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Kuijer PPFM, van der Molen HF, Visser S. A Health-Impact Assessment of an Ergonomic Measure to Reduce the Risk of Work-Related Lower Back Pain, Lumbosacral Radicular Syndrome and Knee Osteoarthritis among Floor Layers in The Netherlands. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4672. [PMID: 36901682 PMCID: PMC10001867 DOI: 10.3390/ijerph20054672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Abstract
Sand-cement-bound screed floor layers are at risk of work-related lower back pain, lumbosacral radicular syndrome and knee osteoarthritis, given their working technique of levelling screed with their trunk bent while mainly supported by their hands and knees. To reduce the physical demands of bending of the trunk and kneeling, a manually movable screed-levelling machine was developed for floor layers in the Netherlands. The aim of this paper is to estimate the potential health gains of working with a manually movable screed-levelling machine on the risk of lower back pain (LBP), lumbosacral radicular syndrome (LRS) and knee osteoarthritis (KOA) compared to traditional working techniques. This potential health gain was assessed using the epidemiological population estimates of the Population Attributable Fraction (PAF) and the Potential Impact Fraction (PIF), combined with work-related risk estimates for these three disorders from systematic reviews. The percentage of workers exceeding these risk estimates was based on worksite observations among 28 floor layers. For LBP, 16/18 workers were at risk when using traditional working techniques, with a PAF = 38%, and for those using a manually movable screed-levelling machine, this was 6/10 with a PIF = 13%. For LRS, these data were 16/18 with a PAF = 55% and 14/18 with a PIF = 18%, and for KOA, 8/10 with a PAF = 35% and 2/10 with a PIF = 26%. A manually movable screed-levelling machine might have a significant impact on the prevention of LBP, LRS and KOA among floor layers in the Netherlands, and health-impact assessments are a feasible approach for assessing health gains in an efficient way.
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Sain MK, Meena M. Identifying musculoskeletal issues and associated risk factors among clay brick kiln workers. INDUSTRIAL HEALTH 2019; 57:381-391. [PMID: 30344230 PMCID: PMC6546584 DOI: 10.2486/indhealth.2018-0096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 09/26/2018] [Indexed: 06/08/2023]
Abstract
The present study is aimed to investigate the musculoskeletal issues and association of risk-factors with these problems among manual brick kiln workers. A modified Nordic Questionnaire was administered among 376 traditional brick kiln workers to collect data. Logistic regression was used to determine the association between musculoskeletal problems and risk-factors. Majority of workers (76.19%) involved in mould evacuating task reported wrist issues whereas lower back issues were reported by 62.35% of spading task workers. Age was a factor associated with musculoskeletal symptoms in the majority of the body regions. Gender was significantly associated with lower back (OR=3.71, CI: 1.51-9.11) MSDs. Spading task was associated with the wrist (OR=2.42, CI: 51.03-5.66), and lower back (OR=3.97, CI: 1.75-8.98) problems. Mould filling was a contributing factor for the wrist (OR=4.27, CI: 1.81-10.09) and knee (OR=6.88, CI: 2.40-19.70) issues. MSDs in wrist (OR=12.22, CI: 4.82-30.98) and fingers (OR=3.57, CI: 1.23-10.36) were significant in mould evacuating workers. Workers having less than 5 yr of experience were less prone to the neck (OR= 0.03, CI: 0.00-0.72) and upper back (OR=0.08, CI: 0.01-0.76) MSDs. For prevention of problems, ergonomic interventions such as workers' training, use of protecting aids, modification in hand tools and work practices are needed.
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Affiliation(s)
- Manoj Kumar Sain
- Department of Mechanical Engineering, Malaviya National Institute of Technology, India
- Department of Mechanical Engineering, Swami Keshvanand Institute of Technology, Management & Gramothan, India
| | - Makkhan Meena
- Department of Mechanical Engineering, Malaviya National Institute of Technology, India
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Exploring the musculoskeletal problems and associated risk-factors among brick kiln workers. INTERNATIONAL JOURNAL OF WORKPLACE HEALTH MANAGEMENT 2018. [DOI: 10.1108/ijwhm-05-2018-0061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Prolonged working in repetitive and awkward postures can result in musculoskeletal disorders among workers involved in labour-intensive jobs like those of brick kiln workers. Unlike other labour-intensive sectors, workers in this particular sector have a lack of awareness about musculoskeletal problems. Therefore, the purpose of this paper is to explore musculoskeletal issues and associated risk-factors among brick kiln workers.
