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HISTOGONOMICS:ERGONOMICS IN THE HISTOLOGY LAB

Brad Flowers, National Equipment Manager, Cancer Diagnostics, Inc.

Allison Eck, HT, Certified Ergonomic Assessment Specialist and Yoga Teacher

Why talk about ergonomics?•According to the 2017 Liberty Mutual Workplace Safety Index, serious, nonfatal workplace injuries now amount to nearly $60 billion in direct U.S. workers' compensation costs per year. This translates into more than $1 billion dollars a week spent by businesses on these injuries. Jan 11, 2017

•Work-related musculoskeletal disorders are the single largest job-related injury and illness problem in the United States and account for nearly 1/3 of all occupational occurrences reported.

Who am I?•National Equipment Manager for Cancer Diagnostics – 3+ years

•BS degree in Kinesiology-Movement Science- University of Michigan

•Associates Degree for Physical Therapy Assistant- Michiana College

•Worked in Outpatient Sports Medicine and Rehabilitation- 6years

•Workplace Ergonomics Education for Delta Airlines and Coca-Cola Co.

•Previously worked at Surgipath Medical Industries- Equipment Specialist – 5 years

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What is Ergonomics?•From Greek: – “ergon” work – “nomos” law

•Ergonomics is the science of designing the workplace, keeping in mind the capabilities and limitations of the worker.

•A systematic ergonomics improvement process removes risk factors that lead to musculoskeletal injuries and allows for improved human performance and productivity as well as reducing operator fatigue and discomfort.

History of Ergonomics

•Italian medical student Bernardino Ramazzini recognized that workers were developing certain diseases.

•In 1700, he published De Mortis Artificum Diaribia(Diseases of workers)

•The term ergonomics dates to the mid-1900s, but credit for applying the term generally goes to Hywel Murrell, a British psychologist.

Categories of Ergonomics

•PHYSICAL – concerned with the human anatomy (physiological and biomechanical) as it relates to physical activity

•COGNITIVE – concerned with mental processes, such as perception, memory, and motor response•ORGANIZATIONAL – concerned with the optimization of socio-technical systems (work design, communication, cooperative work, crew resource management)

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Considerations in the Lab- Physical•Work habits

•Posture / Biomechanics

•Right or Left handedness

•Arrangement of tools or instruments

•Automation/use of instruments

•Counter height

•Seating

•Lighting

•Noise Levels

•Temperatures

•Vibration

Risk Factors For Injuries• Repetition -- performing the same motion over and over again.

• Awkward Body Posture -- sustained holding of a bent position of the neck, back, hands/wrists, arms raised above shoulder level or arms extended out in front of the body.

• Force -- physical exertion or pressure applied to any part of the body while working, such as lifting, pushing, pulling, gripping or pinching equipment or tools.

• Contact Stress -- pressure on soft tissues of the body, such as the soft part of the palm, wrist or the sides of fingers by tools and sharp edges.

• Extreme Temperatures - cold air temperatures (55°F and lower) may cause loss of dexterity proportional to exposure time.

• Individual Susceptibility- Individuals may be predisposed to MSD based on their heredity, prior injuries, other illnesses, medication, smoking, etc.

Risk Factors for Specific Tasks- Embedding

•Awkward Body Posture-Neck and Back

•Lack of adequate leg and knee clearance under worktable

•Overreaching for base molds and/or cassettes

•Repetitive work/pinching forceps in placement of specimens

•Pinching of small tampers

•Contact stress of palms

•Working with elbows winged

•Eyestrain and fatigue

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Risk Factors for Specific Tasks- Microtomy•Awkward Body Posture-Neck and Back

•Overreaching of flywheel and coarse adjustment wheel

•Repetitive Turning of Microtome’s Wheels- Shoulder, Elbow, and Wrist

•Turning microtome's wheel requires force or forceful exertion

• “Rocking” motion creates constant stress

•Repetitive work in placement of cassettes to clamp

•Pinching of forceps for section retrieval

•Repetitive motion of locking flywheel with the thumb

•Repetitive motion with Foot/Ankle with Automation

Risk Factors for Specific Tasks- Microscopy•Awkward and static posture of the lower back, neck, and head

