ARTICLE IN PRESS

International Journal of Industrial Ergonomics 35 (2005) 197–204

www.elsevier.com/locate/ergon

Risk factors for the prevalence of musculoskeletal disorders

among chinese foundry workers
Ling Leia, Patrick G. Dempseya,, Jian-guo Xuc, Lin-na Gea, You-xin Lianga
a
School of Public Health, Liberty Mutual SafeWork Center at Fudan University, Shanghai 200032, P.R. China
b
Liberty Mutual Research Institute for Safety and Health, 71 Frankland Road, Hopkinton, MA, 01748 USA
c
Cixi Municipal Center for Disease Control and Prevention, Cixi, P.R. China
Received 12 April 2004; received in revised form 16 August 2004; accepted 17 August 2004
Available online 13 October 2004

Abstract

The goal of the study was to investigate risk factors for the prevalence of musculoskeletal symptoms (ache, pain, or
discomfort) among foundry workers in China using the standardized Nordic questionnaire. In addition, questions
describing work history and ergonomic conditions at work were used in the investigation of 617 foundry workers. The
study population consisted of 80.0% males and 20% females with a mean age (SD) of 34.4 (9.5) years and a median
foundry work experience of 3 years (range of 1–30 years). Most subjects had an education of junior middle school with
a mean (SD) of 6.8 (2.7) years of education. Among musculoskeletal symptoms, the one-year prevalence of low-back
symptoms ranked first regardless of job title (25.0–32.4%). Risk factors for low-back symptoms lasting a week or
more in the previous 12 months were found to be smoking, lifting and vibrating tool usage. The prevalence of
low-back symptoms lasting a week or longer were highest in the workers with the job title molders (29.9%), followed by
cleaners (26.2%).
r 2004 Elsevier B.V. All rights reserved.
Relevance to industry

This study provides information on the prevalence of musculoskeletal disorders in foundries, and the results suggest
interventions for low-back pain should be a key priority. The selection of tools to minimize exposure to vibration is also
warranted.
r 2004 Elsevier B.V. All rights reserved.

Keywords: Foundry; Musculoskeletal disorders; Ergonomic assessment; Nordic questionnaire

Corresponding author. Tel.: +1 508 497 0225; fax: +1 508 435 0482.
E-mail address: patrick.demspey@libertymutual.com (P.G. Dempsey).

