Guideline Title- Evidence-based Safety Guideline to Reduce the Risk of
Musculoskeletal Injuries for Older Adults in the Workplace
Target Population
Intended Users
Workers 55 years of age and older
Manufacturing &
Nonmanufacturing Settings
Occupational Health Nurses
Occupational Health Nurse Practitioners
Advanced Practice Nurses in Adult Nursing
Guideline Status
This is the first release of the guideline.
Guideline Objectives
1. To increase OHN knowledge of factors that increase risk of musculoskeletal injury to
older adults
2. To perform a comprehensive assessment of physiological age-related changes
3. To increase knowledge in performing an ergonomic assessment
4. To implement prevention strategies to reduce risk of injury
Major Outcomes
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To blend workplace health and safety with our National Health Care Reform initiatives to
improve the overall health and safety of Americans with a focus on the aging population.
To increase OHN knowledge to help reduce the risk of musculoskeletal injury for older
adults in the workplace
The intent of this evidence-based safety guideline is to increase occupational health nurses
knowledge to help reduce the risk of musculoskeletal injury in older adult workers through
primary and secondary prevention and education.
It is wise for the OHN to take a holistic approach to deliver care to older adult employees to
improve overall health and consequently reduce the risk of musculoskeletal injury. Early
detection of symptoms is paramount to decrease the risk of injury, to decrease injury associated
costs and to prevent chronicity. Knowing how to distinguish between what is occupational and
what is non-occupational is a critical skill for OHNs to have.
The worker health benefit is reduction of musculoskeletal injury risk factors and improved
health. The organizational benefit is a sustainable aging workforce.
There are no side effects or risks.
Methodology
Methods used to Collect/Select the Evidence
© 2014 Nancy Delloiacono, MSN, RN, APN-BC
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Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Electronic databases search from 2005-2013-MEDLINE, CINAHL, Business Source Primer
Search Terms- Medline-musculoskeletal disorders, older adult workers yielded 987 results with
no filters, 2005-2013 with full texts yielded 487 results; CINAHL-aging workforce, chronic
illness with no filters, 1994-2013 yielded 49 results, nursing yielded 49 results, filtered with full
text -24 results; Business Source Primer-aging workforce, safety filtered with full text, 20072012 yielded 133 results
Description of Methods Used to Collect/Select the Evidence
AGREE 2 Evaluation of the American College of Occupational and Environmental MedicineMedical Specialty Society Low back disorders: Evaluation and management of common health
problems and functional recovery in workers; Hartford Institute for Geriatric Nursing-academic
institution for age-related changes in health. In: Evidence-based geriatric nursing protocols for
best practice; and American Occupational Therapy Association Occupational therapy practice
guidelines for individuals with work-related injuries and illnesses.
Methods Used to Assess the Quality and Strength of the Evidence
CEBM Levels of Evidence
See Appendix A
Evidence to Support this Guideline
See Appendix B
References to Support this Guideline
See Appendix C
Description of Method of Guideline Validation
Internal Review
Doctoral Committee Members- Dr. Judith Barberio, PhD, RN, APN-c Committee Chair; Clinical
Assistant Professor, Rutgers, the State University College of Nursing; Dr. Edna Cadmus, PhD,
RN, NEA-BC, Clinical Professor & Specialty Director, Nursing Leadership Program, Rutgers,
The State University College of Nursing and Dr. Dean Wantland, PhD, RN, Assistant Professor,
Rutgers, The State University College of Nursing.
External Review
Dr. Jacqueline Agnew, PhD, MPH, RN, John Hopkins Bloomberg School of Public Health, John
Hopkins Center for Injury Research and Policy reviewer of draft 1 Evidence-based Safety
Guideline to Reduce the Risk of Musculoskeletal Injuries for Older adults in the Workplace
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Dr. Joy Wachs, PhD., RN, Professor, East Tennessee State University and Editor of Workplace,
Health and Safety reviewer of national guidelines utilizing the AGREE 2 evaluation
Dr. Barbara Burgel, PhD., RN, Clinical Professor in Community Health track at University of
California San Francisco reviewer of national guidelines utilizing the AGREE 2 evaluation
Assessment Points of Interest
Client Musculoskeletal History
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Musculoskeletal disorders-“Injuries or dysfunctions affecting muscles, bones, nerves,
tendons, ligaments, joints, cartilages and spinal discs.” Includes tears, sprains, strains,
carpal tunnel syndrome, pain, soreness, hernias and connective injuries of the structures
mentioned (daCosta & Vieira, 2009).
Overexertion injury-sprains, strains (scope: low back, shoulder, neck, knee, hand, wrist,
ankle & foot)
Falls (single, multiple)
How long ago did the fall occur?
Fractures- resulting from overuse or trauma, underlying osteopenia
Low bone mass
Osteoporosis-Most common over age 50
Low Vitamin D level
Weight changes ( weight loss may or may not indicate a red flag)
Dehydration
Pain & location (especially widespread pain), pain scale, aching, cramping, stiffness,
tenderness, edema
Itchy, dry, sore eyes, double or blurry vision
Sleep alterations
Musculoskeletal Functional Assessment-activity level, exercise pattern, flexibility, gait,
balance, strength, energy level, endurance
Fall risk assessment, if indicated. For information on The Hendrich 11 Fall Risk Model
go to: http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf
Occupational psychological factors- job satisfaction, work relations, monotonous tasks,
perceived work ability, stress and demands
Medical History
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Arthritis-osteo, rheumatoid, psoriatic. Knee is the joint most affected by arthritis.
Cardiovascular-There is a progressive decline in the functional capacity in the older
adult. Heart rate and perceived work stress is lower for older adults with higher levels of
aerobic fitness.
Hypertension or Hypotension postural changes
Respiratory- clinical measures and risk factors such as family history, genetics,
occupation & smoking, asthma, chronic bronchitis, emphysema, COPD
Neurologic- headaches, stroke, numbness, tingling, burning sensation in hand, decreased
sensation
Diabetes, micro-vascular changes, A1c results
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Seasonal allergies
Chronic fatigue-Older adults need more recovery time for muscles used on the job. If not
enough rest and recovery time, it leads to fatigue and injury.
