Our Ergo Risk Analysis format

There are several established tools for doing an Ergonomics Analysis.  I was frustrated with most because they were taking something simple and making it very very complex.  Many have very questionable methods of “quantifying” risk (one even uses how much the worker grimaces as a measure of loading!).  IT IS DOES NOT NEED TO BE THAT COMPLEX.

We know the individual MSD risks, so we made a simple checklist.  That is what the client workplace wants and needs, without the false complexities of formulas that require another consultant to translate for them.  Attached is our checklist.  You simply check off the presence of observed risks.  You can code them as repetitive or sustained or loaded, if that helps the cause.  But it looks for posture, movement, and loading… at neck, low back, shoulder, elbow, wrist, hand.

When we present an MSD School at the client workplace, we use these findings to customize our presentations.

Neck: forward head posture habit, awkward neck posture required (such as backing up forklift frequently), sustained sitting, sustained standing, awkward heights.  Shoulder reach: how high, how far, how often, how prolonged, how loaded.  Tennis elbow risks: wrist loading how high, how far, how often, how prolonged, how loaded.  Golfer’s elbow loading-grip: how high, how far, how often, how prolonged, how loaded.  Grip or pinch: how often, how prolonged, how wide-narrow, how forceful, vibration.  Wrist loading: how flexed, deviated, force, duration, repetition. Thumb loading, especially in wrist deviation (deQuervains risk).

Low back:  Sitting, prolonged, seating adjustability, foot support.  Bending: how low, how often, how prolonged.  Twisting: how far, how often, how prolonged.  Lifting: how heavy, how low, how high, how far from torso, twisted, cumbersome, handle. Whole body vibration.

Work organization:  How much task variety in posture and movements, length of shift, overtime exposure, production incentive pay (piecework), new employees, older workers, turnover, workplace politics (good luck with that one).

Costs risks… How are claims handled:  Early reporting encouraged or punitive, access to timely healthcare, access to quality occ med healthcare, access to PT care, is restricted duty available, does it progress to regular work in timely manner?

Below is our MSD Risks Checklist (picture and pdf link).  A good one to accompany it to address materials handling-lifting is the WISHA Lifting calculator (very simple and easy to do and understand (much easier that NIOSH Lifting Equation and just as reliable) (pdf link).    REBA and RULA are also recognized assessment tools for documenting MSD risks, providing a raw single score for summarizing ergo risks

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Work.Injury.Prevention.Practice. PT Seminar!

“Where do I learn how to become a successful MSD prevention consultant to workplaces?” you ask?   We now offer a detailed self-study course on this.

Build a Workplace MSD Prevention & Ergonomics Consulting Practice

Topics summary outline…

>The Physical Therapist in the Workplace: Needs, Opportunities !
>Re-defining the Roles of the Physical Therapist
>Safe haven from today’s hostile healthcare rip-off economy
>Success examples: Lauren’s prevention consulting practice; and others

>Re-defining workplace musculo-skeletal disorders (MSD)
>MSD as a “Nutrient Pathway Disorder”
>Repetitive motion injury… versus… “static posture disorder”
>Pathophysiology and pathomechanics of neck-arm overuse disorders
>Pathophysiology and pathomechanics of low back overuse disorders
>The AGING worker !

>Today’s workplace: emerging changes and unique challenges
>Workplace MSD Ergonomics Risk Factors list
>Ergonomics versus worker behaviors risks
>Non-Ergonomics risks: body mechanics, posture habits, fitness-for-work

>Evaluating the workplace; MSD Ergonomics Risks Assessment protocol
>The 5 “E’s” of MSD Elimination
>Newest (versus outdated) Ergonomics tactics
>The MOST effective MSD prevention strategies
>Socio-political complications of MSD and Worker Comp

>Providing the on-site workplace MSD SCHOOL !
>Modifying this to fit the client: Office Ergonomics; Aging Worker School

>>THE KEY: Effective MARKETING of your services !
>Finding your clients workplaces
>Making the proposal
>Overcoming their objections
>Managing workplace POLITICS

>>YOUR Workplace Consulting Practice: startup & growth success plan

This is a collection of powerpoints, audio files, and supportive documents

chapter 1… The scope of PT opportunities for onsite workplace consulting; our underlying strategies; essential foundational PT approaches

chapter 2… Neck-Arm Overuse MSD pathomechanics, risk factors, prevention tactics; how to build these into a workplace Neck-Arm MSD School.

chapter 3… Low Back MSD pathomechanics, risk factors, prevention tactics; how to build these into a workplace Low Back MSD School.

chapter 4… How to evaluate workplace Ergonomics and MSD risks; develop the MSD prevention plan; teaching companies how to reduce their Worker Comp costs.

chapter 5… The key to a successful consulting practice: MARKETING preventionto client workplaces; negotiating a proposal; finding client workplaces; managing for success.

