Introduction
Strategies to tackle Musculoskeletal Disorders (MSDs) at the workplace are characterised by an integrated, multidisciplinary and participatory approach. Due to the multiple risk factors and causes of MSDs, prevention strategies focus as well on technical (engineering) measures, as on organizational aspects of the work but also on the attitude and behaviour of the people involved in the work by training and education.
This article focusses on this last aspect. How important is training in the prevention of work-related MSDs?
European legislative background
The OSH Framework Directive of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work [1] is also applicable in the prevention of MSD. The general principles of prevention listed in the directive are the following:
More specific the Directive 90/269/EEC related to the Manual Handling of Loads describes the obligations of employers in the prevention of MSDs related to manual handling[2]
Employers must take appropriate organisational and technical measures, in order to avoid the need for the manual handling of loads by workers or, if this is not possible, in order to reduce the risk involved in the manual handling.
This Directive clearly refers to the need of training. It is stipulated that workers and/or their representatives must be informed of all measures to be implemented with regard to the protection of safety and health. Employers must ensure that workers and/or their representatives receive general indications and, where possible, precise information on the weight of a load and on the centre of gravity of the heaviest side when a package is eccentrically loaded. Employers must ensure that workers receive in addition proper training and information on how to handle loads correctly and the risks they might be exposed to.
In general employers have to inform workers about the risks related to the work they are doing.
Types of training
Training is widely used in prevention strategies for MSDs. Data from the ESENER Survey (2019) suggests that in more that 80% of European workplaces training is provided on "how to lift or move heavy loads or people"[3]. The fact that training is so widespread has to do with the dominating theory that providing people with better knowledge and skills (and better work conditions) will result in a positive change [4]. Knowledge of how to incorporate ergonomic solutions into one's work and work practices facilitates the implementation process of any intervention to prevent MSDs. Adequate education and training play a large role in the development of this knowledge [5].
Traditionally training related to the prevention of MSDs is associated with ‘Back’ or ‘Neck’ schools. Today this concept is enlarged and fits into a global prevention approach. Information and training activities can play an important role in the primary prevention of MSDs, but only when this training is part of a general prevention strategy focused on the reduction of risks in the work place[6].
Behaviour of individuals is strongly determined by their knowledge and attitudes. An important step in reducing health risks is to ensure that the individuals concerned perceive MSDs to be a genuine risk. Managers are unlikely to implement changes, or employees to adopt changes to their working practices, unless they are genuinely concerned about the issue.
Two main categories of interventions on behavioural modification can be distinguished: education and exercises[7].
Education and training
Education and training evolved from the classic 'back or neck schools' to more general ergonomic-related guidance and training programmes, with different topics (e.g. manual handling, assembling work, computer work). These training programmes are most effective when organised in a simulated work situation or on the job.
Training methods to prevent MSDs generally fall into two parts:
- 1. Education in ergonomics and biomechanical principles to recognise and understand work related risks and how to prevent them, but also to increase awareness of MSDs so that safe work methods and healthy lifestyle are adopted. In many cases training programmes are used to introduce the methodology of participatory ergonomics. People learn about ergonomics and look for risks in their (own) work environment and give ideas to improve the working conditions:
-
- recognition of hazards for MSDs;
- problem-solving programs designed to provide workers with the information and skills necessary to participate in hazard control activities.
Education in the prevention of work-related MSDs can also include campaigns and the dissemination of written information, for example through brochures or leaflets on ergonomics-related topics. Film, video and multimedia can be used to make the training more ‘visual’.
Different target groups can be identified: managers, supervisors, operators, engineering departments, human resource officers, and medical staff.
- 2. Practical training (on the job) in:
-
- the correct use of work equipment (lifting devices, chairs, furniture);
- how to organise work and the work station in an ergonomic way;
- safe working postures (sitting, standing, reaching);
- safe manual work techniques: handling, lifting, pulling and pushing of loads;
- working with a computer in an ergonomic way.
Target groups are managers, supervisors and production operators or office workers.
Physical training or exercises
Physical training or exercises can be encouraged through workplace health promotion programmes. They aim to reduce the discrepancy between the workload and the worker's physical capacity. Physical fitness training and sport are used to increase the individual physical capacity in order to cope with the physical workload.
