Pine Rgonomics: Malcolm H. Pope, Kheng Lim Goh, and Marianne L. Magnusson

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10.1146/annurev.bioeng.4.092101.122107
Annu. Rev. Biomed. Eng. 2002. 4:49–68

doi: 10.1146/annurev.bioeng.4.092101.122107
Copyright °
c 2002 by Annual Reviews. All rights reserved
SPINE ERGONOMICS
Malcolm H. Pope, Kheng Lim Goh, and
Marianne L. Magnusson
Liberty Safework Research Centre, Departments of Environmental and Occupational
Medicine and Bio-Medical Physics and Bio-Engineering, University of Aberdeen,
Aberdeen, AB25 2ZP Scotland, United Kingdom; e-mail: m.pope@biomed.abdn.ac.uk
Annu. Rev. Biomed. Eng. 2002.4:49-68. Downloaded from www.annualreviews.org
Key Words low back pain, occupational, prevention

■ Abstract Occupational low back pain (LBP) is an immense burden for both indus-
by York University on 08/13/14. For personal use only.
try and medicine. Ergonomic and personal risk factors result in LBP, but psychosocial
factors can influence LBP disability. Epidemiologic studies clearly indicate the role of
mechanical loads on the etiology of occupational LBP. Occupational exposures such as
lifting, particularly in awkward postures; heavy lifting; or repetitive lifting are related
to LBP. Fixed postures and prolonged seating are also risk factors. LBP is found in
both sedentary occupations and in drivers as well as those involved in manual materi-
als handling. Any prolonged posture will lead to static loading of the soft tissues and
cause discomfort. Standing and sitting have specific advantages and disadvantages for
mobility, exertion of force, energy consumption, circulatory demands, coordination,
and motion control. The seated posture leads to inactivity causing an accumulation
of metabolites, accelerating disk degeneration and leading to disk herniation. Driver’s
postures can also lead to musculoskeletal problems. Workers in a driving environment
are often subjected to postural stress leading to back, neck, and upper extremity pain.
This exacerbates the problems due to the vibration. Prevention is by far the treatment
of choice. Improved muscle function can be preventative. Poor coordination and motor
control systems are as important as endurance and strength. Fixed postures should be
avoided. Seats offering good lumbar support should be used in the office. A suspension
seat should be used in vehicles whenever possible. Heavy and awkward lifting should
be avoided and lifting aids should be made available. Workers should report LBP as
early as possible and seek medical advice if they think occupational exposure is harm-
ing them. The combined effects of the medical community, labor, and management are
required to cause some impact on this problem.
CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
RISK FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Muscle Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Lifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Pulling and Pushing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
1523-9829/02/0815-0049$14.00 49
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50 POPE ¥ GOH ¥ MAGNUSSON
Whole Body Vibration (WBV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Muscle Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Lifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Pushing and Pulling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Whole Body Vibration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
INTRODUCTION
Occupational low back pain (LBP) is a great burden for industry and medicine.
Kelsey & White (1) found 2% of workers in the United States have a compensable
back injury. LBP is the most expensive United States health problem in ages 20
to 50. The greatest expense is from 25% of the cases, and as the LBP duration
increases, the total cost accelerates. LBP is responsible for 21% of all compensable
work injuries and 33% of the cost. Medical costs are 33% of the total and disability
payments are the remainder (2).
In this article, we examine the epidemiologic relationships between LBP and
physical loading of the spine and the biomechanical etiology.
RISK FACTORS
General
We emphasize ergonomic factors, but other factors result in LBP and especially
LBP disability. Psychosocial factors can influence LBP disability (3). According to
Karasek et al. (4), work stress and ill-health are related to work load and clarity and
conflict at work, but the effect of these work-related characteristics is moderated by
control (decision latitude), career development opportunities, and social support at
work. The combination of high demands and low control at work is supposed to be
stressful and related to adverse health effects. It is now being recognized that there
is a symbiotic relationship between psychological and physiological stress. Psy-
chosocial stress during activity such as lifting under stressful conditions increases
muscle activity and leads to increased spine compression and lateral shear (5).
Other important patient factors are obesity, physical fitness, smoking history,
height, and pregnancy (6). Specific personal factors affect tissue tolerance (i.e., age
and gender). These are important factors to take into account with an aging and
diversified work force.
Muscle Function
Chaffin et al. (7) found that LBP was three times more prevalent in workers who
had less strength than needed for their jobs and that one third of the workforce
SPINE ERGONOMICS 51
is required to exert at their maximum strength [NIOSH (National Institute of

