Effect of lifting belts on trunk muscle activation during a suddenly applied load

The National Institute for Occupational Safety and Health suggests there is insufficient biomechanical or epidemiological evidence to recommend the use of back belts in industry. From a biomechanical perspective, previous work suggests that lifting belts stiffen the torso, particularly in the frontal and transverse planes. To determine whether lifting belts stiffen the torso and alter the trunk muscle response during a sudden loading event, we tested the hypotheses that (a) lifting belts alter peak muscle activity recorded with electromyography (EMG) during sudden loading and (b) lifting belts have a larger impact on trunk muscle response when sudden loads are applied asymmetric to the torso's midsagittal plane. A sudden load was delivered to 10 men and 10 women without history of low back disorder via a cable attached to a thoracic harness; motion was restricted to the lumbar spine. Results indicate that gender was not a significant factor in this study. The lifting belt reduced the peak normalized EMG of the erector spinae muscles on average by 3% during asymmetric loading, though peak normalized EMG was increased by 2% during symmetric loading. Lifting belts have been shown to slightly reduce peak erector spinae activity during asymmetric sudden loading events in a constrained paradigm; however, the effects of lifting belts are too small to provide effective protection of workers. Actual or potential applications include the assessment of lifting belts as protective devices in workers based on the effects of lifting belts on the trunk muscle activity.     

Trunk motion during lifting: The relative cost

The cost of lifting motion to back loading has been investigated traditionally by monitoring the electromyographic (EMG) recordings of trunk muscle during a controlled lift. When subjects are tested on an isokinetic dynamometer, the EMG activity decreases as the velocity increases and trunk torque production also decreases with added velocity. However, during an actual lift, the necessary torque needed to handle the load remains constant regardless of the lift speed. This research has investigated the muscle force per unit torque which is needed to support a load under various trunk velocities. Forty-five subjects were tested for maximum torque production under various velocity and angle conditions. The relative trunk loading cost of velocity was evaluated and described in an equation for slow velocity (0–30 deg/s) trunk exertions. These results were used to discuss how static lifting models might be adjusted to account for the added trunk load due to velocity.     

The effect of stance width on trunk kinematics and trunk kinetics during sagitally symmetric lifting

Lifting technique can have a significant impact on spine loading during lifting. The sports biomechanics literature has documented changes in trunk and lower extremity kinematics and muscle coactivation patterns as a function of stance width during high force dead lift and squat exercises. The focus of the current study was to explore whether these lifting stance width effects might translate into the occupational setting under more moderate load level conditions. Twelve subjects performed repetitions of a sagittally symmetric lifting and lowering task (10 kg load) under three stance width conditions: narrow (feet together), moderate (feet shoulder width) and wide (feet 150% of shoulder width). As they performed these exertions, trunk kinematics were captured using the lumbar motion monitor while the activity of the trunk muscles (erector spinae, rectus abdominis) and lower extremity muscles (gluteus maximus, vastus lateralis and vastus medialis) were evaluated using normalized electromyography. The results showed that both the range of motion and peak acceleration in the sagittal plane were significantly affected by the stance width. The muscle activation levels, however, were not significantly affected by the stance width. These results collectively would indicate that the stance width effects seen in power lifting activities do not translate well into the occupational environment where more moderate loads are typically lifted.

Relevance to industry

Exploring alternative lifting strategies may provide an opportunity to reduce the incidence of low back disorders. Lifting stance width is one variable that has not been explored in the ergonomics literature.     

An electromyographic investigation of asymmetric lifting and moving of a load: II. Effects of load lift from knuckle to target shelves

The range of normalized electromyography (EMG) values when lifting and moving a 5.84 kg box was between 0.08 and 0.63. The right iliocostalis and the left erector spinae showed decreased muscle activity with increasing asymmetry. The right erector spinae and the left and the right external obliques showed significant increases in muscle activity at 90° asymmetry. The left and the right iliocostalis, the left erector spinae, and the right external oblique showed significant reductions in muscle activity for the sternum height when compared to the knuckle height. The right erector spinae exhibited a significant increase at reach height when compared to the knuckle height. The muscle activity for the knuckle lift was significantly lower than the floor lift. The average decrease in muscle activity was approximately 68%. Consequently, asymmetric lifting and moving tasks should be performed from a knuckle height to sternum height. © 2009 Wiley Periodicals, Inc.     

