Effectiveness of preventive and curative ergonomic interventions in work environment in support maritime services

Summary

Introduction:
Many commercial companies are promoting health at the workplace via various means, namely with seminars, workshops and other forms of education. Rarely does any company actually include the active implementation of ergonomics into their occupational setting. All of the activities within the proposed program had the intention to keep workers healthy, and above all reduce absenteeism. Other aims were to keep workers active in any environment, and, especially to prevent further discomfort and functional movement disorders.

Methods:
Three ergonomical studies running from 2010 until 2014 provided instructions and assessed the implementation and improvement of the ergonomical status. A variety of active and passive interventions were used to prevent further musculoskeletal disorders.

Results:
Among the employees, the proportion of discomfort and pain were very high in the locomotor system and increased during and after the work. The later surveys showed a decrease in the number of sick leaves over the period of the three studies. Other key findings include the importance of ensuring that employees are more active during breaks, take account of advice on the correct lifting, perform back and neck exercises, become more health conscious and thus have less problems in the locomotor system.

Conclusions:
The results of the 2012 and 2013 surveys show good step-by-step retrospective of the ergonomic intervention into the work environment. However, to improve and maintain health in the work place it is necessary to implement projects and promote ergonomic interventions, where employees have to actively participate. Thus ergonomics should be preventive, curative or both.

KEYWORDS:
ergonomics – occupational health – working environment – health promotion – physiotherapy

THEORETHICAL BACKGROUND

To some extent the human body is able to adapt to different working conditions and environments. While in fact, it is designed for movement. In today’s society body movement is often replaced by machinery, and as a result today’s movement has become stereotypical, full of repetitive, hypokinetical and non-ergonomical movements. The body adapts slower than the changing environment, the living culture, and its working environments. As a result many people have failures/lesions/injuries of their locomotor system. This is not considered of great importance in the industrial world. However, a diverse range of industries where the influence of the environment is ahead of the development and adaptation of the body, share a very similar problem in so far as the body parts with the highest levels of problems in locomotor system are concerned [1]. It is generally accepted that musculoskeletal disorders are multifactorial, as both individual and environmental agents have impact to the risk of musculoskeletal disorders [2]. The revision of the Slovenian Law on Safety and Health at Work in 2011 (ZVZD-1, Ur. l. RS, No. 43/2011) [3], sets out the rights and duties of employers and employees in relation to health and safety at work, and outlines appropriate measures to ensure health and safety at work. According to the Law more time should be given to educational initiatives focused on health and safety at work, including ergonomics, since in practice the people do not acquire enough knowledge during formal education to be able to avoid malfunctions of the locomotor system. The same law decrees that employers have a duty to plan and implement health promotion in the workplace.

Knowledge and foremost consideration of ergonomics and ergonomic principles has the potential to have a major impact on the development of problems in the locomotor system. It would be completely pointless to talk about ergonomics and healthy lifestyles, without considering the specific work conditions and the general health of the employee [1]. All individual employees should learn the proper movements, proper work and ­health protection in different industries, in order to take responsibility for their own health at home and in the workplace. Consequently, movement and activity of individuals could be correct during most of their daytime, anywhere, anytime, and can prevent discomfort and subsequent functional movement disorders during their life.

Kogi [4] argued that ergonomics improvements can reduce the risk caused by work in different situations and in different sized enterprises. Large size enterprise are much more vulnerable to failure in attending to individual worker’s needs, on the other hand applying compulsory education in a financially healthy business of the whole working force, can have major future benefits. Therefore, initial successes in health promotion programs do not necessarily predict the longevity of health behaviour changes [5]. At many workplaces there is a lack of information on how to maintain the results of health promotion programs, and it is also noted that many programs may be too short to implement sustainable changes on health, or expertise disappears when experts leave the organization [5, 6]. Therefore, there is a clear need for the permanent inclusion of health promotion professionals, ergonomist, physical therapist, nurse and others in large organizations. The success of health promotion is also dependent upon a participatory approach in which employees are actively involved in decision-making and problem-solving, and offer evaluative data. Customize programs which take account of the individual's willingness to engage significantly increase the implementation and maintenance of achieved goals, for example executing of physical activity [1, 7].

