Occupational MedicineProf. Francesco S. Violante
Musculoskeletal Disorders due to Biomechanical Overload
RSI: National Occupational Health and Safety Commitee, 1990 “Occupational overuse syndrome, also known as
Repetition Strain Injury (RSI), is a collective term for a range of conditions characterized by discomfort or persistent pain in muscles, tendons and other soft tissues, with or without physical manifestations. Occupational overuse syndrome is usually caused or aggravated by work, and is associated with repetitive movement, sustained or constrained postures and/or forceful movements. Psycho-social factors, including stress in the working environment, may be important in the development of occupational overuse syndrome”.
Ramazzini (1713) : De morbis artificum diatriba
“Due sono secondo me, le cause che provocano le varie e gravi malattie dei lavoratori: la prima è rappresentata dalle proprietà delle sostanze impiegate che, producendo gas e polveri tossiche, inducono particolari malattie; la seconda è rappresentata da quei movimenti violenti e da quegli atteggiamenti non naturali per I quali la struttura stessa del corpo ne risulta viziata, cosicché col tempo sopraggiungono gravi malattie.”
Names of Muskuloskeletal disorders
Work Related Musculoskeletal Disorders (WRMSD)
Cumulative trauma disorders (CTD)Repetitive trauma disordersRepetitive strain injuries (RSI)Occupational Overuse syndromesOccupational cervicobrachial disordersMusculoskeletal Pain/Symptoms(…)
Properties of Musculoskeletal Disorders
WRMSD is not a diagnosis! It is a name used for a group of disorders that share some common qualities:Mechanical and physiological processRelated to work intensity and duration Require periods of weeks, months or years to
develop Require periods of weeks, months or years for
recovery Poorly localized, nonspecific and episodicOften unreportedMultiple work and personal causes
WHO, 1985 The World Health Organization has characterized
“work-related” diseases as multi-factorial to indicate that a number of risk factors (e.g., physical, work organizational, psychosocial, individual, and sociocultural) contribute to causing these diseases (WHO 1985).
There is disagreement, however, on the relative importance of occupational and individual factors in the development of work-related illnesses. The same controversy has been an issue with other medical conditions (occupational and non-occupational) such as certain cancers and lung disorders, both of which have multiple causality.
Risk Factors
Personal CTD FactorsGender AgeObesityPregnancy Rheumatoid arthritis Oral contraceptives Endocrinological disorders, e.g., diabetesAcute trauma, e.g., bruises, burns, lacerationsVitamin B-6 deficiency Gynecological surgery, e.g., oophorectomy,
hysterectomy(Wrist size and shape) (Fitness)
LBP and Individual Risk FactorsAgeFemale sex (risk 40-57%)Height: although some studies reported a higher
risk in taller subjects, most research does not support this
Weight: increased risk in overweight/obese subjects
Previous LBP episodes: seem to be associated with future episodes
Predisposing disorders: may have a role in the onset of occupational low back pain, but some of them are relatively rare (e.g. spondilolistesis)
LBP and Individual Risk Factors
Smoking: it was considered as a possible risk factor (although there are many other factors that can be related to cigarette smoking: socioeconomic class, lifestyle…), but according to Leboeuf-Yde's revision (Spine 1999, 24(14) 1463-70) it is rather to be considered as a weak risk indicator than as a real causal factor
Alcohol: although there is no evidence of a positive association, this cannot be excluded due to the lack of informative studies in this field
(Leboeuf-Yde C. Alcohol and low-back pain: a systematic literature review. J Manipulative Physiol Ther. 2000;23(5):343-6)
LBP and Individual Risk Factors
Education: when evidence of association between LBP and low educational level exists, we need to evaluate its dependence on socioeconomic status (review by Dionne et al., J Epidemiol Community Health. 2001;55(7):455-68)
Sport: Although the lack of sufficiently informative studies, data support the positive association between sedentary activity (and intense physical exercise) and LBP (review by Hildebrandt et al. Int Arch Occup Environ Health, 2000;73:507-518)
LBP and Psychosocial Factors
Work Organization (production rates, timetables, control and test systems)
Relationships with colleagues and superiors