Trunk muscle activity in different modes of carrying schoolbags

The daily load of carrying schoolbags is influenced by the mode of carriage. Electromyographic (EMG) activity from rectus abdominis and erector spinae was recorded bilaterally in five static conditions: no bag; shoulder bag; backpack; front pack; double pack. Nineteen students carried a load of 15% of their body weight. A double pack, with the load equally distributed in a front and a backpack, showed no significant differences in EMG activity compared with unloaded standing. The activity levels of erector spinae significantly decreased while carrying a backpack and increased with a shoulder bag and a front pack. Rectus abdominis revealed significantly higher EMG levels in the backpack trial. Asymmetrical activity between the right and the left part of the back muscles was clearly observed while carrying a shoulder bag with the weight at the right side of the body. The abdominal muscles revealed a slightly significant asymmetry for the shoulder bag and, surprisingly, also for the backpack. These findings suggest that the physical stresses associated with carrying book bags can be minimized by the design of a double pack. Asymmetry in muscle activity may indicate a failure of trunk stabilization and contribute to the development back pain.     

Trunk muscle activity in different modes of carrying schoolbags

The daily load of carrying schoolbags is influenced by the mode of carriage. Electromyographic (EMG) activity from rectus abdominis and erector spinae was recorded bilaterally in five static conditions: no bag; shoulder bag; backpack; front pack; double pack. Nineteen students carried a load of 15% of their body weight. A double pack, with the load equally distributed in a front and a backpack, showed no significant differences in EMG activity compared with unloaded standing. The activity levels of erector spinae significantly decreased while carrying a backpack and increased with a shoulder bag and a front pack. Rectus abdominis revealed significantly higher EMG levels in the backpack trial. Asymmetrical activity between the right and the left part of the back muscles was clearly observed while carrying a shoulder bag with the weight at the right side of the body. The abdominal muscles revealed a slightly significant asymmetry for the shoulder bag and, surprisingly, also for the backpack. These findings suggest that the physical stresses associated with carrying book bags can be minimized by the design of a double pack. Asymmetry in muscle activity may indicate a failure of trunk stabilization and contribute to the development back pain.     

Muscle activity during patient transfers: a preliminary study on the influence of lift assists and experience

The purpose of this study was to examine muscle activity patterns during patient handling during manual transfers, and transfers using floor and ceiling lifts. EMG patterns during transfers from bed to wheelchair and wheelchair to bed as well as patient repositioning in novices and experienced participants were examined. Surface EMG was recorded from the upper and lower erector spinae, latissimus dorsi and trapezius muscles bilaterally. Overall, normalized mean and peak muscle activity were lowest using the ceiling lift, increasing with the floor lift, which were lower than manual transfers (novices: all p < 0.01). Experienced patient handlers demonstrated approximately two times greater trapezius and latissimus dorsi activity than novices, combined with lower mean erector spinae activity (p < 0.05, for most tasks). Integrated EMG for all muscles was directly proportional to the transfer time and was lowest during the manual transfer followed by the ceiling lift, with the floor lift being highest. The difference between the muscle activity patterns between the experienced and novice patient handlers may suggest a learned behaviour to protect the spine by distributing load to the shoulder. Further examination of the muscle activation patterns differences between experience levels could improve training techniques to develop better patient handling strategies.     

Postural and trunk muscle response to sudden release during stoop lifting tasks before and after fatigue of the trunk erector muscles