Occupational Safety and Health) 1981]. Chaffin et al. (8) suggest industry use
placement programs based on strength performance. Isometric testing is the most
common, but it may be unrealistic and unsafe (3). In isokinetic tests, the lift
velocity is constant. In isodynamic tests, the velocity varies but the resistance is
preset, which is a realistic functional test, but has not been tested prospectively.
The purpose of job simulation is to see if the worker can perform the job required.
Strength testing should be as specific as possible to the job for practical, ethical,
and legal reasons.
More subtle muscle functions such as motor control are also important.
Cholewicki & McGill’s (9) model showed that the spine can buckle during a
minor task with low muscle forces where a small motor error causes over-rotation
of a functional spinal unit and loading of the soft tissues. Magnusson et al. (10)
found that muscles do not respond quickly enough to protect the soft tissues.
Krajcarski et al. (11) found that preactivation of trunk extensor muscles may
serve to reduce the flexion displacements caused by rapid loading. The abdominal
oblique muscles, especially external oblique, will rapidly increase their activation
levels in response to rapid loading. When preactivation levels are low, there is a
lower initial trunk stiffness and spine compression force. Adams & Dolan (12)
found that soft tissues fail with bending moments of 60 Nm, which could be the
torso weight when bending over with no muscle support. Some injuries occur
because of motor control errors. These are random events, but are more likely in
people with poor motor control systems (13). Thus, a back injury can occur in a
simple task if there is insufficient warning of an overload.
Endurance is important because workers fatigue with repetitive tasks (14).
McGill et al. (15) noted that people differ in their ability to hold a load in their
hands and breathe “heavily.” This may be significant because the muscles required
to be continuously active to prevent buckling of the spine are also used to breathe.
Thus, those with compromised lung elasticity (i.e., smokers) may be at risk when
the muscles are relaxed. McGill et al. (15) have identified inappropriate muscle
sequences in subjects loaded while breathing 10% carbon dioxide to elevate breath-
ing. Potvin & O’Brien (16) made the important observation that fatigue results in a
change in the recruitment patterns of trunk muscles: Muscles serving as antagonist
and trunk stabilizers during prolonged axial twist exertions increased their force
levels in response to fatigue.
The stability of the spine can be considered to consist of three subsystems:
the passive musculoskeletal, the active musculoskeletal, and the neural feedback
subsystem. All systems act together. In recent years, more attention has been given
to the neural feedback system. Proprioception is an important factor in stabilization
of the joints and throughout the spine. It is probable that proprioception deficits are
associated with LBP and low back injuries. Proprioception decreases with aging,
with lack of exercise, and in those with LBP. A system with feedback has been
successfully used to rehabilitate those with chronic LBP. With prolonged exposure
to lifting or excessive postures such as full flexion, the viscoelastic structures of the
lumbar spine will become stretched out due to creep. Gedalia et al. (17) reported
that laxity in the viscoelastic structures desensitizes the mechano-receptors within
and causes loss of reflexive stabilizing forces from the multifidus muscles. The first
10 minutes of rest after cyclic loading results in fast partial recovery of muscular
activity; full recovery is not possible even with rest periods twice as long as the
loading period. This may increase the risk of instability, injury, and pain in the spine.
Lifting
LBP is associated with lifting, but instructions for the “proper” technique have
been controversial. The principle is to hold the object as close to the body as
possible, which is more important than keeping a straight back (18). Brinckmann
et al. (19) reported that spinal loading during forward bent posture results in
a height decrease or deformation of lumbar vertebrae. Other things affect the
way we lift. Chen (20) showed that when muscle fatigue occurs in the arms, the
lifting strategy becomes more stressful on the back, and whole-body lifting should
be avoided in order to reduce the risk of injury to the lower back. The worker
should use smooth lifting technique without jerking to minimize the effect of
dynamic loads on the spine. Davis & Marras (21) concluded from an extensive
literature review that the ability of the individual to perform a task “safely” may be
compromised by muscle coactivity during dynamic exertions, e.g., trunk motion
outside the sagittal plane. Fathallah et al. (22) established that lowering of a load
gives consistently lower trunk muscular activities than lifting. Asymmetric lifting
is associated with an increased risk of low back disorders according to Kingma et al.
(23); small deviations of a lifting movement from the sagittal plane can increase
risk of low back disorders. Antagonistic cocontraction affects spinal stability and
spinal compression. For antagonistic cocontraction to be beneficial, stability must
increase more than spinal load. Antagonistic cocontraction is beneficial at low
trunk moments typically observed in upright postures (24). Granata et al. (25)
found that weight, task asymmetry, and job experience (level of experience) affect
the magnitude and variability of spinal load during repeated lifting exertions.
Gagnon & Smith (26) also point out that slower lifts with reduced acceleration
when lifting moderately heavy work may present less of a risk to low back disorder.
With regard to our aging workforce, bending and lifting activities generate loads
on the spine that exceed the failure load of vertebrae with low bone mineral density.
This yields a high factor of risk (ratio of load on spine to failure load of bone) (27).
In critical tasks with twisting, it is important to have the worker turning with the
feet to reduce the torsional loads on the intervertebral discs. The relative merits of
back-stooped posture versus knee lifts are debated. However, lifting a bulky load
with an erect back increases the intradiscal pressure (IDP) compared to the back-
stooped posture because of the increased moment arm and the vertical component
of body weight and hand forces. However, shear forces are greater when lifting
with the back flexed and the articular capsule and the posterior ligaments may
be overstrained. Workers may lift loads with their backs rather than their legs to
SPINE ERGONOMICS 53
maximize the available energy. IDP is similar with back lift and leg lift if the load
moment arm is constant. Intra-abdominal pressure (IAP) has been proposed as a
major source of column support. Asmussen & Poulsen (28) report a maximum
limit of 150 mm Hg for highly trained individuals and 90 mm Hg for the normal
population. Krag et al. (29) established that increasing IAP actually increases
muscle activity and thus spinal load.
Pulling and Pushing