In the secondary prevention (to halt the further development of MSDs) and in the tertiary prevention (reducing disability) training and exercise therapy[8] can also play a role in:
- the reduction of pain related to MSDs;
- the increase of the functional status of the patient.
These positive effects can increase the quality of life and facilitate the return to work.
Effectiveness and limits of training
Education and training
The cost of training includes elements such as the cost for the trainer, venue, supporting materials, possible loss of production time.
The effectiveness of training depends on the type of training and also on how this training is part of a global prevention strategy. Several studies[9][7] [10] [11]show that educational programmes and training as a sole preventive measure, have little effect on the prevention of MSDs, particularly when the realities of the work environment prevent the adoption of safe work postures or hinder the use of optimal lifting techniques.
For example a short training in lifting techniques is not enough to prevent work-related low back pain. If the job requirements are physically stressful, the behaviour modification will not eliminate the inherent risk. Therefore designing ergonomic workplaces (for example an ergonomic manual handling or computer workstation) and working in a safe work organisation are far more efficient and should be preferred over training people to behave safely.
For training to be successful, it must be part of a comprehensive ergonomic intervention. Evidence suggests that such interventions involving participation of workers and managers, the tailoring of training to suit the person and specific task requirements, along with equipment or task design/redesign, are effective in reducing MSDs. The emphasis in training should be on changing attitudes and behaviour and promoting risk awareness among workers and managers [12].
Physical training
There is clear evidence from research that (intensive) physical exercise programmes on the reduction of low back pain and other MSDs are effective. In particular exercises in muscle strengthening appear to have a positive effect[7][13][14].
In the return to work process of persons with chronic low back pain, physical conditioning programmes involving the workplace, or physical conditioning being part of integrated care management may have had a positive effect on reducing sick leave, but the evidence is not conclusive [15].
Training as part of a holistic approach is also important for the retention, rehabilitation and reintegration of workers who already suffer from MSDs.
Training principles and points of attention
Integrated in a global prevention approach
Based on the European OSH legislation and to general accepted good practice, four basic steps can be formulated to tackle MSDs. These steps are applicable as well for manual handling activities as for repetitive work or office work.
Step 1 – Avoid hazardous postures, movements or manual handling as far as possible Attention should be given to the ergonomic design or redesign of the workplace, tools, technical equipment, furniture, chairs, etc. All operations involving repetitive movements, static muscular load, lifting, carrying, transferring, pushing or pulling loads have to be evaluated and one should consider whether the work/task can be performed in another way. The work has to be organised in a way that repetitive or monotonous tasks are avoided and that workers don’t have to adopt awkward work postures. Can things be done differently? By reorganising the way things are done, it is possible to eliminate hazardous manual operations or hazardous work postures (office, assembling task, …).
Step 2 – Assess the risks for injuries related to manual work, manual handling or hazardous working postures that cannot be avoided and reduce the risk as far as possible Observe each manual handling operation and the corresponding work posture that takes place. For office workers this can mean to analyse the work posture of the office workers during their computer work.
Consider how these operations or work postures could be made easier and less risky. Changes in the work organisation can reduce the time exposed to the risks. Ask the workers and involve them in the process of thinking about improvements. Then draw up and implement an action plan. First, tackle those operations or situations that cause the highest risk. Try out changes on a small scale initially, to make sure that they are feasible. Involve the workers in the evaluation of the changes.
Step 3 – Train the management, employees and other target groups in ergonomics and more specific in safe handling techniques and in ergonomic working methods Good training is very important but will never be a solution on its own. The training has to fit into the global approach. Because training is focused on changing values, attitudes, habits and behaviour, it has to be adapted to the company culture and the specific industry or work environment. The training method, the content and the timing of the training have to be suitable for the specific target group.
Step 4 – Physical exercise There is clear evidence that physical exercise is important in the prevention of MSDs. This training has to be well balanced and adapted to the capacity and the preferences of the individual. Full body training, endurance, muscular strengthening and flexibility exercises must be part of the training.
Preparation
As stated before, training must be part of a global prevention programme to tackle MSDs, in which work-related risk factors are avoided or if not possible, are reduced by technical and organisational measures. Before embarking on a training that requires particular working methods, it is important to make sure that:
- there is no work pressure or demands that would make this acquired work behaviour impossible;
- the work environment, the workplace and technical equipment support the desired behaviour and work method.
