437

Work 43 (2012) 437446

DOI 10.3233/WOR-2012-1460
IOS Press

An integrative approach for evaluating work

related musculoskeletal disorders
Wricha Mishraa, , De Amitabhaa, R. Iqbala , S. Gangopadhyayb and A.M. Chandrab
a

National Institute of Industrial Engineering, Mumbai, India

Department of Physiology, University College of Science, Technology and Agriculture, University of Calcutta,
Kolkata, India

Received 10 May 2010

Accepted 15 February 2012

Abstract. Objectives: To develop a framework for evaluating the work related musculoskeletal disorders (WRMSDs).
Participants: The proposed framework was tested on 15 jewellery manufacturing workers working at Chinchpokhli region in
Mumbai, India and on 15 students studying in a management institute of Mumbai, India.
Methods: The framework has been broken into three phases. Phase 1 Ergonomic-risk evaluation; Phase 2 Musculoskeletal
Disorders (MSD) evaluation and Phase 3 Clinical examination. Ergonomic-risk evaluation determines the relationship between
work relatedness and musculoskeletal disorders. Musculoskeletal Disorders (MSD) evaluation tries to assess the presence of
discomforts/disabilities in different body regions, through subjective evaluation tools. Ergonomic-risk evaluation involved QEC,
PLIBEL and posture analysis by RULA. Musculoskeletal Disorders (MSD) evaluation involved administration of self reported
questionnaires. Clinical examination involved muscle grading by a physiotherapist and back strength measurement.
Results: The framework suggested that ergonomic risk evaluation techniques, self reported body part questionnaires and physical
measurement of physiological/biomechanical transients may have a relationship and can be used for the evaluation of work related
musculoskeletal disorders.
Conclusion: The proposed integrative approach will help in developing stage wise intervention strategies for work related
musculoskeletal disorders.
Keywords: Framework, ergonomic-risk, clinical examination

1. Introduction
Work-related musculoskeletal disorders (WMSDs)
have been widely acknowledged as a major part of occupational harm, resulting from the acute and cumulative exposure to physical task demands [8,33,37] and
are the most prevalent cause of lost time injuries and
illnesses in almost every industry and are the costliest
occupational disease [3,33].
Studies have identified that physical [14,41] psychosocial, organizational [5,14,24] and individual [2,
Address for correspondence: Wricha Mishra, National Institute
of Industrial Engineering (NITIE), Vihar Lake, Mumbai 400 087,
India. Tel.: +91 9769393813; E-mail: m.wricha84@gmail.com.

14] occupational risk factors are responsible for the

development of work-related musculoskeletal disorders (WMSDs). Thus, the occurrence of work related musculoskeletal disorders are multifactorial in nature [33]. Reviewers and researchers through numerous findings reported that exposure to risk factors for
work-related musculoskeletal disorders (WMSDs) in a
workplace are a complex area. Since the majority of
the studies are epidemiological (mainly retrospective
and cross sectional) in nature, the relationship between
musculoskeletal disorders, ergonomic risk factors and
their physiological pathways are not always well established [33,42]. Therefore, future studies must include
various characteristics of tasks, physical and biomechanical exposures and identification of physiological
pathways on anatomic structures and tissues [30,37].

1051-9815/12/$27.50 2012 IOS Press and the authors. All rights reserved

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W. Mishra et al. / An integrative approach for evaluating work related musculoskeletal disorders

