Clinical Biomechanics Vol. 12, No. 1, pp. 22-31, 1997 Copyright fQ 1997 Elsevier Science Limited.

All rights reserved Printed in Great Britain 0268-0033197 $17.00 + 0.00 ELSEVIER

PII: s0268-0033(97)00048-4

Arm and trunk posture during work in relation to shoulder and neck pain and trapezius activity
0 Vasseljen Jr
PhD,

R H Westgaard

PhD University of Science and

Division of Organization Technology, Trondheim,

and Work Science, Norwegian Norway

Abstract Objective. To investigate work technique in relation to work-related shoulder and neck pain (SNP) and upper trapezius muscle activity. Design. A matched pair, case-control field study of female employees with and without SNP. Background It has proved difficult to distinguish subjects with SNP from those without by vocational electromyographic recordings from the upper trapezius muscle. Other potential risk indicators include psychosocial factors and work technique. This study focuses on the latter. Methods. Manual (14 pairs) and office workers (24 pairs) were recorded during a 30-min work period. Simultaneous recordings of upper trapezius activity by surface electromyography and arm and upper back postures by inclinometers were analysed. Results. Cases and controls were not differentiated on the basis of arm elevation or of trunk posture in the sagittal plane. No significant correlations were found between variables averaging the muscle activity and the arm elevation over the recording period. Statistically significant correlations were, however, found between these variables when analysing recordings at high time resolution (0.2 s) and adjusting for the delay in arm elevation relative to the upper trapezius muscle activity (r = 0.43, manual group; r = 0.32, office group). Conclusions. Factors other than arm elevation probably contribute more significantly to the load in the upper trapezius muscle, and to the development of work-related SNP in work situations with moderate arm elevation. Relevance The study suggests that arm and trunk posture recordings are not a sensitive indicator of risk of shoulder and neck complaints in work with low to moderate biomechanical demands. @ 1997 Elsevier Science Ltd. All rights reserved. Key words: Postural angles, inclinometers, shoulder Clin. Biomech. Vol. 12, No. 1, 22-31, 1997
and neck, trapezius, EMG, case-control, work

Introduction Both electromyographic (EMG) recordings from the trapezius and recordings of arm posture are used to indicate biomechanical exposure, i.e., forces generated in the body to meet work demands, for the shoulder and neck muscles*2. laboratory studies have shown
Received: 15 February 1995; Accepted: 31 July 1996 Correspondence and reprint requests to: Ottar Vasseljen Jr., Division of Organization and Work Science, Norwegian University of Science and Technology, Trondheim, Norway

that there can be considerable deviations in the two measures3.It is not known whether this is the case also in vocational settings, and if guidelines for vocational muscle load and arm posture are interchangeable. This uncertainty affects commonly used guidelines for acceptable work load in the shoulder and neck region, e.g., average muscle load below 8% of maximal muscle force4 and arm elevation below 1.5. Vocational studies of biomechanical exposure and related health effects have had problems showing a dose-effect relationship between the level of muscle

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activity and complaints in the shoulder and neck region at low biomechanical exposure.. Equivalent studies, using postural angles as an indicator of work load, are rare. In a cross-sectional study upper arm posture was related to symptoms in the shoulder and neck. This relationship weakened during 2-year and 3-year followup9. The results therefore need to be confirmed by other studies. Aaras and Westgaard showed that a reduction in shoulder and neck complaints coincided with a reduction in vocational trapezius activity after ergonomic improvements, but there was no clear evidence of a concurrent reduction in postural angles of the arms. The study showed a positive correlation between arm flexion and trapezius EMG in standardized work tasks, an effect also demonstrated in laboratory studies*,. This association was no longer present when work tasks with more varied work contents were included. The present investigation is part of a stratified casecontrol study of -female office and manual workers. Workers with shoulder and neck complaints and symptom-free controls were individually matched on work tasks, age and employment time. Biomechanical exposure was measured by upper trapezius EMG recordings and recordings of arm and trunk posture. Psychosocial and personality factors were assessedin structured interviews. In previous reports it was shown that EMG measurements, particularly muscle activity at rest, differentiated cases and controls in the manual group, while psychosocial and personality variables were important differentiating variables for the office group4.1. The present study reports the results of the postural recordings, and how these related to the recording of muscle activity in the upper trapezius muscle. The aim of this paper was twofold: (1) to investigate whether cases and controls in the two workgroups could be differentiated on the basis of arm and trunk posture, and (2) to examine to what extent arm elevation and trapezius EMG recordings are equivalent measures of vocational biomechanical exposure in the shoulder and neck region. Methods A case-control design with matching on work-related biomechanical exposure factors was used. The subjects were matched n age and on exposure factors such as working hours, ength and type of employment, both with respect to 0: c rrent and historical exposure factors; see Vasseljen ar d Westgaard14 for details on the matching procedu5e. EMG and postural angle recordings were performed during a 30-min work period. It was ensured that the one or two most commonly performed work tasks were chosen for the work recording, in which the same type of work was performed by both the case and the control of each pair. The study was approved by the regional medical

ethics committee. All participants gave signed informed consent.