•Lack of adequate leg and knee clearance under worktable

•Working with elbows winged

•Pinch grip when adjusting the focus and changing fields

•Wrist and palm contact pressure in the carpal tunnel area

•High repetition

•Eyestrain and fatigue

Risk Factors can contribute to Common Musculoskeletal Injuries

•Carpal Tunnel Syndrome, De Quervains Tenosynovitis

•Elbow Injuries: Tennis Elbow, Golfers Elbow

•Shoulder Impingement Syndrome

•Rotator Cuff injuries

•Back and Neck injuries

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Carpal Tunnel Syndrome•Carpal tunnel syndrome is caused by compression

of the median nerve as it passes through the carpal tunnel and under the transverse carpal ligament at the wrist.

• Symptoms include pain, tingling, numbness, and muscle deterioration/weak grip.

•Tingling often occurs in thumb, index finger, middle finger, and ½ of ring finger.

• Symptoms can worsen at night and often interfere with sleep

Carpal Tunnel Treatment

•Stop the cause of the symptoms

•Shaking your hand when you feel tingling

•Ice your wrist or soak in an ice bath for 10-15 minutes. 3 -4 X/day

•Use a wrist splint at night or during activities

•Non-Steroidal Anti inflammatory Drug – (Ibuprofen or Naproxen)

•Surgery

Carpal Tunnel Exercises•Prayer Stretch- Palms together, lower hands

•Wrist Flexor Stretch-Stop sign motion

•Wrist Extensor Stretch-Palm Down

•Tendon Gliding Exercise-Puppet then rotate palm up, thumb pulled out

•Anterior Scalene Stretch-tilt head to side, lean head back, ear to the sky.

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De Quervains Tenosynovitis•A painful condition affecting the tendons on the thumb side of the wrist. “Snuff box”

•Symptoms include: Pain and swelling near the base of your thumb

•Difficulty moving your thumb and wrist when you're doing something that involves grasping or pinching

•Moving the wrist, grasping, pinching, or making a fist can aggravate the pain.

De Quervains Tenosynovitis Treatment•Ice and compression

•Over-the-counter pain relievers

•Corticosteroid injections

•Physical or Occupational Therapy

•Surgery

De Quervains Exercises•Wrist Flexion and extension

•Radial Deviation strengthening

•Thumb lifts- Palm face up thumb to pinky

•Grip Strengthening-Putty or ball

•Opposition Stretch-Palm up thumb/pinky

•Rubber Band Extensions

•Finkelstein Stretch

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Elbow InjuriesLateral Epicondylitis- Commonly referred

as Tennis Elbow. (Medial Epicondylitis is

referred as Golfer’s Elbow)

• It is the most common injury treated for

patients with elbow pain.

•Thought to be from small tears in the forearm muscle tendons (extensor carpi radialis brevis) that attach at the elbow joint that have occurred from repetitive use.

• Symptoms include pain over the outside of the elbow, pain when lifting objects, and pain radiating down the forearm.

Elbow Injury Treatment

•Change the way you perform specific activities that aggravate your elbow pain.

•Bracing of Elbow and or wrist

•PT – Exercises and Modalities

•Ice, anti-inflammatory medications, cortisone injections, or surgery

Elbow Injury Exercises

•Forearm Flexion and Extension Stretching

•Forearm Flexion and Extension Strengthening

•Supination and Pronation Strengthening exercises

•Exercises done for Carpal Tunnel and De Quervains

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Shoulder InjuriesImpingement Syndrome

•Can be caused from overhead activities or raising the arm repetitively.

• Impingement of the tendons and bursa.

• Inflamed Bursa Sac can also pinch on the tendon causing pain.

• Symptoms include pain with raising the arm above shoulder height or behind the back and muscle weakness.

