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International Journal of Industrial Ergonomics 44 (2014) 817e820

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International Journal of Industrial Ergonomics

journal homepage: www.elsevier .com/locate/ergon

Assessing exposure to risk factors for work-related musculoskeletaldisorders using Quick Exposure Check (QEC) in taxi drivers

Emre €Ozgür Bulduk a, *, Sıdıka Bulduk b, Tufan Süren b, Feride Ovalı c

a Health Faculty, Physiotherapy and Rehabilitation Department, Nuh Nazi Yazgan University, Kayseri, Turkeyb Faculty of Vocational Education, Department of Food and Nutrition, Gazi University, Ankara, Turkeyc Faculty of Industrial Arts and Education, Gazi University, Ankara, Turkey

a r t i c l e i n f o

Article history:Received 17 December 2013Received in revised form25 July 2014Accepted 6 October 2014Available online 7 November 2014

Keywords:ErgonomicsTaxi driversQuick Exposure CheckMusculoskeletal disorders

* Corresponding author.E-mail address: ozgurem@gmail.com (E.€O. Bulduk

http://dx.doi.org/10.1016/j.ergon.2014.10.0020169-8141/© 2014 Elsevier B.V. All rights reserved.

a b s t r a c t

Work-related musculoskeletal disorders (WMSDs) are a common health problem throughout the world.This study aimed to examine the risk factors that are involved in the development of WMSDs in taxidrivers. In total 382 taxi drivers were observed using Quick Exposure Check (QEC) observational tool,which allows practitioners and workers to assess four key areas of the body. Results of the QEC scoreswere found to be very high for the shoulder/arm, wrist/hand and neck, whereas the scores for the backwere found to be high for static use and moderate for moving. The results also showed that the occu-pational risk factors for WMSDs were associated with restricted postures, repetitive movements, vi-bration, work related stress. Essential ergonomic interventions are needed to eliminate risk of exposuresto WMSDs in taxi drivers.Relevance to industry: The study results have relevance for ergonomists, health and safety practitionersas well as the drivers themselves, and helpful for estimating the main physical risk factors for WMDSsbefore choosing a method prior to an ergonomic intervention in industry.

© 2014 Elsevier B.V. All rights reserved.

1. Introduction

Work-related musculoskeletal disorders (WMSDs) are a majorpublic health concern, which often result in work restriction, work-time loss and consequently low retirement age (Cheng et al., 2013).WMSDs are considered to be the most common and costly occu-pational health issue among taxi drivers (Ferguson et al., 2012).Work related risk factors for taxi drivers include physical demandsimposed by prolonged periods of sitting, deviations from neutralbody alignments, repetitive motions, vibration, noise, strenuoustasks, and frequent handling of luggage. A number of studies haveshown that WMSDs are commonly reported by drivers of buses,trucks and taxis (Raanaas and Anderson, 2008; Kankaanp€a€a et al.,2005; Sullman et al., 2013; Thamsuwan et al., 2013; Okunribidoet al., 2007). WMSDs have serious effects on the human body andhave been found to be associated with psychological stressors inthe workplace including anger, anxiety and time pressure, and lowperceived social support. Additional risk factors forWMSDs includehormonal and individual characteristics such as gender, age, socio-economic status and domestic workloads that can cause serious

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hormonal and cardiovascular responses at work (Eatough et al.,2012; Feuerstein, 2004). When examining risk factors, studieslimit their analysis by controlling or adjusting for the individualfactors (Darasieh et al., 2010). Ergonomics focuses on how workaffects people in their working environment developing solutions,with the aim of improving productivity, reducing discomfort andminimizing the hazards of work (Bube, 1985; Boocock, 2007).Discomfort has been assessed using the psychophysical methodssuch as discomfort scales and body maps for preventing musculo-skeletal disorders and improving work environment (Kee andKarwowski, 2003). WMSDs are one of the most important healthproblems that ergonomists encounter all over the world. Physio-logical, psychological and individual stressors can cause pain,tenderness, swelling and even loss of function of hands, wrists,elbows, shoulders, the neck and back (Karimfar, 2008; Sancini,2013). Several observational techniques were developed forassessing risk factors related with musculoskeletal disorders (Keeand Karwowski, 2007).

