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ERGONOMICS AND THE MANAGEMENT OF 0-7506-7409-1MUSCULOSKELETAL
DISORDERS, SECONDEDITIONCopyright 2004, Elsevier (USA). All rights
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Printed in United States of America
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NOTICE
Occupational therapy and ergonomics are ever-changing elds.
Standard safety precautions must befollowed, but as new research
and clinical experience broaden our knowledge, changes in
treatmentmay become necessary or appropriate.
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CHERYL ATWOOD, BSYarns for EweBethlehem, Connecticut
NANCY BAKER, ScD, OTR/LAssistant ProfessorDepartment of
Occupational TherapySchool of Health and Rehabilitation
ScienceUniversity of PittsburghPittsburgh, Pennsylvania
DONALD CLARK, MS, PTPrivate PracticeWesterly, Rhode Island
CHARLES F. DILLON, MD, PhDResearch Medical OfcerDepartment of
Health and Human ServicesCenters for Disease ControlDivision of
Health Examination Statistics/NHANESHyattsville, Maryland
SUSAN V. DUFF, EdD, PT, OTR/L, CHT, BCPClinical Research
DirectorClinical Research DepartmentShriners Hospitals for
ChildrenPhiladelphia, PennsylvaniaClinical Faculty
AssociatePhysical Therapy ProgramNew York Medical CollegeValhalla,
New York
DOROTHY FARRAR EDWARDS, PhDProgram in Occupational
TherapyWashington University School of MedicineSt. Louis,
Missouri
MELANIE T. ELLEXSON, MBA, OTR/L, FAOTAAssistant ProfessorChicago
State University Chicago, Illinois
ROBERT O. HANSSON, PhDProfessor of PsychologyUniversity of
TulsaTulsa, Oklahoma
BARBARA J. HEADLEY, MS, PTInnovative Systems for Rehabilitation
Inc.Boulder, Colorado
CARYL D. JOHNSON, OTR/L, CHTJohnson Hand Therapy ServicesNew
York, New York
JAMES H. KILLIANGraduate StudentIndustrial-Organizational
PsychologyUniversity of TulsaTulsa, Oklahoma
JAMES W. KING, MA, CHT, OTR/LRegional ManagerAlliance
ImagingWaco,Texas
BRENDAN C. LYNCH, MAGraduate StudentClinical
PsychologyUniversity of TulsaTulsa, Oklahoma
MICHAEL MELNIK, MS, OTRPrevention PlusMinneapolis, Minnesota
TIM MORSE, PhDTraining CoordinatorErgotechnology Center of
ConnecticutDivision of Occupational and Environmental
MedicineUniversity of Connecticut Health CenterFarmington,
Connecticut
Contributors
-
CLAUDIA MICHALAK-TURCOTTE, CDA, RDH,MSDH, MSOSHAssociate
ProfessorDepartment of Allied DentalTunxis CommunityTechnical
CollegeFarmington, ConnecticutDepartment of Allied DentalDental
HygieneUniversity of Connecticut School of Dental Medicine
Farmington, Connecticut
NICK WARREN, ScD, MATCoordinator, Ergotechnology Center of
ConnecticutDivision of Occupational and Environmental
MedicineUniversity of Connecticut Health CenterFarmington,
Connecticut
viii Contributors
RICHARD K. SCHWARTZ, MS, OTRRichard K. Schwartz Consulting
Services, Inc.Industrial Medicine and Risk ManagementSan
Antonio,Texas
JUDY SEHNAL, MS, OTR/L, CPEExecutive Technical ConsultantThe
HartfordHartford, Connecticut
ROBYN STRICOFF, OTR/L, CHTOccupational SolutionsMonroe,
Connecticut
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The second edition of Ergonomics and theManagement of
Musculoskeletal Disorders(previously, Management of
CumulativeTrauma Disorders) has added much depth andbreadth to the
rst edition to reflect the majorchanges in the political,medical,
ergonomic,andresearch arenas relative to managing muscu-loskeletal
disorders.The name of this book hasbeen changed to reflect the
adoption of theterm musculoskeletal disorder (MSD) by theNational
Institute of Occupational Safety andHealth.
Seven new chapters have been added andseven new expert
contributors have addedincredible new information and experience
tothe book. The context of work is now framed in the history of
work, all the while maintaininga client-centered perspective. An
update on the regulatory status and incidence of MSDssupports our
need to continue our work towardpreventing such disorders. The
medical chap-ters offer cutting-edge information on
arthritis-related MSDs, heretofore rarely acknowledged in MSD
literature. The entire context of ergo-nomics is expanded and
discussed from a
contemporary perspective that incorporates notonly job design,
but also the organization ofwork and characteristics of the
individual.Ergonomics is taken out of the exclusive arenaof work
and applied to home and leisure envi-ronments, acknowledging that
MSD manage-ment is not limited to medical and
industrialenvironments. Finally, special populations thatprovide
challenges for MSD management, olderworkers and daycare workers,
are presented inthis edition.
As before, Ergonomics and Management ofMusculoskeletal Disorders
is organized topresent information in earlier chapters that
issequentially developed and applied in laterchapters.
Although we should take pride that theoverall number of
musculoskeletal disorders hasbegun to decline, much work still
needs to bedone to prevent, minimize, and treat workerswho have
developed MSDs in the workplace.Acollaborative approach of all
disciplines is crucialto our further understanding and managementof
MSDs.
Martha J. Sanders
Preface
-
This book is dedicated tothe families and colleagues of all
contributors
whose support made this book possible.
More specicallymy family has been a great source of clarity and
drive.
Thanks toDad
who instilled in us the self-fullling nature of workMom
whose compassion compels my quest for clients health and
happinessPeter
whose focus allows us to plan and nish a projectJeffrey
whose balance makes us remember to have funWendy
whose creativity allows us to express ideas with new
flairJimmy
whose broad scope allows us to expand into new horizonsPaul
whose breadth of knowledge invites new applications for
traditional content.But a special thanks to
Addie and Taiwho taught us about perseverance.
-
Many individuals gave their time to thecreation of this second
edition.Again, thanks tothe contributors for tting in this
professionalwriting with daily life. A second thanks toNorma
Keegan, Interlibrary Loan Director atQuinnipiac University, who
gracefully suppliedme with reams of research studies for both
therst and second editions. A special thanks toRuthanna Terreri and
Cheryl Atwood, whoprovided the patience and expertise for many
ofthe photos in this book.
Acknowledgements
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Our society prides itself on the belief thattechnical
advancements in information pro-cessing, manufacturing technology,
and medicalscience will enhance the quality of life for
allindividuals. Logic dictates that if we work moreefficiently, we
will be more productive and,therefore,more satisfied with our
personal work,our wages, and the use of our leisure
time.Unfortunately, the basic assumptions that underliethis logic
are gradually being undermined by thehidden costs of doing business
in todays highlytechnical society. The hidden costs that weaddress
are the escalating incidents of stress-related and musculoskeletal
disorders (MSDs)for the thousands of workers responsible for
oursoaring productivity.
Today,we are witnessing what has been termedan industrial
epidemic (Schenck, 1989)thatis, an overwhelming increase in reports
of work-related disorders that affect not only industryproductivity
and labor costs but also the qualityof workers lives both inside
and outside theworkplace. The problem has dramatic
reper-cussions.As employment positions become lesssecure, workers
are less willing to perform jobsthat jeopardize their health and
limit futureearning potential. As businesses become in-creasingly
competitive, employers complain thatthe cost of MSDs reduces
profits by increasingworkerscompensation costs and decreasing
pro-ductivity.The cost of managing these disordersreverberates from
the factory or office floor tothe medical and often legal arenas,
all of which
remove the employee farther from work anddrive our health care
costs even higher.
The differences in focus among industrial,medical, insurance,
and legal systems exacerbatesthe problem.Each system possesses a
unique setof goals, languages, and procedures that canalienate
other provider systems. Although eachprovider contributes a
valuable perspective,oneprovider cannot effectively remediate MSDs
tothe exclusion of other systems. Clearly, in themanagement of
MSDs, the whole is truly greaterthan the sum of the parts.
The perspective of this book is that effectiveprevention and
management programs for MSDsmust thoroughly integrate all
professionalperspectives. The values of individual workersand
worker cultures must be integrated with themedical, corporate, and
insurance systems so thatlong-term solutions can be reached.
Althoughhealth care practitioners and ergonomic con-sultants will
enter the arena of MSD manage-ment from medical, insurance,
industrial,or eveneducational systems, all practitioners will
needto appreciate the contribution of other systemsand be prepared
to work with representativesfrom those systems toward a thorough,
com-prehensive MSD management plan.
