INTERVENTION AND CONTROLS

In the real world, the incidence of musculoskeletal illness in our workplaces demands actions from employers and workers well in advance of complete scientific understanding or policy formulation. Relationships between certain work or off-work activities and musculoskeletal conditions may be sometimes self-evident; or they may be based on professional judgment of risk factor testing; often they are based on the experience and practical experimentation of ergonomic, occupational medical, labor and management safety and health professionals.

In the past decade or so of dealing with these problems, much useful experience has been gained. While interventions and controls are often unique, based on individual workplace conditions, there may be important, broadly applicable lessons from successful interventions and controls. Various forums have been created to share these experiences, and this session is designed to add to the growing body of general guidelines.

To reduce the risk of injuries effectively we need to know where to intervene and what to do. We hopefully want to start with interventions with proven effectiveness, to the extent that they exist. In the absence of that, we need a strategy on how to intervene effectively. This panel will discuss their experiences and the evidence that interventions work and effective strategies for interventions.

Session Arrangers

Lida Orta-AnJs, PhD, project Ergonomist, International United Auto Workers
Michael J. Fagel, CSP, Corporate Safety Director, Aurora Packing Company

Presenters

Fred Schott, Safety & Environmental Consultant, Aetna Business Resources
Office Ergonomics Interventions and Controls in a Changing Organization

Lytt I. Gardner, PhD, Chief, Injury Casualty Section, Div. of Safety Research, NIOSH
Efficacy of Back Belts for Prevention of Back Injuries in Material Handling Workers

Eric Frumin, Director, Occupational Safety & Health, UNITE
Impact of an Ergonomics Program Featuring Adjustable Chairs on Upper Extremity Musculoskeletal Symptoms Among Garment Workers

Gail B. Sater, Risk Manager, Red Wing Shoe Company

Discussants

Dan Macleod, CPE, Director of Ergonomics, Clayton Environmental Consultants
Howard M. Sandler, MD, President, Sandler Occupational Medicine Associates
Mark Fielder, Coordinator of the UAW-GM Health and Safety Center
Nick Warren, PhD, Ergonomic Technology Center

Mr. DAVID FELINSKI, AAMA

Good afternoon , and welcome back from lunch. It's now my pleasure to introduce our next Session Moderator, Dr. Lida Orta-AnJs. Lida is a Project Ergonomist for the United Automobile, Aerospace and Agricultural Implement Workers of America, otherwise known affectionately as the UAW. Her responsibilities include designing curricula and implementing training in ergonomics, developing assessments and devising recommendations for industrial and office work station redesign, and designing solutions to prevent or reduce musculoskeletal injuries and biomechanical problems. In addition, she is responsible for the design and implementation of surveys for workers assessments of discomfort and the development of a methodology for ergonomic assessments in the workplace. She is also responsible for making recommendations, for contract language and dissemination of federal OSHA and State of Michigan OSHA guidelines regarding ergonomics. Lida received her Ph.D. degree from the University of Michigan six years ago. Dr. Orta-AnJs, the session is yours.

Dr. LIDA ORTA-ANIS, UAW

I guess that's the benefit of traveling with Frank, you always have a nice cheering section. Good morning, again. It's my pleasure to be here this morning, and before I go into the presentation of panel members I would like to acknowledge the contribution of Michael Fagel from Aurora Packing as the co-arranger for this session. Michael couldn't be with us today, and I do appreciate his effort into getting this session together. Though this panel has the charge of discussing control and interventions, design for individual workplaces but yet applicable to broad situations. Our four panel members are going to present proven effective interventions or strategies leading to successful interventions in their specific workplaces. There have been some changes in the panel composition that I would like to present to you. The first panelist will be Fred Schott and he will be making a presentation of the strategy used at Aetna to promote effective interventions in office environments. The second presenter will be Lytt Gardner from NIOSH who will be presenting a study methodology for determining the effectiveness of back belts. Mr. Eric Frumin will be the third speaker, and he will be making a presentation on a research study developed by several authors including Mr. Jonathan Dropkin, who left us this morning to go back to attend a family emergency. So Mr. Frumin will be making the presentation on his behalf. And the fourth presenter will be Ms. Gail Sater from Red Wing Shoe Company, and she will be discussing practical ergonomics changes implemented at their facility. I will ask you to help me welcome Fred Schott.

Dr. Lida Orta-AnJs, UAW: Our second speaker is Lytt Gardner. Lytt is the Chief, Injury Causality Section at Division of Safety Research at NIOSH in

Dr. Lida Orta-AnJs, UAW: Our third presenter will be Eric Frumin. As I mentioned Eric will be making a presentation on impacts to the needle trades. And Eric is the Director of Occupational Safety and Health, Union of Needle Trades Industrial and Textile Employees, UNITE [ Mr. Frumin made the presentation in place of Dr. Dropkin]

Dr. Lida Orta-AnJs, UAW:Our next speaker is Gail Sater. Gail is the Risk Manager for the Red Wing Shoe Company.

Ms. GAIL SATER, Red Wing Shoe Company

Hi! Only twenty more minutes and you get to eat, okay? I want to piggyback on one thing that Eric said, I was at a conference and he was there recently. And one of my counterparts at Oshkosh was there and we were talking about chairs and how do you get your employer to buy in that you really need these? And she came up with a great idea. She had senior management - they were there for an all day planning session - she hauled the chairs in from the manufacturing plant, put them in the conference room where the big shots got to sit on them for 8 hours - she got the chairs. They were so good. Red Wing Shoe Company, for those of you that don't know about us, we're a little shoe making company in Red Wing, Minnesota. It's named after an Indian chief. We've been in business since 1905, started by 15 original investors, and we're family owned. About 5-6 years ago we were in some big trouble financially as far as our workers' compensation costs. I have an overhead I'll show you later. We had some internal and external things coming against us. Going back to 1966, there were 1,100 shoe manufacturers in the United States. By 1994, there was only 340 plants. Shoe imports in 1966 were only 16%. By 1994, they were 89%. We're one of the few that still manufactures in the United States. There used to be 214,000 employees in the shoe business in the United States, and now we're under 49,000. Red Wing Shoe Company itself makes primarily work and service shoes. We're the largest steel toe manufacturer in the United States, and we employ about 1,500 people in manufacturing, making about 3 million pairs of boots a year. We make over 150 styles, going from a size 4 , 2 to a size 18, in widths from a AAA to a EEEE. If you've seen movies like Grumpy Old Men, Overboard, Bridges of Madison County - our boots have all been in there. And if you're fans of Home Improvement, Al Borlin - Mr. Flannel - wears our boots in the show. We're still using our same plant that we had since 1905. We have built a new one in 1967 and we've picked up a couple more plants since then. Some of our costs that we were facing - in 1988, our workers' compensation costs were four million dollars a year. That's a lot of boots that we had to produce to pay for that. By 1995, we had those costs down to about 800,000 dollars. Our experience modification factor, if you're familiar with that at all, was 2.3 in 1988. We're down to .81 right now. We had frequency rates of 28.6; we're down to about 15 right now. We had to do something or we were going to go in the assigned risk pool, we were faced with maybe laying off some workers, all sorts of things. Ergonomics weren't the only thing we did. We hired a full-time risk manager. It wasn't me, it was my predecessor. But he had his Master's Degree in safety and that was his focus when he started out. We also have a full-time disability manager.