0169-8141/$ - see front matter r 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.ergon.2004.08.007
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198 L. Lei et al. / International Journal of Industrial Ergonomics 35 (2005) 197–204
1. Introduction
Musculoskeletal disorders (MSDs) attributed to
work include a group of conditions that involve
the nerves, tendons, muscles, and supporting
structures of the body such as intervertebral discs.
Often attributed to or exacerbated by the work
environment, these disorders are also referred to as
work-related musculoskeletal disorders (WMSDs)
which can cause symptoms such as pain, numb-
ness, and tingling, as well as reduced worker
productivity, lost time from work, temporary or
permanent disability. These disorders lead to
financial losses associated with workers’ compen-
sation insurance, or similar forms of social security
in place.
Highly repetitive work, forceful exertions, lifting
and forceful movements, and whole-body vibra-
tion are examples of risk factors that have been
associated with increased reporting of WMSDs
(Bernard, 1997). Poor working conditions in heavy
manufacturing often expose workers to multiple
risk factors for musculoskeletal disorders. The
level of risk depends on the duration a worker is
exposed to risk factors, the frequency at which
they are exposed, and the magnitude of the
exposure.
The metal casting industry has long been
considered to be a hazardous industry character-
ized by exposure to both chemical and physical
hazards, such as silica, heat, and high forces
required to handle and manipulate molds and
castings during various phases of the forming
processes. Although many changes have occurred
in foundry technology and materials, the basic
processes and the associated hazards have re-
mained much the same in many foundries. In fact,
metal casting is still a labor-intensive and complex
process requiring significant amounts of repetitive
manipulation and stressful physical and postural
loads. The work environment poses work safety
hazards for musculoskeletal disorders and acute
injuries due to falling or moving objects, lifting
and carrying loads, etc. (NIOSH, 1985). However,
in the past, much more effort by safety and health
practitioners was focused on the adverse health
effects resulting from exposure to chemical risk
factors. As a result, fewer studies of ergonomic
problems associated with work processes in the
metal casting industry have been published, and in
particular, studies conducted in China.
One conceptual model of the etiology of
musculoskeletal disorders (MSDs) was presented
by the National Institute for Occupational Safety
and Health (NIOSH, 2001). The mechanical loads
were depicted as being determined by the arrange-
ment of work procedures, temporal exposure
patterns, equipment and the environment. This
load would then cause a tissue response, which
may or may not lead to an undesirable outcome
such as symptoms or impairment. Organizational
factors, individual characteristics and social con-
text were depicted as factors that would influence
how the relationship between load and potential
outcomes. The metal casting industry, which was
the focus of this study, is a typical industry with
complex work processes that generate most, if not
all, the risk factors, particularly high physical
loads.
A tool commonly used for investigating the
prevalence of MSD symptoms in occupational
settings is the standardized Nordic questionnaire
(Kourinka et al., 1987). The questionnaire can be
self-administered or used in interviews, and is well
suited for studying the history of musculoskeletal
symptoms and disability in occupational popula-
tions. The questions concentrate on symptoms
most often encountered in an occupational setting,
particularly those affecting the low-back, neck,
and shoulders. The reliability of the questionnaire
was found to be acceptable (Kourinka et al., 1987).
The questionnaire is subject to recall bias, how-
ever, particularly since some questions ask for
musculoskeletal symptoms and problems experi-
enced during the previous 12 months.
Based on pain complaints, there is also a need to
do a physical examination to exclude the presence
of a serious underlying medical condition. In the
absence of red flags, other more specialized tests
are not warranted during the acute phase. Physical
examination guided by the medical history usually
includes general observation of stance and gait,
regional examination and possibly neurologic or
other specific screening. Observation is useful to
guide the regional examination. The regional
examination is mainly vertebral point tenderness
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L. Lei et al. / International Journal of Industrial Ergonomics 35 (2005) 197–204
to palpation, when associated with other signs or
symptoms, is suggestive but not specific for spinal
fracture or infection. Neurologic screening focuses
on a few tests that reveal evidence of nerve root
impairment, peripheral neuropathy, or spinal cord
dysfunction. These items are testing for muscle
strength, reflexes, sensory and motor examinations
(Harris, 1998).
The goal of this study was to investigate the
prevalence of musculoskeletal disorders in foundry
workers. In order to explore the potential factors
related to the prevalence of reporting musculoske-
letal symptoms such as discomfort and pain, four
different job titles in the foundry industry were
included in the study.
2. Procedures
2.1. Subjects
The study population consisted of 772 foundry
workers from three similar foundry factories in a
city in east China. Manual materials handling and
heavy physical loads were the main task char-
acteristics involved in several of the occupations
studied.
Of the 772 workers, 617 were enrolled to
participate in the questionnaire investigation, with
a response rate of 80% (the main reason for not
participating was being absent or away from the
factory during data collection). Workers with at
least 12 months experience in the current work
Table 1
Components of physical examination
Tenderness Reflex
1. Neck tenderness 1. Straight leg raise tests
2. Back tenderness 2. Straight leg raise intensified tests
3. Ankles reflex
4. Knees reflex
5. Pathologic (pathogenic) reflex
199
task were eligible to participate, since the Nordic
questionnaire includes up to a 12-month recall
period. Following the interview, the enrolled
subjects were divided into four groups in accor-
dance with their job titles, including turner
(standing posture), cleaner (static bending pos-
ture), molder (bending and twisting posture, and
heavy physical load), and ‘other’ (less physically-
demanding occupations). The ‘other’ category
included primarily supervisors, technicians, and a
miscellaneous group.
2.2. Methods
The data collection was initiated by first seeking
consent of the subjects to participate. Following
the consent phase, the investigators took measure-
ments of body weight and height for each subject.
An orthopedist then performed a physical exam-
ination for all workers. The items included in the
exam were categorized as tenderness, reflex,
sensation and motor function (see Table 1).
Finally, each subject was interviewed individu-
ally by an interviewer well-trained before the
survey, and having experience administering the
Nordic questionnaire (Kourinka et al., 1987)
during a pilot investigation. The information
collected from the questionnaire investigation
covered the following four major parts:
(1) Demographic characteristics and back-
ground information: job title, age, gender, educa-
tion, marital status, income, cigarette smoking and
alcoholic drinking.
Sensory Motor function
1. Inside and outside of crus 1. Hip joint flexion–extension
2. Inside and outside of instep 2. Bend down and stand up
3. Inside and outside of sole 3. Knee joint flexion–extension
4. Toe extension
5. Thumb extension
6. Toe flexion
7. Thumb flexion
8. Fibula length
9. Heeling
10. Tibialis anterior muscle
11. Toeing
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200 L. Lei et al. / International Journal of Industrial Ergonomics 35 (2005) 197–204

