Alright, good morning. It's 9 a.m. sharp. So, thank you everybody for being here. It's a pleasure for us to host this session. My name is Akron. I'm an occupational physician in training and an ergonomist. I work at Bellevue NYU Occupational Environmental Medicine Clinic at New York University Grossman School of Medicine. I brought up a really good dream team here with me who are going to help me make the case of how ergonomics can help the practice in occupational medicine. Unfortunately, Dr. Susan Richmond, who is my colleague in our clinic, could not be here for health reasons. I'm going to try my best to deliver her presentation. I work with her on this case, so I'll be presenting for her initially. So, this is going to be the dynamic. We have two sessions, you know. We have the first one and then the second one after the break. So, we're going to have four conventional presentations. Each one of us are going to present our strengths, you know, what we do, you know, on our professions. We have, some of us do micro ergonomics, you know. We go a lot of into the workplaces and assess work-related exposures that end up on most of those diseases and injuries. And some of us do more macro ergonomics. Can you guys hear me? No? Sorry? Oh, okay, okay. So, I'm going to need that because I walk a lot. So, okay. So, and some of us do macro ergonomics, you know. So, the more organizational aspect of the discipline. So, we're going to do a few presentations in the morning and then in the afternoon, not the afternoon, I'm sorry, in the second session, we're going to make it participatory. We're ergonomists. We're going to make it fun and it's going to be kind of like a case discussion. And we want you guys to participate on that case discussion. And it's going to be kind of like a roundtable, okay? And, you know, it should be pretty interesting, okay? All right. So, without further ado, I'll start presenting on this specific case. This case was a company, which was a lamp manufacturing company in New York City, who reached out to us at the clinic and they wanted to proactively improve their workplaces and decrease the case, you know, intervene in the prevalence of musculoskeletal diseases and injuries they were having in their company. So, you know, Dr. Richmond wanted to first make the case about, you know, the importance of macro ergonomics as a proactive and holistic approach of preventing workplace injuries. You know, we're going to have two great speakers who are going to talk about this extensively. And also wanted to acknowledge, you know, how our country and our practice has changed due to the COVID crisis and, you know, workplace and other issues that brought into, you know, sharp focus on the pandemic creating, you know, future solutions that would sustain in time and not just get back to normal, you know. So, right now we talk a lot about, you know, let's get back to normal. But what does that mean, getting back to normal, when we do occupational health, occupational medicine and ergonomics? I mean, a lot of people are just working remotely. Some people are going to work remotely permanently. Some people are going to work remotely partially. And companies are making those changes. So, what does that mean for us as ergonomists or as occupational physicians practicing? You know, we've encountered huge workplace issues, you know, workforce participation by women, unpaid children, elder care. And all this, you know, you say, well, what does this have to do with our discipline? Well, it does impact us. And it does indirectly impact the discipline and impact our practice and impacts also the productivity of companies when you try to make the case and when you propose a workplace intervention. You know, shortness of home care workers, affecting on shifts, rotating shifts, last minute shifts, you know, you name it. We've had so many workplace issues. And, you know, we did want to acknowledge this at the beginning of our session. It's being spoken extensively throughout the conference. But, you know, it is something that we can't leave out and we need to acknowledge. Now, you know, going straight to the micro ergonomics part, you know, we've had, we encounter on this company severe repetitive strain injuries in four production workers, which were the people, the four workers that they first referred to us. It was a fine arts lamp and fixture manufacturer. I mean, these lamps are, I don't know, $10,000 for a lamp, $2,000 for a lamp. They're very expensive lamps. And the people who do this work, they're kind of like an artistic type of work. It's not like mass manufacturing, it's very hand artistic type of work. And the work they do has a very high demand because they're highly qualified on what they specifically do. So, it was a very interesting intervention when it came to that. And, you know, we approached it and we capitalized on the proactivity that the employer had. The employer was proactive and said, hey, listen, we need to do this and we want you to come here and help us. We usually, we do population occupational health. So, you know, we don't see company workers much. We, you know, we focus, New York City is health and hospitals, it's Bellevue Hospital. So, we focus more on the more vulnerable workers out there doing the more precarious work. But, you know, we took this case because we thought it was, we could be helpful with them and we were. So, you know, so we had a utility team approach. You know, we did an ergonomic assessment. We did human factors administrative changes and issues with workers compensation, of course, you know, we had to deal with them. And Dr. Richmond wants to expand on that in her presentation. Ergonomics was part of the treatment. How do you, you know, what does that even mean? So, you know, we're very curative oriented. We always want to cure what's already wrong. But, you know, as ergonomists, we really want to prevent. In fact, as occupational physicians, we also want to prevent. But sometimes it's very challenging because, I mean, how many of you know what's really happening in the workplace? Or how many of you get up and put on your steel tip boots and go and do a walkthrough and see what's really happening in the workplace? So, we as ergonomists can be helpful in that in that sense. So, we see it this way. We see that an ergonomist can be part of your care team, health care team, that can actually give you the resources for you, for us, to make the right decisions and to make the best decisions for the patient care. So, you know, we want to protect not only, we don't not only want to assess, intervene, and have the preventive measure on the workplace, but we also want to protect future workers. We're going to talk, we're going to have an entire presentation on safe return to work. I mean, we're sending back the workers to the same place they got injured from the beginning. So, you know, these are questions we need to ask and these are, we're trying to answer, at least try to answer the questions. So, going straight to the case, you know, these workers had extensive, they were manual labor. They were using orbital sanders because they were metal preps. So, we're doing a lot of biomechanical exposure, hand risk, awkward posture, medial deviation, sustaining extension against resistance of the tool, for example, elbow, forearm pronation, beyond the recommendation angles, isocomfort, shoulder abduction. So, you had people working like this with a heavy orbital sander, with a pronated upper extremity and abducted at the same time for hours end. Okay. And, you know, you name it, you had cervical, awkward exposure, flexion, lateral bending, twisting, lumbar issues as well. There were prolonged standing positions and, you know, and this started taking a toll on the workers. Okay. So, you know, we had, we went from micro to micro ergonomics and then, you know, we set up a holistic comprehensive program in order to really help these workers and also create a preventive culture within the company that would also protect future workers. Okay. So, there were four artists, we call them artists because they're art artists, that, you know, that had working those upper extremity musculoskeletal issues. Workers, KC, MN, KK, and MC, you know, were fine arts graduates from a four-year college. These people went to school to do this. I mean, they didn't go to school to work in that company, but, you know, they were hired because, you know, it's, like I said, you know, it's a very manual artistic work. Symptoms were referable to their work as metal prep associates in Manhattan Lamb Company, four 10-hour days per week, half an hour lunch, two 15-minute breaks. Okay. So, we're starting to see problems right there, you know, on the timing and the organizational factors right there. Our main duties, you know, sanding parts of varying sizes and shapes, some quite large, some of them are lamps, you know, sometimes as big as this one, and they would sand parts of it and then started to assemble them. Use the sanders to attach a drill with hand while holding parts on another. So, you know, you had a person holding a part and then sanding with the other. I have some pictures at the end. And