Subjective perceptions of load carriage on the head and back in Xhosa women

The Impact of Heavy Load Carrying on Musculoskeletal Pain and Disability Among Women in Shinyanga Region, Tanzania

Background

Heavy load carrying has been associated with musculoskeletal discomfort (MSD) and disability. However, there is a lack of research investigating this association in resource-constrained settings where heavy load carrying by women is common.

Objectives

We assessed the impact of heavy load carrying on musculoskeletal pain and disability among women in Shinyanga Region, Tanzania, in an exploratory cross-sectional study.

Methods

Eligible participants were a convenience sample of women, at least 18 years of age, who passed a study recruitment site carrying a load. We collected information on load-carrying practices, including frequency and time spent carrying water, wood, agricultural products, coal, sand, or rocks, and measured the weight of the load carried at the time. Outcomes included self-reported MSDs, defined as experiencing pain lasting >3 days in the neck, head, back, knees, feet and/or ankles within the last 1 year, and related disability. Using multivariable logistic regression we assessed for associations between load carrying exposures and MSDs and disability.

Findings

Results showed a high prevalence of MSDs across the body regions assessed and evidence to suggest a relationship of back pain and related disability with several measures of load-carrying, including duration, frequency, and weight. Multivariable analyses revealed associations of increased load carrying exposures with low back pain (LBP) and related disability, including statistically significant increases in odds of LBP with increasing weight, total duration of load carrying/week and cumulative loads/week.

Conclusions

Findings indicate a substantial burden of MSDs and disability in this population of women who carry heavy loads daily. The extent of discomfort and disability increased with increasing exposure to various load-carrying measures, especially for LBP. Larger epidemiologic studies that definitively assess relationships of load carrying with MSDs and disability are warranted.

Alternative Water Transport and Storage Containers: Assessing Sustained Use of the PackH2O in Rural Haiti

The PackH₂O water backpack carrier was developed to provide safe storage and relieve stress of head-loading during water transport with traditional containers such as buckets and jerry cans. We conducted an evaluation to assess both self-reported and observed use over a 6-month period between November 2014 and May 2015. A total of 866 packs were distributed to 618 households in six communities in rural Haiti, and 431 and 441 households were surveyed at midline and end line, respectively. We performed linear regression to assess change of self-reported use over time. Although 79.3% of respondents reported continued use of the 20-L pack after 6 months, other measures of self-reported use were low, with only 16.8% reporting to have used the pack the last time they collected water and 10.3% preferring the pack over other water collection containers. In addition, only 10.2% of all people collecting water at community sources were observed using packs and 12.0% of all households surveyed had water in the pack at the time of visit. Pack use varied by community and demographics. Although women were targeted during distribution, men preferred the pack and were more commonly observed using it at the community water sources. In conclusion, the use of the PackH₂O was not widely adopted in rural Haiti; however, further research is needed to assess the pack acceptance in areas where back-loading is more common and in emergency settings.

The metabolic demand of external load carriage in golfers: a comparison of a single versus double-strap golf bag

BACKGROUND

A golf bag filled with a set of clubs provides a substantial load. When carried over distance this can increase the demands placed upon the golfer, leading to discomfort, fatigue and injuries. This study aimed to compare the metabolic demands of 2 methods of golf bag carriage.

METHODS

A total of 16 healthy male recreational golfers participated in the study. Participants were given an initial familiarization session in which their self-selected walking speed was determined. This was utilized as the treadmill speed for all subsequent trials. The testing protocol consisted of 3 randomized trials of treadmill walking for 5 minutes in each of three conditions: unloaded, single-strap bag and double-strap bag. Equipment consisted of a double-strap golf bag with a standard set of clubs weighing 12.5kg. For all trials oxygen consumption (L·min-1), VO2 (mL·kg·min-1) respiratory minute volume (VE) (L·min-1), and heart rate (HR) were measured.

