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ORIGINAL ARTICLE

Physical and psychosocial ergonomic risk factors for

low back pain in automobile manufacturing workers
Jonathan L Vandergrift,1 Judith E Gold,1 Alexandra Hanlon,1,2 Laura Punnett3
1
Department of Public Health, ABSTRACT
Temple University, Philadelphia, Objectives To examine the association between What this paper adds
Pennsylvania, USA ergonomic physical and psychosocial exposures and the
2
Department of Family and
Community Medicine, School of risk of prevalent and incident low back pain (LBP) in a < Physical and (less consistently) psychosocial
Nursing, University of longitudinal cohort of automobile manufacturing workers. risk factors have been associated with low back
Pennsylvania, Philadelphia, Methods Ergonomic exposure intensity and LBP pain (LBP); the interaction between these two
Pennsylvania, USA presence were determined through questionnaires at
3
Department of Work categories of exposures has not been resolved
Environment, University of baseline (n¼1181) and to workers in the same job 1 epidemiologically.
Massachusetts Lowell, Lowell, year later (n¼505). Models were constructed using log- < These data support previous findings that self-
Massachusetts, USA binomial regression with special attention to interactions reported occupational physical exposures
between ergonomic exposures. including awkward back postures, hand force,
Correspondence to Results Awkward back posture (prevalence ratio (PR)
Jonathan L Vandergrift, National physical effort and whole body vibration are
Comprehensive Cancer 1.12, 95% CI 1.07 to 1.17), hand force (PR 1.06, 95% CI associated with LBP.
Network, 275 Commerce Drive, 1.02 to 1.10), physical effort (PR 1.10, 95% CI 1.04 to < Psychosocial job strain (high demands, low
Suite 300, Fort Washington, 1.16) and whole body vibration (PR 1.04, 95% CI 1.01 to control) was associated with new LBP only in
PA 19034, USA; 1.08) were each associated cross-sectionally with LBP.
[email protected] those with high baseline physical exposures.
Awkward back posture (RR 1.13, 95% CI 0.98 to 1.31)
Accepted 14 April 2011 and hand force (RR 1.07, 95% CI 0.93 to 1.22) also
Published Online First predicted incident LBP, although estimates were
17 May 2011 statistically less precise. Neither job control, psychological
local low-back muscle fatigue resulting from job-
demands, nor job strain was independently related to
related physical effort9 may increase the risk of LBP
risk of incident LBP. Among participants reporting high
associated with lifting.11 Lastly, evidence from
physical ergonomic exposures and moderate to high job
epidemiological studies of LBP suggests an interac-
control, increasing job demands was associated with
tion between awkward posture and WBV.7
a reduced LBP risk (RR 0.72, 95% CI 0.52 to 1.00). Among
Exposure to job-related psychosocial stress has
participants reporting high physical exposures and low job
also been implicated in the aetiology of work-
control, psychological demands was associated with an
related LBP. Job strain is defined in the job
increased LBP risk (RR 1.30, 95% CI 1.02 to 1.66).
demandecontrol model as a combination of high
Conclusions Psychosocial workplace interventions for
psychological job demands and low decision-
LBP should prioritise jobs in which there are high physical
making authority at work (‘job control’).12 Job
ergonomic exposures. Future studies of LBP should
strain has been associated with LBP in two
examine the interactions between physical ergonomic
prospective13 14 and two cross-sectional studies.15 16
risk factors.
LBP has also been separately associated with both
job demands and job control.3 17
Physical and psychosocial ergonomic risk factors
INTRODUCTION are often correlated with one another in the
Low back pain (LBP) is one of the most common workplace,18 suggesting a more complex aetiology
ailments in the USA and at any one time affects than is characterised by treating them as covariates
12e30% of the population.1 Many of the factors in separate statistical models. In addition, evidence
that are important in LBP aetiology are associated from both experimental19 and epidemiological
with the workplace and as much as 30% of all LBP studies20 21 suggests that psychosocial and physical
can be attributed to occupational exposures.2 The exposures may interact synergistically to cause
occupational physical ergonomic exposures associ- musculoskeletal disorders.
ated with LBP risk include awkward back In the current study, we examined the association
postures,3e5 physical effort, including manual between occupational physical and psychosocial
exertion related to handling objects or people,5 6 ergonomic risk factors and LBP in a 1-year longitu-
and exposure to whole body vibration (WBV).5 7 dinal cohort of automobile manufacturing workers.
In addition to the separate effects of each of The primary aims of the study were to examine: (1)
these physical ergonomic risk factors, experimental the separate associations between physical and
evidence and biomechanical theory suggest that psychosocial ergonomic risk factors and LBP risk;
they may interact, for example, producing a higher (2) selected interactions between physical ergo-
risk of LBP when hand forces8 or physical effort9 10 nomic risk factors for risk of LBP; and (3) the
are exerted in combination with awkward back interaction between physical and psychosocial
posture. Biomechanical theory also predicts that ergonomic risk factors in their association with LBP.

