSDs and Chapter 3 addresses in multiple body sites. In most of these studies,
shoulder MSDs. there were no separate ergonomic exposure
observations or measurements made that
Our discussion of the evidence for work- pertained to the neck region (e.g., there were
relatedness of the neck will include criteria no neck posture observations, neck angle
Tables 2-1 through 2-6 and Figures 2-1 measurements, neck work-load assessment,
through 2-6. Shoulder MSDs will be discussed trapezius electromyographic testing, etc.). In
in the next chapter. these studies, the primary interest and
measurement strategies focused on the hand
Epidemiologic studies have defined neck and wrist region (e.g., Kuorinka and Koskinen
MSDs in one of two ways: (a) by symptoms [1979]; Ohlsson et al. [1989]; Hales et al.
occurring in the neck (usually with regard to a [1989]; Kiken et al. [1990]; Baron et al.
specific duration, frequency, or intensity), or (b) [1991]). In the studies, workers were
by using both symptoms and physical categorized only by hand/wrist exposures.
examination findings. Hand/wrist categorization will not reflect
exposures of the neck region (or other
The prevalence of reported MSDs is generally musculoskeletal sites). For example, workers
lower when they are defined using both who may have frequent and rapid awkward
symptoms and physical examination results than postures of the neck but less frequent or
when defined using symptoms alone. For extreme postures of the hand and wrist region
example, the prevalence rate of tension neck may be misclassified as low risk if classification
syndrome (TNS) among male industrial depends only on hand/wrist exposure. In
workers in the United States was reported to general, we have given these studies less weight
be 4.9% from interview data and 1.4% when because of a significant potential for
case definitions included physical exam findings misclassification.
[Hagberg and Wegman 1987]. The percent of
work-related MSD cases defined by physical The text of this section on neck and
examination findings to those defined solely by neck/shoulder MSDs is organized by work-
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related exposure factor. The discussion within during a cycle), or

each factor is organized according to the
criteria for evaluating evidence for work-
relatedness in epidemiologic studies using the (2) repeated arm or shoulder motions that
strength of association, the consistency of generate loads to the neck/shoulder area (e.g.,
association, temporal relationships, exposure- trapezius muscle). Most of the studies that
response relationship, and coherence of examined repetition or repetitive work as a
evidence. Conclusions are presented with potential risk factor for neck or neck/shoulder
respect to neck and neck/shoulder MSDs as a MSDs had several concurrent or interacting
single disorder for each exposure factor. physical workplace factors that were being
Summary information relevant to the criteria evaluated. Therefore, repetitive work was not
used to evaluate study quality is presented in necessarily considered the primary exposure
Tables 2-1 through factor but was considered along with the other
2-6. A more extensive summary, which work factors.
includes information on health outcome,
covariates, and exposure measures, is Studies Reporting on the Association
presented at the end of this chapter. of Repetition as a Work Factor for
Neck and Neck/Shoulder
Studies Included in Neck MSDs
MSDs Tables Either the risk factor repetition or repetitive
Forty-six epidemiologic studies dealing with work was included in 26 studies as a factor
neck MSDs and 23 dealing with neck/shoulder for selection of the study population in their
MSDs appear in the summary tables. Of the examination of neck and neck/shoulder MSDs
studies, 38 were cross-sectional, 2 were case- in the workplace. However, only a handful of
control studies, and 6 were prospective studies. these studies examined repetitive movements of
Among all the studies pertaining to the neck or the neck. Few of these studies observed or
neck/shoulder area, 35 had participation rates measured: (a) the frequency or duration of
of over 70%, 3 had less than 70%, and 8 did tasks pertaining to the neck, (b) the ratio of
not report their participation rates. work-time-to-recovery time for neck or
neck/shoulder involvement, or (c) the
percentage of the workday spent on repetitive
REPETITION
activities involving the neck. Instead, studies
Definition of Repetition for Neck and tended to compare and contrast the
Neck/Shoulder MSDs prevalences of neck symptoms and/or physical
For our review of the neck or neck/shoulder findings in workers in occupations requiring a
region, we chose those epidemiologic studies combination of forceful, repetitive movements
that examined repetition or repetitive work and extreme postures of the upper extremities
activities and MSDs. Studies generally address (mainly of the hand/wrist) to workers in
repetition as cyclical work activities that occupations without those requirements.
involved either: (1) repetitive neck movements
(e.g., the frequency of different head positions Twenty studies that mentioned repetitive work
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or repetitive movements found a measurements of critical
statistically significant positive association angles (15E and 30E) of flexion of the neck.
between repetition and neck or neck/shoulder Two independent readers determined
MSDs; 6 others had non-significant findings frequency, duration, and critical angles of
(Tables 2-1 and 2-2, Figures 2-1 and 2-2). In movement for each variable by taking the
terms of magnitude of the association, 11 average of the two readings. Weekly working
studies had ORs greater than 3.0, 11 had ORs time, work rotation, patterns of breaks, and
between 1.0 and 3.0, and none had an OR less individual performance rate (piece rate) were
than 1.0. Four studies did not report their recorded and used in the analysis. The study
results in terms of ORs or Prevalence Rate controlled for age, gender (only females were
Ratio (PRRs), although all of these found included), and psychosocial variables
significant associations (p<0.05). (tendency for stress and worry).
Studies Meeting the Four Evaluation Criteria The other study that fulfilled the four criteria
Of the 27 investigations (see Tables 2-1 and 2- concerned a 3-year prospective study written
2), 2 fulfilled all four evaluation criteria outlined up in a series of articles by Kilbom et al.
earlier in the introduction section [Ohlsson et al. [1986], Kilbom and Persson [1987], and
1995; Jonsson et al. 1988]. Only the Ohlsson Jonsson et al. 1988]. Female electronic
study reported ORs. The investigations workers in highly repetitive tasks with static
assessed repetitive work as an independent postural loads to the neck and shoulder areas
variable in terms of frequency and duration of were followed over a 3-year period. In the
neck movements. second year, some of the employees had
workplace interventions that decreased the
In the cross-sectional study by Ohlsson et al. number of repetitive tasks involving extreme
[1995], female industrial assembly-line workers neck and shoulder postures, while others
exposed to repetitive tasks with short (<30 continued to work at unaltered tasks. Three
seconds) cycles were compared to 2 referent separate physical exams were carried out at
groups: 68 former assembly workers and 64 yearly intervals, the first one initially assessing
other workers with no repetitive exposure at tenderness on palpation and pain or restriction
their current jobs. Industrial workers had to with active and passive movements. Ergonomic
perform tasks with a posture requiring an assessments occurred at the outset of the study
intermittently flexed neck and elevated arms, and included video analysis of postures and
which were abducted intermittently. Workers movements of the head, shoulder, and upper
and referents reported neck/shoulder arm. The evaluation recorded work-cycle time
symptom(s) and had physical exams performed and number of cycles per hour; time at rest for
by a single examiner. The examiner was blinded the arm, shoulder, and head; total number of
to exposure status but not completely to group rest periods; and average and total duration per
status. Ergonomic exposure assessment was work cycle and hour. (The method was
extensive. It included videotaping, observation, designed to study short-cycle repetitive work
and analysis of postures, including under visual control.) The mean number of
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neck forward flexions included only occasional sitting tasks,

>20E per hour was 728 (standard deviation caretaking work, surveillance of machinery, or
[s.d.] 365) in the initial 96 workers. The assembling of bigger and heavier equipment.
participation rate of the study was 72% after 3 The article documenting the last phase of the
years; the investigators analyzed several cohort study by Jonsson et al. [1988] did not
variables separately for dropouts and found no specifically address the neck but broadened the
significant differences with regards to medical health outcome definition to include the
status, physiologic capacity, working technique, neck/shoulder area and the rest of the upper
or work history. The investigators performed extremity using cervicobrachial region as the
step-wise logistic regression with deterioration health outcome of interest. A significant
of disorders or remaining healthy in the different association between deterioration of health
locations (neck and neck/shoulder) as the two status of the cervicobrachial region between
dependent variables. Age, muscle strength, job Year II and Year III of the study and work
satisfaction, and high productivity were cycle, total time at the p<0.05 level was found
included in the logistic regression analyses of (ORs were not given).
these studies. Video analysis and observation
were used to assess repetitive exposure on all Studies Meeting at Least One of the Four
CriteriaStrength of Association
subjects, using work cycle time, number of
cycles per hour, as well as number of neck Of the studies that found significant ORs over
flexions per hour as criteria. Work cycle time 3.0 but did not mention or fulfill all of the
varied between 4.6 and 9.1 min, with a mean criteria, almost all focused on working groups
value of 6.6 min. with a combination of repetitive and forceful
work and compared them to either population
Strength of Association for referents or groups in occupations with lower
Repetition exposure. Almost all were cross-sectional
In the Ohlsson et al. [1995] study, the OR for surveys. These studies used health outcomes
the association between repetitive work related from symptom surveys and self-reported
to the neck and any neck/shoulder diagnoses workplace exposure (no direct observations)
was 4.6; for a diagnosis of tension neck and either compared symptomatic workers
syndrome, it was 3.6. (neck MSD cases) to asymptomatic workers in
the same workforce (e.g., Yu and Wong
For the cohort study carried out by Kilbom et [1996]; Bergqvist et al. [1995a]; Schibye et al.
al. [1986], at the 2-year followup, the number [1995]; Hnting et al. [1981]) or in other
of neck flexions per hour appeared as a strong occupations (e.g., Liss et al. [1995]; Andersen
predictor for deterioration to severe disorders and Gaardboe [1993b]; Milerad and Ekenvall
of the neck. Improvement to a healthy status [1990]; Onishi et al. [1976]). Onishi et al.
classification from [1976] found significant differences in
Year I to Year II was seen with reallocating neck/shoulder MSDs (OR 3.8) between
workers to more varied work tasks (which groups involved in repetitive upper limb
required a reorganization of monotonous and operations and office workers. They found
repetitive work tasks). The new tasks were workers involved in repetitive activity had 10%
characterized as more dynamic and varied and to 30% maximum voluntary contraction (MVC)
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of the trapezius muscle. They concluded that disorders among checkers was 2.0 (95%
habitual neck or shoulder muscle fatigue is confidence interval [CI] 0.66.7), in a model
that included age, hobbies, second jobs,
caused by repetitive tasks that result in systemic disease, and obesity.
localized tenderness and may be a precursor to
chronic MSDs. Bergqvist et al. [1995a] carried out a study
comparing office workers using video display
Andersen and Gaardboe [1993a] used a terminals (VDTs) to those who did not. A
cross-sectional design to compare sewing physiotherapists diagnosis of tension-neck
machine operators with a random sample of syndrome was used to define a case. Exposure
women from the general population of the same assessment was based on both self-reports and
region. A neck case required a strict the investigators observation of work postures,
predetermined symptom and physical movements, and measurements of heights of
examination definition. Exposure was assessed work-station equipment in conjunction with the
through observation and categorization of jobs, user. Statistical modeling included several
based on the authors experience and individual factors, organizational factors, and
judgements. However, the main interest for ergonomic factors. For tension neck
exposure assessment was duration of exposure syndrome, no factor related to repetitive work
as a sewing machine operator. Statistical was found to be significantly related.
modeling controlled for age, having children,
not doing leisure exercise, smoking, and Blder et al. [1991] surveyed 199 sewing
socioeconomic status found a significant trend machine operators from 4 plants. Of the 155
for neck/shoulder syndrome in relation to who reported shoulder or neck pain, 131 were
years of exposure as a sewing machine examined. Exposure assessment was by
operator, with ORs from 3.2 to 36.74. The OR questionnaire and addressed employment
for the lowest exposure category, 0-7 years, duration and hours per week. Authors stated
was not statistically significant, although the that the study involved a control group and
higher exposure levels were. For this study, the took into account psychosocial factors, but the
exposure classification scheme does not allow results were not included in the article. Both
separation of the effects of repetition from employment duration and working more than
those of force, and there was no precise 30 hours per week were found to be
measure of repetitiveness. statistically significant at the p<0.05 levels. For
this study, the exposure as duration of work
Baron et al. [1991] studied neck MSDs in 124 (per week and per years) does not allow
grocery store checkers and 157 other grocery separation of the effects of repetition from
store workers who were not checkers. The those of force. There was no direct measure of
neck MSD case definition met predetermined repetitiveness.
symptom and physical exam criteria. Physical
examinations had higher participation rates Ekberg et al. [1994] carried out a case-control
among the checkers (85%) than among the study involving cases from a semi-rural
referents (55%). Telephone interviews to non- community in southern Sweden who had
checkers resulted in questionnaire completion consulted a community physician for MSDs of
by 85% of the non-checkers. The OR for neck the neck, shoulder, arm, or upper thorax.
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Cases had to have been ill immediately prior to (data entry to conversational VDT use),
physician visit and Hnting et al. [1981] used a case definition
requiring symptoms and physical exams and an
have been on sick leave less than 4 weeks. extensive exposure assessment using
Cases were excluded for trauma, infectious questionnaire, observation, and measurements
causes, accident, malignancy, rheumatic of workstations, and body posture
disease, abuse, or pregnancy. Controls were measurements using a prescribed method. Data
randomly selected from the Swedish insurance entry terminal users, whose tasks required
registry. Exposure was obtained by more extensive repetitive work than traditional
questionnaire. The analysis showed that for office workers, found an OR of 9.9 with the
neck disorders with precise repetitive comparison. There were no adjustments for
movements the OR was 3.8 for medium confounders in this analysis.
exposure and 15.6 for high exposure
comparing jobs with low force and low Kamwendo et al. [1991] compared 420
repetition. Gender, immigrant status, work medical secretaries with frequent, significant
pace, and current smoking were also analyzed neck pain to those with few episodes based on
in the logistic model. questionnaire responses. Exposure was also
questionnaire based. The analysis was
Ekberg et al. [1995] surveyed 637 Swedish controlled for age and length of employment. A
residents for the presence of neck symptoms in surrogate for repetitive work consisted of hours
the past six months. Exposure was based on sitting or working with office machines with high
questionnaire responses. Twenty questionnaire exposure equal to 5 hrs or more/day.
items on physical work conditions were factor
analyzed. Age, smoking, exercise habits, and Kiken et al. [1990] also studied poultry
family situation with preschool children were workers at two plants with exposure to highly
not significantly associated with symptoms. forceful, highly repetitive jobs and compared
Repetitive movements demanding precision them to other poultry workers with less
was found to have an OR of 1.2 for neck pain. exposure. Neck case definition required
symptoms and physical examination findings
Hales and Fine [1989] compared 89 female that met predetermined criteria. Exposure
workers in 7 high exposure jobs to 25 female assessment was based on hand/wrist
poultry workers in low exposure jobs assessment of forceful and repetitive jobs. No
employed in poultry processing. Neck case assessment of neck repetition was performed.
definition required symptoms and physical Job turnover was around 50% at plant 1 and
examination findings that met predetermined 70% at plant 2 making survivor bias a strong
criteria. Exposure assessment was based on possibility.
hand/wrist assessment of forceful and repetitive
jobs. No assessment of neck repetition was Kuorinka and Koskinen [1979] studied
performed. Twelve percent of workers in high occupational rheumatic diseases and upper limb
risk jobs versus none in low risk jobs were found strain among 93 scissor makers and compared
to have neck MSDS. them to the same group of department store
assistants (n=143) that Luopajrvi et al. [1979]
In a study of VDT users in a range of jobs used as a comparison group. Temporary
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workers and Milerad and Ekenvall [1990] compared the

self-reported neck and neck/shoulder
those with recent trauma were excluded from symptoms between dentists and pharmacists.
the scissor makers group. Exposure assessment Dentists had been considered the high risk
included videotape analysis of scissor maker group because of awkward postures and
tasks, however exposure assessed for the hand repetitive use of small handtools. Exposure was
and wrist region and not the neck. No formal based on self-reports. The authors examined
exposure assessment was conducted on the several covariates and stratified by gender for
shop assistants. Health assessment involved an their analysis. No difference between groups in
interview and physical examination by a leisure time, smoking, systemic disease, and
physiotherapist following a standard protocol. exposure to vibration.
Diagnoses of tension neck syndrome were
determined using predetermined criteria [Waris Ohlsson et al. [1989] studied 148 electrical
et al. 1979]. In problem cases, orthopedic and equipment and automobile assemblers,
physiatric teams determined case status. It is 76 former female assembly workers who quit
unclear whether cashiers were excluded from within 4 years and compared these two groups
the comparison group in this study as they were to 60 randomly sampled females from the
in the Luopajrvi et al. [1979] study. The study general population. A case was determined by
group was 99% female. questionnaire; exposure was based on job
categorization and questionnaire responses.
Luopajrvi et al. [1979] compared the Repetitive exposure was based upon the
prevalence of neck/shoulder disorders among number of items completed per hour. The work
152 female assembly line packers in a food pace was divided into four classes: (1) Slow:
production factory to 133 female shop <100 items/hr; (2) Medium: 100 to 199
assistants in a department store. Exposure to items/hr; (3) Fast: 200 to 700 items/hr;
repetitive work, awkward hand/arm postures, (4) Very Fast: >700 items/hour. The OR
and static work was assessed by observation increased with increasing work pace, except at
and videotape analysis of factory workers. No very high paces, where there was a decrease.
formal exposure assessment was conducted on This was attributed to selective quitting of
the department store workers; their job tasks subjects with complaints, only the healthiest
were described as variable. Cashiers were being left in the assembly work.
excluded, presumably because their work was
repetitive. No formal assessment occurred for Onishi et al. [1976] compared several groups
neck/shoulder repetition. The health assessment of workers with varying exposure to repetitive
consisted of interviews and physical tasks. Health outcome was based on symptoms
examinations conducted by a physiotherapist, of shoulder stiffness, dullness, pain, numbness;
and diagnoses of tension neck syndrome were pressure measured by strain transducer at
later determined by medical specialists using which a subject felt pain; and a physical exam.
these findings and predetermined criteria (95% Observation and measurements of some job
tasks, including some measures of repetition,
CI 2.636.49). Age, hobbies, and housework
were performed then job categorization was
were considered in the analysis.
done. Based on job
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physical exam findings in the case definition of

categorization and job analysis, and taking into neck and neck/shoulder MSDs when
account shift length, activities, number of comparing workers bagging pears versus
breaks, repetitive movements of the hands, arm apples. Exposure was again based on
manipulations, and length of employment, there measurements of job tasks by a representative
was not a difference between workers with worker.
tenderness threshold above 1.5 kg/cm and
those below with respect to age, height, weight, Schibye et al. [1995] followed up 303 sewing
skinfold thickness, grip strength, upper arm machine operators at nine factories representing
abduction strength, and back muscle strength. different technology levels who completed a
questionnaire in 1985. In April 1991, 241 of
Punnett et al. [1985] compared neck/shoulder 279 traced workers responded to the same
MSDs based on symptom reporting alone in 1985 questionnaire. Operators still working
162 women garment workers and 76 women were compared to those who moved to other
hospital workers such as nurses, laboratory employment in 1991. Exposure was assessed
technicians, and laundry workers. There was a through a questionnaire asking type of machine
low participation rate among the hospital operated, work organization factors,
workers. Eighty-six percent of the garment workplace design factors, units produced per
workers were sewing machine operators and day, the payment system, and the duration of
finishers (sewing and trimming by hand). The employment as a sewing machine operator.
sewing machine operators were described as Although the authors state that the analysis did
using highly repetitive, low force wrist and not show that neck symptoms among workers
finger motions, while the finishers had shoulder who had worked as a sewing machine operator
and elbow motions as well. The exposed to be significantly related to exposure, exposure
garment workers likely had more repetitive time, or age, there was a significant drop-out
jobs than most of the hospital workers. The rate of those above 35 years.
neck/shoulder cases were found to lift both the
typical and heaviest loads with greater Rossignol et al. [1987] chose 38 random sites
frequency than non-cases. from Massachusetts workers with
more than 50 employees, and selected
Sakakibara et al. [1995] found among orchard 191 workers from computer and data
workers that neck shoulder MSDs based on processing services, and public utilities
symptom and physical findings were and the Commonwealth Government. Subjects
significantly higher when performing pear were selected after the
bagging than when apple bagging. Exposure observation of the worksite. A self-
was based on measurements of specific angles administered questionnaire case definition was
of the neck and shoulder and job tasks in a used for neck MSD. Exposure was also based
representative worker. ORs were not derived upon self-reports of number of hours worked
in this study. Confounders were not checked each day with a keyboard machine with a
for in this study. VDT. Analysis controlled for the
Sakakibara et al. [1987] did not include following confounding factors: age, cigarette
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smoking, industry, and educational VDT between symptoms and repetitive work. The
training. Ekberg studies specifically asked about
precise repetitive movements in their
Yu and Wong [1996] chose to compare 90 questionnaire and controlled for confounders
data entry, data processing, and computer and effect modifiers (age, gender, having pre-
programmers from an International Bank in school children) in their analyses. Milerad and
Hong Kong and 61 infrequent users of VDTs. Ekenvall [1990] compared dentists and
Both neck MSD case definition and exposure pharmacists, stratified by gender, and found no
assessment were based on symptom data. association between neck or neck/shoulder
Analysis controlled for age and gender, and MSDs with metabolic disease, smoking, leisure
other covariates (as stated in the paper). For time, exposure, or vibration. Significant ORs of
frequent VDT use an OR of 28.9 was found. 2.0 to 2.6. for neck MSDs were reported for
dentists compared to pharmacists.
Kuorinka and Koskinen [1979] found a
significant difference in neck MSDs between Of those studies reporting no significant
scissor makers (an occupation chosen for study association between repetition and neck or
because of its assembly-line repetitive hand neck/shoulder MSDs, none included exposure
tasks) and shop assistants (non-stereotypic, assessment or observations of the neck or
non-repetitive jobs) with an OR of 4.1. In the neck/shoulder area that were both objective
same study, comparing the different and independent of the hand/wrist. Several of
stereotypic, repetitive jobs in scissor-making, these studies [Baron et al. 1991; Kiken et al.
those in short-cycled tasks (29.5 sec) had no 1990; Hales et al. 1989; Ohlsson et al. 1989;
significantly different prevalence of neck Luopajrvi et al. 1979] categorized workers
disorders than workers in longer-cycled tasks into high and low exposure groups based
(7.326 sec) (OR 1.6, 95% CI 0.7 3.8). It is strictly on hand/wrist exposure and not arm,
important to note that both the longer-cycled shoulder, or neck exposure. All of these studies
tasks and short-cycled tasks in Kuorinkas reported ORs below 2.0.
study would have been classified as highly
repetitive in most other ergonomic studies In the study of VDT users by Bergqvist et al.
[Silverstein et al. 1987; Chiang et al. 1993; [1995a], exposure was based on self-reports
Viikari-Juntura et al. 1991a; Kurppa et al. of the presence of repeated work movements
1991]. When comparing two groups in which for all work tasks and not specifically focused
the level of repetitive exposure may not differ on the neck or neck/shoulder area. They found
by much (in this case, where both groups have no significant association with neck/shoulder
highly repetitive tasks), it is unlikely that one will MSDs when the variable repeated work
find a significant difference because there is not movements was analyzed in the logistic model
enough variance between the exposures. alone, but found a significant relationship with a
combination of variables: (1) workers wearing
Three studies [Ekberg et al. 1994, 1995; glasses, (2) who reported VDT use, and (3)
Milerad and Ekenvall 1990] used health VDT use for more than 20 hours/week. In this
outcomes and exposure assessments based on case, it was the combination of variables at
self-reports and found significant associations higher levels of exposure (VDT use more than
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20 hours per week) that was found to be with less than 6 months (or even longer) of job
statistically significant. experience, thereby omitting from their study
workers who may have developed their MSDs
Temporal RelationshipRepetition prior to working at the job of interest, or who
and Neck/Shoulder MSDs had experienced discomfort or fatigue due to
Of the prospective studies of neck MSDs that new activities or a break-in period at work. It
can be used to establish a temporal relationship is reasonable to assume that in those studies,
between exposure to repetitive work and neck given the exclusions required by the case
or neck/shoulder disorders, the study by definitions, the onset of exposure was prior to
Jonsson et al. [1988] fulfills all the four study the onset of neck/shoulder MSDs in the
criteria. Jonssons study was a followup of the majority of participants.
cohort studied by Kilbom et al. [1986],
electronic workers who entered the study
without MSDs. Exposure assessment pertaining Consistency in Association for
specifically to the neck/shoulder area was Repetition and Neck/Shoulder MSDs
completed three times over 3 years. In the studies fulfilling the four criteria [Ohlsson
et al. 1995; Jonsson et al. 1988; Kilbom et al.
In the longitudinal study by Ohara et al. [1976], 1986], significantly positive associations
the authors attributed the increase in neck between neck MSDs and repetitive work were
symptoms in cash register operators to the found. Many more studies involved workers in
introduction of new electronic cash registers repetitive work from a range of industries
placed at unsuitable heights. They noted an (VDT workers, dentists, electronic assembly,
increase in repetitiveness and an increase in sewing machine operators, etc.), comparing
awkward and static postures by cash register symptom prevalences to those in less repetitive
operators using the new registers. The authors jobs. There was also significant association
reported a relationship between static loading between neck and neck/shoulder MSDs and
and MSDs and found that a subsequent jobs with repetitive tasks, with ORs between
reduction in exposure to static loading resulted 1.6 and 5.9 [Onishi et al. 1976; Kuorinka and
in less worker disability (sick leave). Koskinen 1979; Rossignol et al. 1987; Vihma
et al. 1982; Kamwendo et al. 1991; Andersen
Although temporality cannot be obtained from and Gaardboe et al. 1993b; Ekberg et al.
cross-sectional studies, several studies 1994, 1995; Schibye et al. 1995] indicating
attempted to insure that disorders developed that workers exposed to higher levels of work
following the exposure being studied. In certain risk factors have greater rates of neck and
studies [Baron et al. 1991; Kiken et al. 1990; neck/shoulder symptoms. None of the studies
Hales et al. 1994; Hoekstra et al. 1994], the that failed to find significant associations carried
health outcome definition excluded persons out exposure assessment of the neck or
reporting symptoms prior to the job or neck/shoulder.
reporting acute injury thought to be unrelated to
work, insuring that exposure preceded MSD Coherence of Evidence for
occurrence. Other studies excluded participants Repetition
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Studies outside the epidemiologic literature give exposure assessments for their analyses and did
supportive evidence that repetitive work is not conduct specific neck, shoulder, or upper
related to neck/shoulder disorders. Stevens et extremity (apart from hand/wrist) exposure
al. [1966] found that the neck injuries among assessment. (Only one of the studies finding
fork-lift truck drivers were from repetitive, significant associations did so using hand/wrist
extreme head rotations needed for the exposure assessment.) The possibility of
operation of fork lift trucks and introduced the misclassification affecting the results must be a
sideways-sitting driver forklift. Eklund et al. consideration.
[1994] reported following up on a sideways-
sitting forklift (in an unpublished study); these FORCE
drivers experienced neck pain three times as
Definition of Force for Neck and
often as other drivers on traditional
Neck/Shoulder MSDs
forkliftsindicating that moderate head
rotations during long periods of time can be For our review, we included studies that
more risky than short term and extensive head examined force or forceful work or heavy loads
rotations. Nicholas [1990] reported in his to the neck and neck/shoulder, or described
discussion on pathophysiologic mechanisms of exposure as strenuous work involving the upper
sports injuries that a low-load force with high extremity that generates loads to the trapezius
repetition results in a gradual deterioration of muscles. Most of the studies that examined
tissue strength from strain to fatigue to force or forceful work as a risk factor for
deformation, with prefailure symptoms, such as neck/shoulder had several concurrent or
pain on use, a common clinical sign of early interacting physical work load factors.
inflammation from overuse.
Force has generally been defined as: (1) either
Exposure-Response Relationship for externally as a load or internally as a force on a
Repetition body structure, or (2) a force magnitude
expressed in newtons or pounds or as a
There were no studies reviewed that showed a
proportion of an individuals strength capacity,
clear dose-response relationship between
that is, of a persons MVC, usually measured
repetition and neck and neck/shoulder MSDs.
by EMG. Most studies that have dealt with
force loading of the neck or stress generated on
Conclusions Regarding Repetition
the neck structures are from biomechanical
The association between neck or
studies performed in the laboratory. These
neck/shoulder MSDs and repetitive work
studies are not included in this document. In the
epidemiologic studies reviewed, force is usually
was found to be statistically significant in 19
estimated by either questionnaire,
studies using different epidemiologic
biomechanical models, in terms of weight lifted,
approaches and under different circumstances
electromyographic activity, or the variable,
of exposure. Twenty-seven studies found ORs
heavy physical workload.
above one; of these, 13 were above 3.0.
Almost all the studies (6 of 8) with non-
Seventeen studies reported results on the
significant associations used hand/wrist
association between force or forceful work (in
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combination with repetition) and neck and maximum voluntary contraction (MVC) were
neck/shoulder MSDs. Of the 17 studies of calculated. Post-intervention (which involved
force and neck MSDs, 11 found a statistically changes to the workstation, tools, and
significant positive association between force organization of work)see Table 2-4 at the
and neck or neck/shoulder MSDs; six others end of the chapter for further explanation, the
had non-significant findings. In terms of mean static trapezius load in assemblers was
magnitude of the association, two studies had reduced from 4.3% MVC to 1.4%, the mean
ORs greater than 3.0, seven were between 1.0 static trapezius load in VDT users reduced
and 3.0, and two were less than 1.0. Six from 2.7% MVC to 1.6% MVC (post-
studies did not report their results in terms of intervention). Sick leave also decreased
ORs or prevalence rate ratios (PRRs) but considerably. Because so many interventions
reported that the findings were statistically were involved in this study, it is not clear to
significant at the p<0.05 level. what intervention changes the decrease in sick-
leave per man-labor years might be attributed.
Studies Meeting the Four Criteria for
Bjelle et al. [1981] compared 13 workers of an
Force and Neck/Shoulder MSDs
industrial plant consecutively seen at a health
There were no studies that met the four clinic with acute, nontraumatic shoulder-neck
epidemiologic evaluation criteria for forceful pain not due to causative disease or
exertion of the neck. malformation compared to 26 controls,
matched on age, gender and place of work.
Studies Not Meeting the Four Criteria
for Force and Neck/Shoulder MSDs In another cohort study, Veiersted and
Westgaard [1994] followed 30 female
aras [1994] carried out a cohort study of four
chocolate manufacturing workers, 17 of whom
groups, 15 female assembly workers making
contracted trapezius myalgia within 6 to
telephone exchanges, 27 female VDT users, 25
51 weeks compared to those workers who did
female data entry operators, and 29 male VDT
not. Diagnosis was based on both symptoms
users. Case definition for neck MSD was
and physical exam. There were prospective
based on self-reports. However,
interviews every 10 weeks to detect symptoms
musculoskeletal sick leave per man-labor years
of muscle pain. Daily pain diaries were also
was also used as an endpoint. For force
kept by subjects.
estimate the load on the
Exposure assessment consisted of measured

trapezius was measured by electromyography
static muscle tension recorded by EMG.
(EMG).
Interviews concerning exposure at work were
also conducted prospectively every 10 weeks
Quantification of the muscle load was done by
for 1 year. Only 55% of the subjects were
ranking the interval estimate (0.1 s) to produce
retained during the full study; however, the
an amplitude probability distribution function.
drop-outs were follow-up subjects and had
Both the total duration and number of periods
no significant differences in static muscle tension
per minute when muscle activity was below 1% compared to the participants.
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Viikari-Juntura et al. [1994] , the third about 10 to 30% of the maximum contraction
longitudinal study discussed under force and of the trapezius. This level, 10 to 30% of the
neck and neck/shoulder MSDs, used maximum contraction, was found by Tanii et al.
questionnaire to assess neck symptoms and [1972] to induce static fatigue significant
based exposure on job category, comparing enough to produce electromyographic changes.
688 machine operators, 553 carpenters, and Hales et al. [1989] and Kuorinka and
591 office workers. For the initial evaluation, Koskinen [1979] reported statistically
observation of work sites were performed. In significant ORs (1.6 and 4.1, respectively) for
multivariate analysis occupation, age, and the association between neck MSDs and high
current smoking were significant predictors in levels of force combined with high levels of
change from no neck trouble to severe neck repetition estimated for the hand/wrist areas.
trouble (ORs were not given for logistic There were no separate force measurements
model.) for the neck area. Both studies controlled for
age, gender, and length of employment in the
Wells et al. [1983] evaluated letter carriers with current job. Two of the four studies that used
an increased load on the shoulder from a estimated hand and wrist exposure
mailbag. Letter carriers were compared to gas measurement combinations of force and
meter readers (without heavy loads) and postal repetition (but carried out no neck, shoulder, or
clerks. A telephone survey was used to obtain upper extremity exposure measurements) found
both symptoms and exposure. This analysis non-significant associations between neck
was adjusted for age, number of years on the MSDs and force/repetition exposure [Baron et
job, quetelet (body mass) ratio and previous al. 1991; Kiken et al. 1990].
work experience.
Temporal RelationshipForce and
Of the studies in the tables, five (that did not Neck/Shoulder MSDs
fulfill all the inclusion criteria) examined the risk See temporal relationship above in Repetition
factor, force, either as trapezius muscle load and Neck/Shoulder MSDs.
(using EMG), or as forceful work in
combination with other risk factors [Aras Consistency in Association for Force
1994; Wells et al. 1983; Onishi et al. 1976; and Neck/Shoulder MSDs
Andersen and Gaardboe 1993a; Punnett
Both Kilbom et al. [1986] in their cross-
1991]. Wells et al. [1983] found a significant
sectional study and Jonsson et al. [1988] in
difference (p<0.05) in reported neck pain
their follow-up cohort studies found that
between letter carriers and postal clerks and
attributed it to weight from carrying heavy mail
bags on shoulder straps. In the Wells study,
confounding due to age, number of years on the time spent in physically heavy work before the
job, previous work experience, or quetelet present employment appeared as a strong risk
ratios was ruled out. As noted above, Onishi et factor for deterioration of health of the
al. [1976] reported that the operations studied neck/shoulder area (specifically, the health
required continuous contraction of the trapezius outcome was for the cervicobrachial region in
muscle to sustain the arms, estimated to be the Jonsson study). Jonsson et al. [1988] noted
that the physical demands of the previous jobs
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had only been assessed at the initial interview Other laboratory studies have examined muscle
and constituted a subjective estimate. damage that may arise during static muscle
However, the relationship was strengthened by contractions used to maintain static postures.
the consistency of findings in the prospective Hgg et al. [1990] proposed that while
and cross-sectional studies. maintaining static postures (that have low force
levels), the same low-threshold motor units are
Coherence of Evidence for Force contracted repeatedly for prolonged periods,
There is coherence with the biological during which time they work close to their
mechanisms proposed by Hagberg [1984] for maximal capacity. This may lead to injury of
occupational muscle-related disorders, such as these units, despite the fact that the total
tension neck syndrome. The first mechanism workload is low. This hypothesis was recently
concerns stress on the trapezius and supported by a longitudinal study by Veiersted
surrounding muscles of the neck from heavy et al. [1993] who investigated the number of
physical exertion that causes rupture of the rest-pauses during muscle fiber activity using
muscles z-discs, and an outflow of metabolites EMG recording from neck and shoulder
from the muscle fibers, and activation of pain muscles. Among subjects performing machine-
receptors through edema or other mechanisms. paced repetitive packing work, those with
This temporary high, local stress involving symptoms had fewer rest-pauses (0.9 versus
eccentric contractions in the shoulders 8.4 per minute) and a tendency toward shorter
improves with time through a re-orientation of total duration of rest-pauses in the muscle fiber
collagen in the muscles. This mechanism is activity of their trapezius muscle when
offered as an explanation for MSDs in workers compared with those without symptoms. These
unaccustomed to the work. The second mechanisms of decreased blood flow,
mechanism is from local decreased blood flow increased metabolite concentration, and
(ischemia), as seen in assembly workers whose prolonged activation of certain small units at
tasks involved dynamic, frequent contractions near maximum capacity may explain the chronic
above 10 to 20% of the MVC and few rest myofascial shoulder pain seen in workers
breaks. Reduced blood flow was found to be performing repetitive assembly work with static
correlated with myalgia (muscle pain) and loading of the trapezius muscles [Hagberg and
ragged red fibers in 17 patients with chronic Kvarnstrm 1984; Larsson et al. 1988].
myalgia thought to be associated with static
load during repetitive assembly work [Larsson Exposure-Response Relationship
et al. 1990]. The third pathophysiologic for Force
mechanism for muscle pain deals with energy aras [1994] reported that by reducing static
metabolism disturbance, caused by long-term muscle loading (an indication of force
static contractions of the muscles. Supporting measurement) through equipment changes
this theory was a study finding a correlation among VDT users, as well as improving
between muscle tension and plasma myoglobin workplace organization, he was able to
among patients with regional muscle tenderness decrease the prevalence of neck pain, decrease
and pain [Dammeskiold-Samse et al. 1982]. the number of sick days taken, and cause a
significant reduction in trapezius load measured
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by EMG in VDT operators. prevalences of neck symptoms and/or physical

findings in workers in occupations or tasks
Conclusions Regarding Force requiring some combination of forceful,
There is evidence for forceful exertion and repetitive movements, and extreme or static
neck MSDs in the epidemiologic literature. postures of the upper extremity, and compared
Most of the epidemiologic studies reviewed them to workers in occupations without those
defined forceful work for the neck/shoulder requirements.
as work activities that involve forceful arm or
hand movements that, in turn, generate the Twenty-seven studies that considered extreme
loads to the neck/shoulder area; no study or static posture found a statistically significant
examined a relationship based on actual positive association between posture and neck
forceful neck movements. Of the 17 studies or neck/shoulder MSDs; three had non-
addressing force as one of the exposure significant findings (Table
factors, 5 found statistically significant 2-1. Overall, in terms of magnitude of the
associations but did not derive ORs; 2 found association, looking at both significant and non-
ORs greater than 3.0, 7 found ORs from 1 to significant findings, 13 studies had estimations
3.0, and 2 studies showed ORs less than 1.0. of risk (ORs or PRRs) greater than 3.0, 9 had
Many of the studies regarding measured force risk estimates between 1
(as workload, etc.) and MSDs are in the and 3, and none had an estimate less than 1.0.
biomechanical and ergonomic literature. Eleven studies did not report their results in
terms of ORs or PRRs; of these, all but one
POSTURE found a significant relationship.
Definition of Posture for Neck and Studies Meeting the Four Evaluation Criteria
Neck/Shoulder MSDs Of the 31 studies evaluating neck postures and
We included those articles that mentioned neck neck MSDs, the four investigations mentioned
or head postures, adverse or extreme head or above [Ohlsson et al. 1995; Jonsson et al.
neck postures, or static postures of the head 1988; Kilbom and Persson 1987; Kilbom et al.
and/or neck. 1986] fulfilled the four evaluation criteria. Three
of these studies [Jonsson et al. 1988; Kilbom et
al. 1986; Kilbom and Persson 1987], dealt
with the same cohort; female electronics
workers
Studies Reporting on Posture as a
Work Factor for Neck and
Neck/Shoulder Musculoskeletal
Disorders followed for 3 successive years. These studies
We included 31 studies of the association found significant association between posture
between extreme or static posture and neck variables and neck MSDs; however, none used
and neck/shoulder MSDs, including TNS. methods that reported ORs.
Studies usually focused on the different
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Studies Not Meeting the Four Criteria for on questionnaire responses regarding heavy
Posture and Neck/Shoulder MSDs
lifting, monotonous or assembly line work,
Bernard et al. [1993] carried out a cross- sitting, uncomfortable work postures (bending
sectional study of 894 newspaper employees and twisting), and vibration. The psychosocial
using a questionnaire survey for case definition work environment was also studied; the
based on frequency, duration, and intensity of analysis was stratified for age and gender.
symptoms in the neck. Exposure was based
upon both questionnaire and job analysis. Time As part of a longitudinal study, Viikari-Juntura
spent on the telephone was associated with an et al. [1994] studied 154 subjects from
increased prevalence of neck MSDs, with a Helsinki, Finland that originally entered the
slightly elevated OR of 1.4. Analysis was study in 1955, and had repeated cross-
controlled for age, gender, height, psychosocial sectional exams from 1961 to 1963. During
factors, and medical conditions. that time, 1084 subjects underwent cross-
sectional examination. In 1985, a questionnaire
Kukkonen et al. [1983] compared 104 data was sent to all subjects; 801 (74%) responded.
entry operators with 57 female workers in Of the respondents, 180 lived in the Helsinki
varying office tasks. Neck MSD was based on area. It was from this group that 162
pre-determined symptom and physical exam. responded. Eight were excluded due to
Exposure was based on observation of illnesses. Outcome was based on questionnaire
posture, movements and working techniques, data for this study because of small number
assessment of equipment, interview with of abnormal physical findings, the physical
workers and supervisors. An intervention exam was eliminated from analysis. Exposure
consisting of adjustment of office furniture and was also based on survey, asking the amount of
equipment was carried out. The study group work with hands overhead, work in forward
was given a short course of basic training on bent position, and work in twisted or bent
pertinent aspects of ergonomics. Four lessons position. This analysis was controlled for
on relaxation was given by means of exercises. physical and creative hobbies, with no
interactions seen.
There was no controlling of confounders. There
was a significant decrease in tension neck
In a cross-sectional study of machine
syndrome among the cases involved in the
operators, carpenters were compared to office
intervention compared to those workers who
workers by Tola et al. [1988], who used a
had no change. postal questionnaire to obtain both health
outcome and exposure information. Analysis
Linton and Kamwendo [1989] surveyed used occupation to examine relationships.
22,180 employees undergoing screening Pain Drawing Diagrams were used to
examinations at their occupational health care distinguish body areas. For the logistic
service in Sweden. Neck cases defined from regression model a 12 month prevalence of
questionnaire responses as those persons neck and shoulder symptoms on 8 days or
reporting yes to having seen a health care more was used. The logistic regression models
professional for neck pain in the last year. were adjusted for years working in an
Cases were compared to non-cases defined occupation and age.
by outcome (neck pain). Exposure was based
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Welch et al. [1995] examined 39 electricians at forward flexion, upper arm elevation, and
a screening convention using surveys to collect cervicobrachial disorders weakened
information on symptoms and exposures. The (compared with the results that Kilbom et al.
questionnaire included questions concerning the [1986] had found), but that the results still
frequency of tasks performed, including the remained statistically significant in some of the
percent of time spent hanging duct work. The multifactorial analyses (no numerical results
analysis did not control for confounders except were reported). The most important finding,
for length of employment. according to the authors, was that reallocation
to more varied work tasks was a strong
Strength of Association for Posture predictor of improvement over the second
Ohlsson et al.'s [1995] study, discussed year. This change would have decreased static
previously, compared female industrial workers loading and increased the dynamic pattern of
performing repetitive tasks to referents without movements of the workers.
such exposure and found significant
associations (p<0.05) between (1) neck and Of those studies not fulfilling the four criteria,
neck/shoulder diagnoses with time spent in results regarding extreme or static posture were
neck flexion, with critical angles greater than similar to those of the studies which did fulfill
15E; and (2) neck/shoulder diagnoses and time them. Sakakibara et al. [1995] found a
spent with upper arm abduction greater than significant difference in the prevalence of neck
60E. MSDs when they examined orchard workers
who picked and bagged pears and two months
Kilbom et al. [1986], in the initial paper later picked and bagged apples. Exposure was
concerning the electronic workers, reported assessed by job analysis and posture
two findings: (1) that the more dynamic the measurements of two representative workers.
working technique, the fewer neck symptoms Arm and neck elevation was significantly
experienced by electronic workers; and (2) that greater for bagging pears (more than 90E for
the greater the average time per work cycle 75% of the time) than for bagging apples (less
spent in neck flexion, the greater the association than 40% of the time). The same authors found
with symptoms in the neck and neck/shoulder similar results in 1987 when only the symptoms
angle. A statistically significant association of orchard workers were studied. They found
(p<0.05) was also obtained from the job significant a positive association between
analysis variables describing neck forward posture and neck MSDs, reporting histograms
flexion and upper arm elevation and neck and (not ORs) in their article.
neck/shoulder disorders. Jonsson et al. [1988],
in the follow-up study, performed an analysis Although they did not mention the participation
that grouped the different parts of the neck and rates in their methods, Aras [1994], Veiersted
upper extremity into a health outcome labeled and Westgaard [1994], and Bjelle et al. [1981]
cervicobrachial disorder (unlike the cross- found significant relationships between postures
sectional study by Kilbom et al. [1986] that and neck MSDs (they fulfilled the other three
used neck and shoulder). They found that criteria). Veiersted and Westgaard [1994]
the relationships between MSDs and neck found an association between perceived
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strenuous postures and neck MSDs (OR 7.2), of neck MSDs for scissor makers (chosen for
but found that these perceived postures were their stereotypic, repetitive work using extreme
not reflected in any of the conventional EMG postures) compared to shop assistants,
parameters (static, median or peak loads) although no quantitative measurements or
measured in the participants. One explanation observations of neck posture were reported.
for these results may be information bias, if the One study by Hnting et al. [1981] showed a
data concerning perceived strenuous posture fairly strong association (OR 4.9) with
are from questionnaires. Another explanation constrained postures and neck MSDs in those
may be that EMG testing results reflect workers having neck flexion of more than 56E
parameters for a single day, whereas symptoms and an OR of 9.9 from the comparison of
were asked about concerning the entire groups. Several articles with significant posture
previous year. and neck MSD associations dealt with
comparisons of workers in occupations chosen
for higher observed combinations of exposure
Several studies that carried out no independent
factors and compared them to workers with
assessment of ergonomic factors, but relied on
fewer observed exposure stressors: Viikari-
self-reported exposure found significant
Juntura et al. [1994], OR 3.9 to 4.2; Milerad
relationships between posture variables and
and Ekenvall [1990], OR 2.6; and Wells et al.
neck disorders. Ekberg et al. [1994] found an
[1983], OR 2.57.
OR of 4.8 for the variable work with lifted
arms, and an OR of 3.6 for uncomfortable
For those studies that did not find a significant
sitting position and neck MSDs. Hales et al.
relationship, 2 out of the 3 did not carry out
[1994] found that use of bifocals (OR 3.8) in
observation or measurement (ergonomic
VDT users was significantly associated with
assessment) of the neck or upper extremity
neck MSDs; this variable was interpreted to be
postures. Ferguson [1976] stated that seven
a surrogate for neck posture, as bifocals
body dimensions were measured in the
require either neck flexion or extension for eye
telephonists studied, but that neither discomfort
accommodation when viewing a VDT screen.
nor aching were linked with any of these body
Bernard et al. [1994] reported that as workers
postures. The article does not mention the body
time spent on the telephone increased, so did
postures that were measured. Fergusons
the ORs for neck symptoms, and interpreted
conclusion, that physical complaints in
this variable as a surrogate for static posture
telephonists are probably due to static load on
requiring neck deviation to cradle the telephone
joints and muscles occasioned by the fixed
receiver. Holmstrm et al. [1992] found that
forward bent position determined by visual,
the odds of workers with neck MSDs reporting
auditory
working with hands above their shoulders for
greater than 4 hrs/day compared with those
and manipulative tasks. Ferguson's data are
reporting less than 1 hr/day was 2.0, a
contrary to the conclusions presented. These
statistically significant finding. Bergqvist et al.
conclusions may then only be speculative.
[1995a] reported an OR of 4.4 for workers
using highly placed keyboards in their logistic
modeling of neck MSDs. Kuorinka and
Koskinen [1979] found an increased OR (4.1)
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Temporality for Extreme or Static Coherence of Evidence for Extreme

Postures Or Static Postures
The prospective study by Veiersted and See section above under Coherence of
Westgaard [1994] followed the development Evidence for Force.
of trapezius myalgia among 30 female
chocolate manufacturing workers. Seventeen Exposure-Response Relationship for
workers developed the MSD within 6 to 51 Specific or Static Postures
weeks of starting work. Perceived strenuous The study by Ohara et al. [1976], mentioned
postures on the assembly line were found to earlier, not only portrayed the multifactorial
contribute to the disorders. Although retention nature of neck and shoulder MSDs, but
of subjects was low (55%), the authors found documented that an increase in specific and
that the drop-outs did not differ in exposure static postures by cash register operators using
estimates and symptom reporting from those new registers placed on unsuitable counter
retained in the study. The prospective study of heights increased symptoms in neck MSDs.
Viikari-Juntura et al. [1994] used self-reported
symptoms and exposure defined by Several studies have suggested an
occupational status to find a temporal exposure-response effect between increased
relationship between the development of severe level or duration of exposure and an increase in
and persistent severe neck pain and jobs number of cases of neck MSDs. Burt et al.
involving dynamic work, static posture, and [1990], in their investigation at a major urban
whole body vibration, as compared to office newspaper, found that an increase in the self-
work. reported percentage of time spent typing at
VDT keyboards was associated with a
Consistency in Association for moderate increase in neck symptoms. (Job
Extreme or Static Postures and analysis found a significant relationship between
Neck/Shoulder MSDs independent observation of time spent typing
Of the 31 studies we reviewed reporting results and self-reported time) Keyboard time was
on the association between specific or static considered by the authors to be a surrogate for
posture and neck and neck/shoulder MSDs, 27 time spent with the neck held in static postures
found statistically significant associations. There with arms unsupported. Rossignol et al. [1987]
were many different studies reporting ORs of found that the prevalence of neck symptoms
greater than 3.0 with CIs above 1, indicating among 1,545 clerical workers increased with
that the effects were not explained by chance. the number of hours per day using VDTs.
Consistent associations were also found in Knave et al. [1985] found that, among VDT
those studies dealing with specific postures and operators, total daily working hours and time
neck MSDs across many industries, from fish spent at the VDT screen were significant risk
workers [Ohlsson et al. 1995] to fruit pickers factors for neck pain. Andersen and Gaardboe
[Sakakibara et al. 1995], to assembly line [1993a,b] found an exposure-response
workers [Jonsson et al. 1988], to garment relationship between persistent neck pain and
workers [Vihma et al. 1982; Andersen and years of being a sewing machine operator,
Gaardboe 1993a,b]. controlling for age.
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performed in this study, and vibration was likely

Conclusions Regarding Extreme or to be confounded by neck twisting and static
Static Postures loads.
Overall, the strength of the association (OR
ranging from about 1.6 [Vihma et al. 1982] to ConclusionsVibration and Neck or
7 [Veiersted and Westgaard 1994], dropping Neck/Shoulder MSDs
the outliers) between specific postures and We conclude that there is insufficient
neck MSDs was similar between studies using evidence to support an association between
the most restrictive criteria and carrying out a vibration and neck or neck/shoulder MSDs
prospective design and those that used based on strength-of-association criteria. Too
symptom-based health outcome or self- few studies of neck or neck/shoulder MSDs
reported exposures to static or specific have examined the relationship between
postures and cross-sectional methods. We exposure to vibration and to draw any
conclude that there is strong evidence for conclusions about their relationship.
support of an association between static or
specific postures and neck and neck/ shoulder NECK OR NECK/SHOULDER MSDs
MSDs based on strength of association criteria. AND THE ROLE OF CONFOUNDERS
A positive relationship has been observed As in many MSDs, prevalence of neck and
between exposure to this risk factor and neck neck/shoulder disorders tends to increase with
or neck/shoulder MSDs in studies where age. Therefore, it is important that studies take
chance, bias, and confounding can be ruled out into account when examining the strength of
with reasonable confidence. occupational versus non-occupational factors.
Age and gender were the primary potential
VIBRATION confounders that investigators addressed in
many of the studies on neck and neck/shoulder
No study of neck MSDs met the four criteria to
MSDs (The tables at the end of the chapter list
address strength of association between
summaries of each of the articles and include
vibration and neck MSDs and only one of the
which particular covariates or confounders
reviewed studies in the tables mentioned neck
were considered.) These were either dealt with
MSDs and vibration. Viikari-Juntura et al. by logistic regression modeling, as in the case
[1994] selected study groups for their of age (e.g., Andersen and Gaardboe [1993a];
longitudinal study based on different work Rossignol et al. [1987]; Tola et al. [1988];
exposures. Machine operators exposed to Ohlsson et al. [1989]; Baron et al. [1991]),
static work and whole-body vibration were through matching of case subjects and referents
compared to carpenters exposed to dynamic (e.g., Vihma et al. [1982]), or through study of
physical work and presumably no vibration to a single gender (e.g., Luopajrvi et al. [1979];
see whether occupational status was related to
neck MSDs. Results found that the OR for Hnting et al. [1994]), or stratifying by gender
progressing from no neck pain to moderate to [Sakakibara et al. 1995]. Most studies
severe neck trouble was from 3.9 to 4.2; for performed univariate analysis prior to logistic
operators compared to carpenters; a significant regression to consider factors which needed to
difference. No vibration measurements were be introduced into the logistic models as
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confounders or covariates. There is also reasonable evidence for a causal

relationship between highly repetitive work and
Almost all the studies we reviewed accounted neck and neck/shoulder MSDs. Most of the
for the confounders of age and gender. Many epidemiologic studies reviewed defined
of the studies controlled for leisure exercises repetitive work for the neck as work
[Andersen and Gaardboe [1993a,b] smoking activities which involve continuous arm or hand
(Linton [1990]; Milerad and Ekenwall [1990]; movements which affect the neck/shoulder
Bergqvist et al. [1995a,b]; Viikari-Juntura et al. musculature and generate loads to the
[1994]), medical conditions [Bernard et al. neck/shoulder area; fewer studies examined
[1994]; Hales et al. [1994]). Reviewing the relationships based on actual repetitive neck
methods and results of these studies, the movements. The two studies which measured
confounding factors do not account for the repetitive neck movements by head position
consistent relationship that is found with the (using frequency and duration of movements),
work-related factors.
and fulfilled the four criteria, found strong
associations with neck/shoulder MSDs. In
CONCLUSIONS
those studies defining repetitive work as
Interpreting association for individual continuous arm or hand movements affecting
workplace factors is difficult, as most the neck/shoulder, nine studies found
epidemiologic studies of MSDs used statistically significant ORs greater than 3.0.
populations selected because of multiple factors Eight studies fulfilled all the criteria except for
(such as forceful exertion and repetitive tasks). objective exposure assessment and measured
Unlike laboratory experiments, one cannot repetition for the hand/wrist, not the neck. Of
isolate exposure factors, nor alter some factors these, three had statistically significant ORs
while keeping others constant to insure greater than 3, and five had non-significant
accuracy in examining, recording, and ORs, all under 2.0.
interpreting results. However, one can examine
the body of epidemiologic evidence and infer There is reasonable evidence for forceful
relationships. There have been over 40 exertion and neck MSD found in the
epidemiologic studies which have examined epidemiologic literature. Most of the
work factors and their relationship to neck and epidemiologic studies reviewed defined
neck/shoulder MSDs. Many studies identified forceful work for the neck/shoulder as work
individuals in heavier industrial occupations and activities which involve forceful arm or hand
compared them to workers in light industry or movements which generate the loads to the
office environments. Other studies identified a neck/shoulder area; no study examined a
symptomatic group of workers, or those with relationships based on actual forceful neck
symptoms and physical exam abnormalities, movements. Of the 17 studies
and compared them to asymptomatic workers
at the same worksite, or to population addressing force as one of the exposure
referents, and looked for differences in factors, five studies found statistically significant
exposure. These approaches, although quite associations but did not derive ORs; two
different, by and large have chosen to focus on studies found ORs greater than 3.0, seven
similar workplace risk factors. These include studies from 1 to 3.0, and 2 studies with ORs
repetition, forceful exertions, and constrained less than 1.0.
or static postures, usually found in combination.
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There is strong evidence that working groups have included interventions to decrease
with high levels of static contraction, prolonged workplace risk factor exposures, including
static loads, or extreme working postures decreasing repetitive work and less extreme
involving the neck/shoulder muscles are at working postures, have shown a decrease in
increased risk for neck/shoulder MSDs. incidence of neck MSDs, and an improvement
Consistently high ORs (12 studies found in symptoms among affected workers. These
statistically significant ORs over 3.0) for tension data provide additional evidence that these
neck syndrome associated with static postures disorders are related to work factors.
or static loads have been found.
However, cumulative exposure-response data
The epidemiologic data are insufficient to is lacking, although VDT studies using
document relationship of vibration and neck surrogate exposure variables suggests a
disorders. The few prospective studies which relationship.
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Table 2-1. Epidemiologic criteria used to examine studies of neck MSDs associated with repetition
Investigator
Risk indicator blinded to case
(OR, PRR, IR Participatio Physical and/or exposure Basis for assessing neck
Study (first author and or p-value)*, n rate $$70% examinatio status exposure to repetition
year) n
Met all four criteria:
Ohlsson 1995 3.6 Yes Yes Yes Observation or

measurements
Met at least one criterion:
Andersen 1993b 6.8 Yes Yes Yes Job titles or self-reports
Baron 1991 2.0 No Yes Yes Job titles or self-reports
Bergqvist 1995b 6.9 Yes Yes Yes Job titles or self-reports
Hales 1989 1.6 Yes Yes Yes Job titles or self-reports
Kamwendo 1991 1.65 Yes No NR Job titles or self-reports
Kiken 1990 1.3 Yes Yes Yes Job titles or self-reports
Knave 1985 NR Yes No NR Job titles or self-reports
Kuorinka 1979 4.1 Yes Yes NR Job titles or self-reports
Luopajrvi 1979 1.6 Yes Yes Yes Job titles or self-reports
Onishi 1976 3.8 NR Yes NR Observation or

measurements
Sakakibara 1987 NR Yes No NR Job titles or self-reports
Schibye 1995 3.3 Yes No NR Job titles or self-reports
Yu 1996 28.9 Yes No NR Job titles or self-reports
Met none of the criteria:
Liss 1995 1.7 No No No Job titles or self-reports
Ohlsson 1989 1.9 NR No NR Job titles or self-reports
*Some risk indicators are based on a combination of risk factorsnot on repetition alone (i.e., repetition plus force, posture,
or vibration). Odds ratio (OR), prevalence rate ratio (PRR), or incidence ratio (IR).
Indicates statistical significance. If combined with NR, a significant association was reported without a numerical value.
Not reported.
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Table 2-2. Epidemiologic criteria used to examine studies of neck/shoulder MSDs associated with repetition
Investigator
Risk indicator blinded to Basis for assessing
(OR, PRR, IR Participation Physical case and/or neck/shoulder exposure
Study (first author and or p-value)*, rate $$70% examinatio exposure to repetition
year) n status
Jonsson 1988 NR, Yes Yes Yes Observation or

measurements
Ohlsson 1995 4.6 Yes Yes Yes Observation or

measurements
Andersen 1993a 4.6 Yes No Yes Job titles or self-reports
Bergqvist 1995a 3.6 Yes No Yes Observation or

measurements
Blder 1991 NR Yes Yes No Job titles or self-reports
Ekberg 1994 15.6 Yes No NR Job titles or self-reports
Ekberg 1995 1.2 Yes No NR Job titles or self-reports
Hnting 1981 9.9 NR Yes NR Observation or

measurements
Milerad 1990 2.1 Yes No NR Job titles or self-reports
Punnett 1991 1.8 Yes No NR Observation or

measurements
Rossignol 1987 1.84.6 Yes No NR Job titles or self-reports
Vihma 1982 1.6 NR No NR Observation or

measurements
Not reported.
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Table 2-3. Epidemiologic criteria used to examine studies of neck MSDs associated with force
Investigator
(OR, PRR, IR Participatio Physical and/or Basis for assessing neck
Study (first author and year) or p-value)*, n rate $$70% examinatio exposure status exposure to force
n
Baron 1991 2.0 No Yes Yes Job titles or self-reports
Kiken 1990 1.3 Yes Yes Yes Job titles or self-reports
Luopajrvi 1979 1.6 Yes Yes Yes Job titles or self-reports
Veiersted 1994 6.7 No Yes NR Observation or measurements
Viikari-Juntura 1994 3.0 Yes No Yes Job titles or self-reports
Wells 1983 2.57 Yes No NR Job titles or self-reports
*Some risk indicators are based on a combination of risk factorsnot on force alone (i.e., force plus repetition, posture,
Indicates statistical significance.
Not reported.
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Table 2-4. Epidemiologic criteria used to examine studies of neck/shoulder MSDs associated with force
Risk Investigator Basis for assessing

indicator Participatio Physical blinded to case neck/shoulder exposure
Study (first author and year) (OR, PRR, IR n rate $$70% examinatio and/or exposure to force
or p-value)*, n status
aras 1994 NR, NR No NR Observation or measurements
Bjelle 1981 NR NR Yes Yes Observation or measurements
Jonsson 1988 NR Yes Yes Yes Job titles or self-reports
Punnett 1991 0.9 (females) Yes No NR Observation or measurements

1.8 (males)
Not reported.
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Table 2-5. Epidemiologic criteria used to examine studies of neck MSDs associated with posture
Investigator
Risk blinded to case
indicator Participation Physical and/or Basis for assessing neck
Study (first author and year) (OR, PRR, IR rate $$70% examination exposure exposure to posture
or p-value)*, status
Bernard 1994 1.4 Yes No Yes Job titles or self-reports
Ferguson 1976 NR Yes No No Observation or measurements
Kamwendo 1991 1.65 Yes No NR Job titles or self-reports
Kukkonen 1983 3.6 NR Yes Yes Job titles or self-reports
Linton 1990 3.5 Yes No NR Job titles or self-reports
Onishi 1976 3.8 NR Yes NR Observation or measurements
Sakakibara 1987 NR Yes No NR Observation or measurements
Sakakibara 1995 1.5 Yes Yes NR Observation or measurements
Veiersted 1994 7.2 No Yes NR Observation or measurements
Viikari-Juntura 1994 3.94.2 Yes No Yes Job titles or self-reports
Welch 1995 7.5 Yes No No Job titles or self-reports
Yu 1996 784.4 Yes No NR Job titles or self-reports
*Some risk indicators are based on a combination of risk factorsnot on posture alone (i.e., posture plus force, repetition,
Not reported.
Physical examinations were not analyzed because there were too few cases.
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Table 2-6. Epidemiologic criteria used to examine studies of neck/shoulder MSDs associated with posture
Investigator
Risk indicator blinded to case Basis for assessing
(OR, PRR, IR Participation Physical and/or neck/shoulder exposure
Study (first author and year) or p-value)*, rate $$70% examination exposure to posture
status
Jonsson 1988 NR, Yes Yes Yes Observation or measurements
Kilbom 1986 NR Yes Yes Yes Observation or measurements
Ohlsson 1995 NR Yes Yes Yes Observation or measurements
aras 1994 NR NR No NR Observation or measurements
Bergqvist 1995a 4.4 Yes No Yes Observation or measurements
Blder 1991 NR Yes Yes No Job titles or self-reports
Ekberg 1994 4.8, Yes No NR Job titles or self-reports

3.6
Holmstrm 1992 2.0 Yes No Yes Job titles or self-reports
Hnting 1981 9.9 NR Yes NR Observation or measurements
Rossignol 1987 1.8, Yes No NR Job titles or self-reports

4.0,
4.6
Ryan 1988 NR Yes No Yes Observation or measurements
Tola 1988 1.8 Yes No NR Job titles or self-reports
Vihma 1982 1.6 NR No NR Observation or measurements
Viikari-Juntura 1991a 1.5 Yes Yes NR Job titles or self-reports
Not reported.
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Table 27. Epidemiologic studies evaluating work-related neck musculoskeletal disorders
MSD Prevalence
Study Exposed Referent RR, OR,
Study design Study population Outcome and exposure workers group or PRR 95% CI Comments
Andersen and Cross- 701 female sewing machine Outcome: Case of chronic pain 26.2% General SMO compared Participation rate: 78.2%.
Gaardboe sectional operators (SMO), compared was defined as continuous pain population: to: (1) General
1993a to 781 females from the lasting for a month or more after 9.9% population: Examiners blinded to
general population of the beginning work and pain for $30 Internal OR=3.2 control/subject status.
region and internal referent days within the past year. referent (2) Internal 2.3-4.5
group of 89 females from group: referent group: Controlled for age, having children,
the garment industry. Exposure: Job categorization 6.7% OR=4.9 not doing leisure exercise, smoking
based on authors experiences 2.0-12.8 socioeconomic status.
as occupational health Logistic Model:
physicians and involved crude Years as SMO: Age-matched exposure groups
assessment of exposure level 0 to 7 years: and controls.
and exposure repetitveness. 1.9
Jobs involving high 8 to 15 years: 1.3-2.9 Logistic regression limited to a
repetitiveness (several 3.8 combined neck/shoulder case
times/min) and low or high force, >15 years: 2.3-6.4 definition.
and jobs with medium 5.0
repetitiveness (many times/hr) 2.9-8.7 No difference in education, marital
combined with high force were Age $ 40 status, number of children.
classified as high exposed jobs; years: 1.5
jobs with medium repetitiveness 1.1-2.2 Poor correlation between
and low force and jobs with Children (>0): degenerative X-ray neck changes
more variation and high force 1.3 and cervical syndrome.
were classified as medium 0.8-2.0
exposed. Job titles such as Exercise: 0.9 Most frequent diagnosis among
teachers, self-employed, trained 0.6-1.3 study group was cervicobrachial
nurses, and the academic Socioeconomic fibromyalgia significant for test of
professions were low status: 1.29 trend with exposure time in years.
exposed. 0.7-2.3
Smoking: 1.39 Chronic neck pain and palpatory
0.99-1.9 findings: Sensitivity: 0.85;
Current Specificity: 0.93.
Exposure: 1.3
0.9-1.9
(Continued)
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Table 27 (Continued). Epidemiologic studies evaluating work-related neck musculoskeletal disorders
MSD prevalence
Andersen and Cross- From a historical cohort of Outcome: Measured by health Referents: 0 to 7 years: Participation rate: 78.2%; logistic
Gaardboe sectional 424 sewing machine interview and exam of the neck, OR=1 2.3 0.5-11 regression limited to a combined
1993b operators, 120 were shoulder and arm. Case of neck/shoulder case definition.
randomly selected and 82 chronic pain was defined as 8 to 15 years:
exposed workers were continuous pain lasting for a 6.8 1.6-28.5 Age-matched exposure groups
categorized by number of month or more after beginning and controls.
years of employment: 0-7 work and pain for at least >15 years:
years, 8-15 years and 30 days within the past year. 16.7 4.1-67.5 Examiners blinded to
greater than 15 years. Physical examination: Restricted control/subject status.
These were compared to a movements in the cervical spine Age at least 40
referent group of 25 and either palpatory tenderness years: 1.9 O.9-4.1 Controlled for age, having children,
auxiliary nurses and home in cervical segments or not doing leisure exercise,
helpers. A total of 107 irradiating pain or tingling at Children >0 smoking, socioeconomic status.
subjects participated. maximum movements or positive years: 0.5 0.1-1.7
foraminal test. Poor correlation between
Exercise: 1.4 0.6-2.96 degenerative X-ray neck changes
Exposure: Exposure and cervical syndrome.
categorization broken down Smoking: 1.5 0.7-3.3
according to current Most frequent diagnosis among
occupational status by job title. Current high study group was cervicobrachial
Classification into exposure exposure: 1.6 0.7-3.6 fibromyalgia significant for test of
groups based on authors trend with exposure time in years.
experiences as occupational
health physicians and involved Chronic neck pain vs. palpatory
crude assessment of exposure findings: Sensitivity: 0.85;
level and exposure Specificity: 0.93.
repetitiveness. High exposure
jobs: Involved high
repetition/high force or high
repetition/low force or medium
repetition/high force. Medium
exposure jobs involved medium
repetition/low force and low
repetition and high force. Low
exposure jobs were low
repetition/low force.
(Continued)
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MSD prevalence
Baron et al. Cross- 124 grocery checkers Outcome: Based on symptom 16% 5% Odds of neck Participation rate: 85% checkers;
1991 sectional using laser scanners (119 questionnaire and physical pain, 55% non-checkers in field study.
females, 5 males) exam. Case defined as having checkers vs. Following telephone survey 91%
compared to 157 grocery positive symptoms and a positive non-checkers: checkers and 85% non-checkers.
non-checkers (56 females, physical exam. Symptoms must OR=2 0.6-6.7
101 males); excluded 18 have begun after employment at Examiners blinded to workers job
workers in meat, fish, and supermarket of employment and and health status.
deli departments, workers in current job; lasted one week
under 18 and pregnant or occurred once a month during Adjusted for duration of work, age,
workers. the past year; no history of hobbies, systemic disease obesity.
acute injury to part of body in
question. Total repetitions/hr ranged from
1,432 to 1,782 for right hand and
Exposure: Based on job 882 to 1,260 for left hand.
categorization. Estimates of
repetition and average and peak Average forces for cashiers were
forces of hand and wrist based low and peak forces medium.
on observed and videotaped Force was not analyzed in the
postures, weight of scanned models.
items, and subjective
assessment of exertion. Multiple awkward postures of all
upper extremities recorded but not
Specific neck assessment was analyzed in models.
not done.
Statistically significant increase in
neck MSD with increase in years
checking.
(Continued)
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MSD prevalence
Bergqvist et Cross- Office workers using Outcome: Neck discomfort any Neck: Asympto- Tension neck Participation rate: 92% of 353
al. 1995a sectional VDTs, (n=260), 198 discomfort over the last 12 61.5% matic syndrome: office workers.
females; symptomatic months; intense neck Female: workers Females no
cases compared to non- discomfort as above, if 63% children: Adjusted for age and gender.
cases. occurred in last 7 days and Male: 57% OR= 2.0 0.7-5.6
interfered with work. Factors included in analysis: Age,
Females with gender, smoking, children at home,
Outcome: Physiotherapist's TNS: 22% children: negative affectivity, tiredness-
diagnosis of: (1) tension neck Female: OR=6.4 1.9-21.5 related stress reaction, stomach-
syndrome (TNS): ache/pain in 25% related stress reaction, use of
the neck; feeling of tiredness Male: 13% Limited rest spectacles, peer contacts, rest
and stiffness in neck; possible break: OR=7.4 breaks, work task flexibility,
headache; pain during 3.1-17.4 overtime, static work position, non-
movements; muscular Cervical Too highly use of lower arm support, hand in
tenderness; (2) cervical diagnosis: place non-neutral posture, repeated
diagnosesache/pain in neck 23% keyboard: movements with risk of tiredness,
and arm; headache; decreased Female: OR=4.4 height differences
mobility due to cervical pain 25% 1.1-17.6 keyboard/elbow, high visual angle
during isometric contraction; Male: 20% Cervical to VDT, glare on VDT.
often root symptoms such as Diagnoses:
numbness or parathesias. Age >40 Found that frequent overtime
OR=2.7 protective for cervical diagnoses
Exposure: Based on 1.0-7.2 OR=0.48 (0.23, 0.99).
observation static work Spectacles:
posture, nonuse of lower arm OR=4.0 Examiner and workplace
support, hand in non-neutral 1.3-12.5 investigators blinded to case and
position, insufficient leg space at Static Posture: exposure status.
table, repeated movements with OR=5.1
risk of tiredness, specular glare 0.6-42.5 There are problems with
present on VDT. Measured: Spectral glare: interpreting results because of
Height difference of VDT OR=1.9 multiple comparisons and multiple
keyboard-elbow, high visual 0.9-4.2 models.
angle to VDT. Stomach
reactions: Not all significant findings
OR=3.9 presented in paper.
2.0-7.7
Tiredness: 1.9
1.0-3.5
(Continued)
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MSD prevalence
Bergqvist et Cross- 322 office workers; VDT Outcome: Neck discomfortany Neck Current VDT Participation rate: 76%.
al. 1995b sectional users compared to non- discomfort over the last 12 discomfort: work:
VDT users. months; intense neck/shoulder 60% OR=1.4 0.8-2.4 Adjusted for age and gender.
52% interactive, discomfortas above, if
29% data entry, 19% non- occurred in last 7 days and Intensive neck discomfort
VDT users. interfered with work. Intense Intense associated with VDT work over 20
neck neck hr and having stomach reactions
Outcome: Physiotherapist's discomfort: discomfort: often and repetitive movements:
diagnosis of tension neck 7.4% OR=0.5 0.2-1.8 OR=3.9 (1.1, 13.8).
syndrome (TNS)ache/pain in
the neck; feeling of tiredness Tension Tension Originally 535 workers queried in
and stiffness in neck; possible neck neck 1981. Of those, 182 had left the
headache; pain during syndrome: syndrome: workplace (quit, retired, etc.).
movements; muscular 21% OR=1.0 0.5-1.9 Possible bias from healthy worker
tenderness. effect.
TNS Diagnosis:
Exposure: Based on self- <20 hr/week Covariates considered: Children at
reporting of VDT use. VDT VDT: 1.2 0.4-3.7 home, smoking, negative
users categorized into data affectivity, stomach-related stress
entry or interactive VDT users. >20 hr/week reactions, tiredness-related stress
VDT: 0.7 0.3-1.5 reactions. Organizational factors
considered: limited or excessive
TNS diagnosis peer contacts, limited rest break
with bifocal or opportunity, limited work task
progressive flexibility, frequent overtime.
glasses at VDT
work and $20 For cervical diagnoses: Excess OR
hr/week VDT suggested for combined
work duration: occurrence of VDT work of
OR=6.9 1.1-42.1 >20 hr/week and specular glare on
the VDT screen.
(Continued)
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MSD prevalence
Bernard et al. Cross- Of a total population of Outcome: Health data and 26% (case) Females: Participation rate: 93%.
1994 sectional 3,000 workers in the psychosocial information were OR=2.1 1.4-2.4
editorial, circulation collected using a self- Cases with Examiners blinded to case and
classified advertising and administered questionnaire. daily neck Number of hr exposure status.
accounting departments, Definition: Presence of pain, pain: 22% spent on
1,050 were randomly numbness, tingling, aching, deadline/week Analysis controlled for
selected for study and 973 stiffness or burning in the neck (30 to 39 hr vs. confounders, age, gender, height,
participated. Those fulfilling occurring $ once a month or 0 to 10 hr) psychosocial factors, medical
case definition compared to 7 days continuously within the OR=1.7 1.4-3.0 conditions.
those workers not fulfilling past year, reported as
definition. moderately severe. The Work variance Psychosocial scales analyzed by
symptom must have begun (continually splitting the responses into
during the current job. Workers changing work quartiles, then comparing the 75%
with previous nonoccupational load; response score to the 25%
injuries to the relevant area occasionally response score for deriving the
were excluded. vs. often) ORs in each scale.
OR=1.7 1.2-2.5
Exposure: Based on In sub-analysis of jobs having
observation of work activity Time spent on comparable number of males and
involving keyboard work, work the telephone females. Only number of hr spent
pace, posture, during a typical (4 to 6 hr vs. 0 on deadline/week and perceived
day of a sample of 40 workers to 2 hr): lack of importance for ergonomic
with and 40 workers without OR=1.4 1.0-1.8 issues by management were
symptoms. Exposure to work significant.
organization and psychosocial Perceived lack
factors based on questionnaire of importance
responses. for ergonomic
issues by
management:
OR=1.9 1.4-2.4
(Continued)
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MSD prevalence
Ferguson Cross- 418 telephonists Outcome: Symptoms by Tele- Chi sq=11.01 Participation rate: 95%.
1976 sectional interviewed questionnaire. Neck ache phonists: (df=2), p<0.005
categorized on 3-point Uncomfort- Although author states the
discomfort scale: (1) very able or following: Discomfort, aching, and
comfortable, (2) barely very other symptoms are common,
comfortable, and (3) uncomfort- important but usually neglected
uncomfortable, very able neck problems in telephonists which
uncomfortable. ache =26% could be ameliorated by ergonomic
job and equipment, the results of
Exposure: Personal and social his study did not support his
attributes and attitudes to conclusion.
aspects of the work and the
equipment were obtained by Neither discomfort nor aching was
questionnaire. Seven body linked to any of the body postures
dimensions were measured, and observed.
standing posture was
categorized by observation Height and weight were not related
against a grid according to to discomfort or aching.
predetermined criteria.
Multiple correlations not helpful in
identifying combinations of
personal, equipment, environmental
or other variables predictive of
aching and discomfort.
(Continued)
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MSD prevalence
Hales and Cross- Of 96 female workers Outcome: Period prevalence Period Period Outcome: Neck Participation rate: 93%.
Fine 1989 sectional employed in 7 high symptoms in last 12 months by prevalence: prevalence: symptoms:
exposure jobs in poultry questionnaire. Case defined as: 21% 13% RR=1.64 Adjustment for age and duration of
processing: 89 were Pain, aching, stiffness, 0.4-3.19 employment.
compared to 23 of 25 numbness, tingling or burning in Point Point Outcome: Neck
female workers in low the neck and symptoms began prevalence: prevalence: symptoms and Examiner blinded to case and
exposure jobs. after employment at the plant; 12% 0% physical: exposure status.
were not due to a previous OR
injury or trauma to the joint; indeterminate Exposure based on repetitive and
lasted >8 hr; and occurred 4 or because of 0" forceful hand/wrist motions and
more times in the past year. cell not neck exposure assessment.
Point prevalence: Determined by Estimated OR 80% of workers involved in job

physical exam of the neck using by adding 1 to rotation program.
standard diagnostic. Tension each cell in
neck syndrome: Palpable muscle crude 2 X 2 No information collected on non-
tightness, hardening or pain $ 3 table: 3.69 work related risk factors.
(on 8 point scale) on passive or
resisted neck flexion or rotation. 0.4-164
Cervical root syndrome: Pain $
(on 8 point scale) radiating from
neck to one or both arms with
numbness in the hand criteria.
Case must also fulfill symptom
definition.
Exposure: Observation and

walk-throughs; jobs categorized
as high exposure and low
exposure based on estimates of
force and repetition of hand
maneuvers.
(Continued)
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MSD prevalence
Hales et al. Cross- Telecommunication workers Outcome: Self-administered 9% Lack of Participation rate: 93%.
1994 sectional (n=518, 416 females, 117 questionnaire and standardized decision
males) in 3 offices, physical exam (PE). Case making Physician examiner blinded to
employed > 6 months. defined as: Pain, aching, opportunities: worker case status.
stiffness, burning, numbness or OR=4.2 2.1-8.6 Logistic analysis adjusted for
"Cases" fulfilling neck tingling lasting >1 week or demographics, work practices,
work-related MSD definition >12 times a year; no previous Use of work organization, individual
compared to non-cases. traumatic injury to neck; bifocals: factors; electronic performance
occurring after employment on OR=3.8 1.5-9.4 monitoring; DAO keystrokes;
current job within the last year Denver DAO keystrokes/day.
and positive PEmoderate to Lack of a ORs for psychosocial variables
worst pain experienced with productivity represent risk at scores one
tension neck or cervical root standard: standard deviation above mean
syndrome. OR=3.5 1.5-8.3 score compared to risk at scores
one SD below mean.
Exposure: Assessed by Fear of being
questionnaire and observation; replaced by Because of readjustments and
changes of workstations during
number of keystrokes/day; no computers: study period, measurements of
exposure questions were OR=3.0 1.5-6.1 VDT workstations considered
specifically aimed at the neck unreliable and excluded from
region. High analyses.
information
Physical workstation and processing Number of hr spent in hobbies and
recreational activities not
postural measurements were demands: significant.
taken but not analyzed in OR=3.0 1.4-6.2
models. Although keystrokes/day found not
Job requiring a significant, data available was for
variety of workers typing an average of 8
tasks: words/min over 8-hr period.
OR=2.9 1.5-5.8
97% of participants used VDT
$6 hr so not enough variance to
Increasing evaluate hr of typing.
work
procedure: Over 70 variables analyzed in
OR=2.4 1.1-5.5 models may have multiple
comparison problem.
(Continued)
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MSD prevalence
Hunting et al. Cross- 308 of 400 apprentice and Outcome: Three-symptom 16% Participation rate: 75%.
1994 sectional journeymen, electricians definitions used; most restrictive
from one labor union includes neck symptoms 3% with 1 to 3 years 98% of participants were male.
participated. occurring $once/month or lasting medical worked: OR=1
>1 week during past year, and visits, Stratified by most experienced vs.
no previous traumatic injury to missed 4 to 5 years least experienced electrician, by
site. work, or worked: years worked, by age group,
light duty OR=1.3 current work as an electrician.
Exposure: Questionnaire dealing
with lifting activities, working 6 to 10 years Analysis of specific work factors
overhead, working with hand worked: (repetition, force, extreme posture,
tools. OR=1.6 vibration, or combinations of risk
factors) not analyzed in this paper
>10 years which dealt with prevalence of
worked: symptoms among electricians.
OR=1.3
(Continued)
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MSD prevalence
Kamwendo et Cross- 420 medical secretaries; Outcome: Questionnaire using 6 63% OR for work Participation rate: 96%.
al. 1991 sectional compared those frequently point scale ranging from very period with office
having neck pain to those often to almost never and prevalence. machines 5 hr Neck symptoms associated with a
less frequently having pain. Nordic Questionnaire. Definition or more/day: "poorly experienced psychosocial
of neck MSD: Discomfort, ache, 33% point 1.65 1.02-2.67 work environment.
or pain during previous year; prevalence.
whether they had pain in last 7 Working >5 Age, length of employment
days, whether pain prevented 15% with years: OR=1.6 significantly related to neck pain.
them from doing daily duties. constant 0.9-2.8
10 questions on psychosocial neck pain. Sitting 5 or Questionnaire included
work environment included. more hr/day: psychosocial scales, length of
OR=1.9 employment, part-time or full-time
Exposure: Based on 0.86-2.6 work, average hr sitting working
questionnaire. Low exposure with machines.
was regarded as 1 to 4 hr sitting
or working with office machines, Ability to influence work, a friendly
high exposure was regarded as spirit of cooperation between co-
5 to 8 hr. workers, being given too much to
do significantly positively
associated with neck pain.
(Continued)
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MSD prevalence
Kiken et al. Cross- 294 poultry processors. Outcome: Period prevalence Plant #1: Plant #1: Participation rate: 98%.
1990 sectional Plant #1 (n=174) based on questionnaire. Case (High (Low
Plant #2 (n=120) pain, aching, stiffness, burning, exposure) exposure) OR= Analysis stratified by gender and
numbness or tingling in the neck, Any symp- Any symp- age.
began after employment at the toms: 34% toms: 16% 2.2 0.9-5.0
plant; not due to previous Period Higher exposure jobs (HE) were
accident or injury outside work; Period preva- located in the receiving,
lasted >8 hr and occurred 4 or prevalence: lence: 3% evisceration, whole bird grading,
more times in the past year. 9% 2.9 0.4-21.4 cut up and deboning departments.
Point Lower exposure jobs (LE) were
Point prevalence: Based on Point preva- located in the maintenance,
symptom and physical exam prevalence: lence: 3% sanitation, quality assurance and
using standard diagnostic 4% 1.3 0.2-11 clerical departments.
criteria. Case must fulfill
symptom definition listed above. Plant #2: Examiners blinded to case and
Plant #2: (Low expo- exposure status.
Exposure: Observation and (High sure) Any
walkthrough; jobs categorized exposure) symptoms: OR= 30% of workers in job rotation
as high exposure and low Any 11% program may influence
exposure based on observed symptoms: 3.9 1.5-10.2 associations.
force and repetition of hand 42%
maneuvers. Period Annual turnover rate -50% at plant
Period prevalence: 1 and 70% at plant 2; making
prevalence: 3% survivor bias a strong possibility.
5% 1.8 0.2-15.2
Point
Point prevalence:

prevalence: 0%
1%
(Continued)
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MSD prevalence
Knave et al. Cross- 400 VDT operators from Outcome: Questionnaire Results Results Participation rate: Initially exposed
1985 sectional 4 industries using VDTs >4 symptom questionnaire based on estimated estimated 97%; referent 100%; Phase IV
hr/day; compared to frequency and intensity scores: from from Typing hr exposed 84% referents 84%.
157 office employees negligible=1, slight=2, histogram: histogram: significantly
Cases and referents matched on
without VDT work at the pronounced=3. related to neck age and gender.
same industries. Rt. side of Rt. side of symptoms.
Exposure: Based on self- neck: 5% neck: 5% Musculoskeletal complaints
assessment hrs of typing. A Dose-response grouped in analysis; because of
special gaze direction instrument Lt. side of Lt. side of relationship large number of comparisons,
recorded time spent looking at neck: 20% neck: 0% found between some without a prior hypotheses,
reliable conclusions limited to
VDT screen. Observation was registered p<0.001.
conducted but not included in work duration
analysis. and musculo- Significant difference between
skeletal females and males in reported neck
complaints. symptoms.
No statistical difference between
cases and referents in discomfort
scores, but tendency towards
higher discomfort scores for
shoulder, neck, and back among
the exposed group.
No difference in cases and
referents in whether work was
interesting or they had a positive
attitude towards work.
Age, smoking, educational status,
and drinking did not correlate with
symptoms.
Females reported more symptoms
than males in both referent and
case groups.
Registered total work hr

associated with musculoskeletal
symptoms p<0.05.
(Continued)
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MSD prevalence
Kukkonen et Cross- 104 female data entry Outcome: Questionnaire Data entry 28% 2.3 1.1-4.6 Participation rate: Not reported.
al. 1983 sectional/ workers. 60 data entry stiffness and pain in the neck groups:
Inter- operators (noted as study and shoulder region, frequency 47% Examiners blinded to case status.
vention group) were grouped with of symptoms and localization.
44 data entry operators Physical exam (PE): A clinical No adjustment for confounders.
who worked at another functional examination Tension Tension
bank and were compared performed by a physiotherapist. neck neck Examiner blinded to case status.
with 57 female workers in syndrome syndrome
varying office tasks. Exposure: Observation of in study in data Average duration of employment
posture, movements and group pre- entry 3.5 years.
working techniques, interven- comparison
assessment of characteristics tion: 54% group pre- Intervention consisted of:
of desk, chair, equipment, interven- Adjustment of desk, chairs, data
interview with foremen and tion: 43% processing equipment individually
workers to get determination of to suit each worker, who was
physical, mental, and social Tension Tension instructed to carry out adjustments
environment at workplace. neck neck herself. Document holders were
Foremen and workers were syndrome syndrome added. The study group was
interviewed so that the in study in data given a short course of basic
organization of work and the group post- entry training on pertinent aspects of
physical, mental, and social interven- comparison ergonomics. Four lessons on
environment at the workplace tion: 16% group post- relaxation was given by means of
could be determined. interven- exercises.
tion: 45%
Physiotherapy was given to
workers for whom the doctor
prescribed17 from the study
group and none from the first
reference group had treatments.
(Continued)
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MSD prevalence
Kuorinka and Cross- 93 scissor makers, (n=90 Outcome: Symptoms and 61% 28% Scissor makers Participation rate: 81%.
Koskinen sectional females, 3 males) physical examinationtwo vs. referents: 99% female study group, no
1979 compared with 113 female tender spots symptoms of neck OR=4.1 2.3-7.5 significant age difference.
department store shop stiffness and fatigue/ weakness Used Waris [1979] criteria for
assistants from and/or palpable hardenings + examination which called for
Luopjarvis 1979 study. muscle tenderness in neck Short cycle blinding of examiners, otherwise it
movements. Physiotherapist tasks vs. long- was not mentioned.
Excluded those with examined workers, diagnoses cycle tasks No association between tension
seropositive rheumatic were from predetermined criteria and tension neck syndrome and: (1) age, (2)
affections as well as [Waris 1979]. In problem cases neck duration of employment, and
cashiers. orthopedic and physiatric teams syndrome: (3) weight/height2.
handled cases. OR=1.64 0.7-3.8 Total workload for the number of
pieces handled in one year
Exposure: Based on job significantly associated with
analysis from work history of tension neck syndrome
previous year from production Although authors state no
and salary forms. Conducted relationship between short cycled
record review of hr and longer cycled tasks; both
groups of tasks would be
worked/task, production classified as highly repetitive using
statistics, absences: used only Kilbom, Silversteins and other
cases where 80% of hr cross- criteria. Lack of variance in
checked (n=76). Work methods comparison groups.
for each type of station Authors noted: earlier unpublished
analyzed. Stations classified questionnaire pertaining to
according to dominance of activities outside factory extra
inspection or manipulation of work, hobbies, did not indicate
scissors, and length of cycle correlations with work...
using observation and video- Found that diseases seem to
taping. Observations made accumulate in same individuals.
looking at hand/wrist force, Physical workload was low.
repetition and hand grasp. A slight trend towards tension
Calculated index for wrist neck being more common in
deviation. manipulation tasks than in
Work methods for each work inspection but not statistically
station analyzed: Cycle time. significant.
Total workload during
investigation/year recorded
individually as pieces handled.
(Continued)
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MSD prevalence
Linton 1990 Cross- 22,180 employees Outcome: Cases defined from 18% had Monotonous Participation rate: Authors had
sectional undergoing screening questionnaire responses as seen health work and poor access to all workers records;
examinations at their those persons reporting yes to care psychosocial 85% of working population has
occupational health care having seen a health care profes- environment: occupational health care services.
service in Sweden. 85% of professional for neck pain in the sional for OR = 3.6 2.8-4.6
the Swedish workforce is last year. neck pain Analysis stratified for age, gender.
covered by health care Lifting and
services. Exposure: Based on 31% had poor Lifestyle factors asked: Exercise,
questionnaire responses experi- psychosocial eating, smoking, alcohol
Cases compared to non- questions asked regarding enced neck environment: consumption.
cases defined by outcome. heavy lifting, monotonous or pain OR=2.7 2.0-3.6
Groups selected a priori assembly line work, sitting, On univariate analysis, heavy
which would represent uncomfortable work postures Uncomfortable lifting, monotonous work,
exposure as well as little or (bending or twisting), vibration. posture and uncomfortable posture, and
no exposure for Psychosocial work environment: poor vibration had elevated ORs. Sitting
psychosocial variables. Work content, workload, social psychosocial did not.
support. environment:
OR=3.5 2.7-4.5 On univariate analysis, eating
regularly and smoking had elevated
ORs. Alcohol and exercise did not.
Authors caution direct comparison

of ergonomic and psychosocial
variables ORs. The scales were
not consistent for the different
factors measured.
(Continued)
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MSD prevalence
Liss et al. Cross- 1,066 of 2,142 dental Outcome: Mailed survey, case 43% 30% 1.7 1.1-2.6 Participation rate: 50% from both
1995 sectional hygienists from Ontario definitions based on Nordic groups.
Canada Dental Hygienists Questionnaire, percent reporting
Association compared to neck symptoms >7 days in past Study population >99% female.
referent group, 154 of 305 12 months. Had to modify
dental assistants who do their work or No association with duration of
not scale teeth. Exposure: Based on mailed were unable to employment.
survey and self-reported work at some
answerslength of practice, point, Not controlled for confounders.
days/week worked, (hygienists
patients/day, patients with compared to Very low response rate,
heavy calculus, percent of time dental confounders not considered, study
trunk in rotated position relative assistants): has methodologic problems which
to lower body, instruments used, OR=2.4 1.1-5.4 influence interpretation of results.
hr of typing/week, type of
practice.
(Continued)
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MSD prevalence
Luopjarvi et Cross- Assembly line workers Outcome: Tension neck 37% 28% TNS: OR=1.56 Participation rate: 84%.
al. 1979 sectional (n=152 females) compared syndrome (TNS): Neck stiffness 0.9-2.7
to shop assistants in a and fatigue/weakness and two Had seen a Workers excluded from
department store tender spots and/or palpable doctor for neck participation for previous trauma,
(n=133 females). hardenings + muscle tenderness symptoms: arthritis and other pathology.
in neck movements. OR=4.38
Cashiers excluded from 2.1-9.24 No difference in mean ages
comparison group. Exposure: Observation, video between exposed and referents.
analysis, and interviews used to
assess exposure to repetitive Examined only females.
arm work, static muscle work
affecting neck/shoulder area. Factory opened only short time so
no association between duration of
employment and MSDs possible.
Social background, hobbies,

amount of housework not
significant.
(Continued)
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MSD prevalence
Milerad and Cross- 99 dentists randomly Outcome: Based on telephone Pharma- Participation rate: 99%.
Ekenvall 1990 sectional selected from Stockholm questionnaire. Neck symptoms at 54% cists: 26% 2.1 1.4-3.1
dentist registry who any time before the interview Analysis stratified by gender.
practiced $ 10 years ("lifetime prevalence"). Further Male: 45% Male: 18% 2.6 1.2-5.0
compared to analyzed according to Nordic No difference in leisure time
100 pharmacists selected questionnaire as to duration Female: Female: exposure, smoking, systemic
from all pharmacists in during last 12 months and during 63% 32% 2.0 1.3-3.1 disease, exposure to vibration.
Stockholm. last 7 days, effect on work
performance and leisure Symptoms increased with age in
activities, and sick leave. female dentists only.
Exposure: Based on Duration of employment highly

questionnaire. Exposures correlated with age:
included: (1) abduction of arm dentists (r=0.84), pharmacists
particularly in sit-down dentistry; (r=0.89).
(2) work hrs/day; and (3) static
postures. No relation between symptoms and
duration of employment.
Equal problems dominant and

nondominant sides.
Genders equally prone to develop

neck symptoms when subjected to
equal work-related musculoskeletal
strain.
No analysis of exposure factors.

Only discussion of probable
reasons for high risk using work
positions, flexing neck.
(Continued)
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MSD prevalence
Ohlsson et al. Cross- Industrial Workers Outcome: Pain in the last Tension Tension Tension neck Participation rate: Current
1995 sectional (n=82 females) exposed to 7 days and physical exam (PE) neck: 40% neck: 13% syndrome workers: 96%; past workers:
repetitive tasks with short diagnosing tension neck (industrial 86%; referents: 100%.
cycles mostly far <30 sec, syndrome, cervical syndrome. workers Controlled for age.
usually with a flexed neck compared to
and arms elevated and Tension neck: Tightness of referents): No exposure information available
abducted intermittently; 68 muscles, tender spots in the OR=3.6 1.5-8.8 to examiners, not possible to
completely blind the examiners.
former workers (mean muscles. Cervical syndrome: Cervical Cervical

employment time 21 years) Limited neck movement, radiating syndrome: syndrome: Questionnaire included individual
who had left the factory pain provoked by test 1% 0% factors, work/environment,
during the seven years movements, decreased symptoms, psychosocial scales.
before the study; these sensibility in hands/fingers; Muscle strength measured by
workers were compared to muscle weakness of upper limb. (maximum voluntary capacity) at
64 referents with no elevation, abduction, and outward
repetitive exposure at their Exposure: Videotaping and rotation of both arms measured by
current jobs. observation. Analysis of dynamometer.
postures, flexion of neck (critical Videotape analysis revealed
angles 15E and 30E). 74 considerable variation in posture
workers videotaped $10 min even within groups performing
from back and sides. Average similar assembling tasks.
counts of two independent Logistic models replacing repetitive
readers for frequencies, work with videotape variables
duration, and critical angles of found muscular tension tendency
movement used. and neck flexion movements
Repetitive industrial work tasks significantly associated with
divided into 3 groups: (1) fairly neck/shoulder diagnoses.
mobile work, (2) assembling or Inverse relationship between
pressing items, and (3) sorting, duration of industrial work and
polishing and packing items MSDs, largest OR employed <10
Weekly working time, work years.
rotation, patterns of breaks, Assembly group has high OR (6.7)
individual performance rate with regard to neck/shoulder MSD
(piece rate). Only exposure compared to referents.
readings from right arm were
used. Significant association between
time spent in neck flexion positions
< 60E.
(Continued)
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MSD prevalence
Ohlsson et al. Cross- Electrical equipment and Outcome: Determined by Pain in last Pain in last Participation rate: Not reported.
1989 sectional automobile assemblers questionnaireany neck pain, 12 months: 12 months:
(n=148), 76 former female neck pain affecting work ability, 39% 32% 1.9 0.9-3.7 For younger females, increase in
assembly workers who quit and neck pain in the last 7 days pain occurred with increased
within 4 years compared to and the last 12 months. Work Work duration of employment.
60 randomly sampled inability in inability in
female from general Exposure: Based on job last 12 last 12 OR increased with increasing work
population. categorization and months: months: 7% pace, except for very high paces,
questionnairenumber of items 13% 2.8 0.9-8.8 which there was a decrease.
completed/hr. Pain in last
Pain in last 7 days: Logistic models checked for
Work pace divided into four 7 days: 17% interaction and controlled for age.
classes: (1) slow: <100 21% 1.9 0.7-3.6
items/hr; (2) medium: 100 to 199 Study group consisted of females
items/hr; (3) fast: 200 to 700 only.
items/hr; (4) very fast:
>700 items/hr. Significant association between
symptoms and duration of
employment much stronger for
workers <35 years old than
workers >35 years old.
(Continued)
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MSD prevalence
Onishi et al. Cross- The following were Outcome: Based on Group I: Participation rate: Not reported.
1976 sectional compared to 101 female (1) symptoms of neck stiffness, 29%
office workers: dullness, pain, numbness; (2) Body weight, weight skin fold
pressure (<1.5 kv/cm) Group II: thickness, muscle strength and grip
measured by strain transducer
Film rolling workers: 127 at which subject felt pain; 39% strength obtained.
(females). (3) physical exam: range of
motion, tests, nerve Group III: Body height and weight
Subjects categorized as: compression tenderness. 23% differences not statistically
significant.
Group I: Without symptoms Exposure: Observation of job
tasks, then job categorization.
of cervico- No difference between workers
brachial disorder. Film rollers wind 1 roll of 35 mm with tenderness threshold above
film every 2.5 to 5 sec over 7.5 1.5 kg/cm and those below with
Group II: Subjective hr/day. respect to age, height, weight, skin
symptoms in the neck, fold thickness, grip strength, upper
shoulder, or upper limbs. Loading of trapezius was arm abduction strength, back
examined in two workers during
work activities by muscle strength.
Group III: Symptoms and electromyography.
clinical signs. Authors noted that continuous
loading of the trapezius seems
characteristic to repetitive
operations where the upper limbs
are used.
(Continued)
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MSD prevalence
Ryan and Cross- Data process operators Outcome: Symptoms (pain, Shoulder: Not reported Participation rate: 99%.
Bampton 1988 sectional (n=143). Group with ache, sore, hurts, numb, 44%
highest scores (n=41) swollen, etc.) occurring symptom Interviewers blinded to
designated "cases," $3 times/week with no physical only questionnaire responses.
compared to lowest scores exam signs or $ weekly with
(n=28). physical exam signs of muscle Neck: 43% No adjustment for confounders;
tenderness present; diagnosed symptoms cases for analysis were those
myalgia as diffuse muscle pain only with either neck, shoulder, or
and tenderness. lower arm scales having higher
Neck/ symptom scores compared to
Exposure: Ergonomic shoulder those with low scores.
assessment measuring angles symptoms
and distances of each operator occurring $ Cases had higher visual glare
seated at his/her workstation. 3 times index, feeling there was
Wrist extension, ulnar deviation, weekly insufficient time for rest breaks,
elbow angle, shoulder with no more boredom, more work stress,
abduction, and shoulder flexion signs or and needed to push themselves >3
were measured. Also weekly times/week; lower peer cohesion,
measured: person and furniture with signs: autonomy, clarity. Higher staff
fit, eye-copy and eye-keyboard 44% support and work pressure.
fit, elbow-keyboard height
difference, popliteal-chair height Significant differences in those
difference, and copy placement. trained in adjustment of their
chairs.
No differences for height, weight,

age, marital and parental status,
handedness, time in current job,
time spent keying or typing,
whether this was their first job,
length of training time.
Significant difference in smaller

mean elbow angle and shoulder
flexion of the left arm, and smaller
eye-copy distance.
(Continued)
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MSD prevalence
Sakakibara et Cross- Orchard workers (n=48, Outcome: Shoulder pain Estimated Estimated Participation rate: 77%.
al. 1987 sectional 20 males and 20 females). described as the presence of from from
stiffness and pain daily. histograms histograms Stratified by gender.
Compared symptoms after Pears: Apples:
completion of thinning of Exposure: Observation of jobs. General fatigue, gastric
pears, bagging of pears Angles of flexion of the shoulder Rt. side: Rt. side: disturbances, appetite loss and
and bagging of apples and extension of the neck on 20% 9% p<0.05 headache showed no difference in
(covering fruit with paper one subject were measured Lt. side: Lt. side: 9% frequency between tasks.
bags while on the trees). every 25 min during a whole day 20% p<0.01
doing each task. No observation Exposure data based on
Internal comparison using was made on neck repetition. measurement of one worker may
same study population. not be generalized to others.
Farmers worked approximately 8
hr/day for 10.6 to 13.6 days The angle of forward flexion in the
each year bagging or thinning shoulder and that of extension in
pears and bagging apples. the neck was statisticallly
significantly positively correlated
(r=0.88, p#0.01). The proportion of
workers with >90E forward
shoulder flexion was significantly
higher for thinning out pears and
bagging pears than for bagging
apples.
The authors presumed that the

symptoms of dizziness and tinnitus
may be associated with the
cochlear-vestibular symptoms of
vertebral insufficiency due to
continuous extension of the head.
Results presented in paper in

histograms.
(Continued)
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MSD prevalence
Sakakibara et Cross- Of 65 female Japanese Questionnaire: Stiffness and Pear Apple Participation rate: 80%.
al. 1995 sectional farmers. 52 completed the pain in neck region. Symptoms bagging bagging
questionnaire and physical in past 12 months for $one day, Examiners not blinded to case
exam in late June for or symptoms in past 12 months status due to design of study.
bagging pears and late July for $8 days. Neck Neck Workers
for bagging apples. pain=40% pain=25% bagging pears Same population examined two
Exam: Pain in motion of the neck with neck pain times. 2nd exam occurred one
joint such as flexion/extension, vs. apple month after first. These results
lateral bending, and rotation. bagging used in analyses for comparison of
with neck pain, two tasks.
Exposure: Observation of tasks p<0.05
and measurements of Stiffness and pain during apple
representative workers (only bagging may have been pain that
two workers measured) . Neck pain Neck pain Workers was a residual of pear bagging
in joint in joint bagging pears operations.
Angle of arm elevation during motion: motion: with pain in
bagging was measured in one 55.8% 36.5% joint motion vs. Number of fruit bagged/day was
subject. controls apple bagging significantly more in pear bagging
with pain in than in apple bagging.
joint motion:
PRR=1.5 Exposure measurements only
0.99-2.35 obtained on 2 workers and
generalized to all workers.
(Continued)
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MSD prevalence
Schibye et al. Cohort Follow-up of 303 sewing Outcome: Nordic Neck Developing Participation rate, 1985: 94%.
1995 machine operators at nine Questionnaire discomfort, symptoms neck symptom
factories representing ache, or pain in the neck during in previous improvement in Participation rate, 1991: 86%.
different technology levels the previous year; whether they year for 1991 among All participants were female.
who completed had neck pain in last 7 days, and employees operators 77 of 241 workers still operated a
questionnaire in 1985. whether pain prevented them maintaining compared to sewing machine in 1991.
from doing daily duties. a piece- other
82 workers had another job in
In April 1991, 241 of 279 work employment 1991. Among those 35 years or
traced workers responded Exposure: Assessed by groups of group below, 77% had left job; among
to same 1985 questions regarding type of <100 OR=0.85 0.29-2.4 those above 35 years, 57% left
questionnaire. machine operated, work units/day: job.
organization, workplace design, 36% 20% reported musculoskeletal
Operators still working units produced/day, payment symptoms as the reason for
were compared to those system, and duration of Neck Neck symptom leaving job.
who moved to other employment as a sewing symptoms improvement in No significant changes in
employment in 1991. machine operator. in previous other prevalences among those
year for employment employed as sewing machine
employees group vs. operators from 1985 to 1991;
maintaining operator group: significant decrease in those who
a piece- 12 month changed employment.
work symptoms: As many as 50% of respondents
groups of OR=3.3 reported a change in the response
100 to 125 1.4-7.7 to positive or negative symptoms
units/day: from 1985 to 1991.
53% Operators always working at the
7 day same machines showed
Neck symptoms: significantly higher neck symptoms
symptoms OR=3.9 compared to those working at
in previous 1.3-11.9 different machines
year for Although the authors state that the
employees analysis did not show the
maintaining development of neck (or shoulder)
a piece- symptoms among workers who
work had worked as a sewing machine
groups of operator to be significantly related
to exposure, exposure time, or
>125 age, there was a significant drop-
units/day: out rate of those above 35 years.
61%
(Continued)
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MSD prevalence
Veiersted and Cohort 30 female chocolate manu- Outcome: Trapezius 56% Perceived Participation rate: 55%.
Westgaard facturing workers. 17 who myalgianeck and shoulder pain strenuous Drop-out rate may limit generaliz-
1994 contracted trapezius lasting >2 weeks of a degree postures: ability of results although drop-outs
did not differ in exposure estimates
myalgia within 6 to making it difficult to continue OR=7.2 2.1-25.3 and complaints.
51 weeks compared to work. At least one tender or
those workers without. trigger point present. Physical Excluded subjects with: (1) no
Prospective interviews every environment: similar occupation during last 5
years; (2) known musculoskeletal
10 weeks to detect symptoms of OR=0.9 0.5-1.7 disorder predisposing for myalgia;
muscle pain. Daily pain diaries (3) neck or shoulder pain sufficient
kept by subjects. Psychosocial to initiate medical visit, (4) if
factors: employed <26 weeks.
Exposure: Static muscle tension OR=3.3 0.8-14.2 Several anthropometric, non-work-
during work was between 1 and related, general health, personality,
2% of maximal voluntary activity Perceived psychosocial, and previous
of the trapezius muscles strenuous employment variables included in
initial interview and follow-ups.
recorded by electromyographic previous work:
measurements of trapezius OR=6.7 1.6-28.5 Subjects on a fixed-wage system.
muscle in earlier study.
Interviews conducted Work was mainly machine-paced.
Nine of 17 with trapezius myalgia
prospectively every 10 weeks had sick leave after medical
concerning exposure at work consultation.
for 1 year.
No difference in general health
status, anthropometric measures.
None of the models showed any
effect of the physical environ-
ment. Parameters which in-
cluded exposure to draft, vibration
(floor or machine), or noise.
Observation time was con-
siderably shorter for workers who
contracted neck pain compared to
status used in analysis. Non-
patients had more opportunities to
report a positive answer.
The perceived strenuous postures
were not reflected in any of the
conventional EMG parameters
(static, median or peak loads).
(Continued)
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MSD prevalence
Viikari-Juntura Cohort 688 machine operators and Outcome: Neck trouble, 12 month Carpenters vs. Participation rate: 81% machine
et al. 1994 longitud- 553 carpenters compared categorized on 5 point scale prevalence office workers: operators; 79% carpenters;
inal; to 591 office workers. All ("not any" to "daily"). for severe No neck pain to 89% office workers.
2 quest- male. neck pain moderate:
ionnaires Exposure: Based on job for OR=1.6 1.0-2.5 Adjusted for occupation, smoking,
3 years category. Machine operators 1984/1987 and physical exercise, age,
apart static work with whole body No neck pain to duration or current occupation.
vibration, carpentersdynamic Machine severe:
physical work, office operators: OR=1.6 0.8-3.0 2% had retired.
workerssedentary work. For 28/40%
initial evaluation, observation of Persistently In multivariate analysis;
work sites were performed. Carpenters: severe: occupation was only significant
25/32% OR=3.0 1.4-6.4 predictor in change from no neck
trouble to moderate neck trouble.
Office Machine
workers: operators vs. Twisting or bending trunk not a
9/12% office workers: significant predictor of neck pain.
No neck pain to In multivariate analysis:

moderate: occupation, age, and current
OR=1.8 1.1-2.8 smoking were significant
predictors in change from no neck
No neck pain to trouble to severe neck trouble.
severe:
OR=3.9 2.3-6.9 Interaction between age and
occupation not significant.
Persistently
severe: Job satisfaction not associated
OR=4.2 2.0-9.0 with neck trouble and other
predictors.
(Continued)
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MSD prevalence
Welch et al. Cross- 39 of 47 sheet metal Outcome: Symptom survey; 21% Compari- Percent time Participation rate: 83%.
1995 sectional workers attending a pain, aching, stiffness, burning, son group hanging duct:
screening for occupational numbness or tingling in neck with no OR=7.5 0.8-68 Smoking cigarettes, average
lung disease. Cases $ once/month, or lasting > one symptoms number of years working not found
compared to those without week, no history of previous to be significantly different
symptoms. traumatic injury. Symptoms between symptomatic and
began after working as a sheet asymptomatic; other confounders
metal worker and prior to (age, gender) not mentioned.
retirement.
Average length of employment in
Exposure: Questionnaire survey trade: 33 years.
obtaining types of tasks
performed, tools used, Pilot study.
frequency of task performance.
Hanging duct work dichotomized Hrs/week using hand tools,
into > and <40% of time worked. percent of time in the shop vs. time
in the field not significant.
Duration of employment not

included in article.
(Continued)
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MSD prevalence
Wells et al. Cross- 196 male letter carriers Outcome: Telephone interview All letter Postal All letter Participation rate: 99% among
1983 sectional compared to 203 male case status based on current carriers: clerks: carriers vs. letter carriers, 92% meter readers,
meter readers and postal pain; frequency, severity, 12% 5% clerks and 97% postal clerks.
clerks. interference with work, etc.; readers:
score of 20 required to be a Meter OR=2.57 1.13-6.2 No significant difference in
104 letter carriers had casemore points given to neck readers: schooling and marital status.
weight increased from 25 and shoulder problems that Letter 7% Letter carriers
to 35 lbs. in the year prior to interfered with routine daily carriers with increased Comparison group (gas meter
the study. activities. with weight vs. readers) used because of similar
increased clerks: walking rate without carrying
Exposure: Based on job weight: OR=2.63 0.9-8.8 weight compared to letter carriers.
category; based on self- 12% Postal clerks neither walk nor carry
reported information on weight weight.
carried, previous work involving Letter Letter carriers
lifting and work-related injuries. carriers with no weight More weight given to scoring neck
with no increase vs. and shoulder. Outcome influenced
weight clerks: results when ranking of body
increase: OR=2.87 0.9-9.8 MSDs though would not influence
12% group comparisons.
Adjusted for age, number of years

on the job, Quetelet ratio and
previous work experience.
Study limited to males.
Letter carriers with increased bag

weight walked on average 5.24 hr;
those with no change in bag
weight walked 4.83 hr.
Letter bag straps usually carried

on the shoulder.
(Continued)
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MSD prevalence
Yu and Wong Cross- 151 VDT users from an Outcome: Questionnaire survey 31.4% Frequent users Participation rate: 80%. Ages
1996 sectional international bank in Hong used to collect information on of VDTs vs. ranged from 18 to 41 years, 74%
Kong; of these 90 were discomfort or ache during work infrequent between 21 to 30 years.
data entry, data after starting the current job. users:
processing, computer p=0.0025 Analysis controlled for age and
programmers; 61 infrequent Exposure: Questionnaire survey gender, and other covariates.
users of VDTs. on undesirable postures Logistic model
including frequent bending of the for neck pain Queried about personal particulars,
back and inclining the neck inclining neck job nature and characteristics,
forwards. at work: 33.2- working posture, general health
OR=784.4 18,630 conditions.
Fixed keyboard Males with significantly longer

height: mean VDT working experience
OR=90.1 7.6-1056 compared to females (5 vs. 2.7
years).
Frequent VDT
use: Non-workplace factors not
OR=28.9 2.8-291.8 examined.
Female gender:
OR=1.6 0.35-6.8
Age (years):
OR=1.2 1.02-1.5
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Table 28. Epidemiologic studies evaluating work-related neck/shoulder disorders

MSD prevalence
aras 1994 Prospective 15 female assembly Outcome: Assembly Workers: Number of Duration of Participation rate: Not reported.
workers making musculoskeletal sick leave/man- musculoskeletal sick-leave/man-
telephone exchanges. labor years; pre- and post- diagnoses: pre- labor year Study designed to evaluate if there is
intervention. intervention, (days) a relationship between trapezius load
27 female VDT users. 1967 to 1974: 52 and incidence of MSD.
Data Entry and VDT Users: (30.6%) Median sick
25 female data entry Survey: Pain intensity for the days pre- Other intervening variables that may
operators. neck and shoulder region Number of intervention: have reduced symptoms or sick
according to Nordic musculoskeletal 22.9 4.4-50.8 leave were not discussed.
29 male VDT users. questionnaire. diagnoses post-
intervention, Median sick Mean static trapezius load in
Exposure: Load on trapezius as 1975 to 1982: 35 days post- assemblers was reduced from 4.3%
measured by EMG. (14.3%) intervention: 1.8 MVC to 1.4% (post-intervention);
Quantification of the muscle load 0-34.4 mean static trapezius load in VDT
done by ranking the interval Shoulder pain users reduced from 2.7% MVC to
estimate (0.1 s) to produce an intensity: 1.6% MVC (post-intervention).
amplitude probability distribution 3.4
function. Both total duration and 2.3-4.4 The mean intensity and duration of
number of periods/min. when 2.2 neck pain showed no significant
muscle activity was below 1% 1.3-3.3 reduction after intervention in the
MVC were calculated. data dialogue females.
Intervention: Replacing
workstands with fixed heights to
workplaces easily adjustable for
both sitting and standing. Hand
tools were counter- balanced
and adjustable arm rests
introduced. For VDT operators,
tables and chairs adjusted to
give more relaxed position of the
shoulders, operators given more
work surface for keyboard and
mouse, and distances between
operators and screen/documents
adjusted.
(Continued)
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Table 28 (Continued). Epidemiologic studies evaluating work-related neck/shoulder disorders

MSD prevalence
Andersen Cross- 701 female sewing Outcome: Case of chronic neck 34.2% General Sewing Participation rate: 78.2%.
and sectional machine operators, pain was defined as continuous population: machine
Gaardboe compared to pain lasting for a month or more 12.9% operators Examiners blinded to case status.
1993a 781 females from the after beginning work and pain for compared to:
(1) General
general population of $ 30 days within the past year. Internal population: Respondents excluded if had
the region and internal referent OR=3.5 2.6-4.7 previous trauma to neck, shoulder, or
referent group of Exposure: Categorization broken group: 10.1% (2) Internal arms or had inflammatory disease at
89 females from the down according to current referent group time of response.
garment industry. occupational status by job title. OR=4.6 2.2-10.2
Classification into exposure Odds ratios adjusted for age, having
Logistic model
groups based on authors Years as children, not doing exercise,
experiences as occupational sewing socioeconomic status, smoking, and
health physicians and involved machine current neck/shoulder exposure.
crude assessment of exposure operator (0 to 7
level and exposure years): Age-matched exposure groups and
repetitiveness. High exposure OR=3.17 0.6-16.1 controls.
jobs were those involving high (8 to 15 years):
OR=11.2
repetition/high force or high (>15 years): 2.4-52.3 Presented study as general survey
repetition/low force or medium OR=36.7 of health in the garment industry to
repetition/high force. Medium 7.1-189 minimize information bias.
exposure jobs were those Age >40 years:
involving medium repetition/low OR= 1.96
force and low repetition and high
Current high 0.8-5
force. Low exposure jobs were exposure (-/+):
low repetition/low force. OR=0.32
For the analysis, length of Children (>0): 0.1-1
employment as a sewing OR =0.35
machine operator was
considered the variable of 0.1-1.9
interest, the rest were
confounders.
Exercise (-/+):
OR=1.28 0.5-3.4
Smoking (=/-):
OR=2.3 0.9-6.1
(Continued)
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MSD prevalence
Andersen Cross- From a historical cohort Outcome: Measured by health 50.9% 46.2% Referents: Participation rate: 78.2%.
and sectional of 424 sewing machine interview and exam of the neck, OR=1
Gaardboe operators, 82 were shoulder and arm. Case of Tension neck Logistic regression limited to a
1993b randomly selected and chronic pain was defined as syndrome: 40% 0 to 7 years: combined neck/shoulder case
categorized by number continuous pain lasting for a OR=2.3 0.5-11 definition.
of years of month or more after beginning Cervical
employment: 0 to work and pain for $ 30 days Syndrome: 20% 8 to 15 years: Age-matched exposure groups and
7 years, 8 to 15 years within the past year. Physical OR=6.8 1.6-28.5 controls.
and greater than 15 examination: Restricted
years. These were movements in the cervical spine >15 years: Examiners blinded to control/subject
compared to a referent and either palpatory tenderness OR=16.7 4.1-67.5 status.
group composed of in cervical segments or
21, 25 and 36 irradiating pain or tingling at Age $ 40 Controlled for age, having children,
operators from each maximum movements or positive years: OR=1.9 O.9-4.1 not doing leisure exercise, smoking,
group and 25 of foraminal test. socioeconomic status.
55 auxiliary nurses and Children >0
home helpers who Exposure: Exposure categoriza- years: Poor correlation between
participated in the tion broken down according to OR= 0.5 0.1-1.7 degenerative X-ray neck changes
study. current occupational status by and cervical syndrome.
job title. Classification into Exercise:
exposure groups based on OR=1.4 0.6-2.96 Most frequent diagnosis among study
authors experiences as occupa- group was cervicobrachial
tional health physicians and Smoking: fibromyalgia significant for test of
involved crude assessment of OR=1.5 0.7-3.3 trend with exposure time in years.
exposure level and exposure
repetitiveness. High exposure Current high Chronic neck pain vs. palpatory
jobs: Involved high repetition/ exposure: findings: Sensitivity: 0.85;
high force or high repetition/ low OR=1.6 0.7-3.6 Specificity: 0.93.
force or medium repetition/ high
force. Medium exposure jobs
involved medium repetition/ low
force. Low exposure jobs were
low repetition/low force.
(Continued)
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MSD prevalence
Bergqvist Cross- 260 office workers Outcome: Neck/shoulder Neck/shoulder: Intensive Participation rate: 92% of 353 office
et al. 1995a sectional using VDTs, (198 discomfort: Any discomfort over 61.5% neck/shoulder workers, of which 260 were VDT
females); symptomatic the last 12 months; intense neck Female: 63% discomfort: users.
cases compared to discomfort: As above, if Male: 57% stressful
non-cases. occurred in last 7 days and stomach Adjusted for age and gender.
interfered with work. reactions:
OR=5.4 1.6-17.6 Examiner and workplace
Physiotherapist's diagnosis of investigators blinded to case and
(1) Tension neck syndrome: Repeated work exposure status.
Ache/pain in the neck; feeling of movements:
tiredness and stiffness in neck; OR=3.6 0.4-29.6 Factors included in analysis: Age,
possible headache; pain during gender, smoking, children at home,
movements; muscular Too highly negative affectivity, tiredness-related
tenderness; (2) Cervical placed VDT: stress reaction, stomach-related
diagnoses: Ache/pain in neck OR=4.4 0.9-60.3 stress reaction, use of spectacles,
and arm; headache; decreased peer contacts, rest breaks, work
mobility due to cervical pain task flexibility, overtime, static work
during isometric contraction; position, non-use of lower arm
often root symptoms such as support, hand in non-neutral posture,
numbness or parathesias. repeated movements with risk of
tiredness, height differences
Exposure: Based on observation keyboard/elbow, high visual angle to
an ergonomic evaluation using VDTs, glare on VDTs.
data on each individuals most
common work situations: Static There are problems with interpreting
work posture, nonuse of lower results because of multiple
arm support, hand in non-neutral comparisons and multiple models.
position, insufficient leg space at
table, repeated movements with Not all significant findings presented
risk of tiredness, specular glare in paper.
present on VDT. Measured:
Height difference of VDT
keyboard-elbow, High visual
angle to VDT.
(Continued)
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MSD prevalence
Bergqvist Cross- 322 office workers Outcome: Neck/shoulder Neck/shoulder Neck/shoulder Participation rate: 92% questionnaire;
et al. 1995b sectional from 7 Stockholm discomforts: Any discomfort discomfort: 60% discomfort: 91% physiotherapy exam;
companies; VDT users over the last 12 months; intense Current VDT 82% workplace exam.
compared to non-VDT neck/shoulder discomfort: As work vs. no
users 52% interactive, above, if occurred in last 7 days VDT work: Examiner and workplace
29% data entry, and interfered with work. OR=1.4 0.8-2.4 investigators blinded to case and
19% non-VDT users. exposure status.
Physiotherapist's diagnosis of For
tension neck syndrome: accumulated Intensive neck/shoulder discomfort
Ache/pain in the neck; feeling of VDT work > 5 was associated with VDT work over
tiredness and stiffness in neck; PY: OR=1.3 0.7-2.5 20 hr and having stomach reactions
possible headache; pain during Intense often and repetitive movements.
movements; muscular neck/shoulder Intense OR=3.9 (1.1-13.8).
tenderness. discomfort: 7.4% neck/shoulder
discomfort: Originally 535 workers queried in
Exposure: Video display terminal Current VDT 1981, of those 182 had left the
use: Based on self-reporting of work vs. no workplace (quit, retired,
VDT use. VDT users VDT work: etc.)possible bias from Healthy
categorized into data entry or OR=0.5 0.2-1.8 Worker Effect.
interactive VDT users.
For Covariates considered: Children at
Ergonomic Factors: Same as accumulated home, smoking, negative affectivity,
Bergqvist 1995a. VDT work >5 stomach-related stress reactions,
PY: OR=0.8 0.3-2.5 tiredness-related stress reactions;
organizational factors considered
limited or excessive peer contacts,
limited rest break opportunity, limited
work task flexibility, frequent
overtime.
For cervical diagnoses: Excess OR

suggested for combined occurrence
of VDT work of >20 hr/wk and
specular glare on the VDT screen.
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MSD prevalence
Bjelle et al. Case- 13 workers of Outcome: Physician diagnosed 6 with tendinitis Controls Cases had Participation rate: Not reported.
1981 control industrial plant neck/shoulder pain. without significantly
consecutively seen at tendinitis longer duration Investigators completed the video
health clinic with acute, Exposure: Anthropometric and and higher analyses blinded to case status.
nontraumatic isometric muscle strength were frequency of
neck/shoulder pain not tested with strain gauge abduction or Anthropometric data, age no
due to causative instruments. Patients asked to forward flexion difference between cases and
disease or perform their maximal efforts. than controls, controls.
malformation compared Measurements made for the 2.5/min.
to 26 controls. following contractions: Shoulder (p<0.001). Isometric strength test: Controls
Matched on age, elevation at the acromion, significantly stronger in 6 of 14 tests
gender, and place of abduction and forward flexion of Cases had but probably influenced by pain
work. the shoulder joints at neutral significantly inhibition in cases.
position, and semi-pronated. higher shoulder
loads than No significant difference in cycle time
Grip strength measured by controls. (9 vs. 12 min).
vigorimeter.
Median number
Video recording of arm of sick-leave
movements at work. Shoulder days
loads estimated from videos. significantly
Consisted of measuring the different
duration and frequency of between cases
shoulder abduction or forward and controls
flexion of >60E. (p<001).
Electromyography measurement
of shoulder load during assembly
work on 3 patients and 2 healthy
volunteers. Muscular load level
determination made by computer
analysis of myoelectric
amplitude.
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MSD prevalence
Blder et al. Cross- Of 224 sewing Outcome: Survey: Shoulder or Muscle Age p <0.05 Participation rate: 89% for
1991 sectional machine operators neck pain in past 12 months. tenderness: questionnaire, 87% for physical
from 4 plants, 199 Acromioclavicula Nationality non- exam.
completed a symptom Exam: Tenderness on palpation, r joint: 15% significant
survey. Of 155 who range of motion, pain during Only those with symptoms given
reported shoulder or motion or isometric muscle Biceps tendon: Employment p <0.05 physical exam. Physicians and
neck pain in the past contraction, active and passive 35% duration physiotherapist not blinded to
12 months, 131 were range of motion was measured symptom status.
examined. by use of a goniometer. Decreased ROM: Working >30
Diagnoses were not made during 30% hr/wk p <0.05 High rate of turnover in plant.
the examinations, but test forms
were later analyzed by criteria Acromioclavi- Authors state that study involved
from Waris [1979]. cular: 5% control group taking into account
psychosocial factors, but results not
Exposure: From questionnaire: included in this article.
employment duration, hr/wk.
Questionnaire included information on
Plants selected by background, family situation,
representatives of Swedish employment, job conditions, health.
Labour Union familiar with work
sites with similar loads. Physical exam occurred 1 to 3
months after questionnaire.
In 3 consecutive years 147 sewing

machine operators left this work in
the factories. 48% answered follow-
up questionnaire. (17% left because
of neck problems contributing to
decision to leave work.)
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MSD prevalence
Ekberg et al. Case- Study population were Outcome: Self-administered 90% CI used Participation Rate: 73%.
in this paper
1994 control aged 18 to 59 years, questionnaire; a modified version
had to have yearly of the Nordic questionnaire Female gender: Logistic analysis adjusted for age,
OR=15.5 3.4-71
incomes of SEK 45,000 asking about musculoskeletal gender, smoking, having preschool
and not been on sick symptoms in the past 6 months. Immigrant: children.
OR=28.3 3.1-257
leave for more than Questionnaire included
2 months in past 6 background factors, age, Current smoker: Age and having preschool children
OR=8.2 2.3-29
months, not employed gender, ethnic background, were not significant factors.
in large rubber industry family situation, smoking habits, Repetitive
Precision
in area. and exercise. Movements: Low: Ambiguity of work role, demands on
OR=1 attention and work content also
Med: OR=3.8 0.7-20
Cases had consulted Exposure: Assessed by High: OR=15.6 2.2-113 statistically significant.
a community physician questionnaire; seven Light Lifting:
for musculoskeletal determinants were: Low: OR=1.0
Med + High:
disorders of the neck, uncomfortable sitting position, OR=49.7 9.0-273
shoulder, arm, or upper uncomfortable standing position,
Lifted arms:
thorax during the study physically demanding work, light Low: OR=1.0
period from semi-rural lifting (less than 6 kg), repetitive Med: OR=5.9 0.9-37
High: OR=3.7 0.4-30
community in southern movements demanding precision,
Sweden. Cases had work with lifted arms, and Work Pace:
Low: OR=1
to have been ill monotonous work position. Med: OR=7.6 1.6-36
immediately prior to Rating scales were based on Rushed: OR=10.7
2.2-52
physician visit and average duration of hours per ORs for controls
have been on sick day of each item of exposure. with MSD
symptoms in both
leave at most less than neck and shoulder
4 weeks. No trauma, 52 items on psychosocial work and other body
parts:
infectious cause, conditions reduced to 8 factors
accident, malignancy, by factor analysis: psychological Repetitive
Precision
rheumatic disease, work climate, quality of work Movements:
OR=7.5
abuse, or pregnancy. content, work pace, demands on 2.4-23
attention, work planning, job Light lifting:
OR=13.6
Controls were security, job constraints, and 4.8-39
randomly selected from work role ambiguity. Lifted arms:
OR=4.8
Swedish insurance 1.3-18
registry. Uncomfortable
sitting positions:
OR=3.6
1.4-9.3
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MSD prevalence
Ekberg et al. Cross- 637 of 900 residents Outcome: Based on modified Symptoms neck: Gender: Participation rate: 73%.
1995 sectional between the ages of Nordic questionnaire; case Male: 33% OR=1.3 1.1-1.5
18 to 59 years, with an defined as the presence of Female: 53% Symptom responses in neck and
average yearly income symptoms during the past Immigrant shoulder correlated (r=0.56) and
of $ $8000 U.S. dollars. 6 months. Shoulder: Status: collapsed into one variable for the
Male: 35% OR=1.3 1.0-1.6 analyses.
Exposure: 20 questionnaire Female: 40%
items on physical work Repetitive Age, smoking, exercise habits, family
conditions which were factor movements situation with preschool children not
analyzed. Self-reported demanding significantly associated with
perception of physical work precision: symptoms.
environment factors considered: OR=1.2 1.0-1.3
Uncomfortable sitting or standing Social work climate, demands on
position; physically demanding High work attention, work planning, job security
work; light lifting; repetitive pace: OR=1.2 1.0-1.3 and job constraints not significantly
movements demanding precision; associated with symptoms.
work with lifted arms, Low work
monotonous work position. content lack of
stimulation and
Questionnaire on work variation:
organization, work content and OR=1.3 1.1-1.5
relations in the work situation.
Work role
ambiguity:
OR=1.2 1.0-1.3
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MSD prevalence
Holmstrm Cross- Of 2500 construction Outcome: Self-reported history Hands above Participation rate: 71%.
et al. 1992 sectional workers randomly of musculoskeletal problems was shoulder
selected from 4,159 obtained through a mail survey. <1 hr/day 1.1 0.8-1.5 Neck/shoulder pain related to
active members of 1 to 4 hr/day 1.5 1.2-1.9 increasing age, smoking, weight
inactivity during free time, height
trade union registry of Case of neck and shoulder pain >4 hr/day under 185 cm.
the south of Sweden, defined as: Pain, ache,
1,773 (71%) discomfort from the Hands at waist 2.0 1.4- 2.7 Controlled for age, physical factors.
participated. This neck/shoulder are experienced <1 hr/day /1 to 4
group was sometimes often or very often hr/day Dose-response relationship for
represented by all during the past 12 months. >4 hr/day working with hands above shoulder
construction trades 1.0 0.7-1.3 level.
1.1 0.9-1.3
except painters, Case of considerable neck and Stooping Stress index showed a dose-
electricians and shoulder pain defined as neck <1 hr/day response. Stress questions
plasterers. All and/or shoulder trouble with 1 to 4 hr/day pertained to rushing, job pressure,
participants must severe or very severe >4 hr/day 1.2 0.8-1.6 and inability to relax.
have worked in the functional impairment.
past 6 months, Kneeling Psychosocial factors strongly
associated with neck and/or shoulder
including short periods Exposure: Data on physical <1 hr/day 1.0 0.8-1.3 trouble and neck and shoulder pain
of sick leave or workload, psychosocial factors 1 to 4 hr/day 1.4 1.1-1.8 when age and physical factors kept
unemployment. and individual and employment >4 hr/day constant in logistic models for
related factors obtained from mail 1.5 1.1-2.1 psychosocial pre-rate ratio, high
survey. Sitting level compared with low level for
<1 hr/day 1.4 1.1-1.8 considerable neck pain; the following
1 to 4 hr/day 1.4 1.1-1.8 psychosocial scales were
significant:
>4 hr/day 1.5 1.1-2.1 Qualitative demands: 1.4 (1.0-2.0)
Quantitative demands: 3.0 (2.1-4.0)
Roofers 0.6 0.3-1.0 Solitary work: 1.5 (1.2-1.8)
Plumbers 1.6 0.9-2.7 Anxiety (health): 3.2 (2.5- 4.0)
Floor Psychosomatic: 5.0 (3.6-6.9)
Machines/ Tools. Psychological: 4.7 (3.6-6.0)
Stress: 3.4 (2.6-4.2)
0.7 0.4-1.2 The following were not significant:

