Transcript Estimating Low Back Compression from Back Extensor

STOP
RSI !
Institute for Work & Health
Presentation to
Marconi Research
Conference at Marigold
2003
Intervention Research of
Computer Use
September 13-14, 2003
Intervention &
Evaluation in a
Large Newspaper
By Richard P. Wells PhD and
Donald C. Cole MD, MSc, FRCP(C)
University of Waterloo and
Institute for Work & Health
on behalf of…
Partners
Members of the RSI Committee:
The Toronto Star: Dianne Forsyth, Dana Greenly, Jeff Hoffman,
Vivian Karnilavicius
SONG: Sylvia Cowell, Ann Maguire, John Spears, Paul Willis
University of Waterloo: Dwayne Van Eerd, Richard Wells
York University: Melanie Banina, Anne Moore
The Orthopedic Therapy Clinic: Maureen Dwight, Pam
Honeyman
IWH: Dorcas Beaton, Donald Cole, Sue Ferrier, Sheilah HoggJohnson, Carol Kennedy, Hyummi Lee, Michael Manno,
Michael Polanyi, Harry Shannon, Peter Subrata, Michael Swift
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Key Findings:
1. Reduction in persons with severe/frequent pain
2. RSI has been controlled but not resolved.
3. Ergonomic Policy and STOP RSI! Program
components are important responses.
4. Program participation by individuals associated with
reduction in risk factors and improvement of health
outcomes.
5. The RSI and Joint Health & Safety Committees have
made a difference, but ongoing corporate support is
crucial.
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Outline
1. Nature, timeline and phases of collaborative
research
2. Intervention areas and specific interventions
3. Evaluation framework
4. Exposure assessment
5. Outcomes
6. Key messages & directions
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Collaborative Research: Star-SONG
 The Toronto Star - a large newspaper undergoing
technological and organizational change.
 Southern Ontario Newspaper Guild (SONG) – part
of the Communication, Energy & Paper-workers
union, long history of health & safety activism.
 Two intertwined goals of better musculoskeletal
health (particularly upper extremity WMSD) &
improved business performance.
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Collaborative Research: Process
 Joint development by workplace parties & research
team, approved in collective bargaining, enshrined
in ‘Ergonomic Policy’ and called ‘Stop RSI’
programme with goal of reduced WMSD burden.
 Ongoing parallel, major moves with new
equipment, work re-organization & team training,
new software in different departments, attempts to
contract out distribution, etc. with goal of improved
business performance.
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Overall Evaluation Program
Extensive Repeat Exposure
Measurement (subset of n=44)
For physical Exposures
Status Quo
Rest of Workforce
N approx 800
2001 Cross-sectional Survey
1998
1997 Intensive Studies (Phase II)
1996 Cross-sectional Survey (Phase I)
“Teamed” Group
Workplace Surveillance
Qualitative Documentation & Analysis
Secondary Data Linkage
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Surveys
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1996: Cross-sectional Survey
(descriptive, analytic)
…provided workforce coverage
1997: Suite of Intensive Studies
(multiple methods including in-depth interviews, focus
groups, surface EMG and additional questionnaire
measures)
…deepened understanding
2001: Cross-sectional Survey (individually linked)
(descriptive, analytic)
…measurement of change
Evaluation Framework: (i)
Means
Intermediate Outcomes
Longer Term Outcomes
Strategies
Activity Area
Objectives
Metric
Objectives
Metric
Policy
Formulation of
Ergonomic
Policy
Employees/man
agers
aware of policy
&
contents
Interviews
Policy used to
guide
actions
Document
analysis
Human
Resources
Definition of
employer &
employee
Each aware of
their
Interviews &
document
review
Each fulfilling
their
Joint
committees
Document
review
Questionnaire
% trained by
department
Part of
orientation
of new staff
responsibilities
responsibilities
responsibilities
“Stop RSI”*
training
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Entire office
workforce
has been part
of
training
Changes in
Knowledge
attitudes
& practices
Evaluation Framework
Means
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Intermediate Outcomes
Longer Term Outcomes
Strategies
Activity Area
Objectives
Metric
Objectives
Metric
Human
Resources
Knowledge of
WMSD† risk
factors (incl.
