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Safety and Health Topics > Ergonomics > National Advisory Committee > Meeting Minutes Printing Instructions National Advisory Committee on Ergonomics Minutes of the January 27-28, 2004 Meeting Hotel Washington 15th and Pennsylvania Avenue, NW Washington, DC 20004 Dr. Carter Kerk, Chair of NACE, opened the meeting of the National Advisory Committee on Ergonomics (NACE) at 8:50 am on Tuesday, January 27, 2004. Approximately 50 members of the public were present during the course of the meeting. The following NACE members were present: Edward Bernacki, M.D., MPH Associate Professor and Director Occupational Medicine Johns Hopkins University School of Medicine Baltimore, MD   Lisa M. Brooks, CIE Health and Safety Program Manager International Paper Company Memphis, TN   Paul A. Fontana President/CEO Center for Work Rehabilitation, Inc., Fontana Center Lafayette, LA   Willis J. Goldsmith, Esq. Partner Jones Day Washington, DC   Morton L. Kasdan, M.D., FACS Clinical Professor of Surgery University of Louisville School of Medicine Louisville, KY   Carter J. Kerk, Ph.D., PE, CSP, CPE Associate Professor in Industrial Engineering South Dakota School of Mines & Technology Rapid City, SD   James Koskan, MS, CSP Corporate Director of Risk Control SUPERVALU, Inc. Minneapolis, MN   George P. LaPorte Ergonomics Manager NATLSCO Loss Control Services Division of Kemper Insurance Companies Lake Zurich, IL   Barbara McCabe Program Manager Operating Engineers National Hazmat Program Operating Engineers Beaver, WV   J. Dan McCausland (Arrived late) Consultant Worker Safety and Human Resources Director American Meat Institute Madison, WI   Audrey Nelson, Ph.D., RN Center Director VHA Patient Safety Center of Inquiry Suncoast Development Research Evaluation-Research Center for Safe Patient Transitions Tampa, FL   Lida Orta-Anes, Ph.D. Associate Professor Graduate School of Public Health University of Puerto Rico San Juan, Puerto Rico   Roxanne Rivera Consultant Albuquerque, NM   Richard Wyatt, Ph.D Associate Director Aon Ergonomic Services Huntsville, AL   The following Symposium panelists were present:     Arun Garg, Ph.D., PE, CPE Industrial & Manufacturing Engineering University of Wisconsin—Milwaukee   Nancy N. Menzel, Ph.D., RN, COHN-S University of Florida College of Nursing   Patricia Seeley, MSIE., MEPD, CPE WE Energies, Inc.   Thomas E. Bernard, Ph.D. College of Public Health, University of South Florida   Michael Feuerstein, Ph.D., MPH Department of Medical and Clinical Psychology Uniformed Services University of Health Sciences   Peter C. Amadio, M.D. Mayo Clinic College of Medicine   Brian N. Craig, Ph.D., CPE Department of Industrial Engineering, Lamar University Presentations Chair Carter J. Kerk welcomed the Committee, Symposium panelists, and members of the public to the meeting, and briefly reviewed the agenda for both days of the meeting. Assistant Secretary of OSHA, John Henshaw, welcomed the Committee, Symposium panelists, and the public to the fourth NACE meeting, which was held in conjunction with a research Symposium, entitled, Musculoskeletal and Neurovascular Disorders-The State of Research Regarding Workplace Etiology and Prevention. Mr. Henshaw discussed the purpose of the Symposium, noting that it will help NACE identify gaps in research and assist them as they make recommendations to OSHA later this year. Mr. Henshaw commended NACE's commitment to learning as much as it can prior to making recommendations to OSHA. Mr. Henshaw briefly reviewed the process involved in planning the Symposium, emphasizing that each Committee member received every abstract that was submitted, and that each speaker was carefully selected from a broad spectrum of abstracts. He added that the Committee's willingness to cast a wide net in search of new research is appreciated by OSHA, and thanked the Committee for publishing a notice in the Federal Register and extending the original deadline. Mr. Henshaw also acknowledged that the Committee has reviewed research completed by the National Institute for Occupational Safety and Health (NIOSH) and the National Occupational Research Agenda (NORA), along with literature presented by Dr. David Wegman of the University of Massachusetts–Lowell during the September 2003 meeting. Mr. Henshaw updated the Committee on OSHA's progress on each of the components of the four-pronged comprehensive approach to ergonomics: guidelines, outreach and assistance, research, and enforcement. He noted that the poultry processing guidelines should be completed prior to 2005 and stated that guidelines on shipyards are still in draft development. Mr. Henshaw added that OSHA intends to develop more guidelines and will look to NACE to recommend which industries are in need of guidelines. Mr. Henshaw gave an update on outreach and assistance, noting the over 20 strategic partnerships, 10 grants, and over 62 ergonomic training sessions already in the works, with additional alliances expected. Mr. Henshaw also discussed enforcement, though it is not part of the NACE charter. OSHA conducted 1,474 inspections on ergonomics from January 2002 through December 2003. OSHA has issued 12 General Duty Clause citations and 244 hazard alert letters, including 31 letters acknowledging an employer's effort to make improvements. Mr. Henshaw reiterated that the bottom line is not the number of citations, but whether there is a reduction in workplace injuries and illnesses. Mr. Henshaw repeated the importance of the Symposium and again thanked everyone for participating in the meeting. Dr. Tom Waters of NIOSH provided a brief update on NORA, a program originated by NIOSH to: Identify occupational research priorities for the next decade. Work with partners to address priorities. Identify funding to support research in priority areas. Dr. Waters reviewed NORA's 21 priority areas and discussed the make-up of the NORA teams. Each team is typically composed of between 8 and 15 members, half of whom are from NIOSH and half from external organizations such as academia, labor, industry, and various associations. There is also a liaison committee set up by NIOSH to help guide and direct the teams. Dr. Waters highlighted the teams interested in musculoskeletal disorders (MSDs), discussed the importance of current NORA partnerships and provided information on the status of NORA funding. He also reviewed NORA's two phases. During Phase 1 (1996-2006), NORA has completed or plans to complete the following activities: Develop research agendas for 21 priority areas. Develop partnerships to foster research on identified research topics. Identify additional sources of research funds that could be directed toward research gaps. Provide guidance on research topics to industry partners.. During Phase 2 (2006 and beyond), NORA plans to: Continue to update and prioritize research gaps. Strengthen partnerships with other government agencies. Continue to foster funding of MSD research efforts. Dr. Waters also briefly discussed the various NORA research projects and documents that are now available. Chair Kerk reviewed the purpose of the Symposium, stating that it is in line with NACE's two research-related goals: to identify gaps in existing research and to identify projected research needs and efforts. Chair Kerk gave a brief review of the Committee's interactions with NIOSH, noting that the Committee received a presentation from Dr. John Howard, the director of NIOSH, at the January 2003 meeting, where Dr. Howard issued his support for NACE. In addition, Dr. Waters provided an update on NORA during the January 2003 meeting, and provided another update today. Chair Kerk thanked NIOSH for their support of NACE efforts. Chair Kerk also discussed the planning of the Symposium, noting that the NACE Research Workgroup initiated discussions in May 2003. The full NACE Committee approved the plans for the Symposium during the September 2003 meeting. Shortly thereafter, abstracts were solicited through the Federal Register that focused on the state of new, data-driven, scientific research concerning the relationship between the workplace and neurovascular and musculoskeletal disorders, such as definitions and diagnoses, cause and work-relatedness, exposure/response relationships, intervention studies, and study design. Of the 39 abstracts that were submitted, Chair Kerk clarified that the 10 best-suited and most appropriate (for the previously stated criteria) were selected. He added that other excellent abstracts were received but not invited to participate, including abstracts that focused on literature reviews, other research, or position papers. Finally, Chair Kerk emphasized that the Symposium is but one piece of the efforts of the Research Workgroup, which is but one piece of the intended efforts of the full Committee. Chair Kerk then introduced the facilitator for the Symposium, Mr. Douglas R. Brookman, president of Public Solutions, Incorporated, from Baltimore, Maryland. Mr. Brookman briefly reviewed the agenda for the Symposium, noting that some changes have been made due to the weather delays. Mr. Brookman also noted that anyone from the public that wanted to make a comment would be able to do so at the end of the day. NOTE: Copies of Symposium panelists' presentations have been provided to Committee members. In addition, the transcript of the Symposium and NACE meeting can be viewed in OSHA's docket <http://dockets.osha.gov/>. Panel 1: Interventions Presentation by Dr. Arun Garg, "Long-Term Effectiveness of Zero-Lift Patient Transfer Program in Long-Term Care Facilities and Hospitals" Dr. Arun Garg, Ph.D., PE, CPE, of the University of Wisconsin–Milwaukee discussed the details of how to provide a nearly lift-free environment, or a "Zero-Lift" program to reduce injuries in nursing homes and hospitals. Dr. Garg offered a general overview, stating that while there are many causes for MSDs, the primary source of injury appears to be the manual lifting and transferring of patients, which accounts for more than 50 percent of all injuries of nursing personnel. Presentation by Dr. Nancy N. Menzel, Ph.D., RN, COHN-S, "Stress and Pain Management Intervention for Back Pain in Nursing Staff" Dr. Nancy Menzel of the University of Florida College of Nursing presented information on a feasibility study she conducted with Dr. Michael Robinson of the University of Florida College of Public Health and Health Professions. Dr. Menzel explained that direct care nursing personnel have one of the highest job-related injury rates of any occupation, adding that back injuries are higher in nursing aides than in registered nurses. Dr. Menzel also noted that there are many studies that show that the prevalence of back pain is much higher than the reported incidence, emphasizing the disconnect between nursing personnel who have back pain and nursing personnel who actually report a Workers' Compensation injury due to it. The etiology is thought to be multifactorial, and while physical risk factors are most likely the primary, necessary, and sufficient etiology for back injuries, there are other factors, probably mediating variables, that influence impairment, disability, and claiming of an injury. Presentation by Ms. Patricia Seeley, "Business Cases for Ergonomic Interventions: Measuring Their Short- and Long-Term Benefits" Ms. Seeley, M.S.I.E., MEPD, CPE, of WE Energies, presented information on the Electric Power Research Institute's study of overhead utility line workers. She explained that although many people know that ergonomics is cost effective, getting that message out once the science is completed poses a challenge, particularly when upper management says there is not enough money in the budget. Ms. Seeley explained that the study was completed in 2001 and involved utility line workers, supervisors, the corporate ergonomist, safety professionals, and an applications engineer. The study itself looked at line workers—people that repair overhead power lines—and ways to reduce injury on the job. Ms. Seeley emphasized the difficulty and danger involved in the job, noting that most people don't realize that the power is not shut off when the workers go up to make repairs. She continued that the procedures they perform put them at risk, not just for electrocution, but severe ergonomic injuries. Panel 1 Discussion Dr. Lida Orta-Anes asked Ms. Seeley to provide NACE with a copy of her report once it is published in March. Dr. Peter Amadio, an orthopedic surgeon from the Mayo Clinic, asked each panelist to distinguish between pain and injury. Dr. Menzel replied that looking at the model from NORA, a load leads to a tissue response, which leads to an outcome, and an eventual adaptation. If the load exceeds the capacity, you can get symptoms, such as pain. With adequate rest or treatment, then it might then lead to adaptation. She added that pain can lead to impairment, and then that impairment, which in medical/legal terms is considered