Application of MAPO (Movement and Assistance of Hospitalized Patients) method in hospitals and nursing homes: frequency of manual patient handling-part 2.

This study examines the evolution of MAPO method for estimating the frequency of overloading tasks in healthcare workers during different shifts. The data presented were collected from 51 in-patient wards (25 hospitals and 26 nursing homes), and 917 workers: the frequency of MPH tasks is a complementary value to the MAPO exposure level, which is useful to implement a prevention plan targeted towards the reduction of overloading tasks. Based on the frequency of manual patient handling, it appears that the afternoon shift is at greatest risk, with tasks liable to cause overloading occurring within a frequency range of 70-85 per worker. The study analyzes different pieces of equipment and their relative percentages of use, concluding that, overall, they are underutilised (especially minor aids and height-adjustable beds). Practitioner summary: The organisational data collected in hospitals and nursing homes confirms the availability of patient handling aids and equipment, but also indicates that they are underutilised with respect to the frequency of overloading tasks.

MAPO index for risk assessment of patient manual handling in hospital wards: a validation study.

Manual handling of disabled patients - as regards movement - is one of the major factors affecting acute low back pain of exposed nursing staff. In the absence of quantitative methods assessing this kind of risk, the Research Unit Ergonomics of Posture and Movement of Milan developed in 1997 a risk assessment method called Movement and Assistance of Hospital Patients (MAPO), which is applicable in hospital wards.A first study conducted in 1999 allowed the identification of three levels of MAPO index corresponding with increasing probabilities of being affected by acute low back pain. In accordance with the well-known traffic light model, for MAPO index values between 0 and 1.5 the risk is considered to be absent or negligible. For values between 1.51 and 5.00 the risk is considered to be moderate. For values exceeding 5.00 the risk is considered to be high. In view of the limitations of the previous study, the results needed confirmation and so, in 2000-2001, another cross-sectional study was carried out, which included 191 hospital wards for acute and chronic patients and 2603 exposed subjects. This paper presents the analytical results of the association between the MAPO index and acute low back pain in this new data sample. The agreement between results of the two studies indicates that the MAPO index can be used as a risk index, although with some caution, as detailed in the paper. It can assess the risk exposure level of patient manual handling in wards and can be a useful tool for planning effective preventive actions to reduce the risk of work-related musculoskeletal disorders in health-care workers looking after disabled patients.

[The assessment of the risk due to the manual lifting of patients: the initial descriptive and analytical results on exposure levels]. / Valutazione del rischio da movimentazione manuale di pazienti: primi risultati descrittivi e analitici sui livelli di esposizione.

The paper reports the results of risk evaluation of patient lifting or moving obtained from a multicentre study on 216 wards, for both acute hospital patients and in geriatric residences. In all situations the exposure to patient lifting was assessed using a concise index (MAPO). Analysis of the results showed that only 9% of the workers could be considered as exposed to negligible risk (MAPO Index = 0-1.5); of these 95.7% worked in hospital wards and only 4.3% in geriatric wards. A further confirmation of the higher level of exposure of workers in long-term hospitalization was that 42.3% were exposed to elevated levels (MAPO Index > 5) compared with 27.7% observed in hospital ward workers. The mean values of the exposure index were 6.8 for hospital wards and 9.64 for geriatric residences and, although much higher in the latter, both categories showed high exposure. In the orthopaedic departments of the hospitals the values were higher than in the geriatric wards (MAPO Index = 10.1); medical and surgical departments showed values similar to the mean values observed in the geriatric wards. These high values were due to: severe shortage of equipment life lifting devices (95.5%) and minor aids (99.5%), partial inadequacy of the working environment (69.2%), poor training and information (96.1% lacking); only the supply of wheelchairs was adequate (65.8%). All of which points to an almost generalized non-observance of the regulations listed under Chapter V of Law No. 626/94. However, the proposed method of evaluation allows anyone who has to carry out prevention and improvement measures to identify priority criteria specifically aimed at the individual factors taken into consideration. By simulating an intervention for improvement aimed at equipment and training, 96% of the wards would be included in the negligible exposure class (MAPO Index 0-1.5).

