An a n a lysis on n e ck a n d u ppe r lim b m u scu losk e le t a l sy m pt om s in
Por t u gu e se a u t om ot ive a sse m bly lin e w or k e r s
M. Guerr eiroa, F. Serr anheirab, E.B. Cruzc, A. Sousa- Uvad
aEscola Nacional de Saúde Pública, Univ ersidade Nova de Lisboa, PT (m m .guer r eir o@ensp.unl.pt) ORCI D: 0000- 0003-0682- 2884. bEscola Nacional de Saúde Pública, Univer sidade Nova de Lisboa, PT (serranheira@ensp.unl.pt) ORCI D: 0000- 0001- 7211- 2843. cEscola Superior de Saúde, I nst it ut o Polit écnico de Set úbal, Set úbal, PT
(eduardo.cr uz@ess.ips.pt) ORCI D: 0000- 0003- 1812- 1815. dEscola Nacional de Saúde Pública, Univ ersidade Nova de
Lisboa, PT (asuva@ensp.unl.pt) ORCI D: 0000- 0002- 1575- 2788.
Ar t icle H ist or y
Received 29 January 2017 Accept ed 8 June 2017 Published 1 Sept em ber 2017 Ke y w or ds
w or k- relat ed m usculosk elet al sy m pt om s assem bly lines
upper lim bs
D OI :
10.24840/ 2184- 0954_001.001_0006
I SSN :
2184- 0954
Ty pe :
Research Art icle Open Access
Peer Rev iew ed CC BY
Abst r a ct
Assem bly lines are relat ed t o healt h risks and w or k- relat ed m usculosk elet al disorders ( WMSD) , part icular ly of t he neck and upper lim bs ( WULMSD) . The assessm ent of perceived m usculosk elet al sym pt om s is essent ial t o WULMSD pr event ion, but st udies in t his field ar e lack ing. A cross sect ional sur vey on assem bly line w orker s ( n= 270) w as perfor m ed. The obj ect iv e of t his st udy w as t o analyze t he fr equency and dist ribut ion of upper lim b m usculosk elet al sy m pt om s in assem bly line w orkers. Par t icipant s w ere pr edom inant ly m en, w it h ages bet w een 30 and 40 years. Neck and upper lim bs pain/ discom fort w er e t he m ost r epor t ed sym pt om s ( 35.9% ) , w it h int ensit y predom inant ly m oder at e or sev ere. General Healt h St at us and past m usculoskelet al inj ury w er e t he var iables m ore relat ed t o t he exist ence of m usculosk elet al sy m pt om s; longer w orking life in t he sam e com pany , as under 5 years, w ere relat ed t o higher int ensit y of sym pt om s. An ear ly ident ificat ion of m usculosk elet al sym pt om s and healt h sur veillance over t im e is of m ost im por t ance t o develop WRULMSD pr event ion m easur es.
1 . I N TROD UCTI ON
Alt hough t he int roduct ion of new processes and aut om at ion decreased considerably som e physical dem ands for t he w orker, assem bly lines are associat ed t o dynam ic and high physical w ork t asks, as t o repet it ive m ovem ent s and aw kw ard post ures, part icular ly in ext rem e j oint posit ions w it h force applicat ion, as t o poor recovery t im e ( Buckley, 2016; Edim ansyah et al., 2008; Graham , Agnew, & St evenson, 2009; Holt erm ann et al., 2010; Landau et al., 2008; Sancini et al., 2013; Serranheira, Uva, & Lopes, 2008; Sluit er, 2006; Sundst rup et al., 2013a, 2016) . Assem bly lines are relat ed t o occupat ional healt h risks, work- relat ed m usculoskelet al disorders ( WMSD) , part icular ly of t he neck and upper lim bs ( WULMSD) and absent eeism (Eat ough, Way, & Chang, 2012; Gold, d’Errico, Kat z, Gore, & Punnet t , 2009; Hagberg et al., 2012; Kit is, Celik, Aslan, & Zencir, 2009; Pullopdissakul, Ekpanyaskul, Tapt agaporn, Bundhukul, & Thepchat ri, 2013; Sadi, MacDerm id, Cheswort h, & Birm ingham , 2007; Sancini et al., 2013; Spallek, Kuhn, Uibel, van Mark, & Quarcoo, 2010; Wang et al., 2009; Zebis et al., 2011) .
