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Copyright © 1999, 1995 by Butterworth-Heinemann, an imprint of Elsevier Inc.
Portions of Chapter 15 © E. Kent Gillen

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Neither the Publisher nor the Author assumes any responsibility for any loss or injury and/or
damage to persons or property arising out of or related to any use of the material contained in
this book. It is the responsibility of the treating practitioner, relying on independent expertise
and knowledge of the patient, to determine the best treatment and method of application for
the patient.
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libraries in developing countries
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l n t e rnu t i o n a l
ell-..'ounc1a toIon
>.)(1 )1"C 1
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to my dear friend
and outstanding occupational therapist
Diana Aja
Love is the bond between heaven and earth

Naomi Abrams, MOT, OTR/L Chetwyn Che Hin Chan, PhD, OT(C)
Occupational Therapist, Ergonomic Consultant Professor
NRH Regional Rehab Department of Rehabilitation Sciences
Bethesda, Maryland The Hong Kong Polytechnic University
Hung Hom, Kowloon
Nancy A. Baker, ScD, OTR/L Hong Kong
Assistant Professor
School of Health and Rehabilitation Sciences Susan A. Domanski, BScOT, OT Reg (Ont)
University of Pittsburgh Occupational Therapist
Pittsburgh, Pennsylvania Waterloo, Ontario

Asnat Bar-Haim Erez, PhD

Mary Frances Baxter, PhD, OT Occupational Therapist
Associate Professor The School of Occupational Therapy
Texas Woman’s University Hadassah and the Hebrew University
Denton, Texas Jerusalem, Israel
Research Coordinator
Rehabilitation Services Daniel Focht, MA, OTR
The University of Texas MD Anderson Cancer Therapy Services Coordinator
Center Tri-State Occupational Health
Houston, Texas Medical Associates/Mercy Health Center
Dubuque, Iowa
Valerie J. Berg Rice, PhD, CPE, OTR/L
Human Factors Engineer/Ergonomist, Occupational Robin Mary Gillespie, PhD, MPH
Therapist Director
US Army Whole Ergonomics
Universal City, Texas New York, New York

viii Contributors

E. Kent Gillin, MSc Rhysa Tagen Leyshon, MSc(OT), CHT, OT(c)

Professor of Ergonomics Graduate Student
Department of Kinesiology Department of Health and Rehabilitation Sciences
The University of Western Ontario The University of Western Ontario
London, Ontario London, Ontario

Nancy J. Gowan, BHSc(OT), OT Reg(Ont), CDMP Cecilia W.P. Li-Tsang, PhD, MPhil, PDOT,
Occupational Therapist, President OT(C), HKROT
Gowan Health Consultants Associate Head and Associate Professor
Wallacetown, Ontario Department of Rehabilitation Sciences
The Hong Kong Polytechnic University
Ev Innes, BAppSc(OT), MHPEd, PhD, AccOT, Hung Hom, Kowloon
MHFESA Hong Kong
Senior Lecturer
School of Occupation and Leisure Sciences Rosemary Lysaght, PhD, OT
Faculty of Health Sciences Assistant Professor
University of Sydney School of Rehabilitation Therapy
Lidcombe, New South Wales Queen’s University
Australia Kingston, Ontario

Karen Jacobs, EdD, OTR/L, CPE, FAOTA Denise M. Miller, MBA, OTR/L
Clinical Professor Outpatient Supervisor
Department of Occupational Therapy and Glendale Adventist Therapy and Wellness Center
Rehabilitation Counseling Los Angeles, California
Sargent College of Health and Rehabilitation
Counseling Jill J. Page, OTR/L
Boston University Industrial Rehabilitation Consultant
Boston, Massachusetts Ergoscience, Inc.
Birmingham, Alabama
Paul C.W. Lam, PhD
Occupational Therapist Alan Salmoni, PhD
Elderly Resources Centre Professor
Hong Kong Housing Society School of Kinesiology
Hong Kong The University of Western Ontario
London, Ontario
Tatia M.C. Lee, PhD
Professor Charissa C. Shaw, MA, OTR
Laboratory of Neuropsychology President
The University of Hong Kong Elysian Integrated Health Solutions
Pok Fu Lam Road Long Beach, California
Hong Kong
Lynn Shaw, PhD
Jenny Legge, BPhty, Merg Assistant Professor
Founder/Managing Director/CEO School of Occupational Therapy
JobFit Systems International Faculty of Health Sciences
Mt. Pleasant, Queensland The University of Western Ontario
Australia London, Ontario
Contributors ix

Orit Shenkar, MSc, PhD Connie Y.Y. Sung, MPhil

Occupational Therapist Graduate Student
The School of Occupational Therapy Department of Rehabilitation Services
Hadassah and the Hebrew University The Hong Kong Polytechnic University
Jerusalem, Israel Hung Hom, Kowloon
Hong Kong
Ellen Rader Smith, MA, OTR, CPE
Principal Ergonomist Patrice L. (Tamar) Weiss, PhD
Ergo & Rehab Services Professor
Towaco, New Jersey Department of Occupational Therapy
University of Haifa
Sandi J. Spaulding, PhD, OTR, OT(C) Haifa, Israel
Associate Professor
School of Occupational Therapy Melanie Weller, BHScOT, OT Reg. (Ont.)
Faculty of Health Sciences Occupational Therapist
The University of Western Ontario Gowan Health Consultants
London, Ontario Wallacetown, Ontario

Susan Strong, BScOT Reg (ON), MSc(DME)

Associate Clinical Professor
School of Rehabilitation Science
McMaster University
Coordinator of Program Evaluation/Research
Schizophrenia Service
St. Joseph’s Healthcare
Hamilton, Ontario

The fields of ergonomics, occupational therapy, Not only do societal trends shape ergonomics
and physical therapy have grown increasingly and therapy practice, but practice applications can
intertwined as professional knowledge and skills influence societal trends. The future is rich with
are blended to advance applications that optimize opportunities for collaboration between the fields
human well-being and performance. Practice to create more sophisticated and comprehensive
applications cover many different populations, analyses of conditions that present risks to health
from able-bodied individuals to those with dis- and safety and inform decision making to promote
abilities, and from infants to senior citizens. Soci- health and productivity. Advancements in prac-
etal trends play a major role in influencing the tice have the potential to revolutionize our world
focus and expansion of practice. An aging popula- of work, home life, and leisure activities. Practice
tion and the proliferation of technologies into skills, coupled with creativity and ingenuity, have
seemingly all facets of life are examples of trends the power to spark innovations in the design of
having a profound impact on populations, envi- new products, technologies, and services. This
ronments, and occupations. text serves as a valuable resource to those with a
The impact these trends have on human per- passion to make a difference.
formance continues to challenge ergonomics and
therapy practices. Interactions between people, Phyllis M. King, PhD, OT, FAOTA
environment, and occupations are often complex. Professor
As workforce demographics, work methods, Director, Occupational Therapy Program
schedules, and environments become increasingly Associate Director, Center for
nontraditional, the need for analysis of human Ergonomics
capabilities, limitations, and characteristics to University of Wisconsin-Milwaukee
design for efficiency, effectiveness, and safety will
continue to be paramount.


Ergonomics—a science that continues to evolve New to This Edition

and grow and a field that provides almost limitless All the chapters included in the last edition
opportunities for occupational and physical thera- have been thoroughly revised or rewritten for
pists with expertise in this area. this edition to include the current evidence-
I am delighted that you have selected Ergonom- based science by 31 experts from five countries
ics for Therapists to help guide your best practice. who contributed to this text. The following new
It is a tool to help you develop expertise in ergo- chapters that broaden the scope of this book are
nomics as well as a resource for those of you included:
already practicing in ergonomics. The contribu- • Macroergonomics
tors and I feel great satisfaction in providing you • Ergonomics and work assessments
with cutting-edge chapters on important aspects • Ergonomics of children and youths
of ergonomics. • Ergonomics of aging
• Ergonomics of play and leisure
Organization • Entrepreneurship

This third edition of Ergonomics for Therapists,

like its predecessor, is a user-friendly text divided
into six parts: Distinctive Features of This Book
1. Overview and Conceptual Framework To facilitate your using Ergonomics for Therapists
2. Knowledge, Tools, and Techniques as a training tool, each chapter has the following
3. Special Considerations features:
4. Application Process • Learning objectives
5. Resources • Glossary boxes containing key words and
6. Appendixes definitions

xiv Preface

• Case studies that are threaded throughout the Acknowledgments

chapter “The quality of life is determined by its
• Learning exercises, which engage the reader activities.”
to apply the chapter information to real-life Aristotle
situations and help the reader perform
assessments My appreciation and gratitude are extended to all
• Multiple choice review questions of the authors who have shared their expertise
Another feature is the Appendixes that contain within the pages of this book. I offer appreciation
additional case studies, ergonomic information to Kathy Falk, Melissa Kuster, and Sarah Wun-
sheets for consumers that can be photocopied to derly at Elsevier for using their creative skills to
give to clients, and measurement conversions make this edition of Ergonomics for Therapists
commonly used in ergonomics. even better than its predecessor.
To my family and friends, you are always the
“wind beneath my wings.” Thank you for always
being there for me.

Karen Jacobs
PA R T I Overview and Conceptual Framework

Ergonomics and Therapy:
An Introduction
Valerie J. Berg Rice

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Understand the unique contributions of occupational therapy, physical therapy, and ergonomics (human factors
engineering) professionals to the study, analysis, and improvement of work and work conditions; returning
individuals with disabilities to work; and designing products specifically for human use.
2. Describe the historical beginnings of the professions of occupational therapy, physical therapy, and
3. List some basic principles of ergonomics.
4. List professional terms that have been considered synonymous with ergonomics.
5. Understand and discuss the need for and limitations of the current state of the art of research and design
efforts for populations with disabilities.

Ergonomics. The study of work performance with an Physical therapy. The assessment, prevention, and
emphasis on worker safety and productivity. treatment of movement dysfunction and physical dis-
Occupational therapy. Skilled treatment that helps ability, with the overall goal of enhancing human
individuals achieve independence in all facets of their movement and function.
lives (

2 PART I Overview and Conceptual Framework

CASE STUDY sion to strengthen himself physically and men-

tally. In 1914 he opened Consolation House to
A large health care company just heard about ergonomics. provide similar services for others. Other founders
They own a number of full-service hospitals, rehabilitation of the field of OT held similar beliefs that occupy-
centers, and even day-care centers for children with dis- ing one’s time and doing something of purpose
abilities. They want to improve their services and heard serve both as evaluative tests and as tools for
that occupational therapy and physical therapy often deal “strength, reserve force, nerve and mental poise,
with ergonomics, so they have called your group and and of the several elements that we take together
asked for “full ergonomic consultation services” for all of as character.”7
their facilities. Your group could certainly use the income What was important for the founders of OT
and reputation in the field. What do you tell them? Do was that the individual have pursuits that were
you accept immediately? How will you discover what they important to him or her. The purposeful involve-
really need and what you can comfortably offer within ment helped reduce weaknesses caused by illness
your areas of expertise? or injury by building on personal strengths, allow-
ing people to return as productive members of
their families and society. Dr. Adolph Meyer,
another of the founders of OT, asked his col-

T his chapter defines ergonomics and provides

brief histories of the fields of occupational
therapy (OT), physical therapy, and ergonomics.
leagues at the Chicago Pathological Society in
1893 for their opinions on the types of occupa-
tions that could best be used during patient treat-
It also describes the relationships between thera- ment. Gardening, ward, and shop work were
pists and ergonomists in three areas of practice: mentioned, including raffia and basket work,
(1) workplace analysis, (2) environment and weaving, bookbinding, carpentry, and metal and
product design and redesign, and (3) research. leather working.55 These crafts were not consid-
Principles of therapy and ergonomics are consid- ered leisure activities as they are today; instead,
ered in relation to persons with permanent dis- the practice of a craft was an assignment that
abilities; persons with temporary injuries, such as provided rehabilitation for the client and could be
work-related musculoskeletal disorders; and per- used as full-time employment to support the client
sons without disabilities. This chapter also pro- and client’s family after discharge. Thus, the OT
files considerations for joint ventures between rehabilitation process focused on improving phys-
therapists and ergonomists. ical and mental functioning, as well as returning
the patient to a functional status in society. Indeed,
these activities were often used to train patients
HISTORICAL BACKGROUND for specific jobs, and it was with great alarm that
therapists first realized their patients did not
Occupational Therapy always enter the craft field for which they had
OT is predicated on the belief that eradication of been trained. Questions arose regarding whether
disease alone is insufficient for complete recovery. time, effort, and funds had been wasted in train-
Before the advent of OT, individuals who had ing if the clients did not enter the field for which
been injured or ill were hospitalized, treated, and they had been trained. It was noted, however, that
discharged, only to find themselves unable to with just a few carefully chosen, occupationally
function sufficiently because of physical and based crafts, the habits and skills needed for reha-
mental exhaustion. George Barton, an originator bilitation and employment could be learned and
of OT, spent extensive time as a client in a tuber- transferred to numerous jobs.62 Crafts were cate-
culosis hospital and recognized the need for addi- gorized according to the physical movements
tional therapy. Trained as an architect, he formed (upper and lower extremity, torso, head and
his own rehabilitation program after leaving the neck), balance, and coordination required, as well
hospital by working with the tools of his profes- as according to complexity, pace, stimulation level
Chapter 1 Ergonomics and Therapy: An Introduction 3

provided (monotonous or stimulating), the level • Performance skills assessments and treat-
of problem-solving skills required, initial cost, ment
final product use, level of concentration needed, • Adaptive equipment recommendations and
initiative required, noise created, amount of usage training
mental capacity required, and type of client for • Guidance for family members and care-
which it might be appropriate.5 Thus, the need for givers
simulating the job each client wanted to return to, Both occupational therapists and ergonomists
or undergoing specific new training for a particu- are trained to be aware of normal human abilities.
lar occupation, was eliminated. Therapists must be aware of clients’ current
The question of whether using a few well- physical, cognitive, and psychologic limitations
chosen activities for rehabilitation is more effec- and capabilities; their potential abilities and dis-
tive than individual job simulation has still not abilities; and the physiologic and psychologic
been clearly answered through outcome research. demands of the clients’ activities (including
Work hardening, or the simulation of the work work). Therapists must also be aware of the per-
environment as a means for recovery of ability, formance competencies and limitations of people
has revived the idea that each job and its com- without injuries to be able to assess whether a
mensurate job tasks need to be recreated to client is functioning within normal range. Maximal
provide the best possible rehabilitation and return- functional performance has been the goal of OT
to-work programs for the industrial worker, but since the inception of the profession in 1917
no proof for either argument exists, except anec- (beginning with the founding of the National
dotally. The intent is clear, however, that actively Society for the Promotion of Occupational
engaging the patient in carefully guided physical Therapy). The use of purposeful activities (e.g.,
and mental activities enhances the chances for a work simulation) as treatment modalities was
more successful return to work. integral to the development of the profession, as
The fundamental goal of OT is to enhance “the suggested by its name: occupational therapy. It
capacity [of the client] throughout the life span, must be noted, however, that work or activity
to perform with satisfaction to self and others used in a therapeutic manner is not ergonomics,
those tasks and roles essential to productive living nor is work hardening necessarily a part of
and to the mastery of self and the environment.”33 ergonomics.
OT should also help clients obtain their highest The first articles appearing in OT literature to
functional performance in all areas of life, includ- use ergonomic principles were published by Haas
ing work, recreational activities, and life at home. in the late 1920s and early 1930s. The first article
Clearly, though, the main focus of OT is working involved what has been termed ergonomics-for–
with clients (as opposed to the global workforce special populations.64 Haas designed and con-
population). That is, OT focuses on those indi- structed a weaving frame that could be used for
viduals who need assistance in order to achieve those who were bedridden.30 The second article
independent and satisfying lives. According to the described the combination of the principles of OT
American Occupational Therapy Association’s (therapeutic activity) with the needs of the hospi-
website (, OT is skilled treatment tal (increasing work efficiency): the clients were
that helps individuals achieve independence in all assigned to build a folding conveying chair for the
facets of their lives. OT assists people in develop- hospital.28 As described in a subsequent article,
ing the “skills for the job of living” necessary for the building of an adjustable stool that encour-
independent and satisfying lives. Services typi- aged “good” posture helped hasten recovery,
cally include the following: maintain health, and increase productivity through
• Customized treatment programs to improve the principles of anatomy.29 None of the early
one’s ability to perform daily activities articles applied to the general population; instead,
• Comprehensive home and job site evalua- the articles were designs for special client
tions with adaptation recommendations populations.
4 PART I Overview and Conceptual Framework

Physical Therapy Ergonomics

The American Women’s Physical Therapeutic Although the concept of ergonomics (also called
Association was founded in 1921, becoming the human factors) existed during the Stone Age
American Physiotherapy Association in the 1930s, (humans constructed tools to fit their own hands
and the American Physical Therapy Association for hunting and gathering needs), the first docu-
in the 1940s. The early fundamental intention of mented mention of the field came in 1857, when
physical therapy (PT) was “to assess, prevent, and Wojciech Jastrzebowski published An Outline of
treat movement dysfunction and physical disabil- Ergonomics, or The Science of Work Based upon
ity, with the overall goal of enhancing human the Truths Drawn from the Science of Nature34:
movement and function.”59
“Hail, Thou great unbounded idea of work!
In terms of injury prevention, the overall goal
God, Who, as the Bible teaches us, cursed
conforms to the objectives delineated by ergo-
mankind and subjected him to work,
nomic engineers, particularly those who design
cursed him with a father’s heart; for the
workplaces and equipment for physical safety and
punishment was also a consolation. He
effective work performance. That is, the goal of
who complains against his work knoweth
ergonomics, in terms of injury prevention, is to
not life; work is an uplifting force by which
design products, processes, and places to enhance
all things may be moved. Repose is death,
human performance while simultaneously keeping
and work is life!”
the environment safe. In turn, as industrial con-
sultants, physical therapists often use knowledge Jastrzebowski felt the ideas of work should be
of human motion to evaluate safe and effective studied and preached with the same rigor applied
working postures. Physical and occupational ther- to the more philosophical studies of his time, for
apists who work in industrial environments also he believed that “affections (i.e., beliefs, emo-
evaluate the limitations and capabilities of workers tions) are nothing else, but accessories to deeds.”34
with injuries (functional capacity assessment) and According to Jastrzebowski, the study of work, or
the demands of the work role (workplace analy- ergonomics, should involve all aspects of useful
sis) to establish treatment regimens for those work, the four main components of which are
individuals. Assessment and treatment roles are physical, aesthetic, rational, and moral (Table
sometimes targeted toward specialty areas, such 1-1). Jastrzebowski taught that applying each of
as back care, strength training, or work harden- the four components of work to whatever endeav-
ing. The benefit to companies of having an occu- ors one is involved with increases the benefits
pational or physical therapist on an ergonomic of those activities exponentially. For example,
team is the increased likelihood of the employee’s whereas pure physical work applied to planting
returning to work earlier, matching worker capa- might yield a two-for-one harvest, applying aes-
bilities with work demands, and preventing in- thetic or sensory forces would increase the yield
juries. Each of these benefits can translate into fourfold. Additional application of intellectual
increased revenues for a company.37 A therapist forces would then yield an eightfold gain at harvest
can often provide information about the prognosis time, and so on.34 His treatise is more complex
of an injury or illness, along with knowledge of than this chapter shows; he further subdivided all
the Americans with Disabilities Act (ADA). areas of work. He also sought to identify further
The American Physical Therapy Association areas of study including (1) the animals with
has established guidelines for “Occupational which we share work categories, (2) the periods
Health Physical Therapy,” which focuses on work of our lives that are particularly suited to various
conditioning and work hardening programs (avail- types of work, (3) the manner of work, and (4)
able at Although physical thera- the benefits drawn from work for both the indi-
pists participate in team approaches to solving vidual and the common good of society. His views
ergonomic issues, their focus appears to be on the are remarkably similar to those of the founders of
worker with an injury and preventive education. OT, although the latter applied the theories to
Chapter 1 Ergonomics and Therapy: An Introduction 5

TABLE 1-1 Jastrzebowski’s Divisions of Useful Work

Physical Aesthetic Rational Moral

Kinetic or motor Emotional or sensory Intellectual or rational Spiritual

Labor or toil Entertainment or pastime Thinking or reasoning Devotion or dedication
Breaking stones Playing with stones Investigation of a stone’s Removing stones from the road
natural properties to remove untidiness and
possible suffering for other
persons and animals

Adapted from Jastrzebowski W: An outline of ergonomics, or the science of work based upon the truths drawn from
the science of nature, Warsaw, 1997, Central Institute for Labor Protection (translated by T Baluk-Ulewiczowa).

individuals who were injured or ill, whereas and Ergonomics, the journal of the Ergonomics
Jastrzebowski primarily applied his theories to Research Society, began publication. The Interna-
able-bodied persons, with the ultimate objective tional Ergonomics Association was formed in 1959
of bettering humankind. to join ergonomics societies from several coun-
Ergonomics as a specialty made gains as tries. Since that time, the field of ergonomics has
technologic developments emerged during the had tremendous growth, and many areas of
industrial revolution. Time and motion studies, specialization have been developed. The interface
considered predecessors of our present day ergo- between humans and computers has given rise
nomic discipline, focused on evaluation of work to new specializations in ergonomics, and the
methods, workstation design, and equipment incident at Three Mile Island accelerated the study
design. They were conducted by numerous inves- of the role of ergonomics in the nuclear power
tigators, including the Gilbreths, Taylor, Muen- industry. In addition, more attention to product
sterberg, and Binet.17 liability has increased the number of ergonomics
The field of ergonomics received particular experts needed in forensics to address design defi-
attention during World War II, when the complex- ciencies, instructions, and warning labels.66 Other
ity of military equipment frequently surpassed the areas that are experiencing considerable growth
abilities of human operators18: “Man had become in awareness of ergonomic issues involve design-
the weak link.”19 As during World War I, the ing for special populations including children
primary focus was selection and training of per- (Figure 1-1),14,50 older adults,56 and persons with
sonnel; however, even with extensive training, disabilities.45
personnel could not always perform as needed.66 Ergonomics developed from the common inter-
Because selection and training were not providing ests of a number of professions, particularly engi-
an acceptable solution, the focus changed to fitting neering, psychology, and medicine. It has remained
the task or equipment to the person by using a multidisciplinary field of study. Ergonomists
human dimensions, capabilities, and limitations include professionals with degrees in psychology,
as factors in the design process. engineering, ergonomics, industrial design, educa-
After World War II, the Ergonomics Research tion, physiology, medicine, health and rehabilita-
Society (the current Ergonomics Society) was tion sciences, business administration, computer
founded in England, and the first ergonomics text, science, and industrial hygiene. However, as the
Applied Experimental Psychology: Human Factors discipline evolved, specific areas of knowledge
in Engineering Design by Chapanis, Garner, and and practice have been identified, giving rise to
Morgan, was published.16 In 1957, the Human bachelor’s, master’s, and doctoral degree pro-
Factors Society was formed in the United States, grams, specifically in ergonomics or human
6 PART I Overview and Conceptual Framework

FIGURE 1-1 Ergonomic design for children is challenging. Designs must meet the current physical and cognitive
development of the users while simultaneously challenging users to attempt activities at a slightly higher
level. Designs must also be appropriate for a relatively wide age range, such as these activities shown at the
children’s museum in Chattanooga, Tennessee.

factors. The Human Factors and Ergonomics are relevant to design. Human factors engineering
Society ( offers an accreditation (ergonomics implementation) is the application of
process for these programs. Individual certifica- human factors information to the design of tools,
tion is also offered through the Board of Certifica- machines, systems, tasks, jobs, and environments
tion in Professional Ergonomics (P.O. Box 2811, for safe, comfortable, and effective human use.”15
Bellingham, WA 98227-2811; (see According to the International Ergonomics Associ-
Chapter 19). ation (, ergonomics (or human
factors) is the scientific discipline concerned with
the understanding of interactions among humans
ERGONOMICS DEFINED and other elements of a system, and the profession
Ergonomics (Greek ergon [work] + nomos [law]) that applies theory, principles, data, and other
focuses on the study of work performance with an methods to design in order to optimize human
emphasis on worker safety and productivity. well-being and overall system performance. Ergon-
Although several definitions have been proposed, omists contribute to the design and evaluation of
one of the best was provided by Chapanis, who tasks, jobs, products, environments, and systems
used the terms ergonomics and human factors in order to make them compatible with the needs,
interchangeably: “Human factors (ergonomics) is abilities, and limitations of people.
a body of knowledge about human abilities, human Considerable debate on the definitions of ergo-
limitations, and other human characteristics that nomics and human factors has persisted. The con-
Chapter 1 Ergonomics and Therapy: An Introduction 7

troversy has been especially fervent regarding the behavior, background) characteristics of humans.
differentiation of the terms. Proponents of differ- Accordingly, ergonomics is not solely confined to
entiation argue that the term human factors was the workplace. Products and environments should
first used in psychology and refers primarily to the match the abilities, needs, and perceptions of the
interface of humans with technology, whereas people who use them. In self-care, ergonomically
ergonomics originated in human physiology and designed toothbrushes and spigots are found.
biomechanics and therefore refers primarily to These spigots conform to users’ expectations
physically demanding work.21 The differentiation (e.g., water should emerge when the spigot is
is capricious at best, and both the classic and turned counterclockwise, and cold water should
newer human factors and ergonomics texts encour- be controlled by the spigot on the user’s right).
age use of the two terms interchangeably.* In Bicycles and snow skis are designed with riders
their introduction, Sanders and McCormick state and skiers of differing abilities in mind and are
that “some people have tried to distinguish designed differently for men and women. Numer-
between the two, but we believe that any distinc- ous examples of proper and improper designs can
tions are arbitrary and that, for all practical pur- be found throughout homes and offices. The
poses, the terms are synonymous.”66 concept of making the devices and systems “user-
In this chapter, as well as throughout this book, friendly” extends beyond the workplace.60
the two terms are used interchangeably. It is true To attain the goal of designing user-friendly
that originally ergonomics was not as widely used devices and systems, ergonomists conduct scien-
in the United States and Canada as in other parts tific investigations to identify the limitations,
of the world. In the United States, the terms capabilities, and responses of humans in a variety
human factors engineering, human engineering, of climates and circumstances. This information
engineering psychology, and human factors have is used to produce designs that match human
all been used, although the current term of choice characteristics. Part II of this book, Knowledge,
is human factors. As noted by Chapanis, “whether Tools, and Techniques, provides some necessary
we call ourselves human factors engineers or basic information, as well as examples of how
ergonomists is mostly an accident of where we physical and cognitive information can be applied
happen to live and where we were trained.”15 in the workplace.
Ergonomics is the more recognized term among Part III, Special Considerations, demonstrates
the general public, even in the United States. how human characteristics are applied to specific
Part I of this text establishes the context in situations. Ergonomists evaluate equipment, jobs,
which a therapist chooses to specialize in dealing work methods, and environments to ensure they
with work-related issues such as occupational meet their intended objectives. This section is
health and ergonomics. It includes both a client- more specific, using a microergonomic approach.
centered approach, as well as a broader macroer- Ergonomics can be considered a design phi-
gonomic perspective. losophy that focuses on supplying a product that
Ergonomics focuses on humans and their inter- ensures safety, ease of use, comfort, and effi-
actions with the environment. It involves interac- ciency. However, many distinguished human
tions with tools, equipment, consumer products, factors practitioners and ergonomists contend that
work methods, jobs, instruction books, facilities, ergonomics is a unitary, scholarly discipline with
and organizations. Kantowitz and Sorkin noted unique characteristics, just as OT and PT are
that “the first commandment of human factors is unique disciplines.52-54
‘Honor Thy User’.”36 Ergonomists design environ-
ments and products according to the physical
(visual, auditory, tactile, strength, anthropomet- WHY USE ERGONOMICS?
ric), cognitive (learning, information processing, For the lay person, ergonomics is most noted
retention), and psychosocial (cultural influences, when absent. This is because the focus is to opti-
mize the relationship between the environment
*References 21, 26, 32, 38, 46, 54, 72. and the person.12,36 When an appropriate ergo-
8 PART I Overview and Conceptual Framework

nomic design is in use, the user should be unaware • Costs and revenues to see where they might
of environmental design deficiencies and should have the most impact on a redesign effort
be able to concentrate on the task at hand. For • Information flow throughout the facilities,
example, in a well-designed office workstation, a including client care, team interactions, and
worker should not have to hold his or her neck data management
in an awkward posture to use a visual display Any of these initial approaches would be within
terminal and should not experience neck and the purview of ergonomics as they seek to design
shoulder discomfort. According to Osborne, good products and places to improve efficiency, effec-
ergonomic design in the workplace offers a means tiveness, and safety. However, it is doubtful that
to “victory over the oppressive forces that con- most therapists would be comfortable handling
tinue to make work less productive, less pleasant, any of these approaches based solely on their
less comfortable, and less safe.”58 entry-level education. With advanced education
In the past, industry focused on product in the area of work, perhaps they would be most
outcome, and the needs of workers took second comfortable handling the second approach, espe-
place. Humanistic and economic concerns and cially if the target subset of injuries involved
litigation, however, have convinced industry that musculoskeletal overuse injuries.
consideration of the worker is good business. The
use of sound ergonomic principles has generated THE INTERRELATIONSHIP BETWEEN
many examples of increased worker productivity THERAPISTS AND ERGONOMISTS
and safety. One older example demonstrated that
The interrelationship between rehabilitation and
less training is required if workers’ abilities are
ergonomics has received a great deal of atten-
considered in the design of equipment. In this
tion.2-4,63,64 More recent efforts by ergonomists are
example, the detection efficiency of machine parts
focusing on design issues.47,48 In fact, ergonomic
inspectors was evaluated after either a 4-hour
practice within the field of health care is burgeon-
training program or the use of a set of visual aids
ing, with research being conducted in areas as
and displays that assisted with the detection of
varied as teamwork,6,51 client safety,9,70 informa-
defects. A 32% increase in detected defects was
tion transfer,27 cognitive strategies used by clini-
found with the training, a 42% increase was found
cians,8 and the design of equipment,35 client care
with the use of appropriate visual aids, and a 71%
areas,23 and protocol workflow.1
increase was found when training and visual aids
Therapists and ergonomists share some com-
were combined.13 Although training was useful, a
mon interests, and therapists can contribute their
properly designed environment was needed for
unique strengths to the practice of ergonomics in
superior results.
five principal areas: ergonomics-for-one (individu-
In terms of the case study mentioned at the
als who have a disability); ergonomics for special
beginning of the chapter, asking to have ergo-
populations; prevention of musculoskeletal inju-
nomic consultation for all of their facilities and
ries; equipment design; and the application of the
services is a huge endeavor! Ergonomists could
ADA.64 These five areas can be simplified into
start by evaluating the following:
three major practice application arenas, in addi-
• Safety practices, procedures, and records,
tion to integrating ergonomic principles into thera-
including deaths, injuries, and near-miss
peutic clinical practice: (1) workplace analysis
occurrences in terms of patient safety
aimed at prevention of work-related musculoskel-
• Injuries, illnesses, turnover, and workers’
etal trauma; (2) workplace and tool design
compensation cases among the employees
for individuals with disabilities; and (3) research
• The health care practitioners’ perceptions
through the development and use of databases.
regarding the products they use and environ-
ments they work in to determine if the Work-Site Analysis
designs are as complementary to their work Therapists should be familiar with the field of
as they should be ergonomics as a whole to understand terminology
Chapter 1 Ergonomics and Therapy: An Introduction 9

being used, know how to best describe their own edge of anatomy and physiology, neuroanatomy
expertise, and recognize when an ergonomist with and neurophysiology, kinesiology, and the mecha-
specialized training should be consulted.61,68 A nism and treatment of injuries makes therapists
review of introductory ergonomics texts (as well excellent allies for ergonomists. Knowledge of
as university accreditation requirements for OTs, ergonomics allows therapists to apply their
PTs, and ergonomics) produced the following expertise by specializing in the field of work-
observations about the knowledge base of thera- related musculoskeletal ergonomics and injury
pists compared with that of ergonomists.* prevention.
Some areas of ergonomics with which thera- The application of ergonomics for therapists
pists are familiar are sensory nervous system primarily implies workplace consultation directed
considerations, anthropometry, kinesiology, hu- at preventing musculoskeletal injuries. Therefore,
man development, anatomy and physiology, work in the case study presented at the beginning of the
capability analysis, and basic research. Areas chapter, therapists’ goals would be to promote
familiar to occupational therapists (less so to safety and to decrease the financial costs associ-
physical therapists, based on their required train- ated with lost work time, medical treatment, and
ing) include communication, learning, motiva- retraining of hospital employees. Consultative ser-
tion, normal and abnormal psychology (including vices could be combined with direct services
the effects of stress), job and task analysis, and (client treatment) or offered alone. When provid-
measures of job satisfaction. Workplace design, ing consultative services in addition to direct ser-
seating and posture, and safety may or may not vices, therapists could offer functional capacity
be included in the knowledge of entry-level thera- testing, work hardening, and graded return-to-
pists. Topics in ergonomics with which entry-level work placements along with workplace evalua-
therapists may be unfamiliar include person- tions. They could also conduct ergonomics
machine communication (displays and controls), workplace evaluations specifically to identify situ-
workstation design, vibration, noise, temperature, ations that might contribute to musculoskeletal
illumination, training, inspection and mainte- injuries such as task analysis, videotaping, mea-
nance, error and reliability, signal detection surement and analysis of equipment and worksta-
theory, visual displays, legal aspects of product tions, and workspace analysis (see Lopez49 and
liability, physics as applied to machinery as well Sanders65 for technique suggestions in addition to
as human motion, and advanced statistical this text). The consultations may be primarily
research methods. Although therapists may con- based on physical considerations or may involve
sider themselves educated in safety, they may be psychosocial factors.10,42 The last part of this book
unfamiliar with safety as it is taught in ergonomics addresses the ergonomics intervention process
curricula. In these classes, safety includes acci- from the beginning (program development and
dent losses; the Occupational Safety and Health marketing) through problem identification, analy-
Act; standards, codes, and safety documents; sis, and implementation to the final product (eval-
designing, planning, and production errors; ha- uation and report of results).
zards; acceleration, falls, and other impacts;
pressure and electrical hazards; explosions and Design for Individuals with Disabilities
explosives; toxic materials; radiation; vibration More than 51 million Americans have a physical
and noise; slip, trip, and fall (traction and physical or mental disability, and 32.5 million have a
materials, as well as biomechanics and physiol- severe disability.69 This means that between
ogy); and methods of safety analysis.22,31 11.5% and 18.1% of the total population in the
Therapists are well educated in the procedures United States has a disability. Individuals who
of problem identification, interviewing, observa- have a disability are less likely to finish high
tion, and record review. Their considerable knowl- school or to attend college and are more likely to
live in poverty.69 Many of these individuals either
*References 25, 36, 38, 46, 66, 68. do not work or have difficulty finding a job (Figure
10 PART I Overview and Conceptual Framework

60 concept application in health care and rehabilita-

tion, financial expense, lack of public support for
50 funding, and insufficient databases on which to
base designs for special populations. Although the
40 enactment of the ADA in 1990 encouraged both
% of people

public and private entities to consider individuals

30 with disabilities in the initial designs of work-
places, accommodations, transportation systems,
20 and communication services, the achievements
have not been as great as some hoped. Databases
10 are available on hardware and software for persons
with disabilities who use computers,11 and the
No disability Not severe Severe
increase in the geriatric population has increased
spending and research on the needs of older
Disability status Americans. By designing specifically for the older
Full time Part time Unemployed population, their independence and ability to be
active and engaged in life improves. Many even
FIGURE 1-2 Percentage of individuals 21 to 64 years learn advanced technologies.57,67
of age employed year round in the previous 12 Few data exist, however, on the anthropomet-
months by disability status in 2002. (Data from U.S. ric characteristics, capabilities, and limitations of
Census Bureau, Survey of Income and Program Participa- individuals with disabilities and elderly popula-
tion, June-Sept 2002.) tions in varying climates and conditions. The
argument that has prevented the collection of
1-2). Ergonomic intervention could do much to such information is that the capabilities and limi-
enhance quality of life, at work and home, for tations differ with each disease process and each
these people. person. This argument contends that all of the
Cannon, an ergonomics consultant in Colorado individual differences that exist within an able-
who has designed equipment for persons with bodied population also exist within a population
visual impairments, stated, “No segment of the of persons with disabilities; however, the differ-
population suffers more from neglect of human ences are compounded because of the additional
factors requirements in product design than the contrasts in residual capabilities of individuals
severely handicapped.”26 Unfortunately, that state- with disabilities. Until the abilities and restrictions
ment remains true 20 years later. Opportunities of individuals with disabilities and elderly popula-
abound within the areas of overlap between ergo- tions are identified, however, suitable products
nomics and health care. For example, modifica- for their use will not be developed on a consistent
tions and design features of buildings, vehicles, basis. As noted, the expansion of the older popu-
and appliances could improve independent living lation has resulted in an increased interest and
prospects for those with physical, cognitive, and generation of research in geriatrics.45,67 A com-
emotional disabilities. In the hospital case study mensurate increase in research for individuals
running throughout this chapter, therapists might with disabilities has not occurred, however. The
also contribute by evaluating hiring and place- resistance, location, and shape of hand and foot
ment practices with special consideration for those controls; workplace design for people who must
who have disabilities and how the company is sit; and seat pan depth and width requirements
meeting ADA compliance. Yet much remains to differ for people with disabilities and vary accord-
be done. ing to the disabling condition. Therapists have the
Many factors contribute to the lapse of infor- skills and are in the settings to gather information
mation: seeming unavailability of appropriate for a database on various populations with dis-
resources, lack of data, scarcity of ergonomic abilities. Cases of good research exist, however,
Chapter 1 Ergonomics and Therapy: An Introduction 11

and one notable exception to the paucity of infor-

mation is the research conducted by Das20 on
paraplegic workers. Das has carefully researched
anthropometric information used in design guide-
lines for paraplegics, annotated measurements of
his own, and developed isometric strength profiles
for male and female paraplegics.20,43,44 Another
noteworthy epidemiologic research project identi-
fied injuries of wheelchair users and design and
selection criteria to assist in injury prevention.24
Technologic aids for individuals with disabili-
ties are expensive because small-scale production
is not cost-effective. Although this situation may
continue for high-level technologic equipment,
the concept that assistive equipment designed for
individuals with disabilities could also be attrac-
tive and useful for the able-bodied population
could be further examined.71 This would entail
greater attention to universal design—that is,
FIGURE 1-3 Curb cuts are an example of universal
design that is useful for all persons, regardless of
design. Although they help those in wheelchairs or
age or functional capability. For example, use of using walkers, they also benefit children, elderly,
large numerals on telephones; large, well-marked and those pushing grocery carts.
keys on television remote controls; and door
levers rather than knobs may be equally desirable
for people with and without disabilities. Curb cuts
outside supermarkets are a fairly simple example the user. Such products can increase user accep-
of universal design; they make entering and tance, decrease errors, increase productivity, and
exiting easier for shoppers pushing grocery carts, improve quality of life (see Chapter 10).
elderly persons with mobility difficulties, small Therapists can provide ergonomists and design
children, and wheelchair users (Figure 1-3). engineers with valuable information on the func-
Another excellent resource is the TRACE Center, tional capabilities and limitations of, environmen-
which focuses on universal design and accessibil- tal effects on, and overall prognosis of individual
ity of advanced technologies (information is avail- clients and diagnostic groups. The information is
able at essential to development of products for those
The development and design of products and with disabilities, as well as for identifying needed
places for individuals with disabilities include a accommodations for workers with disabilities.
need for developmental and operational testing of These issues are particularly important in accor-
those products during the prototyping and final dance with the ADA39-41 and as our population
design processes. Although therapists and medical ages.45
practitioners may not typically be involved in Ergonomics applies equally to the interaction
product development and user testing, this is of humans and the tools and environments in-
another area ripe for collaboration between ergon- volved in pursuits other than work. Both thera-
omists and therapists. Medical and rehabilitation pists and ergonomists consult about human
equipment must be designed with the users performance with regard to recreation, transporta-
(medical practitioners, clients, and clients’ family tion, the hospitality industry, city planning, and
members and caregivers) in mind. Thus, iterative the layout and design of home construction. Typi-
testing, including usability testing, is essential to cally therapists consult regarding those with dis-
achieve an ergonomic product—one that truly fits abilities, ergonomists consult regarding the healthy
12 PART I Overview and Conceptual Framework

population, and both consult regarding musculo-

Learning Exercises
skeletal injury prevention.
Research Interests These learning exercises are designed to help you
use recently acquired information within a pro-
Therapists and ergonomists often need the same
fessional therapeutic context.
information on human performance. Therapists
can and do use ergonomics data in clinical treat- Purpose
ment and prevention programs. For example,
These exercises will guide you to an understand-
when treating hospitalized clients, a therapist ing of the interactions between professionals to
should be aware of the effects of diurnal variation solve ergonomic challenges in a work setting, as
on muscle strength during muscle strength testing. well as encouraging them to think in terms of
Therapists should also be aware of the effects of research and design.
sleep deprivation on cognition, perceptual-motor
performance, and learning. Much of this informa- Exercises
tion is found in ergonomics research among the 1. Have colleagues role-play as an employer,
populations without disabilities. corporate safety officer, and a facilities or
Therapists use ergonomic data from both able- plant floor manager experiencing concerns
bodied persons and individuals with disabilities about injuries and ergonomics in a
during the evaluation of, goal-setting with, and workplace. Have others role-play healthcare
treatment of clients. It is easy to envision thera- and ergonomic team members to include
pists, perhaps primarily those serving in academia, several professionals (minimum: an OT, PT,
contributing to the body of knowledge in areas and an ergonomist). Role play their initial
such as human performance, neurosensory func- meeting to discover what the healthcare and
tion, and strength testing, especially as they re- ergonomic team may have to offer.
flect the functionality of those with disabling a. Have the employer and the healthcare
conditions. and ergonomic teams work together to
Certainly, national research goals could be define pertinent issues and areas that
need further exploration.
established that would cover the common areas
b. For each issue or area of further
between ergonomics and health care and rehabili-
exploration, identify what each healthcare
tation. Some of these goals might include anthro-
and ergonomic team member’s role will
pometric and strength (capabilities and limitations) be, according to their professional
databases to assist with design for special po- expertise. Identify any additional
pulations, technology use by and design for spe- professionals who might assist the team
cial populations, epidemiologic investigations of effort.
injuries and illnesses common to people with dis- c. Write a sequential plan of action, including
abilities with suggestions for prevention, and com- when reports on progress and findings will
pilations of ergonomics-for-one success stories.64 be given to the employer team.
d. Identify questions associated with each
issue that might benefit from additional
CONCLUSION research.
2. Pick an environment, an associated job or
Common interests and areas of practice can allow task, and an injury or disability (you could
ergonomists and therapists to blend their knowl- even write several on slips of paper and
edge to benefit both populations of individuals draw them from a hat). Conduct a mental
with and without disabilities. Three broad prac- “walk-through” of a person with the injury
tice areas of common interest are workplace eval- or disability in that environment. Identify
uation for the prevention of musculoskeletal functional issues that could arise, along with
injuries; environment, workspace, and product some potential design solutions.
design; and research.
Chapter 1 Ergonomics and Therapy: An Introduction 13

Ergonomics, in its broadest sense, is the design E. Actively engaging a person in

of products, environments, and processes to make carefully guided physical and
the world user-friendly for humans by creating mental activities enhances the
items and places that enhance productivity, are chances for a more successful return
pleasant to use and view, and do not injure the to work.
user. Although a more specific definition of ergo-
nomics has been identified, it is equally important 2. Ergonomics began as a multidisciplinary
to recognize what ergonomics is not. Ergonomics field and developed from the common
is not simply “(1) applying checklists and guide- interests of a number of professions,
lines, (2) using oneself (or non-target populations) particularly which of the following? (More
as the model(s) for designing objects, or (3) than one may be selected.)
common sense.”66 A “cookbook” approach to A. Engineering, sociology, and health
ergonomics (checklists) is an embarrassment to care
the therapist or ergonomist who uses it and is B. Physical aspects of therapy, industrial
inherently dangerous. Ergonomics also applies to psychology, and occupational
much more than the prevention of work-related medicine
musculoskeletal disorders, although it is in this C. Engineering, psychology, and
realm that therapists are most adept. medicine
Ergonomics can be a satisfying area of special- D. Anatomy, disability, and work
ization for therapists. It provides therapists with methods (such as those introduced by
a growth area of specialization in injury preven- the Gilbreths)
tion. It also is an area that presents considerable
challenge for designing better equipment and 3. The first commandment of human factors
environments for the clients that therapists serve. is “Honor thy user.”
Clients, and all persons, deserve to be considered A. True
in the design of their equipment and environ- B. False
ments. Therapists have the skills, knowledge, and
abilities to contribute to the field of ergonomics, 4. The primary focus of occupational and
and this book provides information and tools to physical therapy is to improve the
enhance that process. physical and cognitive function of the
individual person who has suffered an
Multiple Choice Review Questions injury or disability.
A. True
1. Which of the following is (are) not true B. False
regarding the occupational therapy
profession? (More than one may be 5. The primary focus of ergonomics is
selected.) design.
A. Rehabilitation should improve physical A. True
and mental functioning. B. False
B. Rehabilitation should assist with
returning an individual to a functional 6. Which term has not historically been used
status in society. interchangeably with ergonomics? (More
C. Each job a person returns to should be than one may be selected.)
replicated in a therapeutic setting in A. Occupational medicine
order to ensure the person can return B. Human factors engineering
to his or her job. C. Human engineering
D. Transfer of training occurs easily; D. Engineering psychology
therefore work skills in a craft will E. Industrial and organizational
transfer to a work environment. psychology
14 PART I Overview and Conceptual Framework

7. What percentage of the U.S. population can have on his or her functionality,
has a disability? such as family dynamics, personal
A. Between 5% and 10% motivation, and the assumption of
B. Between 11% and 18% the “worker role”
C. Between 19% and 30%
D. No one really knows, as the research 10. Universal design is the design of
has not been done. equipment and products for use by
individuals with disabling conditions.
8. Which of the following statements A. True
regarding individuals with disabilities is B. False
not true? (More than one may be
A. Those with disabilities have more
difficulty locating a job. REFERENCES
B. Those with disabilities have the same 1. Alper SJ, Karsh B, Holden RJ et al: Protocol viola-
likelihood of finding a job but are less tions during medication administration in pediat-
likely to keep a job throughout their rics. In Proceedings of the Human Factors and
Ergonomics Society 50th Annual Meeting, San Fran-
cisco, Calif, 2006, Human Factors and Ergonomics
C. Those with disabilities are as likely to Society.
finish high school as those who do not 2. Bogner MS: Human error in medicine: a frontier for
have a disability. change, Hillsdale, NJ, 1994, Lawrence Erlbaum.
D. Those with disabilities are less likely 3. Bogner MS: Medical human factors. In Proceedings
to attend college. of the Human Factors and Ergonomics Society 40th
E. Those with disabilities are more likely Annual Meeting, Santa Monica, Calif, 1996, Human
Factors and Ergonomics Society.
to live in poverty. 4. Bogner MS: Special section preface, Hum Factors
38:551, 1996.
9. Some unique contributions of therapists 5. Bowman M: Report of the round table on crafts for
to ergonomic teams include which of the the physically disabled, Arch Occup Ther 2:467,
following (unique meaning that 1928.
ergonomists would not also have this 6. Brown J, Dominguez C, Stahl G: Multidisciplinary
perspectives on collaborative care. In Proceedings of
knowledge from their basic professional
the Human Factors and Ergonomics Society 50th
education)? (More than one may be Annual Meeting, San Francisco, Calif, 2006, Human
selected.) Factors and Ergonomics Society.
A. Knowledge of disability and disease 7. Brush F: Occupational therapy for men in the con-
processes valescent period, Arch Occup Ther 2:87, 1923.
B. Knowledge of design 8. Burns C, Momtahan K, Enomoto Y: Supporting the
C. Knowledge of work processes, such as strategies of cardiac nurse coordinators using cogni-
tive work analysis. In Proceedings of the Human
work and communication flow
Factors and Ergonomics Society 50th Annual
D. Knowledge of task analysis, such as Meeting, San Francisco, Calif, 2006, Human Factors
the breakdown of tasks into their and Ergonomics Society.
smallest component parts (sometimes 9. Carayon P: Handbook of human factors and ergo-
known as “therbligs”) nomics in health care and patient safety, Hillsdale,
E. An understanding of the “big NJ, 2006, Lawrence Erlbaum.
picture” of one’s work life, such as 10. Carayon P, Haims MC: Balanced work system and
participation: applications in the community, Artif
corporate culture and systems Intell Soc 17(2), 2003.
interactions 11. Casali SP, Williges RC: Data bases of accommoda-
F. An understanding of all the aspects tive aids for computer users with disabilities, Hum
of an individual and the impact they Factors 32:407, 1990.
Chapter 1 Ergonomics and Therapy: An Introduction 15

12. Casey S: The atomic chef, Santa Barbara, California, 29. Haas LJ: An adjustable stool chair, Arch Occup Ther
2006, Aegean. 8:367, 1930.
13. Chaney FB, Teel KS: Improving inspector perfor- 30. Haas LJ: Weaving frame for bedside occupational
mance through training and visual aids, J Appl therapy, Arch Occup Ther 4:135, 1925.
Psychol 51:311, 1967. 31. Hammer W, Price D: Occupational safety manage-
14. Chang HY, Jacobs K, Orsmond G: Gender-age envi- ment and engineering, Englewood Cliffs, NJ, 2000,
ronmental associates of middle school students’ low Prentice-Hall.
back pain, Work 26(1):19, 2006. 32. Helander M: A guide to human factors and ergonom-
15. Chapanis A: To communicate the human factors ics, ed 2, New York, 2005, Taylor and Francis.
message, you have to know what the message is 33. Hopkins HL: Current basis for theory and philoso-
and how to communicate it, Hum Factors Soc Bull phy of occupational therapy. In Willard HS, Spack-
34:1, 1991. man CS, editors: Occupational theory, Philadelphia,
16. Chapanis A, Garner WR, Morgan CT: Appl Exp 1978, Lippincott.
Psychol, New York, 1949, Wiley. 34. Jastrzebowski W: An outline of ergonomics, or the
17. Christensen JM: The human factors profession. In science of work based upon the truths drawn from
Salvendy G, editor: Handbook of human factors, the science of nature, Warsaw, 1997, Central In-
New York, 1987, Wiley. stitute for Labor Protection [translated by T
18. Damon A, Randall FE: Physical anthropology in the Baluk-Ulewiczowa].
Army Air Forces, Am J Phys Anthropol 2:293, 35. Jessa M, Cafazzo J, Chagpar A et al: Human factors
1944. evaluation of automatic external defibrillators in a
19. Damon A, Stoudt HW, McFarland RA: The human hospital setting. In Proceedings of the Human Factors
body in equipment design, Cambridge, Mass, 1966, and Ergonomics Society 50th Annual Meeting, San
Harvard University Press. Francisco, Calif, 2006, Human Factors and Ergo-
20. Das B: Physical disability case study: an ergonomics nomics Society.
approach to workstation design for paraplegics. In 36. Kantowitz BH, Sorkin RD: Human factors: under-
Rice VJB, editor: Ergonomics in health care and reha- standing people-system relationships, New York,
bilitation, Boston, 1998, Butterworth-Heinemann. 1983, Wiley.
21. Fraser TM: The worker at work: a textbook con- 37. Key GL: Work capacity analysis. In Scully RM,
cerned with men and women in the workplace, New Barnes MR, editors: Physical therapy, New York,
York, 1989, Taylor and Francis. 1989, Lippincott.
22. Friend MA, Kohn JP: Fundamentals of occupational 38. Konz S, Johnson S: Work design: occupational
safety and health, 2006, Lunham, Md, Government ergonomics, Scottsdale, Ariz, 2004, Holcomb
Institutes. Hathaway.
23. Funk KH, Doolen T, Nicolalde J, et al: A methodol- 39. Kornblau BL: Americans with Disabilities Act and
ogy to identify systemic vulnerabilities to human related laws that promote participation in work,
error in the operating room. In Proceedings of the leisure, and activities of daily living. In Pendleton
Human Factors and Ergonomics Society 50th Annual J, Schultz-Krohn W, editors: Pedretti’s occupational
Meeting, San Francisco, Calif, 2006, Human Factors therapy: practice skills for physical dysfunction, ed
and Ergonomics Society. 6, St Louis, 2006, Mosby.
24. Gaal RP, Rebholtz N, Hotchkiss RD, et al: Wheel- 40. Kornblau BL, Hines M: Advocating for clients
chair rider injuries: causes and consequences for and legal issues. In Bachner S, Ross M, editors:
wheelchair design and selection, J Rehabil Res Dev Adults with developmental disabilities, ed 2,
34(1):58, 1997. Bethesda, Md, 2004, American Occupational
25. Gamache G: Essentials in human factors, 2004, Therapy Association.
Bloomington, Ind, Authorhouse. 41. Kornblau BL, Shamberg S, Klein R: Occupational
26. Gay K: Ergonomics: making products and places fit therapy and the Americans with Disabilities Act.
people, Hillside, NJ, 1986, Enslow. Official position paper of the American Occupa-
27. Gurses A, Xiao Y, Gorman P et al: A distributed tional Therapy Association, replacing the 1993
cognition approach to understanding information position paper, Bethesda, Md, 2000, American
transfer in mission critical domains. In Proceedings Occupational Therapy Association.
of the Human Factors and Ergonomics Society 50th 42. Korunka C, Scharitzer D, Sainfort F et al: Em-
Annual Meeting, San Francisco, Calif, 2006, Human ployee strain and job satisfaction related to an
Factors and Ergonomics Society. implementation of quality in a public service orga-
28. Haas LJ: A folding conveying chair, Arch Occup nization: a longitudinal study, Work Stress 17(1):52,
Ther 7:21, 1928. 2003.
16 PART I Overview and Conceptual Framework

43. Kozey J, Das B: An evaluation of existing anthropo- 57. Murata A, Hrokazu I: Usability of touch-panel inter-
metric measurements of wheelchair mobile indi- faces for older adults, Hum Factors 47(4):767,
viduals. In Proceedings of the Annual Human Factors 2005.
Association of Canada Meeting, Hamilton, Ontario, 58. Osborne DJ: Ergonomics at work, New York, 1982,
1992, Human Factors Association of Canada. Wiley.
44. Kozey JW, Das B: Determination of the normal and 59. Pinkston D: Evolution of the practice of physical
maximum reach measures of adult wheelchair therapy in the United States. In Scully RM, Barnes
users, Int J Ind Ergon 33(3):205, 2004. MR, editors: Physical therapy, New York, 1989,
45. Kroemer KHE: “Extra-ordinary” ergonomics: how to Lippincott.
accommodate small and big persons, the disabled 60. Pruitt J, Adlin T: The persona lifecycle: keeping
and elderly, expectant mothers, and children, Santa people in mind throughout product design, Boston,
Monica, Calif, 2005, HFES. 2006, Elsevier.
46. Kroemer K, Kroemer H, Kroemer-Elbert K: Ergo- 61. Rader Smith E: Evolution of health care and reha-
nomics: how to design for ease and efficiency, bilitation ergonomics. In Rice VJB, editor: Ergonom-
Englewood Cliffs, NJ, 2000, Prentice-Hall. ics in health care and rehabilitation, Boston, 1998,
47. Lin J, Drury CG, Paquet V: A quantitative methodol- Butterworth-Heinemann.
ogy for assessment of wheelchair controllability. In 62. Report of the Committee on Installations and
Proceedings of the Human Factors and Ergonomics Advice: Analysis of crafts, Arch Occup Ther 6:417,
Society 50th Annual Meeting, San Francisco, Calif, 1928.
2006, Human Factors and Ergonomics Society. 63. Rice VJB: Defining common ground: human factors
48. Loewenhardt RAK: Analysis of bread bag closures engineering and rehabilitation, Rehabil Manage
for individuals with rheumatoid arthritis. In Pro- 5:30, 1992.
ceedings of the Human Factors and Ergonomics 64. Rice VJB: Ergonomics in health care and rehabilita-
Society 50th Annual Meeting, San Francisco, Calif, tion, Boston, 1998, Butterworth-Heinemann.
2006, Human Factors and Ergonomics Society. 65. Sanders MJ: Management of cumulative trauma
49. Lopez MS: Musculoskeletal ergonomics: an intro- disorders, Boston, 1997, Butterworth-Heineman.
duction. In Rice VJB, editor: Ergonomics in health 66. Sanders MS, McCormick EJ: Human factors in
care and rehabilitation, Boston, 1998, Butterworth- engineering and design, New York, 1987,
Heinemann. McGraw-Hill.
50. Lueder R, Rice V: Ergonomics for children: designing 67. Sharit J, Rogers W, Charness N et al: Designing for
products and places for toddlers to teens, New York, older adults: principles and creative human factors
Taylor and Francis. In press. approaches, New York, 2004, Taylor and Francis.
51. McHugh A, Crandall B, Miller T: Barriers and facili- 68. Stanton N, Hedge A, Brookhuis K et al: Handbook
tators of common ground in critical care teams. In of human factors and ergonomics methods, Boca
Proceedings of the Human Factors and Ergonomics Raton, 2004, CRC Press.
Society 50th Annual Meeting, San Francisco, Calif, 69. Steinmetz E: Current population reports. In Ameri-
2006, Human Factors and Ergonomics Society. cans with Disabilities: 2002, Washington DC, 2006,
52. Meister D: Conceptual aspects of human factors, U.S. Department of Commerce, Economics and
Baltimore, 1989, Johns Hopkins University Press. Statistics Administration, U.S. Census Bureau.
53. Meister D: The practice of ergonomics: reflections on 70. Tartaglia R: Healthcare systems ergonomics and
a profession, Bellingham, Wash, 1997, Board of patient safety, Boca Raton, 2005, CRC Press.
Certification in Professional Ergonomics. 71. Wilkoff WL, Abed LW: Practicing universal design:
54. Meister D: Conceptual foundations of human fac- an interpretation of the ADA, New York, 1994, Van
tors measurement, Hillsdale, NJ, 2003, Lawrence Nostrand Reinhold.
Erlbaum. 72. Wilson JR, Corlett EN, editors: Evaluation of human
55. Meyer A: The philosophy of occupational therapy, work: a practical ergonomics methodology, New
Arch Occup Ther 1:1, 1921. York, 1990, Taylor and Francis.
56. Mouloua M, Hancock PA: Preface: the importance
of technological solutions to the asymmetric pattern
of global aging, Hum Factors 47(2):217, 2005.
A Client-Centered Framework
for Therapists in Ergonomics
Lynn Shaw, Susan Strong

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Understand why a client-centered approach is an integral part of therapists’ ergonomic practice.
2. Understand the theory and concepts of a client-centered approach.
3. Understand and apply client-centered practice concepts in return to work and occupational ergonomics to
address worker and organizational concerns.
4. Use tools that will help address barriers and support implementation of client-centered principles in practice
with a focus on the Person-Environment-Occupation model.

Client-centered ergonomic approach. This ap- Return to work. The collaborative processes among
proach emphasizes participation of the worker and the worker, employer and health professional involved
organization in return to work and occupational ergo- in establishing, implementing, progressing, and evalu-
nomic processes. It is characterized by the equitable ating a work reintegration plan for enabling a worker
involvement, partnership, and clearly understood with an injury to resume a preinjury job or start a new
responsibilities of all key stakeholders such as the one.
worker, the employer, the union or worker representa- Person-Environment-Occupation model. This mo-
tive, health and safety representatives, allied health del elaborates an understanding of occupational per-
professionals, ergonomists, engineers, and, where formance that is characterized by the complex
appropriate, vendors or manufacturers. interaction of factors and relationships among the
Occupational ergonomics. The strategies and pro- person, the environment, and the occupation. In ergo-
cesses that aim to prevent injury and to promote nomics, the person refers to the worker with the ergo-
optimal human performance and functioning at work nomic concern, the environment refers to the workplace,
through workplace systems design, equipment, and and the occupation refers to the work demands.
tool design.

