Work 39 (2011) 397–408 397

DOI 10.3233/WOR-2011-1190
IOS Press

Case Study

Prevention of musculoskeletal disorders

(MSDs) in office work: A case study
Tânia M. Lima and Denis A. Coelho∗
Human Technology Group, Department Electromechanical Engineering, University of Beira Interior, Covilhã,
Portugal

Received 3 November 2009

Accepted 12 March 2010

Abstract. Twelve recently built office work stations, where jobs imply continued use of information and communication
technologies, were analyzed for ergonomic risk factors. Based on a literature review of ergonomic recommendations for computer
and general office work, a checklist was devised for assistance in identifying inadequate ergonomic situations, a process that was
informed by pain complaints information. RULA (Rapid Upper Limb Assessment) was selected to estimate the risk of MSDs,
considering the criteria of applicability and appropriateness to the case studied. This method was applied by an occupational
health and safety technician to the most critical job observed in the workplace. Criticality was estimated through observations
aided by the systematic use of a checklist tailored to the specific office scenario. Recommendations for change were provided for
implementation in all workplaces in the office, in order to improve work conditions, and guide the setup of a MSD prevention
training program.

Keywords: Physical ergonomics, musculoskeletal disorders, assessment of ergonomic hazards, office work

1. Introduction
A survey carried out in the European Union (EU)
in 2000 showed that 30% of all workers complained
about lower back pain, and that 17% complained about
muscular pain in the arms and legs [8]. Across the
general workforce, musculoskeletal disorders (MSDs)
are prevalent, potentially disabling conditions [29] with
enormous social costs [3,12]. In industrialized soci-
eties, they are the main cause of permanent work dis-
ability and functional loss in adults [35,42,49,51] and
the second greatest cause of short-term temporary work
disability [4]. Costs accruing from the onset of MSDs
∗ Address
for correspondence: Denis A. Coelho, Human Technol-
ogy Group, Department Electromechanical Engineering, Universi-
ty of Beira Interior, 6201-001 Covilhã, Portugal. Tel.: +351 275
329943; Fax: +351 275 329972; E-mail: denis@ubi.pt.
relate not only to health system costs but also to indi-
rect costs such as loss of productivity [31], with pro-
ductivity losses of up to 1.3% of the U.S. gross national
product [52].
The development of computer technology has al-
lowed greater ease of data organization in the work-
place, as well as increased the availability of research
through databases and search engines, promoting in-
creased computer use over the years [17]. Numerous
studies of adult workers have found associations be-
tween computer use and musculoskeletal discomfort [5,
15,18,19,26,27,46–48]. Repeatedly, temporal and pos-
tural factors have been associated with musculoskeletal
symptoms and/or disorders in workers who use com-
puters [37].
Changing patterns of work require management and
professional staff to use computers more and more to
perform their work most efficiently [11]. Many of
these people may not have received formal training in

1051-9815/11/$27.50  2011 – IOS Press and the authors. All rights reserved
398 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work

Table 1
Examples of screening and risk assessment methods for MSDs. Adapted from [44]
Description Suitability
Screening methods
OSHA checklist [45] Screening checklist for the identification of hazards conducive to the onset of MSDs of Upper limbs
the upper limbs
PLIBEL [22] Checklist for the identification of ergonomic hazards, with relevance to different body Whole body
regions.
Assessment methods
RULA [34] Quantitative assessment of postural, dynamic and static occupational hazards (including Upper limbs
force and repetition).
Kilbom Method [25] Semi-quantitative assessment, considering body zones, kind of job and frequency of Upper limbs
exertion.
Strain Index [36] Semi-quantitative assessment based on six variables (intensity of exertion, duration of Upper extremities
exertion per cycle, efforts per minute, wrist posture, speed of exertion, and duration of
task per day).
HAL [28] Quantitative assessment of repetition in hand tasks based on observation. Upper Extremities
OCRA [9,38] Quantitative assessment number of recommended daily actions of the upper limbs in Upper limbs
repetitive tasks
LUBA [21] Quantitative assessment technique for postural loading on the upper body based on joint Torso and upper limbs
motion discomfort and maximum holding time

