Occupational upper extremity disorders have become a major issue in modern society. Poorly designed workplaces, high job demands, and incorrect work-habits can lead to the development of upper extremity disorders (UEDs) in the workplace. This issue not only causes health-relatedproblems for the individual but also forms a significant economic burden on society due to sickleaves, healthcare and untimely exit of affected individuals from the workforce. The risk of developing occupational UEDs varies with different professions. The European Agency for Safety and Health at Work (EU-OSHA) has recognized significant occupational health risks associated with the hairdressing profession. It has been estimated that UEDs are five times more prevalent amongst hairdressers than other professions. Qualitative risk assessment tools based on self-reports and observation have been used to identify the risks of developing UEDs with hairdressing profession before. However, a quantitative risk assessment tool that provides objective data on work posture is more precise and objective than self-report and observation. This data can help to identify the risks of developing UEDs associated with each hairdressing task. Furthermore, it can enable self-assessment of workload and posture awareness by providing feedback to the user. Inertial Measurement Units (IMU) as part of a wearable system developed at KTH were used in this study to investigate the risks of developing UEDs for hairdressing students. The feasibility of using a feedback function for providing posture awareness was also evaluated by comparing the measurements obtained with and without using the feedback function. Twelve hairdresser students were enrolled in the study. The percentage of time for elevated angles above 30°, 60° and 90° for arms, and above 45° or less than 0° for the trunk flexion is presented. In addition, 10th and 90th percentiles (°) of arms and trunk angular distribution is presented. The result of a statistical analysis performed on data with and without feedback was used to evaluate the effectivity of using the feedback function in preventing the development of occupational UEDs. A System Usability Scale (SUS) questionnaire was used to evaluate the overall usability of the system. The result of this study confirms that the hairdressing profession falls in the high-risk category for developing UEDs. The use of this technical system has enabled a precise risk assessment evaluation of each hairdressing task. Such data can be used as a foundation for improving the ergonomic design of the workplace. The feasibility of using the feedback function as a prevention tool on the individual level is highly dependent on the individuals’ motivation and their attitude towards changing their work habits. However, the results in general, indicate a decrease in the abduction angle (°) for both left and right arm when the feedback function is used. For example, the 90th percentile abduction angles (°) for left arm (all 12 subjects) during the drying part of one fundamental work-cycle decreased from a value of 60.4° to 58.2° when the feedback function was used. The 90th percentile abduction angles (°) for the right arm during the same part of the fundamental work-cycle decreased from an angle of 53.1° to 51.4°. The SUS score of 75.6 indicates good overall usability for the system. / Besvär i det muskuloskeletala systemet i överkroppen som uppkommer på grund av påfrestande arbetsställningar och icke-optimala arbetsvanor blir allt vanligare i det moderna samhället. Besvären orsakar inte bara hälsorelaterade problem för individen utan även en avsevärd ekonomisk börda för samhället. Risken för att utveckla skador i överkroppen varierar med olika yrken. Europeiska arbetsmiljöbyrån (EU-OSHA) har identifierat betydande hälsorisker i samband med frisörarbete. Det har uppskattats att besvär i överkroppen är 5 gånger mer förekommande hos frisörer jämfört med andra yrken. Det finns många forskningsprojekt som har använt kvalitativa riskbedömningsverktyg, baserade på självrapportering och observation, som identifierar riskerna med att utveckla skador i överkroppen bland frisörer. Ett kvantitativt riskbedömningsverktyg som ger objektiva data om arbetsställning är dock mer exakt än självrapportering och observation. Ett sådant verktyg kan hjälpa till att identifiera risken för skadeutveckling i överkroppen. Inertial Measurement Units (IMUs) är en del av ett bärbart mätsystem som har utvecklats påKTH. Systemet användes i denna studie för att identifiera risken för skadeutveckling i överkroppen bland frisörer. Riskidentifieringen gjordes genom att mäta vinkel på armar och rygg. Mätsystemet har även en inbyggd återkopplingsfunktion som uppmärksammar användaren om deras kroppsställning. Effektiviteten av att använda återkopplingsfunktionen för att förebygga jobbrelaterade skador utvärderades genom jämförelse av mätningar som erhållits med och utan återkopplingsfunktion. Tolv frisörstudenter deltog i studien. Överkroppspositionen definierades av vinklar över 45° eller mindre än 0° från en position där ryggen är rak. Abduktionsvinklar över 30°, 60° och 90° mättes för armar. Tidsperioden för dessa vinklar d.v.s. hur lång tid överkroppen hölls i dessa vinklar räknades. Armar och överkroppvinklar för 10:e och 90:e percentilen (°) samt resultat av en statistisk analys som utfördes på data samlade med och utan återkopplingsfunktionen presenterades. Analysen utfördes för att utvärdera hur effektiv återkopplingsfunktionen är för att förhindra arbetsskadeutveckling. En System Usability Scale (SUS) frågeformulär användes för att utvärdera systemets övergripande användbarhet.Resultatet av denna studie bekräftar att frisöryrket faller i högriskkategorin för arbetsskadeutveckling. Användningen av detta bärbara mätsystem har möjliggjort en exakt riskbedömning för olika arbetsuppgifter. En sådan information kan användas som grund för att förbättra ergonomiska förhållanden på arbetsplatser. Effektiviteten av återkopplingsfunktionen som ett förebyggande verktyg på individnivå är starkt beroende av individernas motivation och deras inställning till att ändra sina arbetsvanor. Emellertid anger resultaten en generell minskning av armvinklar (°) för både vänster och höger arm när återkopplingsfunktionen används. Till exempel har den 90:e percentil vinklarna (°) för vänsterarm (alla 12 personer) under hög belastning minskat från ett värde av 60.4° till 58.2 °. Den 90:e percentil vinklarna (°)för höger arm under hög belastning har också minskat från ett värde av 53.1° till 51.4°. SUS-poängen på 75.6 indikerar en bra användbarhet för systemet

The National Occupational Research Agenda stresses the importance of identifying work-related musculoskeletal disorder (WMSD) risk factors, understanding their exposure dependent nature, and identifying strategies to reduce their incidence and severity. We first examined behavioral changes after exposure to a low repetition low force (LRLF) reaching task for 12 weeks in young rats. We observed increased movement reversals in LRLF - week 8, indicative of a decline in fine motor control, and a small decrease in voluntary task participation in LRLF - week 12, compared to controls. This decline was associated temporally with a low-grade increase of macrophages in peripheral nerve and distal forelimb bones that correlated with nociceptive neurochemical increases in the spinal cord. We next examined motor behavior changes in young rats exposed to either a food retrieval high repetition negligible force (HRNF) task or a lever pulling high repetition low force (HRLF) reaching task. We found that both tasks led to motor declines, with more marked declines in fine motor control in the HRNF group. Thus, repetition, rather than the difference in force magnitude between the 2 tasks, appears to be the key factor in the induction of motor declines associated with repetitive motion injuries (RMIs). Also, these findings indicate that activities involving negligible force do not necessarily pose a lower risk than activities involving low force. Factors such as fine motor coordination requirements may even pose greater risks. Also, compared to the LRLF task, the high repetition tasks resulted in more motor performance declines, thus confirming exposure-dependency in the context of RMI. We also explored the effects of HRNF and HRLF tasks on supraspinatus tendon of young adult rats in 6 and 12 weeks. We found a small but non-significant elevation of ED1+ macrophages in 6 weeks. The supraspinatus tendon does not appear to develop as many pathological changes as forelimb flexor tendons (Barbe, et al., 2003) with task performance. Lastly, we examined the effects of performing HRLF tasks in aged rats. We found that aged rats demonstrate both declines in motor performance and pathological tissue changes over the course of 12 weeks of exposure to the HRLF lever pulling task. The observed declines in grip strength in aged trained control and HRLF rats over time suggest that both age and cumulative exposure to the repetitive task are factors in the development of WMSDs. Our findings suggest that additional study of exposure-dependency and risk factors is warranted. Deeper understanding of the relative contributions of various risk factors can help inform prophylactic programs and/or interventions for individuals who are at risk for, or suffer from, WMSDs. / Physical Therapy

