– The Revised Strain Index –


A DUE Physical Exposure Model for

Complex Tasks with Job Rotation

Jay Kapellusch, PhD

Associate Professor
Occupational Science & Technology
University of Wisconsin - Milwaukee

Arun Garg, PhD – Distinguished Professor

University of Wisconsin - Milwaukee

J. Steven Moore, MD, PhD – Professor Emeritus

Texas A&M University
 Background
• Occupational physical exposures typically consist of:
• biomechanical stressors, and
• physiological stressors

• Designing jobs by minimizing certain factors (eg

repetition), or considering only one of these
disciplines can mislead us about what is safe and
what is not.
• Physical exposure analysis methods consider
biomechanics and physiology in concert and thus are
potentially useful design tools.
The 1995 Moore & Garg Strain Index
Background

• Semi-quantitative tool for quantifying physical

exposures from hand-intensive work
• Based upon principles of:
• Biomechanics,
• Physiology, and
• Epidemiology

• Several epidemiological studies have shown

association between the SI score, and prevalence and
incidence of distal upper limb MSDs such as CTS.
Baseline +Time

Worker
Time=T1 Time=T2 Time=T3

Job1 Job2 Jobn

Task1 Task2 Taskn

Task(s) Task(s)
5 hours, SI = 4 3 hours, SI = 12 1 hours, SI = 8

Sub-Task1 Sub-Task1 Sub-Task1

Sub-Task2 Sub-Task2 Sub-Task2

Sub-Task3 Sub-Task3 Sub-Task3

Sub-Taskn Sub-Taskn Sub-Taskn

Physical Exposure Map

Baseline +Time

Worker
Time=T1 Time=T2 Time=T3

Job1 Job2 Jobn

Task1 Task2 Taskn

Task(s) Task(s)
5 hours, SI = 4 3 hours, SI = 12 1 hours, SI = 8

Sub-Task1 Sub-Task1 Sub-Task1

Sub-Task2 Sub-Task2 Sub-Task2

Sub-Task3 Sub-Task3 Sub-Task3

Sub-Taskn Sub-Taskn Sub-Taskn

Physical Exposure Map

Baseline +Time

Worker
Time=T1 Time=T2 Time=T3

Job1 Job2 Jobn

Task1 Task2 Taskn

Task(s) Task(s)
5 hours, SI = 4 3 hours, SI = 12 1 hours, SI = 8

Sub-Task1 Sub-Task1 Sub-Task1

Sub-Task2 Sub-Task2 Sub-Task2

Sub-Task3 Sub-Task3 Sub-Task3

Sub-Taskn Sub-Taskn Sub-Taskn

Physical Exposure Map

 Job1 Job2

Task1 Task2 Taskn

Task(s)
5 hours, SI = 4 3 hours, SI = 12 1 hours, SI = 8

Sub-Task1 Sub-Task1 Sub-Task1

Sub-Task2 Sub-Task2 Sub-Task2

Sub-Task3 Sub-Task3 Sub-Task3

Sub-Taskn Sub-Taskn Sub-Taskn

Physical Exposure Map

 Job1 Job2

Task1 Task2 Taskn

Task(s)
5 hours, SI = 4 3 hours, SI = 12 1 hours, SI = 8

Sub-Task1 Sub-Task1 Sub-Task1

Sub-Task2 Sub-Task2 Sub-Task2

Sub-Task3 Sub-Task3 Sub-Task3

Sub-Taskn Sub-Taskn Sub-Taskn

Physical Exposure Map

Example
Complex
Task
Stripping Shielded Cable
5
Intensity of Exertion (SI Scale)

.6 1.7 0.7
4

3
.4 .4 1.4
2
1.5 0.5 0.7 0.4 2.5
1

0
2 4 6 8 10 12 14 16 18 20
Time (s)
 Sub-Task Intensity of Effort Efforts per Minute % Duration of Cycle

1 15/min 28%

2 9/min 11%

4 9/min 15%

Combined ?? 33/min 54%

5
Intensity of Exertion (SI Scale)

.6 1.7 0.7
4

3
.4 .4 1.4
2
1.5 0.5 0.7 0.4 2.5
1

0
2 4 6 8 10 12 14 16 18 20
Time (s)
 Sub-Tasks Intensity of Effort Efforts per Minute % Duration of Cycle

Combined Max = 4 33/min 54%

IM EM DM PM SM HM SI
9 x 3 x 2 x 1 x 1 x 1 = 54

5
Over-Estimation of Risk = 21.2 force-seconds
Intensity of Exertion (SI Scale)

1.5 0.5 0.7 .4 .4 0.4 1.4 2.5 .6 1.7 0.7

4

0
2 4 6 8 10 12 14 16 18 20
Time (s)
 Sub-Tasks Intensity of Effort Efforts per Minute % Duration of Cycle