a physical damage, can lead to disability, where you are unable to perform the normal work activities of your life. Dr. Menzel continued that in occupational health settings, terms might get vague because OSHA has reportable injuries that must meet certain criteria. It is her understanding that many people with pain are not reporting injuries, so they are not recorded on the OSHA injury log. She explained that the article she wrote indicates that there is widespread prevalence of pain among nursing personnel, but that compared to the prevalence of the pain, there are relatively low numbers of injuries as OSHA defines them. In response to Dr. Amadio's questions, Dr. Arun Garg responded that the terms are used very loosely in literature, noting that in the studies that he is conducting, an injury or disease means a specific, diagnosed illness or injury. If it does not meet the criteria, then it is listed as a non-specific pain. He continued that a non-specific pain could be defined based upon the intensity and duration of the pain, adding that the definitions for the upper extremities are much clearer than in the case of lower back pain, which is more difficult to diagnose. Ms. Patricia Seeley agreed with Dr. Garg, noting that they focused more on upper extremity versus lower back injuries, because they are so difficult to diagnose. She added that she did a lot of symptom surveys with a fairly large "N", which meant she had compelling data that could be included in her analysis. She explained that you do have to rely on a thorough analysis of injury and illness data in order to tie pain to a specific task, and therefore a specific intervention. Dr. Audrey Nelson commented that one of the threads that ran through all three presentations was the gross under-reporting of these injuries, regardless of whether they were incurred by nursing home staff, acute injury nursing staff, or line workers. She continued that the silence really undermines NACE's ability to build a convincing business case. She asked the panelists how they address this in the research that they conduct. Ms. Seeley responded that within her company they focus on educational efforts to make sure that everybody understands what they are really doing to themselves, the principles of ergonomics, and that they company needs all of their input to improve ergonomics and prevent injuries before they happen. She emphasized the difficulty of the task ahead, noting that she focuses on capturing, through interviews and health insurance data, the number of claims for their worker population that are work-related but did not go through medical Workers' Compensation. Dr. Garg responded that they are talking about two different things. One is the number and types of injuries reported by the workers to the companies, some of which may appear in the OSHA logs. The other is the number of workers suffering from particular injuries or illnesses independent of the reported injuries and illnesses, which can only be determined by giving interviews and physical exams. He noted that he is doing that in his prospective cohort studies, but the resources and time involved exceed what is typically done in the workplace. Mr. Willis Goldsmith asked whether any of the panelists were concerned that, by constantly describing the workplace or suggesting that the workplace is a cause of pain and injury, they are actually creating or expanding a class of people who may not really be sick or injured, but get involved in the Workers' Compensation and other systems anyway. Ms. Seeley replied that her company is not greatly concerned about that because they focus on the work and how to reduce their exposure through engineering controls. She explained that they leave it to the medical Workers' Compensation and outside health care practitioners to diagnose the individual, and emphasized they believe it is the company's job to diagnose and fix the work. Dr. Garg responded that they are not reminding workers that the workplace is unsafe or that the injury or illness is caused by the work. In addition, he noted, if the worker is reporting an injury or illness, it needs to be diagnosed. He added that he or she may or may not have non-specific pain. The intensity and duration of the pain will decide how serious the issue is, and even then it may or may not be work-related. Dr. Nelson commented that one of the issues that may come out of the under-reporting issue is reduced emphasis on using injury rates and incidence of injuries as the primary outcome measure, and greater emphasis on lost workdays and modified duty days as the outcome measure of choice. She added that too frequently in the literature there is an over-reliance on injury rates as being the primary way of evaluating workplace safety. Ms. Seeley added that lost workdays are still a lagging indicator as opposed to a leading indicator, and in ergonomics, the job is to prevent injuries before they happen. Dr. Menzel agreed, citing that with all of the duty programs that have been put in place, using the lost workday cases as an indication of an outcome indicator is less and less of interest. She recommended that OSHA develop a more sensitive and specific symptom screening tool that researchers could use to find out whether their interventions are having any effect, rather than waiting three years to count the plane crashes versus the near misses. Dr. Garg agreed with Dr. Nelson that ergonomic interventions are more effective in reducing lost workdays and restricted workdays, probably indicating the severity of injuries rather than the actual number of injuries. Mr. Jim Koskan commented that the number of musculoskeletal injuries tracked by BLS over the last five years has decreased for all industries. He continued that if they accept the notion that under-reporting may be a component of that, he would expect that there would be some data to demonstrate that musculoskeletal problems have increased in the general population, as evidenced through some sort of non-work-related injury tracking mechanism. He asked the panelists whether they were familiar with any such data. Dr. Garg responded that there are several prospective cohort studies, funded by NIOSH and CDC, that would be able to answer how many workers have specific and non-specific injuries and illnesses versus how many were reported, which will determine whether they are being under-reported or over-reported. Mr. Koskan commented that those studies may or may not answer the question since there is evidence that a certain percentage of the population has back pain independent of the kind of work they do. Dr. Morton Kasdan asked each panelist to answer whether they believe there is such a thing as an ergonomic screwdriver or an ergonomic chair or an ergonomic hammer. Ms. Seeley responded that she frequently sees vendors using the term "ergonomic" to market their product. She continued that for her company, they consider an ergonomic tool to be something they have had some input and prototyping, testing, and some effect on. She agreed she is worried about putting the word on interventions. Dr. Kasdan noted that Ms. Seeley used the word "ergonomic." Ms. Seeley responded that they use it in a strict sense when they have already documented that a tool will have that effect. Dr. Kasdan asked for clarification on the type of effect and asked Ms. Seeley to define ergonomics. Ms. Seeley commented that in her workplace it is the fit between the work and the worker and the science that directly affects the way a person goes about doing their work, as opposed to trying to fix the person. She continued that when her company uses the words "ergonomic tools," for instance, the battery-operated press and cutter, they call them ergonomic tools. She continued that they try to distinguish between the things that are just popular in the marketplace and the things that have demonstrated value. Ms. Lisa Brooks commented that they have to be very careful not to assume that, just because statistics show that 70 percent of the population has back pain, all instances are related to work. She noted there is a difference between under-reporting when referencing pain and when referencing injury. She continued that they have to really evaluate if, in fact, there is under-reporting, and whether it is under-reporting of pain or under-reporting of injury. Ms. Seeley responded that one of the factors that her study used was looking at the people who had injuries that resulted in substantial lost work time or surgery. Dr. Menzel agreed with Ms. Brooks that having a good case definition is one of the research needs because every article has a different definition of back injury or back pain. Ms. Brooks added there is also a need to understand whether or not there is a work relationship present. She continued that early detection is important, but there is a presumption that injuries are work-related. This presumption may cut off one avenue for helping the employee because the injury may have nothing to do with the workplace. Dr. Michael Feurstein commented that after being on the National Academy of Science committee, he noticed that there are very good case studies of the potential cost benefit of ergonomic interventions, but there are not many controlled case studies. He commented that the committee found that there were many case studies that show that ergonomic intervention could be very useful, but they are not randomized control trials, or even control trials. He continued that there should be integration with industry and science to examine ergonomic interventions and go beyond the case study so that science, in general, can accept these findings. He continued that some people have talked about under-reporting. He noted that he has been involved with several studies in the military where there is 24-hour medical coverage, and it does not really matter if it is sports-related or work-related. During the studies, they have looked at whether injuries are sports-related or work-related, and have found all sorts of problems with the workplace, all sorts of ergonomic problems. He added that the military is a good example of an environment, a workplace, an organization, where the 24-hour coverage, both in terms of indemnity and in terms of medical care. Dr. Menzel added that in England there is also so-called 24-hour coverage in that they have the National Health System and do not have a Workers' Compensation system, as we know it. She continued that, prior to the manual handling regulations that went into effect in 1992, they reported very high injury rates among nurses. Panel 1 Recommendations (Written Responses can be viewed in OSHA's docket <http://dockets.osha.gov/>.) Dr. Menzel commented that she framed her recommendations in terms of both the NORA priority research areas and the Institute of Medicine Recommendations in Musculoskeletal Disorders in the Workplace. As a follow-up to her handout, she believes that further research does need to be done on moderating psychosocial factors. She continued that they would need a very large sample size in conjunction with some sort of intervention that reduces physical stressors, and the research should be conducted at multiple health care sites, nursing homes, hospitals, and long-term care facilities. Dr. Menzel noted that one thing that poses a challenge is the lack of good outcome tools and lack of a good case definition of what a back injury is, in addition to a method of estimating exposure that is inexpensive and less time-consuming. She agreed with one recommendation that said, "to investigate the mechanisms through which psychosocial stressors contribute to or impact work-related MSDs," noting that pursuing the biological basis of pain may not lead us to further enlightenment because pain is a culturally- and gender-influenced variable. Dr. Menzel also urged more research on the mechanisms through which psychosocial stressors affect outcome, even in the presence of reduced physical loads. Ms. Seeley stated that she and Dr. Marklin prepared a written summary, included below: "Our experience in the EPRI overhead line workers study with Marquette University and WE Energies has led us to conclude that a business case is often necessary to cost-justify ergonomic interventions. While medical Workers' Compensation costs are traditionally used, even these costs often are not attributed to the budget of the operations personnel who manage tool, material, and personnel budgets. These managers regularly say that they cannot afford ergonomic improvements, not realizing that they can even less afford the costs of medical treatment, lost productivity, replacement workers, and other non-traditional cost types. Many ergonomic interventions are low-cost, however, the ones with the most significant occupational health benefit in the EPRI study required significant capital outlay. With solid ergonomic science driving the process, the most strenuous, physically challenging tasks were