RESULTS

Results showed that the double-strap bag required significantly less oxygen consumption (1.19±0.19 vs. 1.31±0.16 L·min-1, P<0.01) relative oxygen consumption (14.49±2.06 vs. 15.93±2.25 mL·kg·min-1, P<0.01), reduced respiratory minute volume (29.95±4.19 vs. 32.47±4.26 L·min-1, P<0.05), and lower heart rates (100.14±11.05 vs. 106.96±9.33 BPM, P<0.001) than the single-strap bag. Both methods of carriage showed significantly greater metabolic demands than the unloaded condition (P<0.05).

CONCLUSIONS

The decreased metabolic cost of carrying a double-strap golf bag may facilitate a reduction in fatigue and reduced mechanical stress. Golf bag transportation must therefore be recognized as a factor in reducing the risk of injury and improving playing performance.

Children are not like other loads: a cross-cultural perspective on the influence of burdens and companionship on human walking

A major portion of humans' activity-based energy expenditure is taken up by locomotion, particularly walking. Walking behaviors have energetic outcomes and as such can be important windows into how populations and groups adjust to different environmental and task constraints. While sex differences in the speed of paired walkers have been established by others, the dynamics of how walkers adjust their speed in more varied groups and in groups containing children remains unexplored. Furthermore, little ecological data exists to illustrate the relationships between walking speed and child-carrying. Here, we aim to determine how culture impacts the effects of group composition and infant-carrying on walking speed. Because the determinants of group dynamics and parental investment are partially cultural, we examine walking behavior in the Northwestern United States and in Central Uganda. Using an observational method, we recorded the speed, load carriage, and group composition of pedestrians in a single naturalistic urban environment within each country. Our data suggest that children are treated fundamentally differently than other loads or the presence of walking partners, and that major speed adjustments are child-dependent. Our data furthermore indicate that Ugandans walk more slowly in groups than when alone, while Americans walk more quickly in groups. Clear distinctions between the groups make large generalizations about walking behavior difficult, and highlight the importance of culturally specific contexts.

Gender Differences in Energy Expenditure During Walking With Backpack and Double-Pack Loads

OBJECTIVE

To investigate gender differences in energy expenditure during walking with backpack and double-pack loads.

BACKGROUND

Studies have reported that energy expenditure during walking with double-pack loads is lower compared with backpack carriage. However, the effect of gender on energy expenditure while walking with these two load distribution systems has not been investigated.

METHOD

Thirty healthy young adults (15 female and 15 male participants) walked on a treadmill with backpack and double-pack loads weighing 30% of their body weight at a speed of 0.89 m/s for 10 min. The energy expenditure in terms of oxygen consumption (VO2) and respiratory exchange ratio (RER) were continuously monitored using a portable gas analyzer throughout each walking exercise. A mixed-design analysis of variance model was adopted to test the effects of gender, pack, and time on VO2 and RER.

RESULTS

No time effect was observed on VO2. However, significant gender, pack, and interaction effects were observed. The lowest VO2 was found in female participants under double-pack carriage. No significant gender or pack differences existed in RER. However, RER significantly and incrementally increased in time from the 4th through 6th, 8th, and 10th min.

CONCLUSION

This study revealed that heavy double-pack load carriage for healthy young female participants had significantly lower energy expenditure (normalized by the entire system weight, i.e., the participant's weight plus the weight of the pack) than that of the male participants in a 10-min walking exercise.

APPLICATION

The findings of this study indicated that healthy young female participants carried a heavy double-pack with less energy cost (normalized by the entire system weight, i.e., the participant's weight plus the weight of the pack) compared with their male counterparts during a 10-min walking exercise.

Is water carriage associated with the water carrier's health? A systematic review of quantitative and qualitative evidence

Introduction

The work of carrying water falls mainly on women and children, particularly in sub-Saharan Africa and rural areas. While concerns have been raised, how water carriage is associated with health of the water carrier is not clear. The aim of this review is to summarise evidence on whether, and how, water carriage is associated with the water carrier’s health.

Methods

A systematic review of literature was conducted, searching Embase; Medline; Web of Science Social Sciences Citation Index; Web of Science Arts and Humanities Citation Index; International Initiative for Impact Evaluation website; WHO Virtual Health Sciences Library and WHO African index medicus, from inception to 8 November 2017.