Combined Typical = 1 33/min 54%

IM EM DM PM SM HM SI
1 x 3 x 2 x 1 x 1 x 1 = 6

5
Under-Estimation of Risk = 9 force-seconds
Intensity of Exertion (SI Scale)

.6 1.7 0.7
4

.4 .4 1.4
2

1.5 0.5 0.7 0.4 2.5

1

0
2 4 6 8 10 12 14 16 18 20
Time (s)
 Sub-Tasks Intensity of Effort Efforts per Minute % Duration of Cycle

Combined TWA** = 2 33/min 54%

**Time-Weighted Average

IM EM DM PM SM HM SI
3 x 3 x 2 x 1 x 1 x 1 = 18

Over-Estimation of Risk = 5.8 force-seconds

5 Under-Estimation of Risk = 5.8 force-seconds
Intensity of Exertion (SI Scale)

.6 1.7 0.7
4

1.5 0.5 0.7 .4 .4 0.4 1.4 2.5

2

0
2 4 6 8 10 12 14 16 18 20
Time (s)
Comparison of Intensity
Summarization Techniques
Intensity
Over-estimation Under-Estimation
Summarization SI Score
of Risk of Risk
Technique

Max Force 54 21.2 force-seconds 0 force-seconds

Typical Force 6 0 force-seconds 9 force-seconds
TWA Force 18 5.8 force-seconds 5.8 force seconds
Comparison of Intensity
Summarization Techniques
Intensity
Over-estimation Under-Estimation
Summarization SI Score
of Risk of Risk
Technique

Max Force 54 21.2 force-seconds 0 force-seconds

Typical Force 6 0 force-seconds 9 force-seconds
TWA Force 18 5.8 force-seconds 5.8 force seconds

Seems acceptable? But...

 How Can Adding Efforts Make a
Hazardous Task Safe?
1s 1s 1s 1s 1s 1s
5
Intensity of Exertion (SI Scale)

6 Efforts/Minute
4
10 % Duration
3
SI = 13.0
HAZARDOUS!
2

0
12 24 36 48 60
Time (s)
 How Can Adding Efforts Make a
Hazardous Task Safe?
1s 1s 1s 1s 1s 1s 1s 1s 1s 1s 1s 1s
5 5
Intensity of Exertion (SI Scale)

Intensity of Exertion (SI Scale)

6 Efforts/Minute 8 Efforts/Minute
4 4
10 % Duration 45 % Duration
3
SI = 13.0 3
SI = 4.5
HAZARDOUS! SAFE???
2 2
11s 11s
1 1

0 0
12 24 36 48 60 12 24 36 48 60
Time (s) Time (s)
 Do Equal Force-Duration Efforts
Produce Equal Strain?
1s 1s 1s 1s 1s
5 5

Intensity of Exertion (SI Scale)

Intensity of Exertion (SI Scale)

4 4
20 force-seconds 20 force-seconds
3 3
SI = 6.50 SI = 0.75
2 2
7s 7s 6s
1 1

0 0
12 24 36 48 60 12 24 36 48 60
Time (s) Time (s)

SI Model: Force has much larger effect on Strain

than Duration of the force
The 1995 Moore & Garg Strain Index
Background

• The 1995 SI has several noteworthy limitations, including:

• No reliable method to determine overall force for
complex tasks
• Frequency variable is limited to 20 efforts per minute
• Intensity multiplier lacks fidelity for low-force exertions
and under-penalizes for high-force
• All multipliers are categorized leading to systemic
inconsistencies in the ‘continuous' score
• No method or guidance for quantifying exposure from
multi-task jobs
The Revised Strain Index
Conceptually Similar to the 1995 SI
1995 SI
Intensity of Exertion

Frequency of Exertion

Duty Cycle

Hand/Wrist Posture

Speed of Work

Hours per Day

The Revised Strain Index
Conceptually Similar to the 1995 SI
1995 SI RSI

Intensity of Exertion Intensity of Exertion

Frequency of Exertion Frequency of Exertion

Duty Cycle Duration per Exertion

Hand/Wrist Posture Hand/Wrist Posture

Speed of Work

Hours per Day Hours per Day

The Revised Strain Index
Conceptually Similar to the 1995 SI
1995 SI RSI

Intensity of Exertion Intensity of Exertion

Frequency of Exertion Frequency of Exertion

Duty Cycle Duration per Exertion

Hand/Wrist Posture Hand/Wrist Posture

Speed of Work

Hours per Day Hours per Day

The RSI Model
• 5 variable multiplicative model
• Intensity of exertion, frequency of exertion, duration
per exertion, posture, hours per day
• Key differences between RSI and 1995 SI
• Continuous rather than categorical multipliers
• Duration per exertion rather than duty cycle
• Differentiation between flexion and extension
postures
• Accounts for up to 12 hours per day of exposure
Garg, Arun, J. Steven Moore, and Jay M. Kapellusch. "The Revised Strain Index: an improved upper extremity
exposure assessment model." Ergonomics (2016): 1-11.
Garg, A., Moore, J. S., & Kapellusch, J. M. (2016). The Composite Strain Index (COSI) and Cumulative Strain
Index (CUSI): methodologies for quantifying biomechanical stressors for complex tasks and job rotation using
the Revised Strain Index. Ergonomics, 1-9.
 Intensity of Exertion
• A measure of the force required to perform the task once