There are many tools available for assessing the impact of individual ergonomic risk factors on the causation of musculoskeletal disorders, but no single tool is
suitable for all purposes [38]. For example, tools employed by clinicians are predominantly used for identifying the pathological conditions. Similarly, occupational ergonomists use epidemiological tools (mainly
cross sectional and retrospective) to establish the role
of ergonomic risk factors on the development of work
related musculoskeletal disorders. Therefore, different groups of practitioners approach the problem differently resulting in different management/intervention
protocols which are often found to be inadequate. A
comprehensive framework using multiple tools to capture different aspects of work place would probably be
better way to assess the work related musculoskeletal
disorders [38].
There are several such frameworks available for diagnosing, treatment and management of the work related musculoskeletal disorders. Westlander [40] developed a logic framework to assess occupation specific
musculoskeletal disorders [40]. Shoaf et al. [36] proposed a work system model to evaluate how the complete spectrum of work demands (i.e. physical and mental demands, physical/social/organizational/individual
growth environment conditions) influence human effort [36]. But the model did not provide the relationship between risk factors and pathological conditions of musculoskeletal disorders. Cole et al. [9]
proposed a framework for evaluating field interventions that included strategies, activities, objectives and
metrics for outcomes using quantitative and qualitative methods [9]. But the framework was only meant
for computer intense office jobs. Human Tech developed Risk Priority Management model for diagnosing and management of musculoskeletal disorders predominantly based on work posture, force applied, frequency and duration of exposure mainly for short duration work activities. However, the intensity of discomforts cannot be effectively evaluated by this model [www.humantech.com/products/softwares/rpm dated on 10.9]. 2010. Stock et al. [37] proposed a model to estimate physical work demands taking into account the relationship between the results of physician
evaluation and ergonomic risk factors to describe the
work relatedness [37]. However, the model did not include evaluation methodology for major regions of the
body. In addition, the reliability and validity of these
approaches are not reported.
The evaluation and management of work related
musculoskeletal disorders needs to have a framework

which will provide a) work relatedness b) status of

musculoskeletal health and c) work exposure. Based
on the review of the literature, an attempt was made
to propose an integrative approach for evaluating work
related musculoskeletal disorders. The objective of the
study was to propose an integrative framework for the
evaluation of work related musculoskeletal disorders
and to assess the applicability of the proposed framework on two different groups.
2. The framework
2.1. Formulation of framework
The framework is provided in Fig. 1. It involves three
phases. Phase 1 Ergonomic risk evaluation, Phase 2
MSD evaluation and Phase 3 Clinical examination.
The framework involves self-assessment questionnaires, observational, and direct methods for assessing
musculoskeletal disorders. Self-assessment questionnaires are reported to be powerful instruments in assessing the outcome of medical management and interventions [21]. Observational methods are most often used
to evaluate physical workload in order to identify hazards at work, monitor the effects of ergonomic changes
and/or clinical advices [38]. Moreover, observational
methods have the advantages of being inexpensive and
practical for use in a wide range of workplaces where
using other methods of observing workers would be
difficult because of the disruption caused. It was also
reported that direct measurement systems can provide
large quantities of highly accurate data on a range of
exposure variables [14].
2.1.1. Phase I Ergonomic risk evaluation
Phase 1 involved evaluation of ergonomic risk using subjective evaluation tools. The tools used were
Quick Exposure Check (QEC), Plan for Identifying Av
Belastningsfaktorer (PLIBEL) and Rapid Upper Limb
Assessment (RULA). The positive result of Phase 1
signifies the presence of ergonomic risks.
2.1.1.1. Quick Exposure Check (QEC)
QEC was used for obtaining the views of both the
observers and subjects regarding posture, working
hours, repetition of work. Levels of ergonomic risks
at neck, shoulder, back and wrist were calculated for
both the groups based on the above factors [6]. Intraobserver reliabilities have been proven to be fair to
good for most of the assessment items [15].

W. Mishra et al. / An integrative approach for evaluating work related musculoskeletal disorders

439

Fig. 1. Diagrammatic representation of the framework.

2.1.1.2. Plan for Identifying Av Belastningsfaktorer

(PLIBEL)
PLIBEL was used for determining the relationship
among workplace layout, work relatedness and musculoskeletal risk factors [26]. PLIBEL is a rapid screening
tool of major ergonomic risk factors like awkward posture, frequency, duration and movements which may
have injurious effect on the musculoskeletal system.
It is designed to link ordinarily checked items in the
workplace assessment of ergonomic hazards to primarily five body regions. Reliability of the instrument has
been found to be moderate [38].
2.1.1.3. RULA (Rapid Upper Limb Assessment)
In the RULA method, positions of individual body
segments are observed and scored, with scores increasing in line with growing deviation from the neutral posture. The inter-observer reliability was found to be
good [31,38].
Takaal et al. [38] stated that QEC and PLIBEL are
good screening tools to evaluate musculoskeletal risks.
Since observational methods should include the fre-

