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Based on the responses from three focus groups, the NORA MSD team developed an agenda of the most important research gaps in four primary topic areas. These included surveillance, etiology, intervention, and improving the research process. The Houston workgroup was not asked to develop a list of the most important priorities. The goal in developing the agenda for the four primary topic areas was to synthesize the responses, eliminate duplication, and highlight the most important gaps identified in each area. In some cases, the NORA MSD team also added their viewpoints on the priorities for research. The listings of research issues identified by the focus groups for each topic can be found in the Appendices of this document. There are some issues discussed in more than one topic area.
Surveillance is the ongoing systematic collection, analysis, interpretation, and dissemination of MSD health and hazard information in order to identify trends, develop prevention strategies, and evaluate the effectiveness of those strategies.
The following are the most significant priorities for surveillance research activities identified by the NORA Team:
Surveillance Systems Additional research is needed on how surveillance information can be collected, using existing passive surveillance data (billing records created when employees seek medical care) or active surveillance data (annual symptoms surveys of all employees in manual handling jobs). Evaluation of the different roles for active and passive systems are also needed.
Case Definition Develop and validate standardized case definitions for MSD and key variables, including the levels of symptoms to be included in the definitions (distinguish "ever experienced back pain" from "radiating back pain in the last 3 months with a duration of more than a month with moderate to high intensity"). Medical information on cases should include measures of severity of the disorder. This is particularly important in evaluating progress of disease and effectiveness of interventions over time. Validity and reliability of new surveillance case definitions should be tested and reported.
Methods for High Risk and Changing Jobs New surveillance methods are needed to identify high- risk jobs or tasks when the relationship of the worker to the workplace is changing, such as an increase in temporary workers or workers with multiple jobs with different exposures.
Evaluation of Surveillance Tools Evaluate the validity, reliability and accuracy of hazard surveillance instruments to be used, recognizing that surveillance instruments usually trade simplicity and speed for precision. Make these tools usable by experts and nonexperts.
More user-friendly exposure assessment tools are needed. Devices are needed that are efficient, portable, rugged, flexible, and capable of measuring multiple exposure variables simultaneously and simple enough for those with minimal training to use.
Validation of Surveillance Systems Validate existing or new surveillance systems in terms of usefulness, representativeness, timeliness, simplicity, acceptability, predictive value, and cost.
Development of New Surveillance Tools Research is needed to develop or evaluate surveillance tools to be used for data at the local or national level, and to be applied to various stages of the MSD development process.
Non-health Indicators Determine whether non-health indicators, such as rates of job transfer, absenteeism, reduced productivity, and early retirement, are effective in identifying jobs with elevated risk of MSD.
Background Rates Efforts should be directed toward developing county, state, industry or occupation denominators and rates that can be used for comparison purposes.
Additionally, collaboration with other groups, such as software system developers, insurers, employers, unions, and government groups (NHIS, NHANES), should be encouraged to develop comparability of definitions in data collection.
Many risk factors associated with development of MSD have been identified or suggested. Biomechanical risk factors include exposures to excessive force, awkward posture, movement, and vibration. These can be characterized in terms of their magnitude and temporal factors, such as frequency, repetition, duty cycle, and duration of exposure (See Figure 1). Psychological and social factors include work organization arrangements (extended work hours, shift work, piecework, machine pacing), lack of training, inadequate conditioning, and cognitive or emotional stress. Personal factors include variables associated with size, strength, age, gender, cultural factors, and history of injury. Research is needed to better describe the relationship between exposure to these risk factors, both singly and in combination, and the development of disease and disability.
The most significant priorities for etiologic and medical research activities identified by the NORA Team are to:
Field Research Contribution of Risk Factors Several biomechanical, psychosocial, and personal risk factors have been identified in connection with the MSD process. Research is needed on factors, such as posture, movement, and force within the context of temporal factors (duration and frequency). Research is needed to improve limits for exposure to physical demands and mechanical stresses. This research needs to integrate personal, psychological and social factors. Research is also needed to develop and validate more predictive exposure assessment tools.
Laboratory Research Models Conceptual models of the MSD development and recovery process need to be tested and refined in the laboratory (Figure 1). Such models should link exposures, tissue changes, physiologic responses, adaptation, and disease. Mathematical and animal models are needed to help understand individual variables. Multi-factorial models are also needed to describe relationships between biomechanical and physiological factors. These models will provide useful information on the disease and recovery process that could be tested in the field.