Occup Environ Med 2012;69:29e34. doi:10.1136/oem.2010.061770 29

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METHODS participant’s exposure to job demands and job control. Job strain
Study cohort was defined as a dichotomous variable where job demands
The study was conducted among a cohort of automobile scores were $30.67 and job control scores were #65.92, based on
manufacturing workers (n¼1550) from an automotive stamping mean values for the US male working population.12
plant and an engine assembly plant located in Detroit, LBP was assessed by a question on the presence of any
Michigan.22 Overall, 85% (n¼1315) of workers in the targeted musculoskeletal symptoms experienced more than three times
departments were enrolled in the study. Individuals were or lasting more than 1 week during the previous 12 months.24
excluded from the study for poor baseline data quality or Participants were asked to locate the source of their symptoms
cooperation, inability to participate in a physical examination of using a body map. Those individuals who located the source
the musculoskeletal system due to injury (such as an amputa- of pain in the lower back were designated as having reported
tion) or if they were employed in non-production work duties LBP.
(eg, union officers) (n¼34). Participants were excluded from
these analyses if they reported mechanical back problems Analytical methods
(spondylitis, spondylolisthesis or ankylosing spondylitis), The analysis of LBP was conducted in two stages. First, the
a ruptured disc in the neck or back, or a history of back surgery cross-sectional association between physical exposures and
(n¼100). Only participants who were LBP-free at baseline prevalent LBP at T0 was examined in all subjects. Second, the
(figure 1) and remained in the same job during the study period risk of 1-year ‘incident’ LBP (present at T1 among those pain-
were eligible for inclusion in the analysis of incident LBP free at T0) among participants who remained in the same job
approximately 1 year later. during the study period, was examined in relation to physical
risk factors measured at baseline and psychosocial factors
Assessment of exposures and outcome measured at T1.
Ergonomic exposures, demographics and LBP status were Demographic and occupational factors examined included age,
assessed during structured interviews conducted during work seniority in the company, body mass index (BMI), height,
time. The five physical exposures used in the current analysis weight and gender. Differences between means were assessed
included exposure to awkward back postures, WBV, physical with the Student t test or Satterthwaite’s approximate t test (ts)
effort, hand forces related to handling tools or materials, and if there were significantly different variances between groups.
work pace. The Borg CR-10 scale23 was used to grade the c2 Tests were used to assess differences between proportions. All
intensity of the physical exposures on a 0e10-point scale. analyses were conducted using SAS v. 9.1 (SAS Institute). A
A composite physical exposure metric was computed by p value of #0.05 denoted statistical significance.
summing the five individual psychophysical (Borg CR-10) Univariate and multivariable log-binomial regression models25
exposure scores. Participants were divided into low and high were used to compute prevalence ratios (PR) in the cross-
physical exposure categories based on the median of the sectional analysis of prevalent LBP and RRs in the longitudinal
composite physical score. These physical exposure measures analysis of incident LBP. Physical and psychosocial ergonomic
were obtained at baseline (T0) and at follow-up (T1). risk factors were entered as interval data into the models
The psychosocial work environment was assessed using the predicting LBP.
Job Content Questionnaire (JCQ)12 only in the follow-up Confounding was defined as a change of 20% or more in the
interview. The standard JCQ algorithm was used to score each computed risk estimate. No confounding effects were observed
among the covariates examined.
A number of exposures were hypothesised to interact with
Study population N(%) 1550 one another in their association with LBP. To examine these
conditional relationships, the association between LBP and one
Sample population 1315 (85%) exposure was stratified on the second exposure. Participant
Ineligible at baseline (T0) exposure scores were divided into tertiles (low, medium and
134 (10%) high) based on the distribution of the data in the sample, to give
Eligible at T0 1181 (90%)
roughly one-third of the study population in each stratum. Risk
Reporting LBP at T0 estimates were computed within each strata of the suspected
232 (20%) effect modifier. A noteworthy interaction was defined as
a >100% change in the calculated risk estimates among strata.
LBP free at T0 949 (80%)
Attrition at follow-up (T1) In the analysis of the interaction between physical exposure
351 (37%) and psychosocial job characteristics, there were relatively few
incidents of reported LBP among participants with a high
Assessed at T1 598 (63%)
Changed job T0 to T1 physical workload and medium or high job control. Therefore,
93 (16%) the medium and high job control strata were combined to
505 (84%) ensure convergence of the log-binomial model.