This book systematically examines the meansby which health care
practitioners and consult-ants can effect change to facilitate
safer, moreproductive, and stimulating workplaces. Con-textual
background from the individual worker,medical, and
industrial/regulatory perspectives
3
C H A P T E R 1
Musculoskeletal Disorders: A Worldwide Dilemma
Martha J. Sanders
-
are presented to sensitize health care practi-tioners to the
concerns of each participant.
From all perspectives, worker health is apriority in our
efforts.If companies are to survive,managers need to maximize
productivity andminimize medical costs. If workers are tomaintain
quality of work and home life, workersneed to take responsibility
for protecting theirhealth. If medicine is to alleviate
disability,healthprofessionals must step beyond the clinics intothe
real world of industry and business.Cooperatively, we must balance
productivitywith health, consider long-term gains versusshort-term
profit, and reexamine the value ofwork for todays worker.
From the high-speed assembly lines to thepropagating computer
terminals, modern toolsof the trade certainly have improved
ourstandard of living. But what about our quality ofwork life? Are
we any better off than we were atthe turn of the century? As Eli
Ginzberg (1982)eloquently stated,It remains to be seen whetheror
not the potential of modern technology willturn out to be a
blessing.
HISTORY OF MUSCULOSKELETALDISORDERSThe occurrence of MSDs in
industry is not new.In 1717, Bernardo Ramazzini, the father
ofoccupational medicine, first introduced tophysicians the common
musculoskeletal disordersthat arose from eighteenth-century
occupationsin his treatise De Morbis Artificum Diatriba(The
Diseases of Workers) (translated byWright, 1940). Ramazzini
observed that manydiseases or conditions appeared to be related
tohis patients exposures to hazardous workenvironments.At that
time, however, physiciansrarely asked patients about their
jobs.Ramazzini,therefore, initiated one of the first
systematicattempts to attribute specific diseases orconditions to
factors in workers environments.Ramazzini documented the
musculoskeletal,respiratory,dermatologic, and emotional
problemsexhibited by his patients. He then observed
workers at their jobs and related specificaspects of the
environment (such as hazardousmaterials, airborne toxins,and
excessive physicaldemands) to these medical conditions.In
essence,Ramazzini laid the foundation for occupationalhealth
practices today. Ramazzini (1717) openshis treatise with the
following overview.
Various and manifold is the harvest of diseasesreaped by certain
workers from the crafts andtrades that they pursue; all the profit
that they get isfatal injury to their health. That crop
germinatesmostly, I think, from two causes.The first and mostpotent
is the harmful character of the materialsthat they handle for these
emit noxious vapors andvery fine particles inimical to human beings
andinduce particular diseases; the second cause I ascribeto certain
violent and irregular motions andunnatural postures of the body, by
reason of whichthe natural structure of the vital machine is
soimpaired that serious diseases gradually developtherefrom (p.
15).
Ramazzini poignantly describes the morbidityof many acquired
conditions and the futile rewardof illnesses that many workers
suffered as aresult of enduring hazardous work environments.He
describes the conditions that resulted fromspecific occupations. He
wrote the followingabout sedentary workers.
[M]en and women who sit while they work attheir jobs, become
bent, hump-backed and holdtheir heads like people looking for
something on theground; this is the effect of their sedentary life
andthe bent posture as they sit and sew (p. 282).
He described scribes and notaries this way.[T]he maladies that
afflict the clerks afore said
arise from three causes: First, constant sitting,secondly the
incessant movement of the hand andalways in the same direction,
thirdly the strain onthe mind from the effort not to disfigure the
booksby errors or cause loss to their employers when theyadd,
subtract, or do sums of arithmetic Further-more, incessant driving
of the pen over papercauses intense fatigue of the hand and the
wholearm because of the continuous and almost tonicstrain on the
muscles and tendons, which in courseof time results in failure of
power of the right hand(pp.421, 423).
4 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
Of painters he reported that their sedentarylife and melancholic
temperament may be partlyto blame, for they are almost entirely cut
offfrom intercourse with other men and constantlyabsorbed in the
creations of their imagination(p. 67). He noted of bakers,[N]ow and
again, Ihave noticed bakers with swelled hands, andpainful, too; in
fact, the hands of all such workersbecome thickened by the constant
pressure ofkneading the dough(p. 229).
Ramazzini identified hazards in workersenvironments that we have
come to associatewith the risk factors for MSDs today. Herecognized
not only the physical demands suchas violent and irregular motions,
bent pos-ture, incessant use of the hands, and tonicstrain on the
muscles,but also the emotional ormental demands that contribute to
work-relatedfatigue, such as melancholic temperament,sedentary
life, and strain on the mind. Still,disorders of workers were
treated on an in-dividual basis, and workers had relatively
fewchoices about whether to work in the face ofsuch disorders.
MUSCULOSKELETAL DISORDERSIN THE TWENTIETH CENTURYAs the
Industrial Revolution gained momentumand assembly-line pacing,
predetermined motionand time standards, long hours at work, and
theperformance of repetitive tasks became thenorm, the serious and
problematic nature ofwork-related diseases became
increasinglyapparent. When workers compensation lawswere introduced
in 1911 and then amended in1914 and expanded to cover conditions
such astenosynovitis, insurance companies began torecord and
further examine these injuries asrelated to their clients
occupations (Conn,1931; Hagan, Montgomery, & OReilly,
2001).
Physicians became instrumental in determiningwhether these
disorders were actually related towork. Physicians therefore began
to compiledata that equated musculoskeletal symptomswith workplace
factors. Conn (1931) examined
rubber company workers who had tenosynovitisand determined that
new high-speed handoperations, increased intensity of effort,
andbeing new to the job clearly predisposedindividuals to disorders
such as tenosynovitis.Hammer (1934),who attempted to delineate
thetolerances, or number of repetitions that humantendons could
withstand before tenosynovitisdeveloped, concluded that
tenosynovitis wouldoccur in human tendons if repetitions exceeded30
to 40 per minute, or 1500 to 2000 manip-ulations per hour. Hammer
noted certain handsymptoms consistent with carpal tunnel syn-drome,
but this condition was not exploredfurther until Phalen reported on
it in 1947.
Flowerdew and Bode (1942) raised the issueof improper training
and physical conditioningas contributors to tenosynovitis in some
workers.Among a group of 52 military personnel assignedto farm work
in Great Britain, 16 developedtenosynovitis of the wrist and finger
extensorsshortly after starting intensive manual work.Fourteen of
these 16 individuals had no previousmanual labor experience.Blood
(1942),a medicalofficer at a company in Great Britain,agreed
thatnewcomers to a repetitive stereotyped job areparticularly
vulnerable, but cases crop upamong employees who have had years
ofexperience at these jobs, particularly afterreturning to work
following a holiday or sickleave (p. 468). Blood attributed a 50%
increasein cases of tenosynovitis from 1940 to 1941 toan influx of
new workers in his industry.
As automation progressed and manual workbecame lighter and more
efficient, muscu-loskeletal problems related specifically to
officework became apparent. In the 1950s, new officeequipment such
as high-speed typewriters andkeypunch operations streamlined tasks
byeliminating movements not directly related tothe job (such as
retrieving the typewriter car-riage after each line). Automation
eliminatedboth the brief rest periods inherent in operatingthe old
machinery and the need for workers touse several different muscle
groups to accomplisha task. Physically, jobs became sedentary,
static,
Musculoskeletal Disorders: A Worldwide Dilemma 5
-
and, unvarying; people relied on localizedmuscles to perform the
work.Mentally, the workroutines became highly monotonous,
althoughdetailed work demanded high levels of con-centration.
Workers lost a sense of the overalltask to which they were
contributing (Giuliano,1982).
By the mid-1950s, the musculoskeletal andmental fatigue problems
associated with oper-ating new and repetitive machines were
clear.The Fifth Session of the International LaborOrganization
Advisory Committee on SalariedEmployees and Professional Workers
reportedthe serious physical consequences created bymechanized work
(ILO Advisory Committee,1960). Clerical workers complained of
low-backand neck pain; keypunch operators complainedof painful
nerves in the hands; accounting-machine operators complained of
fatigue, eyestrain, pain and stiffness in cervical and
lumbarregions, and numbness in the right hand(Maeda, Hunting, &
Grandjean, 1980). Althoughthese disorders crossed national
boundaries,peaks in reporting occurred at different timesfor each
country.