• Measured in %MVC, or estimated with Borg CR-10

Scale

• %MVC = Borg CR-10 * 10

Intensity Multiplier (IM)

Where: 'I' is %MVC between 0 and 1

Intensity of Exertion
 Revised Strain Index
Force
• 5 Continuous Variables & Multipliers
• Calculated from sub-tasks
• Uses duration per exertion
• Accounts for flexion vs. extension

Frequency Posture

Duration

Hours
The RSI Score

• Where:

• IM = Intensity Multiplier

• EM = Frequency Multiplier

• DM = Duration Multiplier

• PM = Posture Multiplier

• HM = Hours Multiplier

• A-priori high-risk cut-point: RSI = 10.0

Task Discrimination

1995 SI Score
 The RSI Score
• The Composite SI (COSI) for complex tasks:
Order from highest to lowest RSI

COSI is highest subtask stress plus

incremental stress of remaining
subtasks.

Each delta RSI is the product of the

frequency independent RSI, and
the differential frequency multiplier

FIRSI is the subtask RSI divided

by the subtask frequency multiplier

Differential frequency multiplier is

the penalty as the multiplier moves
from the n-1 to the nth cumulative
frequency of exertion
 The RSI Score
• The cumulative SI (CUSI) for multiple tasks:
Order from highest to lowest COSI

CUSI is highest task stress plus

incremental stress of remaining
tasks.

Each delta CUSI is the product of the

hours independent COSI, and
the differential hours multiplier

HICOSI is the task COSI divided

by the task hours multiplier

Differential hours multiplier is

the penalty as the multiplier moves
from the n-1 to the nth cumulative
hour of daily exposure
Composite Strain Index
&
Cumulative Strain Index

Examples of Utility
Example
Complex
Task
Stripping Shielded Cable
5
Intensity of Exertion (SI Scale)

0
2 4 6 8 10 12 14 16 18 20
Time (s)
Example
Complex
Task
Stripping Shielded Cable
10
Intensity of Exertion (Borg CR-10)

0
2 4 6 8 10 12 14 16 18 20
Time (s)
Example
Complex
Task
Stripping Shielded Cable
15

12
Sub-Task RSI Score

0
2 4 6 8 10 12 14 16 18 20
Time (s)
Example
Complex
Task
Stripping Shielded Cable
15

12
Sub-Task RSI Score

0
 50

40 Exposure Time COSI

8 Hours 50.6
COSI Score

30 2 Hours 30.4
1 Hour 25.3
20 20 Minutes 20.2
5 Minutes 15.2
10

15

12
Sub-Task RSI Score

0
 50

40 Exposure Time COSI

8 Hours 16.0
COSI Score

30 2 Hours 9.6
1 Hour 8.0
20 20 Minutes 6.4
5 Minutes 4.8
10

15

12
Sub-Task RSI Score

0
CUSI Example - Luminaire Wiring & Prep
Pre-Intervention
Wire Stripping - A Wire Stripping - B Termination Wiring
Exposure Time 20 Minutes 100 Minutes 180 Minutes 180 Minutes
COSI 20.2 8.2 3.2 4.6

Job Score Implication

TWA COSI 5.5 SAFE
Typical COSI 4.6 SAFE
Peak COSI 20.2 HAZARDOUS
CUSI Example - Luminaire Wiring & Prep
Pre-Intervention
Wire Stripping - A Wire Stripping - B Termination Wiring
Exposure Time 20 Minutes 100 Minutes 180 Minutes 180 Minutes
COSI 20.2 8.2 3.2 4.6

Job Score Implication

TWA COSI 5.5 SAFE
Typical COSI 4.6 SAFE
Peak COSI 20.2 HAZARDOUS

COSI HICOSI ∑ H (i) ∑ H (i-1) HM (i) HM (i-1) ∆ HM ∆ COSI

20.2 50.6 0.33 — 0.39 0 0.39 20.2
8.2 13.9 2.00 0.33 0.62 0.39 0.23 3.2
4.6 6.6 5.00 2.00 0.83 0.62 0.21 1.4
3.2 4.6 8.00 5.00 1.00 0.83 0.17 0.8
CUSI Example - Luminaire Wiring & Prep
Pre-Intervention
Wire Stripping - A Wire Stripping - B Termination Wiring
Exposure Time 20 Minutes 100 Minutes 180 Minutes 180 Minutes
COSI 20.2 8.2 3.2 4.6