Results

Forty-two studies were included. Their ability to demonstrate cause and effect relationships was limited by study design and fair or poor methodological quality. Overall, the studies suggest that water carriage is associated with negative aspects of the water carriers’ health. There is moderate quantitative and strong qualitative evidence that water carriage is associated with pain, fatigue, perinatal health problems and violence against vulnerable people, and inconclusive evidence of an association with stress or self-reported mental health and general health status.

Conclusion

In many circumstances, water carriage is a potential barrier to Sustainable Development Goal (SDG) 6 target ‘universal and equitable access to safe and affordable drinking water for all’ and SDG 3 ‘ensure healthy lives and promote well-being for all at all ages’. Efforts should focus on providing water on premises, and where this is not possible, providing water close to home and reducing risk of gender-based violence.

Carrying water may be a major contributor to disability from musculoskeletal disorders in low income countries: a cross-sectional survey in South Africa, Ghana and Vietnam

Background

The Sustainable Development Goals include commitments to end poverty, and promote education for all, gender equality, the availability of water and decent work for all. An important constraint is the fact that each day, many millions of women and children, and much less frequently men, carry their household’s water home from off-plot sources. The burden of fetching water exacerbates gender inequality by keeping women out of education and paid employment. Despite speculation about the potential health impacts of fetching water, there is very little empirical evidence. We report the first large study of the health impacts of carrying water on women and children.

Methods

A cross-sectional survey was conducted in South Africa, Ghana and Vietnam during 2012. It investigated water carrying methods and health status. Because areas of self-reported pain were correlated we undertook factor analysis of sites of reported pain, to interpret patterns of pain reporting. Regression analysis using Generalised Estimating Equations (GEE) investigated water carrying as a risk factor for general health and self-reported pain.

Results

People who previously carried water had increased relative risk of reporting pain in the hands (risk ratio RR 3.62, 95% confidence interval CI 1.34 to 9.75) and upper back (RR 2.27, 95% CI 1.17 to 4.40), as did people who currently carry water (RR hand pain 3.11, 95% CI 1.34 to 7.23; RR upper back pain 2.16, 95% CI 1.25 to 3.73). The factor analysis results indicate that factor 1, ‘axial compression’, which is correlated with pain in the head and upper back, chest/ribs, hands, feet and abdomen/stomach, is associated with currently (0.30, 95% CI 0.17 to 0.43) or previously (0.21, 95% CI 0.01 to 0.42) carrying water. Factor 2, ‘soft tissue strain’, which is correlated with pain in the neck, shoulders/arms, lower back and hips/pelvis or legs, is marginally negatively associated with currently (-0.18, 95% CI -0.32 to -0.04) carrying water. The factor ‘axial compression’ was more strongly associated with carrying water containers on the head.

Conclusions

Participants who reported a history of current or past water carrying more frequently reported pain in locations most likely to be associated with sustained spinal axial compression in the cervical region. Given the fact that cervical spinal conditions are globally one of the more common causes of disability, our findings suggest that water carrying, especially by head loading is a major contributing factor in musculoskeletal disease burden in low income countries. Our findings support the proposed indicator for monitoring SDG6.1: “Percentage of population using safely managed drinking water services at home.”

The Biomechanical and Energetic Advantages of a Mediolaterally Wide Pelvis in Women

Here, we argue that two key shifts in thinking are required to more clearly understand the selection pressures shaping pelvis evolution in female hominins: (1) the primary locomotor mode of female hominins was loaded walking in the company of others, and (2) the periodic gait of human walking is most effectively explained as a biomechanically controlled process related to heel-strike collisions that is tuned for economy and stability by properly-timed motor inputs (a model called dynamic walking). In the light of these two frameworks, the evidence supports differences between female and male upper-pelvic morphology being the result of the unique reproductive role of female hominins, which involved moderately paced, loaded walking in groups. Anat Rec, 300:764-775, 2017. © 2017 Wiley Periodicals, Inc.