Pushing and pulling activities can cause occupational LBP. Magora (30) found
increased LBP in those whose jobs involved reaching and pulling, and NIOSH
reported that 20% of injury claims for LBP involved pushing or pulling loads.
Damkot et al. (31) measured pushing exposure by multiplying the weight of pushed
objects by the number of pushing efforts required each day. Those with severe LBP
have five times as much weight-day units as those without LBP. White & Panjabi
(32) have shown that high spine loads result from pulling activities (see Figure 1a).
Ayoub & McDaniel (33) found that body posture plays an important role in the
force capability in both pushing and pulling and is probably very important in
the etiology of pulling or pushing LBP injuries. Friedrich et al. (34) found that
combined walking and pushing under vertical space constraints was associated
with increased lumbar flexion and thoracic extension. The latter increase was due to
an attempt to enhance abdominal muscle strength. The health care professions are
at a high risk of LBP, and pushing-pulling activities are no exception. Lavender et al.
(35) found the most hazardous tasks performed by emergency medical technicians
included pulling a victim from a bed to a stretcher, the initial descent of a set of
stairs when using the stretcher, and lifting a victim on a backboard from the floor.
Posture
The posture at work can cause LBP. We have already mentioned the antagonistic
muscle activity and the effect on spinal loading. McGill et al. (36) pointed out
that anterior shear load on the lumbar spine increases the risk of LBP. Bending
forward allows the spine to fully flex; this changes the line of action of the largest
extensor muscles and reduces their effectiveness to support anterior shear forces.
In fact, in this position, the muscles become inactive and the person is hanging by
their soft tissues. McGill et al. (36) found that fully flexing the spine renders the
lumbar extensor muscles ineffective for supporting anterior shear forces. Anterior
shear load on the lumbar spine is highly related to the risk of back injury. Jobs
such as seated warehouse shipper, gardener, and construction worker require such
postures. Potvin et al. (37) also pointed out that during lifting, the risk of injury to
the spine may be increased more by the degree of lumbar flexion than the choice
of stoop or squat technique. McGill & Brown (38) measured creep response of the
lumbar spine from nine min of full flexion posture. Full recovery took ∼30 min.
Many workers have to work in extreme postures. Gallagher et al. (39) found that
the effect of the kneeling posture, used in construction and mining, is increased

Figure 1 Forces in (a) pulling and (b) pushing activities.

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lumbar compression. Adams & Dolan (40) point out that the risk of bending injury
to soft tissues due to posture will depend not only on the loads applied to the spine,
but also on loading rate and loading history.
The quantification of potentially harmful postures has been an enigma. One
approach to record potentially stressful postures is referred to as posture target-
ing. A worker is observed at random times during the workday and the angular
configuration of various body segments is recorded with the aid of a body dia-
gram. This procedure is useful in evaluating workplace layouts when combined
with worker reports of localized musculoskeletal pain obtained at several intervals
during a workday. Another technique has been to use a trunk goniometer as shown
in Figure 2.
SITTING LC According to Magora (41, 42), there is increased risk of LBP in seden-
tary jobs. There is also an increase in symptoms in those with LBP who sit for
prolonged periods. In sitting, body weight is transferred to supporting areas by the
ischial tuberosities and the soft tissues. Some body weight will be transferred to the
floor, the backrest, and armrests. IDP when sitting with no lumbar support is 35%
higher than standing (43). Increased IDP in sitting occurs due to (a) increased trunk
moment when the pelvis rotates backward and (b) disk deformation caused by
the lumbar spine flattening. Inclination of the backrest backward and increased
lumbar support reduce IDP because (a) body weight is transferred to the backrest
and an increased backrest inclination is beneficial, and (b) lumbar supports increase
lordosis and reduce disc deformation. In addition to the advantage of backrests,
armrests offer support that unloads the spine.
Sitting postures are usually classified as anterior, middle, or posterior. In the
middle posture, the center of mass is directly above the ischial tuberosities and is
unstable due to them acting as a pivot. The lumbar spine is either straight or in
slight kyphosis. The anterior (forward leaning) posture is used when deskwork is
performed. The center of mass is in front of the ischial tuberosities. In the posterior
(backward leaning) posture, the center of mass is behind the ischial tuberosities.
The posterior posture is obtained by a backward pelvic rotation resulting in lumbar
kyphosis. The seated posture depends on factors such as the chair design, sitting
habits, the task, seat height and inclination, backrest position, shape and inclination,
and other supports. The chair should permit easy adjustment because continuous
sitting in one position is a risk factor for LBP. Writing decreases IDP when the
arms are supported by the desk, whereas typing and lifting a phone increase IDP
because of larger load moments. However, there are physiologic reasons to change
one’s working posture to improve both disc nutrition and soft tissue tone. Griffing
(44) noted that postural fatigue, sickness, and absence decrease when postural
changes are required.
STANDING LC Pope et al. (6) have reported the positive relationship between pro-
longed standing and LBP. However, there is no information that prolonged stand-
ing increases IDP unless accompanied by twisting, lifting, or other risk factors.
SPINE ERGONOMICS 57
Muscular activity is required to maintain an upright posture, but as long as the