Reporting LBP No Yes RESULTS

at T1 480 (95%) 25 (5%) Baseline cohort characteristics
In total, 1181 participants were included in the cross-sectional
Figure 1 Sample population enrolment, retention and reported low baseline analysis of prevalent LBP (figure 1). This population was
back pain (LBP) at baseline (T0) and at follow-up (T1). The solid box mostly male and on average overweight (mean BMI 27 kg/m2,
reflects the population included in the baseline prevalent LBP analysis. SD 4.84), with a mean age of 46 years (SD 8.21) and a mean of
The dashed box highlights the populations included in the analysis of 20 years (SD 6.60) of seniority at the automobile manufacturing
incident LBP. company (table 1). The overall age range of the cohort was

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Table 1 Demographic characteristics of the autoworker cohort, overall Awkward back posture (PR 1.12, 95% CI 1.07 to 1.17),
and stratified by LBP status at baseline, and mean baseline physical physical effort (PR 1.10, 95% CI 1.04 to 1.16), WBV (PR 1.04,
exposure ratings and follow-up psychosocial exposures among eligible 95% CI 1.01 to 1.08) and hand force (PR 1.06, 95% CI 1.02 to
participants 1.10) were each significantly associated with LBP at baseline
LBP at T0 (figure 2). No effect was observed for job pace on prevalent
Total Yes No LBP (PR 1.02, 95% CI 0.97 to 1.08). There was no effect modi-
Total, n 1181 232 (20%) 949 (80%) fication between awkward back posture and either physical
Demographics, mean (SD) effort or hand force. Exposure to WBV did not appear to affect
Age 46.3 (8.21) 45.6 (7.82) 45.7 (8.31) the association between awkward back posture and prevalent
Seniority at company 21.4 (6.60) 20.8 (6.95) 21.5 (4.88)* LBP.
BMI (kg/m2) 27.5 (4.84) 27.2 (4.65) 26.9 (4.82)
Height (in) 68.7 (3.62) 68.7 (3.67) 68.1 (3.40) Follow-up cohort and new LBP
Weight (lb) 184 (35.7) 182 (35.9) 179 (34.9) Of the participants without LBP at baseline (n¼949), 598 (63%)
Gender, n (%) were assessed at T1 and 84% of these (505) reported being in the
Male 964 (82%) 185 (80%) 779 (82%) same job (figure 1). A total of 25 cases of incident LBP (5%) were
Female 217 (18%) 47 (20%) 170 (18%) identified among these 505 participants. No significant demo-
Physical exposure, mean (SD), T0 score graphic differences were observed between participants with
Awkward back posture 5.35 (3.06) 6.36 (2.80) 5.11 (3.07) and without incident LBP at follow-up.
Hand force 5.56 (3.21) 6.16 (2.91) 5.41 (3.27) Participants lost to follow-up had slightly higher BMI at
Physical effort 6.80 (2.53) 7.38 (2.44) 6.66 (2.54) baseline (mean 28.0 kg/m2, SD 5.41) than those assessed at
Whole body vibration 2.66 (3.23) 3.12 (3.32) 2.55 (3.20)
follow-up (mean 27.2 kg/m2, SD 7.2) (ts (621)¼2.20, p<0.05).
Job pace 7.12 (2.31) 7.23 (2.33) 7.09 (2.31)
There were no significant differences between the two groups in
Aggregate exposure score 27.6 (9.31) 30.4 (8.89) 26.9 (9.29)
age, seniority or gender. Among the physical exposures measured
Psychosocial exposure, mean (SD), T1 score
at baseline, only the hand force rating differed between those
Job demands 28.3 (3.74)
assessed at T1 (mean 5.63, SD 3.17) and those lost to follow-up
Job control 61.2 (9.43)
(mean 5.02, SD 3.40) (p¼0.01).
*p<0.05, X2 test comparing proportions ; t-test comparing means for demographic factors
only.
For incident LBP, awkward back posture and hand force at
BMI, body mass index; LBP, low back pain; T0, baseline; T1, follow-up. baseline had similar coefficients for risk per unit exposure rating
to those obtained in the cross-sectional data, although with
wider confidence intervals (figure 2). Exposure to physical effort,
20e73 years with the middle 50% of the population between 41 WBV and job pace were unrelated to risk of incident LBP.
and 52 years of age (inter-quartile range of 11 years). The highest The risk due to awkward back posture did not change by
reported exposure rating was for job pace (mean 7.12; table 1), level of exposure to physical effort or hand force. Similarly,
followed by physical effort (mean 6.80). The lowest perceived there was no interaction between physical effort and hand
exposure intensity was reported for WBV (mean 2.66). force. However, the risk of incident LBP associated with
awkward back postures did increase when combined with high
Prevalent LBP exposure to WBV. At low (Borg CR-10 score 0, RR 1.10, 95% CI
At baseline, 20% of participants (n¼232) reported having had 0.94 to 1.32) and medium (Borg CR-10 score 0.5e4, RR 1.11,
LBP in the previous 12 months (figure 1). Participants reporting 95% CI 0.81 to 1.53) levels of WBV, risk estimates associated
LBP at baseline had 8e9 months higher seniority (ts (489)¼2.22, with awkward back postures were similar to those associated
p<0.05) than participants free of LBP (table 1). No other with awkward back posture overall. At higher exposures to
demographic variables examined were associated with prevalent WBV (Borg CR-10 score 5e10), the effect of awkward back
LBP and none of these confounded the effects of the occupational postures was larger although not statistically significant (RR
exposures examined. 1.66, 95% CI 0.91 to 3.03).