computer use and may also lack typing skills. They
may therefore be spending increasing periods of time
each day in positions of extreme neck flexion in or-
der to view the keys while typing [39]. Not only are
there clear links established between sustained periods
of neck flexion and musculoskeletal injury [24], but
pain has been hypothesized as a precursor to injury [2].
Some associations between postural effects and mus-
culoskeletal outcomes are reported in the literature. In
particular, placing the keyboard below the elbow, limit-
ing head rotation, and resting the arms appears to result
in reduced risk of neck/shoulder outcomes, while mini-
mizing ulnar deviation and keyboard thickness appears
to result in reduced risk of hand/arm outcomes [13].
Evidence for a relationship between the duration of
work time spent using the computer and the incidence
of hand-arm and neck-shoulder symptoms and disor-
ders has been reviewed, showing that risk estimates
were in general stronger for the hand-arm region than
for the neck-shoulder region, and stronger for mouse
use than for total computer use and keyboard use [16].
In studies of computer users, the incidence of mus-
culoskeletal complaints, particularly neck and shoulder
disorders, has been high [7,20,43]. Observational in-
struments have commonly been used for ergonomic as-
sessments by therapists and human factors personnel to
document and quantify observed postures and behav-
iors. Commonly used upper extremity assessment tools
include the Upper Extremity Checklist (UEC) [23];
Rapid Upper Limb Assessment (RULA) [34]; Rapid
Upper Limb Assessment for Computer Users [33]; and
The Strain Index [36]. A number of recommendations
for posture have been produced and disseminated by
organizations such as ILO,1 OSHA2 or EU-OSHA,3
based on research results. For example, several studies
have demonstrated that support of the forearm during
computer work reduces discomfort and muscle loading
of the upper extremity and back [1,41,50], yielding the
widely disseminated recommendation that chairs for
sitting while using a computer should have adjustable
armrests.
In workplaces, the practical assessment of the risk
for MSDs of the upper limbs can be supported a two
phase process [44]. The first phase involves identifi-
cation methods to screen for problems, while the sec-
ond one pertains to the analysis of the work stations
where more problems were detected during the screen-
ing phase (Table 1).
The purpose of the study reported in this paper was
to make an assessment of the risk of MSDs in 12 work
stations of a recently built office workplace (in use
for one year at the time of the observations) in Por-
tugal. The results of the assessment then formed the
basis to design an intervention, comprised of specific
training of the workforce involved and both office-wide
and individually-tailored recommendations. The study
entailed assessing the duration of individual work-
place presence and assessing reported pain complaints
through informal conversation with workers, devising
a tailored checklist meant for screening purposes and
afterwards applying RULA [34], one of the standard
1 ILO– International Labor Organization.
2 OSHA – Occupational Health and Safety Administration.
3 EU-OSHA - European Agency for Health and Safety at Work.
 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work
methods deemed applicable to the assessment at hand,
to the work station with more problems detected. The
office scenario where the study took place was signif-
icantly homogeneous, and was thoroughly scrutinized
(including lengthy conversations with individual work-
ers). The particular work station that added up the
greatest sum of checklist issues, was not only similar
to the remaining ones (computer workstation, with the
same tools, although physical layout was deemed more
inadequately set), but the worker in this work station,
with the task of receptionist, spent more time in the
work station than others and was restricted to a more
fixed set of tasks. Therefore, the checklist results cor-
roborated rather than led to the indication of a work
station where the risk for the onset of MSDs seemed
higher, according to the judgment of the authors.
Although specific assessment methods for comput-
er usage have been developed [30,33], restricting to
computer usage was considered inadequate given the
diversity of tasks performed.
2. Case description
The occupational context analyzed was the office of
a regional branch of a Portuguese construction compa-
ny (the observations and assessments took place during
the Spring of 2009, from April to June). With a total of
53 people working at the branch, several kinds of work-
ing arrangements were active in this company, ranging
from employees that worked in construction-sites to of-
fice workers, and encompassing workers who labored
in both kinds of work scenarios. In this sector, resort-
ing to subcontracting of labor was a common practice,
given the fluctuating nature of demand. The design of
the office facilities was laid out in an architectural plan
and in complementing technical studies developed in
the domains of acoustics, thermal behavior and illumi-
nation. Furniture had been transferred from the com-
pany’s previous quarters, and was not new. Every work
station in the office was found to be equipped with desk-
top or laptop computers, and in some cases with a print-
er. The office housed the company’s administrative,
financial, purchasing, equipment and logistics, human
resources, production, commercial-technical, quality,
occupational health and safety departments and the ad-
ministration. Work stations in the production depart-
ment were not continuously occupied, since the jobs in
this department were mostly carried out at construction
site offices.
399
Several software programs were used in the comput-
erized work stations, ranging from personal productivi-
ty applications, to computer aided drawing (CAD) pro-
grams, and including virtual market and public tender
electronic platforms as well as an integrated manage-
ment program. The tasks in the office were diverse and
specific to each department. However, some routines
were to be found across departments, including: (1)
data input and retrieval from software programs, (2)
viewing and editing digital drawings, and (3) collect-
ing information from the screen, in interaction with the
keyboard, the mouse, the telephone, the printer, docu-
ments and paper files that laid on the desk. While in-
volved in the first two afore-mentioned routines, work-
ers typically assumed a static posture, sitting for long
periods of time. However, for the latter routine, the as-
sumed posture lasted for shorter periods of time, since
interaction with the full range of work elements took
place, and hence postural fixation was shorter. The
first two routines involved interaction with the com-
puter screen, keyboard and mouse mostly, leading to
postural fixation over long periods of time.
2.1. Demographic information and office layout
At the time of the study, the workforce of the of-
fice was comprised of 19 people, each one having an
assigned work station (Table 2 and Fig. 1). Of these,
only 12 people were present at the office on a full-
time basis, i.e. those with jobs PT1 (receptionist), PT3
to PT4 (carried out in individual offices) and PT12 to
PT19 (performed in the open-space section of the of-
fice). Besides the rooms where work stations were in
place, the office also had a meeting room, an archive
and equipment room, two gender-specific toilets and a
restroom and pantry.
2.2. Methods
Since each particular office scenario may pose
unique challenges, a tailored checklist was derived from
existing checklists and well accepted ergonomic rec-
ommendations. The checklist that was devised is not
particularly innovative, nor does it represent a signif-
icant departure from existing and validated tools of a
similar nature and with a similar purpose, as it is derived
from recommendations that are considered in standard
practice and that are disseminated by major agencies
(OSHA, EU-OSHA, ILO). This checklist is the out-
come of an attempt to tailor a checklist of simple ‘yes’
and ‘no’ questions to the particular office under study.
400 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work

Table 2
Demographic data of the office workers at the time of the study and work station information
Identification Department Room Gender Age Education
F M
PT 1 Administrative Reception 1 42 High School
PT 2 Financial Office 1 1 33 Higher Education
PT 3 Financial Office 2 1 46 Higher Education
PT 4 Financial Office 3 1 35 Higher Education
PT 5* Administration Office 4 1 53 Higher Education
PT 6 to PT 11* Production Open-space 6 37, 36, 26, 27, 36, 37 Higher Education
PT 12 Purchasing Open-space 1 26 High School
PT 13 Equipment and Logistics Open-space 1 48 High School
PT 14 Human Resources Open-space 1 36 High School
PT 15 to PT 17 Studies and Proposals Open-space 3 55, 42, 50 Higher Education (1), Professional
School (2)
PT 18 Quality and Systems Open-space 1 33 Higher Education
PT 19 Health and Safety at Work. Open-space 1 33 Higher Education
(*) – These work stations were not included in the study, due to the discontinuous nature of the presence of their pertaining workers.