Dynamic analysis of forces in the lumbar spine during bag carrying

OBJECTIVE

The intervertebral disc supports axial and shear forces generated during tasks such as lifting and carrying weights. The objective of this study was to determine the forces in the lumbar spine of workers carrying a bag on the head, on the shoulder and on the anterior part of the trunk.

METHODS

Kinematic measurements were recorded for 10 subjects carrying bags of 10, 20 and 25 kg on each of the three aforementioned positions. A simple dynamic model implemented in a custom program was then developed to determine the lumbar forces using the accelerations and positions obtained from the kinematic analysis.

RESULTS

The analyses yielded a maximum compressive force of 2338.4 ± 422 N when a 25-kg bag was carried on the anterior part of the trunk.

CONCLUSION

Carrying bags on the anterior part of the trunk generated higher lumbar forces compared to those developed by carrying the bag on the head or on the shoulder. Force levels suggest that this activity represents a moderate risk for the subjects. However, future biomechanical models should be developed to analyze the cumulative effect in the discs when longer periods of time are spent in this activity.

The effects of a simple intervention on exposures to low back pain risk factors during traditional posterior load carriage

Traditional posterior load carriage (PLC), typically performed without the use of an assistive device, is associated with a high prevalence of low back pain (LBP). However, there are few studies that have evaluated potential interventions to reduce exposures to LBP risk factors. This work examined the effects of a simple, potentially low-cost intervention using an assistive device (i.e., carrying aid) on exposures to factors related to LBP risk during PLC. Torso kinematics and kinetics, slip risk, and ratings of perceived discomfort (RPD) were obtained during simulated PLC on a walkway. Consistent with earlier results, increasing load mass substantially increased torso flexion and lumbosacral flexion moment, as well as RPDs in all anatomical regions evaluated. Using the carrying aid with a higher load placement resulted in substantially lower mean lumbosacral moments when carrying the heaviest load. In contrast, using the carrying aid with a lower load placement resulted in substantially higher torso flexion angles, higher mean lumbosacral moments when carrying heavier loads, and higher peak lumbosacral moments across all load masses. With use of the carrying aid, both higher and lower load placement resulted in significantly lower RPDs in the elbows and hands compared to the control condition. In summary, use of a carrying aid with higher load placement may be beneficial in reducing the risk of LBP during PLC. Future studies are needed, though, to improve the device design and to enhance external validity.

Traditional posterior load carriage: effects of load mass and size on torso kinematics, kinetics, muscle activity and movement stability

Traditional posterior load carriage (PLC), done without the use of an assistive device (e.g., backpack), has been associated with low back pain (LBP) development. This study evaluated the effects of important task demands, related to load mass and size, on potential mechanisms linking traditional PLC with LBP. Nine healthy participants completed PLC tasks with three load masses (20%, 35% and 50% of individual body mass) and three load sizes (small, medium and large). Torso kinematics, kinetics, muscle activity and slip risk were evaluated during PLC on a walkway, and torso movement stability was quantified during PLC on a treadmill. Increasing load mass caused increased torso flexion, L5/S1 flexion moment, abdominal muscle activity and torso movement stability in the frontal plane. Increasing load size also caused higher torso flexion, peak torso angular velocity and acceleration, and abdominal muscle activity. Complex interactive effects of load mass and size were found on paraspinal muscle activity and slip risk. Specific task demands, related to load mass and size, may thus influence the risk of LBP during PLC.

PRACTITIONER SUMMARY

This study examined the effects of load mass and size on low back pain (LBP) risk using intermediary measures derived from torso kinematics, kinetics and muscle activity. Our current findings, along with earlier work, suggest that load mass and size can influence LBP risk, and that use of smaller and light loads may be beneficial during PLC.

Human footprint variation while performing load bearing tasks

Human footprint fossils have provided essential evidence about the evolution of human bipedalism as well as the social dynamics of the footprint makers, including estimates of speed, sex and group composition. Generally such estimates are made by comparing footprint evidence with modern controls; however, previous studies have not accounted for the variation in footprint dimensions coming from load bearing activities. It is likely that a portion of the hominins who created these fossil footprints were carrying a significant load, such as offspring or foraging loads, which caused variation in the footprint which could extend to variation in any estimations concerning the footprint’s maker. To identify significant variation in footprints due to load-bearing tasks, we had participants (N = 30, 15 males and 15 females) walk at a series of speeds carrying a 20kg pack on their back, side and front. Paint was applied to the bare feet of each participant to create footprints that were compared in terms of foot length, foot width and foot area. Female foot length and width increased during multiple loaded conditions. An appreciation of footprint variability associated with carrying loads adds an additional layer to our understanding of the behavior and morphology of extinct hominin populations.