Individual Variation Variation in individual response and adaptation needs to be investigated. Factors that need to be studied include demographic profiles (age, race, gender), personal history (cultural background, work and injury history), disease states (neurological, endocrine, or circulatory diseases), and work organization factors (work arrangements, time on the job, training, compensation and benefit structure). These need to be considered in the context of biomechanical factors, such as load or repetition.
Childhood Exposures Studies are needed on children at work, and the relationship between childhood exposures to biomechanical factors and later development of MSD (video games or computers, or carrying heavy backpacks).
Fatigue Role Research is needed to determine the impact of whole body fatigue and local muscle fatigue on the development of MSD. New methods for assessing fatigue should be developed, such as human performance testing and biomonitoring.
Disability Research is needed to evaluate the impact of workers' compensation, disability benefits, and wage replacement strategies on effective recovery and return to work. This research, should account for physical factors when studying psychological or social factors that impact the length of disability.
Healthy Populations Research is needed to define a healthy musculoskeletal state and to identify optimal stress and activity levels. Healthy populations who have not developed disease despite exposure to risk factors should be studied.
Predictive Ability of Tools Predictive ability of biomechanical, organizational, and workplace psychological and social exposure assessment tools needs to be evaluated and improved. Greater precision, accuracy, repeatability, and validity of measurements are needed.
Other Assessment Tools Assessment tools need to be developed and evaluated to identify hazards associated with non-stereotypic work, such as jobs in transient or seasonal industries, (construction and agriculture). Consideration of multiple exposure changes in temporal patterns over the course of the workday or workweek should be included in these assessment tools.
Use of Data Research is needed to evaluate the trade off between observation, self reports, and direct measurements in predicting risk. The health-related data sources (OSHA logs, workers' compensation, disability, and health insurance records) need to be evaluated for usefulness in identifying disease patterns (evaluation of reporting bias, over-reporting, under-reporting, and legal and medical criteria). This research would be an additional resource for improving surveillance.
Case Definition Work is needed to develop standard clinical definitions for MSD which include clear endpoints. Definitions are needed for stages of the disease process characterized by such terms as discomfort, pain, injury, disability, and recovery.
Diagnostic Tools Effective diagnostic tools are needed. Existing diagnostic tools and procedures need to be evaluated, including use of MRIs and microsensors. It is particularly important to find good early indicators of the disease process, including biochemical and bioimaging markers. It is important to develop effective tools for establishing an individual baseline for medical monitoring.
Predictive Tools Tests, such as electrodiagnostic testing or functional disability evaluation tools, should be studied for their ability to predict the onset and outcome of MSD. Research is needed to identify and validate practical screening tests that can detect individual physical conditions or biological markers indicative of the MSD process. Tests should be useful for periodic monitoring of individuals for comparison to baseline status. Research is also needed to determine whether changes in biological markers indicate reversible or permanent change; to develop/validate/evaluate tools to assess functional disability; and to determine if structural changes are related to the course or progression of MSD. Populations studies need to be conducted to determine normal population values or ranges for subsequent useful inferences for the MSD process. Criteria for work-related illness should be evaluated.
Treatment Strategies Evaluation of treatment protocols, rehabilitation programs, and return to work strategies is needed.
Research is needed to develop and evaluate new and existing intervention strategies for preventing or reducing the incidence, severity, and disability associated with work-related MSD. A large amount of research has been conducted over the past few decades, but because of the wide variability between individuals and the complexity of causal and contextual factors and their interactions, there is a need for more research on which interventions are the most effective. Moreover, intervention research is difficult to conduct because adequate comparison controls are often not available and because very large sample sizes are needed to show that an intervention is effective in reducing health outcomes. In many cases, it is not possible to conduct studies aimed at reducing health effects, so studies must rely on demonstrating reduced exposure. Interventions can be tested in the laboratory where confounding factors can be controlled, or tested in the field. Effective control technology should work well in both environments.
The most significant priorities for intervention research activities identified by the NORA Team are to evaluate the effects of the following on development and prevention of MSD:
Mechanical Environment Research should investigate the mechanical environment factors that affect posture, movement, force, exertion, and the interface between the worker and the equipment or the task. Such mechanical environment factors include workplace arrangements equipment, and tool design, as well as the design of the products and components that are routinely handled by people. For example, research into alternative seating arrangements or human interactions with semi-automated material-handling devices would be useful.