also sanding tiny parts. So, you know, three or four patients started having severe upper extremity injury, severe upper extremity shoulder and neck symptoms. Within four months of starting to work on the company, one patient, one patient one worker was there since 2019 and started getting worse of their symptoms only after their co-worker left. And then, of course, the workload increased and she started having symptoms. They were experiencing pain, stiffness in the hands, wrists, forearms, shoulders, approximate trapezius and neck, and also numbness and paresthesia and fingers and some other dull sensations. Symptoms worsened when the work the day went on and initially symptoms improved in the weekends or when they were on vacation and so forth. They started having difficulties, which was basically the reason why they were referred, because they were starting having difficulties on their daily lives and everyday life, things that they did, you know, dropping objects, including cups, plates, and many other things just like as simple as dressing or showering and so forth. The four patients were remarkably similar in their symptoms, which is quite interesting because, you know, they were exposed to the same things. And the pace of production and work was very, very similar. I mean, there were different patients, but the symptoms were very similar. Two patients had discomfort, two patients with discomfort at rest before starting the physical examination. There was pain on palpation of the hands, forearms, and elbow, phallic positive, tender positive, but, you know, they have full strength five out of five on the APBs. Pain of the elbows and resistant extension and flexion of the wrist, some with both. Pain on abduction of shoulder and pain on palpation and trapezius. So, you know, they were pretty symptomatic. The initial plan was take them out of work for six weeks and rest those arms, rest the upper extremities, allow them to recover. OTPT one to one, two times a week, and part of the plan and the treatment was the walkthrough and ergonomic assessment by our ergonomist. Me here doing the, trying to do the work and trying to improve the conditions of the workplace. All right. So, workers' compensation. This is what nobody wants to talk about, but we need to talk about it. So, you know, there were delays on establishing the workers' compensation cases. You know, people, you know, we know how bumpy this ride can be. You know, once a C4 was filed and the case was indexed, delays can occur at one or more stages. Controversiality of the case, scheduling of the hearing in case it was controverted, scheduling conducting IME's exam, establishing of the case after the IME accepts the condition is work-related, time during appeal by the carrier and the claimant of workers' compensation decision, requirement by the workers' compensation carrier of a second IME after the original IME found that the disease was work-related. When they saw the ergonomic assessment and what was really happening in the workplace, they still wanted another IME examination. Due to these delays, treatments, you know, appointments were all delayed, diagnostic testing, medication, waste replacement, everything was delayed just because it's just a normal process, unfortunately. So, even after the workers' compensation judge ordered workers' compensation coverage, there was frequently delays even when the judge ordered the payments. And so, you know, diagnostic testing, prescribed treatments, PT, OT, time of work required, adequate healing, durable medical equipment, prescribed medications, medical visits, and, you know, and the delays prolonged recovery time because, you know, the treatment was not being implemented accordingly and, you know, cause of the worsening of the pains and delayed treatments, unfortunately, on the workers. The delay on the payment, which replacement can prevent patients complying with medical leave prescription for time of work to require adequate healing. This can result in worsening of the patient's conditions to continue exposure to the cause. Sometimes the carriers simply don't pay and pay and do not respond to inquiries even on when the judges ordered them. And I apologize, I'm reading a lot. It's just these are Dr. Richmond's slides, you know, so I don't want to say anything that she doesn't want to communicate. So, you know, but this is very common, but we find that although all these delays and what I call the bumpy ride workers compensation establishing cases, we found that they were still well treated and that cases were established because they had the resources of a workplace ergonomic assessment. You see here the workers with all the biomechanical exposures that we were we were describing earlier. And, you know, and we made very concrete recommendations. For example, how do we avoid this suspended upper extremity while they do work here? So, you know, so we, you see the red grid right here, we recommended arm support over here, also recommended an arm support and among many others, many other recommendations. So we applied a postural Rula and Riba score. The Rula gave us a six plus very high risk and the Riba, which is entire body assessment, was more of four of a seven. You know, the Rula was gave us a six because obviously the upper part of the trunk was a lot more exposed to the biomechanical hazards than the lower part of the body. That's why for those of you who don't know, Rula is rapid upper limb assessment score and Riba is rapid entire body assessment. Okay. So what, you know, due to the prolonged standing, we recommended what we call semi sitting or semi standing chairs. It is a standing job, but it doesn't mean you cannot sit or you cannot lay, you cannot alternate your posture, which is what's really giving you the low back pain issue because of the prolonged standing. A lot of times, you know, they ask me, what's better to work standing or sitting? Well, I mean, none of them, you know, if it's prolonged, it just shouldn't be done. You know, I always tell my patients and the companies and everybody I work with, you know, the best posture is the next posture, meaning, you know, the alternation of the posture is what really makes it preventive. So we implemented this semi sitting chairs where they were able to keep working while standing, but they were able to semi sit and that really helped at least the lower, the low back pain symptoms. These were just some of the recommendations that were implemented. It wasn't really, I mean, this is just a picture we downloaded from the internet. You know, they really, they went out and, you know, we met with procurement and they bought something really tailored design to the table they were using. Among other things, you know, they also implemented lowering and raising chair, I mean, tables to the workstations, you know, to adapt to the anthropometrics of the workers. You know, ergonomics principle, you don't adapt the workers to the workplace. You know, it's the other way around. You know, the workplace adapts to you. And so they also implemented that. We just, we wanted to leave the presentation 15 minutes. So, you know, if we can always share the larger document for everybody, whoever wants it. So we also did some organizational recommendations, you know, so we said, okay, fine, you know, we're, we're, we're fixing the problem where the worker is actually standing there being exposed to the hazard, but how do we, how do we, how do we help the rest of the workers? So, you know, so we had a cross-training, cross-training to allow rotation among jobs, decrease constant exposure to musculoskeletal risk factor, and decrease the monotony. Also the job. So what does that mean? So, you know, what we did was we identify, we identify what were, what were the, the, what were the tasks among all the tasks that workers did that were higher in mental load and on physical load that they needed to do during the day. And then we also identify which ones had a lower demand for mental and physical load. So we implemented, we designed a, a, a, a, I published a paper on that. They pushed for me to put my last name on it. So it's the last installment of our rotating scheme, which is from plus to minus, from plus to minus, plus to minus. So you design the rotation allowing the exposure to change, not only in the exposure load, but also changing the economy, what we call the muscle economy or the movement economy. If you're gonna use a right hand for a certain task, well, then you change it for a left hand. So you allow the right hand to rest or vice versa. You get the idea. It was very tailored design to what they were doing. Shorter work days from 10 to eight hours. That was a big one. Very hard to get approved, but we made the case and it was approved. Shorter, I shortened the metal sanding shifts from three to five hours, which was actually the exposure that had the higher demand for potential musculoskeletal disease and injuries. Like I said, height adjustable work tables, anti-fatigue mats, semi-sitting chairs, like I mentioned. And also we implemented a lathe system to do away with the actual hand tool. So you implement the lathe, you put the item there, and