quency and duration of items quantifying exposures

like external forces or postures in addition to their
magnitude. Hence, QEC which is a tool for evaluating the change in exposure to risk for musculoskeletal disorders and PLIBEL which measures the impact
of these ergonomic risk factors on the musculoskeletal
system were included in the framework [38]. RULA
survey is a posture-sampling tool used specifically to
examine the level of risk associated with upper limb
disorders of individual workers. Studies have shown
that RULA scores have an association with increased
discomfort [19,31]. So for further conformation on influence of work load on musculoskeletal discomfort,
RULA was used.
2.1.2. Phase 2 Musculoskeletal disorders evaluation
Phase 2 involved evaluation of MSD through questionnaires such as Nordic Musculoskeletal Questionnaire (NMQ), Disability of arm, shoulder and hand
(DASH), Neck Disability Index (NDI), Oswestry Low
Back questionnaire and IKDC subjective knee questionnaire. The positive response indicates the likelihood
of MSD.

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W. Mishra et al. / An integrative approach for evaluating work related musculoskeletal disorders

Fig. 2. Results of QEC.

2.1.2.1. Nordic Musculoskeletal Questionnaire (NMQ)

NMQ was used for assessing the presence of musculoskeletal discomforts in different anatomical regions.
It deals with questions related to symptoms (ache, pain,
discomfort) experienced during the previous 12-month
period. Respondents are asked if they have had any
musculoskeletal trouble in the last 12 months and last
7 days which has prevented their normal activity [13,
28].
2.1.2.2. Disability of Arm, Shoulder and Hand (DASH)
The main part of the DASH is a 30-item disability/
symptom scale concerning the patients health status
during the preceding week. Each item is rated on a fivepoint Likert scale. The DASH also contains two optional four-item scales concerning the ability to perform
sports and/or to play a musical instrument (sport/music
component), and the ability to work (work component) [22]. The Cronbach alpha coefficient was above
0.9 for the DASH disability/symptoms scale indicating
good internal consistency [4].
2.1.2.3. The Neck Disability Index (NDI)
NDI consists of 10 items referring to various daily
activities (personal care, lifting, driving, work, sleeping, concentration, reading, recreation) and pain (pain
intensity, headache) with 6 possible answers for each
item. The score of each item varies between 0 (no
pain and no functional limitation) and 5 (worst pain
and maximal functional limitation) [35]. The NDI has
been shown to be highly reliable on what is called test
retest reliability [39].

2.1.2.4. Oswestry low back questionnaire

The questionnaire consists of 10 items addressing
different aspects of function. Each item is scored from
0 to 5, with higher values representing greater disability. Measurements obtained with the modified Oswestry
Disability Questionnaire, were the most reliable and
had sufficient width scale to reliably detect improvement or worsening in most subjects [17].
2.1.2.5. IKDC subjective knee questionnaire
It consists of 18 questions in the domains of symptoms, functioning during activity of daily living and
sports, current function of the knee, and participation in
work and sports.The responses to each item are scored
using an ordinal method such that a score of 0 is given to responses that represent the lowest level of function or highest level of symptoms. The IKDC subjective knee questionnaire is a reliable and valid instrument worthy of consideration for use in a broad patient
population [25].
NMQ was incorporated in the framework as it is being used as a standard screening tool for assessing work
related musculoskeletal disorders [12,28]. DASH is a
tool to evaluate the disability and symptoms in single or
multiple disorders of the upper limbs. It enquires about
the degree of difficulty in performing different physical activities because of problems related to the arm,
shoulder or hand, the severity of each of the symptoms
of pain, activity-related pain, tingling, weakness and
stiffness, as well as impact of the problems on social
activities, work, sleep and self-image [22]. NDI was
used to test self-rated disability in neck [35]. It was
reported that the NDI is the most commonly used self-

