Norwegian National Institute of Occupational Health

Danish National Research Centre for the Working Environment

Finnish Institute of Occupational Health

Assessment of physical exposure in relation to work-related musculoskeletal disorders -

what information can be obtained from systematic observations
Author(s): Åsa Kilbom
Source: Scandinavian Journal of Work, Environment & Health, Vol. 20, Twentieth
Anniversary Issue (1994), pp. 30-45
Published by: the Scandinavian Journal of Work, Environment & Health, the Finnish
Institute of Occupational Health, the Danish National Research Centre for the Working
Environment, and the Norwegian National Institute of Occupational Health
Stable URL: https://www.jstor.org/stable/40966300
Accessed: 19-10-2018 23:33 UTC

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ScandJWork Environ Health 1994;20 special issue:30- 45

Assessment of physical exposure in relation to

work-related musculoskeletal disorders - what
information can be obtained from systematic
observations?
by Asa Kilbom, MD1

KILBOM Â. Assessment of physical exposure in relation to work-related musculoskeletal dis

- what information can be obtained from systematic observations? Scand J Work Enviro
1994;20 special issue:30 - 45. Establishing an association between physical work load and
related musculoskeletal disorders requires a quantitative assessment of exposure to the main
tors. Commonly used methods are questionnaires, diaries, interviews, systematic observatio
direct measurements. While questionnaires provide subjective information and have low rel
measurements are technically sophisticated, expensive, and unable to identify some important r
tors. Systematic observations offer a compromise. The observation methods devised during
15 years are described, together with their reliability and validity. Most of them use duratio
quency of certain postures or events as the main measure of exposure. Their ability to qua
main risk factors posture, manual handling, and repetitive work differs. All available met
drawbacks and have been used to a limited extent in epidemiologie studies. There have been
ments however, and it is concluded that observation methods will have a place in epidemiolo
ies on musculoskeletal disorders.

Key terms - epidemiology, exposure, manual handling, musculoskeletal, observation methods, pos-
ture, repetitive work, review.

In spite of the large number of experimental and physical

epi- work loads when the effects of controlled
demiologie studies that have appeared during the interventions
past at the workplace are assessed.
10 years, the etiology and risk factors of work-re- The methods available for measuring physical
lated musculoskeletal disorders remain insufficient- work load can be categorized into a spectrum rang-
ly known. Hypotheses range from purely physical ing from direct measurements, to observations, in-
work load factors, to social and organizational fac- terviews and diaries, to questionnaires. The choice
tors at work, to individual characteristics like of a specific method depends on the resources avail-
strength, personality, and psychological traits. Al-able and the accuracy required of the data.
though physical work load has been considered im- Direct measurements include electromyographic
portant for many years, a critical review of the sci-recordings, posture and movement recordings by go-
entific support for this statement demonstrates many niometers, inclinometers, accelerometers, and opto-
weaknesses. It is true that certain occupations, knownelectronic devices (eg, sel-spot, CODA) (3 - 10).
to be physically demanding, have a very high prev- These methods are quantitative and highly accurate,
alence and incidence of musculoskeletal disorders. but expensive due to the demands for sophisticated
However, many employees in these jobs also suffer equipment and time-consuming calibration, registra-
from inadvertent psychosocial exposures. Moreover, tion, and analysis. Because of this limitation only a
a job title does not allow conclusions concerning certain
the number of body regions and subjects can be
quality and quantity of physical work load and there- assessed. Moreover, monitoring devices carried by
fore does not allow the exposure-response relation- the worker can hinder the worker and thereby influ-
ship to be established and gives little guidanceence forwork methods. Optoelectronic recordings can
prevention. Clearly there is a need for a more-de- only be used for the limb and trunk movements of
tailed and accurate description of physical work an otherwise stationary worker; furthermore the re-
loads, for use in epidemiologie studies of work-re- cording equipment requires even lighting and a rel-
lated musculoskeletal disorders, if the causal and atively
ag- large space.
gravating factors are to be identified quantitatively At the other end of the spectrum, questionnaires
(1, 2). Moreover it must be possible to quantitate have been frequently used for exposure assessment
due to their low cost. The use of questionnaires, di-
1 National Institute of Occupational Health, Solna,aries,
Swe-and interview techniques has the potential of
den.
studying cumulative exposure over time, which is an
important
Reprint requests to: Dr  Kilbom, National Institute of Oc- parameter usually not available with direct
cupational Health, S-171 84 Solna, Sweden. measurements. However, the relatively low reliabil-
30

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 Scand J Work Environ Health 1994, vol 20, special issue

ity and validity of the questionnaires developed so methods selected for inclusion in table 1 assess pos-
far make their use debatable, especially for retrospec-ture, and some of them also assess manual handling
tive assessments. Thus it is usually considered that and repetitive work. It is generally acknowledged that
only dichotomous exposure assessments can be ob- exposure to vibration is monitored better via direc
tained (11). measurements; hence no observation methods have
Recently, diaries and interviews have been dem- been designed specifically for vibration assessment
onstrated to have considerably higher validity than The methods selected for table 1 have all appeared
questionnaires. However, the experience so far is since 1979. Thus methodological development has
limited, and the subjective nature of the information been very fast. However, already before 1979, some
cannot be disregarded (12, Wiktorin, personal com- methods defining postures and movements were de-
munication). Thus observation methods may offer a scribed (22, 23). The Benesh notation system (22)
compromise between the high cost of direct meas- was developed for dancing and is highly specific for
urements and the low validity and the subjectivity the flow of movement in ballet. The system is diffi-
of questionnaires, diaries, and interviews. The objec- cult to transform into digital data and was not de-
tive of this review is to describe and evaluate the veloped with the aim of identifying musculoskele-
potential usefulness of systematic observation tal tech-
risk factors. The "posturegram" method developed
niques in the quantitative assessment of physical by Priehl (23) gives accurate information on the lo-
work load for epidemiologie studies of work-relat- cation and movement of body parts in three coordi
ed musculoskeletal disorders, as well as for interven- nate planes. However, the system is time-consum-
tion. ing and therefore has not been used for studying
changes in posture over time. A similar method is
posture targeting (table 1), which is faster and can
What are the risk factors? therefore be applied for a sequence of postures (24).
Postures have also been described for specific
Selecting a method for assessing physical work load
work situations and linked to workstation layout (eg,
depends on the ability of the method to quantitate
24 - 29). The aim of these methods are ergonomie
risk factors believed to cause or aggravate muscu-
(ie, studying the fit between anthropometry, posture,
loskeletal disorders. Although the risk factors iden-
and workstation and work task can help identify poor
tified for disorders of different body regions differ
design for subsequent improvements). In general, the
slightly, it appears that the broad categories of stat-
postural analysis of these methods concentrates on
ic posture, manual handling, repetitive work, and vi-
one or a few "critical" postures or makes a summary
bration are frequently identified in reviews (2, 13 -
evaluation of the range of postures during a certain
16). The pathophysiological mechanisms of exposure
task. Thus risk factors are not assessed in real time
to these risk factors are biologically plausible, al-
or by time sampling, and therefore a quantitative
though insufficiently known (17), and they have been
evaluation of risk factors is impossible. Ergonomie
identified in several epidemiologie studies. Howev-
methods often have an in-built "acceptability" limit,
er, there still remains considerable doubt concerning
deduced from previous research or consensus agree-
the quantitative importance of physical risk factors.
ments. In this respect too they differ from methods
Several other risk factors, for example, high peak
used in musculoskeletal epidemiology, for which one
loads, high speed or the acceleration of movements,
of the aims is to identify, with higher precision, the
and high demands for precision, have been suggest-
limit(s) of risk increase. It is true, however, that the
ed (8, 18 - 20). They all require more scientific sup-
borderline between observation methods used for er-
port and need to be quantified in epidemiologie
gonomie purposes and those used for musculoskel-
studies before the risk factors can be satisfactorily
coupled with musculoskeletal disorders.
etal epidemiology is relatively vague and that the
methods overlap. For this reason, some of the meth-
ods also used for ergonomie purposes - the Ovako
Review of available methods work posture analyzing system (OWAS) (30), pos-
ture targeting (24), ARB AN (31) - have been in-
In table 1 nineteen observation methods for quanti-
cluded in table 1 . Of these, the OWAS method is the
tatively assessing physical exposures have beenmostsum-
widely used, and many case studies of ergo-
marized. The main quantitative measure of nomieexposure
applications have been reported (32 - 36).
is the duration or frequency of a certain posture or
activity. Therefore all of the observations are per-
formed over time. In the portable ergonomie Generality
obser- of the method
vation (PEO) method, the observation is supplement-
The methods presented in table 1 have been devel-
ed with an interview in which all major work opedtasks
for three types of epidemiologie applications,
during one week are recorded with their proportion-
characterized by the range of job titles and exposures
al duration (Fransson-Hall et al, unpublished manu-
that can be assessed (ie, the generality of the meth-
script). This procedure enables the computer od).
program
First, there are general methods for assessing
to calculate the total exposure profile. Allexposure,
of the applicable to a large range of occupational

