A participatory ergonomics intervention to re-design work and improve the musculoskeletal health of paramedics: protocol for a cluster randomised controlled trial.

BACKGROUND: In this paper, we present the protocol for a cluster randomised controlled trial to evaluate the effectiveness and implementation of a participative risk management intervention to address work-related musculoskeletal disorders (WMSDs). The aims of the study include to evaluate the implementation process and the impact of the intervention on work related musculoskeletal pain and discomfort and exposure to physical and psychosocial hazards in paramedics over a 12-month period. METHODS: The intervention in this study is to implement A Participative Hazard Identification and Risk Management (APHIRM) toolkit in an ambulance service. Eighteen work groups containing eligible participants (registered paramedics) will be randomised into the intervention or wait-list control arm in one of three rolling recruitment periods. The APHIRM toolkit survey will be offered at baseline and 12 months later, to all current eligible participants in each work group allocated to the trial. The intervention work groups will receive the remainder of the APHIRM toolkit procedures. Identifying data about individual participants will not be collected in the survey, to protect participant privacy and encourage participation. Changes in primary (musculoskeletal pain and discomfort) and secondary (exposure to physical and psychosocial hazards at work) outcomes measured in the survey will be analysed comparing the baseline and follow up response of the cluster. A process evaluation is included to analyse the implementation and associated barriers or facilitators. DISCUSSION: This study is important in providing a comprehensive approach which focusses on both physical and psychosocial hazards using worker participation, to address WMSDs, a well-known and significant problem for ambulance services. The effectiveness of the intervention in work groups will be rigorously evaluated. If significant positive results are observed, the intervention may be adopted in ambulance services, both nationally and internationally. TRIAL REGISTRATION: ISRCTN77150219. Registered 21 November 2021.

Increasing physical activity in the vehicle with an interactive seating system in a male sample.

An interactive seating system (IASS) was compared to a state-of-the-art massage seating system (MS) regarding the potential of reducing health risks from prolonged sitting in the vehicle. The study investigated if the systems (1) increase heart rate, which is associated with reduced metabolic and cardiovascular risks; (2) activate muscles with the potential to reduce musculoskeletal pain; (3) influence seating comfort and discomfort. The systems were compared in a passenger scenario in a laboratory study (30 male subjects). Only the use of the IASS significantly elevated the heart rate. Muscle activity showed tendencies to increase in the lower back only while using the MS. In comparison, the IASS activated all six captured muscles. Significantly less discomfort was found for the IASS compared to the MS. In comparison to the MS, the IASS showed a substantially higher potential for reducing health risks from static sitting in the vehicle.Practitioner summary: This laboratory study compared the effects of a novel automotive interactive seating system with those of a state-of-the-art massage seating system. Muscle activity, heart rate and discomfort indicated that the IASS has a significantly higher potential to reduce health risks associated with static seating in a vehicle.Abbreviations: AB: air bladder; AC: active condition; ADSS: active dynamic seating system; CLBP: chronic lumbar back pain; ECG: electrocardiography; EMG: electromyography; IASS: interactive seating system; MS: massage seating system; PC: passive condition; PDSS: passive dynamic seating system; RMS: rootmean-square; TI: time interval.

Effects of Whole-Body Stretching Exercise during Lunch Break for Reducing Musculoskeletal Pain and Physical Exertion among Healthcare Professionals.

Background and Objectives: To investigate the effect of whole-body stretching (WBS) exercise during lunch break for reducing musculoskeletal pain and physical exertion among healthcare professionals. Methods: Full-time healthcare professionals working in hospitals with more than one year of experience were invited to participate. Sixty healthcare professionals (age 37.15 ± 3.9 Years, height 1.61 ± 0.04 m, body mass 67.8 ± 6.3 kg, and BMI 26.5 ± 2.1 kg/m2) participated in this single-blinded, two-arm randomized controlled trial (RCT). Participants were divided into WBS (n = 30) and control (n = 30) groups. The WBS group performed a range of stretching exercises targeting the entire body during a lunch break period for 3 times a week for 6 weeks. The control group received an education program. Musculoskeletal pain and physical exertion were assessed using the Nordic musculoskeletal questionnaire and Borg rating of perceived exertion scale, respectively. Results: The 12-month prevalence of musculoskeletal discomfort among all healthcare professionals was highest in the low back region (46.7%), followed by the neck (43.3%), and then the knee (28.3%). About 22% of participants said that their neck discomfort impacted their job, while about 18% reported that their low back pain impacted their job. Results indicate that the WBS and education program had a beneficial impact on pain and physical exertion (p < 0.001). When comparing the two groups, the WBS group experienced a significantly greater decrease in pain intensity (mean difference 3.6 vs. 2.5) and physical exertion (mean difference 5.6 vs. 4.0) compared to an education program only. Conclusions: This study suggests that doing WBS exercises during lunchtime can help lessen musculoskeletal pain and fatigue, making it easier to get through the workday.

Systemic therapies for preventing or treating aromatase inhibitor-induced musculoskeletal symptoms in early breast cancer.