We hold regular claim review meetings, and we started a safety incentive program. About four years ago, manufacturing decided that we were going to go off the piece work system and we were going to go on job rotation. When you're talking about ergonomics it was fairly simple when one person stayed at one work station all day long. We started out with new chairs - adjustable chairs. And we tilted some of our sewing machines, and did some simple things. But when that was your spot, you didn't have to worry about it as much. Now all of a sudden you were going to be rotating between 8 and 10 different jobs. Primarily in our fitting area. In our fitting area is where they stitch together the top of the boot. That caused some new problems, some new challenges. All of a sudden we had to accommodate the 5'2'' person and the 6'2'' person that may be working at the same work station. We had to work with our unions on this. We're unionized in two of our plants and two of them are not. Everything was collaborative. We had to agree on an alternate duty program, that somebody could come back to work even though they weren't 100%. With job rotation and having ten different jobs, if you will, that we could bring somebody back to work if they could only do two of those jobs, and maybe only work two hours a day. It was a big challenge for us, and a very large leap working with our employees and with our unions on that. And it was a new attitude to get used to, because before, hey, they didn't want anyone back unless they were 100%. By being able to bring our employees back and having them only do certain jobs, it dramatically reduced our temporary total and temporary partial disability costs. We also work with a local physician. Being in a town of only 15,000 people, and we're one of the, well, until the casino came in we were the biggest employer. We only have one clinic in town, so that's one advantage, but sometimes a disadvantage too. We also work with a local physical therapist. We have him under contract, and he's in our plant at least once a month looking at the job set up, seeing how people are doing their jobs, what he can do to help with their posture, and how they're performing the jobs. We also work with our insurance carrier a lot. We do a lot of testing.

I used to be an insurance broker. That was a hat I used to wear years ago. But the insurance premiums that your companies pay in, whatever that is, about 15% of that is for overhead for the insurance company and to go for their services. And Fred may disagree with me, coming from Aetna, but services like his are available to you from your insurance company and your insurance broker. Take advantage of them. There's a wealth of information there. And they can help you. They've been doing it for a long time, and have a lot of data there. We also started a stretching program, some exercise programs. We have this physical therapist come in once a year and talk with our people, he finds out where they're hurting most, what they worked on, and encourages people to do that. And we have to reintroduce that every year because people forget that they need to take that stretch break. Our ergonomist, he doesn't quite like that title, but he use to be a cutter in our cutting department. Started with the company about 27 years ago. And I affectionately called Loren a farm boy that learned how to make stuff with bailing wire and a little chewing gum, and put it together so it would work. And he does a lot of just standing back and watching, seeing what they do, videotaping the jobs, figuring it out, seeing what we can do better. He figured out a lot of new and creative ways to do different things in our company. This helped with our productivity. We've won some awards from our safety council in Minnesota. And, like I said, our costs have been cut by a fourth. I have a little homemade video that was worked on when we were going to our continuous flow manufacturing, we call it. So it's not real high tech and we did it ourselves, but it will give you an idea of some of the ergonomic changes we made in the factory. You can start the video.

Do you feel like you're watching a 3^rd grade program here? Yeah? This is just showing some of the scissor lifts that we use. Some of them have to be punched up this way, but we were having people bending way down and picking material up off the floor and also getting things from way over their heads. This is a tilt master we use. We bail all of our scrap leather. We generate about one semi-load of scrap leather every week and a half. And previously this used to just be in a big box and they had to stick their head down in there and grab it. And we had some back problems out of that. Now using a tilt master, the leather is brought right to them and they can get it right from waist height. It used to be ground up and used for fertilizer. But it has too much oil in it now. So unfortunately, environmentally we have to landfill all of the leather. We put in a lot of anti-fatigue mats; that's helped a great deal. This individual I believe happens to be in our cutting operation. I think you'll see other examples of raised and lowered work stations. This individual was out on workers' compensation. By doing some modifications just to this work station, she's sorting different tickets. And tickets go along with our shoes as they go through the operation. By tilting things, getting a different chair, better work station - she was able to come back to work without any job restrictions. And it's all just setting this up in a better format, working with our maintenance people. Here's a little platform. Some of our people in job rotation, that's a chunk of very stiff form with an anti-fatigue mat on it, they'll carry it from work station to work station. This is down our manufacturing line, our fitting operation. You'll see some people sitting, other ones standing. So we've tried to change what they're doing.

This is how we used to imprint the leather with a dye marking machine. And you'd get your fingers caught in there. Now we put the pieces down, and you'll see the little whisker switches they're called. OSHA loved this 'cause there's no way that you can beat those switches and get your fingers under there. And it's helped with that repetitive arm business, up and down. Pretty inexpensive piece of equipment. They sat there with a watch and they tried to see if they could beat this. And OSHA was concerned about the pinching of it. But they couldn't. Okay, one more. These are arm balancers. Up here is a pulley and it comes down, and these are on their elbows. And it helps. You can adjust this for the weight of the product you're holding. I believe this is a Swedish manufacturer. And one of our employees start out making these at home. It helps reduce the weight off their shoulder because a big insulated boot, once they're near the end of the manufacturing cycle, is very heavy. And it gets awkward when you're doing it day in and day out. These are not mandatory; they're optional for anyone to use. This is on a blade adjuster that used to be manual. And now they've put a power switch in it. So the blades are for thinning down the leather. And they used to have to hand crank this thing down to get it right. And now they can just switch the buttons on and off to get it. So it eliminated one more cranking operation. This is our union president that's in most of these shots. This one, we made it so the foot pedal was centered. It moves on the floor so they can do this stamping operation and use either foot. Just made it so the pedal was not stationary. It's also lengthened, so it was more comfortable. Many of these operations, when you look at these tables, can go up and down. And they used to all be sitting operations where now they're a combination of sitting or standing.

