CONFERENCE CLOSING SESSION

Presentations by Constituencies

Donald Collins, DDS, Interim Director of the Council on Dental Practice of the American
Dental Association

Franklin E. Mirer, PhD, CIH, Dir., Health and Safety Department, International UAW

Larry Fine, MD, DrPH, Director, Division of Surveillance, Hazard Evaluations and Field
Studies, National Institute of Occupational Safety and Health

Session Arranger Remarks

Size, Scope and Definition of the Problem
David Sarvadi, Esq., CIH, Keller & Heckman

Case Definitions and Diagnostic Criteria
Larry Fine, MD, DrPH, NIOSH

Research: Exposure Response in a Research Mode
Steve Lamm, MD, Epidemiology and Occupational Health

Intervention and Controls
P.J. Edington, Center for Office Technology

Economics: Costs of Illnesses and Costs of Controls
Hank Lick, PhD, CIH, CSP, Ford Motor Company

Methods of Ergonomic Exposure Assessment: Validity and Limitations
Brad Joseph, PhD, Ford Motor Company

Case Management
Pat Bertsche, MPH, RN, Ohio State University

OSHA's Statutory Framework
Frank Mirer, PhD, CIH, United Auto Workers

Conference Wrap-Up:

P.J. Edington, Center for Office Technology

Mr. DAVID FELINSKI, AAMA

Good morning ladies and gentlemen. I'm Dave Felinski of AAMA and I'd like to welcome all of you to the last day of our policy conference on managing ergonomics. We're glad that you have stayed with us through thick and thin. There's quite a large crowd here this morning. Certainly larger than we anticipated. So I think that speaks eloquently about the importance of this subject in a broad sense, and in particular, the significance of this conference as an important milestone in the overall policy/science discussion. I anticipate that this morning's session, which will end by 11:30, will be a very important part of the conference. And with that, I'll turn it over to my co-conference sponsor, PJ Edington.

Ms. P.J. EDINGTON, COT

Well, I too am glad to see everybody smiling after three days in these wonderful ergonomically designed chairs because I know that everybody about now has severe fanny fatigue. I know I do. So we'll try and move this along this morning - make it lively so you don't notice that you're having fanny fatigue. I do know we have some great speakers this morning. A couple of them have some pretty sexy slide shows going on here, so I know you will want to stay tuned. First I have a change in the program. I know you don't see Laurie Baulig from the American Trucker's Association up here and unfortunately they've had a major personnel change. The head of the association left and so Laurie had to stay with the search committee this morning and couldn't be with us. But we are very fortunate to have Don Collins here. Dr. Collins is an interim director of the Council on Dental Practice of the American Dental Association. He's a 1976 graduate of Loyola University School of Dentistry. He's also spent a lot of time in school and has a master's in public health. He just received last month his MBA from the University of Illinois. Dr. Collins' activities in five years that he has been with the American Dental Association have involved helping to shape the council policies having to do with regulatory issues, special practice management programs for dentists and their staffs, and liaison functions with related industries. He's also a member of the National Coalition on Ergonomics. Don.

Dr. DONALD COLLINS, DDS, American Dental Association

Good morning. And thank you, PJ, for those very kind words that I wrote. My name, as PJ has just told you, is Dr. Donald Collins, and I'm with the American Dental Association in Chicago. I should say just briefly that the American Dental Association is a member organization that represents 142,000 U.S. dentists. We represent some 72% of all American dentists. So as members of the National Coalition on Ergonomics we serve on the steering committee. We first want to thank all of the participants for their attention, effort and time at this important conference. As we begin to discuss these issues in meetings like this, we can begin to understand each other and to work toward developing a common ground. Let me reiterate our position. The Coalition supports the application of ergonomic principles to prevent injury and illnesses. It remains concerned that the science is not yet suitable for a broad comprehensive national regulatory scheme. We in the Coalition strongly support voluntary prevention methods until such time that the state of scientific knowledge can satisfy statutory criteria. Our conclusions about the results of this meeting reflect our overall viewpoint. We are sure that each of you will take home a different message based on your individual perspective. Overall we have mixed emotions. We are encouraged by some of what we've heard, and discouraged by others. Let me start by highlighting what struck us as important. First, it has long been our position that these kinds of discussions that we've had this week, the scientific debate that you have heard, need to be held in meetings of this kind. Only in this context can the 'off camera' discussions occur, that lead to normal understanding and respect. Individual encounters then lead to the kind of consensus that allows a regulatory proceeding to define the public policy that addresses complex and difficult problems. So we are pleased that this first step has been successful in bringing us all together for these discussions.

My second point. We sense agreement that conditions like carpal tunnel syndrome are devastating for the individuals involved, but that these cases are a small fraction of the overall numbers of injuries and illnesses in the U.S. What struck us about these cases, the pain syndrome culminating in CTS or similar conditions, is that physicians still do not themselves have a good handle on diagnosis and more importantly, appropriate treatment. Drs. Franklin and Louis each in their own way agreed that overly aggressive treatment is a significant yet almost unstated problem. Because the result of inappropriate treatment is potentially so adverse that is, that treatment may disable a person for life, the medical professions and public health community must address these uncertainties. The Coalition commends the American Academy of Orthopaedic Surgeons and the State of Washington for coming to grips with these kinds of problems.

My third point. We heard from various investigators about the experimental models that are now being used to predict risk. If we accept the premises of those models, they give encouraging results. But we remain concerned by the use of models that are complex and difficult to apply. Or that are so non-specific or overly sensitive. We must remember that the outcome at the end of the day is a government inspector and a plant manager discussing whether that particular operation meets the standard established by Congress for workplace safety. The specific characteristics that these two individuals share is the lack of sophisticated technical training of the type that presenters here in the last several days clearly enjoy. So the criterion by which the suitability of the models must be judged in the regulatory context is whether they can be reliably and consistently applied in a wide variety of work environments, and by persons with minimal training. It is our view that there remain some serious deficiencies in the research being performed. We heard in the initial session about the scope of the problem using data from the Bureau of Labor Statistics and from the State of Washington. The strength of these measures lies in their broad comprehensive basis. Their deficiency is in their non-specificity. They do not tell us, for example, of anything at all about the kinds of activities that can lead to the difficulties and the associated risks. This information is necessary to allow extrapolation from individual cases to all individuals, a fundamental prerequisite for a fair and acceptable regulatory scheme. A second deficiency in ergonomics research in our view has to do with the measures of outcome and measures of exposure. We continue to hear about studies which rely on self reported symptoms, although we did hear that, in the case of carpal tunnel syndrome, there is work being done to identify appropriate means of case identification in the epidemiological setting as opposed to that of clinical treatment. In the case of back injuries, disability and medical conditions are often not the same. We must bear in mind that in many cases what is measured is not injury or illness but surrogates for them. Imperfect, though as they are, these surrogates may in fact be the best available at the present time. But that should not, however, keep us from looking at this question more closely. This issue relates to the question of what conditions are appropriate subjects of an OSHA regulation. What is the material impairment or harm that we are trying to prevent. Clearly, disabling conditions are to be addressed. It is not so clear when we begin to discuss a non-specific pain in limbs or in the back. We think there is much work to be done to distinguish, in this latter group, which conditions should be targeted for prevention by an OSHA standard. Exposure methods also need improvement. We heard about a number of reports on upper extremity disorders that relied on expert group evaluations for classifying exposures into quantitative categories. Before such exposure measures can be useful, however, they must be improved in one of two ways - either the measures must become more quantitative or they must be made more suitable for use by non-experts. As one presenter suggested, these methods should be reliable, valid, easy to measure and simple to use. The Coalition believes that the epidemiologic data are still incomplete. We heard from several individuals who described relative risk among people in different industries. But the reports described included precious few studies where risks among non-exposed individuals were compared to exposed persons, or where adequate attention was paid to non-occupational factors. Some of the research designs that were discussed, mentioned concerning these non-occupational factors, but we did not hear clearly articulated studies designed to answer this question of how much, if any, of these conditions occur as background complaints. These are two important parts of our criticism of this work to date. First there has been a failure to consider non-occupational factors in many studies. Largely, we believe, because they are difficult to study properly. This does not excuse their exclusion however. The problem with not studying non-occupational factors in conjunction with the occupational factors is that a positive result can only be associated with occupational factors. Whereas a potentially larger association with non-occupational factors cannot be ruled out. This work has to be done.

Secondly, it is essential to answer this question because as we heard, there is a significant prevalence of conditions of concern to the general public. In particular we saw data suggesting that complaints of pain are far more common than diagnosable conditions. Suppose this is true in the general population as well. That is, suppose the prevalence of arm pain in persons who play tennis is twice that of persons who do not. The assumption in most studies, unexamined to date, is that there is no difference in the number of people who play tennis in the more exposed as opposed to the less exposed group. Given that adverse conditions are likely to be caused by certain activities which may be more prevalent in certain jobs than in others, it would seem that we will only be able to extrapolate from specific cases to the general case if we can identify the activities by quantifiable metrics that can then be used to examine jobs and non-occupational tasks. Unless this approach is taken, we need comparative risk analyses to determine the background prevalence or incidence before regulatory requirements are imposed.