W. Mishra et al. / An integrative approach for evaluating work related musculoskeletal disorders

report measure for neck pain [39]. For assessment of

low back related pain Oswestry Low Back Disability
Questionnaire (Oswestry Disability Index) was used.
Since the questionnaire is considered as the gold standard of low back functional outcome tools so it was
included in the framework [18]. The IKDC Subjective
Knee Evaluation Questionnaire was used for assessing
knee discomforts [1,25].
2.1.3. Phase 3 Clinical examination
Phase 3 involved physical examination namely patient history, observation, palpation and manual muscle testing. Patient history implies understanding of
whether patients past is related to any injury or illness. Observation involves observing the posture and
behaviour of the patient related to sitting and standing.
Palpation is a widely used technique to identify structures and determine the presence and location of patient described pain patterns. Manual Muscle Testing
(MMT) is used for testing the performance and evaluation of muscle strength and length along with neuromuscular conditions. The key to muscle grading used
was 5 as normal, 4 as good, 3 as fair, 2 as poor, 1 as trace
and 0 as no contraction. Normal implies subject can
overcome a greater amount of resistance than a good
muscle; good implies that the subject can raise the body
part against outside resistance as well as against gravity; fair implies subject can raise the body part against
gravity, poor implies movement with gravity eliminated but cannot function against gravity; trace implies
that muscle can be felt to tighten but cannot produce
movement and 0 or gone represents no contraction
felt [27]. The purpose of this phase is to establish confirmatory measures of the indicative musculoskeletal
health status reported in Phase 2. This phase also included direct measurement of the strength of most troubled area before and after the work exposure. Further
clinical tests such as nerve conduction study, Clinical
Electromyography and Magnetic Resonance Imaging
were not included in the framework as they need to be
carried out in specialised clinical setting/ laboratory.
3. Application of the framework
3.1. Methods and materials
3.1.1. Selection of participants
Fifteen jewellery manufacturing working at Chinchpokhli region in Mumbai, India and on 15 students
studying in an management institute of Mumbai, In-

441

Table 1
Depicting general information about subjects
Parameters

Age (years)
Height (cm)
Weight (kg)
BMI(Kg/m2 )

Jewellery manufacturing workers

Mean ( SD)
29.2 ( 5.7)
161.28 ( 5.19)
58.29 ( 9.68)
22.44 ( 3.75)

Students
Mean ( SD)
24.09 ( 2.45)
171.51 ( 5.54)
69.72 ( 13.65)
23.61 ( 3.97)

dia participated in the study. The study was approved

by Ethics Review Board and signed informed consents were obtained from all the participants. These two
groups were chosen as both of them were involved in
sedentary activities, long duration of exposure and low
physical exertions. The jewellery manufacturing activity like in any other sedentary assembly jobs require
repetition, awkward static posture, contact stress and
long duration of work exposure [7,23]. Therefore, it
is expected that jewellery manufacturing workers may
suffer from work related musculoskeletal disorders and
studies have shown the presence of musculoskeletal disorders in this group of workers [16]. Recent study has
shown that there is high prevalence of musculoskeletal disorders among students [29]. Cooper et al. [11]
showed that younger graduate students are exposed to
similar hours reported by younger professionals [11].
Since younger graduate students are the future work
force. So college students were involved in the study
3.1.2. Collection of demographic data
The age of each subject was recorded. The height and
weight were also recorded with help of anthropometer (Siber Hegner, Switzerland) and human weighing
balance (Avery, India) respectively.
The Body Mass Index was calculated by applying
the following formula:
Body Mass Index (BMI) in kg/m2 = weight in
kg/height in m2 [10,35]
3.1.3. QEC, PLIBEL and RULA
The activities of the jewellery manufacturing workers while carrying out manufacturing and the students
in the class room were recorded with the help of Sony
Handycam DCR PC 109E. The videos were replayed.
The predominant postures were used for QEC, PLIBEL
and RULA.
3.1.4. Self reported questionnaires
NMQ, DASH, NDI, OLBP, and IKDC Subjective
Knee Questionnaire were administered to the participants. After filling of the questionnaire they were collected back.

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W. Mishra et al. / An integrative approach for evaluating work related musculoskeletal disorders

Fig. 3. This reveals the susceptible areas of body parts of both jewellery manufacturing workers and students.

3.1.5. Clinical examination

History, observation, palpation and manual muscle
grading, tightness and reflexes, were carried out by a
qualified physiotherapist.
3.1.6. Back strength measurement
Back strength was measured by Back dynamometer
(Takei) in the morning (between 9.30 am and 10.00 am)
before the start of the work and at night (between
9.00 pm and 9.30 pm) after the completion of the work.
Two readings were taken; in-between the measurements 30 seconds rest were given. Highest value was
taken as the back strength for each subject.