Subjects

Based on interviews of 297 employees in both manual and office work, 76 females were included in the study, giving a total of 38 pairs. The main selection criterion for caseswas presence of continuous shoulder and neck pain for at least 2 weeks during the previous year, with pain at 3 or higher on a scale from 0 to 61h. Subjects with no shoulder and neck pain during the same period were included as controls. Those with shoulder and neck pain due to injuries or systemic disease were excluded, as were pregnant women, those with diagnosed fibromyalgia, and those with symptoms of degenerative joint disease of the cervical spine. It was a requirement that individuals in manual and office work had been employed for a minimum of 1 and 2 years respectively. The manual work group included 14 pairs (median age 26.5 (95%CI 25-31) years, median employment time 5.8 (95%CI 4.5-7) years), whereas the office group included 24 pairs (median age 37.5 (95%CI 34-43) years, median employment time 14.8 (95%CI 10-19) years). The manual workers were significantly younger (P<O.Ol) and had been employed for a significantly shorter period (P<O.Ol) than the office workers. A significant difference was found in mean body height between the manual and office group (manual; 165.1 cm, 95%CI 162.9-167.3 and office group; 168.5 cm, 95%CI 167-170.1, P=O.Ol). There was no significant difference in body weight between work groups, nor was there any difference in body height or weight within work groups (casesvs. controls).
Work description

The manual workers were recruited from a postal distribution centre and a paper mill, and the office workers from a bank and an insurance company. The manual work involved tasks where the arms were used in a larger range of motion than for the office work. The postal work consisted of sorting bulk deliveries of mail and letters, was repetitive and monotonous, with job rotation performed once or twice a day. The workers typically lifted light parcels (approx. l-3 kg on the average) or sorted letters in shelves while standing or sitting. The paper mill work consisted of handling paper bags and cardboard in both standing and sitting. The work was machine paced and similar to the postal workers with regards to monotony and repetitiveness. The office workers were seated at a desk, performing regular computer and desk work. The VDU work was mostly performed in a data dialogue mode.
EMG recordings

Surface EMG was used to quantify upper trapezius muscle activity. Integral, integrated-circuit bipolar

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Ag) electrodes, 6 mm in diameter and with a 20-mm intercentre distance, were used. The centre of the integrated electrode was placed at a point 2/3 the distance from the spine of the seventh cervical vertebra (C,) to the lateral edge of the acromion. The EMG signals were band-passed filtered at lo-1250 Hz and stored on a digitizing recorder(Earth Data 128). The signals were later full-wave rectified and averaged at 0.2-s resolution. Detailed information on the EMG recording technique is found in Vasseljen and Westgaard14. EMG calibrations were carried out before and after the vocational recordings. Two maximal contractions were performed both in shoulder elevation (shrugs) and in 90 arm abduction. The contraction that produced the highest EMG amplitude was used as the basis for the EMG calibration procedure (%EMG,,,). The vocational muscle activity was described by variables averaging the EMG over the measurement period (static, median and peak levelsi) and by variables aiming to quantify aspects of the temporal EMG pattern or pauses in the muscle activity (EMG gaps, long gaps, gap timelY).
Postural angle recordings

(flexion/extension) and frontal (abduction/adduction) planes. However, no recording was made of rotation in the glenohumeral joint. For this reason, and since arm movement in both the sagittal and the frontal planes is considered to contribute to the risk of musculoskeletal complaints, the recordings were transformed into polar coordinates according to the equations: arcsin2X = sin2a + sin2b * cos2a
arctan Y

(1)
(2)

= sin b/sin a

where a and b are the two measured angles, X is the elevation angle, and Y indicates horizontal orientation angle relative to the sagittalifrontal planes. In this paper only elevation angle is reported. The data reduction of the continuous recording of postural angles was performed by a cumulative probability function analysis over the entire recording period, giving static (10% probability level), median (50%) and peak (90%) levels18*21,and by variables attempting to quantify aspects of the temporal postural angle pattern (time and number of movements above 30 and below 10 arm elevation).
Statistical analysis

