musculoskeletal disorders within the telecommunications sector—a systematic review

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International Journal of Industrial Ergonomics 38 (2008) 56–72

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Musculoskeletal disorders within the telecommunicationssector—A systematic review

Joanne O. Crawford�, Elpiniki Laiou, Anne Spurgeon, Grant McMillan

Institute of Occupational and Environmental Medicine, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK

Received 31 October 2005; received in revised form 25 May 2007; accepted 18 August 2007

Available online 3 October 2007

Abstract

A systematic review was carried out to address a set of questions with regard to the development and prevention of musculoskeletal

disorders (MSDs) in telecommunications workers. The review was carried out using the methodology developed by the Center for

Reviews and Dissemination, The University of York. After an initial scoping study, searches were undertaken using a variety of

databases. Two researchers reviewed each paper independently and then completed data extraction forms. The review found that MSDs

and related risk factors occurred during a range of service technicians’ work tasks including manhole cover removal, ladder handling,

overhead line work, cable handling and road breaking. There was increased reporting of musculoskeletal symptoms in call center workers

compared to other computer users. Risk factors included non-optimal workplace layout and work organization issues. Although

psychosocial factors were found to be implicated in the etiology of all types of MSDs, they appear to have more of an impact in the neck

and shoulder region. Minimal research was found to support preventive interventions for call center workers. No evidence was found to

support the use of health surveillance in either service technicians or call center workers. Data gaps and examples of best practice were

identified.

Relevance to industry

The telecommunications industry is at the forefront of technological change for business and home communication. This review

identifies risk factors for MSDs within this industry and highlights data gaps which future research needs to address.

r 2007 Elsevier B.V. All rights reserved.

Keywords: Service technicians; Call center workers; Upper limb disorders; Back disorders; Intervention studies

1. Introduction

Within the European Union (EU), the number ofworkers involved in the telecommunications industry is1.3 million (Lumio, 2005). This represents both servicetechnician work (those involved in building, maintainingand setting up telephone networks) and call center staff(those involved in customer services, sales and support). In2004, the Health and Safety Working Group (2004) of theSocial Dialogue Committee for Telecommunications with-in the EU agreed to carry out a survey of all Telecommu-nications workers within the EU to identify the scale andprincipal risks associated with telecommunications work

e front matter r 2007 Elsevier B.V. All rights reserved.

gon.2007.08.005

ing author. Tel.: +44131 419 8037; fax+44870 850 5132.

ess: [email protected] (J.O. Crawford).

including service technician work and call center work. Thesurvey responses represented 420,000 workers who arethought to be at risk of musculoskeletal disorders (MSDs)in their work.The type of work tasks carried out by service technicians

includes underground cabling, cable handling both heavy-weight and fiber optic cables, overhead cable handling andladder handling; road digging to access undergroundcables, maneuvering of manhole (steel access) covers andexposure to vibration from specific tools used. For servicetechnicians, the main concerns identified in the survey weremanual handling, specifically cable activity underground.Call center workers deal with incoming and outgoing

telephone calls for a range of different aspects in thetelecommunications industry; including sales and supportto customers and new customers. The job is often

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ARTICLE IN PRESSJ.O. Crawford et al. / International Journal of Industrial Ergonomics 38 (2008) 56–72 57

pressurized by having specific targets to meet with regardto time on each call or the number of customers dealt witheach day. The majority of staff work both with telephonesand computers in a seated computer workstation. Thesurvey identified that the main hazards for call centerworkers included poor ergonomics and postural issues andone area highlighted was the use of portable computingequipment in vehicles.

The survey demonstrated that there are wide scaleproblems with MSDs within the telecommunicationsindustry. In order to improve this situation a programmeof work was developed by industry representatives todevelop good practice and prevention of MSDs within thissector. The programme included a systematic review ofMSDs in telecommunications workers and the sponsorsdeveloped the questions addressed in the review.

The aims of the systematic review were to address thefollowing:

(1)
Which MSDs are likely to be associated with tele-communications work?
(2)
Which functional activities are particular risk factorsfor the development of MSDs in telecommunicationsworkers?
(3)
How important are psychosocial factors in the devel-opment of MSDs in telecommunications workers?
(4)
What measures are effective in preventing MSDs intelecommunications work?
(5)
Is health surveillance an effective tool in preventing ormodifying the progression of MSDs?
(6)
Identification of best practice in manual handling anddisplay screen equipment (DSE) activities.
2. Methodology

The review was conducted using the methodologydeveloped by the Center for Reviews and Disseminationat the University of York (The University of York: NHSCentre for Reviews and Dissemination, 1996). The searchstrategy was developed after a scoping study and research-ers spent time with employees in a call center identifyingthe specific work tasks carried out. In addition, researchersvisited a service technician training center to observe thework tasks carried out including underground cabling,network installation, overhead cabling and manhole covermaneuvering. A total of 170 single search terms andconcepts for call center and service technician work weredeveloped in conjunction with the sponsors (Tables 2.1 and2.2: published on http://www.msdonline.org/). The searchterms were cross-searched through the following searchengines; Medline, Pub Med, Web of Knowledge (ScienceCitation Index and Social Science Citation Index),Ergonomic Abstracts Online, Psychinfo, SIGLE, COPAC,BLPC and the Cochrane Database of Systematic Reviews.Not all of the 170 search terms could be used within each ofthe search engines because the databases do not have aconsistent vocabulary. Attempts were made to use similar

keyword/phrase combinations in the searches so as tomaintain the same essential pattern for each search butadjustments were made for databases that enabledcontrolled vocabulary searching in addition to keywordsearching. Government literature was also reviewed fromsources including the Health and Safety Executive, theEuropean Agency for Health and Safety and the NationalInstitute for Occupational Safety and Health (NIOSH).The sponsor was asked to provide any industry publica-tions not available in the public domain.Inclusion criteria were developed to ensure that the first

screening of abstracts identified articles that were relevantto the questions to be addressed. All abstracts and fullarticles retrieved were screened according to the following apriori inclusion criteria: (1) is a randomized controlledstudy, quasi-experimental, cross-sectional, observational,case report, or qualitative research in design; (2) includes astudy population of telecommunications service techni-cians, call center workers or workers performing similaractivities, e.g., cable handling, road digging, office workersusing DSE; (3) includes measurement of incidence orprevalence of MSDs or measurement of functionalactivities associated with the development of MSDs orassessment of psychosocial factors in the development ofMSDs or measurement of predictive factors in thedevelopment of MSDs or assessment of preventive inter-ventions in MSDs or identification of best practice; (4)provides information on MSD related outcomes.The searches were managed within the Reference Manager

(version 11) software. In the first instance, abstracts wereprinted and two researchers independently reviewed eachabstract against the inclusion criteria. Where agreement wasreached for abstracts that met the inclusion criteria, fullpapers were obtained. If a disagreement occurred, theresearchers discussed the abstract to reach a conclusion.For abstracts that reached the inclusion criteria, full

papers were obtained and reviewed independently by twoof the four review team members. The data obtained fromeach article was extracted onto prepared data extractionforms. Each reviewer independently rated the quality of thepaper on the scale below based on the study design (RCT,prospective or cross-sectional), numbers in the studypopulation, whether a valid data collection methodologywas used and confidence limits within the data found. Thismethod was successfully used for the development ofoccupational health guidelines for low back pain (Waddelland Burton, 2000):

(***)
strong evidence, provided by consistent findings inmultiple, high quality scientific studies;
(**)
moderate evidence, provided by generally consistentfindings in fewer, smaller or lower quality scientificstudies;
(*)
limited or contradictory evidence, produced by onescientific study or inconsistent findings in multiplescientific studies;
(–)
no scientific evidence;
http://www.msdonline.org/

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where the reviewers did not reach agreement on the quality
of the paper, the reviewers met and discussed the paperuntil a conclusion was reached. If necessary, a thirdreviewer was made available to further review the paperto reach a conclusion.
3. Results

3.1. The review process

The initial search using all the databases identified 643papers relevant to the review. Two reviewers assessed eachabstract to identify those that reached the inclusioncriteria. Out of the original 643 papers, 184 full paperswere obtained for review and data extraction.