Therefore it is necessary, before starting a training programme in a company, to ensure the commitment of the management to apply this global approach to prevent MSDs. Commitment, support and participation are all required for a successful intervention to prevent MSDs. Lack of knowledge on MSDs and their potential work-relatedness may be a barrier as well as resistance to change. Therefore, there is a clear need to also raise the knowledge and awareness of management[11][5] e.g. organising a workshop.
In this stage a decision can be taken for which target groups training has to be organised. To have a significant influence on the company culture, it is necessary to focus on different target groups. For example when workers are given appropriate training, it is important to ensure that managers and supervisors are also aware of the good practices that have been recommended, and that they regularly encourage the workforce to adopt appropriate techniques and ensure they continue to be used.
The objectives of the training have to be determined and have to be communicated to the trainees.
A good planning is important. The number of participants should be limited (maximum 10-12) to make interaction and active participation possible. Enough time is necessary to increase awareness and knowledge, to change attitudes and to learn new skills or work techniques. Repeated training sessions of 2-3 hours seem to be more effective than training sessions of a full day. The time interval between the different sessions should be limited (less than two weeks).
The infrastructure and the technical equipment available in the training room can have an important impact on the effectiveness of the training (PowerPoint computer presentations, video, pictures, …). Didactic material such as anatomical spine models, which are designed for hands-on demonstrations, can help to explain the functioning of the spinal column and to understand the risks. Sufficient place is needed to make the training practical and to be able to organise practical exercises. So the location or training room has to be adapted to this kind of training.
Realistic and Tailor-made
Training to improve work techniques for operators or office workers has to be organised ‘on the job’ or in simulated conditions, with real tools and products and in a realistic environment. To change the behaviour it is important that participants experience the benefit of the new ‘safe’ work techniques. If they are convinced that the principles and the work methods they have learned really help them, they will be more motivated to change habits and to apply the new principles. Workers must know the risk factors, be receptive and ready to make changes in behaviour and practice these behaviours until they become part of their personal habits [16]. This is most likely to be achieved through industry and task specific training that is tailored to recipients’ level of knowledge and understanding of the risks [12].
Keep the training alive
It is also important to keep in mind that each (new) employee must be trained and retrained periodically to reinforce safe and ergonomic practices. Keep records of who has received training, when the training was organised and what the content of the training was.
Trainer
The person who gives the training has to be expert in MSDs but also in educating and training people. This means that he or she has the necessary pedagogic and communicative skills. The trainer has to visit the workplaces of the trainees, determine the best practices and make sure that the content of the training reflects the working conditions.
Content
Training for industrial activities
This training can consist of different topics and can be organised for different target groups:
| Topics |
Management |
Supervisors |
Engineering |
Operators |
| The problem of MSDs: type, consequences, statistics |
Yes |
Yes |
Yes |
Yes |
| Work-related risk factors for MSDs |
Yes |
Yes |
Yes |
Yes |
| Risk assessment methods |
Yes |
Yes |
Yes |
Yes |
| How to tackle MSDs? |
Yes |
Yes |
Yes |
Yes |
| Technical and organisational prevention measures |
Yes |
Yes |
Yes |
Yes |
| Safe work methods |
Yes |
Yes |
Yes |
Yes |
| Practical exercises |
Yes |
Yes |
Yes |
Yes |
| Role of managers and supervisors in organising work and coaching workers |
Yes |
Yes |
Yes |
|
| Anthropometrics, biomechanical and design principles for workplaces and technical equipment |
|
|
Yes |
|
| Integrating feedback of users in a new design |
|
|
Yes |
|
| Correct use of technical equipment and tools to avoid MSDs: attention should also be given to the safety rules (technical tools as a hazard). |
Yes |
Yes |
Yes |
Yes |
Source: [17]
Ergonomic work techniques that can prevent MSDs generally involves training aimed at reducing the number and types of awkward neck, back, wrist and shoulder postures, minimising the levels of mechanical forces applied and reducing the number of repetitive motion patterns. This can be accomplished by analysing the tasks that have to be carried out. Video analysis can be used to make a detailed analysis to look for the best practice. During the training it can also be useful to work with video, in order to give feedback to the trainees about their performance. Some principles to reduce risks for MSDs by improving postures and movements:
- keep joints in neutral (natural) position during work (no bending, twisting or overstretching);
- avoid unnecessary movements or force exertion;
- keep arms and hands close to the body while lifting or manipulating;
- before lifting, put your feet in such a way that the load is as close as possible to the body. When lifting, keep your back in the natural curve, use the muscles of your legs and abdomen to lift the weight. In this position there will be less strain on the low back ligaments, it minimises disc compression and the overall strength requirements and there is a clear mechanical advantage (small lever of the load). This way of lifting requires a good physical condition (strength leg muscles);
- slow lift movement cause less (peak) compressive force on the intervertebral discs;
- during carrying it is also important to keep the load close to the body;
- to push or pull loads, it is important to start the movement slowly: this requires less initial force. The force has to be delivered by the muscles of the legs and to use the body weight to move the load.
