National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Page i

MUSCULOSKELETAL DISORDERS AND THE WORKPLACE

Low Back and Upper Extremities



Panel on Musculoskeletal Disorders and the Workplace

Commission on Behavioral and Social Sciences and Education

National Research Council

and

Institute of Medicine




NATIONAL ACADEMY PRESS
Washington, D.C.

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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    NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418

    NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

    The study was supported by Contract No. HHS-100-99-0001 between the National Academy of Sciences and the U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

    Suggested citation: National Research Council and the Institute of Medicine (2001) Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Panel on Musculoskeletal Disorders and the Workplace. Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

    Library of Congress Cataloging-in-Publication Data

    Musculoskeletal disorders and the workplace : low back and upper extremities / Panel on Musculoskeletal Disorders and the Workplace, Commission on Behavioral and Social Sciences and Education, National Research Council and Institute of Medicine.

    p.; cm.

    Includes bibliographical references and index.

    ISBN 0-309-07284-0 (hardcover)

    1. Backache. 2. Industrial accidents. 3. Arm--Wounds and injuries. 4. Back--Wounds and injuries. I. National Research Council (U.S.). Panel on Musculoskeletal Disorders and the Workplace. II. Institute of Medicine (U.S.)

    [DNLM: 1. Musculoskeletal Diseases--epidemiology. 2. Arm Injuries--epidemiology. 3. Back Injuries--epidemiology. 4. Low Back Pain--epidemiology. 5. Occupational Diseases--epidemiology. WE 140 M98515 2001]

    RD771.B217 M875 2001

    617.4′7044--dc21

    2001000906

    Additional copies of this report are available from National Academy Press, 2101 Constitution Avenue, N.W., Washington, D.C. 20418

    Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area)

    This report is also available online at http://www.nap.edu

    Printed in the United States of America

    Copyright 2001 by the National Academy of Sciences. All rights reserved.

    Cover photographs: Background figure: © Charles Gupton/Stock, Boston/PictureQuest. Inset: © PhotoDisc.

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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    THE NATIONAL ACADEMIES

    National Academy of Sciences
    National Academy of Engineering
    Institute of Medicine
    National Research Council

    The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.

    The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering.

    The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

    The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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    PANEL ON MUSCULOSKELETAL DISORDERS AND THE WORKPLACE

    JEREMIAH A. BARONDESS (Chair), New York Academy of Medicine

    MARK R. CULLEN, Occupational and Environmental Medicine Program, School of Medicine, Yale University

    BARBARA de LATEUR, Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University

    RICHARD A. DEYO, Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle

    SUE K. DONALDSON, School of Nursing and School of Medicine, Johns Hopkins University

    COLIN G. DRURY, Department of Industrial Engineering, State University of New York, Buffalo

    MICHAEL FEUERSTEIN, Departments of Medical/Clinical Psychology and Preventive Medicine/Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and Division of Behavioral Medicine, Georgetown University Medical Center

    BARUCH FISCHHOFF, Department of Social and Decision Sciences and Department of Engineering and Public Policy, Carnegie Mellon University

    JOHN W. FRYMOYER (retired), McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington

    JEFFREY N. KATZ, Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Harvard University Medical School

    KURT KROENKE, Regenstrief Institute for Health Care and School of Medicine, Indiana University, Indianapolis

    JEFFREY C. LOTZ, Orthopaedic Bioengineering Laboratory and Department of Orthopaedic Surgery, University of California, San Francisco

    SUSAN E. MACKINNON, Division of Plastic and Reconstructive Surgery, School of Medicine, Washington University, St. Louis

    WILLIAM S. MARRAS, Institute for Ergonomics and Department of Industrial, Welding, and Systems Engineering, Ohio State University, Columbus

    ROBERT G. RADWIN, Department of Biomedical Engineering, University of Wisconsin, Madison

    DAVID M. REMPEL, School of Medicine, University of California, San Francisco

    ROBERT M. SZABO, Department of Orthopaedic Surgery, School of Medicine, University of California, Davis

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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DAVID VLAHOV, Center for Urban Epidemiologic Studies, New York Academy of Medicine, and Johns Hopkins University School of Public Health

DAVID H. WEGMAN, Department of Work Environment, University of Massachusetts, Lowell

ANNE S. MAVOR, Study Director

JAMES P. McGEE, Senior Research Associate

SUSAN R. McCUTCHEN, Senior Project Assistant

ALEXANDRA K. WIGDOR, Deputy Director, Commission on Behavioral and Social Sciences and Education

ANDREW M. POPE, Director, Division of Health Sciences Policy, Institute of Medicine

FREDERICK J. MANNING, Senior Program Officer, Division of Health Sciences Policy, Institute of Medicine

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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    COMMITTEE ON HUMAN FACTORS

    WILLIAM C. HOWELL, Department of Psychology, Arizona State University, Tempe

    JOHN M. CARROLL, Center for Human-Computer Interaction, Virginia Polytechnic Institute and State University, Blacksburg

    COLIN G. DRURY, Department of Industrial Engineering, State University of New York, Buffalo