Fig. 1. Actual architectural plan depicting office layout with marking of work stations (PT 1 through PT 19) and rooms (abbreviations shown
result from the original Dept. names in Portuguese).
 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work 401

Table 3
Checklist aggregate results for the postural domain
Domain Question Issues
Posture Does the person maintain relaxed shoulders and keep the arms next to the torso? 1
Are the forearms at a 90 degree angle in relation to the upper arms? 2
Does the person use the lumbar support, maintaining the torso slightly reclined? 3
Are the knees at the same height as the hips? 1
Are the feet positioned somewhat beyond the knees and completely supported by the floor, or foot rest?
Is the head aligned with the torso? 3
Does the person frequently adjust his or her posture?
Does the person take small strolls of one to two minutes for every hour working? 1

It is a purpose-made checklist developed by an Occu- necessary to perform sampling through observations

pational Health and Safety (OHS) graduate in collab-
oration with an academic, specializing in ergonomics.
The technician provided the services of OHS preven-
tion to the company involved in the study. Hence, while
the checklist developed is specific to the particular of-
fice at hand, it does not follow any novel methodology
or procedure, and hence does not entail a significant
departure from standard screening checklists that have
been widely in use.
The checklist enabled a systematic evaluation of all
the applicable work stations in addition to unstruc-
tured observations and informal conversations, shed-
ding light on the work stations where more physical
ergonomic problems were expected, contributing to the
risk of MSDs. The checklist devised enabled screening
for inappropriately set particular factors, within the fol-
lowing domains: postural limitations (Table 3); the of-
fice chair (Table 4); the work desk, the document hold-
er and the computer interface peripherals (keyboard,
screen and hand pointing device – Table 5); as well as
the environmental conditions and layout of the office
and the work station (Table 6).
Upon identifying the inadequacies in each work sta-
tion (at this stage the tailored checklist was used as
an instrument to systematize the technician’s observa-
tions, given her knowledge, training and previous expe-
rience), the RULA method [34] was applied to the job
with most detected physical ergonomic problems. The
functions assigned to this job were those of a recep-
tionist, entailing the duties of telephone answering and
call forwarding, welcoming and opening the door to
office visitors, typing and viewing documents, and tak-
ing hand written notes. In this way, the level of risk of
MSDs in the upper limbs and neck was assessed for the
most severe case detected. This method was selected
by the OHS technician from a set of applicable methods
(depicted in Table 2), due to its perceived effectiveness,
applicability, appropriateness and perceived ease of use
(given the quantification of parameters guided by clear
illustrations pertaining to intuitive categories). It was
to enable the visual analysis involved in the method,
since video recording was not authorized by company
management.
Subsequently, a training course was to be assembled,
by the OHS technician, directed at all the people in the
office, consisting of a 45 minute lecture, concerning
the prevalent risks encountered at the work stations and
the corrective actions that should be pursued. This was
planned to be carried out during the year 2010, since
the company’s training plan for 2009 had already been
set (and budgeted at the beginning of the fiscal year).
2.3. Results
Twelve work stations were analyzed, leaving out 7 of
the 19 jobs (work stations PT 5 to PT 11) because these
jobs involved a lot of out of the office work (more than
50% of working hours were spent at construction sites
and temporary offices set up there). The full set of in-
dividual results of the checklist screening has been pre-
viously reported [32]. Of the twelve jobs analyzed, one
was then further analyzed using the RULA method [34].
The work station analyzed was not only similar to the
remaining ones (computer workstation, with similar
tools, although physical layout was deemed more inad-
equately set), but the worker in this work station, with
the task of receptionist, spent more time in the work
station with a restrictive set of tasks (this workstation
was to be manned at all times, during office hours).
The results of the checklist verification corroborated,
rather than led to, the indication of the work station
where the risk for the onset of MSDs seemed higher,
according to the judgment of the analysts. Additional
findings, with regards to work environment and pain
complaints were also obtained from the unstructured
observations carried out at the site and from informal
conversations with the workers maintained by the OHS
technician, respectively, contributing for the selection
of workstation PT1 for further analysis.
402 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work

Table 4
Checklist aggregate results for the seating domain
Domain Question Issues
Office Chair Have the person’s anthropometric, biomechanical and physiological characteristics been taken into account 10
when choosing the chair?
Does the chair offer lumbar support?
Does the chair have an adjustable reclining backrest and can the seat be adjusted in height? 3
Are the chair’s adjustment levers and knobs easily accessible?
Does the chair offer adjustable and removable arm supports? 9
Is the seat’s frontal edge rounded in a water fall shape?
Does the chair’s basis have five support points?
Is the chair stable?
Seat height Does the chair have adjustable seat height, so that the person may keep her or his feet well supported by the 1
floor?
Is the seat height from the floor within the range between 350 and 530 millimetres? If not, is a foot rest or 3
foot support provided?
Seat depth Is the seat’s depth dimension within 380 and 430 millimetres?
Does the frontal part of the seat not touch the back part of the person’s knees?
Seat width Does the seat have at least 430 millimetres of surface width?
Is the aft part of the seat wider than the front of the seat?
Tilting of the Does the seat’s surface tilt, five degrees upward and five degrees downward? 10
seat’s surface Is there an easily accessible mechanism that locks the seat in each possible setting? 9
Seat surface Is the seat cushion firm?
cushion Are the edges of the surface cushioned and rounded?
Is the cushion’s cover porous?
Is the seat cushion’s cover not slippery?
Backrest The surface of the chair’s backrest has at least 380 millimetres in height and 305 millimetres in width?
Can the backrest be reclined up to 15 degrees from its stable position? 4
Is the backrest’s cover porous?
Forearm Is the distance between the forearm supports adjustable? *
support Do the forearm supports offer vertical adjustment? Does the height adjustment vary between 18 and 27 *
(armrest) millimetres of amplitude? Does the length of the forearm supports allow an unencumbered approach to the
work surface?
Are the forearm supports padded in their upper surface? *
Are the forearm supports removable? *
Chair’s basis Do the chair’s legs possess casters to enable small displacements?
Does the chair enable rotation about its central axis of 360 degrees?
Chair Are the controls easily accessed by the sitting person?
adjustment Is the chair easily adjusted using only one hand? 3
Do the controls give immediate feedback? 3
Is the seat height adjustment system pneumatic?
Is it possible to adjust the seat backrest in a fixed position? 2
Chair training Has the person been trained on the appropriate usage of the chair? 12
(*) No data was collected on this subject, because it was not applicable to any of the analyzed work stations.