[Clinical studies in health workers employed in the manual lifting of patients: methods for the examination of spinal lesions]. / Studi clinici negli operatori sanitari addetti alla movimentazione manuale di pazienti: metodi per la rilevazione delle affezioni del rachide.

To enable different research groups to make a standardized collection of clinical data on alterations of the lumbar region of the spine, protocols were used for the collection and classification of data that were proposed and thoroughly validated by the authors. The protocols include a clinical/functional examination of the spine, checking for positive anamnestic threshold, for pain on pressure/palpation of the spiny apophyses and paravertebral muscles, for painful movements, in order to classify 1st, 2nd and 3rd grade functional spondylarthropathy (for different regions of the spine). An ad hoc questionnaire was also prepared for the quantitative and qualitative study of true acute low back pain and the ingravescent low back pain controlled at the onset pharmacologically. The results of this questionnaire make it possible to calculate the incidence of acute low back pain (true and pharmacologically controlled).

[Initial epidemiological data on the clinical effects in health workers employed in the manual lifting of patients in wards]. / Primi dati epidemiologici sugli effetti clinici negli operatori sanitari addetti alla movimentazione manuale di pazienti nei reparti di degenza.

An investigation was carried out by teams from various centres coordinated by the EPM (Ergonomics of Posture and Movement) Research Unit on 54 different hospitals in various regions of northern and central Italy. The teams examined a total of 3341 health workers whose job involved manual handling of patients (553 male and 2788 females, 1568 working in hospitals and 1773 in geriatric residences). Numerous meetings were held to ensure that the methods of assessing the exposure indexes and spinal impairment were identical in the various teams. The final data were processed centrally at the EPM Research Unit. The sample analyzed may be considered as representative of the situation in hospitals in Italy, at least for northern and central Italy. The mean age was 36 years, mean length of service in the department 6 years and mean length of job duration not exceeding 10 years; staff turnover was high. Physical examination revealed that 8.4% of the workers had had at least one episode of acute low back pain in the previous 12 months: i.e., 4 times the values of the reference groups. Also in the case of clinical-functional spondyloarthropathies of the lumbosacral spine, in the females there was a significantly higher prevalence than in the reference groups. All disorders were more severe in sectors more at risk, i.e., old peoples homes, rehabilitation centres, orthopaedic and surgical departments, and in any case higher in old peoples homes and geriatric residences. The initial data concerning the ratio between presence of spinal disease and risk index were also positive.

[The assessment of exposure to and the activity of the manual lifting of patients in wards: methods, procedures, the exposure index (MAPO) and classification criteria. Movimientazione e Assistenza Pazienti Ospedalizzati (Lifting and Assistance to Hospitalized Patients)]. / Valutazione dell'esposizione ad attività di movimentazione manuale dei pazienti nei reparti di degenza: metodi, procedure, indice di esposizione (MAPO) e criteri di classificazione.

Since a method for quantifying exposure to patient handling in hospital wards is lacking, the authors describe and propose a model for identifying the main risk factors in this type of occupational exposure: presence of disabled patients, staff engaged on manual handling of patients, structure of the working environment, equipment and aids for moving patients, training of workers according to the specific risk. For each factor a procedure for identification and assessment is proposed that is easily applicable in practice. The authors also propose a formula for the calculation of a condensed exposure index (MAPO Index), which brings together the various factors. The exposure index, which requires further, detailed study and validation, makes it possible, in practice, to plan the preventive and health measures according to a specific order of priority, thus complying with the requirements of Chapter V of Law 626/94. From a practical point of view, in the present state of knowledge, it can be stated that for MAPO Index values between 0 and 1.5, risk is deemed negligible, average for values between 1.51 and 5, and high for values exceeding 5.