BACKGROUND: Adjuvant aromatase inhibitors (AI) improve survival compared to tamoxifen in postmenopausal women with hormone receptor-positive stage I to III breast cancer. In approximately half of these women, AI are associated with aromatase inhibitor-induced musculoskeletal symptoms (AIMSS), often described as symmetrical pain and soreness in the joints, musculoskeletal pain and joint stiffness. AIMSS may have significant and prolonged impact on women's quality of life. AIMSS reduces adherence to AI therapy in up to a half of women, potentially compromising breast cancer outcomes. Differing systemic therapies have been investigated for the prevention and treatment of AIMSS, but the effectiveness of these therapies remains unclear. OBJECTIVES: To assess the effects of systemic therapies on the prevention or management of AIMSS in women with stage I to III hormone receptor-positive breast cancer. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to September 2020 and the Cochrane Breast Cancer Group (CBCG) Specialised Register to March 2021.  SELECTION CRITERIA: We included all randomised controlled trials that compared systemic therapies to a comparator arm. Systemic therapy interventions included all pharmacological therapies, dietary supplements, and complementary and alternative medicines (CAM). All comparator arms were allowed including placebo or standard of care (or both) with analgesia alone. Published and non-peer-reviewed studies were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies, extracted data, and assessed risk of bias and certainty of the evidence using the GRADE approach. Outcomes assessed were pain, stiffness, grip strength, safety data, discontinuation of AI, health-related quality of life (HRQoL), breast cancer-specific quality of life (BCS-QoL), incidence of AIMSS, breast cancer-specific survival (BCSS) and overall survival (OS). For continuous outcomes, we used vote-counting by reporting how many studies reported a clinically significant benefit within the confidence intervals (CI) of the mean difference (MD) between treatment arms, as determined by the minimal clinically importance difference (MCID) for that outcome scale. For dichotomous outcomes, we reported outcomes as a risk ratio (RR) with 95% CI. MAIN RESULTS: We included 17 studies with 2034 randomised participants. Four studies assessed systemic therapies for the prevention of AIMSS and 13 studies investigated treatment of AIMSS. Due to the variation in systemic therapy studies, including pharmacological, and CAM, or unavailable data, meta-analysis was limited, and only two trials were combined for meta-analysis. The certainty of evidence for all outcomes was either low or very low certainty. Prevention studies The evidence is very uncertain about the effect of systemic therapies on pain (from baseline to the end of the intervention; 2 studies, 183 women). The two studies, investigating vitamin D and omega-3 fatty acids, showed a treatment effect with 95% CIs that did not include an MCID for pain. Systemic therapies may have little to no effect on grip strength (RR 1.08, 95% CI 0.37 to 3.17; 1 study, 137 women) or on women continuing to take their AI (RR 0.16, 95% 0.01 to 2.99; 1 study, 147 women). The evidence suggests little to no effect on HRQoL and BCS-QoL from baseline to the end of intervention (the same single study; 44 women, both quality of life outcomes showed a treatment effect with 95% CIs that did include an MCID). The evidence is very uncertain for outcomes assessing incidence of AIMSS (RR 0.82, 95% CI 0.63 to 1.06; 2 studies, 240 women) and the safety of systemic therapies (4 studies, 344 women; very low-certainty evidence). One study had a US Food and Drug Administration alert issued for the intervention (cyclo-oxygenase-2 inhibitor) during the study, but there were no serious adverse events in this or any study. There were no data on stiffness, BCSS or OS. Treatment studies The evidence is very uncertain about the effect of systemic therapies on pain from baseline to the end of intervention in the treatment of AIMSS (10 studies, 1099 women). Four studies showed an MCID in pain scores which fell within the 95% CI of the measured effect (vitamin D, bionic tiger bone, Yi Shen Jian Gu granules, calcitonin). Six studies showed a treatment effect with 95% CI that did not include an MCID (vitamin D, testosterone, omega-3 fatty acids, duloxetine, emu oil, cat's claw).  The evidence was very uncertain for the outcomes of change in stiffness (4 studies, 295 women), HRQoL (3 studies, 208 women) and BCS-QoL (2 studies, 147 women) from baseline to the end of intervention. The evidence suggests systemic therapies may have little to no effect on grip strength (1 study, 107 women). The evidence is very uncertain about the safety of systemic therapies (10 studies, 1250 women). There were no grade four/five adverse events reported in any of the studies. The study of duloxetine reported more all-grade adverse events in this treatment group than comparator group. There were no data on the incidence of AIMSS, the number of women continuing to take AI, BCCS or OS from the treatment studies. AUTHORS' CONCLUSIONS: AIMSS are chronic and complex symptoms with a significant impact on women with early breast cancer taking AI. To date, evidence for safe and effective systemic therapies for prevention or treatment of AIMSS has been minimal. Although this review identified 17 studies with 2034 randomised participants, the review was challenging due to the heterogeneous systemic therapy interventions and study methodologies, and the unavailability of certain trial data. Meta-analysis was thus limited and findings of the review were inconclusive. Further research is recommended into systemic therapy for AIMSS, including high-quality adequately powered RCT, comprehensive descriptions of the intervention/placebo, and robust definitions of the condition and the outcomes being studied.

