Diagnostic criteria for musculoskeletal disorders for use in occupational healthcare or research: a scoping review of consensus- and synthesised-based case definitions.

BACKGROUND: The aim of this study was to identify case definitions of diagnostic criteria for specific musculoskeletal disorders (MSDs) for use in occupational healthcare, surveillance or research. METHODS: A scoping review was performed in Medline and Web of Science from 2000 to 2020 by an international team of researchers and clinicians, using the Arksey and O'Malley framework to identify case definitions based on expert consensus or a synthesis of the literature. Seven MSDs were considered: non-specific low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral or medial elbow tendinopathy, and knee and hip osteoarthritis (OA). Case definitions for occupational healthcare or research were charted according to symptoms, signs and instrumental assessment of signs, and if reported, on work-related exposure criteria. RESULTS: In total, 2404 studies were identified of which 39 were included. Fifteen studies (38%) reported on non-specific LBP, followed by knee OA (n = 8;21%) and CTS (n = 8;21%). For non-specific LBP, studies agreed in general on which symptoms (i.e., pain in lower back) and signs (i.e., absence of red flags) constituted a case definition while for the other MSDs considerable heterogeneity was found. Only two studies (5%), describing case definitions for LBP, CTS, and SAPS and lateral and medial elbow tendinopathy respectively, included work-related exposure criteria in their clinical assessment. CONCLUSION: We found that studies on non-specific LBP agreed in general on which symptoms and signs constitute a case definition, while considerable heterogeneity was found for the other MSDs. For prevention of work-related MSDs, these MSD case definitions should preferably include work-related exposure criteria.

Towards harmonisation of case definitions for eight work-related musculoskeletal disorders - an international multi-disciplinary Delphi study.

BACKGROUND: International consensus is needed on case definitions of work-related musculoskeletal disorders and diseases (MSDs) for use in epidemiological research. We aim to: 1) study what information is needed for the case definition of work-related low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral and medial elbow tendinopathy, and knee and hip osteoarthritis, and to 2) seek consensus among occupational health professionals/researchers regarding the case definitions of these work-related MSDs. METHODS: A two-round Delphi study was conducted with occupational health professionals/researchers from 24 countries. Definition of work-related MSDs were composed of a case definition with work exposures. Round 1 included 32 case definitions and round 2, 60 case definitions. After two rounds, consensus required 75% of the panellists to rate a case definition including work exposures ≥7 points on a 9-point rating scale (completely disagree/completely agree). RESULTS: Fifty-eight panellists completed both rounds (response rate 90%). Forty-five (70%) panellists thought that for LBP a case definition can be based on symptoms only. Consensus was only reached for work-related medial elbow tendinopathy, while the lowest agreement was found for knee osteoarthritis. Where consensus was not reached, this was - except for LBP - related to physical examination and imaging rather than disagreement on key symptoms. CONCLUSION: Consensus on case definitions was reached only for work-related medial elbow tendinopathy. Epidemiological research would benefit from harmonized case definitions for all MSDs including imaging and physical examination for LRS, SAPS, CTS, lateral elbow tendinopathy and hip and knee osteoarthritis.

Evaluation of the effects of two alternative participatory ergonomics intervention strategies for construction companies.

To improve the use of ergonomics tools by construction workers, the effect of two guidance strategies - a face-to-face strategy (F2F) and an e-guidance strategy (EG) - of a participatory ergonomics intervention was studied. Twelve construction companies were randomly assigned to the F2F group or the EG group. The primary outcome measure, the percentage of workers using ergonomics tools, and secondary outcome measures - work ability, physical functioning and limitations due to physical problems - were assessed using surveys at baseline and after 6 months. Additionally, a cost-benefit analysis was performed on company level. No differences in primary and secondary outcomes were found with the exception of the use of ergonomics tools to adjust working height (F2F +1%; EG +10%; p = .001). Newly-implemented tools were used by 23% (F2F) and 42% (EG) of the workers (p = .271). Costs were mainly determined by guidance costs (F2F group) or purchase costs (EG group). Practitioner Summary: Participatory strategies aim to stimulate behavioural change of stakeholders to increase the use of ergonomics tools. Two guidance strategies - face-to-face or e-mail interventions - among construction companies were studied. Both guidance strategies led to an increase in the use of new ergonomics tools.