The Quick Exposure Check (QEC) was the one of these obser-vational techniques and developed for ergonomists, health andsafety practitioners in order to investigate musculoskeletal riskfactors in workers (David et al., 2008). The present study aimed toinvestigate the risk factors for WMSDs using QEC in taxi drivers.The results of this study will inform practitioners engaged in

Table 1Characteristics of the study subjects.

Age (years) Number %

22e32 102 26.7033e43 109 28.5344e54 97 25.3955e65 71 18.5966 and above 3 0.79

Total 382 100.00

Working experience (in years) Number %

1e5 96 25.136e10 101 26.4411e15 112 29.3216e20 47 12.3021e25 21 4.6026 and above 5 1.31

Total 382 100.00

E.€O. Bulduk et al. / International Journal of Industrial Ergonomics 44 (2014) 817e820818

planning appropriate ergonomics programmes for taxi drivers inthe city of Ankara in Turkey.

2. Materials and methods

2.1. Participants

The participants in this study were recruited through The PublicVehicle Owners and Drivers' Union and a total of 382 Turkish taxidrivers from the city of Ankara (Turkey). In Ankara, taxi driverswork approximately 10e12 h per day, with 6 days on and 1 day off.All taxi drivers must be 18 years or older and the members of ThePublic Vehicle Owners and Drivers' Union in order to work. Taxidrivers were informed as to the purpose of the study. Taxi driverscompleted the survey voluntary. All participants were male andaged between 22 and 66 and above. Only one driver was aged above66. Drivers' occupational experience was evaluated in terms of thenumber of years they had been employed as taxi drivers.

2.2. Task

The physical exposure risk factors of WMSDs and changes inexposure can be measured by various observational assessmenttechniques. QEC was developed by Li and Buckle in 1998 andmodified by David, Woods and Buckle in 2003. Evaluation of theinter-user reliability, validity and usability of QEC were determinedin two phases of development, with participation of 206 practi-tioners (David et al., 2005). This technique has been previouslyapplied to taxi drivers and includes assessment of four areas of thebody, namely the back, shoulder/arm, wrist/hand and neck, withregards to postures and repetitive movements. A combination ofexposures between different risk factors is shown in a scoring table.The exposure levels for back, shoulder/arm, wrist/hand and neckare categorised into four exposure categories: low, moderate, highand very high. The range of score for back (static) is 8e15 for low,16e22 for moderate, 23e29 for high and 29e30 for very high. Therange of score for back (moving), shoulder/arm and wrist/hand is10e20 for low, 21e30 for moderate, 31e40 for high and 41e60 forvery high. Exposure scores of the neck range from 4 to 6 for low,8e10 for moderate,12e14 for high and 16e20 for very high. Finally,QEC analysis also checks the exposure levels of categoriesincluding; driving, vibration, work pace and occupational stress.These exposure scores, ranging from 1 to 4, correspond to low,moderate, high and very high risk levels respectively. In 2008, thereliability of the Turkish translation of the QEC used for risk as-sessments of WMSDs was investigated by €Ozcan and colleaguesand they suggested that, QEC is a useful and sensitive observationaltechnique for assessing exposure to risk factors for WMSDs (€Ozcan,2011). Possible questions about socio-economic status of the taxidrivers could not be included as being too sensitive and intrusive ofprivacy. The required papers on the objective, the subjects and themethod of the study; where the study would be conducted andconfidentiality for study participants were submitted to The PublicVehicle Owners and Drivers' Union in Ankara and permission wasobtained before starting the study.

2.3. Statistics

The association that represents taxi drivers working in the cityof Ankara was approached and informed about this study. Directcontacts were established between the researchers and taxi driverswith the permission of The Public Vehicle Owners and Drivers'Union. The Study was briefly described to taxi drivers whoseparticipation was voluntary. No names were attached to the ques-tionnaires that were carefully administered by the researchers.

Statistical analysis was performed with SPSS (version 15.0). TheChi-square test was used to identify the relationship of themusculoskeletal disorders between drivers' age and duration ofservice. p Values <0.05 were considered statistically significant.