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ScandJWork Environ Health 1994, vol 20, special issue

Table 1. Summary of methods used for the systematic observation of physical exposures during the last 15 years. The methods
included in the table all concentrate on postures.

Scale for

Method Principle posture other bodv

classification Arms Back regions Whole body
Armstrong et al, Pencil and paper, Interval Shoulder: 4-6 cat- • Fingers: six cate-
1979 (65) real time via film, egories of flexion- gories of grips
three frames per tension, abduction-
second adduction and
rotation; elbow:
3-4 categories of
flexion-extension
and rotation;
wrist: 3-5 cate-
gories of flexion-
extension and
deviation

Baty et al, 1986 Pencil and paper, Dichotomous Reach Twist, bend • Stand, walk, squat,
(46) time sampling, >15 degrees sit, kneel, support,
15-s intervals brace

van der Beek et al, Computerized, Interval and Both <60 degrees, Flexion or rotation: Legs both 0-15 Stand, sit, walk,
1992(48) time sampling and dichtomous one > 60 degrees, 0-15,15-45, degrees, one > 15 kneel, squat
real time via video- both >60 degrees 45-75 and >75 degrees, both >15
(based on ROTA "pump" degrees degrees, one loose
principle), 15-s
interval

Chang et al, 1987 Video, time sam- Continuous Shoulder flexion, Flexion Neck flexion
(43) pling, two frames rotation, abduction,
per 15 s every 2 min; elbow flexion
continuous, 60
frames per second
for 1 min; side and
oblique lateral
view

Corlett et al, 1979 Pencil and paper, Continuous in Right and left upper Flexion, side- Also head, thighs, Strike, crank,
(24) time sampling, two planes, arm, forearm bending calves squeeze, twist,
Posture targetting variable intervals horizontal and wipe, walk
vertical

Feuerstein & Video (frontal Dichotomous Wrist-hand

Fitzgerald, 1992 view), pencil and deviations
(19) paper, real time;
frequency of move-
ments and events

Foreman & Troup, Computerized, Dichotomous • Flexion > 15 • Stand, sit, squat,
1987(60); direct or video- degrees, stoop walk, kneel
Foreman et al, based, real time
1988 (40)

Fransson-Hall et al Computerized, Interval and Right and left, Flexion 20-60 Neck flexion, Kneel, squat
(unpublished direct or via video, dichotomous hands above or and > 60 degrees, > 20 degrees;
manuscript) real time; fre- below shoulder twist >45 degrees neck rotation,
Leskinen et al quency, duration >45 degrees
(unpublished of postures and
manuscript) activities
PEO

Fransson-Hall et al Computerized,
(unpublished real-time observa- Interval and Precision, power
manuscript) tion via video; dichotomous grip
Hand-PEO frequency and
duration of hand-
grip and activities

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 ScandJWork Environ Health 1994, vol 20, special issue

Manual materials handling

Lift, carry Push, pull of exposure applied for

Supplemented • • Poultry processing Used for ergonomie
with electro- intervention
myographic and
MTM analysis

Lift, carry Push, pull ■ Interobserver: Comparison with Nursing Poor agreement
>80% agreement accelerometer with questionnaire
in frequent yielded poor
postures (bend, agreement - due
stand, walk, sit); to accelerometer
poor agreement artefacts in fast
some infrequent movements?
postures (lift,
brace, carry,
reach, twist)
<2, 2-10, <2, 2-175, • Interobserver: Compared with Delivery truck Modified version
>10kg >175kg kappa -0.80 except optoelectronic drivers using two observers
trunk, arm, legs measurements: suggested, one
posture; improved error <5 degrees observing postures,
by training; when in trunk flexion one observing
MMH excluded, at static postures activities and
all posture MMH in real time
kappas >0.50
Angular velocities • • Stationary, Larger variation in
calculated from seated work back and neck
continuous (artists) postures for artists
recordings doing large than
for those d
small draw

Hold Push, pull Always supple- Intraobserver Compared with Industrial work Very accurate for
mented with coefficient of frame--by-frame postures but does
discomfort rating correlation 0.67- film: good for head not record
of 15 body regions 0.88 for body and trunk, unsatis- frequency of
posture factory for legs postures, less
and lower arms suitable for
dynamic work
Analysis of hand Interobserver: • Sign language Method concen-
and arm activities: intraclass corre- interpreters trates on pacing,
number of rest lation >0.89 extreme postures
breaks, hand for all except and dynamics of
excursions, high- frequency of wrist hand and wrist
impact hand deviation (0.76) rather than on
contacts, pace and static postures
smoothness of
hand and finger
movements