18 PART I Overview and Conceptual Framework

F or therapists who work in ergonomics, the

need to engage the participation of workers
and workplaces in the ergonomic process is
and increasing accountability in rehabilitation
practice. This trend has encouraged therapists to
focus efforts on effectively achieving clients’ goals.
essential for improving health and productivity An underlying premise of client-centered practice
outcomes.26 However, therapists continue to expe- is that time and resources are effectively used by
rience many challenges that make it difficult to concentrating on the issues that are most impor-
integrate client-centered values and principles tant to the client (workers and organizations) and
into practice.* Historically, ergonomics has exam- by involving the client or clients throughout the
ined the person-machine interface through time process. Furthermore, the evidence suggests that
and motion studies and anthropometric, biome- worker involvement leads to positive outcomes.
chanical, and kinesiologic measurements. In these The client-centered approach and increased client
traditional ergonomic applications, ergonomists, participation are associated with better health out-
therapists, engineers, and kinesiologists provided comes,22,29,34,41 improved practice outcomes such
an expert approach to improving work demands. as adherence to goals,15,19,27 and increased client
The current client-centered practice emphasizes satisfaction.24 Involving clients also supports
participation of the worker and organizations in greater client control through ownership of respon-
the process of fitting work to the worker accord- sibilities and participation in care processes.37 All
ing to the conditions of a particular workplace. of these elements support quality management.
The ability of an individual to safely, efficiently, Organizations now recognize that happy and sat-
and consistently produce a high-quality product is isfied workers perform better.20,48 It follows that a
now viewed as a collection of complex relation- client-centered practice is consistent with good
ships among the worker, his or her occupation, business practices.
and his or her work environment. Therapists are Another factor supporting client-centered
beginning to examine ergonomic issues in terms approaches is the growing disconnect between
of these relationships.1,26 The concept of client in providers and employers in the health, return-to-
a client-centered ergonomic practice is broadened work, and rehabilitation systems in returning
to refer to the individual worker, but also work- workers with injuries to work.21 Loisel and col-
place groups such as unions or work units com- leagues26 recognize the need for greater colla-
posed of workers, and the organization such as boration in ergonomics through participatory
the employer or supervisors. This broader focus ergonomics not only to prevent injury reoccur-
on all of the clients involved in ergonomics builds rence, but also to reduce chronic disability arising
capacity in the workplace to achieve improved from unsafe and inadequate ergonomic practices.
health, safety, and productivity. For instance, Collaboration underscores the behavior of all
attending to worker needs helps enable individu- persons involved in a client-centered approach.
als to proactively manage and apply ergonomic Collaboration assists workers, health providers,
principles in the midst of performing job tasks. insurers, and workplace parties to focus their
Including workgroups or units in ergonomics efforts on shared goals for the client in the return-
encourages involvement of worker teams in gen- to-work process.
erating solutions to common problems. Engaging The other influencing factor for adopting a
organizations helps to foster a workplace culture client-centered approach is the growing endorse-
that supports the mobilization of resources and ment and legitimization of a client-centered
implementation of best practices in ergonomics. approach as a standard of practice through docu-
A number of factors have shaped this transition ments and texts (e.g., policies, acts, professional
toward involvement of workers in the ergonomic position papers). From the early 1980s to the
process and the needs of the workplace. One 1990s, a number of regulations, acts, accreditation
factor is the economic climate of restricted costs criteria, and guiding principles of care within pro-
fessional associations began to incorporate lan-
*References 8, 9, 31, 32, 39, 43, 44. guage in support of more client involvement in
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 19

care processes. There are many examples of docu- Ergonomic Tool Kit approach,3 the multidisci-
ments that, in principle, support the adoption of plinary approach,18 the Person-Process-Environ-
client-centered ideologies within health care. In ment model approach,45 and participatory ergo-
1992 the United States introduced amendments to nomics.26
the Rehabilitation Act to include persons with dis- Theoretically these approaches offer therapists
abilities in making choices and decisions in both a guide or conceptual framework for applying
rehabilitation and education. Canada followed ergonomic applications in workplaces or in client-
suit, albeit not at the regulatory level, but through therapist interactions. All of these approaches
a position paper in 1996 mandating inclusionary require information about human performance to
practices for the delivery of health and social ser- establish just the right interface with equipment,
vices for persons with disabilities. This document, tools, and work processes. However, the extent of
entitled In Unison,16 was a step toward participa- participation and involvement of key stakeholders
tory health practices in Canada. As early as the in the ergonomic process varies depending on the
1980s, guidelines for occupational therapy (OT) theoretic concepts that underpin the approach and
practice introduced the term client-centered.4-6 how the therapist applies these concepts in prac-
Rehabilitation professionals similarly adopted con- tice. For instance, occupational biomechanics7
sumer empowerment and involvement as central and the systems approach47 involve information
tenets of practice in United States35 and Canada.28 gathering and analysis that leads to including
Acceptance of consumers’ rights to self-determina- organizations in the design and change process to
tion by rehabilitation professionals28 also served to improve the worker-workplace interface, product
advance the adoption of participatory approaches design, and/or workplace productivity. The func-
in North America and Europe.10,12,25,46 tional approach,17 the Ergonomic Tool Kit ap-
Such supporting texts have helped to shape proach,3 the multidisciplinary approach,18 and
and legitimize the implementation of practice participatory ergonomics26 may involve the worker
models that are more inclusive of health care and other stakeholders in evaluation and/or
clients in the delivery of health and rehabilitation change processes to prevent injury or disability as
services. It follows then that service delivery well as supporting return to function and return
systems and professional values have evolved to to work. Incorporating a client-centered approach
be more client-focused, and that collaborative to ergonomics can provide therapists with a means
approaches are becoming central to ergonomic to achieve greater consistency for quality manage-
practice in workplaces. ment by including workers and organizations
throughout interactions, assessments, planning,
interventions, and monitoring. In addition, the
PARTICIPATION AND ERGONOMIC principles underlying a client-centered approach
APPROACHES can be used by therapists to foster the necessary
Many different theoretic approaches are used in positive working relationships needed to improve
ergonomics. The approaches presented are used workplace safety and performance with workers
by therapists within the context of therapeutic and employers.
practice (enabling return to safe work after injury)
or occupational ergonomics (preventing injury
and promoting optimal human performance and CLIENT-CENTERED PRACTICE
functioning at work through workplace systems IN ERGONOMICS
design, equipment, and tool design). Some have Routinely client-centered practice is a collabora-
roots in other ergonomic applications, and others tive alliance between client and therapist designed
draw on theories from other disciplines. The seven to use their combined skills, strengths, and re-
ergonomic approaches discussed in the following sources to work toward the client’s occupation-
sections are occupational biomechanics,7 the al performance goals. “Occupational therapists
functional approach,17 the systems approach,47 the demonstrate respect for clients, involve clients in
20 PART I Overview and Conceptual Framework

decision making, advocate with and for clients in A review of client-centered texts such as Client-
meeting clients’ needs, and otherwise recognize Centered Occupational Therapy24 and Client-
clients’ experience and knowledge” (p. 49).6 The Centered Practice in Occupational Therapy43 and
clients may be individuals, groups, agencies, gov- the current literature on involving clients in prac-
ernments, or systems such as families, businesses, tice13,36-38,40 revealed nine principles for consider-
organizations, and communities. “Occupational ation in creating a context for participation and
performance refers to the ability to choose, orga- partnership in ergonomic practice. These princi-
nize, and satisfactorily perform meaningful occu- ples represent the concepts and actions common
pations that are culturally defined and age across client-centered approaches and frameworks
appropriate for looking after one’s self, enjoying and are relevant for therapists in return to work
life, and contributing to the social and economic and occupational ergonomics. In addition, these
fabric of community life” (p. 30).6 The goal of principles can guide therapists in enacting a client-
client-centered practice is to enhance occupational centered approach in the worker-therapist dyad, in
performance, health, and well-being. workgroup interactions as well as in expanded col-
When therapists work in the field of occupa- laborations with workplace stakeholders such as
tional ergonomics, they may work with businesses employers, insurers, and health or safety person-
or other organizations that are not directly expe- nel in addressing workplace needs. Each principle
riencing occupational performance problems; is elaborated in the following pages for use in
rather, they may be attempting to promote safety either workplace practice or in occupational ergo-
and prevent injury. For instance, a new concern nomics and then applied to the case study of the
of many workplaces is addressing the needs of Centralized Booking Company. Questions are then
aging workers (see Chapter 15). Organizations are posed for students to further explore and integrate
seeking consultation with therapists in purchasing concepts and actions required to enact a client-
equipment or in renovating work sites to proac- centered practice. Box 2-1 lists the nine principles
tively redesign workspaces that will optimize of client-centered practice in ergonomics.
occupational performance as workers age. In
occupational ergonomics, client-centered practice
fosters partnerships and encourages collaborative BOX 2-1 Principles of Client-Centered
identification of obstacles and options for inter- Practice
vention that are not only people focused, but also
system related. Organizations may have individu- 1. Enacting participation and partnering
als with occupational performance problems (e.g., throughout the process
workers with persistent complaints of inability to 2. Respecting and enabling worker and
perform specific work tasks because of back pain). organization choices, needs, and knowledge
In addition, various sectors of the organizations 3. Focusing on person-environment-occupation
may experience occupational performance prob- (PEO) relationships in the practice context
4. Addressing physical comfort and emotional
lems such as decreased productivity owing to a
support needs of clients
very hot or a very cold work environment, high
5. Fostering open and transparent
absenteeism rates, lack of computerization for
communications and knowledge exchange
manual work, or ineffective communication and
6. Establishing a shared vision for ergonomic
conflict resolution strategies. Depending on the management
contractual arrangement, the therapist’s consulta- 7. Establishing shared and realistic goals
tion may also be with the organization, or with among work parties
the organization and an external agency (e.g., an 8. Creating opportunities that engage workplace
insurance agency). This assists the overall process parties in problem solving and decision
of managing the changes necessary for individuals making
or groups of workers to perform safely, efficiently, 9. Ensuring a flexible and individualized
and effectively while maintaining the organiza- occupational therapy approach
tion’s goals.
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 21

CASE STUDY Enacting Participation and Partnering

Throughout the Process
An occupational therapist received a request from the
manager-owner of a company called the Centralized Enacting a client-centered approach requires a
Booking Company (CBC) to conduct a work site visit and collaborative partnership between workers, work-
make recommendations to assist in managing ongoing place parties, employers, external agencies such
problems with musculoskeletal injuries. The manager of as insurers, and therapists. These partnerships
CBC shared his concerns about the growing costs of inju- require a power shift in the expertise and knowl-
ries and the negative impact on profitability. He employs edge from the therapist to clients. It goes beyond
100 workers to provide a 24-hour booking service for the conventional involvement of these clients to
medical, dental, community care, and hospital appoint- include a shared responsibility for the identifica-
ments for national and international clients. At CBC all tion of ergonomic risks, implementation of goals,
office workers are required to rotate office duties on a and a shared accountability for partnering in
12-hour basis: 3 days on, 3 days off, 3 nights on, and 3 administrative activities such as identifying the
nights off. Duties include computerized scheduling and need to meet, setting meeting agendas, communi-
booking of appointments for thousands of companies and cating among workers, and giving and receiving
organizations via a national and international network, feedback about commitment to roles and respon-
invoicing and billing clients, and managing telephone sibilities.32,37 This may involve therapists helping
inquiries and customer service relations. workers and workplace groups develop partnering
During the initial work site visit the therapist discov- expertise, for instance, by improving confidence
ered the following: and skills in giving and receiving feedback in
1. The company purchased and installed new office groups or as it pertains to occupational perfor-
equipment to improve worker comfort, reduce time mance problems. The therapist can also take a
lost because of injuries associated with musculo- leadership role in educating workers, workgroups,
skeletal strain, and improve productivity. Six months and organizations about the appropriateness and
after the office redesign, productivity is unchanged effectiveness of collaboration in facilitating the
and lost-time injury rates and levels of absenteeism best approach to solving complex ergonomic
remain high. During the work site visit, workers issues in the workplace. At this time the therapist
consistently complained of dissatisfaction with the can share with organizations and workgroups the
new workstations. growing evidence on collaboration, importance of
2. The manager requested specific assistance with worker engagement, and the need for multiple
how to manage a return-to-work for Jean, an perspectives in the management of ergonom-
employee requesting an accommodation of no shift ics.1,14,26,37 These actions are required for the
work. Jean was an office worker who was well liked worker and workgroups to develop capacity for
by her co-workers, and before her injury engaged collaboration in the implementation and evalua-
in social activities with co-workers. Jean was in a tion of ergonomic activities at work.
car accident and sustained multiple crush injuries At CBC the therapist recognized the need to
to the dominant right hand and a head injury. Her evaluate the extent of the workers’ and the man-
current limitations include decreased sensation and ager’s knowledge about the importance of a col-
coordination in the hand and fingers as well as laborative approach in solving ergonomic problems
figure-ground and visual-perceptual problems. in the workplace. The therapist recommended
3. The manager also revealed that he has received that an initial meeting with a group of worker
complaints from workers regarding fairness of representatives and the manager take place to
workload in light of the workers who are on limited focus on information exchange. To promote
duties. Up to this point the employer has tried to engagement and a sense of partnering, each
follow the recommendations from insurance com- worker and the manager were asked to bring one
panies and medical professionals; however, he now rule or suggestion for how to make the group
recognizes that assistance is needed to find better meeting successful and to identify how he or she
ways to manage disability and workload issues. might contribute to the group.
22 PART I Overview and Conceptual Framework

As a therapist you may need to become more However, during the work site visit the therapist
aware of your own partnering skills and approach discovered that the workers were not involved in
to collaborative care. What are the skills you feel the purchasing decision. This insight provided
are essential to partnering and collaboration? information on one area where worker choice had
What skills are you confident in performing? been overlooked and the need to emphasize
Reflect on and consider an example of how you opportunities to include workers and support their
have practiced or used this skill. Identify the addi- input in future in ergonomic processes.
tional skills you need and how you might learn or How would you find out about the choices that
acquire this expertise. workers have in managing their health safety at
work? What questions would you ask? How would
Respecting and Enabling Clients’ Choices, you as a therapist explore the preferences of
Needs, and Knowledge workers and workplace parties? What kinds of
Understanding worker, workgroups, and employer documents would you need? Who would you talk
preferences, needs, and knowledge is important to about workplace culture?
when enacting a client-centered approach. Respect
is demonstrated through listening, actively learn- Focusing on Person-Environment-Occupation
ing, and understanding. At the worker level, Relationships in the Practice Context
therapists need to consider workers’ diverse life One of the opportunities in using a client-centered
experiences, coping styles, and unique back- approach is that it supports a holistic approach in
grounds. Inviting workers to express their pref- the management of ergonomic concerns. At the
erences, needs, and perceptions about their core of this process is the examination of relation-
capacities for work opens the door for workers to ships among the capacities, skills, and resources
feel that their views are valued. of workers (person), the multidimensional factors
Insight into the workplace culture will also help of the work environment (environment), and
the therapist gain an appreciation of and demon- work demands and processes (occupation) that
strate respect for the past choices, purchases, and may contribute to occupational performance
knowledge of workers and organizations. This issues and their resolution. Occupational perfor-
understanding can be achieved through gathering mance difficulties of workers and those commonly
information about the nature and history of ergo- experienced by groups of workers are closely
nomic experiences, responsibilities for ergonom- interwoven with their environments and occupa-
ics, and decisions made among workers, unions, tions. Environments are multidimensional and
and management, as well as the values and atti- vary from one organization to another (e.g., with
tudes toward safety. Meeting with organization- respect to policies, norms of behavior, methods of
al representatives from management, human re- communication, approaches to dispute resolu-
sources, and/or occupational health and safety and tion). Similarly, workers vary in the skills and
taking a plant or work site tour will assist the thera- capacities to meet the physical, emotional, and
pist in finding information about safety culture and cognitive demands of work. The person-
practices. While on a tour, the therapist can find environment-occupation (PEO) perspective pro-
out how organizational changes are made to vides therapists with an approach that considers
improve worker and workplace productivity. Ther- the worker’s ergonomic needs in the workplace
apists can further reflect on this information to context while recognizing that the worker’s issues
identify potential gaps and new opportunities for are also embedded in the realities and complexi-
organizations to improve programs and involve ties of his or her workplace culture. Implementing
workers in the ergonomic process. an exploration of ergonomic problems using a
The therapist respected CBC’s recent purchase PEO approach can help all workplace parties stay
of workstations and reinforced with the employer focused on the problem and solutions and avoid
that the workstations offered workers the ergo- pitfalls such as blaming individuals and/or inad-
nomic flexibility to support safe work practices. vertently creating tensions and feelings of guilt.
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 23

In the following section the full application of humanistic context when addressing worker’s
using a PEO perspective is elaborated for the case needs.
study example. Jean and the therapist decided that the best
way to conduct an assessment of Jean’s worksta-
Addressing Physical Comfort and Emotional tion needs was to do this at the work site. However,
Support Needs of Clients Jean raised concerns about doing this evaluation
To make informed and effective decisions, clients when many of the other staff may be present. Jean
need to feel comfortable and receive adequate was concerned that she might be perceived as
information about occupational performance disruptive to others if they went during peak
issues. Frameworks emphasize that therapists hours and as receiving more attention than other
need to have an open, caring manner and need to workers. To minimize Jean’s anxieties and con-
carefully listen to workers’ or employer descrip- cerns the therapist and Jean identified opportuni-
tions of problems and needs. The issue of comfort ties when the work site visit might be conducted.
arises when workers are placed in unfamiliar set- Together they decided to do the workstation eval-
tings or situations such as in planning a return to uation at the beginning of the evening shift when
work after illness or injury. For instance, a work- fewer work stations were in use.
er’s comfort may involve the presence of a union What other suggestions would you make to
representative in the evaluation. No matter the Jean in preparation for this work site visit? What
setting, the relationship that the therapist has with tools and resources does Jean need? What tools
the worker or organization ultimately enables and resources do you need?
success. Recent evidence strongly supports that
early and caring supervisor contact with the Fostering Open and Transparent
worker influences return to work. Supervisors Communications and Knowledge Exchange
who demonstrate concern for the worker’s early To foster open and transparent communications
and safe return to work have positive out- the therapist must identify barriers and challenges
comes.2,11,33 that can hinder communications at the individual
The therapist must also pay particular attention level when interacting with workers as well as
to the development and maintenance of relation- with other workplace parties. At the worker level,
ships with different members of the organization workers may fear disclosing information for fear
(e.g., union representatives, management, work- of reprisals in the workplace from employers and
ers, human resources personnel, and health and co-workers. It is imperative that the therapist be
safety representatives). Information needs to be sensitive to the worker’s relationship with the
provided in an understandable format, and the employer and that an environment of trust that
use of language becomes a focus to address poten- encourages knowledge sharing and exchange be
tial tensions that may arise from different work- created. Likewise, at the organizational level the
place parties. Most workplaces have previous therapist must respect the confidentiality of pro-
negative experiences and histories with accom- prietary information. The therapist must be aware
modations or return to work that lead to stereo- of his or her responsibilities and roles within a
typing and negative attitudes about workers in client-centered ergonomic approach that will also
co-workers and supervisors. The therapist must support knowledge exchange and application by
emphasize that these attitudes and beliefs need to the workers and the organization. Building a foun-
be bracketed; understood, but also put aside, dation of trust involves the therapist, worker, and
when interacting with each new worker and each workplace parties establishing ground rules for
new situation. Likewise, the therapist must also what information will be shared with co-workers,
bracket his or her assumptions. Each situation employers, and insurers and the information that
must be addressed anew with an openness to pos- will remain confidential. In addition, efforts are
sibilities. The workplace parties must work jointly needed to establish a location and space for
with the therapist to create an individualized and requesting information (all questions and con-
24 PART I Overview and Conceptual Framework

cerns are worthy of consideration) and providing in your region that might help you explore with
opportunities for feedback. In the return-to-work Jean responses about disclosure and her rights in
process, the therapist can take the lead in initiat- the workplace?
ing a discussion about disclosure of information
as part of the planning process. The therapist can Establishing a Shared Vision for
elicit concerns the worker may have and offer Ergonomic Management
potential options for the worker to consider. In the workplace, different parties may have dif-
A proactive approach to help workers identify ferent views on how ergonomic outcomes are
and resolve communication issues is to rehearse achieved. Thus, the therapist needs to elicit an
or role-play how the worker will share informa- understanding of workers’, unions’, and manage-
tion with the employer and co-workers. With ment beliefs about responsibilities for safe work
the worker’s consent, the therapist can also behaviors. Some parties perceive that safety and
meet with co-workers and provide information ergonomics are an employer’s responsibility, or a
about co-worker concerns, the return-to-work health and safety department’s responsibility, or
process, and how co-workers might offer support the therapist’s responsibility. In the absence of a
and encouragement to workers on modified shared vision about ergonomic management, ther-
duties. apists need to work with workers and employers
In consultations about occupational ergonomic to generate a common understanding about ergo-
concerns, being client-centered requires therapists nomic principles and the types of actions and
to engage in sharing knowledge and expertise efforts required at the individual and workplace
about ergonomics with all workplace parties levels to create opportunities for safe and optimal
rather than withholding information and main- work performance. A common vision for ergo-
taining a power differential. The aim of this nomic management should outline responsibilities
process is to provide the workplace with tools and actions for the identification of risks, the gen-
needed to help workplace parties understand and eration of solutions, and a process for evaluation
apply ergonomic principles and concepts in the of outcomes. The acceptance of a shared vision
identification and management of ergonomic for managing ergonomic concerns will lend
risks. Educating workers, supervisors, and employ- support for collaboration of all stakeholders as
ers about ergonomics will help them build capac- well as provide stakeholders with specific account-
ity to evaluate and address workplace concerns. abilities. For instance, establishing and imple-
In discussing a return-to-work plan Jean con- menting a shared vision would allow workers to
veyed her anxieties about how to respond to ques- contribute their knowledge and help them realize
tions or negative attitudes of co-workers concerning their obligations as workers to work safely. Simi-
her illness and when she will be back to full larly, development of a shared vision on how
duties. To help Jean prepare for these questions ergonomic concerns will be managed will support
the therapist suggested that Jean write out a list the employer as well as the workers to implement
of potential questions other people might ask her, a proactive approach to injury prevention that
then together they would role-play and rehearse includes shared responsibilities for addressing
appropriate and comfortable responses to these problems and supporting safe and optimal occu-
questions before her return to work. pational performance of workers. In turn, this
What types of questions and negative attitudes vision will support workers, supervisors, and
might Jean encounter in returning to work? Gener- management to become partners in the ergonomic
ate a list of comments or concerns that other co- process.
workers might express. Create a response to each CBC does not have a procedure or policy for
concern that would assist Jean in maintaining a managing ergonomics. In this workplace, the
positive relationship with co-workers and at the workers felt left out of previous decision-making
same time allow Jean to maintain confidentiality. processes about the purchase of new workstations
What information tools or brochures are available and subsequently devalued. This led to negative
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 25

worker concerns that the employer views safety as Organizations need objectives not only to
something that can be purchased in terms of equip- help them commit to ergonomics, but also to plan
ment. On the other hand, the employer is feeling for and mobilize resources needed to ensure the
as though he has exhausted all ideas and resources implementation of safe ergonomic practices at
on how to address ergonomic problems and reduce work. Resources can include strategic financing
costs associated with injuries. To address these of new equipment, workstations, and tools, and
workplace tensions, the therapist recommended it can also include time. Providing the time for
that the employer and worker representatives at people to meet and address ergonomic issues
CBC define and establish a common vision and as well as generate solutions is vital to the proac-
components of an ergonomic program. tive management of concerns. Shared goals and
Work in a group and write a vision for ergo- explicit objectives will ultimately assist organiza-
nomic management at CBC. Include the actions, tions in using evidence and knowledge as well
activities, and responsibilities of workers and as building internal capacity and accountability
management and identify potential outcomes. for addressing ongoing and future ergonomic
Establishing Shared and Realistic Goals At CBC, the therapist gained worker and man-
Therapists work in partnership with workers, agement support to set a shared vision for ergo-
workgroups, and employers to set goals for out- nomic management with specific objectives for
comes. As mentioned previously, the therapist improving ergonomic outcomes. A committee was
seeks to understand the knowledge and prefer- set up to meet quarterly to address ergonomic
ences of workers and managers as well as the concerns. At the initial meeting the committee
resources within the workplace context. This decided to establish priorities and goals for imme-
information is also valuable in establishing shared diate, long-term, and ongoing solutions. The com-
and feasible goals to address ergonomic and mittee asked for information from workers, su-
return-to-work concerns and to improve outcomes pervisors, and the therapist to identify common
in the workplace. In a collaborative approach, and unique problems. For each problem the com-
responsibility for goals and outcomes is shared, mittee set an action plan, a target date for
and thus the success is dependent on the com- implementation, and a plan for evaluation of the
mitment of workers and organizations. This type outcomes. This was then shared with workers.
of process can also support setting goals and a What type of information could the workers
shared action plan for how the interventions will provide to help the committee evaluate worker
proceed with a clear ownership for worker and commitment to ergonomics? Likewise, what type
employer responsibilities in the plan. In this of information could the manager-owner provide
process workplace parties need to identify what to demonstrate commitment to and success in
they view as a successful ergonomic program so achieving goals?
that their standards are built into the goals and
objectives, and their expectations are in line with Creating Opportunities That Engage Clients
the shared goals. in Decision Making and Problem Solving
Workers will require resources and support to Involving workers and workplaces in decision
monitor ergonomic needs and forward input making to solve and manage ergonomic problems
needed to generate shared goals. For instance, is key to developing a sense of ownership and
engaging workers in setting shared goals with accountability for implementing safe practices.
management for ergonomics requires that workers Therapists can support this through recognizing
engage in the process of evaluating and monitor- that workers and employers are the experts when
ing ergonomic needs at work. Introducing a form it comes to knowing their problems, how they
to capture information about common ergonomic solve problems, and how these problems affect
problems that cannot be solved at the worker level their lives, especially at work. The workers and
will support collaboration. supervisors have access to invaluable information
26 PART I Overview and Conceptual Framework

and often can make practical, relevant suggestions posture, nor did they understand its application
about how to address concerns. to personal characteristics. The therapist encour-
It is important that the therapist contributes to aged workers to review a credible online video on
and facilitates a culture of self-management and workstation design for office workers and pro-
self-monitoring of ergonomic concerns. The thera- vided them with a tool for recording and analyz-
pist can achieve this through translating policy, ing problems. The form also provided them with
health and safety legislation, procedural informa- a place to document the actions taken to adjust
tion, and research evidence on ergonomics and or alter equipment, processes, or work behaviors.
return to work into an understandable format Workers were asked to identify concerns that
for the end-users. Workers and workplace parties were not answered through the video. A session
can then reframe this information and apply it to was held with workers to review this experience
the workplace. The therapist can offer strategies and to share information with one another on
to support the actions and efforts of workplace corrective strategies and to identify additional
parties in self-management through identifying information they felt they needed to self-monitor
and sharing credible sources of information located ergonomic issues.
on the Internet or through tools and resources for How would you go about ensuring that workers
workers to manage their ongoing ergonomic have the information they need about ergonomics?
needs. In addition, the therapist would encourage Would you provide it or would you help them find
the active solicitation of suggestions and solutions it? How might you assist the workers apply infor-
from various levels of the organization and that mation to personal factors such as height, age,
information collected across workgroups be incor- weight, and gender? What ergonomic approaches
porated into an ongoing process to support will inform the information you provide? What
informed and collaborative decision making. strategies will you use to ensure that workers can
Involvement and participation of the workers use this information to self-manage and to solve
in developing confidence and capacity to make ergonomic problems in their daily work lives?
decisions and apply ergonomic information is key
to enabling and sustaining a proactive ergonomic Ensuring a Flexible and Individualized
program. Workers need a process and tools to Occupational Therapy Approach
support effective decision making and changes in Ensuring a flexible and individualized OT approach
work behavior to perform work safely. The thera- in ergonomics requires therapists to attend to the
pist can offer education, training, and opportuni- structures of health care systems, return-to-work
ties for reflection to support workers enacting systems, and workplace demands. For instance,
ergonomic responsibilities. For instance, the ergo- when working in industry, the therapist needs to
nomic action form (Figure 2-1) is designed to clearly communicate what he or she has to offer
engage workers in gathering information, evaluat- employers or managers and explain how services
ing potential problem areas, making adjustments, may or may not help resolve the ergonomic issues
and documenting outcomes. This form can support under discussion. To be effective, the therapist
the ongoing reflection and self-monitoring by must be flexible in meeting client needs, respect-
workers and help them in taking proactive steps ing the resources and services available uniquely
in managing their health and safety at work and to each organization.
in forwarding unresolved issues for further input Therapists also need to be reflective—to become
and action. more aware of their actions and the efforts needed
At CBC, the workers did not receive education to remain within the scope of practice and to gain
on how to adjust or alter workstations to specific a deeper appreciation of the influence of their
needs. Some workers accessed information on the actions on others. This is especially important in
Internet; however, many did not know how to client-centered practice. It is often easier to tell
apply ergonomic information about their chairs, workers and employers what they need to do to
placement of telephones, lighting, and computer improve safety than it is to help them assume
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 27

Ergonomic Action Form

Job Title: Job Code: Location:

Job Demand/Duty: Date Initiated:

Type of Ergonomic Concern: Physical/Psychological/Sensory/Cognitive/Behavioral

Physical Demands or Task (describe the demand or processes/procedures)

Time performing demand
Effort required
Frequency # of repetitions
Body posture (neutral or awkward)

Summary of Concern:

Sensory/Cognitive/Behavioral (describe the demand or processes/procedures)

Person resources or skills

Interactions with others

Summary of Concern:

Work Environment Factors (weather, hot, cold, tools, workstation design or structures, and work location)

Summary of Factors and Concern:

Actions: (include date and steps taken to address, change, or modify concern, and plans for further action)
1. Date
Follow-up plan

2. Date
Follow-up plan

FIGURE 2-1 Ergonomic action form.

28 PART I Overview and Conceptual Framework

shared responsibilities and enact accountabilities interventions on both personal and environmental
in the workplace. Taking time for active reflection levels. The environment is defined broadly to
is essential in helping therapists become aware of include cultural, socioeconomic, institutional or
how to communicate and act as team members as structural, and social elements. The model has
well as understand how a therapist’s efforts influ- been used by therapists in various roles in a
ence or motivate others to engage in partnering. variety of settings. It has been shown to be a
Therapists must also become aware of personal practical tool to conceptualize, communicate,
biases from previous interactions with other em- plan, and evaluate occupational performance
ployers and learn how to bracket perceptions to interventions.42
maintain a consistently open and responsive The model (Figure 2-2) has three components:
approach with each new client. Therapists can be the person, the environment, and the occupation,
reflexive and learn about themselves in a number imagined as interrelated spheres that move with
of ways—keeping a reflective log of assumptions, respect to one another over time. The spheres
debriefing with peers about challenges and experi- represent how a person continuously engages in
ences, and inviting feedback from clients. occupations and interacts with environments.
After working with the workers at CBC for a Environments, occupations, and people have en-
number of months the therapist wanted feedback abling or constraining effects on one another; the
on her performance and what things she did that components shape one another. A cross-section
kept workers interested and committed to ergo- taken at any discrete point in time would reveal
nomics at work. To do this, she invited workers different interactions.
to share this information anonymously by respond- The greater the degree of overlap between the
ing to three questions: What, if at all, does the three components represents increased congru-
therapist do to help the workers and managers ence, or PEO match, resulting in improved occu-
function as a team? How does the therapist con- pational performance and improved job experience
tribute to the team? What, if at all, does the thera- or satisfaction. Occupational performance is the
pist do to help you feel part of the team? The product of PEO transactions. The aim of interven-
therapist reflected on the responses to gain insights tions is to improve occupational performance and
into the impact of her actions on empowering increase the PEO congruence by removing obsta-
others to work collaboratively. cles or providing supports for more harmonious
Based on your previous work experiences, PEO relationships.
write down your current attitudes and assump- The PEO model can be used as a tool in
tions about workers on modified duty programs client-therapist alliances to systematically examine
and your views about an employer’s commitment complex occupational performance issues. The
to health and safety. Hypothesize on how these model focuses on the relationships among the
views might influence your actions in dealing with worker, the work environment, and the work itself
returning workers with injuries to work. How to create a structure for problem-solving strategies.
might you prepare for your next interaction with This approach can assist therapists to address not
an employer and worker in planning a return to only worker issues, but also the impact of organi-
work? What can you do before the meeting and zational relationships, systems, and attitudes.
during the meeting to maintain a client-centered Ultimately the PEO model is designed to help facili-
approach in discussing return-to-work plans? tate communication with all members of the

THE PERSON-ENVIRONMENT-OCCUPATION Application of the Person-Environment-

MODEL Occupation Model to Ergonomics Practice
Derived from environment behavior studies and To illustrate the PEO model as a practical tool for
principles of client-centered practice, the PEO therapists in ergonomics, the model has been
model23 is suitable for planning client-centered applied to the same three ergonomic problems
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 29

FIGURE 2-2 The person-environment-occupation model. (From Law M, Cooper B, Strong S et al: The Person-
Environment-Occupation model: a transactive approach to occupational performance, Can J Occup Ther 63:9, 1996.)

identified earlier in the case example of the service desk. Information is gathered from the
Centralized Booking Company. This model is par- worker, the supervisor, and the employer. An-
ticularly of value to the therapist for identifying alysis of person-occupation, person-environment,
and clarifying barriers to the resolution of ergo- and environment-occupation relationships reveals
nomic problems such as worker attitudes, systems a number of issues.
issues, organizational issues (e.g., policy, leader- Person-Occupation Issues
ship style), and interpersonal relationships within • The worker’s physical abilities and physical
an organization. restrictions do not match the physical demands
of the job (e.g., pain in hand with prolonged
Ergonomic Problem 1 repetitive posture of right hand, visual-percep-
A worker who sustained injuries in a car accident tual problems working with standard computer
wants to return to work on temporarily modified screen, right hand coordination and sensory
duties, day shift only. Barriers include the resis- impairment make it difficult to manipulate
tance of co-workers and the need to identify the paper and writing utensils, which reduces the
work tasks that will enable the worker to return speed of performing tasks). Jean likes her job
to work on modified duties. and receives a great deal of satisfaction in
helping customers get the information and
Analysis and Assessment assistance they need in a timely fashion. Cur-
The therapist gathers information from the worker rently, Jean has reduced confidence in her
regarding his or her current abilities (e.g., physi- capacity to effectively perform job tasks and
cal, cognitive, affective, emotional). In addition, resume her preinjury level of performance. Pri-
the therapist works in partnership with clients to marily, she is concerned about the increased
gather data on the actual demands and processes time it takes to handle and manipulate paper-
involved in managing customer accounts and the work and the multitasking demands such as
30 PART I Overview and Conceptual Framework

talking on the phone to customers, searching nity to negotiate a return to work plan. The guide-
for information on the computer and in manuals, lines also help other co-workers gain awareness
and recording information. needed to accept co-workers on modified duties
Person-Environment Issues beginning with initial rotations into the day shift,
• Poor match of physical abilities with work ex- and a gradual return to all shifts (afternoons fol-
pectations (e.g., temporary inability to perform lowed by night shifts). Subsequently a plan is
all shifts because of fatigue related to sleep developed to match the worker’s current abilities
disturbance problems). with work demands. The development of this plan
• The employer anticipates a lack of cooperation involves dialogue with the supervisor and the
from co-workers based on co-workers’ previous worker and negotiation of duties that match the
responses when other workers returned to worker’s abilities and under what circumstances
work. Jean is also worried about how she will they are performed (i.e., the parties work together
handle any negative attitudes. In the past, Jean to explore ways to improve the PEO congruence).
perceived her co-workers as liking her and The supervisor, the worker, and the therapist create
viewing her as friendly, and Jean often social- a plan to gradually increase the worker’s duties as
ized with them outside of work. endurance and pain control improves. For instance,
Environment-Occupation Issues to address Jean’s difficulties with decreased coor-
• A lack of formal policy for rehabilitation of dination, she is assigned a group of customer
workers with injuries, in particular no formal- accounts for which all the information she needs to
ized modified duty program source is on one computer. It is anticipated that this
• Workload during modified duty programs per- type of collaborative planning using a PEO perspec-
ceived as inequitable by co-workers tive will help Jean achieve success and gain confi-
• Management wishes to reduce occurences of dence in transitioning back to work.
lost time injuries The therapist in this case also teaches Jean to
• Management identified issues with workplace adjust the sensitivity of keys on the keypad and her
safety practices and desires a program to elimi- computer mouse and helps Jean to use a process to
nate workplace injuries self-monitor her performance during the return-to-
• Management identified issues with team func- work process. This process entails documenting
tioning and wants to improve human relations problems, successes, and strategies she uses to
of staff address problems and evaluate her progress over
time in terms of endurance, effort, and speed. The
Person-Environment-Occupation Interventions process of self-monitoring provides Jean with an
The therapist works in consultation with all parties, active role in the return-to-work process by giving
including the workers, co-workers, and manage- her responsibilities for managing her needs in the
ment, to develop a modified duty program. The midst of performing her work and helps her prepare
PEO model is used to help workers, supervisors, for and participate in feedback of her progress with
and employers understand the impact of relation- the therapist and employer.
ships among the workers and the organization
(person), the work (occupation), and the work- Ergonomic Problem 2
place (environment) that influences human perfor- After the corporation-wide installation of new er-
mance and workplace productivity. Next, the model gonomically designed office equipment, office work-
is used to highlight the barriers to and facilitators ers continued to complain of musculoskeletal pain in
of return to work. This information, along with their necks, shoulders, backs, and wrists.
legislation, can inform the development of a modi-
fied duty program and supporting guidelines. Analysis and Assessment
The modified duty program guidelines provide The therapist began her assessment of this problem
a focus for discussions on issues surrounding the by conducting interviews with the staff to ask
particular worker with an injury, and the opportu- about the factors they perceive to be contributing
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 31

to musculoskeletal pain. In addition, the therapist tions include implementing a new process to
reviews the office equipment and gathers informa- engage employees in providing input and genera-
tion associated with the purchase and installation tion of solutions. The therapist recommends a tool
of the new ergonomic office workstations. The be used by employees to self-monitor and correct
following issues were identified. ergonomic issues in performing daily work tasks
Person-Occupation Issues and a process be adopted to forward more complex
• Pain while performing duties, fears of increas- problems to an ergonomics committee for consid-
ing incapacitation, and reluctance to engage in eration and resolution.
some duties
• Stress believed to be associated with some work Ergonomic Problem 3
duties in the rotation The Centralized Booking Company identified that the
• Not all employees were trained in all work continuation of lost-time claims, absenteeism, and
duties within the rotation worker dissatisfaction and discomfort contributed to
Person-Environment Issues lost productivity, decreased efficiency, difficulty with
• People were not consulted concerning the iden- staffing, and overall poor staff relations.
tification of solutions or factors that potentially
contributed to original problems. Analysis and Assessment
• Workers perceived that the manager was some- To address this problem the therapist gathers in-
what interested in health and safety; however, formation on claims experience, types of injuries,
they were aware that the employer was very work flow processes, and so forth to understand
busy in the day-to-day running of an expanding and evaluate the workplace injury management
business, generating new accounts, and ensur- program. In addition, the therapist considers the
ing that customers were satisfied. Thus, the ergonomic problems within the greater legislative
proactive leadership in managing health and and organizational systems, such as the workplace
safety was compromised. collective agreements, workplace policy, and
Environment-Occupation Issues health and safety legislation.
• Increased workload demands for each em- Person-Occupation Issues
ployee • Lack of management experience and training in
• Rotation of work limited because of absentee- health and safety in office settings
ism (i.e., staff experiencing prolonged periods • Lack of understanding of joint or shared respon-
of high-stress duties) sibilities and processes for enacting safety obli-
• New equipment installed, but workers received gations and accountabilities
no training on how to manage and adjust it • Lack of successful outcomes in previous situa-
tions, despite the fact that management was
Person-Environment-Occupation Interventions motivated to return employees to work
The therapist’s recommendations include training • Lack of employee satisfaction with workload
of staff on basic ergonomic principles to promote and duties
the application of this knowledge in identifying Person-Environment Issues
and self-managing problems with their worksta- • Lack of systems monitoring and opportunities
tions. Training recommendations include adjust- for input, feedback, and collaboration
ment and mechanical management of workstations Environment-Occupation Issues
(to be provided to employees by the vendor) and • Time and manpower constraints have limited
workplace training on basic principles of ergo- implementation of work rotation and limited
nomics such as methods to evaluate, modify, and accommodation of workers.
prevent workplace risks (to be provided to employ- • Purchase of ergonomic equipment did not
ees and management by the therapist). Stretching reduce lost-time injuries.
and exercise programs are also included as part • Workplace injury management strategy lacked
of the training package. Part of the recommenda- direction.
32 PART I Overview and Conceptual Framework

Person-Environment-Occupation Interventions from which to collaboratively move forward. In

A collaborative approach to identifying a rotation turn, this shared understanding helps to build
strategy and efficient sequencing of tasks per rota- trust from the outset among the therapist, workers,
tion is recommended by the therapist. This requires employers, and external agencies.
involvement of the therapist, worker representa- The therapist may encounter attitudinal barri-
tive, and management to design a suitable rotation. ers that have a negative impact on relationships
An additional complementary recommendation is between supervisors and workers. With the client-
the training of office staff on all accounts and the centered approach, these issues need to be
development of skill requirements to enable rota- addressed in an objective and respectful manner.
tion through all tasks, minimizing the length of Negative attitudes can be identified as barriers to
time on stressful work and allowing recovery time effective solutions. For example, a supervisor may
after the most demanding duties. To test the appli- label a worker “unmotivated” or “lazy.” Thus,
cability and feasibility of the rotation a trial of the when the worker returns to work on modified
new job rotation with self-monitoring is recom- duties because of injury, the supervisor may attri-
mended. Then a worker-to-worker training program bute all concerns raised by the worker to laziness.
will be implemented to ensure all staff receive Niemeyer describes how labeling and stereotyping
cross-training in all work tasks. can bias observers’ (i.e., supervisors’) beliefs and
can delay recovery if the individual accepts the
label.30 The early identification of destructive atti-
ETHICS AND CHALLENGES IN tudes allows the therapist to take steps before
IMPLEMENTING A CLIENT-CENTERED plans are undermined. The importance of offering
APPROACH a caring and supportive return-to-work experience
Ethical dilemmas can arise when using a client- must not be overlooked. For example, current
centered approach in the ergonomics field. For evidence suggests that a humanistic approach can
example, the priorities of key parties may conflict. have a positive influence on return-to-work out-
The workers may believe that the most urgent comes.2,11 This approach translates to simple steps
ergonomic issues relate to poor equipment, such as early supervisor contact with the employee
whereas the employer may identify the worker’s with an illness or injury and a sincere expression
unsatisfactory performance and compliance with of concern for the employee. Therapists can work
proper techniques as the priorities. The therapist with employers to translate research evidence on
is confronted with the question of which of these effective return-to-work programs that in turn
clients’ issues and priorities take precedence. help employers create workplace environments
Being client-centered does not mean that the ther- that support return to work.
apist must agree with the client or “take sides.” Problems with negative attitudes also extend to
Rather, the therapist focuses on the issues as co-workers. For example, the therapist can provide
directed by the client and enters the client’s world informed information to co-workers that helps to
in a collaborative partnership. The therapist may counter misinformation and stereotypes. This can
reclarify and ascertain the priorities and needs of be achieved through information sessions with
both parties and with them may negotiate which co-workers about the difficulties and anxieties
issues will be addressed and at what time. For the that workers face when they are alienated from
scenario described, an objective evaluation of the work and attempting to return to work. Positive
views of all participants is necessary to identify moral peer support can help ease the transition of
the extent of all problems. The therapist ensures workers returning to work and help them regain
that all issues are addressed from all perspectives. their sense of belonging.
The goal is to encourage each party to see all Funding issues may also pose ethical dilemmas
points of view. With the introduction of the PEO for the therapist. The employer or insurance com-
model, the parties have a more objective focus pany may not be able to fund what the worker
and develop a shared understanding of the impact and therapist identify as necessary to resolve the
of PEO relationships on occupational performance ergonomic problems. The therapist needs to work
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 33

with workers and organizations to identify options tively involved with employers in the identifica-
for funding and other methods for arriving at an tion, assessment, and resolution of ergonomic
appropriate solution. It is important that the thera- concerns. Using a client-centered approach that
pist address funding proactively to maintain trust embraces the PEO model can help therapists and
throughout the process. clients think critically about ergonomic issues,
Lack of compliance of the worker or employer create innovative solutions, and further develop
in carrying out the agreed-on changes also pres- the practice of ergonomics.
ents the therapist with a dilemma. The client-cen-
tered approach is intended to foster partnerships
and actively engage key parties in meaningful
plans from the beginning. In this way, the situa-
tion of noncompliance can often be avoided. An Learning Exercises
effective client-centered approach to ergonomics Overview
includes the establishment of target dates and
The learning exercise is designed to help you
identifies an individual responsible for monitoring
identify, deconstruct, and articulate the compo-
and re-evaluating changes (e.g., therapist, super- nents of the PEO model as it applies to a worker
visor, employee). The responsible individual(s) with an injury.
notifies the group if issues are not resolved effi-
ciently and completely. However, it is recognized Purpose
that the best intentions to implement ergonomic The purpose of these exercises is to encourage
changes may be impeded by competing priorities you to analyze the barriers and challenges to
in running a business or in managing customer occupational performance using a PEO ap-proach
needs. Thus, it is truly essential that a client-cen- and to consider client-centered strategies to
tered approach in ergonomics also aims to help address ergonomic concerns.
organizations establish an accountability process
for linking ergonomics with organizational out- Exercises
comes of productivity and safety. Linking er- 1. Use a PEO approach to evaluate the
gonomics to strategic priorities will support problems in a workplace setting. Invite
organizations in refocusing on and targeting ergo- colleagues to share their experiences where
nomic risks and solutions as a natural, routine they have encountered a workplace
part of doing business. ergonomic problem. Choose one example in
which a colleague developed a strain or
CONCLUSION 2. Use a role-play that involves the colleague
role-playing the worker with the ergonomic
Organizations are challenged with complying with
concern and the remaining members of the
changes in legislation concerning health and
class role-playing the therapist.
safety, human rights, and disability to ensure
3. The “therapists” will conduct a group
healthy work environments. A highly competitive interview with the “worker” to identify and
marketplace has contributed to the incorporation create a list of P-E, E-O, and P-O concerns or
of ergonomics to maximize productivity and rede- issues that limit optimal performance.
sign for efficiency. The practice of ergonomics 4. For each PEO issue, identify two potential
must continue to develop to meet the changing, interventions for each performance problem.
complex needs of clients through evidence-based 5. Evaluate each intervention to ensure that the
evaluations (see Chapter 18). A client-centered processes and steps in the interventions are
approach can be instrumental to workers and consistent with a client-centered approach.
organizations in building capacity to assume Consider the involvement, accountability,
control and management of ergonomics in the and responsibilities of all of the people
workplace. In this process, not only are workers involved in the intervention process.
viewed as a valuable resource, but they are ac-
34 PART I Overview and Conceptual Framework

Multiple Choice Review Questions 5. Why does a therapist encourage worker

involvement in self-monitoring
1. To be client-centered, therapists must: responsibilities?
A. Always agree with the client. A. To give a worker more things to do
B. Create a collaborative partnership and while on modified duties
enter the client’s world from the B. To give a worker control over work
client’s perspective. tasks
C. Avoid dealing with ethical issues. C. To help a worker work with
D. Rely solely on the client’s skills and co-workers
resources to the exclusion of the D. To help a worker document
therapist’s skills and resources. productivity

2. Concepts central to client-centered 6. In the case of the CBC, the problem of

practice include: a lack of time and manpower
A. Facilitation of client participation in all constraints limiting the implementation
aspects of service. of a work rotation schedule is an example
B. Flexible, individualized service. of what PEO component?
C. Respect for clients and the choices A. A person-environment issue
they make. B. A person-occupation issue
D. All of the above C. An environment-occupation issue
D. A person-environment-occupation
3. Why does a therapist use an ergonomic issue
A. A framework allows the therapist to 7. In the case of the CBC, the problem of a
understand ergonomic problems. worker experiencing pain while perform-
B. A framework directs the therapist’s ing duties is an example of what PEO
observations, data collection, and component?
interpretation of findings. A. A person-environment issue
C. A framework lends comprehensiveness B. A person-occupation issue
to assessments and intervention plans. C. A person-environment-occupation
D. All of the above issue
D. An environment-occupation issue
4. The PEO model is:
A. A tool for therapists’ use to facilitate 8. In the case of the CBC, the problem
client-centered practice. of workers not being consulted
B. An intervention model applicable to concerning the identification of
ergonomics. solutions or identification of potential
C. Flexible and a guide rather than factors that contributed to original
something that dictates practice. problems is an example of what PEO
D. All of the above component?
A. A person-environment-occupation
B. A person-occupation issue
C. An environment-occupation issue
D. A person-environment issue
Chapter 2 A Client-Centered Framework for Therapists in Ergonomics 35

9. Therapists who adopt a client-centered 8. Christiansen C, Baum C: Occupational therapy: over-

approach to address occupational coming human performance deficits, Thorofare, NJ,
1991, Slack.
ergonomic problems will:
9. Christiansen C, Baum C: Person-environment occu-
A. Develop a partnership with workers pational performance: a conceptual model for prac-
and managers to establish a return-to- tice. In Christiansen C, Baum C, editors: Occupational
work plan. therapy: enabling function and well-being, ed 2,
B. Develop a partnership with workers Thorofare, NJ, 1997, Slack.
and management to prevent 10. England S, Evans J: Patients’ choices and percep-
injuries. tions after an invitation to participate in treatment,
Soc Sci Med 34:1217, 1992.
C. Develop an educational session for
11. Friesen M, Yassi A, Cooper J: Return-to-work: the
employers and workers on attitudes importance of human interactions and organiza-
toward injured workers. tional structures, Work 17:11, 2001.
D. Develop a relationship with the union. 12. Gage M, Polatajko HJ: Naming practice: the case for
the term client-driven, Can J Occup Ther 62:115,
10. A therapist who brackets his or her 1995.
assumptions and biases in working with 13. Gerteis M, Edgman-Levitan S, Daley J et al: Through
the patient’s eyes, San Francisco, 1993, Jossey-
workers with injuries and employers is
enacting which client-centered principle? 14. Hignett S, Wilson JR, Morris W: Finding ergonomics
A. Ensuring a flexible and individualized solutions: participatory approaches, Occup Med
approach 55:200, 2005.
B. Establishing shared or realistic goals 15. Horvath A: Research on the alliance. In Horvath
C. Fostering open and transparent A, Greenberg L, editors: The working alliance:
theory, research and practice, New York, 1994,
D. Enacting participation and partnering 16. Human Resources Development Canada: In unison:
throughout the process a Canadian approach to disability issue, 1996,
Government of Canada.
17. Isernhagen SJ: The comprehensive guide to work
injury management, Gaithersburg, Md, 1995,
1. Anema JR, Steenstra IA, Urlings IJM et al: Participa- 18. Jequier JC, Gauthier JM, Lapointe C et al: Model for
tory ergonomics as return-to-work intervention: a a multidisciplinary approach. In Poirier F, editor:
future challenge? Am J Ind Med 44:273, 2003. Rehabilitation and ergonomics, Mississauga, Ontar-
2. Baril R, Clarke J, Friesen M et al: Management of io, 1989, Human Factors Association of Canada.
return-to-work programs for workers with muscu- 19. Kivlighan D, Shaughnessy P: Patterns of working
loskeletal disorders: a qualitative study in three alliance development: a typology of client’s working
Canadian provinces, Soc Sci Med 57:2101, 2003. alliance ratings, J Couns Psychol 47:362, 2000.
3. Burke M: Ergonomics tool kit: practical applications, 20. Koehoorn M, Lowe G, Rondeau K et al: Creating
Gaithersburg, Md, 1998, Aspen. high quality health care workplaces, CPRN Discus-
4. Canadian Association of Occupational Therapists, sion Paper No. W/14, 2002.
Health Services Directorate, and Health Services 21. Korzycki M, Korzycki M, Shaw L: Tug of war
and Promotion Branch: Guidelines for the client- between health and return to work: consumer
centred practice of occupational therapy, Ottawa, experiences with system tensions. In Proceedings of
1983, Minister of National Health and Welfare. the University of Western Ontario Occupational
5. Canadian Association of Occupational Therapists: Therapy Conference on Evidence-Based Practice 6:87,
Occupational therapy guidelines for client-centered 2006, London, Ontario.
practice, Toronto, 1991, CAOT Publications ACE. 22. Law M: Participation in the occupations of everyday
6. Canadian Association of Occupational Therapists: life, Am J Occup Ther 56:640, 2002.
Enabling occupation: an occupational therapy per- 23. Law M, Cooper B, Strong S et al: The person-envi-
spective, Ottawa, 1997, CAOT Publications ACE. ronment-occupation model: a transactive approach
7. Chaffin DB, Anderson G: Occupational biomechan- to occupational performance, Can J Occup Ther
ics, ed 2, New York, 1991, Wiley & Sons. 63:9, 1996.
36 PART I Overview and Conceptual Framework

24. Law M, Mills J: Client-centered occupational process: contextual factors and implications for
therapy. In Law M, editor: Client-centered occupa- practice, Work 23:182, 2004.
tional therapy, Thorofare, NJ, 1998, Slack. 37. Shaw L, McWilliam C, Sumsion T et al: Optimizing
25. Levine S, Greenlick M: Removing barriers to the environments for consumer participation and self-
empowerment of the elderly in health programs, direction in finding employment, OTJR: Occupation,
Gerontologist 3:581, 1991. Participation Health, in press.
26. Loisel P, Durand M, Berthelette D et al: Disability 38. Shaw L, Sumsion T, McWilliam C et al: Service
prevention: a new paradigm for the management provider challenges in implementing participatory
of occupational back pain, Dis Manage Health Out- approaches in employment rehabilitation, J Vocat
comes 9:351, 2001. Rehabil 21:123, 2004.
27. Lustig DC, Strauser DR, Rice ND et al: The 39. Soever L, Cott CA, Boyle J: Client-centered rehabili-
relationship between working alliance and reha- tation II: health care professionals’ perspectives,
bilitation outcomes, Rehabil Couns Bull 46:25, Toronto, 2003, Arthritis Community Research
2002. Evaluation Unit (ACREU).
28. MacDonald JW, Crozier C: Organizations in transi- 40. Stevenson FE: Launching the Tidal Model in an
tion series. Rehabilitation in the 90s and beyond: adult mental health programme, Art Sci Res 15:33,
the challenge for the British Columbia rehabilitation 2001.
society, Can J Rehabil 5:237, 1992. 41. Stewart M, Belle Brown J, Donner A et al: The
29. McWilliam CL, Stewart M, Brown JB et al: Home- impact of patient-centered care on outcomes, J Fam
based health promotion for chronically ill older Med 49:796, 2000.
persons: results of a randomized controlled trial of 42. Strong S, Rigby P, Stewart D et al: Application of
a critical reflection approach, Health Promot Int the person-environment-occupation model: a practi-
14:27, 1999. cal tool, Can J Occup Ther 66:122, 1999.
30. Niemeyer LO: Social labeling, stereotyping, and 43. Sumsion T: Client-centered practice in occupational
observer bias in worker’s compensation: the impact therapy: a guide to implementation, ed 2, Philadel-
of provider-patient interaction on outcome, J Occup phia, 2006, Elsevier.
Rehabil 1:251, 1991. 44. Townsend E: Good intentions overruled: a critique
31. Rebeiro K: Client perspectives on occupational of empowerment in the routine organization of
therapy practice: are we truly client-centered? Can mental health services, Toronto, 1998, University
J Occup Ther 67(1):7, 2000. of Toronto Press.
32. Rebeiro K: Partnerships for participation in occu- 45. Webb RDC: Rehabilitation of the injured worker. In
pation, Ment Health Spec Interest Sect Q 25(3):1, Poirier F, editor: Rehabilitation and ergonomics,
2002. Mississauga, Ontario, 1989, Human Factors Associ-
33. Roberts-Yates C: The concerns and issues of in- ation of Canada.
jured workers in relation to claims/injury mana- 46. Wehmeyer M: Self-determination and the education
gement and rehabilitation: the need for new of students with mental retardation, Educ Train
operational frameworks, Disabil Rehabil 25:898, Ment Retard 27:302, 1992.
2003. 47. Woodson WE, Tillman B, Tillman P: Human factors
34. Roter D: The enduring and evolving nature of the design handbook: information and guidelines for
patient-physician relationship, Patient Educ Couns the design of systems, facilities, equipment, and
39:5, 2000. products for human use, New York, 1992,
35. Rumrill PD, Koch LC, Harris EJ: Future trends in McGraw-Hill.
assessment and planning: priorities for vocational 48. Yardley JK: Healthy employment relationships: the
rehabilitation in the 21st century, Work 10:271, heart of hospitals. A discussion paper prepared and
1998. circulated at the Second Annual OHA Healthy Hos-
36. Shaw L, MacKinnon J, McWilliam C et al: Con- pitals Innovative Practices Symposium, Toronto,
sumer participation in the work rehabilitation Sept. 30–Oct. 1, 2004.

Valerie J. Berg Rice

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Understand the definition, principles, and use of macroergonomics.
2. Describe the role of therapists in assisting in macroergonomic interventions or research efforts.
3. List the ways in which macroergonomics may differ from as well as interface with other disciplines, such as
industrial engineering, organizational psychology, physical therapy, and occupational therapy.
4. List some basic principles of macroergonomics and how they may contribute to long-term, lasting change within
an organization.
5. Select, understand, and discuss a macroergonomic versus a microergonomic approach, when to use each, and
their pros and cons.

Participatory ergonomics. The process by which design and fitting the organization to the person or
workers of all levels help identify ergonomic problems persons within that organization.
and solutions. Microergonomics. An approach to ergonomics that
Macroergonomics. A subdiscipline of human factors emphasizes the examination of the interface between
or ergonomics that emphasizes a broad system view of person and the product, as opposed to other factors.

38 PART I Overview and Conceptual Framework

An example may help the reader understand macroergo-
T his chapter defines macroergonomics and
provides a brief introduction to macroergo-
nomics as a subdiscipline of human factors or
nomics, as well as why a macroergonomic approach is ergonomics and as a problem-solving approach.
more likely to lead to large scale, long-lasting results. In The chapter also investigates the potential role of
this case, the Army Medical Department Center and occupational and physical therapists in using mac-
School commander asked ergonomists (also known as roergonomics, lists governing principles of macro-
human factors engineers) to assist with reducing muscu- ergonomics, and demonstrates with a case study
loskeletal injuries among soldiers attending advanced example. Finally, guidance is given for helping
individual training (AIT) to become U.S. Army Health therapists decide when to use a micro versus a
Care Specialists (Figure 3-1). Soldiers attend this rigorous macro approach.
training program at Fort Sam Houston in San Antonio,
Texas, after completing basic training.5,7 At the time of
the intervention the training program was 10 weeks in
length. The hope was that the intervention program
developed at this training site, if successful, might also be In 1978 the Select Committee on Human Factors
duplicated at other training sites. The ergonomic team Futures (1980-2000) was initiated to study societal
quickly recognized that the most effective method of trends and their impact on human factors and
evaluation and intervention would involve a macroergo- ergonomics.1 The sixth item identified was the
nomic approach. “failure of traditional (micro-) ergonomics.” The
point was that a specific solution to a known
ergonomic issue, regardless of how well it was
conceived or implemented, did not always result
in the expected positive results. Paying attention
to specific components of the system, such as a
workstation, might mean the bigger picture of the
work environment was lost. Therefore, although
an ergonomist might evaluate and redesign a
single workstation to fit an individual, overall
work effectiveness, including productivity, safety,
and the overall work environment, might not
change at all. For more on the history of the
development of macroergonomics, consult Hen-
drick and Kleiner,1 Kleiner,4 and Robertson.10
More recently, organizational design and man-
agement (ODAM) has been integrated into the
human factors or ergonomics field, with venues
including the Macroergonomics Technical Group
within the Human Factors and Ergonomics Society
and other countries’ societies. The Human Factors
in ODAM symposium occurs every 2 to 4 years.
Macroergonomics has also been a major topic at
the International Ergonomics Association triennial
conferences since 1985.

FIGURE 3-1 Musculoskeletal injuries are high among

soldiers attending basic combat training as well as Depending on whom you speak with, macroer-
advanced individual training programs. gonomics can be defined as a perspective, an
Chapter 3 Macroergonomics 39

approach, a specific discipline, or a subdiscipline broader approach that macroergonomics brings.

of human factors or ergonomics. Basically, rather Instead, an initial wide-ranging analysis will
than a “fitting the task to the man,” macroergo- identify existing elements of the organization,
nomics proposes to “fit the organization to the along with the links and the gaps. It will demon-
person or persons within that organization.” Yet strate work flow, information flow, decision
it is more than even that. In fitting the organiza- points, and the need for decision aids. In short,
tion to the people, the ergonomist assesses each when designing an organization, the ergonomist
element of an organization with the thought that needs to understand each of the systems within
each element has the potential for redesign. In that organization, the inside and outside pres-
addition, the ergonomist must also consider sys- sures, and the overarching mission and goals,
tems outside the organization that affect the as well as the intricacies of the culture and
organization. From the highest level of the orga- subcultures. Only by knowing these things, as
nizational hierarchy to the entry-level worker and well as knowing the research literature on orga-
from the most intricate technology to the simple nizational effectiveness, hierarchic structures,
interactions by the water fountain, all elements teamwork and so on, can the ergonomist assist
are interconnected with one another. All have an with designing a thoroughly harmonized organi-
impact on the achievement of an organization’s zation.
objectives. Macroergonomics evaluates and optimizes
Because of the nature of organizations (as the interface among human, machine, organiza-
systems of systems), the design process is neither tion, technology, and environment by examin-
linear nor singular, the way the design of a coffee ing the personnel subsystem, the technologic
cup or a computer wrist rest might be. Instead, subsystem, and the internal and external environ-
the process is complex, iterative, and ever- ments. At the same time, the assessment includes
changing as people, societies, technologies, goals, looking at the organization’s complexity—that is,
missions, and knowledge change. Although hu- both the segmentation of the organization, known
mans are apt to stay with what is familiar to as differentiation, and the integration of the or-
them, metamorphosis is a constant; perhaps it ganization, known as integration, formalization
is the only constant. Metamorphosis can occur (degree of standardization), and centralization.1,4,10
by chance or it can be managed according to The bottom line is that in a true macroergonomic
evidence-based facts, but it will continue none- project, the goal is to design (or redesign) any
theless. and all parts of the organization in order for the
According to Hendrick and Kleiner,1 organiza- entire organization to operate in a harmonized
tional psychology and macroergonomics differ in fashion. A harmonized fashion means that be-
their focus and approach; organization psycholo- cause of the design the organization (or work
gists are more inclined to use selection, incen- system) operates as smoothly, efficiently, and
tives, climate, and leadership to achieve objectives, safely as possible and everyone working there
whereas ergonomists redesign to ensure optimal experiences a sense of value, satisfaction, and
human interactions with “jobs, machines, and commitment.
systems.” It is my opinion that any separation Although this sounds like workplace nirvana,
of the two is arbitrary—that is, the examination it is close to the goal of all ergonomic design: to
and design (or redesign) of a work system will create products, places, and procedures that are
potentially include personnel systems, selection simultaneously efficient, effective, easy-to-use,
processes, and climate (described as part of and sufficiently challenging enough to be interest-
organizational psychology). Only by examining ing, as well as safe and comfortable. The differ-
the whole can an ergonomist know which ence between “regular” ergonomics, also known
portions need redesign. To leave out a part as microergonomics, and macroergonomics lies
because it is psychology or industrial engineer- primarily in the complexity, both in terms of effort
ing rather than macroergonomics defeats the and time.
40 PART I Overview and Conceptual Framework

THE MACROERGONOMIC PROCESS gaged in the decision-making process concerning

the work practices and activities that directly
Initial Evaluation affect their work lives. Because of this, knowledge
and power spread to each organizational level.
As seen by this explanation of ergonomics, the
Although some individuals refer to this as “buy-
first step in the process is to examine all systems
in,” there is more to it. It is a means and process
that influence the issue in question. In the case
to steadily introduce change into the everyday
study mentioned previously, all systems and sub-
business practices of an organization. During this
systems that might affect soldier fitness and mus-
progression, workers at all levels discover how to
culoskeletal injury status were examined. This
investigate and understand their own organiza-
included external factors such as level of fitness
tion, as well as how to introduce lasting change.
before enlisting on active duty, previous dietary
In fact, at the end of a successful macroergonomic
habits, history of exercise and injury during and
program, workers and managers may wonder
before basic training, and recommendations by
what the researchers did, because they “did all
various organizations such as the Centers for
the work themselves.”
Disease Control and Prevention (CDC) and the
It is important to understand the perspectives
American College of Sports Medicine. Internal
of the workers and supervisors at the start, as they
factors included the military structure and sched-
may have preconceived ideas that conflict with
ule, the physical training regimen, current march-
either the process or the research results. For
ing requirements, dietary habits, methods of
example, in this case, not all of the supervisors
seeking medical care, attitudes of the trainers,
believed that musculoskeletal injuries were a
intramural sports and accessible exercise facili-
problem during AIT (Figure 3-2, A) or later at a
ties, doctrine and standard operating procedures,
soldier’s permanent duty station or in a deployed
and so on. In this way, what existed before the
war-time situation. Yet, there were sufficient data
assessment was annotated and what existed at the
to show that all three are true. In fact, supervisors
time of the assessment was plainly delineated.
were not at all sure they could effect changes by
In addition, each system and each level within
the way they trained (and worked with) their
a system, including the organizational structure,
soldiers, which was the basis for the intervention
resources, agencies, personnel, policies, surveil-
(Figure 3-2, B).
lance systems, and communication systems, were
In investigating and reducing musculoskeletal
examined using a broad-to-focused approach.
injuries during the case study, careful attention
Meetings, interviews, and focus groups were con-
was paid to building communication systems
ducted with local supervisors and managers to
between researchers, workers, and supervisors on
ascertain attitudes, as well as noting who would
a regular basis.8 In fact, weekly meetings were
assist with change and who would resist
held between ergonomists and stakeholders
(Table 3-1). The best team member was identified
for each interaction. For example, commanders
Participatory Ergonomics reacted more positively when dealing directly
Orchestrating organizational change takes time. with the research team leader, whereas our civil-
Introducing changes systematically and gradually ian researchers or our physical therapy assistant,
using a participatory process throughout each who was an active duty sergeant, achieved better
level of the organization will vastly improve the results with drill sergeants and instructors. When
probability of success. The participatory process initially developing unit-led injury prevention
is one of the primary methods used during a mac- teams, the research team leader, who was also an
roergonomic project. During this process, workers occupational therapist with considerable experi-
and managers participate in identifying problems, ence running groups (as well as being a human
methods to investigate those problems, and the factors engineer), worked with the team leaders
development of solutions. They are actively en- to help them understand the important role of
Chapter 3 Macroergonomics 41

facilitating interaction among group members.

Don’t know This was particularly important, as many soldiers
do not learn how to facilitate open communication
No among soldiers, but merely expect that it will
happen. They are trained in leadership but not in
group process, group dynamics, motivation, and
Yes methods of recognizing and recording issues for
later resolution. The soldiers often know many of
0 10 20 30 40 50 the involved issues, but they must feel free to
A disclose them and often need subtle, yet pointed
questions or suggestions to help them recall and
Don’t know share pertinent information.

