American J Industrial Medicine 2005 (Dec); 48 (6): 459–469 ~ FULL TEXT
Laura Punnett, ScD, Annette Pruss-Ustun, PhD, Deborah Imel Nelson, PhD, CIH, Marilyn A. Fingerhut, PhD, James Leigh, MD, PhD, SangWoo Tak, MPH, and Sharonne Phillips, BSc, MOHS
Department of Work Environment,
University of Massachusetts Lowell,
One University Avenue,
Lowell, Massachusetts 01854, USA.
BACKGROUND: There is little information about the global burden of non-traumatic low back pain (LBP) attributable to the effects of physical and psychosocial occupational stressors.
METHODS: Based on a review of the epidemiological evidence, occupation-specific relative risks were used to compute attributable proportions by age, gender, and geographical sub-region for the economically active population aged 15 and older. The reference group was professional/administrative workers; other risk categories were Low, clerical and sales; Moderate, operators (production workers) and service; and High, farmers.
RESULTS: Worldwide, 37% of LBP was attributed to occupation, with twofold variation across regions. The attributable proportion was higher for men than women, because of higher participation in the labor force and in occupations with heavy lifting or whole-body vibration. Work-related LBP was estimated to cause 818,000 disability-adjusted life years lost annually.
CONCLUSIONS: Occupational exposures to ergonomic stressors represent a substantial source of preventable back pain. Specific research on children is needed to quantify the global burden of disease due to child labor.
KEY WORDS: back pain; ergonomics; global burden of disease; human factors; musculoskeletal disorders; psychosocial; risk assessment; risk factors; work-related
From the FULL TEXT Article:
Pain in the soft tissues of the back is extremely common
among adults. In the United States, the National Arthritis
DataWorkgroup reviewed national survey data showing that
each year some 15% of adults report frequent back pain or
pain lasting more than 2 weeks [Lawrence et al., 1998]. Back
pain is widespread in many countries, and is associated with
substantial financial costs and loss of quality of life. In
Canada, Finland, and the United States, more people are
disabled from working as a result of musculoskeletal disorders
(MSDs), especially back pain, than from any other
group of diseases [Badley et al., 1994; Riihima¨ki, 1995;
Battie´ and Videman, 1997; Bernard, 1997]. MSDs constitute
a major proportion of all registered and/or compensable
work-related diseases in many countries, representing a third
or more of all registered occupational diseases in North
America, the Nordic countries, and Japan.
The physical ergonomic features of work that are most
frequently cited as MSD risk factors include rapid work pace
and repetitive motion patterns; insufficient recovery time;
heavy lifting and other forceful manual exertions; nonneutral
body postures (either dynamic or static); mechanical
pressure concentrations; vibration (both segmental and
whole-body); and low temperature. Many reviewers from
the United States, Canada, Europe, and Asia have reached
similar conclusions regarding the etiologic importance of
these exposures for low back disorders [Hulshof and
Veldhuijzen van Zanten, 1987; Jensen, 1988; Johanning
et al., 1991; Riihima¨ki, 1991, 1995; Garg, 1992; Hagberg
et al., 1993, 1995; Wikstro¨m et al., 1994; Frank et al., 1996;
Hales and Bernard, 1996; ICOH et al., 1996; Bernard, 1997;
Burdorf and Sorock, 1997; Viikari-Juntura, 1997; Gordon
and Weinstein, 1998; Lagerstro¨m et al., 1998; Hoogendorn
et al., 1999; Nachemson, 1999; Jin et al., 2000; National
Research Council, the Institute of Medicine, 2001].
factors may also play a role, although the evidence for
these is less conclusive to date. Despite this extensive
literature, some still dispute, the evidence for physical
workload, especially in relation to non-occupational causes
[e.g., Battie´ and Bigos, 1991; Waddell, 1991; Nachemson,
1999]. Reasons for the continuing controversy have been
discussed elsewhere [Frank et al., 1995, 1996; Viikari-
Juntura and Riihima¨ki, 1999; National Research Council, the
Institute of Medicine, 2001; Punnett and Wegman, 2004].
Low back pain was identified by the Pan American
Health Organization as one of the top three occupational
health problems to be targeted by surveillance within the
WHO Region of the Americas [Choi et al., 2001]. To
prioritize prevention efforts appropriately worldwide, information
on the burden caused by occupational exposure to
physical and psychosocial stressors would be useful. Guo
et al.  estimated that 65% of low back pain cases in the
United States are attributable to the combined effects of the
occupational exposures listed above. To date, no other
estimates of the fraction of back pain in the total population
that is occupationally induced have been identified. Thus, the
analyses described here sought to quantify the global burden
of work-related low back disorders. Two companion studies
in this issue address the costs and benefits of interventions to
reduce ergonomic stressors at work [Lahiri et al., 2005a,b].
