623964
research-article2016
WHSXXX10.1177/2165079915623964Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
Article
Origin of a Musculoskeletal Guideline
Caring for Older Workers
Nancy Delloiacono, DNP, RN, APN-BC1
Abstract: Today’s employers are hiring a more age-
diverse workforce. As Americans work longer, age-related
changes often create activity limitations. Musculoskeletal
disorders affect many older workers heightening their risk of
workplace injury. Compounded by multiple comorbidities,
older workers will need occupational health nurses
with expert knowledge to maintain safe and productive
workplaces. Older workers do not experience as many
injuries as younger workers, but when they are injured,
recovery is longer. The author developed and conducted a
survey of New Jersey occupational health nurses. The results
showed that overexertion injuries are the most frequently
treated injuries in employee health offices. For occupational
health nurses to keep employees safe, best practices must
be delineated; this musculoskeletal safety guideline provides
recommendations for evidence-based care of older workers.
Keywords: international aging workforce, safety, and age-
related changes
R
    esearch indicates that over 20% of the U.S. population
    will be at least 55 years old by the year 2050 increasing
    the prevalence of chronic illness, musculoskeletal
disorders, and occupational as well as non-occupational
musculoskeletal injuries in older adult workers (Canning &
Bloom, 2012). In addition, many older adults are choosing not
to retire as early as previous generations. These trends suggest
occupational health nurses and advanced practice nurses
working in occupational health will be providing nursing care
for a rapidly increasing elderly workforce employed in
manufacturing and nonmanufacturing settings. These changes,
leading to a new “multigenerational” workforce with multiple
comorbidities, will require nurses with expert knowledge to
evaluate and manage older employees with musculoskeletal
injuries. Safety for the older worker must be a priority.
Besides changes in vision and hearing and decreased
strength and flexibility, older adults experience musculoskeletal
DOI: 10.1177/2165079915623964. From 1Rutgers School of Nursing. Address correspondence to: Nancy Delloiacono, Rutgers School of Nursing, Newark New Jersey, USA;
e-mail: ndelloi@sn.rutgers.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2016 The Author(s)
262
June 2016
changes that can result in arthritis (Blagojevic, Jinks, Jeffrey &
Jordan, 2010; Keller & Burns, 2010). To compound this
physiological effect, the incidence of arthritis increases to one of
every two individuals aged 65 years and older (Caban-Martinez
et al., 2011). Research has documented how aging affects
human body systems but evidence-based safety guidelines for
older workers could provide the foundation for occupational
health nurses to develop strategies and gain insight into the
future nursing care needed by this population.
Needs Assessment
The increase in aging workers will bring challenges for
nurses providing care to older adults. A sound educational
foundation of how aging affects individuals’ risk of injury is
extremely important for nurses in the workplace. Having this
knowledge should lower workers’ risk of musculoskeletal injury.
Occupational health nurses care for employees who have been
injured on and off the job. For this reason, they are essential
members of the health care team.
The need for a musculoskeletal safety guideline as a
resource for occupational health nurses was identified by the
author after participating in informal discussions with New
Jersey occupational health nurses. The author conducted a
series of 12 face-to-face or teleconference interviews with
musculoskeletal experts from physical therapy, occupational
therapy, ergonomics, workplace design, safety, and advanced
practice nursing to understand content that should be included
in the development of a safety guideline.
To evaluate the prevalence of musculoskeletal disorders,
particularly overexertion injuries, a survey was sent to New
Jersey occupational health nurses to determine the three most
common types of injuries the nurses identified in their offices.
