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Contents
NORA Team Agenda
Based on the responses from three focus groups, the NORA MSD team
developed an agenda of the most important research gaps in four primary
topic areas. These included surveillance, etiology, intervention, and
improving the research process. The Houston workgroup was not asked to
develop a list of the most important priorities. The goal in developing
the agenda for the four primary topic areas was to synthesize the
responses, eliminate duplication, and highlight the most important gaps
identified in each area. In some cases, the NORA MSD team also added
their viewpoints on the priorities for research. The listings of
research issues identified by the focus groups for each topic can be
found in the Appendices of this document. There are some issues
discussed in more than one topic area.
Surveillance is the ongoing systematic collection, analysis,
interpretation, and dissemination of MSD health and hazard information
in order to identify trends, develop prevention strategies, and evaluate
the effectiveness of those strategies.
The following are the most significant priorities for surveillance
research activities identified by the NORA Team:
- Develop user-friendly, standardized workplace surveillance tools
for use by both the non-expert and the expert;
- Increase collaboration with federal, state, and non-governmental
organizations (insurers, employers, unions, and academics) to
encourage comparability of data collection methods;
- Conduct an ongoing national hazard survey targeting physical
workplace factors.
Surveillance Systems Additional research is needed on how
surveillance information can be collected, using existing passive
surveillance data (billing records created when employees seek medical
care) or active surveillance data (annual symptoms surveys of all
employees in manual handling jobs). Evaluation of the different roles
for active and passive systems are also needed.
Case Definition Develop and validate standardized case
definitions for MSD and key variables, including the levels of symptoms
to be included in the definitions (distinguish "ever experienced back
pain" from "radiating back pain in the last 3 months with a duration of
more than a month with moderate to high intensity"). Medical information
on cases should include measures of severity of the disorder. This is
particularly important in evaluating progress of disease and
effectiveness of interventions over time. Validity and reliability of
new surveillance case definitions should be tested and reported.
Methods for High Risk and Changing Jobs New surveillance
methods are needed to identify high- risk jobs or tasks when the
relationship of the worker to the workplace is changing, such as an
increase in temporary workers or workers with multiple jobs with
different exposures.
Evaluation of Surveillance Tools Evaluate the validity,
reliability and accuracy of hazard surveillance instruments to be used,
recognizing that surveillance instruments usually trade simplicity and
speed for precision. Make these tools usable by experts and
nonexperts.
More user-friendly exposure assessment tools are needed. Devices are
needed that are efficient, portable, rugged, flexible, and capable of
measuring multiple exposure variables simultaneously and simple enough
for those with minimal training to use.
Validation of Surveillance Systems Validate existing or new
surveillance systems in terms of usefulness, representativeness,
timeliness, simplicity, acceptability, predictive value, and cost.
Development of New Surveillance Tools Research is needed to
develop or evaluate surveillance tools to be used for data at the local
or national level, and to be applied to various stages of the MSD
development process.
Non-health Indicators Determine whether non-health
indicators, such as rates of job transfer, absenteeism, reduced
productivity, and early retirement, are effective in identifying jobs
with elevated risk of MSD.
Background Rates Efforts should be directed toward
developing county, state, industry or occupation denominators and rates
that can be used for comparison purposes.
Additionally, collaboration with other groups, such as software
system developers, insurers, employers, unions, and government groups
(NHIS, NHANES), should be encouraged to develop comparability of
definitions in data collection.
Many risk factors associated with development of MSD have been
identified or suggested. Biomechanical risk factors include exposures to
excessive force, awkward posture, movement, and vibration. These can be
characterized in terms of their magnitude and temporal factors, such as
frequency, repetition, duty cycle, and duration of exposure (See Figure
1). Psychological and social factors include work organization
arrangements (extended work hours, shift work, piecework, machine
pacing), lack of training, inadequate conditioning, and cognitive or
emotional stress. Personal factors include variables associated with
size, strength, age, gender, cultural factors, and history of injury.
Research is needed to better describe the relationship between exposure
to these risk factors, both singly and in combination, and the
development of disease and disability.
The most significant priorities for etiologic and medical research
activities identified by the NORA Team are to:
- Refine instruments to detect and quantify the contribution of
these factors to the disease process;
- More clearly define stages of the MSD process, develop precise
diagnostic tools, and provide guidelines for effective treatment and
return to work; and
- Clarify the interplay of the factors at different stages of
causation, development, and treatment of MSD and measurement of risk
factors.
Field Research Contribution of Risk Factors Several
biomechanical, psychosocial, and personal risk factors have been
identified in connection with the MSD process. Research is needed on
factors, such as posture, movement, and force within the context of
temporal factors (duration and frequency). Research is needed to improve
limits for exposure to physical demands and mechanical stresses. This
research needs to integrate personal, psychological and social factors.
Research is also needed to develop and validate more predictive exposure
assessment tools.
Laboratory Research Models Conceptual models of the MSD
development and recovery process need to be tested and refined in the
laboratory (Figure 1). Such models should link exposures, tissue
changes, physiologic responses, adaptation, and disease. Mathematical
and animal models are needed to help understand individual variables.