LBP and Psychosocial FactorsWorkload perception, organizational aspects,
work social support: (moderate evidence of) no association
Stress: weak evidence of a positive association (systematic review of the literature, Hartvigsen et al, Occup Environ Med 2004; 61(1):e2)
Stress, depression and somatization increase the risk of LBP chronicity (review by Pincus et al. Spine
2002 Mar 1;27(5):E109-20) and also seem to play an important role in the patho-genesis of the acute event (review by Linton, Spine 2000 25(9):1148-56)
LBP and Occupational Risk factors
MHL (manual handling of loads): any transporting or supporting of a load, by one or more workers, including lifting, putting down, pushing, pulling, carrying or moving of a load
Vibrations transmitted to the whole bodyFlexions and torsionsMaintenance of fixed postures for prolonged
periods (repetitive manual work)
Fattori di rischio professionali (AASS)
High-frequency repetitive movementsMovements requiring the use of forceAwkward posturesLocalized compressionsVibrationsOther factors: low temperatures, absence of
adequate recovery times
Evidence of Relation between Biomechanical Risk factors and WMSDs - NIOSH (Bernard,1997)
Hand/Wrist
CTS
Strong Evidence
(+++)
Evidence
(++)
Insufficient Evidence
(+/0)
Repetitiveness X
Force X
Posture X
Vibrations X
Combination X
Evidence of Relation between Biomechanical Risk factors and WMSDs - NIOSH (Bernard, 1997)
Hand/Wrist
Tendonitis
Strong Evidence
(+++)
Evidence
(++)
Insufficient Evidence
(+/0)
Repetitiveness X
Force X
Posture X
Combination X
Evidence of Relation between Biomechanical Risk Factors and WMSDs - NIOSH (Bernard, 1997)
ElbowStrong
Evidence
(+++)
Evidence
(++)
Insufficient Evidence
(+/0)
Repetitiveness X
Force X
Posture X
Combination X
Evidence of Relation between Biomechanical Risk Factors and WMSDs - NIOSH (Bernard, 1997)
ShoulderStrong
Evidence
(+++)
Evidence
(++)
Insufficient Evidence
(+/0)
Repetitiveness X
Force X
Posture X
Vibrations X
Evidence of Relation between Biomechanical Risk Factors and WMSDs - NIOSH (Bernard, 1997)
LombalgiaStrong
Evidence
(+++)
Evidence
(++)
Insufficient Evidence
(+/0)
MHL (Manual Handling of Loads)
X
Flexion/Torsion of trunk
X
Posture X
Vibrations* X
* Vibrations transmitted to the whole body (Whole body vibration)
MHL and Awkward Postures
Rachis Posture: examples
Musculoskeletal Disorders in Europe (European Foundation, Dublin, 2000)
Third Survey on Workers' Health:33 % report backache28 % report stress disorders23 % report shoulder and neck pain13 % report upper limb pain
Percentage of workers reporting each individual symptom (European Foundation 2005)
Incidence of ODs Recognised by INAIL in the Years 1995-1999 within the Industry Sector
INAIL DATA, 2000WRMSDs granted by SMG (incidence rate by type of disorder)
WRMSDs sent to SMG (distribution by region)
Inail Data, 2000: % of Recognized MSDs by Work Process
20,7Other
4,1Footwear and Leather Industry
4,4Driving of Mechanical Vehicles
4,4Wood Smoothing
4,7Confection/ Packaging
5,2Sorting/ Selection
5,8Meat Processing
7,3Clothing Industry
43,4Mounting, Assembly
INAIL - % of MSDs by type of disorder
INAIL - % MSDs by age
Low back pain, LBP
80% of the population suffer from LBP at least once in their lifetime
50% of cases resolve within 4-8 weeks85% of relapsesThe first episode generally occurs between
20 and 40 years of age and affects both sexes
(Hicks GS, et al. Am J Med Sci 2002; 324: 207-211)
USA: Top 10 Most Costly Physical Conditions (by component)
(Goetzel RZ, et al. JOEM 2003: studio riguardante più di 370.000 lavoratori americani)
Health Personnel (nurses, physical therapists, health operators and assistance technicians) are considered among the most at-risk categories for Low Back Pain; the manual handling of patients is the major source of risk
Load Handling Personnel (building sector, portering, foundry, agriculture, store activities, product arrangement)
Drivers of Heavy Vehicles
Workers at risk of Low Back Pain
Musculoskeletal Disorders due to Overload: Physiopathogenesis
EXPOSURE TO BIOMECHANICAL RISK FACTORS
ADAPTATION(TRAINING EFFECT)
DAMAGE(MUSCULOSKELETAL DISORDER)
•Reaction 1•Reaction 2•Reaction 3•Reaction 4•…
Possible Mechanisms involved in the development of WR- fatigue and pain
Shoulder: Anatomical Hints
Shoulder: Main Disorders
Acute TendonitisTendinosis (with/without
calcification)Rotator cuff
lesions/ruptures BursitisConflict SyndromesArthrosis(Scapulo-humeral
Periarthritis ??!!)
