II
WORKSHOP SUMMARY



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--> II WORKSHOP SUMMARY

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--> Introduction In May 1998, the National Institutes of Health asked the National Academy of Sciences/National Research Council to assemble a group of experts for two tasks: to examine the scientific literature relevant to the issue of work-related musculoskeletal disorders of the lower back, neck, and upper extremities and to address seven questions posed by U.S. Representative Robert Livingston on this topic. The steering committee established to carry out these tasks was composed of experts in orthopedic surgery, occupational medicine, epidemiology, ergonomics, human factors, and risk analysis. It was responsible for designing and moderating a workshop, identifying and inviting participation by the leading researchers in relevant areas, and preparing two reports: one presenting the steering committee's conclusions and the other summarizing the workshop and providing the papers prepared for the workshop. The first report (National Research Council, 1998) was issued in September 1998. This is the second report. The workshop was designed to focus on the current state of the scientific research base pertaining to work-related musculoskeletal disorders, including risk factors that can contribute to such disorders, and interventions that may alleviate or prevent such disorders. The steering committee invited approximately 90 leading scientists from the fields of orthopedic surgery, occupational medicine, public health, ergonomics, and human factors to participate in the workshop; 66 of the invitees attended. In selecting participants, the steering committee relied primarily on two criteria: experts who are

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--> actively engaged in pertinent research and diversity of participants, representing a wide range of scientific disciplines, perspectives, beliefs, and approaches. The workshop took place at the National Academy of Sciences on August 20-21, 1998. Several participants were commissioned to prepare and present papers; others provided written and oral responses to the papers. This report summarizes the papers and workshop discussions. (See Appendices A and B for the list of participants and the agenda.) In designing the workshop and commissioning papers, the steering committee chose not to focus on specific parts of the body and associated musculoskeletal disorders. Instead, the steering committee sought to examine the many biological, biomechanical, non-biomechanical, and physical and psychological differences among individuals that might play a role in the development of musculoskeletal disorders. The steering committee believed this approach would provide a framework for reviewing the science base in each area, as well as the overlaps among them. The steering committee organized the workshop around five major topics: (1) biological responses of tissues, specifically muscles, tendons, and nerves, to biomechanical stressors;1 (2) work factors, individual factors, and internal loads—that is, the biomechanics of work stressors; (3) the epidemiology of physical factors; (4) non-biomechanical factors that may affect musculoskeletal disorders; and (5) interventions to prevent or mitigate musculoskeletal disorders. For four of these topics, discussions at the workshop centered on a paper (or papers) commissioned for the workshop, followed by the comments of invited discussants. For the epidemiology of physical factors, the steering committee used a panel format to take advantage of a recent review of this literature (Bernard et al., 1997). Organizing Framework The steering committee developed a conceptual framework integrating the factors thought to be related to the occurrence of musculoskeletal disorders. This framework was used to organize the workshop topics and was presented to all participants at the outset of the workshop. Figure 1 presents that framework. It diagrams the work-related and other factors most frequently involved in the development of musculoskeletal disorders. It is a useful framework for examining the diverse literatures associated with musculoskeletal disorders, each reflecting the roles that work-related biomechanical, psychosocial, organizational, and individual factors can play in the development of musculoskeletal disorders. The framework also suggests the pathways by which musculoskeletal disorders can occur and be avoided. The central musculoskeletal disorder mechanism appears within the load-response box of Figure 1. It shows the load-response relationship that expresses the biomechanical 1   Two papers were commissioned for this topic—one focusing on muscles and tendons and the other on nerves.

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--> FIGURE 1 Conceptual framework of physiological pathways and factors that potentially contribute to musculoskeletal disorders.