The process evaluation of two alternative participatory ergonomics intervention strategies for construction companies.

To gain insight into the process of applying two guidance strategies - face-to-face (F2F) or e-guidance strategy (EC) - of a Participatory Ergonomics (PE) intervention and whether differences between these guidance strategies occur, 12 construction companies were randomly assigned to a strategy. The process evaluation contained reach, dose delivered, dose received, precision, competence, satisfaction and behavioural change of individual workers. Data were assessed by logbooks, and questionnaires and interviews at baseline and/or after six months. Reach was low (1%). Dose delivered (F2F: 63%; EC: 44%), received (F2F: 42%; EC: 16%) were not sufficient. The precision and competence were sufficient for both strategies and satisfaction was strongly affected by dose received. For behavioural change, knowledge (F2F) and culture (EC) changed positively within companies. Neither strategy was delivered as intended. Compliance to the intervention was low, especially for EC. Starting with a face-to-face meeting might lead to higher compliance, especially in the EC group. Practitioner Summary: This study showed that compliance to a face-to-face and an e-guidance strategy is low. To improve the compliance, it is advised to start with a face-to-face meeting to see which parts of the intervention are needed and which guidance strategy can be used for these parts. TRIAL REGISTRATION: ISRCTN73075751.

Stand up: comparison of two electrical screed levelling machines to reduce the work demands for the knees and low back among floor layers.

Electrical screed levelling machines are developed to reduce kneeling and trunk flexion of sand-cement-bound screed floor layers. An observational intervention study among 10 floor layers was performed to assess the differences between a self-propelled and a manually moved machine. The outcome measures were work demands, production time, perceived load, discomfort and applicability. Compared to the self-propelled machine, the duration of kneeling (∆13 min; p = 0.003) and trunk flexion (∆12 min; p < 0.001) was shorter using the manually moved machine, and the duration of pushing and pulling increased (∆39 min; p < 0.001). No significant or relevant differences were found for production time, perceived load and discomfort. Nine out of ten floor layers found the manually moved machine applicable and three out of ten found the self-propelled machine applicable. When compared with the traditional manner of floor laying, both electrical machines reduced the exposure towards kneeling and trunk flexion. Practitioner Summary: Electrical machines may help to reduce high physical work demands on floor layers. A manually moved machine is better applicable for the installation of screed floors in residences with smaller floor areas. A self-propelled machine is better applicable on large floor areas with a minimum width of 4 m.

Microvascular perfusion as a target for fluid resuscitation in experimental circulatory shock.

OBJECTIVES: To study regional perfusion during experimental endotoxemic and obstructive shock and compare the effect of initial cardiac output-targeted fluid resuscitation with optimal cardiac output-targeted resuscitation on different peripheral tissues. DESIGN: Controlled experimental study. SETTING: University-affiliated research laboratory. SUBJECTS: Fourteen fasted anesthetized mechanically ventilated domestic pigs. INTERVENTIONS: Domestic pigs were randomly assigned to the endotoxemic (n = 7) or obstructive shock (n = 7) model. Central and regional perfusion parameters were obtained at baseline, during greater than or equal to 50% reduction of cardiac output (T1), after initial resuscitation to baseline (T2), and after optimization of cardiac output (T3). MEASUREMENTS AND MAIN RESULTS: Regional perfusion was assessed in the sublingual, intestinal, and muscle vascular beds at the different time points and included visualization of the microcirculation, measurement of tissue oxygenation, and indirect assessments of peripheral skin perfusion. Hypodynamic shock (T1) simultaneously decreased all regional perfusion variables in both models. In the obstructive model, these variables returned to baseline levels at T2 and remained in this range after T3, similar to cardiac output. In the endotoxemic model, however, the different regional perfusion variables were only normalized at T3 associated with the hyperdynamic state at this point. The magnitude of changes over time between the different vascular beds was similar in both models, but the endotoxemic model displayed greater heterogeneity between tissues. CONCLUSIONS: This study demonstrates that the relationship between the systemic and regional perfusion is dependent on the underlying cause of circulatory shock. Further research will have to demonstrate whether different microvascular perfusion variables can be used as additional resuscitation endpoints.