then the person doesn't have to carry anything. The lathe does the work for you. It was a big investment, but as we know, we designed the investment with the proper language that they want to hear. Return on investment, long-term, yeah, yeah, the money, el dinero, all right? Yeah, so they were very proactive about it. They were very hesitant at the beginning, but they did it. And the workers are being, not only those four workers that we saw at the clinic benefited from it, but all the workers benefited from it that also were going through the same process. And stuff like, for example, replacing finger pinch grips to hand grip tools, that's by the book recommendation, like I call it, to always try to avoid finger pinch tasks. And improving the ventilation system, we also have an IH at the clinic, because we found we weighted the PPE and they actually were pretty heavy and actually contribute to the neck sustained flexion of the worker. So what we did was like, I mean, why, can we replace this astronaut helmet for just a ventilation system? Can we improve the ventilation system? Because there is a lot of material, metallic dust going around also, which caused some pulmonary problems as well. So that was basically it. We wanted to just, with this first presentation, go right into the ergonomic intervention and show you from the micro perspective on how can we, as occupational physicians, improve the patient care when we really understand what's happening at the job, at the work, and not really rely on the worker's story they tell you or some paper HR sends you, or these are the things that we want to, this is the main, if there's one thing I want everybody to take away on this whole session is this, the importance of having a workplace intervention by a group of people who are trained in ergonomics to give you the resources for you to make the right decision for the best patient care. So George Freeman Jimenez, who's the founder and director of our clinic, Dr. Denise Harrison, myself, Honghong Liu, Latoya Scarrett, Gwendolyn Hicks, and Agnes, who are administrative supportive staff, this is our clinic in New York City. All right, thank you very much. First presentation. So, I mean, I'll leave it up to everybody. You guys want to do Q&As right after every presentation, or you want to leave it at the end, or it's up, whatever people, what do the audience want? You want to ask questions now? Go ahead. Shoot out. Yeah, there's, I believe there's people, there are people connected online, so we have to, there it is, yeah. I will enunciate clearly. If you can please say, present yourself, who you are. I'm Mike Levine, occupational physician from Williamsburg, Virginia. Thank you. I didn't hear you talk about vibration, and I noticed that you had, I think, both air tools and electric hand tools in use, and I wondered if it was not felt to be contributory in this case, or whether you switched out the ones that were troublesome for the stationary tools so it didn't matter. Could you speak to that a little bit? Yeah, that's a very good question. Actually, we purchased the vibration hand, the hand vibration tools for assessment after we saw these cases, but although there was vibration, the tools that we're using were fairly new, and we, and they, quote unquote, met the threshold of acceptable vibration from the vendor, but we didn't really assess the vibration, per se. Now, we did address the vibration, because when implementing the lathe system, then we did away with the hand vibration, you know? But we didn't do the risk assessment, per se, of the vibration while holding the aural center, which I'm sure had to do with their symptoms as well, but we didn't do the risk assessment, but we did, the intervention did address it by changing to a lathe system. Go ahead. How did you figure out why to take these people out of work for six weeks, and then how did your workers' comp carrier who delayed treatment, I assume they didn't delay treatment, they still treated through their group health plans, but how did that delay return to work? Good question. It's a good question for Dr. Richmond, but I'm gonna try to answer. The six weeks, I referred to her that, you know, the decision of the six weeks as a treating physician, but we wanted to give them at least six weeks to allow the musculoskeletal system to heal without having any exposure at all, so we wanted to have complete out of work, and also with home recommendations on everyday life or what to do or not to do so to exacerbate or any symptoms they have. That's the first part of the question. With regards to the workers' compensation treatment case, I remember she actually texted me, give me, can I get my phone? Can I get my phone? Yeah. Yeah, so we were able to keep treatment with them despite of the workers' compensation delay because we are, fortunately, under the health and hospital system in New York City, and you know, so it's a good umbrella to be under where you can actually keep it going, you know, while they decide to pay whoever's gonna pay. So, I mean, it's kind of an advantage that we have that we're under that healthcare system, but we did want to make the case that, you know, there was delay and not everybody's under an umbrella like ours. So, well, I hope I answered your question, you know. These are very specific questions for Dr. Richmond. I don't want to say anything more or less than I should when it comes to the medical treatment. One more question, and then we go to Johanna. Go ahead. Excuse me, sorry. With the use of the REBA and the RULA, and especially the RULA, do you recalculate those based on the solution you're proposing to input? In other words, and since you're shaking your head, how big of a change do you expect to see when going to the extent of creating a lathe system, which obviously is a major investment, to try to justify that? Yeah, that's a great question, yeah. So, we did do a post-assessment, we did a post-intervention assessment, and it improved dramatically, you know. Both the RULA came down to a three, and the REBA came down to a two, to the second level of risk factor. Because, you know, by implementing the lathe system, you basically did away with the, you know, the extended flexion of the neck and the trunk, and all the biomechanical exposures that I spoke about. So, yes, we did do a post-intervention assessment, and then, and then, and, but, the investment was made before the post-interventions, that's where you're getting at. Yeah, yeah, so, so, we were able to convince the employer to make the investment, but what we did was, was that we did a pilot intervention, we did one. And then, we did the post-intervention assessment, it was a minimal intervention, and then they did the whole company afterwards. That's what we usually do, because, you know, we also have to think about the financial part of it. Thank you. All right, so, so, now, I will introduce to you Yohama Caravaglio Arias. Yohama is a great friend and colleague. She is from Venezuela, and she's working right now, doing research with Dr. Violante in University of Bologna. She's gonna talk to you about Return to Work. Yes, thank you, Akron. Hello, everyone. I will start with a story, the beginning of my career. I was an occupational physician at this company, and a worker was doing his grocery shopping. He was holding the bag, and he heard a sound, and he broke his flexor tendon of the index finger, his left hand. He went to the traumatologist. He was cleared, no, he was given 21 days of medical sick leave after the surgery. He came to me for the clearance, and he said that he was really eager to start working, because he didn't have any pain. He was right-handed and a very committed worker. I discussed the case with his permission, with his treating physician, and he said, okay, we made an accommodation. We reduced for part-time, instead of working eight hours, only four, and he started working. What happened? A week later, he started having pain in his good hand, and this is a demonstration that they're not instructions when we are in front of return-to-work procedures. Here is from these pictures from the Global Burn-Off Diseases is an interactive page, highly recommended in case you haven't navigated. Oops, apologize. So if we see here, the space that is occupied by musculoskeletal disorders are pretty much the same as stroke and IHD. So the burden of occupational, no, of musculoskeletal disorders is huge, and when we search the United States, this is the globe, and this is the US, and it looks pretty much the same, and this reality is not always for every country. Every country have their own diseases. For example, if we look Croatia or Italy or countries in Africa or Venezuela, we will see more orange and different behavior, but the United States behaves pretty much like the world. Musculoskeletal disorders do not produce death, but we know that the burden of suffering and economical impact is huge. This is just a reminder of the difference between diseases and disorders because we use them alternatively, like they are synonyms, but they're not. The main difference between a disease and disorder is that when we're speaking about a disease, there