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--> component of musculoskeletal disorders. Loads of various magnitudes are imposed on bone or tissue in various ways. The impact of loads on tissues may change in the course of a day because of changes in fatigue, work pattern or style, coactivation of muscle structures, or other factors. The impact of loads on tissues can provoke several responses. If the load exceeds a mechanical tolerance or the ability of the tissue to withstand the load, tissue damage will occur. For example, damage to a vertebral end plate will occur if the load borne by the spine is heavy enough. Other tissue responses may include such reactions as inflammation, edema, and biochemical responses. Systematic responses of the body to biomechanical loading may produce both symptomatic and asymptomatic reactions. Some of these reactions contain feedback mechanisms that can influence the tissue loading and response relationship, as illustrated in the gray box (physiological pathways) of Figure 1. For example, pain might cause an individual to use muscles in a different way, thus changing the associated loading pattern. Repetitive loading of a tissue might lead an individual to ignore discomfort signals and expose himself to greater loads, which he might or might not be able to bear. The symptom and adaptation portions in Figure 1 can interact with each other as well. For example, swelling might lead to a tissue adaptation, such as increased production of lubricant in a joint. These symptoms, responses, and adaptive behaviors can lead to functional impairment. In the workplace, this might be reported as a work-related musculoskeletal disorder. If severe enough, the impairment could be considered a disability, and lost or restricted workdays could result. In the box to the right, the framework recognizes the influence of individual factors, including physical and psychological factors, that might affect the musculoskeletal disorder sequence. For example, psychological factors can affect one's willingness to report a musculoskeletal disorder or claim that the impairment is a disability. Physical factors might involve reduced tissue tolerance due to age, gender, and overall physical condition. Disease states, such as arthritis, also can affect a person's biochemical response to tissue loading. In the boxes to the left of the central physiological pathways, Figure 1 identifies environmental factors that might affect the development of musculoskeletal disorders, including physical work, organizational factors, and social context. For example, physical work factors (such as lifting heavy boxes or equipment) can affect the loading that is experienced by a worker's tissues and structures, and can also influence the symptoms and reported incidence of a musculoskeletal disorder. Organizational factors can also influence each component of the musculoskeletal disorder sequence. For example, time pressures to complete a task might frustrate a worker and provide an incentive or disincentive to report a musculoskeletal disorder or to claim that an impairment should be considered a disability. Although little studied, pathways exist between organizational influences and the biomechanical and body reaction (symptoms and response) components of the musculoskeletal disorder sequence.

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--> Finally, social context is also a potential modifier of the musculoskeletal disorder sequence. For example, social factors, such as lack of support in dealing with psychological stress (e.g., no spousal support), might influence a worker's reporting behavior or even the worker's biomechanical responses. The steering committee believes that this framework summarizes the diverse literatures regarding musculoskeletal disorders by characterizing the pathways that each literature addresses. For example, epidemiological investigations often explore the pathways between the physical work environment and the reporting of impairments or the pathway between organizational factors and the reporting of symptoms. Ergonomic studies often explore the pathways between physical work factors and biomechanical loads imposed on a tissue. The framework also provides a means to explain the interactions among factors. For example, the combination of a particular set of physical work and organizational factors might yield an increase in the reporting of symptoms that neither, considered alone, would yield. Often the whole is greater than the sum of its parts. The steering committee deliberately sought to examine the evidence as a whole and not to restrict inquiry to one particular sector or field of inquiry. It also sought to place individual studies in context, by showing the factors that they do and do not address. The workshop was designed with these considerations in mind. The next five sections provide summaries of each paper and the workshop discussions of them. Biological Responses of Tissues to Stressors Presentations Soft Tissue Responses to Physical Stressors: Muscles, Tendons, and Ligaments James Ashton-Miller Reported soft tissue injuries can be the result of stresses (e.g., of posture, motion, or vibration) from a single, mechanical event or from repetitive events. The risk of such injury increases with acute or chronic changes in intrinsic factors (age, gender, inherited tissue anatomy, pain responses) related to an individual's physical capacity and extrinsic factors (work and life-style factors) related to the physical demands of the environment. Responses to soft tissue injuries include a complex cascade of events involving inflammatory responses, which mark the first phase of the healing process, followed by a remodeling phase in which tissues are restored. A smooth transition through these healing phases requires that physical loading of tissues be temporarily