4. Results
Results presented in Table 1 indicate that both the
groups were having similar body mass index, the mean
ages were 29.2 and 24.1 yrs for jewellery manufacturing workers and the students respectively.
4.1. Phase 1 Ergonomic risk evaluation
Results of QEC (Fig. 2) showed that the body regions
prone to ergonomic risk factors were neck, wrist /hand,
back and shoulders. The findings of PLIBEL (Fig. 3)
also showed that low back, neck, shoulder and upper
back and knee were the regions which were prone to
ergonomic risk factors.

Results of posture analysis using RULA are presented in Table 2. This showed that postural risks were higher in case of jewellery manufacturing workers. Further
analysis showed that problems were more in neck and
back.
Results presented in Table 2 and Figs 2 and 3 indicated that higher level of ergonomic risks were present
in jewellery manufacturing workers. Neck, shoulder,
hand, back and knee were susceptible to ergonomic
risks.
4.2. Phase 2 Musculoskeletal disorders evaluation
Nordic Musculoskeletal Questionnaire (Table 3)
showed major area of trouble were neck, right shoulder, upper back, low back, right elbow, right hand and
knees for the jewellery manufacturing workers. While
for students the major area of trouble was low back. The
reported troubles were significantly higher for neck,
right shoulders, upper back right elbow, low back and
knees for jewellery manufacturing workers. Frequency
of episodes of low back troubles (Table 4) of jewellery
manufacturing workers showed that about 50% of the
respondents had one or more episodes a week. While for
other body regions such responses were 16.16, 16.77,
4.16 for neck, shoulders and upper back respectively. The responses of the students indicated that they
were experiencing hardly any such episodes. The results, therefore, revealed that low back was the area of
trouble for the jewellery manufacturing workers.

W. Mishra et al. / An integrative approach for evaluating work related musculoskeletal disorders

443

Table 2
Representing posture analysis scores
Subjects
Jewellery manufacturing workers
Students

Score
5

Action level
3

Remarks
Investigation and changes are required soon

Investigation and changes may be required

Table 3
Representing percentage of discomforts of various body parts
Body parts
affected
Neck
Shoulder r
Shoulder l
Upper back
Low back
Thigh r
Thigh l
Knee r
Knee l
Elbow r
Elbow l
Hand r
Hand l

Jewellery
manufacturing workers
(% of positive response)
7 (46.67)
6 (40)
3 (20)
7 (46.67)
12 (80)
1 (6.67)
1 (6.67)
8 (53.34)
8 (53.34)
6 (40)
4 (26.67)
6 (40)
4 (26.67)

Students
(% of positive
response)
4 (26.67)
2 (13.34)

2 (13.34)
7 (46.67)
3 (20)
3 (20)
1 (6.67)
1 (6.67)
1 (6.67)
1 (6.67)
3 (20)
1 (6.67)

Table 4
Represents the frequency of episode of trouble once a week from
NMQ for both jewellery manufacturing workers and students
Body parts

% of positive
response in jewellery
manufacturing workers
16.16
16.77
4.16
50

Neck
Shoulders
Upper Back
Low back

% of positive
response in
students
12.5

4.16
12.5

Table 5
Evaluation of questionnaires scores
Questionnaires
DASH
NDI
Oswestry low back
Knee Questionnaire

Levels of
significance
P < 0.05
P > 0.05
P < 0. 05
P < 0.05

Significant /not
significant
significant
not significant
significant
significant

Table 5 presented the results of self assessment questionnaires of specific body regions. Though, the results showed that discomforts of the jewellery manufacturing workers were more in arm, shoulder and hand
(DASH), low back (Oswestry low back questionnaire)
and knee (knee questionnaire) but the individual scores
showed that the responses for arm, shoulder and hand,
neck and knee were within acceptable zones. However,
33% of the jewellery manufacturing workers indicated
moderate disability for low back.