The full papers were distributed amongst the researchteam for review and data extraction. There was consistentagreement between the reviewers with regard to assessmentof inclusion and quality of the research; only three papersrequired review by a third researcher. Out of the 184 fullpapers selected, only 43 were considered to fit the inclusioncriteria. There were several reasons for the high level ofrejection including the population description not meetingthe criteria, work tasks not being similar to those carriedout by telecommunications workers and the paper beingreview or summary in nature rather than research.

The methodological quality of the research papersincluded in the review was, on the whole papers providingmoderate or limited evidence. There were few randomizedcontrol trials (RCTs) with most being cross-sectionalresearch studies.

3.2. Prevalence of various work related MSDs in

telecommunications workers

3.2.1. Service technicians

Studies that identified which MSDs were associated withservice technician work are reported in Table 1. Muscu-loskeletal discomfort was found in 25% of a sample of 143electricity linesmen (Graves et al., 1996) and 40% oftelephone linesmen surveyed self-reported that they hadhad cumulative trauma disorders during their working lives(Vilkki et al., 1996). The prevalence of low back discomfortranged from 63.6% to 66%, reporting of knee discomfortranged from 30% to 33.6%, shoulder discomfort rangedfrom 31.5% to 43%, hip/thigh discomfort was reported at18.9% as was ankle/feet discomfort and 41% reportedneck discomfort (Graves et al., 1996; May et al., 1997).

In terms of jobs that require similar activities, researchinto hand–arm vibration syndrome (HAVS) found that gasdistribution workers involved in road breaking work havea prevalence of 10% to 24% (Walker et al., 1985; Palmeret al., 1998).

3.2.2. Call center workers

Although 15 studies were included in the review, only 12of these identified which MSDs were linked to call center

work. None of the studies reviewed linked any specificdisorder to call center work; rather they measured pain anddiscomfort. The methodologies used within these studiesincluded clinical examination (four studies), validatedquestionnaires (seven studies) and non-validated measures(five studies). The different methodologies impact on thequality of the research reviewed.One study identified that in comparison with other

computer users, a higher proportion of call center workersreported MSD symptoms (Norman et al., 2004). Theadjusted relative risk (incidence rate ratios) for newsymptoms in call center operators compared with areference group were found to be significantly higher inthe call center operators with 2.1 (95% CI 1.2–3.6) for menand 0.71 (95% CI 30–1.7) for women. When these datawere adjusted for age and gender, the relative risk for thegroup was found to be 1.3 (95% CI 0.79–2.1) indicating anincreased but not significant risk of musculoskeletalsymptoms in the call center group. (Toomingas et al.,2003). From clinical examination, the prevalence of MSDsymptoms was 22% in 533 telecommunications workers(Hales et al., 1994). From questionnaire studies, theprevalence of symptoms ranged from 17% to 75% (Nor-man et al., 2004; Hales et al., 1994; Bergqvist et al., 1995;Chung and Choi, 1997; Cook et al., 2000; Cook andBurgess-Limerick, 2004; Ferreira and Saldiva, 2002;Hoekstra et al., 1992; Jensen et al., 2002b; Park et al.,1997). This range reflects different questionnaire toolsbeing used.The most common symptoms reported were myofascial

pain syndrome, tendon related symptoms, joint relatedsymptoms and nerve related symptoms (Park et al., 1997).The most common body areas affected by discomfort werethe neck, shoulder and hand/wrist (Bergqvist et al., 1995;Chung and Choi, 1997; Ferreira and Saldiva, 2002; Jensenet al., 2002a; Hoekstra et al., 1996).

3.3. Physical and psychosocial risk factors associated with

the development of MSDs

3.3.1. Service technicians

A number of functional activities that pose increased riskfor musculoskeletal injuries have been identified and arepresented in Table 2. There is evidence that manholecover removal results in high compression forces of the lowback that are linked to an increased risk of injury (Changet al., 2003a, b; Imbeau et al., 2001; Mital and Motorwala,1995). A number of tools that reduce the compressionforces on the lower back when lifting manhole coverswere also reported (Chang et al., 2003a, b; Imbeau et al.,2001).Ladders have been suggested as a risk factor for

overexertion injuries of the back and shoulder. Specificrisks were associated with the weight of the ladder, theenvironment in which the ladder is used, loading the ladderonto the shoulder and loading and unloading ladders fromvehicles (Imbeau et al., 1998). In addition to handling

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Table 1

Prevalence and severity of MSDs in telecommunications workers

Study/study

design

Study population Method Outcomes

Service technician workers

Cross-sectional

study (*)

(Graves et al.,

1996)

143 electricity distribution linesmen Nordic musculoskeletal questionnaire

(NMQ), OWAS, biomechanical analysis

of postures

25% of participants reported

musculoskeletal discomfort over an 8-

month period:

63.6% reported low back discomfort

33.6% reported knee trouble

31.5% reported shoulder discomfort

18.9% reported hip/thigh discomfort

18.9% reported ankle/feet discomfort

Cross-sectional

study (*) (May

et al., 1997)

120 linesmen Questionnaire on musculoskeletal

discomfort, on-site task analysis, Extreme

Posture Checklist, RULA

66% of the respondents reported low

back discomfort

30% reported knee trouble

43% reported shoulder discomfort

41% reported neck discomfort

Cross-sectional

survey (**)

(Palmer et al.,

1998)

153 gas distribution operatives Modified Faculty of Occupational

Medicine (FOM) questionnaire, clinical

examination, cold challenge test

24% of the sample had vibration white

finger

Cross-sectional

study (**)

(Walker et al.,

1985)

895 gas distribution workers and 546m

readers (control group)

Nurse-administered questionnaire on

circulation to the hands

Prevalence of white finger was 9.6% in the

exposed group and 9.5% in the control

group Prevalence of white finger in the

exposed group, adjusted for age

differences between the two groups, was

12.2% in the exposed group

Cross-sectional

study (*) (Vilkki

et al., 1996)

72 telephone linesmen Questionnaire on hand tools known to

cause problems and hand tools commonly

used

40% of the linesmen self-reported that

they had had cumulative trauma

disorders during their work history

Call center workers

Cross-sectional

study (***)

(Baker et al.,

2003)

274 call center workers The Meaning of Working Survey, the

Musculoskeletal Discomfort

Questionnaire (MDQ)

Prevalence of:neck discomfort 57%;

shoulder discomfort 41%; elbow

discomfort 19%; wrist discomfort 52%;

back discomfort 63%

Cross-sectional

study (**)

(Baker et al.,

2000)

122 call center workers A background factors questionnaire, a

somatic complaints questionnaire, the

MDQ, a work practices questionnaire, a

psychosocial questionnaire. All

questionnaires had previously been

reliability tested

In the previous year: 72% reported neck

discomfort; 54% shoulder discomfort;

18% elbow discomfort; 48% wrist

discomfort; 67% low back discomfort

Cross-sectional

study (**)

(Bergqvist et al.,

1995)

322 office workers from 7 Stockholm

companies; 52% interactive workers, 29%

data entry workers, 19% non-video

display terminal (VDT) users

The NMQ was used, further information

on VDT use and individual and

organizational factors were collected,

physiotherapy examination, workplace

examination were also carried out

59.6% reported neck/shoulder

discomfort; 7.4% reported intense neck/

shoulder discomfort; 40.7% reported

back discomfort; 28.9% reported arm/

hand discomfort. From the

physiotherapist’s examination, 21.1%

had a Tension Neck Syndrome (TNS)

diagnosis, 22.7% had a cervical diagnosis,

13.0% had a shoulder diagnosis and 9.0%

had an arm/hand diagnosis

Cross-sectional

study (*) (Chung

and Choi, 1997)