Using a Team Approach to Identify

and Fill the Gaps
The immediate team included personnel with
Yes backgrounds in research, ergonomics, physical
and occupational therapy, and athletic training. In
0 20 40 60 80 addition, a team of consultants was developed
B from the initiation of the project. These individu-
als received updates and could voice their opin-
FIGURE 3-2 A, Supervisors’ responses to the question,
ions and provide feedback throughout the process.
“Are there too many overuse injuries occurring in
The consultants included personnel with back-
your unit?” B, Supervisors’ responses to the ques-
grounds in preventive medicine, kinesiology, ex-
tion, “Can injuries be decreased by changing the way
ercise physiology, epidemiology, physical and
you train your soldiers?”
occupational therapy, and ergonomics. They
worked all over the country and were from orga-
nizations that included the CDC, the Department
of Defense Injury Prevention Integrated Process-
ing Team, the U.S. Army Physical Fitness School,
TABLE 3-1 Weekly Meetings Between
Ergonomists and the U.S. Army Center for Health Promotion and
Stakeholders Physical Fitness, and the U.S. Army Research
Institute for Environmental Medicine.
Month of Macroergonomic Number of The existing structure, procedures, and pro-
Project Meetings per Week cesses were evaluated by trainee supervisors and
subject matter experts (SMEs) from the immediate
1-6 4 ergonomic team. This information was compared
7-12 3.5 with research findings and recommendations for
13-18 2 preventing musculoskeletal injuries, as well as
being used to examine alternate methods of injury
Data from Rice VJ, Pekarek D, Connolly V et al: identification and early treatment. Consequently
Participatory ergonomics: determining injury control the gaps between what existed and what should
“buy-in” of U.S. Army cadre, Work 18(2):191-204, exist (according to the literature, supervisors, and
2002. SMEs) were used to develop best practice scenar-
Note: Numerous participatory meetings are required to
involve all levels of workers in the process. These are
ios for physical training of the soldiers.9 This
the average number of meetings per week during the included educational programs as well as changes
macroergonomic injury prevention program at Fort in standard operating procedures and exercise
Sam Houston, Texas. regimens. These solutions were broad-based, as
42 PART I Overview and Conceptual Framework

opposed to being targeted toward a specific cau- 10

sality or type of injury. However, by carefully
documenting the number and types of injuries
throughout the investigation process, we could 6
track how our implemented solutions influenced 4
injury rates. In this case, musculoskeletal injury
rates were measured in terms of medical clinic 2
visits. This overarching set of changes resulted in 0
a decrease in medical clinic visits of approximately Awareness Policies Procedures
11% for musculoskeletal injuries.5,9
FIGURE 3-3 Number of clinic visits for musculoskele-
tal injuries per 100 soldiers in training.
A Research-Based and Community Process
By tracking clinic visits as well as the reasons for
the visits, we were able to identify the type and after initial interventions such as increasing aware-
severity of each injury (as measured by time of ness, changing policies, and changing procedures
limited duty per injury). We also gathered infor- (Figure 3-3), the targeted interventions achieved
mation from a soldier with an injury and the even greater results. The targeted interventions
health care practitioner who treated the soldier. resulted in a 36.5% reduction in medical clinic
With this information, we could begin to identify visit rates for musculoskeletal injuries and a
potential contributing factors in order to target 48.6% reduction in limited duty assignments for
interventions. Clear outcome data should drive musculoskeletal injuries.5,7 All findings were also
decision making and intervention strategies. Mac- described in terms of dollars expended and troops
roergonomic evaluations and interventions can be readily deployable, both of which are important
costly. It is up to the ergonomic team to assure in a military environment.
the funding is well spent by demonstrating results
through evidence-based outcomes.
Simultaneously with the above system, process, THE ROLE OF OCCUPATIONAL
and procedural evaluations, as well as clinical AND PHYSICAL THERAPISTS
tracking, we administered surveys. Surveys were Most occupational or physical therapists will
gathered from all new health care specialist train- not take an assignment or consultation job that
ees and all graduating health care trainees, includ- requires true macroergonomics. Therapists are
ing those experiencing a musculoskeletal injury not trained to evaluate and design organizations
and the health care practitioners who treated their or the interactions between humans and technolo-
injuries. This information allowed us to identify gies from a systems perspective. Therapists spend
soldiers at greatest risk of injury, as well as the years studying and understanding normal and
primary contributing factors. Based on this infor- abnormal human development, interruptions to
mation, a targeted program of intervention was normal functioning, and therapeutic interventions
put into place. The primary contributor to injuries to help their clients return to their roles as spouses,
during AIT was the running portion of the Army parents, workers, students, and children. Well-
physical fitness program. trained therapists should understand the individ-
Significant organizational changes were re- ual. They should recognize how that individual
quired to put such a targeted intervention program can potentially fit into various environments
into place. Enacting these changes was possible during and after treatment, and they provide the
only because of the rapport, processes, regular guidance to help the individual get back to the
injury prevention and fitness council meetings, “job” of life. Most therapists have been involved
and cultural changes that had begun to take place in task analysis, especially on a physical and
over the previous 18 months. Although the previ- biomechanical level. Yet few therapists have
ous changes had resulted in decreased injuries studied organizational effectiveness, work behav-
Chapter 3 Macroergonomics 43

ior, criterion characteristics of performance, judg- count for collective groups of individuals who can
mental measures of performance, or the psycho- work and behave quite differently under diverse
social context of work performance from a systems conditions and situations. Some basic principles
perspective. Most know little about human sys- of macroergonomics follow.
tems integration, just as few ergonomists know • All relationships within an organization are
when and how to construct an ulnar splint or reflected throughout the organization. In us-
what type of movement patterns might be most ing a macroergonomic perspective, ergon-
efficient for a person with cerebral palsy; each omists recognize the impact of all relationships
profession has its own unique set of knowledge within an organization. For example, a hier-
and skills. archic structure will work well for certain
However, therapists can apply a macroergo- types of organizations and people, whereas
nomic approach to a specific problem or parti- a flat system will work better for others.
cipate on an ergonomic team. For example, in- The balanced scorecard approach,2,3 which
dividuals in a work setting might be experiencing helps each person and each section know
a large number of work-related musculoskeletal their role and how they contribute to the
disorders (WRMD). A typical microergonomic good of the whole, is based on this
approach would be to examine and redesign the principle.
workstations of all individuals who have sought • Each potential solution, and each decision
health care for a WRMD. A more comprehensive about design, depends on the results of assess-
approach might be to examine all workstations ments of the organization. Assessment results
and have employees complete a survey on their drive the design. These assessments can be
symptoms or identify the tasks associated with formal or informal and can consist of obser-
their job, in order to help determine physical risk vations, interviews, focus groups, surveys,
factors. An even larger perspective might involve or record reviews. If the goal is to conduct
addressing other contributing factors, such as the an analysis and redesign of an organization,
physical and psychosocial considerations associ- then a 10-step process described as macro-
ated with an impending plant closing, the aging ergonomic analysis and design (MEAD)
workforce, a predominance of workers who no might be used.1,4
longer fit the physical profile to easily use the
equipment (being overweight or underweight, too
short or too tall, or under strength), or an influx
of workers from a different culture with differing LARGE-SCALE AND LASTING CHANGE
values associated with work. Without a broader Ergonomists often choose a macroergonomic ap-
approach, a simple workstation change may influ- proach to achieve large-scale and lasting change
ence very little. (LSLC). The following additional principles apply:
• Any change must clearly support the mission
and goals of the organization.
A FEW PRINCIPLES • Any change must clearly reflect the culture
Ergonomics involves the applied study of humans and values of the organization.
and their capabilities and limitations across a • LSLC is unlikely to occur unless all relevant
broad spectrum of performance in order to design aspects of a system are involved.
products, places, and procedures to match those • LSLC is unlikely unless workers of all levels
capabilities and limitations. Thus all ergonomic understand and agree with the need for
design is human-centered, including designs as change. Dictated changes do not last; atti-
diverse as a particular medical tool and a road tude and belief changes do last.
system to produce a more fluid traffic flow. This • LSLC is more likely when workers of all
does not mean that all design is individual- levels help identify the problems and solu-
centered, as organizational design must also ac- tions (participatory ergonomics).
44 PART I Overview and Conceptual Framework

• LSLC occurs when each individual recog- finding a solution for a single individual with a
nizes his or her role. history of back pain and/or back surgery who
• LSLC occurs more readily when participatory could benefit from a supportive chair and a better
ergonomic methods are conducted from the workstation design. Another example would be if
top down, bottom up, and sideways in. a rash of injuries occurred after the introduction
• LSLC tends to occur when carefully and of a new process or tool. If that tool or process is
methodically introduced, not when intro- undoubtedly the culprit, then large-scale evalua-
duced quickly and dictatorially. tions and interventions are unwarranted. Basi-
• Although evidence-based design can per- cally, a microergonomic approach is best when
suade others that change is necessary, both there is no indication that a larger scale approach
the evidence and the display of the evidence will yield greater results.
must be relevant to the viewer. Limitations in resources can also dictate a
• Overall system change sets the stage, so that microergonomic approach. A macroergonomic ap-
targeted change can occur in a climate of proach is impossible without sufficient funds, per-
acceptance, yielding the greatest results. sonnel, time, or interest on the part of the client.
• Top-level support is essential. Sometimes, when resources are limited, a linear,
When the macroergonomic effort involves in- stepwise approach can be used for problem
jury prevention, it must also be recognized that solving, prioritizing those issues that are most
health care practitioners are consultants only. The important and implementing solutions as resources
workers and supervisors bear the primary respon- become available. An alternative would be to
sibility for maintaining their fitness and health. investigate with a macro approach but to imple-
Although it is not always possible to examine ment changes or interventions in a linear, one-at-
the same facility years later, in this case study a a-time fashion. A third option with low-level
follow-up evaluation occurred 2 years later. Data funding is to make changes but incur the charges
revealed that injuries and limited duty assign- over time.
ments had been reduced even further, with no Many ergonomists move from micro to macro
additional assistance from researchers or health approaches, using the “low-hanging fruit”—that
care providers.6 In the opinion of the researchers, is, quick achievement of lesser goals—to fuel their
this was because the knowledge and the tools future work to make bigger, lasting changes. This
were given to the soldiers and supervisors dur- technique works well in situations where costs
ing the macroergonomic intervention. They had and benefits of ergonomics are relatively unknown,
numerous classes on the most recent literature on or held suspect, by managers. As managers see
injury prevention, given on arrival at their assign- improvements and cost savings, they are more
ment, annually during recertification as drill ser- willing to invest in additional ventures to improve
geants, and during other regularly scheduled conditions.
training times. They were taught how to track
injuries and look for variations and possible causes
of those variations. Most importantly, this infor-
mation was permanently included in their stan- CONCLUSION
dard operating procedures. They owned it. It be- Therapists are unlikely to perform MEAD unless
came part of their normal, everyday job. they obtain substantial additional training, such
as attending a degree program or a series of college
courses. These are not skills that can be gained in
WHEN SHOULD A PRACTITIONER USE a short course. However, therapists can play a
A MICROERGONOMIC APPROACH? significant role in helping individuals and manag-
A microergonomic approach is appropriate when ers see the value of ergonomics through micro-
the identified problem is limited in scope. An ergonomic applications. Subsequently they can
example would be conducting an evaluation and suggest a supplementation of their efforts, and a
Chapter 3 Macroergonomics 45

Learning Exercises
Although the occupational therapy department in quantify the answers (or identify existing
your educational institution is a microcosm of the surveys you could use).
overall university, it is a good place to start think- 4. Discuss the evidenced-based outcome
ing about the use of a macroergonomic approach. measures that might be of interest to the
Imagine you are a consultant and your job is to students, staff, department head, and
evaluate the department regarding overuse inju- college president. Consider the ethics of
ries for both students and staff. The following are such a question. Which interests are more
some questions and exercises to help you think important? Which one is your “client”?
about the issues. 5. What other colleagues might you want on
1. List all the systems that might affect your team, and how do you think they
musculoskeletal injuries among students contribute to the project?
and staff. 6. Imagine you find other issues outside the
2. List all the issues that might also affect realm of musculoskeletal injuries. One
musculoskeletal injuries among students involves an instructor with partial
and staff. blindness who does not seem to have the
3. Identify information you would like to appropriate tools and assistance to do the
have from students, staff, and the college best job possible. How would you handle
or university. that situation, being that you were hired
a. Develop structured interviews for each for a different purpose? Role-play talking
group. with this instructor. Role-play talking with
b. Develop survey questions for both the department head about the issue.
students and staff for which you can

team approach, in order to attain large-scale, long- Multiple Choice Review Questions
lasting organizational changes through macro-
ergonomics. Having an understanding of the 1. Macroergonomics is:
power of system-wide evaluations and interven- A. fitting a task to the individuals who do
tions can help therapists explain why certain the task.
levels of achievement may, or may not, be met B. designing physical items so they fit the
using a specific technique or technology. person using them and can be used by
Based on the case study provided in this other employees also.
chapter, what actions might an ergonomic team C. fitting the organization to the people
take during the initial evaluation phase of a in the organization.
macroergonomic project? What actions did the D. harmonizing the operation of an
ergonomic team evaluating musculoskeletal inju- organization by designing or
ries take? Which principles of macroergonomics redesigning any and all parts of the
did the ergonomic team evaluating musculo- organization.
skeletal injuries seem to consider? How would
you have done things differently? What evidence-
based outcome measures did the ergonomics team
use? What other measures do you assume they
used (but that may not be mentioned in this
46 PART I Overview and Conceptual Framework

2. A macroergonomic project may involve 6. Evidenced-based outcomes, when

which of the following evaluations? considering macroergonomics, include
(Select all that apply.) which of the following? (Select the best
A. Work flow single answer.)
B. Decision points A. Consideration of the basic mission of
C. Periods of high-volume or high-stress the organization
work B. The individual characteristics of the
D. Mission and goals of the organization employees (such as strength and
E. Functional work capacities of the endurance)
workers C. Alignment with traditional clinic-based
outcomes in occupational therapy
3. Differentiation, when speaking of practices, such as functional lifting
macroergonomics, refers to: and carrying abilities of workers
A. the integration of the organization. D. Are not important; we cannot measure
B. the degree of standardization in the everything anyway
C. the segmentation of the organization. 7. Research, data collection, and data
D. the centralization of the organization. comparison after a design intervention are
part of the ergonomic process.
4. Participatory ergonomics refers to: A. True
A. involving the members of the work B. False
force in the ergonomic evaluation and
solution process. 8. Which of the following should drive
B. the communication and integration design decisions within an organization?
among the ergonomic team (Select the single best answer.)
members. A. Interview results
C. the interactions among the workers B. The top decision maker for the
that may affect ergonomics in the organization
workplace. C. Ergonomic assessments results
D. considering the hierarchy and D. Subject matter expert opinions
communication systems as part of the E. Open-literature research results
ergonomic evaluation process.
9. Principles that apply to using
5. A macroergonomic evaluation process macroergonomics to achieve large-scale
looking at musculoskeletal injuries in the and lasting changes (LSLC) within an
workplace would include: organization include which of the
A. identifying the gaps between what following? (Select all that apply.)
currently exists within an organization A. Dictated changes can result in LSLC,
and the best practices within the while attitudes and beliefs change.
research literature. B. LSLC is more likely when workers of
B. evaluating all systems that affect the all levels help identify the problems
workforce. and solutions (participatory
C. evaluating hiring, firing, and prehire ergonomics).
practices. C. Typically the culture and values of an
D. evaluating the workforce population, organization, although important, do
including demographics such as not affect issues of an ergonomic
gender and race. nature, such as musculoskeletal
E. all of the above injuries.
Chapter 3 Macroergonomics 47

D. If workers of all levels understand and 7. Rice VJ, Mays MZ: Combining models to solve the
agree with the need for change, LSLC problem: macroergonomics and public health. In
Proceedings of the Human Factors Society 46th
is more likely.
Annual Meeting, Santa Monica, Calif, 2002, Human
Factors Society.
10. A macroergonomic approach is used 8. Rice VJ, Pekarek D, Connolly V et al: Participatory
when which of the following are true? ergonomics: determining injury control “buy-in” of
(Select all that apply.) U.S. Army cadre, Work 18(2):191, 2002.
A. The ergonomic consultant is an 9. Rice VJB, Connolly V, Bergeron A et al: Evaluation
academic researcher. of a progressive unit-based running program during
advanced individual training, Technical Report No.
B. The complexity of the situation
Aegis T02-1, Fort Sam Houston, Tex, 2002, U.S.
demands that a larger scale evaluation Army Medical Department Center and School.
and set of solutions be developed. 10. Robertson MM: Macroergonomics: a work system
C. The ergonomic consultant wants a design perspective. In Proceedings of the SELF-ACE
long, involved project, so they will 2001 Conference—Ergonomics for Changing Work,
have a greater income for a longer Montreal, 2001.
period of time.
D. A company wants long-term, lasting
organizational change. SUGGESTED READING
E. When there are sufficient subject Brown O: Participatory ergonomics: from participation
matter experts available to put research to high involvement ergonomics. In Brown
O, Hendrick H, editors: Human factors in organiza-
together a good, strong ergonomic
tional design and management, Amsterdam, 1996,
team approach. North-Holland.
Dray SM, Eason K, Gower J, Henderson DA: Macroer-
gonomics in organizations. In Brown ID, Goldsmith
REFERENCES R, Coombes K, Sinclair MA, editors: Ergonomics
1. Hendrick H, Kleiner B: Macroergonomics: an intro- International (Proceedings of the 9th Congress of the
duction to work system design, Santa Monica, Calif, International Ergonomics Association, Bournemouth,
2000, Human Factors and Ergonomics Society. England, September, 1985), Philadelphia, 1985,
2. Kaplan RS, Norton DP: Alignment: using the Taylor & Francis.
balanced scorecard to create corporate synergies, Haines H, Wilson JR, Vink P and others: Validating a
Cambridge, 2006, Harvard Business School Press. framework for participatory ergonomics (the PEF),
3. Kaplan RS, Norton DP: Translating strategy into Ergonomics 45(4):309, 2002.
action: the balanced scorecard, Cambridge, 1996, Heacox NJ, Holly AH: Separate sides of the same coin:
Harvard Business School Press. organizational design and (good) design of a deci-
4. Kleiner BM: Macroergonomics: analysis and design sion support tool. In Proceedings of the Human
of work systems, Appl Ergon 37:81, 2006. Factors and Ergonomics Society 49th Annual Meeting,
5. Rice VJ, Bergeron A, Connolly V et al: A macroer- Orlando, Fla, 2005.
gonomic and public health approach to injury Hendrick HW: Macroergonomics: a conceptual model
control, San Antonio, 2002, presented to the Asso- for integrating human factors with organizational
ciation of the United States Army. design. In Brown O, Hendrick H, editors: Human
6. Rice VJ, Gable C: A combined macroergonomics & factors in organizational design and management,
public health approach to injury prevention: two Amsterdam, 1996, North-Holland.
years later. In Proceedings of the Human Factors Hendrick HW: Organizational design and macroergo-
Society 46th Annual Meeting, Santa Monica, Calif, nomics. In Salvendy G, editor: Handbook of human
2004, Human Factors Society. factors and ergonomics, New York, 1997, Wiley.
PA R T II Knowledge, Tools, and Techniques

Ergonomics and Work
Ev Innes

Learning Objectives
After reading this chapter and completing the exercises, the reader will be able to do the following:
1. Identify when to use various types of work-related assessments for individuals and job requirements.
2. Identify a range of work-related assessments that have acceptable reliability and validity for use in clinical
3. Describe a range of assessments used in workplace assessment and job analysis, including ManTRA, OWAS,
REBA, RULA, and the Strain Index.

Functional capacity evaluation (no job) (FCENJ). place with an identified employer. Results [are] con-
Assessments of this type are “focused on an individual sidered not generalisable to other tasks or workplaces.
worker performing physical demands related to work . . . [FCEJs are] primarily conducted to determine the
in general, rather than to a specific job or duties. worker’s suitability to return to work and develop an
Results [are] considered generalisable to general work appropriate rehabilitation plan, either in the form of a
demands or occupational categories, but not to specific Return to Work (RTW) plan or a clinic-based work con-
jobs. . . . [FCENJs are] performed to determine the ditioning/hardening program” (p. 57)52
worker’s ability to safely perform general physical Physical ergonomic assessment. Assessments that
demands and skills related to work, rather than a spe- examine and measure the physical aspects of a job,
cific job. . . . [FCENJs are] also used to identify further task, and/or environment. This may include measure-
rehabilitation, training and/or education options for the ment and observation of workers’ posture, movements,
worker.” (pp. 56-67) 52 strength, and range of motion; weight handled;
Functional capacity evaluation (job) (FCEJ). force exerted; distances traveled; working heights;
Assessments of this type are “focused on an individual exposure times; and light, sound, and temperature
worker performing specific tasks within a specific work- levels.

Chapter 4 Ergonomics and Work Assessments 49

CASE STUDY ical work demands, and also tools to determine a

range of physical hazards associated with work.
Kim is a therapist employed by a vocational and occu- The case study of Kim is used to explore the range
pational rehabilitation provider. The company provides of assessments therapists may consider using and
injury prevention and ergonomic assessment services to the clinical decision making associated with the
industry and case management and occupational rehabili- scenarios presented.
tation services for workers with injuries. The referred
workers with injuries have varying types of predominantly
musculoskeletal injuries; although the aim is to return
them to their preinjury jobs and employers, this is not SELECTION OF WORK-RELATED
always possible. Kim has a number of new referrals, ASSESSMENTS
including the following: As the first step in all these new referrals, Kim
• Trevor, a 33-year-old crane chaser. A crane chaser must decide what information is needed and the
fixes slings to loads for cranes and winches and best way to obtain it. The most common methods
directs the movement of loads, ensuring they do not of data collection therapists use are observation,
exceed lifting capacities. Trevor sustained a severe interview, and measurement.52 We will look at the
crush injury to his left lower leg 8 months ago when range of assessment options Kim will consider for
a sling slipped on a load and a large (1-tonne [1.1- each of these referrals.
ton]) coil of steel fell on his leg. Trevor’s left ankle In order to select appropriate work-related as-
is fused; he has reduced lower limb strength and sessments to use, Kim must consider the purpose
reduced tolerance for standing and walking. He is of the assessment, the level of assessment (ensur-
unable to return to his previous job and has been ing consistency between the purpose and level),
referred to determine what work he is capable of and then the attributes of the assessment, includ-
doing. ing utility and dependability (Figure 4-1).47 Work-
• Lucy, a 38-year-old office administrator. She has related assessments48 purposes are as follows:
developed an overuse injury affecting her nondom- To determine the need for intervention
inant right upper limb after a significant increase in To assess an individual’s ability to perform the
keyboard work (numeric data entry and word pro- roles, duties, tasks, task elements, and phys-
cessing) related to producing end-of-financial-year ical demands of work
reports. She has had 2 weeks off work and has been To determine effort during work tasks
referred for a return-to-work program. To measure and document outcomes of work-
• The “Women’s Health at Work” program, run by an related interventions
area health service, is concerned about the muscu- To evaluate programs and engage in research
loskeletal risks for female workers on small family- The level of the assessment is determined by
run market gardens in the area. They want the risks ensuring consistency between the worker’s level
identified and assessed and recommendations for of function being assessed (role, activity, tasks,
risk control provided. skill, and/or body system function) and the job
• A manufacturing company with some sections level (job position, duties, tasks, task elements,
reporting a large number of injuries affecting work- and/or elemental motions) (Table 4-1; Figure
ers’ upper limbs and backs. The company has 4-2).49,93
requested an assessment of these areas to identify
potential hazards and develop interventions to
Functional capacity evaluations (FCEs) conducted

T his chapter will introduce a range of work-

related assessments used by therapists to
assess workers’ abilities to perform general phys-
when there is no specifically identified job or
employer to return to are referred to here as func-
tional capacity evaluation (no job), or FCENJ.
50 PART II Knowledge, Tools, and Techniques

Qualified and experienced

Referral Identify WRA required
health professional

Selection process
Purpose of WRA

Level of WRA

Balance between utility

and dependability

Data collection WRA selected

Data analysis Data sources
methods and processes WPA/FCEJ/FCENJ

Results documented/reported, Recommendations/intervention

including conclusions drawn and/or plan implemented
recommendations made

FIGURE 4-1 Model process of excellence in work-related assessments (WRA). (From Innes E: Factors influencing
the excellence of work-related assessments in Australia, Unpublished PhD thesis, Perth, Western Australia, 2001, Curtin
University of Technology.)

TABLE 4-1 Definitions of Individual Performance and Work Levels

Individual Work

Lifetime role—career developed over lifetime; Career—general course of action or progress

not context dependent through life; may be linear, expert, spiral or
transitory, or a combination
Current role—worker; dependent on context Job position—complex of tasks and duties for any
Activities—complex collection of tasks that result Job duties—major activities involved in the job,
in an identifiable whole (e.g., making a table) consisting of several related tasks
Task—discrete identifiable component that Task—a discrete unit of work performed by an
contributes to a whole activity (e.g., hammering individual; logical and necessary step of a duty;
a nail) typically has identifiable beginning and end
Skill—ability to perform specific physical tasks Task elements—smallest step into which it is
(e.g., manual dexterity) practical to subdivide any work activity without
analyzing separate motions, and so on
Body system—physical, cognitive, and psychologic Elemental components—very specific separate
aspects of function (e.g., strength, balance, color motions or movements (biomechanical
discrimination) aspects); may also include cognitive and
psychologic variables

From O’Halloran D, Innes E: Understanding work in society. In Whiteford G, Wright-St Clair V, editors: Occupation
and practice in context, London, 2005, Churchill Livingstone.
Chapter 4 Ergonomics and Work Assessments 51

Individual Work-related Assessments Work

Vocational assessment
Life role Career
Work trial

Role On-the-job evaluation Job position

Workplace assessment
Activity Job duties
Situational assessment
Work simulation
Work sample (actual job)

Task Work sample (simulated job) Tasks

Work capacity evaluation device

Functional capacity evaluation
Work sample (cluster trait)
Skill Task elements
Work sample (single trait)

Body system Physical capacity evaluation Elemental components

Psychometric test

FIGURE 4-2 Work-related assessments relevant to individual performance and work levels. (From O’Halloran D,
Innes E: Understanding work in society. In Whiteford G, Wright-St Clair V, editors: Occupation and practice in context,
London, 2005, Churchill Livingstone.)

They are “performed to determine the worker’s in Hong Kong, VCWS and Baltimore Therapeu-
ability to safely perform general physical demands tic Equipment Technologies (BTE) equipment
and skills related to work, rather than a specific are popular (Figure 4-3).70 In Europe the IWS
job” (p. 57)52 or job duties. These types of assess- FCE, ERGOS, Ergo-Kit FCE, Blankenship FCE,
ments are considered generalizable to general and VCWS are used.34,57,104,110
work demands but not to specific jobs and can be Kim needs to decide which FCENJ will be
used to identify further rehabilitation, training, appropriate to use to determine Trevor’s physical
and/or education options for workers.52 abilities for work in general (purpose of assess-
Therapists may use a range of commercially ment). As the specific job or position has not been
available or published FCEs. The assessments identified, the assessment will focus on the general
commonly used vary from country to country. In tasks and task elements associated with work that
Australia the most popular systems are WorkHab Trevor can do (level of assessment). The utility
FCE, Isernhagen Work Systems (IWS) FCE, Ergo- and dependability of the FCENJ also need to be
science Physical Work Performance Evaluation considered. Kim will consider which work capac-
(PWPE), Blankenship FCE, Key Functional Ca- ity evaluation devices, FCE systems, and/or lifting
pacity Assessment, Workability Mk III, EPIC Lift assessments will be used (Figure 4-4).
Capacity (ELC) Test, WEST Standard Evalua-
tion, Progressive Isoinertial Lifting Evaluation
(PILE), and Valpar Component Work Samples WORK CAPACITY EVALUATION DEVICES
(VCWSs).18,55,122 In the United States, the IWS FCE, Work capacity evaluation devices are computer-
PWPE, Blankenship FCE, WorkSTEPS, and ERGOS linked and capture assessment information. They
Work Simulator are more commonly used,72 and can also be programmed for work conditioning
52 PART II Knowledge, Tools, and Techniques

FIGURE 4-3 Examples of popular work-related assessments. A, Valpar Component Work Sample 19—Dynamic
Physical Capacities. B, ERGOS Work Simulator—Panel 3 Work Endurance Component. C, Baltimore Thera-
peutic Equipment Technologies Work Simulator II.

or hardening programs. Work capacity evaluation Baltimore Therapeutic Equipment

devices tend to assess at the task and task element Technologies Work Simulator II
levels. The BTE WS was the first developed and has static
and dynamic modes. With its various attach-
Baltimore Therapeutic Equipment ments, a wide range of movements associated
Technologies with various functional tasks can be simulated. It
BTE has three work capacity evaluation devices: is used primarily for upper limb assessment and
the BTE Work Simulator II (BTE WS), the BTE intervention. Test-retest reliability for a range of
Primus, and the BTE Evaluation Rehabilitation attachments is considered good to excellent, with
(ER). the static mode more reliable and accurate than
Chapter 4 Ergonomics and Work Assessments 53

Safe WRA

Qualitative attributes Quantitative attributes

Accurate Measurable
Comprehensive Objective
Credible Reliable
Flexible Reproducible
Practical Standardized
Relevant Structured
Useful Valid

FIGURE 4-4 Utility and dependability Utility Dependability

constructs of work-related assess-
ments. (From Innes E, Straker L: Attri- Application
Validity of results Reliability
butes of excellence in work-related as-
sessments, Work 20[1]:63, 2003.) Specific Generalizable

the dynamic mode.* Studies examining aspects of It incorporates a computerized version of the ELC
validity have also been conducted, with varying Test and the Functional Range of Motion (FROM)
results.† Assembly Test as part of its overall FCE. Test-
retest reliability of the FROM Assembly Test is
Baltimore Therapeutic Equipment good to excellent,79 but no other studies using
Technologies Primus other parts of this system have been published.
The BTE Primus is also able to simulate a range The research on the ELC Test also applies, as it is
of movements associated with functional tasks. It included in the BTE ER.
has isotonic, isometric, and isokinetic modes and
has applications for the upper and lower limbs ERGOS Work Simulator
and trunk. As for the BTE WS, the static testing The ERGOS Work Simulator consists of five test
mode of the BTE Primus has better test-retest reli- panels that use simulated work tasks to assess
ability than the dynamic mode.65,108 Fewer attach- strength, body mechanics, cardiovascular endur-
ments have been examined for reliability and ance, movement speed, and accuracy. Results
validity than for the BTE WS, possibly because it are criterion-referenced and use Methods-Time-
was developed more recently. Measurement (MTM) industrial standards to inter-
pret a person’s performance.
Baltimore Therapeutic Equipment Technologies Published reliability studies have examined
Evaluation Rehabilitation only Panel 1 (lifting—static and dynamic) (reli-
The BTE ER Functional Testing System was for- ability of computer versus human instructions)75
merly known as the Hanoun Medical Functional and Panel 5 (seated work tolerances and upper
Occupational Capacity Unbiased System (FOCUS). limb/hand function).8 Concurrent validity of the
ERGOS with other FCE approaches was not dem-
*References 14, 15, 28, 29, 50, 60, 87, 115, 116. onstrated,25,102 indicating that the various systems

References 4, 5, 7, 27, 30, 32, 51, 60, 101, 121. measure different aspects.
54 PART II Knowledge, Tools, and Techniques

FUNCTIONAL CAPACITY EVALUATION (most systems incorporate pre-existing and

Almost all the FCE systems in use are based on established upper limb and hand function
the U.S. Department of Labor’s physical demands tests, such as the Crawford Small Parts Dex-
for work118 or include similar aspects. Each system terity Test, Hand Tool Test, Minnesota Rate
has protocols and subtests for determining the of Manipulation Test/Minnesota Dexterity
following: Test, O’Connor Finger Dexterity Test,
Working positions—sitting, standing O’Connor Tweezer Dexterity Test, Purdue
Manual handling/exertion—lifting, carrying, Pegboard, and/or Jamar Grip Strength
pushing, pulling Dynamometer [Figure 4-5])
Mobility—walking, climbing, crawling Other demands, such as seeing, hearing, and
Other work postures and nonmaterials han- speaking, are usually not formally tested but are
dling—stooping or bending, crouching, commented on if there are difficulties evident dur-
kneeling, balancing ing testing.
Upper limb and hand function and manipula- Although many of the FCEs assess similar items
tion—reaching, handling, fingering, feeling (e.g., lifting, carrying), they determine these in

FIGURE 4-5 Examples of various hand function assessments. A, Hand-Tool Dexterity Test. B, Minnesota Rate
of Manipulation Test. C, O’Connor Finger Dexterity Test. D, O’Connor Tweezer Dexterity Test. E, Purdue
Chapter 4 Ergonomics and Work Assessments 55

different ways, and so results cannot be used Test-retest reliability ranges from moderate to
interchangeably or compared. This has been dem- good for lifting tests, and poor for manipulation
onstrated by poor correlations among several tests.33 Inter-rater reliability was moderate to good
FCEs measuring apparently the same physical for the same subtests. Construct and concurrent
demands.46,102,103 validity have also been examined for the Ergo-
Kit.46,63,102 Findings indicate that results are not
Ergo-Kit Functional Capacity Evaluation interchangeable between different FCEs, and self-
The Ergo-Kit FCE (Figure 4-6) is a relatively reports of lifting capacity should not replace actual
recently developed FCE that incorporates 55 stan- testing of lifting capacity.
dardized work-related tasks. It includes the Physi-
cal Agility Tester (PAT), which is used to test Ergoscience Physical Work Performance
work postures and movements, handling and Evaluation
dexterity, lifting and carrying, and simulation of The PWPE consists of 36 standardized tasks
work-related tasks. Commercial information about covering six areas: dynamic strength, position
the Ergo-Kit is currently available only in Dutch, tolerance, mobility, balance, endurance, and co-
although a number of research publications are ordination and fine motor skills.24 It has substan-
available in English.33,46,63,102 tial test-retest reliability for the dynamic strength

FIGURE 4-6 Ergo-Kit Functional Capacity Evaluation. A, Ergo-Kit FCE. B, Lifting a weighted crate. C, Physical
Agility Tester (PAT), set for low-level task. (Courtesy of Ergo Control.)
56 PART II Knowledge, Tools, and Techniques

tests, fair to substantial for position tolerance published in conference proceedings.6,67,107 Work-
tests, and poor to moderate for mobility tests.117 ability Mk III has moderate content validity,51,109
Inter-rater reliability is also substantial for most but no recent studies have been published.
tests, with the mobility tests having only fair to
moderate reliability.24 The PWPE has been exam-
ined for some aspects of concurrent validity, with LIFTING ASSESSMENTS
moderate correlation between the overall work
level recommended and the level of work cur- EPIC Lift Capacity Test
rently performed.64 The ELC Test77,78 has superseded the WEST Stan-
dard Evaluation74,92 as a test of lifting (Figure 4-7).
Isernhagen Work Systems Functional It tests occasional and frequent lifting over three
Capacity Evaluation
The IWS FCE consists of 20 work-related tests
covering weighted tasks, flexibility and positional
tasks, static work, ambulation and mobility tasks,
and upper limb coordination.54 End-points of the
assessment are primarily based on therapists’
ratings of physiologic and biomechanical signs of
effort to determine safe, maximum performance
levels (kinesiophysical approach).36,53
The IWS FCE is the most extensively researched
FCE available (in 2007). It has well-established
test-retest reliability for those with and without
back pain, especially the lifting subtests.10,96,97 Al-
though the IWS FCE was originally developed as
a 2-day assessment, recent research has indicated
that 1 day is adequate, without losing reliability.98
Intra-rater reliability is also good.31,35,99,100
Validity has also been extensively studied and
found to be weakly linked to a greater likelihood
and speedier return to work38,39,76; however, it did
not predict recurrence of back injury.37,38 Com-
parison with other FCEs indicated that results
were not interchangeable.46,103 This was also the
case when self-reported lifting capacity and clini-
cal examination by a physician were compared
with IWS FCE results,9,63 indicating that assessing
actual physical abilities through an FCE is neces-
sary to gain an accurate picture of a worker’s

Other Functional Capacity Evaluation Systems

Other FCE systems commonly in use have limited
peer-reviewed publications regarding their reli-
ability and validity. The Blankenship FCE, Key
FCA, WorkHab FCE, and WorkSTEPS have no
peer-reviewed studies published on reliability or FIGURE 4-7 EPIC Lift Capacity Test—waist to shoulder
validity,34,50,51 although some papers have been lift.
Chapter 4 Ergonomics and Work Assessments 57

ranges (waist-to-shoulder, floor-to-waist, floor-to- not; formwork carpenters and office workers) has
shoulder), and uses multiple measures to deter- also been demonstrated (VCWSs 8, 19, and
mine safe end-points for the lifts (biomechanical, 204).66,104,105,110
psychophysical, and aerobic). Normative data are
available. It has good to excellent test-retest and
inter-rater reliability1,50,77 and is able to determine FUNCTIONAL CAPACITY EVALUATION (JOB)
change after treatment.78 Functional capacity evaluations (job) (FCEJ) are
“primarily conducted to determine the worker’s
Progressive Isoinertial Lifting Evaluation suitability to return to work and develop an appro-
The PILE81-83 is a lifting assessment using two priate rehabilitation plan, either in the form of a
ranges; the lumbar test from floor to waist (0 to return-to-work program or a clinic-based work
76 cm [30 inches]) and the cervical test from waist conditioning/hardening program” (p. 57).52 In
to shoulder (76 cm [30 inches] to 137 cm [54 Australia FCEJs are often conducted in conjunc-
inches]). The PILE uses endpoints based on psy- tion with a workplace assessment (WPA) in which
chophysical, aerobic, and safety criteria. Norma- the therapist does an on-site assessment of the
tive data are available. worker’s preinjury duties and potential suitable
The PILE has good to excellent test-retest and duties that may be included in a return-to-work
inter-rater reliability for both people without inju- plan. The WPA also includes assessment of the
ries and those with back and neck pain.41,45,69,71,81 work environment, including any equipment or
Construct validity to determine change in lifting tools that may be used. In New South Wales,
ability after intervention has been demonstrated Australia, a return-to-work plan cannot be ap-
in a number of studies.20,40,68,84,123 proved unless a WPA has been conducted by an
occupational therapist or physiotherapist.
Therapists often design their own FCEs, espe-
WORK SAMPLES cially if assessing a worker’s ability to return
to a specific job.18,55,72 The preferred type of FCEJ
Valpar Component Work Samples for many therapists is a battery of tests of the
There are over 20 Work Samples that use general- therapist’s own design that may use elements
ized worklike tasks administered in a standard- of established FCEs, when the subtests are ap-
ized manner. Results are compared with industrial propriate and relevant to the specific job to
standards (MTMs). The work samples can also be which the worker is returning.18,52,72 Many also use
used as part of a work hardening program. The work simulation, such as setting up a keyboard
work samples cited most frequently in the litera- task for a worker returning to computer-based
ture are VCWSs 4 (upper extremity range of duties.
motion), 8 (simulated assembly), 9 (whole body Kim will use an FCEJ to determine Lucy’s
range of motion), 11 (eye-hand-foot coordina- current abilities and how these relate to her spe-
tion), 19 (dynamic physical capacities) and 204 cific work requirements in order to develop an
(fine finger dexterity) (Figure 4-8). appropriate return-to-work plan. Some compo-
Other than information reported by Valpar on nents of standardized FCEs will be used, such as
its website regarding data used to establish learn- upper limb reaching components. Kim will also
ing curves for the work samples,119 no peer- simulate some of Lucy’s job demands by setting
reviewed studies on reliability for these work up a data-entry task on a computer workstation
samples have been published. Good test-retest similar to that used by Lucy at work. Kim will
(VCWSs 4, 9, and 19) and inter-rater reliability make modifications and adjustments to the
(VCWS 19) have been reported in conference pro- workstation to determine what is optimal for
ceedings and research theses.2,3,114 Construct valid- Lucy. Kim may use computer workstation check-
ity for the ability to differentiate between groups lists as well as observing and measuring Lucy’s
(those who are sick-listed and those who are performance.
58 PART II Knowledge, Tools, and Techniques

FIGURE 4-8 Examples of several Valpar Component Work Samples. A, VCWS 4—Upper Extremity Range of
Motion. B, VCWS 8—Simulated Assembly. C, VCWS 9—Whole Body Range of Motion.

ASSESSMENT OF PHYSICAL body discomfort maps, and Rapid Upper Limb

ERGONOMICS OF JOBS Assessment (RULA). More than 70% also used
In a survey of certified professional ergonomists,22 ergonomic checklists.
the most common tools used by more than 80% Other observational techniques frequently
of respondents were tape measures, video and referred to in the literature are whole body pos-
digital cameras, stopwatches, and laptop comput- tural assessments—Ovako Working Posture Anal-
ers. More than half also used spring gauges, scales ysis System (OWAS)58,59 and Rapid Entire Body
(load cells), goniometers, light meters, sound Assessment (REBA)44—and upper limb posture
pressure meters, and thermometers. The most and hand use assessments—RULA85 and the Strain
common direct measurement techniques were the Index.89,90 A recently developed observational
use of grip and pinch dynamometers and push- technique for whole body assessment also in use
pull force sensors. The most popular observa- is Manual Tasks Risk Assessment (ManTRA).13
tional techniques included the National Institute Kim considers the various options regarding
for Occupational Safety and Health (NIOSH) lifting assessing the musculoskeletal hazards and risks
equation, psychophysical material handling data, for the “Women’s Health at Work” program in
Chapter 4 Ergonomics and Work Assessments 59

family-run market gardens and the manufacturing and to make an assessment of exposure to mus-
company. culoskeletal risk factors.13 When used in the work-
place it is used by a team, including workers who
perform the tasks assessed and staff responsible
GENERAL ERGONOMIC ASSESSMENT AND for manual task risk management.13 ManTRA
JOB ANALYSIS CHECKLISTS has been used in a variety of workplaces such
There are almost as many ergonomic and job as mining, food production, construction, and
analysis checklists as there are therapists who health.11-13,113
conduct assessments of work. Each therapist has A task is assessed as a whole, rather than as
his or her preferred checklist or has developed one task elements, and the assessment is based on a
based on components from others. As with FCEs, specific person’s performance of the task, not
the ergonomic and job analysis checklists most people generally. The tool “combines information
commonly used are custom-made (by self or about the total time for which a person performs
company).22 Two main types of checklists have the task in a typical day (exposure) and the typical
been identified: analysis and action checklists.62 time for which the task is performed without
Analysis checklists present a list of items that are break (duration)” (p. 2).13 Four body regions
analyzed and evaluated by the user. They are (lower limbs, back, neck/shoulder, and arm/
useful for inventory purposes to ensure that wrist/hand) are all considered for five character-
important aspects of a job or workplace are con- istics of the task (cycle time, force, speed, awk-
sidered, to identify problem areas and compare wardness, and vibration).13 Scores are calculated,
different jobs or workplaces.62 Action checklists and intervention may be indicated if certain criti-
present a list of actions that can be taken to cal values are exceeded (Figure 4-10).
improve the existing designs or conditions and are
useful for prioritizing improvement options and Ovako Working Posture Analysing System
training needs.62 The Ovako Working Posture Analysing System
Checklists rely on the observation skills of the (OWAS) was developed as a “practical method for
people using them and are often based on subjec- identifying and evaluating poor working postures”
tive assessment, which may lack precision.62 The (p. 199).59 It requires observation of work tasks
role of checklists is “as one of a range of practical every 30 or 60 seconds, and the postures of the
evaluation tools for conducting social dialogue back, upper limbs, and lower limbs are rated.80
between employers, workers, users, and others The various posture combinations are classified
concerned” (p. 1750).62 Many occupational health into four action categories to determine whether
and safety authorities in various countries have a intervention is required and how quickly the
range of checklists available. There are also many problem should be addressed. The length of time
published in various ergonomics texts, such as spent in various postures is also considered.80
Kodak’s Ergonomic Design for People at Work.26 Figure 4-11 demonstrates OWAS postures. OWAS
An example of job analysis based on observa- is considered easy to use and is focused on assess-
tion of physical demands that Kim conducted ing posture, not risk of manual handling.94 There-
for the “Women’s Health at Work” program is fore, if you wish to determine the risk of manual
Figure 4-9. handling operations, other tools should be used,94
such as ManTRA, the NIOSH lifting equation (see
Chapter 11), or Manual Handling Assessment
The OWAS method was originally developed
Manual Tasks Risk Assessment for use in the Finnish steel industry, but it has
ManTRA was developed to assist health and safety also been used in a wide range of other areas,
inspectors audit workplaces for compliance with including in the mining industry,43 with cleaners,
the Queensland Manual Tasks Advisory Standard with mechanics, with construction workers, with
1. Squat (with or without stool) or stand and bend at hips
2. Reach forward bilaterally
3. Using dominant hand, push knife beneath surface to cut roots
4. Pull plant from the soil with nondominant hand
5. Tap roots with knife to remove soil
6. Place to the side to be bundled
7. Repeat steps 2-6 with nondominant hand
8. Gather a bundle (2-3 plants)
9. Tie using a plastic tie (bilateral movement)
10. Place bundle to the side
Environment: Outdoors during daylight hours
Duration: Task performed for up to 3 hours at a time
Equipment: Plastic ties, blunt curved knife, gloves, hat, sunglasses, boots, sleeve protectors

Physical demand Frequency Comments

Squatting Constant Without stool
Kneeling/crawling Infrequent Moving while squatting
a) Forward Constant Mostly bilateral; repetitive over whole task and sustained for short periods
b) Sideways Frequently Predominantly with nondominant hand; repetitive
Neck postures:
a) Flexion Constant Sustained
b) Rotation Infrequent
Side flexion Infrequent Sometimes work for short instances in this position
Shoulder postures
a) Abduction Constant Sustained/repetitive–bilateral
b) Flexion Constant Sustained/repetitive–bilateral
Wrist postures:
a) Flexion Occasional Ulnar deviation (occasional)
b) Extension Frequent To push knife into soil, repetitive, dominant hand
c) Pronation Constant Main position–bilateral
d) Supination Occasional Bilateral
Fine hand coord. Occasional Tying and picking roots
Gripping/grasping Constant Constantly grasping knife and/or vegetables while cutting and tying
a) Floor-to-knee Infrequent Transferring vegetables from one side to the other–v. light
Pulling Occasional Pull plant out; pull roots off
Exposure to Constant Work outdoors
extreme temps
Exposure to Constant Fertilizer and pesticides; low-level exposure

FIGURE 4-9 Example of Task Analysis based on observation: cutting and bunching English spinach. (From
Crowther A, Fonti F, Quayle L: Musculoskeletal pain and injury experienced by Chinese women working on market gardens:
workplace assessment report, Sydney, New South Wales, 2005, Sydney West Area Health Service Women’s Health at Work
Program and The University of Sydney.)
Manual Tasks Risk Assessment Tool (ManTRA) V 2.0 Scoring Matrix
Task codes Cumulative
Body region Total time Duration Cycle time Repetition risk Force Speed Exertion risk Awkwardness Vibration risk

Lower limbs





Cumulative risk is the sum of unshaded cells.

Task codes
Total time
1 2 3 4 5 Scoring keys for repetition and exertion
0-2 hours/day 2-4 hours/day 4-6 hours/day 6-8 hours/day ⬎8 hours/day
Scoring key for repetition
Duration of continuous performance Duration
1 2 3 4 5 Cycle time 1 2 3 4 5
⬍10 minutes 10 min-30 min 30 min-1 hr 1 hr-2 hr ⬎2 hr 1 1 1 2 3 4
Chapter 4

2 1 2 3 4 4
Cycle time 3 2 3 4 4 5
1 2 3 4 5 4 2 3 4 5 5
⬎5 minutes 1-5 minute 30 s-1 min 10 s-30 s ⬍10 s 5 3 4 5 5 5
Force Scoring key for exertion
1 2 3 4 5 Force
Minimal force Moderate force Maximal force Speed 1 2 3 4 5
1 1 1 2 3 4
Speed 2 1 2 3 4 4
1 2 3 4 5 3 2 3 4 4 5
Slow movements Moderately paced Little or no Fast and smooth Fast, jerky 4 2 3 4 5 5
movement– movements movements 5 3 4 5 5 5
static posture
Awkwardness Action may be indicated if, for any region, the exertion risk factor is 5, the sum of exertion and
1 2 3 4 5 awkwardness is 8 or greater, or the cumulative risk is 15 or greater.
All postures Moderate Moderate Near end range Near end range
close to neutral deviations from deviations in of motion posture of motion in
neutral in one more than one in one direction more than one
direction only direction direction

Vibration (whole body or peripheral)

1 2 3 4 5
None Minimal Moderate Large amplitude Severe amplitude

FIGURE 4-10 ManTRA. (From Straker L, Burgess-Limerick R, Pollock C, Egeskov R et al: A randomized and controlled trial of a participative ergonomics
intervention to reduce injuries associated with manual tasks: physical risk and legislative compliance, Ergonomics 47[2]:166, 2004.)
Ergonomics and Work Assessments
62 PART II Knowledge, Tools, and Techniques

(1) (2) (3) (4)


Straight and Bent and

Straight Bent twisted twisted
(1) (2) (3)
An example
Upper limbs

Both One Both

limbs limb limbs
on or below on or above above
shoulder level shoulder level shoulder level
(1) (2) (3)

Back: Bent (2)

Upper limbs:
Both below
shoulder level (1)
Lower limbs:
Loading on one
Loading on both Loading on one Loading on both limb, kneeling (5)
Lower limbs

limbs, straight limb, straight limbs, bent

(4) (5) (6) (7)

FIGURE 4-11 OWAS postures. (From Karhu O,

Kansi P, Kuorinka I: Correcting working postures in
Loading on Loading on one Body is moved Both limbs industry: a practical method for analysis, Appl Ergon
one limb, bent limb, kneeling by the limbs hanging free
8(4):199, 1977.)

dairy farmers, with nurses,80 in the building indus- trunk, neck, and leg postures and load or force
try,88 in the fishing industry,106 and in the seafood (Score A), upper and lower arms, wrist and cou-
retail industry.120 OWAS has also been suggested pling (Score B), and an activity rating.44 The score
for use in occupational rehabilitation.95 Inter-rater is then converted into a recommendation for
and test-retest (intra-rater) reliability of OWAS is action.44,94
considered good.21 As with OWAS, REBA is focused on assessment
of posture rather than manual handling risk.94 It
Rapid Entire Body Assessment is sensitive to detecting changes or improvements
REBA was developed as a postural analysis tool after ergonomic intervention; however, its focus
sensitive to the type of unpredictable working is biomechanical, and workplace changes based
postures found in health care and other service on task repetition, length of shifts, and other
industries.44 It has been used to assess jobs in factors that affect worker performance are not
health care and hospitals,44,56 supermarkets,19 and reflected in REBA scores.19 Initial studies indicate
dental professions.91 REBA’s approach and scoring that REBA has acceptable inter-rater reliability;
system are based on RULA.85 Scoring is based on however, more detailed examination of reliabil-
Chapter 4 Ergonomics and Work Assessments 63

ity and validity is recommended by REBA’s Strain Index

developers.44 The Strain Index is a semi-quantitative job analy-
sis method used to identify jobs that expose
workers to increased risk of developing distal
UPPER LIMB POSTURAL ASSESSMENT upper extremity (elbow, forearm, wrist, hand) dis-
orders.89,90 The Strain Index produces a score rep-
Rapid Upper Limb Assessment resenting the product of six task variables:
RULA was developed “to investigate the exposure intensity of exertion, duration of exertion, exer-
of individual workers to risk factors associated tions per minute, hand and wrist posture, speed
with work-related upper limb disorders” (p. 91).85 of work, and duration of task per day.89,90 It was
It is intended to be used as a screening tool and originally developed for use in a pork processing
as part of a broader ergonomic survey covering plant and has also been used in turkey process-
epidemiologic, physical, mental, environmental ing61 and automotive assembly.23
and organizational factors.85,86 RULA assesses bio- The Strain Index has good test-retest and inter-
mechanical and postural loading of the whole rater reliability111,112 and has demonstrated predic-
body, with particular focus on the neck, trunk, tive validity.61,89 When compared with RULA,
and upper limbs. however, results had very little correlation, indi-
Deciding at what point of the work cycle to cating that results were not interchangeable and
perform a RULA assessment is important. It can the instruments measured different constructs.23 It
be based on the posture held for the longest time was recommended that if the job involved high
or the “worst” posture adopted or taken at regular hand intensity the Strain Index could be used,
intervals over the working period.86 The postures whereas if there were awkward upper limb pos-
for the upper arm, lower arm, wrist, and forearm tures adopted, then RULA could be used.23
(“wrist twist”) are scored (Posture Score A). Following a walk-through survey of the manu-
Static loading or repetition, and force/load facturing company, discussion with supervisors
scores are then estimated. This is repeated for the and workers and examination of injury records,
neck, trunk, and legs (Posture Score B). Combin- Kim has identified the areas with high incidences
ing these scores produces a grand score that is of back and upper limb injuries and also those at
used to determine an action level indicating increased risk. For areas with manual handling
whether the posture is acceptable or requires tasks, ManTRA will be used, whereas in areas that
investigation and change.17,85 Right and left upper require a range of postures (static and dynamic)
limbs can be scored separately if necessary (Figure OWAS or REBA will be used. To address upper
4-12). limb injury concerns, RULA will be used for tasks
RULA was originally developed using workers involving awkward upper limb postures, and the
in the garment-making industry, with computer Strain Index will be used when tasks require high
operators, and with workers performing a variety hand force and intensity.
of manufacturing tasks.85,86 It has also been used
with formwork carpenters,66 with truck drivers,73
in the retail seafood industry,120 in automotive CONCLUSION
assembly plants,23 and to assess the impact of dif- This chapter has presented work-related assess-
ferent mouse positions when doing a computer ments that can be used to assess individuals’ work
task.16 abilities when there is a specific job available or
Construct validity of the RULA method has more generally to consider the physical demands
been established with significant associations of work. Although there are many commercial and
between RULA scores and reported pain.73,85 Inter- home-grown systems available, those that have
rater reliability indicated “high consistency of been included here are in more common use
scoring” (p. 98).85 around the world, and evidence for their reli-

RULA Employee Assessment Worksheet

Complete this worksheet following the step-by-step procedure below. Keep a copy in the employee's personnel folder for future reference.

B. Neck, Trunk & Leg Analysis

SCORES Step 9: Locate Neck Position

A. Arm & Wrist Analysis 0° to 10° 10° to 20° 20°⫹ in extension

Step 1: Locate Upper Arm Position Table A ⫹1 ⫹2 ⫹3 ⫹4
Upper Lower 1 2 3 4
⫹1 ⫹2 ⫹2 ⫹3 ⫹4 Upper
Arm Lower
Arm Wrist Twist Wrist Twist Wrist Twist Wrist Twist
Arm Arm 1 2 1 2 1 2 1 2

⫺15° to 15° ⫺15° ⫹15° to 45° ⫹45° to 90° 90°⫹ 1 1 1 2 2 2 2 3 3 3

Step 1a: Adjust… Step 9a: Adjust…
2 2 2 2 2 3 3 3 3 = Final Neck Score If neck is twisted: ⫹1; If neck is side-bending: ⫹1
If shoulder is raised: ⫹1;
If upper arm is abducted: ⫹1; Final Upper Arm Score = 3 2 3 2 3 3 3 4 4
If arm is supported or person is leaning: ⫺1 1 also if 0° to 10° 0° to 20° Step 10: Locate Trunk Position
2 1 2 2 2 3 3 3 4 4 trunk is 20° to 60°
Step 2: Locate Lower Arm Position well ⫹1 ⫹2 ⫹3
2 2 2 2 3 3 3 4 4 sup- standing
ported 60°⫹
⫹1 ⫹1 3 2 3 3 3 3 4 4 5
⫹1 ⫹2 while
3 1 2 3 3 3 4 4 5 5 seated; seated
2 if not ⫺20°
⫹1 ⫹1 2 2 3 3 3 4 4 5 5
⫺0° to 90° 90°⫹ Step 10a: Adjust…
Step 2a: Adjust… 3 2 3 3 4 4 4 5 5 = Final Trunk Score If trunk is twisted: ⫹1; If trunk is side-bending: ⫹1
If arm is working across midline of the body: ⫹1;
Final Lower Arm Score = 4 1 3 4 4 4 4 4 5 5 Step 11: Legs
If arm out to side of body: ⫹1
If legs & feet supported and balanced: ⫹1;
2 3 4 4 4 4 4 5 5 = Final Leg Score
Step 3: Locate Wrist Position If not: ⫹2
3 3 4 4 5 5 5 6 6
15°⫹ ⫹1 ⫹1 Trunk Posture Score
⫹1 ⫹3 0° to 15° 5 1 5 5 5 5 5 6 6 7
⫹2 ⫹2 1 2 3 4 5 6
2 5 6 6 6 6 7 7 7 Legs Legs Legs Legs Legs Le gs
0° to 15°
⫹3 Nec k 1 2 1 2 1 2 1 2 1 2 1 2
15°⫹ 3 6 6 6 7 7 7 7 8
1 1 3 2 3 3 4 5 5 6 6 7 7
6 1 7 7 7 7 7 8 8 9
Table B 2 2 3 2 3 4 5 5 5 6 7 7 7
Step 3a: Adjust… 2 7 8 8 8 8 9 9 9
If wrist is bent from the midline: ⫹1 Final Wrist Score = 3 3 3 3 4 4 5 5 6 6 7 7 7
Knowledge, Tools, and Techniques

3 9 9 9 9 9 9 9 9 4 5 5 5 6 6 7 7 7 7 7 8 8
Step 4: Wrist Twist
If wrist is twisted in mid-range =1; 5 7 7 7 7 7 8 8 8 8 8 8 8
Wrist Twist Score = 6 8 8 8 8 8 8 8 9 9 9 9 9
If twist at or near end of range = 2 Table C
Step 5: Look-up Posture Score in Table A 1 2 3 4 5 6 7+ Step 12: Look-up Posture Score in Table B
Use values from steps 1,2,3 & 4 to locate Posture Score in 1 1 2 3 3 4 5 5 Use values from steps 9, 10 & 11 to locate Posture Score in
table A Posture Score A = = Posture B Score Table B
2 2 2 3 4 4 5 5

3 3 3 3 4 4 5 6
Step 6: Add Muscle Use Score Step 13: Add Muscle Use Score
4 3 3 3 4 5 6 6
If posture mainly static (i.e. held for longer than 1 minute) or;
+ 5 4 4 4 5 6 7 7
+ If posture mainly static or;
If action 4/minute or more: ⫹1
If action repeatedly occurs 4 times per minute or more: ⫹1 Muscle Use Score = = Muscle Use Score
6 4 4 5 6 6 7 7

Step 7: Add Force/load Score 7 5 5 6 6 7 7 7 Step 14: Add Force/load Score

If load less than 2 kg (intermittent): ⫹0; If load less than 2 kg (intermittent): ⫹0;
8+ 5 5 6 7 7 7 7
If 2 kg to 10 kg (intermittent): ⫹1;
If 2 kg to 10 kg (static or repeated): ⫹2;
+ + If 2 kg to 10 kg (intermittent): ⫹1;
If 2 kg to 10 kg (static or repeated): ⫹2;
If more than 10 kg load or repeated or shocks: ⫹3 Force/load Score = = Force/load Score If more than 10 kg load or repeated or shocks: ⫹3

Step 8: Find Row in Table C = = Step 15: Find Column in Table C

The completed score from the Arm/wrist The completed score from the Neck/Trunk & Leg
analysis is used to find the row on Table C Final Wrist & Arm Score = Final Score = Final Neck, Trunk & Leg Score analysis is used to find the column on Chart C

Subject: Date: / /
Company: Department: Scorer:

FINAL SCORE: 1 or 2 = Acceptable; 3 or 4 investigate further; 5 or 6 investigate further and change soon; 7 investigate and change immediately
© Professor Alan Hedge, Cornell University. Nov. 2000

FIGURE 4-12 RULA worksheet. (Reprinted with permission from Professor Alan Hedge,
Chapter 4 Ergonomics and Work Assessments 65

Learning Exercise
Overview general tasks and task elements associated
The learning exercises provided are designed to with work that Trevor can do (level of
increase your practical understanding of some assessment). The utility and dependability of
basic issues associated with work-related assess- the FCENJ also need to be considered.
ments for individuals and job requirements. Considering all these aspects, make
recommendations regarding which work
Purpose capacity evaluation devices, FCE systems,
The purpose of these learning exercises is to con- and/or lifting assessments would be most
sider the referrals Kim has received and examine appropriate for Kim to use.
the types of work-related assessments for indi- 2. Identify two workplaces you are familiar with
viduals and job requirements that may be most that are from different industry sectors and
appropriate to use. engage in different activities (e.g., a
supermarket and a dental surgery office).
Exercises Consider the types of work-related injuries
1. Consider Kim’s referral for Trevor. Kim needs that people in these workplaces may
to decide which FCENJ will be appropriate to experience. Select ergonomic assessment
use to determine Trevor’s physical abilities tools that would be appropriate to use in
for work in general (purpose of assessment). these workplaces. Justify your selection and
As the specific job or position has not been explain why the tools you selected are the
identified, the assessment will focus on the same or different for the two workplaces.

ability and validity has been published. This Multiple Choice Review Questions
enables therapists such as Kim to select the assess-
ments to use based on a model that presents a 1. When Kim received the referral for
process of excellence in work-related assessments Trevor, what was the first thing that
(see Figure 4-1). needed to be determined?
Therapists also use job analysis techniques to A. Identify whether to do an FCE (No
assess the physical requirements and demands of Job) or FCE (Job)
jobs, identifying potential risks to which workers B. Identify which Valpar Component
may be exposed. This enables therapists to make Work Samples would be most
recommendations regarding the prevention of appropriate
musculoskeletal injuries in the workplace. Various C. Determine the purpose of the
approaches have been presented, including obser- work-related assessment
vation, checklists, and more quantitative instru- D. Determine how the data will be
ments. Tools addressing manual handling risks collected and from what sources
(ManTRA), postural concerns (OWAS, REBA, and
RULA) and high-intensity hand use (Strain Index)
have been included. Therapists are encouraged
to investigate these tools further and develop
expertise in their use.
66 PART II Knowledge, Tools, and Techniques

2. What type of work-related assessment is D. Simulate Lucy’s job demands using a

focused on an individual worker computer workstation that can be
performing physical demands related to adjusted to suit Lucy.
work in general, rather than to a specific
job or duties? 6. Which of the following would be most
A. Physical ergonomic assessment suitable to assess the musculoskeletal
B. Workplace assessment risk factors associated with manual
C. Functional capacity evaluation (job) handling?
D. Functional capacity evaluation (no A. OWAS
job) B. RULA
3. Which of the following hand function D. ManTRA
assessments (see Figure 4-5) is the most
suitable to assess gross grasp and 7. Which of the following would be most
placement? suitable to assess unpredictable working
A. Minnesota Rate of Manipulation Test postures, such as those found in the
B. Purdue Pegboard health care industry?
C. O’Connor Finger Dexterity Test A. OWAS
D. O’Connor Tweezer Dexterity Test B. RULA
4. The EPIC Lift Capacity Test and the PILE D. ManTRA
(Progressive Isoinertial Lifting Evaluation)
both assess a person’s lifting ability. At 8. Using the OWAS postures (see Figure
what individual or job level (see Figure 4-11), score the posture adopted in Figure
4-2) would these assessments be? 4-6, C (Physical Agility Tester [PAT], set
A. Role/Activity (individual) or Job for low-level task).
Position/Job Duties (job) A. 1 (trunk) 3 (upper limbs) 6 (lower
B. Task/Skill (individual) or Tasks/Task limbs)
Elements (job) B. 2 (trunk) 1 (upper limbs) 3 (lower
C. Skill/Body System (individual) or Task limbs)
Elements/Elemental Motions (job) C. 3 (trunk) 2 (upper limbs) 1 (lower
D. Activity/Task (individual) or Job limbs)
Duties/Tasks (job) D. 4 (trunk) 1 (upper limbs) 5 (lower
5. Kim needs to determine Lucy’s ability to
perform her usual duties, such as data 9. What are the five characteristics of the
entry and word processing. What would task that are considered when using
be the most appropriate way to do this? ManTRA?
A. Interview Lucy about her perceived A. Cycle time, force, speed, awkward-
capacity to return to performing these ness, and vibration
duties. B. Trunk posture, upper limb posture,
B. Check with Lucy’s supervisor or lower limb posture, force, and
manager to determine her capacity to duration
return to performing these duties. C. Intensity of exertion, duration of
C. Perform a range of standardized hand exertion, exertions per minute, speed
function assessments, such as the of work, and duration of task per day
Minnesota Rate of Manipulation Test, D. Head and neck posture, arm and wrist
Purdue Pegboard, and O’Connor posture, lower limb support, muscle
Finger Dexterity Test. use, and force and load
Chapter 4 Ergonomics and Work Assessments 67

10. What are the six characteristics of the Ergos Work Simulator: a pilot study, J Occup
task that are considered when using the Rehabil 13(4):219, 2003.
9. Brouwer S, Dijkstra PU, Stewart RE et al: Compar-
Strain Index?
ing self-report, clinical examination and functional
A. Cycle time, force, speed, awkward- testing in the assessment of work-related limita-
ness, duration per day, and vibration tions in patients with chronic low back pain,
B. Head and neck posture, trunk posture, Disabil Rehabil 27(17):999, 2005.
upper limb posture, lower limb 10. Brouwer S, Reneman MF, Dijkstra PU et al: Test-
posture, force, and duration retest reliability of the Isernhagen Work Systems
C. Intensity of exertion, duration of Functional Capacity Evaluation in patients with
chronic low back pain, J Occup Rehabil 13(4):207,
exertion, exertions per minute, hand
and wrist posture, speed of work, and 11. Burgess-Limerick R, Dennis G, Straker L et al:
duration of task per day Participative ergonomics for manual tasks in coal
D. Head and neck posture, trunk posture, mining. In Conference Proceedings of the Queensland
arm and wrist posture, lower limb Mining Industry Health & Safety Conference 2005,
support, muscle use, and force and Townsville, Queensland, 2005, Queensland Mining
load Industry.
12. Burgess-Limerick R, Joy J, Straker L et al: Imple-
mentation of an ergonomics program intervention
to prevent musculoskeletal injuries caused by
REFERENCES manual tasks (Coal Services Health & Safety Trust
1. Alpert J, Matheson L, Beam W et al: The reliability Research Grant Final Report), Brisbane, Queensland,
and validity of two new tests of maximum lifting 2006, University of Queensland.
capacity, J Occup Rehabil 1(1):13, 1991. 13. Burgess-Limerick R, Straker L, Pollock C et al:
2. Ang N: Study on the test-retest reliability of the Manual Tasks Risk Assessment Tool (ManTRA) V
Valpar Component Work Sample 9 (Whole Body 2.0, 2004. Retrieved August 3, 2006, from http://
Range of Motion), Unpublished Honors thesis,
Sydney, New South Wales, 1999, University of 14. Cetinok EM, Renfro RR, Coleman EF: A pilot study
Sydney. of the reliability of the dynamic mode of one BTE
3. Barrett T, Browne D, Lamers M et al: Reliability work simulator, J Hand Ther 8(3):199, 1995.
and validity testing of Valpar 19. In Australian 15. Coleman EF, Renfro RR, Cetinok EM et al: Reli-
Association of Occupational Therapists (AAOT), ability of the manual dynamic mode of the Balti-
editor: Proceedings of the 19th National Conference more Therapeutic Equipment Work Simulator,
of the Australian Association of Occupational J Hand Ther 9(3):223, 1996.
Therapists, vol 2, Perth, Western Australia, 1997, 16. Cook CJ, Kothiyal K: Influence of mouse position
AAOT. on muscular activity in the neck, shoulder and arm
4. Beaton DE, Dumont A, Mackay MB et al: Steindler in computer users, Appl Ergon 29(6):439-443,
and pectoralis major flexorplasty: a comparative 1998.
analysis, J Hand Surg [Am] 20(5):747, 1995. 17. Corlett EN: Assessing the risk of upper limb disor-
5. Beaton DE, O’Driscoll SW, Richards R: Grip ders. In Karwowski W, editor: International ency-
strength testing using the BTE work simulator and clopedia of ergonomics and human factors, vol 3,
the Jamar dynamometer: a comparative study. London, 2001, Taylor & Francis.
J Hand Surg [Am] 20(2):293, 1995. 18. Cotton A, Schonstein E, Adams R: Use of func-
6. Becht TM, Roberts D: Measured functional trends tional capacity evaluations by rehabilitation pro-
in military personnel discharged medically due to viders in NSW, Work 26(3):287, 2006.
low back pain. In Worth DR, editor: Moving in on 19. Coyle A: Comparison of the Rapid Entire Body
occupational injury, Oxford, 2000, Butterworth Assessment and the New Zealand Manual Han-
Heinemann. dling “Hazard Control Record,” for assessment of
7. Bhambhani Y, Esmail S, Britnell S: The Baltimore manual handling hazards in the supermarket
Therapeutic Equipment work simulator: biome- industry, Work 24(2):111, 2005.
chanical and physiological norms for three attach- 20. Curtis L, Mayer TG, Gatchel RJ: Physical
ments in healthy men, Am J Occup Ther 48(1):19, progress and residual impairment quantification
1994. after functional restoration. Part III: Isokinetic
8. Boadella JM, Sluiter JK, Frings-Dresen MHW: Reli- and isoinertial lifting capacity, Spine 19(4):401,
ability of upper extremity tests measured by the 1994.
68 PART II Knowledge, Tools, and Techniques

21. de Bruijn I, Engels JA, van der Gulden JWJ: methods: a systematic review with reference to
A simple method to evaluate the reliability Blankenship system, Ergos work simulation, Ergo-
of OWAS observations, Appl Ergon 29(4):281, Kit and Isernhagen work system, Int Arch Occup
1998. Environ Health 77:527, 2004.
22. Dempsey PG, McGorry RW, Maynard WS: A 35. Gross DP, Battié MC: Reliability of safe maximum
survey of tools and methods used by certified lifting determinations of a functional capacity
professional ergonomists, Appl Ergon 36:489, evaluation, Phys Ther 82(4):364, 2002.
2005. 36. Gross DP, Battié MC: Construct validity of a
23. Drinkaus P, Sesek R, Bloswick DS et al: Compari- kinesiophysical functional capacity evaluation
son of ergonomic risk assessment outputs from administered within a worker’s compensation
Rapid Upper Limb Assessment and the Strain environment, J Occup Rehabil 13(4):287, 2003.
Index for tasks in automotive assembly plants, 37. Gross DP, Battié MC: The prognostic value of func-
Work 21(2):165, 2003. tional capacity evaluation in patients with chronic
24. Durand M, Loisel P, Poitras S et al: The interrater low back pain: Part 2—Sustained recovery, Spine
reliability of a functional capacity evaluation: the 29(8):920, 2004.
Physical Work Performance Evaluation, J Occup 38. Gross DP, Battié MC: Functional capacity evalua-
Rehabil 14(2):119, 2004. tion performance does not predict sustained return
25. Dusik LA, Menard MR, Cooke C et al: Concurrent to work in claimants with chronic back pain, J
validity of the ERGOS work simulator versus con- Occup Rehabil 15(3):285, 2005.
ventional functional capacity evaluation tech- 39. Gross DP, Battié MC, Cassidy JD: The prognostic
niques in a workers’ compensation population, value of functional capacity evaluation in patients
J Occup Med 35(8):759, 1993. with chronic low back pain: Part 1—Timely return
26. Eastman Kodak Company: Kodak’s ergonomic to work, Spine 29(8):914, 2004.
design for people at work, ed 2, Hoboken, NJ, 2004, 40. Hazard RG, Fenwick JW, Kalisch SM et al: Func-
John Wiley & Sons. tional restoration with behavioural support: a one-
27. Esmail S, Bhambhani Y, Britnell S: Gender differ- year prospective study of patients with chronic
ences in work performance on the Baltimore Ther- low-back pain, Spine 14(2):157, 1989.
apeutic Equipment work simulator, Am J Occup 41. Hazard RG, Reeves V, Fenwick JW et al: Test-
Ther 49(5):405, 1995. retest variation in lifting capacity and indices of
28. Fess EE: Correction: instrument reliability of the subject effort, Clin Biomech 8:20, 1993.
BTE Work Simulator: a preliminary study, J Hand 42. Health & Safety Executive (Health & Safety Labora-
Ther 6(2):82, 1993. tory): Manual handling assessment charts, 2003.
29. Fess EE: Instrument reliability of the BTE work Retrieved August 17, 2006, from http://www.hse.
simulator: a preliminary study [abstract], J Hand
Ther 6(1):59, 1993. 43. Heinsalmi P: Method to measure working posture
30. Fraulin FO, Louie G, Zorrilla L et al: Functional loads at working sites (OWAS). In Corlett N,
evaluation of the shoulder following latissimus Wilson J, Manenica I, editors: The ergonomics of
dorsi muscle transfer, Ann Plast Surg 35(4):349, working postures, London, 1986, Taylor &
1995. Francis.
31. Gardener L, McKenna K: Reliability of occupa- 44. Hignett S, McAtamney L: Rapid entire body assess-
tional therapists in determining safe, maximal ment (REBA), Appl Ergon 31:201, 2000.
lifting capacity, Aust Occup Ther J 46(3):110, 45. Horneij E, Holmström E, Hemborg B et al: Inter-
1999. rater reliability and between-days repeatability of
32. Goldner RD, Howson MP, Nunley JA et al: eight physical performance tests, Adv Physiother
One hundred eleven thumb amputations: 4(4):146, 2002.
replantation vs revision, Microsurgery 11(3):243, 46. Ijmker S, Gerrits EHJ, Reneman MF: Upper
1990. lifting performance of healthy young adults in
33. Gouttebarge V, Wind H, Kuijer PP et al: Intra- and functional capacity evaluations: a comparison
interrater reliability of the Ergo-Kit Functional of two protocols, J Occup Rehabil 13(4):297,
Capacity Evaluation method in adults without 2003.
musculoskeletal complaints, Arch Phys Med Rehabil 47. Innes E: Factors influencing the excellence of work-
86:2354, 2005. related assessments in Australia, Unpublished PhD
34. Gouttebarge V, Wind H, Kuijer PP et al: Reliability thesis, Perth, Western Australia, 2001, Curtin Uni-
and validity of functional capacity evaluation versity of Technology.
Chapter 4 Ergonomics and Work Assessments 69