Reproductive costs for everyone: how female loads impact human mobility strategies

While mobility strategies are considered important in understanding selection pressures on individuals, testing hypotheses of such strategies requires high resolution datasets, particularly at intersections between morphology, ecology and energetics. Here we present data on interactions between morphology and energetics in regards to the cost of walking for reproductive women and place these data into a specific ecological context of time and heat load. Frontal loads (up to 16% of body mass), as during pregnancy and child-carrying, significantly slow the optimal and preferred walking speed of women, significantly increase cost at the optimal speed, and make it significantly more costly for women to walk with other people. We further show for the first time significant changes in the curvature in the Cost of Transport curve for human walking, as driven by frontal loads. The impact of these frontal loads on females, and the populations to which they belong, would have been magnified by time constraints due to seasonal changes in day length at high latitudes and thermoregulatory limitations at low latitudes. However, wider pelves increase both stride length and speed flexibility, providing a morphological offset for load-related costs. Longer lower limbs also increase stride length. Observed differences between preferred and energetically optimal speeds with frontal loading suggest that speed choices of women carrying reproductive loads might be particularly sensitive to changes in heat load. Our findings show that female reproductive costs, particularly those related to locomotion, would have meaningfully shaped the mobility strategies of the hominin lineage, as well as modern foraging populations.

Size and Shape: Morphology's Impact on Human Speed and Mobility

While human sexual dimorphism is generally expected to be the result of differential reproductive strategies, it has the potential to create differences in the energetics of locomotion and the speed at which each morph travels, particularly since people have been shown to choose walking speeds around their metabolic optimum. Here, people of varying sizes walked around a track at four self-selected speeds while their metabolic rate was collected, in order to test whether the size variation within a population could significantly affect the shape of the optimal walking curve. The data show that larger people have significantly faster optimal walking speeds, higher costs at their optimal speed, and a more acute optimal walking curve (thus an increased penalty for walking at suboptimal speeds). Bigger people who also have wider bitrochanteric breadths have lower metabolic costs at their minimum than bigger people with a more narrow bitrochanteric breadth. Finally, tibia length significantly positively predicts optimal walking speed. These results suggest sex-specific walking groups typical of living human populations may be the result of energy maximizing strategies. In addition, testable hypotheses of group strategies are put forth.

Trunk postural demands of occupational activities of some merchant pregnant women in Benin, West Africa

Strenuous physical work puts expectant mothers at risk of experiencing back pain during the gestational months. Pregnant women in Benin perform physically demanding occupational tasks that include the lifting and carriage of heavy loads on their heads for commercial activities. A large percentage of pregnant subjects (58%) reported having back pain episodes since the start of their pregnancy. However, the mean Oswestry score of the affected participants was relatively low with a mean score of 0.2 (SD: 0.12), on a scale form 0 to 1. An evaluation of the postural demands of the occupational activities of these women revealed that they performed on average 328 trunk flexions at angles exceeding 60°, with 66 of these flexions sustained for more than 4 s, during the average 7.9 h where trunk postures were recorded. They also spent on average 36% of the recording time at trunk flexion angles larger than 20°. These results show that the merchant pregnant women in the Porto-Novo area in Benin are at great risk for developing back disorders during pregnancy.

PRACTITIONER SUMMARY

Results will make a first contribution to the literature by identifying the stressful postures adopted during a typical day. The findings of this study can help in the development of preventative concepts and postural modification techniques to decrease the occurrence of back pain during pregnancy for women in Benin.

Does load position affect gait and subjective responses of females during load carriage?