Work-related musculoskeletal disorders (WMSDs) due to overexertion and consequently the low back pain (LBP) are one of the most prevalent sources of nonfatal occupational injuries and illnesses in all over the world. In the past several years, the industrial exoskeletons especially the passive ones have been proposed as alternative intervention and assistive devices, which are capable of reducing the risk of WMSDs and LBP. However, more research is warranted to validate the applicability of these exoskeletons. In addition, because the majority of previous studies have been limited to specific lifting tasks using only one type of lift assistive exoskeleton, more research is needed to examine the effect of alteration of different lift-assistive exoskeletons on reducing the activity of back muscles and metabolic reduction. The main objective of this dissertation is to render an overview of three studies that attempt to improve the literature by providing comprehensive biomechanical evaluations and metabolic assessments of three passive lift-assistive exoskeletons (VT-Lowe's Exoskeleton (developed in ARLab at VT), Laevo and SuitX). This dissertation has been composed of three related studies. The first study aimed to investigate and examine the capability of a novel lift assistive exoskeleton, VT-Lowe's exoskeleton, in reducing the peak and mean activity of back and leg muscles. Findings revealed that the exoskeleton significantly decreased the peak and mean activity of back muscles (IL(iliocostalis lumborum) and LT(longissimus thoracis)) by 31.5% and 29.3% respectively for symmetric lifts, and by 28.2% and 29.5% respectively for asymmetric lifts. Furthermore, the peak and mean EMG of leg muscles were significantly reduced by 19.1% and 14.1% during symmetric lifts, and 17.4% and 14.6% during asymmetric lifts. Interestingly, the VT-Lowe's exoskeleton showed higher reduction in activity of back and leg muscles compared to other passive lift-assistive exoskeletons available in the literatures. In the second study, the metabolic cost reduction associated with the use of VT-Lowe's exoskeleton during freestyle lifting was theoretically modelled, validated and corresponding metabolic savings were reported. The metabolic cost and the oxygen consumption results supported the hypothesis that the VT-Lowe's exoskeleton could significantly reduce the metabolic demands (~7.9% on average) and oxygen uptake (~8.7% on average) during freestyle lifting. Additionally, we presented a prediction model for the metabolic cost of exoskeleton during repetitive freestyle lifting tasks. The prediction models were very accurate as the absolute prediction errors were small for both 0% (< 1.4%) and 20% (< 0.7%) of body weight. In the third study, the biomechanical evaluation, energy expenditure and subjective assessments of two passive back-support exoskeletons (Laevo and SuitX) were examined in the context of repetitive lifting tasks. The experimental lifting tasks in this study were simulated in a laboratory environment for two different levels of lifting symmetry (symmetric vs. asymmetric) and lifting posture (standing vs. kneeling). Results of this study demonstrated that using both exoskeletons during dynamic lifting tasks could significantly lower the peak activity of trunk extensor muscles by ~10-28%. In addition, using both exoskeletons could save the energy expenditure by ~4-13% in all conditions tested by partially offsetting the weight of the torso. Such reductions were, though, task-dependent and differed between the two tested exoskeletons. Overall, the results of all three studies in this dissertation showed the capability of passive lift-assistive exoskeletons in reducing the activity of back and leg muscles and providing metabolic savings during repetitive lifting tasks. / Doctor of Philosophy / Low back pain (LBP) due to overexertion is known as one of the most important sources of nonfatal occupational injuries especially for the workers or manual material handlers who are involved in frequent or repetitive lifting tasks. Every year, many workers are temporarily or permanently disabled due to overuse injuries at workplace. In the past several years, industrial exoskeletons have gained growing interest among biomechanist, roboticist, and other human factor researchers as potential assistive devices to reduce the risk of LBP. In general, the industrial exoskeletons are either “passive or “active”; Active exoskeletons are powered by mechanical/electrical motors and actuators, however, the passive exoskeletons often work using cheaper devices such as gas or metal springs, elastic elements, etc. The exoskeletons discussed in this dissertation are categorized as passive rigid lower-back exoskeletons and they function by storing energy in a spring when the wearer bends and returning the stored energy when the wearer lifts. This dissertation consists of three studies that attempt to provide comprehensive biomechanical evaluations and metabolic assessments of three passive lift-assistive exoskeletons (i.e., VT-Lowe’s Exoskeleton, Laevo and SuitX). The first study examined the efficacy of a novel lift-assistive exoskeleton, VT-Lowe’s exoskeleton, in reducing the peak and mean activity of back and leg muscles. The results of this study demonstrated that the exoskeleton reduced the peak and mean activity of back and leg muscles for symmetric and asymmetric lifting tasks. VT-Lowe’s exoskeleton also showed higher reduction in activity of back muscles compared to other passive lift-assistive exoskeletons available in the literature. In the second study, the metabolic cost reduction with VT-Lowe’s exoskeleton was theoretically modeled and the modeling outcomes were compared to metabolic costs measurements when the exoskeleton was worn. The experimental findings of this study supported the applicability of the exoskeleton by significantly reducing the metabolic cost and oxygen uptake during the freestyle repetitive lifting tasks. Moreover, the prediction metabolic cost model of the exoskeleton showed high accuracy as the absolute prediction errors were within 1.5%. In the third study, the biomechanical evaluation, energy expenditure and subjective assessments of two passive back-support exoskeletons (Laevo and SuitX) were examined in repetitive lifting tasks. The lifting tasks of this study were simulated in a laboratory environment for two different levels of lifting symmetry (symmetric vs. asymmetric) and lifting posture (standing vs. kneeling). Findings of this study showed that both exoskeleton significantly lowered the peak activity of back muscles during the dynamic lifting tasks. Moreover, using both exoskeletons provided metabolic cost savings in all of the studies conditions. Overall, results obtained from the three studies in this dissertation verified the capability of these passive lift- vi assistive exoskeleton in reducing the activity of back and leg muscles and providing the metabolic savings during repetitive lifting tasks.