Figure 2 Coefficients for physical

estimates of ergonomic exposures and
prevalent (black diamond) and incident
(white circle) low back pain (LBP), from
univariate log-binomial regression models.
Error bars represent the 95% CI of the risk
estimate from the same regression
models. Prevalence ratios (PRs) are
presented for the entire population eligible
at baseline (T0; n¼1181). Relative risks
(RRs) are presented for participants who
did not report LBP at baseline and
remained in the same job throughout the
1-year follow-up period (n¼505). RR and
prevalence ratios represent the increased
risk or prevalence of reported LBP per unit
increase across the Borg CR-10
psychophysical exertion scale. WBV,
whole body vibration. *p<0.05;
**p<0.01; ***p<0.001.

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Table 2 Relative risks of incident LBP for increasing psychological job One in five participants enrolled at baseline reported LBP in
demands among participants remaining in the same job during the study the prior year. This is similar to the 23% prevalence rate
period, stratified by job control tertiles (n¼485*) observed in a previous study of autoworkers15 and is within the
Job demands and incident 12e30% annual point prevalence of LBP in the US adult popu-
Job control tertile (score range) n LBP: RR (95% CI) lation.1 Among participants who did not report prevalent LBP at
1. Low (24e57) 183 1.03 (0.90 to 1.20) baseline, approximately 5% reported an episode of incident LBP
2. Medium (58e65) 155 0.97 (0.76 to 1.24) during the 1-year follow-up period. This is greater than the
3. High (66e96) 147 0.99 (0.81 to 1.20) 1-year incidence rate of 2% observed in a cohort of Iranian
Risk estimates reflect increasing risk of LBP associated with a per unit increase in reported autoworkers.15
psychological job demands. The date of the first occurrence of LBP was not ascertained in
*Excludes 20 workers who did not complete the Job Content Questionnaire items.
LBP, low back pain.
this cohort. Hence, workers without back symptoms at baseline
may have experienced prior LBP that had resolved. Therefore, it
is possible that LBP ‘incident’ cases (defined as those without
Psychosocial risk factors and new LBP back symptoms at baseline, and with back symptoms at follow-
There was no association between incident LBP and psycho- up) may include both re-occurring and new LBP cases. Because
logical job demands (RR 1.01, 95% CI 0.90 to 1.12) or job control of this limitation, the observed rate of incident LBP may
(RR 0.98, 95% CI 0.95 to 1.03) assessed at T1 for the cohort as overestimate the true rate in the study population.
a whole. In addition, being in a high strain job at T1 was
unrelated to incident LBP (RR 0.96, 95% CI 0.34 to 2.76). The Strengths and limitations of the study
risk of incident LBP due to high psychological job demands did One of the primary strengths of the current study is the large
not change by job control tertile (table 2). cohort of workers (n¼1181) enrolled, representing 85% of the
In contrast, there was an interaction between demands and autoworkers in the targeted departments at baseline. Despite the
control after further stratification on physical workload. Among high enrolment rate, about 40% of participants were lost to
participants with both high physical exposures and low job follow-up. However, many participants probably simply aged
control, job demands was associated with a significantly out of the workforce. The population lost at T1 was similar to
increased risk of incident LBP (RR 1.30, 95% CI 1.02 to 1.66) the population assessed at follow-up in terms of demographics,
(table 3). Among those with high physical exposure and medium physical exposures and baseline reports of LBP. This suggests
to high job control, increasing job demand was protective that attrition did not likely result in selection bias.