Limitations
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Visual, night blindness
Auditory
Mobility
Co-ordination
Dexterity
Psychosocial History
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Self- imagined age
Life and career stage
Cigarettes, cigars, alcohol, drugs
Depression, anxiety, stress, concentration, mental resilience, sleep patterns
Method of relaxation
Socialization
Supervisor/employee working relationship
Job satisfaction-
Medication Safety Risk
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Prescription and OTC- Pay particular attention to antihistamines, pain relievers, muscle
relaxers, anti-anxiety & antidepressants
Job Impact
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Job history- Date of hire, previous jobs and type of work, part-time/full-time, length of
time functioning in an ergonomically demanding environment
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High job demand (frequent interruptions, deadlines, social support, social support), risk
of injury increases
Low job control (no job variability, limited choice of how work should be accomplished),
risk of injury increases
Physical work demands-(There is strong epidemiological evidence that physical
demands(lifting, bending, manual materials handling and twisting and whole body
vibration can be associated with increased reports of back symptoms, aggravation of
symptoms and injuries”(Waddell &Burtob, 2001).
Strong evidence exists for remote & mobile workers indicating the low back pain
prevalence rate is 25% for men & 35% for women (Crawford et al, 2011).
Extended work day
Posture-back & wrist support, height of chair & monitor, placement of document holder
Amount of repetitive movement such as typing, assembly line work
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Amount of overhead reaching
Amount of daily time spent at computer
Shift work(rotational, a series of day shifts alternating with a series of night shifts)
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Stress (home\work balance, social support, work breaks, amount of daily exercise, # of
hours worked per day, frequency of health provider visits)
Supervisor/employee working relationship
Engagement in work
In addition to questioning worker, evaluate the above ergonomic factors by performing
an ergonomic assessment.
Physical exam-Utilize an age sensitive approach for pre-employment, general
physicals & focused exams
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Observation of any overall pattern of deformity at rest
Observe joints that do not work properly while in use
BP (lying, sitting and standing)
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Extra ocular movement exam (EOM)- assess for ability of the eyes to follow visual
targets
Snellen Alphabet chart, Rosenbaum or Jaeger, onsite advanced visual testing (dynamic
visual acuity (DVA) deterioration begins at approximately age 45)
Fundoscopic exam- assess the macula for reading and detailed task work, check for
increased sensitivity, glare. Perform color discrimination test.
Otoscopic exam-Check for eardrum thickening which can affect sound transmission
Check for decreased number of hair cells in inner ear. These changes affect balance.
Whisper test. If indicated, do onsite audiometric testing.
Thyroid exam- 5% of adults over age 60 have Hypothyroidism.
Fine motor function by performing finger to finger touches, tremors
Neurologic sensitivity with sharp and dull sensory testing (cotton ball, split tongue
blade), monofilament for protective sense( if unable to feel at point where it bends, lost
sense & increased risk for injury from trips, slips, falls from same level and falls from
heights. Touch changes can lead to peripheral neuropathy which increases risk of falls.
Check for shortening of the trunk, kyphosis and diminishing height
Check mobility, gait, gait speed. Do the “Tug Test” to check for decreased flexibility
caused by decreased synovial fluid.
Inspect, palpate and determine ROM & muscle strength for hands, wrists, elbows,
shoulder, cervical spine, thoracic & lumbar spine, hips, legs, knees feet &
ankles.(reduced grip strength in hands), crepitus, deformity, warmth. Hands, knees,
wrists, hips and shoulders more prone to developing arthritis.
Phalens Test, if indicated to check for carpal tunnel syndrome.
Joint stiffness and swelling
Ability to make a full fist and to flatten hand onto a flat surface
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Ergonomic Assessment
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Work space design- evaluate the work space and observe the worker performing his/her
job
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Chair seat contact stress ( Internal-blood vessel or nerve stretched around tendon;
External-Irritated or constricted blood vessels)
Task organization
Type of chair (feet need to be flat on floor, backrest support for lower lumbar area, thighs
parallel to floor making an 90 degree angle with lower leg, seat pan length appropriate for
worker), posture, support
Evaluation of upper extremity risk: poorly designed work stations (sitting & standing),
sitting position without proper back support, prolonged same position postures
Evaluation of lower extremity risk: height of chair, footrest, boxes or files under desk
Average daily PC usage (important for evaluating for neck strain)
Monitor-distance ( monitor top should be slightly below eye level when worker is seated)
position, glare, use of eyeglasses for distance and near, contacts, bifocals
Keyboard or keypad(forearms need to be parallel to floor) hand & wrist position, mouse
location & height should be same as keyboard
Document holder-position
Average daily phone usage, if uses a head set (important for evaluating for neck strain)
Breaks, mini-breaks, stretching (gives ample time for muscles to recover)
High Risk Areas of the Body
Low Back
Assessment
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Identify risk factors: bending, twisting, prolonged sitting, pulling, pushing, reaching &
climbing. Additional risk factors for work-related musculoskeletal disorders-awkward
and or sustained postures, repetitive motion, prolonged sitting and standing, heavy
physical tasks, excessive force, elevated BMI & smoking (daCosta & Vieira, 2010).
Age related degeneration of tissue occurs, injury and pain are commonly seen in the older
adult.
Repetitive task increase stiffness and pain
Tears, sprains & strains resulting from overexertion on or off job
Psychosocial risk factors-low level of job control, negative affectivity, unsatisfied with
work
Individual risk factors-female gender, co-morbidity, elevated BMI & sedentary lifestyle.
Prevention
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Exercise programs are an important component in helping to reduce injury. Exercise
needs to be taught correctly and performed with proper technique.
Institute back prevention programs
NIOSH(1997) defines a Recommended Weight Limit (RWL) as the weight of the load
that nearly all healthy workers can lift over a substantial period of time (ex. 8 hours)
without an increased risk of developing back pain. The maximum weight to be lifted with
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2 hands under ideal conditions is 51 pounds. The RWL is based on 6 variables that
reduce the weight to be lifted to less than 51 pounds. See link for variables & additional
information http://www.cdc.gov/niosh/docs/2007-131/pdfs/2007-131.pdf
Do not sit all day (low physical workload) Sitting for long periods of time places the
employee at risk for developing back pain.
Sitting slows metabolic function which causes weight gain (burns 40 calories an hour as
compared to 180 calories an hour when cooking)
Encourage 5 minute breaks every hour (helps to avoid fatigue). Encourage stretching
during breaks.
Do not stand all day (high workload on the body)
Recommend alternating positions between sitting and standing.
Work load parameters-Lift less than 35 pounds & not more than the horizontal distance
of 20 inches from the ankle
Incidence of hernias, sprains & strains are not necessarily seen anymore with lifting
heavy amounts of weight. Maybe related to being out of shape.
