A comparison of peak vs cumulative physical work exposure risk factors for the reporting of low back pain in the automotive industry

Mechanical load on the low back and shoulders during pushing and pulling of two-wheeled waste containers compared with lifting and carrying of bags and bins

OBJECTIVE

Compare the mechanical load on the low back and shoulders during pushing and pulling a two-wheeled container with the load during lifting and carrying the same amount of waste.

BACKGROUND

Only little is known about risk factors and mechanical loads during push/pull operations.

DESIGN

A complete 2(3) factor push/pull experiment. A two-wheeled container with 25 or 50 kg was pushed in front of and pulled behind the body by seven waste collectors. Further, the same subjects lifted and carried a paper bag and a dustbin both loaded with 7 and 25 kg.

METHOD

All operations were video recorded and the push/pull force was measured by means of a three-dimensional force transducer. Peak Motus and Watbak software were used for digitising and calculation of torque at L4/L5 and the shoulder joints and compression and shear forces at L4/L5.

RESULTS

During pushing and pulling the compression at L4/L5 is from 605 to 1445 N. The extension torque at L4/L5 produced by the push/pull force is counteracted by the forward leaning of the upper body. The shear force is below 202 N in all situations. The torque at the shoulders is between 1 and 38 Nm.

CONCLUSION

In the present experiments the torques at the low back and the shoulders are low during pushing and pulling. No relation exists between the size of the external force and the torque at the low back and the shoulder.

RELEVANCE

Pushing and pulling are common in many workplaces and have often replaced lifting and carrying situations. This has emphasised the need for more knowledge of the internal mechanical load on the body during these activities.

An evaluation of predictive methods for estimating cumulative spinal loading

The focus of this study was to assess the amount of error present in several approaches that have been commonly used to estimate the cumulative spinal loading during manual materials handling tasks. Three male subjects performed three sagittal plane lifting tasks of varying loads and postural requirements. Video recordings of the tasks were digitized and a biomechanical model was used to calculate the spinal loading (compression, joint shear, reaction shear, and flexion/extension moment) at L4/L5 for each frame of data. The 'gold standard' for cumulative loading experienced by the subjects was obtained by integrating the resultant biomechanical model outputs for the entire lifting cycle. Five approaches that quantify cumulative spinal loading, four that use discrete measures and one that reduces the number of frames used (5 Hz), were used and compared with the gold standard. The four methods using discrete measures to quantify the cumulative demands of a task resulted in substantial errors (average error across task and subjects was 27-69%). Reducing the number of frames of data processed to 5 frames/s preserved the time varying information and was the only approach examined that did not induce significant error into the cumulative loading estimates. This study indicates that errors in cumulative spinal loading estimates can be large depending upon the approach used, which will hinder any progress in developing a dose-response link between cumulative exposure and an increased risk of low-back pain or injury.

Biomechanical and psychosocial risk factors for low back pain at work

OBJECTIVES

This study determined whether the physical and psychosocial demands of work are associated with low back pain.

METHODS

A case-control approach was used. Case subjects (n = 137) reported a new episode of low back pain to their employer, a large automobile manufacturing complex. Control subjects were randomly selected from the study base as cases accrued (n = 179) or were matched to cases by exact job (n = 65). Individual, clinical, and psychosocial variables were assessed by interview. Physical demands were assessed with direct workplace measurements of subjects at their usual jobs. The analysis used multiple logistic regression adjusted for individual characteristics.

RESULTS

Self-reported risk factors included a physically demanding job, a poor workplace social environment, inconsistency between job and education level, better job satisfaction, and better coworker support. Low job control showed a borderline association. Physical-measure risk factors included peak lumbar shear force, peak load handled, and cumulative lumbar disc compression. Low body mass index and prior low back pain compensation claims were the only significant individual characteristics.

CONCLUSIONS

This study identified specific physical and psychosocial demands of work as independent risk factors for low back pain.

A longitudinal study of the development of low back pain in an industrial population

STUDY DESIGN

This is a longitudinal study in which industrial workers without chronic low back pain (LBP) were initially assessed with a comprehensive test battery and surveyed every 6 months thereafter for 2 years.

OBJECTIVE

To determine factors that may predispose industrial workers who lift over 5000 kg per shift to LBP.