With the advancement of technology, innovative control measures have been introduced to mitigate the risk of work-related musculoskeletal disorders (WMSDs). Among these measures, wearable passive exoskeletons have emerged as promising solutions for addressing WMSDs. Previous studies have demonstrated the effectiveness of wearable passive exoskeletons for improving awkward postures and reducing muscle workload in tasks involving neck extension, limbs, and back. However, the effectiveness of newly developed industrial exoskeletons designed for neck flexion remains uncertain. This study aimed to evaluate the neck exoskeleton's effects on muscle activities and work postures, by comparing the working conditions of floor workers wearing and not wearing these devices. Six subjects were recruited for field measurements. Muscle activity of the neck extensors, as well as the forward inclination angle of the head and trunk, were assessed during the measurements. Data comparison between wearing and not wearing the neck flexion exoskeleton was conducted using the related samples Wilcoxon signed-rank test. Spearman’s rank correlation coefficient was utilized to analyze the correlation between different parameters while wearing the neck flexion exoskeleton. The results showed that compared to not wearing the exoskeleton, wearing the neck flexion exoskeleton significantly reduced muscular activity at the 10th percentile (p=0.028), 50th percentile (p=0.028), and 90th percentile (p=0.028). Wearing the neck flexion exoskeleton also reduced the 10th percentile (p=0.028) and 90th percentile (p=0.046) of the head angle, and the neck angle at the 50th percentile (p=0.028) and 90th percentile (p=0.028). Additionally, the trunk angle was significantly higher with the exoskeleton at the 50th percentile (p=0.046) and 90th percentile (p=0.027). The correlation analysis when wearing the exoskeleton revealed a negative correlation between neck angle and trunk angle at the 10th percentile (r=-0.829, p=0.021). Additionally, a significant negative correlation was found between neck angle and trunk angle at the 90th percentile (r=-0.943, p=0.002), as well as between head angle and trunk angle at the 90th percentile (r=-0.829, p=0.021). Moreover, a strong negative correlation was observed between RMS and head angle at the 50th percentile (r=-0.771, p=0.036) and 90th percentile (r=-0.829, p=0.021). In conclusion, the results show that wearing neck flexion exoskeletons during actual work tasks among floor layers reduces neck extensor muscle activity, excessive neck flexion, and forward head inclination, and it may lead to an increase in forward trunk inclination, without influencing work efficiency. / trätt som en möjlighet för att minska risken för WMSD. Tidigare studier har visat att bärbara passiva exoskelett är effektiva för att minska belastningen vid besvärliga arbetsställningar och minska muskelbelastningen vid arbetsuppgifter som involverar nackextension, extremiteter och rygg. Dock är effektiviteten av nyligen utvecklade industriella exoskelett designade för nackflexion fortfarande osäker. Denna studie syftade till att undersöka effekten av ett nackflexionsexoskelett, med avseende på muskelbelastning och arbetsställningar hos golvarbetare. Sex försökspersoner rekryterades för fältmätningar. Muskelaktiviteten hos nackextensorerna, samt framåtlutningsvinkeln av huvudet och bålen, mättes under arbetet. Statistisk jämförelse mellan att bära och inte bära nackflexionsexoskelettet utfördes med hjälp av Wilcoxon signed-rank test för relaterade prover. Spearman rangkorrelationskoefficient användes för att analysera korrelationen mellan olika parametrar när nackflexionsexoskelettet bars. Resultaten visade att exoskelettet signifikant minskade muskelaktiviteten ; vid 10:e percentilen (p=0.028), 50:e percentilen (p=0.028) och 90:e percentilen (p=0.028). Vidare minskade även huvudvinkeln signifikant, 10:e percentilen (p=0.028) och 90:e percentilen (p=0.046) av, liksomnackvinkelns 50:e percentilen (p=0.028) och 90:e percentilen (p=0.028). Bålvinkeln, däremot, var signifikant högre med exoskelettet både vid 50:e percentilen (p=0.046) och 90:e percentilen (p=0.027). Korrelationsanalysen avslöjade en negativ korrelation mellan nackvinkel och bålvinkel vid 10:e percentilen (r=-0.829, p=0.021) när exoskelettet bars. Dessutom var det en signifikant negativ korrelation mellan nackvinkel och bålvinkel vid 90:e percentilen (r=-0.943, p=0.002), samt mellan huvudvinkel och bålvinkel vid 90:e percentilen (r=-0.829, p=0.021) när exoskelettet bars. Dessutom observerades en stark negativ korrelation mellan muskelaktivitet och huvudvinkel vid 50:e percentilen av de båda måtten (r=-0.771, p=0.036) och vid 90:e percentilen (r=-0.829, p=0.021) när exoskelettet bars. Sammanfattningsvis visar resultaten att användning av nackflexionsexoskelett under faktiska arbetsuppgifter bland golvläggare minskar nackextensorernas muskelaktivitet, nackflexion och framåtlutning av huvudet, samt ökar framåtlutningen av av bålen utan att påverka arbetseffektiviteten.

