Stewart Adele 2009

Manual handling in child care work:
components of back injury risk during

the task of nappy changing
Adele Stewart B.P.E.
This thesis is presented for the degree of

Master of Science of
The University of Western Australia,
School of Sport Science, Exercise and Health
December 2009.
Executive Summary
Manual handling is a duty inherent to child care. Whether it is domestic or

occupational, the manual handling work involved in caring for young children
doesn’t differ. The lifting and handling of young children and interaction with infant
nursery equipment and children’s furniture is relentless. General manual handling (MH)
work is associated with higher than normal levels of musculoskeletal disorder (MSD).
Occupational health and work safety (OHS) practices have been created to identify,
assess and minimise injury risk to workers. The key variables taken into account are the
characteristics of the loads, equipment, job design and the anthropometry and ability
of those doing the work. Although there is no apparent lack of OHS regulations applied
to child care work, unusually high rates of MSD continue to be reported (Owen, 1992;
Bright & Colabro, 1999; King et al., 2006) with lower back injury (LBI) being the main
contributor (Brown & Gerbrick, 1993). The exceptionally high rates of injury for workers
employed in child care, the majority of whom are female, exposes an implication of
injury risk to women caring for young children in the domestic environment. Many of
these women in domestic child care will be pregnant or postpartum and as such
likely to already have some LBI or transient physical disability (Pheasant, 1986). Past
studies of MH in child care have observed likely implications for LBI from lifting children
and interaction with equipment, but to date there has been no biomechanical analysis
or objective measurement of the tasks or the components. That being said, lifting
children is not a standardised activity and therefore difficult to measure. Nappy
changing however, is one MH child care task that is performed frequently and includes
variables that are quantifiable. The aim of this research was to establish an
understanding of the complexities involved in nappy changing and to explore the
biomechanical risk hazards for LBI. Due to the significant number of women involved in
domestic child care and occupational MH work, this study has implications for the child
care environment as well as the broader workplace.
Method: The research comprised of two separate but interrelated studies. Study One, a
self responded questionnaire, was designed to gather information from women (n=411)
who were regularly involved in the task of nappy changing. It also provided frequency
and duration data as well as scaled response feedback on associated lower back pain
(LBP); all of which were used to provide perspective and validity to the overall study.
The data regarding equipment, load and task variables were used to develop the
control variables for the second study. Study Two was a biomechanical analysis using
3DSSPP Version 5.0.4 (University of Michigan, 2005) of the common nappy change task
scenarios. Participants (n=10) included pregnant, postpartum and nulliparae women.
The biomechanical analysis measured posture and spinal loading when lifting a 3
month and an 18 month simulated “baby load” from three heights of purpose built
nappy change furniture, and repeated the test for the two stance alignments. Study
ii
Two also assessed biomechanical outcomes for a floor reaching posture common
when using this change furniture.
Results: Study One indicated that most women in the domestic child care environment
(i) use purpose built nappy change furniture that is around waist height which required
either a symmetric or asymmetric stance; (ii) were working with two or more children
under the age of three; and (iii) associated some level of LBP with the posture and the
lift components of this task. This study also revealed that women have a 50% risk of
developing LBP during and/or subsequent to pregnancy. Furthermore, those who
reported high levels of LBP rated pain associated with posture and lifting components
of the nappy change task as severe. Study Two established that spinal compression
and shear force, ligament strain and torso muscle fatigue were increased to potentially
hazardous levels when lifting the heavy baby load regardless of bench height or
stance alignment. The results also indicated that whilst there was a statistically
significant difference between the two stance alignments, there were both positive
and negative attributes for both stance conditions in terms of injury risk. The results
suggest that some purpose built furniture may be hazardous to LBI. Although not
directly tested, the results indicate that the frequency and duration of the task may
compound the outcomes and that nappy change furniture with the work surface of
waist height may not be optimum for these women when performing this task.
Conclusion: Our results demonstrate that a considerable number of women (i)
experience LBP during and subsequent to pregnancy; (ii) associate the task of nappy
changing with heightened LBP; and (iii) have increased difficulty changing older
babies as they are physically challenging and the task takes longer. Furthermore, these
data indicated that waist height nappy change furniture may be associated with
posture related LBP. The results of Study Two revealed there are several biomechanical
risk consequences for LBI from both the lifting and posture components of this task.
These risks for the operator may be compounded due to the design of equipment, the
nature of the baby loads being handled and for operators who are carrying
abdominal, pelvic and/or lower back injuries. These problems may also be
exacerbated by the frequency and duration of this task. The long term implications of
unresolved LBI in these women are unknown, but may have repercussions for future
workplace injury. This study has highlighted the urgent need for OHS strategies to
address the unique requirements of the individual populations of women working in
child care and manual handling roles and strongly recommend further biomechanics
studies of this nature.
iii
Table of Contents Page
Executive Summary………………….…………………….………….………… ii
Table of Contents………………….………………………………….………… iv
Acknowledgements………………….……………………….………………… vii
List of Tables………………………………………………………………………. viii
List of Figures……………………………………………………………………… ix
List of Abbreviations…………………………………………………………….. xiv
Chapter One – Introduction……………………………………………. 1

Statement of the Problem……………………………………………………... 4
Significance of the Study………………………………………………………. 4
Overview of the Thesis Structure……………………………………………… 4
Aims………………………………………………………………………………… 5
Hypotheses……………………………………………………………………….. 6
Delimitations………………………………………………………………………. 7
Limitations…………………………………………………………………………. 8
Chapter Two - Review of Literature…………………………………… 9

Manual Handling………………………………………………………………… 9
Women in Child care Work……………………………………………………. 10
Identifying the Risk………………………………………………………………. 12
Operator characteristics…………………………………………………………. 12
Difficult loads……………………………………………………………………….. 17
Equipment…………………………………………………………………………... 20
Occupational health and safety issues……………………………………….. 26
Task of nappy changing…………………………………………………………. 27
Assessing the Risk………………………………………………………………… 30
The biomechanics of standing lifts: implications for LBI…………………… 30
Posture strength and lifting……………………………………………………… 33
Implications………………………………………………………………………… 37
Chapter Three – Methods………………………………………………... 40

Study One………………………………………………………………………….. 40
Participants…………………………………………………………………………... 40
Survey design………………………………………………………………………… 41
iv
Distribution………………………………………………………………………….… 42
Data Analysis………………………………………………………………………… 43
Study Two…………………………………………………………………………... 44
Participants…………………………………………………………………………... 44
Instruments and apparatus……………………………………………………….. 45
Procedures…………………………………………………………………………… 47
Treatment of the data……………………………………………………………... 51
Statistical analysis…………………………………………………………………… 53
Chapter Four - Study One Results…………………………………….. 55

Demographics…………………………………………………………………… 55
Equipment………………………………………………………………………… 57
Task Frequency and Duration………………………………………………… 59
Rating of Task Difficulty Associated with Equipment……………………... 60
Rating of Pain and Dysfunction Associated with the Task…………….… 61
Pain and Dysfunction Associated with Respondent Characteristics….. 64
Qualitative Summary…………………………………………………………… 68
Chapter Five - Study Two Results……………………………………… 72

Scenario One – Symmetric Lift……………………………………………….. 74
Scenario Two – Asymmetric Lift………………………………………………. 82
Comparison of Symmetric and Asymmetric Lift…………………………… 90
Scenario Three – Mid-Calf Reach……………………………………………. 98
Chapter Six – Discussion………………………………………………… 106

Outcome of Study One………………………………………………………… 107
Outcome of Study Two…………………………………………………………. 108
Synthesis of the Studies…………………………………………………………. 113
Load………………………………………………………………………………….. 113
Equipment…………………………………………………………………………... 114
Frequency, duration and fatigue………………………………………………. 117
Operator Characteristics………………………………………………………… 119
Summary of Discussion…………………………………………………………. 120
Recommendations………………………………………………………………. 121
Conclusion……………………………………………………………………….. 124
v
References…………………………………………………………………. 125
Appendices……………………………………………………………….. 132
Appendix A: Subject Information Sheet Study One……………………… 132
Appendix B: Study One Questionnaire……………………………………… 135
Appendix C: Subject Information Sheet Study Two………………………. 140
Appendix D: Participant Consent Form Study Two……………………….. 142
vi
Acknowledgements
To my three girls Dempsey, Audrey and Lily for giving me the opportunity to
experience and learn so much more than I could ever have imagined
To my friends and family for their endless support
To my Mother Julie, who has always encouraged me and enabled the

freedom and certainty for me to pursue my challenges
I love you and sincerely thank you all.
To Brian, for having faith in my abilities when mine was faltering
And to my supervisors Tim and Siobhan, who have completed a manual

handling marathon, ever so gently pushing me on through the long and
winding tunnel …toward that light
I am so grateful to have been allowed this indulgence….
Finally, to the many women who so willingly participated in this study, and to
those who will hopefully benefit from it….the work you all do is amazing!
vii
List of Tables Page
Table 2.1 The Average Expected Somatic Growth Measures for children 19
New Born to 24 Months
Table 3.1 Dimensions Used for Baby Load Manikins 46
Table 4.1 Number of Pregnancies to Full term for Each Respondent group 56
Table 4.2 Respondent Characteristics relative to task Associated Low 65

back Pain
Table 4.3 Age and BMI Status Relative to Perceived Task-Associated Low 67
Back Pain/Disability
Table 4.4 Pregnancy status and Number of Births Relative to Perceived 68

Task-Associated Low back Pain/Disability
Table 4.5 Qualitative Theme Summary and Percentage of Responses to 71

general Dimensions Categories
Table 5.1 Participants Demographic and Girth Measurement Information 72
Table 5.2 Repeated Measures ANOVA Summary of Bench Height and 75

Load Main Effects for Scenario One, the Symmetric Lift
Table 5.3 Repeated Measures ANOVA Summary of Bench Height and 83

Load Main Effects for Scenario Two, the Asymmetric Lift
Table 5.4 Repeated Measures ANOVA Summary of Stance Alignment with 91

Bench Height Main Effects for the Comparison of Symmetric and
Asymmetric Lift at Load 2
Table 5.5 Repeated Measures ANOVA Summary of Bench Height Effect 99

Scenario Three, the Mid-calf Reach
viii
List of Figures Page
Figure 2.1 2/3 Tier change table 21
Figure 2.2 Bath and change table 22
Figure 2.3 Fold out frame and sling 23
Figure 2.4 Drawer top changer or changing chest 23
Figure 2.5 Cot top changer or changing board 24
Figure 2.6 Drop down suspended bench top perpendicular or horizontal to 25

the wall
Figure 2.7 Instructions for nappy changing 29
Figure 3.1 Change bench apparatus shown in the Scenario One 45

symmetric lift with an 18 month baby load manikin (11.5 kg
load) at 80 cm, 95 cm and 110 cm bench surface heights.
Figure 3.2 Three month baby load manikin. Rump placement position is 47
marked on the surface of the change bench
Figure 3.3 Eighteen month baby load manikin. Rump placement position is 47
marked on the surface of the change bench
Figure 3.4 Scenario One – Symmetric lift position 49
Figure 3.5 Scenario Two – Asymmetric lift position 50
Figure 3.6 Scenario Three – Mid-calf reach 51
Figure 3.7 Example of 3D SSPP Version 5.0.4 application window depicting 52

modelling file for a pregnant participant performing a
symmetric lift at the 95 cm bench height with an 18 month baby
load manikin
Figure 4.1 Respondent age group frequencies 55
Figure 4.2 Respondent height group frequencies 56
Figure 4.3 Change furniture styles as reported, used in the domestic 57

environment
Figure 4.4 Change surface heights as reported, used in the domestic 57

environment
Figure 4.5 Domestic furniture example of 2/3 tier change unit 58
ix
Figure 4.6 Domestic furniture example of drawer top change unit 58
Figure 4.7 Domestic furniture example of bath/change unit 58
Figure 4.8 Domestic furniture example of frame sling change unit 58
Figure 4.9 Public change unit example of wall mounted, vertical 59
Figure 4.10 Public change unit example of wall mounted, horizontal 59
Figure 4.11 Reported daily task frequency per baby load 60
Figure 4.12 Reported task duration per baby load 60
Figure 4.13 Difficulty associated with using Public furniture styles 61
Figure 4.14 Difficulty associated with using Domestic furniture styles 61
Figure 4.15 Low back pain/dysfunction associated with Lift of load and 62
Posture associated with the nappy change task
Figure 4.16 Low back pain/dysfunction as a result of posture used with 63

each furniture style
Figure 4.17 Low back pain/dysfunction as a result of lift used with each 63
furniture style
Figure 4.18 Low back pain/dysfunction as a result of lifting and relative 64

height of the furniture used by each respondent. Furniture
height is expressed as a proportion of individual stature
Figure 4.19 Low back pain/dysfunction as a result of posture and relative 64

height of the furniture used by each respondent. Furniture
height is expressed as a proportion of individual stature
Figure 4.20 Summary of raw data from written responses and first order 70
key components of themes making up the general dimensions
of observations
Figure 5.1 Representation of Scenario One – Symmetric Lift. Sagittal and 74

Frontal views at 80 cm bench height
Figure 5.2 Mean torso extension as a result of load and height changes 76
in Scenario One – Symmetric lift
Figure 5.3 Mean compression force (N) at L5/S1 as a result of load and 77
height changes in Scenario One – Symmetric lift
Figure 5.4 Mean shear force (N) at L5/S1 as a result of load and height 77
changes in Scenario One – Symmetric lift
Figure 5.5 Mean ligament strain at L5/S1 as a result of load and height 78
changes in Scenario One – Symmetric lift
Figure 5.6 Mean torso flexion/extension muscle fatigue (%MVC) at L5/S1 79

as a result of load and height changes in Scenario One –
Symmetric lift
x
Figure 5.7 Mean torso lateral bending muscle fatigue (%MVC) at L5/S1 80
Symmetric lift
Figure 5.8 Mean torso rotation muscle fatigue (%MVC) at L5/S1 as a 80

result of load and height changes in Scenario One –
Symmetric lift
Figure 5.9 Mean right shoulder abduction/adduction muscle fatigue 81

(%MVC) as a result of load and height changes in Scenario
One – Symmetric lift
Figure 5.10 Mean right shoulder flexion/extension muscle fatigue (%MVC) 81

Symmetric lift
Figure 5.11 Mean right shoulder humeral rotation muscle fatigue (%MVC) 81
Symmetric lift
Figure 5.12 Representation of Scenario Two – Asymmetric Lift. Sagittal and 82

Frontal views at 80 cm bench height
Figure 5.13 Mean torso extension as a result of load and height changes 84
in Scenario Two – Asymmetric lift
Figure 5.14 Mean compression force (N) at L5/S1 as a result of load and 85
height changes in Scenario Two – Asymmetric lift
Figure 5.15 Mean shear force (N) at L5/S1 as a result of load and height 85
changes in Scenario Two – Asymmetric lift
Figure 5.16 Mean ligament strain at L5/S1 as a result of load and height 86
changes in Scenario Two – Asymmetric lift

as a result of load and height changes in Scenario Two –
Asymmetric lift
Asymmetric lift

result of load and height changes in Scenario Two –
Asymmetric lift

(%MVC) as a result of load and height changes in Scenario
Two – Asymmetric lift

Asymmetric lift
Asymmetric lift
xi
Figure 5.23 Representation of Symmetric and Asymmetric Lifts. Sagittal 90
and Frontal views at 80 cm bench height
Figure 5.24 Mean torso extension as a result of stance alignment and 92

height changes in Symmetric vs Asymmetric lift
Figure 5.25 Mean compression force (N) at L5/S1 as a result of stance 92

alignment and height changes in Symmetric vs Asymmetric lift
Figure 5.26 Mean shear force (N) at L5/S1 as a result of stance alignment 93
and height changes in Symmetric vs Asymmetric lift
Figure 5.27 Mean ligament strain at L5/S1 as a result of stance alignment 94

and height changes in Symmetric vs Asymmetric lift

as a result of stance alignment and height changes in
Symmetric vs Asymmetric lift

result of stance alignment and height changes in Symmetric vs
Asymmetric lift

(%MVC) as a result of stance alignment and height changes in

Figure 5.34 Representation of Scenario Three, Mid-calf Reach. Sagittal 98

and Frontal views at 80 cm bench height
Figure 5.35 Mean torso extension as a result of bench height in Scenario 100
Three, Mid-calf Reach.
Figure 5.36 Mean compression force (N) at L5/S1 as a result of bench 100
height in Scenario Three, Mid-calf Reach.
Figure 5.37 Mean shear force (N) at L5/S1 as a result of bench height in 101
Scenario Three, Mid-calf Reach.
Figure 5.38 Mean ligament strain at L5/S1 as a result of of bench height in 102
Scenario Three, Mid-calf Reach.
as a result of bench height in Scenario Three, Mid-calf Reach.
xii
result of bench height in Scenario Three, Mid-calf Reach.

(%MVC) as a result of bench height in Scenario Three, Mid-calf
Reach.
xiii
Definition of Key Terms and Abbreviations
ABS Australian Bureau of Statistics

AL Action Limit (NIOSH)
ANOVA Analysis of variance
ASCC Australian safety and Compensation Council
BCDL Back compression design limit (NIOSH)
CCCL Australian Child Care Centre License
CF Spinal compression force
CNS Central Nervous System
CoG Centre of gravity
CoM Centre of mass
DL Design limit (NIOSH)
DOCEP Department of Consumer and Employment Protection
GLBP Gestational lower back pain
INPAA Infant and Nursery Products Association of Australia Inc
IV Intervertebral
LBD Lower back disorder
LBI Lower back injury
LSAC Longitudinal Study of Australian Children
MH Manual handling
MPL Maximum permissible limit (now AL – NIOSH)
MSD Musculoskeletal disorder
MSI Musculoskeletal injury
MVC Maximum Voluntary Contraction
NIOSH National Institute for Occupational Safety and Health
OHS Occupational health and safety
RWL Recommended Weight Limit
RCN Raising Children Network
SF Spinal shear force
WHO World Health Organisation
xiv
CHAPTER ONE
INTRODUCTION
Nappy changing – “One of the ultimate joys of parenting is undoubtedly

nappy changing. It’s a skill that can be quickly acquired with a few basic rules
to make this unavoidable and essential daily task a straight forward and
relaxed time for both baby and parents”
(http://www.howto.tv/show/how_to_change_a_nappy).
Contrary to this statement, nappy changing is a complex manual handling
task, revealing some underestimated occupational hazards and classic
components of risk for lower back injury.
Any work deemed to be MH, is work that requires the use of body force to lift,
lower or in any way move a load, either inanimate or live (Chaffin & Andersson,
1991; Kroemer & Grandjean, 2001). In the work place, MH is associated with
higher than normal occupational health and safety (OHS) hazards (NIOSH,
1994; NIOSH, 2004; Miller et al., 2006) and as a result workers are faced with a
higher than normal risk of sustaining a musculoskeletal injury (MSI) (McGill, 1997;
Dempsey, 1998). The most problematic MSI or musculoskeletal disorder (MSD)
associated with MH is lower back injury (LBI) (NIOSH, 1994; Dempsey & Hashemi,
1999; ASCC1, 2007). LBI and lower back disorders (LBD) are complex to
diagnose (Karwowski, 2006), frequently result in long periods of absence from
the work place and present an enormous cost to industry (NIOSH, 2004; ASCC,
2007; EASHW, 2007).
Industries that principally involve MH work have typically been linked with part-
time work, shift work and occupational gender segregation (Preston &
Whitehouse, 2004). For example 70% of employees in the transport, mining,
manufacturing and construction industries are men; and 80% of employees
within the health and community service, retail or service industry groups are
women (ABS, 2004; WorkCover, 2007). Furthermore, women currently make up
almost half of the Australian work force and the majority are employed in MH
industries (ABS, 2004). And although OHS policies attempt to standardise safe
work practices in all work place populations, women currently account for 55%
of all lost time work claims from MSD (Miller et al., 2006). Additionally, in the past
1
10 years, Government OHS policies have specifically addressed MH related
LBD (ASCC3, 2007). During this period, although there has been a significant
decline in the rate of LBD among men, the rate in women has slightly
increased (ASCC1, 2007; Hawkes, 2007).
MSI are particularly high among child care workers (King et al. 1996; Wortman,
2003; Gratz et al., 2002). Given the nature of child care, it is perhaps not
surprising that 95% of these employees are women (Wortman, 2003; Gratz et
al., 2002). Of interest though, is the significant risk of injury that the child care
environment poses to the workers (Owen, 1992; Gratz & Claffey, 1996;
Wortman, 2003). Although there is no apparent lack of safety controls and
regulations (ASCC2, 2007), this population of workers consistently present with
unusually high rates of LBD (NIOSH, 1994; Owen, 1994; Bright & Calabro, 1999;
King et al., 2006). With over 115,000 women employed in registered child care
work in Australia (ABS, 2007), the potential cost of injury associated with MH
work in this industry alone is substantial. The exceptionally high rates of injury
for workers employed in child care also exposes an implication of injury risk to
a much broader population – that being women involved in unpaid child
care within the domestic environment. Although there are no statistics on MH
related injuries for women in home duties, the high rate of injury in child care
occupations would indicate that there may be similar injury risks for women
caring for young children at home.
Whether in the domestic or formal child care environments though, MH work

involving very young children doesn’t differ: the objective is to meet their
needs and the work is relentless (Griffin & Price, 2000; Craig, 2007). This MH is
an on-going relay of lifting and carrying children or manipulating these “live
loads” into or onto furniture and equipment that have been purpose built with
mainly the child in mind (Wortman, 2003; Gratz et al., 2002; King et al., 2006).
The situation is further compounded since work place safety in the child care
industry is focused more on safety of the children being handled, rather than
those doing the handling (Griffin, 2006). The task, which involves children as
live loads and the purpose built equipment are MH variables unique to this
work environment and clearly present exceptional problems.
In the domestic child care environment, regardless of whether they are “stay-
at-home mothers” or in paid employment as well, women are the primary
2
care providers for infants (0–12 months) and young children ((Preston &
Whitehouse, 2004; ABS, 2005; Baxter et al., 2007). In Australia 10% of adult
women are pregnant at any one time (ABS, 2007), with more than half of
these women already caring for at least one child under the age of 3 years
(ABS, 2005; ABS, 2007). It is now well documented that between 50–90% of
pregnant women will experience lower back pain (LBP) during pregnancy
(Ostgaard et al., 1996; Sweden, 2003; Carlson et al., 2003; Wang, 2003) which
more than likely will commence within the first trimester (Wu et al., 2004).
Having pregnancy related LBP is the greatest predictor for women suffering
LBP following the birth of a child (Ostgaard & Anderson, 1992; Ostgaard et al.,
1997; Noren et al., 2002; Ostgaard et al., 2002). However, although the cause
for pregnancy related LBP remains uncertain, the severity and duration of this
LBP is a real concern for at least 20% of post partum women (Noren et al.,
2002). Complicating this problem is the fact that many women develop
functional disabilities associated with pelvic floor insufficiency (Mast, 1999;
Newman, 2000; Neuman & Gill, 2002) and abdominal muscle diastases
(Kotarinos, 2003) that can only be repaired through surgery (Mast, 1999).
To date there is no published research that objectively quantifies the MH work

when caring for young children. Lifting and lowering of children is undoubtedly
the most frequent and at times, the most strenuous of these MH tasks (Hostetler,
1984; Kuczmarski et al., 2000; Morehead, 2004), but in child care, lifting children
is not generally a standardised activity. It is possible that because of the
continuous, random and combined nature of lifting tasks in child care, defining
an assessment that is valid and reliable could prove difficult. However, nappy
changing is one MH task that is performed frequently and includes variables
that are quantifiable. Nappy change furniture is used to elevate the working
surface when changing a young child’s nappy and the carer will lower the
child to this surface, and then lift the child from this surface on completion of
the task. The components of this task are measurable and biomechanically
quantifiable in relation to injury risk and therefore, may provide some indication
of the implications for women when lifting young children.
3
Statement of the Problem
We do not know if women working in child care view the task of nappy
changing on a young child as difficult, nor if purpose built nappy change
furniture is problematic to them. Also we have very limited understanding of the
biomechanics of the nappy change task and the spinal loads resulting from the
lifting actions and postures. Handling a young child as a load has not been
investigated scientifically and purpose built nappy change furniture designs
have never been scrutinised in relation to their effect on the operator. Nor do
we know the implications of spinal loading on women whose anatomy may be
compromised due to pregnancy or childbirth; or if these women are at an
increased risk of LBI from MH. These factors all have implications for the child
care environment as well as the broader workplace.
Significance of the Study
There is a heightened risk of LBI for workers employed in child care that appears
to be unaltered by conventional MH risk control protocols. The problems
appear unique to this work and there are several issues of concern that have
never been investigated scientifically. This research will be of significance to:
professionals involved in ergonomics and the development of occupational
health and safety policy; those responsible for nursery furniture design and
manufacturing standards; professionals working in parenting education; and for
anyone undertaking the task of nappy changing in both occupational and
domestic child care settings.
Overview of the Thesis Structure
This introduction is followed by a comprehensive review of literature

investigating relevant aspects of MH; women in MH work, MH involved in child
care and the issues relating to the task of nappy changing. The review will also
address three of the independent variables related to the nappy changing
task that will be tested in this study: the operators, loads and equipment. This is
followed by is an overview of the available OHS publications referring to child
care tasks and a description of nappy changing and finally, a review of
biomechanical outcome measures and a summary of the implications for
women involved in this work.
4
This research comprised of two separate, but interrelated studies. Chapter 3
presents the methods used for Studies One and Two. Study One employed a
questionnaire designed to gather information from women who were regularly
involved in the task of nappy changing. Quantitative data from this study
(Study One) regarding equipment and task variables were used to develop the
control variables for Study Two. Other task related information from Study One
supplied qualitative feedback which was used to provide perspective and
validity to the overall project. Study Two involved a biomechanical analysis of
various nappy changing task scenarios, in which we measured movements
and postures, and estimated spinal loading on women when lifting a child from
purpose built nappy change furniture. Chapters 4 and 5 present the results for
Studies One and Two respectively. Finally Chapter 6 will connect both studies
together highlighting and discussing the main outcome points of interest from
this research.
Aims
The aims of Study One were to gather quantitative and quantitative

information:
 from experienced women in relation to the physical difficulty and LBP
associated with the nappy change task;
 on the task of nappy changing from which to build the test variables
for the biomechanical analysis in Study Two; and
 regarding a range of other lifting tasks involved in child care, in order
to provide a comparison perspective for the task of nappy changing.
The aims for Study Two were to:

 assess biomechanically the act of lifting a young child from the
surface of commonly used purpose built change furniture;
 assess biomechanically the postures involved in the task of nappy
changing when using common purpose built change furniture; and
 assess and quantify the spinal loadings and therefore, potential LBI
risk from the task of nappy changing when using common purpose
built change furniture.
5
Hypotheses
1) Following biomechanical simulation of lifting a baby load from purpose built

nappy change furniture, there will be a difference (p < 0.017) in the angle of
torso extension as a result of three variations in height; two variations in baby
load size and two variations in lifting stance alignment.