The effect of fatigue on the muscular and postural response to sudden release of different stoop lifting loads was studied. Ten male volunteers performed a series of stoop lifting trials before and after fatigue of the erector spinae. Trials were performed using loads of 20, 40, 60, and 80 N, and sudden release of load was triggered randomly on one of the repetitions using an electromagnetic release. The onset of release was registered by an accelerometer, centre of pressure (COP) motion was recorded via a forceplate, and EMG activities of the latissimus dorsi (LD), erector spinae (ES), rectus abdominus (RA), external oblique (EO) and internal oblique (IO) muscles were recorded. A slightly reduced lifting speed was seen after fatigue, particularly at the higher loads, but this had little effect on the perturbing force at release, which was dominated by the release load. A significant effect of fatigue was seen on the antero-posterior COP motion, with the postural disturbance being decreased after fatigue. Fatigue resulted in a significant increase in ES (p = 0.029) and LD (p = 0.015) relaxation times and, while the response patterns (relaxation, contraction or no response) of the anterior trunk muscles (RA, EO, IO) were not always consistent, the proportion of response by relaxation was greater after fatigue. This resulted in a lower incidence but longer duration of co-contraction of the ES-RA, ES-EO and ES-EO muscle groups following fatigue, such that the mean co-contraction duration of these groups showed no significant differences before and after fatigue. The response to sudden release is a balance between maintaining postural stability and at the same time preventing the trunk musculature from overloading the spine and risking tissue injury. While fatigue of the trunk extensors does not appear to increase either the risk of fall or stumble or the incidence of co-contraction following sudden release of stoop lifting tasks, the duration of co-contraction appears to increase following fatigue. Further study is required to quantify the loading on the spine during sudden release of different lifting tasks before and after more realistic fatigue conditions.     

Muscle activity during patient transfers: a preliminary study on the influence of lift assists and experience

The purpose of this study was to examine muscle activity patterns during patient handling during manual transfers, and transfers using floor and ceiling lifts. EMG patterns during transfers from bed to wheelchair and wheelchair to bed as well as patient repositioning in novices and experienced participants were examined. Surface EMG was recorded from the upper and lower erector spinae, latissimus dorsi and trapezius muscles bilaterally. Overall, normalized mean and peak muscle activity were lowest using the ceiling lift, increasing with the floor lift, which were lower than manual transfers (novices: all p?<?0.01). Experienced patient handlers demonstrated approximately two times greater trapezius and latissimus dorsi activity than novices, combined with lower mean erector spinae activity (p?<?0.05, for most tasks). Integrated EMG for all muscles was directly proportional to the transfer time and was lowest during the manual transfer followed by the ceiling lift, with the floor lift being highest. The difference between the muscle activity patterns between the experienced and novice patient handlers may suggest a learned behaviour to protect the spine by distributing load to the shoulder. Further examination of the muscle activation patterns differences between experience levels could improve training techniques to develop better patient handling strategies.     

Lumbar motion response to a constant load velocity lift

An experiment was performed to evaluate the motions of the lumbar spine during a constant load velocity lift. For the purposes of this study, a constant load velocity refers to the linear vertical velocity of the load. This vertical load velocity was controlled using a modified angular isokinetic dynamometer, which produced linear isokinetic motion during a lift. A lumbar monitor was used to observe the position, velocity, and acceleration changes that occurred in the lumbar spine during the lifting task. The results indicate that under constant load velocity conditions, significant angular accelerations occur at the lumbar level. The nature of these accelerations was found to depend on several variables associated with a lifting task, such as the load velocity and the asymmetry of the lift. The physical significance of these results would be increased spinal loading above that which would be predicted using a static model.     

Postural and trunk muscle response to sudden release during stoop lifting tasks before and after fatigue of the trunk erector muscles

The effect of fatigue on the muscular and postural response to sudden release of different stoop lifting loads was studied. Ten male volunteers performed a series of stoop lifting trials before and after fatigue of the erector spinae. Trials were performed using loads of 20, 40, 60, and 80N, and sudden release of load was triggered randomly on one of the repetitions using an electromagnetic release. The onset of release was registered by an accelerometer, centre of pressure (COP) motion was recorded via a forceplate, and EMG activities of the latissimus dorsi (LD), erector spinae (ES), rectus abdominus (RA), external oblique (EO) and internal oblique (IO) muscles were recorded. A slightly reduced lifting speed was seen after fatigue, particularly at the higher loads, but this had little effect on the perturbing force at release, which was dominated by the release load. A significant effect of fatigue was seen on the antero-posterior COP motion, with the postural disturbance being decreased after fatigue. Fatigue resulted in a significant increase in ES (p = 0.029) and LD (p = 0.015) relaxation times and, while the response patterns (relaxation, contraction or no response) of the anterior trunk muscles (RA, EO, IO) were not always consistent, the proportion of response by relaxation was greater after fatigue. This resulted in a lower incidence but longer duration of co-contraction of the ES-RA, ES-EO and ES-EO muscle groups following fatigue, such that the mean co-contraction duration of these groups showed no significant differences before and after fatigue. The response to sudden release is a balance between maintaining postural stability and at the same time preventing the trunk musculature from overloading the spine and risking tissue injury. While fatigue of the trunk extensors does not appear to increase either the risk of fall or stumble or the incidence of co-contraction following sudden release of stoop lifting tasks, the duration of co-contraction appears to increase following fatigue. Further study is required to quantify the loading on the spine during sudden release of different lifting tasks before and after more realistic fatigue conditions.     