48. Innes E, Straker L: A clinician’s guide to work- 63. Kuijer W, Gerrits EHJ, Reneman MF: Measuring
related assessments: 1—Purposes and problems, physical performance via self-report in healthy
Work 11(2):183, 1998. young adults, J Occup Rehabil 14(1):77, 2004.
49. Innes E, Straker L: A clinician’s guide to work- 64. Lechner DE, Jackson JR, Roth DL, and others:
related assessments: 2—Design problems, Work Reliability and validity of a newly developed test
11(2):191, 1998. of physical work performance, J Occup Med
50. Innes E, Straker L: Reliability of work-related 36(9):997, 1994.
assessments, Work 13(2):107, 1999. 65. Lee GKL, Chan CCH, Hui-Chan CWY: Consistency
51. Innes E, Straker L: Validity of work-related assess- of performance on the functional capacity assess-
ments, Work 13(2):125, 1999. ment: static strength and dynamic endurance, Am
52. Innes E, Straker L: Workplace assessments and J Phys Med Rehabil 80(3):189, 2001.
functional capacity evaluations: current practices 66. Lee GKL, Chan CCH, Hui-Chan CWY: Work
of therapists in Australia, Work 18(1):51, 2002. profile and functional capacity of formwork car-
53. Isernhagen SJ: Contemporary issues in functional penters at construction sites, Disabil Rehabil
capacity evaluation. In Isernhagen SJ, editor: the 23(1):9, 2001.
comprehensive guide to work injury management, 67. Legge J: Pre-employment functional assessments
Gaithersburg, Md, 1995, Aspen. can be an effective tool for controlling work-related
54. Isernhagen SJ: Functional capacity evaluation. musculoskeletal disorders: a preliminary study. In
In Isernhagen SJ, editor: Work injury: manage- Burgess-Limerick R, editor: Back to basics: Proceed-
ment and prevention, Gaithersburg, Md, 1988, ings of the 39th annual conference of the Ergonom-
Aspen. ics Society of Australia, Canberra, Australian
55. James C, Mackenzie L, Capra M: Health profession- Capital Territory, 2003, ESA Inc.
als’ attitudes and practices in relation to functional 68. Ljungquist T, Fransson B, Harms-Ringdahl K et al:
capacity evaluations. Poster presented at the 14th A physiotherapy test package for assessing back
World Federation of Occupational Therapists’ Con- and neck dysfunction—discriminative ability for
gress, Sydney, Australia, 2006. patients versus healthy control subjects, Physiother
56. Janowitz IL, Gillen M, Ryan G et al: Measuring the Res Int 4(2):123, 1999.
physical demands of work in hospital settings: 69. Ljungquist T, Harms-Ringdahl K, NygrenÅ et al:
design and implementation of an ergonomics Intra- and inter-rater reliability of an 11-test
assessment, Appl Ergon 37:641, 2006. package for assessing dysfunction due to back or
57. Kaiser H, Kersting M, Schian HM et al: Value of neck pain, Physiother Res Int 4(3):214, 1999.
the Susan Isernhagen Evaluation of Functional 70. Lo EKS: Demographic study on occupational
Capacity Scale in medical and occupational reha- therapy work rehabilitation programs in Hong
bilitation [Der Stellenwert des EFL-Verfahrens Kong Hospital Authority, Work 14(3):185, 2000.
nach Susan Isernhagen in der medizinischen und 71. Lygren H, Dragesund T, Joensen J et al: Test-retest
beruflichen rehabilitation], Rehabilitation (Stuttg) reliability of the Progressive Isoinertial Lifting
39(5):297, 2000. Evaluation (PILE), Spine 30(9):1070, 2005.
58. Karhu O, Harkonen R, Sorvali P et al: Observing 72. Lysaght RM: Approaches to worker rehabilitation
working postures in industry: examples of OWAS by occupational and physical therapists in the
application, Appl Ergon 12(1):13, 1981. United States: factors impacting practice, Work
59. Karhu O, Kansi P, Kuorinka I: Correcting working 23(2):139, 2004.
postures in industry: a practical method for analy- 73. Massaccesi M, Pagnotta A, Soccetti A et al: Inves-
sis, Appl Ergon 8(4):199, 1977. tigation of work-related disorders in truck drivers
60. Kennedy LE, Bhambhani YN: The Baltimore Ther- using RULA method, Appl Ergon 34:303, 2003.
apeutic Equipment work simulator: reliability and 74. Matheson LN: Evaluation of lifting and lowering
validity at three work intensities, Arch Phys Med capacity, Vocational Eval Work Adjustment Bull
Rehabil 72:511, 1991. 19(3):107, 1986.
61. Knox K, Moore JS: Predictive validity of the Strain 75. Matheson LN, Danner R, Grant J et al: Effect of
Index in turkey processing, J Occup Environ Med computerised instructions on measurement of lift
43(5):451, 2001. capacity: safety, reliability, and validity, J Occup
62. Kogi K: Basic ergonomics checklists. In Karwowski Rehabil 3(2):65, 1993.
W, editor: International encyclopedia of ergonom- 76. Matheson LN, Isernhagen SJ, Hart DL: Relation-
ics and human factors, vol 3, London, 2001, Taylor ships among lifting ability, grip force, and return
& Francis. to work, Phys Ther 82(3):249, 2002.
70 PART II Knowledge, Tools, and Techniques

77. Matheson LN, Mooney V, Grant JE et al: A test to 91. Nasl SJ, Hossenini MH, Shahtaheri SJ et al: Evalu-
measure lift capacity of physically impaired adults. ation of ergonomic postures of dental professions
Part 1—Development and reliability testing, Spine by Rapid Entire Body Assessment (REBA). In
20(19):2119, 1995. Birjand, Iran [Farsi], J Dent 18(1):61, 2005.
78. Matheson LN, Mooney V, Holmes D et al: A test 92. Ogden-Niemeyer L: Procedure guidelines for the
to measure lift capacity of physically impaired WEST Standard Evaluation: “Assessment of range
adults. Part 2—Reactivity in a patient sample, of motion under load,” rev ed, Long Beach, Calif,
Spine 20(19):2130, 1995. 1991, Work Evaluations Systems Technology.
79. Matheson LN, Rogers LC, Kaskutas V et al: Reli- 93. O’Halloran D, Innes E: Understanding work in
ability and reactivity of three new functional society. In Whiteford G, Wright-St Clair V, editors:
assessment measures, Work 18(1):41, 2002. Occupation and practice in context, London, 2005,
80. Mattila M, Vilkki M: OWAS methods. In Kar- Churchill Livingstone.
wowski W, Marras WS, editors: Occupational ergo- 94. Pinder ADJ, Monnington SC: Benchmarking of the
nomics handbook, Boca Raton, Fla, 1999, CRC Manual Handing Assessment Charts (MAC), 2002.
Press. Retrieved August 14, 2006, from http://www.hse.
81. Mayer TG, Barnes D, Kishino ND et al: Progressive
isoinertial lifting evaluation I: a standardised pro- 95. Pratt L: The modification of OWAS and RULA for
tocol and normative database, Spine 13(9):993, use in occupational rehabilitation. Paper presented
1988. at the 29th Annual Conference of the Ergonomics
82. Mayer TG, Barnes D, Nichols G et al: Progressive Society of Australia, Perth, Western Australia,
isoinertial lifting evaluation II: a comparison with 1993.
isokinetic lifting in a disabled chronic low-back 96. Reneman MF, Brouwer S, Meinema A et al: Test-
pain industrial population, Spine 13(9):998, 1988. retest reliability of the Isernhagen Work Systems
83. Mayer TG, Gatchel R, Barnes D, and others: Pro- Functional Capacity Evaluation in healthy adults,
gressive isoinertial lifting evaluation: erratum J Occup Rehabil 14(4):295, 2004.
notice, Spine 15(1):5, 1990. 97. Reneman MF, Bults MM, Engbers LH et al: Mea-
84. Mayer TG, Mooney V, Gatchel RJ et al: Quantifying suring maximum holding times and perception of
postoperative deficits of physical function follow- static elevated work and forward bending in
ing spinal surgery, Clin Orthop Relat Res 244:147, healthy young adults, J Occup Rehabil 11(2):87,
1989. 2001.
85. McAtamney L, Corlett EN: RULA: a survey method 98. Reneman MF, Dijkstra PU, Westmaas M et al: Test-
for the investigation of work-related upper limb retest reliability of lifting and carrying in a 2-day
disorders, Appl Ergon 24(2):91, 1993. functional capacity evaluation, J Occup Rehabil
86. McAtamney L, Corlett N: R.U.L.A.—A rapid upper 12(4):269, 2002.
limb assessment tool. In Robertson SA, editor: Con- 99. Reneman MF, Fokkens AS, Dijkstra PU et al:
temporary ergonomics 1994, London, 1994, Taylor Testing lifting capacity: validity of determining
& Francis. effort level by means of observation, Spine 30(2):
87. McClure PW, Flowers KR: The reliability of E40-E46, 2005.
BTE work simulator measurements for selected 100. Reneman MF, Jaegers SM, Westmaas M et al: The
shoulder and wrist tasks, J Hand Ther 5(1):25, reliability of determining effort level of lifting and
1992. carrying in a functional capacity evaluation, Work
88. Monk V: Postural assessment of building industry 18(1):23, 2002.
tasks using the Ovako Working Posture Analysing 101. Rondinelli RD, Dunn W, Hassanein KM et al: A
System, J Occup Health Saf Aust NZ 14(2):149, simulation of hand impairments: effects on upper
1998. extremity function and implications toward medical
89. Moore JS, Garg A: The Strain Index: a proposed impairment rating and disability determination,
method to analyze jobs for risk of distal upper Arch Phys Med Rehabil 78(12):1358, 1997.
extremity disorders, Am Ind Hyg Assoc J 56:443, 102. Rustenburg G, Kuijer PP, Frings-Dresen MH: The
1995. concurrent validity of the ERGOS Work Simulator
90. Moore JS, Garg A: The Strain Index. In Karwowski and the Ergo-Kit with respect to maximum lifting
W, editor: International encyclopedia of ergonom- capacity, J Occup Rehabil 14(2):107, 2004.
ics and human factors, vol III, London, 2001, 103. Schenk P, Klipstein A, Spillmann S et al: The role
Taylor & Francis. of back muscle endurance, maximum force,
balance and trunk rotation control regarding lifting
capacity, Eur J Appl Physiol 96:146, 2006.
Chapter 4 Ergonomics and Work Assessments 71

104. Schult M, Söderback I, Jacobs K: Swedish use and 117. Tuckwell NL, Straker L, Barrett TE: Test-retest
validation of Valpar work samples for patients reliability on nine tasks of the Physical Work Per-
with musculoskeletal neck and shoulder pain, formance Evaluation, Work 19(3):243, 2002.
Work 5(3):223, 1995. 118. U.S. Department of Labor Employment & Training:
105. Schult M, Söderback I, Jacobs K: Multidimen- The revised handbook for analyzing jobs, Indiana-
sional aspects of work capability: a comparison polis, 1991, JIST Works.
between individuals who are working or not 119. Valpar International Corp: Temporal reliability of
working because of chronic pain, Work 15(1):41, selected Valpar Component Work Samples: learn-
2000. ing curve studies, 2003. Retrieved September 22,
106. Scott GB, Lambe NR: Working practices in a 2003, from
perchery system, using the OVAKO Working htm.
posture Analysing System (OWAS), Appl Ergon 120. Weigall F, Simpson K: Manual handling methods
27(4):281, 1996. in the retail seafood industry: final report, 2002.
107. Sellars RGM, O’Neill M, Amber-Scott C et al: Retrieved August 4, 2006, from
Assessing pain and disability exaggeration with the
functional capacity evaluation process. In Worth dling/manualhandlingretailseafoodindustry.htm.
DR, editor: Moving in on occupational injury, 121. Wilke NA, Sheldahl LM, Dougherty SM et al: Bal-
Oxford, 2000, Butterworth Heinemann. timore Therapeutic Equipment Work Simulator:
108. Shechtman O, MacKinnon L, Locklear C: Using the energy expenditure of work activities in cardiac
BTE Primus to measure grip and wrist flexion patients, Arch Phys Med Rehabil 74(4):419, 1993.
strength in physically active wheelchair users: an 122. WorkCover Corporation of South Australia: Occu-
exploratory study, Am J Occup Ther 55(4):393, pational therapy fee schedule and guidelines: South
2001. Australia workers compensation occupational
109. Shervington J, Balla J: WorkAbility Mark III: Func- therapy services, 2004. Retrieved August 9, 2006,
tional assessment of workplace capabilities, Work from
7(3):191, 1996. 9D90BCDC-EC9E-4CC4-B3C2-6623C186776B/0/
110. Söderback I, Jacobs K: A study of well-being proOccTherapyScheduleAmend1104.pdf.
among a population of Swedish workers using a 123. Yílmaz F, Yílmaz A, Merdol F et al: Efficacy of
job-related criterion-referenced multidimensional dynamic lumbar stabilization exercise in lumbar
vocational assessment, Work 14(2):83, 2000. microdiscectomy, J Rehabil Med 35(4):163, 2003.
111. Stephens J-P, Vos GA, Stevens EMJ et al: Test-
retest repeatability of the Strain Index, Appl Ergon
37(3):275, 2006.
112. Stevens EMJ, Vos GA, Stephens J-P et al: Inter- RESOURCES
rater reliability of the Strain Index, J Occup Environ Baltimore Therapeutic Equipment Technologies (BTE
Hyg 1(11):745, 2004. Work Simulator II, BTE Primus, BTE ER Functional
113. Straker L, Burgess-Limerick R, Pollock C, Egeskov Testing System)
R: A randomized and controlled trial of a partici-
pative ergonomics intervention to reduce injuries ERGOS Work Simulator
associated with manual tasks: physical risk and (North American site)
legislative compliance, Ergonomics 47(2):166, (European site)
114. Trevitt N: A test-retest reliability study on the Ergo-Kit FCE
Valpar Component Work Sample 4. Unpublished (in Dutch)
Honours thesis, School of Occupational Therapy, Ergoscience Physical Work Performance Evaluation
Faculty of Health Sciences, Sydney, New South (PWPE)
Wales, 1997, University of Sydney.
115. Trossman PB, Li P-W: The effect of the duration Isernhagen Work Systems (IWS) FCE (WorkWell FCE
of intertrial rest periods on isometric grip strength v.2)
performance in young adults, Occup Ther J Res
9(6):362, 1989.
EPIC Lift Capacity Test
116. Trossman PB, Suleski KB, Li P-W: Test-retest reli-
ability and day-to-day variability on an isometric
grip strength test using the work simulator, Occup Valpar Component Work Samples
Ther J Res 10(5):266, 1990. (North American site)
72 PART II Knowledge, Tools, and Techniques (Australian site) tools available at this site, including REBA, RULA,
Cornell University Ergonomics Web Workplace Ergo- Strain Index)
nomics Tools—Alan Hedge (many ergonomics tools
available via this site, including ManTRA, RULA, COPE Posture Analysis Tools (free online RULA
REBA and Strain Index) software)
Analysis Tools for Ergonomists—Thomas E. Bernard WinOWAS (free computerized version of OWAS)
(University of South Florida) (many ergonomics

Nancy A. Baker

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Identify the strengths and weaknesses of the science of anthropometry.
2. Describe factors that influence human size and shape.
3. Use static anthropometric tables to help guide design parameters.
4. Understand the key concepts of reach, clearance, and posture.
5. Identify the effect that the environment plays on the performance components of precision and strength.

Secular trend. General changes in the size and shape Length. Horizontal measurement in the sagittal
of a population from generation to generation. plane.
Sagittal plane. Vertical plane through the longitudi- Breadth. Horizontal measurement in the coronal
nal axis that divides the body into left and right plane.
sections. Reach. Imaginary sphere around the worker that can
Coronal (frontal) plane. Vertical plane through the be touched by the worker at all points without shifting
longitudinal axis that divides the body into front and the body from the starting point.
back sections. Clearance. The space needed to allow free passage of
Height. Vertical measurement from the floor or seat a person or a body segment.

74 PART II Knowledge, Tools, and Techniques

A large company is considering redesigning their data-
A nthropometry, the science of measurement of
the human body, provides therapists with
building blocks for understanding the complexi-
entry department to improve the configuration of each ties of the human form and how it interfaces with
workstation. The company has three shifts of 50 data- its environment. This chapter reviews the princi-
entry personnel. All workstations are used by at least ples and methods of static anthropometry. Discus-
three employees during these three shifts, and sometimes sions of reach, clearance, and posture are included,
floaters (temporary employees) also use the workstations. as well as tables of measurements. Methods for
The therapist hired to consult about the purchase of the application of these principles to workstation
equipment has ascertained the following information: design are also reviewed. Anthropometric con-
• The population of the company is predominantly cepts will be applied to the case study throughout
female (90%). the chapter.
• The primary ethnicity is white (75%). An equal mix People have always studied and analyzed the
of ethnicities occurs in the remaining 25%. human form. Measurements were often based on
• The company representatives state that the company human body parts; a foot was the length of the
is willing to replace the chairs and provide some human foot, and a yard was the length from
additional small equipment. No budget is pro- midline to the fingertip. These early methods of
vided for completely redesigning all the capital evaluating the human form gradually evolved into
equipment. the modern science of anthropometry. Anthro-
• Each workstation has a standard 30-inch desk and pometry, the measurement of human individuals
a 4-inch-high central processing unit (CPU) with a in order to understand and design for human
16-inch-tall monitor on top of it. This configuration physical variations, is the cornerstone of the
places the top of the monitor 50 inches from the design of all objects and spaces used by humans.
floor. The keyboard is placed on the 30-inch desk. Because ergonomics is concerned with shaping
Each station has a computer wrist rest. The chairs the environment to optimize workers’ abilities to
are adjustable up and down from 17.5 to 22.5 perform their jobs, an understanding of anthro-
inches. pometry is essential to the application of ergo-
• Most of the data entry is numeric; thus, the employ- nomics.
ees use the number pad. The mouse and the alpha- When creating a workspace, designers make
numeric part of the keyboard are seldom used. many complex choices. In addition to the func-
After reading through the chapter, answer the follow- tional use of the space, the parameters of the
ing questions: human form and how it will act within the space
1. Describe how the concepts of reach, clearance, and must be understood and integrated into the overall
posture influence the therapists’ decisions during design. Designers, therefore, must create a space
the design of a computer workstation. that is suitable for all potential users, regardless
2. How would your recommendations for the com- of their size, shape, or capabilities. Often, however,
puter workstation differ if you designed this setup users are envisioned by designers as being the
to accommodate individuals who use wheelchairs same as they are. Consequently designers design
for mobility? the space to fit their own shape and fail to account
3. One of the employees of the company is well below for the great variability of the human form.
the 5th percentile in height (55 inches). What rec- How can designers understand the population
ommendations could you make to help her custom- for which they are designing? They could guess
ize her workstation to fit her? as to the general size and shape of the population,
but guesses are generally incorrect. They could
measure everyone who might use a space or
object, but this is often impractical. Alternatively,
designers can use the science of anthropometry to
develop concrete and scientific information that
Chapter 5 Anthropometry 75

can be used to design spaces that fit the largest of infectious disease. The recent increase in obesity
number of people. Anthropometry provides the in the population,10 in particular, will affect the
parameters of human size and shape that allow circumferential and breadth measurements of the
designers to fulfill the needs of both comfort and population.
function. Anthropometry provides both the under-
standing of why a workspace fits a worker and Gender Differences
the understanding of how a workspace may fail The differences between men and women are
the people who work in it. Anthropometry pro- more than skin deep. Men generally are larger
vides important information on how to shape than women, both overall and in limb length. Less
the environment to fit the greatest number of of male body weight is composed of fat tissue, and
people. what fat men have tends to accumulate at the
The term anthropometry refers to many types abdomen. A woman’s fat tends to accumulate at
of measurements that are used to completely the hips, thighs, and buttocks. It is interesting to
describe the human form. Along with the dimen- note that obesity in women has not significantly
sions of the human form (stature, breadth, length), increased since 1999, but obesity has increased in
anthropometry also describes the mass of the men.10
human form (weight, center of gravity), and the
parameters of human strength and motion. All of Ethnic Differences
these are important when considering how an
Different ethnic groups have different anthropo-
individual uses the environment and how to adapt
metric measurements. A general rule of thumb is
that environment to facilitate each individual’s
that ethnic groups that live primarily in tropical
performance. Scientists have developed data that
climates have a lower body weight than groups
describe many elements of the human form and
that live in colder temperatures.12 Body propor-
that are available for estimating the size, shape,
tions vary among ethnic groups; for example,
and capacities of the population. Anthropometric
black Africans have proportionally longer lower
measurements have been ascertained for children
limbs than Europeans, whereas Asians have pro-
and the elderly, as well as for members of a wide
portionally shorter limbs.11 Differences resulting
variety of ethnic groups. This chapter reviews
from ethnicity, however, tend to diminish as pop-
static anthropometry as it pertains to workstation
ulations migrate and commingle.

STATIC ANTHROPOMETRY It is easy to see the difference age makes in body
Static anthropometry is the science of measur- size and shape when comparing a child with an
ing length, breadth, and width in the human adult. Anthropometric changes during adulthood,
population. Anthropometrists have reported sev- however, are more subtle. As people pass 30,
eral universal factors that seem to influence stature decreases and body weight increases. After
human size and shape: gender, ethnicity, age, and age 50 for men and 60 for women, body weight
occupation.11 again decreases.
Overall the shape of any stable population
changes from generation to generation, a phenom- Occupational Differences
enon termed secular trend.11 In general, the overall The tendency for people of different occupations
world population has been becoming larger. to have different anthropometric proportions is
Although most researchers are cautious in their poorly understood. Some occupations, such as
explanations as to why the population is getting soldier or jockey, are self-selective—a specific
larger, one theory is that this secular trend of size or weight is necessary to perform the job.
increased size is a result of changes in the envi- Why other occupations should be stratified by
ronment such as improved diet and the reduction size is a bit of a mystery. Does the job shape the
76 PART II Knowledge, Tools, and Techniques

person, or does the correctly sized person select as five angular measurements to account for the
the job? inability of many people with disabilities to assume
the “standard” seated posture.7 Therefore indi-
vidual measurements should always be taken for
PERSONS WITH DISABILITIES those with physical challenges.
The presence of a disability is often an overlooked
factor in workstation design. Disability alters not
only the size and shape of individuals but also STATIC ANTHROPOMETRIC
their capacity to perform activities that may be MEASUREMENTS
taken for granted by the general population. Con- Like most sciences, static anthropometry has con-
sider people who use wheeled mobility devices. ventions. Static anthropometry always looks at
Not only do they have to cope with the impair- human dimensions in either the sagittal plane or
ments that placed them in their devices, but the the coronal plane. Static anthropometry also uses
people who use wheeled mobility devices also two standard postures:
have the added anthropometric disadvantage of Standing posture: The person stands erect and
being anywhere from 10 to 18 inches lower than looks straight ahead, with his or her arms
other adults in situations in which standing is in a relaxed posture at the side (Figure
needed.4 In addition, their overall breadth is up to 5-1).
five times that of a person without a device, and Seated posture: The person sits erect and looks
thus they are much larger and bulkier. Consider straight ahead. The sitting surface is adjusted
individuals who have an impairment. These indi- so that the person’s thighs are parallel to the
viduals may lack full motion or strength because floor and the knees are bent to a 90-degree
of a mild disability; examples include the frail angle with the feet flat on the floor. The
elderly who cannot rise from a chair because it is upper arm is relaxed and perpendicular to
too low and individuals with rheumatoid arthritis the horizontal plane, and the forearm is at
who cannot open a car door because of weakened a right angle to the upper arm and thus also
hands. In a well-designed environment, these parallel to the floor. Measurements in sitting
individuals may be able to function fully. However, are made using a horizontal reference point,
if placed in a poorly designed environment, these either the ground or the seat, and a vertical
individuals may be totally disabled. Thus, design- reference point, an imaginary line that
ing an environment that supports the indepen- touches the back of the uncompressed but-
dence of those with disabilities is vital. Using tocks and shoulder blades of the subject.
anthropometric measurements to design the op- Thus, in the standard seated posture, the
timal environment for people with disabilities person is measured with most joints, the
often provides an optimal environment for all ankle, knees, hip, and elbows at 90-degree
populations. angles (Figure 5-2).
When designing for people with disabilities Table 5-1 describes some common anthropo-
(particularly those with physical challenges such metric dimensions. Use Figures 5-1 through 5-4 to
as kyphosis, axial rotation, or limb discrepancies), help to clarify each dimension.
however, the use of standard anthropometric These and other dimensions have been mea-
measurement and techniques is difficult because sured in thousands of people from different popu-
of the high degree of statistical variability in this lations. The measurements have been compiled to
population. Type of disability can markedly affect form tables of anthropometric estimates. These
the distributions of body dimensions. A study of tables can be used to determine the best sizes for
the anthropometrics of a population with severe aspects of the workspace for different ages,
disabilities reported a need for at least four new genders, and ethnic populations. These tables can
linear measurements to capture the spatial require- also be used to get a sense of the range and com-
ments of those with physical challenges, as well plexity of the human form.
Chapter 5 Anthropometry 77

23. 24.

17. 22. 10.


5. 12.
6. 16. 14.

FIGURE 5-2 Static anthropometric dimensions for the

standard sitting posture. The numbers correspond to
data in Table 5-1.


FIGURE 5-1 Static anthropometric dimensions for the
standard standing posture. The numbers correspond All the information described is useful for under-
to data in Table 5-1. standing the shape of humans. However, as with
any averages, these measurements have some
limitations. Remember: anthropometric data offer
The dimensions in the second and third a guide, not an absolute.
columns of Table 5-1 refer to the anthropometric
estimates for a U.S. population in Table 5-2. The Accuracy
dimensions in the fourth and fifth columns of Measuring the human form is a tricky business.
Table 5-1 refer to the estimates in Tables 5-3 and Not only is the body composed of round, soft
5-4 and provide some general estimates for male outlines that are prone to compression, but people
and female individuals who use wheeled mobility also tend to slouch. Measurement methods may
devices. Many of these measurements would vary from study to study depending on the
be similar in a seated population except that researchers. Sometimes, because of the time and
the height and breadth of the wheelchair must expense of anthropometric research, estimates are
be taken into consideration. Table 5-5 provides made using mathematic equations based on
detailed estimates for the hand and refers to Figure stature. Although these provide a very reasonable
5-4. Text continued on p. 85.
TABLE 5-1 Anthropometric Dimensions

Estimates for U.S. Adults Estimates for Wheelchair Users

(see Figures 5-1 and 5-2, Table 5-2) (see Figure 5-3, Tables 5-3 and 5-4)
Dimensions Descriptions Dimensions Descriptions

1 Stature Vertical distance from the floor 1 Overall height Vertical distance from the
to the crown of the head floor to the crown of the
2 Eye height Vertical distance from the floor 2 Eye height Vertical distance from the
to the inner corner of the eye floor to the inner corner of
the eye
3 Shoulder Vertical distance from the floor 3 Shoulder Vertical distance from the
height to the acromion height floor to the acromion
4 Elbow height Vertical distance from the floor 4 Wrist height Vertical distance from the
to the olecranon process of floor to the wrist crease
the elbow just below the radial styloid
5 Hip height Vertical distance from the floor 5 Sitting height Vertical distance from the
to the greater trochanter seat to the crown of the
6 Wrist height Vertical distance from the floor 6 Knee height Vertical distance from the
to the wrist crease just below floor to the top of the
the ulnar styloid patella
7 Fingertip Vertical distance from the floor 7 Overall Distance between the parallel
height to the tip of the third digit breadth vertical planes that cross
the lateral-most points of
the individual or the
individual’s wheelchair
8 Sitting height Vertical distance from the seat 8 Forearm to Distance between the lateral-
to the crown of the head forearm most points of the right
breadth and left forearms
9 Sitting eye Vertical distance from the seat 9 Hip breadth Distance between the lateral-
height to the inner corner of the most points of the right
eye and left hips
10 Sitting Vertical distance from the 10 Waist breadth Distance between the lateral-
shoulder sitting surface to the most points of the right
height acromion of the shoulder and left sides of the waist
11 Sitting elbow Vertical distance from the seat 11 Thigh breadth Distance between the lateral-
height to the olecranon process of most points of the right
the elbow and left thighs
12 Thigh Vertical distance from the seat 12 Overall depth Distance between the parallel
thickness to the top of the thigh at the vertical planes that cross
thickest part the anterior-most and
posterior-most points of the
individual or the
individual’s wheelchair
13 Buttock-knee Horizontal distance from the 13 Abdominal Shortest perpendicular
length uncompressed buttock to the extension distance from seat back
patella depth plane to the most
protruding point of the
abdominal region
TABLE 5-1 Anthropometric Dimensions—cont’d

Estimates for U.S. Adults Estimates for Wheelchair Users

(see Figures 5-1 and 5-2, Table 5-2) (see Figure 5-3, Tables 5-3 and 5-4)
Dimensions Descriptions Dimensions Descriptions

14 Buttock- Horizontal distance from the 14 Buttock-knee Horizontal distance from the
popliteal uncompressed buttocks to length uncompressed buttock to
length the underside of the knee at the patella
the popliteal angle
15 Knee height Vertical distance from the floor 15 Buttock- Horizontal distance from the
to the top of the patella popliteal uncompressed buttocks to
while in the standard sitting length the underside of the knee
position at the popliteal angle
16 Popliteal Vertical distance from the floor
height to the underside of the knee
at the popliteal angle while
in the standard sitting
17 Shoulder Horizontal distance across the
breadth shoulder from acromion to
18 Hip breadth Horizontal distance at the
broadest place on the hips
when in the standard sitting
19 Shoulder- Vertical distance from the
elbow acromion to the olecranon
length process in the standard
sitting position
20 Elbow- Vertical distance from the
fingertip olecranon process to the tip
length of the third digit while in the
standard sitting position
21 Upper limb Horizontal distance from the
length acromion to the tip of the
third digit with the elbow
and wrist extended, and the
shoulder flexed to 90°
22 Shoulder-grip Horizontal distance from the
length acromion to the center of an
object gripped in the hand
with the elbow and wrist
extended and the shoulder
flexed to 90°
23 Standing Vertical distance from the
vertical ground to the center of an
grip reach object gripped in the hand
with the shoulder flexed
to 180° (no stretching)
24 Sitting Vertical distance from the seat
vertical to the center of an object
grip reach gripped in the hand with
the shoulder flexed to 180°
(no stretching)
80 PART II Knowledge, Tools, and Techniques

13 10
15 9

12 7
FIGURE 5-3 A, Static anthropometric dimensions for wheelchair users (side view). The numbers correspond
to data in Tables 5-3 and 5-4. B, Static anthropometric dimensions for the wheelchair users (front view). The
numbers correspond to data in Tables 5-3 and 5-4.

TABLE 5-2 Anthropometric Estimates for U.S. Adults*

No. in
Figures Men Women
5-1 and Percentile Percentile
5-2 Dimensions 5th 50th 95th SD 5th 50th 95th SD

1 Stature 64.7 69.3 73.9 2.8 59.5 64.0 68.6 2.8

1644.4 1760.4 1876.3 70.7 1511.6 1626.7 1741.7 70.2
2 Eye height 60.2 64.7 69.2 2.7 55.4 59.7 64.1 2.7
1528.6 1643.3 1758.0 69.7 1406.1 1517.0 1627.9 67.4
3 Shoulder height 53.3 57.5 61.6 2.5 48.3 52.6 56.9 2.6
1353.9 1459.7 1565.5 64.3 1226.7 1336.2 1445.6 66.5
4 Elbow height 40.4 43.7 47.0 2.0 37.4 40.5 43.6 1.9
1025.8 1110.1 1194.5 51.3 949.5 1028.9 1108.4 48.3
5 Hip height 33.5 36.8 40.0 2.0 29.4 32.7 35.9 2.0
851.3 934.3 1017.2 50.4 747.2 829.9 912.6 50.3
6 Wrist height 30.9 33.8 36.6 1.7 28.6 31.3 34.0 1.6
785.3 857.5 929.7 43.9 726.6 795.5 864.4 41.9
Chapter 5 Anthropometry 81

TABLE 5-2 Anthropometric Estimates for U.S. Adults*—cont’d

No. in
Figures Men Women
5-1 and Percentile Percentile
5-2 Dimensions 5th 50th 95th SD 5th 50th 95th S

7 Fingertip height 23.9 26.3 28.7 1.5 22.1 24.4 26.7 1.4
606.6 667.4 728.1 36.9 562.3 620.3 678.4 35.3
8 Sitting height 33.9 36.3 38.7 1.5 31.6 33.9 36.2 1.4
862.2 923.0 983.7 36.9 802.0 861.1 920.2 35.9
9 Sitting eye height 29.3 31.7 34.2 1.5 27.0 29.3 31.7 1.4
744.2 805.8 867.5 37.5 685.8 745.0 804.2 36.0
10 Sitting shoulder 22.0 24.1 26.1 1.3 20.5 22.6 24.8 1.3
height 558.9 611.3 663.7 31.8 520.9 575.1 629.2 32.9
11 Sitting elbow 7.8 9.6 11.4 1.1 7.4 9.2 10.9 1.1
height 199.2 244.5 289.8 27.6 187.8 232.7 277.5 27.3
12 Thigh thickness 5.2 6.7 8.3 0.9 3.8 6.3 8.8 1.5
131.7 171.3 211.0 24.1 95.4 159.6 223.7 39.0
13 Buttock-knee 21.7 24.4 27.1 1.6 19.9 23.6 27.2 2.2
length 552.0 620.0 688.1 41.4 506.1 598.6 691.1 56.2
14 Buttock-popliteal 18.1 20.6 23.2 1.6 16.6 19.8 23.1 2.0
length 458.5 523.6 588.8 39.6 420.7 503.3 585.9 50.2
15 Knee height 19.6 21.5 23.4 1.1 17.7 19.5 21.4 1.1
498.7 546.1 593.5 28.8 448.4 495.9 543.4 28.9
16 Popliteal height 15.9 17.7 19.5 1.1 13.9 15.7 17.5 1.1
404.3 450.0 495.7 27.8 354.3 399.9 445.5 27.7
17 Shoulder breadth 14.8 16.3 17.7 0.9 13.2 14.5 15.7 0.7
376.8 412.9 449.0 21.9 336.5 367.2 398.0 18.7
18 Hip breadth 12.3 14.6 17.0 1.4 12.1 15.9 19.7 2.3
311.8 371.8 431.9 36.5 307.2 403.6 500.0 58.6
19 Shoulder-elbow 13.7 14.9 16.1 0.7 12.3 13.5 14.7 0.8
length 347.3 377.8 408.3 18.6 311.3 343.0 374.6 19.2
20 Elbow-fingertip 17.4 18.8 20.2 0.9 15.6 17.0 18.5 0.9
length 442.9 478.5 514.1 21.7 395.0 432.9 470.8 23.0
21 Upper limb 29.0 31.4 33.7 1.4 25.6 28.3 31.0 1.7
length 736.9 796.4 855.9 36.2 649.2 718.5 787.8 42.1
22 Shoulder grip 23.9 26.2 28.4 1.3 21.8 24.1 26.3 1.4
length 608.3 664.5 720.6 34.1 554.3 611.0 667.6 34.4
23 Vertical grip reach 76.6 82.7 88.7 3.7 71.7 76.9 82.0 3.1
(standing) 1945.4 2099.5 2253.7 93.7 1822.1 1952.4 2082.6 79.2
24 Vertical grip reach 48.6 52.0 55.5 2.1 44.6 48.1 51.5 2.1
(sitting) 1233.3 1321.5 1409.7 53.6 1133.3 1220.5 1307.7 53.0

*Data in roman type represent inches; data in italics represent millimeters.

Data are reproduced with permission from PeopleSize anthropometry software, Copyright © Open Ergonomics Ltd.,
1999, Melton Road, Hickling Pastures, Melton Mowbray, Leicestershire, LE14 3QG, United Kingdom.
TABLE 5-3 Anthropometric Estimates for Male Wheelchair Users*

No. in Overall Sample (n = 75) Manual Wheelchair Users Power Wheelchair Users
Figure Percentile (n = 37) Percentile (n = 38) Percentile
5-3 Dimensions Mean SD 5th 50th 95th Mean SD 5th 50th 95th Mean SD 5th 50th 95th
Age (Years) 52.0 15.6 23.0 52.0 80.0 57.3 15.6 33.0 57.0 81.0 46.5 13.8 22.0 46.0 70.0
1 Overall 51.1 2.3 47.4 51.2 54.4 50.9 1.8 48.2 51.1 53.8 51.2 2.8 47.3 51.2 58.3
height 1309 60 1216 1312 1394 1306 47 1236 1310 1379 1312 71 1214 1312 1494
2 Eye height 46.6 2.2 43.2 46.6 49.6 46.4 1.8 43.7 46.5 49.3 46.8 2.6 43.0 46.8 53.5
1195 58 1108 1194 1271 1190 46 1122 1193 1263 1200 67 1104 1200 1373
3 Shoulder 40.7 2.0 36.8 40.8 44.3 40.5 1.6 36.5 40.7 42.8 40.8 2.4 36.7 40.8 46.7
height 1043 52 944 1046 1137 1038 40 936 1045 1098 1047 61 941 1046 1197
4 Wrist height 30.3 2.9 25.6 30.2 35.2 29.6 2.5 25.3 29.5 35.4 30.9 3.2 25.9 30.7 35.4
776 75 658 774 904 760 65 650 756 908 792 81 664 788 909
5 Sitting height 30.1 2.3 26.4 30.7 33.2 31.0 1.8 27.1 31.3 33.8 29.3 2.5 23.4 29.5 33.0
773 60 678 786 850 796 47 694 803 867 750 63 601 756 845
6 Knee height 24.8 2.5 21.2 24.9 28.9 24.4 2.7 20.2 24.4 30.8 25.2 2.1 21.7 25.1 29.3
637 64 544 639 742 627 70 518 625 791 646 55 557 643 750
7 Overall 27.8 3.2 23.6 27.7 32.7 27.2 2.7 23.0 26.9 32.7 28.4 3.6 23.7 28.3 34.5
breadth 713 82 604 709 839 698 68 589 690 839 728 92 608 726 885
8 Forearm to 23.4 3.2 18.5 23.1 28.7 23.0 2.5 19.2 22.6 27.3 23.9 3.7 15.2 23.7 29.1
forearm 601 82 475 593 737 590 65 492 579 701 612 95 391 607 747
9 Hip breadth 10.5 1.6 8.1 10.4 13.2 10.3 1.5 8.7 10.9 15.1 10.1 1.6 7.2 9.9 12.8
270 41 207 267 339 263 39 224 280 387 258 40 184 255 328
10 Waist 16.7 2.4 11.9 17.0 20.7 17.3 2.1 12.0 17.4 20.9 16.3 2.6 11.4 16.4 20.7
breadth 429 61 304 435 530 443 54 308 447 536 417 66 292 420 530
11 Thigh 17.2 3.5 10.5 17.2 24.4 17.6 2.6 12.0 18.0 20.6 16.8 4.3 9.8 16.6 27.1
breadth 441 91 270 440 625 451 67 308 461 529 432 110 252 425 696
12 Overall 47.8 3.9 42.6 48.0 55.3 48.2 4.3 41.8 48.4 57.1 47.4 3.7 42.7 46.4 53.9
depth 1225 101 1092 1230 1419 1235 109 1071 1240 1465 1216 94 1096 1189 1381
13 Abdominal 14.5 2.1 11.0 14.1 18.5 13.9 2.0 10.5 13.8 17.0 15.0 2.2 11.9 14.7 19.0
extension 371 55 282 361 474 356 50 270 355 437 385 57 306 376 488
14 Buttock-knee 24.3 2.8 19.6 24.7 28.6 24.5 2.2 20.6 24.8 27.6 24.2 3.3 17.9 24.6 28.8
length 624 72 502 633 734 628 56 529 635 709 620 85 460 630 740
15 Buttock- 20.2 2.8 14.9 20.6 24.5 20.3 2.5 15.5 20.6 23.5 20.2 3.1 13.6 20.5 24.8
popliteal 519 73 382 527 628 520 63 399 529 604 518 81 349 526 635

*Data in roman type represent inches; data in italics represent millimeters.

From Paquet V, Feathers D: An anthropometric study of manual and powered wheelchair users, Int J Ind Ergon, 33:198, 2004.
TABLE 5-4 Anthropometric Estimates for Female Wheelchair Users*

No. in Overall Sample (n = 46) Manual Wheelchair Users Power Wheelchair Users
Figure Percentile (n = 28) Percentile (n = 18) Percentile
5-3 Dimensions Mean SD 5th 50th 95th Mean SD 5th 50th 95th Mean SD 5th 50th 95th
Age (years) 49.5 15.0 28.0 48.5 74.0 53.1 15.2 33.0 51.0 82.0 44.0 15.0 22.0 41.0 72.0
1 Overall 48.8 2.5 44.4 49.1 52.4 48.9 2.3 44.4 48.9 52.4 48.6 2.7 44.1 49.2 52.8
height 1251 63 1139 1258 1343 1254 58 1139 1255 1343 1246 70 1132 1261 1355
2 Eye height 44.5 2.5 40.4 44.8 48.6 44.4 2.1 40.8 44.8 48.6 44.7 3.0 39.3 45.1 48.7
1141 64 10.7 1149 1246 1138 55 1047 1148 1246 1145 78 1008 1158 1249
3 Shoulder 38.9 2.1 35.7 39.0 42.2 38.8 2.0 35.9 38.7 42.3 39.1 2.3 34.9 39.3 42.8
height 998 53 917 1001 1083 994 50 921 992 1084 1003 58 895 1008 1098
4 Wrist height 30.3 3.1 25.0 30.1 35.4 29.4 2.8 24.3 29.7 34.6 31.7 3.1 26.7 32.1 37.5
777 81 641 772 907 754 73 624 761 887 812 80 684 823 961
5 Sitting 28.7 2.5 24.2 28.9 32.5 29.4 1.9 25.9 29.2 32.5 27.7 2.8 23.0 28.5 33.9
height 736 63 621 741 833 753 49 663 749 833 710 73 589 730 868
6 Knee height 62.5 5.6 54.3 61.9 71.2 60.8 5.3 53.5 60.2 70.7 64.9 5.2 56.9 64.1 77.6
276 31 239 269 332 271 30 237 263 329 284 32 240 281 353
7 Overall 70.8 7.9 61.3 68.9 85.2 69.6 7.6 60.8 67.5 84.4 72.8 8.2 61.6 72.1 90.6
breadth 234 32 175 233 283 228 30 175 231 283 238 33 165 239 298
8 Forearm to 59.9 8.1 44.8 59.7 72.6 58.5 7.8 44.9 59.2 72.6 61.0 8.5 42.4 61.2 76.5
forearm 108 20 84 102 149 109 20 84 105 149 107 21 83 99 163
9 Hip breadth 27.7 5.2 21.6 26.1 38.3 27.9 5.2 21.6 26.8 38.3 27.4 5.4 21.2 25.3 41.8
168 20 143 168 202 168 18 143 167 198 168 23 126 170 210
10 Waist 43.1 5.1 36.6 43.0 51.9 43.1 4.6 36.6 42.7 50.8 43.2 6.0 32.4 43.7 53.8
breadth 173 32 132 168 235 170 30 132 167 232 177 35 124 170 255
11 Thigh 44.4 8.2 33.8 43.2 60.3 43.6 7.6 33.8 42.8 59.6 45.5 9.1 31.7 43.6 65.5
breadth 464 39 409 464 523 456 36 400 453 518 477 41 417 477 596
12 Overall 119.0 10.0 104.8 118.9 134.0 116.8 9.3 102.5 116.1 132.9 122.4 10.4 106.8 122.2 152.9
depth 142 22 111 140 178 141 23 103 136 178 145 21 106 142 181
13 Abdominal 36.5 5.6 28.4 35.8 45.7 36.1 5.8 26.4 34.9 45.7 37.2 5.5 27.3 36.5 46.3
extension 625 56 543 619 712 608 53 535 602 707 649 52 569 641 776
14 Buttock-knee 24.4 2.5 21.5 24.5 29.3 24.6 1.7 21.8 24.7 26.6 23.9 3.5 14.3 23.8 30.0
length 625 65 550 627 752 632 45 559 633 683 614 89 367 612 770
15 Buttock- 20.5 2.4 16.9 20.4 20.5 20.7 2.1 17.6 20.4 24.1 20.0 2.9 13.0 20.4 25.9
popliteal 525 62 433 523 527 532 54 452 524 618 514 74 334 522 663

*Data in roman type represent inches; data in italics represent millimeters.

From Paquet V, Feathers D: An anthropometric study of manual and powered wheelchair users, Int J Ind Ergon, 33:197, 2004.
TABLE 5-5 Anthropometric Estimates for the Hand*

No. in
Figure Men Percentile Women Percentile
5-4 Dimensions 5th 50th 95th SD 5th 50th 95th SD

1 Hand length 6.8 7.4 8.1 0.4 6.3 6.9 7.4 0.4
173 189 205 10 159 174 189 9
2 Palm length 3.9 4.2 4.6 0.2 3.5 3.8 4.1 0.2
98 107 116 6 89 97 105 5
3 Thumb length 1.7 2.0 2.3 0.2 1.6 1.9 2.1 0.2
44 51 58 4 40 47 53 4
4 Index finger length 2.5 2.8 3.1 0.2 2.4 2.6 2.9 0.2
64 72 79 5 60 67 74 5
5 Middle finger length 3.0 3.3 3.5 0.2 2.7 3.0 3.3 0.2
76 83 90 5 69 77 84 5
6 Ring finger length 2.6 2.8 3.1 0.2 2.3 2.6 2.9 0.2
65 72 80 4 59 66 73 4
7 Little finger length 1.9 2.2 2.5 0.2 1.7 2.0 2.2 0.2
48 55 63 4 43 50 57 4
8 Thumb breadth (IPJ) 0.8 0.9 1.0 0.1 0.7 0.7 0.8 0.1
20 23 26 2 17 19 21 2
9 Thumb thickness (IPJ) 0.7 0.9 0.9 0.1 0.6 0.7 0.8 0.1
19 22 24 2 15 18 20 2
10 Index finger breadth 0.7 0.8 0.9 0.0 0.6 0.7 0.8 0.0
(PIPJ) 19 21 23 1 16 18 20 1
11 Index finger thickness 0.7 0.7 0.8 0.0 0.6 0.6 0.7 0.0
17 19 21 1 14 16 18 1
12 Hand breadth 3.1 3.4 3.7 0.2 2.7 3.0 3.3 0.2
(metacarpal) 78 87 95 5 69 76 83 4
13 Hand breadth 3.8 4.1 4.5 0.2 3.3 3.6 3.9 0.2
(across thumb) 97 105 114 5 84 92 99 5
14 Hand breadth 2.8 3.2 3.6 0.2 2.5 2.8 3.1 0.2
(minimum)† 71 81 91 6 63 71 79 5
15 Hand thickness 1.1 1.3 1.5 0.1 0.9 1.1 1.3 0.1
(metacarpal) 27 33 38 3 24 28 33 3
16 Hand thickness 1.7 2.0 2.3 0.2 1.6 1.8 2.0 0.1
(including thumb) 44 51 58 4 40 45 50 3
17 Maximum grip 1.8 2.0 2.3 0.2 1.7 1.9 2.1 0.1
diameter‡ 45 52 59 4 43 48 53 3
18 Maximum spread 7.0 8.1 9.2 0.7 6.5 7.5 8.5 0.6
178 206 234 17 165 190 215 15
19 Maximum functional 4.8 5.6 6.4 0.5 4.3 5.0 5.7 0.4
spread§ 122 142 162 12 109 127 145 11
20 Minimum square 2.2 2.6 3.0 0.2 2.0 2.3 2.6 0.2
access|| 56 66 76 6 50 58 67 5

From Pheasant S: Bodyspace: anthropometry, ergonomics, and design, ed 2, Philadelphia, 1998, Routledge/Taylor and
IPJ, Interphalangeal joint (i.e., the articulation between the two segments of the thumb); PIPJ, proximal interphalan-
geal joint (i.e., the finger articulation nearest the hand).
*Data in roman type represent inches; data in italics represent millimeters.

As for hand breadth (metacarpal), except that the palm is contracted to make it as narrow as possible.

Measured by sliding the hand down a graduated cone until the thumb and middle finger just touch.
Measured by gripping a flat wooden wedge with the tip end segments of the thumb and ring fingers.
The side of the smallest equal aperture through which the hand will pass.
Chapter 5 Anthropometry 85

Heavy clothing can add as little as 1/2 inch to as

6 5 4 much as 21/2 inches to measurements.8
7 10

12 As mentioned, people in different populations
2 3 9
13 have different sizes. Estimates should correspond
with the population type of the people who will
use the design. For example, if the population is
predominantly Asian, using the information from
a western group will result in measurements that
are too large. Unfortunately, not all populations
11 17
15 have anthropometric estimates that designers can
8 use. In addition, as populations change over time,
tables of measurements collected in a population
many years previously may not accurately reflect
the present-day size of the people in that
All the measurements are averages of a large popu-
lation. Variations exist for all the measurements
FIGURE 5-4 Static anthropometric dimensions for the when applied to the individual level. Using the
hand. The numbers correspond to data in Table 5-5. average (50th percentile) creates workstations
(From Pheasant S: Bodyspace: anthropometry, ergonomics, that are too large or too small for most people.
and design, ed 2, Philadelphia, 1998, Routledge/Taylor and Even using the 5th and 95th percentiles, as recom-
Francis.) mended by ergonomic texts, misses 10% of the
population. Data from the 99th and 1st percentiles
exclude fewer people but have a greater potential
estimate, they may not be totally accurate.11 For- for error. The data may not be reliable because
tunately, unless form-fitting spaces are being the population used for the measurement is very
designed (such as a space capsule), exact mea- small.
surements are not always necessary. Although anthropometric data may have flaws,
they still provide valuable insights into the overall
Clothing size and shape of the population. They provide a
One of the greatest flaws in anthropometric mea- solid foundation of information that can be used
surements, at least for workstation design, is that to create a workstation that will fit the largest
the measurements are often taken of unclothed, number of people comfortably. The estimates pro-
unshod persons. Fortunately, most clothing adds vided in the tables should be used as a stepping
only minimal bulk, unless it is protective equip- stone to understanding human form when improv-
ment or bulky outdoors clothing. If workers are ing or designing the work environment. Use of
likely to be wearing bulky clothing, adjust the these estimates should help prevent the mistake
measurements accordingly. As a rule of thumb, of designing for only a few members of a
use the following: population.
Shoes: Add approximately 1 inch (25 mm) for
men and 1 to 2 inches (25 to 45 mm) for
women to all measurements involving leg USES OF ANTHROPOMETRIC DATA
height (these heights do not reflect extremes The next sections of the chapter build on the static
in fashion).11 anthropometric estimates and review concepts
86 PART II Knowledge, Tools, and Techniques

such as reach and clearance. These concepts are 64

vital to understanding how to construct a worksta-
tion. As with all measurements, these are aver- 56
ages. Always consider the overall population and
the purpose of the workstation before using any extended
measurement. The numbers included here are for 48 reach
American populations.

Reach is defined as a sphere around the worker 32
that can be touched by the worker at all points
without moving the body from the starting point.
The shoulder is the axis or center of the sphere, 24
and the length of the arm is equal to the radius.
In some cases, when reach is limited to what is 16
available from elbow to fingertips (as when
working on a table), the elbow is the axis and the 8
forearm and hand form the radius. When design-
ing to accommodate reach, consider the smallest
user, the 5th percentile woman. If she can reach 0
an object, all larger individuals can reach it, too. 0 8 16 24 32 40
Vertical Reach
FIGURE 5-5 The vertical envelope in which a 5th per-
Operating buttons on a control panel and getting centile worker can reach an object when sitting. The
objects off high shelves are examples of activities inner line of the arc represents the 5th percentile
that occur during vertical reach. female reach, and the outer line represents the 5th
For a standing reach the 95th percentile man percentile male. (From Cohen AL, Gjessing CC, Fine LJ
can reach a button that is 94.2 inches (2393 mm) et al: Elements of an ergonomics program, DHHS [NIOSH]
from the ground, whereas the 5th percentile wo- Publication No. 97-117, Washington DC, 1997, U.S. Gov-
man would be able to reach a button 75.4 inches ernment Printing Office.)
(1914 mm) high. To be able to grasp an object,
the highest the object can be is 89 inches
(2260 mm) for the 95th percentile man and 71.2 (360 mm). If access is blocked by a shelf or table
inches (1808 mm) for the 5th percentile woman.9 that is between 20 and 25 inches (510 to 635 mm)
These reaches assume that the person can stand wide, the maximum high forward reach height is
directly against the control panel. 44 inches (1120 mm).13
Figure 5-5 provides the vertical envelope in
which a 5th percentile worker can reach an object Horizontal Reach
when sitting. The inner line of the arc represents Horizontal height is usually defined by a tabletop
the 5th percentile female reach, and the outer line or counter; the worker manipulates objects on
represents the 5th percentile man. Individuals can its surface. Four zones need to be considered
reach further by leaning forward, and the outer- (Figure 5-6)3:
most arc represents this occasional extended • Normal work distance is the arc made by the
reach. forearm when the body is as close to the
For people who use wheeled mobility devices table as is comfortable and the elbow is close
the maximum unobstructed (high) forward reach to the side. This is the area where most pre-
height is 48 inches (1220 mm) and the minimum cision work is performed. This distance is
unobstructed (low) forward reach is 15 inches made up of a radius of approximately 13
Chapter 5 Anthropometry 87

FIGURE 5-6 The four zones of horizontal 20"

reach. (From Cohen AL, Gjessing CC, Fine 10"
13"-17" 21"-25"
LJ et al: Elements of an ergonomics program,
DHHS [NIOSH] Publication No. 97-117,
Washington DC, 1997, U.S. Government
Printing Office.)

inches for the 5th percentile woman and 17 a wheelchair, may not be able to reach far
inches for the 5th percentile man (a range of objects easily.
350 to 450 mm). • Blocking by other surfaces: If a person must
• Extended working distance is the area made reach over or around other objects, reach is
by the arc of the arm when the elbow is decreased.
straight. This is best for storing frequently • Job requirements: Reach can be constrained
used tools, supplies, and heavy objects. This by needs for precision or strength.
distance is a radius of approximately 21
inches for the 5th percentile woman to 25 “Visual” Reach (Seeing over Objects)
inches for the 5th percentile man (a range of In the consideration of any workspace, visual
550 to 650 mm). contact with important objects is necessary.
• Maximum work distance is established when Workers must be able to see what they are doing,
the body leans forward. This area is best for as well as lights, controls, and alarms (Figure 5-7).
infrequently used supplies and tools. It is Some rules for visual reach are as follows9:
also the area that is considered for the place- Objects should not block the normal line of
ment of push-buttons and other controls. sight.
This distance ranges from 27.6 inches to 31.5 The most relaxed line of sight when the head
inches (700 to 800 mm). is erect is not actually on the horizontal plane;
• Most efficient workspace is defined by a 10- relaxed sight occurs about 10 to 15 degrees below
inch (250-mm) square directly in front of the the horizontal. Thus, work that requires continu-
worker and about a hand’s span from the ous visual contact, such as work at a computer,
edge of the table. This is the area where most should be placed 10 to 15 degrees below the hori-
people prefer to work, as it places material zontal eye line.
at the most comfortable distance from the The eye can comfortably rotate about 15
body. degrees above and below this imaginary angle.
These reaches are optimal when conditions are Thus, controls that need to be read frequently
perfect. Reach distances can be constrained by the should be placed between 30 degrees below the
following: horizontal and 5 degrees above the horizontal.
• Balance: Greater reach can be achieved by This angle changes if the head flexion angle is
leaning forward and backward. However, increased.
this may not be possible if the worker is in The reading distance of the eye is approxi-
a precarious situation or on a slippery mately 15.8 to 27.6 inches (400 to 700 mm) from
surface. It also increases fatigue for repeti- the eye. The further from the eye the material, the
tive reaching. larger and more clearly it must be displayed.
• Clothing: Bulky clothing such as coats and
other protective suits reduces reach. Clearance
• Overall joint mobility: Persons with decreased Clearance is the space needed to allow free pas-
motion, such as a person with arthritis or in sage of a person or a body segment. Clearance can
88 PART II Knowledge, Tools, and Techniques

50° maximum • The clearance required for one person to

sight line walk alone is 25.5 inches (650 mm).11
• The clearance required for two persons to
walk abreast is 53.1 inches (1350 mm).11
• The clearance required for one person in a
wheelchair is 36 inches (915 mm).13
• The clearance required for a person in a
5° comfortable
sight line wheelchair to complete a 360-degree turn is
Horizontal a 60-inch (1525-mm) square.13

Hand Clearance
15° relaxed
sight line
Sliding the hand in and out of small spaces can
be very important for certain tasks.
30° comfortable The smallest aperture through which a 95th
sight line
percentile man can slide his hand is a square with
each side measuring 5.1 inches (76 mm). If the
opening is at least 2.3 inches (38 mm) thick and
70° maximum
sight line 4.6 inches (114 mm) wide, the hand can slide in.
However, he cannot grasp and remove anything
FIGURE 5-7 “Visual” reach. through an opening of this size; he can only press
If hand access to a place is to be prevented, for
example with hand guards, the opening must be
be as narrow as a hatchway into a submarine or less than 2 inches (50 mm) square or no thicker
as wide as a doorway in a civic center that allows than 1.5 inches (23 mm) and no wider than 3.3
many people to pass in and out at the same time. inches (83 mm).11
Clearance, as with any design, must take into
account the uses the area will have, including Leg Room
the traffic patterns and clothing being worn. Seated work requires space to stretch and position
Historically, clearance has been designed for the the legs in a variety of postures. Areas designated
biggest user, the 95th percentile man. However, for seated work should have enough space for tall
in today’s society, clearance must take into people to comfortably place their legs. Generally,
account the people who use wheeled devices for workspaces designated for seated work should not
mobility, because a wheeled device requires con- have drawers or thick countertops, as this reduces
siderably larger spaces in which to maneuver. knee space.
The following are some general clearance The space should be at least 27.2 inches
heights and widths based on a large man or, when (680 mm) wide and 27.6 inches (690 mm) high.9
appropriate, a user of a wheeled mobility device. When they sit, most people like to lean back
and stretch their legs under the space; therefore
Height the depth of the space should accommodate this
The minimum height of a passageway that will at least at floor level. The space should be 24
allow a 99th percentile man wearing a helmet and inches (600 mm) at knee level and 32 inches
shoes to pass through without ducking is 77 (800 mm) at floor level.9
inches (1955 mm).11
Width Essentially the orientation of body parts in space,
The minimum width of a passageway depends on posture is believed to have a profound effect on
potential use. the health and well-being of the worker. Working
Chapter 5 Anthropometry 89

in one unchanging position, or static posture, has worker to exert body weight as force, and saves
been associated with the development of muscu- space. The advantages of sitting to work are that
loskeletal disorders. Postures that position the it minimizes operator fatigue, increases operator
body or body parts so that muscles must work stability, provides support to exert force, permits
strongly against gravity, such as holding the arms the use of pedals, and accommodates a wide
out at shoulder height or working with the torso range of operator sizes.5
bent, often cause discomfort in the worker.1 Several rules should be kept in mind to help
Anthropometric data are commonly used to decrease the effects posture may have on the
place the body in the best posture for the job. But body:
what is the best posture? In general, maintaining • Position should be changed frequently. Pro-
the limbs and torso as close to the neutral posture longed static postures place a great deal of
as possible is considered to place the least strain stress on the worker.
on the body. When a person is standing, the • Positions that cause forward inclination of
neutral posture can be achieved by having the the head should be avoided. The torque
head upright over the torso, the torso upright with caused by the weight of the head (approxi-
the center of gravity over the hips, the knees mately 8 pounds) increases dramatically the
slightly bent, and the arms in a relaxed position further from midline the head is placed.
at the sides. Working positions that allow the Make sure visual work is high enough to
worker to maintain or return to this posture fre- keep the head balanced over the spine.
quently are considered to put the least amount of • Upper arms should be kept next to the body,
stress on the body. For sitting, the posture is and raising arms overhead should be avoided.
similar, except it is shaped by the chair on which As with the neck, the torque on the shoul-
the worker is sitting. ders increases as the arms move toward 90-
The position in which an individual sits can degree angles.
place a great deal of stress on the lower back. The • Body parts should be kept aligned; twisting
so-called “correct” sitting posture in which the and asymmetry should be avoided. Asym-
individual is positioned at 90-degree hip flexion, metry tends to place muscles in positions of
90-degree knee flexion, and 90-degree elbow weakness.
flexion, with ramrod-straight back and erect head, • Neutral postures should be maintained and
is a myth that may have caused some harm. extremes of range avoided. This is especially
Research on discal pressure during sitting sug- true for the wrist and hands, which can be
gests that this position places greater pressure on in some very awkward postures.
the lower back than sitting in a relaxed posture in • A back support should always be provided,
the chair.2 Observations of workers suggest preferably one that can be inclined to greater
the posture most often selected is one that allows than 90 degrees.
them to lean back in the chair at about an angle • Body parts should be placed in the positions
of 105 degrees.6 This position allows the back of greatest strength.
to be supported by the chair, taking some of
the weight off the spinal disks and musculature. Precision and Strength
The best chair allows the worker to recline Anthropometrics directly affect a worker’s ability
slightly. to do work that requires precision or strength. As
One often asked question: Is it better to sit or with posture, an understanding of anthropomet-
stand on the job? Both have good points. Whether rics can help correctly position workers to perform
a person should sit or stand on the job depends such tasks.
on the requirements of the task. The advantages
of standing to work are that it increases mobility, Precision
allows the worker to cover a larger work area, Precision is strongly influenced by the need to see
makes large control motions possible, allows the work; the smaller the work, the closer it must be
90 PART II Knowledge, Tools, and Techniques

held to the eyes. Precision is enhanced by the balance the task. In general, however, jobs that
worker’s ability to hold the work close to the body require strength should be performed with the
and to support his or her arms or hands while object 6 to 16 inches (150-400 mm) lower than
working. In general, precise work should be posi- the elbow.9
tioned about 2 to 4 inches (50 to 100 mm) above After the basics of anthropometry are under-
elbow height.9 This does not necessarily refer to stood, the therapist will have to integrate the
work-surface height. The actual surface may be information into actual workstation design. Let’s
lower or higher than this, as tools and job demands go back to our case study to apply what we have
may require the worker to position the job above just learned. The therapist realizes she is unable
or below the work surface. For example, when to design each workstation to fit individuals.
considering how to position the work for a welder, Instead, she concentrates on making the worksta-
the therapist must take into account the height of tion fit the greatest variety of workers by using
the welding wand and position the work low the static anthropometric tables to determine the
enough that the hand holding the wand is 2 to 4 optimal sizes for the greatest number of people.
inches (50 to 100 mm) above elbow height. Figure She decides to use the static measurements for
5-8 demonstrates the approximate work heights U.S. adults (see Table 5-2) to help determine
for differing precision requirements. equipment for a group of office workers. The
therapist creates a table to help estimate the
Strength variety of sizes likely to occur within this popula-
Strength is directly influenced by posture and tion (Table 5-6). She makes the following recom-
therefore anthropometrics. All muscles have an mendations based on the table:
optimal muscle-tension length at which they are 1. Purchase adjustable chairs. A review of
strongest.2 When the body part is positioned at available models suggests that most chairs
this optimal length, greater strength is achieved. adjust between 16 and 21 inches. These
Strength alone, however, is not all that is neces- meet the height requirements of taller men
sary for a job. Some tasks are more dependent on and women; however, footrests for shorter
leverage, body equilibrium, and friction. Pulling men and women will need to be available.
often requires the use of body weight to counter- The chairs should have adjustable armrest

Standing work:
Workbench heights should be
—above elbow height for
precision work,
—just below elbow height for
light work, and
—4-6 in. below elbow height for
heavy work. 37"-43" 34"-37" 28"-35"

Precision work Light work Heavy work

FIGURE 5-8 Approximate work heights for differing precision requirements. (From Cohen AL, Gjessing CC, Fine
LJ et al: Elements of an ergonomics program, DHHS [NIOSH] Publication No. 97-117, Washington DC, 1997, U.S. Govern-
ment Printing Office.)
Chapter 5 Anthropometry 91

TABLE 5-6 Case Study Using Static Anthropometric Estimates to Help Determine
Equipment Requirements for Office Workers

Smallest Estimate Largest Estimate Corresponding Workstation

Anthropometric Segment (inches) (inches) Measurement

Popliteal height 13.9 (5th percentile 19.5 (95th percentile Chair seat height
woman) man)
Elbow height from 7.4 (5th percentile 11.4 (95th percentile Armrest height
chair woman) man)
Hip breadth 12.3 (5th percentile 19.7 (95th percentile Seat pan width
man) woman)
Buttock popliteal 16.6 (5th percentile 23.2 (95th percentile Seat pan depth (subtract
length woman) man) 2 inches for actual seat
pan depth)
Sitting elbow height 13.9 + 7.4 = 21.3 19.5 + 11.4 = 30.9 Keyboard height
(popliteal height +
elbow height from
Eye height (popliteal 13.9 + 27.0 = 40.9 19.5 + 34.2 = 53.7 Top of monitor
height + sitting eye (5th percentile (95th percentile
height) woman) man)

heights from 7 to 9.5 inches. The armrests tion on how to adjust the workstation to meet
should also be adjustable in and out to allow individual needs.
for hip breadth. The seat pan should be no
more than 18 inches deep, and the back of
the chair should adjust forward so that the CONCLUSION
seat pan depth can be reduced by 4 inches. This chapter has reviewed the uses of static
2. Provide all desks with adjustable keyboard anthropometric tables for designing workstations
holders. The holders should be adjustable for large populations. Static anthropometry pro-
from between 2 and 7 inches below the desk vides the essentials for understanding the vari-
height (because no chair is going lower than ability of the human form. It can greatly reduce
16 inches, the measurement of the elbow time and effort while greatly increasing the accu-
height from the ground is adjusted to a 16- racy of design by providing the designer with
inches height for 5th percentile women). A information concerning the broadest ranges of
keyboard holder with space for a mouse is measurements in a population, including individ-
recommended. uals with disabilities. These estimates can provide
3. The CPU should be placed to one side on the designer with information about clearance,
the desk, or on the floor. The monitor should reach, and posture that is essential to good design.
be removed from the computer and placed Although these methods do have limitations, such
on an adjustable monitor holder that rises as high variability, lack of measurements with
from desk level to 9 inches above the clothes, and a missing percentage of the popula-
desk. tion, they do provide the best estimates of human
These three recommendations provide size now available. Taken as a whole, static
enough versatility to meet the needs of 95% of anthropometric measurements are invaluable
the workers. The therapist also provides educa- tools for the ergonomist and therapist.
92 PART II Knowledge, Tools, and Techniques

Learning Exercise Multiple Choice Review Questions

Applied Anthropometry—Designing for One
1. Which factor does not influence the size
Overview and shape of the human form?
Apply the principles of ergonomics in your work A. Gender
environment. B. Occupation
C. Education
Purpose D. Clothing
The purpose of this exercise is to evaluate your
own work environment. You will determine if 2. The horizontal distance from the acro-
there are factors in your environment that may mion to the tip of the third digit, with the
be enhancements to your work. You will also elbow and wrist extended and the
try to determine any characteristics of your shoulder flexed to 90 degrees, is the:
work that could be altered using ergonomic
A. shoulder grip length.
B. fingertip height.
Exercise C. popliteal height.
D. upper limb length.
Collect anthropometric measurements of your-
self. Measure the parameters of your worksta-
tion. Identify potential risk factors (hazards). 3. You are designing a utensil with a built-
Prioritize controls. (Resource: Spaulding S: Mean- up handle that you plan to adapt for
ingful motion: biomechanics for occupational many different clients. You know that you
therapists, London, 2005, Churchill Livingston). can make it larger by adding padding.
What should the starting circumference of
this handle be?
A. 1.69 inches
Learning Exercise
B. 1.77 inches
Applied Anthropometry–Designing for a Group
C. 2.32 inches
Overview D. 3.25 inches
Apply the principles of ergonomics to a popula-
tion of people. 4. Through the use of anthropometric
estimates, an accurate prediction of the
Purpose exact size and shape of any individual is
The purposes of this exercise are to practice tech- possible.
niques of measuring a population and to apply A. True
those measurements to workstation design. B. False
Exercise 5. Which of the following are anthropomet-
Measure all the students in the class. Identify the ric measures?
average, 5th, and 95th percentile measurements A. Height
for the classroom population. Using these mea- B. Weight
surements, identify how to design chairs, desks, C. ROM
and the general layout of the classroom to facili-
D. All of the above
tate learning for the population as a whole.
6. With regard to workspace design, the
material currently being manipulated by
ACKNOWLEDGMENT the worker should be no more than how
The author would like to thank Somaya Malkawi many inches from the edge of the work
for her help with the drawings and the tables. table?
Chapter 5 Anthropometry 93

A. 3 inches 4. Das B, Kozey JW: Structural anthropometric mea-

B. 10 inches surements for wheelchair mobile adults, Appl Ergon
30:385, 1999.
C. 17 inches
5. Diffrient N, Tilley AR, Harman D: Humanscale
D. 27 inches 7/8/9, Cambridge, Mass, 1981, MIT Press.
6. Grandjean E, Hunting W, Pidermann M: VDT work-
7. When considering the overall height of a station design: preferred settings and their effects,
person who uses a wheelchair for mobil- Hum Factors 25:161, 1983.
ity, the height of the wheelchair is not 7. Hobson DA, Molenbroek JFM: Anthropometry and
included in the measurement. design for the disabled: experiences with seating
design for the cerebral palsy population, Appl Ergon
A. True
21:43, 1990.
B. False 8. Human Factors Engineering Technical Advisory
Group: Human engineering design data digest, MIL-
8. The hip angle that puts the least pressure STD-1472, Washington DC, 2000, Department of
on the discs while a person is seated is: Defense.
A. 90 degrees. 9. Kroemer KHE, Grandjean E: Fitting the task to the
B. 95 degrees. human, Philadelphia, 1997, Taylor and Francis.
10. Ogden CL, Carroll MD, Curting LR et al: Prevalence
C. 100 degrees.
of overweight and obesity in the United States,
D. 105 degrees. 1999-2004, JAMA 295:1549-1555, 2006.
11. Pheasant S: Bodyspace: anthropometry, ergonomics,
9. Which of the following percentiles is best and design, ed 2, Philadelphia, 1998, Taylor and
for determining reach requirements? Francis.
A. 5th percentile men 12. Roberts DF: Climate and human variability. An
Addison-Wesley module in anthropology, No. 34,
B. 5th percentile women
Reading, Mass, 1973, Addison-Wesley.
C. 50th percentile women 13. United States Access Board: Revised ADA-ABA
D. 95th percentile women Guidelines, 2004. Retrieved June 12, 2006, from
10. If a push button is placed at 56 inches
above the ground, what is the furthest
horizontal distance it can be (measured in SUGGESTED READING
the same plane as the backrest of the Diffrient N, Tilley AR, Bardagly JC: Humanscale 1/2/3,
chair) and still be accessible to 95% of Cambridge, Mass, 1974, MIT Press.
the population? Food and Nutrition Technical Assistance (FANTA):
A. 12 inches Anthropometric Indicators Measurement Guide, 2003
Edition. Available online at
B. 16 inches
C. 20 inches Peebles L, Norris B: Adultdata: the handbook of adult
D. 24 inches anthropometric and strength measurements—data
for design safety, Nottingham, United Kingdom,
1998, University of Nottingham. Available free at
Smith S, Norris B, Peebles L: Older adultdata: the hand-
1. Bernard BP, editor: Musculoskeletal disorders and
book of measurements and capabilities of the older
workplace factors, DHHS (NIOSH) Publication No.
adult, Nottingham, United Kingdom, 2000, Univer-
97-141, Washington DC, 1997, U.S. Department of
sity of Nottingham. Available free at
Health and Human Services.
2. Chaffin DB, Andersson GBJ: Occupational biome-
chanics, ed 2, New York, 1991, Wiley.
3. Cohen AL, Gjessing CC, Fine LJ et al: Elements of Web Sites
an ergonomics program, DHHS (NIOSH) Publication Ergoweb:
No. 97-117, Washington DC, 1997, U.S. Govern- Strength data for design safety:
ment Printing Office. file21827.pdf
Basic Biomechanics

Sandi J. Spaulding

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Understand biomechanical principles that are vital to practice in ergonomics, with emphasis on the principles
implicit in assessments such as the NIOSH manual lifting equation.
2. Use biomechanical principles when working in the area of ergonomics.
3. Apply biomechanics principles in ergonomic practice.

