![[Worker entering data on a computer keyboard]](images/2001-117d-1.jpg)
Appendix A contains bullets which were abstracted by NORA Musculoskeletal Team members from focus group meetings. In this abstraction process, the team members attempted to accurately describe the ideas being presented. No effort was made to evaluate the ideas in terms of relative priority, likelihood of success, or resources required to accomplish the research priority, or to eliminate the diversity in proposed research topics. There is some overlap between bullets within each major section.
Incorporate into state and national reporting systems more clinical information on musculoskeletal disorder cases.
Develop a standardized work history surveillance form for individual workers related to medical end points.
Incorporate measures of severity of the specific health outcomes into surveillance systems.
Improve diagnostic reliability of surveillance data through health care provider training.
Consider specific populations for inclusion in existing or new surveillance systems, including workers with chronic pain or permanent disability, arthritis, and cartilage damage (especially to knees and lower extremities).
Modify and update the 1995 OSHA ergonomic workplace checklist for surveillance use.
Evaluate process hazard review and hazard control review as surveillance methods.
Develop tools which account for inter- and intraperson variability in task performance.
Develop different sets of survey tools for different uses, such as national surveys, hazard identification, known "problem" work areas, injury and symptom surveillance, early detection or preclinical phase, job transfer, absenteeism, functional impairment, productivity, and retirement summaries.
Develop hazard surveillance checklists and other tools usable with minimal training for use by health and safety committees, employees, and medical personnel and compare them with detailed exams/interviews and exposure assessments to evaluate trade-offs in simplicity and precision.
Update the list of high-risk jobs and industries and ensure that new occupations and industries are included in older, established surveillance systems.
Develop standardized case definitions of musculoskeletal disorders and "key variables" for inclusion in different surveillance tools, such as state workers' compensation systems.
Coordinate uniform reporting requirements, such as the OSHA 200 log, ICD codes, workers' compensation, and defined health endpoints. Facilitate retrieval of all records (OSHA 200 log, medical reports, etc.) related to an injury.
Conduct a hazard survey modeled after the NIOSH National Occupational Exposure Survey (NOES).
Consider surveillance of specific worker populations, such as computer users, nurses, workers excluded from the Bureau of Labor Statistics data (office workers and federal workers), and workers with long cycle jobs, such as those in the construction industry.
Survey companies to identify measures of organizational health, possibly using QS 9000 and ISO 9000 (quality standards of work processes) registries at the national level.
Develop surveillance tools that capture "expert judgement," but include "decision trees" which allow the nonexpert and expert to arrive at similar conclusions.
Determine the validity, reliability, and accuracy of surveillance tools.
Develop easy access to denominators, such as improve state-based surveillance through the use of county business patterns or census data for denominators.
Determine whether workplace accommodations of injured workers have changed over time and affected MSD reporting.
Determine the impact that changes in workers' compensation laws or management/employee relations have on reporting and seeking treatment.
Utilize existing data sources, such as employers, unions, government groups (NHIS, NHANES), workers' compensation, physician reports, hospital emergency departments, health maintenance organizations, health care insurers, disability reports, physical therapy reports, or other individualized state sources, to encourage comparability of data collection.
Use surveillance systems to determine the validity of Bureau of Labor Statistics data by comparing them to an independent audit of company reports, especially in industries suspected of undercounting.
Use surveillance systems to determine the economic costs of MSD.
Use surveillance systems to determine whether there has been a trend in restricted work.
Use surveillance systems to determine whether gender affects response to hazards.
Use surveillance systems to determine the efficacy of participatory or grass-roots interventions and ergonomic programs.
Examine the link between exposure to varying intensities of biomechanical stress and the occurrence of MSD. Biomechanical exposures may include repetition, force, static and awkward postures, duration, and vibration. Research is needed to determine how much is too much.
Evaluate physical demand limits for the hands and wrists on sub-assembly operations for the incidence of hand disorders.
Evaluate differences in the incidence of MSD among operations with sitting/standing postures versus standing postures.
Investigate the effects of psychological, psychosocial, and work organizational factors on the occurrence of MSD. These studies should examine the effects of hours of work, shift work, paced work, piecework, teamwork, alternate work sites (telecomuting), temporary work, extended hours, and other supervisory or management arrangements.
What is the impact of downsizing, labor shortages, or increased overtime on the occurrence of MSD? Why do some solutions work in one plant but not in another?