The survey included questions to determine whether any
policies or musculoskeletal safety guidelines were used in New
Jersey organizations and the types of charting procedures
occupational health nurses were using. To search for strong
evidence to support the guideline, an extensive review of the
literature using key words (e.g., international aging workforce,
vol. 64  ■  no. 6
Table 1.  Agree 2 Evaluation of National Guidelines
Elements ACOEM
Scope and purpose health question Present
Clarity of presentation Present
Applicability No plan included
Editorial independence Present
Rating score 5/7
Stakeholder involvement Absent
Target users Present
Population Present
Rigor Present
Note. ACOEM = American College of Occupational and Environmental Medicine; HIGN = Hartford Institute for Geriatric Nursing; AOTA = American
Occupational Therapy Association.
safety, and age-related changes) was completed. To identify if a
gap existed in this area of research, three national occupational
health nurse experts used the Agree 2 evaluation tool to
compare the strengths and weaknesses of three national
guidelines. This instrument is used to evaluate the quality of an
existing guideline and newly developed guidelines being
considered for clinical practice (Brouwers et al., 2010).
Method
The search engines for the literature review were Medline,
CINAHL, Business Source Primer and Google Scholar. Thirty-
two articles were reviewed. Five studies were rejected because
they did not meet the inclusion criteria (i.e., publications in
English and articles that reviewed age-related changes and
ergonomic impact) and exclusion criteria (i.e., data published
before January 2005, publications focusing on chronic disease,
unpublished works, individuals aged 55 or younger, and
emphasis on the psychosocial impact of occupational injury
rather than musculoskeletal disorders or injuries).
Next, a doctoral committee was assembled to guide the
project. The committee members were chosen for their expert
knowledge needed for the development and implementation of
the project. Because “older adults” were the target population,
an expert in adult and gerontology nursing was selected to
review the disease content and chair the committee. The
guideline was meant to be used by occupational health nurses
in all types of organizational settings. So, a nurse expert in
leadership was chosen to provide organizational management
of the project. The final committee member was a statistical
expert to assist in data analysis.
The external reviewers were three individuals considered
experts in the field of occupational health nursing. One
university professor in the group is well recognized as a
Workplace Health & Safety
HIGN AOTA
Present No patient outcomes
Not consistent Present
Absent Present
Missing Present
3/7 4/7
Present Present
Present Present
Present Present
Not complete Present
musculoskeletal injury researcher. The second reviewer is a
university professor and expert reviewer of scholarly
publications for peer-reviewed journals. The third reviewer is a
university clinical professor in the field of community health.
The Agree 2 evaluation was applied to national guidelines by
two of the three occupational health nurse experts. The
musculoskeletal injury researcher reviewed the initial draft of the
musculoskeletal safety guideline later developed by the author.
This instrument was used to appraise the American College of
Occupational and Environmental Medical Specialty Society Low
Back Disorders: Evaluation and management of common health
problems and functional recovery in workers (American College
of Occupational and Environmental Medicine [ACOEM], 2009),
Hartford Institute for Geriatric Nursing Academic Institute for
Age-Related Changes in Health (Smith et al., 2008), and the
American Occupational Therapy Association’s Occupational
Therapy Practice Guidelines for Individuals With Work-Related
Injuries and Illnesses (Kaskutas & Snodgrass, 2009).
After the Agree 2 evaluations were completed, a comparison
table was developed by the author to identify key elements that
should definitely be included in the musculoskeletal safety
guideline (Table 1). The rigorous evaluations demonstrated that
no quality nursing guidelines were available for nurses to identify
age-related risk factors. The highest Agree 2 rating was given to a
medical guideline. These evaluations further supported the need
for a standardized nursing guideline. The Center of Evidence-
Based Medicine (CEBM) levels of evidence were used for rating
all five main articles included in the evidence table (Phillips et al.,
2009). The guideline was further supported by the use of
additional relevant articles.
After the previous steps were completed, a comprehensive
evidence-based safety guideline to lower the risk of
musculoskeletal injuries was developed from an in-depth
263
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Table 2.  Synthesis of Evidence and Levels of Evidence

Study topic/ Level of

Author/year title problem Intervention Outcome Results Comments evidence
1. Blagojevic, Jinks, Lack of All types of review Prevention factors 2,233 studies were found, Further longitudinal studies Level 1A
Jeffery, and systematic publications from 85 studies were used. needed, SR and MA.