In the opening remarks by Marc Freedman, the Coalition listed seven questions that we felt illustrated the depth and breadth of the scientific debate. The results of this conference show that others recognize these questions and are making efforts to answer them. We come away encouraged therefore, but cautious about pushing the envelope at this point. As noted previously, we must remember the difference between voluntary actions and mandatory requirements imposed by government agencies. We have had here, the active engagement of ideas and perspectives that we sought at the outset. We hope that we have broken ground to build a foundation for the kind of understanding that will help to illuminate the road ahead. The National Coalition on Ergonomics remains committed to this goal, that whatever approach might be adopted, it will be one based on the best available scientific evidence and will provide the highest degree of protection for employees at the least cost to all of us. And I hope that you will each join me in this quest. Thank you.

Ms. P.J. Edington, COT: Thanks, Don. I know our next speaker needs no introduction because he probably knows everybody in the room personally, but I'll just give you a little background on Frank. Dr. Frank Mirer serves as the Director of the UAW Health and Safety Department. He received his Ph.D. in organic chemistry from Harvard University in 1972, and trained further as a research fellow in toxicology at the Harvard School of Public Health. He joined the UAW staff in 1975, and was named director in 1982. He's developed and delivered testimony before OSHA regarding dozens of health and safety issues and standards, and has testified before House and Senate committees on numerous occasions. He's also co-authored and authored many books and articles.

Dr. FRANKLIN MIRER, PhD, International UAW

Thanks very much for that introduction. I want to start by saying that I really appreciate the opportunity and the effort that everybody made to come together. And particularly the efforts of our management colleagues and practitioners to try to come together and frame this discussion. And especially to all the UAW folks who've taken the time working on this issue at the plant level to come out here. In a way I think you're all like the civilians watching a conflict - some kind of war that's happening at the national level. The problem with any one of these conflicts is that the civilians suffer more than the combatants. And that, not only if you sat and listened for a long time, but also some of this national debate spills over into your day to day efforts. Hopefully you've gotten some information on the broad national issues that will permit you to argue, whether you're labor or management, with your upper management about implementing programs at the workplace. And that at least you will be informed as this goes forward at the national level. So what I want to do is frame the issue and raise a few points that have been amplified as we've worked through the conference here. The theme of my take home lesson, and I hope the theme of what you can do in your future is, to use somebody else's phrase, 'ergonomics, ergonomics implementation, ergonomics as a scientific issue,' is an 80/20 problem or a 90/10 problem, and that we need to emphasize and implement the 80% while we're trying to figure out what those other 20% issues are. I would hope that's what everybody can come away from. I would hope, and heard it from the last speaker, ergonomics is a major component of a health and safety program in any industry sector in this country. Now there's some sectors where there may not be any health and safety issues at all. And ergonomics may be not an issue there. There may be small employers that don't have physical work going on and there's no issue. But any place where you have a health and safety program, you have to have ergonomics. The evaluation of health effects and exposures, I would argue is about 80% done. What we need to know about or maybe more. I mean, there's an argument that low back pain doesn't come from work. That's obviously true. But we know that back pain and these disorders come from stresses at work and we can probably figure out what the proportions are pretty easily. We know what the methods of abatement are - not every method of abatement, and not every method of abatement is a cheap hundred dollar solution, either. But we know a lot. And in the past five to ten years we've learned a lot. Finally, the components of ergonomic activity are pretty much the same every place where people are doing ergonomics. Find the bad jobs through health complaints and other means. Have a group of people work on analyzing the risk factors. Work together with the employee to figure out what the abatements are. Implement the abatements. Have medical surveillance. Everybody does it the same way. That's a sign that there is a consensus and we know what we're doing. So, that's the 80%. There are certainly some difficult issues that we would like to know more about. But I want to go on a little bit longer on this theme of stuff we know that can help us move forward. And this is stuff that we didn't know 10 or 15 years ago. Ten or fifteen years ago everybody didn't focus on the force/frequency/posture paradigm for stress factors. I didn't even know what it was. And I claimed I knew every thing. Barbara taught it to me. But, anyway, that's what everybody's doing. That's what all these risk factor analyses are based on. Pretty much people accept expert ergonomic analysis for the measurement of risk factors according to that paradigm. If Bill Marras comes and analyzes your job for back risks, or Don Chaffin, pretty much everybody would buy into that. And this is, I think, the critical thing that's changed over time is the development of simplified approaches to the measurement of risk factors. So you don't need a master's degree or Ph.D. ergonomist every time you do it. We have the NIOSH lifting guide now being amplified for back risk. We have validated semi-quantitative risk factor checklists for upper extremity CTD's. And I would say that every investigator likes their own best, but I would argue that the similarities that a lay person sees indicate that they're measuring something that's the same. We have diagnostic criteria for many upper extremity CTD's. It's not totally a cult art. This diagnostic criterion is as good as anything that a physician gives you. We have standardized physical examination protocols for upper extremity CTD's. They're embodied in a lot of documents. It's not all a black art. What else?

We have validated symptom surveys as a risk identification tool. We have validated the combination of the risk factor checklist and symptom survey by work force personnel to identify high risk jobs and propose abatement methods. As I talked before, we have acceptance of the plant ergonomic committee as a model. People generally recognize the extent and gravity of the problem of the work force. It's recognized by the work force, the general population and the medical community. And what we're haggling over is, I think, the dispute over what are the risk rates of basically low risk jobs. How much…where is the threshold. Not that there aren't major risks on production jobs. We have enforcement of OSHA injury and illness recordkeeping requirements. We have a General Duty Clause enforcement strategy. We have all of those things that move us forward. Now what are the problems we're having? In the auto industry, and we spent a lot of time on this in the last round of collective bargaining and I'm sure it's true in a lot of other places, our problem is stalling investment in abatement after the risk factors on jobs are identified. We're not fixing jobs fast enough. And we're bargaining over how fast the jobs are going to be fixed. That's true everywhere. That is the number one obstacle in seeing improvement in this area. I think that's where the OSHA standard and other things come in. We have, again, in most of American industry the cover up of injuries and illnesses, under-reporting. We have this whole issue of abatement being tied up in workers' compensation liability, and maybe we need to work there. If management admits these things are work-related, they've got to pay the comp. I mean, that's where, I think, this tangle is over. We have what I would call political interference with OSHA rulemaking and enforcement. And then I think, well let's just say it here, there's a fundamental issue spilling out which is management domination and control, and their refusal to empower employees to work for ergonomics abatement, access to data and authority. And I think the idea is we're never going to get anywhere with resolving this issue in the United States, but we can work on many of these other issues effectively.

Let me turn a little bit to some of the things that were said here this week, and throw in my two cents I didn't get in from the floor, I'll get in now that I'm at the podium. The BLS has published three years now a survey of disabling work injuries in the United States. They called in the OSHA 101 equivalent for disabling injuries from every industry sector. And there's millions of them. You can download this all through the Internet by the 4-digit SIC code if you want to know what the problem is in your workplace. In the auto sector, SIC 3711, 63% of all disabling injuries are musculoskeletal disorders, strain and sprain which I'll get to in a minute, cumulative trauma disorders and other diagnoses. Sixty-three percent. Parts manufacturing, SIC 3714, it's 51%. Then we have automotive stamping and foundry with lower percentages. You can do this for each and every 4-digit SIC code in the United States and figure out what the proportion is. Here's a database we can use. The other issue in applying BLS nationally is this is the trend of injuries in the auto industry over a couple of decades now, and the trends nationally. Since we reformed injury and illness recording in our industry, the total rate went up 6 times, lost work day rate 5 times, cumulative trauma rate 60 times. Actually, nobody else fixed a damn thing anywhere else that we can tell. We think there's a four-fold under-reporting, and this is preventing abatement of the problem. You can't make any progress if you don't do ergonomics. You can't do it without ergonomics, you're done. As far as OSHA's concerned, they're done if they don't work on this problem because you can't get anywhere.

Now when we get to size and scope, there is a big open issue that can be resolved by practitioners. What proportion of the strain and sprain and back injuries are preventable by reducing biomechanical stress? If you want to look with Frank, CTD diagnoses - they're about a quarter to a fifth of the problem compared to what we see from strain and sprain pain diagnoses. But, again, if you're looking at people getting time off work, it's a major part of the problem. What's the full extent of the BLS under count? We have to integrate lost sources of cases which are workers' compensation, medical only, sickness and accident, disability and early retirements from musculoskeletal diagnoses. So those are some issues. That's the 20% issue. The 80% is a big problem. The 20% might be even bigger than that.