Guidance strategies for a participatory ergonomic intervention to increase the use of ergonomic measures of workers in construction companies: a study design of a randomised trial.

BACKGROUND: More than seven out of 10 Dutch construction workers describe their work as physically demanding. Ergonomic measures can be used to reduce these physically demanding work tasks. To increase the use of ergonomic measures, employers and workers have to get used to other working methods and to maintaining them. To facilitate this behavioural change, participatory ergonomics (PE) interventions could be useful. For this study a protocol of a PE intervention is adapted in such a way that the intervention can be performed by an ergonomics consultant through face-to-face contacts or email contacts. The objective of this study is to evaluate the effectiveness of the face-to-face guidance strategy and the e-guidance strategy on the primary outcome measure: use of ergonomic measures by individual construction workers, and on the secondary outcome measures: the work ability, physical functioning and limitations due to physical problems of individual workers. METHODS/DESIGN: The present study is a randomised intervention trial of six months in 12 companies to establish the effects of a PE intervention guided by four face-to-face contacts (N = 6) or guided by 13 email contacts (N = 6) on the primary and secondary outcome measures at baseline and after six months. Construction companies are randomly assigned to one of the guidance strategies with the help of a computer generated randomisation table. In addition, a process evaluation for both strategies will be performed to determine reach, dose delivered, dose received, precision, competence, satisfaction and behavioural change to find possible barriers and facilitators for both strategies. A cost-benefit analysis will be performed to establish the financial consequences of both strategies. The present study is in accordance with the CONSORT statement. DISCUSSION: The outcome of this study will help to 1) evaluate the effect of both guidance strategies, and 2) find barriers to and facilitators of both guidance strategies. When these strategies are effective, implementation within occupational health services can take place to guide construction companies (and others) with the implementation of ergonomic measures. TRIAL REGISTRATION: [corrected] Trailnumber: ISRCTN73075751, Date of registration: 30 July 2013.

Successful treatment of massive pulmonary embolism using a pulmonary artery catheter during prolonged normothermic cardiopulmonary resuscitation.

Massive pulmonary embolism has a high mortality rate. Standard treatment includes systemic thrombolysis. If this fails, surgical embolectomy or a percutaneous catheter-guided approach is advised in current guidelines. However, these treatment options might not be available in many non-tertiary care hospitals. We describe a case of a 25-year old woman with cardiac arrest from massive pulmonary embolism. She was treated with thrombus fragmentation using a pulmonary artery catheter and intra-pulmonary thrombolysis after failure of systemic thrombolysis along with 90 minutes of cardiopulmonary resuscitation (CPR). Neurological recovery was excellent and pulmonary pressure was normalized after one month. Besides catheter guided thrombus fragmentation and thrombolysis, we contribute the successful outcome to a combination of ultrasound-guided therapy, capnography-guided CPR, and "crew resource management" principles. Our case illustrates that a pulmonary artery catheter can be used successfully in a non-tertiary setting, to perform a percutaneous procedure during CPR and that full neurological recovery is possible after 90 minutes of CPR.

Evaluation of two working methods for screed floor layers on musculoskeletal complaints, work demands and workload.