are structural change. Something that we don't have with a disorder. We can have a patient with a lot of pain. He goes through all the exams, MRI, x-rays, and he's healthy. No diagnosis, but he continues with the pain, and especially in the United States, this is being used. It was funny, I am teaching now in Italian, so I heard, I was finding the translation between illness and sickness is malatia, and in Spanish, it's enfermedad. So they're not synonyms. In English, you have two words for illnesses and sickness. So the Return to Work program, it is a collaborative, proactive process that we use to help injured workers stay at work or return to productive and safe employment as soon as physically possible. But I would add, also psychologically, because psychosocial factors are always involved. There's not a physical disease that do not produce emotional impact, and there are not emotional diseases that do not have a physical impact. So each state and country, the regulations I, my colleagues from the United States, they would know more about workers' compensation that it's very different in every country. The health system varies, and in the US, you have different states and different regulations. So Return to Work plans should state that regular monitoring will take place. Be consistent with the business goals and the department area the employee is returning to. And some companies, they have essential workers and they need that person urgently. So how to balance that need, the needs of the company and the needs of the worker? That's sometimes very challenging, especially at the beginning of our careers. Specify that gradual increase in both hours and duties will occur until a return to full duties or alternate employment is achieved. Detail where the employee can obtain additional help. For example, employee assistance program. If we have permanent complication, a disability, this worker would have psychological support. And unfortunately, only 10% of the world population have access to occupational health services and even less to psychological support. Respect the employee's dignity, privacy of personal information and confidentiality. That goes without saying. And delay reporting. These are some indicators that may present when there is a complex case. Unfortunately, not all the cases will be easy. And delay reporting the injury can complicate the situation. Without a diagnosis, we cannot intervene. Previous performance issues, we have to take that in consideration. Person with poor self-efficacy. And job insecurity, security in jeopardy. Some examples of accommodation. This is just some. I think the slides will be shared. But it's interesting. Limiting tasks to those that are safe for the employee. Making changes in the way duties are performed. Physical adjusting the workstation based on an ergonomic evaluation. And that's a privilege. Not everyone can have an ergonomic evaluation. Providing a new equipment and training on how to use it. Establishing a part-time or work schedule. Or reduced hours. That's, from the productive and economical point of view, is better than nothing. Sometimes it's better to have three hours work schedule than a huge absence. It's been known that absence, the more the worker is absent, the less probability to return to work in a successful way. Allowing time for medical appointments. This is really important. Many, many times we would have employees that will return to work under rehabilitation. And they can go through 20 sessions of physiotherapy. So we have to set that with the human resources, with the supervisor. Examples, another example is part of the job the worker was doing before the injury. Not everything, but just part of it. Different duties all together. Duties at a different site. Training opportunities. And for those that, when we have an injury, we know that after 24 hours, then the days away from work have a huge impact on some companies. Submitable duties can be best described as the process of matching the employee capability, skill level, and position with appropriate job tasks. And a short-term work duties agree between the employer and the injured worker. This is really important. So we are in the middle of the worker and the employee always. This is, I think it's a good scheme to remember. For example, we have to exclude serious pathologies. If we're speaking about disorder, if it's really a disease or a disorder, what is it is not malignant. For example, that is a prostate cancer that is causing the back pain. We have to really make an accurate diagnosis. Provide symptomatic relief. Encourage light activity and self-management. Educate the patient and manage expectations. This is mighty important. Arrange their return to work. And this is what I spoke a little bit before, that when we are in front of a sick patient, there are many factors to take into consideration, the physical pain, social factors. How is this person feeling guilty? Because thanks to that injury, now the statistics and the metrics of the company are going to be bad. I don't know if anyone has been in that situation, that they have 20,000 hours away without any incidents and there's an incident, the person feels so guilty because now the bonus is not going to be given to, thanks to his injury. So this is very important, attitudes and beliefs, psychological distress, illness and behavior. So benefits for us, occupational physicians, of a successful return to work process, increased changes of meeting targets, promote an increased sense of teamwork, because there's a lot of people involved in the return to work process. Promote a supportive and positive safety culture. I was reading once that to create a safety culture it takes about three years, so it's not an instantaneous thing, it's not fast food. Enables early intervention, a greater understanding of the rehabilitation process, this is really nice when we have a team and we can give them a call and learn about the process. Increased likelihood of positive performance review meeting with increased productivity, enhanced and demonstrated leadership role within the company. So we, when we're doing this process, we're building our own credibility. And I think I was kidding that my job is not an occupational physician, I'm a problem solver. We become, we're solving problems all the time, we're not occupational physicians. And then we have sometimes even logistic issues that we have to solve. So to conclude, these are all the teams that are involved in a return to work process. It's impossible to work in silos. There's no way that return to work process is just for occupational physicians. We have to work with human resources. Are they days, the sick days, are going to be paid? Are they being compensated? Are they going to lose any bonuses of productivity? Are they going to, do they have to do any paperwork for the reduction of the work schedule? And even legal sometimes, especially if it's work related. With this patient that was doing his grocery shopping and he did this injury, it's not so bad. It's so bad. But there's implications when there's a work, an incident related to the job, then we're in, we have to pay a lot of attention. And communication and information. Maybe we don't speak much about this, but the way we communicate is essential. Even the empathy that we create with a patient, ask the right and effective questions. Regular contact made between the supervisor and employee increase substantially the probability of a return to work. Transparency in the system and timing is really important. Some authors believed that we have to start with a return to work process once the accident occurs or the incident. Consultation, compassion, and respect. Assume that the injury is genuine rather than an innocent. Sometimes we have, that's a reality. We have people that simulate and people that dissimulate. That's written. And our job in the return to work process is building a safety culture. The employer is required to take all the appropriate steps to ensure that the workplace is a safe working environment as possible. If it's work related, Dr. Akron said, are we going to send the worker to the same place that damaged him? So that's a key message takeaway. Employees have a duty of care to ensure that they work in a manner that is not harmful to their own health and safety. Our plan should be clear. It should clarify the employee's medical restrictions. We have to write a lot. We have to get in love with writing. Writing can save our lives. It should match the employee's physical capacity for work to the job demands, provide suitable duties and hours for the employee to follow, should clear details on how the program will operate, and contain approval for the employee's treating doctor to their return to work. So I'm about to finish. When assistance or referral is required, whenever the following occurs, when there is a dispute about the injury, where there are safety concerns about the return to work, or where the supervisor feels that the process is not being made, or where the supervisor feels that do not have the skills required to deal with the situation. So something I tell my students, networking, have a phone of an expert, a neurologist. I mean, we have to have in our phones people to make a phone call and ask their opinion. And I'm so glad that we're here facing each other and we can make connections. Where the supervisor believes that the relationship is not sufficiently good enough to be able to communicate about problem issues, or when the supervisor feels that they are unable to provide positive support to the employee. So this is the end. Thank you so much for your attention. I am very pleased to be here. I'm Joana Caravaglio and I had a TikTok account, but I don't do dances. These are my social media. Thank you so much. It was a pleasure. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Tha system, as humans, we are systems. And if you've ever worked with a bad boss, with a mean, mean coworker, you know what all the things on the left side are, right? Boy, if you had a slight headache, you said, you know what, maybe I won't go to work today. Think back on your first job, yeah? Yeah, of course it does. There is no physical pain without psychological pain. And there is no psychological pain without physical pain. So I think we learned a lot in this system. But let me break down to you what I think ergonomics is, and maybe it'll make sense to you. So here's a human performance model that I really, really like. This is really easy, because it breaks things down really simply. And it says that there are three elements in this. The human, the activity that the human is engaged in, and the context. And I work in the context. I work with the organizational factors that surround that. But let me break it down for a little bit. This first interface between the human and the activity is what we typically think about ergonomics, right? How high is the chair? How high is the computer screen? Sorry to use this example. And how tall is the human? You are trying to match the machine and the human. We get that. We're asking how much force? Where is the arm position that Akron showed you about those workers? But there is also the relationship with the human and the context. For example, what is the temperature? What time of the day is it working in? What are the job demands for that, competing job demands for that person? How many are you required to do? Do you like doing that? We can look at that aspect. And then the activity and the context is how those jobs fit into the organization, okay? So you recognize that there are people who do all of these things, right? There's people who do red line things, people who do yellow line things, and people who do blue line things. But I want you to think back when you were in university. I don't know what you remember. I remember people thinking, that's a biology question. This is a chemistry class. They were siloed, right? We had red lines, yellow lines, and blue lines. Don't cross those lines. Where would we be today if we didn't know what biochemistry was? Well, we stopped thinking in terms of silos. When we look at the affective neuroscience, what would we say if we said, you know, religion has very little to do with psychology. That's religion. That's not us. If you look at the work that Richard Davidson is doing on the effects of meditation and centering devices on people's well-being, it's stunning, what we now know about the human brain. So what macroergonomics does is, what ergonomics does and what macroergonomics does is to blend the organizational context, everything together. And he said this in the second session, I hope to demonstrate the kinds of things that we do that you see that can cause us to look at injuries a little differently. So what this means is, human performance, productivity, and injury occurs when someone does something somewhere. That's it. That's the test question. What is ergonomics? It's looking at someone doing something somewhere. So if you're a physiologist, if you're a physician, you look at the human. If you're an engineer, you might look at the activity. And maybe if you're a macroergonomist, you look at the context and all of them put together. And I invite you to look at all of these things together, because the injury does not occur simply because you have a malinger or a short person or a tall person. That short or tall person is doing something that has been designed by humans in a specific way for a specific purpose. And they are feeling things as they do them. Here's an example I'd like to leave you with. I saw this picture and I thought it was a great picture. They are repairing the flag that flew, that inspired Frances Scott Key to sing that song that no other country can sing, our national anthem. This is the flag. They're fixing it. And I thought, wow, what is the context? Does it give us some sense of pride of how important this task is? And look how beat up it is and look how huge it is. That really struck me. So that's the context, right? We are preserving something that has a national interest. Is it important? I think it's important. You think it's important? Sure. Context. Look closer. What's the activity? Who's doing the activity? Yeah. You know, imagine if this were a group of quilters. Who get together on their own on Saturdays to say, let's go fix that flag, shall we? These are paid employees. You can tell because they are wearing uniforms. They are women. They are women of various size and various ethnicities. That's important to know of what they are doing to achieve that larger contextual goal. Look even closer. Look at this woman. Why this woman? What is it about this woman? Well, I don't know, actually. But if you look at her job design, it's not a bad design. I mean, I have seen people working on a lathe like this, literally, all day. They put the lathe on the floor, which Akron, I'm glad you didn't do. This is a reasonable, the arms are supported. You know, she can move closer for near-point vision. Her wrists can assume a normal position. And look at her hands. What is it about this woman? What is it, go to the left and look at the other women next to them. Why are they not hurt? It is someone doing something somewhere. And I think what we do in macroeconomics is to look at not only the human that's doing the work, but it's also all of the things that surround it. How much do you think these women actually like doing this? I don't know. Do the injured worker like it more or less? I don't know. And neither do you. And that's why I think walking around and asking questions, and then this afternoon we'll have some things where I want you to have multiple hypotheses about the potential causes of injury because we know what causes repetitive strain injuries. The causes are, things we look for are gender, age, physical well-being. You know all the factors. Those are things leads us to hypotheses. But there are always other factors. So I invite you to keep an open mind and that how ergonomics can help us solve these, answer these kinds of questions. All right, thanks very much. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. It's, they were laying internet cables and it's when you lay undersea cables and you don't light it up because you may need more. So you just lay the cable anyway because you don't want to go back. And so you just lay cables and don't put, don't use it because it's too expensive. That's a great question. Give that guy extra points for listening to the joke. Okay. There's more questions. This isn't really for you, but for you guys, maybe more. Oh, sorry. This is not really for this great talk that just happened, but for you two guys. How do you decide about how many weeks to take somebody off of work and let them rest? Like why six weeks? Because that makes a huge difference in workers' comp. If it's four weeks or five weeks or six weeks. So is there a physiologic basis? Is there research that says six weeks or where does that come from? Yeah, that's a good question. There is scientific evidence that sick for at least six weeks will help recover the, you know, and musculoskeletal disorder depending, but that's gonna depend on which one, where and how severe is the injury. So to answer that question, I think it's a decision made case by case depending on the injury and where the injury is allocated. But there is no kind of protocol on timing and type of injury that you can just refer to and say, yeah, this is it. Dr. Richmond decided six weeks because on her assessment on the severity of the injury that she was seeing or the disorders that she was seeing, she considered that was at least the timing that she needed for the workers to get better. And in fact, I think two of them, she gave them more time after she re-evaluated them. So it does make a difference with workers' comp, but, you know, I guess that's the answer I have to your question. I don't even know if I addressed it yet, but it's a tough question. But I think it's a case by case basis. Correct. There is some scientific publication that does show that evidence, but it depends on the case. It depends on the case. I mean, you know, we specifically focus on the workplace and we see patients that are improving after six weeks and we see them improve. And if they need more time, well, you know, they give them