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--> reduced, in part because of pain and discomfort. This should be followed by a careful increase of physical loading during remodeling to avoid exacerbating symptoms. Muscles Muscles can suffer from a variety of injuries, including contraction induced injuries, single-event muscle strain injuries, and fatigue. There is considerable scientific exploration of these types of muscle injury. Three models of muscle injury promise the most return in understanding work-related muscle disorders. The first is an ''eccentric contraction model" in which muscles are subjected to a single, rapid stretch or a series of repetitive contractions. Research using this model has been conducted over the past 15 years in human and animal studies. The animal studies, in particular, have demonstrated that if a period of healing is allowed, the same forces can be later applied without reinjury. Age can affect the ability of the muscles to heal, and exercise, at any age, improves muscle strength and endurance, though it does not compensate for all the advantages of youth. A second promising model has been developed to investigate muscle fatigue. This model is driven by theories that a muscle's ability to sustain power output is a function of its fiber composition and oxidative capacity. Recent in vivo laboratory studies of human muscle have used noninvasive spectroscopy to measure changes in tissue oxygenation in response to varying levels and duration of force. Decreased oxygen levels with increasing force were demonstrated (in nearly linear proportions) and also were associated with higher reports of discomfort by the study subjects. The third model suggests that muscle stiffness, tenderness, and pain are associated with the release of substances, such as potassium chloride and lactic acid, during muscle contraction. Laboratory experiments testing this model involve either induced muscle fatigue or the injection of irritants into human muscle tissue. Both subjectively reported pain and myoelectric activity are monitored. The results of these studies also suggest that different muscle groups have different pain levels (jaw muscles, for example, are more sensitive than neck muscles). Tendons and Ligaments Tendons, ligaments, retinaculae, intervertebral discs, and the fasciae of muscles are all connective tissues between bone and muscles. The primary structural component of these tissues is collagen, which is demonstrably susceptible to external stresses. In the case of ligaments, theory suggests that strains can reduce the crimp or waviness of collagen fibrils in the ligaments and increase susceptibility to injury. Most studies of ligament injuries have focused on the knee; these studies show that ligaments are generally slow to heal and repair themselves (up to 2 years in animal studies). Aging also appears to affect the tensile strength and elasticity of the ligaments. Biomechanical, in vitro laboratory studies have shown that human hand tendons can be weakened under the friction generated by awkward hand or wrist postures when the hand is

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--> gripping an object. Animal studies show that repetitive strains on tendons can cause degenerative changes—increased inflammation, more capillaries, edema and fibrosis. These study findings could be augmented by in vivo evidence of the link between cumulative strain and tendon and ligament injury. The ability to study cause and effect in overuse-related injuries is hampered by difficulties in accurately estimating the relationships between force and human muscles and tendons throughout different parts and activities of the day—commuting, work, and home and leisure activities. A laudable goal would be to reduce work-related stress on tissues sufficiently so that whether injured "on" or "off" the job, tissues can heal and repair in a reasonable time without risk of becoming chronic conditions. Soft Tissue Responses to Physical Stressors: Nerves David Rempel, Lars Dahlin, and Göran Lundborg We focus on the effects of compression on peripheral nerve functioning as demonstrated in human and animal studies. Peripheral nerve dysfunction associated with nerve compression typically occurs where nerves pass through a tight tunnel formed by stiff tissue boundaries. The resulting "confined space" limits tissue movement and can lead to sustained tissue pressure. Well-known examples are compression of the median nerve at the wrist, of the ulnar nerve at the wrist or elbow, and the spinal root nerves at the vertebral foramen. Clinical reports suggest that lesions that take up some of this confined space (tumors, cysts, and so forth) can cause nerve injury. So too can edema and extracellular matrix in the soft tissues (such as those associated with pregnancy and congestive heart failure). Other conditions, such as diabetes mellitus or an inflammatory reaction, can also increase the susceptibility of nerves to compression injuries. The studies we examined to illustrate the effects of nerve compression on peripheral nerves included human and animal laboratory studies of the physiologic, pathophysiologic, biochemical, and histologic effects of "loading." Four of these studies demonstrate the state of the evidence on peripheral nerves as well as its limitations. The first of these studies is an histological study on laboratory rats. In this study, varying levels of nerve compression were applied to the sciatic nerves. Endoneurial fluid pressure was measured at several time intervals up to 24 hours after the removal of compression. Greater levels of compression were associated with greater and longer lasting levels of endoneurial fluid pressure. Histologic examination of nerve tissue showed edema and degenerating nerve fibers after 8 hours even at the lowest levels of induced compression used in the study. A second, similar study examined nerve compression over longer time periods—up to 4 weeks, under relatively high levels of nerve compression. The histologic results were edema, inflammatory reactions, and fibrosis within hours of compression. After 2 to 3 weeks, marked fibrosis, demyelination, and axonal degeneration were evident.