This is an edge stitching operation. You can see the pinch grips that are needed for this. If any of you have ever done any sewing, it's very difficult. And with leather it's much more difficult to do it. She's even wearing wrist guards on hers. Some of ours is still done manually. And you'll see that our sewing machines are slanted at about a 30 degree angle. We have coming up, one of our computer stitching machines. I think that's what's up next here. Now you know why the boots are so expensive. There's over 200 different individual operations that go together to make one pair of boots. And this is a computer stitching operation. This one is about $80,000. So you're not going to get that into your budget initially. We have one that's about $140,000. But really that could be one serious workers' comp claim.

These are examples of some different floor pedals. They're cut into a floor mat here, so they can use either foot to do the operation, so they're not standing all day long balanced on one foot. And these operations are rotated about every hour to two hours depending on the department that they're in. They say they can teach you how to do this job in about 2-3 days, where the other job doing it by hand may take you 4 to 6 months of practice before it meets our quality standards. Some of the chairs we've put in, and the adjustability of them. This is just a standing sewing operation with a height adjustable table. This woman happens to be about 5'2''; some of the other ladies in the area are 5'8. She also brings her own little stand with her because I think she is the shortest in the department. And, yes, some of the sewing machines are about 30 or 40 years old. We have one piece of equipment that was made in the 1920's, and we have to make our own parts for it. Notice also, the bins that are floating around in these are all tilted also. That makes it easier for them to access the pieces in there. They're all tilted towards the operator.

This is a cementing operation. It adjusts the height and the tilt of the tabletop. And also we have anti-fatigue mats there. And some of this has been there's whisker switches on some of these too. She just flipped the whisker switch right here to help prevent her hands getting inside the machine at all. And you have to flip there's one on each side - flip that so there's no way your hands can get inside of it. This just down our line of operation, you can see the tilted bins that make it easier for the operators to get things in and out, and also to slide it up and down the floor, going around rotating or transferring the product from operator to operator. This plant on the day shift is about 400 employees, putting out about 9,000 pairs of shoes a day. Okay we've seen enough bins. Come on. We're on our fourth generation of some employees in our plants, which is kind of fun to have. Oh, this is just a machine we made ourselves, it's for drying cemented parts. And it's our own design, we just came up with it. The previous one was very awkward. This is just an adjustable tote stand. Here this was made for this job by our maintenance guys. It's just some tubular steel, some pegs in there, nothing fancy. Probably cost us five bucks to make it. Just a lot of different pedals and things like that. You can stop the video. Thanks.

So, that just gives you a little flavor of some of the things we've done in our plants that don't cost a lot of money, that are simple to do - it just takes a little ingenuity. We've done a lot with floor pedals on our sewing machines. And it just gives you an idea of some simple things that you can do to help reduce your comp costs and make it more comfortable for your employees. I'm done.

Dr. Lida Orta-AnJs, UAW

We're going to start with the second part of this session. And I would like to mention once more that we did have some changes in our panel of discussants. Talking about control interventions we have been struggling to keep the control in this session as well. For the panel of discussants we have Dan Macleod who will be the first discussant. We have also Howard Sandler as our second discussant, and Mark Fielder will be the third discussant. Nick Warren, who was one of the co-authors of the Dropkin study has very graciously accepted to do a second pinch hit for that study. And he's going to be making some comments that should round up Eric Frumin's presentation. So let begin and introduce them.

Dan Macleod is the Director Ergonomics for Clayton Environmental Consultants and is a certified professional ergonomist. He has been a leader in the health and safety field for 25 years, and has developed a number of corporate programs that have resulted in thousands of ergonomic improvements. Dan will be our first discussant.

Mr. DAN MACLEOD>, Clayton Environmental Consultants

Well, good to be here and welcome you back after lunch - you're good and sleepy. I'll try to be loud and keep you awake. A couple reactions to the discussion earlier. First of all, Gail from Red Wing, Minnesota talked about the guy that does ergonomics there and how he learned the trade of ergonomics on the farm doing things the country boy way. And actually he and I went to the same school of design. I was raised up in northern Minnesota, and I learned ergonomics from my dad and my granddad who never heard the word, but they certainly knew the process. Gail mentioned the guy who tended to stand back and observe. Well, the job analysis technique that I learned was not only to stand back and look, but every once in a while you take three steps back, rub the back of your neck, tug your ear three times, and you think, how am I going to do this job without killing myself? That's what I was taught. I remember my dad catching me when I was 12 years old, we were working on a project, and I was shoveling some dirt and it was going in the wrong spot. You know, it was where I was going to have to dig again. And he got a horrified look on face. And he said, No! No! Don't do work twice. Don't do work the hard way. I was raised in that kind of tradition, and I think there's a lot of that common sense ergonomics. It wasn't quite clear in Lida's introduction, but I was also with the United Auto Workers Union myself for ten years in Detroit. I'm very proud of that background. And I think if there's any one single organization that has led to the development of ergonomics in the United States, it's probably been the UAW. I mean, they made the University of Michigan. Well, what I'd really like to do for those of you who are not familiar with the labor movement and so forth, would all the UAW people please stand? I mean, if that doesn't speak to commitment and interest by the labor movement and people's health and safety and so forth, I don't know what else does.

Anyway my experience at the UAW certainly reinforced what I think is important in intervention which is practical, low tech, common sense kinds of things. A general reaction to both Fred's presentation on Aetna and Gail's on Red Wing Shoes, is I can just confirm that. The process works. You know, so far now, I've helped hundreds of different companies set up ergonomics processes. And, if this was a congressional hearing, if you all were congress folks and I was testifying at that little table there, I'd be saying in my experience, this stuff works. If you do it right. If you do it right, you can cut injuries, you can cut the CTD's and you can increase profits. Fred talked about that saw with the teeth on it, and I don't know either which of those teeth on the saw works, and which cuts better and which doesn't. And, we need to find that out. But I think right now you'd be pretty hard pressed to say that that saw doesn't cut wood. That saw works. I think we're getting an increasing amount of evidence, financial evidence, that it works, not only at cutting injuries but this is good for business. And we're going to hear, in the next session after us, on the cost benefits. I gave a presentation at the Human Factors and Ergonomics Society meeting last Fall and just described a program where I've been working with the Crane Paper Company up in Massachusetts. Crane, best guess now, they spent 2 2 Y these are numbers you can write down. They spent 2 million dollars on their ergonomic program, and they've benefited 3 2 million dollars on their ergo program over a 5-year period. That's a 40% return. And that number is only going to get better because many of those costs were fixed costs. And the benefits keep on accruing and accruing. So in another five years, you know, ten years of the experience of their ergo process it's going to be, oh, three, four million dollars of investment and ten million dollars of benefit. By the way, for those who'd like to see that whole description, and it parallels what we've heard from Fred and Gail, that's in the Human Factors Proceedings from last Fall. Another thing you ought to do if you're interested in thisYthis is totally self serving, but I wrote a book on this. I guess I have to say if there's any one thing you ought to read, I think it ought to be my book. It explains that. Lots of case studies. And again my point is that it's been confirming what we've heard this morning. I've also been heavily involved in meat packing. I represented the industry in working with OSHA to develop the meat packing guidelines and help many of the big meat packing companies implement their programs. And, again, to confirm what we're hearing - the process works. Here we have a whole industry. To the extent of my knowledge, that is virtually the only industry where the CTD rate is now decreasing. And I think that says something about guidelines and regulations and something in there someplace. Meat packing guidelines have worked. Good medical management, thousands of improvements in those packing plants, big and little. Another comment on medical management. You know when I first started out doing this, I was just doing ergonomics. Well, I still just do ergonomics. I don't know anything about medical management. But it was a big meat packing plant where I was working developing the ergo process, and with me were medical people studying the medical process. And we started looking at the numbers, and all of a sudden the CTD's dropped down. And I said, Awhoa, how could that happen? We haven't gotten the ergo stuff, there's no ergo interventions yet. I was confused. What I was seeing was the impact of a good medical management program. You know, in fact, I think that you can get faster bang for your buck out of a good systematic medical management process than you can with ergonomics. I sort of think that you use medical management to stop the hemorrhaging. And then you use ergonomics for the prevention. And obviously the two work hand-in-hand.