To inquire… email Lhebertpt@prexar.com

**More detailed info & content outline: SelfStudyInfo

**PREVIEW Part One seminar powerpoint..1intro


Lauren teaching an MSD School session at local workplace


Self-study course cost? $200

AND, as a shortcut to success… if you choose to later acquire our prevention consulting practice “kit” containing all my consulting practice tools, we will apply the self-study course cost to reduce the cost of you acquiring that ‘kit’. This allows you to launch your practice by simply copying all of my practice tools and materials. The kit includes all versions of my workplace MSD School powerpoints, lecture scripts, employee handouts on pdf, ergonomics risk assessment tools, all marketing materials and guidelines and use of the impacc.com web site to allow your client workplaces to preview your (our) prevention program. Using my program allows you to point out its outcomes, extremely valuable in client marketing. Kit normally sells for $600. But now, minus the cost of the self-study course.


EXAMPLE: preview our workplace MSD SCHOOL (Office Ergonomics version)

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1. WORKPLACE MSD SCHOOL workplace handout…


2.  OFFICE ERGONOMICS  handout manual & summary pg


ComputerSetup2 summary handout



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4. MSD PATHO-PHYSIOLOGY outline,  references-evidence list


4.  E-books for injured workers – patient educ – self care




AND OUR FAVORITE… how to slow-stop-reverse MSK AGING !




Excellent on eccentric exercises for tendinopathy:

Managing LB Pain Risks (2) :
The Next Path for Pain Neuroscience Education


Critical factors re Subacromial Impingement Sx (posture, etc)

Non-surgery Rx for Rotator Cuff Tears:

The APTA self-study The Injured Worker (APTA Ortho Section)

What is an MSD SCHOOL ?



IT IS A GREAT CONSULTING PRACTICE FORMAT.  Just 2 days/wk of this consulting action generates half of my clinic’s income.  There have been a few years where I did not have a clinic and did only this, earning great income with no clinic overhead costs.  So, what is this??

We all remember the workplace “Back School”, introduced back in the 1980’s.  They worked very well to reduce workplace back injuries, especially those that were McKenzie-based.  We designed a similar “risk factor education” strategy to address neck-arm CTD overuse disorders.  This also worked very well.

We designed a version of Back School that encompasses a range of LBI risks beyond “lifting” (since lifting is not cause of many back injuries. LBI occurs during lifting mostly to a back that is already screwed up with degenerative changes and dysfunctions). Our version addresses the wider range of low back dysfunction risk factors… materials handling, posture risks, ergonomics, fitness-for-work, aging changes.. and a wide range of personal prevention interventions that can reverse these varied risks.

We also designed a Neck-Arm CTD School that is based NOT on repetitive motion risks, but more on Static Posture risks (far more important and fixable than repetitive motion).

We merged these into our “MSD School” addressing low back and neck-arm MSDs.  THAT is what we now bring to the workplace, teaching everyone how MSDs develop and how to avoid or reverse them.

Our “MSD School” spends first hour on neck-arm risks, then the second hour on LB risks.  It teaches musculoskeletal anatomy and pathomechanics of neck risks, rotator cuff risks, tennis elbow risks, golfers elbow risks, deQuervains, and CTS.  Then, follows the same pattern for LB problems for facets joint, disc, ligs, muscle, SIJ risks.  Prevention interventions proposed include ergonomics changes, work task rotations, sit-stand rotations, job specific micro-stretches, after work recovery stretches… all customized to the jobs being addressed.  That means the PT must assess the workplace prior to MSD School in order to customize presentation, for maximum effect.

MSD School teaches workers musculoskeletal biomechanics, MSD pathomechanics, personal ergonomics tactics, posture control (the key!), and self-care microstretching.



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Does this work?  Is it effective?  We have done this at 600 workplaces since 1982, with average decrease in MSD lost work days of 72% in the year following MSD School.

One published study in APTA Ortho Section Self-study graduate course monograph (strictly peer-reviewed) “The Injured Worker: Prevention & Ergonomics” is summarized below.  Yeah, this works.

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What does our MSD School look like?   Here are selected portions of our presentation, first hour addressing neck-arm overuse MSD, second hour addressing low back MSD:





HERE IS A PDF OF ONE VERSION OF OUR MSD SCHOOL (office-computer version).   computerMSDschool 

Here is employee handout for our MSD School…MSDschool

DESIGN YOUR OWN PROGRAM?    You can build your own presentation using a PowerPoint program… OR… you can acquire an established program, like ours, all ready to go, with a highly marketable track record of good outcomes.

OUR PREVENTION CONSULTING PRACTICE PACKAGE…  a thumb drive or CD of all of our powerpoint programs, including several versions of our MSD School such as the Office Ergonomics School (big demand for this) and Aging Worker School (also big demand), plus all support documents and marketing protocols (a critical part of this package!).

Our program package is structured to allow you to customize it to match your philosophies and to address specific risks for each client workplace.