Multi-factorial models are also needed to describe relationships between
biomechanical and physiological factors. These models will provide
useful information on the disease and recovery process that could be
tested in the field.
Individual Variation Variation in individual response and
adaptation needs to be investigated. Factors that need to be studied
include demographic profiles (age, race, gender), personal history
(cultural background, work and injury history), disease states
(neurological, endocrine, or circulatory diseases), and work
organization factors (work arrangements, time on the job, training,
compensation and benefit structure). These need to be considered in the
context of biomechanical factors, such as load or repetition.
Childhood Exposures Studies are needed on children at work,
and the relationship between childhood exposures to biomechanical
factors and later development of MSD (video games or computers, or
carrying heavy backpacks).
Fatigue Role Research is needed to determine the impact of
whole body fatigue and local muscle fatigue on the development of MSD.
New methods for assessing fatigue should be developed, such as human
performance testing and biomonitoring.
Disability Research is needed to evaluate the impact of
workers' compensation, disability benefits, and wage replacement
strategies on effective recovery and return to work. This research,
should account for physical factors when studying psychological or
social factors that impact the length of disability.
Healthy Populations Research is needed to define a healthy
musculoskeletal state and to identify optimal stress and activity
levels. Healthy populations who have not developed disease despite
exposure to risk factors should be studied.
Predictive Ability of Tools Predictive ability of
biomechanical, organizational, and workplace psychological and social
exposure assessment tools needs to be evaluated and improved. Greater
precision, accuracy, repeatability, and validity of measurements are
needed.
Other Assessment Tools Assessment tools need to be developed
and evaluated to identify hazards associated with non-stereotypic work,
such as jobs in transient or seasonal industries, (construction and
agriculture). Consideration of multiple exposure changes in temporal
patterns over the course of the workday or workweek should be included
in these assessment tools.
Use of Data Research is needed to evaluate the trade off
between observation, self reports, and direct measurements in predicting
risk. The health-related data sources (OSHA logs, workers' compensation,
disability, and health insurance records) need to be evaluated for
usefulness in identifying disease patterns (evaluation of reporting
bias, over-reporting, under-reporting, and legal and medical criteria).
This research would be an additional resource for improving
surveillance.
Case Definition Work is needed to develop standard clinical
definitions for MSD which include clear endpoints. Definitions are
needed for stages of the disease process characterized by such terms as
discomfort, pain, injury, disability, and recovery.
Diagnostic Tools Effective diagnostic tools are needed.
Existing diagnostic tools and procedures need to be evaluated, including
use of MRIs and microsensors. It is particularly important to find good
early indicators of the disease process, including biochemical and
bioimaging markers. It is important to develop effective tools for
establishing an individual baseline for medical monitoring.
Predictive Tools Tests, such as electrodiagnostic testing or
functional disability evaluation tools, should be studied for their
ability to predict the onset and outcome of MSD. Research is needed to
identify and validate practical screening tests that can detect
individual physical conditions or biological markers indicative of the
MSD process. Tests should be useful for periodic monitoring of
individuals for comparison to baseline status. Research is also needed
to determine whether changes in biological markers indicate reversible
or permanent change; to develop/validate/evaluate tools to assess
functional disability; and to determine if structural changes are
related to the course or progression of MSD. Populations studies need to
be conducted to determine normal population values or ranges for
subsequent useful inferences for the MSD process. Criteria for
work-related illness should be evaluated.
Treatment Strategies Evaluation of treatment protocols,
rehabilitation programs, and return to work strategies is needed.
![[Tomato workers bringing full buckets to a truck to be counted]](images/2001-117b-1.jpg)
David Bacon Photographs
Research is needed to develop and evaluate new and existing
intervention strategies for preventing or reducing the incidence,
severity, and disability associated with work-related MSD. A large
amount of research has been conducted over the past few decades, but
because of the wide variability between individuals and the complexity
of causal and contextual factors and their interactions, there is a need
for more research on which interventions are the most effective.
Moreover, intervention research is difficult to conduct because adequate
comparison controls are often not available and because very large
sample sizes are needed to show that an intervention is effective in
reducing health outcomes. In many cases, it is not possible to conduct
studies aimed at reducing health effects, so studies must rely on
demonstrating reduced exposure. Interventions can be tested in the
laboratory where confounding factors can be controlled, or tested in the
field. Effective control technology should work well in both
environments.
The most significant priorities for intervention research activities
identified by the NORA Team are to evaluate the effects of the
following on development and prevention of MSD:
- Alternative (product and/or tool) design criteria (force, spatial
requirements of work);
- Optimization of mechanical work demands (force, movement, and
posture) and temporal patterns of exposure;
- Manual handling alternatives in posture, movement, force,
productivity, and quality;
- Ergonomic training and education;
- Costs and benefits of ergonomic intervention;
- Evaluate job assignment, selection, and choice on development of
MSD; and
- Emerging technologies.