The effects of load weight and load starting height on variability of lifting kinematics and kinetics

Trunk kinematic variables have been used to understand the risk of low back injuries in the workplace. Variability in the trunk kinematics as an individual performs a repetitive lifting task is an underexplored area of research. In the current study, it was hypothesized that workplace variables (starting height of lift and load weight) would have an impact on the variance in the kinematic and kinetic variables. Twenty participants performed 60 repetitions of an asymmetric lifting task under four different conditions representing two levels of load weight (5% or 10% of the participant's body weight) and two levels of starting height (80% or 120% of the participant's knee height). The Lumbar Motion Monitor was used to capture trunk kinematic variables from the concentric range of lifting motion while ground reaction forces were collected using a force platform. The primary dependent variables were the variance of kinematic and kinetic variables across these 60 repetitions. The results showed a significant effect of starting height on the variance of sagittal plane trunk kinematics with the lower starting height generating an increased variance (sagittal range of motion increased by 55%, average sagittal velocity increased by 95%, peak sagittal velocity increased by 105%, and peak sagittal acceleration increased by 130%). There was no consistent significant main effect of either independent variable on the variance of the transverse plane kinematics. Additionally, there was no significant effect of load weight on the variance of any trunk kinematic variables tested. In terms of ground reaction forces, it was shown that the starting height of the load had a significant effect on the variance of peak vertical ground reaction force, while the weight of the load had a significant effect on the variance of the peak shear force.     

Trunk kinematics of one-handed lifting,and the effects of asymmetry and load weight

Abstract

This study investigated trunk kinematic differences between lifts performed using either one hand (unsupported) or two hands. These effects were studied while beginning the lifts from different asymmetric starting positions and while lifting different load weights. Each subject lifted a box from a lower to an upper platform under one- and two-handed lifting conditions. Subjects wore a lumbar spine electrogoniometer, from which relative motion components were calculated in the trunk's three cardinal planes. Results of this study showed that one-handed lifting resulted in significantly higher ranges of motion in the lateral and transverse planes and greater flexion in the sagittal plane. Back motion characteristics previously found to be associated with low back disorders were all significantly higher for one-handed lifts. The two-handed lift technique, on the other hand, produced overall faster trunk motions in the sagittal plane and equal or larger acceleration and deceleration magnitudes in all planes of motion. Increases in load asymmetry affected trunk kinematics, in that magnitude values for range of motion, velocity and acceleration became much greater with increasingly asymmetric load positions. Increasing the load weight appeared to have less of an effect on trunk kinematics, with increases in position mostly occurring during sagittal and lateral bending. These results suggest that unsupported one-handed lifting loads the spine more than two-handed lifts, due to the added coupling. Applying these results to a previously developed model, one-handed lifting was also found to increase one's risk of suffering a low back disorder.     

A study by EMG stick diagrams of the muscular activities in the trunk flexion and extension movement

The activity of the leg and abdominal muscles in trunk flexion and extension was investigated with reference to the sudden decreases and increases of the erectores spinae activity. The movement was performed under conditions with and without an additional load, and with and without fatigue. Surface EMGs were recorded from the erectores spinae, the gluteus maximus, the semitendinosus, the rectus abdominis and the external oblique. The pattern of activity was analysed using EMG stick diagrams. Under the condition without fatigue, the semitendinosus activity increased during the sudden changes of the erectores spinae activity, but the abdominal muscles were not activated during the movement. However, the rectus abdominis was activated whenever the semitendinosus activity did not increase during the changes of the erectores spinae activity. Under the condition of fatigue, the leg muscle was vigorously active during the movement, and the abdominal muscles were activated before and after the erectores spinae activity changed suddenly. The results suggest that the leg muscle plays some important part during the sudden changes of the erectores spinae activity.     