Pain management in eldercare employees - the role of managers in addressing musculoskeletal pain and pain-related sickness absence.

PURPOSE: Managers' knowledge and behaviors in addressing musculoskeletal pain and sickness absence is not well understood. We investigated the association between managers' knowledge and behaviours in relation to employees' pain and their future risk of musculoskeletal pain and associated sickness absence. METHODS: The prospective study included 535 eldercare employees, and 42 managers from 20 nursing homes. Managers' self-reported knowledge and behaviors in relation to employees' pain were grouped using Principal Components Analysis. Eldercare employees reported pain-related sickness absence, and number of days with musculoskeletal pain repeatedly over 1 year. We investigated associations using mixed-effects regression models. RESULTS: We identified four types of managers' knowledge and behaviors: 1) Pain-prevention (actions for prevention of employee pain), 2) Pain-management (actions to assist employees manage pain), 3) Pain-entitlements (communicating entitlements to employees with pain), and 4) Pain-accommodations (ability to facilitate workplace accommodations for employees with pain). The employees of managers with higher scores on knowledge of pain-entitlements reported fewer days of pain-related sickness absence (ß = -0.62; 95%CI [-1.14; -0.10]). The employees of managers with higher scores on pain-management were more likely to report low back pain (ß = 0.57; 95%CI [0.02; 1.11]). We found several key associations between the knowledge and behaviors measures and pain-related sickness absence (interactions). CONCLUSION: Managers' knowledge and behaviors in relation to employees' pain were associated with employees' future musculoskeletal pain and sickness absence. The relationships are complex, suggesting that a multifaceted approach is needed to ensure that managers are adequately informed on how to manage and accommodate employees with musculoskeletal pain to reduce sickness absence.

Usefulness of the Rapid Office Strain Assessment (ROSA) tool in detecting differences before and after an ergonomics intervention.

BACKGROUND: Most ergonomics studies on office workstations evaluate the effects of an intervention only by subjective measures such as musculoskeletal pain and discomfort. Limited evidence has been provided regarding risk factor reduction in office environments through standardized methods assessments. The Rapid Office Strain Assessment (ROSA) tool can provide an estimation of risk factor exposure for office workers as a means by which the outcome of interventions can be quantified. PURPOSE: The aim of the study was to evaluate if ROSA scores reflect changes in risk factors after an ergonomics intervention among office workers. METHODS: Office workers (n = 60) were divided into two groups. The experimental group received a workstation intervention and the control group received no intervention. Changes in ROSA scores were compared before and after the intervention in both groups. RESULTS: Statistically significant reductions in the ROSA final and section scores occurred after the intervention in the experimental group with (mean reduction of 2.9, 0.8 and 1.6 points for sections A, B and C, respectively). In contrast, no differences were detected in the control group (mean increase of 0.1 point for sections A and C and mean reduction of 0.1 point for Section B). CONCLUSIONS: These findings show that ROSA scores reflect changes in risk factors after an ergonomics intervention in an office environment. Consequently, this tool can be used for identifying and controlling risk factors among computer workers, before and after interventions.

Intraoperative stretching microbreaks reduce surgery-related musculoskeletal pain in otolaryngologists.

OBJECTIVE: The purpose of this study was to examine the role intraoperative otolaryngology stretching microbreak (OSMB) has on musculoskeletal (MSK) pain and discomfort in otolaryngologists. BACKGROUND: Otolaryngology procedures subject surgeons to significant amounts of pain and strain over their years of training. MSK pain is a serious concern for otolaryngologists' career longevity as well as their general wellbeing. METHODS: Participants from two different hospitals and one private practice were recruited to participate in this study. An initial ergonomic survey was obtained to assess baseline MSK pain, and its subjective impact on operative performance. The participants then completed three control days without OSMB exercises, followed by three intervention days with OSMB exercises which were completed at 20-40 minute intervals. Preoperative and postoperative pain rating surveys were completed before and after each procedure and at the end of the day to determine changes in pain and/or discomfort. RESULTS: Ten otolaryngologists (50 % men, 50 % women; mean age 35.6 years) participated in this study. Half of the participants indicated that they were concerned their pain would limit their ability to operate in the future. 70 % of participants indicated that they have not attempted to treat this pain and 60 % did not try any stretching exercises outside the operating room (OR) to mitigate their symptoms. Participants reported neck, upper back, and lower back to be the primary MSK discomfort. OSMB improved participants' pain scores in neck, shoulders, hands, and lower back pain (p < 0.05). CONCLUSION: MSK pain has shown to be a serious concern for the ability of otolaryngologists to continue performing surgery in the future. OSMB may be an effective strategy that can be implemented by otolaryngologists intraoperatively to improve MSK pain and overall well being.

