1. OVERVIEW AND DESCRIPTION
As physicians focusing on function, considering how our patients interface with their environment is a crucial part of evaluation and management. For the purpose of this review, environmental assessment is broken into three broad categories that represent the general areas with which people regularly interact: workplace, home, and public spaces. Each category contains unique components and potential environmental risk factors that may contribute to injury, prevent recovery, or limit accessibility to those with impaired mobility. It is important to evaluate for potential environmental risk factors that may predispose to injury, create barriers to injury recovery, or present safety and accessibility concerns for those with functional impairment. Once identified, suggestions for environmental risk modifications can be made in order to maximize the safety and recovery of our patients.
In the workplace, poor posture and repetitive stressful movements often lead to musculoskeletal disorders and missed time from work. Epidemiological evidence has demonstrated a causal relationship between musculoskeletal disorders (MSDs) and workplace exposure to sustained abnormal postures, high repetition, and high force movements.1Biomechanical laboratory studies demonstrate increased tissue stress and decreased performance when forces are exerted on the trunk and upper limbs at positions away from neutral, overhead, and repetitious tasks.2,3 Repeated and prolonged tissue strain can lead to gradual breakdown and increased potential for injury. A poor workplace environment can cause an employee to perform repetitive tasks in suboptimal postural alignment and place him at a mechanical disadvantage. Understanding and identifying workplace environmental risk factors contributing to the development of MSDs are essential to providing recommendations aimed at reducing these risks.
Considerations for home environments include fall prevention and function in the home. Falls are a large contributor to morbidity and mortality in the elderly.4,5 Home safety interventions have been shown to reduce the rate and risk of falling.6 Room setup, home furnishings, and building design can contribute to fall risk, leading to injury and a decline in quality of life. Aging often leads to changes in mobility requirements that may lead to functional limitations in an unmodified home. Age-related changes to vision, strength, endurance and the addition of assistive devices for mobility can impact the function of elderly individuals living in homes which are not set up to accommodate these changes. Environmental barriers to safety and function should be discussed in the clinic and prior to discharge from acute rehabilitation. Once these barriers are identified, recommendations regarding proper home modifications and assistive devices can limit risks and improve function.
Patients with various forms of disability often require modifications to the public environment in order to allow access to public facilities. A working knowledge of regulations regarding accessibility for the disabled can aid the clinician in providing recommendations for those with accessibility needs. Familiarity with current accessibility standards and future accessibility goals helps the clinician advocate for patients whose needs are not being met, and presents opportunity to contribute to future accessibility projects. A brief discussion of the American with Disabilities Act and the concept of Universal Design will be presented in order to familiarize the reader with current accessibility standards and future design goals.
2. RELEVANCE TO CLINICAL PRACTICE
Evaluation of environmental risk factors in clinical practice can be difficult. Ideally, direct observation of the patient interacting with their environment would prove most beneficial; however, this is typically not feasible in clinical practice. Therefore, a detailed history from the patient is essential to accurately identify risk factors and functional barriers.
Ergonomics is an applied science concerned with fitting a person to their job in order to improve comfort, safety, and productivity.7 Proper ergonomic work programs are multidimensional and include systems that monitor worker injury, provide employee education, and control potential hazards. Hazard control encompasses three tenets: Environmental Modification (EM), Policy/Procedure Modification and Personal Protective Equipment. Of the three, the Occupational Safety and Health Administration (OSHA) describes EM as being the most effective at preventing MSDs and provides recommendations for workplace design in multiple fields based on ergonomic principles. Current recommendations are based on promoting neutral postural alignment to improve comfort, and decreasing prolonged or repetitive musculoskeletal stress. Neutral posture denotes joint positions that exert the least amount of stress on the surrounding tissues. OSHA provides examples of common workplace environmental risks with recommended solutions. The following examples are taken from the OSHA computer station eTtool.8 Guidelines are also available for alternative work environments (e.g., meat packing plants, grocery stores, poultry processing) on the OSHA.org website.
Computer Work Stations
|Viewing Distance||Too Long: Cause forward lean and back stress|
Too Short: Visual convergence issues leading to awkward postures
|Sit at comfortable distance, head and torso upright, back supported: 20-40 inches from screen|
|Viewing Angle/Height||Rotated head: Increases load on neck muscles|
Too High or Low: Awkward postures of head, neck, shoulders, back
|Position directly in front of user: No greater than 35 degrees left or right|
Top of monitor at or slightly below eye level: 15-20 degrees below horizontal.