against risk of incident LBP (RR 0.72, 95% CI 0.52 to 1.00). Another advantage of the current study is that it included
When physical exposure was low, job demand was unrelated to both a cross-sectional and longitudinal component. The longi-
LBP, regardless of level of job control. tudinal analysis ensured that the physical exposures being
A moderate correlation was observed between physical examined occurred prior to the outcome of new LBP, providing
workload and psychological job demands (r¼0.33, p<0.001). support for a causal association. In addition, validated measures
This correlation was consistent across job control tertiles (low were used for grading participant’s perceived physical (Borg
job control: r¼0.33, p<0.001; medium job control: r¼0.38, CR-10)23 and psychosocial exposures (JCQ).12
p<0.001; high job control: r¼0.33, p<0.001). No correlation was Despite the large cohort of participants enrolled at baseline,
observed between job control and physical exposures (r¼0.03, the analysis of incident LBP is limited by statistical power,
p¼0.55). specifically the small number of new cases. In part, this may be
a function of the maturity and seniority of the cohort, repre-
DISCUSSION senting a ‘survivor’ group. The current cohort of automobile
Awkward back posture and hand force were associated with an manufacturing workers was on average employed in the
increased risk of both prevalent and 1-year incident LBP in company for over 20 years. If musculoskeletal pain leads to
a cohort of automobile manufacturing workers. Neither earlier departure from the workplace, it is possible that those
psychological job demands nor job control alone was associated workers still employed after 20 years, and subsequently enrolled
with incident LBP for the cohort as a whole. Among participants in the current study, would have a lower risk of work-related
with high physical exposure at baseline and low job control, job pain associated with ergonomic exposures than an employee
demand was associated with an increased risk of incident LBP who had recently started working (the ‘healthy worker
during the 1-year follow-up period. effect’).26 For example, Miranda et al27 observed a stronger
relationship between exposure to physical ergonomic risk factors
and incident LBP among younger than older workers. If the
Table 3 Relative risks of incident LBP for increasing psychological job population included in our study was less susceptible to devel-
demands among participants remaining in the same job during the study oping work-related LBP, the effects observed could underesti-
period, stratified by both job control (tertiles) and physical exposure mate the true risk that a new employee would face from similar
(split at the median) (n¼485y) exposures.
Physical Job control Job demands and incident One limitation in the analysis of psychosocial factors is that
exposure (score) tertile (score) n LBP: RR (95% CI)
these variables were only assessed at follow-up. Although
Low (0e27) Medium to high (58e96) 172 1.13 (0.92 to 1.40) subjects analysed at follow-up were in the same jobs as at
Low (0e27) Low (24e57) 102 0.98 (0.83 to 1.18) baseline, the study is unable to address definitively the direc-
High (28e50) Medium to high (58e96) 130 0.72 (0.52 to 1.00)* tionality of the association between LBP and psychological job
High (28e50) Low (24e57) 81 1.30 (1.02 to 1.66)* demands or job control. It has been suggested that the devel-
Risk estimates reflect increasing risk of LBP associated with a per unit increase in reported opment of LBP may lead individuals to perceive a poorer
psychological job demands. psychosocial work environment,28 and it cannot be conclusively
*p<0.05.
yExcludes 20 workers who did not complete the JCQ survey item. determined that LBP did not affect the participant’s reporting of
LBP, low back pain. their psychosocial work environment.