Screed floors are bound by sand-cement (SF) or by anhydrite (AF). Sand-cement floors are levelled manually and anhydrite floors are self-levelling and therefore differences in work demands and prevalences of musculoskeletal complaints might occur. The objective was to assess among SF layers and AF layers (1) the prevalence of musculoskeletal complaints and (2) the physical work demands, energetic workload, perceived workload and discomfort. A questionnaire survey and an observational field study were performed. Compared with AF layers (n = 35), SF layers (n = 203) had higher, however, not statistically significant different, prevalences of neck (20% vs. 7%), shoulder (27% vs. 13%), low back (39% vs. 26%) and ankles/feet (9% vs. 0%) complaints. Sand-cement-bound screed floor layers (n = 18) bent and kneeled significantly longer (Δ77 min and Δ94 min; respectively), whereas AF layers (n = 18) stood significantly longer (Δ60 min). The work demands of SF layers exceeded exposure criteria for low back and knee complaints and therefore new working measures should be developed and implemented. PRACTITIONER SUMMARY: In comparison with anhydrite-bound screed floor layers, sand-cement-bound screed floor layers exceeded exposure criteria for work-related low back and knee complaints. New working methods and measures for sand-cement-bound screed floor layers should be developed and implemented to reduce the risk for work-related musculoskeletal complaints.

A Health-Impact Assessment of an Ergonomic Measure to Reduce the Risk of Work-Related Lower Back Pain, Lumbosacral Radicular Syndrome and Knee Osteoarthritis among Floor Layers in The Netherlands.

Sand-cement-bound screed floor layers are at risk of work-related lower back pain, lumbosacral radicular syndrome and knee osteoarthritis, given their working technique of levelling screed with their trunk bent while mainly supported by their hands and knees. To reduce the physical demands of bending of the trunk and kneeling, a manually movable screed-levelling machine was developed for floor layers in the Netherlands. The aim of this paper is to estimate the potential health gains of working with a manually movable screed-levelling machine on the risk of lower back pain (LBP), lumbosacral radicular syndrome (LRS) and knee osteoarthritis (KOA) compared to traditional working techniques. This potential health gain was assessed using the epidemiological population estimates of the Population Attributable Fraction (PAF) and the Potential Impact Fraction (PIF), combined with work-related risk estimates for these three disorders from systematic reviews. The percentage of workers exceeding these risk estimates was based on worksite observations among 28 floor layers. For LBP, 16/18 workers were at risk when using traditional working techniques, with a PAF = 38%, and for those using a manually movable screed-levelling machine, this was 6/10 with a PIF = 13%. For LRS, these data were 16/18 with a PAF = 55% and 14/18 with a PIF = 18%, and for KOA, 8/10 with a PAF = 35% and 2/10 with a PIF = 26%. A manually movable screed-levelling machine might have a significant impact on the prevention of LBP, LRS and KOA among floor layers in the Netherlands, and health-impact assessments are a feasible approach for assessing health gains in an efficient way.

Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial.

RATIONALE: It is unknown whether lactate monitoring aimed to decrease levels during initial treatment in critically ill patients improves outcome. OBJECTIVES: To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate levels in intensive care unit (ICU) patients admitted with a lactate level of greater than or equal to 3.0 mEq/L. METHODS: Patients were randomly allocated to two groups. In the lactate group, treatment was guided by lactate levels with the objective to decrease lactate by 20% or more per 2 hours for the initial 8 hours of ICU stay. In the control group, the treatment team had no knowledge of lactate levels (except for the admission value) during this period. The primary outcome measure was hospital mortality. MEASUREMENTS AND MAIN RESULTS: The lactate group received more fluids and vasodilators. However, there were no significant differences in lactate levels between the groups. In the intention-to-treat population (348 patients), hospital mortality in the control group was 43.5% (77/177) compared with 33.9% (58/171) in the lactate group (P = 0.067). When adjusted for predefined risk factors, hospital mortality was lower in the lactate group (hazard ratio, 0.61; 95% confidence interval, 0.43-0.87; P = 0.006). In the lactate group, Sequential Organ Failure Assessment scores were lower between 9 and 72 hours, inotropes could be stopped earlier, and patients could be weaned from mechanical ventilation and discharged from the ICU earlier. CONCLUSIONS: In patients with hyperlactatemia on ICU admission, lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors. As this was consistent with important secondary endpoints, this study suggests that initial lactate monitoring has clinical benefit. Clinical trial registered with www.clinicaltrials.gov (NCT00270673).

