Awkward neck postures are characterized by prolonged neck flexion (forward bending ), extreme neck postures (such as bending or twisting), and prolonged static loading of the neck. Working with awkward neck postures is a risk factor associated with musculoskeletal disorders of the neck and shoulders.
Neck pain and disorders
Neck pain is among the most common health complaints in working-aged populations worldwide. Studies from Canada, the United Kingdom, and the Netherlands have shown the annual incidence of new neck pain to be as high as 15-18% among working-age adults. Furthermore, studies have shown that neck pain is persistent and up to 50% adults will have symptoms one year later. Numerous studies have shown women are at a greater risk for neck pain than men. Neck pain is characterized by having pain in the soft tissues of the neck and shoulder girdle. Neck pain can be accompanied by tingling or numbness into the arms, wrists, and hands.
Work-Related Risk Factors
Awkward neck postures may be more harmful if they are combined with the following:
• Static loading of neck or shoulder muscles
• Repetitive movements of the shoulder or wrist
• Awkward trunk postures (bending and twisting)
• Psychosocial factors including job demand, control over work, support at work, and job strain
Development and Progression
The neck is the most mobile and least stable portion of the spine, which makes it susceptible to ligament, muscle, and intervertebral disc injury. Neck pain can occur from inflammation, trauma, myofascial pain syndrome, intervertebral disc disorders, and osteoarthritis.
The intervertebral disc is composed of an outer ring of fibers surrounding a sac of gel-like material. The ring of fibers can be damaged from a sudden stress, such as a fall, or cumulative stress. When the fibers can no longer contain the fluid, small leaks or bulges (herniations) can occur or the disc may flatten. Disc problems may lead to a compressed nerve (Figure A).
Figure A. A herniated disc. The picture on the left depicts a normal disc and the picture on the right is a herniated disc.
The cause for the majority of episodes of neck pain remains unknown. Once serious medical problems have been ruled out, patients are seldom given an accurate diagnosis. Because of the difficulty to diagnose neck problems most are classified as either being related to the disc or to “mechanical neck disorders”. Mechanical neck disorders are those related to improper movement or function of the neck tissues.
Neck pain is often accompanied by headaches or radiating pain into the upper back, shoulders, arms, and hands. Point tenderness and trigger points (knots) in the neck and shoulder muscles are common in patients with neck disorders. Limited range of motion is common in patients with neck pain.
Initial treatment for most episodes of neck pain includes avoidance of stressful activities and use of nonsteroidal anti-inflammatory medications (NSAIDs, e.g. Advil ® or Aleve®). Medical practitioners will often prescribe stronger drugs (muscle relaxants or narcotics) for more severe, acute pain. Other treatment options may include application of heat and cold, spinal manipulation, traction, injections, and physical therapy. Current evidence suggests the most appropriate interventions focus on strengthening the neck and shoulder muscles, and increasing mobility of the spine and surrounding soft tissues. Some neck pain cases may require surgery (e.g. ruptured disc or severe trauma cases).
Most workers with occupational neck pain get better with minimal treatment. However, a significant portion of workers will develop chronic neck pain. At least 42% of workers will miss at least 1 week of work and 37% will still have symptoms after one year. In the general population, 5% of people with neck pain become disabled.
Work loads or activities are of such a magnitude and character that all or most workers risk developing an MSD in the short or long term.
Prolonged neck flexion (forward bending), extreme neck postures (such as bending or twisting), and prolonged static loading of the neck are associated with neck musculoskeletal disorders. Research has shown that the more the neck is bent forward, the more likely the worker will experience neck disorders. In addition, longer time periods with the neck bent forward increases the risk.
Repetitive movements at the shoulder and hand are also associated with neck disorders. Shoulder muscles connect directly to the neck, so movements and positions of the shoulder directly affect the neck. Repetitive movements of the hands are associated with neck disorders because of the shoulder movement and neck flexion when working with the hands.
Prolonged neck flexion (forward bending), extreme neck postures, and prolonged static loading of the neck are common with construction tasks. Palmer and colleagues reported construction as the number one industry associated with neck pain in British men with 24.4% experiencing pain in the past week and 38.5% experiencing pain in the last year.
The National Institute of Occupational Safety and Health (NIOSH) reports that, “there is strong evidence that working groups with high levels of static contraction, prolonged static loads, or extreme working postures involving the neck/shoulder muscles are at increased risk for neck/shoulder MSDs.”
Several observational methods are available to evaluate the risk of exposure to awkward neck postures. For individual worker analysis, the most important factors are the amount of time spent in flexed neck postures and the angle of neck flexion. Typically angles of neck flexion greater than 20 degrees are considered at risk (Figure B).
Figure B. Neck flexion angle.
Taken from the Rapid Entire Body Assessment (REBA) accessed at Thomas Bernard’s website http://personal.health.usf.edu/tbernard/ergotools/index.html
The Rapid Entire Body Assessment (REBA) is a quick tool to assess worker exposure to several risk factors, including neck posture. Awkward neck postures combined with flexion of the trunk and legs increases worker risk.
The Rodger’s Muscle Fatigue Index is also a useful tool to assess exposure to risk factors[DCA1] involving the neck. This observation method can be used to assess the amount of fatigue that accumulates in a muscle during 5 minutes of work. The premise is that fatigued muscles are more susceptible to injury. Using this tool, a safety manager can assess which tasks are potentially harmful for the neck, and prioritize tasks that could be modified.
The Washington Industrial Safety and Health Act (WISHA) provides a checklist to determine which risk factors are present in work activities. Included in the checklist is an assessment of neck postures. According to the checklist, flexion angles of the neck greater than 30 degrees for 2 hours of the day is considered cautionary. Angles greater than 45 degrees for more than 4 hours a day is considered hazardous.
All three assessment tools above can be accessed at Thomas Bernard’s website:
Regulations adopted by a state must be at least as protective as the corresponding federal standard. Work may also be subject to rules of other federal, state and local agencies. Even where there is no hazard specific standard, OSHA provides a general duty for the employer to provide a work site free from recognized hazards.
Federal OSHA Standards are enforced by the U.S. Department of Labor in 26 states. There are currently 22 states and jurisdictions operating complete State plans (covering both the private sector and state and local government employees) and 5 - Connecticut, Illinois, New Jersey, New York and the Virgin Islands - which cover public employees only. If you are working in one of those states or jurisdictions you should ensure that you are complying with their requirements.