(2) Physical workloads: the work tasks involving
lifting, pushing and pulling loads and vibrating
tools usage were assessed by three questions:
a) What loads do you lift at your work usually?
None; p10 kg; 11 20 kg; 21 50 kg; 450 kg
b) What loads do you push and pull at your
work usually?
None; p10 kg; 11 20 kg; 21 50 kg; 450 kg
c) How often do you usually use vibrating tools
at your work?
Never; Seldom; Half day; Whole day
(3) Work-related factors: work history, employ-
ment duration, heavy work activities at leisure,
exercise, psychological and social status.
(4) MSD symptoms investigation: The ques-
tionnaire used was the Standardized Nordic Mus-
culoskeletal Syndrome Analysis Questionnaire
(Kourinka et al., 1987).
There were two case definitions analyzed: The
term musculoskeletal symptom (MSS) was used in
reference to reports of neck, shoulder, low back, as
well as elbow, hand, hip, knee, and/or multiple
joints trouble (ache, pain, or discomfort) in the 12
months prior to being interviewed. Symptoms
attributed to current work and lasting for at least
a week with no history of injury to that body
region (Bernard et al., 1994; Lemasters et al., 1998)
were referred to as musculoskeletal symptoms-
week plus (MSS-WEEK+). Statistical analyses,
including multiple logistic regression, were per-
formed with SPSS for Windows (version 10.0).
3. Results
The basic demographic and background infor-
mation is summarized in Table 2. Those in the
‘Others’ category were, on average, older and
more experienced than workers in the remaining
three job titles, suggesting the possibility of a
healthy worker effect. The self-reported informa-
tion on materials handling tasks and non-work
habits is presented in Table 3.
3.1. Prevalence of musculoskeletal symptoms
The highest prevalence of symptoms was found
in the body part of back followed by shoulders,
but there was no siginificant difference among the
four groups. The prevalence of MSS in other sites

Table 2
Anthropometric and background characteristics of subject sample

Job title Molders Turners Cleaners Others

Sample size 284 130 84 119

Gender (male:female) 7.4:1 7.1:1 20:1 2.1:1
Age (yr). 34.579.8 31.178.9 32.875.7 38.579.9
Years of school 6.472.7 7.572.5 6.671.7 7.373.2
Employment duration (yr) 3.0 (1–34) 2.0 (1–28) 2.0 (1–22) 6.0 (1–37)
Height (cm) 163.876.3 164.376.6 162.975.9 163.577.3
Weight (kg) 56.776.3 54.677.5 57.876.2 59.978.8

Table 3
Self-reported occupational exposure and leisure activities of subjects (%)

Lifting (kg) Push & pull (kg) Vibrating tool usage Heavy activities at leisure Exercise (times/month) Sleeping (h)

None 31.3% None 37.1% None 71.2% No 95.8% None 75.4% ~6 4.7%
p10 kg 12.2% p10 kg 1.6% Seldom 12.3% Yes 4.2% ~1 6.5% ~8 49.3%
11–20 kg 16.5% 11–20 kg 3.4% Half day 6.8% ~3 5.7% ~10 41.3%
21–50 kg 26.7% 21–50 kg 7.3% All day 9.7% X4 12.4% X10 4.7%
450 kg 13.3% 450 kg 50.6%
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L. Lei et al. / International Journal of Industrial Ergonomics 35 (2005) 197–204 201

Table 4
One-year prevalence of musculoskeletal symptoms (MSS) by body part (%)

No Neck(%) Shoulder(%) Elbow(%) Wrist & hand(%) Back(%) Hip(%) Knee(%) Ankle(%)
a
Molders 284 5.3 8.8 1.4 8.8 32.4 4.2 1.4 2.1
Turners 130 10.0 13.1 3.8 9.2a 26.9 5.4 7.7a 8.5a
Cleaners 84 2.4 6.0 0.0 1.2 25.0 2.4 0.0 1.2
Others 119 6.7 15.1 2.5 1.7 26.9 2.5 1.7 4.2
Total 617 6.2 10.5 1.9 6.5 29.2 3.9 2.6 3.7
a
Indicates significant difference.