Discretion, support, under-
1.6 stimulation, anxiety (work), job
1.5 satisfaction, quality of life.
1.3
1.1
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MSD prevalence
Hnting et al. Cross- VDT users: 53 data Outcome: Questionnaire: Medical findings Medical Medical Participation rate: Not reported.
1981 sectional entry; 109 Symptoms of pain, stiffness in shoulder and findings in findings:
conversational VDT fatigue, cramps, numbness, neck: shoulder and No adjustment for age and gender.
users; 78 typists; tremor scaled as: Daily, neck:
compared to occasionally, seldom, never; Blinding of examiners not mentioned
55 traditional office Conversational Traditional Conversational in paper.
workers not using Medical Exam: Included an VDT users: 28% office terminal VDT
VDTs or typewriters. anamnesis and palpation of workers: users vs. trad. Medical findings in neck and shoulder
painful pressure points and 11% office workers: significant in data entry workers for
tendons and tendon insertion OR=1.35 0.6-3.1 head inclination greater than 56E vs.
points in the shoulders, arms, <56E. Not significant in
and hands. Typewriter: Typewriter vs. conversational terminal workers or
35% trad. office typewriters.
Exposure: (1) Questionnaire, workers:
(2) Observation and OR=3.18 1.3-2.6 Medical findings in neck and shoulder
measurements of work-station, significant for typists with head
and (3) Body posture measured Data Entry Data entry rotation greater than 20E compared to
using method described by terminal VDT terminal users <20E.
Hnting et al. 1980b. users: 38% vs. trad. Office
workers: The lower the table and keyboard
OR=9.9 3.7-26.9 heights, the more frequently pains in
the shoulder, neck, and arms. No
document holders used. Authors
concluded the higher the table, the
higher the documents, the better the
posture of the head and trunk.
Increased neck/shoulder findings
occurred with increased turning of
the head or head inclination.
Job satisfaction, relationship with

colleagues, superiors, decision
making abilities, use of skills not
significantly different among groups.
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MSD prevalence
Jonsson Cohort Electronics Workers Outcome: Three separate Severe neck Severe neck Predictors of Participation rate: 72%.
et al. 1988 (n=69 female) out of physical exams at yearly disorders: disorders: change of
initial 96 workers. intervals (one initially) assessing After 1 year: 11% initially health status Predictors of deterioration were
tenderness on palpation, pain or 24% from 2nd to 3rd previously physically heavy jobs,
restriction with active and examination: high productivity (after 1 year), and
passive movements; symptoms 22% at 2nd previous sick leave.
in previous 12 months with exam Palpation
regard to character, frequency, tenderness, Predictors of improvement were
duration, localization, and relation At 3rd exam, 38 neck/ shoulder reallocation, physical activity in spare
to work or other physical subjects angle: OR=1.6 time, and high productivity (after 2
activities. Analyzed if score on reallocated to years).
any symptom of 2 or greater than varied tasks had Shoulder
on a 4 point scale; severe improved (16% elevated, % of Predictors of remaining healthy were
symptom score = 4. of these had work-cycle: work without elevating the shoulders
severe OR= 1.04 and satisfaction with work tasks.
Carried out at outset of study: symptoms)
MVC of forearm flexors, Satisfaction Subjects reallocated to new tasks
shoulder strength, handgrip, 26% with with work characterized as more dynamic and
heart rate using a bicycle unchanged colleagues: varied: Non-sitting, no inspection of
ergometer and rating of working OR=25 small details on printed circuit boards,
perceived exertion. conditions standing and walking, occasionally
deteriorated Satisfaction sitting, caretaking work, surveillance
Exposure: Computerized via two further with work of machinery, assembling of bigger
video recordings (rear and side), tasks: OR=24.5 and heavier equipment.
real time; obtained frequency and
duration of working postures and
movements, neck flexion greater
than 20E.
(Continued)
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MSD prevalence
Kilbom et al. Cross- 106 of 138 female Outcome: Three separate MSD symptoms Logistic Participation rate: 77%. The authors
1986 sectional assemblers in two physical exams at yearly in the neck/ Regression followed up on the non-participants
electronic intervals (one initially) assessing shoulder using a model (all and found no significant differences
Kilbom and manufacturing tenderness on palpation, pain or 4 point severity variables from participants.
Persson companies agreed to restriction with active and scale: significant at
1987 participate; 10 passive movements; symptoms the p<0.05 No relation between maximal static
excluded because of in previous 12 months with None: 78% level) strength and symptoms.
symptoms in past 12 regard to character, frequency,
months. 96 underwent duration, localization, and relation Slight: 8% Headache Examiner blinded to case status.
medical, physiological, to work or other physical
and ergonomic activities. Analyzed if score on Moderate: 7% Average Questions included spare time
evaluation. any symptom of 2 or >on a 4 time/work cycle physical activities, hobbies,
point scale; severe symptom Severe: 3% with upper arm perceived psychosocial stress at
score = 4. 0-30E abducted work, work satisfaction, number of
breaks, rest pauses.
Exposure: Carried out at outset Average
of study: MVC of forearm time/work cycle Clinically diagnoses found were
flexors, shoulder strength, in neck flexion largely myofascial symptoms.
handgrip, heart rate using a
bicycle ergometer and rating of Excessive Headache, sleep problems, dizziness
perceived exertion. Included general fatigue showed a weak positive correlation.
video analysis of postures and at end of
movements of the head, shoulder working day Age, years of employment,
and upper arm including productivity, muscle strength were
durations and frequencies. not related to symptoms.
Recorded work cycle time and
number of cycles/hr, time at rest There was large inter-worker
for the arm, shoulder and head, variation in working posture and
rest periods, and average and working techniques.
total duration/work cycle and hr.
The mean number of neck The more dynamic working
forward flexions >20E/hr was technique, the less symptoms in the
728 (s.d. 365) in the initial 96 neck and neck/shoulder symptoms.
workers.
Authors note: a strong positive
relationship to disorders was
obtained with VIRA variables
describing neck forward flexion and
upper arm elevation.
See Jonsson et al. 1988 for follow-
up.
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MSD prevalence
Linton and Cross- 420 of 438 medical Outcome: 3-point scale Shoulder pain Those Participation rate: 96%.
Kamwendo sectional secretaries and office collapsed from 6-point frequency frequency frequently
1989 personnel at a scale ranging from almost having neck 75% sat >5 hr/day.
Swedish hospital. never to almost always having Very often: and shoulder
neck or shoulder discomfort; and 16.9% pain vs. those 43% worked with office machines
Those reporting Nordic Musculoskeletal Pain less frequently each day.
frequently having neck Questionnaire. Sometime wk: having pain:
and shoulder pain 3.8% Psychosocial scale scored: 10 to 20
(1 to 3) compared to Exposure: 10-question Poor Work as good environment. 20 to 40 as
those less frequently standardized form on the Sometimes a wk: Content: poor environment.
having pain (4 to 6) psychological work environment 4.8% OR= 2.5 1.3-4.9
points). with 1 to 4 categorical scales. Authors noted that: (1) Secretaries
Overall score and indexes on Sometimes days: Lack of Social exposed to high work demands
work content, psychologic work 13.8% Support: periodically, (2) they also felt helpless
demand and social support at OR=1.6 0.9-2.8 to change the work environment, and
work. Sometimes 1 that (3) internal conflict within
day: 28.6% departments may have affected
Duties included daily use of responses.
typewriter, VDT, plus mail Never: 32.1%
telephone and appointment
duties.
(Continued)
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MSD prevalence
Maeda 1982 Cross- 119 accounting Outcome: Based on Partial Participation rate: Not reported.
sectional machine operators questionnaire responses of pain correlation
aged 17 to 29 years in and stiffness in the right and left coefficient Examiners blinded to case status:
a post-check office. sides of the neck and shoulder between head Not reported.
based on frequency of almost neck tilt and
every day, occasionally, and factor score Constrained tilted head posture was
never or seldom during the 1 to 5, associated with neck/shoulder
previous several wk. Scores controlling for stiffness.
were factor analyzed. other angles
A and C, age,
Exposure: Anthropometric and length of
parameters relevant to the job p<0.05 service 0.25
tasks were measured on
51 operators who showed large
or small factor scores.
(Continued)
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MSD prevalence
Milerad and Cross- 99 dentists randomly Outcome: Based on telephone All dentists: Participation rate: 99%.
Ekenvall sectional selected from questionnaire: Neck symptoms Neck and
1990 Stockholm dentist at any time before the interview Shoulder: 36% 17% 2.1 1.3-3.0 Analysis stratified by gender.
registry who practiced ("lifetime prevalence"). Further
$ 10 years compared analyzed according to Nordic Neck and No difference in leisure time, smoking,
to 100 pharmacists questionnaire as to duration Shoulder and systemic disease, exposure to
selected from all during last 12 months and during Arm: 16% 3% 5.4 1.6-17.9 vibration.
pharmacists in last 7 days, effect on work
Stockholm. performance, leisure activities, Symptoms increased with age in
and sick leave. female dentists only.
Exposure: Questionnaire Duration of employment highly
included: (1) abduction of arm correlated with age (r=0.84, 0.89).
particularly in sit-down dentistry,
(2) work hr/day, (3) static No relation between symptoms and
postures. duration of employment.
Equal problems dominant and non-
dominant sides.
(Continued)
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MSD prevalence
Ohara et al. Cross- For cross-sectional Outcome: Assessed by Cash registerOffice NR Participation rate: for prospective
1976 sectional study: 399 cash standard health inventory and operators machine study = 100%.
register operators medical examination (used operators
and pro- compared with clinical classification according to and other Participation rate: for cross-sectional
spective 99 office machine the committee on cervicobrachial Interventions did workers study, unable to calculate from data
operators and disorders of the Japan not result in (clerks and presented.
410 other workers Association of Industrial Health, reduced muscle saleswomen
(clerks and in Table 3 in the paper). fatigue of the ) Unknown whether examiners blinded
saleswomen). All neck, shoulders, to case status.
female. Periodic physical exam and upper back
performed twice a year from brought on Interventions did not reduce
For prospective study: 1973. Primary exams performed presumably by complaints in the shoulder region, but
56 workers employed on 371 operators. 130 (35%) the continuous did improve symptoms in the arms,
<7 months had testing received detailed exams. lifting of the hands, fingers, low back, and legs.
pre- and post- upper limbs. The lack of improvement in the
intervention using Exposure: To repetitive shoulder region was stated to be due
questionnaire and movements relocating to the use of the same narrow check
physical exam. merchandise across counter and stands, unsuitable counter height,
bagging, involved muscle activity and necessity of continuous lifting of
86 operators, newly of the fingers, hands, and arms; the upper limbs.
hired after extreme and sustained postures.
interventions, also had Operators hired after the
evaluation after Interventions: (1) a 2-operator interventions and then examined after
10 months of working. system, 1 working the register, 10 months had less Grade I,
one packing articles, changing II , or III occupational cervicobrachial
roles every hr; (2) continuous disorders in examination than those
operating time <60 min; max. hired before intervention.
working hr/day 4.5 hr;
(3) 15-min resting period every Only 14.5% with >3 years
hr; (4) electronic cash registers employment at worksite.
with light touch keyboard
substituted for half of previously Narrow work space and counter
used height not adjusted for height of
worker. mechanical cash registers.
(Continued)
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MSD prevalence
Ohlsson Cross- Industrial Workers Outcome: Pain in the last 7 days Industrial Referents: All Participation rate: Current workers:
et al. 1995 sectional (n=82 females) and PE diagnosing tension neck workers: 50% 16% neck/shoulder 96% Past workers: 86%;
exposed to repetitive syndrome, cervical syndrome. clinical Referents: 100%.
tasks with short cycles diagnoses
mostly far <30 sec., Tension neck: Tightness of (industrial No exposure information available to
usually with a flexed muscles, tender spots in the workers examiners, not possible to
neck and arms muscles. Cervical syndrome: compared to completely blind the examiners.
elevated and abducted Limited neck movement, radiating referents):
intermittently; 68 former pain provoked by test OR=2.7 1.2-6.3 Questionnaire included individual
workers (mean movements, decreased factors, work/environment,
employment time 21 sensibility in hands/fingers; Logistic Model: symptoms, psychosocial scales.
years) who had left muscle weakness of upper limb. Repetitive work
the factory during the 7 vs. none: Videotape analysis revealed
years before the Muscle strength measured by OR=4.6 1.9-12 considerable variation in posture
study; these workers MVC at elevation, abduction, and even within groups performing similar
were compared to 64 outward rotation of both arms Age (57 vs. assembling tasks.
referents with no measured by dynamometer. 37): OR=1.9 1.0-3.5
repetitive exposure at Logistic models replacing repetitive
their current jobs Exposure: Videotaping and Muscular work with videotape variables found
(female residents of a observation. Analysis of tension muscular tension tendency and neck
nearby town currently postures, flexion of neck (critical tendency: flexion movements significantly
employed as customer angles 15E and 30E). 74 (score 4.5 vs. associated with neck/shoulder
service, ordering and workers videotaped $10 min. 1) : OR=2.3 1.3-4.9 diagnoses.
price marking in from back and sides. Average
supermarkets, as counts of two independent Stress/worry Inverse relationship between duration
office workers (no readers for frequencies, tendency: of industrial work and MSDs, largest
constant computer duration, and critical angles of OR=1.9 1.1-3.5 OR in those employed <10 years.
work) or as kitchen movement used.
workers. Assembly group had high OR (6.7)
Repetitive industrial work tasks with regard to neck/shoulder MSD
divided into 3 groups: (1) Fairly compared to referents.
mobile work; (2) Assembling or
pressing items; and (3) sorting, Significant association between time
polishing and packing items. spent in neck flexion positions <60E.
Weekly working time, work
rotation, patterns of breaks,
individual performance rate
(piece rate).
Only exposure readings from
right arm were used.
(Continued)
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MSD prevalence
Punnett et al. Cross- 254 of 275 (92%) Outcome: Based on self- Overall Male: 1.8 1.0-3.2 Participation rate: 92%.
1991 sectional meatcutters and reported symptom survey. Prevalence Female: 0.9 0.5-1.9
wrappers who Cases were defined if they met Neck/Shoulder: Stratified by gender and age.
attended health and the following: $ 20 episodes in 53%
safety training classes.the previous year or usual Neck/shoulder disorders associated
duration of $ one wk; reported with external duration of static
Workers fulfilling date of pain onset after postures (>5 sec.) or lifting $ 5 lbs.
outcome case employment in the retail meat while abducting, flexing or extending
definition (cases) were industry; no history of systemic the shoulder.
compared to non- disease related to soft tissue
cases; also compared pain; and, no history of acute Neck/shoulder pain did not vary by
to the U.S. industrial injury. job category.
population.
Exposure: Based on interview 98% of respondents performed lifting
and authors observations. tasks at work. They judged lifting an
average load/day was 41 (+ 23) lb
Exposure: Repetitive and lifted 33 times and carried 9 feet.
strenuous activities (it was not Heaviest load = 71 (+ 31 lb), lifted
stated whether this was for 11 times and carried 9 feet/lift.
specific area or involved neck Listing an average load with a 40 to
and all upper extremity areas) for 50% standard deviation can be
0.5 to 8 hr/day in refrigerated misleading.
areas.
Neck/shoulder cases lifted both the
Cutters cut an average typical and heaviest loads with
121 (+ 278) large pieces of greater frequency than non-cases.
meat/day filled 701 (+ 830 boats).
Association was found for extended
Wrappers filled duration of and lifting weight in
374 (+ 602 boats/day). Wrapped abduction/flexion and extension of
1,299 (+ 1,365 boats and the shoulder.
weighed 1,399 boats).
(Continued)
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MSD prevalence
Rossignol Cross- 191 Computer and data Outcome: Self-administered to 3 hr of VDT No VDT use Up to 3 hr of Participation rate: In 6 industry
et al. 1987 sectional processing services, questionnaire case defined as: use/day (n=31): (n=28): VDT use groups 67 to 100%.
public utilities of Neck pain, stiffness, or soreness 39% 25% compared to 0
Massachusetts State occurring almost always or hr of use: Participation rate: For individual
Department, at 38 work missed work due to neck pain, OR=1.8 0.5-6.8 clerical workers; 94 to 99%.
sites selected at stiffness or soreness.
random from 4 to 6 hr of VDT 4 to 6 hr of VDT Assessed magnitude of confounding
Massachusetts Exposure: Self-reports of use/day (n=28): use compared by age, cigarette smoking, industry,
employers of >50 number of hr worked each day 57% to 0 hr of use: educational VDT training.
workers. with a keyboard machine with a OR=4.0
VDT. Subjects selected after 1.1-14.8 Study presented to participants as a
28 of the 191 did not observation of worksite. >7 hr of VDT general health survey (as opposed
use a computer. 7 or more hr of use compared to an occupationally related survey)
VDT use/day to 0 hr of use: to avoid observation bias.
(n=104): 61% OR=4.6 1.7-13.2
(Continued)
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MSD prevalence
Ryan and Cross- 143 data process Outcome: Based on symptoms Shoulder: 44% Comparison More non- Participation rate: 99%.
Bampton sectional operators; using a 0 to occurring three or more times/wk symptom only group had cases trained in
1988 10 point scale, the with no physical exam signs, or symptom adjustment of Interviewers blinded to questionnaire
group with symptom $ weekly symptoms with Neck: 43% scores <2. chairs p<0.05 responses.
scores of 8 or above physical exam signs of muscle symptoms only
(n=41) were tenderness or hardening Cases with Height, weight, sex, age, marital
designated "cases," present. Neck/shoulder higher scores status, parental status evaluated and
and were compared to symptoms of visual not found to be confounders.
group with symptom Cases were selected by having occurring $ 3 discomfort p<0.05
scores of 2 or less a combination of symptoms in the times weekly Handedness, time spent in current
(n=28). lower arm and shoulder/neck with no signs or Cases felt there job, time spent altogether keying or
area meeting a summary score weekly with was not typing work, training in adjustment of
of eight or more. These cases signs: 44% enough time for keyboard and desk evaluated in two
were compared to a comparison rest breaks groups and no significant differences
group with a score of 2 or less. compared to found.
non-cases p<0.05
Exposure: Ergonomic Psychosocial and work environment
assessment measuring angles Cases had scales included pertaining to job
and distances of each operator more boredom, satisfaction as well as the Work
seated at his/her workstation more work Environment Scale [R. Moos 1974].
performed; Questionnaire stress, and
responses to: Time spent in needed to push Authors diagnosed myalgia as
current job, time spent altogether themselves >3 diffuse muscle pain and tenderness.
keying or typing work, training in times/wk; lower
the adjustment of their chair, peer cohesion,
desk, or keyboard. autonomy,
clarity in the
authority
structure.
Higher staff
support and
work pressure. p<0.05
(Continued)
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MSD prevalence
Tola et al. Cross- 828 Machine Outcome: Postal questionnaire Daily symptoms: Daily Machine vs. Participation rate: 74% machine
1988 sectional operators; 658 on neck or shoulder symptoms symptoms: office: operators, 67% carpenters, 67%
carpenters; frequency in last year, and machine OR=1.7 1.5-2.0 office workers.
compared to 657 office influence on work methods, daily operators: 11% office Carpenter vs. Adjusted for years in occupation,
workers; All male, duties and activities or leisure carpenters: 8% workers: 2% office: age. Interaction terms tested for,
ages 25 to 49 years. time hobbies. Pain Drawing OR=1.4 1.1-1.6 none found.
Diagram used to distinguish body Change work Change work
areas. For logistic regression methods: methods: Machine vs. Education, general health, and leisure
model 12 month prevalence of carpenter: time activities, car driving included in
neck and shoulder symptoms on machine office OR=1.3 1.1-1.4 analysis.
8 days or more. operators: 19% workers: Use of twisted Study restricted to males aged 25 to
carpenters: 10% or bent 49 years.
Exposure: Exposure based on 21% postures during
occupation: Machine operators work Education status ($ some vocational
known to be exposed to static Little: OR=1.0 1.0-1.5 school compared to no > some
loading due to prolonged sitting Moderate: courses) statistically significant for
and low-frequency whole body OR=1.2 1.4-1.9 machine operators and carpenters
Rather much: reporting of symptoms.
vibration, fast work pace, and OR=1.6 1.5-2.2
upper trunk twisting. Carpenters Very much:
exposed to dynamic physical OR=1.8
work with varying postures and
loads, static loading of Working in a
neck/shoulder-arm, and male draft:
No: OR=1.0 1.0-1.3
office workers, of whom only Yes: OR=1.1
40% were performing routine
office tasks. Job satisfac-
tion
Very good:
OR=1.0 1.0-1.3
Rather good:
OR=1.1
Moderate or
poor: OR=1.2 1.1-1.4
Age (years)
25 to 29:
OR=1.0
30 to 34:
OR=1.2 1.0-1.5
35 to 39:
OR=1.3 1.1-1.6
40 to 44:
OR=1.5 1.3-1.8
45 to 49:
OR=1.6 1.4-1.9
(Continued)
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MSD prevalence
Vihma et al. Cross- 40 Sewing machine Outcome: Neck or shoulder Sewing machine Seam- Participation rate: Not reported.
1982 sectional operators with short complaints defined by operators with stresses
work cycles compared questionnaire: Recurrent pain or neck/shoulder with neck/ Random selection of participants.
to 20 seamstresses. aching in present work (during or complaints: 98% shoulder
after work). complaints: Cases and referent group matched
60% PRR = 1.6 1.1-2.3 for age and duration of employment.
Exposure: Observation and
interview; hr continuously sitting, Sewing machine operators found to
standing time, survey of work have significantly greater static work
postures, length of work cycle. compared to seamstresses.
Sewing machine operator cycle
time was 30 to 60 sec. in
duration. Seamstresses had
longer cycle.
(Continued)
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MSD prevalence
Viikari- Cohort 154 subjects (72 Outcome: Based on 10% of female Female: Participation rate: 90%.
Juntura et al. female, 82 male) from Questionnaire data: Ache, pain, and 2% of male Severe Controlled for physical and creative
1991a Helsinki, Finland. stiffness, numbness in their reported severe neck/shoulder hobbies, no interactions seen.
Subjects were part of neck/shoulder in last 12 months. radicular neck symptoms vs.
a longitudinal study Visual analogue scale of pain no symptoms
Alexithymia Because of low numbers, males
population that started intensity, disability. Severe neck (low verbal were not included in analysis.
in Finland in 1955; and disability: Pain for >7 days in last 21% of female productivity)
from 1961 to 1963. 12 months and mean disability and 2% of male (continuous): Subjects comprised of mostly high
During that time, 1084 index $ 15. reported any OR=1.02 0.97-1.1 socioeconomic status who reported
subjects underwent type of severe
cross-sectional Physical exam (P.E.): Two tests neck/shoulder Social confi- light physical workloads.
examination. In 1985, a for cervical nerve root pain dence (mode-
questionnaire was involvement, neck compression rate fears vs. Data collection in 1955 to 1963:
sent to all subjects; test, shoulder abduction test. no fears): Intelligence, alexithymia, social
801 (74%) responded. Because of small number of OR=0.04 0.0-4.5 confidence, hobbies, motor
Of the respondents, abnormal physical findings, the (much fear vs. development, verbal development,
180 lived in the Helsinki P.E. was eliminated from analysis no fears): level of education of parents, type of
area. It was from this OR=1.4 0.05-42.2 income of family.
group that Exposure: Questionnaire:
162 responded. Eight Amount of work with hands Type of income
(monthly Data collection in 1985:
were excluded due to overhead, work in forward bent salary): OR=0.5 Questionnaire on family relationships,
illnesses. The position, work in twisted or bent 0.05-5.2 socioeconomic status, work history,
proportions of the position. Sense of characteristics of present work, job
highest income levels coherence satisfaction, mental resources.
in the sample (continuous):
exceeded the Finnish OR=0.95
population. 0.9-0.99 Data collection in 1986 to 1987:
Twisted or bent Questionnaire: Physical
torso characteristics of work, amount of
(>3 hr/day vs. physical exercise, illnesses, trauma.
<1 hr/day:
OR= 0.9 Measurements taken in adolescence,
>3 hr/day vs.<1 0.8-10.0 such as intelligence, alexithymia,
hr/day social confidence, hobbies and
socioeconomic status of the family
Sitting in a showed no consistent association
forward with neck/shoulder symptoms in
posture 1-3 adulthood.
hr/day vs.
<1hr/day:
OR=10.7 >3 .4-291
hr/day vs. <1
hr/day: OR=1.5 0.07,29.6
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CHAPTER 3
Shoulder Musculoskeletal Disorders:
Evidence for Work-Relatedness
SUMMARY
There are over 20 epidemiologic studies that have examined workplace factors and their relationship to
shoulder musculoskeletal disorders (MSDs). These studies generally compared workers in jobs with higher
levels of exposure to workers with lower levels of exposure, following observation or measurement of job
characteristics. Using epidemiologic criteria to examine these studies, and taking into account issues of
confounding, bias, and strengths and limitations of the studies, we conclude the following:
There is evidence for a positive association between highly repetitive work and shoulder MSDs. The
evidence has important limitations. Only three studies specifically address the health outcome of shoulder
tendinitis and these studies involve combined exposure to repetition with awkward shoulder postures or
static shoulder loads. The other six studies with significant positive associations dealt primarily with
symptoms. There is insufficient evidence for a positive association between force and shoulder MSDs
based on currently available epidemiologic studies. There is evidence for a relationship between repeated
or sustained shoulder postures with greater than 60 degrees of flexion or abduction and shoulder MSDs.
There is evidence for both shoulder tendinitis and nonspecific shoulder pain. The evidence for specific
shoulder postures is strongest where there is combined exposure to several physical factors like holding a
tool while working overhead. The association was positive and consistent in the six studies that used
diagnosed cases of shoulder tendinitis, or a constellation of symptoms and physical findings consistent
with tendinitis, as the health outcome. Only one [Schibye et al. 1995] of the thirteen studies failed to find a
positive association with exposure and symptoms or a specific shoulder disorder. This is consistent with
the evidence that is found in the biomechanical, physiological, and psychosocial literature.
There is insufficient evidence for a positive association between vibration and shoulder MSDs based on
currently available epidemiologic studies.
INTRODUCTION
Shoulder MSDs and their relationship to work work-relatedness, especially showing an
risk factors have been reviewed by several increased risk for overhead and repetitive
authors [Hagberg and Wegman 1987; work.
Kuorinka and Forcier 1995; Sommerich et al.
1993; Winkel and Westgaard 1992]. Hagberg The focus of this review is to assess evidence
and Wegman [1987] attributed a majority of for a relationship between shoulder tendinitis
shoulder problems occurring in a variety of and workplace exposures to the following:
occupations to workplace exposure. Kuorinka awkward postures, forceful exertions, repetitive
and Forcier [1995] looked specifically at exertions, and segmental vibration. Also
shoulder tendinitis and stated that the included are studies relevant to shoulder
epidemiologic literature is most convincing disordersas defined by a combination of
regarding symptoms and physical examination findings or
by symptoms alone, but not specifically defined
as tendinitisand those studies for which
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the health outcome combined neck and considered the primary exposure factor,
shoulder disorders, but where the exposure particularly independent of posture. Some
was likely to have been specific to the shoulder. studies indirectly inferred shoulder repetition by
Chapter 2 discusses studies involving neck- characterizing hand, wrist, and forearm
shoulder disorders where assessment of movements.
exposure was likely specific to the neck region.
Studies Reporting on the Association
Pertinent information about the 39 reviewed of Repetition and Shoulder MSDs
studies is presented in several ways. Detailed Three of the reviewed studies reported results
descriptions of the studies are provided in on the association between repetition and
Table 3-5. The text of this section on shoulders shoulder tendinitis [English et al. 1995; Ohlsson
is organized by exposure risk factor. The et al. 1994, 1995]. For all three studies, some
discussion within each risk factor is organized or all of the results were for associations with a
according to criteria presented on Pages 1-1 to combined exposure to repetition and awkward
1-10 of the Introduction. Conclusions are posture. Six additional studies reported results
presented with respect to the specific MSD of on the association between repetition and non-
concern, shoulder tendinitis. specific shoulder disorders [Sakakibara et al.
1995], non-specific shoulder symptoms
REPETITION [Andersen and Gaardboe 1993a; Ohlsson et al.
1989], combined neck-shoulder disorders
Definition of Repetition for Shoulder
[Bjelle et al. 1981; Chiang et al. 1993] or
MSDs
combined neck-shoulder symptoms [Kilbom et
Studies that addressed the physical factor of
al. 1986; Kilbom and Persson 1987].
repetition and its relation to shoulder MSDs
were included in this review. Studies usually Studies Meeting the Four Evaluation Criteria
defined repetition, or repetitive work, for the
Four studies met all four of the criteria [Chiang
shoulder as work activities that involved
et al. 1993; Kilbom et al. 1986; Ohlsson et al.
cyclical flexion, extension, abduction, or
1994, 1995] (Table 3-1, Figure 3-1). Chiang
rotation of the shoulder joint. Repetitiveness
et al. [1993] studied workers in the fish
was defined in four different ways in the
processing industry in Taiwan. The health
reviewed studies: (1) the observed frequency of
outcome of shoulder girdle pain was defined
movements past pre-defined angles of shoulder
as self-assessed symptoms of pain in the neck,
flexion or abduction, (2) the number of pieces
shoulder or upper arms, and signs of muscle
handled per time unit, (3) short cycle
tender points or palpable hardenings upon
time/repeated tasks within cycle, and (4) a
physical examination. Pain referred from a
descriptive characterization of repetitive work
nerve root or other spinal source was included
or repetitive arm movements. Some of the
in the case definition. The force requirements of
studies that examined repetition as a risk factor
the jobs were estimated by surface
for shoulder MSDs had several concurrent or
interacting physical work load factors.
Therefore, repetitive work should not be
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electromyographs (EMGs) in the forearm flexor In the first of the Ohlsson et al. studies, a cross-
muscles. This is not a direct measure of sectional study, women in the fish industry were
shoulder muscle activity. There may be no compared to a control population of women
relationship between the level of activity in the employed in municipal workplaces in the same
forearm and shoulder girdle muscles. Three towns [Ohlsson et al. 1994]. Diagnoses of
categories, based on both force and shoulder disorders (e.g., tendinitis,
repetitiveness, were used as the exposure acromioclavicular syndrome, frozen shoulder)
outcome: Group I (low force, low were made on the basis of symptoms
repetitiveness), Group II (high force or high determined by interview and a physical exam.
repetitiveness), and Group III (high force and Exposure evaluation of each work task held by
high repetitiveness). Force was also evaluated the fish industry population was evaluated with
independently in multivariate analyses. ergonomic workplace analysis (EWA). Ten
different factors were rated on a scale from 1 to
Kilbom et al. [1986] performed a prospective 5 and the combined ratings were used as a
study in which female employees in the profile of the work task. Based on this profile,
electronics manufacturing industry were the authors reported that fish industry work was
observed for a 2-year period. The health found to be highly repetitive and to include
outcome in the neck, shoulder, or arm regions poor work postures.
was based on symptoms and physical findings.
Symptom severity was coded on the basis of its Ohlsson et al. [1995] compared a group of
character, frequency, and/or duration. Changes women who performed industrial assembly
in severity status at follow-up evaluations were work to a referent group of women from a
used as the dependent variables in multiple nearby town who were employed in jobs
regression analyses. Neck, shoulder, and upper characterized as having varied and mobile work
arm posture was determined by VIRA. tasks. One examiner assessed signs and
Although the health outcome combined symptoms. The examiner was blinded to
symptoms from different body regions, specific exposure information, but not
knowledge of biomechanical theory can be completely blinded to factory worker versus
used to identify significant predictors related to referent group status. Shoulder tendinitis
the shoulder symptom severity. included supraspinatus, infraspinatus, and
bicipital tendinitis. Another health outcome
For the two Ohlsson et al. [1994, 1995] combined neck and shoulder disorders (tension
studies, the authors reported that the examiners neck, cervical syndrome, thoracic outlet
could not be completely blinded to exposed syndrome, frozen shoulder, tendinitis,
versus referent status, but that a standard acromioclavicular syndrome). In a descriptive
protocol was followed and observer bias was assessment, it was reported that the work tasks
likely to have been minimal. As examiners were in the study group involved repetitive arm
blinded to objective exposure measures, movements with static muscular work of the
analyses testing associations between neck-
shoulder disorders and specific postures would
not have been biased [Ohlsson et al. 1995].
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neck and shoulder muscles. The percentage of outcome was defined by self-assessed
time spent in specific upper arm postures was symptoms of shoulder stiffness and pain and a
determined from videotaped observation of 74 physical examination for muscle tenderness and
(out of 82) workers. The average result from joint pain on movement. Whether the examining
two independent videotape analyses was used. physician was aware of the prior hypothesis
Posture category demarcations included 0, 30, regarding differing exposures between the two
and 60 degrees for arm elevation, and 30, 60, tasks (bagging pears versus bagging apples)
and 90 degrees for arm abduction. was not stated. Exposure was based on self-
report of the number of hours per day spent
Studies Not Meeting the Four Evaluation bagging, the number of pears or apples bagged
Criteria
per day, and the total number of days spent
Bjelle et al. [1981] compared cases with acute, bagging each fruit. One worker was observed
non-traumatic shoulder-neck pain to age- and for 3 hours while performing each bagging job,
sex-matched, paired controls. To determine with repeated goniometric measures of
exposure, each case and control was filmed shoulder forward flexion angles done each
and a biomechanical analysis was performed to minute. While there was no difference in the
determine the frequency and duration of total number of days or number of hours per
shoulder abduction or forward flexion > than day spent bagging each fruit, significantly more
60 degrees. pears than apples were bagged per day. The
proportion of time spent with the angle of
In the study by English et al. [1995], cases shoulder forward flexion greater than 90
were determined by medical diagnosis and degrees was significantly larger when bagging
controls were selected from patients evaluated pears (75%) than when bagging apples (41%).
at specified orthopedic clinics. For statistical
analyses, all diagnoses were grouped by One study did not meet any of the criteria. In a
anatomical site. The diagnoses for shoulder cross-sectional study by Ohlsson et al. [1989],
cases were rotator cuff injury, rupture of long the exposed population was factory employees
head of biceps, shoulder capsulitis, and who produced and assembled plastic
symptomatic acromioclavicular arthritis. It is components. Work exposure was
assumed that shoulder tendinitis is included in characterized as repetitive arm and hand
this group. Exposure measures were movements in constrained work postures. The
determined by a standardized interview referent population was composed of women
conducted by an interviewer who was randomly sampled from the general population
unaware of the case-control status of the in a nearby area. The health outcome was
individual wherever this was possible. determined by self-reported symptoms of
shoulder pain during the previous seven days.
In a study by Sakakibara et al. [1995], the The exposure measure was the self-reported
health status of a group of women farm number of items completed per hour. The range
workers was assessed during the performance was from less than 100 items completed per
of two different tasks, with a hour (slow category) to more than 700 items
1-month interval between the tasks. The health
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per hour (very fast category). Self-reporting shoulder MSDs, the major limitation of this
was believed to be accurate because workers study was that the exposure assessment was
were paid by the piece. not specific to movement at the shoulder joint
and may therefore have either over- or
Strength of Association: underestimated repetition at the shoulder. In
Repetition and Shoulder MSDs some cases the exposure assessment may have
Using the data presented in the study by been a measure of repetitive upper arm
Ohlsson et al. [1994], for supraspinatus, movements, but it may also have been a
infraspinatus, or bicipital tendinitis the odds measure of repetitive hand and distal upper
ratio (OR) for working in the fish industry extremity activity occurring in the context of a
(repetitive work, poor posture) was calculated static load on the shoulder muscles.
as 3.03 (95% CI 2.57.2). For shoulder
tendinitis alone, the PRR was calculated as 3.5 For the shoulder diagnoses used to form their
(95% CI 2.05.9). For clinical diagnoses of the group of cases, English et al. [1995] found an
neck and shoulder, the OR for working in the association with repeated shoulder rotation with
fish industry versus the referent population was an elevated arm (OR 2.30, p< 0.05). They also
3.2 (95% CI 2.05.3). found what appeared to be a protective effect
associated with elbow flexion (OR 0.4, 95%
Using data presented in the study by Ohlsson et CI 0.20.8). This effect was greatest at low
al. [1995] for supraspinatus, infraspinatus, or amounts of daily cumulative exposure to elbow
bicipital tendinitis, the OR for being an flexion; the protective effect decreased (RR
assembly worker (repetitive arm movements increased) as the number of hours of total daily
with static load on shoulders) versus the elbow flexion increased. In a laboratory study
referent population was 4.2 (95% CI of shoulder muscle activity in relation to
1.3513.2). For neck-shoulder disorders, the different combinations of shoulder and elbow
OR for being an assembly worker versus the joint postures (a total of 21 different postures),
referent group was 5.0 (95% CI 2.211.0). Herberts et al. [1984] found that humeral
rotation and elbow flexion had insignificant
Using multiple logistic regression analysis with effects on shoulder muscle activity. However,
age, gender, and force as covariates, Chiang et the postures tested by that study were
al. [1993] found that highly repetitive upper stationary, whereas the associations reported
extremity movements were associated with by English et al. [1995] appear to be related to
shoulder girdle pain (OR 1.6, 95% CI repetitive movements.
1.12.5). When tested in the same model with
force and repetition, the interaction term for For symptoms of shoulder pain within the
force and repetition was also significant (OR previous 7 days, the OR for assembly workers
1.4, 95% CI 1.02.0). Several factors could versus the referent group was 3.4 (95% CI
have resulted in an underestimation of the 1.67.1) [Ohlsson et al. 1989]. A significantly
strength of association: no requirement that higher proportion of the farm workers studied
symptoms had begun on current job means that by Sakakibara et al. [1995]
some symptomatic workers may have
transferred to lower risk jobs. Relative to
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had signs of shoulder muscle tenderness while Repetition Characterized as Short Cycle Time
bagging pears than while bagging apples. There Chiang et al. [1993] found a significant
was no way to analyze the relative contribution association between a very short or repetitive
to risk of repetitive shoulder exertions cycle (<30 seconds or >50% spent repeating
(increased number of pears picked per day) same task) and shoulder girdle pain.
and awkward posture (greater portion of each
day spent with extreme forward flexion when Repetition Characterized Descriptively
picking pears). Three studies by Ohlsson et al. found a
significantly higher proportion of shoulder
Consistency of Association MSDs in exposed populations with work
Repetitiveness was defined in four different characterized as involving repetitive arm and
ways in the reviewed studies: (1) the observed hand movements than in referent populations
frequency of movements past pre-defined [Ohlsson et al. 1989, 1994, 1995].
angles of shoulder flexion or abduction, (2) the
number of pieces handled per time unit, (3) Repetition Combined with Static Shoulder
Load
short cycle time/repeated tasks within cycle,
and (4) a descriptive characterization of Except for the study by Sakakibara et al.
repetitive work or repetitive arm movements. [1995], in which the increased number of pears
bagged per day was associated with an
Repetition Characterized as Frequency of increased proportion of the work day spent
Movements Past Pre-Defined Shoulder with extreme shoulder flexion, the studies using
Angles measures of piece work or repetitive arm
Bjelle et al. [1981] and Ohlsson et al. [1995] movements as the exposure outcome did not
found a significant positive association between specify which joints or body regions
the prevalence of neck-shoulder disorders and participated in the repetitive action. Ohlsson et
the frequency of upper arm movements past 60 al. [1995] described the assembly work
degrees of flexion or abduction. English et al. performed by the exposed population as
[1995] found a significant association between combining repetitive arm movements with a
diagnosed cases of shoulder disorders and static shoulder load. It is possible that the
repeated shoulder rotation with an elevated arm association between piece work, short cycles,
posture. or repetitive hand-arm movements and
shoulder disorders reported by the other
Repetition Characterized as the Number of authors is related to a sustained, static load on
Pieces Handled per Time Unit
the shoulder muscles as the upper arm is
A significant positive association was found stabilized in a posture of mild to severe flexion
between both nonspecific shoulder symptoms or abduction, while repetitive movements are
[Ohlsson et al. 1989] and nonspecific shoulder performed by the hand-wrist-forearm.
disorders [Sakakibara et al. 1995] and the
number of pieces handled per hour or per day.
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Temporal Relationship associated (p<0.05) with both the number of

In the prospective study by Kilbom et al. 1986; arm elevation movements from less than to
Kilbom and Persson 1987; and Jonsson et al. greater than 60 degrees and the number of arm
1988 the number of shoulder elevations per abduction movements from less than to greater
hour was a strong predictor for a change to than 60 degrees. Bjelle et al. [1981] found that
severe status at the 1- and 2-year follow-up the frequency of shoulder abduction or forward
evaluations. Although the change in status flexion (past 60 degrees) was significantly
included problems in the neck and arm, as well greater (p<0.005) for cases with neck-shoulder
as the shoulder, it is reasonable to assume that disorders than for controls.
repetitive shoulder elevations would have had
the greatest effect on disorders of the shoulder. In the study of assembly workers by Ohlsson et
al. [1989], the number of pieces completed per
Several studies with a cross-sectional design hour was categorized as follows: slow: <100,
used techniques to determine whether the medium: 100299, fast: 300699, very fast:
health outcome of interest had occurred since, >700. In this study, the ORs are shown in a
or was present during, exposure to figure, rather than reported in the text.
hypothesized risk factor(s) of interest. Case Compared with the slow-paced group, the
definitions which required a positive physical odds for symptoms of shoulder pain is
examination finding [Chiang et al. 1993; approximately seven times that for those
Ohlsson et al. 1994, 1995] or where symptoms workers in the medium-paced group and
had occurred within the recent past [Chiang et approximately nine times that for those in the
al. 1993; Ohlsson et al. 1989, 1994] were fast-June 26, 1997 pace group. While adjusting
designed to focus on disorders most likely to for age and length of employment, the OR for
have been caused or aggravated by current shoulder pain was significantly higher for the
work exposures. medium- and fast-paced groups than for the
slow-paced group (p=0.0006). The OR for the
Exposure-Response Relationship very fast-paced group compared to the slow-
Chiang et al. [1993] found a significant paced group was between 1.0 and 2.0 and was
increasing trend in the prevalence of shoulder not significantly different from the slow-paced
girdle pain from Group I (low force, low group. The authors hypothesized that
repetitiveness) to Group III (high force, high symptomatic workers may have self-selected
repetitiveness). However, the health outcome out of the very fast paced jobs or that other
was not specific to shoulder disorders, and the unknown factors may have mitigated the effects
exposure categories combine increasing of work pace.
repetitivenessas defined by either less than a
30-second cycle time or a repeated task within When comparing fish industry workers to the
the job cycleand increasing forearm flexor reference population, Ohlsson et al. [1994]
muscle activity. Ohlsson et al. [1995] found that found that among those workers younger than
neck and shoulder disorders among assembly age 45, the ORs for disorders of the neck and
workers were significantly shoulders were significantly elevated and
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increased with duration of employment [05 Some of the significant associations reported
years, OR 3.2 (95% CI 1.57.0); >5 years, may have been related to exposure to repetitive
OR 10 (95% CI 4.524)]. In their study of work in the distal upper extremity while the
assembly workers, Ohlsson et al. [1989] found shoulder and upper arm were maintained in a
a statistically significant increase in the odds for static posture [Chiang et al. 1993; Ohlsson et
pain in the shoulder with duration of al. 1989, 1994, 1995]. Winkel and Westgaard
employment (p=0.03) which was dependent on [1992] have pointed out that, It is not possible
age. The increase with duration of employment to use the arm/hand without stabilizing the
had a steeper slope for younger (<35 years) rotator cuff girdle and the glenohumeral joint.
assembly workers than for the older subgroup Therefore, work tasks with a demand of
(i.e., among those workers employed for short continuous arm movements generate load
durations, older women had more symptoms, patterns with a static load component.
and among those workers employed for long
durations, younger women had more The finding that the supra- and infraspinatus
symptoms). This was thought to be a reflection muscles were particularly prone to fatigue when
of both survivor bias as well as the possibility subjects performed overhead work led
that older new hires may have experienced a Herberts et al. [1984] to hypothesize that the
relatively more rapid onset of symptomatic rotator cuff muscles may develop high
problems than do younger women. intramuscular pressures at relatively low
contraction levels. These high intramuscular
Coherence of Evidence pressures could lead to an impairment of
Repetitive movements of the upper extremity intramuscular circulation, which could
involving flexion or abduction of the contribute to the early onset of fatigue.
glenohumeral joint would increase the Intramuscular pressure increases with the
frequency of effects such as fatigue and tendon muscle contraction level, and impaired
circulation disruption hypothesized to occur as circulation has been demonstrated at levels of
a result of such postures. These effects could contraction as low as 1020 percent of
be magnified by the addition of a hand-held maximal voluntary contraction (MVC).
load. Repetition may also be solely related to [Hagberg 1984].
the development of tendinitis. In a laboratory
study, Hagberg [1981] induced acute shoulder The increased pressure in rotator cuff muscles
tendinitis in female subjects performing and increased pressure on the supraspinatus
repetitive shoulder elevations for one hour. Six tendon may trigger two different events that are
female students, ages 1829, all developed both related to impaired microcirculation. The
shoulder tenderness (two with tendinitis) when impaired microcirculation in the tendon may
exposed to 15 shoulder flexions (from 0 to 90 also result from tension within the tendon
degrees) per minute for 60 minutes while produced by forceful muscle contractions
holding up to 3.1 kg (6.4 lb) of weight. [Rathburn and Macnab 1970]. An
inflammatory infiltrate with increased
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vascularity and edema within the rotator cuff method, and shoulder MSDs or symptoms
tendons, especially the supraspinatus tendon were found in all studies. Of the eight studies in
may be a result of or a contributor to the which the effect of repetition was examined,
process. If the inflammation process is three studies found ORs above 3.0 [Ohlsson et
sufficiently intense, then shoulder tendinitis may al. 1989, 1994, 1995] and three studies found
occur. If the process is less intense, and more ORs from 1.0 to 3.0 [Chiang et al. 1993;
chronic, then it may contribute to a English et al. 1995; Sakakibara et al. 1995].
degenerative process in the tendons of the The remaining studies were prospective studies
rotator cuff. In the muscles of the rotator cuff, [Jonsson et al. 1988; Kilbom and Persson
the impaired microcirculation may lead to small 1987] or studies that reported risk indicators
areas of cell death. A reasonable hypothesis is other than OR [Bjelle et al. 1981].
that repeated or sustained episodes of muscle
ischemia result in localized cell death and In none of these studies is it likely that age, the
persistent inflammation. most important personal characteristic
associated with shoulder tendinitis and other
Neither of these proposed models for shoulder shoulder disorders, or nonoccupational factors
muscle pain or tendinitis suggest that all muscle such as sports activities, caring for young
activity is potentially harmful. Both muscles and children, or hobbies explained these
tendons are strengthened by repeated activity if associations. There is evidence of a relationship
there is sufficient recovery time. However, the between shoulder tendinitis and highly repetitive
models present plausible mechanisms by which work.
work tasks with substantial shoulder abduction
could contribute both to shoulder pain and FORCE
tendinitis.
Definition of Force for Shoulder
There is evidence of a relationship between MSDs
shoulder tendinitis and highly repetitive work. Studies that examined force or forceful work or
However, there are several limitations to the heavy loads to the shoulder, or described
evidence. In the three studies for which the exposure as strenuous work involving the
health outcome was shoulder tendinitis, the shoulder abduction, flexion, extension, or
exposure combined repetition with awkward rotation that could generate loads to the
shoulder posture and/or a static shoulder load shoulder region were also included. Most of the
[English et al. 1995; Ohlsson et al. 1994, studies that examined force or forceful work as
1995]. Five out of the eight studies reviewed a risk factor for shoulder symptoms or tendinitis
used either nonspecific shoulder disorders, had several concurrent or interacting physical
nonspecific shoulder symptoms or combined work load factors. However, there is still a
neck-shoulder disorders as the health outcome. need to summarize present knowledge about
the relationships between forceful work and
Despite the limitations of the evidence, shoulder MSDs. This section summarizes that
significant and positive relationships between knowledge, while acknowledging that other
repetitiveness, regardless of the measurement factors can modify the response.
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Neck-shoulder disorders are discussed in experience and knowledge of the jobs were
Chapter 2. used to assign job titles to exposure categories
based on crude assessments of force and
Studies Reporting on the Association repetitiveness. High exposure was
of Force and Shoulder Tendinitis characterized as a combination of high
There are five studies which reported results on repetitiveness (activity repeated several times
the association between force and adverse per minute) and low or high force, or medium
shoulder health outcomes (Table 32, Figure repetitiveness (activity repeated many times per
32). The epidemiologic studies that addressed hour) and high force. Medium exposure was
forceful work and shoulder MSDs tended to characterized as medium repetitiveness and low
compare working groups by classifying them force, or low repetitiveness (jobs with more
into broad categories based on an estimated variation) and high force. Those in teaching,
amount of resistance or force of exertion and a academic, self-employed, or nursing
combination of estimated rate of repetition professions were classified as low exposure.
[Andersen and Gaardboe 1993a; Chiang et al. The exposure classification scheme in this study
1993] or in terms of overall load [Herberts et does not allow separation of the effects of force
al. 1984; Stenlund et al. 1992; Wells et al. from those of repetition. More sewing machine
1983]. operators than referents were considered to
have high exposure (41% versus 15%), but
Studies Meeting the Four Evaluation Criteria more in the referent population were
Chiang et al. [1993] studied workers in the fish considered to be in the medium exposure group
processing industry. (This study was described (44% versus 22%). Because the outcome of
in detail in the section on shoulder MSDs and interest was duration of historical exposure,
repetition.) Chiang et al. [1993] did not report current exposure was included as an
an exposure specific to the shoulder. independent variable in multivariate regression
analyses.
Studies Not Meeting the Four Evaluation
Criteria Herberts et al. [1984] added to the 1981 study
Andersen and Gaardboe [1993a] performed a by comparing the prevalence of supraspinatus
cross-sectional study in which a cohort of tendinitis between plate-workers and office
sewing machine operators was compared to a clerks. Tendinitis in welders was determined by
random sample of women in the general a combination of self-reported symptoms and
population of the same region. Chronic positive physical examination findings. The only
shoulder pain was defined as a having information given regarding plate-work is that it
experienced a continuous pain episode lasting is dynamic in character. It is presumed that
more than 1 month and either daily pain or pain plate-workers handled heavy loads more
lasting more than 30 days in the same location frequently than office clerks.
within the previous year (per self-administered
questionnaire). In order to compare the current In a cross-sectional study, the prevalence of
exposure of sewing machine operators and osteoarthrosis in the acromioclavicular joint,
those in the control group, the authors
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as determined by radiography, was compared current work as a sewing machine operator

among three groups of workers in the was associated with chronic shoulder pain (OR
construction industry [Stenlund et al. 1992]. 1.72, 95% CI 1.172.55). Using multiple
The three groups were bricklayers, rock logistic regression analysis with age, gender,
blasters, and construction foremen. The and repetitiveness as covariates, Chiang et al.
foremen did not perform manual work [1993] found that high force exertions
currently, or in the past, and were considered measured in the forearm were associated with
the control population. A standardized shoulder girdle pain (OR 1.8, 95% CI
interview was used to determine exposure 1.22.5). When tested in the same model with
factors, including job title and the sum of loads force and repetition, the interaction term for
lifted during all working years (expressed in force times repetition was also significant (OR
tonnes). Analyses were performed separately 1.4, 95% CI 1.02.0). Two factors could have
for right and left sides. resulted in an underestimation of the strength of
association: (1) no requirement that symptoms
In a study of letter carriers, Wells et al. [1983] have started on current job meant that some
symptomatic workers may have transferred to
evaluated the effect of a load carried on the
lower risk jobs, and (2) no matching of health
shoulder. Letter carriers, who carry a load and
status and exposure status by side (left, right, or
walk, were compared to gas meter readers
both) may have caused non-differential
(who walk without carrying a load) and postal
misclassification. For supraspinatus tendinitis,
clerks. Utilizing information from telephone
Herberts et al. [1984] calculated a prevalence
interviews, points were assigned to symptom
rate ratio (PRR) for plate-workers versus office
characteristics such as frequency, length of
clerks of 16.2 (90% CI 10.921.5) under the
episodes, and interference with work ability. assumption that missing data had the same
Case definition required a report of recurrent characteristics as those considered. The
shoulder pain with greater than 20 points. A absence of specific exposure information was a
subset of letter carriers had experienced an major limitation of this study.
increased load during the previous year. (The
Postal Service had increased maximum weight The age-adjusted OR associated with
carried from 25 to 35 pounds, but not all osteoarthritis of the acromioclavicular
locations had implemented this change.) joint was 2.16 (95% CI 1.144.09)
(right side) and 2.56 (95% CI 1.334.93)
Strength of AssociationForce (left side) for manual construction workers
and Shoulder MSDs versus foremen [Stenlund et al. 1992]. Because
The studies are presented in alphabetical order there was a lower participation rate among
bricklayers and blasters, self-selection into the
in Table 3-2. Results of studies where ORs, or study because of having symptoms could have
other measures of association, were specifically resulted in overestimation of the strength of
associated with a measure of exposure, are association. While some of the items handled
presented in the section on Exposure-Response required a bilateral lift (e.g., jackhammer),
Relationship. other loads may have been specific to the right
or left hand. Because the
Andersen and Gaardboe [1993a] found that
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exposure measure did not separate load by disorders between letter carriers with and
sides, non-differential misclassification may without the increased load was related to
have caused underestimation of the strength of current exposure rather than past peak
association. exposures or cumulative duration. Although
baseline symptom status in the group with the
Consistency of Association: increased load could not be obtained, there
Force and Shoulder MSDs was no significant difference in the prevalence
Despite different outcome and exposure of shoulder problems between the two groups
measures, all of the studies had positive when results were adjusted for the amount of
associations. Each study used a different case weight currently carried. Therefore, the
definition, ranging from relatively mild difference in symptom prevalence was likely
symptoms to radiographic evidence of related to the load increase rather than prior
osteoarthritis, and a different measure of differences in symptom status. The cross-
exposure. Chiang et al. [1993] used EMG sectional studies are consistent with exposure
measures of forearm flexor muscle activity. occurring before the onset of the shoulder
Wells et al. [1983] evaluated the effect of a MSDs.
direct load on the shoulder. Stenlund et al.
[1992] used an estimate of the cumulative, Exposure-Response Relationship
lifetime load carried. Andersen and Gaardboe When sewing machine operators were
[1993a] compared sewing machine operators compared with an external control population,
to a referent population. However, positive and there was a trend of increasing ORs for chronic
significant associations were found, regardless shoulder pain with increasing duration of work
of the measure of health outcome or exposure. as a sewing machine operator [Andersen and
Gaardboe 1993a]. The OR for 07 years was
Temporal Relationship: Force and 1.38 (95% CI 0.862.39), for 815 years it
Shoulder MSDs was 3.86 (95% CI 2.296.50), and for >15
All of the studies of forceful exertions used a years it was 10.25 (95% CI 5.8517.94),
cross-sectional study design. To increase the while controlling for other factors including age
likelihood that shoulder symptoms were caused and current exposure.
or aggravated by current exposure, Chiang et
al. [1993] required that symptoms had Chiang et al. [1993] found a significant
occurred within the previous 30 days. increasing trend in the prevalence of shoulder
girdle pain from Group I (low force, low
Wells et al. [1983] used several analytical repetitiveness) to Group III (high force, high
methods to increase confidence in a relationship repetitiveness). However, the health outcome is
between carrying the increased load and having not specific for shoulder tendinitis and the
shoulder disorders. The use of age, the number exposure categories combine increasing force,
of years on the job, and previous heavy work as measured in the forearm flexor muscles, and
experience as covariates when performing increasing repetitiveness.
analysis of covariance helped ensure that the
difference in the proportion of shoulder
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In the study of bricklayers and blasters, and that muscular fatigue will occur at EMG levels
acromioclavicular osteoarthritis, Stenlund et al. as low as 5% of maximal voluntary contraction
[1992] found that for the left side, ORs (MVC) if sustained for 1 hour. Other studies
increased with the level of lifetime load lifted. have demonstrated that when the period of
For a lifetime load of 71024,999 tonnes muscle contraction is extended to more than an
versus less than 710 tonnes, the left side OR hour, the endurance limit of force may be as
was 7.29 (95% CI 2.4921.34), and for low as 8% MVC [Jonsson 1988]. Workers
greater than 25,000 tonnes versus less than 710 performing repetitive work with the hands and
tonnes, the left side OR was 10.34 (95% CI wrists, while maintaining static upper arm
3.1034.46). elevation may experience fatigue even at low
load levels. Jonsson [1988] reported that many
For severe, but not disabling, shoulder pain, the constrained work situations are characterized
OR for letter carriers versus postal clerks was by static load levels near or exceeding 5%
3.6 (95% CI 1.87.8) [Wells et al. 1983]. For MVC, even when characterized by a fairly low
those letter carriers who had experienced a mean muscular load.
weightload increase within the previous year,
versus postal clerks, the OR was 5.7 (95% CI Because the five studies reviewed had a
2.117.8). Furthermore, letter carriers who had considerable diversity of exposure assessment
experienced the weightload increase had approaches and health outcomes, there is
significantly more shoulder problems than those insufficient epidemiologic evidence to conclude
whose bag weight had not been increased. If that forceful exertions are associated with
letter carriers tend to keep the mail-bag strap rotator cuff or bicipital tendinitis. The one study
on one shoulder, the fact that the side of the that used shoulder tendinitis as the health
load was not matched with the side of the outcome reported a strong association related
shoulder problem could have resulted in non- to job category (OR for plate-workers versus
differential misclassification and an clerks: 16.2 (95% CI 10.921.5), but did not
underestimation of the strength of association. describe or measure specific exposure risk
However, some of the health effects may have factors [Herberts et al. 1984]. One of the
been related to activation of contralateral reviewed studies did present evidence for an
muscles involved in stabilizing the shoulder association between acromioclavicular
girdle [Winkel and Westgaard 1992]. osteoarthrosis and cumulative, lifetime load on
the shoulder muscles [Stenlund et al. 1992].
Coherence of Evidence Another study reported a significant association
High shoulder muscle force requirements can between severe shoulder pain and a direct
cause increased muscle contraction activity, shoulder load [Wells et al. 1983].
which may lead to an increase in both muscle
fatigue and tendon tension, and may possibly
impair microcirculation as well.
Force may also be related to a static load on

shoulder muscles. Sjgaard et al. [1988] found
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POSTURE Ohlsson et al. 1995] or combined neck-

shoulder symptoms [Kilbom and Persson
Definition of Awkward Posture for
1987].
Shoulder MSDs
For the shoulder, a relaxed, neutral posture is Studies Meeting the Four Evaluation Criteria
one in which the arm hangs straight down by Four studies met all four of the evaluation
the side of the torso. As the arm is flexed, criteria.
abducted, or extended, the included angle
between the torso and the upper arm increases. Using a prospective study design, Jonsson et al.
In one study, postures in which the included [1988] assessed the health and exposure status
angle was equal to or greater than 45 degrees of 69 electronics manufacturing plant
required substantial supraspinatus muscle employees at the beginning of the study and
activity, while deltoid muscle activity underwent after one and two years. Employees who
a pronounced increase as the angle of shoulder dropped out before completion of the study
flexion or abduction increased from 45 to 90 were compared to those who fully participated;
degrees [Herberts et al. 1984]. As the arm is there was no significant difference in medical
elevated, the space between the humeral head status, working technique, or work history.
and the acromion narrows such that mechanical Employees who had upper extremity disorders
pressure on the supraspinatus tendon is greatest resulting in a physician visit or sick leave were
between 60 and 120 degrees of arm elevation excluded from the initial study group. The
[Levitz and Iannotti 1995]. While there is a dependent variables related to health status
continuum of severity from an included angle of were of two types: a change in symptom
30 degrees to a maximally abducted arm, severity and being symptom free. Symptom
postures with shoulder abduction or flexion past status was assessed by interview and a physical
60 degrees are considered awkward. examination by a physiotherapist. The
symptoms severity index compiled data from
Studies Reporting on the Association the five body regions combined and was not
of Awkward Postures and Shoulder specific for the shoulder region. Because the
MSDs exposure was determined by direct observation
Six of the reviewed studies reported results on for each individual, and clearly separated
the association between awkward postures and ergonomic risk factors by body region, it was
shoulder tendinitis [Baron et al. 1991; Bjelle et still possible to evaluate associations likely to
al. 1979; English et al. 1995; Herberts et al. specifically involve the shoulder.
1981; Ohlsson et al. 1994, 1995] (Table 3-3,
Figure 3-3). Seven additional studies reported Kilbom and Persson [1987] and Kilbom
results on the association between awkward et al. [1986] performed a study in
postures and non-specific shoulder disorders which female employees in the
[Sakakibara et al. 1995], non-specific shoulder electronics manufacturing industry were
symptoms [Hoekstra et al. 1994; Milerad and observed for a 2-year period. The health
Ekenvall 1990; Schibye et al. 1995] combined outcome of fatigue, ache, or pain
neck-shoulder disorders
[Bjelle et al. 1981; Jonsson et al. 1988;
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in the neck, shoulder, or arm regions was based different factors were rated on a scale from 1 to
on symptoms information. Symptom severity 5 and the combined ratings were used as a
was coded on the basis of its character, profile of the work task. Based on this profile,
frequency, and/or duration. Changes in severity the authors reported that fish industry work was
status at follow-up evaluations were used as the found to be highly repetitive and include
dependent variables in multiple regression poor work postures.
analyses. Neck, shoulder, and upper arm
posture was determined by computerized Ohlsson et al. [1995] compared a group of
analysis (VIRA) of videotapes of individuals. women who performed industrial assembly
Although the health outcome combined work to a referent group of women from a
symptoms from different body regions, nearby town who were employed in jobs
knowledge of biomechanical theory can be characterized as having varied and mobile work
used to identify significant predictors related to tasks. One examiner assessed signs and
the shoulder symptom severity. symptoms. The examiner was blinded to
specific exposure information, but not
Two of the reviewed studies in which tendinitis completely blinded to factory worker versus
was the health outcome are Ohlsson et al. referent group status. Shoulder tendinitis
[1994, 1995]. For both studies, the authors included supraspinatus, infraspinatus, and
reported that the examiners could not be bicipital tendinitis. Another health outcome
completely blinded to exposed versus referent combined neck and shoulder disorders (tension
status, but that a standard protocol was neck, cervical syndrome, thoracic outlet
followed and observer bias was likely to have syndrome, frozen shoulder, tendinitis, and
been minimal. Because examiners were blinded acromioclavicular syndrome). In a descriptive
to objective exposure measures, analyses assessment, it was reported that the work tasks
testing associations between neck-shoulder in the study group involved repetitive arm
disorders and specific postures would not have movements with static muscular work of the
been biased [Ohlsson et al. 1995]. neck and shoulder muscles. The percentage of
time spent in specific upper arm postures was
In a cross-sectional study, women in the fish determined from videotaped observations of 74
industry were compared to a control population (out of 82) workers. The average result from
of women employed in municipal workplaces in two independent videotape analyses was used.
the same towns [Ohlsson et al. 1994]. Posture category demarcations included 0, 30,
Diagnoses of shoulder disorders (e.g., and 60 degrees for arm elevation, and 30, 60,
tendinitis, acromioclavicular syndrome, frozen and 90 degrees for arm abduction.
shoulder) were made on the basis of symptoms
determined by interview and a physical exam. Studies Not Meeting the Four Evaluation
Criteria
Exposure evaluation of each work task held by
the fish industry population was evaluated with Summaries of studies that specifically evaluated
ergonomic workplace analysis (EWA). Ten associations with shoulder tendinitis are
presented next [Baron et al. 1991; Bjelle et al.
1979, 1981;
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English et al. 1995; Herberts et al. 1981]. working as a checker.

Summaries of other studies are presented in
alphabetical order. Bjelle et al. [1979] compared cases with
persistent shoulder pain to controls employed
In the study by Baron et al. [1991], grocery as manual workers. After an extensive medical
store workers who performed the job of evaluation, a diagnosis of bicipital and/or
checker were compared to a non-checker supraspinate tendinitis was made for a majority
group that performed a variety of other jobs (12/17) of the cases. Physical workload was
(e.g., general stocking, working in the produce categorized in relation to sitting or standing
section, the bakery, salad bar, pharmacy, and posture, weight lifting, and carrying. The work
courtesy counter). There was a low height of the hands was categorized based on
participation rate among non-checkers (55%), position relative to the acromion height, per
which could have resulted in an underestimation individual. Placement of workers into exposure
of the OR for checkers if symptomatic non- categories was determined by the combined
checkers were more likely to participate than efforts of each study participant and a
those non-checkers without symptoms. The physician.
authors evaluated this possibility by performing
a sufficient number of telephone interviews with Bjelle et al. [1981] compared cases with acute,
non-participants to raise the non-checker non-traumatic shoulder-neck pain to age- and
participation rate for interviews to 85%. The sex-matched, paired controls. An extensive
OR for shoulder symptoms among the full physical examination was performed and
participant population was similar to the OR for workers with inflammatory rheumatoid diseases
the full participant plus telephone interview were excluded. To determine exposure, each
population. The case definition was shoulder case and control was filmed and a
symptoms lasting at least one week or biomechanical analysis was performed to
occurring at least once per month during the determine the duration and frequency of
previous year that began while the worker was shoulder abduction or forward flexion greater
performing her current job and positive physical than 60 degrees.
examination findings consistent with a shoulder
tendinitis. Detailed descriptions of the checker In a study by English et al. [1995], cases
jobs were presented based on both on-site and determined by medical diagnosis, and controls
videotape analyses of a few representative were selected from patients evaluated at
workers per workstation. No videotaping of specified orthopedic clinics. For statistical
non-checkers was performed. Shoulder flexion analyses, all diagnoses were grouped by
and/or abduction ($90 degrees) was observed anatomical site. The diagnoses for shoulder
during a variety of different tasks performed by cases included rotator cuff injury, rupture of the
the checkers. The exposure measures used in long head of the biceps, shoulder capsulitis, and
statistical analyses were: (1) checker versus symptomatic acromioclavicular arthritis. It is
non-checker and, (2) for exposure-response assumed that shoulder tendinitis was included in
assessment among checkers, the total number this group. Exposure measures were
of months and the number of hours per week determined by a standardized interview
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conducted by an interviewer who was, In a prospective study by Sakakibara et al.

unaware of the case-control status of the [1995], the health status of a group of women
individual wherever this was possible. farm workers was assessed during the
performance of two different tasks, with a 1-
In a study by Herberts et al. [1981], the month interval between the tasks. The health
prevalence of supraspinatus tendinitis was outcome was defined by self-assessed
compared between welders and office symptoms of shoulder stiffness and pain and a
workers. Tendinitis cases were based on a physical examination for muscle tenderness and
combination of symptoms reported on a nurse- joint pain on movement. Whether the examining
administered questionnaire and a positive physician was aware of the prior hypothesis
physical examination done by a physiotherapist. regarding differing exposures between the two
For welders, an experienced physiotherapist tasks (bagging pears versus bagging apples)
rated work-load on the shoulder as low, high, was not stated. Exposure was based on self-
or very high; no description of the classification report of the number of hours per day spent
scheme was given. bagging, the number of pears or apples bagged
per day, and the total number of days spent
Hoekstra et al. [1994] evaluated government bagging each fruit. One worker was observed
office workers at two locations. The case for 3 hours while performing each bagging job,
definition for shoulder symptoms was with repeated goniometer measures of shoulder
symptoms that began after starting current job, forward flexion angles done each minute. While
lasting greater than one week, or occurring at there was no difference in the total number of
least once per month during the past year with days or number of hours per day spent bagging
an intensity greater than two on a five point each fruit, significantly more pears than apples
scale, and no preceding acute, non- were bagged per day. The proportion of time
occupational injury. A self-administered spent with the angle of shoulder forward flexion
questionnaire was used to determine exposure greater than 90 degrees was significantly larger
to factors such as perceived adequacy of when bagging pears (75%) than when bagging
adjustment of video display terminal (VDT). apples (41%).
Walk-through ergonomic evaluations of factors
such as workstation surface height and furniture Schibye et al. [1995] performed a prospective
adjustability were used to provide descriptive study of a population of sewing machine
differences between the two office locations. operators in which the change in self-reported
shoulder symptom status was compared with
Milerad and Ekenvall [1990] compared the those sewing machine operators who continued
prevalence of self-reported, non-specific to work and those operators that moved into
shoulder symptoms between dentists and other occupations (e.g., shop assistant, health
pharmacists. Dentistry, as a profession, was care worker, and fishing industry worker).
described as work with the arms abducted
and unsupported whereas, pharmacists had
physically light and varied work.
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Strength of AssociationAwkward OR for being a checker versus a non-checker

Posture and Shoulder MSDs was 3.9 (95% CI 1.411.0). Because non-
Results are presented in the section on checkers also performed work requiring
Exposure-Response Relationship (Table 3-3, awkward postures, the reported OR may
Figure 3-3) for studies where ORs, or other underestimate the risk for checkers. Short
measures of association, were specifically stature (# 5'2") was associated with an
associated with a measure of exposure. elevated, but not statistically significant, OR for
shoulder disorders (2.1, 95% CI 0.76.9).
Using data presented in the study by Ohlsson et Because work-station height was fixed, it is
al. [1994], for supraspinatus, infraspinatus, or likely that short stature workers experienced
bicipital tendinitis, the PRR for working in the more frequent and/or more severe episodes of
fish industry (repetitive work, poor posture) shoulder flexion and/or abduction.
versus the referent population was calculated as
3.03 (95% CI 2.04.6). For shoulder tendinitis The OR for work performed at or above
alone, the PRR was calculated as 3.5 (95% CI acromion height (i.e., hands above the
2.05.9). In the same study, the authors also shoulder) versus work performed below
interviewed a large group of former fish acromion height was 10.6 (95% CI 2.354.9)
industry employees and found that a quarter of [Bjelle et al. 1979]. In this study, all cases were
those workers who left employment had done patients who had been examined by the same
so because of problems with their neck or physician. Placement of cases and controls into
upper limbs. This proportion increased with age exposure categories was performed by each
and also occurred after a shorter duration of subject in collaboration with a physician who
employment among the oldest workers. This had personal knowledge of the work involved
evidence of a survivor bias highlights the in each case. Whether or not the physician
importance of controlling for age. Higher risks who performed the clinical examinations is the
were found for the workers less than 45 years same person as the physician involved in
old and these risks may be a more accurate exposure classification is not stated. If this was
assessment of the true risk. the same person, a potential bias towards
assigning cases to higher exposure categories
Using data presented in the study by Ohlsson et could have resulted in overestimation of the
al. [1995], for supraspinatus, infraspinatus, or strength of association. However, two other
bicipital tendinitis, the OR for being an factors could have resulted in an
assembly worker (repetitive arm movements underestimation of the strength of association.
with static load on shoulders) versus the The exposure outcome was based on current
referent population was 4.2 (95% CI work load without any stated restriction that
1.3513.2). For neck-shoulder disorders, the cases symptoms had started on their current
OR for being an assembly worker versus the job. If some of the cases, defined as having
referent group was 5.0 (95% CI 2.211.0). problems non-responsive to therapy lasting
longer than 3 months, had transferred to a
For shoulder disorders consistent with lower risk job, the strength of association
tendinitis, Baron et al. [1991] found that the
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may have been underestimated. Location of the two locations provided a plausible explanation
disorder and exposure were not matched by for this finding. At the higher risk location, the
side (left, right, or both) and this would have workstation surface was too high to serve as a
caused non-differential misclassification, keyboard support, there were nonadjustable
resulting in some underestimation of the strength chairs, and it was observed that nonadjustable
of association. furniture universally promoted undesirable
postures (i.e. elevated arms, hunched
English et al. [1995] found that the risk of shoulders). Having shoulder symptoms was
having a medically diagnosed shoulder also positively associated with using a non-
condition was increased by repeated shoulder optimally adjusted desk height (OR 5.1, 95%
rotation with an elevated arm (OR 2.30, CI 1.715.5) and a non-optimally adjusted
p<0.05). Non-differential misclassification due VDT screen (OR 3.9, 95% CI 1.411.5).
to a combination of complicated exposure Because exposure was self-reported without
definitions using a questionnaire, and the fact any indication of whether or not study
that analyses did not relate health outcomes and participants had received education regarding
exposure on a temporal basis, or by left/right good VDT workstation design, the phrase,
side, may have caused an under-estimate of the non-optimally adjusted, may have had various
strength of association. meanings to the study participants. This could
have caused non-differential misclassification of
For supraspinatus tendinitis, Herberts et al. exposure and an under-estimation of the
[1981] found that the PRR for welders strength of association. On the other hand, a
(characterized as using awkward postures to possible reporting bias related to self
perform overhead work) versus clerks was assessment of both symptoms and exposure
18.3. However, in determining this PRR, the could have resulted in an overestimation of the
authors performed extrapolation based on an strength of the association. A plausible
assumption that, the drop-out group does not explanation for the association between
deviate from the examined group, without any shoulder symptoms and these workstation
data to support this assumption. To determine a design factors is that the non-optimally adjusted
more reliable indicator of risk, unextrapolated workstation components forced the employees
data presented in the study were used to to abduct the upper arms and/or hunch the
calculate a crude OR=8.3 (95% CI 0.63432). shoulders.
The office clerks were older than the welders,
so that confounding by age may have caused an For shoulder symptoms without concomitant
under-estimation of the strength of association. neck symptoms, Milerad and Ekenvall [1990]
found that the OR for being a dentist (work
In a study of teleservice employees, there was with both arms abducted) versus being a
an association between reporting shoulder pharmacist was 3.8 (95% CI 1.2 10.3). As
symptoms and working at one location versus with most cross-sectional studies, the survivor
another location; the OR was 4.0 (95% CI bias may have resulted in
1.213.1) [Hoekstra et al. 1994]. Descriptive
differences between workstation design at the
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underreporting of the strength of exposure. shoulder symptoms and awkward shoulder

Conversely, the exposed group may have had posture. Awkward postures were consistently
better recall of self-reported symptoms with a described as overhead work, arm elevation,
resultant overestimation of the OR. and specific postures relative to degrees of
upper arm flexion or abduction. This
In the study of farm workers by Sakakibara et association was found in cross-sectional, case-
al. [1995], the point prevalence of muscular control, and prospective studies among a great
tenderness in the shoulder regions (per physical variety of types of work performed.
examination) was significantly higher when
performing pear bagging (48%) than when Temporal Relationship
performing apple bagging (29%). The It is important to determine whether symptoms
proportion of time spent with the shoulder in or MSDs occur as a consequence of work-
forward flexion greater than 90 degrees was related exposures. This can be done most
significantly larger when bagging pears (75%) clearly with a prospective study design.
than when bagging apples (41%). Whether or
not there was a recovery period between pear In the study by Jonsson et al. [1988], the
and apple bagging is not stated. If there was percent of the work cycle spent with the
insufficient recovery after pear bagging, shoulder elevated was negatively associated
persistent muscle tenderness or increased with remaining healthy (symptom free).
susceptibility may have caused underestimation Because workers with pre-existing shoulder
of the difference in shoulder conditions were excluded from study
disorder prevalence between these two work ta participation, the onset of new symptoms may
sks. have been associated with the daily and/or
cumulative duration of exposure to elevated
With the exception of the study by English et al. shoulder postures. In the study by Kilbom and
[1995], in which the strength of association may Persson [1987], three of the work exposure
have been underestimated, for the studies in variables that were strong predictors for a
which the health outcome was shoulder change to severe status at the 1- and/or 2-year
tendinitis [Baron et al. 1991; Bjelle et al. 1979; follow-up evaluations were related to shoulder
Herberts et al. 1981; Ohlsson et al. 1994, posture: (1) percent of work cycle time with
1995], the magnitude of association was strong. arm abduction greater than 30 degrees, (2)
ORs ranged from 2.0 to 10.6. In none of these percent of work cycle time with arm abduction
studies is it likely that nonoccupational factors greater than 60 degrees, and (3) percent of
such as sports activities or personal work cycle time with arm extension.
characteristics such as age explain these
associations. A few studies utilized techniques to improve the
ability to detect possible relationships
Consistency of Association
All but one of the reviewed studies relevant to
posture and shoulder disorders found a positive
association between shoulder disorders or
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despite a cross-sectional study design. The this association was significant despite very little
case definition used by Baron et al. [1991] variability in exposure to arm abduction greater
required that symptoms began while the worker than 60 degrees. While the analysis among
was on the currently held job. Bjelle et al. assembly workers was performed without
[1979] filmed and analyzed the job held at the controlling for age, there is no evidence to
time the worker/case became symptomatic. suggest that older workers were more likely to
The results of the prospective studies are be on high exposure jobs, and therefore a
similar to the cross-sectional studies. There is substantial bias is unlikely.
no evidence that shoulder disorders predicted
the onset of exposure. When comparing fish industry workers to the
reference population, Ohlsson et al. [1994]
Exposure-Response Relationship found that among those workers younger than
The level of an exposure can be described in 45 years, the ORs for disorders of the neck
two different ways. It may be related to the and shoulders were significant and increased
amount of exposure over a relatively short time with duration of employment (05 years, OR
period, such as a day or week, or it may be 3.2; 95% CI 1.57.0) (>5 years, OR 10; 95%
related to cumulative or life-time exposure over CI 4.524). Ohlsson et al. [1995] found a
a number of years. Studies that tested decreasing trend when they compared OR after
associations related to daily or weekly variation stratifying the factory workers by employment
in exposure are presented first, followed by duration (<10 years, OR 9.6; 1019 years, OR
studies that evaluated cumulative exposure by 4.4 and $20 years: 3.8). Given the cross-
using independent variables, such as duration of sectional study design, this finding could be an
employment or estimated lifetime exposure. artifact caused by the survivor bias (i.e.,
workers with disorders left, while symptom-
Four studies have some evidence of exposure- free survivors stayed; see Table 3-5). The
response relationships. Baron et al. [1991] assumption of a survivor bias is based on the
found a significantly larger OR for shoulder finding that 28% of a group of former assembly
disorders among employees working greater workers reported pain in the musculoskeletal
than 25 hours/wk as a checker compared to system as their reason for leaving employment
those working less than 20 hours/wk. Bjelle et at the factory. In the study by Schibye et al.
al. [1981] found that the duration of hours [1995], improvement in shoulder symptoms
worked per day with the shoulder flexed or among those who were no longer sewing
abducted >60 degrees was significantly higher machine operators appeared greater at follow-
(p<0.025) for cases with neck-shoulder up, but was not significant. The fact that many
disorders than for controls. Ohlsson et al. of those who left sewing jobs moved into
[1995] found that neck and shoulder disorders industries such as health care and fishing, where
among assembly workers were significantly awkward postures and high force loads may
associated (p<0.05) with the percent of time occur, might explain why a large difference
spent with the shoulder abducted or elevated between sewing machine operators and non-
>60 degrees. Although it is more difficult to
detect associations with homogenous exposure,
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sewing machine operators was absent. These is evidence for both shoulder tendinitis and
four studies provide some support for the nonspecific shoulder pain. The evidence for
relationship between shoulder abduction and increased risk of MSDs due to specific
shoulder MSDs. shoulder postures is strongest when there is a
combination of exposures to several physical
Coherence of Evidence factors such as force and repetitive work. An
Discussions of the probable influence of example of this combination would be holding a
workplace exposure factors in the tool while working overhead. The strength of
pathophysiology of localized muscle fatigue, association was positive and consistent in the
myalgia, and tendinitis have been presented by six studies that used diagnosed cases of
a number of authors [Bjelle et al. 1981; shoulder tendinitis, or a combination of
Hagberg 1984; Herberts and Kadefors 1976; symptoms and physical findings consistent with
Herberts et al. 1984; Levitz and Iannotti 1995]. tendinitis, as the health outcome [Baron et al.
Posture is important: when the arm is raised or 1991; Bjelle et al. 1979; English et al. 1995;
abducted, the muscle activity in supraspinatus Herberts et al. 1981; Ohlsson et al. 1994,
and other muscles increases, and the 1995]. Only one [Schibye et al. 1995] of the
supraspinatus tendon comes in contact with the thirteen studies failed to find a positive
undersurface of the acromion. The mechanical association with exposure and symptoms or a
pressure on the tendon from the acromion is specific shoulder disorder. However, in this
greatest between 60 and 120 degrees of arm study discontinuing employment as a sewing
elevation. [Levitz and Iannotti 1995]. The machine operator was associated with a
degree of upper arm elevation is also important reduction in neck and shoulder symptoms.
in the onset and intensity of localized muscle While most of the studies that considered
fatigue in the trapezius, deltoid, and rotator cuff specific shoulder postures as an exposure
muscles. [Hagberg 1981; Herberts and variable were cross-sectional, the two
Kadefors 1976; Herberts et al. 1984]. In a prospective studies found that the percent of
laboratory study, EMG signals from these work cycle spent with the shoulder elevated
muscles were analyzed. The supraspinatus [Jonsson et al. 1988] or abducted [Kilbom et
muscle was found to be highly active at $45 al. 1986; Kilbom and Persson 1987] predicted
degrees of abduction. The deltoid muscle change to more severe neck and shoulder
underwent a pronounced increase in activity as disorders. While there is insufficient evidence to
shoulder flexion or abduction increased from 45 develop a quantitative exposure-disorder
to 90 degrees [Herberts et al. 1984]. The relationship, three studies reported a significant
earlier sections on Coherence of Evidence also association with shoulder flexion or abduction
discussed the rate of fatigue and role of greater than 60 degrees [Bjelle et al. 1981;
impaired micro-circulation in shoulder tendinitis. Kilbom and Persson 1987; Ohlsson et al.
1995]. Among the studies for which shoulder
Overall, there is epidemiologic evidence for a tendinitis was the health outcome, the largest
relationship between repeated or sustained ORs were associated with work above
shoulder postures with more than 60 degrees of acromion height [Bjelle et al. 1979;
flexion or abduction and shoulder MSDs. There
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Herberts et al. 1981]. These results are non-significant.

consistent with the current models for the
pathophysiology of shoulder tendinitis and In the study by Stenlund et al. [1993], the same
stressful shoulder muscle activities. In none of population of bricklayers, rock blasters, and
these studies does age, an important personal foremen described in Stenlund et al. [1992]
characteristic associated with shoulder were evaluated to determine whether signs of
tendinitis, explain the positive results. Most of tendinitis or muscle attachment inflammation in
the studies controlled for a variety of the shoulders were related to lifetime work
confounders, such as occupational sports load, years of manual work, lifetime exposure
activities in their analyses. In summary, there is to vibration, or job title. The case definition for
evidence that repeated or sustained shoulder signs of shoulder tendinitis was pronounced
abduction or flexion is associated with shoulder (i.e., grade 3 out of 3) pain upon palpation of
tendinitis, and the evidence is stronger for highly the muscle attachment or pronounced pain in
repetitive, forceful work. response to isometric contraction of any of the
rotator cuff muscles or the biceps muscle. The
VIBRATION case definition of clinical entity of tendinitis
Three of the studies evaluated exposure to low- was signs of shoulder tendinitis plus the
subjects report of shoulder pain during the past
frequency vibration found in industrial settings
year. Using multivariate models that included
(Table 3-4, Figure 3-4). Because of the small
age and hours spent in arm intensive sports
number of studies, the full outline used for the
sections on repetition, force, and posture will activities, a significant association with
cumulative vibration exposure was found when
not be repeated here. The study by Stenlund et
it was tested in isolation from the other
al. [1992] is summarized in the section on
exposure variables. For clinical entity of
force. Vibration exposure occurred in one of
tendinitis the OR for the left side was 1.86
the three job categories: rock blaster. The
exposure outcome, lifetime exposure to (95% CI 1.003.44) and the OR for the right
side was 2.49 (95% CI 1.065.87).
vibration expressed in hours, was determined
For signs of shoulder tendinitis the OR
from a weighted summary of the number of
for the left side was 1.66 (95% CI 1.062.61)
self-reported hours using specific tools.
However, because the rock blaster job and the OR for the right side
was 1.84 (95% CI 1.103.07). When
category was also the only one where workers
cumulative vibration exposure was tested
performed heavy lifts several times per day, the
in the same model with cumulative lifting load,
authors concluded that, vibration exposure is
indivisible from static load and heavy lifting in significant associations were not found for
either variable. Several factors could have
the present data. When both cumulative lifting
resulted in an underestimation of the strength of
exposure and cumulative vibration exposure
association: (1) bricklayers or rock blasters
were included in the same multivariate model of
an association with acromioclavicular with tendinitis may have been more likely to
leave their jobs than foremen, (2) subjects may
osteoarthrosis, the OR for lifting and right- side
have had difficulty recalling exposure
osteoarthrosis remained significant
throughout their
while the weaker ORs for vibration became
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lifetimes, (3) the inability to separate exposure weighted according to International Standards
by left and right sides. These factors may have Organization (ISO) standards. Tool vibration
caused nondifferential misclassification. Most profiles and time-work studies of riveters and
important is the authors observation that controls were used to determine daily vibration
vibration exposure occurred through the used exposure for each group. For riveters, on the
of hand-held, heavy tools (e.g., jack-hammers) basis of daily tool operating time, the equivalent
and thus is intertwined with exposure to a static frequency-weighted acceleration for a period of
load on the shoulders (from stabilizing the upper 4 hours was 2.8 m s -2. For controls, it was 1.0
extremity while using the tool) as well as being m s -2. Using a multiple logistic regression
associated with the heavy lifting tasks model that included age, there was a weak
performed by rock blasters. association between shoulder symptoms and
the number of years riveting (0.05# p<0.10).
In a cross-sectional study by Burdorf and When the age-adjusted ORs for riveters
Monster [1991], riveters and control subjects compared to controls were plotted by the
in an aircraft company were investigated for duration (in years, from 0 to 20) of riveting, the
vibration exposure and self-reported symptoms slope for shoulder symptoms was very gradual,
of pain or stiffness in the shoulder. Riveters with ORs ranging from 1.0 to 2.0. While the
were exposed to hand-arm vibration from results of the analysis of non-respondents
working with hand drills, riveting hammers, described above suggest that the strength of
bucking bars, and grinders. Controls were association may have been underestimated, the
manual workers selected from the machine reported associations are weak and it is
shop, maintenance, and welding departments in unlikely that the response bias would have
the same factory. In order to focus on the effect resulted in a large increase in the magnitude of
of vibration alone, a walk-through survey was association.
performed to confirm that there were no
striking differences in dynamic and static joint There is insufficient evidence for an association
loads during normal working activities. between shoulder tendinitis
Participation was 76% among riveters and 64% and exposure to segmental vibration. In
among controls. An analysis of non- four separate evaluations, stratified by signs of
respondents revealed that controls with health tendinitis (positive physical examination
complaints were more likely to have findings), clinical entity
participated than those without, while riveters of tendinitis (signs plus symptoms), left and
with health complaints were less likely to have right side, Stenlund et al. [1993]
participated. The health outcome, determined found an association between shoulder
by a self-administered questionnaire, was tendinitis and vibration exposure to segmental
shoulder pain or stiffness occurring for at least a vibration; the range of ORs
few hours during the prior year. Only subjects was from (OR for right side 1.66, 95% CI
who reported having no symptoms before 1.062.61) (OR for left side 1.84, 95% CI
starting their present work were included in 1.103.07). However, work with vibration
logistic regression analyses. The vibration exposure also placed a large, static load on
transmitted by hand-tools was measured and
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shoulder muscles so that the effects of forceful characteristics. Using epidemiologic criteria to
shoulder muscle exertions could not be examine these studies, and taking into account
separated from vibration. issues of confounding, bias, and strengths and
limitations of the studies, we conclude the
ROLE OF CONFOUNDERS following:
Shoulder MSDs are multifactorial in origin and
may be associated with both occupational and There is evidence for a positive association
non-occupational factors. The relative between highly repetitive work and shoulder
contributions of these covariates may be MSDs. The evidence has important limitations.
specific to particular disorders. For example, Only three studies specifically addressed the
the confounders for non-specific shoulder pain health outcome of shoulder tendinitis and these
may differ from those for shoulder tendinitis. studies investigated combined exposure to
Two of the most important confounders or repetition with awkward shoulder postures or
effect modifiers for shoulder tendinitis are age static shoulder loads. The other six studies with
and sport activities. Most of the shoulder significant positive associations dealt primarily
studies considered the effects of age in their with symptoms. There is insufficient evidence
analysis. Some studies considered sport for a positive association between force and
activities [Baron et al. 1991; Stenlund et al. shoulder MSDs based on currently available
1993; Jonsson et al. 1988; Kilbom et al. epidemiologic studies. There is epidemiologic
1986]. Some studies also used multivariate evidence for a relationship between repeated
methods to simultaneously adjust for several or sustained shoulder postures with greater than
confounders or effect modifiers. For example, 60 degrees of flexion or abduction and shoulder
Ohlsson et al. [1995] found that for MSDs. There is evidence for both shoulder
shoulder/neck diagnoses, repetitive work was tendinitis and nonspecific shoulder pain. The
the strongest predictor 4.6 (95% evidence for specific shoulder postures is
CI 1.912); age, muscle tension, and strongest where there is combined exposure to
stress/worry tendency were also significant several physical factors like holding a tool while
predictors. It is unlikely that the majority of the working overhead. The strength of association
positive associations between physical was positive and consistent in the six studies
exposures and shoulder MSDs are due to the that used diagnosed cases of shoulder tendinitis,
effects of non-work confounders. or a combination of symptoms and physical
findings consistent with tendinitis, as the health
CONCLUSIONS outcome. Only one [Schibye et al. 1995] of the
There are over 20 epidemiologic studies that thirteen studies failed to find a positive
have examined workplace factors and their association with exposure and a specific
relationship to shoulders (MSDs). These shoulder disorder or symptoms of a shoulder
studies generally compared workers in jobs disorder.
with higher levels of exposure to workers with
lower levels of exposure, following observation
or measurement of job
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This is consistent with the evidence that is found There is insufficient evidence for a positive
in the biomechanical, physiological, and association between vibration and shoulder
psychosocial literature. MSDs based on currently available
epidemiologic studies.
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Table 3-1. Epidemiologic criteria used to examine studies of shoulder MSDs associated with repetition
Investigator
(OR, PRR, IR, Participatio Physical and/or Basis for assessing
Study (first author and or p-value)*, n rate $ 70% examinatio exposure shoulder
year) n status exposure to repetition
Chiang 1993 1.6 Yes Yes Yes Observation or measurements
Kilbom 1986, 1987 NR, Yes Yes Yes Observation or measurements
Ohlsson 1994 3.5 Yes Yes Yes Observation or measurements
English 1995 2.3, Yes Yes Yes Job titles or self-reports
Sakakibara 1995 1.7 Yes Yes NR Job titles or self-reports
Ohlsson 1989 3.4 NR No NR Job titles or self-reports
Not reported.
Repeated shoulder rotation with elevated arm.
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Table 3-2. Epidemiologic criteria used to examine studies of shoulder MSDs associated with force
Investigator
Risk indicator blinded to
(OR, PRR, IR or Participatio Physical case and/or Basis for assessing
Study (first author and p-value)*, n rate $ 70% examination exposure shoulder exposure to
year) status force
Andersen 1993a 1.3810.25 Yes No Yes Job titles or self-reports
Herberts 1981, 1984 1518 NR Yes NR Job titles or self-reports
Stenlund 1992 2.24.0 Yes Yes Yes Job titles or self-reports
Not reported.
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Table 3-3. Epidemiologic criteria used to examine studies of shoulder MSDs associated with posture
Investigator
Risk blinded to
indicator Participatio Physical case and/or Basis for assessing
Study (first author and (OR, PRR, IR, n rate $ 70% examination exposure shoulder
year) or status exposure to posture
p-value)*,
Jonsson 1988 NR, Yes Yes Yes Observation or measurements
Kilbom 1986, 1987 NR Yes Yes Yes Observation or measurements
Baron 1991 3.9 No Yes Yes Observation or measurements
Bjelle 1979 10.6 NR Yes No Observation or measurements
English 1995 2.3, Yes Yes Yes Job titles or self-reports
Herberts 1981 8.3 NR Yes NR Job titles or self-reports
Hoekstra 1994 5.1 Yes No Yes Job titles or self-reports
Sakakibara 1995 NR Yes Yes NR Observation or measurements
Schibye 1995 NR Yes No NR Job titles or self-reports
Not reported.
Repeated shoulder rotation with elevated arm (p< 0.05 level, most of study used 0.01 level).
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Table 3-4. Epidemiologic criteria used to examine studies of shoulder MSDs associated with vibration
Investigator
indicator Participatio Physical and/or Basis for assessing
Study (first author and (OR, PRR, IR, n rate $ 70% examination exposure shoulder exposure to
year) or p-value)* status vibration
Burdorf 1991 1.5 No No NR Observation or measurements
Stenlund 1992 2.23.1 Yes Yes Yes Self-reports, weight of tools
Stenlund 1993 1.71.8 Yes Yes Yes Job titles or self-reports
*Some risk indicators are based on a combination of risk factorsnot on vibration alone (i.e., vibration plus force, posture,
or repetition). Odds ratio (OR), prevalence rate ratio (PRR), or incidence ratio (IR).
Not reported.
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Table 3-5. Epidemiologic studies evaluating work-related shoulder musculoskeletal disorders

MSD prevalence
Andersen Cross- 424 female sewing Outcome: Case of chronic Shoulder pain: Participation rate: 78.2%.
and sectional machine operators shoulder pain was defined as Sewing
Gaardboe (SMO), compared to continuous pain lasting for a machine Examiners blinded to case status.
1993a 781 females from the month or more after beginning operators,
general population of the work and pain for at least 25.2% 8.5% 3.21 1.68-7.39 Respondents excluded if had
region and internal 30 days within the past year. previous trauma to neck, shoulder,
referent group of Years of or arms or had inflammatory disease
89 females from the Exposure: Categorization broken exposure: at time of response.
garment industry. down according to current 0-7=12.3% 1.56 0.76-3.75
occupational status by job title. ORs adjusted for age, having
Classification into exposure 8-15=33.7% 4.28 2.14-10.0 children, not doing exercise,
groups based on authors socioeconomic status, smoking, and
experiences as occupational >15=57.1% 7.27 3.82-16.3 current neck/shoulder exposure.
health physicians and involved
crude assessment of exposure Age-matched exposure groups and
level and exposure controls.
jobs were those involving high Presented study as general survey
repetition/high force or high of health in the garment industry to
repetition/low force or medium minimize information bias.
exposure jobs were those
involving medium repetition/low
force. Low exposure jobs were
low repetition/low force.
For the analysis, length of

employment as a sewing
machine operator was
considered the variable of
interest, the rest were
confounders.
(Continued)
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Table 3-5 (Continued). Epidemiologic studies evaluating work-related shoulder musculoskeletal disorders
MSD prevalence
Andersen Cross- From a historical cohort Outcome: Measured by health Rotator cuff Participation rate: 78.2%; logistic
and sectional of 424 sewing machine interview and exam of the neck, syndrome: regression limited to a combined
Gaardboe operators, 120 were shoulder and arm. Case of neck/shoulder case definition.
1993b randomly selected and chronic pain was defined as Number of Controls: 1 Chi sq for
82 exposed workers continuous pain lasting for a workers by trend=9.51, Age-matched exposure groups and
were categorized by month or more after beginning exposure time p<0.01 controls.
number of years of work and pain for at least in years:
employment: 0 to 30 days within the past year. 0-7: 1; Examiners blinded to control/subject
7 years, 8 to 15 years Physical examination: Restricted 8-15: 6; status.
and greater than 15 movements in the cervical spine >15: 11
years. These were and either palpatory tenderness Controlled for age, having children,
compared to a referent in cervical segments or not doing leisure exercise, smoking,
group of 25 auxiliary irradiating pain or tingling at socioeconomic status.
nurses and home maximum movements or positive
helpers. A total of 107 foraminal test. Poor correlation between
subjects participated. degenerative X-ray neck changes
Exposure: Exposure and cervical syndrome.
categorization broken down
according to current Most frequent diagnosis among
occupational status by job title. study group was cervicobrachial
Classification into exposure fibromyalgia significant for test of
groups based on authors trend with exposure time in years.
experiences as occupational
health physicians and involved Chronic neck pain vs. palpatory
crude assessment of exposure findings: Sensitivity: 0.85;
level and exposure Specificity: 0.93.
jobs: Involved high
repetition/high force or high
repetition/low force or medium
exposure jobs involved medium
repetition/low force and low
repetition and high force. Low
exposure jobs were low
repetition/low force.
(Continued)
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MSD prevalence
Baron et al. Cross- 124 Grocery checkers Outcome: Based on symptom Checkers: Other Checkers vs. Participation rate: 85% checkers; 55%
1991 sectional using laser scanners (119 questionnaire and physical exam. 15% grocery others: non-checkers in field study.
females, 5 males) (1) Rotator cuff syndromepain workers: OR=3.9 1.4-11.0 Following telephone survey 91%
compared to 157 other with resisted abduction or deltoid 7% checkers and 85% non-checkers.
grocery workers (56 palpation (2) Bicipital Checkers Checkers Examiners blinded to workers job and
females, 101 males). tendinitispain on Yergasons using using health-status.
Excluded 18 workers in maneuver. Case defined as scanners: scanners vs.
meat, fish, and deli having positive symptoms in 34% others: Logistic regression model adjusted for
departments, workers shoulder and a positive physical OR=8.6 1.0-72.2 duration of work. No difference in
under 18, and pregnant exam of a particular body part. groups between age, gender, and
workers. Symptoms must have begun after Checkers Other Checkers hobbies so that these were not
employment at the supermarket 5'2" or less in grocery <5'2" vs. controlled for.
and in the current job; lasted one height: 21% workers other grocery
week or occurred once a month 5'2" or workers Number of hr worked/week as a
during the past year; and where less in <5'2": checker statistically significantly
there was no history of acute height: OR=2.1 0.7- 6.9 related to shoulder disorders for
injury to body part in question. 13% workers checking >25-hr/ /week
(OR=3.5, p<0.05)
Exposure: Job category and (OR estimated from figure).
estimates of repetitive and Total repetitions/hr ranged from 1,432
average and peak forces based to 1,782 for right hand and 882 to
on observed and videotaped 1,260 for left hand.
postures, weight of scanned
items, and subjective assessment Average forces were low and peak
of exertion. forces medium.
Multiple awkward postures recorded
for upper extremities among cashiers.
No statistical significance associated
between duration of employment as a
checker and shoulder MSDs.
(Continued)
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MSD prevalence
Bergenudd Cross- 574 of 830 survey Outcome: Based on symptom Prevalence Participation rate: 69%.
et al. 1988 sectional respondents participated in survey: Occurrence of shoulder of Unknown whether examiners blinded
a health exam. pain lasting $24 hr during the last occupational to case status.
month and physical exam (joint workload in Analysis stratified by gender.
In 1983, 1,070 residents of motion, tenderness on palpation subjects with Only 9% of workers included in study
Malm, Sweden, of supraspinatus, biceps, shoulder pain were in the Heavy Physical Demands
responded to questions on tendons and acromioclavicular Jobs category, compared to 49% in
shoulder pain in a health joint). Heavy work: Light category and 42% in moderate
survey as part of a 11% category. Only 1% of females were
longitudinal study begun in Exposure: Based on job in Heavy Physical Demand
1,938 of 1,542 residents. classification; classified as: Light Moderate Jobs category.
physical demands (white collar) work: 49% Sick leave due to shoulder pain was
=275; Moderate physical restricted to males in jobs with
demands (nurses, light Light work: moderate or heavy physical demands
industry)=237; Heavy (blue collar, 40% (p<0.05) (data not shown in article).
e.g., carpenters, bricklayers)=50. At one year follow-up, 61 (77%) of 79
subjects with shoulder pain re-
examined. 35 had continued shoulder
pain.
Misclassification of work categories a
possibility: Likely no observation of job
tasks performed..
No differences in overall physical
demands of jobs among subjects with
shoulder pain compared to those
without shoulder pain, but females
with signs of supraspi-natus tendinitis
more often had jobs with physical
demands.
Authors state that shoulder pain may
be related to intelligence in males in
this study; more talented males had
less shoulder joint symptoms. We
question authors conclusions.
Females showed significant
association with shoulder pain and
dissatis-faction. No association with
relation to family or friends or level of
life success. Author states both
groups of females rated their life
success low, and subjects with
shoulder pain did not rate level of
success differently.
(Continued)
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MSD prevalence
Bernard Cross- Of a total population of Outcome: Health data and 17% (case) Female: Participation rate: 93%.
et al. 1994 sectional 3,000 workers in the psychosocial information were OR=2.2 1.5-3.3
editorial, circulation, collected using a self- 3% (case Examiners blinded to case and
classified advertising, and administered questionnaire. with daily Perceived exposure status.
accounting departments, Definition: Presence of pain, pain) lack of
1,050 were randomly numbness, tingling, aching, decision For calculation of the ORs of the
selected for study and stiffness or burning in the making psychosocial scales, the responses
973 participated; shoulder occurring $once a participation: were divided into quartiles, then the
894 responded to the month or 7 days continuously OR=1.6 1.2-2.1 75th percentile was compared to 25th
shoulder questions. within the past year, reported as percentile.
moderately severe. The symptom Years at the
Cases fulfilling shoulder must have begun during the newspaper: Model adjusted for race, age, gender,
definition compared to non- current job. Workers with OR=1.4 1.2-1.8 height, psychosocial factors, medical
cases. previous injuries to the relevant conditions.
area were excluded. Perceived
increased job Age, height, hr typing away from
Exposure: Based on observation pressure: work, other medical conditions were
of work activity involving OR=1.5 1.0-2.2 not found to be significant.
keyboard work, work pace,
posture, during a typical day of a In a sub-analysis of jobs with
sample of 40 workers with comparable number of males and
symptoms and 40 workers females, there were no significant
without symptoms. Exposure to factors related to shoulder MSDs.
work organization and
psychosocial factors based on
questionnaire responses.
(Continued)
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MSD prevalence
Bjelle et al. Case- 17 cases of shoulder Outcome: Cases were non- With work at With work Participation rate: Not reported.
1979 control tendinitis from a population responsive to analgesics, non- or above at or
of male industrial workers steroidal anti-inflammatory shoulders: above Matched for age, gender and
who were patients at an agents, physiotherapy, and 65% shoulders: workshop.
occupational health center. outcome measured by exam. 15% 10.6 2.3-54.9
These 17 were chosen Case defined as shoulder pain Three of the 20 were diagnosed with
from 20 consecutive male lasting >3 months with no inflammatory rheumatoid diseases not
patients from 6 industries resolution post-treatment. previously diagnosed, 17 had no
and had been suffering inflammatory rheumatic disease.
from pain over a period of Exposure: Defined as work with
>3 months in one or both hands at or above shoulder level. Mean age (53 years) of cases
shoulders. 3 classes work performed: (A) significantly older than other workers
with hands below shoulder or (37.6 years).
34 non-cases were acromion height, (B) at or above
matched for age and acromion 3 to 8 times/day (<1/hr Myopathic signs not found on EMG or
workshop. plus for duration >1 min) (C) $8 muscle biopsies. Muscle enzymes
times at or above acromion (creatine phosphokinase and/or
( $1/hr. plus duration >1 min). aldolase) were elevated in 6 cases.
Exposure assessed by interview
and physician observation and Present and previous employment,
knowledge of work. physical workload not different
between cases and referents.
Electromyographs on 15 cases.
Work performed with hands above
Open muscle biopsies on acromion height significantly greater
11 cases. for cases than referents.
2-year follow-up showed that only

8 cases working in the same or less
heavy types of work, 7 of these had
slight shoulder complaints.
(Continued)
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MSD prevalence
Bjelle et al. Case- 20 workers of industrial Outcome: Physician evaluated all 6 with right No Cases had Participation rate: Not reported.
1981 control plant consecutively seen at patients with acute non-traumatic shoulder Controls significantly
health clinic with acute, shoulder-neck pains referred to tendinitis: with longer Video analyses were done blinded to
nontraumatic shoulder-neck the outpaient clinic of the 46% tendinitis: duration and case status.
rheumatology department. Each
pain. patient had to undergo an 0% higher
extensive clinical examination, frequency of No significant difference between
Of these, 13 were not due including local anaesthesia for the abduction or cases and controls in anthropometry.
to causative disease or definition of pain location. forward
malformation. These Exploratory puncture of the flexion than Isometric strength test: controls
13 were compared to glenohumeral joint was performed controls, significantly stronger in 6 of 14 tests
in patients with tenderness over
26 controls, matched on the joint. p<0.001. but probably influenced by pain
age, gender and place of inhibition in cases.
work. Exposure: Anthropometric and Cases had
Isometric muscle strength were significantly No significant difference in cycle time
tested with strain gauge higher (9 vs. 12 min) between cases and
instruments. Patients asked to shoulder controls.
perform their max-mal efforts. loads than
Measurements made for the
following contractions: shoulder controls. The supraspinatus muscle showed a
elevation at the acromion, significant change of the mean power
abduction and forward flexion of frequency (p<0.05) towards lower
the shoulder joints at neutral Median levels, indicating a fatiguing process
position and semipronated. Grip number of for four of the five investigated
strength measured by sick-leave assemblers during work.
vigorimeter.
days
Video recording of arm significantly
movements at work. Shoulder different
loads estimated from videos. between
Consisted of measuring the cases and
duration and frequency of controls
shoulder abduction or forward (p<0.01).
flexion of >60.
EMG measurement of shoulder
load during assembly work on 3
patients and 2 healthy volunteers.
Muscular load level determination
made by computer analysis of
myo-electric amplitude.
(Continued)
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MSD prevalence
Burdorf and Cross- 194 riveters exposed to Outcome: Standardized Nordic 31% 20% 1.5 Participation rate: Riveters=76%,
Monster sectional vibration compared to 194 questionnaire, pain or stiffness. controls=64%.
1991 workers in the same plant
with little or no exposure to Exposure: Employed >12 months, Examiners blinded to exposure or
vibration. not exposed to hand/arm case status: Not reported.
vibration.
Confounders controlled for included
Observation, time-work studies, height, weight, and smoking habits.
measurements of vibrating tools.
Age and height significantly different
No shoulder measurements. between groups.
Occupational history treated as Years of riveting work associated

dichotomous variable with 1 for with pain or stiffness in shoulder
heavy physical work. (0.05#p#0.10).
Follow-up of nonrespondants
showed no difference in age or work
experience. Sick leave significantly
different.
(Continued)
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MSD prevalence
Burt et al. Cross- 836 Newspaper employees Outcome: Based on symptom Time spent Participation rate: 81%. (Authors
1990 sectional in the Editorial Department questionnaire. Case defined as typing: 50% 42% note that those out on assignment or ill
and selected jobs in the pain, aching, stiffness, burning, or on vacation counted as non-
Advertising, Circulation, numbness or tingling in shoulder Typing Typing Speed: participants.)
Data Processing, and lasting >1 week or occurring one Speed:
Finance Departments from time/month in the past year. Slow: 6% Moderate: 2.6 Number of workers in number of non-
4 company locations, Symptoms must have begun on Moderate: Fast: 4.1 typing jobs not reported.
(460 female and 376 male). current job; no previous accident 11% 1.1-5.9
or acute injury to the joint, no Fast: 15% Pre-existing 1.8-9.4 Reporters characterized by high
Cases compared to non- related systemic disease. Arthritis: periodic demands (deadlines)
cases. OR=2.3 although they had high control and job
Exposure: Based on satisfaction.
questionnaire and job sampling. Dissatisfied 1.2-4.4
Exposure variables included work with job: Job analysis found significant
time spent typing on computer; OR=2.3 correlation (r=0.56) between reported
typing speed; keyboard type; hr average typing time/day and observed
worked/week; workload; number 1.2-4.3 8 hr period of typing (p<0.0001).
of years worked.
Length of employment and symptoms
in shoulder not significant.
(Continued)
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MSD prevalence
Chiang et al. Cross- 207 fish processing Outcome: Shoulder girdle pain as Prevalence Prevalenc Repetitive Participation rate: Not quantified;
1993 sectional workers, 67 males and defined by Anderson (1984) (the of Physician- e of movement of however, authors stated that all of
140 females, divided in painful condition of the shoulder observed Physician- the upper limb the workers who entered the fish
3 groups: with limitation of movement, Disorders: observed (Rep): processing industry before June 1990
which may occur in association Disorders: OR=1.6 1.1-2.5 and were employed there full-time
(I) Low force, low with tension neck or merge with were part of the cohort. Of the
repetition (comparison pain in the suprascapular or Group II: 37% Group I: Sustained 232 employees who agreed to
group, n=61); upper dorsal regions). Symptoms (male 31%; 10% forceful participate, 207 met study criteria.
in these regions occurring in last female 39%) (male 9% movement of Examiners blinded to exposure status.
(II) High force or high 30 days and physical exam female the upper limb (Workers examined in random
repetition (n=118); findings of $two tender points or Group III: 10%) (force): sequence to prevent observer bias.)
palpable hardenings which may 50% OR=1.8 1.2-2.5 Workers with hypertension, diabetes,
(III) High force and high either be caused or aggravated (male 50% history of traumatic injuries to upper
repetition (n=28). by work conditions. female 50%) Rep times limbs, arthritis, collagen disease
force: excluded from study group.
Exposure: Assessed by OR=1.4 1.0-2.0 Eight plants used in study. Authors
observation and recording of reported no plant effect".
tasks and biomechanical Age: Case definition based on physician
movements of three workers OR=1.0 0.9-1.1 diagnosis not significantly different
each representing one of 3 study from definition based on symptoms in
groups. Highly repetitive jobs Gender: Groups II : 37% vs. 44% or Group III:
with cycle time k=<30 sec or OR=1.1 0.7-1.7 50% vs. 50%. Group I about 2/3 the
>50% of cycle time performing prevalence (10% vs. 15%).
the same fundamental cycles. Dose-response for physician
Hand force estimate from EMG observed shoulder girdle pain among
recordings of forearm flexor three exposure groups.
muscles. Classification of Dose-response for physician
workers into 3 groups according observed shoulder girdle pain by
to the ergonomic risks of the gender in three exposure groups.
shoulders and upper limbs: Group Logistic model controlled for age and
I: Low repetition and low force; gender.
Group II: Low repetition or low Significant trend found for duration of
force; Group II: High repetition employment and exposure group in
and high force. workers <12 months, 12 to 60
months, but not in workers employed
>60 months.
(Continued)
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MSD prevalence
English Case- Cases: n=580; 174 males Outcome: Based on standard Frequency of Per 5 years of Participation rate: 96%.
et al. 1995 control and 406 females with diagnosis for rotator cuff injury; shoulder age: 1.4 1.2-1.5,
diagnosed soft tissue rupture of the long head of problems p<0.01 Administered questionnaire blinded to
conditions of the upper limb biceps, shoulder capsulitis, case status.
at 2 orthopedic clinics; symptomatic acromioclavicular Rotator cuff: For elbow
ages 16 to 65 years. arthritis. 8.3% flexion: 0.4 0.2-0.8, Controlled for age, height, gender,
p<0.01 weight, whether MSD was due to an
Controls: 996 controls; Exposure: Based on self- Rupture of Per hr of total accident, study center.
558 males and 438 females reported risk factors at work for long head of daily elbow
attending the same clinics; musculoskeletal disorders biceps: 0.3% flexion: 1.1 0.9-1.2, Total daily exposure to elbow flexion
diagnosed with conditions concentrating on detailed p<0.01 did not contribute to shoulder injury.
other than diseases of the components of movements and Shoulder
upper limb, cervical or activities at work: awkward capsulitis: Repeated Risks highest for female hairdressers.
thoracic spine; ages 16 to postures, grip types, wrist 3.6% shoulder
65 years. motions, lifting, shoulder rotation with Not Repetitive defined as a frequency of
postures, static postures, hand Symptomatic elevated arm: reported >once/min of 14 specific movements.
tool use, and job category. acromiocla- RR=2.3 p<0.05
vicular Sporting activities, hobbies; average
Questionnaire obtained arthritis: Wrist rotation Not hr of driving/week; whether claim for
information on repetitive 0.2% at low rates: reported compensation made were analyzed in
movements of the upper limb: RR=0.18 p<0.05 models.
Shoulder flexion, shoulder
rotation with elevated arm, Wrist rotation Jobs with pinching between thumb
keeping the whole arm raised >1 with and forefinger protective against
min, shoulder rotation with elbow increasing shoulder disorders. May reflect hand
flexed. rates: Not movement and exertion with no
RR=2.02/30 reported shoulder movement or exertion.
reps/min. p<0.05
Small number of subjects/group limits
power to detect significant
differences.
(Continued)
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MSD prevalence
Flodmark Cross- 58 industrial workers Outcome: Questionnaire survey Symptoms in Symptoms Participation rate: 87%.
and Aase sectional making ventilation shafts using Nordic questionnaire for past 12 in past 12
1992 (51 males and 7 females) symptoms as to duration during months: 40% months: Aim of the study was to further
compared to symptom last 12 months and during last 23% 2.2 1.4-4.4 investigate relationship between Type
prevalence in 170 blue- 7 days, effect on work A behavior and musculoskeletal
collar workers in rebro, performance and leisure symptoms.
Sweden. activities, and sick leave. Type A
behavior assessed by Bortner The Bortner Score for Type A
Compared workers with questionnaire. behavior significantly higher for those
symptoms to those with shoulder symptoms than those
workers without symptoms Exposure: No objective without.
for risk factor analysis. measurements.
No difference in headache, tiredness,
sleeping, irritation, lack of
concentration or problems with eyes,
nose, stomach, skin.
Authors suggest that Type A persons

more likely to ignore symptoms to
minimize their potential effect on work
capacity.
(Continued)
3-46
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MSD prevalence
Hales and Cross- Of 96 female workers Outcome: By questionnaire: Any 43% (low Participation rate: 91%.
Fine 1989 sectional employed in 7 high Period Prevalence: Symptoms in symptom of exposure
exposure jobs in poultry last 12 months. Case defined as: the shoulder: group) 1.2 0.7-2.0 Examiner blinded to case and
processing, 89 were pain, aching, stiffness, 49% (high exposure status.
compared to 23 of numbness, tingling or burning in exposure
25 female workers in low the shoulder, and symptoms group) Analysis adjusted for age and
exposure jobs. began after employment at the duration of employment.
plant; were not due to a previous Period
injury or trauma to the joint; lasted prevalence Although shoulder MSDs surveyed by
>8 hr; and, occurred 4 or more for shoulder questionnaire, exposure assessment
times in the past year. case: 19% 4% 3.8 0.6-22.8 was based on hand/wrist exposure,
so that risk for shoulder may not be
Point Prevalence: Determined by Point accurate.
physical exam of the upper prevalence
extremity using standard for shoulder High exposure departments: Breast
diagnostic criteria case must also case: 7% 4% 0.9 0.1-7.3 trim, thigh debone, leg cut/disjoint,
fulfill symptom definition (listed tender cut, knuckle cut, breast,
above). knuckle cut, thigh fat trim.
Exposure: Observation and Lower exposure departments: Breast,

walk-through; jobs categorized thigh, or quality control inspectors.
as High exposure and Low
exposure based on estimated
hand force and hand repetition,
not shoulder exposure.
(Continued)
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MSD prevalence
Hales et al. Cross- 533 Telecommunication Outcome: Self-administered Rotator cuff Fear of Participation rate: 93%.
1994 sectional workers (416 females and questionnaire and standard tendinitis: replacement
117 males) in 3 offices, physical examination; case 6% (n=513) by computers: Physician examiner blinded to worker
employed $6 months. defined as: pain, aching, 1.5 case study.
stiffness, burning, numbness or Bicipital 1.1-2.0
"Cases" fulfilling shoulder tingling >1 week or >12 times a tendinitis: Number of Logistic analysis adjusted for
WRMSD definition year; no previous traumatic injury less than 1% times arising demographics, work practices, work
compared to non-cases. to the area; occurring after (n=516) from chair: organization, individual factors;
employment on current job within 1.9 1.2-3.2 electronic performance monitoring;
the last year and positive physical Overall DAO keystrokes; Denver DAO
exam: moderate to worst pain shoulder: keystrokes/day.
experienced with positive 6%
physical finding of the ORs for psychosocial variables
symptomatic joint. represent risk at scores one standard
deviation above mean score
Exposure: Work practices and compared to risk at scores one SD
work organization assessed by below mean.
questionnaire and observation;
number of keystrokes/day. Because of readjustments and
changes of workstations during study
Physical workstation and postural period, measurements of VDT
measurements obtained but not workstations considered unreliable
used in final analyses. and excluded from analyses.
Number of hr spent in hobbies and

recreational activities not significant.
Although keystrokes/day was found

to not be significant, data available
was for workers typing an average
of 8 words/min over 8-hr period.
97% of participants used VDT