Classification of kneeling and squatting in workers wearing protective equipment: development and validation of a rule-based model using wireless triaxial accelerometers.

Several professions in industries, such as petroleum, manufacturing, construction, mining, and forestry require prolonged work tasks in awkward postures, increasing workers' risks for musculoskeletal pain and injury. Therefore, we developed and validated a rule-based model for classifying unilateral and bilateral kneeling and squatting based on 15 individuals wearing personal protective equipment and using three wireless triaxial accelerometers. The model provided both high sensitivity and specificity for classifying kneeling (0.98; 0.98) and squatting (0.96; 0.91). Hence, this model has the potential to contribute to increased knowledge of physical work demands and exposure thresholds in working populations with strict occupational safety regulations. Practitioner summary: Our results indicate that this rule-based model can be applied in a human-factors perspective enabling high-quality quantitative information in the classification of occupational kneeling and squatting, known risk factors for musculoskeletal pain, and sick leave. This study is adapted for working populations wearing personal protective equipment and aimed for long-term measurements in the workplace.

Computer workstation ergonomics: Current evidence for evaluation, corrections, and recommendations for remote evaluation.

STUDY DESIGN: Literature Review INTRODUCTION: Computer use in the workplace has increased substantially since the start of the information age in the mid-1980s through 2020. Desktops, laptops, and tablets are essential tools for communication and project management. As a result of the COVID-19 pandemic, many workers have transitioned to work from home (WFH) to sustain public health emergency guidelines, and it is anticipated that many WFH jobs will be maintained post-pandemic. The transition to WFH occurred rapidly without time to establish ideal workstations. Ergonomic assessments that were typically performed in person needed to be performed using virtual technology. PURPOSE OF THE STUDY: The purpose of this review is (1) to describe the components of a computer workstation evaluation; (2) to offer suggestions for identifying computer workstation problems that may be contributing to the client's musculoskeletal (MSK) pain and symptoms; (3) to provide suggestions that may improve the safety and comfort at the computer workstation, and (4) to suggest a method of completing the workstation analysis virtually, without onsite in-person evaluation. METHODS AND RESULTS: There is a paucity of peer-reviewed literature regarding computer workstation evaluations to be performed in person, let alone using a virtual method. The components of computer workstation evaluations have been recommended by regulatory agencies that survey injuries in the workplace. Prior to 2020, these evaluations were done in person at the office workstation. Modifications in data collection were needed to transition the analysis to a reliable virtual format. The remote method described provides a consistent approach that engages the client in the process.

Feasibility and impact of a musculoskeletal health for musicians (MHM) program for musician students: A randomized controlled pilot study.

BACKGROUND: There is a high incidence of performance-related musculoskeletal disorders in musicians that may be reduced via education programs. However, the efficacy of formalized injury prevention programs has not been rigorously studied. PURPOSE: To assess the feasibility and effect of a formalized injury prevention education workshop on incidence and severity of musculoskeletal pain in a cohort of musician-students attending an intensive summer music festival compared to controls. STUDY DESIGN: Randomized-controlled-pilot trial. METHODS: Musicians at an 8-week long intensive summer festival were randomized to an intervention (workshop) or control group. Workshop attendees participated in a 90-minute session of injury prevention strategies. Musculoskeletal outcome data were collected at the start and end of the festival. Outcomes included presence of musculoskeletal pain, adherence level, and sub-scales of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians. RESULTS: A total of 57 musician-students (ages 17-30, 23 females) participated in the study, and 48(84%) completed the study. Seventy-five percent of workshop participants reported adherence over 8 weeks. At baseline, 84% of participants reported a history of playing-related pain, and 47% recent or current pain. Participants played a range of instruments (50% string, 34% piano, 16% woodwind/brass). At baseline, average weekly reported playing time was 39 hours (±11). At follow-up, reported pain decreased by 32% in the intervention group and increased by 8% in controls (P < .01). Pain interference scores were lower (Post - Pre = -4.58, 95% CI -9.26 to 0.11, P = .055). There was no statistically significant difference between groups for pain intensity. CONCLUSIONS: The high compliance and willingness to participate suggests that injury prevention education implementation is feasible. Our preliminary findings suggest a positive effect on pain incidence and pain interference in the intervention group. Future studies will examine the relationship between adherence levels and injury rates in a larger cohort and identify obstacles to implementation.

The development and use of an anatomy-based retraining program (MusAARP) to assess and treat focal hand dystonia in musicians-A pilot study.