nappy change furniture, there will be a difference (p < 0.017) in compression
force at L5/S1 as a result of three variations in height; two variations in baby
load size and two variations in lifting stance alignment.

nappy change furniture, there will be a difference (p < 0.017) in shear force at
L5/S1 as a result of three variations in height; two variations in baby load size
and two variations in lifting stance alignment.

nappy change furniture, there will be a difference (p < 0.017) in ligament strain
at L5/S1 as a result of three variations in height; two variations in baby load size
and two variations in lifting stance alignment.

nappy change furniture, there will be a difference (p < 0.017) in the estimated
percentage of torso muscle fatigue as a result of three variations in height; two
variations in baby load size and two variations in lifting stance alignment.

percentage of (right) shoulder muscle fatigue as a result of three variations in
height; two variations in baby load size and two variations in lifting stance
alignment.

nappy change furniture, there will be a difference (p < 0.017) in the angle of
torso extension as a result of three variations in height during a hold and reach
posture.
6
nappy change furniture, there will be a difference (p < 0.017) in the
compression force at L5/S1 as a result of three variations in height during a hold
and reach posture.

nappy change furniture, there will be a difference (p < 0.017) in the shear force
at L5/S1 as a result of three variations in height during a hold and reach
posture.
nappy change furniture, there will be a difference (p < 0.017) in the ligament
strain at L5/S1 as a result of three variations in height during a hold and reach
posture.
percentage of torso muscle fatigue as a result of three variations in height
during a hold and reach posture.
percentage of (right) shoulder muscle fatigue as a result of three variations in
height during a hold and reach posture.
Delimitations
Study One
This questionnaire involved only women who had recent experience in the task
of nappy changing on a young child and was made available for a collection
period of four months.
Study Two
Participants in this study were either pregnant or post partum with experience in
the task of nappy changing; and nulliparae women who represent
occupational child care workers who have never been pregnant. They were
aged between 20 and 45 years, of average height and within a BMI range of
7
18–25. The biomechanical outcomes were measured at the L5/S1 joint in the
lumbar spine.
Limitations
Study One
The respondents to the questionnaire were self-selected and the question
responses were self-assessed. The respondent sample may be biased and may
not adequately represent the target population which could limit the strength
of the qualitative component of this questionnaire. The validity and reliability of
the questionnaire was not known or tested.
Study Two
The sample size for this study was small and as such all participant data for
each lifting task was combined and presented as average data, thus being a
stronger representation of the outcome measures, but possibly lacking
accuracy in relation to the individual populations concerned. The
biomechanical analyses were performed using static measures, not dynamic
motion and measures of shoulder muscle fatigue were reported for the right
shoulder muscle groups only. The static strength prediction program cannot
recreate the frontal mass increase or simulate the pregnant and postpartum
weight distribution. This may have underestimating true values for subject
anthropometry and the inertial parameters input to the model.
8
CHAPTER TWO
REVIEW OF LITERATURE
MANUAL HANDLING
When reviewing the literature on occupational health and safety, it is clear that
MH has provided a rich field for research. Equally, when considering themes
within MH; lifting tasks, associated MSD and the enormous costs incurred from
lost time due to injuries, seem to dominate the literature (ABS, 2003).
Although MH work is generally referred to in an occupational sense, it may be

equally relevant to unpaid work in the domestic environment. According to the
(ABS, 2005), at least 80% of Australian women will experience motherhood and
the majority of 25 to 50 year old women not employed in paid work, will be
occupied full time in caring for their young children (Chaffin & Andersson, 1991;
McGill, 1997; Kroemer & Grandjean, 2001). Although there are few studies
reporting the specifics of tasks involved in child care, there is little doubt that
lifting is a frequent requirement when working with babies and young children
(NIOSH, 1994; Dempsey & Hashemi, 1999; WorkCover, 2004)
Lifting is reported to be a significant contributor to MSD (Marras et al., 1995) of

which LBI is the most frequently sustained, prolonged and costly work related
health problem (Karwowski, 2006). Unresolved injury to the spine can reduce an
individual’s capacity to perform physical activity and increase the likelihood of
developing chronic disability (ASCC1, 2007; Hawkes, 2007). Furthermore a
history of LBD heightens the risk of serious acute back injury (ASCC1, 2007;
Hawkes, 2007).
In Australia in 2006, 61% of all lost time workers compensation claims made by
women were for MSI, with more than a third of those resulting from LBD
associated with lifting (ABS, 1998; ABS, 2007). What’s more, the highest rate of
lost time claims for MSD over the past 10 years was recorded by women
between the ages of 35 to 54 years (ABS, 1998). Although in the same period,
the number of LBD compensation claims made by men decreased by 18%, the
percentage of those made by women increased by 1% (ABS, 2005).
9
WOMEN IN CHILD CARE WORK
Over the last 30 to 40 years there has been a notable change in the
participation rate of women in the work force (Baxter & Gray, 2008). In 1960 less
than 33% of Australian women (aged 15 to 64) were employed and only 31% of
these were married women (Pocock, 2003; Craig, 2007). Currently in Australia
70% of women are employed (Baxter et al., 2007; Craig, 2007) with the largest
employer groups being Health and Community Services, Retail and
Manufacturing (ABS, 2005). Because women in Australia are still the primary
care providers to their children (ABS, 2005), working women are combining
paid work with family responsibilities (Craig, 2007). It is no surprise then that the
demand for secondary child care support has also changed.
In Australia, mothers of children up to 12 months of age will generally be the full

time carer for this child (ABS, 2003) with grandmothers being the preferred
secondary support (Whitebook & Ginsburg, 1983; Hostetler, 1984; Moorehead,
2004). The Longitudinal Study of Australian Children (LSAC) (ABS, 2005) reported
that mothers working at home with an infant (0–12 months) spent 10 hours per
day in high contact activities which included bathing, changing nappies and
feeding; and holding, carrying or cuddling the child (ABS, 2005). In addition
though, over half of the pregnant and early post partum women working at
home will also be caring for at least one other child between the ages of 12
and 24 months (Brown & Gerberich, 1993). Although children of this age have
more developed cognitive processes, they are still fully dependent and require
constant supervision (Griffin & Price, 2000; Sanders & Morse, 2005). However, as
the age of children increases out of infancy the use of formal day care as the
secondary support also increases (ABS, 2005). Indeed the largest group of
children attending formal day care centres in Australia is represented by the
one to three year olds with more than 62% of them being in care for some
period (Brown & Gerberich, 1993; Gratz et al., 2002).
Caring for young children is extremely demanding, the physical work of which is
often relentless (Shultz et al., 2004; Karageanes, 2005) It requires the continuous
necessity for lifting, bending, carrying, reaching, stooping, pushing and pulling
awkward and heavy loads; getting children in and out of prams, high chairs
and cots as well as interacting with equipment, purpose built for children
(Charlton et al., 2001; Palejwala et al., 2001). There are relatively few studies
10
reporting the specific physical demands of child care, but perhaps because of
the non-specific and continual nature of the tasks throughout a day,
formulating a research perspective is difficult. According to Hostetler (1984), the
first empirical study of this MH work; a worker employed within formal child care
and responsible for eight children, will bend and lift at least 200 times in an
eight hour day, potentially lifting around 4,350 kg in that time. In addition to the
handling of children, is the regular moving of furniture, equipment and toys; the
use of child size furniture and spending large amounts of time sitting on the floor
(Dragoo et al., 2003).
Much of the manual handling required of all child care workers, presents classic
LBD and other physical risk (Owen, 1992; Gratz & Claffey, 1996; Wortman, 2003).
A five year study by (Pheasant, 1988; ABS, 2006) reviewing the cause and rate
of injuries in American child care workers, reported that LBD accounted for the
greatest proportion of the total injuries, and that 68 percent of all MSD involved
lifting or lowering children. Regardless of this only a handful of published studies
have since attempted to reveal the ergonomic and issues for child care
workers (Baxter & Gray, 2008) and fewer published studies have attempted to
quantify the MSD associated with these workers (Foti et al., 2000). In an effort to
identify and reduce risk to occupational child care workers, King et al. (2006)
designed a program of ergonomic intervention, introducing alternative
methods of manual handling. The program participants (95% women) all of
whom reported some level of work related MSD were surveyed before and
after the prescribed changes. The majority of the 258 respondents had, where
possible, implemented the ergonomic interventions, but at the end of the six
month program there was little empirical data to support any change to
reported rates of MSD. King et al. (2006) noted that a number of factors may
have confounded the results, but also that some of the advised changes could
not be implemented. The changes not undertaken were those that required
the use of two adult workers to lift or lower children when using equipment such
as prams, cots and change tables. Of the tasks reported to contribute most to
lower back pain (LBP) as well as upper back and shoulder pain, nappy
changing and the working height of change bench furniture presented
significant risk (King et al., 2006). Concerns raised by other observers include the
lifting and lowering of children onto the change furniture and the awkward
and sustained postures maintained during the change task (Owen, 1992; Grant
11
et al., 1995; Wortman, 2003; Gratz et al., 2002; King et al., 2006). Wortman (2003)
and King et al. (2006) suggested using waist height furniture when lifting heavy
items and change tables should adjusted so that the carer is working at waist
level with the child. Generally though, the results from these few studies have
highlighting the clear MH risk to workers with recommendations for further
research as well as the need for teaching proper lifting techniques.
It is perhaps not surprising therefore, that the rates of occupational sick leave
and compensation in formal child care workers remains unusually high
(Kristiansson et al., 1996) with the most serious health problem for employees in
formal child care being LBD (Charlton et al., 2001; Shultz et al., 2004). It seems
also somewhat obvious that the same cause for LBD in occupational child care
is surely duplicated in those working with young children in the domestic
environment although this has to date, not been acknowledged. Plainly there
are a number of possible contributing factors to LBD from lifting tasks in child
care and nappy changing is just one of them. However, lifting a child after
nappy changing is the most frequent, repetitive task that engages the use of
purpose built furniture (National Childbirth Trust (NCT), 2004) and provides an
opportunity for research that is both observable and measurable. Hence, in this
thesis we are reviewing the lifting involved in nappy changing.
IDENTIFYING THE RISK
This literature review will explore three main ergonomic considerations that may
have influence on lower back injury in women in this lifting task. It will then
review the task of nappy changing, and then follow with a review of the
biomechanical variables of interest in relation to standing lifting postures.
Operator Characteristics
The ability to perform lifting work is affected by the anthropometry, strength,

age, and physical ability of an individual (Chaffin & Andersson, 1991; Kroemer
& Grandjean, 2001). In women though, the periodical increase in oestrogen
and relaxin may influence the strength of the musculoskeletal system
(Karageanes, 2005). These hormones have a softening effect on elastin and
collagen, increasing connective tissue laxity (Jang et al., 2008) altering the
structure and integrity of ligament tissues (Pheasant, 1988). Increased relaxin is
12
an influencing factor in the high rate of sport associated knee, ankle (Pheasant,
1988; Jang et al., 2008) and lower back joint injuries suffered by women as
opposed to men (Dragoo et al., 2003). Therefore, it is possible that some
women may have a heightened risk of work related musculoskeletal injury
during periods of elevated hormones (Dragoo et al., 2003).
Pregnant women
Ten percent of women in western countries between the ages of 25 to 35 will
be pregnant at any one time (Foti et al., 2000) with the average age for a first
pregnancy currently being 32.5 years (ABS, 2007). Approximately two thirds of
Australian women are employed during pregnancy (Sweden, 2001; Jang et al.,
2008). The physical changes in a pregnant woman’s body occurring from early
in the first trimester are vast and dynamic (Sweden, 2001; Jang et al., 2008). At
around 12 weeks gestation, the level of serum relaxin is most potent, having
increased ten fold from that before pregnancy (Wu et al., 2004; Jang et al.,
2008). At this time, connective tissues start softening (Wu et al., 2004) creating
separation, movement and laxity in spinal, lumbo-pelvic and the other core
stability ligaments and joints (Gutke et al., 2006).
From around 12 weeks gestation, the uterus expands anteriorly, laterally and
superiorly (Carlson et al., 2003), eventually increasing the abdominal depth by
20 cm or more (Ostgaard et al., 1994; Colliton, 1996; Kristiansson et al., 1996).
Through a singleton pregnancy, a woman’s weight will increase by around 16
kg (Perkins et al., 1998; Noren et al., 2002) with the majority of this being located
as a frontal mass (Sweden, 2001). As a result of the increased frontal load, the
centre of mass (CoM) shifts and may affect the pregnant woman’s balance
(Ostgaard et al., 1997; Wu et al., 2004). As her weight increases, so too does the
work load on her musculoskeletal system, increasing at the same time as the
load bearing capacity is decreasing (Perkins et al., 1998). Because of laxity in
core stabilisers, the spreading symphysis pubis and forwardly rotating pelvis, the
lumbar lordosis is disturbed and her ability to walk and stand with ease are also
increasingly challenged (Karageanes, 2005).
Frequently coinciding with the early peaking of serum relaxin levels is the onset
of pregnancy related pelvic pain (Fast et al., 1987) and gestational lower back
pain (GLBP). LBP is often considered an inevitable consequence of pregnancy
(Nicholls & Grieve, 1992). However, LBP is a debilitating disorder experienced by
13
50–90 percent of pregnant women(Paul & Frings-Dresen, 1994) and is their most
frequent cause of sick leave (OHCOW, 2008). Compared to the expected rate
of 20–25 percent in non-pregnant women of the same age (OHCOW, 2008)
back pain during pregnancy is not trivial (Schytt et al., 2008) and for some
women may be the beginning of life long chronic back pain (McGovan et al.,
2007).
There are many possible contributing factors to GLBP; biomechanical changes,

muscle fatigue, radiated pain and ligament laxity are all potential contributors
(Kristiansson et al., 1996; Sweden, 2001; Sloane, 2002; Qu et al., 2006).
Additionally, multiparae women and those who have experienced LBD prior to
pregnancy are more likely than not, to suffer from GLBP (Liu et al., 2002; Sloane,
2002). The significant point is that women are pre-disposed to LBP during
pregnancy and from around 12–18 weeks gestation, this condition can be
severe and debilitating (Ostgaard et al., 1997; Karageanes, 2005; Gutke et al.,
2006).
A woman in advanced pregnancy is considered anthropometrically extreme

(Pheasant, 1988; Paul et al., 1994). The new physical shape restricts her ability to
perform tasks that require reaching, lifting, bending and twisting, and these
limitations classify her as disabled (Liu et al., 2002; Sloane, 2002). In a study of
200 pregnant women, (Ostgaard & Andersson, 1992; Ostgaard et al., 1997)
identified 48 common domestic duties that they regularly engage in. The task
of lifting items from floor level was rated by 98% of participants as extremely
difficult, but amongst the most strenuous were those tasks that required
standing and reaching postures, including ironing and washing dishes. A more
complex study by (Mast, 1999) reviewed standing work postures in a group of
27 women in their third trimester of pregnancy compared with non-pregnant
women. Three table heights were imposed; waist height (the apex of the
abdomen); a height set in accordance with Dutch ergonomic guidelines
(approximately 90 cm); and a self-selected table height (average 13.8 cm
under the apex of the abdomen). The women were required to engage in a
variety of six task positions, the most frequently encountered in their workplace.
The postural differences between participants demonstrated that the pregnant
women stood with their feet further from the table edge; the calf angles were
smaller as a result of a backward lean; the trunk was flexed more (with
14
pregnant women also keeping their abdomen away from the edge of the
table) with hips being in a more backward position; the upper arms and
forearms were more raised and extended. Furthermore, the self selected height
chosen by the pregnant women, although being the lowest of the three
heights, allowed them to stand closer to the table in a more upright position
and with their arms more relaxed, resulting in the least postural difference
between the pregnant and non-pregnant women.
Having made similar observations in regard to the postural consequences for

pregnant women in standing bench work, Nicholls and Grieve (1992) pointed
out that lifting any load from a flexed; reaching posture may substantially
increase the torque about the lumbo-sacral joint. Although increasing the
height of the bench would put operators into a more upright stance (Nicholls &
Grieve, 1992), this may impact on the muscle strength requirements to
complete the task. In ironing for example, Paul and Frings-Dresen, (1994)
suggested that raising the height of the work surface may restrict the subject’s
ability to exert downward pressure when performing the work. This point relates
to our study in that it is often necessary for a carer, standing at a change
bench, to apply a securing force to the baby with one hand while reaching to
access change items on a lower level.
Occupational Health Clinics for Ontario Workers, Ergonomics and Pregnancy

Policy (Boissonault & Blaschak, 1988; Kotarinos, 2003), makes the following
recommendations: women in the third trimester of pregnancy should not
perform jobs that require balance, lifting weights over 10 Kg, awkward postures,
high force, no rest or repetitive work. Workstations should be adjustable to
reduce any awkward postures and to accommodate the pregnant woman’s
body. Unfortunately, there appears to be very few published papers regarding
biomechanics of pregnant women. Equally, no publication has been found
that mentions MH restrictions in the first or second term of pregnancy. The
concerns here perhaps are two fold: general OHS practices view the third
trimester as the time to limit physically strenuous work (Neumann & Gill, 2002);
pregnant women in domestic environments generally have no option but to
engage in MH work throughout their pregnancy.
15
Post partum women
The physical strain associated with birth is often extreme (Richardson et al.,
2002) and traumas associated with parturition frequently include: episiotomy
repair weakened pelvic floor, general body pain, back pain and fatigue
(Neumann & Gill, 2002). Prior to the mid 1960s, it was common for a woman to
recover in hospital for 10 days following the birth of a baby (Wijma et al., 2001;
Neumann & Gill, 2002). However, the average hospital stay following an
uncomplicated vaginal delivery is now 12–48 hours (Carriere & Feldt, 2006). Also
around 35 percent of births are through caesarean section, from which the
recovery is reportedly longer and more complex (Qu et al., 2006), nevertheless
the hospital recovery time for these women is three to five days (Sloane, 2002).
Upon leaving hospital most women will be released into home care to
complete their recovery.
Many women can suffer the physical side effects of pregnancy and child birth
for 12 months or more (McGill, 1997; Kroemer & Grandjean, 2001). Around 40%
of women will continue to experience back pain for at least three months
following delivery (McGovan et al., 2007), with the greatest predictor of
postpartum back pain being the occurrence of GLBP (Pheasant, 1988; Chaffin,
2005). A prospective follow up study by Noren et al. (2002) reviewed 800
postpartum women and showed that 20% of those who had GLBP continued to
experience moderate to severe LBP symptoms three years on from parturition.
However, an explanation for the long duration and severity of postpartum LBD
remains elusive.
Some injuries resulting from pregnancy or the birth can linger for years, often
requiring surgical repair to assist recovery (Fathallah et al., 1998). The most
common of these are diastasis rectus (Mital et al., 1997), pelvic floor
insufficiency and prolapse (Mast, 1999; Waters et al., 1993) and lower back
disorders (Davis & Marras, 2005). Boisannault and Blaschak (1988) reported that
36% of women don’t spontaneously reduce during the postpartum period and
subsequent prevailing abdominal muscle separations can vary from one to
several centimetres. In cases of obese women, multiparas women or those with
multiple birth pregnancies, the separation can extend from the umbilicus down
to the pubis (Kotarinos, 2003). As a result the rectus sheath can diverge enough
to allow the herniation of abdominal contents to occur (Kotarinos, 2003).
16
The functioning of the abdominal wall in relation to posture, trunk stability and
movement is well established (Waters et al., 1994). As the transverse
abdominals and oblique muscles are recruited with pelvic floor contractions, a
weakened abdominal wall also augments pelvic floor weakness (Davis &
Stubbs, 1977; Sapsford & Hodges, 2001). About 60% of postpartum women
experience pelvic floor weaknesses and 30% of all women will develop chronic
disabilities associated with pelvic floor insufficiency (Pheasant, 1988; Eveleth &
Tanner, 1990). There appears to be a relationship between pelvic floor pain
and LBP (Kramer et al., 2002) and it is possible that pelvic floor weakness may
facilitate instability of the lumbar spine, but there is no apparent study on this
topic. Richardson et al. (2002) researched the relationship between abdominal
strength, LBP and sacroiliac joint mechanics. She suggested the contraction of
transversus abdominis increased stability of the sacroiliac joints more than the
activation of all the lateral abdominals, potentially alleviating pain during lifting
work.
Postpartum women are advised that the body will take between three to six
months to recover (Sweden, 2001; NCT, 2004), and weight bearing activity
should be kept to a minimum for the first eight weeks (NCT, 2004). Following a
short hospital stay, 50% of women will return to households to care for at least
one child less than two years of age, as well as the new born. It is likely that
these women will be involved in tasks that necessitate the lifting and lowering
of young children and the interaction with purpose built furniture. Sanders &
Morse, (2005) noted that there is a high risk of mothers developing MSD as a
result of child care work.
Difficult Loads
When assessing loads for task management the dimensions, weight, CoM and
coupling of the item need to be taken into account (Moorhead, 2005). Loads
of greater than 10 kg are generally considered heavy (NCHS, 2000) but
perhaps one of the more significant factors in relation to handling is the inertial
qualities of a load (HealthWest, 2000). Ergonomically, the CoM should be
located near the centre of a load (Kroemer & Grandjean, 2001) and it should
be stable. Unpredictable and unexpected inertial characteristics should be
avoided (Pheasant, 1988; ACA, 2004).
17
According to the American National Institute for Occupational Safety and
Health (NIOSH) (INPAA, 1998.), the maximum recommended weight for a single
lift in optimum conditions, is 23 kg. In reality this figure is an overestimate and
the application in a work environment is very limited (OHCOW, 2008). However,
the NIOSH lifting equation (1993) in which the recommended weight limit for a
given task is calculated, has been adopted into occupational ergonomics as
the standard for evaluating load limits in various lifting scenarios (ACA, 2004;
NCT, 2004). The lifting equation takes into account the coupling as well as the
horizontal and vertical location of the load at origin. It also considers the
duration of the task, the frequency of the lift and the symmetry of the posture
(Waters, Putz-Anderson et al., 1994). Unfortunately, the NIOSH lifting equation
(1993) cannot be applied if the task involves one handed lifting, restricted
workspace, unstable loads, pulling the load before lifting or awkward postures
(Chaffin & Andersson, 1991). According to Chaffin and Andersson, (1991) and
Jorgensen et al. (2005), the maximal acceptable load for healthy women
under 50 years of age, in optimum lifting posture is 18 kg. However, guidelines
for maximal acceptable weights in lifting are useful in the sense that the limit
provides an indication of safe limits in optimum conditions, and therefore the
limits make obvious where load weights should be reduced for conditions that
are less than optimum (Pheasant, 1988). Applying these guidelines though to
animate or “live” loads is theoretically accounted for, but in reality perhaps not
so easy, particularly in the case of young children.
Growth in young children is complex and rapid and in order to understand the
implications for managing a child as a MH load, it is fundamental to be aware
of the behavioural as well as the physical changes in their development
(Bogduk & Endres, 2005). Growth and development rates in children are not
universal (Dempsey, 1998) therefore, references regarding child growth are
reflective of population averages. During the first year, growth is more
advanced in proximo-distal direction and from the midline to extremities, with
the region of greatest mass being located within the torso and head
(Pheasant, 1988). By the time a child is two years old it will have a body 10% the
size of its adult potential (Pheasant, 1988).
The following (Table 2.1) is a compilation of the average expected somatic

growth, measurements and developmental stages of a young child. The
18
information provided is drawn from Pheasant (1988); NIOSH (1981); the United
States National Centre of Health Statistics revised data, collected between
1988 to 1994 by the Growth Chart Working Group; Bogduk and Endres, (2005);
and the Health West Child Health Record (2000).
Table 2.1 The Average Expected Somatic Growth Measures for Children New Born to 24 Months.
Infant Health Growth Chart Measures
Baby Age Head Weight Crown to Heal

Circumference (cm) (kg) Length (cm)
Neonate 36 to 40 3.5 to 6.0 50 to 57

(first four weeks)
One to three months 38 to 44 4.5 to 7.5 55 to 66
Three to six months 41 to 47 6.0 to 10.0 60 to 73
Six to 12 months 43 to 50 7.5 to 12.5 66 to 82
12 to 24 months 46 to 52 10.0 to 18.0 75 to 95
During the first two years the child also develops movement skills that
commence as rudimentary involuntary reflexes. A neonate can be a
surprisingly lively and spontaneous with an array of reflexes including a walking
reflex; startle reflex; tonic-labyrinthine reflex, in which the baby will try to lift its
head when placed in a prone or supine position; and a palmer grasp so strong
that it can lift its own body weight. From around six to eight weeks the cylinder
shaped baby load will start rolling movements. By six months the child can
move into crawling position and the lumbar curvature is developing shape and
strength. From 6 to 12 months the child is sitting and pulling to a stand position;
is becoming independently mobile (crawling) to a point of learning to walk;
and develops from reaching to grasping objects with fine motor skills. From 18
to 24 months physical development is slowing but motor and cognitive abilities
are rapidly developing. These children are top heavy, 11 to 18 kg in weight
with a body length of up to a metre long.
19
Because of the pattern of body growth in the first two years, the CoM in the
baby load remains high in the torso. The implication for the task of lifting from a
change table surface is that as the baby is growing, the CoM of the load is
becoming more distal to the operator. This is further complicated by the
behavioural characteristics of the baby load, which at 12 months is mobile and
unpredictable, socially interactive, increasingly independent, thinking
strategically, behaviourally demanding and has no concept of danger (NCT
2004).
Equipment
In a work situation specifically designed for standing bench work, good

ergonomic design (NIOSH, 1991; Kroemer & Grandjean, 2001) would be
considerate of:
 the operator maintaining an upright trunk posture.
 the work surface height being relative to the task.
 the available horizontal foot space.
 the available horizontal knee space.
 reach and access to other levels.
 allowable symmetry of operator posture.
 available space for operator to move in.
Anecdotal information suggests that purpose built change bench furniture, is

the most frequently used equipment in paediatric and formal child care work
places. It is a mandatory requirement in all commercial locations (AS1428.1/
Australian Building Codes Board) and recommended by consumer advice
authorities as a necessity in the domestic environment (Dolan et al., 1994).
Information regarding change bench furniture for this review has come from
popular press sources; the European Standard EN 12221-1:1999 Changing units
for domestic use Part 1: Safety requirements (2000); and anecdotal advice and
experience.
Domestic furniture
Over the past 30 years, change furniture has becoming more elaborate, more
available and according the Infant and Nursery Products Association of
Australia Incorporated (McGill et al., 1998; Mital, 1999) designed to improve
child safety, versatility and aesthetic appeal. Domestic change units are
20
available in various designs, but in general, all provide a baby change surface
space with width of 380–550 mm and length of 650 –750 mm (EN 12221-2, 1999);
the working change surface height is generally 800–950 mm from the ground;
the surface provides enough space for the baby only and accessory change
items are usually positioned for access somewhere other than the change
surface. Change furniture should be made from either wood, plastic or metal or
a combination of these materials (EN 12221-2, 1999). The popular purpose built
change furniture designs include the following.
 2/3 Tier change table (Figure 2.1)