Occupational Cervicobrachial Disorderin JapanIn Japan, a
dramatic increase in musculoskeletaldisorders was reported between
1960 and 1980.Comparatively high prevalence of hand and armpain was
first reported in keypunch operators(17% of the occupational
sample). Later, typists(13%),telephone operators (16%),office
keyboardoperators (14%), and assembly-line workers(16%) reported
pain in the hands and arms thatinterfered with their abilities to
perform theirjobs (Maeda,1977;Ohara, Itani,& Aoyama,1982).The
claims rose to such a proportion that, in1964, the Japanese
Ministry of Labour issuedguidelines for keyboard operators,
demandingthat workers spend no more than 5 hours perday on the
keyboard, take a 10-minute rest breakevery hour, and perform fewer
than 40,000keystrokes per day. In companies that imple-mented these
preventive measures, the preva-lence of arm and hand disorders
decreased from
an overall prevalence of 10% to 20% down to 2%to 5% (Ohara et
al., 1982). However, the overallnumber of individuals who received
compen-sation for hand and arm disorders in the privatesector in
Japan increased from 90 in 1970 to 546in 1975 (Maeda, 1977).
In 1971, Japan formed the Japanese Com-mittee on Cervicobrachial
Syndrome to definethe syndrome and fully identify
contributingfactors. The committee proposed the nameoccupational
cervicobrachial disorder (OCD)and defined the problem as a
functional ororganic disorder (or both) resulting from mentalstrain
or neuromuscular fatigue due to per-forming jobs in a fixed
position or withrepetitive movements of the upper
extremity(Keikenenwan Shokogun Iinkai [JapaneseAssociation of
Industrial Health], 1973).
The Japanese committee then conducted amass screening of
individuals in private industryto further delineate the causative
factors forOCD. Researchers concluded that how theworkers use their
muscular and nervoussystems at work and how the task is
organizedinto the work system as a whole underlie thecondition
(Maeda, 1977, p. 200). Researchersspecifically identified static
loading of thepostural muscles, dynamic loading of localizedarm and
hand muscles, and lack of active restbreaks during the day as
factors contributing to OCD. The condition was found to advancewith
excessive workload and insufficientrecovery from fatigue.
The Japanese committee astutely regardedvisual eye strain and
mental fatigue as beingrelated to OCD. It urged physicians to
furtherinvestigate the relationship between sleepdisturbance,
chronic fatigue, and symptoms ofOCD (Maeda, 1977). A 20-year review
of thedisorder by Maeda analyzed the progression ofthe disease in
Japan and posed questions aboutexposure or dose-effect
relationships. Maeda,Horiguchi, and Hosokawa (1982) found thatOCD
first peaked in individuals within 6 to 12months of starting a new
job (possibly due tooverwork of untrained individuals) and
thenpeaked again between 2 and 3 years (possibly
6 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
due to chronic fatigue of muscles). Maedaidentified the
fundamental controversy thatexists today: whether OCD is caused by
factorssolely within the workplace or by psychologicalfactors such
as personal anxiety or workplacestress that becomes magnified by
the physicalaspects of the workplace.
Other countries subsequently began toexamine the incidence of
musculoskeletal dis-orders related to office work. In each country,
agross rise in workers compensation claims formusculoskeletal
disorders served as the catalystfor research of the problem.
Specific task forceswere established in each country to study
MSDswithin the socioeconomic context of that country.Most countries
followed a similar chronologicpattern of first recognizing acute
hand and armpain in workers, then identifying problemsrelated to
static posturing of the shoulder andcervical regions, and finally
relating specificmedical problems to workplace factors.
REPETITIVE STRAIN INJURY INAUSTRALIAIn the 1970s and 1980s,
Australia observed adramatic increase in the number of
telecom-munications workers who reported symptomsof arm pain or
muscular fatigue (Chatterjee,1978; Ferguson, 1971a; McDermott,
1986).Ferguson (1971a) first investigated the prevalenceof
telegraphists cramp in 517 male workers inthe Australian telegraph
service and found that20% of the workers complained of an
occupa-tional cramp or occupational myalgias. Fergusonreported that
75% of these workers had a historyof neurosis and complained of
work overload orjob dissatisfaction.Ferguson therefore
attributedthe cramp more to psychological and socialfactors within
the workplace than to thephysical performance of the job.
In a later study of 77 female workers in anelectronics assembly
plant who were diagnosedwith tendinitis, Ferguson (1971b)
acknowledgedthe awkward and repetitive nature of electronicsjobs as
contributing to workers symptoms.However, Ferguson questioned the
validity of
the initial diagnosis of tendinitis and thenecessity for the
excessive medical leave (morethan 4 months) for workers with this
condition.Ferguson (1971b) advocated early return towork and
medical surveillance in addition toergonomic changes.
The term repetitive strain injury (RSI) wasadopted among
Australian medical investigatorsin the early 1980s,although most
did not believethat the term adequately described the con-dition
(Ireland, 1992; McDermott, 1986; Stone,1983). Within years, RSI had
affected Australiantelegraphists and typists,tradesmen,and
assembly-line,clerical,data-processing,and postal workers.McDermott
(1986) explained that the numberof occupational claims for RSI in
Australiaincreased generally from 300% to 400% in data-processing,
accounting, and postal services from the mid-1970s to the early
1980s. TheCommonwealth Government of Australia, inresponse to the
spiraling cost of RSI in thatcountry, set up a task force on RSI,
seeking inputfrom the National Occupational Health andSafety
Commission. This task force concludedthat a combination of
ergonomic and psy-chological factors contributed to the
problem(McDermott, 1986).
Clearly, investigators in Australia resistedrelating RSI to
biomechanical factors within theworkplace and struggled with the
definition ofRSI as a separate disease entity as opposed to
agrouping of conditions with similar occu-pational etiologies.
Ireland (1992), a researcherfrom Australia, still contends that
musculoskele-tal pain relates only to workers psychologicalstress,
because no objective medical tests (e.g.,nerve conduction or
electromyography) candiagnose the condition definitively. Despite
thestrong association of RSI with psychologicalfactors, few studies
attempted to evaluate thepsychological aspects of RSI.
Occupational Disorders in EuropeThe Nordic countries have long
been involvedin industrial health care. Whereas most of theresearch
in musculoskeletal problems initiallyfocused on factors related to
low-back pain,
Musculoskeletal Disorders: A Worldwide Dilemma 7
-
Swedish researchers began to examine upper-extremity
musculoskeletal disorders related to work in the 1980s in response
to in-creasing complaints of neck and shoulder painamong
blue-collar workers (Bjelle, Hagberg,& Michaelson, 1981;
Dimberg et al., 1989;Kvarnstrom, 1983).
Kvarnstrom (1983) and Bjelle et al. (1981)examined the records
of workers on long-termsick leave in large industrial plants in
Swedenand noted the increasing magnitude of neck andshoulder
problems. Kvarnstrom found that 48%of all workers on long-term sick
leave hadmusculoskeletal conditions; neck and shoulderproblems were
the most common disordersamong light-manufacturing workers.
WhenKvarnstrom (1983) studied the demographic,work task, and social
factors related to shoulderproblems in 112 workers, the variables
relatedto the presence of shoulder pain were asfollows: older
workers were affected moreoften; female workers were 10 times more
likelythan male workers to suffer shoulder pain;
light-manufacturing jobs were most often associatedwith shoulder
pain; piece-rate incentives werepositively correlated with shoulder
pain; andimmigrants were at higher risk than otherworkers for
developing shoulder pain. Somefactors could be explained by the
relationshipamong variables.For example,women tended tobe clustered
in the higher-risk jobs, andimmigrant workers, because of their
limitedlanguage skills, did not have the opportunity forproper
training or job rotation.
When cases were matched with controls,Kvarnstrom (1983) found
that a group piece-rate system, shift work, and regard for the
workas repetitive, monotonous, and stressful weresignificant among
case subjects. More casesubjects than controls cited a poor
relationshipwith their supervisors, although no difference
inrelationships with their peers was seen betweengroups. Finally,
Kvarnstrom noted a significantassociation of shoulder pain with
social factors,including being married, having a sick spouse,having
children at home, working alternate
shifts from ones spouse, and having few leisureactivities.
Researchers discussed the heavyburden placed on workers with both
job andhome responsibilities (see Chapter 2). This study heralded
the beginning of many futurestudies to systematically examine the
relation-ship between physical and psychosocial factorsin the
development of MSDs.
Nordic researchers recognized the difficultyin comparing studies
from country to countrybecause of a lack of uniform terminology and
criteria for diagnosis (Kuorinka et al., 1987;Kvarnstrom, 1983).
The Nordic Council ofMinisters therefore supported a project
todevelop a standardized Nordic questionnaire for the purposes of
collectively recording andcompiling information.The Standardized
NordicQuestionnaire, now widely used and trans-lated into four
Nordic languages, is meant as a screening for musculoskeletal
disorders of the low back, neck, and shoulder complaintsrelated to
ergonomic exposures (Kuorinka et al.,1987). Using this
questionnaire, the estimatedprevalence of hand and wrist disorders
inSweden ranged from 18% among Swedishscissor makers to 56% among
Swedish packers(Luoparjrvi, Kuorinka,Virolainen, &
Holmberg,1979).