3. Results

A total of 382 drivers participated in this study. The age of thedrivers and their work experience in years are summarized inTable 1. The exposure score standards of QEC analysis for back(static), back (moving), shoulder/arm, wrist/hand and neck aregiven in Table 2. As shown in Table 3, the QEC analysis revealed thatamong the drivers, the score of risk exposure was 32.1 ± 4.4 (high)for back (static), 19.3 ± 4.7 (moderate) for back (moving), 43.7 ± 3.2(very high) for shoulder/arm, 43.4 ± 6.3 (very high) for wrist/handand 17.1 ± 2.2 (very high) for neck. Standards of the exposure scoresfor the other factors like; driving, vibration, work pace and stresswere shown in Table 4. In 49.00% of the taxi drivers, the drivingscores were high, but in 23.80% of the taxi drivers the driving scoreswere low. Vibration scores in 35.34% of the taxi drivers weremoderate, in 39.01% of the taxi drivers the vibration scores werehigh. While the working pace scores of the taxi drivers in 56.50%were high, the scores were moderate in 39.00% of them. In 52.10%and 23.80% of the taxi drivers, stress scores were evaluated as veryhigh and high respectively (Table 5). The results demonstrated theexposure risks to musculoskeletal disorders were high or very highin taxi drivers. The most common factors are awkward workingpositions, handling heavy loads, variable working hours and lack ofrest. In Table 6, there was a significant association between theprevalence rate of musculoskeletal problems and the increase inthe ages of the drivers (p < 0.05). Table 7 indicates that the prev-alence rate of musculoskeletal problems increases significantlywith the number of years drivers have worked (p < 0.05).

4. Discussion

This study was conducted to investigate the exposure to riskfactors for WMSDs in taxi drivers. Driving is known as a stressfultask that requires high levels of strength and attention in order tocope with the demands of the job demands, traffic conditions,variableworking hours and the safety of passengers and goods. Thisstudy based on QEC method allowed to perform a rapid evaluationof exposure to risk factors for WMSDs. QEC focuses primarily onphysical workplace factors and allows four main body areas to beassessed. But also includes the evaluation of psychosocial factors.However this study had two limitations. First, the self-reported

Table 2Exposure level standards for back, shoulder, wrist and neck (David et al., 2005).

Exposure level

Score Low Moderate High Very high

Back (static) 8e15 16e22 23e29 29e40Back (moving) 10e20 21e30 31e40 41e56Shoulder/arm 10e20 21e30 31e40 41e56Wrist/hand 10e20 21e30 31e40 41e56Neck 4e6 8e10 12e14 16e18

Table 3Exposure level (quick exposure check).

Back(moving)

Back(static)

Shoulder/arm Wrist/hand Neck

Score 32.1 ± 4.4 19.3 ± 4.7 43.7 ± 3.2 43.4 ± 6.3 17.1 ± 2.2Exposure

levelHigh Moderate Very high Very high Very high

Table 6Relationship between risk factors for musculoskeletal disorders and age.

Age N Risk factors for musculoskeletal disorders

Available Not available

N % N %

22e32 (102) 13 12.75 89 87.2533e43 (109) 26 23.85 83 76.1544e54 (97) 81 83.51 16 16.4955e65 (71) 71 100.00 e e

65 ve üstü (3) 3 100.00 e e

c2 ¼ 5.89, df ¼ 4, p < 0.05.