Just a couple more comments on the nature of intervention. Or I call it improvements. I think one of the important things to do as part of setting up an ergo process is to establish a culture of innovation. One of the storiesYit's the crane company again. When I first started working with them, they had actually gotten a little bit discombobulated about the word ergonomics. You know, it sounded hard and they were mystified. And they didn't want to do it. Crane is up there in the Berkshire Hills of Massachusetts - 200 year old company. And I said, ah, don't get too worried about this ergo stuff. It's just Yankee ingenuity recycled. You see people doing stuff with your wrist, bending your wrist, bending, working bent over, twisted, loads on your back - use your Yankee ingenuity to figure out a way not to do that. And their reaction was, huh, Yankee ingenuity - we know how to do that. So it was sort of empowering to say that. And this culture of trying to figure out ways of using Yankee ingenuity to improve the workplace added to it, putting on their 'ergonomic glasses' and understanding the principles of ergonomics and so forth. That worked very well for them.

One particular story that I really like, my favorite story, is Crane makes high end paper, cotton paper. They make, for example, all the currency paper. Every single dollar bill you've got in your wallet comes from one of their mills. Part of what they do is very high quality cards, stationery. One of the things they do there is for birth announcement cards. They tie on little pink ribbons and little blue ribbons for birth announcement cards. Which means that there's a whole bunch of ladies, sitting in a room, tying ribbons, 8 hours a day. And their having, obviously, problems with their wrists. As part of their process, I gave a little presentation. One of the ladies went home that night, took a manila envelope - just a regular file folder - took a couple of paper clips, bent them open, took about 8,000 yards of scotch tape, taped this whole thing up, put this little card on the paper clips, put a little ribbon in. She pulled off the card, flipped it around and put it back in, and the ribbon was tied. It was the most amazing thing you've ever seen. You have to watch the tape in slow motion to see what exactly happens there. And the contraption, well, it worked. It tied the ribbons. She took it into work the next day, showed it to the engineer and he scratched his head, shook his head and said, I don't believe it. I've been working for 3 years trying to develop a machine to do this. If I ever built it, it would cost three quarters of a million dollars, and it still doesn't work on paper. And she developed this little contraption. He did pretty it up a little. He made it look like a real machine; got rid of the scotch tape and the folder. Made a device. It cut their injury rate . . . I forgot the percent, but the CTD rate went down, and productivity went up about 30, 40%. That was an employee who invented a solution for the problem. She was applying Yankee ingenuity. The contraption she made really did look like something that came out of the 1800's. And it speaks to the idea of creating a culture of innovation where people can feel free, can feel empowered, to go out and invent things.

Let me just say another thing job analysis. I think the term job analysis, task analysis, is confusing. Analysis - what does it mean? It means taking a whole and breaking it down into its subparts. Now the confusion comes when people think of analysis as being measurements. You don't have to measure, you don't have to count repetitions and measure angles and forces and that sort of thing. If you just put on your ergonomic glasses and stare at the issues and then start brainstorming how you make improvements. The sort of thing that Gail was doing because we saw the videos of what she was showing. All of my best success stories, examples, come from using that low tech approach. We didn't do any measurements of counting this and measuring that and so forth. One final comment, just reacting to the back belts. Some of the companies that I've worked with, they have their own internal data. Some clients, some companies show improvements, some don't. It's hard to sort it out, why. Maybe it has to do with the nature of the industries they're working with. Maybe it has to do with how the back belts were introduced, if it was part of a larger process or not. It's a little hard to say. But because of the NIOSH study and other things like that we'll eventually learn. I don't have much to offer there. What I do have to offer in this whole debate about back belts is, number one, back belts are not ergonomics. Back belts are the antithesis of ergonomics. Ergonomics is designing the task to fit the person. What is the back belt doing? The back belt is shoring up a human to try to compensate for a task which clearly exceeds human limitation. Now I'm not saying they're bad. I'm not saying don't do it. But, I'm just saying don't call it ergonomics. The second thing, and more important thing that I can add to this debate has to do with business. From a purely business point of view, making money, I think that as long as you're screwing around with the workplace, with tools, with equipment, with process, designing the task - as long as you're screwing around with how do we make this better to fit the person - you have the hope of stumbling into a completely better way of doing that job. If you rely strictly on back belts and don't do any ergonomics if you pass these things out and that's what you do - you wear them and you hope for the best - if you do that, you are giving up all hope of coming up with a better way of doing the task. If you think back to the 1910's and 1920's, ditch digging. Everybody digging ditches, in all thousands of people out there, thousands of guys digging ditches. They must have had a horrendous back injury rate back in the '20s. What solved the back injury problem in ditch digging in the 1920's? It wasn't back belts. It wasn't debates on how many times they could shovel. It was back hoes and drag lines and equipment that made the American construction industry the most productive in the world. And that's what we have to remember as we implement our processes. Thank you.

Dr. Lida Orta-AnJs, UAW: Our next discussant is Howard Sandler. Dr. Sandler is the President of Sandler Occupational Medicine Associates, Inc., or SOMA, an occupational environmental health and safety consulting firm, and he received his graduate degree in medical education from the University of Maryland. Howard.