Force. Force is defined as mass (m) times acceleration application. To increase this distance a person can
(a) (F = ma, with the units in Newtons). For example, either move the hand farther down the wrench or use
a person may try to pound a nail into a piece of wood a longer wrench.
and increase the force used, relative to an earlier Friction. Friction is the product of the characteristics
attempt. The person can either use a heavier hammer of two surfaces relative to one another (coefficient of
with the same acceleration or can use the same hammer friction) and the normal force exerted on the upper
but with an increase in the speed (with respect to time) surface (a normal force is one that is exerted straight
with which he or she hits the wood. downward). The greater the roughness of one or both
Torque. Torque is force (F) times distance (d) (T = Fd, of the two surfaces, the greater the coefficient of fric-
with the units in Newton-meters). To increase the tion. The greater the normal force, the greater will be
torque, for example, when trying to loosen a lug nut, the friction (F = µFN, where F is the force of friction, µ
a person can either increase the force he or she is using is the coefficient of friction, and FN is the normal
or place his or her hand farther away from the point of force).

Chapter 6 Basic Biomechanics 95

CASE STUDY the British system of measurement (BTU). The

international system is most commonly used, but
Ms. Marion Stonehouse is the owner and sole proprietor both are currently in practice in different places
of a small pet food store, which is one of a chain in the in the world. See Table 6-1 for some of the bio-
country in which she lives. She is in her 40s, is about 5 mechanical terms, their definitions, and units in
feet 6 inches tall, and is quite fit. the SI system.
Her work appears, from the customer’s perspective, to
be sedentary because someone buying something in her
store will find her behind the cash register. However, BIOMECHANICS
when the store is closed, she does a great deal of heavy Biomechanics, or the study of human movement
lifting. She lifts 40-pound bags of pet food and birdseed, using mechanical principles, consists of two main
as well as all the other merchandise that she sells in the categories: kinematics and kinetics. Kinematics is
store. Stacking shelves and maintaining extra inventory in the study of movement without the involvement
the back of the store involves not only lifting but also of the forces used in the movement. Kinetics is
carrying large objects to heights above her shoulders, as the discipline of including the forces acting to
well as climbing ladders to stock merchandise for storage create motion. Biomechanics can also be consid-
above the shelves from which the customers take their ered to be divided between statics and dynamics.
purchases. The study of statics includes the forces on an
One aspect of the job for Ms. Stonehouse and her object or person without the occurrence of move-
worker is unloading the products once a week from a ment. Dynamics includes the forces as well as
large truck that comes from a central warehouse. The movement. This chapter will begin with a discus-
worker on the truck and Ms. Stonehouse have many good sion of kinematics and kinetics and then will
techniques to ensure that they undergo the least amount cover some other mechanical principles that are
of stress possible. Lifting techniques that demonstrate required by ergonomists.
good practices include using a mechanically driven lift to
move pallets of supplies, using a wide base of support Kinematics
when reaching for objects, using a portable cart with Kinematics includes movement without consider-
wheels to increase ease of moving products, and having ing the source of the movement. There are differ-
two people move the cart when it is fully loaded. ent aspects of kinematics: displacement, velocity,
Ms. Stonehouse has no physical difficulties at present and acceleration. Displacement is distance with a
because she is using good equipment for moving heavy direction (meters [m]). Velocity is a change in
loads, but given the extensive lifting and shifting of displacement or speed with direction (meters per
product that she does, she is concerned that she might second [m/s]). Acceleration is an increase in
have problems in the future. Ms. Stonehouse and the velocity (meters per second squared [m/s2]) and
ergonomist she is consulting are evaluating her work and deceleration is a decrease in velocity (also m/s2).
making suggestions for change so that she can avoid Kinematics can occur in a straight line (linear
work-related injuries. kinematics), in curves, or in a combination of
both linear movement and curves, which is called

T his chapter will explain the units of measure

for biomechanical principles and discuss im-
portant biomechanical principles that are used in
curvilinear kinematics.

the study of ergonomics. The material about bio- Kinetics is the discipline of engineering and bio-
mechanics will be incorporated into consider- mechanics that considers the effects of forces
ations of the work Ms. Stonehouse is doing. acting on a person, object, or system.


There are two systems of units for mechanical Force is a term that is used in everyday life. For
terms: the international system of units (SI) and example, someone may talk about a jar taking a
96 PART II Knowledge, Tools, and Techniques

TABLE 6-1 Definition of Some Mechanical Terms and Their Units of Measurement

Mechanical Units of Measure

Concept Definition of Concept (SI Units)

Displacement Displacement is distance with a direction. m

Velocity Velocity is displacement divided by time or the distance m/s
an object moves in a certain amount of time.
Acceleration Acceleration is velocity divided by time or is how quickly m/s2
or slowly an object can increase in speed.
Force Force is the mass of an object times acceleration. kgm/sec2 or newtons (N)
Mass Mass is the physical property of matter that gives it kg
weight and inertia.
Moment of force A moment of force is the distance times time. kgm2/s2
Weight Weight is mass times the force of gravity (9.8 m/s2). kgm/s2
Momentum Momentum is mass times velocity. kgm/s

lot of force to open or having to force open a door has strong enough muscles to do her work. Some-
in winter because of frost. However, force also has times the force of the muscles is not great enough,
a mechanical definition. By understanding the or the number of repetitions a person does is too
concept of force we can understand one of the many, so the muscles become fatigued or injured.
basic issues of ergonomics, because force can aid Ms. Stonehouse must be concerned about keeping
or be a problem for a worker. Force is equal to her lifting within her strength range; otherwise
mass times acceleration: she could be subjecting herself to injury if she
either has to use too much force to lift or has to
Force = mass times acceleration
create a force too frequently. Those two factors,
Where mass is expressed in kg and acceleration
the mass of the object and the acceleration inher-
in m/sec2 (SI)
ent in the movement, can be manipulated so that
or mass is expressed in slugs and acceleration in
less force is required. These factors are taken into
ft/sec2 (BTU)
account in the National Institute of Occupational
Now, what does that mean? It implies that if Safety and Health (NIOSH) Manual Lifting equa-
there is a greater mass, then the force will be tion, which is discussed in Chapter 11, Lifting
greater. For example, if Marion Stonehouse were Analysis.
to spend much of her time lifting 40-kilogram (kg)
bags of food, rather than 20-kg bags, she might Lever Systems
have less difficulty. It also suggests that the faster Forces often do not work in isolation; there is
she tries to lift and move the wares, the greater often resistance to force. A lever system exists
the force that will be required by her. Therefore, when there are one or more active forces and one
when evaluating a worker, the therapist should or more resistive forces working against the action.
be aware of the weight lifted and whether or not Levers involve an active and a resistive force, as
this can be altered to make the task easier. well as an axis of rotation. There are three catego-
Another issue concerning force is important for ries of levers. Where the forces and axis are placed
Marion. The reason she is able to lift objects at all and the magnitude or size of the forces will affect
is because her muscles produce force within her how a lever operates. Levers can often be used to
body. That muscle force produces movement. She make work easier.
Chapter 6 Basic Biomechanics 97

Downward force Weight (resistance force)

exerted by the person at end of shovel

Axis, created by putting a block

under the handle of a shovel

Weight of the contents Upward force exerted
of the wheelbarrow by the person

Axis, at the axis of the wheel

Upward force exerted Downward force exerted
by the biceps muscle by the forearm and hand

Axis, at the elbow joint

FIGURE 6-1 A, First-class lever. If the downward force exerted by the person is greater than the resistive force
of the weight, then the weight will move upward. B, Second-class lever. The resistance is between the axis
of rotation and the effort force, for example, a wheelbarrow. The axis is at the center of the wheel; the weight,
or resistance, is in the wheelbarrow; and the effort is in the hands of the person. C, Third-class lever. The
effort is between the resistance and the axis.

First-Class Lever
A first-class lever is one in which the active or has a mechanical advantage. The mechanical ad-
motive force is at one end and the resistive force vantage is the length of the effort arm divided by
is at the other end, with the axis in the middle the length of the weight or resistance arm. If that
(Figure 6-1, A). A first-class lever example would number is greater than one, there is a mechanical
be lifting a load of concrete by hand. If a person advantage for the person doing the lifting. If Ms.
uses a shovel as a lever, rather than trying to lift Stonehouse has to move an object off the floor
it by hand, the shovel can be put under the object, onto a pallet, she can put a shovel or other imple-
an axis could be created by putting a block under ment under the object, create an axis with another
the handle of the shovel, and the person could object such as a block of wood, then push down
push down on the shovel and rotate the load to at the other end of the lever and rotate the object.
where it is needed. If the lever arm between the The longer her distance from the axis relative to
axis and the hand is greater than the lever arm the distance from the object to be lifted, the easier
between the axis and the weight, then the person it will be for her to lift.
98 PART II Knowledge, Tools, and Techniques

Second-Class Lever of canned goods out 30 cm in front of her, her

In a second-class lever, the weight is between the muscles must work harder than if the box were
axis and the effort (Figure 6-1, B) Always, in a only 10 cm in front of her.
second-class lever, the mechanical advantage is Within the body, the muscles contract to
greater than one, but again it can be increased produce force. Those muscles are attached at spe-
by increasing the distance from the effort to the cific places on bones, so there is also a torque
axis or decreasing the distance from the weight to component because there is always a distance
the axis. between the point of attachment and the joint or
axis about which the body part moves. The biceps
Third-Class Lever muscle is attached very close to the elbow joint.
A third-class lever has the effort between the axis Because it is so close, most of the torque will come
and the resistance (Figure 6-1, C). Most muscles from the muscle strength rather than the distance
in our bodies are third-class levers. Think of the from the rotation point.
insertion of the biceps tendon. It attaches on the A number of other biomechanical principles
forearm, near the elbow, but is one of the movers become important when considering the inter-
of the forearm and the hand. Third-class levers action between a person and his or her en-
are useful in that the effort can have a short lever vironment.
arm, but they always have a mechanical advan-
tage less than one. Friction
If you have ever stepped out onto a wet ceramic
Torque step while wearing shoes without tread, you are
Torque is force created through a distance: very aware of the effects of having a very low
level of friction between two surfaces. Research
Torque = force × distance
suggests that friction needs to be taken into
Where force is expressed in kgm/s2
account in many work environments, including
and distance in m
the hospital environment in which lifting patients
Therefore torque is expressed in kgm2/s2
must occur.13 The force of friction (Ff) is equal to
Torque is also called a moment of force, which the characteristics of two surfaces in relation to
usually is a term related to rotation. If one wants one another (the coefficient of friction, or µ) times
to increase torque, consider the equation: one can the downward, or normal, force (FN) that is exerted
either increase the force of an object or increase on the surfaces. The formula for friction is as
the distance from the object. An increased torque follows:
can be useful. Moments of force are often evalu-
Ff = µ × FN
ated in research for people performing tasks with
equipment and affect the ability to perform activi- The coefficient of friction does not have any
ties.6 If Marion wants to rotate a display cabinet units because it involves one surface relative to
using a metal bar to help her, she can increase another. The friction force has the same units as
the amount of torque she can produce on the any other force: kgm/s2. Shoe sole properties and
cabinet without increasing the amount of force ground surfaces can be analyzed to determine
that she has to produce, just by increasing the how much slip may occur with them.9-12 Marion
length of the bar. can be helped by an increase in friction if she
You can think about the torques produced begins to wear shoes that have rough soles and
when lifting. Some work has been done to deter- keeps the floor dry or chooses floor material that
mine the effects of actually moving objects farther is rougher than the one she has. Then the coeffi-
from a person in the attempt to force him or her cient of friction will be increased, so she is less
to move closer. However, this research suggests likely to slip. She may decide that rather than
that people do not take a step under such circum- carrying or dragging large bags of food from one
stances.7 For example, if Marion is holding a box area to another, she will put them on a wheeled
Chapter 6 Basic Biomechanics 99

cart. Then she will reduce both the amount of under the load. This is extremely unlikely, because
effort she expends and also the effect of friction equipment is designed to withstand appropriate
on her. Antislip devices should be considered for loads, but is an example of what might occur if
individuals.4,5 However, it has been found by the equipment were not designed in a manner that
some researchers that for loads to be pushed on can withstand loading. Stress and strain as well
the floor, a high enough coefficient of friction may as other mechanical phenomena can occur within
be needed.4 Often, floor slipperiness is considered the human body. See Chapter 11 for examples of
in a laboratory environment, but research sug- mechanical principles related to the spine and
gests that analyses should be conducted in the lifting.
Dynamic friction is the friction that exists when Elasticity
one object is moving on another one. Dynamic Elasticity is related to the length an object is
friction is always less than static friction if all stretched relative to its resting length. If a person
other aspects of the situation are constant. There- stretches an elastic band, the longer it is stretched,
fore, if Ms. Stonehouse starts sliding one product the more force is present when it is released. It
on another she will find it easier to keep moving has stored elastic energy. If the material is
the product once it has started to move. stretched and then released, it returns to its origi-
Rolling friction, or the friction generated within nal length. If two elastics are put side by side,
wheel configurations, may also need to be taken their strength is added together; to increase
into account when evaluating ergonomics.1 strength of elastics, this configuration would be
Slip potential is always increased when friction useful. If elastics with the same properties in
is reduced. For example, applying the base of a terms of strength and material are combined, one
ladder to dry surfaces has been shown to increase to the end of the other, then the force they exert
friction, but when the ladder is used on an oily together is half the force that would be exerted if
surface, friction is reduced and slip potential is one were working alone.
increased.2 Materials can be brought to a state of failure
by either too much or too frequent stretching.
Stress and Strain Carpal tunnel syndrome (CTS), a problem in the
Two mechanical principles, stress and strain, play area of the wrist, might occur if someone stretches
an integral part in how the body responds to or holds the wrist and hand in awkward positions
forces. Stress is the internal deformation in re- for too long over a period of time. Extensive
sponse to an externally applied load. For example, research has been conducted into repetitive strain
a person who has a spastic upper extremity that injuries (RSIs). An article by Keller, Corbett, and
moves toward flexion can be using a splint to Nichols provides insight into the pathogenesis and
reduce potential flexion contractures. The person’s problems related to repetitive strain injuries. The
muscle strength can push against the splint authors determined that a large number of com-
but not bend it. The splint may experience stress, puter users experience high rates of repetitive
or internal deformation, without any outward strain injury related to work and discussed the
sign of change. The unit of measure for stress is assessment and treatment of RSI.8
N/m2. Many other biomechanical principles can be
Strain is the change in dimension that occurs and are applied to ergonomics. Some of these prin-
because of an external load. For example, if a ciples are discussed in Chapter 9, Physical Environ-
person is using a mechanical lift, such as a forklift, ment. Other principles can be found in the resource
on a worksite to carry a large load on a pallet, materials noted at the end of this chapter. It is
there may be no problem for the forklift. However, important for the therapist working in ergonomics
if the weight to be lifted exceeds the strength of to be very familiar with these principles because
the material in the lift component of the equip- they are the underpinning of the physical aspects
ment, the metal material of the fork may bend of the worker and his or her environment.
100 PART II Knowledge, Tools, and Techniques

2. Ms. Stonehouse is trying to carry a large

Learning Exercise
bag of food and do it with as little force
Overview on her arms as possible. To keep the
The learning exercises provided are designed to effect of the weight low, she might try to:
increase your practical understanding of some A. keep her feet as close together as
basic biomechanics concepts. possible.
B. move quickly.
Purpose C. keep the food as close to her body as
The purpose of these learning exercises is to she can.
consider the case of Ms. Stonehouse and how D. be sure that the ground friction force
biomechanical principles would be coming into is high.
effect in her work in more ways than have been
alluded to in this chapter. You will try to deter- 3. Ms. Stonehouse has found that if she
mine how she could change aspects of her work, stretches the stretchable ropes holding
based on the knowledge of basic biomechanics the food on the shelves, when she
you have learned in this chapter. releases the ropes the food is held tightly
Exercise on the shelves. She is using the property
Create a list of 10 discrete tasks you think
A. strain, in which the force is
someone in a job such as the one held by Ms.
Stonehouse could be asked to do. Once you have
proportional to the relaxed state.
created the list, write down any biomechanical B. viscosity, in which the force is related
principles that would be applicable to the task. to the thickness of the material.
For example, if one of the tasks you have imag- C. stress, in which the force is increased
ined is that she is using a ladder to lift dog beds with the distance from the origin.
up to a storage area, consider the biomechanical D. elasticity, in which the force is
aspects of this—for example, she would have to proportional to length relative to the
be on a ladder. When you have created the 10 resting state.
tasks, determine the biomechanical principles,
then determine how you might make each task 4. Lifting an object that is in a crate by
easier based on biomechanical principles. Perhaps using a lever will be harder if:
the ladder used could be a stepladder, rather than A. the axis is closer to the hands than to
a straight ladder, which could slip because of the the object in the crate.
ladder-floor characteristics. B. the handles are increased in length to
increase the lifting force.
C. the object in the crate is increased in
D. the person doing the lifting bends to
Multiple Choice Review Questions increase the lever arm.

1. If a person is trying to push an 5. An individual who is trying to increase

object along the floor and it suddenly the torque applied to an object is
gives way and moves along, the following attempting to:
principle of mechanics has come into A. make the task more difficult.
play: B. work around a corner that protrudes
A. Dynamic friction into the work space.
B. Static friction C. increase the efficiency with which he
C. A first-class lever or she is working.
D. Stress tension D. decrease the difficulty of the task.
Chapter 6 Basic Biomechanics 101

6. Ms. Stonehouse is attempting to increase REFERENCES

the force she is exerting on a carton of 1. Al-Eisawi KW, Kerk CJ, Congleton JJ et al: Factors
cleaning products. To increase this force affecting minimum push and pull forces of manual
she can: carts, Appl Ergon 30:235, 1999.
A. increase the acceleration of her 2. Chang WR, Chang CC, Matz S: Available friction of
movement. ladder shoes and slip potential for climbing on a
straight ladder, Ergonomics 48:1169, 2005.
B. decrease the velocity of her pushing.
3. Chang WR, Li KW, Huang YH et al: Assessing floor
C. increase the displacement of the slipperiness in fast-food restaurants in Taiwan using
object. objective and subjective measures, Appl Ergon
D. increase the static friction between 35:401, 2004.
herself and the object. 4. Ciriello VM: Psychophysically determined horizon-
tal and vertical forces of dynamic pushing on high
7. Velocity: and low coefficient of friction floors for female
A. is the speed of a movement in a industrial workers, J Occup Environ Hyg 2:136,
direction. 2005.
5. Gard G, Berggard G: Assessment of anti-slip devices
B. is measured in kgm/s2. from health individuals in different ages walking on
C. is noted by whether or not there is slippery surfaces, Appl Ergon 37:177, 2006.
displacement occurring. 6. Greig M, Wells R: Measurement of prehensile grasp
D. cannot be measured by an ergonomist. capabilities by a force and moment wrench: meth-
odological development and assessment of manual
8. Momentum is measured in: workers, Ergonomics 47:41, 2004.
A. feet per second. 7. Jorgensen MJ, Handa A, Veluswamy P et al: The
B. kilograms times meters per second. effect of pallet distance on torso kinematics and low
back disorder risk, Ergonomics 48:949, 2005.
C. kilograms times meters per second
8. Keller K, Corbett K, Nichols D: Repetitive strain
squared. injury in computer keyboard users: pathomechanics
D. force times distance. and treatment principles in individual and group
intervention, J Hand Ther 11:9, 1998.
9. In a second-class lever: 9. Kim IJ, Smith R, Nagata H: Microscopic observa-
A. the force is between the axis and the tions of the progressive wear on shoe surfaces that
working force. affect the slip resistance characteristics, Int J Ind
B. the effort force is farther from the axis Ergon 28:17, 2001.
than the resistance. 10. Koningsveld E, van der Grinten M, van der Molen
H et al: A system to test the ground surface condi-
C. the axis is between the effort and the
tions of construction sites—for safe and efficient
resistance. work without physical strain, Appl Ergon 36:441,
D. the forces are equal and opposite. 2005.
11. Li KW, Chen CJ: The effect of shoe soling tread
10. Ms. Stonehouse has noted that she has groove width on the coefficient of friction with dif-
slipped a couple of times in her storeroom. ferent sole materials, floors, and contaminants,
Although she has not hurt herself, she is Appl Ergon 35:499, 2004.
afraid that she might in the future. She has 12. Lipscomb HJ, Glazner JE, Bondy J et al: Injuries
from slips and trips in construction, Appl Ergon
asked you to help her avoid further slips,
37:267, 2006.
if possible. One of the first things you 13. McGill SM, Kavicic NS: Transfer of the horizontal
might consider examining is: patient: the effect of a friction-reducing assistive
A. the height to which she is lifting device on low back mechanics, Ergonomics 48:915,
boxes. 2005.
B. the width of the shelving units.
C. the lighting conditions in the room.
D. the material that has been used for the
floor surface.
102 PART II Knowledge, Tools, and Techniques

Kumar S, editor: Biomechanics in ergonomics, Philadel-

phia, 1999, Taylor & Francis.
Brand PW, Hollister A: Clinical mechanics of the hand, Nordin M, Frankel VH: Basic biomechanics of the mus-
ed 3, St Louis, 1999, Mosby. culoskeletal system, ed 3, Philadelphia, 2001, Lip-
Chaffin DB, Andersson GBJ, Martin BJ: Occupational pincott Williams & Wilkins.
biomechanics, ed 4, Hoboken, NJ, 2006, John Wiley Robertson GE: Introduction to biomechanics for human
& Sons. motion analysis, Canada, 2004, Waterloo
Dvir Z: Clinical biomechanics, London, 2000, Churchill Biomechanics.
Livingstone. Spaulding SJ: Meaningful motion: biomechanics for
Hall S: Basic biomechanics, ed 4, Boston, 2002, McGraw- occupational therapists, London, 2005, Churchill
Hill Higher Education. Livingstone.
Hall S: Basic biomechanics with dynamic human CD Winter DA: Biomechanics and motor control of human
and PowerWeb/OLC bind-in passcard, Boston, 2002, movement, ed 3, 2004, John Wiley & Sons Canada,
McGraw-Hill Humanities/Social Sciences/Languages. Ltd.
Kreighbaum E, Barthels K: Biomechanics: a qualitative
approach for studying human movement, ed 4, 1995,
Benjamin Cummings.
Cognitive and Behavioral
Demands of Work
Lynn Shaw, Rosemary Lysaght

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Discuss the cognitive and behavioral demands of work occupations.
2. Describe how cognitive and behavioral risks are measured.
3. Discuss external factors that influence optimal cognitive and behavioral performance in the workplace.
4. Evaluate the cognitive requirements and behavioral demands of work needed to inform return-to-work

Cognitive demands. Demands associated with work performed, when it is performed, and under what con-
tasks that require thinking, information processing, ditions it is performed.
learning, imagining, and anticipating. Work occupations. Productive occupations, career,
Behavioral demands. The actions, efforts, and inter- profession, or jobs that workers perform for monetary
actions required to conduct work tasks. reimbursement.
Workplace contextual factors. Aspects of the work-
place environment that affect the way work may be

104 PART II Knowledge, Tools, and Techniques

• How can these job demands be measured? What

CASE STUDY tools and processes exist? Are they valid and
Kara has worked as a laboratory technician and area reliable?
supervisor for 10 years. She is a petite, soft-spoken woman • What job specific information does the employer
in her late 50s and has been off work for 12 months. have—for example, job descriptions or procedure
Currently she is on long-term disability leave for depres- manuals?
sion. Three months before she left work, her performance • What job demands are cognitively or behaviorally
started to decline. Her co-workers noticed that she was complex?
not completing her work, and they frequently had to • How do situations or factors in the workplace
perform some of her duties before the end of her influence the temporality or frequency of these
shifts. Her co-workers liked Kara. To them, Kara was a demands?
mother figure who had trained them in some of the • How do I match Kara’s functional capacities with
essential tasks needed to be a successful laboratory tech- work demands and requirements?
nician in the hospital. Her pace at work was less than • How can Kara be included in this evaluation
moderate, yet the work demanded a consistently high process?
pace in order to keep up with the testing required in the
When she was no longer able to function at work, she
went on short-term disability leave and then advanced to
long-term disability. For 4 months she was suicidal and
unable to manage self-care. With medication and treat-
U nderstanding and differentiating cognitive
and behavioral demands of work is a complex
endeavor. It is often difficult to separate the cogni-
ment, she was able to regain a sense of functional com- tive and behavioral demands required of work
petency in daily self-care activities. occupations from the human capacity to execute
As an occupational therapist, you received a referral those demands. Some of the confusion is caused
from the insurance company to assist Kara in determining by the inconsistent use of terms such as skills,
her capacity for returning to work and to set up an RTW tasks, demands, workload, capacities, and poten-
plan. After meeting with Kara and reading her file, you tial, as well as the overlap of factors described
begin to get a sense that Kara has low self-esteem, lacks within the psychosocial, cognitive, and behavioral
confidence in her ability to return to the workplace for domains of work. The aim of this chapter is to
fear of poor performance, and is somewhat anxious about provide therapists with information and a process
her relationship with co-workers. Kara reported that she for evaluating cognitive and behavioral demands
feels she has lost her sense of identity because she has of work that can, in turn, be used to develop
been out of the workplace for so long. She also lacks a disability prevention programs and inform return-
sense of power to make changes that could improve to-work (RTW) programs for workers with inju-
things for her in the workplace. She is afraid that the ries or disabilities. Information in this chapter
employer will not let her come back to work. may also assist therapists in working with employ-
As the occupational therapist, you contact the staff ers, workers, worker representatives, and engi-
ergonomist, who agrees to meet with you to conduct an neers to develop strategies for managing or
evaluation of the work demands. Although the workplace adjusting work demands when cognitive and
has provided you with a physical demands analysis of a behavioral demands of work are high relative to
laboratory worker job, you note that most of the informa- worker capacity.
tion about the job relevant to Kara’s return to work is not
evident on the form.
You require the following information before develop- BACKGROUND
ing an RTW plan: A number of disciplines and fields of knowledge
• What are the cognitive and behavioral demands of are contributing to the emergence of classifica-
the job that Kara will need to resume on her return tions, taxonomies, and tools for evaluating cog-
to work? nitive components of work. Researchers in
Chapter 7 Cognitive and Behavioral Demands of Work 105

psychology have examined cognitive workload factors (e.g., engagement and support), and aging
from a human information processing pers- factors (e.g., cognitive and physical effects of
pective,1 and organizational psychologists have aging). As a result, therapists are required to
recently begun to focus on positive psychology, provide advice and expertise to enable optimal
studying “human strengths and optimal function- worker performance through strategies that might
ing” and their impact on the health and productiv- prevent injury or support successful transitions
ity of workers.5 Occupational health researchers back to work for persons with cognitive or
have also advanced knowledge about the behav- behavioral impairments. To generate solutions,
ioral and cognitive demands that influence mental the therapist must know what information is rel-
health and functioning of workers. For example, evant to the case, situation, or problem, how to
both the Job Demands and Control model2,3 and measure the demands of work, and how to antici-
the Effort-Reward Imbalance model7 provide mea- pate potential risks and challenges in the work-
sures used to examine the impact of work demands place. The case study about Kara will be used
and work capacities on health. These tools are throughout this chapter to demonstrate the infor-
designed to study the relationship of workplace mation and process needed to provide recommen-
strain to outcomes such as back pain and cardio- dations for RTW programs.
vascular disease, and human resource issues such
as worker motivation and job satisfaction. Cogni-
tive science, a field within human factors, has UNDERSTANDING COGNITIVE AND
contributed to the development of a cognitive tax- BEHAVIORAL WORK DEMANDS
onomy that elaborates on cognitive attributes and In conducting job demands analyses, it is impor-
actions required to process, synthesize, and use tant to distinguish between the requirements for
information in performing jobs.10 A process for competent job performance and work capacity.
consistently evaluating cognitive demands was Job demands and requirements refer to the tasks
proposed by Wei and Salvendy to assist in job and components of work, or the specific require-
evaluation, job design, and job rotation, as well ments of a work occupation. Worker skills and
as in personnel selection and training.10 abilities refer to the capacities and expertise of the
Clinical occupational health providers such person that are used in performing or executing
as ergonomists, occupational health nurses, oc- job demands. Although these elements are related,
cupational therapists, physicians, and social especially if the worker’s skills are a good match
workers have used evidence-based tools in the for the job demands, each must be evaluated
evaluation of cognitive and behavioral work separately using appropriate tools and measures.
demands to assist in the matching of workers In the same way that we would evaluate the
with mental or behavioral health problems to physical demands of a job (e.g., a worker is
appropriate job tasks during the RTW process. required to lift 50-pound boxes to a surface at
The clinical community has also contributed to shoulder height up to 10 times a day) separately
assessments of cognitive function and neurolo- from a worker’s physical capacity (e.g., maximum
gic trauma or impairments. These developments lifting capacity and tolerances), we must consider
across disciplines have contributed to the depth cognitive and behavioral demands as separate
and breadth of information available to therapists from the incumbent worker’s abilities. This
to address a multitude of issues central to cogni- chapter will address how to rate and measure
tive and behavioral job demands and worker cognitive and behavioral job demands. For infor-
functioning. mation on assessment of human cognitive per-
In clinical practice there is growing acceptance formance and behavioral skills, abilities, and
for the use of a holistic approach to understanding expertise, therapists should consult appropriate
factors that influence worker health and perfor- texts and literature. Further information about
mance, including workplace factors (e.g., psycho- these sources is located in the reference list at the
social and physical work environments), individual end of this chapter.
106 PART II Knowledge, Tools, and Techniques

Cognitive Demands
Typically, therapists view cognitive skills at the BOX 7-1 Cognitive Demands of Work
level of the person. The domain of human cogni-
tive abilities is often understood and expressed Cognitive Requirements of Job Tasks
through terms such as short-term or long-term Critical thinking (judgment, analysis, reasoning,
memory, problem solving, attention span, com- calculation, manipulation, generation of
munication skills, and computational ability. knowledge and ideas)
Cognitive functioning is essential to occupational Creative thinking using imagination and
competence at a personal level but is also impor- generating creative ideas
Information acquisition, searching, and retrieval
tant in the workplace, as it enables workers to be
Information processing: assimilate, organize
productive and fulfill the demands of work. For
Mental planning and scheduling
instance, cognitive functioning is a multilevel
process that enables a person to perceive, imagine,
organize, assimilate, analyze, communicate, sense Comprehending
problems, and manipulate information and knowl- Translating knowledge
edge9 in order to understand, reason, make deci- Perceiving and interpreting interpersonal
sions, create ideas, problem solve, and take actions information
in the context of doing a work activity. The execu- Using intuition—sensing or anticipating
tion of job tasks that require cognitive functions problems
also requires human cognitive resources such
as memory, vision, hearing, attention, concentra- Cognitive Resources
tion, literacy skills, communication, and an in- Memory (short-term, long-term)
creasing reliance on electronic and technologic Attention, visual and auditory concentration
skills. Wei and Salvendy suggest that cognitive Imagination
work tasks or job elements can be classified into Communication skills (verbal, nonverbal),
the cognitive skills required to carry out work interpersonal skills, graphic expression,
tasks and the cognitive resources needed to execute written skills
those cognitively based performance skills.10 We Vision
drew on the work of Wei and Salvendy10 and Visual processing
others2,3,9 to compile a list of cognitive (skill) re- Visual perception
quirements and a list of cognitive resources needed Auditory processing
Hearing and listening skills
to perform cognitive work tasks (Box 7-1).
Literacy and reading, writing, and
Each job can be thought of as having a particu-
documentation skills
lar physical or cognitive load, and often one of
Computer and technologic skills
these elements is in higher demand than the other.
All work requires cognitive skills, but the cogni-
tive load may be high or low, and the profile of
cognitive skills required is unique for each job.
The role of the therapist is to identify and describe skills in task analysis to identify and analyze cog-
the work demands or tasks that require specific nitively based work demands. Box 7-1 can assist
application of cognitive functioning and to iden- the therapist in framing the cognitive demands of
tify the nature and level of the cognitive demands. work. Cognitive requirements of work must be
In this process, therapists must be careful to eval- fully understood in terms of their complexity, then
uate and define the nature of the cognitive work translated into terms to which the end-user, such
task requirements, not the worker. To do this, as the worker, the employer, the supervisor, or
therapists can draw on their knowledge of human the insurer, can relate.
cognition, their awareness of the complexities of Once the cognitive work requirements are
occupation-environment interactions, and their understood, the therapist may then take steps
Chapter 7 Cognitive and Behavioral Demands of Work 107

1. Identify the essential job tasks

or duties–use workplace
terminology to describe Identify gaps
and mismatches
2. Evaluate 3. Evaluate between work Assess worker
the cognitive the cognitive demands and abilities, expertise
functional resource worker and skills
requirements requirements capacities
of job of job
demands demands

4. Evaluate the
behavioral Develop RTW
job demands strategies and
5. Evaluate
the contextual
Workplace Worker
strategies strategies

FIGURE 7-1 Process for evaluating cognitive and behavioral demands and the workplace context in developing
an RTW plan.

to identify cognitive performance strengths and or injury. This process of evaluating the cogni-
weaknesses of the worker, acknowledge gaps or tive requirements of a job and the cognitive
mismatches between the worker and the work resources required to execute job demands in
requirements, and develop a comprehensive RTW consideration of workplace influences is shown in
intervention that matches a worker’s abilities to Figure 7-1.
suitable job demands. Therapists need to adopt a For Kara’s job as a supervisor, the first step is
consistent approach to defining and describing to identify the job demands or tasks that are
cognitive demands through translating informa- required. In this case example, scheduling staff is
tion about cognition into understandable language one of Kara’s responsibilities. Step two is to iden-
when requesting procedural changes or accom- tify and evaluate the cognitive demand. The job
modations to a worker’s cognitive workload. The demand of scheduling staff in the laboratory
range of cognitive work demands and the work- requires the mental functions of planning and
place dynamics must also be determined to assist scheduling. Step three is considering the cognitive
the therapist in identifying contextual factors that resource requirements. This cognitive demand
might hinder performance, as well as opportuni- is enacted using cognitive resources such as
ties for creating a successful transition and resump- short- and long-term memory, concentration, pri-
tion of duties as a person recovers from an illness or knowledge and experience, reading literacy,
108 PART II Knowledge, Tools, and Techniques

writing, and technologic skills because scheduling In order to begin development of a plan to
is done on the computer. return Kara to the workplace, use the behavioral
Many tools or lists of cognitive skills may serve demands from Table 7-1 and identify the demands
as resources when evaluating these demands of that Kara can be expected to perform in her role
work occupations. Existing tools commonly used as a laboratory supervisor. Based on the informa-
to measure cognitive components of work, dis- tion from the case, prioritize the demands that
cussed later in this chapter, do not capture or may be challenging for Kara and require consid-
measure all cognitive demands. Thus, the thera- eration in developing a modified RTW strategy.
pist must use judgment in attempting to com- What demands would you consider modifications
prehensively appraise the diversity of and in- for, or address in a progressive work conditioning
terrelationship between the cognitive skills and process?
resources required to execute job demands. Spe- Develop a set of questions for Kara and for
cific tools for evaluating and rating these demands Kara’s manager to assist you in obtaining informa-
are provided later in this chapter. tion you will need to implement an RTW plan that
offers a gradual resumption of full duties. Next,
Behavioral Demands consider what each stakeholder will need to do in
Behavioral demands of work occupations refer to order for a feasible and client-centered plan to be
the actions and interactions a worker may encoun- developed. Consider Kara’s role (worker strate-
ter that require a specific response or subsequent gies), as well as what the manager needs to do
set of actions to manage or perform duties and (workplace strategies). What is your role as a
tasks in the workplace. These include the enact- therapist in creating the return-to-work plan?
ment of social processes and relationships with
others, performance of management responsibili-
ties, enactment of worker responsibilities, gener- CONTEXTUAL INFLUENCES ON COGNITIVE
al competencies, and accountabilities, and enact- AND BEHAVIORAL WORK DEMANDS AND
ment of specific competencies. An overview of the WORKER PERFORMANCE
specific behavioral demands that may be associ- Workplace factors include the governance struc-
ated with work is provided in Table 7-1. These tures in a workplace, workplace culture, exposure
demands require a person to be able to demon- to change, and risk concerns such as physical
strate specific social and interpersonal skills or security and safety. All of these factors can affect
competencies that often combine or draw on prior the nature of cognitive and behavioral demands
experience, specific training, cognition, and affec- and influence the success of the worker-job match.
tive skills in order to successfully exercise these Box 7-2 includes some of the workplace factors
behaviors. For the most part, these demands are that need to be considered in evaluating the
defined as actions and are thus conceptualized impact of contextual factors on worker productiv-
using a gerund, or “-ing” word. The role of the ity and performance. Governance and position
therapist is to identify which demands are required status factors can affect the degree of power or
and to determine the nature of these demands and responsibility a worker can exercise at work.
how they unfold when work occupations are exe- Workplace culture can influence the acceptance
cuted. Again, this list of behaviors is not complete; and belonging needs of a worker.8 In addition,
however, it is meant to organize an array of productivity dynamics such as the urgency, speed,
behavioral demands that therapists can draw on degree of interruptions, and unplanned or unex-
when considering the types of behaviors and pected tasks can, in turn, influence the cognitive
demands required in the workplace. and behavioral requirements and demand an
Step 4 of the process illustrated in Figure 7-1 adaptive response from the worker. For thera-
indicates that the therapist identifies the behav- pists, the consideration of the environment and
ioral demands and appraises the salient interac- how it shapes the way work unfolds in a given
tions required to perform work. environment is essential for designing a successful
Chapter 7 Cognitive and Behavioral Demands of Work 109

TABLE 7-1 Behavioral Components of Work

Component Examples

Enactment of social Interacting with supervisor

processes, Interacting with others
interactions, and Providing supervision
relationships with Managing conflict
others Working cooperatively with other employees or customers
Working in isolation from others
Interpreting and responding to nonverbal cues and gestures
Providing social support to co-workers
Implementing a social interaction approach when working with others:
Using a friendly, congenial customer-oriented approach
Using a caring approach
Using a professional, expert-oriented approach
Using a collaborative-partnership, team-oriented approach
Using a business-oriented, networking approach
Enactment of worker Exercising supervision
responsibilities and Receiving supervision
requirements Exercising self-supervision
Training self and others
Taking initiative
Working safely
Socializing with others
Networking with others
Working independently
Working interdependently
Working cooperatively with others; using team work
Exercising independent control and autonomy over decisions and problem
Exercising control over work pace
Self-directing schedule and prioritizing work tasks
Solving problems
Making decisions
Executing emotional Exercising self-awareness; demonstrating a high self-regard and self-confidence
job demands Exercising autonomy through reflection and action in midst of practice or
performing duties
Exercising self-regulation of emotions (e.g., be calm in emotionally charged
Exercising sensitivity toward others
Exercising or conveying compassion, empathy, sympathy
Executing a positive attitude
Conveying hopefulness
Acting in a courteous manner
Acting in a kind and thoughtful manner
Exercising emotional intelligence
Motivating self
Managing emotions of others

110 PART II Knowledge, Tools, and Techniques

TABLE 7-1 Behavioral Components of Work—cont’d

Component Examples

Enactment of Managing material, financial, human resources, quality, and production of

management work
responsibilities and Managing negative attitudes of others
requirements Managing and resolving conflict
Managing cultural sensitivities
Managing through training, instructing, negotiating, or persuading,
giving feedback, coaching, mentoring
Managing social and emotional needs
Engaging a directive, supportive, participative, or achievement-oriented
supervisory or leadership approach
Solving problems
Making decisions
Enactment of general Paying attention to detail
competencies and Performing multiple tasks
Enactment of specific Operating lift truck
competencies Using statistical software
Dispensing pharmaceuticals

BOX 7-2 Emotional, Cognitive, Security- RTW program. The workplace environment can
Related, and Environmental have a significant impact on a person in terms of
Tasks feedback regarding performance when returning
to work, but returning to work also requires a
Time pressures person to be ready to accept changes and adapt
Deadline pressures activities and actions based on the pressures
Safety pressures exerted by the workplace environment. Other
Security pressures environmental considerations such as noise, heat,
Life and death pressures cold, physical space, location, tools and equip-
Exposure to emotional situations ment, and resources and supports may also influ-
Exposure to confrontational situations
ence a worker’s capacity to fulfill cognitive and
Exposure to high risk with regard to safety and
behavioral demands.
physical well-being
Step 5 in the process outlined in Figure 7-1
Exposure to environmental stimuli (noise,
people, machines, distractions)
requires that the contextual factors that influence
Position status the performance of work in this workplace be
Union status considered. In this case, for example, the sched-
Type of governance (style): ules are done biweekly to make adjustments for
Authoritative changes in shift resulting from employees who are
Directive ill or absent, holidays, and vacation planning.
Supportive Based on our case, create a description that
Participative captures the essence of the workplace. What are
Achievement-oriented the challenges and facilitators that might inform
the implementation of the RTW plan? How might
Chapter 7 Cognitive and Behavioral Demands of Work 111

contextual factors affect Kara’s ability to adapt to ment, one may anticipate that a high level of
modified work and accept and respond to changes attention to detail and accountability are required.
and pressures in the workplace? How can this A worker who is required to pass numerous police
information be used to support the RTW process? screenings will likely have some level of self-
Consider how the worker or others involved in supervision, as well as personal accountability.
the workplace might be included to support a Other sources outside of the workplace, such as
transitional RTW process for Kara. government job descriptions and ratings, like the
What contextual information do you need that National O*Net Consortium: Occupational Infor-
cannot be assumed from the case information mation Network (O*Net) (http://online.onetcen-
provided? Develop a list of additional information, also provide good background information,
you need, and develop a set of strategies for but it may not be directly relevant to the demands
obtaining this information. Then follow through of work in a particular workplace. For example,
with the process to identify the areas requiring the cognitive and behavioral demands of a clean-
consideration and create a plan to address these ing job may be quite different for a worker who
issues. works on a crew with other workers than for one
who is independently responsible for an entire
building, although the physical demands may be
Numerous challenges are involved in assessing Observation
workload, because many cognitive and beha- An impartial rater, such as a therapist or occupa-
vioral demands are less observable than physical tional health nurse, may observe job performance
demands. By focusing on the behavioral aspects and note the variety of demands required in the
of cognitive skills, however, it is possible to iden- cognitive and behavioral spectrum. Use of a struc-
tify and rate demand levels. For example, record- tured format or checklist helps observers attend
ing the degree to which one is exposed to emotional to key factors and to consistently record demand
situations on a job is arguably more objectively levels. In order for analyses to be complete, it may
determined than is measuring the level of sensitiv- be necessary to observe for extended time periods
ity required. Another challenge lies in the fact that or to sample time segments from different times
cognitive and behavioral ratings are often done by of the day or week. Observational analysis is gen-
or with workers themselves so that a broad and erally done in conjunction with other information
inclusive spectrum of the job demands is consid- sources (e.g., review of job descriptions, inter-
ered. Individual worker perceptions of the inher- views) in order to guide time sampling to ensure
ent cognitive demand of a job may vary greatly, that the review is comprehensive.
however, based on their personal qualities, such
as the worker’s ability to function in the pre- Worker Interviews
sence of multiple stimuli or with high or low Job incumbents possess the most in-depth knowl-
supervision. edge of a job and are an invaluable source of
information concerning job demands. Although
Document Review some workers will lack the experience to critically
Job descriptions provided by a company or work evaluate the level of job demand, many contem-
unit can provide useful background information porary workers have been employed in a number
on the position in question, including responsibili- of different positions over the course of their
ties, physical risks, hours of work, and specific working life and will have keen insight into the
knowledge or preparation required. The latter can key risks or demands associated with the cur-
provide insight into the nature of the work. For rent job. Use of behaviorally based scales and
example, if a worker is required to have many examples is helpful in identifying the level of
years of experience in the use of technical equip- demand.
112 PART II Knowledge, Tools, and Techniques

Supervisor Interviews demand than when few reference points are

Supervisor input is useful for understanding job available.
duties and how they fit with the overall flow of
the workplace. Expectations of worker perfor- Rating Systems
mance in such functions as customer service, A number of approaches to identifying the cogni-
emergency preparedness, and cooperation with tive and behavioral demands of work are available
other workers may be best identified by a person in the literature and from corporate and govern-
with a broad, supervisory perspective. Supervisor ment sources. Functional demands are examined
interviews alone typically provide insufficient in different ways depending on the group con-
information on which to base job demands an- ducting the analysis and the group’s purpose.
alysis (JDA), however, as often the supervi- Government agencies (such as the U.S. Depart-
sor is removed from a job and its detailed ment of Labor, Employment and Training Admin-
requirements. istration [DLET] and Statistics Canada) maintain
As with any measurement system, cognitive databases of jobs and their corresponding training
and behavioral job rating tools must satisfy basic and skill requirements. These systems include
standards for reliability and validity. Validity ratings related to the knowledge level required
issues in rating forms are typically addressed in and other cognitive components of work. For
the developmental stages by including vocational example, O*Net, the job database maintained by
and occupational health experts in the creation DLET, includes ratings on more than 40 cognitive
and refinement of tools such that the items and behavioral skills for each job (Table 7-2).
included are meaningful, relevant, and compre- These skills range from the basic skills required
hensive. The reliability of a measure, which is the to perform a job to required aptitudes in areas
reproducibility of the score over time or across such as complex problem solving, resource man-
raters, is enhanced by the following: agement, and social, technical, and systems skills.
• Clear definitions: The levels of an item and Skill ratings are done by incumbent workers who
their meaning must be clearly stated and are assumed to have in-depth knowledge of jobs,
defined for the rater. Ambiguous definitions and the resulting scales are used primarily for
lead to wide variance in scoring, based on vocational guidance and planning and for public
differences in interpretation from one job policy development.
setting to another and from one rater to Unions typically perform job demands analyses
another. for the purpose of delineating the responsibility
• Training: Job raters require both thorough level of work in order to determine the relative
orientation to rating tools and experience in value of the job, with the goal of creating fair and
using the tool under supervision in order to equitable compensation scales. The Uniform Clas-
eliminate misconceptions. This is particu- sification Standard developed by the Treasury
larly important in the case of tools measur- Board of Canada for classification of public sector
ing the cognitive and behavioral aspects of jobs has been used or adapted by major unions
work, because of the less observable nature in that country. It rates four key elements of jobs:
of many of the items. Training is generally Responsibility, Effort, Skills, and Working Condi-
enhanced by providing detailed documenta- tions. Table 7-3 demonstrates how the Univer-
tion as to how to use the tool, along with sal Classification has been modified for use by
sample cases. one major union, the Canadian Union of Public
• Experience: As in other areas of JDA, famil- Employees (CUPE). Many of these demands
iarity with a measurement tool and exposure address the cognitive and behavioral aspects of
to a wide variety of job types help to situate performing work. A sample rating scale is shown
observations in a broader context. Observers in Figure 7-2. In order to allocate point values to
are more able over time to differentiate jobs using the various scales, determinations are
among levels of cognitive and behavioral typically done by job evaluation committees that
Chapter 7 Cognitive and Behavioral Demands of Work 113

TABLE 7-2 O*NET Skill Requirements Categories

Skills Developed Capacities

Basic Skills Capacities That Facilitate Learning or the More Rapid Acquisition of Knowledge
Active learning Understanding the implications of new information for both current and future
problem solving and decision making
Active listening Giving full attention to what other people are saying, taking time to understand
the points being made, asking questions as appropriate, and not interrupting
at inappropriate times
Critical thinking Using logic and reasoning to identify the strengths and weaknesses of alternative
solutions, conclusions, or approaches to problems
Learning strategies Selecting and using training or instructional methods and procedures appropriate
for the situation when learning or teaching new things
Mathematics Using mathematics to solve problems
Monitoring Monitoring and assessing performance of one’s self, other individuals, or
organizations to make improvements or take corrective action
Reading Understanding written sentences and paragraphs in work-related documents
Science Using scientific rules and methods to solve problems
Speaking Talking to others to convey information effectively
Writing Communicating effectively in writing as appropriate for the needs of the

Complex Problem- Capacities Used to Solve Novel, Ill-Defined Problems in Complex, Real-World
Solving Skills Settings
Complex problem Identifying complex problems and reviewing related information to develop and
solving evaluate options and implement solutions

Resource Management Capacities Used to Allocate Resources Efficiently

Management of Determining how money will be spent to get the work done and accounting for
financial resources these expenditures
Management of Obtaining and seeing to the appropriate use of equipment, facilities, and
material resources materials needed to do certain work
Management of Motivating, developing, and directing people as they work, identifying the
personnel resources best people for the job
Time management Managing one’s own time and the time of others

Social Skills Capacities Used to Work with People to Achieve Goals

Coordination Adjusting actions in relation to others’ actions
Instructing Teaching others how to do something
Negotiation Bringing others together and trying to reconcile differences

114 PART II Knowledge, Tools, and Techniques

TABLE 7-2 O*NET Skill Requirements Categories—cont’d

Skills Developed Capacities

Persuasion Persuading others to change their minds or behavior

Service orientation Actively looking for ways to help people
Social perceptiveness Being aware of others’ reactions and understanding why they react as they do

Systems Skills Capacities Used to Understand, Monitor, and Improve Sociotechnical Systems
Judgment and Considering the relative costs and benefits of potential actions to choose the
decision making most appropriate one
Systems analysis Determining how a system should work and how changes in conditions,
operations, and the environment will affect outcomes
Systems evaluation Identifying measures or indicators of system performance and the actions needed
to improve or correct performance, relative to the goals of the system

Technical Skills Capacities Used to Design, Set up, Operate, and Correct Malfunctions Involving
Application of Machines or Technologic Systems
Equipment Performing routine maintenance on equipment and determining when and what
maintenance kind of maintenance is needed
Equipment selection Determining the kind of tools and equipment needed to do a job
Installation Installing equipment, machines, wiring, or programs to meet specifications
Operation and Controlling operations of equipment or systems
Operation monitoring Watching gauges, dials, or other indicators to make sure a machine is working
Operations analysis Analyzing needs and product requirements to create a design
Programming Writing computer programs for various purposes
Quality control Conducting tests and inspections of products, services, or processes to evaluate
analysis quality or performance
Repairing Repairing machines or systems using the needed tools
Technology design Generating or adapting equipment and technology to serve user needs
Troubleshooting Determining causes of operating errors and deciding what to do about them

TABLE 7-3 Work Characteristics Included in the Canadian Union of Public

Employees Gender-Neutral Job Evaluation Plan

Characteristic Examples Characteristic Examples

Responsibility Accountability Skill Knowledge

Safety of others Experience
Supervision of others Judgment
Contacts with others Working conditions Disagreeable working conditions
Effort Concentration
Physical effort
Chapter 7 Cognitive and Behavioral Demands of Work 115

Subfactor 4 - Concentration

DEFINITION: This subfactor measures the period of time wherein mental, visual, and/or aural concentration is
required on the job. Both the frequency and duration of the effort are to be considered.

DEGREES: 1. Occasional periods of short duration.

2. Frequent periods of short duration; OR

Occasional periods of intermediate duration.

3. Almost continuous periods of short duration; OR

Frequent periods of intermediate duration; OR
Occasional periods of long duration.

4. Almost continuous periods of intermediate duration; OR

Frequent periods of long duration.

5. Almost continuous periods of long duration.

NOTES TO 1. Attentiveness is required for all jobs; rate tasks requiring concentration.
2. Concentration includes activities such as listening, interpreting, reading, watching, driving,
inputting data, or when a combination of the five senses, sight, taste, smell, touch, and hearing,
is required in the course of doing the job that result in mental/sensory fatigue.

3. Consider components such as interruptions and the requirements for simultaneous processing
of information (i.e., maintaining concentration despite frequent interruptions or changes in work

4. Duration of uninterrupted time is measured as follows:

Short — Up to and including 1 hour.
Intermediate — Over 1 hour, and up to and including 2 hours.
Long — In excess of 2 hours.
Frequency relates to work carried out on a regular basis throughout the year.
Occasional — Once in a while, most days.
Frequent — Several times a day or at least 4 days per week.
Almost Continuous — Most working hours for at least an average of 4 days per week.

5. Subfactor Chart

Short Intermediate Long
Occasional 1 2 3
Frequent 2 3 4
Almost Continuous 3 4 5

FIGURE 7-2 Sample rating format from the Universal Classification Standard.
116 PART II Knowledge, Tools, and Techniques

base job ratings on job questionnaires completed over several years. A four-point rating scale is
by workers and supervisors. provided for each item, with “4” representing the
Measures emerging from psychology, as previ- highest level of demand, and unique descriptions
ously mentioned, are used primarily in research are provided for each rating level within each
in order to measure the relationship between job item. Figure 7-3 shows the section of this tool
demands and various outcomes of interest. An that is used for evaluating the responsibility and
example of a scale used for this purpose is the accountability demands of work. The full list of
Job Content Questionnaire,3 a standardized, self- cognitive and behavioral demands addressed in
administered tool that measures a number of this tool is shown in Figure 7-4 as it would be
cognitive, behavioral, and contextual job factors completed for Kara’s job. It includes factors rang-
including decision authority, choice and variety in ing from relationships with others (e.g., supervi-
work, psychologic demands and mental workload sion, cooperation with other workers, communi-
(including general psychologic demands, role cation) to independent cognitive demands (e.g.,
ambiguity, concentration, and mental work dis- memory, literacy, attention to detail, exposure to
ruption), job security, and supports available. The distracting stimuli) and emotional control (e.g.,
subject is asked to indicate on a scale ranging working with deadline pressures, exposure to
from “Never” to “Extremely Often” the extent to emotional and confrontational situations).
which the job requires him or her to work fast, The CoT established content validity of this
how often the worker must expend excessive tool6 and more recently inter-rater reliability was
effort, whether the job is hectic, and other similar established through a study using student and
factors. This tool has well-established predictive expert raters.4 The second part of the CoT tool
validity and reliability but is available only from provides therapists with a means to record the
the authors for use in research. worker’s functional capacity, based on separate
From a rehabilitation perspective, the cognitive clinical assessments. A parallel process of rating
and behavioral demands of jobs are of increasing of the worker’s capacity to perform these job
interest to therapists and occupational health per- demands is completed to identify areas of poten-
sonnel, given their relevance to successful job tial mismatch. These mismatches are then used as
performance. The goal of JDA in rehabilitation is a basis for developing an RTW plan.
to understand and objectify the requirements of
the work for use in work conditioning and modi-
fied return-to-work programs. Many JDA tools in CONCLUSION
use provide only global ratings of cognitive and This chapter draws attention to the need for a
behavioral demands and lack sufficient detail to broader evaluation of the demands and require-
match jobs to the functional capacities of the ments of work occupations. Measuring the cogni-
worker. In addition, only a few JDA tools identify tive and behavioral demands of work in addition
the demands of work versus the capabilities of the to the physical elements of the job will lead to a
worker. more complete and comprehensive JDA. Efforts of
therapists to rate these demands and identify
inherent challenges will assist them in the devel-
USING JOB DEMANDS ANALYSIS TOOLS: opment of RTW plans for clients. In addition,
CITY OF TORONTO JOB DEMANDS through the JDA process therapists may identify
ANALYSIS INSTRUMENT potentially highly complex or behavioral work
One example of a JDA tool that addresses physi- requirements that may lead to risks such as stress
cal, cognitive, and behavioral aspects of work is and anxiety. Thus, therapists may use this infor-
the City of Toronto Job Demands Analysis Tool mation to make recommendations for changes in
(CoT).6 This instrument was developed by thera- work processes, procedures, or the workplace
pists, ergonomists, occupational health personnel, context to help workers and employers reduce
and a consulting psychiatrist based on their expe- the onset of problems and improve workplace
riences with a broad spectrum of jobs and workers health.
Chapter 7 Cognitive and Behavioral Demands of Work 117

Responsibility and accountability Responsibility and accountability

required The ability to exercise appropriate judgment
“Responsibility and accountability and behave in a responsive manner during
required” refers to the extent of liability or the performance of work. A low rating
safety risk that could result if the indicates a potential error or inattention that
employee does not exercise appropriate could have grave consequences if the
judgment or attention during the worker is required to perform safety-
performance of job tasks. A high rating sensitive work.
indicates that the job is a safety-sensitive
position with the potential for grave
consequences if errors or inattention

Job Demands Analysis Definitions Rating Functional Abilities Definitions

Error in judgement or attention would May be prone to errors in judgment and/or

have insignificant consequences lapses of attention and therefore should only
perform work in which such errors or lapses
would have insignificant consequences

Error in judgment or attention would Able to exercise some judgment and

create inconvenience responsibility, but occasional lapses may
2 occur; the worker should be assigned to
work in which such lapses would not create
serious difficulties

Error in judgement or attention could Able to exercise a moderate degree of

create serious difficulty or significant judgment and responsibility, but not to a
expense sufficient extent to assume responsibility for
safety of others

Error in judgment or attention could Able to exercise sufficient judgment and

have grave or life-threatening conse- responsibility to perform well in safety-
quences 4 sensitive positions in which the worker is
responsible for the safety of others

FIGURE 7-3 City of Toronto JDA sample of behavioral demand.

118 PART II Knowledge, Tools, and Techniques

Job Demands Analysis Definitions Ratings Functional Abilities Definitions

Degree of Self-Supervision Required The Ability to Self-Supervise
Predominantly self-supervised through- Can tolerate infrequent supervision
out the shift (may contact supervisor to 4 3
obtain work direction as needed)
Degree of Supervision Exercised The Ability to Supervise Others
Has full supervisory responsibility for Able to provide work direction and some
other employees 4 3 elements of managing work performance
with the exclusion of disciplinary action
Deadline Pressures (time pressure) The Ability to Tolerate Deadline
Pressures (time pressure)
Time pressure is high: the majority of Capable of moderate work pace and can
work is performed under rigid time occasionally work under time constraints
constraints and the volume of work is 4 2
high (assumes that the work pace is high
OR the worker must extend the workday
to manage the volume of work)
Attention to Detail The Ability to Attend to Detail
Significant attention to detail or concen- Able to concentrate on or attend to details
tration required for many tasks or intense for some tasks, although not at an intense
3 2
attention to detail or concentration level
required for some tasks

Performance of Multiple Tasks The Ability to Perform Multiple Tasks

Responsible for multiple tasks, with Can handle more than one task, but requires
some time-management skill and 3 2 clear cues to indicate when each task should
judgment required to determine priorities be performed

Exposure to Distracting Stimuli Tolerance to Distracting Stimuli

Moderate degree of distracting stimuli Able to work effectively with a moderate
3 3
during some tasks or portions of the shift degree of distracting stimuli
Need to Work Cooperatively The Ability to Work Cooperatively
with Others with Others
The majority of work requires close Can work cooperatively with others on some
cooperation with others tasks
4 3

Exposure to Emotional Situations Ability to Tolerate Emotional Situations

Occasional exposure (approx. weekly) to Able to tolerate infrequent exposure (e.g.,
emotionally stressful circumstances or monthly) to emotionally stressful circum-
emotionally distressed individuals with 3 2 stances or emotionally distressed individuals
whom the worker must interact in order
to complete job requirements

FIGURE 7-4 Sample behavioral and cognitive job rating using the CoT JDA tool applied to Kara’s job
Chapter 7 Cognitive and Behavioral Demands of Work 119

Exposure to Confrontational Situations Ability to Tolerate Confrontation

Occasional exposure (up to weekly) to Able to tolerate occasional exposure (up to
confrontational situations in which 2 2 weekly) to confrontational situations in which
assistance is immediately available assistance is immediately available
Responsibility and Accountability Responsibility and Accountability
Errors in judgment or attention could Able to exercise a moderate degree of
have grave or life-threatening conse- judgment and responsibility, but not to a
quences 4 3 sufficient extent to assume responsibility for
safety of others
Reading Literacy Ability to Read
A high degree of reading literacy is Able to read at an advanced level without
required to read reports, manuals, or 4 4 difficulty
other documents with a high degree of
Written Literacy Ability to Write
Required to create reports, complex Able to compose memos or letters with
documents, or any communications that 4 3 accurate spelling, grammatical construction,
require a high degree of grammatical and clarity.
form and/or careful wording
Numerical Skills Ability to Perform Numerical Skills
Required to use more complex arithmetical Able to use more complex arithmetical
operations such as division, multiplication, 3 3 operations such as division, multiplication,
percentages, or ratios percentages, or ratios

Verbal Communication Ability to Communicate

Moderate communication skills are Has sufficient communication skills to
required to comprehend and communicate 3 3 comprehend and communicate information
information fluently (e.g., to work crews) fluently

Memory Memory

Moderate memory ability is required to Has moderate memory ability; can recall
recall information that is harder to information that is harder to remember
remember because it is recalled 3 3 because it is infrequently used or because
infrequently, or because there are time of time pressures
constraints within which to recall the

Computer Literacy Ability to Use Computers

Required to use one or more computer Able to use one or more computer programs
programs at a competent level (e.g., most at a competent level expected for most office
3 3
office workers using word processing and workers
e-mail applications)

FIGURE 7-4 cont’d.