SUMMARY OF BACKGROUND DATA

Prospective studies are small in number and often limited in breadth or depth of the test battery, methodologic issues, or investigator expertise. There are no prospective studies that focus on a homogeneous work sample of industrial employees.

METHODS

Production workers (n = 149) who volunteered for the 2-year study were assessed using physical measures (e.g., muscular strength, endurance, and flexibility), lifting kinematics (a sagittal plane box lift), and health, lifestyle, and work environment data (paper questionnaires). Follow-up questionnaires were distributed every 6 months for 2 years.

RESULTS

Using self-report of LBP as the main outcome measure, eight variables predicted LBP in this sample with a 75% correct prediction rate. Predictor variables included age, thoracic acceleration during the trunk velocity test, median frequency intercept of electromyography of the right L3 erector spinae, quadriceps strength, quadriceps endurance, self-assessment of fitness, having a confidante, and number of medications currently taken.

CONCLUSION

Results confirmed the multifactorial nature of low back pain and suggest that personal fitness is an important defense against low back pain, even in manual handling lifting tasks.

Biomechanical analysis of peak and cumulative spinal loads during simulated patient-handling activities: a substudy of a randomized controlled trial to prevent lift and transfer injury of health care workers

Back injuries are a serious problem for nursing personnel who perform frequent patient-handling activities. Common prevention strategies include body mechanics education, technique training, and ergonomic interventions such as the introduction of assistive equipment. This investigation assessed and compared the effectiveness of two patient-handling approaches to reducing injury risk. One strategy involved using improved patient-handling technique with existing equipment, and the other approach aimed at eliminating manual patient handling through the use of additional mechanical and other assistive equipment. Both intervention arms received training in back care, patient assessment, and use of the equipment available on their particular wards. An analysis of compliance with interventions and the effects of patient-handling methods on both peak and cumulative spinal compression and shear during various tasks was conducted. Results showed greater compliance with interventions that incorporated new assistive patient-handling equipment, as opposed to those consisting of education and technique training alone. In several tasks, subjects who were untrained or non-compliant with interventions experienced significantly higher peak spinal loading. However, patient-handling tasks conducted with the aid of assistive equipment took substantially longer than those performed manually. This, along with variations in techniques, led to increases in cumulative spinal loading with the use of patient-handling equipment on some tasks. Thus, the use of mechanical assistive devices may not always be the best approach to reducing back injuries in all situations. No single intervention can be recommended; instead all patient-handling tasks should be examined separately to determine which methods maximize reductions in both peak and cumulative lumbar forces during a manoeuver.

The effects of motion on trunk biomechanics

OBJECTIVE

To review the literature that evaluates the influence of trunk motion on trunk strength and structural loading.

BACKGROUND

In recent years, trunk dynamics have been identified as potential risk factors for developing low-back disorders. Consequently, a better understanding of the underlying mechanisms involved in trunk motion is needed.

METHODS

This review summarizes the results of 53 studies that have evaluated trunk motion and its impact on several biomechanical outcome measures. The biomechanical measures consisted of trunk strength, intra-abdominal pressure, muscle activity, imposed trunk moments, and spinal loads. Each of these biomechanical measures was discussed in relation to the existing knowledge within each plane of motion (extension, flexion, lateral flexion, twisting, and asymmetric extension).

RESULTS

Trunk strength was drastically reduced as dynamic motion increased, and males were impacted more than females. Intra-abdominal pressure seemed to only be affected by trunk dynamics at high levels of force. Trunk moments were found to increase monotonically with increased trunk motion. Both agonistic and antagonistic muscle activities were greater as dynamic characteristics increased. As a result, the three-dimensional spinal loads increase significantly for dynamic exertions as compared to isometric conditions.

CONCLUSIONS

Trunk motion has a dramatic affect on the muscle coactivity, which seems to be the underlying source for the decrease strength capability as well as the increased muscle force, IAP, and spinal loads. This review suggests that the ability of the individual to perform a task "safely" might be significantly compromised by the muscle coactivity that accompanies dynamic exertions. It is also important to consider various workplace and individual factors when attempting to reduce the impact of trunk motions during dynamic exertions. Relevance This review provides insight as to why trunk motions are important risk factors to consider when attempting to control low-back disorders in the workplace. It is apparent that trunk motion increases the risk of low-back disorders. To better control low-back disorders in industry, more comprehensive knowledge about the impact of trunk motion is needed. A better understanding of muscle coactivity may ultimately lead to reducing the risk associated with dynamic exertions.