Dr. HOWARD SANDLER>, Sandler Occupational Medicine Associates

Thank you very much. It is a pleasure to be here today as a discussant. I would also like to comment that I've worked with Dan on numerous workplace ergonomic problems and medical management issues, ranging from Chrylser to Crane to the meat packing companies and a variety of others. What I've noted from my own perspective is that you have to be very careful in what you say and what you do in terms of trying to figure out what really works. I want to thank Eric Frumin, Fred Schott, Gail Sater and Lytt Gardner for their very interesting presentations. First, it doesn't matter to me whether somebody is hurt from work or simply they've got a condition they bring to work and work aggravates it. The number one issue is trying to keep people healthy and safe on the job because that's good for the worker, and it's good for everybody. The issues come when, I think to coin a phrase, when you have to 'show me the data.' That is critical. Because if you don't have the data, you don't know what works and you don't know how it works, and you don't know if what you're really measuring is the thing that's working for you. You can put intervention and control in a variety of different categories. Clearly you can have physical ergonomic changes, you can make changes to work organization, you can have training, you can have worker conditioning, you can have personal protective equipment like back supports. You can have proper employee placement. And last, but not least, medical management. Sometimes these things work; sometimes they don't. My own experience has been kind of shotgun. It's amazing to me when certain things work, and other times they don't. And I would try to find out why they didn't.

You've heard four different presentations today. The first one from Fred Schott presented an approach. I was a little bit concerned when he said it doesn't matter which tooth on the saw causes your cut. And you know what? You're right. The problem there was that you know what caused the problem. It was the saw. You don't have to get to the microscopic level. And, two, you had a measurable specific outcome event. What was that? Obviously a laceration, if not worse. But that's the difference. You had those two things to measure. Gail Sater described one company's experience - and I'll get into that in a bit. Eric Frumin reported on a completed study, and Lytt Gardner showed us how to construct, which I thought was very good, an appropriate investigation as to the efficacy, meaning does an intervention work. It's very similar, if you might take a second to consider the way that the Food and Drug Administration determines whether a drug really works. They have a good well controlled study. It's well formulated. They measure what goes in, they measure the effect and they and make sure it's not due to placebos or a variety of other things. And we depend on them to protect us. In musculoskeletal disorders you have to be very careful to measure the disorder. And you also have to measure the control. If you have five possible ergonomic controls you're throwing in there all at once, how are you going to know which one or ones, or which combination really made the difference? If you measure symptoms, as we heard yesterday at the clinical session, what are you truly measuring? That is what NIOSH, I think NIOSH is doing the right thing with the way they've constructed their back support study. I did a study with Fleming Foods on back supports. I got good results. But you can't rely on that because you know what I didn't do? I didn't publish the stuff. It's not peer reviewed. Home Depot did publish it. They found good results. But you know what? You also need repetition. You can't just believe one study. It's important to have consistency; it's important to have reproducible effects, or studies. The study presented by Eric Frumin was very interesting, and I think it's a win-win. Every time workers feel better, lose symptoms, there's no question. It's the right thing to do. A couple of points I would like to do from a scientific standpoint was, number one, the only exposure measure that changed from the chair which was statistically significant was at the left wrist. Yet, what was interesting was you'd expect to also see the corresponding change in the reduction of a statistically significant reduction in the left wrist symptoms. You didn't find that. What you found was, or at least what was presented was, that there was a statistical reduction in the right shoulder symptoms, in the left elbow symptoms and the left forearm symptoms. I can't see at this point, and I really try to figure out from a physical ergonomic standpoint, how would that have occurred? He listed a number of limitations to the study. I think that one limitation that you have to be very careful about is that thing called the Hawthorne effect. Everybody feels better if you make a very good intervention in the work place. You put in new chairs. Those chairs look disgusting, I agree. But, is that what's really making the difference in true disorders or the way people that, you know when you don't feel good, symptoms are a problem. Ms. Sater talked about great reductions in workers' compensation costs and frequency rates. But there is no way to determine, based on what she presented, as to what to attribute those. Do you attribute it to the fact that they had better medical management or risk management at all? Or better working conditions? So you need to have the data. Fred Schott, and I think Dan talked about approaches. Approaches make sense from doing the right thing, and making people feel better. But it's critical to use strong scientific approaches and generate objective data to help industry, labor, health and safety professionals and, yes, even regulators to identify appropriate interventions and controls for work-related musculoskeletal disorders that really work. Thank you very much.

Dr. Lida Orta-AnJs, UAW

Our third discussant is Mark Fielder. Mark is the Coordinator of the UAW-GM Health and Safety Center, and ergonomics is one of his primary work responsibilities. Some of you may remember Mark from the 1980's when he was an Administrator for the UAW-GM Pilot Project on Ergonomics. Mark has his master's from Central Michigan University Human Resource Management, and a bachelor's from the University of Michigan. Mark.

Mr. MARK FIELDER,> UAW-GM

Ergonomically I don't want to walk way over there, so I'm going to come here. First of all, I have to let you know that Dan and I met back when he was in the UAW. Of course he had long hair and he was playing a guitar then, but he's still got some of that blood in him. I have 20 years with the UAW, soY First of all I want to thank Debbie Berkowitz for allowing me to take her place. And based on the last week's ANSI meeting, I thought it was important that she got some comments in. And so she sent a few comments, and here's some of the things that she would like to say. First of all, that her union's experience with industry and occupations they experienced the highest rates of CTD's. And their design changesYand she underlines 'always and unequivocally' led to a decrease in incidence, especially in serious CTD's. Design changes cannot occur, though, without worker involvement. And Debbie states, worker involvement and education are crucial to the accepting of that change. And she also expressed the importance of good medical departments - they're able to deal with early symptoms. But I just wanted to pass that along.

First comments, I'm going to talk a little bit about the Aetna presentation. I thought what they're doing is very good, but I had some questions in regards to the fact there was no awareness provided to the employees that I heard. Now maybe that did occur. But I think that's a gap. I think it's very important that the employees in your organization understand what you're doing, understand why you're making job changes. And I was kind of concerned about how the solutions were dealt with in a remote location without that employee involvement. We have found in UAW-General Motors locations that without that worker involvement, interventions are very hard and very difficult to implement on the floor. Not only that, we have found that it takes a very diverse group of employees in our setting, which includes skilled trades, engineering, union representatives and that actual employee working on that job, to make that intervention the correct one and to come up with the best solutions. To move on to the discussion about back belts. I don't know if I can add too much to what Dan said. I think the jury's still out in that regard. I think there's many variables that have to be looked at. In our situation in the automobile industry, the repetitiveness is a big issue. Some of the lifts in our organization are beyond what's going on in some of the stores that are being studied. And I always have a concern that it makes people a little over confident, that they may be able to lift something that they may not necessarily be able to. To continue with Eric's discussion, I think it's very important that the chair intervention brought about a drop in the amount of pain amongst the people. And I think it was very important not only that they provided that intervention but they also trained those folks on how to use those chairs. So many times I think that an intervention may come from an engineer or someone of that nature without that employee knowing what it's about, knowing what it's for and knowing how to use it.