In the session on case definitions and diagnostic criteria we need the medical community to put in writing, and NIOSH or OSHA to adopt, criteria for diagnoses of disorders and work-relatedness. If we write down what the criteria are then we can argue whether they're the right criteria and being applied, but of course there's external sources of these injuries and particularly acute back injury. I honestly don't see anybody getting rotator cuff out of gardening unless their spouse has an automatic weapon making them work 8 hours. We have to distinguish between surveillance definitions, individual diagnoses and criteria for OSHA recordability, those are all different things. What would you do if you're 80% sure that something's work-related, do you record it or not? Or do you contest the comp claim?

In exposure assessment, we need to continue the reconciliation of these non-expert survey methods for ranking job hazards. To me, they look all the same, but Lida would strangle me if I told her that the questionnaire, the one she uses, is the same as Barbara's or Tom Bernard's. We've got to maintain that convergence because that's where the future lies, because there'll never be enough ergonomists. We need to continue validating employee reports of risk factors. And we have to distinguish in the symptom survey, between asking the employee which part of the job is giving you a problem, which is a great source of information, from just eliciting symptoms. Those are two different things. The first one is absolutely essential. The second one, we have enough cases. We don't need more symptoms. We have plenty of cases to work on. And finally we have to simplify the quantitative lifting evaluation methods for non-expert use and by the time you go to 3-D dynamic models, that's got to be made user-friendly.

In the section on intervention and controls, we have to verify that job modifications have reduced risk factors - that's often the 'empty box.' We put in an ergonomics program. We had injury rate on Day A, injury rate on Day C - it's the same or different. How did we really reduce the risk factors before we start evaluating whether our program worked. I would argue that the level of risk factors is the performance measure of an ergonomic program, not the injury rate. In particular because when we're looking at outcomes, you have to take into account recurrent effects of past injuries in an experienced work force. Most back injuries that we see in the OSHA 200 system are recurrences. You're talking about in auto, 40-50 year old people who have been under stress all their life. You don't know what you can do to impact that immediately.

For economics we have to resolve all those under-count issues because that's a multiplier. We have to capture a lot of costs like workers' compensation, medical, time off the job costs for people not on compensation which can be a lot - sickness and accident . To get a full economic analysis we need - and you can help estimate the value of quality and efficiency improvements that come with ergonomic modifications which everybody in experience and anecdote says are huge. I think quality is probably the biggest one and it's not measured at all. But we're getting charged for all this new production equipment and not being given credit for it. We have to develop an approach to how the economists are going to treat the costs of turnover of equipment. How the costs are associated with that. Are we going to be every 5 years, or 7 years, or 10 years when that equipment turns over, are we going to be putting in crummy stuff that hurts people or good stuff that doesn't hurt people, and how do we allocate that cost?

Finally on the legal issues. I thought that was a very productive session. I'll talk about it more. But we have to gain some kind of social concurrence on what the employer's General Duty Clause obligation really is as just a social concern, and that's "what must an employer do after a worker reports a work-related CTD?" Getting over all those issues, what is the employer's obligation when he or she knows that. And then I think we can move to the standard from there. The standard defines prospectively what the General Duty Clause observation is.

Finally, do we need the National Academy of Sciences? I would argue that the remaining technical issues are really detailed matters for the practitioners to resolve within their own discipline. Physical exam protocol for work-related CTD - is that an NAS issue? An NAS committee limits practitioners to a few individuals in any discipline. You got two doctors who get to argue about it instead of the 100 that are actually doing it. And take it from me, I've been on three NAS committees. This 2-year delay that was reported for OSHA, I don't know what they're smoking over there, frankly. It takes a year even to appoint the committee. I've been on three of these. It takes a year to get together and figure out what you're talking about. And then 2 years to produce the report and another one to print it. You're looking at five years if we go to the NAS. So finally, let me conclude. I was trying to be helpful there.

What I'm hearing is that this dispute over ergonomics is part of a larger problem in American industry. You have the 'Deming school' and you have the 'financial results school' of American industry. This has nothing to do necessarily with safety and health. But are we going to make a good product and get it out. Do what the mission statement says? The fact is, there's a lot of management that can do very well with financial results which I interpret as, squeeze the supplier, sweat the work force, out-source the jobs to the cheapest wage place even if it costs money initially, and then short change the customer by charging the highest price possible for the lowest quality goods shipped late. Right? And, you know, we're all part of that system. And the system makes you do it half the time. And ergonomics fits in to that. Some people can do very well, at least for awhile, by crunching up people and throwing them away. I mean, it's pretty simple. And unless we have something social, something governmental, something outside the game of business imposing the positive strategy, you will always be doing ergonomics. You're all doing ergonomics. You're all from employers that have recognized the need to do that. Unless we get something outside the game of business to force that on the financial managers, we're always going to be struggling against a boat that's going in the wrong direction. And it's going to take over the falls down into the whirlpool. And that's why we need an OSHA standard, and that's why we need to find some way to work together to get there. Thank you very much.

Ms. P.J. Edington, COT: Thank you, Frank. I just used a new technical term that I'm going to put in some of my stuff - 'crummy.' I like that one - 'crummy stuff.' I understood it, and I'm sure everybody in the audience understood it too. Our next speaker has been introduced previously, but I get to do it again. And I think for most of us, if you haven't met Larry Fine then you should know him because he's truly one of the real nice guys around. Larry is the Director of the Division of Surveillance, Hazard Evaluations and Field Studies of the National Institute on Occupational Safety and Health, or as we know it, NIOSH. Previously he's been at the University of Michigan School of Public Health. He's been an Assistant Professor of Occupational Medicine at the Harvard School of Public Health. And he's been a lecturer on neurology and occupational medicine at the Boston School of Medicine. He received his MD from the University of Illinois, and his MPH and Doctor of Public Health in occupational medicine from Harvard University. Larry.

Dr. LARRY FINE, MD, NIOSH

Thank you very much for that very nice introduction. Can I have the first slide, please. I wanted to speak briefly on three things, magnitude, science and solutions. I'll try to go through my presentation fairly quickly. Several of the other speakers have talked already about magnitude. My point about magnitude is that when you look at the surveillance information we have, the workers' compensation data that Dr. Silverstein presented, the BLS statistics, what strikes me is that there are definite places where risks are clearly elevated. In this debate about whether there is a lot of under counting or not, it is clear that whether you look at the data in the 1970's or the 1990's, surveillance information allows you to identify some places where risks are clearly high. This is some of the current BLS data. There are clearly industries that consistently have statistically significant increases in their rates of problems - whether we're looking at the back in terms of over-exertion and lifting, or whether we're looking at repetitive motion in the upper extremity. From either a national perspective or when you look inside of a specific facility or within a specific industry, you can always identify, or usually identify, that there are high risk industries, high risk jobs, and that's really one of the places that we should focus our preventive strategy. And then, of course, different industries and different facilities will have a different profile. Using your surveillance information you can target your preventive activities as many of you are doing. I think it is also true, something that several people have said in this debate, is that we need to remember that in many situations, and certainly from a national perspective this is true, lower back problems represent a larger problem than the upper limb. On the other hand if you define upper limb disorders as solely carpal tunnel syndrome, you miss the size of the upper limb problem. As I look at both the BLS data and the workers' compensation data, there is really essential agreement in those two data sources, that essentially the upper limb is half as large as the back as a problem. So the back is 2, the upper limb is 1, if we look at it from the national perspective. I think that's important to keep in mind as we move forward and try to find solutions.