Throughout Europe, the European Union has exerted strength in
the formation ofOccupational Safety and Health laws thatemphasize
social policy, improvements toquality of life, protection of the
environment,and a minimum common standard for workingconditions in
member countries (Batra &Hatzopoulou, 2001).
Musculoskeletal Disorders in NorthAmericaThe United States
witnessed a gradual rise inMSDs from 1980 to 1986. The incidence
thenrose tremendously from less than 50,000 in1985 to 330,000 in
1994 (BLS, 1992, 2002).Theincidence has fallen steadily over the
past 6years to 241,800 in 2000, most likely because ofergonomic
changes and early intervention. (See
8 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
Chapter 4 for a compete discussion.) In theUnited States,carpal
tunnel syndrome (CTS) wasthe initial focus of investigation.The
occupationalcauses of CTS were first investigated byArmstrong and
Chaffin (1979) in two groups offemale seamstresses, one with a
known historyof CTS and one with no previous history.Researchers
found that women with a history ofCTS used more force and wrist
deviation whenperforming the work tasks than those with nohistory
of CTS. Researchers questioned whetherthe differences in work
methods between thegroups was the cause or the effect of CTS in
theaffected women.
In an effort to delineate risk factors in an in-dustrial
population,Silverstein,Fine,& Armstrong(1987) investigated the
relationship betweenforce and repetition in a job task and the
preva-lence of CTS in 652 industrial workers. Resultsof a physical
examination and interview indi-cated that workers in high-force,
high-repetitionjobs were 15 times more likely to have CTS
thanworkers in low-force, low-repetition jobs(Silverstein et al.,
1987). (See Chapter 10 for acomplete discussion.) This study became
thehallmark for identifying biomechanical risk factorsand drawing
an association between exposuresand musculoskeletal conditions.
As the reported incidence of MSDs sky-rocketed, researchers
began to document andexamine the prevalence of MSD in specific
high-risk occupations. Self-reported studies
indicatedupper-extremity symptoms among the fol-lowing occupational
samples: 62.5% of femalesupermarket checkers (Margolis &
Kraus,1987),63% to 95% of dental hygienists (Atwood &Michalak,
1992; Shenkar, Mann, Shevach, Ever-Hadani, & Weiss, 1998), and
82% of electricians(Hunting, Welch, Cuccerini, & Seiger, 1994),
toname a few. A compilation of well-documentedresearch attributed
the high prevalence of MSDsto job tasks involving postural loads at
the neckand shoulders, awkward postures, and longhours of
repetitive and static work along withorganizational factors
(Bernard, 1997). (SeeChapter 10 for a complete discussion).
However, a group of physicians in the mid-1990s argued that
solely psychosocial issues andthe sociopolitical climate were
causal in theetiology of MSDs, particularly with regard to
theincidence of CTS in keyboard users.This groupattributed the rise
in CTS to workers frus-trations with their jobs, difficulty coping
withnondescript, short-lived pain, and the contagionof inflammatory
self-reports (Hadler, 1996).Hadler contended that typical exposures
expe-rienced during keyboard tasks were not excessiveor hazardous
to the worker and were unrelatedto health outcomes.
Silverstein, Silverstein, and Franklin (1996)countered this
argument citing a well-researched body of evidence indicating
dose-response relationships between biomechanicalrisk factors in
the workplace and the devel-opment of MSDs. Although Silverstein et
al.shared Hadlers concern for the management ofMSDs and some
physicians preponderancetoward surgery, their distinct beliefs
about thecauses of MSDs also represent divergent beliefson
prevention.
Finally, in 1997 in the United States, theNational Institute for
Occupational Health andSafety (NIOSH) adopted the term
work-relatedmusculoskeletal disorder (WMSD), or MSD, toreplace the
term cumulative trauma disorder(Bernard, 1997; NIOSH, 1997). This
changerepresented an effort to accommodate the widerange of
disorders associated with work expo-sures. Ongoing efforts continue
to establish anergonomics standard as part of the federal
OSHAlegislation. (See Chapter 4 for a completediscussion.)
GLOBAL APPRECIATION FOR THE IMPACT OF WORK-RELATED STRESSAs
industrialized nations have identified thatstress is contributory
to the overall MSDetiology, more global legislative efforts
areaddressing the impact of stress on workers,identifying the
sources of work-related stress,
Musculoskeletal Disorders: A Worldwide Dilemma 9
-
and advocating that institutions take respon-sibility for
minimizing stress by examining theirorganizational frameworks
(Levi, Sauter, &Shimomitsu, 1999; Sanders, 2001).
In the United States, NIOSH (1999) publishedits monograph on
stress prevention strategiesfor the workplace, stating that because
work ischanging at whirlwind speed perhaps nowmore than ever, job
stress poses a threat to thehealth of workers and in turn, to the
health oforganizations (p. 10). NIOSH upholds thatworkplaces should
address not only thebiomechanical aspects of a job but also
thepsychosocial aspects focusing on providingworker control,
skill-enhancing, and decision-making opportunities. Levi et al.
(1999) contendthat the widely used routine of providing
stressmanagement skills to help individual workerscope with
stressful situations is merely a short-term approach to solving
greater,more complexproblems for the entire organization (Levi et
al.,1999). (See Chapters 8 and 12 for furtherdiscussions of
work-related stress.)
Initiatives have been taken throughout theworld to encourage
employers to look internallyto minimize stresses in work
environments. Inthe United Kingdom, the reduction of work-related
stress is part of a greater proposal by theHealth and Safety
Commission to promotehealth across all industrial and
governmentalsectors from line workers to administrativelevels
(Health and Safety Commission, 1999).The European Parliament
Resolution in 1999urged employers to adapt work to the
workersabilities, thus minimizing the disparity betweenwork demands
and workers capacities. Theinfluence of limited job autonomy, job
variety,and worker participation on worker health hasrung loud and
clear in current programming(Levi et al., 1999).
The culmination of these legislative efforts is the Tokyo
Declaration, a treatise developed by worldwide experts on stress
research inresponse to mounting evidence as to the pro-found
influence of stress in industrializednations. Researchers expressed
concern about
the effects of technological changes in worklife(i.e.,
increasing cognitive workloads) on indi-viduals and their abilities
to function to theirmaximum potential given these demands.
Thephilosophy of the Declaration, Investment forHealth, implies
that a commitment to individualworkers will also bring about social
benefits.The Declaration endorses developing measure-ment tools to
measure psychosocial stress,examining health outcomes based on
stressexposures,monitoring psychosocial health stress,providing
education and training, and creating asystem for gathering and
disseminating in-formation (Tokyo Declaration, 1999).
THE ROLE OF ERGONOMICS ININDUSTRIAL DEVELOPING COUNTRIESWhereas
ergonomics has traditionally consultedwith businesses in
industrially advanced coun-tries (IACs), the role of ergonomics in
indus-trially developing countries (IDC) is beingexpanded with
regard to productivity and healthand safety (Ahasan, Mohiuddin,
Vayrynen,Ironkannas, & Quddus, 1999; Brunette, 2002;ONeill,
2000). An IDC is a country whoseexistence is based on either
commercializingnatural resources or on simply surviving. In both
cases, the infrastructure is rarely adequateto sustain the
characteristically high populationgrowth. Although nutrition and
basic safety are clearly lacking, it is suggested that
muscu-loskeletal injuries in IDCs are also growing at ahigher rate
than in IACs.This is not surprising,since legislation in IDCs is
either nonexistent orineffective at controlling health and safety
risks(ONeill, 2000; Stubbs, 2000). Arguments fordeveloping
prevention programs for MSDs inIDCs will need incentives such as
economicgrowth, social responsibility, or perhaps
researchopportunities to advance quality of work andquality of life
in these countries.
ONeill (2000) more specifically discussesergonomic issues
currently at the forefront inIDC manufacturing, the agriculture
industry, and
10 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
in transporting materials. In agriculture, thegreatest
constraints to crop production are landpreparation and weeding.
Both require high-energy activities and laborious work,
usuallywithin a limited amount of time. Interventionsto reduce work
intensity in IDCs have includedbetter hoe designs for weeding, and
improveddesigns of animal-drawn equipment.