Encourage movement of the body ( increases circulation, flexibility & concentration)
Walk regularly to a common area printer, to meetings and to lunch. Encourage use of
stairs.
Discuss with management the consideration of standing desks
Recommend an ergonomic chair. If worker has an adjustable seat, reminders of the health
benefits are important.
Encourage open discussion with workers, so a plan to help can be devised together.
Shoulder
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Assessment
Risk factors are heavy lifting & psychosocial factors (daCosta & Vieira, 2010).
Insufficient strength
Glenohumeral joint(most unstable joint) to perform manual tasks in the workplace
Evaluate for subacromial impingement syndrome, rotator cuff and scapular dyskinesia
Visually inspect and palpate for tenderness on posterior aspect of scapula
Range of motion (ROM) to note quality of movement (active & passive)
Perform upper extremity strength testing
Perform empty can test to assess for muscle weakness
Evaluate posture
Muscle assistance testing (active resistance testing)
Prevention
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To help reduce risk of shoulder injury the worker should: have arm free to externally
rotate, low frequency of arm elevation & vertical plane should be the primary applied
force area
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Avoid work tasks that require more than 60 degrees of arm elevation (National Institute
for (Occupational Health & Safety, n.d.)
Neck
Assessment
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Risk factors are prolonged work time at the computer without a break
Assess ROM, strength, pain, tension, tenderness, posture & work position
Pain scale
Prevention
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Avoid prolonged periods of working at a computer without a break.
Avoid overreaching across desk or assembly line
When doing heavy physical work, use proper body mechanics
Lift appropriate weight limits and use assistive devices when needed.
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Assessment
Risk factors repetition, lifting, award posture & co-morbidity
Assess ROM, pain, tenderness
Pain scale
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Prevention
Encourage weight reduction if needed
Knee
Hand, Wrist, Elbow & Forearm, Ankle & Feet
Assessment
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Risk factors for wrist and hand are prolonged computer work, repetitive work, awkward
static postures, older age, female, & high distress levels (da Costa & Vieira, 2010).
Risk factors for elbow and arm are older age, repetitive tasks, Co-morbidity and
awkward postures (daCosta & Vieira, 2010).
Assess for ROM, swelling, pain, numbness, tingling, mobility & repetitive movement.
Prevention
Use of wrist rests
Gentle exercises at desk
There is a lack of longitudinal studies investigating ankle and feet (daCosta & Vieira,
2010).
Eye
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Assessment
Visual correction for near and far vision, bifocals, trifocals
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Distance working from monitor
Posture (eyes usually dominate even if it means being uncomfortable at the desk)
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Prevention
Regular eye exam, adequate visual correction
Encourage regular use of corrective lenses
Encourage task lighting to reduce glare
Laptop users without docking station, suggest a stack of books ( eyes at same level)
Adequate breaks
These suggestions help prevent eyestrain.
Age-related Musculoskeletal Education
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Age related functional declines and concurrent risk of work related injury can be
prevented with the lifestyle addition of regular exercise (Kenny et al, 2008).
Between the ages of 40-60, there is about a 20% age-related decline in the functional
capacity to accomplish work for the older adult. Physical fitness effects how much
decline.
Mobility loss, lack of good balance & degeneration of joints increase risk for injury.
Health problems that reduce physical activity accelerate the musculoskeletal changes
(Seidel, 2010).
Loss of bone density has a pronounced effect on the long bones and vertebrae
Alteration of muscle mass due to increased quantities of collagen going into the tissues
leads to fibrosis of collective tissue (Seidel, 2010).
Regular physical exercise training, improves the older workers maximal capacity needed
to perform a job and in turn reduces the risk of injury (Kenny et al, 2008).
Decline in flexibility & endurance
Gait speed can be affected by potential energy and available energy which declines as
individual’s age. This finding implies that reserve capacity and the amount of energy
available for use regarding all physical activity decreases with age.
Gait speed can be affected in individuals with increased fat mass levels- have lower
reserve capacity and lower levels of all around energy available for use in physical
activity.
With the aging process, individuals generally experience some increase with resting
blood pressure. Impaired myocardial contractility can result in a lower ceiling of blood
pressure for older adults than for younger adults. Older adults also have impairment in
reflex adjustments of pressure when they suddenly change posture. “This reflects a low
level of cardiovascular fitness, impairment of the cardiovascular reflexes and often
creates pathological changes such as varicose veins”. Older adults are at risk to suffer
loss of consciousness from postural hypotension episodes (Perry, 1010).
Typing and reading, although sedentary tasks require repetitive movement which can
cause injury. This risk of injury rises with advancing age (Kenny et al, 2008).
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Falls Education
Medical risk factors associated with falls:
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Impaired musculoskeletal function
Arthritis, hip weakness & imbalance
Visual & hearing loss
Medication adverse effects
Medical condition examples-bone cancer, multiple sclerosis, stroke, Parkinson’s disease
cardiac arrhythmias and alterations in blood pressure
Personal risk factors
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Due to normal age-related changes in vision, strength, balance, and the ability to quickly
respond to our environment, the risk of falling increases.
Decreased activity and exercise compromises coordination, balance, energy level, bone
and muscle strength, flexibility & strength (ACOSM, 2011; ACOEM, 2012).
As individual’s age, muscle strength and endurance significantly impact the ability to lift
heavy objects, participate in repetitive movement and affect the ability to sit or stand for
long periods of time (Kenny et al, 2008). Maintaining this strength reduces the risk of
injury for older adults.
With the aging process, a main contributing factor to decreased strength is loss of skeletal
muscle mass (sarcopenia).
Smoking decreases bone strength, increases risk for COPD (chronic bronchitis), impairs
wound healing & circulation (ACOEM, 2012).
Lack of rest and sleep
Increasing age factor and highest past body weight- a risk factor for osteoarthritis of the
knee (Blagojevicet al, 2010).
Risk factors for knee osteoarthritis in older adults-female gender, intensive physical
activity, increased BMI, increased bone mineral density ( BMD), Heberden’s nodes, hand
OA and occupational activities such as squatting & kneeling (Blagojevic et al, 2010).
Job Impact Education
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Lumber support & steering wheel adjustment will help decrease musculoskeletal
symptoms for driving workers.
Isolation, lack of social contact & a decreased amount of clients seen per month is a risk
factor for traveling sales employees. (Crawford et al, 2011).
Moderate evidence exists as to # of hours driving without a break causing fixed postures
which increase the risk of neck, upper limb and lower back pain. Crawford et al, 2011).
Higher mileage is associated with musculoskeletal symptoms.