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--> Related studies of animals exposed to vibration of the hind limbs for 4 hours over a period of 5 days suggest similar edema and structural nerve changes. These two studies deal with sciatic nerves. Two other illustrative studies deal with nerves in the fingers and wrists. One study examined carpal tunnel nerve pressure in 20 people by asking them to press a load cell with their index fingers and then pinch the same cell between thumb and index finger. Both the pressing and pinching tasks led to increasing extraneural pressure in the carpal tunnel, but the pinching task was associated with pressures twice as high as the pressing task. The other study involved 10 men (ages 17-30) exposed to hand vibration in their work who were matched with 12 male cadavers of similar ages without such work exposures. Biopsies of the nerve just proximal to the wrist in both the living subjects and the control group (cadavers) showed pathological changes to the nerve in all 10 subjects and in one of the controls. Nerve changes included the breakdown of myelin and fibrosis. These studies demonstrate a clear biological effect: that nerves are particularly sensitive to loading at relatively low levels of compression and exhibit changes that can persist. Humans exposed to hand vibrations or performing certain maneuvers can experience elevated extraneural pressures that in laboratory animals would result in nerve injury. All of these studies are limited in some ways: limited exposures to compression, lack of statistical comparisons, investigation of only one area of nerve dysfunction when multiple nerves are involved, and measurement difficulties that limit understanding of precise dose-response relationships. Further research could overcome some of the limits and usefully add to our understanding of these biological effects. Discussion The papers provide evidence for several conclusions about soft tissue response to physical stress. Although certain loads can be tolerated or adapted to, all soft tissues, including muscle, tendon, ligament, fascia, synovia, cartilage, intervertebral disc, and nerve, fail if subjected to sufficient force. Data from cadaver studies provide ranges within which such failures occur, as do animal models of some soft tissues tested in laboratory studies. Even at levels clearly below these failure ranges, however, there is scientific evidence from laboratory studies that soft tissue responses include inflammation, muscle fatigue, and ultrastructural degeneration that does not heal without cessation or restriction of the provoking force. As Figure 1 illustrates, intrinsic factors, such as age and conditioning, can influence soft tissue response and recovery, as can extrinsic factors, including the work environment and life-style characteristics. The discussants of the Ashton-Miller and Rempel et al. papers did not generally dispute the conclusions presented, though many believe that greater attention to some aspects of the scientific evidence on soft tissue responses to stress could provide additional, important insights on tissues responsible for work-related musculoskeletal disorders. Suggested research areas included: studies of the synovium (the tissue lining the tendons and joints);

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--> recent biological work on cytokines and growth factors considered important in tissue inflammation, healing, and repair; more scrutiny of studies using electromyography (EMG) to monitor muscle fatigue and pain (EMG measurement is noninvasive, objective, and can be used to establish biomarkers for muscle injury); and studies of the effects of peripheral tissue inflammation on the central nervous system, especially in cases where muscle pain lasts much longer than expected. Several other themes emerged from the discussions of these papers. The need for more research and more integrative research was a major theme. The long-term or chronic effects of soft tissue responses to stressors was one area in which discussants believed further research was critical. Steven Lehman, University of California at Berkeley, raised this issue in discussing the need to better understand the physiology of low-force, long-duration work and its effects on motor control, muscle fatigue, pain, and the recovery process. Carlo de Luca, Boston University, suggested the use of electromyography as a method for studying muscle fatigue. The clinicians among the discussants stressed that, although most of the laboratory evidence presented in the papers corroborated their own case observations, that laboratory evidence deals primarily with acute stressors while they find the most difficult cases to be those involving chronic stressors. Susan Mackinnon, Washington University School of Medicine, noted that her experience indicates that an understanding of patient symptoms requires an understanding of chronic nerve compression. She described a model of chronic nerve compression in rats and primates that closely mimics the pathological changes seen in humans. These pathological changes (ranging from edema to degeneration) are paralleled by the symptoms of patients in clinical testing. Patient complaints typically begin with intermittent numbness brought on by specific postures, but not apparent when the patient is resting. As compression continues or increases, numbness becomes more persistent and, eventually, permanent. There are also neural and physiological symptoms which begin with complaints of aching and progress to weakness and finally, to muscle atrophy. We need a good model of chronic nerve compression. (Robert Szabo, University of California, Davis) Robert Szabo, University of California, Davis, reinforced Mackinnon's comments, noting that the Rempel et al. paper's discussion of laboratory studies on nerve compression over time did not highlight the clinical relevance of the findings. The findings show a progressive degeneration of nerve health under sustained compression, which suggests that nerve compression effects can be viewed on a spectrum divided into early, intermediate, and late categories. In clinical terms, early stages respond most favorably to conservative treatment (such as steroid injections and splinting for carpal tunnel syndrome). For intermediate stages of nerve compression, involving numbness and parasthesia, patients