In factories, heat stresses, poor air quality(from fumes, dusts,
and particulates), and awk-ward postures and noise are commonly
found.Ahasan et al. (1999) illustrate these issues inexamining jobs
at a metal working plant inBangladesh. Although many ergonomic
inter-ventions have been employed, attitudinal bar-riers and access
to adequate training resourcesand support from the international
communityare still lacking. Finally, transporting materialsusing
people as transporters takes its toll inhuman injury and energy
costs. For example,head loading, a prevalent mode of
transportinggoods over hilly terrain, involves carrying loadsup to
15 lb over distances of 10 miles severaltimes per week. The
practices of transportinggoods and people are in dire need of
inno-vations to increase efficiency.
To date, researchers have found that high-endergonomic
interventions employed in indus-trially advanced countries (IAC)
are rarelyfeasible in IDCs. In fact, simple interventionsmay have
even greater potential to affect thehealth, productivity, and
quality of life forworkers in such countries. The challenge
todevising acceptable solutions and transferringtechnology to IDCs
is to understand andintegrate the cultural dimensions into
therecommendations.Cultural dimensions refer notonly to the
physical attributes of the workers(such as anthropometrics, typical
postures) butalso the cognitive, social, and conceptualaspects. For
example, human factor informationusually conveyed by color must be
reassessedrelative to the stereotypes of a country (e.g., inthe
United States red means stop); attitudestoward wearing protective
equipment must beaddressed,explained,and supported by workers.
Brunette (2002) suggests that corporatesocial responsibility
should be a vehicle for pro-moting improved working conditions in
develop-ing countries. Partnerships between universitiesand
multinational corporations (MNC) mayincrease awareness of ergonomic
factors andbegin to create an infrastructure that will
allowimplementation of ergonomic recommenda-tions in IDCs. Above
all, the recommendationsmust emanate from multidisciplinary
teamswith close collaboration between ergonomicand occupational
health practitioners in thecultural context (ONeill, 2000; Stubbs,
2000).
GLOBAL TRENDS IN THETWENTY-FIRST CENTURY ANDIMPLICATIONS
FORERGONOMICSGlobalization has created large multinationalcompanies
(MNC) whose strong occupationalhealth and safety programs have
positivelyimpacted the working lives of their employeesin IDCs
(Rantanen, 1999). It is hoped that thesecorporate standards along
with the support fromthe international community may influence the
future legislative development of nationalergonomic and safety
standards in developingcountries (Ahasan et al, 1999).
Flexibility in Work StructureDecentralization of the large
companies intosmaller networks creates a reliance on outsourcingor
contracting work to smaller companies.Thispractice has created work
organizations withincreasing numbers of temporary,e-lance, andtele-
workers. Such variability in work struc-ture affects the ability to
reach, train, and trackthe injury status of self-employed workers
andworkers in small to midsize companies over along period of time
(Rantanen, 1999).
The Aging PopulationAs a whole, the world is aging because
ofincreasing life expectancy and decreasing pop-ulation growth in
IACs. Since people will be
Musculoskeletal Disorders: A Worldwide Dilemma 11
-
working longer to support themselves, re-searchers in both the
United States and Europemust contend with new situations: How can
wekeep an older population actively engaged andproductive in the
workforce in light of the newjob demands? What are the effects of
aging onphysical and mental work capacity? Can wedevelop
age-related criteria for using infor-mation technology (Rantanen,
1999;Westgaard,2000)? Illmarinen (1997) has offered a model to
promote and maintain work capacities ofolder employees. The model
is based on factorsfrom the work environment, organization,
andindividual functioning.
New TechnologyInformation and communication technologies(ICT)
have become integral to the existence ofindustrialized countries in
an astonishinglyshort time. Research has just begun to addressthe
burgeoning questions of how the newtechnology will interact with
and sustain thework ability, aspirations, and long-term
produc-tivity of workers (Rantanen, 1999; Westgaard,2000). Critical
areas for ergonomic growth andresearch will include understanding
the ICTdemands on the visual and auditory systems,cognitive
ergonomics for intensive computerwork, and physical demands and
organization ofICT work.
CHALLENGES FOR RESEARCHINGMSDs IN THE TWENTY-FIRST CENTURYRapid
and significant changes in work life overthe last decade have
created new challenges forMSD research that will demand more
innovativemeans to studying these conditions. In 1983,Kvarnstrom
noted the existing epidemiologicstruggles in compiling and
comparing databetween countries and occupational groups. Studies
from different time periods are
difficult to compare because of differences inthe social roles
of health and illness.
Socioeconomic differences between studygroups may invalidate
comparisons.
The gender bias in different populations andoccupations affects
results (e.g., women tendto be clustered in high-risk jobs).
Reporting systems for epidemiologic studiesdiffer among
countries.
Inclusion criteria for diagnostic categoriesand the
quantification of risk factors differamong studies.The preceding
challenges have been surpassed
by even broader concerns created by ouraccelerated use of
technology, globalization, andchanges in the structure of work and
workerdemographics (also see Chapter 2 for furtherdiscussion).
Research challenges exist not onlyin comparing data from country to
country, butalso in gathering data, identifying
exposures,andmeasuring health outcomes.
Research Baselines and Follow-UpThe process of establishing a
baseline of occu-pational exposures as a means of measuring
theimpact of exposures over time and the efficacyof interventions
is more difficult than inprevious times (Rantanen, 1999; Stubbs,
2000).As indicated, the once stable core of homog-enous full-time
workers who formed the basisfor epidemiological studies has been
replacedby a population of workers who enjoy flexibilityin
employment structures, patterns, and loca-tions. Even the regular
monitoring of employeeswill demand new models. Research designs
mayneed to include shorter periods of follow-up andaccommodations
for diverse populations andinternational migration.Rantanen (1999)
suggestsa smart card to follow the worker throughoutthe career
irregardless of type and location ofemployment.
Exposure MeasuresErgonomic exposures typically include
severaltypes of hazards based on physical demands and changes in
work organization (i.e., workschedules, work teams, work
locations). Newexposure concepts are surfacing related to
ourprimarily service-oriented society and thecontinued prevalence
of human-to-humaninteraction between service workers and
clients
12 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
(Rantanen, 1999).The emotional load in caringoccupations, threat
of violence, and dealing with anger are issues yet to be identified
andaddressed in most classic MSD research designs.
Health OutcomesThe traditional means of measuring
occupationaloutcomes have been the presence or absence of
musculoskeletal injury. However, Rantanen(1999) suggests that our
new work life hasspurred interest in the functional and
behavioralaspects of the workplace such as functionalcapacities,
innovation, work motivation, thecapacity to handle clients, and
psychologicaloverload (to name a few). These outcomescannot easily
be measured by traditional means;therefore,new methods will have to
be identified.
SUMMARYIn summary, researchers throughout the worldhave come to
recognize the contribution ofbiomechanical factors and psychosocial
factors(including workplace stressors) to the overalldevelopment of
MSDs in the individual worker.Research and legislation in
industrialized coun-tries has demonstrated continued commitmentto
minimizing ergonomic hazards for workersand has acknowledged the
strength of multi-disciplinary, participative approaches to
inter-ventions.As interested health care practitionerswe all must
encourage both research and socialresponsibility to improve worker
health through-out the world.
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H., &
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Kuorinka, B., Jonsson, B., Kilbom, A.,Vinterberg, H.,
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Kvarnstrom, S. (1983). Occurrence of musculoskeletaldisorders in
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Luoparjrvi,T., Kuorinka, I.,Virolainen, M., & Holmberg,
M.(1979). Prevalence of tenosynovitis and other injuries ofthe
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Maeda, K. (1977). Occupational cervicobrachial disorderand its
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Localizedfatigue in accounting machine operators. Journal
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Margolis,W., & Kraus, J. F. (1987).The prevalence of
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developingcountries: Does its application differ from that
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631640.
Phalen, G. S. (1947).The carpal-tunnel syndrome. Journal ofBone
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Ramazzini, B. (1717). De Morbis Artificum Diatriba. In W.Wright
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Rantanen, J. (1999). Research challenges arising fromchanges in
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Sanders, M. J. (2001). Minimizing stress in the workplace:whose
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Schenck, R. R. (1989). Carpal tunnel syndrome: the newindustrial
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Shenkar, O., Mann, J., Shevach, A., Ever-Hadani, P., &
Weiss, P.L. (1998). Prevalence and risk factors of upper
extremitycumulative trauma disorders in dental hygienists. Work,11,
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Silverstein, B.A., Fine, L. J., & Armstrong,T. J.
(1987).Occupational factors and carpal tunnel syndrome.American
Journal of Industrial Medicine, 11(3),343358.
Silverstein, M., Silverstein, B.A., & Franklin, G. M.
(1996).Evidence for work-related musculoskeletal
disorders:Ascientific counterargument. Journal of Occupationaland
Environmental Medicine, 38(5), 477484.