Job Score Implication

TWA COSI 5.5 SAFE
Typical COSI 4.6 SAFE
Peak COSI 20.2 HAZARDOUS
CUSI 25.6 HAZARDOUS

COSI HICOSI ∑ H (i) ∑ H (i-1) HM (i) HM (i-1) ∆ HM ∆ COSI

20.2 50.6 0.33 — 0.39 0 0.39 20.2
8.2 13.9 2.00 0.33 0.62 0.39 0.23 + 3.2
4.6 6.6 5.00 2.00 0.83 0.62 0.21 + 1.4
3.2 4.6 8.00 5.00 1.00 0.83 0.17 + 0.8
CUSI: 25.6
CUSI Example - Luminaire Wiring & Prep
Post-Intervention
Wire Stripping - A Wire Stripping - B Termination Wiring
Exposure Time 20 Minutes 100 Minutes 180 Minutes 180 Minutes
COSI 6.4 8.2 3.2 4.6

Job Score Implication

TWA COSI 4.9 SAFE
Typical COSI 4.6 SAFE
Peak COSI 8.2 SAFE

COSI HICOSI ∑ H (i) ∑ H (i-1) HM (i) HM (i-1) ∆ HM ∆ COSI

8.2 13.9 1.67 — 0.59 0 0.59 8.2
6.4 16.0 2.00 1.67 0.62 0.59 0.03 0.5
4.6 6.6 5.00 2.00 0.83 0.62 0.21 1.4
3.2 4.6 8.00 5.00 1.00 0.83 0.17 0.8
CUSI Example - Luminaire Wiring & Prep
Post-Intervention
Wire Stripping - A Wire Stripping - B Termination Wiring
Exposure Time 20 Minutes 100 Minutes 180 Minutes 180 Minutes
COSI 6.4 8.2 3.2 4.6

Job Score Implication

TWA COSI 4.9 SAFE
Typical COSI 4.6 SAFE
Peak COSI 8.2 SAFE
CUSI 10.9 HAZARDOUS

COSI HICOSI ∑ H (i) ∑ H (i-1) HM (i) HM (i-1) ∆ HM ∆ COSI

8.2 13.9 1.67 — 0.59 0 0.59 8.2
6.4 16.0 2.00 1.67 0.62 0.59 0.03 + 0.5
4.6 6.6 5.00 2.00 0.83 0.62 0.21 + 1.4
3.2 4.6 8.00 5.00 1.00 0.83 0.17 + 0.8
CUSI: 10.9
CUSI Example - Luminaire Wiring & Prep
Post-Intervention
Wire Stripping - A Wire Stripping - B Termination Wiring
Exposure Time 20 Minutes 100 Minutes 180 Minutes 180 Minutes
COSI 6.4 8.2 3.2 4.6

Job Score Implication

Needs Intervention
TWA COSI 4.9 SAFE
Typical COSI 4.6 SAFE
Peak COSI 8.2 SAFE
CUSI 10.9 HAZARDOUS

COSI HICOSI ∑ H (i) ∑ H (i-1) HM (i) HM (i-1) ∆ HM ∆ COSI

8.2 13.9 1.67 — 0.59 0 0.59 8.2
6.4 16.0 2.00 1.67 0.62 0.59 0.03 + 0.5
4.6 6.6 5.00 2.00 0.83 0.62 0.21 + 1.4
3.2 4.6 8.00 5.00 1.00 0.83 0.17 + 0.8
CUSI: 10.9
 Conclusions
• COSI and CUSI are powerful design tools:

• Discrete estimates of physical exposure for sub-

tasks and tasks

• Require fewer assumptions to use

• Should prove more repeatable and reliable for

continuous improvement of manual and semi-
automated operations
 References:
Garg, A., & Kapellusch, J. M. (2016). The cumulative lifting index
(CULI) for the revised NIOSH lifting equation: quantifying risk for
workers with job rotation. Human factors, 58(5), 683-694.

Garg, Arun, J. Steven Moore, and Jay M. Kapellusch. "The

Revised Strain Index: an improved upper extremity exposure
assessment model." Ergonomics (2016): 1-11.

Garg, A., Moore, J. S., & Kapellusch, J. M. (2016). The Composite

Strain Index (COSI) and Cumulative Strain Index (CUSI):
methodologies for quantifying biomechanical stressors for
complex tasks and job rotation using the Revised Strain Index.
Ergonomics, 1-9.

kap@uwm.edu
NIOSH Upper Limb Consortium
Studies:
What did we learn about Carpal
Tunnel Syndrome, and what
should we do next?
Bradley Evanoff, MD, MPH
 Overview
• NIOSH Upper Extremity Consortium Study
– Design
– Main findings
– Comparison to OCTOPUS studies
• Thoughts on future MSD research
 Why study CTS?
• Most common entrapment neuropathy –
compression of median nerve at the wrist
• Common upper extremity surgery: almost
twice as common as rotator cuff repair
among people aged 45-64
• Associated with large financial burden in
compensation systems, disability
• Model for other UE MSD
 Problems with studying CTS
• Common enough to be a societal problem,
rare enough to make it difficult to study
• Estimates of prevalence and incidence
vary widely depending on how CTS is
defined (case definition) and counted
(active vs. passive surveillance)
• Multiple exposures thought to be relevant
(force, repetition, posture, vibration)
• Important personal risk factors
• Highly politicized controversies
 Rationale for NIOSH Upper
Extremity Consortium (2001)
• Few previous studies with
– Prospective design
– Individual level exposures
– Assessment of both work-related and
personal risk factors
– Rigorous case definitions
• Exposure response relationships,
attributable risk not well defined
 Six NIOSH
studies collected
similar data