more time, but it's a negotiation with the employer too, depending on the workers' compensation case. Thank you. To compliment my colleague's comment, in my experience working in Latin America, there was no evidence base to make the decision. And that makes us very uncomfortable. Why six weeks and not five and a half? Or why 21 days and not 22? So many times, what we adopt, the decision is not the occupational physician, but the treating physician. And unfortunately, many times, there's no evidence base for that. Because we ask, why 21 and not 22? Why seven days and not eight? Or not six? And I think it's a great question because we are, the language that we should speak is evidence-based. Here we have an international audience and our common language should be evidence-based medicine, no matter if I graduated from Harvard or I graduated from Central University of Venezuela. Thank you for that. And I also have to add that sometimes, the fact that there is no scientific evidence doesn't mean that the experience and what we see with patients is not true. It's just we need to do more research to elevate the level of evidence. But as we know, the evidence pyramid, the base of the pyramid is the expertise of the person, the expertise is the least of the strength of the evidence. So we need to do more research and publish and do more studies to elevate the evidence. And that's a fact. I'm a physical therapist by background, so I'm glad that's your decision to make, not mine at this point. Although someday, maybe I hope that I get into that realm. But two comments. One is looking at America's favorite pastime, start with a three-day DL, right? And they actually don't call it a disabled list anymore. They call it an injured reserve list where they can actually put in a different worker, right? Because baseball, if you're out, that's worker's comp and in the space. So, I mean, they start with as low as three days and then work their way up from there. So just a little food for thought. And then I think the other thing is, if you're bringing in the psychological aspects and to the extent that we think we know what needs to happen to healing, there's a lot more evidence that in repetitive motion type of dysfunctions, there's no injury per se, right? I mean, I think the best evidence has to do with kind of trapalga, as they call it in Scandinavian countries, which really just seems to be an increase in muscle tone that leads to soreness in somebody's neck. And so there isn't really any tissue damage there. It's really just a neuromuscular phenomenon that we need to learn how to interrupt, whether it's through ergonomics or through some other type of training and probably pulling them off of work might be the worst thing we could do for them. Thanks. All right, so in the interest of time, I'll present to you now a good friend and colleague, Jack. Generally. Hi, is this the controller? Yes, I think. I pressed and a picture showed up. Good morning, good afternoon back in Boston. With the Red Sox are failing miserably. But anyway, it's a pleasure being here. Similar to Andy, I'm an ergonomist. I come here through the ergonomics field, not the medicine field, but I taught at Harvard for many years and many of my former students who were part of the occupational medicine residency at Harvard are here today and it's great to see you, so many of you here and actually be part of the group. It's also, I wanna thank Andy because he used a couple of my slides, but which is great because it's gonna reinforce some of these ideas. A little bit about my background. I'm a mechanical engineer who studied occupational biomechanics. So I was really interested in the tissue response that we talked about and actually in repetitive, there's been animal models that actually have demonstrated inflammation processes happening under repetitive stress, injuries and the like. So there is some, although a lot of, when we look at humans, we can't go into them like we can with animals and see the evidence as much, but the implementation process is happening often in the people who suffer from work-related musculoskeletal disorders. Anyway, my background as an engineer, my favorite topic was systems, system dynamics, system analysis, whenever the word system came about, I was usually doing very well in that class and enjoyed it a lot. And so when I think about micro, when I think about macro, I think about systems and thinking about the overall system of both those. So I don't really think about ergonomics as either micro or macro. I think about it as that full circle of human activity and context that Andy just presented and thinking about it. And one of my roles at Harvard is I'm also the Associate Director for the Center for Work Health and Wellbeing, which is one of the total worker health centers of excellence that NIOSH funds around this. And when you look at the total worker health centers across the country, a lot of the principles that they're applying for total worker health looks at that full circle and apply ergonomic approaches. They call it something a little bit more fancier. I work with a lot of social scientists. They go ecological models and all these type of things. And that's really, and I'll show you some photos of those. By the way, I'm always the one who draws the pictures of showing the systems in my group, but that's part of that. And so thinking about systems overall as part of the thing, is this, this is how I advance. Okay, just, I was at a medicine conference. So I'm like, I have to declare that I have no conflict of interest and some of my research and where it's funded from just so that you are aware of my context that I'm presenting today in terms of this. I love this case study. I was preceded at Harvard by somebody named Stover Snook who taught me a lot about ergonomics. Because remember, I was a mechanical engineer who studied occupational biomechanics and got a job in ergonomics at Harvard. And so Stover was one of my teachers. And you've heard of, many of those who've, how many people have heard of the Snook-Seriello tables in terms of that? Okay, very few. This is good, getting an assessment of your audience. See, ask questions like Andy talked about. So this is a case, and actually I didn't have, the reference didn't show up here. It's from 1973. That's why I tried to find the oldest looking circuit board I could find. But I remember my brother's TI, in 1973, my brother graduated from high school and for college, we gave him a Texas Instruments calculator. And it was like $150, and it added. That was about it, so. But anyway, and multiplied and things like that. Had a little bit of memory. But electronic devices were really expensive. And essentially, this one company was losing a lot of these devices because people were dropping them all the time. And the workers were dropping them, and they're like, hey, can you come and train our workers to be better and not drop these things all the time? Okay, and so the human factors, I'm gonna use the word human factors, which is another, you have micro, macro, and human factors. All three of those are kind of domains of ergonomics. And so they brought in a human factors guy who came in and measured how often people were dropping things. And he said, you know, these people are really, really good at not dropping things, to be honest. I mean, think about the last time you dropped your phone. Was it today? Or yesterday, right? You know, people drop things all the time. We trip up. We're human. It's part of the thing. And so what he realized was it wasn't that these were people who were, you know, klutzes. These were actually high-performing humans and that, you know, what was wrong was the system. And so they came in and they redesigned the system. The system required that these things be carried a lot, you know, and so as a result, the probability of something being dropped was very, very, very high because the process required things to be carried a lot. And so what they had to do was really rethink the process and redesign the process. Redesign the job. We just talked about a workers' comp where somebody was, you know, believed that work hasn't really changed. Why should I go back? That's a very valid perception because if we aren't changing the work, how is anyone going to get better? Okay, and that's really the issue that I think ergonomics is trying to solve, and that's also another thing I'll get to when I use Andy's slide about the definition of ergonomics is that ergonomics is a solution and it's not really a problem or an adjective, which is one of my pet peeves. So basically, you know, we realized that humans were doing their best. We had to really fix the system instead of that and redesign the whole system. So when I think about work-related musculoskeletal disorders, some of the things that I've learned... By the way, I've been doing research in work-related musculoskeletal disorders for 30 years, starting as a graduate student with David Rempel out in California and then at Berkeley, and then, I mean, at Berkeley, and then moving to Harvard and now at Northeastern. These are sort of my three takeaway messages around work-related musculoskeletal