As the name suggests, this trolley framed furniture has one or two shelves
beneath the top work surface. The lower shelves are designed to store change
items within easy reach however, the operator will be reaching, usually with
one hand, to a level lower than work height in order to access these items. The
unit may or may not be on caster wheels, but will generally have space for the
operators’ feet underneath the bottom shelf.
Figure 2.1. 2/3 Tier change table (picture from Glenhuntly Baby
Carriages retail catalogue, Melbourne, Australia. 2005).
21
 Bath and change table unit (Figure 2.2)
This has a similar construction and user functionality as the 2/3 tier unit, but
usually with the padded change surface hinged on one long side. Underneath
the baby bath are generally one or two shelves or drawers.
Figure 2.2. Bath and change table (picture from Glenhuntly Baby Carriages retail
catalogue, Melbourne, Australia. 2005).
 Fold out frame and sling (Figure 2.3)
This consists of a sling of textile across a collapsible “A” frame. The sling has a
natural dip like a hammock. The frame legs spread, opening the area of the
change surface and allowing the operator to move their feet and body close
to the work area. The hammock provides a natural resistance to baby sitting up
or rolling over and out. A low level shelf may or may not be provided for
accessory change items. Foot space is available, but knee and leg space may
be inhibited.
22
Figure 2.3. Fold out frame and sling (picture from Glenhuntly Baby Carriages
retail catalogue, Melbourne, Australia. 2005).
.
 Drawer top changer (Figure 2.4)
This is either a rectangular shallow box with padded change mat insert that sits
on top of a set of drawers or a semi enclosed area on top of a set of drawers.
The height of this surface is generally dependent on the height of the drawer
set. Usually this change situation does not allow for knee space, the operators’
feet may not fit under the drawer unit and there is no obvious location for
accessory change items. The operator is positioned either along side the baby
load or symmetric to the baby load with movement usually confined by the
wall barrier.
Figure 2.4. Drawer top changer or changing chest (picture from Glenhuntly Baby
Carriages retail catalogue, Melbourne, Australia. 2005).
23
 Cot top changer (Figure 2.5)
This is a firm rectangular change board surface designed to fit over the rails of a
standard cot. The height of this surface is dependent on the height of the cot
sides. The operator can generally fit the feet under the cot, but the dropped
side of the cot inhibits knee space. No obvious easy access to change items
exists.
Figure 2.5. Cot top changer or changing board (picture from Glenhuntly Baby Carriages
retail catalogue, Melbourne, Australia. 2005).
Commercial and public change facility furniture

It is a mandatory requirement for public locations and commercial and
buildings in Australia to have adequate parent and baby change facilities
available (AS1428.1/ Australian Building Codes Board). Of the locations that
have facilities for changing baby, according to sales figures from Baby
Changers (2006), approximately 80% provide a drop down suspended bench
top (Figure 2.6). The drop down bench will be mounted on the wall either
horizontal or perpendicular to the wall. With the majority of these units, the
change surface provides enough space for the baby only (no standardised
dimensions or work surface height available) and accessory change items must
be positioned for access somewhere other than the change surface. Some
nappy change stations consist of a built-in counter top surface and others
consist of domestic furniture. Generally the work surface height for the drop
down units is a standard 800–850 mm from the ground.
24
Figure 2.6. Drop down suspended bench top perpendicular or horizontal to the wall (picture from
Janitorial Direct trade catalogue, U.K. 2006).
Child care and paediatric furniture

Nappy change stations within these work locations are not standardised and
vary according to facilities available in each work place. In the paediatric
health care environment, babies and young children are changed either in
their bed, cot or bassinet, or on a work bench surface which may not allow for
horizontal knee and foot space. In formal child care environments sanitation,
safety and supervision are key criteria (Dolan & Adams, 1993) for the design
and location of nappy change furniture. Child care occupational health and
safety guidelines usually include comments on the height of the nappy change
surface, suggesting it be at a height that will minimize back injury (Aronson,
1999), but no mention of knee or foot placement or lift symmetry have been
observed in the available literature.
Safety and design standards

The only design standards available for nappy change furniture are the
European Standard EN 12221-1:1999 Changing units for domestic use – safety
requirements and EN 12221-2:1999 Changing units for domestic use – test
methods. These standards are bound by CEN/CENELEC Internal Regulation
(1998) to be implemented by the countries of the European Union and have
been adopted and published in Britain as the British Standards.
25
The scope of Changing Units specifies safety requirements for all types of
changing units for children with a body weight of up to 15 kg. The Standard
specifies minimum change surface dimensions for 12 month and 36 month old
children; it defines a variety of change unit types and provides design
recommendations for child safety such as child roll barriers, restrictions to child
body part access and the assembly, strength, stability and general design of
the change furniture. The final section of the Standard provides instructions for
use in which the warning: “Do Not Leave the Child Unattended” must be
included, as well as the requirement of “information concerning the adequate
height of the unit” (BS 12221-1:2000, 2000. p14). However, there is no
recommendation for the working height of a change unit. In relation to working
height, the regular advice is when changing a baby’s nappy on a change
bench use a bench that is waist height (Wortman, 2003; King et al., 2006).
In Australia, there are currently 25 organisations involved in the revision process

of design standards for nursery equipment. These organisations include: Infant
and Nursery Products Association of Australia Incorporated (INPAA), The
Children’s Hospital of Westmead, Consumers Federation of Australia, Australian
Chamber of Commerce and Industry and the National Council of Women of
Australia. Additionally, consumer occupational safety and health information in
relation to the purchase and use of domestic equipment is scant. The INPAA
advises that, “the onus is on the consumer to make sure that the change
bench furniture they buy for their children is safe, and that invariably means
buying a premium product” (Nursery Furniture – How safe is it? INPAA, 1998. p5).
It is clear though that the focus of equipment specification is on child safety
and not the safety of the operator.
Occupational Health and Safety Issues
Popular press articles (Marras et al., 1998) that instruct on nappy changing
often refer to choosing furniture that is “waist height”, and that which allows
change items to be “kept within reach to avoid unnecessary twisting and
turning” (Birthnet:birth.com.au.,p3). Published advise also suggests that
operators avoid leaning over and over – reaching when changing a nappy,
and for new mothers the advice includes having someone else lift heavy
objects (NCT, 2004; Raising Children Network, 2006; Birthnet:birth.com.au). In
26
contrast to this advice however, the most common change furniture styles
available for domestic and public use (Figures 2.1–2.6), require operators to
flex, reach, twist, turn and sustain awkward postures whilst carrying out the
nappy change task.
Furthermore, even though it is a mandatory requirement for change furniture to

be available in public and commercial locations in Australia (AS1428.1/
Australian Building Codes Board), there is no Standard for the design of the
furniture. Neither is there a Standard for change benches being used in day
care centres or hospitals or any other location. Currently in Australia there is no
national, independent nursery equipment safety framework and there is no
occupational health and safety guideline for the use of change furniture by
adults working with young children. In relation to the MH work performed by
child care workers, there are no relative occupational guidelines for task
design, the handling of live loads, or equipment design (Gratz & Claffey, 1996;
Bright & Calabro, 1999; King et al., 2006). It is relevant that consideration should
be for the safety of the child, but there is nothing that indicates consideration
for the safety of the operator.
Task of Nappy Changing
The following instructional diagram (Figure 2.7), is an extract from a popular

child care education internet site (abc.net.au/articles/babies_dailycare.htm), it
has been included in this review to demonstrate a typical information
publication for parents. The nappy change task sequence commences with a
pre-change lift then lowering of the child to the change surface. Then follows
the nappy change during which time the operator may be required to hold
the child down with one hand, and perhaps reach asymmetrically to a lower
level in order to access change items. After completing the change, the child is
finally lifted from the change surface and carried or lowered again. An infant
child will require nappy changing between eight to12 times a day; a young
toddler 12 to 24 months, will require changing 6 to 8 times a day and an older
toddler of 24 to 36 months will require changing 4 to 6 times per day (NCT,
2004). There is no information regarding the duration of this task however,
popular press publications make regular mention that as a child gets older, the
task can become more complicated.
27
In formal child care, the number of children per carer varies, but the Australian
Child Care Centre Licence (CCCI 46-05D, 2004) allows for eight children under
the age of two per carer. And for those over 2 years, one carer can be
responsible for up to 16 children (CCCI 46-05D, 2004). Anecdotal information
from child care workers in Western Australia suggests though, that nappy
changing of toddlers is attended to every 3 to 4 hours with one carer often
changing nappies consecutively on 20 children.
28
Set-up and strip off
Before you change a nappy, make sure you have everything you need within arm's reach of the
change area. This includes: a fresh nappy, baby wipes and baby cream. Lie baby down on the
change table. If she grizzles, sing her a song or give her a favourite toy to keep her entertained.
Undress baby's bottom half and unfasten the nappy. Use the front of the nappy to wipe off any
poo, then fold the nappy into a tight bundle before putting it in a plastic bag.
Cleanse and apply cream
Gently cleanse baby's bottom using baby wipes. Make sure you get into the crevices but avoid
separating a baby girl's labia to 'clean inside'. Likewise, a boy's foreskin should never be
pushed back. To wipe the back of baby's bottom, hold her by the legs with your fingers between
her ankles and gently lift so her bottom comes slightly off the change table. Wiping girls front to
back will help avoid vaginal infections. Apply a dollop of baby cream to prevent against nappy
rash.
Applying the new nappy
Open a clean nappy, making sure the fastening tabs are towards the top. Lift baby up by the
ankles and slip the nappy beneath her bottom. Fold the front flap up, tuck it firmly around
baby's waist and secure each tab. Once you've dressed baby, secure her in a bouncer or cot and
dispose of the nappy. Wash your hands before touching baby's hands or face. Remember: never
leave a baby unattended on a change table. They can squirm or roll off in seconds. If you have
to take your eyes off baby, keep your hands on.
Figure 2.7. Instructions for nappy changing (ref: web site abc.net.au/articles/babies
_dailycare.htm).
29
ASSESSING THE RISK
We know the spinal column carries the weight of the trunk and upper body
and in neutral stance; forces are cushioned uniformly within intervertebral (IV)
joint structures. Moving into a non-neutral stance, changes in body weight
distribution, or lifting a load destabilises the force through the lumbar spine
(Dolan & Adams, 1993; Delleman et al., 2004; Genaidy et al., 2006) It is an
individual’s capacity to manage the variations of force in the lumbar spine
which influences the process of LBD or injury (McGill et al., 1998). We have
reviewed the task of nappy changing and identified characteristics of each of
the three main variables; the operators, the loads and the equipment. Clearly
there are elements in each of these variables that make the task of nappy
changing difficult and an injury risk. A biomechanical assessment is one way of
measuring the risk from lifting (Kingma et al., 2006) following the task of nappy
changing.
The Biomechanics of Standing Lifts: Implications for LBI
Lifting frequently engages the whole body, but it is the upper body that
manipulates the load. The lumbar spine is the region of greatest mobility yet it
sustains the largest forces under loading (Chaffin & Andersson, 1991; Jorgensen
et al., 2005). The biomechanical outcome measures most familiar to risk
assessment in lifting are compression force (CF), shear forces (SF) and spinal
ligament tension (Dempsey, 1998). Measuring these parameters provides an
indication of mechanical stress on the vertebral column at a moment in time.
Compression and shear force

The standard benchmark analysis of injury risk from lifting was originally
prescribed by (McGill et al., 1998) based on the measurement of lumbar spine
CF in a static, symmetric lift observed in the sagittal plane (McGill, 1986,
Fathallah et al., 1998). This method estimates CF on an IV segment at one
moment in time with magnitude of the load and angle of torso flexion being
the significant contributors (Fathallah et al., 1998; Gallagher et al., 2005). The
magnitude of CF relates to the degree of injury risk for a healthy adult
population, of that particular loading or lift in that particular posture.
30
The NIOSH Lifting Equation (1981) was created using three critical
biomechanical outcome conditions:
 The joint between vertebra L5 and S1 experiences the greatest lumbar
stress during lifting.
 CF at this IV level is the significant strain vector.
 CF criterion that defines the threshold of acceptable compression limits
is 3400 N (NIOSH, 1981), which indicates safe lifting for 75% of healthy
females engaged in occasional lifting tasks; and upper threshold for
compression force is 6400 N being LBI hazard to the majority of healthy
population (Waters, 1993).
However the reality is that lifting is a combined sequence of torso motion during
loading which is frequently performed without symmetry (Dolan et al., 1994).
Due to the recruitment of additional torso muscles, the predicted spinal
compression force from asymmetric lifting is between 13 to 30 percent higher
than when a load is lifted in symmetry (Dolan & Adams, 1993). So to
compensate for this, the back compression design limit for L5/S1 in asymmetric
lifting is reduced by 20 percent to 2700 N (NIOSH, 1994). Furthermore,
quantifying spinal loads requires measuring SF and ligament strain to more
accurately assess lower back injury risk (McGill, Norman et al. 1998; Fathallah et
al., 1998). Understanding the contribution of SF on lower back injury is
imperative to successfully minimise the risk of LBD associated with lifting
(Cholewicki & VanVliet, 2002).
SF is the outcome of torsion created across an IV joint as a result of IV ligament

and muscle strains and is generally measured based on the direction of the
force. SF is affected by the directional changes in motion as well as the rate of
loading (Gardner et al., 1975) that is spinal rotation and lateral bending in
asymmetric postures and the interrelationship of these with torso
flexion/extension movements (Butler et al., 2007). For example, comparing
lifting of light weights in symmetric and asymmetric postures, CF and anterior SF
outcomes are similar. However, Fathallah et al. (1998) found that the SF in
asymmetric lifting is substantially elevated if the rate of loading is increased. The
greatest effect on lateral SF is produced when both the weight of the load and
the loading rate are increased, which can result in extreme levels of SF. In
addition, the sequencing of loading and motion heightens the risk of SF injury, in
31
that shear effects from lifting will be augmented by pulling a load prior to lifting
it (Anderson et al., 1985). McGill et al. (1998) have also pointed out that lumbar
lordosis is an important element in the manageability of SF during MH work. The
natural spinal curvature controls tension on the obliquely oriented interspinous
ligaments, which minimizes anterior/posterior SF (Dragoo et al., 2003). This is
perhaps relevant to those people who may have some perturbation to their
natural lumbar lordosis as can be the case with pregnant or post partum
women. (McGill et al., 1998) found that force which pulls the trunk forward
results in flattening of the lumbar lordosis. This posture increased the shear force
measured at L5/S1 joint significantly. However, the aetiology and ultimate load
tolerance thresholds for SF remain uncertain (Fathallah et al., 1998), and much
of what has been researched has been done through using cadaver material
(McGill & Brown, 1992). As such, research has not yet been able to clearly
define the effects of repetitive or prolonged SF on the tolerance of spinal tissues
to shear (Friden et al., 2005). Nevertheless, there is evidence that in postures
where CF may not aggravate LBD, paradoxically SF may well do so (Kroemer,
1997).
To quantify SF risk, McGill et al., (1998) proposed a Maximal Permissible Limit

(MPL) of 1000 N of lumbar spine SF for single exertions and an Action Limit (AL)
of 500 N. They suggested that the MPL be one third of the maximum tolerance
threshold and the AL be half of the MPL. Several authors report that the risk of
LBD from SF incurred during MH work, can be minimized by: maintaining lordosis
in flexed lifting postures; avoiding excessive pulling actions; avoiding loaded
lateral bending; avoiding asymmetric simultaneous handling actions; and by
rotating the trunk about the hips rather than the lumbar spine (Davis & Marras,
2005).
Ligament strain
Ligaments are tensile collagen structures, but under prolonged static or
repetitive loading and lifting strains, ligaments can become lax reducing the
joint structure strength they are designed to maintain (Marras et al., 2004). The
spinal vertebra and IV segments are interconnected and bound by 14 main
spinal ligaments that together with muscle function to provide structural stability
to the spine (Bogduk & Endres, 2005). The lumbo-dorsal fascia contains both
longitudinal and transverse fibres, connecting and binding the extensor
32
muscles of the vertebral column separating them from the muscles connecting
the vertebral column to the upper extremities (Kroemer & Grandjean, 2001;
Davis & Marras, 2005). Loose ligaments in the lumbar spine are often thought to
be the cause of recurring dysfunction in an IV joint (Fathallah et al., 1998).
Together with loose ligaments in the pelvis, these may lead to an inability to
maintain a posture for any prolonged period of time (Butler, Hybley-Kozey et al.
2007). This could be relevant for some women in standing lifting work that is
preceded with a period of torso flexion.
This study uses ligament strain on the lumbo-dorsal fascia at L5/S1 to provide a
comprehensive understanding of LBI hazards associated with lifting. Anderson
et al., (1985) reported the observed elastic limit for the lumbar dorsal fascia to
be 30%, indicating a heightened risk of injury if L5/S1 ligament strain exceeds
this amount (Anderson et al., 1985; Anderson et al., 1985). However, the limit of
elasticity of ligaments in the knee joint varies with cruciate ligaments 20–30%
and lateral ligaments 11% (Gallagher et al., 2005; Butler et al., 2007), hence it is
possible that ligament strain injuries in the lower back may be influenced by
varying thresholds of elasticity. Stretched ligaments increase the risk of injury
through instability of the joint potentially allowing increased shearing and
hyperflexion (McGill & Brown, 1992). It is also possible that female hormones
may relax the ligaments in the back, thereby increasing the injury risk
associated with joint laxity (Bogduk & Endres, 2005). In neutral stance ligament
strain is zero, therefore the greatest biomechanical influence on lumbo-dorsal
ligament strain will be from trunk flexion (Bonato et al., 2003).
Posture, Strength and Lifting
The concept of MH work conjures thoughts of the strength required to

complete a task. Whilst muscle strength can be quantified in a static moment,
strength capability is not necessarily a fixed or transferable outcome (Chaffin &
Andersson, 1991). Available strength in any given scenario is dependant on a
range of influencing factors. From the mechanical point of view; characteristics
of the load, the engaged posture, lifting patterns and the rate, frequency and
duration of lifting can undermine available strength (Fathallah et al., 1998;
(Friden et al., 2005)
33
Load considerations
The closer the CoM of the load is to the lifter, the more easily it will be
counterbalanced by the lifter’s body, hence less likely to get out of control
(Pheasant, 1988; Kroemer & Grandjean, 2001). Also, larger forces can be
generated if the lifter’s body can be braced against a supportive object, for
instance bracing could enhance the available strength when lifting heavy
loads from a table surface (Delleman et al., 2004). The ability to bring the load
closer to the body is largely reliant on foot placement. That is, getting the feet
beneath or close to the vertical plane of the CoM of the load reduces the
reach of the lifter (Shirazi-Adl, 1991). Chaffin (2005) reported that the
moment/torque about the L5/S1 joint is directly related to the horizontal
distance from the operator’s feet to the load being lifted. When comparing CF
between LBD symptomatic and non-symptomatic people performing standing
lifting tasks, (Dolan & Adams, 1998) concluded that load origins closest to the
body resulted in the least difference between the two groups. Furthermore, if
the load is “heavy” (≥ 10kg) and is situated further than 30 cm from the lifter’s
mid-line, even table surface symmetrical lifting will result in CF greater than the
NIOSH BCDL (Chaffin, 2005).
Biomechanically, the least stressful position for lifting heavy loads is near waist
height (NIOSH, 1994), approximately 900 mm for the average woman and 1000
mm for the average man (Chaffin, 2005). In standing work activities, the height
of the work surface is the major determinant of the operator’s posture. When
the working level is too high, fatigue in the shoulder and upper back can
occur, but if this is too low, the head, neck and trunk will incline forward
causing stress to the lower back (Parrakkat et al., 2007).
Flexed postures
Lifting a load from a bench is often commenced with the torso in a flexed
position. The torso movement into a flexed position is initiated and supported
by contraction of the abdominal muscles and controlled primarily, by
eccentric work of the erector spinae group (Bonato et al., 2003). Pheasant
(1988) pointed out that the long erector spinae muscles are important in
supporting the weight of the upper body if the trunk is inclined forward. In
addition, if the lifter uses a straight leg stance, the degree of torso flexion will
34
increase markedly (Marras et al., 1995). Assuming that the operator maintains a
flexed posture (for some period of time) prior to lifting, isometric contractions of
already lengthened spinal muscles hold the trunk in the flexed position
(Cholewicki & Van Vliet, 2002; Bogduk & Endres, 2005) with support from
abdominal, gluteal and hamstring muscles to stabilise the body (Chaffin &
Andersson, 1991). Lifting from a forward flexed trunk posture, results in the
vertebral column supporting the weight of the upper body as well as the
weight of the load through the extension phase (Chaffin & Andersson, 1991).
Extension requires support from the abdominals through synchronised muscle
contractions initiated by the gluteus and hamstring muscles as well as the
erector spinae, which then continue to pull the trunk into upright position
(Bogduk & Endres, 2005). Lifting a load in torso flexion as opposed to an upright
stance will affect the magnitude of loading, load rate and loading path within
the lumbo-sacral spine which may impact the development of fatigue in spinal
muscles (Marras et al., 2004). Furthermore, fatigue from lifting in flexion is
dramatically increased with the angle of flexion. Gallagher et al. (2005) showed
that lifting 9 kg at 22.5 degrees of flexion increases muscle fatigue by 125% from
that of upright stance; and lifting 9 kg at 45% flexion increases muscle fatigue
twenty fold.
Static flexed postures

Held, static flexed postures can cause the vertebral joint tissues to stretch or
“creep” beyond the normal limit (Marras et al., 1995). The stretch applied to the
spinal ligaments, causes joint laxity followed by a period of destabilisation in
structures of the lumbar spine (McGill & Brown, 1992). If lifting is performed
during the torso extension phase, or the recovery period, the destabilised
vertebral joint structures are clearly subject to heightened risk of injury (McGill &
Brown, 1992). Creep is reportedly worse in the morning, presumably after the
body has relaxed in supine position during sleep. It is also possible that “micro-
failure” in filaments of connecting muscle and ligaments occurs during creep,
augmenting the laxity of the IV joints (Lariviere et al., 2002). Dolan and Adams
(1998) reported that micro-damage accumulates in the annulus fibrosis at
loads above 45% of its maximal tensile strength. Furthermore the residual joint
laxity is reported to remain for periods of 30 minutes or more after the torso
regains upright position (McGill & Brown, 1992).
35
The risk of injury may also be greater in people with “stiff backs” who habitually
apply higher than average bending stresses to their lumbar spine during
forward bending activities (Dolan & Adams, 1998). It is the eccentric muscle
work that is most strongly associated with prolonged or delayed muscle fatigue
and soreness (Granata & Marras, 1999) and periods of static contraction also
influence localised muscle fatigue by reducing the amount of oxygen
available to the working muscle (Dolan & Adams,1998).
Awkward or combined postures and lifting patterns

Mixed MH activities, requiring dynamic motion postures, are far more common
in the work place than single, symmetric lifting tasks (Gallagher, 2004).
Abundant evidence exists for the relationship between LBD and combined or
awkward postures in MH work, yet relatively little is known of the biomechanical
implications. Fathallah et al. (1998) suggested simply, that the mechanics of
failure under different loading conditions will be different. Nevertheless,
combining torso flexion and rotation or lateral bending or flexing to reach a
lower work level following static flexion, are common movement patterns
associated with hazardous eccentric muscle work (NIOSH, 1994; ASCC1, 2007).
(Nicholson, 1989; ASCC2, 2007) demonstrated that the strains on spinal disc
annulus fibres from the combination of torso flexion, lateral bending and
twisting, dramatically increased to levels that may exceed tissue tolerance
limits. Marras et al. (1998) compared the outcomes of twisting in upright position
with twisting in symmetric flexed posture and in asymmetric bent posture.
Although twisting in the upright position is supported by latissimus dorsi and the
abdominal oblique muscles, this was not the case in the flexed trunk positions.
Marras et al. (1998) found that twisting in flexed postures disengaged the
obliques and increased the activity of the erector spinae muscles. However, in
the asymmetric bending posture, twisting disengaged the obliques as well as
the latissimus dorsi, thereby further increasing the demand on erector spinae
muscles. Furthermore, in asymmetric lifting the lifter is subject to substantial
levels of simultaneously occurring CF and SF for a good portion of the lift
(Chaffin, 2005).
Effects of rate, frequency and duration of lifting