Postural angles of the upper arms and upper back were recorded continuously during the 30-min work period, in parallel with the bilateral EMG recordings from the upper trapezius. Postural angles were measured by electrolytic liquid level sensors (Physiometer PHY-400, Premed A/S, Norway). Two sensors were placed at right-angles in a cylinder (weight 60 g, length 60 mm; diameter 30 mm), allowing measurements of postural angles in two planes. The accuracy of the postural measurements have been evaluated by mounting the potentiometer on an isokinetic device and measuring dynamic movements at different speeds (3O*s- to 903- ) 2. The difference between the predetermined position and the measured position varied by no more than 3.6. The sensors are thus considered acceptable for the purpose of ergonomic studies. The postural signals were recorded and stored on the digital tape recorder simultaneously with the EMG signal. They were later sampled in the laboratory by a computer and time-averaged at a resolution of 0.2 s. Sensors were attached to the lateral aspect of both upper arms at the mid-point between the shoulder and elbow joint. On the upper back the sensor was placed at the upper thoracic spine, attached to a back-pack worn by the subject. Postural angles were measured in terms of deviations from the reference body position; a relaxed standing position with the arms hanging along the side of the body and the eyes fixed at a distant eye-level point. The back recording was analysed for movement in the sagittal plane only; i.e. trunk flexion and extension. For the upper arms, the sensors were located to nominally record movements in the sagittal

An ANOVA model with repeated measures was used for comparisons of casesand controls in both work groups. Variables showing significant differences were retained for post hoc analyses. In compliance with the distribution of the observations, either unpaired t test or Mann-Whitney U test was used to test differences between work groups22. Comparisons were performed two-tailed and differences were considered significant at the PcO.05 level. Pearson product moment correlation for normally distributed data and Spearman rank order correlation in case of non-normal distributions were used to test correlationS22. Correlation coefficients (r) were calculated and PcO.05 taken to indicate statistical significance. It was anticipated that the response measured by the postural angle is slightly delayed relative to the EMG response of muscles that contribute to the movement. Cross-correlation functions23 between trapezius EMG and arm elevation were therefore constructed by calculating the correlation coefficient between the two channels with the signals time-shifted in 0.2 s intervals from zero to a maximal time shift of 30 s. The delay of the mechanical response relative to the muscle activity was determined by the time shift of the central peak in the cross-correlation function. The half-width of the central peak was used to indicate the sharpness of association between the two variables.
Results Postural angles vs. musculoskeletal complaints

The side with the highest median arm elevation level

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was considered most at risk for developing shoulder and neck myalgia, and thus used in the further presentation of the group data. The static, median and peak arm elevation levels are given for cases and controls in the manual group (Figure la) and the office I There was no difference between group (Figure lb,. cases and controls in either work group. In fact a high consistency between cases and controls was found for all variables in both work groups. The considerable variation in job characteristics of the manual and office groups was not to any appreciable extent reflected in the static level (7.1 v,s 6.1, P=O.O4), but the manual group showed a marginally higher median (19.5 vs 15.6, P=O.O03) and a clearly higher peak (40.6 vs 26.6, P<O.OOl) arm elevation, all values given as the median of the distribution curve for each variable. The mean difference between static and peak levels for each individual was significantly larger for the manual (31.4, 95%CI 28.6-34.3) than for the office workers (19.8, 95%CI 18.0-21.7), P<O.OOl. The temporal pattern of arm elevation was quantified in terms of the number and time of movements above 30 (high load) and below lo (low load) arm elevation (Figure 2). Again, no difference was found between casesand controls for any of these variables in either work group. Overall comparisons of the manual and office work groups showed clearly higher levels (P<O.OOl) for the manual workers on number of movements above 30 (12.6 vs 2.1 min-; Figure 2a), time above 30 arm elevation (11.5 vs. 3.8 s.min-; Figure 2b), and number of movements below lo arm elevation (17.4 VJ. 7 min-; Figure 2~). However, no difference was seen for time below 10 arm elevation (Figure 2d; 10.9 ssmin- in the manual and 13.1 semin- in the office group, P = 0.08). Flexion and exl.ension movements of the trunk were analysed for the manual group only. The cases and

controls worked with median forward trunk flexion of 7.9 (95%CI 4.7-11.1) and 9 (95%CI 5.8-12.2) respectively (overall mean 8.4), with a difference between the static and peak levels of 28.4 (95%CI 21.1-35.7) for the cases and 33.3 (95%CI 23.2-43.4) for the controls (overall mean 30.9). There was no significant effect of pain status.
Relationship between arm elevation and trapetius EMG activity