[The application of a synthetic index of exposure in the manual lifting of patients: the initial validation experiences]. / L'applicazione dell'indice sintetico di esposizione nella movimentazione manuale pazienti: prime esperienze di validazione.

Via a multicentre study coordinated by the EPM research group carried out in 216 wards in a total of 56 hospitals, old peoples homes and geriatric departments, it was possible to quantify exposure to patient handling (classified in 4 classes: 0-1.5 negligible, 1.51-5 slight to average, 5.01-10 average to high, > 10 elevated), and at the same time identify the damage to the lumbosacral spine thus caused. Both assessment of exposure and identification of health impairment were carried out using homogeneous methods. Subjects with work seniority in the job of less than 6 months and subjects who had been transferred because of back trouble were excluded from the study. It was therefore possible to carry out two types of study to assess the association between exposure and impairment. In study A, covering 3021 subjects, an analysis was performed of the association between exposure index, positive response to the anamnestic threshold for lumbosacral disorders and acute low back pain using the method of logistic analysis to obtain the prevalence odds ratios. In study B, covering 418 subjects, the analysis of association was performed on the incidence rates of episodes of acute low back pain and pharmacologically controlled acute low back pain, assuming that exposure in the wards had remained constant. The technique used was Poisson regression, thereby calculating the relative incidence rate ratios. Both for PORs and IRRs the reference group consisted of the exposure class judged as negligible (exposure index 0-1.5). The results showed that the PORs calculated for positive lumbar threshold were significant for increasing exposure classes with a positive trend for the second and third exposure class but not for the last, presumably due to a healthy worker selection effect. Neither in Study A nor in Study B were any associations observed between exposure and acute low back pain occurring in the previous 12 months: this may be due to the fact that the impairment indicator does not appear to be appropriate in terms of latency period. A different result was obtained in Study B which showed a good association between exposure and incidence rates of episodes of acute low back pain and pharmacologically controlled acute low back pain according to department. The IRRs showed a positive trend both for acute episodes (IRR: 1.932, 2.439, 2.847) and for acute plus pharmacologically controlled acute episodes (1.798, 1.830, 4.523). On the basis of these results, even with the caution required for the reasons explained in the text, it seems to be possible to identify three grades of exposure which correspond to increasing probability of impairment of the lumbosacral region of the spine: the first where risk seems negligible corresponds to an exposure level between 0 and 1.5. The second, where the episodes of low back pain may occur with an incidence 3.8 times greater, corresponds to an exposure level between 1.51 and 5, and the third corresponds to exposure levels exceeding 5, where the episodes of low back pain may occur with an incidence up to 5.6 times greater than expected.

[Worker turnover because of spinal pathologies in the wards and outpatient clinics of the hospitals of Leno and Manerbo, Brescia]. / Il turn-over, per patologie del rachide, dei lavoratori nei reparti di degenza e negli ambulatori degli ospedali di Leno e Manerbio (BS).

A total of 306 employees of the hospitals of the Leno/Manerbio health area underwent clinical and anamnestic examination in order to ascertain the existence of degenerative diseases of the spine associated with "manual handling of loads" risk. The prevalences obtained for positive anamnestic threshold concerning the lumbosacral spine, the trend of total acute low back pain and of low back pain in the last year showed lower values compared to the entire national group and in any case lower or only slightly above the values for the reference group of non-exposed subjects. Therefore, in order to assess the real prevalences of disorders due to incorrect load handling in hospital environments, it is important to assess the presence of associated disorders of the spine also and especially in outpatients departments. In fact, unsuitable or unfit staff had recently been transferred from the wards to outpatients departments. 56 workers from outpatients departments underwent physical-anamnestic examination: 16 workers (4.5% of the entire group under study) from average-to-high risk wards were identified as suffering from degenerative disorders of the lumbosacral spine. Therefore the prevalence of unfit subjects from hospital wards, cancelling the effect of the turnover factor on outpatients departments, led to an almost twofold total frequency, which rose from 6.9% to 11.4%.