studied. The results were solutions, which dramatically reduced the magnitude of the risk factors and simultaneously improved productivity and customer service. The National Research Council recommended improved methods to measure the efficacy of ergonomic interventions. We respectfully recommend that OSHA fund research, which would develop business case models and track the short- and long-term benefits of ergonomic investments. Often, the science of ergonomics is the easiest part. It is making it happen in the workplace and selling the science to mid- and upper management, which is the challenge. We offer our experience as a success story for future investigation." Dr. Garg stated that he believes there is a need for intervention studies to show their impact in the workplace. He continued that he agrees it would be desirable to have controlled intervention studies, but does not know how feasible they are given the reluctance of some companies to participate, and the cost and the resources needed to conduct them. He added that intervention studies should show their effect on productivity, quality, injuries, and illnesses, as well as cost benefit. He added that if an intervention study in one industry can show that improvements are possible in these areas, it could probably attract similar industries to follow those footsteps. Mr. Brookman stated a change to the agenda, noting that the afternoon session would have only one panel, instead of two. Mr. George Henschel, Department of Labor's legal counsel for NACE, introduced the following items as exhibits: Exhibit 1 is Dr. Garg's presentation. Exhibit 2 is Dr. Menzel's presentation. Exhibit 2A is Dr. Menzel's article, entitled. "Back Pain Prevalence in Nursing Personnel."Exhibit 2A is Dr. Menzel's article, entitled. "Back Pain Prevalence in Nursing Personnel." Exhibit 2B is Dr. Menzel's chart of test instruments. Exhibit 2C is Dr. Menzel's written recommendations to NACE. Exhibit 3 is Ms. Seeley's presentation and attachments. Exhibit 3A is the summary of Ms. Seeley's presentation, which is a separate document. Chair Kerk noted that Dan McCausland had arrived. Panel 2: Etiology 1 Presentation by Dr. Peter Amadio, "The Evidence for Repetitive Microtrauma as a Factor in the Etiology of Carpal Tunnel Syndrome" Dr. Peter Amadio, M.D., presented information on a National Institutes of Health (NIH) funded research study on carpal tunnel syndrome that he has been conducting at the Orthopedic Department at the Mayo Clinic. He clarified that idiopathic carpal tunnel syndrome is the most common entrapment neuropathy, yet its etiology is poorly understood. He continued that the underlying mechanism is increased pressure in the carpal tunnel, either caused by reduction in the size of the space that builds up the pressure, or by an increase in the volume of the contents, noting that the latter is probably the more common. Dr. Amadio explained that many investigators believe that repetitive or forceful hand or wrist motion is a significant etiological factor. He explained that the relationship between these activities and the tenosynovial thickening, which is the pathological hallmark or the characteristic finding, is unknown. He continued that recent studies suggest that there may be some mechanical changes in the synovium in carpal tunnel syndrome patients, suggesting that there may be some mechanical changes that go along with these histological changes that may be important in the etiology. Presentation by Brian N. Craig, "A Prospective Field Study of the Relationship of Potential Personal, Non-Occupational, Occupational, and Psychosocial Risk Factors with Occupational Injury." Dr. Brian Craig, Ph.D., CPE, presented his study on potential risk factors, including personal, non-occupational, occupational, and psychosocial, for occupational injury. Summarizing the study, Dr. Craig explained that the study had 442 subjects with 15 job descriptions from three companies at nine locations around the United States. Dr. Craig provided an overview of the study, noting that it looked at potential risk factors including everything from age and gender to aerobic power and other fitness activities, general fitness measurements, food consumption, perceptions of personal health, smoking, some dynamic lifting, and other factors. He continued that the study also looked at occupational activities, such as frequency of the lift, average weight of the lift, work intensity and the maximum weight of lift, and then looked at a lot of different postures. Separate from the postures, they also measured the working oxygen consumption. In addition, they used two psychosocial surveys—a NIOSH General Stress Survey, and the Modified Work APGAR. Presentation by Thomas Bernard, "Job Risk Factors for Work-Related Musculoskeletal Symptoms and Injuries in Automotive Manufacturing" Dr. Thomas Bernard, Ph.D., presented information on a study examining job risk factors. He noted that Don Bloswick of the University of Utah was the principal investigator. He added that prior to starting the study, there was already a successful ergonomics program in place at UAW-Ford that was both reactive when there were worker complaints or a history of injuries on the job, and proactive in trying to get ahead of the curve and recognize problems before injuries occurred. In addition, UAW-Ford has a joint local ergonomics committee. He continued that when assessing a job, the study tried to use its own metric, so that the so-called "good" jobs and the so-called "bad" jobs really were good or bad jobs. He added that since it is not possible to do this you have to throw a threshold in or establish a line that defines the jobs. He emphasized that the study provided a low threshold so that the researcher could be fairly certain that if a subject said a job was good that it was good. They acknowledged that they would still capture a couple of the bad jobs, but also set a high threshold with much the opposite philosophy, trying to capture the bad jobs without many good. Presentation by Michael Feurstein, "Multidisciplinary Perspective on Work-Related Musculoskeletal Disorders" Dr. Michael Feurstein, Ph.D., of the Uniformed Services University of Health Sciences, presented information about the psychosocial aspects of ergonomics. He discussed a model, noted in the Institute of Medicine National Academy of Sciences booklet that presented the idea that individual factors occur before the onset of biomechanical loading, internal tolerances, and outcomes. He noted that it is important to remember there is a person that these external loads, various organizational factors, and the social context would actually impinge upon, resulting in biomechanical loads, internal tolerances, and outcomes. He emphasized the need to look at the relationship between the physical factors and psychosocial factors very carefully and also discussed the various components of that relationship, explaining that it is important to look at the odds ratio, the magnitude or the strength, the consistency, the number of studies that have reported this, the specificity, and an association that's limited to certain kinds of disorders. Panel 2 Discussion Mr. Jim Koskan stated that it seems clear that there is a multifaceted reason for MSDs. He continued that they certainly involve psychosocial issues, as well as some work-related risk factors that may have an impact on these injuries. He asked the panelists what impact an ergonomics initiative that is focused on on-the-job physical risk factors can have if it does not incorporate the other pieces. Dr. Michael Feurstein agreed, noting that in the field of ergonomics and MSDs, it is time to seriously consider studies that integrate these risk factors, and, more importantly, develop tools and techniques for intervention. He continued that there is a need to think carefully about effective interventions that look at both psychosocial and work-related factors. Dr. Feurstein noted that they would need to evaluate whether these interventions change behavior or impact the problem. He explained that NIOSH has been more focused on trying to get the organization to change in terms of psychosocial factors. He continued that it is time to try a combination of changing the physical ergonomics and changing some of the individual responses to the work people have, but not trying to change organizations totally, which was proven to be a very difficult thing. Dr. Tom Bernard reiterated what Dr. Feurstein stated, noting that there are some things that will improve with interventions and some that will not. He explained that they could probably intervene on the physical nature of a job. He continued that the organization factors are probably things that are intervenable, as are some personality traits. There are also elements, such as weight or smoking that are intevenable. However, he added there is one thing that will just never change, which is the workforce. Dr. Peter Amadio agreed that MSDs are a multi-factorial problem. He emphasized that it is easy to misinterpret these work-related disorders, because a disorder can be anything from a symptom to an amputation. He continued that it does not make sense—if you look at the broad spectrum from a backache to a vertebral compression fracture—that the same type of solution, or one family of solutions, is going to address all those things. He acknowledged that the Committee is focusing on ergonomics, which can address the physical or mechanical problems. Dr. Amadio continued that the work environment has to do with the context of the workplace, which has to do with the organization of the work and what the job requirements are, and so forth. These can be modified sometimes by changing job organization and sometimes by changing the physical requirements. He continued that there are also the attributes of the worker that are psychological as well as physical. In addition, there is the disease process that occurs within the worker, or the injury process, that is anatomic and very specific. He added that one of the things that has impressed him is that the epidemiologists see it one way, the ergonomists see it another way, and the clinicians see it another way, and the psychologists see it another way. Dr. Amadio explained that to get to his earlier recommendation, there is a strong need for much more multidisciplinary research, where the experts get together to try to address the issue rather than focusing simply on one component. Dr. Brian Craig stated that he could not agree more that ergonomics are a multifactorial situation. He explained there is a need to look at the entire system, recognizing that a human being is probably the most important component of the system. He explained that his work in industry has focused primarily on improving the job because that was the low-hanging fruit. The other components pose a challenge and are a lot more difficult to measure and control. He stated there are initiatives focusing on behavioral-based safety systems where the goal is to change attitudes over periods of years. He continued that during his time in industry, safe behaviors and safe attitudes were the things that people would do without even thinking twice. They actually would stop and do a job safety analysis before they did the job, and injury rates were practically zero. He emphasized that in his opinion, there are ways to improve job safety. Dr. Feurstein added that it is true that any good engineer would deal with the human element, but in reality, it does not happen. He emphasized that there is a need for some kind of multidisciplinary team to help understand these problems to a greater degree. Mr. Koskan asked whether given Dr. Feurstein's statement and a couple of others, the issues of back pain and MSDs and repetitive motion are more public health issues than occupational issues. Dr. Amadio stated that he thinks it is more of a public health issue than an occupational issue, because it relates to almost everything you do. He continued that trying to isolate the 40 hours a week you happen to work does not put it in the right context because there are many more factors involved. He added that you take things from home to work, and from work to home, both mentally as well as physically. He continued that a lot of what is discussed is a conflation of symptoms and feelings of being unwell, and then an actual physical malady that the physician can define. He explained that there are few things that only occur in the context of work, which makes it difficult to isolate. Dr. Feurstein added that the population's health is another related area, explaining that it is a way of making sure that you address risk factors that actually contribute to health problems in the population as a whole. He reiterated that there are all sorts of diseases beyond musculoskeletal that make it difficult to return to work or stay at work. He agreed that it is a public health problem, but it is translated into a work-related