Design/methodology/approach
A questionnaire survey was conducted among 217 male and 111 female workers aged between 17 and 53 years. They were employed in traditional brick kiln units situated in Rajasthan, India. Postures were analysed by Rapid Upper Limb Assessment and Rapid Entire Body Assessment methods. Binary logistic regression was used to find the association between musculoskeletal problems and risk-factors.
Findings
For the mould evacuating task, wrist (76.2 per cent) and lower back (56 per cent) issues were the most frequently reported musculoskeletal problems, while in spading task, lower back (62.4 per cent) and shoulder (57.7 per cent) problems were prominent. Musculoskeletal symptoms in one or more body regions were associated with personal and work-related factors including the type of task and experience.
Research limitations/implications
Kiln workers are exposed to high musculoskeletal and postural risks, particularly in spading and mould filling tasks. To reduce these risks, ergonomic interventions are needed.
Originality/value
It is recognised that the musculoskeletal health of brick kiln workers is a cause for concern. The present study provides the evidence of the prevalence of musculoskeletal symptoms experienced by brick kiln workers and the association of symptoms with various risk-factors, which has not been addressed in previous studies.
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Zare M, Biau S, Brunet R, Roquelaure Y. Comparison of three methods for evaluation of work postures in a truck assembly plant. ERGONOMICS 2017; 60:1551-1563. [PMID: 28475477 DOI: 10.1080/00140139.2017.1314023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 03/27/2017] [Indexed: 06/07/2023]
Abstract
This study compared the results of three risk assessment tools (self-reported questionnaire, observational tool, direct measurement method) for the upper limbs and back in a truck assembly plant at two cycle times (11 and 8 min). The weighted Kappa factor showed fair agreement between the observational and direct measurement method for the arm (0.39) and back (0.47). The weighted Kappa factor for these methods was poor for the neck (0) and wrist (0) but the observed proportional agreement (Po) was 0.78 for the neck and 0.83 for the wrist. The weighted Kappa factor between questionnaire and direct measurement showed poor or slight agreement (0) for different body segments in both cycle times. The results revealed moderate agreement between the observational tool and the direct measurement method, and poor agreement between the self-reported questionnaire and direct measurement. Practitioner Summary: This study provides risk exposure measurement by different common ergonomic methods in the field. The results help to develop valid measurements and improve exposure evaluation. Hence, the ergonomist/practitioners should apply the methods with caution, or at least knowing what the issues/errors are.
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Affiliation(s)
- Mohsen Zare
- a Equipe ERCOS-UTBM - Université de Bourgogne Franche-Comté , Belfort , France
| | - Sophie Biau
- a Equipe ERCOS-UTBM - Université de Bourgogne Franche-Comté , Belfort , France
- b French Institute of National Horse Riding School (IFCE) , Saumur , France
| | - Rene Brunet
- c INSERM, U1085, IRSET, ESTER Team, University of Angers , Angers , France
| | - Yves Roquelaure
- c INSERM, U1085, IRSET, ESTER Team, University of Angers , Angers , France
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Wang X, Dong XS, Choi SD, Dement J. Work-related musculoskeletal disorders among construction workers in the United States from 1992 to 2014. Occup Environ Med 2016; 74:374-380. [PMID: 28039200 DOI: 10.1136/oemed-2016-103943] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/18/2016] [Accepted: 12/04/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Examine trends and patterns of work-related musculoskeletal disorders (WMSDs) among construction workers in the USA, with an emphasis on older workers. METHODS WMSDs were identified from the 1992-2014 Survey of Occupational Injuries and Illnesses (SOII), and employment was estimated from the Current Population Survey (CPS). Risk of WMSDs was measured by number of WMSDs per 10 000 full-time equivalent workers and stratified by major demographic and employment subgroups. Time series analysis was performed to examine the trend of WMSDs in construction. RESULTS The number of WMSDs significantly dropped in the US construction industry, following the overall injury trends. However, the rate of WMSDs in construction remained higher than in all industries combined; the median days away from work increased from 8 days in 1992 to 13 days in 2014, and the proportion of WMSDs for construction workers aged 55 to 64 years almost doubled. By occupation, construction labourers had the largest number of WMSD cases, while helpers, heating and air-conditioning mechanics, cement masons and sheet metal workers had the highest rates of WMSDs. The major cause of WMSDs in construction was overexertion, and back injuries accounted for more than 40% of WMSDs among construction workers. The estimated wage loss for private wage-and-salary construction workers was $46 million in 2014. CONCLUSIONS Construction workers continue to face a higher risk of WMSDs. Ergonomic solutions that reduce overexertion-the primary exposure for WMSDs-should be adopted extensively at construction sites, particularly for workers with a higher risk of WMSDs.