The right arm posture and the right upper trapezius were used to investigate relationships between arm elevation and trapezius EMG recordings. The median EMG activity in the right upper trapezius ranged from 0.6 to 12.5%EMG,,, for the manual workers, and from 0.5 to 9.3%EMG,,, for the office workers. Median right arm elevation ranged from 6.1 to 36.1 for the manual workers, and from 7.1 to 27 for the office workers. There was no correlation between median arm elevation and median upper trapezius muscle activity levels in either work group when values averaged over the 30-min work period were used (Figure 3a). Similar results were seen when other EMG and posture variables, presumably quantifying related exposure dimensions, were analysed, such as number of EMG gaps below O.S%EMG,,, versus number of movements below lo arm elevation (30.2 s duration for both variables; Figure 3b), or time with muscle activity levels below O.S%EMG,,,, versus time below lo arm elevation (Figure 3~). Weak correlations were found between the peak EMG level and the number of movements above 30, both for the manual (r=0.37, P=O.O5) and the office group (r=0.29,
P= 0.05).

A
5Or

B
50" f

WI-r

Static

Median

Peak

Static

Median

Peak

Fiquro 1. Arm elevation angles (degrees) obtained from the vocational recordings for the manual (A), n = 14 pairs, and office (B), n = 24 pairs, workers. Mean values with 95% confidence interval are given for static, median, and peak levels. Arm with highest median arm elevation value was used as basis for all data generation in Figures 1 and 2.

The relationship between right arm elevation and EMG activity in the right upper trapezius was examined at high time resolution by computing the cross-correlation function (see Methods). Figure 4 shows representative cross-correlation functions for a manual worker (Figure 4a) and an office worker (Figure 4b). The narrow central peak in Figure 4a relative to Figure 4b is probably due to the more rapid arm movements of the manual worker. This difference in the cross-correlation function of the manual and office worker was confirmed in a larger material of six manual and 10 office workers (mean half-width 1.8 s and 5.4 s respectively). The mean time delay of the peak of the crosscorrelation function was 0.44 s for the manual workers and 0.34 s for the office workers. For the manual workers the adjusted peak correlation (r = 0.43, 95%CI 0.37-0.49), i.e. adjusting for the time delay to achieve maximal correlation, was 33% higher than the correlation without time adjustment (r = 0.32, 95%CI 0.27-0.38). The respective values for the office group were 0.32 (95%CI 0.26-0.37) and 0.29 (95%CI 0.23-0.34), a 10% increase after adjustment.

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oManual Office Manual Office

Manual

Office
for both work groups, as illustrated with the number of arm movemants (s) with the arm located above 30 (B) and below 10 (0) arm elevation,

Figure 2. Temporal arm elevation pattern obtained from vocational recordings per minute above 30 (A) and below 10 (C) arm elevation, and time per minute Median values with 95% confidence intervals are given.

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The variation in muscle activity at different intervals of arm elevation (O-15, 16-30, 31-45 and >45) was investigated after adjusting for the delay in the arm elevation. A considerable variation in the muscle activity was found for all intervals of arm elevation, exemplified in Figure 5 for a manual worker. Slightly lower variations were seen for the office workers.

2 14c3 g 12g I0 .$ arn 6.2 2 mo 4f; s 25 f O 0 IO 20 30 40 Arm elevation

Generally, the EMG activity at arm elevation above 45 showed approximately twice the variation of the EMG activity at arm elevation below 15. Static, median and peak EMG activity were investigated for the same postural intervals in eight manual and eight office workers. Four cases and four controls were selected at random from each work group. Large interindividual variation in the EMG variables was seen for all arm elevation intervals in both work groups (Figure 6). The static EMG activity level was similar in the two work groups, and little affected by arm elevation at angles up to 45. Both

A
0.7 0.6

0.2 0.1 0.0 IAL

-0.1 I, I I I I I I

-30
O* dc4 I ' 0 0 0

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-10

0 Seconds

10

20

30

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30 0.7 , 0.6 1

I I I

10

15

20

25

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10

20

30

40

50

60

-30

-20

-10

0 Seconds

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30

Time below IO arm elevation (wmin-)

Figurr 3. Relationships between simultaneously recorded arm elevation and upper trapezius EMG activity averaged over a IO-min work recording for manual (filled symbols, n = 28). and office workers (open symbols, n = 48). Median traperiu:; activity (%EMG,.,) against median arm elevation (A), number of EMG gaps against number of movements below 10 arm elevation (B), and time below 0.5 %EMG,, against time below 10 arm elevation (C) are shown. Values are given for right arm and trapezius.