The primary advantage of using an established program like this is you can refer to its track record of outcomes, since that is the primary criterion a workplace will use in deciding whether to hire you to provide a prevention program.

Check out our Workplace Consulting “kit” that allows PTs to replicate our programs at http://www.smartcarept.com and got to page “NLT Kit”  (No-Lost-Time).  Or email me to receive description details

Check out how we describe our services to client workplaces. We direct potential client workplaces to preview our programs at http://www.impacc.com

Our MSD School can be customized to fit any type of workplace. We also have a version dedicated specifically to office ergonomics. This is a version many PTs use to start their consutling practice, since it is so easy to address this high-risk work setting. We also have a version dedicated to the AGING Worker (The Age*Less Program). These are all a consistent 2-hr workplace presentation.

A complete program for most client workplaces starts with a unique version of the PT doing an on-site MSD Ergo Risk Analysis, producing a written risk report for the client workplace detailing all the MSD risks for each job. This serves as the basis for customizing your MSD School to fit the client workplace.

See other posts on this blog re. setting up the Micro-Stretch program that fits their jobs, plus a post on doing an MSD-Ergonomics Risk Assessment for the client workplace as a basis for customizing their MSD School presentation.

FMI… Lhebertpt@prexar.com.

Lauren teaching an MSD School for the night shift at the millimage

Seminar we do for employers in the community to preview our program.

Training an in-house ‘Ergonomics Team’ at client workplace8981810d-f2b1-4698-87ae-513e5c404518

…including the ‘Aging Worker’

New Computer-Office Ergonomics


The “rules” and recommendations for proper computer setup have changed and improved. There is still too much incorrect and outdated advice out there.

Proper chair setup? 90 degrees at hips, knees, elbows is not correct. So what is proper chair setup? It really doesn’t matter what is correct or proper. Why?? Because proper or perfect posture is NOT good for you… if you sustain that posture for more than an hour. It is not the posture that does the damage… it is the TIME sustaining that posture. That is the weight-bearing tissues are getting inadequate blood supply that feeds those tissues.

No matter how proper and good is your posture, you still are working against gravity. Muscles are sustaining their contraction, tendons holding their position, joints and disc under weight-bearing. This creates tissue pressures that exceed blood pressure feeding those tissues. Lack of oxygen delivery leads to anaerobic metabolism, burning way more glucose and creating way too much metabolic wastes that are trapped in those tissues. This causes pain, inflammation, and degeneration.

The best tactic is POSTURE VARIETY !… change seat height 2″ up or down every 15-30 minutes; change seat tilt; change something-anything to create some variety of posture.

Next critical issue is upper extremity weight-bearing support. Neck and thoracic outlet structures work hard to keep head upright. They work equally hard to suspend and support the arms that hang from the neck and thoracic outlet structures when the arms are held unsupported while hands-fingers enter data. But resting weight of upper extremities on a padded desk surface can greatly reduce posture loads on neck-shoulder girdle-thoracic outlet. Push keyboard few inches back from front edge of desk. Place cushion pad there to support forearms. Better yet, position monitor and keyboard deep in the corner of two adjacent desks that form a right-angle to each other (corner desk). This provides full support surface under each forearm.

Monitor squarely in front, not turned at all one side.
Height such that top edge at eye level, so eyes track from zero to 30 degrees down… UNLESS you wear bifocal eyeglasses!  Discussed later below.

Keyboard pushed in few inches from front edge of desk to provide some surface upon which to rest forearms, padded with gel pad. Best way to do that is place monitor and keyboard deep in corner formed by adjacent desks at right angle to each other (corner setup) which allows maximum surface upon which to rest forearms.  Supporting arms like this reduces neck posture loading and reduces thoracic outlet compression.

Switch between mouse vs trackball every hour, for muscle load variety. Mouse all day risks golfers elbow, but trackball all day risks tennis elbow. Switch between these every hour to load exposure to each muscle group… work task VARIETY is key.

Keyboard legs at back corners of keyboard should be folded out for an hour, then folded in for an hour, to create variety of wrist posture, easing time tendons are under a static load… posture variety is key

Headset headset headset, rather than holding phone tucked between head and shoulder. Terrible neck risk!

Chair adjustment… the key is variety! Perfect posture is bad for you if you sustain the position more than an hour. Simply change height 1-2 inches every hour to change neck-lower back alignment slightly, change tilt or other adjustment as may be available… variety is key.
And do 10-second standing backbend at lower back to unload discs every hour.

BETTER YET, use a VariDesk where you place platform under computer, sit there and work, then an hour later pull level on platform to raise it to work standing for a period. Sitting is very bad, standing is bad, so do both, switching at least hourly. Posture variety is key

Use thick soft pad on pens-pencils to reduce thumb joint loading during prolonged pinch.