INTRODUÇÃO: Os trabalhadores dos Serviços de Nutrição Hospitalar são submetidos às exigências físicas, cognitivas e psíquicas que levam à distúrbios osteomusculares relacionados ao trabalho. O objetivo deste estudo foi implantar ações de melhorias nas situações de trabalho de um serviço de nutrição hospitalar e avaliar a percepção dos trabalhadores e as repercussões sobre os sintomas osteomusculares. MÉTODO: Esta pesquisa foi desenvolvida em um hospital público especializado em cardiologia, localizado em São Paulo, Brasil, após aprovação pelo comitê de ética da instituição. A coleta de dados foi realizada por meio da aplicação de questionários e análise ergonômica do trabalho. Os questionários continham dados sócio-demográficos, história ocupacional, situação de trabalho atual, sintomas osteomusculares e satisfação no trabalho. Do total de 130 trabalhadores, 115 participaram voluntariamente. A análise ergonômica do trabalho foi efetuada de acordo com Guérin et al (2001), sendo realizadas entrevistas, medições do ambiente da cozinha e análises biomecânicas. A partir dos resultados foram implantadas ações de intervenção baseadas na ergonomia participativa durante um ano. Após esta fase, 89 (77%) trabalhadores responderam novamente ao questionário, sendo incluídas perguntas sobre a percepção das modificações. A análise dos dados incluiu testes estatísticos para verificar se houve mudança da prevalência de sintomas antes e após as intervenções, com nível de significância de 5%, por meio dos Programas SPSS 13.0 e Excel 2003. Além disso, foram analisados os dados de percepção dos trabalhadores e dos especialistas em ergonomia sobre o impacto das melhorias na saúde e no processo de trabalho. RESULTADOS: A população constitui-se, em sua maioria, por mulheres, na faixa etária de 25 a 34 anos, com grau médio de escolaridade, casadas, com filhos, e ocupavam o cargo de atendente de nutrição. A maioria trabalhava de 5 a 10 anos no hospital e em jornada de trabalho de 40 horas semanais. Os principais problemas observados foram espaço físico reduzido, equipamentos e materiais de trabalho inadequados, absenteísmo e déficit de pessoal, volume excessivo de trabalho com elevado esforço mental, alta prevalência de sintomas osteomusculares, principalmente nos membros inferiores e ombros. Após as intervenções realizadas, houve melhoria na situação de trabalho com redução nos sintomas osteomusculares e os trabalhadores perceberam as seguintes mudanças nas situações de trabalho: melhoria na iluminação e no controle do ar condicionado, aquisição de batedeira de tamanho médio, conserto de equipamentos, substituição dos pratos de vidro por descartáveis, aquisição de cadeiras, introdução de pausas durante a jornada de trabalho, ginástica laboral e treinamento em liderança para as chefias. Neste período houve ampliação no número de leitos do hospital com conseqüente aumento no volume de trabalho e diminuição da satisfação no trabalho associados à crise financeira da instituição com suspensão de contratações e da compra de materiais e equipamentos. CONCLUSÕES: As intervenções repercutiram em melhorias, principalmente quanto ao ambiente e equipamentos, e na redução dos sintomas osteomusculares nos membros inferiores, ombros, pescoço/região cervical, antebraço e região lombar, apesar desta redução não ter sido estatisticamente significativa. / INTRODUCTION: Hospital food service workers have high level of physical, cognitive and mental demands that are associated with musculoskeletal disorders. The objective of this study was to introduce improvements in the working conditions in a hospital food service and to evaluate the workers perceptions and its effects on musculoskeletal symptoms. METHOD: this study was performed in a public cardiac hospital in São Paulo, Brazil, after its approval by the Ethics Committee. The data were collected by questionnaires and ergonomic analysis of the work. The questionnaire included: socio-demographic, workhistory, work conditions, musculoskeletal symptoms and job satisfaction. A hundred and fifteen questionnaries were applied from 130 workers. The work ergonomic analysis was carried out in accordance with Guérin et al (2001), by means of interviews, observations of kitchen working conditions and biomechanical analyses. Based on the results, interventions have been undertaken by means of a participatory ergonomic approach over one year. After this, another ergonomic analysis was carried out and 89 workers (77%) answered a new questionnaire that also included questions about their perception of the improvements. Data analysis was done by statistical tests to verify symptom prevalences before and after the interventions with a 5% level of significance. SPSS 13.0 and Excel 2003 software was used. RESULTS: The workers were women in the 25-34 age-group, had secondary education, were married, had children and occupied the position of nutrition attendants. They were in this hospital for from 5 to 10 years and on a 40 hour working week schedule. Most of problems observed were reduced space, inadequate equipment and work materials, absenteeism, insufficient number of workers, great volume of work with mental demands, high prevalence of musculoskeletal symptoms mainly in lower members and shoulders. After the improvements in working conditions, the symptoms of musculoskeletal disorders reduced and the workers perceived the following changes in the work process: better lighting and control of air conditioning, acquisition of low capacity mixer, repair of equipment, use of disposable utensils instead of glass plates, acquisition of more chairs, introduction of breaks during working hours, work related gymnastics, workshops for leadership training. In this period the number of hospital beds was increased with a corresponding intensification of the work load and a decline on job satisfaction. The hospital was in a financial crisis with consequences in terms of the hiring of personnel and the acquisition of equipment and materials. CONCLUSION: Interventions brought improvements mainly as regards the work environment and equipment and in the reduction of musculoskeletal symptoms in the lower members, shoulders, neck/cervical region, forearm and lumbar region, though this reduction has not been statistically significant.