Figure 4. Cross-correlation functions between upper trapezius activity and arm elevation. One manual worker (A) and one office worker(B) are shown. Dots represent correlation coefficients for various time shift intervals of 0.2 s from zero to + 30s. Zero corresponds to correlation coefficient without time adjustment, indicated by the arrows. Highest correlation occurred at a latency of 0.6 s for the manual worker and 0.4 s for the office worker.

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groups showed a clear increase in the static level at arm elevations above 45.

15 O-16" A

Discussion This study has shown that -a number of variables, derived from the continuous recording of arm elevation angle, did not distinguish cases with complaints in the shoulder and neck region from healthy controls in the two study groups. Nor was there any significant effect of pain status on trunk posture in the sagittal plane for the manual workers. Arm elevation and trapezius EMG appeared to be largely independent representations of biomechanical exposure in the shoulder and neck region for these work situations, where arm elevation in excess of 45 rarely happened.

10 5-

O,5 I 10 0

10 20

30

40

50

1630"

Methods Continuous measurements of arm posture during work, for assessment of biomechanical exposure relating to shoulder and neck complaints, have been carried out only to a limited extent. Such techniques have more frequently been used to analyse back movements24725. In studies comparing observational and instrumentation-based techniques it is argued that observational techniques are insufficient in field trials. Percentage of worktime with flexed trunk (>20) is reported to vary by more than 20% when direct observation (the OWAS method) was compared with simultaneous measurement of back postural angle by inclinometers25. Direct observation, self-reported postures and instrumentation-based techniques for recording of posture gave significantly different results in another study2(j. The inaccuracy of observational methods is to some extent acknowledged by their quantification systems, operating only with three or four categories of postural angle quantifications2. The introduction of apparatus that continuously records body postures allows quantification of postural angles at high time and spatial resolution. The higher accuracy relative to observational methods presumably ensures better reliability and sensitivity, but not necessarily improved validity when used as a risk indicator for shoulder and neck pain. Several factors modify the relationship between arm posture and biomechanical forces in the body, including arm support, hand loads, speed and accuracy of movements, eccentric or concentric work, and shoulder elevation. Due to the pairwise matching of cases and controls on physical exposure factors at work, we assume that these factors do not seriously bias the inferences made from the results of this study. Only trunk and upper arm postures were recorded to avoid cumbersome instrumentation. The upper arm posture was only quantified in terms of vertical displacement from the reference position and not

5 0 IL ,5 0 ( -, 40 , 50

10 20

30

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5 0 IAl&+, ,5 I 0 ,

10 20

30

40

50

>46"

10 I
5

0 L4hb4 0 10

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30

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50

Upper trapezius activity (%EMG,,)

Figure 5. Distribution of the vocational EMG recorded trapezius muscle activity at different arm elevation intervals for a manual worker. The intervals O-15 (A), 16-30 (6). 31-45 (CL and >45 (D) are shown. Within each arm elevation interval the histogram columns are scaled to show relative distribution of EMG activity levels.

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for horizontal movements (i.e. horizontal arm adduction/abduction), since ergonomic guidelines for arm posture almost exclusively state risk of musculoskeletal complaints in terms of arm flexion or abduction. The trapezius activity is 20-50% higher in arm abduction relative to the same elevation in flexion3T*. Horizontal arm position may thus partially explain the observed dissociation between arm elevation and trapezius EMG activity. Variation in head inclination may likewise contribute to the dissociation. However, in an occupational task with increasing arm flexion and

a simultaneous reduction in the forward flexion of the head towards a neutral posture, trapezius EMG was positively correlated with arm flexion and negatively correlated with head inclination. This indicates that arm posture, rather than head posture, is the more important postural variable to influence the trapezius EMG level.
Trapezius EMG vs. arm elevation

In the present study there was a concurrent increase in

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2 A
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25

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Figure 6. Vocational eight office workers

static, median, and peak upper trap&us EMG levels at different arm elevation (B,D,F; open symbols). Lines represent median levels for the subjects shown.