Table 5
Prevalence of positive signs found by physical examination (%)

Groups No. Neck tenderness Back tenderness Straight leg raise test Straight leg raise (intensified) test

Molder 284 7.0 16.9a 0.4 0.4

Turner 130 4.6 4.6 0.8 0.8
Cleaner 84 1.2 9.5a 1.2 0.0
Others 119 9.2 1.7 0.0 0.0
Total 617 6.9 10.4 0.5 0.3
a
Indicates significant difference.

was varied with different work titles. The pre- Table 6

Prevalence of musculoskeletal symptoms lasting a week or
valence of MSS found in the wrists and hand, and
longer (MSS-WEEK+)
knees and ankles in turners was significantly
higher than those in other job titles, the same Group n Neck Shoulder Back
tendency was observed at wrists and hands of
Molder 284 5.3 4.6 29.9a
molders (Table 4).
Turner 130 8.5a 11.5a 15.4
Table 5 summarizes the positive signs found Cleaner 84 1.2 2.4 26.2a
during the physical examination. The positive rate Others 119 2.5 5.9 14.3
of back tenderness (16.9%) in molders was Total 617 4.9 6.0 23.3
significantly higher than others, followed by p 0.05 0.018 0.007
cleaners (9.5%). There was no difference in neck a
Indicates significant difference.
tenderness or the straight leg raise tests by job
titles.
MSS-WEEK+ of the neck, shoulders, and low-
3.2. Prevalence of and risk factors associated with back (Tables 7–9, respectively). Variables initially
MSS-WEEK+ entered into model were job title, body mass index
(BMI), gender, marital status, education, income,
The prevalence of MSS-WEEK+ differed by smoking, alcoholism, duration of employment,
job titles. For turners, neck and shoulder pre- age, lifting, pushing and pulling, vibrating tools
valence was found higher than the other special- use, work intensity, heavy loads at leisure, sleeping
ties; cleaners and molders, however, had a hours, and exercise. Two risk factors associated
significantly higher prevalence of back symptoms with neck MSS-WEEK+ identified were job title
lasting a week or more (Table 6). (significantly higher in turners compared to
Multiple logistic regression analysis (backwards ‘other’) and gender (Table 7). For shoulder MSS-
wald) indicated that a number of risk factors were WEEK+, risk factors identified were job title
significantly associated with the occurrence of (significantly higher in turners compared to
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202 L. Lei et al. / International Journal of Industrial Ergonomics 35 (2005) 197–204

Table 7 4. Discussion
Risk factors associated with neck MSS-WEEK+ (n=617)