To go on with Gail, I think one of the important pieces of her presentation was that the union representatives were involved in the changes that occurred, especially when they went from piece work to the job rotation. There's all kinds of aspects that somebody with credibility, whether it's a union representative, or if you're in a non-union organization, it may be just an employee that's very outspoken, can assist that organization in regard to selling that idea that this is good for you, that here is the importance of these ergonomic changes. The other piece, and Dan brought it up, is that when you take someone from your organization that's worked in that organization for some time and knows not only the people in that operation but the job to that operation, and give them the expertise around ergonomics - in other words, provide them with some training or some skills that will allow them to look at jobs with some ergonomic expertise, you'll find the solutions not only are better but they also get accepted more readily. And with that, I guess I'd like to just state that in UAW-GM, the best interventions in our experience are from involving the employees. That when an employee comes to us and says they hurt, we don't have the flexibility to say 'show us the data.' We respond, we examine the job, we work with people to find a solution. Solutions are measured by the response of our membership that we represent. We can't wait for studies, science or for more data. Even our grievance procedure has timelines. So, thank you.

Dr. Lida Orta-AnJs, UAW

We're going to open up for floor questions in one second. I would like to introduce to you Nick Warren. And he is co-author of that study performed with the sewing workers. And Nick is going to share with you what happened after that intervention was done so you can have the benefit of that information as well. Nick.

Dr. NICK WARREN>, Ergonomic Technology Center

I was a last minute conscript so please excuse my lack of tie and natty suit. It means no disrespect. This also is an object example for you of the tempting of the American work force. Or maybe a little bit better managed care. I am your 'Dropkin provider' for the afternoon. There were a few things Y actually to begin, I'd like to just respond to what Howard said about the study. He's right in asking for, how could it be that we see a reduction in exposure, the only significant reduction in exposure on the left wrist and the only significant reduction in symptoms on the left forearm and elbow and the right shoulder? There is a biomechanically plausible explanation which is that wrist motions involve a lot of flexor, alternate flexor and extensor motion. Those of course have the insertions on the lateral and medial epicondyle. So you could make a plausible hypothesis for decrease in symptoms significant in the forearm and elbow, even if not in the wrist. More important, remember that the sample for the videotape for the exposure assessment was smaller by almost half. It's only 19 individuals, so that a similar reduction in symptoms wouldn't necessarily be significant. In any case, the point is well taken and should be considered, and a lot more work has to be done.

Eric wanted me to share with you what happened in the process of this, and actually, after the study. And I'm going to do this very quickly because I know that we're low on time. But just to share with you what happened since. One of the things that did happen were actually some fairly significant psychosocial changes or organizational changes within the workplace, as well as these very precisely delineated biomechanical changes, meaning simply the introduction of chairs. I should tell you that when this was happening there was actually a tremendous amount of experimentation going on at the inception of this project involving certain employees in playing with different engineering changes. The chair was not the only one which was originally thought of. They had a very good plant engineer who was working with employees to figure out a number of different ways for reducing repetitions and certainly changing postures. In the end the only one that made sense and was economical was the chair. What happened since? There were actually a number of measurable changes that happened as a result of this particular intervention and what happened after. The first one was measurable reduction in workers' comp costs and injuries. And the same thing that Fred Schott mentioned, there was a brief increase in incidents and then decrease in incidents accompanied by a reduction in length of time of people out on comp. There was improved quality. In fact, the next session is going to be talking about the broader sense of economic changes that can happen. It doesn't mention some of the things that actually came out of this - not only increased quality, decreased re-work, decreased scrap, certainly decreased turnover and training costs, things like that. And improved worker satisfaction. Most important, I think, from my point of view, was the improved use made of worker's creativity and innovation. They changed after the film that you saw and after the study ended, the company changed to a cell structure which involves what most of you know as work enlargement as opposed to work rotation. A number of these different operations were brought into a single cell which one or two people would operate. The productivity certainly increased, partly because of this. Unfortunately we don't have psychosocial measurements. We didn't give people any JCQ questions or anything like that. What we did find is that there is certainly an increase in control. Workers can decide when to start and stop each aspect of the cell operations, how to arrange them, moving around there's a lot more simple schedule control involved in addition to having kind of continual input with the engineer about how to improve the cell structure. It's still evolving as we speak.

And lastly there were improved labor relations as a result of this. There is a down side however. There was some lay offs of workers as a result of this. So there, labor relations were not improved. But on the whole, in the company overall, both the physical structure of the workplace, the nature and intensity and amount of ergonomic injuries were reduced. Quality, productivity, labor relations all increased. And the final point here, I think, actually refers back to something that has bothered me about this conference, and it's simply a definitional issue. From the start, we often have heard people talking about ergonomic injuries when they really mean biomechanically induced injuries, or ergonomic exposures when what we really mean is biomechanical or physical exposures. I would like to make a plea that we think of ergonomics as what it actually is - changing the work place to fit the worker. And that means changing not just the physical biomechanical aspects of the workplace, but the psychosocial and organizational aspect of the workplace. All of those, in my work, I consider ergonomics. And that's what happened in this particular study. That there was a broad spectrum change in the ergonomic quality of the workplace. Thank you.

Dr. Lida Orta-AnJs, UAW

Thank you all very much. And now I would like to ask our speakers to join us as well so they could respond to some of the questions, please. Yes sir?

Mr. Don Crabtree: My name is Don Crabtree. I'm a UAW health and safety rep from the Sharonville Transmission Plant, Local 863. I have a brief comment on Dan Macleod's presentation. I thought you all made a right choice on the first speaker after lunch. He sure kept me awake. The presentation was great. And I agree with you on your views on the back belts. I don't believe those are ergonomic solutions. In fact I think they could possibly even mask an existing condition. Appreciate it.

Mr. DAN MACLEOD: I just want you to know when I first started at the UAW I was sort of shy. But it was the UAW who taught me how to keep an audience alive.

Mr. Scott Schneider: Scott Schneider, Center to Protect Workers' Rights. Thanks for your presentations. I'm hearing two different things this week. One of them is, oh, you know, 'Awe don't really know enough to do anything, and we're not really sure what to change. And then we're hearing on the other hand that hundreds of companies are doing things, and they're having successful interventions. And most of these are not expensive; most of them are paying for themselves very quickly. And we'll hear more about the economics this afternoon. I mean, how much data do you really need in order to justify doing the intervention, given that the vast majority of them are going to pay for themselves rather quickly if they're not expensive?