Lift, carry Push, pull ■ Interobserver • Nursing Manual handling

agreement: high for and posture codes
frequency, except combined in two-
squatting, high for letter mnemonic
duration except
stoop and lift;
intraobserver: high
(>90% agreement)
for duration and
frequency for
trained observer;
stooping, lifting V
<80% for
untrained observer

Lift ■ 1 - 5, 6 - 15, 1-5,6-15, Repetitive work: Interobserver: no Sel-spot and video All jobs Interviews to
16- 45, >45 kg; 16- 45, >45kg prosupination, systematic differ- recordings: high calculate weekly
lifts above shoulder; (See lift, carry) wrist flexion, enee in duration agreement for exposure to all
below knee, wrist extension, except neck and postures (except categories; obser-
twisted back noted finger flexion, manual handling; neck) and long- vation of all
finger extension; low correlation for lasting repetitive categories
"extra events" frequency of neck, activities simultaneously, or
recorded; interview lift and MMH one at a time
to calculate (ANOVA); intraob-
weekly exposure server: high agree-
ment (ANOVA)
Hold ■ Hand tools x 4, ■ • Developed for Separate obser-
machine tools x 2, assembly work, vations right-
hand as hitting applicable for left hand
tool, manual many jobs
assembly,
hand as support
(continued)
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Scand J Work Environ Health 1994, vol 20, special issue

Table 1. Continued

Scale for

Method Principle posture nth h d

classification Arms Back «„¡«„e Whole bodv

Harber et al, 1987 Pencil and paper, Ordinal and ■ • • Static posture:
(47) real time; dichotomous above shoulder,
duration and below waist,
frequency sagital or symmetric,
upright, sq
Holzmann, 1982 Computerized, Interval Right and left Ten levels Also head, legs,
(31) film-based, time (Borg's 10-level 10 levels Borg scale 10-level Borg scale
ARBAN sampling, 1- to 2-s scale with ratio Borg scale
intervals properties)

Karhu et al, Pencil and paper, Ordinal Both hands on or Straight, bent, Legs in seven cat- Optional additional
1977 (30), computerized, below shoulders, straight and egories, modified posture: sitting
Kivi & Mattila, time sampling one on or above, twisted, version; five head
1991 (33) (usually 30 s) or both on or above, bent and twisted postures
OWAS direct modified versions
of four arm
postures

Keyserling, 1986 Computerized, real Interval Right and left Standing: • Lie, sit neutral,
(39) time observation and shoulder flexion- extension > 20 sit mild flexion,
via video; frequen- dichotomous abduction degrees; flexion- sit twisted or bent
cy and duration of <45, 45-90, bending: neutral,
postures, number >90 degrees 20 - 45 and >45
of postural degrees, twist or
changes bend > 20 degrees

Kilbom et al, 1986 Computerized Interval and Shoulder elevation; • Neck flexion
(44) via two video dichotomous upper arm > 20 degrees
Jonsson et al, recordings abduction 0-30,
1988 (21) (rear and side), 30-60, 60-90,
VIRA realtime; > 90 degrees,
frequency and upper arm flexion
duration of <0, 0-30,
postures and 30-60, 60-90,
movements >90 degrees

Ridd et al, 1989 Computerized, Optional • Optional definition ■ Optional definition

(37) direct or video- of postures of postures
ROTA based, real time or
time sampling

Rohmert & Landau, Pencil and paper, Ordinal • Stand straight, ■ Sit straight,
1979 (38) classification done stand slightly bent, sit forward bent
AET at end of observa- stand considerably
tion period bent

Ryan, 1989 Pencil and paper, Dichotomous • Flexion • Stand, walk, sit,
(42) time sampling >40 degrees, kneel, squat
(10 s during twisting
30 min) >20 degrees
Stetson et al, Pencil and paper, Dichotomous Wrist flexion,
1991 (45) direct or video, and interval extension, ulnar
real time; deviation, pinch
frequency and grip
duration of hand
exertions

Wickström et al, Pencil and paper, Interval and ■ Straight, bent

1985 (18) time sampling; dichotomous 15-90 degrees,
observer 1: task bent >90 degrees,
and manual backwards,
handling, rotation
observer 2:
postures

titles (30, 37, 38, Fransson-Hall, unpublished man-

methods have been thoroughly documented, and ref-
uscript). The OWAS and AET (arbeitswissenschaft- erence data are available. Second, there are methods
liche Erhebungsverfahren zur Tätigkeitsanalyse),for a narrower group of occupations, for example,
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 Scand J Work Environ Health 1994, vol 20, special issue

Manual materials handling

Lift, carry Push, pull of exposure applied for

Number of lifts • Static-dynamic, ■ ■ Nursing

>30 kg patient -nonpatient
contact

"Dynamic stress" • Total "ergonomie • Good agreement Building industry Analysis time-
for six body regions, stress" = mean for between expert consuming,
10-level Borg scale each body region panel and workers' done in laboratory;
of posture, dynamic ratings at high "typical" work
stress, isometric loads; observers analyzed, not
muscle stress and overestimated individual variation
vibration or shock low loads

< 10, 10- 20, ■ Static -dynamic Interobserver: ■ Widely used in Less suitable for
>20 kg posture, combina- coefficient of cor- many branches fast dynamic
tions classified relation 0.74-0.99, of industry activities
into four cate- low for forward
gories of accept- bend + twisting
ability; tasks can
be recorded

Interobserver agree- Compared with Automobile Separate replay

ment (inexperi- frame-by-frame: assembly for each joint:
enced): moderate good agreement 1. trunk; 2 left
for left shoulder, except for twisted/ shoulder; 3 right
less for trunk and bent trunk shoulder
right shoulder;
intraobserver:
frequency and
duration: high for
trunk, less
consistency for
nonneutral shoulder

Interobserver ■ Stationary, No difference in

agreement (inex- preferably work cycle time
perienced): all seated work between morning -
observations except afternoon; large
percentage of work interindividual
cycle time at rest difference between
and 0-30 degrees workers with
of flexion good; same task
intraobserver:
good except per-
centage of work
cycle time 0-30
degrees flexion
Optional definition • Task, workstation • • Developed for all Versatile system
of manual handling or tool recorded jobs; applied by where exposure
activities (nine categories) van der Beek (48) categories can be
selected by
observer

Dynamic large, ■ Static postures, Interobserver: • Widely used in Few posture

dynamic small (three body regions) coefficient of Germany and classes, therefore
muscle groups heavy dynamic correlation -0.8 Finland, for crude; method
(two regions), comparison also registers
repetitive (three between all jobs hygienic and work
regions) organizational
factors; "
work ana
not individual
variation

Hold, reach, lift Push, pull ■ • • Supermarket Strong association:

workers symptoms feet and
legs and duration
of standing
Hand exertions as Interobserver, ■ Assembly, Direct analysis
power tool use, no significant manufacturing more accurate
use of high differences than video
force or hand as (multiple
striking tool regression)