Assess the physiological response to mental and/or emotional stress. Do physiological changes occur as a result of mental stress?
Evaluate whether environmental, social, and psychological stressors contribute to fatigue.
Investigate the relative effects of age, gender, physical condition, biological characteristics, cultural differences, diurnal variation, genetics, and history of previous injury/illnesses (acute, cumulative, or chronic) on the development of MSD. Investigate why individuals respond differently.
Study adaptation to repetitive work determine the body's normal physiological adaptive response and the pathophysiologic responses requiring intervention.
Studies are needed to examine physical, non-physical, and personal variables separately and in combination.
Examine how physical, environmental, and mental stresses affect workers off the job.
Develop, evaluate, and refine theoretical models of musculoskeletal disease and injury that link exposures, tissue changes, and disease manifestation.
Determine when work becomes illness-producing (the transition between normal work and excess load). Establish acceptable levels of repetition and force.
Identify antecedent factors by looking both at injured and healthy workers (examine jobs that do not cause problems). Study long-term workers who have not been injured to learn more about optimal activity levels and contributing physical, personal, and behavioral factors.
Utilize a variety of study designs, including both experimental and natural or observational (longitudinal, retrospective, and cross-sectional). Longitudinal studies are important because they follow workers throughout their careers and after retirement and allow assessment of why workers change jobs. Cross-sectional studies are not sufficient; it is important to include ex-workers. New epidemiological methods may be needed to track transient employees. Develop mathematical and/or statistical methods for dealing with enormous amounts of data.
Study low- and medium-risk exposures to understand the subacute process, as well as high-risk exposures.
Study specific diseases and quantified exposures rather than generic. Study continuous exposure variables as preferred to dichotomous.
Although human models are preferable, good animal models for MSD are also needed.
Research musculoskeletal effects and changes in risk factor tolerance for an aging work force.
Incorporate what is known from the field of exercise physiology about the effects of aging (for example, whether it is harder to recover from MSD at older ages than younger).
Produce anthropometric data related to age, and conduct anthropometry studies on industrial populations so tool designers have information on how anthropometric variables change with age.
Evaluate whether workers with chronic or infectious diseases are at increased risk for MSD. For example, does the high prevalence of diabetes among some groups place them at increased risk? What about workers with past or present exposure to toxic chemicals, including childhood lead exposure, or pregnancy?
Evaluate occupational and non-occupational exposures of children, such as extensive computer work, agricultural work, grocery store baggers, and other jobs. Although they have less strength, they are often exposed to the same physical factors as adults. Determine if childhood exposures cause problems in adulthood.
Develop/establish standardized definitions for exposure terms, such as force, vibration, pressure, frequency, and repetition.
Systematically evaluate the precision and accuracy of existing exposure assessment tools and methods. Test the tools to ensure they are comparable and used the same way by all users.
Develop tools with greater specificity many current analytic tools may be too sensitive but not specific, meaning they rate too many situations as stressful.
Improve exposure assessment tools by making them portable, easy to use by non-experts, telemetric, non-invasive, and able to detect a wide range of exposures. They should be capable of measuring multiple exposure variables simultaneously.
Develop new instrumentation for assessing exposure to physical and non-physical factors (for measuring non-lifting force applications, such as arm, shoulder, hand grip, and pinch forces).
Develop methods that rely on non-traditional approaches, e.g., use of surface temperature as an indicator of strain on the hand/wrist during keyboarding or during high impact activities. New exposure methods should incorporate individual differences, such as size, gender, and anthropometry.
Develop new methods for assessing jobs with multiple tasks and variable task characteristics, as in the construction, agriculture, and warehouse industries. These tools should be capable of assessing work load in real-time with minimal expertise.
Determine the effectiveness of dynamic biomechanical models versus static models in the prediction and control of MSD.
Develop procedures for job task analysis through actual job site measurements that can catalogue stressors, evaluate workload risk and analysis, and use existing ergonomics check lists and data sources. These methods should allow the user to evaluate a variety of different factors (including vibration) simultaneously to determine overall workload.
Develop tools for determining both physical and psychosocial factors that are easy to use like the NIOSH lifting equation. For example, in an office environment, include such factors as keying rate, breaks, postures, and work and personal psychosocial factors.
Develop standard definitions for work-related MSD, risk factors, and for terms, such as discomfort, pain, injury, disease, disability, and recovery. Establish endpoints that are clear, definitive, valid, and reliable.
Develop better diagnostic tools for MSD, including its early stages.