body segments are well aligned with respect to the center of gravity, the activity
is small. Any shift in the center of gravity of the trunk requires active counterbal-
ancing by muscle force to maintain equilibrium. Muscle forces are also required
to counterbalance the moment caused by an outstretched arm, an external weight,
or any other force applied to the trunk, head, and upper extremities. The combined
effect of all these forces upon the lumbar spine produces a moment that must be
counterbalanced by the spinal muscles to maintain equilibrium.
It was first reported by DePuky (45) that the height of the human spine decreases
during the day and increases at night while resting. It has been shown, by use of a
precise height-measuring device called the stadiometer (Figure 3), that the overall
height decreases with loading but increases in the hyperextended posture. Thus,
creep occurs throughout the day.
AWKWARD POSITIONS LC Muscle force, and thus IDP, is increased in postures in-
volving lateral bending or twisting (46). A much more complex situation occurs
when asymmetry prevails. In postures such as lateral flexion, rotation, and com-
binations thereof, other appropriate muscles will contract. In rotation and lateral
bending, high levels of activity occur contralateral to the direction of postural
asymmetries, whereas the activities on the ipsilateral side are small. The asym-
metry in muscle activity can lead to unequal stress concentrations on the different
component structures of the spine. Electromyographic (EMG) studies demonstrate
the antagonistic activity and resulting higher IDP in awkward postures. Antago-
nistic cocontraction of trunk muscles was beneficial in improving stability at low
trunk moments observed in upright postures (24). Antagonistic cocontraction was
less in high trunk moments and more in low trunk moments.
Troup et al. (47) and Frymoyer et al. (48, 49) found twisting to be related to
LBP. Basmajian (50) reported antagonistic EMG activity of the deep trunk muscles
during axial rotation. Thus, the high level of muscle activity and the resultant
IDP may explain the relationship between twisting and LBP. Sudden loading and
awkward postures occur from slipping, tripping, and falling and range from 36%
to 70% of LBP injuries (51, 52, 53). Grieve (54) pointed out that slipping is often
accompanied by lifting. Measurement of slip resistance is not difficult. Strandberg
(55) listed over 60 different methods to measure the frictional characteristics of
the floor. If the slip resistance is greater, a worker is less likely to slip.
Whole Body Vibration (WBV)

Extensive reviews of the literature have been made by Hulshof & van Zanten (56)
and Bovenzi & Hulshof (57), and it has been concluded that there is a positive
relationship between LBP and WBV. There are a few studies with dose–response
relationships. From a survey of occupational drivers (of many types), Schwarze
et al. (58) concluded that, with increasing dose, it is probable that LBP is caused
by exposure to WBV. Fritz (59) found the risk from exposure to WBV increases

Figure 3 Stadiometer system for measuring in vivo vertical creep of

the seated subject.
SPINE ERGONOMICS 59
with age. Interestingly, Hinz et al. (60) suggested that a person with a low vertebral
strength may be more at risk to degenerative changes in the lumbar spine during
repetitive exposures to moderate transient whole-body vibrations. Magnusson et al.
(61) measured WBV while the drivers were traveling on their usual routes accord-
ing to the recommendations set out by ISO (International Standards Organization)
2631 E (62, 63). Male bus drivers and lorry drivers were age matched to a cohort
of sedentary workers. There was a significant difference between length of time off
work due to LBP between the three occupations. Bus drivers took more time off
work than truck drivers in both subjects in Sweden and the United States. Of the bus
drivers, the Swedes were exposed to higher vibration levels, whereas the United
States truckers were exposed to higher vibration levels than the Swedish truck
drivers. Swedish city bus drivers experienced more vibration exposure than did
the United States long-haul bus drivers. This is probably due to the difference in
bus types, road conditions, and driving demands. The United States truck drivers
were vibrated more than anyone in the study, possibly due to travel on poorer roads
and less vibration attenuated seats and driver’s cabs.