Because the number of days lost in sick leave are highly integrated with ergonomy [8], the most com­mon objective of the present studies was to prevent work-related musculoskeletal disorders [9], to assess whether education was actually ­enhancing the effect of applied interventions, and to ensure longevity of such effect. In practice the latter was insured by including an ergonomist-physiotherapist, since 2010, in the team that monitored the quality health of workers at Port of Koper INPO LLC. and who developed programs according to the preliminary analysis and needs.

METHODS

In 2010, the Port of Koper Inpo LLC. carried out a study (R1): “Preserving and enhancing the health of employees with ergonomic measures and to promote a healthy lifestyle – study of health promotion for workers“, which was financially supported by the Slovenian Health Insurance Institute. The study was organized and executed by a team including a registered European ergonomist, an occupational physician and a study coordinator (occupational therapist). The survey was composed of two sections: symptomatology of the whole body before work, and during and after work (addopted from the questionnaires used in the study by Ravnik [26] and Ravnik et al. [20]), and the job classifications and health data (lenght of employment, gait specifics of the workplace, lifting heavy loads, work satisfaction, percepted stress, vibration exposure, joints, nerves or muscle health problems, feeling after the job an personal opinion about work environment and its influence on the general health). The questionnaire further includes eating habits and physical activity. This data are not shown in this research. Participation in the workshop was mandatory for employees and included consideration of the following [1]: demonstration of correct posture (correct lifting, working on a stable base, tai-chi step), demonstration of self-removing of pain and discomfort (su jok, breathing exercises, exercises to strengthen the vision, exercises for different parts of the body), active and healthier approach to work breaks, a call to work in a safe working environment, ergonomic modifications of existing job aids (mostly handles, height work surfaces, eliminating barriers and non-compliant devices), changing of posture during work, demonstration of the proper use of tools and increased awareness of health, and informative booklets (1: exercises for upper extremities and su jok, 2: exercises for the neck and spine, su jok, 3 breathing exercises and exercises for the eyes, su jok 4: exercises for lower extremities and su jok), conceptual design of continuous ergonomics - preparation and implementation of programs of preventive-curative activities [1]. Six sessions of the exercise program were similar as described by Pillastrini et al. [10], whilst the ergonomic modification and workplace exercises were adapted from Mehrparvar et al. [11].

Two years after the start of the programme a retrospective study was conducted to afford comparative results as presented in this present paper (R2) – the survey was composed of three ­sectio­ns: symptomatology of the whole body before work, and during and after work, the job classifications and health data and an additional third retrospective section, where respondents were given the possible answers YES or NO to the questions stated in Table 6, while three years after the start of the programme a further study was conducted among the employees in which workplace-specific exercises were prepared (R3). This exercise programme called: “Strengthening the health of employees with specific ergonomic interventions in the workplace as well as measures to raise awareness about healthy way of life and work”, contained warming up, breathing exercises, skin moving, stretching, muscle strengthening, final stretching and relaxation with visualisation, that were directly performed in the workers occupational setting, similar to programs conducted by Sell et al. [12]. As a passive method kinesiotape [13] was applied to the employees on the most vulnerable areas of the body (mainly the lumbar spine and cervical spine). Skin moving as a therapy is basically originated from myofascial release therapy or soft tissue mobilisation, similar to therapy used in research by Balasubramaniam et al. [14].

Data were collected as part of the study R1 carried out in 2010, the retrospective survey R2 conducted in 2012 and third study R3 carried out in 2013. The R1 survey was composed of two sections: symptomatology of the whole body before work, and during and after work, and the job classifications and health data. The R2 survey provided additional retrospective results. The R3 study was only applicative without re-evaluation of discomfort and pain, the job classification and health data. Only the satisfaction with exercise program was evaluated.

The well stated goals of the program guarantee a high level of participation and empowerment [12]: in 2010, 81% of employees in the company Port of Koper Inpo LLC. participated in the study. All who fulfilled the questionnaire participated in ergonomic workshops explained above. Whilst the retrospective study in 2012 involved 85% employees, study in 2013 involved 83% employees. The actual numbers of employees participating in the individual studies are stated in Table 1.