|Height||Too Low: Wrist extension|
Too High: Shoulder flexion to elevate arms
|Adjust chair and work surface to maintain neutral posture|
Elbows at height of keyboard, shoulder relaxed, wrists neutral
|Distance||Too close: Extreme elbow angles|
Too Far: Forward lean, back stress. Reaching
|Keep directly in front of user, elbows close to body, forearms parallel to floor|
|Design and Use||Tasks performed without wrist/palm support may increase wrist extension|
Resting on support while typing: May inhibit wrist motion, promote awkward postures, cause contact stress
|Supports should be part of ergonomic workstation|
Hands should move freely and elevate above support while typing. When resting, support should contact the heel or palm, NOT wrist
|Backrest||Inadequate size, material, positioning: Awkward postures leading to back pain||Adjustable: Lumbar support, Can recline at least 15 degrees, should lock in place, A-P adjustability|
Lumbar support: Can use rolled towel if not incorporated in backrest
|Seat||Too High: Decreased foot support, encourages to sit too far forward in chair limiting back support both leading to awkward postures||Adjustable: Height, to allow flat feet with back of knees slightly higher than seat|
|Armrest||Too Low: Lateral lean|
Too High: Maintained shoulder elevation
Too Wide: Elbow Reach
Too Narrow: Restricted Movement
Too Large: Inhibits proper chair positioning
|Adjustable: Height, Width. If not properly adjustable, remove from chair.|
|Prolonged Activity||Repetitive Tissue Activation: Localized tissue stress/Fatigue|
Prolonged Static Postures: Neck, back, shoulder fatigue/stress
|Micro-Breaks: Periodically stand, stretch move around|
Adjustable Workstation: Sit to stand work stations
Labor Intensive Job Setting
|Transfer of Products||Risks||Solutions|
|Repeated, Extended, Elevated Reaches: Shoulder, Neck and Low back Strain|
Repeated torso bending with lifts from low to high surface: Shoulder, Neck, Low back strain
|Use Ladders, Pullout Steps, Portable Platform, Hand trucks, Ramps|
Mechanical Lifts for repeated product transfers
Proper Lifting Mechanics
Application to Various Workplace Scenarios
Any modification to the workplace or work process promoting proper postural alignment and decreasing strain on the body has the potential to reduce injury. With expertise in kinesiology, biomechanics, resting joint angles, and proper lifting mechanics, the Physiatrist can troubleshoot unique workplace environmental risk factors and suggest modifications that fit the individual. Proper education is crucial for proposed changes to be effective. For example, providing a highly adjustable chair is of no benefit to a person if they are not taught the body position that the chair aims to achieve. Some changes may appear cumbersome or time consuming (e.g., taking frequent small breaks, or changing positions), which may not be utilized unless the potential benefits are fully understood by the user. In order to address these education needs, some workplaces have employed departments dedicated to ergonomic workplace design, providing workspace evaluation and education for employees. The provider can complement any education attained in workplace by reinforcing ergonomic principles and their effect on MSD prevention and recovery.
Home Safety Evaluation
Evaluating the home environment is necessary to identify risk factors that may contribute to falls and to provide recommendations aimed at mitigating these risks. While there is no standardized list of risk factors, the general principles in risk assessment/modification focus on keep living spaces well lit, eliminating floor level objects that could lead to tripping, and reducing clutter to promote accessibility. The following are examples taken from a home safety evaluation form used by therapists and consumers.9
- Worn, torn or loose carpeting and rugs can catch the foot while ambulating or shifting. Remove worn carpeting, avoid throw rugs, and secure frayed edges with carpet trim.
Stairs and Doors
- Stairways in good condition and free of objects.
- Non-skid strips can be installed for added traction.
- Handrails on both sides
- Light switches available at top and bottom of stairwell, in order to avoid unnecessary stair climbing
- Doorway thresholds should be securely in place. Rubber threshold ramps can be installed if thresholds are too high (concern for tripping) or hinder the use of mobility devices.
- Apply non-skid mat or strips to reduce fall risk
- Use a tub bench for patients who are unable to stand during bathing due to weakness, fatigue or balance issues
- Install grab bars for assistance with transfers
- Avoid throw rugs and bath mats
- Bathroom door should open outward, to maximize bathroom space for safe transfers and use of assistive devices
- Have a flashlight or lamp within reach of the bed, to improve visibility (especially with patients who rise frequently during the night)
- Use nightlights in the hallway to improve nighttime visibility
- Use a bedside commode to limit nighttime trips to the bathroom
Public Spaces: Accessibility For The Disabled
Both the American with Disabilities Act (ADA) of 1990 and the concept of Universal Design focus on improving accessibility for those with disability. The ADA includes public accessibility requirements outlined in the 2010 ADA Standards for accessible design. These requirements mandate specific building codes that improve accessibility and prevent discrimination of those with mobility, stamina, sight, hearing, communication, and learning disabilities.10 For example, buildings are required to have entrance access that does not require stairs, and these entrances are required to incorporate specific grade requirements. Access routes should be at least 36 inches wide to accommodate wheelchair travel and door widths/bathrooms need to be accessible with 5-foot clearances to allow wheelchair turning. ADA requirements are extensive and specific with recommendations for both existing and newly constructed facilities and encompass accessibility from the parking lot to facility layout. A complete description of current requirements can be reviewed at www.ADA.gov with a convenient checklist found at www.ADAchecklist.org.10 While these requirements do not extend to private properties, the recommendations can be applied to the home when evaluating in home accessibility needs as described in the previous section.