Jordan (2010) reviews for 1960 to January Predisposition—history of Gender bias Included cohort
Risk factors osteoarthritis of of 2008 knee trauma, Heberden’s Meta-analysis limitation as well as
Workplace Health & Safety

for onset of the knee. nodes, obesity, job-related noted identification of few case–control
osteoarthritis Higher prevalence (stooping), advancing age contributing factors to studies
of the knee in of osteoarthritis and female gender sustaining an injury.
older adults: in the knee Cohort and case–control
a systematic with adults over studies revealed similar
review and meta- age 50 conclusions, case–control
analysis studies had larger effect
sizes
2. Crawford, Probable Systematic reviews Musculoskeletal 280 studies reviewed, 11 Further research needed to Level 1A
MacCalman, and medical and have shown the complaints can articles calculated the determine if access to OH SR and RCT;
Jackson (2011). psychosocial musculoskeletal be reduced correlation between care is a problem. Quasi-
The health and implications for medical and with ergonomic musculoskeletal Transporting heavy objects experimental
well-being of workers psychological screening. symptoms, work impact to and from vehicles and
remote and effects that affect Risk of social and lifestyle. predisposes the worker to observational
mobile workers well-being isolation and Strong evidence that most back issues.
mental health frequent injury sites are Age-related physiological
issues heighten neck, shoulder, and lower alterations need
without enough back consideration in regard to
social interaction (CI [1.72, 4.43]) correlating lower injury rates
neck complaints and
female gender.
Increased musculoskeletal
problems found when
sitting at least 10 hours/
week, driving in excess
of 20 hours/week and
prolonged distance driving
June 2016
 vol. 64  ■  no. 6

Table 2.  (continued)

Study topic/ Level of

Author/year title problem Intervention Outcome Results Comments evidence
3. da Costa and Data can help the Systematic Review only 63 studies, reasonable Weak evidence exists for Level 1A
Vieira (2010) OH team design longitudinal covered cohort evidence concluding pushing the musculoskeletal SR.
Risk factors for interventions review to and case–control biomechanical risk factors system beyond its capacity. Cohort and
work-related that lower determine studies; first (i.e., repetitive motion, Needs further investigation case control
musculoskeletal injury risk work-associated published heavy lifting and poor
disorders: A factors vs. NIOSH evidence on body posture) show causal
systematic findings locations association with WMSD
review of recent
longitudinal
studies
4. Linton (2001) Prompt Systematic review Strong evidence 21 studies encompassed Awareness of work-related Level 1B
Occupational recognition of psychological showed that prospective design, psychological factors to SR.
psychological of work- workplace tiresome evaluation, monitoring, prevent injury and hasten Prospective
factors increase associated elements in work, work comparative, randomized rehabilitation. studies used
the risk for factors will relation to back relationships, clinical trials (RCT), and Data from only 2 studies and
back pain: A improve back pain. job fulfillment, clinical trials. use of questionnaire were
systematic pain treatment Outcome variables job stress, and Most clinical trials lacked limitations of this study.
review and disability. included injury, job requests data on psychological Attributable fraction of female
Identification of lost time, and influence future predictor variables so the back pain reduction (0%
age-related return to work back pain in older author did not use them effect on recovery of lost
physiological workers time to more than 1 week to
changes is vital 66% for job satisfaction).
to preventing Data indicate it is desirable to
future disability lower or eradicate these risk
factors

Note. CI = confidence interval; SR = systematic review; MA = meta-analysis; RCT = randomized control; OH = occupational health; NIOSH = National Institute for Occupational Safety; WMSD = work-related
musculoskeletal disorders; Level 1A = systematic reviews (with homogeneity) of randomized controlled trials; Level 1B = individual randomized controlled trials (with narrow confidence interval).
Workplace Health & Safety

265
 Table 3.  Additional Research Supporting Development of Evidence-Based Safety Guideline/Educational Program
266
Author/year title
Agnew et al. (2007)
Use of employer administrative
databases to identify
systematic causes of injury in
aluminum manufacturing
Alipour et al. (2008).