Moderate evidence for mobile workers to be able to balance work & life.
Psychosocial factors are associated with musculoskeletal complaints
Job Stress
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Mistakes & injury can result if the position demands exceed the worker’s
capabilities(causes physiological & psychological stress)
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Repeated exposure to high levels of physiological stress over an extended time period can
lead to chronic musculoskeletal injuries as well as disorders (Kenny et al, 2008).
OHNs need to assist management in adapting job responsibilities to accommodate the
age-related changes that occur with the older worker. This will aid to increase the safety
of all employees in the workforce.
Medical Risk Factor Education
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Physiological fatigue results when an older worker’s muscles become overstressed.
Along with decreased physiological age-related changes, more often, time is needed to
recover physiologically..
Performing a job in extreme hot and cold temperatures presents more difficulties for the
older adult than a younger adult.
For employees coping with pain at work, encourage them to remain active, avoid
provocative movement, educate on use of pain medication( de Vries et al, 2011).
Personal Risk Factor Education
Primary Prevention
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Getting Back to Basics-regular exercise, proper nutrition, stress reduction, smoking
cessation, adequate sleep and rest limits the effects of aging & decreases risk of chronic
disease which in turn reduces risk of musculoskeletal injury
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Cardiovascular disease places an individual at risk for not healing well with
musculoskeletal injuries.
Encourage regular exercise and offer exercise programs (strengthening, stretching,
balance, flexibility, endurance & possibly resistive) Consult with primary care provider
before participating in an exercise program. Always include a 5-10 minute warm up and
cool down.
Increase muscle strength to assist with decreasing cardiovascular stress during lifting and
carrying. Increase endurance for human performance. Increase muscle power to climb
stairs, lift, improve stability and prevent falls. Properly conducted resistive training
improves these areas, but only engage in these activities with primary care provider
approval.
Basic Muscular Fitness-Repetitions-10-15 (one set); How often-two to three days a week;
eight to ten types of exercises; appropriate weights (ACSM, 2011).
Encourage activities that increase energy and help with weight reduction or weight
maintenance to help increase gait speed. Start counseling in middle life before gait speed
declines naturally.
Psychological fatigue can occur when an older worker’s job requires high accuracy work
demands, high volume of work, deadlines, frequent distractions and even noise.
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Secondary Prevention
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Screen for Prehypertension- blood pressure readings that are higher than normal but have
not progressed to the high blood pressure range.
Screen for Pre-diabetes- impaired fasting glucose (IFG), impaired glucose
tolerance,(IGT) or may have both impairments.
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Hypoglycemia increases the risk of injury
Screen lipids, Vitamin D level
Bone density testing
Screen for BMI changes (BMI) equal to or more than 25 indicates overweight,( BMI) 30
or greater indicates obesity
 Screen for COPD- spirometry
 Vision and hearing screening
Hypertension Education
 Exercise lowers blood pressure
 Nutritional counseling
Diabetes Education
 For every 1% drop in Hg A1c, the risk of micro-vascular complications increases to 40%
 Hypoglycemia increases the risk of injury
BMI Changes, Obesity Education
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Losing 5-7% of body weight reduces the risk of cardiovascular disease, stroke, diabetes
and some cancers.
 Walking 30 minutes/day five days a week lowers risk of osteoporosis, cardiovascular
disease, hypertension, and diabetes
 Consider pedometer incentive programs.
COPD Education
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Educate that COPD is preventable and treatable
Advocate for State COPD Action Plan, smoke free policies, good worker respiratory
protection, improved air quality, asthma education
Improve exercise capacity
Smoking cessation programs
Instruct on reducing exposure of fumes and dust at work & home
Proper respiratory personal protective measures to reduce exposure
General Summary of Recommendations
The following is a general summary of recommendations:
1. Early detection of musculoskeletal symptoms is critical to decrease the risk of injury and
to prevent chronicity and disability.
2. When taking a musculoskeletal history, key into complaints that may lead to overexertion
injury and falls.
3. If indicated, perform a fall risk assessment. Suggested tool- The Hendrich 11 Fall Risk
Model
4. When taking a medical history, the onset of chronic disease is important in identifying
level of injury risk. Health problems that reduce physical activity accelerate
musculoskeletal changes.
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5. When taking a psycho-social history, factors such as self -imagined age, work\home
balance, social support, work breaks, job satisfaction, supervisor /employee working
relationship, socialization, relaxation methods and sleep patterns can significantly
increase risk of injury.
6. Evaluate for medication adverse reactions which may be increased due to age-related
changes and cause increased risk of injury on the job.
7. When taking a job history pay particular attention to length of time functioning in an
ergonomically demanding environment.
8. Utilize an age sensitive approach when performing a pre placement physical examination,
complete physical or a focused exam on the older adult.
9. When performing a musculoskeletal physical exam pay particular attention to the
following: high risk areas of the body (eye, low back, shoulder, neck, hand, wrist, ankle
and foot).
10. Perform an ergonomic assessment, evaluate the work space and observe the worker
actually doing his/her job to determine the severity of ergonomic interplay on worker
symptoms. Encourage open discussions with worker so a plan can be devised together.
11. Refer early to physical therapy to prevent or reduce loss work time and disability.
12. Educate on low back risk factors: bending, twisting, pulling, pushing, reaching, climbing
and prolonged sitting.
13. Recommend alternating positions between sitting and standing while working.
14. When assessing the shoulder, evaluate the glenohumeral joint. This is the most unstable
joint to perform manual tasks in the workplace.
15. Older adults are at risk for postural changes in blood pressure and are at risk to suffer loss
of consciousness from postural hypotension episodes. Educate to change positions
slowly.
16. Encourage walking. Decreased activity and exercise will negatively affect coordination,
balance, energy level, flexibility and strength which are already decreased in the older
adult.
17. Cardiovascular disease places an individual at risk for not healing well with
musculoskeletal injuries. Therefore, it is important to educate worker on “The Sitting
Disease”.
18. Instruct that lifting 35 pounds or more and lifting more than the horizontal distance of 20
inches from the person’s ankle, increases risk of injury.
19. In jobs that require repetitive movement, encourage adequate time for muscles and
tendons to recover by taking adequate rest breaks.
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Synthesis of Evidence and Levels of Evidence Cited
Author/Year
Title
Study Topic\
Problem
Intervention
Outcome
Results
Comments
Level of
Evidence
Blagojevic,
M., Jinks, C.,
Jeffery, A. &
Jordan, K.P.