O presente estudo nasce da necessidade de melhorar a integralidade da atenÃÃo à saÃde dos trabalhadores, destacando o trabalhador com lesÃes por esforÃos repetitivos e distÃrbios osteomusculares relacionados ao trabalho - LER/DORT. Assim tivemos como objetivo construir participativamente uma linha de cuidado integral para o trabalhador com LER/DORT no Ãmbito do SUS a partir da experiÃncia dos profissionais, gestores e usuÃrios que compÃem as redes de atenÃÃo à saÃde. Desenvolvida no municÃpio de Sobral- CearÃ, esta pesquisa à de natureza qualitativa do tipo exploratÃria. A pesquisa aÃÃo foi a metodologia de escolha por constitui-se como uma metodologia que visa à aÃÃo e promove a capacidade de transformaÃÃo da realidade pelos sujeitos da pesquisa. Para tal, utilizamos a pesquisa em grupo, onde os participantes, profissionais das redes de atenÃÃo à saÃde de Sobral, foram os responsÃveis pela construÃÃo da linha de cuidado em um processo que levou à formulaÃÃo, dos fluxos e atribuiÃÃes que os prÃprios participantes da pesquisa e seus pares deverÃo desenvolver nos serviÃos em que trabalham com o objetivo de promover a integralidade da atenÃÃo à saÃde do trabalhador. Ressaltamos que estas aÃÃes da linha de cuidado foram construÃdas no ano de 2012 coletivamente, apÃs quatro encontros do grupo. O primeiro encontro foi para debater sobre integralidade e definir as aÃÃes prioritÃrias apontadas pelo grupo, o segundo encontro foi uma oficina que teve como objetivo construir o fluxo da linha de cuidado, o terceiro encontro a segunda oficina que teve como objetivo definir as atribuiÃÃes dos profissionais dos serviÃos que atendem o trabalhador, e o quarto encontro, e Ãltima oficina, tiveram como objetivos apresentar o fluxo construÃdo pelo grupo e validar as atribuiÃÃes da rede de serviÃos que atende o trabalhador com LER/DORT. Como mÃtodo de tratamento dos dados obtidos utilizamos a anÃlise do discurso. Os resultados apontam que trabalhadores com a doenÃa podem buscar diversos pontos da rede de atenÃÃo, dentre eles serviÃos da AtenÃÃo Primaria a SaÃde, da AtenÃÃo Ambulatorial Especializada, da AtenÃÃo Hospitalar e da UrgÃncia e EmergÃncia. Surgiram apÃs a validaÃÃo 36 atribuiÃÃes para os profissionais. As atribuiÃÃes identificadas incluÃram aÃÃes promocionais, preventivas, curativas e de reabilitaÃÃo. Ressaltamos que para construir a linha de cuidado pensamos na necessidade do trabalhador como o aspecto central para seu fluxo de atendimento e assistÃncia. Dessa forma, a linha de cuidado proposta demonstra uma possibilidade da garantia da integralidade relacionada à organizaÃÃo dos serviÃos de saÃde, mostrando o caminho a ser percorrido por um usuÃrio, desde a APS e passando por diferentes serviÃos na busca de um leque de cuidados necessÃrios para resolver seu problema de saÃde. Para o funcionamento da linha de cuidado proposta à necessÃrio à existÃncia de um trabalho compartilhado entre os profissionais da APS e os demais serviÃos de saÃde. Nesse processo, alÃm da construÃÃo e pactuaÃÃo do fluxo da atenÃÃo, à necessÃrio a elaboraÃÃo de estratÃgias para efetivar esse caminho a ser percorrido pelo trabalhador na rede de atenÃÃo, estabelecer e negociar responsabilidades para garantir a qualidade e continuidade do cuidado.

Introdução: O Código de Processo Civil determina que nos processos judiciais em que a matéria depender de conhecimento técnico ou científico, o juiz será assistido por perito, que produzirá um laudo. Foram analisados 83 laudos de processos judiciais do Tribunal Regional do Trabalho da 2ª Região (TRT-2), referentes a reclamantes com Lesões por Esforços Repetitivos ou Distúrbios Osteomusculares Relacionados ao Trabalho (LER/Dort), que abrangem afecções crônicas do sistema musculoesquelético de origem ocupacional e são decorrentes, dentre outros motivos, da execução de movimentos repetitivos por tempo prolongado e sobrecarga estática, sem que haja tempo para uma recuperação fisiológica. Deveriam abordar os vários aspectos do adoecimento para auxiliar a decisão judicial quanto à existência de agravo à saúde relacionado ao trabalho, assim como sua extensão e repercussões sobre a vida e capacidade laboral do trabalhador. Objetivos: Identificar e analisar, nos laudos, conceitos sobre adoecimento ocupacional e incapacidade laboral, bem como as principais linhas de argumentação, para a descaracterização do nexo causal nos casos em que havia nexo causal presumido pelo critério epidemiológico. Material e método: O material de estudo (83 laudos) foi buscado dentre os processos arquivados no período de 2012 a 2016 na Coordenadoria de Gestão de Arquivo do TRT-2, que abrange 30 municípios da região metropolitana de São Paulo e Baixada Santista. Atributos associados aos grandes temas da pesquisa foram codificados com o objetivo de melhor sistematização para uma análise de conteúdo. Resultados: Os laudos periciais foram elaborados, na sua quase totalidade por médicos, dentre os quais 56 (67,47%) médicos do trabalho, 13 (15,66%) médicos sem especificação de especialidade, 9 (10,84%) médicos com especialização em perícia ou legistas e 4 ortopedistas (4,82%). Um deles (1,21%) foi elaborado por fisioterapeuta. Do total de laudos, 25 (30,12%) não tinham quaisquer informações sobre o processo de adoecimento e apenas 23 (27,71%) contemplaram uma história clínica abrangente. Em 34 (40,96%) não havia qualquer informação sobre as características da atividade de trabalho e em 30 (36,15%) havia a citação de alguns aspectos biomecânicos. Apenas 19 (22,89%) apresentaram uma análise da atividade de trabalho, incluindo aspectos biomecânicos e organizacionais. Nenhum laudo continha uma análise da incapacidade para o trabalho de forma ampla, sendo que em 50 laudos (60,24%), o perito considerou apenas o diagnóstico para se pronunciar sobre a incapacidade. Do total dos laudos, apenas 13 (15,66%) utilizaram o conceito de multicausalidade e 12 (14,46%) o de concausalidade. Dos 15 laudos com nexo causal presumido pelo critério epidemiológico, descaracterizados no caráter ocupacional na perícia, nenhum continha uma análise da atividade de trabalho, embora 9 deles tenham utilizado argumentos biomecânicos, 8 tenham utilizado o argumento de que se tratava de doença degenerativa e 3 de que o quadro era de fibromialgia não ocupacional. Foram discutidos conceitos de adoecimento ocupacional, nexo causal e incapacidade, além da relação de desigualdade, presenteísmo, individualização do adoecimento e culpabilização. Conclusão: A maioria dos laudos periciais peca pela falta de consistência conceitual, metodológica e argumentos fundamentados, deixando lacunas na área clínica, na análise da atividade de trabalho e na avaliação de incapacidade. / Introduction: The Civil