5- 20, > 20 kg ■ Static-dynamic • ■ Construction work No difference in

(weighing); hori- (back), work posture between
zontal distance surface: good, workers in same
<30, >30cm; intermediate, poor occupation;
level of load: minor accidents
toe, hip, shoulder recorded by diary
and teleph
interview

manufacturing (24, 39), nursing (40, 46, 47), andprobably be applied to a wider range of occupations
construction work (18, 31). Some of these methods(39-41). The method presented by Keyserling (39)
have features similar to the general methods and and
can posture targeting (24) have also been thorough-

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ScandJWork Environ Health 1994, vol 20, special issue

ly documented. Finally, there are methods for one ual lifting is identified as the major exposure haz-
specific occupation, for example, sign language in- ard. In a study by Huang et al (5 1 ) a similar approach
terpreters (19), supermarket workers (42), and artists was used for a comparison between musculoskele-
(43), or one body region, generally the hand or shoul- tal disorders in two workplaces.
der (19, 44, 45, Fransson-Hall et al, unpublished Only the PEO method (Fransson-Hall et al, unpub-
manuscript). These methods have usually been docu- lished manuscript) and the observation method used
mented only in conjunction with the epidemiologie by Feuerstein & Fitzgerald (19) attempt to quantify
study for which they were developed. the duration or frequency of repetitive movements
The advantage of the first group is that they per- of the forearm, wrist, and hand. Systematic obser-
mit comparisons between occupations. On the other vations of repetitive work have been performed suc-
hand, the necessity to record many risk factors si- cessfully by Silverstein et al in several studies (52 -
multaneously makes them relatively crude. One ex- 54). A work task was defined as repetitive when
ception is the PEO method, which attempts to quan- work cycles were shorter than 30 s or when funda-
tify a large number of risk factors, however at the mental work cycles constituted more than 50% of the
cost of a somewhat lower reliability and validity of total work cycle. Each job was characterized with
some variables (Leskinen et al, unpublished manu- regard to its force demands into high or low force
script). The third group, and to some extent the sec- jobs, but no postures were systematically observed.
ond, concentrates on only a few risk factors, for ex- The studies were performed in an industrial setting,
ample, wrist movements and handgrips (19, 45, and tasks with a high or low amount of repetition and
Fransson-Hall et al, unpublished manuscript) or up- a high or low amount of force could be observed re-
per arm postures and movements in seated work (43, liably.
44). Two other methods record "dynamic stress,"
which may partly incorporate manual materials han-
dling but is likely also to include dynamic activities
Risk factors assessed in observation methods without the exertion of force (31, 38). The OWAS
All of the methods in table 1 concentrate on postures, method also permits the observer to record the static
since it is one of the most commonly identified risk or dynamic conditions of the observation (30). Dy-
factors. Back and arm postures are registered by most namic exercise is usually not included among risk
methods, because of the common occurrence of back factors for musculoskeletal disorders. This factor has
and shoulder musculoskeletal disorders. For catego- been introduced into some methods because the
ries of postural analysis, see the section on the de- methods were designed for jobs in which the work-
sign of scales. er was highly mobile, and it was important to dis-
In addition, nine methods also incorporate manu- tinguish between the fatiguing effect of static ver-
al handling, either by observation only (24, 40, 42, sus dynamic components.
46, 47) or with supplementary measurement of the The computerized methods presented by Ridd et
weights handled or forces exerted, usually catego- al (37) and Fransson-Hall et al (PEO) (unpublished
rized into two to four classes (30, 41, 48, Fransson- manuscript), as well as OWAS (30), also allow the
Hall, unpublished manuscript). Six of these methods observer to record the tasks (or special events). This
distinguish between lifting-carrying, usually recorded is an important parameter if the observation aims at
as the number of actions per unit of time, and push- quantifying risk factors by task, for example, for sub-
ing-pulling. Only two methods record pushing-pull- sequent intervention. Many other methods can be
ing in real time, which allows the time spent in these modified to record risk factors by tasks, but they
activities to be calculated (40, Fransson-Hall, unpub- were not primarily designed for this purpose.
lished manuscript). This may be an important param- In conclusion, among the major risk factors iden-
eter, since a case-referent study of reported occupa- tified for musculoskeletal disorders, postures and
tional musculoskeletal disorders showed that the cas- manual handling are commonly assessed with obser-
es spent about three times longer pushing and pull- vation methods. Few attempts have been made to
ing than the referents (49). quantify repetitive work, and a quantitative assess-
For a more-detailed and quantitative evaluation of ment of vibration requires measurements.
lifting, the procedure recommended in the revised
equation of the National Institute for Occupational
Safety and Health (NIOSH) in the United States can Reliability
be used (50). This method does not register the se- The reliability of an observation method is the co-
quence of lifting over time, neither does it record herency of results when the observations are dupli-
pushing, pulling, carrying, or body postures. The re- cated. Hence the intraobserver reliability is the ex-
vised equation includes the calculation of a lifting tent of identical results obtained in repeated obser-
index (ie, the ratio between the load lifted and the vations of the same work situation by the same ob-
recommended weight limit). This index may become server, and the interobserver reliability is the extent
an interesting measure of exposure to lifting, and it of identical results obtained by several observers
should be useful in epidemiologie studies when man- when observing the same work situation. The out-

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 Scand J Work Environ Health 1994, vol 20, special issue