Both the frequency and duration of a lifting task are determined by the lifter’s
strength, the characteristics of the load and the postural position that is
36
adopted for the task (Fairbank & Pynsent, 2000). Fatigue is an obvious outcome
when any of these variables impact on the lifter’s available strength, and so the
cycle continues. Many studies have reviewed injury risk based on lifting weight
and the number of repetitions per hour (Chaffin & Andersson, 1991; Kroemer et
al., 1997; NIOSH 1997). Regardless of lifting frequency criteria, lifting strategies
and motion patterns can affect the outcome of localised muscle fatigue
(Kuczmarski, 2000). (NIOSH, 2004; ASCC2, 2007) also proposed that when
muscles are fatigued, a compensatory mechanism alters the biomechanics of
lifting motion, changing the patterns of force through the spine.
However, frequent and prolonged periods of combined movement lifting or

handling tasks, even with relatively light weights, can create a cumulative CF
effect, which may be a more important risk to LBD than performing the same
task with high repetitions. Genaidy et al. (2006) made similar observations of
significantly more LBD in workers involved in prolonged periods of combined
handling tasks, than those performing the same task repetitively (Genaidy et
al., 2006).
IMPLICATIONS
With regard to LBD, the weight of evidence suggests that reduced strength of
back extensor muscles in people with a history of LBP is a reliable predictor of
their recurrent or persistent LBP (Miller et al., 2006; ASCC1, 2007). Some back
injury patients are unable to recruit the transverse abdominals and multifidus to
effectively stabilise the spine prior to loaded movement (Griffin & Price, 2000;
Gratz et al., 2002; Sanders & Morse, 2005; King et al., 2006; Craig, 2007).
Evidence also suggests that if the abdominal muscles are weak, then the
vertebral column may be predisposed to injury from lifting (Griffin & Price, 2000).
Each of these theoretical outcomes is relevant to women working in domestic
and formal child care environments.
Women with unresolved LBD may have a reduced ability to perform lifting and
other MH tasks (Kuczmarski, 2000). They can become accustomed to their own
movement restrictions and in an effort to prevent re-injury and lessen
associated pain, may modify their movement pattern when lifting or handling
loads (Lariviere, Gagnon et al. 2002). A past history of LBD heightens the risk of
serious back injury particularly in times of fatigue, load stress and awkward or
37
sudden movements (Karwowski, 2005). Perhaps the greatest impact from LBD
apart from the re-injury (Chaffin & Andersson, 1991) is the potential for
developing chronic disease (Delleman et al., 2004) and from the ongoing cost
of long duration lost time work claims . As a result, developing chronic LBD is
usually considered to be a major disability and therefore costly in every sense.
Understanding the contributing factors influencing LBD is imperative to
managing and minimising the risk.
We have some understanding of how LBD can manifest from mechanical

perturbations. For example, poor task design can place unnecessary demands
and restrictions upon the body, and the size and shape of a worker is an
important consideration in ergonomic design. Furthermore, we have guidelines
directing a framework of acceptable limits for loads, work heights and task
design. However, these guidelines and practices are intended to meet the
“lowest common denominator” in a healthy population of adults and the
extremes outside that normal distribution are generally beyond primary
consideration (Kroemer & Grandjean, 2001). It is likely that pregnant and
postpartum women fall outside these extremes. As a result, designing tasks in a
way that meets their physical capabilities has perhaps been overlooked. To
date there has been no known investigation of this specific population, the
loads, the equipment or the mechanics of MH work involving the nappy
changing task.
In regard to lifting a child load from a change bench, the general

recommendation is to work at waist height, keep accessory change items
within reach, avoid awkward and sustained postures, and never leave a baby
unattended (Birthnet:birth.com.au., 2007. p3). We know that live loads behave
very differently to inanimate loads; they don’t meet any NIOSH guidelines and
handling them safely presents a variety of complex issues. We know too, that
some of the purpose built equipment used in lifting tasks with live baby loads
conflicts with fundamental ergonomic principals. Finally, it is also clear that
women working with young children are likely to have physical disabilities (as a
result of pregnancy and child birth) that significantly increase their risk of injury;
these women are frequently performing combination MH and repetitive lifting
tasks and those involved in occupational child care have unusually high rates
of LBD.
38
However, there are no specific empirical data on the biomechanical issues for
pregnant and postpartum women performing MH duties. We don’t know if
there are implications from repeated lifting of young children, nor do we know
the outcome of tasks involving this purpose built furniture. There exists little
information on the immediate and long term LBD implications for these women
and there are no OHS recommendations or guidelines for pregnant and
postpartum women or other operators in relation to nappy changing or any
other MH task involving young children. Hence the two studies were
undertaken.
The aims of Study One were to gather quantitative and quantitative

information:
 from experienced women in relation to the physical difficulty and LBP
associated with the nappy change task;
 on the task of nappy changing from which to build the test variables
for the biomechanical analysis in Study Two; and
 regarding a range of other lifting tasks involved in child care, in order
to provide a comparison perspective for the task of nappy changing.
The aims for Study Two were to:

 assess biomechanically the act of lifting a young child from the
surface of commonly used purpose built change furniture;
 assess biomechanically the postures involved in the task of nappy
changing when using common purpose built change furniture; and
 assess and quantify the spinal loadings and therefore, potential LBI
risk from the task of nappy changing when using common purpose
built change furniture.
39
CHAPTER THREE
METHODS
Two comprehensive and interrelated studies were undertaken to learn more

about the MH task of nappy changing and the potential outcomes for women.
The first study (Study One) was a survey designed to provide information from
the operators’ perspective regarding this task. The data were then used to
inform and direct the criteria for the second stage of the research. The second
study (Study Two) observed and measured the biomechanical outcomes of a
series of stance and lifting postures adopted during simulated nappy change
tasks by a group of 10 female participants.
STUDY ONE
The aim of this survey was to first clarify the perception of difficulty related to
posture and lifting in the nappy change task compared to other lifting
scenarios involving young children. The primary objective was then to quantify
the elements of the nappy change task and to evaluate the difficulties
experienced by carers when performing the task. Study One included
respondent perceptions of physical difficulty, and task-associated LBP/LBD. The
survey requested information on task frequency and duration, equipment, load
characteristics and operator handling procedures with which to create and
test the dependent variables for Study Two. One limitation of the questionnaire
is that the results are self-reported and provided by self-selected respondents.
Therefore, it is acknowledged that without examiner control, individual
responses may create potential for bias in the results.
Participants
The survey sample was delimited by gender, age and task experience. Self-
selected female respondents (n=411) aged 20+ y, who had been engaged
regularly in the task of changing nappies for a period of 3 months or longer
within the 18 months preceding the survey period, were recruited from the
Australian population. Respondents from the target population ranged in age:
under 25 y (n=11), 25–30 y (n=60), 31– 35 y (n=166), 36–40 y (n=131), over 40 y
40
(n=32), with 8.5% being pregnant and 56% post-partum (up to 12 months since
the birth of their last child) at the time of completing the questionnaire.
Survey Design
A small pilot study was undertaken prior to designing the final survey
questionnaire. The pilot questionnaire was distributed and collected, with the
support of several obstetrics practices, to women (n=35) from the target
population. Responses were collated and the master questionnaire was revised
in accordance with respondent feedback and the experience of analysing
pilot data.
The final questionnaire (Appendix B) was accompanied by a cover letter that

briefly informed respondents of the purpose of the research program, ethics
approval for the study (Appendix A), the contents of the questionnaire, the
date and method of returning the questionnaire and contact details for the
School in which the research was undertaken. Return of the completed survey
indicated consent to participate in this study. The questionnaire was designed
to elicit general information on MH tasks involved in caring for young children,
and the epidemiology of task-associated back pain in this population was also
of interest. The Oswestry Disability Index (ODI) self-response questionnaire has
been generally recommended as highly reliable and a valid tool for indicating
levels of pain and disability in people suffering lower back pain. The
questionnaire used the ODI as a style guide for wording the questions and the
scaled rating response. Questions specific to quantifying characteristics of the
nappy changing task were presented collectively within the first section of the
survey. The questionnaire was divided into three sections, as follows.
Demographics and task associated characteristics

Sixteen questions were related to the demographics of the respondent. These
were categorical style questions requesting personal information on age,
height, weight, occupation, the number of pregnancies, the number of full
term births and the age range of offspring. The questionnaire provided “yes” or
“no” responses and category ranges for respondents to identify their closest fit
answer.
41
Another eight categorical response questions were asked about frequency
and duration of the nappy change task, and the equipment used. The latter
section included questions on the type and dimensions of purpose built as
opposed to generic furniture used in nappy changing tasks in the domestic,
commercial child care and public change facility environments. In addition,
two qualitative response questions provided a five-point scaled response
regarding the perceived physical difficulty associated with using domestic and
public nappy change furniture. As with all of the scaled response questions, the
intervals between responses were assumed to be equal. The rating used for
those responses, was 1 “always easy”, 2 “mostly easy”, 3 “mildly difficult”, 4
“frequently difficult” and 5 being “very difficult” to use.
History of lower back pain

The existence of associated LBP in pregnant and postpartum women was
reviewed in this questionnaire. Respondents were asked to rate symptoms of
LBP before, during and since pregnancy. A five-point scaled response was
provided with 1 being “no symptoms”, 2 “occasional symptoms”, 3 “frequent,
mild symptoms”, 4 “moderately painful symptoms” and 5 “frequently painful
and/or disabling symptoms”. Respondents were also invited to make written
comment.
Manual lifting tasks involving the baby as a load

A range of child care tasks were addressed in this section of 12 questions. All
questions related to the lifting frequency and the perceived LBP/LBD
associated with each of the tasks. The questions relating to the nappy change
task were positioned at the beginning of this section with two questions
differentiating LBP/LBD outcomes associated either with the lifting component
or with the posture adopted when performing the task. The same five-point
response selection (as above) was provided for this range of questions. Once
again, provision was also made for written responses and comment.
Distribution
Following University of Western Australia Human Ethics Committee approval, the

promotional launch of the study coincided with Mothers Day celebrations and
was widely promoted with the support of radio and syndicated print media.
Information regarding the study and request for participants was also posted
42
on several Australian parent forum and education websites and approximately
500 printed questionnaires were distributed to women through commercial
child care centres, infant health clinics, kindergartens and pre-schools,
mothers’ groups and play group locations. Survey respondents returned
completed questionnaires either directly to the researcher, or by post or email.
The survey was available throughout Australia for a collection period of 4
months.
Data Analysis
Because of the broad content of Study One, only questions that relate to the
variables for Study Two were analysed for this thesis. The data were coded,
stored and analysed using Microsoft Office Excel 2003 and SPSS Version 12. The
questionnaire did not apply a value or score to each response, but the
frequency of responses was summed and standard descriptive statistics were
used to analyse the variables of interest for this study. Cronbach’s alpha
(≥0.72) was used as a measure of the internal consistency of the scaled
components of the questionnaire − task difficulty, pain and/or disability
associated with pregnancy, and pain and/or disability associated with the task.
Some of the scaled response data that were not fully completed or numbered
inaccurately were removed or recoded.
Relationships between variable responses were explored using cross-

tabulations. The objectives for this were two-fold; firstly to identify any
respondent bias by comparing outcome responses (for example, relating
difficulties associated with equipment use to the responses of task
pain/disability outcomes associated with equipment styles). Secondly,
responses were explored to review and compare the demographic and history
of pain variables with task LBP/LBD outcomes.
As with all of the five-point scaled response questions, the intervals between
responses were assumed to be equal. Questions relating to task associated
difficulty were reported such that the responses rating an outcome of some
difficulty (2 to 5) were grouped into two main categories: 2–3 “mostly easy to
mildly difficult” and 4–5 “difficult to very difficult”. These were summed and
analysed quantitatively. Likewise, the responses that rated an outcome of pain
or disability were grouped into two main categories: 2–3 “occasional symptoms
43
or frequent mild symptoms” and 4–5 “moderately painful symptoms to
frequently painful and/or disabling”. These were summed and analysed
quantitatively, then either presented as a percentage of the whole respondent
population or as a percentage of the particular respondent group.
The written responses from each question were coded for common themes
and the frequencies of responses and examples of key content recorded.
Specific comments regarding pain and/or disability other than LBP/LBD were
noted and relevant data were used to determine the outcome measures for
Study Two.
STUDY TWO
This study was designed to assess the biomechanical effects of MH during a

simulated baby changing task. In Study Two, average sized women engaged
in the lifting of two different baby size “loads” using three common stance
scenarios, while their actions, postures and hand loads were recorded.
Participants
Participants from three sub-populations were recruited to represent the range

of women who commonly perform this task; including pregnant, postpartum
and women without children. With University of Western Australia Human Ethics
Committee approval, volunteers responded to a letter distribution that
targeted mothers’ groups. Those who met the inclusion criteria were provided
with information regarding the study, including an outline of the task and any
potential risks. Prior to testing, all participants were invited to sign a written
informed consent document (Appendix C).
Of the 10 women eventually recruited, three were pregnant between 32–36
weeks gestation of a second or subsequent pregnancy, four were between
12–18 weeks postpartum, and three women had never been pregnant and
had no previous experience in the task of nappy changing. All women met the
following general inclusion criteria:
 Age (20–45 y)
 Height (160–170 cm)
 Pre-pregnancy Body Mass Index (BMI 19–24)
 No history of previous back injury
44
Instruments and Apparatus
The change bench apparatus was designed using height and surface area
dimensions common to commercially available change furniture, while
alignment and height details were also supported by data gathered in Study
One. The bench was constructed to enable locked surface adjustment at the
three test heights of 80 cm, 95 cm and 110 cm above the floor (Figure 3.1).
Change surface area was defined by markings with the long sides being
marked at 5 cm inward from the edge of the bench. This indicated the width of
a baby roll barrier which exists on most change surfaces. The surface was also
marked to indicate the positions for manikin placement.
Figure 3.1: Change bench apparatus shown in the Scenario One symmetric lift with an 18 month
baby load manikin (11.5 kg load) at 80 cm, 95 cm and 110 cm bench surface heights.
Two baby “load” simulation manikins, designed to replicate the mass of a baby
at 3 months and 18 months of age were made. The 3 month load was chosen
because postpartum women are generally instructed to limit lifting and weight
bearing activities for 8–12 weeks following parturition (Das, 1999). The 18 month
load manikin was selected because 45% of pregnant women also have a child
12–24 months of age (ABS, 2003). The largest group of children in day care
facilities in Australia is those between 12–24 months with 45% of this age group
being in care for periods of 20–40 hours per week (ABS, 2003). Developmentally,
most children of this age will still be incontinent and require regular nappy
changing. Hence, the 18 month manikin represents the average size and
weight for this target group.
45
Both manikins were built based on anthropometric measurements from
Pheasant (1988), and Growth Charts (HealthWest 2000). However, due to
generational growth since the period of these publications, the measures
(Table 3.1) were taken from the 95th percentile data. The 3 month baby load
manikin weighed 7.5 kg, and 75% of this weight was located in the torso and
head (Pheasant, 1988). At this developmental stage, when the baby is lifted its
lower legs are retracted toward the body (Hills, 1991). Therefore, lower limbs
were not included for this manikin.
In order to duplicate the horizontal reach distance in a real change task

situation, the location for placement of the “rump” of the manikin was marked
at 15 cm from the operator standing end; a distance that approximated the
rump-to-knee length of a 3 month baby (Figure 3.2).
Table 3.1. Dimensions Used for Baby Load Manikins.
Baby Load Manikins
3 month load 8 month load
Weight (kg) 7.5 11.5
Crown-Rump Length (cm) 43.0 50.0

Head Circumference (cm) 42.0 50.0
Head Length (cm) 15.0 17.0
Shoulder Breadth (cm) 19.0 23.0
Hip Breadth (cm) 16.0 18.0
Rump-Knee Length (cm) N/A 22.0
The 18 month manikin (Figure 3.3) was constructed based on the dimensions of
a male child at the 95th percentile. However, the Occupational Health Clinics
for Ontario Workers (Ergonomics and Pregnancy Policy, 2000) recommend that
women in the third trimester of pregnancy should not perform jobs that require
lifting weights over 10 kg. As a result, although the weight of an 18 month child
at the 95th percentile is 14 kg, so as to limit the risk of injury to participants, the
weight of this manikin (11.5 kg), was based on that of a male child at the 50th
percentile. To increase the distribution of the weight in realistic dimensions,
rump to knee “limbs” were attached to this manikin. The horizontal reach
46
distance for this manikin required the “rump” to be positioned 20 cm from the
standing end of the bench (Figure 3.3).
Figure 3.2: Three month baby load manikin. Figure 3.3: Eighteen month baby load manikin.
Rump placement position is marked on the Rump placement position is marked on the surface
surface of the change bench. of the change bench.
Three digital video cameras, a synchronisation light and a calibration scale

were used to accurately capture and record the test lift motion. Computer
programs SiliconCoach® Pro Version 6.1.5.0 ( Dunedin, New Zealand) and the
3D Static Strength Prediction Program (3DSSPP) Version 5.0.4 (University of
Michigan, 2005) were used to digitize and analyse the test data. All output
variables from Silicon Coach and 3DSSPP were charted on Microsoft Office
Excel 2003 and selected output variables were then analysed using SPSS
Version 12.
Procedures
A pilot program was undertaken prior to the data collection trials. The data
from the final pilot testing, a series of three trials for each of the test conditions,
was processed and used in a test repeatability analysis (Appendix C). Prior to
testing, participants were measured for height (to the nearest 0.5 cm), weight
(to nearest 0.5 kg) and girths were recorded at the chest, waist and hips (to the
nearest 0.5 cm) using ISAK approved protocols (ISAK, 2001). Waist girth
measurements for the pregnant women were taken at the maximum
abdominal girth.
White adhesive markers were then applied to bony landmarks that

approximated the 2D joint centres at:
47
 Shoulders - most anterior and superior point of the acromion process
 Elbows - lateral epicondyle of the humerus
 Wrists - styloid process of the ulna
 Hips - greater trochanter (according to de Leva, 1999)
 Knee - lateral epicondyle of femur
 Ankle - lateral malleolus of fibula
Markers were also applied lateral to the right and left posterior superior iliac
spines as an indication of the horizontal line for the rear video capture and
analysis. All measures and marker placements were attended to by the one
examiner, using the same equipment throughout the test series.
The video cameras were set in orthogonal positions to capture transverse

(overhead), sagittal and frontal plane data (frontal plane views were captured
from the rear). The sagittal and frontal plane cameras were mounted on tripods
set at a height of 95 cm, whereas a ceiling mounting was used for the
transverse camera and all cameras were operated by remote control. At the
commencement of each capture period, the calibration stick was aligned and
filmed by each of the cameras. A synchronisation light was flashed prior to the
first of each series of test captures. Cameras ran for the duration of the testing
of Scenarios One and Three. Prior to the trials for Scenario Two, the bench
equipment was shifted to fit the overhead capture field of view and distance
measures and synchronisation were recalibrated.
Participants engaged in three postural test scenarios, two of which involved

lifting and the third requiring a reaching task. The test tasks were designed to
simulate, as closely as possible, the real environment. Participants were
instructed to limit their risk of injury and not proceed if they felt physical
discomfort.
The lifting tasks consisted of one lift of each of the two baby manikin loads (7.5
kg and 11.5 kg) from each of the three test bench heights (80 cm, 95 cm and
110 cm). The manikins were lifted with hands placed directly under the upper
limb attachments on the upper torso. Approximately one third of the mass of
the load is situated above the holding point and because of this, participants
were instructed that significant control was required of the manikins throughout
the action of the lift. The horizontal distance for the origin of the lift (hand
48
placement) for the 7.5 kg manikin was 32 cm from the standing end of the
change bench and 43 cm for the 11.5 kg manikin. Participants were tested in
groups of three or four at a time and given a familiarisation lift of each baby
load manikin before the trial commenced. Lifts were not fully randomised, but
the bench height and baby load were randomised within each scenario and
participants were provided adequate rest between trials.
Scenario One consisted of a symmetrical lift of the manikin with both hands
directly in front of the body (Figure 3.4). Participants were instructed to stand at
the end of the change bench with feet comfortably apart. Subjects were also
requested to not support their own body against the bench when lifting. This lift
scenario was completed at each bench height for each load type, totalling six
lifts per participant.
Figure 3.4: Scenario One − Symmetric Lift Position.

Centre top: Test position with 18 month manikin. Top
right: Carer in symmetric lift position with 18 month child.
(picture from Glenhuntly Baby Carriages retail catalogue,
Melbourne, Australia. 2005). Right: Carer in symmetric
lift position with 6 month child (picture from Glenhuntly
Baby Carriages retail catalogue, Melbourne, Australia.
2005).
49
Scenario Two consisted of a horizontal bench alignment and an asymmetric lift
(Figure 3.5). This alignment to the bench required participants to twist and flex
toward the bench surface to lift the manikin. Participants were required to
stand at the side of the bench with feet comfortably positioned and with heels
aligned to the end of the bench. Participants were requested not to lean on
the bench and could not take a step. The horizontal left and right hand
placements for the 3 month manikin were at 5 cm and 25 cm respectively from
the side of the change surface, and 5 cm and 30 cm for the 18 month manikin.
This lift style was again completed at each bench height for each load type,
totalling six lifts for each participant for this scenario.
Figure 3.5: Scenario Two − Asymmetric Lift

Position. Centre top: Test position with 18
month manikin. Top right: Example of “drawer
top” unit, carer would perform task in
asymmetric lift position. (picture from
Glenhuntly Baby Carriages retail catalogue,
Melbourne, Australia. 2005); Right: Carer
using public facility with 12 month child,
requiring asymmetric lift. (picture from
Janitorial Direct trade catalogue, U.K. 2006)
Scenario Three (Figure 3.6) required participants to stand at the end of the
change bench as for Scenario One. This task was performed at each of the
three test heights, but only using the 11.5 kg manikin. Participants were required
to apply a downward force of approximately 10 kg (100 N) with the right hand
50
onto the middle of the torso of the manikin at a distance of 40 cm from the
standing end of the bench. At the same time, subjects were required to rotate
and flex the upper body to the left of the change bench and place their left
hand on the surface of a small stool (Ht = 35 cm). Subjects’ feet were required
to remain unmoved at the end of the change bench. Because of safety issues
(Child Accident Prevention Trust, 2002) and the behavioural habits of an 18
month old child, previous pilot testing indicated that 10 kg was the
approximate downward force applied by a carer to stabilise this baby load.
Figure 3.6: Scenario Three − Mid-calf reach test position.

This is a familiar task in both domestic and public change
facilities in that change items are often kept on a low shelf or in
a bag positioned on the floor.
Treatment of the Data
Digital video files were downloaded to PC and analysed with SiliconCoach®

Pro (50 Hz) Version 6, 2D biomechanics software. The task outcome variables for
Scenarios One and Two were measured at the point of lift, which was defined
by the rump of the manikin lifting off the bench surface. This point was
determined by first viewing the sagittal plane video capture. The same point
was then located on the overhead and rear camera images by using the
synchronisation light-out as the frame count-back point. Scenario Three data
were recorded at a point when the participant had adopted and held the
51
position in a steady stance for three seconds. Segment angles and distance
measures at the point of lift, were recorded onto a spreadsheet to input into
the 3D Static Strength Prediction Program Version 5.0.4 (3D SSPP). The three
cameras recorded each participant performing 12 lifts and three mid-calf
reaches, hence 45 individual analyses of outcome measures from
SiliconCoach® were recorded for each participant.
The outcome angles and distance measures from the video analysis were used
to reconstruct a simulation model for each participant’s posture for every
condition. 3D SSPP models were built for every independent variable condition
for each participant trial and saved to file (Figure 3.7).
Figure 3.7: Example of 3DSSPP Version 5.0.4 application window depicting modelling file for a
pregnant participant performing a symmetric lift at the 95 cm bench height with an 18 month baby
load manikin.
52
The input data required for each modelling analysis were:
 Anthropometry: gender, height and weight
 Body segment angles:
o trunk flexion, rotation and lateral bend
o left and right hip angle
o left and right knee angle
o left and right forearm angle (horizontal and vertical)
o left and right upper arm angle (horizontal and vertical)
 Hand loads (N) and direction of load force (pressing or lifting)
N.B. The lift load is known, but the pressing load is an estimate.
The outcome variables from the 3D SSPP of significance to this study were:
 Estimated compression force at the L5/S1 joint
 Estimated shear force at the L5/S1 joint
 Estimated torso extension angle from the hip joint
 Estimated percentage of ligament strain at L5/S1
 Estimated percentage of torso muscle fatigue at L5/S1 for:
o flexion/extension
o lateral bending
o rotation
 Estimated percentage of (right) shoulder muscle fatigue for:
o adduction/abduction
o flexion/extension
o humeral rotation
Statistical Analysis
Output data from 3D SSPP were recorded on a MS Excel spreadsheet and

statistical analysis was performed using Statistical Packages for Social Science
(SPSS®) version 12.0 for Windows. Descriptive statistics, including group mean,
standard deviation, skewness and kurtosis, were calculated for each
dependent variable at every test condition.
The independent variables, baby load and bench height were tested within
the Symmetric Lift (Scenario One) and Asymmetric Lift (Scenario Two) tasks
independently. A 2 x 3 factor repeated measures analysis of variance (ANOVA)
was used to identify any significant main and interaction effects of the
53
independent variables. Following this, postures were then compared between
the Symmetric and Asymmetric lifts with interaction between the independent
variables of (stance) alignment and bench height tested using the higher baby
load (11.5 kg), again in a 2 x 3 factor repeated measures ANOVA. The effect of
the independent variable bench height was tested in the Mid-calf Reach
Scenario Three, using repeated measures ANOVA.
Because of the multiple comparisons being made, the alpha level for
significance was adjusted to avoid Type 1 errors. In accordance with Perneger
(1998), a Bonferroni adjustment was considered as too conservative for these
test procedures, hence the alpha level was determined by dividing p < 0.05 by
3 (since the comparisons were made at three height levels). Subsequently,
alpha was set at p < 0.017 for significance. Mauchley’s test for sphericity was
noted and the F ratio was calculated for each independent variable. Power of
an interaction was considered good if it scored 0.800 or higher and post hoc
paired t-tests were performed when a significant interaction occurred.
54
CHAPTER FOUR
STUDY ONE – RESULTS
The reliability of this self-reported questionnaire was tested using Cronbach’s

alpha and the data were re-coded and cleaned accordingly. As the content
of Study One was very broad, only questions that relate to the variables for
Study Two were analysed for this chapter. The variables relating to
demographics have been presented in categorical format, whereas a five
point Likert scale response format was used for the qualitative components of
the questionnaire. Cronbach’s alpha coefficient for task difficulty was 0.721;
task associated pain and/or dysfunction was 0.751; and LBP associated to
pregnancy 0.783, indicating that reliability for each of these scales was good.
The variables of interest were analysed using descriptive statistics, and then
relationships between variables of interest for this study were explored using
cross-tabulation.
DEMOGRAPHICS
The median age group of respondents was 31–35 y with 40% (n=166) in this
category. The 36–40 y (n=131) and the over 40 y (n=32) together comprised
40% of respondents, indicating that 80% of respondents to this questionnaire
were aged 31 y or older (Figure 4.1). In terms of stature, 43% of respondents
reported to be 161–170 cm tall, 35% were over 171 cm and 22% were 150–160
cm (Figure 4.2).
Age of Respondents
180
160
140
Frequency (n=400)
120 Figure 4.1 Respondent age group