2.3.1. Screening gonomics or on the recommended use of their work

The twelve work stations focused upon were eval-
uated with systematization performed using a specifi-
cally devised checklist. The results of the evaluation
are depicted in Tables 3 through 6 in aggregate form
for the postural, seating, equipment and miscellaneous
domains of physical aspects of work and the work en-
vironment. In these Tables, the English translations of
the questions in the checklist are shown (originally the
checklist was formulated in Portuguese) together with
the number of respective negative answers obtained,
identified as “Issues”.
The results obtained display a prevalence of issues
in three domains: training, chairs and work surfaces
and equipment. Workers had not been trained in er-
equipment by the employer. Some of the chairs used
were no longer operating in their best condition as ad-
justments could not be made because levers had been
broken or were immovable. All the desks in the office
had fixed height, at 700 millimeters, causing postural
constraints to some of the workers. PT 1 was the work
station with the highest number of detected physical
ergonomic issues resulting from the checklist screen-
ing (Table 7). Moreover, the person manning this work
station, reported more complaints (pain in the arms,
wrists and lower back), performed all the physical jobs
that the remaining office workers performed, but for
longer periods of time and with greater intensity of rep-
 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work 403

Table 5
Checklist aggregate results for the domain of equipment at the work station
Domain Question Issues
Foot support Is the foot support adjustable height wise and inclination wise? *
Is its surface big enough for the person’s feet? *
Is the foot support easily removable? *
Is the foot support covered by an anti-slipping material? *
Work surface Are the dimensions and the shape of the work surface adequate to the tasks the person has to fulfil?
Does the surface enable the accommodation of the monitor and the documents that support the tasks at hand? 1
Is its height adjustable, between 56 and 71 centimetres, measured from the floor level? 12
Does the surface have a matte finish?
Does it have no protruding edges?
Does it have no elements placed underneath the top, in order to keep from encumbering the person’s movements,
and provide space for the legs?
If it is a fixed surface, does it have 700 millimetres height?
Document Is there a document holder? Is it on the work surface? Does its placement contribute to reduce visual fatigue? 12
holder Has the person been trained on the best way to use the keyboard? 12
Keyboard Does the keyboard have wrist support? 3
Does the keyboard have forearm support? 9
The placement of the keyboard is in agreement with its use?
Does the keyboard have a matte finished surface?
Screen Did the screen’s purchase take into account its expected usage?
Is the screen in front of the person? 2
Are there no reflexes from natural means or external lighting sources?
Is the screen at a distance of approximately 750 millimetres from the person (measured at the eye level)? 1
Are artificial sources of light oriented in parallel to the work surface (and the screen)? 3
Is the person not facing a window?
Hand Did the person receive training on the best way to use the computer mouse? 12
pointing Is the computer mouse at the same level as the keyboard?
device Can the computer mouse be easily accessed?
(mouse) Is the computer mouse periodically clean?
Is the computer mouse used over a mat with an ergonomic design (gel padded wrist support)? 9
(*) No data was collected on this subject, because it was not applicable to any of the analyzed work stations.

Table 6
Checklist aggregate results for miscellaneous aspects (including layout and environmental conditions)
Domain Question Issues
Layout in Does the person have free unencumbered space around her or him, of at least 1.8 square meters?
the office Do the aisles between work stations have a minimum breadth of 750 millimetres?
Do secondary corridors have a minimum width of at least 1200 millimetres?
Do main corridors, leading to emergency exits have a minimum breadth of 2000 millimetres?
Is the person adequately positioned, considering his or her functions?
Is the person protected against noise?
Layout of In the layout of the work station, was the normal work zone (comfortable reach) taken into account? What 2
the work about the maximum reach limit of the person?
station Is there no equipment above shoulder level or beyond the maximum reach limit?
Illumination In vertical surfaces, is the illumination level between 300 and 1000 lux?
level Is natural sunlight illumination preferred in the workplace? 7
Luminance Is there uniform brilliance in the person’s vision filed?
Reflection When laying out the work stations, was the reflection of the floor, walls, ceiling, furniture and equipment
and the existing colors taken into account?
Glare Is the layout of the illumination sources protective against glare situations?
Do the exterior windows have protection against the occurrence of glare? 1
The level of brilliance in the furniture, and the way it is setup, protects the person against the occurrence of
glare?
Contrast Are the existing contrasts within admissible values of luminosity ratios in work surfaces?
Refresh The frequency of screen refresh is equal or greater than 75 Hz?
frequency and The frequency of scintillation of illumination sources is greater than 60 Hz?
scintillation
Telephone Does the person frequently use the telephone? Does the person not use the shoulder and the head to support 2
the phone handset during long periods of time?
404 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work

Table 7
Total number of issues found through checklist screening for each of the twelve work stations that were evaluated
Work station PT 1 PT 2 PT 3 PT 4 PT 12 PT 13 PT 14 PT 15 PT 16 PT 17 PT 18 PT 19
Issues 22 8 17 6 13 13 12 11 18 15 17 19