Shoulder InjuriesRotator Cuff injuries

• Rotator “Cuff ” is made of four muscles-Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis. Supraspinatus muscle is the most commonly affected.

• Most often in people who repeatedly perform overhead motions in their jobs or sports.

• Can also occur with a trauma such as a fall.

• Symptoms include pain on top of shoulder and arm. Pain can descend down the outside of the arm to the elbow.

• Disturbed sleep, particularly if you lie on the affected shoulder

• Difficulty with combing your hair or reaching behind your back

• Can be accompanied by arm weakness

Shoulder Injuries Treatment•Ice and rest

•Physical Therapy including modalities and exercises

•Kinesiotaping

•Injections

•Surgery

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Shoulder Exercises

•Pendulum Stretch

•Isometric internal and external rotation

•Theraband IR and ER

•Bentover row/Lawnmower pull

•Crossover arm stretch

•Doorway stretch

Back Injuries Most Common Causes

•Force -- Exerting too much force on your back, such as lifting or moving heavy objects

•Repetition -- Repeating certain movements leads to muscle fatigue or injury

•Posture -- Slouching exaggerates your back’s natural curves, which leads to muscle fatigue and injury

Back and Neck Injuries- The most common reason for missing work after the common cold and account for 24% of all workplace injuries.

•Muscle strains

•Bulging Disc

•Herniated/Ruptured Disc

•Spinal Stenosis

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Back injuries• Muscle strain occurs when fibers in a

muscle begin to tear from being overstretched or overused (commonly called a pulled muscle).

• A bulging disc (protrusion) occurs when the disc annulus remains intact, but forms an outpouching that can press against the nerves.

• A herniated disk occurs when a portion of the nucleus pushes through a crack in the annulus. Symptoms may occur if the herniation compresses a nerve.

Back Injuries cont.•Spinal Stenosis-Narrowing of the spinal canal and contributes to pinched spinal cord and or nerve roots. Often occurs from age-related wear and tear.

•Symptoms include pain, numbness, muscle weakness, and impaired bladder or bowel control.

•Treatment includes medication, physical therapy, and possibly surgery. Focus on flexion exercises. Can sometimes be a Catch 22 scenario with other spinal issues.

Back Injuries Treatment

◦Rest◦Ice/Heat◦Physical Therapy-stretching, strengthening exercises, modalities◦Anti-Inflammatories◦Injections◦Surgery

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Back exercises Neck Exercises• Standing Hamstring Stretch Lateral Flexion

• Standing Back Extension Chin Tucks

•Lateral Flexion Levator Scapula Stretch

•Upper Back Stretch

•Prone Press ups

•Bridging

•Knees to chest

•Piriformis Stretch

General Prevention• Rotate tasks among several people or between laboratory tasks

• Take micro-breaks of 2 minutes for every 20 minutes of a task. Mild hand, arm, shoulder, neck, and back exercises and stretches are beneficial

• Use tools/forceps that fit comfortably and with easier mechanisms requiring less force to activate(ie. forceps, tampers, larger handles)

• Education- Reminders to use proper mechanics

• Move to automation in the lab (Fully Automatic Microtomes, Stainers, Automatic Coverslippers, Embedders)

• Improve your lab set up for optimum efficiency and improved biomechanics (chair height, arrangement of the equipment, lumbar support, wrist pads, ergonomic mouse and keyboards, lift tables, padded mats)

Proper Lifting Techniques•Stand close with your feet spread shoulder width apart

•One foot should be slightly in front of the other

•Squat down, bending at your knees.