With mounting epidemiologic evidence associating LBP with WBV environ-
ments there has been an increasing focus on the mechanical effect of occupational
vibrations on LBP. WBV has many, and quite varied, effects on the human. Mechan-
ical studies have focused on the resonant frequency, transmissibility, impedance,
spinal muscle activity, and effects on the spinal tissues. When the spinal system
is excited at the resonant frequency, there are major mechanical consequences be-
cause the associated stress can lead to the structure’s mechanical failure. Failure
can occur because the structure oscillates at the maximum excursion, creating the
greatest possible strains on the tissues. The natural frequency of a single degree of
freedom structure can be determined by two means: driving point impedance and
acceleration transmissibility. In impedance studies, the driving force is divided by
the resultant velocity. Resonance occurs when both the driving force and resultant
velocity are in phase and the impedance versus frequency curve reaches a maxi-
mum. They found resonant frequencies to occur between 4 and 6 Hz when the
upper torso vibrates vertically, and between 10 and 14 Hz when there is a bending
vibration of the upper torso with respect to the lumbar spine. Studies also report
resonant frequencies of standing and supine subjects, and resonant frequencies of
seated subjects as affected by side to side or fore to aft vibrations. The effect can
also be characterized by a transfer function, describing the relationship of input
acceleration and measured output acceleration at a point in the body. In frequency
ranges where attenuation is low, resonance occurs causing increases in the transfer
function magnitude. In sitting subjects, resonance occurs at the shoulders at 5 Hz
and also, to some degree, at the head. A significant resonance from shoulder to
head occurs at approximately 30 Hz.
The acceleration transmissibility method determines the output acceleration
caused by a given driving acceleration. Transmissibility is defined as the ratio of
the output acceleration, Aout, as measured on the body to the input acceleration, Ain,
as measured on the system. At resonance, Aout exceeds Ain. Using accelerometers

Figure 4 Impact system to test the frequency response in seated or standing

subjects.
implanted in the lumbar vertebrae and an impact introduced by a pendulum

(Figure 4), Pope et al. (64) showed that the resonant frequency was 4.5 Hz. These
studies demonstrated that much of the dynamic response is due to the combined
rotation and vertical compression of the pelvis-buttocks system. The frequency re-
sponse of a tested subject is influenced by posture. Lateral bending and rotation of
the trunk, which have a higher risk of disc herniation, also lead to a greater transmis-
sion of vibration. Due to fatigue during whole body vibration, there is a significant
increase in EMG response of paravertebral lumbar muscles to a sudden unexpected
load applied to the upper trunk. Thus, truckers who unload their truck right away
after longer driving have a high risk of soft tissue or muscle injury. Of concern to the
spine is the fatigue life of the tissues. This can occur with relatively small stresses
SPINE ERGONOMICS 61
compared to those required for a static stress failure. A tissue’s fatigue life depends
on the range of stress imposed. We have found that an intervertebral disc can fatigue
and herniate and can develop a tracking tear due to cyclic vertical vibration. This
is increased if the vibration is asymmetric or the specimen is preloaded.
Forklift drivers, farmers, and construction workers are exposed to long periods
of twisted posture. The twisted posture in a vibrational environment has been shown
to cause increased energy consumption compared to twisted posture or vibration
as single exposure variables (65). Seated whole body vibration in a position that
ensured muscular activity of the erector spinae muscles caused faster and more
pronounced muscular fatigue in the lumbar erector spinae muscles when compared
to the absence of vibration (66). Both static sitting and seated whole body vibration
caused increased height loss in subjects, suggesting increased spinal load (67).
PREVENTION
General
Because LBP disability is due to more than ergonomics, it is advisable to consider
them in a prevention strategy. Psychosocial factors can influence LBP disability, so
it would seem to be advisable to improve this aspect of the working environment.
A conflict-free workplace is probably healthier. Personal fitness programs aimed
at obesity, physical fitness, and smoking history are also likely to be beneficial.
Such programs should take into account the role of age and gender.
Muscle Function
LBP is more prevalent in workers who have less strength than needed by their jobs,
and thus, it makes sense to build up the trunk strength of these workers. Screening
or placement programs based on strength performance are problematic unless
clearly legal in that jurisdiction. Emphasis should also be placed on endurance,
motor control, and proprioception.
Lifting
The NIOSH guide, which is a very useful and important contribution, is only
applicable to smooth lifting, two-handed symmetrical lifting in the sagittal plane,
and the lifting of moderate-width objects. However, Dolan et al. (68) report that
spinal loading during lifting, which is controlled by muscles from the trunk and
fascia, depends as much on the speed of movement as the size of and position
of the object lifted. Gagnon & Smyth (26) showed that rapid lifting increases
moments and forces in the spine and the musculature. NIOSH also prescribes that
the standing postures should be unrestricted, there should be good handles on the
object, favorable environmental conditions, and no other activities going on at the
same time. If any of these other provisions do apply, then the load should be reduced
even further. When the object is large and heavy, it is desirable to make available
a hoist or crane to assist in its movement. Obviously, this must be conveniently