[Acute lumbago due to the manual lifting of patients in wards: prevalence and incidence data]. / La lombalgia acuta da movimentazione manuale di pazienti nei reparti di degenza: dati di prevalenza e incidenza.

The aim of the study was to measure the occurrence (prevalence and incidence) of episodes of acute low back pain (definite effect) in a wide sample of health workers assisting disabled patients. A questionnaire was used for the study both of true acute low back pain and of episodes of ingravescent low back pain controlled pharmacologically at the onset. The questionnaire identified overall acute and pharmacologically controlled episodes occurring in the previous 12 months, both in the course of work and over the whole life of the subject. Appropriately trained operators administered the questionnaire to 551 subjects; 481 valid answer cards were obtained from 372 females and 109 males working in medical, orthopaedic and geriatric departments. 75.4% of the sample had high exposure index levels for patient lifting. The prevalence of true acute low back pain was 9% in males and 11% in females referred to the previous 12 months. Taking acute true and pharmacologically controlled low back pain together the prevalences rose to 13.8% for males and 26.9% in females. Data from the reference populations showed that acute low back pain did not exceed 3% on average in the previous year. Since work seniority in the hospital wards was known, the incidences were calculated, giving 7.9% in females and 5.29% in males for acute low back pain, and 19% in females and 3.49% in males for pharmacologically controlled low back pain. Considering the number of episodes in 100 workers/year, acute low back pain alone reached prevalences of 13-14%. This therefore appears to confirm the positive ratio between episodes of low back pain and duties involving assistance to disabled patients.

[Assessment criteria in the choice of aids for the lifting of patients]. / Criteri di valutazione nella scelta degli ausili per la movimentazione dei pazienti.

A fundamental part of the prevention strategies aimed at reducing risk due to manual handling of patients is the use of appropriate aids. This paper defines the basic types of aids for hospital wards: patient lifting devices, aids for hygiene and minor aids; and also proposes a procedure for choice of the type of aid: the procedure uses a specific protocol and also analyzes work organization and the environmental features of the ward. The proposed criteria for choice concern in the first place the fundamental requirements of the equipment: safety for operator and patient, simplicity of use and comfort for the patient. Secondly the basic determinants for choice of the type of aid are the type of disabled patient usually present in the ward and the analysis of the movements made in handling patients. On this basis, for each type of aid, the specific features are defined which direct the choice of supply for the various wards that will be adequate and effective both in reducing risk due to manual handling of patients and in improving the comfort of the patients.

Clinical trials among worker populations: a model for an anamnestic survey of upper limb pathologies and its practical application methods.

Following a brief review of the principal clinical characteristics of musculoskeletal disorders of the upper limbs, the authors propose a protocol for a structured anamnestic examination featuring a series of set questions. The anamnestic model is based on a detailed listing of the symptoms to be analysed, which are divided into four categories: pain, paraesthesia, symptoms attributable to hyposthenia, and neurovegetative disorders. Regarding pain and paraesthesia, the authors list the localization, pattern of onset, duration and number of episodes, irradiation and treatment. The patients can thus be classified as anamnestic cases based on the following criteria: presence of pain or paraesthesia during the last 12 months, with episodes lasting for at least 1 week or occurring at least once a month, with no previous acute trauma. For hyposthenia, the authors report on the conditions under which the disorder may develop. The neurovegetative disorders considered are modifications in colour of the fingers and reaction to exposure to low temperatures. The structure of the proposed anamnestic chart permits all findings to be easily encoded for subsequent storage in a dedicated database. The appendix contains an annotated facsimile of the anamnestic chart.

The occurrence of musculoskeletal alterations in worker populations not exposed to repetitive tasks of the upper limbs.