Table 8
Assessment of the risk level of task 1 (reaching for the telephone and for relatively distant objects)
Score Position Muscular Total per Total
exertion group
GROUP A Arms 0 3
3 Between 45◦ to 90◦ of flexion
GROUP B Neck 0 3 6
1 Neck side-bending
Trunk 0
2 Trunk side-bending

Table 9
Assessment of the risk level of task 2 (pressing the door opening button)
Score Position Muscular Total per Total
exertion group
GROUP A Arms
1 0◦ –90◦ flexion 0
Wrist 5 5
2 0◦ –15◦ palmar flexion
2 Supination of the wrist 0

Table 10
Assessment of the risk level of task 3 (answering the telephone)
Score Position Muscular Total per Total
exertion group
GROUP A Arms
3 Between 45◦ to 90◦ of flexion 1 7
Forearms
2 More than 90◦ of flexion 1 12
GROUP B Neck
1 Neck side-bending 1 5
Trunk
2 Trunk side-bending 1

etition, and, spent more time in the workstation she was
assigned to.
2.3.2. RULA assessment
The RULA method [34] was applied to work station
PT 1, with the aim of assessing the level of risk of de-
veloping MSDs of the upper limbs and neck. In carry-
ing out her daily tasks, the worker with this job was not
observed doing any material handling or physical exer-
tion. Therefore, muscular exertion was only considered
to be null or very weak throughout the analysis.
Upon initial observation of the worker’s physical ac-
tivity, and in order to structure the risk assessment pro-
cedure, the tasks repeatedly carried out by the worker
were categorized as follows:
task 1 – reaching for the telephone and for relatively
distant objects (Table 8),
task 2 – pressing the door opening button (Table 9),
task 3 – answering the telephone (Table 10),
task 4 – typing and viewing documents (Table 11),
and
task 5 – hand writing (Table 12).
The results of the RULA assessment [34] show that
the worker in work station PT1 was exposed to physical
work hazards that placed her at the risk of developing
MSDs, since two out of her five usual tasks that were
analyzed, yielded a level of risk equal to 4 (tasks 3 and
4), while the three remaining tasks yielded a level of
risk of 3 (out of a maximum of 7). This corresponds,
for all tasks, to action level 2 (further investigation is
needed and changes may be required) of the RULA
method [34]. This outcome led to the redesign of the
layout of the work station, and the worker was urged
 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work
Table 11
Assessment of the risk level of task 4 (typing and viewing documents)
Score Position
GROUP A Wrists
2 0◦ –15◦ of dorsal or palmar flexion
GROUP B Neck
2 10◦ –20◦ of flexion
1 Neck twisting
Trunk
2 Trunk flexed up to 20◦
Table 12
Assessment of the risk level of task 5 (hand writing)
Score Position
GROUP B Neck
2 10◦ –20◦ of flexion
Trunk
2 Trunk flexed up to 20◦
to take immediate preventive measures, especially con-
cerning the tasks where higher risk was detected (an-
swering the telephone and typing and viewing docu-
ments).
2.3.3. Course of action recommended and discussion
of results
In what follows, the improvement proposals de-
scribed have a general nature, and are based on the
recurring physical ergonomic issues that were detect-
ed throughout the 12 work stations analyzed. Recom-
mendations of improvement specifically aimed at work
station PT 1 are also presented.
Office chairs in PT 18 and PT 19, were recommended
for immediate substitution, due to their broken controls,
forcing the workers to sustain hazardous postures while
sitting on them. Workers at work stations PT 13 and
PT 16 were urged to place their screens in front of
their usual sitting area, instead of laterally to that area,
as they had been encountered during the observations
performed. A recommendation was given concerning
the keyboards and mouse pads in work stations PT 12,
PT 13 and PT 14, which should have been upgraded to
offer adequate padded, or gel filled, wrist support.
Additionally, retro-fitting the windows in the ‘open-
space’ area with exterior mounted solar protection, in
order to enable the use of indirect sunlight was recom-
mended, since artificial light had been the main light
source in use in that space, as a compensation for the
use of drapes to prevent the direct incidence of sunlight.
The creation of compartments in this area, setup with
the use of transparent and noise dampening dividing
405
Muscular Total per Total
exertion group
1 3
1 10
7
1
Muscular Total per Total
exertion group
1 6 6
1
panels, was also recommended as a means of creating
a quieter environment.
In what concerns work station PT 1, a number of
recommendations were formulated, leading to the re-
design of its layout. It was recommended that the sur-
face of the desk be reorganized, placing the telephone
closer to the worker, so that she no longer had to repet-
itively flex her arm and side-bend her neck and trunk
(task 1). In what concerns task 2, it was recommended
that the door opening control button be placed closer to
the area where the worker was usually sitting, so that
she would not have to perform repetitive movements
of arm and wrist flexion, as well as adopting a posture
with supination of the wrist. As pertaining to task 3, us-
ing an earpiece and a microphone headset was recom-
mended as a means of avoiding the repetitive flexion of
the forearm and upper arm, as well as the side-bending
of the neck and trunk. Fitting a document holder on
the side of the computer screen was recommended to
reduce repetitive neck rotation and flexion, trunk bend-
ing and wrist flexion, while typing (task 4). The chair
in use should have matched the worker’s dimensions
and task demands, enabling a comfortable and healthy
posture. This had not been possible using the existing