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nature of all outcome measures. The data may be influenced by theself-reported assessment techniques. Second, the lack of evaluationof the lifestyle factors such as smoking, eating habits and alcoholconsumption of the taxi drivers. The results of our study indicatedthat taxi drivers in Ankara had very high scores of risk exposures forshoulder/arm (43.7 ± 3.2), wrist/hand (43.4 ± 6.3) and neck(17.1 ± 2.2). However the risk exposures for back (static) and back(moving) were found high (32.1 ± 4.4) and moderate (19.3 ± 4.7)respectively. It was suggested that working style or how a personresponds to work demands may be related to upper extremitysymptoms (Haufler et al., 2000). According to the literature themost affected body regions for WMSDs are shoulders, arms, wrists,fingers and the neck (Akbal, 2012; €Oztürk and Esin, 2012; Eatoughet al., 2012; Ronchese and Bovenzi, 2012). Lewis et al. (2002) andEsmaeilzadeh et al. (2012) indicated that ergonomic interventionsare very necessary and effective for reducing the risks of muscu-loskeletal disorders in neck and upper extremities. Daily exposureto constrained body postures and deviations from neutral posturesover a long period may result in discomfort in joints, muscles andsoft tissues (Kee and Karwowski, 2001). Gourdeau (1997) investi-gated the prevalence of neck and shoulder musculoskeletal disor-ders in 126 schoolbus drivers. The results showed that schoolbusdrivers had more musculoskeletal problems in their necks and

Table 4Exposure level standards for other factors.

Exposure level

Score Low Moderate High Very high

Driving 1 4 9 e

Vibration 1 4 9 e

Work pace 1 4 9 e

Stress 1 4 9 16

Table 5Exposure level for other factors.

Score Driving Vibration Working pace Stress

N % N % N % N %1 91 23.80 98 25.65 21 5.50 3 0.794 104 27.20 135 35.34 145 39.00 89 23.319 187 49.00 149 39.01 216 56.50 91 23.8016 e e e e e e 199 52.10

Total 382 100.00 382 100.00 382 100.00 382 100.00

shoulders in the previous 12 months (Lewis et al., 2002;Esmaeilzadeh et al., 2012; Gourdeau, 1997). Alperovitch-Najensonet al. (2010) studied the prevalence of upper body quadrant painamong 384 Israeli professional urban bus drivers. According to theirresults; the 12-month prevalence of neck pain was 21.2%, followedby shoulder: 14.7%, upper back: 8.3%, elbow and wrist: 3.0% pain. Inour study, exposure levels for shoulder/arm, wrist/hand and neckwere found to be very high (Alperovitch-Najenson et al., 2010).Szeto and Lam (2007) investigated the prevalence and character-istics of WMSDs among 481 urban bus drivers in Hong Kong. Theyfound that long driving hours put the bus drivers in a high riskgroup for musculoskeletal disorders. Stress associated with longworking hours causes musculoskeletal disorders, depression of theimmune system and psychosomatic problems. In our study 49% ofthe taxi drivers reported a high level of driving hours. These taxidrivers had been driving a vehicle more than 4 h per a day. Based onbiomechanical knowledge, continuous vibration, working pace andwork stress affect the spine and the soft tissues. In our study, vi-bration and working pace scores were found to be high and thework stress scores were very high (Szeto and Lam, 2007). Pope et al.(2002) found that when the spine was loaded axially for long pe-riods, the muscles and soft tissues became fatigued (Pope et al.,2002). Prolonged seated exposures and long car journeys couldhave potential for lumbar spine stiffness, back pain and injury.Potential causes for low back pain, vibration exposure and exposureto flexed postures for prolonged periods had been shown to in-crease the stress on the posterior elements of the spine and intra-discal pressures (De Carvalho and Callaghan, 2011). It is known thatlow back pain causes reflexive muscle spasms and alters kin-aesthetic awareness (Solomonow et al., 2003). In our study, expo-sure levels for back (moving) and back (static) were found to behigh and moderate respectively. Okunribido et al. (2007) investi-gated the exposures to posture demands, manual materialshandling and whole-body vibration in bus drivers. They found thatdrivers were exposed to high levels of vibration. Our results alsosupported these results (Okunribido et al., 2007). Massaccesi et al.(2003) and Hulshof et al. (2006) found that musculoskeletal

Table 7Relationship between risk factors for musculoskeletal disorders and workexperience.

Year of workexperience

N Risk factors for musculoskeletal disorders

Available Not available

N % N %

1e5 (96) 16 16.67 87 90.636e10 (101) 24 23.76 77 76.2411e15 (112) 61 54.46 51 45.5416e20 (47) 45 95.74 2 4.2621e25 (21) 21 100.00 e e

26 and above (5) 5 100.00 e e

c2 ¼ 6.81, df ¼ 5, p < 0.05.