(2010)
No
comprehensiv
e SR’s of knee
osteoarthritis
SR & MA
review of
studies
published
from1960Jan. of 2008
Identified
factors can
help to
prevent
knee OA
Out of 2,233
studies, 85
included in the
review.
Primary risk
factors
identified for
knee OA -prior
knee trauma,
Heberden’s
nodes\ hand
OA, obesity,
physical
occupational
activity(squatti
ng
,kneeling)inten
sive physical
therapy, older
age & female
gender
More
longitudinal
studies need
to be
conducted
Some
publication
bias
regarding
gender,
Level 1A
Musculosk
eletal
symptoms
can
improve
with
proper
ergonomic
interventio
ns
11 studies out
of 280 were
utilized &
findings show
an association
between
musculoskelet
al symptoms,
work factors &
lifestyle factors
Further
research is
needed to
determine if
access for
mobile
workers to
OH is an issue
Lack of
social
contact
Strong
evidence
indicates-neck,
Risk factors
for onset of
osteoarthriti
s of the knee
in older
adults: a
systematic
review and
metaanalysis
Crawford,
J.O.,
MacCalman,
L. & Jackson,
C.A. (2011).
The health
and
wellbeing of
remote and
mobile
workers
Risk factors,
aged 50 &
older have
increased
prevalence of
knee OA
Potential
health &
psychosocial
effects exist
for the remote
& mobile
worker
SR to identify
the health
effects
(musculoskel
etal) &
psychological
effects which
influence the
state of
health of the
remote &
mobile
worker
14
SR & MA
Cohort &
Case
Control
studies
utilized
Metaanalysis
limited by
small # of risk
factor studies
Cohort &
case-control
studies
showed
consistent
findings Case
control larger
effect size
Risk factor
for low back
pain
identifiedcarrying
Level 1 A
SR
RCTs,
quasiexperiment
al, case
reports &
observatio
nal
increases
risk of
social
isolation,
social
support &
mental
well-being
Da Costa,
B.R., &
Vieira, E.R.
(2010)
Risk factors
for workrelated
musculoskel
etal
disorders: A
systematic
review of
recent
longitudinal
studies
Linton, S., J.
(2001)
Occupational
Psychological
factors
increase the
Information
needed to help
healthcare
providers,
ergonomists
and
researchers to
design
interventions
to identify risk
factors to help
reduce the
rate of workrelated
musculoskelet
al disorders
SR of
longitudinal
studies to
evaluate the
evidence for
risk factors
for workrelated
musculoskele
tal disorders
(WMSD) to
be compared
to NIOSH
review
findings
Review of
WMSD
with only
cohort &
casecontrol
studies,
first
evaluation
of available
evidence
reviewing
each body
part
identified
Early
identification
of work
related risk
factors are
needed to
effectively
SR of the role
that
psychological
Workplace
variables
play in
relation to
Strong
evidence
that
monotono
us tasks ,
work
relations,
15
shoulders &
lower back
were the most
common injury
sites affected
Moderate
evidence) (CI
1.72-4.43 for
association of
neck
symptoms &
female gender
Greater than
sitting in
vehicle more
than 10hr/wk,
driving more
than 20hr\wk
& greater
mileage
Out of 63
studies, most
frequently
reported
biomechanical
identified risk
factor with
reasonable
evidence for
causal
association
with
WMSD is
excessive
repetition,
heavy lifting &
poor postures
21 studies
included
prospective
design studies,
Randomized
controlled
trials,
heavy bulky
materials in
& out of
vehicles
Age related
physiological
changes in
the joints
need
consideration
for reduction
of injury
Factors found
without
strong
evidence
need further
investigation
because
WMSD’s may
occur when
the
musculoskele
tal system is
pushed
beyond
physiological
limit
Level 1 A
Incorporating
knowledge of
the role that
psychological
factors play
at work, may
enhance
Level 1 B
SR
Cohort &
case
control
studies
utilized
SR
Prospective
studies
utilized
risk for back
pain: A
systematic
review
improve
treatment &
help prevent a
worker from
developing
long term back
pain &
associated
disability
This need is
increased with
age related
physiological
changes
back pain
Return to
work,
absenteeism,
& injury was
used as an
outcome
variable in
half of the
studies,
injury
considered
from 2
studies
job
satisfaction
stress, job
demands &
perceived
work
ability
were
related to
future back
pain
problems
evaluation
studies, followup studies,
comparative
studies &
clinical trials,
Most clinical
trials were
excluded
because they
did not include
data on a
psychological
predictor
variable
prevention
and
rehabilitation
, injury
information
from 2
studies &
questionnaire
data
collection
were two
limitations
Attributable
fraction- back
pain
reduction
ranged from
0% regarding
effect of pace
on sick leave
to greater
than 7 days
for females
to 66% for
satisfaction
with job,
majority in
the upper 30s
or lower 40s,
This data
suggests it is
worthwhile
to try to
eliminate
these risk
factors
Adapted from Blagojevic, M., Jinks, C., Jeffry, A., & Jordan, K.P. (2010). Risk factors for onset of osteoarthritis of the knee in older adults: A
systematic review and meta-analysis. Osteoarthritis and Cartilage, 18, 24-33.
16
Crawford, J.O., MacCalman, L. & Jackson, C. A. (2011). The health and well-being of remote and mobile workers, Occupational Medicine,
61, 385-394.
Da Costa, B., & Vieira, E., R. Risk factors for work-related musculoskeletal disorders: A systematic Review of recent longitudinal studies,
American Journal of Industrial Medicine, 53,285-323.
Linton, S., J. (2001). Occupational psychological factors increase the risk for back pain: A systematic review, Journal of Occupational
Rehabilitation, 11(1), 53-65.
Guideline Developer
Nancy Delloiacono, MSN, RN, Certificate in Primary Care of the Adult and Aged Nurse
Practitioner Postmaster’s Program, Rutgers, The State University College of Nursing, ANP-BC,
DNP student, Rutgers, The State University College of Nursing, 7 years of experience as an
OHN
Implementation Strategy- implemented through an online educational program for OHN
members of the NJSAOHNs.
Source of Funding-Rutgers University Alumni Association Fenlasen Award and Scholarship
17
Appendix A
The CEBM 'Levels of Evidence 1' document sets out one approach to systematising this process
for different question types.