• Multiple health outcomes via interview and

questionnaire
• Individual level exposure assessment
• Structured physical examination
• Nerve Conduction Studies
• Prospective, longitudinal follow up 3-7 years
NIOSH Upper Extremity Consortium

Pooled
Data Set
Total = 4321 Workers
Subjects/site = 346-1219
55 Companies in 10 US States
Production, food processing, health care,
construction, service, technical
 Common case definition for CTS required
symptoms and abnormal nerve conduction
• Symptoms of numbness, burning, tingling,
or pain in digits 1,2, or 3 - and -
• Median neuropathy (NCS adjusted for skin
temperature and electrode placement)
– median sensory latency (peak >3.7 ms) –or-
– median motor latency (onset >4.5 ms) –or-
– median ulnar sensory difference (>0.85 ms)
 Biomechanical Exposure

*Forceful = ≥9N (1 kg) pinch force or ≥45N (4.5 kg) of power

grip
Borg CR-10, HAL Scales
Multimedia Video Task Analysis used to estimate:
• Time spent in flexion/extension
• Total repetition rate / forceful repetition rate
• Time spent in all hand exertions / forceful hand exertions
NIOSH Upper Extremity Consortium:
Research Outputs to Date
>80 Publications; 13 Publications using
pooled consortium data
• Exposure methods
• Case definitions
• Risk factors for Prevalent CTS
• Risk Factors for Incident CTS
5 Incidence Studies
Kapellusch, SJWEH 2014 
N = 2751 (186 cases, 6243 PY)

Harris-Adamson, SJWEH 2013

N=3515 (206 cases, 8833 PY)

Harris-Adamson, OEM 2015

N=2474 (179 cases, 5103 PY)

Rempel, OEM 2015

N=2396

Dale, Am J Epidemiol 2015

N=3452
5 Incidence Studies
Kapellusch, SJWEH 2014 
N = 2751 (186 cases, 6243 PY)

Harris-Adamson, SJWEH 2013

N=3515 (206 cases, 8833 PY)

Harris-Adamson, OEM 2015

N=2474 (179 cases, 5103 PY)

Rempel, OEM 2015

N=2396

Dale, Am J Epidemiol 2015

N=3452
 Statistical Analysis
• Categorical splits based on baseline
exposure distribution
• Cox Proportional Hazards model using
robust confidence intervals
• Adjusted for age, gender, BMI, study site, &
non-overlapping biomechanical exposures
 Demographic Characteristics
[Dale SJWEH 2013]

Pooled cohort n=4321

Male 52 %
Caucasian race 54 %
Mean Age 38.5 years
Mean Body Mass Index 28.6 %
Smoking 26%
< High School Diploma 16%
Mean time in current job 6.5 years
Incidence of CTS 2.3 per 100 person years
 Hazard Ratios for Personal Factors
[Harris C et al. OEM 2013]

Factor HR (95% c.i.)

Female 1.30 [0.98-1.72]
Age (≥40 years) 2.84 [1.85-4.37]
BMI (≥30 kg/m2) 1.67 [1.26-2.21]
Co-morbidities (DM, RA, thyroid) 0.95 [0.62-1.44]
 Hazard Ratios: Wrist Posture*
[Harris C et al. OEM 2015]

*Adj. for age,

gender, BMI, Study
site and non-
overlapping
exposures
Hazard Ratios: Peak Hand Force*

*Adj. for age, gender,

BMI, Study site and
non-overlapping
exposures
 Hazard Ratios: Hand Repetition*

*Adj. for age,

gender, BMI,
Study site and
non-overlapping
exposures

Forceful = ≥9N
pinch force or
≥45N of power
grip
 Duty Cycle ≈
% Time in Hand Exertions

same repetition rate !

same peak force !
 Hazard Ratios: Duty Cycle*

*Adj. for age,

gender, BMI, Study
site and non-
overlapping
exposures

Forceful = ≥9N
pinch force or ≥45N
of power grip
HR for Peak Force
HR for Forceful Repetition Rate
HR for % Time in Forceful Exertion
 HAL (Computed)

Repetition
Alone
Duty Cycle Frequency
Threshold Limit Value for
Hand/Wrist Exposures
(ACGIH, 2001)

TLV for HAL score = PF/(10-HAL)

 OCTOPUS study
[Bonfiglioli R, et al. OEM 2013; Violante et al. SJWEH 2016]

• Prospective cohort study in manufacturing and

service workers
• 4232 in cohort; study population 3131
• Ratings of Peak Force and Hand Activity Level
performed at task level by trained observers
• Case definition including CTS symptoms and slowing
of median nerve conduction
• 126 cases of CTS observed in 8883 person years
 Hazard Ratios for TLV
TLV for HAL Bonfiglioli et Violante et al Kapellusch
al 2013 2016 et al 2014