Code Procedure determines that in judicial proceedings in which the matter depends on technical or scientific knowledge, the judge will be assisted by experts, who will produce a forensic report. A total of 83 reports, from the Regional Labor Court of the 2nd Region (TRT-2), were analysed, concerning claimants suffering from Repetitive Strain Injury or Work-Related Musculoskeletal Disorders (RSI/WRMD), which include occupational chronic conditions of the musculoskeletal system, that are due, among other reason to the execution of repetitive movements for a prolonged time and static overload without pause foa a physiological recoevery. They should address the various aspects of illness in order to assist the judge in his decision regarding the existence of as aggravated health related to work, as well as its extent and repercussions on the life and work capacity of the worker. Objectives: To identify and analyse concepts about occupational illness and disability to work, expressed in the reports, as well as the main lines of argument, for the de-characterization of the causal nexus in cases where there was causal nexus presumed by the epidemiological criterion. Material and method: The study material was searched from the archived processes from 2012 to 2016 in the File Management Coordination of TRT-2, which covers 30 municipalities in the metropolitan region of São Paulo and Baixada Santista. Attributes associated with the major themes of the research were codified with the aim of better systematization for a content analysis. Results: The expert reports were elaborated almost entirely by physicians, among them 56 (67.47%) occupational physicians, 13 (15.66%) doctors without a declared specialty, 9 (10.84%), forensic doctors, 4 orthopedists (4,82%). One of the reports (1.21%) was elaborated by a physiotherapist. Of the total reports, 25 (30.12%) did not have information about the illness process and only 23 (27.71%) contemplated a comprehensive medical history. In 34 (40.96%) there was no information about the characteristics of the work activity and in 30 (36.15%) there were citation of some biomechanical aspects. Only 19 (22.89%) presented an analysis of the work activity, including biomechanical and organizational aspects. No report contained an embrancing analysis of disability to work comprehensively, and in 60.24% of them, the expert considered only the diagnosis to pronounce on the disability. Of the total reports, only 13 (15.66%) used the concept of multicausality and 12 (14.46%) the concept of concausality. Of the 15 reports with a presumed causal nexus by the epidemiological criterion, which were not characterized in the occupational character, none contained an analysis of the work activity, although 9 of the 15 reports used biomechanical arguments to de-characterize the occupational character, 8 used the argument that it was degenerative disease and 3 that the condition was non-occupational fibromyalgia. Concepts of occupational illness, causal nexus and disability were discussed, as well as the relationship of inequality, presenteism, individualization of illness and blame. Conclusions: Most of the expert reports are lacking in conceptual, methodological and reasoned arguments, leaving relevant gaps in the clinical area, in the analysis of the work activities and in the assessment of disability.

INTRODUÇÃO: Os trabalhadores dos Serviços de Nutrição Hospitalar são submetidos às exigências físicas, cognitivas e psíquicas que levam à distúrbios osteomusculares relacionados ao trabalho. O objetivo deste estudo foi implantar ações de melhorias nas situações de trabalho de um serviço de nutrição hospitalar e avaliar a percepção dos trabalhadores e as repercussões sobre os sintomas osteomusculares. MÉTODO: Esta pesquisa foi desenvolvida em um hospital público especializado em cardiologia, localizado em São Paulo, Brasil, após aprovação pelo comitê de ética da instituição. A coleta de dados foi realizada por meio da aplicação de questionários e análise ergonômica do trabalho. Os questionários continham dados sócio-demográficos, história ocupacional, situação de trabalho atual, sintomas osteomusculares e satisfação no trabalho. Do total de 130 trabalhadores, 115 participaram voluntariamente. A análise ergonômica do trabalho foi efetuada de acordo com Guérin et al (2001), sendo realizadas entrevistas, medições do ambiente da cozinha e análises biomecânicas. A partir dos resultados foram implantadas ações de intervenção baseadas na ergonomia participativa durante um ano. Após esta fase, 89 (77%) trabalhadores responderam novamente ao questionário, sendo incluídas perguntas sobre a percepção das modificações. A análise dos dados incluiu testes estatísticos para verificar se houve mudança da prevalência de sintomas antes e após as intervenções, com nível de significância de 5%, por meio dos Programas SPSS 13.0 e Excel 2003. Além disso, foram analisados os dados de percepção dos trabalhadores e dos especialistas em ergonomia sobre o impacto das melhorias na saúde e no processo de trabalho. RESULTADOS: A população constitui-se, em sua maioria, por mulheres, na faixa etária de 25 a 34 anos, com grau médio de escolaridade, casadas, com filhos, e ocupavam o cargo de atendente de nutrição. A maioria trabalhava de 5 a 10 anos no hospital e em jornada de trabalho de 40 horas semanais. Os principais problemas observados foram espaço físico reduzido, equipamentos e materiais de trabalho inadequados, absenteísmo e déficit de pessoal, volume excessivo de trabalho com elevado esforço mental, alta prevalência de sintomas osteomusculares, principalmente nos membros inferiores e ombros. Após as intervenções realizadas, houve melhoria na situação de trabalho com redução nos sintomas osteomusculares e os trabalhadores perceberam as seguintes mudanças nas situações de trabalho: melhoria na iluminação e no controle do ar condicionado, aquisição de batedeira de tamanho médio, conserto de equipamentos, substituição dos pratos de vidro por descartáveis, aquisição de cadeiras, introdução de pausas durante a jornada de trabalho, ginástica laboral e treinamento em liderança para as chefias. Neste período houve ampliação no número de leitos do hospital com conseqüente aumento no volume de trabalho e diminuição da satisfação no trabalho associados à crise financeira da instituição com suspensão de contratações e da compra de materiais e equipamentos. CONCLUSÕES: As intervenções repercutiram em melhorias, principalmente quanto ao ambiente e equipamentos, e na redução dos sintomas osteomusculares nos membros inferiores, ombros, pescoço/região cervical, antebraço e região lombar, apesar desta redução não ter sido estatisticamente significativa. / INTRODUCTION: Hospital food service workers have high level of physical, cognitive and mental demands that are associated with musculoskeletal disorders. The objective of this study was to introduce improvements in the working conditions in a hospital food service and to evaluate the workers perceptions and its effects on musculoskeletal symptoms. METHOD: this study was performed in a public cardiac hospital in São Paulo, Brazil, after its approval by the Ethics Committee. The data were collected by questionnaires and ergonomic analysis of the work. The questionnaire included: socio-demographic, workhistory, work conditions, musculoskeletal symptoms and job satisfaction. A hundred and fifteen questionnaries were applied from 130 workers. The work ergonomic analysis was carried out in accordance with Guérin et al (2001), by means of interviews, observations of kitchen working conditions and biomechanical analyses. Based on the results, interventions have been undertaken by means of a participatory ergonomic approach over one year. After this, another ergonomic analysis was carried out and 89 workers (77%) answered a new questionnaire that also included questions about their perception of the improvements. Data analysis was done by statistical tests to verify symptom prevalences before and after the interventions with a 5% level of significance. SPSS 13.0 and Excel 2003 software was used. RESULTS: The workers were women in the 25-34 age-group, had secondary education, were married, had children and occupied the position of nutrition attendants. They were in this hospital for from 5 to 10 years and on a 40 hour working week schedule. Most of problems observed were reduced space, inadequate equipment and work materials, absenteeism, insufficient number of workers, great volume of work with mental demands, high prevalence of musculoskeletal symptoms mainly in lower members and shoulders. After the improvements in working conditions, the symptoms of musculoskeletal disorders reduced and the workers perceived the following changes in the work process: better lighting and control of air conditioning, acquisition of low capacity mixer, repair of equipment, use of disposable utensils instead of glass plates, acquisition of more chairs, introduction of breaks during working hours, work related gymnastics, workshops for leadership training. In this period the number of hospital beds was increased with a corresponding intensification of the work load and a decline on job satisfaction. The hospital was in a financial crisis with consequences in terms of the hiring of personnel and the acquisition of equipment and materials. CONCLUSION: Interventions brought improvements mainly as regards the work environment and equipment and in the reduction of musculoskeletal symptoms in the lower members, shoulders, neck/cervical region, forearm and lumbar region, though this reduction has not been statistically significant.

Introdução: O Código de Processo Civil determina que nos processos judiciais em que a matéria depender de conhecimento técnico ou científico, o juiz será assistido por perito, que produzirá um laudo. Foram analisados 83 laudos de processos judiciais do Tribunal Regional do Trabalho da 2ª Região (TRT-2), referentes a reclamantes com Lesões por Esforços Repetitivos ou Distúrbios Osteomusculares Relacionados ao Trabalho (LER/Dort), que abrangem afecções crônicas do sistema musculoesquelético de origem ocupacional e são decorrentes, dentre outros motivos, da execução de movimentos repetitivos por tempo prolongado e sobrecarga estática, sem que haja tempo para uma recuperação fisiológica. Deveriam abordar os vários aspectos do adoecimento para auxiliar a decisão judicial quanto à existência de agravo à saúde relacionado ao trabalho, assim como sua extensão e repercussões sobre a vida e capacidade laboral do trabalhador. Objetivos: Identificar e analisar, nos laudos, conceitos sobre adoecimento ocupacional e incapacidade laboral, bem como as principais linhas de argumentação, para a descaracterização do nexo causal nos casos em que havia nexo causal presumido pelo critério epidemiológico. Material e método: O material de estudo (83 laudos) foi buscado dentre os processos arquivados no período de 2012 a 2016 na Coordenadoria de Gestão de Arquivo do TRT-2, que abrange 30 municípios da região metropolitana de São Paulo e Baixada Santista. Atributos associados aos grandes temas da pesquisa foram codificados com o objetivo de melhor sistematização para uma análise de conteúdo. Resultados: Os laudos periciais foram elaborados, na sua quase totalidade por médicos, dentre os quais 56 (67,47%) médicos do trabalho, 13 (15,66%) médicos sem especificação de especialidade, 9 (10,84%) médicos com especialização em perícia ou legistas e 4 ortopedistas (4,82%). Um deles (1,21%) foi elaborado por fisioterapeuta. Do total de laudos, 25 (30,12%) não tinham quaisquer informações sobre o processo de adoecimento e apenas 23 (27,71%) contemplaram uma história clínica abrangente. Em 34 (40,96%) não havia qualquer informação sobre as características da atividade de trabalho e em 30 (36,15%) havia a citação de alguns aspectos biomecânicos. Apenas 19 (22,89%) apresentaram uma análise da atividade de trabalho, incluindo aspectos biomecânicos e organizacionais. Nenhum laudo continha uma análise da incapacidade para o trabalho de forma ampla, sendo que em 50 laudos (60,24%), o perito considerou apenas o diagnóstico para se pronunciar sobre a incapacidade. Do total dos laudos, apenas 13 (15,66%) utilizaram o conceito de multicausalidade e 12 (14,46%) o de concausalidade. Dos 15 laudos com nexo causal presumido pelo critério epidemiológico, descaracterizados no caráter ocupacional na perícia, nenhum continha uma análise da atividade de trabalho, embora 9 deles tenham utilizado argumentos biomecânicos, 8 tenham utilizado o argumento de que se tratava de doença degenerativa e 3 de que o quadro era de fibromialgia não ocupacional. Foram discutidos conceitos de adoecimento ocupacional, nexo causal e incapacidade, além da relação de desigualdade, presenteísmo, individualização do adoecimento e culpabilização. Conclusão: A maioria dos laudos periciais peca pela falta de consistência conceitual, metodológica e argumentos fundamentados, deixando lacunas na área clínica, na análise da atividade de trabalho e na avaliação de incapacidade. / Introduction: The Civil Code Procedure determines that in judicial proceedings in which the matter depends on technical or scientific knowledge, the judge will be assisted by experts, who will produce a forensic report. A total of 83 reports, from the Regional Labor Court of the 2nd Region (TRT-2), were analysed, concerning claimants suffering