$6 hr/day, so not enough variance to
evaluate hr of typing.
Over 70 variables analyzed in models

may have multiple comparison bias.
(Continued)
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MSD prevalence
Herberts Cross- 131 male shipyard welders Outcome: Positive answers to Supraspi- Shoulder Prevalence Participation rate: Not reported.
et al. 1981 sectional with >5 years of work questions about repeated natus Pain rate ratio
experience compared to 57 occurrences of shoulder pain tendinitis Prevalenc (PRR) of Incidence estimated to be 15 to 20% a
male office clerks. All during work; shoulder stiffness (ST) results e from shoulder pain year.
workers participated in the that affected work and of 23 question- results from
shipyards medical program weakness in shoulder that welders naire: questionnaire, Welders with and without tendinitis
which offered medical affected work or weakness or called back 1.8% welders vs. were age-matched.
exams every 5 years. numbness in arm or hand and for clinical office
participation in a follow up exam. follow-up workers: We question the methods used to
exams: PRR=15.2 2.1-108 approximate the prevalence of
Clinical examination with joint 16 welders (90% CI) shoulder tendinitis. Authors stated
range of motion, active and had PRR from that they took into account the missing
passive and simultaneous pain supraspi- estimated data in the investigation and assumed
analysis, rating of gross power in natus prevalence that the drop-out group did not deviate
flexion, abduction and rotation, tendinitis. (propor- from the examined group, so they
rating of tenderness to palpation. tionation of used proportionation to obtain the
cases) number of cases of supraspinatus
Exposure: Estimation of workload Shoulder reported in tendinitis cases in the welders for
with assessment of the Pain reports article: calculations of prevalence rate ratios;
workplace into 3 groups very from the PRR=18.3 14.7-22.1 number of supraspinatus tendinitis
high, high or low. Static loading question- (90% CI) cases increased from 16 to 24.
while holding tools; awkward naire: 27%
postures; shoulder level or Number of years active welding,
overhead work. shoulder load, and welding years
showed no significant difference.
However, a sample size of 11
matched pairs may not have enough
power to detect a difference.
Turnover of shipyard welders

mentioned at 33%.
Shoulder tendinitis was not found to

be associated with increasing age.
(Continued)
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MSD prevalence
Herberts Cross- 131 male shipyard welders Nurse-administered symptom Question- Question- Participation rate: Not reported.
et al. 1984 sectional and 188 plate workers questionnaire: Case defined as naire results, naire
compared to 57 male office pain, weakness, stiffness in shoulder pain results, Not mentioned whether examiners
clerks. Welders and shoulder excluding effects of the supra- shoulder blinded to case or exposure status.
plateworkers chosen had spinatus
originating from neck, plus clinical pain of the
>5 years of job experience. exam with tenderness, range of tendinitis supraspi- Controls were matched for age and
motion gross power measured by type natus gender.
23 symptomatic welders, dynamometer. Welders: tendinitis
27% type: PRR=18.3 13.7-22.1
30 symptomatic plate Plateworkers with shoulder pain
Plate- Office (90% CI)
workers compared to 18 Exposure: Observation of jobs; worker: averaged 6 years older than welders
asymptomatic welders and workers compared by use of job workers: 2% PRR=16.2 10.9- with shoulder pain.
30 plate workers by clinical title; EMG measurements of 32% 21.5
exam. muscles of shoulder region. Supraspi- (90% CI) EMG analysis using fine monopolar
natus wire electrodes showed that in work
Age-matched pairs: Electromyographic analysis of the tendinitis where the hand was positioned
11 welders; shoulder muscle load completed results of 23 overhead, the intramuscular pressure
15 plateworkers. on 9 volunteers to study the welders in the supraspinatus muscle had
influence of hand tool mass and called back extremely high pressure levels
arm posture. for clinical compared to pressure levels in other
follow-up skeletal muscles.
exams:
16 welders Turnover rate of welders was 30%;
had supra- may be explanation for lack of
spinatus
association with duration.
tendinitis
Supraspi- Welding seen as static work;
natus plateworking dynamic work.
tendinitis
results of 30
plate-
workers
called back
for clinical
follow-up
exams: 15
plateworkers
had supra-
spinatus
tendinitis
(Continued)
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MSD prevalence
Hoekstra Cross- 108 of 114 teleservice Outcome: Self administered Center A: Participation rate: 95%.
et al. sectional representatives working at questionnaire. Case defined as 13%
1994 2 Government the presence of pain, numbness, Representatives perceived little
administration centers: A tingling, aching, stiffness or Center B: control over actions of others; little
and B. burning in the shoulder, and no 44% 4.0 1.2-13.1 participation in decision making; little
previous injury; symptoms began freedom to regulate own activities.
after starting the job; lasting >1 Non-optimally
week or occurred once a month adjusted Perception that workload was high
within the past year; reported as desk height and variable.
moderate or greater on a 5-point work
scale. 5.1 1.7-15.5 Analysis controlled for gender and
Non-optimally location and interactions checked.
Exposure: Observation of work adjusted
stations, measurement and screen Variables considered in logistic model
evaluation of work station; included location, age, seniority, hr
observation of postures. 3.9 1.4-11.5 spent typing at VDT, hr on the phone,
3 chair variables, and perceived
adequacy of: (1) chair adjustment,
VDT screen, (2) keyboard adjustment,
VDT screen, (3) desk adjustment; job
control, workload variability.
Center B location had nonadjustable

work stations and mostly
nonadjustable chairs causing elevated
arms, hunched shoulders and other
undesirable postures.
Linear regression also performed on

psychosocial variables in separate
models for health outcomes of job
dissatisfaction and mental and
physical exhaustion (not for shoulder
MSDs).
Did not include non-work-related

variables in analyses.
(Continued)
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MSD prevalence
Hughes et Cross- 104 male aluminum smelter Outcome: Symptoms occurring in 14.9% with Model based Participation rate: carbon
al. 1997 sectional workers: 62 carbon the shoulder >once per month or positive on MSD setters: 65%; crane operators: 56%;
setters, 36 crand lasting longer than 1 week in the symptoms defined by carbon plant: 33%.
operators, 9 carbon plant previous year, no acute or and physical symptoms
workers. There were 14 traumatic onset; occurrence exam. and physical Examiners blinded to exposure and
workers who were not since working at the plant, no exam health status: Not reported.
from selected jobs and systemic disease. Physical 24% had Age: OR=0.93 0.8-1.0
were excluded. examination: Active, passive, symptoms in Good health: Analysis controlled for age, smoking
and resisted motions, pinch and the elbow- OR=0.35 0.1-0.87 status, sports and/or hobbies.
grip strength, 128 Hz vibration forearm in
sensitivity, two-point the previous Low decision Psychosocial data collected
discrimination. Psychosocial week. latitude: individually; physical factors based on
scales from questionnaire based OR=4.0 0.8-19 estimates of each job.
on Theorell and Karasek Job Years of
Stress Questionnaire, and on forearm twist: Job risk factors entered into the model
Work Apgar questionnaire used. OR=46 for hand/wrist included (1) the
3.8-550 number of years of handling >2.7
Exposure: For carbon setters Model based kgs./hand, (2) push/pull, (3) lift/carry,
and crane operators (non- on MSD (4) pinching, (5) wrist
repetitive jobs) and modified job- defined by flexion/extension, 60 ulnar deviation,
surveillance checklist method symptoms and (7) forearm twisting.
was used. Job task analysis Age: OR=0.96
used a formula based on the 0.8-0.98 Health interview included information
relative frequency of occurrence Smoker: about metabolic diseases, acute
of posture during tasks. OR=0.41 0.1-1.4 traumatic injuries, smoking, hobbies.
Low decision
latitude: Low participation rate limits
OR=4.5 1.3-16 interpretation.
High Job
demand:
OR=3.0 0.7-13
Years
forearm twist:
92 7.3-4
(Continued)
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MSD prevalence
Ignatius Cross- 1,917 of 3,248 male postal Outcome: history of symptoms Recurrent Participation rate: 59%
et al. 1993 sectional employees completed an and severity of recurrent joint joint pain:
interviewer-administered pain as defined by Wells et al. 55.1% 38.4% 1.8 1.5 -2.2 Severe shoulder pain associated with
questionnaire; 1,081 were [1983]. age, work experience, bag weight
letter delivery postmen Severe joint and walking time.
compared to 836 other Exposure: work factors related to pain: 12.0% 6.2% 2.2 1.5-3.1
postal workers. weight of letter bags, distance Bags usually carried on one shoulder.
walked each day, use of
transporting tools.
Postmen carry/day an average

load of 45 lbs; walked 4.5 km plus
1,300 steps for 3.7 hr/day.
(Continued)
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MSD prevalence
Jonsson Prospec- Electronics Workers Outcome: Three separate Severe At 3rd exam Participation rate: 72% of original
et al. 1988 tive (n=69 females) out of initial physical exams at yearly intervals shoulder during 3rd group had 3 exams one year apart.
96 workers. (one initially) assessing disorders: year of longi- 80% had 1st and 3rd year exams.
tenderness on palpation, pain or tudinal study: Questionnaire included spare time
(See Kilbom et al. 1986 restriction with active and 22% at 2nd Initially: 38 subjects physical activity, hobbies, perceived
for initial study.) passive movements; symptoms in exam 11% of reallocated to psychological stress at work, work
previous 12 months with regard subjects varied tasks satisfaction, number of breaks, rest
pauses.
to character, frequency, duration, had had improved
localization, and relation to work shoulder (16% of these Most of physiologic and ergonomic
or other physical activities. MSDs had severe evaluations conducted only at outset
Analyzed if score on any symptoms of study.
symptom of $2, on a 4 point initially) Low muscle strength not a risk factor
scale; severe symptom score significance for subsequent symptoms.
equals 4. at p<0.05 Relative time spent with shoulder
elevated negatively related to
Exposure: Carried out at outset Those with remaining healthy after both 1 and 2
of study: Maximum voluntary After 1 year; 20% with unchanged years.
isometric contraction (MVC) of 24% unchan- working tasks Muscular strength and endurance not
forearm flexors, shoulder ged deteriorated related to improvement nor remaining
strength, handgrip, heart rate working further (26%). healthy.
using a bicycle ergometer and conditions At 2nd and 3rd examination, there
rating of perceived exertion. was a strong negative relationship
Videotaping performed for the between remaining healthy and
analysis of working postures and satisfaction with colleagues.
movements. Predictors of remaining healthy were
work without elevating the shoulders
Reallocation tasks: and satisfaction with work tasks.
Non sitting; no inspection of small No mention of examiner being blinded
details on printed circuit boards; to case status.
standing and walking, Predictors of deterioration were
occasionally sitting; caretaker previously physically heavy jobs, high
work; surveillance of machinery; productivity (after 1 year), and
and assembling bigger and previous sick leave.
heavier equipment. Predictors of improvement were
reallocation, physical activity in spare
time, and high productivity (after 2
years).
(Continued)
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MSD prevalence
Kiken et al. Cross- 294 Poultry Processors at Outcome: Period prevalence Plant #1: Participation rate: 98%.
1990 sectional 2 plants. symptom in last 12 months by Any
Plant #1=174 questionnaire. Case: Pain, symptom for Examiners blinded to case and
Plant #2=120 aching, stiffness, burning, shoulder exposure status.
numbness or tingling in the case: 46% 28% 1.6 0.9-2.9
shoulder, began after employment Analysis stratified for gender and
at the plant; not due to previous Period age.
accident or injury outside work; prevalence:
lasted >8 hr and occurred 4 or 13% 3% 4.0 0.6-29 Higher exposure jobs (HE) were
more times in the past year. located in the receiving, evisceration,
Point whole bird grading, cut up and
Point prevalence determined by prevalence deboning departments. Lower
physical exam. Rotator cuff for shoulder exposure jobs (LE) were located in
defined as pain $3 on a 0 to 8 case: 3% 0% Indeterminate the maintenance, sanitation, quality
scale on active and resisted assurance and clerical departments.
shoulder abduction. Case must Plant #2:
fulfill symptom definition (listed Any 30% of workers involved in a job
above). symptom for rotation program may have influenced
shoulder associations made.
Exposure: Determined by case: 50% 30% 1.7 0.8 -3.3
observation; level of exposure Annual turnover rate close to 50% at
was based on exposure to Period plant 1 and 70% at plant 2 making
repetitive and forceful hand prevalence: survivor bias a strong possibility --
motions, not shoulder. 14% 5% 2.8 0.4-19.6 leading to underestimation of
associations.
Exposure measurements Point
estimated for the hand and prevalence
wrist region and NOT the for shoulder
shoulder area. case: 3% 0% Indeterminate
(Continued)
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MSD prevalence
Kilbom et al. Cross- 106 of 138 female Outcome: Three separate MSD Logistic Participation rate: 77%.
1986 sectional assemblers in two physical exams at yearly intervals symptoms in Regression
electronic manufacturing (one initially) assessing the shoulder model (all See Jonsson et al. 1988 for follow-up.
companies agreed to tenderness on palpation, pain or using a four variables
participate; 10 excluded restriction with active and point severity significant at No relation between maximal static
because of symptoms in passive movements; symptoms in scale: the p<0.05 strength and symptoms.
past 12 months. previous 12 months with regard level).
96 underwent medical, to character, frequency, duration, None: 84% Examiner blinded to case status.
physiological, and localization, and relation to work Shorter
ergonomic evaluation. or other physical activities. Slight: 5% stature Questions included spare time
Analyzed if score on any physical activities, hobbies, perceived
(See Jonsson et al. 1988, symptom of $2, on a 4 point Moderate: Years of psychosocial stress at work, work
earlier in this table, for scale; severe symptom score 7% employment in satisfaction, number of breaks, rest
follow-up.) equals 4. electronics. pauses.
Severe: 3%
Exposure: Carried out at outset Fewer total 59% had no symptoms or only slight
of study: Maximum voluntary number of ones. There were no cases of
isometric contraction (MVC) of upper arm shoulder tendinitis.
forearm flexors, shoulder flexions/hr.
strength, handgrip, heart rate Age showed a weak positive
using a bicycle ergometer and Greater correlation.
rating of perceived exertion. percentage of
Videotaping during the work cycle Years of employment, productivity,
representative part of working time with muscle strength were not related to
day from rear and side. Upper upper arm symptoms.
arm studied at rest and in 0 to abducted 0 to
30E, 30 to 60E, 60 to 90E, in 30E. There was large inter-worker
extension and >90E abduction. variation in working posture and
The shoulder recorded as resting working techniques.
or elevated; also frequency of
changes in posture between The authors followed up on the non-
different angular sectors/hr, participants and found no significant
duration of postures. Work cycle differences from participants.
time and number of cycles/hr,
time at rest for arm, shoulder, The more dynamic working technique,
head. the less symptoms.
(Continued)
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MSD prevalence
Kvarnstrm Cross- 112 cases of prolonged Outcome: Shoulder cases Die casting Participation rate: Not reported.
1983b sectional shoulder disorders fulfilled the following: symptoms machine
identified in a workplace of from shoulder was the main operators Examiners not blinded to exposure,
and 11,000 employees. The reason for inability to work, off (involved but selection based on diagnosis of
total number of employees work longer than 4 weeks, heavy work shoulder MSD.
Case- was approximately half fatigue in one of both shoulders, with repetitive All 112 shoulder disorders occurred in
control factory workers and half pain in shoulder brought on by movements of laborers; none in office workers.
office workers. work and aching at rest were the RR for Swedish workers: 0.46; RR for
present, and Clinical examination shoulders): immigrants: 3.1.
demonstrated tenderness of the RR=5.4 All cases except one were paid piece
Case more than control shoulder muscles, especially rate.
study: muscularis trapezius, levator Plastic Young persons significantly less ill
scapulae, and/or infraspinatus workers: than middled-aged.
Controls chosen at random and/or tenderness at the tendon RR=2.2 The following questionnaire
from factory workers, insertions of the rotator cuff responses were significantly different
matched for age and muscles. Spray between cases and controls: Group
gender. painters: piece rate, shift work, heavy work,
Muscle strength in shoulder RR=3.7 monotonous, stressful, detrimental to
assessed with regards to four health, heavy lifting, and unsuitable
functions Surface working conditions. 9 cases and 1
treatment control cited poor relationship with
Exposure: (1) Information operators: supervisor.
obtained through interview: RR=4.7 No difference in environmental
organization of work, physical condition, job content.
work load, physical environment, Assembly line Cases more likely to be married, have
psychosocial work environment, workers: ill spouses, have children at home,
social and ethnic conditions, RR=5.2 work alternating shifts than controls.
(2) detailed work history. Factors Ergonomic Work history showed no difference
0,1, or 2 given to different types experts between points for cases and
of work depending on the evaluation: controls (see exposure column).
workload borne by the shoulder. cases had Muscle strength bilaterally significantly
This factor multiplied by number significantly lower in cases in four functions.
of years spent at job, and more mono-
products were added, (3) 2 tonous and
company engineers graded the repetitive
degree of monotony and work than
repetitiveness in each job held by controls.
cases and controls.
(Continued)
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MSD prevalence
McCormack Cross- Manufacturing workers: Outcome: Questionnaire and Packaging/ Participation rate: 91%.
et al. 1990 sectional packaging or folding physical examination initially by folding non-office
workers (41 males, 328 nurse screening; if employee workers: workers: Examiners not blinded to exposure
females); sewing workers answered affirmative to question 2.7% 2.1% 1.3 0.5-3.8 status (information obtained from
(28 males, 534 females); regarding symptoms in upper personal communication).
boarding workers (19 extremity and/or had any positive Sewing
males, 277 females) physical findings, then had workers: 11 Physician examiners; inter-
compared to knitting physician examination. The term 2.5% 2.1% 1.2 0.5-2.7 examiner potential problem
workers (203 males, 149 "shoulder condition" used to acknowledged by authors.
females); non-office define abnormalities of shoulder; Boarding
workers (204 males, 264 consisted of bursitis, bicipital workers: Questionnaire asked types of jobs,
females) compared with tendinitis and impingement 2.4% 2.1% 1.1 0.4-2.9 length of time on job, production rate,
knitting workers syndrome. nature and type of upper extremity
(203 males, 149 females). Knitting complaint and general health history.
These groups were Exposure: Based on observation workers:
compared to a referent of job activities; only the boarding 1.1% 2.1% 1.3 0.5-3.1 Age, sex, race, job category and
group consisting of non- workers had activities requiring years of employment not statistically
office workers maintaining reaching overhead (from significant with "shoulder conditions."
machinery, involved in personal communication with first
transportation, or worked author). Patients with objective diagnostic
as cleaners and sweepers. shoulder findings: Of 45 cases
None of the referent group diagnosed: 25 graded as mild,
used rapid repetitive 19 graded as moderate; 1 graded as
movements comparable to severe.
the employees in the other
job categories.
21, 25 and 36 operators
from each group and 25 of
55 auxiliary nurses and
home helpers (controls)
participated in the study.
(Continued)
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MSD prevalence
Milerad and Cross- 99 Dentists randomly Outcome: Based on telephone Male: 36% Participation rate: 99%.
Ekenvall sectional selected from Stockholm questionnaire: Shoulder Female: 67% 15% 2.4 1.0 -5.4
1990 dentist registry who symptoms at any time before the 28% 2.4 1.5-3.7 Stratified analysis by gender.
practiced $10 years interview "lifetime prevalence." Neck and
compared to Further analyzed according to shoulder: No difference in leisure time
100 pharmacists selected Nordic questionnaire as to 36% exposure, smoking, systemic disease,
from all pharmacists in duration during last 12 months 17% 2.1 1.3-3.0 exposure to vibration.
Stockholm. and during last 7 days, effect on Neck and
work performance and leisure shoulder and Symptoms increased with age in
activities, and sick leave. upper arm: female dentists only.
16%
Exposure: Questionnaire 3% 5.4 1.6-17.9 Duration of employment highly
included: (1) abduction of arm, correlated with age (r=0.84, 0.89).
particularly in sit-down dentistry,
(2) static postures, (3) work No relation between symptoms and
hr/day. duration of employment.
Equal problems dominant and

nondominant sides.
(Continued)
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MSD prevalence
Ohara et al. Cross- For cross-sectional study: Outcome: Assessed by standard Shoulder Shoulder Participation rate: for prospective
1976 sectional 399 cash register health inventory and medical stiffness: stiffness : study = 100%.
and Pro- operators compared with examination (used clinical
spective 99 office machine classification according to the Cashiers: Office Participation rate: for cross-sectional
operators and 410 other committee on cervicobrachial 81% Workers: study, not reported.
workers (clerks and disorders of the Japan 72% 1.7 1.0-2.8
saleswomen). All female. Association of Industrial Health, in Unknown whether examiners blinded
Table 3 in the paper). Shoulder Shoulder to case status.
For prospective study: dullness dullness
56 workers employed <7 Periodic physical exam performed and pain: and pain: Interventions did not reduce
months had testing pre- twice a year from 1973. Primary complaints in the shoulder region, but
and post-intervention using exams performed on 371 Cashiers: Other did improve symptoms in the arms,
questionnaire and physical operators. 130 (35%) received 49% workers: hands, fingers, low back, and legs.
exam. detailed exams. 68% 2.0 1.4-2.8 The lack of improvement in the
shoulder region was stated to be due
86 operators, newly hired Exposure: To repetitive to the use of the same narrow check
after interventions, also movements relocating Office stands, unsuitable counter height, and
had evaluation after merchandise across counter and workers: necessity of continuous lifting of the
10 months of working. bagging, involved muscle activity 30% 2.2 1.4-3.5 upper limbs.
of the fingers, hands, and arms;
extreme and sustained postures. Operators hired after the interventions
and then examined after 10 months
Interventions: (1) a 2-operator had less Grade I, II , or III occupational
system, 1 working the register, cervicobrachial disorders in
one packing articles, changing examination than those hired before
roles every hr; (2) continuous intervention.
operating time <60 min; max.
working hr/day 4.5 hr; Only 14.5% with >3 years
(3) 15- min resting period every employment at worksite.
hr; (4) electronic cash registers
with light touch keyboard Narrow work space and counter
substituted for half of previously height not adjusted for height of
used mechanical cash registers. worker.
(Continued)
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MSD prevalence
Ohlsson Cross- Electrical equipment and Outcome: Based on Shoulder Participation rate: Not reported.
et al. 1989 sectional automobile assemblers questionnaire: Any shoulder pain in
(n=148), former female pain, shoulder pain affecting previous 12 Significant association for shoulder
assembly workers who work ability, and shoulder pain in months: 55% symptoms and medium and fast pace
quit within 4 years (n=76) the last 7 days. 45% 2.0 1.1-4.0 compared to slow pace but not very
compared to randomly Shoulder fast pace.
sampled females from Exposure: Based on job pain in
general population (n=60). category. previous 7 Significant association with duration
days: 38% of employment (p=0.03), but much
18% 3.4 1.6-7.1 stronger for workers <35 years than
Work in workers >35 years.
auxiliary
previous 12 Significant interaction between age
months: 21% and employment.
10% 2.4 1.0-5.8 Older females employed for shorter

periods had more symptoms than
younger ones.
(Continued)
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MSD prevalence
Ohlsson Cross- Exposed Group: 206 of Outcome: Defined by criteria Frozen Participation rate: 83%.
et al. 1994 sectional 247 females working in from questionnaire and physical shoulder: 2% No exposure information available to
13 fish processing plants examination: standard diagnosis 0.5% 4.1 0.5-37 examiners, however, it was not
participated. of frozen shoulder, Supraspi- possible to completely blind the
natus study/referent group status.
supraspinatus tendinitis, tendinitis:
322 females who left infraspinatus tendinitis, bicipital All activities (trimming of cod, packing
15%
employment in the fish tendinitis acromioclavicular 5% 3.4 1.6-7.2 fish and herring filleting) were found
to be highly repetitive with poor
processing industry in the syndrome. Infraspinatus working postures and fast
10 years prior to the study. tendinitis: movements by standardized
Exposure: Assessed by 12% ergonomic workplace analysis
Comparison group: All 208 questionnaire (length of 3% 4.7 1.4-15.2 (EWA) methods; very few pauses in
females employed in the employment; psychosocial Bicipital the work cycle; tasks not varied.
same towns as the factors, physical factors) and by tendinitis:
10% Sports activities were highly
exposed; 71 were observational methods 4% 2.4 1.1-5.4 associated with shoulder tendinitis
employed in day nurseries; (Ergonomic Workplace Analysis) Acromiocla- (OR=4, 9) in multiple logistic
92 in offices; 42 caretakers and NIOSH guidelines for lifting. vicular regression analysis.
of elderly; 3 gardeners. Analyzed 10 items: work site, syndrome: In the control group, prevalences of
general physical activity, lifting, 17% upper limb disorders increased
work postures and movements, 6% 3.1 1.6-6.0 substantially with age. Among the
job content, job restrictiveness, exposed, the prevalence remained
almost constant with age.
worker communication, difficulty
of decision making, repetitiveness Excess prevalence for exposed
females most pronounced for females
of the work, and attentiveness. PRR of <45 years. There was a pronounced
shoulder dose-response for disorders of the
74 workers videotaped $10 min. disorders: neck or shoulders vs. duration of
from the back and sides. 2.95 2.2-4.0 exposure in the industry. No such
Average counts of two PRR for associations seen in group >45 years.
independent readers for Authors explained as perhaps due to
suprapi- the healthy worker effect, but, it
frequencies, duration and critical natus, would be more accurate to describe it
angles of movement used. infraspinatus as survivor bias.
and bicipial
tendinitis: 3.03 2.0-4.6 Psychosocial work environment,
stress and worry factors, tendencies
PRR for towards muscular tension differed
suprapinatus significantly between exposed and
and controls.
infraspinatus
tendinitis
alone: 3.5 2.0-5.9
(Continued)
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MSD prevalence
Ohlsson Cross- Industrial Workers Outcome: Measured by physical 50% (n=82) 16% 5.0 2.2-11.0 Participation rate: current workers:
et al. 1995 Sectional (n=82 females) exposed to exam and questionnaire. (n=64) 96%; past workers: 86%;
repetitive tasks with short Frozen shoulder: Limited out- referents: 100%.
cycles mostly far <30 sec, ward rotation and abduction. Employment Questionnaire included individual
usually with a flexed neck duration: factors, work/environment,
Infraspinatus, supraspinatus symptoms.
and arms elevated and tendinitis: Local tenderness over <10 years
abducted intermittently; (n=19): 53% No exposure information available to
tender insertion, pain with
68 former workers (mean resisted abduction. 9.6 2.8-33.0 examiners, however, it was not
possible to completely blind the
employment time 21 years) Bicipital tendinitis: Pain with 10 to 19 study/referent group status.
who had left the factory resisted elevation of arm, resisted years
Psychosocial scales assessed:
during the 7 years before flexion of elbow. (n=25): 48% control over ones work, stimulation,
the study; these workers psychological climate, work strain,
Acromicoclavicular syndrome:
were compared to 64 >20 years 4.4 1.5-13.0 fellowship at work and social network
referents with no repetitive Pain with horizontal adduction (n=38): 50% at work. Age, stress/worry
exposure at their current and/or outward rotation of arm. tendency, subjective muscular tension
jobs (female residents of a Exposure: Videotaping and tendency, social network outside of
nearby town currently observation. Analysis of 3.8 1.4-10.0 work, psychosomatic symptoms.
employed as customer elevation of the arm: 0E, 30E, 60E, Age and employment status (repetitive
service, ordering and price and for abduction 30E, 60E, 90E. vs. referent) controlled for in logistic
model.
marking in supermarkets, 74 workers videotaped $10 min.
as office workers (no from back and sides. Average For continuous variables, OR are for
constant computer work) counts of two inde-pendent 75th vs. 25th percentiles.
or as kitchen workers. readers for frequencies, duration, Videotape analysis revealed
and critical angles of movement considerable variation in posture even
within groups performing similar
used. assembling tasks.
Repetitive industrial work tasks Logistic models replacing repetitive
divided into 3 groups: (a) fairly work with videotape variables found
mobile work, (b) assembling or muscular tension tendency and neck
pressing items, and sorting, flexion movements significantly
polishing and packing items associated with neck/shoulder
diagnoses.
Weekly working time, work Significant association between time
rotation, patterns of breaks, spent with upper arm abducted >60
individual performance rate (piece and neck/shoulder diagnoses.
rate).
Only exposure readings from
right arm were used.
Muscle strength (maximum
voluntary capacity) measured by
hand dynamometer at elevation,
(Continued)
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MSD prevalence
Onishi et al. Cross- Female industrial workers: Outcome: Based on Shoulder Participation rate: Not reported.
1976 sectional 42 reservationists; (1) symptoms of shoulder Tenderness:
95 fluorescent lamp stiffness, dullness, pain, Unknown whether examiners blinded
assemblers; numbness; (2) pressure (<1.5 Reserva- Office to case status.
109 photographic film kv/cm2) measured by strain tionists: workers
rollers; 46 teachers of transducer at which subject felt assemblers: (n=101): Body height, weight skin fold
handicapped children; pain. (3) physical exam: range 70% 48% 1.1 0.6-1.9 thickness and muscle strength, grip
101 office workers. of motion, tests, nerve strength, obtained.
compression tenderness. Film rollers:
84% 6.0 3.0-12.2 Body height and weight differences
Exposure: Observation of job not significant.
tasks, then job categorization. Teachers:
58% 1.6 0.7-3.3 Significant difference between body
Reservations; Key 15,000 to fat in reservationists and office
20,000 strokes/day or more on Shoulder workers.
busy days 2 to 3 times/week. Stiffness:
Significant difference in grip strength
Assemblers inspect lamps once Reservatio- in teachers and nurses compared
every 3.5 to 4.5 sec; all work nists with office workers.
12 hr/day. (N=45):
56.6% 34.7% 2.5 1.1-5.6 Those with habitual shoulder stiffness
Film rollers wind 1 roll of 35mm had lower threshold of local
film every 2.5 to 5 sec over 7.5 Assemblers tenderness than those without
hr/day. (N=94): stiffness.
66.6% 3.7 2.0-7.0
Prolonged contraction of No difference between workers with
trapezius noted in 2 film rollers. Film Rollers tenderness threshold above
(N=127): 1.5 Kb/cm2 and those below with
Teachers and nurses daily care 59.1% 2.7 1.5-4.9 respect to age, height, weight, skin
of disabled children e.g., lifting. fold thickness, grip strength, upper
Teachers arm abduction strength, back muscle
Office workers: Record keeping, (N=52): strength.
copying, etc. 65.4% 2.1 0.9-4.6
(Continued)
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MSD prevalence
Punnett Cross- 162 female garment Outcome: Self-administered Garment Hospital Shoulder Participation rate: 97% (garment
et al. 1985 sectional workers, 85% were questionnaire about pain and workers: employees MSDs in workers), 40% (hospital workers).
employed as sewing standardized physical exam. 19.6% 8.8% Garment
machine operators and workers vs. Analysis stratified for number of
sewing and trimming by Cases defined as the presences Hospital years employed, decade of age,
hand. of persistent shoulder pain employees: native language.
(lasted for most days for one OR= 2.2 1.0-4.9
Comparison: 76 of 190 full month or more within the past Age and length of employment not a
or part-time workers on year); were not associated with Shoulder predictor of risk of shoulder MSDs.
day shift in a hospital who previous injury, and, began after MSDs in
worked as nurses or aids; first employment in garment Straight stitch Prevalence of pain not associated
lab techs or therapists; manufacturing or hospital workers vs. with years of employment in garment
food service workers. employment. Key questions Hospital workers.
based on the arthritis supplement employees:
Employees typing >4 hr/day questionnaire of NHANES. OR=3.9 p#0.05 Non-English speakers significantly
excluded from comparison less likely to report pain (RR 0.6
group. Exposure: Self-administered Shoulder p<0.05).
questionnaire; number of years in MSDs in Top
the industry, job category, stitch Native English speakers significantly
previous work history. workers vs. older than non-native English
Hospital speakers (p<0.03).
employees
OR=5.0 p#0.05 Logistic regression model found
garment work and language
significantly related to shoulder pain.
(Continued)
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MSD prevalence
Rossignol Cross- 191 computer and data Outcome: Self-administered 0.5 to 3 hr of Compari- Up to 3 hr of Participation rate: in six industry
et al. 1987 sectional processing services, public questionnaire case defined as: VDT use/day son group VDT use groups 67 to 100%.
utilities of Massachusetts Almost always experienced (n=31): 35% (with no compared to
State Department, 28 of shoulder pain, stiffness or computer 0 hr of use. Participation rate: for individual
whom did not use a soreness or missed work due to use) OR=2.5 0.7-10.8 clerical workers: 94 to 99%.
keyboard with a VDT. shoulder pain, stiffness or 4 to 6 hr of (n=28):
soreness. VDT use/day 18% Assessed magnitude of confounding
Centers selected at random (n=28): 48% 4 to 6 hr of by age, cigarette smoking, industry,
from 38 work sites with Exposure: Self-reported number VDT use educational VDT training.
>50 employees. of hr/day working on a keyboard >7 hr of VDT compared to
with a VDT. Subjects selected use/day 0 hr of use: The study was presented as General
after observation of work sites. (n=104): OR=4.0 1.0-16.9 health survey to avoid observation
51% bias.
>7 hr of VDT
use compared
to 0 hr of use:
OR=4.8 1.6-17.2
(Continued)
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MSD prevalence
Sakakibara Cross- 48 Orchard workers Outcome: Shoulder pain Workers Workers Workers Participation rate: 77%.
et al. 1987 sectional (20 males and 20 females). described as the presence of thinning bagging thinning pears
stiffness and pain daily. pears apples: vs. workers Stratified by gender.
Compared symptoms after (estimated 21% bagging
completion of thinning of Exposure: Observation of jobs. from apples: General fatigue, gastric disturbances,
pears, bagging of pears Angles of flexion of the shoulder histograms): OR=2.2 1.2-4.1 appetite loss and headache showed
and bagging of apples on one subject were measured 46% no difference in frequency between
(covering fruit with paper every 25 min. during a whole day tasks.
bags while on the trees). doing each task. Workers
Workers bagging pears Stiffness and pain in shoulders
Internal comparison using Farmers worked approximately 8 bagging vs. bagging significantly higher from thinning and
same study population. hr/day for 10.6 to 13.6 days each pears apples: bagging pears than apples which
year bagging or thinning pears (estimated OR=1.4 0.7-2.8 authors attributed to working posture
and bagging apples. Median from of elevated arms and neck extension.
shoulder flexion was 110E to histograms):
119E for thinning pears and 29% Exposure data based on
bagging pears; 30E bagging measurement of one worker may not
apples. be generalized to others.
The proportion of workers with >90E

forward shoulder flexion was
significantly higher for thinning out
pears and bagging pears than for
bagging apples.
(Continued)
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MSD prevalence
Sakakibara Cross- Of 65 female Japanese Questionnaire: Stiffness and pain Pear bagging Apple Participation rate: 80%.
et al. 1995 sectional farmers. 52 completed the in shoulder region. Symptoms in bagging
questionnaire and physical past 12 months for $one day, or Examiners not blinded to case status
exam in late June for symptoms in past 12 months for Muscle Muscle Workers due to design of study.
bagging pears and late July $8 days. tenderness: tender- bagging pears
for bagging apples. 48.1% ness: with muscle Same population examined two times.
Exam: Muscular tenderness in 28.8% tenderness 2nd exam occurred one month after
shoulder region; maximal grasping vs. apple first. These results used in analyses
power measured by bagging for comparison of two tasks.
dynamometer and back muscle with muscle
power by myosphenometer. tenderness: Stiffness and pain during apple
OR=1.7 1.1-2.9 bagging may have been pain that was
Exposure: Observation of tasks a residual of pear bagging operations.
and measurements of Pain in joint Pain in joint Workers
representative workers (only two motion: motion: bagging pears Number of fruit bagged/day was
workers measured). 23.1% 21.2% with pain in significantly more in pear bagging than
controls joint motion in apple bagging.
Angle of arm elevation during vs. apple
bagging was measured in one bagging with Exposure measurements only
subject. pain in joint obtained on 2 workers and
motion: generalized to all workers.
Angle of forward flexion of OR=1.1 0.53-2.3
shoulder for bagging pears was
110 to 139o. 75% of angles were
above 90o. For bagging apples
the angle of forward flexion was
0 to 140o; 41% of the angles
were >90o.
(Continued)
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MSD prevalence
Schibye et Pro- Follow-up of 303 sewing Outcome: Cases defined by the Workers Participation Rate in 1985: 94%.
al. 1995 spective machine operators at nine Nordic questionnaire for who Participation Rate in 1991: 86%.
factories representing symptoms as to duration during delivered or All participants were female.
different technology levels last 12 months and during last 7 collected
who completed days, effect on work their own 77 of 241 workers still operated a
questionnaire in 1985. performance and leisure materials: sewing machine in 1991.
activities, and sick leave. 18%
In April 1991, 241 of shoulder 82 workers had another job in 1991.
279 traced workers Exposure: Assessed by symptoms; Among those 35 years or younger,
responded to same questions regarding type of the rest 33% 77% had left their jobs; among those
questionnaire. machine operated, work above 35 years, 57% had left their
organization, workplace design, jobs.
units produced/day, and payment
system, time of employment as a 20% reported musculoskeletal
sewing machine operator. symptoms as the reason for leaving
job.
No significant changes in prevalences

among those employed as sewing
machine operators from 1985 to 1991;
significant decrease in those who
changed employment.
(Continued)
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MSD prevalence
Stenlund Cross- 55 of 75 rockblastors, 54 of Outcome: Based on a grading of Bricklayers Foremen Participation rate: 80%.
et al. 1992 sectional 75 bricklayers randomly acromioclavicular joints of Rt side: Classification of X-rays achieved with
selected from union shoulders. 59.3% 36.7% 2.2 1.0-4.7 blinding of investigators to age, name
records and 98 of 110 Grade 0 = normal Lt side: or exposure status.
foremen selected from Grade 1 = minimal changes 40.7% 23.4% 1.8 0.8-3.9
foremen employed in large Grade 2 = moderate changes Study looked at manual work and
construction firms. Grade 3 = severe osteoarthritis Rockblasters Foremen exposure to vibration and relationship
Grade 4 = joint destroyed Rt side: to osteoarthritis in acromioclavicular
61.8% 36.7% 2.1 0.9-4.6 joint using shoulder x-rays.
Exposure: Based on self- Lt side: Logistic regression models adjusted
reported estimates of loads lifted, 56.4% 23.4% 4.0 1.8-9.2 for age, smoking, dexterity, checked
hr of exposure to vibration, job for interactions.
title, and years of employment. Years of
The weights of tools also manual work Questionnaire included questions
obtained. >28 years vs. about smoking, dexterity, ethnicity,
citizenship.
<10 years
Bricklayers lifted a mean of Rt side: 2.9 1.2-7.4 Risks were elevated as length of
29,439 tonnes; Rockblasters, a Lt side: 2.5 1.0-5.9 employment increased and as
mean of 33,210 tonnes; Foremen, exposure to vibration and amount
a mean of 2,261 tonnes. 10 to 28 lifted increased.
years vs. X-ray grades 2 and 3 for analysis.
<10 years
Rt side: 1.1 1.1-4.7 Smoking significantly associated with
Lt side: 2.3 1.0-5.3 osteoarthritis of right shoulder (OR=2,
2.4) but not left side. Significance
Load lifted found, but is it meaningful?
725,000 vs. Left handedness significantly
710 tonnes associated with osteoarthritis of left
Rt side: 3.2 1.1-9.2 side (OR=2.5).
Lt side:10.3 3.1-34.5
The age adjusted odds ratio for
osteoarthrosis in the right
Vibration acromioclavicular joint for brick layers
725,000 hr and rock blasters as compared with
vs <9001 hr foremen, was 2.16 on the right side
Rt side: 2.2 1.0-4.6 95%CI(1.14-4.09), and was 2.56 95%
Lt side: 3.1 1.4-6.9 CI (1.33-4.93).
(Continued)
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MSD prevalence
Stenlund Cross- 55 of 75 rockblasters and Outcome: Based on Bricklayers Foremen Participation rate: 80%.
et al. 1993 sectional 54 of 75 bricklayers questionnaire of previous injuries Rt. side:
selected randomly from and diseases of musculoskeletal 11.1%; 8.2% 0.4 0.2-1.3 Examiners blinded to exposure status
union records, and 98 of system and previous shoulder Lt. side: or job title.
110 foremen randomly pain, and physical exam. 14.8% 17.1%
selected from foremen Unconditional multiple regression

employed in large Case defined as Signs of Rockblasters analysis adjusted for age,
construction companies. shoulder tendinitis as palpable Rt. side: handedness, smoking and sport
pain of the muscle attachment or 32.7% 8.2% 1.7 0.7-4 activities. In all models left and right
pronounced pain reaction to Lt. side: sides calculated separately.
isometric contraction in any of the 40.0% 17.1% 3.3 1.2-9.3
4 rotator cuff muscles or biceps Vibration related to shoulder tendinitis
muscles. Clinical Entity although confounded by static loads
Load and lifting.
Clinical entity of tendinitis Rt. side: 1.0 0.5-2.2
defined as pain during the last Lt. side: 1.6 0.6-4.1 Interactions tested for.
year, pronounced pain reaction to
palpation or isometric contraction. Vibration The study looked at manual work and
Rt. side: 1.9 1.0-3.4 exposure to vibration and their
Exposure: Based on self- Lt. side: 2.5 1.1-5.9 relationship to signs of tendinitis of the
reported estimates of load lifted, shoulder.
hr of exposure to vibration, job Manual Work
title and years of employment. Rt. side: 0.9 0.5-1.8 Exposure-response found where
Lt. side: 2.3 0.9-6.3 comparison of high vibration exposure
Load defined as 0 to 709 tonnes, compared to low exposure.
710 to 25,999 tonnes, >25,999 Signs of
tonnes vibration defined as hr of Tendinitis
exposure: 0 to 8,999, 9000 to Load
255,199, >255,999 hr to each tool Rt. side: 1.0 0.6-1.8
multiplied by factor corresponding Lt. side: 1.8 0.9-3.4
to vibration energy. Years of
manual work: 0 to 9, 10 to 28, Vibration
>28 years. Rt. side: 1.7 1.1-2.6
Lt. side: 1.8 1.1-3.1
Manual Work
Rt side: 1.1 0.7-1.8
Lt side: 1.9 1.0-3.4
(Continued)
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MSD prevalence
Sweeney Cross- 105 of 164 sign language Outcome: Symptom questionnaire Symptom >20 hr Participation rate: 64%.
et al. 1994 sectional interpreters for the deaf, and physical exam: case: 22% signing,
who attended a compared Examiner blinded to exposure status.
professional conference of Symptom case defined as the Symptom to
sign language interpreters. presence of pain, aching, case with <10 hr/we Generalizability of results to other sign
stiffness, burning, numbness or moderate to ek 2.5 0.8- 8.2 language interpreters is limited.
tingling in the shoulder lasting severe
$ one week or once/month within shoulder
the past 12 months; no previous discomfort:
injury and symptoms occurred 50%
after becoming a sign-language
interpreter. Positive
symptom +
Symptom-exam case: Defined as positive
the presence of symptoms and a exam: 1%
positive exam for the shoulder.
Exposure: Based on
questionnaire (years of
employment as a sign language
interpreter; numbers of hrs/week
engaged in signing).
(Continued)
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MSD prevalence
Wells et al. Cross- Of 199 letter carriers, Outcome: Telephone interview All letter Postal Participation rate: 99% among letter
1983 sectional 196 were compared to based on current pain; carriers: clerks: carriers, 92% meter readers, 97%
76 of 79 meter readers and frequency, severity, interference 18% 5% 3.6 1.8-7.8 postal clerks.
127 of 131 postal clerks. with work, etc; score of 20
required to be a case. More Letter Schooling and marital status asked.
points given to neck and shoulder carriers: Postal
problems that interfered with increased clerks: Symptoms alone used for MSD
routine daily activities. weight: 23% 5% 5.7 2.1-17.8 definition.
Exposure: Based on job Letter Comparison group (gas meter

category; based on self-reported carriers: readers) used because of similar
information on weight carried, no weight Postal walking rate without carrying weight
previous work involving lifting and increase: clerks: compared to letter carriers. Postal
work-related injuries. 13% 5% 3.3 1.1-11.1 clerks neither walk nor carry weight.
During analysis, more weight was

given to scoring neck and shoulder
than other body regions. Outcome
influenced results when ranking of
body MSDs, though, would not
influence group comparison.
Adjusted for age, number of years on

the job, quetlet ratio and previous
work experience.
104 letter carriers had bag weight

increased from 25 to 35 lbs in the
year prior to the study.
Letter carriers with increased bag

weight walked on average 5.24 hr;
those with no change in bag weight
walked 4.83 hr.
Letter bags usually carried on the

shoulder.
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CHAPTER 4
Elbow Musculoskeletal Disorders
(Epicondylitis): Evidence for
Work-Relatedness
SUMMARY
Over 20 epidemiologic studies have examined physical workplace factors and their relationship to
epicondylitis. The majority of studies involved study populations exposed to some combination of work
factors, but among these studies were also those that assessed specific work factors. Each of the studies
examined (those with negative, positive, or equivocal findings) contributed to the overall pool of data to make
our decision on the strength of work-relatedness. Using epidemiologic criteria to examine these studies,
and taking into account issues of confounding, bias, and strengths and limitations of the studies, we
conclude the following:
There is insufficient evidence for support of an association between repetitive work and elbow
musculoskeletal disorders (MSDs) based on currently available epidemiologic data. No studies having
repetitive work as the dominant exposure factor met the four epidemiologic criteria.
There is evidence for the association with forceful work and epicondylitis. Studies that base exposure
assessment on quantitative or semiquantitative data tended to show a stronger relationship for epicondylitis
and force. Eight studies fulfilling at least one criteria showed statistically significant relationships.
There is insufficient evidence to draw conclusions about the relationship of postural factors alone and
epicondylitis at this time.
There is strong evidence for a relationship between exposure to a combination of risk factors (e.g., force
and repetition, force and posture) and epicondylitis. Based on the epidemiologic studies reviewed above,
especially those with some quantitative evaluation of the risk factors, the evidence is clear that an exposure
to a combination of exposures, especially at higher exposure levels (as can be seen in, for example,
meatpacking or construction work) increases risk for epicondylitis. The one prospective study which had a
combination of exposure factors had a particularly high incidence rate (IR=6.7), and illustrated a temporal
relationship between physical exposure factors and epicondylitis.
The strong evidence for a combination of factors is consistent with evidence found in the sports and
biomechanical literature. Studies outside the field of epidemiology also suggest that forceful and repetitive
contraction of the elbow flexors or extensors (which can be caused by flexion and extension of the wrist)
increases the risk of epicondylitis.
Epidemiologic surveillance data, both nationally and internationally, have consistently reported that the
highest incidence of epicondylitis occurs in occupations and job tasks which are manually intensive and
require high work demands in dynamic environmentsfor example, in mechanics, butchers, construction
workers, and boilermakers.
Epicondylar tenderness has also been found to be associated with a combination of higher levels of forceful
exertions, repetition, and extreme postures of the elbow. This distinction may not be a true demarcation of
different disease processes, but part of a continuum. Some data indicate that a high
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percentage of individuals with severe elbow pain are not able to do their jobs, and they have a higher rate of
sick leave than individuals with other upper extremity disorders.
INTRODUCTION cohort. Those studies using symptom and

Epicondylitis is an uncommon disorder, with the physical examination findings to define
overall prevalence in the general population epicondylitis used consistent criteria
reported to be from 1% to 5% [Allender almost all studies using physical examination for
1974]. There are fewer epidemiologic studies diagnosis required pain with palpation of the
addressing workplace risk factors for elbow epicondylar area and pain at the elbow with
MSDs than for other MSDs. Most of these resisted movement of the wrist. However,
studies compare the prevalence of epicondylitis studies using a definition based on symptom
in workers in jobs known to have highly data alone used various criteria, some based on
repetitive, forceful tasks (such as meat frequency and duration of symptoms [Burt et
processing) to workers in less repetitive, al.1990; Hoekstra et al. 1994; Fishbein et al.
forceful work (such as office jobs); the majority 1988] others based on elbow symptoms
of these studies were not designed to identify preventing work activities [Ohlsson et al.
individual workplace risk factors. 1989].
The text of this section on epicondylitis is REPETITION

organized by work-related exposure factor. Definition of Repetition for Elbow
The discussion within each factor is organized MSDs
according to the criteria for evaluating evidence
For our review, we chose studies that
for work-relatedness in epidemiologic studies
addressed the physical factor of repetition and
using the strength of association, the
its relation to elbow MSDs, especially those
consistency of association, temporal
studies that focused on epicondylitis. Studies
relationships, exposure-response relationship,
usually defined repetition, or repetitive work,
and coherence of evidence. Conclusions are
for the elbow as work activities that involved
presented with respect to epicondylitis for each
(1) cyclical flexion and extension of the elbow
exposure factor. Summary information relevant
or (2) cyclical pronation, supination, extension,
to the criteria used to evaluate study quality is
and flexion of the wrist that generates loads to
presented in Tables 4-1 to 4-4. A more
the elbow/forearm region. Most of the studies
extensive summary (Table 4-5) includes
that examined repetition as a risk factor for
information on health outcomes, covariates, and
epicondylitis had several concurrent or
exposure measures. All tables are presented at
interacting physical work load factors. We
the end of this chapter. Not all the articles
attempted to select those studies in which
summarized in the tables are referenced in this
repetition was either the single risk factor or the
narrative, but they have been reviewed and
dominant risk factor based on our review
evaluated and are included for information.
of the study and our knowledge of the
There are 19 studies referenced in Tables 4-1
occupation. This method eliminated those
through 4-4, 18 cross-sectional studies and one
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studies in which a combination of high levels of based on self-reported symptoms lasting more
repetition and high levels of force exist, or those than 1 month since starting career, or pain for
studies which selected their exposure groups more than 30 days. Exposure was based on the
based on highly repetitive, forceful work. authors experiences as occupational health
physicians and involved crude assessment of
Studies Reporting on the Association exposure level and exposure repetitiveness.
of Repetition and Epicondylitis Analysis dealt with exposure as duration of
Seven studies reported results on the exposure as a sewing machine operator.
association between repetition and adverse Statistical modeling controlled for age, having
elbow health outcomes including epicondylitis. children, not doing leisure exercise, smoking,
The epidemiologic studies that address and socioeconomic status. For this study, the
repetitive work and epicondylitis compare exposure classification scheme does not allow
working groups by classifying them into separation of the effects of repetition from those
categories based on some estimation of of force, although repetition may be a more
repetitive work, such as percent of time typing obvious exposure.
[Burt et al. 1990], number of items per hour
[Ohlsson et al. 1989], or number of hand Baron et al. [1991] explored epicondylitis
manipulations per hour [Baron et al. 1991]. among grocery store workers, comparing the
Those studies which may have measured prevalence among grocery store cashiers to
repetitive work but have exposure to higher that among non-cashiers and identified work
levels of force will be discussed in the Force risk factors while controlling for covariates.
section. Detailed ergonomic assessment of grocery
checking and cashiering was completed using
Studies Meeting the Four Evaluation both on-site observational techniques and
Criteria videotaped analyses. The majority of cashiers
None of the studies (see Table 4-1 and Figure were categorized as having medium levels of
4-1) reviewed for the elbow summary section repetition for the hand (defined in this study as
met all four evaluation criteria outlined in the making 1250 to 2500 hand movements per
Introduction Section. hour). Repetitive movements were not
recorded directly for the elbow; however, the
Studies Meeting at Least One of the Criteria number of hand movements serve as an
The studies will be summarized in alphabetical approximation for elbow repetitions. Age,
order as they appear in hobbies, second jobs, systemic disease, and
Table 4-1. height were considered as covariates in the
multivariate analyses. The diagnosis of
Andersen and Gaardboe [1993a] used a cross- epicondylitis required standard physical
sectional design to compare sewing machine examination techniques of palpation and
operators with a random sample of women resisted extension and flexion of the elbow.
from the general population of the same region.
Elbow pain, not epicondylitis, was the MSD of Burt et al. [1990] studied 834 employees using
interest in this study. A case of elbow pain was computers at a metropolitan newspaper, using a
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self-administered questionnaire for case assembly workers and compared these two
ascertainment. Exposure assessment was based groups to a random sample from the general
on self-reported typing time and observation of population. A case of elbow pain was based on
employees job tasks, then categorization by questionnaire responses; exposure was based
job title. A separate job analysis using a on job categorization as well as questionnaire
checklist and observational techniques was responses. Repetitive exposure was based on a
carried out for validating questionnaire self-reported frequency of task items
exposure data. Workers fulfilling the case completed per hour (work pace). Results
definition for elbow/forearm pain were showed no association with work pace and
compared to those who did not fulfill the case elbow symptoms, and no association between
definition. Prevalence of cases was associated length of employment and elbow symptoms.
with percent of time typing and typing speed.
Logistic regression controlled for age, gender, Punnett et al. [1985] compared neck/shoulder
metabolic disorders, and job satisfaction. MSDs based on symptom reporting alone in
162 women garment workers and 76 women
Automobile assembly line workers were hospital workers such as nurses, laboratory
compared to a randomly selected group from technicians, and laundry workers. There was a
the general population in the study by Bystrm low participation rate among the hospital
et al. [1995]. A case of epicondylitis required workers. Eighty-six percent of the garment
symptoms and physical examination. Job title workers were sewing machine operators and
was used as a surrogate for exposure in the finishers (sewing and trimming by hand). The
analysis. No assessment of repetition or sewing machine operators were described as
repetitive work was completed specifically for using highly repetitive, low force wrist and
the elbow. finger motions, while the finishers had shoulder
and elbow motions as well. The exposed
McCormack et al. [1990] had a randomly garment workers likely had more repetitive
selected population of 2,261 textile workers jobs than most of the hospital workers.
from over 8,000 eligible workers. Workers
were analyzed by job category, after Strength of AssociationRepetition
observation of jobs. Epicondylitis case and Elbow MSDs
ascertainment was by clinical exam. Of the 37 No studies met the four criteria to discuss
cases of epicondylitis identified, 13 were strength of association.
categorized as mild, 22 were moderate, and 2
were severe. Eleven examiners may have Strength of AssociationStudies Not
introduced an interexaminer reliability problem. Meeting the Four Criteria
Age, gender, race, and years of employment For the other studies not fulfilling all the criteria,
were analyzed as confounders. the odds ratio (OR) reported in the
Baron et al. [1991] study for epicondylitis

Ohlsson et al. [1989] studied electrical overall was 2.3, but this was not statistically
equipment and automobile assemblers, former significant.
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Anderson and Gaardboe [1993a] used years addressed repetition as a physical factor alone;
employed as a sewing machine operator as a all the studies were cross-sectional, so a
surrogate for exposure and found no significant temporal relationship cannot be established.
association with epicondylitis. However, some cross-sectional studies allow
None of the other studies that looked at us to infer causality by use of restrictive case
epicondylitis among working groups carried out definitions. Studies by the National Institute for
independent exposure assessment of workers Occupational Safety and Health (NIOSH)
or representative workers that focused on the investigators [Burt et al. 1990; Baron et al.
elbow. 1991] excluded from analysis those workers
who reported symptoms experienced prior to
Burt et al. [1990] found a statistically significant their present job and those with acute injury to
OR of 2.8 for elbow/forearm symptoms in the elbow not related to the job.
newspaper employees who reported typing
80%100% of their working day compared to Consistency in Association for
those typing 0%20%. (Typing hours has been Repetition and Epicondylitis
used as a surrogate of both repetition and The studies were not consistent in showing an
duration of exposure.) association between repetitive work and
epicondylitis. In terms of strength of
Likewise, Punnett et al. [1985] found a association, there were no studies that had
significant prevalence rate ratio (PRR=2.4) of statistically significant ORs greater than 3.0,
persistent elbow symptoms among garment four studies had ORs between 1.0 and 3.0, that
workers performing repetitive, forceful work were statistically significant; and two studies
compared to hospital workers. Analysis by job had nonsignificant ORs less than 1.0.
title showed that underpressers, whose jobs
consisted of ironing by hand, had a PRR of 6.0. Coherence of Evidence for Repetition
Among stitchers (sewing machine operators), The evidence for epicondylitis in the
the significant PRR for the task of setting linings biomechanical and sports literature does not
was 7.7. When standardized to the age address repetition alone, but has consistent
distribution of the hospital workers, the rate evidence with a combination of forceful
ratio did not change. exertion, awkward or extreme postures, and
repetitive movements. Please refer to the
McCormack et al. [1990] and Ohlsson et al. discussion under Coherence of Evidence for
[1989] based exposure on job title and found Force.
no association between repetitive work and
epicondylitis, with non-significant ORs between
0.5 and 2.8.
Temporal RelationshipRepetition
and Epicondylitis
There were no prospective studies which
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Exposure-Response Relationship for categories based on an estimated amount of

Repetition resistance or force of exertion and a
In Baron et al.s [1991] study, there was a combination of estimated rate of repetition
dose-response relationship for the elbow for (e.g., Viikari-Juntura et al. [1991b]; Kurppa et
the number of hours per week working as a al. [1991]; Chiang et al. [1993]) or in terms of
checker, with ORs up to around 3.0, but not overall elbow stress [Dimberg 1987; Ritz
for the duration of employment (the average 1995].
length of employment was 8 years).
Studies Meeting the Four Evaluation
Criteria
Conclusions Regarding Repetition
Of the studies examining epicondylitis and
There is insufficient evidence for support of an forceful exertion, three studies [Chiang et al.
association between repetitive work and 1993; Luopajrvi et al. 1979; Moore and Garg
elbow MSDs based on currently available 1994] fulfilled all four criteria. Most of these
epidemiologic data. There were no studies that studies used combinations of risk factors in their
met the four criteria. Of the 7 studies examining analysis, of which forceful exertion was one.
repetitive work, no studies found ORs above
3.0, 5 studies found ORs from 13, and 2 Chiang et al. [1993] assessed exposure though
studies found an OR less than one. observational methods, recording of tasks and
biomechanical movements of representative
FORCE workers. With these methods, they categorized
Definition of Force for Elbow MSDs fish processing workers into three exposure
groups according to the ergonomic risks to the
For our review, we included studies that
shoulders and upper limbs: (1) those with low
examined force or forceful work or heavy loads
force and low repetition (the comparison
to the elbow, or described exposure as
group), (2) those with high force or high
strenuous work involving the forearm extensors
repetition, and (3) those with both high force
or flexors, which could generate loads to the
and high repetition. The diagnosis of
elbow/forearm region. Most of the studies that
epicondylitis included standard physical
examined force or forceful work as a risk factor
examination techniques of palpation and
for epicondylitis had several concurrent or
resisted extension and flexion of the elbow.
interacting physical workload factors.
Examination-defined cases were about one-half
the number of cases defined by symptom alone.
The analysis was stratified by gender, and those
of Force and Epicondylitis
with metabolic diseases associated with MSDs
Thirteen studies reported results on the were excluded. There was no significant
association between force and adverse elbow difference in age between the comparison
health outcomes, including epicondylitis. The groups. Multivariate analysis was not carried
epidemiologic studies that addressed forceful out for the elbow in this study.
work and epicondylitis compared working
groups by classifying them into broad
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Luopajrvi et al. [1979] determined MSDs estimated as percent of maximal strength by

differences between female assembly line comparing the reported weight of the pertinent
workers and shop assistants in a department object with estimated average maximal strength
store (cashiers were excluded from the of the worker for different types of pinches and
comparison group). Exposure assessment grasps, then categorized into five levels.
involved on-site observation, video analysis and
interviews. The assembly work was found to be These values were derived from population-
repetitive, with up to 25,000 cycles per based data stratified according to age, gender,
workday involving hand and finger motions. and hand dominance. Repetition was recorded
Specific cycles were not recorded for elbow as cycle-time and exertions per minute. The
motions; however, motions involving the hands exposure assessment in this study gave more
and fingers involve tendons and muscles from weight to the factor of force than to repetition
the flexors and extensors that have their origin or posture (the force variable could increase to
at the elbow. Static muscle loading of the a higher categorization level if the job was
forearm muscles, deviations of the wrist, and repetitive, involved jerky motions, or extreme
lifting were also found. The diagnosis of postures). Work histories, demographics, and
epicondylitis included standard physical pre-existing morbidity data were not collected
examination techniques of palpation and on each participant. The diagnosis of
resisted extension and flexion of the elbow. epicondylitis extracted from the medical
Subjects with previous trauma, arthritis, and records included standard physical examination
other pathologies associated with MSDs were techniques of palpation and resisted extension
excluded. All participants were female. and flexion of the elbow. Analyses were based
Covariates considered in the analysis included on full-time equivalents for jobs, not individual
age, social background, hobbies, and the workers. This analysis did not control for
amount of housework performed. Duration of potential confounders; there was a slight
employment was not an issue because the preponderance of morbidity of all MSDs
factory had only been open a short time. among females.
Moore and Garg [1994] carried out a medical Studies Meeting at Least One Criteria
records review using an epicondylitis case The Andersen and Gaardboe study [1993a],
definition based on symptoms and physical which did not carry out ergonomic assessment
examination and a semi-quantitative ergonomic pertaining to the elbow, found a non-significant
assessment of 32 jobs at a meatpacking plant. association between repetitive, forceful work
The authors used their Strain Index to and symptoms or physical findings consistent
categorize jobs as hazardous or safe based with epicondylitis. In the Andersen and
on a number of factors: observation, video Gaardboe study [1993a], the exposed group
analysis, and judgements based on force, consisted of sewing machine operators.
repetition, posture, and grasp. Force was
Baron et al.s [1991] measure of force was

based on estimated assessment of exertion by
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experienced ergonomists through observation focused on the stress to the hand/wrist, elbow,
of tasks and video analysis, as well as weight of and shoulder areas.
scanned items. Average forces for the grocery
checkers were categorized as low and peak One study by Kurppa et al. [1991] was
forces medium on a three-tiered scale (low, prospective. Here, workers in meat processing
medium, and high). were categorized into strenuous and
nonstrenuous jobs based on repetitive and
Bystrm et al.s [1995] study of automobile forceful work. The strenuous tasks for the
assembly workers is reviewed in the Repetition meatcutters consisted of cutting approximately
section. 1,200 kg of veal or 3,000 kg of pork per day;
the nonstrenuous tasks consisted primarily of
Dimbergs studies [1987] fulfilled three of the office work. Workers had to have a physician
criteria but did not mention if examiners were visit and diagnosis in order to be considered a
blinded to exposure status. In the 1987 study, casea restrictive definition requiring
exposure was assessed by observational significant enough symptoms to seek out
methods, jobs were categorized according to
medical care.
the amount of elbow stress in a particular job,
but no individual measurements were made.
Twenty-five percent of cases were diagnosed
Numerical results from the logistic regression
by physicians outside the plant, so examination
model were not given in the paper, although
techniques may not have been the same as
employee category (blue collar versus white
collar), gender, and degree of elbow stress those for the other 75%. The nonstrenuous
were said not to be significant predictors of group was similar to the strenuous group with
having any one of the three types of regards to age, gender, and duration of
epicondylitis. The author classified epicondylitis employment, except for the small number of
into three types: leisure-related, no known male sausage makers and male
cause, and work-related groups based on meatpackersthese were excluded from
history. When the author specifically looked at calculation of individual IRs.
work-related epicondylitis (criteria for such
designation was not given) with respect to Punnett et al.s [1985] study of garment
elbow stress, he found a significant trend with workers is reviewed in the Repetition section.
increasing levels of elbow stress.
Ritz [1995] did not mention the participation
The exposure assessment approach was rate in their study of welders and pipefitters but
different for the 1989 study by Dimberg et al. fulfilled the other three criteria. Workers
In the 1987 study by Dimberg, the exposure studied were likely to be a representative
classification scheme was focused principally sample, however, since all male employees
on the elbow and identified jobs with heavy who were taking their
elbow-straining work. In the 1989 study, the
author focused on multiple health outcomes in
the upper extremity and used an exposure
classification scheme that was more broadly annual examinations during a three month
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period were enrolled in the study. The multiple examinations and may have influenced results.
logistic model analysis considered age and a The investigators stated the comparison group
variety of confounding factors. Among these was selected similar to the study group in
public gas and water work employees, the gender, age, and duration of employment.
welders and pipefitters who installed and
repaired pipes were considered to have high In conclusion, for the studies with less than our
exposure. four criteria, four are supportive [Kurppa et al.
1991; Ritz 1995; Dimberg 1987; and Roto and
Roto and Kivi [1984] based their exposure on Kivi 1984], two are non-supportive [Dimberg
job title alone, but fulfilled the other three et al. 1989; Bystrm et al. 1995], and one is
criteria. They compared meatcutters who had not very informative [Andersen and Gaardboe
forceful, repetitive work to construction 1993a]. The results from the positive studies
workers who had more varied tasks. The are unlikely to be due to confounding or
authors stratified the analysis by age and found selection bias. Overall, these studies provide
the majority of cases in the older age groups. limited support for the association of forceful
They also found that the meatcutters with repetitive work and epicondylitis.
epicondylitis had been exposed, on the
average, five years longer than the other Strength of AssociationForce and
meatcutters. All the meatcutters had more than Epicondylitis
15 years in their current occupation, which the Chiang et al. [1993] did not find an association
authors attributed to support of the work- between hand-intensive work (categorized
relatedness of the condition, although increasing based on forceful exertion and repetition) and
age may have been a confounder or effect epicondylitis when analyzing all workers at six
modifier. fish processing plants. However, in examining
the highest level of exposure (we calculated the
Viikari-Juntura et al. [1991b] studied subjects odd ratios for men and women separately,
at the same meat processing plant as Kurppa et which was not done in the article), we found a
al. [1991] using 3 cross-sectional examinations significant difference between males in the
covering a period of 31 months. The same highest exposed group (Group III) and males in
exposure assessment scheme used in the the lowest exposed group (Group I) (OR=
Kurppa et al. [1991] study mentioned above 6.75) and a non-significant OR of 1.44 for
was used comparing workers in strenuous and women. Exposure in Group III was based on a
nonstrenuous work. This study compared the combination of high-force exertion and high
prevalence of all cases of epicondylitis; cases repetition; analysis of working techniques by
due to injury or known non-occupational gender was not performed, so the reason for
causes were not excluded. The diagnosis of the difference in the groups by gender is not
epicondylitis included standard physical known. The Chiang et al. [1993] study
examination techniques of palpation and provides limited support for the association
resisted extension and flexion of the elbow; the
authors stated that palpation pressure increased between high levels of forceful repetitive elbow
on the second of the three cross-sectional work and epicondylitis.
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Luopajrvi et al. [1979] found a non-significant

Strength of AssociationStudies Not Meeting
difference overall in the prevalence of
the Four Criteria: Force and
epicondylitis and pronator teres syndrome (3 Elbow MSDs
versus 11 cases, OR 3.35 [95% confidence Baron et al. [1991] found an OR of 2.3 for the
interval (CI) 0.8619.1]); for lateral combination of factors, but this was not
epicondylitis only, an OR of 2.73 (95% CI statistically significant. The authors mention that
0.6615.94). There were five cases of medial ergonomic analysis of the non-checkers
epicondylitis in the assembly workers and none showed that they also performed work
in the shop assistants. The increase in medial requiring repetitive motions and awkward
epicondylitis (an indeterminate OR because of postures; therefore, the comparison probably
zero cases in the shop assistants) was resulted in a lower OR than had the referent
attributed to the difficult grasping movements group been truly unexposed to the ergonomic
involved in the assembly line work. They found stressors.
that their female assembly workers tended to
have physically light work, but this work Kurppa et al. [1991] found a strong significant
required highly repetitive movements of the relationship between strenuous jobs and
wrists and fingers and static muscle loading of epicondylitis (IR= 6.7), while Viikari-Juntura et
the forearm muscles. al. [1991b] did not (OR=0.88, nonsignificant).
These results may have been influenced by
Using the Strain Index, Moore and Garg allowing cases who had recurrence in the
[1994] found a significant relationship between same elbow to be counted as new cases (12
hazardous jobs (of which force was a major out of 57 employees with epicondylitis had
component) and upper extremity MSDs (of more than one episode, and were counted
which epicondylitis was an important twice). There was a median of 184 days
component). The results found a significant OR between the episodes. In examining this study,
of 5.5 for a case of epicondylitis to occur in a it is important to see if the odds of having
hazardous job. When approximating the epicondylitis would be elevated if these
classification scheme for low and high force workers with recurrences were only counted
used by Silverstein et al. [1987] and then by once. We recalculated the OR using only
Kurppa et al. [1991], Viikari-Juntura et al. persons and not single episodes of
[1991b], and Chiang et al. [1993], the epicondylitis in order to obtain a more
association between forcefulness and the conservative estimate. We counted, only once,
overall upper extremity morbidity in the study the employees with recurrence, as well as the
was again statistically significant (p<0.02). four employees mentioned with simultaneous
occurrence in both elbows and subtracted these
The overall conclusion from the three studies from the strenuous job cases. This gave a total
that met our four criteria is that there is of 44 cases of epicondylitis among the
evidence for association between force strenuous group.
and epicondylitis based on strength of

association. Using this estimate, more restrictive than that
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found in the article, gives an OR of 5.5 (2.4, The study conducted by Roto and Kivi [1984]
12.7) for epicondylitis among the workers with found an OR of 6.4 (95% CI 0.9940.9) using
strenuous jobs versus those with nonstrenuous an exposure assessment based on job title
jobs. The Kurppa et al. [1991] prospective alone (meatcutters were assumed to have more
study also found the IR of epicondylitis in forceful jobs than construction workers). Only
nonstrenuous jobs to be similar to Allender's one referent had epicondylitis.
[1974] population background prevalence rate
(1%) for epicondylitis. In the paper by Viikari-Juntura et al. [1991b],
the cases of epicondylitis not listed as insidious
Ritz [1995] found a significant OR for 10 years all involved forceful, repetitive tasks (although
of high exposure to elbow straining work: 1.7 some of these tasks were not related to work).
for currently held jobs and 2.2 for formerly held Prevalences of epicondylar pain and sick
jobs. The significant OR for moderate exposure leave due to epicondylar pain were
in the current job was 1.4 for 10 years of significantly different between the two groups
exposure. This study provides support for the (OR 1.9 and 2.1). There was no significant
association of forceful work with epicondylitis. difference in the prevalence of epicondylitis
(combined work and non-work related)
We calculated odd ratios from data in between workers in strenuous versus
Dimbergs [1987] study and found an OR for nonstrenuous jobs (OR=0.88). In 95 women
moderate stress versus none or light elbow sausage makers, there were four cases with
stress of 2.9, and for heavy versus none or light insidious onset, while among 160 women
stress of 7.4. Heavy stress in the elbows was referents there were two cases, one with
assigned to job titles like blaster, driller, or insidious onset, the other related to an
grinder. The major limitation of this analysis of exceptional task of cutting cheese. The
the work-related cases is that it did not resulting OR was 6.9 (95% CI 0.74171). This
consider age, a likely confounder. Overall, this study also found that rates of epicondylar
study provides support for the association pain and sick leave due to epicondylar pain
between forceful work and epicondylitis, differed significantly between the two groups
particularly in older workers. (OR 1.9 and 2.1, respectively). Rates of
medically diagnosed cases of epicondylitis were
The 1989 Dimberg et al. study was not not statistically different between the two
supportive of an association between lateral groups, but the results for epicondylar pain
epicondylitis and forceful repetitive work, but (causing sick leave in the two groups), and the
was positive for mental stress at work at the fact that the majority of cases in both groups
onset of symptoms for lateral epicondylitis were due to events involving strenuous,
(p<0.001). As a result of the specific elbow repetitive tasks, give some support to forceful,
exposure assessment, we believe that with repetitive work as
regards to stressful or a cause.
forceful elbow exertions that the 1987 study is Bystrm et al. [1995] noted that the low
more informative. frequency could not be attributed to selected
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subjects being absent, as all persons on leave Viikari-Juntura et al.s [1991b] study did not
participated in the investigation. The authors exclude workers with elbow symptoms or
also stated that exposure to repetitiveness and physical findings that were due to acute injury
force in automobile assembly line work may be not related to the job, which may account for
less than in other investigated work situations. the contrasting result. In fact, in that study, four
Because the authors did not give quantitative or workers with acute non-work-related
qualitative information on the forcefulness or epicondylitis in the nonstrenuous group were
repetitiveness of jobs included in the study noted in the journal article. Another
group, it is difficult to know whether these jobs consideration for inconsistency is due to
were appropriate to use to study epicondylitis. grouping of studies, which may all fulfill good
epidemiologic criteria, may all examine the
Temporal Relationship: Force and same risk factor, but may compare groups that
Epicondylitis do not have similar contrasting levels of
See temporal relationship above in Repetition exposure. For example, the Chiang et al.
and Epicondylitis. [1993] study found statistically significant
results in men when comparing high force/high
Consistency of Association repetition jobs to low force/low repetition jobs.
The studies that met the four criteria were fairly Baron et al. [1991], on the other hand,
consistent in their strength of association compared checkers in low force, medium
between force and epicondylitis, with most repetition jobs to noncheckers in low force, low
ORs between 2.5 and 7.0. Focusing on those repetition jobs.
studies that compared workers exposed to
force that was documented to be at a high level, Two factors explain the difficulty in determining
to those exposed to a low level, all studies the reasons for the apparent inconsistencies
[Chiang et al. 1993; Kurppa et al. 1991; among the studies on forceful and repetitive
Moore and Garg 1994] were consistent. work. First, very few of the exposure
assessments were quantitativethis is due to
Of those 10 studies that examined force but did existing limitations in directly measuring
not fulfill the four criteria, two studies had a exposure in detail in most field studies. As a
significant OR greater than 3.0, three studies result, there is likely to be frequent non-
had significant ORs between 1.0 and 3.0, one differential misclassification of exposure.
had a nonsignificant OR between 1.0 and 3.0, Second, most of the studies completed have
and two had an OR less than 1.0. Two had been cross-sectional, and therefore subject to
statistically significant findings but did not report survivor bias.
ORs. Most of these studies examined workers
in repetitive, forceful job tasks and did not As an example, Chiang et al. [1993] found that
separate out epicondylitis was significantly associated with
increasing repetitiveness and
the independent effect of repetition through any
analytic method. forcefulness among fish processors employed
less than 12 months. For those working for 12
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to 60 months, a similar trend was found, but a workers in the automobile industry. In both of
reverse trend was found in those workers these studies, those cases of epicondylitis listed
employed for over 60 months. The authors in the comparison groups were due to highly
stated that because most of the workers were repetitive, forceful activities. The lack of a
semi-skilled, they were likely to leave their job significant difference in the prevalence of the
if they felt frequent muscle pain because of it. disorder between the two groups may be
They went further to say that the selection because the referent, low exposure groups
mechanism may explain the lack of significant had a higher incidence of non-work-related
associations between the disorders and the lateral epicondylitis.
duration of employment. There was no
indication that the authors pursued this Coherence of Evidence
hypothesis by trying to identify former workers The epidemiologic results of finding the majority
who may have left. Turnover rate was not of cases occurring in highly repetitive, forceful
discussed. This example highlights two work [Moore and Garg 1994; Chiang et al.
important factors concerning the cross- 1993; Kurppa et al. 1991; Kopf et al.1988]
sectional studies examining work-related are consistent with the evidence from
epicondylitis: there is some evidence that older biomechanical and physiologic findings, as well
workers may be at higher risk of epicondylitis as from sports medicine literature and older
[Dimberg 1987; Ritz 1995], and there is also a medical clinical case series. In cases of lateral
survivor effect, which results in the loss to the epicondylitis occurring in workplaces as well as
study of affected workers. These two factors in sports, the forearm extensors are repetitively
make the interpretation of duration of disease contracted and produce a force that is
relationships complex and may affect the transmitted via the muscles to their origin on the
estimate of the risk of disease. lateral epicondyle. These repetitive contractions
There were studies that used more accurate produce chronic overload of the bone-tendon
exposure assessment or had comparison junction, which in turn leads to changes at this
groups with marked differences in levels of junction. The most common hypothesis is that
exposure to forceful and repetitive work that microruptures occur at the attachment of the
were positive, such as the Kurppa et al. [1991] muscle to bone (usually at the origin of the
study of meatcutters, sausage makers, and extensor carpi radialis brevis muscle), which
packers, Moore and Garg's [1994] study of causes inflammation. Peina et al. [1991] did
pork processors; Dimberg's [1987] study of not agree with the microrupture theory; they
blasters, drillers, grinders, and others in an theorized that overuse leads to avascularization
engineering industry; Ritzs [1995] study of of the affected muscle origin, which leads to
pipefitters and welders in a public utility; and overstimulation of the free nerve endings and
Roto and Kivis [1984] study of meatcutters. results in aseptic inflammation. Further
There were studies with these characteristics repetition of the offending movements causes
that were negative, such as the Viikari-Juntura angiofibroblastic hyperplasia of the origin.
et al. [1991b] study of meatcutters, sausage Nirschl [1975] stated that the degree of
makers, and packers; and the study by angiofibroblastic hyperplasia is correlated to the
Dimberg et al. [1989] of blue- and white-collar duration and severity of symptoms. On
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histologic analysis of severe cases of forearm extensor muscle contraction and

epicondylitis, one can see the characteristic repetitive supination/ pronation of the forearm.
invasion of fibroblasts and vascular tissue, the In the second group of 26, the 23 (88%) who
typical picture of angiofibroblastic hyperplasia. had spontaneous onset worked in jobs with
constant gripping or repetitive movements.
Prior to many of the epidemiologic studies,
there were numerous reports in the medical Many case studies of professional athletes have
literature of clinical case series that suggest a documented that forceful, repeated dorsiflexion,
relationship between epicondylitis and pronation, and supination movements with the
repetitive, forceful work. For example, as early elbow extended can cause epicondylitis.
as 1936 Cyriax reported that with regard to [Ollivierre et al. 1995; Priest et al. 1977; King
patients with lateral epicondylitis, those et al. 1969]. Most cases have occurred in
patients who remember no special overexertion baseball pitchers and tennis players.
will be found to be working at screwing, lifting, Occupations involving movements described
hammering, ironing, etc., or to be violinists, above have also been found to have increases
surgeons, masseurs, etc. Cyriax had in rates of elbow MSDs. This literature has also
designated a Chronic Occupational variety of referred to increased occurrence in occupations
tennis elbow, in which he stated that often no requiring force, awkward postures, and
history of an injury is obtainable, but the repetitive use of the elbow and forearm
patient's occupation at once provides the clue. [Lapidus and Guidotti 1970; Mintz and Fraga
He cited work which entails repeated 1973; Berkeley 1985]. These reports, though
pronation and supination movements with mainly case series, have lead to further studies
elbow almost fully extended to be responsible that examined the links between exposure and
for epicondylitis [Cyriax 1936]. Feldman et al. epicondylitis.
[1987] reported that occupations with work
tasks requiring repeated pronation and An example of an early occupational study is
internal/external rotation of the forearm are at one by Mintz and Fraga [1973], who found
high risk of pronator teres syndrome that foundry workers (with an average of 14
(compression of the median nerve as it courses years of employment) who used tongs requiring
through the pronator teres muscle in the twisting and bending of the elbows/forearms for
forearm). A number of case series have eight hours per day had decreased elbow
reported similar findings [Hartz et al. 1981; flexion and extension and
Morris and Peters 1976]. pain on physical examination, as well as severe
radiographically documented osteoarthritis
Sinclair [1965] reported 2 case series of localized to the elbows. In the studies that are
patients with tennis elbow (lateral epicondylitis), reviewed in Tables 4-1
44 patients treated between 1959-1961 and 38
patients treated between 1961-1963. In the through 4-4, the occupations with the highest
first group of 267, the 130 (48%) whose onset rates of epicondylitis, such as drillers, packers,
occurred spontaneously had occupations that meatcutters, and pipefitters, are consistent with
included gripping tools with consequent the force-repetition model of the causation of
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epicondylitis. The development of epicondylitis Relationship for Force

in these workers is consistent with proposed The Baron et al. [1991] study is mentioned
biological mechanisms and is plausible. above in the Repetition Section as showing a
dose-response relationship for number of hours
The lack of elbow MSDs and work factors in of work per week. Chiang et al. [1993] found
some of the studies with occupations like that among men the prevalence of epicondylitis
sewing workers [McCormack et al. 1990] or increased with increasing force and repetition in
automobile assembly line workers [Bystrm et fish processors. In several studies, only
al. 1995], most likely reflects the interplay of dichotomous divisions were made, so
two factors. The movement of affected workers conclusions concerning an exposure-response
out of high exposure jobs limits the ability of relationship cannot be drawn. However, we
cross-sectional studies to accurately determine can see significantly contrasting rates of elbow
associations between work factors and MSDs between high- and low-exposure
epicondylitis. Our ability to accurately identify groups. Moore and Garg [1994] found a higher
working conditions with an elevated risk for risk in workers with high-strain jobs compared
epicondylitis may require an exposure to those with low-strain jobs. Kurppa et al.
assessment of each job to a degree that has [1991] found higher risk in workers with
been beyond the limits of current strenuous jobs compared to those with
epidemiological methods. As a result, nonstrenuous jobs, and that female sausage
misclassification of exposure may be common. makers had an increase in epicondylar
Overall, the majority of the epidemiologic tenderness with increasing duration of
studies are supportive of the hypothesis of an employment. While Dimberg [1987] found no
increase risk of epicondylitis for occupations difference in epicondylitis between blue- and
that involve forceful and repetitive work, white-collar workers, he found that workers
frequent extension, flexion, supination, and with elbow pain severe enough to require a
pronation of the hand and the forearm. The physician consult were significantly more often
surveillance data are also supportive of this in those jobs identified independently as having
hypothesis [Roto and Kivi 1984; Washington high elbow stress. Dimberg also found a
State Department of Labor and Industry 1996]. statistically significant correlation coefficient for
The highest relative risks for epicondylitis in lateral epicondylitis and time spent in the
Finland were with mechanics, butchers, food present job. Luopajrvi et al. [1979] found a
industry workers, higher rate of epicondylitis and pronator teres
and packers; the highest industries in syndromes in a
Washington State for 1987-1995 [Silverstein et high-exposure group of assembly line packers
al. In Press] were construction workers, meat compared to the referent group of shop
dealers, and foundry workersall occupations assistants. Overall, these studies provide
with repetitive, forceful work involving the arms considerable evidence for a
and hands and requiring pronation and
supination. difference in level of risk for epicondylitis when
there are marked differences in the level of
Evidence of a Dose-Response exposure to forceful and repetitive tasks.
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Ritz [1995] reported a positive dose-response Strength of AssociationPosture

relationship between duration of exposure to and Epicondylitis
gas and waterworks jobs regarded as Studies Meeting the Four Evaluation
moderately and highly stressful to the elbow Criteria
and epicondylitis. Roto and Kivi [1984] The Moore and Garg [1994] study (also
reported that all workers with epicondylitis in discussed above) recorded wrist posture using
their meat-packing facility worked for more a classification similar to Armstrong et al.
than 15 years in the strenuous job category and [1982] and Stetson et al. [1991]. Pinch grasp
had been exposed an average of 5 years longer was also noted to be present or absent. In this
than non-diseased workers. Kopf et al. [1988] study, posture was not found to be significantly
reported that in their study of brick layers, with associated with hazardous jobs. This may be
increasing levels of job demands (defined as due to the heavier weighting given the force
either heavy physical work, awkward working rating system than the posture or repetition
postures, repetitive movements, or restriction in scale. For example, if a job required extreme
standing position), the OR increased from 1.8 posture, the authors increased the force rating
to 3.4. These studies, with less clear contrasts instead of the posture rating. If a combination of
in exposure, provide support for the exposure- extreme posture and high-speed movement was
response relationship between epicondylitis and required, then the force rating was raised by
forceful, repetitive work. two levels, but not the posture rating. Data that
would allow analysis of the incidence of
POSTURE epicondylitis and the exposure to extreme
Definition of Postures for posture were not presented.
Elbow MSDs
Luopajrvi et al.s [1979] assessment was
We chose to include those studies that
focused on the extreme work position of the
addressed posture or examined workers in
hands but not the elbow; it included extension,
those activities or occupations that require
flexion and deviation of the wrists. Although
repeated pronation and supination, flexion/
there was a non-significant association between
extension of the wrist, either singly or in
assembly line work and the presence of either
combination with extension and flexion of the
epicondylitis or pronator teres syndrome in
elbow.
shop assistants (11 cases versus 3), there were
5 cases of medial epicondylitis and 2 cases of
pronator teres syndrome in the assembly
of Posture and Epicondylitis
workers and none in the shop assistants. The
The six studies in Table 4-3 addressed posture greater prevalence of medial epicondylitis in
variables. Of these, only the studies by Moore
and Garg [1994] and Luopajrvi et al. [1979] assembly workers was attributed to the difficult
fulfilled all four criteria. The details of these grasping movements involved in the assembly
studies are discussed in the Repetition and line work. The authors stated that the overall
Force sections. prevalence may have been connected with the
constant overstrain of flexors in work.
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Studies Not Meeting the Four wrist deviation, thus producing more symptoms.
Evaluation Criteria
These conclusions should be considered to be
The Dimberg [1987] study stated that over- hypothesis generating and not definitive.
exertion of the extensor muscles of the wrist
due to gripping and twisting movements prior to Temporal Relationship
the onset of symptoms was verified in 28 of the There are no prospective studies that address
40 (70%) of the cases, of which 14 were posture and epicondylitis. The one prospective
considered to be caused by work. In the study study concerning epicondylitis did not address
by Dimberg et al. [1989], the guidelines for posture.
classification include repeated rotation of the
forearms and wrists in Group 1, large and Consistency in Association
frequent rotations in extreme positions in Group
There are too few occupational epidemiologic
2, but fail to include work involving frequent
studies that address posture and epicondylitis to
rotations in the highest exposed group, Group
meaningfully discuss consistency of association.
3. The difference in exposure classification
scheme may explain why there was no
Coherence of Evidence
relationship between prevalence of epicondylitis
and increasing work strain. Please refer to the Repetition Section and
Coherence of Evidence for a discussion of the
Hughes and Silverstein [1997] found a strong, sports literature, and the combination of factors,
statistically significant association (OR 37) including extreme postures that have been
between elbow/forearm disorders and the documented concerning epicondylitis.
number of years of forearm twisting in their
study of aluminum workers. However, this Exposure-Response Relationship
study had an overall low participation rate There is little evidence on which to base a
(55%), which limits the interpretation of its discussion exposure response relationship in the
result. epidemiologic studies. Once again, the reader is
referred to the biomechanical sports literature.
The other study that may be interpreted as
related to a posture variable is the one by EPICONDYLITIS AND THE ROLE OF
Hoekstra et al. [1994]. This study evaluated CONFOUNDERS
video display terminal users at two work sites The model for epicondylitis clearly implies that
differing only in whether adjustable office both occupational and non-occupational
equipment was present. By self-reported activities can cause the disorder. Several
symptoms and exposure studies [Ritz 1995; Andersen and
Gaardboe 1993a; Dimberg 1987] directly
observations, the Hoekstra et al. [1994] study address the issue of work-related versus non-
found that having a non-optimally adjusted work-related exposures by assessing both.
chair was associated with elbow MSDs. This Two of the most important potential
improper chair adjustment was thought to confounders or effect modifiers are age and
increase shoulder and elbow flexion, as well as duration of employment. In Dimberg's [1987]
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and Ritzs [1995] studies, older workers had recognize this limitation of the epidemiologic
high rates of epicondylitis. Nevertheless, in both studies, there is value in assessing where we are
studies the increase in the risk for epicondylitis in regards to the epidemiologic evidence of
in the high-exposure group does not seem causal inference.
related primarily to age, independent of
intensity and duration of exposure. There is epidemiologic evidence for the
Furthermore, the incidence of elbow MSDs relationship between forceful work and
unlike most MSDs, has been found to decrease epicondylitis. Those studies that base their
after exposure assessment on quantitative or
retirement age, after peaking during the fourth semiquantitative data have shown a solid
and fifth decades. relationship. We conclude that there is
insufficient evidence for the association of
Many of the studies controlled for several repetitive work and epicondylitis. For extreme
possible confounders in their analyses. In posture in the workplace, the epidemiologic
general, for epicondylitis, psychosocial factors evidence thus far is also insufficient, and we
or gender do not appear to be important turn to the sports medicine literature to assist us
confounders in occupational studies. in evaluating the risk of the single factors of
repetition and posture. The strongest evidence
CONCLUSIONS by far when examining the relationship between
The epidemiologic studies reviewed in this work factors and epicondylitis is the
section focused principally on the risk of combination of factors, especially at higher
epicondylitis in workers performing repetitive levels of exposure. This is consistent with the
job tasks requiring forceful movements. These evidence that is found in the biomechanical and
forceful movements included, but were not sports literature.
limited to, repeated dorsiflexion, flexion,
pronation, and supination, sometimes with the Most of the relevant occupational studies were
arm extended. Clinical case series of cross-sectional; the current estimates of the
occupationally-related epicondylitis and studies level of exposure were used to estimate past
of epicondylitis among athletes had suggested and current exposure. Despite the cross-
that repeated forceful dorsiflexion, flexion, sectional nature of the studies, it is likely, in our
pronation, and supination, especially with the opinion, that the exposures predated the onset
arm extended, increased the risk of of disorders in most cases.
epicondylitis. In general, the epidemiologic
studies have When we examine all of the studies, a majority
of studies are positive. The association between
not quantitatively measured the fraction of forceful and repetitive work involving
forceful hand motions most likely to contribute dorsiflexion, flexion, supination, and pronation
to epicondylitis; rather, they have used as a of the hand is definitely biologically plausible.
surrogate qualitative estimation the presence or These motions can cause the contraction of the
absence of these types of hand movements muscle-tendon units that attach in the area of
[Viikari-Juntura et al. 1991b]. Although we the medial and lateral epicondyles of the elbow.
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The evidence for a qualitative exposure- that cause contractions of the muscles whose
response relationship overall was considerable tendons insert in the area of the lateral and
for the combination of exposures, with studies medial epicondyles of the elbow. While the
examining differences in levels of exposure for studies do not identify the number or intensity of
the elbow, and corresponding evidence for forceful contractions needed to increase the
greater risk in the highly exposed group. In risk of epicondylitis, the levels are likely to be
contrast, we found one study with clear substantial. Future studies should focus on the
differences in exposure and no evidence of an types of forceful and repetitive hand motions
increase in risk [Viikari-Juntura et al. 1991b]. such as forceful dorsiflexion, pronation, and
supination that result in forceful contractions of
In summary, the combination of the biological the muscle tendon units that insert in the area of
plausibility, the studies with more quantitative the lateral and medial epicondyles. Common
evaluation of exposure factors finding strong non-occupational activities, such as sport
associations, and the considerable evidence for activities, which cause epicondylitis should be
the occurrence with combinations of factors at considered. Older workers may be at some
higher levels of exposure provide evidence for increased risk. Finally, even though the
the association between repetitive, forceful epidemiologic literature shows that many
work and epicondylitis. There are several affected workers continue to work with definite
important qualifications to this conclusion. symptoms and physical findings of epicondylitis,
Forceful and repetitive work is most likely a survivor bias should be addressed.
surrogate for repetitive, forceful hand motions
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Table 4-1. Epidemiologic criteria used to examine studies of elbow MSDs associated with repetition
Risk Investigator
indicator (OR, Participation Physical blinded to case Basis for assessing elbow
Study (first author and PRR, IR or p- rate $$70% examination and/or exposure exposure to repetition
year) value)*, status
Burt 1990 2.8 Yes No Yes Job titles or self-reports
Bystrm 1995 0.74 Yes Yes No Job titles or self-reports
McCormack 1990 0.51.2 Yes Yes NR Job titles or self-reports
Ohlsson 1989 1.52.8 NR No NR Job titles or self-reports
Punnett 1985 2.4 No No NR Job titles or self-reports
Not reported.
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Table 4-2. Epidemiologic criteria used to examine studies of elbow MSDs associated with force
Risk indicator Investigator

(OR, PRR, IR or Participation Physical blinded to case Basis for assessing
Study (first author and p-value)*, rate $$70% examination and/or exposure elbow exposure to force
year) status
Chiang 1993 6.75 (males) Yes Yes Yes Observation or

1.44 (females) measurements
Luopajrvi 1979 2.7 Yes Yes Yes Observation or

measurements
Moore 1994 5.5 Yes Yes Yes Observation or

measurements
Baron 1991 2.3 No Yes Yes Observation or

measurements
Dimberg 1987 NR, Yes Yes NR Observation or

measurements
Dimberg 1989 NR Yes Yes NR Observation or

measurements
Kurppa 1991 6.7 Yes Yes NR Observation or

measurements
Punnett 1985 2.4 Yes No NR Job titles or self-reports
Ritz 1995 1.41.7 NR Yes Yes Observation or

measurements
Roto 1984 6.4 Yes Yes Yes Job titles or self-reports
Viikari-Juntura 1991b 0.88 Yes Yes NR Observation or

measurements
*Some risk indicators are based on a combination of risk factorsnot on force alone (i.e., force plus repetition, posture, or
vibration). Odds ratio (OR), prevalence rate ratio (PRR), or incidence ratio (IR).
Not reported.
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Table 4-3. Epidemiologic criteria used to examine studies of elbow MSDs associated with posture
Physical Investigator
Risk examination blinded to
indicator Participation or medical case and/or Basis for assessing
Study (first author and (OR, PRR, IR rate $$70% records exposure elbow exposure to
year) or p- status posture
value)*,

measurements
Moore 1994 NR Yes Yes Yes Observation or

measurements

measurements

measurements
Hoekstra 1994 4.0 Yes No Yes Job titles or self-reports
Hughes 1997 37.0 No Yes NR Observation or

measurements
*Some risk indicators are based on a combination of risk indicatorsnot on posture alone (e.g., posture plus repetition, force,
Not reported.
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Table 4-4. Epidemiologic criteria used to examine studies of elbow MSDs associated with vibration
Risk Physical Investigator

indicator examination blinded to case
(OR, PRR, IR Participatio or medical and/or Basis of assessing elbow
Study (first author and or n rate $$70% records exposure exposure to vibration
year) p-value)*, status
Bovenzi 1991 4.9 NR Yes Yes Observation or

measurements
*Some risk indicators are based on a combination of risk indicatorsnot on vibration alone (e.g., vibration plus repetition,
force, or posture). Odds ratio (OR), prevalence rate ratio (PRR), or incidence ratio (IR).
Not reported.
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Table 45. Epidemiologic studies evaluating elbow musculoskeletal disorders
MSD prevalence
Andersen Cross- 424 female sewing Outcome: Questionnaire: 4.5% 2.6% 1.7 0.9-3.3 Participation rate: 78.2%.
and Gaardbo sectional machine operators, continuous pain lasting > 1
e compared to month since starting career; Examiners blinded to
1993a 781 females from the pain for > 30 days. control/subject status.
general population of
the region and an Exposure: Job categorization Adjusted for age, number of
internal referent based on authors children, exercising, smoking,
group of 89 females experiences as occupational socioeconomic status.
from the garment health physicians and
industry. involved crude assessment
of exposure level and
exposure repetitiveness.
Jobs involving high
repetitiveness (several
times/min) and low or high
force, and jobs with medium
repetitiveness (many
times/hr) combined with high
force were classified as high
exposed jobs; jobs with
medium repetitiveness and
low force and jobs with more
variation and high force were
classified as medium
exposed. Job titles such as
teachers, self-employed,
trained nurses, and the
academic professions were
low exposed. Exposure
also measured as years as
sewing machine operator.
(Continued)
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Table 45 (Continued). Epidemiologic studies evaluating elbow musculoskeletal disorders
MSD prevalence
Baron et al. Cross- Grocery checkers using Outcome: Self-administered 8% among 2.3 0.5-11 Participation rate: 85%
1991 sectional; laser scanners (n=124, questionnaire and physical checkers checkers; 55% non-checkers in
case- 119 females, 5 males) exam. Case defined as the field study. Following telephone
referent compared to other presence of pain, numbness, survey 91% checkers and 85%
grocery store workers tingling, aching, stiffness or non-checkers.
(n=157, 56 females, 101 burning in the elbow region
males); excluded 18 as previous non-occupational Examiners blinded to workers
workers in meat, fish, injury; symptoms must have job and health status.
and deli departments, begun after employment at
workers under 18, and the supermarket of Age, hobbies, second jobs,
pregnant workers. employment and in the systemic disease and height
current job, and last >1 week were considered as covariates
or occurred once a month in the multivariate analyses.
within the past year.
Total repetitions/hr ranged from
Physical Exam: Tenderness 1,432 to 1,782 for right hand
at the lateral/medial and 882 to 1,260 for left hand.
epicondyle and pain with
palpation and resisted motion. Average forces were low and
peak forces medium.
Exposure: Based on job
category, estimates of No statistical significance
repetitiveness, average and associated between duration of
peak forces based on employment as a checker and
observed and videotaped elbow MSDs.
postures, weight of scanned
items, and subjective Multiple awkward postures of
assessment of exertion. all upper extremities recorded
but not analyzed in models.
The majority of cashiers
were categorized as having Statistically significant increase
medium levels of repetition in elbow MSD with increase in
for the hand (defined in this hr/week checking.
study as making 1250 to
2500 hand movements/hr).
(Continued)
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MSD prevalence
Bovenzi et al. Cross- Vibration-exposed Outcome: Epicondylitis 29.3 6.4% For vibration Participation rate: Not reported.
1991 sectional forestry operators using syndrome: Pain at the exposed
chain-saws (n=65) and epicondyle either during rest group Analysis controlled for age and
maintenance workers or motion, local tenderness at >7.5 m/s 2: ponderal index.
(n=31, control group). the lateral or medial OR=4.9 1.27-56
epicondyle; pain during (adjusted) Controls found to have several
resisted flexion/extension of risk factors for MSDs at work-
the fingers and wrist with the OR=5.99 static arm and hand overload,
elbow flexed, palpated local (unadjusted) overhead work, stressful
tenderness at the postures, non-vibrating hand
lateral/medial epicondyle. tool use.
Exposure: Direct observation Controls actually had a greater

of awkward postures, proportion of the time in work
manual forces and cycles shorter than 30 sec than
repetitiveness evaluated via forestry workers.
checklist. Vibration
measured from two chain
saws.
(Continued)
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MSD prevalence
Burt et al. Cross- Newspaper employees Outcome: Self administered Male: 11% 80% to 100% Participation rate: 81%.
1990 sectional (n=836, females=55%). questionnaire. Case defined Female: 14% time typing
Workers fulfilling case as the presence of pain, compared to Analysis controlled for age,
definitions compared to numbness, tingling, aching, 0% to 19%: gender, years on the job.
those who did not fulfill stiffness, or burning in the OR=2.8
case definition. elbow region as previous 1.4-5.7 Psychosocial factors dealing
non-occupational injury. Reporters with job control and job
Symptoms began after compared to satisfaction were addressed in
starting the job, last > 1 week others: questionnaire.
or occurred once a month OR=2.5
within the past year; reported 1.5-4.0 Job analysis found significant
as moderate (3) or greater correlation (0.56) between
on a 5-point scale. reported average typing
time/day and observed 8 hr
Exposure: Based on period of typing (p < 0.0001).
observation of job tasks, then
categorized by job title. A Reporters were characterized
separate job analysis using a by high, periodic demands
checklist and observational (deadlines), although they had
techniques was carried out high control and high job
for validating questionnaire satisfaction.
exposure data.
Number of workers in some
non- typing jobs not reported.
Case definition based on

symptoms alone.
(Continued)
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MSD prevalence
Bystrm Cross- Automobile assembly Outcome: Epicondylitis was Tender Tender PRR for Participation rate: 96%.
et al. 1995 sectional line workers (n=199) defined as tenderness to lateral lateral tender lateral Comparison group is from the
compared to a randomly palpation of the lateral or epicondyle: epicondyle: epicondyle: MUSIC study (Hagberg and
selected group from the medial epicondyle and pain at 4.3% 12.4% 0.74 0.04-1.7 Hogstedt, 1991).
general population the same epicondyle or in the
(n=186). The forearm extensors or flexors Epicondy- Epicondy- Examiners were blinded to
automobile assembly on resisted wrist extension litis: 0 cases litis: 1% questionnaire responses but
line workers were or flexion. not exposure status.
randomly selected from
a primary group of Exposure: No evaluation of Analysis stratified by gender
700 assembly line repetition, force, posture, or and age <40 years.
workers. These vibration occurred in this Psychosocial variables and
original 700 workers study to evaluate risk factors other potential confounders or
had been randomly for epicondylitis. Assembly effect modifiers were
selected from the line worker vs. Population addressed by Fransson-Hall
2,334 assembly referent was used. Hand et al. [1995].
workers of a Swedish grip strength was evaluated.
automobile factory. Forearm muscular load and Pain-pressure threshold (PTT)
wrist angle were evaluated was evaluated. PTT was not
for a subgroup in this related to age. It was higher
population but were not used among women with short
in this analysis [Hgg et al employment compared to those
1996]. who had been employed for a
long time.
No correlation was found

between low MCV and
subjective or objective signs.
(Continued)
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MSD prevalence
Chiang et al. Cross- 207 fish processing Outcome: Prevalence of Group II: Group I: Crude ORs Participation rate: Authors
1993 sectional workers, 67 males and lateral or medial epicondylitis 15% 10% calculated reported: In order to prvent
140 females, divided (local tenderness, pain in Male: 10%; Male: 6%; from data selective bias all employees in
in 3 groups: (I) low resisted extension or flexion Female: 17% Female: 14% presented: the fatories were observed
force, low repetition of the wrist and fingers, Group II vs. initially.
(comparison group, decreased hand grip strength Group III: Group I,
n=61); (II) high force compared to the opposite 21% males: Workers examined in random
or high repetition hand). Male: 33%; OR=1.7 0.3-9.2 sequence to prevent observer
(n=118); (III) high Female: 18% bias, examiners blinded to case
force and high Exposure: Assessed by Group II vs. status.
repetition (n=28). observation and recording Physician Group I,
of tasks and biomechanical observed females: Analysis stratified by gender.
movements of three workers, epicondy- OR=1.2 0.4-3.4 No significant age difference in
each representing one of litis, all exposure groups.
3 study groups. Highly cases: Group III vs.
repetitive jobs with cycle time 14.5 % Group I, Logistic regression not
<30 sec or >50% of males: performed for epicondylitis
cycle-time performing the OR=6.75 1.6-32.7 because of lack of significant
same fundamental cycles. trend with increasing exposure.
Hand force from EMG Group III vs.
recordings of forearm Group I, Workers with hypertension,
flexor muscles. females: diabetes, history of traumatic
Classification of workers into OR=1.44 0.3-5.6 injuries to upper limbs, arthritis,
3 groups according to or collagen diseases excluded
the ergonomic risks of the from study group.
shoulders and upper limbs:
Group I: low rep. and low Physician observed cases had
force; Group II: high repetition about the prevalence of
or high force; Group III: high symptoms of elbow pain (9.8
repetition and high force. vs. 18.0; 5.3 vs. 19.5; 35.7 vs.
17.9).
No dose-response for elbow

pain or physician observed
epicondylitis.
(Continued)
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MSD prevalence
Dimberg 1987 Cross- A questionnaire was Outcome: Only workers Lateral Epicondylitis, Participation rate: 98.9%.
sectional distributed to every fifth reporting elbow problems humeral blue vs. Physician blinded to exposure
person in the automobile were examined by the epicondylitis white collar status: not reported.
companys personnel physician. Physical exam: among all workers:
0.7 0.3-1.2 Results age stratified.
file selected by random case defined as physical subjects: Physician-consulted elbow pain
numbers. Final sample findings of lateral elbow pain 7.4% Distribution of
epicondylitis significantly greater in jobs with
consisted of and pain with palpation over increased elbow stress.
cases by
546 workers, 494 males lateral epicondyle and pain Blue collar type of work Work considered to be the
and 52 females. increase with dorsiflexion of workers: stress: cause in 35%. Authors found
(25 were excluded due wrist with resistance. 5.3% that work-related group had
Leisure work defined by high stress
to military service, related (categorized by low, moderate,
pregnancy, or study Exposure: Observation of White collar epicondylitis: and high) compared to leisure-
away). the work site then workers: related epicondylitis and
low work epicondylitis of no-known-
categorization of jobs with 11% stress: 85%; cause.
respect to elbow stress by medium work Authors reported that
a Physical Work Stress Blue collar: stress: 15%; proportion of workers who
Group composed of a under age 40 high work consulted a physician for their
stress: 0% elbow problems was
physician, physiotherapist, years: 4.6% significantly greater with
and safety engineer. Table 2 No-known- increasing elbow stress (p <
in the article lists types of Blue collar: cause group: 0.05).
epicondylitis: Multiple regression analyses
jobs with respect to over age 40 low work
subjectss elbow stress. years: 8.9% stress: 75%; included gender, employee
category, age, and degree of
medium work stress as independent
White collar: stress: 25%; variablesonly age significantly
under age 40 high work related to prevalence.
years: 6.1% stress: 0% Overexertion of the extensor
Work-related muscles of the wrist due to
epicondylitis: gripping and twisting
White collar: movements prior to onset was
over age 40 low work verified in 28 (70%) of those
years: stress: 14%; with epicondylitis.
medium work
13.9% stress: 36%; Tennis players among
sufferers: 15% total
high work population: 12%. All racquet
stress: 50% sports: 20% among sufferers,
15% among total population.
(Continued)
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MSD prevalence
Dimberg et al. Cross- 2,814 automotive Outcome: Questionnaire Blue collar White collar Univariate Participation rate: 96%.
1989 sectional workers, both blue- results of elbow trouble Results: Not stated whether examiner
and white-collar (pain, ache, discomfort) p<0.001: blinded to exposure status.
workers: 2,423 males, preventing normal work in higher age;
longer time in Multivariate analysis performed,
382 females. last 12 months. although the confounders
present job;
ponderal controlled for were not stated
Physical exam performed on by authors, nor were ORs
index, more
615 of 641 symptomatic symptoms; presented. Vibrating tools,
workers. Epicondylitis: more mental ponderal index, and mental
tenderness at the stress at the stress at work listed as
lateral/medial epicondyle onset of significant.
and pain with resistance. symptoms. Guidelines for classification of
p<0.05: jobs as listed in the article do
Exposure: Observation of salaried staff not seem to reflect increasing
vs. others; elbow stress. Group 1 includes
jobs, then classification into 3 repeated rotation of the
Physical Work Stress Groups heavy forearms and wrists occurs
by physician, weight; less
racquet sporadically; Group 2 includes
physiotherapist, and safety sports, more less specifically large and
engineer. Guidelines for symptoms. frequent rotations in extreme
classification with respect to positions; Group 3 does not
the strain on the subjects p<0.01: include any reference to
vibrating repeated rotation or extreme
neck and upper extremities hand tools, position of the forearms or
listed for light, moderately more wrists. The classification used
heavy, and heavy work symptoms; seems unlikely to pick up
included in article. time in increased elbow stress that
present job, would reflect higher strain and
more risk of epicondylitis.
symptoms. Increased ponderal index
p>0.05: correlated with elbow
gender; strain symptoms in multivariate
group; full analysis.
time; Mental stress at work with the
hrs/week;
piece-work; onset of symptoms correlated
fixed pay; with right-sided lateral
smoking, epicondylitis.
house- Mental stress variables not
owner. uniformly collected, so this may
impact interpretation.
(Continued)
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MSD prevalence
Fishbein et al. Cross- 2212 musicians Outcome: Outcome based on 10% right Severe Participation rate: 55%. Low
1988 sectional performing on a regular self-reported responses from elbow: 6 % medical response rate due to the fact
(mailed basis with one or more survey. Self-reported elbow severe problem and that many orchestras were not
survey) of the International pain, with severity defined its affect on in season at the time of the
Conference of in terms of the effect of 8% left performance, survey.
Symphony and Opera the problem on the musicians elbow: 4% females vs.
Musicians (ICSOM). performance. severe males: Statistical weighting performed;
Total population of the OR=2.04 1.6-2.6 "severe" pain was defined as
membership was 4,025 Exposure: Questionnaire pain that affects performance.
musicians in 48 ICSOM responses to orchestral
orchestras. One instrument, age they began Health habits, such as extent of
orchestra did not playing, age they joined the exercise, use of cigarettes,
participate. orchestra, number of weeks alcohol, beta blockers, and
each year spent playing other drugs.
professionally.
Average age beginning playing
instrument is 10 years.
Average age joining a
professional orchestra is 23
years. Average age: male
musicians43 years, female
musicians40 years.
Severe problems were more

likely in ages under 35 than
over 45 years. Authors
speculated that musicians with
severe problems leave the
orchestra.
Low participation rate limits

interpretation.
(Continued)
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MSD prevalence
Hales et al. Cross- 518 telecommunication Outcome: Pain, aching, 7% Fear of being Participation rate: 93%.
1994 sectional workers (416 females stiffness, burning, replaced by
and 117 males). numbness, or tingling >1 computers: ORs for psychosocial represent
Workers fulfilling week or >12 times a year; OR=2.9 1.4-6.1 risk at scores one standard
outcome definition occurring after employment deviation (SD) above the mean
compared to those not on current job within the last Lack of compared to risk at scores one
fulfilling outcome year and positive physical decision- SD below mean. May be a
definition. examination (PE): Moderate making problem with non-normal
to worst pain experienced opportunities: distribution.
with medial or lateral OR=2.8 1.4-5.7
epicondyle palpation. Analysis controlled for age,
Surges in gender, individual factors, and
Exposure: Assessed by workload: number of keystrokes/day.
questionnaire. Questions OR=2.4 1.2-5.0
addressed number of Physician examiners blinded to
overtime hr, co-worker use Race (non- case and exposure status.
of same workstation, task white)
rotation, hr spent at the OR=2.4 1.2-5.0 Although keystrokes/day was
(VDT) workstation, hr spent not significantworkers only
typing, number and types of typed average of 8 words/min
work breaks, length of time over 8-hr period.
sitting, frequency of arising
from a chair, number of 97% of workers used VDTs $
keystrokes estimated for 6 hr/daynot enough variance
each directory assistance to adequately evaluate hr
operator. typing.
Number of hr on hobbies and

recreation not significant.
Over 70 variables analyzed in

modelsmay have multiple
comparison problem.
(Continued)
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MSD prevalence
Hoekstra Cross- 108 of 114 teleservice Outcome: Self administered Center A 19% Participation rate: 95%.
et al. 1994 sectional representatives working questionnaire. Case defined
at 2 government as the presence of pain, "Non- Analysis controlled for gender.
administration centers: numbness, tingling, aching, optimally"
A and B. stiffness, or burning in the adjusted Interactions evaluated.
elbow region as previous Center B 21% chair: 4.0 1.2-13.1
non-occupational injury; Variables considered in logistic
symptoms began after model included location, age,
starting the job, last > 1 week seniority, hr spent typing at
or occurred once a month VDT, hr on the phone, 3 chair
within the past year; reported variables: (1) Perceived
as moderate (3) or greater adequacy of chair adjustment,
on a 5-point scale. VDT screen, (2) Perceived
adequacy of keyboard
Exposure: Measurement and adjustment, VDT screen,
evaluation of work station; (3) Perceived adequacy of desk
observation of postures to adjustment, job control,
provide descriptive workload variability.
differences between the two
locations. Linear regression also
performed on psychosocial
variables in separate models for
job dissatisfaction and
exhaustion.
Center B generally had

nonadjustable chairs and work
stations. Authors noted
elevated arms, hunched
shoulders and other
"undesirable" postures.
Did not include non-work-

related variables in analyses.
(Continued)
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MSD prevalence
Hughes and Cross- 104 male aluminum Outcome: Symptoms 11.6% with Model based Participation rate: Carbon
Silverstein sectional smelter workers: occurring in the positive on MSD setters: 65%; crane operators:
1997 62 carbon setters, elbow/forearm > symptoms defined by 56%; carbon plant: 33%.
36 crane operators, once/month or lasting and physical symptoms
9 carbon plant workers. longer than one week in exam and physical Examiners blinded to exposure
There were 14 workers the previous year, no exam and health status: not stated.
who were not from acute or traumatic onset; 24% had
selected jobs and were occurrence since working symptoms in Age: Analysis controlled for age,
excluded. at the plant, no systemic the OR=0.96 0.9-1.2 smoking status, sports, and/or
disease. elbow/forear hobbies.
m in the Low decision
Physical examination: Active, previous latitude: Psychosocial data collected
passive, and week OR=3.5 0.6-19 individually; physical factors
resisted motions, pinch based on estimates of each job.
and grip strength, 128 Years of
Hz vibration sensitivity, two- forearm Job risk factors entered into the
point discrimination. twist: OR=37 model for hand/wrist included:
3.0-470 (1) the number of years
Psychosocial scales from Model based handling > 2.7 kg/hand,
questionnaire based on on MSD (2) push/pull, (3) lift/carry,
Theorell and Karasek Job defined by (4) pinching, (5) wrist
Stress Questionnaire, and symptoms flexion/extension, (6) ulnar
on Work Apgar deviation, and (7) forearm
Questionnaire. Age: twisting.
OR=0.96
Exposure: For carbon 0.9-1.2 Health interview included
setters and crane Years of information about metabolic
operators (non-repetitive ulnar diseases, acute traumatic
jobs) a modified job- deviation: injuries, smoking, hobbies.
surveillance checklist OR=0.005 0.0-16
method was used. Job task Low participation rate limits
analysis used a formula Years interpretation.
based on the relative forearm
frequency of occurrence twist: OR= 4 0.18- 4
of postures during (a)
task(s).
(Continued)
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MSD prevalence
Kopf et al. Cross- Bricklayers (n=163) Outcome: Questionnaire Not reported Not reported Painful left Not Participation rate: bricklayers:
1988 sectional compared to other based, self-reported elbow, reported 65%, manual workers: 69%.
manual workers (n=144) symptoms. Self-reported bricklayers
employed by state pain in the elbow. vs. other Controlled for confounders:
agencies in Hamburg, manual age, job satisfaction, job
Germany. Exposure: Based on job workers: security, vibration, moistness,
categories, bricklayer vs. OR=2.8 Scheuermans disease.
other manual laborers.
Physical stress of bricklayers Karaseks model of job latitude
described as lifting and and job demands were included
carrying bricks weighing 5 to in the questionnaire.
24 kg up to 100 times/hr with
the left hand and handling the Physically demanding previous
bricklayers trowel with the tasks, medical disposition for
right hand. MSD, being a member of a trade
union included in analysis.
64% attributable risk proportion

of elbow pain is explained by
being a bricklayer.
For increasing levels of job

demands (heavy physical work,
awkward working positions,
repetitive movements, and
restriction in standing position),
OR increased from 1.8 to 3.4.
(Continued)
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MSD prevalence
Kurppa et al. Cohort; 31 Sausage makers (107 Outcome: Tenderness to Sausage Workers in IR of males in Participation rate: 93% of
1991 month females) compared to palpation of the epicondyle makers Non- strenuous strenuous workers retained
follow-up nonstrenuous jobs (197 and epicondylar pain (females): strenuous jobs vs. during study; 90% of
nonstrenuous workers.
females). provoked by resisted 11.1 jobs: 1.1 nonstrenuous
extension or flexion of the cases/100 cases /100 jobs: 5.7 Examiners blinded to exposure
Meatcutters (102 males) wrist and fingers with the person- person- or past episodes: not reported.
compared to elbow extended. Incidence years years IR of females Diagnoses made by different
physicians at different
nonstrenuous jobs based on visits to doctor in strenuous locations. Plant physicians
(n=141). during 31 month visit. Workers in jobs vs. agreed to the diagnostic criteria
Meatcutters non- nonstrenuous and made 75% of diagnoses.
Packers (118 females) Disease considered "new" (males): strenuous jobs: 8.1 25% of physicians were not
involved in agreement of
compared to episode if new sick leave 6.4 jobs: 0.9 diagnostic criteria. 13% of
nonstrenuous jobs (197 with same diagnosis cases/100 cases/100 IR of total epicondylitis diagnosed by
females). occurred at same anatomic person- person- number of consulting specialists at the
site within 60 days after end years years cases of nearby medical center, 12%
elsewhere, usually at municipal
of former sick leave. epicondylitis health centers.
Workers in in strenuous
Exposure: Data obtained Nonstrenu- jobs vs. No adjustment for confounders,
from previous published Packers ous jobs: 1.1 nonstrenuous but referent group selected
similar to strenuous group with
literature and walkthrough. (males): cases/100 jobs: 6.7 3.3-13.9 regards to age, gender, and
7.0 person- duration of employment, except
Cutting of veal (appx. 1,200 cases/100 years for male sausage makers and
kg/day) or pork (appx. 3,000 person- male packers who were
younger than the rest of the
kg/day) (meatcutters); years study populationthese were
spraying the sausages and excluded from calculations of
hanging them on bars incidence rates.
(sausage makers); peeling New" episode of epicondylitis
sausages, inserting them into may be recurrence of same
slicing machine, setting the disease. 12 employees
slices into packages, setting reafflicted with epicondylitis
packages on a conveyor belt, with median of 184 days
between episodes.
collecting finished packages
into bags; room temperature There were 68 diagnoses of
8E to 10E (packers); epicondylitis among 57
nonstrenuous tasks included individuals.
primarily office work.
(Continued)
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MSD prevalence
Luopajrvi et Cross- Female assembly line Outcome: Epicondylitis 5.9% 2.3% 2.7 0.66- Participation rate: 84%.
al. 1979 sectional workers (n=152) diagnosed by interview and 15.9 Workers excluded from
compared to female physical exam. participation for previous
shop assistants in a trauma, arthritis and other
department store Symptoms include muscle pathologies.
(n=133). Cashiers pain during effort, local
excluded from swelling, and local ache at Examiner blinded to case
comparison group. rest. Signs include status: yes, according to the
tenderness at the ateral or Waris et al. 1979, epidemiologic
medial epicondyle on screening procedure, which
palpation, pain during was used in study.
resisted extension/flexion of
the wrist and fingers with the No association between age
elbow extended. and MSDs or length of
Physiotherapist examined employment and MSDs. Gender
workers, diagnoses were not an issue because study
from pre-determined criteria population was all female.
(Waris 1979). In problem
cases orthopedic and Factory opened only short time
physiatric teams handled so no association between
cases. duration of employment and
MSDs possible.
Exposure: Exposure to
repetitive work, awkward Social background, hobbies,
hand/arm postures, and amount of housework not
static work assessed by significant.
observation, video analysis
and interviews. Video
recordings showed repetitive
motins of the hands and
fingers up to 25,000
cycles/day, static muscle
loading of the forearm
muscles, and deviations of
the wrist, lifting.
(Continued)
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MSD prevalence
McCormack Cross- Randomly selected Outcome: Based on Boarding Non-office Boarding vs. Participation rate: 91%.
et al. 1990 sectional population of 2,261 physician administered workers: workers: non-office:
textile workers from physical exams. 1.0% 1.9% OR=0.5 0.09-2.1 Physician or nurse examiners
8,539 eligible workers; Reproducible tenderness not blinded to case or exposure
status (personal
4 groups compared with with direct pressure on the Sewing Sewing vs. communication).
468 non-office workers lateral epicondyle. Severity workers: non-office:
graded as mild, moderate, 2.1% OR=1.1 0.4-2.9 Age, gender, race, and years
Manufacturing workers: and severe. of employment analyzed.
Packaging/ Packaging vs.
A. Packaging/folding Exposure: Assessment by folding non-office: Prevalence higher in workers
0.4-3.2 with < 3 years of employment.
workers (41 males, observation of jobs. workers: OR=1.1
238 females). Exposure to repetitive finger, 2.2% Questionnaire asked types of
wrist and elbow motions jobs, length of time on job,
B. Sewing workers assumed from job title; no Knitting: Knitting vs. production rate, nature and type
(28 males, 534 females). objective measurements 1.4% non-office: of upper extremity complaint,
performed. OR=1.2 0.5-3.4 and general health history.
C. Non-office workers 11 physician examiners;
(204 males, 264 interexaminer reliability potential
females). problem acknowledged by
authors.
D. Boarding workers
(19 males, 277 females). Epicondylitis significantly
associated with years of
employment, age, race.
Job category not related to
epicondylitis, however no
measurement of force,
repetition, posture analysis, etc.
Of 37 cases of epicondylitis
identified: 13 were categorized
as mild, 22 were moderate, and
2 were severe.
(Continued)
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MSD prevalence
Moore and Cross- Workers employed in Outcome: OSHA logs Workers in Workers in Odds of Participation rate: Cases
Garg 1994 sectional 32 jobs at a pork verified by medical records hazardous safe jobs: epicondylitis identified from medical records.
processing plant data for 20 months. jobs: 23% 3% in workers in Jobs analyzed from
(n=230). Epicondylitis: localized elbow hazardous observational methods.
pain that increased with jobs Investigators blinded to
Workers in jobs tension of muscle-tendon unit compared to exposure, case outcome
classified as and direct palpation. A case workers in status, and personal identifiers
hazardous compared required that a physical safe jobs: on medical records.
to those in safe jobs. examination specific to OR=5.5 1.5-62 Repetitiveness and type of
epicondylitis was performed. (based on grasp were not significant
personal factors between hazardous-
Exposure: Observation and communi- and safe-job categories.
video analysis, semi- cation)
quantitative methods using No pattern of morbidity accord-
motion and time methods ing to date of clinic visits.
(MTM), force estimated as % Strength demands significantly
maximal strength (5 levels), greater for hazardous job
wrist posture (3 levels), type categories compared to safe.
of grasp (2 levels), high IR based on full-time equivalents
speed work (yes or no), and not individual workers, may
localized mechanical have influenced overall results.
compression (yes or no),
vibration (yes or no), and Workers had a maximum of
cold (yes or no). Observed 32 months of exposure at
videotaped representative plantduration of employment
worker in each job. analysis limited.
Repetition as cycle-time and Duration of exposure not
exertions/min measures. collected on study sample.
Jobs classified as Average maximal strength
"hazardous" or "safe" based derived from population-based
on data, experience of data stratified for age, gender,
authors, and judgements. and hand dominance.
Using estimates of Silversteins
Work histories, demographic, classification, association
pre-existing morbidity data between forcefulness, and
not collected on each overall observed morbidity was
participant. statistically significant; repetition
was not. 31 of 32 jobs were in
high repetitive categoryno
variance to find difference.
(Continued)
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MSD prevalence
Ohlsson Cross- Electrical equipment and Outcome: Questionnaire: Elbow pain in Elbow pain Participation rate: Not reported.
et al. 1989 sectional automobile assemblers Any elbow pain, elbow pain last 12 in last 12
(n=148), former female affecting work ability, months: 21% months: Work pace assessed by
assembly workers who and elbow pain in the last 17% 1.5 0.6-3.4 questionnaire, the number of
quit within 4 years seven days and the last Elbow pain in items completed/hr.
(n=76) compared to 12 months. last 7 days: Elbow pain
randomly sampled 14% in last 7 No association between length
females from general Exposure: No exposure days: 11% 1.9 0.7-5.3 of employment and elbow
population (n=60). measurements; based on job Work inability symptoms.
categorization. in last 12 Work
months: 10% inability in No statistical significance
Work pace divided into last 12 associated with work pace
4 classes: months: 3% 2.8 0.8-10.7 (data not present).
(1) Slow <100 items/hr;
(2) Medium 100 to 199 Logistic models evaluated for
items/hr; (3) Fast 200 to 700 interaction and controlled for
items/hr; (4) Very Fast >700 age.
items/hr.
Study group consisted of
females only.
(Continued)
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MSD prevalence
Punnett et al. Cross- 162 female garment Outcome: Self-administered Garment Hospital Elbow Participation rate: 97%
1985 sectional workers, 85% were questionnaire concerning workers: employees: Symptoms in (garment workers), 40%
employed as sewing symptoms 6.5% 2.8% Garment (hospital workers).
machine operators and workers vs.
sewing and trimming by Cases defined as the Hospital Analysis stratified for number
hand. presences of persistent employees: of years employed, decade of
elbow pain, numbness or OR= 2.4 1.2-4.2 age, native language.
Comparison: 76 of 190 tingling (lasted for most
full or part-time workers days for one month or more Health outcome based on
on day shift in a hospital within the past year); were Persistent symptoms alone for elbow
who worked as nurses not associated with previous elbow pain in MSDs.
or aids; lab technicians injury; and, began after finishers vs.
or therapists; food first employment in garment hospital Age and length of employment
service workers. manufacturing or hospital employees: not a predictor of risk of elbow
employment. Key questions OR=5.6 MSDs.
Employees typing based on the arthritis
>4 hr/day excluded supplement questionnaire of Persistent Prevalence of pain not
from comparison group. National Health and Nutrition elbow pain in associated with years of
Examination Survey underpresser employment in garment
(NHANES). vs. hospital workers.
employees:
Exposure: Self-administered OR=5.0 Non-English speakers
questionnaire; # of years in significantly less likely to report
the industry, job category, pain (RR 0.6 ; p<0.05).
previous work history.
Native English speakers
significantly older than non-
native English speakers
(p<0.03).
(Continued)
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MSD prevalence
Ritz 1995 Cross- 290 males from the Outcome: Physician 41 10 years of Participation rate: Not reported.
sectional public gas and water diagnosed; required local employees: high
works of Hamburg, tenderness to palpation at the 14% had exposure to Examiner blinded to exposure
Germany examined epicondyle and pain during epicondylitis elbow status.
during routine medical resisted movement of the straining Logistic regression model
check-up at the wrist and fingers (extension 11% fulfilled work for controlled for age, age-
company occupational or flexion of the wrist or Wariss currently held squared, and an indicator term
health center. fingers with an extended criteria for job: OR=1.7 1.0-2.7 for history of cervical spine
Employees, excluded if elbow) AND elbow pain epicondylitis symptoms (yes, no).
on sick leave, came for during the lifting of a chair. (Waris, High
The following variables tested
medical treatment, pre- Epicondylitis was 1979) exposure to for confounding: having ever
employment checkups, categorized as severe elbow played tennis, squash, other
or to file a workers (Grade II and Grade III) if both straining racquet sports, rowing,
compensation claim. functional tests were positive work for bowling, the duration of having
and as moderate (Grade I) if formerly held played these sports, injuries
only symptom was a severe job: involving the elbow joint,
tenderness to palpation or a OR= 2.16 1.1-4.3 ponderal index, handedness,
and former surgical treatment
moderate pain in the for epicondylitis.
resistance test. Clinical signs 10 years of
of epicondylitis > Grade 0 at high The variable time in years
one or more of the four exposure to since retiring from a job with
anatomical sites was elbow high or moderate exposure
considered sufficient for the straining was retained in the model for
workers formerly employed in
diagnosis. work for high exposure jobs when
currently held duration of exposure was
Exposure: All current and job using tricotomized.
former job titles evaluated by diagnostic
members of the team criteria for Mean length of employment
according to possible bio- epicondylitis was not significantly different
mechanical strain to the [Waris et al. between cases and non-cases.
elbow and grouped into 1979]: Increasing duration of current
categories of high, moderate, OR=1.89 1.2-3.1 exposure increased the risk of
and non work-related being diagnosed with
exposure. Exposure epicondylitis.
categorization was based on
company job descriptions,
interviews with employees,
and workplace observations.
Exposure duration was

defined for all subjects as the
(Continued)
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MSD prevalence
Roto and Kivi Cross- Meatcutters, (n=90) Outcome: Defined by Meatcutters: Construc- 6.4 0.99-40.9 Participation rate: 100% for
1984 sectional compared to physical exam: local 8.9% tion meat cutters, 94% for
construction workers tenderness, pain during workers: p= 0.05 construction workers.
(n=72) not exposed to resisted extension/flexion of 1.4%
repetitive movements. the wrist and fingers, and Authors state that examiners
decreased hand grip power were blinded to occupation of
in comparison to other hand. subjects because part of larger
group of meat processing
Exposure: Based on job title workers examined, but it is
(meatcutter vs. construction unclear whether construction
worker). foremen (referents) were
examined separately.
Serologic testing for rheumatoid

arthritis was done to control for
potential confounding (none
detected).
7 additional meatcutters had

local tenderness in epicondylar
region.
All with epicondylitis had > 15

years of employment.
Authors stated that on average,

meatcutters with epicondylitis
had been exposed five years
longer than other meatcutters,
supporting the association with
meatcutting.
(Continued)
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MSD prevalence
Viikari- Cross- All permanent workers Outcome: Elbow trouble Epicondy- Epicondy- The Odds Participation rate: 94%.
Juntura sectional exposed to repetitive (pain, ache, discomfort) litis: 0.8% litis: 0.8% Ratio of
1991b and manually stressful preventing normal work in epicondylitis No adjustment for confounders
tasks in a meatpacking last 12 months and physical Lateral: Lateral: in strenuous in analysis. Authors stated that
plant (102 meatcutters, exam: tenderness at the 0.6% 0.6% jobs vs. non- the comparison group was
150 packers, and lateral/medial epicondyle and Medial: Medial: strenuous selected similar to the study
125 sausage makers) pain with resistance. 0.2% 0.3% jobs: 0.88 0.27-2.8 group to sex, age, and duration
were compared to of employment.
332 workers in Exposure: Based on Elbow Pain
nonstrenuous jobs observation: (without the Examiners blinded to case and
(supervisors, physical exposure status.
maintenance men, Meatcutters: High force/high exam):
accountants, and office repetition. Male: 1.8 1.1-2.8 Male packers and male sausage
workers). Female: 1.6 1.2-2.3 makers younger and length of
Sausage makers: High employment shorter than other
repetition/low force with high groups.
force tasks.
Palpation pressure increased on
Packers: High repetition/low 2nd of cross-sectional
force with high force jobs. examinationsmay have
influenced results.
Nonstrenuous jobs, mainly
office jobs. For female sausage makers,
elbow pain for preceding 12
Cutting of veal (appx. 1,200 months increased with age and
kg/day) or pork (appx. 3,000 duration of employment. No
kg/day) (meatcutters); such associations in other
spraying the sausages and groups.
hanging them on bars
(sausage makers); peeling Age and current occupational
sausages, inserting them into correlated (r=0.52) for female
slicing machine, setting the sausage makers.
slices into packages, setting
packages on a conveyor belt, Cases were not excluded due
collecting finished packages to direct trauma.
into bags; room temperature
8E to 10E (packers);
nonstrenuous tasks included
primarily office work.
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CHAPTER 5
Hand/Wrist Musculoskeletal Disorders
(Carpal Tunnel Syndrome, Hand/Wrist
Tendinitis, and Hand-Arm Vibration
Syndrome): Evidence for Work-Relatedness
Musculoskeletal disorders (MSDs) of the hand/wrist region have been separated into three components
for the purpose of this review: (a) Carpal Tunnel Syndrome (CTS), (b) Hand/Wrist Tendinitis, and (c)
Hand-Arm Vibration Syndrome (HAVS). Each of these are described with regard to the evidence for
causality between workplace risk factors and development of MSDs.
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CHAPTER 5a
Carpal Tunnel Syndrome
SUMMARY
Over 30 epidemiologic studies have examined physical workplace factors and their relationship to carpal
tunnel syndrome (CTS). Several studies fulfill the four epidemiologic criteria that were used in this review,
and appropriately address important methodologic issues. The studies generally involved populations
exposed to a combination of work factors, but a few assessed single work factors such as repetitive
motions of the hand. We examined each of these studies, whether the findings were positive, negative, or
equivocal, to evaluate the strength of work-relatedness using causal inference.
There is evidence of a positive association between highly repetitive work alone or in combination with
other factors and CTS based on currently available epidemiologic data. There is also evidence of a positive
association between forceful work and CTS. There is insufficient evidence of an association between CTS
and extreme postures. Individual variability in work methods among workers in similar jobs and the influence
of differing anthropometry on posture are among the difficulties noted in measuring postural characteristics
of jobs in field studies. Findings from laboratory-based studies of extreme postural factors support a positive
association with CTS. There is evidence of a positive association between work involving hand/wrist
vibration and CTS.
There is strong evidence of a positive association between exposure to a combination of risk factors (e.g.,
force and repetition, force and posture) and CTS. Based on the epidemiologic studies reviewed above,
especially those with quantitative evaluation of the risk factors, the evidence is clear that exposure to a
combination of the job factors studied (repetition, force, posture, etc.) increases the risk for CTS. This is
consistent with the evidence that is found in the biomechanical, physiological, and psychosocial literature.
Epidemiologic surveillance data, both nationally and internationally, have also consistently indicated that
the highest rates of CTS occur in occupations and job tasks with high work demands for intensive manual
exertionfor example, in meatpackers, poultry processors, and automobile assembly workers.
INTRODUCTION [Washington State Department of Labor and

In 1988, CTS had an estimated population Industry 1996]. These data suggest that about
prevalence of 53 cases per 10,000 current 5 to 10 workers per 10,000 workers will miss
workers [Tanaka et al. (in press)]. Twenty work each year due to work-related CTS.
percent of these individuals reported absence
from work because of CTS. In 1994, the In recent years, the literature relating
Bureau of Labor Statistics (BLS) reported that occupational factors to the development
the rate of CTS cases that result in days away of CTS has been extensively reviewed
from work was 4.8 cases per 10,000 by numerous authors [Moore 1992; Stock
workers. The agency also reported that the 1991; Gerr et al. 1991; Hagberg et al. 1992;
median number of days away from work for Armstrong et al. 1993; Kuorinka and
CTS was 30, which is even greater than the Forcier 1995; Viikari-Juntura 1995]. Most
median reported for back pain cases [BLS of these reviews reach a similar
1995]. In 1993, the incidence rate (IR) for conclusionwork factors are one of
CTS workers compensation cases was 31.7 the important causes of CTS. One review
cases per 10,000 workers; only a minority of [Moore 1992] found the evidence
these cases involved time off of work
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more equivocal, but stated that the of labeling workers as having CTS or
epidemiologic studies revealed a fairly median nerve mononeuropathy based on
consistent pattern of observations regarding the abnormal sensory nerve conduction alone
spectrum and relative frequency of CTS (without symptoms). The reason for this view is
[among other musculoskeletal disorders illustrated in a recent prospective study by
(MSDs)] among jobs believed to be hazardous. Werner et al. [1997]. On follow-up six to
The epidemiologic studies which form the basis eighteen months after initial evaluation, they
for these reviews are outlined in Tables 5a1 to found that asymptomatic active workers with
5a4 of this chapter. abnormal sensory median nerve function (by
Nerve Conduction Studies [NCS]) were no
Thirty studies of occupational CTS are listed on more likely to develop symptoms consistent
Tables 5a5. Twenty-one are cross-sectional with CTS than those with normal nerve
studies, six are case-control, and three involve function. Studies which have used nerve
a longitudinal phase; all have been published conduction tests for epidemiologic field studies
since 1979. We included one surveillance study have employed a variety of evaluation methods
[Franklin et al. 1991] because it has been and techniques [Nathan et al. 1988, 1994b;
included in many of the earlier reviews. The few Bernard et al. 1993; Osorio et al. 1994].
earlier studies of CTS identified were clinical Normal values for nerve conduction studies
case series, or did not identify work place risk have also varied from laboratory to laboratory.
factors and were not included in the tables NCS results have been found to vary with
related to CTS. electrode placement, temperature, as well as
age, height, finger circumference and wrist ratio
OUTCOME AND EXPOSURE [Stetson 1993], suggesting that normal values
MEASURES may need to be corrected for those factors.
In four of 30 studies listed in Tables 5a1 to
5a4, CTS was assessed based on symptoms Several epidemiologic studies have used a
alone; in another nine studies, the case surveillance case definition of CTS based
definition was based on a combination of on symptoms in the median nerve distribution
symptoms and physical findings. and abnormal physical examination findings
Electrophysiological tests of nerve function using Phalens test and Tinels sign, and have
were completed in 14 studies. Electrodiagnostic not included NCS. Two recent studies
testing (nerve conduction studies) has been [Bernard et al. 1993; Atterbury et al. 1996]
considered by some to be a requirement for a looked at CTS diagnosis based on
valid case definition of CTS, as is similarly used questionnaire and physical examination findings
for a clinical diagnosis in individuals with CTS. and its association with the gold standard of
A few studies which have looked at the nerve conduction diagnosed median
relationship of occupational factors to CTS mononeuropathy. Both studies found
have used a health outcome based on statistically significant evidence to support the
electrodiagnostic testing alone [Nathan et al. use of an epidemiologic CTS case definition
1988; Schottland et al. 1991; Radecki 1995.] based on symptoms and physical examination
However, some authors [Nilsson 1995; (not requiring NCS) for
Werner et al. 1997] have discouraged the use epidemiologic surveillance studies. Nathan
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[1992a] also found a strong relationship of Repetition and CTS

between symptoms and prolonged sensory Nineteen studies reported on the results of the
median nerve conduction. (It is important to association between repetition and CTS.
note here that a case definition used for Several studies in Table 5a-1 quantitatively
epidemiologic purposes usually differs from one measured [Moore 1992; Chiang et al. 1990,
used for medical diagnosis and therapeutic 1993; Silverstein et al. 1987] or observed
intervention.) [Stetson et al. 1993; Nathan et al. 1988,
1992a; Barnhart et al. 1991; Osorio et al.
Researchers have relied on a variety of 1994] and categorized repetitive hand and wrist
methods to assess exposure to suspected movements in terms of: a) the frequency or
occupational risk factors for CTS. These duration of tasks pertaining to the hand/wrist, b)
methods include direct measurement, the ratio of work-time to recovery time, c) the
observation, self-reports, and categorization by percentage of the workday spent on repetitive
job titles. Most investigators agree that use of activities, or d) the quantity of work performed
observational or direct measurement methods in a given time. The rest of the studies generally
increases the quality (both the precision and used job titles or questionnaires to characterize
accuracy) of ergonomic exposure assessments, exposure.
but these methods also tend to be costly and
time consuming. In general, misclassification Studies Meeting the Four Evaluation Criteria
errors tend to dilute the observed associations Five epidemiologic studies of the hand/wrist
between disease and physical workload area addressing repetitiveness and CTS
[Viikari-Juntura 1995]. [Chiang et al. 1990, 1993; Moore and Garg
1994; Osorio et al. 1994; Silverstein et al.
REPETITION 1987] met the four criteria. Chiang et al. [1990]
Definition of Repetition for CTS studied 207 workers from 2 frozen food
For our review, we identified studies that processing plants. Investigators observed job
examined repetition or repetitive work for the tasks and divided them into low or high
hand and wrist for CTS as cyclical or repetitive repetitiveness categories of wrist movement
work activities that involved either 1) repetitive based on cycle time, as previously described by
hand/finger or wrist movements such as hand Silverstein et al. [1987]. Jobs were also
gripping or wrist extension/flexion, ulnar/radial classified according to whether or not workers
deviation, and supination or pronation. Most of hands were exposed to cold work conditions.
the studies that examined repetition or repetitive The resulting exposure groups were:
work as a risk factor for CTS had several Group 1Not Cold, Low Repetitiveness
concurrent or interacting physical workload (mainly office staff and technicians);
factors. Therefore, repetitive work should be Group 2Cold Exposure or High
considered in this context, with repetition as Repetitiveness; and Group 3Cold Exposure
only one exposure factor, accompanied by and High Repetitiveness. CTS diagnosis was
others such as force, extreme posture, and, less based on abnormal clinical examination and
commonly, vibration. nerve conduction studies. Prevalence of CTS
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was 3% in Group 1, 15% in Group 2, and 37% females. The OR for repet-itiveness was 1.5
in Group 3. Statistical modeling that also (95% CI 0.82.8), con-trolling for oral
included gender, age, length of employment, contraceptive use and force.
and cold resulted in an odds ratio (OR) of 1.87
(p=0.02) for CTS among those with highly Moore and Garg [1994] evaluated 32 jobs in a
repetitive jobs. The OR for CTS among those pork processing plant and then reviewed past
exposed to cold conditions and high OSHA illness and injury logs and plant medical
repetitiveness was 3.32 (p=0.03). The authors records for CTS cases in these job categories.
cautioned that cold exposure may have at least A CTS case required the recording of
partially acted as a proxy for forceful suggestive symptoms (numbness and tingling)
hand/wrist exertion in this study group. combined with electrodiagnostic confirmation
(as reported by the attending
Chiang et al. [1993] studied 207 workers from electromyographers) of a case. Incidence ratios
8 fish processing factories in Taiwan. Jobs were (IRs) were calculated using the full-time
divided into 3 groups based on levels of equivalent number of hours worked reported
repetitiveness and force. The comparison group on the logs. The exact number of workers was
(low force/low repetitiveness) was comprised not reported. Exposure assessment included
of managers, office staff, and skilled craftsmen videotape analysis of job tasks for
(group 1). The fish-processing workers were repetitiveness and awkward postures. The
divided into high repetitiveness or high force force measure was an estimate of the percent
(group 2), and high force and high maximum voluntary contraction (%MVC)
repetitiveness (group 3). Repetition of upper based on weight of tools, and parts and
limb movements (not specifically the wrist) was population strength data adjusted for extreme
defined based on observed cycle time posture or speed. Jobs were then categorized
[Silverstein et al. 1987]. CTS was defined on as hazardous or safe (for all upper extremity
the basis of symptoms and positive physical MSDs, not for CTS), based on exposure data
examination findings, ruling out systemic and the judgment of the investigators. The
diseases and injury. CTS prevalence for the hazardous jobs had a relative risk (RR) for
overall study group was 14.5%. CTS CTS of 2.8 (95% CI 0.236.7) compared to
prevalence increased from group 1, to group 2, the safe jobs. Due to the lack of data from
and to group 3 (8.2%, 15.3%, and 28.6%, individual workers, the study was unable to
respectively), a control for common confounders. Potential for
statistically significant trend (p<0.01). survivor effect (79% of the workforce was laid
Repetitiveness alone was not a significant off the year prior to the study), a limited latency
predictor of CTS (OR 1.1). Statistical modeling period (832 months), and the potential for
showed that women in this study group had a incomplete case ascertainment (underreporting
higher prevalence of CTS than men (OR 2.6, is known to be a problem with OSHA illness
95% confidence interval [CI] 1.35.2). and injury logs) limit confidence in this estimate.
Because the proportion of women varied by This study did not specifically address the
exposure group (48%, 75%, and 79% from relationship between repetitiveness and CTS.
group 1 to 3), further analyses were limited to No significant association was identified
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between repetitiveness and the grouped upper force/low repetitiveness, low force/high
extremity musculoskeletal disorders, but there repetitiveness, and high force/high
was very little variability in repetitiveness (31 of repetitiveness. Fourteen cases (2.1%
the 32 jobs had a cycle time less than 30 prevalence) of CTS were diagnosed based on
seconds). standardized physical examinations and
structured interviews.
Osorio et al. [1994] studied 56 supermarket
workers. Exposure to repetitive and forceful The OR for CTS in highly repetitive jobs
wrist motions was rated as high, moderate, or compared to low repetitive jobs, irrespective of
low, following observation of job tasks. The force, was 5.5 (p<0.05) in a statistical model
CTS case definition was based on symptoms that also included age, gender, years on the job,
and nerve conduction studies. CTS-like and plant. The OR for CTS in jobs with
symptoms occurred more often (OR 8.3, 95% combined exposures to high force and high
CI 2.626.4) among workers in the high repetition was 15.5 (p<0.05), compared to
exposure group compared to the low exposed jobs with low force and low repetition. Age,
group. The odds of meeting the symptom and gender, plant, years on the job, hormonal
NCS-based CTS case definition among the status, prior health history, and recreational
high exposure group were 6.7 (95% CI activities were analyzed and determined not to
0.852.9), compared to the low exposure confound the associations identified.
group.
Studies Meeting at Least One Criterion
Silverstein et al. [1987] studied 652 workers in Fourteen additional studies met at least one of
39 jobs from 7 different plants (electronics, the criteria.
appliance, apparel, and bearing manufacturing;
metal casting, and an iron foundry). Barnhart et al. [1991] studied ski manufacturing
Investigators divided jobs into high or low workers categorized as having repetitive or
repetitiveness categories, based on analysis of nonrepetitive jobs based on observational
exposure methods for hand/wrist exposure. The
videotaped job tasks of 3 representative
participation rate for this study was below
workers in each job. High repetitiveness was
70%. Three different case definitions were used
defined as cycle time less than 30 seconds or at
for CTS based on symptoms, physical exam
least 50% of the work cycle spent performing findings, and NCS using the mean median-ulnar
the same fundamental movements. Jobs were difference in each group. Each case definition
also divided into high or low force categories used the NCS results. The authors reported a
based on EMGs of representative workers significant prevalence ratio (PR) of 2.3 for the
forearm flexor muscles while they performed mean median-ulnar sensory latency nerve
their usual tasks. EMG measurements were difference among those in repetitive jobs
averaged within each work group to compared to those in non-repetitive jobs.
characterize the force requirements of the job. However, the difference was found in the ulnar
High force was defined as a mean adjusted rather than in the median nerve. The median
force >6 kg. Jobs were then classified into 4 nerve latencies were not statistically different
groups: low force/low repetitiveness, high between the two groups.
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Baron et al. [1991] studied CTS in 124 occupational factors:

grocery store checkers and 157 other grocery 1) uninterrupted shoulder rotation with elevated
store workers who were not checkers. The arm (OR 1.8, 95% CI 1.22.8) and 2)
CTS case definition required symptoms that protection from repeated finger tapping (OR
met pre-determined criteria on a standardized 0.4, 95% CI 0.20.7). The authors note that
questionnaire and physical examinations. The the latter observation presented difficulties of
OR for CTS among checkers was 3.7 (95% interpretation. Limitations of this study concern
CI 0.716.7), in a model that included age, the lack of exposure assessment for repetition,
hobbies, second jobs, systemic disease, and and the questionable reliability for reported limb
obesity. Participation rates at the work sites movements as an accurate measure of
were higher among the exposed group repetition.
(checkers: 85% participation, non-checkers:
55% participation). After telephone interviews Feldman et al. [1987] studied electronic
in which 85% of the non-checkers completed workers at a large manufacturing firm using a
questionnaires, investigators reported that the questionnaire survey and biomechanical job
proportion of non-checkers meeting the case analysis. Four work areas with 84 workers
definition did not increase. were identified as high risk with highly
repetitive and forceful tasks. Workers in these
Cannon et al. [1981] in a case-control study of high risk areas had physical examinations and
NCS. Sixty-two workers from the high risk
aircraft engine workers did not find a significant
area had repeat NCS one year later.
association with the performance of repetitive
Comparing these high risk workers to the
motion tasks (OR 2.1, 95%CI 0.95.3), but
others, one can calculate ORs for symptoms of
found a significant association with self- numbness and tingling [OR 2.26 (p<0.05)] and
reported use of vibrating hand tools, history of a positive Phalens sign [2.7 (p<0.05)].
gynecologic surgery, and an inverse relationship Longitudinal NCS of workers in the high risk
with years on the job. One must assume from area showed significant worsening in the
the article that repetitive motion tasks were median motor latency and sensory conduction
defined by job title. The diagnosis of CTS was velocity in the left hand, and motor changes
based on medical and workers compensation over a years period, which the authors
records. attributed to work exposure. A limitation of this
study concerns inadequate exposure
In English et al.s [1995] case-control study of information about the extent of worker
upper limb disorders diagnosed in orthopedic exposure to repetitive and forceful work.
clinics, the case series included 171 cases of
CTS and 996 controls. Exposure was based on McCormack et al. [1990] studied 1,579 textile
self-reports; repetitiveness was defined as a production workers and compared them to 468
motion occurring more than once per minute. other nonoffice workers, a comparison group
that included machine maintenance workers,
The logistic regression model of CTS found
transportation workers, cleaners, and
significant associations with height (negative), sweepers. The textile production workers were
weight (positive), presentation at the clinic as a divided into four broad job categories based on
result of an accident (negative), and two similarity of upper extremity exertions. No
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formal exposure assessment was conducted. both a general population comparison group
Health assessment included a questionnaire and and a low exposed checker group. The
screening physical examination followed by a limitations of this study are: 1) the use of an
diagnostic physical examination. CTS was overly sensitive health outcome measure, for
diagnosed using predetermined clinical criteria. example, 32% of the surveyed population
The severity of cases was also reported as
reported numbness; and 2) the use of self-
mild, moderate, or severe. The overall
reported exposure.
prevalence for CTS was 1.1%, with 0.7% in
boarding, 1.2% in sewing, 0.9% in knitting,
Nathan et al. [1988] studied median nerve
0.5% in packaging/folding, and 1.3% in the
comparison group. None of the differences conduction of 471 randomly selected workers
were statistically significant. A statistical model from four industries (steel mill, meat/food
that also included age, gender, race, and years packaging, electronics, and plastics
of employment showed that CTS occurred manufacturing). Median nerve sensory latency
more often among women in this study values were adjusted for age for statistical
(p<0.05). Interpretation of these data, analyses. Thirty-nine percent of the study
especially with a low prevalence disorder like subjects had impaired sensory nerve
CTS, is difficult since gender varied with job conduction, or slowing of the median nerve.
(94% of boarding workers were female, The five exposure groups were defined as
compared to 56% in the comparison group), follows: Group 1 is very low force, low
and the comparison group (machine
repetition (VLF/LR); Group 2 is low force,
maintenance workers, transportation workers,
cleaners and sweepers) may have also been very high repetition (LF/VHR); Group 3 is
exposed to upper extremity exertions. moderate force, moderate repetition (MF/MR);
Interactions among potential confounders were Group 4 is high force/moderate repetition
not addressed, but they are suspected because (HF/MR); and Group 5 is very high force/high
of significant associations between race and repetition (VHF/HR). There was no significant
three MSDs. difference between Group 1 and Group 2, the
groups that had the greatest differences in
Morgenstern et al. [1991] mailed repetition. The authors reported a significantly
questionnaires to 1,345 union grocery checkers higher number of subjects with median nerve
and a general population group. Exposure was slowing in Group 5 (VHF/HR) compared to
based on self-reported time working as a Group 1 (VLF/LR), but not in other groups,
checker. Symptoms of CTS were significantly using a statistical method described as a
associated with age and the use of diuretics, pairwise unplanned simultaneous test
and nonsignificantly associated with average procedure [Sokal and Rohlf 1981]. The
hours worked per week, and years worked as authors also reported that when individual
a checker. A positive CTS outcome was based hands were the basis of calculations rather than
on the presence of all four symptoms: pain in subjects, Group 3 had a significantly higher
the hands or wrist, nocturnal pain, tingling in the prevalence of median nerve slowing.
hands or fingers, or numbness. The estimated Calculations of the data using PRs and chi-
attributable fraction of CTS symptoms to squares [Kleinbaum et al. 1982] resulted in
working as a checker was about 60%, using significantly higher prevalences of median nerve
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slowing in each of Groups 3, 4, and 5 drop in prevalence of median nerve slowing in