placed, otherwise the worker will not use it. The load acting on the lumbar spine
during lifting is a combined result of the object weight, the upper body weight, the
back muscle forces, and their respective lever arm to the disc center. Therefore,
the distance of the object from the body is a very important ergonomic factor. This
distance should be considered in designing a container or other things that are often
lifted. If a container is compact, a worker can minimize the spinal load moment
by keeping the object’s center of mass close to the body. If the container must
be lifted from the floor, and it is too large to pass between the knees, it requires
the person to lift the object in front of the knees. This causes a larger spinal load
moment than would be the case if the object could be lifted between the knees. Any
object larger than approximately 30 cm cannot easily be lifted between the knees,
thus increasing the horizontal distance. Thus, the admonition to lift by the knees
and not by the back is nonsense—it depends entirely on the load shape and size!
Most likely, what is of importance is the pelvic orientation. Delitto & Rose (69)
reported that trunk muscle activity occurring with the anterior tilt position of the
pelvis may ensure muscular support for the spine while handling loads. Granata
et al. (25) found that box weight, task asymmetry, and job experience (level of
experience) affect the magnitude and variability of spinal load during repeated
lifting exertions and may be responsible for LBP. Low lifting-index values were
observed by Kee & Chung (70) for relatively high L5/S1 compressive forces from
the EMG-assisted model. This suggests that the 1991 NIOSH lifting equations
may not fully evaluate the risk of dynamic symmetric lifting tasks. Marras et al.
(71) found that the position from which the worker lifted a box on a pallet affects
spine loads with the lower level of the pallet being the greatest. Thus, the effects
on spine loading can be controlled depending on its position on the pallet. Handles
on the box also reduce spine loading.
Commissaris & Toussaint (72) suggest the absence of load knowledge, and
hence overestimating the load to be lifted, may lead to an increased spinal load
and to an increased risk of losing balance in lifting tasks. Underestimating the load
mass to be lifted may lead to similar problems. Thus it is important to label objects
with the weight and to encourage testing of the load by the worker.
Pushing and Pulling

To avoid high compressive forces in the disc, the pulling or pushing hand force
should be below 225 N. Several factors such as vertical handles that can be grasped
at various heights, large low-friction rubber wheels, and two wheels that easily
pivot are important. The workplace floors must be clean and free of hazards. The
floors and shoes must be clean and dry and be high friction. Pushing or pulling
force requirements should be made low, below 225 N, and the hands should be
between the hip to waist level so as to minimize spine load moments. The floor
surfaces and areas where pushing and pulling activities occur must be kept clean
and dry and workers should be instructed to use shoes with traction.
SPINE ERGONOMICS 63
Posture
SITTING The posture of a seated person depends not only on the design of the
chair, but on sitting habits and the task to be performed. The height and inclination
of the seat of the chair, the backrest, and other types of support all influence the
resulting posture. The chair should also permit regular and easy alterations in
posture. Inclination of the backrest backward from vertical results in decreased
IDP. Support of the lumbar spine via a backrest towards lordosis reduces the
deformation of the lumbar spine and resultant IDP. Van Dieen et al. (73) suggest
that sitting is a risk factor for LBP due to the prolonged and monotonous low-level
mechanical load imposed by a seated posture. Spinal shrinkage was increased in
a fixed rather than dynamic chair.
STANDING To maintain low muscle stresses on the spine when standing, an upright
symmetric posture should always be advocated, and all material should be handled
as close to the body as possible. It is often reported that a compliant mat under the
feet will reduce subjective complaints of back fatigue in standing workers. These
mats may attenuate impact to the discs. Alternating between sitting and standing
is also a good idea.
AWKWARD POSTURES Muscle force and thus disc pressure is increased in pos-
tures involving lateral bending or twisting (46). In most cases, these postures can
be avoided by redesign of the workplace to ensure axially symmetric postures.
Workplaces should be kept clear of hazards that workers must walk around, and
parts must be delivered at a convenient height in front of the worker.
Whole Body Vibration