The data were collected on the basis of individual circumstances and environment tailored question­naires and explored the individual’s experience of problems in the locomotor system. SPSS 20.0 statistical package and Statistical calculator company StatPacInc. were used. Descriptive statistics was applied (average, standard deviation, frequencies and relative frequencies). Bivariate analysis was performed by using paired and unpaired t-test, Fisher's Exact test and Chi-square test.

RESULTS

The concepts of discomfort and pain are under debate. There is no widely accepted definition, although it is beyond dispute that comfort, discomfort and pain are feelings that are subjective in nature. The pain could be explained as stronger discomfort and discomfort could be explained as an absence of comfort or ease, or anything that disturbs our comfort. The discomfort and pain appearance varies according to the organizational units of Port of Koper Inpo LLC. as well as the specificity of the compared groups. The largest occurrence of discomfort or pain was in the spine (neck and thoracic spine, lumbar spine). Table 2a shows the frequency of discomfort and/or pain in the locomotor system according to the different locations while table 2b shows comparison of occurrence of discomfort and/or pain within or in between the R1–R2 surveys.

Table 3 shows that the discomfort and pain before work and during and after work was sustained from R1 to R2. However, the pain before work diminished over the time period 2010–2012, while for the same period the pain during and after work decrease slightly. Although the proportion of job satisfaction tended to increase over the period 2010–2012 (Table 4), the only statistical difference was identified between two groups in the group of undecided. When comparing data regarding job satisfaction and its effect on the occurrence of discomfort and pain (Table 5) in R2 survey, the only statistical difference was found between pain before work and pain during and after work.

Information derived from the retrospective study R2 (survey questions and answers in %) is presented in table 6.

More than 70% of them consider some advice from the workshops of the study R1, namely 60.7% cor­rect posture, proper lifting 54.2%, 33.3% by the exercise of arms, 29.2% exercises for legs, 45.2% of exercises for neck and back, 24.4% exercises for eyes, 38.7% of active breaks and 43.5% carried any advice from the presentation, how employees can help themselves to eliminate the discomfort and pain. Slightly more than half of respondents (53.6%) took into account some advice from the workshops of the study R1 at home and in their free time and 44% of respondents would like refreshing workshops. Apparently, some advice was followed and implemented after the practical workshop of 2010 as 70.2% responded to follow advice from the practical workshops received in 2010. This was especially noticed in more responders (60.7%) positively adjusting to correct posture. However, exercises for both hands and legs were nearly not implemented (64.4% and 68.5% respectively). On the other hand it was more frequently noted (67.9%) that there were fewer problems in the locomotor system after the implementation of the studies.

Table 7 shows associations regarding the activities and problems arising in the locomotor system (implemented the Fisher’s Exact test), showing statistically significant differences only and pos­sible interpretations. Data on sick leaves that are longer than 18 days derive from official records of the company. Compared to the average in 2008, the latter percentage was 10.1% (13 people) in 2009, 7.0% (8 people) in 2010, 7.8% (9 people) and in 2011 6.1% (5 people).

DISCUSSION

The previous and present results generally sup­port the claim that the occurrence of discomfort and pain of today's lifestyle is high, regardless of the industrial setting [1]. Discomfort usually manifests in the cervical, thoracic and lumbar spine as well as the buttocks, the region of the knees and shoulders. Discomfort in the area of the lumbar spine is the largest. Employment in industry, in our case in the support maritime services – port industry, was found to result in a large proportion of the occurrence of discomfort in the locomotor system, including in the area of the lumbar spine. This is mainly a result of heavy physical work, exposure to vibration, previous injuries and lifestyle factors. In general, occupations with high physical work demands show increased prevalence of musculoskeletal discomfort and pain [15]. Respondents in the study R1 and R2 were also many people who have been granted different levels of disability. A major impact on the perception of discomfort and pain is definitely muscle tension [16]. More than half of the people participating in the survey also indicate discomfort in the form of muscle tension. We can agree with the argument that dynamic activities, wanted or unintended, have a positive impact on the prevention of discomfort unlike the static load [17].