problem because of the laws of the country, which are not really changing. Panel 2 Recommendations Dr. Tom Bernard described his recommendations, starting with four premises: There are work-related MSDs. The panelists were asked to consider NIOSH's report, the NORA report, and the IOM report. He stated he thinks they are unassailable conclusions and recommendations. Musculoskeletal discomfort that persists from day to day or interferes with work or daily living should not be considered an acceptable outcome of work. He borrows that from the ACJHTLV statement on MSDs. OSHA has an important role. He continued that if you accept these premises, he thinks there are two things to consider—one is in the form of a question, and the other is in the form of a recommendation. The question is what model of exposure control do you wish to present to the public in the short- to medium-term as all of this research comes to a head. He added that the definitive models are out there on the horizon, but asked what will be done in the meantime. He explained four models that come to mind. Make it a local issue, and OSHA and the ergonomists will provide information and some assistance. He continued that in this model you are allowing Workers' Compensation costs, union contracts, lawsuits, psychosocial unrest, or similar vehicles to make the control worthwhile. He noted that this model is prevalent now and is a completely passive approach. Ionizing radiation. The way that ionizing radiation is controlled occupationally is through the Olera principles; low is reasonably achievable. There are occupational limits for ionizing radiation that are believed to be protective of most people that would represent health risks that would be equivalent in an otherwise safe industry. He continued that industry is pushing itself for individual dose and population dose levels well below those occupational limits. Most are now operating at 20 percent of the occupational exposure limits and continue to lower this level. This is a fully proactive approach. A normal industrial hygiene model of exposure assessment with control based on an exposure limit or an occupational exposure limit. This model could be considered an active approach that tries to prevent the illness or injury. A variation of the industrial hygiene model. Dr. Bernard noted that a reasonable example/analogy for MSDs is noise. For the OSHA PEL for noise, somewhere between 10 to 25 percent of the working population exposed at that PEL will suffer an occupational noise-induced hearing loss. He continued that the way to bring control back to that susceptible population is annual audiograms, and then targeting controls to those individuals. This is a blended approach. Dr. Bernard explained that the bottom line concern for him is that injury is becoming the de facto marker of problems, which does not fit the ideal public health model. He commented that public health applies to occupational health. He continued that, in terms of the recommendations, there are some things they could do now, noting that NIOSH, with NORA, is on target, and the IOM report is on target. In an effort to represent the user community, Dr. Bernard explained that there are many tools or ways of analyzing jobs out there, and it would be worthwhile to bring those publicly available tools together and put together an exposure assessment strategy that runs from a broad screening approach down through a detailed analysis of where each of these tools might be appropriate. Then, within each of those tools, the assessment should include a description of information such as the summary of the method and the type of exposure assessment. He explained that there are qualitative, semi-quantitative, and quantitative groups of muscles and joints that might be applicable; a summary of the strengths and weaknesses of that tool; validity with prediction validity; content validity; and face validity. Dr. Bernard emphasized that this kind of information would be ideal for OSHA to collect and make available. Dr. Brian Craig reiterated the discussion of multifactorial research and also noted that he is comfortable with the OSHA four-prong initiative. He continued that he respectfully recommends to the Committee that as much as possible there is a need to set aside differences and remember that it is trying to provide real benefit to the U.S. workforce, and real bottom line value to the companies they work for. He added that he struggles with the lack of integration of any sort of ergonomics initiative into a business system. He continued that, as much as possible, through industry/university collaboration, he would like to see ergonomics integrated into a management system because basic ergonomics principles address the vast majority of these company initiatives. Specifically, he would recommend the following: Design changes in tools, tasks, facility design, production, and maintenance. True ergonomic changes, which he considers to be operational changes. This is a little outside the scope of just dealing with MSDs. It is the true bottom line value. Increase support of OSHA's industry-specific guideline initiatives. He added that he could not ignore the influence that personal and non-occupational risk factors, or potential risk factors, may play in the development of work-related injuries or illnesses. They are hard to measure and even harder to control, but at the end of the day, if the Committee is trying to protect our workforce and companies are trying to reduce their Workers' Compensation and other insurance, they are real risk factors. Dr. Craig also explained the importance of the following issues when considering further research: Increasing support for long-term comprehensive research to prospectively explore relationships. Understanding different areas of the country, including different weather climates, management climates, labor climates, management styles, facility types, lifestyles, etc. He continued that OSHA and NIOSH provide a lot of support for training centers and employers, but he recommends also providing low-cost or no-cost training to company employees. Dr. Peter Amadio explained that he thinks there should be more multidisciplinary research. He continued that his other two specific focus areas are establishing a correlation between the problems that ergonomic solutions are designed to address, such as posture, force, repetition, and so forth, and specific pathologies in tendons, muscles, ligaments, bones, nerves, and so forth, rather than simply on symptoms that are specific, definable, anatomically identifiable, and with physiologically identifiable pathologies. He reiterated that this effort must be multidisciplinary because of the need for epidemiological science, medical science, biology, physiology, as well as engineering, and ergonomics. He said that his second recommendation is to emphasize the establishment of animal models in which the effects of these ergonomic stressors in living tissues can be studied in a controlled manner so that there is a clearer understanding of how those things—posture, force, repetition, and so forth—actually affect living tissues in a controlled system. He emphasized that it is very, very difficult to do this in humans because it's so difficult to get a well-controlled study in a workplace environment. Dr. Michael Feurstein reiterated that it is really important to get a series of well-controlled studies, and while it is difficult, it is important to remember that many, including the scientific community on the NAS-IOM, do not believe case studies. He explained that the committee is important because Congress requested that it take a look at ergonomics and MSDs, and on numerous occasions the group discussed the need for well-controlled studies on the cost-benefit of ergonomic interventions. His second recommendation was to look very seriously at the psychosocial variables and not just use the term psychosocial, but be very specific as to what it means. He added that people who are not satisfied with their job will have all sorts of problems, but it does not help in terms of trying to intervene or change the workplace, other than trying to make it a more satisfying place to work. Dr. Feurstein also explained that OSHA should begin looking at other illnesses in addition to MSDs, because OSHA is talking about the safety of the workforce and the workforce is getting older and sicker. He continued that OSHA should look at other chronic, life-threatening illnesses such as cancer, diabetes, and heart disease. He explained that people with these illnesses have the same kinds of problems as the MSD cases, at least in terms of returning to work and staying at work. He added that it is also important to try to understand biological mechanisms in order to establish some kind of true relationship between physical and psychosocial factors and how those relate to MSDs. He also emphasized developing truly effective interventions for these problems. He continued that they know those MSDs, whether they are upper extremity disorders or low-back problems, non-specific or specific low-back problems, consume a lot of health care costs, and they are not improving. He noted that there is enough data now, on a preliminary basis, in terms of epidemiological studies looking prospectively at risk factors and the occurrence or exacerbation of these disorders, so it's another important area that OSHA should seriously consider. Public Comment Dr. Janice Jaeger added a point of information. EPRI is the Electric Power Research Institute in Palo Alto, California. It is a private, nonprofit research institute. She is head of the program in Occupational Health and Safety Research. EPRI encourages private/public partnerships, and also has a consortium with other government agencies; not NIOSH and OSHA yet, but they certainly are interested in that. They also supported one of the studies presented by Marquette University and WE Energies. Closing Remarks Chair Kerk thanked the panelists and Mr. Brookman for participating in the Symposium. He also thanked everyone who helped to plan the Symposium, including OSHA. Mr. George Henschel, Department of Labor's legal counsel for NACE, introduced the following items as exhibits: Exhibit 4 is Dr. Amadio's presentation. Exhibit 5 is Dr. Craig's presentation. Exhibit 6 is Dr. Bernard's presentation. Exhibit 7 is Dr. Feurstein's presentation. Chair Kerk adjourned the meeting. January 28, 2004 The meeting of the National Advisory Committee on Ergonomics (NACE) continued on Wednesday, January 28, 2004. Chair Carter Kerk opened the meeting at 8:14 am. Approximately 30 members of the public were present during the course of the meeting. The following NACE members were present: Edward Bernacki, M.D., MPH Associate Professor and Director Occupational Medicine Johns Hopkins University School of Medicine Baltimore, MD   Lisa M. Brooks, CIE Health and Safety Program Manager International Paper Company Memphis, TN   Paul A. Fontana President/CEO Center for Work Rehabilitation, Inc., Fontana Center Lafayette, LA   Willis J. Goldsmith, Esq. Partner Jones Day Washington, DC   Morton L. Kasdan, M.D., FACS Clinical Professor of Surgery University of Louisville School of Medicine Louisville, KY   Carter J. Kerk, Ph.D., PE, CSP, CPE Associate Professor in Industrial Engineering South Dakota School of Mines & Technology Rapid City, SD   James Koskan, MS, CSP Corporate Director of Risk Control SUPERVALU, Inc. Minneapolis, MN   George P. LaPorte Ergonomics Manager NATLSCO Loss Control Services Division of Kemper Insurance Companies Lake Zurich, IL   Barbara McCabe Program Manager Operating Engineers National Hazmat Program Operating Engineers Beaver, WV   J. Dan McCausland Consultant Worker Safety and Human Resources Director American Meat Institute Madison, WI   Audrey Nelson, Ph.D., RN Center Director VHA Patient Safety Center of Inquiry Suncoast Development Research Evaluation-Research Center for Safe Patient Transitions Tampa, FL   Lida Orta-Anes, Ph.D. Associate Professor Graduate School of Public Health University of Puerto Rico San Juan, Puerto Rico   W. Corey Thompson (Arrived late) National Safety and Health Specialist American Postal Workers Union Washington, DC   Roxanne Rivera Consultant Albuquerque, NM   Richard Wyatt, Ph.D Associate Director Aon Ergonomic Services Huntsville, AL   The following speakers were present:     David Alexander, PE, CPE Auburn Engineers   John Holland, M.D., MPH Holland Associates, Inc.   Hal Corwin, M.D.   