chair, which led to neck and trunk flexion for extended
periods of time during hand writing (task 5).
The recommendations for improving work condi-
tions were subsequently used as a guide to set up a
training program, directed at company workers. Most
of the workers in the company had been aware of the
ergonomic issues that resulted from the checklist based
evaluation, especially those concerning their assumed
postures. Most of the preventive and corrective ac-
406 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work
tions recommended depended on an investment being
made by the company, and the responsibility for carry-
ing them out did not solely rest on the workers. It was
expected that their implementation would significantly
decrease the actual risk for the onset of MSDs, and
therefore increase workers’ health. However, it is not
certain that the implementation of the actions recom-
mended would necessarily mean that the risk would be
brought down to negligible levels.
2.3.4. Additional case information
The instability of the market for construction and
public infrastructure sub-contracting was a concern for
the workers in the company at the time when infor-
mation was collected. Public tender announcements
were on a downward trend, both in terms of value and
quantity. These were likely consequences of the global
economic recession of the time.
In the company under focus, pressure was generally
felt by the workers, since the amount of work had in-
creased substantially in many of the departments, with
no accompanying increase in personnel. In this sector,
the negotiating capacity of firms had decreased signifi-
cantly, and it became increasingly difficult for the com-
pany to win profitable sub-contracting, supply or labor
tenders. This was clearly reflected on the day-to-day
activities of the company’s workers, requiring a faster
reaction from them, with tighter and more frequent
deadlines. This gave rise to increased workload, but
with fewer contracts awarded to the company, contrast-
ing sharply with the increased amount of tender bid-
ding performed. Since there was less demand for the
services of companies in this sector, more rival compa-
nies competed more often than previously within each
single tender process, but for a reduced universe of con-
tracts. This was likely to result in increased psycho-
logical stress, anxiety and frustration of the workers,
who had to work harder, for the same salary, but with
less successful outcomes, than they had in the period
preceding the economic downturn.
3. Discussion
New work station design ought to always consid-
er an ergonomic perspective. Decreased productivity,
increased risk of musculoskeletal disorders and added
job stress are likely consequences of the disregard for
ergonomic concerns at the design stage. The case re-
ported constitutes an example of how a new office, re-
cently built, but equipped with older furnishings, may
entail many physical ergonomic hazards.
Significant changes are taking place in the world of
work. In particular, unstable working conditions can
give rise to job insecurity, which significantly increases
work-related stress. Work intensification and precar-
ious contracts can lead to health problems, with tight
deadlines leading to a growing number of workers ex-
periencing work pressure. Inflexible working hours al-
so make it more difficult to achieve a decent work-life
balance. In the EU, a growing number of workers are
increasingly affected by stress [10], but there is no sin-
gle standard methodology for measuring the effects of
stress in the workplace. The generalized high stress
environment of today’s office work environment [11],
with high work demands or little control at work, has
been related to neck and upper limb problems, although
this relationship is neither very strong nor very specif-
ic [6]. Increasingly available convergent evidence sug-
gests that modification of the various physical and psy-
chosocial factors could substantially reduce the risk of
symptoms of upper extremity disorders, as well as low
back pain [40]. However, research on the quantification
of the impact of job stressors on musculoskeletal symp-
toms is ongoing [14]. Accordingly, the standard meth-
ods for assessment of hazards conducive to the onset of
MSDs (examples of these were given in Table 1) have
yet to incorporate work related psychosocial factors.
The approach for risk assessment followed in the
case did not consider psychosocial factors. The as-
sessment of risk obtained may be significantly milder
than what it might have been if consideration were giv-
en to the influence of psychosocial factors. Given the
changing panorama of office work, exemplified by this
case study, psychosocial factors should be considered
in standard methods of assessment of the risk of MSDs,
which should thus be revised accordingly, as soon as
high quality research results become available.
4. Summary
The case study presented in this paper exemplifies
a practitioner’s approach to the assessment of the risk
of MSDs of the neck and upper limbs in office work-
ers, based on the consideration of physical ergonomics
factors. Considering the increasingly prevalent stress-
ful working environment, practical methods are need-
ed that extend consideration to psychosocial factors in
assessing the risk of developing MSDs.
 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work
Acknowledgements
This paper benefited from valuable insight provided
by Professor David M. Rempel and Doctor David L.
Lee. The authors also express their gratitude to the
anonymous subjects participating in the case study. The
second author’s role was supported in part by schol-