2016) and it is est im at ed t hat over 3 m illion of new w orkers have WULMSD ( Pullopdissak ul et al., 2013) . Recent st udies report an average of 14.1 lost days in t he period 2015- 16 in European count ries (Buckley, 2016) .
To really underst and t he burden of upper lim bs m usculoskelet al disorders and develop prevent ion m easures, it is essent ial t o clearly ident ify t he consequences, as m usculoskelet al pain, disabilit y, absent eeism , and it s relat ion t o t he causes (Woolf, Vos, & March, 2010) . Despit e w orkers in assem bly lines are exposed t o w ork risk fact ors of m ost im port ance t o WULMSD developm ent , t he cont ribut ion of psychosocial/ organizat ional and individual risk fact ors should also be addressed, as t heir int eract ion, t hat changes accordingly t o t he w orker ( gender, age) , w orkplace and organizat ion (Eat ough et al., 2012; Ellis et al., 2010; Johnst on, Jim m ieson, Jull, & Souvlis, 2009; Madan I , 2015; Oakm an & Chan, 2015) .
This highlight s an early ident ificat ion of w orkers at risk t o develop WULMSD or at risk of w orsening t heir sym pt om s in high dem anding j obs. The assessm ent of perceived m usculoskelet al sym pt om s m ay help dist inguishing bet ween t he “ physiological effect s” from t he “ adverse effect s” (Hagberg et al., 2012) and t hat is for t he m ost im port ance. Pain and discom fort should be t he m usculoskelet al sym pt om s t o assess, once t hey are t he first ones report ed by w orkers and t he m ain causes t o search clinical help ( Buckle & Devereux, 1999; Buckle & Devereux, 2002; Werner, Franzblau, Gell, Ulin, & Arm st rong, 2005; Zebis et al., 2011) . Addit ionally, st udies have been relat ing pain and discom fort t o higher prevalence of m usculoskelet al disorders (Bosch, de Looze, & van Dieën, 2007; Buckle & Devereux, 2002; Hansen, Edlund, & Bränholm , 2005; Schneider, I rast orza, & Copsey, 2010) . Discom fort is a percept ion phenom enon relat ed t o pain, fat igue and perceived effort ( Hagberg et al., 2012; Madeleine, 2010) and has been used as a subj ect ive out com e for short t erm effect s (Ham berg-van Reenen et al., 2008) . I t can be defined as t he t hreshold level below w here a w orker can cont inue perform ing t he t ask (Corlet t & Bishop, 1976) . I t s evolut ion t o chronic m usculoskelet al pain suggest s discom fort as a WMSD predict or (Ham berg- van Reenen et al., 2008) .
Nevert heless, incidence rat es and prevalence of upper lim b m usculoskelet al sym pt om s and disorders are difficult t o find and com pare, probably because t here is not an universal st andard for classificat ion and diagnosis (da Cost a & Vieira, 2008; Huisst ede, Bierm a- Zeinst ra, Koes, & Verhaar, 2006; Shanahan & Sladek, 2011) . I n Port ugal, t he PROUD St udy ident ified WMSD com plaint s in 2010 and report ed, for 11% of t he w orking populat ion, WULMSD as m ore com m on in t he Aut om ot ive I ndust ry and Elect ronic and Elect rical Assem bly Lines (Miranda, Carnide, & Lopes, 2010) . At t he present , st udies analyzing t he dist ribut ion and frequency of upper lim b m usculoskelet al sym pt om s overt im e are st ill m issing (Kennedy et al., 2010; Zoer, Frings- Dresen, & Sluit er, 2014) .
The obj ect ive of t his st udy is t o analyze t he frequency and dist ribut ion of upper lim b m usculoskelet al sym pt om s in assem bly line w orkers, according t o individual fact ors ( as age, w ork experience, gender…) , sym pt om s exist ence ( body area affect ed, int ensit y) and w ork perceived r isk fact ors ( m anual handling, force applicat ion, post ure, vibrat ion, repet it ive m ovem ent s) .
2 . M ATERI ALS AN D M ETH OD S
2 .1 . St u dy D e sign a nd Popu la t ion
A cross- sect ional survey w it h 270 assem bly w orkers w as perform ed bet w een t he 17t h
Sept em ber 2014 and 1st Oct ober 2014 in an aut om ot ive indust ry of Port ugal.