Opening Remarks Chair Kerk briefly reviewed the agenda and asked for approval of the minutes from the September 24, 2003 meeting, noting that a slight grammatical change had been made. Before approving the minutes, Chair Kerk called the roll. All members were present except Mr. Corey Thompson. The minutes were approved. Mr. George Henschel, Department of Labor's legal counsel for NACE, introduced the following items as exhibits: Exhibit 8 is the approved minutes from the September 24, 2003 NACE meeting. Exhibit 9 is a letter from the National Coalition on Ergonomics. Exhibit 10 is a letter from Mr. David Rempell, Professor, Department of Medicine, University of California-San Francisco. Mr. Henschel asked Chair Kerk if he wanted to include the presentations of the two presenters who were not able to attend the January 27 symposium. Chair Kerk agreed. Mr. Henschel continued: Exhibit 11 is Dr.Woldstad's presentation, entitled Theoretical Approach to Ergonomics Based on Biomechanics. Exhibit 12 is Dr. Wiker's presentation on Reduction of Musculoskeletal Discomfort and Mental Fatigue in Lumber Graders. Chair Kerk introduced David Alexander from Auburn Engineers in Auburn, Alabama. Presentation by Mr. David Alexander, "Making a Case for Ergonomics" Mr. David Alexander, PE, CPE, presented ways to talk with managers about the benefits of ergonomics in terms of injury/illness costs and take-away costs. Mr. Alexander continued that there are additional areas to consider that impact costs, such as performance losses due to injury and illness and design opportunities, which can save costs and enhance business performance. He explained that it is important to address what the works manager, plant manager, and operations VP are interested in accomplishing, emphasizing that it is possible to describe cost justifications in terms that management can understand. Mr. Alexander presented several different examples illustrating the effectiveness of ergonomics if you control at the risk factor level. He added that it is important to look at risk factors, pain and discomfort surveys, and medical treatment because they can provide guidance as to where to make improvements in an operation. Mr. Alexander also discussed ways to make improvements on existing operations, emphasizing the need to set an expectation that equipment will be designed properly from the beginning. He explained that at the start of the project, designing for ergonomics can cost as low as 0.5 percent of the total project cost, versus paying up to 20 percent of the total project cost when fixing the problem after there have been several injuries. He also discussed the meaning of ergonomic culture and its implications, noting that ergonomics is more than just safety and health, it is keeping experienced people in appropriate positions, working efficiently, and aiming for high quality. Discussion Ms. Roxanne Rivera asked Mr. Alexander what percentage of his clients are small businesses. Mr. Alexander responded that he tends to deal with larger businesses, noting that approximately 95 percent of his firm is spent with clients that have over 100 people. Ms. Rivera asked for clarification on Mr. Alexander's statement that one company saved 83 percent of Workers' Compensation costs, and whether that included premiums. Mr. Alexander responded that the company was self-insured, so the statement referred to the dollars that they were spending. He continued that if they were not self-insured, then they would have to wait a period of time for the premium to adjust. Mr. Willis Goldsmith asked for clarification about the lost time calculation, and specifically the components of the $49,500 in savings. Mr. Alexander responded that they wanted to develop an algorithm that could be used throughout the company, so he worked with production supervisors, a cost accountant, and human resources personnel to find specific opportunities to save money. One opportunity was that workers seemed to be moving faster in the morning. He and an industrial engineer checked records and found essentially that workers were getting tired in the afternoon and could not keep up with the line. He continued that the calculation was simply a matter of looking at the types of batches and doing the mathematical calculations on saving that amount of time on those runs at $330 per minute. Mr. Goldsmith asked how an analysis of fatigue relates to Mr. Alexander's statement stressing the importance of objectively auditing results to achieve ergonomics in engineering design. Mr. Alexander clarified that when discussing design, they are looking at the risk factors, and are asking questions about, for example, lifting excessive weights. He continued that if a job requires imbedded risk factors, then they would say the design engineer has not done an adequate job. He continued that they certainly encourage a company to say, "unsafe from an ergonomics standpoint is exactly the same as unsafe from a lock-out/tag-out standpoint, and they are simply not going to accept that as a quality design project." He agreed that the design engineer would not know that they are creating fatigue, but would know that they are creating risk factors—a much more sensitive measure—and would be asked to control at that level. Mr. Dan McCausland commented that in that category, lost time was about $50,000 of the $68,000 in savings. He asked whether there was any differentiation between the savings that were attributable to ergonomics and the savings that were simply attributable to the practice of sound industrial engineering. Mr. Alexander responded that they do not differentiate between the two. Mr. McCausland noted a typo in the Basic Anthropometry chart, stating that the stature on the male side appeared to be off. Mr. Alexander agreed that there may have been a typo in the slide. Mr. Jim Koskan referred to the case study that identified their OSHA ratings at 70 plus, commenting that is an incredibly high number. He asked whether that was a point in time number or a sustained, multi-year rate that the firm was incurring. Mr. Alexander answered that the company reported it that way, and that it was ZF industry data from the year before the ergonomic intervention and the year after ergonomic intervention. Mr. Koskan asked whether Mr. Alexander knew if the company had incurred that rate for multiple years. Mr. Alexander explained that it was a fairly new operation that had only been in business for three or four years. He added that the rate had not been 70 for the whole time, but the company was concerned with the upwards trend. Dr. Lida Orta-Anes referred to the slide titled, "The Cost of Using Ergonomics in Design," and Mr. Alexander's statement that ergonomics is never free, even if designed for early in the process. She asked for clarification as to whether the costs he was referring to were training costs for industrial engineers and whether those costs were a one-shot deal. Mr. Alexander said they were. Dr. Orta Anes commented that once you train the engineers, you expect them to continue applying the skills, so the costs at this stage may involve the first intervention, but the skills stay with whatever organization requires the services. Mr. Alexander reinforced her comment stating that engineers have been trained, they don't need to be trained again unless there's been some turnover. Dr. Orta-Anes asked whether they should expect a different template for bigger companies versus the smaller ones, in terms of how the different costs are identified. Mr. Alexander answered that there would be a slightly different template, noting that smaller companies often have a shorter and faster time of making improvements, whereas in a larger company, there are more steps to get things done. Mr. Alexander continued that the costs of making corrections are much lower in smaller organizations because it is a different type of cost structure. Dr. Morton Kasdan asked if the interventions included personal attributes, such as fitness, alcoholism, or smoking. Mr. Alexander answered that they rarely looked at personal activities and instead looked at trying to design from a systematic standpoint toward a certain level. Dr. Richard Wyatt asked for comments on ways to sell ergonomics to businesses smaller than 50 employees. Mr. Alexander responded that with small businesses the key is to work within trade associations and to network via trade magazines. Chair Kerk thanked Mr. Alexander and added that the first two speakers of the day, including Mr. Alexander, were talking about the economics of ergonomics because of a recommendation at the September 2003 NACE meeting by the Outreach and Assistance Workgroup. Presentation by Dr. John Holland, "A Microeconomic Model For Estimating Cost of Care for Acute Low Back Problems: A Useful Paradigm for Estimating Costs and Benefits of Workplace Ergonomic Interventions" Dr. John Holland, M.D., MPH, presented information about a health economics model that he was involved with in the mid-1990s and how it can be applied to ergonomics. He continued that it was an evidence-based model of care for acute low back problems, which is the most common and most expensive occupational condition dealt with in Workers' Compensation. Dr. Holland explained the conceptual issues of looking at outcomes of any occupational health and safety intervention, whether it is medical management, ergonomics, or benefit design, in terms of how Workers' Compensation insurance and operations are structured. He then discussed the study itself, which was a microeconomic model of the cost of projected savings following an evidence-based low back guideline. He added that it was the HCPR guideline versus actual claims data from usual care. He also reviewed how the model relates to ergonomics and evaluating ergonomic interventions. Dr. Holland emphasized it has become increasingly important in occupational medicine and occupational health and safety to find a scientific, ethical, and economic justification for each action. He provided a brief overview of medicine, clinical outcomes, and employer-focused arguments. He continued that employers involved with workplace occupational health and safety interventions find some of the following issues important: direct health care costs, indirect productivity costs, property damage from accidents, and third-party liability from accidents. He added that it is crucial to focus on outcomes in which the employer is interested. Dr. Holland offered examples on ways to pitch intervention programs to management, such as focusing on actual data that is relevant to the employer and scientific evidence to guide programs and policies. He continued that you want to design occupational health and safety and benefits programs based on evidence of effectiveness. He also reviewed the specifics of the study, suggesting how the microeconomic model might be useful in looking at general interventions in the workplace, or ergonomics specifically. He stated that macroeconomic models benchmark against historical experience, internal comparisons, national data, or the other employers. He continued that the microeconomic model focused on a specific condition to estimate the likelihood of events; established unit prices for interventions; aggregate the transactions; and estimate total cost. Dr. Holland continued that the advantage of using a model is that a large employer or large insurer can plug in different claims data and prices and change the assumptions as needed. He reiterated the need for flexibility because groups will vary in terms of demographics, frequency of clinical findings, care patterns, and cost. He continued that the model is useful for researchers because it can be used for evaluating cost-effectiveness of best practices and evidence-based care, and allows the study of the individual factors that drive the process. He emphasized the usefulness of the microeconomic model for evaluating the impact of workplace ergonomic interventions. Discussion Mr. Willis Goldsmith referred to Dr. Holland's statement that the "economic impact of ergonomics can be modeled," acknowledging that for a particular business or work site a model might show the value of a particular ergonomic intervention. He asked how it could be modeled on a broader basis considering the number of variables, lack of real data, and lack of data-driven evidence. Dr. Holland agreed that the value of economic models is that they are built on the assumption of data and science, and explicitly state those assumptions, encouraging people to challenge them. Dr. Holland acknowledged that modeling could be condition-specific or industry-specific, noting that it is more difficult to generalize across industries or across multiple employers. He emphasized that it is important to consider the intermediate factors to find out, for example, if total Workers' Compensation costs changed, how much was due to changes in care patterns versus fewer injuries. Chair Kerk commented that Mr. Corey Thompson arrived. Presentation by Dr. Hal Corwin, "The Diagnosis of Neuropathy in the Workplace" Dr. Hal Corwin, M.D., presented information on the diagnosis of neuropathy in the workplace, both in terms of how to make the diagnosis and the implications of a mis-diagnosis. He stated that the main reasons for inaccurate diagnosis are inaccurate observations, poor examination, and false conclusions. Dr. Corwin offered an overview of the nervous