Odds
ratio
2.406
4.331

5.685
4.572
0.286
0.286
15.997
15.997
9.329
0.583
0.167
0.583

95% CI

significant /not
significant

1.3314.35
2.1478.737

2.8311.42
2.448.567
0.1130.721
0.1130.721
6.64738.503
6.64738.503
3.86422.527
0.1632.08
0.0550.508
0.1632.08

significant
significant

significant
significant
not significant
not significant
significant
significant
significant
not significant
not significant
not significant

4.3. Phase 3 Clinical examination

Results (Table 6) of the clinical examination showed
that the major affected area of problem was low back.
Thirty three percent of the jewellery manufacturing
workers tested grade 3 i.e. fair grade. Thus, it may be
assumed that some loss of strength might have been
taken place in low back muscle.
Table 7 showed the scores of back strength before
and after work. The results showed that strength of
back muscles after the work exposure had significantly
reduced in jewellery manufacturing workers. However,
similar results were not observed for the students. This
once again established that the problem of back may be
due to work exposure.
5. Discussion
An effective framework for assessing work related
musculoskeletal disorders must include theoretical constructs, combining the physiological, epidemiological,
and biomechanical knowledge, which have their impact
on causation of work related musculoskeletal disorders.
The paper proposed an integrative methodology to ascertain the relationship of work relatedness with occurrence of musculoskeletal disorders. Since the primary
objective of an integrative work related musculoskeletal disorders assessment framework is hazard identifi-

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W. Mishra et al. / An integrative approach for evaluating work related musculoskeletal disorders
Table 6
Depicting odds ratio of muscle grading for both the groups
Muscle grading
Flexors
Extensors
Lateral flexor right
Lateral flexor left
Lateral Rotator right
Lateral Rotator left

Odds ratio
15.1667
0.2549
5.1563
5.1563
6.4286
5.1563

Confidence interval
2.8364 to 81.098
0.044 to 1.4753
1.2335 to 21.5545
1.2335 to 21.5545
1.5169 to 27.2448
1.2335 to 21.5545

Remarks
significant
not significant
significant
significant
significant
significant

Table 7
Depicting back strength scores before and after work between same groups
Groups

Morning (kg)

Late evening (kg)

Jewellery Manu- facturing Workers

Students

105.54 ( 10.10)
119.96 ( 14.48)

96.75 ( (9.38)
118.52 ( 13.36)

cation and risk quantification so Phase 1 ergonomic

risk evaluation helps in analyzing the root cause of the
disorders. Phase 2 helps in understanding the presence
and severity of the existing WMSDs. In this phase the
impact of ergonomic risk factors on the prone anatomical zones are identified. Further, Phase 3 gives the
actual status of the severity of WMSDs.
The proposed integrative approach will help in developing stage wise intervention strategies for WMSDs. Positive results of Phase 1 requires ergonomic interventions. Positive result of Phase 2 requires both ergonomic intervention and postural modifications along
with muscle conditioning and further clinical examination. Positive results of Phase 3 require medical intervention along with intervention measures suggested in
Phases 1 and 2.
The framework suggests that ergonomic risk evaluation techniques, self reported body part questionnaires
and physical measurement of physiological/ biomechanical transients can be used for the evaluation and
management of work related musculoskeletal disorders.
The applicability of the framework was tested on
jewellery workers and students. The framework revealed that jewellery manufacturing workers were exposed to higher level of work related musculoskeletal
discomforts as compared to the students and the low
back is the major area of trouble.
However, the framework requires testing on larger samples and on varied occupations to establish its
validity and reliability. Clinical examination including
tests such as Nerve Conduction Study, Clinical Electromyography and Magnetic Resonance Imaging were
not included in the study as they need to be carried out
in specialized clinical setting/ laboratory. Inclusion of
these tests may reveal clear status of musculoskeletal
disorders in the working group.

Levels of
significance
P < 0.05
P > 0.05

Significant/not
significant
significant
not significant

6. Conclusion
The study proposed an integrative framework which
is divided into three phases; Phase 1 Ergonomic Risk
Evaluation, Phase 2 MSD Evaluation, Phase 3 Clinical Examination. The framework tries to establish a
relationship among ergonomic risk factors; self reported discomforts and physical measurement of physiological/biomechanical transients. The applicability of
the framework was tested on jewellery manufacturing workers and students which revealed that jewellery
manufacturing workers suffered from more discomforts
as compared to students.

Acknowledgements
We are thankful to National Institute of Industrial
Engineering (NITIE) and TIFAC CORE NITIE for providing the necessary finance and support for the project.
We are also thankful to the jewellery manufacturing
units and the subjects who voluntarily participated in
the study with their full consent.

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