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--> cal diagnoses or also embrace reported symptoms? Third, are the musculoskeletal disorders under consideration serious enough to merit attention in a public forum and as a matter of public policy? Finally, she noted the differences that exist between the public health perspective and the clinical perspective, pointing out that during the workshop clinicians presented somewhat different viewpoints and emphasized somewhat different concerns than those of public health researchers. Several other panelists echoed Agnew's questions about the seriousness of the musculoskeletal disorders that were the focus in the workshop (the emphasis on carpal tunnel syndrome and repetitive stress injuries had been denoted by several participants). Donald Bloswick, for example, urged that musculoskeletal disorders not be defined just in terms of carpal tunnel syndrome or upper extremity cumulative trauma disorder. He noted that the NIOSH report indicated that 700,000 workdays per year are lost due to musculoskeletal disorders, only 100,000 of which are upper extremity or repetitive trauma disorders. Susan Mackinnon suggested the need to educate the American public that keyboarding has not been shown to cause anything and that neuromusculoskeletal disorders are not dangerous and should not cause permanent disability. W. Monroe Keyserling noted that the focus of the workshop had been on injuries that result from repetitive job requirements, but that musculoskeletal disorders can result from irregular and sometimes unexpected events, which should also be seriously considered. The importance of secondary and tertiary, as well as primary, conditions in understanding and intervening in the workplace were also reinforced and expanded on by other panelists, especially with regard to interventions. Richard Wells, for example, advocated a more applied research focus, particularly with respect to intervention research, so that ongoing changes can be better monitored and reported. Barbara Silverstein suggested that intervention research would gain from better feedback from employers and scientists to designers and manufacturers. More broadly, Peter Nathan argued that monies being spent on ergonomic assessments and many workplace interventions would be better spent on focusing and improving the overall health of workers. General Discussion The workshop ended with a number of comments from invited participants and the attending public. Several participants highlighted employers' perspectives. David Roy, Travelers Insurance, noted that employers must ask and get answers to questions about what to fix and how to fix it. He noted employers' uneasiness with the medical community's diagnosis of musculoskeletal disorders, especially in terms of numbers of such disorders reported, and employer concern with costs from faulty diagnosis and overreporting (coverage) above and beyond the costs of workplace preventive measures. Wendy Latko, Xerox Corporation, noted that employers cannot wait for research to be perfected before taking action in dealing with injuries and illnesses in the workplace. Xerox, for example, has taken a two-pronged approach emphasizing both wellness programs to enhance general fitness levels and the incorporation of sound