•Tuck you chin while keeping your back as vertical as possible

•Get a firm grasp before lifting

•Slowly lift straightening your legs

•Once the lift is complete, keep the object as close to your body as possible

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Prevention-Embedding• Use an ergonomically designed chair that provides adequate back support, adjustable

height, and adjustable seat angle

• Pull the embedding center toward the edge of the work surface to position the operator in a more upright posture

• Avoid leaning on hard edges or use a pad to cushion the edges

• Keep elbows close by your sides

• Work with wrists in straight, neutral positions

• Use Ergonomic tools (i.e. forceps, tampers)

• Alternate use of paddle dispenser and foot pedal

• Use magnifying glass and proper lighting to prevent eye strain

• Take breaks

Prevention- Microtomy• Use an ergonomically designed chair that provides adequate back support, adjustable

height, and adjustable seat angle

• Pull the microtome and water bath toward the edge of the work surface to position the operator in a more upright posture and to minimize reaching

• Avoid leaning on hard edges or use a pad to cushion the edges

• Keep elbows close by your sides

• Work with wrists in straight, neutral positions

• Don’t “Rock”- Use full revolution of the flywheel

• Use Ergonomic tools (i.e. forceps, larger handles)

• Use Fully Automatic Microtomes

• Consider Magnifying Glass and Lights

Prevention-Microscopy• Use an ergonomically designed chair that provides adequate back support, adjustable

height, and adjustable seat angle

• Avoid jutting your chin forward or bending your neck down when using the microscope

• Adjust the height of your microscope, workbench or chair as needed to avoid bending or tilting your neck

• Avoid leaning on hard edges or use a pad to cushion the edges

• Provide sloping arm rests to support the operator’s forearms while using adjustment knobs

• Keep elbows close by your sides

• Work with wrists in straight, neutral positions

• Pull the microscope toward the edge of the work surface to position the operator in a more upright posture

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Now what? Regulatory Guidelines-You know the risk factors and ways to prevent the injuries but how do we implement?

Does your lab have an ergonomics plan?• CAP Standards

• GEN.77200

• GEN.73400

• GEN.73600

• GEN.77300

• ANSI Standard – General and Office Standards

• OSHA standard/Joint Commission 29 CFR 1910.900

• NIOSH ergonomic plan

CAP STANDARDS• GEN.77200 Ergonomics Phase II

• There is a written ergonomics program to prevent musculoskeletal disorders (MSDs) in the workplace through prevention and engineering controls.

• NOTE: The program may include training of employees about risk factors, identifying physical work activities or conditions of the job commonly associated with work related MSDs, and recommendations for eliminating MSD hazards.

• Laboratory activity, workplace and equipment (e.g. chairs, laboratory workstations, computer keyboards, and displays) should be designed to reduce the risks of ergonomic distress disorders and accidents.

• Evidence of Compliance: ✓ Records of ergonomic evaluation including recommendations for eliminating MSD hazards and appropriate corrective action based on assessment findings

CAP STANDARDS• GEN.73400 Safe Work Practices Review Phase II

• There are records of periodic review (at least annually) of safe work practices to reduce hazards.

• NOTE: Review must include bloodborne hazard control and chemical hygiene. If the review identifies a problem, the laboratory must investigate the cause and consider if modifications are needed to the safety policies and procedures to prevent reoccurrence of the problem or mitigate potential risk.

• Evidence of Compliance: ✓ Safety committee minutes OR records of regular safety inspections OR incident reports and statistics OR another method defined by the laboratory director

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CAP STANDARDS•GEN.73600 Occupational Injuries Phase II

•There are written policies and procedures for the reporting of all occupational injuries or illnesses that require medical treatment (except first aid).

•NOTE: For US laboratories subject to OSHA regulations, all workplace fatalities must be reported to the Occupational Safety and Health Administration (OSHA) within eight hours and work related in-patient hospitalizations, amputations, or losses of an eye within 24 hours.

CAP STANDARDS• GEN.77300 Excessive Noise Phase II

• The laboratory has a policy to protect personnel from excessive noise levels.

• NOTE: The laboratory should provide protection against the effects of noise exposure when sound levels equal or exceed an 8-hour time-weighted average sound level of 85 decibels. The laboratory should monitor noise exposure if there is an indication that excessive noise levels are present (for example, when noise levels exceed 85 decibels, people have to shout to be heard).