    MARTHA GRABOWSKI, Rensselaer Polytechnic and LeMoyne College, Cazenovia, New York

    DANIEL R. ILGEN, Department of Psychology and Department of Management, Michigan State University, East Lansing

    RICHARD J. JAGACINSKI, Department of Psychology, Ohio State University, Columbus

    LAWRENCE R. JAMES, Department of Management, University of Tennessee, Knoxville

    BONNIE E. JOHN, Human-Computer Interaction Institute, School of Computer Science, Carnegie Mellon University

    KURT KRAIGER, Department of Psychology, University of Colorado, Denver

    WILLIAM S. MARRAS, Institute for Ergonomics and Department of Industrial, Welding, and Systems Engineering, Ohio State University, Columbus

    RAJA PARASURAMAN, Department of Psychology, Catholic University

    KARLENE ROBERTS, Haas School of Business, University of California, Berkeley

    KIM J. VICENTE, Cognitive Engineering Laboratory and Department of Mechanical and Industrial Engineering, University of Toronto

    GREG L. ZACHARIAS, Charles River Analytics, Cambridge, Massachusetts

    ANNE S. MAVOR, Director

    SUSAN R. MCCUTCHEN, Senior Project Assistant

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Contents

PREFACE xiii
EXECUTIVE SUMMARY 1
PART I: INTRODUCTION
    1     INTRODUCTION 17
        Charge to the Panel, 18
        Background, 20
        Approach to the Problem, 21
        The Whole Person: Injury, Illness, and Disease, 23
        Levels of Analysis: Individuals and Populations, 27
        Contextual Factors, 28
        Mechanical, Physiological, and Psychological Factors, 31
        Guide to the Report, 35
    2     DIMENSIONS OF THE PROBLEM 38
        Musculoskeletal Disorders in the General Population, 38
        Work-Related Musculoskeletal Disorders, 44
        Data on Economic Costs, 57
        Limitations of the Data, 59
        Summary, 64
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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    3     METHODOLOGICAL ISSUES AND APPROACHES 65
        Research Perspectives, 66
        Determining Causality Within Studies, 71
        Criteria for Causality Across Studies, 77
        Study Designs, 79
        Pattern of Evidence Comparisons, 81
PART II: REVIEW OF THE EVIDENCE
    4     EPIDEMIOLOGIC EVIDENCE 85
        Methods, 85
        Results, 98
        Conclusion, 113
        Appendix, 117
    5     TISSUE MECHANOBIOLOGY 184
        Pain Pathways from Peripheral Tissues, 185
        Literature Review, 187
        Vertebral Bone and Spinal Disc, 187
        Tendons and Ligaments, 194
        Skeletal Muscle, 199
        Peripheral Nerve, 210
        Spinal Nerve Roots, 213
        Summary, 216
    6     BIOMECHANICS 219
        Concepts of Load Tolerance, 219
        Low Back Mechanics, 235
        Upper Body Biomechanics, 253
    7     OCCUPATIONAL STRESS 287
        General Models of Occupational Stress, 288
        Biological Response, 289
        Occupational Stress and Work-Related Musculoskeletal Disorders: Some Working Hypotheses, 291
        Summary, 300
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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    8     INTERVENTIONS IN THE WORKPLACE 301
        Context, 302
        Principles of Ergonomics, 303
        Specific Interventions: Back, 308
        Specific Interventions: Upper Extremities, 314
        Challenges During the Process of Ergonomic Intervention, 320
        Summary, 327
    9     WORK NOW AND IN THE FUTURE 330
        Trends in Employment by Industry Sector and Occupation, 331
        External Factors Influencing the Nature of Work, 335
        Summary, 346
PART III: IMPLICATIONS
    10     PATTERNS OF EVIDENCE 351
        Back Disorders and the Workplace, 354
        Upper Extremity Disorders and the Workplace, 358
        Summary, 361
    11     CONCLUSIONS AND RECOMMENDATIONS 364
        Conclusions, 364
        Recommendations, 365
        Additional Considerations, 367
    12     RESEARCH AGENDA 370
        Methodological Research, 370
        Topic Area Research, 372
REFERENCES 375
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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APPENDIXES
A     Answers to Questions Posed by Congress, 431
B     Dissent, Robert M. Szabo, 439
C     Panel Response to the Dissent, 458
D     Contributors to the Report, 461
E     Biographical Sketches of Panel Members and Staff, 465
INDEX 471
Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Page xiii

Preface

This report is the output of two years of dedicated labor on the part of a diverse, talented, and energetic panel of experts supported by an experienced, dedicated, and equally energetic staff. The effort was organized by the National Research Council (NRC) and the Institute of Medicine (IOM), in response to a charge from the National Institute for Occupational Safety and Health and the National Institutes of Health to conduct a comprehensive review of the scientific literature on the relationship of work and the workplace to musculoskeletal disorders of the low back and upper extremities. The impetus for the study was a set of questions posed by Congress. These questions and the panel's responses, are presented in Appendix A.