100 frequencies
80
60
40
20
0
<25 25-30 31-35 36-40 >40
Age Groups (y)
55
Height of Respondents
200
180
160
Frequency (n=404)
140
120
100 Figure 4.2 Respondent height
group frequencies
80
60
40
20
0
150-160 161-170 171-180 >180
Height Groups (cm )
Body Mass Index (BMI) calculations were made for each respondent based on
height and weight measurements as reported. Approximately half (51%) of
respondents were categorised within a normal BMI range (18.5–24.9), while 47%
were categorised as either “overweight” (25–29.9) or “obese” (≥30).
At the time of this survey, 56% of respondents were postpartum (i.e. up to 12

months since the birth of the last child), 8% (n=35) were pregnant and 36% were
neither pregnant nor postpartum (of which 13 respondents had never been
pregnant); 30% of those with children, had one full term pregnancy, 27% had
two pregnancies and 27% had three or more. Each of the pregnant
respondents had one or more previous pregnancies, with 14 of these women
attending to a baby under 12 months old at the time of responding to this
questionnaire. Of the postpartum respondents, 35% had one pregnancy and
60% had either two or three pregnancies (Table 4.1).
Table 4.1 Number of Pregnancies to Full Term for Each Respondent Group.
Number of Pregnancies
Status nil one two three four ≥five Total
Pregnant 0 15 17 3 0 0 35
Postpartum 0 86 78 57 4 0 225
Other 13 47 46 33 7 5 151
NB: Other = neither pregnant nor postpartum at the time of the survey.
56
EQUIPMENT
Most respondents (74%) were using purpose-built change furniture in the

domestic environment and a variety of furniture styles and sizes were reported
(Figures 4.3, 4.4). A 2/3 tiered change table was used by 37% of respondents,
while 12% use a change/bath combination unit, 6% use a frame and sling, and
19% operated on a drawer top unit (Figures 4.5 to 4.8). Those not employing
purpose built furniture (other = 26%), reported using kitchen bench and table
tops, bed and floor surfaces.
Domestic Change Furniture

Styles Used
40
35
30
Frequency (%)
25
20 Figure 4.3 Change furniture styles as reported,

used in the domestic environment.
15
10
0
2/3 tier bath/ch sling drawer o ther
Furniture Style

Heights Reported
60
50
Frequency (%)
40
Figure 4.4 Change surface heights as reported,
30 used the domestic environment.
20
10
0
<80 80 - 90 91-100 100 - 110 >110
Height Groups (cm )
Respondents were given a range of “closest fit” change surface heights. These
estimations varied from under 80 cm to over 110 cm from floor level. The
median height reported (52% of respondents) was 91–100cm (Figure 4.4).
57
In addition to domestic use, participants were asked about their use of public
facilities. The majority of respondents (79%) used public changing facilities up to
five times per week. This included wall mounted (43%), free standing (6%) and
built-in (34%) furniture styles (Figures 4.9, 4.10).
Figure 4.6. drawer-top change unit. .
Figure 4.5 Domestic furniture, example of: 2/3 tier Figure 4.6 Domestic furniture, example of: drawer top
change unit. (picture from Glenhuntly Baby Carriages change unit. (picture from Glenhuntly Baby Carriages
retail catalogue, Melbourne, Australia. 2005) retail catalogue, Melbourne, Australia. 2005)
Figure 4.7 Domestic furniture, example of: Figure 4.8 Domestic furniture, example of: frame sling
bath/change unit. (picture from Glenhuntly Baby unit. (picture from Glenhuntly Baby Carriages retail
Carriages retail catalogue, Melbourne, Australia. 2005) catalogue, Melbourne, Australia. 2005)
58
Figure 4.9 Public change unit example of: wall Figure 4.10 Public change unit example of: wall
mounted, vertical (picture from Janitorial Direct mounted, horizontal (picture from Janitorial
trade catalogue, U.K. 2006). Direct trade catalogue, U.K. 2006).
TASK FREQUENCY AND DURATION
The frequency of the change task was dependent on the age of the baby. Most
respondents (70%) reported they would perform the change task 6–12 times per
day on a 3 month baby and (68%) 6 times a day on an 18 month baby (Figure
4.11). Responses to the question of task duration indicated that 56% of
respondents take 2–4 minutes to perform the change task for both 3 month and
18 month babies (Figure 4.12). However, 20% of respondents take between 4 and
8 minutes to complete the task on a 3 month old but 23% reported taking 4 to 8
minutes to complete a nappy change on the larger, 18 month load. Almost two
thirds of the respondents (71%), including 14 pregnant women, were changing
nappies on two or more children each day.
59
Daily Frequency of Nappy Changes
per Baby Age
80
70
Respondent (%)
60
50
40 Figure 4.11 Reported daily task frequency

3 mnth
per baby load.
30
18 mnth
20
10
0
<6 6 to 12 >12
Task Frequency
Duration of Nappy Change

per Baby Age
60
50
Respondent (%)
40 Figure 4.12 Reported task duration

per baby load.
30 3 mnth
20 18 mnth
10
0
1to 2 2 to 4 4 to 6 6 to 8
Task Duration (m inutes)
RATING OF TASK DIFFICULTY ASSOCIATED WITH EQUIPMENT
Respondents were asked to rate the physical difficulty of the task when using both
public change furniture and their own domestic change furniture. A five point
scaled rating was used for those responses, with 1 being “always easy”, 2 “mostly
easy”, 3 “mildly difficult”, 4 “difficult” and 5 being “very difficult” to use. As with all
of the scaled response questions, the intervals between responses were assumed
to be equal. The responses that rated an outcome of some difficulty (2 to 5) were
grouped into 2 main categories: 2–3 “mostly easy to mildly difficult” and 4–5
“difficult to very difficult”. These were summed according to the style of furniture
and analysed quantitatively.
Of the respondents who use public change equipment (n=342), 37% of those who
used the wall mounted and 46% of the free standing furniture style users reported
these change bench items as difficult or very difficult to use. The built-in units were
60
rated as easier to use, but only 10% of respondents to this question had no difficulty
using public change facilities (Figure 4.13).
Task Difficulty Rating for

Public Change Furniture
70
60
Respondent (%)
50
Figure 4.13 Difficulty associated with using Public
40
wall mo unt change furniture styles.
30 (Ratings 2-3 =mostly easy to mildly difficult;
free stand
4-5 difficult to very difficult) (n=341).
20
built in
10
0
2 to 3 4 to 5
Rating Scale
Task Difficulty Rating for

70
60
Respondent (%)
50
Figure 4.14 Difficulty associated with using
40 2/3 tier Domestic change furniture styles.
30
bath/ch (Ratings 2-3 =mostly easy to mildly difficult;
sling 4-5 difficult to very difficult) (n=303).
20
drawer
10 o ther
0
2 to 3 4 to 5
Rating Scale
Of respondents rating the difficulty in using their own domestic change equipment
(n=303), 63% rated some difficulty associated with its use. Of the respondents using
the bath change unit style (n=48), 51% reported it to be difficult to very difficult to
use, which contrasts in comparison to the 2/3 tier unit which had 45% of users
(n=146) report a difficulty rating of “mostly easy” to “mildly difficult” (Figure 4.14).
RATING OF PAIN AND DYSFUNCTION ASSOCIATED WITH THE TASK
Respondents were asked to comment on their experience with LBP or dysfunction

in relation to the task of changing a baby’s nappy. Differentiation of the cause of
any perceived LBP outcome associated with the task was highlighted in two
separate questions; the first referring to pain or dysfunction as a result of the
61
posture sustained during the change task; the second question referred to pain or
dysfunction as a result of the lifting component of the task.
A five point scaled rating response was used to indicate the intensity of perceived
pain or dysfunction; with 1 being “no symptoms” and 5 being “frequent painful
and/or disabling symptoms”. Of the 405 responses to these two questions, 29% of
respondents reported no LBP or disability associated with either the lift or posture
sustained during the task. The respondents that rated an outcome of pain or
disability were grouped into two main categories: “occasional symptoms or
frequent mild symptoms” and “moderately painful symptoms to frequently painful
and/or disabling”. These were summed and analysed quantitatively (Figure 4.15).
The outcome of responses to these two questions indicated that respondents
made little differentiation of LBP symptoms between the lifting component and the
sustained posture with 45% rating the associated LBP/dysfunction for both as
moderate to strong.
Rating of LBP Associated with

Nappy Change Task
50
45
40 Figure 4.15 Low back pain/dysfunction
Respondent (%)
35 associated with Lift of load and Posture

30 associated with the nappy change task (2-3 =
25 P o sture
occasional or mild symptoms; 4-5 = moderately
20 painful to frequently painful and disabling
Lift symptoms).
15
10
5
0
2 to 3 4 to 5
Rating Scale
A series of cross-tabulation analyses were performed between the independent

variables of change bench style, and the associated dependent variable of
perceived LBP as reported by the respondents. Figures 4.16 and 4.17 show the
cross-tabulation outcome of change furniture styles with perceived LBP. These
figures represent the percentage of respondents to each furniture style. The
outcomes indicate that the drawer top change unit evoked the highest rating of
LBP, with over 50% rating moderate to strong symptoms for both the lift and posture
components. Of those employing 2/3 tier change unit, over 40% rated moderate
to strong LBP associated with the task. For the frame and sling style users 52%
62
reported occasional to mild symptoms for the lift component, but sustained
posture was reported by 50% of users as moderate to severe LBP outcome.
Perceived LB Pain/Dysfunction Associated

with Posture using Domestic Change Furniture
60
50
Respondent (%)
Figure 4.16 Low back pain/dysfunction as a

40 result of posture used with each furniture style.
2 to 3 Percentage of responses per furniture style. (2-3
30
= occasional or mild symptoms, 4-5 = moderate
4 to 5
to frequently painful and disabling symptoms).
20
10
0
2/3 tier bath/chn sling drawer o ther
Change Bench Style
Perceived LB Pain/Dysfunction Associated

with Lift from Domestic Change Furniture
60
50
Respondent (%)
40
result of lift from each furniture style. Percentage
30 2 to 3 of responses per furniture style. (2-3 = occasional
or mild symptoms, 4-5 = moderate to frequently
4 to 5
20 painful and disabling symptoms).
10
0
2/3 tier bath/chn sling drawer o ther
Change Bench Style
The average height of the domestic change furniture used by each respondent
was then compared to the respondents’ height and reported as a percentage of
stature. The proportions correspond (anthropometrically) to an average female
adult as follows: 45% = mid thigh; 55% = pubis; 65% = waist height (Pheasant, 1988).
These measures were then cross-tabulated with LBP/dysfunction ratings associated
with the lift and posture components. Of the (n=282) responses to this question,
less than 10% of respondents were working at heights under 45%, hence these
data were not reported.
According to the remaining data analysed, the LBP associated with the lift
component of the task was reported as more severe at the mid-thigh to pubis
range of change furniture surface heights (Figure 4.18). However, the LBP outcome
63
associated with posture is greatest at the pubis to waist height range (Figure 4.19)
with 55% of the respondents in this category reporting moderate to frequently
painful or disabling symptoms of LBP.
Perceived Lower Back Pain Associated

with Lift and Proportional Height of
Change Furniture
60 Figure 4.18 Low back pain/dysfunction as a result
of lifting and relative height of the furniture used by
50
Response (%)
each respondent. Furniture height is expressed as

proportion of individual stature (2-3 = occasional
40
or mild symptoms; 4-5 = moderately painful to
30
frequently painful and disabling symptoms).
2 to 3
20
4 to 5
10
0
45-55% 55-65% >65%
Relative Furniture Surface Heights
Perceived Lower Back Pain Associated

with Posture and Proportional Height of
Change Furniture
60
50 result of posture and relative height of the
Response (%)
furniture used by each respondent. Furniture

40 height is expressed as proportion of individual
stature (2-3 = occasional or mild symptoms; 4-5
30 2 to 3 = moderately painful to frequently painful and
disabling symptoms).
20
4 to 5
10
0
45-55% 55-65% >65%
Relative Furniture Surface Heights
PAIN AND DYSFUNCTION ASSOCIATED WITH RESPONDENT CHARACTERISTICS
The risk of injury associated with MH tasks can be affected by worker

characteristics (Chaffin & Anderson, 1991); hence, it was important to review
respondent characteristics in relation to perceived LBP and disability associated
with the task. These characteristics included age, BMI, history of LBP and number of
births. Tables 4.2 and 4.3 present a cross-tabulation of respondent characteristics
and their rating of LBP associated with both the lift and posture components of the
64
nappy change task. The data are presented as a percentage of respondents for
each independent variable category. The total number of respondents in each
category is also included in these tables.
The epidemiology of back pain in this respondent population is of interest to this

study, so the pathology of back pain in pregnant women was reviewed. Table 4.2
indicates the progress of perceived LBP before, during and subsequent to
pregnancy. Respondents were asked to rate the level of LBP and dysfunction,
before, during and since pregnancy. The left hand column (“sum”) indicates the
frequency of responses to each of the respondent characteristic ratings: 1 no
symptoms, 2–3 occasional to mild, 4–5 moderately painful to frequently painful and
disabling.
Table 4.2 Respondent Characteristics Relative to Task-Associated Low Back Pain/Disability
Current Pain During Task
No Occasional to Mild Moderate to Severe

Symptoms Symptoms Symptoms
Rating 1 Rating 2 to 3 Rating 4 to 5
(%) (%) (%)
Respondent
Characteristics Sum Lift Posture Lift Posture Lift Posture
Back pain 1 264 34 39 27 Rating 1 26 39 35

before (%)
pregnancy
2-3 80 21 13 32 34 47 53
(n-402)
4-5 58 16 6 4 22 80 72
Back pain 1 141 53 56 23 21 24 23

during
pregnancy
2-3 116 19 20 26 32 55 48
(n-397)
4-5 140 13 10 18 21 69 69
Back pain 1 125 58 57 24 18 18 25

since
pregnancy
2-3 128 27 27 36 38 37 35
(n-398)
4-5 145 4 7 15 21 81 72
Note: a. Percentage Rating = % of responses (rounded) per independent variable.
Note: b. Sum = sum of responses to each category.
Note: c. Respondent characteristics 1 = no symptoms, 2-3 = occasional to mild symptoms, 4-5 = moderate to
severe pain and/or disability.
65
Of the respondents to these questions, 20% reported occasional to mild symptoms
and only 15% reported moderate to severe experience of LBP prior to pregnancy.
During pregnancy 30% of respondents reported occasional to mild symptoms and
35% reported moderate to severe symptoms of LBP. In those reporting back pain
since pregnancy, 33% reported occasional to mild and 36% experience moderate
to severe LBP symptoms. These data indicate that pregnancy and or child birth
could increase by more than 50% the risk of LBP injury in women with no previous
history of LBP. One cannot be more definite since these are cross-sectional rather
than prospective data. The cross-tabulation with task-associated LBP indicates that
those who have a moderate to severe pain rating before, during or after
pregnancy had also the highest rating of LBP as a result of lifting and posture
associated with the task. The cross-tabulation also indicates that the majority of
women who reported no symptoms of LBP before, during and after pregnancy still
reported symptoms of LBP associated with nappy changing.
Reviewing the information in Table 4.3, the age category of 31–40 y was the
highest scoring age group in relation to LBP rating, whereas the youngest age
group reported the least levels LBP/disability. With regard to BMI and the
relationship of pain associated with the task, it appears that respondents with a
larger BMI provided higher ratings of LBP/disability associated with lift and posture.
Ten respondents were under weight, seven of those participants related their
experience with lifting in the task as eliciting moderate to severe LBP outcome;
however this result needs to be treated with caution because of the sample size.
More than 50% of the over weight and obese women though reported moderate
to severe symptoms of LBP.
66
Table 4.3 Age and BMI Status Relative to Perceived Task-Associated Low Back Pain/Disability

(%) (%) (%)
Respondent
<25 11 45 50 27 Rating 120 28 30

(%)
25-30 80 25 25 40 40 35 35
Age (y) 31-35 161 25 29 28 22 47 48

(n=411)
36-40 127 32 29 20 25 48 46
>40 32 34 35 28 6 38 39
Under
Weight 10 30 30 0 30 70 40
Normal 208 29 40 29 18 42 41
BMI
(n=405) Over
Weight 121 32 21 25 29 43 50
Obese 66 19 10 16 38 65 52
With respect to the pregnancy status sub-groups (pregnant, postpartum and

other), each group rated moderate to severe pain as a result of lift and posture
associated with the task (Table 4.4). Upon further scrutiny of the birth rates and
pain ratings, the majority of this small group of never pregnant women reported
little or no pain associated with the task. However, almost 50% of the respondents
who had experienced multiple births rated the lift and posture components as
moderate to severe and 25% rated zero pain outcome. All the women who have
given birth to four or more children reported experiencing pain, and although the
ratings are spread, they have clearly differentiated between pain from lifting and
pain from sustained posture in the task. However, some of these sample sizes are
small and should be reviewed with some caution.
67
Table 4.4 Pregnancy Status and Number of Births Relative to Perceived Task-Associated Low Back
Pain/Disability

(%) (%) (%)
Respondent
Pregnant 35 24 17 32Rating 1 29 44 54
Pregnancy (%)
Post
Status partum 225 25 27 20 22 55 51
Other 151 32 29 31 31 37 40
Nil 13 75 82 17 18 8 0
1 141 26 27 20 30 54 43
Number
of
2 138 23 28 28 24 49 48
Births
(n=401)
3 94 33 30 26 20 41 50
4-5 15 0 0 70 40 30 60
QUALITATIVE SUMMARY
Analysis of the qualitative component of the study involved the organisation of

raw data from 183 written comments. Raw data were organised into collective
themes and expressed as a summary of 16 common thread groups. Using an
inductive and deductive process, the raw data grouped summaries were
organised into 14 first-order key component categories which were then refined
into nine highest-level themes expressed in relation to MH analysis.
Seven of the themes relevant to this research program, were summarised and
presented in Figure 4.20. Of the total number of written comments recorded, 75%
were relevant for inclusion to this study. Table 4.5 represents the percentage of
responses organised into the General Dimension categories, highlighting that 20%
of comments related to pain and disability associated with the task, 8% related to
the technique and 7% to the equipment associated with the task. The difficulties
68
associated with baby loads made up 11% of the comments and pain or disabilities
associated with pregnancy or birth were made by 6% of written responses.
Medical intervention was acknowledged by 8% of respondents and observations
relating to the inevitability and lack of control of injury process, was expressed by
8% of participants.
69
General
Summary of Raw Data Themes First Order Themes Dimensions
Comments re: task demands and physical outcomes Key components Manual handling issues
 Changing nappies and lifting have injured my back.  I have upper back
 Some lower back pain and slight sciatica. and other pain or
 Pain in upper back, between shoulder blades, disability assoc with Task associated
I have put it down to nappy changing. nappy change task. with pain and
 The constant lifting and lowering has wrecked my  I have lower back disability outcomes
pelvic floor and injured my back. pain associated with
 A lot of pain in my upper back. nappy change task.
 Nappy changing puts you in a very unnatural position  Posture causes pain
and causes me a great deal of back pain on a daily as a result of nappy
basis. change task.
 The extra weight on the front of my body affects my  My weight affects my Posture
back when I bend to change the nappy. pain
 Bending and lifting children is a strain on back and associated with
 Lifting my baby causes pain and/or
shoulders. pain.
 Despite my attempts to lift correctly and minimize I know how to lift
disability outcomes
strain, repetitive tasks definitely have an impact on correctly, it doesn’t
my back pain. always help.
 Lifting onto change table contributes to upper back
pain, some days I am in constant pain.
 I am pregnant; a low change surface is so much Equipment

more difficult.  Height of change associated with
 I am tall so I find most equipment does not suit my furniture causes pain. pain and disability
height. outcomes
 My 2 year old is 17kg. Sometimes he struggles so  My baby/s is/are heavy Load and
much when I change his nappy that my husband has and difficult to frequency
to hold him down. It can be exhausting. manage. characteristics
 My back pain has increased significantly as the  I have more than one
weight of the babies has increased. associated with
child to manage. pain and disability
 I think twins make it worse.
 My posture changed with pregnancy, I don’t know  My body has changed

why, now I suffer debilitating back pain. because of pregnancy Existing or
 My back is killing me. It was sore before pregnancy or birth. progressing injury
but having a baby makes it so much worse.  My body was strong exacerbated by
 My back pain started 3 months after my baby was before I had children. lifting and handling
born.
 LBP increased with each baby.
 As a parent you don’t even think about what you are  My pain is no different
doing to your back, you just do it because it needs to Self-effacing
to anyone else.
be done. attitude to injury
 My pain is inevitable.
 Am happy to know others might have a problem, you outcome
don’t feel like you should complain.
 My physiotherapist says pain in thoracic spine is  I have on-going

common in mums due to the nature of breast symptoms common to Medical
feeding, nappy changing etc. motherhood that may intervention,
 I have had deep massage and acupuncture and or may not be relieved treatment of injury
although these helped, they didn’t fix the problem. by medical
intervention.
Figure 4.20 Summary of raw data from written responses (n=183) and first order key components of themes
making up the general dimensions of observations
70
Table 4.5 Qualitative Theme Summary and Percentage of Responses to General Dimension Categories.
General Dimension Categories
Manual Handling Themes Percent response (%)

Pain and disability symptoms associated with task 20
Pain and disability associated with posture 8
Pain and disability associated with equipment characteristics 7
Pain and disability associated with load characteristics 11
Pain and disability associated with other baby load handling tasks 25
Existing or progressing injury 6
Self-effacing attitude 8
Medical intervention 8
Education and training 7
STUDY ONE OUTCOME VARIABLES AND APPLICATION TO STUDY TWO
The results from Study One were used to inform the methodology for Study Two.
The following key points were included:
 The domestic change bench furniture used involved predominantly

two styles; one requiring the operator to stand perpendicular to the
load, the other required the operator to stand parallel to the load,
creating both symmetric and asymmetric lift scenarios.
 The domestic furniture style most frequently used was the 2/3 tier style
(including the bath/change unit) designed to store change items on
shelves below the working surface; therefore, it is appropriate to
analyse this flex and reach posture.
 Bench heights varied from 80–110 cm.
 Baby load characteristics were used in determining the nature of the
baby load manikins.
 Due to the frequency of complaints regarding upper back, shoulder
and neck pain associated with the task, estimated percentage of
(right) shoulder muscle fatigue was included as an outcome variable
in Study Two.
 Estimations of task frequency and duration will be used when
reviewing implications for the biomechanical outcomes of Study Two.
71
CHAPTER FIVE
STUDY TWO – RESULTS
Height and weight measurements prior to pregnancy were self-reported and

were used to calculate BMI for criterion suitability. An individual chart of
measurements (Table 5.1) and performance notes was kept for each
participant.
Table 5.1 Participants’ (n=10) Demographic and Girth Measurement Information
Subjects
Nulliparae Pregnant Postpartum Combined
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 Mean SD
Age 31 42 33 30 33 25 37 32 42 30 34 5
(y)
Height 166 168 160 163 166 170 164 165 168 168 166 3
(cm)
Weight 63 51 62 74 64 78 62 59 76 77 66 9
(kg)
Chest Girth 90 88 85 93 90 94 94 92 103 108 94 7

(cm)
Waist Girth 68 67 67 104 94 110 77 76 89 99 85 16

(cm)
Hip Girth 92 91 100 109 97 107 93 94 105 110 100 7

(cm)
BMI 23 18 24 28 23 27 23 22 27 27 24 3
N.B. Figures rounded up.
P1 = Participant number 1, etc.
The dependent variables; angle of torso extension, CF at L5/S1, SF at L5/S1,

ligament strain at L5/S1, torso and (right) shoulder muscle fatigue were
measured in each of the three tested scenarios. The results from load and
bench height effects for Scenario One (symmetric lift) and Scenario Two
(asymmetric lift) are presented independently; posture and work heights were
then compared between the symmetric and asymmetric lifts. Finally, the
analysis of bench height effects for Scenario Three (mid-calf reach) are
presented.
72
All output data are produced from the 3D Static Strength Prediction Program
Version 5.0.6 and provide an estimated value calculated for the 50th percentile
of the population, representing the average sized adult female (3DSSPP V 5.0.6,
2006). Descriptive statistics summaries for each scenario are presented in
Appendix D, whereby the mean, standard error, standard deviation, skewness
and kurtosis were recorded for each dependent variable. These data are for
each combination of three bench heights (80, 95 and 110 cm), and two baby
loads (Load 1 represents the 7.5 kg baby and Load 2 represents the 11.5 kg
baby). All data were considered to be normally distributed given that the
skewness and kurtosis values were ≤2.0.
Dependent variable outcome graphs are presented throughout the text.

Repeated measures analysis of variance (ANOVA) was used to identify any
significant main and interaction effects of the independent variables for each
of the scenarios at p<0.017. The individual ANOVA summary tables are
presented at the beginning of each test scenario section. Post hoc paired t-
tests were used to identify where the significant (p<0.017) differences occurred
within the interaction effects. It should also be noted that post-hoc tests have
only been conducted to identify differences between bench heights.
73
SCENARIO ONE – SYMMETRIC LIFT
Scenario One looked at the interaction of bench height and load in

a symmetric lift of the baby load manikins. Figure 5.1 is a diagrammatic
representation of Scenario One in which participants were instructed to stand
at the end of the change bench with both hands directly in front of their body
holding the baby manikin either side of the torso, then to lift the manikin without
leaning their body against the bench. This lift scenario was completed at each
bench height for each load type totalling six lifts per participant. Table 5.2
presents the summary of ANOVA outcomes from the effects of bench height
and load types during the symmetric lift. Further details related to each
variable are presented in the subsequent sections.
Figure 5.1 Representation of Scenario One - Symmetric Lift. Sagittal and Frontal views at 80 cm bench
height. (Images from 3DSSPP, Version 5.0.6)
74
Table 5.2 Repeated Measures ANOVA Summary of Bench Height and Load Main
Effects for Scenario One, the Symmetric Lift.
Outcome variable Variables df F Significance Power
Torso Extension (degrees)

Main effect Load 1,9 76 0.001 1.000
Bench Ht 2,18 26 0.001 1.000
Interaction Load/B.Ht 2,18 144 0.001 1.000
Compression Force (N)

Bench Ht 2,18 22 0.001 1.000
Shear Force (N)

Main effect Load 1,9 265 0.001 1.000
Bench Ht 2,18 62 0.001 1.000
Ligament Strain (%)

Bench Ht 2,18 140 0.001 0.979
Interaction Load/B.Ht 2,18 0.23 0.977 0.053
Fatigue Torso (%MVC)

Flex/Ext Main effect Load 1,9 0.3 0.622 0.074
Bench Ht 2,18 9 0.002 0.941

Lat. Bend Main effect Load 1,9 7 0.026 0.661
Bench Ht 2,18 1 0.404 0.190

Rotation Main effect Load 1,9 0.2 0.661 0.069
Bench Ht 2,18 4 0.028 0.681
Fatigue Shoulder (%MVC)

Abd/Add Main effect Load 1,9 272 0.001 1.000
Bench Ht 2,18 21 0.001 1.000

Flex/Ext Main effect Load 1,9 16 0.003 0.947
Bench Ht 2,18 2 0.136 0.396

Hum Rot. Main effect Load 1,9 17 0.003 0.991
Bench Ht 2,18 94 0.001 1.000
* P values shown in bold denote significance at p< 0.017.
75
Torso extension was measured at hip level with 0° representing a horizontal
torso (full forward flexion) and 90° being an upright torso. Considering Figure
5.2, it is clear that regardless of baby load there was an increase in torso
extension as the height of the change bench increased. However, comparing
baby loads, torso extension was reduced when lifting the heavier load. Post
hoc comparisons (80–95 cm, 80–110 cm, 95–110 cm), demonstrated significant
differences existed for both baby loads at each of the bench heights.