Establish approved methods and objective tests to diagnose and evaluate whether an injury is physical, psychological, or psychosocial.
Standardize diagnostic physical examinations.
Evaluate available high-technology imaging tools, such as microsensors and magnetic resonance imaging (MRI), for the diagnosis of MSD, and design new diagnostic tools specifically for ergonomic research.
Develop and validate biochemical markers to identify injured workers and to follow their recovery.
Conduct research (clinical trials) to evaluate the efficacy of various forms of treatment for MSD, including surgery and rehabilitation. Evaluate the impact of workers' compensation and disability benefit availability and other factors on treatment and outcome.
Delineate the natural history of MSD (pathogenesis and recovery).
Quantify the time of symptom onset to the time of injury onset, and study the relationship between these two variables.
Study muscle fatigue, strain, and injury, and quantify variables where possible. Use biomonitoring to determine fatigue, possibly involving muscle testing and grip strength tests. Combine research on performance with fatigue, muscle, and physiology factors. Obtain more information on workers' strength while in movement for use in design.
Compare cumulative exposures from the effects of repetitive activity on muscles, tendons, or nerves and the role of infrequent or rapid exertion when performing primarily sedentary jobs. Study pain occurring after an injury. Assess what factors make individuals respond to pain in different ways. Study the occurrence of sensitization (decrease of pain threshold) in the central nervous system after injury.
Study whether the central nervous system is affected by repetitive activity and injury. Do workers develop maladaptive patterns of movement by doing repetitive tasks?
Study problems with lower extremities, especially knees, using field research and animal models.
Evaluate the effectiveness of equipment, such as chairs and power tool handles, used to control risk factors for MSD.
Evaluate the effect of warning devices, such as those for posture and keystroke counters, on prevention or reduction of MSD.
Studies are needed to determine the effectiveness of using sit/stand seating and footrests to reduce the postural stress associated with continuous standing at work.
Evaluate the biomechanical risk imposed by infrequent heavy workloads on several parts of the body.
Validate the effectiveness of fasteners and palm buttons in controlling upper extremity MSD.
Evaluate different training modalities, delivery methods, and materials that are correlated with a reduction of MSD.
Evaluate who should be trained and duration and frequency of training.
Evaluate effectiveness of the content and methods of training programs.
Determine the best intervention(s) to use for work environments where engineering solutions are difficult to implement and for "unpredictable" situations that happen in the workplace, such as machine or equipment breakdowns or slips and falls.
Determine the effectiveness of incorporating ergonomic principles at the design stage versus retrofitting or fixing high-risk jobs.
Determine why similar interventions instituted in similar plants have widely varying results.
Determine the cost effectiveness of designing jobs using 'ergonomic' principles in the design phase in comparison to the reactive strategy of fixing jobs after MSDs are observed.
Determine the effectiveness of designing jobs to meet recommended exposure limits defined by job assessment methods (e.g., the NIOSH lifting equation, 3-D computer based biomechanical models, psychophysical databases, , risk prediction models, and upper extremity evaluation methods).
Determine the effectiveness of traditional and new engineering solutions (e.g., manual handling devices, workspace layout, tools, containers, etc.).
Compare the effectiveness of general wellness and fitness programs versus engineering strategies in preventing MSD.
Evaluate the effects of job rotation, job enlargement, and shift work patterns in reducing MSD.
Evaluate injury reporting trends among operations with and without job rotation.
Identify and validate the primary elements of effective early screening programs in the reduction of MSD.
Determine significant differences in injury reduction between early medical intervention techniques and behavioral change techniques.
Assess the impact on injury prevention of using alternative job placement programs for different age groups.
Validate the use of pre-placement screening as an indicator of an individual risk of MSD.
Compare the effectiveness of engineering interventions versus organizational interventions in reducing the rate of MSD.
Evaluate whether early warning programs that use symptom and discomfort surveys are effective in the prevention of MSD.
Determine if there is a high correlation between time of day, level of experience, under-staffing, and the incidence of MSD.
Determine the impact and effectiveness of safety incentives and behavior-based safety programs in the reduction of MSD.
Validate and standardize basic elements of a medical management program directed toward the reduction of MSD.
Identify and validate a business model criteria that quantifies costs and benefits of ergonomic programs. Assess the benefits of establishing an ergonomics program in terms of productivity, product quality, workers' compensation, and medical costs. Develop better measures of productivity.