Level
1a
1b
1c
2a
2b
Therapy /
Prevention,
Aetiology /
Harm
Prognosis
SR (with
SR (with
homogeneity*) homogeneity*) of
of RCTs
inception cohort
studies;
CDR" validated
in different
populations
Individual RCT Individual
(with narrow
inception cohort
Confidence
study with > 80%
Interval"¡)
follow-up;
CDR" validated
in a single
population
Diagnosis
Differential
diagnosis /
symptom
prevalence
study
SR (with
SR (with
homogeneity*) of
homogeneity*)
Level 1 diagnostic of prospective
studies; CDR" with cohort studies
1b studies from
different clinical
centres
Validating** cohort Prospective
study with
cohort study
good" " " reference with good
standards; or
follow-up****
CDR" tested within
one clinical centre
Economic and
decision
analyses
SR (with
homogeneity*)
of Level 1
economic
studies
Analysis based
on clinically
sensible costs or
alternatives;
systematic
review(s) of the
evidence; and
including multiway sensitivity
analyses
All or none§
All or none case- Absolute SpPins and All or none
Absolute betterseries
SnNouts" "
case-series
value or worsevalue analyses
""""
SR (with
SR (with
SR (with
SR (with
SR (with
homogeneity*) homogeneity*) of homogeneity*) of
homogeneity*) homogeneity*)
of cohort
either
Level >2 diagnostic of 2b and better of Level >2
studies
retrospective
studies
studies
economic
cohort studies or
studies
untreated control
groups in RCTs
Individual
Retrospective
Exploratory**
Retrospective Analysis based
cohort study
cohort study or cohort study with
cohort study, or on clinically
(including low follow-up of
good" " " reference poor follow-up sensible costs or
© 2014 Nancy Delloiacono, MSN, RN, APN-BC
1
quality RCT;
e.g., <80%
follow-up)
2c
3a
3b
4
5
untreated control
patients in an
RCT; Derivation
of CDR" or
validated on
split-sample§§§
only
"Outcomes"
"Outcomes"
Research;
Research
Ecological
studies
SR (with
homogeneity*)
of case-control
studies
Individual
Case-Control
Study
Case-series
(and poor
quality cohort
and casecontrol
studies§§)
Expert opinion
without explicit
critical
appraisal, or
based on
physiology,
standards;
CDR" after
derivation, or
validated only on
split-sample§§§ or
databases
Ecological
studies
SR (with
SR (with
homogeneity*) of 3b homogeneity*)
and better studies
of 3b and better
studies
Non-consecutive
Nonstudy; or without
consecutive
consistently applied cohort study, or
reference standards very limited
population
Case-series (and
poor quality
prognostic cohort
studies***)
Case-control study,
poor or nonindependent
reference standard
Expert opinion
without explicit
critical appraisal,
or based on
physiology,
bench research or
Expert opinion
Expert opinion
without explicit
without explicit
critical appraisal, or critical
based on physiology, appraisal, or
bench research or
based on
"first principles"
physiology,
2
Case-series or
superseded
reference
standards
alternatives;
limited
review(s) of the
evidence, or
single studies;
and including
multi-way
sensitivity
analyses
Audit or
outcomes
research
SR (with
homogeneity*)
of 3b and better
studies
Analysis based
on limited
alternatives or
costs, poor
quality
estimates of
data, but
including
sensitivity
analyses
incorporating
clinically
sensible
variations.
Analysis with
no sensitivity
analysis
Expert opinion
without explicit
critical
appraisal, or
based on
economic theory
bench research "first principles"
or "first
principles"
bench research or "first
or "first
principles"
principles"
Produced by Bob Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian
Haynes, Martin Dawes since November 1998. Updated by Jeremy Howick March 2009.
Notes
Users can add a minus-sign "-" to denote the level of that fails to provide a conclusive answer
because:


EITHER a single result with a wide Confidence Interval
OR a Systematic Review with troublesome heterogeneity.
Such evidence is inconclusive, and therefore can only generate Grade D recommendations.
*
"
"¡
§
§§
§§§
""
By homogeneity we mean a systematic review that is free of worrisome variations
(heterogeneity) in the directions and degrees of results between individual studies. Not all
systematic reviews with statistically significant heterogeneity need be worrisome, and not
all worrisome heterogeneity need be statistically significant. As noted above, studies
displaying worrisome heterogeneity should be tagged with a "-" at the end of their
designated level.
Clinical Decision Rule. (These are algorithms or scoring systems that lead to a prognostic
estimation or a diagnostic category.)
See note above for advice on how to understand, rate and use trials or other studies with
wide confidence intervals.
Met when all patients died before the Rx became available, but some now survive on it;
or when some patients died before the Rx became available, but none now die on it.
By poor quality cohort study we mean one that failed to clearly define comparison groups
and/or failed to measure exposures and outcomes in the same (preferably blinded),
objective way in both exposed and non-exposed individuals and/or failed to identify or
appropriately control known confounders and/or failed to carry out a sufficiently long and
complete follow-up of patients. By poor quality case-control study we mean one that
failed to clearly define comparison groups and/or failed to measure exposures and
outcomes in the same (preferably blinded), objective way in both cases and controls
and/or failed to identify or appropriately control known confounders.
Split-sample validation is achieved by collecting all the information in a single tranche,
then artificially dividing this into "derivation" and "validation" samples.
An "Absolute SpPin" is a diagnostic finding whose Specificity is so high that a Positive
result rules-in the diagnosis. An "Absolute SnNout" is a diagnostic finding whose
Sensitivity is so high that a Negative result rules-out the diagnosis.
3
"¡"¡
Good, better, bad and worse refer to the comparisons between treatments in terms of their
clinical risks and benefits.
" " " Good reference standards are independent of the test, and applied blindly or objectively to
applied to all patients. Poor reference standards are haphazardly applied, but still
independent of the test. Use of a non-independent reference standard (where the 'test' is
included in the 'reference', or where the 'testing' affects the 'reference') implies a level 4
study.
" " " " Better-value treatments are clearly as good but cheaper, or better at the same or reduced
cost. Worse-value treatments are as good and more expensive, or worse and the equally or
more expensive.
**
Validating studies test the quality of a specific diagnostic test, based on prior evidence.
An exploratory study collects information and trawls the data (e.g. using a regression
analysis) to find which factors are 'significant'.
*** By poor quality prognostic cohort study we mean one in which sampling was biased in
favour of patients who already had the target outcome, or the measurement of outcomes
was accomplished in <80% of study patients, or outcomes were determined in an
unblinded, non-objective way, or there was no correction for confounding factors.