Surveillance, of course, is not perfect. But it certainly increases your chances of making the right decisions, and where to focus your preventive activities. I think the heart of the scientific debate, I'm sure is clear to all of you now which is, really, what is the relative importance of societal factors, individual factors and workplace factors. But I think what's important is that the debate goes on, and that debate will go on a long time in the scientific community. It will go on a long time, I'm sure, in the political and social context. But I think a step forward is to put the first two thoughts together. One is surveillance and one is this: By using your surveillance data you can identify places where it is clear that workplace factors are very important. Now that may not mean that if you ask how much of lower back pain in the entire society is due to work, you are able to answer that question with great clarity. But when you look at the surveillance data you can identify industries and jobs where work is extraordinarily important in either precipitating or aggravating lower back problems. You may not be able to scientifically determine whether it's aggravation or precipitation, but you certainly can associate and identify jobs where workers cannot work with back pain and who have to take time off. So while this larger debate goes on, you can use your surveillance information to target where we should be taking activities. The second point I want to make on that slide is, in this debate, there has emerged a sort of discussion between the relative importance of physical factors, like lifting heavy objects, versus psychosocial or work organization factors. Essentially I think there is consensus that we know more about physical factors than we do about work organization and psychosocial factors. Not that the latter are not important. But in terms of preventive concrete specific activities, we can focus on physical factors and they certainly are a major part of the problem. Another thing I think where there is really virtual consensus - maybe not complete but virtual consensus - is that where you have multiple risk factors, where their intensity is high, there is excess risk. What do we mean by intense exposures? We mean bending your wrist 20,000 times a day. Now we may not know much about bending your wrist 4,500 times a day versus 6,000 times a day, but it is clear where the risk factors and exposures are intense. For example, there are jobs where people lift 1,000 pounds or more an hour. Now my point of view is that's clearly a high exposure. And while this larger debate goes on we should not lose focus on identifying those jobs and taking preventive actions. Prolonged overhead work, working with your hands at shoulder height. Again, those jobs are a tiny minority of all jobs in America. But clearly the consensus is that those are high risk jobs. If you design work so that it accommodates the vast majority of the work force you will have lower rates of back injuries and other types of injuries. This is data from 1984 dividing up rates of back injuries based on work that's acceptable or not acceptable to different proportions of the working population. You can see the lower bar which is for jobs which are designed to accommodate 90% of the people in terms of what people tell you is their lifting capacity versus jobs that are not acceptable to 90% of the population. Clear differences. And there are other studies that confirm this kind of perspective. I think the other thing about this is using the NIOSH lifting equation, with the top being low values of the NIOSH lifting equation around 1, and the lower bars being in the range of 2 to 3. But these are not back injuries. These are all traumatic injuries. The other benefit, I think, of ergonomics if you begin to look at physical factors is, you will have an impact not just on cumulative trauma disorders but you will have an impact on other types of injuries because you're looking at jobs, you're identifying stressful risk factors, you're reducing them. So this is, I think, a side benefit to focusing on this problem.

Now I think there are areas of uncertainty. But they're not so much about the impact of intense multiple risk factors exposure. They're about a different issue, which is a difficult issue people wrestle with, and which is that a lot of these disorders are acute, the majority of people recover relatively quickly, particularly if you change the level of exposure. But some people go on to chronic conditions, conditions characterized by a lot of pain, a lot of impairment, a lot of disability. The process by which someone goes from an acute episode to a chronic condition is a complex process for which we do not know a lot of information. Now we know it occurs. We know the vast majority of people will get better with conservative treatment. But we don't understand the process by which people go from acute to chronic.

Another point that I think is important from my perspective is that these high risk jobs, in an absolute sense, are a small proportion of all jobs in America. But in absolute magnitude, it's a large number. We don't know whether the number is one million or five million. But the absolute number of people who are working in these conditions today in the United States is a large number. Particularly if you look at other exposures. If you look at the number of people who are working with benzene or toluene or xylene or other things, if you compare the relative magnitude of the total number of exposures, then for those things that I think there's 80 or 90% consensus about what are truly high exposures, we're still dealing with a large number of people. One thing I wanted to say, and this is anecdotal, but I think that the huge effort that the automobile industry has been making on ergonomics in the last decade is, in fact, having a positive impact. Two of my colleagues, two different colleagues, have told me stories within the last year or two of being in modern plants that have been newly designed, and saying they really look to them, from an ergonomic point of view in terms of physical factor exposure, remarkably better than what they remember from 5 or 10 years ago. So I do think that ergonomic programs do have an impact in industries like the automobile industry which has really dedicated substantial resources to it, and are in fact, making a big difference. I'm sure there's still a lot of work to be done.

Now, I'll turn to three beliefs. These are not based necessarily on scientific information. The first point I've already made. Ergonomic interventions, I believe, will reduce not only lower back pain and upper extremity disorders, but they will impact acute traumatic injuries if you make work that accommodates a larger fraction of the work force. Secondly, and I haven't been able to attend all of the conference so I don't know if this point has been made, but good medical management, i.e., building programs that accommodate people who have problems, whether that problem is work-related or non-work-related, which encourages early reporting which has flexible ability to put people on jobs that they can do, has tremendous cost savings in terms of worker comp. Again these things are not necessarily scientific studies but for those of you who attended the Chicago conference, time and time again companies with progressive medical management programs that were flexible, that accommodated employees with problems, that encouraged early reporting, reported 50% drops in workers' compensation costs. And then informally in a corridor if you talk to people, if you do that in ergonomics for work-related injuries you can do that for all injuries within your organization whatever their source and you really have a workplace that is far more efficient, at least in terms of time off. And the other point is, pain is a big part of this problem. Pain clearly is a difficult problem for everyone who's involved. It's difficult for medical practitioners who can't necessarily resolve chronic pain quickly, who can't necessarily identify the specific anatomical structure it's coming from. But another point that the people within companies who advocate for ergonomic programs made at Chicago repeatedly again is, people who are in pain have trouble producing quality products. So if you're in the business of producing a quality product, if you accommodate people, you use the scientific of ergonomics to make people more comfortable, then in fact you're probably going to have a better quality product. I do think that a big part of the pain around this issue is in fact the issue of pain. And there's two perspectives of pain. The perspective of some clinicians…this is an English clinician from 1994, long before the debate occurred in the United States. He says, some consulting rooms are full of complainers, professionals for whom pain is a career. That expresses the frustration of some clinicians who, not being able to solve the problem of the patient in pain, I think, have a tendency to blame the patient. Then there's what the Pope said in 1956, bodily pain afflicts man as a whole down to the deepest layers of his moral being. It forces him to face again the fundamental question of his fate, of his attitude towards God and his fellow man, and of his individual and collective responsibility. Pain is a difficult issue, but it does impair people and it does disable people. And I would suggest that the science of ergonomics and epidemiology suggests that we do know how to design work to reduce discomfort, to reduce pain. Thank you very much.

Ms. P.J. Edington, COT: Thank you, Larry. Now I'd like to call up to the stage my fellow session arrangers who are going to sum up each of the 8 sessions, and a session arranger is going to give a few salient points from their particular session. And then we'll open it all up for a period of question and answer. The first panel was Size, Scope and Definition of the problem. David Sarvadi's going to give a little summary of that session.

Mr. DAVID SARVADI, Esq., Keller & Heckman

Thank you, PJ. I worked with Scott Schneider on this. Scott and I were trying to put together the points that we could agree on. Somebody came over and took a picture of us, because that was the first time apparently they had seen Scott and I talking to one another in, I guess, somewhat of a civil manner. He and I tend to be on opposite sides of the issue. I want to thank Frank for summarizing most of the sessions pretty well. And I found myself nodding in agreement with a lot of what he said. But I will tell you, Frank, my wife has rotator cuff problems and she doesn't work, and I think it's from the golf that she does. And, believe me, I'm not holding a gun to her head to get her to go do that.

On the size and scope of the problem, Scott and I concluded the following. Clearly, musculoskeletal disorders, if we classify them the way we have, represent a very large fraction of the injuries identified in OSHA logs and by workers' compensation. I'm not sure that I would agree with Frank's contention that there's an under-counting of as much as four fold across industry. I've had some recent personal experiences where we examined the OSHA log in great detail under the watchful eye of an OSHA inspector who was very aggressively looking for cases to add to the log so that she could issue a citation. And in that case we had about a 5 or 6% increase in the number of recordable cases, not lost work day cases, recordable cases.

Point number two that Scott and I agreed on was that both upper extremity CTD's and back injuries were discussed and that ergonomic principles can be applied to both problems, was pretty clear.

Number three, back injuries are a much larger problem than upper extremity CTD's, and that's whether we count only the lost work day cases or the total cases. Clearly back injuries are a much larger problem both in terms of cost and in terms of number.

Number four, upper extremity CTD problems are smaller, but individual cases can be very, very costly. There's a high average number of days a week, high cost and most importantly, a high personal cost associated with some of those cases. And clearly those individual cases need attention. The upper extremity CTD rate as reported by BLS has been declining in the last year or so. We're not sure why it's going down. We'll be very interested to see what the 1996 numbers show in September.

Number five, the back injury rate has not been declining as much. My concern is, I'm not sure we know what the back injury rate has been over a long enough period of time to begin talking about that and I'm hopeful that there will be some folks taking a look at the longer history so that we can try to get a handle on that question.

Number six, back injuries are primarily related to manual materials handling although a significant number are due to slips and falls. Tom Leamon's presentation showed that clearly, manual materials handling is where we ought to be spending some time.

Number seven, certain occupations in industries have significantly higher rates of work-related musculoskeletal disorders than others, but the data presented do not identify specific high risk activities. Scott's and my conclusions about this is that construction and transportation are involved in the back injuries, sprains and strains, and manufacture and retail and service have the most upper extremity conditions.

Number eight, OSHA recordable cases and workers' compensation cases are the best data available, but we do not have a good handle on the true magnitude of the problem and I think that's consistent with what Frank was just saying.

