Analysis of Musculoskeletal Disorder Risk in Cotton Garment Industry Workers

ABSTRACT Work-related musculoskeletal disorders (wMSDs) are common workplace health hazard among sewing, ironing and packing workers, which can be caused by the manual and repetitive work in the garment industry. This research evaluates and categories the risk variables for 63 people took part in the Musculoskeletal Disorders study for garment material protection. The primary goal of this research is to determine the prevalence of Musculoskeletal Disorders (MSDs) and to reduce their risk. The data were gathered using a questionnaire and an observational checklist, and the risk was calculated using the Rapid Entire Body Assessment (REBA) and Rapid Upper Limb Assessment (RULA) approach and human postures were captured by camera for analysis. Reported musculoskeletal symptoms occurring in sewing, packing, ironing are lower back pain (50%, 61.5%, 42.5%), knee (30%, 15.3%, 27.5%), wrist pain (20%, 23%, 20%), shoulder pain (40%, 46.15%, 27.5%) and neck pain (40%, 23%, 32.5%), respectively, and ironing workers reported calf pain of 52.5% were the most common sites of pain. It is critical that awkward posture, uncomfortable movements, prolonged standing, and other factors contributed to an increase in worker risk while protecting garments.


Introduction
India's garment industry is a one-trillion-rupee industry. By volume, over a third of its knitwear production and around a quarter of its woven-garment manufacturing are exported. In all, around 25% of the amount of its garment production is exported, leaving the remaining 75% for domestic use. The indirect element supports the direct production sector by providing sewing/embroidery thread, buttons, buckles, zippers, metal plates, cardboard sheets, plastic butterflies, and packaging material

Related works
The study of humans in their working environment is referred to as ergonomics. The objective is to eliminate work-related pain and injury risk. The most common problem among Indian workers appears to be occupational work injuries (Lombardo, Khan, and Khan 2012). People working in cottage businesses in India are unaware of the health risks associated with repeated employment. In this study, it is clear that both male and female ironing workers experience a variety of work-related problems while ironing clothes in various postures (Chaiklieng and Thanyawat 2019). Physical and ergonomic dangers were shown to be more closely linked to sewing machine operators than any other type of hazard. Textile sewing machine workers should be made aware of and educated on safe techniques in order to reduce dangers and long-term consequences. They may have pain as a result of their routine operations, which could result in temporary or permanent health problems. It is critical to emphasize that cohort in this study, impacts were recognized as a key constraint (Vandyck and Docea 2012). Partially scored biomechanical risks revealed that the cervical spine (neck) and shoulders/arms are at moderate risk, while the lumbar spine and wrists/hands are at high risk. Workers in the finishing sector had a somewhat higher perception of stress at work than those in other sections. The differences between the portions were not statistically significant (p > .05) (Ahmad et al. 2007). The findings revealed an 85.8% prevalence rate and a robust link between WMSDs (Sharma and Neetu 2019) and depression. Physical exertion and pain showed an exposure-response relationship in four body parts, with physical isometric loads above the mean increasing neck/shoulder and lower extremity discomfort (Çivitci 2004). Musculoskeletal pain was most common among ironers, packers, and cutters, followed by sewers, quality control assistants, and supervisors and recorders. A Body Mass Index (BMI) of 27 or higher was linked to with a 40% increase in the risk of musculoskeletal problems with age, and self-reported symptoms were more prevalent. We discovered that lower educational attainment was linked to higher rates of pain and dysfunction among garment workers, as reported previously. However, after accounting for other characteristics in our analysis, the association did not hold (Berberoğlu and Tokuç 2013). Individuals who had only been in the sector for a year or less were much more likely to report, muscle or joint pain, but they were reluctant to seek medical attention or take time off from work (Pun et al. 2004). The goal of this study was to look at the prevalence of low back pain (LBP) and the relationship between LBP and postural risk factors among female informal garment workers. A follow-up questionnaire was used to obtain data on the incidence of LBP. The standard Rapid Upper Limb Assessment (RULA) method was used to assess ergonomic risk. The nine-month LBP incidence was determined to be 30.98%, with the peak incidence occurring in the ninth month (5.99%). Shoulder flexion 45, 90 degrees, shoulder abduction, elbow flexion 60, 100 degrees, wrist twist, neck twist, and trunk twist were all found to be substantially linked with LBP. The data confirmed that the incidence of LBP increased over time, and that the working risk posture contributed to the increased risk of LBP development. The findings suggest that workers should receive ergonomics training and workstation modifications in order to maintain a safe posture while sewing (Robin et al. 2001). A physical discomfort survey was used to determine which injuries they linked to the performance of tasks at work. Noise, poor ventilation, improper seat heights, widths, and depths, and difficult postures were discovered as stresses (Polat, Olcay and Kalayci 2016).