**** Good follow-up in a differential diagnosis study is >80%, with adequate time for
alternative diagnoses to emerge (for example 1-6 months acute, 1 - 5 years chronic)
Grades of Recommendation
A
B
C
D
consistent level 1 studies
consistent level 2 or 3 studies or extrapolations from level 1 studies
level 4 studies or extrapolations from level 2 or 3 studies
level 5 evidence or troublingly inconsistent or inconclusive studies of any level
"Extrapolations" are where data is used in a situation that has potentially clinically important
differences than the original study situation
4
Appendix B
Evidence to support this safety guideline
Evidence to Support Safety Guideline to reduce the risk of musculoskeletal injury in older adults
in the workplace











Projected annual growth rate of older adults is 4.1% (Silverstein, 2008).
Increased projected growth rate of older adults in the workforce is due to : deferring
retirement, longer life expectancies, choosing a second career (Canning & Bloom, 2012)
As proportions of older adults in the workforce increases, the impact of treating &
associated costs will continue to increase (Foster et al, 20120).
Due to the nursing shortage, organizations need to take every effort to safely retain older
nurses. Only with the OHN and employer having comprehensive knowledge of agerelated changes and environmental accommodations, will the older adult nurse be able to
work safely delaying retirement (Keller & Burns, 2010; Palmer, 2003).
Age-related musculoskeletal changes place older adults at risk for injury (Foster et al,
2012; Perry, 2010; Bohle et al, 2010;
Health status identified as a critical factor related to safety in the workplace (Keller &
Burns, 2010; Perry, 2010).
Chronic disease along with acute illness in older adults can adversely influence daily job
performance & consequently cause increased risk of work-related safety in the workplace
(Silverstein, 2008).
Hearing problems affect approximately one third of our American population who are
between age 65 and 74 (Perry, 2010 Dynamic visual acuity (DVA) deteriorates under age
60. If a job requirement involves visual acuity of highly mobile information or controls,
this responsibility should probably be handled by a younger employee (Perry, 2010).
Dynamic visual acuity (DVA) deteriorates under age 60. If a job requirement involves
visual acuity of highly mobile information or controls, this responsibility should probably
be handled by a younger employee (Perry, 2010).
As proportions of older adults in the workforce increases, the impact of treating &
associated costs will continue to increase (Foster et al, 2012).
The aging process causes a progressive deterioration in every link in the oxygen transport
chain. As a result, a decrease of maximum oxygen intake from about 45 ml\kg per minute
found in young women to approximately 25-28 ml\kg in women 65 years of age occurs
(Perry, 2010). Obesity compounds this issue. If an obese person is exercising, there is a
greater need for skin blood flow which reduces arterial-venous oxygen difference
(Sheppard, 1987)
© 2014 Nancy Delloiacono, MSN, RN, APN-BC
1














According to Schrack et al, 2010), the hypothesis of a lack of available energy causing
the decline in everyday walking speed with aging and disease has been validated. “The
Established Populations for Epidemiologic Studies of the Elderly (EPESE) found that
lower baseline lower extremity performance scores were associated with increased
frequency of mobility disability and dependence in one or more activities of daily living”
(Schrack et al, 2012). “In the Women’s Health and Aging study (WHAS) 11, if women
had difficulty walking half a mile, slowed walking speed or difficulty climbing stairs,
these limitations predicted disability in older women. “(Schrack et al, 2010). Collectively,
these two studies showed that physical performance, particularly walking speed, predicts
the state of functional disability for the future (Schrack et al, 2012).
If the older adult suffers from recurrent bronchitis or emphysema, vital capacity is not as
good and the lungs must work harder to breath. An exercise physiologist may be needed
to coach exercise tolerance (Sheppard, 1987).
Muscle mass changes which occur with the aging process, causes an older adult to have
more difficulty lifting heavy objects and participating in prolonged repetitive tasks
(Keller & Burns, 2010).
Fine motor skills, manual dexterity and tactile sensations decline as we age (Perry, 2010)
Decrease in flexibility, has been linked to loss of balance and strength, improper posture,
restricted movements, slower injury recovery and stress (Perry, 2010).
The amount of cells being replaced with fat tissue is determined by the amount the
muscle is exercised, diet and prevalence of disease and injury (Perry, 2010).
Chronic pain, most expensive problem for US Workers Compensation costing $14
million\year (Vieira & Kumar, 2006)
Osteoporosis decreases while low bone mass does not (Bone & Joint Initiative, 2011).
Muscle strength & neuromuscular function can impact vitamin D deficiency (Bone &
Joint, 2011).
Weight loss may not be considered a red flag because it may be related to
musculoskeletal disorders (Foster et al, 2012).
Age related changes, underlying pathologies, acute health issues and chronic disease in
workers beginning at age 45, can affect everyday task performance and lead to an
increased risk of work-related injuries (Keller & Burns, 2010).
#1 injury found in the 2007 Liberty Safety Index (LSI) is overexertion injury (Liberty
Mutual, 2007).
70 % of low back injuries result from overexertion and manifest themselves as tears,
sprains & strains (Viera & Kumar, 2006).
In comparison to other musculoskeletal injuries, shoulder injuries have the longest
average recovery time (Dickerson et al, 2010).
2
















Strategies to help lower company costs incurred by medical claims & to decrease worker
compensation injury: employee education on health improvement & managing chronic
illness (Keller & Burns, 2010).
Once an older worker is inflicted with a disability, they will need more time to
convalesce and return to work than a younger worker (Keller & Burns, 2010; Silverstein,
2008).
Older workers document less disability incidents than younger workers, especially
incidents resulting from musculoskeletal injuries (Keller & Burns, 2010).
In order of occurrence, types of muscular pain areas encountered are low back, shoulder,
neck, knee & widespread complaint of pain (Foster et al, 2012).
Early treatment by physical therapists for commonly suffered musculoskeletal problems
reduces the amount of lost time & decreases chances of progression to chronic illness
(Foster et al, 2012).
For low back & shoulder pain, there can be a relationship between low variation & low
satisfaction with the job (Guara, 2002).
Force exertion utilizing the back muscles such as lifting heavy weights can result in
precipitation of low back injury (Vieira & Kumar, 2006).
Workers perceptions of stresses encountered in lifting a load may not be reliable enough
to protect workers from back injury (Vieira & Kumar, 2006).
Lifting 35 pounds or more & lifting more than the horizontal distance of 20 inches from
the person’s ankle increases the risk of injury (Chaffin & Park, 1973).