A total of 749 workers (males: 139 aged between 15 and 35 years, and 171 aged > 35 years; females: 176 aged between 15 and 35 years, and 263 aged > 35 years) performing tasks not at risk for work-related musculoskeletal disorders of the upper limbs (WMSDs) underwent a clinical examination using a standardized method. The 'anamnestic cases' were defined on the basis of pain or paraesthesia present for at least 1 week during the previous 12 months, or appearing at least once a month, and not subsequent to acute trauma. The anamnestic cases among the males amounted to 4.4% (age 15-35 years) and 12.3% (age > 35 years); among the females, 4.6% (age 15-35 years) and 14.2% (age > 35 years). Of the 1498 limbs examined, the prevalent diseases reported were: suspect narrow chest syndrome: 0.3% among the males > 35 years, 0.6% among the females aged 15-35 years, 1% among the females > 35 years; scapulo-humeral periarthritis: 0.3% among the males aged > 35 years, 0.3% among the females aged 15-35 years, 1.3% among the females aged > 35 years; lateral epicondylitis: 0.3% among the males aged > 35 years, 0.2% among the females aged > 35 years; trapeziometacarpal arthrosis: 0.8% among the females aged > 35 years; wrist-hand tendinitis: 0.9% among the males aged > 35 years, 0.9% among the females aged 15-35 years; carpal tunnel syndrome: 2.5% among the females aged > 35 years. No disorders were detected outside the age ranges indicated. Several workers reported more than one disorder. The number of workers with at least one WMSD was: males 0% in the 15-35 years age range, 3.5% in the > 35 years age range; females 2.3% in the 15-35 years age range, 7.2% in the > 35 year age range; 3.9% of the total sample population. The prevalences were on average quite low, particularly among the older workers, hence the authors recommend that even minimal prevalences detected in particular work environments should not be underestimated.

[Clinical studies in working populations: a model for the anamnestic investigation of the pathology of the upper limbs and its practical application]. / Studi clinici in popolazioni lavorative: un modello per l'indagine anamnestica delle patologie degli arti superiori e sue modalità applicative.

Following a brief review of the principal clinical characteristics of musculo-skeletal disorders of the upper limbs, the authors propose a protocol for a structured anamnestic examination featuring a series of set questions. The anamnestic model is based on a detailed listing of the symptoms to be analysed, which are divided into four categories: pain, paraesthesia, symptoms attributable to hyposthenia, and neurovegetative disorders. Regarding pain and paraesthesia, the authors list the localisation, pattern of onset, duration and number of episodes, irradiation, and treatment. The patients can thus be classified as anamnestic cases based on the following criteria: presence of pain or paraesthesia during the last 12 months, with episodes lasting for at least one week, or occurring at least once a month, with no previous acute trauma. For hyposthenia, the authors report on the conditions under which the disorder may develop. The neurovegetative disorders considered are modifications in colour of the fingers and reaction to exposure to low temperatures. The structure of the proposed anamnestic chart permits all findings to be easily encoded for subsequent storage in a dedicated database. The Appendix contains an annotated facsimile of the anamnestic chart.

[Clinical studies in working populations: value and significance of anamnestic findings, clinical tests and instrumental tests for the diagnosis of musculoskeletal disorders of the upper extremities]. / Studi clinici in popolazioni lavorative: valore e significato dei rilievi anamnestici, dei test clinici e degli esami strumentali per la diagnosi delle affezioni muscolo-scheletriche degli arti superiori (WMSDs).

The authors discuss the value and significance of symptoms in WMSDs, considering that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculo-skeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The Appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.

[Occurrence of musculoskeletal disorders in working populations not exposed to repetitive tasks of the upper arms]. / L'occorrenza delle alterazioni muscolo-scheletriche in popolazioni lavorative non esposte a compiti ripetitivi degli arti superiori.