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Affiliation(s)
- Xuanwen Wang
- CPWR-The Center for Construction Research and Training, Silver Spring, Maryland, USA
| | - Xiuwen Sue Dong
- CPWR-The Center for Construction Research and Training, Silver Spring, Maryland, USA
| | - Sang D Choi
- Department of Occupational & Environmental Safety & Health, University of Wisconsin-Whitewater, Whitewater, Wisconsin, USA
| | - John Dement
- Division of Occupational and Environmental Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Visser S, van der Molen HF, Kuijer PPFM, Sluiter JK, Frings-Dresen MHW. Stand up: comparison of two electrical screed levelling machines to reduce the work demands for the knees and low back among floor layers. ERGONOMICS 2016; 59:1224-1231. [PMID: 26589236 DOI: 10.1080/00140139.2015.1122233] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Electrical screed levelling machines are developed to reduce kneeling and trunk flexion of sand-cement-bound screed floor layers. An observational intervention study among 10 floor layers was performed to assess the differences between a self-propelled and a manually moved machine. The outcome measures were work demands, production time, perceived load, discomfort and applicability. Compared to the self-propelled machine, the duration of kneeling (∆13 min; p = 0.003) and trunk flexion (∆12 min; p < 0.001) was shorter using the manually moved machine, and the duration of pushing and pulling increased (∆39 min; p < 0.001). No significant or relevant differences were found for production time, perceived load and discomfort. Nine out of ten floor layers found the manually moved machine applicable and three out of ten found the self-propelled machine applicable. When compared with the traditional manner of floor laying, both electrical machines reduced the exposure towards kneeling and trunk flexion. Practitioner Summary: Electrical machines may help to reduce high physical work demands on floor layers. A manually moved machine is better applicable for the installation of screed floors in residences with smaller floor areas. A self-propelled machine is better applicable on large floor areas with a minimum width of 4 m.
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Affiliation(s)
- Steven Visser
- a Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Henk F van der Molen
- a Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
- b Arbouw , Harderwijk , The Netherlands
| | - P Paul F M Kuijer
- a Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Judith K Sluiter
- a Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Monique H W Frings-Dresen
- a Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
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Jia N, Li T, Hu S, Zhu X, Sun K, Yi L, Zhang Q, Luo G, Li Y, Zhang X, Gu Y, Wang Z. Prevalence and its risk factors for low back pain among operation and maintenance personnel in wind farms. BMC Musculoskelet Disord 2016; 17:314. [PMID: 27461535 PMCID: PMC4962352 DOI: 10.1186/s12891-016-1180-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 07/21/2016] [Indexed: 01/07/2023] Open
Abstract
Background With the increasingly severe energy shortage and climate change problems, developing wind power has become a key energy development strategy and an inevitable choice to protect the ecological environment worldwide. The purpose of this study was to investigate the prevalence of low back pain (LBP) and analyze its risk factors among operation and maintenance personnel in wind farms (OMPWF). Methods A cross-sectional survey of 151 OMPWF was performed, and a comprehensive questionnaire, which was modified and combined from Nordic Musculoskeletal Questionnaires (NMQ), Washington State Ergonomics Tool (WSET) and Syndrome Checklist-90(SCL-90) was used to assess the prevalence and risk factors of LBP among OMPWF. Results The prevalence of LBP was 88.74 % (134/151) among OMPWF. The multivariable model highlighted four related factors: backrest, somatization, squatting and lifting objects weighing more than 10 lb more than twice per minute. Conclusions The prevalence of LBP among OMPWF appears to be high and highlights a major occupational health concern.