MATERIALS AND METHODS
Basic Methodology and Population
This comparative risk assessment (CRA) exposure
assessment was conducted using the overall methodology
developed estimating the global burden of occupational
disease and injury [Concha-Barrientos et al., 2004; Nelson
et al., 2005]. The age- and gender-specific distribution of the
workforce aged 15 or older in each occupational group, as
compiled by the International Labour Organization and the
World Bank, was categorized by sub-region and adjusted by
the economic activity rate (EAR) to generate the denominator
for these analyses [see Nelson et al., 2005].
In the absence of data on worldwide prevalence of all
relevant physical and psychosocial exposures, we used broad
occupational category as a proxy for exposure to the
combined stressors that produce excess risk of low back
pain. Estimates of relative risk by age, sex, region, and exposure
category were applied to compute stratum-specific
attributable proportions; multiplying these by persons at risk
gave numbers of cases, which could then be summed across
strata for estimation of the global attributable proportion. The
same fractions for each age-sex-region stratum were applied
to the total of disability-adjusted life years (DALYs) caused
by low back pain.
Definition of Outcome
Lowback pain (LBP) was defined as any ‘‘non-traumatic
musculoskeletal disorder affecting the lowback.’’ It included
all back pain, regardless of diagnosis, that was not secondary
to another disease or injury cause (e.g., cancer or motor
vehicle accident). It included lumbar disk problems (displacement,
rupture) and sciatica but excluded cervical spine
problems, such as neck pain or neck torsion problems.
Reviews of lowback pain epidemiology have implicated
an overlapping set of occupational exposures such as lifting,
forceful movements, awkward postures, whole-body vibration,
and perhaps psychosocial stressors. However, such
exposures are rarely assessed in surveillance activities on a
large scale, and thus data are not available for risk assessment
calculations at the global level. An alternative strategy was
applied for this assessment, using occupation as a proxy for
specific combinations of physical and psychosocial stressors.
The reference group (background risk) was comprised of
professional and administrative workers. The other risk
categories were defined as follows:
Low exposure, clerical and sales workers;
Moderate exposure, operators (production workers) and service workers;
High exposure, farmers.
This method thus required the assumption that the
distribution of the combined individual risk factors (psychosocial
as well as physical exposures) is similar within each
occupational group across geographical regions. It also
assumed that the relative risks among occupational groups
were stable across studies, although this assumption could be
examined directly in available published reports (see below).
For low back pain, ‘‘theoretical minimum risk’’ was
considered to represent the level of disease that would occur
in the population if all excessive physical workload were
abated by effective implementation of ergonomic control
measures. This would be equivalent to the achievement of
relative risks of 1.0 in each occupational group.
Relative Risk of LBP by Exposure Category: Data sources
Electronic literature searches were conducted in MEDLINE
and the WHO Regional libraries, and published
statistics of national occupational health and safety institutes
were consulted. Epidemiologic studies published between
1985 and 2001 were sought that compared the risk of low
back pain among the occupational groups specified above (by
odds ratio, prevalence ratio, or incidence ratio) and comprehensively
enough to cover the range of occupations within
each group. Smaller, more specific studies limited to relatively
narrow occupational groups (e.g., nurses, dockers,
drivers) were checked for consistency with the more comprehensive
data sets. Studies where the reference groups
were engaged in substantial physical activity (e.g., house
painters) were excluded. In addition, reviews and studies
were identified that might provide evidence to support or
contest the selected approach.
Occupation-specific estimates of relative risk for LBP
were applied to compute stratum-specific attributable fractions,
for eachWHOsubregion, age group, and gender. These
were weighted by population to determine the regional
attributable proportion. Applying the same attributable fractions
for each age-sex category to the disability-adjusted life
years (DALYs) for LBP experienced by that category yielded
estimates of attributable DALYs for each sub-region.
Unlike the global burden analyses of other conditions,
the effect of occupational turnover was not utilized in
estimating the numbers of workers exposed to ergonomic
stressors, as the latent effects could not be quantified (see
Relative Risks of Low Back Pain by Occupational Group
Leigh and Sheetz  measured low back pain on the
basis of a national survey and a self-reported statement
regarding ‘‘trouble with back or pain during the last year.’’