297 VDT operators in a

telecommunications company

Questionnaire survey of demographic

information and self-reported

musculoskeletal discomfort rating via

body maps using a recognized

methodology

Musculoskeletal discomfort reported:

almost constantly in the neck 20%; left

shoulder 28%; right shoulder 46%; left

upper arm 11%; upper back 26%; lower

back 9%; left wrist 15%, right wrist 22%;

left hand 15%, right hand 25%

J.O. Crawford et al. / International Journal of Industrial Ergonomics 38 (2008) 56–72 59

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Table 1 (continued )

Study/study

design


Cross-sectional

study (**) (Cook

et al., 2000)

302 workers in 15 workplaces including a

telecommunication company

Questionnaire on work patterns, use of

computer and mouse

75.7% of participants reported

musculoskeletal symptoms in one or more

regions in the last 12 months; 46.4% in

the last 7 days

Questions on musculoskeletal symptoms

based on the NMQ

RCT (**) (Cook

and Burgess-

Limerick, 2004)

57 call-center workers The NMQ, workstation measurement At baseline 75% reported musculoskeletal

discomfort in the last 7 days

RCT (**)

(Faucett et al.,

2002)

55 telemarketers, 10 engineers, 43

assembly workers

Symptom measures at the end of each

workday for two weeks on a Visual

Analogue Scale (VAS) for pain, stiffness

and numbness

At baseline level, 73% reported

symptoms of pain, stiffness or numbness

Data could not be broken down into the

three work sites

Retrospective

cohort study

(**) (Ferreira et

al., 1997)

106 call center workers All data retrieved from personnel and

medical records from January 1993 to

June 1995. Only cases where two

specialists had confirmed the case and this

had resulted in one or more periods of

related absence were included

During the time period of the study, 24

cases of upper limb disorders (ULDs)

were physician diagnosed

Cross-sectional

study (*)

(Ferreira and

Saldiva, 2002)

62 call center workers in two groups;

ATC—active telemarketing N ¼ 14 and

TCC—customer services N ¼ 38

Tailor made questionnaire on

musculoskeletal symptoms, habits,

workstation, information network, work

organization and social environment

54% of ATC workers had neck/shoulder

problems for more than 7 consecutive

days

33% had hand/wrist problems for more

than 7 consecutive days

10.5% of the TCC staff reported neck/

shoulder problems for more than 7

consecutive days

8% reported hand/wrist problems for

more than 7 consecutive days

Cross-sectional

study (**) (Hales

et al., 1994)

533 telecommunication workers in 5 job

types

Self-administered questionnaire on

musculoskeletal symptoms (design not

specified) and standardized medical

examination

Overall symptom prevalence was 22%

Identified in the sample were probable

tendon disorders (15%), probable muscle

related disorders (8%), probable nerve

entrapments (4%), joint related findings

(3%) and ganglion cysts (3%)

Cross-sectional

study (**)

(Hoekstra et al.,

1992)

108 teleservice representatives Self-administered questionnaire survey on

musculoskeletal symptoms, previously

used in NIOSH studies, job tasks, work

history, work environment and indicators

of job stress

68% of the sample reported symptoms

meeting case definitions for neck,

shoulder, hand/wrist or back disorders

Prevalences of individual symptoms were

neck, 44%, shoulder, 35%, elbow, 20%,

hand/wrist, 30% and back 33%

Cross-sectional

study (**)

(Jensen et al.,

2002a,b)

3475 employees including 629 call center

workers

Questionnaire on physical and

psychosocial factors and a modified NMQ

was used

For female call center employees the odds

ratio was 2.06 for shoulder symptoms

(95% CI 1.19–3.56) and 1.95 for hand/

wrist symptoms (95% CI 1.06–3.61)

Cross-sectional

baseline study

(*) (Norman et

al., 2004)

57 call center employees; reference group

of 1459 professional computer users

Validated questionnaire on physical and

psychosocial working conditions and

symptoms during the previous month

86% of females reported significantly

more musculoskeletal symptoms lasting

more than 3 days in the previous month

compared to 72% in the reference group

For men, 68% of call-center workers

reported significantly more symptoms

than the reference group (50%)

Cross-sectional

study (*) (Park

et al., 1997)

827 female telephone operators using

VDTs; Domestic Operators, N ¼ 188,

International Operators, N ¼ 91,

Directory Assistance Operators N ¼ 548

Self-administered questionnaire, (not

clear about questionnaire design), medical

examination including range of motion,

strength and anthropometric

measurement and ergonomic evaluation

of the workplace

80% of respondents complained of pain

in multiple body areas; 35% reported

pain in all upper extremity areas with

9.8% of respondents reporting no pain or

pain in one single body area

35.1% were graded as normal, 53.9%

were graded as potential cases and 11.0%

were graded as cases

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Study/study

design


Closed

prospective

cohort study (*)

(Toomingas et

al., 2003)

57 call center workers at one call center;

reference group of 1226 professional

computer users

Baseline validated questionnaire on

musculoskeletal symptoms, 10 monthly

follow-ups

The odds ratio for being classified as a

symptom case among call center

operators versus the reference group was

OR ¼ 2.2 (95% CI ¼ 1.2–4.3)Medical examination performed within a

few weeks of incident cases. Medical

examination performed on 78% of the

incident call center cases

The age and gender adjusted relative risk

for incident symptoms among call center

operators versus the reference groups was

1.3 (95% CI 0.79–2.1)

The incidence of new symptoms was

approximately 1 case/person-year; this

was significantly higher among male call

center workers (1.7 case/person-year) and

for women this was 0.93 case/person-year

Table 2

Physical and psychosocial risk factors associated with the development of MSDs

Study/study design Study population Method Outcomes

Service technicians

Manhole cover removal

Laboratory based

experimental study

(**) (Chang et al.,

2003a, b)

9 telecommunication

field technicians

Reaction forces and moments recorded

with a force and moment transducer and

participants’ motion tracked with a

motion-tracking device during utility

cover removal operations

High levels of low back compression forces identified

when using lifting aids to maneuver manhole covers

Biomechanical

evaluation (*) (Imbeau

et al., 2001)

20 volunteers

experienced in

handling aqueduct-

access well and sewer

manhole covers

Volunteers observed lifting 20 manhole

covers, their weights ranging from 75 to

132kg, using different tools

The study suggests that a relatively important

proportion of healthy workers would not have been

able to perform the lifting safely regardless of the tool

used

Laboratory based

case study (**) (Mital

and Motorwala, 1995)

20 male and 20 female

volunteers

Measures of isometric back strength,

individual and unmatched team

psychophysical capacities, rating of

perceived exertion and spinal

compression forces to evaluate the use of

steel (80.36 kg) and composite (38.13 kg)

manhole covers

Males had significantly higher back strength than

females

Male teams had significantly higher back strength than

female teams

Team lifters had significantly higher lifting strength

than individuals

The steel cover if lifted individually would impose

spinal compression of 13210 N—this is reduced to 6186

N when lifted in a team, which still exceeds the

compressive strength of the spinal column

Ladder handling

Observational study (-)

(Imbeau et al., 1998) 42 telephone

technicians

Workplace observations on ladder

handling in the telecommunications

industry carried out in 7 different sites

Ladder handling represents a risk factor for

overexertion injuries:

the weight of the ladder used (24–31kg)

the environment the ladder is used in

loading of the ladder onto the shoulder

loading and unloading ladders from vehicles

Working overhead

Cross-sectional study (*)