BACKGROUND: Movement dysfunctions are commonly reported in musicians, and in extreme cases may result in a persisting loss of motor control. This condition, whereby motor control of the hand during previously highly trained movements on the instrument is lost, is termed focal hand dystonia. It is widely considered to be a consequence of prolonged repetitive daily practice, often in combination with exposure to a range of other risk factors. Current literature recommends retraining as a promising treatment intervention, although only scant scientific evidence exists on which components should be included in a retraining program, and how these may be best administered. METHODS: A progressive muscle activation and movement exercise program was devised by one of the authors applying a series of anatomy-based off-instrument movement tasks. This series of fine motor control exercises, was used to both assess and retrain focal hand dystonia in a population of musicians. The standardized approach aimed to provide a systematic method of retraining musically relevant muscular synergies that could later be applied to the instrument, while still allowing individual modifications. Retraining sessions were mostly run online as a consequence of the coronavirus pandemic, although some early sessions were also able to be undertaken face to face. Both qualitative and quantitative measures were used in this case series to evaluate program efficacy, due to the typical heterogeneity of the focal hand dystonia participants. This included: blinded external neurological evaluation of video footage using the Tubiana grading system, written subjective feedback, exercise progressions, and performance outcomes. RESULTS: Pilot testing of 4 patients indicated the utility of the program over approximately a 12- month time period. All subjects improved, 2 of whom have returned to pre-dystonia performance levels. These patients reported the importance of patience and persistence with daily exercise sessions in their recovery. CONCLUSION: Using off-instrument playing-relevant exercises to enhance fine motor control and muscle activation can be effective in retraining focal hand dystonia, regardless of additional treatments or level of performance. They should be regularly practiced and progressed in order for effects to be best progressed to instrumental applications. Further research may elucidate whether there are optimal outcomes with single or particular combinations of treatment approaches.

The effectiveness of ergonomics interventions in reducing upper limb work-related musculoskeletal pain and dysfunction in sonographers, surgeons and dentists: a systematic review.

The aim of this systematic review was to summarise the effects of ergonomics interventions on work-related upper limb musculoskeletal pain and dysfunction, and on productivity in sonographers, surgeons and dentists. A total of 31 studies were included. All studies reported effects on upper limb pain. Nine studies reported effects on dysfunction and only two studies reported effects on productivity. Moderately strong evidence in reducing upper limb pain was found for instigation of microbreaks into long duration surgical procedures, and the use of wider, lighter handles in dental instruments. Moderate evidence was also found for use of prismatic glasses and favourable positioning in reducing upper limb pain. Weak, inconsistent or no evidence was found for all other ergonomics interventions in reducing upper limb pain and dysfunction and increasing productivity. The lack of high quality research, particularly in sonographers and in the outcome of productivity, should be addressed. Practitioner summary: This systematic review investigates the effectiveness of ergonomics interventions on upper limb pain, dysfunction and productivity in sonographers, dentists and surgeons. Instigation of microbreaks during long duration procedures and the use of wider, lighter instrument handles were most effective in reducing upper limb work-related pain. Abbreviations: ANOVA: analysis of variance; CLS: conventional laparoscopic surgery; DMAIC: define, measure, analyze, improve and control; GRADE: grading of recommendations, assessment, development and evaluations; HD: high definition; PRISMA: preferred reporting items for systematic reviews and meta-analyses; PROSPERO: The International Prospective Register of Systematic Reviews; RCT: randomised control trial; SILS: single incision laparoscopic surgery; VITOM: video telescopic operative microscope; WNSWLHD: Western New South Wales Local Health District; WMSD: work related musculoskeletal disorder.

Use of Patient Abdominal Compression Device Reduces Staff Musculoskeletal Pain Associated With Supporting Colonoscopy: Results From a Randomized Controlled Trial.

Work-related musculoskeletal disorders occur frequently among the endoscopy staff, and patient-handling duties involved with colonoscopy-applying manual pressure and repositioning patients-are particularly physically demanding. This study explored whether the use of a lower abdominal compression device (ColoWrap), previously shown to reduce the need for manual pressure and patient repositioning, would diminish the frequency of staff-reported musculoskeletal pain. A randomized, blinded, sham-controlled clinical trial was performed at the University of North Carolina Hospitals. Three hundred fifty patients had either ColoWrap or a sham device applied before colonoscopy. The primary outcome was the frequency of staff-reported musculoskeletal pain after assisting with colonoscopy. In the intention-to-treat analysis, which included procedures in which ColoWrap was removed, there was no statistical difference in the frequency of staff-reported pain in the control versus ColoWrap arm (4.6% vs. 3.4% of procedures, p = .59). However, when ColoWrap was used as directed (e.g., remained in place for the duration of the procedure), the frequency of staff-reported musculoskeletal pain was significantly reduced (4.6% vs. 0.7% of procedures, p = 0.04). Use of ColoWrap as directed was also found to be independently associated with reduced odds of staff-reported pain relative to the sham arm (OR = 0.12; 95% CI [0.02, 0.95]). When used as directed, ColoWrap reduced the frequency of musculoskeletal pain experienced related to assisting with colonoscopy and may reduce the risk of musculoskeletal disorders and injuries among the endoscopy staff.

Assurance for Endurance? Introducing a Novel Ergonomics Curriculum to Reduce Pain and Enhance Physical Well-Being Among GI Fellows.