(moderate to high repetition, with moderate to Group 5 between 1984 and 1989 might be
very high force) compared to Group 1 explained by the higher drop-out rate among
(VLR/LF). PRs are 1.9 (95% CI 1.32.7), 1.7 cases in Group 5 compared to Group 1 (PR
(95% CI 1.12.5), and 2.0 (95% CI 1.13.4) 2.9, 95% CI 1.36.6). This was not addressed
for Groups 3, 4, and 5, respectively. A by the authors.
conservative (Bonferroni) adjustment of the
significance level to 0.0125 for multiple Punnett et al. [1985] compared the symptoms
comparisons [Kleinbaum et al. 1982] would and physical findings of CTS in 162 women
result in Group 5 no longer being statistically garment workers and 76 women hospital
significantly different from Group 1 (p=0.019), workers such as nurses, laboratory technicians,
but Group 4 (p=0.009), and Group 3 and laundry workers. Eighty-six percent of the
(p=0.000) remain statistically significantly garment workers were sewing machine
higher than Group 1 in prevalence of median operators and finishers (sewing and trimming by
nerve slowing. hand). The sewing machine operators were
described as using highly repetitive, low force
In 1992, Nathan et al. [1992a] reported on a wrist and finger motions, whereas finishing
follow-up evaluation in the same study group. work also involved shoulder and elbow
Sixty-seven percent of the original study motions. The exposed garment workers
subjects were included. Hands (630), rather probably had more repetitive jobs than most of
than subjects, were the basis of analysis in this the hospital workers. CTS symptoms occurred
study. Novice workers (those employed less more often among the garment workers (OR
than 2 years in 1984) were less likely to return 2.7, 95% CI 1.27.6) compared to the hospital
than non-novice workers (56% compared to workers. There was a low participation rate
69%, p=.004). Maximum latency differences in (40%) among the hospital workers.
median nerve sensory conduction were
determined as in the Nathan et al. [1988] study. Schottland et al. [1991] carried out a
The authors state that there was no significant comparison of NCS findings in poultry workers
difference in the prevalence of median nerve and job applicants as referents. No exposure
slowing between any of the exposure assessment was performed, and applicants
categories in Nathan et al. [1988] using the were not excluded if they had prior
same statistical method described in the Nathan employment in the plant. Results indicated that
et al. 1988 study. However, calculations using the right median nerve sensory latency was
common statistical methods result in the significantly longer in 66 female poultry workers
following PRs for slowing: Group 31.5 (95% compared to 41 female job applicants. In these
CI 1.02.2), Group 41.4 (95% CI 0.92.1), two groups of women there were less
and Group 51.0 (95% CI 0.52.2), pronounced differences in the left median
compared to Group 1. Group 5 had the same sensory latency. The latencies in the 27 male
prevalence of slowing (18%) as Group 1 in poultry workers did not differ significantly from
1989. In 1984 the prevalence of slowing was the 44 male job applicants, although the power
29% in Group 5, and 15% in Group 1. The calculations presented in the paper noted
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limited power to detect differences among male symptomatic industrial workers, the mean
participants. The OR for percentage of female exposure for the symptomatic industrial
poultry workers who exceeded the criteria workers was nonsignificantly slightly greater for
value for the right median sensory latency is all exposure factors except for repetitiveness.
2.86 (95% CI 1.17.9). The major limitations The median sensory amplitudes were
of this study are the absence of detailed significantly smaller
information on exposure and the inclusion of (p<0.01) and latencies longer (p<0.05 ) for
former poultry workers into the applicant industrial workers with exposure to high grip
group, as well as the inadequate sample size, forces compared to those without. Mean
and the personal characteristics of these sensory amplitudes were significantly smaller
workers. This study found a significant (p<0.05) and motor and sensory latencies were
association between highly repetitive, highly significantly longer (p<0.01) in the industrial
forceful work and abnormal NSC consistent asymptomatic workers compared to the control
with CTS. It does not allow analysis of group. These findings for the motor latencies
repetition alone. are similar to Feldman et al. [1987]. Since most
of the industrial workers were exposed to
Stetson et al. [1993] used measurements of repetitive work, it is not clear whether this
sensory nerve conduction velocity of the study population allowed a comparison
median nerve as indicators of nerve impairment between repetitive and non-repetitive work.
or CTS; clinical examination results were not Overall this study suggests that repetitive work
reported in this article. Three groups were combined with other risk factors is associated
studied: a reference group of 105 workers with slowing of median nerve conduction.
without occupational exposure to highly forceful
or repetitive hand exertions, 103 industrial The Wieslander et al. [1989] case-control
workers with hand/wrist symptoms, and 137 study used self-reported information collected
asymptomatic industrial workers. Exposure was via telephone interview about the duration of
assessed with a checklist by trained workers. exposure (number of years and hours per
Factors considered included repetitiveness week) to several work attributes including
(Silverstein criteria), force defined by the repetitive work. Definitions for these work
weight of an object that is carried or held, attributes were not provided. Three categories
localized mechanical stress, and posture. of duration of exposure were defined for each
Exposure assessments were available on 80% attribute (<1 year,
of the industrial workers. Most of the industrial 120 years, and >20 years), but the asymmetry
workers were on repetitive jobs (76%), a of the categories was not explained. A
minority carried more than ten pounds some of significant OR for reporting repetitive
the time (32%), and gripped more than six movements of the wrist comparing CTS
pounds at least some of the time (44%). The patients to hospital referents (OR 4.6) and
analysis controlled for several confounders general population referents (OR 9.6) was
including age, gender, finger circumference, reported, but only among those employed
height, weight, and a square-shaped wrist. In greater than 20 years. Those employed from
the comparison of the asymptomatic to 120 years compared to the referent
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population had elevated ORs for repetitive to cold may be at least partially explained by
movements of the wrist (1.5 for CTS patients forceful motions among workers who were also
compared to hospital referents, and 2.3 exposed to cold. Force was not evaluated in
compared to population referents), but these this study.
were not significant. Jobs with increasing
numbers of work risk factors gave increasing Silverstein et al. [1987] reported an OR of 5.5
ORs (from 1.7 to 7.1) among CTS cases when (p<0.05) for repetition as a single predictor of
compared to referents; these were statistically CTS. Among workers exposed to high
significant when there were two or more risk repetition and high force, the OR was 15.5
factors. Given the limited quality of the (p<0.05).
exposure data and findings (repetition is a
significant risk factor only after 20 years of Chiang et al. [1993] reported a significant trend
exposure), this is only suggestive of a of increasing prevalence of CTS with increasing
relationship between repetition alone and CTS. exposure to repetition and/or force (8.2%,
15.3%, and 28.6%, p<0.05). Repetition (of the
Studies Not Meeting Any of the Criteria whole upper limb, not the wrist) alone did not
Liss et al. [1995] conducted a mail survey significantly predict CTS (OR 1.1).
concerning CTS among 2,124 Ontario dental
hygienists compared to 305 dental assistants In summary, three studies that met all four
who do not scale teeth. Both groups had a low criteria reported ORs for CTS associated with
response rate (50%). The age adjusted OR repetition. The statistically significant ORs for
was 5.2 (95% CI 0.932) for being told by a CTS attributed to repetition alone ranged from
physician that you had CTS and 3.7 (95% CI 1.9 to 5.5. The statistically significant ORs for
1.11.9) using a questionnaire-based definition CTS attributed to repetition in combination with
of CTS. The major limitations of this study are force or cold ranged from 3.3 to 15.5. Gender,
the low participation rate, the lack of a detailed age, and other potential confounders were
exposure assessment for repetitiveness, and addressed and are unlikely to account for the
self-reported health outcome. associations reported.
Strength of AssociationRepetition Five other studies observed job tasks, then

and CTS grouped them into categories according to
Three of the five studies that met all four criteria estimated levels of repetitiveness combined
evaluated the effect of repetitiveness alone on with other risk factors [Feldman et al. 1987;
CTS: Chiang et al. [1990], Silverstein et al. Moore and Garg 1994; Nathan et al. 1988,
[1987], and Chiang et al. [1993]. 1992a; and Osorio et al. 1994]. CTS case
definitions reported here required more than
Chiang et al. [1990] reported an OR of 1.9 symptom-defined criteria. Moore and Garg
(p<0.05) for CTS among those with highly [1994] reviewed medical records; Nathan et al.
repetitive jobs. The OR for CTS among those [1988] and Osorio et al. [1994] performed
exposed to high repetitiveness and cold was nerve conduction studies.
3.32 (p<0.05). The additional effect attributed
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Feldman et al. [1987] reported an OR of 2.7 comparison groups was 8.3 (95% CI 2.6
(p<0.05) for a positive Phalens test among 26.4).
workers in high exposure jobs, compared to
low exposure jobs. To summarize, three of the five studies
reviewed resulted in statistically significant
Moore and Garg [1994] reported an OR of positive findings for CTS associated with
2.8 (0.2, 36.7) for CTS among workers in combined exposures. Feldman et al. [1987]
hazardous jobs compared to workers in reported an elevated OR for CTS with high
nonhazardous jobs. combined exposure. Nathan et al.s [1988]
data resulted in elevated PRs for CTS among
Nathan et al.s [1988] data result in PRs the three highest combined exposure groups.
for four groups with varying levels of Nathan et al.s [1992a] data resulted in an
repetitiveness and force from very low (VL) to elevated PR for CTS among one of the high
very high (VH), compared to a very low force, combined exposure groups. There was
low repetition group (VLF/LR): evidence of survivor bias in the highest
LF/VHR versus VLF/LR: 1.0 (95% CI exposure group.
0.52.0)
MF/MR versus VLF/LR: 1.9 (95% CI The following studies used job title or job
1.32.7) category to represent exposure to
HF/MR versus VLF/LR: 1.7 (95% CI 1.1 repetitiveness combined with other exposures
2.5) and defined CTS based on physical
VHF/HR versus VLF/LR: 2.0 (95% CI examination [Baron et al. 1991, McCormack et
1.13.4). al. 1990, Punnett et al. 1985] or nerve
conduction studies [Schottland et al. 1991].
Nathan et al. [1992a] data, a 5-year follow-up
of the 1988 study, result in PRs for the Baron et al. [1991] reported an OR of 3.7
following groups: (95% CI 0.716.7) for CTS, defined by
LF/VHR versus VLF/LR: 1.0 (95% CI 0.6 symptoms and physical examination, among
1.9) grocery checkers compared to other grocery
MF/MR versus VLF/LR: 1.5 (95% CI 1.0 workers.
2.2)
HF/MR versus VLF/LR: 1.4 (95% CI 0.9 McCormack et al. [1990] reported the
2.1) following ORs for CTS among workers in each
VHF/HR versus VLF/LR: 1.0 (95% CI 0.5 of four broad job categories that were
2.2). considered exposed, compared to a
comparison group of maintenance workers and
Osorio et al. [1994] reported an OR of 6.7 cleaners that was considered to have low
(95% CI 0.852.9) for CTS among workers in exposure:
high exposure jobs, compared to workers in Boarding versus Low: 0.5 (95% CI 0.12.9)
low exposure jobs. Using a symptom-based Sewing versus Low: 0.9 (95% CI 0.32.9)
case definition, the OR for the same
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Packaging versus Low: 0.4 (95% CI 0.02.4) combined with other job risk factors and CTS.
Knitting versus Low: 0.6 (95% CI 0.13.1)
Temporal Relationship: Repetition
Punnett et al. [1985] reported an OR of 2.7 and CTS
(95% CI 1.27.6) for CTS among garment The question of which occurs first, exposure or
workers versus hospital workers. disease, can be addressed most directly in
prospective studies. However, study limitations
Schottland et al. [1991] reported an OR of such as survivor bias can cloud the
2.86 (95% CI 1.17.9) for prolonged right interpretation of findings. In our analysis of
median sensory latency among female poultry Nathan et al.s [1992a] data, 2 of 3 groups that
workers, compared to female applicants for the were exposed to forceful hand/wrist exertions
same jobs. No significant differences were were more likely to have median nerve slowing
identified among males. when nerve conduction testing was repeated 5
years later. The highest exposure group had the
In summary, two of the four studies reviewed same prevalence of slowing as the lowest
above reported significantly elevated ORs for exposure group in 1989, whereas they had a
CTS or median sensory nerve conduction higher prevalence rate in 1984. As discussed
slowing. above, this apparent decrease in prevalence
over 5 years can probably be explained by a
Wieslander et al. [1989] reported an OR for higher drop-out rate among cases in the highest
CTS (surgical cases, confirmed by NCS) of exposure group, compared to the lowest
2.7 (95% CI 1.35.4) among those with self- exposure group. These interpretations of the
reported exposure to repetitive wrist movement data differ from those of the authors. Further
>20 years, compared to hospital referents, and study is needed to clarify these issues.
4.5 (95% CI 2.010.4), compared to However, to our knowledge, there is no
population referents. Significant OR s for CTS evidence demonstrating that those with CTS
among those with combined job risk factors would be more likely to be hired in jobs that
ranged from 3.3 to 7.1. involve high exposure to repetitive hand/wrist
exertions and combined job risk factors,
The remaining two studies relied on self- compared to those without CTS. In fact,
reported symptoms and self-reported employment practices tend to exclude new
exposures from mail [Morgenstern et al. 1991] workers with CTS from jobs that require
or telephone surveys [Liss et al. 1995]. Data repetitive and intensive hand/wrist exertion.
quality and response rates limit interpretation of
findings. Feldman et al. [1987] reported longer median
motor (but not sensory) latencies among
In conclusion, among the studies that measured workers with combined exposure to hand/wrist
repetition alone, there is evidence that repetition exertion, compared to nerve conduction
is positively associated with CTS. The majority findings in the same group one year earlier.
of studies provide evidence of a stronger
positive association between repetition Cross-sectional studies provide evidence that
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exposure occurred before CTS, by using case then it may trigger a fibrosis which damages the
definitions that exclude pre-existing cases, and function of the nerve. The interplay between
by excluding recently hired workers from the acute increases in pressure and chronic changes
study. The studies that provide evidence that to the nerve could partially explain why there is
repetitive and combined job exposures are not a stronger correlation between symptoms of
associated with CTS followed these practices, CTS and slowing of the median nerve. Both
therefore the associations identified cannot be symptoms and slowing of the median nerve are
explained by disease occurring before likely to have both acute and chronic
exposure. components in many cases of CTS.
Consistency in Association for The work determinants of pressure in the

Repetition and CTS carpal tunnel are wrist posture and load on the
One study [English et al. 1995] reported a tendons in the carpal tunnel. For example, the
statistically significant negative association normal resting pressure in the carpal tunnel with
between repetitive work and CTS. The specific the wrist in a neutral posture is about 5
exposure was self-reported repeated finger millimeters of mercury (mmHg), and typing with
tapping; the investigators stated that they had the wrist in 45E of extension can result in an
difficulty interpreting this finding. All of the other acute pressure of 60 mmHg. Substantial load
statistically significant findings pointed to a on the fingertip with the wrist in a neutral
positive association between repetitive work posture can increase the pressure to 50 mmHg.
and CTS. The non-significant estimates of RR A parabolic relationship between wrist posture
were also mostly greater than one. and pressure in the carpal tunnel has been
found. In laboratory studies of normal subjects,
Coherence of Evidence for Repetition elevated carpal tunnel pressures quickly return
One of the most plausible ways that repetitive to normal once the repetitive activity stops;
hand activities may be associated with CTS is patients with CTS take a long time for the
thorough causing a substantial increase in the pressure to return to their baseline values. One
pressure in the carpal tunnel. This in turn can of the supporting observations for this model is
initiate a process which results in either that at surgery for CTS, edema and vascular
reversible or irreversible damage to the median sclerosis (fibrosis due to ischemia) are common
nerve [Rempel 1995]. The increase in pressure, [Rempel 1995].
if it is of sufficient duration and intensity, may
reduce the flow of blood in the epineural This model of the etiology of work-related CTS
venules. If prolonged, this reduction in flow is consistent with two observations from the
may affect flow in the capillary circulation, epidemiological literature. First, it illustrates
resulting in greater vascular permeability and why both work and nonwork factors such as
endoneural and synovial edema. Because of the obesity may be important because anything that
structure of the median nerve and the carpal increases pressure in the carpal tunnel may
tunnel, this increase in fluid and resulting contribute to CTS. Second, it explains why
increase in pressure may persist for a long repetitiveness independent of wrist posture and
period of time. If the edema becomes chronic, load on the flexor tendons may not be a major
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risk factor for CTS. [Nathan et al. 1988; Stetson et al. 1993;
Barnhart et al. 1991].
Exposure-Response Relationship for
Repetition There is evidence of a positive association
Evidence of an exposure-response relationship between highly repetitive work alone and CTS.
is provided by studies that show a correlation There is strong evidence of a positive
between the level or duration of exposure and association between highly repetitive work in
either the number of cases, the illness severity, combination with other job factors and CTS,
or the time to onset of the illness. Silverstein et based on currently available epidemiologic
al. [1987] showed an increasing prevalence of data.
CTS signs and symptoms among industrial
workers exposed to increasing levels of FORCE AND CTS
repetition and forceful exertion. This Definition of force for CTS
relationship was not seen when repetition alone The studies reviewed in this section determined
was assessed. Similar findings on an exposure- hand/wrist force exposure by a variety of
response relationship were reported by Chiang methods. Some investigators [Armstrong and
et al. [1993], Osorio et al. [1994], Wieslander Chaffin 1979; Chiang et al. 1993; Silverstein et
et al. [1989], and by Stock [1991] in her al. 1987] measured force by EMGs of
reanalysis of the Nathan et al. [1988] data. representative workers forearm flexor muscles
while they performed their usual tasks. EMG
Morgenstern et al. [1991] and Baron et al. measurements were averaged within each work
[1991] reported increased prevalence of CTS group to characterize the force requirements of
with increasing length of time working as a the job; jobs were then divided into low or high
grocery cashier. categories if the average force was above or
below a cutoff point. Moore and Garg [1994]
Conclusions Regarding Repetition estimated force as %MVC, based on weight of
Based on the epidemiologic studies noted tools and parts and population strength data,
above, especially those with quantitative adjusted for extreme posture or speed. Jobs
evaluation of repetitive work, the strength of were then predicted to be either hazardous or
association for CTS and repetition has been safe (for any upper extremity musculoskeletal
shown to range from an OR of 2 to 15. The disorder), based on exposure data and
higher ORs are found when contrasting highly judgment. Stetson et al. [1993] estimated
repetitive jobs to low repetitive jobs, and when manipulation forces based on weights of tools
repetition occurred in combination with high and parts and systematically recorded
levels of forceful exertion. Those studies with observations of one or more workers on each
certain epidemiologic limitations have also been job. Jobs were then ranked according to grip
fairly consistent in showing a relationship force cutoffs. Nathan et al. [1988, 1992a] and
between repetition and CTS. The evidence Osorio et al. [1994] estimated relative levels of
from those studies which defined CTS based force (e.g., low, moderate, high) after
on symptoms, physical findings, and NCS is observation of job tasks. McCormack et al.
limited, due to the variety of methods used [1990] grouped jobs into broad job categories
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based on similarity of observed job tasks; one force/low repetitiveness) was managers, office
job group (boarding) required forceful staff, and skilled craftsmen. The fish-processing
hand/wrist exertions. Baron et al. [1991] and workers were divided into high force or high
Punnett et al. [1985] used job title as a repetitiveness (group 2), and high force and
surrogate for exposure to forceful hand/wrist high repetitiveness (group 3). Hand force
exertions. requirements of jobs were estimated by
electromyographs of forearm flexor muscles of
Much of the epidemiologic data on CTS and a representative worker from each group
force overlaps with those studies discussed in performing usual job tasks. High force was
the above section on repetition. Repetitive defined as an average hand force of >3 kg
work is frequently performed in combination repetition of the upper limb (not specifically the
with external forces, and much of the wrist) was defined based on observed cycle
epidemiologic literature has combined these time [Silverstein et al. 1987]. CTS was defined
two factors when determining association with on the basis of symptoms and positive physical
CTS. examination findings, ruling out systemic
diseases and injury. CTS prevalence for the
Studies Reporting on the Association overall study group was 14.5%. CTS
of Force and CTS prevalence increased from group 1 to group 3
Eleven studies reported results on the (8.2%, 15.3%, and 28.6%), a statistically
association between force and CTS. The significant trend p<0.01). Statistical modeling
epidemiologic studies that addressed forceful showed that women in this study group had a
work and CTS tended to compare working higher prevalence of CTS than men (OR 2.6,
groups by classifying them into broad 95% CI 1.35.2). Force also significantly
categories based on estimates of the predicted CTS (OR 1.8, 95% CI 1.12.9), but
forcefulness of hand/wrist exertions in not repetitiveness. Because the proportion of
combination with estimated repetitiveness. In women varied by exposure group (48%, 75%,
most studies the exposure classification was an and 79% from groups 1 to 3), the possibility of
ordinal rating (e.g., low, moderate, or high); in an interaction between gender and job
some studies job categories or titles were used exposure exists, but this was not statistically
as surrogates for exposure to force exertions. examined. In an analysis limited to females, the
2 significant predictors of CTS were oral
Studies Meeting the Four Evaluation Criteria contraceptive use (OR 2.0, 95% CI 1.25.4),
Four studies that evaluated the relationship and force (OR 1.6, 95% CI 1.13.0). Concern
between forceful hand/wrist exertion and CTS over interpretation of these findings is raised
met all four criteria: Chiang et al. [1993], because oral contraceptive use varies with age,
Moore and Garg [1994], Osorio et al. [1994], and age may vary with job exposures.
Silverstein et al. [1987]. Chiang et al. [1993]
studied 207 workers from 8 fish-processing
factories in Taiwan. Jobs were divided into 3 These potential interactions were not examined,
groups based on levels of force and and womens ages by job group were not
repetitiveness. The comparison group (low reported.
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jobs studied allowed for up to a 32-month

Moore and Garg [1994] evaluated 32 jobs in a latency period. The possibility of differential
pork processing plant and then reviewed past case ascertainment between exposed and
OSHA 200 logs and plant medical records for unexposed jobs exists, both because of
CTS cases in these job categories. IRs were different observation periods, as well as the
calculated using the full-time equivalent (FTE) likelihood that turnover may have been greater
number of hours worked as reported on the in the exposed jobs. It is also unclear whether
logs. The exact number of workers was not employees worked full-time or part-time hours.
reported. Exposure assessment included
videotape analysis of job tasks for
repetitiveness and awkward postures. The Osorio et al. [1994] studied 56 supermarket
force measure was an estimate of the %MVC, workers. Exposure to repetitive and forceful
based on weight of tools and parts and wrist motions was rated as high, moderate, or
population strength data, adjusted for extreme low, following observation of job tasks (97%
posture or speed. Jobs were then predicted to initial concordance with 2 independent
be either hazardous or safe (for all Upper observers). The CTS case definition was based
Extremity MSDs), based on exposure data and on symptoms and nerve conduction studies.
judgment. CTS was determined by reviewing CTS-like symptoms occurred more often (OR
OSHA 200 logs and plant medical records. 8.3, 95% CI 2.626.4) among workers in the
The proportion of CTS in the overall study high exposure group compared to the low
group during the 20 months of case exposed group. The odds of meeting the
ascertainment was 17.5 per 100 FTEs. If the symptom and NCS-based CTS case definition
occurrence of CTS did not vary over this among the high exposure group were 6.7 (95%
period, the proportion of CTS in a 12-month CI 0.852.9), compared to the low exposure
period would be 10.5 per 100 FTEs. The group.
hazardous jobs had a RR for CTS of 2.8 (0.2,
36.7) compared to the safe jobs. Potential for Silverstein et al. [1987] measured force by
survivor effect (79% of the workforce was laid electromyographs of representative workers
off the year before the study), limited latency forearm flexor muscles while they performed
period (8-32 months), and the potential for their usual tasks. EMG measurements were
incomplete case ascertainment (underreporting averaged within each work group to
is common on OSHA 200 logs, and logs were characterize the force requirements of the job;
not reviewed for the first 12 months of the jobs were then divided into high or low
study) limit confidence in this estimate. One of categories if the mean adjusted force was
the more hazardous jobs, the Ham Loaders, above or below
required extreme wrist, shoulder and elbow 4 kg. Jobs were then classified into 4 groups
posture and was rated 4 on a 5-point scale for that also accounted for repetitiveness: low
force, yet there was no observed morbidity. force/low repetitiveness, high force/low
Since this job did not start until 1989, the repetitiveness, low force/high repetitiveness,
period of observation for musculoskeletal and high force/high repetitiveness. Fourteen
disorders for this job was only 8 months. Other cases (2.1% prevalence) of CTS were
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diagnosed based on standardized physical sweepers. The textile production workers were
examinations and structured interviews. divided into four broad job categories based on
similarity of upper extremity exertions. The
The OR for CTS in high force jobs compared Boarding group required the most physical
to low force jobs, irrespective of repetitiveness, exertion. No formal exposure assessment was
was 2.9 (p>0.05). The plant- adjusted OR for conducted. Health assessment included a
CTS in jobs with combined exposures to high questionnaire and screening physical
force and high repetition was 14.3 (p<0.05), examination followed by a diagnostic physical
compared to jobs with low force and low examination. CTS was diagnosed using
repetition. Age, gender, plant, years on the job, predetermined clinical criteria. The severity of
hormonal status, prior health history, and cases was also reported as mild, moderate or
recreational activities were analyzed and severe. The overall prevalence for CTS was
determined not to confound the associations 1.1%, with 0.7% in Boarding, 1.2% in Sewing,
identified. The OR for CTS in jobs with 0.9% in Knitting, 0.5% in Packaging/Folding,
combined exposure from the multiple logistic and 1.3% in the comparison group. None of
analysis was 15.5 (95% CI 1.7142.) the differences were statistically significant. A
statistical model that also included age, gender,
Studies Meeting at Least One Criterion race, and years of employment showed that
Baron et al. [1991] studied CTS in 124 CTS occurred more often among women in this
grocery store checkers and 157 other grocery study (p<0.05). Interpretation of these data,
store workers who were not checkers. The especially with a low prevalence disorder like
CTS case definition required symptoms that carpal tunnel syndrome, is difficult since gender
met pre-determined criteria on a standardized varied with job (e.g., 94% of Boarding workers
questionnaire. Physical examinations were also were female, compared to 56% in the
performed, but participation rates at the work comparison group), and the comparison group
sites were higher among the exposed group may have also been exposed to upper extremity
(checkers: 85% participation, non-checkers: exertions (machine maintenance workers,
55% participation). Telephone interviews to transportation workers, cleaners and
non-checkers resulted in questionnaire sweepers). Interactions among potential
completion by 85% of the non-checkers. confounders were not addressed, but they are
Based on a questionnaire case definition, the suspected because of significant associations
OR for CTS among checkers was 3.7 (95% between race and three musculoskeletal
CI 0.716.7), in a model that included age, disorders.
hobbies, second jobs, systemic disease, and
obesity. Nathan et al. [1988] studied median nerve
conduction of 471 randomly selected workers
McCormack et al. [1990] studied 1,579 textile from four industries (steel mill, meat/food
production workers compared to 468 other packaging, electronics, and plastics
nonoffice workers, a comparison group that manufacturing). Jobs were grouped into 5
included machine maintenance workers, relative levels of force (from very light to very
transportation workers, cleaners, and high) after observation of job tasks. Jobs were
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also rated for repetitiveness (5 levels). Thirty- significantly higher than Group 1 in prevalence
nine percent of the study subjects had impaired of median nerve slowing.
sensory conduction, or slowing of the median
nerve. The 5 exposure groups were defined as In 1992 Nathan et al. [1992a] reported on a
follows: Group 1 is very low force, low follow-up evaluation in the same study group.
repetition (VLF/LR); Group 2 is low force, Sixty-seven per cent of the original study
very high repetition (LF/VHR); Group 3 is subjects were included. Hands (630), rather
moderate force, moderate repetition (MF/MR); than subjects, were the basis of analysis in this
Group 4 is high force/moderate repetition study. Novice workers (those employed less
(HF/MR); and Group 5 is very high force/high than 2 years in 1984) were less likely to return
repetition (VHF/HR). The most logical than non-novice workers (56% compared to
comparisons to evaluate the effect of force 69%, p=0.004). Probable CTS was defined on
would be Groups 3, 4, and 5 (moderate, high, the basis of symptoms reported during a
and very high force) compared to Group 1 (low structured interview and a positive Phalens or
force). Group 2 jobs are not a good Tinels test. Maximum latency differences in
comparison because they are very highly median nerve sensory conduction were
repetitive, which may confound the determined as in the 1984 study. The authors
comparisons. The authors reported a state that there was no significant difference in
significantly higher number of subjects with the prevalence of slowing between any of the
median nerve slowing in Group 5 (VHF/HR) exposure categories in 1989. However,
compared to Group 1 (VLF/LR), but not in calculations using common statistical methods
other groups, using an uncommon statistical show significantly higher prevalences of slowing
method (pairwise unplanned simultaneous test in Group 4 (PR 1.4, 95% CI 0.92.1)
procedure [Sokal and Rohlf 1981]). The compared to Group 1. Group 3's prevalence of
authors also reported that when individual slowing was 26% compared to Group 1's
hands were the basis of calculations rather than 18%, but this difference was not statistically
subjects, Group 3 had a significantly higher significant (p=0.07). Group 5 had the same
prevalence of median nerve slowing. prevalence of slowing (18%) as Group 1 in
Calculations of the more familiar PRs and chi- 1989; the prevalence of slowing in Group 5
squares [Kleinbaum et al. 1982], using the was 29% in 1984. The drop in prevalence of
published data, result in higher prevalences of slowing in Group 5 between 1984 and 1989
median nerve slowing in each of Groups 3, 4, might be explained by the higher drop-out rate
and 5, compared to Group 1 (PRs: 1.9, 95% among cases in Group 5 compared to Group 1
CI 1.32.7; 1.7, 95% CI 1.12.5; and 2.0, (PR 2.9, 95% CI 1.36.6). This was not
95% CI 1.13.4, respectively). A conservative addressed by the authors.
adjustment (Bonferroni) of the significance level
to 0.0125 for multiple comparisons [Kleinbaum Punnett et al. [1985] compared the symptoms
et al. 1982] would result in Group 5 no longer and physical findings of CTS in 162 women
being statistically significantly different from garment workers and 76 women hospital
Group 1 (p=0.019), but Group 4 (p=0.009) workers such as nurses, laboratory technicians,
and Group 3 (p=0.000) remain statistically and laundry workers. Eighty-six percent of the
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garment workers were sewing machine ulnar nerve function showed lower amplitudes
operators and finishers (sewing and trimming by and longer latencies (p<0.05) among the
hand). The sewing machine operators were asymptomatic automotive workers; differences
described as using highly repetitive, low force were greater between the symptomatic
wrist and finger motions, whereas finishing automotive workers and the white collar
work also involved shoulder and elbow workers. The symptomatic automotive workers
motions. The exposed garment workers likely had lower amplitudes and longer latencies for 5
had more repetitive jobs than most of the of 6 median sensory measures (p<0.05),
hospital workers. CTS symptoms occurred compared to the asymptomatic automotive
more often among the garment workers (OR workers; there were no significant differences in
2.7, 95% CI 1.27.6) compared to the hospital ulnar nerve function between these two groups.
workers. There was a low participation rate Asymptomatic automotive workers had
(40%) among the hospital workers. healthier median nerves than automotive
workers with CTS symptoms, but there were
Stetson et al. [1993] conducted nerve no differences between these 2 groups in ulnar
conduction studies on 105 administrative and nerve function, suggesting that the case
professional workers, and 240 automotive definition was specific for CTS.
workers. Hand/wrist forces were estimated
based on weights of tools and parts and Of the studies that addressed CTS, almost all
systematically recorded observations of one or examined occupations and jobs in which force
more workers on each job. Jobs were then was combined with another exposure factor
ranked according to grip force cutoffs: <6 lb, (such as repetition or awkward postures).
>6 lb, >10 lb. Median nerve measures differed Chiang et al. [1993] estimated exposure to
among the groups: index finger sensory hand/wrist force independent of repetitiveness
amplitudes were lower and distal sensory and found statistically significant RRs for CTS
latencies were longer among automotive ranging from 1.6 to 1.8. Estimates of RR that
workers in jobs requiring grip force >6 lb and were not statistically significant ranged from 0.4
>10 lb, compared to those requiring less than 6 to 6.7 [McCormack et al. 1990; Osorio et al.
lb (p<0.05 for all). At the wrist, median sensory 1994]. Relative risk estimates for CTS among
amplitudes were also lower and distal median workers exposed to a combination of forceful
sensory latencies were also longer among the and repetitive hand/wrist exertions ranged from
>6 lb, and the >10 lb exposure groups (p<0.05 1.0 to 15.5 [Nathan et al. 1988, 1992a;
for 3 of 4 differences). Age, height, and finger Silverstein et al. 1987].
circumference were included in statistical
models. The automotive workers were then Study limitations may impact the interpretation
divided into two groups, symptomatic (n=103) of findings. One limitation to consider is gender
and asymptomatic (n=137), based on whether effect. Of the studies listed above reporting
or not they met standard interview criteria for statistically significant associations between
CTS symptoms. When comparisons were forceful hand/wrist exertions and CTS, gender
made to the administrative and professional effect was controlled for in the analyses. Other
workers, 15 of 16 measures of median and potential limitations such as selection factors
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impact the interpretation of the studies limitations, such as survivor bias, can cloud the
reviewed. Survivor bias can be a concern. If findings of even prospective studies. In our re-
workers with CTS are more likely to leave jobs analysis of Nathan et al.s [1992a] data, 2 of 3
that require forceful and repetitive hand/wrist groups exposed to forceful hand/wrist exertions
exertions than jobs without those demands, were more likely to have median nerve slowing
then the workers in the highest risk jobs may be when nerve conduction testing was repeated 5
survivors (those who did not get CTS). Our years later. The highest exposure group had the
analysis of Nathans [1992a] data from a same prevalence of slowing as the lowest
follow-up of industrial workers shows that exposure group in 1989, whereas there had
cases (with median nerve slowing) were more been a higher prevalence rate in 1984. As
likely to drop out of the most highly exposed discussed above, this apparent decrease in
group than the unexposed group, which might prevalence over 5 years can likely be explained
explain why the RR for high exposure by survivor bias. Our interpretations of the data
decreased from 2.0 to 1.0 over a 5-year differ from those of the author. Further study is
period. Survivor bias results in an needed to clarify these issues. To our
underestimate of the RR. knowledge, there is no evidence that workers
with pre-existing CTS are more likely to seek
Refined or exact measures of exposure to or to be employed in jobs with high force
forceful hand/wrist exertions are not always requirements. We believe that employment
used in epidemiologic studies (e.g., sometimes practices would, if they had any influence, tend
exposure is based on job category and not to exclude new hires with CTS from jobs with
actual forceful measurements); this can result in high force requirements for the hand/wrist.
some study subjects being assigned to the
wrong exposure category. When this occurs, Case definitions in most of the cross-sectional
the usual effect is again to underestimate the RR studies excluded cases that occurred before
between exposure groups. working on the current job. This limits CTS
cases studied to those that occurred following
Stetson et al. [1993] did not report RR current exposure. Several of the studies
estimates for exposure variables, but they reviewed also required a minimum time period
reported that median sensory amplitudes were of working on the job before counting CTS
significantly smaller and distal sensory latencies cases. This increases the likelihood that
were significantly longer in groups with forceful exposure to forceful hand/wrist exertion
hand exertions (p<0.05). Age, height, and occurred for a sufficient length of time to
finger circumference were included in statistical develop CTS.
models. There is evidence that CTS is also attributable
to nonwork causes (hobbies, sports, other
medical conditions, and hormonal status in
Temporality, Force and CTS women, etc.). One issue which deals with
temporality is whether those with
Temporal issues can usually best be addressed nonwork-related CTS would be more likely to
using longitudinal studies. However, study be hired into jobs requiring more forceful
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hand/wrist exertions than those without CTS. that increasing levels of force alone resulted in
Again, it seems unlikely that those with increased risk for CTS. The only evidence for
pre-existing CTS would be preferentially hired an increasing risk for CTS that can be
into jobs requiring highly forceful hand/wrist attributed to increasing levels of force alone is
exertions. from a comparison across 2 studies that used
the same methods. Chiang et al. [1993] and
Consistency of Association for Force Silverstein et al. [1987] used the same methods
and CTS to measure hand/wrist force requirements and
repetitiveness of jobs. Chiang et al. [1993]
Most of the statistically significant estimates of used a lower cutoff point (3 kg compared to 4
RR for CTS among workers with exposure to kg) in Silverstein et al.s [1987] study for
forceful hand/wrist exertions were positive. No classifying jobs as high force; these
studies found statistically significant negative investigators used identical definitions of
associations between forceful hand/wrist repetitiveness. Therefore, a comparison of the
exertions and CTS. One study reported ORs RR estimates between the 2 studies provides
that were less than one among the groups that some information about the level of risk
were described as exposed to repetitive hand associated with different levels of force. Chiang
movements; chance and study limitations et al. [1993] reported an OR of 2.6 (95% CI
cannot be ruled out as possible explanations for 1.07.3) for the high force and repetitive
this finding. The other nonsignificant estimates (HF/HR) (>3 kg) group (limited to females to
of RR were, with one exception, greater than avoid confounding) compared to the low force
one. and repetitive (LF/LR) group; whereas
Silverstein et al. [1987] reported an OR of
Statistical significance can be a function of 15.5 (95% CI 1.7142) for the HF/HR group
power (the ability of a study to detect an (in a statistical model that included gender, age,
association when one does exist). In general, years on the job, plant and exposure level)
larger studies are necessary in order to have compared to the LF/LR group. This
sufficient power to detect associations with rare comparison provides limited evidence of an
diseases. CTS is a less frequently observed increased RR for CTS with increasing level of
disorder than tendinitis, for example, and so hand/wrist force.
larger studies are required to detect
associations with confidence. There is more evidence of a dose-response
relationship for CTS with increasing levels of
Coherence of Evidence, Force and force and repetition combined. Chiang et al.
CTS [1993] reported a statistically significant trend
of increasing prevalence of CTS with increasing
Please refer to the Repetition and CTS Section. exposure level (8.2% [LF/LR], 15.3% [HF or
HR], and 28.6% [HF/HR], p<0.01). Silverstein
et al. [1987] suggested a multiplicative effect
Exposure-Response Relationship, when exposure to high force and high
Force and CTS repetitiveness were combined (15.5),
compared to high force (1.8) or high
None of the studies reviewed demonstrated repetitiveness (2.7) alone.
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Of the remaining nine studies, seven are Studies Meeting the Four Evaluation Criteria
consistent with the combined effect of force and Two studies fulfilled the four criteria for posture
repetition [Stetson et al. 1993; Moore and and CTS: Moore and Garg [1994], Silverstein
Garg 1994; Osorio et al. 1994; Armstrong and et al. [1987]. The overall study designs are
Chaffin 1979; Nathan et al. 1988; Punnett et al. mentioned above; the following section will
1985; Baron et al. 1991], one is not cover the posture assessment.
[McCormack et al. 1990]; and one is equivocal
[Nathan et al. 1992a]. For the exposure assessment of the posture
variables in the Silverstein et al. [1987] study,
In conclusion, there is evidence that force three representative workers from each
alone is associated with CTS. There is strong selected job performing the jobs for at least
evidence that a combination of forceful three cycles were videotaped using two
hand/wrist exertion and repetitiveness are cameras. The authors then extrapolated the
associated with CTS. posture data to non-observed workers.
POSTURE AND CTS Moore and Garg [1994] used a wrist

Definition of Extreme Postures For classification system similar to that used by
CTS Stetson et al. [1993], classifying the wrist angle
We selected those studies which addressed estimated from videotape as neutral, non-
posture of the hand/wrist area including those neutral or extreme if the flexion/extension angle
addressing pinch grip, ulnar deviation, wrist was 0 to 25, 25 to 45 and greater than 45,
flexion/extension. Posture is a difficult variable respectively; or if ulnar deviation was less than
to examine in ergonomic epidemiologic studies. 10, 10 to 20, and greater than 20,
It is hypothesized that extreme or awkward respectively.
postures increase the required force necessary
to complete a task. Posture may increase or Strength of Association: Posture and
decrease forceful effort; its impact on MSDs CTS
may not be accurately reflected in measurement Silverstein found no significant association
of posture alone. Reasons that the variable between percentages of cycle time observed in
extreme posture has not been measured or extreme wrist postures or pinch grip and CTS.
analyzed in many epidemiologic studies are: 1) CTS jobs had slightly more ulnar deviation
because of the extreme variability of postures and pinching but these differences were not
used in different jobs as well as the extreme statistically significant. The authors noted that
variability of postures between workers among all the postural variables recorded, the
performing the same job tasks, variability between individuals with similar or
2) because several studies have taken into identical jobs was probably the greatest for
account the effects of posture when determining wrist postural variables. This individual variation
other measured variables such as force within jobs was not taken into account in the
[Silverstein et al. 1987; Moore and Garg analysis, creating a potential for
1994]; and 3) stature often has a major impact misclassification of individuals by using the
on postures assumed by individual workers variable job category in the analysis. The
during job activities. effect of exposure misclassification is usually to
decrease differences between exposure groups
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and decrease the magnitude of association. a pinched grasp. Given the period of recall for
self-reported exposure (05 years), and no
Moore and Gargs [1994] classification of jobs independent observation or attributes of
did not separate the posture variables from exposure, these results must be interpreted with
other work factors, and used posture along caution (meaning that within the limitations of
with other variables to classify jobs into the data and conclusions, when considered with
hazardous and safe categories. The RR of other studies that have more stringent methods,
CTS occurring in hazardous jobs was 2.8 but the RRs seem consistent and supportive and do
not statistically significant (p=0.44). not offer alternate conclusions).
Studies Not Meeting All Four Evaluation Armstrong and Chaffins [1979] pilot study of
Criteria
female sewing machine operators with
deKrom et al. [1990] compared certain symptoms and/or signs for CTS compared to
exposure factors between 28 CTS cases from controls found that pinch force exertion
a community sample and 128 CTS cases from (exposure measurements estimated from EMG,
a hospital (a total of 156 CTS cases) to 473 film analysis) was significantly associated (OR
community non-cases (n=473). The authors 2.0). Pinch force was a combination of
relied on self-reported information about factorsposture and forceful exertion. The
duration of exposure (hours per week) to CTS authors reported that CTS-diagnosed subjects
risk factors (flexed wrist, extended wrist, used deviated wrist postures more frequently
extended and flexed wrists combined; pinch than nondiseased, particularly during forceful
grasp and typing), with respondents recalling exertions. What is unable to be answered due
exposure from the present to 5 years prior from to the study design, was whether the deviated
the questionnaire date. Four groups of duration postures were necessitated due to symptoms
were used in the analyses (0; 17; 819, and signs of CTS, or the deviated postures
2040 hours/week). In this study, the selection caused or exacerbated the symptoms and signs.
process of cases was not consistent. Initially, a
random population sample was used, then Stetson et al. [1993] found that gripping
hospital outpatients were used to supplement greater than 6 pounds per hand was a
the number of CTS cases when numbers were significant risk factor for median distal sensory
found to be insufficient. This may be a problem dysfunction (an indicator of CTS) when the
when estimating the etiologic role of workload, study population was divided into exposed and
as cases seeking medical care may cause a non-exposed groups. Gripping greater than 6
referral bias. However, the authors stated that pounds is a variable which combines two
they came up with the same relationship work-related variables, posture and forceful
between flexed and extended wrist using only exertion. As seen with other studies referenced
CTS cases from the population-based data. above, the single work-related variable was not
The risk of CTS was found to increase with the found to be associated with median nerve
reported duration of activities with flexed wrist dysfunction, but the combination of variables
(RRs from 1.5 to 8.7, with increasing hours) or was significant. Looking specifically at wrist
activities with extended wrist (RR from 1.4 to deviation in the Stetson et al. [1993] study, the
5.4 with increasing hours) over the past 5 midpalm to wrist sensory amplitude was smaller
years, but not for working with a flexed or in the group not exposed to wrist deviation
extended wrist in combination, or working with
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(p=0.04) compared to those exposed to wrist significantly associated with CTS when
deviation (contrary to what was expected). comparing jobs where grip strength was three
Also, no significant differences were found in times greater than in the low risk jobs. In those
the mean measurements between nonexposed studies which used self-reports for categorizing
and exposed groups for use of pinch grip. posture, the associations were also positive.
Tanaka et al. [1995] analysis of the Temporal Relationship

Occupational Health Supplement of the NHIS There were no longitudinal studies which
population survey depended on self-reported examined the relationship between extreme
CTS, self-reported exposure factors, and posture and CTS. Two cross-sectional studies
occupation of the respondent for analysis. Self- that met the evaluation criteria addressed the
reported bending and twisting of the hand and association between posture and CTS.
wrist (OR 5.9) was found to be the strongest Silverstein et al. [1987] did not find a significant
variable associated with medically-called relationship between CTS and extreme
CTS among recent workers, followed by race, posture, but exposure assessment was limited
gender, vibration and age (repetition and force to representative workers; inter-individual
were not included in the logistic models). variability limited the ability to identify actual
Limitations of self-reported health outcome and relationships between postures and CTS. In the
exposure do not allow the conclusions of this Stetson et al. [1993] study, the authors
study to stand alone; however, when examined mentioned the limitations of interpretation of
with the other studies, it suggests a relationship their posture results due to misclassification of
between posture and CTS. workers. They extrapolated exposure data to
non-observed workers, so individual variability
The two other studies which examined posture in work methods and differing anthropometry
and its relationship to CTS did not focus on the are not accounted for. These limitations all
hand and wrist. English et al. [1995] found a influence outcome, and the conclusions must be
relationship between self-reported rotation of interpreted with caution, and considered along
the shoulder and elevated arm and CTS, an OR with biomechanical and laboratory studies.
of 1.8. Liss et al. [1995] found an OR of 3.7
for self-reported CTS comparing risk factors Coherence of Evidence
from dental hygienists to dental assistants, with Flexed wrist postures may reduce the area of
self-reported percent of time the trunk was in a the carpal tunnel thus potentially increasing the
rotated position relative to the lower body as pressure in the tunnel with a concomitant
one of the factors. increase in the risk of CTS [Skie et al. 1990;
Armstrong et al. 1991]. Marras and
Given these limitations of categorizing posture, Shoenmarklin [1993] found that the variables of
three studies [Stetson et al. 1993; Loslever and wrist flexion, extension, angular velocity, and
Ranaivosoa 1993; Armstrong and Chaffin wrist flexion, extension, angular acceleration
1979] using different methods to measure discriminated between jobs with a high versus a
posture and estimate force, found that the low risk of having an upper extremity
combination of significant force and posture reportable injury (an OSHA recordable
was significantly related to CTS. Marras and disorder due to repetitive trauma). The authors
Shoenmarklin [1993] also found posture to be suggested that this result was due to high
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accelerations requiring high forces in tendons. [Chatterjee 1992; Silverstein et al. 1987].
Szabo and Chidgey [1989] showed that Chatterjee et al. [1982] performed independent
repetitive flexion and extension of the wrist exposure assessment of the vibrating tools, and
created elevated pressures in the carpal tunnel found the rock drillers to be exposed to
compared to normal subjects, and that these vibration between the frequencies of 31.5 and
pressures took longer to dissipate than in 62 Hertz.
normal subjects. Observed repetitive passive
flexion and extension appeared to pump up Silverstein et al. [1987] is discussed above.
the carpal tunnel pressure; active motion of the Silverstein [1987] had no quantitative measures
wrist and fingers also had an effect over and of vibration, but observed exposure from
above that of the passive motions tested. videotapes and found all jobs with vibration
Laboratory studies demonstrate that carpal exposure to be highly repetitive and mostly
canal pressure is increased from less than forceful jobs.
5mmHg to more than 30 mmHg during wrist
flexion and extension [Gelberman et al. 1981]. Studies Not Meeting the Evaluation Criteria
There are seven studies on Table 5a4 that
Exposure-Response Relationship, meet at least one of the four criteria.
CTS and Posture
Few studies address exposure-response In addition, there are 2 clinical case studies of
relationship between CTS and extreme vibration and CTS [Rothfleish and Sherman
posture. deKrom et al. [1990] reported an 1978; Lukas 1970] that were not controlled for
increased risk of CTS with workers reporting confounders and not referenced in Table 5a4.
increasing weekly hours of exposure to wrist Rothfleisch and Sherman [1978] found an
flexion or extension (but not a combination of excess of power hand tool users among CTS
flexion/extension). Laboratory studies also patients. Lucas [1970] examined workers using
support a dose-response relationship of vibrating hand tools including stone cutters,
increased carpal tunnel pressure due to tunnelers, coal miners, forest workers and
increasing wrist deviation from neutral [Weiss grinders (all with a mean of 14 years exposure
et al. 1995] and pinch force [Rempel 1995]. to vibration) and found CTS in 21%. He found
that the prevalence of CTS in some groups was
In conclusion, there is insufficient evidence in as high as 33% (neither study had a referent
the current epidemiologic literature to group.)
demonstrate that awkward postures alone are
associated with CTS. Cannon et al. [1981] found that the self-
reported use of vibrating tools, in combination
VIBRATION AND CTS with reported forceful and repetitive hand
Definition of Vibration for CTS motions, was associated with a greater
We selected studies that addressed manual incidence of CTS than was repetitive motion
work involving vibrating power tools and CTS alone.
specifically.
Bovenzis study in 1994 compared stone
Studies Meeting the Four Evaluation Criteria workers (145 quarry drillers and 425 stone
Two studies examining the association between carvers) exposed to hand-transmitted vibration
vibration and CTS fulfilled the four criteria to 258 polishers and machine operators who
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performed manual activity only not exposed to a strong potential for confounding by hand or
hand-transmitted vibration. CTS was assessed wrist posture and forceful exertion.
by a physician, and exposure was assessed
through direct observation to vibrating tools and Temporal Relationship
by interview. Vibration was also measured in a There were no longitudinal studies which
sample of tools. examined the relationship between vibration
and CTS.
Strength of Association: Vibration
and CTS Consistency in Association
Chatterjee et al. [1982] found a significant All studies on Table 5a4 examining vibration
difference between rock drillers with symptoms and CTS found a significantly positive
and signs of CTS and the controls using the relationship between CTS and vibration
following NCS measurements: median motor exposure. Most studies had ORs greater than
latency, median sensory latency, median 3.0, so that results were less likely to be due to
sensory amplitude, and median sensory confounding.
duration, all at the p<0.05 level. Based on
nerve conduction measurements, they also Coherence of Evidence and Vibration
found an OR of 10.9 for rock drillers having The mechanism by which vibration contributes
abnormal NCS amplitudes in the median and to CTS and tendinitis development is not well
ulnar nerves compared to controls. Bovenzi et understood, probably because vibration
al. [1991] found an OR of 21.3 for CTS based exposure is usually accompanied by exposure
on symptoms and physical exam comparing to forceful and repetitive movements. Muscles
vibration-exposed forestry operators using exposed to vibration exhibit a tonic vibration
chain-saws to maintenance workers performing reflex that leads to increasing involuntary
manual tasks. Bovenzis study in 1994 found an muscle contraction. Vibration has also been
OR of 0.43 for CTS defined by signs and shown to produce short-term tactility
symptoms, controlling for several confounders. impairments which can lead to an increase in
In the Silverstein et al. [1987] study the crude the amount of force exerted during manipulative
OR for high force/high repetition jobs with tasks. Vibration can also lead to mechanical
vibration compared to high force/high repetition abrasion of tendon sheaths. Neurological and
without vibration was 1.9, but not statistically circulatory disturbances probably occur
significant. This suggested that there may have
been confounding (the OR was not statistically independently by unrelated mechanisms.
significant) between high force/high repetition Vibration may directly injure the peripheral
and vibration. Nilsson et al. [1990] found that nerves, nerve endings, and mechanoreceptors,
platers operating tools such as grinders and producing symptoms of numbness, tingling,
chipping hammers had a CTS prevalence of pain, and loss of sensitivity. It has been found in
14% compared to 1.7% among office workers. rats that vibration has caused epineural edema
Nathan et al. [1988] found a PR of 2.0 (95% in the sciatic nerve [Lundborg et al. 1987].
CI 1.33.4) for slowing of nerve conduction Vibration may also have direct effects on the
velocity when grinders were compared to digital arteries. The innermost layer of cells in
administrative and clerical workers. Cannon et the blood vessel walls appears especially
al. [1981] found an OR of 7.0 for CTS with the susceptible to mechanical injury by vibration. If
use of vibrating hand tools, although there was damaged, these vessels may become less
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sensitive to the actions of certain vasodilators epidemiologic studies of CTS that address
that require an intact endothelium. The NIOSH work factors also take into account potential
Criteria Document on exposure to hand-arm confounders.
vibration NIOSH [1989] quoted Taylor [1982]
as follows: It is not known whether vibration Almost all of the studies reviewed controlled for
directly injures the peripheral nerves thereby the effects of age in their analysis [Chiang et al.
causing numbness and subsequent sensory loss, 1990, 1993; Stetson et al. 1993; Silverstein et
or whether the para-anaesthesia of the hands is al. 1987; Wieslander et al. 1989; Baron et al.
secondary to the vascular constriction of the 1991; Tanaka et al. 1995, In Press;
blood vessels causing ischemia . . . in the nerve McCormack et al. 1990]. Likewise, most
organs. studies included gender in their analysis, either
by stratifying [Schottland et al. 1991; Chiang et
Exposure-Response Relationship, al. 1993], by selection of single gender study
CTS and Vibration groups [Morganstern et al. 1991; Punnett et al.
In the studies examined, only dichotomous 1985] or by including the variable in the logistic
categorizations were made, so conclusions regression model [Silverstein et al. 1987;
concerning an exposure-response relationship Stetson et al. 1991; Baron et al. 1991].
cannot be drawn. However, we can see Through selection of the study population and
significantly contrasting rates of CTS between exclusion of those with metabolic diseases,
high and low exposure groups. Wieslander et most studies were able to eliminate the effects
al. [1989] found that based on exposure from these conditions. Other studies did control
information obtained from telephone interviews, for systemic disease [Chiang et al. 1993; Baron
CTS surgery was significantly associated with et al. 1991]. Anthropometric factors have also
vibration exposure. Exposure for 120 years been addressed in several studies [Stetson et al.
gave an OR of 2.7, more than 20 years gave an 1993; Nathan et al. 1997; 1992b; Werner et
OR of 4.8. al. 1997]. As more is learned about
confounding, more variables tend to be
Conclusion addressed in more recent studies (smoking,
In conclusion, there is evidence supporting caffeine, alcohol, hobbies). In those older
studies which may not have controlled for
an association between exposure to vibration multiple confounders, it is unlikely that they are
and CTS. highly correlated with exposure, especially
those with ORs above 3.0. When examining
CONFOUNDING AND CTS those studies that have good exposure
It is clear that CTS has several non- assessment, widely contrasting levels of
occupational causes. When examining the exposure, and that control for multiple
relationship of occupational factors to CTS, it is confounders, the evidence supports a positive
important to take into account the effects of association between occupational factors and
these individual factors; that is, to control for CTS.
their confounding or modifying effects. Studies
that fail to control for the influence of individual CONCLUSIONS
factors may either mask or amplify the effects There are over 30 epidemiologic studies which
of work-related factors. Most of the have examined workplace factors and their
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relationship to CTS. These studies generally jobs with exposure to vibration and CTS.
compared workers in jobs with higher levels of There is strong evidence for a relationship
exposure to workers with lower levels of between exposure to a combination of risk
exposure, following observation or factors (e.g., force and repetition, force and
measurement of job characteristics. Using posture) and CTS. Ten studies allowed a
epidemiologic criteria to examine these studies, comparison of the effect of individual versus
and taking into account issues of confounding, combined work risk factors [Chiang et al.
bias, and strengths and limitations of the studies, 1990, 1993; Moore and Garg 1994; Nathan et
we conclude the following: al. 1988, 1992a; Silverstein et al. 1987;
Schottland et al. 1991; McCormack et al.
There is evidence for a positive association 1990; Stetson et al. 1993; Tanaka et al. [In
between highly repetitive work and CTS. Press]. Nine of these studies demonstrated
Studies that based exposure assessment on higher estimates of RR when exposure was to a
quantitative or semiquantitative data tended to combination of risk factors, compared to the
show a stronger relationship for CTS and effect of individual risk factors. Based on the
repetition. The higher estimates of RR were epidemiologic studies reviewed above,
found when contrasting highly repetitive jobs to especially those with quantitative evaluation of
low repetitive jobs, and when repetition is in the risk factors, the evidence is clear that
combination with high levels of forceful exposure to a combination of job factors
exertion. There is evidence for a positive studied (repetition, force, posture, etc.)
association between force and CTS based on increases the risk for CTS. This is consistent
currently available epidemiologic data. There is with the evidence that is found in the
insufficient evidence for a positive biomechanical, physiologic, and psychosocial
association between posture and CTS. There is literature.
evidence for a positive association between
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Table 5a-1. Epidemiologic criteria used to examine studies of carpal tunnel syndrome (CTS) associated with
repetition
examination, blinded to
Risk indicator and/or nerve case and/or
(OR, PRR, IR or Participatio conduction exposure Basis for assessing
Study (first author and p-value)*, n rate $$70% studies status hand exposure to repetition
year)
Moore 1994 2.8 Yes Yes Yes Observation or measurements
Osorio 1994 6.7 Yes Yes Yes Observation or measurements
Silverstein 1987 5.5 Yes Yes Yes Observation or measurements
Met at least one

criterion:
Barnhart 1991 1.94.0 No Yes Yes Observation or measurements
Cannon 1981 2.1 NR Yes NR Job titles or self-reports
English 1995 0.4 Yes Yes Yes Job titles or self-reports
Feldman 1987 2.26 Yes No NR Observation or measurements
McCormack 1990 0.5 Yes Yes NR Job titles or self-reports
Morgenstern 1991 1.88 Yes No No Job titles or self-reports
Nathan 1988 1.0 NR Yes NR Observation or measurements
Nathan 1992a 1.0 No Yes NR Observation or measurements
Punnett 1985 2.7 No Yes NR Job titles or self-reports
Schottland 1991 2.86, NR Yes NR Job titles or self-reports

1.87
Stetson 1993 NR Yes Yes NR Observation or measurements
Weislander 1989 2.7 Yes Yes No Job titles or self-reports

3.7
Not reported.
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Table 5a-2. Epidemiologic criteria used to examine studies of carpal tunnel syndrome (CTS) associated with force
Physical Investigato
examination, r blinded to
(OR, PRR, IR, Participatio conduction exposure Basis for assessing
Study (first author and year) or p-value)*, n rate $$70% studies status hand exposure to force
Osorio 1994 6.7 Yes Yes Yes Observation or measurements
Armstrong 1979 2.0 NR No No Observation or measurements
McCormack 1990 0.4-0.9 Yes Yes NR Job titles or self-reports
Nathan 1988 1.7-2.0 NR Yes NR Observation or measurements
Nathan 1992a 1.0, 1.4, 1.6 No Yes NR Observation or measurements
Punnett 1985 2.7 No Yes NR Job titles or self-reports
Not reported.
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posture
examination, blinded to
(OR, PRR, IR, Participato conduction exposure Basis for assessing
Study (first author and or p-value)*, n rate studies status hand exposure to posture
year) $$70%
Silverstein 1987 NR Yes Yes Yes Observation or measurements
Armstrong 1979 2.0 NR No No Observation or measurements
deKrom 1990 5.4 Yes Yes NR Job titles or self-reports
English 1995 1.8 Yes Yes Yes Job titles or self-reports
Tanaka 1995 5.9 Yes No No Job titles or self-reports
*Some risk indicators are based on a combination of risk factorsnot on posture alone (i.e., posture plus repetition, force,
Not reported.
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vibration
Physical Investigato
examination, r blinded to
(OR, PRR, IR, Participation conduction exposure Basis for assessing hand
Study (first author and or p-value)*, rate $$70% studies status exposure to vibration
year)
Chatterjee 1992 10.9 Yes Yes Yes Observation or measurements
Bovenzi 1991 21.3 NR Yes Yes Observation or measurements
Bovenzi 1994 3.4 Yes Yes No Observation or measurements
Cannon 1981 7.0 NR Yes NR Job titles or self-reports
Frkkil 1988 NR NR Yes NR Job titles or self-reports
Koskimies 1990 NR NR Yes No Observation or measurements
Tanaka In Press 1.8 Yes No No Job titles or self-reports
Weislander 1989 3.3 Yes Yes No Job titles or self-reports
*Some risk indicators are based on a combination of risk factorsnot on vibration alone (i.e., vibration plus repetition, posture,
or force). Odds ratio (OR), prevalence rate ratio (PRR), or incidence ratio (IR).
Not reported.
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Table 5a5. Epidemiologic studies evaluating work-related carpal tunnel syndrome (CTS)
MSD prevalence
Armstrong Case- 18 female sewing Outcome: CTS defined as For pinch force Participation rate: Not reported.
and Chaffin control machine operators with history of symptoms, surgical exertion: 2.0 1.6-2.5
1979 CTS histories compared decompression of the median All cases of CTS diagnosed prior to
to 18 female sewing nerve, positive Phalens test, or For hand study in working sewing machine
machine operators thenar atrophy. force: 1.05 1.0-1.2 operators, may cause referral bias
without CTS histories. in estimating role of workload.
Exposure: Hand/wrist
postures and estimation of Subjects excluded if history of
forearm flexor force in various fractures, metabolic or soft tissue
wrist and hand postures disease.
assessed by film analysis and
EMG. No association found between
hand size or shape and CTS.
CTS diagnosed subjects used

deviated wrist more frequently than
non-diseased, particularly during
forceful exertions.
(Continued)
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Table 5a5 (Continued). Epidemiologic studies evaluating work-related carpal tunnel syndrome (CTS)
MSD prevalence
Barnhart Cross- Ski manufacturing Outcome: CTS determined by: Case 1: Participation rate: 70% (repetitive
et al. 1991 sectional workers: 106 with (1) Case 1: Electro-diagnosis 34% 19% 1.9 1.0-3.6 jobs), 64% (non-repetitive jobs).
repetitive jobs compared of median-ulnar difference
to 67 with non-repetitive (latency on response time); Case 2: Examiner blinded to subjects job
jobs. (2) Case 2: Either Tinel's or 15.4% 3.1% 3.95 1.0-15.8 status but clothing may have biased
Phalen's test and electro- observations.
diagnosis; (3) Case 3: Ever Case 3:
having symptoms of hand pain, 32.5% 18.2% 1.6 0.8-3.2 Controlled for age and gender.
tingling, numbness, or
nocturnal hand pain and Tinel's Found for both right and left hand
or Phalen's test and electro- of those with repetitive jobs; mean
diagnosis. difference between distal sensory
latencies of median and ulnar
Exposure: Jobs classified as nerves were primarily due to a
repetitive and non-repetitive. shorter mean sensory latency of
Repetitive jobs entailed the ulnar nerve.
repeated or sustained flexion,
extension, or ulnar deviation of There was no difference in median
the wrist by 45E, radial nerve distal sensory latencies
deviation by 30E, or pinch grip between groups.
(determined by observation).
Hormonal status, systemic disease
included in questionnaire.
Diabetes significantly more frequent

in those with CTS than without
(p=0.01).
(Continued)
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MSD prevalence
Baron et al. Cross- 119 female grocery Outcome: CTS case defined 11% 4% 3.7 0.7-16.7 Participation rate: 85% checkers;
1991 sectional checkers vs. 56 other as having moderate to severe 55% non-checkers in field study.
female grocery store symptoms of pain, stiffness, Following telephone survey 91%
employees (comparison numbness, tingling. Symptoms checkers and 85% non-checkers.
group). begun after employment in the
current job; lasted > one week Adjusted for duration of work.
or occurred > once a month
during the past year; no history Total repetitions/hr ranged from
of acute injury to part of body 1,432 to 1,782 for right hand and
in question and a positive 882 to 1,260 for left hand.
physical exam of either
Phalen's or Tinel's test. Multiple awkward postures of all
upper extremities recorded but not
Exposure: Based on job analyzed in models.
category, estimates of
repetitive, average, and peak Examiners blinded to workers job
forces based on observed and and health status.
videotaped postures, weight of
scanned items, and subjective Controlled for duration of work,
assessment of exertion. hobbies.
Exposure level in checkers:

Average forces: Low
Peak force: Medium
Repetition: Medium
Exposure level in referents:

Average force: Medium
Peak force: Medium to low
Repetition: Medium.
(Continued)
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MSD prevalence
Bovenzi Cross- 65 vibration-exposed Outcome: CTS cases defined 38.4% 3.2% 21.3 (adjusted) p=0.002 Participation rate: Not reported.
et al. 1991 sectional forestry operators using as having symptoms of pain,
chain-saws compared to numbness, or tingling in the Examiners blinded to case status.
referents composed of median nerve distribution, and
31 maintenance workers physical exam findings of Controlled for age and ponderal
(electricians, mechanics, Tinel's or Phalen's test, index (height and weight variable).
and painters). diminished sensitivity to touch Metabolic disease also considered.
or pain in 3 fingers on radial
side, weakness in pinching or Controls also found to have several
gripping. risk factors for MSDs at
workstatic arm and hand
Exposure: Direct observation overload, overhead work, stressful
of awkward postures, manual postures, non-vibrating hand-tool
forces, and repetitiveness use.
evaluated via checklist. The
focus of the study was to Controls had a greater proportion of
compare vibration-exposed time in work cycles shorter than
workers to controls doing 30 sec than forestry workers.
manual work. Vibration
measured from two chain- Chain saw operators worked
saws. Vibration exposure for outdoors and were exposed to
each worker assessed in lower temperatures than
terms of 4-hr energy- maintenance workers.
equivalent frequency-weighted
acceleration according to ISO
5349.
(Continued)
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MSD prevalence
Bovenzi and Cross- Case group: Stone Outcome: CTS assessed by 8.8% 2.3% 3.4 1.4-8.3 Participation rate: 100%. All the
the Italian sectional workers employed in physician assessment. CTS active stone workers participated in
Group 1994 9 districts in Northern defined as symptoms, the study, so self-selection was
and Central Italy; (1) parathesias, numbness, or not a source of bias.
145 quarry drillers and pain in median nerve
425 stone carvers distribution; (2) nocturnal Physician administered
exposed to vibration. exacerbation of symptoms and questionnaires containing work
positive Tinel's or Phalen's test. history and examinations, so
Referent group: unlikely to be blinded to case
Polishers and machine Exposure: Direct observation status.
operators (n=258) who of vibrating tools assessed by
performed manual interview. Vibration measured Adjusted for age, smoking, alcohol
activity but were not in a sample of tools. consumption, and upper limb
exposed to hand- injuries.
transmitted vibration.
Leisure activities and systemic
All stone workers diseases included in questionnaire.
employed in 6 districts
participated in the survey Univariate analysis showed no
(n=578, 69.8%), association between systemic
whereas, in the three diseases and vibration so were not
other districts they were criteria for exclusion.
selected on basis of
random sampling of the Dose-response for CTS and lifetime
quarries and mills in the vibration exposure not significant.
geographic areas
(n=250, 30.2%).
(Continued)
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MSD prevalence
Cannon et al. Case- Aircraft engine workers Outcome: CTS cases identified For vibrating Participation rate: Participation rate
1981 control at 4 plants: 30 CTS through workers hand tool use: unable to be calculated from data
cases identified through compensation claims and 7.0 3.0-17 presented. 30 cases identified
workers compensation medical department records through record review of 20,000
claims and medical during a 2-year period. For repetitive workers.
department records motion tasks:
during a 2-year period Exposure: Based on job 2.1 0.9-5.3 Cases and controls on gender.
compared to 90 controls category, years on the job,
from the same plant, identified through record History of Controlled for gynecologic surgery,
16 workers receiving review and interviews. gynecologic race, diabetic history, years on the
compensation benefits Exposure to vibrating tools, surgery: job, use of low-frequency vibrating
for treatment of CTS, and repetitive motion. 3.7 1.7-8.1 tools.
14 cases who had not
received compensation Buffing, grinding, and hand Years on the Information obtained through self-
benefits. tools were measured with an job: administered questionnaires and
accelerometer and found to be 0.9 0.8-1.0 personal interviews on cases and
Three controls randomly in the range of 10 to 60 Hz. controls on age, sex, race, weight,
chosen from the same occupation, years employed,
plant for each CTS case. worker compensation status,
history of metabolic disease,
hormonal status of females, history
of gynecologic surgery.
Number of years employed

significantly different among cases
(5.5 years) and controls
(11.7 years). Range of years
employed among cases included
0.1 year to 28 years.
(Continued)
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MSD prevalence
Chatterjee Case- 16 rock drillers compared Outcome: CTS was 44% 7% Abnormal Participation rate: 93%.
et al. 1982 control with 15 controls. determined by symptoms from amplitudes of
questionnaire and interview by digital-action Examiners blinded to case status.
medical investigator, clinical potentials from
exams carried out blindly, and fingers Groups standardized for age and
nerve conduction studies. For supplied by the gender.
Table 5-7, CTS based solely on median and
NCS results; Table 5-9 based ulnar nerves; Exclusionary criteria: History of
on symptoms and NCS. the OR in constitutional white finger,
vibration secondary causes of Raynauds
Exposure: To vibration carried exposed vs. phenomenon, > one laceration or
out by measurement of controls: fracture in the hands or digits,
vibration spectra of the rock OR=10.89 1.02-524 severe or complicated injury
drills and observation of jobs. involving nerve or blood vessels or
Exposed group were those significant surgical operation,
miners who regularly used history of exposure to vibration
rock-drills in the fluorspar from tools other than rock drills.
mines or other miners using
similar rock-drills. Exposure Significant differences found
varied from 18 months to between controls and vibration
25 years (mean 10 years). group for symptoms of numbness
The rock drillers were exposed and tingling: median motor latency;
to vibration level in excess of median sensory latency; median
the damage level criterion sensory amplitude; median sensory
between the frequencies of duration. All at the p< 0.05 level.
31.5 and 62 Hz.
Skin temperature controlled for in
NCVs.
(Continued)
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MSD prevalence
Chiang et al. Cross- 207 active workers from Outcome: CTS defined as Group 1: Participation rate: Not specifically
1990 sectional 2 frozen food plants symptoms of numbness, pain, 4% clinical mentioned, however, paper states
divided into 3 groups: tingling in the fingers plus 2% that in order to prevent selective
(1) low-cold, low- innervated by the median sub-clinical bias, all of the employees in the
repetition (comparison nerve, onset since work in factories were observed initially.
group, mainly office staff current job, no relationship to Group 2: Group 2 vs.
and technicians, n=49), systemic disease or injury and 40.5% Group 1: Examiners blinded to exposure
(2) low-cold, high- physical exam of Tinel's test or clinical plus OR=8.28 1.18-58.3 status and medical history.
repetition (non-frozen Phalen's sign. Nerve 8.1%
food packers, n=37), conduction testing was sub-clinical Controlled for age, sex, and length
(3) high-cold, high- performed on motor and of employment. Interaction terms
repetition (frozen food sensory nerves of both upper Group 3: Group 3 vs. tested.
packers, n=121). limbs. If subject had abnormal 37.2% Group 1:
results and symptoms and clinical plus OR=11.66 2.92-46.6 Excluded subjects with diabetes,
physical exam findings, was 22.3% thyroid function disorders, history
considered CTS. If no sub-clinical of forearm fracture, unspecified
symptoms, considered as polyneuropathy, rheumatoid
subclinical CTS. Logistic arthritis.
Regression
Exposure: Job analyses Model: Workers in cold groups wore
conducted by industrial Cold: gloves and exerted higher forces
hygienist, to cold and repetition OR=1.85 than workers in non-cold groups.
assessed by observation. (p<0.22) Force was not evaluated in this
study. Confounding is possible
Highly repetitive jobs had cycle Repetitiveness: according to authors.
times <30 sec. >50% of cycle OR=1.87
time cold exposure was (p<0.018) CTS was independent of age and
defined as whether the job length of employment. Authors
required hands to be locally Cold x considered this to be due to healthy
exposed to cold. The mean Repetitive- worker effect.
skin temperature of their hands ness:
was in the range of 26 to OR=1.77 OR for group 1 vs. group 2 is 8.3
28EC, even with wearing (p<0.03) (1.2-58.3) when adjusted for sex
gloves. but 2.2 (0.2-21.1) when adjusted
for sex, age, and length of
employment suggesting survival
bias.
(Continued)
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MSD prevalence
Chiang et al. Cross- 207 fish processing Outcome: CTS defined as Group 2 Group 1 Participation rate: Paper stated that
1993 sectional workers divided in having symptoms of (Male): (Male): 2 vs. 1 (male): all of the workers who entered the
3 groups: (1) low-force, numbness, pain, or tingling in 6.9% 3.1% OR= 2.2 0.2-22.0 fish-processing industry before
low-repetition the fingers innervated by the June 1990 and were employed
there full-time were part of the
(comparison group, median nerve, onset after job Group 2 Group 1 2 vs. 1 cohort.
n=61); (2) high-force or began, and no evidence of (Female): (Female): (female):
high-repetition (n=118); systemic disease or injury and 18.0% 13.8% OR=1.3 0.5-3.5 Workers examined in random
sequence to prevent observer bias;
(3) high-force and high- physical exam findings of examiners blinded to case status.
repetition (n=28). positive Tinel's sign or Phalen's Group 3
Analysis controlled for age,

test. (Male): 3 vs. 1 (male):
0.0% stratified by gender.
Exposure: Assessed by Contraceptive use (females):
observation and recording of Group 3 significant (OR=2.0, 95% CI 1.2 to
tasks and biomechanical (Female): 3 vs. 1 5.4); tubal ligation not significant.
movements of 3 workers, each 36.4% (female): Workers with hypertension,
representing 1 of 3 study OR=2.6 1.0-7.3 diabetes, history of traumatic
groups. Highly repetitive jobs injuries to upper limbs, arthritis,
with cycle time <30 sec or collagen diseases excluded from
study group.
>50% of cycle time performing
the same fundamental cycles. Repetition: No significant age difference in
Hand force from EMG OR=1.1 0.7-1.8 exposure groups.
recordings of forearm flexor Physician-observed cases about
muscles. Classification of Force: the prevalence of symptoms of
workers into 3 groups OR=1.8 1.1-2.9 elbow pain (9.8 vs. 18.0; 15.3 vs.
according to the ergonomic 19.5; 35.7 vs. 17.9).
risks of the shoulders and Repetition and Dose-response for symptoms both
upper limbs: Group 1: low- force: in the hand and in the wrist
repetition and low-force; Group OR=1.1 0.7-1.8 (p<0.03) and physician-observed
2: high-repetition and high- CTS (p<0.015).
force; Group 3: high-repetition Male vs. Age, gender, repetitiveness,
or high-force. female: forceful movement of upper limbs
OR=2.6 1.3-5.2 and interaction of repetitiveness
and forceful movement calculated
in logistic regression.
Significant trend for duration of
employment in <12 months but not
12 to 60 months or >60 months.
(Continued)
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MSD prevalence
deKrom et al. Nested 28 CTS cases from a Outcome: Tingling pain and 5.6% For work: Participation rate: 70% response
1990 case community sample and numbness in median prevalence 20 to 40 hr/wk rate obtained for both hospital and
community samples.
control 128 CTS cases from a distribution, frequency in the with flexed Controlled for age, weight, slimming
hospital (total n=156) $2/week, awakened at night general wrist: OR=8.7 3.1-24.1 courses, gender, and checked for
compared to community and nerve conduction studies. population interactions.
non-cases (n=473). Motor latency < 4.5 months, (28 cases For work: Cases seeking medical care may
different median to ulnar DSL < from 20 to 40 hr/wk cause referral bias in estimating
Participants blinded to 4.0 months, controlled for 501 subject with extended etiologic role of work-load.
However, authors came up with
aim of studytold it was temperature. community wrist: same relationship between flexed
about general health. sample) OR= 5.4 1.1-27.4 and extended wrist using only CTS
CTS diagnosed by clinical cases from population-based data.
history and neurophysiological The associations from this study
are based on very small sample
tests. sizes. >64% of cases reported 0
hr/wk to each of the exposures.
Exposure: Awkward In random sample, age, and sex
hand/finger postures and pinch stratified, included twice as many
grasps assessed by females as males.
questionnaire: Self-reported No significant relationship between
pinch grasp or typing.
information about duration of Dose-response found for duration
exposure (hr/wk) to flexed of activities with flexed or extended
wrist, extended wrist, wrist statistically significant; dose-
extended and flexed wrist response relationship for both
present but not statistically
combined, pinched grasp. significant.
Typing hr categorized as Typing hr not significant but very
0, 1 to 7, 8 to 19, 20 to small numbers (<5 in comparison
40 hr/wk of exposure 0 to 5 groups); may have been unable to
detect a difference.
years ago, responses
Females with hysterectomy without
truncated at 40 hr/wk. oophorectomy significantly
increased risk, PRR=2.0 (1 to 3.6),
compared to females not operated
on; increase may be detection bias.
Wrist fractures, thyroid disease,
rheumatism, and diabetes not
significant for CTS.
Varicosis significant risk for males
12.0 (3.6-40.1).
Oral contraceptives not significantly
associated with CTS.
(Continued)
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MSD prevalence
English et al. Case- Cases: CTS patients Outcome: CTS based on Rotating Participation rate: 96%.
1995 control (n=171) ages 16 to 65 agreed criteria diagnosed by shoulder with
years from orthopedic orthopedic surgeons using elevated arm Due to design of study (cases
clinics. Controls: common diagnostic criteria (not and CTS: selected by diagnoses), blinding of
(n=996) 558 males and specified). OR=1.8 1.2-2.8 examiners not an issue.
438 females attending
the same clinics Exposure: Based on self- Repeated Adjusted for height, weight, and
diagnosed with reported risk factors at work: finger tapping gender.
conditions other than questions addressed: and CTS:
diseases of the upper awkward postures, grip types, OR=0.4 0.2-0.7 Significant negative association
limb, cervical, or thoracic wrist motions, lifting, shoulder with height and presentation at the
spine; ages 16 to 65 postures, static postures, etc. clinic as a result of an accident and
years. and job category. CTS.
A significantly positive association

with height.
Included frequency of movements

in regression analysis.
(Continued)
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MSD prevalence
Frkkil Cross- 79 chain saw users Outcome: CTS based on nerve 26% Significant Participation rate: 100% of
et al. 1988 sectional randomly selected from conduction studies, motor and correlation professional forestry workers.
186 forestry workers sensory conduction velocity, between
with >500 hr of distal and proximal latencies, numbness in Significant correlation between CTS
sawing/year. Tinels and Phalen's tests and the hands and HAVs found.
subjective symptoms. (r=0.38,
p<0.05) and Randomly selected from EMG out of
Exposure: Chain saw vibration CTS and 186.
not measured. Duration of muscle fatigue
chain saw use determined by (r=0.47, Alcohol consumption did not
interview. p<0.05) and correlate with numbness in the
CTS. hands or arms (r=0.14, p=NS) or
sensory disturbances.
Only motor nerve recordings were

analyzed for this study.
(Continued)
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MSD prevalence
Feldman Cross- 586 electronics workers Outcome: Based on Wrist Wrist Numbness and Participation rate: 84%.
et al. 1987 sectional at a manufacturing firm questionnaire survey and in tingling and tingling and tingling in Examiners blinded to case and
for with 700 employees. some an abbreviated numbness: numbness: fingers: exposure status: Not stated.
symptom neurologic examination that 18% 8.7% OR=2.26 1.4-4.46
involved tests of hand Analysis not controlled for
survey sensation, finger grip, and confounders.
strength of thenar muscles. High-risk vs. Questionnaire obtained data on
Pro- Tinels and Phalen's done. low-risk jobs: past medical history, exposure to
spective Standard nerve conduction of p<0.005 neurotoxins, cigarettes, hobbies,
for nerve left and right median nerves. and symptoms.
con- For nerve conduction testing, the
Exposure: Two subjects temperature of limbs was monitored
duction randomly selected for
studies and controlled for.
biomechanical analyses from
each of four high-risk areas, More females were in high-risk
determined from questionnaire areas and jobs than males.
and walk-through observations There were no workers >60 years
of tasks involving repetitive old in high-risk group. There were
flexion, extension, pinching, 34 workers >60 years in
and deviated wrist postures. comparison groups.
Videotaping and Rheumatoid arthritis more prominent
electromyography done. in low-risk group (8.2%) than high-
risk (2.4%) group.
Highly repetitive job task
defined as <30 sec cycle or Nerve conduction in high-risk
>50% of cycle performing the workers performed year 1 and
fundamental cycle. year 2. Right sensory amplitude
abnormal (<8V) in 22% of
Wrist posture characterized in workers at year 1 and 35.5% at
terms of flexion and extension: year 2. Left sensory amplitude
>45 flexed, 15 to 45 flexion, abnormal in 16.7% and 29% at
neutral, 15 to 45 extension, and year 2.
>45 extension and deviation. Most apparent changes (increases)
Hand posture characterized by seen in bilateral sensory velocities
6 types of grip. and motor latencies (abnormal
>4.5). Right motor latency abnormal
No quantitative measures of in 8% at year 1 and 11% in year 2.
vibration were obtained. Left motor latency abnormal in 2%
in year 1 and 23% at year 2.
Authors offered parameters for
staging CTS in high-risk subjects (0
to 4 stages).
(Continued)
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MSD prevalence
Franklin Retro- Workers in Washington Outcome: Assessed using 25.7 claims/ 1.74 14.8 (oyster 11.2- 19.5 Participation rate: This is a records
et al. 1991 spective State (n=1.3 million full- workers compensation claims 1,000 FTEs claims/ and crab review so it does not apply.
cohort: time workers in 1988). for CTS using ICD codes 354.0 (oyster and 1,000 FTEs packers)
from and 354.1. Incident claim was crab (industry Among claimants, the female-to-
1984 to Workers compensation the first appearance of a paid packers) wide rate) male ratio was 1.2:1.
1988 data for Washington bill for claimant with a
State, using physician diagnosis. Algorithm Mean age of claimants was 37.4.
compensable (time loss) was developed to identify 23.9 claims/
and non-compensable unique claimants which 1,000 FTEs 13.8 (meat and 11.6- 16.4 Diagnosis and data entry errors
claims for January 1984 removed multiple claims. (meat and poultry comprised 25% of CTS surgery
to December 1988. poultry workers) claimscases were not coded as
Exposure: Not measured. workers) CTS.
Workers in the same industrial
classification assumed to 82% of claims were true cases of
share similar workplace CTS.
exposures.
(Continued)
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MSD prevalence
Koskimies Cross- 217 forestry workers Outcome: 125 randomly Active Alcohol Participation rate: Not reported.
et al. 1990 sectional who used chain saw selected for EMG of sensory vibration: consumption
>500 hr during previous and motor nerves both hands. 5% white and CTS cases Examiners may not have been
3 years. finger r=0.15 p=NS blinded to exposure status because
CTS diagnosis based on Vibration of design of study.
symptoms, exclusion of other CTS: 20% exposure time
conditions, results of Phalens and motor NCV No comparison group because
and Tinels test, and findings in in median study was part of longitudinal study
sensory and motor nerve EMG. nerve of right of workers followed since 1972.
hand: r=-0.27 p=0.01
but not left
Exposure: Number of years of hand: r=-0.12 p=NS Most of 25 CTS workers had mild
vibration exposure (only symptoms at work despite severe
workers who had 500 hr Exposure time reduction of sensory NCS of
during previous 3 years were with both median nerve.
included. motor NCV in
ulnar nerve of Males with primary Raynauds
right hand disease, rheumatoid arthritis,
r=-0.26 and left p=0.05
hand diabetes, or positive urine glucose
r=-0.39. p<0.001 slide test results excluded from
study.
Distal latencies
in median 12 (48%) of those with CTS had
nerve and bilateral diagnosis. The authors
exposure in
right hand stated that the left hand is the
r=0.17; p=0.05 dominant working hand in sawing,
left hand the right hand acting more to direct
r=0.21. p=0.05 the saw during the operation.
Numbness and
sensory NCS
of median
nerve; right
hand r=0.679; p<0.001
left hand
r=0.53. p<0.01
(Continued)
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MSD prevalence
Liss et al. Cross- 1,066 of 2,142 dental Outcome: Mailed survey, Responder Responder Participation rate: 50% response
1995 sectional hygienists from Ontario 2 CTS case definitions: told that told that rate from both groups.
Canada Dental (1) based on positive response they had they had
Hygienists Association to "told by a physician that you CTS: CTS: 0.9% OR=5.2 0.9-32 Study population >99% female.
compared to referent had CTS", (2) if during last 12 7%
group, 154 of 305 dental months, for >7 days Question- OR were age adjusted.
assistants. experienced numbness and Question- naire
tingling, pain, or burning in naire based based Confounders considered included
distribution of median nerve, CTS: 11% CTS: 3.0% OR=3.7 1.1-11.9 typing, hobbies, and taking
night pain or numbness in estrogens.
hands, and no previous
wrist/hand injury.
Exposure: Based on mailed

survey: Length of practice,
days/wk worked, patients/day,
patients with heavy calculus,
percent of time trunk in rotated
position relative to lower body,
instruments used, hr of
typing/wk, type of practice.
(Continued)
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MSD prevalence
Loslever and Cross- 17 selected jobs with Outcome: Occupational Mean High force with Participation rate: Cases selected.
Ranaivosoa sectional frequent and repeated physician from each factory prevalence high flexion
1993 absences of workers involved in the study completed rate among and CTS: Occupational doctor supplied
due questionnaire concerning each jobs (jobs r=0.62 information on gender, age, years
to CTS investigated at job and the number of CTS chosen at on the job, hand orientation, has or
the request of cases. The prevalence of CTS workplaces High force and has not contracted CTS.
occupational doctors and was then calculated from ratio where CTS high extension
managers. of CTS cases and total number had been and CTS: Subjects spent 60 to 80% of their
Biomechanical data of employees that worked at reported): r=0.29 time in extension ranging from 13 to
recorded on a number of that place. 35% (range 30E.
workers from each job, 8 to 66%);
ranging from 1 to Exposure: Videotaping of prevalence Vibratory tools more often used in
4 workers. Involving movements, use of vibrating of CTS in tasks with high prevalence of CTS
961 workers. tools, and two measurement both hands: (27%) than in ones with low
techniques used: (1) Flexion- 20% prevalence of CTS (13%).
extension measurements:
Subjects recorded at several 92% of population were female.
points during the day for
15 min. An angle meter used to Non-standard data analysis
measure flexion-extension approaches, no statistical testing.
angles of the wrist: Rated high
flexion, low flexion, low Examiners not blinded.
extension, and high extension
using fuzzy cutting functions. Authors believe higher rate of CTS
Each modality characterized by in both hands (20%) vs. dominant
its arithmetic mean and its hand (100%) argue for non-
relative duration. (2) Force: occupational factors being more
Electromyography used; values important.
under 2 daN considered as low
forces. Calculated time spent
over 2 daN, maximal force,
number of peak exertions, and
the arithmetic mean of the n
values during a period.
(Continued)
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MSD prevalence
Marras and Cross- 40 volunteers at a highly Outcome: CTS was High-risk Low-risk Model for Participation rate: Not reported.
Shoenmarklin sectional repetitive, hand- determined from evaluation of job: 8 job: 0 predicting high
1993 intensive industrial jobs OSHA illness and injury logs incidents/ incidents vs. low job risk Examiners blinded: not stated.
in 8 different plants. Half and medical records. The 200,000 hr based upon
motion Confounders controlled for: Age,
the workers were independent variable was exposure component: gender, handedness, job
employed in jobs that had exposure to jobs in which CTS satisfaction.
OSHA recordable had occurred previously. A Position
repetitive trauma low-risk job was defined as Radial/ulnar All the jobs required gloves except
incidents, half the having a zero incidence rate; a ROM: OR=1.52 1.1-2.1 two-one low-risk and one high-
workers were in jobs high-risk job was defined as Flexion/exten- risk.
sion ROM:
with no history of having an incidence rate of OR=1.3 1.0-1.7 Significant difference between
recordable repetitive eight or more recordable Pronation/ groups with regards to age, years
trauma incidents. Two repetitive trauma. supination with the company, and trunk depth.
subjects from 10 ROM:
repetitive, hand- Exposure: Included number of OR=1.2 0.9-1.6 No significant difference in job
intensive jobs were wrist motions/8-hr shift, weight satisfaction, number of wrist
randomly chosen to of loads, handgrip types and Velocity movements, age, weight, stature,
Radialulnar vel: hand dimensions.
participate. forces, work heights, and OR= 2.4 1.3-4.3
motion descriptions. Wrist Flexion/ Turnover rate: High-risk jobs: 33%;
motion monitors measured in extension vel: low-risk jobs: 0.5%.
the radial/ulnar, OR=3.8 1.5-9.6
flexion/extension, and Pronation/ Grip forces were three times as
pronation/supination planes: supination vel: great in the high-risk jobs than in
OR=1.9 1.2-3.2 the low-risk jobs.
wrist angles, angular velocity,
angular acceleration. Acceleration Variance between subjects within
Radial/ulnar jobs accounted for a substantial
accel: percentage of total variance in
OR=2.7 1.5-4.9 wrist motion.
Flexion/
extension
accel:
OR=6.1 1.7-22
Pronation/
supination
accel: OR=2.96 1.4-6.4
(Continued)
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MSD prevalence
McCormack Cross- Textile workers: Outcome: Assessed by Prevalences 1.3% Participation rate: 91%.
et al. 1990 sectional 4 broad job categories questionnaire and screening of CTS (non-
involving intensive physical examination initially by office) Physician or nurse examiners not
upper extremity use. nurse. CTS diagnosed on Boarding: Boarding vs. blinded to case or exposure status
Workers randomly clinical grounds of symptoms 0.7% non-office (personal communication).
chosen: Sewing and positive Tinel's sign and OR=0.5 0.05-2.9
workers (n=562); Phalen's test. Physician Prevalence higher in workers with
boarding workers reassessed physical findings Sewing: Sewing vs. <3 years of employment. Race and
(n=296); packaging by standardized methods. 1.2% non-office age not related to outcome.
workers (n=369); and OR=0.9 0.3-2.9 Females found to have significantly
knitting workers Exposure: Assessment by more CTS than males.
(n=352) compared to observation of jobs. Exposure Packaging: Packaging vs.
other non-office to repetitive finger, wrist and 0.5% non-office Job category not found to be
workers (n=468). elbow motions assumed from OR=0.4 0.04-2.4 significant, however no
job title; no objective measurement of force, repetition,
measurements performed. Knitting: Knitting vs. posture analysis, etc.
0.9% non-office
OR=0.6 0.1-3.1 Questionnaire asked types of jobs,
length of time on job, production
rate, nature and type of upper
extremity complaint, and general
health history.
11 physician examiners;
interexaminer reliability potential
problem acknowledged.
(Continued)
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MSD prevalence
Moore and Cross- 32 jobs in which 230 Outcome: CTS identified from 13.7% 4.9% 2.8 0.2-36.7 Participation rate: Study based on
Garg 1994 sectional workers were employed. OSHA logs and medical records.
This study was more an records. A case required Investigators blinded to exposure,
evaluation of jobs than of electrophysiologic testing, case outcome status, and personal
individuals. confirmed as abnormal by identifiers on medical records.
electromyographer and Repetitiveness, type of grasp
presence of suggestive were not significant factors
symptoms. between hazardous and safe job
categories.
Exposure: Observation and No pattern of morbidity according to
videotape analysis of jobs. date of clinic visits.
Force, wrist posture, grasp Strength demands significantly
type, high-speed work, increased for hazardous job
localized mechanical stress, categories compared to safe job
vibration, cold, and work time categories.
assessed via observation of IR based on full-time equivalents
videotape. Jobs classified as and not individual workers, may
hazardous or safe based on have influenced overall results.
data and judgement. Workers had a maximum of 32-
months of exposure at plantso
duration of employment analysis
limited.
Average maximal strength derived
from population-based data
stratified for age, gender, and hand
dominance.
Using estimates of Silversteins
classification, association between
forcefulness and overall observed
morbidity was statistically
significant; repetition was not.
No control for confounders.
No information on work history,

number of unaffected workers, or
exposure duration.
(Continued)
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MSD prevalence
Morgenstern Cross- 1,058 female grocery Outcome: Defined CTS as self- For a Participation rate: 82%.
et al. 1991 sectional cashiers from a single reported hand/wrist pain, difference of
union. nocturnal pain, tingling in the 25 hr/wk: 1.88 0.9-3.8 Controlled for age.
hands or fingers, and 12% 5.4%
Comparison group was numbness. Information collected on age, sex,
those who reported no pregnancy status, work history as
symptoms. Exposure: Duration, use of a checker, specific job-related
laser scanner determined from tasks, use of selected drugs,
Cashiers were also survey (no measurements). history of wrist injury.
compared to results from
a general population In logistic regression, Use of
study from Rochester, diuretics significantly associated
Minnesota (Stevens et al. with CTS, OR=2.66 (1.00-7.04);
1988). thought to be related to fluid
retention by authors.
Laser scanning found not to be

significant factor.
(Continued)
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MSD prevalence
Nathan et al. Cross- 471 industrial workers Outcome: Case defined as Prevalence Prevalence Participation rate: Not reported.
1988 sectional from 27 occupations in NCS-determined impaired of abnormal of
4 industries. Jobs sensory conduction (sensory nerve abnormal Analysis controlled for age and
grouped into 5 classes latency). Sensory latencies conduction nerve gender.
assessed antidromically for sensory conduction
based on resistance and eight consecutive 1-cm latency: sensory No description of symptom status
repetition rate. segments of the nerve. A latency: for defining CTS.
maximum latency difference of
0.4 ms or greater used to Group II: Group I: Group II vs. I: Method of categorization of jobs
define impaired sensory 27% 28% PR=1.0 0.5-2.0 and occupations not described.
conduction. Case definition did
not deal with symptoms. Group III: Group I vs. III: Classification system is based on
47% PR=1.9 1.3-2.7 only repetition and not resistance
Exposure: Jobs grouped into as listed.
27 occupations with similarities Group IV: Group I vs. IV:
of characteristics as to type of 38% PR=1.7 1.3-2.7 Initially excluded cases of CTS in
grip, wrist position, study population, yet was
handedness pattern, Group V: Group I vs. V: supposedly identifying prevalences
resistance, frequency, and 61% PR=2.0 1.1-3.4 of CTS in exposure groups.
duration of grasp and
presence of vibratory and For nerve conduction analysis,
ballistic components. The wrongly assumed that each hands
27 occupations then grouped nerve conduction study results in
into 5 classes. Resistance an individual were independent.
(Res.) rated from very light to The 2 hands in a single individual
very heavy; repetition rate are not independent of each other.
rated from low to high.
Group I: very light resistance

and low repetition
Group II: light resistance and
very high repetition
Group III: moderate resistance
and moderately high repetition
Group IV: heavy resistance
and moderate repetition
Group V: very heavy
resistance and high repetition.
(Continued)
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MSD prevalence
Nathan 1992a Long- 315 workers using both Outcome: Case defined as Group II: Group 1: Groups II vs. Participation rate: Overall: 67%;
itudinal hands (each hand NCS-determined impaired 19% 18% Group I: Group 3 participation rate was
analyzed separately) sensory conduction (sensory PR=1.1 0.6-1.9 59%.
from four industries. latency). Sensory latencies Examiners blinded: Not reported.
These represented 67% assessed antidromically for Group III: Group III vs.
of original group of eight consecutive 1-cm 26% Group I: Analyzed using gender, hand
workers from 1988 segments of the nerve. A PR=1.5 1.0-2.2 dominance, occupational hand use,
published study maximum latency difference of duration of employment, and
randomly selected from 0.4 ms or greater used to Group IV: Group IV vs. industry.
four industries (67% of define impaired sensory 24% Group I: 76% of participants employed in
original subjects) conduction. PR=1.4 0.9-2.1 same occupational hand-use class
as in 1988. A lower percentage of
Group I: Very light Probable CTS: Presence of Group V: Group V vs novice workers returned (56%)
resistance and low any two primary symptoms 18% Group I: than non-novice workers (69%) for
repetition (numbness, tingling, nocturnal PR=1.0 0.5-2.2 follow-up study.
awakening) or one primary Analysis of hands instead of
Group II: Light symptom and 2 secondary individual would cancel contribution
resistance and very high symptoms (pain, tightness, of exposure effect if there was
repetition clumsiness). unilateral slowing.
Group III: Moderate Exposure: For this article, Data in table two for 1984 subjects
resistance and previous exposure is not the same data as presented
moderately high classification was used from in previous article; numbers have
repetition 1988 Nathan article. Jobs had shifted to other groups. The
been grouped into 27 significant difference seen
Group IV: Heavy occupations with similarities of between nerve slowing between
resistance and moderate characteristics as to type of Class 1 and Class 5 in 1988 paper
repetition grip, wrist position, is no longer significantly different.
handedness pattern, Authors note that 130 hands
Group V: Very heavy resistance, frequency, and experienced a decrease in
resistance. duration of grasp and occupational use. No parameters
presence of vibratory and given for decrease and assumption
ballistic components. The 27 is made that both hands in an
occupations then grouped into individual had similar decrease in
5 classes. Resistance rated use.
from very light to very heavy; With one-third of cohort missing
repetition rate rated from low to from 1984 study, there is no way to
high. determine if homogeneity in
symptoms prevalence in 1984 and
1989 reflects absence of
progression or drop-out.
(Continued)
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MSD prevalence
Nathan 1994b Long- 101 Japanese furniture Outcome: Case defined as 8 cm. 8 cm. Participation rate: For Japanese
itudinal factory workers. There NCS-determined impaired Sensory Sensory Workers: 100%
were 27 managers, 35 sensory conduction (sensory latency: latency: Americans: Overall: 67%; Group 3
clerical workers, 21 latency). Sensory latencies 0.30 0.31 participation rate was 59%.
assembly-line or food
service workers and 18 assessed antidromically for
machine operators. Their eight consecutive 1 cm. 14 cm. 14 cm. Examiners blinded: Not reported.
NCS results were segments of the nerve. A Sensory Sensory
compared to 315 maximum latency difference of latency: latency: Analyzed using gender, hand
workers using both 0.4 ms or greater used to 0.36 0.45 dominance, occupational hand use,
hands (each hand define impaired sensory duration of employment, and
analyzed separately)
from four industries. conduction. industry.
(These represented 67% Probable CTS: Presence of Probable Probable
of original group of any two primary symptoms CTS: 2.5% CTS: Analysis of hands instead of
workers from 1988 (numbness, tingling, nocturnal 2.0% individual would cancel contribution
published study awakening or one primary of exposure effect if there was
randomly selected from Definite Definite unilateral slowing.
four industries (67% of symptom and 2 secondary
original subjects) and are symptoms (pain, tightness, CTS: CTS:
the subject of a separate clumsiness). 2.0 8.3 Conducted step-wise regression
table entry in this analysis for Probable CTS and
document. Exposure: Exposure was not reported that repetitions and
addressed except is assumed duration of employment were
Group I: Very light protective. Cigarettes and Age
resistance and low to be self-reported by
questionnaire for the Japanese were also retained in the model.
repetition.
workers. The jobs were
Group II: Light grouped into 5 classes.
resistance and very high Resistance rated from very
repetition. light to very heavy; repetition
Group III: Moderate rate rated from low to high
resistance and repetition.
moderately high
repetition.
Group IV: Heavy
resistance and moderate
repetition.
Group V: Very heavy
resistance.
(Continued)
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MSD prevalence
Osorio et al. Cross- 56 supermarket workers. Outcome: CTS assessed via Symptoms: 0% for 8.3 2.6-26.4 Participation rate: 81%.
1994 sectional Comparison was medical history, physical exam, 63% in low- (for CTS-
between high and low median nerve conduction high- exposure symptoms high Adjusted for age, gender, alcohol
exposure groups. studies, and vibratory exposure; group vs. low consumption, and high-risk medical
thresholds. 10% in exposure history.
moderate- groups)
A. CTS-like syndrome: exposure Interview and testing procedures
Probable diagnosis: (1) Pain group performed by personnel blinded to
tingling numbness in median case status.
nerve distribution and Positive
(2) symptoms last >1 wk or $ NCS: 33% 0% for 6.7 (for 0.8-52.9 Skin surface temperature not
12 times in last year, no acute in high- low- abnormal NCS, controlled.
trauma or systemic disease, exposure; exposure high vs. low
onset or exacerbation since 7% in group exposure Dose response for presumptive
working on current job. moderate- groups) (symptoms of) exposure to
exposure forceful, repetitive wrist motion:
B. Median neuropathy: group CTS-prevalence 63% high
Sensory median nerve exposure; 10% medium exposure;
conduction velocity 44 m/sec 0% low exposure.
or less.
Dose response for prevalence of
Exposure: Observation of jobs abnormal median nerve velocity:
by ergonomist and industrial 33% high; 7% medium; 0% low.
hygienist. Analysis based on
categorization by job title after Linear regression showed
observation. Jobs divided into significant relationship between
3 categories based on the years worked and worsening of
likelihood of exposure to nerve conduction (decreased
forceful and repetitive wrist nerve conduction velocity and
motions (low, moderate, high), decreased nerve conduction
years worked at this store, amplitude) adjusted for
total years worked as checker, confounders (above), however
total years using laser small sample size.
scanners.
(Continued)
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MSD prevalence
Punnett et al. Cross- 162 female garment Outcome: CTS assessed by 18% 6% 2.7 1.2-7.6 Participation rate: 97% (garment
1985 sectional workers; 85% were symptom questionnaire and workers), 40% (hospital workers).
employed as sewing physical exam. Cases defined
machine operators who as the presence of persistent Controlled for age, hormonal status,
and native language.
sewed and trimmed by pain (lasted for most days for
hand. one month or more within the Pain in the wrist and hand
past year); were not significantly correlated (p<0.01;
Comparison: 76 of 190 associated with previous r=0.41).
full- or part-time workers injury; and, began after first
on day shift in a hospital employment in garment Age distribution not significantly
different metabolic disease.
who worked as nurses manufacturing or hospital
or aids; lab technicians employment. Key questions Symptoms of CTS showed trend by
or therapists, or food based on the arthritis age (p<0.01).
service workers. supplement questionnaire of
the National Health and Nutrition Prevalence of pain not associated
Employees typing >4 Examination Survey (NHANES). with years of employment in
hr/day excluded from Median nerve symptoms (pain, garment workers.
comparison group. 162 numbness, or tingling) if Length of employment not predictor
female garment workers present at night or early in the of risk.
compared to 73 female morning or met 2 of 3 criteria:
hospital workers. (1) accompanied by weakness Change in hormonal status
in pinching or gripping; significantly associated with CTS
(2) alleviated by absence from symptoms but negatively
associated with employment in
work for >1 wk; garment shop.
(3) aggravated by housework
or other non-occupational Logistic model found garment work
tasks. and age significant for symptoms of
CTS.
Exposure: Observation of job
tasks. Information on work Neither metabolic disease nor
change in hormonal status
history obtained by statistically significant risk.
questionnaire. Job title used as
a proxy for exposure in
analyses.
(Continued)
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MSD prevalence
Schottland Cross- Poultry workers (27 Outcome: Defined as 41% 20% 2.86 1.1-7.9 Participation rate: Not reported.
et al. 1991 sectional males, 66 females) prolonged motor or sensory exceeding exceeding
compared to job median latencies. No 2.2 ms for 2.2 ms for Not mentioned whether examiners
applicants (44 males, symptoms or physical exam sensory median blinded to case status or exposure.
41 females). included in case definition. latency sensory
value of latency Controlled for age and gender.
Exposure: Based on current median value
employment status at plant. No nerve on (right- Referents not excluded if prior
measurements made. NCS (right- hand, employment at poultry plant;
Repetitive tasks (15 to 50 hand, females, 15 referents had previous
complex operations/min not females, corrected employment in poultry plant; this
rare), requiring firm grip, with corrected for age) would result in poor selection of
wrists in flexion or extension, for age) controls, would tend to bias results
with internal deviations. towards the null.
24% 15% 1.87 0.6-9.8 Right-hand of female applicants
exceeding exceeding who never worked in a poultry
2.2 ms for 2.2 ms for plant had significantly longer
median median median palmar latency (MPS) on
nerve nerve nerve conduction than referents
sensory sensory (p<0.04).
latency latency
value on value on Symptoms of CTS not inquired.
NCS (left- NCS (left- Right hand of male workers had
hand, hand, longer MPS on nerve conduction
females, females, but not significant (p<0.07).
corrected corrected
for age) for age) From Table 5-2 in paper it shows
there is inadequate sample size for
detecting differences in females
left-hand and males left- and right-
hand MPS.
Concluded there is an elevated risk
of CTS, roughly equal to risk from
aging for the right hands of female
workers, less risk for male both
hands and female left hands.
(Continued)
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Silverstein Cross- 652 industrial workers in Outcome: CTS determined by 1.0 0.6 Group 2 vs. Participation rate: 90% response
et al. 1987 sectional 4 groups: (1) low-force, medical examination and (Group 2) Group 1: rate obtained.
low-repetition interviews. OR=1.8 0.2-21
(comparison group, Controlled for age, gender, plant,
n=93 males, 64 females); Symptoms of pain, numbness 2.1 Group 3 vs. years on the job. No interactions
(2) high-force, low- or tingling in median nerve (Group 3) Group 1: found.
repetition (n=139 males, distribution. OR=2.7 0.3-28 Jobs evaluated by investigators
56 females); (3) low- blinded to worker health status.
force, high-repetition Nocturnal exacerbation; 5.6 Group 4 vs.
(n=43 males, 100 symptoms >20 times or >1 wk (Group 4) Group 1: Examiner blinded to medical history
females); (4) high-force, in previous year; no history of OR=15.5 1.7-142 and exposure.
high-repetition (n=83 acute trauma; no history of
males, 74 females). rheumatoid arthritis; onset of Random sample of 12 to 20 active
symptoms since current job; In separate workers/job with 1 years seniority,
positive modified Phalens test logistic models: stratified by age and gender.
(45 to 60 sec) or Tinels sign;
rule out cervical root thoracic (1) Repetitive- Interview data included prior health
outlet, pronator teres ness: OR=5.5 and injuries, chronic diseases,
syndrome. (p<0.05) reproductive status of females,
recreational activities, prior job
activities.
Exposure: To (1) forceful, (2) Force:
(2) repetitive, and (3) awkward OR=2.9 (non- No association found with wrist
hand movements assessed by significant) posture, type of grasp, or use of
EMG and video analysis of vibrating tool.
jobs. Three workers in each
selected job videotaped for (at Positive associated with age but
least) 3 cycles. High-force job: not statistically significance.
A mean adjusted force >6 kg
(mean adjusted force = No differences in health history or
[(variance/mean force)+ mean recreational activities.
force]); low-force job: A mean No association with gender, or
adjusted force <6 kg. industrial plant.
High repetition = work cycles Negatively associated with years
<30 sec or work cycles on the job but not statistically
constituting >50% of the work associated.
cycle.
Repetitiveness found to be stronger
risk factor than force.
No association with hormonal
status.
(Continued)
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MSD prevalence
Stetson et al. Cross- Comparison of 137 Outcome: Symptoms Participation rate: 71% seen, 16%
1993 sectional asymptomatic industrial consistent with CTS defined as refused, others unavailable
workers, 103 industrial numbness, tingling, or burning because of layoffs, transfers, or
workers with hand/wrist localized to median nerve sick leave.
symptoms, and 105 anatomic area, not caused by
control subjects acute injury, and occurred >20 Industrial population randomly
randomly selected not times in previous year. Nerve selected.
exposed to highly conduction studies conducted
forceful or repetitive on the dominant hand; median Controlled for age, height, skin
hand exertions. sensory and motor, ulnar temperature, and dominant index
sensory, distal amplitudes and finger circumference.
latencies were measured.
Temperature monitored. Comparing the means of the nerve
conduction measures, the following
Exposure: Observation and were statistically significantly
worker interviews using different between: (1) the
ergonomic checklist. One or asymptomatic hand group and the
more workers on each job controls: median sensory amplitude
were evaluated based on and distal latency, and median to
repetitiveness, forcefulness, ulnar comparison measures; (2) the
mechanical stress, pinch grip, symptomatic hand group and
and wrist deviation, then data controls: median sensory distal
extrapolated to other workers latency, and median to ulnar
performing jobs. A 3-point comparison measures.
ordinal scale used to estimate
exposure (none, some, Median sensory amplitudes were
frequent or persistent). smaller and distal latencies longer in
symptomatic compared to
asymptomatic hand group.
Forceful hand and upper extremity

exertions were significantly
different between exposed and
non-exposed groups. Repetition
not significantly different, but little
statistical power to detect
difference.
(Continued)
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MSD prevalence
Tanaka et al. Cross- Data from the Outcome: Outcomes included Prevalence Logistic model Participation rate: 91.5%.
In Press sectional Occupational Health those Recent Workers who of self- for medically
interview Supplement of 1988 worked anytime during the past reported called CTS Multiple logistic regression used to
survey National Health Interview 12 months (excluding armed CTS among among recent examine age, gender, race,
Survey conducted by the forces). Self-reported carpal recent workers exposure to vibration, and
National Center for tunnel syndrome= yes to workers: bending/twisting of the hand/wrists
Health Statistics. question: During the past 1.47% Bend/twist: to odds of reporting CTS.
Households are selected 12 months, have you had a OR=5.9 3.4-10.2 Interactions were checked for.
by multistage probability condition affecting the wrist Prevalence
sampling strategy. One and hand called carpal tunnel of medically White race: Self-reported CTS prevalence
adult, 18 years or older, syndrome? Medically called called CTS OR=4.2 1.9-15.6 among recent workers higher in
was randomly selected CTS = a response of carpal among whites compared to non-whites,
for interview. 44,233 tunnel syndrome to the recent Female gender: highest in white females.
interviews completed. question: What did the medical workers: OR=2.4 1.6-3.8
person call your hand 0.53% When vibration was not in the
discomfort? Vibration: model the bend/twist OR=5.99.
OR=1.85 1.2-2.8 When bend/twist is not in the
Exposure: By questionnaire: model, vibration OR=3.00.
Did the most recent job require BMI $25:
you to bend or twist your OR=2.1 1.4-3.1 Major limitation is CTS is based on
hands or wrists many times an self-reports without medical
hr? Did you work with hand- Cigarette use: validation.
held or hand-operated tools or OR=1.6 1-2.5
machinery. No temporal relationship could be
Age $40: found between reported CTS and
OR=1.3 0.2-1.9 the reported occupation/industry or
exposure to bending/twisting of the
Annual income hand/wrist.
$$20,000:
OR=1.5 1-2.4
Education
>12: OR=1.2 0.8-1.8
(Continued)
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MSD prevalence
Weislander Case- 34 male CTS patients, Outcome: CTS diagnosed Cases Participation rate: 93%.
et al. 1989 control each matched to 2 other clinically by a hand surgeon, compared to all
hospital referents confirmed by electro-diagnostic referents Referents matched for gender and
(drawn from among studies. (hospital- and age (3 years.), hospital referents
population- for year of operation.
other based):
surgical cases, one Exposure: To vibrating tools, Vibrating tool Hospital referents and population
referent had been repetitive wrist movements, use: OR=3.3 1.6-6.8 referents statistically different
operated on for gall and loads on the wrist comparing: use of vibrating tool,
bladder surgery and the assessed via telephone Use of hand- repetitive movements of wrist,
other for varicose veins) interview using a standardized held vibrating workload on wrist, obesity.
and 2 population questionnaire. The degree of tools 1-20
referents (from a general exposure was evaluated both years: OR=2.7 1.1-6.7 Hospital-based population may not
reflect industrial workplace.
population register and with regard to the total number Loads on the
telephone directory) of work years and the average wrist: Interviewers not blinded to case
(total comparison number of exposed hr a wk. OR=1.8 1.0-3.5 status.
group=143 males). Repetitive movements
classified independently by Cases Elevated OR for repetitive
physician interviewer and compared to movements of the wrist only
occupational hygienist. population statistically significant for the
Exposure to repetitive wrist referents category >20 years.
alone:
movements was considered to Vibrating tool Odds ratios (OR) for any of the
exist if they agreed. use: three diseases (thyroid disease,
OR=6.1 2.4-15 diabetes, rheumatoid arthritis)
found to be statistically significant
Repetitive among cases with CTS compared
wrist to 143 referents; OR=2.8 (1.0-7.6).
movement for
>20 years: ORs tended to increase with
OR=4.6 1.8-11.9 increasing number of risk factors
present. One factor, OR=1.7 (0.6-
Repetitive 4.4); two factors, OR=3.3 (1.2-9.1);
wrist >two factors, OR=7.1 (2.2-22.7).
movement:
OR=2.7 1.3-5.4 Obesity is >10% above reference
weight.
Obesity:
OR=3.4 1.2-9.8
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CHAPTER 5b
Hand/Wrist Tendinitis
SUMMARY
Eight epidemiologic studies have examined physical workplace factors and their relationship to hand/wrist
tendinitis. Several studies fulfill the four epidemiologic criteria that were used in this review, and
appropriately address important methodologic issues. The studies generally involved populations exposed
to a combination of work factors; one study assessed single work factors such as repetitive motions of the
hand. We examined each of these studies, whether the findings were positive, negative, or equivocal, to
evaluate the strength of work-relatedness, using causal inference.
There is evidence of an association between any single factor (repetition, force, and posture) and
hand/wrist tendinitis, based on currently available epidemiologic data. There is strong evidence that job
tasks that require a combination of risk factors (e.g., highly repetitious, forceful hand/wrist exertions)
increase risk for hand/wrist tendinitis.
INTRODUCTION example, one study used very strict criteria

Since the hand/wrist area may be affected by [Bystrm et al. 1995]. The case definition
more than one musculoskeletal disorder, only required observation of swelling along the
those studies that specifically address tendon at the time of the physical examination.
hand/wrist tendinitis are considered here. The only cases of tendinitis diagnosed were
Studies with outcomes described as hand/wrist deQuervains disease; no other cases of
disorders or symptoms in general, or those in tenosynovitis or peritendinitis were diagnosed
which hand/wrist tendinitis was combined with among 199 automobile assembly line workers.
epicondylitis, e.g., were excluded from this In contrast, the studies with the highest
section because it was not possible to evaluate prevalence rates either did not clearly state
evidence for work-related hand/wrist tendinitis what diagnostic criteria were used to determine
from the data. The seven studies referenced in the case definition, or the case definition
Table 5b-1 provided data specifically considered recurrences of tendinitis new cases.
addressing hand/wrist tendinitis. In each of Whether case definitions were inclusive or
these studies the outcome was determined using exclusive would not affect the relative risk (RR)
physical examination criteria, although the case as long as they were applied non-differentially
definitions varied among studies. Prevalence or between groups designated as exposed or
incidence rates of hand/wrist tendinitis reported unexposed.
in these exposed groups ranged from 4% to
56%, and in unexposed groups from 0% to Although several studies reported odds ratios,
14%. Such wide ranges of prevalence rates published data were reanalyzed and the results
probably reflect the variability in diagnostic presented here and in
criteria as much as they do the range of Tables 5b1-3 as prevalence ratios (PRs). This
workplace exposures in these studies. For was done because odds ratios may
overestimate RR when prevalence rates are
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high, and to make estimates of RR comparable though the risk estimates mostly refer to
across studies. In studies that presented odds combined exposures.
ratios in the original articles, the recalculation of
data as PRs resulted in lower estimates of the REPETITION
RR. In the one prospective cohort study
[Kurppa et al. 1991] incidence rates and risk Definition of Repetition for
ratios are presented. Hand/Wrist Tendinitis
Armstrong et al. [1987a] analyzed videotaped
Except for a study reported by Armstrong et al. job tasks of a sample of workers, then divided
[1987a], risk estimates were not reported job tasks according to level of repetitiveness:
separately for single risk factors. Only the high repetition (cycle time <30 sec, or $50% of
Armstrong et al. study used a formal the cycle spent performing the same
quantitative exposure assessment as the basis fundamental motions) or low repetition.
for determining exposure groups. Other studies Kuorinka and Koskinen [1979] created a
grouped jobs with similar risk factors together workload index based on the number of
and compared them to jobs without those risk pieces handled per hour multiplied by the
factors. Typically, the selection of jobs for the number of hours worked, for a dose-response
exposed and unexposed groups was based on analysis within the exposed group. Comparison
general knowledge of the jobs, previously groups in the other studies were job categories;
published literature, or questionnaire data. selection of the groups to be compared was
Repetition, force, and extreme postures were based on observations, questionnaire data, or
considered in combination to determine which surveillance data.
workers were exposed or unexposed. Formal
exposure assessment (such as videotape Studies Reporting on the Association
analysis for cycle time, repetition, extreme of Repetition and Hand/Wrist
postures, and estimates of force), was usually Tendinitis
conducted on a sample of jobs and used as Seven studies addressed repetition: Amano et
rationale in the grouping of jobs into exposed al. [1988]; Armstrong et al. [1987a]; Bystrm
and unexposed categories, rather than to create et al. [1995]; Luopajrvi et al. [1979]; Roto
quantitative measures of risk factors. In some and Kivi [1984]; Kuorinka and Koskinen
cases (e.g., Luopajrvi et al. [1979]), [1979]; and McCormack et al. [1990].
investigators noted the difficulty in examining
risk factors separately because of job rotation. Studies Meeting the Four Evaluation
For the purpose of this review, we have Criteria
grouped study findings according to the risk Two of the seven studies that addressed
factors present in the exposed job categories, repetition met all four of the evaluation criteria:
based on the information in published articles. Armstrong et al. [1987a], and Luopajrvi et al.
In Tables 5b13, studies are listed under single [1979]. Armstrong et al. studied 652 industrial
risk factors if there was evidence that the workers at seven manufacturing plants
exposed and unexposed groups differed in that (electronics, sewing, appliance, bearing
risk factor, fabrication, bearing assembly, and investment
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casting). Exposure assessment of jobs included interviews and physical examinations conducted
videotape analysis and electromyography by a physiotherapist (active and passive
(EMG) of a sample of workers. Data from this motions, grip-strength testing, observation, and
assessment were then used to categorize jobs palpation). Diagnoses of tenosynovitis and
according to level of repetitiveness and force. peritendinitis were later determined by medical
Health assessment of workers focused on specialists using these findings and
deQuervains disease, trigger finger, tendinitis, predetermined criteria. The PR for tendinitis
and tenosynovitis. The hand/wrist tendinitis among the assembly line packers compared to
case definition required abnormal physical the shop assistants was 4.13 (95% CI
examination findings (increased pain with 2.636.49). Age, hobbies and housework
resisted but not passive motion or tendon were addressed and no associations with
locking with a palpable nodule, or a positive musculoskeletal disorders were identified.
Finkelsteins test) in addition to meeting
symptom criteria on standardized interviews. Studies Meeting at Least One Criteria
The PR for the high repetition/low force group Amano et al. [1988] reported the prevalence of
(n=143) compared to the low repetition/low cervicobrachial disorders, including
force group (n=157) was 5.5 (95% confidence tenosynovitis, among 102 assembly line
interval [CI] 0.746.3). The PR for the high workers in an athletic shoe factory and 102
repetition/high force group (n=157) compared age- and gender-matched non-assembly line
to the low repetition/low force group (n=157) workers (clerks, nurses, telephone operators,
was 17.0 (95% CI 2.3126.2). The effect of cooks, and key punchers). Exposure
age, gender, years on the job, and plant were assessment was based on videotape analysis of
analyzed. A higher prevalence of tendinitis was the tasks of 29 workers on one assembly line.
noted among women but was not significantly Assembly line workers produced about 3,400
associated with personal factors, whereas shoes a day. All but one task had cycle times
significant differences in posture were observed less than 30 seconds. No formal exposure
between males and females. assessment of the comparison group was
reported. Diagnoses were determined by
Luopajrvi et al. [1979] compared the physical examination, including palpation for
prevalence of hand/wrist tendinitis among 152 tenderness. The PRs for tenosynovitis of the
female assembly line packers in a food right and left index finger flexors among the
production factory to 133 female shop shoe factory workers were 3.67 (95% CI
assistants in a department store. Exposure to 1.857.27) and 6.17 (95% CI 2.7213.97)
repetitive work, awkward hand/arm postures, respectively, compared to the non-factory
and static work was assessed by observation workers. Tenosynovitis of the other digits was
and videotape analysis of factory workers. No not diagnosed in the comparison group. Shoe
formal exposure assessment was conducted on assembly workers held shoe lasts longer in the
the department store workers; their job tasks left hand and had greater frequency of
were described as variable. Cashiers were symptoms in the left hand. Comparison subjects
excluded, presumably because their work was were matched to shoe factory workers on
repetitive. The health assessment consisted of gender and age (within five years).
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cycle was multiplied by the number of pieces