I want to make one more comment about the discussion yesterday afternoon about interventions and controls. Just kind of deviate a little bit from my task here. And that is that there have been some statements of "doing nothing is not an option." Nobody is doing nothing that I know of. Everybody is doing something. The question is not whether people will use ergonomics to try to improve their workplaces. It's being done day in and day out across the country by the vast majority of employers. The real question is what will the government have to do? And I think that's still an open question. Employers all over the country, as I say, are doing this. There are large benefits in productivity. That's what we have been hearing. And my suggestion to you is to consider the possibility that if there are such large increases in productivity and quality available, then it seems incongruous that employers would not wholesale and wholeheartedly adopt these principles in trying to improve their workplaces. And with that, thank you.

Ms. P.J. Edington, COT: Thank you, David. I forgot to mention - if the speakers could try and hold their comments to a few minutes so we can get into a dialogue and then we can talk with the audience, which I know there are some people out there and after everybody's made their presentation if they'd please come up to the mike. A lot of people have been coming up to me and giving me their comments. And now's the time to get up to the microphone. The next session was Case Definitions and Diagnostic Criteria. Larry.

Dr. LARRY FINE, NIOSH

I think my session already has been fairly well summarized. I think one of the places that there was the greatest agreement was that - and even though it's probably a relatively small problem, but when it happens it has a high cost is, it is clear that in some instances, and again, the proportion is not known - that there is too much surgery for carpal tunnel. In particular, cases where people have more than one operation. So I think if there's one take home message from that session, it is that if anyone proposes a second operation for an upper limb disorder, it is time for a second and a third, and maybe a fourth, opinion before you proceed in that circumstance. As already noted, there has been some progress, at least in the epidemiological front of reaching some consensus about how to define carpal tunnel syndrome. There is also agreement that carpal tunnel syndrome is a minority of the upper limb problems, and that there are other specific upper limb disorders that one can diagnose. And that one is still left with a fraction of people who have complaints and limited physical findings where you cannot identify a specific anatomical diagnosis. Which is not really that much different than the back. It's actually better than back wherein with the back, in the majority of cases as was made clear, one is not able to make a specific anatomical diagnosis. I think that's an appropriate summary. While much is known there is still much to be learned about how to diagnose and treat these conditions. Thank you.

Ms. P.J. Edington, COT: Thank you, Larry. The next session was on Research: Exposure Response in a Research mode. And that will be Steve Lamm.

Dr. STEVE LAMM, M.D., Consultants in Epidemiology and Occupational Health

Thank you. I apologize for having some prepared comments. The purpose of our session was to deal with exposure response in the research mode, i.e., the research development of a dose response relationship. We started off first with Mr. Bettendorf who gave a global overview or framework of the wide variety of factors to be considered. Then Dr. Agnew focused in and said let us be very clear in identifying what exposure variables we're talking about and what outcome variables we're talking about - what are the specific health conditions and what are their criteria. Dr. Sauter focused in on the work organization and psychosocial factors and said, the same level of quality control and definition that we want in biomechanical and clinical factors should also be applied in his area. Finally we had Dr. Franzblau's presentation that reported on the relationship of repetitive work to upper extremity musculoskeletal disease. All of these studies and the whole area which we dealt with is that we're attempting to relate the distinctions of exposures to the distinctions of health outcomes. Dr. Franzblau had tried that. Unfortunately their exposure variable, while called repetitiveness, is rather a judgmental scale of which repetitiveness is only one part. Dr. Rogers has continually emphasized the concepts of fatigue and recovery time, both of which are hidden within the scale that they presented. We need greater clarity in both the exposure variable and the outcome variable. Dr. Steve Moore has given us greater clarity in the distinctions of clinical diagnosis, focusing on the specific muscle tendon units. We need to incorporate this into our studies. Many physician groups, as seen in the recent notice in the British Medical Journal, The Lancet, have rejected the generic diagnostic labels of cumulative trauma disorder or repetitive stress injuries, because they cannot confirm either pathological process, preferring to give either a specific clinical diagnosis such as tendonitis or carpal tunnel syndrome when the clinical criteria are met, or to label the case as a localized pain syndrome when they are not met. Calling the condition a 'pain syndrome' does not make it a determination that the condition is not work-related. The determination that a condition is work-related is separate from the determination of the diagnosis of the condition. That's an important distinction that I think we should pay attention to. The recent workshop on work-related musculoskeletal conditions held by the American Academy of Orthopaedic Surgeons developed the proposal that the label, "work-related," should allow for three subcategories rather than two. It should include a determination that a condition is caused by work, that the pathology of a condition is aggravated by work, or that the symptoms of a condition are enhanced or aggravated by work in the circumstance where the pathology is not increased. The determination of the manner in which a condition is related to work is separate from the determination of the mechanism by which a condition is related to work, and is still separate from the determination of the degree to which it is related to work. The questions for epidemiologists and occupational physicians relate to which specific conditions are related to which specific workplace factors, and where intervention will give the greatest yield. It is likely that the answers will differ for different joints and different general magnitudes of forces involved. The energy domains of the keyboard operator are markedly different from those of the construction worker and the industrial worker. The answers to their problems may be different. An earlier session dealt with fine distinctions of clinical diagnostic labeling, i.e., outcome assessment. A later session dealt with the fine distinctions of biomechanical measurements, i.e., exposure assessment. Unfortunately, the validation of these measurements, meaning the exposure measurements, has been related to the entries on the OSHA log a measure for which there has been no quality control. The contents of the OSHA log, in fact, have regularly been cited as the basis for intervention, whether by regulators, management or unions, or groups like Ford Motor Company. All OSHA log discussions have related to its completeness, none to its accuracy or its specificity. Musculoskeletal disorders among workers are real. However, we have to define them more clearly, as well as their associated risk factors. I suggest that a next and necessary research step for epidemiologic and our operational studies is to present both the medical conditions and the workplace stressors with fine specificity in the same studies. Let us find out if the measurements made by Dr. Marras relate similarly to all types of lower back pain syndromes in workers, or differently with different types. Does Ford find that certain specific upper extremity pain disorders are more susceptible to ergonomic interventions than are others? These are two specific sites where helpful research can be done now. Thank you.

Ms. P.J. Edington, COT

Thanks, Steve. You sneaked some other stuff in there on me. I'm going to cover the next session, which is Intervention and Controls, for Lida who left me some points that she thought were salient points out of her session. The first on intervention and controls is that the dose response argument remains, but data shows that a relationship does exist between dose response. Assessment of those exposures is critical and the quantification is necessary for legal intervention but not for voluntary actions. Some of the speakers felt that each facility when they were speaking, should have the latitude to apply the combination of interventions they see fit - that was the Red Wing [Shoe Company - not the NHL Stanley Cup Champion] example - and that a strategy with specific components can be recommended - that was, I think, Fred Schott's Aetna example. Flexibility is the key in these programs, or in these interventions. Bureaucratic methods may hinder rather than help. Interventions can be simple and inexpensive. We certainly saw the tape from Red Wing on that point. But if you listened to Dr. Chaffin, interventions and controls may also may be expensive and very complex. Four, interventions have some relationship with reduction of severity rates - that was Aetna and Red Wing - or as another speaker pointed out the converse, that was that prevalence and frequency may increase and not be affected. The last point that I think maybe Howard Sandler made was that we need good data to justify controls and interventions. And these are not always obvious. What gets measured gets attention. I think several speakers have said that over and over again. And that we need better metrics. Unfortunately Gordon Reeve had to leave so Hank Lick has agreed to pinch hit for him and mention a few points that came out of the Economics: Costs of Illnesses and Costs of Controls Session.