The influence of psychosocial stress, gender, and personality on mechanical loading of the lumbar spine

STUDY DESIGN

The effects of psychosocial stress on muscle activity and spinal loading were evaluated in a laboratory setting.

OBJECTIVE

To evaluate the influence of psychosocial stress, gender, and personality traits on the functioning of the biomechanical system and subsequent spine loading.

SUMMARY OF BACKGROUND DATA

Physical, psychosocial, and individual factors all have been identified as potential causal factors of low back disorders. How these factors interact to alter the loading of the spine has not been investigated.

METHODS

Twenty-five subjects performed sagittally symmetric lifts under stressful and nonstressful conditions. Trunk muscle activity, kinematics, and kinetics were used to evaluate three-dimensional spine loading using an electromyographic-assisted biomechanical model. A personality inventory characterized the subject's personality traits. Anxiety inventories and blood pressure confirmed reactions to stress.

RESULTS

Psychosocial stress increased spine compression and lateral shear, but not in all subjects. Differences in muscle coactivation accounted for these stress reactions. Gender also influenced spine loading; Women's anterior-posterior shear forces increased in response to stress, whereas men's decreased. Certain personality traits were associated with increased spine loading compared with those with an opposing personality trait and explained loading differences between subjects.

CONCLUSIONS

A potential pathway between psychosocial stress and spine loading has been identified that may explain how psychosocial stress increases risk of low back disorders. Psychosocially stressful environments solicited more of a coactivity response in people with certain personality traits, making them more susceptible to spine loading increases and suspected low back disorder risk.

Changes in lumbar lordosis modify the role of the extensor muscles

STUDY DESIGN

Fiber angles of longissimus thoracis and iliocostalis lumborum at L3 were documented in vivo, using high resolution ultrasound, with the lumbar spine in neutral curve and when fully flexed.

OBJECTIVES

To evaluate the effect of changes in lumbar curvature on the mechanics of these muscles.

BACKGROUND

Full flexion modifies the failure tolerance of the lumbar spine, determines the load distribution among muscle and passive tissues, and modulates the types of tissue damage that occur. Related to this issue are the possible changes in muscle line of action with full flexion which changes the ability of the spine to support shear loads.

METHODS

Nine normal men and 5 normal women were scanned in three positions: (1) an upright standing posture; (2) with the hips flexed to approximately 30 degrees and the spine fully flexed; (3) hips flexed but the spine returned to a neutral curvature.

RESULTS

Mean longissimus/iliocostalis fiber angles for upright standing, hips flexed-spine flexed, and hips flexed-spine neutral lordosis were 25. 7 degrees, 10.7 degrees and 28.3 degrees, respectively.

CONCLUSIONS

Anterior shear load on the lumbar spine has been recently shown to be highly related to the risk of reporting a back injury. Bending forward allowing the spine to fully flex changes the line of action of the largest lumbar extensor muscles compromising their role to support anterior shear forces. Relevance Fiber angles of longissimus thoracis and iliocostalis lumborum were documented with high resolution ultrasound at L3, with the spine in neutral curvature and fully flexed. Full lumbar flexion changes the line of action of these muscle compromising their role to support anterior shear forces on the spine - anterior shear forces have been recently documented to be highly related to the risk of reporting a back injury.

Flexion and rotation of the trunk and lifting at work are risk factors for low back pain: results of a prospective cohort study

STUDY DESIGN

A 3-year prospective cohort study among workers of 34 companies in the Netherlands.

OBJECTIVES

To investigate the relation between flexion and rotation of the trunk and lifting at work and the occurrence of low back pain.

SUMMARY OF BACKGROUND DATA

Previous studies on work-related physical risk factors for low back pain either lacked quantification of the physical load or did not take confounding by individual and psychosocial factors into account.

METHODS

The study population consisted of 861 workers with no low back pain at baseline and complete data on the occurrence of low back pain during the 3-year follow-up period. Physical load at work was assessed by means of analyses of video-recordings. Information on other risk factors and the occurrence of low back pain was obtained by means of self-administered questionnaires.