Stone,W. E. (1983). Repetitive strain injuries. MedicalJournal
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Stubbs, D.A. (2000). Ergonomics and occupationalmedicine: Future
challenges. Occupational Medicine,50(4), 277282.
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14 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
Nick is a 47-year-old meat cutter whodeveloped a chronic lateral
epicondylitis aftercutting meat for 25 years. After 3 years
ofintermittent therapy that brought little relief,Nick nally
underwent surgery and embarkedon a gradual return-to-work program.
Within 3 months, the pain had returned. When thetherapist revisited
Nick at his job, the therapistadvised Nick to stretch periodically
and to slowdown. Nick stated, I cant. Thats what Imknown for. Im
the best because Im fast, with or without a bum elbow.Well have to
think ofsomething different.
The causes of musculoskeletal disorders(MSD) are complex and
include personal, bio-mechanical, and psychosocial factors.
Althoughan initial evaluation of a job may involveidentifying
factors in the workplace design oradministrative procedures that
can contributeto the development of MSDs, these are not theonly
areas that need assessment. We mustconsider that the worker is an
individual in thework environment, an individual with uniquebeliefs
and values about work. Workers beliefsand values about work and
what work requiresof them have been associated with
muscu-loskeletal discomfort at work (Baker, Jacobs,
&Tickle-Degnen, 2003) and may well influence a workers choice
to accept and implementrecommendations to improve the
workplace.Understanding workersbeliefs and values aboutwork may be
one way to identify appropriate
interventions and facilitate the acceptance byworkers of
appropriate workplace interventions.
This chapter presents an overview of thetheoretical and
practical constructs that underliethe beliefs and values associated
with work inthe United States. In this chapter we denework,
identify how historical context hasshaped present work beliefs, and
discuss somework beliefs and values. The chapter alsoaddresses the
concept of work groups asminicultures that shape workers values,
skills,and behaviors relative to work. Finally, trends inthe social
context of work, such as workerdemographics, worker aging,
downsizing, andjob security issues, are addressed.
DEFINITION OF WORKWhat is work? Many denitions of work exist,but
there is no comprehensive denition thatsuits all purposes. At its
most basic level, theterm work refers to any activity in which
anindividual expends energy (Oxford EnglishDictionary, 1989).
However, this denition is too broad to clarify the nature of work.
Work is frequently dened as an activity that is donefor nancial
recompense (Ruiz-Quintanilla &England, 1996). Unfortunately,
this denitionignores the importance of nonnancial workroles as well
as people who work for little or no pay (Friedson, 1990). Another
denition ofwork describes it as an activity that is obligatory,
15
C H A P T E R 2
The Individual Worker Perspective
Nancy A. BakerMartha J. Sanders
-
directed by others, and done in a specic placeand at a specic
time (Hearnshaw, 1954).Work,therefore, is the opposite of leisure;
it is anactivity that must be done and, by implication,
isonerous.Yet work can be creative, self-fullling,and even
enjoyable. Work has been described as a means to contribute to
society (Ruiz-Quintanilla & England, 1996; Jahoda, 1981). It
isalso a strong role identity that provides rewardsbeyond income
(Burke, 1991; Jahoda, 1981;Roberson, 1990). What becomes obvious
fromall these specications of work is that work isdifcult to dene
because it has many aspects.Each person will, therefore, dene work
dif-ferently based on the beliefs and values that heor she most
identies with it.
A Historical Perspective of WorkOur present beliefs and values
about work havetheir antecedents in the history of work.Americans
have a love-hate relationship withwork (Tausky, 1992).This attitude
can be tracedback through the varied historical beliefs
aboutworking. (See Applebaum, 1992 for a completehistory of
working.) The nature of work hasshifted radically throughout the
centuries, fromthat of performing daily tasks engaged in
forsurvival to the modern exchange economy in which work is
perceived as a means to an end (Applebaum, 1992; Primeau, 1996;
Ruiz-Quintanilla & England, 1996; Wilcock, 1998).The
dichotomous nature of work, however, hasbeen present in all but the
earliest agrariansocieties.Work began as a means of survival
andbecame at various times throughout the ages ameans of
categorizing social class, of monetaryexchange, of fullling
spiritual obligations, andof developing personal growth and
self-esteem.
The concept of the type of work as distinct to social classes
was evident with the Greek andRoman aristocrats. Aristocrats did no
manuallabor, instead participating in government, war,and leisure
pursuits. They viewed all manuallabor, except farming, as degrading
(Applebaum,1992; Wilcock, 1998). With the advent ofChristianity,
manual work was viewed as
spiritual, a way to serve God (Applebaum, 1992;Ruiz-Quintanilla
& England, 1996), and also as apunishment for original sin
(Thomas, 1999). Allwere expected to perform manual tasks
regard-less of class structure.The social class structurewas
gradually reintroduced in the Middle Ages ascommerce and the
formation of guilds gainedmomentum.In general,however,work was
still asubsistence undertaking.
The idea of working hard to achieve materialwealth and salvation
was introduced in themid-1500s with the advent of
Protestantism,particularly Calvinism. Protestants believed thateach
person had a calling, or a specic workrole within Gods scheme. If
that work wasperformed well, one was worshiping God. If the person
did well nancially, it demonstratedthat the individual was one of
the chosen.Hence, individuals worked long hours and accu-mulated
wealth for wealths sake in order todemonstrate that they had
achieved salvation(Hill, 1996). Calvinist Protestants beliefs
aboutwork eventually became known as the Protestantwork ethic
(Weber, 1958). These beliefs includ-ed concepts that work was
itself good, that hardwork would overcome all obstacles, that
successwas measured by both effort and material wealth,and that
frugality was a virtue (Buchholz, 1978).The belief that work, in
and of itself, was goodand linked to success was an idea that
wouldshape many modern work beliefs.
During the Industrial Revolution (early1700s) the nature of work
changed dramatically.Prior to the Industrial Revolution,
craftsmenworked alone or in small conclaves dedicated to the
production of a product. They primarilyworked at home, used hand
tools to craft thegoods, and paced their work based on their own
abilities. After the Industrial Revolution,workers were essentially
machine tenders and paced their work to match the pace of
themachine (Applebaum, 1992; Primeau, 1996; Ruiz-Quintanilla &
England, 1996). Men, women, andchildren worked outside the home and
werepaid a wage for their labor. Each worker did onlyone small
aspect of the job, since, according to
16 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
Frederick Taylors Principles of ScienticManagement, production
was more efcientwhen jobs were divided into small,
repetitivesubdivisions (Liebler & McConnell, 1999; Parker,Wall,
& Cordery, 2001). Workers lives werestructured around the time
clock with limitedleisure time.
In the 1940s, behavioral and organizationaltheorists initiated a
shift in industrial focus fromemphasis on work tasks to emphasis on
theworker. The Human Relations Approach tomanagement identied work
as a means to fulllworkers social and motivational needs
(Liebler& McConnell, 1999).Thus, jobs became increas-ingly
enriched, and work became associatedwith self-actualization and
personal growth(Parker et al., 2001).
Over the last 50 years, the perception andstructure of work has
been shifting again (Ryan,1995). The information age has caused
manyworkers to move from manufacturing to theservice arena. Because
the products of servicework are often intangible, intellectual
propertyand consumer satisfaction become the endproduct rather than
manufactured goods. Assuch, work is often not proscribed by time
orplace. Work can now occur virtually anywherethat one is able to
think.The strict demarcationbetween working time and home time has
alsoblurred, with telecommuting becoming analternative to onsite
work. Rapid communi-cation allows workers to work not only
outsidethe ofce but also across the globe fromcorporate
headquarters. Finally, workers rarelystay at one job for their
entire careers but shiftfrom position to position (Ryan, 1995).
Thesenew working parameters are likely to changemany of the beliefs
about working, particularlythose associated with work as a
constrainedactivity.
BELIEFS AND VALUES ABOUTWORKBeliefs are statements that
individuals hold astrue. Beliefs shape the values of an
individual
and culture; these values, in turn, form the basisfor individual
behavior and opinions (OToole,1992). Our present-day beliefs and
values aboutwork are grounded both in the historical per-spective
of work and in socialization experiences(Hasselkus & Rosa,
1997; Trombly, 1995). Thehistorical perspective provides the
ontologicalbackground from which we develop our beliefsand
expectations about work and what theworker role will bring to
us.Examples of specicbeliefs about working based on historical
expe-riences include work as a burden, a constraint,a reciprocal
arrangement, a means of self-actualization, and a means to
contribute tosociety (Ruiz-Quintanilla & England, 1996).
Earlysocialization experiences draw upon whatworkers have learned
about working from theirparents, friends, and society and what they
haveexperienced in the working role.