Dr. HANK LICK, Ph.D., Ford Motor Company

Okay. To sum up Gordon's session, Dave Alexander opened and talked about a number of methods that could be used as economic justification for ergonomic programs. He also said that these had been poorly done. Steve Moore continued on looking at savings in ergonomics from a workers' compensation cost viewpoint and pointed out that even though the incidence increased, there was a reduction in overall costs in workers' comp in the cases that he looked at. Mark Berkman contended that cost benefit really wasn't there, and that the ATA study suggested that OSHA estimates of cost were grossly understated. And then finally Sue Pastula continued to describe the elegant data system that we have at Ford and its ability to track workers' comp costs. Probably one of the goals when we were setting this thing up was to bring up a discussion of the economics, which really is I think, one of things that is at the root cause of the contentious issues. I don't know whether Frank and I have just been together too long or whatever, but I noticed in his presentation he did admit to quality and efficiency improvements. Probably if you look at a pure cost benefit model you have to look at what you'd get as far as quality and efficiency improvements. This has probably been taboo to look at the efficiency improvements because it comes in the area of collective bargaining. But if you're to look at a true equation, that's probably where it's at. And also, David admitted that there was probably some justification in this particular argument - that there were other things other than what's been mentioned. I think when you look at economics, it becomes the application of the standard - how it's going to be applied, that will determine the economics and the costs that are involved. Even though costs for fixes can be small, they can also be large. So it becomes an access question to capital not only for big manufacturers but also small manufacturers. The final thing I'd like to say is that anything you do in ergonomics that you take beyond big manufacturers has to meet a small business test. We really had no real discussion of the small business implications, the SBREFA hurdles that have to take place. So however anything that happens in a regulatory context unfolds, the small business model has to be considered. Those of you who go to NACOSH meetings and hear other things other than I'm quoted on, hear me a lot of times talk about that has to pass "my brother's test." My brother runs a small tire company in Cleveland, and he employs 10 or 15 people, I forget what it is. Essentially, he changes tires in 20 minutes. That's his whole thing in life. And he has back troubles with it. There's very little that he can do and still stay in business. So there's a lot of business people that do contribute to the economy that you have to look at. In my brother's case, he employs several people that are unemployable in the normal business economy. They're unemployable at Ford. So the small business test certainly has to come into play and that's the economics of it.

Ms. P.J. Edington, COT: Thanks, Hank, I appreciate it. The next session we had was Methods of Ergonomic Exposure Assessment: Validity and Limitations, and Brad's going to sum that up.

Dr. BRAD JOSEPH, Ph.D., Ford Motor Company

I had several questions throughout the conference and I think it deals with my particular session. The questions were how much and how long and how many? To sort of frame it from our perspective, sometimes from industry I felt like I was on the periphery, but actually I think I'm in the middle of this on a daily basis. I think we've got to perhaps pull the other folks from the periphery into us. From the biomechanics side they concentrated on how much. From a fatigue side, they concentrated on how long and how many and how much. From an academic side, they concentrated on a $500,000 study, three years in five plants, as for how long and how much and how many. On the legal side, we talked about the number of articles that were published as a state of the science. And how useful those articles were as a sort of a method or measure of the state of the science. I'm not so sure if that's a corollary to look at case law out there and to look at that the state of the science rather than as a state of the law in this country. One thing I found very interesting, and PJ must have called me five times if she called me once about discussants. Now don't let them have anything prepared, just have them get up there and talk about what they heard. It's amazing how fast some of these discussants can be with PowerPoint. I saw five color, overhead graphics with things going up there and I thought, well that's pretty amazing. I didn't know PowerPoint was quite that good. But, now getting to my session. My session was the Method of Exposure Assessment: Validity and Limitations. Actually if I reframed this I would like to have actually done this with the medical community here, because the medical community had some interesting things with tic tac toe - XXO - that means we have the disease, or XXX - maybe we don't have the disease. I kind of thought that was an interesting way of doing that science. I feel a little bit better now about going to my medical doctor. However, in our area, measures of exposure assessment, we really have four big areas, but I think you can really put them into three. We had manual material handling and Bill Marras and Don Chaffin talked a lot about that. It was actually quite interesting when someone said, well, the medical community says we can't really diagnosis back injuries and you see Don's face seeming to say 'well wait a minute, we know all the problems with back injuries.' But I do think they have a pretty good metric of what's going on. They know how to look at the body. And they also know how to evaluate what's going on. They have some good methods of measurement and I think we should start using these things, as we do right now. It doesn't mean you have to use all of them. But you can use, certainly, part of them. Tom Bernard talked about short cycle jobs. He looked more at a fatigue analysis approach. He tried to put a lot of the current research into sort of a system that we actually quite honestly, are using at Ford. And I think this is the type of system that we need to look at. We can't have these independent tools out there. We actually have to start using these systems in a valid way. And finally Dr. Hegmann I think had a sort of a different system. He looked at hand and wrist, or as Steve Moore says, "distal upper limb problems" and he deals with those as being biomechanically and fatigue driven. He said we need to do more research on the shoulder which I absolutely agree with. So I think generally those were some very big areas in which we need to deal. I think the outcome of that was, they felt very confident that the research could probably be used to assess risk on the floor. It was actually quite interesting when the lawyer yesterday was talking about the back problems and to see Bill walk in here and see his face. It was more interesting to watch Bill's face than it was to watch the lawyer's speech at that particular time.

So what do we do now? Well, UAW-Ford has been at this for about 9 years. We've been at it before that from an informal perspective. And we're going to still continue to look at injury/illness data, complaints and proactive analysis, and we'll still try to solve problems. The last couple of years we've solved a lot of them, we think. Can we measure the outcomes? I think we can. We can't measure them to the finest detail, to four decimal points, but I think it's a very positive process. And that's what we're going to continue to do. In the meantime, I hope that the experts on the fringe, I think, can come to the middle with us and work on this process. And we can develop an action plan to go forward with what we know, and we can then continue to progress the science. Thank you.

Ms. P.J. Edington, COT: Thanks, Brad. Our next session was on Case Management, and I have to put in a plug for Pat Bertsche here because as a Session Arranger, she was a dream come true. I mean, this woman worked and worked and worked, and got her session together before anybody else. And from a Conference Co-Sponsor's point of view, thank you. We'd have you back in a second.

Ms. PAT BERTSCHE, Ohio State University

Well, but what she failed to tell you is I went through four co-arrangers, and I wondered if it was me. I had the pleasure of putting together the Case Management Session with four different people. And I thank Brian for agreeing to put up with me to the bitter end. Case management, obviously, focuses on early intervention of workers with musculoskeletal disorders and getting them back to work. The four speakers that we had addressed a variety of issues relevant to case management. Nancy Schott discussed case management under the Americans With Disabilities Act. She described management's responsibilities under the Act, and stated that the ADA requires an interactive process that includes the injured worker, management and the health care provider. She discussed the feasibility of making accommodations, and in particular, the requirement to make accommodations and feasibility issues were addressed. She also emphasized the need to maintain the confidentiality of medical information. This is a requirement under the ADA and it's, of course, a requirement under any medical professional's code of ethics. People that are non-health care providers in the work environment should receive appropriate information regarding the workers' ability to perform the job, regarding work restrictions, but not medical information. Bruce Kaye presented a particular case of workers that have sustained work-related musculoskeletal disorders. He talked about the discrimination of employees with work-related musculoskeletal disorders under the Americans with Disabilities Act. These particular employees were placed in a, quote, "graveyard restricted duty work pool" requiring the injured workers to work the night shift and perform, as he described, less than desirable work activities. Gary Franklin encouraged us to change the paradigm from injury disability to injury prevention as a result of research that he's conducted. He presented a model that described the exposure leading to potential injury as well as then the possibility of leading to disability. Brian brought this up to me this morning and he's right, he noted that psychosocial factors may, in fact, be more important during the disability phase as opposed to during the exposure or injury phase of this model that Gary described. Gary also talked about a variety of people doing case management. I had no idea there were that many different types doing case management. But he said employers should be cautioned and look for an integrated delivery model and always look for some sort of evaluation component of case management. Dr. Robin Baver described a retrospective study of occupational carpal tunnel syndrome in a cohort of 133 truck assembly workers. The greater majority of these workers had carpal tunnel surgery for the treatment of the problem. She concluded that in this particular study surgical treatment was successful in returning workers to work, as opposed to previously reported studies. She cautioned, however, about the generalizability of the study results, since apparently 96% of the people in this study were males. In fact, during the question and answer session Dr. Baver generally recommended conservative treatment as opposed to going to the knife right away.

So where do we go from here? Brian and I discussed that this morning. We believe that our speakers and discussants generally believe that early intervention must continue to be emphasized to prevent disability. We would encourage an integrated case management team. This is a professional activity. The people involved must be knowledgeable of the worker's work environment and the job that he or she is working on and might be able to go back to. And they should possess the needed skills and be given the appropriate responsibility and authority. Finally, case management must involve an evaluation component to make sure it is effective and successful in returning the workers to work. And ultimately, as Larry said this morning, must result in a significant cost savings.

Ms. P.J. Edington, COT: Thank you, Pat. The last session we had was on OSHA's Statutory Framework. I know you touched on it in your remarks, Frank. But maybe you would like to elaborate for a couple minutes.