work
organization &
physical)
Employees/
managers
aware of such
factors
and attempting
to deal with
them
Interviews
Observations
during joint
committees
Document
review
Managers
incorporating
consideration of
in
Work design &
operations
decision
making
Interviews
Participation in
joint
committees
Questionnaire
Team Work
Team training
Consideration of
work
organization and
physical WMSD
risk
factors in
training
Document
review
Interviews
Ongoing
training and
new team
structures
incorporate
WMSD
risk factor
considerations
Document
review
Interviews
Evaluation Framework
Means
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Intermediate Outcomes
Longer Term Outcomes
Strategies
Activity
Area
Objectives
Metric
Objectives
Metric
Team Work
Team formation
&
implementation
Multi-skilling
Increased
variety
iImproved
productivity
Interviews
Number
of tasks & %
time
Variation in
surface EMG
Improved:
Synchronization
of tasks,
handling of
deadlines &
workflow
ditto
Equipment
and
Environment
New spatial
layout of
workstation
Allow adequate
space for work
and improves
contact between
team members
Observation
Interview
Workflow
improvement &
increased
teamwork
Interviews
New adjustable
workstations
Improved
‘ergonomic
design’ of
workstations
Workstation
dimensions,
Observational
data on
postures, EMG
Purchasing
policies
revised
Interviews
Ergonomic
assessment
data,
Questionnaire
Evaluation Framework
Means
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Intermediate Outcomes
Longer Term Outcomes
Strategies
Activity
Area
Objectives
Metric
Objectives
Metric
Information
Systems
New software
Improved
workflows
& productivity
Interviews
Observations
Productivity
data
in departments
New software
designs
incorporate
WMSD
considerations
Interviews with
system staff
Questionnaire
Productivity
data in
departments
Human
resource
(HR)
information
systems
Improve
ongoing
surveillance of
WMSD
risk factors
(ergonomic
assessments)
and
reporting
Data from
relevant HR
data bases to
joint
committees
Reduce overall
risk
factors and
severity of
WMSD
Decline in
WMSD severity
on injury
reports
Regular
ergonomic
assessments
Assessment Methods
Methodologies include:






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Interviews
Questionnaires and diaries
Observation and video
Measures of EMG, postures, dimensions
Site administrative data
Compensation system, health care system records
linkage
Assessment: Workstations (1)
45 Participants (31 female, 14 male)
(40/41 new workstations, 3/41> 1
workstations, adjustable keyboard tray
36/41)
Did the installation
of new workstations
improve the postures
adopted?
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Wrist, neck and shoulder
postures and dimensions of
VDT location on workstation
taken, EMG:
 Spring/Summer 1999
 Winter 2000
(excluding circulation)
 Spring/Summer 2000
(41 participants)
Assessment: Muscle Activity (i)
How to assess muscle activity in a workplace setting?
Muscle activity in a naturalistic setting is determined by: tasks
performed, workload, workstation, equipment, technique,
task/time organization
Electromyographic signals bilaterally from:Extensor Carpi
Ulnaris Brevis (ECRB),Trapezius, recorded using portable
EMG system with simultaneous video recording
 On/off states of 7 tasks identified while viewing video and
simultaneously recorded on computer (Observer Pro 4.0,
Noldus Technology, Netherlands): Keying, mousing, phone,
deskwork, sitting/standing, at/away from desk, other.
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Assessment: Muscle Activity (ii)
 Two hours of work (on 2 days (am and pm) pre, during, and
after interventions).