In a vehicle, the primary source of WBV is the interaction of the vehicle and the
ground surface, but any component of the vehicle could be a source. In some cars,
driving 100 km h−1 over California expressways and the joints in the concrete
slabs, which are placed at 5 m intervals, cause resonance of the spine. Thus, the
terrain, speed, and vehicle characteristics can all be of importance.
There can be a considerable muscular effort associated with driving due to
the forces necessary to maintain posture and to control the vehicle and resist its
movements. The components of vibration and shock may not be enough to cause
acute injury, but lateral thrusts may add to the spinal stress. Thus, there may
be a symbiotic effect of vibration and posture. The seat itself is only one part
of the sitting workplace. Cyclic loading should not exceed ISO 2631 E (62, 63)
requirements. Vibration isolation seats should be used where possible, and firm
cushions with lumbar support should be employed. If possible, support of the
arms and the feet should also be used. The posture should permit the backrest to be
used where possible. One method of reducing whole body vibration is to reduce
the vibration input. This can only be done by the choice of vehicles, by training
drivers to choose the vehicle that they drive, and to reduce vibrations by changing
their driving speed and style. Much of this is within the control of the operator and
can be influenced by training.
Other factors to bear in mind are that a hazardous exposure to WBV can be found
in various forms including driving off-road too fast or over a rough route and driv-
ing on badly paved surfaces in vehicles with poor suspension. Exposure to WBV is
not the only cause of back pain. Other factors that can cause or increase back pain
include general posture; poor design of controls, making them difficult to operate;
and poor driver visibility, making twisting and stretching necessary when driving.
The employer should assess the health risks to workers from WBV and identify
what is needed to control those risks and should ensure that the equipment the em-
ployer provides for his employees has been designed or adapted to minimize WBV.
SUMMARY
Occupational LBP is of major importance both economically and in terms of dis-

ability. The problem is getting worse each year and major steps should be taken
toward prevention. LBP has been called the albatross of industry and the nemesis
of medicine. LBP is one of the most important disabling health problems facing
industrialized societies. The medical, industrial, and socioeconomic costs of LBP
are immense. In the United States, LBP is the leading cause of industrial disability
payments and the second most common medical cause of work loss in industry. In
the United States, the total cost of LBP currently comes to nearly 80 billion dollars
per annum (74) and can be anticipated to be far more in the future. Occupational
exposures such as lifting, particularly in awkward postures; heavy lifting; or repeti-
tive lifting are related to LBP. Fixed postures and prolonged seating are also risk
factors. Any prolonged posture will lead to static loading of the muscles and joint
tissues and, consequently, cause discomfort. The human being’s natural behavior is
to change posture often. Even during sleep, there is a need for posture adjustments.
No single position should be maintained for a long period of time without con-
siderable discomfort. LBP is found in both sedentary occupations and in drivers,
as well as those involved in manual materials handling. The seated posture leads
to inactivity that may itself be injurious. Lack of motion leads to an accumula-
tion of metabolites, which probably accelerates the degeneration of the disks and
increases the probability of disk herniation. Drivers postures can also lead to mus-
culoskeletal problems in the neck, shoulder, and arm. At the workplace, standing
and sitting are the two basic forms of postures. These postures have their specific
advantages and disadvantages for mobility, exertion of force, energy consump-
tion, circulatory demands, coordination, and motion control. Workers in a WBV
environment are often also subjected to postural stress, whether they are seated or
standing.
Although it can be a problem, prevention is by far the treatment of choice.
Epidemiologic studies clearly indicate the role of mechanical loads on the etiology
of occupational LBP. Methods are available for characterizing the mechanical
environment of the worker. This information can be used to adapt the workplace to
SPINE ERGONOMICS 65
prevent injuries. It is probable that mechanical risk factors along with psychosocial
factors combine as to total risk for LBP disability. Workers should be made aware
of the importance of personal factors such as level of general fitness, obesity,
smoking, and leisure pursuits. Workers should report LBP as early as possible and
seek medical advice if they think occupational exposure is harming them. The
combined effects of the medical community, labor, and management are required
to cause some impact on this problem.
The Annual Review of Biomedical Engineering is online at

http://bioeng.annualreviews.org
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1 Jul 2002
16:18
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Figure 2 Trunk goniometer.