Low back pain cost-effectiveness data found during random clinical trials shows costeffectiveness only occurs with addition of behavioral counseling, exercise & chiropractic
care (Foster et al, 2012).
Clinical outcomes poorer in individuals experiencing depression along with chronic
musculoskeletal pain (Foster et al, 2012).
Early treatment by physical therapists for commonly suffered musculoskeletal problems
reduces the amount of lost time & decreases chances of progression to chronic illness
(Foster et al, 2012).
Primary prevention of many chronic diseases has been demonstrated with the addition of
regular intentional exercise to healthy living (Neilson et al, 2007).
In comparison to other musculoskeletal injuries, shoulder injuries have the longest
average recovery time (Dickerson et al, 2010).
The amount of the cells being replaced with fat tissue is determined by the mount the
muscle is exercised, diet and prevalence of disease and injury (Perry, 2010).
Decrease in flexibility, has been linked to loss of balance and strength, improper posture,
restricted movements, slower injury recovery, and stress (Perry, 2010).
3

Older adults who participate in regular intentional exercise is key to maintaining good
health. Primary prevention of many chronic diseases such as cardiovascular, type 2
diabetes, osteoporosis and a number of cancers, has been demonstrated with the addition
of regular exercise to healthy living (Neilson et al, 2007).
Ergonomic Evidence
 Keep in mind the principals of how low physical effort, flexibility & simple design to










improve workplace safety (Silverstein, 2008).
There is a strong musculoskeletal injury association with psychosocial factors. How well
a worker gets along with his/her boss can have a significant influence on recovery & the
prevalence of injury (Bohle et al, 2010).
To increase ergonomic intervention success, reduce work physical demands (Vieira &
Kumar, 2006).
Ergonomic committees-Employers and OHNs need to identify work hazards, find
solutions, raise awareness, educate and modify the environment for older workers to
increase safety and support the needs of the older worker (Bloom & Canning, 2012;
Perry, 2010; Leggert, 2012).
There is no recommendation to sit or stand. Both have advantages and disadvantages. If
an individual alternates postures, it will give the body time to rest specific body parts and
reduce the potential to develop risk factors commonly associated with the development of
musculoskeletal disorder s (UCLA Ergonomics, n. d.).
“The maximum reach envelop when standing is significantly larger than the
corresponding reach envelop when sitting for both men and women (Sengupta & Das,
2000).
In a study by Vieira et al (2012), it was found that workers surveyed in an automobile
industry showed strong evidence between Kaizen and ergonomics.
Due to the nursing shortage, organizations need to take every effort to safely retain older
nurses. Only with the OHN and employer having comprehensive knowledge of agerelated changes and environmental accommodations, will the older adult nurse be able to
work safely delaying retirement (Keller & Burns, 2010).
The reduced physical activity that results in sitting all day on the job (Sitting Disease)
increases the risk of cardiovascular disease. Exercising outside of work does not reduce
the damage of sitting all day at work (AHA, 2008; ACSM, 2011).
Exercise increases cognitive performance which in turn increases productivity (McCraty
et al, 2006).
Less active workers are 30-50% more at risk of developing hypertension (CDC, 2008).
4


Repetitive movement with motions that occur often for long periods of time may cause
insufficient time for muscles & tendons to rest & recover. Combined with activities
requiring concentrated force can lead to stiffness & pain indicating that the muscle or
tendon has been stretched beyond its capacity (OSHA, n. d.).
Finding solutions to task organization & heightening awareness to early warning signs
can reduce risk of developing musculoskeletal disorders (MSDs) & eliminate the chances
of injury (OSHA, n. d.).
Prevention










To prevent further deterioration of arthritic disorders: encourage adherence to
medications, adequate rest & sleep, educate on ice and heat
Interventions to help prevent work-related musculoskeletal disorders should take into
account not only risk factors with strong evidence but those suppose risk factors should
also be addressed (daCosta & Vieira, 2010).
There is strong evidence that the following occupational psychological factors increase
the risk of future complaints of back pain- low job satisfaction, monotonous work, social
work relations, work pace, lack of control, self- reported stress, work demand, emotional
effort and perceived ability to work (Linton, 2001).
To prevent low bone mass, recommend bone density testing according to national
guidelines, encourage regular exercise with low impact on joints such as walking &
swimming
To prevent spinal injury, instruct on proper body mechanics, strengthening exercise &
regular exercise
Educate on strength training, balance, gait exercises, flexibility endurance (Seidel et al,
2011).
Yoga encourages reduction of work-related tension & injury risk (Guara, 2002).
General health maintenance should include proper nutrition, adequate calcium intake,
adequate intake of water (eight (8) glasses), regular activity & exercise, stress
management techniques: if possible, reduce job demands, offer corporate exercise and
stress management programs, employee assistance program referrals.
Localized fatigue results from uninterrupted contraction of muscles (Lindstrom et al,
1977).
Workers perceptions of stresses encountered in lifting a load may not be reliable enough
to protect workers from back injury (Vieira & Kumar, 2006).
5
Appendix C
References
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employer administrative databases to identify systematic causes of injury in aluminum
manufacturing, American Journal of Industrial Medicine, 50, 676-686.
Alipour, A. et al. (2008). Occupational neck and shoulder pain among automobile manufacturing
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American College of Occupational and Environmental Medicine Clinical Practice and Guideline
Center (2009). Guidelines for common health problems and functional recovery in workers,
healthy workforce now American College of Occupational and Environmental Medicine
(ACOEM), Retrieved from http://www.acoem.org/PracticeGuidelines.aspx.
Blagojevic, M., Jinks, C., Jeffrey, A., & Jordan, K.P. (2010). Risk factors for onset of
osteoarthritis of the knee in older adults: A systematic review and meta-analysis,
Osteoarthritis and Cartilage, 18, 24-33.
Braddock, E. J., Greeniee, J., Hammer, R. E., Johnson, S. F, Martello, M. J., O’Connell, M .R.,
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in France, Occupational Environmental Medicine, 59, 537-544.
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i
Crawford, J.O., MacCalman, L., & Jackson, C.A. (2011). The health and well-being of remote
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Culp, K., Tonelli, S. & Ramey S. (2011). Gerontological nursing and the aging workforce,.
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DaCosta, B., & Vieira, E., R. (2010). Risk factors for work-related musculoskeletal disorders: A
systematic review of recent longitudinal studies, American Journal of Industrial Medicine,
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Harris, J. L., Roussel, J., Walters, S. E., & Dearman, C. (2011). Project planning and
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