Symmetric Lift.
Extension
90
Torso Extension (Degrees)
80
70
60
80 cm
50
40 95 cm
30 110 cm
20
10
0
Flexion
Load 1 Load 2
Load Type
Figure 5.2 Mean (±SD) torso extension as a result of load and height changes in Scenario
One - Symmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.
Figure 5.3 indicates that decreasing bench height and increasing baby load
both increased L5/S1 CF. Baby load 2 at the 80 cm height resulted in the
greatest CF of 2701 ± 291 N, which is just below the BCDL of 3400 N for a single
lift according to the Work Practices Guide for Manual Lifting (NIOSH, 1981). Post
hoc outcomes indicated that for both load types, all bench heights caused
significant changes in compression force.
76
Symmetric Lift
3500
3000
2500
80 cm
2000
95 cm
1500
110 cm
1000
500
0
Load 1 Load 2
Load Type
Figure 5.3 Mean (±SD) compression force (N) at L5/S1 as a result of load and height changes in
Scenario One - Symmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg. The BCDL (indicated by red line) for a
single symmetric lift = 3400 N (NIOSH, 1981).
A review of Figure 5.4 indicates that increasing baby load increased the SF
outcome more than bench height changes. Furthermore, increasing bench
height reduced the SF in both load conditions. The post hoc t-tests showed that
all the differences between heights in both load conditions were significant.
The suggested SF single lift DL (McGill, 1998; as cited in Daynard et al., 2001) is
indicated by the red line at 500 N.
Shear Force (N)

Symmetric Lift
600
500
Shear Force (N)
400
80 cm
300 95 cm
200 110 cm
100
0
Load 1 Load 2
Load type
Figure 5.4 Mean (±SD) for shear force (N) at L5/S1 as a result of load and height changes in
Scenario One - Symmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg. The shear force DL (indicated by red
line) for a single symmetric lift = 500N (McGill, 1998).
77
Ligament strain was increased with the heavier baby load and with decreased
height of the bench as depicted in Figure 5.5. No significant interaction was
observed; hence no further analysis was made. Ligament strain is an estimation
of strain on the lumbodorsal fascia attached between the L5 and S1 vertebrae.
Based on a single lift, the observed limit of elasticity at this joint is 30% of
maximum strain, and exceeding this limit indicates a heightened risk of injury for
most normal healthy adults (Anderson et al., 1985).
Ligament Strain (%)

Symmetric Lift.
35
30
Estimated Strain (%)
25
80 cm
20
15 95 cm
10 110 cm
0
Load 1 Load 2
Load Type
Figure 5.5 Mean (±SD) ligament strain (%) at L5/S1 as a result of load and height changes in
Scenario One- Symmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg. Ligament strain of 30% for a single
symmetric lift (indicated by red line) = injury risk for most healthy adults (3DSSPP, 2006).
Figure 5.6 indicates that torso flexion/extension muscle fatigue increased with
the heavier baby load and lower bench heights; however, all lifts recorded
averages greater than 50% MVC for Load 2. The t-tests revealed significant
differences for Load 1 between 80 cm and 110 cm bench heights and for the
95 cm–110 cm comparison, but no significant differences as a result of bench
height changes for Load 2.
78
Fatigue Torso Muscle (%MVC)
Flexion/Extension
Symmetric Lift
100
Muscle Fatigue (%MVC) 90
80
70
60 80 cm
50 95 cm
40
30 110 cm
20
10
0
Load 1 Load 2
Load Type
Figure 5.6 Mean (±SD) torso flexion/extension muscle fatigue (%MVC) at L5/S1 as a result of load
and height changes in Scenario One - Symmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.
Figure 5.7 shows that both the changes in bench height and baby load had
minimal effect on torso fatigue (% MVC) in the lateral bending muscles.
Although fatigue in torso rotation muscle was also minimal (Figure 5.8), there
was an increase in the percentage of MVC when lifting baby Load 2 at the
lower height conditions. The t-test demonstrated a significant difference
between 95 cm and 110 cm bench heights, for both loads. The percentage of
MVC for right shoulder abduction/ adduction was increased as the bench
heights increased and when lifting baby Load 2 (Figure 5.9). The highest mean
score being 80% MVC ± 3.6% at the 110 cm, Load 2 condition. The t-test
identified significant differences in Load 1 at all of the bench height
comparisons, and significant differences for Load 2 at the 80 cm– 110 cm and
95 cm–110 cm comparisons. Figure 5.10 reveals that there was little difference
between load or height conditions on the percentage of MVC for right
shoulder flexion/extension muscles. Figure 5.11 indicates that there is a fatigue
effect on the humeral rotation muscles in the right shoulder when lifting at the
110 cm bench height regardless of load type, but no significant interaction
occurred.
79
Lateral Bending
Symmetric Lift
100
Muscle Fatigue (% MVC)
90
80
70
60 80 cm
50
40 95 cm
30
110 cm
20
10
0
Load 1 Load 2
Load Type
Figure 5.7 Mean (±SD) torso lateral bend muscle fatigue (%MVC) at L5/S1 as a result of load and
height changes in Scenario One - Symmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.

Rotation
Symmetric Lift
100
90
80
70
80 cm
60
50 95 cm
40
30 110 cm
20
10
0
Load 1 Load 2
Load Type
Figure 5.8 Mean (±SD) torso rotation muscle fatigue (%MVC) at L5/S1 as a result of load and height
changes in Scenario One - Symmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.
80
Fatigue Shoulder Muscle (%MVC)
Abduction/Adduction
Symmetric Lift
100
Muscle Fatigue (%MVC)

90
80
70
60 80 cm
50
95 cm
40
30 110 cm
20
10
0
Load 1 Load 2
Load Type
Figure 5.9 Mean (±SD) right shoulder abduction/adduction muscle fatigue (%MVC) as a result of load and
height changes in Scenario One - Symmetric Lift including. Load 1=7.5 kg. Load 2 =11.5 kg.

Flexion/Extension
Symmetric Lift
100
90
80
70
60 80 cm
50
95 cm
40
30 110 cm
20
10
0
Load 1 Load 2
Load Type
Figure 5.10 Mean (±SD) right shoulder Flexion/Extension muscle fatigue (%MVC) as a result of load and
height changes in Scenario One - Symmetric Lift including. Load 1=7.5 kg. Load 2=11.5 kg.

Humeral Rotation
Symmetric Lift
100
90
80
70
80 cm
60
50 95 cm
40
30 110 cm
20
10
0
Load 1 Load 2
Load Type
Figure 5.11 Mean (±SD) right shoulder humeral rotation muscle fatigue (%MVC) as a result of load and
height changes in Scenario One - Symmetric Lift including. Load 1=7.5 kg. Load 2=11.5 kg.
81
SCENARIO TWO – ASYMMETRIC LIFT
Scenario Two looked at the interaction of bench height and load in an

asymmetric lift of the baby load manikins. Figure 5.12 is a diagrammatic
representation of the asymmetric lift. This alignment to the bench required
participants to twist and flex toward the bench surface to lift the load. The
participants were required to stand on the right side of the bench with feet
comfortably positioned and with heels aligned to the end of the bench.
Participants were requested not to lean on the bench and could not take a
step. This lift scenario was completed at each bench height for each load type
totalling six lifts per participant. The ANOVA Summary Table 5.3 presents the
main effect and interaction outcomes of bench height and load type changes
resulting from the asymmetric lift.
Figure 5.12 Representation of Scenario Two, Asymmetric Lift. Sagittal and Frontal views at 80 cm bench
height. (Images from 3DSSPP Version 5.0.6)
82
Table 5.3 Repeated Measures ANOVA Summary of Bench Height and Load Main Effects
for Scenario Two, the Asymmetric Lift.

Bench Ht 2,18 21 0.001 1.000

Main effect Load 1,9 105 0.001 1.000
Bench Ht 2,18 20 0.001 1.000
Shear Force (N)

Main effect Load 1,9 294 0.001 1.000
Bench Ht 2,18 25 0.001 1.000
Ligament Strain (%)

Bench Ht 2,18 40 0.001 1.000

Flex/Ext Main effect Load 1,9 0.4 0.552 0.086
Bench Ht 2,18 11 0.001 0.979

Lat. Bend Main effect Load 1,9 11 0.009 0.844
Bench Ht 2,18 2 0.202 0.318

Rotation Main effect Load 1,9 23 0.001 0.988
Bench Ht 2,18 18 0.001 0.999

Abd/Add Main effect Load 1,9 38 0.001 1.000
Bench Ht 2,18 3 0.121 0.418

Flex/Ext Main effect Load 1,9 57 0.001 1.000
Bench Ht 2,18 3 0.128 0.408
Interaction Load/B.Ht 2,18 0.02 0.980 0.053

Hum Rot. Main effect Load 1,9 47 0.001 1.000
Bench Ht 2,18 4 0.046 0.598
* P values shown in bold denote significance at p< 0.017.
83
With asymmetric lifting, torso extension (Figure 5.13) increased with bench
height evaluation, but decreased when lifting the heavier load. The post hoc
paired t-test analysis revealed that in the Load 1 condition, a significant
difference was evident between 80 cm–110 cm and 95 cm–110 cm bench
heights, whereas in the Load 2 condition, significant differences occurred for all
height changes.

Asymmetric Lift.
Extension
90
80
70
60
50 80 cm
40 95 cm
30
110 cm
20
10
0
Flexion
Load 1 Load 2
Load Type
Figure 5.13 Mean (±SD) torso extension as a result of load and height changes in Scenario Two -
Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.
Figure 5.14 shows that CF increased with decreasing bench heights and
increased with the heavier load. The highest individual mean CF outcome was
2700 N. Due to the recruitment of additional torso muscles, the L5/S1 disc
compression force in asymmetric lifting may be underestimated in the 3DSSPP
analysis (3D SSPP version 5.0.6). As a result the single lift BCDL is reduced by 20%
to 2700 N to compensate for this (NIOSH, 1991).
84
Asymmetric Lift.
3500
Compression Force (N) 3000
2500
2000 80 cm
1500 95 cm
1000
110 cm
500
0
Load 1 Load 2
Load Type
Figure 5.14 Mean (±SD) compression force (N) at L5/S1 as a result of load and height changes in
Scenario Two - Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg. The BCDL (indicated by red line) for a
single asymmetric lift = 2700N (NIOSH, 1994).
SF in the asymmetric lift was increased with the larger baby load, but not by
bench height changes. The greatest mean SF was 277 N occurring in the Load
2, 80 cm condition (Figure 5.15). The post hoc tests indicated in the Load 1
height comparisons, a significant difference occurred between 80 cm–110 cm
and 95 cm–110 cm, and for all height changes in the load 2 comparisons.
Shear Force (N)

Asymmetric Lift.
600
500
Shear Force (N)
400
80 cm
300
95 cm
200
110 cm
100
0
Load 1 Load 2
Load Type
Figure 5.15 Mean (±SD) shear force (N) at L5/S1 as a result of load and height changes in Scenario Two
- Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg. The Shear Force DL (indicated by red line) for a single
symmetric lift = 500N (McGill, 1998).
85
The mean estimated ligament strain (Figure 5.16) was increased with
decreasing bench heights and with the greater load. Individual scores ranged
from 6% to 16%. T-tests indicated for Load 1, that significant difference occurred
between 80 cm–110 cm and 95 cm–110 cm, and significant differences for the
three height changes for Load 2.
Ligament Strain (%)

Asymmetric Lift
35
Estimated Strain (%)
30
25
80 cm
20
95 cm
15
110 cm
10
5
0
Load 1 Load 2
Load Type
Figure 5.16 Mean (±SD) estimated ligament strain at L5/S1 as a result of load and height changes in
Scenario Two - Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg. Ligament strain of 30% for a single
symmetric lift (indicated by red line) = injury risk for most healthy adults (3DSSPP, 2006).
Torso flexion/extension muscle fatigue (%MVC) as seen in Figure 5.17 was

increased with the heavier load and was affected more by the changes in
load than those resulting from varying bench heights within each load group. T-
tests showed significant differences for bench height comparisons at 80 cm–
110 cm and 95 cm–110 cm with both Loads 1 and 2.
86
Flexion/Extension
Asymmetric Lift

90
80
70
80 cm
60
50 95 cm
40
30 110 cm
20
10
0
Load 1 Load 2
Load Type
Figure 5.17 Mean (±SD) torso flexion/extension muscle fatigue (%MVC) at L5/S1 as a result of load
and height changes in Scenario Two - Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.
Figure 5.18 indicates that the percentage of MVC on lateral bending was
increased by increasing bench height, but there was little difference between
baby loads. Post hoc analysis was not required.

Lateral Bending
Asymmetric Lift
100
80
80 cm
60
95 cm
40
110 cm
20
0
Load 1 Load 2
Load Type
Figure 5.18 Mean (±SD) torso lateral bending muscle fatigue (%MVC) at L5/S1 as a result of load and
height changes in Scenario Two - Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.
In contrast, torso rotation muscle fatigue (%MVC) was clearly increased by

decreasing bench height and with the greater baby load (Figure 5.19). The
post hoc tests revealed that when lifting Load 1, there were significant
87
differences at the 80 cm–110cm and the 95 cm–110 cm comparisons, while
significant effects were present at all height changes for Load 2.

Rotation
Asymmetric Lift
100
80
80 cm
60
95 cm
40
110 cm
20
0
Load 1 Load 2
Load Type
Figure 5.19 Mean (±SD) torso rotation muscle fatigue (%MVC) at L5/S1 as a result of load and height
changes in Scenario Two - Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.
Figure 5.20 reveals that the percentage of MVC for right shoulder abduction/
adduction is increased for the heavier baby load. The post hoc t-tests
indicated there were no significant differences as a result of height changes
within either of the load types. With reference to Figure 5.21, fatigue in the right
shoulder flexion/extension muscles is increased with increasing bench height,
but not load changes. ANOVA indicated no significant interaction; hence no
further analysis was made. Humeral rotation muscle fatigue was increased by
increasing baby load. Figure 5.22 shows that the percentage of MVC was
greatest at the 110 cm height for both loads. The post hoc tests revealed that
when lifting Load 1, there were significant differences at the 80 cm–110 cm and
the 95 cm–110 cm comparisons, whereas significant effects were present at all
height changes for Load 2.
88
Abduction/Adduction
Asymmetric Lift
100

90
80
70
60 80
50 95
40
110
30
20
10
0
Load 1 Load 2
Load Type
Figure 5.20 Mean (±SD) right shoulder abduction/adduction muscle fatigue (%MVC) as a result of load
and height changes in Scenario Two - Asymmetric Lift. Load 1=7.5 kg. Load 2=11.5 kg.

Flexion/Extension
Asymmetric Lift
100
80
60 80
95
40
110
20
0
Load 1 Load 2
Load Type
Figure 5.21 Mean (±SD) right shoulder flexion/extension muscle fatigue (%MVC) as a result of load and

Humeral Rotation
Asymmetric Lift
100
90
80
70
60
80
50 95
40
30 110
20
10
0
Load 1 Load 2
Load Type
Figure 5.22 Mean (±SD) right shoulder humeral rotation muscle fatigue (%MVC) as a result of load and
89
COMPARISON OF SYMMETRIC AND ASYMMETRIC LIFTS
This analysis compares the resultant effects on the body between alignment of
the symmetric and asymmetric lifts at the three bench heights. Figure 5.23 is a
diagrammatic representation comparing both lift postures. These analyses
were performed using baby Load 2 only. The ANOVA summary Table 5.4
presents the outcomes from the main effects of stance or lift alignment and
bench height when lifting the 11.5 kg baby load manikin.
Scenario One. Symmetric Lift. Scenario Two. Asymmetric Lift
Figure 5.23 Representation of Symmetric and Asymmetric Lifts. Sagittal and Frontal views at 80 cm
bench height. (Images from 3DSS PP Version 5.0.6)
90
Table 5.4 Repeated Measures ANOVA Summary of Stance Alignment and Bench
Height Main Effects for the Comparison of Symmetric and Asymmetric Lift at Load 2.

Main effect Alignment 1,9 34.5 0.001 0.999
Bench Ht 2,18 103 0.001 1.000
Interaction Align/B.Ht 2,18 3.7 0.046 0.600

Main effect Alignment 1,9 35 0.001 0.999
Bench Ht 2,18 37 0.001 0.999
Shear Force (N)

Bench Ht 2,18 56 0.001 1.000
Interaction Align/B.Ht 2,18 3 0.062 0.547
Ligament Strain (%)

Bench Ht 2,18 86 0.001 1.000

Flex/Ext Main effect Alignment 1,9 34 0.001 0.999
Bench Ht 2,18 3 0.065 0.537

Lat. Bend Main effect Alignment 1,9 23 0.001 0.990
Bench Ht 2,18 3.5 0.053 0.376

Rotation Main effect Alignment 1,9 0.85 0.381 0.131
Bench Ht 2,18 18.7 0.001 0.999

Abd/Add Main effect Alignment 1,9 4 0.088 0.402
Bench Ht 2,18 19 0.001 0.999

Flex/Ext. Main effect Alignment 1,9 28 0.001 0.996
Bench Ht 2,18 5 0.017 0.753

Hum Rot. Main effect Alignment 1,9 14 0.004 0.919
Bench Ht 2,18 26 0.001 1.000
*P values shown in bold denote significance at p< 0.017
91
The asymmetric lifting produced greater torso extension than the symmetric lift
(Figure 5.24) and changing bench height had an effect in both stance
alignments. The ANOVA (Table 5.3) revealed no significant interaction.

Symmetric vs Asymmetric Lift
Extension
90
80
70
60
80 cm
50
40 95 cm
30 110 cm
20
10
0
Flexion
symmetric asymmetric
Lift Alignment
Figure 5.24 Mean (±SD) degrees of torso extension as a result of stance alignment and height changes in
Symmetric vs Asymmetric lift.
The symmetric lift generated a higher back CF outcome than the asymmetric
lift (Figure 5.25). The ANOVA indicated significant main effects for both
alignment and bench height, but no significant interaction.

3500
3000
2500
80 cm
2000
95 cm
1500
1000 110 cm
500
0
Lift Alignment
Figure 5.25 Mean (±SD) compression force (N) L5/S1 result of stance alignment and height changes in
Symmetric vs Asymmetric lift. The BCDL for a single symmetric lift = 3400 N (NIOSH, 1981), and for a
single asymmetric lift = 2700 N (NIOSH, 1994), indicated by red and blue lines respectively.
92
Figure 5.26 indicates higher mean SF outcomes for the symmetric alignment.
The ANOVA revealed significant main effects for both alignment and bench
height, but no significant interaction.
Shear Force (N)

600
500
Shear Force (N)
400
80 cm
300
95 cm
200 110 cm
100
0
Lift Alignment
Figure 5.26 Mean (±SD) shear force (N) L5/S1 result of stance alignment and height changes in
Symmetric vs Asymmetric Lift. The Shear Force DL for a single symmetric lift = 500N (McGill, 1998).
Level indicated by red line.
Estimated ligament strain was affected in both alignments, but the symmetric
lift scenario recorded higher mean scores throughout the bench height
changes (Figure 5.27). However, in both lifting postures the greatest ligament
strain occurred at the 80 cm bench height. No significant interaction was
observed and no post hoc analysis was required.
93
Ligament Strain (%)
35
Estimated Strain (%) 30
25
80 cm
20
15 95 cm
10 110 cm
5
0
Lift Alignment
Figure 5.27 Mean (±SD) estimated ligament strain (%) L5/S1 result of stance alignment and height
changes in Symmetric vs Asymmetric lift. Ligament strain of 30% for a single symmetric lift (indicated by
red line) = injury risk for most healthy adults (3DSSPP, 2006).
The torso flexion/extension muscle fatigue graph (Figure 5.28) shows the
symmetric lift produced a higher mean percentage of MVC, and the ANOVA
identified a significant main effect for alignment and significant interaction. The
post hoc analysis revealed that this effect of stance was significant at the 80
cm and 95 cm bench heights but not at 110 cm.

Flexion/Extension
100
80
80 cm
60
95 cm
40
110 cm
20
0
Lift Alignment
Figure 5.28 Mean (±SD) torso flexion/extension muscle fatigue (%MVC) result of stance alignment and
height changes in Symmetric vs Asymmetric lift.
Figure 5.29 shows that torso fatigue in lateral bending muscles was greater (%
MVC) with the asymmetric stance across the bench height changes. The t-test
94
revealed a significant difference occurred between stance alignment only at
the 95 cm and 110 cm bench heights.

Lateral Bending
100
80
80 cm
60
95 cm
40
110 cm
20
0
Lift alignment
Figure 5.29 Mean (±SD) torso lateral bending muscle fatigue (%MVC) result of stance alignment and
height changes in Symmetric vs Asymmetric lift.
Torso rotation fatigue (Figure 5.30) was clearly affected by lift alignment, with
the asymmetric lifting having a greater impact on the percentage of MVC
than the symmetric lifting. The post hoc tests indicated significant difference
between lift alignments at all bench heights.

Rotation
100
80
60 80 cm
95 cm
40
110 cm
20
0
Lift Alignment
Figure 5.30 Mean (±SD) for torso rotation muscle fatigue (%MVC) result of stance alignment and height
changes in Symmetric vs Asymmetric lift.
95
The percentage of MVC required for right shoulder abduction/adduction
(Figure 5.31) is greater in the symmetric alignment. Although the ANOVA
revealed a significant main effect for bench height, there was no significant
interaction.

Abduction/Adduction
100
80
60 80 cm
40 95 cm
20 110 cm
0
Lift Alignment
Figure 5.31 Mean (±SD) right shoulder abduction/adduction muscle fatigue (%MVC) result of stance
alignment and height changes in Symmetric vs Asymmetric lift.
Figure 5.32 indicates a slight increase in the percentage of MVC for right
shoulder flexion/extension as a result of asymmetric alignment, but no
significant interaction was identified by the ANOVA.

Flexion/Extension
100
Muscle Fatigue
80
(%MVC)
60 80
40 95
110
20
0
Lift Alignment
Figure 5.32 Mean (±SD) right shoulder flexion/extension muscle fatigue (%MVC) result of stance
96
Asymmetric stance alignment created greater fatigue in the right humeral
rotation muscles (Figure 5.33) and the bench height changes in the asymmetric
stance also revealed a greater difference in the percentage of MVC than the
symmetric lift. The post hoc analysis indicated there were significant differences
between lift alignments at the 95 cm and 110 cm bench heights.

Humeral Rotation
100
Muscle Fatigue
80
(%MVC)
60 80
95
40
110
20
0
Lift Alignment
Figure 5.33 Mean (±SD) right shoulder humeral rotation muscle fatigue (%MVC) result of stance
97
SCENARIO THREE – MID-CALF REACH
Scenario Three tested the outcome of bench height changes to a flexed, twist
and reach posture. The test required participants to stand at the end of the
change bench as for Scenario One. Figure 5.34 is a diagrammatic
representation of the mid-calf reach in which participants were required to
apply a downward force of approximately 10 kg (100 N) with the right hand
onto the middle of the torso of the 11.5 kg manikin at a distance of 40 cm from
the standing end of the bench. At the same time, subjects were required to
reach with their left hand to the surface of a small stool (Ht = 35 cm). This
“reach and hold” posture was completed at each bench height using only the
baby load 2 manikin, totalling three tests per participant. The ANOVA summary
Table 5.5 presents the main effect of bench height changes on the dependent
variables.
Figure 5.34 Representation of Scenario Three, Mid-calf Reach. Sagittal and Frontal views at 95 cm bench
height. (Images from 3DSSPP Version 5.0.6)
98
Table 5.5 Repeated Measures ANOVA Summary of Bench Height Effect for Scenario
Three, the Mid-calf Reach.

Main effect Bench Ht 2,18 13 0.001 0.992

Shear Force (N)

Main effect Bench Ht 2,18 15.5 0.001 0.917
Ligament Strain (%)


Flex/Ext Main effect Bench Ht 2,18 16 0.001 0.998

Lat. Bend Main effect Bench Ht 2,18 8 0.003 0.915

Rotation Main effect Bench Ht 2,18 2 0.139 0.391

Abd/Add Main effect Bench Ht 2,18 1 0.380 0.200

Flex/Ext Main effect Bench Ht 2,18 19.5 0.001 1.000

Hum Rot. Main effect Bench Ht 2,18 25.5 0.001 1.000
*P values shown in bold denote significance at p< 0.017
99
Figure 5.35 indicates the degree of torso flexion/extension required to meet the
conditions of this scenario, with a mean of 6° extension at 80 cm bench height
and an increase in torso extension of approximately 5° at each increase in
bench height. The post hoc analysis revealed significant differences between
all height changes; 80 cm–95 cm, 80 cm–110 cm, and 95 cm–110 cm.
Torso Extention (degrees)

Mid-calf Reach
Extension
90
Torso Extention (degrees)
80
70
60
50
Load 2
40
30
20
10
0
Flexion
80 cm 95 cm 110 cm
Bench Height (cm)
Figure 5.35 Mean (±SD) degrees of torso extension as a result of bench height in Scenario Three, Mid-
calf Reach. Right hand down-ward push of 100N.
The L5/S1 CF was affected by bench height changes (Figure 5.36) with the
greatest outcome at the 95 cm with a mean of 1972 N and a SD of 775 N. The
single effort BCDL for an asymmetric posture is 2700 N (NIOSH, 1991) as
indicated by the blue line. The t-test revealed significant differences between
all bench height changes; 80 cm–95 cm, 80 cm–110 cm, and 95 cm–110 cm.