A total of 749 workers (males: 139 aged between 15 and 35 years, and 171 aged over 35 years; females: 176 aged between 15 and 35 years, and 263 aged over 35 years) performing tasks not at risk for work-related musculo-skeletal disorders of the upper limbs (WMSDs) underwent a clinical examination using a standardised method. The "anamnetics cases" were defined on the basis of pain or paraesthesia present for at least one week during the previous 12 months, or appearing at least once a month, and not subsequent to acute trauma. The anamnestic cases among the males amounted to 4.4% (age 15 divided by 35 years) and 12.3% (age > 35); among the females 4.6% (age 15 divided by 35 years) and 14.2% (age > 35). Of the 1498 limbs examined, the prevalent pathologies reported were: suspect narrow chest syndrome: 0.3% among the males > 35 years, 0.6% among the females aged 15 divided by 35 years, 1% among the females > 35 years; scapulo-humeral periarthritis: 0.3% among the males aged > 35 years, 0.3% among the females aged 15 divided by 35 years, 1.3% among the females aged > 35 years; lateral epicondylitis: 0.3% among the males aged > 35 years, 0.2% among the females aged > 35 years; trapezio-metacarpal arthrosis: 0.8% among the females aged > 35 years; wrist-hand tendinitis: 0.9% among the males aged > 35 years, 0.9% among the females aged 15 divided by 35 years; carpal tunnel syndrome: 2.5% among the females aged > 35 years. No disorders were detected outside of the age ranges indicated. Several workers reported more than one disorder. The number of workers with at least one WMSD was: males 0% in the 15 divided by 35 years age range, 3.5% in the > 35 year age range; females 2.3% in the 15 divided by 35 year age range, 7.2% in the > 35 year age range; 3.9% of the total sample population. The prevalences were on average quite low, particularly among the older workers, hence the authors recommend that even minimal prevalences detected in particular work environments should not be underestimated.

[Criteria for the reintegration to their jobs of workers with musculoskeletal pathologies of the upper limbs based on preliminary practical experiences]. / Criteri per il reinserimento lavorativo di soggetti portatori di patologie muscolo-scheletriche degli arti superiori sulla base di prime esperienze applicative.

The report presents a preliminary study on the return to the workforce of employees with WMSDs of the upper limbs, and their reallocation to jobs with "low exposure". The study, which is still underway, involves a large engineering firm and includes some 100 workers affected by WMSDs. The trial envisages: providing a definition of the criteria for characterising "accommodating" jobs (i.e. frequency of action < or = 20 actions per minute; virtual absence of other risk factors such as force, posture, inadequate pauses, etc.); concretely identifying jobs meeting such criteria (or jobs which, with minimal modifications, could be made suitable); classifying WMSDs workers, according to the type and severity of the disorder; matching WMSDs workers with the jobs best suited to them; specific training for the workers and their supervisors; carrying out a follow-up of the return of WMSDs workers to the workforce in organisational terms (i.e. need for further modifications to equipment or procedures) and clinical terms (i.e. symptom patterns, acceptability of the condition). The preliminary results, 6-12 months after the start of the trial, are extremely encouraging, and show that when workers return to the workforce in jobs that fully meet defined criteria, a significant prevalence of "improvements" are reported among the involved workers. The investigation will need to be extended, but already it shows quite convincingly that it is possible for workers with what can be described as a "reduced working capacity" to remain "productive" (albeit in jobs featuring a lower exposure potential than the acceptable threshold for "healthy" workers).

[Guidelines for redesigning jobs with repetitive tasks]. / Orientamenti per la riprogettazione del lavoro con compiti ripetitivi.