E.€O. Bulduk et al. / International Journal of Industrial Ergonomics 44 (2014) 817e820820

problems increased in drivers due to age and the number of yearsthey had been driving. These findings are closely related with ourresults. We observed that an increase in drivers' age and thenumber of years they had been driving were key indicators of theirrisk of developing musculoskeletal problems. Based on our find-ings, there are significant correlation between our study and thestudies about WMSDs in the literature.

5. Conclusion

In summary, the present research was the first to investigate theexposure to risk factors for WMSDs among taxi drivers in Ankara.The results showed the exposure risks tomusculoskeletal disorderswere high or very high in taxi drivers. Restricted postures, repeti-tive movements, vibration, continuous attention to the road andwork related stress are suspected risk factors for musculoskeletaldisorders in taxi drivers. Adjusting steering wheel, mirrors and seatheight to get better back support, avoiding stressful driving situa-tions and taking regular breaks during long drives are the appro-priate ergonomic recommendations aiming at reducing the riskfactors.

References

Akbal, A., 2012. Mesleki maruziyetler ve kas iskelet sistemi bulguları. J. Phys. Med.Rehabil. Sci. 15, 73e76.

Alperovitch-Najenson, D., Katz-Leurer, M., Santo, Y., Golman, D., Kalichman, L., 2010.Upper body quadrant pain in bus drivers. Arch. Environ. Occup. Health 65 (4),218e223.

Boocock, M.G., May 2007. Interventions for the prevention and management ofneck/upper extremity musculoskeletal conditions: a systematic review. Occup.Environ. Med. 64 (5), 291e303.

Bube, J.L., Jul. 1985. The ergonomics/human factors approach to health sciences li-braries. Bull. Med. Libr. Assoc. 73 (3), 254e258.

Cheng, K.H.Y., Cheng, C.Y., Ju, Y.Y., 2013. Work-related musculoskeletal disorders andergonomic risk factors in early intervention educators. Appl. Ergon. 44 (1),134e141.

Darasieh, N.M., Cronin, S.N., Davis, L.S., Shell, R.L., Karwowski, W., 2010. Low backsymptoms among hospital nurses, associations to individual factors and pain inmultiple body regions. Int. J. Occup. Saf. Ergon 40, 19e24.

David, G., Woods, V., Buckle, P., 2005. Further Development of the Usability andValidity of the Quick Exposure Check (QEC). Research Report: RR211/2005. HSEBooks, Sudbury, Suffolk.

David, G., Woods, V., Buckle, P., Jan. 2008. The development of the Quick ExposureCheck (QEC) for assessing exposure to risk factors for work-related musculo-skeletal disorders. Appl. Ergon. 39 (1), 57e69.

De Carvalho, D.E., Callaghan, J.P., 2011. Passive stiffness changes in the lumbar spineand effect of gender during prolonged simulated driving. Int. J. Ind. Ergon. 41(6), 617e624.

Eatough, E.M., Way, J.D., Chang, C.H., 2012. Understanding the link between psy-chosocial work stressors and work-related musculoskeletal complaints. Appl.Ergon. 43 (3), 554e563.

Esmaeilzadeh, S., Ozcan, E., Capan, N., 2012. Effects of ergonomic intervention onwork-related upper extremity musculoskeletal disorders among computerworkers: a randomized controlled trial. Int. Arch. Occup. Environ. Health 32.

Ferguson, S.A., Marras, W.S., Allread, W.G., Knapik, G.G., Splittstoesser, R.E., Jul. 2012.Musculoskeletal disorder risk during automotive assembly: current vs. seated.Appl. Ergon. 43 (4), 671e678.

Feuerstein, M., Nov. 2004. Job stress management and ergonomic intervention forwork-related upper extremity symptoms. Appl. Ergon. 35 (6), 565e574.

Gourdeau, P., 1997. Study of the prevalence of neck and shoulder musculoskeletaldisorders in schoolbus drivers. Can. J. Public Health 88 (4), 271e274.

Haufler, M.N., Feuerstein, M., Huang, G.D., Nov. 2000. Job stress, upper extremitypain and functional limitations in symptomatic computer users. Am. J. Ind. Med.38 (5), 507e515.