Elbow: Anatomical Hints
Elbow and Forearm Pain Diagram
EpicondylitisMedial
EpicondylitisOlecranon
BursitisCompression of
the ulnar nerve at the elbow
Elbow: Main Disorders
Estensori
Flessori
Hand: Anatomical Hints
Hand: Anatomical Hints
Hand: Main Disorders
Tenosynovitis of the carpal and finger extensors/flexors
De Quervain's Syndrome Trigger Digit Carpal Tunnel Syndrome Guyon's Canal Syndrome Ganglion Cysts
Inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis
Pain is increased by ulnar deviation of the wrist
Finkelstein sign
De Quervain's Syndrome
Tendon nodule at the metacarpal-phalangeal level associated with deficit in digit extension due to purely mechanical factors
Trigger Digit
Carpal Tunnel Syndrome
Clinical condition caused by the compression of the median nerve at the carpal tunnel (focal compression neuropathy), which manifests as tingling, numbness sensation, soreness, pain involving at least one of the first three fingers
Musculotendinous Disorders of the Upper Limb: diagnosis
Clinical: Symptoms: pain, difficulty sleeping on the
affected sideSigns: Clinical tests and specific provocative
tests - e.g. Finkelstein – active, passive and against-resistance mobilizations
Functional limitation
Diagnostic Imaging (US, XR, MR)Laboratory Tests can help determine the
etiology of these disorders
Clinical: signs and symptoms (paresthesias, Tinel's and Phalen's tests)
Electrodiagnostic tests are useful to confirm diagnoses and estimate severity
Further tests: ultrasound scan, laboratory tests, XR tests can help determine the etiology of these disorders
Diagnosis of CTS and other Peripheral Neuropathies
US: Longitudinal Section of the Wrist
US: Cross Section of the Wrist
Cross-sectional MR of the Wrist
Rachis: Most Frequent Disorders
Intervertebral Disc Degeneration progressive thinning of cartilage with consequent loss of shock absorbing function
Arthrosis (radiculopathy) degenerative disease of the bone leading to the formation of osteophytes
Herniated Disc (radiculopathy) condition due to the degeneration or acute rupture in the fibrous ring of the intervertebral disc with consequent migration of the nucleus pulposus to the periphery
ARTROSI
ERNIA
COMPRESSIONE NERVOSA
Rachis: Most Frequent Disorders
Changes in the curvature of the spine (scoliosis, kyphosis, lordosis)
Osteoporosis
Spondilolisis, spondilolistesis
SCOLIOSI
LORDOSI
CIFOSI
Rachis Disorders: Diagnosis
Clinical: Signs and SymptomsProvocative TestsDiagnostic Imaging (XR, CT, MR)Electrophysiological Tests
The Problem of Diagnosis
Pain is the primary symptom (often the only one) of most spinal disorders
The literature abounds with different diagnostic terms, often used together to describe the clinical history of a patient
The classification of low back pain in Occupational Medicine should have specific characteristics
Quebec Task Force Classification for Spinal Disorders (1987)
1) Pain without radiation
2) Pain with proximal radiation
3) Pain with distal radiation
4) Pain with radiation to the extremities and neurological signs
5) Presumptive compression of a spinal nerve root on the basis of simple X-rays of the spine (spinal instability or fracture)
The Problem of Diagnosis
Pain is the primary symptom (often the only one) of most spinal disorders
The literature abounds with different diagnostic terms, often used together to describe the clinical history of a patient
The classification of low back pain in Occupational Medicine should have specific characteristics
Quebec Task Force Classification for Spinal Disorders
1) Confirmed compression of a spinal nerve root (CT or MR)
2) Stenosis of the vertebral canal
3) Post-surgical status (1-6 months after intervention)
4) Post-surgical status (more than 6 months after intervention) asymptomatic\symptomatic
5) Chronic painful syndrome
6) Other diagnoses
Quebec Task Force Classification for Spinal Disorders
Categories 1-3 are based only on anamnesis
Category 4 is based on clinical testsCategories 5-7 are based on instrumental
test resultsCategories 8-10 are based on the response
to therapyClassification is mainly based on the
clinical picture
Quebec Task Force Classification for Spinal Disorders
Categories 1-4 (pain with or without radiation) can be further specified on the basis of
Symptoms duration:a) acute (less than 7 days)b) subacute (from 7 days to 7 weeks)c) chronic (over 7 weeks)
Duration of work status (at work or on leave)
Biomechanics of the Rachis
The L5-S1 junction represents the fulcrum of a lever
It is the area most subject to strain (biomechanical models)
FULCRO
Forces on L5/S1
BW Body weight
LH load weight
b distance CMbody-L5/S1
h distance CMobject-L5/S1
(MC: mass centre)
Low back muscle force FM
Disc CompressionForce FC
LH
hb
BW
L5-S1Disc Moment
W
Biomechanics of the Rachis
Biomechanics of Rachis
Load on L3 in different positions (subject weighing about 70 Kg)
Is there a Limit?