ANSI STANDARDS• General Ergonomics Standards - apply in a wide range of situations, providing procedures,

practices, and design considerations that assure consumer and worker productivity, safety, and health. Furthermore, they serve as the baseline for the ergonomics standards for environments and industries with more specialized needs.

• Office Ergonomics Standards - office ergonomics, the design of workspaces, and the work environment help employers and employees maintain productivity and safe working conditions. Office ergonomics standards provide guidance to designers of office space, workstations and office equipment. Facility managers and safety officers are also concerned with these standards as back, neck, and spinal injuries, and repetitive stress injuries impact performance and attendance. The standards cover visual displays and computer keyboards, office chairs and desks as well as office environmental factors such as lighting, noise, ventilation and temperature that affect significant numbers of people.

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ANSI STANDARDS Cont…

•A selection of office ergonomics standards are listed here that specifically deal with office work. Some are applicable to tasks common in many types of offices and across widely differing industries such as telecommunications, medical or scientific. Combined with training, awareness and other good practices, these standards can help improve the workplace.

OSHA/JOINT COMMISSION•Provides training and outreach for safe working practices in a variety of workplace settings.

•OSHA standard 5110 - A minimum level of safety practice that a company must meet

•OSHA general duty clause (5(a)-1) - States that a workplace must be free of hazards

NIOSH ERGONOMICS PLAN

6 steps needed to create an ergonomics plan for your workplace

1. Identify risk factors

2. Involve and train management and workers

3. Collect health and medical evidence

4. Implement your ergonomics plan

5. Evaluate your ergonomic program

6. Maintain your involvement

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ERGONOMICS PLANStep #1: Identify your risk factors

• Checklist for employees to fill out

• Review of occupational health records

STEP #2: Involve and Train Management and Workers

• Ergonomics Awareness Training (should be provided to all employees)

• Learn how to recognize the risk factors and symptoms for WMSDs

• Understand general methods for reducing risk factors for WMSDs

• Become aware of your company’s health care procedures

• Learn your employer’s role in addressing and controlling risk factors for WMSDs

• Learn how workers can address risk factors for WMSDs

• Learn how to report your concerns of WMSDs

ERGONOMICS PLAN

STEP #3: Collect Health and Medical Evidence

•Utilize the attached questionnaires to help determine areas that need attention

•Computer-Workstation-Checklist.pdf

•WMSD-Hazard-Identification-Checklist.pdf

•Workstation-Checklist.pdf

•Leading vs Lagging Indicators

ERGONOMICS PLANSTEP #4: Implement your Ergonomics Plan

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ERGONOMICSPLAN

STEP #5: Evaluate your Ergonomic Program

• Compare data from before implementation and after:

• job analyses

• checklists

• symptom surveys

• OSHA form 300 logs

• employee absentee rates

• turnover rates

• workers’ compensation costs

• productivity indicators

• quality of products and services

• savings

ERGONOMICS PLANSTEP #5: Evaluate your Ergonomic ProgramCompare data from before implementation and after:

• job analyses

• checklists

• symptom surveys

•OSHA form 300 logs

• employee absentee rates

• turnover rates

•workers’ compensation costs

• productivity indicators

• quality of products and services

• savings

ERGONOMICS PLANSTEP #6: Maintain Involvement – Encourage Involvement

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Work Station SetupsREACH ZONES• Zone A – Neutral zone or optimal reach zone– Vertical zone A – 5’-8’ above and below the desk height• Items you use most in the day• Zone B – the area you can reach with your arm stretchedout– Vertical zone B – 8’-12’ above and below the deskheight• Items that you use frequently but for short durations• Zone C – Extended reach zone– Vertical zone C – greater than 12’ above shoulder height• Infrequently used items

Proper Seated Posture• Feel flat on the floor

• Hips and knees bent at 90 degrees

• Back of the chair should support the natural curve

of your back

• Shoulders relaxed with arms at your sides

• Forearms parallel to the floor

• Wrists neutral

Office Set Up Considerations• The Big 3• Work Surfaces• –Where your eyes and hands are• determines your posture• Wrist / mouse rest• Dynamic sitting• Lighting / Glare• Temperature / Humidity

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Why Bother?