They estimated relative risks (RRs) by comparing the
outcome frequency among occupational groups, using
managers as a reference group (Table I). This study was
relatively large (n¼1,404), covered a comprehensive sample
of occupations, and involved statistical adjustment for
numerous potential confounders (sex, race, height, smoking,
etc.). Thus, despite some methodological limitations, it became
the primary basis for the statistical computations of
global burden. Its findings were checked for consistency with
the body of evidence on work-related back pain and its values
adapted slightly to reflect the overall evidence (see below).
Operators and service workers had very similar estimated
relative risks so these were averaged to form a ‘‘moderate’’
exposure category, even though intervention strategies would
differ between these two occupational groups.
Within the limits of the available literature, the relative
risks reported by Leigh and Sheetz  appeared to be
generally consistent with other reported values (Table II).
The most comparable study (managers as the reference
group, adjusted for confounders) was that by Leino-Arjas
et al. . The values for office workers and for manual
workers were quite similar; however, the relative risk for
farmers was lower (2.13) than the value put forward by Leigh
and Sheetz (5.17). To be conservative in the CRA, we used
the average of these two values, or a relative risk of 3.65
Since many other studies used office workers or other
sedentary occupations as the reference group, an additional
computation was needed to compare their findings with those
of Leigh and Sheetz . This involved dividing the Leigh
relative risks for categories 3, 4, and 5 by 1.38 (the RR for
clerical or sales work), in order to estimate the relative risk
with clerical jobs as the reference group. The new values
were 1.73, 1.93, and 3.75, respectively (Table II). Keeping in
mind that these estimates represent the average values for the
entire occupational category, it can be seen that the other
studies cited fall within the CIs, with very few exceptions,
and in fact generally have similar point estimates. For
example, Morken et al.  conducted a questionnaire
survey of 5,654 people working at light aluminum smelting
plants across Norway in 1998. Operators suffered more low
back pain than office workers, with an odds ratio of 1.8 (95%
confidence interval 1.5–2.1). A total of 18 studies (including
Morken) compared specified types of operators to clerical
workers; the average of 33 relative risks from these studies
provided a RR of 1.9. This agreed rather closely with Leigh
and Sheetz’s estimate of 1.73 for operators compared with
clerical or sales workers.
Also available were administrative statistics from three
different countries on the annual number of cases of workrelated
back conditions. These were compiled from employer
reports of work-related injuries in the United States (Bureau
of Labor Statistics 2001), compensation statistics for the
Australian workforce (National Occupational Health and
Safety Commission 2001), and statistics for the German
national workforce (Bundesverband der Betriebskrankenkassen
2001). These data could be used to estimate rates for
certain occupational groups in comparison with Table III.
LBP rates were consistently lowest for managers and
professionals. The point estimates for other occupations
varied somewhat. None of these frequency estimates could
be adjusted for potential confounding variables. The rates
were lower overall than those assessed by population
surveys. The incidents assessed in the first two data sets
were limited to cases recognized as work-related and
resulting in absence from work or a claim for compensation.
In contrast, the German study sought to assess the health
status of the population more comprehensively and these data
are, therefore, likely to be more comparable to those reported
by Leigh and Sheetz. In fact, the values were relatively close
to the final CRA values shown in Table I.
Attributable Proportion of Low Back Pain
Generally, men had higher exposure due to higher rates
of participation in the labor force. The participation of
women in the labor force was particularly low in eastern
Mediterranean regionsBand D. Exposures were higher in the
less developed regions because of a higher proportion of
workers in agriculture than in the developed regions. Over
one-half of the working populations of African regionsDand
E and SEAR D worked in agriculture [Concha-Barrientos
et al., 2004; Nelson et al., 2005]. In contrast, about onethird
of the total American and European workforce was
in production occupations (‘‘operators’’) and another large
fraction (40% or more) in professional, sales, and clerical
jobs. More specifically, farmers were 54% of the male work
force in SEAR D, 21% in Europe C, but only 5% in America
A. In contrast, operators were 30% of male workers in SEAR
D, 54% in Europe C, 30% and 42% in America A.
Globally, 37% of low back pain was deemed attributable
to occupational risk factors. The proportion varied somewhat
among regions (21–41%) and was generally higher in those
regions with lower overall health status, that is, groups B
through E compared withA (Table IVand Fig. 1). The highest
attributable fractions, around 40%, were reached in European
regions B and C, South-East Asian regions B and D, and
Western Pacific region B.