120 PART II Knowledge, Tools, and Techniques

Learning Exercise
Overview of strategies you would use to evaluate
This learning exercise is designed to make the the cognitive and behavioral components
student aware of various aspects of the cognitive that you remain unsure about.
and behavioral demands of work. • As a group, describe the contextual
factors you observed in the workplace.
Purpose Identify the factors in the workplace
The purpose of this exercise is to encourage the context that are constant and those that
student to use a critical and thorough approach are variable. Create a list of questions you
in evaluating the cognitive and behavioral de- would ask the librarian to enhance your
mands of work. understanding of the nature of the
contextual factors.
Exercise • Identify potential people you would
To apply the information from this chapter and involve if you were developing an RTW
enhance practical skills in identifying cognitive plan for an employee.
and behavioral demands, choose a commonly 2. Alternative exercise for the same job:
understood job such as a resource or reference Conduct a formal worksite visit (one in
librarian in the local university or college library. which you ask the employer’s permission to
This exercise may be approached as a casual perform an evaluation as part of a learning
observation or as a formal worksite visit. exercise) with opportunity for interviews
1. Using a casual observation only: Visit the and use of other collateral information. First,
library and observe the librarian review a job description and conduct an
performing his or her job. Use Boxes 7-1 Internet search to identify some key
and 7-2, Table 7-1, and/or the CoT JDA behavioral or cognitive demands of the
form to observe, identify, and record the position. Next, conduct an observation and
cognitive and behavioral requirements of a identify demands as above. From your
resource librarian. Choose a rating scale, observations, try to rate the behavioral and
then try to rate the demands you observe cognitive demands. Work in a small group
as well as categorizing them into simple and identify a list of questions you want to
complex requirements. Identify demands ask to further your understanding of these
that you cannot observe and about which tasks. Ask to meet with the librarian to
you require further information. What interview him or her for more detailed
questions might you pose to the librarian information, or invite the librarian to a
to get the information you need and to class. In class, conduct a group interview to
justify your rating of these demands? further refine your understanding of these
• Hold a small group discussion about the demands. Write up a description of the
experience of conducting the observa- cognitive and behavioral demands. Identify
tion. Identify what was easy and what and record the simple and highly complex
was difficult to observe, and create a list demands of this workplace.
Chapter 7 Cognitive and Behavioral Demands of Work 121

Multiple Choice Review Questions 6. Evaluating cognitive and behavioral

demands of work is conducted for:
1. Measuring cognitive and behavioral A. planning return to work.
demands of work requires a therapist to: B. evaluating risks in the workplace.
A. interview the supervisor. C. rating jobs for compensation.
B. discuss job demands with the insurer. D. All of the above
C. collect information from a variety of
sources. 7. Making numeric calculations at work is
D. use a form that the union endorses. an example of a:
A. highly complex behavioral demand.
2. Cognitive and behavioral job demands B. highly complex cognitive demand.
are: C. cognitive demand.
A. the skills and abilities of workers. D. behavioral demand.
B. requirements of the work itself.
C. easily understood by supervisors. 8. Interviewing the supervisor as part of the
D. outcome measures of human JDA process is:
performance. A. the easiest way to gather information
about cognitive demands.
3. In order to create an effective RTW plan B. the best way to gather information
for clients who have experienced injury about cognitive demands.
or disability, the therapist should: C. necessary for assuring the insurer that
A. measure or evaluate the physical the information collected is accurate.
demands of work. D. one way to gather information.
B. measure or evaluate the behavioral
and cognitive demands of work. 9. The goal of job demands analysis in
C. identify client characteristics. rehabilitation is:
D. conduct a job demands analysis and A. to involve the worker in evaluating his
evaluate worker capacity. or her work modification process.
B. to satisfy the employer that all areas
4. Managing and resolving conflict is an of work are considered in RTW
example of a: planning.
A. cognitively based job requirement. C. to provide an objective evaluation of
B. behavioral job requirement. work demands for RTW planning.
C. physical job requirement. D. to provide a health and safety risk
D. cognitive skill. assessment for all work tasks.
E. contextual influence on performance.
10. Consideration of factors in the workplace
5. After worker characteristics and context is important in the JDA process
limitations are assessed, an initial step in because:
planning a return-to-work intervention A. these factors affect the way work is
is to: conducted.
A. identify gaps and mismatches between B. these factors are very similar in every
the work demands and the worker’s worksite.
capabilities. C. these factors always positively support
B. evaluate the cognitive functional the return-to-work process.
requirements of the job. D. these factors include the essential
C. evaluate the behavioral job demands. duties of work occupations.
D. determine what contextual factors are
122 PART II Knowledge, Tools, and Techniques

9. Venesy BA: A clinician’s guide to decision making

capacity and ethically sound medical decisions, Am
1. Giannini AJ, Giannini JN, Melemis SM: Visual sym- J Phys Med Rehabil 73:219, 1994.
bolization as a learning tool, J Clin Pharmacol 10. Wei J, Salvendy G: The utilization of the Purdue
37:559, 1997. Cognitive Job Analysis methodology, Hum Factor
2. Karasek R: Job decision latitude, job demands and Ergon Man 13:59, 2003.
mental strain: implications for job redesign, Adm
Sci Q 24:285, 1979.
3. Karasek R, Brisson C, Kawakami N et al: The job
content questionnaire (JCQ): an instrument for Raskin SS, Mateer CA: Neuropsychological management
internationally comparative assessments of psycho- of mild traumatic brain injury, New York, 2000,
social job characteristics, J Occup Health Psychol Oxford Press.
3:322, 1998. Sohlberg MM, Mateer CA: Introduction to cognitive
4. Kirley W, Shaw L, Jogia A: Evaluating inter-rater rehabilitation: theory and practice, New York, 1989,
accuracy and consistency in conducting job Guilford Press.
demands analysis, Proceedings of the University of Zoltan B: Vision, perception, and cognition: a manual
Western Ontario Occupational Therapy Conference for the evaluation and treatment of the neurologi-
on Evidence Based Practice, 5:33, 2005. cally impaired adult, ed 3, Thorofare, NJ, 1996,
5. Maslach C, Schaufeli W, Leiter M: Job burnout, Slack.
Annu Rev Psychol 52:397, 2001.
6. Raybould K, McIwain L, Hardy C, Byers J: Improv- Web Sites
ing the effectiveness of the job demands analysis Human Resources and Skills Development Canada—
tools, Unpublished article publicly available from National Occupational Classification Career Hand-
the author. book:
7. Siegrist J: Effort-reward imbalance at work and
health. In Perrewe PL, Ganster DC, editors: Histori- Job Stress Network:
cal and current perspectives on stress and health, National O*Net Consortium: Occupational Information
Amsterdam, 2002, JAI Elsevier. Network (O*Net) Online: http://online.onetcenter.
8. Strong S, Rebeiro K: Creating a supportive work org
environment for people with mental illness. In Letts
L, Rigby P, Stewart D, editors: Using environment
to enable occupational performance, Thorofare, NJ,
2003, Slack.
Psychosocial Factors in Work-
Related Musculoskeletal
Asnat Bar-Haim Erez

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Increase awareness of the need to assess psychosocial risk factors in ergonomic intervention.
2. Increase understanding of which factors are the most relevant for evaluation and intervention.
3. Have basic ergonomics tools for analysis of psychosocial risk factors.

Psychosocial factors. Ergonomic risk factors that factors and work-related musculoskeletal disorders.24
describe how the work organization is perceived by According to this model, psychologic demands have
workers and managers10 and that can be roughly adverse effects on a worker if they occur jointly with
divided into three categories: factors associated with low decision latitude (i.e., the opportunity to use and
the work environment, factors associated with the develop skills at work). The social support component
extra-work environment, and individual characteristics in this model is the support available in the workplace
of the worker.36 The assumption is that conflicts in one that is thought to mediate between the demands and
of these categories precipitate a process of mental the appearance symptoms.
stress that affects the worker’s physical health. Cognitive-behavioral strategies. Strategies based
Demand-control-support model. A theoretic model on the cognitive-behavioral psychotherapy frame of
for identifying the relationship between psychosocial reference. Such strategies include focusing on the

*Portions of this chapter are retained from the previous edition chapter written by Karen Lindgren.

124 PART II Knowledge, Tools, and Techniques

source of the stress and paying close attention to its include relaxation (including use of biofeedback), ac-
interpretation, examining the attribution style after tivity pacing, cognitive restructuring, and mental
symptoms and stress occur, and adopting alternative imagery.25
methods for addressing problems. The techniques used

“I gave my employees the best chairs and they are still P sychosocial issues in the workplace are one
of the areas included in risk factors analysis
during an ergonomic assessment. This chapter
Sara has been an operator in the obituary department defines psychosocial risk factors, including those
of a large national newspaper for the last 3 years. Her job proposed by the National Institute of Occupational
is to take telephone calls from people who are interested Safety and Health (NIOSH) and the Internation-
in placing an obituary in the newspaper. She came to al Labor Office (ILO), and reviews research re-
therapy with complaints of headaches and pain in her garding the relationship of specific risk factors
upper extremities and wrist and was diagnosed with de and work-related musculoskeletal disorders
Quervain’s tendonitis in the hand. She has been in (WRMSDs), along with methodologic problems.
therapy for 4 weeks and has made good physical prog- The chapter also discusses four pathways that
ress, but efforts to place her back at work failed even explain this relationship, interventions for clini-
though light duty status was offered. Sara is single (with cians, and future directions for intervention.
no children) but has a friend who accompanies her to Understanding the role of psychosocial risk
therapy and appears to be a good support for her. She factors is important in the intervention and pre-
has a college education (a bachelor’s degree in general vention of disability. NIOSH called for researchers
world history) but has never really used it for higher-levels to address the variety of risk factors thought to
jobs. contribute to job stress and work-related disabil-
Sara was reluctant to complete formal questionnaires, ity in the work environment.35 Consequently,
so an informal interview was conducted to get to the researchers began to study the relationship
bottom of her feelings toward going back to work. It between psychosocial factors and disability.
became clear that several issues bother her at work. Evidence has verified the importance of the rela-
Apparently she does not have control over how many calls tionships between psychosocial stressors and psy-
she gets per shift, and she cannot stop for a break between chologic dysfunction and between psychosocial
calls (she is permitted only a formal break for lunch and and musculoskeletal problems.
two more short breaks). On the lower side of the screen, Although the occurrence of WRMSDs is gener-
a message telling her how many calls are waiting for her ally considered multifactorial, past research has
is constantly running. She has hardly made any friends at focused mainly on physical load. More recent
work because she and her co-workers are constantly research, however, has included an examination
working, each person in his or her own cubicle. She feels of the relationship between psychosocial factors
she is considered a troublemaker because she tried to and WRMSDs. For example, in the Netherlands
change some of the conditions and her superiors did not these health problems (i.e., psychologic dysfunc-
back her up. She feels that the job itself is stressful tion and musculoskeletal problems) are the main
enough, because it involves talking with bereaved people causes of disability in two thirds of occupation-
all day with lack of time to relate to them. related disability cases.15 Despite this research, no
Sara does have biomechanical risk factors (sitting in consensus has been reached regarding the defini-
front of the computers all day); however, the psychosocial tion of psychosocial factors and how such factors
risk factors appear to be the significant ones with regard relate to WRMSDs.36,39
to helping her return to work. As you read the chapter,
try to identify the psychosocial stressors that might be PSYCHOSOCIAL RISK FACTORS
relevant for Sara and how did they affect both her symp- Several definitions of psychosocial factors have
toms and her return to work. been proposed. Most definitions suggest that psy-
Chapter 8 Psychosocial Factors in Work-Related Musculoskeletal Disorders 125

chosocial factors depend on workers’ perceptions, affects the way workers perceive or react to the
a point emphasized by Hagberg and colleagues: same work situation.17
“Psychosocial factors at work describe how the In contrast to NIOSH, the World Health Orga-
work organization is perceived by workers and nization and ILO35, in a joint report, organized
managers; work organization is the objective work-related psychosocial factors into five catego-
nature of the work process and it deals with the ries: the physical environment; factors intrinsic to
way in which work is structured and processed” the job (e.g., workload, work design); arrange-
(p. 11).10 ment of work time (e.g., hours of work, shifts);
NIOSH defines psychosocial factors as a general management or operating practices (e.g., roles
term that identifies many variables that can be of the worker, relationships at work); and tech-
roughly divided into three categories: factors asso- nologic changes. This definition is similar to the
ciated with the work environment, factors asso- NIOSH description but does not identify individ-
ciated with the extra-work environment, and ual worker differences or extra-work environ-
individual characteristics of the worker.36 The ments.
assumption is that conflicts in one of these areas
precipitate a process of mental stress that affects
the worker’s physical health. The psychosocial PSYCHOSOCIAL FACTORS AND WORK-
risk factors in each category are detailed in the RELATED MUSCULOSKELETAL DISORDERS
following sections. NIOSH examined the research and literature
related to all aspects of psychosocial risk factors
Work Environment and reported that there is evidence for five psy-
Psychosocial work environment (or work or- chosocial factors potentially related to WRMSDs
ganization) risk factors include the following: (1) (mainly in areas of the back and upper extremity
characteristics of the job (e.g., workload, job disorders).36 These variables are job satisfaction,
control, repetition and monotonous tasks, mental intensified workload, monotonous work, job con-
and cognitive demands, clear job definitions), trol, and social support. NIOSH reports stronger
(2) organizational structure (e.g., communication support for the relationship between these psy-
issues), (3) interpersonal relationships at work chosocial factors and WRMSDs in the back, neck,
(e.g., relationships with employer, supervisor, and shoulder area than in the hand and wrist
co-workers), (4) temporal aspects of work (e.g., area.36 This may be because a larger number of
shift work, cycle time of tasks), (5) financial and studies concentrated on the back, neck, and shoul-
economic aspects (e.g., salary, benefits), and der area rather than on the hand and wrist area
(6) community aspects of occupation (e.g., pres- or because most studies done on the hand and
tige, status). wrist area did not consider psychosocial variables.
Studies examining these relationships are reviewed
Extra-Work Environment in Table 8-1.
Extra-work environment includes factors that
come from outside the work. These include psy- Job Satisfaction
chosocial factors that relate to the worker’s other Low levels of job satisfaction may be associated
life-roles, such as responsibilities and function with high levels of upper extremity musculoskel-
with the family. etal symptoms.14,47 Several researchers have re-
ported that low levels of job satisfaction correspond
Individual Worker Characteristics to the development and duration of musculoskel-
Individual worker characteristics include the etal symptoms, although these results did not hold
genetic factors (e.g., anthropometric characteris- true in a longitudinal study with Finnish workers
tics, gender, intelligence), acquired aspects (e.g., in which job satisfaction did not predict neck and
social class, culture, educational factors), and dis- shoulder symptoms in a follow-up 1 year later.7,13,49
position (e.g., personality, characteristic traits, Hughes and colleagues16 reported low job satisfac-
attitudes toward life and work). Disposition often tion (and decision latitude) to be important
TABLE 8-1 Psychosocial Factors Associated with Upper Extremity and Back Musculoskeletal Disabilities

Occupational Control Body Area Job Monotonous Social

Study (Year) Population Used Studied Satisfaction Workload Work Job Control Support

Ahlberg-Hulten Health care workers Longitudinal Back + (with high

(1995) (female) (study of demands)
same group)
Bernard et al Newspaper workers None Upper + + (for data- +
(1992, 1994) extremity entry
Bigos et al Aircraft plant History of Back + + +
(1991) workers back injury
Bongers et al Longitudinal Back + +
Hales et al Telecommunications Extra-job Upper + + +
(1994) workers factors extremity
Head et al Civil service Longitudinal Sickness + + +
(2006) employees (study of absence
same group)
Knowledge, Tools, and Techniques

Himmelstein General population Upper + +

et al (1995) extremity
Hopkins (1990) Keyboard clerks Upper + + + +
Houtman et al General population Physical Back, upper +* +*† +*†
(1994) stressors extremity
Hughes et al Aluminum smelter Back +
(1997) workers
Jensen et al Computer workers Repetitive Neck, hand, +
(2002) movements and
and time of wrist MSD
work at the symptoms
Johansson Home care workers Upper + (with
(1995) extremity physical
Kaila-Kangas Cohort of metal Longitudinal Back + +
et al (2004) industry data
Karasek et al White collar Upper + + +
(1987) workers extremity
Leino and Factory workers Physical load + +
Hanninen (blue and white
(1995) collar)
Linton (1990) General population + +
Nielson et al Pharmaceutical, Two-year Sickness +
Chapter 8

(2004) municipality, longitudinal absence

services study (of
same group),
Ostergren et al General population Cohort study Shoulder + (in + (in
(2005) with 1-year and neck women) women)
follow up
Svensson and Health care Physical load, Back + +
Anderson workers life and job
(1983) satisfaction
Thorell et al Six different Physical load Upper + +
(1991) occupational extremity
Tola et al Mechanics, Upper +
(1988) carpenters, office extremity
Toomingas Furniture movers, Upper + (with +
et al (1997) general workers extremity mental
Viikari-Juntura General population Longitudinal Upper + (women)
et al (1991) extremity

MSD, Musculoskeletal disorder.

*Upper extremity.

Psychosocial Factors in Work-Related Musculoskeletal Disorders
128 PART II Knowledge, Tools, and Techniques

predictors of increased back pain in heavy-indus- Monotonous Work

try workers. The variation in results may be a Monotonous work is associated with neck symp-
result of population differences. Going back to our toms and low back pain.14,15,31,44 Some theorize
case study, Sara is an educated woman who found that the rate of detection of symptoms is higher
herself in a job that appears to be not up to her in “less-interesting” jobs because boring work
cognitive skills; does this factor play a role in her fails to distract attention from symptoms.39
Job Control
Intensified Workload Job control, one of the most consistently resear-
Intensified workload is most consistently associ- ched psychosocial factors, is frequently linked
ated with WRMSDs and is usually measured to musculoskeletal symptoms.11,44,46 Bernard and
by perceived time pressure, workload (and work- colleagues4 speculated that the introduction of
load variability), and work pressure.2,7,11,46 computers caused a lack of control over specific
Houtman and colleagues15 reported that a fast aspects of work, reduction of task diversity, and
pace of work had a significant relationship to increased isolation. These psychosocial factors
WRMSDs and primarily caused back symptoms, were more important predictors of hand and wrist
even when data were adjusted for the degree of symptoms in newspaper departments with a high
physical load. A study that controlled for physical concentration of data-entry workers (thought to
load found an association between workload and have low-control jobs) compared with editorial
upper back and limb symptoms.29 Others have workers (thought to have jobs involving more
found that increased workload (time pressure decision making and varied tasks). Ahlberg-Hulten
and greater time at a computer) was related to and colleagues1 reported that lower back symp-
symptoms in the neck, shoulder, hand, and toms are associated with lack of job control and
wrist.3,4,19,38 the presence of extremely demanding work,
To help distinguish among various elements of whereas upper back symptoms appear to be asso-
workload, Lindstrom30 identified two types: quan- ciated with emotional and interpersonal factors. A
titative workload (large amount of work, long longitudinal study of the role of psychosocial
hours, or haste at work) and qualitative workload factors on neck and shoulder and low back pain
(tasks too simple or too difficult). Both types among Finnish men and women reported that a
affect workers’ health negatively but through dif- poor sense of job control was associated with neck
ferent mechanisms. Quantitative workload affects and shoulder pain and that fewer years of educa-
biomechanical factors and stress, whereas qualita- tion corresponded with low back pain.49 In an
tive workload affects mental overload and thus investigation of home care workers, decreased job
overall physical well-being. Similarly, Toomingas control combined with high physical workload
and colleagues48 differentiated physical workload increased the prevalence of musculoskeletal symp-
from mental workload. They discovered that high toms in the neck and shoulders.20 A more recent
mental demand was related to general musculo- study also found low job control to be one of the
skeletal sensitivity, especially in the neck and low main factors to be associated with hospitalization
back. resulting from back disorders other than interver-
Think about Sara’s work. It is basically defined tebral disk disorders.21
as quantitative: “Take as many ads as you can.” Another way of examining the effect of job
However, as Sara commented, she mostly deals control on workers is to look at the time they are
with bereaved individuals and has to be strict with absent from work. One of the more recent studies
them. This approach appears to go against her investigated the impact of job control on absence
personality; she takes her customers’ situations to from work and reported that high levels of deci-
heart. This means her therapist and employer sion authority predicted low absence rates.34 In
need to take into account the qualitative elements reference to our case study of Sara, this risk factor
that affect Sara. is obviously the greatest.
Chapter 8 Psychosocial Factors in Work-Related Musculoskeletal Disorders 129

As can be seen from the review, job control has

been linked to musculoskeletal symptoms, but the THEORIES EXPLAINING THE RELATIONSHIP
locations of injuries have varied from study to BETWEEN PSYCHOSOCIAL FACTORS AND
study. In addition, major methodologic differences WORK-RELATED MUSCULOSKELETAL
exist among studies (e.g., differences in the popu- DISORDERS
lations studied and definitions of job control). Several theories attempt to explain the influence
Individual factors, such as gender or education, of psychosocial factors on the development of
may affect psychosocial factors and physical symp- musculoskeletal symptoms. Most of these theories
toms, making definitive conclusions difficult. assume that psychosocial factors help cause symp-
toms, although some suggest other relationships.
Social Support Four main theories are reviewed in this section.
Social support from co-workers or supervisors has One of the most popular explanations suggests
been studied in a variety of populations with fairly that psychosocial factors increase muscle tension
consistent results. Perception of poor social sup- and exacerbate existing biomechanical strain on
port is associated with increased reports of symp- the musculoskeletal system through increased
toms, although the direction of this relationship mental stress.4,36,50 In one study, increased elec-
is unclear. Himmelstein and colleagues13 differ- tromyographic activity was recorded from the
entiated individuals who worked with WRMSDs muscles of the neck (trapezius) and the erector
from those who did not by noting that the indi- spine muscles during mentally stressful activi-
viduals who did not work because of WRMSDs ties.48 Electromyographic activity increased with
expressed more anger toward their employers ergonomic loads and increased further when psy-
(although both groups had a similar perception of chologic loads were added, which supports the
the work environment). In a rare longitudinal theory of increased muscular tension resulting
study, Bongers and colleagues reported that high from mental stress. Absence of relaxation medi-
physical demands combined with poor social ates the effects of poor psychosocial work con-
support increased symptoms.7 Feuerstein reported ditions.33 Bongers and colleagues7 suggest that
that decreases in co-worker cohesion correlated psychosocial factors directly influence mechanical
with higher pain ratings (but not with distress).9 loads through changes in posture caused by stress.
Other research supports the theory that decreased For example, people tend to change posture when
social support from co-workers and supervisors pressured by deadlines (e.g., hunched trunk, ele-
correlates with increased musculoskeletal symp- vated shoulders). In addition, stress originating
toms in the upper extremities (neck and shoulder from the combination of few variables, such as
area, wrist and hand area) in a variety of occupa- poor job control or poor social support joined with
tions (e.g., furniture movers, secretaries)3,4,11,14,48 a poor capacity to cope, may increase muscle tone
and is a cause for sickness absence from and, in the long run, lead to musculoskeletal dis-
work.12,32 orders. Theorell and colleagues demonstrated that
Despite these fairly consistent results, several increased mental demands are associated with
studies have not found an association between increased worry, fatigue, and difficulty sleeping.45
social support and symptoms such as the neck These symptoms correspond with behavior that
and shoulder pain or general musculoskeletal increases muscle tension, which is associated
aches.23,46 In addition, the relationship between with back, shoulder, and neck discomfort.
social support and symptoms is unclear; perhaps Sauter and Swanson39 suggest an ecologic
symptoms lead to decreased social support. Bigos model describing a pathway leading from work
and colleagues5 and Leino and Hanninen29 have organization to musculoskeletal outcome in office
attempted to clarify this relationship. Both groups workers. The pathways included in this model are
reported that dissatisfaction with social relation- based on research with a specific population
ships at work predicted the report of musculo- (computer workers). The model identifies a direct
skeletal symptoms. path between work technology (tools and work
130 PART II Knowledge, Tools, and Techniques

system) and both physical demands (including Research examining this model showed that
ergonomics) and work organization. A direct path these factors are significant at work, but their
also exists between physical demands and work association with specific physical complaints is
organization, suggesting that physical demands mixed. Kopek and Sayre26 used longitudinal data
are exacerbated by organizational demands (i.e., from a national survey in Canada and found that
increased job specification increases repetition). high psychologic demands and low skill discretion
Another path identified in the model exists were independently associated with pain and dis-
between work organization and psychosocial comfort but not in diagnosed back pain. They
strain (i.e., stress). This path is suggested to affect concluded that work-related stress is a significant
musculoskeletal outcomes in two ways. First, risk factor for nonspecific complaints of pain or
stress increases muscle tension and autonomic discomfort among workers. Ostergren and col-
processes and adds to the biomechanical strain leagues38 assessed the impact of mechanical expo-
that already exists. Second, cognitive processes sure and the work related psychosocial factors on
mediate the relationship between biomechanical specific pain, in the neck and shoulder. They
strain and musculoskeletal symptoms (i.e., the found that high psychologic demands and low job
process of detecting and interpreting symptoms decision latitude correlated with increased risk for
can further influence stress at work). Stress-related developing neck and shoulder pain, although it
arousal may increase sensitivity to normal mus- was true for women and not for men even after
culoskeletal sensation; the worker becomes aware controlling for high mechanical exposure and
of any small sensation that in other situations sociodemographic factors.
would be suppressed. Workers involved in stress- Another model on which more recent re-
ful work conditions may also attribute normal search is based is Siegrist’s Effort-Reward Im-
musculoskeletal sensation to work conditions and balance model.40,41 This model rests on the hy-
believe such sensations to be a sign of injury and pothesis that a combination of high level of effort
illness. Musculoskeletal disorder is influenced by expended and little reward received (money and
environmental forces that include medical, soci- career opportunities) have pathologic effects on
etal, and cultural factors; legal and compensation health.
systems; and workplace relationships. The cogni-
tive-perceptual process may lead to interpretation
of discomfort as an underlying injury and may METHODOLOGIC PROBLEMS
develop into sickness and lead to disability. Interpretation of the research is complicated by
The demand-control-support model22,24 pro- the different designs used, populations studied,
vides another view for identifying the relationship and type of psychosocial factors and WRMSDs
between psychosocial factors and WRMSDs and is examined. Several methodologic problems are
a widely accepted model for work-related stress. included here to clarify research techniques. Most
According to this model, psychologic demands of the research examining the relationships be-
have adverse affects on a worker if they occur tween psychosocial risk factors and WRMSDs use
jointly with low decision latitude. Low decision cross-sectional designs, making causality impos-
latitude is identified by the absence of authority to sible to determine.7,13 Few studies have considered
decide what to do and how to do it and by the lack the confounding effect of physical stressors (static
of intellectual discretion (i.e., the opportunity to load and repetitive work) when assessing the rela-
use and develop skills at work). The social support tionships between psychosocial risk factors and
component in this model is the support available WRMSDs.7,15,39 An exception is the study by
in the workplace that is thought to mediate between Theorell and colleagues,46 who did control for
the demands and the appearance of symptoms. physical stressors when assessing factors such as
Research on this model supports the assumption social support. NIOSH notes that changes in phys-
that these components are relevant to the develop- ical and biomechanical demands frequently occur
ment of musculoskeletal disorders.46 simultaneously with changes in psychosocial
Chapter 8 Psychosocial Factors in Work-Related Musculoskeletal Disorders 131

demands, making it difficult to delineate the role overload (how much job demands exceed
causal relationships between them.36 resources and whether the worker can accomplish
Another problem arises from the tools used to the expected workloads); role insufficiency (appro-
measure psychosocial factors. Psychosocial factors priateness of the worker’s training, education,
are difficult to measure with objective measure- skills, and experience to job requirements); role
ments and are usually subjective, assessed through ambiguity (the level of the worker’s understand-
surveys or self-report techniques. Cognitive theo- ing of the expectations and evaluation criteria);
rists suggest that the individual is a filter through role boundary (the extent to which the worker
which the environment is observed; for instance, experiences conflicts in role demands or loyal-
Lazarus28 emphasizes the cognitive and affective ties); responsibility (the amount of responsibility
functions of the individual identifying work de- perceived by or given to the worker to ensure the
mands. Thus determining whether risk factors are performance and welfare of others on the job);
colored by one’s perception or are reflective of the and physical environment (the frequency with
“true” situation is difficult. which the worker is exposed to extreme condi-
Although many studies found the relationships tions [e.g., high levels of environmental toxins]).
to be significant, the strength of these relation-
ships is modest.36,39 This prevents definitive con- Psychologic Strain
clusions or solutions when creating and using Psychologic strain is measured with four scales of
programs for workers suffering from WRMSDs. the personal strain questionnaire that include
Sauter and Swanson39 suggested ways to improve vocational strain (the amount of difficulty the
research by (1) developing longitudinal studies, worker is having in work quality or output);
(2) improving the tools used to assess health and psychologic strain (the effect of any emotional
psychosocial factors, (3) improving analytic meth- problems); interpersonal strain (the amount of
ods to separate the effects of the psychosocial disruption in interpersonal relationships); and
factors, and (4) examining the suggested path- physical strain (physical illness or poor self-care
ways and explaining the relationships. Siegrist habits).
suggests analyzing combined models of stress and
its effect on work and moving beyond a single Coping Resources
assessment of occupational exposure to study its Coping resources are measured with four scales
dynamics over time.42 of the personal resources questionnaire that
include recreation (pleasure and relaxation derived
from regular recreational activities); self-care (the
ASSESSMENT: THE OCCUPATIONAL frequency with which the worker engages in per-
STRESS INVENTORY sonal activities that reduce or alleviate chronic
The occupational stress inventory (OSI) was de- stress); social support (the extent to which the
signed to measure occupational stressors and to individual feels support and help from those
provide measures for the theoretical model linking around him or her); and rational and cognitive
work-related stress with the psychological strains coping (how frequently the individual uses cogni-
experienced by the worker.37 It also aims at iden- tive skills to deal with work-related stress).
tifying coping resources available to the worker to These three categories indicate the dynamics
deal with the stressors and the psychologic strain. among work-related stressors, strain experiences,
The OSI measures three dimensions in occupa- and coping resources.
tional adjustment: occupational stress, psycho-
logic strain, and coping resources.
Occupational Stress Psychosocial factors alone cannot account for dis-
Occupational stress is measured with six scales of ability. Excluding them in the evaluation and pre-
the occupational roles questionnaire that include vention processes, however, may inhibit successful
132 PART II Knowledge, Tools, and Techniques

intervention. The nature of the psychosocial risk behavioral, and affective responses. The tech-
factors and their distribution among workers may niques used include relaxation (including using
suggest the direction and level of intervention biofeedback), activity pacing, cognitive restructur-
(i.e., individual or organizational). Three levels of ing, and imagery and distraction to deal with
intervention are used to improve the work envi- pain.25 These techniques require a clinical psy-
ronment: prevention that aims at reduction in chologist who is able to assess and treat within
work constraints; prevention that aims to increase the framework of cognitive-behavioral therapy.
individuals’ ability to cope with stress and change; Lavoie-Tremblay and colleagues27 implemented
and individual rehabilitation of employees who a different concept of intervention to improve the
have already shown consequences of occupation- psychosocial work environment of health care
al stress.27 It has been suggested that interven- workers. Based on combined models of Karasek
ing at the first level of prevention is the most and Siegrist (mentioned previously), they used a
efficient.6 five-step program in which the organization and
Himmelstein and colleagues suggested that employees were active participants. The first
early intervention to prevent work disability might step was getting the organization to commit. The
benefit from focusing on reducing employer- second step was identifying job constraints by
employee conflicts, improving medical manage- using evaluation forms used in the two models
ment of pain, and enhancing the ability to cope and grouping them into known psychosocial
with residual pain and distress and avoiding factors (the most frequent identified factors were
unnecessary surgery.13 Lindstrom describes a workload and social support). Step 3 involved
research-based model for creating a good work developing action plans to improve work environ-
organization based on psychosocial intervention.30 ment in the areas that were identified as stressful.
The need to optimize quantitative workload and Step 4 involved implementation of the action
qualitative workload is emphasized, and the level plans. Step 5 involved evaluation of the action
of autonomy and freedom at work is maximized plans’ success and follow-up. The process was not
because they are thought to decrease stress and an easy one, and the readers are referred to this
hence musculoskeletal symptoms. Improving paper for more elaboration.27 However, the impor-
interpersonal relationships among workers and tance of this study lies first in its theoretic frame-
improving communication between employees work (basing the assessment and implementation
and supervisors is encouraged. Coping skills are on known models) and second in the process
improved either through mental exercises or itself—mainly the involvement of the employees
increased mastery of work. The organization of and management in the program and including a
the entire workplace is evaluated and altered by follow-up to assess long-term effect.
occupational health professionals. Workers at risk Changing the psychosocial environment in the
are provided with support and skills to deal with workplace is essential but may be difficult.27 Think
the work demands through group workshops, about the newspaper Sara is working for; the
new skills-development workshops, and individ- company would like both to serve the people who
ual support from occupational psychologists. want to place obituaries and to make a profit.
Other intervention programs use cognitive- How do we create an environment that fits both
behavioral methods, such as relaxation and cogni- the employer and the employee? How would you
tive restructuring, to provide the worker with approach the psychosocial factors presented by
coping skills.8,43 Cognitive strategies include focus- Sara to help her return to work?
ing on the source of the stress and paying close
attention to its interpretation, examining the attri-
bution style after symptoms and stress occur, and CONCLUSION
adopting alternative methods for addressing prob- The role of psychosocial factors in WRMSDs has
lems. Cognitive-behavioral strategies also help received increased attention from researchers and
improve pain management by altering cognitive, clinicians. However, the field needs standardized
Chapter 8 Psychosocial Factors in Work-Related Musculoskeletal Disorders 133

instruments to measure psychosocial factors to 2. The psychosocial factor most consistent

further cross-study comparisons. In addition, with WRMSD is:
clinical tools should be developed to assess A. social support.
work-related psychosocial factors and treatment B. job satisfaction and job control.
outcomes. C. social support, workload, and job
D. monotony at work.

Learning Exercise 3. What is the most common explanation for

the relationship between psychosocial
factors and WRMSDs?
This exercise is designed to help you learn to A. Physical demands increase the
incorporate psychosocial factors into routine
biomechanical stress on muscles,
ergonomic evaluation and intervention.
leading to WRMSDs.
Purpose B. Cognitive processes cause
The purposes of this exercise are to identify risk
musculoskeletal symptoms to be
factors that might affect workers in your work- magnified.
place and to suggest ways to reduce factors you C. Psychosocial factors increase mental
find to be harmful to various employees. stress, which in turn increases muscle
tension that exacerbates existing
Exercise biomechanical strain on the
Choose various departments to which you have musculoskeletal system.
access. Interview employers and employees from D. Work organization affects social
various departments in order to assess the exis- support.
tence of psychosocial risk factors that they view
as significant to them. Prioritize which risk factors 4. Why is it difficult to find a causal
might be the most influential on the workers’ relationship between psychosocial factors
health. Think about possible solutions that may and WRMSDs?
be applicable (and acceptable) in this place. Do A. Most studies use a cross-sectional
a follow-up visit to reassess both the risk factors design, making it difficult to determine
and how the employees view the risk factors and causality.
solutions. B. Changes in physical and
biomechanical demands frequently
occur together with changes in
psychosocial demands, making it
difficult to determine causality.
C. Both A and B
Multiple Choice Review Questions D. Not enough research exists to
determine causality.
1. The difference between the NIOSH and
the ILO definitions of work-related factors For questions 5 to 10, look at the case
is that: study. Would the following approaches
A. ILO includes the physical and help Sara get back to work?
ergonomics environment.
B. NIOSH includes extra-work factors and 5. To get Sara back to work, her employer
ILO does not. should provide her with incentives such
C. NIOSH includes organizational factors as bonuses, etc.
and ILO does not. A. True
D. Both A and B B. False
134 PART II Knowledge, Tools, and Techniques

6. Her employer should assess with Sara the 5. Bigos SJ, Battie MC, Spengler DM et al: A prospec-
areas that she feels hinder her productive tive study of work perceptions and psychosocial
factors affecting the report of back injury, Spine
work and set priorities and an action
16:1, 1991.
plan. 6. Bond F, Bunce D: Job control mediates change in a
A. True work reorganization intervention for stress reduc-
B. False tion, J Occup Health Psychol 6:290, 2001.
7. Bongers PM, Winter CR, Kompier MA et al:
7. Her employer should advise Sara to take Psychosocial factors at work and musculoskeletal
a relaxation technique course so she can disease, Scand J Work Environ Health 19:297,
practice during and after work. 1993.
8. Feuerstein M: Workstyle: definition, empirical
A. True
support, and implications for prevention, evalua-
B. False tion, and rehabilitation of occupational upper-
extremity disorders. In SD Moon, SL Sauter, editors:
8. Her employer should provide the Beyond biomechanics: psychosocial aspects of mus-
employees in Sara’s department culoskeletal disorders in office work, Bristol, Penn,
opportunities to socialize, such as special 1996, Taylor & Francis.
days out, lunchtime, etc. 9. Feuerstein M, Sult SC, Houle M: Environmental
A. True stressors and low back pain: life events, family, and
work environment, Pain 22:295, 1985.
B. False
10. Hagberg M, Silverstein B, Wells R et al, editors:
Work related musculoskeletal disorders (WMSDs): a
9. Her employer should provide the
reference book for prevention, London, 1995, Taylor
employees with seminars aimed at stress & Francis.
management. 11. Hales TR, Sauter SL, Peterson MR et al: Musculo-
A. True skeletal disorders among video display terminal
B. False users in a telecommunications company, Ergonom-
ics 37:1603, 1994.
10. Sara’s condition stems from work 12. Head J, Kivimaki M, Martikainen P et al: Influence
overload only. of change in psychosocial work characteristics on
sickness absence: the Whitehall II study, J Epide-
A. True
miol Community Health 60:55, 2006.
B. False 13. Himmelstein JS, Feurstein M, Stanek EJ et al: Work-
related upper-extremity disorders and work disabil-
ity: clinical and psychosocial presentation, J Occup
REFERENCES Environ Med 37:1278, 1995.
1. Ahlberg-Hulten GK, Theorell T, Sigala F: Social 14. Hopkins A: Stress, the quality of work, and repeti-
support, job strain and musculoskeletal pain among tive strain injury in Australia, Work Stress 4:129,
female health care personnel, Scand J Work Environ 1990.
Health 21:435, 1995. 15. Houtman IL, Bongers PM, Smulders PG et al: Psy-
2. Bernard B, Sauter S, Fine L: Hazard evaluation and chosocial stressors at work and musculoskeletal
technical assistance report. NIOSH Report No. HHE problems, Scand J Work Environ Health 20:139,
90-013-2277, Cincinnati, 1993, U.S. Department of 1994.
Health and Human Services, Public Health Service, 16. Hughes RE, Silverstein BA, Evanoff BA: Risk factors
Centers for Disease Control and Prevention, National for work-related musculoskeletal disorders in an
Institute for Occupational Safety and Health. aluminum smelter, Am J Ind Med 32:66, 1997.
3. Bernard B, Sauter S, Fine L et al: Job task and psy- 17. Hurrell JJ, Murphy LR: Psychological job stress. In
chosocial risk factors for work-related musculoskel- Rom WN, editor: Environmental and occupational
etal disorders among newspaper employees, Scand medicine, ed 2, New York, 1992, Little, Brown.
J Work Environ Health 18(suppl 2):119-120, 1992. 18. International Labor Office (ILO): Psychosocial fac-
4. Bernard B, Sauter S, Fine L et al: Job task and psy- tors at work: recognition and control, Geneva, 1986
chosocial risk factors for work-related musculoskel- ILO.
etal disorders among newspaper employees, Scand 19. Jensen C, Ryholt CY, Burr H et al: Work-related
J Work Environ Health 20:417, 1994. psychosocial, physical and individual factors associ-
Chapter 8 Psychosocial Factors in Work-Related Musculoskeletal Disorders 135

ated with musculoskeletal symptoms in computer 35. NIOSH: Proposed national strategy for the preven-
users, Work Stress 16:107, 2002. tion of musculoskeletal injuries, Washington, DC,
20. Johansson JA: Psychosocial work factors, physical 1986, U.S. Department of Health and Human
workload and associated musculoskeletal symp- Services.
toms among home care workers, Scand J Psychol 36. National Institute for Occupational Safety and
36:113, 1995. Health (NIOSH): Musculoskeletal disorders and
21. Kaila-Kangas L, Kivimaki M, Riihimaki H et al: workplace factors, Washington, DC, 1997, U.S.
Psychosocial factors at work as predictors of Department of Health and Human Services, Public
hospitalization for back disorders, Spine 29:1823, Health Service, Centers for Disease Control and
2004. Prevention, NIOSH.
22. Karasek RA: Job demands, job decision latitude, 37. Osipow SH, Spokane AR: Manual for the occupa-
and mental strain: implications for job redesign, tional stress inventory, Odessa, Fla, 1987, Psycho-
Adm Sci Q 24:285, 1979. logical Assessment Resources.
23. Karasek RA, Gardell B, Lindell J: Work and non- 38. Ostergren P-O, Hanson BS, Balogh I et al: Incidence
work correlates of illness and behavior in male and of shoulder and neck pain in a working population:
female Swedish white collar workers, J Occup Behav effect modification between mechanical and psy-
8:187, 1987. chosocial exposures at work? Results from a one
24. Karasek RA, Theorell T: Healthy work, New York, year follow up of the Malemo shoulder and neck
1990, Basic Books. study cohort, J Epidemiol Community Health 59:721,
25. Keefe FJ, Egert JR: A cognitive-behavioral perspec- 2005.
tive on pain in cumulative trauma disorders. In SD 39. Sauter SL, Swanson NG: An ecological model of
Moon, SL Sauter, editors: Beyond biomechanics: musculoskeletal disorders in office work. In SD
psychosocial aspects of musculoskeletal disorders in Moon, SL Sauter, editors: Beyond biomechanics:
office work, Bristol, Penn, 1996, Taylor & Francis. psychosocial aspects of musculoskeletal disorders in
26. Kopek JA, Sayre EC: Work-related psychosocial fac- office work, Bristol, Penn, 1996, Taylor & Francis.
tors and chronic pain: a prospective cohort study in 40. Siegrist J: Adverse health effects of high-effort/
Canadian workers, J Occup Environ Med 46:1263, low-reward conditions, J Occup Psychol 1:27,
2004. 1996.
27. Lavoie-Tremblay M, Bourbonnais R, Viens C et al: 41. Siegrist J: Reducing social inequalities in health:
Improving the psychosocial work environment, J work-related strategies, Scand J Public Health 30:49,
Adv Nurs 49:655, 2005. 2002.
28. Lazarus RS: Psychological stress and adaptation and 42. Siegrist J: Psychosocial work environment and
illness, Int J Psychol Med 8:225, 1974. health: new evidence, J Epidemiol Community
29. Leino PI, Hanninen V: Psychosocial factors at work Health 59:888, 2004.
in relation to back and limb disorder, Scand J Work 43. Spence SH: Cognitive behavior therapy in the treat-
Environ Health 21:134, 1995. ment of chronic, occupational pain of the upper
30. Lindstrom K: Psychosocial criteria for good work limbs: a two-year follow-up, Behav Res Ther 29:503,
organization, Scand J Work Environ Health 20:123, 1991.
1994. 44. Svensson H, Anderson GBJ: Low-back pain in 40- to
31. Linton SJ: Risk factors for neck and back pain in a 47-year-old men: work history and work environ-
working population in Sweden, Work Stress 4:41, ment factors, Spine 8:272, 1983.
1990. 45. Theorell T: Possible mechanisms behind the rela-
32. Lund T, Labriola M, Christensen KB et al: Psycho- tionship between the demand-control-support
social work environment exposures as risk factors model and disorders of the locomotor system. In SD
for long-term sickness absence among Danish Moon, SL Sauter, editors: Beyond biomechanics:
employees: results from DWECS/DREAM, J Occup psychosocial aspects of musculoskeletal disorders in
Environmental Med 47:1141, 2005. office work, Bristol, Penn, 1996, Taylor & Francis.
33. Lundberg U, Kadefors R, Melin B et al: Stress, mus- 46. Theorell T, Harms-Ringdahl K, Ahlberg-Hulten G et
cular tension and musculoskeletal disorders, Int J al: Psychosocial job factors and symptoms from the
Behav Med 1:354, 1994. locomotor system: a multicausal analysis, Scand J
34. Nielsen ML, Rugulies R, Christensen KB et al: Rehabil Med 23:165, 1991.
Impact of the psychosocial work environment on 47. Tola S, Riihimaki H, Videman T et al: Neck and
registered absence from work: a two-year longitu- shoulder symptoms among men in machine operat-
dinal study using the IPAW cohort, Work Stress ing, dynamic physical work and sedentary work,
18:323, 2004. Scand J Work Environ Health 14:299, 1988.
136 PART II Knowledge, Tools, and Techniques

48. Toomingas A, Theorell T, Michelsen H et al: Asso- factors in neck-shoulder and low-back pain, Spine
ciation between self-rated psychosocial work condi- 16:1056, 1991.
tions and musculoskeletal symptoms and signs, 50. Waersted M, Bjorklund RA, Westgaard RH: Shoul-
Scand J Work Environ Health 23:130, 1997. der muscle tension induced by two VDU-based
49. Viikari-Juntura E, Vuori J, Silverstein BA et al: Life- tasks of different complexity, Ergonomics 34:137,
long prospective study on the role of psychosocial 1991.
Physical Environment

Sandi J. Spaulding

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Discuss issues in the physical environment that can have an impact on work performance.
2. Understand the components of the physical environment that are inherent in workplaces.
3. List methods to ameliorate problems in the physical environment.

Lighting. “Light is a wave, similar to a wave on the Vibration. Vibration is a motion that repeats over and
surface of the ocean. The quantity that characterizes over. Vibration can vary both in size (amplitude) and in
the color is the wavelength, or the distance between how often it repeats (frequency). A hand tremor in a
adjacent crests of the wave. For red light this distance person who has Parkinson’s disease occurs at a low
is about twice as great as for violet light . . . a light frequency of about 8 cycles per second, and the indi-
wave can travel through empty space, as it does vidual cycles can usually be seen by someone watching.
between the sun and the earth.”1 Light seems to have A vibration from equipment can occur at a much higher
a wave structure, and it appears to have discrete com- frequency and, although the overall movement can
ponents because of the manner in which it stimulates sometimes be seen, it is often occurring so quickly that
visual receptors.3 is impossible to see individual movements up and
Sound. Sound consists of waveforms, either simple or down.
complex, that are heard by a person or are recorded
with a microphone that picks the sound waves out of
the air.

138 PART II Knowledge, Tools, and Techniques

CASE STUDY spring and late fall. So the outside physical environment
varies greatly for him and depends on the season of the
Mark du Toit owns a large landscaping business. He
year. The inside of the larger pieces of equipment that he
works outside using equipment such as forklifts (Figure
drives is the second environment. Most of his equipment,
9-1, A), jackhammers, bulldozers, excavators (Figure 9-1,
other than the jackhammer, is equipment in which he sits
B) and large trucks. His work consists of removing con-
and operates controls to move and work with heavy mate-
crete; digging foundations for large landscaping projects;
rials. The inside of such equipment often can be noisy, can
delivering large loads of gravel, plants, and trees; and
vibrate, and can move around erratically while a person
doing other types of outdoor work that is contracted to
is working. Mr. du Toit is very aware of safety consider-
him by homeowners and businesses. To do this work he
ations, incorporates many safety features into his equip-
must use all the equipment he has, as well as employing
ment, and provides protection against noise by ensuring
people in the summer to help him. He works outside
that there is ear protection equipment in each piece of
approximately 8 to 10 hours a day during the spring,
machinery (Figure 9-2).
summer, and fall. He lives in a climate in which outside
Presently, Mr. du Toit does not have any health con-
work is not possible during the winter months, so that
cerns, but many aspects of his physical environment might
is usually when he takes his vacation and repairs his
lend themselves to someone in his position having diffi-
culties in the future. Some solutions, such as buying
He has other people working with him and will hire
appropriate equipment, can make the job less physically
occasional workers if he finds that his work is more than
demanding for the workers. This chapter addresses some
he and his assistants can handle. However, both he and
of the components of the physical environment that can
his assistants work very long hours when there is work,
present long-term difficulties for workers and that can be
which is for about 10 months of the year. Additional help
controlled through the use of ergonomics.
does not preclude him or his permanent employees from
using the equipment all day; it simply permits him to meet
his deadlines by having more of his equipment in use at
one time.
Mr. du Toit has two physical environments. The first
T he physical environment is the context in
which an individual works. The person may
work outside, as is the case for Mr. du Toit, where
environment is the outside environment. In this environ- natural environmental characteristics affect per-
ment, he is coping with high light conditions and high formance. A worker might be in an indoor envi-
heat, in the 30º C (86º F) range on sunny days, or he could ronment, in which other issues come into play.
be working in relatively cool conditions, such as between For example, equipment that is used or how much
5º and 10º C (41º to 50º F) with rain or frost in the early and what type of artificial lighting is used to

FIGURE 9-1 A, A front-end loader forklift. B, An excavator.
Chapter 9 Physical Environment 139

FIGURE 9-2 A, Ear protection equipment and danger notices. B, Forklift with cushioned seat and fire

replace ambient lighting may be problematic. A scribe many environmental characteristics, includ-
third environment in which some workers find ing both light and sound. To understand any of
themselves is an enclosed machine, such as a these environmental features, it is helpful to
front-end loader, a truck, or a backhoe, each of understand some of the concepts of waveforms.
which has its own environmental issues. The therapist should refer to a book on signal
Some environmental issues can be the same processing, advanced mathematics, or engineer-
regardless of whether the worker is outside, inside, ing aspects of waves to gain a more extensive
or operating machinery. This chapter, rather than understanding of waves.
being divided into where work occurs, focuses on A motion that repeats itself is called a vibra-
environmental components including vibration, tion.25 Three waveforms are shown in Figure 9-3.
lighting, sound, and physical characteristics of The waveforms in Figure 9-3, A and B, are
work and the environment such as friction and periodic waveforms that will continue oscilla-
load-carriage. Attributes of each environmental ting, with the waveform looking the same. These
feature are discussed, with the differences among figures were created from mathematic formulas.
environments noted. The waveform in Figure 9-3, C, is a random
waveform created with a random number–
generation program. Its behavior cannot be
VIBRATION determined.
Vibration can be present in an environment Several definitions are used in the understand-
either because of equipment that a person is han- ing of waves and vibrations:
dling, such as a chainsaw, or because it is trans- • Cycle: The movement of a body from an
lated to the person in a “whole body” sense (i.e., undisturbed position, to a maximum posi-
vibration that affects the whole body). Whole- tion in one direction, through equilibrium,
body vibration (WBV) occurs often in enclosed- and to the other extreme or minimum posi-
machine environments, such as in the type of tion. A pendulum demonstrates a cycle. If a
equipment that Mr. du Toit uses, unless vibration- ball on a string is hanging straight down then
reducing design features, such as keeping the is pulled to one side and let go, it will go
seat as separate from the cab as possible, are from that position, down through the resting
incorporated. position and up to a maximum level on the
Concepts of wave patterns are used to describe other side. It will continue to do this until it
vibrations. Wave characteristics are used to de- is slowed by the pull of gravity and possible
140 PART II Knowledge, Tools, and Techniques

A Simple Periodic Waveform


Amplitude (unitless)

0 0.5 1 1.5 2


Time (seconds)
A Simple Periodic Waveform
Amplitude (unitless)

Time (each tick mark represents a second)
Random Waveform
Values between 1 and ⫺1 (unitless)


0 1 2 3 4 5 6 7 8 9 10


Time (seconds)
Chapter 9 Physical Environment 141

wind resistance. Figure 9-3, A, shows two anticipate the vibration of a machine, despite
complete cycles of a waveform. the fact the vibration can be detrimental to
• Amplitude: The maximum displacement of him. Contrarily, it is difficult for him to antic-
the object (in Figure 9-3, A, this amplitude ipate random situations, such as driving into
is 1, whereas in Figure 9-3, B, it is 4). a pothole in the road in the spring in a cold
• Frequency: The number of times that an climate, especially if that pothole is not easily
object completes one cycle in a given amount visible to the driver of the machine.
of time. The frequency of the wave in Figure Vibrations are often present in machines, usu-
9-3, A, would be 1 cycle per second if the x ally as cyclic physical phenomena. Workers such
or horizontal axis were in seconds, with one as Mr. du Toit who come in contact with these
second occurring when the wave crosses vibrating machines will also vibrate. These exter-
zero the second time (or 1 Hertz [Hz]). The nally induced vibrations can cause negative reper-
frequency of the wave in Figure 9-3, B would cussions for the worker.21
be 10 cycles per second, or 10 Hz. The fre-
quency of sound vibrations that a healthy, Measurement of Vibrations
young adult can hear can range up to approx- Vibration can be measured using biomechani-
imately 20,000 Hz. cal equipment. For example, an accelerometer (a
• Resonant frequency: If the frequency of an piece of equipment that measures acceleration),
object, including tissues in a person, has a when used with data collection and analysis hard-
natural frequency, and this frequency is the ware and software, can determine the amplitude
same as an external excitation, then the and frequency of vibrations (Figure 9-4). Sources
object or tissues in a person are said to reso- for more information about measuring vibration
nate, which means that there will be exces- and obtaining equipment to measure vibration are
sive amplitudes present in the object. Harm listed in Box 9-1.
can occur in a person who is constantly It is not always easy to reduce vibration. Engi-
subjected to external physical vibrations in neers often try to understand the causes of vibra-
a work environment. tion, then design equipment with reduced vibratory
• Random vibrations: The value of a signal at amplitude. Solutions for the worker may be diffi-
any time cannot be predicted (see Figure 9-3, cult to manage; however, it is important, when
C).25 It is more difficult for people to prepare possible, to have the individual exposed to as few
for a random event than it is for them to vibratory incidents as possible. Vibrating environ-
stabilize themselves for a predictable, peri- ments such as a moving vehicle, and particularly,
odic vibration. For example, Mr. du Toit can heavy machinery, can cause degenerative changes

FIGURE 9-3 A, A simple periodic waveform that repeats over and over. This type of waveform can represent
the vibration of a piece of equipment, such as a jackhammer. B, A simple periodic waveform that has a higher
frequency because it goes up and down more often in the same length of time as the wave shown in A. It
also has a larger amplitude, so if it were being used to describe a similar piece of equipment as that shown
in A, the equipment would be moving up and down more and would be moving more quickly. Mr. du Toit
will experience vibration during his work, through his body when he is in the machines and up through his
arms when he is using handheld equipment. The amplitude of the vibration will be manifested in how much
the equipment moves up and down. The frequency will be shown by how often the equipment moves through
the cycle. C, With a random waveform the characteristics of the wave are not simple and cannot be described.
If a person were driving a car on a dirt road and hit holes in the road randomly, a random waveform could
describe the movement of the car and the people bouncing around in it. For Mr. du Toit, this type of vibra-
tion may affect him when he is going from job to job or when he is collecting gravel from a site in which
the roads are not well maintained.
142 PART II Knowledge, Tools, and Techniques

BOX 9-1 Sources for Purchasing Vibration

Monitoring Equipment

Canadian Centre for Occupational Health and

National Instruments—
A NexGen Ergonomics—
Response Dynamics—
Reliability Direct—

Standard Organization (ISO) standards during

operation. However, researchers are beginning to
understand the anthropometric characteristics
that affect WBV30 and design seating to reduce
B WBV,19 and it is hoped that this knowledge, as it
is acquired, will decrease the vibration to which
FIGURE 9-4 An accelerometer can determine the individuals are exposed.
amplitude and frequency of vibrations. A and B,
Series 3 accelerometers. (Courtesy NexGen Ergonomics,
Inc., Pointe Claire, Quebec.) SOUND
Sound is also a combination of either simple or
complex waveforms. Sounds are all around us,
to the body.7 Exposure to WBV may cause a but when sound is interfering, either because it is
variety of health difficulties.24,26 WBV exposure unwanted and disrupts concentration or because
varies with type of terrain and with type of load it is too loud (which would be considered noise),
in a vehicle, with the highest magnitudes demon- it can interfere with a worker’s functioning.
strated during traveling, suggesting that exposure Factors that affect noise risk include noise level,
assessments should include several measure- duration of exposure, frequency of the sound,
ments, taking into consideration the terrain type individual susceptibility, vulnerability resulting
and adjusting the method of driving a vehicle from environmental factors, and vulnerability
when it is loaded.26 Biomechanical models used resulting from biologic factors.20
to simulate the responses of the body12,13 help in Sound is the result of wave activity in the air
simulating and designing vibration isolators, that reaches a person’s ear. Figure 9-3 not only
which can separate the driver from the effect of applies to vibration but can be used to describe
vibrations. Vibrations measured at levels of the sound as well. Noise, which could be considered
vertebrae in heavy haul truck operators15 and to be a random waveform (Figure 9-3, C) is a
framesaw operators9 can exceed International subset of sound that is either annoying to the
Chapter 9 Physical Environment 143

Box 9-2 Sources for Purchasing Sound


Professional Equipment—
Test Equipment Depot—

either too high or too low.4 Not only can it impede

performance, it can also eventually damage the
worker’s vision.

Lighting in an indoor environment includes both
ambient light from the outside (usually visible
through windows) and artificial light. The quality
and quantity of light can vary in work environ-
ments, and it can vary over time of day or time
FIGURE 9-5 A sound level meter, used by ergonomists
of year.
to measure noise. (Courtesy Extech Instruments,
Waltham, Mass.)
Light can be measured by examining the light
person and may interfere with performance of reflected off a surface. This type of measurement
tasks or is so loud that it is injurious to a person’s is used by photographers who use light meters
hearing. that are within a camera. The second method of
A person can be negatively influenced by sound measuring light is to examine the light hitting an
in a variety of ways. Sound then can be consid- object, rather than reflecting off it. Measuring the
ered noise. For example, researchers have found light directed toward a person or an object gives
that reaction time on a visual display terminal task a better estimate of the light source; however, in
can be prolonged. The authors suggested that work situations reflected light can be a major
even low-intensity background noise can be asso- issue. For example, if the worker is working in an
ciated with impaired performance in spatial at- indoor environment on an assembly line that
tention and can cause an increase in energy conveys shiny metal objects, the worker is affected
consumption.29 Workers report that concentration by the ambient light (light in the environment) as
was impaired by office noise.2 Box 9-2 lists some well as the light reflecting off the equipment, thus
sources for purchasing sound meters (Figure increasing the amount of light reaching the eyes
9-5). of the worker. Some of that light might be detri-
mental, in that it can cause glare. Conversely a
person can be working in an environment in
LIGHTING which the walls are painted a dark color, which
Lighting can facilitate a worker’s sight if it is at absorbs light rather than reflects it, creating a light
the right level but can impede function if it is environment very different from one that includes
144 PART II Knowledge, Tools, and Techniques

Box 9-3 Sources for Purchasing Light


D.A.S. Distribution—
International Light Technologies—

distinguish the letters only to a certain level of

sensitivity. There can be very high contrast in the
environment. For example, many workshop floors
or stairs have stripes on the edges to either denote
the boundaries within which the worker can work
or to denote a change in surface characteristics.
These stripes are usually a very different color
from the background. If one were to look at them
FIGURE 9-6: A light measurement device. (Courtesy
in terms of contrast only, there would be high
International Light Technologies, Peabody, Mass.)
contrast so that most people should be able to see
them whether or not they have normal color
reflected light (Figure 9-6). Sources for measure- Studies have been conducted to explore the
ment devices are included in Box 9-3. effect of lighting and medium on a person’s func-
Visual difficulties have been reported not only tion.28 The results of these authors’ work suggests
by individuals with poor vision but also by older that using either the display medium of a screen
individuals without visual impairment, suggesting or paper does not change memory performance or
that environments might be designed to take electroencephalographic response; however, the
changes in vision throughout the life cycle into individuals preferred paper to screen. Individuals
account.23 also demonstrated better performance under lower
contrast ratios. This work suggests that luminance
Luminance contrast can affect performance. New lighting in
Researchers suggest that low luminance levels a workplace may influence the workers’ perfor-
around a computer display should be avoided but mance, from visual performance to problem solv-
that individuals are more comfortable with levels ing. To estimate the influence of lighting change,
at or a little below that of the central task.27 it may be appropriate to separate the mechanisms
affected by the changes.11
Contrast Sensitivity Mr. du Toit must contend with many different
Contrast sensitivity is the ability to see differences lighting situations. If it is bright outside and he is
between different tonalities of surfaces. Contrast manipulating levers within one of his pieces of
sensitivity can be measured using a Pelli-Robson equipment, he may have difficulty distinguishing
chart, in which letters show increasing similarity the levers because of glare. He might be wise to
to the background and a person will be able to use protective eyewear and give consideration to
Chapter 9 Physical Environment 145

how much ultraviolet light is entering his equip- Temperature

ment through the windows. Temperature surrounds the worker. If the tem-
perature of the environment is out of the safe
range for the person and the task that he or she
is performing, the body will be under stress. Mr.
Structural features of the environment are du Toit must be cognizant of the environment in
extremely important and can be designed to which he is working, to be sure that it is comfort-
lighten the workload and improve performance. able for him. Temperatures can be too high or too
If the structure of the environment is not con- low. Controlling temperature can be difficult if a
sidered, the opposite may occur—the worker person is changing his or her activity level and
may have difficulty, and performance may be thus changing how much internal heat is pro-
degraded. duced. It can also be influenced by movement of
machinery that in itself can generate heat.
Ground Characteristics
Ground characteristics such as soil or ground con- CHEMICALS AND TOXINS
ditions and other working surfaces may influence
Some workers may be in situations in which they
the safety of a worker.14,18 The interrelationship
have to handle chemicals or come into contact
between a worker’s footwear and the ground is
with them in their work. Workers may need spe-
dependent on friction. Friction, both static and
cialized knowledge to handle chemicals in small
dynamic, was discussed in Chapter 6. The reader
quantities. If a person is in physical contact with
is referred to that chapter for details about the
small doses of acetylsalicylic acid (the active
concepts. Friction could be an issue for Mr. du
ingredient in aspirin), there may be no specialized
Toit in terms of the footwear he uses when han-
knowledge for handling the chemical. However,
dling equipment outside. He might also consider
chemicals can be extremely toxic and capable of
whether gloves would be appropriate to use when
causing injury.16 Toxic chemicals can enter the
holding equipment, using levers in the larger
environment in many ways, including the air,
pieces of equipment, or turning the steering wheel
water, soil, or food, and may enter the body by
of his truck.
inhalation, ingestion, or skin absorption, be
The issue for the worker is that the friction
absorbed into the bloodstream, and undergo
between the ground and the foot be adequate so
metabolism or be delivered to organs.16 Chemi-
that slipping is improbable. However, antislip de-
cals, depending on their composition, can cause
vices on the bottoms of shoes8 and tread grooves
injury because they are toxic when inhaled, cause
on shoes17 may provide a good foothold, safety,
burns if the person comes in contact with them,
and improved balance when a worker walks on
can be highly flammable (burn easily), or have a
slippery surfaces. It has been suggested that focus-
flash point such that they can burn spontaneously
ing on work surfaces may reduce the trips and
under certain conditions. The effects on an indi-
slips on the worksite.18
vidual after toxic chemical exposure can be pro-
gressive, permanent, or reversible.16 The reader is
Equipment Related to Posture referred to Levy and colleagues16 for a detailed
(Sitting or Standing) analysis of chemical toxins, their effects, and
Workstation height and orientation, when adjusted methods of dealing with them.
optimally for the worker, can help both wrist and There are specific requirements for handling
upper extremity posture.22 Workplace layout, spe- chemicals safely. The worker must be trained in
cifically the path of moving objects to be lifted6 reading and understanding warning labels on con-
and the distances they should be lifted,10 affect tainers or in rooms that hold chemicals. People
kinematics and loads of workers’ spines. must be protected from toxic chemicals. This pro-
146 PART II Knowledge, Tools, and Techniques

ering the presence and potential impact of latex

BOX 9-4 Sources of Information about materials within a worker’s environment.
Toxic Chemical Issues

Agency for Toxic Substances and Disease AIR QUALITY

Air quality is a global environmental concern. Air
quality can be more specifically an issue for
National Institute for Occupational Safety and
workers in particular environments. For example,
individuals who were active in coal mining before
U.S. Environmental Protection Agency— there was an understanding of the effect of coal dust inhaled into a worker’s lungs could have
developed a lung disease that may have been
fatal. A less devastating example of the effects of
poor air quality is exemplified in a poorly venti-
lated university classroom in which students may
tection can range from simple precautions, such feel drowsy but recover quickly after leaving the
as wearing protective gloves, to handling chemi- room.
cals only when totally isolated from them, either Air pollution can be present either in the
through use of protective clothing including a ambient environment or in an indoor environ-
breathing apparatus that brings air from outside a ment. Ambient air pollutants are thought to be
potentially toxic air situation or through working derived mainly from fuel combustion and include
in a highly controlled environment. See the re- many different pollutants. Progress to control air
sources listed in Box 9-4 for further understanding pollution must be made at a societal level. For
of toxic chemical issues. example, the United States’ Clean Air Act of 1970
mandated that the government develop air-quality
standards.16 Adverse health effects of exposure to
ALLERGIES such pollutants can include excess cardiorespira-
Some workers have allergies to aspects of their tory mortality, asthma, increased respiratory dif-
working environment. Glove use has increased in ficulties, decreased lung function, and reduced
the health care professions to protect the profes- immune function.16 It appears, then, that it would
sionals from diseases such as acquired immuno- be appropriate to keep workers away from ambient
deficiency syndrome (AIDS). One of the allergies air pollution wherever possible.
that has become a problem for many individuals, It is possible that indoor air quality can be
often related to glove use, is an allergy to latex.5 better controlled by the employer and/or building
Latex-related symptoms include a localized contact designer. Many people work indoors and may be
urticaria (a localized flare reaction after contact engaged in many types of jobs, from highly physi-
between a substance and the skin or mucous cally active work on a shop floor to sedentary
membranes) to asthma and anaphylaxis.5 Indi- work, such as a job performed while sitting at a
viduals can be advised to avoid natural rubber desk.
latex and to recognize and manage allergic reac-
tion. Local symptoms can be dealt with using
anitihistamines, but systemic symptoms require WATER QUALITY
major intervention, including rescue medication Water quality, like air quality, is a global environ-
for anaphylaxis.5 Obviously, the potential for latex mental issue. Very little of the world’s water is
allergies should not be considered lightly. Further usable, but it must be available to people for their
reading in the comprehensive text edited by survival. The quality and availability of water can
Chowdhury and Maibach5 would be appropriate both be issues that must be specifically addressed
for employers and employees who may be consid- for some workers.
Chapter 9 Physical Environment 147

Learning Exercises
Overview 2. Consider Mr. du Toit and his occupations.
The learning exercise is designed to make the What aspects of his work environment might
student aware of various aspects of a work envi- you want to consider evaluating?
ronment that may affect the worker. 3. Consider watching someone at a construction
site. While you are watching, think about the
Purpose various environmental characteristics that
The purpose of these exercises is to encourage the affect the worker. Consider how, if you were
student to become a good observer of various asked to evaluate the environment, you
environments. Once the student is able to observe might go about doing so. Can you see
the environment, when called on to evaluate an anything at the worksite that could be a
environment he or she will be able to focus on potential hazard for the worker, either in a
aspects of the environment that are important to brief period of time, or over a long work
the worker. time? Remember to think about the physical
environment, lighting, vibration, and all the
Exercises other concepts considered here. Are there
1. Consider your own work environment. Think other aspects of the environment that you
about each of the concepts discussed in this notice that have not been discussed in this
chapter and see if any of them affect the chapter but that may have an impact on the
tasks you do. For example, if you use a worker? Compare your observations with
computer, what is the ambient light level those of other people who are doing the
around you relative to the light emitted by same observations in a different setting. Are
the computer screen? If you are sitting at a there differences in the environments that
desk, are the heights of the chair and the will affect the worker? Compare protective
table correct? What sort of ground equipment that you saw in use, and also
characteristics do you encounter as you are surmise from your observations other types
going to classes? Do you ever find yourself in of protection, such as vibration-damping
situations in which friction is less than techniques that may be being used but that
desirable? would be difficult for you to see.