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--> ergonomic principles in job and product design. Barbara Silverstein, Washington State Department of Labor and Industries, added that her department's surveys of employers in the state indicated that approximately one-third were directly dealing with workplace injuries and illnesses through engineering, organizational, and personal fitness education programs. Waldemar Karwowski, University of Louisville, emphasized that ergonomics does indeed offer principles that enable employers to design better work places and reduce work-related injuries. Charles Barrett, International Union of Electronic and Electrical Workers, Margaret Seminario, AFL-CIO, and Scott Schneider, Laborers Health and Safety Fund, all emphasized the employees' perspective through the lens of organized labor. They noted that work-related musculoskeletal disorders are real and that they account for many days of lost work in addition to disabling injuries and suffering at work. Seminario echoed the view of many other participants that the workshop presentation and discussions were valuable because they enabled people from different perspectives to share information and interpretations. References Adams, M.A., W.C. Hutton, and J.R.R. Stott 1980 The resistance to flexion of the lumbar intervertebral joint. Spine 4:245-253. Armstrong, T.J., and D.B. Chaffin 1979 Some biomechanical aspects of the carpal tunnel. Journal of Biomechanics 12:567-570. Bernard, B.P., ed. 1997 Musculoskeletal Disorders and Workplace Factors : A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. Cincinnati, OH: U.S. Department of Health and Human Services. Chaffin, D.B., and G.B.J. Andersson 1991 Occupational Biomechanics . Second Edition. New York, NY: John Wiley and Sons. National Research Council 1998 Work-Related Musculoskeletal Disorders : A Review of the Evidence. Steering Committee for the Workshop on Work-Related Musculoskeletal Injuries: The Research Base. Washington, DC: National Academy Press. [Part I of this volume]

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--> Appendix A Invitees and Participants, Workshop on Work-Related Musculoskeletal Injuries: Examining the Research Base Participants Jacqueline Agnew, Johns Hopkins University Thomas Albin, 3M Company, St. Paul, Minnesota Kai-Nan An, Mayo Clinic and Mayo Foundation, Rochester, Minnesota Gunnar Andersson,* Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois Thomas Armstrong,* University of Michigan, Ann Arbor James Ashton-Miller, University of Michigan, Ann Arbor Bruce Bernard, National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, Cincinnati, Ohio Sidney Blair, Loyola University Medical Center Donald Bloswick, University of Utah, Salt Lake City Paulien Bongers, TNO Prevention and Health, Leiden, Netherlands Stephen Burastero, Lawrence Livermore National Laboratory, Livermore, California Dennis Carter, Stanford University Martin Cherniack, University of Connecticut Health Center, Farmington Linda Cocchiarella, American Medical Association, Chicago, Illinois David Cochran, Occupational Safety and Health Administration, U.S. Department of Labor, Washington, DC David Cordray,* Vanderbilt University Theodore Courtney, Liberty Mutual Insurance Company, Hopkinton, Massachusetts Mark Cullen,* Yale University School of Medicine Carlo De Luca, Neuro Muscular Research Center, Boston, Massachusetts Raymond Donnelly, Occupational Safety and Health Administration, U.S. Department of Labor, Washington, DC Colin Drury,* State University of New York, Buffalo Bradley Evanoff, Washington University School of Medicine Julia Faucett, University of California, San Francisco Lawrence Fine, National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, Cincinnati, Ohio Baruch Fischhoff,* Carnegie Mellon University David Florence, American Academy of Orthopedic Surgeons, Rosemont, Illinois *   Member, Steering Committee for the Workshop on Work-Related Musculoskeletal Injuries: The Research Base

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--> Alfred Franzblau, University of Michigan, Ann Arbor Steven Garfin, University of California, San Diego Arun Garg, University of Wisconsin-Milwaukee Robert Gatchel, University of Texas, Dallas Fredric Gerr, Emory University Ronald Gray, Johns Hopkins University Manny Halpern, New York University Medical Center Steven Johnson, University of Arkansas, Fayetteville Brad Joseph, Ford Motor Company, Dearborn, Michigan Bentzi Karsh, University of Wisconsin-Madison Waldemar Karwowski, University of Louisville Michael Kerr, Institute for Work and Health, Toronto, Ontario, Canada W. Monroe Keyserling, University of Michigan, Ann Arbor Karl Kroemer, Virginia Tech Mary Laedtke, U.S. Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland Wendi Latko, Xerox Corporation, Webster, New York Steven Lavender, Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois Steven Lehman, University of California, Berkeley Thomas Mayer, PRIDE, Dallas, Texas Susan Mackinnon, Washington University School of Medicine William Marras,* Ohio State University, Columbus Gary Mirka, North Carolina State University, Raleigh Samuel Moon, Duke University Medical Center Steven Moore, Texas A&M University, College Station Robert Morency, L.L. Bean, Inc., Freeport, Maine Francisco Moro, University of Wisconsin-Madison Peter Nathan, Portland Hand Surgery Rehabilitation Center, Portland, Oregon Robert Norman, University of Waterloo, Ontario, Canada Lida Orta-Anés, United Automobile Aerospace and Agricultural Implement Workers of America, UAW, Detroit, Michigan Richard Pew,* Independent Consultant, Cambridge, Massachusetts Malcolm Pope, University of Iowa Laura Punnett, University of Massachusetts, Lowell Robert Radwin, University of Wisconsin-Madison Mark Redfern, University of Pittsburgh David Rempel, University of California, San Francisco David Roy, Travelers Insurance, Hartford, Connecticut Howard Sandler, Sandler Occupational Medicine Associates, Inc., Melville, New York Scott Schneider, Laborers' Health and Safety Fund of North America, Washington, DC Margaret Seminario, AFL-CIO, Washington, DC Barbara Silverstein, Washington State Department of Labor and Industries, Olympia