BIFOCAL EYEGLASSES vs COMPUTER SETUP… Bifocal, progressives, other split-vision glasses are made for reading a book, but will force your neck into a terrible posture when viewing computer screen (you round over upper back to get eyes closer, then hyperextend head on neck to look thru lower portion of eyeglasses… destroying your neck!).
Switch to single vision longer focus distance eyeglasses during computer use, allowing neck posture to be more upright and able to vary-shift neck posture during work time.


Perform miscro-stretches every hour to relax and return blood supply to structures being loaded by prolonged static posture (chin-tucks, lateral neck stretch, jacobesn’s muscular relaxation, wirst flexor stretch, tennis elbow stretch, standing backbend.. and TAKE A 5-10 MINUTE WALK AT BREAK TIME and especially a longer one after work.

See PDF handout re computer setup… ComputerSetup2

Corner desk setup (best UE support)… bifocals risk (severe FHP risk)… Vari Desk




Here is a comprehensive handout I use when teaching workers our Office Ergo School training session… officeErgoEbook

PTs just starting out in the field of MSD prevention & ergonomics consulting often find Office Ergonomics consulting is a GREAT startup service.  It is easy.  It is rather generic from one workplace to another (everyone is doing the same work!).  And there are many, many workplaces that need you for this.  We have fully-developed OFFICE-COMPUTER ERGO-SCHOOL employee training powerpoint program you can bring to the client workplace to teach them all how to take control of this high-risk work.

Our 2-hr employee training session” Office Ergo School

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FMI… Lhebertpt@prexar.com

Perfect Posture is bad for you?

Ergonomics advisors often recommend “rules” for proper work posture…. e.g., sitting with knees and hips at 90 degrees, elbows at 90 degrees, wrists neutral.  Some will recommend keyboard position for wrists slightly flexed, or slightly extended, or neutral.  Some will recommend using a standard mouse versus trackball.  So what is the correct definition of proper posture?
But really, does it matter?  Maybe not!

Could it be that “proper” posture is actually BAD for you?
Consider this: It is not the posture that is good or bad.

The true issue is: time + gravity.
Even ‘good’ posture must endure weight-bearing over a period of time.
Joints and discs are compressed by wieghtbearing…
muscles sustain their contraction…
while tendons sutain tension to mantain that posture.

These loads create tissue pressures that exceed perfusion pressures feeding those tissues… shutting down blood supply, accumulating anaerobic metabolic wastes that lead to irritation, pain, inflammation.
THIS IS POSTURE LOADING… TIME exposure is the hazard, not the position per se.

Yes, poor posture may increase these stresses.
But good posture is stressful if it is SUSTAINED.
The true risk is not the posture; it is the time spent NOT CHANGING posture.

So when I am asked the proper desk chair setup, or keyboard tilt, or mouse versus trackball… my answer is: IT DOES NOT MATTER.   The prevention intervention is POSTURE VARIETY.  Set up the chair any old way, But CHANGE that setup every half-hour simply by changing seat height 2″ up or down; change seat tilt or any other adjustmentevery half hour to create posture VARIETY.

Same with keyboard tilt.  Flip the rear legs of keyboard out for half hour, then flip them in half hour, to create wrist position VARIETY.

Switch between mouse versus trackball every hour to rotate work stresses between tennis elbow versus golfer’s elbow loading.  Reduce TIME EXPOSURE or loading to each vulnerable tissue.

Even better… switch between sitting versus standing every 30-60 minutes




This strategy, of course, extends beyond office ergonomics to include manufacturing and other work categories. Driving jobs should allows frequent posture changes, and these can be effective even if the changes are subtle or slight (shifting seat adjustment slightly often; lumbar roll or pad placed and moved often; switching sit versus stand; rotating between different tasks or jobs; changing how certain items are held or grasped or handled).

Simply ask workers how they may alter postures and movements and actions… after you have educated them on the basic strategy of rotating workloads. Certain individuals will likely have suggestions that can be shared

This is really cheap and highly effective “ergonomics” …and is a greatly under-utilized tactic.

This is what gives us PTs advantage over the engineering-based ergonomists who spend their days arguing over what is proper posture… which misses the boat entirely.

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Micro-stretching WORKS… and works very well…IF IT IS DONE RIGHT !!

But most workplaces don’t do this correctly.
You cannot simply Google up a download and tell workers to do them.

Stretches (or, better yet, microstretches) must be selected to match the MSD risks for the jobs. That can only be done by a professional who is expert on the pathomechanics of MSD (such as the Physical Therapist… the MOST highly trained profesional on this).  

Then, employees must be professionally trained: not just on what stretches to do and how to do them, but on WHY… othwise, they won’t do them.  Once they understand exactly how each MSD develops and how to reverse that process… then they will commit to doing them.

At least that is our experience at the last 500+ workplaces where we have done this.