Occupational neck and
shoulder pain among
automobile manufacturing
workers in Iran
Cassou, Derriennic, Monfort,
Norton, and Thouranchet
(2002). Chronic neck
and shoulder pain, age,
and working conditions:
longitudinal results from
a large random sample in
France
Harvey and Thurnwald
(2009). Ageing well, ageing
productively: The essential
contribution of Australia’s
ageing population to the
social and economic
prosperity of the nation
Leino and Hanninen (1995).
Psychological factors at
work in relation to back and
shoulder disorders
Note. MSD = musculoskeletal disorder.
Study topic/problem Intervention Outcome Results Comments
Employee files are Employee files, Physical job demand shown 2,495 workers studied from Employer administrative
underutilized in occupational health to be the strongest the period 2002-2004, found records found to be a
epidemiological studies surveillance data predictor in determining 32% suffered sprains, 24% useful source of data
examining injuries and industrial employee injury risk level contusions, and 14% lacerations because utilizing these
hygiene data Logical regression model to records allows risk factor
evaluate data analysis and identification
of potential confounders
Workplace Health & Safety
Upper extremity MSD Questionnaire Ergonomic deficiencies 14,384 workers participated Multiple logistic regression
musculoskeletal injury linked to problems with in completing the MSD model. Physiological
constitutes a problem the musculoskeletal Questionnaire. Several risk manifestations and
experienced throughout system resulting in illness factors were identified from psychosocial factors
the world or injury the questionnaire data such as linked to neck and
repetitive motion, working in shoulder complaints
awkward positions, prolonged
sitting, and lack of consistent
exercise
Determining how aging Participants Multifactorial nature exists Advancing age increases Findings indicate that proper
and work relate to completed a with job strain due to prevalence and incidence of ergonomic adaptation
chronic neck and questionnaire imbalance of physical WMSD and early management of
shoulder pain addressing pain workload and physical More prevalent in females chronic neck and shoulder
and psychosocial workload capacity was pain for aging workers is
job issues through found to be a determinant vital for injury prevention.
random selection in future development of Prospective longitudinal study
MSDs with advancing age
In dealing with aging Descriptive review on A disparity was identified Current generation is more Improved illness treatment
workers, management societal influences between rich and poor knowledgeable than previous have had a positive impact
should consider on aging individuals over age 65 generations about aging on living longer
alternative views and gracefully
solutions to address
social and economic
outcomes
Identification of factors Study duration of Results found statistical An investigation of how morbidity On-the-job psychosocial
that lead to neck, 10 years using a significance between is affected by gender and factors play a major role
shoulder, and low back questionnaire and the level of stress occupational class. in determining positive
pain that potentiates performance of a and musculoskeletal Data were analyzed by two-way effects on WMSDs
risk of injury clinical exam complaints analysis of variance. considering age and
Research finding: prolonged mental physical workload
strain is associated with WMSDs
June 2016
vol. 64  ■  no. 6
literature review, expert reviewers, and evaluation of three
national guidelines using the results of the Agree 2 evaluations.
The intended users of this guideline are occupational health
nurses and advanced practice nurses. The recommendations
below are intended to increase occupational health nurses’
knowledge of assessment, education, and evaluation of age-
related risk factors for musculoskeletal injuries.
The following is a synopsis of the recommendations from
the comprehensive guideline:
1. Age-related musculoskeletal changes increase injury risk
for older adults (Bohle, Pitts, & Quinlan, 2010; Centers for
Disease Control and Prevention, 2009; da Costa & Vierira,
2010; Foster, Hartvigsen, & Croft, 2012; Hush, Cameron, &
Mackey, 2013; Perry, 2010). Prompt detection of
musculoskeletal symptoms is paramount to improving
injury rates and recurrent injuries.
2. While gathering a musculoskeletal history, concentrate
on symptomology that can precipitate overexertion
injuries or result in falls.
3. Conduct a fall risk evaluation of older workers by using
the Hendrich 11 Fall Risk Model (retrieved from http://
consultgerirn.org/uploads/File/try_this_8.pdf)
4. When documenting health histories, record the onset of
chronic conditions to calculate workers’ injury risks.