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--> Mary Lou Skovron, Genentech, Inc., South San Francisco, California, and New York University School of Medicine Michael Smith, University of Wisconsin-Madison Moshe Solomonow, Louisiana State University Medical Center, New Orleans Carolyn Sommerich, North Carolina State University, Raleigh Robert Szabo, University of California, Davis David Wegman, University of Massachusetts, Lowell Richard Wells, University of Waterloo, Ontario, Canada Robert Werner, University of Michigan, Ann Arbor Invitees Who Were Unable to Attend Peter C. Amadio, Mayo Clinic, Rochester, Minnesota Mohamed M. Ayoub, Texas Tech University Susan Baker, Johns Hopkins University Stanley J. Bigos, University of Washington Claire Bombardier, Institute for Work and Health, Toronto, Ontario, Canada Patricia Buffler, University of California, Berkeley Donald B. Chaffin, University of Michigan, Ann Arbor Harvey Checkoway, University of Washington Jerome Congleton, Texas A&M University Thomas Cook, University of Iowa Marvin J. Dainoff, Miami University, Oxford, Ohio Richard Deyo, University of Washington Michael Feuerstein, Uniformed Services University of the Health Services, Bethesda, Maryland, and Georgetown University School of Medicine Adam Finkel, Occupational Safety and Health Administration, U.S. Department of Labor, Washington, DC Gary Franklin, University of Washington Andris Freivalds, Pennsylvania State University John Frymoyer, University of Vermont Nortin Hadler, University of North Carolina School of Medicine, Chapel Hill Hal Hendrick, Consultant, Englewood, Colorado William Howell,* Arizona State University, Tempe Morton Kasdan, Physician, Louisville, Kentucky Jeffrey Katz, Brigham and Women's Hospital, Boston, Massachusetts Jennifer Kelsey, Stanford University Jess F. Kraus, University of California, Los Angeles Steven Lamm, Consultants in Epidemiology and Occupational Health, Inc., Washington, DC Tom Leamon, Liberty Mutual Insurance Company, Hopkinton, Massachusetts Steven Linton, Orebro Medical Center Hospital, Orebro, Sweden

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--> Paul Marxhausen, University of Nebraska at Lincoln Stuart McGill, University of Waterloo, Ontario, Canada Steven Newell, Organization Resources Counselors, Washington, DC Robert Ochsman, Consumer Products Safety Commission, Lovettsville, Virginia Suzanne Rodgers, Consultant, Rochester, New York Steven L. Sauter, National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, Cincinnati, Ohio Stover H. Snook, Harvard School of Public Health Carol Stuart-Buttle, Stuart-Buttle Ergonomics, Philadelphia, Pennsylvania David Vlahov,* Johns Hopkins University Kathryn G. Vogel, University of New Mexico Laura Welch, Washington Hospital Center, Washington, DC Savio Woo, University of Pittsburgh Craig Zwerling, University of Iowa Staff E. William Colglazier, Executive Officer, National Research Council Barbara Boyle Torrey, Executive Director, Commission on Behavioral and Social Sciences and Education Alexandra Wigdor, Director, Division on Education, Labor, and Human Performance Anne Mavor, Study Director, Steering Committee for the Workshop on Work-Related Musculoskeletal Injuries James McGee, Senior Research Associate, Steering Committee for the Workshop on Work-Related Musculoskeletal Injuries Renae Broderick, Writer/Editor, Cornell University, Ithaca, New York Susan Coke, Administrative Associate, Steering Committee for the Workshop on Work-Related Musculoskeletal Injuries Susan McCutchen, Senior Project Assistant, Steering Committee for the Workshop on Work-Related Musculoskeletal Injuries Nat Tipton, Senior Project Assistant, Division on Education, Labor, and Human Performance