Why workplaces micro-stretching ? … the critical value of micro-stretching?   Many jobs have MSD risks that just cannot be engineered away… no ergonomics corrections available.  How do we protect these workers?  Job task rotation to minimize uninterrupted exposure time… and micro-stretching.

MSD is a nutrient pathway-perfusion problem: When muscles contract, pulling on their tendons, moving or posturing body parts.. they create pressures and tension that exceed the blood pressure feeding those working tissues. That reduces blood flow to working tissues. That allows the waste products of work (acid wastes that become urine) to back up in those tissues, leading to irritation-inflammation and chemical damage… tendinitis, tendinosis, and degeneration of joints and discs.

Ongoing tension or repetitive contractions mechanically inhibit blood flow.  Very brief stretches to muscle-tendon groups can create nerve responses (the inhibitory response of the Golgi tendon organs) that relax these tissues, allowing improved blood supply, thus removing irritating and damaging chemical wastes.  We are not seeking lengthening of muscles with this particular tactic;  just relaxation of the muscle-tendon unit. The objective is to pause loading and relax the built-up background tension, to allow cleansing blood flow to remove metabolic wastes that accumulate and irritate. It also restores coordination and postural awareness.

One major advantage of brief targeted micro-stretches is it offers a prevention tactic that protects workers on jobs that cannot be made harmless through ergonomic modifications (as is so often the case on many jobs).

These may be done as a structured ‘everyone-do-it-together’ routine (less that 2 min total)… or… even better… everyone gets MSD School training teaching what stretches fit what risks and discomforts, so each individual worker will then be self-motivated and skilled at self-selecting stretches to be done whenever they encounter work discomfort (only 10 sec each).  This works great.

NEW CONCERN… Many companies now employ workplace stretches. But a new problem has appeared: INCORRECT STRETCHES.  Here are some at we recommend, because they are specifically targeted to the highest risk body parts.

CHIN TUCK stretches the upper spine into a posture that corrects slouching (a severe risk of neck, upper back, and shoulder degeneration).

STANDING BACK-BEND stretches lower back into extension, needed for proper disc health and to reduce gradual disc bulging from too much bending or sitting.  We recommend the worker flex at neck, not extend head on neck, to moderate spinal forces.

HAMSTRING STRETCH because tight hamstrings reduces hip bending, thus increasing bending loads on the vulnerable lower back, risking disc herniation and degeneration.

LATERAL NECK SCALENI STRETCHES because sitting and slouch allows later neck muscles to tighten, compressing blood vessels and nerves that pass through them on their way to the arm and carpal tunnel.  Common error is allowing rotation to occur during sidebending stretch.

SHOULDER CODMAN-PENDULUM for jobs with reaching, loading rotator cuff tendons.   This greatly relaxes cuff and restores blood supply to shoulder muscles.

TENNIS ELBOW STRETCH is often done incorrectly in many workplaces. This must stretch both wrist and finger extensors that usually lose elasticity from over-use. This micro-stretch restore blood supply and elasticity here.  Common error is stretching into wristflexion with fingers open-neutral… NOT correct…should be done with fist closed to include digit extensors in the stretch, since they share that proximal tendon and are part of radial tunnel.

GOLFER’S ELBOW & CARPAL TUNNEL STRETCH is also often done incorrectly by many workplaces. This is to stretch wrist-finger flexors (grip and pinch work) PLUS the pronator muscle at the front-to-inside of forearm-elbow, responsible for stressing inner elbow and squeezing nerves to carpal tunnel.  Common error is doing this stretch with forearm pronated… NOT correct… forearm should be supinated to include pronator teres in the stretch, since that is a source of median nv entrapment adding to CTS risk.

DEQUERVAIN’S–THUMB STRETCH addresses work tasks that use thumb loads.

CALF STRETCH reduces plantar fasciitis heel spur and achilles tendon risks.

There may be others, customized to specific jobs (middle back torsion for forklift drivers, others for maintenance tasks, e.g.).

Stretch programs should be designed by a professional Physical Therapist with knowledge of the jobs… to design a small, practical, targeted program.. that is taught to employees by that PT to motivate employee acceptance and skills in these.  The key is face to face training in an MSD School format that teaches not only what to do, but WHY to do it… or else they won’t do it at all.


Here is one version customized for office setting (with a blocking overlay to inhibit download use).  Other versions customized for other settings, e.g., warehouse materials handling work, repetitive task mfg, etc.

Office format of micro-stretching


Wider workplace demands micro-stretch program

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OUR OUTCOMES… Table of data from a study we did of our outcomes, published in Ortho APTA’s monograph self-study course “The Injured Worker” encompassing several thousand workers in multiple states trained by several PT’s using the same MSD School program and micro-stretch protocol. Claims reduced 37%; lost time claims reduced 59%; MSD lost days reduced 78%.

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The AGING Worker… reverse aging?