A present at ion of t he st udy w as m ade t o Hum an Resources and Product ion. Aft er t he aut horizat ion of t he com pany and et hics considerat ions ( CNPD – Port uguese Dat a Prot ect ion Aut horit y) , a 20 m inut es briefing t o invit e t o part icipat ion w as prepared and done in bot h shift s ( n= 1100) . A flyer w it h a sum of t he inform at ion w as dist ribut ed. The w orkers t hat w ant ed t o part icipat e signed an inform ed consent ( n= 400) and filled a form w it h t heir em ail address and num ber of em ployee, for post erior codificat ion.
2 .2 . On lin e Qu e st ion na ir e ( W ORK4 H EALTH ® PLATFORM )
The Work4Health® plat form is an online quest ionnaire t hat collect ed infor m at ion using SurveyMonkey.inc. Dat a w as organized in 5 groups: dem ographic inform at ion, healt h dat a, healt h st at us percept ion, w ork- relat ed sym pt om s and w ork- relat ed inform at ion. I t s const ruct ion had as basis t he Nordic Musculoskelet al Quest ionnaire ( Kuorinka et al., 1987) , t he SALTSA crit eria docum ent for WULMSD (Sluit er, Rest , & HW Frings- Dresen, 2001) and a baseline survey conduct ed by Bohr (Bohr, 2000) .
To address t he m usculoskelet al sym pt om s, t he SALTSA t em poral crit er ia allow ed t o ident ify current cases ( at t he m om ent , do you have any pain or discom fort ?) and a second m om ent w as added ( last m ont h, did you have any pain or discom fort ?) so t hat t he baseline could be follow ed in t im e in ot her st udy. To det erm ine t he int ensit y of m usculoskelet al sym pt om s, it w as used t he num eric pain scale ( NPS) , validat ed t o m easure bot h pain and discom fort ( Johnson, 2005) and a body- chart t o m ark t he body area affect ed. Regarding t he healt h st at us, t he first quest ion of t he Port uguese version of t he 12- it em short form Healt h Survey ( Sf- 12: v2) w as used (Cunha- Miranda, Vaz- Pat t o, Micaelo, Teixeir a, Silva, Saraiva- Ribeiro, 2010) . Work- relat ed inform at ion gat hered t he subj ect ive inform at ion concerning work charact erist ics (Serranheira et al., 2008) , m usculoskelet al sym pt om s exist ence and it s associat ion t o w ork. Ot her inform at ion, like service t im e or w orker’s age, w as ext ract ed from t he com pany.
2 .3 D a t a a n a ly sis
First , a descript ion of t he baseline and t he analysis of t he m usculoskelet al sym pt om s dist ribut ion w ere m ade. Associat ions bet w een t he sym pt om s exist ence and int ensit y w it h gender, age, w ork experience, healt h past hist ory, general healt h st at us and w ork- relat ed dat a, w ere done using Chi- Square (χ2) t est s of independence and correlat ions t est s. The
analysis w as carried out w it h SPSS soft w are ( I BM SPSS St at ist ics for Window s, Version 22.0. Arm onk, NY: I BM Corp.).
3 . RESULTS AN D D I SCUSSI ON
3 .1 . Ba se lin e Cha r a ct e r ist ics
From t he 400 w orkers t hat ret urned t he inform ed consent , 272 answ ered t he quest ionnair e and 270 com plet ed it ( 24.5% of t he 1100 assem bly line w orkers) .
3.1.1. Dem ographic Variables
Part icipant s w ere m ainly m en ( 87% ) , right - handed ( 88% ) , w it h an average age of 36 years, w orking at t he com pany in t he last 15 years and t he m aj orit y ( 65.2% ) had secondary school educat ion (Table 1) .
3.1.2. Health Dat a
Healt h dat a show s t hat 46.7% had a norm al body m ass index ( BMI ) and 44.8% w ere overw eight - World Healt h Organizat ion ( WHO) crit eria.