RESULTS

An increased risk of low back pain was observed for workers who worked with the trunk in a minimum of 60 degrees of flexion for more than 5% of the working time (RR 1.5, 95% CI 1.0-2.1), for workers who worked with the trunk in a minimum of 30 degrees of rotation for more than 10% of the working time (RR 1.3, 95% CI 0.9-1. 9), and for workers who lifted a load of at least 25 kg more than 15 times per working day (RR 1.6, 95% CI 1.1-2.3).

CONCLUSIONS

Flexion and rotation of the trunk and lifting at work are moderate risk factors for low back pain, especially at greater levels of exposure.

Disability measurement in persons with back pain: a validity study of spinal range of motion and velocity

OBJECTIVE

To evaluate the criterion validity and responsiveness to change of spine kinematic variables to assess disability in patients with low back pain.

DESIGN

Blinded comparison between spine kinematic variables, Oswestry disability questionnaire scores, and work status.

SETTING

Multidisciplinary occupational rehabilitation clinic of a university hospital.

PATIENTS

Population-based cohort of 111 patients with subacute work-related back pain who were absent from regular work for more than 4 weeks because of back pain.

INTERVENTIONS

This study was part of a population-based randomized clinical trial. Patients were randomized to 4 different methods of management: usual care, rehabilitation, ergonomics, or rehabilitation and ergonomics.

MAIN OUTCOME MEASURES

Oswestry disability questionnaire, kinematic analysis of the spine during flexion and extension of the trunk, and work status were collected at weeks 4, 12, 24, and 52 after the back accident.

RESULTS

Kinematic variables were poorly to moderately related to work status and Oswestry questionnaire scores. Kinematic variables were also unresponsive to change in work status and Oswestry questionnaire scores over time.

CONCLUSION

Spine kinematics during flexion and extension of the trunk do not appear to be a valid measure of disability in patients with subacute and chronic back pain.

Occupational low back disorder causation and control

Low back disorders (LBDs) continue to be the most common musculoskeletal problem in the workplace. It affects many workers, is associated with high costs to industry and the individual, and can negatively influence the quality of life for the workers. Currently there is significant controversy about the work-relatedness of LBD and the ability of ergonomics interventions to control the problem. This paper systematically examines the body of knowledge associated with LBDs and considers how information from different disciplines of study collectively might be used to assess the causality and control of LBD due to physical factors associated with work.

Metabolic cost and subjective assessment of palletizing and subsequent recovery

Twenty-one male blue collar workers repeatedly lifted (palletized) a box weighing 22 kg six times min(-1) for 5 min to a shelf of fixed height. The experimental conditions included two planes of lifting (symmetries), two shelf clearances, and three headrooms. The metabolic (heart rate, caloric cost and ventilation volume) and psychophysical variables (rate of perceived exertion, RPE; visual analogue score, VAS; and body part discomfort ratings, BPDR) were measured during resting, palletization, and recovery phases. In palletization the heart rate and metabolic cost ranged between 25 to 35% of the maximal aerobic capacity. Of the three factors only headroom had a significant effect on metabolic cost (p<0.02) and the BPDR for low back (p<0.05). In the recovery phase only headroom had significantly effect (p<0.001) on metabolic cost. The metabolic recovery took 10 min; however, recovery measured through psychophysical indices appeared to continue for 20 min.

Cost-benefit of muscle cocontraction in protecting against spinal instability

STUDY DESIGN

Lifting dynamics and electromyographic activity were evaluated using a biomechanical model of spinal equilibrium and stability to assess cost-benefit effects of antagonistic muscle cocontraction on the risk of stability failure.

OBJECTIVES

To evaluate whether increased biomechanical stability associated with antagonistic cocontraction was capable of stabilizing the related increase in spinal load.

SUMMARY OF BACKGROUND DATA

Antagonistic cocontraction contributes to improved spinal stability and increased spinal compression. For cocontraction to be considered beneficial, stability must increase more than spinal load. Otherwise, it may be possible for cocontraction to generate spinal loads that cannot be stabilized.

METHODS

A biomechanical model was developed to compute spinal load and stability from measured electromyography and motion dynamics. As 10 healthy men performed sagittal lifting tasks, trunk motion, reaction loads, and electromyographic activities of eight trunk muscles were recorded. Spinal load and stability were evaluated as a function of cocontraction and trunk flexion angle. Stability was quantified in terms of the maximum spinal load the system could stabilize.

RESULTS

Cocontraction was associated with a 12% to 18% increase in spinal compression and a 34% to 64% increase in stability. Spinal load and stability increased with trunk flexion.