Especially for the  AGING WORKER  in today’s workplace…

Companies are begging us to help them protect their Aging Workforce.  This is a huge concern, as these are often their most valuable employees, many irreplaceable.  And there is so much valuable advice we PTs can offer to help workplaces and their people avoid age-related MSD issues.  It is becoming our “hottest” program demand.  Do NOT miss out on this opportunity and critical need.

We now provide workplaces a new prevention/wellness program… now in great demand.. called  “Age*Less”  … teaching employees how to take control of their AGING changes.  Workplaces are losing their most valuable employees to MSD with significant aging risks.   Musculoskeletal Aging is REVERSIBLE!…

This is a modification of our MSD School to re-focus content on aging-degenerative changes affecting the middle-aged worker.  we also use this as a seminar for the public to educate the community on utilizing PT to take control of aging issues (great marketing and PR tool).

We offer two definitions of musculoskeletal aging.

Musculo-skeletal tissues (muscles, tendons, ligaments, joint cartilage, spinal discs) are about 80% WATER at age 20. The water makes tissue ELASTIC. But water content drops to 40% by age 40. This greatly reduces elasticity and tensile strength, accelerating more damage, faster, with less loading demand.

Also, daily use breaks off hundreds of microscopic tissue fibers (normal daily life wear and tear), not enough to cause pain. That damage heals during rest, but it heals with scar fibers that have much less elasticity and tensile strength. This daily growth of scar fibers makes tissues weaker and stiffer over time, allowing more damage with less work demands.

This is similar to degenerative arthritis in joints, except in tendons we call it tendinosis.  Normally-elastic tendons no longer freely absorb pulls placed on them.  The resulting internal strain creates pain that some call tendinitis.  This is not an accurate term, because in many there is no actual “inflammation” but, rather, pain from nerve endings being distorted by the non-elastic strain of work (which is why cortisone injections often fail).

Spinal discs shrink (degenerative disc disease), shifting loads to spinal joints (degenerative arthritis) and reducing stability. All THIS is AGING.

GOOD NEWS… These degenerative changes are highly REVERSIBLE with very simple frequent MICRO-STRETCHING and AFTER-WORK RECOVERY STRETCHES. Can we ask workers to do this? Absolutely. These workers are professional athletes… and can be motivated (professionally trained) to accept that self-care responsibility. THIS will be a key component to our upcoming employee training… and critical where ergonomics hazards cannot be corrected !

AGE*LESS ebook manual, handout: AgeLess

Parts of “Age*Less” workplace wellness class…  plus at-work & after-work stretches.  Note changes from our std MSD School vs Aging Worker School (Age*Less program)agel1.png


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Forward head Posture !

My favorite PT motto is “Be An Inch Taller” !

FHP, round-shoulders, slouching… This is the basis for so much aging effects as well as workplace ergonomics and MSD risks.

Think about it… how many UE MSD issues such as longstanding tendinitis-tendinosis, plus neurovascular entrapments such as CTS, cubital tunnel syndrome (underling so many golfers elbow, med epicond), pronator NVE, radial tunnel (underlying so many tennis elbow, lat epi), and other overuse sx… how many actually have potential inputs from some degree of thoracic outlet-inlet compression??  How many have neurogenic nociceptive effects from cervical-thoracic posture strain??  Many?  Most??

FHP is almost always present with sustained sitting and prolonged standing.  Gravity wins. Worsens with fatigue.

FHP:  Fixed flexion of upper thoracic (sustained tension of post ligaments of upper thoracic blanching their blood supply, creating ischemic pain, with nearby secondary spasm) (abnormal loads on discs and facet joints, speeding degeneration). This also creates a stretch weakness of thoracic and scapular stabilizers

FHP:  With flexed upper thoracic, there will be hyperextension at upper cervical to restore level vision.  This compresses subcranial tissues, including greater occipital neurovascular bundle.. headache), as well as upper cervical facets in a close-packed position (DJD).  This also creates the flattening of mid-cervical lordosis.  This degenerates those discs, bringing the uncus of the vertbrae together to form an unco-vertebral joint (joint of vonLusca) leading to the infamous bone spurring at C5-6!

FHP: lateral neck muscles responsible for keeping vision level-horizontal (scaleni) must now shorten to do their job, compressing brachial plexus and obstructing venous-lymph flow out of the UE… backup of interstitial fluids down the UE… slight compression of nerves, causing swelling and irritation further down the arm… TOC leading to double-crush at various “tunnels” in UE.

FHP:  tilts shoulder blade to compress the space occupied by the rotator cuff, reducing blood supply and compressing tissues.

FHP: in standing, there will be a compensatory flattening of the lumbar to maintain balance.  This risks degenerated, bulging, herniated lumbar discs.

FHP:  Pulls on infra-hyoid muscles of swallowing, pulling down on jaw, which is countered by excessive posture work from massetter muscle trying to keep mouth closed.  Leads to over-closing jaw, causing TMJ problems (my favorite patient challenge, so easy to improve).