come of reliability testing is highly dependent upon Hence, for evaluating observation methods, calcula-
the methodology used. Several factors influence the tions of the kappa coefficient are restricted to time-
reliability assessment of an observation method. sampled data; real-time observations should not be
assessed with this method.
The proportion of agreement can be used for both
Basis for observations. Video recordings are the most intraobserver (two sessions) and interobserver (two
frequently used in determinations of reliability, but observers) reliability assessments. The overall pro-
is it also possible to use observations in three dimen- portion of agreement (57) is the simplest and most
sions by utilizing a subject performing predefined frequently used index of agreement. If the category
tasks according to recorded instructions transmitted under study is relatively rare, the proportion of spe-
by a portable tape recorder with earphones (Leskin- cific agreement is preferable (58, 59).
en et al, unpublished manuscript). Furthermore, the A multivariate data analysis of observer agreement
observations can be made from simple, stereotype can be used for interobserver reliability assessments
movements or realistic work situations, and the tem- for several observers to reflect the observers' con-
poral base varies from single operations to several gruity for each category.
work tasks. Naturally, the calculated reliability canReliability can be expected to depend on the ac-
be expected to decrease as the complexity of the curacy with which a posture or activity is assessed,
study material increases. the number of simultaneous exposures to be record-
ed, the training of the observer, and his or her fa-
miliarity with the work to be performed. In general,
Number of observers. Most studies use only one or reliability testing confirms these expectations. How-
two observers. However more information is ob-
ever, few of the methods included in table 1 have
tained if several observers are used.
been thoroughly tested for reliability. Interobserver
reliability has been assessed by van der Beek using
calculations of kappa (48). High reliability was ob-
Potential learning effects. Intraobserver reliability
tained for observations of posture (four levels of arm
can be influenced by learning effects (ie, the se-
and back postures on an interval scale), provided that
quence of postures and activities can be memorized
manual materials handling was not simultaneously
from one observation session to the next). This prob-
observed. The authors therefore concluded that, if
lem can be overcome if enough time is allowed be-
information on manual materials handling is need-
tween the observation sessions and, if possible, the
ed, it should be obtained by a second observer. In-
studied sequences are alternated.
terobserver reliability has also been assessed by
Fransson-Hall et al using an analysis of variance of
Number of simultaneously observed categories. The observer correlations (unpublished manuscript). The
calculated reliability can be expected to decreasereliability
as was higher for registrations of duration
the number of simultaneously observed categories than of frequency, probably reflecting a discrepan-
increases. cy between the observers according to the accuracy
with which the work was registered (ie, a specific
posture or activity recorded as one continuous event
Statistical methods. The choice of statistical meth- or separated into several shorter events). In general,
od for reliability assessment is crucial and should be
the interobserver reliability was high for trunk and
considered when investigations of reliability arm are posture, but low for registrations of neck pos-
planned, since it influences the number of observ- ture and manual handling activities. Stetson et al
ers, the number of observation sessions, and the (45), using multiple regression analysis, found no
number of situations required. significant differences between four trained analysts
An analysis of variance (ANOVA) can be usedwho forobserved video recordings of hand and wrist
both intra- and interobserver reliability assessmentspostures and grip types. They also noted that the
for two or several observers to reveal systematic as-
identification of extreme wrist postures yielded a
sociations and also covariations between two or sev- high interobserver agreement, but that different in-
eral factors. All available data (main- and subcate- terpretations sometimes occurred close to the deci-
gories, first and second observing session, observ- sion criteria.
ers, studied situations, etc) are included and consid- Most other authors have measured the proportion
ered in the model. of agreement between two observers, but this meth-
The kappa coefficient (55) can be calculated for od may give a falsely high estimate of reliability for
both intra- and interobserver reliability assessmentsexposure factors which occur infrequently. As ex-
for two or several observers. Kappa is an improve- pected, the percentage of agreement is high for sim-
ment of the simpler calculation of percentage ple, of dichotomous assessments of frequently occur-
agreement, correcting for observations by chance. ring exposures (sit-stand, back bent-back straight),
However, kappa is not applicable to continuous data, when both duration and frequency of exposure are
not even when grouped into ordinal categories (56). observed (40, 46). However, when the complexity of
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ScandJWork Environ Health 1994, vol 20, special issue

the observation increases because several classes of

The frequency of clearly distinguishable actions like
lifts could also be recorded accurately. Even reduc-
postures are incorporated, the consistency between
observers decreases (39). This decrease confirmsing
the
the number of exposure types by half did not sub-
results of van der Beek and Fransson-Hall. As stantially improve the agreement between the obser-
pointed out by Keyserling, differences between vations ob-
and measurements, and this result was inter-
preted
servers, when recording the posture of a certain as indicating that demands on the data
body
region in several classes, are due to disagreements
processing capacity of the observer during simulta-
concerning the boundaries of adjacent postures.
neous measurements of several factors were too high.
Among the body regions, neck posture appears For
to detailed
be observations of postures, it appears
the most difficult to assess accurately, even with
that the
only
ability of the observer to distinguish between
three classes (Fransson-Hall et al, unpublished adjacent
man-angular sectors (eg, more or less than 60
uscript). degrees of flexion) is the crucial problem. In an ex-
Intraobserver reliability appears to be relatively perimental study, Ericson et al (62) compared the
high, and higher than interobserver reliability, even observations obtained by experienced ergonomists,
with several months separating repeated observations direct observations, and observations from video re-
of a video recording (39, 60, Fransson-Hall et al, un- cordings to those obtained by a video position ana-
published manuscript). lyzer. The observations were made in the sagittal
plane. Observations of the trunk, neck, and upper-
arm inclinations could be made with an accuracy of
Internal validity about five degrees during static conditions and with
The internal validity of observations (ie, the extent somewhat higher accuracy during dynamic condi-
of agreement between observations and other, more tions, and direct observations did not differ from
accurate measurements) have only been tested for a those obtained from video recordings. The accuracy
few methods. Keyserling compared results obtained was somewhat better close to horizontal and verti-
in a simulated real-time observation with a frame- cal than in the intermediate range. Similar results
by-frame video analysis and obtained a high degree were obtained by van der Beek et al (47) when they
of agreement for the proportion of time spent with compared observations from a photograph with op-
the back in a neutral position and in severe flexion, toelectronic recordings. Obviously these results were
the shoulders in a neutral position and in mild obtained and under optimal conditions, and in a more
severe flexion or abduction (39). Observations complex of environment accuracy is likely to be lower.
back and left-right shoulders were made in three Nevertheless,
sep- systematically trained observers should
arate sessions. Time spent with the back twisted beor able to observe angular sectors and thus achieve
bent was overestimated, probably due to the difficul- more than a mere dichotomous observation of pos-
ty of translating a two-dimensional video observa- ture.
tion into three dimensions. Burdorf validated OWAS
External validity and applicability
observations of trunk flexion (> 20 degrees) using
For the purpose of this review, external validity is
inclinometer recordings and found a significant cor-
defined as the ability of an observation method to
relation between the two methods for the time spent
identify physical exposures associated with an in-
in forward flexion, during both sedentary and dynam-
creased risk of musculoskeletal disorders. Prerequi-
ic work (61). However, large differences between the
two methods were obtained for individual subjects. sites for high external validity are (i) a correct un-
Especially, the proportion of time in forward flex- derlying hypothesis (ie, a relationship between cer-
ion of the back was vastly overestimated by seden- tain physical exposures and musculoskeletal disor-
tary workers. In a recent study, Leskinen et al (un- ders exists) and (ii) an exposure observation meth-
published manuscript) validated the PEO method us- od designed (operationalized) to permit exposures to
ing video recordings and an optoelectronic record- be assessed with sufficient accuracy.
ing system (sel-spot). Measured trunk flexions be- Even though the underlying hypothesis may be
tween 50 and 60 degrees were systematically coded correct, the latency time between exposure and the
as exceeding 60 degrees, but there was good agree- overt symptom or disease may be too long to per-
ment between the proportion of time observed as ex- mit an association to be demonstrated in a cross-sec-
ceeding 60 degrees, but recorded as exceeding 50 tional study. This however is a problem inherent for
degrees. The requirement for recording trunk rota- any method used to assess current physical exposure,
tion (ie, >45 degrees) proved unrealistic, as it did be it by direct measurement, observation, or ques-
not occur in the realistic range of the tasks studied.tionnaire.
Observations of neck postures (> 20 degrees) wereTable 2 summarizes some epidemiologie studies
unreliable with regard to both duration and frequen- in which observation methods have been used to
cy. The authors concluded that there was a high de- quantify exposure. The table contains two studies in
gree of agreement between measured and observed which neck flexion, shoulder elevation, and abduc-
data for durations of sustained postures (except neck tion are associated with shoulder-neck disorders. In
four studies repetitivity, force, and speed of hand-
flexion) and long-lasting repetitive activities (typing).