Workers also develop values that relate to theproper way to
perform work and execute theworker role.These values are also
influenced byearly socialization and become rmly embeddedin a
workers role performance and self-perception as a worker. The
introductory case of Nick illustrates the powerful influence
ofthese behavioral values on work performance.Nick believed that he
was a model worker. Hefelt that he was respected among his
fellowworkers because he valued efcient work andwas the speediest,
most efcient meat cutter.Although pacing himself at work might
havedecreased his elbow pain, admiration from hisfellow workers and
the ability to execute hisvalues was integral to his self-esteem
andidentity as a meat cutter and therefore not anacceptable mode of
intervention.
VALUES OF A WORK CULTUREThe concept of work values relates not
only toindividual workers but also to groups ofworkers in the same
job or profession (referredto as work groups). Work groups share
similarvalues or ideas about the right way to do thejob. These
ideas may relate to the quality of
The Individual Worker Perspective 17
-
the job, how the job is performed, the prioritiesfor performing
tasks, or even to the unspokenrules of conduct that govern how and
whenworkers ask each other for help or complainabout pain. Social
networks between workersare believed to have a signicant impact
onindividuals attitudes toward work and on theirtendency to report
symptoms or painfulconditions arising from work-related
tasks(Finholt, 1994).
In addition to sharing similar values, workgroups share similar
tools, daily routines,language, and symbols that reflect their
jobs. Inother words, work groups are miniculturesthat develop from
shared work experiencesamong their members. In the context of
work,institutions that shape culture include the work-place
environment, supervisor and peer rela-tionships, roles, and
work-related responsibilities.The culture of the work group
influences andgradually shapes workers perspectives onperforming or
modifying their jobs (Hosteded,1996).
The ability of group culture to shapeworkers attitudes toward
work is clearly shownin Ashforth and Keiners (1999) analysis
ofworkers who do dirty work (i.e., work that isphysically,
socially, or morally repugnant to mostof society). They reported
that although mostliterature would suggest that dirty work should
cause its members to have low self-esteem and a poor social
identity, the oppositetends to be true. They hypothesized that
dirty workers develop a strong work culture,which has a strong
element of us versus them.This strong culture allows them to
reframe theirwork to emphasize its importance to
society,recalibrate the job to change the values that areviewed as
important, and reframe the job tofocus on its positive aspects. By
the end of anindoctrination period, most dirtyworkers whoremain on
the job have attained the commonlanguage and attitude that allows
them to per-form the work. The worker is assimilated intothe
culture of the job.
18 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
WORK CULTURE ASSIMILATIONIndividuals become assimilated into a
work culturethrough various channels, including technicaltraining,
formal orientations, and informalexperiences. New workers learn
technical skillsthrough educational programs, vocational train-ing,
on-the-job training, and trial and error.They learn the formal
workplace rules such aspunctuality, work quality, and
productivitystandards through company orientations, policyand
procedure manuals, and yearly performancereviews. New workers learn
the important, yetunspoken, informal dos and donts of the
jobthrough conversation with seasoned workers,by modeling others,
and by observing usual andunusual events (Van Maanen, 1976). These
in-formal channels may exert the greatest impacton work attitudes
as demonstrated by the dirtyjobs study (Ashforth & Kreiner,
1999).
Initially, new workers are concerned withperforming and
complying with work roleexpectations. However, over time,
individualscontribute their own talents and perspectives toboth the
task and to interactive aspects of thejob, so that the work culture
subtly changeswith the input of new workers (Jablin, 1987;Van
Maanen, 1976). (For further reading aboutorganizational
socialization, see Van Maanen,1976 and Jablin, 1987.)
Cultural assimilation is so insidious that indi-viduals are
generally unaware of the elements oftheir own culture
(Hall,1973).However,workersattitudes toward injury prevention can
beaffected at every step of the assimilation processthrough
establishing a safety culture that pro-vides positive feedback,
injury awareness, andsupport from management and peers
(Krause,1997). (See Chapter 15 for a complete dis-cussion.) The
better we understand the workculture,work role
assimilation,workersroutines,daily priorities,and relationships
with other workgroups, the better will we understand
workersattitudes and behaviors toward accepting orrejecting
intervention strategies.
-
An ethnographic interview is one means tolearn about workers
cultures, including theirenvironments, daily routines, and tools.
Anethnographic interview enables health care andergonomic
practitioners to answer such questionsas the following. Can one
worker realistically ask another
worker for help, or is this considered to be acop-out?
Can workers be expected to slow down orpace themselves if pay
depends on piece-rateincentives?
What determines quality for certain workgroups both personally
and professionally?
What aspects of a particular job should notbe changed?These
seemingly simple questions offer
much information about workers values andhow they perceive their
work role.
Appendix 2-1 offers a semistructured inter-view that seeks to
understand workers cul-tures on the basis of the interview
techniquesdescribed by Spradley (1979). The interviewbegins with a
grand tour of the workersphysical environment, then narrows the
scopeto the workers specic work area and worktasks. Next, the
interview addresses such jobassimilation issues as training and
learning the ropes and ends with a discussion of hisemployers
response to a work-related injury,the workers social relationships,
and workvalues. The goal of the interview is to provide a context
for understanding the workplacedemands. Ultimately, health care
practitionersseek to understand aspects of the job that
areimportant to the worker.
Spradley (1979) advocates that interviewersuse the technical
words or jargon particular to a work group to encourage workers to
explaintheir jobs more vividly. Although the interviewwas designed
for an individual worker, it can be adapted for a group interview
format.Readers will nd that stories relative to un-expected events
at work add particular insightinto understanding a workers
perspectives.
THE CHANGING SOCIAL CONTEXT OF WORK:TRENDS IN WORKAs discussed
earlier, beliefs and values aboutworking are not static; they shift
and changedepending on social and historic events thatframe a
workers career. The social context re-flects not only the attitudes
or values of societytoward work during a certain period but alsothe
worker demographics, the industry or tech-nology trends that shape
employees jobs, andthe public policy mandates that affect
managingwork-related conditions. The following sectiondiscusses
changes in the social context of workthat will influence our
understanding of workersvalues, roles, and services needed.
Worker DemographicsWorker demographics have been changingsince
the 1950s. In the 1950s the workforce was predominately male
(70.4%), white (essen-tially 100%), and older (87% of men between
55and 64 worked). Job categories were as follows:41% worked in
manufacturing,mining,construc-tion, or transportation; 13% worked
in govern-ment; and 37% worked in areas such as trade,nance, or
service (Kutscher, 1993). By 1992,46% of the workforce was female
and 22% of theworkforce was a minority; 27% worked inmanufacturing,
mining, construction, or trans-portation; 17% worked in the
government; and62% worked in areas such as trade, nance, orservice
(see Figure 2-1). Only 67% of men be-tween 55 and 64 worked
(Kutscher, 1993),although this trend seems to be slowing. Withthe
baby boom population aging, there will begreater numbers of older
workers in the work-force over the next few years. Another
demo-graphic characteristic of the present workforceis that a
higher percentage has a collegeeducation. In 1960, 9.7% of males
and 5.8% offemales had a college education; in 2000, 27.8%of all
males and 23.6% of all females had acollege education (U.S. Census
Bureau, 2001).This level of education is becoming more nec-
The Individual Worker Perspective 19
-
essary for a service-based working force (Hill,1996; Ryan,
1995).
The Aging WorkforceThe trend in aging baby boomers suggests that
older workers are a growing percentage ofthe workforce. Older
workers can contribute astrong work ethic, good judgment, and
valuableinsights about job safety and training. However,employers
must acknowledge that older workersmay need environmental
modications to main-tain productivity (e.g., brighter lighting,
lessbackground noise, a temperature-controlledatmosphere, and
flexible working parameters)(Connolly 1991; Coy & Davenport
1991).Employers must also realize that although olderworkers as a
group have fewer injuries, theypresent a higher risk for injuries
because ofrepeated exposure over time and changes in thebodys
resilience, reaction time, and depth per-ception. They generally
take a longer time torecover from injuries. Isernhagen (1991)
suggestsergonomic job task modications for olderworkers that demand
less lifting and impact on
joints and slower reaction times as well as envi-ronmental
modications (see Chapter 21 for acomplete discussion).
The Culturally Diverse WorkforceAs we approach a global economy,
there will beincreasing numbers of companies owned byforeign
subsidiaries with a greater percentage of workers coming from
diverse ethnic back-grounds (Naisbitt & Aburdene, 1990).
Thisdiversity brings creativity and manpower to acompany. However,
it also brings a need tounderstand other ethnic culturesperceptions
ofthe worker role, work environment, and thebeliefs and values of
individuals.