(Graves et al., 1996) 143 electricity

distribution linesmen

The NMQ, OWAS and biomechanical

analysis of postures

High risk tasks identified included lifting tools up via a

pulley rope, lifting pole platforms, hammering nails

into poles, circuit testing, using pick axes, lifting

wooden blocks and heavy tools, crimping tool work,

drilling for new poles and working on the pole

Cross-sectional study (*)

(May et al., 1997) 120 linesmen Over 90% of cable crimping was done at or above

shoulder height


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Questionnaire on musculoskeletal

discomfort, task analysis, Extreme

Posture Checklist, RULA

The main task involving awkward positions of the arms

while working was using the crimping task tool (56.7%)

Tasks identified to have extreme postures included pole

climbing, using the Power Auger, pole work using the

wrench, lifting tools up via a pulley rope, lifting pole

platforms, changing insulators using a wrench,

tightening wire between two poles, using the crimping

tool, hammering actions, using a ratchet, changing an

old transformer to a new one, earthing the wire, putting

a fuse box up on pole, taking barbed wire off and

putting it on the pole

Cross study (-)

(Picton, 2003) Cable technicians 2 month observations, video footage,

unstructured interviews, ergonomic

analysis

The frame design used did not allow for optimal

handling zones and cable technicians worked in

awkward postures perched atop ladders

The Queensland Manual Tasks Advisory

Standard 2000 (DWHS 1999) was used to

compile the information and guide

recommendations

Cable handling

Laboratory based

experimental study

(**) (Gallacher et al.,

2001)

6 underground miners Subjects performed 12 cable-hanging

tasks in standing, stooping, and kneeling

postures in restricted roof space

It was concluded that biomechanical loading might be

an inherent aspect of working in confined vertical

workspaces

Measures included kinematic data from

force plates and 3D motion analysis

Laboratory based

experimental study

(**) (Gallacher et al.,

1993)

7 coal miners Subjects performed 12 cable-hanging

tasks in internal environments involving

six posture/vertical space constraint

conditions and two techniques of

securing a continuous

Stooping postures resulted in significantly higher forces

than when kneeling in the tests involving restricted

ceiling heights

Greater forces were associated with higher lifting

conditions

Laboratory based

experimental study

(**) (Hamrick et al.,

1993)

7 coal miners Subjects performed a cable-pulling task

in 8 different lifting conditions involving

four levels of posture and two levels of

cable pulling resistance

Peak cable tension, peak resultant force and peak

ground reaction forces were all significantly higher in

the high pulling resistance conditions than in the low

pulling resistance conditions

Case study (–)

(Picton, 2003)

Cable technicians 2 month observations, video footage,

unstructured interviews, ergonomic

analysis

The crimping tool (KM8 termination tool) had no

mechanical leverage and dug into the soft tissue of the

palm of the hand -the cable technicians used this tool

150–200 times per dayThe Queensland Manual Tasks Advisory

Standard 2000 (DWHS 1999) was used to

compile the information and guide

recommendations

The frames were placed into the rooms before the cable

technicians arrived on the scene

Cable technicians were carrying boxes of copper cables

weighting up to 25 kg, the nature and package of which

made it difficult to grip

When filling the bottom quarter of the frames, the cable

technicians were kneeling for over 30min on concrete

floors with no support

Cross-sectional

study (*) (Vilkki et al.,

1996)

72 telephone linesmen Questionnaire on hand tools known to

cause problems and hand tools

commonly used

70% of the linesmen answered that the main reason

causing their musculoskeletal pain had been the

connecting tool

Connecting tools were rated as the most stressful tools

Climate conditions (cold), working in the poles, too

little working room and dirty and greasy cables were

perceived as the main causes making the work with

hand tools more straining

Hand–arm vibration

Cross-sectional

survey (**) (Palmer et

al., 1998)

153 gas distribution

operatives

Modified Faculty of Occupational

Medicine questionnaire, clinical

examination, cold challenge test

HAVS was linked to a lifetime use of vibrating tools of

5000 h or more; lifetime dose of vibration of more than

26 500ms�2 d

Blanching was linked to a lifetime use of tools of 5000 h

or more and a lifetime dose of vibration of

36 000ms�2 d or more


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Neurological symptoms were linked to a lifetime use of

tools of 5000h or more and a lifetime dose of vibration

of 26 500ms�2 d or more

Cross-sectional

study (**) (Walker et

al., 1985)

895 gas distribution

workers; 546m readers

(control group)

Nurse-administered questionnaire on

circulation to the hands

No significant associations found between the

prevalence rates and the number of years vibrating

tools had been used

Call center workers

Cross-sectional study

(**) (Bergqvist et al.,

1995)

322 office workers

from 7 Stockholm

companies; 52%

interactive workers,

29% data entry

workers, 19% non-

VDT users

The NMQ was used, further information

on VDT use and individual and

organizational factors were collected,

physiotherapy examination, workplace

examination were also carried out

Working more than 20 h per week at a VDT was

associated with intensive neck and shoulder discomfort

(O.R. ¼ 3.9, 95% CI 1.1–13.8)


associated with a diagnosis of tension neck syndrome

for users of bifocal or progressive glasses (O.R. ¼ 6.9,

95% CI 1.1–42.1)


associated with arm/hand diagnosis for individuals

with limited rest break opportunity combined with the

non-use of lower arm support (O.R. ¼ 4.6, 95% CI

1.2–17.9)

No significant associations found between interactive

work, symptoms, length of career and working hours


(*) (Chung and Choi,

1997)

297 operators Questionnaire survey of demographic

information and self-reported

musculoskeletal discomfort rating via

body maps using a recognized

methodology. 70 participants were

randomly selected and their workstations

evaluated

Relative seat back height and left shoulder abduction

angle had significant influence in trunk discomfort

Trunk discomfort increased as left shoulder abduction

became larger

Relative keyboard height, body size, and shoulder

abduction, sitting posture and relative seat back height

were identified as influencing factors on discomfort


(**) (Cook et al., 2000)

302 workers in 15

workplaces including a

telecommunications

company

Questionnaire on work patterns, use of

computer and mouse

Neck and shoulder symptoms were associated with

screen position above eye height (OR ¼ 3.19, 95%CI

1.50–6.78 and OR ¼ 2.38, 95% CI 1.20–4.71,

respectively)

Questions on musculoskeletal symptoms

based on the NMQ

Shoulder elevation was associated with neck symptoms

(OR ¼ 2.01, 95% CI 1.04–3.88)

Shoulder symptoms (OR ¼ 2.69, 95% CI 1.49–4.90)

Wrist/hand symptoms (OR ¼ 2.28, 95% CI 1.30–4.00)

Upper back symptoms (OR ¼ 2.26, 95%CI 1.28–3.98)

Neck symptoms were associated with arm abduction

(OR ¼ 2.07, 95% CI 1.11–3.84) and screen position

above eye height (OR ¼ 2.19, 95% CI 1.16–4.14)

Retrospective cohort

study (**) (Ferreira et

al., 1997)



June 1995. Only cases where two

specialists had confirmed the case and

this had resulted in one or more periods

of related absence were included in the

study

No associations found between length of service or

ergonomic hazards and the development of ULDs

ULD incidence was reduced when 10min h�1 rest

breaks were introduced


(*) (Ferreira and

Saldiva, 2002)

62 call center workers

in two groups; ATC—

active telemarketing

N ¼ 14 and TCC—

customer services

N ¼ 38

Tailor made questionnaire on MSD

symptoms, habits, workstation,

information network, work organization

and social environment

Duration in the job, work in ATC and low level of

satisfaction with the workstation arrangement were

significantly associated with neck/shoulder and hand/

wrist musculoskeletal symptoms and MSD induced

time away from workInterviews, observation and measures of

workplace dimensions and physical

environment


(**) (Hoekstra et al.,

1992)