FHP: Compresses lungs down into diaphragm, flattening it, reducing its breathing role, shifting breathing to scaleni for paradoxical breathing that shortens and overloads scaleni (more TOC risk).

PREVENTION:  Be An Inch Taller! and people will comply once properly educated on this, a simple self-awareness that may improve posture by 10% about 10% of the time… often enough to reverse or at least slow the damage.  Frequent micro-stretches (10 sec) at scalenus medius-anticus, and axial-extended chin-tucks.  Frequently switch between sitting and standing, such as using the Vari-Desk on computer jobs.  Strengthen upper back (Theraband scap retract, eg).  Lateral pterygoid exercises to quiet and correct TMJ.

FHP looking down by flex neck on thoracic FHP.png

Bifocals while working on computer…

MSD treatment & recovery

This essay merges prevention strategies with clinic treatment approaches. Our MSD prevention tactics offer principles for more effective clinical treatment.

MSD is a Cumulative Trauma Disorder… microtrauma accumulates gradually over time, with no symptoms until the sufferer reaches a ‘critical mass’ of damage.  Symptoms arise late, in the ‘end-stage’ of their disease process.

When the injured worker arrives in the PT clinic with one MSD problem, it is usually only one hint of a larger underlying disease process, the first noticeable sign of a “complex of MSDs”.

A tennis elbow, or golfer’s elbow, or deQuervain’s, or rotator cuff impingement, or plantar fasciitis, or one of several neurovascular entrapments such as CTS… BUT any one of these is the result of a wider accumulation of microtraumas, degenerations, and dysfunctions.

We can provide Our PT interventions for the presenting symptoms, and we will likely see success… but how many will later suffer recurrences, plus develop a series of other MSD complaints?  Most will.

We too often treat the presenting complaint rather than address the underlying collection of MSD risk factors and dysfunctions.  Addressing the full scope of MSD risk factors bring better, faster, more longterm success.

I try to assume the presenting epicondyalgia, tendinitis, tendinosis, or CTS is the result of a “cascade of dysfunctions” starting with sustained sitting, forward head posture, a degree of thoracic outlet compression, secondary double crush effects (e.g., TOC leads to pronator entrapment leads to CTS).  There has been ongong degenerative changes predisposing the MSD complaint.  The tendinitis is likely, by now, actually tendinosis (degeneration vs inflammation, which changes PT Rx strategies).

I find this a useful assumption (primary sx arise from a collection of MSD-degenrative changes) when we develop our clinic treatment plan of care.  While we treat the primary site, we EDUCATE the patient on what likely led to sx, and how to correct it all, to maximize recovery and avoid recurrences, thus avoiding a lifetime of issues.

Round shoulders slouching forward head posture stresses nerves and blood supply to the working arms, allowing distal UE tissues to become inflamed from inadequate removal of working tissue metabolic waste products.  Stressful neck posture proximally can lead to distal arm-hand problems.  “So hassle yourself to sit up straight, switch between sit-stand, do frequent micro stretches in chin-tuck and at lateral neck, strengthen scap retractors.”

Check for Adverse Neural Tension signs, implying peripheral nerve entrapments or hypomobilities that may be contributing to medial epicondylalgia (ulnar… VERY common), lateral epicodyalgia (radial tunnel sx), deQuervains (musculocutaneous nv input), just as you would check for CTS sx.  Check for pronator compression of median nv as a contributor to CTS sx  (Kamath & Stothard Score best for implying symptomatic CTS).

Consider this: Simply ask each patient presenting with an UE overuse problem, “does your neck bother you?” (runs about 90%).

MY POINT… always consider PROXIMAL dysfunctions as a potential contributory issue for distal sx.  Proximal static posture stressors are a major risk for distal overuse problems.  This is a primary basis of our MSD School PREVENTION program, which serves us well in our clinic treatment work.

No, this does not overgrow treatment of a MSD complaint to make it unnecessarily bigger than it needs to be.  It does not add costly extra PT visits.  It is part of your care of the patient to address why they have a problem.  Adding some manual therapy and stretches and stability-strength home exercises is not a big add-on, especially when it prevents future recurrences and stops those other subsequent MSD complaints that will appear soon.

I mentioned plantar fasciitis, which another great example of this… especially if sx are bilateral.  Picture this cascade of dysfunctions… degenrated disc for sitting and bending exposures, distorts iliolumbar ligament support of SIJ, leads to tight piriformis.  The tight piriformis, or any disc HNP, irritates sciatic nerve proximally.  This risks secondary entrapment  (double crush) at tarsal tunnel.  A mild degree of TT compression can cause pain at medial distal calcaneous/medial prox plantar fascia.

How much of the plantar fasciitis sx is actually some degree of tarsal tunnel sx? And how much of that is caused by some degree of sciatic irritation from LB and-or piriformis.  We usually include LB-LS-SIJ stretches to address these potential risks when treating for PF… especially if sx are bilateral.