Force Factors More engineering research is also needed to identify and evaluate the factors that affect the force required by the worker. For example, intelligent material-handling devices are being developed that compensate for different loads. Research is also needed to measure the versatility, operator acceptance, protective capabilities, and safety aspects of these devices. In the area of manipulation of tools and smaller objects, as in assembly work, food processing, retail, and dentistry, additional engineering research is needed to provide the optimal balance between the force requirements for the efficient completion of the work task and the prevention or reduction of MSD.
Dynamic Forces More research is needed to develop interventions directed at reducing the dynamic demands of work tasks (kinematic or motion parameters and kinetic or force parameters), such as redesigned workspaces and tools that minimize required forces and movements.
Specific Industries Work is needed to develop additional engineering solutions for several industry- specific problems, including fork truck design and health care, warehousing, construction, maritime, agriculture, meatpacking, and poultry processing.
Participatory Approaches Research is needed on when and how participatory programs work to prevent/reduce MSD.
Work Interaction Research is needed to increase knowledge of the interactions between the cognitive, environmental, social, organizational, economic, and political contexts of work which can be used to develop interventions aimed at preventing MSD.
Job Content and Scheduling Further research is needed in the areas of task assignment and work/rest schedules, job rotation, job enlargement, and length of the workday. Research is needed on the effect of worker control of pace (piece rate and incentives) and job content.
Behavioral Intervention Studies are needed to determine what factors are effective in getting workers to incorporate modification in work methods, such as increasing use of assistive equipment, taking regular rest breaks, or avoiding hazardous activities, such as heavy lifting or lifting from the floor.
Safety and Fitness Effects Research is needed to determine the effectiveness of general safety, wellness, and fitness programs and their impact on work-related MSD.
Accommodation and Functional Capacity Research is needed to determine the effectiveness of interventions directed at matching the individual characteristics, capability, and vulnerability of workers to the work demands. Such research would cover issues of selection, training, work hardening, rehabilitation, and restricted work assignments. In addition, because of the indication that a history of musculoskeletal illness and injury is predictive of future episodes, more intervention guidance is needed regarding the assignment of particular individuals to particular jobs.
Personal Protective Equipment Personal protective equipment may be used to modulate the interface between the body and external forces or to restrict joint movement. Interventions of the former type, such as gloves and kneepads, are generally accepted, although there may be an opportunity to evaluate the effectiveness of personal protective devices in the attenuation of vibration from hand tools. Further research could evaluate a wider range of work environments to determine if there is a role for joint restraint devices in MSD treatment protocols.
Training and Education Research is needed to develop and investigate effective training and educational interventions to diverse audiences. These include workers or management in the workplace and students in vocational, engineering, occupational health, and management programs. Such interventions include: programs in the workplace, ergonomics material in grade school, engineering and business curricula, extension of specialist education, and professional certification. Educational interventions may have far-reaching effects on reduction of the incidence and severity of work-related musculoskeletal disorders.
Exposure Guidelines and Regulations Research is needed to determine the effectiveness of voluntary exposure guidelines and regulations. Studies are needed to determine the difference in impact between voluntary guidelines and regulations and the impact of varying exposure criteria.
Compensation More research is needed to determine the prevention role of the workers compensation system and how it could be used more effectively to reduce MSD.
Cost Benefit Evaluate the impact of ergonomic interventions on non-health-related outcomes such as quality and productivity. Develop business models that quantify the costs and benefits of ergonomic programs.
Participants indicated that the research process could be improved by strengthening communication between those who conduct research and those who apply research. Researchers expressed frustration at the difficulties associated with gaining access to industrial sites to conduct research, and management and labor felt the need for more input into the research process. Some participants suggested that research might be more applicable to industry if management and labor reviewed research proposals and had a say in funding and prioritization. For example, workforce representatives expressed disappointment that researchers often did not have a thorough knowledge of the workplace process being studied, or performed their research under "best case" scenarios.
There seemed to be general agreement that improvements in dissemination of research results were needed. Most of the dissemination problems were attributed to inadequate communication between the parties involved in the research process. More effective methods of dissemination are needed to improve the application of research findings in the workplace. Furthermore, when valuable research data were obtained, the method of dissemination made it difficult to apply in the workplace.
The NORA Musculoskeletal Team considers coordination of research activities and information dissemination to be of prime importance in this area. As suggested by several of the focus group participants, coordination of studies through partnerships involving government agencies, university researchers, private industry, and labor unions could be extremely beneficial in bridging communication gaps, developing efficient research strategies, and improving the dissemination of information.
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