108 teleservice

representatives

Self-administered questionnaire survey

on musculoskeletal symptoms, previously

used in NIOSH studies, job tasks, work

history, work environment and indicators

of job stress

Neck symptoms were significantly associated with

perceived chair discomfort (OR ¼ 3.5, 95%CI 1.4–8.9)


ARTICLE IN PRESS



Ergonomic evaluation of representative

workstations

Shoulder symptoms were significantly associated with

reporting a non-optimal desk height (OR ¼ 5.1,

95%CI 1.7–15.5) and non-optimal VDU screen height

(OR ¼ 3.9, 95%CI 1.4–11.5)

Elbow symptoms were significantly associated with

perceived non-optimally adjusted chair (OR ¼ 4.0,

95%CI 1.2–13.1)

Hand/wrist symptoms were significantly associated

with using the telephone more than 8 hd (OR ¼ 4.7,

95%CI 1.3–17.4)

Back symptoms were significantly associated with

perceived non-optimally adjusted chair (OR ¼ 4.6,

95%CI 1.7–12.5)


(**) (Jensen et al.,

2002a,b)

3475 employees

including 629 call

center workers

Questionnaire on computer work,

psychosocial factors and a modified

NMQ was used

For females, neck symptoms were significantly

associated with working all the time at the computer

(OR ¼ 1.92, 95% CI ¼ 1.21–3.02); shoulder symptoms

were significantly associated with working all the time

at the computer (OR ¼ 1.83, 95% CI ¼ 1.13–2.95)

For men, hand/wrist symptoms were associated with

working at the computer for three quarters of the time

(OR ¼ 2.09, 95% CI ¼ 1.17–3.72) and all the time

(OR ¼ 2.76, 95% CI ¼ 1.51–5.06)

Age-adjusted odds ratios for female call center

employees compared to female computer users

performing any other computer work were 1.59 (95%

CI ¼ 0.98–2.60) for neck symptoms, 2.06 (95%

CI ¼ 1.19–3.56) for shoulder symptoms and 1.95 (95%

CI ¼ 1.06–3.61) for hand/wrist symptoms


(**) (Marcus and

Gerr, 1996)

Female office workers

including those using

VDTs and telephones;

N ¼ 416 for neck and

shoulder symptoms,

N ¼ 409 for arm or

hand symptoms

Questionnaire on lifestyle,

musculoskeletal symptoms (derived from

the NIOSH questionnaire), occupational

psychosocial stress (derived from the Job

Content Instrument), job tasks and

medical history

Compared to those reporting no current and no past

VDT use, for neck or shoulder symptoms ORs were

4.13 (95% CI 1.53–11.15) foro3 year duration of VDT

use, 5.56 (95% CI 1.97–15.73) for 4–6 years and 4.28

(95% CI 1.35–13.60) for female subjects who had used

a VDT for 46 years

Female subjects reporting more than 6 years of VDT

use were significantly more likely to report hand or arm

symptoms than women who never used a VDT

(OR ¼ 3.87 95% CI 1.24–12.02)

Psychosocial factors in the development of MSDs


(***) (Baker et al.,

2003)

274 call center workers The meaning of Working Survey and the

MDQ

Multiple regression analysis revealed a significant

association between musculoskeletal discomfort and

gender (po0.05), age (po0.05), promotion/power

(po0.001) and average hours worked (po0.001)

The pattern suggested that females who work longer

hours, valued promotion and disliked social support

were more likely to develop moderate to severe

musculoskeletal discomfort


(**) (Baker et al.,

2000)

122 call center workers A background factors questionnaire, a

somatic complaints questionnaire, the

MDQ, a work practices questionnaire

and a psychosocial questionnaire

Neck symptoms were significantly associated with

somatic complaints and age (po0.01)

Shoulder symptoms were significantly associated with

somatic complaints, age, quantitative workload,

alcohol (po0.01) and workload (po0.04)

Elbow symptoms were significantly associated with

somatic complaints (po0.02), having another job

(po0.03), job satisfaction (po0.03) and skill utilization

(po0.03)

Wrist symptoms were significantly associated with

workload variety (po0.01) and having own

workstation po0.02)

Back symptoms were significantly associated with

somatic complaints (po0.01), childcare (po0.01),


ARTICLE IN PRESS



workstation monitor (po0.05) and social support from

co-workers (po0.04)

The study suggests that musculoskeletal discomfort

may be a somatic stress symptom


(**) (Devereux et al.,

2002)

891 participants

working in varied

physical environments

and office

environments

Self-administered validated questionnaire

on physical and psychosocial factors and

musculoskeletal symptoms

Hand/wrist symptoms were significantly associated

with low physical/high psychosocial (OR ¼ 2.32 95%

CI 1.15–4.70)

Participants grouped into low physical/

low psychosocial, high physical/low

psychosocial, low physical, high

psychosocial and high physical/high

psychosocial exposure groups

high physical/low psychosocial (OR ¼ 4.42 95% CI

2.20–8.90)

high physical/high psychosocial exposure (OR ¼ 7.50

95%CI 3.76–15.16)

Upper limb symptoms were significantly associated

with the high physical/low psychosocial (OR ¼ 2.28

95%CI 1.31–3.98) high physical/high psychosocial

exposure (OR ¼ 3.74 95% CI 2.12–6.60)


(**) (Devereux et al.,

1999)

As above As above Back pain in the past 7 days was significantly associated

with the high physical/high psychosocial group

(OR ¼ 2.41 95% CI ¼ 1.51–3.85)

Recurrent back problems (not experienced before

present job) were significantly associated with high

physical/low psychosocial (OR ¼ 2.80 95% CI

1.48–5.35) and high physical/high psychosocial

exposures (OR ¼ 3.58 95%CI 1.99–6.77)

Retrospective cohort

study (**) (Ferreira et

al., 1997)



June 1995

24 ULD cases were diagnosed by at least two

physicians

Associations were identified between time pressure at

work and ULD incidence (r2 ¼ 0.049; p ¼ 0.008) and

work/rest scheduling and ULD incidence (r2 ¼ 0.047;

p ¼ 0.02)


(*) (Ferreira and

Saldiva, 2002)


in two groups; ATC—

active telemarketing

and TCC—customer

services

Questionnaire on MSD symptoms,

habits, workstation, information

network, work organization and social

environment

A positive association was found between

dissatisfaction between MSD complaints and

workplace ergonomics (po0.05), work organization

(po0.05) and the social environment (po0.05)

Interviews, observation and measures of

workplace dimensions and physical

environment

Multivariate logistic analysis identified that MSD

related time away from work was associated with the

workstation (po0.05), duration in the job (po0.05)

and the working conditions in the ATC (po0.05)


(**) (Hales et al., 1994)

533

telecommunications

workers in 5 job types

Self-administered questionnaire on

musculoskeletal symptoms, followed by a

medical examination

Significant associations included bifocal use with neck

disorders (OR ¼ 3.8 95% CI 1.5–9.4); job security

including fear of being replaced by computers with

neck (OR ¼ 3.0 95% CI 1.5–6.1), shoulder (OR ¼ 2.7

95% CI 1.3–5.8) and elbow disorders (OR ¼ 2.9 95%

CI 1.4–6.1); routine work lacking decision making

opportunities with neck (OR ¼ 4.2 95% CI 2.1–8.6)

and elbow disorders (OR ¼ 2.8 95% CI 1.4–5.7); high

information processing demands with neck (OR ¼ 3.0

95% CI 1.4–6.2) and hand/wrist disorders (OR ¼ 2.3

95% CI 1.3–4.3); neck disorders with not having a

productivity standard (OR ¼ 3.5 95% CI 1.5–8.3), jobs

requiring a variety of tasks (OR ¼ 2.9 95% CI 1.5–5.8)

and increasing work procedure (OR ¼ 2.4 95% CI

1.1–5.5); elbow disorders with surges in workload

(OR ¼ 2.4 95% CI 1.2–5.0)