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Affiliation(s)
- Ning Jia
- Department of Occupational Protection and Ergonomics, National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, NO.29, Nanwei Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Tao Li
- Department of Occupational Protection and Ergonomics, National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, NO.29, Nanwei Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Shuangqiu Hu
- Labor Health Occupational Disease Prevention and Control Center in Zhuzhou, Zhuzhou, 412011, Hunan, People's Republic of China
| | - Xinhe Zhu
- Labor Health Occupational Disease Prevention and Control Center in Zhuzhou, Zhuzhou, 412011, Hunan, People's Republic of China
| | - Kang Sun
- Labor Health Occupational Disease Prevention and Control Center in Zhuzhou, Zhuzhou, 412011, Hunan, People's Republic of China
| | - Long Yi
- Wind power Division of Zhuzhou Electric Locomotive Institute Corporation, China South Locomotive and Rolling Stock (CSR), Zhuzhou, 412007, Hunan, People's Republic of China
| | - Qiong Zhang
- Wind power Division of Zhuzhou Electric Locomotive Institute Corporation, China South Locomotive and Rolling Stock (CSR), Zhuzhou, 412007, Hunan, People's Republic of China
| | - Guilian Luo
- Hunan University of Technology, Zhuzhou, 412007, Hunan, People's Republic of China
| | - Yuzhen Li
- Department of Occupational Protection and Ergonomics, National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, NO.29, Nanwei Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Xueyan Zhang
- Department of Occupational Protection and Ergonomics, National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, NO.29, Nanwei Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Yongen Gu
- Department of Occupational Protection and Ergonomics, National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, NO.29, Nanwei Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Zhongxu Wang
- Department of Occupational Protection and Ergonomics, National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, NO.29, Nanwei Road, Xicheng District, Beijing, 100050, People's Republic of China.
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Dale AM, Miller K, Gardner BT, Hwang CT, Evanoff B, Welch L. Observed use of voluntary controls to reduce physical exposures among sheet metal workers of the mechanical trade. APPLIED ERGONOMICS 2016; 52:69-76. [PMID: 26360196 PMCID: PMC4631612 DOI: 10.1016/j.apergo.2015.06.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 05/26/2015] [Accepted: 06/29/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Little is known about the transfer into the workplace of interventions designed to reduce the physical demands of sheet metal workers. METHODS We reviewed videos from a case series of 15 sheet metal worksite assessments performed in 2007-2009 to score postures and physical loads, and to observe the use of recommended interventions to reduce physical exposures in sheet metal activities made by a NIOSH stakeholder meeting in 2002. RESULTS Workers showed consistent use of material handling devices, but we observed few uses of recommended interventions to reduce exposures during overhead work. Workers spent large proportions of time in awkward shoulder elevation and low back rotation postures. CONCLUSIONS In addition to the development of new technologies and system designs, increased adoption of existing tools and practices could reduce time spent in awkward postures and other risks for musculoskeletal disorders in sheet metal work.
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Affiliation(s)
- Ann Marie Dale
- Washington University School of Medicine, Division of General Medical Sciences, Campus Box 8005, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA.
| | - Kim Miller
- Washington University School of Medicine, Division of General Medical Sciences, Campus Box 8005, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA; Washington University School of Medicine, Program in Physical Therapy, 4444 Forest Park Avenue, Campus Box 8502, Saint Louis, MO 63108, USA
| | - Bethany T Gardner
- Washington University School of Medicine, Division of General Medical Sciences, Campus Box 8005, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA
| | - Ching-Ting Hwang
- Washington University School of Medicine, Program in Physical Therapy, 4444 Forest Park Avenue, Campus Box 8502, Saint Louis, MO 63108, USA
| | - Bradley Evanoff
- Washington University School of Medicine, Division of General Medical Sciences, Campus Box 8005, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA
| | - Laura Welch
- The Center for Construction Research and Training (CPWR), 8484 Georgia Avenue, Silver Spring, MD 20910, USA
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Lipscomb HJ, Schoenfisch AL, Cameron W, Kucera KL, Adams D, Silverstein BA. Workers' compensation claims for musculoskeletal disorders and injuries of the upper extremity and knee among union carpenters in Washington State, 1989-2008. Am J Ind Med 2015; 58:428-36. [PMID: 25712704 DOI: 10.1002/ajim.22433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Numerous aspects of construction place workers at risk of musculoskeletal disorders and injuries (MSDIs). Work organization and the nature of MSDIs create surveillance challenges. METHODS By linking union records with workers' compensation claims, we examined 20-year patterns of MSDIs involving the upper extremity (UE) and the knee among a large carpenter cohort. RESULTS MSDIs were common and accounted for a disproportionate share of paid lost work time (PLT) claims; UE MSDIs were three times more common than those of the knee. Rates declined markedly over time and were most pronounced for MSDIs of the knee with PLT. Patterns of risk varied by extremity, as well as by age, gender, union tenure, and predominant work. Carpenters in drywall installation accounted for the greatest public health burden. CONCLUSIONS A combination of factors likely account for the patterns observed over time and across worker characteristics. Drywall installers are an intervention priority.