Musculoskeletal pain and injuries (MSKPI) are common among gastroenterologists (GI) and GI fellows. Common areas of pain include the back, neck, hands/fingers, shoulders, and elbows. Although the prevalence of career-related pain and injuries among GIs is high, few endoscopists receive training in how to prevent MSKPI. We developed an ergonomics curriculum for our GI fellows that consisted of two modules that were led by physical therapists. Twelve out of 15 GI fellows, and one out of two hepatology fellows, participated in Module 1. Prior to the first module, 77% of participants reported pain in one or more body parts. Of those who reported pain, 100% of the fellows stated that this pain occurred during procedures, and 50% indicated this pain was performance-limiting. After completing Module 1, 100% of fellows reported that this was a valuable topic and 100% of the participants felt that this information would both help them feel and perform better. All fellows stated they had an immediate decrease in physical discomfort after engaging in the exercises that were included in Module 1. Eight fellows participated in Module 2. At the end of this module, 100% of fellows reported that this ergonomics training would likely help them to "physically perform better during procedures" and 100% of fellows indicated a reduction of physical discomfort (pain, aching) immediately after completing these exercises. Preliminary data indicated that this novel curriculum was perceived as valuable by GI fellows and that practicing these exercises reduced pain, particularly in the neck and the lower back.

Exercise therapies for preventing or treating aromatase inhibitor-induced musculoskeletal symptoms in early breast cancer.

BACKGROUND: Survival for stage I to III, hormone receptor-positive, breast cancer has substantially improved over time due to advances in screening, surgery and adjuvant therapy. However many adjuvant therapies have significant treatment-related toxicities, which worsen quality of life for breast cancer survivors. Postmenopausal women with hormone receptor-positive breast cancer are now prescribed aromatase inhibitors (AI) as standard, with longer durations of therapy, up to 10 years, being considered for certain women. AI treatment is associated with a high incidence of AI-induced musculoskeletal symptoms (AIMSS), often described as symmetrical pain and soreness in the joints, musculoskeletal pain and joint stiffness. AIMSS reduces compliance with AI therapy in up to one half of women undergoing adjuvant AI therapy, potentially compromising breast cancer outcomes. Exercise has been investigated for the prevention and treatment of AIMSS but the effect of this intervention remains unclear. OBJECTIVES: To assess the effects of exercise therapies on the prevention or management of aromatase inhibitor-induced musculoskeletal symptoms (AIMSS) in women with stage I to III hormone receptor-positive breast cancer. SEARCH METHODS: We searched Cochrane Breast Cancer's Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases up to 13 December 2018. We also searched two conference proceedings portals and two clinical trials registries for ongoing studies or unpublished trials, or both, in August 2019. We also reviewed reference lists of the included studies. SELECTION CRITERIA: We included randomised controlled trials that compared exercise versus a comparator arm. We did not impose any restriction on the comparator arm, which could include an alternative type of exercise, no exercise or a waiting list control. Both published and non-peer-reviewed studies were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data, assessed risk of bias and certainty of the evidence using the GRADE approach. The outcomes investigated were pain, joint stiffness, grip strength, health-related quality of life, cancer-specific quality of life, adherence to AI therapy, adverse events, incidence of AIMSS, breast cancer-specific survival and overall survival. For continuous outcomes that were assessed with the same instrument, we used the mean difference (MD); for those outcomes that used different instruments, we used the standardised mean difference (SMD) for the analysis. For dichotomous outcomes, we reported outcomes as an odds ratio (OR). MAIN RESULTS: We included seven studies with 400 randomised participants; one study assessed exercise for preventing AIMSS and six studies assessed treating AIMSS. For preventing AIMSS, the single study reported no difference in pain scores, grip strength or compliance to taking AI medication between groups. Data values were not provided in the study and no other outcomes were reported. For managing AIMSS, we found that the evidence for the effect of exercise therapies on overall change in worst pain scores was very uncertain (SMD -0.23, 95% confidence interval (CI) -0.78 to 0.32; 4 studies, 284 women; very low-certainty evidence). The evidence suggested that exercise therapies result in little to no difference in overall change in stiffness scores (Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) stiffness score MD -0.76, 95% CI -1.67 to 0.15 and Visual Analogues Scale (VAS) stiffness score MD -0.42, 95% CI -2.10 to 1.26; 1 study, 53 women; low-certainty evidence). The evidence was very uncertain for the outcomes of overall change in grip strength (MD 0.30, 95% CI -0.55 to 1.15; 1 study, 83 women; very low-certainty evidence); overall change in health-related quality of life (subscales of SF-36 tool ranged from least benefit of MD 1.88, 95% CI -2.69 to 6.45 to most benefit of MD 9.70, 95% CI 1.67 to 17.73; 2 studies, 123 women, very low-certainty evidence); overall change in cancer-specific quality of life (MD 4.58, 95% CI -0.61 to 9.78; 2 studies, 136 women; very low-certainty evidence); and adherence to aromatase inhibitors (OR 2.43, 95% CI 0.41 to 14.63; 2 studies, 224 women; very low-certainty evidence). There were no adverse events identified across four studies in either arm (0 events reported; 4 studies; 331 participants; low-certainty evidence). There were no data reported on incidence of AIMSS, breast cancer-specific survival or overall survival. AUTHORS' CONCLUSIONS: Given the wide-ranging benefits of exercise for people affected by cancer, it was surprising that this review provided no clear evidence of benefit for exercise therapies in women with early breast cancer with AIMSS. This review only yielded seven eligible studies with 400 participants, which is likely to have underpowered the findings. The meta-analysis was challenging due to the considerable heterogeneity amongst the trials, with a wide range of exercise regimens and follow-up periods. Despite these inconclusive findings, exercise needs to be part of routine care for women with breast cancer due to its wide-ranging benefits. Future research in this area would be enhanced with further understanding of the mechanism of AIMSS, a single clear definition of the condition, and phase III randomised controlled trials that are adequately powered to test targeted exercise interventions on the key clinical outcomes in this condition.