Lifting in stooped and kneeling postures: Effects on lifting capacity,metabolic costs,and electromyography of eight trunk muscles

Twelve healthy, experienced underground coal miners performed lifting capacity tests in stooped and kneeling postures using a modified psychophysical, procedure. Subjects adjusted weight in a lifting box to the maximum they could handle without undue fatigue in an asymmetric lifting task. Lifting periods were 20 min in duration and the frequency was 10 lifts/min. Tests were performed under a 48-in. roof that restricted the subject's posture. Psychophysical, physiological, and biomechanical dependent measures included the maximum acceptable weight of lift (MAWL), heart rate (HR), rate of oxygen consumption (V̇O₂), ventilation volume rate (V̇_E), respiratory exchange ratio (R), and integrated electromyography (EMG) of eight trunk muscles. Results indicated that the MAWL was significantly lower when kneeling than when stooped (p < 0.05). Furthermore, metabolic demands were greater in terms of HR (p < 0.005) and VO₂ (p < 0.05) when kneeling. Left and right erectores spinae muscles exhibited increased EMG activity in the kneeling posture (p < 0.001). It was concluded that psychophysical lifting capacity is decreased, while the metabolic stress and internal load on the spine are increased, in the kneeling posture. Results of this Bureau of Mines study indicate that it may be advisable to reduce the weight of materials that are handled repetitively in the kneeling posture.     

A novel optimization model for predicting trunk muscle forces during asymmetric lifting tasks

Low back pain (LBP) is a social and economic problem throughout industry. Repetitive asymmetric postures frequently occur in manual materials handling tasks and such asymmetric lifting has been epidemiologically linked to LBP. Therefore, biomechanical lifting models must be developed to predict muscle forces during asymmetric lifting tasks. This paper proposes an optimization model that was revised to take into account the activities of trunk muscles during asymmetric lifting tasks. Also, three optimization models (minimize maximum muscle intensity: MIN_I_MAX, minimize sum of magnitudes of the muscle forces raised to power 3: MIN_F³, and minimize sum of the muscle intensities raised to power 3: MIN_I³) are compared under various asymmetric lifting conditions. The revised model not only reflects the twisting effect of muscle force vectors for eight primary trunk muscles when trunk rotation is involved, but also accurately predicts the forces of left erector spinae, left latissimus dorsi and left external oblique muscles when compared with EMG signals obtained from experiments. Furthermore, MIN_I_MAX exhibits the best prediction capability among the three optimization models.Relevance to industryA novel optimization model proposed herein considers the twisting effect of muscle force vectors for eight trunk muscles when trunk rotation is involved. An accurate biomechanical model which reflects the asymmetric lifting conditions would significantly facilitate the evaluation of job and workplace design as well as provide a practical clinical evaluation technique.     

Effect of wearing jeans on the back muscle flexion-relaxation phenomenon

The flexion–relaxation phenomenon (FRP) in back muscles is related to the lower back load. Although the FRP has been widely discussed, the effect of wearing jeans—a common attire in workplaces—on the FRP is unexplored. This study recruited 20 male participants with high and low flexibilities (10 each) and measured the related muscle activity and lumbopelvic movement at five trunk flexion angles (0°–90°) when wearing two types of bottom wears (swim trunks and fit jeans). Results revealed that the bottom wear type and trunk angle significantly affected all responses, whereas flexibility affected only erector spinae and hamstring activities. Participants with high flexibility and wearing swim trunks exhibited greater erector spinae activity than did those with low flexibility and wearing jeans. Thus, those who have low flexibility or are wearing jeans are likely to experience more activity reductions in erector spinae. However, the result with hamstring activity was the opposite. Wearing jeans limited participants’ pelvic rotation, forcing them to bend their lumbar spine further to complete trunk flexion, thus reducing erector spinae activity. A looser attire should be chosen to avoid constraining the pelvic rotation when work involves a deep trunk flexion.Relevance to industryPeople wearing jeans have limited pelvic movement and decreased erector spinae activity during deep trunk flexion, and this may further strain their interspinous ligaments. Thus, people should not wear fit jeans when in workplaces where their work involves stooping or trunk flexion exceeding 45° to minimize the load on their lower back.     