Psychosocial issues were assessed by a

validated measure, demographics,

keystrokes and electronic performance

monitoring information was obtained

Cross-sectional survey

(*) (Halford and

Cohen, 2003)


currently or recently

working

Interview/questionnaire in five parts

including questions on demographics,

hardware issues, MSD symptoms,

computer use psychosocial factors,

technology used, management/worker

relations and workplace conditions

No significant relationship found between cumulative

musculoskeletal problems and cumulative psychosocial

factors

Individual factors found to be significantly associated

with musculoskeletal symptoms included monitoring

by management (w2 ¼ 10.15, df ¼ 4, po0.05) workload


ARTICLE IN PRESS



(w2 ¼ 18.99, df ¼ 8, po0.05) and managerial support

(w2 ¼ 26.67, df ¼ 16 po0.05)


(**) (Hoekstra et al.,

1996)

108 employees from

two call centers

Validated questionnaire on symptoms,

stress and job satisfaction

A higher prevalence of symptoms was found in Center

B

Neck symptoms were associated with perceived

workload variability (continually changing workload

during the day) (OR ¼ 1.2, 95% CI 1.0–1.4)

Back symptoms were inversely associated with

perceived degree of job control (OR ¼ 0.6, 95% CI

0.5–0.7)

Multiple regression analysis identified that job

satisfaction was significantly associated with perceived

lack of future certainty (po0.01), perceived non-

optimally adjusted keyboard (po0.01), perceived poor

supervision (po0.01) and perceived non-optimally

adjusted screen (po0.01)


(**) (Marcus and

Gerr, 1996)

Female office workers

including those using

VDTs and telephones;

N ¼ 416 for neck and

shoulder symptoms,

N ¼ 409 for arm or

hand symptoms

Questionnaire on lifestyle,

musculoskeletal symptoms (derived from

the NIOSH questionnaire), occupational

psychosocial stress (derived from the Job

Content Instrument), job tasks and

medical history

The proportion of female participants reporting neck

or shoulder symptoms (N ¼ 374) increased significantly

with increased reporting of job stress during the

previous 2 weeks (OR ¼ 2.47 95% CI 1.20–5.10) and

reporting of increased likelihood of job loss (OR ¼ 2.23

95% CI 1.35–3.69)

The proportion of female participants reporting arm or

hand symptoms (N ¼ 367) increased significantly with

increased reporting of job stress during the previous

weeks (OR ¼ 2.04 95% CI 1.04–4.00)

Neither occupational psychosocial strain nor social

support was significantly associated with hand or arm

symptoms using a multivariate model


(**) (Nag and Nag,

2004)

136 female call center

operators

Survey of workstation, equipment and

work methods

Factors identified included organizational,

environmental, mechanistic, perceptual and motor and

motivational

Interview using a validated checklist Prevalence of musculoskeletal pain was greatest in the

lower back, with night shift and evening shift reporting

47% and 45%, respectively

Long hours and seated work resulted in constant

musculoskeletal symptoms, mainly lower back

complaints

Day workers had fewer complaints than other shift

workers

Cross-sectional base

line survey (*)

(Norman et al., 2004)

57 employees at a call

center in Sweden

Questionnaire on physical and

psychosocial working conditions and

symptoms during the previous month

Psychosocial environment was deficient including poor

support from the immediate supervisor, low control

and limited opportunities to influence their work

1459 other computer

users (reference group)

Structured observations made by

ergonomists on healthy workers

A higher proportion of call center employees had long

continuous work in front of the computer compared to

controls

Compared to the reference group, call center workers

reported a higher proportion of musculoskeletal

symptoms


ladders, overhead working has also been identified as a riskfactor including lifting tools via a pulley rope, hammeringnails into poles, circuit testing, using pick axes, liftingwooden blocks, handling heavy tools, crimping tool work,drilling for new holes and tightening wire between poles(Graves et al., 1996; May et al., 1997).

Cable handling has also been identified as a risk factorfor back injuries (Gallacher et al., 2001, 1993; Hamrick etal., 1993). However, these research studies were graded as

moderate evidence due to the small numbers of partici-pants. In addition, although the work tasks are similar interms of the postures adopted when handling cables, themining cable used in these studies is both heavier and largerin diameter than the cable traditionally used in thetelephone industry. Connecting cables and connectingtools were also perceived to be difficult to use and presenta risk of cumulative trauma disorders (Vilkki et al., 1996;Picton, 2003).


Service technician workers in the telecommunicationssector, as in other service industries, are involved in roadbreaking work. The research identified in the review wascarried out with gas distribution workers but the worktasks involved would be similar in both industries. HAVSwas not found to be significantly higher in gas distributionworkers involved in road breaking tasks (Walker et al.,1985). However, a later study found that the developmentof HAVS in road breaking work in the gas industry waslinked to a cumulative lifetime exposure of 5000 h or alifetime dose exceeding 26 500ms�2 d (Palmer et al., 1998).The study by Palmer et al. highlights that road-breakingtechniques have changed, which does reduce the exposurelevel of workers to vibrating tools. However, with enoughexposure, HAVS does occur.

3.3.2. Call center workers

Much of the research identified for inclusion into thereview was cross-sectional in design with the definition ofthe MSD derived from self-reporting rather than a medicalexamination. Low numbers in some of the studies furthercompounded these issues.

Physical factors influencing discomfort included key-board height (Chung and Choi, 1997), screen height aboveor below eye level (Cook et al., 2000; Hoekstra et al., 1996),low level of satisfaction with the workstation (Ferreira andSaldiva, 2002), non-optimal desk height (Hoekstra et al.,1996) and chair discomfort (Hoekstra et al., 1996).

Work factors positively influencing discomfort includedworking with computers for the whole working day(Bergqvist et al., 1995; Jensen et al., 2002a) and, forhand/wrist symptoms, using the telephone more than 8 hper day (Hoekstra et al., 1996).

One study identified a reduction of upper limb disordersreported in medical and personnel records following theintroduction of 10min h�1 rest breaks (Ferreira et al.,1997).

3.3.3. The impact of psychosocial factors

A total of 26 papers looking at psychosocial factors wereidentified from abstracts. The number selected for inclusionwithin the review was 12. Further papers were rejectedbased on population descriptions or no link to MSDs. Themajority of the studies were carried out in call centerenvironments. Only two studies dealt with heavy physicalwork (Devereux et al., 2002, 1999).

The review identified that both physical and psychoso-cial risk factors are implicated in the etiology of MSDs(Devereux et al., 2002, 1999). Using the breakdowndeveloped by Bernard (1997), the impact of psychosocialfactors can be grouped into those associated with the joband work environment; including workload, job control,social support and job satisfaction. Where the job andwork environment are concerned the review identifieswithin call center workers that intensified workloads wereassociated with neck symptoms, elbow symptoms and wristand hand symptoms (Hales et al., 1994). In addition,

workload variability was associated with neck symptoms(Hoekstra et al., 1996) and wrist symptoms (Baker et al.,2000).Job control issues were found to be inversely associated

with back symptoms (Hoekstra et al., 1996). Monotonousor routine work was associated with neck symptoms, andelbow symptoms (Hales et al., 1994). One study identifiedissues with regard to job clarity and job security. Haleset al. (1994), found that neck; shoulder and elbowsymptoms were associated with uncertainty about jobsecurity including fear of being replaced by a computer.Lack of social support from managers and coworkers

was found to be associated with musculoskeletal symptomreporting in three studies (Baker et al., 2000; Hales et al.,1994; Halford and Cohen 2003). However, Marcus andGerr (1996) did not find the same association betweensocial support and symptom reporting in their study offemale office workers.Within this review, only one study found a link between

elbow discomfort and job satisfaction (Baker et al., 2000).Although further links were found in other reviews(Bernard, 1997), job satisfaction has not been consistentlymeasured within the telecommunications workforce.Marcus and Gerr (1996) surveyed female office workers

for neck, shoulder, arm or hand symptoms. They identifiedthat all symptoms assessed increased significantly with thereporting of increased job stress in the two weeks precedingthe study.General symptoms of musculoskeletal discomfort were

found to be significantly related to gender, age, promotion/power, long hours and to be negatively associated with jobsatisfaction (Baker et al., 2003). This research suggests thatsymptoms are more likely in females who work longerhours, value promotion and dislike social support (Bakeret al., 2003).Due to the cross-sectional nature of the research studies,

it is not possible at the current time to quantify theimpact of psychosocial factors on the development ofMSDs. Psychosocial factors rather than physical factorsappear to have a bigger influence on the neck and shoulderregion.