Experimental data obtained from corpses
Critical force value above which the risk for lumbar damage increases: 3400 N
Factors Influencing the load exerted on the rachis during Lifting Operations
Load magnitudeFrequency of lifting Duration of lifting Load distance from the bodyPosition of load at the beginning and end of
lifting(Lifting speed)
Risk Assessment of MHL
NIOSHWashinghton's Standard Method Method proposed by ACGIHSnook & Ciriello tables on pushing, pulling
and carryingEN 1005-2…
Equazione NIOSH
Recommended weight limit (RWL) It is the product of the load constant and six
multipliers LC x HM x VM x DM x AM x FM x CM = RWL
Exposure Measurement
Exposure measurements used in work-related MSD studies range from very crude measures (e.g., occupational title) to complex analytical techniques (e.g., spectral analysis of electrogoniometer measurements of joint motions). Some studies have relied on self-assessment of physical workload by the study subjects.
The accuracy of such self-assessment has been debated (both for under-estimation and over-estimation).
http://www.cdc.gov/niosh/docs/97-141/ergotxt1.html
Biomechanical Risk Assessment for the Upper LimbsGeneral Ergonomic Standards OSHA proposed ergonomic protection standard (OSHA ‘95) OSHA ergonomics program standard (OSHA 2000) Washington State ergonomics rule (no longer official) CEN EN1005-3: recommended force limits for machinery
operation CEN EN1005-4: evaluation of working postures in relation to
machinery ISO 11226: ergonomics- evaluation of working postures
Guidelines ANSI-Z 365 1996 (4^ review) California State Standard (1997) IEA TG 2001 exposure assessment of upper-limb repetitive
movements: a consensus document TLV for hand activity level - ACGIH (2001) (…)
TLV - ACGIH
_____ TLV
- - - - Action Limit
Biomechnical VR for the Upper Limbs: further Methods reported by the Literature
Check-list proposed by KeyserlingJob Strain IndexOCRA Index (and OCRA check-list)OREGE MethodRULA Method (Rapid Upper Limb
Assessment)
Occupational MedicineProf. Francesco S. Violante
Relational Factors, Work and Health
Health
“stato di benessere psico-fisico e sociale che consente all’individuo di fruire di tutte le sue risorse fisiche, emotive e mentali”
(WHO 1988)
Classification
Person/Environment Relationships Interpersonal Relationships
Person/Environment Relationships
Temporal aspects of the work day and work itself
Content of work
Work organization
Interpersonal Relationships
Interpersonal relationships in the work group
Interpersonal relationships with supervisors
Stress
“risposta aspecifica dell’organismo per ogni richiesta effettuata su di esso dall’ambiente esterno”
(Hans Selye, Nuture 1936)
Work-related Stress
“reazione emotiva, cognitiva, comportamentale e fisiologica ad aspetti avversi e nocivi del contenuto, dell’ambiente e dell’organizzazione del lavoro”
(Agenzia Europea per la Sicurezza e la Salute sul Lavoro, 2000)
Work-related Stress
“l’insieme delle risposte psichiche e fisiche di allarme che occorrono quando le richieste lavorative non corrispondono alle capacità, alle risorse o alle necessità del lavoratore”
(National Institute for Occupational Safety and Health-NIOSH, 2000)
Work-related Stress
Size of the Problem
28% of EU workers (about 41 millions) suffer from work-related stress disorders at least once a year
24% of EU workers have been absent from work in the last 12 months due to work-related stress problems
In the EU countries, 600 million working days are lost every year (4/year per worker)
(European Foundation, Dublin, 1996)
Stressor or Stressing Agent
“fattore che spinge l’organismo all’adattamento”
(Hans Selye, Nuture 1936)
Stressors
Classification
p Physical
p Chemical
p Biological
p Biomechanical
p Psychosocial
(International Labour Organization, ILO 1986)
Stressors
Physical Causes
Noise Vibrations Ionizing radiations High and low temperatures High humidity, etc.