< AL 1.00 1.00 1.00

>AL < TLV 1.95 1.93 (1.38- 1.73 (1.19-

(1.21 – 3.16) 2.71) 2.50)

>TLV 2.70 1.95 1.48 (1.02-

(1.48 – 4.91) (1.27 – 3.00) 2.13)
Contour Plot for PF + HAL Model
score = PF + 0.3*HAL (Kapellusch et al. 2014)
 ACGIH TLV (HAL & PF)
• Consistent results from two large cohorts
• TLV predicts CTS; different calculations using
HAL and PF are even more predictive
• Current Action Limit and TLV are too high to
adequately protect workers
• Non-linearity of risk; highest exposures
sometimes associated with lower risk than
“intermediate” exposures (survivor effect?)
• Higher rates of CTS among newer workers
(NIOSH); higher rates among those that
decreased exposures during study (OCTOPUS)
 Consortium Study Strengths
• Prospective design
• Large cohort
• Varied workplaces – generalizable findings
• High participation rate (>80%)
• Specific CTS case criteria using nerve conduction
• Quantitative individual exposure measures
• Both personal and workplace factors measured
• Exposure response modeling
 Limitations
• Six individual studies with different designs
• Exposure based on limited windows of
observation
• Relatively few low exposure or variable
exposure jobs included in pooled analyses
• Limited data on vibration exposure
• Few workers with long duration of exposure in
extreme flexion or extension
 Summary of Consortium Findings
 Biomechanical factors associated with CTS
•Peak hand force (Borg CR10 ≥ 3)
•Forceful hand repetition rate (>3 exertions/min)

•% time in forceful hand exertions (> 11%)

 Biomechanical factors not associated with CTS

•Total hand repetition rate
•% time any hand exertions

•Wrist posture

 Interventions for CTS in production workers

should focus on reduction in peak force and
duration of forceful hand activity
 Next Steps
• Analyze other endpoints:
– Wrist tendinitis
– Elbow and shoulder disorders
• Evaluate functional outcomes
• Combine data with other large cohorts
• Revise TLV for HAL (ACGIH)
• Revise the Strain Index
 What should we do now?
Outcomes, Exposures, Interventions
• Longitudinal studies
– Expensive, labor intensive
• Outcome assessment
– Are we measuring the most important outcomes?
• Exposure assessment
– Expensive, labor intensive
– Variable jobs an issue
• Interventions – design for dissemination
 Outcomes
• Most case definitions centered on clinical
diagnosis: symptoms, physical signs
• Research should incorporate more worker-
centered outcomes (pain, function, work
limitation) and employer-centered
outcomes (productivity, cost, quality)
• More use of registry studies; electronic
health records and Workers’ Compensation
• Link EHR to SOC codes
PROMIS: Patient-Reported Outcomes
Embrace New Approaches to Exposure
Assessment
• New technologies – wearable sensors
• Automated coding of videos (Radwin)
• Job Exposure Matrix (JEM) allows
exposure estimation for large registry and
cohort studies based on job titles
• TLV for HAL, other less labor intensive
assessment tools (JEM) appear valid and
usable for workplace prevention
 Approaches to intervention
• Build case for urgency – MSD are a major
source of morbidity, disability, cost
• Provide practitioners with better tools to identify
and reduce the exposures associated with
disease (design for dissemination)
• Validate usable exposure assessment tools
• Test practical interventions for exposure
reduction
• Focus on the most important exposures in high
risk groups– prolonged and repeated forceful
hand exertions
Translate our work into prevention
B. Silverstein D. Rempel S. Burt A. Garg F. Gerr

K. Hegmann J. Kapellusch C. Harris- E. Eisen A.M. Dale

Adamson

ZJ
Fan

S. Bao L. Merlino A. Meyers M. Thiese

Work-related Psychosocial Risk Factors
for Low Back Pain
Evidence from 2015 NHIS Data
June 22, 2017

Ming-Lun (Jack) Lu, PhD, CPE (NIOSH)

Haiou Yang, PhD and Scott Haldeman, DC, MD (Center for
Occupational and Environmental Health, University of
California, Irvine, California.)
Sara Luckhaupt, MD, MPH and Stephen Hudock (NIOSH)
National Institute for Occupational Safety and Health (NIOSH)
1190 Tusculum Ave., C-24, Cincinnati, OH 45226
(513) 533-8158
email: mlu@cdc.gov

“The findings and conclusions in this presentation have not been formally disseminated by the
National Institute for Occupational Safety and Health and should not be construed to represent
any agency determination or policy.”
 Impact of Low Back Pain
• Burden:
– Low back pain (LBP) is a common health problem (~1 in 4 adults)
– Tremendous economic burden ($119-238 Billion per year).
– Leading cause of disability
• #1 Years Lived with Disability (YLDs) in the US
• #1 in YLDs Globally

• Need:
– >85% of LBP are non-specific abnormality. Need research.
– Understanding of interactions between risk factors for LBP is poor.