3.4. Effectiveness of intervention strategies in the prevention

of MSDs in telecommunications workers

No papers were identified that examined prevention ofMSDs in service technician work. For call center workersminimal research was available and is presented in Table 3.The study by Cook and Burgess-Limerick (2004) identifiedthat there is no current evidence that forearm support onthe workstation reduces MSDs. Faucett et al. (2002)carried out a randomized controlled trial based onoccupational health training or muscle learning therapy(MLT) to reduce MSD symptoms. MLT is a techniquebased on the use of EMG feedback and operantconditioning to reduce muscle tension in complex worktasks. The occupational health training intervention

ARTICLE IN PRESS

Table 3

Effective measures in the prevention of MSDs


RCT (**) (Cook

and Burgess-

Limerick, 2004)

59 call center

workers

Participants randomly sampled into a study group

of 30 and a control group of 29 and given training

in workstation adjustment and posture

In the intervention group, the proportion of

reported discomfort in one or more body area in

the last 7 days decreased from 79% to 62% at 6

weeks

Study group workstations adjusted to allow

forearm support on the desk surface

In the control group, reports of discomfort

increased from 71% to 75%

NMQ administered at baseline, 6 weeks and 12

weeks

At 12 weeks, there was a significant decrease in

discomfort for both groups

There were no significant differences between the

study and control group

RCT (**) (Faucett

et al., 2002)

55 telemarketers, 10

engineers, 43

assembly workers

Control group of 47, and 2 experimental groups

of 46

The education and training group initially

improved then returned to baseline at 32 weeks

Interventions: Muscle Learning Therapy (MLT)

and Occupational Health Nurse delivered

education and training (EDUC)

For the MLT, symptom reports stayed the same at

6 weeks but worsened at 32 weeks

Symptoms measured at the end of each workday

for two weeks on a VAS for pain, stiffness and

numbness

The control group symptom level increased

throughout the study

Surface EMG measures and identification of new

MSD symptoms at 32 weeks from medical records

Health surveillance

Review Paper (�)

(Ricci et al., 1998)

Workers exposed to

repetitive movements

Reviews the evidence for health surveillance for

workers exposed to repetitive movements and

gives an outline strategy for a health surveillance

programme for the upper limbs

No outcome measures reported

Description of a two-stage approach covering

individual and group analysis

Cross-sectional

prevalence study (*)

(Roquelaure et al.,

2002)

253 blue-collar shoe

factory workers; 191

reviewed at follow-

up

Interview and examination by occupational

physician, health outcomes defined for CTS,

rotator cuff syndrome, TNS and cubital tunnel

syndrome

Prevalence data detected 3 high-risk areas for

MSDs (cutting, sewing and assembly preparation)

Ergonomic exposure measurements by direct

observation and using a risk factor checklist

Incidence data identified sewing preparation,

mechanized assembling and finishing as high risk

for MSDs

Incidence data calculated at one yearThe diagnostic value of the methods used could

not be assessed

Authors state that surveillance of adverse

outcomes and ergonomic risk factors are

important in preventing MSDs

Cross-sectional

study (*) (Silverstein

et al., 1997)

626 active workers in

the automotive

industry

Authors compared the strengths and limitations of

surveillance tools for MSDs including workers

compensation, sickness and accident insurance,

OSHA 200 logs, plant medical records, self-

administered questionnaires including body maps

from the NMQ, professional interviews and

physical examination

The magnitude of MSDs was greater using self-

administered questionnaires and professional

interviews than surveillance based on pre-existing

health data

Plant medical records yielded the lowest rates

The study suggests that symptoms questionnaires

and checklist based hazard surveillance are more

sensitive indicators of ergonomic problems than

pre-existing data sources


included class and discussion sessions covering aspects ofMSDs, ergonomics, self-care within the office environmentand in addition the use of teaching techniques which aimedto be interactive rather than didactic teaching. Althoughthe occupational health education group did show im-provements at 6 weeks, at 32 weeks the group returned tobaseline levels. For the MLT group, symptoms worsened at32 weeks. This indicates that within this population,

neither of the interventions were found to be effective(Faucett et al., 2002).Health surveillance within the context of the review was

defined as periodic medical or physiological examination ofworkers exposed to risks to detect and/or prevent occupa-tionally related MSDs. To address whether health surveil-lance has a positive effect on reducing MSDs, three paperswere included in the review. Although these papers are not


specifically related to the telecommunications industry, theydescribe and evaluate setting up and using health surveillancefor MSDs. The papers are summarized in Table 3.

What is made evident from the papers on healthsurveillance is that when using self-report measures, themagnitude of MSDs was greater than that identifiedthrough medical records or medical examination (Silver-stein et al., 1997). However, there is no current evidenceavailable to support or refute that health surveillance is ofbenefit in preventing or modifying the progression ofMSDs in telecommunications workers (Silverstein et al.,1997; Ricci et al., 1998; Roquelaure et al., 2002).

4. Best practice

One of the aims of the review was to identify current bestevidence-based practice in manual handling and displayscreen work. This was in the context of general researchacross the fields of ergonomics and occupational health.Research was found that identified the principles of manualhandling for inclusion in training courses from a DELPHIexercise (Graveling et al., 2003). Eleven principles weresuggested in this research including thinking before youlift, adopting a stable position and not flexing the spine.Other recommendations included ensuring that jointemployer–employee initiatives are set up when assessingrisk factors (De Beeck and Hermans, 2000). There is,however, no evidence that this is effective in injuryreduction.

4.1. Service technicians

With regard to specific areas, guidance on ladderhandling was identified (Imbeau et al., 1998). Suggestionsincluded lightweight materials for ladders, using theshortest and lightest ladders, carrying the ladder suspendedto the shoulder rather than on the shoulder and ensuringusers assess the risk of access routes to work tasks (Imbeauet al., 1998). For manhole cover removal, two importantareas were highlighted including ensuring that the toolsused actually reduce biomechanical stress and that employ-ees are trained to use tools where possible (Chang et al.,2003a, b). In addition, engineering controls may also be amethod to consider, reducing risk via the use of compositematerials for manhole covers (Mital and Motorwala,1995).

The cable handling research reviewed was based in themining industry; thus, caution should be taken with theresults found. However, recommendations include usingmechanical force rather than physical effort (Gallacher etal., 2001, 1993; Hamrick et al., 1993). For cable handling ininternal environments, one low quality paper made anumber of recommendations regarding cable installationincluding engineering controls such as altering the size ofthe frames to decrease handling zone difficulties, redesign-ing crimping tools, using trolleys to maneuver equipmentand mats while kneeling (Picton, 2003). None of the

previous recommendations have been assessed as to theireffectiveness.HAVS was identified as a possible risk factor for

individuals involved in road breaking in the utilitiesindustries (Walker et al., 1985; Palmer et al., 1998).Unpublished research from the UK identified a numberof recommendations on managing individuals exposed tovibration (BT, 2001). These included measurement ofvibration levels of tools, risk assessment, raising awarenessamong staff and ongoing health surveillance for staffexposed to vibration. There is no current data at this timeto assess the effectiveness of the recommendations inmanaging exposure to vibration.