Evaluation of upper body kinematics and muscle activity during milking attachment task

The objective of the study was to evaluate the effects of udder height on upper body kinematics and muscle activity during a simulated attachment task in a parallel parlor set up, and the effects of udder access method (back or side) on the task biomechanics. Twenty males performed the task under conditions that simulated three udder heights and two udder access methods. The muscular load and kinematics during the task confirmed that milking is a physically demanding task. Trunk flexion angle increased with decreasing udder height, and the erector spinae activation was higher when the udder was below shoulder height compared to at or above. Compared to accessing the udder from side of the cow (herringbone parlor style), accessing from behind (Parallel parlor style) was associated with lower trunk flexion, greater shoulder horizontal adduction, lower shoulder elevation, and greater anterior deltoid activation. Milking in herringbone parlor style and with the udder at or above shoulder level may help reduce strain on the trunk/neck.     

A biomechanical analysis of anterior load carriage

Front load carriage is a common occupational task in some industries (e.g. agriculture, construction), but, as compared to lifting tasks, relatively little research has been conducted on the biomechanical loading during these activities. The focus of this study was to explore the low back biomechanics during these activities and, specifically, to examine the effects of load height and walking speed on trunk muscle activity and trunk posture. Eleven male participants participated in two separate front load-carriage experiments. The first experiment called for carrying a barbell (with weight corresponding to 20% of elbow flexion strength) at three heights (knuckle height, elbow height and shoulder height) at a constant horizontal distance from the spine. The second experiment called for participants to carry a bucket of potatoes weighing 14 kg at the same three heights, but with no further restrictions in technique. In both experiments, the participants performed this task while either standing still or walking at a self-selected speed. As they performed these tasks, the activity levels of the right-side muscle of the rectus abdominis, external oblique, biceps brachii, anterior deltoid and three levels (T9, T12 and L3) of the erector spinae were sampled. Mid-sagittal plane trunk posture was also quantified using three magnetic field-based motion sensors at T9, T12 and L3. The results showed a significant effect of both walking speed and load height on trunk posture and trunk muscle activity levels in both the barbell and bucket experiments. In the barbell experiment, the walking trials generated 43% more trunk muscle activity than the standing trials. Trials at shoulder height produced 11% more muscle activity than trials at elbow height in the T9 erector spinae muscles and 71% more muscle activity in the anterior deltoid. In the bucket experiment, trunk muscle activity responded in a similar fashion, but the key result here was the quantification of the natural hyperextension posture of the spine used to balance the bucket of potatoes. These results provide insight into muscle activation patterns in dynamic settings, especially (load) carrying biomechanics, and have implications in industrial settings that require workers to carry loads in front of their bodies.     

Manual materials handling in mining: the effect of rod heights and foot positions when lifting "in-the-hole" drill rods

There is a paucity of studies focusing on the lifting of rods or long awkward heavy objects. In-the-hole (ITH) drilling is a heavy repetitive mining task, which has been identified as having a relatively high incidence and severity rate of musculoskeletal injuries. The purpose of this study was to examine how the load experienced by ITH drill operators changed when lifting a vertical drilling rod (1.61 m, 35 kg) using two rod heights and four different foot positions. In addition, a symmetrical lift with a lifting index (LI) of 1.4 also served as a comparison to determine possible risk of low back injury. Eleven experienced ITH drill operators participated in the study. Each subject was required to lift a vertical drilling rod until the upper body was in an erect posture using four different foot positions (0°=subject facing the rod, 45°=subject oblique to the rod, 90°=subject right side to the rod and freestyle). In addition, two rod height conditions were studied where the base of the vertical rod was supported either (1) at ground level (height of rod CG=0.83 m) or (2) on a 20 cm rack (height of rod CG=1.03 m). Finally, each subject lifted a 21.5 kg box in the sagittal plane, which corresponded to an LI of 1.4 in the NIOSH lifting equation. Reflective markers were placed on the subjects, and three video cameras and one force plate were used to record the forces and the motion of the subjects’ segments. Two surface electrodes were applied on the right and the left erector spinae (ES) at the level of L3. Back loading was defined by the level of the peak moments, the mechanical work and erector spinae muscle activity (EMG). It was found that the vertical height of the rod had the most significant impact on back loading, while the effect of the initial foot positioning relative to the rod was limited by the technique adopted by the drillers. Moreover, it was found that some of the subjects used techniques less strenuous for the back than others. Finally, the asymmetrical lifting component was found to be the most negative aspect of lifting an ITH drill rod compared to a standard symmetrical lift (NIOSH).