• Impact:
– All walks of life, in particular 3.7 million workers involving repetitive manual
materials handling (MMH) as part of their regular job.
– Top impacted industries: Manufacturing, warehousing, retail trade and
transportation; and health care.
 Background
• Workplace psychosocial factors play some role
in the development of back pain.
• Interactions of psychosocial factors with other
risk factors are poorly understood.
• Insight into the interactions may provide
information needed for effective LBP
prevention strategies.
 National Health Interview Survey
• NHIS is a questionnaire-based cross-sectional health
survey of a nationally representative population of
the US.
• NHIS covers a broad range of health questions,
demographic, personal behavior and work-related
factors.
• NHIS has core and occupational health supplement
(OHS) questions.
• Final sample adult response rate was 55.2% in 2015.
 Methods
• Selected variables from 2015 NHIS dataset.
• Respondents aged 18 and over, employed and
worked at least 20 hours per week (N=17,911).
• Multivariable logistic regression analyses: full
model; sex or age (“young”=18-40; “old”=41-64
and over) stratified model.
• Tree analysis (Breiman et al., 1984) as a
supplementary analysis for a deeper understanding
of interactions of risk factors.
 Tree Analysis
• Recursive partitioning of data to minimize
impurity of tree nodes (Breiman et al., 1984).
• Tree model set up
– Model construction rule: Gini algorithm
– 80% learn and 20% test samples
– Tree selection: minimal cost
• ∆ Gini (Y, x) = Gini (Y)- p (YL)Gini (YL)- p (YR)Gini (YR)
• (1-sensitivity)+(1-specificity))

– Minimal size below which node will not be split: 100

– Minimal size for end node: 50
 Variables
• Dependent variable: Self-reported LBP in the past
three months (Yes or No).
• Independent variables:
– Personal: sex, age, race/ethnicity, education, obesity (BMI≥30),
leisure-time physical activity, serious psychological distress
– Workplace psychosocial: job demand, job control, supervisory
support, work-life interference, exposure to hostile work, job
insecurity
– Work organizational: job arrangement, shiftwork, work hours,
occupation category, earnings.
– Workplace physical: physical exertion, sedentary work
 Independent Variables
• Most independent variables were dichotomized by
the mid point of the 4-point frequency Likert scale
(i.e., low exposure: 1-2; high exposure: 3-4).
• Independent variables dichotomized by other
methods:
– Shiftwork: Regular shift vs. other shifts.
– Physical exertion and sedentary work: 5-point frequency Likert scale:
categories 1-2 (low) vs. 3-5 (high)
– Psychological distress was measured by the Kessler 6 Scale. Sum of
score for the 6 scales was calculated. A score > 13 was used to indicate
psychological distress (Pratt et al., 2007)
– Obesity: Yes if BMI≥30
 Independent Variables (cont.)
• Other multi-level categorical independent variables:
– Age: 18-25; 26-40; 41-55; 55-64; 65 and over
– Work hours (20-39; 40; 41-45; 46-59; 60 and over)
– Occupation (22 categories)
– Earnings (5 categories)
– Education (5 categories)
– Race/Ethnicity (white, black, Asian, Hispanic, Others)