Differences in language and cultural morespresent a challenge to
professionals who striveto provide health care, work incentives,
andopportunities for career growth. For example,traditional
Japanese workers work in cohesivegroups that collectively solve
problems. Hence,they are rarely singled out for individual praiseor
punishment. Japanese workers develop strongsocial bonds with
supervisors and are accus-
20 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
Gender Ethnicity Job categories
Perc
ent
male
0
female
white
ethnic
100
90
80
70
60
50
40
30
20
10
man
ufactu
ring
governmen
t
service
19501990
Figure 2-1 Changes in worker characteristics from the 1950s to
the 1990s. (Data from Kutscher, R.(1993). Historical trends,
19501992 and current uncertainties. Monthly Labor Review
online.Retrieved November 10, 2001 from
http://stats.bls.gov/opub/mlr/1993/11/art1full.pdf.)
-
tomed to more personal,paternal,and supervisorystyles of
management than the strictly businessrelationship common with
supervisors in theUnited States. Evidence exists that
Japaneseworkers have a higher sense of organizationalcommitment
that may be partly due to theirsystem that rewards workers based on
seniorityrather than job content (Lincoln,1996). Japaneseworkers
tend to view working as more of aneconomic exchange through life
commitment,whereas a greater percent of those in the UnitedStates
are more inclined to view working as ameans to contribute to
society and develop asense of identity (England & Whitely,
1990). U.S.managers may encounter workers from a varietyof ethnic
backgrounds and must realize thatclassically American rewards based
on individualachievement and ambition may be ignoring thegreater
human needs and work potential of theiremployees.
Salimbene (2000) presents guidelines forsuccessful interactions
with individuals fromdifferent ethnic backgrounds when
discussingwork-related health care issues. These tips arebroad and
not specic to any one ethnicbackground (see Box 2-1).
Use of Self-Managed and Self-LeadingWork TeamsSelf-managed work
teams are those that havethe direct responsibility for product
set-up,process, and outcome (Manz, 1996).Workers inself-managed
teams perform a variety of worktasks and are given discretion over
their workmethods, task scheduling, and task assignment.General
goals for self-managed teams are toincrease production for the
company whileincreasing quality of life for the employees. Infact,
self-managed teams bear a resemblance to the job design in
preassembly-line days inwhich each individual clearly influenced
thenal product. Self-leading teams furtherincrease worker control
by making workersresponsible for strategically dening goals
andestablishing process and productivity standardsthat govern the
system (Manz, 1996).The skills
and capacities of each worker in self-managedand self-leading
work teams ultimately affect theentire team and work process.
Therefore, aninjured worker in such an environment mayperceive
different work values and perspectiveson returning to work than
those of a worker in amore typical work environment. This
conceptneeds to be understood for workers returning towork after an
injury.
Americans with Disabilities Act andthe Culture of AblenessThe
Americans with Disabilities Act (ADA) wasdesigned to present
opportunities for qualiedworkers with disabilities to enter or
return toworkplaces provided with the necessary
jobaccommodations.The ADA focuses on providingreasonable
accommodationsand making publicbuildings accessible for workers
with physical oremotional disabilities (U.S. Department of
Justice,
The Individual Worker Perspective 21
BOX 2-1Guidelines for Successful Interactions withIndividuals
from Varied Ethnic BackgroundsRegarding Health Care Issues
Begin the interaction more formally with workerswho were born in
another country. Use the lastname when initially addressing
workers. It is auniquely American tradition to address
individualsby their rst names.
Dont automatically treat someone as you wouldlike to be treated.
Culture determines the norms forpolite, caring behaviors.
Dont be put off if the worker fails to give eyecontact. In some
countries it is disrespectful to lookdirectly at another
person.
Dont make any assumptions regarding theworkers beliefs regarding
illness and health.Encourage individuals to share their
beliefs.
Present information in a succinct manner. Provideonly essential
information at rst so as not toconfuse the worker.
Recheck workers understandings of your words. Aworker may
interpret instructions in a radicallydifferent manner than you
intended.
Compiled from Salimbene, S. (2000). What language does
yourpatient hurt in? A practical guide to culturally competent
patientcare. St. Paul, MN: EMC Paradigm.
-
1991) (See Chapters 13 and 15 for further dis-cussion.) Although
critics were initially con-cerned about the ADAs cost to
companies,research has suggested that about two thirds ofall job
accommodations cost less than $500 andthat these costs were often
more than recoupedthrough lower job training costs,
insuranceclaims, increased worker productivity, andreduced
rehabilitation costs after injury on thejob. The estimated savings
was $50 for every $1 spent (Blanck, 2000).
Despite the success of many interventions,there are still issues
with developing reasonableaccommodations within companies. Harlan
and Robert (1998) have suggested that someemployers and managers
still have a standard of ableness that is not related to actual
ability.This standard is related to beliefs about therightway to
work,which has its underpinningsin the historical concepts of
working discussedpreviously. They report that some employershave
prevented workers with disabilities fromreceiving reasonable
accommodations througha variety of strategies: denying the need
foraccommodation; renouncing responsibility foraccommodation;
withholding legal informationabout the ADA; and using intimidation
to forcethe worker to work within the able-bodied workculture.
Health care practitioners should famil-iarize themselves with the
ADA and advocateimplementation of the law for qualied workers.
Job SecurityTodays workers are rightfully skeptical abouttheir
job futures.Few organizations are insulatedfrom economic pressures,
and the potential forlayoffs is real in many companies.For this
reason,some workers may be hesitant to report injuriesfor fear of
losing their jobs, or they may notreport work-related injuries
because they do notget reimbursed their total salary (or the
totalcosts of an injury) (Morse, Dillon, Warren,Levenstein,&
Warren,1998). In fact,when Morseet al. (1998) examined the
incidence of chronicupper extremity pain in a random
Connecticutsample, they found that only 10.6% of those
who reported a work-related injury had led aworkers compensation
claim. Thus, under-reporting may be a common practice.
DownsizingBusiness has become more competitive. One re-sult of
this competition is the increase of organ-izational restructuring
and downsizing (Ryan,1995). The process of downsizing companieshas
affected workers from high-performing,high-salaried executives to
loyal, skilled machin-ists. For those remaining on the job,
downsizingcan create a grossly overworked and stressedworkforce.
Production workers are forced toincrease the speed of their tasks
withoutsacricing quality, and managers are respon-sible for a
multitude of departmental respon-sibilities and tasks. Open
communication,however, may be the buffer for the negativeeffects of
downsizing. A recent large-scale studyon the effect of downsizing
(Pepper &Messinger, 2001) found that workers who feltthat the
process was equitable and that com-munication was open had fewer
symptoms and health problems. Workers who remainedand who had
low-decision/high-demand jobsreported increased symptoms. These
resultssuggest that during downsizing, employersshould emphasize
fair proceedings and com-municate openly about what is going on. It
alsosuggests that managers need to monitor workdemands carefully
after downsizing. Health carepractitioners can assist with this
process andencourage employers to acknowledge that bothwhite-collar
and blue-collar workers are at riskof developing a stress-related
disorder or MSD.
SUMMARYThis chapter has provided an overview of thebeliefs and
values associated with work and hasalso discussed how these beliefs
and values maybe integral to managing workers with
injuries.Although individuals beliefs and values aboutwork may
vary, there are underlying themes thatare common to many workers.
These beliefs
22 Systems Involved in MSD Management: Worker, Medical, and
Regulatory Perspectives
-
will shape workers perceptions and interactionswithin the
working environment.Clinicians mustbe sensitive to a workers
beliefs and values inorder to shape an intervention that can
bestreduce disability and return that worker toproductive work.
The following case exemplies the strongbonds and self-identity
some workers associatewith work. Health care professionals need
tounderstand this relationship in order to provideclient-centered
treatment and vocational planning(Sanders, 1994).
Barbara Ann was a 59-year-old woman whoworked at a steel mill
for 17 years prior todeveloping carpal tunnel syndrome and
degen-erative changes in her right thumb carpo-metacarpal joint.
Her job as a Z-mill operatordemanded that she perform repetitive
pinchingand grasping of tight machine controls, lifting of 50-pound
metal cylinders, and operating 40-pound shears. After undergoing
surgery anddeveloping reflex sympathetic dystrophy, it was clear
that Barbara Ann would not be able toreturn to this physically
demanding job. Al-though she had described the work environ-ment as
noisy, hot, and awful smelling, whenshe was given the option of
being retrained as atravel agent (her avocational passion),
shedeclined. Well have to nd something at themill. I was the rst
female Z-mill operator in theUnited States, and a steel worker is
who I am.Mill life was central to her identity.
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