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Physical exposures were assessed through self-report, which exposed to physical ergonomic factors. No effect modification
introduces the potential for information bias. An analysis of self- was observed between job control and demands in the incident
reported versus direct measures of exposure in this cohort found LBP analysis for the cohort as a whole. However, there was
no evidence of a differential bias that might lead to a spurious a three-way interaction among physical exposures, psychological
association with musculoskeletal symptoms.29 This analysis demands and job control. The association between job demands
examined upper extremity exposures, and, as such, examined all of and incident LBP was only observed among participants with
the physical exposures analysed in the current study with the low job control who were also highly exposed to physical
exception of self-reported awkward back postures. Hence, there is stressors. Surprisingly, the risk of LBP decreased with increasing
still potential for a bias in this self-reported exposure. But the job demands in participants with medium to high job control
nature of this bias (whether differential or non-differential) is and high physical exposures. It was anticipated that risk of LBP
unknown, as the published literature is inconclusive with regard to would not be associated with job demands in these participants.
how those with back pain estimate their physical exposures.30e32 Potentially, this may represent a protective effect of the
Lastly, only automobile manufacturing workers were included psychosocial work environment for musculoskeletal disorders
in the study suggesting there may be limited variability in ergo- associated with increased active learning (eg, high demand, high
nomic exposures. However, the two plants included in the study control jobs). Active jobs have been associated with other
had different degrees of automation and were selected to enrol protective health effects.38 Further research is needed to confirm
a cohort of autoworkers with variability in physical ergonomic a protective effect of active learning on LBP.
exposures. Nonetheless, at baseline, almost all participants were A moderate correlation between psychological demands and
working in highly routinised jobs, such as on machine paced physical exposures was observed suggesting that the findings in
assembly lines, with the majority focused on a single cyclical table 3 are due to psychological demands over and above phys-
task.33 Therefore, there may be limited variation in psychosocial ical demands. In addition, this correlation was consistent across
ergonomic exposures, particularly with regards to job control. job control tertiles. The observed interaction between job
demands, job control and physical exposures suggests a more
Physical exposures complex relationship between psychosocial and physical
Awkward back posture, hand force, physical effort and WBV ergonomic exposure than one of simple confounding.
were associated with an increased prevalence of LBP at baseline. The association between the physical and psychosocial risk
In the analysis of incident LBP, only exposure to awkward back factors in the aetiology of LBP has been explored in previous
postures and hand force predicted an LBP episode, although with studies.20 21 39 40 Waters et al21 identified an interaction between
low precision. work stress and heavy lifting. Huang et al20 found effect modi-
Awkward back postures have been previously associated with fication between biomechanical exposures and low ‘participatory
LBP in a number of prospective,3 4 27 caseecontrol5 24 and cross- management’, which may be analogous to greater job control.
sectional studies.34 35 The LBP risk estimates associated with Devereux et al40 examined the interaction between psychosocial
awkward back postures observed in the current study are smaller and physical exposures and LBP in a cross-sectional survey using
than the majority of the risk estimates previously reported. additive risk models. A large proportion of risk (65%) was
However, a direct comparison of effect sizes is problematic due attributed to interaction effects for recent LBP in mixed-sex
to differences in exposure assessment. Similarly, the risk of LBP models using proportional prevalence ratios. However, there
associated with hand force observed in the current study is were no female participants in the high physical exposure group;
smaller than the associations observed in previous studies.6 when the model calculating proportional prevalence ratios was
WBV was associated with a small, but statistically significant, examined in only male participants, a minimal deviation from
increased prevalence of LBP at baseline. A number of epidemio- additivity was observed (12%). The impact of job control
logical studies have examined the association between WBV and modifying the risk of LBP (or any other musculoskeletal disorder)
LBP.5 7 27 36 Much of the epidemiological literature examining the due to psychological demands in the presence of high, but not
effect of WBV on LBP has been conducted in drivers or in heavy low, physical exposures has not been previously reported.
machine operators exposed through the seat of a vehicle. In the The exact mechanism by which psychosocial stress may lead
current study, exposure occurred as a steady state vibration to an increased risk of musculoskeletal disorders is not well
through the feet and legs when workers were in contact with the understood. One hypothesis is that job strain leads to increased
vibrating floor in the stamping plant. Biomechanically, the muscle tension that magnifies the impact of physical stressors
stiffness of the coupling (in the current study, whether or not on the lower back.5 Alternatively, observed increased spinal
the supporting legs are flexed) may have had a substantial effect loading when a lifting task was combined with simultaneous
on the transmission of vibration to the spinal column.37 Since mental processing was attributed to an over-reaction of the
this factor was not accounted for, there may have been some musculoskeletal system characterised by less controlled
further misclassification of exposure leading to dilution of effect. movements and increases in muscle co-activation.19
There was limited evidence of an increased risk of incident
LBP in participants exposed to both WBV and awkward back CONCLUSION
postures, compared to those exposed only to awkward back Exposure to awkward back postures and hand force exertion in
postures. An interaction between WBV and awkward postures in automotive manufacturing increased the risk of LBP at both
bus drivers was previously reported by Okunribido et al.7 The baseline and 1-year follow-up. Job demands were associated
physiological mechanism for this interaction is unknown, with the development of incident LBP, although only in workers
although laboratory studies suggest possible mechanisms with low job control and high reported baseline exposure to
including increased muscle fatigue and disc compression.37 physical risk factors. Results suggestive of an interaction
between awkward postures and WBV were also observed.
Psychosocial exposures The observed relationship between psychosocial and physical
Incident LBP was higher in a high demandelow control exposures may help explain some of the inconsistency observed
psychosocial work environment for workers also heavily between studies examining the impact of the psychosocial work