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--> Appendix B Workshop on Work-Related Musculoskeletal Injuries: Examining the Research Base August 20-21, 1998 Auditorium, National Academy of Sciences 2101 Constitution Avenue, N.W., Washington, DC AGENDA Thursday, August 20 7:30 a.m. Continental Breakfast Room 250: Participants A-J Room 280: Participants K-Z Public: Cafeteria is available to purchase breakfast 8:30 a.m. Welcome and Introduction William Colglazier and Richard Pew 8:50 a.m. BIOLOGICAL RESPONSE OF TISSUES TO STRESSES: MUSCLES, TENDONS, AND NERVES INVITED PAPER ON MUSCLES AND TENDONS: James Ashton-Miller Panel Discussion: Kai-Nan An, Sidney Blair, Dennis Carter, Carlo De Luca, Steven Lehman, Steven Moore, Moshe Solomonow, Questions from Invited Participants INVITED PAPER ON NERVES: David Rempel Panel Discussion: David Florence, Steven Garfin, Thomas Mayer, Susan Mackinnon, Robert Szabo Questions from Invited Participants

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--> 10:50 a.m. Break 11:15 a.m. WORK FACTORS, INDIVIDUAL HOST FACTORS, AND INTERNAL LOADS: BIOMECHANICS OF WORK STRESSORS INVITED PAPER: Robert Radwin and Steven Lavender Panel Discussion: Arun Garg, W.Monroe Keyserling, Robert Norman, Mark Redfern, Carolyn Sommerich, Richard Wells Questions from Invited Participants 12:30 p.m. Lunch Room 250: Participants A-J Room 280: Participants K-Z Public: Cafeteria is available to purchase lunch 1:30 p.m. EPIDEMIOLOGY: PHYSICAL FACTORS Panel Discussion Moderator: Ronald Gray Panelists: Bradley Evanoff, Alfred Franzblau, Fredric Gerr, Laura Punnett , Howard Sandler, David Wegman Questions from Invited Participants 3:30 p.m. Break 4:00 p.m. General Discussion with Paper Presenters: Invited Participants and Public Friday, August 21 8:00 a.m. Continental Breakfast Room 250: Participants A-J Room 280: Participants K-Z Public: Cafeteria is available to purchase breakfast

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--> 9:00 a.m. NON-BIOMECHANICAL FACTORS POTENTIALLY AFFECTING MUSCULOSKELETAL DISORDERS INVITED PAPER: Julia Faucett and Robert Werner Panel Discussion: Jacqueline Agnew, Paulien Bongers, Robert Gatchel, Michael Kerr, Samuel Moon, Peter Nathan Questions from Invited Participants 10:15 a.m. Break 10:45 a.m. INTERVENTIONS TO CONTROL MUSCULOSKELETAL DISORDERS INVITED PAPER: Michael Smith Panel Discussion: Donald Bloswick, Stephen Burastero, Martin Cherniack , Linda Cocchiarella, Brad Joseph, Lida Orta-Anés, Scott Schneider, Barbara Silverstein Questions from Invited Participants 12:00 p.m. Lunch Room 250: Participants A-J Room 280: Participants K-Z Public: Cafeteria is available to purchase lunch 1:00 p.m. Panel on the Integration of Workshop Presentations and Discussions Chair: Colin Drury Panelists: Jacqueline Agnew, Sidney Blair, Donald Bloswick, Alfred Franzblau, Fredric Gerr, W.Monroe Keyserling, Susan Mackinnon, Steven Moore, Peter Nathan, Barbara Silverstein, Robert Szabo , Richard Wells 2:00 p.m. Questions and Comments from Invited Participants and Public

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