Determine which segments of society currently carry the economic burden of MSD (employee, employer, government, family, social services, etc.).
Evaluate the effects of risk communication to workers.
Assess use of confidential employee surveys to collect more useful information on near-miss 'accidents', under-reporting of hazards or disorders, and possible solutions to hazardous exposures.
Evaluate the effectiveness of personal protective equipment (PPE) in the prevention or reduction of MSD.
Evaluate the effect of PPE on reporting MSD.
Assess how cultural factors may affect adoption of ergonomic improvements.
Evaluate whether cultural factors affect an individual's participation in symptom and discomfort surveys.
Evaluate the communication strategies used for non-English speaking employees in agriculture, construction, fishing, and forestry.
Foster partnerships among government agencies, private employers, and unions. Coordination of studies among organizations or agencies may help improve communication and the dissemination of results.
Disseminate information to both academics and practitioners about completed and continuing studies, particularly successful studies. Put the results for practitioners in less technical language, explaining all design information and how the findings apply to real situations. A user advisory group could be formed to interpret and disseminate information in a practical and usable fashion. Small businesses could be reached via information clearinghouses, Internet websites, conferences, and speakers bureaus.
Develop a user-friendly, employer-accessible intervention database (including industry benchmarks and case histories) on topics applicable to a wide variety of settings, in addition to industry-specific solutions. Employers could use the database to identify interventions for their specific hazards.
Create practical software for designing good workplaces that practitioners can use in their work and which would also help bridge the gap between researchers and practitioners who do not speak the same language.
Create incentives for companies to publicly disseminate their research results because companies sometimes consider this information to be competitive or proprietary.
Initiate a public awareness campaign stressing ergonomic success stories, prevention of MSD, and ergonomics as a standard part of doing business.
Encourage collaboration using a multi-disciplinary team approach (engineers, ergonomists, clinicians, academicians, industry, and labor). NIOSH-sponsored centers could be a model.
Facilitate a dialogue between labor, management, practitioners, and researchers. Insure that practitioners have a role in prioritizing/funding research.
Ensure that investigators have a thorough knowledge of the workplace process before designing studies, including the best and worst case scenarios.
To gain access, address companies' and unions' concerns about the utility and value of research.
Create a task force to link researchers and industries to show industries how research will benefit them.
Create new incentives for industry to participate in ergonomic studies. Private organizations, NIOSH, or OSHA could initiate programs to recognize companies with exemplary ergonomics programs or that cooperate in research. Ensure that ergonomic research leads to immediate benefits for the participating company, such as improvements in productivity or training programs.
Garner management and union support by working with researchers whom both sides trust.
Hold "research fairs" to create forums for researchers to meet with companies and funding agencies to facilitate access to sites and funding.
Experienced researchers could tutor new researchers about effective methods for obtaining access.
Access by NIOSH-sponsored researchers may be enhanced by an educational campaign explaining NIOSH's mission.
Piggyback ergonomic medical tests onto large, pre-existing longitudinal studies like those of NHANES or the Institute of Aging.
Improve the research proposal process by encouraging collaboration among researchers, particularly regarding competing theories and methods.
Reduce workers' objections to participating in research by replacing painful tests; assuring proper and confidential handling of sensitive data, including biological specimens, medical information and responses to study-relevant questions; and requesting workers' permission when videotaping.
Enlist the aid or secure the support of labor, insurance companies, and other companies that are interested in ergonomic research and will contribute funds.
Coordinate funding and research among federal agencies (e.g., NIOSH, the National Institutes of Health, the National Science Foundation, the National Institute for Aging). Consider an approach like that of the National Science Foundation, which partially funds research with industries; the EPA-industry collaborative Health Effects Institute; or the Center for VDT Research. Enhance the awareness of non-NIOSH, federal, intramural research groups of occupational etiologies, and encourage them to do relevant basic and transnational research.
Ensure that funding sources commit to supporting longitudinal studies over many years because of their scientific merit. They should also fund smaller, individual studies that together will build the requisite, sequential steps to answer the big questions.
To address perceptions of bias, develop mechanisms that might provide oversight and/or funding of research projects, e.g., independent advisory boards, multi-stakeholder funding consortia, etc.
Improve the initial and continuing education of practitioners on research methodology. Topics could include how to collect data, how to define control groups, how to deal with jobs that change in the middle of a research project, standards for best practices, statistics and experimental design, and setting "gold standards" for biomechanical factors and diagnosis of MSD.
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