Bystrm et al. [1995] studied forearm and hand handled per hour and the number of hours
disorders among 199 automobile assembly line worked to create a workload index. Cycle
workers and compared them to 186 randomly times ranged from 2 to 26 seconds; the number
selected subjects from the general Swedish of pieces handled per hour ranged from 150 to
population. For both groups, exposure was 605. No formal exposure assessment was
assessed using rating scales on nurse- conducted on the shop assistants. Health
administered questionnaires that addressed assessment involved interview and physical
daily duration of hand and finger movements, examination by a physiotherapist following a
wrist position, grip, and hand tool use standard protocol. Diagnoses of tenosynovitis
[Fransson-Hall et al. 1995]. Videotape analysis and peritendinitis were later determined from
and electromyograms were conducted on a these findings using predetermined criteria
subgroup [Hgg et al. 1996]. A diagnosis of (localized tenderness and pain during
tenosynovitis or peritendinitis required the movement, low-grip force, swelling of wrist
observation of swelling and pain during active tendons [Waris et al. 1979]). In equivocal
movement on physical examination. A diagnosis cases, orthopedic and physiatric teams
of deQuervains disease required a positive determined case status. The PR for muscle-
Finkelsteins test. No cases of tenosynovitis or tendon syndrome among the scissor makers
peritendinitis, other than deQuervains disease, was 1.38 (95% CI 0.762.51) compared to
were found in this study, probably because of the department store assistants. Whether or not
strict clinical criteria used for the case definition. cashiers were excluded from the comparison
The PR for deQuervains disease among the group in this study, as they were in the
automobile assembly line workers was 2.49 Luopajrvi et al. [1979] study is unclear. The
(95% CI 1.006.23) compared to the general study group was 99% female. No relationship
population group. Psychosocial variables and was found between age- or body-mass index
other potential confounders or effect modifiers and muscle-tendon syndrome. The number of
were addressed by Fransson-Hall et al. [1995]. symptoms increased with the number of parts
A higher prevalence of deQuervains disease handled per year. Analyses of subgroups of
was noted among men than women. scissor makers showed non-significant
increased prevalence of muscle-tendon
Kuorinka and Koskinen [1979] studied syndrome in short versus long cycle tasks and
occupational rheumatic diseases and upper limb in manipulation versus inspection tasks. The
strain among 93 scissor makers and compared authors noted a lack of contrast in exposures
them to the same group of department store between the subgroups. A non-significant trend
assistants (n=143) that Luopajrvi used as a of increasing prevalence of diagnosed muscle-
comparison group. Temporary workers and tendon syndrome with increasing number of
those with recent trauma were excluded from pieces handled per year was noted in a nested
the scissor case-control
analysis (n=36).
makers group. Exposure assessment included
videotape analysis of scissor maker tasks. The McCormack et al. [1990] studied tendinitis and
time spent in deviated wrist postures per work related disorders of the upper extremity among
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1,579 textile production workers compared to tendinitis (p=0.01), but job category was a
468 non-production textile workers, a stronger predictor (p=0.001).
reference group that included machine
maintenance workers, transportation workers, Roto and Kivi [1984] studied the prevalence of
cleaners, and sweepers. The textile production tenosynovitis among 92 male meatcutters
workers were reported as being exposed to compared to 72 male construction foremen. No
repetitive finger, wrist and elbow motions based formal exposure assessment was conducted.
on knowledge of jobs; no formal exposure Meatcutters work entailed repetitive physical
assessment was conducted. Health assessment exertion of upper extremities and shoulders.
included a questionnaire and screening physical Construction foremens work did not involve
examination followed by a diagnostic physical repetitive movements of the upper extremities.
examination. The diagnosis of tendinitis Health assessment was by questionnaire and
required positive physical findings suggestive of physical examination. Tenosynovitis was
inflammation. The textile production workers defined as swelling, local pain, and finger
were divided into four broad job categories: weakness during movement. The prevalence of
boarding (n=296), which was noted to require tenosynovitis among the meatcutters was 4.5%.
forceful work as well as the repetitive hand- The PR for tenosynovitis as defined by physical
intensive work of the other categories; sewing examination could not be calculated because
(n=562); packaging (n=369); and knitting there were no cases among the comparison
(n=352). The PR for tendinitis among all textile group. The PR of tendinitis-like symptoms
production workers was 1.75 (95% CI reported on the questionnaire among the
0.93.39), compared to the reference group meatcutters was 3.09 (1.43, 6.67) compared
non-production textile workers. The PRs and to the construction foremen. Serologic testing
95% CIs comparing tendinitis among each for rheumatoid arthritis was done to control for
broad category of textile production workers to potential confounding, none was detected.
the reference group are as follows: Authors noted that tenosynovitis occurred in
boarding3.0 (1.4, 6.4); sewing2.1 (1.0, younger age groups.
4.3); packaging1.5 (0.7, 3.5); and
knitting0.4 (0.1, 1.4). The authors noted that Strength of AssociationRepetition
the knitting work was more automated than the and Hand/Wrist Tendinitis
other textile production job categories. Race The PRs for repetitive work and hand/wrist
and age were not related to outcome, but the tendinitis in the studies reviewed above ranged
prevalence of tendinitis was higher in workers from 1.4 to 6.2:
with less than three years of employment.
Female gender was a significant predictor of
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Repetition and Hand/Wrist Tendinitis
PR and 95% CI Authors Exposed/Unexposed Groups

5.5 (0.746.3) Armstrong et al. [1987a]* HI REP & LO FORCE/LO
REP & LO FORCE
17.0 (2.3126.2) HI REP & HI FORCE/LO
REP & LO FORCE
3.7 (1.97.3) to Amano et al. [1988] Shoe assemblers/clerks, nurses,

6.2 (2.714.0) operators, cooks, keypunchers
2.5 (1.06.23) Bystrm et al. [1995] Auto assemblers/general

population
1.4 (0.82.5) Kuorinka and Koskinen [1979] Scissor makers/department

store assistants
1.8 (0.93.4) McCormack et al. [1990] Textile production/ maintenance

workers, etc.
3.1 (1.46.7) Roto and Kivi [1984] Meatcutters/construction

foremen
4.1 (2.66.5) Luopajrvi et al. [1979]* Food packers/department store
assistants excluding cashiers
*Study met all four criteria.
cleaners and sweepers, whose exposure to
In evaluating these RR estimates, study repetition was not measured. If there were
limitations should be considered in addition to some exposure to repetitive work in the
statistical significance. Statistical significance comparison group, then this would tend to
addresses the likelihood that the results are not decrease the RR for hand/wrist tendinitis among
due to chance alone, whereas study limitations the textile workers. Another concern with this
can bias the RR estimates in either direction. All study is the possibility that the knitting workers
of the PRs were greater than one, and four of may not have been exposed to very repetitive
the seven were statistically significant. The work due to greater automation in the knitting
range (1.46.2) might reflect the level of process. The effect of this potential
contrast in repetitiveness between the exposed misclassification of exposure would also be to
and comparison groups. For example, in decrease the RR.
McCormack et al. [1990], the comparison
group consisted of machine maintenance Note that Kuorinka and Koskinen and
workers, transportation workers, and Luopajrvi et al. both used the same
comparison group, but the number of subjects
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in the department store assistant group was 143 Temporal RelationshipRepetition

for Kuorinka and Koskinen, and 133 for and Hand/Wrist Tendinitis
Luopajrvi (who excluded cashiers from the All of the studies reviewed for this section were
comparison group). If Kuorinka and Koskinen cross-sectional, so proving that exposure to
did not exclude cashiers, this might tend to repetitive work occurred before hand/wrist
decrease the RR. tendinitis is not possible. However, information
in several of the studies suggests the likelihood
The highest RR (6.2) reported for repetitive that exposure to repetitive work occurred
work was by Amano et al. [1988]. In this study before the diagnosis of tendinitis. For example,
it is unclear whether the examiner was blinded recently employed workers were excluded by
to whether the subjects were shoe assemblers Kuorinka and Koskinen [1979]. In Luopajrvi
or in the comparison group of non-assembly et al.s [1979] study group, the minimum length
line workers that included clerks, nurses, of employment was
telephone operators, cooks, and key punchers. 3 years. In the McCormack et al. [1990] study,
Because the occupational groups were the minimum average length of employment in
examined on separate dates blinding seems the job categories was more than 7 years.
unlikely. The lack of a clear case definition Bystrm et al. [1995] noted that subjects were
leaves open the possibility of examiner bias, selected for clinical examination 5 months after
which might lead to an increased RR. completion of questionnaires on exposure. Roto
Alternatively, if there were a significant number and Kivis [1984] subjects had all worked in
of key punchers in the comparison group, who the food industry for more than one year.
may have been exposed to repetitive work, that Armstrong and Chaffin [1979] required a
would tend to decrease the contrast in minimum length of employment of one year.
exposure and might lead to a decrease in the Case definitions generally required that
RR. symptoms began after starting the current job
or employment at the plant. This also suggests
In summary, the potential for underestimation of that exposure occurred before disease.
the RR has been noted in studies where the RR
is at the low end of the range, and the potential Consistency in Association for
for overestimation of the RR has been noted at Repetition and Hand/Wrist Tendinitis
the high end of the range. Considering these All of the studies reviewed showed positive RR
concerns and statistical significance, the RR for estimates for hand/wrist tendinitis among
hand/wrist tendinitis attributable to occupational groups exposed to repetitive
repetitiveness is probably more likely to be in work, ranging from 1.4 to 6.2. Four of the
the middle range of the estimates, based on the seven studies resulted in statistically significant
studies reviewed. The statistically significant PRs. Considering only statistically significant
estimates of RR in this middle group range from estimates from studies not noted to have serious
2.5 to 4.1. limitations (which might bias the RR), the range
narrows to 2.54.1.
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Coherence of Evidence for Repetition Schoenmarklin [1991] reported that velocity

and Hand/Wrist Tendinitis and acceleration significantly predicted upper
DeQuervains disease and other extremity musculoskeletal disorders (including
tenosynovitis of the hand, wrist, and forearm tendinitis) among industrial workers performing
have been associated for decades with hand-intensive job tasks.
repetitive and forceful hand activities as one of
the possible causal factors [Amadio 1995]. Dose-Response Relationship For
DeQuervains disease is the entrapment of the Repetition and Hand/Wrist Tendinitis
tendons of the extensor pollicis brevis and Kuorinka and Koskinen [1979] reported that
abductor pollicis longus. Other similar within the group of scissor makers, increased
conditions are trigger thumb and triggering of prevalence of muscle-tendon syndrome
the middle and ring fingers, characterized by occurred in short versus long cycle tasks and in
pain with motion of the affected tendon. manipulation versus inspection tasks. These
Despite the fact that the tendon and its sheath increases were not statistically significant. The
may be swollen and tender, the histopathology authors noted a lack of contrast in exposures
shows peritendinous fibrosis without between the subgroups. A non-significant trend
inflammation, and fibrocartilaginous metaplasia of increasing prevalence of diagnosed muscle-
of the tendon sheath tissue. The role of tendon syndrome with increasing number of
inflammation early in the process is not clear pieces handled per year was also noted in a
[Hart et al. 1995]. As in carpal tunnel nested case-control analysis (n=36) in the same
syndrome or epicondylitis, acute classical study.
inflammation does not seem a critical
pathophysiological component of the clinical The Armstrong et al. [1987a] data resulted in a
condition, at least once it becomes chronic. PR of 17.0 (2.3, 126.2) for jobs that were
Despite the observations that too much forceful highly repetitious and required highly forceful
and repetitive activity contributes to carpal exertions. This suggests a synergistic effect
tunnel syndrome and epicondylitis, the response when both risk factors are present because the
of the tendons and the muscles to repetitive estimate is greater than the sum of the RR
activity is likely that of a U-shaped curve. Too estimate for force or repetition alone.
little and too much activity may be harmful, but
intermediate levels of activity are probably Conclusions on Repetition and
beneficial. The studies of tendon and muscle Hand/Wrist Tendinitis
physiology suggest that a certain amount of There is strong evidence for a positive
activity maintains the normal state of these association between highly repetitive work, in
tissues and leads to adaptive changes. These combination with other job risk factors, and
tissues have the ability to repair significant hand/wrist tendinitis based on currently
amounts of damage from some overuse; the available epidemiologic data. All seven of the
poorly understood issue is when overuse studies reviewed reported positive RR
exceeds the ability of the tissue to repair the
damage or triggers a more harmful type of estimates. Four of these estimates were
statistically significant. Potential confounders
damage [Hart et al. 1995]. Marras and
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(factors associated with both exposure and according to level of repetitiveness and force.
outcome that may distort interpretation of Health assessment of workers focused on
findings) considered in the studies of hand/wrist deQuervains disease, trigger finger, tendinitis,
tendinitis included gender, age, other medical and tenosynovitis. The hand/wrist tendinitis
conditions, and outside activities. There is no case definition required abnormal physical
evidence that the associations reported here examination findings (increased pain with
between repetitive work and hand/wrist resisted but not passive motion or tendon
tendinitis are distorted by gender, age, or other locking with a palpable nodule, or a positive
factors. Finkelsteins test) in addition to meeting
symptom criteria on standardized interviews.
FORCE The PR for the high force/low repetition group
(n=195) compared to the low force/low
Definition of Force for Hand/Wrist
repetition group (n=157) was 4.8 (95% CI
Tendinitis
0.639.7). The PR for the high repetition/high
Armstrong et al. [1987a] based high and low force group (n=157) compared to the low
force categories on electromyographs of repetition/low force group (n=157) was 17.0
forearm flexor muscles of representative (95% CI 2.3126.2). The effect of age,
workers. Comparison groups in the other gender, years on the job and plant were
studies were job categories; selection of the analyzed. A higher prevalence of tendinitis was
groups to be compared was based on noted among women, but was not significantly
observations, questionnaire data, or associated with personal factors, whereas
surveillance data. significant differences in posture were observed
between males and females.
of Force and Hand/Wrist Tendinitis Studies Meeting at Least One Criteria
Five studies addressed force: Armstrong et al. Bystrm et al. [1995] studied forearm and hand
[1987a]; Bystrm et al. [1995]; Kurppa et al. disorders among 199 automobile assembly line
[1991]; McCormack et al. [1990]; and Roto workers and compared them to 186 randomly
and Kivi [1984]. selected subjects from the general Swedish
population. For both groups, exposure was
Studies Meeting the Four Criteria assessed using rating scales on nurse-
One of the studies that addressed force met all administered questionnaires that addressed
four of the evaluation criteria: Armstrong et al. daily duration of hand and finger movements,
[1987a]. Armstrong et al. studied 652 industrial wrist position, grip, and hand-tool use
workers at seven manufacturing plants [Fransson-Hall et al. 1995]. Videotape analysis
(electronics, sewing, appliance, bearing and electromyograms were conducted on a
fabrication, bearing assembly, and investment subgroup [Hgg et al. 1996]. A diagnosis of
molding). Exposure assessment of jobs tenosynovitis or peritendinitis required the
included videotape analysis and EMG of a observation of swelling and pain during active
sample of workers. Data from this assessment movement on physical examination. A diagnosis
were then used to categorize jobs of deQuervains disease required a positive
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Finkelsteins test. No cases of tenosynovitis or among the meatcutters (100% males)

peritendinitis, other than deQuervains disease, compared to the male comparison group was
were found in this study, probably because of 14.0 (5.7, 34.4); the RR for tendinitis among
strict clinical criteria used for the case definition. the meatpackers (79% female) compared to
The PR for deQuervains disease among the the female comparison group was 38.5 (11.7,
automobile assembly line workers was 2.49 56.1); and the risk ratio for tendinitis among the
(95% CI 1.006.23) compared to the general sausage makers (86% female) was 25.6 (19.2,
population group. Psychosocial variables and 77.5). A limitation of the study is the fact that
other potential confounders or effect modifiers the subjects were not actively evaluated for
were addressed by Fransson-Hall et al. [1995]. musculoskeletal disorders. Investigators relied
A higher prevalence of deQuervains disease on workers to seek medical care. This could
was noted among men than women. result in a difference in case ascertainment
between the exposed and unexposed groups
Kurppa et al. [1991] conducted a prospective because workers in non-strenuous jobs may
cohort study of tenosynovitis or peritendinitis not have sought medical care for
(and epicondylitis) in a meat processing factory musculoskeletal disorders since they might still
in Finland. Three hundred seventy-seven be able to perform their jobs, whereas workers
meatcutters, meatpackers, and sausage makers with MSDs in strenuous jobs might not be able
were compared to 338 office workers, to perform their jobs, and would be more likely
maintenance workers, and supervisors. to seek medical care. If subjects sought medical
Exposure assessment was based on previously care, investigators were very likely to capture
published literature and knowledge of jobs at the information, even if medical care was
the plant. Job categories were selected based provided outside the plant, plant nurses
on whether or not strenuous manual work was received and reimbursed the bills, and recorded
required. The cohort was followed for 31 the diagnosis and sick leave. However, when
months. Health assessment consisted of diagnoses were made by physicians outside the
physical examinations by plant physicians who plant, diagnostic criteria were unknown; this
were on-site daily, using predetermined criteria occurred in 25% of the cases. Exposed and
for diagnosing tenosynovitis or peritendinitis comparison groups were similar in age and
(swelling or crepitation and tenderness to gender mix, although gender varied with job.
palpation along the tendon and pain at the
tendon sheath, in the peritendinous area, or at McCormack et al. [1990] studied tendinitis and
the muscle-tendon junction during active related disorders of the upper extremity among
movement) and deQuervains disease (positive 1,579 textile production workers compared to
Finkelsteins test). Incidence density rates (if a 468 referents that included machine
recurrence of tendinitis occurred after 60 days, maintenance workers, transportation workers,
it was considered a new case) for tendinitis cleaners, and sweepers. The textile production
were compared between each of the strenuous workers
job categories and either the male or female
comparison group of combined non-strenuous were reported, based on knowledge of the jobs
job categories (office workers, maintenance to be exposed to repetitive finger, wrist and
workers and supervisors). The RR for tendinitis elbow motions; no formal exposure assessment
5b-10
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was conducted. Health assessment included a Strength of AssociationForce and

questionnaire and screening physical Hand/Wrist Tendinitis
examination followed by a diagnostic physical Estimates of RR for hand/wrist tendinitis among
examination. The diagnosis of tendinitis those in jobs requiring forceful exertion range
required positive physical findings suggestive of from 2.5 to 38.5:
inflammation. The textile production workers
were divided into four broad job categories. The very large risk ratios reported by Kurppa
Boarding (n=296), was the only category noted et al. [1991] could be biased upward because
to require forceful work. The PR for tendinitis of the difference in case ascertainment between
among the boarding workers was 3.0 (95% CI the exposed and unexposed groups.
1.46.4), compared to the reference group. Investigators did not actively evaluate subjects
Race and age were not related to outcome, but for MSDs, but relied on workers to seek
the prevalence of tendinitis was higher in medical care. As the authors noted, workers in
workers with less than three years of non-strenuous jobs may not have sought
employment. Female gender was a significant medical care for MSDs since they might still be
predictor of tendinitis (p=0.01), but job able to perform their jobs, while workers in
category was a stronger predictor (p=0.001). strenuous jobs may not have been able to
perform their jobs and would be more likely to
Roto and Kivi [1984] studied the prevalence of seek medical care. This potential for differential
tenosynovitis among 92 male meatcutters case ascertainment between the exposed and
compared to 72 male construction foremen. No unexposed groups undermines the credibility of
formal exposure assessment was conducted. the magnitude of the risk estimate.
Meatcutters work entailed repetitive physical
exertion of upper extremities and shoulders. Statistically significant estimates of RR for
Construction foremens work did not involve hand/wrist tendinitis among workers who
repetitive movements of the upper extremities. perform strenuous tasks from the remaining
Health assessment was by questionnaire and studies range from 2.5 to 3.1.
physical examination. Tenosynovitis was
defined as swelling, local pain, and finger
weakness during movement. The prevalence of
tenosynovitis among the meatcutters was 4.5%.
The PR for tenosynovitis as defined by physical
examination could not be calculated because
there were no cases among the comparison
group. The PR of tendinitis-like symptoms
reported on the questionnaire among the
meatcutters was 3.09 (1.43, 6.67) compared
to the construction foremen. Serologic testing
for rheumatoid arthritis was done to control for
potential confounding, none was detected.
Authors noted that tenosynovitis occurred in
younger age groups.
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Force and Hand/Wrist Tendinitis

4.8 (0.639.7) Armstrong et al. [1987a] HI FORCE & LO REP/LO
FORCE & LO REP
17.0 (2.126.2) HI FORCE & HI REP/
LO FORCE & LO REP

population
14.0 (5.734.4) to Kurppa et al. [1991] Meat processors/office

38.5 (11.756.1) workers, maintenance workers,
supervisors
3.0 (1.46.4) McCormack et al. [1990] Textile boarding workers/

maintenance workers, etc.
3.1 (1.46.7) Roto and Kivi [1984] Meatcutters/construction

foremen
* Study met all four criteria .
Temporal RelationshipForce and in the job categories studied was more than 7
Hand/Wrist Tendinitis years. Roto and Kivis
The Kurppa et al. [1991] study determined
exposure status of 83% of the cohort on [1984] subjects had all worked in the food
October 2, 1982, and followed their health industry for more than one year. Armstrong et
status until April 30, 1985. The remaining al. [1987a] required a minimum of 1 year of
subjects entered the study when they became employment to be included in the study.
permanent employees, and were also followed
until April 30, 1985. Consistency of AssociationForce
and Hand/Wrist Tendinitis
Although the remaining studies that addressed All of the studies reviewed reported positive
force were cross-sectional, the following RR estimates for hand/wrist tendinitis among
information increases the likelihood that occupational groups exposed to forceful
exposure to forceful work occurred before the exertions, ranging from 1.8 to 38.5. Four of the
occurrence of tendinitis; Bystrm et al. [1995] five studies reported statistically significant
noted that subjects were selected for clinical findings. If only statistically significant estimates
examination from studies in which limitations were not noted
5 months after completion of questionnaires on are considered, RR estimates for force and
exposure. McCormack et al. [1990] reported hand/wrist tendinitis range from 2.5 to 3.1.
that the minimum average length of employment
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Coherence of EvidenceForce and Tendinitis

Hand/Wrist Tendinitis Kuorinka and Koskinen [1979] determined the
See Repetition Section. time spent in deviated wrist postures per work
cycle as part of their workload index that was
used in a dose-response analysis
Evidence of a Dose-Response
RelationshipForce and Hand/Wrist within the exposed group. Comparison groups
Tendinitis in the other studies were job categories;
Armstrong et al. [1987a] demonstrated a dose- selection of the groups to be compared was
response relationship between jobs requiring based on observations, questionnaire data, or
forceful exertions and hand/wrist tendinitis. The surveillance data.
estimate of RR for hand/wrist tendinitis among
workers with jobs that were classified as HIGH Studies Reporting on the Association
FORCE & LOW REPETITION was 4.8 (0.6, of Posture and Hand/Wrist Tendinitis
39.7), while the estimate for HIGH FORCE & Four studies addressed posture: Amano et al.
HIGH REPETITION jobs was 17.0 (2.3, [1988]; Bystrm et al. [1995]; Luopajrvi et al.
126.2), compared to the comparison group of [1979]; and Kuorinka and Koskinen [1979].
LOW FORCE & LOW REPETITION jobs.
Studies Meeting the Four Criteria
Conclusions on Force and Luopajrvi et al. [1979] met all four evaluation
Hand/Wrist Tendinitis criteria. Luopajrvi et al. [1979] compared the
There is strong evidence for an association prevalence of hand/wrist tendinitis among 152
between work that requires forceful exertions, female assembly line packers in a food
in combination with other job risk factors, and production factory to 133 female shop
hand/wrist tendinitis based on currently assistants in a department store. Exposure to
available epidemiologic data. All five of the repetitive work, awkward hand/arm postures,
studies reviewed reported data that resulted in and static work was assessed by observation
positive RR estimates. Four of the five and videotape analysis of factory workers. No
estimates were statistically significant. formal exposure assessment was conducted on
Eliminating one estimate of RR from a study the department store workers; their job tasks
with noted limitations that might bias the were described as variable. Cashiers were
estimate upward does not change this excluded, presumably because their work was
conclusion. Potential confounders such as age repetitive. The health assessment consisted of
and gender were examined in these studies (see interviews and physical examinations conducted
discussion of potential confounders on page by a physiotherapist (active and passive
5b-16) and there was no evidence that motions, grip-strength testing, observation, and
reported associations were distorted by palpation); and diagnoses of tenosynovitis and
confounders. peritendinitis were later determined by medical
specialists using these findings and
POSTURE predetermined criteria. The PR for tendinitis
among the assembly line packers compared to
Definition of Posture for Hand/Wrist
the shop assistants was 4.13 (95% CI
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2.636.49). Age, hobbies, and housework assessed using rating scales on nurse-
were addressed, and no associations with administered questionnaires that addressed
musculoskeletal disorders were identified. daily duration of hand and
Studies Meeting at Least One Criteria finger movements, wrist position, grip, and
Amano et al. [1988] reported the prevalence of hand-tool use [Fransson-Hall et al. 1995].
cervicobrachial disorders, including Videotape analysis and electromyograms were
tenosynovitis, among 102 assembly line conducted on a subgroup [Hgg et al. 1996]. A
workers in an athletic shoe factory and 102 diagnosis of tenosynovitis or peritendinitis
age- and gender-matched non-assembly line required the observation of swelling and pain
workers (clerks, nurses, telephone operators, during active movement on physical
cooks, and key punchers). Exposure examination. A diagnosis of deQuervains
assessment was based on videotape analysis of disease required a positive Finkelsteins test.
the tasks of 29 workers on one assembly line. No cases of tenosynovitis or peritendinitis,
Characteristic basic postures were summarized other than deQuervains disease, were found in
by the investigators as: holding a shoe or a tool, this study, probably because of strict clinical
extending or bending the arms, and keeping the criteria used for the case definition. The PR for
arms in a certain position. Assembly line deQuervains disease among the automobile
workers produced about 3,400 shoes a day. assembly line workers was 2.49 (95% CI
All but one task had cycle times less than 30 1.006.23) compared to the general population
seconds. No formal exposure assessment of the group. Psychosocial variables and other
comparison group was reported. Diagnoses potential confounders or effect modifiers were
were determined by physical examination, addressed by Fransson-Hall et al. [1995]. A
including palpation for tenderness. The PRs for higher prevalence of deQuervains disease was
tenosynovitis of the right and left index finger noted among men than women.
flexors among the shoe factory workers were
3.67 (95% CI 1.857.27) and 6.17 (95% CI Kuorinka and Koskinen [1979] studied
2.7213.97) respectively, compared to the occupational rheumatic diseases and upper limb
non-factory workers. Tenosynovitis of the other strain among 93 scissor makers and compared
digits was not diagnosed in the comparison them to the same group of department store
group. Shoe assembly workers held shoe lasts assistants (n=143) that Luopajrvi used as a
longer in the left hand and had greater comparison group. Temporary workers and
frequency of symptoms in the left hand. those with recent trauma were excluded from
Comparison subjects were matched to shoe the scissor makers group. Exposure assessment
factory workers on gender and age (within five included videotape analysis of scissor maker
years). tasks. The time spent in deviated wrist postures
per work cycle was multiplied by the number of
Bystrm et al. [1995] studied forearm and hand pieces handled per hour and the number of
disorders among 199 automobile assembly line hours worked to create a workload index.
workers and compared them to 186 randomly Cycle times ranged from 2 to 26 seconds; the
selected subjects from the general Swedish number of pieces handled per hour ranged from
population. For both groups, exposure was 150 to 605. No formal exposure assessment
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was conducted on the shop assistants. Health significant estimates. As noted in the Repetition
assessment involved interview and physical Section, the possibility of examiner bias might
examination by a exist in the study reported by Amano et al.
[1988], potentially biasing the RR estimate
upward. The middle of the range of statistically
physiotherapist following a standard protocol. significant estimates for RR for hand/wrist
Diagnoses of tenosynovitis and peritendinitis tendinitis is 2.5 to 4.1.
were later determined from these findings using
predetermined criteria (localized tenderness Temporal Relationship
and pain during movement, low-grip force, Although all of the studies reviewed in this
swelling of wrist tendons [Waris et al. 1979]). section were cross-sectional, at least two of the
In equivocal cases, orthopedic and physiatric studies addressed temporality by reporting a
teams determined case status. The PR for minimum length of employment (Luopajrvi et
muscle-tendon syndrome among the scissor al. [1979]5 years) or by evaluating exposure
makers as 1.38 (95% CI 0.762.51) before health outcomes [Bystrm et al. 1995],
compared to the department store assistants. as discussed in the previous sections on
Whether or not cashiers were excluded from Repetition and Force.
the comparison group in this study, as they
were in the Luopajrvi et al. [1979] study is Consistency
unclear. The study group was 99% female. No All of the studies reviewed showed positive RR
relationship was found between age or body estimates for hand/wrist tendinitis among
mass index and muscle-tendon syndrome. The occupational groups exposed to extreme
number of symptoms increased with the number postures, ranging from 1.4 to 6.2. Three of the
of parts handled per year. Analyses of four studies reviewed resulted in statistically
subgroups of scissor makers showed non- significant PRs. Considering only statistically
significant increased prevalence of muscle- significant estimates from studies not noted to
tendon syndrome in short versus long cycle have design limitations that might bias the RR,
tasks and in manipulation versus inspection narrows the range to 2.5 to 4.1.
tasks. The authors noted a lack of contrast in
exposures between the subgroups. A non- Coherence of Evidence
significant trend of increasing prevalence of See Repetition Section.
diagnosed muscle-tendon syndrome with
increasing number of pieces handled per year Dose-Response
was noted in a nested case-control analysis See Repetition Section.

(n=36).
Strength of AssociationExtreme
Posture and Hand/Wrist Tendinitis
The PRs for extreme postures and hand/wrist
tendinitis ranged from 1.4 to 6.2. All of the PRs
were greater than one and three of the four
studies reported statistically
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Posture and Hand/Wrist Tendinitis

4.1 (2.66.5) Luopajrvi et al. [1979] Food packers/department store
assistants
3.7 (1.97.3) to Amano et al. [1988] Shoe assemblers/clerks, nurses,

6.2 (2.714.0) operators, cooks, keypunchers

population
1.4 (0.82.5) Kuorinka and Koskinen [1979] Scissor makers/department.

store assistants
There is strong evidence for a positive tendinitis among women but found no significant
association between work that requires associations with other medical factors or
extreme postures, in combination with other job activities outside of work. However, significant
risk factors, and hand/wrist tendinitis, based on differences in posture were observed between
currently available epidemiologic data. All of males and females. Differences in postures may
the studies reviewed reported be due to differences in height between men
data that resulted in positive RR estimates. and women whose workstations have uniform
Three of the four estimates from these studies dimensions. In McCormack et al.s [1990]
were statistically significant. Taking into account study of textile workers, three of the four
the effect of potential confounders (See exposed groups were largely female
Repetition Section) such as gender, age, and (89%95%), limiting the ability to separate the
study limitations does not alter this conclusion. effect of gender from job effect. However, in an
analysis that included gender and job as risk
Potential Confounders factors, they reported that gender was a
significant predictor of tendinitis (p=0.01), but
Gender not as significant a predictor as job category
The association between gender and tendinitis (p=0.001). The other studies reviewed did not
is not uniform. Bystrm et al. [1995] reported a have both male and female subjects.
higher prevalence of deQuervains tendinitis in
men than in women, and proposed the Age
explanation that men in their study group used Several investigators noted that tendinitis
hand tools more often than women. Ulnar appears to be more prevalent in younger age
deviation and static muscle loading were groups. Bystrm et al. [1995] reported that
likewise more often reported among men. most of the cases of deQuervains tendinitis
Armstrong et al. [1987a] reported a higher occurred in the <40-yr age group.
prevalence of
McCormack et al. [1990] reported that age
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was not a significant predictor of tendinitis, but There is no evidence in the studies reviewed
years on the job was inversely here that the associations reported between
associatedprevalence was higher if less than work factors and hand/wrist tendinitis are
3 years on the job. Armstrong et al. [1987] explained by gender, age, or other factors.
noted that a significant interaction between
sex, age, and years on the job suggested that CONCLUSIONS
the risk of hand/wrist tendinitis might actually Eight epidemiologic studies have examined
decrease with an increased number of years on physical workplace factors and their
the job, but the effect was too small to merit relationship to hand/wrist tendinitis. Several
further discussion. Roto and Kivi [1984] noted studies fulfill the four epidemiologic criteria that
that The few cases of tenosynovitis occurred in were used in this review, and appropriately
younger workers. Kuorinka and Koskinen address important methodologic issues. The
[1979] and Luopajrvi et al. [1979] found no studies generally involved populations exposed
significant association between age and to a combination of work factors; one study
tendinitis. assessed single work factors such as repetitive
motions of the hand. We examined each of
Other Potential Confounders these studies, whether the findings were
McCormack et al. [1990] reported that race positive, negative, or equivocal, to evaluate the
was not associated with tendinitis. Armstrong et strength of work-relatedness, using causal
al. [1987a] found no significant associations inference.
with personal factorsbirth control pills,
hysterectomy, oophorectomy, recreational There is evidence of an association between
activities. No subjects with seropositive any single factor (repetition, force, and posture)
rheumatic diseases were included in the and hand/wrist tendinitis, based on currently
Kuorinka and Koskinen [1979] study. They available epidemiologic data. There is strong
reported that their earlier unpublished evidence that job tasks that require a
questionnaire found no correlations between combination of risk factors (e.g., highly
illness and extra work, work outside the repetitious, forceful hand/wrist exertions)
factory, work at home, or hobbies. Luopajrvi increase risk for hand/wrist tendinitis.
et al. [1979] excluded subjects with previous
trauma, arthritis, and other pathologies.
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Table 5b-1. Epidemiologic criteria used to examine studies of hand/wrist tendinitis associated with repetition
Investigator
Risk blinded to
indicators Participation Physical case and/or Basis for assessing
Study (first author and (OR, PRR, IR rate $$70% examination exposure hand/wrist exposure to
year) or p-value)*, status repetition
Armstrong 1987a 5.5, Yes Yes Yes Observation or measurements

17.0
Luopajrvi 1979 4.1 Yes Yes Yes Observation or measurements
Amano 1988 3.76.2 NR Yes NR Job titles or self-reports
Kuorinka 1979 1.4 Yes Yes NR Observation or measurements
Not reported.
EMG and video analysis of subgroup reported in Hgg et al. [1996].
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Table 5b-2. Epidemiologic criteria used to examine studies of hand/wrist tendinitis MSDs associated with force
Investigator
Risk blinded to
indicator (OR, Participation Physical case and/or Basis for assessing
Study (first author and PRR, IR or p- rate $$70% examination exposure hand/wrist exposure to
year) value)*, status force
Armstrong 1987a 17.0, Yes Yes Yes Observation or

4.8 measurements
Kurppa 1991 14.038.5 Yes Yes NR Observation or

measurements
Not reported.
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Table 5b-3. Epidemiologic criteria used to examine studies of hand/wrist tendinitis MSDs associated with posture
Investigator
indicator (OR, Participation Physical and/or Basis for assessing
Study (first author and PRR, IR or p- rate $$70% examination exposure hand/wrist exposure to
year) value)*, status posture

measurements
Amano 1988 3.76.2 NR Yes NR Job titles or self-reports
Kuorinka 1979 1.4 Yes Yes NR Observation or

measurements
Not reported.
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Table 5b4. Epidemiologic studies evaluating work-related hand/wrist tendinitis
MSD prevalence
Study Outcome and Exposed Referent RR, OR,

Study design Study population exposure workers group or PRR 95% CI Comments
Amano Cross- 102 assembly line Outcome: Examination Tenosynovitis, Tenosynovitis Participation rate: Not reported.
et al. 1988 sectional workers in an by a physician: palpation right index finger right index
athletic shoe factory for tenosynovitis and flexors: 32.35% finger flexors: Unclear whether examiner was blinded
compared to 102 tenderness. 8.82% PRR=3.67 1.85-7.27 to job category (occupational groups
examined on separate dates). No clear
age and gender case definition provided. Potential for
matched non- Exposure: One line of Tenosynovitis, Tenosynovitis examiner bias exists.
assembly line 29 shoe assembly left index finger left index
workers (clerks, workers was selected flexors: 36.27% finger flexors: Comparison group was matched in
nurses, telephone for job analysis. 5.88% PRR=6.17 2.72-13.97 gender and age (within 5 years).
operators, cooks, Videotapes were
Tenosynovitis of other digits was not
and key punchers). evaluated diagnosed in the comparison group.
for movements of the
upper extremities and Neurological exam and clinical tests of
shoulders and cycle pinch strength, tapping, pressure, and
and holding times. vibration sensibility were also done.
No significant differences between
No formal exposure groups in finger-pinch strength. Shoe
workers failed the tapping test more
assessment of often, had lower pressure-sensibility in
comparison group. 1 of 10 fingers tested, and had lower
vibration-sensibility in 2 of 10 fingers.
One of 3 neurological maneuvers
(Morleys test) was more often positive
in shoe workers. Exposure to toluene
is noted and is a potential confounder
for neurological findings.
Assembly line workers produced about
3,400 shoes a day. All but one task
had cycle times <30 sec.
Assembly workers held shoe lasts
longer in the left hand and had greater
frequency of symptoms in left hand vs.
non-assembly workers, who were
assumed to use right hand (dominant
hand) more frequently.
(Continued)
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Table 5b4 (Continued). Epidemiologic studies evaluating work-related hand/wrist tendinitis
MSD prevalence
Armstrong Cross- 652 industrial Outcome: Positive 3.1% (Group 2) 0.6% PRR=4.8 0.6-39.7 Participation rate: 90% of workers
1987a sectional workers divided into findings on interview originally selected for inclusion actually
4 groups: (1) low and physical exam were 3.5% (Group 3) PRR=5.5 0.7-46.3 participated.
force, low repetition required for case
(comparison group, definition. 10.8% (Group 4) PRR=17.0 2.3-126.2 The effect of age, gender, years on the
n=157), (2) high Tendinitis/teno-synovitis: job, and plant were analyzed. Higher
force, low repetition localized pain or prevalence of tendinitis among women,
(n=195), (3) low swelling lasting > a but not significantly associated with
force and high week, and increased personal factors. Significant
repetition (n=143), pain with resisted but differences in posture were observed
and (4) high force not passive motion. between males and females.
and high repetition Trigger finger: locking in
(n=157). extension or flexion and Examiners were blinded to exposure
a palpable nodule at status of study participants.
base of finger.
DeQuervains: positive
Finkelstein test with
localized pain score of
>=4 (range 1 to 8).
Exposure: To force and

repetition assessed by
EMG and video analysis
of jobs performed by a
sample of workers.
(Continued)
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MSD prevalence
Bystrm Cross- 199 automobile Outcome: Tenosynovitis 8.04% 3.23% PRR=2.49 1.00-6.23 Participation rate: 96%. Study group
et al. 1995 sectional assembly line or peri-tendinitis were (deQuervains randomly selected from assembly
workers, compared diagnosed based on tendinitis) division of a plant. Comparison group is
to 186 general physical examination from the MUSIC study [Hagberg and
population. observations: swelling Hogstedt 1991].
and pain at the tendon
sheath, peritendinous Examiners blinded to exposure status:
area or muscle-tendon no, everyone examined by the authors
junction during active was in the exposed group.
movement of the tendon.
deQuervains tendinitis: Results are reported separately for
Positive Finkelsteins males and females, and for age <40
test. years. Psychosocial variables and
other potential confounders or effect
Exposure: Daily modifiers were addressed by
duration of hand and Fransson-Hall et al. [1995].
finger movements,
manual handling, wrist Higher prevalence of deQuervains
position, grip type, and tendinitis in males than in
hand-tool use were femalespossibly related to greater
rated by workers on use of hand tools, ulnar deviation,
6-point scales in and/or static muscle loading.
questionnaires
[Fransson-Hall et al. No cases of tenosynovitis or
1995]. Forearm peritendinitis were found in this study,
muscular-load and wrist probably because of strict clinical
angle were evaluated criteria (required observation of
by EMG and videotape swelling).
analysis for a subgroup
[Hgg et al. 1996].
(Continued)
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MSD prevalence
Kuorinka Cross- 93 scissor makers Outcome: Tenosynovitis 18.3% 13.5% PRR=1.38 0.76-2.51 Participation rate: 81%.
and sectional compared to 143 and peritendinitis
Koskinen shop assistants. diagnosed by interview Examiner was not blinded to case
1979 and physical exam. status, but diagnosis was made
Phase One: physical Physiotherapist separately, using predetermined criteria
examination and examined workers, [Waris et al. 1979].
interview. diagnoses were from
predetermined criteria Study group was 99% female. No
Phase Two: work [Waris 1979] (localized relationship found between age or
analysis. 10-month tenderness and pain body mass index and muscle-tendon
interval between during movement and syndrome.
phases. low grip-force and
swelling of wrist The number of symptoms increased
Comparison group tendons). In problem with the number of parts handled/year.
was from another cases orthopedic and Workers were paid by piece rate.
study that used the physiatric teams
same method determined case status. Within the group of scissor makers,
[Luopajrvi et al. non-significant increased prevalences
1979]. Exposure: Work history, of muscle-tendon syndrome in short
hr, and production rates vs. long cycle tasks and in manipulation
for the previous year vs. inspection tasks was reported.
were taken from The authors noted a lack of contrast in
company records. A exposures between the subgroups. A
workload index was non-significant trend of increasing
based on videotape prevalence of diagnosed muscle-
analysis of scissor tendon syndrome with increasing
maker workstations: number of pieces handled/year was
time spent in deviated noted in a nested case-control analysis
wrist-posture (n=36).
(>20E)/work cycle;
multiplied by number
pieces handled multiplied
by hr worked. No
exposure assessment
of shop assistants.
(Continued)
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MSD prevalence
Kurppa Cohort: 377 meatcutters, Outcome: Defined as 12.5/100 person 0.9/100 14 (meat- 5.7-34.4 Participation rate: >70%. Job transfers
et al. 1991 31-month meatpackers and physician-diagnosed years person years cutters) and employee termination followed up
follow-up sausage makers tenosynovitis or (meatcutters) (males) with questionnaire. Questionnaire
compared to peritendinitis of the hand response rate over 70%.
388 office workers, or forearm. Criteria 25.3/100 person 0.7/100 38.5 (meat- 11.7-56.1
maintenance were swelling or years (meat- person years packers) Exposed and comparison groups were
workers, and crepitation and packers) (females) similar in age and gender mix, although
supervisors. tenderness to palpation gender varied with job.
along the tendon and 16.8/100 person 25.6 19.2-77.5
pain at the tendon years (sausage (sausage If same diagnosis occurred at same
sheath, in the makers) makers) site in worker after 60 days, it was
peritendinous area, or at considered new episode. Therefore,
the muscle-tendon separate episodes may be
junction during active recurrences, and thus influence
movement of the tendon. results. Median interval of 233 days
deQuervains tendinitis: between episodes.
positive Finkelsteins
test (if not positive, Packers worked in temperatures 8E to
included in tendinitis 10EC; sausage makers worked in
group). 25% of temperatures 8E to 20EC.
diagnoses made by
physicians outside plant, Examiners were not blinded to
criteria unknown. occupation of subjects.
Exposure: Job Plant selected because of high number

categories selected of reports of musculoskeletal
based on whether or disorders. All permanent workers in
not strenuous manual meat cutting, sausage making and
work was required. packing departments were included,
Exposure data obtained after 3 months of work.
from previous published Case ascertainment: Workers in non-
literature and plant walk- strenuous jobs may not have sought
throughs. medical care for MSDs since they might
still be able to perform their jobs.
(Continued)
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MSD prevalence
Luopajrvi Cross- 152 female Outcome: Tenosynovitis 55.9% 13.5% PRR= 4.13 2.63-6.49 Participation rate: 84%. Workers
et al. 1979 sectional assembly line and peritendinitis excluded from participation for
packers in a food diagnosed by interview previous trauma, arthritis and other
production factory and physical exam. pathologies.
were compared to Physiotherapist
133 female shop performed active and Examiner blinded to case status: Not
assistants in a passive motions, grip stated in article.
department store. strength tests,
Cashiers were observation and No association between age and MSDs
excluded from palpation. Medical or length of employment and MSDs.
comparison group. specialists used these Factory opened only short time.
findings later to Hobbies and housework were not
diagnose disorders significantly associated with outcome.
using predetermined
criteria [Waris 1979]. Unable to examine effect of job-
specific risk factors because of job
rotation.
Exposure: Exposure to
repetitive work,
awkward hand/arm
postures, and static
work assessed by
observation and video
analysis of factory
workers. No formal
exposure assessment
of shop assistants.
(Continued)
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MSD prevalence
McCormack Cross- Textile workers: 4 Outcome: Assessed by Boarding: 6.4% Other non- PRR=3.0 1.4-6.4 Participation rate: 90.5% for screening;
et al. 1990 sectional broad job categories questionnaire and office: 2.1% 93.6% of those screened went on to
involving intensive screening physical Sewing: 4.4% PRR=2.1 1.0-4.3 complete physical examination.
upper extremity exam, followed by
usesewing diagnostic physical Packaging: 3.3% PRR=1.5 0.7-3.5 Stratified random sampling within
(n=562), boarding examination. occupational groups.
(n=296), packaging Knitting: 0.9% PRR=0.4 0.1-1.4
(n=369), and knitting Tendinitis: Positive Not mentioned whether examiners
(n=352); compared physical findings Overall exposed blinded to exposure status (job
to other non-office suggestive of group: 3.75% PRR=1.75 0.9-3.39 category).
workers (n=468), inflammation.
including machine Prevalence higher in workers with
maintenance Severity reported as <3 years of employment. Race and
workers, mild, moderate or age not related to outcome. Female
transportation severe. gender was a significant predictor of
workers, and tendinitis (p=0.01), but job category
cleaners and Exposure: To repetitive was a stronger predictor (p=0.001).
sweepers. finger, wrist and elbow
motions based on 10/12 physician examiners recorded
knowledge of jobs; no diagnoses within 12% of the mean for
formal exposure the group.
assessment performed.
47.9% of workers who had either
positive screening physical exams or
reported symptoms on questionnaire
were diagnosed with tendinitis or
tendinitis-related syndromes.
(Continued)
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MSD prevalence
Roto and Cross- 90 meatcutters Outcome: Tenosynovitis 4.5% 0.0% Indetermin- Participation rate: 100% for
Kivi 1984 sectional compared to defined as swelling, ate meatcutters, 94% for comparison
reference group of local pain and finger Symptom Symptom group.
72 construction weakness during prevalence rate: prevalence
foremen who had movement (determined 30.0% rate: 10.0% PRR=3.09 1.43-6.67 Authors state that examiners were
not been exposed to by questionnaire and blinded to occupation of subjects
repetitive physical exam). because part of larger group of meat
movements of the processing workers examined, but it is
upper extremities in Exposure: Based on job unclear whether construction foremen
their work. All title. Study groups were (referents) were examined separately.
participants were selected based on
male. general knowledge of Serologic testing for rheumatoid
job tasks: meatcutters arthritis was done to control for
work entailed physical potential confounding (none detected).
exertion of upper
extremities and Relatively strict diagnostic criteria used
shoulders. Construction to avoid false positive cases. Authors
foremens work did not note that tenosynovitis occurred in
involve repetitive younger age groups.
movements of the upper
extremities. No formal Although the only diagnosed cases of
exposure assessment. tenosynovitis occurred in the
meatcutters (none in the referents), the
authors were reluctant to infer
association with meatcutting because
of the relatively low prevalence rate
(4.5%).
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CHAPTER 5c
Hand-Arm Vibration Syndrome
SUMMARY
In general, the studies listed in Table 5c1 show strong evidence of a positive association between high
level exposure to hand-arm vibration (HAV) and vascular symptoms of hand-arm vibration syndrome
(HAVS). These studies are of workers with high levels of exposures such as forestry workers, stone drillers,
stone cutters or carvers, shipyard workers, or platers. These workers were typically exposed to HAV
acceleration levels of 5 to 36 m/s. These studies typically were cross sectional studies which examined
the relationship between workers with high levels of exposures to HAV with a non-exposed control group.
There is substantial evidence that as intensity and duration of exposure to vibrating tools increase, the risk
of developing HAVS increases. There also is evidence that an increase in symptom severity is associated
with increased exposure. As intensity and duration of exposure are increased, the time from exposure
onset and beginning of symptoms is shortened.
As described above, the relationship between vibration exposure and HAVS was evaluated favorably with
regard to other epidemiological causality criteria, including consistency and coherency of available
information and evidence describing the temporal sequence of exposure and outcome.
INTRODUCTION In addition to the four criteria we used to

The 20 epidemiologic studies discussed in this evaluate the studies, we determined whether
review were selected according to criteria that studies demonstrated statistically significant
appear in the introduction of this document. In associations between exposure attributes and
our review, we evaluated the studies according health outcomes. We also examined whether
to criteria that enabled us to assess the the observed associations were likely to be
research. These criteria, including adequate caused or substantially influenced by major
participation rate, definition of health outcome study flaws, including confounding and selection
by both symptoms and medical exam criteria, bias. Some of these limitations are shown in the
blinding of investigators to exposure/outcome descriptions of individual studies (Table 5c2).
status, and independent/objective measure of
exposure, also are described in detail in the We then reviewed and summarized the studies
Introduction. with regard to standard criteria used by
epidemiologists to evaluate the causal
In reviewing the studies, we gave greatest relationship between a health outcome and an
qualitative weight to those which fulfilled all four exposure of interest. These criteria included
of the above criteria. Table 5c-1 (all tables are strength of association, temporal relationship,
presented at the end of the chapter) consistency of association, coherence of
characterizes the 20 reviewed Hand-Arm association, and exposure-response
Vibration studies according to the four relationships.
evaluation criteria. Full summary descriptions of
all the studies appear at the end of the chapter. In this review, results of each of the studies
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examined, whether negative, positive, or sectional studies are limited in their ability to
equivocal, contributed to the pool of data used ascertain temporal relationships between
to make our decision regarding the strength of exposure and outcome. Because results are
the causal relationship between HAVS and obtained at only one point in time, the cross-
workplace risk factors. Greater or lesser sectional study design also is subject to
confidence in the findings reflected the underassessment of the health outcome
evaluation criteria described above. (particularly in groups with longer durations of
employment and higher participant attrition).
Definition of HAV for HAVS
Hand-Arm Vibration is defined as the transfer The studies included in this review varied in
of vibration from a tool to a workers hand and design and quality of information. Sixteen were
arm. The amount of HAV is characterized by cross-sectional in design, and three were
the acceleration level of the tool when grasped prospective cohort in design. One study was
by the worker and in use. The vibration is both cross-sectional and prospective, including
typically measured on the handle of tool while 10 cross-sectional follow-ups over time and a
in use to determine the acceleration levels cohort group [Koskimies et al. 1992]. Thirteen
transferred to the worker. of the 20 studies reported assessing case status
using physical exams, while other studies used
EVIDENCE FOR THE WORK- only a questionnaire to determine outcomes. Of
RELATEDNESS OF HAVS the studies in which the subjects underwent a
The hazardous effects of occupational exposure physical exam, five performed a cold
to HAV have been discussed in hundreds of provocation test [Bovenzi et al. 1988; Bovenzi
studies dating to the work of Loriga in 1911. et al. 1995; Brubaker et al. 1983; Brubaker et
The composite of vibration-induced signs and al. 1987; McKenna et al. 1993], three
symptoms referred to as hand-arm vibration performed a nail compression test [Mirbod et
syndrome includes episodic numbness; tingling al. 1992b; Nagata et al. 1993; Saito 1987],
and blanching of the fingers, with pain in one performed a nerve conduction test
response to cold exposure; and reduction in [Virokannas 1995], one performed
grip strength and finger dexterity. These signs sensorineural physician testing [Bovenzi and
and symptoms are known to increase in Betta 1994], one performed a neurological
severity as exposure to vibration increases in exam [Shinev et al. 1992], one performed an
intensity and duration. Allan test [Nilsson et al. 1989] and one used
physician judgement based on workers
A review of pertinent epidemiologic studies of complaints and history [Koskimies et al. 1992].
HAVS has been previously presented [NIOSH
1989]; therefore, Table 5c2 includes only Twelve of the 20 studies conducted an
those studies completed after 1989. Except for exposure assessment of the tools subjects were
a few longitudinal studies of chain sawyers in using; an additional study used exposure
the United Kingdom, Finland, and Japan, the assessment information the authors had
literature comprises largely cross-sectional collected in a previous investigation. The
studies carried out within an industry. Cross- remaining studies estimated exposures by self-
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report or job title. Koskimies et al. [1992] examined vibration

syndrome in a group of forestry workers
The one study that met all four criteria and the employed by the National Board of Forestry in
four studies which met the three criteria are Finland. All those employed in one parish
discussed in the following section. Detailed participated in a series of 10 cross-sectional
descriptions for all 20 investigations can be studies from 1972 to 1990. Results also were
found at the end of the chapter. reported for a cohort of 57 individuals who
remained in the study from 1972 to 1986.
HAVS symptoms were assessed by
Comments Related to Specific
questionnaire and physical exam criteria.
Studies of HAVS
Exposure to chain saw vibration was
The Bovenzi et al. [1995] cross-sectional determined by measurement of front handle
investigation of forestry workers compared acceleration. Cross-sectional analysis results
vibration white finger (VWF) in this group with showed a monotonic decrease in prevalence of
shipyard worker referents. VWF was VWF from 40% in 1972 to 5% in 1990. In the
diagnosed by symptom report and cold cohort of 57, VWF increased from 30% in
provocation test; vibration exposures were 1972 to 35% in 1975. VWF decreased
estimated by questionnaire report on frequency monotonically to approximately 6% in 1986.
of chain saw work and types of saws used, Over the same time period, modifications of
along with direct measurement of vibration chain saws used by the workers resulted in a
produced by 27 antivibration and 3 non- decrease in saw vibration acceleration from 14
antivibration saws. Daily exposure to saw m/s2 to
vibration was estimated by linking the two 2 m/s2. The authors attributed the reduction in
assessments. The prevalence rates for VWF VWF to saw changes, although exposures and
were 23.4% in forestry workers and 2.6% in outcomes were never linked for individual
shipyard referents [Odds ratio (OR) 11.8, 95% workers. Strengths of the study included
Confidence Interval (CI) 4.531.1]. For observation of similar results from the series of
workers using only antivibration saws, the OR cross-sectional analyses and full participation
was 6.2 (95% CI 2.317.1); for those using on the part of the 57 subjects. Limitations
non-antivibration saws, the OR was 32.3 (95% included failure to assess chain saw exposure
CI 11.293). A dose-response was observed measures at the individual level. The study
for VWF and lifetime vibration dose (OR 34.3, demonstrated the potential for symptom
95% CI 11.999, for the highest category). improvement after exposure reduction.
Although participation rates were not stated for
referents, the participation appeared to be In the Nilsson et al. [1989] cross-sectional
100% for forestry workers. Authors included study of male pulp mill machine manufacturing
10 retired workers to lessen the problems with employees, VWF was examined in a group of
selection out of the workforce. Results 89 platers and 61 office workers. VWF was
demonstrated that antivibration saw use was ascertained by physical exam and interview.
associated with a lower prevalence of VWF. For platers, vibration exposure was assessed
by measuring acceleration intensity on a sample
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of tools and linking results to subjective ratings by participant attrition.

of exposure time. Current and past exposures
were estimated for both platers and office The Bovenzi et al. [1988] cross-sectional
workers (some office workers had experienced investigation examined VWF in vibration-
exposures in the past). Prevalence for platers exposed stone drillers and stone
with current exposure was 42%, in comparison cutters/chippers and a reference group of
to 2.3% for office workers with no exposures quarry and mill workers. VWF was assessed
(OR 85, 95% CI 15486). When those by questionnaire and physical exam. Exposure
exposed to vibration (platers plus office was assessed by measuring acceleration
workers with previous vibration exposure) intensity on a sample of tools and linking it with
were compared to unexposed office workers, self-reported exposure time. VWF prevalence
prevalences were 40.0% and 2.3% rates were 35.5% in exposed and 8.3% in
respectively (OR 56, 95% CI 12269). A unexposed groups (OR 6.06, 95% CI
dose-response was observed for VWF and 2.019.6; OR 4.26, 95% CI 1.810.4). A
years of exposure. The relationships between significant association was observed between
outcome and exposure, after adjustment for vibration acceleration level and severity of
age, were strong. Representativeness of the VWF symptoms (0% and 18.4% in the lowest
referent group of office workers could not be and highest categories, respectively).
determined.
Bovenzi [1994] examined HAVS cross-
sectionally in 570 quarry drillers and stone One of the studies examined met all four of the
carvers, along with a referent group of polishers evaluation criteria [Bovenzi et al. 1995]. Five
and machine operators who were not exposed investigations met three of the criteria [Bovenzi
to hand-transmitted vibration. HAVS was et al. 1988, 1994; Kiveks et al. 1994;
assessed by physician interview, and Koskimies et al. 1992; and Nilsson et al.
sensorineural symptoms were staged and 1989]. The criterion that was not met (or not
graded. Exposure to vibrating tools was reported) by four of the studies was blinding of
assessed by interview and linked to vibration the physician with regard to worker job status.
measurements obtained from assessment of a However, most studies used objective
sample of tools. Prevalences of HAVS were measures for determining case status: cold
30.2% in the exposed and 4.3% in the provocation [Bovenzi et al. 1988, 1995],
unexposed groups (OR 9.33, 95% CI sensorineural physician grading [Bovenzi and
4.917.8). Symptoms of VWF increased with the Italian Study Group 1994], and the Allan
lifetime vibration dose (OR 10.2, 95% CI test [Nilsson et al. 1989]. Use of objective
4.821.6, for the highest category). Study measures lessens the likelihood that case status
strengths included detailed exposure was influenced by knowledge of participants
assessment and modeling of relationships, exposures.
100% participation, and a very stable work
population. Because of the work population In the Bovenzi et al. [1988] cross-sectional
stability, results were unlikely to be influenced investigation, vibration-exposed stone drillers
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and stone cutters/chippers showed a 6.06-fold from 1972 to 1986 showed a decrease in
(95% CI 2.019.6) increase in risk of VWF in VWF from 30% to 6%. The reductions were
comparison to unexposed quarry and mill attributed to modifications in chain saws during
workers. Similar results were observed in
the same time period.
another study of stone workers conducted by
Bovenzi in 1994. Quarry drillers and stone The remaining, less rigorous, studies showed
carvers exposed to vibration showed an OR for
varying relationships between HAVS and
VWF of 9.33 (95% CI 4.917.8) when
exposure. The majority of the studies
compared to a reference group of polishers and
demonstrated moderate to strong positive
machine operators. A dose-response
associations. Most compared exposed to
relationship was observed for VWF and
unexposed groups with little or no detailed
lifetime vibration dose, with an OR of 10.2
analysis by exposure level. Two investigations
(95% CI 4.821.6) for the highest exposure
examined HAVS in exposed groups and found
category. A study of forestry workers [Bovenzi
an increase in risk by years of employment,
et al. 1995] demonstrated an OR of 11.8 (95%
with ORs of 8.4 and 8.9 (95% CI 2.928.9)
CI 4.531.1) for VWF when comparing
when comparing the highest and lowest
forestry workers with exposure to chain saw
vibration to an unexposed group of shipyard categories [Mirbod et al. 1992b; Kiveks et al.
workers. A lower risk of VWF (OR 6.2, 95% 1994]. Another study that examined HAVS
CI 2.317.1) was observed for those using only prevalence in power tool users found no
antivibration saws. A dose-response between association with duration of employment (with a
VWF and vibration exposure also was observed participation rate of only 38%) [Musson et al.
in this investigation, with an OR of 34.3 (95% 1989]. For other investigations, exposed and
CI 11.999) for the highest exposure category. unexposed groups were defined by job titles.
Nilsson et al. [1989] observed very strong ORs for these studies ranged from 3.2 to 40.6
relationships between VWF and exposure to (relative risk [RRs] from 3.2 to 16) [Brubaker
vibration in machine manufacturing platers. In et al. 1983; Dimberg and Oden 1991; Letz et
comparison to office workers with no al. 1992; McKenna et al. 1993; Mirbod et al.
exposure, platers had an OR of 85 (95% CI 1992a; Mirbod et al. 1994; Nagata et al.
15486). Kiveks et al. [1994] found a 1993]. Three studies demonstrated varying
significantly increased OR in the cumulative HAVS rates for exposed groups, but included
incidence of HAVs in a 7-year cohort study no referents [Shinev et al. 1992; Starck et al.
(OR 6.5, 95% CI 2.417.5). Koskimies et al. 1990; Virokannas and Tolonen 1995].
[1992] examined a dynamic cohort of forestry
workers at 10 intervals from 1972 to 1990 Two investigations produced conflicting
during which time saws were being modified in evidence related to the effects of chain saw
weight, vibration frequency, and vibration modifications on HAVS in forestry workers.
acceleration. Over the 18-year period, a The Brubaker et al. [1987] study, observed a
monotonic decrease in VWF was observed in 28% increase in prevalence of VWF in a
the 10 cross-sectional examinations, with an cohort of tree fellers over a 5-year period and
overall eight-fold reduction in prevalence. A claimed that saw modifications were ineffective.
subset of workers followed Saito [1987] found no new HAVS symptom
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development over 6 years in a cohort of chain saws [Pyykk and Starak 1986; Koskimies et
sawyers in reducing symptoms. al. 1992].
Comparing construction workers to office Consistency

workers, one study demonstrated an OR of 0.5 The literature consistently shows that workers
(95% CI 0.111.8) for HAVS. This study met exposed to HAV develop HAVS at a
none of our four criteria [Miyashita et al. 1992]. substantially higher rate than workers not
exposed to vibration. Although there is
In general, the studies in Table 5c-1 show considerable variation in the occurrence of
strong evidence of a positive association HAVS among different groups using similar
between exposure to HAV and vascular types of vibrating tools, the lack of consistency
symptoms of HAVS. probably is explained by methodological
differences between studies (i.e., some
Temporality researchers did not account for exposure
variation over time in the summary estimate of
The temporal relationship between HAV
exposure) or by differences in work methods,
exposure and symptoms of HAVS is well
work processes, and work organization
established by studies which have determined
[Gemne et al. 1993]. Important also is the
the latency between exposure and symptom
difference in the intensity and duration of
onset. Of 52 studies reviewed by NIOSH in
exposure.
1989, 44 included some information about the
latency period for the development of vascular
HAVS symptoms following initial exposure. Coherence of Evidence
Latency ranged from 0.7 to 17 years, with a The mechanisms by which HAV produces
mean of 6.3 years. Unfortunately, because most neurological, vascular, and musculoskeletal
of these studies were cross-sectional (i.e., damage are supported by some experimental
latency was determined retrospectively) and evidence [Armstrong et al. 1987b; Lundborg et
because HAVS develop slowly, the possibility al. 1990; Necking et al. 1992]. Neurological
of recall bias is strong [Gemne et al. 1993]. and circulatory disturbances probably occur
However, longitudinal studies provide support independently and by unrelated mechanisms.
for the temporal nature of the association. Vibration may directly injure the peripheral
Kiveks et al. [1994], in a 7-year follow-up of nerves, nerve endings, and mechanoreceptors,
Finnish lumberjacks, found a cumulative producing symptoms of numbness, tingling,
incidence rate (IR) of 14.7%, compared to a pain, and loss of sensitivity. Vibration also may
cumulative IR of only 2.3% among referents. have direct effects on the digital arteries. The
The cumulative IR of lumberjacks who had innermost layer of cells in the blood vessel walls
more than 25 years of exposure at the end of appears especially susceptible to mechanical
the follow-up period was 30.6%. Other studies injury by vibration. If these vessels are
of Finnish forestry workers also showed a damaged, they may become less sensitive to the
marked decrease in HAVS prevalence actions of
following the introduction of improved chain
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certain vasodilators that require an intact relationship between the dose and the latency
endothelium. Experiments involving of symptom onset.
lumberjacks exposed to chain saw vibration
support this hypothesis [Gemne et al. 1993]. Support for the first relationship is provided by
There also is evidence that the walls of the a few longitudinal studies of workers exposed
digital blood vessels are thickened in persons to HAV. In general, all show strong evidence
with HAVS [Takeuchi et al. 1986]. During that decreasing the acceleration level of a hand-
cold exposure, vessels with these changes will held vibrating tool has a positive relationship
become abnormally narrow and may close with prevalence of HAVS. In a study of Finnish
entirely [Gemne 1982]. Symptoms of numbness forestry workers using chain saws, Koskimies
and tingling which characterize HAVS may be et al. [1992] found that the prevalence of
secondary to vascular constriction of the blood HAVS symptoms declined from a peak of 40%
vessels, resulting in ischemia in the nerve-end to 5% after the introduction of light-weight,
organs. low-vibration chain saws with reduced
acceleration from 14 to 2 m/s2. Likewise, a
Other evidence concerning the coherence of study of similar workers in Japan found that the
information regarding the association between prevalence of vascular symptoms among chain
vibration exposure and HAVS relates to saw operators who began their jobs before the
background prevalence of similar disorders in introduction of various engineering and
the general population. One estimate placed the administrative controls peaked at 63%.
prevalence of Raynaud's phenomenon at 4.6% (Vibration acceleration levels for chain saws
for females and 2.5% for males in the general used during this period ranged from 111 to 304
population [Iwata and Makimo 1987]. Only 7 m/s2.) In contrast, the peak prevalence for
of the studies examined in this review found chain saw operators who began working after
prevalence rates less than 20% among workers the introduction of antivibration chain saws
exposed to HAV. In the 1989 NIOSH review, (acceleration level: 10-33 m/s2) and exposure
only 9 of 52 cross-sectional studies reported a duration limits (2 hrs/day) was only 2%
prevalence rate of less than 20% among [Futatsuka and Uneno 1985, 1986].
workers exposed to HAV. This provides
strong evidence that individuals working in NIOSH authors ranked 23 cross-sectional
vibration-exposed occupations are at much studies that measured HAV acceleration levels
higher risk of these disorders than those in the and estimated a prevalence rate for vascular
general population. symptoms [NIOSH 1989]. To test whether a
linear relationship existed between the HAV
level and the prevalence of vascular symptoms,
Exposure-Response Relationship
a correlation coefficient was calculated. The
Exposure-response relationships involving correlation analysis found a statistically
HAV have been postulated, including: (1) a significant linear relationship between HAV
relationship between the prevalence of HAVS acceleration level and prevalence of vascular
and vibration acceleration (and cumulative symptoms (R 0.67, p<0.01), indicating that
exposure time), (2) a relationship between the prevalence of vascular symptoms tends
dose and symptom severity, and/or (3) a to increase as the HAV acceleration level
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increases. However, the absorption of vibration latency of symptom onset is provided by British
energy by the hand is influenced by the studies conducted in the 1970s among various
vibration intensity, as well as by frequency, occupational groups, including chain sawyers,
transmission direction, grip and feed forces, grinders, chiselers and swagers [Gemne et al.
hand-arm postures, and anthropometric factors 1993]. Exposure to 10-25 m/s2 chainsaw
[Gemne et al. 1993]. vibration correlated with a latency of about 3
years. Pedestal grinders using machines with
Several studies reviewed for the current zirconium wheels were exposed to vibration
document found relationships between levels of 50 m/s2 and demonstrated a mean
prevalence of HAVS and duration of vibration- latency of 1.8 years, whereas grinders who
exposed work [Bovenzi 1994; Bovenzi et al. used softer wheels with accelerations of 10-20
1995; Letz et al. 1992; Nilsson et al. 1989]. m/s2 had a mean latency of 14 years. Exposure
One cross-sectional study with a very poor to 70 m/s2 vibration during swaging correlated
response rate found no association with with a mean latency of about 7 months,
duration of exposure [Musson et al. 1989]. although some swagers developed symptoms in
as few as 6 weeks.
Justification for a relationship between dose and
HAVS prevalence and symptom severity is Confounding and HAVS
provided by Bovenzi et al. [1988] and Mirbod Age and metabolic disease are the primary
et al. [1992b]. In a study of stone-cutters using potential confounders for HAVS.
rock drills and chisel hammers, Bovenzi found
that HAVS prevalence increased linearly with It is important that epidemiologic studies
the total number of working hours, from about examine non-occupational factors, and control
18% for persons with 6,000 hrs of exposure, to for them. Most of the studies were able to
more than 50% among persons with more than address age by stratification in their analyses,
26,000 hrs of exposure. Likewise, in a study of or through use of multiple logistic regression.
447 workers using chain saws, Mirbod et al. [Bovenzi and Betta 1994; Bovenzi et al. 1995;
[1992b] found that the prevalence of HAVS Brubaker et al. 1983, 1987; Kiveks et al.
increased from 2.5% among workers with less 1994; Letz et al. 1992; McKenna et al. 1993;
than 14 years of exposure to 11.7% among Mirbod et al. [1994]. Several authors
workers with 2024 years exposure, to 20.9% controlled for metabolic disease [Bovenzi and
among workers exposed 30 years or more. Betta 1994; Bovenzi et al. 1995; Letz et al.
Both studies found a statistically significant 1992; McKenna et al. 1993]. This is important
correlation between the severity of symptoms because of the effects that some disorders have
(graded according to the Taylor-Pelmear scale) on peripheral circulation which may have
and a dose measure based on total exposure symptoms similar to HAVS.
time.
Support for a relationship between dose and

Nonoccupational Raynauds phenomena - a
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rare disorder which mimics HAVS has been HAVS increases. Most of the studies showed a
known to occur in individuals with metabolic positive association between high level
disorders, peripheral neuropathy, alcohol- exposure to HAV and vascular symptoms of
related illness, as well as other conditions. HAVS. For many of the studies there is a
strong association between HAVS and
In reviewing the methods and results of these exposure to vibrating tools in the workplace.
studies, taking into account substantially The temporal relationships and consistency
elevated ORs and evidence of dose-response between exposure and symptoms of HAVS are
relationships, it appears that potential well established in these studies. The
confounders do not account for the consistent mechanisms by which HAV produces
relationships seen. neurological, vascular, and musculoskeletal
damage are supported by some experimental
Review of the 20 studies, leads us to the evidence. Many of the studies showed an
conclusion that there is substantial evidence that exposure-response relationship between dose
as intensity and duration of exposure to of HAV and the HAVS prevalence and
vibrating tools increase, the risk of developing symptom severity.
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Table 5c-1. Epidemiologic criteria used to examine studies of hand/wrist and hand/arm MSDs associated with
vibration
Risk Investigator
indicator Physical blinded to
(OR, PRR, IR examination case and/or Basis for assessing
Study (first author and or p- Participation or cold exposure hand/wrist or hand/arm
year) value)*, rate $ 70% provocation status exposure to vibration
Bovenzi 1995 6.232.3 Yes Yes Yes Observation or measurements
Bovenzi 1988 6.06 NR Yes NR Observation or measurements
Bovenzi 1994 9.33 Yes Yes No Observation or measurements
Brubaker 1983 NR Yes Yes NR Job titles or self-reports
Brubaker 1987 NR No Yes NR Observation or measurements
Dimberg 1991 NR Yes No NR Job titles or self-reports
Kiveks 1994 3.46.5 Yes Yes Yes Job titles or self-reports
Koskimies 1992 NR Yes Yes NR Observation or measurements
Letz 1992 5.040.6 Yes No No Job titles or self-reports

previous study results used
McKenna 1993 24.0 NR Yes No Job titles or self-reports
Mirbod 1992a, 1994 3.77 NR No NR Observation or measurements
Mirbod 1992b NR NR Yes No Observation or measurements
Musson 1989 NR No No NR Observation or measurements
Nagata 1993 7.1 NR Yes No Job titles or self-reports
Nilsson 1989 1485 Yes Yes NR Observation or measurements
Saito 1987 NR No Yes NR Job titles or self-reports
Shinev 1992 NR NR Yes NR Observation or measurements
Starck 1990 NR NR No No Observation or measurements
Virokannas 1995 NR NR Yes NR Observation or measurements
Miyashita 1992 0.5 NR No No Job titles or self-reports
*Some risk indicators are based on a combination of risk factorsnot on vibration alone (i.e., vibration plus force, posture,
or repetition). Odds ratio (OR), prevalence rate ratio (PRR), or incidence ratio (IR).
Not reported.
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Table 5c2. Epidemiologic studies evaluating work-related hand-arm vibration syndrome
MSD prevalence
Bovenzi et Cross- Vibration-exposed stone Outcome: Assessed by 35.5% 8.3% 6.06 2.01-19.6 Participation rate: Participation
al. 1988 sectional drillers (n=32) and stone physical examination and rate cannot be determined from
cutters/chippers (n=44); questionnaire. VWF data in the study.
quarry and mill workers symptoms staged using the
not exposed to vibration Taylor-Pelmear scale. Significant association
(control group, n=60). between vibration acceleration
Exposure: Vibration level and severity of VWF
exposure assessed by symptoms.
measuring the acceleration
intensity on a sample of tools, Mean latency period to
together with subjective symptom onset =12.3 yr.
ratings of exposure time.
Frequency-weighted
acceleration levels ranged from
19.7 to 36.4 m/s 2 (rock drills
and chipping hammers) and
from 2.4 to 4.1 m/s 2 (grinders
and hand cutters).
(Continued)
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MSD prevalence
Bovenzi Cross- Case group: Stone Outcome: HAVs assessed 30.2% 4.3% 9.33 4.9-17.8 Participation rate: 100% All
and the sectional workers employed in nine by physician-administered the active stone workers
Italian districts in Northern and interview; sensineural participated in the study, so
Group Central Italy: 145 quarry symptoms staged according self-selection was not a
source of bias.
1994 drillers and 425 stone to Brammer [1992]. Graded
carvers exposed to according to the Stockholm Physician administered the
vibration. Referent group: scale [Gemne 1987]. questionnaires containing work
polishers and machine history and examinations, so
operators (n=258) who Exposure: To vibrating tools unlikely to be blinded to case
status.
performed manual activity assessed by interview.
only not exposed to Vibration measured in a Adjusted for age, smoking,
hand-transmitted sample of tools used. alcohol consumption, and
vibration. upper limb injuries.
Leisure activities, systemic
diseases included in
questionnaire. Univariate
analysis showed no
association between systemic
diseases and vibration so was
not criteria for exclusion.
Univariate analysis showed no
association between systemic
diseases and vibration so was
not criteria for exclusion.
Doseresponse for CTS and
lifetime vibration exposure not
significant.
Frequency-weighted
acceleration levels = 15 m/s 2
(stone drills), 21.8 m/s 2 (stone
hammers), 2.84 m/s 2 (rotary
grinding tools).
Percent of workers affected

with HAVs increased in
proportion to the square root of
the exposure duration.
(Continued)
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MSD prevalence
Bovenzi et Cross- 222 active forestry Outcome: (1) History of All Forestry Shipyard (adjusted Participation rate: 95% vibrating
al. 1995 sectional workers and 10 retired episodes of cold provoked workers: workers: ORs) tool users, not reported for
forestry workers with welldemarcated blanching in 23.4% 2.6% 11.8 4.5-31.1 control.
>400 hr of sawing one or more fingers and Analysis controlled for age,
compared with 195 (2) occurrence after Workers using
employment and exposure to only AV chain smoking, drinking habits.
randomly chosen
shipyard workers never hand vibration and vibration saws: 13.4% 6.2 2.3-17.1 Physicians blinded to case
exposed to hand white finger (VWF) attacks in statussince cold provocation
vibration. Controls last 2 years and (3) abnormal Workers using test was used, it was not an
excluded for digital arterial response to chain saws 32.3 11.2-93 issue.
cardiovascular and cold provocation. Clinically, without
VWF graded using Stockholm vibration VWF Smoking, alcohol, metabolic,
metabolic disease. cardiovascular, neurologic,
scale. isolation operators of
systems: non-AV and previous musculoskeletal
Exposure: Vibration 51.7% AV saws vs. injuries, use of medicines
measured on front and rear Operators of included in questionnaire and
of 27 antivibration (AV) chain antivibration accounted for in logistic
saws used in the forest; for saws only: regression model.
previous exposure OR=4.0
assessment, 3 non-AV chain Cold provocation testing
saws were measured. performed on both forestry
Lifetime workers and controls.
Vibration measurements vibration
were made in the field during dose Exposureresponse
cross-cutting operations by in 9m relationship found between
skilled workers according to (m2S-4 hd) VWF and vibration exposure:
ISO 7505. <19: the expected prevalence of
Forestry workers gave OR=4.1 1.1-16.4 VWF increased almost linearly
19-20: to either the 8-hr
detailed list of chain saws energyequivalent
used. OR=4.7 1.3-16.1
20-21: frequencyweighted
Workplace questionnaires OR=9.4 3.1-28.4 acceleration or the number of
validated by direct interviews >21: years of exposure (with
with employers and OR=34.3 11.9-99 equivalent acceleration
employees, employment unchanged).
records, and amount of fuel
used by chain saws
Daily exposure to saw
vibration assessed in terms
of 8-hr energyequivalent
frequencyweighted
acceleration.
(Continued)
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MSD prevalence
Brubaker et Cross- 146 tree fellers in 7 Outcome: VWF symptoms With With Participation rate: 100%.
al. 1983 sectional camps employed for $1 staged using Taylor-Pelmear symptoms: symptoms:
year compared to 142 scale. 51% 5% Smoking, no significant
workers not exposed to differences.
vibration matched for Ischemic water bath testing Stage 3: 22% Stage 3: 2%
location. for VWF completed on all Age was significantly different
subjects. Excluding between cases and controls.
other vibration
Exposure was based on exposure and Height and weight not
questionnaire data. medical 2% significantly different.
history: 54%
Stage 3: 1% Mean latency period between
Stage 3: 25% work and symptoms 8.6 years.
Records of duration of
exposure.
(Continued)
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MSD prevalence
Brubaker et Cohort: Fellers at Canadian Outcome: Defined as HAVs Raynauds Raynauds Participation rate: 53%.
al. 1987 5-year lumber camps (n=71) symptoms, assessed by symptoms: symptoms:
follow-up who had questionnaire and digit 53% 51% Original group (1979 to 1980)
of been interviewed systolic blood pressure. (1984 to 1985) (1979 to included 146 fellers.
exposed and tested in 1979 to 1980)
group. 1980 then again in VWF symptoms staged using Tingling, 16 fellers excluded because of
1984 to 1985. Taylor-Pelmear scale. numbness: Tingling potential confounders.
56% numbness:
Ischemic water bath testing (1984 to 1985) 65% Author concluded antivibration
for VWF completed on all (1979 to saws not effective at
subjects. 1980) preventing HAVs.
Exposure: Vibration 15% of fellers reported new
measurements recorded from symptoms of VWF over 5-year
a representative sample of period.
chain saws used in the
logging camp. 28% increase in prevalence of
VWF in workers using
antivibration chain-saws.
Correlation between objective
test and symptoms poor: 54%
reporting symptoms with
positive findings on objective
tests.
(Continued)
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MSD prevalence
Dimberg Cross- 2,814 Aircraft engine Outcome: Exposure to 23% Multivariate Participation rate: 96%
and Oden sectional workers. vibrating hand-tools (polishers/ analysis questionnaire.
1991 assessed by questionnaire. grinders) showed
68 Sheet metal workers. White fingers as a spasm in increased Vibrating tool use significantly
26 Polishers/grinders. blood vessels occurring in 19% (sheet symptoms correlated with HAVs symptom
20 Cleaners. one or more fingers in metal with prevalence.
connection with cooling workers) increasing
40 Forklift-truck drivers. leading to reversible pallor age, work Analysis was stratified by
46 Engine testers. followed by redness. 15% with vibrating gender, age, and employment
146 Fitters. (cleaners) hand tools category.
Exposure: Vibration and weight
49 Storemen assessed by questionnaire: loss
38 Electric welders. working with vibrating tools,
time in present job, leisure
No control group used. activities.
(Continued)
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MSD prevalence
Kiveks et Cohort 213 lumberjacks and Outcome: HAVs assessed Prevalence Prevalence Participation rate: 76% among
al. 1994 with 140 referents. by questionnaire, clinical (HAVs) (HAVs): exposed workers, 78% among
7-year examination, and control.
follow-up radiographs. 1978: 5.0% For 1978:
(1978 to 1978: 16.9% OR= 3.4 1.7-6.9 Follow-up group included 76%
1985) Exposure: Not measured. of lumberjacks and 78% of
Exposure history determined 1985: 5.7% referents from original group.
via questionnaire. For 1985:
1985: 24.9% Cumulative OR= 4.4 2.3-8.1 Adjusted for age.
incidence
Cumulative HAVs (7 X-ray films read by radiologists
incidence, years): blinded to case status
HAVs (7 2.3%
years): After adjusting for age, no
14.7% OR=6.5 2.4-17.5 difference in lumberjacks with
<15-years exposure and
referents, but risk increased
with increasing duration of
exposure. For those exposed
RR=8.9 (2.9-28.9).
No X-ray differences in
prevalence of detectable
translucencies or osteoarthritic
changes in wrists or hands.
(Continued)
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MSD prevalence
Koskimies Cohort Finnish forest workers Outcome: HAVs assessed Prevalence of Prevalence Participation rate: 100% of
et al. 1992 (18-year (n=118-124). by questionnaire and HAVs among of HAVs those who had a yearly
follow-up) physical examination. forestry among physical exam.
workers in forestry
Exposure: Vibration 1990: 5% workers in Decrease in prevalence
acceleration of the front 1972: 40% attributed to reduction in weight
handle of chain saws of saws, increase in vibration
analyzed. frequency, and reduction in
vibration acceleration (from 14
to 2 m/s 2).
(Continued)
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MSD prevalence
Letz et al. Cross- Shipyard workers with Outcome: HAVs assessed Vascular Vascular Part-time Participation rate: 79%.
1992 sectional full-time vibration by self-administered symptoms symptoms: vibration-
exposure (n=103); part- questionnaire; graded among part- 5.7% exposed Participants randomly selected
time vibration exposure according to the Stockholm time vibration- workers vs. within departments.
(n=115), and no vibration scale. exposed controls:
exposure (n=53, workers: 33% OR=8.23 2.3-35.4 Significant exposureresponse
comparison group). Vibration measurements from relationship found after
51 pneumatic tools made in 3 Vascular Full-time adjustment for smoking, not
studies. Extreme variability symptoms vibration- age or race.
precluded direct comparison among full- exposed
of tools. Number of hours per time vibration- workers vs. Average latency to symptom
week and years using tools exposed controls: onset <5 years.
asked. workers: OR=40.6 11-177
70.9%; Alcohol consumption, past
medical conditions considered
Sensorineural Sensori- Part-time in analysis.
symptoms neural vibration-
among part- symptoms: exposed Exposureresponse
time vibration- 17% workers vs. relationship found regarding
exposed controls: self-reported cumulative
workers: OR= 5.0 2.1-12.1 exposure to vibratory tools,
50.4% sensorineural stages, and
corresponding vascular
Sensorineural Full-time classifications but no further
symptoms vibration- increases in workers with >
among full- exposed 17,000 hr of exposure.
time vibration- workers vs.
exposed controls: Median latency for appearance
workers: OR=24.7 9.5-67 of symptoms of white finger
83.5% was 8,400 hr of vibratory
tool/use and 8,200 hr for
numbness.
Participants not blinded to
purpose of questionnaire may
have been over-reporting.
(Continued)
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MSD prevalence
McKenna Cross- 46 pairs of riveters and Outcome: Defined as cold- 35% 2% 24 3.1-510 Participation rate: Not reported.
et al. 1993 sectional matched control subjects induced digital vasospasm.
(machine operators who Matched on age and smoking
had never used vibrating Exposure: To specific tools habits.
tools). assessed via questionnaire.
Only males studied.
Excluded those with injury to

neck, trunk, upper limbs.
44% of riveters had <2.5 years

of vibration exposure.
Did not of blind examiners

because they tested the most
symptomatic finger.
No differences in resting finger

systolic pressure, vibration
perception, or finger
temperature between cases
and controls.
17% of riveters reported

symptoms of VWF.
(Continued)
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MSD prevalence
Mirbod et Cross- Forestry workers Outcome: HAVs assessed 9.6% overall Participation rate: Not reported.
al. 1992b sectional (n=447) by interview and physical
examination. Symptoms 20.9% among HAVs symptom severity
No control group used. graded using the workers with positively correlated with
Stockholm scale. 30 or more exposure duration.
years
Frequency-weighted experience Chain saw vibration levels
vibration-acceleration ranged from 2.7 to 5.1 m/s 2.
measurements made on the 2.5% among Low prevalence attributed to
hands of chain workers <14 recent improvements in
saw operators during years working conditions.
different job processes.
11.7% 20 to
24 years
(Continued)
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MSD prevalence
Mirbod et Cross- (A) 164 male dental Outcome: HAVs assessed (See first Males: H vs. 2.1-6.8 Participation restricted to
al. 1994; sectional technicians, (B) 54 male by questionnaire, interviews, column for job 2.7% unexposed workers age 30 to 59 years.
Mirbod et orthopedists, (C) 256 field visits, or annual health categories) Females: Males: 3.77 Subjects stratified by age in
al. 1992a male aircraft technicians, examinations. 3.4% analysis.
(D) 79 male laborers, A: 4.8%
(E) 27 male grinders, Exposure: To vibrating B: 3.7% Hand-transmitted vibration
(F) 46 female sewing- tools assessed by C: 2.3% levels in groups A to G ranged
machine operators, questionnaire and D: 2.5% from 1.1 to 2.5 m/s 2. Hand-
(G) 23 male tea- interviews. Hand- E: 3.7% transmitted vibration levels in
harvesting-machine transmitted vibration F: 4.3% group H ranged from 2.7 to 5.1
operators, (H) 272 male measured among a sample G: 0.0% m/s 2.
chain-saw operators; of workers using H: 9.6%
compared with 1,027 representative tools in actual
males and 1,301 females work activities.
not exposed to vibration.
(Continued)
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MSD prevalence
Miyashita Cross- 355 Male construction Outcome: HAVs assessed 1.1% 2.3% 0.5 0.1-11.8 Participation rate: Not reported.
et al. 1992 sectional workers (machine by self-administered
operators) compared questionnaire. Participation restricted to male
with 44 male office workers age 30 to 49.
workers. Exposure: Status assumed
(A) 184 power shovel from job title (no objective Vibration due to construction-
operators. measurements performed). machinery operation.
(B) 127 bulldozer
operators.
(C) 44 forklift operators.
(Continued)
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MSD prevalence
Musson et Cross- Impact power-tool users Outcome: HAVs based on 17% Participation rate: 38%
al. 1989 sectional in The Netherlands symptoms, assessed via questionnaire.
(n=169). postal questionnaire.
Adjusted for age.
No control group used. Exposure: Vibration intensity
measured using five Exposure duration not related
representative tools. to HAV symptoms.
Duration of vibration
exposure assessed via
questionnaire.
(Continued)
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MSD prevalence
Nagata et Cross- 179 chain-saw workers Outcome: HAVs assessed >20-years 2.9% 7.1 for >20- 2.5-19.9 Participation rate: Not reported.
al. 1993 sectional and 205 local inhabitants by dermatological tests and exposure: years
who had never used physical examination. 16% vibration Adjusted for age.
vibrating tools (control exposure
group). Exposure: Vibration not < 20-years Examiners not blinded to
measured directly; exposure exposure: exposure status.
duration expressed as years 2.4%
since commencement of
occupation.
(Continued)
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MSD prevalence
Nilsson Cross- Platers (n=89) and office Outcome: Assessed by Platers with Office Participation rate: 79% among
et al.1989 sectional workers (n=61) divided physical examination current workers platers, not reported among
into 4 groups according and interview. VWF exposure: with no control.
to current and past symptoms staged using 42% exposure:
vibration exposure. the Taylor-Pelmear scale. 2% 85 15- 486 Controlled for age.
Exposure: Vibration Platers with Office Vibration acceleration levels

exposure assessed by current and workers =5.5 m/s 2 (grinders), 10.3 m/s 2
measuring the former with no (hammers), 1.5 m/s 2 (die
acceleration intensity on exposure. vibration grinders).
a sample of tools, exposure
subjective ratings, and and former Mean latency to symptom onset
objective measures of exposure. 14 5-38 = 9.8 years.
exposure time.
Platers and Office Odds ratio increased by 11%
office workers for each year of exposure. No
workers with with no correlation between the Taylor-
current or vibration Pelmear stage and years of
former experience. 56 12-269 exposure.
exposure.
(Continued)
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MSD prevalence
Saito 1987 Cohort: Chain sawers without Outcome: Assessed by 0% in 1983 0% in 1978 Participation: Follow-up of
6-year HAV symptoms in 1978 symptoms, skin temperature, cohort.
follow-up (n=155) followed up in vibration threshold, nail
prospect- 1983. compression, pain sense, Improvements in chain saw
ive and cold provocation. design, age restrictions, and a
decrease in weekly operating
Exposure: Chain saw time credited for preventing
operating time determined by HAV.
questionnaire.
Recovery rates of skin
temperature after 10-min
provocation test significantly
better in 1982 and 1983
compared to 1978.
Vibratory sense thresholds at

5th minute after cold
provocation significantly better
in 1980, 1982, and 1983
compared with 1978.
Age significance correlated to

recovery rates from 1978 to
1983.
(Continued)
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MSD prevalence
Shinev et Cross- 77 male fettlers; 59 male Outcome: HAV assessed by 22.1% Participation rate: Not reported.
al. 1992 sectional molders; 85 male neurological examination. (fettlers)
polishers. 6.8% Percussive vibration had
Exposure: Vibration (molders) greater effect on muscle and
No control group used. characteristics of chipping 25% bone pathology than constant
and caulking hammers, air (polishers) high-frequency vibration.
tampers, and polishing
machines measured.
(Continued)
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MSD prevalence
Starck et Cross- Forest workers (n=200), Outcome: HAV based on 40% (forest Participation rate: Not reported.
al. 1990 sectional pedestal grinders (n=12), symptoms, assessed via workers using
shipyard workers questionnaire. 1st generation No demographic data about
(n=171), stone workers chain saw) study participants provided.
(n=16), and platers (n=5). Exposure: Vibration
measurements taken on a 16% (forest Poor correlation between
No control group used. sample of tools during normal workers using vibration exposure and HAV
operation at the workplace. 2nd when tools were highly
generation impulsive.
chain saw)
<7% (forest
workers using
3rd generation
chain saw)
100% (for
pedestal
grinders with
zirconium
wheels)
5% (shipyard
workers)
75% (stone
workers using
pneumatic
hammers)
50% (stone
workers using
chisel heads)
40% (platers)
(Continued)
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MSD prevalence
Virokannas Cross- Railway workers (n=31) Outcome: History of attack Railway Participation rate: Not reported.
and sectional and lumberjacks (n=32) of white finger reported by workers: 45%
Tolonen exposed to HAV. No subjects. VWF Total exposure to HAV had
1995 controls used. Article significant correlation with VPT
in railway workers (r=0.55-
evaluates the vibration VPT and electroneuro- Lumberjacks: 0.47; p=0.017) and lumberjacks
perception threshold myography used as 38% VWF (r=0.77-0.59; p=0.003).
(VPT) among exposed indicators of sensory nerve
workers and tries to damage (outcome measure). Increase in VPT approximately
determine a dose- 2 times greater in railway
response relationship Exposure: To vibrating tools workers.
between exposure to assessed by interview. (No
HAV and the VPTs. measurements performed). 7 workers excluded2
railway workers with
Groups asked about polyneuropathy; 4 railway
exposure time with self- workers with CTS;
estimated annual use of 1 lumberjack with CTS. These
vibrating tools and vehicles may have been related to
(hr) and number of years of vibration exposure.
exposure to vibration. Mean
(SD) duration of exposure to Lumberjacks used chain saws
vibration was 8,050 (3,500) daily >1,000 hr per year.
Railway workers used hand-
among railway workers and held tamping machines -500
21,250 (10, 950) hrs among hrs per year.
lumberjacks.
Found peak value differences
for hand-held tamping
machines (40 to 60 Hz) and
chain saws (120 to 150 Hz).
Nerve-conduction
measurements adjusted for
skin temperature.
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CHAPTER 6
Low-Back Musculoskeletal Disorders:
Evidence for Work-Relatedness
SUMMARY
Over 40 recent articles provided evidence regarding the relationship between low-back disorder and the five
physical workplace factors that were considered in this review. These included (1) heavy physical work, (2)
lifting and forceful movements, (3) bending and twisting (awkward postures), (4) whole-body vibration (WBV),
and (5) static work postures. Many of the studies addressed multiple work-related factors. All articles that
addressed a particular workplace factor contributed to the information used to draw conclusions about that
risk factor, regardless of whether results were positive or negative.
The review provided evidence for a positive relationship between back disorder and heavy physical work,
although risk estimates were more moderate than for lifting/forceful movements, awkward postures, and
WBV. This was perhaps due to subjective and imprecise characterization of exposures. Evidence for dose-
response was equivocal for this risk factor.
There is strong evidence that low-back disorders are associated with work-related lifting and forceful
movements. Of 18 epidemiologic studies that were reviewed, 13 were consistent in demonstrating positive
relationships. Those using subjective measures of exposure showed a range of risk estimates from 1.2 to
5.2, and those using more objective assessments had odds ratios (ORs) ranging from 2.2 to 11. Studies
using objective measures to examine specific lifting activities generally demonstrated risk estimates above
three and found dose-response relationships between exposures and outcomes. For the most part, higher
ORs were observed in high-exposure populations (e.g., one high-risk group averaged 226 lifts per hour with
a mean load weight of 88 newtons [N]) . Most of the investigations reviewed for this document adjusted for
potential covariates in analyses; nevertheless, some of the relatively high ORs that were observed were
unlikely to be caused by confounding or other effects of lifestyle covariates. Several studies suggested that
both lifting and awkward postures were important contributors to the risk of low-back disorder. The observed
relationships are consistent with biomechanical and other laboratory evidence regarding the effects of lifting
and dynamic motion on back tissues.
The review provided evidence that work-related awkward postures are associated with low-back disorders.
Results were consistent in showing positive associations, with several risk estimates above three.
Exposure-response relationships were demonstrated. Many of the studies adjusted for potential covariates
and a few examined the simultaneous effects of other work-related physical factors. Again, it appeared that
lifting and awkward postures both contribute to risk of low-back disorder.
There is strong evidence of an association between exposure to WBV and low-back disorder. Of 19
studies reviewed for this document, 15 studies were consistent in demonstrating positive associations, with
risk estimates ranging from 1.2 to 5.7 for those using subjective exposure measures, and from 1.4 to 39.5
for those using objective assessment methods. Most of the studies that examined relationships in high-
exposure groups using detailed quantitative exposure measures found strong positive associations and
exposure-response relationships between WBV and low back disorders. These relationships were observed
after adjusting for covariates.
Both experimental and epidemiologic evidence suggest that WBV may act in combination with
other work-related factors, such as prolonged sitting, lifting, and awkward postures, to cause
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increased risk of back disorder. It is possible that effects of WBV may depend on the source of exposure
(type of vehicle).
With regard to static work postures and low-back disorder, results from the studies that were reviewed
provided insufficient evidence that a relationship exists. Few investigations examined effects of static
work postures, and exposure characterizations were limited.
INTRODUCTION The relationship of the disorder with

Low-back pain (LBP) is common in the employment can be complex: individuals may
general population: lifetime prevalence has been experience impairment or disability at work
estimated at nearly 70% for industrialized because of back disorders whether the latter
countries; sciatic conditions may occur in one was directly caused by job-related factors or
quarter of those experiencing back problems not. The degree to which ability to work is
[Andersson 1981]. Studies of workers impaired is often dependent on the physical
compensation data have suggested that LBP demands of the job. Furthermore, when an
represents a significant portion of morbidity in individual experiences a back disorder at work,
working populations: data from a national it may be a new occurrence or an exacerbation
insurer indicate that back claims account for of an existing condition. Again, originally it may
16% of all workers compensation claims and have been directly caused by work or by
33% of total claims costs [Snook 1982; nonwork-related factors. Those suffering back
Webster and Snook 1994b]. Studies have pain may modify their work activities in an
demonstrated that back disorder rates vary effort to prevent or lessen pain. Thus, the
substantially by industry, occupation, and by relationship between work exposure and
job within given industries or facilities [see disorder may be direct in some cases, but not in
Bigos et al. 1986a; Riihimki et al. 1989a; others.
Schibye et al. 1995; Skovron et al. 1994].
When discussing causal factors for low-back
Back disorder is multifactorial in origin and may disorders, it is important to distinguish among
be associated with both occupational and the various outcome measures, such as LBP,
nonwork-related factors and characteristics. impairment, and disability. LBP can be defined
The latter may include age, gender, cigarette as chronic or acute pain of the lumbosacral,
smoking status, physical fitness level, buttock, or upper leg region. Sciatic pain refers
anthropometric measures, lumbar mobility, to pain symptoms that radiate from the back
strength, medical history, and structural region down one or both legs; lumbago refers
abnormalities [Garg and Moore 1992]. to an acute episode of LBP. In many cases of
Psychosocial factors, both work- and LBP, specific clinical signs are absent. Low-
nonwork-related, have been associated with back impairment is generally regarded as a loss
back disorders. These relationships are of ability to perform physical activities. Low-
discussed at length in Chapter 7 and Appendix back disability is defined as necessitating
B. restricted duty or time away from the job.
Although it is not clear which outcome measure
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is best suited for determining the causal It is important to include subjectively defined
relationship between low-back disorder and health outcomes in any consideration of work-
work-related risk factors, it is important to related back disorders because they comprise
consider severity when evaluating the literature. such a large subset of the total. It may be too
restrictive to define cases of back disorder
In addition to level of severity, outcomes may using objective medical criteria. Therefore, in
be defined in a number of other ways, ranging contrast to chapters for musculoskeletal
from subjective to objective. Information on disorders or other anatomic regions, this review
symptoms can be collected by interview or of literature on the back used slightly different
questionnaire self-report. Back incidents or evaluation criteria. For consideration of back
reports include conditions reported to disorders, use of a subjective health outcome
medical authorities or on injury/illness logs; was not necessarily considered a study
these may be symptoms or signs that an limitation. Furthermore, because back
individual has determined need for medical or disorders were rarely defined by medical
other attention. They may be due to acute examination criteria, the evaluation criterion
symptoms, chronic pain, or injury related to a related to blinding of assessors (to health or
particular incident, and may be subjectively or exposure status) was also less relevant to a
objectively determined. Whether an incident is discussion of this literature.
reported depends on the individuals situation
and inclinations. Other back disorders can be In this review, epidemiologic studies of all
diagnosed using objective criteriafor forms of back disorder were included. The
example, various types of lumbar disc term back disorder is used to encompass all
pathology. health outcomes related to the back. It should
be pointed out that, in some studies, disorders
There are many conditions in the low back of the low back were not distinguished from
which may cause back pain, including muscular total back disorders. We assumed that a
or ligamentous strain, facet joint arthritis, or significant portion of these related to the low
disc pressure on the annulus fibrosis, vertebral back, and articles using such a definition were
end-plate, or nerve roots. In most patients, the included in our review.
anatomical cause of LBP, regardless of its
relationship to work exposures, cannot be The 42 epidemiologic studies discussed below
determined with any degree of clinical certainty. were selected according to criteria that appear
Muscle strain is probably the most common in the introduction of this document. Most (30)
type of work or nonwork back pain. While used a cross-sectional design, followed by
there is sometimes a relationship between pain prospective cohort (5), case-control (4), and
and findings on magnetic resonance imaging retrospective cohort (2) designs. One study
(MRI) of disc abnormalities (such as a combined both cross-sectional and cohort
herniated disc and clinical findings of nerve analyses. Full descriptions of the studies appear
compression), unfortunately, the most common in Table 6-6. Twenty-four investigations
form of back disorder is non-specific defined the health outcome only by report of
symptoms, which often cannot be diagnosed. symptoms on questionnaires or in interviews
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(for example, total back pain, LBP, and are discussions of the evidence for each work-
sciatica); used symptoms plus medical related physical risk factor.
examination (back pain, low-back syndrome,
sciatica, back insufficiency, lumbago, herniated
HEAVY PHYSICAL WORK
lumbar disc, and lumbar disc pathology),
Definition
2 used sick leaves and medical disability
retirements, and 6 used injury/illness reports. Heavy physical work has been defined as work
The last category included outcomes defined as that has high energy demands or requires some
low-back complaints, injuries caused measure of physical strength. Some
specifically by lifting or mechanical energy, and biomechanical studies interpret heavy work as
acute industrial back injury. Clearly, the 42 jobs that impose large compressive forces on
studies used outcome definitions that the spine [Marras et al. 1995]. In this review,
correspond to several regions of the back and the definition for heavy physical work includes
include disorders that may have been acute or these concepts, along with investigators
chronic and subjectively or objectively perceptions of heavy physical workload, which
determined. range from heavy tiring tasks, manual materials
handling tasks, and heavy, dynamic, or intense
In the studies included in this review, exposures work. In several studies, evaluation of this risk
were assessed primarily by questionnaire or factor was subjective on the part of participant
interview (n=17), followed by observation or or investigator, and in many cases, heavy
direct measurement (n=15) and by job title only physical work appeared to include other
(n=10). Study groups included general potential risk factors for back disorder,
populations (Swedish, Dutch, U.S., Finnish, particularly lifting and awkward postures.
and English) and occupational groups (nurses,
clerical employees, school lunch preparers,
baggage handlers, and individuals working in Between LBP and Heavy Physical Work
construction, agriculture, maritime, petroleum, Eighteen studies appeared to address the risk
paper products, transportation, automobile, factor related to heavy physical work, although
aircraft, steel, and machine manufacturing none of them fulfilled all four evaluation criteria
industries). (Table 6-1, Figure 6-1). In fact, most (78%)
had acceptable participation rates, but only
This review of epidemiologic studies of low- three defined health outcomes using both
back disorder examined the following potential symptoms and medical exam criteria, and only
risk factors related to physical aspects of the two assessed exposure independent of self-
workplace: (1) heavy physical work, (2) lifting report.
and forceful movements, (3) bending and
twisting (awkward postures), (4) WBV, and In nearly all of these studies, covariates were
(5) static work postures. Psychosocial addressed in at least minimal fashion, such as
workplace factors were also included in a restricting the study population as to
number of studies; these relationships are gender and conducting age-stratified or
discussed separately in Chapter 7. Following
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adjusted analyses; in many, multivariate symptoms.

analyses were carried out. With regard to
health outcome, while only three used medical Burdorf and Zondervan [1990] carried out a
exams, in addition to symptoms or injury cross-sectional study comparing 33 male
reports, to arrive at case definitions, in many workers who operated cranes with age-
instances standard questionnaire instruments matched workers from the same Dutch steel
were used. The major study limitations, overall, plant who did not operate cranes. Symptoms of
were related to relatively poor ascertainment of LBP and sciatica were assessed by
exposure status. questionnaire. Exposure was assessed by job
title (crane operators were noted to experience
Following are descriptions of seven studies that frequent twisting, bending, stooping, static
were most informative. Detailed descriptions sedentary postures, and WBV) and by
for all 18 investigations can be found in Table questionnaire (exposures to sedentary postures,
6-6. WBV, heavy physical work, and frequent lifting
were assessed for both current and past jobs).
Bergenudd and Nilsson [1988] followed a Crane operators were significantly more likely
Swedish population-based cohort established in to experience LBP (OR 3.6, 95% CI
1938. Back pain (total) presence and severity 1.210.6). Among crane operators alone, the
were self-assessed by questionnaire, as of OR for heavy work was 4.0 (95% CI
1983; exposures (light, moderate, or heavy 0.7621.2) after controlling for age, height, and
physical work) were assessed based on weight. It was determined that this heavy work
questionnaires completed by the cohort from occurred in past and not in current jobs.
1942 onward. Univariate results demonstrated Among crane operators alone, the OR for
that those with moderate or heavy physical frequent lifting was 5.2 (95% CI 1.125.5).
demands in their jobs had more back pain than The frequent lifting in crane operators was also
those with light physical demands (OR 1.83, determined to be from jobs held in the past.
95% Confidence Interval [CI] 1.2-2.7). When Among workers who were not crane
stratified by gender, the relationship was slightly operators, history of frequent lifting was not
stronger for females (OR 2.03, 95% CI associated with LBP (OR 0.70, 95% CI
1.13.7) than for males (OR 1.76, 95% CI 0.143.5). Among crane operators, univariate
1.013.1). When prevalence was examined by ORs for WBV and prolonged sedentary
exposure category, rates were 21.4%, 32.8%, postures were 0.66 (95% CI 0.143.1) and
and 31.3% for males (no trend was available 0.49 (95% CI 0.112.2), respectively. In
for females, as none worked in the highest multivariate analyses controlled for age, height,
exposure category). Analyses were stratified by weight, and current crane work, most of the
gender but did not account for other potential associations with specific work-related factors
covariates. The longitudinal design ensured that were substantially reduced. The high
exposures preceded health outcomes. prevalence of LBP in crane operators was
Shortcomings included a relatively low explained only by current crane work. No
response rate (67%), minimal exposure measures of dose-response were examined.
assessment, limited adjustment for covariates in
analyses, and self-reporting of health
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Limitations included a relatively low response drivers, welders, smiths, and operators of
rate for crane operators (67%)with some several types of machines (lathes, punch
suggestion that those with illness may have been presses, and milling). Outcome information was
under-represented (perhaps underestimating obtained by questionnaire. Exposure data were
the OR)and self-reporting of health also obtained by questionnaire and included
outcomes and exposures. The investigators information on occupational, psychosocial, and
attempted to clarify the temporal relation physical workloads, including sitting, carrying,
between exposure and outcome by excluding pushing, pulling, lifting, work postures, and
cases of back pain with onset before the repetitive movements. Questionnaire items
present job. related to carrying, pushing, pulling, and lifting
were combined to produce an index of manual
As part of a Finnish population-based health materials handling. The prevalence of work-
survey, Helivaara et al. [1991] conducted a related LBP was significantly higher in blue-
cross-sectional analysis of chronic low-back collar employees than in white-collar workers
syndrome, sciatica, and LBP. Health outcomes (RR 1.8, p<0.05). In both white and blue-
were determined by interview and examination; collar workers, work-related LBP was not
work-related exposure information was significantly associated with either heavy or light
obtained by a self-administered questionnaire, materials handling, or bent or twisted work
which included items related to lifting, carrying postures, after adjustment for age and gender.
heavy objects, awkward postures, WBV, LBP was significantly associated with extreme
repeated movements, and paced work. The work postures (blue-collar workers only) and
total number of factors was designated the monotonous working movements (white-collar
sum index of occupational physical stress. workers only). In these analyses, relationships
Mental work stress measures were also were presented as partial correlations; thus, a
included. A dose-response was observed for comparison of risk estimates was not possible.
sciatica and the physical stress score (with an Limitations of the study included the cross-
OR of 1.9, 95% CI 0.84.8 for the highest sectional design, collection of outcome and
score) and for low-back syndrome and exposure data by self-report, and potential
physical stress (OR 2.5, 95% CI 1.44.7), problems with multiple comparisons, as many
after adjusting for a number of covariates. The independent variables were examined in
study did not address temporal relationships, analyses. Many of the exposed group (blue-
and exposure information was derived from collar workers) were engaged in machine
self-reports. Strengths included a high response operation tasks with perhaps limited
rate, objective measure of health outcomes, and opportunity for exposure to work with heavy
multivariate adjustment for covariates. physical demands. Also, heavy physical work
and lifting were combined into a single index.
Johansson and Rubenowitz [1994] examined Strengths included consideration of age and
low-back symptoms cross sectionally in 450 gender as covariates and inclusion of both
blue- and white-collar workers employed in physical and psychosocial workplace
eight Swedish metal companies. The exposed measures.
group included assemblers, truck
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Svensson and Andersson [1989] examined 83% for light, intermediate, and heavy
LBP in a population-based cross-sectional categories). The trend was not observed in
study of employed Swedish women. older age groups, nor for sciatica in any age
Information on LBP and sciatica was obtained group. LBP and sciatica rates were slightly
by questionnaire, as were exposure-related higher for nurse aides than for qualified nurses,
items. Physical exposures included lifting, although the differences were not statistically
bending, twisting, other work postures, sitting, significant. The authors suggested that aides
standing, monotony, and physical activity at had higher rates of back pain because of
work. Lifetime incidence rates (IRs) varied by heavier workload, including patient handling
occupation, with ranges from 61%83% in and lifting. Lack of consistency of LBP OR
younger age groups and 53%75% in older across exposure and age groups suggested that
groups. A posteriori, the authors noted that, a healthy worker effect was operating and that
for these women, the highest lifetime incidence injured workers might be leaving the field, a
of LBP was not found in the jobs with the phenomenon that the cross-sectional study
highest physical demands. The measure for design could not address.
physical activity at work was also not
significantly associated with LBP in univariate Videman et al. [1990] carried out a cross-
analyses. Bending forward (RR 1.3), lifting (RR sectional study of 86 males who died in a
1.2), and standing (RR 1.3) were associated Helsinki hospital to determine degree of lumbar
with lifetime incidence of LBP in univariate spinal pathology. Disc degeneration and other
analyses (p<0.05). None of the measures of pathologies were assessed in the cadaver
physical workplace factors were associated specimens by discography and radiography.
with lifetime incidence of LBP in multivariate Subjects symptoms and work
analyses. exposuresheavy physical work, sedentary
work, driving, and mixedwere determined by
A cross-sectional study of LBP in Finnish interview of family members. In comparison to
nurses was conducted [Videman et al. 1984]. those with mixed work exposures, those with
LBP and sciatica were ascertained by sedentary and heavy work had increased risk
questionnaire; exposure information was also of symmetric disc degeneration with ORs of
self-reported and included items related to both 24.6 (95% CI 1.5409) and 2.8 (95% CI
physical loading factors at work and to work 0.323.7), respectively). Similar relationships
history. Exposures were reclassified as were seen for vertebral end-plate defects and
heavy, intermediate, and light, based on facet joint osteoarthrosis. Risk of vertebral
questionnaire responses. The derivation of this osteophytosis was highest for those in the heavy
classification was not clear, but it may have work category (OR 12.1, 95% CI 1.4107).
been a combination of responses to questions For most pathologic changes, sedentary work
on lifting, bending, rotation, standing, walking, appeared to have a stronger relationship than
and sitting. A dose-response was observed heavy work. Back pain symptoms were
between prevalence of previous LBP and consistently higher in those with any form of
workload category in younger women (77%, spinal pathology, although the difference was
79%, and significant only for anular ruptures. Results of
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this study were notable in that anular rupture, a overall physical workload in a group of Belgian
classic pathologic condition of the disc, was not steelworkers, although LBP was related to
associated with exposure. This study was heavy shoulder efforts. In a study of blue-and
unusual in design in that it examined a white-collar workers, Johansson and
combination of spinal pathological outcomes, Rubenowitz [1994] found higher LBP rates in
symptoms, and workplace factors. However, blue-collar workers (RR 1.8, p<0.05).
participation in the study was dependent on However, in more detailed analyses of
obtaining information from family members; exposure, back pain was not associated with
participation rates were not stated. While recall indices for heavy or light materials handling
bias is often a problem in studies of the after adjustment for age and gender (with
deceased, in this case, it should have been partial correlation coefficients of less than
nondifferential, if present. 0.10). Burdorf and Zondervans 1990 study of
crane operators demonstrated increased risk of
Strength of Association LBP with exposure to heavy work (OR 4.0,
The most informative studies were generally 95% CI 0.821.2) after controlling for age,
those that carried out exposure assessments height, and weight. Two studies used indices of
which ranked physical workload based on physical stress to create questionnaire
questionnaire report. In a prospective study of responses related to lifting, carrying heavy
back injury reports, Bigos et al. [1991b] found objects, awkward postures, repeated
no associations with physical job characteristics movements, and others. Helivaara et al.
(although the authors stated that the study [1991] found that both low-back syndrome
population had low overall exposures). This and sciatica were associated with physical
study described the biomechanical methods that stress scores, with ORs of 2.5 (p<0.05) and
were used to directly assess spinal loads 1.9 (not significant) for the highest scores,
associated with jobs, but no results related to respectively. A study of Finnish nurses
these measures were presented. Svensson and classified exposures as heavy, intermediate,
Andersson [1989] appear to have examined a and light based on questionnaire response
measure for physical activity at work and its scores [Videman et al. 1984]; prevalence of
relationship to LBP in Swedish women. No LBP was slightly higher in the heavy category
associations were observed. In a population- than in the light (RR 1.1, not significant) for
based study, Bergenudd and Nilsson [1988] younger women only. Sciatica was also
observed significantly more back pain in those examined, and no relationships were found.
with heavier physical work (OR 1.8 for
moderate/heavy versus light work, p<0.01). The other studies that examined heavy physical
ORs were slightly higher for females (OR 2.0) work as a risk factor for back disorder
than for males (OR 1.8). Leigh and Sheetz classified exposure in a simpler manner, either
[1989] found that back symptoms were by job title alone or by grouping jobs based on
associated with self-reporting that job requires prior knowledge of the work or questionnaire
a lot of physical effort (OR 1.5, 95% CI responses. Burdorf et al. [1991] found that
1.02.2). Masset and Malchaire [1994]
observed that LBP was not associated with
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heavy physical work was associated with back impact injuries, with RRs of 2.2 and 4.3 (no
pain in concrete workers in univariate, but not significance testing was done) in comparison to
multivariate models (no risk estimate was control room operators and maintenance
reported). Hildebrandt [1995] found that professionals, those with the lowest rates. A
individuals in jobs described as heavy non- study of hospital employees that matched cases
sedentary were more likely to experience with controls by department found that those on
back pain than those in sedentary jobs (OR the day shift had an OR of 2.2 (p<0.005) in
1.2, p<0.05). In a cadaver study of lumbar disc comparison to those working other shifts
pathology, Videman et al. [1990] found that [Ryden et al. 1989]. In the last two studies, the
those with jobs involving heavy physical work authors determined a posteriori that job titles
had increased risk of disc pathology in (or shifts) that were observed to have high back
comparison to those with mixed work disorder rates were those requiring the heaviest
exposures (e.g., an OR of 2.8, 95% CI physical effort.
0.323.7, for symmetric disc degeneration and
an OR of 12.1, 95% CI 1.4107, for vertebral Although in all 18 of these studies the authors
osteophytosis). For most pathologic changes, stated that heavy physical effort or work was
sedentary work had a stronger relationship than at least one of the risk factors of interest, the
heavy work. actual estimates of these exposures varied from
assumptions based on job title to self-reported
Finally, several studies examined back disorder scores based on self-reported work activities.
rates by job title or occupation alone. In no case were measured physical loads used
Hildebrandt et al. [1996] observed differences as independent variables. Study populations
in back symptom rates by unit and task group included individuals working in health care,
in nonsedentary steel workers. The reference office work, manufacturing, construction, and
group also had high symptom rates; general populations, all with varying degrees of
comparisons between the two groups did not physical work requirements. Some studies
yield significant differences. In multivariate created physical stress indices that included
analyses, Riihimki et al. [1989b] found no more than one risk factor. Since most estimates
significant difference in sciatic pain for of physical load were subjective, they tended to
carpenters and office workers (OR 1.0, 95% reflect the relative requirements of the jobs and
CI 0.81.3). Partridge and Duthie [1968] individuals included in each study. Health
found that dock workers had slightly higher outcomes also varied.
LBP rates than civil servants (RR 1.2, not
significant). In a similar study, strand [1987] In summary, the strength of the relationship
classified pulp mill jobs as heavy and the between back disorder and heavy physical
referent group of clerical jobs as light; mill work in some of the studies with more
workers were 2.3 times more likely to quantitatively defined exposures ranged from
experience back pain than clerical staff none [Bigos et al. 1991b; Johannsson and
(p=0.002). Clemmer et al. [1991] found that Rubenowitz, 1994; Masset and Malchaire
floor hands, roustabouts, and derrickhands had 1994; Svensson and Andersson 1989;
the highest rates for low-back strains and Videman et al. 1984] to ORs of 1.9 (not
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significant) for sciatica and 2.5 (p<0.05) for Temporal Relationship

low-back syndrome [Helivaara et al. 1991], Fourteen of the 18 reviewed studies had a
1.5 (95% CI 1.02.2) [Leigh and Sheetz cross-sectional design that could not directly
1989], 1.8 (95% CI 1.22.7) [Bergenudd and address this issue. Three mentioned potential
Nilsson 1988], and 4.0 (p<0.05) for LBP problems related to this study design. strand
[Burdorf and Zondervan 1990]. In another [1987] suggested that exposure
study, which used a scoring system and focused misclassification occurred in her study of paper
on a subject group of nurses, the RR was 1.1 mill workers (some individuals were transferred
(not significant) for the high-exposure category to clerical jobsthe unexposed groupafter
[Videman et al. 1984]. experiencing a back injury in the mill). In the
Videman et al. 1984 study of nurses, lack of
Dichotomous estimates of physical workload consistency of LBP OR by age and exposure
yielded ORs of 1.2 [Hildebrandt 1995], 2.8- group suggested that injured workers were
12.1 [Videman et al. 1990], and no association leaving the field. A study of cadavers carried
(results were observed in univariate but not out by Videman et al. [1990] seemed to have
multivarate analyses, with no risk estimates potential for problems with temporal
reported) [Burdorf et al. 1991]. Exposures relationships, as exposure information for past
based on job title alone yielded estimates from periods depended on recall of study
none [Hildebrandt et al. 1996], nonsignificant participants activities by family members.
ORs of 1.0 and 1.2 [Partridge and Duthie
1968; Riihimki et al. 1989b], to significant Two cross-sectional studies attempted to clarify
ORs of 2.24.3 [strand 1987; Clemmer et al. temporal relationships by excluding from
1991; Ryden et al. 1989]. Half of the studies analysis the cases with disorder onset prior to
had positive point estimates for this risk factor current job [Burdorf et al. 1991; Burdorf and
but were low to moderate in magnitude. In five Zondervan 1990]. Both showed results
studies that found no association between back suggesting a positive relationship between
disorder and heavy physical work, no details exposure and back disorders. Three studies
were given. Two of the highest significant ORs had cohort designs in which temporal
were based on exposed groups in the oil and relationships between outcome and exposure
steel industries [Burdorf and Zondervan 1990; could be determined [Bergenudd and Nilsson
Clemmer et al. 1991]. For these, true exposure 1988; Bigos et al. 1991b; Clemmer et al.
to heavy physical work was probably more 1991]: in one, no association was observed, in
likely than for some of the other study another, a modest increase in risk was seen. In
populations. For many of the investigations, the third, exposure (assessed a posteriori by
exposure estimates were subjectively assessed. job title) was significantly associated with back
In many cases, study groups had potentially low injuries. A case-control study conducted using
exposures or exposure to heavy physical work hospital personnel records appeared free from
in combination with other risk factors. recall bias and showed a significant association
between low-back injury and working the day
shift (assessed a posteriori as having the
heaviest workload) [Ryden et al. 1989].
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Although the majority of studies were limited by materials handling are due to a combination of
their cross-sectional designs, results were the weight lifted, and the persons method of
similar for these and other studies with designs handling the load. The internal reaction forces
that could assess temporal relationships. needed to equilibrate the body segment weights
and external forces such as weight of the load
For most studies, the data are compatible with being lifted are supplied by muscle contraction,
a temporal relationship in which exposure ligaments, and body joints. Injury to the
preceded disorder. supporting tissues can occur when the forces
from the load, body position, and movements
Consistency in Association of the trunk create compressive, shear, or
Half of the 18 studies examined demonstrated rotational forces that exceed the capacities of
no significant association between exposure the discs and supporting tissues needed to
and outcome. All of those which showed counteract the load moments. Rowe [1985]
significant associations (n=9) were positive in hypothesized that disc and facet degeneration
direction, (one OR of 1.2, two ORs between and ligament strain are responsible for the
1.5 and 2, and six ORs between 2.2 and 12.1). potentially high rates of LBP disability in those
whose jobs demand heavy physical activity.
Study groups included males working in
industrial environments, office workers, health The Videman et al. [1990] cross-sectional
care employeesfemale, for the most study of cadavers addressed two aspects of the
partand population-based groups that causal chain linking exposure to heavy physical
included both genders and many occupations. work and back disorder. First, the study
That some consistency in results was noted demonstrated an association between
among these diverse groups, particularly after subjective health outcome measures and more
adjustment for covariates, suggests that the objective measures: back pain symptoms
observed associations have validity and can be (assessed from family members) were
generalized across working populations. consistently higher in those with signs of spinal
pathology. Second, the study demonstrated an
Coherence of Evidence association between objective measures of
Information derived from a large number of disorder and heavy work exposures: individuals
laboratory and field studies using a wide variety whose jobs included heavy work exposures
of approaches provides a plausible explanation showed increased risk of symmetric disc
for associations between LBP and physically degeneration, vertebral osteophytosis, and facet
demanding jobs [Waters et al. 1993]. Research joint osteoarthrosis. Significant relationships
conducted in the 1950s demonstrated that disc were also found for back pain and disability.
degeneration occurs earlier in life among We agree with the conclusion of Videman et al.
workers who perform heavy physical work [1990] that states that back injury and
than among those who perform lighter work.
Similar findings are reported in more recent
investigations [Videman et al. 1990]. The
stresses induced at the low back during manual
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sedentary or heavy (but not mixed) work Only a few studies examined exposure in
contributed to the development of pathologic sufficient detail to assess exposure-response
findings in the spine. The severity of back pain relationships with low-back disorders. Results
was related to the heaviness of work. Work- were mixed. Helivaara et al. [1991] observed
related factors may be responsible for the an exposure-response between sciatica and
development of pathologic changes and for physical stress score; the Videman et al. [1984]
increased episodes of LBP and disability. results demonstrated a dose-response between
LBP prevalence and workload categories in
Another important contribution to the younger nurses, but not in older groups, or for
coherence of evidence is that the Bureau of sciatica in any age group. In strands 1987
Labor Statistics Annual Survey of Injuries and high exposure group (pulp mill workers),
Illnesses has demonstrated significant elevations duration of employment was associated with
in overexertion injuries and disorders in back pain. Bergenudd and Nilsson [1988] and
industries which are associated with heavy Johansson and Rubenowitz [1994] observed
work, such as nursing and personal care and air no exposure-response relationships between
transportation. Some broad population surveys back disorders and their exposure measures.
such as the National Health Interview Survey On the whole, evidence of exposure-response
(NHIS) from 1988 and the 1990 Ontario is equivocal, based on the paucity of
Health Survey (OHS) found increased back information available.
pain or long-term back problems with exposure
to factors such as lifting, pulling, and physical Conclusions: Heavy Physical Work
pushing [Guo et al. 1995; Liira et al. 1996]. In The reviewed epidemiologic investigations
the NHIS, the two occupations with the highest provided evidence that low-back disorders are
significant rates of work-related LBP were associated with heavy physical work. Despite
male construction laborers (with a prevalence the fact that studies defined disorders and
ratio [PR] of 2.1) and female nursing aides, assessed exposures in many ways, all studies
orderlies, and attendants (PR 2.8) [Guo et al. which demonstrated significant associations
1995]. In the OHS, the number of simultaneous between exposure and outcome were positive
physical exposures was directly related to risk in direction and showed low to moderate
increase after adjustment for covariates. For increased risk. Exposures were assessed
the highest exposure index level, the adjusted subjectively, for the most part; and in some
OR was 3.18 (95% CI 1.725.8), which cases, classification schemes were crude. This
occurred in 3% of the population [Liira et al. study limitation may have led to
1996]. It is important to point out that truly misclassification of exposure status to the extent
heavy work probably occurs in only a tiny that it caused a dampening effect on risk
proportion of all jobs in most industries and in estimates, where nondifferential
only a minority of many high-risk industries, misclassification caused bias toward a null value
which is why misclassification of exposures is for the measure of association. This may
likely in population-based studies. account for the moderate ORs that were
Exposure-Response Relationships
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observed. A few studies were able to examine Between LBP and Lifting and
dose-response relationships between outcomes Forceful Movements
and exposure; these results were equivocal. Eighteen studies examined relationships
Most studies utilized cross-sectional study between back disorders and lifting or forceful
designs; however, five of six studies which used movements. Only one, Punnett et al. 1991
specific methodologies to address temporality case-control study of back pain in auto
showed positive associations between exposure workers, fulfilled the four evaluation criteria
and outcome. Many studies addressed potential (Table 6-2, Figure 6-2). The majority (66%)
effects of covariates by restriction in selection had adequate participation rates; four defined
of study participants, stratification, or outcomes using both symptoms and medical
multivariate adjustment in statistical analyses. exam criteria. Blinding of investigators with
regard to case/exposure status was not
In many studies, heavy physical work mentioned in most, but it could be confirmed in
exposure appeared to include other work- two papers and inferred (by study methodology
related physical factors (particularly lifting and ) in two others. Seven studies used an exposure
awkward postures). assessment that included observation or direct
measurement; an additional nine obtained
LIFTING AND FORCEFUL exposure information by self-report on
MOVEMENTS questionnaire or interview. Only two relied on
Definition job title alone to characterize exposure.
Lifting is defined as moving or bringing
something from a lower level to a higher one. Thirteen investigations were cross-sectional in
The concept encompasses stresses resulting design; three were case-control, and two were
from work done in transferring objects from prospective. Eleven defined the health outcome
one plane to another as well as the effects of by symptom report on interview or
varying techniques of patient handling and questionnaire.
transfer. Forceful movements include
movement of objects in other ways, such as Descriptions of seven studies which provided
pulling, pushing, or other efforts. Several the most information regarding the relationship
studies included in this review used indices of between low-back disorder and lifting and
physical workload that combined lifting/forceful forceful movements follow. Detailed
movements with other work-related risk factors descriptions for all 18 investigations can be
(particularly heavy physical work and awkward found in Table 6-6.
postures). Some studies had definitions for
lifting which include criteria for number of lifts The Punnett et al. [1991] case-control study
per day or average amount of weight lifted. examined the relationship between back pain
and occupational exposures in auto assembly
workers. Back pain cases (n=95) were
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determined by symptoms at interview and group of maintenance workers. Back pain