 30 minute segment analysed; work at desk over-sampled
 33 Participants: Newspaper advertising and finance employees,
Clerical, administration, sales, customer accounts and call
centre,10 male/ 23 female
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Assessment: Muscle Activity(iii)
 Extracting mousing task EMG from working EMG
EMG (% MVC)
50
40
30
20
10
0
-10 0
1
2
3
4
5
6
50
Mousing On
8
50
40
40
30
30
20
20
10
10
0
9
10
Mousing Off
0
0
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7
Time (min)
1
2
3
Time (min)
4
5
6
0
1
2
Time (min)
3
Static EMG (% MVC)
Assessment: Muscle Activity
3
Low static is better
*
*
2.5
*
2
*
1.5
keyoff
keyon
1
0.5
0
20
High gaps is better
Gaptime (sec/min)
Rt ECRB Rt T raps Lt ECRB Lt T raps
15
Keyoff
10
Keyon
5
0
R.ECRB
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R. Traps
L. ECRB
L. Traps
Static EMG (% MVC)
Assessment: Muscle Activity
5
4
*
3
mouse off
2
mouse on
*
1
0
Rt ECRB Rt T raps Lt ECRB Lt T raps
Institute for Work & Health
Assessment: Muscle Activity
Static EMG (% MVC)
Holding Handset (in right hand)
2
1.5
Phoneoff
1
Phoneon
0.5
0
R.ECRB R. Traps L. ECRB L. Traps
Institute for Work & Health
Intermediate Outcomes
 Shorter term outcomes such as reductions in
exposures, that are thought to precede
improvements in longer term outcomes such
as pain levels and lagging indicators such as
injury or lost time from work…
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Process Indicators: Education
 1998 STOP RSI! training sessions in all
departments – 58% reported on 2001 survey
 RSI training as part of orientation – 11% of 2001
survey respondents
 90% of 2001 survey respondents felt that The
Toronto Star STOP RSI! program had completely
to moderately “ensured that all employees are
informed about RSI”
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Intermediate Outcomes: Education
Awareness of Causes of RSI
Perceived Cause
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1996 Survey 2001 Survey
Respondents Respondents
Poorly designed workstations
68%
78%
Working without breaks
40%
52%
Excessive workload
27%
40%
Lack of training
37%
23%
Process Indicators: Equipment/ Workspace
 Input by RSI Committee during purchasing
process
 Over 2000 Ergonomic Reports/ Workstation
Assessments completed by over 20 trained
assessors (56% (459) of 2001 survey respondents)
 Among a smaller group, the research team
measured workstation dimensions and conducted
postural assessments.
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Feedback Information
Analyses of xxxxx when performing keyboarding tasks.
Measure
Sept 17/99
May 3/00
Preferred Range
Interpretation
Head Tilt Angle
Needs Improvement
5 (up)
11 (up)
0-20 (down)
Gaze Angle
Within Preferred Range
20 (down) 1 (down)
0-30 (down)
Head Rotation
20
11 (right) 15 (left) - 15 (right) Within Preferred Range
Glare
Yes
No
No
Within Preferred Range
Right Shoulder Abduction 30
Within Preferred Range*
22
0-20 *
Left Shoulder Abduction
20
Within Preferred Range
25
0-20 *
Right Shoulder Flexion
Within Preferred Range*
30
22
0-20 *
Left Shoulder Flexion
Within Preferred Range
30
20
0-20 *
Inner Elbow Angle (right) 115
Within Preferred Range
115
80 - 120
Inner Elbow Angle (left)
120
Within Preferred Range
115
80 - 120
Supported Right Elbow
No
Yes
Yes
Within Preferred Range
Supported Left Elbow
Yes
Yes
Yes
Within Preferred Range
Supported Right Wrist
No
Yes
Yes-when not typing Within Preferred Range
Supported Left Wrist
No
Yes
Yes-when not typing Within Preferred Range
Right Wrist Extension
Within Preferred Range
15
27
0-30
Left Wrist Extension
Within Preferred Range
5
0
0-30
Rt Wrist Ulnar Deviation
Within Preferred Range
15
6
0-20 (ulnar)
Lt Wrist Ulnar Deviation
Within Preferred Range
15
0
0-20 (ulnar)
* - If arms are supported on armrests, shoulder flexion and abduction measures that exceed the
preferred range represent minimal increases in risk of injury.
Institute for Work & Health
Feedback Example
The figures below are a visual representation of your posture on the dates indicated, as well as a
preferred posture when using the computer. The first figure is the view from the side, while the
second figure is a top view. The black box represents your monitor position relative to your
body. The contrasting color scheme in the figures is used so that the arms will stand out, not to
indicate a potential location of risk.
Institute for Work & Health
Feedback Diagrams
The figures below are a visual representation of your posture on the dates indicated, as well as a
preferred posture when using the computer. The first figure is the view from the side, while the
second figure is a top view. The black box represents your monitor position relative to your
body. The contrasting color scheme in the figures is used so that the arms will stand out, not to
indicate a potential location of risk.