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain (PREVSAM): a randomised controlled trial protocol.

BACKGROUND: Musculoskeletal pain is globally a leading cause of physical disability. Many musculoskeletal-related pain conditions, such as low back pain, often resolve spontaneously. In some individuals, pain may recur or persist, leading to ong-term physical disability, reduced work capacity, and sickness absence. Early identification of individuals in which this may occur, is essential for preventing or reducing the risk of developing persistent musculoskeletal pain and long-term sickness absence. The aim of the trial described in this protocol is to evaluate effects of an early intervention, the PREVSAM model, on the prevention of sickness absence and development of persistent pain in at-risk patients with musculoskeletal pain. METHODS: Eligible participants are adults who seek health care for musculoskeletal pain and who are at risk of developing persistent pain, physical disability, and sickness absence. Participants may be recruited from primary care rehabilitation centres or primary care healthcare centres in Region Västra Götaland. Participants will be randomised to treatment according to the PREVSAM model (intervention group) or treatment as usual (control group). The PREVSAM model comprises an interdisciplinary, person-centred rehabilitation programme, including coordinated measures within primary health care, and may include collaboration with participants' employers. The primary outcome sickness absence is operationalised as the number and proportion of individuals who remain in full- or part-time work, the number of gross and net days of sickness absence during the intervention and follow-up period, and time to first sickness absence spell. Secondary outcomes are patient-reported short-term sickness absence, work ability, pain, self-efficacy, health-related quality of life, risk for sickness absence, anxiety and depression symptoms and physical disability at 1 and 3 months after inclusion (short-term follow-up), and at 6 and 12 months (long-term follow-up). A cost-effectiveness analysis is planned and drug consumption will be investigated. DISCUSSION: The study is expected to provide new knowledge on the effectiveness of a comprehensive rehabilitation model that incorporates early identification of patients with musculoskeletal pain at risk for development of sickness absence and persistent pain. The study findings may contribute to more effective rehabilitation processes of this large patient population, and potentially reduce sickness absence and costs. TRIAL REGISTRATION: ClinicalTrials.gov Protocol ID: NCT03913325 , Registered April 12, 2019. Version 2, 10 July 2020. Version 2 changes: Clarifications regarding trial aim and inclusion process.

Evaluation of a Lower Leg Support Exoskeleton on Floor and Below Hip Height Panel Work.

OBJECTIVE: The aim of this study is to determine the effectiveness of using a leg support exoskeleton (legX) in different modes on simulated work tasks which emulate real-world job tasks. BACKGROUND: Prolonged kneeling and squatting tasks increase the risk of work-related musculoskeletal disorders at the knee in industrial occupations. METHODS: We evaluated legX capable of spring assistance throughout one's range of motion and/or locking support at a fixed angular position. Participants performed a dynamic panel task, alternating between hip and knee height, and a sustained floor level task with and without the exoskeleton. The exoskeleton was evaluated in spring mode, locking mode, and spring + locking mode for the panel task and only in locking mode for the floor task. The participants' (N = 15) muscle activity was recorded for the right lumbar erector spinae, thoracic erector spinae, tibialis anterior, rectus femoris, semitendinosus, and lateral gastrocnemius. RESULTS: Significant reduction of the rectus femoris activity was observed with the exoskeleton (median reduction: 22%-56% and peak reduction: 12%-48% for the panel task and median reduction: 57% and peak reduction:34% during the floor task). CONCLUSION: legX significantly reduces rectus femoris activity during squatted static (floor) and dynamic (panel) work and may reduce pain and discomfort associated with squatting and potentially reduce the risk of developing knee disorders. Dynamic tasks benefit from both locking modes and spring assistance, the greatest benefit occurring with a combination of the two. APPLICATION: These results show that the legX can be beneficial to activities such as electrical panel work, grinding, sanding of larger surfaces, and concrete laying.

Supporting Surgical Teams: Identifying Needs and Barriers for Exoskeleton Implementation in the Operating Room.