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Affiliation(s)
- Hester J. Lipscomb
- Division of Occupational and Environmental Medicine; Duke University Medical Center; Durham North Carolina
| | - Ashley L. Schoenfisch
- Division of Occupational and Environmental Medicine; Duke University Medical Center; Durham North Carolina
| | - Wilfrid Cameron
- Strategic Solutions for Safety; Health and Environment; Seattle Washington
| | - Kristen L. Kucera
- Department of Exercise and Sport Science; University of North Carolina; Chapel Hill North Carolina
| | - Darrin Adams
- Department of Labor and Industries; Safety and Health Assessment and Research Program (SHARP); State of Washington; Olympia Washington
| | - Barbara A. Silverstein
- Department of Labor and Industries; Safety and Health Assessment and Research Program (SHARP); State of Washington; Olympia Washington
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Dale AM, Ryan D, Welch L, Olsen MA, Buchholz B, Evanoff B. Comparison of musculoskeletal disorder health claims between construction floor layers and a general working population. Occup Environ Med 2015; 72:15-20. [PMID: 25224720 PMCID: PMC4270930 DOI: 10.1136/oemed-2014-102313] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Compare rates of medical insurance claims for musculoskeletal disorders (MSD) between workers in a construction trade and a general worker population to determine if higher physical exposures in construction lead to higher rates of claims on personal medical insurance. METHODS Health insurance claims between 2006 and 2010 from floor layers were frequency matched by age, gender, eligibility time and geographic location to claims from insured workers in general industry obtained from MarketScan. We extracted MSD claims and dates of service from six regions of the body: neck, low back, knee, lower extremity, shoulder and distal arm, and evaluated differences in claim rates. RESULTS Fifty-one per cent of floor layers (n=1475) experienced musculoskeletal claims compared with 39% of MarketScan members (p<0.001). Claim rates were higher for floor layers across all body regions with nearly double the rate ratios for the knee and neck regions (RR 2.10 and 2.07). The excess risk was greatest for the neck and low back regions; younger workers had disproportionately higher rates in the knee, neck, low back and distal arm. A larger proportion of floor layers (22%) filed MSD claims in more than one body region compared with general workers (10%; p<0.001). CONCLUSIONS Floor layers have markedly higher rates of MSD claims compared with a general worker population, suggesting a shifting of medical costs for work-related MSD to personal health insurance. The occurrence of disorders in multiple body regions and among the youngest workers highlights the need for improved work methods and tools for construction workers.
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Affiliation(s)
- Ann Marie Dale
- Washington University School of Medicine in St. Louis, Division of General Medical Sciences Department, Saint Louis, Missouri, USA
| | - Daniel Ryan
- Northwestern University, Feinberg School of Medicine, Department of Medical Social Sciences Chicago, Illinois, USA
| | - Laura Welch
- The Center for Construction Research and Training CPWR, Silver Spring, Maryland, USA
| | - Margaret A. Olsen
- Washington University School of Medicine in St. Louis, Department of Internal Medicine, Saint Louis, Missouri, USA
| | - Bryan Buchholz
- University of Massachusetts Lowell, Work Environment Department, Lowell, Massachusetts USA
| | - Bradley Evanoff
- Washington University School of Medicine in St. Louis, Division of General Medical Sciences Department, Saint Louis, Missouri, USA
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