system and how it works, including information on neurological diseases and disorders. He also discussed carpal tunnel syndrome, the most common neurological problem. He explained that there are several illnesses that may cause identical symptoms to those of carpal tunnel syndrome, and provided a series of specific examples. He added that too often, industrial patients arrive at a physician's office, state they are numb or tingly, and that is the end of the examination, and emphasized that examining workers with numbness and tingling in the hand should be no different than examining anybody else. Dr. Corwin provided detailed information about electrodiagnostic testing (EMG). He added that a variety of medical professionals perform the test, which means that the quality of the reports is extremely variable depending upon the person doing the test, their background, and their training. Dr. Corwin explained the need for consistency and guidelines in terms of how to perform the test, read the results, and provide accurate diagnoses in borderline cases. He added that the American Academy of Neurology and the Association for Physical Medicine Doctors have written and approved a practice parameter for how to conduct the electrodiagnostic study and properly diagnose carpal tunnel syndrome. He noted that the Organization of Electrodiagnostic Physicians has also signed on, and explained the importance of having a practice parameter for how to diagnose carpal tunnel syndrome, ulnar nerve injury, and many other common problems. He also explained some of the common errors that affect the test, such as hand temperature and incorrect distance. Discussion Mr. Jim Koskan asked what percentage of cases resulted in unnecessary surgery for carpal tunnel. Dr. Corwin responded that he was not aware of any such studies, noting that in his experience he sees at least one illness per week out of 10 patients that is not carpel tunnel, but shares the symptoms. He added that if you took the whole universe of patients who have slow nerve tests and are diagnosed with carpal tunnel syndrome, the majority would be the patients that are in the mild group, and if their test was redone, they may fall below the line. Dr. Corwin continued that many doctors will not operate on those patients because they are mild, but it is up to the physician's practice technique. He acknowledged that some physicians send the patient into surgery as soon as they see the test results, regardless of whether the numbers are mild, moderate, or severe. Dr. Lida Orta-Anes asked for clarification about his statement that the injuries were not work-related, and for an explanation of his use of the term work-relatedness. Dr. Corwin responded that there is no physical difference between neuropathy on an exam, explaining that there is no electrical difference on a test that tells you, "this carpal tunnel problem is due to repetitive or work injury." He continued that if a person is an assembly-line worker and they come in with a test that indicates carpal tunnel, some physicians unfortunately stop looking for more information. He explained that a lot of mistakes are made because a physician has bought into the idea that the disease process has to be work-related. Dr. Morton Kasdan asked Dr. Corwin to discuss the behavior he sees in people when they are mislabeled and they are given the nocebo effect. Dr. Corwin explained that there is a reverse of the placebo effect, the nocebo effect, meaning that when a patient is labeled by a well-meaning health care worker or physician as having a specific disease process that they do not have, they tend to continue to develop more and more symptoms that they believe is part of the disease. He added that once the patient is labeled, depending upon their cultural and medical background, they may go in the wrong direction with the disease process. Dr. Richard Wyatt asked how something as simple as exercise might affect mild cases of this type of injury. Dr. Corwin responded that the effect of exercise depends upon where the problem is. Ms. Lisa Brooks asked about the success rates of surgery if it includes those who are incorrectly diagnosed and those who are correctly diagnosed. Dr.Corwin responded that if you operate on patients that have a slow nerve on the test, but do not have carpal tunnel syndrome, they would probably do worse because they had no problems to start with. He asked Dr. Kasdan if he had information on the improvement rates of people that truly had carpel tunnel syndrome. Dr. Kasdan responded that the success rate with accurately diagnosed carpal tunnel syndrome is probably in the realm of 90 percent. He continued that for some of the patients who have a normal nerve study or a bad nerve study and had the operation, there is a placebo effect. Dr. Corwin agreed, noting that studies have been done in which a patient's diagnosis on the nerve test is compared to the diagnosis that the doctor thought they had going into the nerve test, and the nerve test gives a different diagnosis about 37 to 39 percent of the time. This difference would ultimately change the treatment of the patient about 40 to 45 percent of the time. Dr. Corwin reiterated the importance of the guidelines on how industry should address the testing written by the American Association of Electrodiagnostic Medicine. Ms. Barbara McCabe asked what combination of exam, symptoms, correct diagnostics, and looking at a person's occupation would be required for Dr. Corwin to feel comfortable saying that it is workplace-related injury. Dr. Corwin responded that you have to look at all the different factors, including examining the patient, looking at their weight, and checking for thyroid problems and diabetes. He added that the question she is asked, such as how many repetitions, how much force, etc., is something for the Committee to determine. Dr. Ed Bernacki asked for the indications for release of a patient. Dr. Corwin replied that his surgical indications would be based upon the patient, noting there are some patients who have a mild case electrically, but complain of severe numbness, and so those patients will sometimes be ok for surgery. He continued that from a strictly electrical and examination standpoint, the surgical indications involve the depth of the injury to the axon and the center of the nerve. Chair Kerk indicated that the demonstration of the EMG would begin, noting that it would be recorded and placed on the record. The Committee and public was invited to come forward for a better look at the demonstration. Dr. Corwin performed the test on Dr. Morton Kasdan, reiterated how to perform the test correctly, and illustrated the steps that can impact the results, such as taking the temperature of the hand and measuring the distance of the nerves correctly. (The Video of Dr. Corwin's demonstration is included in OSHA's docket <http://dockets.osha.gov/>.) Chair Kerk adjourned the public portion of the meeting and announced minor adjustments to the agenda, explaining that the Workgroups would meet next and the full meeting would begin again later in the day. Presentation from Guidelines Workgroup Mr. J. Dan McCausland was recognized as the Guidelines Workgroup representative. As a follow-up to the September 23, 2003, meeting, the Guidelines Workgroup looked at the Bureau of Labor Statistics (BLS) five-year trend data provided by OSHA. The goal of this meeting was to compare the trend data to the industry selections that were made based on objective criteria during the September 2003, meeting. The Workgroup also needed to consider other potential guidelines, applications, and structures. The Workgroup developed two criteria for selecting their recommendations—"Primary" and "Other." "Primary" criteria include industries with the largest number of people affected by MSDs and industries with the highest incidence rates of MSDs. "Other" criteria include trends; alliances; transferability; severity of injuries/time away from work; finding elements to the industry that make covering only the problematic area, as opposed to the entire industry, worthwhile; and absence of available guidelines. The Workgroup applied the newly established criteria to the industries chosen based on the objective criteria. The new criteria did not affect the original list of 19 industries that were chosen during the September 2003 meeting. On the basis of the data available, the Guidelines Workgroup suggested that the Committee recommend that OSHA consider developing guidelines for the 16 industries or industry groups chosen based on the Guidelines Workgroup criteria, excluding the three industries for which guidelines are already complete or are in development. Secondly, the Guidelines Workgroup recommended that OSHA consider the "Other" criteria when making specific industry selections, instead of making choices based on the most number of MSD cases to the least number. The 16 industries on the list are the highest in terms of MSD incidence rate and size of industry. Mr. McCausland discussed the Workgroup's tasks for the next meeting, which are to evaluate task and occupational data and further explore the development of some general ergonomics tools. Mr. McCausland concluded by saying that the NACE Committee should give the list of 16 industries to OSHA and suggest that the next guidelines be for an industry on that list. Discussion Dr. Richard Wyatt asked Mr. McCausland to go through the complete list of industries to make sure the construction industry was included. Mr. McCausland said that Jim Maddux of OSHA confirmed for the Guidelines Workgroup that construction was in the list of 950 industries. Ms. Lisa Brooks asked for clarification that industries selected by the Guidelines Workgroup were chosen based not on the number of people affected by MSDs and the incident rates, but on the industry with the largest number of people and the highest incident rate. Mr. McCausland confirmed Ms. Brooks' statement, saying that industries had to meet both criteria to make the list. Dr. Lida Orta Anes asked for clarification on the data collection definition and whether it was used for the criteria. Mr. McCausland explained that the definition was given to the Workgroup along with the data taken from BLS. Without any further questions, Chair Carter Kerk initiated discussion on whether the Committee was ready to draw a consensus on the recommended industries. Mr. McCausland spoke on behalf of the Workgroup saying that they made their recommendations based on available information and they like the fact that they were able to make the recommendation on the basis of some objective data. He asked that if any Committee member does not like this method, they can provide a suggestion of where else to look. Mr. Jim Koskan emphasized that the reason the list was not ranked was because the guidelines are voluntary, so there has to be some sort of arrangement with an industry that OSHA wants to work with, or a cooperative effort. Mr. Koskan said the Workgroup felt that a larger list with a variety of industries for OSHA to work with to generate guidelines or alliances would make sense, as opposed to limiting it to a very short list. He said that the list they presented provides the opportunity for finding some partners. Dr. Audrey Nelson stated that some of the industries identified by the Workgroup were very large industries with a diverse group of tasks. Dr. Nelson asked how the guidelines be developed for these broad groups could be detailed enough to pertain to more specific tasks. Mr. McCausland explained that the reason for developing the list of "Other" criteria was because the Workgroup is aware that some of the industries are very large. Mr. McCausland said that if there were one or more associations willing to represent hospitals, as the guideline development moved forward, the groups would be able to focus on a smaller number of predominant causes of most of the incidents, as was done with nursing homes. Dr. Nelson asked if the list of 16 would increase if a number of targeted areas came out of an industry. Mr. McCausland responded that every set of guidelines for every industry is the same, but no two are identical, adding that each set of guidelines will develop over time. At this time, there is no way for the Workgroup to target specific areas within the industries on the list. Dr. Nelson recommended that hospitals be broken out by patient handling versus materials handling, because the tasks are very different. Mr. Paul Fontana said the Workgroup believes it would be up to those who are developing guidelines to separate tasks within the industry. Mr. Fontana added that guidelines would cover the gamut of the tasks an industry performs. If the industry wanted to focus on more task-specific guidelines, it would be up to the industry to create them. Dr. Nelson suggested that the Committee get guidance from OSHA on the level of detail they are looking for in the guidelines because the 16 industries that have been identified by the Guidelines Workgroup are too large and broad. Chair Kerk asked for consensus. Dr. Nelson asked if the Committee could first get OSHA's comment on what level of detail they would like for the guidelines. Mr. McCausland said that the Workgroup is going on the original instructions of Secretary Henshaw, which did not specify what level of detail was needed beyond industry groups. Mr. McCausland said it will be up to OSHA to work with partners to develop these guidelines, adding that Dr. Nelson's concern was addressed by the Workgroup when they developed the list of "Other" criteria. Determining whether to focus on specific industry tasks will have to happen on a case-by-case basis as OSHA moves forward with developing the guidelines. Based on the criteria, the list is correct, but the next step will be to find what it is about each industry that made them qualify for the list.  