•Proper ergonomics reduces costs.

•Productivity increases

•Improved quality

•Improved employee engagement

•Promotes a culture of safety

Conclusion•Your jobs are incredibly repetitive

•Make changes around your lab to be better suited to minimize risk factors for injuries.

•Use ergonomic tools, automation when appropriate, and simple devices to improve ergonomics

•Use better body mechanics

•Add some cardio to your lifestyle and do stretching and strengthening exercises.

•Take care of your bodies (Eat properly, stop smoking, get a good night’s sleep)

• Implement a plan at work

Conclusion

•Things will improve and make you happier and more productive!

“An ounce of prevention is worth a pound of cure”.

- Benjamin Franklin

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References• Giangarra CE, et al. Rotator cuff repair. In: Clinical Orthopaedic Rehabilitation: A Team Approach. 4th ed.

Philadelphia, Pa.: Elsevier; 2018. https://www.clinicalkey.com. Accessed Feb. 20, 2018.

• Rotator cuff tears. American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases--conditions/rotator-cuff-tears. Accessed Feb. 20, 2018.

• Ferri FF. Rotator cuff disease. In: Ferri's Clinical Advisor 2018. Philadelphia, Pa.: Elsevier; 2018. https://www.clinicalkey.com. Accessed Feb. 20, 2018.

• Simons SM, et al. Presentation and diagnosis of rotator cuff tears. https://www.uptodate.com/contents/search. Accessed Feb. 20, 2018.

• Martin SD, et al. Management of rotator cuff tears. https://www.uptodate.com/contents/search. Accessed Feb. 20, 2018.

• AskMayoExpert. Rotator cuff surgery. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2017.

• Azar FM, et al. Shoulder and elbow injuries. In: Campbell's Operative Orthopaedics. 13th ed. Philadelphia, Pa.: Elsevier; 2017. https://www.clinicalkey.com. Accessed Feb. 22, 2018.

• Hattrup SJ (expert opinion). Mayo Clinic, Phoenix/Scottsdale, Ariz. March 8, 2018.

• Morrow ES. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Oct. 2, 2017.

References Cont.• Wheeler, Tyler. What Exercises Help for Carpal Tunnel Syndrome? (20017, June 6). WebMD Retrieved January 17, 2019

from https://www.webmd.com/pain-management/exercises-carpal-tunnel-syndrome#1

• A web page with an unknown author: Workplace Ergonomics 101. Retrieved January 17, 2019 from https://ergo-plus.com/workplace-ergonomics/

• A web page with an unknown author: 5 Ways you Can Ease Carpel Tunnel Syndrome Pain Without Surgery (August 11, 2016/Orthopaedics) Retrieved January 28, 2019 from https://health.clevelandclinic.org/5-ways-can-ease-carpel-tunnel-syndrome-pain-without-surgery/

• Cluett M.D., Jonathan. Tennis Elbow: All you need to know about Tennis Elbow. (2018, January 29). Retrieved February 11,2019 from https://www.verywellhealth.com/tennis-elbow-a2-2549917

• Cluett M.D., Jonathan. An Overview of Rotator Cuff Tears : A Guide to Treatment of a Torn Rotator Cuff (2019, January 23). Retrieved February 11,2019 from https://www.verywellhealth.com/rotator-cuff-tears-2549783

• A web page with unknown author: https://www.mayoclinic.org/diseases-conditions/de-quervains-tenosynovitis/diagnosis-treatment/drc-20371337

• A web page reviewed by Robert Bohinski, MD, PhD, Mayfield Clinic, Cincinnati, Ohio. https://mayfieldclinic.com/pe-hldisc.htm

Thank you!•Questions and discussion