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 Scand J Work Environ Health 1994, vol 20, special issue

arm movements have been associated with rorearm-
wrist-hand disorders, and in two studiesMoreover,
twisted back has been associated with low-back dis-
orders. One study has demonstrated a relationship
between the duration of standing and back, lower-
limb and foot symptoms, and another has shown
association between accidents and back postureand
lifting.
Considering that table 1 contains 19 observation
methods for postural assessment, to which can be
added NIOSH's procedure for evaluating lifting and
the method of Silverstein et al for repetitive work,
the application of observation methods for muscu-
loskeletal epidemiology is certainly very sparse.
Their application for ergonomie purposes is more
common, but even then each group of researchers
appears to favor the development of a new method
rather than the use of one developed by others. As
a matter of fact, only the OWAS method has been
applied widely for epidemiologie and ergonomie
purposes. It may be that most methods have been
documented only in the last six or seven years and
that more applications can be expected as the impor-
tance of exposure assessment becomes more evi-
dent. Even though table 2 demonstrates that obser-
vation methods can be used to study the relationship
between physical exposures and musculoskeletal
disorders, more studies need to be performed before
the external validity of observation methods has
been proved.
Operationalization
The design of scales, the number of exposure fac-
tors recorded simultaneously, the mode of observa-
tion (film-video or direct), the mode of time moni-
toring (continuous or time sampling), and the record- the observer carries only a hand-held computer rather
ing system (pencil and paper or computer) all con-
stitute aspects of the operationalization of an obser- tention and adjustments. On the other hand, a video
vation method. All of these factors profoundly influ- recording can be analyzed repeatedly, and this abil-
ence the reliability and validity of the method.
Pencil-and-paper or computerized registration?
Most observation methods of recent years are com-
puterized (ie, the internal clock of the computer is
used for keeping time and automatically recording
the durations), and each exposure factor is assigned
one key or a combination of keys on the computer
keyboard. The recordings can either be performed
directly at the workplace, by use of a portable or
hand-held computer, or from video recordings sub-
sequently analyzed in the laboratory. The most wide-
ly used observation method, OWAS, has now also
been computerized (33). The gains of computeriza-
tion are twofold. The time needed for recording is
reduced, and the entire cognitive capacity of the ob- and each separate exposure factor. Alternatively, reg-
server is made available for observation rather than
for keeping time. Use of a portable computer has the (which may be regular or irregular, depending on the
advantage of enabling direct feedback of detailed in-regularity of the job). Such a time-sampling proce-
formation from the screen to the observer. Therebydure, with sampling intervals of 10 - 30 s has been
errors in registration can be detected immediately.
a bent or for teaching and training purposes this
feedback is valuable. A small hand-held computer
provides less detailed feedback to the observer but
is, on the other hand, easier to carry at the workplace.
an
Experience with the PEO method shows that intra-
or interobserver reliability is not negatively affected
by the use of hand-held computers versus portable
computers, provided the observers are trained (Frans-
son-Hall et al, unpublished manuscript).
Direct or film-video registration? The advantage of
direct observation is that postures are likely to be re-
corded more accurately, since human vision is three-
dimensional whereas a film-video recording is re-
duced to a two-dimensional image. In an experimen-
tal study, Ericson et al (62) did not find any differ-
ences between observations registered directly and
via video recordings, provided the observations were
performed in the sagittal plane. Paul & Douwes (64)
compared a two-dimensional assessment of postures
from photographs with a three-dimensional evalua-
tion using an optoelectronic system. Their results in-
dicate that two-dimensional recordings give suffi-
cient accuracy, as long as some guidelines for the
reduction of perspective errors are followed. Keyser-
ling noted however that the observers misjudged the
proportion of time spent with a twisted back when
the assessment was done from a video recording,
while a direct assessment was more accurate (39).
Stetson et al (45), comparing direct observations with
a video analysis of hand and wrist postures and grip
types, concluded that direct observations were more
accurate. In addition, it is easier to move around a
workplace and secure optimal viewing angles when
than a video camera, which requires additional at-
ity is necessary when tasks done at a high work pace
are being observed, and also when many exposure
factors are recorded simultaneously. Therefore, di-
rect registration at the workplace can only be rec-
ommended when only a few variables are being as-
sessed or when the work pace is slow.
Real time or time sampling? A certain exposure can
be registered when a new situation arises, for exam-
ple, when a posture changes or a manual handling
activity is performed (19, 39, 44, 45, 47, 65, Frans-
son-Hall et al, unpublished manuscript). This is an
event-driven procedure, in real time or simulated real
time, and it enables the computer program to assess
the sequence, duration, and frequency of each event
istrations can be performed at certain intervals

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Scand J Work Environ Health 1 994, vol 20, special issue

Table 2. Associations between observed physical exposures and musculoskeletal disorders in some epidemiologie studies.
(OR = odds ratio)

Author Type of study Occupational group Exposure assessment

Feuerstein & Fizgerald Case-referent Sign language interpreters, Observation of standard

1992 (19) 16 with and 13 without pain interpretation task

Fransson-Hall et al Cross-sectional Automobile assembly-line Hand PEO, see table 1;

(unpublished manuscript) workers, 11 from low and observation of representative
9 from high-symptom work tasks
divisions

Jonsson et al 1988 (21) One- and two-year 69 electronics assembly VIRA at start of study;
follow-up workers see table 1.