Universal Design (UD) aims to design products and spaces that can be used by the widest range of people possible regardless of their functional abilities, thereby creating public spaces that are universally accessible to all from the time of their inception.11 For example, a building with a stairway to enter would also have a ramp to comply with ADA regulations. UD would promote a primary graded entrance that follows ADA requirements, is accessible to all individuals, and is aesthetically pleasing from an architectural standpoint. In contrast to the ADA, UD also includes design solutions for the home. UD aims to design homes that can accommodate the individual at any functional level, allowing the owner to age in the home without the need for future home renovations or change locations.11
4. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
As technology advances, more people are using mobile devices (smartphones, tablets) more frequently for both personal and work related tasks. These devices present new risk factors for developing MSDs, particularly cervical and upper limb pain. Users tend to access these devices at low viewing angles, promoting sustained neck flexion and slumped posture of the spine. Mobile devices should be raised to a higher viewing angle (i.e., placed on a table and propped up with a viewing case) in order to promote a more neutral posture, especially in the setting of prolonged use.12 Smartphone and tablet applications are available to promote acceptable viewing angles and neutral postures. Similar programs also exist for desktop and laptop computers.
5. GAPS IN KNOWLEDGE/EVIDENCE BASE
While moderate evidence exists for the use of ergonomic design in the prevention of MSDs, high quality research regarding ergonomic workplace modifications is lacking.7,13 Studies vary in design and methods with a lack of consensus on commonly used terminology, making comparison across studies difficult.7,13,14 Also missing is a consistent focus on all components of ergonomic design (comfort, safety, productivity) with limited focus on safety and productivity.7 This may present a barrier to the implementation of ergonomic design in the workplace, as markers of safety (e.g., injury prevention, decreased time away from work) and productivity may correlate to the potential financial impact on a company considering ergonomic modifications. However, there is limited research exploring the cost benefit ratio in regards to the application of ergonomic design. Workplace modifications can be costly; if a fiscal benefit is not clearly conveyed, the immediate financial burden may be seen as outweighing the potential benefit.
The concept of Universal Design is also lacking in academic research. Proponents of UD state that while the upfront cost of implementing universally accessible products/design may appear costly, it is globally less expensive than retrofitting pre-existing spaces.11 However, without quality evidence that specific products/design provide universal accessibility while maintaining the quality standards of more traditional design modalities, it will be difficult to implement broadly.
- National Institute for Occupational Safety and Health(NIOSH). Musculoskeletal Disorders and Workplace Factors. Cincinnati, OH: US Department of Health and Human Services, 1997. Report No. 97-141
- Keyserling WM: Workplace Risk Factors and Occupational Musculoskeletal Disorders, Part 1: A Review of Biomechanical and Psychophysical Research on Risk Factors Associated with Low Back Pain. AIHAJ. 2000;61:39-50.
- Keyserling WM: Workplace Risk Factors and Occupational Musculoskeletal Disorders, Part 2: A Review of Biomechanical and Psychophysical Research on Risk Factors Associated with Upper Extremity Disorders. AIHAJ. 2000;61:231-238.
- Campell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and Consequences of Falls Experienced by a Community Population 70 Years and Over During a Prospective Study. Age Ageing. 1990;19:136-41.
- Keene GS, Parker MJ, Pryor GA. Mortality and Morbidity After Hip Fracture. BMJ. 1993;307:1248-50.
- Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community(Review). The Cochrane Library.2012;9.
- Leyshon R, Chalova, L Gerson, A Savtchenko, R Zakrzewski, A Howie, L Shaw. Ergonomic interventions for office workers with musculoskeletal disorders. Work. 2010;35:335-348.
- Occupational Safety and Health Administration (OSHA). Computer Workstations eTool. https://www.osha.gov/SLTC/etools/computerworkstations/index.html. Accessed May 18, 2015.
- Rebuilding Together. Safety at Home Checklist. http://rebuildingtogether.org/wp-content/uploads/2012/06/RT-Aging-in-Place-Safe-at-Home-Checklist.pdf. Accessed May 18, 2015.
- United States Department of Justice: Human Rights Division. 2010 ADA Standards for Accessible Design. http://www.ada.gov/2010ADAstandards_index.htm Accessed May 18, 2015.
- Joines S. Enhancing quality of life through Universal Design. NeuroRehabil. 2009; 25:313-26.
- Young JG, Trudeau MB, Odell D, Marinelli K, Dennerlein JT. Touchscreen tablet user configurations and case-supported tilt affect head and neck flexion angles. Work. 2012;41:81-91.
- Hoe VCW, Urquhart DM, Kelsall HL, Sim MR. Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults(Review). The Cochrane Library. 2012;8.
- Dick FD, Graveling RA, Munro W, Walker-Bone K. Workplace management of upper limb disorders: a systematic review. Occup Med. 2011;61:19-25.
Jennifer Yang, MD
Nothing to Disclose
Derek Davidson DO, PT
Nothing to Disclose