6QI (Six Question Initiative)

Why have we not solved the MSD problem?

Richard Wells has created a framework for an MSD Prevention Strategy in WORK, a Journal of Prevention, Assessment & Rehabilitation, 34 (2009) 117–121: Why have we not solved the MSD problem?

Despite worldwide attention for more than four decades, musculoskeletal disorders (MSDs) remain a substantial concern at work and result in considerable personal and societal burden. We are left with a major question: Why have we not solved the MSD problem?

In order to answer this question, CRE-MSD’s, has chosen to frame its research agenda with six questions. These six questions can be seen as a flow of logic. The answers to each question can help identify weak links, and prioritize where the Centre’s researchers need to put their energies, skills and experience. Asking each of these six questions helps us identify where our knowledge and practice may be wanting and the key factors that are limiting our ability to prevent MSDs at work.

The six questions are:

1. How well do we understand MSDs and their burdens?
2. How good are our MSD risk factors?
3. How effective and informative are current workplace MSD assessment approaches?
4. How effective are the recommended interventions in actually reducing MSDs in the workplace?
5. How intensely and widely implemented are workplace interventions to prevent MSD?
6. How well are we improving disability outcomes for MSDs?


In asking the first question, How well do we understand MSDs and their burdens? We are trying to identify the knowledge gaps that could be frustrating our prevention efforts. We may choose to use tissue damage, physiological function, clinical examination, pain, functional decrements, or work disability as measures of MSD burden or to define a case. But different choices could misrepresent the burden, risk factors, the effects of treatment, or the workplace interventions.

There is a cascading effect from our knowledge of the disorders themselves to our knowledge of risk factors, and hence we ask our second question: How good are we at identifying MSD risk factors? Exposure measures have improved over the years from initially just considering job titles, to self-reports of physical and psychosocial risk factors, to structured observations, and more recently to technical measures of muscle activity or modeled joint loads. Identified risk factors now include physical or mechanical factors (force, posture, repetition, duration), work organizational factors (worker perceptions of demand, control, and co-worker and supervisor support; the so-called psychosocial factors) as well as individual factors.

Yet, while it is possible to identify risk factors without having knowledge of the underlying patho-physiology, it would give us more confidence that the relationships are causal if we had a better grasp of statistical and physiological information, and it would increase the likelihood that our interventions of risk factors would be effective.

We also know that poorly characterized risk factors will lead to inadequate assessments. We know that hazard identification and risk assessment is an important first step for workplaces. This leads to our third question: How effective and informative are current workplace risk assessment approaches? Our existing hazard identification and risk assessment approaches include interviews, questionnaires, observational approaches and pencil and paper tools. But we don’t know much about the reliability of these measures between people, or over time, or their responsiveness to workplace change. There are more technically demanding methods but these are seldom used by anyone but experts or researchers.

We have also been focusing on physical risk factor assessments, and have given low priority to psychosocial factors or workplace organizational factors assessments. Interventions on potentially critical workplace-organizational factors are often not pursued since they are regarded as outside the realm of MSD prevention. The other problem is that because risk factors for MSDs can be found everywhere, there needs to be some judgment when prioritizing which risks should be corrected. After the low hanging fruit has been eliminated, identifying further risks becomes increasingly more difficult without training and better tools. Yet little attention has been paid to the training required to use even simple tools effectively.

Our fourth question is also difficult to answer: Are the interventions we are recommending actually reducing MSDs in the workplace? It can be argued that most of the intervention research studies that have been published represent the very best cases. They are performed in a laboratory or workplace settings under well-controlled, even ideal, conditions -- the interveners are highly competent, the organizations are carefully selected, and a large amount of resources are typically dedicated to the intervention. Yet even in these cases, one is often unable to detect any changes. You are left with the question of whether the implementation was not intense enough, or sustained for long enough, or whether the study and its design were ineffective. It is important to understand why the intervention was or was not efficacious so that we can plan broad implementation strategies.

This leads to our fifth question. How intensely and widely implemented are workplace interventions against MSD? To improve health (MSD) outcomes generally, an intervention must be implemented widely and intensely. The intervention must substantially reduce exposure in high risk tasks, must address the highest risks, either peaks or long term exposures, be available to all those with high exposures, and must be used by those same people. If any of these factors are small, the resulting intensity of the intervention will be low and the probability of improved musculoskeletal health outcomes will also be low. Moreover, to have a useful impact on society, we need to implement good interventions in a large proportion of workplaces with risk factors. Yet, it seems that few workplaces are containing their MSD hazards.

Finally, we address our sixth question: How well are we improving disability outcomes for MSDs? It is known that those people who have had an MSD are much more likely to suffer a second MSD. It also seems that some MSDs persist for long periods. Because most people suffer from MSDs at some point in their lives, to have an impact, our prevention activities should take place at the primary, secondary and tertiary levels simultaneously. We also know that it is important for workers’ psychological health and commitment to the workplace that workers return to work even if they are not totally pain free. The social support provided by supervisors, co-workers, workplace policy and procedures, as well as clinical management is key. However, this is proving to be difficult to execute.

In conclusion, in order to truly make a difference we need to fashion and test MSD prevention strategies that are feasible, socially acceptable, affordable, scalable and sustainable -- and which have good coverage for substantial parts of the working population, and which result in measurable MSD improvements within a reasonable time-frame. Yet with limited resources we need to prioritize the issues that are restraining our effectiveness. We need to focus our energies on specific research that will potentially maximize our intervention impact at the societal level while we continue to build our knowledge base around MSDs and improve prevention strategies. More than anything, we need to identify knowledge practice gaps which may be acting as major barriers to our success.