• All categorical variables were used in the tree analysis

except age (continuous).
 Results:
Logistic Regression Analysis (full model)
OR CI
All N=14,580
Workplace psychosocial factors
Work family interference 1.21 (1.07,1.35)
Hostile work environment 1.67 (1.37,2.04)
Job insecurity 1.39 (1.2,1.61)
High demand 1.25 (1.08,1.44)
Low control 0.95 (0.83,1.09)
Lack of supervisor support 1.1 (0.95,1.28)
Physical risk factor
Physical exertion 1.33 (1.19,1.5)
Sedentary work 0.94 (0.83,1.05)
Health behaviors
Leisurely Active 0.92 (0.82,1.03)
Serious psychological distress 2.51 (2.09,3.03)
Obesity (BMI≥30) 1.19 (1.08,1.31)
Sex
Female 1.06 (0.95,1.17)
Age group
18-25 1
26-40 1.36 (1.13,1.65)
41-55 1.78 (1.48,2.14)
56-64 1.73 (1.41,2.14)
65 and over 1.68 (1.29,2.2)
Note: OR adjusted for race/ethnicity, education, earnings, job arrangement, shiftwork, work hours, occupation
OR in bold font indicates a statistical significance (P<0.05)
 Results:
Logistic Regression Analysis (Sex-stratified)
OR CI OR CI
Male N=7,335 Female N=7,245
Workplace psychosocial factors
Work family interference 1.19 (1.02,1.38) 1.22 (1.01,1.48)
Hostile work environment 1.63 (1.2,2.2) 1.71 (1.34,2.19)
Job insecurity 1.49 (1.19,1.87) 1.26 (1.01,1.57)
High demand 1.13 (0.91,1.39) 1.36 (1.13,1.64)
Low control 0.92 (0.75,1.12) 1 (0.82,1.21)
Lack of supervisor support 1.17 (0.94,1.45) 1.05 (0.85,1.29)
Physical risk factor
Physical exertion 1.31 (1.1,1.57) 1.32 (1.12,1.56)
Sedentary work 0.98 (0.83,1.16) 0.92 (0.77,1.1)
Health behaviors
Leisurely Active 0.79 (0.67,0.94) 1.06 (0.9,1.25)
Serious psychological distress 2.18 (1.63,2.92) 2.79 (2.18,3.57)
Obesity (BMI≥30) 1.08 (0.93,1.25) 1.32 (1.13,1.53)
Sex
Female
Age group
18-25 1 1
26-40 1.31 (1,1.71) 1.44 (1.11,1.87)
41-55 1.81 (1.39,2.36) 1.81 (1.41,2.32)
56-64 1.59 (1.18,2.15) 1.96 (1.47,2.61)
65 and over 1.57 (1.05,2.35) 1.89 (1.32,2.71)
Note: OR adjusted for race/ethnicity, education, earnings, job arrangement, shiftwork, work hours, occupation
OR in bold font indicates a statistical significance (P<0.05)
 Results:
Logistic Regression Analysis (Age-stratified)
OR CI OR CI
Young N=6,981 Old N=6,877
Workplace psychosocial factors
Work family interference 1.38 (1.2,1.6) 1.07 (0.9,1.26)
Hostile work environment 2 (1.47,2.72) 1.45 (1.12,1.88)
Job insecurity 1.27 (1,1.61) 1.51 (1.24,1.83)
High demand 1.29 (1.04,1.62) 1.23 (1.02,1.48)
Low control 0.87 (0.71,1.08) 1.01 (0.83,1.24)
Lack of supervisor support 1.01 (0.81,1.27) 1.17 (0.95,1.45)
Physical risk factor
Physical exertion 1.24 (1.02,1.51) 1.42 (1.22,1.66)
Sedentary work 0.97 (0.8,1.19) 0.9 (0.76,1.05)
Health behaviors
Leisurely Active 1.04 (0.87,1.25) 0.84 (0.72,0.99)
Serious psychological distress 2.5 (1.95,3.2) 2.44 (1.86,3.2)
Obesity (BMI≥30) 1.19 (1.02,1.39) 1.19 (1.05,1.36)
Sex
Female 1.21 (1.03,1.42) 0.97 (0.84,1.13)
Note: OR adjusted for race/ethnicity, education, earnings, job arrangement, shiftwork, work hours, occupation
OR in bold font indicates a statistical significance (P<0.05)
Results: Tree Analysis
 Highlights of Results
• Per NHIS data, the 3-month prevalence of LBP in
the US working population was 26.7%.
• Serious psychological distress had the highest
odds (OR=~2.5 or 150% increased risk) of LBP.
• High physical exertion, work-life interference,
hostile work environment, job insecurity were
associated with LBP.
 Discussion (Regression Models)
• Female workers aged between 18-40 may have an
increased risk (20%) of LBP.
• Age was associated with LBP in both sexes.
• Psychosocial job demands were not associated
with LBP for male workers.
• Work-life interference was associated only with
workers aged 40 and younger.
 Discussion (Tree Analysis)
• Under no serious psychological distress and hostile work
environment, job insecurity was a risk factor for workers
older than 42 involving increased job physical exertions;
while work-life interference was a risk factor for workers
younger than 42 involving increase job physical exertions.
• Among workers without serious psychological distress,
exposure to a hostile work environment had an increased
rate (42.5%) of LBP vs. the rate (24.4%) without the
exposure.
• Sex was not a significant factor in moderating the risk
associations.
 Limitations
• Cross-sectional design. No causal
implications.
• Frequency and intensity of pain was not
analyzed although available.
• Single item risk assessments for both
workplace psychosocial and physical
factors were likely to be less reliable.
 Take-Home Messages
• Sex may not be a significant factor moderating various
risk factors for LBP.
• Age may play a more important role in developing LBP
than sex.
• Psychological distress, hostile environment and
physical exertion were three main risk factors for LBP.
• The tree analysis that simulates human decision
making may be more practical for implementing or
prioritizing interventions for reducing risk factors.
 Questions?
Presenter: Jack Lu, PhD, CPE
National Institute for Occupational Safety and Health (NIOSH)
1190 Tusculum Ave
Cincinnati, OH 45226
(513) 533-8158
email: mlu@cdc.gov

References:
• Haiou Yang, Scott Haldeman Ming-Lun Lu and Dean Baker: Low back pain prevalence
and related workplace psychosocial risk factors: A study using data from 2010 NHIS. J of
Manipulative Physiological Therapeutics. 39: 459-472 (2016).
• Leo Breiman et al. Classification and regression trees. Wadworth and Brooks, Monterey,
CA (1984).
• Pratt LA, Dey AN, Cohen AJ. Characteristics of adults with serious psychological distress
as measured by the K6 scale: United States,2001-04. Adv Data. 2007;382(382):1-18.