medical examination; controls included those symptoms were assessed by questionnaire.
free of back pain. For all participants (or Exposures were measured using the Ovako
proxies in the same jobs), jobs were Working Posture Analysis System, which
videotaped and work cycles were reviewed assessed postures for the back and lower limbs
using a posture analysis system. Exposures along with lifting load. Information on
included time spent in various awkward exposures in previous jobs was also collected.
postures. Peak biomechanical forces were Concrete workers experienced significantly
estimated for up to nine postures where a load more back symptoms than referents (OR 2.8,
weighing at least 10 lb was held in the hands. In 95% CI 1.36.0). Univariate results showed
multivariate analyses that adjusted for a number associations between back pain and both
of covariates (age, gender, length of posture index and WBV in current job
employment, recreational activities, and medical (correlations were presented). Lifting was not
history), time in non-neutral postures (mild or found to be associated with back pain (and
severe flexion and bending) was strongly exposure was found not to vary significantly
across the six job categories examined in the
associated with back disorder (OR 8.09, 95%
study). In multivariate analyses adjusting for
CI 1.444). Lifting was also associated with
age, both posture index and WBV were
back disorder (OR 2.16, 95% CI 1.04.7).
significantly associated with back pain, with
When the subset with physical medical findings
ORs of 1.23 (p=0.04) (for an ordinal scale of
was examined, associations were more
6) and 3.1 (p=0.01) (dichotomous),
pronounced. Although few study subjects were
respectively. These two measures were highly
unexposed to all of the postures studied, a
correlated and analyzed separately. Strengths
strong increase in risk was observed with both of the study include use of a standard symptom
intensity and duration of exposure. It was not questionnaire, high participation rates, an
possible to determine the relative contributions objective measure of exposure, and an attempt
of different awkward postures because all were to clarify the temporal relation between
highly correlated. Only participants current exposure and outcome by excluding cases of
jobs (for referents), or job when symptoms back pain with onset before the present job.
started (for cases) were analyzed; the study
design thus assumed a short-term relationship Chaffin and Park [1973] carried out a
between exposure and outcome (although prospective study of back complaints in 411
length of time in job was also included in the employees of four electronics manufacturing
models). The authors attempted to ensure that plants. The outcome included visits to the plant
exposure preceded disease by identifying time medical department because of back
of onset and measuring exposures in the job complaints over a one-year period. Exposure
held just prior. The strong associations, after was assessed by evaluating 103 jobs with a
adjustment for covariates, are notable. range of manual lifting for lifting strength rating
(LSR) and load weights. The LSR is a ratio of
Burdorf et al. [1991] examined back pain the maximum weight lifted on the job to the
symptoms in a cross-sectional study of male lifting strength, in the same load position, for a
concrete fabrication workers and a referent large/strong man. Results
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showed a strong increase in back complaint 1.37.5). The highest risk was observed for
incidence with LSR for both males and females simultaneous lifting and twisting with straight
(with an approximate five-fold increase in risk knees (OR 6.1, 95% CI 1.327.9). Despite
comparing males in the highest and lowest the fact that exposures were self-reported,
LSR). A similar increase was observed for these associations were notably strong. The
females, although there were no women in the potential existed for differential recall bias for
highest exposure category. No dose-response cases and controls because study subjects were
was observed by frequency of lifts (a relatively interviewed about work-related factors after
high risk of back complaints was observed for case status was established. Interviewers may
the lowest exposure category). Covariates not have been blinded to case/control status.
(age, weight, and stature) were examined and
found not to contribute to back complaints. The In Liles et al. [1984] prospective study of 453
prospective study design helped increase the individuals working in jobs with manual material
likelihood that exposure preceded disorder. handling requirements, incidence of back
Study limitations include lack of information on injuries was examined with regard to lifting. The
participation rates and an outcome consisting of study group included those who lifted frequently
incident reports. Time of true onset was not (at least 25 lifts per day of not less than 4.53
ascertained, and it is possible that symptom kg, with exposure of at least two hours per
onset preceded or coincided with exposure day). The outcome included reported or
assessment despite the longitudinal study recorded lifting injuries to the back. Lifting
design. The detailed exposure assessment exposures were assessed until job change (up
addressed only lifting as a risk factor; presence to a two-year period) using the Job Severity
of other risk factors related to back disorders Index (JSI). The JSI is a measure of the
was not identified. physical stress level associated with lifting jobs
and is a function of the ratio of job demands to
A case-control study of prolapsed lumbar disc the lifting capacities of the person performing
was carried out using a hospital population- the job. Information on weight, frequency of
based design [Kelsey et al. 1984]. Cases lifting, and task geometry is collected through
(n=232) included individuals diagnosed with comprehensive task analysis. When the study
prolapsed lumbar disc; an equal number of group (working in 101 jobs from 28 plants)
controls matched on sex, age, and medical was classified into 10 equal categories
service were selected. Exposure was assessed according to JSI, a dose-response relationship
using a detailed occupational history that was with injury was observed (RR 4.5, 95% CI
not described but presumably was obtained by 1.0219.9 for total injuries, comparing
interview. An association with work-related category 10 to category 1). Study limitations
lifting without twisting the body was observed included no statement relating to response rate
at the highest lifting level (25 lb or more) or participant selection, no adjustment for
(OR 3.8, 95% CI 0.720.1). Twisting without confounders, and no statistical testing. The
lifting was associated with disc prolapse (OR outcome definition specified that the back injury
3.0, 95% CI 0.910.2); a combination of both be lifting-
risk factors had an OR of 3.1 (95% CI
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related, which increased the likelihood that the for measurement of lifting motions. However,
outcome would be related to the exposure the unit of analysis was job, and each was
measured. The prospective designassured that characterized by measurement of at least one
measured exposures preceded injury onset. study subject. Effects of covariates were not
Other strengths included objective assessment addressed (multivariate analyses appeared to
of exposure. include only biomechanical variables). The
study results emphasized the multifactorial
Using an unusual cross-sectional study design, etiology of back disorders, including
Marras et al. [1993, 1995] examined the contributions of lifting frequency, loads, and
relationship between low-back disorders and trunk motions and postures. The study design
spinal loading during occupational lifting. A total did not allow for examination of temporal
of 403 jobs from 48 diverse manufacturing relationships.
companies were assessed for risk of low-back
disorder using plant medical department injury Walsh et al. [1989] examined the relationship
reports. Jobs were ranked into three categories between self-reported LBP and work-related
according to risk, then assessed for position, factors in a population-based cross-sectional
velocity, and acceleration of the lumbar spine study of 436 English residents. LBP was
during lifting motions in manual materials ascertained by interview, as was lifetime
handling using electrogoniometric techniques. occupational history (including exposures to
Those in high-risk jobs averaged 226 lifts per standing, walking, sitting, driving, lifting, and
hour, with an average load weight of 88.4 N. A using vibrating machinery). Exposures were
combination of five factors distinguished ascertained either as of the birthday prior to
between high- and low-risk jobs: lifting onset of symptoms or by lifetime occupational
frequency, load moment, trunk lateral velocity, history prior to onset of symptoms. Using the
trunk twisting velocity, and trunk sagittal angle. most recent job (as of the birthday prior to
The highest combination of exposure measures symptoms), driving was associated with
produced an OR of 10.7 (95% CI 4.923.6 in symptoms in males (RR 1.7, 95% CI 1.02.9),
comparison to the lowest combined measures). as was lifting or moving weights of 25 kg or
In univariate analyses, the most powerful single more (RR 2.0, 95% CI 1.33.1), when all
variable was maximum moment (a combination exposures were considered in multivariate
of both weight of the object and distance from analyses. For women, lifting (RR 2.0, 95% CI
the body), which yielded a significant OR of 3.3 1.13.7) was associated with symptoms. When
between low- and high-risk groups [Marras et lifetime exposures were considered, lifting
al. 1995]. The study design was unusual in that remained significantly associated for males (RR
the unit of analysis appeared to be the job 1.5, 95% CI 1.02.4). Both sitting (RR 1.7,
rather than the individual. Neither participation 95% CI 1.12.6) and use of vibrating
rates nor total number of participants was machinery (RR 5.7, 95% CI 1.129.3, based
stated. No information appeared regarding the on one case) were associated with symptoms in
proportions of individuals within jobs who were females. The multivariate analyses stratified on
recruited sex and adjusted for age and simultaneous
work exposures. While information on
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symptoms and exposures was obtained the highest rate was seen for those who did it
crosssectionally, the authors attempted to often, with a dose-response for three categories
construct a retrospective cohort design by (10.9, 11.3, and 18.0, respectively, with a RR
gathering data on lifetime work exposures and of 1.65 [95% CI 1.32.1]) when comparing
back symptoms. While in the design lifetime lowest to highest). Liles et al. [1984] found a
exposures were cumulated only prior to significant association between incidence of
disorder onset, it would not be expected that back injuries related to lifting and lifting
participants could recall these relationships exposures as assessed by JSI: the RR was 4.5
accurately. Temporal relationships were (95% CI 1.0219.9) comparing the highest and
unclear. lowest exposure categories. Burdorf et al.
[1991] found no association between back pain
Strength of Association symptoms and lifting load (the latter did not
The most informative studies included those that vary across the six job categories examined in
employed independent measures of exposure to the study). Huang et al. [1988] conducted
assess lifting demands, as they provided the detailed ergonomic evaluations of two school
best contrast among levels of exposure and lunch preparation centers with differing rates of
were subject to the least misclassification. A musculoskeletal (including back) disorders. The
case-control study by Punnett et al. [1991] center with higher disorder rates had greater
found an OR of 2.16 (95% CI 1.04.7) for the lifting and other work-related demands.
relationship between back pain (ascertained by Unfortunately, the study was ecologic in design
symptoms and medical exam) and lifting, after and did not link exposures and outcomes to
adjusting for covariates (including awkward calculate risk estimates for the study groups,
postures). In their 1973 investigation, Chaffin although several areas for ergonomic
and Park found a strong increase in incidence intervention were identified.
of medical visits related to back problems with
increased LSR (with an approximate five-fold Other studies assessed exposures by self-
increase in risk comparing males in the highest report on interview or questionnaire. Johansson
and lowest categories); they did not find a and Rubenowitz [1994] examined low-back
similar dose-response relationship for symptoms by index of manual materials
frequency of lifts. Marras et al. [1993, 1995] handling (which included lifting and other risk
examined the relationship between low-back factors). In neither white- nor blue-collar
injury reports and spinal loading during lifting, workers was LBP significantly associated with
and found an OR of 10.7 (95% CI 4.923.6) the index. In Kelseys 1975 case-control study
for simultaneous exposures to lifting frequency, of herniated lumbar discs, cases and controls
load weight, two trunk velocities, and trunk had similar histories of occupational lifting (RR
sagittal angle. Both lifting and postures 0.94, p=0.10). In a second case-control study
contributed to the high ORs. In Magoras of prolapsed lumbar disc, Kelsey et al. [1984]
[1972, 1973] studies of LBP and occupational found that an association with work-related
physical efforts, the highest LBP rate was lifting without twisting was observed only at the
observed in those who lifted rarely. When LBP
was ranked by level of sudden maximal effort,
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highest lifting level (OR 3.8, 95% LBP rates were higher for registered nurses
CI 0.720.1). A combination of both risk than for nursing aides, whom they stated had
factors at moderate levels yielded an OR of 3.1 more lifting responsibilities (OR 1.2, p=0.04).
(95% CI 1.37.5). The highest risk was seen After adjusting for hours worked, however,
for simultaneous lifting and twisting with straight aides had the higher rate (RR 1.3, no statistical
knees (OR 6.1, 95% testing done). Undeutsch et al. [1982]
CI 1.327.9). Svensson and Andersson [1989] examined back pain in baggage handlers, a
found a significant association between lifetime group characterized by frequent bending, lifting,
incidence of LBP and lifting in univariate and carrying of loads. Although no exposures
analyses (RR 1.2, p<0.05), but not in were estimated for this group, symptoms were
multivariate analyses. Holmstrm et al. [1992] significantly associated with length of
found an association between one-year employment after adjusting for age (p=0.035).
prevalence of LBP and an index of manual
materials handling (OR 1.27, 95% CI 1.21.4), In the studies using more quantitative exposure
after adjusting for age. No association was assessments, strengths of association for the
observed in multivariate analyses. Toroptsova relationships between low-back disorder and
et al. [1995] found that LBP and lifting were lifting included estimates including a negative
related in univariate analyses (OR 1.4, p<0.05); relationship [Magora 1972], no association
no multivariate analyses were conducted. In the [Burdorf et al. 1991], and several positive
Walsh et al. [1989] examination of LBP and associations with ORs in the 2.210.0 range.
work-related factors, LBP was associated with One study found a positive relationship
lifting (in jobs just prior to injury) (RR 2.0, 95% between sudden maximal efforts and LBP (OR
CI 1.13.7), when age, sex, and all exposures 1.7) [Magora 1973]. Punnett et al. [1991]
were considered in multivariate analyses. When found a point estimate of 2.16 after adjusting
lifetime exposures were considered, lifting for other covariates; Chaffin and Park [1973]
remained significantly associated for males (RR found a strong relationship (OR 5) for LSR (but
1.5, 95% CI 1.02.4). In Burdorf and not lifting frequency); Marras et al. [1993,
Zondervans 1990 study, an OR of 5.2 (95% 1995] found that the highest risk of injury was
CI 1.125.5) was observed for LBP and related to lifting in combination with posture-
frequent lifting among crane operators. No related risk factors (OR 10.7). Liles et al.
relationship was seen for the referent group of [1984] observed an OR of 4.5 for back injuries
noncrane operators from the same plant (OR and the highest JSI. The investigation of school
0.70, 95% CI 0.143.5). lunch preparers did not calculate risk estimates
[Huang et al. 1988].
In a study that determined exposure status on
the basis of job title, Videman et al. [1984] Studies that used subjective measures of
found slightly higher rates (not significant) of exposure found point estimates including none
LBP in nursing aides than in qualified nurses. [Johansson and Rubenowitz 1994; Kelsey
The authors stated that aides had higher 1975a,b; Videman et al. 1984] to a range
workloads related to patient handling and
lifting. Knibbe and Friele [1996] found that
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including 1.3, 1.4, 2.0, 3.8, and 5.2 [Burdorf outcomes, and exposure assessment methods,
and Zondervan 1990; Holmstrm et al. 1992; they were fairly consistent in demonstrating a
Kelsey et al. 1984; Knibbe and Freile 1996; relationship between lifting and low-back
Toroptsova et al. 1995; Undeutsch et al. 1982; disorder when objective measures of exposure
Walsh et al. 1989]. Although the Kelsey et al. were used to evaluate populations with high
[1984] exposure estimates were based on self- exposures. Results were less consistent when
report, they showed important relationships subjective exposure measures were utilized.
between lifting and posture in multivariate
analyses. While the OR for lifting alone was 3.8 A NIOSH review of earlier publications related
(for the highest lifting level), the OR rose to 6.1 to patient lifting demonstrated results consistent
when postures related to twisting and bent with this review [Jensen 1990]. A
knees were included in the model. comprehensive literature search evaluated all
studies published between 1967 and 1987 that
In summary, the articles reviewed provide contained original research on nursing
evidence of a strong positive association personnel and back problems. Of 90 studies,
between low-back disorder and lifting. Results six were identified which distinguished between
from these and other studies emphasized the two or more groups of nurses with differing
importance of awkward postures in the risk of frequencies of patient handling and reported on
low-back disorder. back problems for each group. A weighted
analysis of results from the six reports
Temporal Relationship demonstrated an overall increase in back
Two prospective studies assessed exposures problems of 3.7 in those in the higher lifting
prior to identification of back disorders. Both frequency category.
demonstrated positive associations between
exposure and back disorder. Thirteen of the 18 Coherence of Evidence
studies were cross-sectional analyses. In two of Lifting and manual materials handling have been
these, investigators excluded cases of LBP with studied as risk factors for low back disorder for
onset prior to the current job to increase the decades. Studies of workers compensation
likelihood that exposure preceded disorder. A claims have shown that manual material
third cross-sectional study truncated self- handling tasks, including lifting, are associated
reported exposures on the birthday preceding with back pain in 25%-70% of injuries [Cust et
disorder onset. One case-control study al. 1972; Horal 1969; Snook and Ciriello
truncated exposures prior to disorder onset. Of 1991]. Data from the 1994 Bureau of Labor
the four cross-sectional and case-control Statistics annual Survey of Occupational
studies which attempted to address temporality, Injuries and Illnesses demonstrated that the
three found positive relationships between lifting industry with the highest rate of time-loss
and back disorder. injuries due to overexertion was nursing and
personal care facilities (where employees are
Consistency in Association
Although the 18 studies used varying designs,
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required to engage in frequent patient handling 1993]. Other criteria include physiologic
and lifting). measures of metabolic stress and muscle fatigue
and psychophysical considerations (the
During lifting, three types of stress are workers perception of his/her lifting capacity, a
transmitted through the spinal tissues of the low combination of perceived biomechanical and
back: compressive force, shear force, and physiologic attributes of the job). All three
torsional force [Waters et al. 1993]. It has been criteria are important in assessing risk across
suggested that disc compression is believed to the full spectrum of job and individual worker
be responsible for vertebral end-plate fracture, variability.
disc herniation, and resulting nerve root
irritation [Chaffin and Andersson 1984]. In Exposure-Response Relationships
early biomechanical assessments, models Eight studies examined exposure-response
showed that large moments are created in the relationships in some form. Of these, four found
trunk area during manual lifting. Static dose-response relationships between low-back
evaluations of the trunk demonstrated that lifting disorder and objective measures of lifting
results in large compressive forces on the spine. [Chaffin and Park 1973; Liles et al. 1984;
Marras et al. 1995; Punnett et al. 1991];
More recently, biomechanical investigations another found a dose-response between
have focused on spine loading and disc disorder and sudden maximal efforts [Magora
tolerances associated with asymmetric loading 1973]. A study of baggage handlers found an
of the trunk. In laboratory experiments, association between back disorder and length
dynamic trunk motion components of lifting of employment [Undeutsch et al. 1982]. Two
have been associated with greater spine studies found no dose-response relationship
loading. Increased trunk motion during lifting (using a posture analysis assessment and a
activities has been associated with increased manual materials handling index) [Burdorf et al.
trunk muscle activity and intra-abdominal 1991; Johansson and Rubenowitz 1994].
measures, among other changes [Marras et al.
1995]. Some laboratory studies have shown The majority of studies which examined
that lateral shear forces make trunk motions exposure-response relationships, and in
more vulnerable to injury than in a compressive particular those that utilized quantitative
loading situation. There is also in vitro exposure measures, demonstrated these trends.
evidence that the viscoelastic properties of the
spine may cause increased strain during
increased speed of motion [Marras et al. Conclusions: Lifting and Forceful
1995]. Movements
There is strong evidence that low-back
Current models for lifting-related disorders are associated with work-related
musculoskeletal injury stress that biomechanical lifting and forceful movements. The five studies
considerations comprise only part of the reviewed for this chapter which showed no
assessment of risk [Waters et al. association between lifting and
back disorder used subjective measures of
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exposure, poorly described exposure BENDING AND TWISTING

assessment methodology, or showed little (AWKWARD POSTURES)
differentiation of exposure within the study
Definition
group. The remaining 13 studies were
consistent in demonstrating positive Bending is defined as flexion of the trunk,
relationships, where those using subjective usually in the forward or lateral direction.
measures of exposure showed a range of risk Twisting refers to trunk rotation or torsion.
estimates from 1.2 to 5.2, and those using more Awkward postures include non-neutral trunk
objective assessments had ORs ranging from postures (related to bending and twisting) in
2.2 to 11. Studies using objective measures to extreme positions or at extreme angles. Several
examine specific lifting activities generally studies focus on substantial changes from non-
demonstrated risk estimates above three and neutral postures. Risk is likely related to speed
found dose-response relationships between or changes and degree or deviation from non-
exposures and outcomes. For the most part, neutral position. For the purposes of this
higher ORs were observed in high-exposure review, awkward postures also included
populations (e.g., one high-risk group kneeling, squatting, and stooping. In most of the
averaged 226 lifts per hour with a mean load studies included in this review, awkward
weight of 88 N. Evidence from other studies postures were measured concurrently with
and reviews has also suggested that groups with other work-related risk factors for back
high- frequency exposure to lifting of heavy disorder.
loads, such as nursing staff, are at high risk of
back disorder. Studies Reporting on the Association
Between LBP and Awkward Postures
Most of the investigations reviewed for this Twelve studies examined the relationship
document adjusted for potential covariates in between low back disorder and bending,
analyses: two-thirds of the studies showing twisting, and awkward postures (Table 6-3,
positive associations examined effects of age Figure 6-3). Most (nine) also examined the
and gender. Nevertheless, some of the effects of occupational lifting. See the previous
relatively high ORs that were observed were discussion of lifting and forceful movements.
unlikely to be caused by confounding or other Nine studies were cross-sectional in design,
effects of lifestyle covariates. Several studies two case-control, and one prospective.
suggested that both lifting and awkward
postures were important contributors to the risk Participation rates were adequate for 83% of
of low-back disorder. The observed the investigations (Table 6-3). Four studies
relationships are consistent with biomechanical assessed postures using objective measures
and other laboratory evidence regarding the (however, in the study by Magora [1972],
effects of lifting and dynamic motion on back details on their observation methods were not
tissues. reported; the rest estimated exposures from
interview or questionnaire responses). Health
outcomes included low-back and sciatic pain
symptoms, lumbar-disc prolapse, and back
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injury reports. In four investigations, outcomes analyses that adjusted

were defined using both symptoms and medical
examination criteria. Only one investigation, the
Punnett et al. [1991] case-control study of for a number of covariates (age, gender, length
back pain in auto workers, fulfilled the four of employment, recreational activity and
evaluation criteria (Table 6-3, Figure 6-3). medical history), time in non-neutral postures
mild or severe flexion and bending were
Several other studies, while not meeting all of strongly associated with back disorder (OR
the four criteria, are particularly notable 8.0, 95% CI 1.444). In the same model, lifting
because they used objective measures of was also associated (OR 2.16, 95% CI
exposure assessment [Burdorf et al. 1991; 1.04.7). When the subset with physical
Marras et al. 1993, 1995] or met more than medical findings was examined, associations
one of the criteria [Holmstrm et al. 1992; were more pronounced. Although few study
Kelsey et al. 1984]. As discussed earlier, the subjects were unexposed to all of the postures
physical examination criterion may be less studied, a strong increase in risk was observed
important in low-back disorders because of the with both intensity and duration of exposure. It
paucity of specific physical findings in most was not possible to determine the relative
cases of low-back disorders. contributions of different awkward postures
because all were highly correlated. Only
Descriptions of five studies which offered the participants current jobs (for referents) or jobs
most information regarding the effects of when symptoms started (for cases) were
bending, twisting, and awkward postures analyzed; the study design thus assumed a
follow. Please note that there is some overlap short-term relationship between exposure and
with studies that examined lifting effects. outcome. Although length of time in job was
Detailed descriptions of the 12 studies appear also included in the models, the authors
in Table 6-6. attempted to ensure that exposure preceded
disease by identifying time of onset and
The Punnett et al. [1991] case-control study measuring exposures in the job held just prior.
examined the relationship between back pain The strong associations, after adjustment for
and occupational exposures in auto assembly covariates, are notable.
workers. Back pain cases (n=95) were
determined by symptoms at interview and Burdorf et al. [1991] examined back pain
medical examination; controls included those symptoms in a cross-sectional study of male
free of back pain. For all participants or proxies concrete fabrication workers and a referent
in the same jobs, jobs were videotaped and group of maintenance workers. Back pain
work cycles were reviewed using a posture symptoms were assessed by questionnaire.
analysis system. Exposures included time spent Exposures were measured using the Ovako
in various awkward postures. Peak Working Posture Analysis System, which
biomechanical forces were estimated for up to assessed postures for the back and lower
nine postures where a load weighing at least 10 limbs, along with lifting load. Information on
lb was held in the hands. In multivariate exposures in previous jobs was also collected.
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Concrete workers experienced significantly between high- and low-risk jobs: lifting
more back symptoms than referents (OR 2.8, frequency, load moment, trunk lateral velocity,
95% CI 1.36.0). trunk twisting velocity, and trunk sagittal angle.
The highest combination of exposure measures
Univariate results showed associations between produced an OR of 10.7 (95% CI 4.923.6)
back pain and both posture index and WBV in (in comparison to the lowest combined
current job. Correlations were presented measures). The study design was unusual in that
showing lifting was not found to be associated the unit of analysis appeared to be job rather
with back pain or to vary significantly across than individual. Neither participation rate nor
the six job categories examined in the study. In total number of participants was stated. No
multivariate analyses adjusting for age, both information appeared regarding the proportions
posture index and WBV were significantly of individuals within jobs who were recruited
associated with back pain, with ORs of 1.23 for measurement of lifting motions. However,
(p=0.04) (for an ordinal scale of 6) and 3.1 the unit of analysis was job, and each was
(p=0.001) (dichotomous), respectively. Those characterized by measurement of at least one
in the highest posture index category were steel study subject. Effects of other covariates were
benders, who spent an average of 47% of their not addressed (multivariate models appeared to
time in bent back postures (compared to 12% include only biomechanical variables). The
for the lowest exposed group). The posture study results emphasize the multifactorial
index and WBV measures were highly etiology of back disorders, including
correlated and analyzed separately. Strengths contributions of lifting frequency, loads, and
of the study included use of a standardized trunk motions and postures. The study design
symptom questionnaire, high participation rates did not allow for examination of temporal
and objective measure of exposure, and an relationships.
attempt to clarify the temporal relation between
exposure and outcome by excluding cases of A case-control study of prolapsed lumbar disc
back pain with onset before the present job. was carried out using a hospital population-
based design [Kelsey et al. 1984]. Cases
Using an unusual cross-sectional study design, (n=232) included individuals diagnosed with
Marras et al. [1993, 1995] examined the prolapsed lumbar disc; an equal number of
relationship between low-back disorders and controls matched on sex, age, and medical
spinal loading during occupational lifting. A total service were selected. Exposure was assessed
of 403 jobs from 48 diverse manufacturing using a detailed occupational history (not
companies were assessed for risk of low-back described, but presumably obtained by
disorder using plant medical department injury interview). An association with work-related
reports. Jobs were ranked into three categories lifting, without twisting the body, was observed
according to risk then assessed for position, at the highest lifting level (OR 3.8, 95% CI
velocity, and acceleration of the lumbar spine 0.720.1). Twisting without lifting was
during lifting motions in manual materials associated with disc prolapse (OR 3.0, 95%
handling using electrogoniometric techniques. A CI 0.910.2); a combination of both risk
combination of five factors distinguished factors had an OR of 3.1 (95% CI 1.37.5).
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The highest risk was observed for simultaneous Strength of Association

lifting and twisting with straight knees (OR 6.1, The more informative studies included the
95% CI 1.327.9). Despite the fact that Punnett et als [1991] case-control
exposures were self-reported, these investigation, which fulfilled the four evaluation
associations were notably strong. The potential criteria, plus several others that used
existed for differential recall bias for cases and independent exposure assessments. In the
controls, because study subjects were Punnett et al. study, multivariate analyses that
interviewed about work-related factors after adjusted for covariates demonstrated that time
case status was established. Interviewers may in non-neutral postures was strongly associated
not have been blinded to case/control status. with back disorders (OR 8.09, 95% CI
1.444). In the same model, the OR for lifting
Holmstrm et al. [1992] examined the was 2.2. Burdorf et al. [1991] found
relationship between LBP and work task associations between posture index and back
activities in a cross-sectional study of male symptoms in both univariate and multivariate
construction workers. One-year prevalence of analyses: in multivariate analyses adjusting for
LBP was ascertained by questionnaire. A age, the OR for posture index was 1.23
sample of workers was clinically examined. (p=0.04), for an ordinal scale of six levels.
Exposure relative to lifting, handling, and work Posture index was highly correlated with WBV.
postures was obtained by self-report. After However, the Kelsey et als [1984] case-
adjustment for age, the index for manual control study of prolapsed lumbar discs found
material handling, which included lifting, was that twisting without lifting had an OR of 3.0
associated with LBP with a RR of 1.27 (95% (95% CI 0.910.2); in combination, the two
CI 1.21.4). Stooping and kneeling postures had an OR of 3.1 (95% CI 1.37.5). The
showed a dose-response relationship with highest risk was observed for a combination of
LBP, particularly severe LBP (with ORs 1.3, lifting, twisting, and straight knees (OR 6.1,
1.8, and 2.6 in comparison to those with no 95% CI 1.327.9). In the Marras et al. [1993,
stooping; ORs 2.4, 2.6, and 3.5 in comparisons 1995] cross-sectional study, back injuries were
to those with no kneeling, respectively). No associated with spinal loading during lifting,
association was observed with sitting. In which included simultaneous exposures to lifting
multiple regression analyses, LBP was frequency, load weight, trunk lateral velocity,
associated with stooping (p<0.001) and trunk twisting velocity, and trunk sagittal angle.
kneeling (p<0.01). While the authors attempted An OR of 10.7 (95% CI 4.923.6) was
to adjust for some covariates (age, gender, and observed for the highest combination of
psychosocial factors) in analyses, they did not exposure measures. Univariate ORs were 1.73
appear to examine simultaneous effects of (95% CI 1.382.15) for trunk lateral velocity,
physical work-related factors in a single model. 1.66 (95% CI 1.342.05) for trunk twisting
The cross-sectional design could not ascertain velocity, and 1.60 (95% CI 1.31193) for
the temporal relationships between exposure maximum sagittal flexion when comparing the
and disorder. high-and low-risk groups [Marras et al. 1993].
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The other studies showed a range of point disorder, with ORs of 2.6 and 3.5 (p<0.05),
estimates. In univariate analyses, Magora respectively.
[1972, 1973] found that for bending, the
highest rate of LBP was observed for the In summary, three of the four studies using
rarely/never category. For twisting and more quantitative exposure assessments
reaching, the highest LBP rate was in the showed elevated risk estimates for the
sometimes category. Johansson and relationship between low-back disorder and
Rubenowitz [1994] found no associations bending, twisting, or awkward postures, with
between low-back symptoms and bent or ORs ranging from 1.23 (for a scaled variable)
twisted work postures in blue- and white-collar to 8.09; the highest risk estimate, an OR of
workers. After adjustment for age and gender, 10.7, was based on combined exposure to
however, extreme work postures were lifting and posture risk factors. Most of these
significantly associated with the outcome in were based on multivariate analyses that
blue-collar workers. Relationships were adjusted for covariates (usually age and
presented as partial correlations, thus gender). The remaining studies demonstrate
preventing calculation of risk estimates. risk estimates ranging from no association (in
Riihimki et al. [1994] observed that one study), 1.31.7 in univariate but not
occupational exposure to twisted and bent multivariate analyses, to a high of 3.5 in another
postures were associated with incidence of study. Studies utilized a number of definitions
sciatic pain in univariate but not multivariate for awkward postures, as noted.
analyses. No risk estimates were provided. In
Svensson and Anderssons 1989 study of LBP Temporal Relationship
in Swedish women, bending forward was One prospective study assessed exposures
associated with lifetime incidence in univariate prior to identification of back disorders. Results
(RR 1.3, p<0.05) but not multivariate analyses. demonstrated positive associations in univariate
The Masset and Malchaire [1994] univariate but not multivariate analyses. [Riihimki et al.
analyses demonstrated that trunk torsions were 1994]. Nine of 12 studies were cross-sectional
associated with LBP in steel workers (OR in design. In one of these, investigators
1.55, p<0.05); no associations were shown in excluded cases of LBP with onset prior to the
multivariate analyses. Toroptsova et al. [1995] current job to increase the likelihood that
demonstrated that LBP in the past year was exposure preceded disorder. [Burdorf et al.
associated with bending (OR 1.7, p<0.01) in 1991]. No association between exposure and
univariate analyses (multivariate analyses were back disorder was observed. One case-control
not conducted). Riihimki et al. [1989a] study examined only exposures experienced in
observed a dose-response for sciatic pain and the job just prior to disorder onset [Punnett et
self-reported twisted or bent postures; the OR al. 1991]. A strong association between
for the highest exposure category was 1.5 exposure to awkward postures and back pain
[95% CI 1.21.9]. Holmstrm et al. [1992] was observed.
observed that stooping and kneeling postures
were associated with LBP, particularly severe
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Consistency in Association studies found risk estimates above three and

Although the 12 studies used varying designs, dose-response relationships between exposures
outcomes, and exposure assessment methods, and outcomes. Many of the studies adjusted for
the studies using quantitative exposure potential covariates in their analyses, and a few
measures were fairly consistent in examined the simultaneous effects of other
demonstrating a moderate relationship between work-related risk factors in analyses. Several
awkward postures and low-back disorder. studies suggested that both lifting and awkward
postures were important contributors to risk of
Coherence of Evidence low back disorder.
Nine of the 12 studies which examined posture
effects also studied effects of lifting. Therefore, WHOLE BODY VIBRATION (WBV)
a discussion of coherence of evidence for the Definition
former relationship is similar to that found in the WBV refers to mechanical energy oscillations
section on lifting and forceful movements. which are transferred to the body as a whole
Forward flexion can generate compressive (in contrast to specific body regions), usually
forces on the structures of the low back similar through a supporting system such as a seat or
to lifting a heavy object. Similarly, rapid twisting platform. Typical exposures include driving
can generate shear or rotational forces on the automobiles and trucks, and operating industrial
low back [Marras et al. 1995]. vehicles.
Exposure-Response Relationships Studies Reporting on the Association

Six studies examined dose-response Between LBP and Whole Body
relationships between posture and low-back Vibration
disorder. In one, no dose-response relationship Nineteen investigations addressed WBV as a
was found between LBP and estimates for risk factor for back disorder. Fifteen study
bending and twisting/reaching. In the other five designs were cross-sectional, two were cohort,
studies, relationships were demonstrated one was case-control, and one had both cross-
between back injury and spinal loading score, sectional and cohort components.
LBP and posture index, sciatic pain and
awkward postures, LBP and stooping, and None of the 19 studies fulfilled all of the four
low-back symptoms and kneeling. evaluation criteria (Table 6-4, Figure 6-4).
Participation rates were over 70% for 13
Conclusions: Awkward Postures investigations. Seven used independent
The investigations that were reviewed provided measures of exposure for estimation of WBV;
evidence that low-back disorders are in 10 studies, exposure information was
associated with work-related awkward obtained by questionnaire or interview. In two
postures. Results were consistent in showing studies, exposure to WBV was based on job
increased risk of back disorder with exposure, title alone. Health outcomes included symptom
despite the fact that studies defined disorders report of LBP, sciatica, or
and assessed exposures in many ways. Several
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lumbago, sick leaves or disability retirements with ORs of 4.56 (95% CI 2.68.0) for LBP in
related to back disorders, and medically the past year and 2.30 (95% CI 1.24.5) for
confirmed herniated lumbar disc. chronic LBP (for the highest exposure
categories). Multivariate analyses adjusted for
Five of the nine studies which met two or more age, body mass index, education, sports
of the evaluation criteria used similar activity, car driving, marital status, mental
methodologies and offered the most information stress, climatic conditions, back trauma and
regarding the association between WBV and postural load (or vibration dose, depending
back disorder. Detailed descriptions for all 19 upon the exposure examined).
investigations can be found in Table 6-6.
Bovenzi and Zadini [1992] used a similar
Bovenzi and Betta [1994] examined the cross-sectional study design to examine low
relationship between WBV and back disorder back symptoms in male bus drivers. Referents
in a cross-sectional study of male tractor included maintenance employees who worked
drivers. The unexposed group included male for the same company. Back pain symptoms
revenue inspectors and administration workers were assessed by questionnaire. WBV was
with no vibration exposure. Outcomes included measured for a sample of buses used over the
various types of back symptoms reported by relevant time period. Cumulative vibration
questionnaire. Vibration measures were exposures were calculated using this
obtained from a representative sample of information, along with questionnaire items
tractors and linked to individual information on related to work duration, hours, and previous
number of hours driven yearly (obtained by exposures. In comparison to referents, bus
questionnaire). Self-reported exposures to drivers demonstrated an OR of 2.80 (95% CI
postural loads were also obtained. In 1.65.0) for lifetime LBP; the OR for LBP in
comparison to referents, tractor drivers the past year was 2.57 (95% CI 1.54.4). In
demonstrated an OR of 3.22 (95% CI multivariate analyses, the ORs for LBP in the
2.15.2) for lifetime LBP. For LBP in the past previous year were 1.67, 3.46, and 2.63 for
year, the OR was 2.39 (95% CI 1.63.7). For three total vibration dose categories. Similar
LBP in the past year, ORs ranged from 2.31 to trends were observed for other measures of
3.04 by exposure levels for total vibration dose, vibration (equivalent vibration magnitude and
total duration of exposure), and after exclusion
equivalent vibration magnitude, and duration of
of those with exposure in previous jobs.
exposure, after adjustment for covariates. In
Statistically significantly increasing trends were
multivariate analyses, chronic LBP showed a
observed for nearly all types of back symptoms
dose-response relationship with total vibration
by exposure level (to all three measures of
dose (OR 2.00, 95% CI 1.23.4, for the
vibration) after adjustment for covariates.
highest category), equivalent vibration
Multivariate analyses adjusted for age,
magnitude (OR 1.78, 95% CI 1.043.0, for awkward postures, duration of exposure, body
the highest category), and duration of exposure mass index, mental workload, education,
(OR 2.13, 95% CI 1.23.8, for the highest smoking, sports activities, and previous
category). Exposure-response relationships exposures.
were observed for postural load categories,
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Three studies of WBV effects were conducted 1990a,b]. Two investigations were conducted
by the same group of Dutch investigators. The using the same population: a 1986 cross-
first examined back pain and WBV exposures sectional study of a cohort identified in 1975,
cross sectionally in male helicopter pilots and a cohort analysis of sick leaves and
[Bongers et al. 1990]. A referent group of disability retirements due to back disorder
nonflying Air Force officers (with through the same time period. For the cross-
characteristics similar to pilots) was also sectional analyses, information on back
included. Information on back symptoms was symptoms was obtained by questionnaire.
obtained by questionnaire. Vibration measures Vibration was measured for a sample of
were assessed in two helicopters of each type vehicles and linked with questionnaire
used by the study group. Individual exposures information related to types of vehicles driven,
were calculated by matching this with hours, and previous employment. Information
questionnaire items related to hours of flying regarding exposure to awkward postures was
time and types of helicopters flown. Information also collected. Results from the cohort analysis
on exposure to bent/twisted postures was also showed an incidence density ratio of 1.47
obtained by questionnaire. In comparison to (95% CI 1.042.1) for a comparison of sick
controls, ORs for pilots were elevated for a leaves due to back disorders in exposed and
number of back symptoms: 9.0 (95% CI referent groups. An increase in sick leaves for
4.916.4) for LBP and 3.3 (95% CI 1.38.5) disc disorders by vibration dose was observed,
for sciatica. All of the above were adjusted for with an OR of 7.2 (95% CI 0.92179) for the
age, height, weight, climate, bent and twisted highest category. Cross-sectional study results
postures, and feeling tense at work. In demonstrated increases in LBP symptom
multivariate analyses, ORs for LBP were 13.8, prevalence by vibration dose category.
7.5, 6.0, and 13.4 for four categories for total Multivariate ORs increased by vibration dose
flight time (in comparison to controls). ORs for (an OR of 2.8, 95% CI 1.65.0, for the highest
LBP by total vibration dose were 12.0, 5.6, category) and years of exposure (an OR of 3.6,
6.6, and 39.5. By hours of flight time per day, 95% CI 1.211, for the highest category) after
ORs were 5.6, 10.3, and 14.4 for LBP. adjustment for duration of exposure, age,
Although there was some concern that pilots height, smoking, awkward postures, and mental
with back pain may have dropped out of workload.
employment, risk estimates were high
(particularly in analyses by exposure level). Boshuizen et al. [1992] also conducted a
Transient back pain appeared to increase with cross-sectional study of back pain in fork-lift
daily exposure time, while chronic back pain truck and freight container tractor drivers
appeared more associated with total flight time exposed to WBV. Referents included other
and total vibration dose. employees working for the same shipping
company, but with no vibration exposure. Back
In a second study by the same group, WBV pain symptoms were assessed by questionnaire.
exposures were examined in male tractor Exposures were estimated by measurement of
drivers and a referent group of inspectors and vibration in a sample of vehicles, combined with
maintenance technicians [Boshuizen et al. questionnaire responses. Cumulative exposures
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were calculated, truncating at time of symptom [Boshuizen et al. 1992] to 9.5 [Bongers et al.
onset. Prevalence of back pain was higher in 1990]. Analyses conducted by exposure level
the exposed group than in referents: the RR for demonstrated stronger relationships. In Bovenzi
back pain was 1.4 (p<0.05); RRs for LBP and and Bettas 1994 study of tractor drivers, ORs
lumbago were 1.4 (p<0.05) and 2.4 (p<0.05), for lifetime LBP were 3.79 for total vibration
respectively, after adjusting for age. Differences dose, 3.42 for equivalent vibration magnitude,
in LBP were observed only in younger age and 4.51 for duration of exposure (for the
groups after multivariate adjustment for mental highest exposure levels). For LBP in the
stress, years of lifting, awkward postures, previous year, ORs were 2.36, 2.29, and 2.74
height, smoking, and hours of sitting. There was for the highest levels of the same three
no association between total vibration dose and exposure measures. In Bovenzi and Zadinis
back pain (OR 0.99, 95% CI 0.851.2) or 1992 study of urban bus drivers, the highest
lumbago (OR 1.14, 95% CI 0.911.4). Only ORs for LBP were observed for intermediate
vibration in the 5 years immediately preceding rather than the highest exposure categories:
symptom onset was significantly associated with 3.46 for total vibration dose, 3.77 for
back pain (OR 2.4, 95% CI 1.34.2) and equivalent vibration magnitude, and 3.08 for
lumbago (OR 3.1, 95% CI 1.27.9). It total duration of WBV exposure. The Bongers
appeared that a healthy worker selection effect et al. [1990] investigation of back pain in
was operating, as differences in back pain were helicopter pilots demonstrated that the highest
observed only for those in younger age groups. ORs for LBP were found in the highest
categories for total flight time (OR 13.4, 95%
Evaluation of the Causal Relationship CI 5.732), total vibration dose (OR 39.5,
Between Back Disorder and Whole 95% CI 10.8156) and hours of flight time per
Body Vibration day (OR 14.4, 95% CI 5.438.4). A study of
tractor drivers demonstrated LBP ORs of 2.8
Strength of Association (95% CI 1.65.0) for the highest total vibration
Recent studies that included quantitative dose and 3.6 (95% CI 1.211) for the highest
exposure assessments provided the most exposure duration category [Boshuizen et al.
information regarding the relationship between 1990a]. In the same population, the OR for all
WBV and back disorder [Bongers et al. 1988; sick leaves due to back disorder was 1.47,
Boshuizen et al.1990a, b; Bovenzi and Betta comparing exposed (95% CI 1.042.1) and
1994; Bovenzi and Zadini 1992]. (Two other referent groups [Boshuizen et al. 1990b]. For
recent studies also described quantitative sick leaves related to intervertebral disc
exposure assessments, but no results relating to disorders, the highest OR was observed for the
these were presented [Burdorf et al. 1993; highest exposure category (OR 7.2, 95% CI
Magnusson et al. 1996]). In all five, ORs were 0.92179). The Boshuizen et al. [1992] study of
calculated by levels of vibration exposure, forklift truck and freight container tractor
expressed in several ways (usually including drivers showed no association between back
magnitude and duration of exposure). In the pain and total vibration dose (OR 0.99, 95% CI
five studies, overall ORs comparing back pain 0.851.2) but did show an association for
in exposed and referent groups ranged from 1.4 vibration in the preceding five years (OR 2.4,
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95% CI 1.34.2). In this study the increase in 1.02.9) after adjusting for age and other job
LBP prevalence in the exposed group was only exposures in multivariate analyses. Burdorf et
significant for those in younger age groups (an al. [1991] found that WBV was significantly
OR of 5.6 for those age 25-34) in multivariate associated with back pain (OR 3.1, p=0.001)
analyses. In all five of these cross-sectional in multivariate analyses that adjusted for age.
studies, ORs were calculated by vibration The Kelsey [1975a] case-control study found a
exposure category after adjusting for a number significant association between herniated
of covariates, as mentioned in the detailed study lumbar disc and time driving (OR 2.75,
descriptions, above. p=0.02), and more specifically, working as a
truck driver (OR 4.7, p<0.02). Burdorf et al.
Other studies assessed both exposure and low- [1993] investigation demonstrated an OR of
back disorder by interview or questionnaire. 3.29 (95% CI 1.57.1) for crane operators
Burdorf and Zondervan [1990] observed no and 2.51 (95% CI 1.55.4) for vibration-
association between WBV exposure and LBP exposed straddle-carrier drivers after adjusting
in crane operators in univariate analyses (OR for a number of covariates. In a study of Danish
0.66, 95% CI 0.143.1); no associations were salespeople, annual driving distance was
observed in multivariate analyses. Toroptsova associated with low-back symptoms [Skov et
et al. [1995] also found no association between al. 1996]. A dose-response relationship was
LBP and vibration in their study (no definition observed in multivariate analyses, with an OR
for vibration was provided, but WBV was of 2.79 (95% CI 1.55.1) for the highest
suggested). In the Riihimki et al. 1994 category.
prospective study, sciatic pain was associated
with vibration in univariate but not multivariate Four studies assessed exposures primarily by
models (no risk estimates were provided). job title. Magnusson et al. [1996] observed an
While the definition for vibration was not OR of 1.79 (95% CI 1.22.8) for bus and
clear, the authors suggested it could be truck drivers in comparison to an unexposed
interpreted as low-level WBV. The Masset and referent group. In a study of crane operators,
Malchaire [1994] cross-sectional study found the exposed group demonstrated ORs of 2.00
that LBP was associated with vehicle driving (95% CI 1.13.7) for all intervertebral disc
(OR 1.2, p<0.001) in univariate analyses. disorders and 2.95 (95% CI 1.27.3) for disc
Similar results were observed in multivariate degeneration after adjustment for age and shift
analyses (OR 1.2, p<.005). Riihimki et al. [Bongers et al. 1988]. An examination of risk
[1989a] observed an OR of 1.3 (95% CI estimates of disc degeneration by years of
1.11.7) for longshoremen and earthmovers in exposure showed the highest OR (5.73) in the
comparison to a referent group with no highest exposure category. In the Johanning
vibration exposure. In the same study, no [1991] study of subway train operators, an OR
association was seen for annual car driving (OR of 3.9 (95% CI 1.78.6) was observed for
1.1, 95% CI 0.91.4). Walsh et al. sciatica. While not a primary focus of
[1989] found that driving (on job held prior to the Magora [1972, 1973] studies of LBP in
symptoms) was significantly associated with eight selected occupations, it was observed that
low-back symptoms in males (RR 1.7, 95% CI bus drivers had back pain rates similar to those
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of the comparison group of bankers (RR 1.19, 1988; Boshuizen et al. 1990b]. Twelve studies
95% CI 0.81.7). had a cross-sectional design that could not
directly address temporality. However, three
Thus, four out of five studies using quantitative attempted to clarify relationships by excluding
exposure assessments demonstrated positive from analysis the cases with disorder onset
associations between back disorder outcomes prior to current job [Burdorf et al. 1991, 1993;
and vibration exposures, with ORs ranging from Burdorf and Zondervan 1990]. A fourth cross-
1.4 to 39.5. The fifth cross-sectional study sectional study truncated self-reported
found no overall association between exposure exposures on the birthday preceding disorder
and back disorder but found associations in onset [Walsh et al. 1989]. In these four
selected subgroups (which suggested that the investigations, positive relationships between
study population was biased, as noted above). back disorder and WBV were also observed.
In all of these studies, risk estimates by
exposure category were calculated after Consistency in Association
adjustment for many covariates. Results with regard to the relationship between
low back disorder and WBV were most
In the remaining studies, risk estimates varied, consistent in the studies using observational or
including no association (n=3), ORs of 1.2, 1.7, measurement approaches to exposure
and 2.8 for driving, an OR of 1.8 for truck or assessment. The strength of association was
bus driving, an OR of 4.7 for truck driving, an more variable in studies using job titles or
OR of 1.3 for machine operation, ORs of 2.0, questionnaires to assess exposures. The
2.95 and 5.73 for crane operation, an OR of variability in the associations does not appear to
3.1 for WBV, and an OR of 3.9 for subway be related to confounding exposures, since
train operation. most studies adjusted for age, gender and at
least several other confounders. Studies using
In summary, the evidence from these more quantitative exposure measures were
investigations suggests a positive association fairly consistent in showing the higher risk
between WBV and back disorder. estimates.
Relationships were particularly strong for high-
exposure groups where exposures were In addition to the epidemiologic investigations
assessed using observational or measurement that were reviewed for this document, many
approaches. more were conducted in the 1960s though the
1980s. Others have summarized this evidence
Temporal Relationship in earlier reviews. Hulshof and Veldhuijzen van
Three studies had prospective designs in which Zanten [1987] concluded that, although studies
temporal relationships between outcome and varied in methodologies and quality, most
exposure could be determined [Bongers et al. showed a strong tendency toward a positive
1988; Boshuizen et al. 1990b; Riihimki et al. association between WBV exposure and LBP.
1994]. In two of these, clear positive Seidel and Heide [1986] stated that the
relationships between back disorder and literature they reviewed indicated an increased
exposure were demonstrated [Bongers et al. risk of spine disorders after intense long-term
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exposure to WBV. Bongers and Boshuizen peaks may cause ruptures in the superficial
[1990] conducted a meta-analysis of studies structure of the disc and changes in the
published through 1990 that examined the nutritional balance that lead to degeneration.
relationship between WBV and several back Thus, prolonged vibration exposure may cause
disorders. The overall OR for WBV exposure spine pathology through mechanical damage
and degenerative changes of the spine was 1.5; and/or changes in tissue metabolism.
the summary OR for LBP was also 1.5. These
conclusions are consistent with the positive In addition to pathology of the vertebrae and
associations observed in the evidence reviewed intervertebral discs, vibration exposure has
above (although the studies published in the been shown to cause changes in
1990s have tended to report larger ORs). electromyographic (EMG) activity in muscles of
the lower back [Wikstrm et al. 1994]. For
Other evidence for the relationship is provided example, EMG experiments have demonstrated
by surveillance data. The U.S. population- that lower back muscle exhaustion increases
based National Health Interview Survey, during WBV exposure in truck driving.
carried out in 1988, found that males Decreased stability of the lower back may
employed as truck drivers and tractor result from slower muscle response, perhaps
equipment operators had a RR of 2.0 for back increasing the risk of injuring other structures.
pain in comparison to all male workers [Guo et
al. 1995]. Laboratory investigations have shown that
other work-related factors, including prolonged
Coherence of Evidence sitting, lifting, and awkward postures, may act
Laboratory studies have shown that exposure in combination with WBV to cause back
to WBV causes spine changes that may be disorder [Dupuis 1994; Wikstrm et al. 1994;
related to back pain. These include fatigue of Wilder and Pope 1996].
the paraspinal muscles and ligaments, lumbar
disc flattening, disc fiber strain, intradiscal Exposure-Response Relationships
pressure increases, disc herniation, and Five of six studies which carried out
microfractures in vertebral end-plates [Wilder quantitative exposure assessment demonstrated
and Pope 1996]. Studies of acute effects have exposure-response relationships between
shown that the vertebral end-plate is the WBV and back disorder.
structure that is most sensitive to high WBV
exposure, followed by the intervertebral disc
[Wikstrm et al. 1994]. Experimental
investigations have demonstrated that high
exposures to vibration cause injuries such as
degeneration and fracturing of the vertebral
end-plate. With regard to intervertebral discs,
several studies have suggested that vibration
causes creep, an increase in intradiscal pressure
resulting from compressive loading. Pressure
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Bovenzi and Betta [1994] observed a dose- consistent in demonstrating positive

response between chronic LBP and total associations, with risk estimates ranging from
vibration dose, equivalent vibration magnitude, 1.2 to 5.7 for those using subjective exposure
and duration of exposure. Bovenzi and Zadini measures, and from 1.4 to 39.5 for those using
[1992] found statistically significantly increasing objective assessment methods. Most of the
trends for nearly all types of back symptoms by studies that examined relationships in high-
exposure level, after adjustment for covariates. exposure groups using detailed quantitative
Bongers et al. [1990] demonstrated increased exposure measures found strong positive
ORs for sciatic pain and transient back pain associations and exposure-response
with increasing hours of daily flight time. In relationships between WBV and back pain.
their cohort of tractor drivers, Boshuizen et al. These relationships were observed after
[1990b] observed an increase in risk of sick adjusting for age and gender, along with several
leaves for disc disorder by total vibration dose other covariates (which, depending on the
level. study, may have included smoking status,
anthropometric measures, recreational activity,
In other studies, Bongers et al. [1988] found an and physical and psychosocial work-related
increase in risk of disc degeneration by years of factors). This evidence is supported by results
exposure to crane operation; Skov et al. observed in many earlier epidemiologic
[1996] found an increase in low-back investigations that have been summarized in
symptoms with annual driving distance. other reviews.
Johanning [1991] found no association between
years of employment as a subway train Laboratory studies have demonstrated WBV
operator and back pain symptoms. effects on the vertebrae, intervertebral discs,
and supporting musculature. Both experimental
The majority of studies which examined back and epidemiologic evidence suggests that WBV
disorders by exposure level demonstrated may act in combination with other work-related
dose-response relationships. factors such as prolonged sitting, lifting, and
awkward postures to cause increased risk of
Conclusions: Whole Body Vibration back disorder.
There is strong evidence of a positive
association between exposure to WBV and It is possible that effects of WBV may depend
back disorder. Of the 19 studies reviewed for on the source of exposure. For example, in the
this chapter, four demonstrated no association studies reviewed for this document, ORs were
between WBV and back pain. Possible particularly high for helicopter pilots. It was not
explanations for these results included use of possible to determine differences for other
subjective exposure assessments that perhaps types of vehicles (automobiles, trucks, and
resulted in misclassification of exposure status agricultural, construction, and industrial
and, in one cross-sectional study, operation of vehicles).
a healthy worker selection effect (where those
with higher exposures dropped out of the study
group). The remaining 15 studies were
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STATIC WORK POSTURES Below are descriptions of four of the more

informative studies. Detailed descriptions for all
Definition
10 investigations are found in Table 6-6).
Static work postures include isometric positions
where very little movement occurs, along with Burdorf and Zondervan [1990] carried out a
cramped or inactive postures that cause static cross-sectional study comparing 33 male crane
loading on the muscles. In the studies reviewed, operators with noncrane operators from the
these included prolonged standing or sitting and same Dutch steel plant, matched on age.
sedentary work. In many cases, the exposure Symptoms of LBP and sciatica were assessed
was defined subjectively and/or in combination by questionnaire. Activities in current and past
with other work-related risk factors. jobs were assessed by questionnaire;
exposures were rated according to level of
Studies Reporting on the Association heavy work, frequency of lifting, WBV, and
Between LBP and Static Work prolonged sedentary posture. Crane operators
Postures were significantly more likely to experience
Ten studies examined relationships between LBP (OR 3.6, 95% CI 1.210.6). Among
low back disorder and static work postures, crane operators alone, the OR for heavy work
which may have included prolonged sitting, was 4.0 (95% CI 0.7621.2) after controlling
standing, or sedentary work. For none was for age, height, and weight. It was determined
static work posture the primary occupational that this heavy work occurred in the past and
exposure of interest. Instead, it was often one not in current jobs. Among crane operators
of many variables examined in larger studies of alone, the OR for frequent lifting was 5.2 (95%
several or many work-related risk factors. Nine CI 1.125.5). The frequent lifting in crane
of the studies were cross-sectional in design; operators was also determined to be from jobs
one was a case-control study. held in the past. Among noncrane operators,
history of frequent lifting exposure was not
None of the investigations fulfilled the four associated with LBP (OR 0.70, 95% CI
research evaluation criteria (Table 6-5, Figure 0.143.5). Among crane operators, univariate
6-5). Participation rates were acceptable for ORs for WBV and prolonged sedentary
60%. For four, case definitions included both postures were 0.66 (95% CI 0.143.1) and
symptoms and medical examination criteria. 0.49 (95% CI 0.112.2), respectively. In
Health outcomes included symptom report of multivariate analyses controlled for age, height,
back pain, sciatica, or lumbago, back pain as weight, and current crane work, associations
ascertained by symptoms and medical exam, with specific work-related factors were
herniated lumbar disc, and lumbar disc substantially reduced; the high prevalence of
pathology. One study claimed to assess job- LBP in crane operators was explained only by
related exposures by observation; the nine current crane work. No measures of dose-
others obtained information on static work response were examined. Limitations included
postures by self-report on interview or a low response rate for crane operators (67%),
questionnaire. with some suggestion that those with illness may
have been underrepresented (perhaps
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underestimating the OR), and self-report of by questionnaire, as were exposure-related

health outcomes and exposures. The items. Physical exposures included lifting,
investigators excluded cases of LBP with onset bending, twisting, other work postures, sitting,
before the present job to increase the likelihood standing, monotony, and physical activity at
that exposure preceded disease. work. Lifetime IRs varied by occupation, with
ranges from 61%83% in younger age groups
Kelsey [1975b] carried out a hospital and 53%75% in older groups. After the study
population-based case-control study of was completed, the authors noted that for these
herniated lumbar discs and their relationship to women, the highest lifetime incidence of LBP
a number of workplace factors, including time was not found in jobs with the highest physical
spent sitting, chair type, lifting, pulling, pushing, demands. The measure for physical activity at
and driving. Cases were defined by symptoms, work was also not significantly associated with
medical evaluation, and radiology; exposures LBP in univariate analyses. Bending forward
were ascertained by interview (over lifetime job (RR 1.3), lifting (RR 1.2), and standing (RR
history). Cases (n=223) and controls (n=494 1.3) were associated with lifetime incidence of
unmatched controls) had similar histories of LBP in univariate analyses (p<0.05). Sitting
job-related lifting (RR 0.94, p=0.10). Findings was not (OR 0.84, p=0.10). None of the
indicated that sedentary work (sitting more than measures of physical workplace factors were
half the time at work) was associated with disc associated with lifetime incidence of LBP in
herniation, but only for the age group 35 years multivariate analyses.
and older (RR 2.4, p=0.01). (The RR for those
less than 35 was 0.81). Disc herniation was Videman et al. [1990] studied 86 males who
also associated with time spent driving (RR died in a Helsinki hospital to determine the
2.75, p=0.02) and, more specifically, with degree of lumbar spinal pathology. Disc
working as a truck driver (RR 4.7, p<0.02), degeneration and other pathologies were
suggesting a relationship with WBV. The study determined in the cadaver specimens by
design had several potential limitations, discography and radiography. Subjects
including possible unrepresentativeness of the symptoms and work exposures (heavy physical
study population (because the group was work, sedentary work, driving, and mixed)
hospital-based). As exposure information was were determined by interview of family
obtained retrospectively, cases may have over- members. In comparison to those with mixed
reported exposures thought to be associated work exposures, those with sedentary (OR
with back problems. Strengths include a well- 24.6, 95% CI 1.5409) and heavy work (OR
defined outcome and consistent results in 2.8, 95% CI 0.323.7) had increased risk of
comparisons to the two control groups. symmetric disc degeneration. Similar
relationships were seen for end-plate defects
Svensson and Andersson [1989] examined and facet joint osteoarthrosis. For most
LBP in a population-based cross-sectional pathologic changes,
study of employed Swedish women.

Information on LBP and sciatica was obtained
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sedentary work appeared to have a stronger found that standing was associated with lifetime
relationship than heavy work. Back pain incidence of LBP in univariate analyses (OR
symptoms were consistently higher in those 1.3, p<0.05), but not in multivariate models.
with any form of spinal pathology, although the Sitting was not associated in univariate analyses
difference was significant only for anular (OR 0.84, p=0.10). Walsh et al. [1989] found
ruptures. This study was unusual in design in that low-back symptoms were associated with
that it examined a combination of spinal lifetime occupational exposure to sitting in
pathological outcomes, symptoms, and females only (RR 1.7, 95% CI 1.12.6) in
workplace factors. However, participation in multivariate analyses that considered other
the study was dependent on obtaining work exposures. Kelseys 1975b case-control
information from family members; participation study demonstrated that sedentary work (sitting
rates were not stated. While recall bias is often more than half the time at work) was associated
a problem in studies of the deceased, in this with lumbar disc herniations, but only for those
35 and older (RR 2.4, p=0.01); the RR for those
case it should have been nondifferential, if
less than 35 was 0.81. In a study of salespeople ,
present.
a dose-response was observed for sedentary
work and low back symptoms. An OR of 2.45
(95% CI 1.24.9) was seen for the highest
The ten studies were approximately equal in
category after adjustment for covariates [Skov
terms of information they provided relating to
et al. 1996]. The Videman et als [1990] study
static work postures. Burdorf and Zondervan
of cadavers found that those with histories of
[1990] observed an OR of 0.49 (95% CI
either sedentary or heavy work exposure had
0.112.2) for the univariate relationship
increased risk of symmetric disc degeneration
between prolonged sedentary postures and
(OR 24.6, 95% CI 1.5409 and OR of 2.8,
LBP in crane operators. Holmstrm et al.
95% CI 0.323.7, respectively). Similar results
[1992] found no association between LBP and
were seen for other disc pathologies. For most
sitting (in univariate or multivariate analyses). In
pathologic changes, sedentary work appeared
the Magora [1972, 1973] cross-sectional
to have a stronger relationship than heavy
investigation, the highest LBP rates were
work.
observed for those in the rarely category for
variables related to sedentary postures, sitting,
In summary, most (n=6) risk estimates for
and standing. No dose responses were
variables related to static work postures,
observed. In the Toroptsova et al. [1995] study
including standing and sitting, were not
of machine manufacturing workers, sitting,
significantly different from one. Others found
standing, and static work postures were not
small to moderate significant increases in risk:
associated with LBP history in univariate
ORs of 1.3 for standing, 1.7 for sitting (females
analyses. No details were provided. In
only), and 2.4 and 2.5 for sedentary work. The
multivariate analyses, Masset and Malchaire
Videman et al. [1990] cadaver study found high
[1994] found a nonsignificant association
risks of disc pathology in those with a history of
between LBP and seated posture (OR 1.5,
sedentary work. Study quality was similar
p=0.09) in multivariate analyses. Svensson and
across the range of point estimates observed.
Anderssons 1989 study of Swedish women
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Therefore, an estimate of the strength of disorder. Kelsey [1975a] observed that, in

association is difficult to determine. The addition to sedentary work, amount of time
magnitude cannot be estimated based on the spent sitting on weekends was associated with
available data. herniated discs. The finding that sedentary
work was associated with herniated discs only
Temporal Relationship in older age groups suggested that duration of
Eight of 10 studies were cross-sectional in exposure may be important and that a threshold
design. Two of these attempted to use may exist. Toroptsova et al. [1995] observed
additional methodologies to increase the that back pain was lower in those who engaged
likelihood that exposure preceded disorder by in sports activity, perhaps suggesting that
excluding cases with onset prior to current job greater muscle strength prevents back pain.
and truncating exposures prior to disorder
onset. One found a positive relationship Several authors offered explanations for the
between prolonged sitting and LBP symptoms. lack of associations they observed. It was
pointed out that perception of sedentary is
Consistency in Association subjective and that many jobs that investigators
The studies showed poor consistency in (or subjects) considered to include prolonged
estimation of the relationship between low- static postures may actually have allowed
back disorder and static work postures, considerable movement throughout the day
perhaps due to considerable differences in (such as office workers). Other sedentary
definition of exposure. groups (such as industrial sewing machine
operators) may be forced by work schedules to
Coherence of Evidence maintain static postures for long periods. It is
important to have a true range of exposure if
As mentioned elsewhere, LBP has been
differences in associated disorders are to be
associated with mechanical forces causing an
detected.
increased load on the lumbar spine [Waters et
al. 1993]. Increased loading on the spine
Exposure-Response Relationships
causes increased intervertebral disc pressures,
Three studies addressed dose-response
which in turn, may be responsible for herniation
relationships, two of which did not demonstrate
and back pain. In laboratory experiments, disc
any trends. Magora [1972, 1973] found the
pressure has been found to be substantially
highest risk of LBP in the lowest exposure
greater in unsupported sitting than in standing
categories for sedentary postures, sitting, and
positions [Chaffin and Andersson 1984].
standing. Videman et al. [1990] found a high
rate of lumbar disc pathology in those with
Studies reviewed for this document suggested
histories of sedentary and heavy work, with
relationships between back disorder and
relationships stronger for sedentary work. A
nonwork activities seemed to be consistent with
dose-response for LBP symptoms and
the hypothesis that static
sedentary work was observed by Skov et al.
[1996].
work postures might be associated with back
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Conclusions: Static Work Postures 1992]. The relative contributions of these

Ten studies examined the relationship between covariates may be specific to particular
low-back disorder and static work postures. In anatomic areas and disorders. For example, a
most cases, this exposure was not of primary recent study of identical twins demonstrated
interest but was one of many potential that occupational and leisure time physical
workplace risk factors that were included in loading contributed more to disc degeneration
analyses. Static work posture was defined in of the upper than the lower lumbar region
several ways, including sedentary work and [Batti et al. 1995]. For both anatomic areas,
work-related sitting and standing. Exposure age and twin effects (genetic influences and
information was ascertained by interview for early shared environment) were the strongest
nine of 10 studies. The strength of association identifiable predictors for this particular health
could not be easily estimated because a large outcome.
proportion of point estimates did not differ
statistically significantly from unity. As a whole, Psychosocial factors, both work- and
the results from these studies provide nonwork-related, have been associated with
inadequate evidence that a relationship exists back disorders. These relationships are
between static work postures and low-back discussed at length in Chapter 7 and Appendix
disorder. B.
ROLE OF CONFOUNDERS In the studies reviewed for this document,

As mentioned above, back disorder is gender and age effects were addressed in most
multifactorial in origin and may be associated (86% and 74%, respectively). Approximately
with both occupational and nonwork-related 40% addressed work-related psychosocial
factors and characteristics. The latter may factors. In addition to these, many studies
include demographics, leisure time activities, addressed other potential confounders in their
history of back disorder, and structural analyses.
characteristics of the back [Garg and Moore
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Table 6-1. Epidemiologic criteria used to examine studies of low back MSDs associated with heavy physical work
Investigator
Risk indicator blinded to case Basis for assessing back
(OR, PRR, IR Participation Physical and/or exposure to heavy physical
Study (first author and or p-value)*, rate $ 70% examination exposure work
year) status
strand 1987 2.3 Yes Yes No Job titles or self-reports
Bigos 1991b No association No No NR Observation or measurements
Burdorf 1991 No risk Yes No No Observation or measurements

estimate
Clemmer 1991 2.2, 4.3 Yes No NR Job titles or self-reports
Helivaara 1991 1.9, Yes Yes No Job titles or self-reports

2.5
Hildebrandt 1995 1.2 Yes No No Job titles or self-reports
Hildebrandt 1996 No association Yes No No Job titles or self-reports
Johansson 1994 No association Yes No NR Job titles or self-reports
Leigh 1989 1.5 Yes No NR Job titles or self-reports
Masset 1994 No association Yes No NR Job titles or self-reports
Partridge 1968 1.2 Yes Yes No Job titles or self-reports
Riihimki 1989b 1.0 Yes No NR Job titles or self-reports
Ryden 1989 2.2 Yes No NR Job titles or self-reports
Svensson 1989 No association Yes No NR Job titles or self-reports
Videman 1984 1.1 Yes No NR Job titles or self-reports
Videman 1990 2.8, NR Yes NR Job titles or self-reports

12.1
Bergenudd 1988 1.8 No No NR Job titles or self-reports
Burdorf 1990 4.0 No No NR Job titles or self-reports
*Odds ratio (OR), prevalence rate ratio (PRR), or incidence ratio (IR).
Not reported.
Significant associations found in univariate but not multivariate results.
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Table 6-2. Epidemiologic criteria used to examine studies of low back MSDs associated with lifting and forceful
movements
Investigator
(OR, PRR, IR Participation Physical and/or exposure to lifting and
Study (first author and or p-value)*, rate $ 70% examination exposure forceful movements
year) status
Punnett 1991 2.2 Yes Yes Yes Observation or

measurements
Burdorf 1991 No association Yes No No Observation or

measurements
Chaffin 1973 Approx. 5 NR No NR Observation or

measurements
Holmstrm 1992 1.3 Yes Yes Yes Job titles or self-reports

Huang 1988 No risk estimate Yes No NR Observation or
measurements
Johansson 1994 No association Yes No NR Job titles or self-reports
Kelsey 1975b 0.94 Yes Yes NR Job titles or self-reports
Kelsey 1984 3.8 Yes Yes NR Job titles or self-reports
Knibbe 1996 1.3 Yes No No Job titles or self-reports
Liles 1984 4.5 NR No No Observation or

measurements
Magora 1972 No association, NR No NR Observation or

1.7 measurements
Marras 1995 10.7 NR No NR Observation or

measurements
Svensson 1989 1.2 Yes No NR Job titles or self-reports
Toroptsova 1995 1.4 Yes Yes NR Job titles or self-reports
Undeutsch 1982 No risk estimate NR Yes NR Job titles or self-reports
Videman 1984 No association Yes No NR Job titles or self-reports
Walsh 1989 1.5, Yes No NR Job titles or self-reports

2.0
Burdorf 1990 0.70, No No NR Job titles or self-reports

5.2
Not reported.
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Table 6-3. Epidemiologic criteria used to examine studies of low back MSDs associated with bending, twisting, or
awkward postures
Investigator
(OR, PRR, IR Participation Physical and/or exposure to bending,
Study (first author and year) or p-value)*, rate $ 70% examination exposure twisting, or awkward
status postures
Met back criteria:
Punnett 1991 8.09 Yes Yes Yes Observation or measurements
Burdorf 1991 1.2 Yes No No Observation or measurements
Holmstrm 1992 2.6, Yes Yes Yes Job titles or self-reports

3.5
Johansson 1994 NR, Yes No NR Job titles or self-reports
Kelsey 1984 3 Yes Yes NR Job titles or self-reports
Magora 1972, 1973 No association NR No NR Observation or measurements

Marras 1993, 1995 10.7 NR No NR Observation or measurements
Masset 1994 No association Yes No NR Job titles or self-reports
Riihimki 1989b 1.5 Yes No NR Job titles or self-reports
Riihimki 1994 No association Yes No NR Job titles or self-reports
Svensson 1989 No association Yes No NR Job titles or self-reports
Toroptsova 1995 1.7 Yes Yes NR Job titles or self-reports
Indicates statistical significance. If reported with NR, a significant association was reported without a numerical value.
Not reported.
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Table 6-4. Epidemiologic criteria used to examine studies of low back MSDs associated with whole-body
vibration
Investigator
Risk blinded to case Basis for assessing back
indicator (OR, Participation Physical and/or exposure to lifting and
Study (first author and PRR, IR rate $ 70% examination exposure whole-body vibration
year) or p-value)*, status
Bongers 1988 2.05.7 Yes Yes NR Job titles or self-reports
Bongers 1990 3.339.5 Yes No NR Observation or measurements
Boshuizen 1990a, 1990b 1.53.6 Yes No NR Observation or measurements
Boshuizen 1992 0.99 Yes No NR Observation or measurements
Bovenzi 1992 2.6 Yes No NR Observation or measurements
Bovenzi 1994 2.44.6 Yes No NR Observation or measurements
Burdorf 1991 3.1 Yes No No Job titles or self-reports
Burdorf 1993 2.53.3 Yes No NR Observation or measurements

Kelsey 1975b 2.8, Yes Yes NR Job titles or self-reports
4.7
Magnusson 1996 1.8 NR No NR Observation or measurements
Magora 1972 1.2 NR No NR Observation or measurements
Masset 1994 1.2 Yes No NR Job titles or self-reports
Riihimki 1989a 1.3 Yes No NR Job titles or self-reports
Riihimki 1994 No association Yes No NR Job titles or self-reports
Toroptsova 1995 No association Yes Yes NR Job titles or self-reports
Walsh 1989 1.7 Yes No NR Job titles or self-reports
Johanning 1991 3.9 No No NR Job titles or self-reports

Skov 1996 2.8 No No NR Job titles or self-reports
Not reported.
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Table 6-5. Epidemiologic criteria used to examine studies of low back MSDs associated with static work
postures
Investigator
Risk blinded to Basis for assessing back
indicator Participation Physical case and/or exposure to static work
Study (first author and year) (OR, PRR, IR rate $ 70% examination exposure postures
or p-value)*, status

Holmstrm 1992 No Yes Yes Yes Job titles or self-reports

association
Kelsey 1975b 0.81, Yes Yes NR Job titles or self-reports

2.4
Magora 1972, 1973 No NR No NR Observation or
association measurements
Masset 1994 1.5 Yes No NR Job titles or self-reports
Svensson 1989 1.3 Yes No NR Job titles or self-reports
Toroptsova 1995 No Yes Yes NR Job titles or self-reports

association
Videman 1990 24.6 NR Yes NR Job titles or self-reports
Walsh 1989 1.7 Yes No NR Job titles or self-reports

(females)

Skov 1996 2.45 No No NR Job titles or self-reports
Not reported.
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Table 6-6. Epidemiologic studies evaluating back musculoskeletal disorders
MSD prevalence
Study Study Outcome and Exposed Referent RR, OR,
Study design population exposure workers group or PRR 95% CI Comments
strand 1987 Cross- 391 male employees Outcome: Medical, 29.4 % of manual 12.9% of p=0.002 Participation rate: 82.5%.
sectional, in a Swedish pulp psychological and social workers reported clerks
1987 and paper industry indicators. Questionnaires back pain in reported back The proportion of backs evaluated as
located at one of 4 on social and psychological response to: Do pain in abnormal by physical examination
strand and Retro- sites: Mill 1, Mill 2, Mill factors; medical you often have response to was 16%, similar to U.S. data
Isacsson 1988 spective 3, and Head Office. examination of thoracic and back pain? same collected in 1971. 66% of group with
22 years lumbar spine. question. back abnormalities reported back pain.
follow up,
1988 Exposure: Based on the Duration of Psychosocial work factors did not
type of work performed at employ- show any significant association with
each job site. All mill work ment:1.2 1.0-1.5 back pain.
jobs were judged as
heavy; all office/clerk jobs Neuro- The working conditions of back pain
were judged as light. Some ticism: 2.8 1.4-5.4 sufferers were changed because of
worker movement between their reduced working capacity,
office/clerk jobs and mill which tends to offset differences in
work, based on health prevalence of back pain between
status. groups doing heavy work and control
populations.
Results support Magoras findings that

heavy work over time is associated
with increased back pain.
Back pain was associated with

occupation, low education, duration of
employment, and neuroticism.
In follow-up study, a healthy worker

effect was documented.
(Continued)
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Table 6-6 (Continued). Epidemiologic studies evaluating back musculoskeletal disorders
MSD prevalence
Bergenudd Longitudinal 323 males and 252 Outcome: Back pain not Point prevalence: LBP in All: 1.83 1.2-2.7 Participation rate: 67% in
and Nilsson females; all tracked by exam. LBP unexposed Females: questionnaire and health survey from
1988 participants in Attended for exam but BP males: 28% males: 21.4% 2.03 1.1-3.7 830 individuals living in Malmo.
Malmo, Sweden, based only on self females: 30% females: Males:
Longitudinal Study assessment and 23.9% 1.76 1.01-3.1 Not controlled for confounders.
since 1938. questionnaire, 1983. 5% prevalence
of sciatica Exposures rated from job title.
Exposure: Exposures and
occupations tracked by In heavy or Weak support for occupational
questionnaires since 1942. moderate work factors in causation. Some support
Work classified into (LBP): for workload causing symptoms.
3 categories of heaviness males: 32.4%
based on 10 years work. females: 38.9% Moderate or heavy physical demands
had more back pain; then light
(1) Light physical work: physical demand group (p<0.01)
white collar. statistically significant only in females.
(2) Moderate: Nurses, Those with back pain had fewer

shop assistants, bakers, years of education and were less
and light industry. satisfied with their working
conditions. There was no difference
(3) Heavy: Carpenters, in the relationship between family,
bricklayers, and heavy relatives, or friends.
industry.
(Continued)
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MSD prevalence
Bigos et al. Retro- Aircraft Outcome: Report of low Highest LB injury Lowest LB Highest to Participation rate: 100% (includes all
1986a spective manufacturer back injury. rates in mechanics injury rates in lowest records).
cohort employees in 33 job Rate=38.2 electronic compari-
morbidity classifications Exposure: 33 job technicians son is in Exact rates by job titles not reported.
(15-month (n=31,200). classifications. and tool range of 5
follow-up) grinders to 7 (exact Authors state that differences by job
Rate=NS numbers title are difficult to interpret because
not of overlapping confidence intervals.
reported)
(Continued)
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MSD prevalence
Bigos et al. Prospective 3,020 aircraft Outcome: A case was 8% to 9% of N/A Lack of Participation rate: 43% of the original
1991b assembly workers; defined as a subject workers reported enjoyment number of workers solicited 54% of
1,613 involved in reporting an acute industrial an acute industrial of job tasks: participants returned questionnaire
work perception and back injury. back injury. OR=1.7 1.3-2.2 with Minnesota Multiphasic Personality
psychosocial portion Inventory (MMPI); 75% participated in
some part of the study. Of
of study. Subjects answered series MMPI: tend volunteers, respondents and non-
of questionnaires: On towards respondents were similar.
demographic and somatic
psychosocial factors, a complaint or Employees work exposure not as
cardiovascular denial of well documented as psychosocial
questionnaire, and a take- emotional factors.
home questionnaire on distress:
psychosocial and individual OR=1.37 1.1-1.7 Take home questionnaire had 566
question Minnesota Multiphasic
factors (see comments). Personality Inventory (MMPI), family
Prior back function questionnaire (APGAR),
Subjects had physical pain: Health locus of control (HLOC).
examination to assess OR=1.7 1.2-2.5
physical attributes: Lifting Other information included medical
strength, aerobic capacity, history, previous back discomfort or
and flexibility. problem, and previous back injury
claims in prior 10 years.
Exposure: Based on
Study did not investigate actual
questionnaire data of work presence of back symptoms or
and home activities. Also specific disorders; subjects followed
All jobs employing >19 for three years and became a case if
workers analyzed for they: (1) reported to medical
heavy and tiring tasks in department, (2) filed an incident or
terms of maximal loads. report, (3) filed an industrial insurance
claim.
Also analyzed perceived
Authors state that results may not
physical exertion as apply as strongly to cases of severe
potential risk factor. symptoms or in work involving heavy
job requirements (study performed in
a manufacturing industry where job
tasks do not tend to be extremely
stressful for the back.
(Continued)
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MSD prevalence
Bongers et al. Retro- Dutch, male, steel Outcome: Disability pension Crane operators Floor workers Incidence Participation rate: $70%.
1988 spective workers (n=1,405) for back-related disorder. (n=743) in same Density
cohort departments Ratios Adjusted for nationality, shiftwork,
(January, Exposure: Job title and (n=662) age, and calendar time.
All back
1975- duration of employment. disorders:
December Measurements of vibration 1.32 ORs likely are underestimated
1984) in cranes but not used in because of slight vibration exposure
this study. Interverte- of the control group and potential
bral disc health-based selection of the exposed
disorders: group before start of the follow-up
2.00 0.84-2.1 period.
Degenera- The combination of exposure to W.V.,

tion of unfavorable postures, and adverse
interverte- climatic conditions is the probable
bral disc: cause of the back disorders.
2.95 1.1-3.7
COX
regression:
IDR for
displace-
ment of
disc: 2.46 1.2-7.3
IDR for
degenera-
tion of
inteverte-
bral disc:
3.28 1.2-12.5
(Continued)
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MSD prevalence
Bongers et al. Cross- Dutch, male, Outcome: Back symptoms, Dutch helicopter Non-flying air Participation rate: $70%.
1990 sectional helicopter aircrew by questionnaire. pilots and aircrew force officers
and non-flying air observers (n=163) (297) Adjusted for age, height, weight,
force officers Exposure: Hr of flight time, climate, bending forward, twisted
types of helicopters flown, Back pain, 68%; 17% 8.0 4.5-14.3 postures, and feeling tense at work.
and time spent in bent or LBP, 55%; 11% 9.0 4.9-16.4
twisted postures were Lumbago, 13%; 9% 2.6 1.1-6.0 Prevalence of transient back pain, in
obtained by questionnaire. Sciatica, 12%; 6% 3.3 1.3-8.5 particular, was higher for exposed
Vibration measurements Pattern alternating, than referent group.
were taken in two 41% 6% 9.5 4.8-18.9
helicopters of each type Prevalence of transient back pain
used in the study. increased with daily exposure time.
Cumulative exposures
were obtained by Chronic back pain increased with total
combining questionnaire flight time and total vibration dose.
and measurement data.
Postures of pilots were constrained
due to cockpit conditions.
Selection bias possible in that pilots

with back trouble could have dropped
out of employment.
(Continued)
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MSD prevalence
Boshuizen Cross- Employees of two Outcome: Back pain Sick leave for all Participation rate: 79%.
et al. sectional Dutch companies symptoms were obtained back disorders 1.47 1.04-2.1
1990a,b follow-up of performing land by questionnaire in the ORs corrected for duration of
a cohort reclamation and cross-sectional study, and LBP prevalence: by RR: 19.1, exposure, age, height, smoking,
identified in inspection of roads, back-related sick leave and vibration dose, 4 29.4, 28.03, awkward postures, and mental
1975. Also, dikes, and building disability retirement categories 8.1 workload.
includes sites. Several information was collected
entire cohort workers operate in the cohort study. By vibration, 3 1.80, 1.78, Association greater with duration of
in vehicles. The cross- categories 2.8 exposure than magnitude.
examination sectional study Exposure: Vehicle vibration
of sick leave included 577 information was combined By years of
and disability workers, and the with questionnaire data exposure 3 2.44, 2.50,
follow-ups. cohort study 689. regarding vehicle types categories 3.60
driven, awkward postures
maintained, hr of work, and Sick leave by
previous jobs held. vibration dose, 4 1.0, 0.97,
categories 1.51, 1.45
Dose of 5 years, all 1.13

back disorders COX
regress.
adj. for age
(Continued)
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MSD prevalence
Boshuizen Cross- Male employees of Outcome: Back pain Fork-lift truck and Employees of Participation rate: $70%.
et al. 1992 sectional six Dutch shipping symptoms by questionnaire freight tractor the same
companies (n=452). drivers (n=242). companies Adjusted for age, mental stress,
Exposure: Measurement without years lifting > 10 kg and twisting
of vibration in sample of vibration spine, height, smoking, looking
vehicles combined with exposure backwards, and hr sitting.
questionnaire responses (n=210)
to calculate cumulative Authors suggested that a healthy-
dose (before symptom Prevalence (age worker effect was operating in that
onset. standardized: older drivers were subject to health-
Back pain, 48% 34% p=<0.05 based selection.
LBP, 41% 30% p=<0.05
Lumbago, 19% 8% p=<0.05 Psychosocial factors were not
addressed, except for mental stress
Cox regression: from work.
Back pain and total
dose: 0.99 0.85-1.2
Lumbago and total

dose: 1.14 0.91-1.4
Vibration exposure
in last 5 years and
back pain: 2.4 1.3-4.2
and lumbago: 3.1 1.2-7.9
Age and
prevalence of LBP

(multivariate OR):

25-34 5.6

35-44 1.96
45-54 0.68
(Continued)
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MSD prevalence
Bovenzi and Cross- Male bus employees Outcome: Back-pain 234 bus drivers 125 Participation rate: $70%.
Zadini 1992 sectional mail working in Trieste symptoms from maintenance
survey questionnaire (rev. Nordic). workers Adjusted for age, awkward posture,
working for duration of exposure, BMI, mental
Exposure: WBV measured. same bus load, education, smoking, sport
Cumulative exposures company activities, previous jobs at risk for
estimated from Univariate results: back pain and duration of employment.
measurements plus lifetime prevalence
questionnaire results of LB symptoms, Does not address sedentary nature of
(duration of work, previous 83.8%; 66.4% 3.12 1.8-5.3 work (states sitting is poorly
exposures, etc.). LBP, 36.3%; 15.2% 2.80 1.6-5.0 correlated with LBP unless in
combination with WBV).
Previous 12
months: Psychosocial: adjusted for mental
LB symptoms, load (no risk estimate provided).
82.9% 65.6% 2.99 1.8-5.1
LBP, 39.7%; 20.0% 2.57 1.5-4.4 Results were similar after excluding
those with WBV exposure in previous
Dose-response for jobs from analyses.
total vibration and
lifetime LBP; 4.05 1.8-9.3
Dose-response for
12-mo. LBP. 3.25 1.5-7.0
(Continued)
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MSD prevalence
Bovenzi and Cross- Tractor drivers, Outcome: Survey Tractor drivers Revenue Participation rate: 91.2% for exposed
Betta 1994 sectional aged 25-65, working questionnaire (modified officers and 92.2% for unexposed.
in Italy (n=1155) and Nordic) Univariate:
male revenue Back Pain: 86.1% 57.3% 1.83 1.1-3.0 Multivariate analyses adjusted for
officers engaged in Exposure: Vibration levels LBP Lifetime: age, BMI, education, sport activity, car
inspection and were measured for a 81.3% 42.3% 3.22 2.1-5.2 driving, marital status, mental stress,
administrative work representative samples of climatic conditions, back trauma, and
(n=220). tractors. Information on 12-month LBP, postural load.
awkward postures gained 71.7% 36.8% 2.39 1.6-3.7
from questionnaire. Number Dose-response Relationships reported between
of hr operating yearly (highest vibration exposure and back pain,
estimated from tractor categories) with clearest dose-responses for
maintenance records. Lifetime LBP and chronic LBP outcome.
Cumulative exposures tot. vib. dose; 5.49 3.6-8.5
estimated by combining the Chronic LBP and Independent effects observed for
information. tot. vib. dose; 2.63 1.7-4.10 postural load and vibration.
Lifetime prevalence Results were similar after excluding

LBP and duration of those with WBV exposure in previous
exposure: jobs from analyses.
5-15 years
16-25 years 3.08 1.88-5.07
>25 years 3.03 1.80-5.12
4.51 2.43-8.34
Lifetime prevalence
LBP and total
vibration dose
(years m2/s 4)
<15
15-30 2.79 1.70-4.58
>30 3.44 2.05-5.77
3.79 2.20-6.53
(Continued)
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MSD prevalence
Burdorf and Cross- 33 male crane Outcome: Back pain 61% of crane 27% of 3.6 1.2-10.6 Participation rate: 67% of crane
Zondervan sectional operators and 30 assessed by questionnaire operators had controls had operators and 100% of controls.
1990 male non-crane (Nordic). Pain in lower back pain back pain
operator control back in the last 12 months. Control workers carried out more
subjects matched moderate or heavy work, lifting,
for age. Employed Exposure: Defined by job Risk Factors: walking, and standing than crane
for $ one year. title and questionnaire operator in past.
items: heavy physical Heavy work 4.02 0.76-21.2
work, lifting, WBV, and Physical demands are not significant
sedentary postures Frequent lifting 5.21 1.10-25.5 in multivariate analyses.
(current and past).
Whole body 0.66 0.14-3.1 Controlled for age, height, and weight.
vibration
Crane operators with long work
absences over-represented among
non-responders.
Results indicate that the current job of

crane operator is associated with
reports of onset of back pain.
(Continued)
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MSD prevalence
Burdorf et al. Cross- 114 concrete Outcome: Back pain 59% of concrete 31% of 2.80 age 1.31-6.01 Participation rate: 95% concrete
1991 sectional workers compared symptoms assessed by workers had back controls adjusted workers; 91% maintenance males.
prevalence to 52 maintenance questionnaire. Back pain pain had back and
study engineers (controls). defined as pain which pain controlled Workload related to prevalence of
All male. continued for $ a few hr for back back pain.
during the past 12 months. pain from
previous job Postural load, bending and twisting,
Exposure: Assessed by as well as whole body vibration
task analysis and OVAKO Model 1 causal factors.
working posture analysis Postural
system (OWAS) index Questionnaire included previous
observation method. OR=1.23 p=0.04 employment history, risk factors in
Eleven postures of present and previous jobs.
importance for occupational Model 2
strain on the back were Whole body Univariate analysis controlled for
used. vibration confounders using Mantel-Haensel
OR=3.1 p=0.001 chisquare. Age, height, and weight
For each job, two or three not significant factors.
workers were chosen at
random. Age controlled for in logistic
regression.
Index for postural load
constructed using ordinal 30% with back pain had symptoms
scale for rating the average >30 days.
proportion of poor back
postures. Six jobs were Concrete workers spent significantly
ranked by index. more time in bent and/or twisted
postures.
Postural index and whole body

vibration significantly correlated (0.48,
p<0.001). Therefore, authors
designed two separate logistic
regression models.
Prolonged standing or sitting not found

to be risk factors.
(Continued)
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MSD prevalence
Burdorf et al. Cross- Crane operators, Outcome: Back pain Crane operators Office Participation rate: $70%.
1993 sectional saddle-carrier symptoms, by (n=94) and saddle- workers
drivers and office questionnaire. carrier drivers (n=86) Adjusted for age and confounders
workers aged 25- (n=95) (history of heavy work, exposure to
60, working in a Exposure: Postures WBV (y/n), history of work requiring
large transport assessed with OWAS, Multivariate prolonged sitting, cold and drafts,
company (n=275). WBV measured in sample analyses: working under severe pressure, job
of each group, and past satisfaction, height, weight, duration
work exposures estimated Crane operators 3.29 1.52-7.12 of total employment were
by questionnaire. Straddle-carrier considered).
drivers 2.51 1.2-5.4
Risk estimates were not presented by
exposure categories, despite
quantitative assessment.
Risk estimates reflect simultaneous

exposure to WBV, static postures,
and awkward postures.
Only persons with no complaints of

low back pain before starting their
current jobs were included in
analyses.
(Continued)
6-61
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MSD prevalence
Chaffin and Prospective 5 plants in large Outcome: Visit medical Overall back rate, Participation rate: Not reported.
Park 1973 with approx. electronics department because of low annual 7.2/100
1 year company. n=411 back complaint. FTEs (25 total back Age, weight, stature not associated
follow-up individuals (279 injuries) with low back injuries.
males and 132 Exposure: 103 jobs
females). evaluated for Lifting A strong positive trend is indicated in
Strength Rating (LSR) and the incidence rate data as the LSR
lifting frequency. increases.
(Continued)
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MSD prevalence
Clemmer et al. Retro- Offshore drilling Outcome: Back-injury 543 cases of low Control room RR=2.2 Participation rate: Not reported.
1991 spective workers. cases reported on back injuries. and
cohort standard forms with maintenance Workers performing the heaviest
14,518,845 worker- mention of rheumatogical 7.5/100 3.18 physical labor had highest number of
hr over 1979 to 1985 crux for which the agent injuries and highest rates.
(7,259 FTEs), 4,765 of injury was mechanical Roustabouts,
total injuries. energy excluding other floorhands, and Controlling for job, age significantly
body sites. derrick workers, associated with back strain in
low-back strains workers performing heaviest length of
Exposure: Based on job rate: 6.92 employment work not associated with
title. back pain.
Job was best predictor of lost time.
Back injuries largely from falls. 75% of

back strains precipitated by pushing,
pulling, or lifting.
(Continued)
6-63
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MSD prevalence
Deyo and Cross- From the NHANES-II Outcome: Low-back pain Prevalence of LBP Prevalence of Participation rate: Not reported.
Bass 1989 sectional national survey of within the past year with in current smokers: LBP current Not
27,801 individuals, $ one episode of near daily 10.7%. non-smokers: significant Lifestyle factors, including smoking
10,404 files of adults pain for $ two weeks. 10.2% and obesity, are risk factors for low-
age 25 or older who back pain.
had a physical Exposure: Smoking and
examination were obesity, personal Ever smoked vs. The attributable risk for smoking was
reviewed and 1,134 characteristics. LBP: 10.9% 9.6% 1.13 1.3 cases/100 persons.
who met the case Significant
definition were 50 pack years vs. Smoking risk increases steadily with
selected for this LBP: 14.1% 9.6% 1.47 cumulative exposure and with degree
study. The mean Significant of maximal daily exposure.
age of the subjects BMI vs LBP,
was 48.3 years and Highest quintile: Lowest A stronger association exists
half (51.7) were 14.8% quintile: 8.5% 1.70 between back pain and smoking in
females. Significant younger subjects than among those
Odds ratio >age 45.
each
increment There is a steady increase in back
LOG REGRESSION: pain prevalence with increasing
Obesity 1.12 p<0.0006 obesity, but this elevates most
Smoking 1.05 p<0.0006 strikingly in the highest 20% of body
Chronic cough 1.36 p<0.0006 mass index (levels over 29.0
Activity 1.22 p<0.0006 kg/sq m).
Education 0.84 p<0.0006
Age 1.01 p<0.0006 The association between obesity and
Working 0.8 NS LBP could be confounded by other
unmeasured lifestyle differences
between the obese and non-obese so
that obesity is just a marker for a true
causal factor or factors.
(Continued)
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MSD prevalence
Helivaara Cross- 2,727 males and Outcome: LBP interview Prior traumatic No prior Participation rate: 93% in screening.
et al. 1991 sectional 2,946 females (30 to and tests at medical mobile injury increased injury
46 years) with clinic with uniform criteria. risk of LBP and, Physical and mental stress loads
history, symptoms, sciatica 2.5 1.9-3.3 related to both sciatica and LBP.
or findings indicating Low-back syndrome: and,
musculoskeletal Symptoms during the low back syndrome Controlled for age and gender.
disease. preceding month and major 2.6 2.1-3.1
pathologic finding on Work load index Body mass index, alcohol
physical exam (fingertip- and, consumption, work-related driving,
floor distance >25 cm at sciatica parity, and height were not
flexion, rotation restricted and, 2.4 1.0-5.7 associated with LBP.
to 25 degrees or less, low back syndrome
objective signs of scoliosis Diabetes had a significantly
of 20 degrees or more, Stress index 3.1 1.7-5.7 decreased prevalence of LBP
Lumbar Lordosis, and, (OR=0.4 CI 0.3-0.8).
Ladegues test positive at sciatica
60 degrees or less, or and, There was no statistical difference in
severe abnormality. low back syndrome 2.4 1.7-3.5 LBP between sexes; sciatica
significantly more prevalent among
Sciatica: Symptoms males.
radiating down leg and 2.0 1.5-2.6
findings of Lumbar nerve No association between smoking and
root compression. sciatica.
Exposure: Based on self- Significant association between

administered questionnaire; smoking and LBP in both older and
index for occupational younger males, but only older
physical stress and females.
occupational mental stress.
Significant association between LBP
and osteoarthritis, mental disorders,
and respiratory disease.
(Continued)
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MSD prevalence
Hildebrandt Cross- From the Dutch Outcome: Back pain cases 29.6% (2,327) of 23.9% of p<0.05 Participation rate: Population
1995 sectional population; a sample defined by symptom heavy workers sedentary sampled was representative of Dutch
of 8,748 workers questionnaire ("yes" to reported back pain workers OR=1.2 1.33-1.55 population. Unable to calculate.
from three surveys "back pain quite often") and quite often. reported back
on successive responses to interviewer. pain quite Workers performing non-sedentary
years. often. work at highest risk.
Exposure: Based on job
title classification of work Rates increase with age for males, to
demands; four categorical Rates of LBP: age 54, and for females to age 64.
exposure variables: trade
branch, trade class, Construction: Controlled for age and gender by
professional branch, and 35%; stratification.
professional class.
Truckers: 31%; Professions with high prevalence of
back pain on average were
Plumbers: 31%. characterized by physically
demanding work with dynamic
components.
Data originally collected for screening

of health and medical consumption,
therefore less specific exposure
variablesonly job titles. However,
there may be less potential for
information bias because respondents
did not then focus exclusively on back
pain and work-relatedness.
Conclusion: In non-sedentary work,

both males and females have higher
prevalence rates than those who
work in sedentary jobs.
(Continued)
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MSD prevalence
Hildebrandt Cross- 436 male workers in Outcome: Low back pain Prevalence: Reference Participation rate: Varied from 60% to
et al. 1996 sectional five maintenance cases defined by symptom 1-year; LBP: 53% group had 80% in different departments.
departments of a questionnaire (yes to low high physical
steel company, back pain in last exposures. Reference group characterized by
compared to 396 12 months). high levels of exposure to adverse
non-sedentary working conditions.
workers also Exposure: Assessed by
exposed to heavy questionnaire. Workers Poor selection of referents.
workloads. placed into one of 18
groups based tasks Prevalence rates adjusted for age
performed often or differences between groups.
predominantly. Tasks
assigned a score on four Task groups with high prevalence
indices: (1) physical rates of low back symptoms also
workload, (2) psychosocial associated with high exposures to
workload, (3) poor climate, unfavorable working conditions.
and (4) vibration.
Rates work groups (within units)
according to self-reported exposures
but does not cross-tab these with
LBP.
(Continued)
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MSD prevalence
Holmstrm Cross- 1,773 randomly Outcome: (1) LBP history 1-year prevalence Participation rate: 76%.
et al. 1992 sectional sampled from postal questionnaire. rate LBP 54%;
construction Back pain defined as pain, 1-year prevalence Examined medical records for
workers (male). ache, or discomfort in for severe LBP 7%. nonrespondents; same as for
lower back, including respondents.
gluteal regions with or Lifting freq: >1/5
without radiating pain into min <1/5 1.12 p<0.001 Information included individual and
leg/s experienced employee-related factors, disorders in
sometime, often, or very Stooping: >4 hr locomotor system, physical workload,
often during past year, seldom 1.29 1.1-1.5 and psychosocial factors.
(2) $ for 1 to 7 days, (3) Kneeling: > 4 hr
with any degree of seldom 1.24 1.1-1.4 Examiners blinded to case and
functional impairment. Stress: high exposure status.
1.6 1.4-1.8
A sample of workers had Anxiety: high Multiple logistic regression models
clinical exam: Active spinal 1.3 1.1-1.4 used; separate models for individual,
mobility test, springing test, manual materials handling, and
straight leg raising, working postures.
interspinal and paraspinal
palpation from T11 to S1, In univariate analysis, no relationship
combined extension and with daily traveling time, leisure
lateral flexion while activity, or height and weight.
standing and passive
lumbar flexion and Construction tasks such as
extension while lying on bricklaying or carpentry did not affect
one's side. LBP.
Exposure: Based on Stress index reflected a high achiever

questionnaire data person.
reporting of task activity.
Longer duration of stooping and
kneeling was associated with LBP in
all age groups (dose-response).
Only severe LBP related to smoking.
(Continued)
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MSD prevalence
Huang et al. Cross- Subjects consisted Outcome: Symptoms Consistently N/A Participation rate: All 42 workers
1988 sectional of all 24 female full- relating to upper limbs, constrained completed a symptom, health, and
time workers from trunk and lower limbs postures: work history questionnaire and
school lunch center during the previous month 17 workers 3 workers p<0.05 20 from each center also participated
A and 20 female full- were solicited from a (70.8%) (15%) in a physical examination. Six
time workers from questionnaire, while clinical workers from center B declined to
center B. findings of pain during Poor equipment participate for personal reasons
movements, muscle layout: 18 workers 3 workers p<0.01 unrelated to the purpose of the study.
All 42 workers tenderness, signs of CTS, (75%) (15%)
completed a signs of epicondylitis, and Center A had a significantly higher
symptom, health and signs of tenosynovitis Consult physician: prevalence of musculoskeletal
work history were documented in a 17 workers 5 workers p<0.01 complaints, more clinical findings, and
questionnaire and physical examination. (70.8%) (25%) greater medical treatment experience
20 from each center than those in center B.
also participated in a Exposure: Ergonomic risk Muscle tenderness:
physical factors included handling 5.1 +/- 5.6 The ratio of the actual lifting load to
examination. Six heavy objects, holding 0.8 +/-2.3 p<0.01 the Action Limit was also larger in
workers from center constrained postures, too Signs of center A than in center B.
B declined to much stooping, repetitive tenosynovitis:
participate for use of arms and hands, 6 workers No significant difference was found
personal reasons and poor equipment layout. (30%) 1 workers p<0.05 between the centers for low back
unrelated to the NLE used to evaluate (5.0%) pain.
purpose of the manual lifting tasks.
study. Upper back pain: Study design was ecologic. Health
significant outcomes and exposures were
examined separately for two centers.
Information was not combined for
individual participants.
(Continued)
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MSD prevalence
Johanning Cross- Employees of the Outcome: Back-pain Subway train Subway Participation rate: Not reported.
1991; sectional mail New York City symptoms in past year, by operators (n=492) control tower
Johanning survey transit system questionnaire survey. operators Controlled for age, gender, job title,
et al. 1991 (n=584) (n=92) employment duration.
Exposure: Job title.
Although, WBV measures Any back pain, Study groups are stable working
were taken for the 41% 25% PRR=1.11 1.04-1.19 populations with low turnover rates.
exposed group, no
analyses were presented. Sciatic pain 3.9 1.7-8.6 Exposed and unexposed groups are
similar with regard to demographics
and job histories.
Workers with a history of back

problems or previous WBV exposure
were excluded from the study.
Duration of employment not

associated with risk.
Exposure data was not associated

with outcome data in these articles.
Vibration measures showed high

lateral and vertical acceleration levels.
(Continued)
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MSD prevalence
Johansson Cross- Subjects were 241 Outcome: Low-back Prevalence of low- Prevalence of PRR=1.76 1.25-2.47 Participation rate: The participation
and sectional blue-collar (39% symptoms during the back symptoms LB symptoms rate was approximately 90%. Eighty-
Rubenowitz females) and 209 past 12 months as self- =0.43 (CI 0.37- =0.42 (CI 0.35- seven percent of the blue-collar and
1994 white-collar (35% reported on the Nordic 0.50) for blue-collar 0.49) among 95% of the white-collar workers had
females) workers Musculoskeletal workers, which wt. collar >2 years experience in their current
from eight diversified Questionnaire (NMQ), reduced to p=0.32 workers, jobs.
metal industry which was supplemented (CI 0.26-0.39) which
companies in with an additional when solely work- reduced to Among blue-collar workers 12 of 15
Sweden. question regarding the related symptoms p=0.18 correlation tests regarding workload
work-relatedness of the were considered. (CI 0.11-0.24) factors and work-related symptoms
The participation rate symptoms. when solely were not significant.
was approximately work-related
90%. Eighty-seven Exposures: Individual and symptoms Among blue-collar workers 10 of 15
percent of the blue- employee-related variables were partial correlation tests (adjusted for
collar and 95% of related to the psychosocial considered. the effects of age and sex) regarding
the white-collar work environment and the psychosocial job factors and work-
workers had physical workload (sitting, related musculoskeletal symptoms
>2 years experience manual materials handling, were significant.
in their current jobs. lifting).
Among blue-collar workers 7 of 15
partial correlation tests regarding
psychosocial job factors and
musculoskeletal symptoms, according
to the NMQ, were significant.
Among white-collar workers none of

the relationships between the five
psychosocial factors and low-back
symptoms were significant, whether
or not work-related.
Calculations of associations based on

the NMQ, without an effort to
determine the work-relatedness of
symptoms, could have a powerful
effect-masking result.
(Continued)
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MSD prevalence
Kelsey 1975b Case-control Cases were Outcome: Herniated lumbar Sitting >half the Participation rate: 79% cases;
obtained from a intervertebral time: 77% controls.
population in the age discs were the outcomes <35 years Equal RR=0.81
range 20 to 64 years of interest in this study. >35 years Fewer RR=2.40 p=0.01 Results were similar for two control
residing in the New Three levels of herniated groups (less strong for unmatched
Haven SMSA who disc were classified: Time driving: controls).
had lumbar X-rays Surgical cases, probable >half vs. herniation
taken during the cases, and possible cases. Fewer RR=2.75 p=0.02 Study design subject to nondifferential
period June 1971 Occupation: recall problems (with regard to
through May 1973 at Exposure: Occupation, Truck driver vs. case/control status).
the three hospitals in years of employment, herniation
the area and at the amount of time worked, Fewer RR=4.67 p=0.02 The association between sedentary
office of two of the amount of time spent sitting, Lifting vs. occupations, especially those which
private radiologists type of chair, lifting, herniation involve driving, and herniated lumbar
in New Haven. A pushing, pulling, carrying, Equal RR=0.94 p=0.10 discs exists in both sexes and in
total of 217 pairs (89 lifting frequency, and comparisons between cases and
females and 128 weight of objects lifted both control groups.
males) was obtained were the exposures of
for the comparison interest. The strength of this association in
of cases and those aged 35 and older and the lack
matched controls. of association in those who are under
For the analysis of that age suggest that a certain amount
cases and of time in sedentary occupations is
unmatched controls, necessary for an effect to be seen.
there were
223 cases (91 This study gave no evidence of an
female and 132 increased risk for herniated lumbar
males) and discs among males who did lifting on
494 controls their jobs, and little indication of this
(225 females and among the females. Chance could
269 males). explain the slight tendency toward
significance in the female subjects.
(Continued)
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MSD prevalence
Kelsey et al. Case-control Persons in the age Outcome: Status N/A N/A Lifting: Participation rate: 72% cases;
1984 range of 20 to 64 determined on the basis of >11.3 kg 79% controls.
years who had an interview, diagnostic >25/day:
lumbar X-ray films or tests performed by OR=3.5 1.5-8.5 All case categories combined in case-
myelograms taken interviewers, and data control analyses (same results
during 1979 to 1981, recorded in medical Lifting: observed for all categories).
in one of three records. Cases classified > 11.3 kg
hospitals, one as surgical cases, >5/day and Controls matched with cases on sex,
neurosurgical probable cases, and twisting the age and hospital service.
private practice, or possible cases. Control body half
two orthopaedic group composed of the time: Frequent twisting alone did not affect
private practices in persons without known OR=3.1 1.3-7.5 the risk of prolapsed disk, while
the New Haven and prolapsed disc admitted to twisting with lifting had a detrimental
Hartford, CT areas. the same medical services Lifting: effect.
for conditions not related to >11.3 kg
232 matched case- the spine. Cases and while Study design subject to nondifferential
control pairs. controls all with recent twisting recall problems (with regard to
(within 1 year) disease body with case/control status).
onset. the knees
almost
Exposure: Exposure to straight:
activities performed on the OR=6.1 1.3-27.9
current job assessed by
interview and Carrying:
questionnaire. >11.3 kg
5 to 25/day:
OR=2.1 1.0-4.3
Carrying:
>11.3 kg
>25
per/day:
OR=2.7 1.2-5.8
(Continued)
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MSD prevalence
Knibbe and Cross- 355 females Outcome: Questionnaire, Lifetime LBP N/A Participation rate: 94%. Males and
Friele 1996 sectional employed as developed from Nordic prevalence: pregnant females excluded from
(study community nurses or questionnaire for 87% Back pain in sample.
intended to community nurse musculoskeletal disorders, last 7 days,
provide auxiliaries by the mailed to nurses. 1-year LBP community 89.9% of nurses described situations
baseline data home care prevalence: 66.8% nurses vs. they considered physically
for organization of the Exposure: Questionnaire community demanding. 82.1% of tasks described
longitudinal city of Rotterdam. asked (1) if nurses could Auxiliaries: nurse involved patient transfers. Static load
study). describe any work tasks 61.2 auxiliary: on the back was mentioned in 23.2%
they considered physically OR=0.84 0.49-1.45 of descriptions.
demanding, and 1-week LBP
(2) whether the onset of prevalence: Backpain in Prevalence appeared to decrease
back pain was related to a 20.6% previous 12 with age. Cross-sectional study
specific work situation. months; design prevented investigators from
Also job title: Community Prevalence of sick community determining whether observation was
nurses vs. Auxiliaries. leave due to back nurses vs. due to selection effect or due to
pain in previous 3 community experience.
months: 9.7% nurse
auxiliary: Rates for community nurses and
OR=1.54 0.97-2.47 auxiliaries do not reflect significant
differences in hrs worked/week (30.7
vs. 26.2). Adjusted for hrs worked
OR is 1.3 (auxiliaries higher).
Authors state that auxiliaries are

responsible for more lifting activities.
(Continued)
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MSD prevalence
Leigh and Cross- 959 working males Outcome: LBP based on 1-year LBP past Managers Participation rate: Not reported.
Sheetz 1989 sectional and 455 working national survey of working prevalence: and (Probably to national survey).
females in the United conditions. Question: Is 19.4% males Professional
States employed >20 the trouble with back or 20.7% female Workers in jobs requiring lots of
hr/week. spine in past year? physical effort and lots of repetitive
Occupations: work report more back pain.
(U.S. Department of Exposure: Defined by job Farmers Managers 5.17 1.57-17.0
Labor QES Survey title and questionnaire on Clerical Managers 1.38 0.85-2.25 Exposure information based on self
respondents.) work conditions, including Operator Managers 2.39 1.09-5.25 report and job title.
workload. Service Managers 2.67 1.26-5.69
Health outcome did not distinguish
Job demands: between upper and lower back pain.
High Low 1.68 1.05-2.90
Gender, race, obesity, height, and
Smoker Non smoker 1.48 1.00-2.19 repetitious work are not significantly
associated with back pain.
(Continued)
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MSD prevalence
Liles and Prospective 28 companies, 63 Outcome: Lifting injury to Total injuries: Total injuries: Participation rate: Not reported (all
Deivanayagan jobs in study 1, 38 in back, as recorded or volunteers).
1984 study 2. Selected reported. Injury rate for the Injury rate for
jobs with frequent highest job severity the lowest job Dose response for lifting injuries by
lifting requirements; Exposure: Jobs rated by index category: severity index JSI.
manual handling Job Severity Index for lifting 17.1 injuries/100 category:
requirements. (observation, use of FTES 3.8 injuries/ No adjustment for confounders.
records for calculation). 100 FTES RR=4.5
Study 1: 220 males; Each individual followed Outcome defined as lifting injuries.
24 females. until job change (up to 2 Disability injury rate Disability injury Not distinct from exposure.
years). for the highest job rate for the
Study 2: 165 males; severity index lowest job
44 females. Total of 529 FTEs divided category: 11.4 lost severity index
equally into 10 SI levels. time injuries/100 category 3.0
FTES lost time
injuries/100
FTES RR=3.0
Severe injury rate Severe injury

for highest job rate for the
severity index lowest job
category: 120.8 severity index
days lost/number category 3.0
of lost time injuries days
lost/number of
lost time
injuries RR=40
(Continued)
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MSD prevalence
Magnusson Cross- Bus drivers, truck Outcome: Back pain Bus drivers Sedentary Participation rate: Not reported.
et al. 1996 sectional drivers, and symptoms, by (n=111) and truck workers
sedentary workers questionnaire. drivers (n=117) (n=137) ORs do not appear to be from
recruited in the state multivariate analyses including other
of Vermont and Exposure: Ergonomic Driving 1.79 1.16-2.75 covariates, except as stated.
Gothenburg, exposures, by
Sweden questionnaire and vibration Freq. lifting 1.55 1.01-2.39 Quantitative exposure measures are
level measurements not used in analyses that are
according to ISO Heavy lifting 1.86 1.2-2.8 presented.
standards. Long-term
vibration exposure Long-term vibration
calculated as product of exposure 2.0 0.98-4.1
daily exposure and years
driving. Vibration and freq.
lifting 2.1 0.8-5.7
Vibration and
heavy lifting 2.06 1.3-3.3
(Continued)
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MSD prevalence
Magora 1972 Cross- A previous article Outcome: The outcome The exposed group The controls NR Participation rate: Not reported.
sectional (1970) described the variable, low-back pain, consisted of consisted of
process for was defined in a previous workers from 8 2887 The use of two hands to lift a load,
selecting 3,316 article [1970]. Symptoms occupations. The individuals and especially holding the load away
individuals from 8 by self-report. selection process from 8 from the body, are related to a higher
occupations for was described in occupations. incidence of LBP.
inclusion into this Exposure: The physical an earlier article by The selection
study. activities studied in this the same author process was The lifting risk factors are magnified
investigation were sitting, [1970]. described in when completing unaccustomed
standing, weight lifting, and an earlier tasks.
weight lifting technique. article by the
same author Rarely sitting reported to be
[1970]. associated with LBP.
Standing less than 4 hr daily reported

Sitting > 4 hr day: to be associated with LBP.
Often: 0.95 0.8-1.14
Sometimes: 0.09 0.05-0.14 Variable sitting and standing reported
Rarely: 3.20 2.69-3.8 to be protective.
Standing
Variable:
< 4 hr daily 2.38 1.99-2.85
(Continued)
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MSD prevalence
Magora 1973 Cross- A previous article Outcome: The outcome The exposed group The controls Sudden Not Participation rate: Not reported.
sectional (1970) described the variable, low-back pain, consisted of consisted of maximal reported
process for was defined in a previous workers from 8 individuals physical It appears that sudden maximal
selecting 3,316 article (1970). occupations. The from 9 efforts efforts, especially if unexpected, play
individuals from 8 selection process occupations. were found an important role in the causation of
occupations for Exposure: The physical was described in The selection to be LBP.
inclusion into this activities studied in this an earlier article by process was related to a
study by investigation were bending, the same author described in high Many of the physical causative
observation and rotation, reaching, sudden (1970). an earlier incidence of factors, such as bending or rotation,
interview. maximal efforts, and the article by the LBP. found by other investigators to be
number and type of work same author related to a high incidence of LBP are
breaks, by observation, (1970). actually sudden maximal efforts
and interview. incidentally carried out at that moment
Among those with Among in a certain position of the spine.
LBP: controls:
While most bending, twisting, and
Bending: Bending: reaching motions required by each
Often: 14.5% Often: 85.5% occupation are knowingly carried out,
Sometimes: Sometimes: sudden maximal physical efforts are
3.4% 96.6% characterized by their
Rarely: 23.2% Rarely: 76.8% unexpectedness. This may actually
trigger LBP through sudden strain of
Spine rotation: soft tissues, possibly caught in a
Spine Often: 87.9% condition or posture < optimal for this
rotation: Sometimes: kind of effort.
Often: 12.1% 78%
Sometimes: 22.0% Rarely: 89.7%
Rarely:
10.3% Sudden
maximal
Sudden efforts:
maximal Often: 82% Sudden
efforts: Sometimes: maximal
Often: 18.0% 88.7% efforts and
Sometimes: 11.3% Rarely: 89% LBP: 1.65 1.3-2.1
Rarely: 10.9%
(Continued)
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MSD prevalence
Marras et al. Cross- 403 industrial jobs Outcome: Existing medical Maximum load Participation rate: Numbers and
1993 sectional from 48 and injury records in each moment: 73.65 Nm proportions of those sampled by job
manufacturing industry were examined for 23.64 Nm 5.17 3.19-8.38 group. No information on number of
Marras et al. companies: e.g., each job to determine if Sagittal mean individual participants.
1995 automobile workers on those jobs had velocity:
assembly, food reported work-related low- 11.74 E/sec Study provides linkage between
processing, lumber back disorders. The result 6.55 E/sec 3.33 2.17-5.11 epidemiologic measures of injury (i.e.,
and wood, yielded an outcome Maximum weight: probabilities of high-risk LBD group
construction, metal measure of LBD risk, 104 N 23.3 lb Maximum membership) and select
and paper which was a normalized weight: biomechanical and task factors for
production, printing, rate of work-related LBD. 37 N 8.3 lb 3.17 2.19-4.58 repetitive lifting jobs.
and rubber
production. No data Exposure: A triaxial Study illustrates multi-factored nature
provided on the electrogoniometer was of injury risk, but it does not indicate
number of workers worn by workers to record the risk of LBD.
in study. position, velocity and
acceleration of the lumbar Quality and accuracy of injury and
spine while workers lifted medical records are unknown.
in either high or low risk Inaccuracies or underreporting would
jobs. Workplace and affect the accuracy of the model.
individual characteristics
were recorded. High risk Exposure assessors may not have
exposed was >12% injury been blinded to risk status of jobs
rate, yielding 111 high risk they were evaluating.
jobs, while 124 jobs were
low risk, serving as the
control group.
(Continued)
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MSD prevalence
Masset and Cross- Steel workers Outcome: Interview-based Lifetime LBP N/A Participation rate: 90%.
Malchaire sectional (n=618). checklist and questionnaire: prevalence for all
1994 Back pain defined for three workers: Low back fatigue accounted for 25%
All male and all periods: (1) during lifetime, 66% LBP cases.
under 40 years of (2) past 12 months, and (3) Vehicle
age. past 7 days by the 1-year LBP driving: No objective measure of workload.
question, Did you have prevalence for all 1.15 <0.005 Stratified by age and exposure risk
any problems in the lower workers: level.
back? 50%
Heavy Ergonomic redesign prior to study,
Exposure: Interview-based 1-week LBP efforts of reduced ergonomic hazards.
exposure assessment prevalence: the
using checklist: postures 25% shoulder: Physical workload, posture,
and movements of the 1.62 <0.01 movements of the trunk, repetition,
negative perception of working
trunk, efforts, physical and Prevalence of environment, exposure to WBV, not
psychosocial environment sciatica was low: associated with back pain.
(monotony, responsibility), 2-3% Seated
vehicular driving and posture: Information obtained included
exposure to whole body 1.46 0.09 demographics, height, weight, medical
vibration. history, personality, and social status
(smoking, sports, satisfaction with
family and occupation, abnormal
fatigue, temper, headache,
depressive tendency, present and
past working environment.
All long-lasting sick workers excluded

from study; may cause survivor bias.
Back fatigue separated from back
pain.
This cross-sectional study was first
part of a prospective study.
Heavy efforts with shoulders were
strongly correlated with LBP.
(Continued)
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MSD prevalence
Partridge and Cross- 206 male civil Outcome: Low-back pain Dockers: current Civil servants: RR=1.27 0.98-1.64 Participation rate: 95.7% for dockers
Duthie 1968 sectional servants (clerical (including lumbar disc rheumatic current and 91.0% for civil servants.
workers), age 15 disease, pelvic girdle pain, symptoms: 43.2% rheumatic
to 64 years, and 171 and leg pain). symptoms: Analyses corrected for age.
male dock workers, Low-back pain, 61 34.5%
age 25 to 64 years. Participants attended an dockers Overall complaint rates did not differ
interview at which time a (Standardized Ratio Low-back between occupations, despite
medical and social (SR) by age 106.1) pain, 33 civil differences in physical effort
questionnaire was servants (SR requirements. Older civil servants
administered and a medical 90.4) complained of more neck/shoulder
examination was pain than dockers of a similar age.
performed. Difference attributed to static working
postures involving the neck and
Complaints classified into 8 shoulder.
categories.
Among civil servants, only 5 weeks
Exposure: Based on job (16.1%) of sickness absence in
title (civil servant or previous year due to back pain.
docker). Among dockers, 75 weeks (68%) of
work lost attributed to lumbar disc
disease and backache. Authors
conclude that there is a positive
correlation between the heaviness of
work and time lost due to back
complaints, even if the complaint rate
in different occupations does not vary
significantly.
Medical examiners probably not

blinded to exposure status.
(Continued)
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MSD prevalence
Punnett et al. Case- 219 automotive Outcome: Back pain 84% (185) 20 workers Non-neutral Participation rate: 84%.
1991 referent assembly workers. cases: (interview and unexposed postures:
(retro- exam) defined as workers 4.9 1.4-17.4 Healthy worker effect.
spective) 95 cases compared who filed new reports of
to 124 referents back disorders at plant Mild flexion: Of the 124 referents, only 20 workers
without back pain. during a 10-month period. 5.7 1.6-20.4 were unexposed to all awkward
Back pain in interview postures.
defined as history of $ 3 Severe
episodes or $ one episode flexion: 5.9 1.6-21.4 Back disorders were found to be
lasting $ one week within associated non-neutral trunk
the year preceding the date Time in non- postures.
of the interview. neutral
posture: 69% of subjects in job <5 years.
Physical exam consisted 8.09 1.5-44.0
of active, passive, and Questionnaire involved demographics,
resisted motions Lift 44.5N: work history, medical history, and
concentrating 11 ranges 2.16 1.0-4.7 non-occupational activities.
of motion of the back.
Age Analyses controlled for gender, age,
Referents: No report of (years): length of employment, recreational
back disorders. 0.96 0.9-1.0 activity, medical history, and maximum
weight lifted in study job.
Exposure: Based on video Back injury:
analysis of job postures 2.37 1.3-4.3 Exposure variable for non-neutral
and bio-mechanical data posture: The sum of the duration
spent in non-neutral postures as a
continuous variable.
A strong trend found for increasing

length of exposure and risk of back
disorders to both mild and severe
trunk flexion.
Only current job analyzed: Assumes
short-term relationship between
outcome and exposure (however,
also included duration of employment
variables).
(Continued)
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MSD prevalence
Riihimki et al. Cross- Longshoremen, Outcome: Back pain Longshoremen Office Participation rate: $70%.
1989a sectional mail earth moving symptoms, by (n=542), earth workers
survey equipment operators questionnaire. movers (n=311), (n=674) Longshoremen and earthmovers
(WBV), carpenters and carpenters combined in analysis (machine
(heavy physical Exposure: Job title and (n=696) operators).
work), and office questionnaire responses
workers (sedentary regarding work history, Sciatic pain and After adjustment for age, duration of
work) (n=2,223) physical work factors, and machine operators 1.3 1.1-1.7 employment was not associated with
work stress. symptoms in any group.
Sciatic pain and
carpenters 1.0 0.8-1.3 Of the three back symptoms, sciatica,
lumbago, and LBP, sciatica
Sciatica and discriminated the best among
twisted or bent occupational groups.
postures 1.5 1.2-1.9
All three exposed groups were
Sciatica and annual exposed to $ one work-related risk
driving 1.1 0.9-1.4 factor for back disorder.
(Continued)
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MSD prevalence
Riihimki et al. Cross- 216 concrete Outcome: Radiographically Grade 2 to 3 Grade 2 to 3 Participation rate: 84% concrete
1989b sectional workers compared detectable degenerative disc problem: disc problem: N/A p=0.001 workers and 86% house painters.
to 201 house changes in lumbar region.
painters (all male), 27.8% concrete 15.4% house Occupa-tion Examiners (radiologists) blinded to
age-matched. Exposure: Based on job workers painters effect of case or exposure status.
Restricted to title (article refers to concrete
workers with 5 Wickstrm [1985] Back problems: Back work: Age, self-reported back accidents,
years work evaluation of concrete 55% problems: OR=1.8 1.2-2.5 body mass index, height, and smoking
experience and to reinforcement workers). 45% controlled for in analysis.
workers <55 years. Age:
Sciatic: Sciatic: OR=6.5 1.7-26 Height, weight, smoking no effect on
53% 39% degenerative X-ray changes.
Spondy-
lophytes Negative bias for occupational factor
due to healthy worker effect.
Occupa-tion
effect of Positive bias due to recall for
concrete identifying accidents as risk factors.
work:
OR=1.6 1.2-2.3 Individual exposure data not available
for workers.
Age:
OR=14.9 2.3-95 Radiographically detectable
degenerative changes associated
with sciatic pain (1.0, 1.4, 1.9) for
three grades of degeneration (not for
LBP or lumbage).
No hypotheses regarding specific risk

factors. Exposure assessed by job
title only.
(Continued)
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MSD prevalence
Riihimki et al. Prospective Machine (heavy Outcome: Based on 2 22% machine 14% office 1.4 0.99-1.87 Participation rate: For follow-up: 81%
1994 (3-years) equipment) Postal questionnaires; operators workers machine operators, 79% carpenters,
operators (688), LBP=Low-back symptoms and 89% office workers.
Pietri-Taleb carpenters (533), in preceding 7 days, 12 24% carpenters 1.5 1.1-2.1
et al. 1995 and office workers months, and lifetime. Questionnaire included age, level of
(591). All males. Sciatic pain = pain radiating education, annual car driving, weekly
to leg/s. physical exercise, occupational
exposure, and history of other back
Exposure: Based on Physical exercise > Maximum problems.
specific occupation: once a week physical
Machine operators were exercise once Questionnaires administered in 1984
exposed to static loads, a week. 1.26 1.0-1.6 and 1987.
low-level, whole body (p<0.06)
vibration. Carpenters Separate logistic regression models
exposed to dynamic Smokers and ex- Non-smokers 1.29 0.98-1.7 created for specific occupation.
physical work. Office smokers p<0.06)
workers were sedentary History of other types of low back
workers. pain predicted sciatica in all groups.
History of lower
Questionnaire asked back pain: Monotonous work, problems with co-
amount of twisted or bent workers or supervisors, and high-
postures, pace of work, Mild LBP; None 2.7 1.7-4.2 paced work were not associated with
monotonous work, Severe LBP 4.5 2.7-7.6 sciatica three-year cumulative Incident
problems with co-workers (p<0.001) Rate.
or superiors, draft, cold,
vibration. Article examines only sciatic pain.
(Continued)
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MSD prevalence
Ryden et al. Case-control Cases consisted of Outcome: Reported work- Low-back Previous Participation rate: Not reported.
1989 84 employees with related low-back injuries pain: OR=2.27 back injury:
back injuries and while employed at the site OR=2.13 1.07-4.24 Disadvantages of the design include:
168 controls of the study during the time a lack of detailed information that
(matched triplets).
Mean age was 34 period of 1983 through Working could have helped to focus on
and 83.3% were 1985. day shift: selected risk factors. For example,
female. OR=2.23 1.28-3.89 knowledge of pack-years rather than
Exposures: History of only number of cigarettes smoked/day
Cases: Employees previous back injury at Low back would have been valuable, if
with injuries from work, work shift, heavy pain: available, as would more specific
job-related activities work, lifting, bending, OR=2.27 1.25-4.12 information on body build, including
that occurred during
the working day, slipping, self-reported low- percent body fat and fitness level,
not based on back pain or slipped disc, Self-report rather than using height/weight and
individual lost time and individual risk factors. slip disc: self-reported exercise level.
from the job or OR=6.20 2.64-14.57
workers Advantages of the design included
compensation. The economy, time savings, flexibility, and
incidence rate at the
work site during the the analysis of a large group of risk
study period was factors simultaneously.
29/1,000 in 1983,
29/1,000 in 1984 and Immediate reporting of injuries,
33/1,000 in 1985. including the nature of the injury and
pertinent data regarding where and
Controls selected how the injuries occurred, is essential
from the same
population by age, to efforts both to reduce injuries and
sex, and to rehabilitate those who are injured.
department. For
each case, two Cases and controls were (over)
controls were matched on occupation risk factors.
selected from a list Could not examine these effects.
of all employees,
stratified by
department. Those working day shift felt to have
Matching for age greater physical demands.
was done within a
5-year span.
(Continued)
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MSD prevalence
Schibye et al. Longitudinal Follow-up of 303 Outcome: Based on Nordic Prevalences of LBP Participation rate: 1985: 94%;
1995 sewing machine Questionnaire: pain in the in Sewing jobs: 1991: 86%. All participants were
operators at nine last 12 months in the low females.
factories back (last 7 days). 12-month: LBP:
representing 1985=38% 77 of 241 workers still operated a
different technology Exposure: Assessed by 1991=47% sewing machine in 1991.
levels who questions regarding:
completed (1) type of machine Prevalences 82 workers had another job in 1991
questionnaire in operated, (2) work 1-week: LBP: among those 35 years or below, 77%
1985. organization, (3) workplace 1985=23% had left job; among those above 35
design, (4) units 1991=25% years 57% left job.
In April 1991, 241 of produced/day, (5) payment
279 traced workers system, and (6) time of 20% reported musculoskeletal
responded to same employment as a sewing symptoms as the only reason for
questionnaire. machine operator. leaving job. Healthy worker effect.
Another 13% said symptoms were
part of the reason.
No significant changes in prevalences

among those employed as sewing
machine operators from 1985 to 1991;
significant decrease in those who
changed employment.
As many as 50% of respondents

reported a change in the response to
positive or negative symptoms from
1985 to 1991.
This was due to a decrease in the risk

factors: e.g., decreased in output and
hrs worked/week.
Article examines only neck/shoulder

area in detail (no exposure analyses
for back outcome).
(Continued)
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MSD prevalence
Skov et al. Cross- 1,306 Danish Outcome: Musculoskeletal Danish No unexposed Participation rate: Not reported.
1996 sectional salespersons symptoms, by salespersons group included
questionnaire. (n=1,306) Covariates considered in multivariate
analyses included age, sex, height,
Exposure: Self-reported Annual driving Annual weight, smoking, work-related
driving distance, time in distance driving psychosocial variables, lifting, leisure
sedentary work, lifting of distance, time sports activities.
heavy loads, psychosocial highest
job characteristics. category: No unexposed group was included.
OR=2.79 1.5-5.1
Sedentary work (% Sedentary

of worktime) work (% of
worktime)
highest
category:
OR=2.45 1.2-4.9
(Continued)
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MSD prevalence
Skovron et al. Cross- 4,000 random- Outcome: Based on back Point prevalence Participation rate: 86%.
1994 sectional stratified sampled pain symptom reporting LBP: 33%
adults in Belgium; a from structured interviews. Information included age, gender,
bicultural country, Back pain defined by Lifetime social class, habitat, language,
uniform health care question Have you ever prevalence: 59% working status, occupation, work
system; 48% male. had back pain? Cases satisfaction, lifestyle factors, and
restricted to those subjects Among workers family history.
Population-based currently working. occupation: NS
telephone survey. Logistic regression models controlled
Exposure: Based on Work for age, and gender; interaction
interview data: occupation dissatisfaction: 2.4 p=0.02 tested.
and working status, Are
you satisfied with work First episode of back pain not
question.. Female gender: 2.16 p=0.001 associated with work satisfaction.
Increasing age: 2.0 p=0.001
Language influence reporting of first
time occurrence and history of back
pain but not severity of impairment as
expressed as daily back pain.
Uniform health care assured equal

access and reporting.
Results suggest that work

satisfaction is not a cause of LBP, but
it intervenes in the expression of LBP.
(Continued)
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MSD prevalence
Svensson and Cross- Random sample of Outcome: Low-back pain Univariate Participation rate: Approximately 80%
Andersson sectional 1,760 38 to 64-year- (LBP) was defined as all analysis of the final sample of 1,746 females
1989 old females from conditions of pain, ache, found participated in the study.
Goteborg, Sweden. stiffness, or fatigue significant
At the time of the localized to the lower back. correlations The analysis of correlations between
investigation, 14 All episodes of LBP were between the occurrence of LBP and the
females could not be included in the study, as LBP and 5 different variables describing work
located. determined by exposures history, work environment, and stress
questionnaire. in ages 50- was restricted to wage-earning
Approximately 80% 64 years: females only (sick-listed included).
of the final sample of Exposure: Variables More
1,746 females included working hr, bending, p<0.05 No significant differences existed
participated in the working hr/week, amount lifting, p<0.01 between the two age groups
study. of overtime, lifting, standing, p<0.01 concerning the incidence and
frequency of forward higher prevalence rates of LBP. However,
bending and twisting, work degree of several parameters indicated that the
posture, possibility to worry, p<0.01 LBP in the older age group was more
change work posture, need and severe.
to concentrate, monotony, exhaustion
satisfaction with work at the end Several of the correlations in the
tasks, possibility to take of the work univariate analysis, when tested in
rest breaks, worried and day. p<0.0001 the covariate analysis, were found to
tense after work, fatigued be dependent on other confounding
at the end of the work day, factors.
and education.
The findings in the present study
Exposed and unexposed stress the importance of
were determined by psychological factors in relation to
questionnaire responses. low-back pain. These factors are
probably not only related to the
individuals personality but also to the
type of work and the environment at
the workplace.
Medical examiners discussed

questionnaires with participantsnot
blinded.
(Continued)
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MSD prevalence
Toroptsova Cross- 701 random- Outcome: LBP history from Frequent trunk No trunk 1.66 p<0.01 Participation rate: 88%.
et al. 1995 sectional stratified sampled structured interviews. flexion flexion
employees of a Back pain defined as pain Analysis did not control for
Russian machine lasting in area below 12th confounders.
building plant 47% rib and above gluteal folds. Frequent lifting Occasional 1.43 p<0.05
male. All persons with LBP required in job lifting (2 or Information included personal data,
complaints examined by less/day) family status, education, profession,
rheumatologist. anthropometric data, smoking, sport
activity, and professional factors.
Exposure: Based on
interview data: Work, Lifetime prevalence: 48%. Prevalence
sports, and personal higher among older workers and
factors. 10 industrial smokers >10/day.
factors examined: Lifting,
standing, sitting, walking, Back pain decreased in group
vibration, static work, >55 years. The year of retirement for
postures, repetitive work, females.
and bending.
No association with sitting or standing
postures, walking, vibration, static
work postures, and repetitive work.
(Continued)
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MSD prevalence
Undeutsch Cross- 366 male cargo Outcome: Standardized Prevalence of N/A N/A N/A Participation rate: Not reported (46%
et al. 1982 sectional transport workers at interview administered to all previous back of target population included).
a large airport. workers to detect complaints: 56%
(Baggage handlers). subjective previous and Current back symptoms positively
present back symptoms. Prevalence of correlated with height, age, and length
Clinical orthopaedic present back of experience in transport work.
examination administered to symptoms: 66%
134 workers to detect Among workers with present
objective findings. Prevalence of symptoms, symptoms occurred most
objective back frequently during lifting of loads (75%)
Exposure: Data on work findings at and while in bended body positions
experience in the present examination: 70% (61%). Changing body position (71%)
occupation was collected. and absence of work for one or more
No other exposure data days were relieving factors for back
collected. symptoms.
Comparison of interview and clinical