The current effort was focused on the science base supporting current concepts of musculoskeletal disorders as they relate to the workplace, ranging from consideration at the level of tissue biology, through the variety of mechanical, organizational, and psychosocial factors operating in the complex environment that is the workplace. It also extended to the array of clinical expressions of such disorders, as acted on and modified by the interaction of the individual with the range of influences and responses that characterize his or her milieu. In addition, the literature on interventions, as appropriate to low back and upper extremity disorders and the workplace, was reviewed with regard to its scientific quality; the literature on best practices interventions was also reviewed to provide information on approaches thought by industry to be worthy of incorporation into industrial practice. Both types of evidence were weighed and considered by the panel as it formulated its conclusions and recommendations.

The panel, in seeking to be responsive to its task, confined itself in this fashion to the science base and the conclusions that the science could bear.

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Policy considerations were not part of the panel's mandate and were not addressed in its deliberations.

The panel members worked hard and in a collegial fashion throughout the study. We talked, listened, and argued, and the process resulted in an almost unanimous outcome. One panel member found, at the end, that he was unable to agree with all the conclusions and recommendations endorsed by the rest of the panel and wrote a dissent (see Appendix B). We believe that dissent misstates part of this report, and we have responded to it (see Appendix C).

In addition to its own study and deliberations, the panel sought and received information from many sources. We commissioned 19 outside scholars to examine the scientific literature in a variety of areas germane to its work. We had the benefit of briefings by a number of individuals from industry, the Bureau of Labor Statistics, the Livermore National Laboratories, the United Auto Workers, and researchers active in the field. Presentations by representatives of a number of clinical societies, corporations, and public service groups were heard, at the panel's invitation, in an open forum. Finally, the panel had the advantage of a visit to two auto assembly plants to which the Ford Motor Company kindly provided access. A list of those who provided commissioned papers, those who briefed the panel, and others who presented their views in various formats is presented in Appendix D.

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the Report Review Committee of the National Research Council (NRC). The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their participation in the review of this report: Jacqueline Agnew, Johns Hopkins Education and Research Center in Occupational Health and Safety, Johns Hopkins School of Hygiene and Public Health; Peter Amadio, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; Gunnar Andersson, Department of Orthopedic Surgery, Rush Presbyterian St. Lukes Medical Center, Chicago, Illinois; Thomas Armstrong, Department of Industrial and Operations Engineering, Center for Ergonomics, University of Michigan; Peter Buckle, Robens Centre for Health Ergonomics, European Institute of Health and Medical Science, University of Surrey, England; Fredric Gerr, Department of Environmental and Occupational Health, Rollins School of Public Health, Emory University; Ronald K. Leonard, Deere and

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Company (retired); Michael D. Lockshin, Barbara Volcker Center, Hospital for Special Surgery; J. Steven Moore, Department of Nuclear Engineering, Texas A&M University; Neal A. Vanselow, School of Medicine and Chancellor (emeritus), Tulane University Health Sciences Center; Eira Viikari-Juntura, Musculoskeletal Research Unit, Finnish Institute of Occupational Health, Helskinki.

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Enriqueta C. Bond, Burroughs Wellcome Fund, Durham, North Carolina, and Dorothy P. Rice, Institute for Health & Aging, School of Nursing, University of California, San Francisco. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring panel and the institution.

I would like to thank our sponsor representatives, Lawrence J. Fine, National Institute for Occupational Safety and Health, and James S. Panagis, National Institute of Arthritis, Musculoskeletal, and Skin Diseases for their interest in this important project. My personal gratitude goes to our talented staff, Anne Mavor, James McGee, Susan McCutchen, and Alexandra Wigdor for the efficiency and good cheer with which they shepherded the group through its task. My appreciation to the members of the panel, for the intelligence and sense of public purpose with which they approached our task, is unbounded. I regret that as a panel we were unable to reach complete consensus; however, I appreciate the diligent efforts made throughout the process in this regard.

Jeremiah A. Barondess
Chair, Panel on Musculoskeletal
Disorders and the Workplace

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: The National Academies Press. doi: 10.17226/10032.
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MUSCULOSKELETAL DISORDERS AND THE WORKPLACE

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Every year workers' low-back, hand, and arm problems lead to time away from jobs and reduce the nation's economic productivity. The connection of these problems to workplace activities-from carrying boxes to lifting patients to pounding computer keyboards-is the subject of major disagreements among workers, employers, advocacy groups, and researchers.

Musculoskeletal Disorders and the Workplace examines the scientific basis for connecting musculoskeletal disorders with the workplace, considering people, job tasks, and work environments. A multidisciplinary panel draws conclusions about the likelihood of causal links and the effectiveness of various intervention strategies. The panel also offers recommendations for what actions can be considered on the basis of current information and for closing information gaps.

This book presents the latest information on the prevalence, incidence, and costs of musculoskeletal disorders and identifies factors that influence injury reporting. It reviews the broad scope of evidence: epidemiological studies of physical and psychosocial variables, basic biology, biomechanics, and physical and behavioral responses to stress. Given the magnitude of the problem-approximately 1 million people miss some work each year-and the current trends in workplace practices, this volume will be a must for advocates for workplace health, policy makers, employers, employees, medical professionals, engineers, lawyers, and labor officials.

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