disorders. They cannot be fixed with training alone. We can't teach people how to lift differently. We actually have to think about redesigning the system. And that's what my case is about. Musculoskeletal disorders are a systems problem. These are people... People integrate all their experiences at work, including, you know, what the social aspects of work are, what the organization, what the job demands are, as well as the physical demands in terms of that. And really, ergonomics can help us address all of these multiple conditions of work that are impacting the worker. If we're not addressing these conditions of work, then, you know, it gets back to that point. A worker doesn't feel safe going back to work, and how do we do that? So that's sort of the key three messages that I want to leave you with today. So I'll start talking now. I love this one. In all my ergonomics classes, I always start to talk about this. You know, I'm a mechanical engineer, so I start thinking about joint torques and things like this. And, you know, how many people... You go into a room and say, how many people are taught or teach their employees lift with your knees? Anybody here teach with your... No, Tom, Tom, even you, Tom. Okay. So have you talked to Tucker about this? Tucker O'Day is one of our colleagues. So Tom... So anyway, so, you know, lift with your knees. The issue is that, you know, there's actually been a lot of randomized control tiles that have looked at training workers on how to lift differently. And there's moderate evidence that shows that that doesn't work. Okay. A Cochran review based in 2011, you know, that's the conclusion that that Cochran review came up. Moderate evidence suggesting it doesn't work. From an engineering point of view, if you look at the biomechanics, it doesn't work because the big thing is when you lift with your knees, you have to... Your butt goes this way and the load goes that way. And so all of a sudden you have a larger moment arm. So it often increases the mechanical load on your low back when you lift with your knees. And so it actually... So from a biomechanical point of view, there's not much difference. And when you start looking at when there is a difference, the difference is in the noise of the system. It's a very small difference. When our understanding of what causes injury to the low back, you know, the range, the variability is quite large. This is, you know, if you're in that... You know, the difference of lifting technique is very little in terms of the probability of an injury between those. And so there's a lot of evidence in this. And so that's one of my things I like to say is training alone usually won't make a difference in terms of this. The other thing, being an engineer, is that I always believe I could design some new tool and it will solve all the problems. Design a new computer mouse, design a new keyboard, and it will solve all the problems. Give people a highly adjustable workstation, problem solved. No. So the physical aspect doesn't work alone either because what happens is you got, you know, is that in both these scenarios, so I... Whoops. Human factors. Where's the laser? Oh, there it is. When you look at this, you know, giving somebody... This is a picture of an experiment we did in the lab, but it's a highly adjustable workstation. You're not always, well, folks, you know, be able to know how to use the equipment. So we can give people technology, and, you know, the issue is acceptably, you know, you give people iPhones, and usually they figure it out, but with most workstations, you know, the whole workstation becomes subservient to the task, so people forget about their keyboard. They forget about that they can adjust things and make things things. So usually a highly adjustable workstation won't work, and there's actually evidence suggesting that out there, moderate evidence suggesting that just giving people adjustments to the workstation doesn't work in terms of keyboards. And also, how many hospitals went out there and bought all this lifting equipment and, you know, saw no change in their low back disability, right? And because, again, the idea is that you have to have a system, and, in fact, Ben Amick talks about this in his thing about office chairs, is that you actually have to have a theory of change model to understand how are you gonna really change behavior when you give them some sort of technology, a highly adjustable chair was the thing he looked at, and really what you're hoping is that that changed postures and behaviors and health and functional health and productivity and satisfaction, but you actually also had to give them training and knowledge on how to use this, okay? And the same is true with the safe patient handling systems. There was... Oh, I don't have it here. I have it somewhere else, where I'll talk about it again in a few moments, where we had to do a systems approach looking at safe patient handling things. One other thing, we talked about vibration a little bit. Sometimes, when we do these physical interventions, we try to do a placebo effect on our control, and we do... So this is a... You know, the results are funny in that we don't really understand what happens when we give something to somebody, and that happened... This was a study that I led where we looked at truck drivers. We did a randomized control trial with 135 truck drivers where we gave them this really cool seat and basically it was a Bose ride. They don't make it anymore, but they did for about 10 years, enough that we were able to do the study. Noise cancellation idea, it canceled the vibration that the drivers experienced. So an active electromagnetic reduced the whole body vibration by over 50%, brought it way down into the ISO standards, into the safe levels, because truck drivers are right about the... You know, if you look at their whole body vibration, they're right at the threshold for injury, for the limits on there and stuff. So we were like... And the anecdotal information was like, this was great. Truck drivers just weren't suffering as much with the low back pain, and those who had low back pain or disability were able to get back to work a lot earlier with this kind of thing. Anyway, we did three-month follow-up after seat install. The intervention, yay, low back pain decreased by 50%. Problem is in the control where we gave people the exact same model, a brand-new version of the exact model of seat that they already had in their truck to say, hey, you got a new seat. We also saw a 50% reduction in them, too. And we were trying to be as smart as we could about this. Like, you know, we had a one-month lead-up period. We did all this stuff, and we're like, oh, really? And David Ripples had similar experiences with dental hygienists and garment workers as well where, you know, something happened in the control, whether we were just simply talking to the drivers and they felt energized by us and learning stuff and interacting with us and felt somebody cared about them, or something happened in there that we don't really understand, and we didn't measure well enough. So getting back to the same kind of... Andy shows that complex model, the William... I call it the William Tell model, which I was gonna show. I boil it down to, you know, the physical, the social, and the individual, and really, I show a Venn diagram because they overlap very much. This picture is way old, as you can tell, by the technology in it, but I love it because it really demonstrates all three, right? The physical aspects of it. The social, where you see she's sticking out her tongue at her co-worker. And violence is a huge... You know, workplace violence is a huge issue. And bullying, especially in health-care workers, it's a huge issue around health. And so if you're not thinking about what's the social context that somebody's in. And then this poor fella... I don't know if it's a fella or a girl, but anyway, the... Actually, that's something... Just gender is actually a whole new topic of the future of work. But anyway, often we ask people to do things, and what's great about why we employ humans is that they're problem-solvers as well, that we're asking them to problem-solve. And this person, you know, isn't even giving... Doesn't even have the digits to really complete the task of typing. But we actually ask people to do jobs that go beyond their capability all the time, and I think that's something that we need to think about as well. So anyway, now I'm starting to get into... Andy left out one part of the definition of ergonomics, and that is really matching... So to address all these, you really need the systems approach and really start thinking about, well, if we're gonna look at human well-being and system performance that he talks about, we need to think about the physical, the organizational, and the cognitive that sort of interacts with these muscles, the things. And so getting back to Andy's, this is... What does this slide say, by the way, everybody? What did Andy say? Blah, blah, blah, blah, blah, blah, blah, blah, blah. And he pulls out, you know... We pull out the same thing as to, you know... It's to optimize human well-being