4.2. Call center workers

When using DSE, areas identified as important includepermitting rest breaks and ensuring that these are taken(Ferreira et al., 1997), providing workstations and equip-ment that allow neutral postures and ensuring that theseare set up in optimal positioning for the users (Cook et al.,2000; Ferreira and Saldiva, 2002; Hoekstra et al., 1992).Work organization issues identified as important within thereview included time pressure, high information processingdemands, workload surges, job security issues and routinework (Hales et al., 1994; Ferreira et al., 1997; Hoekstraet al., 1996). This indicates that future research needs toaddress both workplace and work organization issues toreduce musculoskeletal symptoms.Psychosocial issues identified as affecting call center

workers included job stress, decreased social support, lowjob satisfaction and perceived lack of job control (Normanet al., 2004; Baker et al., 2003; Marcus and Gerr, 1996;Hoekstra et al., 1996). This highlights a further area ofintervention but further research is needed to quantify howpsychosocial factors affect the etiology of MSDs.Although no research was found with regard to the use

of laptops or display screens in vehicles, the Health andSafety Executive in the UK does make reference to usinglaptops in the guidance for DSE work (HSE, 2002). Therecommendation is that portable computers should not beused in motor vehicles. However, where there is arequirement to use portable computers, users should usea suitable workstation (HSE, 2002).

5. Discussion

5.1. Prevalence of various work related MSDs in

telecommunications workers

The data gaps highlighted by this review include lack ofinformation regarding the incidence and prevalence ofMSDs in telecommunications workers. Where data havebeen obtained, there is a lack of consistency in themeasurement tools, i.e., the use of non-validated instru-ments rather than the Nordic Musculoskeletal Question-naire. There was also a lack of clarity in the diagnostic or


surveillance methods used where clinical examination wasundertaken. This should be addressed in the future by theuse of validated measurement tools or consistent clinicaldiagnoses including a description of the methods used.

Only advisory information was obtained in relation tousing DSE equipment in vehicles. This recommended notusing DSE equipment but if it had to occur, designing aspecific workstation for this (HSE, 2002). With theincreased use of remote computer technology, using DSEequipment in vehicles is perceived as a risk. Operators havebeen seen to sit in the driving seat while operating thecomputer on the passenger seat resulting in a twisted spineposture. Working practices research may need to identifyhow individual telecommunications companies managethis issue. Where there are instances of workstations beingdeveloped within vehicles, these should be evaluated as totheir effectiveness.

5.2. Physical and psychosocial risk factors associated with

the development of MSDs

Physical risk factors associated with the development ofMSDs in service technician work included manhole covermaneuvering, ladder handling, cable handling and roadbreaking work. The manhole cover maneuvering was basedon laboratory studies. However, previous epidemiologicalresearch has identified that there is a strong correlationbetween compressive forces on the L5/S1 disk and theincidence rates of low back pain (Chaffin et al., 1976).

With regard to the physical risks identified, the sectionon best practice gave a number of suggested recommenda-tions to reduce risks including engineering controls such asusing the lightest weight materials available, redesigningframes for internal cabling and redesigning tools. Althoughthese are based on good ergonomic principles and thusmake sense to do, there is no further research to provideevidence that such interventions do reduce the risk to theworker. This highlights the issue that when examiningevidence, suggestions can be made to improve the workand working environment, however, further data need tobe collected to show that interventions have or have notsucceeded.

Research within the review including mining and roadbreaking work does need to be treated with caution. Thisinclusion was based on similarities within the work tasksand the environment within which the data were collected.However, mining cable is larger in both diameter andweight than cables used within telecommunications thusthe work tasks carried out when cable handling are similarbut the risk from the weight of the cable is larger within themining industry. The same basis was used for including theresearch on HAVS within the gas industry, as road-breaking tasks are similar for both utilities.

For call center workers, a number of areas wereidentified as contributing to discomfort including work-place layout and design issues and the impact of poor workorganization. Again, although best practice identifies rest

breaks, workplace layout and work organization as factorswhich should be addressed, apart from taking rest breaks,there is no further intervention research in call centerworkers at this time to show that such changes are effectivein reducing the risks for MSDs.Research on the role of psychosocial factors in the

development of MSDs does suggest that they have animpact in MSD development (Baker et al., 2000; Devereuxet al., 2002, 1999; Ferreira and Saldiva, 2002; Ferreira etal., 1997; Hales et al., 1994; Halford and Cohen, 2003;Hoekstra et al., 1996; Marcus and Gerr, 1996; Normanet al., 2004). What is unclear at the moment is the role thatpsychosocial factors play in heavy physical work in thetelecommunications sector.The majority of the research with regard to psychosocial

factors was based in call center work (Baker et al., 2000;Ferreira and Saldiva, 2002; Ferreira et al., 1997; Haleset al., 1994; Halford and Cohen, 2003; Hoekstra et al.,1996; Marcus and Gerr, 1996; Nag and Nag, 2004;Norman et al., 2004). Using the breakdown of psychosocialfactors developed by Bernard (1997), the review has foundsimilar results to the NIOSH evidence review. However,contradictory evidence was found with regard to socialsupport in that it was not linked to symptom reporting in asurvey of female workers (Marcus and Gerr 1996).With regard to the associations found between psycho-

social factors and symptom or discomfort reporting, theredoes appear to be an increased risk of neck and shouldersymptoms when exposed to different variables. However, itis not clear what mechanism is involved in this process andwhether it is due to increased muscle loading from tensionis yet to be elucidated.The research found was mostly cross-sectional in design

but did indicate a number of factors that may have anassociation with MSD symptoms. Future research needs toaddress the issue of cross-sectional experimental design andallow data to be collected in a more rigorous way such aslongitudinal studies to examine incidence and work factorsaffecting incidence as well as consideration of case-controlresearch.

5.3. Effectiveness of intervention strategies in the prevention

of MSDs in telecommunications workers

Only two studies examined interventions to reduceMSDs (Cook and Burgess-Limerick, 2004; Faucett et al.,2002). Neither study provided evidence of effectiveness forthe interventions tried. Although these are negative results,the reporting of such studies is vital to inform futureresearch design. Future research needs to address this issuefurther with both service technician workers and call centerworkers. Interventions should address both physical work-place factors and psychosocial issues.The lack of evidence to support or refute the use of

health surveillance for MSDs in telecommunicationsworkers is indicative of the lack of research in this area.As there is no current evidence that health surveillance is


effective in reducing the progression of MSDs, futureresearch needs to evaluate the effectiveness of healthsurveillance but also bear in mind the quality of the datacollected. In short, any system developed to monitor theprogression of MSDs should be accurate and consistent inthe data collection techniques used and if self-reportmeasures have to be used, using validated tools only.

6. Conclusion

The review has identified a number of risk factors forMSDs that are related to telecommunications work bothservice technician and call center working. However, noresearch papers were identified in relation to hand-roddingand using DSE equipment in vehicles. The majority ofexisting research with regard to MSD development andpsychosocial factors has been based in call center work,while the role of psychosocial factors in heavy physicalwork within the telecommunications sector is unclear.There is little research available to support interventions toreduce the incidence of MSDs in either type of telecom-munications work but there is evidence of best practice toaim for within the telecommunications industry.

The research assessed within this review highlighted anumber of difficulties that impact on systematic reviewmethodology and the quality of the subtracted evidence inthe fields of ergonomics and occupational health. Thequality of a review is impacted by the quality of theprimary research it covers. There were few RCTs or otherintervention studies and much of the research was cross-sectional in design often involving small numbers ofparticipants. Furthermore, there was a lack of consistencyin the measurement tools and diagnostic criteria used.These are issues that future research within the disciplinesshould aim to address.

Acknowledgment

The authors would like to thank UNI-Europa whofunded this systematic review.

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