People adapt to work with different layouts of the limbs, while the position of the torso remains relatively constant, which then in itself can be a factor that contributes to the occurrence of discomfort [18]. Problems in the locomotor system are always the first to appear as a functional disorder, and if not detected in time and eliminated, this may result in morphological or structural disorder. There is no position of the body which can be comfortably maintained for a long time. The position of the body, which is maintained for a long time leads to static loads of muscles and joints, which in turn leads to the phenomenon of discomfort and pain. Additional exposure of the organism to mechanical vibration may cause changes in muscle activity and this is a factor that becomes the backbone more susceptible to the emergence of discomfort, pain and injury [19, 20]. Any change of posture can be due to discomfort [21]. It is therefore important how we exercise and in particular how do we sit.

Seating, even on a good chair or armchair, is not recommended for a long time. Sitting is not a physiological position for man and it depends on many factors. Inadequate seating tilts the pelvis back (posterior pelvic inclination) which offset the lumbar curve and increases muscle tension and pressure on disks, tailbone and sitting bone, which may then cause pain and discomfort in the spine. Thus sitting static for long periods of time can lead to discomfort, pain, irregular curvature of the spine and loss of functional independence [22]. Therefore it is very important to interrupt prolonged sitting. A retrospective study R2 shows that 38.7% of respondents, who have been involved in the study R1, take active breaks or they claim to be more active during breaks.

According to research R1, R2 and R3 the most com­mon reasons for the occurrence of problems in the locomotor system [1] are especially frequent forced posture and ergonomically incorrect movements, frequent trigger points and the emergence of functional disorders of the locomotor apparatus because of irregular and repetitive movements. Although the proportion of problems in the locomotor system is relatively high, it is important to realize that problems do not necessarily arise from the current work environment and we might look for reasons elsewhere. As such it is important to consider a full and detailed history of each case including aspects of lifestyle, at home life alongside employment and work history.

The results of a retrospective survey R2 shows that the survey completed 78% of respondents who have been involved in the study R1 in 2010. One fifth had been changed the working environment and facilities. Positive health promoting effects achieved through physical exercises at workplace were generally accepted, similar to Robertson et al. [23] where significant increase in overall ergonomic knowledge was observed for the intervention groups and exhibited higher level behavioral translation and had lower musculoskeletal risk than the control group [23].

The results show that different parts of the body have different susceptibility to the emergence of discomfort. The results of the final evaluation, conducted workshops and lectures in the study R1 show that the introductions of ergonomic interventions in the workplace were appropriate and successful. Evaluation of education and training, which was conducted at the end of the study R1 showed that about 78% of respondents were satisfied with the workshops and lectures, while in study R3 this rate increased to 83%. Based on the results of the study R1, 62.5% of workers felt more health aware. In addition, from the follow up R2 in 2012, there was a significantly lower number of workers that felt bad after work (t = 2.164, p = 0.03). The R2 study showed that more than a quarter (26.8%) reported less problems in the locomotor system, while more than 70% were taken into account at least one of the advices from practical workshops. Of those who indicated decreasing of problems in the locomotor system, 71% of them indicated greater health awareness. According to a comparison the results of R1 and R2 can be noted that, on the average, occurrence of discomfort before work decreased for 4% and discomfort during and after the work decreased for 5%, but no evidence of statistically significant differences with the exception of discomfort in the area of the lower leg (p = 0.047) and the occurrence of pain in the neck (p = 0.02) has been noted.

The results also suggest that both lifting heavy loads, as well as a subjective assessment of the work, have an impact on health, as well on the existence of problems in their free time. It is interesting that the workers, who have problems in the cervical spine, are the ones who take the most advices and take into account not only advices for the neck and spine, but also advices on other areas of the body. Positive effects of exercises on neck are consistent with the results published by Andersen et al. [24].

It is worrying that a high proportion of the occur­rence of discomfort can already be considered a social problem, since functional independence movement and the ability to have a significant impact on attitude towards life and value of it. It is interesting that dissatisfaction at work can lead to the occurrence of chronic pain, which has an impact on the psychosocial aspect of man (table 6). People, who are unsatisfied at work, are often unsatisfied at home and have a higher occurrence of pain, but the work does not increase it, because they have pain in any case – they are in pain already when they come to work. However, during and after work respondents have similar proportion of discomfort and pain, regardless of satisfaction.