Mid-calf Reach
3000
2500
2000
1500
Load 2
1000
500
0
80 cm 95 cm 110 cm
Bench Height (cm)
Figure 5.36 Mean (±SD) compression force (N) L5/S1 result of bench height in Scenario
Three, Mid-calf Reach. Right hand down-ward push of 100N. The BCDL (indicated by blue line)
for a single asymmetric lift = 2700 N (NIOSH, 1991).
100
SF was also affected by bench height changes, the greatest outcome being at
the 95 cm height with 289 N (Figure 5.37). The post hoc tests indicated
significant differences at bench height comparisons between 80 cm–95 cm
and 95 cm–110 cm.
Shear Force (N)

Mid-calf Reach
600
500
Shear Force (N)
400
300 Load 2
200
100
0
80 cm 95 cm 110 cm
Bench Height (cm)
Figure 5.37 Mean (±SD) shear force (N) L5/S1 result of bench height in Scenario Three, Mid-
calf Reach. Right hand down-ward push of 100N. The Shear Force DL (indicated by red) line
for a single symmetric lift = 500N (McGill, 1998).
The group mean for estimated L5/S1 ligament strain was consistent across all
height changes with 19% for both the 80 cm and the 95 cm heights and 18% at
the 110 cm bench height. A 30% level of ligament strain (Figure 5.38) indicates
the extent of elastic strength of these ligaments and hence, an increased risk of
injury to most healthy adults. The post hoc revealed the only significant
difference in heights being at the 80 cm–110 cm height comparison.
101
Ligament Strain (%)
Mid-calf Reach
35
Estimated Strain (%) 30
25
20
Load 2
15
10
5
0
80 cm 95 cm 110 cm
Bench Height (cm)
Figure 5.38 Mean (±SD) estimated ligament strain (%) L5/S1 result of bench height in Scenario Three,
Mid-calf Reach. Right hand down-ward push of 100N. Ligament strain of 30% for a single symmetric lift
(indicated by red line) = injury risk for most healthy adults (3DSSPP, 2006).
Torso flexion/extension muscle fatigue was affected by bench height as can be

seen in Figure 5.39 and the t-test revealed significant differences at all height
comparisons; 80 cm–95 cm, 80 cm–110 cm, and 95 cm–110 cm.

Flexion/Extension
Mid-calf Reach
100
80
60
Load 2
40
20
0
80cm 95cm 110cm
Bench Height (cm)

Figure 5.39 Mean (±SD) torso flexion/extension muscle fatigue (%MVC) result of bench height in Scenario
Three, Mid-calf Reach. Right hand down-ward push of 100N.
Lateral bending fatigue (Figure 5.40) shows only small changes in the
percentage of MVC with bench height changes. The t-test revealed a
significant difference occurred only between the 80 cm–95 cm bench height.
102
Lateral Bending
Mid-calf Reach
100
80
70
60
50 Load 2
40
30
20
10
0
80cm 95cm 110cm
Bench Height (cm)

Figure 5.40 Mean (±SD) torso lateral bending muscle fatigue (%MVC) result of result of bench height in
Scenario Three, Mid-calf Reach. Right hand down-ward push of 100N.
Muscle fatigue as a result of torso rotation (Figure 5.41) was considerably higher
than that reached in torso bending and flexing and presents the anomaly of
the lowest percentage of MVC incurred at the 95cm height. The ANOVA
presented no significant differences between rotation fatigue for bench
heights.

Rotation
Mid-calf Reach
100
80
60
Load 2
40
20
0
80cm 95cm 110cm
Bench Height (cm)
Figure 5.41 Mean (±SD) torso rotation muscle fatigue (%MVC) result of result of bench height in Scenario
Three, Mid-calf Reach. Right hand down-ward push of 100N.
The review of muscle fatigue in the right shoulder indicates that in shoulder
abduction/adduction (Figure 5.42), the percentage MVC was minimal with the
changes only occurring at the 95 cm bench height.
103
Abduction/Adduction
Mid-calf Reach
80
60
Load 2
40
20
0
80cm 95cm 110cm
Bench Height (cm)
Figure 5.42 Mean (±SD) right shoulder abduction/adduction muscle fatigue (%MVC) result of result of
bench height in Scenario Three, Mid-calf Reach. Right hand down-ward push of 100N.
The right shoulder flexion/extension muscle fatigue (Figure 5.43) was affected
by bench changes with the 95 cm height reporting a mean of 72% MVC. The t-
tests showed a significant difference occurred between the 80 cm– 95 cm and
80 cm– 110 cm bench heights.

Flexion/Extension
Mid-calf Reach
100
80
60
Load 2
40
20
0
80cm 95cm 110cm
Bench Height (cm)

Figure 5.43 Mean (±SD) right shoulder flexion/extension muscle fatigue (%MVC) result of bench height in
104
The greatest right shoulder muscle fatigue scores were recorded by the
humeral rotation muscles (Figures 5.44), and height changes clearly influenced
the percentage of MVC with scores observed to increase by approximately
25% of MVC at each bench height level. Muscle fatigue was significantly
different at each bench height.

Humeral Rotation
Mid-calf Reach
100
80
60
Load 2
40
20
0
80cm 95cm 110cm
Bench Height
Figure 5.44 Mean (±SD) right shoulder humeral rotation muscle fatigue (%MVC) result of bench height in
105
CHAPTER SIX
DISCUSSION
Work place MH is typically coupled with the common problem of work place
musculoskeletal injury, of which LBD is the most costly. Research in the area of
OHS has identified common hazards in handling, with progress over the past 20
years being made to reduce or eliminate associated injury risks. In the past 10
years there has been evidence that OHS strategies have been very effective in
reducing LBD in male dominated MH work places; however, the outcome for
women has not been so positive. One work place which consistently reports
higher than normal levels of LBD is occupational child care (Gratz et al., 2002).
Child care is a field of MH work that is equally demanding in both the
occupational and domestic environments and typically dominated by women.
Current OHS policies and procedures appear to be inadequate in regard to
injury prevention in this MH work and there is little or no quantified research
addressing the unique issues. The “constant” lifting involved in caring for
children has been suggested as the main contributing factor for the high rates
of LBD (Hostetler, 1984); however, the frequent and non-standardised nature of
lifting young children is perhaps difficult to assess accurately. Nappy changing
has been mentioned (Griffin & Price, 2000; Gratz, Claffey et al., 2002; Sanders &
Morse, 2005; King, Gratz et al., 2006) as a task contributing to LBD and is one of
the few lifting tasks in this work that provides an opportunity for repeatable,
valid and applicable biomechanical measurement of risk.
The primary aim of this thesis was to assess the task of changing a baby’s
nappy to determine if there were implications of physical risk for the women
involved. This was initiated in the first instance by Study One in which a
questionnaire was used to obtain feedback from women regularly involved in
the task. Study One quantified elements of the nappy change task for use in
the follow up biomechanical study (Study Two). It also provided a qualitative
perspective of the perceived LBP/LBD associated with the task. In Study Two
the three main variables involved in this MH task the operators, the loads and
the equipment, were then standardised; the task was simulated in the
laboratory and the lifting component tested using the 3D Static Strength
Prediction Program V5 (3DSSPP Version 5.0.4) (University of Michigan, 2005).
106
OUTCOME OF STUDY ONE
The questionnaire was widely distributed throughout Australia and although the
respondent sample was relatively small (n=411), the spread of responses
represented a broad ranging sample within the target population. However, as
response to this questionnaire was self selected, it is possible that those who
chose to respond were also those who have LBP, so the results may reflect this
bias. That being said, the demographics of the respondents represent the
average population of women involved in domestic (Pocock, 2003; Morehead,
2004; Preston & Whitehouse, 2004; Craig, 2007) child care as well as the general
work place (ABS, 2006). Quantitative information regarding the styles and
heights of purpose built nappy change furniture was accepted as being
representative of usage within the population. Over 50% of respondents used a
two or three tier change bench style which generally allows the operator to lift
in a symmetric posture and around 20% used a drawer top unit which usually
requires an asymmetric posture. However 25% of respondents reported using
surfaces other than purpose built furniture, including table tops, kitchen
benches, beds and floor surfaces. In regard to the qualitative aspects of the
questionnaire, the descriptions “lower back pain/ lower back disorder”
(LBP/LBD) were referred to jointly in the response options. This was done
because diagnosing pain verses disability is perhaps more a clinical practice,
but using one term and not the other within the questionnaire may cause
confusion and preclude a potentially relevant response. If the qualitative data
is accepted as reliable, the survey indicates that for 50% of respondents both
posture and lifting in the task of nappy changing are associated with LBP/LBD.
Furthermore LBP/LBD was also associated with the use of the nappy change
furniture with almost 50% of those using the two or three tier styles reporting
moderate to severe symptoms of LBP/LBD. A cross tabulation of relative
furniture heights comparing lifting and posture with LBP/LBD, indicated that as
the relative height of the bench surface increased, the LBP/LBD from lifting
decreased; however, LBP/LBD from posture was highest at the mid range
height (pubis to waist). Nonetheless, the cause of pain associated with posture
is not clear; it could be as a result of the awkward, prolonged pre-lift posture or
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it could be as a result of increased trunk flexion associated with lower level
reaching required from the tiered change furniture.
The majority of survey respondents had two or more children that required
nappy changing. The data also indicated a 3 month old child will need around
12 nappy changes a day, and the 18 month old will need at least six changes
per day. Although the average duration for the task was 3 minutes, of those
that reported longer durations, the lengthier periods were often associated with
older babies. Furthermore 11% of all the written responses mentioned heavier
loads were problematic in the nappy change task and this was perceived as
the cause of LBP/LBD. The estimated frequencies and duration of the nappy
change task provide a valuable insight to the degree of cumulative hazard
associated with the posture and lifting aspects of this task.
Qualitative responses also indicated that at least 50% of women appear to

develop LBP/LBD as a result of pregnancy; that the majority of pregnant and
postpartum women experience LBP/LBD associated with the task of nappy
changing; and multiparae women indicate a strong relationship between
nappy changing and LBP/LBD. It is also apparent that at least 8% of the
respondents had required medical intervention for their LBP, but equally many
women have a self effacing attitude to their LBP/LBD: “as a parent you don’t
even think about what you are doing to your back” …. “you don’t feel like you
should complain” (refer to Fig 4.20, Chapter 4, p 18.).
OUTCOME OF STUDY TWO
This study involved 10 female participants; three nulliparae, three in late

pregnancy and four unipara postpartum, all within the average height and BMI
range (Pheasant, 1988). The individual populations for this thesis were not in
question, so Study Two combined all participant results, from each test,
creating an average that is representative of women performing this task. The
3DSSPP was used to assess the outcome of a lift in a static position for a single
point in time.
Three separate postural scenarios, symmetric and asymmetric lifting postures

and a mid-calf reach posture were devised based on the styles and dimensions
of baby change furniture provided by Study One. Six biomechanical outcome
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measures were compared between three bench heights, two loads (3 month
and 18 month baby manikin) and the two stance alignments (symmetric and
asymmetric lifting postures). The third scenario, was a measure of an extreme
torso flexion posture duplicating the extended reach position required when
accessing nappy change items from either a lower shelf (when using two or
three tier change furniture styles); or the floor (often required in many of the
public nappy change facilities). When women are engaged in this flexed
reaching posture, the baby load atop the change bench must be secured
and generally this is done by holding the baby down with the available hand.
This posture was tested at the three bench heights and was reported
separately from the two lifting scenarios. The following presents results from
Study Two providing evidence to support or refute the hypotheses. Hypotheses
one to six relate to the symmetric and asymmetric lifting stances and seven to
12 are regarding the extended reach posture.
1. The hypothesis that

“there will be a difference (p < 0.017) in angle of torso extension as
a result of variations in height, load and stance”
is supported. The angle of torso extension was significantly affected by each of
the variations in bench height, load and stance alignments. Across all bench
heights and comparing both baby loads, the symmetric stance required
greater torso flexion at the point of lift than did the asymmetric stance. In both
stance alignments the greatest torso flexion was incurred at the 80 cm height
when lifting the heavier load. Secondly, the greatest difference in torso
extension between the two lifting alignments, 46° (symmetric) as opposed 60°
(asymmetric) was at the 80 cm bench height when lifting the 18 month load.

“there will be a difference (p < 0.017) in compression force at L5/S1
as a result of variations in height, load and stance”
is supported. Compression force (CF) was significantly affected by variations in
the height of the change bench, the load and the stance. In both lifting
scenarios the CF was greatest at the 80 cm bench height, but reduced as the
height of the change bench increased. The larger load augmented the CF at
all heights with the most hazardous being the 80 cm, 18 month load
combination. And although it is the symmetric lifting of the large load that
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creates the greatest CF at 3000 N (asymmetric 2120 N), both stance scenarios
created CF levels close to their respective back compression design limits
(BCDL) (NIOSH, 1991).

“there will be a difference (p < 0.017) in shear force at L5/S1 as a
result of variations in height, load and stance”
is supported. Shear force (SF) was significantly affected by variations in the
height of the change bench, the load and the stance. In this test the range of
SF reported was greater in the symmetric lift than asymmetric; and in both lifting
alignments SF appeared to be augmented more by the increased baby load
than variations in the height of the change bench.

“there will be a difference (p < 0.017) in ligament strain at L5/S1 as a
result of variations in height, load and stance”
is supported. Ligament strain was significantly affected by variations in the
height of the change bench, the load and the stance. The mean estimated
ligament strain was greatest in symmetric lifting, was reduced as the bench
height increased and was augmented by the larger load, with individual scores
as high as 18% at the 80 cm level for a single lift.

“there will be a difference (p < 0.017) in the estimated percentage
of torso muscle fatigue as a result of variations in height, load and
stance”
is partially supported in that the torso flexion/extension muscles fatigue (%MVC)
was significantly affected by variations in bench height as well as stance
alignment, but not from the variations in load. The hypothesis was also
supported in torso muscular fatigue in lateral bending from load variations in
the asymmetric alignment and as a result of variations in stance alignments.
The hypothesis is also supported in the (%MVC) torso rotation muscles for bench
height and load variations in the asymmetric lifts and the variations in stance
alignment. Clearly, in the symmetric stance, the requirement for torso rotation
and lateral bending is minimal and the results are a reflection of this. However,
regardless of load size, torso flexion/extension fatigue for a single lift in this
stance was very high, with mean values reaching almost 70 %MVC lifting the
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heavy load from the 80 cm height. Furthermore, in the asymmetric stance, the
mean lateral bending muscles %MVC was the same regardless of load and
change bench height variations. In contrast to this, %MVC for torso rotation in
the asymmetric stance was clearly influenced by both load and height
changes with the highest bench height reducing the impact from lifting the
heavier load.

“there will be a difference (p < 0.017) in the estimated percentage
of shoulder muscle fatigue as a result of variations in height, load
and stance”
is partially supported in shoulder abduction/adduction muscles (%MVC) for
load variations in both lifting postures and bench height variations in the
symmetric posture only. The hypothesis was supported in shoulder
flexion/extension muscle (%MVC) for load variations in both lifting postures and
stance alignment only. The hypothesis was supported in humeral rotation for
variations in load and stance alignments as well as the bench height variations
in the symmetric stance, but not the asymmetric stance.

“there will be a difference (p < 0.017) in angle of torso extension as
a result of variations in height during a flexed, hold and reach
posture”
is supported. The angle of torso extension was significantly different as a result
of variations in the height of the change bench. The mean angle of extension
at the 80 cm height was 6° however, the range included angles of flexion
below 0° (horizontal). Even at the 110 cm height though, the mean angle of
extension was 15°.

“there will be a difference (p < 0.017) in compression force at L5/S1
as a result of variations in height during a flexed, hold and reach
posture”
is supported. There was a significant difference in CF at L5/S1 as a result of
variations in the height of the change bench during the reach posture. At the
95 cm bench height, in the asymmetric posture some of the individual
outcomes exceeded the NIOSH (1991) BCDL.
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“there will be a difference (p < 0.017) in shear force at L5/S1
posture”
is supported. There was a significant difference in SF at L5/S1 as a result of
variations in the height of the change bench during the reaching posture. SF
was also greatest at the 95 cm bench height.

“there will be a difference (p < 0.017) in ligament strain at L5/S1
posture”
is supported. Ligament strain at L5/S1 was significantly different as a result of
variations in the height of the change bench during the reaching posture.
Ligament strain in this posture varied between 17% and 20% with increasing
bench height.

“there will be a difference (p < 0.017) in torso muscle
fatigue(%MVC) as a result of variations in height during a flexed,
hold and reach posture”
is partially supported in that the %MVC of torso flexion/extension muscles and
the lateral bending muscles, but this hypothesis was not supported for changes
in torso rotation muscle fatigue. The %MVC for this muscle group ranged
between 40% and 60%. The 95 cm bench height elicited the greatest fatigue in
flexor/extensor muscles and in the lateral bending muscles.

“there will be a difference (p < 0.017) in shoulder muscle fatigue
(%MVC) as a result of variations in height during a flexed, hold and
reach posture”
is supported in %MVC in shoulder flexion/extension and humeral rotation
muscle groups, but is not supported by fatigue changes in the muscle groups
responsible for shoulder abduction/adduction.
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SYNTHESIS OF THE STUDIES
The scope of this study was quite broad and interrelated, with the results
revealing so many apparent hazards that it is difficult to make a prioritised
discussion without devaluing outcomes of equal relevance. The following
section will synthesise the results from Studies One and Two and draw reasoning
from the review of literature to present what is now a more informed
perspective of the MH task of nappy changing while caring for young children.
The discussion of dependent variable outcomes cannot be made without
summarising the five key independent variables which are also the ergonomic
elements influencing risk of LBI through this task; namely load, equipment,
frequency, duration and operator characteristics.
Load
The one independent variable common to all child care MH work is the baby
load. “The constant lifting and lowering of children has wrecked my pelvic floor
and injured my back” (refer to Fig. 4.20, Chapter 4, p18.). Study One indicated
that over half of the respondents reported moderate to severe symptoms of
LBP/LBD associated with lifting children from the change bench. Furthermore,
over 50% of respondents were caring for two children, one under 2 years, and a
second under 6 months. The baby as a load is unlike other MH loads; it’s top
heavy, unpredictable and undergoing rapid physical and mental
development; and it’s not usual for two or more operators to be lifting it (King et
al., 2006). Furthermore, work involving the MH of young children, always
prioritises the safety of the child above that of the carer. The implications for
operators lifting these loads are two fold; firstly in grasping and lifting the child
and secondly in managing the inertia, particularly when the child is in supine
position and is being demonstrative. “My two year old is 17 kg, sometimes he
struggles so much when I change his nappy that my husband has to hold him
down, it can be exhausting” (refer to Fig. 4.20, Chapter 4, p 18.).
From the analysis of the static lifts performed in Study Two, CF at the L5/S1 joint
is increased significantly in all conditions as a result of the increased size of the
baby load. Furthermore, lifting the large load from the 80 cm bench height
created a CF outcome which came to within 400 N of the BCDL for both lifting
stance alignments, thereby indicating that a single lift of the heavy baby load
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(11.5 kg) resulted in near hazardous CF levels. That being said, the 18 month
baby load manikin used in Study Two was reduced to 11.5 kg for the safety of
the participants in the study and to provide a sense of reality to the lifting
posture. The true average weight 13 kg means the actual CF outcome is likely
to be higher than the BCDL for a single lift, increasing the probability of LBI risk
to the operators regardless of lifting alignment.
According to Chaffin (2005), if a heavy load (i.e. ≥ 10 kg), is lifted from a

distance of more than 30 cm from the midline of the lifter, then the resultant CF
will be greater than the NIOSH BCDL. It is also worth noting that although the
average 3 month old baby weighs less than 10 kg, in symmetric alignment it will
be lifted approximately 32 cm from the end of the bench. Furthermore, the
baby as a load opposes all the standard ergonomic MH load design
conventions. Coupling and inertia are a challenge and compounding this is
the unpredictable behaviour of the load; and the increased postural strain
from lifting a load in which the CoM becomes more distal to the lifter as it gets
larger.
Whilst the prediction method in the biomechanical analysis of Study Two may
have its limitations, the estimated values provide a benchmark indication of
biomechanical stress in the IV joints of the lower back. So although we don’t
know the real impact of lifting these animate and complex loads, the Study
One reports of LBP/LBD associated with lifting supports the notion that handling
these loads may be more hazardous than we have been able to estimate in
this study.
Equipment
The style and surface height of nappy change furniture determines the
operators’ lifting stance alignment, posture and in this case, the torso motion
components of the task. According to Study One, about 75% of respondents
use purpose built nappy changing furniture, with the majority lifting from a
surface height of between 80 cm–110 cm. With respect to the two styles of
furniture that are predominately used in the domestic environment, almost 50%
of respondents reported moderate to frequently painful symptoms of LBP/LBD
associated with both the posture and lifting aspects of the task when using this
furniture. Interestingly, the LBP/LBD rating associated with proportional height of
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the change furniture indicated that lifting from the lowest height (mid thigh to
pubis) incurred the maximum LBP/LBD rating. In contrast though, the LBP/LBD
relating to posture was greatest when using furniture that was pubis to waist
height or higher. “Nappy changing puts you in a very unnatural position and
causes me a great deal of back pain on a daily basis” (refer to Fig. 4.20
Chapter 4, p 18).
Because nappy change furniture dimensions dictate the posture and motion of
operators performing this task, it also affects spinal loading and forces during
the task. For example, SF is influenced by dynamic aspects of lifting, with the
rate and symmetry of loading having greater bearing on the outcome of SF
than increased size and weight of the load alone (Fathallah et al.,1998). The SF
Action Limit (AL), the point of heightened risk of LBI in a one off lift, is 500 N
(McGill et al., 1998). In reviewing the results from Study Two, the highest mean
for sagittal plane SF at L5/S1 was 300 N reported for the heavy load at the 80
cm bench height in the symmetric lift. SF is augmented in spinal rotation so the
expectation perhaps was that SF would have been greater in the asymmetric
lift. It is possible that our test results have been influenced by the methodology
of using a static analysis for measuring this dynamic motion and the true SF may
be much greater.
The result of the mid-calf reach indicates surprisingly, a quite marked increase
in SF at the mid range bench height of 95 cm and higher. Although again the
mean SF was around 300 N for the static test, the range of scores included
outcomes of up to 400 N from this torso twisted, hyper-flexed, reaching posture.
It should be noted that the CF was also greatest at this bench height in this
posture, with the standard deviation indicating levels higher than the BCDL.
Both the CF and SF outcomes support the LBP/LBD reports from task related
posture at this height indicated in Study One. Standard OHS and ergonomic
advice is that the risk of LBI would decrease as a result of optimising the work
surface to waist height (90 cm) or higher for both lifting alignments (Kroemer &
Grandjean, 2001; Chaffin, 2005). However, when performing this reaching task
using waist height furniture, it’s possible that some operators may be at higher
risk of LBP/LBD. The other point to note here is that waist height for pregnant
women is at around the same level as the apex of their abdominal girth, i.e.
placing their midline further from the load and the lifting surface. This again
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suggests that caution is required when prescribing optimum bench heights in
this task.
The angle of torso flexion indicates the posture of the operator and further
highlights the biomechanical forces that may be exerted on the intervertebral
(IV) joint structures. In our study there was clear differentiation in the degree of
flexion/extension between the two stance alignments which reflect a more
upright position in the asymmetric alignment. The varying heights of the
change bench also have an obvious effect on angle of flexion/extension in
both stance alignments. As we would expect, the lower bench heights require
a more flexed posture with the larger baby load augmenting flexion and
eliciting an angle of 35° (0° being torso horizontal) at the 80 cm height from the
symmetric lift.
Furthermore, torso flexion in the mid-calf reach task recorded angles of less
than 0°. The degree of flexion augments the magnitude of loading,
dramatically increasing fatigue in erector spinae muscles (Gallagher et al.,
2005). Ligament strain in the lower back is a further indicator of stress within the
IV joints. The lumbar dorsal fascia between L5/S1 is the location at which the
3DSSPP estimates ligament strain resisting forward flexion and reports the limit of
elasticity to be 30% for a one off lift. Our study revealed that ligament strain
increased when lifting the heavier load and decreased as the posture became
more upright. The highest level of strain recorded was 15%, occurring in the
symmetric stance and clearly well under the 30% limit. Although the outcome
from 3DSSPP estimates the ligament flexion strain in the asymmetric stance is
less than the symmetric stance, it gives no indication of the torsion strain on IV
ligaments that may occur as a result of the complex three dimensional nature
of this task. Also, it is important to point out that the mid-calf reach posture
would generally be one component within a sequence to complete the MH
task of nappy changing. Combing torso flexion, with rotation and/or lateral
bending; or flexing to reach a lower work level following static flexion are
movement patterns that have been associated with LBI hazard .
Dynamic and static postures involving hyperflexion, awkward twisting, lateral

bending and extended reaching augment SF, CF, ligament strains and muscle
fatigue and as such are opposed in all OHS recommendations for safe lifting
practices. Our results indicate that, regardless of the load, purpose built
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equipment designs often require operators to adopt dangerous postures to
complete this MH task.
Frequency, Duration and Fatigue
Study One responses indicated a 3 month old child will have a nappy change
10–12 times a day, whereas an 18 month child will be changed approximately
six times per day. The majority of Study One respondents (55%) were changing
nappies on at least two children, therefore potentially repeating this task
approximately 18 times per day. Study One indicates that after lifting the load
onto the work surface, operators will spend around 4 minutes engaged in the
actual task of nappy changing prior to lifting the child from the change
surface. Changing a young baby load is reasonably straight forward, but as the
child develops, so too can the duration of the task, the physical complexities
and the demand on the carer’s strength requirements. There are no reported
data on the frequency of nappy changing in occupational child care, but
standard practice dictates that most of the children will be between 1–3 years
of age and will have a nappy change every 3–4 hours. Anecdotal information
is that one carer will be responsible for completing nappy changes on all the
children in their care, consecutively; which can often mean 16–20 changes
within a short period of time.
“I think twins make it worse” (refer to Fig. 4.20, Chapter 4, p 18). The frequency
and the duration will affect the outcome of localised muscle fatigue, and
muscle fatigue affects lifting strategies and motion patterns (Dolan & Adams,
1998; Parakaat et al., 2007, Bonato, 2003). Lifting from a flexed posture implies
that the spinal muscles have lengthened, perhaps employing eccentric
contraction to reach the flexed position. Therefore, the duration of the task
prior to lifting becomes an issue because of the amount of stretch or creep and
destabilising of the IV joint structures during the period of the held posture
(McGill, 1997). The 3DSSPP results indicated that muscle fatigue in torso flexion-
extension (%MVC), was greatest in the symmetric stance. However %MVC in
the torso muscle groups involved in lateral bending and rotation was
considerable in the asymmetric alignment with rotator muscles reaching almost
80% MVC for the single lift at the lowest bench height. These results indicate
that in asymmetric lifting, torsion is likely to become a hazard due to torso
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rotator muscle fatigued. However, in all three test scenarios the stretched torso
flexor/extensor muscles which actively support loading during lift and extension,
exhibit high levels of fatigue compromising IV joint stability and increasing the
risk of LBI, which may be exacerbated by the frequency and duration of this
MH task (Kroemer & Grandjean, 2001).
Due to the large number of respondents in Study One complaining of upper