Mr. DAN MACLEOD: Let me address that. I mean, I really believe in low tech, common sense stuff. Sometimes you run into really hard issues. There's some companies where I've worked, some industries where I worked - I can't figure out a simple way of doing things, where the fix - if there is a fix - is going to be real expensive. And at that point we've gone from what's obvious to a gray area. And that's when we really do needYyou know, if we spend the millions doing this, is it really going to work? Now, you've heard me all of my life say talk about low tech and common sense and so forth. But, yes indeed, we've got to have science. My own view is, you make your best decisions with the information you have available at the time, but simultaneously, we gotta get more. Howard is absolutely right. We gotta get more, we gotta find out which tooth of Fred's saw works the best.

Dr. HOWARD SANDLER: I think what you're asking boils down to two different things. One is, what should good companies do on their own, and what should companies have to do from prescription? Prescription requires that certain hurdles are met. And it's the science at those hurdles that, I think, is where the difference of opinion is at this point in time. As the data comes in, where it shows strong stuff, you do it, you move. I don't think companies should wait on their own to do these things. I think most companies are not waiting, as you say. I think a lot of us wouldn't be in business who are here if it wasn't for that. So at the time, one says, well, do I have to do it? Or if I'm doing an experiment, how much of an experiment is it? And I think that's what it comes down to.

Mr. Schneider: I think for the million dollar investment I can understand that. But if most of the investments are, say, under a hundred dollars - which seems to be the case - I mean, how much information do you really need to try out that experiment to say, well, let's try it and see given that we have a good chance of success?

Dr. SANDLER: If I can field that for a second. I have something I called 'Howie's Rule of Thirds.' What that means is very simple. You have three groups of people that are truly injured from the work place. You've got people who are injured; they think it's from the workplace, and when I say workplace, I'm talking about physical biomechanicalYand I think we're all using the same definition now. And then you've got some people who are symptomatic from, quote, Aproblems. And even if people who are from a psychosocial, they don'tYyou know, you look at Fred Geer's study, you look at the NIOSH HHEs that have been done, especially on office workers - the correlations there are sometimes on psychosocial factors. Extremely difficult to measure. I mean, it's hard to do something with it. Those have to be looked at though and have to be accounted for. So you may find that you've got certain things that will work, but many interventions. If you put in people's heads - everything is work related, and it's always work related, then what happens is you miss the opportunity for other interventions that will work. Some people are afraid of losing their jobs. You can't approach that from a biomechanical standpoint. You need to approach it, don't get me wrong. Those things, though, have to be separated and you have to look at those and make sure that you're not putting the wrong people in the wrong group when you apply your interventions. In most instances, if you put the right salve on the right affliction - it'll work. I mean, as physicians, most people survive despite our best efforts.

Mr. John Amell: My name is John Amell with the Boeing Company in Seattle, Washington. I have a couple questions for someone representing the NIOSH back belt study. I want to premise that first by saying that I'm not a believer in back belts as far as ergonomic intervention, I do agree with Dan. But, one part of the study that showed that we're just looking at the elastic high back belts. Is that correct? There are a variety of different back belts on the market. If we're trying to make decisions over a broad range of devices, shouldn't NIOSH look at the variety of types of belts as well?

Dr. LYTT GARDNER: Well I think that gets to the issue of whether you're considering back belts as a biomechanical device or whether they operate in some other way, such as a reminder. And I think it's really not very clear at this point what the mechanism is. And I think the first step is to use something which is being used already in a number of workers, which is the flexible elastic belt. If the study shows a big effect, then I think that you have an answer. If the study shows no effect, I think that the manufacturers of belts which have different properties will raise up and say, well of course this has no relationship to our belt. It means nothing. I think that there is an opportunity for other studies. I don't know that NIOSH is the organization that will pursue those. But I certainly think there's a role for laboratory studies to evaluate different belts. It's very difficult to do large epidemiological studies. There's a limit. And I think that before one pursues an additional study using different belt styles, such as very stiff belt, there needs to be some evidence to support that that type of belt would have an impact. And so I think that that's an issue which needs to be debated in academia where a lot of the lab studies are coming from.

Mr. Amell: I also have a question on the methodology on the study and the use of volunteers on half of the study. And the question - how would you extrapolate the population based on volunteers when the volunteers may be substantially different from the rest of the population? They may be volunteering because they're already suffering from some kind of back disorder.

Dr. GARDNER: Well I can tell you that the response rate for the study is about 90% overall. And for survey research, this is an excellent response rate. We're really not worried about the representativeness of the participants in the study. We think they represent adequately workers in this type of industry. So I don't think that's really a concern.

Mr. Amell: One last comment. On the study of the chairs for the spoolers, Eric had mentioned the fact that some of the participants had dropped out due to the automation of the job at the time they were running this study on the chairs. I had asked him afterwards if they had some results of why we weren't comparing the automation of the work cell to the manual job.

Dr. NICK WARREN: Let me get it clear what you're asking. You're asking about the comparability of those who dropped out of the study than those who remained?

Mr. Amell: Well, it mentioned the fact in the presentation that they had some automated spoolers?

Dr. WARREN: Yes.

Mr. Amell: And that they came into being while they were doing the study? And it seems to me that's more the intervention than is the chair. And I was wondering if you had any data collected on how the problems the automation brought in were solved with the other problems of the manual problems there?

Dr. WARREN: No, we didn't. The problem was that the operation involved in using the manual spooler is so different from what you saw up there, that there wasn't any easy way to compare pre- and post. And in the study we were very narrowly, quite narrowly I have to admit, focused upon pre- and post- with keeping everything else as much the same as possible. So that's a long answer to your question - no we didn't.

Mr. Amell: Hopefully they're happier with the automated system.

Dr. WARREN: They are, although the automated system itself as far as giving you more control, a more interesting job - it was, if anything, a little less interesting. The incorporation of an automated spooler into the cell structure that I mentioned was actually a much more valuable piece of the interventions that happened after.

Mr. Don Fair: Good afternoon. My name is Don Fair. I'm with Ford Motor Company at the Saline's Plastics plant in Saline, Michigan. I'm the UAW-Ford hourly representative for the local ergonomics committee sent here with my salaried side representative. I'm particularly interested on one personal level of the psychosocial aspect of the back belt study. My question is, primarily, to Dr. Lytt Gardner. Dr. Gardner I understand that you have not yet completed this particular study that you presented here and that it's still a few months early for the interim assessment, so to speak. But I was wondering if you could give a brief explanation of the correlation between the psychosocial factor and the physical factor of this study, either as a preassessment interim assessment, or just a more personal level and unofficial aspect.