OR 90%CI p The positive signs noted most often during the

physical examinations were neck and back tender-
Job titles 0.05 ness. Only a few persons had positive signs during
Others 1
the straight leg raise tests. Other physical exam-
Turner 4.78 1.53–14.95 0.02
Cleaner 0.62 0.09–4.36 0.69 ination items including reflex, sensory and motor
Molder 2.58 0.86–7.71 0.15 function did not show any abnormal findings.
Gender Male 1 These rates could be affected by the healthy
Female 2.41 1.14–5.08 0.05 worker effect, since workers with decreased func-
tion would not be present in the workplace to
participate in the study, or would have been more
Table 8 prone to seek employment in jobs with lower
Risk factors associated with shoulder MSS-WEEK+ (n=617) physical demands. Thus, the rates of positive
findings could be underestimates.
OR 90%CI p
The rates of positive findings during the physical
Job titles 0.02 exam are cross-sectional whereas the symptom
Other 1 data are based on recall of symptoms occurring in
Turner 2.83 1.25–6.44 0.04 the previous 12 months. This is most evident when
Cleaner 0.59 0.15–2.33 0.53
comparing the results in Tables 4 and 5, as Table 4
Molder 1.03 0.45–2.34 0.96
Gender Male 1 shows high rates of MSS of the low-back reported
Female 3.11 1.63–5.93 o 0.01 by workers in all job titles. The rates of positive
findings during the physical exam are not only
lower than the rates of MSS, but there is more
variation in physical exam findings among job
Table 9
titles. The patterns of physical findings during
Risk factors associated low-back MSS-WEEK+ (n=617)
examination tend to more closely follow the MSS-
OR 90%CI p WEEK+ findings, but there is some discordance,
for example in the neck region that may be due to
Smoking (cig/day) o 0.01
1.00
small sample size within groups and other sources
~1
~10 0.66 0.41–1.07 0.16 of variation.
~20 1.01 0.67–1.52 0.97 Among the four groups of job titles studied,
X20 2.93 1.63–5.27 o 0.01 molders had the highest prevalence of back
Lifting (kg) 0.02 tenderness (16.9%), followed by the cleaners
None 1.00
~10 0.84 0.44–1.62 0.66
(9.5%). Molders and cleaners also had the highest
~20 2.03 1.22–3.39 0.02 rates of self-reported low-back MSS-WEEK+
~50 2.05 1.32–3.18 0.01 (29.9% and 26.2%, respectively). Although the
X50 1.38 0.80–2.39 0.33 cleaners tended to work often in static bending
Vibrating tool use 0.01 postures, molders were also in static bending
None 1.00
Seldom 1.51 0.92-2.49 0.17
postures, but also manipulated heavy loads
Half day 2.19 1.21-3.95 0.03 including lifting tasks. Turners tended to work
Whole day 2.28 1.37-3.80 0.01 standing with neck bent, while others including
supervisors, technicians and miscellaneous work-
ers engaged in a lighter work with more varied
postures.
‘others’) and gender (Table 8). For low-back MSS- The prevalence of low-back MSS was highest,
WEEK+, smoking, lifting, and vibrating tools use followed by shoulder, neck, and wrist and hand
were found to be significant risk factors (Table 9). pain, regardless of job title. This result suggests
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L. Lei et al. / International Journal of Industrial Ergonomics 35 (2005) 197–204
that the predominant ergonomic problems in the
metal casting industry are related to exposures that
stress the low-back and upper extremities. This is
consistent with the materials handling demands
and awkward postures observed.
From the crude data in which case definition
was not limited (MSS), there was no difference in
low back pain prevalence among workers in the
four job titles. However, when the case definition
of musculoskeletal symptoms lasting longer than a
week was analyzed, the prevalence of low back
pain among cleaners and molders was significantly
higher than others and turners, while that of neck
and shoulder pain in turners was the highest. This
may be due to these jobs either causing more
injury to soft tissues that leads to specific
symptoms lasting longer, these jobs may inhibit
healing, or these jobs may lead to more symptom
expression due to the physical demands. Differ-
ences in rates are also likely affected by recall bias
since both definitions involved symptom history in
the prior 12 months.
There is literature that has quantified how
different case definitions lead to different results
in the prevalence of musculoskeletal disorders
(e.g., Ozguler et al., 2000). Some outcomes are
specific diagnoses (e.g., shoulder tendonitis, epi-
condylitis, tension neck syndrome) and others are
nonspecific musculoskeletal symptoms (e.g., pain,
tenderness, tingling, and numbness) in a specific
body region or all areas combined. For the current
study, two outcome definitions were chosen to
reflect different symptom levels. Any pain or
discomfort in the past 12 months lasting more
than one week represents a more severe outcome,
and presumably even though self-reported, repre-
sents a more severe musculoskeletal condition. In
terms of prevention and ergonomic efforts, these
more severe cases would suggest where interven-
tions to reduce pain and discomfort during work
should be targeted.
According to a multiple logistic regression
analysis, the risk factors associated with neck
and shoulder MSS-WEEK+ were work title and
gender. For both body areas, turners had sig-
nificantly higher risk compared to those in the
‘other’ category. This is consistent with the
physical demands associated with manipulating
203
heavy loads by the turners. The MSS results
in Table 4 showed relatively high prevalence of
neck and shoulder symptoms among turners,
although these rates were not significantly higher
than the rates for other job titles. No significant
differences for neck tenderness among workers in
different job titles were found for the physical
exam.
Low-back MSS-WEEK+ was associated with
smoking, lifting, and vibration tool exposure. The
association between smoking and low-back pain is
unclear in the literature, as there are numerous
studies reporting positive associations, while other
studies report negative associations (Dempsey
et al., 1997). It should be noted that an effect
was only noted for those reporting smoking 20 or
more cigarettes per day. Job title did not have a
significant difference, likely because lifting de-
mands entered the model and these are likely the
most important job demand among different jobs
associated with low-back complaints. Molders had
the highest lifting demands, thus there was
some collinearity between job title and lifting
demands, thus it is reasonable that only one
variable would be in the final model. Since the
survey questions were more related to low-back
stressors than shoulder and particularly neck
stressors, this is likely the reason that none of
these items were significant for the neck and
shoulder models, whereas job title was significant
in those models.
The most important limitation of the study is
the cross-sectional design. The association between
risk factors and MSDs cannot be inferred to
represent a causal relationship. The potential for
recall bias exists as well. The prevalence odds
ratios reported are not as desirable as incidence
odds ratios. The significant risk factors reported
may increase the risk (incidence) of musculoskele-
tal disorders, or they may increase the duration of
the disorders in the exposed population. Finally,
workers with one year or more of experience were
included due to the recall period. Thus, the sample
is biased since the workers that choose to leave
before one year, some possibly due to injury, were
not included. In spite of these limitations, the
study does add knowledge about work-related
musculoskeletal disorders among foundry workers
 ARTICLE IN PRESS
204 L. Lei et al. / International Journal of Industrial Ergonomics 35 (2005) 197–204
in China. Significant opportunities for ergonomic
intervention exist, and the current study provides
information for focusing the interventions for the
different jobs studied.
Acknowledgments
The authors would like to thank David Lom-
bardi and Santosh Verma for their critical reviews
of an earlier draft.
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