Perceived general healt h st at us ( GHS) w as signed as “ good” by 56.7% of t he w orkers; from t hese, 13.7% had diseases and t ook m edicat ion. The m aj orit y ( 56.7% ) referred a m usculoskelet al inj ury in t he past and 2.6% report ed having a m edical rest rict ion at w ork for upper lim bs condit ions (Table 1) .
3.1.3. Work- relat ed Musculoskelet al Sym pt om s
Regarding discom fort or pain, 68.1% answ ered posit ively in t he last m ont h and 68.5% at t he m om ent . The m ost report ed locat ions for bot h periods were neck/ cervical ( 7.4 last m ont h and at t he m om ent ) , lum bar spine ( 15.9 and 13% ) , shoulder ( 9.2 and 9.3% ) , w rist ( 5.9 and 5.5% ) and t he hands ( 5.5 and 5.6% ) – Table 2. I n sum , upper lim bs w ere t he body areas m ost report ed in bot h periods.
V a r ia ble N ( % ) M e a n SD
Age ( y e a r s) - - - 36.2 5.03
Ge n de r Fe m a le M a le
33 ( 12.2) 237 ( 87.8)
- - - - - -
Adm ission ( y e a r s) - - - 15.07 6.25
BM I
Un de r w e igh t N or m a l Ove r w e igh t Obe se
1 ( 0.4) 126 ( 46.7) 121 ( 44.8) 22 ( 8.1)
- - - - - -
Edu ca t ion
Low e r sch ool M iddle Sch ool Se con da r y Sch ool H igh e r e du ca t ion
4 ( 1.5) 73 ( 27) 176 ( 65.2)
17 ( 6.3)
- - - - - -
D ise a se s Ye s N o
57 ( 21.1) 213 ( 78.9)
- - - - - -
M e dica t ion Ye s N o
67 ( 24.8) 203 ( 75.2)
- - - - - -
M u scu losk e le t a l in j u r y ( pa st ) Ye s
N o
153 ( 56.7) 117 ( 43.3)
- - - - - -
Ge n e r a l H e a lt h St a t u s Ex ce lle n t V e r y good Good Fa ir Poor
18 ( 6.7) 47 ( 17.4) 153 ( 56.7)
49 ( 18.1) 3 ( 1.1)
- - - - - -
Ta ble 1 . Dem ographic, individual and healt h charact erist ics.
la st m on t h - n ( % ) a t t h e m om e n t - n ( % )
D iscom for t / Pa in
Ye s 184 ( 68.1) 185 ( 68.5)
N o 84 ( 31.9) 85 ( 31.5)
Body a r e a
Ce r vica l/ n e ck 20 ( 7.4) 20 ( 7.4)
D or sa l spin e 6 ( 2.2) 8 ( 3)
Lu m ba r spin e 43 ( 15.9) 35 ( 13)
Low e r lim bs 43 ( 15.9) 46 ( 17)
Uppe r lim bs: 72 ( 26.6) 76 ( 28.1)
Sh ou lde r 25 ( 9.2) 25 ( 9.3)
Ar m 6 ( 2.3) 7 ( 2.6)
Elbow 3 ( 1.1) 7 ( 2.6)
For e a r m 7 ( 2.6) 7 ( 2.6)
W r ist 16 ( 5.9) 15 ( 5.5)
H a n d 15 ( 5.5) 15 ( 5.6)
3.1.4. Work- relat ed data
Workers w ere m ainly line operat ors ( 46.7% ) , alt hough inspect ors and break- dow n m echanics also part icipat ed ( 14.4 and 12.6% , respect ively) .
Considering t he perceived w ork risk fact ors, m anual m at erial handling ( MMH) w as present in 59.3% of a w orkday ( 46.88% of t hese part icipant s report ed it as being present in 25% of t he day) , repet it ive m ovem ent s in 91.9% of t he day ( 100% of a w orking day for t he m aj orit y of part icipant s) , t asks w it h force applicat ion w ere report ed by 83.3% of t he w orkers ( 62.22% referred 25 t o 50% of a w orking day) , st at ic posit ions in 76.3% of a w orking day ( in 25% of t he day for 41.26% of t he part icipant s report ing st at ic posit ions) and pow er t ools vibrat ion was m ent ioned by 52.6% of t he part icipant s ( for 33% of t he part icipant s w as present in 25% of t heir w orking day) .