Karhu et al 1977 (30) Cross-sectional 120 male workers (4 occu- Random selection of two or
Burdorf 1992 (69) pational groups) versus three workers per job;
52 referents observation of back, legs and
lifting by OWAS, interval 20s,
all activities recorded

Keyserling 1986 (39) Case-referent Automobile assembly See table 1, some "proxy"
Punnett et al 1991 (63) workers: workers also analyzed when
95 cases reporting observation of case was not
back pain, 124 referents possible
without back bain

Kilbom et al 1986 (44) Cross-sectional 96 female electronics VIRA, see table 1,

assembly workers observation of typical work
tasks, also work history and
productivity
Ryan 1989 (42) Cross-sectional 513 supermarket workers See table 1; sampling for
30 min, one to two workers
per store observed

Silverstein et al 1986 (52) Cross-sectional 574 industrial workers Observation of individual

representing 34 jobs, jobs, video and electro-
>20 workers per job myography of typical jobs;
high repetitivity cycle time
<30 s, high force >4 kg,
low force < 1 kg
Silverstein et al 1987 (53) Cross-sectional 652 industrial workers See above
representing 39 jobs,
>20 workers per job

Wickström et al 1985 (18) Cross-sectional Concrete reinforcement Observation of all work tasks
work and house painting for 272 h at eight work sites;
two observers, see table 1

used, for example, in OWAS (30) and posture in fast jobs. The solution may be to use repeated ob-
tar-
servations of a video recording in slow motion or two
geting (24) and by Baty et al (46), Ryan (42), Wick-
observers instead of one, as done by Wickström et
ström et al (18), and van der Beek et al (48). Pro-
al (18) and proposed by van der Beek et al (48). So
vided sampling intervals are chosen appropriately
far the advantage of real-time observations over time
with regard to the pace of the job, time sampling
gives a reasonable approximation of the durationsampling
and has not been proved conclusively. Although
information gathered on the duration of each
frequency of each exposure factor. The ROTA meth-
exposure event is likely to be of large potential val-
od developed by Ridd et al provides the possibility
of using either real time or time sampling (37).ue for understanding the etiology of musculoskele-
Real-time procedures provide more information tal disorders, it has not been used in epidemiologie
studies so far.
but put very large cognitive demands on the observer

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 ScandJ Work Environ Health 1994, vol 20, special issue

Responses Control Main results Comments

Current arm pain during in- Job seniority, age Fewer rest breaks, more
terpretation frequent hand and wrist
deviations and more rapid
hand and finger movements
among symptomatic
subjects
7-d and 12-month prevalence • Duration and frequency of
of symptoms, forearm-hand operations differed between
high- and low-symptom
division and between right
and left

Deterioration or improvement ■ Percentage of work cycle in Satisfaction with work

of neck-upper limb disorders; shoulder elevation negatively tasks positively associated
Remaining healthy for two associated with remaining with remaining healthy
years healthy; work cycle time
negatively associated with
deterioration

Twelve-month prevalence of Previous back pain, age Study group versus reference Previous physically heavy
back disorders by Nordic group: OR 2.80, log job; height, weight and
questionnaire regression: time spent with heavy lifting not associated
back bent or twisted and with back disorders
whole-body vibration (two
levels) both significant for
back disorders

Filed reports of back Gender, age, job seniority, OR -10 for back in mild,
disorders leisure-time habits, medical severe flexion and twist or
history lateral bend, OR ~5 for
proxy subjects; high
duration of exposure
increased risk estimate Productivity a
Neck and upper extremity Previous neck-shoulder Multiple regression analysis: with disorder
disorders in four degrees sick leave time in neck flexion, arm
of severity abduction related to neck
shoulder disorders

Twelve-month prevalence of ■ Strong association for per-

disorders by Nordic centage of time standing
questionnaire and disorders of back,
lower limb and foot

Cumulative trauma disorders Previous cumulative trauma OR for high force -high Force stronger risk factor
by questionnaire and disorders repetitivity 29, high force- than repetitivity
clinical examination low repetitivity 5, low force
-high repetitivity 3,
all versus low force -low
repetitivity
Carpal tunnel syndrome by Previous carpal tunnel OR for high force-high Repetitiveness stronger risk
questionnaire and clinical syndrome repetitivity 16, high force- factor than force; slight age
examination low repetitivity 2, low force (not significant), no gender
-high repetitivity 3, effects; vibration likely risk
all versus low force -low factor
repetitivity
Minor accidents in study • Concrete workers more Exposure and responses
group, reported accidents back flexion, static postures, not recorded on same
(national statistics) more lifting; also more group
minor and reported
accidents

sufficient
Number of exposure factors. Most observation meth- in many ways (see the preceding disc
ods use a number of main exposure categories,
sion), itfor
can be concluded that a large number of
example, posture of trunk and arms, manual served han-
factors reduce the precision of observat
dling, repetitive work, tasks. In each ofvanthese
dermain
Beek et al (48), using a time-sampling m
categories several subcategories can be used, for ex-
ification of the ROTA method with 23 exposure
categories,
ample, posture of trunk in three subcategories of flex- evaluated the interobserver reliabil
ion and two subcategories of side-bending or twist-
from video recordings. Their conclusion was that
ing. The methods presented in table 1 contain up to
observers are needed to perform all required re
23 different subcategories of exposures, to be ob-
trations. One observer should pay attention onl
served simultaneously. Although the tests posture, while the second observes tasks, man
of relia-
bility and internal validity performed sohandling, workplace characteristics, and used
far are in-

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Sc and J Work Environ Health 1994, vol 20, special issue