AR164-03-COLOR.SGM
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June 20, 2002 10:12 Annual Reviews AR164-FM
Annual Review of Biomedical Engineering

Volume 4, 2002
CONTENTS
Frontispiece—Kenneth R. Foster xii
HERMAN P. SCHWAN: A SCIENTIST AND PIONEER IN BIOMEDICAL
ENGINEERING, Kenneth R. Foster 1

ROLES FOR LEARNING SCIENCES AND LEARNING TECHNOLOGIES IN
BIOMEDICAL ENGINEERING EDUCATION: A REVIEW OF RECENT
ADVANCES, Thomas R. Harris, John D. Bransford, and Sean P. Brophy
29
SPINE ERGONOMICS, Malcolm H. Pope, Kheng Lim Goh,
and Marianne L. Magnusson 49
THREE-DIMENSIONAL CONFOCAL MICROSCOPY OF THE LIVING
HUMAN EYE, Barry R. Masters and Matthias Böhnke 69
BIOENGINEERING OF THERAPEUTIC AEROSOLS, David A. Edwards
and Craig Dunbar 93
DENATURATION OF COLLAGEN VIA HEATING: AN IRREVERSIBLE
RATE PROCESS, N.T. Wright and J.D. Humphrey 109
DNA MICROARRAY TECHNOLOGY: DEVICES, SYSTEMS, AND
APPLICATIONS, Michael J. Heller 129
PEPTIDE AGGREGATION IN NEURODEGENERATIVE DISEASE,
Regina M. Murphy 155
MECHANO-ELECTROCHEMICAL PROPERTIES OF ARTICULAR
CARTILAGE: THEIR INHOMOGENEITIES AND ANISOTROPIES,
Van C. Mow and X. Edward Guo 175
ELECTROMAGNETIC FIELDS: HUMAN SAFETY ISSUES, Om P. Gandhi 211
ADVANCES IN IN VIVO BIOLUMINESCENCE IMAGING OF GENE
EXPRESSION, Christopher H. Contag and Michael H. Bachmann 235
PHYSICS AND APPLICATIONS OF MICROFLUIDICS IN BIOLOGY,
David J. Beebe, Glennys A. Mensing, and Glenn M. Walker 261
TELEREHABILITATION RESEARCH: EMERGING OPPORTUNITIES,
Jack M. Winters 287
BIOMECHANICAL DYNAMICS OF THE HEART WITH MRI, Leon Axel 321
ADVANCES IN PROTEOMIC TECHNOLOGIES, Martin L. Yarmush
and Arul Jayaraman 349
v
P1: FRK
June 20, 2002 10:12 Annual Reviews AR164-FM
vi CONTENTS
ON THE METRICS AND EULER-LAGRANGE EQUATIONS OF

COMPUTATIONAL ANATOMY, Michael I. Miller, Alain Trouvé,
and Laurent Younes 375
SELECTIVE ELECTRICAL INTERFACES WITH THE NERVOUS SYSTEM,
Wim L.C. Rutten 407
INDEXES
Subject Index 453
Cumulative Index of Contributing Authors, Volumes 1–4 475
Cumulative Index of Chapter Titles, Volumes 1–4 477
ERRATA
An online log of corrections to Annual Review of Biomedical
Engineering chapters (if any, 1997 to the present) may be found at
http://bioeng.annualreviews.org/

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Annu. Rev. Biomed. Eng. 2002. 4:49–68

Key Words low back pain, occupational, prevention

50 POPE ¥ GOH ¥ MAGNUSSON

Whole Body Vibration (WBV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

is required to exert at their maximum strength [NIOSH (National Institute of

52 POPE ¥ GOH ¥ MAGNUSSON

Pulling and Pushing

54 POPE ¥ GOH ¥ MAGNUSSON

Figure 1 Forces in (a) pulling and (b) pushing activities.

56 POPE ¥ GOH ¥ MAGNUSSON

Muscular activity is required to maintain an upright posture, but as long as the

Whole Body Vibration (WBV)

58 POPE ¥ GOH ¥ MAGNUSSON

Figure 3 Stadiometer system for measuring in vivo vertical creep of

and less vibration attenuated seats and driver’s cabs.

60 POPE ¥ GOH ¥ MAGNUSSON

Figure 4 Impact system to test the frequency response in seated or standing

implanted in the lumbar vertebrae and an impact introduced by a pendulum

62 POPE ¥ GOH ¥ MAGNUSSON

a hoist or crane to assist in its movement. Obviously, this must be conveniently

Pushing and Pulling

a fixed rather than dynamic chair.

Whole Body Vibration

64 POPE ¥ GOH ¥ MAGNUSSON

Occupational LBP is of major importance both economically and in terms of dis-

The Annual Review of Biomedical Engineering is online at

66 POPE ¥ GOH ¥ MAGNUSSON

horts. Clin. Biomech. 13:S1–36 history, work environment and low-back

21. Davis KG, Marras WS. 2000. The effects JB Lippincott

AL. 1974. The sitting posture: an elec- Technol.

In Modern Occupational Medicine, ed. Environ. Health 59:205–20

68 POPE ¥ GOH ¥ MAGNUSSON

Pope MH, Hansson T. 1992. Measurement gonomics 40:559–75

Figure 2 Trunk goniometer.

Annual Review of Biomedical Engineering

ENGINEERING, Kenneth R. Foster 1

ON THE METRICS AND EULER-LAGRANGE EQUATIONS OF

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