Differences by age groups were quite small. The
attributable fraction in men (41%) was higher than in women
(32%), because of men’s higher participation in the labor
force and in occupations with heavy physical workload,
material handling, and whole-body vibration. The gender
difference was most pronounced in the eastern Mediterranean
region, where women’s participation in the labor force
is quite low, and in the less developed countries of the
Americas. The attributable fraction was lower for men as
well as women in EMR-B, reflecting regional variation in
economic activity rates [Nelson et al., 2005 ].
Attributable Proportion of Disability
Low back pain does not directly produce premature
mortality but causes substantial disability and has potentially
severe societal consequences, particularly when workers
suffer the outcomes at an early age. Combined occupational
ergonomic stressors were estimated to cause 818,000DALYs
lost from LBP in the year 2000. Again, the estimates were
about 50% higher for men than women (Table V and Fig. 2)
Among regions, the highest values were found in the
South-East Asian regions, European regions B and C, and
Western Pacific region B. Again, these values reflect the high
proportions of the working population in the occupational
categories of operator and, especially, farmer. In absolute
terms, more DALYs were lost in South-East Asia and
Western Pacific D, as these are by far the most populated
regions. In per capita terms, the regions with highest loss of
DALYs were the same as those with the highest attributable
Worldwide, 37% of low back pain was deemed
attributable to occupational risk factors. The fraction varied
somewhat among regions (21–41%) and was higher in areas
with lower health status in general. Regional differences
were driven by the labor force participation rate and the
population distribution of occupations, especially the
proportion of farmers. In each region, the attributable risk
fraction was higher for men than for women, largely because
of men’s higher participation in the labor force and in
occupations with heavy lifting and whole-body vibration.
Lowback pain does not directly produce premature mortality
but causes substantial disability and has potentially severe
societal consequences. Combined occupational ergonomic
stressors were estimated to cause 818,000 DALYs lost
annually from LBP.
Although the present analysis was limited to low back
pain, the evidence on MSDs caused by occupational
ergonomic stressors is broader. MSDs affecting the neck
and the upper and lower limbs result from the same risk
factors as are implicated in low back pain [Hagberg
et al., 1995; Hales and Bernard, 1996; Bernard, 1997;
Malchaire et al., 2001; National Research Council, the
Institute of Medicine, 2001]. Also excluded here are other
types of health effect related to ergonomic stressors, such as
acute workplace injuries, cardiovascular disease, mental
health, and adverse reproductive effects [Punnett, 2002].
These results are derived from occupation-specific
relative risks, in the context of substantial epidemiologic
and experimental literature on the exposure-response
relationships between LBP and specific occupational exposures.
Similar exposures have been implicated across sectors
of the economy and around the world, wherever the LBP
problem has been studied. Internationally, there is broad (but
not universal) agreement that among people occupationally
exposed to ergonomic stressors, an important proportion of
MSD morbidity results from those exposures.
This analysis may be subject to several sources of error,
stemming both from the methods used and the available
evidence on work-related back pain. Regarding the methodology,
each occupation was taken to represent the
combination of specific exposures typically found in that
job setting. Although there is substantial evidence of interoccupational
differences in exposures, this approach is
assumed to reflect the effects of average risks within each
broad occupational category and is justified by similar
relative risks being reported by numerous epidemiologic
studies. This assumption may, however, introduce an error
when transposing the risk values to the various geographical
regions, as the risks within each occupational category may
vary. In particular, different degrees of mechanization,
general working conditions, or ergonomic interventions
may vary across regions.
The limited evidence available that
allowed comparisons across regions did show some variations,
but no general trend according to degree of development
[Kuwashima et al., 1997; Volinn, 1997; Jin et al., 2000]
(summary in Table VI). To the extent that there are
unmeasured geographical differences in exposures within
occupational category, it is most likely that physical workload
is higher in less developed countries. Since the risk
estimates were mostly derived from studies of developed
countries, this would lead to an underestimate of attributable
risk in a majority of geographical regions.
The distribution of workers into occupational categories
was based on employment data in economic subsectors,
which may also have introduced limited misclassification.
Several errors may have been introduced as a consequence
of the nature of the epidemiologic literature on back
pain. MSDs defined by self-report are not universally
accepted as valid. Cases of back pain reported on interview
often cannot be diagnosed on the basis of physical
examination [e.g., Riihima¨ki et al., 1990; Punnett et al.,
1991]. Furthermore, the definition of back pain may vary
substantially across studies, and prevalence estimates can
therefore vary substantially [Loney and Stratford, 1999].