Accuracy of AccuChek glucose measurement in intensive care patients.

OBJECTIVE: To evaluate the accuracy of the AccuChek Inform point-of-care glucose measurement device as compared with central laboratory glucose measurement. DESIGN: Prospective, observational study. SETTING: A ten-bed mixed closed format intensive care unit ina 500-bed general hospital. The unit has a computerized insulin protocol aiming for 81 to 135 mg/dL. PATIENTS: All intensive care unit patients were eligible. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Paired samples (AccuChek glucose in whole blood calibrated to give whole blood results and central laboratory glucose in serum) were taken simultaneously. In 32 critically ill patients, we obtained the following information: mean +/- standard deviation age 71.6 +/- 11.9 yrs; mean Acute Physiology and Chronic Health Evaluation II score at admission 17.8 +/- 6.7; 239 paired samples were taken from arterial catheters. Mean AccuChek whole blood glucose was 126 +/- 36 mg/dL (7.0 +/- 2.0 mmol/L); mean central laboratory serum glucose was 137 +/- 38 mg/dL (7.6 +/- 2.1 mmol/L). Mean difference was 11 mg/dL (0.61 mmol/L) (8%) (95% Confidence Interval 9-13 mg/dL, p < .001). ISO 15197 guideline requires 95% of point-of-care measurements to be within 15 mg/dL margins with reference <75 mg/dL or within 20% if reference is higher. In total, 216 (90.4%) of AccuChek measurements were within ISO 15197 margins. Because AccuChek was calibrated to give whole blood results, we calculated a correction factor of 1.086 from the two mean values to correct whole blood AccuChek into serum-like results. This is almost the same as the correction factor of 1.080 given by Roche Diagnostics. By multiplying AccuChek whole blood results with 1.086, 225 (94.1%) of results were within the ISO 15197 margins. Hematocrit did not influence AccuChek results in the 0.20 to 0.44 range. Beyond this range, there were not enough data to draw conclusions. CONCLUSIONS: In critically ill patients, the accuracy of AccuChek glucose measurement calibrated to give serum-like results with blood samples derived from arterial catheters is acceptable but falls short by about 1% of complying with the ISO 15197 guideline.

Lumbar compression forces while lifting and carrying with two and four workers.

Team lifting and carrying is advised when loads exceed 25 kg and mechanical lifting is not feasible. The aim of this study was to assess mean, maximum and variability of peak lumbar compression forces which occur daily at construction sites. Therefore, 12 ironworkers performed 50-kg two-worker and 100-kg four-worker lifting and carrying tasks in a laboratory experiment. The 50-kg two-worker lifts resulted in significantly higher mean (Δ 537 N) and maximum (Δ 586 N) peak lumbar compression forces compared with the 100-kg four-worker lifts. The lowest mean and maximum peak lumbar compression forces were found while carrying on level ground and increased significantly when stepping over obstacles and up platforms. Lifting 100 kg with four workers in a rectangular line up resulted in lower compression forces compared with lifting 50 kg with two workers standing next to each other. When loads are carried manually routes should be free of any obstacles to be overcome.

Evaluation of team lifting on work demands, workload and workers' evaluation: an observational field study.

The objective of this study was to assess differences in work demands, energetic workload and workers' discomfort and physical effort in two regularly observable workdays in ironwork; one where loads up to 50kg were handled with two persons manually (T50) and one where loads up to 100kg were handled manually with four persons (T100). Differences between these typical workdays were assessed with an observational within-subject field study of 10 ironworkers. No significant differences were found for work demands, energetic workload or discomfort between T50 and T100 workdays. During team lifts, load mass exceeded 25kg per person in 57% (T50 workday) and 68% (T100 workday) of the lifts. Seven ironworkers rated team lifting with two persons as less physically demanding compared with lifting with four persons. When loads heavier than 25kg are lifted manually with a team, regulations of the maximum mass weight are frequently violated. STATEMENT OF RELEVANCE: Loads heavier than 25kg are frequently lifted during concrete reinforcement work and should be lifted by a team of persons. However, the field study showed that loads above 25kg are most of the time not lifted with the appropriate number of workers. Therefore, loads heavier than 25kg should be lifted mechanically.