Dr. FRANK MIRER, UAW

I must say, Dave Sarvadi was one of the advocates in the conference planning group, of having this session included, and that was against some rather stiff opposition. But I think it proved to be a very useful addition to the program. Basically three of the presenters focused on requirements for setting a standard and for General Duty Clause, and I think very well amplified the issues that'll be debated over a long period of time. OSHA standards must address, or rather health standards must address material impairment of health. And so the gravity and the nature of the musculoskeletal disorders which could be the target of intervention was discussed. Health standards must identify significant risk and demonstrate a prospect of reducing that risk. The participants then talked about all the ways that could be interpreted and how high a barrier that was. And one of the important points was the discussion of criteria for technical and economic feasibility. And I think that it's clear that from a legal precedent, OSHA standards can require efforts by employers beyond the cost benefit test and can impose and may be required to impose very significant costs in abatement beyond the costs of the injuries. I think that that's the crux in the argument about going forward with a standard. There was discussion of the General Duty Clause citation and the issue was raised that the effects which trigger General Duty Clause obligations of the employer may be higher gravity health effects than those which would be needed to trigger the standard. Finally, Terry Murphy, I think educated the technical people in the audience of what they're going to have to do to prove that back injuries can be work-related. There was also discussion of percentage of back injuries which are work-related. Finally Sid Shapiro gave, I think, an elegant set of criteria for how to evaluate the need for external review of standards, and in particular, the National Academy of Science's review. And those would be whether it would contribute to the accuracy of the assessment of health risks, the efficiency by which OSHA might complete the rule and acceptance of the rule by the Agency participants and public. And that framework will be, I think, what we will use for arguing about whether the Bonilla Amendment requiring an NAS study is really required. I think it was a very useful session. Your case never seems so strong as before the other guy starts talking about what it's like.

Ms. P.J. EDINGTON, COT: Thank you, Frank. Because this conference is being recorded, everything that's said from the people in the audience to the people up here will be transcribed and will be on Ergoweb®. If anybody would like to go to the mike and make a comment, ask a question of somebody up here, or correct the record - now is the time to do it.

Dr. Pat Beecher: Hi, I'm Pat Beecher from Ford Motor Company. I'd just like to make five short observations from this last week. First I think we need to get a better data system. I think our data's pretty poor. If we're to rely on the OSHA recordkeeping system I think we need to really push for the new revised proposed system that we're trying to put in place. Secondly, CTD's or RSI's, or whatever we want to call them, I think there's no doubt that they're multifactorial. I think there's work-related issues. I think there's non-work issues. But I think we need to look at those. We need to do more research into that. I think they also vary by the diagnosis and the individual, and I think we need to look into that. Thirdly, I've heard a lot of this week. We must remember that medicine is an art, it is not an exact science. We try to move into the scientific principles as much as we can, but it is an art. Fourthly, I think as physicians, we have to remember for those in this group and for a lot of the discussion this week, it actually bothered me to a certain extent. We treat people, we treat individuals. We don't treat positive MRI's. We don't treat positive x-rays or tests. And we really to develop a medical management model to treat people as individuals and not as a diagnosis. And lastly I think this conference is a good start. But I think we have a long ways to go in terms of developing an ergonomics policy especially in those areas that we can control. Thanks.

Ms. P.J. EDINGTON: Thank you, Pat.

Mr. Don Fayre: Yes, good morning. My name is Don Fayre and I'm with the UAW-Ford at Saline Plastics in Saline, Michigan. I have a couple of comments and then a final question. First off, I'd just like to thank all the members who worked to put this meeting together we appreciate the level of intellect and the enthusiasm that each of you gave each of us. Next, I'd like to thank all of the members of the audience here for your participation and your support and obviously the level of commitment that's here by your physical presence right now. We lost quite a few people and I think it's important to hang in there. Now moving on to my question. It's based on the last question of the evaluation form dealing with best practices. The question is simple. Would it be possible for next year to have several different companies, local ergonomics committees, give a brief explanation of what they do and how they do it, and what works for them. So as an observer of the audience we can kind of network and write down notes and take practical information back as to what we can do at the grass roots levels.

Ms. P.J. EDINGTON: The answer to your question is yes. But I also may point that Nancy Adams is in the back of the room and is putting together ten OSHA Regional "best practices" conferences. I think, Nancy, you've got the first two planned, which is another source for that kind of information. But to answer you, we've already talked about next year's conference and that's exactly what we'll be doing.

Mr. Don Crabtree: Don Crabtree, UAW Ergonomic Committee, Local 863, Sharonville Transmission plant. I also want to thank the folks that were here and gave us the information. Just like Brad said, we're going to keep on going on the ergonomics committee, we're going to try and solve some problems. I'd sure like to see some OSHA standards though.

Ms. Shauna Cole: Hi. I am Shauna Cole from the Oakridge National Laboratory in Tennessee. Several years ago I had an opportunity to work with an industrial hygienist who was on the ACGIH threshold limit value committee at that time. He was talking about the process of developing threshold limit values, and he said that we read everything that we can find, we pull a number out of the air, we throw it into the ring and we try it out. And I really think that it's time to start looking at some numbers and throwing them in the ring. I think that we are that far along and we need to just draw a line in the sand. There seems to be a pretty firm agreement about the high risk, high exposure people and the problem seems to come as we talk about the low risk, lower exposure folks. And even when we control carcinogens through the permissible exposure limits, we all know that some people are still going to get cancer who have had those exposures. So similarly when we draw a line in the sand for other exposures there are still going to be some persons who have low exposures who still get sick. And that is unfortunate. But we need to draw a line in the sand and start stating some threshold limit values and exposures for the people who are clearly at high risk and clearly getting sick. And one of those things that could really help us is to see a lot more data of population prevalence in these disorders. And my question is, am I missing this data or is it just not out there? I would like to see population prevalence data on each of the upper extremity musculoskeletal disorders that we've been talking about. I haven't been seeing that, so I'd like to challenge the group to make that information readily available and then start throwing out some numbers and 'fight it out.'.

Ms. PJ EDINGTON: Thank you. Did anybody want to respond to that?

Mr. DAVID SARVADI: Yes. It might seem odd coming from a lawyer, but I participated in the meeting that Steve was talking about at the American Academy of Orthopaedic Surgeons. Let me give you just one example of a data point that exists. And I think the data may be out there, we just haven't gotten to it yet. At the Academy meeting, we had about 20 hand surgeons. To a person, to an individual, they agreed that the background incidence of carpal tunnel syndrome in unexposed individuals is about one per thousand. One per thousand. The incidence of people who are exposed they suggest, is about two per thousand. Now we heard something different from the Navistar folks and some of the data that we see from the surveillance systems suggest that it's different. And, so you're very correct. I think there's a question that needs to be answered about, what's the background level and where do we go to look for definitions for those terms "high risk" and "high exposure."

Ms. PJ EDINGTON: Thanks, David. Frank?

Mr. Frank Rooney: Frank Rooney. Digital Equipment Corporation. Sort of a question and also a comment. This week has sort of been focused on ergonomics and it is an ergonomics standard or a ergonomics regulation. What I would suggest because of all the uncertainty and disagreement I've heard all week is that, and maybe Frank would like to comment on this, is what about setting a health and safety management standard that would dictate the process all of us should go through for all health and safety issues and drawing ergonomics to more at guidelines and advice or counsel, since the science is not clear on what is right and what is wrong, and maybe taking that approach to get us a little further in trying to argue over distinct numbers and distinct outcomes.

Dr. FRANK MIRER: The proposal that labor has advocated for an ergonomic standard is essentially a process standard that would be generally applicable in workplaces, at least in those above a certain level of incident risk. Rather than a specific limit on exposure or specific specifications for types of equipment, it was a process standard, and not that dissimilar from the Safety Process Management Standard. I will tell you that for the Process Management, the general standard, the burdens of regulatory analysis, cost benefit and all the other barriers to setting a standard are virtually impossible to overcome without almost unanimous, or even unanimous industry support for moving forward with that sort of thing. The other issue, this is kind of an abstract intellectual point, any one of these process standards is really a specification standard. It specifies what has to be in the process that it's going forward with. It's sort of the opposite of a performance kind of standard which would be an exposure limit. And that's the reason why these are difficult to move forward.

Mr. DAVID SARVADI: Let me react to that from the perspective of a practitioner in Washington. We've looked at the question of the safety and health program standard that OSHA's been considering, and we come to a lot of the same kinds of questions. If you accept that the statutory parameters that you have to work within are that you have to show there's a significant risk, you have to show that you're able to mitigate that risk, and so on and so forth, you begin to ask the question, "what's the significant risk that the generic program safety and health standard will address in comparison to what current standards and the General Duty Clause and the present scheme now address?" And the conclusion has to be, if you're proposing a general program standard, is that the current system doesn't work. So I think the people at OSHA that are working on the safety and health program standard are starting to react to some of these considerations because I know that they have looked at some things that we've put together at Keller and Heckman and sent to them. Now that suggests one other problem. And having worked on this problem now for about four years and having lived with it all of my professional career, I've come to the conclusion that perhaps what we really need to do is talk about the OSHA statute, the underlying legal framework that we're working within. If our premise is that we want to start with a significant risk and address a significant risk, then the current system works. However, if the premise is that we want to start talking about promotion of well being in the workplace and about programmatic approaches, I think Frank is entirely right. We are going to run into some very significant procedural problems and difficulties, and it's going to be extraordinarily expensive and extraordinarily difficult to come to those conclusions. So, from the purely legal point of view, I think it's going to be very difficult. If you think ergonomics has been hard wait until we start talking about safety and health programs in the kind of detail that we're talking about them now. I see Hank wants to get a word in too.