Mechanical Environment Research should investigate the
mechanical environment factors that affect posture, movement, force,
exertion, and the interface between the worker and the equipment or the
task. Such mechanical environment factors include workplace arrangements
equipment, and tool design, as well as the design of the products and
components that are routinely handled by people. For example, research
into alternative seating arrangements or human interactions with
semi-automated material-handling devices would be useful.
Force Factors More engineering research is also needed to
identify and evaluate the factors that affect the force required by the
worker. For example, intelligent material-handling devices are being
developed that compensate for different loads. Research is also needed
to measure the versatility, operator acceptance, protective
capabilities, and safety aspects of these devices. In the area of
manipulation of tools and smaller objects, as in assembly work, food
processing, retail, and dentistry, additional engineering research is
needed to provide the optimal balance between the force requirements for
the efficient completion of the work task and the prevention or
reduction of MSD.
Dynamic Forces More research is needed to develop
interventions directed at reducing the dynamic demands of work tasks
(kinematic or motion parameters and kinetic or force parameters), such
as redesigned workspaces and tools that minimize required forces and
movements.
Specific Industries Work is needed to develop additional
engineering solutions for several industry- specific problems, including
fork truck design and health care, warehousing, construction, maritime,
agriculture, meatpacking, and poultry processing.
Participatory Approaches Research is needed on when and how
participatory programs work to prevent/reduce MSD.
Work Interaction Research is needed to increase knowledge of
the interactions between the cognitive, environmental, social,
organizational, economic, and political contexts of work which can be
used to develop interventions aimed at preventing MSD.
Job Content and Scheduling Further research is needed in the
areas of task assignment and work/rest schedules, job rotation, job
enlargement, and length of the workday. Research is needed on the effect
of worker control of pace (piece rate and incentives) and job
content.
Behavioral Intervention Studies are needed to determine what
factors are effective in getting workers to incorporate modification in
work methods, such as increasing use of assistive equipment, taking
regular rest breaks, or avoiding hazardous activities, such as heavy
lifting or lifting from the floor.
Safety and Fitness Effects Research is needed to determine
the effectiveness of general safety, wellness, and fitness programs and
their impact on work-related MSD.
Accommodation and Functional Capacity Research is needed to
determine the effectiveness of interventions directed at matching the
individual characteristics, capability, and vulnerability of workers to
the work demands. Such research would cover issues of selection,
training, work hardening, rehabilitation, and restricted work
assignments. In addition, because of the indication that a history of
musculoskeletal illness and injury is predictive of future episodes,
more intervention guidance is needed regarding the assignment of
particular individuals to particular jobs.
Personal Protective Equipment Personal protective equipment
may be used to modulate the interface between the body and external
forces or to restrict joint movement. Interventions of the former type,
such as gloves and kneepads, are generally accepted, although there may
be an opportunity to evaluate the effectiveness of personal protective
devices in the attenuation of vibration from hand tools. Further
research could evaluate a wider range of work environments to determine
if there is a role for joint restraint devices in MSD treatment
protocols.
Training and Education Research is needed to develop and
investigate effective training and educational interventions to diverse
audiences. These include workers or management in the workplace and
students in vocational, engineering, occupational health, and management
programs. Such interventions include: programs in the workplace,
ergonomics material in grade school, engineering and business curricula,
extension of specialist education, and professional certification.
Educational interventions may have far-reaching effects on reduction of
the incidence and severity of work-related musculoskeletal
disorders.
Exposure Guidelines and Regulations Research is needed to
determine the effectiveness of voluntary exposure guidelines and
regulations. Studies are needed to determine the difference in impact
between voluntary guidelines and regulations and the impact of varying
exposure criteria.
Compensation More research is needed to determine the
prevention role of the workers compensation system and how it could be
used more effectively to reduce MSD.
Cost Benefit Evaluate the impact of ergonomic interventions
on non-health-related outcomes such as quality and productivity. Develop
business models that quantify the costs and benefits of ergonomic
programs.
Participants indicated that the research process could be improved by
strengthening communication between those who conduct research and those
who apply research. Researchers expressed frustration at the
difficulties associated with gaining access to industrial sites to
conduct research, and management and labor felt the need for more input
into the research process. Some participants suggested that research
might be more applicable to industry if management and labor reviewed
research proposals and had a say in funding and prioritization. For
example, workforce representatives expressed disappointment that
researchers often did not have a thorough knowledge of the workplace
process being studied, or performed their research under "best case"
scenarios.
There seemed to be general agreement that improvements in
dissemination of research results were needed. Most of the dissemination
problems were attributed to inadequate communication between the parties
involved in the research process. More effective methods of
dissemination are needed to improve the application of research findings
in the workplace. Furthermore, when valuable research data were
obtained, the method of dissemination made it difficult to apply in the
workplace.
The NORA Musculoskeletal Team considers coordination of research
activities and information dissemination to be of prime importance in
this area. As suggested by several of the focus group participants,
coordination of studies through partnerships involving government
agencies, university researchers, private industry, and labor unions
could be extremely beneficial in bridging communication gaps, developing
efficient research strategies, and improving the dissemination of
information.
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Introduction
![[Worker using a powered hand tool suspended by a ceiling-mounted hoist]](images/2001-117b-2.gif)
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