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environment on the risk of LBP. The current results suggest that 9. Dolan P, Adams MA. Repetitive lifting tasks fatigue the back muscles and increase
if the association between the psychosocial work environment the bending moment acting on the lumbar spine. J Biomech 1998;31:713e21.
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Acknowledgements The authors thank Dr Deborah Nelson for her guidance during 25. Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and
the development of this paper. We also thank the many individuals at the United differences. Am J Epidemiol 2005;162:199e200.
Automobile Workers and the manufacturing company who assisted with data 26. Pearce N, Checkoway H, Kriebel D. Bias in occupational epidemiology studies.
collection. Participation of the individual workers is gratefully acknowledged. Occup Environ Med 2007;64:562e8.
27. Miranda H, Viikari-Juntura E, Punnett L, et al. Occupational loading, health behavior
Funding This research was supported by the National Joint Committee on Health and and sleep disturbance as predictors of low-back pain. Scand J Work Environ Health
Safety jointly sponsored by the manufacturing company involved and the United 2008;34:411e19.
Automobile Workers. This manuscript is solely the responsibility of the authors and 28. Frank JW, Pulcins IR, Kerr MS, et al. Occupational back pain-an unhelpful polemic.
does not necessarily represent the official views of any other agency or institution. Scand J Work Environ Health 1995;21:3e21.
Competing interests None. 29. Buchholz B, Park JS, Gold JE, et al. Subjective ratings of upper extremity exposures: inter-
method agreement with direct measurement of exposures. Ergonomics 2008;51:1064e77.
Contributors All authors contributed to the conception and design, acquisition of data 30. Wiktorin C, Vingard E, Mortimer M, et al. Interview versus questionnaire for
or analysis and interpretation of data, and to the drafting or critical revision of the assessing physical loads in the population-based MUSIC-Norrtalje Study. Am J Ind
article for important intellectual content. All authors gave final approval for the version Med 1999;35:441e55.
published. 31. Wiktorin C, Karlqvist L, Winkel J. Validity of self-reported exposures to work
postures and manual materials handling. Stockholm MUSIC I Study Group. Scand
Provenance and peer review Not commissioned; externally peer reviewed. J Work Environ Health 1993;19:208e14.
32. Viikari-Juntura E, Rauas S, Martikainen R, et al. Validity of self-reported physical
work load in epidemiologic studies on musculoskeletal disorders. Scand J Work
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34 Occup Environ Med 2012;69:29e34. doi:10.1136/oem.2010.061770

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Physical and psychosocial ergonomic risk

factors for low back pain in automobile
manufacturing workers
Jonathan L Vandergrift, Judith E Gold, Alexandra Hanlon and Laura
Punnett

Occup Environ Med 2012 69: 29-34 originally published online May 17,
2011
doi: 10.1136/oem.2010.061770

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