Methodology
The study includes sewing, ironing and packing workers of garment industry. Only workers who performed a task for a lengthy duration on an average of 1 year and 6 days per week were included in the study.

Rapid Entire Body Assessment (REBA)
The Rapid Entire Body Assessment (REBA) is a method for determining the risk of musculoskeletal diseases (MSDs) related to certain employment duties (Karuppiah et al. 2020). It is a whole-body screening tool that assesses biomechanical and postural loads on the body using a systematic process.
Assessment worksheet for REBA is shown in Figure 1. For left and right, score was given to the postures in Group A (Trunk, Neck, and Legs) and Group B (Upper Arms, Lower Arms, and Wrists). There includes a posture score system for each location, as well as adjustment remarks for further concerns. Then, a score was provided to the factors of Load/ Force and Coupling. Finally, marked the activity as a grade. For Group A posture scores, Table A was referred, and for Group B posture scores, the Table B. The tables were arranged in the same order as the data collecting page. The total of the Table A and Load/Force scores was marked as Score A. For each hand, Score B is the total of the Table B and Coupling scores. Score C was read from Table C, by entering it with the Score A and the Score B.
The REBA score is the sum of the Score C and the Activity score. The output of the Rapid Entire Body Assessment tool is the final REBA Score, which is a single score that represents the level of MSD risk for the job task being evaluated. The minimum REBA Score = 1, and the maximum REBA Score = 15. Outlined in the above chart are the REBA level of MSD risk descriptions and cut points (Hossain et al. 2018).

Rapid Upper Limb Assessment (RULA)
The Rapid Upper Limb Assessment (RULA) is a workplace risk assessment tool based on ergonomics that allows to quantify the risk of musculoskeletal loading in the upper limbs and neck (Chan et al. 2002). Assessment worksheet for RULA is shown in Figure 2.
RULA's useful scoring system allows to take a snapshot of the highest risk posture adopted during the task (Sarder, Nabeel, and Mandahawi 2006). The scoring system was broken down into four action levels with indications in as to the urgency of the investigation.
Action level 1. Score of 1-2 = Acceptable Action level 2. Score of 3-4 = Investigate further Action level 3. Score of 5-6 = Investigate further and change soon Action level 4. Score of 7 = Investigate further and change immediately RULA is designed to assess the force, posture and movement associated with sedentary tasks including manufacturing, retail, computer tasks, and laboratory work or where the individual is seated or standing without moving about.
Step by step analysis

A. Arm and Wrist Analysis
Step 1: Locate Upper Arm Position: Step 1a: Adjust. If shoulder is raised: +1 If upper arm is abducted: +1 If arm is supported or person is leaning: −1 Step 2: Locate Lower Arm Position: Step 2a: Adjust. If either arm is working across midline or out to side of body: Add +1 Step 3: Locate Wrist Position: Step 3a: Adjust. If wrist is bent from midline: Add +1 Step 4: Wrist Twist: If wrist is twisted in mid-range: +1 If wrist is at or near end of range: +2 Step 5: Look-up Posture Score in Table A: Using values from steps 1-4 above, locate score in Table A Step 6: Add Muscle Use Score If posture mainly static (i.e. held >10 minutes), Or if action repeated occurs 4× per minute: +1 Step 7 Step 8: Find Row in Table C Add values from steps 5-7 to obtain Wrist and Arm Score. Find row in Table C.