More t han half of t he part icipant s ( 54.4% ) answ ered posit ively w hen quest ioned about t he m usculoskelet al com plaint s and it s perceived associat ion t o w ork dem ands.
3 .2 . N e ck a n d u ppe r lim b m u scu losk e le t a l sy m pt om s
Concerning t he populat ion w it h neck and upper lim b sym pt om s ( n= 96) , 16 w om en ( 48% ) report ed neck/ cervical, shoulder and hand discom fort / pain; 80 m en ( 33.75% ) report ed sym pt om s in neck/ cervical, shoulder and w rist .
Regarding w ork experience, classes w ere creat ed t o det erm ine t he dist ribut ion of neck and upper lim bs sym pt om s exist ence ( 0- 5y; 6- 10y; 11- 15y; 16- 20y; + 20y) . The m ost represent at ive periods of w ork experience were 0 t o 5 years ( 15.6% ) and 16 t o 20 years ( 62.5% ) .
Applying t he sam e analysis t o age’s classes, 32.3% of t he w orkers w it h discom fort / pain had 31 t o 35 years and 35.4% had 36- 40 years ( 67.7% of t he populat ion wit h neck and upper lim bs sym pt om s) .
From t he 96 w orkers, 59 report ed a m usculoskelet al inj ury in t he past ( 61.46% ) .
At t he survey m om ent t he m aj orit y of w orkers w it h neck and upper lim bs m usculoskelet al sym pt om s report ed pain/ discom fort int ensit y above 4 in NPS (Table 3) . Analyzing t he int ensit y cat egories and t he GHS, 51% of t he “ good” responses w ere classified in t he “ m oderat e int ensit y” , against 28.6% in t he “ severe” . The “ fair” responses w ere m ainly in t he “ severe” cat egory – 61.54% .
D iscom for t a n d Pa in I n t e n sit y n ( % )
M ild discom for t / pa in ( 1 - 3 ) 18 ( 18.8)
M ode r a t e discom for t / pa in ( 4 - 6 ) 39 ( 40.6)
Se ve r e discom for t / pa in ( 7 - 1 0 ) 39 ( 40.6)
Ta ble 3 . I nt ensit y by cat egory
3 .3 . Associa t ion s be t w e e n va r ia ble s
The “ at t he m om ent ” dat a w as chosen t o analyze t he possible associat ions bet ween variables.
Associat ions bet w een having/ not having m usculoskelet al sym pt om s w it h all t he groups of
variables were determined. No relations were found with age (χ2= - 0.020; p= 0.794; n= 270) , work experience (χ2= -0.016; p=0.791; n=270) or professional designation (χ2 = 0.714;
p= 0.023; n= 270) . I nj ury in t he past had significant correlat ion t o sym pt om s exist ence ( r= 0.212; p= 0.01) , as GHS ( r= - 0.308; p= 0.01) .
Ot her analysis w as m ade concerning t he w orkers only w it h neck and upper lim bs m usculoskelet al sym pt om s ( n= 96) . I nt ensit y of discom fort / pain w as only significant associat ed
3 .4 . D iscussion
Being m en, w it h ages bet w een 30 and 40 years, w it h an average of 15 years w orking in t he sam e com pany, w ere t he m ost com m on charact erist ics in t his survey, in agreem ent w it h ot her st udies (Ferguson, Marras, Allread, Knapik, & Split t st oesser, 2012; Gold et al., 2009; Kit is et al., 2009; Menegon & Fischer, 2012; Ohlander, Keskin, Weiler, St ork, & Radon, 2016; Pullopdissakul et al., 2013) . Regarding m usculoskelet al sym pt om s, despit e t he different m et hods and crit eria used, neck and upper lim bs w ere also t he m ost report ed body areas, as in ot her st udies (Colom bini & Occhipint i, 2006; Eat ough et al., 2012; Eerd et al., 2016; Gold et al., 2009; Kit is et al., 2009; Sundst rup et al., 2013b) . Referring t he int ensit y of m usculoskelet al sym pt om s, in w ork cont ext t he m aj orit y of com plaint s int ensit y appear t o be m ild; our st udy point s out higher values, being m usculoskelet al pain over 4 in NPS considered as significant (Werner et al., 2005) .