Chair Kerk said he was comfortable with Mr. McCausland's earlier comment that there will be guidelines for each industry, and specific chapters will cover specific tasks within that industry. Mr. McCausland still agreed with that comment as well. Chair Kerk asked if it was necessary to wait for an explanation from Mike Seymour or Jim Maddux of OSHA. Dr. Nelson said that since Mr. Seymour and Mr. Maddux participated in the Workgroup meeting, input would have been given if the industry level was not correct. Mr. McCausland said Mr. Seymour and Mr. Maddux agreed with the way the Guidelines Workgroup used the data. Dr. Nelson approved. The Committee reached consensus on the recommendation. Mr. McCausland added that the recommendation is in two parts: 1) that the chosen industries be from the Guidelines Workgroup list; and 2) that OSHA use the "Other" criteria when considering guidelines. Presentation from Outreach and Assistance Workgroup Dr. Audrey Nelson led the presentation for the Outreach and Assistance Workgroup. Dr. Nelson gave an overview of the Outreach and Assistance Workgroup foci and gave a progress report and recommendations for each focus area. Articulate and sell the business and social value of ergonomics. This strategy involves building a business case for ergonomics and applying social marketing techniques. The recommendation at the September 2003 meeting to have a speaker was followed up by asking David Alexander, an expert on building a business case for ergonomics, to participate in the January 2004 Committee meeting. The Workgroup made three new recommendations based on the business and social value of ergonomics. The first recommendation was to develop a cost calculator that is specific to ergonomics. Secondly, the Workgroup recommended that OSHA develop a resource guide that outlines a process for identifying and quantifying costs and benefits, both short and long term, specific to ergonomics. The third recommendation was that the Committee endorse plans to contact the American Society of Safety Engineers (ASSE), ask them for an abstract of their work to date, and invite them to present at the next NACE meeting or subcommittee meeting. The Outreach and Assistance Workgroup completed a literature review on social marketing and will select a speaker for the May 2004 meeting. Enhance OSHA's Web site. OSHA has implemented most of the Web site recommendations given by the Workgroup at the September 2003 Committee meeting. OSHA is collaborating with the director of information technology for those recommendations that require additional resources for implementation. Develop dissemination strategies. The Workgroup has some recommendations to make on the current template and success story examples and has developed an enhanced template for presenting and standardizing this information. The Workgroup is also in the process of developing a resource guide, which will define what should go in each element of the template. The Workgroup proposed four recommendations. The first was that Paula White from OSHA speak and present at OSHA's May 2004 meeting. The second recommendation is for OSHA to contact its cooperative program participants to solicit success stories and have them posted on their own Web site and linked to from OSHA's Web site. The third recommendation is for OSHA to solicit success stories for its Web site from speakers who presented at the Research Conference and evaluated interventions. Finally, the Workgroup recommended that OSHA provide a speaker at the May 2004 meeting to discuss the Susan Harwood Grant Program, which is related to several initiatives the Outreach and Assistance Workgroup is focusing on. Implement strategies to more effectively achieve implementation of the guidelines. The Workgroup's strategy is to establish an Early Adopters Program, which was discussed at the September 2003 meeting. One goal of the program is to provide an incentive for industries to adopt guidelines as they first come out. A second goal is to standardize how industries evaluate the guideline implementation and provide this information to OSHA as a way of encouraging others to implement guidelines in the future. The concept, approved by NACE at the last meeting, is still developing. The Workgroup has no actions in this area at this time. Discussion Mr. Fontana suggested that information not just be submitted to Web sites, but also to professional journals as a way to reach small business owners. Dr. Nelson acknowledged that the dissemination plan is still in process and Mr. Fontana's point will continue to be considered. Mr. Willis Goldsmith asked for clarification on the relationship between the business case recommendation and the expertise of those submitting success stories. The Workgroup had not discussed the expertise level. Mr. Goldsmith suggested that the Committee avoid coming up with anecdotal approaches to developing a business case. Mr. Goldsmith said it was important to know who would be involved in developing the cost calculator and how to prove that the resource guide would be a reliable tool.  Dr. Nelson offered to add the level of expertise to the recommendation. Ms. Brooks said that the group's reasoning behind having the resource guide was to give reliability to the cost calculator. Ms. Brooks added that a concern of the Workgroup was that the cost calculator be user-friendly for people other than professional accountants and ergonomists. Mr. Goldsmith added that a sufficient degree of rigor should be involved in developing the resource guide and it should be completed by people with appropriate experience or expertise. Dr. Nelson added that assumptions and rationale for decisions should be provided in the resource guide recommendation. Mr. Koskan suggested that it might be clearer to combine the cost calculator and resource guide into one recommendation instead of two. Dr. Nelson implemented the change. Dr. Nelson clarified for Mr. Koskan that when the Workgroup refers to injury reduction benefits from ergonomic initiatives, they are considering the big picture, which includes productivity and quality. Mr. McCausland asked if creating the resource guide was an appropriate activity for OSHA to undertake or if it was more appropriate for NIOSH to do, since it seems related to NIOSH's Elements of Ergonomics Programs. Mr. McCausland added that since NIOSH is the research arm for occupational safety and health, the tool might have more scientific validity if it was created by NIOSH. Since the Committee can not make recommendations to organizations outside OSHA, Dr. Nelson asked whether it was appropriate to make the recommendation to OSHA and let them decide if they had the internal resources to create the resource guide or they could choose to send it out. Ms. Susan Sherman confirmed that the Committee could only make recommendations to OSHA. Ms. Brooks referred to Mr. Goldsmith's comment on rigor and expertise in developing the resource guide, saying it would be incumbent upon OSHA to ensure that a group with the appropriate training, knowledge, and expertise develops the tool. Dr. Nelson added to the presentation that OSHA should consider using NIOSH to help develop the guide. Mr. Goldsmith expressed concern that there is not enough expertise to standardize how costs and benefits are calculated within the context of ergonomics. Mr. Goldsmith and Dr. Nelson discussed and agreed on providing general recommendations for the resource guide and adding details later. Chair Kerk initiated discussion on whether the Committee was ready to draw a consensus on the resource guide recommendation. Mr. Goldsmith said that he thought a general recommendation was going to be made and the details would be discussed later. Dr. Nelson suggested including the resource guide recommendation and having the cost calculator information included as supplemental information for OSHA. Ms. Brooks added that the recommendation needed to include both the resource guide and the cost calculator, which would ensure the resource guide was used consistently. Mr. Goldsmith said that discussing the cost calculator was premature, and suggested that OSHA focus on developing a resource guide that outlines a process and allow the Department of Labor to decide whether they should use a cost calculator or something else, since it is not proven whether a cost calculator will work. Chair Kerk presented two thoughts. First, the Committee could try to seek consensus with adjustments made so far. Second, it could agree on a simpler concept and discuss details later, possibly suggesting a cost calculator among other things. Mr. Goldsmith agreed as long as the recommendation would include room for other options. Mr. Goldsmith expressed concern that the Committee did not know enough about creating or using a cost calculator to make a recommendation to OSHA. Dr. Orta-Anes asked whether a consensus on a recommendation means that the Committee can no longer make changes to the recommendation. Assuming that the recommendations can be modified, Dr. Orta-Anes suggested that the recommendation be revisited later. Mr. McCausland suggested that OSHA consider the resource guide, which may include many tools. Mr. McCausland expressed concern with having a cost calculator, adding the people may have issues with it. Dr. Nelson got approval from the Workgroup to give a general recommendation on creating a resource guide. The information on suggested tools that will be included in the guide, such as the cost calculator, will still be included as supplemental material to the recommendation. Mr. Goldsmith agreed with Dr. Orta-Anes that the Committee should keep in mind the relationship between what the Outreach and Assistance Workgroup is doing and what the Research Workgroup is doing in connection with their work. Mr. McCausland asked if the Committee would still be satisfied if the words "may include a cost calculator" were removed from the recommendation. Ms. Brooks said it would be fine to include that information in the sub-bullet. Ms. Brooks reiterated that the most important issue was that small business owners could implement the resource guide. Dr. Nelson read the revised recommendation, "OSHA should develop a resource guide that outlines a process for identifying and quantifying costs and benefits, both short and long term, related to ergonomics." Dr. Nelson confirmed that mention of the cost calculator and supplemental materials for the guide would be in the recommendation's background materials. Chair Kerk asked for and received consensus from the group on the resource guide recommendation. He acknowledged that if the Workgroup wants to modify the recommendation and provide more detail, the Committee would be willing to hear them. Dr. Nelson introduced the second recommendation: "NACE will endorse plans for the Outreach and Assistance Subgroup of NACE to contact the American Society of Safety Engineers (ASSE), who have established a Workgroup on building a business case for ergonomics. We will ask them for an abstract of their work, and NACE may request that OSHA invite them to present at the next NACE meeting or the subcommittee meeting."  