Stressors
Chemical Causes
Toxic substances Harmful substances
Stressors
Biological Causes Seasonal Changes Infections Low-calories diets Diseases Organic traumas Jet-lag (caused by fast travel across different
time zones), etc.
Stressors
Biomechanical Causes Manual handling of heavy loads Uncomfortable or tiring postures, etc.
Stressors
Psychosocial Factors
“ sono quegli aspetti relativi alla progettazione, organizzazione e gestione del lavoro, nonché ai relativi contesti ambientali e sociali, che potenzialmente possono dar luogo a danni di natura psicologica, sociale o fisica”
(Cox T and Griffiths AJ. Handbook of Workand Health Psychology 1995)
Stressors
Several authors have tried to identify work-related factors that might constitute stressors; these factors may include objective conditions (shiftwork, nightwork, unemployment, etc.) and subjective conditions (perception of overwork, role ambiguity, interpersonal conflicts, etc.)
Kasl's List Temporal aspects of the work day and work itself Content of work Interpersonal relationships in the work group Interpersonal relationships with supervisors Work organization(European Agency for Safety and Health at Work. Research on work-related stress, 2000)
Work-related Stress Factors
Temporal aspects of the work day and work itself
Shiftwork and nightwork
Undesired overtime
Inflexible work schedule
Piecework
Increased work pace
Lack of time to meet deadlines
Kasl's List
Content of Work
Fragmented, repetitive and monotone work
Uncertainty about tasks and demands
Lack of decision latitude
Lack of control over working life
Inadequacy of commitment requested
Lack of resources
Kasl's List
Interpersonal relationships in the work group
Lack of social support
Moral harassment (mobbing) and sexual harassment
Lack of recognition for achievements
Unfair distribution of workload
Intense conflict among colleagues
Kasl's List
Interpersonal relationships with supervisors
Lack of social support
Moral harassment (mobbing) and sexual harassment Lack of recognition for achievements
Lack of participation in decision-making processes
Authoritarian leadership
Uncertainty and inconsistency of demands
Kasl's List
Work organization
Jobs at the organizational periphery
Low job prestige
Undefined organizational structure
Excess of organizational (administrative) bureaucracy
Inadequate (non-functional) organizational procedures
Discriminatory company policies
Kasl's List
Society and Stress
CHANGES IN PATTERNS OF WORK
SOCIAL DISINTEGRATION
INCREASE IN METRIAL BENEFITS
BREAKDOWNOF FAMILY
FAST & QUICK’SOCIETY VALUES
BREAKDOWNOF NEIGHBOURHOOD
ENVIRONMENTAL DAMAGE
INCREASED UNEMPLOYMENT
SHIFT TOWARDSSKILLED LABOUR
Causes of Stress:Organizational Influence
Intrinsic tothe job
Relationshipat work
Factors
Intrinsic
To the individual
Role in the organization
Organizationalstructure
and climate
Career development
Home-workinterface
Demand-control
Demand-control-support
Person-environment Fit
Effort-reward
Effort-distress
Work-related Stress Models
Job demand
Decision latitude:
Skill discretion identifies:
-the opportunity to develop new skills
-the degree of repetitiveness of tasks
-the opportunity to upgrade one's competence Decision authority represents:
- the individual's degree of control over work design and organization
The Demand-Control Model
Working Conditions
High strainhigh demand and low decision latitude
Examples: assembly-line jobs, supermarket cashiers, security forces
Passivelow demand and low decision latitude
Examples: data entry employees, room cleaners, refuse collectors
The Demand-Control Model
Working Conditions
Activehigh demand and high decision latitude
Examples: physicians, teachers, researchers, lawyers, journalists
Relaxed (or Low strain)low demand and high decision latitudeExamples: sales representatives, pharmaceutical representatives
The Demand-Control Model
The Demand-Control Model of Stress (Karasek)
High control
Low control
Low High
Dec
isio
n La
titud
e
Job Demands
Low strain Job Active Job
Passive Job High Strain Job
Job demand
Decision latitude
Workplace social support
The Demand-Control-Support Model
Low CONTROL High
Low
SU
PPO
RT H
igh
Low DEMAND High
RelaxedActive
PassiveHigh
Strain
The Demand-Control-Support Model (Johnson and Hall, 1988)
The Different Aspects of Stress
Stress response:
Physiological processes
Cognitive reactions
Emotional reactions
Behavioural reactions
Physiological Processes
The physiological response to stress has been defined as general adaptation syndrome. It is ineliminable and “vital” for the organism, because it enables the individual to face possible changes and problems through a typical aspecific response.