Despit e t he sm all num ber of associat ions bet ween variables, GHS and m usculoskelet al inj ury in t he past appear t o be t he m ost im port ant variables relat ed t o m usculoskelet al sym pt om s exist ence and int ensit y. As report ed, part icipant s w it h low er GHS, as t hose having a past m usculoskelet al inj ury, rat ed discom fort / pain int ensit y w it h higher values. When people have been w orking for years in assem bly lines, chronic condit ions are expect ed; physically dem anding j obs have 80 t o 150% higher risk t o develop chronic healt h condit ions ( Shanahan & Sladek, 2011) . Along w it h t his, t he relat ion of perceived healt h st at us w it h chronicit y (Koolhaas, van der Klink, de Boer, Groot hoff, & Brouw er, 2013) , could suggest t he presence of chronic healt h condit ions in t his populat ion.
Alt hough GHS and past m usculoskelet al inj ury w ere t he variables m ore relat ed t o t he exist ence of m usculoskelet al sym pt om s of t he neck and upper lim bs, longer w orking life in t he sam e com pany ( over 15 years) had associat ions t o higher int ensit y sym pt om s as sm aller periods ( under 5 years) . These result s could suggest t hat chronic condit ions prevent ion should st art w it h younger workers (Macdonald, Driscoll, St uckey, & Oakm an, 2012) . These dat a, along w it h t he fact t hat our result s show ed no associat ions t o age, goes on w it h ot her st udy, t hat report s t hat even t hough age and lengt h of service at t he sam e com pany could be expect ed t o correlat e w it h m usculoskelet al sym pt om s, not exist ing associat ions could m ean t hat t he allocat ion of w orkers in cert ain t asks can influence m usculoskelet al sym pt om s ( Landau et al., 2008) . A hypot hesis for t he aut hors is t hat t he younger w orkers could be allocat ed t o “ unfavourable” t asks, as t he older ones could go t o m ore “ favourable” . Ot her st udies report low er w ork experience and it s relat ion t o m usculoskelet al sym pt om s (MacDonald, Cairns, Angus, & St ead, 2012). Addit ionally, our result s suggest s t hat having neck and upper lim b m usculoskelet al sym pt om s is independent also of gender and educat ion (Loeppke, Edingt on, Bender, & Reynolds, 2013; Sant os & Moreira, 2013; Werner et al., 2005) . Gender appears t o be not im port ant t o det erm ine j ob allocat ion in t his populat ion. Crit eria and healt h recom m endat ions for j ob allocat ion could be an im port ant st ep.
There are som e lim it at ions t o point out on t his survey. First ly, t he low rat e of part icipat ion and t herefore is lim it ed t o com pare w it h ot her aut om ot ive assem bly lines. On t he ot her hand, WULMSD have a m ult ifact orial et iology and psychosocial/ organizat ional and work risk fact ors w ere not fully addressed in t his survey. Perceived w ork- relat ed inform at ion should be analyzed t oget her w it h an assessm ent of work risk fact ors, work ability and clinical examination. Furt her analysis should det erm ine if our findings could be relat ed t o low levels of w ork abilit y and qualit y of life (Sj øgaard, Just esen, Murray, Dalager, & Søgaard, 2014) .
Despit e a consensus concerning predict ive fact ors for m usculoskelet al pain and discom fort does not exist (St ew art et al., 2014) , our st udy point s out t he age under 40, w orking life over 15 years and GHS as t he variables m ore relat ed t o t hose com plaint s. More st udies on predict ive m odels are im port ant , as m onit oring t hose w orkers during a period at least of 6 m ont hs (Nelson et al., 2006) .
4 CON CLUSI ON S
explanat ory values for m usculoskelet al sym pt om s. GHS and past m usculoskelet al inj ury were t he variables w it h associat ion t o t he exist ence of m usculoskelet al sy m pt om s of t he neck and upper lim bs.
An early ident ificat ion of m usculoskelet al sym pt om s and cont inuous healt h surveillance is of m ost im port ance t o develop WULMSD prevent ion m easures. Fut ure st udies should focus on surveillance m et hods and follow ing t hese w orkers for a broader period.
ACKN OW LED GEM EN TS
This st udy w as funded by t he FCT – Port uguese Nat ional Funding Agency for Science, Research and Technology ( SFRH/ BD/ 90794/ 2012) .
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