intervals

for eight manual

(A,C,E; filled symbols)

and

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arm elevation and median and peak EMG muscle activity, but not in static EMG level at arm elevation angles below 45. Analysis of the complete material of 76 subjects may have shown a statistically significant association also for static EMG level. However, the practical result of a low association between static EMG level and arm elevation at low to moderate elevation angles is likely to remain; thus there appears to be a potential for short periods of rest for the trapezius muscle at moderate arm elevation. This result probably rests on (1) the trapezius being a stabilizer of the shoulder girdle and not a primary mover of the arm, and (2) dynamic movement rather than static posture was examined. There were no correlations between EMG and arm posture when both types of variables were averaged over the recording period. Correlations were, however, observed when analysing recordings at high time resolution and adjusting for the time delay between the activity in the upper trapezius and the mechanical response of the arm. These correlations were stronger for the manual workers, presumably due to the more rapid arm movements in this group. Considerable interindividual variation in the EMG activity was observed at all arm elevation intervals and for both work groups. Differences in the weight handled have probably contributed to the interindividual variation in case of the manual workers. Some of the postal workers were using dynamic throwing movements, which may cause the hand load to change according to arm elevation, thereby masking a presumed relationship between EMG and arm posture; However, the interindividual differences in the handling of external loads were small or nonexistent in case of the office workers. The dissociation between trapezius EMG levels and arm elevation angles is thus not easily explained by applying more complete biomechanical models including, e.g. hand loads. Trapezius EMG and arm elevation may therefore be considered independent indicators of postural load in the shoulder and neck region for work situations with low biomechanical exposure. Shoulder elevation and the level of agonist-antagonist cocontraction in the stabilization of the shoulder girdle may contribute to the dissociation.
Arm elevation as a risk indicator for complaints in the neck and shoulder

Work at constantly high arm elevation angles has been found to cause more pain and stiffness in the neck and shoulder than similar work tasks with variable working height 28 . This is also an assumption of observational methods quantifying postural stress in the shoulder and neck region. Such methods have defined various low risk limits for developing shoulder and neck complaints at arm flexion or abduction of O-45o29,3o,O-3031 or 0- 15 (neutral)/45 (mild elevation)32. Thus most subjects of our study groups were in the low-risk

category with respect to biomechanical exposure. In the manual group workers exceeded 45 arm elevation 5-10% of the observation time, but there was no indication that this contributed to an increased risk of shoulder and neck complaints, nor would it be considered a significant risk situation in terms of the biomechanical guidelines. A potentially interesting extension of traditional biomechanical analysis is to consider time in low elevation positions, i.e. below 10 of arm elevation, as an analogy to the EMG gap analysis. However, this variable showed no sign of differentiating cases and controls either in the manual group, who previously were differentiated on the basis of the EMG gap analysis14,or in the office group. The result is consistent with the finding that the static trapezius activity in both the office and the manual groups were not much affected by arm elevation at elevation angles below 45. The present study does not rule out the possibility that those with pain had modified their earlier pain eliciting posture and movements to those less loading, e.g. by cases changing work technique after pain development. Longitudinal studies of the relationship between postural variables and health effects are needed to confirm the results of the present study. Cases and controls were, however, distinguished on basis of variables not easily transformed into postural variables measured during occupational activity. Furthermore, a recent longitudinal study did not find evidence of a change in EMG variables following a change in pain status6,33.A masking of an underlying biomechanical exposure-health effect relationship by pain-related changes in work technique therefore appears less likely. These results put a perspective on biomechanical guidelines for arm posture. While near-neutral work postures have been recommended, there is little evidence in this study to suggest that median arm elevation is a sensitive indicator of risk of shoulder complaints at elevations below 45. This conclusion is qualified by the following points: (1) choosing cases with complaints located to the glenohumeral joint or rotator cuff muscles may have yielded a different result; (2) postural variables not monitored (e.g. head inclination) may contribute as discriminating risk factors, either by themselves or interacting with arm elevation; (3) the hand load is an important contributor to biomechanical load, but was in this study hopefully eliminated by the pairwise matching procedure; and (4) median arm elevation may be a risk factor in work situations with more static arm postures than for the present workgroups. However, shoulder elevation, rest ing EMG activity (manual workers in this study and6), perceived general tension (both groups of this study and34), and psychological and psychosocial risk factors (office workers in this study and35) are probably more important risk factors in the development of shoulder and neck complaints at low biomechanical exposure levels.

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Acknowledgements This study was supported by a grant from the Norwegian Research Council. References
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