and overall system performance. And this definition really calls out systems, specifically human systems, design, and then two outcomes, human well-being and system performance, to reiterate that. And it also... But the IEA also goes one step further and talks about these sort of three domains, the physical, the organizational, and the cognitive. And I would like to beg to... In this definition, in the physical is what we would consider the micro ergonomics, the organizational is the macro, and the cognitive is what we would traditionally call the human factors. And all three of these things are usually at play at the same time. And so, really, from a systems point of view, it's hard to sort of... I don't separate myself out. I have to think about all three of these when we start thinking about trying to create solutions with that and stuff. A little aside here, one of my pet peeves is when people use ergonomics as an adjective to describe either injuries or furniture or devices. Because although it's practice and usage is part of the definition, to me, ergonomics is a science, it's a discipline, and it's a solution. And when we start labeling things as ergonomic injuries, it starts getting into it. They're muscle skeletal disorders. They're not repetitive stress injuries. They're muscle skeletal disorders. They're soft tissue injuries and that kind of thing. And they're hazards or risk factors for such devices. So, just wanted to do that little pet peeve thing. So, again, this idea of a systems approach to safe patient handling, I actually come back to the individual and saying, once someone's at a bedside or you've got someone making decisions whether to use a piece of equipment or not, what's informing their behavior? And this really gets to that cognitive aspect of it. But there's also the physical, and really, it's back to the systems. So, first of all, you have to... Whoops, I've done that again. The physical environment needs to be there. You have to have the equipment. It's a necessary condition. Not necessarily sufficient, but necessary condition. You know, do I have time to use the equipment? Is it designed as part of how my job is designed? The organization, is it part of the prescribed plane of care? Is there... Do I have the authority? Do I have the knowledge to use this equipment? We actually saw a difference between PCAs and nurses on low back injuries after we did a safe patient handling thing. And part of it was that the patient caregivers didn't have as much training and authority to use this type of equipment in this hospital, which created huge disparities among our population. Psychosocial, you know, was the supervisors, was the culture of the organization say, it's okay to use this equipment? You don't have to prove yourself by lifting this thing and run across... What was that Farside ad with the three dogs running across the road saying, yay, you're now in the club. You don't need to do that kind of thing. So those type of things, and you have to address all of those. And there is actually, it's in blue here, you can't see it, but there are many systems, most safe patient handling guidelines and recommendation address all four of these type of issues. And at the Center for... Oh, and so we actually did an implementation of this. This is at a hospital in Boston where we looked at a pre-post program that was really looking at how do we increase patient mobilization? Because that's a healthcare quality improvement act to, you know, the faster and sooner you mobilize a patient after a procedure, the better outcomes they have. But they also, in this, wanted to reduce worker injuries associated with this mobilization. And what we did, the program had all these key characteristics from commitment, leadership commitment, comprehensive collaborative approaches, physical, and addressing the conditions of work. Physical work organization is psychosocial. And we saw an increase in use of the devices. We also saw a decrease in the injuries associated with lifting by 25%. So again, the systems approach seems to work. The evidence is pointing towards these. It's harder to do randomized controlled trials at such programmatic levels. There are clusters, but it gets much more difficult to do it. So how am I doing for time? I have totally lost for time. Close and finish up? Okay. So, you know, one example of this is looking at any sort of safety management system. And so part of what I do, and I really like what David Michaels talks about, and it gets back to what Andy talks about. And this was in Harvard Business Review. And he says, seven ways to improve operations without sacrificing worker safety. And I love this because he's speaking directly to the managers in this. And that's part of what ergonomics is about. It's about improving performance as much as it is preventing disorders and stuff. So when you go back to that triangle that I have, the inner circle there is that system performance. And again, he talks about many things that we've talked about here. Safety culture, management commitment, don't blame workers for injuries, rethink about injury rates, this whole idea that we talked about, the incentive. I forget who said it. Oh, I think it was Tom who said it about how people don't want to report injuries because it ruins other things like their EMR and the like. Focus on leading integrates and health management systems. And this was just a cool kind of article that talks about it. Total worker health is very much the same idea. Looking at policies, programs, and practices that think about this integration about work-related safety and health hazards. It gets back to what Akram said earlier that we're thinking about overall health promotion and preventative care in ergonomics as much as we are secondary and tertiary type of approaches. With that kind of complex organization, we've created one of these social ecological models that we have in our center that's really at the heart of it, suggests that the conditions of work, the physical, the organizational, the psychosocial, and the job task and demands is at the heart of most of the problems that we're looking at. And if you don't change those, how are you going to really improve worker outcomes in terms of injury, illness, and well-being? Again, thinking about how does this impact the bottom line of enterprise outcomes as well. One of the key things that we have in here is that the worker responds to these conditions. So without changing these conditions, even if you want to train people and get them to behave differently, unless you're changing these conditions, you're really not going to do it. This comes actually out of the smoking sensation literature where if you're trying to get people to stop smoking in a workplace, but you're not reducing the hazards in the air. If you think about a guy in a foundry who's exposed to all these fumes and you're telling him to stop smoking, he's like, WTF. I'm like, you're not doing anything else about the bad air. I'd have to breathe every day. Why should I quit smoking? Because I'm going to die anyway kind of feeling. So unless you address those, even in the wellness communities, and we've seen all these wellness programs who haven't been as productive and the like. So that's thinking about it from there. We've updated this because the pandemic and the future of work is changing how we're thinking about this. So as we move into coming out of the pandemic, not only just remote workers, but just how work is organized, the gig economy has been here a long time, but it's now with the online platforms going into a lot of different areas in terms of it used to be just the entertainment business, but now it's in everything. And thinking about this, we have to start thinking about the context, right? Getting back to Andy's kind of thing. It's not only the context in the workplace, it's also the social, political, and economic environment. Akram talked about regulations. We talked about international, how it's very different in different countries compared to here, as well as employment and labor patterns. So just another idea there. I already talked about this. Take this safety management, really thinking about what are the engineering controls and thinking about the hierarchy of controls and thinking about that. So I just wanna say, wrap up and just say, this is the three key messages I wanna say. Basically, ergonomics is a way of, if you think about it from the holistic system level approach, can really help address the multiple conditions of work that impact the outcomes that we're talking about here today. So with that, thank you. And that's Eli, Ernest, and Harold. Great, as always. Well, we're gonna stop. And then, so we're gonna go for a break. And we're gonna have a second session with one more presentation. And then we're gonna do an interactive case discussion. Hope you guys can come back, everybody. Thank you.

occupational physician

ergonomics

return to work

collaboration

safety culture

productivity

clear communication

problem-solving skills

return to work program

work-related musculoskeletal disorders

systems approach

worker well-being

COVID-19 pandemic

gig economy