back and “shoulder blade” pain, Study Two also assessed shoulder muscle
fatigue during the nappy change task. The 3DSSPP reports indicated much the
same outcome for both stance alignments with %MVC shoulder
abduction/adduction being significantly affected by increased baby load, as
well as the increasing height of the change bench surface. It was noted, that in
the symmetric stance, at the highest bench surface, most of the participants
pulled the load toward the body before lifting it. This is relevant in that SF can
be augmented if the load is pulled prior to lifting (Dolan & Adams, 1993;
Delleman et al., 2004; Genaidy et al., 2006). Regardless of this, both stance
alignments reported high levels of shoulder muscle fatigue and as a result,
appear to add credence to the comments of upper back pain made in Study
One. Further supporting these respondent comments is the outcome of
shoulder muscle fatigue in the mid-calf reach. This posture required the right
arm to apply a force to the baby load manikin equivalent to that applied in a
real situation. The 3DSSPP outcome indicated extreme fatigue in the humeral
rotation and shoulder flexion/extension muscle groups which increased along
with the height of the change surface.
“Despite my attempts to lift correctly and minimise strain, constant lifting has
definitely had an impact on my back pain” (refer to Fig. 4.20 Chapter 4, p 18).
Muscle fatigue and ligament laxity are both products of the duration and/or
frequency of either dynamic or static work. In the most favourable conditions
lifting a baby load is hazardous, but the frequency, duration and conditions of
this task heighten the risk of LBI for any healthy adult. That being said, it must
also be acknowledged that these biomechanical outcomes are complicated
and compounded by the characteristics of the individuals performing the task.
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Operator Characteristics
Study One indicated that most women associated some level of LBP/LBD with
the posture and the lift components of this task. This study also revealed that
women have a 50% risk of developing LBP during and/or subsequent to
pregnancy. Furthermore, those who reported high levels of LBP rated the LBP
associated with the posture and lifting components of the nappy change task
as severe. Study Two has revealed implications for spinal CF and SF, ligament
strain and muscle fatigue for anyone performing this MH task. The women
involved in child care include grandmothers, paediatric nurses, child care
workers, postpartum women and around half of all pregnant women.
Although the morphology of these women was not assessed as part of this
study, we must acknowledge the diversity of the operators’ physical
characteristics as well as the circumstances in which they work.
It is likely that child care workers performing this task repeatedly, sustaining
combined and hazardous postures for long periods of time, have an increasing
likelihood of cumulative muscle and ligament fatigue. It is likely that new
mothers have a destabilised CoG as well as compromised pelvic floor and
potential loss of abdominal and spinal muscle integrity. Individually and when
combined, these individual characteristics have implications for spinal loading.
Moreover, it is likely that mothers who are also pregnant have compounding
issues with compromised muscle function, increased shear spinal loading and
are forced to work at a greater distance from the load. These issues warrant
further investigation in terms of ensuring safe practices for women involved in
occupational child care and for mothers and babies in domestic environments.
However, there are also implications for new mothers and pregnant women
who may be involved occupational MH tasks in their workplaces.
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SUMMARY OF DISCUSSION
Study One respondents complained that lifting the baby load was difficult and
caused LBP/LBD. Respondents also suggested that as the baby gets older, the
load becomes more difficult to manage. Study Two indicated that the
increased load was implicit in escalating all outcome measures and raising CF
close to the BCDL for a single lift. Furthermore, live baby loads do not conform
in any way to the standardised loads used in biomechanical analysis, hence
the outcomes are likely to be an under estimate of the true hazard.
Study One respondents reported that the task of nappy changing and the
posture associated with using purpose built change furniture was linked to
LBP/LBD. Study Two indicated that the change furniture dictated the posture
and motion required in the task. Although the asymmetric stance appears to
limit the biomechanical implications, it is possible that the dynamic nature of
the task has not been fully accounted for in these tests and CF, SF and
ligaments strains may be much greater than our results indicate. Furthermore,
bending, rotating and reaching to a lower level during the task appear to be
extremely hazardous, straining the lower back and shoulder region. With regard
to bench height, lifting from waist level (90 cm for the average height female)
has been reported by many to be the safest operating position (Wortman,
2003; King et al., 2006; Griffith & Price, 2000), however this recommendation has
not necessarily been supported in this study. It may be that some results have
been confounded by the anthropometry and limitations of the pregnant
women in Study Two. That being said, the results from this study indicate that for
both stance alignments the 110 cm bench height elicited the least CF, SF and
ligament strain in lifting and this is reinforced by the results of Study One.
Furthermore, Study Two revealed that use of these purpose built furniture
designs facilitate dangerous postures and loaded motion that in terms of OHS
standards would not be permitted.
Study One indicated that pregnant women with no previous history of LBP/LBD
have a 50% chance of developing moderate to severe back pain during their
pregnancy. It further indicated that postpartum women are more likely than
not, to experience LBP/LBD. Whilst Study Two did not assess the variations in task
performance by women who are pregnant and postpartum, nevertheless, the
biomechanical implications will be complicated by the anthropometrics of
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handlers and it is important to note the increased LBI risk to pregnant and
postpartum women. That being said the outcomes indicate that handling
these loads and performing this task are hazardous to a healthy population;
hence anyone performing regular MH work involved in child care is potentially
at risk of LBI.
Finally, Study One indicated that most women working in child care in the
domestic environment are performing many manual lifting tasks involving
young children and at least 55% of the respondents were caring for two
children under the age of 2 years. This leads to the implication that the
frequency and duration of the nappy changing task may pose a cumulative
risk of soft tissue injury to the lower back.
Recommendations
The results of this research have clearly just scratched the surface of this issue
and obvious attention should be directed toward quantifying other potentially
risky MH work involved in the care of young children. This should include
determining the optimum postures and weight limits when lifting these baby
loads and understanding more about the biomechanical implications for
carers when handling young children. Further to this, equipment designs need
closer scrutiny to understand the implications for carers when interacting with
baby loads and purpose built equipment; and to optimise the functionality and
safety for operators as well as the children. We also need to understand more
about the biomechanical changes affecting pregnant and postpartum
women and the implications for these women performing MH tasks.
The research demonstrates a number of hazards for women performing MH

duties; therefore, we make the following recommendations in terms of OHS
policy, equipment manufacturing and safety education.
1. OHS Policy
 Review child care work practices and policies to better address
the specific nature of MH in child care.
 Explore the possibility of a unified independent authority
researching, regulating and testing nursery furniture and
equipment designs, incorporating Design Standards for purpose
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built furniture that address the OHS needs of the operators as well
as the children.
2. Equipment manufacturers need to:

 Be informed of the biomechanical implications for women
interacting with baby loads and purpose built equipment.
 Take responsibility for the functional design elements of
equipment purpose built for child care and consider including
adjustability in the height and manoeuvrability of the change
surface as well as design of the work surface to include space for
change items. Other design changes should include realistic knee
and foot placement to allow the operator close body access to
the change surface.
 Take responsibility for instructing educators, sales representatives
and consumers on correct and safe use of equipment for both
child and operator. This could include instruction to work on a
higher surface with smaller baby loads, lowering the work height
to a comfortable level as the baby increases in size; also to
alternate work between left and right side, so as to avoid
repetitive muscle fatigue.
3. Safety education is needed to inform:

 Child care workers on how to minimise injury risk from lifting young
children and interaction with purpose built nappy change
furniture.
 Pregnant and postpartum women of safe postures and weight
limits during MH work with young children and how to minimise risk
of injury from MH work in general.
 Professionals, educators and publications involved in women’s
health, of MH implications for women, specifically from the
interaction of the baby load and infant nursery equipment.
 Employers of women in general MH work of implications and
limitations associated with the morphology and physiology of
pregnant and postpartum women that may predispose them to
further MSI from MH tasks.
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Finally, it is important for women involved in child care to know how to limit the
risk of LBI associated with both the posture and the lifting aspects of this task.
Although common advice is to use furniture that is waist height, the physical
diversity of the operators suggests that care should be taken not to prescribe a
“one size fits all” approach. It is further advised that a symmetric upright stance
in this task will limit biomechanical implications for LBI, but if the furniture being
used inhibits knee flexion and/or limits foot space then the posture is
compromised (Chaffin & Andersson, 1991; Kroemer & Grandjean, 2001). Until
further research is completed the simple recommendation to operators would
be to work at a bench height that supports a comfortable upright position, but
not so high as to cause difficulty in lifting the baby load to and from the
surface. In short as the baby grows operators should adjust the work surface
height to find the “happy medium” between upper back pain associated with
the high bench lift and LBP lifting from the low surface. Operators could brace
against stationary change furniture to stabilise their body (Chaffin & Andersson,
1991; Kroemer & Grandjean, 2001), this will also help to position the baby load
as close as possible to the operator’s midline limiting extended reaching.
However, pregnant women may find that the asymmetric stance alignment
reduces the biomechanical hazards imposed by their abdominal girth. Also
bracing the side of the body against the change table during the task may
help the pregnant operator to retain an upright posture as well as support her
balance throughout the task and the subsequent lift. The pregnant operator
(and those using an asymmetric alignment) may also benefit from alternating
the asymmetric alignment so that one change is completed from the right side,
the subsequent change from the left so as to lessen one sided repetition. This
could also be practiced in procedure where the operator is holding down a
baby load with one hand, we would suggest alternating the hand used to
apply supportive force to the child. Also, we would suggest that risk of LBI is
reduced by increasing the height of the change table to between waist and
diaphragm level when nappy changing smaller baby loads, but as the load
mass increases, the surface level should be lowered to a comfortable work
level. Furthermore baby change items should be kept close by and at the
same height as the work surface to avoid extended reaching, excessive trunk
flexion and awkward postures.
123
CONCLUSION
Our results demonstrate that a considerable number of women (i) experience

LBP during and subsequent to pregnancy; (ii) associate the task of nappy
changing with heightened LBP; and (iii) have increased difficulty changing
older babies as they are physically challenging and the task takes longer.
Furthermore, these data indicated that waist height nappy change furniture
may be associated with posture related LBP. The results of Study Two revealed
there are several biomechanical risk consequences for LBI from both the lifting
and posture components of this task. These risks for the handler may be
compounded due to the design of equipment, the nature of the baby loads
being handled and for operators who are carrying abdominal, pelvic and/or
lower back injuries. All these parameters may be exacerbated by the
frequency and duration of this task. The long term implications of unresolved LBI
in these women are unknown, but may have repercussions for future workplace
injury. This study has highlighted the urgent need for further research into the
biomechanical hazards specific to women working in child care, as well as a
more thorough understating of the biomechanical implications of frequent
child care related manual handling tasks. It also underscores the imperative for
OHS strategies to address the unique requirements of women performing
manual handling work.
124
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Appendix A
Manual handling in child care work: Components of back

injury risk during the task of nappy changing
Subject Information Sheet- Study One
Purpose
This study will collect information data on equipment used by women when changing a
baby’s nappy and on any pain or disability associated with the use of baby changing
furniture and equipment. This will enable the estimation of usage and injury trends
relating to the task. The outcome will highlight potential risk factors or implications
associated with either the technique used to change nappies or the design of the
equipment involved in the task. Although the study is most specifically focussed on
pregnant and postpartum women, outcomes will also be relevant to the occupational
health of employees within the child care and health service industries.
Procedures
Participation in this study requires that you complete the enclosed questionnaire as
accurately as possible, then return it by the due date to the School of Human
Movement and Exercise Science at the University of Western Australia, either by e-
mail or by using the stamped self addressed envelope provided for your use.
Benefits.
Currently there are only a hand full of studies relating to ergonomics and pregnant and
postpartum women. There are no ergonomic studies or guidelines available for
operators to limit personal risk when using baby changing furniture.
A large percentage of women in western populations who have become mothers,

continue to suffer long term injuries as a result of pregnancy and child birth. It is
possible that these injuries become chronic because the weakening of musculoskeletal
tissue through pregnancy is sustained by performing tasks that knowingly cause this
type of insidious injury process.
133
Nappy changing is just one of the physical tasks required when caring for a baby, but it
is the task most often performed and includes bending, lifting and sustained postures.
This study will identify and quantify the forces and, therefore, the associated risks
when using baby change furniture to assist in the task of nappy changing.
Confidentiality
Personal details and test results will be treated confidentially at all times. Individual
data will not be identifiable, but collective results may be published.
Participant Rights
Participation in this research is voluntary and you are not obliged to return this survey.
However by returning the questionnaire, it is implied that you have given your consent
to participate in this survey. No further request for information will be made.
Thank you for your time and interest in this project.
Adele Stewart
MSc candidate.
Professor Timothy R. Ackland

School of Human Movement and Exercise Science
The University of Western Australia
35 Stirling Highway, Crawley WA 6009
Phone +61 8 6488 2361

Fax +61 8 6488 1039
The Human Research Ethics Committee at the University of Western Australia requires that all
participants are informed that, if they have any complaint regarding the manner in which a
research project is conducted, it may be given to the researcher or, alternatively to the
secretary, Human Research Ethics Committee, Registrar’s Office, University of western
Australia, 35 Stirling Highway, Crawley, WA 6009 (telephone number: 6488 3703). All study
participants will be provided with a copy of the information Sheet and Consent Form for their
personal records.
134
Appendix B
Masters Thesis Study

PLEASE READ THE SUBJECT INFORMATION SHEET BEFORE COMPLETING THIS

QUESTIONNAIRE.
Please answer the questions as accurately as possible and return to the School of Human
Movement and Exercise Science at the University of Western Australia by using the pre-paid
self addressed envelope enclosed with this questionnaire. This survey should take no more
than 10 minutes to complete.
THANK YOU for your important contribution.
Yours sincerely,
Adele Stewart
MSc candidate
135
QUESTIONNAIRE
General
1. Residential Postcode ..………....………
2. Age Less than 25  25-30  30-35  35-40  40+ 
3. Height: (current) . ………………cm
4. Weight (current) .....…………….kg
5. Currently working (if No, go directly to question 9) Yes  No 
6. Occupation (closest category)
Professional  Clerical  Health/Child Care  Manual Handling 
7. Hours per week at work up to 10  10- 20  20-30  30+ 
8. Are you engaged in bending/lifting activities in your employment
Yes  No 
9. Are you currently pregnant (if No, go directly to question 11) Yes  No 
10. Indicate term of current pregnancy
1-3 months  3-6 months  6-9months 
11. Are you currently postpartum Yes  No 
12. How long since the birth of your last child
1-3 months  3-6 months  6 -12 months  12-18 months  18-24 months 
13. Number of pregnancies to third trimester
0  1  2  3  4  5 or more 
14. Age of youngest offspring ……………yrs
15. Age of eldest offspring ..…………. yrs
16. Have you experienced any multiple birth pregnancy to the third trimester
Current pregnancy  One pregnancy  Two or more pregnancies 
136
Nappy Changing
17. What type of nappy do you/have you used most cloth  disposable 
18. How many times a day would you change a nappy on a baby
3 months old up to 6  up to 12  ≥12 
18 months old up to 6  up to 12  ≥12 
19. On average, how long do you take to change a nappy (duration of held posture)
3 months old 1-2 mins  2-4 mins  4-6 mins  6-8 mins  ≥ 8 mins 
18 months old 1-2 mins  2-4 mins  4-6 mins  6-8 mins  ≥ 8 mins 
20. When changing a nappy, do you / did you usually use a baby change table
YES  NO 
21. Which style closest resembles your equipment
2/3 Tier change table  Bath & change table unit  Fold out frame and sling 
Drawer top change unit  General furniture 
Other:________________________________________________________________
22. What is the height of this change equipment surface
≤ 80cm  80-90cm  91-100cm  101-110cm  ≥110cm 
Brief comments:________________________________________________________
23. Rate the physical difficulty of the task when using this equipment
1=always easy 2=mostly easy 3=mildly difficult 4= difficult 5 = very difficult
1 2 3 4 5
Brief comments:________________________________________________________
24. On average how often would you use a public nappy changing facility
never  up to 5 times/week  up to 10 times/week  more than 10/week 
25. If you use a public nappy changing facility which of these would you use
Prioritise (1, 2, 3):
wall mounted  free standing  built in 
26. Rate the physical difficulty of the task when using this furniture
1=always easy 2=mostly easy 3=mildly difficult 4=difficult 5 = very difficult
1 2 3 4 5
Brief comments:_______________________________________________________
137
THIS SECTION IS OPTIONAL BUT HIGHLY RELEVANT TO THE STUDY
NB: “Disability” is any restriction or lack of ability to perform an activity within a normal range.
Physical
Please rate the following 1-5 for symptoms
1=nil 2=occasional mild 3=frequent mild 4= moderately painful 5 = frequent painful/ disabling
27. Before you were pregnant for the first time did you experience
Abdominal wall hernia/diastasis 1 2 3 4 5
Abdominal wall weakness/disability 1 2 3 4 5
Pelvic floor hernia/prolapse 1 2 3 4 5
Pelvic floor weakness/disability 1 2 3 4 5
Lower back disc hernia 1 2 3 4 5
Lower back pain/disability 1 2 3 4 5
28. During any pregnancy did you experience

29. Since parturition have you experienced

138
Please rate the following 1-5 for symptoms
NB: “Disability” is any restriction or lack of ability to perform an activity within a normal range.
1=nil 2=occasional mild 3=frequent mild 4=moderately painful/disabling 5 = frequent painful/ disabling
30. When you are changing a baby’s nappy does the posture cause you:
Comments please:___________________________________________________________
31. When you are lifting a baby from a change bench does the lift cause you:
Comments please:___________________________________________________________
32. When you are lifting a baby in or out of a car seat does the lift cause you:
Comments please:______________________________________________________
33. When you are lifting a baby in or out of a pram does the lift cause you:
Comments please:______________________________________________________
34. When you are lifting a baby in or out of a cot does the lift cause you:

Comments please:______________________________________________________
35. When you are lifting a baby in or out of a bath does the lift cause you:

Comments please:______________________________________________________
139
36. When you are lifting a baby from or to the floor does the lift cause you:
Comments please:__________________________________________________________
How many times a day would you / did you

37. Lift baby into/out of a car seat 1 2 3 4  5+ 
38. Lift/lower baby in/out of a pram 1 2 3 4  5+ 
39. Lift/lower baby in/out of a cot 1 2 3 4 5+ 
40. Lift/lower baby in/out of a bath 1 2 3 4 5+ 
41. Lift/lower baby from /to the floor 1 2 3 4 5 +
Comments please_____________________________________________________
Please make any other comments you feel might be relative to this
topic:……………………………
……………………………………………………..……………………………………………
…………………………………………………..………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Thankyou for your VALUABLE contribution.
140
Appendix C

Subject Information Sheet - Study Two

Purpose
This study will provide information on postures adopted by women when using baby change
furniture. This will enable estimation of the forces applied to the lower back during the task of
changing a nappy and highlight potential risk factors or postural implications associated with
either the technique, or the design of the furniture. Although the study is focussed on pregnant
and postpartum women, outcomes will also be relevant to the occupational health and safety of
employees within the infant/child care and associated health services.
Procedures
Your participation in this study requires you to attend one testing session conducted within the
School of Human Movement and Exercise Science at the University of Western Australia. The
total time of testing will be approximately 45 minutes.
a) Preparation
During the test, you will be required to wear either a one or two piece swimming costume or
something similar (tight pants and top) that will provide visible body contours. Measurements of
height, weight, abdominal and chest girths will be taken. Markers (non-toxic washable pen or
“stickers”, please indicate if you suffer from skin allergies) will be applied to joint centres: ankle,
knee, hip, elbow and shoulder.
b) Testing
You will be required to participate in two tests. Both procedures will involve video photography.
Test 1: requires you to stand at a sample “change table”, flex and reach to pick up a simulated
“baby load” (1 x 3 month, 1 x 18 month) as you would in normal conditions. This test will be
performed at three heights and with each “baby load” at each height each with two differing
change bench position alignments a total of 12 tests. Movements and postures will be recorded
from upright stance to baby load pick up.
Test 2: requires you to stand at a sample “change table”, keep one hand on the “baby load” and
reach toward the floor with the other (as you would in normal conditions). Measures will be
taken of your optimum reach. This test will be performed at three heights, with 1 “baby load”, a
total of 3 tests. Movement will be recorded from upright stance to extent of reach.
Risks
This study requires you to work within your limits of comfort. It is a measure of posture not
exertion. The requirements will not exceed those that would be experienced under normal baby
change task conditions. Every effort will be made to minimise any perceived risk and to
maintain your physical comfort.
141
Benefits
Currently there are only a hand full of studies relating to ergonomics and pregnant and
postpartum women. There are no ergonomic studies or guidelines available for operators to
limit personal risk when using baby changing furniture.
A large percentage of women in western populations who have become mothers, continue to
suffer long term injuries as a result of pregnancy and child birth. It is possible that these injuries
become chronic because the weakening of musculoskeletal tissue through pregnancy is
sustained by performing tasks that often exacerbate symptoms.
Nappy changing is just one of the physical tasks required to care for a baby, but it is the single
task most often performed and includes bending, lifting and holding sustained postures. This
study will identify and quantify the forces and, therefore, the associated risks when using baby
change furniture to assist in the task of nappy changing.
Confidentiality
Personal details and test results will be treated confidentially at all times. Individual data will not
be identifiable, but collective results may be published. Once analysed, all video recordings will
be kept in a secure cabinet within the School.
Participant Rights
Participation in this research is voluntary and you are free to withdraw from the study at any
time and for any reason without prejudice in any way.
If you withdraw from the study and you are an employee or student at the University of Western
Australia (UWA) this will not prejudice your status and rights as employee or student of UWA.
Your participation in this study does not prejudice any right to compensation that you may have
under the statute of common law.
Further information on this study may be obtained by contacting Adele Stewart on

64888002
Thank you for your time and your interest in this project.
Adele Stewart
MSc candidate.
personal record.
142
Appendix D

Study Two
Consent Form
1. I (the participant) have read the information provided and any questions I have
asked have been answered to my satisfaction. I agree to participate in this
activity, realising that I may withdraw at any time without reason and without
prejudice.
I understand that all information provided is treated as strictly confidential and

will not be released by the investigator unless required to by law. I have been
advised as to what data are being collected, what the purpose of the study is,
and what will be done with the data upon completion of the research.
________________________ _______________________
Participant Name Date
______________________
Participant Signature
personal records.
143

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Stewart Adele 2009

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Manual handling in child care work:

components of back injury risk during

Adele Stewart B.P.E.

This thesis is presented for the degree of

Manual handling is a duty inherent to child care. Whether it is domestic or

Chapter One – Introduction……………………………………………. 1

Chapter Two - Review of Literature…………………………………… 9

Chapter Three – Methods………………………………………………... 40

Chapter Four - Study One Results…………………………………….. 55

Task Frequency and Duration………………………………………………… 59

Rating of Task Difficulty Associated with Equipment……………………... 60

Rating of Pain and Dysfunction Associated with the Task…………….… 61

Pain and Dysfunction Associated with Respondent Characteristics….. 64

Chapter Five - Study Two Results……………………………………… 72

Chapter Six – Discussion………………………………………………… 106

To my friends and family for their endless support

To my Mother Julie, who has always encouraged me and enabled the

I love you and sincerely thank you all.

To Brian, for having faith in my abilities when mine was faltering

And to my supervisors Tim and Siobhan, who have completed a manual

I am so grateful to have been allowed this indulgence….

Table 3.1 Dimensions Used for Baby Load Manikins 46

Table 4.2 Respondent Characteristics relative to task Associated Low 65

Table 4.4 Pregnancy status and Number of Births Relative to Perceived 68

Table 4.5 Qualitative Theme Summary and Percentage of Responses to 71

Table 5.1 Participants Demographic and Girth Measurement Information 72

Table 5.2 Repeated Measures ANOVA Summary of Bench Height and 75

Table 5.3 Repeated Measures ANOVA Summary of Bench Height and 83

Table 5.4 Repeated Measures ANOVA Summary of Stance Alignment with 91

Table 5.5 Repeated Measures ANOVA Summary of Bench Height Effect 99

Figure 2.1 2/3 Tier change table 21

Figure 2.2 Bath and change table 22

Figure 2.3 Fold out frame and sling 23

Figure 2.4 Drawer top changer or changing chest 23

Figure 2.5 Cot top changer or changing board 24

Figure 2.6 Drop down suspended bench top perpendicular or horizontal to 25

Figure 2.7 Instructions for nappy changing 29

Figure 3.1 Change bench apparatus shown in the Scenario One 45

Figure 3.4 Scenario One – Symmetric lift position 49

Figure 3.5 Scenario Two – Asymmetric lift position 50

Figure 3.6 Scenario Three – Mid-calf reach 51

Figure 3.7 Example of 3D SSPP Version 5.0.4 application window depicting 52

Figure 4.1 Respondent age group frequencies 55

Figure 4.2 Respondent height group frequencies 56

Figure 4.3 Change furniture styles as reported, used in the domestic 57

Figure 4.4 Change surface heights as reported, used in the domestic 57

Figure 4.5 Domestic furniture example of 2/3 tier change unit 58

Figure 4.7 Domestic furniture example of bath/change unit 58

Figure 4.8 Domestic furniture example of frame sling change unit 58

Figure 4.9 Public change unit example of wall mounted, vertical 59

Figure 4.10 Public change unit example of wall mounted, horizontal 59

Figure 4.11 Reported daily task frequency per baby load 60

Figure 4.12 Reported task duration per baby load 60

Figure 4.13 Difficulty associated with using Public furniture styles 61

Figure 4.14 Difficulty associated with using Domestic furniture styles 61

Figure 4.16 Low back pain/dysfunction as a result of posture used with 63

Figure 4.18 Low back pain/dysfunction as a result of lifting and relative 64

Figure 4.19 Low back pain/dysfunction as a result of posture and relative 64

Figure 5.1 Representation of Scenario One – Symmetric Lift. Sagittal and 74

Figure 5.6 Mean torso flexion/extension muscle fatigue (%MVC) at L5/S1 79

Figure 5.8 Mean torso rotation muscle fatigue (%MVC) at L5/S1 as a 80

Figure 5.9 Mean right shoulder abduction/adduction muscle fatigue 81

Figure 5.10 Mean right shoulder flexion/extension muscle fatigue (%MVC) 81