Institute for Work & Health
Feedback Diagrams
Institute for Work & Health
Feedback Diagrams
The figures below are a visual representation of your posture on the dates indicated, as well as a
preferred posture when using the computer. The first figure is the view from the side, while the
second figure is a top view. The black box represents your monitor position relative to your
body. The contrasting color scheme in the figures is used so that the arms will stand out, not to
indicate a potential location of risk.
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Intermediate Outcomes : Workstation
Dimension Change over Time
Angle
vs Monitor height
Gaze Angle vs Gaze
Monitor
Height
Monitor Height (cm from floor)
Gaze Angle (deg)
-20
0.0
20.0
40.0
60.0
80.0
100.0
120.0
0
20
40
60
80
1999
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w2000
S2000
S2001
140.0
160.0
Intermediate Outcomes : Workstation
Dimension Change over Time
Mouse Location (fore/aft vs side/side)
Mouse Position
Mouse fore/aft (cm from table
edge)
70
60
50
40
30
20
10
0
-60
-40
-20
-10 0
20
40
-20
-30
Mouse side/side (cm from j key)
1999
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w2000
S2000
S2001
60
80
Intermediate Outcomes : Equipment/
Workspace (ii)
Proportion inside preferred location (from questionnaire)
Piece of
Equipment
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1996 Survey
Respondents
2001 Survey
Respondents
Keyboard
56%
72%
Mouse
17%
61%
Monitor/Screen
72%
71%
Intermediate Outcomes : Change in Working
Postures over Time
Shoulder Posture; Percentage within Preferred Range
Measure
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Preferred
Range
Summer
1999
Winter
2000
Summer
2000
Right Shoulder
Abduction (°)
0-20 *
57
66
36
Left Shoulder
Abduction (°)
0-20 *
67
74
45
Right Shoulder
Flexion (°)
0-20 *
47
47
60
Left Shoulder
Flexion (°)
0-20 *
45
50
62
Supported Right
(%)
Yes**
41
79
68
Supported Left (%)
Yes**
39
87
79
* If arms are supported on armrests, shoulder flexion and abduction measures
that exceed the preferred range represent minimal increases in risk of injury.
** Wrist Support optimum when not typing
Intermediate Outcomes : Summary of
Equipment/ Workspace/Work Postures
Detailed dimension and posture measures
 From 1999 to 2001, changes among group of
employees (mostly Advertising):
 reduced extreme mouse positions (horizontal
and vertical)
 monitor heights higher but fewer extreme
head tilts
 fewer monitors displaced to the side and less
head rotation
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Intermediate Outcomes:
Job Changes (i)
Over past 3 years among 2001 respondents
 Different job title/description (32%)
 Different tasks in same job (37%)
 Broader job scope (29%)
 Increased job responsibility (47%)
 Changes in immediate supervisor (42%) or coworkers (45%)
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Intermediate Outcomes:
Job Changes (ii)
 Increased use of computer (27%) and addition of
mouse (36%)
 Among users, increased mean hours of use of
keyboard (extra 40 min.) and mouse (extra 56
min.) between 1996 & 2001
 Time sitting >2 hours continuously, increased by
9% to 33% of 2001 respondents
 Both keyboard use and time sitting were RSI risk
factors in 1996
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Longer Term Outcomes
 Among the entire workforce period
prevalence of more severe pain (NIOSH
case) decreased;
 205/1007 or 20% in 1996
 127/813 or 16% in 2001 difference p<0.01
NIOSH case: those who have experienced moderate or severe pain and
discomfort either once per month or longer than a week over the past
year and had no trauma to the area.
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Longer Term Outcomes: Symptom Level
Transitions in 1996-2001 Cohort
From:
1996 Symptom To: 2001 Symptom Level
Level
1
2
3
Totals
non-case (1)
Stable
97 (23.0%)
Incident
53 (12.6%)
Incident
13 (3.1%)
163
(38.6%)
mild (2)
Resolved
42 (10.0%)
Ongoing
93 (22.0%)
Worsened
21 (5.0%)
156
(37.0%)
Improved
54 (12.8%)
Chronic
37 ( 8.8%)
103
(24.4%)
200 (47.4%)
71 (16.8%)
422 (100%)
more severe or Resolved
frequent (3) 12 (2.8%)
Totals
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151
(35.8%)
Longer Term Outcomes: Changes in
RSI 1996-2001(ii)
Among those with pain
 Fewer wrist/hand (- 6%), more shoulder (+7%) and
neck (+12%)
 Majority in 2001 aggravated by work
(yes, 57%; to some extent, 34%)
 Persistent problems with work function: WorkDASH (Disability of Arm, Shoulder & Hand) 1996
mean 6.3/100, SD 14.9; 2001 mean7.8, SD15.3 (no
significant difference)
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All Kinds
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NSAIDS
OPIATE AGONISTS
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
19
91
Costs/Quarter
Longer Term Outcomes: Trends in Musculoskeletal
Related Drug Costs
Longer Term Outcomes: Analyzing linkages in
1996-2001 cohort
Reported Program
Participation:
(n=433)
• Training
• Workstation Asst.