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Check this out… a summary of MSD treatment protocol used by my students

Here is a link to powerpoint of the course I teach on this

Neck-Arm MSD self-care eBook Neck-Arm



Excellent on eccentric exercises for tendinopathy:

Managing LB Pain Risks (2) :
The Next Path for Pain Neuroscience Education


Critical factors re Subacromial Impingement Sx (posture, etc)

Non-surgery Rx for Rotator Cuff Tears:

To purchase self-study The Injured Worker (APTA Ortho Section)

LowBack Dysfunction-Derangement Cycle

Yes, this is a structural biomechanical model. I am fully aware of the pain science and biopsychosocial concerns we employ in the clinic. But this essay here is purely to common pathomechanics concerns.

One cannot reasonably generalize, of course, about low back problems.  …BUT… the onset of workplace Low Back Pain-Injury often follows a common “cascade of dysfunctions” that may help to define a course of mgt (prevention & recovery).

Let us describe a typical course of evolving dysfunction, leading to degeneration, leading to derangement… typical pathomechanics… which can then define a list of targets for the PT to pursue in primary prevention as well as treatment, recovery, return to work.

This is the story I tell workers in the course of our prevention program… and what I tell patients seeking recovery.  Important… the only P.T. intervention that is truly effective on the long-term is:  education (patient education and worker education) to make the individual an EXPERT on how their low back is put together mechanically, how it works mechanically, how it breaks down mechanically.  This informs, empowers, and motivates the individual to take control of their risk factors and spinal mechanics… and achieve effective recovery and prevention. And, again, we must also consider the biopsychosocial model.

The story… Part 1… The vertebra bones sit on one another, weight shared between the discs and facet joints (show them the picture of this).  The disc is 80% water (when you are 20 yrs old)… but gradually loses that water over time, dropping to 40% water around 40 yrs old.  Disc goes from 2/3 inch thick to 1/3 inch thick.  This is a degenerated disc. That increases weight on facet joints by 200-300%.  That can lead to degenerative joint changes.  Pain-stiffness leads to muscle weakness, reducing muscle control, allowing strain-sprain-instability.

Part 2… How I explain it to worker or patient: We spend so much of life sitting and bending.  This shifts weight from facet joints to disc, especially the back half of the disc.  This speeds the out-flow of water from disc.  It also shifts-leans the nucleus of the disc posteriorly against the back wall of disc.  Sitting and bending over-stretches that back wall.  Back wall of disc eventually weakens and over stretches, allowing jelly center to push out on wall… bulging disc.  Wall can eventually fail to contain the jelly, and it blows through… herniated disc.  NOTE… this does not cause pain (very few pain nerves in the disc itself)… unless the bulge or herniation pushes on other structures that are pain-sensitive.

Part 3… Shrinkage of disc or herniation-bulge reduces the space between vertebae.  That allows ligaments that support and stabilize the spine to go slack.  Bones now unstable, shifting abnormally during movement, causing sprain, strain, damage, apin.

Part 4… This instability is especially an issue where pelvis bone attaches to spine (sacro-iliac joint).  This is very stable joint that hardly moves at all, held snug by ligaments.  Some of those ligaments come off the lower two vertebrae (L4 or L5) (iliolumbar ligaments).  If there is reduced or bulging discs at L4-L5-S1, then iliolumbar ligaments go slightly slack, causing abnormal stress-strain at sacroliac joint. This can cause Rotator Cuff of hip (piriformis) to tighten as it tries to help support the sacroiliac joint.  This causes that pain-spasm deep in the buttock.  Piriformis pulls on its tendon at hip, leading to hip bursitis.  It also compresses hip risking hip arthritis.  Thight piriformis can also compress sciatic nerve running underneath it… one more cause of sciatica.

The story… changes at disc, allow ligaments to no longer adequately support sacoiliac, causing tight piriformis, irritating hip and sciatic nerve.

Treatment sequence typically calls for restoring disc mechanics (usually with lower back extension stretches)… stretching hamstrings that may be pulling abnormally on pelvis to stress sacroiliac… stretching muscles at front and back of hip (single knee-to chest with other leg totally flat) to reduce sacroiliac stress and strain… stretching piriformis to reduce its stress and strain to sacroiliac-sciatic-hip.

Then, once disc mechanics and muscle flexibility stresses are improved, we must strengthen the deepest layers of spine stability muscles… supine powerbridges, prone planks, side planks, and quadrupedal multifidus.

Yes, we are threatening to attempt proposing a general low back care protocol with this essay… but it is a good basis for address the pathomechanics of a large group of workplace low back “injuries” and aging worker concerns.

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disc mechanics affects facet WB and lig support, which affects SIJ support, affected by hams & piriformis function.

I will add link here to a powerpoint/PDF of the seminar I teach on this topic… at…

Low Back Dysfunction eBook: LOW.BACK