Dr. HANK LICK: I agree with Frank Rooney. As far as I'm concerned on safety and health program standard, there were a number of us in stakeholder meetings with OSHA several years back that said our contention was what you really ought to do is concentrate on building block standards. Building block standards to us are really safety and health program standards and ergonomics. To me, the standard system is essentially broken. We can have this dialog which is good. It's probably the only way we'll ever get past some things. But if we had safety and health program standards and if my friend Frank would be willing to accept that, if you had a good safety and health program standard that included job analysis and planning and everything else that went with it, you probably wouldn't need ergonomics. I would agree with you on that. In a perfect world at OSHA, safety and health program standards forever, no more "standards" ever, and that's the way I would go with it.

Ms. PJ EDINGTON: Thanks, Hank. Sue?

Dr. Sue Rogers: Sue Rogers. Rochester, New York. Let me ask you if there's still a feeling that what had happened back in the '70's where we looked at guidelines, such as the lifting guidelines, and use of association of hazard for use in the General Duty Clause to cite plants for unsafe practices. Will the same be true when the ANSI 365 guideline comes through. It's coming to the end of its development, that's one of the things on the way. I'm just wondering if when that is issued, whether it will be used for a General Duty Clause citation of company's for unsafe work practices?

Mr. DAVID SARVADI: I take it that was directed at me since I'm the only attorney up here. If you were asking me that question and I were a Solicitor of Labor or Assistant Solicitor of Labor, I would say absolutely we would use the ANSI standard to try to show that there's a general recognition and that a particular employer had failed to do what was necessary to address the problem. The difficulty that OSHA has in proving recognition is that you also have to show that that set of criteria apply to that specific employer. Randy Rabinowitz yesterday mentioned the Pepperidge Farm case, I would not, if I were in OSHA's shoes, get too excited about that because Pepperidge Farm was kind of a unique situation. They had lots of ergonomists talking about lots of different things and they had lots of different cases on their injury logs. I don't think anybody would suggest, including Pepperidge Farm, that they should have done nothing. In fact, the argument in the Pepperidge Farm case was that they had not done enough quickly enough and tried everything all at once in order to get accomplished. So from my perspective, an ANSI standard in an enforcement situation is going to be something that I'm going to have to take into account if I'm defending the case and certainly OSHA's going to use in favor of it. But it's not going to be a determinative answer 100% of the time.

Dr. FRANK MIRER: I think the General Duty Clause, or our understanding of that obligation, is the road forward towards an OSHA standard. The way we look at it, if the employer knows somebody got hurt and they know there is a solution to that problem that caused the worker to be injured then they have to fix it. That's basically what the General Duty Clause says. A lot of places have 100, 200 cases on the OSHA log which pretty much demonstrate that there's a problem in that workplace. Certainly in large manufacturing operations. So our view is that what the standard is accomplishing is, first, what's the employer's obligation to do under the General Duty Clause to deal with these problems. I'd like to move beyond that, which is to require analysis of these jobs before somebody gets hurt. We want to be working upstream. Frankly the current situation in the American manufacturing industry is that they've got plenty of cases already. You don't have to be out there looking for symptoms or things that could cause a problem. There's problems out there now that aren't being fixed. Let me go back to this question of "well, if it were economically efficient employers would do it anyway." First of all, there's no law against being stupid, even for management. If people are being hurt because management's making a bad economic decision, that's something that we need protection from. I'm sure many of you would argue, on the management side out here, that your plant management isn't putting enough emphasis on safety and health now and that's not a smart thing to do. That's why we need OSHA and an OSHA standard even for the better employers, even for the best employers, that's a grounding that we need.

Ms. PJ EDINGTON: Thank you, Frank. I see there's no one else on the mike.

Dr. LAMM: I'm sorry. You said that the purpose here was to deal with the issues and also to correct the record.

Ms. PJ EDINGTON: Okay.

Dr. LAMM: One of the things I want to deal with that was discussed yesterday. There was a great deal of discussion on the benzene standard and what it was that was said in there. I had to go and refresh my memory and re-read the particular section. Basically it dealt with the issue as to whether the court was describing a dose response relationship. Fundamentally what the decision said was that if there was a risk of death of 1 in a thousand, that that was clearly significant and was a situation where OSHA ought to regulate. In another circumstance where the risk would be one in a billion, they gave the example of, for instance, drinking a glass of water with a minute trace of benzene in it. If the risk was only one in a billion that was something insignificant and not appropriate to regulate. Then it went on to say that given these two ends of the dose response curve that the court was not giving direction to OSHA as to where within that range the standard ought to be set, and that it left that to OSHA and to legal processes. I wanted to put that in as clarifying the issue there.

Ms. PJ EDINGTON: Thank you. And I see we've got another brave soul at the mike.

Mr. Jerry Wagner: Jerry Wagner. UAW Delphi Chassis. Dr. Collins said that it was questionable whether a person with minimal training could do a good job of analyzing jobs and reducing injuries. I'm from the school of backyard mechanics and baling wire. Four years ago when we started this program, our injury rate was about 30% and total injuries were musculoskeletal. Last year it was 15%. So we did do a good job, and I'm a person who has minimal training.

Dr. DON COLLINS: My only response to that is that for my particular association, we're always concerned about complex regulations that might come from OSHA. What we're interested in always is that regulations that are produced can be effectively complied with by our members. So we always look for simplicity and unfortunately, that is not generally what we get from regulations that come out of Washington. So while I commend that you have been able to unravel some of the mystery of regulations that have been applied to your particular area, we're just vigilant that we always want to be certain that regulations that might apply to our particular industry are understandable and can be applied.

Mr. Wagner: I guess the other comment that I wanted to make is that when you have achieved this dramatic reduction in injuries, had we not been part of an industry-wide agreement with OSHA that required us to be analyzing jobs, look for these injuries and try to abate them anyway. I think that's a very important point. It does work.

Mr. DAVID SARVADI: This is David Sarvadi. Let me respond to the question. One of the points that we're trying to keep foremost in front of us here about this question of simplicity and ease of use has to do with things like Dr. Marras' back injury model. It is elegant. There's no question about it. I'm sure that if Dr. Marras were given the opportunity to analyze every job in the country that he could tell us which ones are problems and which ones are not. My problem is I don't think there is enough time for Dr. Marras to do that. And what we need is something that translates Dr. Marras' system into something that can be used by individuals all around the country. And let me respond to the second point that you made about being the UAW. Are you with GM or Ford, I don't know.

Mr. Wagner: General Motors Delphi.

Mr. SARVADI: General Motors segment. I work with a lot of clients that are doing exactly the same thing that you're doing and they don't have bargaining agreements and they don't have the government looking over their shoulder. They don't have anything except their conscience and their pocketbook to guide them and they're experiencing the same kinds of things. So my question to you is, why do we need to be forced into a model that is not necessarily applicable across the board?

Ms. PJ EDINGTON, COT

Do we have any more comments? Because I think as they sage goes, the mind can only absorb what the heiny can tolerate. And I think we're hitting that point. And of course, Brad has been pointing out to me all week that he wants to include the bladder in that because he keeps saying to me, PJ, you're not giving people enough time to get up and get rid of the coffee they've been drinking.

So, in summary I'd just like to thank all of you again that attended and those that stayed to the bitter end. I would also like to thank the planning committee. A lot of work went into this and a lot of people spent a lot of time, and particularly at AAMA, Brian and Brad and Hank and Dave put a lot of work into this. Also Dave wants me to remind you to hand in those pink evaluation sheets because, believe it or not, we really do read them and we really do pay attention. And for you people who said we weren't in Tampa this year, we didn't pay attention to that, but we're listening.

The other thing is I did want to underscore is that the proceedings will be on Ergoweb®. For some of you that came up and asked me would they be available in July, the answer is, no, they won't be available in July. But we hope to have them available by September. If there's some piece of information that you need, critical information, call us at the Center for Office Technology and we'll try and get it to you. And, lastly, I would be negligent if I didn't thank the COT staff. There's a lot of macro stuff that goes on to a conference this size but there's a million micro details. And I hope you all have noticed that this has gone on without a glitch. From the program to the AV to everything else. I hope you all found your stay comfortable, and that's because of Karen, Sherry and Siggy who are here. They've put in a lot of effort, and I'd just like to thank them personally.

If you have any ideas for us, as always, if you have good comments, see me. If you have complaints, see Dave Felinski. He takes all the complaints. And I thank you and hope to see you next year.