• New equipment
∆ Potential
Risk Factors:
• Biomechanical
• Psychosocial
Reported Work
Changes:
• Computer-related
• Job-related
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∆ Health Outcome:
• Pain intensity (all)
• Disability WorkDASH &QuickDASH
(sub-set)
Confounders/ Effect Modifiers
(age, seniority, gender) accounted for
Longer Term Outcomes : Predictors of changes
in risk factors
 Of biomechanical risk factors
 multiple kinds of new equipment with likelihood
of worse telephone setup (p=0.005)
 broader responsibility & scope in job with
physical effort (p=0.098)
 Of psychosocial risk factors
 having a workstation assessment (p=0.062),
participation in Stop RSI training (p=0.007), &
broader responsibility & scope in job (p=0.032)
with decision latitude
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Longer Term Outcomes : Predictors of changes
in health outcomes
 In pain intensity

supervisor awareness & concern associated with
(p=0.161)

keyboard time with pain (p=0.125)
pain
 In upper extremity related disability

management support for RSI (p=0.006) & frequency
of workers taking part in decisions (p=0.082) with
disability (QuickDASH)

physical effort (p=0.119) & decision latitude
(p=0.121) with work disability (Work-DASH)
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Longer Term Outcomes:
2001 Survey Respondents’ Assessment
 The STOP RSI! program “promoted continuous
improvement in the technology and management practices
to control exposure to workplace risk factors that can
cause RSI” - 85% completely to moderately agreed
 Toronto Star management were supportive in dealing with
RSI - 74% agree or strongly agree (vs. 64% in 1996)
 Immediate supervisor was aware and concerned - 57%
(unchanged from 1996)
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Future Directions: 2001 Survey
Respondents’ Suggestions
 Equipment:
 mouse wrist rests and longer cords
 monitors should be placed at an appropriate distance
and height, adjustable to height of person
 Workspaces:
 all workstations should be assessed/set up for each
new employee during 1st week at work and regularly
thereafter
 working at workstation other than one's own usually
uncomfortable - cannot adjust
 Social Supports:
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 awareness sessions with [RSI] “victims” for
immediate supervisors
Future Directions: Ongoing Tensions
Relevant to RSI
 Proportion of respondents who disagree that “I
can take breaks when I want to” unchanged
from 1997 to 2001 (28%)
 “…productivity is really important here. You
have to be always available on your phone.
And all their incentives …[are] based on how
much you’re producing.” - manager
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Ongoing Workplace Directions:
 RSI/JH&S committees are continuing training,
ergonomic assessments, purchasing guidelines
and therapy initiatives
 Struggling with:
 strengthening management practices supportive of
dealing with RSI, particularly at the supervisory
level
 need to persuade organizational leaders to move
“upstream” to influence decisions on new
technology, organization of work and design of
jobs, as per Ergonomic Policy
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Key Findings:
1. Reduction in persons with severe/frequent pain
2. RSI has been controlled but not resolved.
3. Ergonomic Policy and STOP RSI! Program
components are important responses.
4. Program participation by individuals associated with
reduction in risk factors and improvement of health
outcomes.
5. The RSI and Joint Health & Safety Committees have
made a difference, but ongoing corporate support is
crucial.
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Ongoing Research:




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Changes in exposure
Company surveillance review
Path modeling for changes in cohort
Integrating the quantitative and qualitative
components
Supported by:





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NIOSH/NIH R010H03708-02
Centre for VDT & Health Research
Toronto Star
Southern Ontario Newspaper Guild
IWH and indirectly, the Ontario WSIB