arship SFRH/BSAB/845/2008 from Fundação para a
Ciência e a Tecnologia.
References
[1] A. Aaras, K.I. Fostervold, O. Ro, M. Thoresen and S. Larsen,
Postural load during VDU work: a comparison between vari-
ous work postures, Ergonomics 40 (1997), 1255–1268.
[2] T.J. Armstrong, P. Buckle, L.J. Fine, M. Hagberg, B. Jonsson,
A. Kilbom, G. Sjogaard and E. Viikari-Juntura, A conceptual
model for work-related neck and upper-limb musculoskeletal
disorders, Scandinavian Journal of Work, Environment and
Health 19 (1993), 73–84.
[3] E.M. Badley, I. Rasooly and G.K. Webster, Relative impor-
tance of musculoskeletal disorders as a cause of chronic health
problems, disability, and health care utilization: findings from
the 1990 Ontario Health Survey, J Rheumatol 21 (1994), 505–
514.
[4] E.M. Badley, The economic burden of musculoskeletal disor-
ders in Canada is similar to that for cancer, and may be higher
[editorial], J Rheumatol 22 (1995), 204–206.
[5] L. Birch, H. Christensen, L. Arendt-Nielsen, T. Graven-
Nielsen and K. Søgaard, The influence of experimental muscle
pain on motor unit activity during low level contraction, Eur
J Appl Physiol 83 (2000), 200–206.
[6] P.M. Bongers, S. Ijmker, S. van den Heuvel and B.M. Blatter,
Epidemiology of work related neck and upper limb problems:
Psychosocial and personal risk factors (Part I) and effective
interventions from a bio behavioural perspective (Part II), J
Occup Rehabil 16 (2006), 279–302.
[7] S. Burt, B. Silverstein, R. Hornung, L. Fine and T. Arm-
strong, Musculoskeletal problems associated with keyboard
use among newspaper employees, International Scientific
Conference on Prevention of Work-Related Musculoskeletal
Disorders PREMUS, Sweden (1992).
[8] A. Coelho, Perturbaç ões músculo-esqueléticas: realidade na-
cional [In Portuguese: Musculoskeletal disorders: national
reality] European Week 2000 – Prevention of Work Related
Musculoskeletal Disorders, Lisbon: IDICT (2000).
[9] D. Colombini, E. Occipinti and M. Fanti, Il Metodo OCRA Per
L’analisi e La Prevenzione del Rischio da Movimenti Ripetu-
ti – Manuale per la Valutazione e la Gestione del Rischio, Re-
search unit for Ergonomics of Posture and Movement (EPM),
Clinica del Lavoro Luigi Devoto (Università degli Studi di
Milano), Milan (2005).
[10] European Agency for Safety and Health at Work, EU-OSHA
Annual Report 2008: Health and Safety in Hard Times (2009),
URL: http://osha.europa.eu/en/publications/annual report/20
08full/view.
[11] O. Evans and K. Patterson, Predictors of neck and shoulder
pain in non-secretarial computer users, International Journal
of Industrial Ergonomics 26 (2000), 357–365.
407
[12] W. Felts and E. Yelin, The economic impact of the rheumatic
diseases in the United States, J Rheumatol 16 (1989), 867–884.
[13] F. Gerr, C.P. Monteilh and M. Marcus, Keyboard use and
musculoskeletal outcomes among computer users, J Occup
Rehabil 16(3) (2006), 265–277.
[14] B.A. Greiner, N. Krause, D. Raglandc and J.M. Fisher, Oc-
cupational stressors and hypertension: a multi-method study
using observer-based job analysis and self-reports in urban
transit operators, Social Science & Medicine 59 (2004), 1081–
1094.
[15] W. Hünting, T. Läubli and E. Grandjean, Postural and vi-
sual loads at VDT workplaces. I. Constrained postures, Er-
gonomics 24 (1981), 917–931.
[16] S. Ijmker, M.A. Huysmans, B.M. Blatter, A.J. van der Beek,
W. van Mechelen and P.M. Bongers, Should office workers
spend fewer hours at their computer? A systematic review of
the literature, Occup Environ Med 64(4) (2007), 211–222.
[17] K. Jacobs, S. Hudak and J. McGiffert, Computer-related pos-
ture and musculoskeletal discomfort in middle school students,
Work 32 (2009), 275–283.
[18] B.R. Jensen, M. Pilegaard and G. Sjøgaard, Motor unit re-
cruitment and rate coding in response to fatiguing shoulder
abductions and subsequent recovery, Eur J Appl Physiol 83
(2000), 190–199.
[19] R. Kadefors, M. Forsman, B. Zoega and P. Herberts, Recruit-
ment of low threshold motor-units in the trapezius muscle in
different static armpositions, Ergonomics 42 (1999), 359–375.
[20] K. Kamwendo, S. Linton and U. Moritz, Neck and shoulder
disorders in medical secretaries – Part 1 – Pain prevalence
and risk factors, Scandinavian Journal of Rehabilitation and
Medicine 23 (1991), 127–133.
[21] D. Kee and W. Karwowski, LUBA: an assessment technique
for postural loading on the upper body based on joint motion
discomfort and maximum holding time, Appl Ergon 32(4)
(2001), 357–366.
[22] K. Kemmlert, A method assigned for the identification of
ergonomic hazards, PLIBEL Applied Ergonomics 26 (1995),
199–211.
[23] W.M. Keyserling, D.S. Stetson, B.A. Silverstein and M.L.
Brouwer, A checklist for evaluating ergonomic risk factors
associated with upper extremity cumulative trauma disorders,
Ergonomics 36 (1993), 807–831.
[24] A. Kilbom and J. Persson, Work technique and its conse-
quences for musculoskeletal disorders, Ergonomics 30 (1987),
273–279.
[25] A. Kilbom, Assessment of physical exposure in relation to
work-related musculoskeletal disorders – what information
can be obtained from systematic observations? Scand J Work
Environ Health 20 (1994), Spec No., 30–45.
[26] T. Kitahara, M. Schnoz, T. Läubli, P. Wellig and H. Krueger,
Motor-unit activity in the trapezius muscle during rest, while
inputting data, and during fast finger tapping, Eur J Appl
Physiol 83 (2000), 181–189.
[27] T. Läubli and E. Grandjean, The magic of control groups in
VDT field studies, in: Ergonomics and Health in Modern
Office, E. Grandjean, ed., London: Taylor and Francis, 1984,
pp. 105–112.
[28] W.A. Latko, T.J. Armstrong, J.A. Foulke, G.D. Herrin, R.A.
Rabourn and S.S. Ulin, Development and evaluation of an