Topics of training for office workers include:
- Principles of ergonomic work design and work organisation;
- The health risks of office work and more particularly of working with visual display units;
- MSDs and the risk factors of MSDs;
- Prevention measures related to:
- computer equipment and furniture
- sitting and working posture
- arrangement of the workspace and lay-out
- work environment
- work organisation;
- Physical exercise.
Psychosocial factors
Most interventions aimed at reducing MSDs focus on the physical aspects. Such an approach overlooks important psychosocial influences, which have been found to be associated with MSDs[3]. This aspect has to be considered in the strategy to prevent MSDs. Organisational measures can reduce stress. This should also be integrated in the training of the employees: how to cope with work-related stress and what measures can they take to improve working methods/the work organisation?
Physical exercises
There are several types of physical training programmes: spinal flexion exercise, extension exercise, isometric strengthening exercise for abdominal and lumbar muscles and aerobic exercise. The possible exercises used as a prevention method include strengthening of weak muscles and of tight muscles and ligaments, stabilisation of hypermobile segments, correcting poor posture, etc.
The general purpose is to increase the physical capacity to cope with the workload. All kinds of sport activities (e.g. football, basketball, jogging, swimming) can have positive effects and are often more appreciated and motivating (having fun). These activities also offer a possibility to strengthen muscles and tendons and have a positive effect on the cardiovascular system. It is known that sports activities also reduce the negative effects of stress on the human body. Therefore, physical training and sports can be recommended, not only for industrial workers involved in manual handling or assembly work, but also for office workers who have often a lack of movement.
Companies try to motivate their employees to participate in physical exercise by:
- paying a part of or the total participation fee;
- organising physical exercises in group or sports activities;
- providing accommodation and material;
- allowing participation to activities during working hours or during breaks;
- sponsoring participation in activities such as ‘start to run’, organised joggings, tournaments etc.
Young people
Very often people become aware of MSDs problems when they have experienced them themselves. Nevertheless it is worthwhile trying to ensure a correct understanding of MSDs risks and prevention at an early age. Many young people use computers, mobile devices and computer games intensively and often also carry heavy school bags. The consequence of this is that many young people who enter the workforce may have already been exposed to MSDs risks. Targeting information, education and training at these young people can help to reduce these MSDS risks and contribute to a better awareness of the risks.
Conclusion
Training, education and physical exercise can be effective if it is embedded in a comprehensive prevention approach of MSDs. The aim is to change the ergonomic culture of a group and the attitude and behaviour of individuals related to the prevention of MSDs. Also healthy lifestyle has to be promoted.
Training in the prevention of MSDs can be useful for an industrial environment but also for office workers. Training in companies should only be started when there is a clear commitment of the management to such a comprehensive prevention approach. Training must be well planned (timing, location, small groups…), well prepared and adapted to the target group. The objectives must be clear. After the training the participants of the different target groups must realise what their specific role is in the prevention of MSDs. The new and safe work techniques that are educated to workers should be realistic and applicable in the real work. The technical equipment and the workplace have to support the desired behaviour. Training can also be an occasion to start with participatory ergonomics.
Physical exercises and training can also help persons who already suffer from MSDs and have a positive effect on the return to work. Because of the impact of MSDs on the working population, this topic should be part of the education of young people. They should be made aware of the risks related to and the prevention of MSDs.