exam results show interview to be a
suitable screening method for clinical
back pain (sensitivity=86%,
specificity=31%).
Significant association between

length of transport work and back
symptoms (p=0.035) adjusted for age.
No heterogeneity with regard to

exposure.
(Continued)
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MSD prevalence
Videman et al. Cross- 562 nurses and 318 Outcome: Based on results 85% of aides had $ 79% of $ one life- Participation rate: 88% nurses; 85%
1984 sectional nursing aides in from a pre-tested one life-time nurses had time nurses aides.
Finland, all of them questionnaire and from episode of LBP and experienced episode of
females. health information obtained their point $ one life- LBP: 1.1 1.01-1.14 Workers with back pain were
employed in heavy jobs on average 1
from the local Pension prevalence was time episode year longer than those with no
Registers that were used 50% for LBP. of LBP; point previous LBP.
to identify nurses who had prevalence
been pensioned due to ill was 41% for Musculoskeletal disorders as a cause
health during a 4-year LBP of disability increased with age; the
period immediately 30-years risk for 25-years old aides
preceding the mailing of the Sciatica: 43% life- Sciatica: 38% was 3.4 times greater than for the
nurses; similar results for sciatica
questionnaire. time prevalence. life-time with a risk of 4.5 times greater for the
prevalence aides than nurses.
Exposure: Based on self-
assessments from data Aides had twice The prevalence of LBP and sciatic
obtained using a mailed the lifting, bending symptoms in both nurses and in aides
questionnaire that included and rotation. are high and similar to the results
found in Britain.
nine questions on physical
loading factors at work and Physical workload related to patient
seven questions on work handling was mainly responsible for
history and occupation. the differences in LBP and sciatica
rates between the aides and nurses.
Jobs were reclassified as The finding was most evident under
heavy, intermediate, and the age of 30 years.
light based on results of Non work-related factors, such as
questionnaire items dealing childbirth, also contributed to the
with workload. adverse back conditions.
Study lacks a good unexposed
population since both nurses and
aides were exposed to varying
degrees of risk factors for LBP and
sciatica.
Workers with LBP were in heavier
jobs for longer time than those without
LBP.
(Continued)
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MSD prevalence
Videman et al. Cross- From a Finnish Outcome: Objective 54% of heavy 10% of Heavy vs. Participation rate: Not reported.
1990 sectional workforce of 86 radiologically and workers had LBP sedentary Mixed:
males who had discography-based often, and 36% had workers had 2.7 1.1-6.2 Strength: First study linking pathologic
worked in four pathologic criteria from the sciatica LBP often, and data with history of occupation and
distinct occupational cadaver spines of the 19% had Driving vs. physical loading factors.
groups: Sedentary, study population. Degree of sciatica Mixed:
Mixed, Driving, and degeneration was outcome 2.3 0.8-6.2 Weakness: Do not know the temporal
Heavy. Criteria for measure, i.e., annular 50% of drivers had 29% of mixed pattern in development of the
inclusion: Deceased ruptures. Information on LBP often, and group had LBP Sciatica: pathologic changes.
below the age of 64 symptoms was obtained 29% of them had often, and NS
who had been from family members. sciatica 10% had Possible selection bias due to potential
employed before sciatica differential rates between work
death and the Exposure: Type of work, Heavy physical groups in leaving jobs because of
subjects family able based on work history load vs. not: degenerative diseases.
to provide working reports from family; OR=2.8
information. classification of work Two important findings: Sedentary or
based on heaviness, Sedentary vs. not: heavy work contribute to the
Exclusion criteria driving, and sedentary jobs. OR=24.6 development of pathologic findings in
were long illnesses Classification based on (symmetric disc spine. Severity of back pain was
or a diseased state, physically heaviest degeneration) related to the heaviness of work, i.e.,
such as cancer or occupation held for $ 5 work factors responsible for
infectious disease. years. development of pathologic changes
and for the production of pain.
Back pain more common with

physically more loading occupations;
p<0.001. Similar but weaker trend
between loading and sciatica; p=0.03.
General: p<0.01 between groups for

back pain; and p<0.07 for sciatica.
Relationships were observed

between report of symptoms and disc
pathology; also, exposures and disc
pathology.
(Continued)
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MSD prevalence
Walsh et al. Cross- A postal Outcome: Self-reported Lifetime incidence Participation rate: 436 questionnaires
1989 sectional questionnaire was low-back pain, by of LBP was 63%. were returned, giving an overall
sent to a random interview. response rate of 81%.
sample of 267 males Recent Occup. The association with use of vibrating
and 268 females in Exposure: Standing or Activity: machinery among females (repetitive
the age range of 20 walking for > 2 hr; sitting Males risk=5.7) was based on only one
to 70 who lived in for > 2 hr; driving a car or Driving>4hr/d RR=1.7 1.0-2.9 exposed case.
Whitchurch, van for > 4 hr; driving a Lifting 25kg RR=2.0 1.3-3.1 Cases of low-back pain were
England. truck, tractor or digger; Females ascertained solely on the basis of
lifting or moving weights of Lifting 25kg RR=2.0 1.1-3.7 reported symptoms.
Four hundred, thirty- 25kg or more by hand; or Successive birth cohorts reported the
six questionnaires using hand held vibrating Lifetime Occup. development of low-back pain at any
were returned, machinery were the Activity: given age with increasing frequency.
giving an overall exposures of interest. Males Driving a car for >4 hr a day was
response rate of Lifting 25kg RR=1.5 1.0-2.4 associated with low-back pain in
81%. Lifetime occupational Females males but not with low-back pain in
history obtained by Sit >2hr/d RR=1.7 1.1-2.6 females.
interview. Vib. machine RR=5.7 1.1-29.3 Authors believe the data give strong
support for a role of regular heavy
Risk of unremitting lifting in the etiology of low-back pain
LBP: and add weight to the evidence
Males implicating occupational driving as a
risk factor. At the same time,
Lifting 25kg RR=5.3 1.3-20.9 however, they suggest that such
Females activities account for only a small
Lifting 25kg RR=2.9 0.8-10.2 proportion of the total burden of low-
back pain in the general population.
Authors estimates of the fraction of
disease attributable to heavy lifting
and car driving are 14 and 4%,
respectively, leaving a substantial
proportion of cases unexplained.
Authors attempted to recreate a
retrospective cohort design; asked
participants to remember dates and
jobs and LBP. Questionable recall for
temporal relationships.
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CHAPTER 7
Work-Related Musculoskeletal Disorders
and Psychosocial Factors
SUMMARY
While the etiologic mechanisms are poorly understood, there is increasing evidence that psychosocial
factors related to the job and work environment play a role in the development of work-related
musculoskeletal disorders (MSDs) of the upper extremity and back. Though the findings of the studies
reviewed are not entirely consistent, they suggest that perceptions of intensified workload, monotonous
work, limited job control, low job clarity, and low social support are associated with various work-related
musculoskeletal disorders.
As some of these factors are seemingly unrelated to physical demands, and a number of studies have
found associations even after adjusting for physical demands, the effects of these factors on MSDs may be,
in part or entirely, independent of physical factors. It is also evident that these associations are not limited
to particular types of jobs (e.g., video display terminal work [VDT]) or work environments (e.g., offices) but,
rather, seem to be found in a variety of work situations. This seems to suggest that psychosocial factors
may represent generalized risk factors for work-related MSDs. These factors, while statistically significant
in some studies, generally have only modest strength.
At present, two of the difficulties in determining the relative importance of the physical and psychosocial
factors are: (1) psychosocial factors are usually measured at the individual level, while physical factors are
more often measured at the group (e.g., job or task) level and often by methods with limited precision or
accuracy and (2) objective measures" of aspects of the psychosocial work environment are difficult to
develop and are rarely used, while objective methods to measure the physical environment are more readily
available. Until we can measure most workplace and individual variables with more comparable techniques,
it will be hard to determine precisely their relative importance.
INTRODUCTION
There is considerable confusion regarding the
contribution of psychosocial factors to that fall within three separate domains:
musculoskeletal illness and injury. Because of (1) factors associated with the job and work
this, it is examined in this separate section of the environment, (2) factors associated with the
report. Unlike the more finite (and generally extra-work environment, and
more familiar) range of physical factors (e.g., (3) characteristics of the individual worker.
force, repetition, and posture), the concept of Interactions among factors within each of these
psychosocial factors includes a vast array of domains constitute what is referred to as a
conditions. Indeed, the term psychosocial is stress process, the results of which are
commonly used in the occupational health arena thought to impact upon both health status and
as a catchall term job performance [Bongers and deWinter 1992;
to describe a very large number of factors ILO 1986; Sauter and Swanson 1996; WHO
1989].
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Included in the domain of job and work conditions. In particular, both personal and
environment are a host of conditions, situational characteristics may lead to
sometimes referred to as work organization differences in the way individuals exposed to
factors, which include various aspects of job the same job and work environment perceive
content (e.g., workload, repetitiveness, job and/or react to the situation [Hurrell and
control, mental demands, job clarity, etc.); Murphy 1992]. Recent theoretical models of
organizational characteristics (e.g., tall versus the relationship between psychosocial factors
flat organizational structures, communications and MSDs [Bongers et al. 1993; Sauter and
issues); interpersonal relationships at work Swanson 1996] clearly reflect the complexity
(e.g., supervisor-employee relationships, social and multifactorial nature of the problem.
support); temporal aspects of the work and
task (e.g., cycle time and shift work); financial In general, four plausible types of explanations
and economic aspects (e.g., pay, benefit, and have been suggested to account for
equity issues); community aspects (e.g., associations between work-related
occupational prestige and status). These work psychosocial factors and MSDs [Bergqvist
and job environment factors are often thought 1984; Bongers et al. 1993; Bernard et al.
of as demands, or risk factors, that may pose 1993; Sauter and Swanson 1996; Sauter et al.
a threat to health [Hurrell and Murphy 1992]. 1983; Ursin et al. 1988]. First, psychosocial
Extra-work environment parameters typically demands may produce increased muscle
include factors associated with demands arising tension and exacerbate task-related
from roles outside of work, such as biomechanical strain. Second, psychosocial
responsibilities associated with a parent, demands may affect awareness and reporting of
spouse, or children. Finally, individual worker musculoskeletal symptoms, and/or perceptions
factors are generally of three types [Payne of their cause. Within this second explanation
1988] corresponding to: genetic factors (e.g., may fall the perverse incentive view, in which
gender and intelligence); acquired aspects (e.g., societies may provide workers with systems
social class, culture, educational status); and (such as workers' compensation) that may lead
dispositional factors (e.g., personality traits, and to overreporting of MSD symptoms [Frank et
characteristics and attitudes such as life and job al. 1995]. Third, initial episodes of pain based
satisfaction). on a physical insult may trigger a chronic
nervous system dysfunction, physiological as
PSYCHOSOCIAL PATHWAYS well as psychological, which perpetuates a
The purpose of this discussion is to summarize chronic pain process. Finally, in some work
research evidence linking work-related situations, changes in psychosocial demands
psychosocial factors, as described above, to may be associated with changes in physical
MSDs of the neck, shoulder, elbow, demands and biomechanical stresses, and thus
hand/wrist, and back. It should be recognized associations between psychosocial demands
at the outset, however, that the linkages and MSDs occur through either a causal or
between work-related psychosocial factors and effect-modifying relationship.
health outcomes of all varieties are often
complex and influenced by a multitude of
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The research evidence reviewed in the UPPER-EXTREMITY DISORDERS

following discussion is organized into two (NECK, SHOULDER, ELBOW, HAND
separate sections. The first section includes AND WRIST)
studies of disorders of the neck, shoulder,
Individual and Extra-Work
elbow, hand and wrist which are discussed
Environment Factors
under the rubric of upper extremity disorders.
This convention was adopted because many of A variety of psychosocial factors associated
the studies utilize measures which combine with both the individual worker and extra-work
symptoms associated with several upper environment have been linked to upper
extremity body areas (e.g., neck and shoulder), extremity MSDs [Sauter and Swanson 1996;
and it is therefore not possible in reviewing Bongers and deWinter 1992; Bongers et al.
these studies to isolate the effects of the 1993]. These factors have included such
psychosocial variables under consideration on conditions as depression and anxiety [Helliwell
more specific areas. The second section et al. 1992], symptoms of psychological
examines studies of back disorders. distress [Leino 1989], and home problems
Associations reported in this review are [Karasek et al. 1987]. The connection between
statistically significant in nearly all cases (at the factors of this nature and the job and work
p<0.05 level and frequently also at the p<0.01 environment, however, is unclear. While
level). Where possible, odds ratios (ORs) are affective problems (such as anxiety and
also reported. depression) and symptoms of distress may
certainly be a consequence of the work
The studies examined in this review are situation, they may also be causally related to
summarized in Tables 7-1 and 7-2. In non-work circumstances only. Likewise, while
interpreting the studies reviewed, it is necessary extra-work environment conditions (e.g.,
to be aware that, in general, researchers have home problems") may be exacerbated by the
not used standardized methods for assessing work situation (e.g., shift work) their work-
psychosocial factors in relationship to MSDs. relatedness remains unclear. Because of the
Thus, individual psychosocial factors assessed uncertainty regarding the work-relatedness of
by investigators vary from study to study. these individual and extra-work environment
Moreover, even when work-related factors (and because discussions can be found
psychosocial factors (e.g., workload , job in other sources), only the individual
control, social support, job satisfaction, etc.) psychosocial factor, job dissatisfaction, is
included by various investigators are the same examined here.
or similar, they may be measured by different
Job Dissatisfaction
methods and different kinds of scales which can
vary in psychometric quality. These A number of studies suggest associations
methodological limitations complicate the between low levels of satisfaction with work
process of drawing definitive conclusions and upper extremity musculoskeletal symptoms
regarding the literature as a whole and when and disorders. Tola et al. [1988], for example,
comparing results between studies, one must in a study of 1,174 machine operators, 1,054
take these differences into account. carpenters, and 1,013 office workers, found an
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association (OR 1.2) between job Positive associations with upper extremity
dissatisfaction and neck and shoulder physical disorders have also been found in studies using
findings or symptoms, after adjusting for measures of perceived work pressure and
confounders. Likewise, Hopkins [1990] workload. High levels of perceived workload,
reported a positive association between job for example, were found to be positively
dissatisfaction and musculoskeletal symptoms. associated with musculoskeletal symptoms in
However, low job satisfaction was not found to the Pot et al. [1987] and Theorell et al. [1991]
predict neck and shoulder problems one year studies (which adjusted for physical demands
later in a study of 154 Finnish workers [Viikari- such as lifting and awkward postures) reported
Juntura et al. 1991a]. Likewise, in a study of above. Kvarnstrm and Halden [1983], in a
273 nursing aids employed in a geriatric case control study of 112 cases and 112 age-
hospital [Dehlin and Berg 1977] job satisfaction and sex-matched controls from an engineering
was found to be unrelated to reports of ever firm, found sick leave due to fatigue or shoulder
having cervical pain. muscle soreness to be positively associated
with high perceived workload. Karasek et al.
Job and Work Environment Factors [1987], in a study of 8,700 full-time members
Intensified Workload
of the Swedish white collar labor union
federation, found perceived workload to be
One of the factors most consistently associated
positively associated with musculoskeletal
with upper extremity MSDs has been the
aches as measured by a combination of several
perception of an intensified workload, as
questions (OR 1.1 for males, 1.2 for females).
measured by indices of perceived time
Likewise, Sauter et al. [1983], in a study of
pressure, workload, work pressure, and
248 VDT users, found perceived workload and
workload variability. Pot et al. [1987], for
demands for attention to be associated with
example, in a cross-sectional study of 222
neck, back, and shoulder discomfort after
VDT operators, found high levels of perceived
adjusting for a wide variety of variables
time pressure associated with the reporting of
denoting physical demands. Bernard et al.
upper extremity musculoskeletal complaints.
[1993], in a study of 1,050 newspaper
Kompier [1988] found perceived time pressure
employees, found perceived increased
to be associated with upper extremity
workload demands (increased time working
complaints (in the preceding 12 months) among
under deadline and increased job pressure) to
some 158 male bus drivers. Likewise, Takala
be positively associated with neck, shoulder,
et al. [1991], in a longitudinal study of 351
and hand-wrist symptoms. Similarly, Hales et
female bank cashiers, reported a positive
al. [1994], in a study of 553
association between perceived time pressure
telecommunications workers, found increased
and symptoms of the neck and shoulder after
work pressure to be associated with neck (OR
adjusting for postural load. Theorell et al.
1.2) and upper extremity
[1991], however, in a sample of some 206
(OR 1.1) disorders, as defined by physical
workers from six occupations, found that
examination and questionnaire. Ryan and
perceived time pressure was not significantly
Bampton [1988], using a total sample of 143
correlated with neck or shoulder symptoms.
data processors, compared 41 individuals
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reporting a number of neck symptoms to 28 that self-reports of being bored most of the
reporting very few neck symptoms (middle time were highly (OR 7.7) associated with
group left out) and found a positive association neck symptoms. Likewise, Linton [1990], in a
between symptom reports and reports of study of approximately 22,200 Swedish
having to push themselves (OR 3.9). Ekberg workers undergoing a screening examination by
et al. [1994] compared 109 workers who the occupational health care service, found that
consulted a physician for new musculoskeletal monotonous work was positively associated
neck and shoulder disorders with 637 controls with neck/shoulder pain (OR 2.3) during the
and found a positive association (OR 3.5) with preceding year. Ekberg et al. [1994], in the
rushed work pace. Houtman et al. [1994], in a study described above, found an association
representative sample of 5,865 workers in the between low quality work (lacking stimulation
Netherlands, found reported high work pace and variation) and neck and shoulder problems
associated with muscle or joint symptoms (OR (OR 2.6). Similarly, Kvarnstrm and Halden
1.3) after adjusting for physical stressors and [1983] in the case control study described
modifying personal characteristics. However, above, found monotonous work to be
Dehlin and Berg [1977] in the study described associated with sick leave due to fatigue or
above, found no relationship between reports tenderness in the shoulder muscles. Finally,
of high perceived physical and psychological Hopkins [1990] in a study of around 280
demands and reports of ever having pain in the clerical workers found high levels of boredom
cervical region. Finally, Houtman et al. [1994], to be associated with musculoskeletal
in a representative sample of 5,865 workers in symptoms (in any part of the body) during
the Netherlands, found reported high work work hours.
pace associated with muscle or joint symptoms
(OR 1.29) after adjusting for physical stressors Job Control
and modifying personal characteristics. Numerous studies have reported positive
associations between limited job control or
Variability in workload (surges in workload) autonomy at work and upper extremity
has also been linked to upper extremity problems. These include neck symptoms [Ryan
disorders. The studies by Hales et al. [1994] of and Bamptom 1988, OR 3.9; Hales et al.
553 telecommunication workers and Hoekstra 1994, OR 1.6], neck/back/shoulder symptoms
et al. [1994] of some 108 teleservice [Sauter et al. 1983; Theorell et al. 1991],
representatives, found perceived workload musculoskeletal aches [Karasek et al. 1987],
variability to be associated with elbow (OR and muscle/joint symptoms [Hopkins 1990;
1.2) and neck (OR 1.2) disorders, but not with Houtman et al. 1994]. The study by Pot et al.
shoulder or hand disorders. [1987], however, failed to support this
relationship.
Monotonous Work
Monotonous work has been positively linked to Job Clarity
the prevalence of upper extremity symptoms in A number of studies, including those of Ryan
various studies. In a study of 143 data and Bamptom [1988], Karasek et al. [1987],
processors, Ryan and Bamptom [1988] found
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and Ekberg et al. [1994], have shown positive Extremities

associations between reports of role ambiguity Overall, the epidemiologic studies of upper
(uncertainty about job expectations) and upper extremity disorders suggest that certain
extremity disorders (particularly neck psychosocial factors (including intensified
disorders). Similarly, uncertainty regarding job workload, monotonous work, and low levels of
future was found to be predictive of neck and social support) have a positive association with
shoulder discomfort [Sauter et al. 1983] and these disorders. Lack of control over the job
elbow, neck, and hand/wrist symptoms [Hales and job dissatisfaction also appear to be
et al. 1994]. positively associated with upper extremity
MSDs, although the data are not as supportive.
Social Support
Limited social support from supervisors and The evidence for the relationship between
coworkers has been found to be positively psychosocial factors and upper extremity
associated with a variety of upper extremity disorders appears to be stronger for
symptoms. The studies by Pot et al. [1987], neck/shoulder disorders or musculoskeletal
Kompier [1988], Hopkins [1990], Sauter et al. symptoms in general than for hand/wrist
[1983], and Hales et al. [1994], all support a disorders. This stronger association for
positive association. Linton [1990] reported a neck/shoulder disorders may be due to the
positive association between neck symptoms following reasons: the large number of studies
and limited support from supervisors. Ryan and performed in the Nordic countries which have
Bampton [1988] reported an effect of limited focused more on the neck/shoulder MSD
support from coworkers (OR 6.7), but not health outcome than a hand/wrist outcome;
supervisors, on neck symptoms, while many of the neck/shoulder studies included
Kvarnstrm and Hagberg [1983] reported an numerous psychosocial variables in their
effect of limited support from supervisors but models, whereas studies of hand/wrist MSDs
not coworkers on sick leave due to shoulder have not, as a rule, included as extensive
muscle symptoms. Dehlin and Berg [1977], psychosocial variable testing (therefore the
however, found no effect of social support on variables are absent from the risk factor
neck/shoulder symptoms, while Theorell et al. models); and the fact that most of the studies
[1991] found no effect of social support at with extensive psychosocial scales were in
work on neck and shoulder symptoms or office settings, where physical factors may be
symptoms of the other joints (with or without less important than psychosocial factors in their
adjustment for physical load). Likewise, relationship with MSDs. This finding can be
Karasek et al. [1987] found no significant contrasted with studies in heavy industrial
association between musculoskeletal aches and settings, where higher exposure to physical
social support at work. factors may have
Summary and Conclusions for Upper
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played a greater role than psychosocial factors While there are a number of prospective
in the development of MSDs. Also, studies of low back pain and individual physical
pathophysiologic processes resulting from factors, there appear to be only a few
adverse psychosocial and work organization prospective studies that incorporate individual
factors may exert a greater effect on the and extra-work environment psychosocial
neck/shoulder musculature to produce factors. Bigos et al. [1991b] defined, in a 4-
increased muscle tension and strain than on the year study of 3,020 hourly wage earners at an
hand/wrist region. aircraft manufacturing plant, an outcome as
reporting a back pain complaint to the company
BACK DISORDERS medical department, filing a back-related
incident report, or filing an industrial insurance
Individual and Extra-Work
claim. The psychosocial assessment included
Environment Factors
personality traits, as measured by the
As with upper extremity disorders, a host of Minnesota Multiphasic Personality Inventory
psychosocial factors associated with the (MMPI), and limited information on family
individual worker (e.g., personality and support, health locus of control, and work
psychological status) and extra-work social support. One question about enjoyment
environment (e.g., living alone) have been of tasks in the job was also included. Of the 37
linked to back pain and disability [Bongers et variables used to evaluate the role of social
al. 1993]. As the work-relatedness of these support, health locus of control, and personality
factors is unclear and because they have been traits, three were found to be significant in a
examined by others (e.g., Bongers [1993]), multivariate analysis. They were Scale 3 of the
with the exception of job dissatisfaction MMPI [tendencies towards somatic complaints
discussed above, they will not be extensively or denial of emotional distress (relative risk
reviewed in this report. In general, these studies [RR]=1.4), dissatisfaction with work (RR=1.7),
show clear associations between measures of and prior back pain (RR=1.7)]. Although
psychological distress or dysfunction and self- significant, these variables explained only a
reported back pain. However, the temporal small fraction of the back pain reports in this
relationship between psychological factors and population. The number of back pain reports
musculoskeletal symptoms/ disorders remains was three times higher in the group with the
unclear. One possibility is that psychological highest scores on these three variables
distress is simply a consequence of chronic low compared with the group with the lowest
back pain, with no etiologic role in the scores, although only 9% of the work force
development of the disorder. Alternatively, it is was in the highest risk group. Because this
possible that psychological factors may have study focused on the reporting of back pain
some etiologic role in the transition from an complaint and not the actual development of
employee with a history of back pain to the back pain, it would be a mistake to generalize
status of an unemployed patient with chronic the results to workers developing back pain.
back pain, due to fear of re-injury, or other This study suggests
factors which would make it impossible to
perform the job [Feyer et al. 1992].
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that individual premorbid personality traits only The cross-sectional study by Dehlin and Berg
explain a small fraction of work-related lower [1977] of nursing aids described earlier found
back problems. an association between dissatisfaction and self-
reported back symptoms. However, this study
Job Dissatisfaction did not adjust for confounders. Likewise,
Job dissatisfaction has been associated with Magora [1973] in a mailed survey study of
back disorders in both longitudinal and cross- Israeli workers in 8 occupational categories
sectional investigations. Bergenudd and Nilsson found job satisfaction to be associated with
[1988], studying some 575 residents of Malmo reports of sick leave due to low back pain. This
for over 19 years, found job dissatisfaction to study also did not adjust for potential
be associated with self-reported back pain. As confounders. Svensson and Anderson [1989],
described above, Bigos et al. [1991b] found a in a cross-sectional study of 1,746 Swedish
positive association between job dissatisfaction residents, found an association after adjustment.
and workers filing compensation claims for However, in a cross-sectional study by strand
back injury. Here, subjects who stated that they [1987] of 391 male Swedish paper company
hardly ever enjoyed their job tasks were 2.5 workers (clerks and manual workers), no
times more likely to report a back injury than association was found between dissatisfaction
those who almost always enjoyed their job and back disorders, as assessed by symptoms
tasks. However, as Frank et al. [1995] point and physical examination after confounder
out, some reviewers have argued that the adjustment.
airplane manufacturing jobs with the highest
levels of dissatisfaction were also the most Job and Work Environment Factors
physically demanding. Frank et al. [1995] also Intensified Workload
noted that, unfortunately, the extent of the
A number of studies have reported associations
interaction is difficult to assess because of the
between perceptions of intensified workload, as
limited measurement of workplace
measured by reports of time pressure and high
biomechanical exposures in the Bigos et al.
work pace, and self-reports of back pain.
studies [1986a,b; 1991a,b]. While
Helivaara
psychosocial and psychological factors were
et al. [1991] in a study of approximately 5,600
assessed at the individual level, workplace
Finns, found a composite measure (containing
biomechanical factors were assessed only at
items on perceived time pressure at work,
the group level. Biering-Sorensen et al. [1989],
monotony, and fear of mistakes) to be
in a one-year follow-up mail survey study of
associated (OR 2.0) with back disorders
some 928 inhabitants of Denmark (which
(defined by interview and physical examination)
adjusted for confounders such as previous back
after adjusting for potential confounders,
pain), also found no association of back pain
including physical load and previous back pain.
with job dissatisfaction. Because information
Lundberg et al. [1989] found perceived time
was limited to the use of mailed survey
pressure to be associated with perceived back
questionnaires, no workplace biomechanical
load among 20 workers on a Swedish
factors were measured in this study either.
assembly line. In a similar vein, Houtman et al.
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[1994], in the study of 5,865 Dutch workers monotonous work is often work which is also
across all occupations reported above, found either short-cycled or involves a high static
an association (OR 1.21) between reporting (postural) load.
high work pace and self-reported back pain
(but not chronic back pain problems, defined as Job Control
back pain for more than three months or at In the study of teleservice operators cited
least three times in the study period) (OR above, Hoekstra et al. [1994], after controlling
1.2). Magora [1973], in the study of Israeli for a number of individual and work-related
workers described above, found high levels of factors, found perceived job control at work to
concentration to be associated with reports of be inversely associated with back disorders
sick leave due to low back pain (OR 2.9). (OR 0.6), that is, the less perceived job control
However, strand [1987], found no at work, the higher the odds of back disorders.
association between hustling and nerve Likewise, as noted above, Sauter et al. [1983]
wracking work and back pain in male paper found that low job control was related to neck,
company workers. back, and shoulder discomfort.
Monotony Social Support

Several studies described above [Helivaara et Bigos et al. [1991b] found a significant
al. 1991; Houtman et al. 1994] have reported univariate relationship between limited social
associations between perceived monotony and support at work and back trouble. However,
reports of back complaints. Svensson and this association was found to be nonsignificant
Anderson [1983], in a study of 940 male by the investigators when included in a
residents of Goteborg, Sweden, between the multivariate analysis.
ages of 40 and 47, similarly found monotonous
work (rated absolutely or unacceptably Summary and Conclusions for
boring) to be associated with back complaints. Back Disorders
This relationship remained after adjusting for In general, the studies reviewed suggest an
several physical factors. However, Svensson association between back disorders and
and Anderson [1989] found no relationship perceptions of intensified workload as
between monotony and back pain complaints measured by indices of both perceived time
among Swedish women in a multivariate pressure and workload. Despite the
analysis which included measures of job and considerable differences in the types of
task satisfaction. Similarly, in the Houtman et al. methods used to assess both the independent
[1994] study, controlling for a combination of and dependent variables, four of the five studies
physical stressors (dangerous work, heavy that explicitly included measures of intensified
physical load, noise at work, dirty work, and workload found significant associations. It is
bad smell at work) reduced the magnitude of also noteworthy that all four of these studies
the relationship (for back complaints, the OR attempted to control or adjust for potential
decreased from 3.90 to 3.46.) The authors covariates. Five of the seven studies that assess
suggest that this may be because job dissatisfaction
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also found positive associations with back of these factors on MSDs may be, in part or
disorders. While this evidence is clearly entirely, independent of physical factors. It is
suggestive, Biering-Sorensen et al. [1989] also evident that these associations are not
found no association in a large-scale limited to particular types of jobs (e.g., VDT
one-year follow-up study; while strand work) or work environments (e.g., offices) but,
[1987] likewise found no evidence of an rather, seem to be found in a variety of work
association among 391 paper workers. Limited situations. This observation seems to suggest
support for an association between back that psychosocial factors may represent
disorders and low job control is also evident, generalized risk factors for work-related
while the evidence for a relationship between MSDs. These factors, while statistically
monotonous work and back disorders is mixed. significant in some studies, generally have only
Only one study examined the relationship modest strength.
between social support and back disorders and
found only weak evidence for an association. At present, two of the difficulties in determining
the relative importance of the physical and
Overall Conclusions psychosocial factors are the following: (1)
While the etiologic mechanisms are poorly psychosocial factors are usually measured at
understood, there is increasing evidence that the individual level, while physical factors are
psychosocial factors related to the job and more often measured at the group (e.g., job or
work environment play a role in the task) level and often by methods with limited
development of work-related MSDs of the precision or accuracy, and (2) objective
upper extremity and back. Though the findings measures of aspects of the psychosocial work
of the studies reviewed are not entirely environment are difficult to develop and are
consistent, they suggest that perceptions of rarely used, while objective methods to
intensified workload, monotonous work, limited measure the physical environment are more
job control, low job clarity, and low social readily available. Until we can measure most
support are associated with various work- workplace and individual variables with more
related MSDs. As some of these factors are comparable techniques, it will be hard to
seemingly unrelated to physical demands, and a determine precisely their relative importance in
number of studies have found associations even the causation of MSDs.
after adjusting for physical demands, the effects
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Table 71. Summary of studies examining psychosocial factors

and upper extremity disorders (neck, shoulder, elbow, hand, and wrist)
Methods Associations with UE outcomes
Worker
group Psychosocial MSD Covariate Low Low Low
(particip. factor outcome adjust- Job/task Int. Mono. job job social
Study rate) Design assessment assessment ments dissat. wkld. work control clarity supp.
Bernard et 1,050 Cross- Self-report MSD case + +

al. 1993 newspaper sectional questionnaire definition based
workers with job stress on
(93%) scales questionnaire
Dehlin and 233 nursing Cross- Self-report Interviews o o o

Berg 1977 aides (85%) sectional questionnaire pain/ache
7 scales symptoms
Ekberg et al. 109 Cross- Self-report MD consults for + +

1994 workers vs. sectional modified Nordic MSD disorders
637 controls (case- questionnaire
control)
Hales et al. 553 Cross- Self-report Disorders Controlled + + +

1994 telecom- sectional questionnaire based on for extra
munications with job stress symptom job factors
workers scales questionnaire
and MD exam
Hoekstra et 108 Cross- Self-report job MSD case +

al. 1994 teleservice sectional stress definition based
workers questionnaire on self-report
(95%) questionnaire
Hopkins 291 Cross- Self-report Questionnaire + + + +

1990 keyboard sectional questionnaire symptoms
operators items from habits
and other of living
clerical questionnaire
groups
See footnotes at end of table. (Continued)
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Table 71(Continued). Summary of studies examining psychosocial factors

Worker
Houtman et 5,865 Cross- Self-report work- Symptoms Physical + +

al. 1994 workers sectional living questionnaire stressors
general questionnaire
population personal
character-
istics
Karasek et 8,700 white Cross- Self-report Questionnaire + + + +

al. 1987 collar labor sectional questionnaire musculoskeletal
union (random aches
members sample)
(87%)
Kompier 158 male Cross- Self-report Self report + +

1988 bus drivers sectional questionnaire questionnaire
(73%) complaints and
sick leave
Kvarnstrom 224 Cross- Structured Disorders from + + +/o

and Halden fabrication sectional interview medical and sick
1983 workers (case- questionnaire absence
control) records
Linton 1990 22,200 Cross- Self-report work Pain + +

workers sectional environment
general questionnaire
population and habits of
living
questionnaire
Pot et al. 222 VDT Cross- Structured Complaints +/+ o +

1987 operators sectional interview structured
questionnaire interview
7-12
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Table 71(Continued). Summary of studies examining psychosocial factors

Worker
Ryan and 143 data Cross- Self-report Symptoms + + + + +/o

Bampton processors sectional questionnaire based on MD
1988 (high vs. items from work interview and
low environment exam
symptoms) scale
Sauter et al. 248 VDT Cross- Self-report Questionnaire Physical + + + +

1983 users and sectional questionnaire discomfort work
85 nonwork scale demands
users (90%) environment (adj.)
scale items
Takala et al. 351 bank Longi- Self-report Questionnaire Postural +

1991 cashiers tudinal questionnaire muscle load (adj.)
symptoms
Theorell et 207 Cross- Self-report Questionnaire Physical +/o + o

al. 1991 workers in 6 sectional questionnaire muscle tension load (adj.)
occupations symptoms
Tola et al. 1,174 Cross- Mailed Symptoms in o

1988 machinists; sectional questionnaire last 12 months;
1,034 worker questionnaire
carpenters; characteristics and interview
1,013 office
workers
(67% to
76%)
+ = Significant association found.

o = No significant association found.
+/+ = Two different measures of factor (e.g., time pressure and workload) found significant.
+/o = Mixed results (on factor significantly associated; second factor not significantly associated).
7-13
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Table 72. Summary of studies examining psychosocial factors and back disorders
Methods Associations with back disorders
Worker group Psychosocial MSD Covariate Low Low

(participation factor outcome adjust- Job Int. Mono. job social
Study rate) Design assessment assessment ments dissat. wkld. work control supp.
strand 391 workers in Cross- Questionnaire Interview and MD o o

1987 paper-pulp sectional questions on examback pain
industry work conditions abnormalities
Bergenudd 575 55-year-old Longi- Interview and Interview reports +

and Nilsson city residents tudinal mailed of back pain
1988 (96%) questionnaire
Biering- 928 persons Longi- Mail Questionnaire o

Sorenson et general tudinal questionnaire back pain in last
al. 1989 population 12 months
(82%)
Bigos et al. 3,020 male Longi- Questionnaire Back problems Control for + o
1991b aircraft plant tudinal Personality medical reports, prior back
employees Inventory (MMPI), insurance claims problems
(54% with all other questions
data)
Dehlin and 233 nursing Cross- Questionnaire Interview +

Berg 1977 aides (85%) sectional 7 scales, reported pain/ache
52 items symptoms
Helivaraa 5,600 Cross- Questionnaire MD exam and Physical Combined

et al. 1987 workers sectional scale assessing interviewback load, prior + +
general combined hurried disorders back
population work, problems
(92%) monotonous
work, tight work
schedules
7-14
7-12
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Table 72 (Continued). Summary of studies examining psychosocial factor and back disorders

Hoekstra et 108 teleservice Cross- Job stress MSD case Individual +

al. 1994 workers (95%) sectional questionnaire definition based on work
questionnaire data factors
Houtman et 5,865 Cross- Questionnaire Questionnaire Physical + +

al. 1994 workers sectional work living symptoms stressors;
general questionnaire personal
population survey character-
istics
Lundberg et 20 male Cross- Ratings of time Back load ratings +

al. 1989 assembly line sectional pressure during during 2-hr work
workers 2-hr work period period
Magora 3,316 workers Cross- Questionnaire Questionnaire Analyses + +

1973 in 8 sectional ratings of job reports of low- stratified by
occupations (low pain aspects and back pain and sick occupation
vs. satisfaction leave due to low-
controls) back pain
Sauter et al. 248 VDT users; Cross- Questionnaire Questionnaire Physical +

1983 85 non-users sectional work reports of work
(90%) environment discomfort demands
scale survey
Svensson 940 males Cross- Questionnaire Interview report of Physical +

and general sectional perceptions of back pain work
Anderson population stress, boredom demands
1983 life and job
satisfaction
7-15
7-13
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Table 72 (Continued). Summary of studies examining psychosocial factor and back disorders

Svensson 1,746 females Cross- Questionnaire Interview Physical + o

and ages 3864 sectional items on job and reports of back workload
Anderson general task satisfaction pain
1989 population
+ = Significant association found.

o = No significant association found.
7-16
7-14
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REFERENCES
aras A [1994]. Relationship between trape- manufacturing assembly line workers and a
zius load and the incidence of musculoskele-tal cross-sectional factor-control study on
illness in the neck and shoulder. Int J Ind occupational cervicobrachial disorders. Jpn J
Ergonomics 14(4):341348. Ind Health 30:312.
Abenhaim L, Suissa S [1988]. Economic scope Andersen JH, Gaardboe O [1993a]. Muscu-
of occupationally-induced back pain. Institute loskeletal disorders of the neck and upper limb
de recherche en sante et en securite du travail among sewing machine operators: a clinical
du Quebec. Quebec, Canada: IRSST, investigation. Am J Ind Med 24(6): 689700.
Research Summary No. 66.
Andersen JH, Gaardboe O [1993b]. Preva-
AFL-CIO [1997]. Stop the pain. Washing-ton, lence of persistent neck and upper limb pain in
a historical cohort of sewing machine
DC: AFL-CIO.
operators. Am J Ind Med 24:677687.
Alexander and Alexander [1996]. 1996 U.S.
Andersson GBJ [1981]. Epidemiologic aspects
risk management survey. New York, NY: of low back pain in industry. Spine 6:5360.
Alexander and Alexander, Inc.
Andersson GBJ [1996]. The epidemiology of
Allender E [1974]. Prevalence, incidence, and spinal disorders. In: Frymoyer JW, ed. The
remission rates of some common rheumatic adult spine: principles and practice. 2nd ed.
diseases or syndromes. Scand J Rheumatol New York, NY: Raven Press Ltd.
3:145153.
Andersson GBJ, Pope MH, Frymoyer JW,
Alterman T, Shekells RB, Vernon SW, Burau Snook S [1991]. Epidemiology and cost. In:
KD [1994]. Decision latitude, psy-chologic Pope M, ed. Occupational low back pain.
demand, job strain and coronary heart disease St. Louis, MO: Mosby Year Book.
in the Western Electric study. Am J Epidemiol
139(6):620627. Andersson JAD [1984]. Shoulder pain and
tension neck and their relation to work. Scand J
Amadio PC [1995]. De Quervains disease Work Environ Health 10(6): 435442.
and tenosynovitis. In: Gordon SL, Blair SJ,
Armstrong RB, Warren GL, Warren JA
Fine LJ, eds. Repetitive motions disorders of
[1991]. Mechanisms of exercise-induced
the upper extremity. Rosemont, IL: American
muscle fibre injury. J Sports Med 12(3):
Academy of Orthopaedic Surgeons, pp. 184207.
435448.
Armstrong TJ, Chaffin DB [1979]. Carpal
Amano M, Gensyo U, Nakajima H, Yatsuki K tunnel syndrome and selected personal
[1988]. Characteristics of work actions of shoe
R-1
Back to Main
attributes. J Occup Med 21(7):481486. cross-sectional study of male employees in a

Swedish pulp and paper industry. Br J Ind Med
Armstrong TJ, Foulke JA, Joseph BS, 44(5):327336.
Goldstein SA [1982]. Investigation of
cumulative trauma disorders in a poultry strand NE, Isacsson SO [1988]. Back pain,
processing plant. Am Ind Hyg Assoc J back abnormalities, and competing medical,
43(2):103116. psychological, and social factors as predictors
of sick leave, early retirement, unemployment,
Armstrong TJ, Fine LJ, Goldstein SA, Lifshitz labour turnover and mortality: a 22-year
YR, Silverstein BA [1987a]. Ergonomic follow-up of male employees in a Swedish pulp
considerations in hand and wrist tendinitis. J and paper company. Br J Ind Med
Hand Surg 12A(5):830837. 45(6):387395.
Armstrong TJ, Fine LJ, Radwin RG, Silverstein Atterbury MR, Limke JC, Lemasters GK,
BS [1987b]. Ergonomics and the effects of Li Y, Forrester C, Stinson R, Applegate H
vibration in hand-intensive work. Scand J [1996]. Nested case-control study of hand
Work Environ Health 13:286289. and wrist work-related musculoskeletal
disorders in carpenters. Am J Ind Med
Armstrong TJ, Punnett L, Ketner P [1989]. 30:695701.
Subjective worker assessments of hand tools
used in automobile assembly. Am Ind Hyg Barnhart S, Demers PA, Miller M, Longstreth
Assoc J 50(12):639645. WT Jr., Rosenstock L [1991]. Carpal tunnel
syndrome among ski manufacturing workers.
Armstrong TJ, Buckle P, Fine LJ, Hagberg M, Scand J Work Environ Health 17(1):4652.
Jonsson B, Kilbom [1993]. A conceptual
model for work-related neck and upper-limb Baron S, Milliron M, Habes D, Fidler A
musculoskeletal disorders. Scand J Work [1991]. Hazard evaluation and technical
Environ Health 19(2):7384. assistance report: Shoprite Supermarkets, New
JerseyNew York. Cincinnati, OH: U.S.
Aro S, Leino P [1985]. Overweight and Department of Health and Human Services,
musculoskeletal morbidity: a ten-year follow- Public Health Service, Centers for Disease
up. Int J Obes 9:267275. Control, National Institute for Occupational
Safety and Health, NIOSH Report No. HHE
Asbury FD [1995]. Occupational repetitive 883442092.
strain injuries and gender in Ontario
19861991. J Occup Environ Med 37(4): Batti MC, Bigos SJ, Fisher LD, Hansson TH,
479485. Jones ME, Wortley MD [1989]. Isometric
lifting strength as a predictor of industrial back
strand NE [1987]. Medical, psychological, pain. Spine 14(8):851856.
and social factors associated with back
abnormalities and self-reported back pain: a Batti MC, Bigos SJ, Fisher LD, Spengler
R-2
Back to Main
DM, HanssonTH, Nachemson AL, et al. Bergqvist U [1989]. Possible health effects of
[1990]. The role of spinal flexibility in back working with VDUs (editorial). Br J Ind Med
pain complaints within industry: a prospective 46:217221.
study. Spine 15(8):768793.
Bergqvist U, Wolgast E, Nilsson B, Voss M
Batti MC, Videman T, Gibbons LE, [1995a]. Musculoskeletal disorders among
Fisher L, Manninen H, Gill K [1995]. visual display terminal workers: individual,
Determinants of lumbar disc degeneration: ergonomic, and work organizational factors.
a study relating lifetime exposures and magnetic Ergonomics 38(4):763776.
resonance imaging findings in identical twins.
Spine 20:26012612. Bergqvist U, Wolgast E, Nilsson B, Voss M
[1995b]. The influence of VDT work on
Behrens V, Seligman P, Cameron L, Mathias musculoskeletal disorders. Ergonomics
CGT, Fine L [1994]. The preva-lence of back 38(4):754762.
pain, hand discomfort, and dermatitis in the
U.S. working population. Am J Public Health Bergqvist-Ullman M, Larsson N [1977]. Acute
84(11):17801785. low back pain in industry. Acta Orthop Scand
170(Suppl):1117.
Bennett GE [1946]. Shoulder and elbow
lesions distinctive of baseball players. Ann Surg Berkeley M, Bennett J, Woods W [1985].
126:107110. Elbow problems: injuries to the throwing arm.
Zarins B, Andrews J, Carson W, eds.
Berg M, Sanden , Torell G, Jrvholm B Phildelphia, PA: W.B. Saunders Publishing
[1988]. Persistence of musculoskeletal symp- Company, pp. 235249.
toms: a longitudinal study. Ergonomics
31(9):12811285. Bernard B, Sauter S, Fine LJ [1993]. Hazard
evaluation and technical assistance report: Los
Bergenudd H, Nilsson B [1988]. Back pain in Angeles Times, Los Angeles, CA. Cincinnati,
middle age. Occupational workload and OH: U.S. Department of Health and Human
psychologic factors: an epidemiologic survey. Services, Public Health Service, Centers for
Spine 13(1):5860. Disease Control and Prevention, National
Institute for Occupational Safety and Health,
Bergenudd H, Lindgrde, Nilsson B, Petersson NIOSH Report No. HHE 900132277.
C [1988]. Shoulder pain in middle age: a study
of prevalence and relation to occupational Bernard B, Sauter S, Fine LJ, Petersen M,
work load and psychosocial factors. Clin Hales T [1994]. Job task and psychosocial risk
Orthop Res 23:234238. factors for work-related musculoskeletal
disorders among newspaper employees. Scand
Bergqvist U [1984]. Video display terminals J Work Environ Health 20(6):417 426.
and health. Scand J Work Environ Health
10(2):6877. Biering-Srensen F [1983]. A prospective
R-3
Back to Main
study of low-back pain in a general population. Bjelle A, Hagberg M, Michaelsson G [1979].

I. Occurrence, recurrence, and aetilogy. Scand Clinical and ergonomic factors in prolonged
J Rehabil Med 15:8188. shoulder pain among industrial workers. Scand
J Work Environ Health 5(3):205210.
Biering-Srensen F [1984]. Physical
measurements as risk indicators for low back Bjelle A, Hagberg M, Michaelson G [1981].
trouble over a one-year period. Spine Occupational and individual factors in acute
9(2):106119. shoulder-neck disorders among industrial
worker. Br J Ind Med 38:356363.
Biering-Srensen F, Thomsen CE, Hilden J
[1989]. Risk indicators for low back trouble. Blder S, Barck-Holst U, Danielsson S, Ferhm
Scand J Rehabil Med 21:151157. E, Kalpamaa M, Leijon M, et al. [1991]. Neck
and shoulder complaints among sewing-
Bigos SJ, Spengler DM, Martin NA, Zeh J, machine operators: a study concerning
Fisher L, Nachemson A, et al. [1986a]. Back frequency, symptomatology and dysfunction.
injuries in industry: a retrospective study. II. Appl Ergonomics 22(4):251 257.
Injury factors. Spine 11:246251.
Bleecker ML, Bohlman M, Moreland R,
Bigos SJ, Spengler DM, Martin NA, Zeh J, Tipton A [1985]. Carpal tunnel syndrome: role
Fisher L, Nachemson A [1986b]. Back injuries of carpal canal size. Neurol 35(11):
in industry: a retrospective study. III. 15991604.
Employee-related factors. Spine 11:252256.
BLS [1995]. Workplace injuries and ill-nesses
Bigos SJ, Batti MC, Fisher LD [1991a]. in 1994. Washington, DC: U.S. Department of
Methodology for evaluating predictive factors Labor, Bureau of Labor Statistics, USDL
for the report of back injury. Spine 95508.
16(6):669670.
Bongers PM, Boshuizen HC [1990]. Back
Bigos SJ, Batti MC, Spengler DM, disorders and whole-body vibration at work
Fisher LD, Fordyce WE, Hansson TH, et al. [Dissertation]. Amsterdam, The Nether-lands:
[1991b]. A prospective study of work per- University of Amsterdam.
ceptions and psychosocial factors affecting the
report of back injury. Spine 16(1):16. Bongers PM, de Winter CR [1992]. Psy-
chosocial factors and musculoskeletal disease:
Bigos S, Bowyer O, Braen G, et al. [1994]. a report of the literature. The Netherlands:
Acute low back problems in adults. Clinical TNO Institute of Preventive Health Care,
practice guideline, quick reference guide No. Report No. 92082.
14. Rockville, MD: U.S. Department of Health
and Human Services, Public Health Service, Bongers PM, Boshuizen HC, Hulshof CTJ,
Agency for Health Care Policy and Research, Koemeester AP [1988]. Back disorders in
AHCPR Pub. No. 956043. crane operators exposed to whole-body
R-4
Back to Main
vibration. Int Arch Occup Environ Health vibration syndrome and dose-response relation
60:129137. for vibration-induced white finger among quarry
drillers and stonecarvers. Occup Environ Med
Bongers PM, Hulshof CTJ, Dijkstra L, 51(9):603611.
Boshuizen HC [1990]. Back pain and exposure
to whole-body vibration in helicopter pilots. Bovenzi M, Zadini A [1992]. Self-reported low
Ergonomics 33:1007 1026. back symptoms in urban bus drivers exposed
to whole-body vibration. Spine
Bongers PM, de Winter CR, Kompier MAJ, 17(9):10481059.
Hildebrandt VH [1993]. Psychosocial factors
at work and musculoskeletal Bovenzi M, Betta A [1994]. Low-back
disease. Scand J Work Environ Health disorders in agricultural tractor drivers exposed
19(5):297312. to whole-body vibration and postural stress.
Appl Ergonomics 25:231241.
Boshuizen HC, Bongers PM, Hulshof CTJ
[1990a]. Self-reported back pain in tractor Bovenzi M, Franzinelli A, Strambi F [1988].
drivers exposed to whole-body vibration. Int Prevalence of vibration-induced white finger
Arch Occup Environ Health 62:109115. and assessment of vibration exposure among
travertine workers in Italy. Int Arch Occup
Boshuizen HC, Hulshof CTJ, Bongers PM Environ Health 61:2534.
[1990b]. Long-term sick leave and disability
pensioning due to back disorders of tractor Bovenzi M, Zadini A, Franzinelli A, Borgogni F
drivers exposed to whole-body vibration. Int [1991]. Occupational mus-culoskeletal
Arch Occup Environ Health 62:117122. disorders in the neck and
upper limbs of forestry workers exposed to
Boshuizen HC, Bongers PM, Hulshof CTJ hand-arm vibration. Ergonomics 34(5):
[1992]. Self-reported back pain in fork-lift 547562.
truck and freight-container tractor drivers
exposed to whole-body vibration. Spine Bovenzi M, Franzinelli A, Mancini R, Cannava
17:5965. MG, Maiorano M, Ceccarelli F [1995]. Dose-
response relation for vascular disorders
Boshuizen HC, Verbeek JHAM, Broersen JPJ, induced by vibration in the fingers of forestry
Weel ANH [1993]. Do smokers get more workers. Occup Environ Med 52:722730.
back pain? Spine 18(1):3540.
Boyce RW, Jones GR, Hiatt AR [1991].
Bovenzi M [1990]. Medical aspects of the Physical fitness capacity and absenteeism of
hand-arm vibration syndrome. Int J Ind police officers. J Occup Med 33(11):1137
Ergonomics 6(1):6173. 1143.
Bovenzi M, Italian study group on physical Brammer AJ, Taylor W, eds. [1981]. Vibration
hazards in the stone industry [1994]. Hand-arm effects on the hand and arm in industry. New
R-5
Back to Main
York, NY: John Wiley and Sons. Burdorf A, Zondervan H [1990]. An epi-
demiological study of low-back pain in crane
Brattberg G, Thorslund M, Wikman A [1989]. operators. Ergonomics 33(8):981987.
The prevalence of pain in a general population:
the results of a postal survey in a county of Burdorf A, Monster A [1991]. Exposure to
Sweden. Pain 37:215222. vibration and self-reported health complaints of
Brinckmann P [1988]. Stress and strain of riveters in the aircraft industry. Ann Occup Hyg
human lumbar discs. Clin Biomechanics 35(3):287298.
3(4):232235.
Burdorf A, Govaert G, Elders L [1991].
Broberg E [1984]. Ergonomic injuries at work: Postural load and back pain of workers in the
ISA-information system on occupa-tional manufacturing of prefabricated concrete
injuries. Swedish National Board of elements. Ergonomics 34(7):909918.
Occupational Safety and Health, Report No.
1984:3E. Burdorf A, Naaktgeboren B, deGroot HC
[1993]. Occupational risk factors for low back
Bross JD [1966]. Spurious effects from an pain among sedentary workers.
extraneous variable. J Chron Dis 19:736747 J Occup Med 35:12131220.
Brubaker R, Mackenzie C, Bates D [1983]. Burry HC, Gravis V [1988]. Compensated

Vibration white finger disease among tree back injury in New Zealand. N Z Med J
fellers in British Columbia. J Occup Med 101(852):542544.
25(5):403408.
Burt S, Hornung R, Fine L [1990]. Hazard
Brubaker RL, Mackenzie CJG, Hertzman C, evaluation and technical assistance report:
Hutton SG, Slakov J [1987]. Longitudinal Newsday, Inc., Melville, NY. Cincinnati, OH:
study of vibration-induced white finger among U.S. Department of Health and Human
coastal fallers in British Columbia. Scand J Services, Public Health Service, Centers for
Work Environ Health 13(4):305 308. Disease Control, National Institute for
Occupational Safety and Health, NIOSH
Buckwalter JA, Woo SL-Y, Goldberg VM, Report No. HHE 892502046.
Hadley EC, Booth F, Oegema TR, et al.
[1993]. Current concepts review: soft-tissue Bystrm S, Hall C, Welander T, Kilbom
aging and musculoskeletal function. J Bone [1995]. Clinical disorders and pressure-pain
Joint Surg [Am] 75A(10):15331548. threshold of the forearm and hand among
automobile assembly line workers. J Hand Surg
Burdorf A [1992]. Exposure assessment of risk [Br] 20B(6):782790.
factors for disorders of the back in
occupational epidemiology. Scand J Work Cady LD Jr., Bischoff DP, O'Connell ER,
Environ Health 18(1):19. Thomas PC, Allan JH [1979]. Strength and
fitness and subsequent back injuries in fire-
R-6
Back to Main
fighters. J Occup Med 21(4):269272. Occupational Safety and Health, DHEW

(NIOSH) Publication No. 77163.
Cady LD Jr., Thomas PC, Karwasky RJ
[1985]. Program for increasing health and Chatterjee D [1992]. Workplace upper limb
physical fitness of firefighters. J Occup Med disorders: a prospective study with inter-
27(2):110114. vention. J Occup Med 42(3):129136.
Cannon LJ, Bernacki EJ, Walter SD [1981]. Chatterjee DS, Barwick DD, Petrie A [1982].
Personal and occupational factors associated Exploratory electromyography in the study of
with carpal tunnel syndrome. J Occup Med vibration-induced white finger in rock drillers.
23(4):255258. Br J Ind Med 39:8997.
CDC (Centers for Disease Control) [1989]. Chiang H, Chen S, Yu H, Ko Y [1990]. The
Occupational disease surveillance: carpal tunnel occurrence of carpal tunnel syndrome in frozen
syndrome. MMWR 38(28):485489. food factory employees. Kao Hsiung J Med
Sci 6:7380.
Chaffin DB [1973]. Human strength capability
and low back pain. Unpublished paper Chiang H, Ko Y, Chen S, Yu H, Wu T, Chang
presented at the American Industrial Health P [1993]. Prevalence of shoulder and upper-
Conference, Denver, CO, April 1619, 1973. limb disorders among workers in the fish-
processing industry. Scand J Work Environ
Chaffin DB [1979]. Manual materials handling Health 19(2):126131.
the cause of overexertion injury and illness in
industry. J Environ Pathol Toxicol 2(5):6773. Christensen H, Pedersen MB, Sjgaard G
[1995]. A national cross-sectional study in the
Chaffin DB, Park KS [1973]. A longitudinal Danish wood and furniture industry on working
study of low-back pain as associated with postures and manual materials handling.
occupational weight lifting factors. Am Ind Hyg Ergonomics 38(4):793805.
Assoc J 34:513525.
Clemmer DI, Mohr DL, Mercer DJ [1991].
Chaffin DB, Andersson GBJ [1984]. Occu- Low-back injuries in a heavy industry: I.
pational biomechanics. New York, NY: John Worker and workplace factors. Spine
Wiley and Sons. 16(7):824830.
Chaffin DB, Herrin GD, Keyserling WM, Cohen S, Pyrrell DAJ, Smith AP [1991].
Foulke JA [1977]. Preemployment strength Psychological stress and susceptibility to the
testing in selecting workers for materials common cold. New Engl J Med 325(9):606
handling jobs. Cincinnati, OH: U.S. 612.
Department of Health, Education, and Welfare,
Health Services and Mental Health Cornfield J [1956]. A statistical problem arising
Administration, National Institute for from retrospective studies. Pro-ceedings of the
R-7
Back to Main
third Berkely Symposium, pp. 135148. logical perception of work and low back
symptoms in nursing aides. Scand J Rehabil
Cornfield J, Haenszel W, Hammond EC, Med 10(4):201209.
Lilienfeld AM, Shimkin MB, Wynder EL
[1959]. Smoking and lung cancer: recent Dehlin O, Berg S, Andersson GBJ, Grimby G
evidence and a discussion of some questions. J [1981]. Effect of physical training and
Natl Cancer Inst 22:173203. ergonomic counseling on psychological
perception of work and on the subjective
Cust G, Pearson JCG, Mair A [1972]. The assessment of low-back insufficiency. Scand J
prevalence of low back pain in nurses. Int Nurs Rehabil Med 13:19.
Rev 19(2):169179.
deKrom MCT, Kester ADM, Knipschild PG,
CWCI [1993]. Report on CTDs. San Spaans F [1990]. Risk factors for carpal tunnel
Francisco, CA: California Workers syndrome. Am J Epidemiol
Compensation Institute. 132(6):11021110.
Cyriax JH [1936]. The pathology and treatment Deyo RA, Bass JE [1989]. Lifestyle and low
of tennis elbow. J Bone Joint Surg Am back pain: the influence of smoking and obesity.
18(4):921940. Spine 14(5):501506.
Damkot DK, Pope MH, Lord J, Frymoyer JW Dieck GS, Kelsey JL [1985]. An epidemio-
[1984]. The relationship between work history, logic study of the carpal tunnel syndrome in an
work environment and low-back pain in men. adult female population. Prev Med
Spine 9(4):395399. 14(1):6369.
Dammeskiold-Samse B, Christiansen E, Lund Dimberg L [1987]. The prevalence and

B, Andersen RB [1982]. Regional muscle causation of tennis elbow (lateral humeral
tension and pain (fibrositis). Scand J Rehabil epicondylitis) in a population of workers in an
Med 15:1720. engineering industry. Ergonomics
30(3):573580.
Dehlin O, Berg S [1977]. Back symptoms and
psychological perception of work: a study Dimberg L, Oden A [1991]. White finger
among nursing aides in a geriatric hospital. symptoms: a cross-sectional study. Aviat Space
Scand J Rehabil Med 9:6165. Environ Med 62:879883
Dehlin O, Hedenrud B, Horal J [1976]. Back Dimberg L, Olafsson A, Stefansson E, Aagaard

symptoms in nursing aides in a geriatric H, Oden A, Andersson GBJ, et al. [1989]. The
hospital. Scand J Rehabil Med 8(2):47. correlation between work environment and the
occurrence of cervicobrachial symptoms. J
Dehlin O, Berg S, Hedenrud B, Anderson G, Occup Med 31(5): 447453.
Grimby G [1978]. Muscle training, psycho-
R-8
Back to Main
Dixon SJ [1973]. Progress and problems in tunnel syndrome in butchers. Scand J Work
back pain research. Rheumatol Rehabil 12:165. Environ Health 9(3):291297.
Dupuis H [1994]. Medical and occupational Frkkil M, Aatola S, Starck J, Korhonen O,

preconditions for vibration-induced spinal Pyykk I [1986]. Hand-grip force in lumber-
disorders: occupational disease No. 2110 in jacks: two-year follow-up. Int Arch Occup
Germany. Int Arch Occup Environ Health Environ Health 58:203208.
66:303308.
Frkkil M, Pykk I, Jntti V, Aatola S,
Starck J, Korhonen O [1988]. Forestry
Earman WA, Andersson GB, Leavitt F, workers exposed to vibration: a neurological
McNeill TW, Durudogan H, Reagan J [1996]. study. Br J Ind Med 45:188192.
Factors influencing the cost of chronic low
back injuries: an analysis of data from Feldman RG, Travers PH, Chirico-Post J,
independent medical examinations. Keyserling WM [1987]. Risk assessment in
J Occup Rehabil 6(1):516. electronic assembly workers: carpal tunnel
syndrome. J Hand Surg [Am] 12A(5):
Ekberg K, Bjrkqvist B, Malm P, Bjerre-Kiely 849855.
B, Karlsson M, Axelson O [1994]. Case-
control study of risk factors for disease in the Ferguson D [1976]. Posture, aching and body
neck and shoulder area. Occup Environ Med build in telephonists. J Hum Ergol 5:183196.
51(4):262266.
Feyer A, Williamson A, Mandryk J, de Silva I,
Ekberg K, Karlsson M, Axelson O [1995]. Healy S [1992]. Role of psychosocial risk
Cross-sectional study of risk factors for symp- factors in work-related low back pain. Scand J
toms in the neck and shoulder area. Work Environ Health 18(6):368375.
Ergonomics 38(5):971980.
Finkelstein MM [1995]. Back pain and
Eklund J, Odenrick P, Zettergren S, Johansson parenthood. Occup Environ Med 52(1):
H [1994]. Head posture measure-ments among 5153.
work vehicle drivers and implications for work
and workplace design. Ergonomics Fishbein M, Middlestadt S, Ottati V,
37(4):623639. Straus S, Ellis A [1988]. Medical problems
among ICSOM musicians: overview of a
English CJ, Maclaren WM, Court-Brown C, national survey. Med Prob Perform Art
Hughes SPF, Porter RW, Wallace WA 1:136139.
[1995]. Relations between upper limb soft
tissue disorders and repetitive movements at Flodmark BT, Aase G [1992]. Musculo-skel-
work. Am J Ind Med 27(1):7590. etal symptoms and type A behaviour in blue
collar workers. Br J Ind Med 49(10):
Falck B, Aarnio P [1983]. Left-sided carpal 683687.
R-9
Back to Main
Frank JW, Pulcins IR, Kerr MS, Shannon HS, low-back pain in industry. Occup Med: State
Stansfield SA [1995]. Occupational back of the Art Rev 7(4):593608.
painan unhelpful polemic. Scand J Work
Environ Health 58:203208. Gelberman RH, Herginroeder PT, Hargens
AR, Lundborg GN, Akeson WH [1981]. The
Franklin GM, Haug J, Heyer N, Checkoway carpal tunnel syndrome: a study of carpal canal
H, Peck N [1991]. Occupational carpal tunnel pressures. J Bone Joint Surg 63A(3): 380383.
syndrome in Washington State, 19841988.
Am J Public Health 81(6): 741746. Gemne G [1982]. Pathophysiology and
multifactorial etiology of acquired vaso-spastic
Fransson-Hall C, Bystrm S, Kilbom disease (Raynaud Syndrome) in vibration
[1995]. Self-reported physical exposure and exposed workers. Scand J Work Environ
musculoskeletal symptoms of the forearm-hand Health 8:243249.
among automobile assembly-line workers. J
Occup Environ Med 37(9): 11361144. Gemne G, Lundstrm R, Hansson J [1993].
Disorders induced by work with hand-held
Frymoyer JW, Pope MH, Costanza MC, vibrating tools: a review of current knowledge
Rosen JC, Goggin JE, Wilder DG [1980]. for criteria documentation. Arbete och Hlsa
Epidemiologic studies of low-back pain. Spine 6:183.
5(5):419423.
Gerr F, Letz R [1992]. Risk factors for carpal
Frymoyer JW, Pope MH, Clements JH tunnel syndrome in industry: blaming the victim?
[1983]. Risk factors in low back pain. [Letter to the editor.] J Occup Med
J Bone Joint Surg [Am] 65A:213. 34(11):11171119.
Frymoyer JW, Cats-Baril WL [1991]. An Gerr F, Letz R, Landrigan PJ [1991]. Upper-

overview of the incidence and costs of low extremity musculoskeletal disorders of
back pain. Orthop Clin North Am 22: occupational origin. Ann Rev Public Health
262271. 12:543566.
Futatsuka M, Uneno T [1985]. Vibration Graham NM, Douglas RM, Ryan P [1986].
exposure and vibration induced white finger Stress and acute respiratory infection. Am J
due to chain saw operation. J Occup Med Epidemiol 124(3):389401.
27:257264.
Grandjean E, Hunting W, Nishiyama K [1984].
Futatsuka M, Uneno T [1986]. A follow-up Preferred VDT workstation settings, body
study of vibration-induced white finger due to posture and physical impairments. Appl
chain saw operation. Scand J Work Environ Ergonomics 15(2):99104.
Health 12(4):304306.
Guo HR, Tanaka S, Cameron LL, Seligman
Garg A, Moore SJ [1992]. Epidemiology of PJ, Behrens VJ, Ger J, et al. [1995]. Back pain
R-10
Back to Main
among workers in the United States: national London, England: Taylor and Francis.
estimates and workers at high risk. Am J Ind
Med 28(5):591602. Hgg G, Suurkla J, Kilbom [1990].
Predictors for work-related shoulder/neck
Hadler NM [1993]. Occupational musculo- disorders: a longitudinal study of female
skeletal disorders. New York, NY: Raven assembly workers. Arbete och Hlsa 10:178.
Press.
Hgg GM, ster J, Bystrm S [1996].
Hadler N [1997]. Repetitive upper-extremity Forearm muscular load and wrist angle among
motions in the workplace are not hazardous. J automobile assembly line workers in relation to
Hand Surg [Am] 22A(1):1929. symptoms. Appl Ergonomics 28(1):4147.
Hagberg M [1981]. Work load and fatigue in Hales TR, Fine L [1989]. Hazard evaluation
repetitive arm elevations. Ergonomics and technical assistance report: Cargill Poultry
24:543555. Division, Buena Vista, CA. Cincinnati, OH:
U.S. Department of Health and Human
Hagberg M [1984]. Occupational musculo- Services, Public Health Service, Centers for
skeletal stress and disorders of the neck and Disease Control, National Institute for
shoulder: a review of possible pathophysio- Occupational Safety and Health, NIOSH
logy. Int Arch Occup Environ Health Report No. HHE 892511997.
53:269278.
Hales TR, Sauter S [1992]. Hazard evalua-tion
Hagberg M, Kvarnstrm S [1984]. Muscular and technical assistance report: U.S. West
endurance and electromyographic fatigue in Communications, Phoenix, AZ; Minneapolis,
myofascial shoulder pain. Arch Phys Med MN; Denver, CO. Cincinnati, OH: U.S.
Rehabil 65:522525. Department of Health and Human Services,
Public Health Service, Centers for Disease
Hagberg M, Wegman DH [1987]. Preva-lence Control and Prevention, National Institute for
rates and odds ratios of shoulder-neck diseases Occupational Safety and Health, NIOSH
in different occupational groups. Br J Ind Med Report No. HHE 892992230.
44(9):602610.
Hales TR, Habes D, Fine L, Hornung R,
Hagberg M, Morgenstern H, Kelsh M [1992]. Boiano J [1989]. Hazard evaluation and tech-
Impact of occupations and job tasks on the nical assistance report: John Morrell and Co.,
prevalence of carpal tunnel syndrome. Scand J Sioux Falls, SD. Cincinnati, OH: U.S.
Work Environ Health 18(6):337 345. Department of Health and Human Services,
Public Health Service, Centers for Disease
Hagberg M, Silverstein B, Wells R, Control, National Institute for Occupational
Smith M, Hendrick H, Carayon P [1995]. Safety and Health, NIOSH Report No. HHE
Work-related musculoskeletal disorders 881801958.
(WMSDs): a reference book for prevention.
R-11
Back to Main
Hales TR, Sauter SL, Peterson MR, Fine LJ, Wright V [1992]. Work-related upper limb
Putz-Anderson V, Schleifer LR, et al. [1994]. disorders: the relationship between pain,
Musculoskeletal disorders among visual display cumulative load, disability, and psychological
terminal users in a telecom-munications factors. Ann Rheum Dis 51(12): 13251329.
company. Ergonomics 37(10): 16031621.
Herberts P, Kadefors R [1976]. A study of
Harms-Ringdahl K, Ekholm J [1986]. Intensity painful shoulders in welders. Acta Orthop
and character of pain and muscular activity Scand 47:381387.
levels elicited by maintained extreme flexion
position of the lower-cervical-upper thoracic Herberts P, Kadefors R, Andersson G,
spine. Scand J Rehabil Med 18:117126. Petersen I [1981]. Shoulder pain in industry: an
epidemiological study on welders. Acta Orthop
Hart DA, Frank CB, Bray RC [1995]. Scand 52:299306.
Inflammatory processes in repetitive motion
and overuse syndromes: potential role of Herberts P, Kadefors R, Hgfors C, Sigholm
neurogenic mechanisms in tendons and G [1984]. Shoulder pain and heavy manual
labor. Clin Orthop 191:166178.
ligaments. In: Gordon SL, Blair SJ, Fine, LJ,
eds. Repetitive motions disorders of the upper
Herrin GD, Jaraiedi M, Anderson CK [1986].
extremity. Rosemont, IL: American Academy
Prediction of overexertion injuries using
of Orthopaedic Surgeons, pp. 247262. biomechanical and psychophysical models. Am
Ind Hyg Assoc J 47(6):322 330.
Hartz CR, Linscheid RL, Gramse RR, Daube
JR [1981]. The pronator teres syndrome: Heyer N, Checkoway H, Daniell, et al. [1990].
compressive neuropathy of the median nerve. J Self-reported musculoskeletal symptoms
Bone Joint Surg 63(6): 885890. among office video display terminal operators.
In: Sakurai H, Okazaki I, Omae I, eds.
Helivaara M [1987]. Occupation and risk of Occupational epidemiology. Amsterdam, The
herniated lumbar intervertebral disc or sciatica Netherlands: Elsevier Science Publishers, B.V.,
leading to hospitalization. J Chronic Dis pp. 255258.
40(3):259264.
Higgs P, Young VL, Seaton M, Edwards D,
Helivaara M, Knekt P, Aromaa A [1987]. Feely C [1992]. Upper extremity impairment in
Incidence and risk factors of herniated lumbar workers performing repetitive tasks. Plast
intervertebral disc or sciatica leading to Reconstr Surg 90(4):614620.
hospitalization. J Chronic Dis 40:251 258.
Hildebrandt VH [1987]. A review of epi-
demiological research on risk factors of low
Helivaara M, Mkel M, Knekt P, Impivaara
back pain. In: Buckle P, ed. Musculoskeletal
O, Aromaa A [1991]. Determi-nants of sciatica disorders at work. Proceedings of a con-
and low back pain. Spine 16(6):608614. ference held at the University of Surrey,
Guilford, April, 1987. London, England: Taylor
Helliwell PS, Mumford DB, Smeathers JE, and Francis, pp. 916.
R-12
Back to Main
Hildebrandt VH [1995]. Back pain in the interview and clinical examination. Scand J
working population: prevalence rates in Dutch Rehabil Med 23:119125.
trades and professions. Ergonomics
38(6):12831298. Holmstrm EB, Lindell J, Moritz U [1992].
Low back and neck/shoulder pain in
Hildebrandt VH, Bongers PM, Dul J, van Dijk construction workers: occupational work-load
FJH, Kemper HCG [1996]. Identifica-tion of and psychosocial risk factors. Spine
high-risk groups among maintenance workers 17(6):663671.
in a steel company with respect to
musculoskeletal symptoms and workload. Holmstrm E, Lindell J, Moritz U [1993].
Ergonomics 39(2):232242. Healthy lower backs in the construction
industry in Sweden. Work and Stress
Hill AB [1965]. The environment and disease: 7(3):259271.
association or causation. Proc Royal Soc Med
58:295300. Hopkins A [1990]. Stress, the quality of work,
and repetition strain injury in Australia. Work
Hill AB [1966]. Principles of medical statistics. and Stress 4(2):129138.
8th ed. London, England: Lancet.
Horal J [1969]. The clinical appearance of low
Hill AB [1971]. Principles of medical statistics. back disorders in the city of Gothen-burg,
9th ed. New York, NY: Oxford University Sweden. Acta Orthop Scand
Press. 118(Suppl):737.
Hoekstra EJ, Hurrell JJ, Swanson NG [1994]. Houtman ILD, Bongers PM, Smulders PGW,
Hazard evaluation and technical assistance Kompier MAJ [1994]. Psychosocial stressors
report: Social Security Admin-istration at work and musculoskeletal problems. Scand J
Teleservice Centers, Boston, MA; Fort Work Environ Health 20(2):139145.
Lauderdale, FL. Cincinnati, OH: U.S.
Department of Health and Human Services, Hrubec Z, Nashold BS [1975]. Epidemio-logy
Public Health Service, Centers for Disease of lumbar disc lesions in the military in World
Control and Prevention, National Institute for War II. Am J Epidemiol 102(5):366 376.
Occupational Safety and Health, NIOSH
Report No. 9203822450. Huang J, Ono Y, Shibata E, Takeucki Y,
Hisanaga N [1988]. Occupational musculo-
Holmstrm E [1992]. Musculoskeletal skeletal disorders in lunch centre workers.
disorders in construction workers. Lund, Ergonomics 31(1):6575.
Sweden: Lund University, Department of
Physical Therapy, pp. 1175. Hughes RE, Silverstein BA, Evanoff BA
[1997]. Risk factors for work-related
Holmstrm E, Moritz U [1991]. Low back musculoskeletal disorders in an aluminum
pain correspondence between questionnaire smelter. Am J Ind Med 32:6675.
R-13
Back to Main
Hulshof C, Veldhuijzen van Zanten B [1987]. Jensen RC [1988]. Epidemiology of work-

Whole-body vibration and low-back pain: a related back pain. Top Acute Care Trauma
review of epidemiologic studies. Int Arch Rehabil 2(3):115.
Occup Environ Health 59:205220.
Jensen RC [1990]. Back injuries among nursing
Hunting KL, Welch LS, Cuccherini BA, Seiger personnel related to exposure. Appl Occup
LA [1994]. Musculoskeletal symptoms among Environ Hyg 5:3845.
electricians. Am J Ind Med 25(2):149163.
Johanning E [1991]. Back disorders and health
Hnting W, Lubli TH, Grandjean E [1981]. problems among subway train operators
Postural and visual loads at VDT workplaces. exposed to whole-body vibration. Scand J
I. Constrained postures. Ergonomics Work Environ Health 17(6):414 419.
24(12):917931.
Johanning E, Wilder DG, Landrigan PJ, Pope
Hurrell JJ, Murphy LR [1992]. Psycho-logical MH [1991]. Whole-body vibration exposure in
job stress. In: Rom WN, ed. Environmental and subway cars and review of adverse health
occupational medicine. 2nd ed. New York, effects. J Occup Med 33(5):605612.
NY: Little, Brown and Company, pp.
675684. Johansson JA [1994]. Work-related and non-
work-related musculoskeletal symptoms. Appl
Hurrell JJ Jr., Murphy LR, Sauter SL, Cooper Ergonomics 25(4):248251.
CL [1988]. Occupational stress: issues and
developments. New York, NY: Taylor and Johansson JA, Rubenowitz S [1994]. Risk
Francis. indicators in the psychosocial and physical
work environment for work-related neck,
Ignatius Y, Yee T, Yan L [1993]. Selfreported shoulder and low back symptoms: a study
musculoskeletal problems amongst typists and among blue and white collar workers in eight
possible risk factors. J Hum Ergol 22:8393. companies. Scand J Rehabil Med 26:131142.
ILO [1986]. Psychosocial factors at work: Johnson JV, Stewart W, Hall EM,
recognition and control. Geneva, Switzer-land: Fredlund P, Theorell T [1996]. Long-term
International Labour Office. psychosocial work environment and
cardiovascular mortality among Swedish men.
Iwata H, Makimo S [1987]. Prevalence of Am J Public Health 86(3):324331.
Raynauds phenomenon in individuals not using
vibrating tools. Sangyo Igaku 29: 500503. Jonsson B [1988]. The static load component
in muscle work. Eur J Appl Physiol
Jensen RC [1987]. Disabling back injuries 57:305310.
among nursing personnel: research needs and
justification. Res Nurs Health 10(1): 2938. Jonsson BG, Persson J, Kilbom [1988].
Disorders of the cervicobrachial region among
R-14
Back to Main
female workers in the electronics industry: a tennis players with lateral epicondylitis. Am J
two-year follow-up. Int J Ind Ergo 3(1):112. Sports Med 22(3): 359363.
Kaji H, Honma H, Usui M, Yasuno Y, Saito K Kellgren JH, Lawrence JS [1958]. Osteo-
[1993]. Hypothenar hammer syndrome in arthrosis and disc degeneration in an urban
workers occupationally exposed to vibrating population. Ann Rheum Dis 17(4):338397.
tools. J Hand Surg [Br] 18B(6):761766.
Kelsey CA, Mettler FA [1990]. Flexible
Kamwendo K, Linton, SJ, Moritz U [1991]. protective gloves: the Emperor's new clothes?
Neck and shoulder disorders in medical Radiology 174(1):275276.
secretaries. Part I. Pain prevalence and risk
factors. Scand J Rehabil Med 23(3):12733. Kelsey JL [1975a]. An epidemiological study
of acute herniated lumbar inter-vertebral disc.
Karasek RA, Baker D, Marxer F, Ahlbom A, Rheumatol Rehabil 14:144.
Theorell T [1981]. Job decision latitude, job
demands, and cardiovascular disease: a Kelsey JL [1975b]. An epidemiological study
prospective study of Swedish men. Am J Public of the relationship between occupations and
Health 71(7):694705. acute herniated lumbar intervertebral discs. Int
J Epidemiol 4(3):197205.
Karasek RA, Gardell B, Lindell J [1987].
Work and non-work correlates of illness and Kelsey JL, Hardy RJ [1975]. Driving of motor
behaviour in male and female Swedish white vehicles as a risk factor for acute herniated
collar workers. J Occup Behav 8(3):187 207. lumbar intervertebral disc. Am J Epidemiol
102(1):6373.
Karasek RA, Theorell T, Schwartz JF, Schnall
PL, Pieper CF, Michela JL [1988]. Job Kelsey JL, White AA [1980]. Epidemiology
characteristics in relation to the preva-lence of and impact on low back pain. Spine 5(2):
myocardial infarction in the U.S. Health 133142.
Examination Survey (HES) and the Health and
Nutrition Examination Survey (HANES). Am J Kelsey JL, Golden AL [1988]. Occupational
Public Health 78(8):910 918. and workplace factors associated with low
back pain. Occup Med: State of the Art Rev
Katz JN, Punnett L, Simmons BP, Fossel AH, 3(1):716.
Mooney N, Keller RB [1996]. Workers
compensation recipients with carpal tunnel Kelsey JL, Githens PB, White AA, Holford
syndrome: the validity of self-reported health TR, Walter SD, OConnor T, et al. [1984]. An
measures. Am J Public Health 86(1):5256. epidemiologic study of lifting and twisting on the
job and risk for acute pro-lapsed lumbar
Kelley JD, Lombardo SJ, Pink M, Perry G, intervertebral disc. J Orthop Res 2(1):6166.
Giangarra CE [1994]. Electromyographic and
cinematographic analysis of elbow function in Kelsey JL, Golden AL, Mundt DJ [1990].
R-15
Back to Main
Low back pain/prolapsed lumbar inter- Kiveks J, Riihimki H, Husman K, Hnninen

vertebral disc. Epidemiol Rheum Dis K, Hrknen H, Kuusela T, et al. [1994].
16(3):699716. Seven-year follow-up of white-
finger symptoms and radiographic wrist findings
Kennedy JC, Hawkins R, Krissoff WB [1978]. in lumberjacks and referents. Scand J Work
Orthopaedic manifestations of swimming. Am J Environ Health 20(2):101106.
Sports Med 6:309322.
Kivi P [1984]. Rheumatic disorders of the
Keyserling WM, Herrin GD, Chaffin DB upper limbs associated with repetitive
[1980]. Isometric strength testing as a means of occupational tasks in Finland, 19751979.
controlling medical incidents on stren-uous Scand J Rheumatol 13:101107.
jobs. J Occup Med 22(5):332336.
Klein BP, Jensen RC, Sanderson LM [1984].
Kiken S, Stringer W, Fine LJ [1990]. Hazard
Assessment of workers compen-sation claims
evaluation and technical assistance report:
for back strains/sprains.
Perdue Farms, Lewiston, NC; Roberson-ville,
NC. Cincinnati, OH: U.S. Department of J Occup Med 26(6):443448.
Health and Human Services, Public Health
Service, Centers for Disease Control, National Kleinbaum DG, Kupper LL, Morgenstern H
Institute for Occupational Safety and Health, [1982]. Epidemiologic research: principles and
NIOSH Report No. HHE 893072009. quantitative methods. London, England:
Lifetime Learning Publications.
Kilbom [1994]. Repetitive work of the upper
extremity. Int J Ind Ergonomics 14(1/2):5186. Knave BG, Wibom RI, Voss M, Hedstrm
LD, Bergqvist UO [1985]. Work with video
Kilbom , Persson J [1987]. Work technique display terminals among office employees. I.
and its consequences for musculo-skeletal Subjective symptoms and discomfort. Scand J
disorders. Ergonomics 30(2): 273279. Work Environ Health 11(6):457466.
Kilbom , Horst D, Kemfert K, Richter A Knibbe JJ, Friele RD [1996]. Prevalence of

[1986]. Observation methods for reduction of back pain and characteristics of the physical
load and strain on the human bodya review.
workload of community nurses. Ergonomics
Abetarskyddsstyrelsen Publikation Service
39(2):186198.
171(84):92.
Kim SH, Chung MK [1995]. Effects of Kompier MAJ [1988]. Arbeid en gezondheid
posture, weight and frequency on trunk van stadsbus-chauffeurs. Delft Eburon
muscular activity and fatigue during repetitive (Proefschrift Rijksuniversitiet Groningen).
lifting tasks. Ergonomics 38(5):853863.
Kopf T, Von Feder T, Karmaus W [1988].
King JW, Brelsford HJ, Tullos HS [1969]. Risks for musculoskeletal disorders of the low
Analysis of the pitching arm of the pro-fessional back, the shoulders, the elbows, and the wrists
baseball pitcher. Clin Orthop 67:116123. in bricklayers. In: Hogstedt C, Reuterwall C,
R-16
Back to Main
eds. Progress in occupational epidemiology. Kvarnstrm S [1983a]. Incidence of

Amsterdam: Elsevier Science Publishers B.V., musculoskeletal disorders in a mechanical
pp. 219222. engineering plant, with emphasis on occupat-
ional shoulder injuries. Abetarskyddssty-relsen
Koskimies K, Frkkil M, Pyykk I, Jntti V, Publikation Service 171(84):79.
Aatola S, Starck J, et al. [1990]. Carpal tunnel
syndrome in vibration disease. Br J Ind Med Kvarnstrm S [1983b]. Occurrence of
47(6):411416. musculoskeletal disorders in a manufac-turing
industry with special attention to occupational
Koskimies K, Pyykk I, Starck J, Inaba R shoulder disorders. Scand J Rehabil Med
[1992]. Vibration syndrome among Finnish (Suppl 8):1114.
forest workers between 1972 and 1990. Int
Arch Occup Environ Health 64:251256. Kvarnstrm S, Halden M [1983]. Occupa-
tional cervicobrachial disorders in an
Kukkonen R, Luopajrvi T, Riihimki V engineering company. Scand J Rehabil Med
[1983]. Prevention of fatigue amongst data 8:1114.
entry operators. In: Kvalseth TO, ed.
Ergonomics of workstation design. London, Lapidus PW, Guidotti FP [1970]. Lateral and
England: Buttersworth, pp. 2834. medical epicondylitis of the humerus. Ind Med
Surg 39(4):3032; 171173.
Kumar S [1994]. The back compressive forces
during maximal push-pull activities in the sagittal Larsson SE, Bengtsson A, Bodegard L,
plane. J Hum Ergol 23(2):133 150. Henriksson KG, Larsson J [1988]. Muscle
changes in work-related chronic myalgia. Acta
Kuorinka I, Koskinen P [1979]. Occupa-tional Orthop Scand 59(5):552556.
rheumatic diseases and upper limb strain in
manual jobs in a light mechanical industry. Larsson SE, Bodegard L, Henriksson KG,
Scand J Work Environ Health 5(Suppl berg PA [1990]. Chronic trapezius myalgia:
3):3947. morphology and blood flow studied in 17
patients. Acta Orthop Scand 61(5):394398.
Kuorinka I, Forcier L [1995]. Work-related
musculoskeletal disorders (WMSDs): Lawrence JS [1955]. Rheumatism in coal
a reference book for prevention. London, miners. Part III: Occupational factors. Br J Ind
England: Taylor & Francis, p. 1. Med 12(3):249261.
Kurppa K, Viikari-Juntura E, Kuosma E, Leboeuf-Yde C, Klougart N, Lauritzen T

Huuskonen M, Kivi P [1991]. Incidence of [1996]. How common is low back pain in the
tenosynovitis or peritendinitis and epicondy-litis Nordic population? Spine 21(13):1518 1526.
in a meat-processing factory. Scand J Work
Environ Health 17(1):3237.
Leigh JP, Sheetz RM [1989]. Prevalence of
R-17
Back to Main
back pain among full-time United States Liira JP, Shannon HS, Chambers LW, Haines
workers. Br J Ind Med 46:651657. TA [1996]. Long-term back problems and
physical work exposures in the 1990 Ontario
Leigh JP, Markowitz S, Fahs M, et al. [1996]. Health Survey. Am J Public Health
Costs of occupational injuries and illnesses in 86(3):382387.
1992. NIOSH cooperative agreement with
ERC, Inc., contract no. U60/CCU902886. Liles DH, Deivanayagam S, Ayoub MM,
Mahajan P [1984]. A job severity index for the
Leino P [1989]. Symptoms of stress predict evaluation and control of lifting injury. Hum
musculoskeletal disorders. J Epidemiol Com- Factors 26(6):683693.
munity Health 43(3):293300.
Lindman R, Hagberg M, ngqvist KA,
Leino P, Lyyra A [1990]. The effect of mental Sderlund K, Hultman E, Thornell L [1991].
stress and social support on the development of Changes in muscle morphology in chronic
musculoskeletal morbidity in the engineering trapezius myalgia. Scand J Work Environ
industry. In: Sakurai H, Okazaki L, Omae I, Health 17(5):347355.
eds. Occupational epidemiology. Amsterdam,
The Nether-lands: Elsevier Science Publishers Linton SJ [1990]. Risk factors for neck and
B.V., pp. 267272. back pain in a working population in Sweden.
Work and Stress 4(1):4149.
Leino P, Aro S, Hasan J [1987]. Trunk muscle
function and low back disorders: a ten-year Linton SJ, Kamwendo K [1989]. Risk factors
follow-up study. J Chronic Dis 40(4):289296. in the psychosocial work environ-ment for neck
and shoulder pain in secre-taries. J Occup Med
Leino P, Hasan J, Karppi SL [1988]. 31(7):609613.
Occupational class, physical workload, and
musculoskeletal morbidity in the engineer-ing Liss GM, Jesin E, Kusiak RA, White P [1995].
industry. Br J Ind Med 45(10):672681. Musculoskeletal problems among Ontario
dental hygienists. Am J Ind Med
Letz R, Cherniack MG, Gerr F, Hershman D, 28(4):521540.
Pace P [1992]. A cross-sectional epide-
miological survey of shipyard workers exposed Loslever P, Ranaivosoa A [1993]. Biome-
to hand-arm vibration. Br J Ind Med chanical and epidemiological investigation of
49(1):5362. carpal tunnel syndrome at workplaces with high
risk factors. Ergonomics 36(5): 537555.
Levitz CL, Iannotti JP [1995]. Overuse injuries
of the shoulder. In: Gordon SL, Blair SJ, Fine Louis, Harris & Associates [1996]. Pain and
LJ, eds. Repetitive motions disorders of the absenteeism in the workplace. New York, NY:
upper extremity. Rosemont, IL: American Louis, Harris & Associates.
Academy of Orthopaedic Surgeon.
Luka E [1970]. Lesion of the peripheral
R-18
Back to Main
nervous system due to vibration. Work Environ at an increased risk for developing
Health 7(1):6779. musculoskeletal disorders? Spine 6:710717.
Lundberg U, Granqvist M, Hansson T, Magora A [1970]. Investigation of the relation

Magnusson M, Wallin L [1989]. Psycho- between low back pain and occupation. Ind
logical and physiological stress responses Med 39:3137.
during repetitive work at an assembly line.
Work and Stress 3(2):143153. Magora A [1972]. Investigation of the relation
between low back pain and occupation. III.
Lundborg G, Dahlin LB, Danielsen N, Hansson Physical requirements: sitting, standing, and
HA, Necking LE, Pyykk I [1987]. Intraneural weight lifting. Ind Med 41(12):59.
edema following exposure to vibration. Scand J
Work Environ Health 13(4):326329. Magora A [1973]. Investigation of the relation
between low back pain and occupation. IV.
Lundborg G, Dahlin LB, Hansson HA, Kanje Physical requirements: bending, rotation,
M, Necking LR [1990]. Vibration exposure reaching, and sudden maximal effort. Scand J
and peripheral nerve fiber damage. J Hand Rehabil Med 5:191196.
Surg [Am] 15A(2):346351.
Magora A, Schwartz A [1978]. Relation
Luopajrvi T, Kuorinka I, Virolainen M, between the low back pain syndrome and
Holmberg M [1979]. Prevalence of teno- x-ray findings. I. Degenerative osteoarthritis.
synovitis and other injuries of the upper Scand J Rehabil Med 10:135145.
extremities in repetitive work. Scand J Work
Environ Health 5(Suppl 3):4855. Maizlish N, Rudolph L, Dervin K,
Sankaranarayan M [1995]. Surveillance and
Maeda K, Hirayama H, Takamatsu M [1977]. prevention of work-related carpal tunnel
Occupational cervicobrachial disorders in syndrome: an application of the Sentinel Events
workwomen in assembly lines of a cigarette Notification System for Occupational Risks.
factory. Jpn J Ind Health 19:821. Am J Ind Med 27(5):715729.
Maeda K, Horiguchi S, Hosokawa M [1982]. Mkel M, Helivaara M, Sievers K,

History of the studies on occupa-tional Impivaara O, Knekt P, Aromaa A [1991].
cervicobrachial disorders in Japan and Prevalence, determinants, and consequences of
remaining problems. J Human Ergol 11:1729. chronic neck pain in Finland. Am J
Epidemiol 134(11):13561367.
Magnusson M, Hanson T [1994]. The effect of
seat back inclination on spine height changes. MaKinnon SE, Novak CB [1997]. Repeti-tive
Appl Ergonomics 25(5):294298. strain in the workplace. J Hand Surg [Am]
22A(1):218.
Magnusson ML, Pope MH, Wilder DG,
Areskoug B [1996]. Are occupational drivers Marcus M, Gerr F [1996]. Upper extremity
R-19
Back to Main
musculoskeletal symptoms among female office Masset D, Malchaire J [1994]. Low back pain:
workers: associations with video display epidemiologic aspects and work-
terminal use and occupational psychosocial related factors in the steel industry. Spine
stressors. Am J Ind Med 29(2):161170. 19(2):143146.
Marley RJ, Fernandez JE [1995]. Psycho- Matheson LN, Brophy RG, Vaughan KD,
physical frequency and sustained exertion at Nunez C, Saccoman KA [1995]. Workers
varying wrist postures for a drilling task. compensation managed care: preliminary
Ergonomics 38(2):303325. findings. J Occup Rehabil 5(1):2736.
Marras WS, Schoenmarklin RW [1991]. Mathiowetz V, Kashman N, Volland G,

Quantification of wrist motion in highly Weber K, Dowe M, Rogers S [1985]. Grip
repetitive, hand-intensive industrial jobs. and pinch strength: normative data for adults.
Washington, DC: U.S. Department of Health Arch Phys Med Rehabil 66(2):6972.
and Human Services, Public Health Service,
Centers for Disease Control, National Institute Matthews KA, Cottington EM, Talbott E,
for Occupational Safety and Health. Kuller LH, Siegel JM [1987]. Stressful work
conditions and diastolic blood pressure among
Marras W, Schoenmarklin RW [1993]. Wrist blue collar factory workers. Am J Epidemiol
motions in industry. Ergonomics 126(2):280290.
36(4):341351.
Mayer TG, Gatchel RJ, Kishino N, Keeley J,
Marras WS, Lavender SA, Leurgans SE, Capra P, Mayer H, et al. [1985]. Objective
Rajulu SL, Allread WG, Fathallah FA, et al. assessment of spinal function following
[1993]. The role of dynamic three-dimen-sional industrial injury: a prospective study with com-
trunk motion in occupationally- parison group and one-year follow-up. Spine
related low back disorders: the effects of work- 10(6):482493.
place factors, trunk position, and trunk motion
characteristics on risk of injury. Spine McCormack RR Jr., Inman RD, Wells A,
18(5):617628. Berntsen C, Imbus HR [1990]. Prevalence of
tendinitis and related disorders of the upper
Marras WS, Lavender SA, Leurgans SE, extremity in a manufacturing workforce. J
Fathallah FA, Ferguson SA, Allread WG, et al. Rheumatol 17:958964.
[1995]. Biomechanical risk factors for
occupationally-related low back disorders. McKenna K, McGrann S, Blann A, Allen J
Ergonomics 38(2):377410. [1993]. An investigation into the acute vascular
effects of riveting. Br J Ind Med 50:160166.
Martin DK, Dain SJ [1988]. Postural
modifications of VDU operators wearing McNeil T, Warwick D, Andersson G, Schultz
bifocal spectacles. Appl Ergonomics A [1980]. Trunk strengths in attempted flexion,
19(4):293300. extension, and lateral bending in healthy
R-20
Back to Main
subjects and patients with low back disorders. Moon SD, Sauter SL [1996]. Beyond
Spine 5(6):529538. biomechanics: psychosocial aspects of
musculoskeletal disorders in office work.
Merriam WP, Burwell RG, Mulholland RC, London, England: Taylor and Francis.
Pearson JCG, Webb JK [1980]. A study
revealing a tall pelvis in subjects with low back Moore JS [1992]. Carpal tunnel syndrome.
pain. J Bone Joint Surg [Br] 65B:153156. Occup Med: State of the Art Rev 7(4):741
763.
Milerad E, Ekenvall L [1990]. Symptoms of
the neck and upper extremities in dentists. Moore JS, Garg A [1991]. Determination of
Scand J Work Environ Health 16(1): 129134. the operational characteristics of ergonomic
exposure assessments for prediction of
Mintz G, Fraga A [1973]. Severe osteo- disorders of the upper extremities and back. In:
arthritis of the elbow in foundry workers. Arch Proceedings of the 11th Congress of the
Environ Health 27:7880. International Ergonomics Association. London,
England: Taylor & Francis, pp. 144146.
Mirbod SM, Inaba R, Iwata H [1992a]. A
study on the vibration-dose limit for Japanese Moore JS, Garg A [1994]. A comparison of
workers exposed to hand-arm vibration. Ind different approaches for ergonomic job
Health 30:122. evaluation for predicting risk of upper extremity
disorders. IEA 94. Occup Health Saf 2.
Mirbod SM, Yoshida H, Nagata C, Inaba R,
Komura Y, Iwata H [1992b]. Hand-arm Morgenstern H, Kelsh M, Kraus J, Margolis
vibration syndrome and its prevalence in the W [1991]. A cross-sectional study of
present status of private forestry enterprises in hand/wrist symptoms in female grocery check-
Japan. Int Arch Occup Environ Health ers. Am J Ind Med 20(2):209218.
64:9399.
Morris HH, Peters BH [1976]. Pronator
Mirbod SM, Yoshida H, Komura Y, syndrome: clinical and electrophysiological
Fujita S, Nagata C, Miyashita K, et al. [1994]. features in seven cases. J Neurol Neurosurg
Prevalence of Raynauds phenome-non in Psychiatry 39:461464.
different groups of workers operating hand-
held vibrating tools. Int Arch Occup Environ Mostardi RA, Noe DA, Kovacik MW,
Health 66:1322. Porterfield JA [1992]. Isokinetic lifting strength
and occupational injury: a prospective study.
Miyashita K, Morioka I, Iwata H, Takeda S Spine 17(2):189193.
[1992]. Symptoms of construction workers
exposed to whole-body vibration and local Musson Y, Burdorf A, van Drimmelen D
vibration. Int Arch Occup Environ Health [1989]. Exposure to shock and vibration and
64:347351. symptoms in workers using impact power tools.
Ann Occup Hyg 33(1):8596.
R-21
Back to Main
Nachemson A, Lindh M [1969]. Measure- Nathan PA, Keniston RC, Meadows KD,
ment of abdominal and back muscle strength Lockwood RS [1994a]. The relationship
with and without low back pain. Scand J between body mass index and the diagnosis of
Rehabil Med 1:6065. carpal tunnel syndrome [letter to the editor].
Muscle Nerve, December 1994,
Nachemson A, Elfstrom G [1970]. Intravital pp. 14911492.
dynamic pressure measurements in lumbar
discs. Scand J Rehabil Med 1(Suppl):140. Nathan PA, Takigawa K, Keniston RC,
Meadows KD, Lockwood RS [1994b].
Nagata C, Yoshida H, Mirbod S, Komura Y, Slowing of sensory conduction of the median
Fujita S, Inaba R, et al. [1993]. Cutaneous nerve and carpal tunnel syndrome in Japanese
signs (Raynauds phenomenon, sclerodacty-lia, and American industrial workers. J Hand Surg
and edema of the hands) and hand-arm [Am] 19B(1):3034.
vibration exposure. Int Arch Occup Environ
Health 64:587591. Necking LE, Dahlin LB, Fridin J,
Lundborg G, Lundstrm R, Thornell LE
Nathan PA, Meadows KD, Doyle LS [1988]. [1992]. Vibration-induced muscle injury: an
Occupation as a risk factor for impaired experimental model and preliminary findings. J
sensory conduction of the median nerve at the Hand Surg [Br] 17B:270274.
carpal tunnel. J Hand Surg [Br] 13B(2):
167170. Nicholas JA [1990]. Clinical observations on
sports-induced soft-tissue injuries in sports-
Nathan PA, Keniston RC, Myers LD, induced inflammation. In: Leadbetter WB,
Meadows KD [1992a]. Longitudinal study of Buckwalter JA, Gordon SL, eds. Rosemont,
median nerve sensory conduction in industry: IL: American Academy of Orthopedic
relationship to age, gender, hand dominance, Surgeons, p. 143.
occupational hand use, and clinical diagnosis. J
Hand Surg [Am] 17A(5):850857. Nilsson T, Burstrm L, Hagberg M [1989].
Risk assessment of vibration exposure and
Nathan PA, Keniston RC, Myers LD, white fingers among platers. Int Arch Occup
Meadows KD [1992b]. Obesity as a risk Environ Health 61(7):473481.
factor for slowing of sensory conduction of the
median nerve in industry: a cross-sectional and Nilsson T, Hagberg M, Burstrm L [1990].
longitudinal study involving 429 workers. J Prevalence and odds ratio of numbness and
Occup Med 34(4):379383. carpal tunnel syndrome in different exposure
categories of platers. In: Okada A, Dupuis
Nathan PA, Keniston RC, Meadows KD, WTH, eds. Hand-arm vibration. Kanazawa,
Lockwood RS [1993]. Validation of Japan: Kyoei Press Co., pp. 235239.
occupational hand use categories. J Occup
Med 35(10):10341042. Nilsson T, Hagberg M, Burstrm L, Kihlberg S
[1994]. Impaired nerve conduction in the
R-22
Back to Main
carpal tunnel of platers and truck assemblers Nirschl RP [1975]. The etiology and treatment
exposed to hand-arm vibration. Scand J Work of tennis elbow. J Sports Med 2(6):308319.
Environ Health 20:189199.
Nirschl R [1993]. Muscle and tendon trauma:
Nilsson T, Hagberg M, Burstrm L, Lundstrm tennis elbow. In: Morrey B, ed. The elbow and
R [1995]. A five-year follow-up study of nerve its disorders. 2nd ed. Philadel-phia, PA: W.B.
conduction across the carpal tunnel among Saunders Company, pp. 552573.
workers at a heavy engineer-ing production
plant. In: International Conference on the Nordgren B, Schek R, Linrotn K [1980].
Prevention of Musculo-skeletal Disorders Evaluation and prediction of back pain during
(PREMUS). Montreal, Canada: International military field service. Scand J Rehabil Med
Committee on Occupational Safety and Health, 12(1):18.
pp.8183.
Ohara H, Nakagiri S, Itani T, Wake K,
NIOSH [1989]. NIOSH criteria for a Aoyama H [1976]. Occupational health
recommended standard: occupational exposure hazards resulting from elevated work rate
to hand-arm vibration. Cincinnati, OH: U.S. situations. J Hum Ergol 5(2):173182.
Department of Health and Human Services,
Public Health Service, Centers for Disease Ohlsson K, Attewell R, Skerfving S [1989].
Control, National Institute for Occupational Self-reported symptoms in the neck and upper
Safety and Health, DHHS (NIOSH) limbs of female assembly workers. Scand J
Publication No. 89106. Work Environ Health 15(1):7580.
NIOSH [1991]. Epidemiological basis for Ohlsson K, Hansson GA, Balogh I, Strmberg
manual lifting guidelines. In: Scientific support U, Plsson B, Nordander C, et al. [1994].
documentation for the revised 1991 NIOSH Disorders of the neck and upper limbs in
lifting equation: technical contract reports. women in the fish processing industry. Occup
Springfield, VA: National Technical Information Environ Med 51:826832.
Service (NTIS), NTIS No. PB91226274.
Ohlsson K, Attewell R, Paisson B,
NIOSH [1996]. National occupational Karlsson B, Balogh I, Johnsson B, et al.
research agenda. Cincinnati, OH: U.S. [1995]. Repetitive industrial work and neck
Department of Health and Human Services, and upper limb disorders in females. Am J Ind
Public Health Service, Centers for Disease Med 27(5):731747.
Control and Prevention, National Institute for
Occupational Safety and Health, DHHS Olafsdottir H, Rafnsson V [1995]. New tech-
(NIOSH) Publication No. 96115. niques increases the prevalences of
musculoskeletal symptoms from upper limbs
Nirschl RP [1973]. Tennis elbow. Orthop Clin among women in fish fillet plants. In: Second
North Am 4(3):787800. International Scientific Conference on
Prevention of Work-Related Musculoskeletal
R-23
Back to Main
Disorders. Montreal, Canada, pp. 248249. Pietri-Taleb F, Riihimaki H, Viikari-Juntura E,

Lindstrm K, Moneta GB [1995]. The role of
Ollivierre CO, Nirschl RP, Pettrone FA psychological distress and personal-ity in the
[1995]. Resection and repair for medical tennis incidence of sciatic pain among working men.
elbow: a prospective analysis. Am J Sports Am J Public Health 85:541 545.
Med 23(2):214221.
Pope MH, Rosen JC, Wilder DG, Frymoyer
Onishi N, Namura H, Sakai K, Yamamoto T, JW [1980]. The relation between biome-
Hirayama K, Itani T [1976]. Shoulder muscle chanical and psychological factors in patients
tenderness and physical features of female with low back pain. Spine 5(2): 173178.
industrial workers. J Hum Ergol 5(2):87102.
Pope MH, Frymoyer JW, Andersson GBJ, et
Osorio AM, Ames RG, Jones J, Castorina J, al. [1984]. Occupational low back pain. New
Rempel D, Estrin W, et al. [1994]. Carpal York, NY: Praeger.
tunnel syndrome among grocery store workers.
Am J Ind Med 25(2):229245. Pope MH, Andersson GBJ, Frymoyer JW, et
al. [1991]. Occupational low back pain:
Owen B, Damron C [1984]. Personal assessment, treatment, and prevention. St.
characteristics and back injury among hospital Louis, MO: Mosby-Year Book, pp. 105108.
nursing personnel. Res Nurs Health 7:305313.
Porter RW [1987]. Does hard work prevent
Parker KG, Imbus HR [1992]. Cumulative disc protrusion? Clin Biomechanics 2(4):
trauma disorders. Current issues and 196198.
ergonomic solutions: a system approach.
Chelsea, MI: Lewis Publishers. Pot F, Padmos P, Brouwers A [1987].
Determinants of the VDU operators well-
Partridge REH, Duthie JJR [1968]. Rheu- being. In: Knave B, Wideback PG, eds. Work
matism in dockers and civil servants: a with display units 86. Selected papers from the
comparison of heavy manual and sedentary International Scientific Conference on Work
workers. Ann Rheum Dis 27:559568. with Display Units, Stockholm, Sweden, May
1215, 1986. Amsterdam: Elsevier Science
Payne R [1988]. Individual differences in the Publishers B.V., pp. 1625.
study of occupational stress. In: Cooper CL,
Payne R, eds. Causes, coping, and Priest JD, Braden V, Gerberich SG [1980].
consequences of stress at work. Chichester, The elbow and tennis, part 1: an analysis of
England: John Wiley & Sons, pp. 209232. players with and without pain. Physician Sports
Med 8:8191.
Pecina M, Krmpotic-Nemanic J, Markiewitz A
[1991]. Tunnel syndromes. Boston, MA: CRC Priest JD, Hones HH, Tichenor CJ, Nagel DA
Press. [1977]. Arm and elbow changes in expert
tennis players. Minn Med 60:399 404.
R-24
Back to Main
Punnett L, Robins JM, Wegman DH, vascular pattern of the rotator cuff. J Bone Joint
Keyserling WM [1985]. Soft-tissue disorders Surg [Br] 52B(3):540553.
in the upper limbs of female assembly workers:
impact of length of employment, work pace, Rempel D [1995]. Musculoskeletal loading and
and selection. Scand J Work Environ Health carpal tunnel pressure. In: Gordon SL, Blair SJ,
11(6): 417425. Fine LJ, eds. Repetitive motions disorders of
the upper extremity. Rosemont IL: American
Punnett L, Fine LJ, Keyserling WM, Herrin Academy of Orthopaedic Surgeons, pp.
GD, Chaffin DB [1991]. Back disorders and 123133.
nonneutral trunk postures of automobile
assembly workers. Scand J Work Environ Rempel D, Harrison R, Barnhart S [1992].
Health 17(5):337346. Work-related cumulative trauma disorders of
the upper extremity. JAMA 267(6): 838841.
Pyykk I, Starak J [1986]. Pathophysiologic
and hygienic aspects of hand-arm vibration. Rempel D, Dennerlein J, Mote CD, Armstrong
Scand J Work Environ Health 12(4):237 241. T [1994a]. A method of mea-suring fingertip
loading during keyboard use. J Biomechanics
Queinnec Y, Daniellou F, eds. [1991]. 27(8):11011104.
Shoulder symptoms and headache in light
sedentary work. In: Designing for everyone. Rempel D, Manojlovic R, Levinsohn DG,
Proceedings of the 11th Congress of the Bloom T, Gordon L [1994b]. The effect of
International Ergonomics Association, Paris, wearing a flexible wrist splint on carpal tunnel
France, July 1520, 1991. London, England: pressure during repetitive hand activity. J Hand
Taylor and Francis, pp. 129131. Surg [Am] 19A(1):106110.
Radecki P [1995]. Variability in the median Riihimki H [1991]. Low-back pain, its origin
and ulnar nerve latencies: implications for and risk indicators. Scand J Work Environ
diagnosing entrapment. J Occup Med 37: Health 17(2):8190.
12931299.
Riihimki H [1995]. Hands up or back to
Radwin RG, VanBergeijk E, Armstrong TJ workfuture challenges in epidemiologic
[1989]. Muscle response to pneumatic hand research on musculoskeletal diseases. Scand J
tool torque reaction forces. Ergonomics Work Environ Health 21(6):401403.
32(6):655673.
Riihimki H, Tola S, Videman T, Hnninen K
Ranney D, Wells R, Moore A [1995]. Upper [1989a]. Low-back pain and occupation: a
limb musculoskeletal disorders in highly cross-sectional questionnaire study of men in
repetitive industries: precise anatomical physical machine operating, dynamic physical work, and
findings. Ergonomics 38(7):1408 1423. sedentary work. Spine 14:
204209.
Rathburn JB Macnab I [1970]. The micro-
R-25
Back to Main
Riihimki H, Wickstrm G, Hnninen K, Advances in industrial ergonomics and safety,

Luopajrvi T [1989b]. Predictors of sciatic IV, Proceedings of the Annual International
pain among concrete reinforcement workers Industrial Ergonomics and Safety Conference,
and house painters: a five-year follow-up. Denver, CO, June 1014, 1992. London,
Scand J Work Environ Health 15(6):415 423. England: Taylor and Francis, pp. 303310.
Riihimki H, Wickstrm G, Hnninen K, Rossignol AM, Morse EP, Summers VM,

Mattson T, Waris P, Zitting AG [1989c]. Pagnotto LD [1987]. Video display terminal
Radiographically detectable lumbar use and reported health symptoms among
degenerative changes as risk indicators of back Massachusetts clerical workers. J Occup Med
pain. Scand J Work Environ Health 29(2):112118.
15:280285.
Rothfleisch SD, Sherman S [1978]. Carpal
Riihimki H, Viikari-Juntura E, Moneta G, tunnel syndrome: biomechanical aspects of
Kuha J, Videman T, Tola S [1994]. Incidence occupational occurrence and implications
of sciatic pain among men in machine operating, regarding surgical management. Orthop Rev
dynamic physical work and sedentary work. 7(6):107109.
Spine 19(2):138142.
Rothman KJ, ed. [ 1986]. Modern epidemio-
Ringel SP, Treihaft M, Carry M, Fisher R, logy. Boston, MA: Little, Brown, and Com-
Jacobs P [1990]. Suprascapular neuropathy in pany.
pitchers. Am J Sports Med 18(1):8086.
Roto P, Kivi P [1984]. Prevalence of epicon-
Ritz BR [1995]. Humeral epicondylitis among dylitis and tenosynovitis among meatcutters.
gas- and waterworks employees. Scand J Scand J Work Environ Health 10(3):203 205.
Work Environ Health 21:478486.
Rowe ML [1965]. Disc surgery and chronic
Rodgers SH, The Ergonomics Group, Health low back pain. J Occup Med 7(5):196202.
and Environment Laboratories, Eastman
Kodak Co. [1986]. Ergonomic design for Rowe ML [1985]. Backache at work. Fair-
people at work. Vol. II: The design of jobs, port, NY: Perington Press.
including work patterns, hours of work, manual
materials handling tasks, methods to evaluate Ruberman W [1992]. Psychosocial influences
job demands, and the physiological basis of on mortality of patients with coronary heart
work. New York, NY: Van Nostrand Reinhold disease. JAMA 267(4): 559560.
Co., Inc.
Ruberman W, Weinblatt E, Goldberg JD,
Rose L, Ericson M, Glimskar B, Nordgren B, Chaudhary BS [1984]. Psychosocial
Ortengren R [1992]. Ergo-index: a model to influences on mortality after myocardial
determine pause needs after fatigue and pain infarction. N Engl J Med 311(9):552559.
reactions during work. In: Kumar S, ed.
R-26
Back to Main
Ryan GA, Bampton M [1988]. Comparison of Grandjean E, ed. Ergonomics and health in
data process operators with and without upper modern offices. London, England: Taylor and
limb symptoms. Community Health Stud Francis, pp. 129135.
12(1):6368.
Sauter SL, Swanson NG [1996]. Psycho-
Ryan GA, Hage B, Bampton M [1987]. logical aspects of musculoskeletal disorders in
Postural factors, work organization and office work. In: Moon S, Sauter S, eds.
musculoskeletal disorders. In: Buckle P, ed. Psychosocial factors and musculoskeletal
Musculoskeletal disorders at work. disorders. London, England: Taylor and
Proceedings of a conference held at the Francis.
University of Surrey, Guilford, April, 1987.
London, England: Taylor and Francis, Sauter SL, Gottlieb MS, Jones KC, Dodson
pp. 251253. VN, Rohrer KM [1983]. Job and health
implications of VDT use: initial results of the
Ryden LA, Molgaard CA, Bobbitt S, Wisconsin-NIOSH study. Commun of the
Conway J [1989]. Occupational low-back ACM 26(4):284294.
injury in a hospital employee population: an
epidemiologic analysis of multiple risk factors of Schibye B, Skov T, Ekner D, Christiansen J,
a high-risk occupational group. Spine Sjgaard G [1995]. Musculoskeletal symptoms
14:315320. among sewing machine operators. Scand J
Work Environ Health 21:427434.
Sairanen E, Brshaber L, Kaskinen M [1981].
Felling work, low back pain and osteoarthritis. Schierhout GH, Meyers JE, Bridger RS
Scand J Work Environ Health 7(1):1830. [1995]. Work-related musculoskeletal
disorders and ergonomic stressors in the South
Saito K [1987]. Prevention of the hand-arm African workforce. Occup Environ Med
vibration syndrome. Scand J Work Environ 52(1):4650.
Health 13:301304.
Schlesselman J [1978]. Assessing the effects of
Sakakibara H, Masaru M, Kondo T, Yamada confounding variables. Am J Epidemiol
S [1987]. Relation between overhead work 108:38.
and complaints of pear and apple orchard
workers. Ergonomics 30(5):805815. Schlesselman J [1982]. Monographs in
epidemiology and biostatistics. Case-control
Sakakibara H, Miyao M, Kondo T, Yamada S studies: design, conduct, analysis. New York,
[1995]. Overhead work and shoulder-neck NY: Oxford University Press.
pain in orchard farmers harvesting pears and
apples. Ergonomics 38(4):700706. Schnall PL, Pieper C, Schwartz JE, Karasek
RA, Schlussel Y, Devereux RB, et al. [1990].
Sauter SL [1984]. Predictors of strain in VDT The relationship between job strain, workplace
users and traditional office workers. In: diastolic blood pressure, and left ventricular
R-27
Back to Main
mass: results of a case-control study. JAMA Hand wrist cumulative trauma disorders in
263(14):19291935. industry. Br J Ind Med 43(11):779784.
Schnall PL, Schwartz JE, Landsbergis PA, Silverstein BA, Fine LJ, Armstrong TJ [1987].
Warren K, Pickering TG [1992]. The Occupational factors and the carpal tunnel
relationship between job strain, alcohol, and syndrome. Am J Ind Med 11(3):343 358.
ambulatory blood pressure. Hypertension
19:488494. Silverstein B, Grossman E, Kalat J,
Nelson N [in press]. Upper limb and low back
Schnall PL, Landsbergis PA, Baker D [1994]. musculoskeletal disorders: State and national
Job strain and cardiovascular disease. Ann Rev estimates based on workers' compensation
Public Health 15:381411. accepted claims. Proceedings for managing
ergonomics in the 90's. Alexandria, VA: Center
Schottland JR, Kirschberg GJ, Fillingim R, for Office Technology and the American
Davis VP, Hogg F [1991]. Median nerve Automobile Manufacturer's Association.
latencies in poultry processing workers: an
approach to resolving the role of industrial Sinclair A [1964]. Tennis elbow in industry. Br
"cumulative trauma" in the development of J Ind Med 22:144148.
carpal tunnel syndrome. J Occup Med
33(5):627631. Sjgaard G [1988]. Intramuscular changes
during long-term contraction. In: Corlett N,
Scott V, Gijsbers K [1981]. Pain perception in Wilson J, Manenica I, eds. The ergonomics of
competitive swimmers. Br Med J 283: 9193. working postures: models, methods and cases.
Proceedings of the First International
Seidel H, Heide R [1986]. Long-term effects of Occupational Ergonomics Symposium, Zadar,
whole-body vibration: a critical survey of the Yugoslavia, April 1820, 1985, London,
literature. Int Arch Occup Environ Health England: Taylor and Francis, pp. 136143.
58:126.
Sjgaard G, Savard G, Juel C [1988]. Muscle
Shinev V, Komleva L, Zhuravlev A, Druzhinin blood flow during isometric activity and its
V [1992]. Study of the physical characteristics relation to muscle fatigue. Eur J Appl Physiol
of percussive vibration of hand-held machines 57:327335.
and its effect on the body. Noise and Vibration
Bulletin, pp. 138140. Skie M, Zeiss J, Ebraheim NA, Jackson WT
[1990]. Carpal tunnel changes and median
Silverstein BA [1985]. The prevalence of nerve compression during wrist flexion and
upper extremity cumulative trauma disorders in extension seen by magnetic resonance imaging.
industry [Dissertation]. Ann Arbor, MI: The J Hand Surg [Am] 15A(6):939.
University of Michigan.
Skov T, Borg V, Orhede E [1996]. Psycho-
Silverstein BA, Fine LJ, Armstrong TJ [1986]. social and physical risk factors for musculo-
R-28
Back to Main
skeletal disorders of the neck, shoulders, and disability. Clin Orthop 221:7784.
lower back in salespeople. Occup Environ
Med 53:351356. Snook SH, Ciriello VM [1991]. The design of
manual handling tasks: revised tables of
Skovron ML, Mulvihill MN, Sterling RC, maximum acceptable weights and forces.
Nordin M, Tougas G, Gallagher M, et al. Ergonomics 34(9):11971213.
[1987]. Work organization and low back pain
in nursing personnel. Ergonomics Snook SH, Campanelli RA, Hart JW [1978].
30(2):359366. A study of three preventive approaches to low
back injury. J Occup Med 20(7):478 487.
Skovron ML, Szpalski M, Nordin M,
Melot C, Cukier D [1994]. Sociocultural Sokal RR, Rohlf FJ [1981]. Biometry: the
factors and back pain: a population-based principles and practice of statistics in biological
study in Belgian adults. Spine 19(2):129 137. research. 2nd ed. San Francisco, CA: WH
Freeman and Co.
Slocum D [1960]. Overuse syndromes of the
lower leg and foot in athletes. AAOS Sommerich CM, McGlothin JD, Marras WS
Instructional Course Lectures, pp. 359367. [1993]. Occupational risk factors associated
with soft tissue disorders of the shoulder: a
Smith MJ, Stammerjohn LW, Cohen BGF, review of recent investigations in the literature.
Lalich NR [1977]. Job stress in video display Ergonomics 36(6):697717.
operations. In: Grandjean E, Vigliani E, eds.
Ergonomic aspects of video display terminals. Spengler DM, Bigos S, Martin NA, Zeh J,
London, England: Taylor and Francis, pp. Fisher L, Nachemson A [1986]. Back injuries
201210. in industry: a retrospective study. I. Overview
and cost analysis. Spine 11: 241245.
Snook SH [1978]. The design of manual
handling tasks. Ergonomics 21(12):963 985. Starck J, Jussi P, Ilmari P [1990]. Physical
characteristics of vibration in relation to
Snook SH [1982]. Low back pain in industry. vibration-induced white finger. Am Ind Hyg
In: White AA, Gordon SL, eds. American Assoc J 51(4):179184.
Academy of Orthopaedic Surgeons Sym-
posium on Idiopathic Low Back Pain. St. Stenlund B [1993]. Shoulder tendinitis and
Louis, MO: C.O. Mosby Company, osteoarthritis of the acromioclavicular joint and
pp. 2338. their relation to sports. Br J Sports Med
27:125128.
Snook SH [1987]. Approaches to preplace-
ment testing and selection of workers. Stenlund B, Goldie I Hagberg M, Hogstedt C,
Ergonomics 30(2):241247. Marions O [1992]. Radiographic osteo-
arthrosis in the acromioclavicular joint resulting
from manual work or exposure to vibration. Br
Snook SH, Webster BS [1987]. The cost of
R-29
Back to Main
J Ind Med 49:588593. 648.
Stenlund B, Goldie I, Hagberg M, Hogstedt C Svensson H [1982]. Low back pain in 40- to
[1993]. Shoulder tendinitis and its relation to 47-year-old men: II. Socioeconomic factors
heavy manual work and exposure to vibration. and previous sickness absence. Scand J Re-
Scand J Work Environ Health 19: 4349. habil Med 14:5560.
Stetson DS, Keyserling WM, Silverstein BA, Svensson H, Andersson GBJ [1983]. Low-
Leonard JA [1991]. Observational analysis of
back pain in 40- to 47-year old men: work
the hand and wrist: a pilot study. Appl Occup
history and work environment factors. Spine
Environ Hyg 6(11):927937.
8:272276.
Stetson DS, Silverstein BA, Keyserling WM,
Wolfe RA, Albers JW [1993]. Median sensory Svensson H, Andersson GBJ [1989]. The
distal amplitude and latency: comparisons relationship of low-back pain, work history and
between nonexposed managerial/professional work environment, and stress: a retrospective
employees, and industrial workers. Am J Ind cross-sectional study of 38- to 64-year old
Med 24:175189. women. Spine 14(5):517522.
Stevens JC, Sun MD, Beard CM, OFallon Sweeney MH, Petersen M, ONeill V [1994].
WM, Kurland LT [1988]. Carpal tunnel Hazard evaluation and technical assistance
syndrome in Rochester, Minnesota, 1961 to report: Registry of Interpreters for the Deaf,
1980. Neurology 38:134138. Ohio Chapter. Cincinnati, OH: U.S.
Department of Health and Human Services,
Stevens PH, Chase DO, Brownlie AW [1966]. Public Health Service, Centers for Disease
Industrial design of a narrow aisle sit-down lift Control and Prevention, National Institute for
truck. Hum Factors 8:317325. Occupational Safety and Health, NIOSH
Report No. HHE 9202682477.
Stock SR [1991]. Workplace ergonomic
factors and the development of musculo-
Szabo RM, Chidgey LK [1989]. Stress carpal
skeletal disorders of the neck and upper limbs:
a meta-analysis. Am J Ind Med 19(1):87107. tunnel pressures in patients with carpal tunnel
syndrome and normal patients. J Hand Surgery
Stubbs DA [1986]. Back pain and its [Am] 14A(4):624627.
relationship to manual handling. In: Morrison D,
Hartley L, Kemp D, eds. Trends in the Takala E, Viikari-Juntura E [1991]. Muscle
ergonomics of work. Proceed-ings of the 23rd force endurance and neck-shoulder symp-toms
Annual Conference of the Ergonomics Society of sedentary workers: an experimental study on
of Australia, pp. 118128. bank cashiers with and without symptoms.
Amsterdam, The Netherlands: Elsevier Science
Susser M [1991]. What is a cause and how do Publishers. B.V., pp. 123132.
we know one?: a grammar for pragmatic
epidemiology. Am J Epidemiol 133(7):635 Takala EP, Viikari-Juntara E, Moneta G,
R-30
Back to Main
Saarenmaa K, Kaivanto K [1991]. Predic-tors factors and symptoms from the locomotor
for the natural course of neckshoulder system: a multicausal analysis. Scand J Rehabil
symptoms and headache in light sedentary Med 23(3):165173.
work. In: Queinnec Y, Daniellou F, eds.
Designing for everyone. Proceedings of the Theorell T, Ahlberg-Hulten G, Jodko M, Sigala
11th Congress of the International Ergono-mics F, de la Torre B [1993]. Influence of job strain
Association, Paris, France, July 1520, 1991. and emotion on blood pressure levels in female
London, England: Taylor and Francis, pp. hospital personnel during work hours. Scand J
129131.
Work Environ Health 19(5):313318.
Takeuchi T, Futatsuka M, Imanishi H, Yamada
Tola S, Riihimki H, Videman T, Viikari-
S [1986]. Pathological changes observed in the
finger biopsy of patients with vibration-induced Juntura E, Hnninen K [1988]. Neck and
white finger. Scand J Work Environ Health shoulder symptoms among men in machine
12:280283. operating, dynamic physical work and
sedentary work. Scand J Work Environ Health
Tanaka S, Wild DK, Seligman PJ, Halperin 14(5):299305.
WE, Behrens VJ, Putz-Anderson V [1995].
Prevalence of work-related carpal tunnel Toomingas A, Hagberg M, Jorulf L, Nilsson T,
syndrome among U.S. workers: analysis of the Burstrm L, Kihlberg S [1991]. Outcome of
occupational health supplement data of 1988 the abduction external rotation test among
National Health Interview Survey. Am J Ind manual and office workers. Am J Ind Med
Med 27(4):451470. 19(2):215227.
Tanaka S, Wild DK, Cameron L, Freund E [in Toomingas A, Theorell T, Michlsen H, et al.
press]. Association of occupational and [1992]. Associations between preceived
non-occupational risk factors with the psychosocial job factors and prevalence of
prevalence of self-reported carpal tunnel
musculoskeletal disorders in the neck and
syndrome in a national survey of the working
shoulder regions. In: Hagberg M, Kilbom ,
population. Am J Ind Med.
eds. International Scientific Conference on
Tanii K, Kogi K, Sadoyama T [1972]. Prevention of Work-Related Musculo-skeletal
Spontaneous alteration of the working arm in Disorders PREMUS, Sweden, May 1214,
static overhead work. J Hum Ergol 1:143155. 1992. Arbete och Hlsa 17:289.
Tauber J [1970]. An unorthodox look at Toroptsova NV, Benevolenskaya LI, Karyakin

backaches. J Occup Med 12(4):128130. AN, Sergeev IL, Erdesz S [1995].
Cross-sectional study of low back pain among
Taylor W [1982]. Vibration white finger in the workers at an industrial enterprise in Russia.
workplace. J Soc Occup Med 32:159166. Spine 20(3):328332.
Theorell T, Harms-Ringdahl K, Ahlberg- Torrell G, Sanden A, Jrvholm B [1988].