The evaluation of team lifting on physical work demands and workload in ironworkers.

Lifting and carrying heavy loads occur frequently among ironworkers and result in high prevalence and incidence rates of low back complaints, injuries and work-disability. From a health perspective, little information is available on the effect of team lifting on work demands and workload. Therefore, the objective of this study was to compare the effects of team lifting of maximally 50 kg by two ironworkers (T50) with team lifting of maximally 100 kg by four ironworkers (T100). This study combined a field and laboratory study with the following outcome measures: duration and frequency of tasks and activities, energetic workload, perceived discomfort and maximal compression forces (Fc peak) on the low back. The physical work demands and workload of an individual iron worker during manual handling of rebar materials of 100 kg with four workers did not differ from the manual handling of rebar materials of 50 kg with two workers, with the exception of low back discomfort and Fc peak. The biomechanical workload of the low back exceeded for both T50 and T100 the NIOSH threshold limit of 3400N. Therefore, mechanical transport or other effective design solutions should be considered to reduce the biomechanical workload of the low back and the accompanying health risks among iron workers.

Does team lifting increase the variability in peak lumbar compression in ironworkers?

Ironworkers frequently perform heavy lifting tasks in teams of two or four workers. Team lifting could potentially lead to a higher variation in peak lumbar compression forces than lifts performed by one worker, resulting in higher maximal peak lumbar compression forces. This study compared single-worker lifts (25-kg, iron bar) to two-worker lifts (50-kg, two iron bars) and to four-worker lifts (100-kg, iron lattice). Inverse dynamics was used to calculate peak lumbar compression forces. To assess the variability in peak lumbar loading, all three lifting tasks were performed six times. Results showed that the variability in peak lumbar loading was somewhat higher in the team lifts compared to the single-worker lifts. However, despite this increased variability, team lifts did not result in larger maximum peak lumbar compression forces. Therefore, it was concluded that, from a biomechanical point of view, team lifting does not result in an additional risk for low back complaints in ironworkers.

[Rapid response system in derangement of vital signs: five years experience in a large general hospital]. / Spoedinterventiesysteem bij vitale bedreiging: 5 jaar ervaring in een groot algemeen ziekenhuis.

OBJECTIVE: Hospitalized patients are at risk for adverse events such as unexpected cardiac arrest or admission to an Intensive Care Unit (ICU). Prior to these adverse events these patients often have derangements in vital signs that are not recognized and treated adequately. To identify and treat those patients at risk, our hospital implemented a rapid response system in 2004. The purpose of this paper is to describe implementation and results of our rapid response system. DESIGN: Prospective cohort study. METHOD: The implementation of the rapid response system started by training all doctors and nurses to score vital signs using a dedicated score card. If a patient scores 3 or more points, the patients' treating physician has to see the patient and - if necessary - call the medical emergency team (MET), consisting of an ICU physician and an ICU nurse. We analyzed all consecutive MET calls in the period January 2005-December 2009. RESULTS: A total of 1058 MET calls for 981 patients were analyzed. In 606 patients (57.3%) it was decided to transfer the patient to a higher dependency unit, in most cases the ICU. In 353 patients (33.4%) treatment could be continued on the ward. In 88 patients (8.4%) it was decided that ICU treatment would not be beneficial and limits on treatment were put in place. Of the 981 patients, 255 (26.0%) died in hospital. CONCLUSION: In our hospital the rapid response system has developed into an important tool for the early identification and treatment of patients at risk. However, our data cannot prove the efficacy of the rapid response system in terms of reducing hospital mortality.