However, such differences in definitions are not likely to
affect the estimation of relative risks, as long as applied in a
consistent manner within each study. This assertion is
scientifically parsimonious and consistent with the very
limited published data [Ozguler et al., 2000].
Regarding possible confounders, socio-economic status
(SES) and gender have been reported as potential risk factors.
However, to the extent that these factors are associated with
and thus act through or are surrogates for working conditions
[Behrens et al., 1994; Leino and Ha¨nninen, 1995; Denton and
Walters, 1999; Hollman et al., 1999; Marmot, 1999; Punnett
and Herbert, 2000; MacDonald et al., 2001], adjusting for
them would serve to obscure the role of those exposures.
Relative risks for occupational exposures have often not
reported separately by gender or SES. ‘‘Lifestyle’’ factors, or
non-occupational correlates of SES, appear to explain only a
small amount of variation in back pain [e.g., Smedley et al.,
1995; Leino-Arjas, 1998; Morken et al., 2000]. Although the
causal pathway(s) remains uncertain, adjusting for SES in the
estimation of LBP relationships with ergonomic exposures
would certainly be conservative because SES would capture
at least some of the explanatory power of occupational
factors. The most influential study for this analysis [Leigh
and Sheetz, 1989] included SES in the multivariate analysis,
so the estimated RRs for occupation, and thus for this analysis,
were likely to be underestimates of the work-related
The attributable fractions were here estimated within
strata of age and gender, but this approach assumed uniform
distribution of potential confounding variables by occupational
group across the population and no effect modification.
However, if there is effect modification by age, gender, or
other covariates, error would have been introduced by this
assumption. The direction of any such error is unknown.
Additional potential sources of error include the
‘‘healthy worker effect;’’ unknown effects on LBP of work
in the household or the informal sector or child labor;
possible evolution of disease after retirement; possibly differential
under-reporting of LBP among occupations or
sectors; and possible variability in exposure intensity, timing,
co-variation, and other characteristics within occupation (see
more detailed discussion in [Concha-Barrientos et al., 2004].
None of these could be taken into account due to scarce data.
Given the inevitable uncertainties accompanying such
analyses, we have sought wherever possible to ensure that
any resulting bias was more likely to be in the direction of the
null value rather than overestimating the disease burden.
Ergonomic exposures have been demonstrated to be
modifiable by application of ergonomic job design principles.
Minimum risk was thus defined here as the risk that
would occur if all excessive physical and psychosocial
stressors were abated, by effective implementation of ergonomic
controls, to the levels experienced by managers and
The public health importance of these findings is
striking. While interventions to reduce ergonomic stressors
have not yet been widely implemented, studies from specific
settings demonstrate the great potential for exposure (and
disease) reduction. Removal of ergonomic stressors can lead
to the removal of back pain or its reduction to negligible
levels [Frank et al., 1996; Westgaard and Winkel, 1997;
Marras et al., 2000; National Research Council, the Institute
of Medicine, 2001]. The available literature includes evidence
of the feasibility and benefits of workplace ergonomics
interventions (training and engineering controls) that
have been implemented by employers in numerous economic
sectors. Effective abatement measures include redesign of
workstations to eliminate need for bending and twisting;
installation of material or patient hoists and other lifting
devices; greater variety of work tasks, to avoid repetitively
loading the same body tissues; and improved mechanical
isolation to reduce whole-body vibration transmission.
Training programs are most effective when they address
job design, target supervisory, and management personnel
along with the hourly labor force, and empower workers to
utilize the knowledge imparted. The coordination of multiple
interventions, workstation improvements, training, enhanced
medical surveillance, and management, appears to be the
most effective [Hagberg et al., 1995]. Similar conclusions
were reached in the analyses of cost-effectiveness of
ergonomic interventions [Lahiri et al., 2005a].
In summary, this highly preventable risk is very common
in working populations with high physical loading on the
back and possibly also high psychosocial strain. Outcomes
such as days of restricted activity, long-term disability, health
care utilization, and use of medication are very common
among people with back pain, indicating the public health
importance and cost of these disorders even when selfreported
pain is not confirmed objectively [Badley et al.,
1994, 1995; Guo et al., 1999; Miedema et al., 1998; Punnett,
1999]. Prevention of the relevant exposures should be given
The authors express their appreciation to Lucy Schoolfield
of NIOSH, Cincinnati, for her generous help in locating
reference materials, and to Norrey Hopkins of WHO,
Geneva, for her assistance in preparing the manuscripts.
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