In the case of the sick leave in the company, it is notice to mention a trend of reduced number of sick leaves that are longer than 18 days. It is true that the latter data do not distinguish how much of the phenomenon is accounted for by problems with the locomotor apparatus, which was the goal of the study R1. But in general over a period of 5 years sick leaves caused by problems in the locomotor system have been reduced to almost half.

According to the results of the previous research of the preventive-curative programs that have been implemented since 2010 in the Port of Koper Inpo LLC. [1], the program is introduces directly into the workplace – occupational setting. It includes the traditional health safety at the workplace (applied ergonomics, occupational safety, industrial hy­giene) and health promotion (supporting workers to improve their health behaviors). Besides, it introduces an active and passive model of ­employee involvement in the program (physiotherapy: active = supervised physical activity, passive = kinesiotape application and introduction of methods of manual therapy). Similar programs named Henning et al. [5] as a Participatory Ergonomics. According to recent research, in addition to the health promotion and applied ergonomics, it is necessary to afford attention to the aesthetics of the workplace [8] as there is evidence to indicate that the latter may affect the mental health and well-being of employees [25].

Recommendations to maintain the results achieved and further improve the health status of employees in terms of ergonomics are:

• Organizing occasional motivational workshops about ergonomics and activation of employees (guided and targeted physical activity);
• Use of existing leaflets (issued in 2010) and manual (issued in 2014), and an eventual production of new leaflets (customized according to the worksite problems);
• Apply the principles of ergonomics or engage in a critical modification of jobs, to include the purchase of equipment, which will be handled by the employees;
• Health promotion in the workplace, including ergonomics and physiotherapy with manual therapy;
• Improving the health status of the essential elements of health and lifestyle: physical activity, nutrition, sleep, stress management, etc.;
• Informing the ergonomic counselling and other therapeutic options.

Research is continuing in 2015 to determine the perception of health and workers' needs for further work.

CONCLUSIONS

Manual therapy, physical therapy, ergonomy, occupational therapy and other approaches should strive for the same goal, namely to reduce discomfort in the locomotor system and thus directly affect the quality of life. On the other hand, for many years, a lot of companies in Slovenia have promoted the health of their employees in different ways, through seminars, workshops and other training programs, primarily in order to reduce absenteeism. The latter has very negative impact on the productivity of the company and individual obstacle at work, as well as the private environment.

One of the important factors in reducing the discomfort is also the approach in terms of ergonomics, manual therapy, physiotherapy, occupational therapy and others. Therefore, the contribution of this article is to warn executives that their team can make very positive use of knowledge of the aforementioned experts; this can directly affect the well-being of ­employees and thus the productivity in the workplace, supporting achievements and the quality of life of the workforce. Discomfort and pain can be prevented. Improved physical health can then have a major impact on quality of life (both at work and at home and in their spare time) and job satisfaction, particularly in the perception and manifestation of pain. One can do most for his health if one uses newly acquired knowledge in everyday life.

Ethics

This study was approved and co-funded by Slovenian Health Insurance Institute as a part of practical preventive programes "Preserving and enhancing the health of employees with ergonomic measures and to promote a healthy lifestyle – study of health promotion for workers", (Official Gazette of Republic of Slovenia, no. 14/2010) and “Strengthening the health of employees with specific ergonomic interventions in the workplace as well as measures to raise awareness about healthy way of life and work”, (Official Gazette of Republic of Slovenia, no. 35/2013). Work was done under the Recommendations from the Declaration of Helsinki (1983) and informed consent was obtained from each subject participated in study.

Do redakce došlo dne 14. 12. 2015.

Do tisku přijato dne 21. 12. 2015.

Adresa pro korespondenci:

Doc. PhDr. mag. David Ravnik, Ph.D. PT. Eur. Erg.

Faculty of Health Sciences,

Department of Nursing Care,

University of Primorska,

Polje 42

SI-6310 Izola/Isola d’Istria, Slovenia

e-mail: david.ravnik@fvz.upr.si