Leskinen et al (unpublished manuscript) studied the some methods (46, 48). On the basis of the afore-
validity of the PEO method, which uses real-time mentioned results, it is suggested that back flexion
observations, by comparing optoelectronic registra- be classified into the following three categories:
tions with direct observations. Their conclusion was straight (<20 degrees), moderate flexion (20 - 60
that, even when the number of subcategories is degrees) and pronounced flexion (>60 degrees).
halved (from 21 to 10), the agreement between meth- More methodological studies are needed to clarify
ods does not improve substantially. These results whether
in- better training of observers can improve the
dicate that a maximum of about 10 simultaneous sub- precision in the classification of twisting and side-
categories can be observed simultaneously. In high- bending.
paced and dynamic jobs the number of categories Another problem is that the exact definition of
will probably have to be substantially reduced; alter- postural angles is insufficiently reported in many
natively the analysis has to be performed repeated- method documentations. This situation indicates that
ly from video recordings. Whenever a simultaneous observers have not been sufficiently informed and
observation of several exposure categories is made, trained and that the accuracy of angle estimations can
a priority list should be followed so that assessment be improved by training, as demonstrated by van der
of the most important categories is guaranteed. Beek et al (48).
In parallel with back posture, arm posture should
preferably be subdivided into several classes for bio-
Design of scales. The majority of categories or sub- mechanical reasons. Such a subdivision was possi-
categories are dichotomous (ie, an exposure is reg- ble with sufficient reliability in the VIRA method,
istered only when it occurs, eg, sit, push, lift, neck which registers in the sagittal or frontal plane, and
flexion, back flexion, repetitive work). More detail only records upper arm, neck, and shoulder postures
can be obtained by subdividing into classes using in- (44). In the general methods no attempts have been
terval scales (eg, back neutral, bent 20 - 45 degrees, made to subdivide arm postures into angular sectors
bent >45 degrees, or lifting 1 - 5, 6 - 15, 16 - 45 and(48, Fransson-Hall et al, unpublished manuscript).
>45 kg). Unfortunately the class limits vary consid- Keyserling (classifying in >45- or <45-degree up-
erably between methods. Continuous scales have per-arm elevation) obtained a relatively low reliabil-
been tried in the posture targeting method (24) and ity for arm postures (39). It is probably easier for the
by Chang et al (43), but they are extremely time con- observer merely to classify the hand position (above
suming. or below shoulder level), as done in the PEO meth-
The reliability of dichotomous, gross body posture od, although the estimate of the biomechanical load
registrations like sit, walk, kneel, and squat is usu- on the shoulder is less accurate.
ally reported to be high, whereas postural assess-
ments are sometimes relatively unreliable (eg, neck
flexion). Data reduction indices. The OWAS, the RULA, and
Classifying back posture into several categories the ARB AN methods use the original exposure data
must be considered biologically relevant, as the load to develop indices for acceptability (28, 30, 31).
on the back extensor muscles and the compressive These indices are primarily intended as an instrument
forces in the spine are highly dependent on the flex- for priority setting in ergonomie work, and they have
ion angle. The choice of a dichotomous or interval not been validated. The lifting index, as calculated
scale with up to three classes does not, however, ap- in the revised NIOSH procedure, is another such
pear to influence reliability. Burdorf & Laan (66) composite measure of exposure (50). Recently Hag-
used the OWAS back-posture categories and defined berg pointed out that the pattern of exposure (ie, the
bent back as flexion exceeding 20 degrees, without combination of exposure factors and their distribu-
using additional classes of flexion. Yet large errors, tion over time) may provide better estimates of risk
usually excess classification of bent back, were ob- than single exposure variables (67). For such an ap-
tained by the observers. When Leskinen et al (un- proach, models based on pathophysiological consid-
published manuscript) validated the PEO method erations must be developed. Moreover, the observa-
(which classifies back flexion into the three catego- tion (or measurement) of exposure must be per-
ries of straight, 20 - 60 degrees and >60 degrees), formed in real time. This should be an important top-
they obtained errors of about 10 degrees, also with ic for future research. However, indices or compos-
a tendency for observers to overestimate the angle ite measures must never be used in a way that ob-
of flexion. Under optimal conditions both Ericson et scures an analysis of the effects of single exposure
variables.
al (62) and van der Beek et al (48) brought the error
of angle estimation down to 5 degrees. Errors of 5 -
1 0 degrees must be considered acceptable when back
Strategy for exposure assessment
flexion is classified. Twisting and side-bending of the
back has been found difficult to classify accurately Most systematic observations of physical work load
in most observation methods. Consequently bending have been performed on industrial populations, for
and twisting of the back are classified together in whom the variation in exposure, over time and be-

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 Scand J Work Environ Health 1994, vol 20, special issue

tween workers, has been considered small. Modern measurement) that so far has received little attention
trends in industrial rationalization are towards multi- in epidemiologie studies of musculoskeletal disor-
skilling, which implies that exposures are becoming ders. Even though the cited considerations give some
even more varied, both over time and between indi- guidance, this area is in urgent need of further theo-
viduals. In the service branches - hotels, restaurants, retical and empirical study.
cleaning, nursing - as well as among white-collar
workers, the variations in exposure have always been
Discussion
marked.
The variability of exposure, both within and be- This review has revealed several drawbacks of avail-
tween workers in the same occupational group, is a able methods for systematically observing physical
factor that has been neglected in most exposure stud- exposure. From this review, the following recom-
ies. Intraworker variability can be expected to vary mendations can be given for improving and further
over the workday, over the week, and between sea- developing observation methods:
sons. Interworker variability may differ by training
and working technique, by age, and by the physical 1 . Postures of the trunk should be classified into sev-
characteristics of the worker. For example, among
eral (two to three) categories. A consensus agreement
electronics workers who assembled identical circuit
is needed to define these categories, and observers
boards, work-cycle times and the distribution of pos-
need to be trained carefully in the identification of
tures over time varied markedly (44). In a study of
angular sectors. Whether twisting and side-bending
supermarket checkers, Harber et al (41) showed con-
can be assessed separately from flexion needs to be
siderable variation in trunk flexion, both within and
studied with the use of better definitions of these pos-
between workers. In the vast majority of studies tures.
the
magnitude of these variations is however unknown.
When different occupational groups are compared,
the total variability in exposure assessment is a2. Postures of the shoulder-arm complex appears to
re-
be
sult of variability within and between workers in the difficult to classify into more than two categories,
same group and variability between occupational unless both sagittal and frontal views can be guar-
anteed.
groups. In a comparison between five occupational
groups, Burdorf (68) calculated that the between-
group variance accounted for 47% of the total vari-
3. Postures of the neck and head appear difficult to
assess
ability in trunk flexion and 72% of the variability in with the classifications used so far. Results
trunk rotation. The within- worker and between- work-
may improve if different posture classes are used.
er variance was considerably lower, 29 - 24% and
16 - 12%, respectively. The effect of within- and 4. Gross body postures like sit, stand, kneel can be
between-worker variability on the bias in risk esti-
observed with high accuracy.
mates when occupational groups are compared has
been discussed by Burdorf (69). In essence, the over-
lap in exposure between occupational groups leads 5. Repetitive hand-arm work needs to be defined
to a risk of misclassification that lowers the true risk more precisely and methodological development of
estimate (odds ratio or prevalence rate ratio). both observation and direct measurement techniques
is needed.
In occupational groups with a relatively large with-
in-worker variability, a more accurate measure of
exposure can be obtained if the observation period 6. Manual handling can be assessed crudely, but it
is prolonged or repeated exposure assessments are needs complementary measurements for classifica-
made. Carmines & Zeller (70) and Liu et al (71) have tion into subcategories.
developed statistical methods to assess and minimize
intraindividual variability by performing two meas-
7. The number of simultaneously observed exposure
urements or more on each worker. The application variables should be reduced to less than 10. For ob-
of these considerations for strategy when postural
serving highly dynamic or high-paced work, the
load on the back is being assessed has been discussed
number of variables probably has to be reduced fur-
extensively by Burdorf (72). An important practical ther. If a higher number of variables needs to be ob-
conclusion is that, when the strategy for exposure served simultaneously, either two observers or video
assessment is being optimized, the variability of ex-
recordings with repeated viewing need to be used.
posure needs to be assessed on the intended study
population. The choice between a prolongation of the
observation period, versus repeated observations,8. Computerization of the method is necessary.
depends on whether the variation in exposure occurs
during the same day or between workdays. 9. More emphasis on training observers and more
In conclusion, strategy is an important part of ex-
exact definitions of exposure factors will probably
posure assessment (whether by observation or direct improve the reliability and validity of observations.

43

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Scand J Work Environ Health 1994, vol 20, special issue

10. Observations need to be supplemented with an 9. Kadefors R, Areskoug A, Dahlman S, Kilbom Â, S

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drawbacks, it is justified to discuss whether system-
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direct measurements. However, direct measurements
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