Preventive measures aimed at minimising the occurrence of work-related musculo-skeletal disorders of the upper limbs (WMSDs) associated with repetitive tasks can be divided into 3 categories: structural, organisational and educational. Whenever specific risk and injury assessments have shown the need for preventive action, this is most often implemented within the framework of a range of assorted measures. In particular, structural measures pertain to optimising the layout of the work area and furnishings, and the "ergonomic" properties of work tools and equipment. Such measures serve to alleviate the problems caused by the use of excessive force and improper postures. The authors refer to the principles guiding such structural measures, in the light of the extensive literature that has been published on the subject. Organisational (or re-organisational) measures essentially relate to job design (i.e. distribution of tasks, speeds and pauses). They serve to alleviate problems connected with highly repetitive and frequent actions, excessively lengthy tasks and inadequate recovery periods. Very few relevant findings are available: the authors therefore illustrate in some detail a practical trial conducted in a major engineering firm. The objective was to lower to acceptable limits the frequency of certain repetitive tasks performed by workers using their upper limbs. The trial made it possible to identify a suitable plan and schedule of measures taking into due consideration the impact of the plan on production levels (and costs). The fundamental principles guiding the adoption of specific educational and training programmes for the workers and their supervisors are presented and discussed.

[Criteria for the health surveillance of WMSDs in exposed working populations]. / Criteri per la sorveglianza sanitaria di WMSDs nelle popolazioni lavorative esposte.

In the light of the experiences and guidelines developed by other countries and of Italian legislative and operational conditions, the authors outline a strategy for a health surveillance programme for work-related musculo-skeletal disorders of the upper limbs. In particular, the paper defines the various aims of the health surveillance programme and identifies significant relevant criteria for its implementation (i.e. existence of risks or effects). A screening schedule is presented based on successive investigations (1st and 2nd level surveillance); the authors discuss the principal methods used for processing the results of the health surveillance programme, in collective (i.e. statistical comparisons; planning of periodical investigations) and individual terms (job fitness judgements; reporting of suspected occupational diseases.

[Diseases of the dorsal-lumbar spine and manual handling of loads: guidelines for fitness assessment]. / Patologie del rachide dorso-lombare e movimentazione manuale di carichi: orientamenti per la formulazione di giudizi di idoneità.

In occupational medicine, degenerative diseases and malformations of the spine are one of the main reasons for requests for fitness assessment for specific jobs, especially among workers involved in manual handling tasks. By means of a selected review of the specialised literature, the authors identify analysis procedures and precise criteria for assessing compatibility between the clinical condition of the spine and manual handling tasks. Attention is drawn in particular to the diseases caused or at least aggravated by mechanical overloading of the spine. For each of these a set of diagnostic criteria is established which could be useful in defining the various levels of severity. On another front, by using tried and tested methods and criteria to identify the weight limits that can be lifted by healthy subjects in various manual handling situations, an approach was developed that can be applied to establish the weight limits that can be lifted by subjects with spinal diseases. By combining the two factors, risk level and damage level, a set of disorders was established that correspond to three different fitness levels. At each level, manual load handling was only allowed up to certain weights and for handling conditions that became increasingly stringent as the severity of the disorder increased. The paper outlines the clinical protocols and the protocols for reconstructing work exposure. The procedural differences involved in the case of fitness assessments in the pre-employment stage are also briefly discussed.

Muscular effort and musculo-skeletal disorders in piano students: electromyographic, clinical and preventive aspects.

An investigation was made on the relationship between music practice and musculo-skeletal disorders among piano students, with the main aim of developing health education programmes that would improve the performance and health of the students. The investigation covered three areas: (a) Analysis of study organization and main musculo-skeletal complaints achieved by a questionnaire distributed to all piano students at the Milan Conservatory. (b) Vocational electromyographic analysis of the effort exerted by the various muscle groups of the trunk, of the shoulder and shoulder blade girdle, and of the arm during performance of a standard set of piano exercises, an unseen passage and a passage of maximum difficulty. This analysis was made on a sample of six subjects. (c) A series of preventive measures was developed on the basis of a critical assessment of the results (38% of the students practised for excessively long periods without breaks; 62% had from 1 to 5 complaints, the most affected sites being the spine and the trapezius muscles). These consisted largely of a health education programme aimed at helping the students to suitably organize practice and rest periods and in instructing them in appropriate exercises for relaxation and stretching of overused muscle groups and strengthening the supporting muscle groups. Changes in lifestyle were also suggested.