from Repetitive Strain Injury or Work-Related Musculoskeletal Disorders (RSI/WRMD), which include occupational chronic conditions of the musculoskeletal system, that are due, among other reason to the execution of repetitive movements for a prolonged time and static overload without pause foa a physiological recoevery. They should address the various aspects of illness in order to assist the judge in his decision regarding the existence of as aggravated health related to work, as well as its extent and repercussions on the life and work capacity of the worker. Objectives: To identify and analyse concepts about occupational illness and disability to work, expressed in the reports, as well as the main lines of argument, for the de-characterization of the causal nexus in cases where there was causal nexus presumed by the epidemiological criterion. Material and method: The study material was searched from the archived processes from 2012 to 2016 in the File Management Coordination of TRT-2, which covers 30 municipalities in the metropolitan region of São Paulo and Baixada Santista. Attributes associated with the major themes of the research were codified with the aim of better systematization for a content analysis. Results: The expert reports were elaborated almost entirely by physicians, among them 56 (67.47%) occupational physicians, 13 (15.66%) doctors without a declared specialty, 9 (10.84%), forensic doctors, 4 orthopedists (4,82%). One of the reports (1.21%) was elaborated by a physiotherapist. Of the total reports, 25 (30.12%) did not have information about the illness process and only 23 (27.71%) contemplated a comprehensive medical history. In 34 (40.96%) there was no information about the characteristics of the work activity and in 30 (36.15%) there were citation of some biomechanical aspects. Only 19 (22.89%) presented an analysis of the work activity, including biomechanical and organizational aspects. No report contained an embrancing analysis of disability to work comprehensively, and in 60.24% of them, the expert considered only the diagnosis to pronounce on the disability. Of the total reports, only 13 (15.66%) used the concept of multicausality and 12 (14.46%) the concept of concausality. Of the 15 reports with a presumed causal nexus by the epidemiological criterion, which were not characterized in the occupational character, none contained an analysis of the work activity, although 9 of the 15 reports used biomechanical arguments to de-characterize the occupational character, 8 used the argument that it was degenerative disease and 3 that the condition was non-occupational fibromyalgia. Concepts of occupational illness, causal nexus and disability were discussed, as well as the relationship of inequality, presenteism, individualization of illness and blame. Conclusions: Most of the expert reports are lacking in conceptual, methodological and reasoned arguments, leaving relevant gaps in the clinical area, in the analysis of the work activities and in the assessment of disability.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic and Somatology, Faculty of Health Sciences, Durban University of Technology, Durban, South Africa. 2017. / Background The growing popularity and competitive nature of the beauty industry has resulted in beauty therapists performing an extensive range of treatments to meet the demand, often at the jeopardy of their own well-being. Treatments include massage, waxing, pedicures and facials. These techniques involve vigorous and repetitive movements that may lead to overuse and strain on the musculoskeletal system, resulting in injury. Work-related activities together with factors such as socio-demographic, psychosocial, environmental and anthropometric can influence the prevalence of work-related musculoskeletal disorders (WRMDs). There has been little investigation into the WRMDs of beauty therapists both locally and internationally. Aim The aim of this study was to determine the prevalence, selected risk factors and impact of self-reported work related musculoskeletal disorders (WRMDs) in beauty therapists working within the hotel spa industry in the eThekwini municipality. Method A cross sectional epidemiological design was used to survey 254 beauty therapists working in the hotel spa industry in the eThekwini municipality of Durban. A pre-validated questionnaire was hand delivered to beauty therapists working at all hotel spas that agreed to participate. Informed consent was obtained. The survey contained questions related to musculoskeletal pain, socio-demographic, psycho-social, lifestyle and occupational factors. Results A response rate of 70% was obtained (n=178). The majority of the respondents were female (94.3%; n=165), the mean age of the respondents was 27.74 (SD±4.83) years. The respondents had been working as beauty therapists for an average of 5.91 (SD±4.19; n=176) years and performed on average 27.89 (SD±13.33; n=170) treatments per week, working 47.38 (SD±13.36; n=175) hours per week. Those working overtime worked on average 5.43 (SD±2.94; n=59) hours of overtime per week. There was a high rate of reported WRMDs with the lifetime, current and 12 month period prevalence being 86% (n=153), 85% (n=151) and 83% (n=148), respectively. The area most affected were the low back followed by the neck, the hand and wrist. Ninety percent of the respondents indicated that their pain was mild to moderate in nature, with half expressing an inability to cope with the pain, and 78% reporting that it interfered with their ability to work. Mental exhaustion (p=0.032), suffering from a concomitant co-morbidity (p=0.031), years worked as a beauty therapist (p˂0.001) and treating clients after hours (p=0.007) were significantly associated with the presence of musculoskeletal pain. Performing manual massage (p=0.043) and reporting feelings of exhaustion whilst performing specialised massage techniques (p=0.014) and applying makeup/eyelashes (p=0.022) were associated with the presence of WRMDs. Those who reported having co-worker (p=0.006) and managerial support (p˂0.001) were less likely to experience musculoskeletal pain. In contrast, feeling frustrated by work (p=0.007), being under pressure (p=0.005) and over worked (p=0.009) increased the chances of experiencing WRMDs. Working with the back in an awkward position (p˂0.001), standing for prolonged periods (p˂0.001), lifting heavy loads (p=0.019) and working in a hot and humid environment (p<0.001) increased the risk of WRMDs. Conclusion WRMDs have a significant impact on beauty therapists’ ability to work. Effective strategies to prevent and manage WRMDs in hotel spa beauty therapists is required, along with governmental regulation. / M