OBJECTIVE: The objective of this study was to identify potential needs and barriers related to using exoskeletons to decrease musculoskeletal (MS) symptoms for workers in the operating room (OR). BACKGROUND: MS symptoms and injuries adversely impact worker health and performance in surgical environments. Half of the surgical team members (e.g., surgeons, nurses, trainees) report MS symptoms during and after surgery. Although the ergonomic risks in surgery are well recognized, little has been done to develop and sustain effective interventions. METHOD: Surgical team members (n = 14) participated in focus groups, performed a 10-min simulated surgical task with a commercial upper-body exoskeleton, and then completed a usability questionnaire. Content analysis was conducted to determine relevant themes. RESULTS: Four themes were identified: (1) characteristics of individuals, (2) perceived benefits, (3) environmental/societal factors, and (4) intervention characteristics. Participants noted that exoskeletons would benefit workers who stand in prolonged, static postures (e.g., holding instruments for visualization) and indicated that they could foresee a long-term decrease in MS symptoms with the intervention. Specifically, raising awareness of exoskeletons for early-career workers and obtaining buy-in from team members may increase future adoption of this technology. Mean participant responses from the System Usability Scale was 81.3 out of 100 (SD = 8.1), which was in the acceptable range of usability. CONCLUSION: Adoption factors were identified to implement exoskeletons in the OR, such as the indicated need for exoskeletons and usability. Exoskeletons may be beneficial in the OR, but barriers such as maintenance and safety to adoption will need to be addressed. APPLICATION: Findings from this work identify facilitators and barriers for sustained implementation of exoskeletons by surgical teams.

The Impact of Ergonomics on Recruitment to Surgical Fields: A Multi-Institutional Survey Study.

BACKGROUND: Awareness of ergonomics in surgery is growing, but whether musculoskeletal (MSK) injuries in surgery influence trainee career choices remains unknown. This study aimed to characterize medical students' MSK pain during surgical rotations and determine whether ergonomics influence student interest in surgical fields. METHODS: An online survey was administered to medical students in North Carolina. Students were asked about specialty interest, MSK pain on surgical rotations, and deterrents from surgical fields. Students were exposed to literature about ergonomics in surgery then queried again about relative specialty interest (medical versus surgical). Differences in specialty interest before and after the exposure were compared using a Wilcoxon signed-rank test. RESULTS: Of 243 participants, 44.0% were interested in pursuing a surgical specialty. Overall, 75.3% reported MSK pain during their surgical rotation, with the average daily pain score highest during surgery rotations compared to all other clinical rotations. The worst pain was reported in the feet and low back while "standing in the operating room" (81.2%) or "retracting" (59.4%). Among students initially interested in surgery but whose interest changed to a medical specialty during medical school, "physical demands of the field" was a common deterrent (36.4%). After exposure to literature regarding the incidence of MSK injuries in surgery, student interest in surgical fields on a 10-point scale significantly decreased (average -0.5 points; P < 0.01). CONCLUSIONS: High incidence of MSK injury among surgeons may be one factor deterring medical students from surgical careers. Ergonomic interventions may be important both to improve surgeon longevity and maintain the surgical workforce.

An innovative method for clinical practice guideline contextualisation for chronic musculoskeletal pain in the South African context.

BACKGROUND: Clinical guidelines produced in developed nations may not be appropriate in resource-constrained environments, due to differences in cultural, societal, economic and policy contexts. The purpose of this article is to describe an innovative and resource-efficient method to develop a clinical practice guideline (CPG), using the CPG contextualisation approach. METHODS: The four phased contextualisation framework was applied to produce a contextualised, multidisciplinary CPG for the primary health care of adults with chronic musculoskeletal pain (CMSP) in the South African context. The four phases were: a contextual analysis, evidence synthesis, contextual integration and external evaluation. Qualitative methodology was used to investigate context factors influencing health care in this environment. A systematic review was conducted to identify current, high-quality CPGs on the topic, and to synthesise a core set of clinical recommendations from the CPGs. Consensus methods were used to integrate context information with recommendations. A multidisciplinary panel of local experts authenticated and contextualised recommendations. The resultant CPG was externally reviewed using a survey. RESULTS: The results from the contextual analysis phase indicated a wide range of contextual factors that could influence the applicability and implementability of the recommendations, including: the personal characteristics of the patient and clinician, social and environmental circumstances, healthcare interventions available, and healthcare system factors. During phase two, six existent high quality CPGs were identified and a core set of multidisciplinary recommendations were sourced from them. The contextual integration phase produced the validated recommendations, accompanied by its underpinning body of evidence and context specific information. The outcome of phase four (external review) was that the recommendations were confirmed as relevant for the intended setting. CONCLUSION: CPG contextualisation was found to be a practical approach to develop a contextualised multidisciplinary CPG for the primary health care of adults with CMSP in a South African setting. The contextualisation approach enhanced the integration of multiple stakeholder perspectives and highlighted the importance of considering clinical, social and economic complexities during CPG development. Attention to contextual information is advocated to enhance the uptake of CPG recommendations, particularly in resource constrained settings. TRIAL REGISTRATION: Health Research Ethics Committee of Stellenbosch University, South Africa (S14/01/018); the review protocol was registered on PROSPERO (registration number CRD42015022098 ).