Hultn G, Westin B [1991]. Psychosocial job Musculoskeletal disorders in shipyard workers.
R-31
Back to Main
J Soc Occup Med 38(4):109112. related risk factors for trapezius myalgia. In:
Hagberg M, Kolbom , eds. International
Troup JDG [1978]. Drivers back pain and its Scientific Conference on Prevention of Work-
preventiona review of the postural, vibratory, Related Musculoskeletal Disorders PREMUS,
and muscular factors, together with the problem Sweden, May 1214, 1992. Arbete och Hlsa
of transmitted road shock. Appl Ergonomics 17:307309.
9(4):207214.
Veiersted KG, Westgaard RH [1994].
Subjectively assessed occupational and
Troup JDG, Martin JW, Lloyd DC [1981].
individual parameters as risk factors for
Back pain in industry: a prospective survey.
trapezius myalgia. Int J Ind Ergo
Spine 6(1):6169. 13(3):235245.
Troup JDG, Foreman TK, Baxter CE, Brown Veiersted KB, Westgaard RH, Andersen P
D [1987]. Musculoskeletal disorders at work, [1993]. Electromyographic evaluation of
tests of manual working capacity and the muscular work pattern as a predictor of
prediction of low back pain. In: Buckle P, ed. trapezius myalgia. Scand J Work Environ
Musculoskeletal disorders at work. London, Health 19:284290.
England: Taylor and Francis, pp. 165170.
Vessey MP, Villard-Mackintosh L, Yeates D
Uhl JE, Wilkinson WE, Wilkinson CS [1987]. [1990]. Epidemiology of carpal tunnel
Aching backs? A glimpse into the hazards of syndrome in women of childbearing age.
nursing. AAOHN J 35(1):1317. Findings in a large cohort study. Int J
Epidemiol 19(3):655659.
Ulin SS, Armstrong TJ, Snook SH, Keyserling
WM [1993]. Perceived exertion and Videman T, Nurminen T, Tola S, Kuorinka I,
Vanharanta H, Troup JDG [1984]. Low-back
discomfort associated with driving screws at
pain in nurses and some loading factors of
various work locations and at different work
work. Spine 9(4):400404.
frequencies. Ergonomics 36(7):833846.
Videman T, Rauhala H, Asp S, Lindstrom K,
Undeutsch K, Grtner KH, Luopajrvi T, Cedercreutz G, Kamppi M, et al. [1989].
Kpper R, Karvonen MJ, Lwenthal I, et al. Patient-handling skill, back injuries, and back
[1982]. Back complaints and findings in pain: an intervention study in nursing. Spine
transport workers performing physically heavy 14(2):148156.
work. Scand J Work Environ Health 8(Suppl
1):9296. Videman T, Nurminen M, Troup JDG [1990].
Lumbar spine pathology in cadaveric material in
Ursin H, Endresen IM, Ursin G [1988]. relation to history of back pain, occupation, and
Psychological factors and self-reports of muscle physical loading. Spine 15(8):728740.
pain. Eur J Appl Physiol 57(3):282290.
Vihma T, Nurminen M, Mutanen P [1982].
Veiersted KG, Westgaard RH [1992]. Work-
Sewing machine operators work and
R-32
Back to Main
musculoskeletal complaints. Ergonomics [1986]. Generation of muscle tension related to

25(4):295298. a demand of continuing attention. In: Knave B,
Wideback PG, eds. Work with display units.
Viikari-Juntura E [1995]. The role of physical Amsterdam, The Netherlands: Elsevier Science
stressors in the development of hand/wrist, and Publishers, B.V. North-Holland, pp. 288293.
elbow disorders. In: Gordon SL, Blair SJ,
Armstrong, et al., eds. Pathophysiology and Walsh K, Varnes N, Osmond C, Styles R,
Coggin D [1989]. Occupational causes of low
clinical factors in upper extremity repetitive
back pain. Scand J Work Environ Health
motion syndromes. Bethesda, MD: American
15(1):5459.
Academy of Orthopedic Surgeons.
Waris P, Kuorinka I, Kurppa K, Luopajrvi T,
Viikari-Juntura EJ, Vuori J, Silverstein B, Virolainen M, Pesonen K, et al. [1979].
Kalimo R, Kuosma E, Videman T [1991a]. A Epidemiologic screening of occupational neck
life-long prospective study on the role of and upper limb disorders: methods and criteria.
psychosocial factors in neck-shoulder and low Scand J Work Environ Health 5(Suppl
back pain. Spine 16:10561061. 3):2538.
Viikari-Juntura E, Kurppa K, Kuosma E, Washington State Department of Labor and

Huuskonen M, Kuorinka I, Ketola R, et al. Industries [1996]. Work-related musculo-
[1991b]. Prevalence of epicondylitis and elbow skeletal disorders. Washington State summary
pain in the meat-processing industry. Scand J 19921994. Olympia, WA: Washington State
Work Environ Health 17(1):3845. Department of Labor and Industries,
Consultation and Compliance Services
Viikari-Juntura E, Riihimki H, Tola S, Division.
Videman T, Mutanen P [1994]. Neck trouble
Waters TR, Putz-Anderson V, Garg A, Fine LJ
in machine operating, dynamic physical work
[1993]. Revised NIOSH equation for the
and sedentary work: a prospective study on
design and evaluation of manual lifting tasks.
occupational and individual risk factors. J Clin
Ergonomics 36:749776.
Epidemiol 47(12):1411 1422.
Webster BS, Snook SH [1994a]. The cost of
Virokannas H [1995]. Dose-response relation compensable upper extremity cumulative
between exposure to two types of hand-arm trauma disorders. J Occup Med 36(7):713
vibration and sensorineural per-ception of 727.
vibration. Occup Environ Med 52:332336. Webster BS, Snook SH [1994b]. The cost of
1989 workers compensation low back pain
Virokannas H, Tolonen U [1995]. Responses claims. Spine 19(10):11111116.
of workers exposed to vibration in autono-mic
nervous function tests. Int Arch Occup Environ Weiss ND, Gordon L, Bloom T, So Y, Rempel
Health 67(3):201205. DM [1995]. Position of the wrist associated
with the lowest carpal-tunnel pressure:
Waersted M, Bjorklund R, Westgaard RH implications for splint design.
R-33
Back to Main
J Bone Joint Surg 77A (11):16951699. muscle load. Ergonomics 30(7):911923.
Welch LS, Hunting KL, Kellogg J [1995]. White AA, Gordon SL [1982]. Synopsis:
Work-related musculoskeletal symptoms workshop on idiopathic low back pain. Spine
among sheet metal workers. Am J Ind Med 7(2):141149.
27(6):783791.
WHO [1985]. Identification and control of
Wells JA, Zipp JF, Schuette PT, McEleney J work-related diseases. Geneva, Switzerland:
[1983]. Musculoskeletal disorders among World Health Organization. WHO Technical
letter carriers. J Occup Med 25(11):814 Report Series 714.
820.
WHO [1989]. Work with visual display
Werner RA, Franzblau A, Albers JW, Buchele terminals: psychosocial aspects and health. J
H, Armstrong TJ [1997]. Use of screening Occup Med 31(12):957968.
nerve conduction studies for predicting future
carpal tunnel syndrome. Occup Environ Med Wickstrm BO, Kjellberg A, Landstrm U
54:96100. [1994]. Health effects of long-term occupa-
tional exposure to whole-body vibration: a
Werner RA, Franzblau A, Johnston E [1994a]. review. Int J Ind Ergonomics 14:273292.
Quantitative vibrometry and electro-
physiological assessment in screening for carpal Wieslander G, Norbck D, Gthe CJ,
tunnel syndrome among industrial workers: a Juhlin L [1989]. Carpal tunnel syndrome (CTS)
comparison. Arch Phys Med and exposure to vibration, repetitive wrist
Rehabil 75:12281232. movements, and heavy manual work:
a case-referent study. Br J Ind Med 46(1):
Werner S, Albers JW, Franzblau A, Armstrong 4347.
TJ [1994b]. The relationship between body
mass index and the diagnosis of carpal tunnel Wiktorin C, Karlqvist L, Winkel J [1993].
syndrome. Muscle Nerve December:1492. Validity of self-reported exposures to work
postures and manual materials handling. Scand
Westerling D, Jonsson BG [1980]. Pain from J Work Environ Health 19:208214.
the neck-shoulder region and sick leave. Scand
J Soc Med 8(3):131136. Wilder DG, Pope MH [1996]. Epidemio-
logical and aetiological aspects of low back
Westgaard R, Aaras A [1985]. The effect of pain in vibration environmentsan update. Clin
improved workplace design on the develop- Biomechanics 11:6173.
ment of work-related musculoskeletal
disorders. Appl Ergonomics 16(2):9197. Wilson RN, Wilson S [1957]. Tenosynovi-tis in
industry. Practitioner 178:612615.
Westgaard R, Bjorklund R [1987]. Genera- Winkel J, Westgaard R [1992]. Occupational
tion of muscle tension additional to postural and individual risk factors for shoulder-neck
R-34
Back to Main
complaints. Part II: the scientific basis (literature Eastman Kodak, Windsor, Colorado.
review) for the guide. Int J Ind Ergonomics Cincinnati, OH: U.S. Department of Health,
10:85104. Education, and Welfare, Public Health Service,
Center for Disease Control, National Institute
Winkel J, Westgaard R [1992]. Occupational for Occupational Safety and Health, DHEW
and individual risk factors for shoulder-neck (NIOSH) Report No. TA 760131.
complaints. Part II. The scientific basis
(literature review) for the guide. Int J Ind Yu ITS, Wong TW [1996]. Musculoskeletal
Ergonomics 10:85104. problems among VDU workers in a Hong
Kong bank. Occup Med 46(4):275280.
Winn FJ, Habes DJ [1990]. Carpal tunnel area
as risk factor for carpal tunnel syndrome. Zwerling C, Ryan J, Schootman M [1993]. A
Muscle Nerve 13:254258. case-control study of risk factors for industrial
low back injury: the utility of preplacement
Wisseman C, Badger D [1976]. Hazard screening in defining high-risk groups. Spine
evaluation and technical assistance report: 18(9):242247.
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APPENDIX A
Epidemiologic Review
Various investigators have used different occupational epidemiologic methods to identify the patterns of
work-related MSD occurrence in different working groups, as well as the factors that influence these
disease patterns. The following section briefly summarizes these study designs and then addresses the
most common biases (such as misclassification or selection) that can affect the results of these studies.
TYPES OF EPIDEMIOLOGIC STUDY DESIGNS REVIEWED

The NIOSH reviewers have first addressed studies that use a prospective approach. Prospective
cohort studies, identify groups of subjects (exposed and nonexposed) and observe them over a period
of time to compare the number of new work-related MSD cases in the two groups. All subjects are
initially disease-free. The rate (or risk) of new cases (the incidence) is calculated for both groups, and
the ratio of these two incidences (the relative risk or rate ratio, RR) can be used to assess the
association of the exposure with the occurrence of the MSD. A RR greater than 1.0 implies that the
incidence of cases was higher in the exposed group than in the nonexposed group and that an
association has been observed between the exposure and the disease. A confidence interval (CI) is
derived, which is an estimated range of values within which the true RR is likely to fall. The CI reflects
the precision of the effect observed in the study. Ordinarily, if the CI includes 1.0, the association
between the exposure and the MSD could be due to chance alone and the elevated odds ratio (OR) is
not considered statistically significant.
The cohort study ensures that the exposure to work-related factors occurs before the observation of
the MSD, thereby allowing a causal interpretation of the observed association. Cohort studies are often
done prospectively; they follow a group of current workers forward in time. The length of time required
for a prospective study depends on the problem studied. With adverse health conditions that occur as a
result of long-term exposure to some factor in the workplace, many years may be needed. Extended
time periods make prospective studies costly. Arguing causation is more difficult with extended time
periods because other events may affect outcome. Prospective studies that require long periods of time
are especially vulnerable to problems associated with worker follow-up, particularly worker attrition
(workers discontinue participation in the study) and worker migration (diseased workers move to other
employment before investigators ascertain their disease).
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The second type of epidemiologic study evaluated for this document is the case-control study, which
is retrospective and examines differences in exposures among workers with (cases) and without
(controls) MSDs. In such studies, cases should be all incident (new) cases in a given population over a
defined period or a representative sample of the cases. Controls should be a representative sample of
non-cases from the same population. The ratio of the odds of exposed cases to the odds of exposed
controls is called the OR. An OR above 1.0 indicates an association between the exposure and the
work-related MSD, and a 95% CI indicates the probable range of the true OR. Case control studies
are useful for evaluating rarely occurring conditions or small numbers of cases. One limitation of case
control studies is the difficulty of obtaining accurate information about past exposures. In occupational
studies of MSDs, a further limitation of case-control studies is the difficulty of identifying cases who are
representative of all cases that occurred in a defined period (many of these workers will have left the
workforce). Another problem with case-control studies is the selection of an inappropriate control
group.
Third, the reviewers considered cross-sectional studies. Cross-sectional studies provide a snapshot
in time of a disease process; that is, they measure both health outcomes and exposures at a single point
in time. These studies usually identify occupations with differing levels of exposure and compare the
prevalences of MSDs in each group. Cross-sectional studies are most useful for identifying risk factors
of a relatively frequent disease with a long duration that is often undiagnosed or unreported [Kleinbaum
et al. 1982]. Typically, cross-sectional studies do not provide the evidence of the correct temporal
relationship between exposure and disease inherent in prospective studies, but they nevertheless can be
valuable. Some cross-sectional studies discussed here had inclusion criteria such as working at a
specific job for a defined period of time before onset of symptoms. This condition adds a dimension of
temporality to the studies. A common problem with cross-sectional studies that use surveys is obtaining
sufficiently large response rates; many people who are asked to participate decline because they are
busy, not interested, etc. The conclusions are therefore based on a subset of workers who agree to
participate, and these workers may not be representative of or similar to the entire population of
workers. Furthermore, cross-sectional studies are often confined to current workers who may not be
representative of true prevalence rates if workers with disease have left the workforce. (The problem of
representativeness is not confined to cross-sectional studies and may occur in the other study designs
mentioned whenever subjects are selected, decline, or drop out.) Either ORs or prevalence ratios
(PRs) (proportion of diseased in exposed divided by the proportion of diseased in unexposed) may be
used to report results in cross-sectional studies.
The last type of observational study used is the case-series study, in which certain characteristics of a
group (or series) of cases (or patients) are described. The simplest design is a set of case reports for
which the author describes some interesting or intriguing observations that occurred in a small number
of patients. Cases included in case series have usually been drawn from a single patient population,
whose makeup may have influenced the observations noted because of selection bias. Case-series
studies frequently lead to a generation of hypotheses that are subsequently investigated in a cross-
sectional, case-control, or prospective study. Because case-series do not involve comparison groups
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(who do not have the condition or exposure to the risk factors being studied), some investigators would
not consider them epidemiologic studies because they are generally not planned studies and do not
involve any research hypotheses.
BIASES AND OTHER ISSUES IN EPIDEMIOLOGIC STUDIES

In interpreting the validity of epidemiologic studies to provide evidence for work-relatedness of MSDs,
several assumptions and sources of bias must be considered when analyzing the findings from such
studies.
1. Selection bias (internal validity). In occupational health studies, at least two types of selection bias
may occur: (a) a selection of healthy workers in the work population studied, and (b) an exclusion
of sick workers who leave the active workforce. Both of these biases tend to cause an
underestimate of the true relationship between a workplace risk factor and an observed health
effect because the workers who are in better health tend to be those in the workforce and available
for study.
A basic assumption underlying the analysis of these studies is that the selected cases of work-
related MSDs in the specific studies are representative of all workers at that worksite with work-
related MSDs. In a single study, representativeness generally increases with increasing population
size and participation rate. A parallel assumption is that the nondiseased groups are representative
of the entire nondiseased population. The fact that some cases leave the workforce causes the
disease prevalence among currently employed workers to be underestimated. However, if cases
are missing from the current workforce in equal proportion for both nonexposed and exposed
workers, the underestimate of prevalence will not affect the internal validity of the study.
2. Generalizability (external validity). Some studies are based on a single population, occupation, or
restricted data base (individual insurance companies, specific industrial settings) and, therefore, the
sample may not be representative of the general population. Another assumption is that MSD cases
in one study are comparable to cases in another study. This assumption needs particular scrutiny in
work-related MSD studies because no standardized case definitions may exist for the particular
illnesses.
3. Misclassification bias. Misclassification bias may be introduced during selection of cases and
determination of their exposure. Erroneous diagnoses may result in work-related MSD cases
misclassified as noncases, and similarly, noncases may be misclassified as cases. The calculated RR
or OR would usually underestimate the true association because of a dilutional effect if both
exposed and nonexposed cases are equally misclassified. Similarly, misclassification can occur
when determining the exposure factor of interest. Again, such misclassification will create a bias
towards finding no association if equal misclassification is assumed for cases and noncases.
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4. Confounding and effect modification. Other factors may explain the supposed relationship between
work and disease. Confounding is a situation in which the relationship (in this case with MSDs)
appears stronger or weaker than it truly is as a result of something (the confounder) being
associated with both the outcome and the apparent causal factor. In other words, the risk estimate
is distorted because symptoms of exposed and nonexposed workers differ because of some other
factors that cause disease. For example, diabetes might result in abnormal nerve conduction testing,
a sign of CTS. If a higher proportion of exposed workers than nonexposed workers were diabetic,
diabetes would act as a positive confounder, causing an apparent exposure-disease association.
An effect modifier is a factor that alters the effect of exposure on disease. For example, it is
possible that repetitive motion causes tendinitis only in older workers; in this case, age would be an
effect modifier. Although effect modification is not a bias per se, if an investigator has failed to
analyze old and young workers separately, the investigator might have missed a true work/disease
association.
5. Sample size, precision, and CIs. The CI around an estimated measure of effect (such as a RR) is an
estimated range of values in which the true effect is likely to fall. It reflects the precision of the effect
observed in the study. Large studies generally have smaller CIs and can estimate effects more
precisely. In studies that are statistically significant the CI excludes the null value for no effect (for
example, a RR of 1.0). Small studies are generally less precise, lead to wider CIs, and less likely to
be statistically significant even if the exposed have a greater prevalence of disease than the
nonexposed.
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APPENDIX B
Individual Factors Associated with Work-
Related Musculoskeletal Disorders (MSDs)
Although the purpose of this document is to examine the weight of evidence for the contribution of
work factors to MSDs, the multifactorial nature of MSDs requires a discussion of individual factors that
have been studied to determine their association with the incidence and prevalence of work-related
MSDs. These factors include age [Guo et al. 1995; Biering-Sorensen 1983; English et al. 1995;
Ohlsson et al. 1994]; gender [Hales et al. 1994; Johansson 1994; Chiang et al. 1993; Armstrong et al.
1987a]; anthropometry [Werner et al. 1994b; Nathan et al. 1993, Helivaara 1987]; and cigarette
smoking [Finkelstein 1995; Owen and Damron 1984; Svensson and Andersson 1983; Kelsey et al.
1990; Hildebrandt 1987], among others. Nonoccupational physical activities, such as nonoccupational
VDT use, hobbies, second jobs, and household activities that might increase risk for MSDs are
described in the detailed tables for those studies in which they were analyzed as risk factors.
A worker's ability to respond to external work factors may be modified by his/her own capacity, such
as tissue resistance to deformation when exposed to high force demands. The level, duration, and
frequency of the loads imposed on tissues, as well as adequacy of recovery time, are critical
components in whether increased tolerance (a training or conditioning effect) occurs, or whether
reduced capacity occurs which can lead to MSDs. The capacity to perform work varies with gender
and age, among workers, and for any worker over time. The relationship of these factors and the
resulting risk of injury to the worker is complex and not fully understood.
Certain epidemiologic studies have used statistical methods to take into account the effects of these
individual factors (e.g., gender, age, body mass index), that is, to control for their confounding or
modifying effects when looking at the strength of work-related factors. Studies that fail to control for the
influence of individual factors may either mask or amplify the effects of work-related factors. The
comments column of the detailed tables notes whether studies have adjusted for potential confounders.
A number of factors can influence a person's response to risk factors for MSDs in the workplace and
elsewhere. Among these are the following:
AGE
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The prevalence of MSDs increases as people enter their working years. By the age of 35, most people
have had their first episode of back pain [Guo et al. 1995; Chaffin 1979]. Once in their working years
(ages 25 to 65), however, the prevalence is relatively consistent [Guo et al. 1995; Biering-Sorensen
1983]. Musculoskeletal impairments are among the most prevalent and symptomatic health problems of
middle and old age [Buckwalter et al. 1993]. Nonetheless, age groups with the highest rates of
compensable back pain and strains are the 2024 age group for men, and 3034 age group for
women. In addition to decreases in musculoskeletal function due to the development of age-related
degenerative disorders, loss of tissue strength with age may increase the probability or severity of soft
tissue damage from a given insult.
Another problem is that advancing age and increasing number of years on the job are usually highly
correlated. Age is a true confounder with years of employment, so that these factors must be adjusted
for when determining relationship to work. Many of the epidemiologic studies that looked at
populations with a wide age variance have controlled for age by statistical methods. Several studies
found age to be an important factor associated with MSDs [Guo et al. 1995; Biering-Sorensen 1983;
English et al. 1995; Ohlsson et al. 1994; Riihimki et al. 1989a; Toomingas et al. 1991] others have not
[Herberts et al. 1981; Punnett et al. 1985]. Although older workers have been found to have less
strength than younger workers, Mathiowetz et al. [1985] demonstrated that hand strength did not
decline with aging; average hand pinch and grip scores remained relatively stable in their population with
a range of 29 to 59 years. Torell et al. [1988] found no correlation between age and the prevalence of
MSDs in a population of shipyard workers. They found a strong relationship between workload
(categorized as low, medium, or heavy) and symptoms or diagnosis of MSDs.
Other studies have also reported a lack of increased risk associated with aging. For example, Wilson
and Wilson [1957] reported that the age and gender distribution of 88 patients with tenosynovitis from
an ironworks closely corresponded to that of the general population of that plant. Similarly, Wisseman
and Badger [1976] reported that the median age of workers with chronic hand and wrist injuries in their
study was 23 years, while the median age of the unaffected workers was 24 years. Riihimki et al.
[1989a] found a significant relationship between sciatica and age in machine operators, carpenters, and
sedentary workers. Age was also a strong risk factor for neck and shoulder symptoms in carpenters,
machine operators and sedentary workers [Riihimki et al. 1989a]. Some authors may have incorrectly
attributed age as the sole cause of their findings in their analysis, when data presented suggested a
relationship with work [Schottland et al. 1991].
An explanation for the lack of an observed relationship between an increased risk for MSDs and aging
may be survivor bias (this is different from the healthy worker effect). If workers who have health
problems leave their jobs, or change jobs to one with less exposure, the remaining population includes
only those workers whose health has not been adversely affected by their jobs. As an example, in a
study of female plastics assembly workers, Ohlsson et al. [1989] reported that the degree of increase in
the odds of neck and shoulder pain with the duration of employment depended on the age of the
worker. For the younger subjects, the odds increased significantly as the duration of employment
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increased (p=0.01), but for the older ones no statistical change was found with length of employment.
The older women who had been employed for shorter periods of time had more reported symptoms
than the younger ones, while older workers with longer employment times reported fewer symptoms
than younger workers. Ohlsson et al. [1989] interviewed 76 former assembly workers and found that
26% reported pain as the cause of leaving work. This finding supports the likely role of a survivor bias
in this study, the effect of which is to underestimate the true risk of developing MSDS, in this case in the
older workers.
GENDER
Some studies have found a higher prevalence of some MSDs in women [Bernard et al. 1994; Hales et
al. 1994; Johansson 1994; Chiang et al. 1993]. A male to female ratio of 1:3 was described for carpal
tunnel syndrome (CTS) in a population study in which occupation was not evaluated [Stevens et al.
1988]. However, in the Silverstein [1985] study of CTS among industrial workers, no gender
difference could be seen after controlling for work exposure. Franklin et al. [1991] found no gender
difference in workers compensation claims for CTS. Burt et al. [1990] found no gender difference in
reporting of neck or upper extremity MSD symptoms among newspaper employees using video display
terminals (VDTs). Nathan et al. [1988, 1992a] found no gender differences for CTS. In contrast,
Hagberg and Wegman [1987] reported that neck and shoulder muscular pain is more common among
females than males, both in the general population and among industrial workers. Whether the gender
difference seen with some MSDs in some studies is due to physiological differences or differences in
exposure is unclear. One laboratory study, Lindman et al. [1991], found that women have more type I
muscle fibers in the trapezius muscle than men, and have hypothesized that myofascial pain originates in
these Type I muscle fibers. Ulin et al. [1993] noted that significant gender differences in work posture
were related to stature and concluded that the lack of workplace accommodation to the range of
workers' height and reach may, in part, account for the apparent gender differences. The reporting bias
may exist because women may be more likely to report pain and seek medical treatment than men
[Armstrong et al. 1993; Hales et al. 1994]. The fact that more women are employed in hand-intensive
jobs and industries may account for the greater number of reported work-related MSDs among
women. Bystrm et al. [1995] reported that men were more likely to have deQuervains disease than
women; they attributed this to more frequent use of hand tools. Some studies have reported that
workplace risk factors account for increased prevalence of MSDs among women more than personal
factors (e.g., Armstrong et al. [1987a], McCormack et al. [1990]). In a recent evaluation of Ontario
workers compensation claims for RSI, Asbury [1995] reported a RR for female to male claims
ranging from 1.3 to 1.6 across industries. Within 5 different broad occupational categories, females
were approximately 25 times as likely to have a lost-time RSI claim. No information on gender
differences in hand intensive jobs was reported. May researchers have noted that men and women tend
to be employed in different jobs.
In order to separate the effect of work risk factors from potential effects that might be attributable to
biological differences, researchers must study jobs that men and women perform relatively equally.
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SMOKING
Several papers have presented evidence that a positive smoking history is associated with low back
pain, sciatica, or intervertebral herniated disc [Finkelstein 1995; Owen and Damron 1984; Frymoyer et
al. 1983; Svensson and Anderson 1983; Kelsey et al. 1984]; whereas in others, the relationship was
negative [Kelsey et al. 1990; Riihimki et al. 1989b; Frymoyer 1993; Hildebrandt 1987]. Boshuizen et
al. [1993] found a relationship between smoking and back pain only in those occupations that required
physical exertion. In their study, smoking was more clearly related to pain in the extremities than to pain
in the neck or the back. Deyo and Bass [1989] observed that the prevalence of back pain increased
with the number of pack-years of cigarette smoking and with the heaviest smoking level. Helivaara et
al. [1991] only observed a relationship in men and women older than 50 years. Two studies did not find
a relationship between sciatica and smoking among concrete reinforcement workers and house painters
[Helivaara et al. 1991; Riihimki et al. 1989b].
In the Viikari-Juntura et al. [1994] prospective study of machine operators, carpenters, and office
workers, current smoking (OR 1.9 1.03.5), was among the predictors for change from no neck
trouble to severe neck trouble. In a study of Finnish adults ages 3064, [Mkel et al. 1991], neck
pain was found to be significantly associated with current smoking (OR 1.3, 95% CI 11.61) when the
logistic model was adjusted for age and gender. However, when the model included mental and
physical stress at work, obesity, and parity, then smoking (OR 1.25, 95% CI 0.991.57) was no
longer statistically significant [Mkel et al. 1991]. With univariate analysis, Holmstrm [1992] found a
PRR of 1.2 (95% CI 1.11.3) for neck-shoulder trouble in current smokers versus never smokers.
But using multiple logistic regression, when age, individual and employment factors were in the model,
only never smoked contributed significantly to neck-shoulder trouble. Toomingas et al. [1991] found
no associations between multiple health outcomes (including tension neck, rotator cuff tendinitis, CTS
or problems in the neck/scapula or shoulder/upper arm) and nicotine habits among platers, assemblers
and white collar workers. In a case/referent study, Wieslander et al. [1989] found that smoking or using
snuff was not related to CTS among men operated on for CTS .
Several explanations for the relationship have been postulated. One hypothesis is that back pain is
caused by coughing from smoking. Coughing increases the abdominal pressure and intradiscal pressure
and puts strain on the spine. A few studies have observed this relationship [Deyo and Bass 1989;
Frymoyer et al. 1980; Troup et al. 1987]. The other mechanisms proposed include nicotine-induced
diminished blood flow to vulnerable tissues [Frymoyer et al. 1983], and smoking-induced diminished
mineral content of bone causing microfractures
[Svensson and Andersson 1983]. Similar associations with diminished blood flow to vulnerable tissues
have been found between smoking and Raynaud's disease.
PHYSICAL ACTIVITY
The relationship of physical activity and MSDs is more complicated than just cause and effect.
Physical activity may cause injury. However, the lack of physical activity may increase susceptibility to
injury, and after injury, the threshold for further injury is reduced. In construction workers, more
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frequent leisure time was related to healthy lower backs [Holmstrm et al. 1993] and severe low back
pain was related to less leisure time activity [Holmstrm et al. 1992]. On the other hand, some standard
treatment regimes have found that musculoskeletal symptoms are often relieved by physical activity.
Having good physical condition may not protect workers from risk of MSDs. NIOSH [1991] stated
that persons with high aerobic capacity may be fit for jobs that require high oxygen uptake, but will not
necessarily be fit for jobs that require high static and dynamic strengths and vice versa.
When physical fitness is examined as a risk factor for MSDs, results are mixed. For example, some
early case series reported an increased risk of MSDs associated with playing professional sports
[Bennet 1946; Nirschl 1993], or with physical fitness and exercise [Kelsey 1975b; Dehlin et al. 1978,
1981] while other studies indicate a protective effect and reduced risk [Cady et al. 1979; Mayer et al.
1985; strand et al. 1987; Biering-Sorensen 1984]. Boyce et al. [1991] reported that only 7% of
absenteeism could be explained by age, sex, and physical fitness among 514 police officers 35 years or
older. Cady et al. [1979, 1985], on the other hand, found that physical capacity was related to
musculoskeletal fitness. Cady defined fitness for most physical activities as combinations of strength,
endurance, flexibility, musculoskeletal timing and coordination. Cady et al. [1979] evaluated male fire
fighters and concluded that physical fitness and conditioning had significant preventive effects on back
injuries (least fit 7.1% injured, moderately fit 3.2% injured and most fit 0.8% injured). However, the
most fit group had the most severe back injuries. Low cardiovascular fitness level was a risk factor for
disabling back pain in a prospective longitudinal study among aerospace manufacturing workers by
Battie et al. [1989]. Good endurance of back muscles was found to be associated with low occurrence
of low back pain [Biering-Sorensen 1984].
Few occupational epidemiologic studies have looked at non-work-related physical activity

in the upper extremities. Most NIOSH studies [Hales and Fine 1989; Kiken et al. 1990; Burt
et al. 1990; Baron et al. 1991; Hales et al. 1994; Bernard et al. 1994] have excluded MSDs
due to sports injury or other nonwork-related activity or injury and have not included these factors in
analyses. However, many of the risk factors that are important in occupational
studies occur in sports activitiesforceful, repetitive movements with awkward postures.
A combination of high exposure to load lifting and high exposure to sports activities that
engage the arm was a risk factor for shoulder tendinitis, as well as osteoarthritis of the acromioclavicular
joint [Stenlund et al. 1993]. Kennedy et al. [1978] found that 15% of competitive swimmers with
repetitive overhead arm movements had significant shoulder disability primarily due to impingement
from executing butterfly and freestyle strokes. Epicondylitis in professional athletes has been well
documented, and many of the
biomechanical and physiological studies of epicondylitis have been conducted
in professional tennis players and baseball pitchers [King et al. 1969; Nirschl 1993]. One prospective
study of healthy baseball players has found slowing of the suprascapular nerve function as the season
progresses [Ringel et al. 1990]. Scott and Gijsbers [1981] found an association between athletic
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performance and pain tolerance, and suggested that physically fit persons may have a higher threshold
for injury.
In summary, although physical fitness and activity is generally accepted as a way of reducing work-
related MSDs, the present epidemiologic literature does not give such a clear indication. The sports
medicine literature, however, does give a better indication that sports involving activities of a forceful,
repetitive nature (such as tennis and baseball pitching) are related to MSDs. It is important to note that
professional sports activities usually provide players (i.e., workers) with more substantial breaks for
recovery and shorter durations for intense tasks as compared with more traditional work settings in
which workers are required to perform repetitive, forceful work for 8 hours per day, 5 days per week.
STRENGTH
Some epidemiologic support exists for the relationship between back injury and a mismatch of physical
strength and job tasks. Chaffin and Park [1973] found a sharp increase in back injury rates in subjects
performing jobs requiring strength that was greater or equal to their isometric strength-test values. The
risk was three times greater in the weaker subjects. In a second longitudinal study, Chaffin et al. [1977]
evaluated the risk of back injuries and strength and found the risk to be three times greater in the
weaker subjects. Keyserling et al. [1980] strength-tested subjects, biomechanically analyzed jobs, and
assigned subjects to either stressed or non-stressed jobs. Following medical records for a year, they
found that job matching based on strength criteria appeared to be beneficial. In another prospective
study, Troup et al. [1981] found that reduced strength of back flexor muscles was a consistent
predictor of recurrent or persistent back pain, but this association was not found for first time
occurrence of back pain.
Other studies have not found the same relationship with physical strength. Two prospective studies of
low back pain reports (or claims) of large populations of blue collar workers [Battie et al. 1989; Leino
1987] failed to demonstrate that stronger (defined by isometric lifting strength) workers are at lower
risk for low back pain claims or episodes. One study followed workers for ten years after strength
testing and the other followed workers for a few years. Neither of these studies included precise
measurement of exposure level for each worker, so the authors could not estimate the degree of
mismatch between workers' strength and tasks demands. Battie et al. [1990] compared workers with
back pain with other workers on the same job (by isometric strength testing) and did not find that
workers with back pain were weaker. In two studies of nurses [Videman et al. 1989; Mostardi et al.
1992] lifting strength was not a reliable predictor of back pain.
When examined together, these studies reveal the following: The studies that found a significant
relationship between strength/job task and back pain used more thorough job assessment or analysis
and have focused on manual lifting jobs. However, these studies only followed workers for a period of
one year, and whether this same relationship would hold over a much longer working period remains
unclear. Studies that did not find a relationship, although they followed workers for a longer period of
time, did not include precise measurements of exposure level for each worker, so they could not assess
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the strength capabilities that were important in the individual jobs. Therefore, they could not estimate the
degree of mismatch between workers' strength and task demands.
ANTHROPOMETRY
Weight, height, body mass index (BMI) (a ratio of weight to height squared), and obesity have all been
identified in studies as potential risk factors for certain MSDs, especially CTS and lumbar disc
herniation.
Few studies examining anthropometric risk factors in relationship to CTS have been occupational
epidemiologic studies; most have used hospital-based populations who may differ substantially from
working populations. Nathan et al. [1989, 1992, 1994] have published several papers on the basis of a
single industrial population and have reported an association between CTS and obesity; however, the
methods employed in their studies have been questioned in a number of subsequent publications [Gerr
and Letz 1992; Stock 1991; Werner et al. 1994b]. Several investigators have reported that their
industrial study subjects with CTS were shorter and heavier than the general population [Cannon et al.
1981; Dieck and Kelsey 1985; Falk and Aarnio 1983; Nathan et al. 1992; Werner et al. 1994b;
Wieslander et al. 1989]. In the Werner et al. [1994b] study of a clinical population requiring
electrodiagnostic evaluation of the right upper extremity, patients classified as obese (BMI>29) were
2.5 times more likely than slender patients (BMI<20) to be diagnosed with CTS. Werner et al. [1994b]
developed a multiple linear regression CTS model (with the difference between median and ulnar
sensory latencies as the dependent variable) that demonstrated that BMI was the most influential
variable, but still only accounted for 5% of the variance in the model. In Nathan's [1994a] logistic
model, body mass index accounted for 8.6% of the total risk; however, this analysis used both hands
from each study subject as separate observations, although they are not independent of each other.
Falck and Aarnio [1983] found no difference in BMI among 17 butchers with (53%) and without
(47%) CTS. Vessey et al. [1990] found that the risk for CTS among obese women was double for that
of slender women. The relationship of CTS and BMI has been suggested to relate to increased fatty
tissue within the carpal canal or to increased hydrostatic pressure throughout the carpal canal in obese
persons compared with slender persons [Werner 1994b].
Carpal tunnel canal size and wrist size has been suggested as a risk factor for CTS, however, some
studies have linked both small and large canal areas to CTS [Bleecker et al. 1985; Winn and Habes
1990].
For back MSDs, Hrubec and Nashold [1975] found that height and weight were predictive of
herniated disc disease among World War II U.S. army recruits compared with age-matched controls.
Some studies have reported that people with back pain, are, on the average, taller than those without it
[Rowe 1965; Tauber 1970; Merriam et al. 1980; Biering-Sorensen 1983]. Helivaara et al. [1987], in
a Finnish population study, found that height was a significant predictor of herniated lumber disc in both
sexes, but a moderately increased BMI was predictive only in men. Severe obesity (exceeding 30
kg/m2) involved less risk than moderate obesity. Kelsey [1975a] and Kelsey et al. [1984] failed to
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reveal any such relationships between height or BMI among patients with herniated lumber discs and
control subjects. Magora and Schwartz [1978] found an association between obesity and radiological
disc degeneration, but Kellgren and Lawrence [1958] did not. A study of Finnish white collar and blue
collar workers found no association between overweight (relative weight (>120%) and lumbosacral
disorders either cross-sectionally or in a 10-year follow-up [Aro and Leino 1985].
Schierhout et al. [1995] found that short stature was significantly associated with pain in the neck and
shoulder among workers in 11 factories, but not in the back, forearm, hand and wrist. Height was not a
factor for neck, shoulder or hand and wrist MSDs among newspaper employees [Bernard et al. 1994].
Kvarnstrm [1983a] found no relationship between neck/shoulder MSDs and body height in a Swedish
engineering company with over 11,000 workers.
Anthropometric data are conflicting, but in general indicate that there is no strong correlation between
stature, body weight, body build and low back pain. Obesity seems to play a small but significant role in
the occurrence of CTS.
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APPENDIX C
Summary Tables
Appendix C contains summary tables of articles reviewed in this document. These tables provide a
concise overview of the studies reviewed relative to the evaluation criteria, risk factors addressed, and
other issues.
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Appendix C Table C-1. Summary table for epidemiologic studies evaluating work-related neck musculoskeletal disorders
Components
of study Andersen 1993a Andersen 1993b Baron 1991 Bergqvist 1995a Bergqvist 1995b Bernard 1994 Ferguson 1976 Hales 1989
Study type CS CS CS CS CS CS CS CS
Participation Y Y N Y Y Y Y Y
rate $ 70%
Outcome S S and PE S and PE S and PE S and PE S S S and PE

Exposure Job title Categorization by Observation, Questionnaire, Questionnaire, Observation, Measurements, Observation, video
categorization job duration video analysis, observation observation questionnaire observation, taping, job
measurement of questionnaire categorization,
items, (assessment was
(assessment was for hand/wrist, not
for hand/wrist, not neck)
neck)
Covariates Age, having Age, having Age, gender, Age, gender Adjustments made Age, gender, Height, weight Age, duration of
considered children, not children, not duration of work for confounders height, employment
exercising, exercising, environment psychosocial
smoking, SES, smoking, SES factors
marital status
Investigators Y Y Y Y Y Y NR Y
blinded
Repetition Combined Combined Combined Repeated work Combined Time spent typing: Combined
movements: 3.6 NS
(0.4-29.6)
Force Combined Combined Combined Combined

Extreme Combined Combined Too highly placed Time spent on NR, sig.
posture keyboard: 4.4 telephone: 1.4
(1.1-17.0) (1.0-1.8)
Vibration
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Components
of study Andersen 1993a Andersen 1993b Baron 1991 Bergqvist 1995a Bergqvist 1995b Bernard 1994 Ferguson 1976 Hales 1989
Risk factors Sewing operators Current high Checkers vs. VDT work >20 hr High exposure vs.
(combined) vs. referents: 4.9 exposure: noncheckers: 2.0 and eye glasses at Low exposure
(2.0-12.8) 1.6 (0.7-3.6) (0.6-6.7) VDT: 6.9 (1.1-42) jobs
8 to 15 years: 6.8 (estimated crude
(1.6-28.5) OR): 3.7 (0.4-164)
Outcome, neck
symptoms:
RR=1.64 (0.4-3.9)
Duration of 0 to 7 years: 1.9 0 to 7 years: 2.3 NS NS Adjusted for in

employment (1.3-2.9) (0.5-11) analysis
8 to 15 years: 3.8 8 to 15 years: 6.8
(2.3-6.4) (1.6-28.5)
>15 years: 5.0 >15 years: 16.7
(2.9-8.7) (4.1-67.5)
Physical
workload
Psychosocial Job satisfaction: Limited break Deadline hr: 1.7

factors NS opportunity: 7.4 work variance: 1.7
(3.1-17.4) management
issues: 1.9
Individual/oth Age at least 40 Age $ 40 years: Age, gender, Females with Smoking, stress Age, gender, Age
er factors years: 1.5 1.9 (0.9-4.1); hobbies controlled children: 6.4; reaction, height,
considered (1.1-2.2); having having children: for in analysis smoking, stress stomach-related psychosocial
children: 1.3 0.5 (0.1-1.7); reaction, stress, use of factors; VDT use
(0.8-2.0); SES: exercise: 1.4 stomach-related spectacles, peer outside of work
1.29 (0.7-2.3); (0.6-2.9); stress, use of contacts, rest
smoking: 1.39 smoking: 1.5 spectacles, peer breaks, work task
(0.99-1.9) (0.7-3.3) contacts, rest flexibility, overtime,
breaks, work static work
task flexibility, position, nonuse of
overtime, static lower arm support,
work position, hand in
nonuse of lower non-neutral
arm support, posture, high
hand in visual angle to
non-neutral VDT, glare on VDT
posture, high
visual angle to
VDT, glare on
VDT
Dose/respon Years worked:

se Sig.
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Components
of study Hales 1994 Hunting 1994 Kamwendo 1991 Kiken 1990 Knave 1985 Kukkonen 1983 Kuorinka 1979 Linton 1990
Study type CS CS CS CS CS Prospective, CS CS

intervention
Participation Y Y Y Y Y NR Y Y
rate $ 70%
Outcome S and PE S S S and PE S S and PE S and PE S
Exposure Observation, Questionnaire Questionnaire Observation, Observation, gaze Observation, Observation, job Questionnaire
questionnaire (assessment was direction interview analysis, video
for hand/wrist, instrument, job title taping
not neck) or self-report (assessment was
for hand/wrist,
not neck)
Covariates demographics, Years worked, Age, length of Age, gender Age, gender, Gender, Age, duration of Age, gender,
considered work practices, age, current work employment, smoking, prospective employment, BMI, exercise, eating
age, gender, as electrician, psychosocial educational design metabolic disease, regularly, smoking,
hobbies gender work environment status, drinking hobbies, extra alcohol
work consumption,
psychosocial
variables
Investigators Y NR NR Y NR Y NR NR
blinded
Repetition Combined Combined Combined Combined Scissor makers
vs. Referents: 4.1
(2.3-7.5)
Short cycle tasks
vs. long cycle
tasks: 1.64
(0.7-3.8)
Force Combined Combined

Extreme Use of bifocals: Combined Combined Combined Combined Combined Uncomfortable
posture 3.8 (1.5-9.4) posture and poor
psychosocial
environment: 3.5
(2.7-4.5)
Vibration Univariate
analysis showed
elevated OR for
vibration
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Components
of study Hales 1994 Hunting 1994 Kamwendo 1991 Kiken 1990 Knave 1985 Kukkonen 1983 Kuorinka 1979 Linton 1990
Risk factors Work with office High exposure vs. Typing hr: Sig. Intervention Scissor-makers
(combined) machines >5 low exposure group: PRR=3.6 vs. department
hr/day: 1.65 jobs: 1.3 (0.2-11) (2.2-5.9) No store shop
(1.02-2.67) intervention 1.0 assistants:
OR=4.1 (2.3-7.5)
Duration of NS 1 to 3 years: 1 Length of Controlled for
employment 4 to 5 years: 1.3 employment: Sig.
6 to 10 years: 1.6
>10 years: 1.3
Physical Being given too

workload much to do: Sig.
Psychosocial Decision making: Ability to influence Interest in work, Monotonous work

factors 4.2; productivity work, cooperative positive attitude SS, work content,
standard: 3.5; spirit between work load, social
fear of co-workers: sig. support
replacement by
computer: 3.0;
higher information
processing
demands: 3.0; job
task variety: 2.9;
work pressure:
2.4
Individual/oth Electronic Age group, Sitting 5 or more Extra work, Exercise, eating,
er factors performance current work as hr/day: 1.6 hobbies, outside smoking, alcohol
considered monitoring, electrician: NS (0.9-2.8); age: activities: NS consumption
keystrokes, Sig.
hobbies,
recreational
activities: NS
Dose/respon Between
se registered work
duration and
musculoskeletal
complaints
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Components
of study Liss 1995 Luopajrvi 1979 Milerad 1990 Ohlsson 1989 Ohlsson 1995 Onishi 1976 Ryan 1988 Sakakibara 1987
Participation N Y Y NR Y NR Y Y
rate $ 70%
Outcome S S and PE S S S and PE S and PE S and PE S
Exposure Questionnaire Observation, Questionnaire Questionnaire Videotaping, Observation, then Observation Observation job
video analysis, observation, job categorization measurements at analysis and neck
interviews analysis of work stations angle
posture, flexion of measurements
neck,
questionnaire
Covariates N Age, gender, Gender, age, Age, gender, Age , gender, Age, height, length
considered social leisure-time duration of psychosocial of training time
background, exposure, employment scales
hobbies, amount systemic disease
of housework
Investigators N Y NR NR Blinded to NR Y NR
blinded exposure
information but
Not possible to
completely blind
the examiners.
Repetition Combined Combined Combined Combined Combined Combined Combined
Force Combined Combined Industrial workers Combined

exposed to
repetitive tasks
vs. referents: 3.6
(1.5-8.80)
Extreme Combined Combined Combined Combined Combined Significant Combined

posture difference in mean
elbow angle and
shoulder flexion of
left arm
Vibration NS for exposure

to vibration
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Components
of study Liss 1995 Luopajrvi 1979 Milerad 1990 Ohlsson 1989 Ohlsson 1995 Onishi 1976 Ryan 1988 Sakakibara 1987
Risk Factors Dental hygienists Assembly Dentists compared Assemblers vs. Film rolling Pear work vs.
(Combined) vs. dental workers vs. shop to pharmacists: referents pain in workers: 3.8 apple work right
assistants: 1.7 assistants: 1.6 2.1 (1.4-3.1) last 12 months: Lamp assemblers: side: p<0.05
(1.1-2.6) (0.9-2.7) 1.9 (0.9-3.7) Pear work vs.
3.8 (2.1-6.6)
Teachers and Apple work at left
nurses: 1.5 side: p<0.01
(0.7-3.2)
Duration of NS NS Employees NS
employment <35 years: Sig.
Physical
workload
Psychosocial Increased OR for Insufficient rest,

factors medium and fast break time, more
paced work boredom, more
compared to slow stress, lower peer
paced but OR cohesion, lower
lower for very antonomy, lower
fast paced work job clarity, higher
staff support,
higher work
pressure
Individual/oth Gender (99% Leisure time Age, height,

er factors females in study exposure, marital and
considered group); had to smoking systemic parental status,
modify work or disease handedness,
unable to work at length of training
some point: 2.4 time
(1.1-5.4)
Dose/respon
se
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Components
of study Sakakibara 1995 Schibye 1995 Veiersted 1994 Viikari-Juntuna Welch 1995 Wells 1983 Yu 1996
1994
Study type CS Cohort Cohort Cohort CS CS CS
Participation Y Y N (55%) Y Y (83%) Y Y

rate $ 70%
Outcome S and PE S S and PE/ pain diaries S S S S

Exposure Observation, Questionnaire EMG, interviews Questionnaire, Questionnaire Questionnaire, Questionnaire
measurements every 10 weeks observation interview
Covariates Subjects served as Metabolic or other All male, smoking, Smoking, years of Age, gender, number Age, gender, other
considered their own controls diseases, gender age, physical employment of years on job, covariates
exercise, occupation, previous work
duration of work, car experience,
driving education, marital
status, quetelet ratio
Investigators NR NR NR Y N NR NR
blinded
Repetition Combined Combined Frequent VDT use:

28.9 (2.8-291.8)
Force Combined Strenuous previous Combined Combined

work: 6.7 (1.6-28.5)
Extreme Combined Combined Strenuous postures: No neck pain to Percent of time Combined Inclining neck at
posture 7.2 (2.1-25.3) severe, machine hanging duct: 7.5 work: 784.4
operators vs. office (0.8-68) (33.2-18,630)
workers: 3.9
(2.3-6.9)
Persistently severe:
4.2 (2.0-9.0)
Vibration Vibration (floor or Combined (machine
machine) operators)
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Components
of study Sakakibara 1995 Schibye 1995 Veiersted 1994 Viikari-Juntuna Welch 1995 Wells 1983 Yu 1996
1994
Risk factors Pear vs. Apple Other employment Physical Occupation Sig. from All letter carriers vs. Frequent video
(combined) bagging: 1.5 group vs. garment environment: 0.9 no neck trouble to Clerks and readers: display terminal use:
(0.99-2.35) workers: 3.3 (0.5-1.7) moderate neck 2.57 (1.13-6.2) 28.9 (2.8-291.8)
(1.4-7.7) trouble; occupation
Sig. from no neck to
severe neck trouble
Carpenters vs.
Office workers
persistently severe:
3.0 (1.4-6.4)
Duration of NS Controlled for in
employment analysis
Physical
workload
Psychosocial Psychosocial Job satisfaction: NS
factors` factors: 3.3
(0.8-14.2)
Individual/oth Age Anthropometrics, Current smoking and Education, marital General health
er factors general health, age Sig. in model of status, quetelet ratio
considered previous employment no neck trouble to
variables, draft, severe neck trouble
noise, personality
Dose/respon
se
Not studied.
BMI Body mass index.
CS Cross-sectional.
EMGElectromyography.
hrs Hours.
MSDMusculoskeletal disorders
MVCMaximum voluntary contraction.
N No.
NR Not reported.
NS Not statistically significant.
OR Odds ratio.
PE Physical examination.
PRR Prevalence rate ratio.
S Symptoms.
SES Socioeconomic status.
Sig. Statistically significant.
VDT Video display terminal.
vs. Versus.
Y Considered (yes).
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Appendix C Table C-2. Summary table for evaluating work-related neck/shoulder disorders
Components
of study aras 1994 Andersen 1993a Andersen 1993b Bergqvist 1995a Bergqvist 1995b Bjelle 1981 Blder 1991 Ekberg 1994
Study type Prospective CS CS CS CS Case Control CS Case Control
Participation NR Y Y Y Y NR Y Y
rate $$70%
Outcome S and Records S S and PE S S and PE S and PE S and PE S
Exposure Observation and Job title Categorization by Observation, Job title and Observation, Questionnaire Questionnaire
EMG categorization job duration measurements questionnaire videotape
analysis
Covariates Age, having Age, having Age, gender, Age, gender, Age, Age, nationality, Age, gender,
considered children, children, smoking, rest smoking anthropometric employment time, smoking, having
education, marital education, marital breaks, stress data working hr/week preschool children
status, smoking, status, smoking,
not exercising not exercising
Investigators NR Y Y Y Y Y; Videotape N NR
blinded analysis blinded to
case status
Repetition Combined Combined For intensive <20 hr/week VDT No sig difference Combined Precise repetitive
neck/shoulder use: 1.2 (0.4-3.7) in cycle time movements
discomfort: 3.6 >20 hr/week VDT High: 15.6
(0.4-29.6) use: 0.7 (0.3-1.5) (2.2-113.0)
Force Static trapezius Combined Combined Cases had
load dropped from significantly

4.1 to 1.4% higher shoulder
NR, Sig. loads than
controls
Extreme Intervention For tension neck Cases with longer Combined Work with lifted
posture consisted of syndrome: too duration and arms 4.8 (1.3-18);
equipment and highly placed higher frequency uncomfortable
tool adjustment to VDT: 4.4 of abduction or sitting posture: 3.6
create relaxed (1.1-17.6) forward flexion (1.4-9.3)
position of than referents:
shoulders and NR, Sig.
neck: NR, Sig.
Vibration
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Components
of study aras 1994 Andersen 1993a Andersen 1993b Bergqvist 1995a Bergqvist 1995b Bjelle 1981 Blder 1991 Ekberg 1994
Risk factors Sewing machine Current high VDT work >20 hr Working >30 hr
(combined) operators vs. exposure (yes vs. and stressful per

referents: no): 1.6 (0.7-3.6) stomach week: p<0.05
4.6 (2.2-10.2) reactions: 3.9
(1.1-13.8)
VDT work $ 20 hr
and bifocals or
progressive
glasses: 6.9
(1.1-42.1)
Duration of Years as sewing Years as sewing Working >30
employment machine machine hr/week and

operators 0 to 7 operators tension neck
years: 3.2 0 to 7 years: 2.3 syndrome: p<0.05
(0.6-16.1) (0.5-11)
8 to 15 years: 8 to 15 years: 6.8
11.2 (2.4-52) (1.6-28.5)
>15 years: 36.7 >15 years: 16.7
(7.1-189) (4.1-67.5)
Physical
workload
Psychosocial For cervical Combined Smaller High work pace:
factors diagnoses: randomized study 3.5 (1.3-9.4);
Stressful stomach group interviewed Low work
reactions: 5.4 by sociologist and content: 2.6
(1.6-17.6) psychologist for (0.7-9.4);
psychosocial Work role
history ambiguity: 16.5
(6.0-46);
Demands on
attention: 3.8
(1.4-11)
Individual/ Median sick days Age >40 yrs: 1.96 Age $ 40 years: Children at home, Children at home, Age-isometric Cervical Female: 11.4
other factors decreased from (0.8-5); 1.9 (0.9-4.1); negative, negative, testing syndrome (4.7-28);
considered 22.9 to 1.8 exercise: children: 0.5 affectivity, peer affectivity, peer correlated with immigrant status:
1.28 (0.5-3.4); (0.1-1.7); contacts, contacts, age 4.9 (1.8-14);
smoking: exercise: 1.4 overtime, work overtime, work current smoker:
2.3 (0.9-6.1); (0.6-2.96); task flexibility, task flexibility, 8.2 (2.3-29)
children: 0.35 smoking: 1.5 visual angle to visual angle to
(0.1-1.9) (0.7-3.3) VDT VDT
Dose/respon Duration of Duration of Repetitive
se employment as employment precision
sewing machine movements, work
operator pace
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Components Kilbom 1986,
of study Ekberg 1995 Holmstrm 1992 Hnting 1981 Jonsson 1988 1987 Linton 1989 Maeda 1982 Milerad 1990
Study type CS CS CS Cohort CS CS CS CS
Participation Y Y NR Y Y Y NR Y
rate $$70%
Outcome S S S and PE S and PE S and PE S S S
Exposure Questionnaire Questionnaire Observation, Observation, Observation, video Questionnaire Observation, Questionnaire
questionnaire video taping, job taping, job dealing with measurement
analysis, MVC of analysis, MVC of psychosocial
forearm forearm issues
Covariates Age, smoking, Age, physical Psychosocial Used prospective Age, spare time Gender, leisure
considered exercise habits, factors, factors cohort design physical activities, time, smoking,
family situations psychosocial with same study hobbies, systemic disease
with preschool stress scales sample psychosocial
children, immigrant stress, muscle
status, gender strength
Investigators NR Y NR Y Y NR NR NR
blinded
Repetition Repetitive Combined Combined Combined Combined
movements
demanding
precision: 1.2
(1.0-1.3)
Force Combined Combined
Extreme Hand above Combined/head Combined Combined Constrained tilted Combined

posture shoulder: <1 inclination >56E head posture:
hr/day: 1.1 Sig. for p<0.05
(0.8-1.5) neck/shoulder
1 to 4 hr/day: 1.5 MSDs
(1.2-1.9)
>4 hr/day: 2.0
(1.4-2.7)
Vibration NS
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Components Kilbom 1986,
of study Ekberg 1995 Holmstrm 1992 Hnting 1981 Jonsson 1988 1987 Linton 1989 Maeda 1982 Milerad 1990
Risk factors Roofers: 1.6 Data entry At third year, 38 Average time/work Dentists vs.
(combined) Plumbers: 1.5 workers vs. workers cycle in neck pharmacists:
Floor workers: 1.3 non-keyboard- reallocated had flexion sig, Upper 2.1 (1.3-3.0);
using office improved, 26% arm abducted males: 2.6
workers: 9.9 with unchanged 0-30E: NR, Sig. (1.2-5.0); females
(3.7-26.9) conditions 2.0 (1.3-3.1)
deteriorated
further: NR, Sig.
Duration of NS NS
employment
Physical
workload
Psychosocial Qualitative Job satisfaction; Job satisfaction, Productivity, work Poor work content:
factors demands: 1.4 relationship with productivity satisfaction, 2.5 (1.3-4.9)

(1,2) supervisors, perceived stress: Lack of social
Quantitative colleagues; NS support: 1.6
demands: 3.0 decision making, (0.9-2.8)
(2.1-4) use of skills all NS Work demand
Solitary work: 1.5 social support at
(1.2-1.8) work
Anxiety: 3.2
(2.5-4)
Individual/ Immigrant status: Psychosomatic: Medical findings in Age, muscle Age Leisure time,
other factors 1.3 (1.1-1.5) 5.0 (3.6-6.9) neck and shoulder strength, rest smoking NS
considered Social work Psychological: 4.7 significant for pauses: NS
climate, work (3.6-6) typists with head
planning, job Stress: 3.4 rotation
security, job (2.6-4.2) >20E compared to
constraints Discretion, < 20E
support, under
stimulation,
anxiety, job
satisfaction,
quality of life
Dose/respon Stress index and
se neck-shoulder
MSDs
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Components Viikari-Juntura
of study Ohara 1976 Ohlsson 1995 Punnett 1991 Rossignol 1987 Ryan 1988 Tola 1988 Vihma 1982 1991a
Study type CS and Cohort CS CS CS CS CS CS Cohort

Participation CS study: NR; Y Y N to Y (6 Y Y overall: NR Y
rate $$70% industries) 67% carpenters
Cohort: Y 67% office
workers
Outcome S and PE S and PE S S S S S S and PE
Exposure Observation Observation, Observation, Questionnaire Observation, Occupation title Observation, Questionnaire
video, analysis, questionnaire workstation interview
muscle strength measurement,
testing questionnaire
Covariates Used prospective Age, gender, Age, gender Age, cigarette Height, weight, Years in Age, duration of Physical hobbies,
considered cohort design psychosocial smoking, industry, gender, age, occupation, age, employment creative hobbies
with same study scales education, VDT marital status, leisure time
sample training parental status activities, car
driving, general
health
Investigators NR Y to exposure NR NR Y NR NR NR
blinded information,
no for physical
Repetition Combined Repetitive work: Combined Combined Combined
4.6 (1.9-12)
Force Combined
Extreme Combined Significant time Associated with Combined More non-cases Use of twisted or Combined Sitting in a
posture spent in neck extended duration trained in bent postures forward posture
flexion <60: NR of and lifting adjustment of during work: Little Sewing machine 1-3 hr/day: 10.7
weight in furniture than (referent): 1.0 operator with (0.4-291);
abduction/flexion cases: NR, Sig. Moderate: 1.2 significantly >3 hr/day: 1.5
and extension of (1.0-1.5) greater static (0.7-29.5)
the shoulder Rather much: 1.6 work compared to
(1.4-1.9) seamstresses
Very much: 1.8
(1.5-2.2)
Vibration
See footnotes at end of table. (continued)
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Components Viikari-Juntura
of study Ohara 1976 Ohlsson 1995 Punnett 1991 Rossignol 1987 Ryan 1988 Tola 1988 Vihma 1982 1991a
Risk factors Operators hired Industrial workers Male: 1.8 (1.0-3.2) to 3 hr of VDT Machine operators Sewing machine
(combined) post-intervention vs. referents: 2.7 Female: 0.9 use: 1.8 (0.5-6.8) vs. office operators vs.
had less reports (1.2-6.3) (0.5-1.9) 4 to 6 hr of VDT workers: 1.7 seamstresses:
of MSDs use: 4.0 (1.5-2.0) 1.6 (1.1-2.3)
(1.1-14.8) 7 $ hr Carpenters vs.
of VDT use: 4.6 office workers:
(1.7-13.2) 1.4 (1.1-1.6)
Duration of
employment
Physical Cases had
workload significantly
higher shoulder
loads
Psychosocial Stress/worry Adequate rest Job satisfaction, Social confidence,

factors tendency: 1.9 breaks, boredom, poor vs. very much fear vs.
(1.1-3.5) work stress job good: 1.2 (1.1-1.4) none: 1.4
pressure, (0.05-42.2);
autonomy, peer Sense of
cohesion, role coherence: 0.95
ambiguity, staff (0.9-0.99)
support
Individual/oth Muscle tension Smoking, industry, Working in a draft: Alexithymia
er factors tendency: 2.3 education 1.1 (1.0-1.3) 1.02 (0.97-1.1)
considered (1.3-4.9)
Dose/respon Hours of VDT use Use of twisted or
se bent posture
Not studied S Symptoms
CI Confidence interval Sig. Statistically significant
CS Cross-sectional VDT Video display terminal
EMG Electromyography vs. Versus
hr Hours Y Considered (yes)
Med. Medium
MSDSMusculoskeletal disorders
MVC Maximum voluntary contraction
N No
NR Not reported
NS Not statistically significant
OR Odds ratio
PE Physical examination
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Appendix C Table C-3. Summary table for evaluating work-related shoulder musculoskeletal disorders
Components
of study Andersen 1993a Andersen 1993b Baron 1991 Bergenudd 1988 Bernard 1994 Bjelle 1979 Bjelle 1981 Burdorf 1991
Study type CS CS CS CS CS Case control Case control CS

Participation Y Y N N Y NR NR Y for riveters;
rate $$70% N for referents
Outcome S S and PE S and PE S and PE S S and PE PE S
Exposure Job title, Job title, Observation and Questionnaire, job Questionnaire and Observation, Measurement, Observation,
categorization by categorization by videotape classification observation measurement, videotape measurement of
job duration job duration analysis, weight (light, moderate, analysis, vibration
of scanned items, heavy physical EMG on 15 cases, observation, EMG
job category demands) open muscle on 3 subjects and
biopsies on 11 2 healthy
cases volunteers
Covariates Age, having None for the Age, gender, Gender Age, race, Age, gender, and Age, gender, and Height, weight,
considered children, not shoulder analysis hobbies, duration gender, height, workshop place of work smoking status
exercising, of work, second medical
duration of job, metabolic conditions,
employment, disease, duration psychosocial
socioeconomic of employment factors, typing hr
status, smoking away from work
status, current
neck/shoulder
exposure
Investigators Y Y Y NR N N Y NR
blinded
Repetition for Combined Combined Combined R no surrogate for Combined Combined
shoulder hand used:

number of hr
typing
Force Combined Combined Combined Combined Cases had Sig.
higher shoulder
loads than
controls
Extreme Combined Combined Combined Combined Combined
posture
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Components
of study Andersen 1993a Andersen 1993b Baron 1991 Bergenudd 1988 Bernard 1994 Bjelle 1979 Bjelle 1981 Burdorf 1991
Vibration 1.5 (no

confidence limits)
Risk factors Increasing years Chi sq test for Checkers vs. Work at or above Cases had Sig.
(combined) of experience: trend using others 3.9 shoulders, cases longer duration
1.38-10.25 (Sig.) exposure time in (1.4-11.0) (65%) vs. and higher
years for rotator Checkers using referents (15%): frequency of
cuff syndrome: scanners vs. 10.6 (2.3-54.9) abduction or
9.51; p<0.01 others 8.6 forward flexion
(1.0-72.2) than controls,
p<0.001
Duration of See under See under Risk Number of hr per Years at Years of riveting:
employment Physical factors combined week as a newspaper: 1.4 0.05# p<0.10
workload checker Sig. (1.2-1.8)
Physical 0 to 7 years: 1.56 Prevalence of
workload (0.76-3.75) occupational

8 to 15 years: workload in
4.28 (2.14-10.0) subjects with
>15 years: 7.27 shoulder pain:
(3.82-16.3) Heavy, 11%;
Moderate, 49%;
Light, 40%
Psychosocial Females showed Lack of decision
factors Sig. association making

with shoulder pain participation: 1.6
and (1.2-2.1)
dissatisfaction job pressure: 1.5
(1.0-2.2)
Individual/oth Age-matched Age-matched Age, gender, Gender Gender, race, Age, gender Age, gender; Age
er factors controls controls metabolic disease height median number of
considered sick-leave days
Sig. different
between cases
and controls,
p=0.01
Dose/respon Y with years of Y with years of
se employment exposure
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Components
of study Burt 1990 Chiang 1993 English 1995 Flodmark 1992 Hales 1989 Hales 1994 Herberts 1981 Herberts 1984
Study type CS CS Case control CS CS CS CS CS
Participation Y Y Y Y Y Y NR NR
rate $$70%
Outcome S S and PE S and PE S S and PE S and PE S and PE S and PE
Exposure Observation, Observation and Self-reports Observation Observation and Analyses by job Analyses by job
questionnaire, job recording of walk-through, job questionnaire title title
sampling representative categorization
jobs, hand F
estimation High vs. low
exposure
(hand/wrist
exposure)
Covariates Age, gender, Age, gender, Age, height, Age, headache, Age and duration Age, race, Age, job duration Controls matched
considered psychosocial metabolic gender, weight, tiredness, medical of employment gender, work for age and
factors, metabolic diseases injury, study problems, practices, work gender
disease duration center, hobbies, sleeping problems organization
of employment sporting activities, or lack of factors, individual
average hr of concentration, factors, electronic
driving, sleep performance
compensation monitoring,
claim made recreational
activities, hobbies
Investigators Y Y Y Y NR NR
blinded
Repetition for Typing speed fast Repetitive Combined Combined No Combined Combined
shoulder compared to movement of
slow: 4.1 upper limb: 1.6
(1.8-9.4) (1.1-2.5)
Force Sustained forceful Combined Welders vs. office Welders vs. office
movement of workers: 15-18 workers: 15-18
upper limb: 1.8
(1.2-2.5)
Extreme Combined Combined Number of times Combined Combined

posture arising from chair:
1.9 (1.2-15.5)
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Components
of study Burt 1990 Chiang 1993 English 1995 Flodmark 1992 Hales 1989 Hales 1994 Herberts 1981 Herberts 1984
Vibration
Risk factors Repetition Repeated Any symptom of Welders vs. office ST results of 23
(combined) multiplied by shoulder rotation shoulder: 49% vs. workers: shoulder welders called
force: 1.4 with elevated arm: 43%; symptoms: 15.2 back for clinical
(1.0-2.0) 2.3, p<0.05 1.2 (0.7-2.0) (2.1-108) follow-up exams:
16 had ST; 18.3
Period Shoulder (13.7-22.1)
prevalence: 19% Tendinitis: 8.3 (90% CI)
vs. 4%; 3.8 (NS)
(0.6-22.8) ST results of 30
plate-workers
Point prevalence: called back for
7% vs. 4%;0.9 clinical follow-up
(0.1-7.3) exams: 15
plate-workers had
ST: 16.2
(10.9-21.5)
(90% CI)
Duration of NS
employment
Physical NS
workload
Psychosocial Job Type A Behavior: Fear of
factors dissatisfaction: p<0.001 replacement by

2.3 (1.2-4.3) computers: 1.5
(1.1-2.0)
Individual/oth Pre-existing Plant effect age: Per 5 years of Typing outside of
er factors arthritis: 2.3 1.0 (0.9-1.1) age: 1.4 (1.2-1.5) work

considered (1.2-4.4) Gender: 1.1
(0.7-1.7)
Dose/respon Dose response
se found for
shoulder
diagnosis as
exposure status
increased from
Group 1 to
Group 3
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Component Kilbom 1986,
of study Hoekstra 1994 Hughes 1997 Ignatius 1993 Jonsson 1988 Kiken 1990 1987 Kvarnstrm McCormack
1983 1990
Study type CS CS CS Prospective CS CS CS and Case CS
control
Participation Y N N Y Y Y NR Y
rate $$70%
Outcome S S and PE S S and PE S and PE S and PE S and PE S and PE
Exposure Analyses based Observation and Observation, Observation, Observation Observation, Observation, Observation
on questionnaire, job analysis questionnaire, measurement of (exposure based measurement, interview,
self-reports weight of mail exertion, on repetitive and videotaping, questionnaire
bags videotaping forceful hand observation
motions, not
shoulder)
Covariates Age, seniority, Controlled for age, Age, duration of Age, hobbies, Age and gender Age, years of Age, gender,
considered gender smoking status, employment, bag spare time, employment, race, job
sports, hobbies weight, walking physical action, productivity, category, duration
time psychosocial muscle strength of employment,
factors, breaks, general health
rest pauses history
Investigators Y NR NR Y Y Y N N
blinded
Repetition for Combined Combined Combined Fewer total Combined Combined
shoulder number of upper
arm flexions/hr.
(p<0.05)
Force Combined Combined Combined
Extreme Non-optimally Years of forearm Combined Relative time Combined Greater Combined Combined
posture adjusted desk twist: 46.0 spent with percentage of
height work: 5.1 (3.8-550) shoulder elevated work cycle time
(1.7-15.5) negatively related with upper arm
to remaining abducted 0-30
healthy after (p<0.05)
both 1 and 2
years: Sig.
Vibration
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Component Kilbom 1986,
of study Hoekstra 1994 Hughes 1997 Ignatius 1993 Jonsson 1988 Kiken 1990 1987 Kvarnstrm McCormack
1983 1990
Risk factors Center B Letter delivery 38 subjects who Plant #1 Die casting Boarding workers
(combined) compared to postal workers were reallocated Any symptom for machine vs. knitting
Center A: 4.0 compared to other to more varied shoulder: 46% vs. operators: 5.4; workers: 2.1
(1.2-13.1) postal workers tasks improved 28%; 1.6 (0.9-2.9) plastic workers: (0.6-7.3)
Recurrent: 1.8 2.2; spray
(1.5-2.2) Period prevalence: painters: 3.7;
13% vs. 3%; 4.0 surface treatment
Severe joint pain: (0.6-29) operators: 4.7;
2.2 (1.5-3.1) Plant #2 assembly line
Any symptom for workers: 5.2
shoulder: 50% vs.
30%; 1.7 (0.8-3.3)
Period prevalence:
14%vs. 5%; 2.8
(0.4-19.6)
Duration of Years of NS
employment employment in
electronics:
p<0.05
Physical Low muscle
workload strength no a
predictor for
shoulder MSD
Psychosocial Job Low decision Strong negative 9 cases and 1
factors dissatisfaction, latitude: 4.0 relationship control reported

exhaustion (not (0.8-19) between poor relationship
for shoulder) remaining health with supervisor.
and satisfaction Sig. differences in
with colleagues group piece rate,
shift work, heavy
work, monotonous
work, stressful
work,
Individual/oth Location Age: 0.93 Age, work Predictors of Shorter stature: Sig. differences in
er factors (0.8-1.0); good experience, bag deterioration, p<0.05, heavy lifting and
considered health: 0.35 weight, walking previously productivity: NS, unsuitable
(0.1-0.87) time physically heavy muscle strength: working
job, high NS conditions
productivity, and
sick leave
Dose/respon
se

Back to Main
Components
of study Milerad 1990 Ohara 1976 Ohlsson 1989 Ohlsson 1994 Ohlsson 1995 Onishi 1976 Punnett 1985 Rossignol 1987
Study type CS CS and CS CS CS CS CS CS
Prospective
Participation Y NR (CS), NR Y Y NR Y Y: clerical
rate $$70% Y (Prospective) workers
N: industry groups
Outcome S S and PE S S and PE S and PE S, PE, and S and PE S
measurement
Exposure Questionnaire Observation Job categorization Observation, Observation, Observation Observation and Observation and
questionnaire, video analysis, questionnaire questionnaire
video analysis measurement
Covariates Age, gender, Age, gender Sports activities, Age, employment Body height, Age, number of Age, cigarette
considered leisure time (females only) age, gender status weight, grip years employed, smoking, industry,
exposure, (females only) strength native language VDT educational
smoking, systemic psychosocial training
disease, duration factors
of employment
Investigators NR NR NR Y Yes, to exposure NR NR
blinded information
Repetition for Combined Combined Combined Combined Combined Combined Combined 4-6 hrs. VDT use:
shoulder 4.0 (1.0-16.9)
>7 hrs. VDT use:
4.8 (1.6-17.2)
Force Combined Combined Combined Combined Combined Combined Combined
Extreme Combined Combined Combined Combined Combined Combined Combined
posture
Vibration NS
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Components
of study Milerad 1990 Ohara 1976 Ohlsson 1989 Ohlsson 1994 Ohlsson 1995 Onishi 1976 Punnett 1985 Rossignol 1987
Risk factors Dentists vs. Shoulder Assemblers vs. Supraspinatus, Assembly work Shoulder Garment workers
(combined) pharmacists: stiffness: referents shoulder infraspinatus, or compared to tenderness: vs. hospital
males: 2.4 cashiers (81% vs. pain last 7 days: bicipital tendinitis referent 5.0 assemblers vs. employees 2.2
(1.0-5.4), office workers 3.4 (1.6-7.1) working in the fish (2.2-11.0) ref.: 1.1 (0.6-1.9); (1.0-4.9)
females: 2.4 (72%), 1.7 industry: OR=3.03 film rollers vs.
(1.5-3.7) (1.0-2.8) (2.5-7.2) ref.: 6.0
Shoulder dullness (3.0-12.2);
and pain: Shoulder tendinitis teachers vs. ref.:
cashiers (49%) alone: PRR=3.5 1.6 (0.7-3.3)
vs. other workers (2.0-5.9) Shoulder
(68%), 2.0
(1.4-2.8); vs. stiffness:
office workers reservationists
(30%), 2.2 vs. ref: 2.5
(1.4-3.5) (1.1-5.6);
assemblers vs.
ref.: 3.7 (2.0-7.0);
film rollers vs.
ref.: 2.7 (1.5-4.9);
teachers vs. ref.:
2.1 (0.9-4.6)
Duration of NS Sig. with duration For age <45 <10 years: 9.6 NS
employment of employment years, duration of (2.8-33.0)

(p=0.03) for employment 10-19 years: 4.4
younger workers showed dose- (1.5-13.0)
but not older response with >20 years: 3.8
workers shoulder MSDs (1.4-10.0)
Physical
workload
Psychosocial Increasing work Stress, worry Control,
factors pace factors, stimulation,
tendencies psychosocial
towards muscle climate, work
tension Sig. strain, social
support,
psychosomatic
symptoms
Individual/oth Sports activities: Employment Body height and
er factors 4-9 status weight: NS

considered
Dose/respon Reported pain For age <45 As VDT use
se increased with years, duration of increased,
increasing work employment and shoulder
pace except for shoulder MSDs symptoms
very high paces increased
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Components
of study Sakakibara 1987 Sakakibara 1995 Schibye 1995 Stenlund 1992 Stenlund 1993 Sweeney 1994 Wells 1983
Study type CS CS Cohort CS CS CS CS
Participation Y Y Y (But there was a Y Y N Y

rate $$70% significant dropout of
work as a sewing
machine operator in
those >35 years
Outcome S S and PE S S and PE S and PE S and PE S
Exposure Observation and Observation and Questionnaire Questionnaire, Questionnaire and Questionnaire Questionnaire, job
measurement of measurement of self-reports, weight self-reports categorization
postures representative of tools
workers or job titles job title, duration of
employment
Covariates Gender, age Cohort study: Age, smoking, Age, handedness, Age, number of
considered followed same dexterity, ethnicity smoking, sports years on job,
workers over time activities, duration of quetelet ratio,
employment previous work
experience,
education
Investigators NR NR Y Y Yes NR
blinded
Repetition for Combined Combined Combined
shoulder
Force Combined Combined Manual work: Combined
right side: 1.1
(0.7-1.8)
left side: 1.9
(1.0-3.4)
Extreme Thinning out, bagging Combined Combined Combined Combined

posture pears had
significantly more
forward shoulder
flexion than bagging
apples
Vibration Right side: 2.2 Right side 1.7
(1.0-4.6) (1.1-2.6)
Left side: 3.1 left side 1.8 (1.1-3.1)
(1.4-6.9)
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Components
of study Sakakibara 1987 Sakakibara 1995 Schibye 1995 Stenlund 1992 Stenlund 1993 Sweeney 1994 Wells 1983
Risk factors Pear baggers Development of Rockblasters vs. Rock blasters >20 hrs./ week Letter carriers with
(combined) compared to apple shoulder symptoms Foremen: 4.0 compared to signing: 2.5 (0.8-8.2) increased shoulder
baggers: 1.7 not related to work (1.8-9.2) foremen: load vs. postal
(1.1-2.9) exposure but Bricklayers right side: 1.7 clerks: 5.7 (2.1-17.8)
Posture: NR, Sig. significant dropout of (0.7-4.0)
workers >35 years compared to left side: 3.3
foremen: (1.2-9.3)
right side: 2.2
(1.0-4.7)
Physical Right side: 1.0
workload (0.6-1.8)
left side: 1.8
(0.9-3.4)
Psychosocial
factors
Individual/oth Rock blasters
er factors compared to
considered foremen:
Right side: 2.1
(0.9-4.6)
Left side: 4.0
(1.8-9.2)
Duration of Right side: 2.9 NS

employment (1.2-7.4)
Left side: 2.5
(1.0-5.9)
Dose/respon None for increasing As length of High vibration
se piece work in employment and compared to low

previous years exposure to vibration vibration
and amount lifted
increased,
osteoarthritis of
shoulder increased
Not studied. Ref. Referents.
EMGElectromyography. S Symptoms.
F Force. Sig. Significant.
MSDMusculoskeletal disorders. ST Supraspinatus tendinitis.
N Considered (no). PE Physical examination.
NR Not reported. VDT Video display terminals.
NS Not statistically significant. Y Considered (yes).
R Repetition.
C-25
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Appendix C Table C-4. Summary table for evaluating elbow musculoskeletal disorders
Components
of study Andersen 1993a Baron 1991 Bovenzi 1991 Burt 1990 Bystrm 1995 Chiang 1993 Dimberg 1987 Dimberg 1989
Participation Y N NR Y Y Y Y Y
rate $$70%
Outcome S S and PE S and PE S S and PE S and PE S and PE S and PE
Exposure Job categorization Observation Observation, Questionnaire Observation, Observation Observation job Observation, job
by job duration videotape, checklist, vibration videotape videotape analysis analysis,
questionnaire measured analysis, EMG of analysis, EMG categorization categorization
forearm muscle
load collected,
however, job title
used for analysis
Covariates Age, number of Age, gender, Age, ponderal Age gender, Gender, age >40 Age, gender, Gender, age, Ponderal index,
considered children, smoking, hobbies, second index years on job, years, psycho- metabolic disease employee gender, age, time
socioeconomic jobs, height, psychosocial social variables category, degree in present job,
status systemic disease factors and potential of stress, tennis height, weight,
confounders playing smoking, house
addressed by ownership,
Fransson-Hall et racquet sports
al. 1995
Investigators Y Y Y Y Y to Y NR NR
blinded questionnaire
responses,
No to exposure
status
Repetition Combined Combined 80% of time Combined Combined
reported typing
vs. 0-19% of time:
2.8 (1.4-5.7)
Force Combined Combined Combined Combined Combined Combined Combined
Extreme Combined Combined Combined Combined Combined Combined Combined

posture
C-26
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Components
of study Andersen 1993a Baron 1991 Bovenzi 1991 Burt 1990 Bystrm 1995 Chiang 1993 Dimberg 1987 Dimberg 1989
Vibration Vibration-exposed p<0.01

forestry workers
vs. referents: 4.9
(1.27-56.0)
Risk factors Sewing machine Checkers vs. Reporters Assembly line Group III vs. Group Force and posture: Force and
(combined) operators vs. Noncheckers: compared to workers vs. I (females): 1.44 NR, Sig. posture: NR, NS
general population 2.3 (0.5-11.0) others: 2.5 population referen (0.3-5.6)
1.7 (0.9-3.3) (1.5-4.0) ts: 0.74 High force/high
(0.04-1.7) repetition vs. low
force/low
repetition: (males)
6.75 (1.6-32.7)
Physical
workload
Psychosocial Job satisfaction: Job control and Addressed by Mental stress at

factors NS satisfaction: NS Fransson-Hall et the onset of
al. 1995 symptoms:
p<0.001
Individual/oth Sick leave more Work the cause Ponderal index
er factors common among in 35% of elbow associated with
considered strenuous jobs problems, most elbow symptoms
than white collar
nonstrenuous jobs
Duration of NS
employment
Dose/respon Y for time spent Y for males with
se typing increasing
force/repetition
C-27
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Components
of study Fishbein 1988 Hales 1994 Hoekstra 1994 Hughes 1997 Kopf 1988 Kurppa 1991 Luopajrvi 1979 McCormack
1990
Study type CS CS CS CS CS Cohort CS CS

Participation N Y Y N N Y Y Y
rate $$70%
Outcome S S and PE S S and PE S S and PE S and PE S and PE
Exposure Questionnaire Observation and Observation and Observation, Questionnaire, job Observation, Observation, Observation, job
Questionnaire Questionnaire checklist, formal categories measurements, interviews, categories based
job analysis categorized by job videotape analysis on manual
titles exposure
Confounders Age, gender Age, gender, Age, gender, Age, smoking Age, job Workers used as Age, gender, Gender, age,
considered stratification, metabolic location, seniority status, sports, satisfaction, job their own social race, job
smoking status, disorder, hobbies, hobbies, metabolic security, controls; age, background, category, years
alcohol, beta recreation diseases, acute moistness, gender, duration hobbies, amount of employment
blockers, other traumatic injuries, vibration, of employment of housework,
drugs smoking Scheuermans (with exceptions) length of
Disease employment
Investigators NR Y Y NR NR NR Y NR
blinded
Repetition Combined Number of key- Combined Combined Combined Combined
strokes per day:
NS
Force Number of years Combined Combined Combined Combined

handling >2.5
kg/hand: NS
Extreme Combined Non optimally Wrist flexion/ Combined Combined Combined
posture adjusted chair: 4.0 extension: NS;

(1.2-13.1) years of ulnar
deviation: NS;
years of forearm
twisting: 37
(3.0-470.0)
Vibration
C-28
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Components
of study Fishbein 1988 Hales 1994 Hoekstra 1994 Hughes 1997 Kopf 1988 Kurppa 1991 Luopajrvi 1979 McCormack
1990
Risk factors Female musicians Bricklayers Workers in Assembly Boarding vs. Non-
(combined) compared to compared to strenuous vs. workers vs. shop office workers:
males: 2.04 manual workers: nonstrenuous assistants: 0.5 (0.09-2.1)
(1.6-2.6) 2.8; Increasing job jobs: 6.7 for epicondylitis: Knitting vs. Non-
demands OR (3.3-13.9) 2.7 (0.66-15.9) office workers:
increased from 1.2 (0.5-3.4)
1.8 to 3.4
Physical Push/pull; lift Sig
workload carry: NS
Psychosocial Fear of Job Low decision
factors replacement by dissatisfaction; latitude:

computers: 2.9 exhaustion 3.5 (0.6-19.0)
(1.4-6.1); decision
making: 2.8
(1.4-5.7); surge in
workload: 2.4
(1.2-5.0)
Individual/oth Race (non-white): Age: 0.96 Age, race Sig

er factors 2.4 (1.2-5.0) (0.9, 1.2)
considered
Duration of Y, Sig, with <6
employment months and
>13 years
Dose/respon Yes, increasing No

se levels of job
demands
C-29
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Components
of study Moore 1994 Ohlsson 1989 Punnett 1985 Ritz 1995 Roto 1984 Viikari-Juntura 1991b
Study type CS CS CS CS CS CS
Participation Y NR Y for cases NR Y Y

rate $$70% N for referents
Outcome PE records S S S and PE S and PE S and PE
Exposure Observation, videotape Questionnaire, job Questionnaire, job Observation and record Job categorization Observation, job
analysis, job strain index categorization category review and employee analysis; weights of
interviews items
Confounders Age, gender, duration of Age, gender, duration of Age, number of years Age, age-squared, and Gender, other work Age, gender, duration of
considered employment employment employed, native history of cervical spine tasks employment, leaving the
language symptoms. Having ever company, changing the
played tennis, squash, task, being on sick leave
other racquet sports,
rowing, bowling,
Investigators Y NR NR Y Y NR
blinded
Repetition Combined Combined Combined Combined
Force 5.5 (1.5-62) Combined 10 years of high Combined Combined

exposure to elbow
straining work: 1.7
(1.0-2.7)
Extreme NR: was not found to be Combined Combined Combined
posture sig. associated with

hazardous jobs.
Vibration -
Risk factors Non significant pain in Garment workers vs. Meatcutters vs. Strenuous vs.
(combined) last year assembly vs. hospital employees: 2.4 construction workers: nonstrenuous: NS;
referents: 1.5 (0.6-3.4) (1.2-4.2) 6.4 (0.99-40.9), p=0.05 difference: 0.88
Work inability in last year (0.27-2.8)
assembly vs. Referents:
2.8 (0.8-10.7)
C-30
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Components
of study Moore 1994 Ohlsson 1989 Punnett 1985 Ritz 1995 Roto 1984 Viikari-Juntura 1991b
Physical
workload
Psychosocial
factors
Individual/oth Not associated with Age; Non-English
er factors work pace speakers sig. less likely

considered to report symptoms
Duration of No association Increased duration of All with epicondylitis had
employment current exposure >15 years of employment

increased risk of
epicondylitis
Dose/respon
se
Not studied.
CS Cross-sectional.
F force.
Hrs Hours.
MSDMusculoskeletal disorders.
N no.
NR Not reported.
R Repetition.
Sig. Statistically significant.
S Symptoms.
Y Considered (yes).
C-31
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Appendix C Table C-5a. Summary table for evaluating work-related carpal tunnel syndrome (CTS)
Components
of study Armstrong 1979 Barnhart 1991 Baron 1991 Bovenzi 1991 Bovenzi 1994 Cannon 1981 Chatterjee 1982 Chiang 1990
Study type CS CS CS CS CS Case control Case control CS

Participation NR N N NR Y NR Y Y
rate $$70%
Outcome S or surgery or PE PE and NCS S and PE S and PE S and PE Industry medical S and PE and NCS S and PE and NCS
findings records
Exposure Observation, Observation Observation, Observation, Observation, Medical records, Observation, Observation
video, EMG videotape measurement vibration, job category Measurement
analysis, job measurement
category
Covariates Gender, metabolic Age, gender Age, gender, Age, gender, Age, smoking, Age, gender, Age, gender Age, gender,
considered or soft tissue hobbies, past weight alcohol, upper limb race, weight, length of
disease employment, injuries occupation, years employment,
years on job employed, history of
workers metabolic disease
compensation
status, history of
metabolic disease,
hormonal status,
gynecologic
surgery
Investigators N Y, but clothing Y Y N NR Y Y

blinded may have biased
observation
Repetition Repetitive ski Combined 2.1 (0.7-5.3) 1.87
manufacturing vs. (p<0.018)
others NCS: 1.9
(1.0-3.6) PE+NCS:
4.0 (1.0-15.8)
S+PE+NCS: 1.6
(0.8-3.2)
C-32
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Components
of study Armstrong 1979 Barnhart 1991 Baron 1991 Bovenzi 1991 Bovenzi 1994 Cannon 1981 Chatterjee 1982 Chiang 1990
Force Pinch F: 2.0 Combined
(1.6-2.5)
Hand F: 1.05
(1.0-1.2)
Extreme Pinch force
posture exertion: 2.0

(1.6-2.5)
Vibration 23.1 (no Quarry drillers and 7.0 (3.0-170.0) 10.89
confidence limits) stone carvers vs. (1.02-524.0)

p=0.002 polishers and
machine
operators: 3.4
(1.4-8.3)
Risk factors Grocery checkers Chain saw High cold/ high
(combined) vs. other grocery operators vs. repetition: 11.66
workers: 3.7 maintenance (2.92-46.6)
(0.7-16.7) workers: 18.8
(2.7-795)
Duration of Y, Sig. 0.09 (0.8-10) NS

employment
Physical
workload
Psychosocial
factors
Individual/oth
er factors
considered
Dose/respon Y, Sig. Y, NS
se
C-33
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Components
of study Chiang 1993 deKrom 1990 English 1995 Frkkil 1988 Feldman 1987 Franklin 1991 Koskimies 1990 Liss 1995
Study type CS CS Case control CS CS for symptoms Retrospective CS CS

and cohort for cohort
NCS
Participation Y Y Y NR Y Y NR No
rate $$70%
Outcome S and PE S and PE and NCS S and PE S and PE and NCS S and in some PE Records review S and PE and NCS Mailed survey
and NCS of workers
compensation
cases
Exposure Observation, Questionnaire Questionnaire Interview Observation, Job title and Records of Mailed survey
measurement, biomechanical industry vibration exposure
EMG analysis,
videotaping
Covariates Age, gender, Age, gender, Gender, height, Alcohol Gender, past None NR Gender, age
considered metabolic disease, weight, slimming weight medical history,
hormonal status courses cigarette smoking,
hobbies
(No analyses
performed to take
these into
account)
Investigator Y NR, participants Y NR NR Y NR N

blinded blinded
Repetition Repetitive fish CTS patients vs. Combined Combined Combined

processing vs. other patients: 0.4
other: 1.1 (0.2-0.7)
(0.7-1.8)
Force Repetitive fish Combined Combined
processing vs.
other: 1.8
(1.1-2.9)
Extreme Reported 20 to 40 CTS patients vs. Combined Combined
posture hrs./week Flexed other patients: 1.8
wrist: 8.7 (1.2-2.8)
(3.1-24.1)
Extended 5.4
(1.1-27.4)
C-34
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Components
of study Chiang 1993 deKrom 1990 English 1995 Frkkil 1988 Feldman 1987 Franklin 1991 Koskimies 1990 Liss 1995
Vibration Vibration: Vibration
p< 0.05 exposure time and

NCS Sig. Right
hand: r=-0.27;
p=0.01
Left hand r=-0.12
p=NS
Risk factors Repetitive and Year 2 vs. Year 1, Oyster and crab CTS symptoms,
(combined) forceful fish numbness and packers vs. dental hygienists
processing vs. tingling in fingers: industry-wide vs. dental
others: 1.1 2.26 (1.14-4.46) rates: 14.8 assistants: 3.7
(0.7-1.8) (11.2-19.5) (1.1-11.9)
Female poultry Responder told
workers hi R/hi F that they had CTS:
vs. low R F: 2.6 5.2 (0.9-32.0)
(1.0-7.3)
Duration of Y,<12 months; No Exposure time Sig.
employment for 12 to 60
months and >60
months
Physical Y
workload
Psychosocial
factors
Individual/oth
er factors
considered
Dose/respons Y, Sig. Y, Sig.
C-35
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Components Morgenstern
of study Loslever 1993 Marras 1991 McCormack 1991 Moore 1994 Nathan 1988 Nathan 1992a Nathan 1992b
1990
Study type CS CS CS CS Retrospective CS Cohort Longitudinal

cohort
Participation Jobs selected due NR Y Y Y NR N Y=Japanese
rate $$70% to CTS N=Overall
occurrence
Outcome S Records and S and PE S PE and NCS from NCS S and NCS S and NCS
medical records records
Exposure Observation; Observation; Observation, job Survey Observation, Observation Observation Questionnaire
measurements, measurements title videotape,
videotaping measurement
Covariates Gender, age, Age, gender, Age, gender, Age, gender, None Age, gender Age, gender, hand Gender, hand
considered years on the job, handedness, job race, job pregnancy status, dominance, dominance,
hand orientation satisfaction category, years of work history job duration of occupational hand
employment tasks, use of employment and use, duration of
selected drugs, industry employment,
history of wrist industry, leisure
injury exercise, heavy
lifting, keyboard
use, coffee, tea,
alcohol
Investigator N NR NR N Y NR NR NR
blinded
Repetition Number of wrist Combined 1.88 (0.9-3.8) Combined Group II vs. Group Combined Found to be
movements: NS 1:1.0 (0.05-2.0) protective
Force Combined Grip forces three Combined Combined Combined Combined

times as great in
high-risk jobs
Extreme Combined Radial/ulnar ROM: Combined
posture 1.52 (1.1-2.1);

Flexion/extension
ROM: 1.3
(1.0-1.7);
Pronation/supinati
on ROM: 1.2
(0.9-1.6)
C-36
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Components Morgenstern
of study Loslever 1993 Marras 1991 McCormack 1991 Moore 1994 Nathan 1988 Nathan 1992a Nathan 1992b
1990
Vibration
Risk factors High force with Flexion/extension Boarding vs. Meat processors Group I vs. Group Group V vs. Americans with
(combined) high flexion: velocity: 3.8 non-office: 0.5 in hazardous vs. III: 1.7 (1.3-2.3) Group I: 1.0 significantly
r=0.62; high force (1.5-9.6) (0.05-2.9) safe jobs: 2.8 Group I vs. Group (0.5-2.2) greater
and high Flexion/extension Packing vs. Non- (0.2-36.7) V: 2.2 (1.3-3.3) Group IV vs. prevalence of CTS
extension: r=0.29 acceleration: 6.1 Group I: 1.4 compared to
office 0.4
(1.7-22) (0.9-2.1) Japanese
(0.04-2.4)
Group III vs. Group
Sewing vs. Non-
I: 1.5 (1.0-2.2)
office 0.9
(0.3-2.9)
Duration of Sig. Prevalence higher >34 hrs./week: Duration of
employment in workers with 1.9 (1.1-3.1) employment found
<3 years >9 years: 1.7 to be protective
employment (1.0-3.2)
Physical
workload
Psychosocial Job satisfaction:
factors NS
Individual/oth trunk depth: Sig. Age, hand Mean age, body
er factors dominance sig. mass index and
considered leisure exercise
Sig., cigarettes Sig
.
Dose/respons Y, Sig.
C-37
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Components
of study Osorio 1994 Punnett 1985 Schottland 1991 Silverstein 1987 Stetson 1993 Tanaka (In Press) Weislander 1989
Study type CS CS CS CS CS CS Case control

Participation Y Y for cases; N for NR Y Y Y Y
rate $$70% comparison group
Outcome S and PE, NCS S and PE NCS S and PE S and PE and NCS S S and PE and NCS
Exposure Job title, observation Observation, Job title Observation, Observation, Questionnaire Telephone interview
questionnaire videotape analysis, questionnaire, job
EMG analysis
Covariates Age, gender, alcohol, Age, gender, Age, gender Age, gender, plant, Age, height, skin Age, gender, race, Age, gender, year of
considered medical history hormonal status, years on job temperature, cigarettes, income, operation
native language, dominant index finger education, BMI
history of metabolic circumference
disease
Investigator Y NR NR Y NR No No
blinded
Repetition Combined Combined Combined Repetition: 5.5 p<0.05 NS 2.7 (1.3-5.4)
Force Combined Combined Combined Combined Y, Sig. combined
Extreme Combined Ulnar deviation and Combined (pinch Bending/twisting of
posture pinching, elevated grip) the wrist: 5.9

but NS (3.4-10.2)
Vibration 5.3 Vibration: 1.85 Vibrating tool use 3.3

(no confidence limits) (1.2-2.8) (1.6-6.8)
Risk factors NCS: 6.7 (0.8-52.9) Force, repetition, Workers vs. High force/high Y, Sig. median
(combined) Super-market posture: 2.7 (1.2-7.6) applicants: repetition vs. low sensory amplitudes
workers, high vs. females, right hand: force/low repetition: Sig. smaller (p <
low exposure 2.86 (1.1-7.9); 15.5 (1.7-142.0) 0.01) and latencies
symptoms: 8.3 males, right hand: longer (p<0.05) with
(2.6-26.4) 1.87 (0.6-9.8) exposure to high
pinch grip forces
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Components
of study Osorio 1994 Punnett 1985 Schottland 1991 Silverstein 1987 Stetson 1993 Tanaka (In Press) Weislander 1989
Duration of Y NS 0.9
employment p>0.09
Physical Y Loads on wrist 1.8
workload (1.0-3.5)
Psychosocial
factors
Individual/oth Female gender: 2.4
er factors (1.6-3.8); BMI $25:

considered 2.1 (1.4-3.1); white
race: 4.2 (1.9-15.6)
Cigarettes: 1.6
(1-2.5); annual
income $$20,000: 1.5
(1-2.4)
Dose/respons Y, Sig. Y, Sig.
e
Not studied
BMI Body Mass Index
CS Cross-sectional
CTS Carpal tunnel syndrome
EMGElectromyography
F Force
hrs Hours
NCS Nerve conduction studies
NR Not reported
NS Not statistically significant
PE Physical examination
R Repetition
Sig. Statistically significant
S Symptoms
Y Considered (yes)
C-39
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Appendix C Table C-5b. Summary table for evaluating work-related hand/wrist tendinitis
Components
of study Amano 1988 Armstrong Bystrm 1995 Kuorinka 1979 Kurppa 1991 Luopajrvi 1979 McCormack Roto 1984
1987a 1990
Study type CS CS CS CS Cohort CS CS CS
Participation NR Y Y Y Y Y Y Y
rate $ 70%
Outcome S and PE S and PE S and PE S and PE S and PE S and PE S and PE S and PE
Exposure Job titles or self- Observation, Questionnaire, Records, Observation, Observation, Observation, job Job title
reports measurements, observation, observation, measurements, measurements, category
video analysis, measurements, measurements, video analysis. video analysis
EMG videotape videotape Reader referred
analysis, EMG analysis to methods found
in previous
publications
Covariates Age, gender Age, gender, Age, gender, Age, gender, Age, gender Gender (only Race, age, gender Rheumatoid
considered years on job, and psychosocial body mass index, females in study arthritis
industrial plant factors muscle-tendon groups), age,
(addressed by syndrome hobbies,
Fransson-Hall housework,
et al. 1995) medical conditions
Investigator NR Y No NR NR Y NR Y=occupation
s blinded No=occupation of meat processing
subjects No=construction
foremen
(referent)
Repetition Combined Combined Combined Combined Combined Combined Combined Combined

Force Combined Combined Combined Combined Combined Combined Combined Combined
Extreme Combined Significant Combined Combined Combined Combined Combined

posture differences
between males
and females
Vibration
See footnotes at end of table (Continued)
C-40
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Appendix C Table C-5b. Summary table for evaluating work-related hand/wrist tendinitis
Components
of study Amano 1988 Armstrong Bystrm 1995 Kuorinka 1979 Kurppa 1991 Luopajrvi 1979 McCormack Roto 1984
1987a 1990
Risk factors Right index finger Comparison De Quervains Scissor makers Meat cutter Assembly line Textile workers Meat cutters vs.
(combined) flexor: 3.67 between low tendinitis among vs. shop compared to workers vs. shop compared to non- construction
(1.85-7.27) R/low F and high among auto assistants: 1.38 office workers: assistants: 4.13 office workers: workers: 3.09
Left index finger R/high F: assembly (0.76-2.51) risk ratio: 14.0 (2.63-6.49) 3.0 (1.4-6.4) (1.43-6.67)
flexor: 6.17 4.8 (0.6-39.7) workers vs. (5.7-34.4); Overall group
(2.72-13.97) 5.5 (0.7-46.3) general Meat packers exposed: 1.75
17.0 (2.3-126.2) population: 2.5 compared to (0.9-3.39)
(1.00-6.23) office workers:
risk ratio: 38.5
(11.7-56.1);
sausage makers
compared to
office workers:
risk ratio: 25.6
(19.2-77.5)
Physical
workload
Psychosocial Analyzed by
factors Fransson-Hall
et al. 1995
Individual/ Pieces handled NS for age, Female gender Rheumatoid

other factors over the years: a hobbies, or significant for arthritis found not
considered nonsignificant housework tendinitis at to be a
trend with p=0.01; confounder
increasing number job category
of pieces handled significant at
p=0.001
Duration of No association
employment
Dose/respon With increasing

se combination of R
and F
Not studied. NS Not statistically significant.
CS Cross-sectional PE Physical examination.
EMG Electromyography. R Repetition.
F Force. S Symptoms.
HAVSHand-arm vibration syndrome Y Considered (yes).
NR Not reported.
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Appendix C Table 5c. Summary table for evaluating hand-arm vibration syndrome
Components Brubaker Brubaker Dimberg Koskimies McKenna
of study Bovenzi 1988 Bovenzi 1994 Bovenzi 1995 1983 1987 1991 Kiveks 1994 1992 Letz 1992 1993
Study type CS CS CS CS Cohort CS Cohort Cohort CS CS
Participation NR Y Y Y N Y Y Y Y NR
rate $$70%
Outcome S and PE; S and PE S and PE; S and PE; S and PE; S S and PE S and PE S S and
cold cold cold cold PE;
provocatio provocation provocatio provocatio cold
n n n provocati
on
Exposure Observatio Observatio Questionnair Question- Observati Questionn Questionna Measureme Questionnai Question
n; n, e, naire data on; aire ire nt of the re, naire
measurem interview, observation, measure tools measureme
ents of the measurem measureme ments of nts of the
tool ents of the nts of the the tool tool used
tool tool from
previous
studies
Covariates Age, Age, Smoking, Age, Age Age, race, Age,
considered smoking, smoking, age, gender, smoking, smoking,
alcohol drinking height, psychoso alcohol, only
consumpti habits, weight cial medical males
on, upper cardiovascul scales conditions studied,
limb ar, those
injuries; neurologic, with
leisure previous injury to
activities, musculoskel the neck,
systemic etal injuries, upper
diseases use of limbs
medicines excluded.
Investigator NR N Y NR NR NR Y NR No N
s blinded
Repetition
Force
Extreme
posture
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Components Brubaker Brubaker Dimberg Koskimies McKenna
of study Bovenzi 1988 Bovenzi 1994 Bovenzi 1995 1983 1987 1991 Kiveks 1994 1992 Letz 1992 1993
Vibration Stone Stone Forestry NR 15% of Vibrating Lumberjack Decrease Full-time Riveters
drillers and workers workers and fellers tool use es vs. in vibration vs.
cutters vs. vs. 2.6% in ship- reported sig. referents: prevalence workers vs. referents:
quarry and polishers yard new Correlated for 1978: in forest referents: 24
mill and referents: symptom with HAVS 3.4, workers 5.0 (3.1-510)
workers: machine OR = 11.8 s of VWF symptom (1.7-6.9) from 1972 (2.1-12.1)
6.06 operators: (4.5-31.1) from 1979 prevalance Cumulative to 1990, Full-time
(2.0-19.6) 9.33 For workers to 1985; incidence attributed to vibration
(4.9-17.8) only using 28% HAVs reduction in workers vs.
antivibration increase (7-years) weight of Controls:
saws: OR = in 14.7% vs. saws, 40.6
6.2 prevalenc 2.3%: 6.5 increase in (11-177)
(2.3-17.1) e of VWF (2.4-17.5) vibration
For those in workers frequency,
using non- using reduction in
antivibration antivibrati acceleratio
saws: OR = on chain- n
32.3 saws
(11.2-93)
Risk factors
(combined)
Physical
workload
Psychosocial
factors
Individual/ See See Age Vibrating Smoking
other factors Covariate Covariates significantl tool use Sig.
considered s considered y different significantl
considered above between y
above cases and correlated
controls, with HAVS
height and symptoms
weight prevalence
were not.
Duration of No
employment differece in
lumberjack
s with <15
years of
exposure,
but then
increased
with
duration of
exposure
Dose/respon Y, between Increased Sig. for
se increasing HAVS with reported

vibration duration of exposure to
exposure exposure vibratory
and tools in
vibration workers
white finger with
<17,000
hours of
exposure

Back to Main
Components Mirbod Mirbod Miyashita Virokannas
of study 1992a, 1994 1992b 1992 Musson 1989 Nagata 1993 Nilsson 1989 Saito 1987 Shinev 1992 Starck 1990 1995
Study type CS CS CS CS CS CS Cohort CS CS CS
Participation NR NR NR N NR Y for N NR NR NR
rate $$70% platers;
NR for office
workers
Outcome S S and PE S S S and PE S and PE S and S and PE S S and PE
PE
Exposure Questionn Questionn Job Title Postal Based on Questionnai Question Measurem Measurem Interview
aire; aire; questionnai years of re, naire ent of tool ent of
interviews, measurem re, exposure measureme tools
measurem ents of the measurem since nt of tool,
ents of the workers ent of employme exposure
workers and the representat nt time
and the tools ive tools
tools
Covariates Age Age, height, Age Age Follow- Age, N Age,
considered weight, up of cigarette duration of
smoking, cohort smoking, employme
time industry, nt
pressure, education
working VDT
posture training
Investigator NR N N NR N NR NR NR N NR
s blinded
Repetition
Force
Extreme
posture
Vibration Male chain Symptom Male Exposure For >20 Office NR Percussiv High NR
saw severity Constructi duration not years workers e vibration prevalenc
operators positively on related to vibration with no had a e of HAVS
vs. correlated workers HAVS exposure: vibration greater among
referents: with compared symptoms 7.1 exposure to effect on workers
3.77 exposure to male (2.5-19.9) former muscle using
(2.1-6.8) duration office exposure: and bone vibrating
workers: 14 (5-38) pathology tools
0.5 Office than
(0.1-11.8) workers constant
with no high-
exposure: frequency
85 (15-486) vibration
C-44
Back to Main
Components Mirbod Mirbod Miyashita Virokannas
of study 1992a, 1994 1992b 1992 Musson 1989 Nagata 1993 Nilsson 1989 Saito 1987 Shinev 1992 Starck 1990 1995
Risk factors
(combined)
Physical
workload
Psychosocial
factors
Individual/ Age Sig. Poor
other factors Correlat correlation

considered ed to between
recovery vibration
rates exposure
from and HAVS
1978 to when
1983 tools were
highly
impulsive
Duration of
employment
Dose/respon HAVS OR increased by
se symptom 11% for each

severity year of
positively exposure
correlated
with
exposure
duration
Not studied.
CS Cross-sectional.
CTS Carpal tunnel syndrome.
F Force.
Hrs Hours.
NCSNerve conduction studies.
NR Not reported.
OR Odds ratio.
R Repetition.
S Symptoms.
Sig Statistically significant.
VPT Vibration perception threshold.
Y considered (yes).
C-45
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Appendix C Table C-6. Summary table for evaluating back musculoskeletal disorders
Components Boshuizen 1990a,
of study strand 1987, 1988 Bergenudd 1988 Bigos 1991b Bongers 1988 Bongers 1990 1990b
Study type 1987: CS; Cohort Cohort Retrospective cohort CS CS

1988: Cohort Cohort
Participation Y N N Y Y Y
rate $$ 70%
Outcome S and PE S S Physical exam from S CS: S

disability records Cohort: records
Exposure Questionnaire Questionnaire Questionnaire; For jobs Job title and records; Questionnaire; vibration Questionnaire; vibration
with >19 workers: job vibration measurements measurements measurements
analysis obtained but not used
Covariates Education level, Years of education, Medical history, previous Nationality, shift-work, Age, height, weight, Duration of exposure,
considered psychosocial factors psychosocial factors episodes of back pain, age, and calendar time climate, bending forward, age, height, smoking,
(including neuroticism) individual factors, twisted postures and awkward postures, and
psychosocial factors feeling tense at work mental workload
(from MMPI)
Investigators N NR NR NR NR NR
blinded
Heavy Combined Workers in moderate and No association
physical work heavy physical demand

work groups vs. light
physical demand group:
1.8 (1.2-2.7)
Lifting and Combined
forceful
movements
C-46
Back to Main
Components Boshuizen 1990a,
of study strand 1987, 1988 Bergenudd 1988 Bigos 1991b Bongers 1988 Bongers 1990 1990b
Awkward
postures
Whole body All back disorders: 1.32 LBP in exposed vs. LBP by vibration dose
vibration (0.84-2.1); referents: 9.0 (4.9-16.4), category: ORs=19.1,
Intervertebral disc Sciatica: 3.3 (1.3-8.5); 29.4, 28.0, 38.1;
disorders: 2.00 (1.1-3.7); LBP by total vibration By vibration dose:
Disc degeneration by dose: ORs=12.0, 5.6, ORs=1.80, 1.78, 2.8;
years of exposure: 5.7 6.6, 39.5 years of exposure: 3.6
(for highest exposure LBP by hours of flight (1.2-11)
category) time per day: 5.6, 10.3,
14.4;
Static work
postures
Risk factors Mill workers vs. clerical
(combined) workers: 2.3 p=0.002
Psychosocial Neuroticism and back Those with back pain MMPI: tend towards
factors pain: 2.8 (1.4-5.4) less satisfied with somatic complaint or

working conditions; no denial of emotional
difference in social distress and reporting
support injury: 1.37 (1.1-1.7)
Individual/oth Does not enjoy job tasks
er factors and reporting injury: 1.7

considered (1.3-2.2)
Duration of Duration of employment Prior back pain and
employment and back pain: 1.2 reporting injury: 1.7

(1.0-1.5) (1.2-2.5)
Dose/respon
se
C-47
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Components
of study Boshuizen 1992 Bovenzi 1992 Bovenzi 1994 Burdorf 1990 Burdorf 1991 Burdorf 1993
Study type CS CS mail survey CS CS CS CS
Participation Y Y Y N Y Y
rate $$70%
Outcome S S S S S S
Exposure Questionnaire; vibration Questionnaire, Questionnaire, Questionnaire, Questionnaire, task Questionnaire,

measurements measurement of WBV measurement of vibration job title, and expert analysis and OWAS measurements of WBV,
levels knowledge Postures assessed with
OWAS
Covariates Mental stress, years Age, awkward posture, Age, BMI, education, Age, height, and weight Age, height, and weight Age, history of heavy
considered lifting >10 kg and twisting duration of exposure, sport activity, car driving, work, exposure to WBV,
spine, height, smoking, BMI, mental load, marital status, mental work requiring prolonged
looking backwards, education, smoking, stress, climatic sitting, cold, drafts,
hours sitting sport activities and conditions, back trauma, working under severe
previous jobs at risk for and postural load (or pressure, job
back pain total vibration dose) satisfaction, height,
weight, duration of total
employment
Investigators NR NR NR NR N NR
blinded
Heavy Heavy work: 4.02 Heavy physical work sig
physical work (0.76-21.2) in univariate but not

multivariate model
Lifting and Frequent lifting: 5.21 No association
forceful (1.10-25.5)
movements
Awkward Postural Index and LBP:
postures 1.23 p=0.04
Whole body Total vibration dose and Low back: LBP in the past year: WBV: 0.66 (0.14-3.1) WBV and LBP, 3.1 Combined
vibration back pain: 0.99 Previous 12 months OR=2.39 (1.6-3.7) p=0.001
(0.85-1.2); In younger prevalence of LBP, bus Postural load category:
workers: vibration in drivers vs. controls: 2.57 OR=4.56 (2.6-8.0) (for
past 5 years and (1.5-4.4) the highest exposure
lumbago, 3.1 (1.2-7.9) Multivariate: category)
LBP symptoms in
previous. 12 months: and
total vibration dose:
ORs= 1.67, 3.46, 2.63
C-48
Back to Main
Components
of study Boshuizen 1992 Bovenzi 1992 Bovenzi 1994 Burdorf 1990 Burdorf 1991 Burdorf 1993
Static work For univariate analysis: Posture index based on
postures sedentary postures in time spent in a working

crance operators: 0.49 posture with the back in
(0.11-2.2) a bent and/or twisted
position: 1.23 p=0.04
Risk factors Job title: 3.6 (1.2-10.6) Crane operators vs.

(combined) office workers: 3.29
(1.52-7.12)
Straddle-carrier drivers
vs. office workers: 2.5
(1.2-5.4)
Psychosocial
factors
Individual/oth Postural load, bending,
er factors and twisting are causal

considered factors.
Standing and sitting are
not found to be risk
factors.
Duration of
employment
Dose/respon Univariate analysis, total Dose/response of
se vibration dose: combined effects to total

lifetime LBP symptoms: vibration dose and
4.05 (1.8-9.3); postural load, highest
12 months LBP combination of
symptoms: 3.25 categories: 4.58.
(1.5-7.0).
C-49
Back to Main
Components
of study Chaffin 1973 Clemmer 1991 Deyo 1989 Helivaara 1991 Hildebrandt 1995 Hildebrandt 1996
Study type Cohort CS CS CS CS CS
Participation NR Y NHANES-ll data Y Y Y, but varied from 60%
rate $$70% to 80% by department
Outcome S Injury report Data base S and PE S S
(LBP)
Exposure Observation and Job title Data base Questionnaire Questionnaire Questionnaire
measurement (smoking, obesity,
personal characteristics)
Covariates Age, weight, stature, Age, job, length of Age, gender, smoking, Age and gender Age and gender Age
considered number of prior back employment obesity, exercise level,
episodes, isometric lifting employment status
strengths
Investigators NR NR N N N N
blinded
Heavy Roustabouts vs. control Combined Heavy physical work Nonsedentary steel
physical work room operator: 4.3 (no ORs=1.9, 2.5 vs. sedentary work: 1.2, workers vs. referents:
confidence limits) p<0.05 No association
Lifting and Approx. 5
forceful
movements
Awkward
postures
Whole body
vibration
Static work
postures
C-50
Back to Main
Components
of study Chaffin 1973 Clemmer 1991 Deyo 1989 Helivaara 1991 Hildebrandt 1995 Hildebrandt 1996
Risk factors Lifting of loads in Job was best predictor LBP and physical stress: NS,
(combined) positions which create a of lost time. 2.5 (1.4-4.7) Reference group had
Lifting Strength Rating $ high exposure to
was considered adverse working
potentially hazardous to conditions
some people
Psychosocial Ever smoked vs. LBP: Stress load index: 2.4
factors 1.13, Sig. 50 pack years (1.7-3.5)

vs. LBP: 1.47, Sig.
Body mass index vs.
LBP: 1.70, Sig.
Individual/ Age, weight, and stature 75% of back strains Body mass index, alcohol Rates of LBP:
other factors did not correlate with precipitated by pushing, , work-related driving, construction: 35%;
considered increased incidence of pulling, or lifting. parity, height not truckers: 31%;
LBP associated with LBP. plumbers: 31%
Smoking sig in both older
and younger males, but
only older females.
Prior traumatic injury
increased risk of LBP:
2.5 (1.9-3.3); and
sciatica: 2.6 (2.1-3.1)
Duration of Smoking risk increases
employment steadily with cumulative

exposure and with
degree of maximal daily
exposure.
There is a steady
increase in LBP with
increasing obesity.
Dose-
response
C-51
Back to Main
Appendix C Table C-6. Summary table for evaluating back musculoskeletal

disorders
Components
of study Holmstrm 1992 Huang 1988 Johanning 1991 Johansson 1994 Kelsey 1975b Kelsey 1984 Knibbe 1996
Study type CS CS CS mail survey CS Case control Case control CS

Participation Y Y N Y Y Y Y
rate $$70%
Outcome S; (A sample had PE S S S Medical records: S S and PE S
for purposes of and PE required
validation)
Exposure Postal questionnaire Ergonomic Job title, Questionnaire Questionnaire Interview and Questionnaire
assessment including measured WBV in questionnaire
NLE exposed group but
results not presented
Covariates Daily traveling time, Age, height, length of Age, gender, job Age and gender. Non Age, gender Age, gender, medical Age
considered leisure activity, height employment, title, employment work-related S could service
and weight olecranon height, duration have an effect
weight masking result, if not
identified.
Investigators Y NR NR NR NR NR N
blinded
Heavy Blue collar workers
physical work vs. white collar

workers: no
association
Lifting and One year prevalence The workers in the No association Lifting vs. herniation: Lifting >25 lb or more, Registered nurses vs
forceful of BP and manual center with higher 0.94, p=0.10 without twisting the nursing aides:
movements materials handling: rates had greater body: 3.8 (0.7-20.1) Unadjusted OR=1.2,
1.3 (1.2-1.4); lifting compared to p=0.04; after
Lifting frequency: >1 the referent center: adjusting for hr
per 5 min vs.<1 per 5 no risk estimate worked, aides had
min: 1.12, p<0.001 higher rate: 1.3
Awkward Stooping and More awkward Extreme work Combined Twisting without
postures kneeling with severe postures found in postures sig lifting: 3.0 (0.9-10.2)
LBP compared to no center A than B, associated with
stooping: 2.6; in p=0.05. outcome in blue collar
comparison to no workers
kneeling: 3.5
Whole body WBV and sciatica Combined
vibration pain: 3.9 (1.7-8.6)
C-52
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disorders
Components
of study Holmstrm 1992 Huang 1988 Johanning 1991 Johansson 1994 Kelsey 1975b Kelsey 1984 Knibbe 1996
Static work No association Sedentary work and
postures disc herniation for

workers 35 years
and older: 2.4,
p=0.01; for those <
35 years, 0.81
Risk factors Time sitting, >35 Lifting >25 lb >5 times Physically demanding
(combined) years old: 2.4 per day, and twisting work vs. lifetime LBP,
p=0.01; More than the body half the prevalence: 87%;
half time driving vs. time: 3.1 (1.3-7.5); 1-year LBP,
herniation: 2.75, prevalence: 67%;
p=0.02; Simultaneous lifting 1-week LBP,
Truck driver vs. and twisting with prevalence: 21%;
herniation: 4.67, straight knees: 6.1 Prevalence of sick
Chi-sq.=5.88, p=0.02 (1.3-27.9) leave due to back
pain in previous 3
months: 9.7%
Psychosocial High stress and LBP: Blue collar workers In blue-collar
factors 1.6 (1.4-1.8); were less satisfied workers, 10 of 15

high anxiety: 1.3 with influence on psychosocial job
(1.1-1.4). and control of work, factors sig; in
supervisor climate, white-collar workers,
stimulus from work none of the five
itself, and relations psychosocial factors
with fellow workers sig
Individual/oth Severe LBP related Gastrointestinal Carrying >11.3 kg,
er factors to smoking; problems: subway 5-25 per day: 2.1

considered construction tasks train operators vs. (1.0-4.3)
such as brick laying, referents: 1.6
carpentry, etc. did (1.1-2.5) Carrying >11.3 kg ,
not affect LBP. >25/day: 2.7
(1.2-5.8)
Duration of
employment
Dose/respon
se
C-53
Back to Main

disorders
Components
of study Leigh 1989 Liles 1984 Magnusson 1996 Magora 1972, 1973 Marras 1993, 1995 Masset 1994 Partridge 1968
Study type CS Cohort CS CS CS CS CS

Participation Y NR NR NR NR Y Y
rate $$70%
Outcome S Records S S Records review S S and PE
Exposure Questionnaire Observation, use of Questionnaire, Observation, Observation, Interview, Questionnaire,

(job title) records vibration interview, measurements self-reports job title
measurements questionnaire
Covariates Gender, race, Gender (males only), Age

considered obesity, height, and age (all participants
repetitious work younger than 40).
General health
status, social,
demographic,
psychologic factors
Investigators NR N NR NR NR NR N
blinded
Heavy Self reporting: Job No association Combined

physical work requires a lot of
physical effort: 1.5
(1.0-2.2)
Lifting and Injury rate for highest Heavy lifting: 1.86 1973: Sudden Combined Heavy efforts of the
forceful job severity index (1.2-2.8) maximal efforts and shoulder, 1.62,
movements category vs lowest : Frequent lifting: 1.55 LBP: 1.65 (1.3-2.1) p<0.01
4.5 (1.01-2.39)
Awkward No association: Univariate analysis
postures highest rate of back showed trunk

pain found in the torsions associated
rarely/never bend with LBP in steel
category workers; no
association seen in
multivariate
Whole body Bus and truck drivers Bus drivers Vehicle driving: 1.2
vibration compared to compared to (p<0.001)

referents: 1.8 bankers: 1.2
(1.2-2.8) (0.8-1.7)
C-54
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disorders
Components
of study Leigh 1989 Liles 1984 Magnusson 1996 Magora 1972, 1973 Marras 1993, 1995 Masset 1994 Partridge 1968
Static work No association Seated posture: 1.5,
postures p<0.09
Risk factors High vs. low physical Driving: 1.79 Sudden maximal Max. load moment, Rheumatic S:
(combined) demands: 1.68 (1.16-2.75) physical efforts; max. lateral velocity, dockers vs. civil
(1.05-2.90) Vibration plus prolonged sitting or ave. twisting servants: 1.2
frequent lifting: 2.1 standing, inability to velocity, lifting (0.98-1.64);
(0.8-5.7) sit during the working frequency, and max. LBP: dockers vs. civil
Vibration plus heavy day, and poor lifting sagital trunk angle servants: NS
lifting: 2.06 (1.3-3.3) technique related to related to high-risk
LBP LBP groups:
10.7(4.9-23.6)
Psychosocial Negative perception
factors of the work

environment: NS.
Individual/oth Smoker vs. Maximum load Physical work load
er factors nonsmoker and LBP: moment: 73.65 Nm (no objective

considered 1.48 (1.0-2.19) vs. 23.64 Nm: 5.17, measurement) and
(3.19-8.38); repetition were NS.
Sagittal mean Final logistic model
velocity: 11.74 included whole set
degrees/sec. vs. of variables from
6.55 degrees/ general health status,
sec: 3.33 social, demographic,
(2.17-5.11); and psychologic
Max. weight: 104 N characteristics.
vs. 37 N: 3.17
(2.19-4.58)
Duration of
employment
Dose/respon
se
C-55
Back to Main
Components Riihimki 1994;
of study Punnett 1991 Riihimki 1989a Riihimki 1989b Pietri-Taleb 1995 Ryden 1989 Schibye 1995 Skov 1996
Study type Case referent CS mail survey CS Prospective Case control Cohort CS
(retrospective)
Participation Y Y Y Y Y Y N
rate $$70%
Outcome S and PE S X-ray confirmed S Records S S

Exposure Observation and Job title and Questionnaire and Postal questionnaire Work injury reports Questionnaire Questionnaire,
measurements, questionnaire job title and self-reports self-reports
Videotape analysis
Covariates Gender, age, length Age, previous back Age, self-reported Age, gender (only Age Subjects served as Age, gender, height,
considered of employment, accidents, awkward back accidents, body males were studied, their own controls weight, smoking,
recreational activity, postures at work, mass index, height, previous history of work-related
medical history, and and annual car and smoking back accidents, psychosocial
maximum weight driving mental distress, variables, lifting,
lifted in study job general state of leisure time sports
health, smoking, activities
lifestyle factors,
education
Investigators Y NR Y NR NR NR NR
blinded
Heavy Combined Combined
physical work
Lifting and Lift 44.5 N: 2.16 (1.0-
forceful 4.7)
movements
Awkward Time in non-neutral Sciatica and twisted Association found
postures postures, mild or or bent postures: 1.5 between twisted and

severe bending: 8.09 (1.2-1.9) bent postures with
(1.4-44) sciatica in univariate,
but not multivariate
analysis
C-56
Back to Main
Components Riihimki 1994;
of study Punnett 1991 Riihimki 1989a Riihimki 1989b Pietri-Taleb 1995 Ryden 1989 Schibye 1995 Skov 1996
Whole body Longshoremen and No association In Danish
vibration earthmovers salespeople, the
compared to annual driving
referents: 1.3 distance for highest
(1.1-1.7) category: 2.8
(1.5-5.1)
Static work Sedentary work

postures (% of worktime):
2.45 (1.2-4.9)
Risk factors Time in non-neutral Sciatic pain and Concrete vs. painting Machine operators Job title or shifts No sig differences in Annual driving
(combined) posture: 8.09 machine operators: work and disc space vs. office workers: requiring heaviest back pain in garment distance: 2.79
(1.5-44.0) 1.3 (1.1-1.7) narrowing: 1.8 1.4 (0.99-1.87); physical efforts: 2.2 workers versus (1.5-5.1)
Sciatic pain and (1.2-2.5); carpenters vs. office (1.28-3.89) other employment
carpenters: 1.0 Spondylophytes: 1.6 workers: 1.5 group upon follow-up
(0.8-1.3) (1.2-2.3) (1.1-2.1)
Psychosocial Monotonous work,
factors problems with

co-workers or
supervisors, and
high paced work
were NS.
Individual / Age: 0.96 (0.09-1.0) Age and disc space Physical exercise >1 Previous back injury: Of 82 workers with
other factors back injury: 2.37 narrowing: 6.5 time per week vs. 1 2.13 (1.07-4.24); another job in 1991,
considered (1.3-4.3) (1.7-26.0) time per week: 1.26 Working day shift: 20% reported MSDs
(1.0-1.6) 2.23 (1.28-3.89); a s the reason for
Spondylophytes: Smokers vs. Self-reported LBP: change.
14.9 (2.3-95.0) non-smokers: 1.29 1.25 (1.25-4.12);
(0.98-1.7) Self-reported slipped
Severe back pain disc: 6.20
and later sciatica: 4.5 (2.64-14.57)
(2.7-7.6)
Duration of Analysis controlled Sig
employment for length of

employment.
Dose/respon A strong trend found Dose/response is Dose/response is
se for increasing length observed for twisted observed for annual
of exposure and risk or bent postures driving and
of back disorders to (see above) sedentary work (see
both mild and severe above)
trunk flexion.
C-57
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Components
of study Skovron 1994 Svensson 1989 Toroptsova 1995 Undeutsch 1982 Videman 1984 Videman 1990 Walsh 1989
Study type CS CS CS CS CS CS and lab study CS

(retrospective)
Participation Y Y Y NR Y NR Y
rate $$70%
Outcome S S S; then S and PE S and PE (Clinical S X-ray confirmed S
orthopaedic exam
given to 134 of the
366 subjects)
Exposure Interview Questionnaire Interview Interview and Postal questionnaire Questionnaire, Postal
questionnaire Reports from family questionnaire
members
Covariates Age and gender Age, gender (only Analysis did not Age, height, weight, Age, gender (only Age, gender (only Age, year of onset
considered females studied), control for nationality, years of females studied), male cadavers used) of symptoms,
level of education, confounders experience in menstruation, physical exercise, gender
psychosocial transport work pregnancy, exercise heaviness of
factors, work occupation
breaks, demand on
concentration
Investigators NR NR NR NR NR NR NR
blinded
Heavy No association Sig. difference in Heavy vs. mixed
physical heavy occupational work: 2.8 (0.3-23.7)

work workload category
among ages 20-29 Heaviest work
year olds but not category: 12.1
other age groups: 1.1 (1.4-107)
Lifting and Lifetime incidence of Frequent lifting and Combined No association - no Lifting in jobs just
forceful LBP and Lifting: 1.2, LBP: 1.43, p<0.05 sig difference prior to injury: 2.0
movements p<0.01 found in between qualified (1.1-3.7)
univariate analysis nurses and nursing
but not in multivariate aides
analysis
Awkward LBP and bending Trunk flexion and
postures forward: 1.3, p<0.05 LBP: 1.7 p<0.01

in univariate; not sig
in multivariate
analysis
C-58
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Components
of study Skovron 1994 Svensson 1989 Toroptsova 1995 Undeutsch 1982 Videman 1984 Videman 1990 Walsh 1989
Whole body No association Combined Driving on job held

vibration prior to symptoms
in males: 1.7
(1.0-2.9)
Static work Standing No association Sedentary work and Sitting and LBP:
postures associated with LBP: disc degeneration: females: 1.7
1.3 in univariate 24.6 (1.5-409) (1.1-2.6)
analysis, not sig in
multivariate
Risk factors Occupation: NS In workers with Driving vs. Mixed Driving and LBP:
(combined) present S, they work: 2.3 (0.8-6.2) males: 1.7 (1.0-2.9)
occurred most
frequently while
lifting loads and while
in bended postures:
no risk estimate
Psychosocial Work dissatisfaction: LBP and worry and
factors 2.4, p=0.02 fatigue at end of

work day: p<0.0001
Dissatisfaction with
work tasks: p<0.05
Individual / Female gender: 2.16, LBP and standing: NS for sitting, Current back S
other factors p=0.001; p<0.01 standing, walking, or positively correlated

considered increasing age: 2.0, repetitive work with height and age.
p=0.001
Duration of Current back S
employment positively correlated

with length of
experience in
transport work.
Dose/respon
se
N No. Y Considered (yes).
Not studied.
ADL Activities of daily living. NHANESNational Health and Nutrition Examination Survey.
CS Cross-sectional. NR Not reported.
F Force. NS Not statistically significant.
Hrs Hours. OWASOVAKO working posture analysis system.
LBP Low-back disorders. PE Physical examination.
LBP Low-back pain. R Repetition.
LBS Low-back symptoms. S Symptoms.
MMPI Minnesota Multiphasic Personality Inventory. Sig. Statistically significant.
MS Musculoskeletal. WBV Whole body vibration.
C-59

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Back to Main

Musculoskeletal Disorders and

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Copies of this and other NIOSH documents are available from

National Institute for Occupational Safety and Health

Telephone number: 180035NIOSH (18003564674)

This publication is also available from the

Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence

Linda Rosenstock, M.D., M.P.H.

NOTE TO THE READER

Page 3-69: Schibye et al. [1995] was added to Table 3-5.

Page 4-25: Dimberg [1989] was changed to Dimberg [1987].

Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1

Chapter 2. Neck Musculoskeletal Disorders: Evidence for

Chapter 3. Shoulder Musculoskeletal Disorders: Evidence for

Chapter 4. Elbow Musculoskeletal Disorders (Epicondylitis):

Chapter 5. Hand/Wrist Musculoskeletal Disorders (Carpal Tunnel

Chapter 5a. Carpal Tunnel Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a-1

Chapter 5b. Hand/Wrist Tendinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b-1

Chapter 5c. Hand-Arm Vibration Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c-1

Chapter 6. Low-Back Musculoskeletal Disorders: Evidence for

Chapter 7. Work-Related Musculoskeletal Disorders and

MAGNITUDE OF THE PROBLEM

C 83,483 injuries or illnesses in other and unspecified overexertion events.

IDENTIFICATION AND SELECTION OF STUDIES

METHODS FOR SYNTHESIZING STUDIES

Strong evidence of work-relatedness (+++). A causal relationship is shown to be very likely

Evidence of work-relatedness (++). Some convincing epidemiologic evidence shows a causal

Insufficient evidence of work-relatedness (+/0). The available studies are of insufficient

Hand-arm vibration syndrome

In general, there is limited detailed quantitative information about exposure-disorder relationships

Penny Arthur Rose Hagedorn Marty Petersen

Gunnar B.J. Andersson, M.D., Ph.D. Robert Harrison, M.D., M.P.H.

Mohammed M. Ayoub, Ph.D., P.E., C.P.E. William S. Marras, Ph.D.

Vance C. Calvez, M.S., C.P.E. Margareta Nordin, Dr. Med. Sc.

Don B. Chaffin, Ph.D. Donald C. Olsen, Jr., C.S.P., C.P.E.

Jerome J. Congleton, Ph.D., P.E., C.P.E. Thomas Owens, C.I.H., P.E.

Theodore Courtney Laura Punnett, Sc.D.

Michael Feuerstein, Ph.D. Robert G. Radwin, Ph.D.

Eric Frumin David Rempel, M.D.

Michael Gauf Suzanne H. Rodgers, Ph.D.

Fred Gerr, M.D. C. Jivan Saran

Lawrence P. Hanrahan, Ph.D., M.S. Scott Schneider, C.I.H.

Barbara Silverstein, Ph.D., M.P.H., C.P.E.

conducted by the Bureau of Labor Statistics number of cases decreased by 7% to 308,000

Industries with the highest IRs of work-related

Standard Industrial Classification Manual, 1987 edition.

Excludes farms with fewer than 11 employees.

Standard Industrial Classification Manual, 1987 edition.

Excludes farms with fewer than 11 employees.

The large number of work-related low-back COST

DEFINING HEALTH OUTCOMES Certain authors have noted the scarcity of

The second step of the analytical process was

likely to be substantially influenced by viewed individually (taking into account good

Debate is ongoing in the epidemiologic Rothman [1986] referred to specificity of effect

With additional information (e.g., laboratory THE EVIDENCE OF WORK-

Insufficient Evidence of Work- agency reports that have undergone peer

This document does not necessarily cite all of

INTRODUCTION symptoms has ranged from approximately 50%

related exposure factor. The discussion within during a cycle), or

or repetitive movements found a measurements of critical

neck forward flexions included only occasional sitting tasks,

workers and Milerad and Ekenvall [1990] compared the