Multiple Choice Review Questions 2. If Mr. du Toit reports that he is

experiencing difficulty feeling objects with
1. The following issue will probably be a his index fingertip and has a feeling of
problem for someone trying to tingling, you might suspect that the
concentrate in a crowded room full of following is the most likely environmental
computer users: cause of his problem:
A. Vibration A. The truck he drives does not have
B. Noise enough heat during the colder days.
C. Friction B. The equipment he is using is going
D. Lighting over rough roads.
C. The jackhammer he is using is causing
a sinusoidal vibration.
D. The weight of the levers in his front-
end loader is excessive.
148 PART II Knowledge, Tools, and Techniques

3. If a student is setting up a workstation for 6. The floors of the pieces of machinery that
his or her computer and asks you to help Mr. du Toit is using are made of a type of
make the environment as comfortable as sheet metal that is easy to clean. The
possible, you will focus much of your issue that could arise because of the floor
attention on: type is:
A. the noise level that is created by the A. contrast sensitivity issues with his
student listening to music while vision.
working. B. low static friction between the floor
B. the vibration that is being caused by and his shoes.
the constant motion of the internal C. increased lighting in the cab of the
hard drive of the computer. equipment.
C. the lighting of the room in relation to D. vibration increase caused by the
the ambient outdoor lighting. flexibility of the floor.
D. the height of the chair and desk,
relative to the student. 7. Light can be measured:
A. at the source of the light, especially
4. Mr. du Toit wants to upgrade his out of doors.
heavy machinery, specifically his front- B. at the object absorbing the light
end loader, which is used to dig and because of black surfaces.
move dirt. He asks you for some of the C. at the object reflecting the light.
specific features that might be D. at the source with a meter to
ergonomically appropriate to improve determine contrast sensitivity.
his working environment. The one issue
you might focus most highly on could 8. The peak amplitude of a wave is:
be: A. the distance between the peaks of the
A. the damping of vibration from the waveform.
machine to the seat. B. the frequency of the waveform.
B. the noise in the cab of the machine. C. the distance between the top and the
C. the position of the handles in the bottom of the waveform.
equipment. D. the highest point on the waveform.
D. the temperature control of the cab.
9. The physical environment that is
5. Mr. du Toit finds that his eyes are most likely to have a physical
becoming fatigued on the job. You will impact on Mr. du Toit’s health over
need to evaluate the lighting situation. time is:
Your first approach might be to: A. the outside environment, because of
A. test Mr. du Toit’s eyes using a contrast the temperature fluctuations.
sensitivity chart. B. the inside of his equipment,
B. evaluate the glare coming from the because of the potential for
ground surrounding his worksite. vibration.
C. consider the time of year he is C. the indoor environment, because of
working. the desk work he has to do.
D. determine whether the lighting D. the environment related to the
conditions in his equipment are equipment that he has to use with his
adequate. hands.
Chapter 9 Physical Environment 149

10. One of the factors of noise risk is: 14. Koningsveld E, van der Grinten M, van der
A. duration of noise. Molen H et al: A system to test the ground surface
conditions of construction sites for safe and efficient
B. repeated sinusoidal properties of
work without physical strain, Appl Ergon 36:441,
noise. 2005.
C. vulnerability resulting from size of 15. Kumar S: Vibration in operating heavy haul trucks
machinery. in overburden mining, Appl Ergon 35(6):509,
D. random access to the noise. 2004.
16. Levy BS, Wegman DH, Baron SL et al, editors:
Occupational and environmental health: recog-
nizing and preventing disease and injury, ed 5,
REFERENCES Philadelphia, 2006, Lippincott Williams & Wilkins.
1. Atkins KR: Physics, ed 2, New York, 1970, John 17. Li KW, Chen CJ: The effect of shoe soling tread
Wiley & Sons. groove width on the coefficient of friction with dif-
2. Banbury SP, Berry DC: Office noise and employee ferent sole materials, floors, and contaminants,
concentration: identifying causes of disruption Appl Ergon 35:499, 2004.
and potential improvements, Ergonomics 48(1):25, 18. Lipscomb HJ, Glazner JE, Bondy J et al: Injuries
2005. from slips and trips in construction, Appl Ergon
3. Bennett AG, Rabbetts RB: Clinical visual optics, ed 37:267, 2006.
2, Boston, 1989, Butterworths. 19. Makhsous M, Hendrix R, Crowther Z et al: Reducing
4. Boyce PR: Human factors in lighting, New York, whole-body vibration and musculoskeletal injury
2003, Taylor & Francis. with a new car seat design, Ergon 48(9):1183,
5. Chowdhury MMU, Maibach HI: Latex intolerance: 2005.
basic science, epidemiology, clinical management, 20. Maltby M: Occupational audiometry: monitoring
Boca Raton, 2006, CRC Press. and protecting hearing at work, London, 2005,
6. Davis K, Marras W: Load spatial pathway and spine Butterworth-Heinemann.
loading: how does lift origin and destination influ- 21. Mansfield NJ: Human response to vibration, Wash-
ence low back response? Ergonomics 48(8):1031, ington DC, 2005, CRC Press.
2005. 22. McGorry RW, Dempsey PG, O’Brien NV: The effect
7. Fritz M, Fischer S, Brode P: Vibration induced of workstation and task variables on forces applied
low back disorders—comparison of the vibration during simulated meat cutting, Ergonomics 47:1640,
evaluation according to ISO 2631 with a force- 2004.
related evaluation, Appl Ergon 36(4):481, 2005. 23. McGregor LN, Chaparro A: Visual difficulties
8. Gard G, Berggard G: Assessment of anti-slip devices reported by low-vision and nonimpaired older adult
from healthy individuals in different ages walking drivers, Hum Factors 47:469, 2005.
on slippery surfaces, Appl Ergon 37:177, 2006. 24. McPhee B: Ergonomics in mining, Occup Med
9. Goglia V, Grbac I: Whole-body vibration transmit- (Lond) 54(5):297, 2004.
ted to the framesaw operator, Appl Ergon 36(1):43- 25. Rao SS: Mechanical vibrations, Upper Saddle River,
48, 2005. NJ, 2004, Pearson/Prentice Hall.
10. Jorgensen MJ, Handa A, Veluswamy P, Bhatt M: 26. Rehn B, Lundstrom R, Nilsson L et al: Variation in
The effect of pallet distance on torso kinematics and exposure to whole-body vibration for operators of
low back disorder risk, Ergonomics 48(8):949, forwarder vehicles—aspects on measurement strat-
2005. egies and prevention, Int J Ind Ergon 35(9):831,
11. Juslen H, Tenner A: Mechanisms involved in 2005.
enhancing human performance by changing the 27. Sheedy JE, Smith R, Hayes J: Visual effects of the
lighting in the industrial workplace, Int J Ind Ergon luminance surrounding a computer display, Ergo-
35(9):843, 2005. nomics 48:1114, 2005.
12. Kim IJ, Smith R, Nagata H: Microscopic observa- 28. Shieh KK, Chen MH, Wang YW: Effects of display
tions of the progressive wear on shoe surfaces that medium and luminance contrast on memory perfor-
affect the slip resistance characteristics, Int J Ind mance and EEG response, Int J Ind Ergon 35(9):797,
Ergon 28(1):17, 2001. 2005.
13. Kim TH, Kim YT, Yoon YS: Development of a bio- 29. Trimmel M, Poelzl G: Impact of background noise
mechanical model of the human body in a sitting on reaction time and brain DC potential changes of
posture with vibration transmissibility in the verti- VDT-based spatial attention, Ergonomics 49(2):202,
cal direction, Int J Ind Ergon 35(9):817, 2005. 2006.
150 PART II Knowledge, Tools, and Techniques

30. Wang W, Rakheja S, Boileau PE: The role of Putz-Anderson V, editor: Cumulative trauma disor-
seat geometry and posture on the mechanical ders—a manual for musculoskeletal diseases of the
energy absorption characteristics of seated occu- upper limb, Bristol, Penn, 1988, Taylor & Francis.
pants under vertical vibration, Int J Ind Ergon Stanton NA, Salmon P, Walker G et al: Human factors
36(2):171, 2006. methods: a practical guide for engineering and
design, Hampshire, England, 2005, Ashgate.
Tochihara Y, Ohnaka T: The ergonomics of human
SUGGESTED READING comfort: health and performance in the thermal envi-
ronment, London, 2005, Churchill Livingstone.
Kroemer K, Kroemer H, Kroemer E: Ergonomics—how
to design for ease and efficiency, Englewood Cliffs,
NJ, 1984, Prentice-Hall.
Human Factors in Medical
Rehabilitation Equipment:
Product Development and
Usability Testing
Valerie J. Berg Rice

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Understand the definition, principles, and use of usability testing for rehabilitation product design.
2. Describe the role of therapists in assisting in usability testing of rehabilitation equipment and products.
3. List basic principles of usability testing and how they contribute to product design.
4. Understand each of the three phases and each of the nine steps suggested for conducting usability evaluations
of products.

User-centered design. The process by which a pro- Efficacy testing. A more formal process of perfor-
duct is designed so that the user is given the most mance testing in a controlled setting to determine the
important influence. effectiveness of the product.
Prototype testing. The evaluation of a newly devel- Magnitude estimation. An experimental technique
oped trial product by the end-users who represent the used in psychophysical experiments that involves
target market. having a subject compare his or her current sensation
with a reference sensation.

152 PART II Knowledge, Tools, and Techniques

The New Equipment Company calls you and asks you to
help them as they develop a new walker. They have other
walkers in their line of products, but they think they can
create a new series of walkers specifically designed for
various populations. Although they understand many of
the basic components of walkers and know about the
extra accoutrements that can be attached, they are less
certain about how to design walkers that might benefit
specific populations, such as those who have experienced
a stroke versus those who have cerebral palsy or are
elderly (Figure 10-1). They know the basic principle of
ergonomics—that is, that products should be designed to
fit the individuals who use them—but they don’t work
with those who might benefit from using a walker on a
daily basis. You do, as you work with clients with varying
degrees of physical disabilities. What will you, as a con-
sultant, do for this company? Where does your expertise
fit in with that of a usability expert (an ergonomist or
human factors engineer)? Can you consult with them and
do all the testing on your own, or do you need to form a
team? Do they have the necessary team members already
on their staff? Would they even know who would be
needed, or are they looking to you to supply that informa-
tion? You’ve received the call. They need help. Where and
FIGURE 10-1 Different designs of walkers may benefit
how do you begin . . . or do you get involved at all? one population more than another.

T his chapter examines the development of an

assistive walker to illustrate and describe the
process of usability testing during product devel-
effectiveness, ease-of-use, comfort, and accept-
ability for all three user groups. This process is
called usability testing (also known as evaluative
opment. Product development has three basic testing, development research, or operational
phases: initial development, efficacy and accep- testing) (Box 10-1). Introducing changes to a
tance testing, and comparison testing. These product line is easier during the initial develop-
phases can be conducted during pilot, laboratory, ment of the product, with small changes made
and field testing. Usability testing helps to ensure throughout the development process as required.
the final product does what it was designed to do, If necessary, however, usability testing can be
is acceptable to the people who use it, and can be implemented during any of the stages of product
used easily and safely. Each of the phases of development, and products can even be retrofit-
product development involves a nine-step testing ted.22 Usability testing provides valuable informa-
process. The objective of usability testing is to tion for equipment design, and knowledge of
match the product with human capabilities, limi- usability testing can help therapists make recom-
tations, and acceptance to produce an environ- mendations for equipment purchase by their
ment or product that is user-friendly. patients. Usability testing that helps provide an
Three groups use medical and rehabilitation appropriate equipment design or work process
equipment: health care personnel, clients, and can help prevent injuries, reduce human error
caregivers. Equipment should be evaluated for during product use, and increase product sales.
Chapter 10 Human Factors in Medical Rehabilitation Equipment 153

BOX 10-1 What Is Usability Testing? BOX 10-2 What Is User-Centered Design?

Usability measures the quality of a user’s experi- User-centered design (UCD) is the structured
ence when interacting with a product or system— process for product development that includes
whether a website, a software application, mobile users throughout each phase of the design
technology, or any user-operated device. process. In addition, a macroergonomic approach
In general, usability refers to how well users is often used that includes the overall business
can learn and use a product to achieve their goals mission, goals, and culture, as well as the
and how satisfied they are with that process. target audiences’ preferences, abilities, and re-
Usability may also consider such factors as cost- quirements.
effectiveness and usefulness.
Two international standards further define
usability and human-centered design:
• [Usability refers to] the extent to which a
product can be used by specified users to important influence on product design. This is
achieve specified goals with effectiveness, referred to as user-centered design (Box 10-2).
efficiency and satisfaction in a specified Usability testing is most well known when used
context of user (ISO 9241-11). to evaluate the interface between the user and a
• Human-centered design is characterized by machine or technology, such as in the computer
the active involvement of users and a clear industry. Examples include evaluating controls
understanding of user and task and displays on automobile consoles or in aircraft
requirements; an appropriate allocation of cockpits, designing user-friendly software, and
function between users and technology; the designing human-computer interfaces and web-
iteration of design solutions; multi- sites. However, usability testing also applies to
disciplinary design (ISO 13407). products that are not considered machines, such
as workstations.14 Both complex equipment (e.g.,
From the U.S. Department of Health and Human
anesthesia monitors and mammography machines)
and simple equipment (e.g., walkers and dynamic
splints) can benefit from experimental evaluation
that concentrates on users.
User testing may or may not be conducted by
OVERVIEW the equipment manufacturer. However, in an
Usability testing is the systematic evaluation of effort to reduce user errors and improve safety,
the “interaction between people and the products, the U.S. Food and Drug Administration (FDA)
equipment, environments, and services they use” initiated requirements in 1997 that manufacturers
and “is the fundamental principle that underpins of Class II and III medical devices (and certain
all ergonomics.”20 Usability testing also has been Class I devices) adhere to design practices that
called user-acceptance testing, user trials, and include addressing the needs of the users. This
usability engineering and is usually conducted by includes all users—practitioners, clients, clients’
human factors engineers or ergonomists. caregivers, and even corporate users—if the device
Some products are developed by designers or might be used by workers in a work setting. Some
engineers who assume their products are func- of the concerns include human-machine interface
tional, easy to use, and acceptable. This assump- design, understandability of labeling and instruc-
tion is often based on the designer’s own know- tions, effective operation of the device, and proper
ledge or on the fact that the designer (and his or storage, maintenance, and calibration. Obviously,
her colleagues) can easily use the product. Usabil- this can be accomplished only through human
ity testing makes no such assumptions; it makes factors evaluations and targeted user testing. The
the user (within the target audience) the most Association of Medical Instrumentation (AAMI)
154 PART II Knowledge, Tools, and Techniques

Human Factors Engineering Guidelines and Pre- especially for special populations such as those
ferred Practices for the Design of Medical Devices with lifelong disabilities.17 Usability evaluations
addresses human factors evaluations, including involving the intended users are crucial in the
appropriate steps to user-friendly, error-resistant design of medical and rehabilitation equipment to
design and scaling of human factors efforts to the ensure safety and efficacy.
match the device.* The FDA monitors manufac- Usability testing applies equally to the design
turers though field inspections, product reviews, of procedures, processes, and systems. A macro-
and postmarket surveillance.30 In fact, the distinc- ergonomic systems perspective addresses the
tion has been made between clinical trials and entire problem, rather than a small part (see
targeted usability testing when demonstrating Chapter 3). Standard operating procedures (SOPs)
user-effectiveness. During clinical trials, users for client treatment written for worst-case scenar-
follow strict protocols. However, during targeted ios must address issues of comprehension, linear
usability testing, all target user groups are included versus multitrack processes, availability of per-
and testing includes understanding of instruc- sonnel and equipment, levels of employee train-
tions, product use, the potential for product ing, levels of client education, and sometimes
misuse, and use under less-than-optimal condi- even clients’ cultural background. For example, if
tions.27 Although human factors engineers or a U.S. rehabilitation facility is located in a region
ergonomists may be the lead in such evaluations, with a significant Hispanic population, emergency
health care professionals can contribute substan- SOPs should be printed in both Spanish and
tially as team members during evaluation of English and employees should be able to com-
medical or rehabilitation equipment. municate and understand emergency messages
in Spanish. Procedures guiding medical decision
making can do much to prevent human error.
CONSIDERATIONS Considering errors as evidence of the failure of a
Users of health care equipment have different system rather than the failure of an individual is
skills, abilities, knowledge, and requirements4-6; a more effective alternative in reducing human
they range from physicians, technicians, and reha- error,12 including medically related human
bilitation specialists to clients and nonprofessional errors.6,19,25
providers, such as friends and family members. The context of device use is important,23 and
Caregivers caring for an older individual (such as ecologic validity (how closely the testing environ-
spouses) may have impairments themselves. The ment resembles the actual environment) is a sig-
physical and cognitive characteristics of each user nificant consideration during usability testing. For
group, along with any symptoms of disease pro- example, if users are expected to operate equip-
cesses, must be considered in the design of the ment in adverse conditions, such as providing
equipment they will use. For example, diabetic emergency medical care while on board an air-
retinopathy may impair the ability of a person craft, the design should take into account factors
with diabetes to read the small pen and credit card such as lighting, font size and shape on any instruc-
design displays on blood glucose meters.5 If the tions, and equipment layout. Precision guides
product is to be used internationally, usability might even be considered, in case of turbulence.
evaluations must be conducted in a variety of set- Inadequate staffing, shift work, double shifts, or
tings or conditions. In many cases, adequate infor- using contractors who are unfamiliar with particu-
mation about the target population is not available, lar devices or SOPs are relatively common and can
result in failure to follow proper instructions, inad-
*The AAMI guidance document entitled Human Factors vertent operation of controls, failure to recognize
Engineering Guidelines and Preferred Practices for the critical circumstances, poor decision making, or
Design of Medical Devices (HE48-1993) as well as
Human Factors Design Process for Medical Devices
lack of attention.16 Failsafe designs may have mul-
(ANSI/AMI HE74-2001) are available from AAMI at tiple safety features to help avoid improper use of or within the U.S. at 1-800-332-2264, equipment, such as preventing the improper
ext. 217. attachment of two pieces of equipment, which
Chapter 10 Human Factors in Medical Rehabilitation Equipment 155

could occur in emergency (i.e., hurried) situations. The first step in the usability testing process is
Human factors or ergonomic considerations in the to identify subject matter experts (SMEs) and the
design of equipment and processes should be pre- user population (Figure 10-2, step 1, p. 159). An
ventive. Demands of equipment setup and adjust- SME is any person who can be a valid judge of
ment, durability, maintainability, and interaction a design by virtue of his or her experience,
with other devices should be considered. education, or research of system operations, job
Iatrogenic injuries or illnesses are adverse performance, or task dimensions. SMEs and rep-
effects resulting from medical procedures or medi- resentatives from the user group meet to define
cations that are not a direct or indirect complica- the project and ask questions about the product
tion of a client’s injury or illness.24 Sometimes, (see Figure 10-2, step 2). During this meeting the
iatrogenic injuries are the result of errors facili- groundwork is laid for development of design
tated by inadequate labeling of a device or medi- objectives and task and function analysis (steps 3
cation, inherent defects in the design of the device, and 4). Therapists might serve in this capacity
or improper use of the equipment. Medical equip- rather than being part of the overall (ongoing)
ment associated with user problems and errors usability testing team. Certainly, therapists’ exper-
ranges from the relatively simple (syringes) to the tise on life skills and expectations throughout the
complex (computer-controlled diagnostic equip- life span, human development milestones, disease,
ment).13 Well-designed usability testing is impor- and future expectations of the disease process will
tant, as the design of the equipment and the assist with developing the test objectives and
instructions for using the equipment may influ- tasks. Techniques used during meetings with user
ence the occurrence of errors. Appropriate design groups can include focus groups and user work-
may assist in preventing human error. Design shops, informal discussions, interviews (struc-
interventions can assist with relatively simple tured or open-ended), questionnaires, brainstorm-
“devices” such as home pill dispensers just as well ing, checklists, and observations.18,28
as with complex devices such as anesthesia The next two steps, which can occur simultane-
machines or diagnostic equipment. The proper ously, are to identify design objectives more explic-
design of rehabilitation equipment can encourage itly and to conduct a task and function analysis (see
independence, boost self-esteem, and broaden Figure 10-2, steps 3 and 4). Design objectives focus
abilities in activities of daily living.3 Basic princi- on product features that affect performance, safety,
ples of usability testing are shown in Box 10-3. expense, acceptance, comfort, ease of use, and
aesthetics. Inclusion of these objectives in initial
product development helps confirm that the
PROCESS product is effective, safe, and accepted by user
If therapists decide to take on the task of consult- groups before expensive investments are made in
ing regarding the development of a new walker product creation and large-scale production.
(as in the case study mentioned at the beginning Changes are not as easy to implement and are more
of the chapter), they must first become familiar expensive when attempted after final creation,
with the equipment. This includes the current production, and dissemination. Design should be
design and any prior difficulties with this or closely related to task and function analysis pro-
similar products. Some of this information can be vided by investigators, users, and SMEs as a team.
obtained through the FDA, as the team can request These are the critical success factors. Establishing
copies of any negative reports regarding the equip- critical success factors for the users and the produc-
ment. This requires sufficient lead time to order ers of the equipment identifies usability as essential
and read through the reports before beginning to ensuring a successful product. This lets the user
testing. Once familiar with the equipment, the and producer know that their problems and con-
purpose of the equipment, the situations and envi- cerns are the focus of the design. During a task and
ronments in which the equipment would be used, function analysis, the task and subtasks to be per-
and the target populations, the team can move on formed are selected in terms of those that are most
to usability testing. Text continued on p. 160
156 PART II Knowledge, Tools, and Techniques

BOX 10-3 A Few Basic Principles

1. Testing should resemble the actual situation 2. Worst case scenario testing reveals worst case
in which the item will be used, as closely as information.
possible. A. As mentioned in the preceding section, at
A. That is, participants should complete a times it is beneficial to use additional
task simulation that closely resembles tasks during usability testing, sometimes
their normal activity or activities. It is even using a “worst case scenario.” There
important to know whether the item being are good reasons for doing this. First, with
tested is easy and helpful to use during the introduction of difficult tasks the
the tasks for which it was designed. After maximum capabilities of the participants
this is known, adding additional tasks can can be defined. This type of testing is
be useful, such as more complicated tasks often done when it is imperative to design
or alternate scenarios. Some researchers a task within a person’s capabilities in
will test using a more difficult task or order to reduce human error. An example
scenario, with the idea that if the worker would be testing airplane pilots on dual
can do the more difficult task, then surely task performance; as their primary task
they can accomplish the easier tasks. becomes more difficult, they spend less
Although this may be true, if the target time on secondary tasks. By carefully
audience participants cannot do the annotating where and when this happens,
additional task, the essential question will designers gain knowledge about designing
remain: Can this person use this device or the equipment and tasks in a cockpit so
process in the way it was intended to be the pilot is not overtaxed.
used, with the intended consequences, B. A second reason for this type of testing is
easily? to identify the maximum number and
B. Care should be taken when adding diversity of problems associated with a
additional tasks, as this could prolong a product or procedure. This is important
test session beyond the length of time the so designers can use the information to
target population would normally engage redesign the product or procedure to
in an activity. This is especially true in address the identified problems. The
situations in which the individual is able difficulty can be in the interpretation of
to work at his or her own pace. This is this information. Although a carefully
another area in which therapists can designed study that slowly introduces
provide valuable information. For more and more difficulty can tell you
example, certain diseases and disabling about a participant’s basic capabilities, a
conditions are especially likely to cause study that simply has a participant do
fatigue, such as multiple sclerosis, very difficult tasks does not answer the
amyotrophic lateral sclerosis, and even same question. For example, if a person
recent stroke. Therapists can help can lift and carry 50 pounds (i.e.,
researchers design tasks and scenarios accomplish the most difficult task
that are realistic and will not unduly scenario), he or she can probably lift and
challenge the participants. This will carry 30 pounds (i.e., accomplish the less
reduce frustration for participants and difficult “basic” task). However, if testing
should result in more accurate test shows the participant cannot lift and carry
feedback in terms of the number and 50 pounds (i.e., accomplish the most
pattern of errors, as well as subjective difficult task scenario), the tester has no
responses. idea if the participant can lift and carry
Chapter 10 Human Factors in Medical Rehabilitation Equipment 157

BOX 10-3 A Few Basic Principles—cont’d

30, 25, or even 20 pounds (i.e., feedback, and coaching during testing
accomplish the less difficult “basic” task). have been shown to influence the test
In other words, using a worst case results. This means that all feedback to
scenario does not answer the question of participants should be exactly the same.
whether the participant can do a B. Potential methods to control the
particular job or task other than the one influence of the individual testers
tested. include following a specific protocol,
3. Usability testing should be unobtrusive. including all verbalizations and/or
A. Although participants will be aware they having each tester brief and evaluate an
are taking part in a study and will equal number of participants from each
typically sign a consent form to disability group. That is, if a tester gives
participate, it helps if task instructions to and evaluates an equal
accomplishment is paramount during number of persons in each testing
testing and the test process is invisible to situation, then this potential influence
the user. For example, camera setup on outcome can be controlled.
should be done before arrival and tested, 5. Usability testing should be free of bias.
so that participants can perform the task A. All instructions and comments by
as normally as possible during testing. reviewers must be free of bias. This can
Minimal adjustments should be made be more difficult than it seems, and it is
after the participant arrives, such as always beneficial to have individuals
raising or lowering the camera to capture experienced in writing surveys and
the full individual or pertinent actions on questionnaires to help in their design.
camera. Even the wording of a survey question, if
B. During data collection, extraneous different from wording typically used by
variables that could influence the outcome the target group, could bias the results.
need to be controlled as much as possible. B. All recording of data must be precise and
This means that the individuals free from bias. That is, when recording
conducting testing should offer no subjective data from participants, the
coaching, no additional instructions individuals conducting the evaluation
during the task (unless those instructions should not record the information in their
are part of the normal process), and no own words. Instead, participants can
feedback to the participant. In addition, select their responses from a given list or
no additional distractions should be a Likert Scale or their comments should
present, other than those that are be recorded verbatim. If data collection is
normally part of the task or situation. done in a focus group, having one or two
4. During testing, all instructions need to be recorders, as well as a tape recorder, can
precise and exactly the same for each help.
participant. 6. Measures must reflect the target audience,
A. This is a basic tenet of all research and the product, and the actual situation in which
data collection, as to do otherwise can the person would act.
bias the results (as mentioned in 3B, A. Usability testing should simulate the
above). “Instructions” include all actual situation in which the item will be
information (verbal or written) on how to used (as mentioned in 1), use the
use a product or do a procedure. It also appropriate target audience(s), and
includes any verbal feedback to demonstrate product use in the way the
participants. Positive feedback, negative product is intended to be used.
158 PART II Knowledge, Tools, and Techniques

BOX 10-3 A Few Basic Principles—cont’d

B. When conducting usability testing with completion. This information is essential to

health care products, the target audience determine whether the present product or
can include the client, client’s family procedure offers advantages or disadvantages.
members or caregivers, and health care 8. Concomitant verbalization is a good
professionals. If the client is elderly, the technique during usability testing but must be
caregiver may be a spouse who is also accomplished with care.
elderly and could have associated A. Concomitant verbalization means that the
difficulties, such as reading small print participant verbalizes aloud what he or
(presbyopia) or having difficulty with she is doing, and why, while taking
precision tasks. All of these considerations action. The purpose of this technique is to
must be taken into account. have the participant “think out loud,” so
C. If the product is likely to be used in the tester can understand why a process
numerous situations and environments, or device is a problem or one is better
some of those may need to be added to than another. Without this information, an
the testing schedule. For example, people evaluation may discover that a mistake
with diabetes do not test their blood sugar has been made (an error), but not why—
only at home and under excellent lighting that is, the evaluators may not understand
conditions. They may also test their blood whether the product design or an errant
sugar just before eating at a restaurant or thought process might have contributed to
while on a picnic at the beach with their the error.
family. Therefore, the ability to read the B. There are difficulties with this process,
digital signal must be evaluated in however. Verbalizing what you are doing,
differing lighting and environmental while you are doing it, requires additional
conditions. cognitive effort. Therefore the participant
7. Ease-of-use is partially determined by user must be permitted to do the task and
feedback. verbalize what he or she is doing and
A. Acceptance testing must be accomplished, why, without interruptions. Additional
in part, by having participants report on instructions, coaching, or feedback will
how easy a product was to use and what disrupt the process. If the participants
problems they had. However, if they have have to listen to and process additional
no reference point of comparison, their feedback while verbalizing what they are
feedback cannot be taken in context. This doing, they are likely to lose track of what
means that a member of a target audience they are doing as they seek to listen to,
who has never previously used the remember, and act on the new
product or attempted to do the task in instructions. Therefore, as previously
question may have difficulty providing stated, this technique requires the
useful feedback. In these situations, monitor to quietly observe (or film)
participants may be asked to accomplish a without disrupting the process or
task with and without a particular device, distracting the participant. In addition,
thus providing contextual information. this technique introduces additional time,
B. If participants have performed the task as the respondent will take longer to
previously, it is helpful to understand the verbalize what he or she is doing than if
conditions in which they completed the he or she were to simply perform the
task, whether assistance was provided, or actions.
whether an additional, but somewhat 9. Each process should clearly be evaluated with
different, tool was used to assist with task regard to the impact on the system.
Chapter 10 Human Factors in Medical Rehabilitation Equipment 159

BOX 10-3 A Few Basic Principles—cont’d

A. If the process or product being tested experience with the equipment based on
includes reading, understanding, and their own abilities and needs, and each
following instructions, these portions may experience is equally valid.
need to be evaluated separately from the B. Without sufficient representation, the end
task itself. The participant’s ability to users may be misrepresented. For
remember the instructions and the need example, having five members of a target
for repeated exposure such as looking group may not provide sufficient
back or asking questions are also information to generalize the results:
important. statistical assessments cannot reach an
B. In the same way, if a task has several appropriate level of significance, and
subtasks, they may also need to be designers may be left to draw conclusions
incorporated into testing. from insufficient descriptive data.
10. The target audience needs to be well-defined Although it is possible to conduct
and appropriately represented. assessments with a low number of
A. This is necessary for accuracy of participants, and indeed, the target
representation and generalizability of audience may be so small that finding a
results. As mentioned previously, the large enough representation is difficult,
target audience for health care and care should be taken to ensure a well-
rehabilitation equipment may include the defined target audience and sufficient
client, family member caregivers, or representation. Regardless, the population
medical professionals. Members of each should be thoroughly described in any
group may have a very different consequent reports.

This information was compiled, in part, during consultation with Vote-PAD, Inc.,

FIGURE 10-2 Usability test procedures. SME, Subject matter expert.

160 PART II Knowledge, Tools, and Techniques

demanding, frequent, and essential for the user An experimental evaluation requires measure-
population. These need to be balanced in accor- ment of subject performance under contrasting
dance with the normal activities of the user group. conditions in a controlled environment and use of
The analysis also identifies the pattern and sequence experimental and statistical controls. A nonexperi-
of tasks and subtasks. mental evaluation does not require contrasting
The design objectives and the information from conditions or strict controls. For example, evaluat-
the task and function analysis are used for the ing a subject’s reaction time and subjective reac-
fifth step, the development of performance crite- tion to several versions of a product in a laboratory
ria. Performance criteria should closely resemble is experimental. Having subjects complete a sub-
the requirements of the task and should be per- jective rating scale while using a single product
formance oriented (action oriented). For example, on the job is nonexperimental. Formal assess-
a task analysis of an assembly job might indicate ments have definite procedures and are well
that fine-motor coordination is important for defined; informal assessments have less well-
performance. defined objectives and procedures. For example,
Measurement techniques to quantify perfor- a questionnaire is formal, but an open-ended
mance are chosen (see Figure 10-2, step 6). These group discussion is informal. Two-dimensional
techniques include both objective and subjective evaluations examine a product’s attributes through
measurements. Typical objective measurements checklists, whereas three-dimensional evaluations
include reaction time, number of errors, and type may use mock-ups or prototypes and can incor-
of error. Subjective measurements include user porate either nonperformance or performance
ratings of comfort, convenience, ease of use, and measurements.21
aesthetics. An experimental evaluation of two or more
Once the measurement techniques are chosen, prototypes determines which design is better or
subjects are recruited and trained (see Figure 10-2, best according to user performance and prefer-
step 7). Completing steps 1 to 6 before recruiting ence. If only one product is evaluated, the assess-
subjects is important to guarantee full disclosure ment addresses the same design questions of
of the evaluation process. A walk-through or trial effectiveness, ease of use, accomplishment of the
of the evaluation process should be conducted at mission, and deficits or areas that need improve-
this time. ment, but only for that one product.
Finally, the evaluation process is conducted as As mentioned, an important aspect of usability
either a formal or an informal research project testing is that it is performed during each stage of
(see Figure 10-2, step 8). The results are used to development. Even after the product is on the
critique or redesign the product (see Figure 10-2, market, usability assessment can be conducted to
step 9). ensure the product remains useful and effective. If
The process is repeated as new information product development occurred without usability
becomes available or the design is changed. A testing, evaluation may be the first step in deter-
design is proposed, tested, rejected (or accepted), mining whether change is needed. The user popu-
and revised repeatedly.21 During the initial design lation, especially clients, may not voice their
and development a number of prototypes may be concerns about the effectiveness of a product. This
developed and tested. Designs can be assessed leaves the responsibility with the developers and
using product description, mock-ups, prototypes SMEs. The information gained from a usability
(partial or full), or complete functional products. evaluation after the product is on the market can
One or two design options are then chosen for determine the need for product redesign and assist
rigorous evaluation. The evaluations can be cate- medical personnel in making recommendations.
gorized as experimental or nonexperimental, Information regarding the effectiveness, efficiency,
formal or informal, two-dimensional or three- and ease-of-use of a product is important in the
dimensional, and nonperformance or performance recommendation of a product for purchase by a
oriented.21 client, a client’s family, or a medical facility.
Chapter 10 Human Factors in Medical Rehabilitation Equipment 161

PRODUCT DEVELOPMENT, EFFICACY is evaluated by obtaining information from repre-

TESTING, AND COMPARISON TESTING sentative users, often while they use the product.
OF AN ASSISTIVE WALKER To reiterate, the goals of usability testing are to
Given that therapists have accepted the job as develop a product that accomplishes the purpose
consultants and members of the ergonomic evalu- for which it was designed, is easy and safe to use,
ation team, they first review the literature and and will be used.
construction of walkers and refamiliarize them- Creating a product that will be utilized involves
selves with the types of clients who use them. other factors, such as aesthetics, that influence
They review the accoutrements that users may whether a person chooses to use the product. In
want, such as baskets, pouches for carrying small addition, the best design is one that does not
items, and drink holders. They examine the require the user to study an instruction manual;
balance characteristics of walkers. Some are bal- instead, the design should guide the user’s actions
anced at the center handle; these walkers are so that use of the product is intuitive.
designed for clients with hemiplegia and thus with
limited use of one hand. Wheeled walkers may be First Iteration: Product Development
especially beneficial during the early rehabilita- The goal of product development is to produce
tion process, but it is difficult to know whether several design alternatives and to select one for
one with front wheels only or one with three additional evaluation. The first step is to identify
wheels will best serve a client. Other important the SMEs, users, and investigators (see Figure 10-
features are the weight, portability, and stability 2). This group could include product developers,
of the walker and the height, shape, and size of medical personnel who have prescribed walkers
the grip handles. Some clients may want a walker for clients, therapists and nurses who work closely
with an attached seat. with clients who use walkers, family members of
Given that the New Equipment Company has clients who use walkers, and the clients them-
an idea for a new walker design, the team decides selves. A target group of clients should be identi-
to start there. They plan for three iterations of the fied, because the needs of various groups, such as
usability process. During the first iteration (product those with hemiplegia and those with cerebral
development), several variations of the new palsy, differ. For example, a client who has prob-
walker design will be constructed and evaluated. lems with balance and coordination may not want
This is prototype or pilot testing, which involves wheels on his or her walker, and a client who
the evaluation of a newly developed trial product quickly becomes fatigued may need an attachable
by the end-users who represent the target market. seat that folds while he or she is walking. Identi-
Both the walker design and the testing process are fication of a target group should be based on
evaluated. The information gained from the pilot demographics; knowledge, skills, and experience;
test is used in the second iteration of the usability attitude; lifestyle; cognitive and physical abilities;
process, in which the best walker design (as deter- and cultural background. In the case study, New
mined during the pilot test) is evaluated (effica- Equipment Company wants to create several
cy testing). This phase involves a more formal walkers for different populations; therefore more
process of performance testing in a controlled than one target group would be identified and
setting to determine the effectiveness of the new involved in testing. It may be that New Equipment
walker. The final phase (comparison or field Company has already had their marketing depart-
testing) involves a field study to determine user ment identify the groups that will have the largest
acceptance and performance. This testing is con- population that could benefit from, and would be
ducted in a setting similar to the environment in likely to purchase, their walkers over the next 25
which the walker will be used (see Figure 10-2, years.
phase 3). The second step is the interactive process be-
Each phase is considered part of the usability tween the investigators and the SMEs and users
testing. Usability testing means that the product (see Figure 10-2). During this interaction, defi-
162 PART II Knowledge, Tools, and Techniques

BOX 10-4 Design Objectives for Product


Adjustable height
Adjustable width

Appropriate weight distribution
Ability to maintain erect posture during use

Ease of use
Ease of adjustment
Ease of storage
Optimum grip height
FIGURE 10-3 Being able to fold a walker for storage
Tertiary may be important to a person who does not need to
Attractiveness use it to walk for short distances or on a daily
Convenience basis.

design features are important for a walker to be

used by this target population?” The purpose of a
walker is to assist people in walking by allowing
ciencies in existing walker designs are identified them to stabilize themselves by putting some of
and consequent research questions are developed. their weight on the walker handles. Thus, the first
Positive aspects of existing walker designs may objective should be stability. Secondary character-
also be identified and incorporated into the design istics of the design are those that are important to
objectives (see Figure 10-2, step 3). If the produc- a user but that may not influence the primary
ers of the equipment have different aims, these purpose of the product. An example is making
also need to be identified. Such aims could the walker easily collapsible for placing into a car
include high sales, marketability, production loca- or storage area (Figure 10-3). Tertiary items
tion or costs, and user education or manual include attractiveness and convenience. Conve-
development. nience characteristics of a walker might include
Design objectives are developed as a result of baskets or pouches for personal items and attach-
the observations, replies to questionnaires, and able trays to hold food or drinks.
discussions among SMEs, users, and investigators Labeling design objectives as primary, second-
(Box 10-4). Design objectives should include any ary, and tertiary does not mean one level is more
items considered important to enable full, practi- important than another. Secondary and terti-
cal use of the walker. The development of design ary items are important because they influence
objectives should answer the question, “What whether the product will be accepted and used. A
Chapter 10 Human Factors in Medical Rehabilitation Equipment 163

product may help clients accomplish a task but be

so difficult, inconvenient, or unattractive to use BOX 10-5 Dependent Measurements for
that people choose to do without it. The impor- Product Development
tance of individual design objectives should be
determined by the combined interaction of the Objective
SMEs, users, and investigators. Walker weight
While design objectives are being defined, a Height adjustment
task and function analysis should be accomplished Percentage of the target population that can use
(see Figure 10-2, step 4). Information gained from the walker
Distance between walker legs
establishing the design objectives should be used
Biomechanical analysis of weight distribution
in conducting the task and function analysis and
Material strength
vice versa. The task and function analysis is based
on input from users and SMEs. The investigator Subjective
who conducts the assessment should observe Perceived stability
the user performing a typical task and break the Perceived comfort
task into its component parts. These components Perceived pain or strain
should be described using action phrases. The Perceived exertion
design objectives and the information gained from Perceived ease of use
the task and function analysis are used to develop Perceived ease of adjustment
performance criteria (see Figure 10-2, step 5). Perceived portability
Representative tasks are identified on the ba- Forced-choice rankings
sis of criticality, frequency, and difficulty. The
selected tasks can be used as independent vari-
ables (the different walkers are also independent
variables). For this situation, the tasks chosen
could include walking and maneuvering around Design objectives (dependent measurements)
items that block the user’s path; entering, using, require both objective and subjective measure-
and exiting a restroom; and using a small set of ments. Dependent measurements for the sample
stairs. The first task is used to test the walker situation are listed in Box 10-5. In addition to
prototypes. Performance criteria are developed the measurements listed, the base and depth of
from the selected task or tasks. the walker should be measured to determine
The sixth step is to establish subjective and walker stability. Many manufacturers list the
objective measurements. Because the first itera- weight capacity of walkers. If more information is
tion is the development phase, the investigator required, however, material strength can be deter-
may decide to use only one task to select the new mined through consultation with an engineer
design for the walker. Similarly, the investigating familiar with the materials and construction of
team may choose to use only the design objectives walkers. Subjective measurement techniques may
deemed most important. The breadth and depth include interviews, questionnaires, rankings,
of the evaluation during the product-development Likert scale ratings, or ratings by means of tech-
stage are determined by the investigator or inves- niques such as magnitude estimation (Box 10-
tigating team. Consideration of costs and benefits 6).1,11 Group interviews, rather than open-ended
assist the investigator in making the determina- individual interviews, are often used to promote
tion. For example, if construction of the walkers discussion.20 Forced-choice rankings, especially
for additional testing is expected to be expensive, useful in the comparison of several designs, re-
the testing should be thorough. If construction quire the user to rank the designs in order of
and possible alterations are relatively inexpensive, preference. Observations and ratings by the inves-
the prototype study may be smaller in terms of tigator can be helpful, but the investigator must
breadth and depth (or complexity). take care not to bias the results.
164 PART II Knowledge, Tools, and Techniques

Each hospital or nursing facility usually has a

BOX 10-6 What Is Magnitude Estimation? human-use committee that determines the require-
ments for briefing, screening, and the format and
Magnitude estimation is an experimental tech- contents of the consent form.
nique used in psychophysical experiments. Mag- The experimental design is a repeated-mea-
nitude estimations involve having a subject
surements design, counterbalanced for order. The
compare a current sensation with a reference
term repeated-measurements design means that
sensation. For example, a subject might be asked
each subject serves as his or her own control and
to handle a box of a particular weight and then
completes the task under each of the experimental
be asked to judge other weights as weighing
more or less than the reference weight. Another conditions (various walker designs). Counterbal-
example would be the comparison of tactile pres- ancing for the order in which each walker is used
sures administered by a monofilament as being can be accomplished by using a balanced Latin-
of greater or lesser sensation. square design. This means each treatment condi-
tion (each walker design) is immediately preceded
and followed once by each of the other condi-
tions.31 (This is often the preferred method to
counterbalance a design without having to conduct
Subject training and a walk-through of the tests of all possible ordering combinations.)
testing process constitute the seventh step (see Another method of controlling for order effects is
Figure 10-2, step 7). Enough training should be to randomize the order of administration.
done to eliminate a learning (or practice) effect. Analysis of the subjective data can be accom-
Subjects should not continue to improve with plished by the use of nonparametric statistical
time, regardless of experimental condition. analysis.26,31 Nonparametric statistical analysis is
The eighth step is the actual assessment; in this a useful tool for usability studies that collect sub-
case it involves a comparison study of several jective data and use small sample sizes. Paramet-
prototype walkers. Subjects perform one or more ric statistical analysis can be used for objective
of the reference tasks, and the investigator collects data when proper experimental design and suffi-
and analyzes objective and subjective informa- cient population sampling are used. Considerable
tion. On the basis of the analysis, one design is debate exists about using parametric statistics
usually selected for the next phase, efficacy test- with subjective data.2,15,29
ing. In the example, the walking task is evaluated The results should clearly indicate the pre-
in a nonexperimental, formal-informal, three- ferred design on the basis of user preference and
dimensional, and performance-oriented context. performance data. The investigator may give a
Nonexperimental means no statistical controls, weighting factor to items considered to be of
even though contrasting conditions are used (one primary importance. For example, object load,
walker design compared with another). The com- adjustability, use by the greatest percentage of the
parison study contains both formal and informal target population, and biomechanical advantage
elements: A formal procedure and questionnaire may be weighted more than convenience and
are used in addition to an informal interview aesthetics.
session. The process is three-dimensional because As a result of the first iteration, design 1 is
prototypes of the walkers are used in a realistic selected for additional testing. As seen in Table
task or series of tasks. 10-1, the design is selected because it has the
The goal of the evaluation (to identify one largest height range and is considered the most
walker for additional testing) can be met with a stable, adjustable, and portable. Its use caused the
relatively small number of participants. Subjects least pain and strain, and it was ranked the pre-
receive a detailed briefing, undergo a medical ferred walker. Note that design 1 was selected
screening, and sign an informed-consent form. despite being the most difficult to use.
Chapter 10 Human Factors in Medical Rehabilitation Equipment 165

TABLE 10-1 Hypothetical Results from Product Development

Design 1 Design 2 Design 3

Load 6 lb 7 lb 16 lb
Height 17-37 in 32-37 in 30-38 in
Weight distribution Good Good Good
Material construction 350-lb capacity 375-lb capacity 500-lb capacity
Posture Good Good Good
Stability 17.5* 12.2 14
Comfort 14.5 15.8 16
Pain or strain 12.1* 14.2 14.6
Ease of use 10.3 12.2 16.8*
Ease of adjustment 18.7* 16 14.8
Portability 16.5* 13.9 9.8
Ranking 1.25* 2.25 2.5

*Significantly different from other two walkers (P < .05).

Note: All ratings (except ranking) used a Borg-type scale with anchored subjective ratings of 0 to 20.8 The lower
number indicates less and the higher number indicates more of the given quality. Rankings were 1 to 3.

Second Iteration: Efficacy Testing the investigator should focus on the results of the
(Controlled Setting) pilot test accomplished during phase 1.
The goal of efficacy testing is to determine whether The design objectives for the walker most likely
the walker improves the user’s ability to walk and will remain the same as those identified in the
maneuver through the activities of daily living— development phase (see Figure 10-2, phase 2, step
that is, it answers the question of whether the 3; Box 10-4). However, additional objectives can
walker is effective for completing the tasks the be identified in the pilot testing and in the interac-
user needs to complete. Therefore, testing consists tions among the subjects, SMEs, and users.
of having subjects use the walker, as opposed to The task and function analysis should be re-
not using a walker, while performing several rep- evaluated (see Figure 10-2, phase 2, step 4). The
resentative tasks. If the investigator believes that representative tasks can be altered on the basis of
walkers have been shown to be effective ambula- information gained during the development phase.
tion tools and that such an evaluation would be For the second iteration of the process (efficacy
superfluous, this phase can be eliminated. If this testing), all three representative tasks are used
phase is eliminated, usability testing begins with to ascertain whether the new walker meets the
a comparison between the new design and exist- functional goals. The tasks identified during the
ing designs (usability [comparison] testing; see task or functional analysis are walking and maneu-
Figure 10-2, phase 3). vering around items that block the user’s path;
Identification of the SMEs and users was entering, using, and exiting a restroom; and using
accomplished in the beginning of phase 1 (pilot a small set of stairs. Each task is completed in a
testing); the experimental subjects now are added controlled laboratory setting. In each task, per-
to the group as SMEs (see Figure 10-2, phase 2, formance criteria should provide information
step 1). The interaction among SMEs, users, and essential to successful performance and include
166 PART II Knowledge, Tools, and Techniques

an easy chair, turning right, walking 5 feet and

TABLE 10-2 Hypothetical Results from maneuvering to the left of a chair that blocks the
Efficacy Testing: Walking path, walking 4 feet and maneuvering right to
and Maneuvering Task avoid a child’s toy, walking another 5 feet, and
sitting in a kitchen chair.
Walker No walker
In addition to the primary task of walking,
Total time 9.2 min 15.6 min important secondary tasks should be included in
Get up 1 min 2 min the testing procedure. For example, if the walker
is used to enable someone to move between a
Turn right 0.45 min 1.2 min
desk and a filing cabinet, such a task pattern
Walk 5 ft 1.5 min 2.6 min
should be incorporated into the testing pro-
Walk around 0.6 min 1.5 min cedure.
chair Again, subjects should be trained in each task
Walk 4 ft 1.3 min 2 min used in the test procedure (see Figure 10-2, phase
Avoid toy 1 min 1.9 min 2, step 7). Because more than one task is being
Walk 5 ft 1.77 min 2.9 min studied (walking, maneuvering in a restroom, and
Sit in chair 1.4 min 1.5 min using stairs), the order of the tasks should be bal-
Heart rate 145 beats/min 155 beats/min anced to control for order effects, such as transfer
of learning or a conditioning effect. Training of
Perceived 15.8* 18.3
test subjects in testing procedures also decreases
the likelihood that learning effects will influence
Stability 19.7* 5.1
the study results.
Comfort 18.5* 6.7 After training, the actual assessment (experi-
Pain or strain 5.5* 14.2 mental evaluation) takes place. Task performance
should be evaluated by timing and accuracy data.
*Significantly different from no walker (P < .05). In the example, efficacy testing is experimental,
Note: All ratings (except ranking) used a Borg-type
formal, three-dimensional performance testing.
scale with anchored subjective ratings of 0 to 20.8 The
lower number indicates less and the higher number As with any research method, consistency in
indicates more of the given quality. experimental testing must be ensured in subject
training, measurement techniques, and data com-
pilation. Two excellent resources on these topics
objective and subjective data (see Figure 10-2, are Winer and colleagues31 for laboratory studies
phase 2, step 5). When the same criteria are used and Cook and Campbell10 for field studies.
for product development, efficacy testing, and During efficacy testing, the number of subjects
comparison testing, performance standards can be will probably be greater than the number who
developed and product improvement can be mon- participated in the pilot test. Adequate results can
itored. Additional dependent measurements in be obtained with a relatively small number of sub-
the example include time to complete each ele- jects, especially because this is a repeated-mea-
ment of the task, time to complete the entire pro- surements study. Statistical analysis can include a
cedure, heart rate, and perceived exertion (Table repeated-measurements analysis of variance and
10-2).7-9 post hoc testing.
In the example, the same objective and subjec- The results should give the investigator clear
tive measurement techniques used during the information about the efficacy of use of the walker
development phase are used during efficacy (as opposed to no walker) in terms of both the
testing (see Figure 10-2, phase 2, step 6; Box 10- subjects’ performances and their preferences. Effi-
5). The first task is walking and maneuvering cacy testing provides information on the benefits
around items that block the user’s path and and limitations of using the walker in three differ-
involves the following procedures: rising from ent situations for men and women. Initial results
Chapter 10 Human Factors in Medical Rehabilitation Equipment 167

suggest that the walker is beneficial (see Table 4). The purpose of the comparison field testing is
10-2). The subjects performed the task more to compare one or more designs with one another
quickly, experienced less subjective exertion, less in a realistic environment. The investigator can
pain and strain, more stability, and more comfort, compare the findings obtained when a subject
and had a lower heart rate when they used the uses the new walker design with the findings
walker than when they did not use the walker. obtained when no walker is used to verify the
The final output is the product (see Figure 10-2, results of the efficacy test in a realistic envi-
phase 2, step 9), which is reevaluated by the ronment.
research team. The task in comparison testing should be
similar to the task used during efficacy testing
Third Iteration: Comparison Field Testing in the laboratory. The tests can be conducted in
The second iteration of the usability cycle (effi- nursing homes, rehabilitation centers, or even in
cacy testing) revealed that the walker was helpful a home environment in which throw rugs, narrow
in improving ambulation and maneuvering in halls, and wheelchairs are obstructions. It can also
using a restroom. However, the following con- be conducted in a work setting in which storage
cerns were identified during testing: cabinets are located in the halls, ramps are located
• The gripping edge of the walker was uncom- between split-level floors, and low-level ambient
fortable and caused pain on the thenar emi- light is used. The most appropriate setting for the
nence during ambulation. target group is determined by the users, SMEs,
• Subjects requested a handle material that and the investigator. If users are required to
does not feel cold to the touch and comes in perform additional tasks or carry objects, these
different colors. tasks are included in the evaluation (see Figure
• Subjects requested detachable accessories, 10-2, phase 3, step 5). The objective and subjec-
such as a tray for holding objects, a recessed tive measurement techniques are the same as
cup holder, and a basket with adjustable those used during efficacy testing to verify results
sections. (see Figure 10-2, phase 3, step 6). In this case, the
• The fold-up seat was weak and unstable investigating team might decide to have individu-
and did not have appropriate contour or als who use walkers to use each of the candidate
padding. walkers in their own home environments and
The concerns must be discussed by SMEs, sub- observe them performing each of the identified
jects, users, and investigators (see Figure 10-2, tasks (maneuvering around objects, going to the
phase 3, steps 1 and 2). The cost of product devel- restroom, and going up and down a small stair
opment and the purchase price must be consid- [Figure 10-4, A-D]). Because each subject is using
ered, along with the preferences expressed. The each of the candidate walkers, the subjects serve
changes that can be made are incorporated, and as their own comparison, and the task does not
a new walker is constructed (see Figure 10-2, have to be identical for each subject.
phase 3, step 3). The new design must then be Training and walk-through of the test situation
reevaluated in the type of environment in which are conducted because the conditions have
it is to be used. In addition, the investigator should changed from a laboratory-based evaluation to a
compare this design with that of other walkers field test. Training helps prevent mistakes during
available on the commercial market (usability testing and eliminates a learning effect (see Figure
[comparison] testing; see Figure 10-2, phase 3). 10-2, phase 3, step 7). The assessment is the
A review of the task and function analysis eighth step, and applying the data obtained to the
reveals that the assistance provided by the walker product design is the ninth step.
is most pronounced during the walking task. The results of the comparison test in the
Because both the old and the new design objec- example were as follows: The new design was
tives can be tested by walking, this task is chosen ranked as the preferred walker compared with the
as representative (see Figure 10-2, phase 3, step other two walkers. The subjects’ heart rates were
168 PART II Knowledge, Tools, and Techniques


FIGURE 10-4 Evaluating the use of each walker in several tasks within the users’ home environment allows
the investigators to get accurate measures of ease-of-use, effectiveness, and efficiency. A, In this case, Mary
Jo maneuvers around furniture and into her living room, where there is a large rug. B, She goes to the bath-
room, but the walker does not fit through the doorway, so she must approach sideways and then hold onto
the doorway itself. C and D, She exits her home down a single small step, which calls for balancing herself,
lifting the walker, and placing it down the step—not an easy process!
Chapter 10 Human Factors in Medical Rehabilitation Equipment 169

Learning Exercises
TABLE 10-3 Hypothetical Results of
Walker Subjective Ratings The best way to understand usability testing is to
conduct a user-centered evaluation of a product.
New Walker Walker Imagine you are a consultant and you have been
design A B asked to evaluate a product. This can be a reha-
bilitation device, a toy, a consumer product, or
Stability 18.8 17.7 19 even a “health aid” such as a therapeutic back
Comfort 15.3* 12.3 14 scratcher. Once you have selected a product,
Pain or strain 8.9* 17.3 16.2 conduct the following exercises.
Ease of use 15 15.9 16.5 1. Develop a “panel of experts” to include
members from a user group or groups, a
Perceived exertion 16.4 15 15.2
researcher/ergonomist, and a therapist. Each
Ranking 1.25* 2.5 2.25
person should agree to speak (and think)
from their perspective.
*Significantly different from other two walkers
(P < .05). 2. Have the panel discuss the product, past
Note: All ratings (except ranking) used a Borg-type concerns with the product, what they would
scale with anchored subjective ratings of 0 to 20.8 like to see in a “perfect” product, and the
A lower number indicates less and a higher number environments in which they might use it.
indicates more of the indicated quality. Rankings are 3. Write down some objectives relating to what
1 to 3. the product should do, what design features
should be included, and what types of task(s)
lower with the new design. Subjects completed would be most common for its use.
the task faster when they used the new design; 4. Decide which scenario(s) you will use for
however, time to stand and sit was slower. Sub- testing the product; include the environment,
jects found the new design easier to use. Use of the tasks, and the target population(s).
the new design increased comfort and decreased 5. Decide what performance you want to
measure. Remember that you may want to
pain and strain. No differences were found for
include the user’s ability to read and follow the
ratings of stability, perceived exertion, or perfor-
instructions for product use, if there are any.
mance of ancillary tasks. These results showed
6. Decide how you will measure the
the new design to be superior for ambulatory
performance in number 5. Will you count
assistance as measured by user preference and errors, time completion of a task, or merely
performance (Table 10-3). observe the product use and ask questions?
Remember, children may not be able to
easily verbalize their likes and dislikes.
7. If the evaluation process requires it, conduct
Usability testing of medical or rehabilitation equip- a walk-through of the evaluation process.
ment is an essential component of product devel- Sometimes this is not desirable as you want
opment but is often neglected. This neglect to see how the individual uses the product
becomes obvious when practitioners or clients for the first time. Have a colleague assume
attempt to use the product. Without user testing, the role as a member of the target
products are often difficult to use, cannot be used population and use the product as you have
intuitively, and are not comfortable. Unfortu- designed the evaluation. If there is more
nately, it becomes obvious they are not made for than one target population, have colleagues
all categories of users, such as technicians, medical assume those roles.
practitioners, and clients. The importance of 8. Evaluate the product, obtain feedback from
usability testing of medical equipment has become the target population, and then meet as a
widely recognized, as evidenced by its consider- group to evaluate and interpret the results.
ation as one criterion for approving products and 9. Write a synopsis of your findings and
recommendations for product design changes.
170 PART II Knowledge, Tools, and Techniques

setting international and national standards. For- 2. In usability testing of medical and
tunately, testing and designing evaluative and rehabilitation equipment, what user
treatment equipment, devices for special popula- groups should be considered? (Select the
tions, and technology for groups that consider single best answer.)
themselves technically challenged have gained the A. All health care professionals and
attention of a number of human factors or ergo- health care technicians who use the
nomics practitioners. equipment
Medical professionals often design equipment B. All health care professionals, health
based on their experience with clients or accord- care technicians, and family members
ing to individual client needs but fail to complete of clients who might benefit from the
the design sequence by conducting systematic equipment, as well as the clients
user tests. Rather than have complete knowledge themselves
of the success of the product, they have two sets C. Anyone who is around the client on a
of opinions: their own and those of the clients regular basis
with whom they work. Little attempt is made to D. Any person who is expected to use the
make the product effective for a broad client equipment
population. E. All family members of and health care
Usability testing provides a mechanism to eval- providers for clients who might benefit
uate a product from a user’s perspective. The from the equipment
procedure should be used to assess all rehabilita-
3. Which of the following statements
tion and medical equipment. Usability testing
are true with regard to user-centered
should include factors such as ease of operational
design (UCD)? (More than one may be
learning, effectiveness, efficiency, flexibility,
maintainability, durability, safety, and task match-
A. User-centered design is synonymous
ing with user characteristics. Manufacturers, prac-
with usability testing.
titioners, and instructors in professional programs
B. User-centered design is a structured
should begin introducing the concepts and proce-
process for product development and
dures of usability testing to improve client care.
includes users throughout each phase
of the design process.
C. User-centered design often involves a
Multiple Choice Review Questions macroergonomic approach that
includes the mission, goals, and
1. Select the true statements among the
culture of the business, as well as the
likes, abilities, and requirements of the
A. Usability testing is the systematic
target audience.
evaluation of the “interaction
D. User-centered design is design that
between people and the products,
benefits not only persons with
equipment, environments, and services
disabilities, but those who are
they use.”
B. Usability testing “is the fundamental
principle that underpins all
4. The U.S. Food and Drug Administration
has standards that address the need for
C. Usability testing has been called user-
user-testing of medical devices and
acceptance testing, user trials, and
usability engineering.
A. True
D. Choices A and C are true.
B. False
E. Choices A and B are true.
F. Choices A, B, and C are true.
Chapter 10 Human Factors in Medical Rehabilitation Equipment 171

5. Which of the following are true with B. Initial development, comparison

regard to ecologic validity? (More than testing, efficacy, and acceptance
one may be selected.) testing
A. Ecologic validity is important because C. Initial development, efficacy testing,
a person’s environment can influence comparison testing, and acceptance
his or her performance. testing
B. Ecologic validity refers to how closely D. Initial development, efficacy and
the testing environment resembles the acceptance testing, and comparison
actual environment. testing
C. Ecologic validity refers to making E. Any of the phases can occur in any
the person’s environment order; it depends on the product and
“user-friendly.” the process desired by the
D. An experiment has ecologic validity manufacturer.
if investigators are actually evaluating
what they think they are evaluating. 9. Select the statements below that are not
true with regard to concomitant
6. Which of the following are true with verbalization. (More than one answer
regard to this basic principle of usability may be selected.)
testing: Testing should resemble as A. Concomitant verbalization is a good
closely as possible the actual situation in technique during usability testing but
which the item will be used”? must be accomplished with care.
A. This means that those members of the B. Concomitant verbalization means that
target audience who are participating the participant verbalizes aloud what
should complete a task simulation that he or she is doing, and why, while
closely resembles their normal activity performing actions.
or activities. C. Concomitant verbalization requires no
B. The investigator decides on his or her additional cognitive effort.
own which tasks are important to D. Concomitant verbalization helps
include. the investigator understand why a
C. The best idea is to use the most user does what he or she does. It
difficult task the target audience has to helps the investigator understand
do, because if they can do that task, whether the product design or an
they can do all of the other tasks. errant thought process might have
D. All pertinent tasks the users have to contributed to the error.
do should be included in usability E. Providing feedback or asking questions
testing, regardless of how long the during user testing and concomitant
testing takes. verbalization is acceptable, as long as
the investigator gets the additional
7. Usability testing is considered an information necessary to ascertain the
“iterative” process. usability of the product.
A. True
B. False 10. Prototype testing involves the evaluation
of a newly developed, trial product, most
8. The phases of usability testing occur in often involving end-users of the product
the following order: as participants in the evaluation of the
A. Efficacy testing, comparison testing, product.
acceptance testing, and initial A. True
development B. False
172 PART II Knowledge, Tools, and Techniques

REFERENCES 18. Kuniavsky M: Observing the user experience: a prac-

1. Allard F: Information processing in human percen- titioner’s guide to user research, San Francisco,
tual motor performance, Kin 356 course notes, 2003, Morgan Kaufmann Publishers.
Waterloo, Ontario, 2001, Department of Kinesiol- 19. Leape LL: The preventability of medical injury.
ogy, University of Waterloo. In Bogner MS, editor: Human error in medicine,
2. Anderson NH: Scales and statistics: parametric and Hillsdale, NJ, 1994, Erlbaum.
nonparametric, Psychol Bull 58:305, 1961. 20. McClelland I: Product assessment and user trials. In
3. Bamforth S, Brooks N: Effective design methodolo- Wilson JR, Corlett EN, editors: Evaluation of human
gies for rehabilitation equipment: the cactus project. work: a practical ergonomics methodology, Boca
Design applications for industry and education. Raton, Fla, 2005, CRC Press.
In Proceedings of the 13th Annual Conference on 21. Meister D: Behavioral analysis and measurement
Engineering Design, London, 2001, Professional methods, New York, 1985, Wiley.
Engineering Publishing. 22. Meister D: Conceptual aspects of human factors,
4. Bogner MS: An introduction to design, evaluation, Baltimore, 1989, Johns Hopkins University Press.
and usability testing. In VJB Rice, editor: Ergonom- 23. Moray N: Error reduction as a systems problem.
ics in health care and rehabilitation, Boston, 1998, In Bogner MS, editor: Human error in medicine,
Butterworth-Heinemann. Hillsdale, NJ, 1994, Erlbaum.
5. Bogner MS: Human error in medicine, Mahwah, NJ, 24. Perper JA: Life-threatening and fatal therapeutic
1994, Lawrence Erlbaum Associates. misadventures. In Bogner MS, editor: Human error
6. Bogner MS: Misadventures in health care: inside in medicine, Hillsdale, NJ, 1994 Erlbaum.
stories (Human error and safety series), Mahwah, 25. Rice VJ, Gable C: A combined macroergonomic and
NJ, 2003, Lawrence Erlbaum Associates. public health approach to injury prevention: two
7. Borg GA: Physical performance and perceived exer- years later. In Proceedings of the Human Factors and
tion, Lund, Sweden, 1962, Gleerup. Ergonomics Society Annual Conference, New
8. Borg GA: Perceived exertion as an indicator of Orleans, 2004.
somatic stress, Scand J Rehabil Med 2:92, 1970. 26. Siegel S, Castellan NJ: Nonparametric statistics for
9. Borg GA: Subjective aspects of physical and mental the behavioral sciences, New York, 1988,
load, Ergonomics 21:215, 1978. McGraw-Hill.
10. Cook TT, Campbell DT: Quasi-experimentation: 27. Swain E: FDA to emphasize human factors, Med
design and analysis issues for field settings, Boston, Device Diagn Ind Mag September:20, 2005.
1979, Houghton Mifflin. 28. Vink P: Comfort and design, Florida, 2005, CRC
11. Cordes RE: Use of magnitude estimation for evaluat- Press.
ing product. In Grandjean E, editor: Ergonomics and 29. Westermann R: Interval-scale measurement of atti-
health in modern offices, New York, 1984, Taylor & tudes: some theoretical conditions and empirical
Francis. testing methods, Br J Math Statistic Psychol 36:228,
12. Dekker S: The field guide to human error investiga- 1983.
tions, Burlington, Vt, 2002, Ashgate Publishing. 30. Wiklund ME: Is your human factors program ready
13. Dhillon D: Medical device reliability and associated for FDA scrutiny? Med Device Diagn Ind Mag
areas, NY, 2000, CRC Press. January:100, 2003.
14. Erickson BJ, Kossack MF, Blaine JG et al: Applica- 31. Winer BJ, Brown DR, Michels KM: Statistical prin-
tion of usability testing for improving PACS work- ciples in experimental design, New York, 1991,
station design. Proceedings of the International McGraw-Hill.
Society for Optimal Engineering, San Diego, Calif,
2000. Available from the Society of Photo-Optical
Instrumentation Engineers, Bellingham, Wash.
15. Gaito J: Measurement scales and statistics: resur-
gence of an old misconception, Psychol Bull 101:159, Crocker P: Focus group research for marketers, 2001,
1987. Xlibris.
16. Hyman WA: Errors in the use of medical equip- Krueger RA, Casey MA: Focus groups: a practical guide
ment. In Bogner MS, editor: Human error in medi- for applied research, Belmont, Calif, 2000, Sage
cine, Hillsdale, NJ, 1994, Erlbaum. Publishing.
17. Kumar S, Rice VJB: Ergonomics for special popula- Rice VJB: Ergonomics in health care and rehabilitation,
tions: an introduction. In VJB Rice, editor: Ergonom- Boston, 1998, Butterworth-Heinemann.
ics in health care and rehabilitation, Boston, 1998, Wilson JR, Corlett N: Evaluation of human work, Boca
Butterworth-Heinemann. Raton, FL, 2005, CRC Press.
PA R T III Special Considerations

Lifting Analysis*

Daniel Focht

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Use biomechanical principles when analyzing a lift.
2. Critically analyze three lifting techniques.
3. Develop an abatement protocol to prevent commonly encountered lift-related injuries.

Low back. The lumbar spine and its anterior/posterior Prevention. The use of accepted scientific principles
components. Iliosacral area may also be included. in the obviation of risk factors that may predispose an
Pain. Subjective, often nocuous response to stressors individual to injury.
that overwhelm the tissues being exposed.

*Portions of this chapter are retained from the previous edition chapter written by Diane Aja and Krystal Laflin.