Dr. LYTT GARDNER: Thanks for the question. Well, we put a pretty fair effort into this study and we did measure a number of things that we think relate causally, or may relate causally, to back injuries. The reason for that was to make sure, particularly, that in the analysis where we're looking at the wearing of belts, forgetting about what stores people are in, but just back to the wearing of belts, once we do that then we are in an environment, the prospective epidemiologic cohort environment where, I guess I'm trying to say this nontechnically. The possibility arises that some of these factors will be distributed differently between wearers and non-wearers. We call it confounding. It's an issue that we need to deal with when we analyze the belt effect. Psychosocial factors, if they indeed are causally related to back injuries could be distributed differently. We want to make sure that those psychosocial factors weren't distributed differently. Now, were you interested more in the details of what kinds of factors we were measuring? The factors come out of the scales in Dr. Corasic's job content questionnaire instrument - job demand, job control. We have the University of Michigan job satisfaction index. We also have a NIOSH index in this. We have, all together, six scales or sub scales. So we have a very complete psychosocial instrument, and we feel comfortable that we will be able to get some additional information on the causation of back injuries separately and apart from the issue of back belts. So we're working very hard to get that information pulled together. And we may have a publication on that part of the data prior to the publication on back belts because this is an area which is very controversial and very important.

Mr. Don Fair: Thank you.

Dr. NICK WARREN: I'd like to add something to this actually, because the psychosocial issues with back belts and personal protective equipment in general are actually quite interesting. I should say that although I worked on the study with John and Eric, I got my doctorate from U Mass-Lowell so I work with those folks and I'm working now with the Ergonomic Technology Center in Connecticut. In our work we run into these issues quite a bit. And one of things that I think is truly important in introducing something that seems as kind of reduced in value as a back belt, is related to my work. I did some epidemiologic work on a big Dutch data set that suggested that one of the strongest predictors for rates of injury, disability, long term sick leave, whatever, in a very large population - 7,700 workers - was the degree of agreement or disagreement between workers and owners on risk perception in the workplace. If you have even relatively high biomechanical risk in the workplace, and managers and workers agree on roughly the level, the rates of all these outcomes are substantially lower, significantly lower than if employers are saying, no, nothing wrong here. So I think the introduction of a back belt is a very interesting piece. Because what it's saying is, management is saying, yeah, actually we got a problem here. Even though the response is a poverty stricken response, I think, it's at least a response. The second piece that it does, looking at the job content questionnaire and issues of control, it also gives workers a measure of control over their work. Again, a poverty stricken type of control - but a control nonetheless. So I think that your question about the psychosocial impact of this is very, very interesting, and actually quite complicated. So those are two pieces that I wanted to add on top of that.

Dr. GARDNER: Thank you. That's actually a good point. I neglected to say that the causal relationship really is not established. And it could be that the introduction of a back belt would actually lead to a change in the psychosocial work environment.

Mr. Paul Adams: My name's Paul Adams. I'm corporate ergonomist for Owens Corning. And I have a question also for Dr. Gardner regarding the back belt study. As most of us in the room, know there was a study done at Home Depot regarding back belts that had some problems, but I think one thing they admit in their study, if you read the fine print, is that they did not account for the fact that Home Depot started increasing dramatically the use of forklifts at the same time they started using back belts. I was wondering how you plan to look at similar confounding variables in your study to avoid that, and also if you have any other comments regarding that Home Depot study?

Dr. LYTT GARDNER: Our primary way of dealing with the issue of what's changed over time was to do the prospective design. So we weren't saddled with the difficulty of trying to figure out what changed, because you frequently won't know everything that changed. You can't measure everything. So when I gave one of my last two slides where I said that this was a prospective cohort with concurrent back belt data, concurrent just meant that the belt wearing and non-wearing was at the same point in time. We then don't have such a burden to figure out what was different. Because these stores come out of one corporate climate, they make their changes in lock step. And when they introduce a new piece of equipment it has fairly rapid penetration throughout the company. So that was a design feature. Now as far as the control of confounding and measuring things that would show up in the analysis, we do a 48 store job analysis. It's in a subset of the stores. We think we'll have very detailed information both on what we can observe people to do and we also have the questionnaire information - what people report that they're doing. So I really think that we have about as much information as you can collect. And in the Home Depot study, the design was an historical cohort. There are serious problems with interpretation of what changed over time. So I think that although we certainly are glad to see that report and it does I think in the margin, sort of move us toward believing that there is affect going on. There are so many questions that are unanswered but this does not cause us to pull back any. I think we will need the information coming out of the NIOSH study too. We'll either see it'll be consistent with the findings or it will move us in

Dr. HOWARD SANDLER: I'd like to make just one quick observation, if I can take a little liberty, and that is, what was interesting to hear was all the questions about the back support study to make sure you had it right. I think that we should apply the same type of approaches across any intervention control studies because it's important. You know, it doesn't matter whether it's a confounder on back supports or if it's a confounder on repetition or rate changes. Let's make sure we get it right.

Ms. Kathleen Buckheit: My name is Kathleen Buckheit. I work for the North Carolina Ergonomics Resource Center in Raleigh. And I am an occupational health nurse. My husband used to take me to Home Depot, Peckingers, Lowells, all these places and he stopped doing that because I used to 'attack' those people wearing back belts to ask them if they've ever had any training on proper lifting techniques. And the answer was always 'no.' So I'd stand there and teach them how to do the proper lift and use your legs. So my question is for Lytt. Do you have any information that you're collecting as to who has the training and who has the safety behaviors monitored to make sure they continue to do proper lifting techniques with the back belts?

Dr. LYTT GARDNER: We have a little bit. It wasn't the focus of our study. There is another study going on in Holland that actually has by design, a component which does lifting training. Ours does not do that. I do have a question in the interview which asks: a) have you received any training prior to doing your job; and, b) when did you receive that training most recently. So we do have that. It's certainly not a very elegant question and it's not detailed, but at least we have that much to go on. But like I said, the primary way to address that is in the design. And you really have to have a different design study to address that properly. And I think that you will hear something from the study in the Netherlands in the next year.

Ms. Buckheit: At least you've asked it. And it's something that the employer can use too. Thank you.

Dr. ORTA-ANIS: I guess we have time for... oh, that's my boss, okay, we definitely have time for...

Dr. Frank Mirer: No, if you want to cut me off before the break, that's OK. Lida, you-re free to cut me off before the break. [laughter] This is Frank Mirer, UAW Health and Safety Department. After all this talk about methodology I wanted to make one point for the audience generally. If you don't know what people are exposed to, whatever your intervention is, or whatever factor you're looking it, if you don't really know the level of exposure to people, if everybody had the same exposure to biomechanical stress, then everything you observe in that study is going to be the result of a host factor in the individuals - either a personality, gender, age, weight, whatever it is. If you don't distinguish the exposure everything is a host factor and you haven't really found out anything at all about the effect of the biomechanical stresses. And so exposure assessment is absolutely critical, I think, primarily in these intervention studies.

Dr. ORTA-ANIS: Thank you all very much. Thank you.