Hulshof, C.T., Verbeek, J.H., Braam, I.T., Bovenzi, M., van Dijk, F.J., 2006. Evaluation ofan occupational health intervention programme on whole-body vibration inforklift truck drivers: a controlled trial. Occup. Environ. Med. 63 (7), 461e468.

Kankaanp€a€a, L.V., Kankaanp€a€a, M., Vanharanta, H., Airaksinen, O., H€anninen, O., Dec.2005. Back and neck extensor loading and back pain provocation in urban busdrivers with and without low back pain. Pathophysiology 12 (4), 249e255.

Karimfar, M.H., 2008. Musculoskeletal problems among workers of an Iranian zincindustry. Pak. J. Biol. Sci. 11 (1), 32e36.

Kee, D., Karwowski, W., 2001. The boundaries for joint angles of discomfort forsitting and standing males based on perceived comfort of static joint postures.Ergonomics 44 (6), 614e648.

Kee, D., Karwowski, W., 2003. Ranking systems for evaluation of joint motionstressfulness based on perceived discomforts. Appl. Ergon 34, 167e176.

Kee, D., Karwowski, W., 2007. A comparison of the obsevational techniques forassessing postural loads in Industry. Int. J. Occup. Saf. Ergon 13 (1), 3e14.

Lewis, R.J., Krawiec, M., Confer, E., Agopsowicz, D., Crandall, E., 2002. Musculo-skeletal disorder worker compensation costs and injuries before and after anoffice ergonomics program. Int. J. Ind. Ergon. 29 (2), 95e99.

Massaccesi, M., Pagnotta, A., Soccetti, A., Masali, M., Masiero, C., Greco, F., 2003.Investigation of work-related disorders in truck drivers using RULA method.Appl. Ergon. 34 (4), 303e307.

Okunribido, O.O., Shimbles, S.J., Magnusson, M., Pope, M., Jan. 2007. City bus drivingand low back pain: a study of the exposures to posture demands, manualmaterials handling and whole-body vibration. Appl. Ergon. 38 (1), 29e38.

€Ozcan, E., 2011. _Is yerinde Ergonomik Risklerin De�gerlendirilmesi ve HızlıMaruziyetDe�gerlendirme Y€ontemi. Mühendis Makina 52 (616), 86e89.

€Oztürk, N., Esin, M.N., 2012. Investigation of musculoskeletal symptoms and ergo-nomic risk factors among female sewing machine operators. Int. J. Ind. Ergon.41 (6), 585e591.

Pope, M.H., Goh, K.L., Magnusson, M.L., 2002. Spine ergonomics. Annu. Rev. Biomed.Eng. 4, 49e68.

Raanaas, R.K., Anderson, D., 2008. A questionnaire survey of Norwegian taxi drivers'musculoskeletal health, and work-related risk factors. Int. J. Ind. Ergon. 38(3e4), 280e290.

Ronchese, F., Bovenzi, M., 2012. Occupational risks and health disorders in transportdrivers. G. Ital. Med. Lav. Ergon. 34 (3), 352e359.

Sancini, A., Jan. 2013. Risk of upper extremity biomechanical overload in automotivefacility. Biomed. Environ. Sci. 26 (1), 70e75.

Solomonow, M., Baratta, R.V., Banks, A., Freudenberger, C., Zhou, B.H., 2003. Flex-ionerelaxation response to static lumbar flexion in males and females. Clin.Biomech. 18 (4), 273e279.

Sullman, M.J., Stephens, A.N., Kuzu, D., Jul. 2013. The expression of anger amongstTurkish taxi drivers. Accid. Anal. Prev. 56, 42e50.

Szeto, G.P., Lam, P., 2007. Work-related musculoskeletal disorders in urban busdrivers of Hong Kong. J. Occup. Rehabil. 17 (2), 181e198.

Thamsuwan, O., Blood, R.P., Ching, R.P., Boyle, L., Johnson, P.W., 2013. Whole bodyvibration exposures in bus drivers: a comparison between a high-floor coachand a low-floor city bus. Int. J. Ind. Ergon. 43 (1), 9e17.