174 PART III Special Considerations

CASE STUDY medical costs have led to an aggressive movement

You have received notification that one of the employers by industry as a whole, medical professionals, and
you work with, Boston Packaging, Inc., is experiencing an ergonomists to focus on prevention via workplace
inordinate amount of new injuries, primarily low back. education and design.51 This combined effort has
Apparently the employer, which specializes in the binding, resulted in some exciting and novel approaches to
packaging, and distribution of reference textbooks, has counter these work-related injuries, as you will
installed a new line. The area in which the majority of the see in the following review.
injuries are occurring is in the packaging department. You
have been asked to assess the area and recommend THE BIOMECHANICS OF LIFTING
The essential functions of an employee working in the Since Nachemson’s landmark 1964 study,37 myriad
packaging department are that he or she packages the studies have been conducted to accurately assess
books in boxes ranging in size from 50 × 50 × 30 cm the internal and external stressors that influence
(20 × 20 × 11 in). The textbooks vary in size and weight, spinal function and contribute to injury. Chapter
which results in boxes ranging in mass from 20 to 30 6 on Basic Biomechanics provides an excellent
pounds. The books are packaged and sealed on a roller overview of biomechanics, and the reader is asked
line that stands approximately 75 cm (30 inches) from the to review this information before reading this
floor. Once packaged the boxes are placed on pallets chapter. Please pay particular attention to the
directly behind the employee. Each pallet raises the pal- terms compression, shear, and torsion.
letized material approximately 9 cm (31/2 inches) from the
floor. Boxes are stacked three deep and four high. When LIFTING TECHNIQUES
full the pallet is transported via fork truck to shipping, and
a new pallet replaces the old. Traditionally, one of the first and most easily
applied administrative controls to prevent the
high incidence of low back injuries at the work
site is training the workers to lift in a biomechani-

T his chapter covers the present evidence on

lifting and discusses the various lifting tech-
niques that are used in the study of ergonomics.
cally safe manner. There has been, however, con-
siderable controversy as to which of the most
commonly used lifts (stoop, squat, or semi-squat)
Because the lower lumbar region has been the is most effective in protecting the worker.45 For
joint complex that has received the most scrutiny, this reason a critical analysis of each lift is
it will be the focus of the chapter. Our case study warranted.
at Boston Packaging, Inc. will be incorporated into
the chapter contents. Stoop Lift
Lifting is an activity that is an essential part of The stoop lift (Figure 11-1) is a maneuver that
everyday life. Unfortunately, it has been impli- typically requires maximal flexion of the trunk
cated as a contributing factor in the development and as near to terminal extension of the knees
of a variety of musculoskeletal injuries, particu- (without locking) as possible.
larly those that involve the lumbar spine.1,8 To
illustrate the gravity of this pervasive problem, a Squat Lift
review of contemporary data shows that of the The squat lift (Figure 11-2) requires knee flexion
1.4 million occupational injuries reported to the >90 degrees and trunk flexion <30 degrees.
Bureau of Labor Statistics in 2002, 11.7% involved
injury to the lower back. Of these, 38.8% corre- Semi-Squat Lift
lated positively with a mechanism of injury related The semi-squat lift shares characteristics of the
to lifting.3 This results in a staggering financial stoop and squat. As can be seen in Figure 11-3,
cost that has been estimated in terms of work days the semi-squat uses a posture calling for knee
lost per year, and the combined direct and indirect flexion >45 degrees and trunk flexion at approxi-
Chapter 11 Lifting Analysis 175

FIGURE 11-1 A stoop lift.

FIGURE 11-3 A semi-squat lift.

floor grasp.14 If the near-floor hand couple is

adopted in an attempt to maintain the integrity of
the lift, the squat lift soon becomes a semi-squat
when the subject attempts to negotiate the lower

Freestyle Lift
Additional lifting styles deserve attention, as they
have been reported in the literature. These include
the freestyle lift. This lift resembles in most re-
spects the semi-squat but can differ from person
to person. It is this variability that makes it diffi-
cult to examine during controlled studies.51
FIGURE 11-2 A squat lift. Trunk Kinetic Lift
The trunk kinetic lift is characterized by a sudden
extensor moment of the knees before the lift.48
mately the same angulation. Note the greater ante-
rior tilt of the pelvis with this approach in Load Kinetic Lift
comparison with the other lifts, promoting a The load kinetic lift requires a closer approxima-
lumbar lordosis. tion of the load to the body just before the initial
Research studies suggest that hand placement acceleration moment. This lift, too, is seen as a
should avoid the more precarious floor or near- variation of the three more standard lifts.48
176 PART III Special Considerations

(Dead load) 130N .07g Horizontal acceleration

3.3° Acceleration vector angle

Vertical acceleration 1.15g 150N (Live load)

B 18.4 cm

1800N 500N B 15.3 cm

Body weight
above L5/SI
Load center- center-of-gravity
of-gravity 340N
FIGURE 11-4 An approximate
350N 50% variance in lumbar mo-
2700N ments at the L5/S1 segment
when comparing squat and
35.0 cm
H 50.9 cm stoop lift. (From Chaffin DB,
150N H 150N Andersson GB: Occupational biome-
chanics, ed 2, New York, 1991, John
Wiley & Sons.)

CRITIQUE OF LIFTING TECHNIQUES minished the resultant compressive forces to the

lumbar spine (Figure 11-4).2 This is a strategy that
Biomechanical Analysis is employed more effectively in the semi-squat lift
Toussaint and colleagues47 determined that the (load between the feet and knees) than with the
lumbar moment at L5/S1 and compressive forces stoop or squat lift.
were equal for the stoop and squat lifts when When assessing the relative effects of both
testing young and middle-aged male subjects compression and shear forces, the data remain
lifting barbells weighing 8 kg and 15 kg. Van contentious. Although increased compression ap-
Dieen demonstrated a slight difference, with the pears to be present with the stoop versus the
stoop lumbar moments being 2% to 8% less than squat lift, the shear forces are significantly higher
for the squat lift.49 (in some cases 180%) during the squat lift.16,40
Kumar reported that lumbar moments were This finding was further supported by Kingma and
similar in nine male subjects who performed co-workers,23 who reported that low back loading
maximum isometric and isokinetic exertions when was significantly higher during squat lifting than
using the squat and stoop lift.27 When analyzing with the stoop lift when lifting from the floor
all three lifts, Mittal and Malik36 and de Looze and (0.05 m). It is speculated that this is a result of
co-workers10 found that the semi-squat demon- the longer moment arm created by the more pos-
strated higher lumbar moments, but that the dif- terior fulcrum of L5/S1 in relation to the load
ference among all three lifts was only 5%. being lifted during the squat lift. These stressors
It is generally accepted that the closer the load can be ameliorated, however, by decreasing the
is placed to the body, the more significantly di- moment arm with placement of the load between
Chapter 11 Lifting Analysis 177

the feet, as noted during the modified or semi- jects tend to switch from the squat and semi-squat
squat lift,12 rather than behind, as noted during to the stoop lift because of the increased energy
the pure squat or stoop lifts. demands of the squat lifts.49
Foot placement, however, is contingent on the
size of the load. If the container is too wide (large) Perceived Exertion
to allow for proper foot placement (greater than Rating of perceived exertion (RPE), a subjective
shoulder width—approximately 30 cm [12 in]), measure, rates the individual’s own awareness of
then the ideal lift would be the stoop, since it the effort required to perform a particular activity.
would result in less compressive forces. Straker and Duncan reported that subjects rated
Soft tissue compliance, another consideration the squat lift at a higher RPE than both the semi-
(e.g., lumbothoracic paraspinals and spinal liga- squat and the stoop lifts.46 In a separate study
ments), follows standard length-tension relation- 90% of the subjects rated the squat lift as more
ships during the various lifts. It was reported that fatiguing than the stoop lift.41 Another more sub-
the supraspinous and interspinous ligaments more jective measure of individual lifting tolerances
effectively countered the lumbar moment (be it as uses maximum allowable weight (MAW) as a de-
a result of shear or compressive forces) during the termining factor. In these cases a psychophysical
stoop rather that the squat and semi-squat lifts.34 factor is used, characterized by the subject’s holis-
This phenomenon is extremely important to keep tic perceptions as to his or her maximal effort.42
in mind because it can modify the shear force at With this in mind, researchers reported that 17
the lumbar disc by up to 700 N purely by support- females selected a MAW 20.5% greater for the
ing the activation of the erector spinae.35 stoop than for the squat lift.46 When comparing
the squat and semi-squat exclusively, subjects
Physiologic Response chose a greater 25.4% MAW, preferring the semi-
Oxygen uptake/consumption, %VO2 max, the gold squat over the squat.17
standard of energy expenditure, was found to be Finally, and most compelling, is the response
greater with the squat lift than with the stoop.22 of an individual experiencing low back pain and
This was a result of the increased effort require- what adjustments are made to negotiate a lift from
ments of the quadriceps and hip extensors and the floor to waist. A survey of asymptomatic individu-
resultant increased blood perfusion noted during als and individuals with low back pain promul-
the squat and semi-squat lifts versus the lesser gated by Damkot and colleagues revealed that the
demands of the erector spinae and trunk muscula- asymptomatic group showed no preference be-
ture during the stoop lift.17 In a study measuring tween the squat or stoop lift but that more than
overall lifting endurance, 12 subjects were tested two thirds of those with back pain (symptomatic
while lifting a 10-kg load at a rate of six times per group) had adopted the squat or semi-squat as
minute using both the squat and stoop lift. There their preferred lift.9
was a 38% disparity in oxygen consumption, with Table 11-1 shows that none of the lifts demon-
the stoop requiring less effort.27 strate a clear advantage over the others. In fact,
Lifting capacities did show slight but contradic- all lifts, to some extent, have the potential to
tory differences when the various lifts were com- create stressors not only to the spine but to a
pared. Granata and colleagues reported that the number of other structures (e.g., knees, hips,
squat, semi-squat, and stoop lifting potentials shoulders). It is important for therapists to criti-
were similar.21 Conversely, Magnusson and co- cally appraise lifting techniques and recommend
workers reported squat capacities to be on average those that match the client’s capacities to the task
10% greater than those of the stoop lift.30 This that is to be performed.
propensity, however, was neutralized as repeti- Knowing that increased angulation of the
tion, exposure rate, and time increased, with the lumbar spine—through flexion—causes both
stoop lift winning out.30 In fact, it has been found increased compression and shear forces to the
that with repetition and increased exposure, sub- intervertebral disc, it would make intuitive sense
178 PART III Special Considerations

lift would be a viable option. The caveat here

TABLE 11-1 Comparison of Lifts would be whether or not the stoop requires a
multiplanar effort, which would then put the
Criteria Squat Semi-squat Stoop lower lumbar segments at increased risk.
Maximum * *** ** Marras and colleagues demonstrated that there
allowable are additional risk factors to be considered when
weight (MAW) assessing the injury potential of various lifting and
Oxygen * ** *** high exertion efforts above and beyond what we
consumption have already discussed.32 This section identifies a
Heart rate * ** *** number of these factors and provides recommen-
dations that the therapist can use.
Ventilation * ** ***
The rate at which any lift is performed is
Relative load ** ** ** extremely important. It has been well documented
Lumbar ** ** ** that lumbar compressive forces increase by 15%
movement when lifting is performed quickly, as compared
Lumbar ** ** ** with using a steady, smooth approach when lifting
compression identical loads.4 The frequently seen phenomena
Lumbar shear *** ** * of the “jerk lift” generally results from lifting a
Fatigue * ** *** load in which the mass of the object to be lifted
kinematics is unknown. Butler and colleagues compared the
Strength ** ** ** lifting strategies of subjects exposed to unmarked
capacity loads weighing 0, 150, 250, and 300 N.5 They
Effect of pain *** ** * found that the majority of subjects were more
prone to overestimate the mass of the unmarked
The number of stars denotes the preferred lift: load and braced for a heavy lift. This resulted in
3 = best, 1 = worst. a rapid ascent and acceleration when lifting the
Data from Straker LM: A review of research on lighter 0 and 150-N loads, which caused an unbal-
techniques for lifting low-lying objects: 2. anced effort, hyperextension of the lumbar spine,
Evidence for a correct technique, Work 20(2):83, and subsequent higher compressive lumbosac-
ral moments. These findings imply that appro-
priate marking or “weight coding” may be an
inexpensive and effective control to obviate this
to prescribe the semi-squat or squat technique tendency.
when an individual is required to lift heavy objects The National Institute for Occupational Safety
on an occasional basis.38 The semi-squat lift allows and Health (NIOSH) revised lifting formula of
for closer placement of the load to the body, thus 1991 identified the important role of an effective
creating a smaller moment arm and less compres- hand grip and couple in the practice of safe
sive force.2 The preferred lift between the semi- lifting.39 An additional consideration is the benefit
squat lift and the pure squat would be the of a secure grasp when handling an unstable load.
semi-squat. In addition, the squat requires more Instability resulting from the lack of an effective
energy expenditure, thus making the semi-squat grasp can adversely affect stability (of the load),
the preferred lift for occasional heavy effort (four which can and frequently does result in the invol-
work cycles per minute). Van Dieen and col- untary increased recruitment of the core-trunk
leagues suggest that the physical plant may not muscle groups (rectus and external and internal
allow for such a lift (because of cramped spaces obliques). This greater coactivation of antagonis-
and so on).49 For this reason a variation can be tic muscles during the lift generally leads to
prescribed, with all practical considerations kept increased lumbar compressive forces.31
in mind. If lighter loads are to be handled but at The accepted design, although not always used
a higher frequency than four per minute, the stoop in practice, is to have hand holes and handles on
Chapter 11 Lifting Analysis 179

the object to reduce the incidence of unstable and

“jerky, uncontrolled” efforts when lifting from a TABLE 11-2 Correlation Coefficients r2
variety of work surface heights and when negoti- between Maximum Spinal
ating loads of differing mass. It was reported that Compressive-Shear Forces
acceleration times, vertical ground reaction forces,
and the Probability of a
High-Risk Classification
and L5/S1 compression were higher for boxes
with handles than without in Freivalds’ study
Lateral AP
of 1984.14 These findings, albeit noteworthy, ex- Shear Shear Compression
pressed only a small variance of 5 N (329 versus
324) and most probably were a result of the sub- Static load — — 0.135
jects being aware of the obvious hazard when Dynamic load 0.191 0.195 0.441
lifting an object without handles and taking the Load rate 0.343 0.345 0.428
necessary precautions.
AP, Anterioposterior.

In the past numerous intangibles were not con- impact on the potential for injury. Poor footing
sidered when researching the risk factors associ- and ground slope were investigated to assess the
ated with lifting. Marras and Sommerich33 and potential for risk and resulted in the following
Granata and Marras19 reported the benefit of conclusions. Kollmitzer et al reported that there
using three-dimensional dynamic models when was a definite advantage in a parallel vs. step-
assessing the biomechanics of the lumbar spine forward (staggered) stance when attempting to
during multiplanar movements outside of the sag- minimize the involuntary, often hazardous, pos-
ittal plane. They postulated that the two-dimen- tural adjustments that typically occur during a
sional dynamic and static models grossly front load knee-to-chest lift.24 The center of mass
underestimated the true stress to the lower lumbar (COM) was maintained more efficiently, and com-
segments that typically occurred during a “real pressive forces and lateral and anteroposterior
world effort.” shear involving the L5/S1 joint were significantly
Granata and Marras reported that compression less.
at the L5/S1 joint was a poor indicator of the
potential for injury.20 Their findings concluded Incline
that accurate predictions, correlating effort and Shin and Mirka suggested that lumbosacral mo-
the potential for injury, would also have to take ments were considerably larger when lifting from
into consideration a number of other factors an inclined slope compared with a declined
including the following: surface.44 The explanation was that as the slope
• Load rate increased from −20 degrees to 0 degrees to +20
• Lateral shear and torsion (side bending degrees, so did the flexion angle of the lumbar
and twisting in coupled and uncoupled segments. This subsequent increase in angulation
movements) resulted in an increased moment arm of the trunk,
• Velocity hydrostatic pressure of the disc, and torque at the
• Acceleration L5/S1 segment. This finding was consistent with
• Worker experience and attitudes toward the all lift variations (stoop, squat, and semi-squat).
job It is interesting to note, however, that although
Table 11-2 depicts the correlation coefficients there was a discernible difference in moment at
r2 between maximum spinal compressive-shear the low back with varying slope surfaces, there
forces and the probability of a high-risk classi- was no appreciable difference in lifting capaci-
fication. ties.50 When assessing equal numbers of male and
Other situations common to some occupations, female subjects, there was less than a 2% vari-
but rarely seen in others, may have considerable ance between 40 degrees of slope angle (25.1 to
180 PART III Special Considerations

25.5 kg [55.3 to 56.2 lb] in male subjects and 19.9 enumerated provide us with very basic but proven
to 20.3 kg [43.9 to 44.8 lb] in female subjects). standards that can be used to implement such an
effort. These standards include the following:
• Keep the load close. Evidence overwhelm-
Stability of the Load ingly identifies the benefit of maintaining the
Stability of the load to be lifted will be our final load close to the body while lifting from a
analysis of extraneous physical factors influencing variety of work surface heights. The reduc-
a subject’s lifting capacity. The untoward results tion in lumbar stress has been documented,
of negotiating a lift during which the subject’s and the behavior can be easily addressed in
perception of effort is blinded have been dis- injury-prevention protocols.
cussed, but Lee and Lee took it one step further • Ensure the placement of a secure hand couple.
in their 2002 endeavor.28 When comparing their The presence of an effective grasp assist
subjects’ response to lifting a stable load with one (handle or hand hole) minimizes trunk insta-
that has been manipulated to shift both anterior bility during a lift involving asymmetric han-
to posterior and vice versa, they found that the dling and load shift. Studies have shown that
unstable loads carried significantly higher risks for handling an unstable load results in extrasag-
poor mechanics and low back injury. ittal moments (lateral bending and torsion),
Postural data demonstrated that the lumbar causing increased compression, shear, and
spine flexes more during the unstable situation torque on the intervertebral disc. The uncon-
than when one is maneuvering a load that does trolled and “jerky” movements that typically
not shift.28 The tendency was to preserve a stable ensue also result in the recruitment of antag-
center of gravity (COG) by flexing the trunk and onist muscle groups, which adds to the co-
lowering the load and body as a unit. This resulted activation factor and can further stress the
in a more kyphotic lumbar spine and exposed the lower lumbar components.
intervertebral disc to even greater hydrostatic • Maintain a degree of lumbar lordosis at the
pressure. The lesson to be learned by these find- initiation and during the lift. Granata and
ings, and the application to the work site, would Bennett18 and many other researchers have
include the implementation of appropriate pack- proven that the curvature (flexion beyond
aging processes and further education of those neutral) of the lumbar spine can exponen-
employees handling the material in a more bio- tially increase the compressive and shear
mechanically efficient manner. forces to the disc, particularly during lifting
A major goal for the therapist is to reduce the of loads in excess of 50 pounds. What is to
risk of lift-related injuries at both the work site be considered heavy is of course relative and
and at home. The primary concern is to recognize should take a number of factors into account.
the presence of risk factors and understand how However, the premise is sound; maintain as
each factor influences the pathologic process. much lordosis as the situation will allow.
Many risk factors that can predispose an individ- • Use the lifting technique that is most appli-
ual to a lift-related injury have been identified cable to the situation. Although controversy
in this chapter. A number of others have been exists as to which lifting technique is the
researched, including the correlation between most beneficial, there does appear to be
injury and anthropometrics, age, gender, smoking, some agreement as to which of the three
obesity, and even parity.29 These are factors, most accepted lifts is more appropriate under
however, that either are inherited or reflect a per- what circumstances.
sonal choice and are not easily influenced by our Semi-squat. Frequently seen as the safest lift
interventions. in terms of resultant forces to the inter-
Factors that can be manipulated are the physi- vertebral disc, but it does carry a high
cal plant and worker attitude, if managed prop- energy cost, which will limit applicability
erly. The biomechanical analyses that have been during highly repetitive efforts. Conven-
Chapter 11 Lifting Analysis 181

tion would dictate that this would be the De Looze and co-workers examined subjects
ideal lift for heavy loads performed on an who performed pushing and pulling tasks while
occasional basis (10% to 33% of the work walking on a treadmill.11 One stage of the assess-
day). ment monitored their performance when pushing
Squat lift. To be used as an alternative to the or pulling against a stationary bar, and the other
semi-squat when space is limited and involved pushing and pulling a four-wheeled cart
load size does not allow for foot place- on the same treadmill. Both experiments were
ment to the side of the object to be lifted. conducted at the same rate of speed.
This also is the lift preferred by individu- Both the low back and shoulder complexes
als experiencing acute and chronic low were examined. Results demonstrated that the net
back pain. joint torques at the shoulder were minimal during
Stoop lift. Although this lift is the antithesis pushing maneuvers but greatly increased during
of what is usually professed by the thera- pulling efforts. Horizontal force, as opposed to
pist as being the ideal lift, it apparently torque, at the shoulder was significant during
has an application. Lifting scenarios re- both activities. The mediating factor was that of
quiring light loads (20 pounds and below) handle height and hand placement, with the cor-
on a frequent basis (defined as 33% to relation being positive as the height increased
66% of the workday by the Department from 50% to 80% of shoulder height. Vertical
of Labor’s Dictionary of Occupational forces were most prominent with the handle and
Titles) are more efficiently managed using hand placement at the lowest positions, whereas
this technique. horizontal forces remained constant or slightly
• When lifting on an uneven-sloped surface, face increased as the handle placement became
down the slope to negotiate the lift. Although higher.
the ideal would be to seek a level surface, when Compressive forces to the shoulder while
these circumstances do arise this approach has pushing changed as the approach became more
been proven to be the less hazardous. vertical, implying that handle heights at or below
• When lifting, do so as much as is possible in the 50% of shoulder height may predispose the shoul-
sagittal plane. Although we live in a three- der to impingement.11 No inferences were made
dimensional world, we need to be cognizant of relative to the potential for injury while pulling,
the degree of deviation into multiplanar fields but it would make intuitive sense that with
while lifting. increased loads, torque at the shoulder, particu-
larly through internal rotation, would increase,
Pushing and Pulling subjecting the soft tissue of the subacromial region
This chapter would be remiss if pushing and to insult. However, more research in this area is
pulling activities were not discussed in the exami- warranted.
nation of material handling and injury potential. Optimal pushing height for the best perfor-
With the increasing evidence correlating lifting mance appeared to be at or about waist level. The
and carrying with low back and other musculosk- greatest potential to overcome inertial forces and
eletal disorders, engineering controls have focused sustain the effort occurred at handle heights
on converting these processes to ones that are between 100 and 109 cm, approximately 70% of
seemingly less menacing and more biomechani- shoulder height.18 Chaffin and colleagues have
cally efficient, namely pushing and pulling.42,43 determined this optimal zone to be quite similar,
What was found, however, was that the magni- between 91 and 114 cm.7
tude and type of forces acting on the spine, and Although there is an optimal zone to generate
the resultant vectors changed from the vertical to maximal pushing efforts, the effect such efforts
the horizontal axis, added the component of fric- may have on the lower lumbar region reveals that
tional resistance to the equation when pushing or different vectors of force result as the lumbar
pulling.42 moments change. Using the more horizontal ap-
182 PART III Special Considerations

proach was found to increase lumbar moments Once the risk factors have been identified, it is
substantially as compared with a more vertically the therapist’s mission to control the frequency,
oriented effort.18 The tendency of those subjects severity, and, if possible, the very presence of the
participating in this study was to change from risk. For this reason standardized material han-
a more forward, flexed-at-the-waist, extended- dling guidelines have been developed by a number
elbow position to a more extended trunk and of authors and agencies. The gold standard, to
flexed-elbow strategy as the load increased. This date, is that which has been developed by NIOSH.
appeared to be an automatic strategy to protect A review and critique follow.
lower lumbar structures from increased stress.
Comparing pulling with pushing, the vector of
force is substantially higher at the L5/S1 joint MANUAL LIFTING ANALYSIS
when pulling as compared with pushing. This
comes as a direct result of the increased moment NIOSH developed the Work Practices Guide for
and flexed posture (at the waist) inherent with Manual Lifting as the first comprehensive tool to
pulling as opposed to pushing.18 De Looze and assist in the process of risk factor identification
co-workers also found that torque at the L5/S1 and subsequent ergonomic abatement to correct
was significantly higher with pulling as opposed those factors identified as being potential prob-
to pushing, further illustrating that, if possible, lems. Terms such as action limit (AL) and
pushing should be the preferred method of mate- maximum permissible limit (MPL) became syn-
rial transport over pulling.11 onymous with this first true work practices
The final consideration when evaluating push- guide.38
ing and pulling tasks is foot placement and the The requirements for the analysis were that the
avoidance of slippage resulting from a poor coef- lift to be analyzed be two-handed, be smooth,
ficient of friction (COF). Injuries secondary to provide unrestricted posturing, and involve the
these conditions can be serious and usually result handling of a container whose width did not
from the loss of balance and uncontrolled accel- exceed 76.2 cm—basically, an ideal lift. The goal
eration of the whole body. was to establish the AL, which was defined as the
The optimal COF while pushing appears to calculated-average load for a lift that could be
be 0.6. In their landmark study of 1971, Kroemer managed safely by 99% of the working male pop-
and Robinson reported that pushing force poten- ulation and 75% of the working female popula-
tial decreased significantly when the COF fell tion. The MPL then would be the product of three
below this mark.26 Gao and Abeysekera reported times the AL.
that walking on a dry, level surface results in The equation that was developed looked like
an acceptable COF of 0.5.15 Adding water, oil, this:
or other contaminants to the surface, however, AL = 90 × (6/H) × (1 − [0.01|V − 30|]) × (0.7
greatly decreased the COF and resulted in de- + [3/D]) × (1 − [F/Fmax])
creased balance and sway patterns. The need,
then, for careful analysis of the flooring type
and tripping and slipping hazards cannot be H = The horizontal distance of the load from the
overstated. worker
COF considerations are also a factor when con- V = The vertical distance of the load from the
sidering potential force production. It was found floor or work surface to the hand couple
that subjects were capable of efforts in excess of before the lift
66% higher when pushing objects on surfaces D = The vertical displacement of the lift from
carrying a COF greater than 0.5.6 This agreed with start to finish
previous studies affirming the need for a level, dry F = The frequency of the lift
surface when any pushing or pulling activity is Fmax = The frequency coefficient based on the
being evaluated.13,25 length of the work day (1 to 8 hours)
Chapter 11 Lifting Analysis 183

The calculation then resulted in determining worker fills the trays with food. The filled trays of food
the AL. If the actual weight of the object being weigh as much as 5 pounds (2.3 kg), and the worker is
lifted in the analysis exceeded the MPL (3 × AL), not allowed to slide the tray of food across the counter.
then the lift was deemed hazardous.
The ergonomic community initially applauded Job Analysis
the guideline as precedent setting and a welcomed The calculations using the 1981 formula are as follows:
standard from which to conduct accurate mea-
AL = 90 × (6/H) × (1 − [0.01 |V − 30|]) × (0.7 +
sures of potential risk. It wasn’t long, however,
[3/D]) × [1 − (F/Fmax])
before the instrument came under fire for being
H origin = 18 inches (46 cm); V origin = 42 inches
impractical and not applicable to endeavors that
(107 cm)
required asymmetric lifting efforts. This resulted
H destination = 30 inches (76 cm); V destination =
in the revision of the guideline in 1991.
50 inches (127 cm)
The revised guideline took into consideration
D = 8 inches (20 cm); F = four lifts per minute
two new, but very important, real-world variables
Fmax = 18 (from Fmax table, NIOSH 1981)
that occurred during most lifting activities, those
AL (destination) = 90 × (6/30) × (1 − [0.01 |50 − 30|]) ×
being an angle of asymmetry and the quality of
(0.7 + [3/8]) × (1 − [4/18])
hand couple.39 As the original guideline assessed
= 90 × 0.2 × 0.8 × 1.075 × 0.78
the lift only in the sagittal plane, the new guide-
= 12 pounds (5.4 kg)
line made provisions for the angle of displacement
from the line of load center to the center of the The calculations using the 1991 lifting formula are as
ankle from beginning to end point. This was mea- follows:
sured relative to the midsagittal plane.
RWL (destination) = 51 × (10/H) × (1 − [0.0075 |V − 30|])
The other added feature was efficacy of hand
× (0.82 + [1.8/D]) × (1 − 0.0032 A) × FM × CM
couple. This was classified using the following
H origin = 18 inches (46 cm); V origin = 30 inches
three criteria: (1) good—fingers wrapped com-
(76 cm)
pletely around the object or handle; (2) fair—not
H destination = 30 inches (76 cm); V destination = 50
all but a few of the fingers could grasp the object
inches (127 cm)
or handle; and (3) poor—partial or fingertip grasp
D = 8 inches (20 cm); A = 0
of the object or handle.
FM = 0.84 (from table; using the criteria of four lifts per
The revised equation would now result in the
minute, duration of ≤1 hour, V ≥ 30 in. [76 cm])
determination of a recommended weight of lift
CM = 1 (from table; using the criteria of good coupling
(RWL). This value would represent the MAW rec-
and V ≥ 30 inches [76 cm])
ommended to pose a minimal amount of risk to
RWL = 51 × (10/30) × ([1 − (0.0075 |50 − 30|]) × (0.82 +
90% of the working population as a whole.
[1.8/8]) × 1 × 0.84 × 1
= 51 × 0.33 × 0.85 × 1.045 × 0.84
CASE STUDY = 12.56 pounds (5.7 kg)
Job Description
Harold works as a cook and order-taker at a fast-food Discussion
restaurant. He is 6 feet 4 inches (193 cm) tall, of slender The actual weight of the object being lifted is 2.3 kg (5
build, and the primary provider for his family. After suf- pounds), well below the 5.4-kg (12-pound) AL calculated
fering sporadic lower back pain for several years, Harold using the 1981 formula and the 5.7-kg (12.56-pound)
received the diagnosis of acquired spinal stenosis with RWL calculated using the 1991 formula. Clearly, more risk
shooting pain in the right leg. Harold experiences the factors are present for Harold than just lifting food trays.
most pain when he repetitively hands trays of food to For someone with Harold’s diagnosis, activities that
customers during a busy lunch hour. The counter is 36 involve repetitive forward flexion should be avoided. This
inches (91 cm) wide, 48 inches (122 cm) high at the cus- example demonstrates an important concept for evalua-
tomer service end, and 36 inches (91 cm) high where the tors of work sites. The NIOSH formula was designed to be
184 PART III Special Considerations

used as a guideline only and is not the only factor to be Although the revised version of the NIOSH
considered in the evaluation of a workstation. The lifting lifting formula was more flexible in its scope, it
formula does, however, provide a way to break the lifting still lacked the pragmatic application that most
task into components. Analysis of the task variables of clinical staff would require in their everyday
both calculations shows that the horizontal multiplier practice.
causes the greatest reduction in each LC (0.2 in the 1981 NIOSH has made a number of additional
formula and 0.33 in the 1991 formula). Figure 11-5 shows attempts to upgrade the model, but to date, their
that the horizontal reach of the job is of primary application far exceeds what most therapists
importance. would consider practical in the quick but discern-
This lifting task can be analyzed with the 1981 formula ing evaluation of workplace risk factors. To this
because no asymmetric twisting is involved in the lift. end the search for an expeditious but effective
When the 1991 formula is used, the asymmetric and cou- screening tool that could identify a potentially
pling multipliers are not a factor (A = 0; CM = 1). For this hazardous work practice led to my endorsement
job, the difference between the 1981 AL (12 pounds of the Utah Assessment of Back Compressive
[5.4 kg]) and the 1991 RWL (12.56 pounds [5.7 kg]) is Forces.
Harold never successfully returned to work as a fast-
food employee. He did benefit from education in proper UTAH ASSESSMENT OF BACK COMPRESSIVE
body mechanics and learned how to stabilize his back FORCES (BLOSWICK ESTIMATION OF BACK
when performing the tray-lifting job. However, Harold COMPRESSIVE FORCE)
could not tolerate the constant standing and repetitive The Utah Assessment of Back Compressive
movements involved in all aspects of fast-food work. He Forces is a relatively simple and concise tool to
moved from a cold to a warm climate and assumed a job evaluate the compressive forces encountered by
as a bookstore manager. He reported that he finds the the lower lumbar spine during various lifting
warm climate better for his back. efforts. As can be seen by reviewing Figure 11-6,

FIGURE 11-5 Fast-food worker handing food tray to customer.

Chapter 11 Lifting Analysis 185

Estimation of Back Compressive Force

A representation of the model by Donald S. Bloswick at the University of Utah.

Job Analyst

Task Date

Measure Symbol Value

Body weight [lb]
Load [lb]
Horizontal distance [in]
(Hands to lower back {L5-S1 joint} ) [in]
Back posture (angle from vertical) Θ [°] sin Θ Θ
Vertical 0 0.0 [°]
Bent 1/4 of the way 23 0.4
sin Θ
Bent 1/2 of the way 45 0.7 [–]
Bent 3/4 of the way 67 0.9
Horizontal 90 1.0

Contributor Computation Value

Back posture
A = 3(BW) sin Θ 3 * ( )*( )
Load moment
B = 0.5(L * HB) 0.5 * ( )*( )
FIGURE 11-6 Bloswick’s revised
estimation of back compressive Direct compression
C = 0.8[(BW)/2 + L] 0.8 * {( )/2+( )}
force. (From Bloswick DS: Ergonom-
Estimated compressive force Sum computed values in last column.
ics. In Harris RL, editor: Patty’s indus- Fc = A + B + C Comparison value: 700 lb
trial hygiene and toxicology, ed 5, vol
If the estimated compressive forces exceeds 700 lb, consider a more detailed analysis or
4, New York, 2000, John Wiley & make changes. Note: This is just an estimate and its accuracy varies with posture,
Sons.) especially as the hands move forward of the shoulders.

the examiner determines the values listed on tially hazardous by this preliminary assessment
the worksheet and addresses the variables of tool, then a more elaborate biomechanical analy-
body weight, load, horizontal distance, and back sis taking into account multiplanar movement pat-
posture. These then become the components of terns can be applied.
an equation that can predict the potential or actual Let’s review our case study of Boston Packag-
existence of excessive lower lumbar compressive ing, Inc. The first step for the therapist was to
forces. At this juncture the therapist can mani- assess, via a quick screen, the risk potential of the
pulate any of the variables to provide the neces- job. At the time of the ergonomic assessment, two
sary ergonomic abatement. This can be done employees were working the line, one male and
on site and in many cases affect the situation one female. The man weighed 210 pounds, and
immediately. the woman weighed 130 pounds.
Although the issue of asymmetry is not ad- The Bloswick Estimation of Back Compressive
dressed in this quick screen, all of the most fre- Force was chosen as the quick reference guide.
quently encountered risk factors are identified and To illustrate the differences between potential
measured. If, again, the activity is deemed poten- and actual compressive forces, both individuals
186 PART III Special Considerations

were assessed. Figure 11-6 has the following com- the angle of trunk flexion. The comparative analy-
putations: sis of the two approaches, using the equation in
Figure 11-6, demonstrated the following.
Male Employee Female Employee
Body weight 210 lb 130 lb
Load 20 lb 20 lb Male Employee Female Employee
Horizontal 50 inches 24 inches Back posture 567 156
distance Load moment 500 240
(hands to Direct 100 68
lower back) compression
Trunk angle 0.9 (3/4 bend) 0.4 (1/4 bend) Sum 1167 lb 464 lb (2042 N)
(5134 N)
The reason for the considerable differences
between the male and female employees’ horizon-
tal and trunk angle distances was the male’s ten- It is quite clear that the male employee’s ex-
dency to stack the pallets back row first with a tremely forward bent posture, in addition to the
front-oriented approach. This resulted in his adop- excessive moment arm created by reaching over
tion of a stooped posture while lowering the load the length of the pallet, created forces to the lower
to the pallet, thus increasing the lever and moment lumbar structure far in excess than has been
arm and angle of trunk flexion (Figure 11-7, A). deemed safe by NIOSH’s lifting guidelines. In con-
Conversely the female employee chose a differ- trast, the female employee handled the same
ent approach. She preferred to walk behind the object in a much more efficient manner, exposing
pallet to load the back row. This allowed for the her to significantly less compressive force.
box to be maintained closer to the body and for The therapist’s first recommendation would be
her to employ the squat lift, one more appropriate to train all employees assigned to this packaging
for heavier loads (Figure 11-7, B). This in turn line in the proper loading of the pallet, in addition
reduced the lever and moment arm and decreased to demonstrating the proper lifting technique.

FIGURE 11-7 A, Male worker—stoop lift. B, Female worker—squat lift.
Chapter 11 Lifting Analysis 187

Further considerations would include recommen- everyday stressors can be mitigated if these crite-
dations regarding pallet height assistive devices ria are followed.
such as scissor or other hydraulic lifts that would Occupational and physical therapists possess a
limit the horizontal distance that would have to breadth of knowledge relative to the factors that
be negotiated. These, again, are examples of influence human performance. It is our responsi-
knowing what variables contribute to the risks bility as therapists to incorporate this knowledge
and how the variables can be manipulated to into common processes to prevent the maladies
mitigate the risks. associated with aberrant lifting practices through
After reflecting on the case study, answer the education, early intervention once an injury has
following questions:
1. Identify the most critical aspects of the sub-
ject’s work characteristics as outlined in this
case study that predispose him or her to Learning Exercise
injury. Overview
2. Which risk factors can be addressed imme-
Can the biomechanical analysis of a potentially
diately, and which can be minimized
injurious lift be captured by observation alone?
through work site design modification?
3. How are you, as the consulting therapist, Purpose
going to justify to the company’s adminis- The purpose of this exercise is to determine,
trators the expenditure of nonbudgeted through observation, what happens at various
monies to rectify the potential risks? joint structures (particularly the low back, hips,
knees, neck) at and approaching an individual’s
stated or perceived maximum lifting effort. If
your observations are reliable and can be repli-
The analysis of lifting, and the inherent risk cated, they can serve as means by which a work
factors associated with it, is an ongoing process. situation can be identified as potentially hazard-
The review of evidence literature reveals that ous. From that point a more empirically based
there is no particular lifting technique that is supe- analysis can be performed.
rior to another, but there are a number of princi-
ples that need to be observed when an individual Exercise
is exposed to a potentially difficult and injury- Observe classmates during a floor-to-waist lift
producing endeavor. To reiterate, these include using a standard milk crate as the container.
the following: Increase the load to be lifted by regular incre-
• Maintain the load as close to the body as ments (5 to 10 pounds) until the individual
possible reaches his or her safe lifting maximum. Observe
• Ensure adequate hand couple for the following:
1. At what point does the subject’s lifting
• Maintain the lumbar spine in as much of a
style change?
lordotic curve as possible
2. What lifting style (squat, stoop, semi-
• Lift in the sagittal plane, and avoid extrane-
squat) does the subject adopt at the
ous multiplanar movement patterns outset, and what style is employed at the
• Ensure proper footing maximal effort?
• Lift slowly 3. What changes in joint angulation (estimate
• Use the lifting technique (stoop, squat, semi- only) occur at the hip versus the low
squat) best suited for the situation back, knees, and head and neck as the
These principles can easily be applied to any subject advances from an easily managed
number of occupational scenarios that require load to one that is subjectively perceived
moderate or heavy lifting. From the shipping and as difficult?
receiving dock floor to the nursing unit, common
188 PART III Special Considerations

occurred, and postinjury maintenance program- 4. The lifting technique that requires greatest
ming. aerobic cost is:
A critical component of our involvement is to A. the stoop.
become familiar with the nuances of our patients’ B. the squat.
lifestyles, be it at work or at home, and what C. the semi-squat.
practices may put them at risk for lift-related low D. the kinetic lift.
back injury or the aggravation of an ongoing con-
dition. This requires observation not only in the 5. Per the NIOSH lifting guide, the
clinic but also at the work site and at times at maximum allowable force that the L5/S1
home. We must become mobile therapists, because segment can withstand is:
practice demands may require that we treat offsite, A. 2000 N.
at the work place, or in the clinic and that we B. 3400 N.
follow the patient once he or she has returned to C. 5000 N.
full duty. As a result I have been able to devote D. 1000 N.
this comprehensive care model for the worker
with an injury. It is through this ongoing involve- 6. Which of the following lifting techniques
ment with our clients and the commitment to would be ideal for a task that requires
further research that we can make a positive lifting frequent, light loads from the
impact on the occurrence and prevalence of lift- floor?
related injuries. A. Stoop
B. Squat
C. Semi-squat
Multiple Choice Review Questions D. Kinetic

1. The spinal motion segment consists 7. Which is the preferred lift of those who
of: are experiencing chronic or acute low
A. the apophyseal joint and lumbar back pain?
paraspinals. A. Stoop
B. adjacent vertebral bodies and the B. Squat
intervertebral disc. C. Semi-squat
C. the junction of the sacrum and the D. Kinetic
D. interspinous ligaments and vertebral 8. The optimal height range from which
endplates. to overcome inertial forces while pushing
2. The motion segment is exposed to which A. 90 to 115 cm.
force vectors(s)? B. 50 to 65 cm.
A. Compression, torsion, shear C. 100 to 125 cm.
B. Flexion, extension, sidebending D. 70 to 90 cm.
C. Sagittal, transverse, frontal
D. Ascending, descending, lateral 9. The variable that was used in the 1991
NIOSH lifting guide that set it apart from
3. The three most researched lifting its predecessor (i.e., the 1981 lifting
techniques include: guide) was:
A. squat, semi-squat, and stoop. A. vertical displacement.
B. stoop, kinetic, and crouch. B. horizontal distance from the load.
C. squat, quad, and astride. C. type of hand couple.
D. golfer’s, lateral, and semi-squat. D. frequency of the lift.
Chapter 11 Lifting Analysis 189

10. The Bloswick Evaluation of Low Back 14. Freivalds A, Chaffin DB, Garg A et al: A dynamic
Compressive Forces uses what benchmark biomechanical evaluation of lifting maximum
acceptable loads, J Biomech 17(4):251, 1984.
as its maximum allowable aggregate?
15. Gao G, Abeysekera J: A systems perspective of slip
A. 500 pounds and fall accidents on icy and snowy surfaces, Ergo-
B. 800 pounds nomics 47(5):573, 2004.
C. 1000 pounds 16. Garg A: What basis exists for training workers in
D. 700 pounds correct lifting technique? In Marras WS, Karwowski
W, Smith JL et al, editors: The ergonomics of manual
work, London, 1993, Taylor & Francis.
17. Garg A, Saxena U: Physiological stresses in ware-
REFERENCES house operations with special reference to lifting
1. Andersson GBJ: Epidemiologic aspects on low back technique and gender: a case study, Am Ind Hyg
pain in industry, Spine 6(1):53, 1981. Assoc J 46(2):53, 1985.
2. Bendix T, Eid SE: The distance between the load 18. Granata KP, Bennett BC: Low-back biomechanics
and the body with bi-manual lifting techniques, and static stability during isometric pushing, Hum
Appl Ergon 14(3):185, 1983. Factors 47(3):536, 2005.
3. Bureau of Labor Statistics: Lost-work time injuries 19. Granata KP, Marras WS: An EMG-assisted model of
and illness: characteristics and resulting time away loads on the lumbar spine during asymmetric trunk
from work, USDL 04-460, Washington, DC, 2002, extensions, J Biomech 26(12):1429, 1993.
U.S. Department of Labor. 20. Granata KP, Marras WS: Relation between spinal
4. Bush-Joseph C, Schipplein O, Andersson GB et al: load factors and the high-risk probability of occu-
Influence of the dynamic factors on the lumbar pational low-back disorder, Ergonomics 42(9):1187,
spine moment in lifting, Ergonomics 31(2):211, 1999.
1988. 21. Granata KP, Marras WS, Davis KG: Variation in
5. Butler D, Andersson GB, Trafimow J et al: The spinal load and trunk dynamics during repeated
influence of load knowledge on lifting technique, lifting exertions, Clin Biomech 14(6):367, 1999.
Ergonomics 36(12):1489, 1993. 22. Hagen KB, Harms-Ringdahl K, Hallen J: Influ-
6. Chaffin DB: A biomedical model for use in industry, ence of lifting technique on perceptual and cardio-
Am Ind Hyg Assoc J 3(3):79, 1988. vascular responses to submaximal repetitive
7. Chaffin DB, Andersson GB, Bernard MJ: Occupa- lifting, Eur J Appl Physiol Occup Physiol 68(6):477,
tional biomechanics, ed 4, New York, 2006, John 1994.
Wiley & Sons. 23. Kingma I, Bosch T, Bruin L et al: Foot positioning
8. Chen Y-L: Optimal lifting techniques adopted by instruction, initial vertical load position and lifting
Chinese men when determining their maximum technique: effects on low back loading, Ergonomics
acceptable weight of lift, Am Ind Hyg Assoc J 47(13):1365, 2004.
61(8):642, 2000. 24. Kollmitzer J, Oddsson L, Ebenbichler GR et al: Pos-
9. Damkot DK, Pope MH, Lord J et al: The relationship tural control during lifting, J Biomech 35(5):585,
between work history, work environment and low 2002.
back pain in men, Spine 9(4):395, 1984. 25. Kroemer KHE: Push forces exerted in 65 common
10. de Looze MP, Kingma I, Thunnissen V et al: The work positions, AMRTL-68-143, Wright-Patterson
evaluation of practical biomechanical model esti- Air Force Base, Ohio, 1969, Aerospace Medical
mating lumbar moments in occupational activities, Research Laboratory.
Ergonomics 37(9):1495, 1994. 26. Kroemer KHE, Robinson DE: Horizontal static forces
11. de Looze MP, van Greuningen K, Rebel J et al: Force exerted by men standing in common working pos-
direction and physical load dynamic pushing and tures on surfaces of various tractions, AMARL-TR-
pulling, Ergonomics 43(3):377, 2000. 70-114, Wright-Patterson Air Force Base, Ohio,
12. Dolan P, Earley M, Adams MA: Bending and 1971, Aerospace Medical Research Laboratory.
compressive stresses acting on the lumbar spine 27. Kumar S: Lumbosacral compression in maximal
during lifting activities, J Biomech 27(10):1237, lifting efforts in sagittal plane with varying mechan-
1994. ical disadvantage in isometric and isokinetic modes,
13. Fox WF: Body weight and coefficient of friction Ergonomics 37(12):1975, 1994.
determinants of pushing capability. In Human Engi- 28. Lee YH, Lee TH: Human muscular and postural
neering Special Studies Series, No 17, Marietta, Ga, responses in unstable load lifting, Spine 27(17):1881,
1967, Lockheed. 2002.
190 PART III Special Considerations

29. Levangie PK: Association of low back pain with 43. Schibye B, Skogaard K, Laursen B et al: Mechanical
self-reported risk factors among patients seeking load of the spine during pushing and pulling. In
physical therapy services, Phys Ther 79(8):757, Seppalla P, Luopajarvi T, Nygard CH et al, editors:
1999. Proceedings of the 13th Triennial Congress of the
30. Magnusson M, Granqvist M, Jonson R et al: The IEA, vol 4, 1997.
loads on the lumbar spine during work at an assem- 44. Shin G, Mirka G: The effects of a sloped ground
bly line. The risks for fatigue injuries of vertebral surface on trunk kinematics and L5/S1 moment
bodies, Spine 15(8):774, 1990. during lifting, Ergonomics 47(6):646, 2004.
31. Marras WS, Davis KG, Kirking BC et al: A compre- 45. Straker LM: A review of research on techniques for
hensive analysis of low-back disorder risk and lifting low-lying objects: 2. Evidence for a correct
spinal loading during the transferring and reposi- technique, Work 20(2):83, 2003.
tioning of patients using different techniques, Ergo- 46. Straker L, Duncan P: Psychophysical and psycho-
nomics 42(7):904, 1999. logical comparison of squat and stoop lifting
32. Marras WS, Lavender SA, Leurgans SE et al: The by young females, Austr J Physiother 46(1):27,
role of dynamic three-dimensional trunk motion 2000.
in occupationally-related low back disorders. The 47. Toussaint HM, van Baar CE, van Langen PP et al:
effects of workplace factors, trunk position, and Coordination of leg muscles in backlift and leglift,
trunk motion characteristics on risk of injury, Spine J Biomech 25(11):1279, 1992.
18(5):617, 1993. 48. Troup JD, Leskinen TP, Stalhammar HR et al: A
33. Marras WS, Sommerich CM: A three-dimensional comparison of intraabdominal pressure increases,
motion model of loads on the lumbar spine: I. hip torque, and lumbar vertebral compression in
model structure, Hum Factors 33(2):123, 1991. different lifting techniques, Hum Factors 25(5):517,
34. McGill S: Low back disorders: evidence-based pre- 1983.
vention and rehabilitation, Champaign, Ill, 2002, 49. van Dieen JH, Hoozemans MJ, Toussaint HM: Stoop
Human Kinetics. or squat: a review of biomechanical studies on
35. McGill SM, Norman RW: Effects of an anatomically lifting technique, Clin Biomech 14(10):685, 1999.
detailed erector spinae model on L4/L5 disc com- 50. Wickel E, Reiser RF: Effect of floor slope on submaxi-
pression and shear, J Biomech 20(6):591, 1987. mal lifting capacity, Presented at the Rocky Moun-
36. Mittal M, Malik SL: Biomechanical evaluation of lift tain Bioengineering Symposium & International ISA
postures in adult Koli female labourers, Ergonomics Biomechanical Sciences Instrumentation Sympo-
34(1):103, 1991. sium, Ft. Collins, Colo, 2004.
37. Nachemson A: In vivo measurements of intradiscal 51. Wrigley AT, Albert WJ, Deluzio KJ et al: Differenti-
pressure, J Bone Joint Surg Am 46:1077, 1964. ating lifting technique between those who develop
38. NIOSH: Work practices guide for manual lifting, low back pain and those who do not, Clin Biomech
U.S. Department of Health and Human Services, 20(3):254, 2005.
NIOSH Technical Report No. 81122, Cincinnati,
1981, NIOSH.
39. NIOSH: Scientific support documentation for the
revised 1991 NIOSH lifting equation: technical con- SUGGESTED READING
tract reports, Springfield, Va, 1991, U.S. Department The resources below may be obtained
of Commerce, Technical Information Service.
through the following website:
40. Potvin JR, McGill SM, Norman RW: Trunk, muscle
and lumbar ligament contributions to dynamic lifts ~tbernard/ergotools:
with varying degrees of trunk flexion, Spine • Liberty Mutual Manual Materials Handling
16(9):1099, 1991. Tables (1991)
41. Rabinowitz D, Bridger RS, Lambert MI: Lifting tech- • Utah Back Compressive Force by Donald S.
niques and abnormal belt usage: a biomechanical, Bloswick
physiological and subjective investigation, Safety • NIOSH Work Practices Guide for Lifting
Sci 28:155, 1998.
42. Resnick ML, Chaffin DB: Kinematics, kinetics, and
psychophysical perceptions in symmetric and twist- • Static Work Analysis, based on Rohmert
ing pushing and pulling tasks, Hum Factors methods.
38(1):114, 1996. • Estimation of Metabolic Rate

Ellen Rader Smith

Learning Objectives
After reading this chapter and completing the exercises, the reader should be able to do the following:
1. Appreciate the importance of the seated worker’s need for good chair support.
2. Appreciate the natural conflicts between the body’s need for dynamic movement and the need for support
while seated.
3. Apply basic ergonomic and biomechanical principles and job or task analysis to make appropriate chair

Adjustability. The ability to change; with reference to Static muscle loading. A continuous state of muscle
chairs, features should allow, rather than inhibit, pos- contraction without active movement; as related to
tural changes. maintaining one fixed work posture; associated with
ANSI/HFES. The American National Standards Insti- depleting muscles of oxygen and fresh blood supply
tute/Human Factors and Ergonomics Society, the orga- and the accumulation of waste products.
nizations that are jointly developing new ergonomic
guidelines for computer workstations.

*Portions of this chapter are retained from the previous edition chapter written by Diane C. Hermenau.

192 PART III Special Considerations

It has long been known that movement is essen-
Jim is a dental technician and the owner of a full-service tial to health, well-being, and levels of alertness.
dental laboratory. He sustained injuries to the cervical People are designed for activity and not sitting.
spine in a motor vehicle accident. Following C4-5 surgical The body’s need for movement is common knowl-
fusion, Jim was initially unable to resume work duties edge even to laypersons, who, for example, begin
because of his inability to maintain the required work seeking more comfortable positions and making
posture or sustain his upper body in a position to allow postural adjustments during extended car rides,
the performance of fine precision required to finish dental after initially being able to sit comfortably. While
crowns, paint and glaze teeth, or sit at a computer and true for both passengers and drivers, this is par-
perform the administrative aspects of his business. Occu- ticularly true for the driver who is “glued” to the
pational therapy and ergonomic intervention were initi- steering wheel and needs to remain focused on
ated to facilitate Jim’s return to work. This involved a the road. Changing the seat inclination and stop-
review of his specific work duties at two dental benches ping the car to take a stretch break are other
and at his desk so that the appropriate chairs could comfort-driven actions with which lay persons are
be selected in conjunction with other ergonomic inter- familiar. Take this real-life situation a step further
ventions. and consider the effects of prolonged sitting on a
long-distance truck driver, who is also exposed to
jarring shocks and vibration and who is limited in
his freedom to stop because of his need to reach
his destination in a timely manner. Similarly,

C oncomitant with the growth of computers

throughout industrial and traditional offices
and the changed nature of workplace from multi-
employees at light assembly, inspection, and con-
veyor workstations are captives in their chairs and
work areas and lack the free-dom to get up45 or
dimensional to unidimensional is the importance move around because they are performing one
of supportive chairs for workers who are required step in a work process that depends on each
to sit the majority of the day. The workday no worker in the production process. Office workers
longer has many of the natural breaks that used in nonelectronic offices used to have many built-
to be related to the diverse job tasks that allowed in breaks, such as retrieving files or reference
workers greater opportunities to get up and move information, faxing, copying, and face-to-face
around. For this reason, chair design and selection communication with co-workers. In today’s elec-
are at the core of ergonomic workstation design tronic office workers are no longer afforded many
and are critical to the comfort, well-being, and of the traditional breaks from prolonged sitting,
productivity of all seated persons, whether they because these tasks can now be routinely per-
be office workers, assembly line workers, produc- formed at self-contained workstations, minimiz-
tion workers, students, administrative assistants, ing workers’ need to get up.13
or office executives, because poorly designed Researchers began studying the effects of sitting
workstations put users at risk for musculoskeletal on the body in the 1940s. Sitting has been defined
injuries. as a position in which the weight of the body is
Increasingly, therapists with expertise in seating transferred to a supporting area, mainly by the
and ergonomic workplace design are working as ischial tuberosities of the pelvis and their sur-
industrial consultants for seating issues. This rounding soft tissues.49 In sitting, most of the body
chapter discusses the biomechanics of sitting, the weight is on the buttocks, back, and feet. Biome-
risks related to prolonged sitting and poor posture, chanical and ergonomic research has flourished
the features of ergonomic chair design, and since the 1970s when back pain and other mus-
the importance of a proper worker-workstation culoskeletal issues related to sitting and static
fit as part of an ergonomically correct work muscle loading were identified as a larger part of
environment. health and wellness issues, particularly as work
Chapter 12 Seating 193

in many sectors, such as textiles and laboratories, allows the chair, along with the floor or a footrest,
has become more sedentary. Jobs that once to support the seated person’s body mass. With
involved a variety of tasks that allowed workers all this said, it must be realized that the body was
the opportunity to freely move around their work designed not to sit, but rather to move. This pres-
areas now require sitting for prolonged periods in ents a dichotomy: Should we sit or stand, as
fixed postures at computer terminals. neither is entirely restful for our bodies, or should
Occupational and physical therapists who ad- we find some balance between the two?
dress well populations, young and old, working Most sitting or sedentary work tasks require
and nonworking, realize that the issues related to the use of the hands and arms to accomplish
sitting comfortably are not restricted to the work- meaningful tasks or work. However, with little
place. Consider students from preschool through active or dynamic movement of larger muscle
college who are using computers more and more. groups, these muscles are in a prolonged state of
What type of chairs do they have? On what type of contraction and a state of heightened tension.23
work surfaces are the computers placed? Are Because the muscles are not afforded the benefits
changes made to one or the other or both as a child of active pumping of blood that transports sugar
grows? Have the schools recognized the role of and oxygen to dynamically contracting muscles,
ergonomic furnishings for computers that are now they must depend on their own reservoirs. This
used throughout the system, and in particular results in the buildup of waste products such as
placed side by side in limited areas at tables that CO2 and lactic acid, which then causes muscle
are not always intended for computers? Consider spasms and fatigue.
students who sit in the classroom all day and who Movement helps increase blood flow through-
then sit at their home computers to do homework out the body to the muscles and relieves pressure
or in front of electronic game systems. Whether on the discs. A lack of active movement while
doing research at home or in the library, students, sitting and working in relatively flexed postures
professionals, and nonprofessionals alike can do also results in static muscle loading, which can
more from one sedentary posture by clicking on lead to venous pooling, causing the legs to swell.
the Internet than by actively exploring bookshelves Another consideration in assessing the effect on
or files. It is clear that healthy sitting habits need seated posture is how the maximal voluntary
to be instilled in students from a young age and contraction (MVC) relates to the onset of muscle
that they need to integrate movement into their fatigue and the recovery time from static work
regular lifestyle and way of life, to reduce the risk loads.12 Cortlett compares the limits of static work
for any of the conditions that are well known to a to the experience of muscle pain, similar to how
generation of “couch potatoes” (see Chapter 14). elevated heart rates or shortness of breath are
indicators of the limits of physical activity. Grand-
jean notes that MVCs of <20% of the maximal
THE BODY’S NEED FOR MOVEMENT muscle contraction, and in particular those not
We often sit because of the fatigue that results greater than 8% of the maximum, can be held for
from standing, as sitting requires about 20% less longer periods without fatigue, in contrast to
energy in comparison with standing.25 Sitting is shorter tolerances to sustain static work when a
also a more efficient way to perform many occu- high percent of a person’s maximum force is
pational and nonoccupational tasks, as the chair required.23 Rodgers has done extensive research
offers the necessary support and stability that is a on the interrelationships of static work loads,
prerequisite to performing purposeful coordinated required rest periods, job design, and job enlarge-
movement or work tasks. Sitting in many jobs ment to minimize the effects of these issues for
makes good sense, as it relieves the body’s sup- seated workers.44
porting muscles (e.g., those of the trunk and legs), At the computer, keyboarding involves both
offers them a chance to rest, and is less demand- static and dynamic work, as does light assembly
ing on the blood circulation to the legs. Sitting work when the work object is near the operator.
194 PART III Special Considerations

Static muscle work is required by the shoulders Although blood flows along the spine, there is a
and arms to hold the hands at the required work limited blood supply to the discs.
position, and dynamic finger and hand motions
are required to key or manipulate objects. Use of Lower Body
a mouse is often associated with higher static When sitting, the pressure falls onto the two small
loading factors, as the mouse is not always adja- “sit bones” or the ischial tuberosities. Compres-
cent to the keyboard, resulting in arm postures sive stresses exerted on areas of the buttocks
associated with extended forward or lateral arm beneath the tuberosities are high and have been
reaches. It will become more evident throughout estimated as 85 to 100 psi, with the forces almost
this chapter that the chair must provide users with doubled when sitting cross-legged.51 Studies of
optimal support, enabling them to best interface persons sitting upright on flat seating, such as
with their work tools. At the same time, workers bleachers, have found significant buildups of pres-
need regular dynamic movement interspersed sure that can exceed those that have been deter-
throughout the day to relieve the cumulative mus- mined to cause blood circulation problems in
culoskeletal strain that results from sustained, users of wheelchairs.11 This can easily explain
static body postures. We may even know this why this type of sitting posture cannot be sus-
subconsciously when we squirm in our seats or tained more than briefly and why most of the
get up to take breaks. In a sense, we are listening chairs we sit in offer more padding and support.
to the body’s cues that it is time to relieve the When one sits upright, approximately two thirds
static posture and change positions. The tenet of of the body’s weight is distributed to the chair
movement must be included as a regular part of seat, with the backrest, armrest, and floor sup-
all ergonomics training, including that for new porting the remainder.11 Research suggests that
chairs, because workers may inadvertently think maintaining one third or less of the body
that they can sit without breaks in their new weight on the feet is necessary to minimize leg
chairs. discomfort.12
The sacrum is essentially fixed and moves in
relation to the pelvis. A forward or anterior rota-
ANATOMIC AND BIOMECHANICAL tion of the pelvis causes the lumbar spine to move
CONSIDERATIONS toward increased lordosis to maintain an upright
A review of anatomy is helpful to fully appreciate trunk. When the pelvis tilts backward, the lumbar
the biomechanics of sitting. Thirty-three vertebrae spine tends to flatten, causing kyphosis. Radio-
comprise the spine, including the cervical, tho- graphic studies have verified that the pelvis rotates
racic, and lumbar vertebrae; the sacrum; and the backward and the lumbar spine flattens during
coccyx. In standing the spine forms three natural sitting.* Disc pressures also change dramatically
curves: the cervical and lumbar curves are inward when a person moves among standing, upright,
(lordosis), and the middle or thoracic curve is and slouched seated postures (Figure 12-1).
outward (kyphosis). The cervical and lumbar por- Nachemson and Elfström36 and Andersson and
tions of the spine are mobile in relation to the Ortengren5 found that disc pressure is greater
thoracic spine. The intervertebral discs are located during sitting than during standing and that disc
among the vertebrae, act as shock absorbers, and pressures drop with an inclination of the chair
provide flexibility to the spine. Ligaments provide backrest (the angle formed between the seat and
stability to the vertebrae and are located on the the backrest), especially when it is tilted from
anterior and posterior walls of the spine. Muscles vertical to 110 degrees. Nachemson and Morris
along the spine maintain posture and provide sta- published data on in vivo disc pressure measure-
bility to the trunk. The nerves that comprise the ments in people who stood and sat without
spinal cord are protected by the vertebrae and support. They reported that the pressures mea-
pass to the extremities, allowing motor and
sensory information to pass to and from the brain. *References 1, 4, 7, 8, 29, 48, 49, 52.
Chapter 12 Seating 195






Standing Sitting Relaxed Relaxed Straight Anterior Anterior Posterior

at ease relaxed Arms Feet un- straight
supported supported

FIGURE 12-1 Variations in disc pressure among various unsupported seated postures, in comparison with a
person standing at ease. (From Chaffin D, Andersson G: Occupational biomechanics, New York, 1984, Wiley & Sons.)

sured in standing subjects were approximately increases the viewing distance and arm reach to
35% lower than those measured in seated sub- the work area. It can also increase strain on the
jects.37 Research also demonstrates that increased neck if the user flexes his or her head forward for
disc pressure means that the discs are being over- viewing, without the benefits of a high backrest
loaded and will wear out more quickly.24 or even a headrest. Upright postures involve the
There are several reason why preserving the trunk being upright and straight, with the seat and
lumbar lordosis is critical to healthy sitting. With backrest at an approximate 90-degree angle and
a change to kyphosis, the body’s center of gravity the center of body mass over the ischial tuberosi-
shifts from over the lumbar spine to in front of it. ties. In forward postures, the seat and backrest are
With the shift of upper body weight, the space tilted forward, placing the center of mass in front
between lumbar discs is compromised, causing of the ischial tuberosities. These postures are
low back muscle fatigue and pressure on the usually assumed in relation to the task, for
lumbar discs, disrupting the normal equilibrium.13 example, fine detail work often involves leaning
Various sitting positions also reflect changes in forward, telephone conversations can be con-
the seated person’s center of gravity (Figure 12-2). ducted while reclined, and work at a keyboard is
In reclined postures, the seat and backrest are usually performed in an upright posture (or the
tilted backward and the center of body mass is so-called “traditional series” of 90-degree body
behind the ischial tuberosities. Although this links).
posture reduces the pressure on the discs, it is not Muscle activity has been extensively researched
necessarily functional for working because it also through electromyography (EMG) of the back mus-
196 PART III Special Considerations





Arms Writing Type- Lifting Depression Relaxed

hanging writing weight of pedal

FIGURE 12-2 Disc pressure has been compared in various seated postures while the person with low back
support performs usual desk activities. (From Chaffin D, Andersson G: Occupational biomechanics, New York, 1984,
Wiley & Sons.)

cles during standing and sitting. Studies by Lun- by bringing the upper trunk over the hips.
dervold31-33 and Floyd and Roberts22 reported that Zacharkow points out that because sitting is a
myoelectric activity decreases when the back dynamic activity, people sit on their ischial tuber-
support is located in the lumbar region rather than osities, causing the pelvis to rock. Without sacral
in the thoracic region. This confirmed a finding by support to produce an anterior pelvic tilt, the
Åkerblom,1 who performed the first comprehen- sacrum rotates posteriorly, bringing the lumbar
sive study of the biomechanics of sitting, that a spine into a flattened or kyphotic position. A
support in the lumbar region is as effective as a full forward seat-pan tilt, advocated by Mandal,34 can
back support. Fifty years later, however, the needs also reduce pressure on the discs and increase the
of many seated workers and, in particular, compu- lordosis. An issue for many workers in this posture
ter operators also require upper body support to is a feeling that they are sliding from the seat. This
address the static muscle demands posed by the issue can, however, be adjusted for by proper seat
nature of work today. height adjustments, which usually require increas-
Zacharkow’s research supports the theory that ing the overall seat height and providing the
supporting the sacrum and lower thoracic spine proper support beneath the feet.
is necessary to achieve proper sitting posture.56 EMG supports the finding that sitting in a
The rationale behind sacral–lower thoracic support slouched or reclined position relaxes the trunk
when sitting is that the proper axial relation muscles and requires minimal muscle activity to
between the thorax and the pelvis must be restored hold the body weight in balance. However, disc
Chapter 12 Seating 197

pressures are greatest when a person sits with a movement distance between the axis of motion
slouched posture. This represents another dichot- and the head’s center of gravity, can show a five-
omy between postures that are best for minimiz- fold increase acting on the erector spinae muscle
ing disc pressures and those that involve less and an almost two-and-one-half–fold increase in
muscle exertion. Similarly, although the reclined the reaction force on the C5 disc when comparing
sitting posture is associated with lesser amounts erect postures with 45-degree flexed postures for
of disc pressure, this cannot be a functional work screen viewing.43 In addition, when the head is
position, and the associated extended reaches to held forward for extended periods of time,
the work area will again throw off the body’s increased posterior cervical muscle activity is
equilibrium. required to support the weight of the head, result-
When someone is seated, the legs need to be ing in increased muscle fatigue.
supported so that they do not dangle, allowing the The line of vision dictates head and neck
muscles to pull on the hip and in turn the low posture. If the work surface is too low or the
back. Prolonged sitting can also cause compres- computer screen is too far away from the user,
sion of the sciatic nerve, resulting in paresthesias. neck and trunk flexion result. If work items are
Proper positioning and support are also important located to the sides, there is increased strain on
when sitting because of circulatory issues related the lateral support muscles, as the head rotates to
to the lower extremities being in a dependent allow viewing of the work item (e.g., a monitor
position and vulnerability of the popliteal area that is not positioned in-line relative to the key-
behind the knee. This can result in restricted board). Studies of computer operators reveal that
blood circulation if the two major veins in this while the small muscles of the forearms and hands
area are compressed by the weight of the body or are undergoing near constant dynamic contrac-
from a seat pan that is too deep and does not tions, the proximal muscles of the shoulders and
provide 1 to 2 inches of clearance between the neck statically contract to provide postural
seat edge and back of the knees. Winkel notes that support. Onishi and co-workers reported that
increases in lower extremity volume of 4% occur EMG activity of the trapezius muscle reached 20%
over a workday, that supporting the legs with to 30% of its maximal level of contraction during
either the floor itself or a footrest can help mini- keyboard operations.40 Having the arms supported
mize this effect, and that movement every 15 has been found to decrease activity levels of the
minutes can reduce swelling up to 2.3%.54,55 trapezius muscle, but this is not always a feasible
work posture. Improper visual correction is
Upper Body