observational method for assessing repetition in hand tasks,
Am Ind Hyg Assoc J 58(4) (1997), 278–285.
[29] R.C. Lawrence, C.G. Helmick, F.C. Arnett, R.A. Deyo, D.T.
Felson, E.H. Giannini, S.P. Heyse, R. Hirsch, M.C. Hochberg,
G.G. Hunder, M.H. Liang, S.R. Pillemer, V.D. Steen and F.
408 T.M. Lima and D.A. Coelho / Prevention of musculoskeletal disorders (MSDs) in office work
Wolfe, Estimates of the prevalence of arthritis and select-
ed musculoskeletal disorders in the United States, Arthritis
Rheum 41 (1998), 778–799.
[30] D.L. Lee, J.T. Dennerlein and N.A. Baker, Inter-Rater Relia-
bility of the Mouse-Personal Computer Style Instrument (M-
PeCS), Proceedings of the Human Factors and Ergonomics
Society 53rd Annual Meeting (2009), 917–921.
[31] L. Leon, J.A. Jover, G. Candelas, C. Lajas, C. Vadillo, M.
Blanco, E. Loza, M.A. Perez, M. Redondo and I. Abasolo,
Effectiveness of an Early Cognitive-Behavioral Treatment in
Patients With Work Disability Due to Musculoskeletal Dis-
orders, Arthritis & Rheumatism (Arthritis Care & Research)
61(7) (2009), 996–1003.
[32] T.M. Lima, Análise Ergonómica do trabalho com as novas tec-
nologias – uma perspectiva da prevenção de lesões músculo-
esqueléticas [in Portuguese – Ergonomic analysis of work with
the new technologies – a prespective of the prevention of mus-
culoskeletal disorders], Master of Science Dissertation in In-
dustrial Engineering and Management, Universidade da Beira
interior, Portugal (2009).
[33] R. Lueder, A Proposed RULA for Computer Users, Proceed-
ings of the Ergonomics Summer Workshop, UC Berkeley Cen-
ter for Occupational & Environmental Health Continuing Ed-
ucation Program, San Francisco, CA (1996), 1–11.
[34] L. McAtamney and E.N. Corlett, RULA: a survey method for
the investigation of work-related upper limb disorders, Applied
Ergonomics 24(2) (1993), 91–99.
[35] W.J. Meerding, L. Bonneux, J.J. Polder, M.A. Koopmanschap
and P.J. van der Maas, Demographic and epidemiological de-
terminants of healthcare costs in Netherlands: cost of illness
study, BMJ 317 (1998), 11–15.
[36] J.S. Moore and A. Garg, The Strain Index: A Proposed Method
to Analyze Jobs for Risk of Distal Upper Extremity Disorders,
Am Ind Hyg Assoc J 56(5) (1995), 443–458.
[37] K.L. Noack-Cooper, C.M. Sommerich and G.A. Mirka, Col-
lege students and computers: Assessment of usage patterns
and musculoskeletal discomfort, Work 32 (2009), 285–298.
[38] E. Occhipinti, OCRA: a concise index for the assessment
of exposure to repetitive movements of the upper limbs, Er-
gonomics 41 (1998), 1290–1311.
[39] K. Patterson and O. Evans, Touch Typing Skill and Neck Flex-
ion During Computer Use, Proceedings of the 32nd Annu-
al Conference, Ergonomics Society of Australia, Canberra,
1996, 44–50.
[40] Panel on Musculoskeletal Disorders and the Workplace –
Commission on Behavioral and Social Sciences and Educa-
tion – National Research Council and Institute of Medicine,
Musculoskeletal Disorders and the Workplace: Low Back and
Upper Extremities, Washington, DC: National Academy Press
(2001).
[41] D.M. Rempel, N. Krause, R. Goldberg, D. Benner, M. Hudes
and G.U. Goldner, A randomised controlled trial evaluating
the effects of two work station interventions on upper body
pain and incident musculoskeletal disorders among comput-
er operators, Occupational and Environmental Medicine 63
(2006), 300–306.
[42] D.L. Reynolds, L.W. Chambers, E.M. Badley, H.J. Bennet,
C.H. Goldsmith, E. Jamieson, G.W. Torrance and P. Tugwell,
Physical disability among Canadians reporting musculoskele-
tal diseases, J Rheumatol (19) (1992), 1020–1030.
[43] S. Sauter, L. Schleifer and S. Knutson, Work posture, work
station design, and musculoskeletal discomfort in a VDT data
entry task, Human Factors 33(2) (1991), 151–167.
[44] F.M.S. Serranheira, Lesões Músculo-esqueléticas Ligadas ao
Trabalho – Que Métodos de Avaliação de Risco [in Por-
tuguese – Work Related Musculoskeletal disorders – what
risk assessment methods], Doctoral Dissertation in Pub-
lic Health (specializing in Occupational Health), Universi-
dade Nova Lisboa, Lisbon (2007) URL: http://www.ergonet.
com.br/download/lesoes-serranheira.pdf.
[45] B. Silverstein, The Use of Checklists for Upper Limb Risk As-
sessment, Proceedings of the International Ergonomics Asso-
ciation triennial meeting, Tampere, Finland, (1997).
[46] G. Sjøgaard, U. Lundberg and R. Kadefors, The role of mus-
cle activity and mental load in the development of pain and
degenerative processes at the muscle level during computer
work, Special Issue: Eur J Appl Physiol 83 (2000), 99–105.
[47] S.J. Starr, C.R. Thompson and S.J. Shute, Effects of video
display terminals on telephone operators, Hum Factors 24
(1982), 699–711.
[48] S. Thorn, M. Forsman, Q. Zhang and K. Taoda, Low-threshold
motor unit activity during a one-hour contraction in the trapez-
ius muscle, IJIE 30 (2000), 225–236.
[49] D. Van Schaardenburg, K.J. van den Brade, G.J. Ligthart,
F.C. Breedveld and J.M. Hazes, Musculoskeletal disorders and
disability in persons aged 85 and over: a community survey,
Ann Rheum Dis 53 (1994), 807–811.
[50] B. Visser, E. de Korte, I. van der Kraan and P. Kuijer, The effect
of arm and wrist supports on the load of the upper extremity
during VDU work, Clinical Biomechanics 15(Suppl 1) (2000),
S34–S38.
[51] E.H. Yelin, C.J. Henke and W.V. Epstein, Work disabili-
ty among persons with musculoskeletal conditions, Arthritis
Rheum 29 (1986), 1322–1333.
[52] E.H. Yelin and W.R. Felts, A summary of the impact of mus-
culoskeletal conditions in the United States, Arthritis Rheum
33 (1990), 750–755.
Copyright of Work is the property of IOS Press and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.