CONCLUSIONS

Despite increases in spinal load that had to be stabilized, the margin between stability and spinal compression increased significantly with cocontraction. Antagonistic cocontraction was found to be most beneficial at low trunk moments typically observed in upright postures. Similarly, empirically measured antagonistic cocontraction was recruited less in high-moment conditions and more in low-moment conditions.

Viscoelastic finite-element analysis of a lumbar motion segment in combined compression and sagittal flexion. Effect of loading rate

STUDY DESIGN

A study using a validated viscoelastic finite-element model of a L2-L3 motion segment to identify the load sharing among the passive elements at different loading rates.

OBJECTIVE

To enhance understanding concerning the role of the loading rate (i.e., speed of lifting and lowering during manual material handling tasks) on the load sharing and safety margin of spinal structures.

SUMMARY OF BACKGROUND DATA

Industrial epidemiologic studies have shown that jobs requiring a higher speed of trunk motion contribute to a higher risk of industrial low back disorders. Consideration of the dynamic loading characteristics, such as lifting at different speeds, requires modeling of the viscoelastic behavior of passive tissues. Detailed systematic analysis of loading rate effects has been lacking in the literature.

METHODS

Complex flexion movement was simulated by applying compression and shear loads at the top of the upper vertebra while its sagittal flexion angle was prescribed without constraining any translations. The lower vertebra was fixed at the bottom. The load reached its maximum values of 2000 N compression and 200 N anterior shear while L2 was flexed to 10 degrees of flexion in the three different durations of 0.3, 1, and 3 seconds to represent fast, medium, and slow movements, respectively. The resisted bending moment, gross load-displacement response of the motion segment, forces in facet joints and ligaments, stresses and strains in anulus fibrosus, and intradiscal pressure were compared across different rates.

RESULTS

The distribution of stress and strain was markedly affected by the loading rate. The higher loading rate increased the peak intradiscal pressure (12.4%), bending moment (20.7%), total ligament forces (11.4%), posterior longitudinal ligament stress (15.7%), and anulus fiber stress at the posterolateral innermost region (17.9%), despite the 15.4% reduction in their strain.

CONCLUSIONS

Consideration of the time-dependent material properties of passive elements is essential to improving understanding of motion segment responses to dynamic loading conditions. Higher loading rate markedly reduces the safety margin of passive spinal elements. When the dynamic tolerance limits of tissues are available, the results provide bases for the guidelines of safe dynamic activities in clinics or industry.

Anterior shear of spinal motion segments. Kinematics, kinetics, and resultant injuries observed in a porcine model

STUDY DESIGN

A basic study of 56 porcine specimens in anterior shear loading.

OBJECTIVES

To determine some modulators of the biomechanics of spinal motion segments exposed to acute shear loading and to identify the resultant injuries.

SUMMARY OF BACKGROUND DATA

Most research on spinal injury mechanisms has focused on compressive loading, leaving a void in understanding of the effect of shear loading on origin of injury.

METHODS

Cervical spines (n = 56) of domestic pigs (6 months old) were loaded to failure in a specially designed jig that restricted their motion to primarily the shear plane. The specimens were tested at load rates of 100 N/sec or 10,810 N/sec and either in a flexed or neutral posture. In addition, the function of the individual structures of the motion segment were determined by serial dissection forming three groups: whole specimens, specimens with no posterior ligaments, and specimens with no posterior ligaments or facet joints. Load-deformation curves were collected using analog-to-digital sampling rates of 50 and 100 Hz. The mode of failure was then documented through systematic dissection of the specimen and/or radiology techniques. Modeling approaches were then used to gain insight into the failure mechanisms.

RESULTS

Dynamic loading (10,810 N/sec) and flexion of the specimens were found to increase the ultimate load at failure when compared with quasistatic loading (100 N/sec) and neutral postures. The disc resisted up to 70% of an applied load, with the pars interarticularis responsible for only 30% of the load. Nonetheless, the pars was the primary site of failure. Furthermore, higher load rates also caused endplate avulsion, specifically in the lateral borders of the anulus.

CONCLUSIONS

The porcine model appears to reproduce injuries found in the data available on human lumbar material. Fractures in the pars interarticularis may not greatly weaken the joint, given the dominant role of the disc, but compromise its normal kinematics. Clinically, this may explain the occurrence of pars fractures, without total disability.