Health issues that lower physical activity increase the
risk of musculoskeletal injury (Linton, 2001).
5. “When taking a psycho-social history, factors such as
self-imagined age, work\home balance, social support,
work breaks, job satisfaction, supervisor and employee
working relationship, socialization, relaxation methods
and sleep patterns can increase risk of injury” (Hauke,
Flintrop, Brun, & Rugulies, 2011; Linton, 2001, pp. 56-57).
6. Assess for adverse medication reactions that occur with
advancing age that can lead to increased risk of
work-related injury.
7. When documenting occupational histories, the time workers
have been functioning in an ergonomically demanding
environment is important to identifying injury risk (Agnew et
al., 2007; Cassou, Derriennic, Monfort, Norton, & Touranchet,
2002).
8. Use an age-sensitive manner when examining older
employees (Leggert, 2007).
9. When examining older workers for musculoskeletal
issues, focus on the areas of the body where injury
tends to occur: “eye, low back, shoulder, neck, hand,
wrist, ankle and foot” (Crawford, MacCalman, & Jackson,
2011; da Costa & Vieira, 2010, pp. 32-33).
10. Assess the areas where workers perform job functions,
and observe workers engaged in daily activities. This
process will determine how much ergonomic factors
influence workers’ risk and complaints.
11. Refer workers as soon as possible to physical therapy
and occupational therapy to lower absenteeism rates
(Foster et al., 2012).
Workplace Health & Safety
12. Increase workers’ knowledge of low back risk factors:
bending, twisting, pulling, pushing, reaching, climbing,
and prolonged sitting (da Costa & Vieira, 2010; Leino &
Hanninen, 1995).
13. Encourage rotation of sitting and standing while
completing job tasks (Alipour, Ghaffari, Shariati, Jensen
& Vingard, 2008).
14. The glenohumeral joint should be examined. This is the
most unstable joint when engaged in hand-operated
workplace activities (Seidel et al., 2011).
15. Older workers can suffer loss of consciousness from
postural hypotensive changes (Harvey & Thurwald,
2009; Perry, 2010). Instruct older workers to move
slowly when standing and sitting.
16. Encourage older workers to walk. Instruct employees that
not enough exercise can interfere with coordination,
balance, flexibility, and strength. These areas are already
compromised with advancing age (Kravitz & ACOSM, 2011;
ACOEM Clinical Practice and Guideline Center, 2012).
17. Cardiovascular disease negatively affects older workers
with slower healing after suffering work-related
musculoskeletal injuries. Therefore, instruct older
workers not to sit for extended periods of time at their
desks (American College of Sports Medicine, 2011;
Goff et al., 2014).
18. Instruct workers that “lifting 35 pounds or more and
lifting more than the horizontal distance of 20 inches
from the person’s ankle, increases the risk of injury”
(Chaffin & Park, 1973, p. 516).
19. In positions requiring repetitive motion, encourage
sufficient time for muscle and tendon recovery by
participating in adequate rest breaks.
Conclusion
When developing an evidence-based guideline, the author
must be immersed in the process using a structured organized
approach for the assessment, education, and prevention of the
problem. The approach used in this article to design a
musculoskeletal guideline can be used as a springboard for
occupational health nurses and other nurse specialties to
improve their practice. Due to the shortage of evidence-based
“best practices” available for registered nurses and advanced
practice nurses working in occupational health and safety,
these guideline recommendations will assist nurses caring for
older workers to prevent musculoskeletal injuries.
Conflict of Interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
267
 Workplace Health & Safety
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Author Biography
Nancy Delloiacono received a Doctor of Nursing Practice degree, and
a Post-Masters Certificate, Primary Care of the Adult and Aged Nurse
Practitioner Post Master’s Program from Rutgers, The State University
of New Jersey School of Nursing. She is employed at Rutgers School of
Nursing as the nursing resource center coordinator and also
employed as an APN-BC in home care at Universal Health Care
Navigators. She has 7 years of experience as an occupational health
nurse.