B. Neck, Trunk and Leg Analysis
Step 9: Locate Neck Position: Step 9a: Adjust . . . If neck is twisted: +1 If neck is side bending: +1 Step 10: Locate Trunk Position: Step 10a: Adjust . . . If trunk is twisted: +1 If trunk is side bending: +1 Step 11: Legs: If legs and feet are supported: +1 If not: +2 Step 12: Look-up Posture Score in Table B: Using values from steps 9-11 above, locate score in Table B Step 13: Add Muscle Use Score If posture mainly static (i.e. held >10 minutes), Or if action repeated occurs 4× per minute: +1 Step 14 Step 15: Find Column in Table C Add values from steps 12-14 to obtain Neck, Trunk and Leg Score. Find Column in Table C Result and discussion Table 1 and Table 2 show the REBA, RULA scores for sewing, ironing and packing machine operators. Figures 3 to 8 show the percentage of REBA and RULA scores for sewing, ironing and packing machine operators.
Average REBA AND RULA scores for sewing machine operators (10 numbers) are 9 and 5, respectively. As the REBA score is 9, the respondents are at very high risk and no one at low risk and in safe zone in sewing activity. Action should be taken immediately for such activity. However, RULA score indicates that respondents are at medium risk.
Average REBA AND RULA scores for ironing workers are 10 and 7, respectively, for 40 people. As the REBA and RULA score is 10 and 7, the respondents are at very high risk and no one at low risk and in safe zone in ironing activity. This is in line with the earlier investigation and actions should be taken immediately (Sarder, Nabeel, and Mandahawi 2006). RULA score indicates that the respondents are at medium risk.
Average REBA AND RULA scores for packing workers are 8-9 and 6, respectively, for 13 people. As the REBA score is 8-9, respondents are at very high risk and no one at low risk and in safe zone in packing activity. Thus, action should be taken immediately to reduce the risk.

Pain identified
From the questionnaire, data collection percentage of pains identified in neck, shoulder, wrist, lower back, and knee is common site of pain in sewing, ironing and packing. Calf pain is especially seen in ironing workers. Musculoskeletal symptoms are occurring in sewing, packing, ironing as lower back pain (50%, 61.5%, 42.5%), knee pain (30%, 15.3%, 27.5%), wrist pain (20%, 23%, 20%), shoulder pain (40%, 46.15%, 27.5%) and neck pain (40%, 23%, 32.5%), respectively, and calf pain of 52.5% is the most common sites of pain in ironing. This can happen when mechanical or structural problems develop in the spine, discs, muscles, ligaments, or tendons in the back.
Musculoskeletal disorders are the group of disorders which affect the muscles, tendons, ligaments, joints, peripheral nerves and supporting blood vessels in the body. Sewing machine involves  continuous, repetitive tasks like cutting, assembly, pressing and finishing. These works are performed in a sitting posture with upper back curved forwards and the head is bent toward the sewing machine. Working in this faulty posture for a long time increases the chance of developing work-related musculoskeletal disorder among them.

Conclusion
Risk of musculoskeletal diseases (MSDs) related to certain employment duties in cotton garment industry was investigated by evaluating biomechanical and postural loads on the body by using REBA technique. The risk of musculoskeletal loading in the upper limbs and neck during garmenting operation was assessed on the basis of RULA technique.
The prevalence of musculoskeletal disorders is high in this study. It is critical that awkward posture, uncomfortable movements, prolonged standing, and other factors contributed to an increase in  worker risk particularly in India. In order to ameliorate the current catastrophic situation of garment industry employees in sewing, packing and ironing areas, it is desired to reduce their ergonomic hazards and to protect the material.

Disclosure statement
No potential conflict of interest was reported by the authors.