Chair Kerk questioned if this needed to be a recommendation since it would be a routine request for a speaker. Chair Kerk suggested getting an abstract from the potential speakers to be reviewed by the Workgroup, then the Workgroup can present their chosen abstracts to Chair Kerk, who would then present the chosen abstracts to OSHA as a potential speaker either to the full Committee or specifically the Outreach and Assistance Workgroup. Ms. Brooks said that the Workgroup was under the impression that a recommendation had to be approved by the Committee in order to have a speaker, but added that if the recommendation is not necessary, it does not have to be included. Dr. Nelson added that the Workgroup wanted coverage for contacting an outside organization on behalf of NACE. Ms. Brooks asked Mr. George Henschel and Ms. Sherman to clarify if the Committee needed an approved recommendation to contact an outside group and invite them to present at the next NACE Meeting. Ms. Sherman said that OSHA would have the final decision as to whether someone should be invited to speak. She said she thought no formal recommendation had to be made, and that in the past, speakers have been invited without formal Committee recommendations. Mr. McCausland added that OSHA has an alliance with ASSE, and he felt OSHA would be willing to contact them. Chair Kerk asked for and received a consensus on the recommendation. Dr. Nelson introduced the third recommendation, "NACE will endorse OSHA's collaboration with the Applied Ergonomics Group to develop a process for solicitation of success stories." Dr. Nelson added that Paula White of OSHA may be the person attending this event that could further the discussion. Dr. Orta-Anes asked for clarification on who the Applied Ergonomics Group is. Dr. Nelson responded with a background, saying that the biggest problem is that there are not many OSHA success stories that have been presented and are available. The mission of the Applied Ergonomics Group is to take success stories or front-line innovations and do a series of paper and poster presentations. Since the Applied Ergonomics Group is doing so much in this area, the Workgroup would like to look at their efforts and see how they could link up with them as a way of soliciting more success stories for OSHA to tap into. Dr. Wyatt added that the attendees of the Applied Ergonomics Conference are the actual users of ergonomics, so there are before and after situations. The idea is to add more practical information to the success stories for people to learn from. Dr. Orta-Anes realized that the Applied Ergonomics Group and the Applied Ergonomics Conference were the same. Mr. McCausland suggested that the Committee should not target the Applied Ergonomics Conference because that could be considered a show of preference. He said the Institute of Industrial Engineers and the Human Factors in Ergonomics Society could also be targeted. As long as the group is a professional group, non-profit, engineering association, etc., success stories will be welcome. Dr. Nelson asked if Mr. McCausland was recommending professional organizations replace the Applied Ergonomics Conference in the presentation. Chair Kerk asked for approval from Ms. Sherman. Ms. Sherman pointed out the reason for mentioning the Applied Ergonomics Conference is because it is coming up and NACE could consider recommending to OSHA that the first action could be taken at this upcoming conference. Mr. McCausland said action could still be taken without specifically mentioning the group. Mr. Goldsmith concurred with Mr. McCausland, adding that the other groups are doing the same thing as the Applied Ergonomics Group. Mr. Goldsmith asked why the Committee needed to get involved. Ms. Brooks said that one of the Workgroup's future actions is to solicit more success stories, and the recommendation was a way to solicit stories from the conference designed around applied ergonomics and interventions. The Workgroup did not intend to exclude other groups; in fact, the Workgroup had discussed going to other group events. They focused on the Applied Ergonomics Conference because it was planned and the date was approaching. Ms. Brooks mentioned that a recommendation may not be necessary. Mr. Goldsmith asked if Paula White could bring her materials back from the conference. Chair Kerk asked if the Committee would make an endorsement for the conference, rather than a recommendation, adding that Paula White will be attending the conference regardless of what the Committee decides. Ms. Brooks clarified that the case studies from the conference would be given to OSHA, but they would not be allowed on the OSHA Web site. The challenge is to get individuals and companies willing to submit their interventions and their success stories, and give OSHA permission to put them on their Web site in that format. Ms. Brooks added that the issue is not the availability of success stories, but getting people to offer their solutions in a way that can be shared on OSHA's Web site. Chair Kerk asked for and received consensus on the recommendation, which Dr. Nelson read again – "NACE will endorse OSHA collaboration with professional organizations to develop a process for soliciting success stories." Dr. Nelson introduced the next recommendation, which was that OSHA contact their cooperative program participants to solicit success stories that they post on their own Web site using the OSHA template, and ultimately these could be linked to the OSHA Web site. Mr. McCausland and Dr. Nelson discussed whether or not OSHA already does this. Dr. Nelson said the information was solicited in the past but they were going to ask for it again, and the new element would be posting it to the Web sites and creating links. Mr. McCausland brought up rules about linking. Dr. Nelson confirmed that LeeAnne Jillings of OSHA was present in the Workgroup meeting and this issue was discussed. Dr. Wyatt added that it is in the best interest of a company to share its good ergonomic interventions amongst its participants, and by linking to the OSHA Web site, users are easily able to navigate between Web sites. Chair Kerk asked for and received consensus on this recommendation. Dr. Nelson introduced a recommendation that OSHA should solicit the case studies and data that were presented by the speakers at the January 27, 2004, Symposium. Dr. Nelson added that the group would need permission from each presenter before putting his or her information on the Web site. Ms. Brooks added that the information would also need to be in a consistent format. Chair Kerk asked for and received consensus on this recommendation. Another recommendation from the Workgroup was for OSHA to provide a speaker to present at the May 2004 meeting regarding the Susan Harwood Grant Program. The program, an OSHA initiative, could tie into the Early Adopters Program. Mr. Fontana asked if the information could be presented to the Outreach and Assistance Workgroup instead of the entire Committee. Dr. Nelson said the Workgroup was fine with either way, as long as others felt they would still benefit. Ms. Brooks said that the full Committee might benefit from hearing the speaker because the Susan Harwood Grants have been used to roll out guidelines, for example. Ms. Brooks added that the Workgroup was fine with either way. Chair Kerk asked for and received consensus on this recommendation. Chair Kerk thanked the Workgroup for their efforts. Presentation from Research Workgroup Dr. Orta-Anes acknowledged the members of the Research Workgroup and said their discussion began with a review of the effectiveness of the presentations in meeting the Symposium objectives. The Symposium objectives were: Address current and projected research needs and efforts relating to ergonomics. Collect information from experts on known research gaps relating to critical research issues that will help move the science into the applied world. Consider how to determine the effectiveness of ergonomic interventions, what scientifically valid evidence exists, or can be developed, establishing the effectiveness of ergonomic interventions. The Workgroup had different concerns on the degree to which the goals had been accomplished. The Workgroup decided to collect additional information and recommend additional presentations to the entire Committee. Additional research will be sought from presentations given at NACE meetings, the NIOSH/NORA agenda, NAS research summaries, NACE Symposium presentations, STAR Papers, AAEM guidelines, and the NIOSH Intervention Effectiveness Booklet. Information from these sources will be collected through March and presented to the Committee at the May 2004 meeting. Dr. Orta-Anes said the Committee was welcome to contribute additional resource ideas. Potential research topics proposed by the Workgroup are: Diagnosing and misdiagnosing problems. Developing definitions of terms the Workgroup feels are controversial. The Committee was invited to add terms to the list created by the Workgroup. Impact of reporting or over-reporting. Multifactorial nature of ergonomics research including research teams and control groups. Economics of ergonomics—need to identify specific experts to develop a good model. Intervention effectiveness—identify worthwhile research pieces. Mechanism of injury to tissue—knowing what is causing certain types of injuries. Since the Workgroup did not have any recommendations, Dr. Orta-Anes listed the action items for the Workgroup: Review and summarize information presented. Consider having Dr. Woldstad and Dr. Wiker invited to other NACE meetings. Discussion Dr. Nelson commented that one of the threads that came out of the January 27, 2004, Symposium was the need for multi-disciplinary research, which was not listed. She asked if "multidisciplinary" should replace "multifactorial." Dr. Orta-Anes explained that the Workgroup is looking at the multifactorial nature of injuries and the fact that more information is needed to look at all of the variables involved in the development and etiology of these types of disorders. The Workgroup also looked at the importance of having research teams with multiple expertise. Dr. Nelson suggested changing "multifactorial" to "multidisciplinary." Dr. Nelson said she saw the scope and intent between looking at the economics of interventions and building a business case for ergonomics on a continuum. The building of a business case that the Outreach and Assistance Workgroup is looking at is a more facility-based program evaluation activity versus the rigorous research involved in looking at a larger multi-site study. Dr. Orta-Anes agreed that the economics of interventions and the business case are different in terms of the level of rigor. Mr. McCausland asked if it was the Workgroup's intention at a future meeting to make a recommendation on a specific list of research directions or areas to fill assumed gaps.  Dr. Orta-Anes said Workgroup's plan is to be able to present to the Committee at the May 2004, meeting a list of areas the Workgroup feels should be researched. Dr. Nelson suggested building on the NORA document to identify gaps in research and a research agenda, as opposed to starting from scratch. Dr. Orta-Anes agreed, and said recommendations from the research documents would be covered and used as a template to develop additional recommendations. Ms. Brooks commended the Workgroup for including the different sources of information for their large task. Ms. Brooks recommended that the Workgroup consider adding validation of risk quantification tools to their list, adding that the many tools available vary greatly in terms of the degree to which they have been validated by scientific research. Dr. Tom Watersk said that the Workgroup discussed their next steps and asked for the Committee to share their ideas on what was presented. Dr. Orta-Anesk said Mr. Goldsmith would provide a centralized location for all of the Committee's comments to be sent. With no other comments, Chair Kerkk thanked the Workgroup. Closing Chair Kerkk announced the dates for the future meetings: May 11-12, 2004 and September 14-15, 2004. He encouraged the Committee to add these dates to their calendars, adding that lots of important business will be taken care of as those dates approach. Chair Kerk encouraged 100 percent attendance and participation at the meetings. Chair Kerk encouraged the Workgroups to continue to press forward, with an emphasis on recommendations. He emphasized that information can continue to be gathered until the last meeting, by seeking input from colleagues, the public, etc. Chair Kerk asked for comments from the public. With no comments, he thanked everyone for their attendance and efforts. Chair Kerk asked Dr. Orta-Anes about the status of inviting Dr. Jeff Woldstad and Dr. Steve Wiker to the May Meeting. Dr. Orta-Anesk said the full Committee needed to make a decision. Chair Kerk asked for consensus on inviting Dr. Wiker to speak on "Reduction of Musculoskeletal Discomfort and Mental Fatigue in Lumber Graders" and Dr. Woldstad to speak on "A Theoretical Approach to Ergonomics Based on Biomechanics." Mr. Fontanak suggested reviewing their abstracts instead of asking them to speak in front of the Committee, adding that he did not see the presentations helping the Committee to look at research needs. Dr. Morton Kasdank seconded Mr. Fontana's suggestion, saying that extending an invitation to speak would be a matter of courtesy but was not necessary. Dr. Nelsonk suggested inviting Dr. Wiker and Dr. Woldstad as a courtesy, but it would not be on a high priority list for the next meeting. Chair Kerk asked for consensus from the Committee and they agreed to not invite Dr. Wiker and Dr. Woldstad to an upcoming meeting. Chair Kerk thanked everyone again and adjourned the meeting.

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