Recreational hikers carry heavy loads while often walking long distances over uneven terrain. Previous studies have suggested that not only the load mass but also the position of the load may influence load carriage. The purpose of this study was to determine the effect of vertical load position on gait and subjective responses of female recreational hikers. Fifteen experienced female hikers walked for 2 km over a simulated hiking trail carrying 30% BW in three vertical load positions (high, medium and low). Lower limb and trunk kinematic, electromyography (EMG) and ground reaction force (GRF) data were collected together with heart rate (HR), ratings of perceived exertion (RPE) and discomfort measures. Although HR, RPE and discomfort measures were not able to discern statistical differences between load positions, the high load position was the most preferred by participants. The high load position also resulted in a more upright posture (p < 0.001), decreased gastrocnemius integrated EMG compared to the medium (p = 0.005) and low load positions (p = 0.02) and a higher first peak deceleration vertical GRF compared to the low load position (p = 0.011). However, the absolute differences were small and unlikely to be functionally relevant in load carriage studies. Based on the findings of this study, a high, medium or low load position cannot be preferentially recommended for healthy, experienced, female hikers carrying 30% BW.

A kinetic comparison of back-loading and head-loading in Xhosa women

The purpose of this study was to compare the kinetic responses associated with ground reaction force measurements to both head-loading and back-loading in a group of Xhosa women. Altogether, 16 women were divided into two groups based on their experience of head-loading. They walked over a force plate in three conditions: unloaded or carrying 20 kg in either a backpack or on their head. The most striking finding was that there was no difference in kinetic response to head-loading as a consequence of previous experience. Considering the differences between the load carriage methods, most changes were consistent with increasing load. Head-loading was, however, associated with a shorter contact time, smaller thrust maximum and greater vertical force minimum than back-loading. Both loading conditions differed from unloaded walking for a number of temporal variables associated with the ground contact phase, e.g. vertical impact peak was delayed whilst vertical thrust maximum occurred earlier. STATEMENT OF RELEVANCE: Consideration of the kinetics of head and back load carriage in African women is important from a health and safety perspective, providing an understanding of the mechanical adaptations associated with both forms of load carriage for a group of people for whom such load carriage is a daily necessity.

Domestic water carrying and its implications for health: a review and mixed methods pilot study in Limpopo Province, South Africa

BACKGROUND

Lack of access to safe water remains a significant risk factor for poor health in developing countries. There has been little research into the health effects of frequently carrying containers of water. The aims of this study were to better understand how domestic water carrying is performed, identify potential health risk factors and gain insight into the possible health effects of the task.

METHODS

Mixed methods of data collection from six were used to explore water carrying performed by people in six rural villages of Limpopo Province, South Africa. Data was collected through semi-structured interviews and through observation and measurement. Linear regression modelling were used to identify significant correlations between potential risk factors and rating of perceived exertion (RPE) or self reported pain. Independent t-tests were used to compare the mean values of potential risk factors and RPE between sub-groups reporting pain and those not reporting pain.

RESULTS

Water carrying was mainly performed by women or children carrying containers on their head (mean container weight 19.5 kg) over a mean distance of 337 m. The prevalence of spinal (neck or back) pain was 69% and back pain was 38%. Of participants who carried water by head loading, the distance walked by those who reported spinal pain was significantly less than those who did not (173 m 95%CI 2-343; p = 0.048). For head loaders reporting head or neck pain compared to those who did not, the differences in weight of water carried (4.6 kg 95%CI -9.7-0.5; p = 0.069) and RPE (2.5 95%CI -5.1-0.1; p = 0.051) were borderline statistically significant. For head loaders, RPE was significantly correlated with container weight (r = 0.52; p = 0.011) and incline (r = 0.459; p = 0.018)

CONCLUSIONS

Typical water carrying methods impose physical loading with potential to produce musculoskeletal disorders and related disability. This exploratory study is limited by a small sample size and future research should aim to better understand the type and strength of association between water carrying and health, particularly musculoskeletal disorders. However, these preliminary findings suggest that efforts should be directed toward eliminating the need for water carrying, or where it must continue, identifying and reducing risk factors for musculoskeletal disorders and physical injury.