Nervous pathway
Endocrine pathway
The Nervous Pathways
Activation of the nervous sympathetic system and medullary portion of the suprarenal glands (liberation of catecholamines)
The Endocrine Pathway
Activation of the cortical portion (liberation of corticosteroids) of the suprarenal glands
HypothalamusHypothalamus
Anterior HypophysisAnterior Hypophysis
Suprarenal CortexSuprarenal Cortex
Immune SystemLymphocytesMacrophages/monocytesNeutrophils
Immune SystemLymphocytesMacrophages/monocytesNeutrophils
IL – 1IL – 2IL – 6
TNF - a
CortisolCortisol
The Endocrine Pathway
Hypophysis
Hypophysis Hormones
Hormonal Receptors
Immune System
Autonomous Nervous SystemCytokines
Temperature Anorexia Drowsiness
Reduced LibidoSTRESS
Hypothalamus
The Endocrine Pathway
The Endocrine Pathway
Organic Response to Stress
The activation of these pathways gives rise to an “ergothrope” response of the organism, which allows facing the stressing event in a rapid and valid way
Types of Ergotrope Responses
“Positive” Stress or eustress
“Negative” Stress or distress
0 1 2 3 4 5 6 7 8 9 10
Distress Eustress Distress
Best
Worst
Is Stress Harmful? When?
Stimuli are too intense or too weak for the individual
Stimuli are too close or prolonged (insufficient recovery time)
The high number of events that we must face every day is the major cause of stress
Human Performance and Stress
OPTIMUMPERFORMANCE
BURNOUT
BOREDOMFRUSTATION
INCREASING STIMULATION
STRESS
EFFECTIVE,ALERT
60
50
40
30
20
10
0
IncreasingLevel ofperformance
The Role of Psychological and Social Stressors
Social Readjustment Rating Scale by Holmes and Rahe
(Holmes JS and Rahe RH. Journal of Psychosomatic Research 1967)
Social Readjustment Rating Scale by Sarason
(Sarason IG, de Monchaux C, Hunt T. Methodological issues in the assesment of live stress. Emotion: Parameters and Measurement. Raven, New York 1975)
Everyday Problems as a Cause of Stress
Everyday Problems Scale by Lazarus
(Lazarus RS. Psychological Stress and the Coping Process. Mc Graw-Hill, New York 1966)
Why does an Event become Stressful?
Distress does not only depend on thebuilding up of events, but also on theperception that individuals have of them, i.e,the emotional weight that they carry
“Evaluation ” of the Stressful Event
“processo mentale mediante il quale diamo all’evento un significato soggettivo (cioè personale) positivo (cioè buono) o trascurabile o negativo (cioè cattivo)”
(Lazarus RS. Psychological Stress and the Coping Process. Mc Grawl-Hill, New York 1966)
“Coping” Process
“l’insieme dei tentativi per controllare gli eventi ritenuti difficili o superiori alle nostre risorse”
(Lazarus RS. Psychological Stress and the Coping Process. Mc Grawl-Hill, New York 1966)
03/06/08 Medicina del Lavoro – Prof. Francesco S. Violante
122
The Coping Balance
PRESSURECAN’T COPE
EXCESSPRESSURE COPING
EQUILIBRIUM
Dynamics of the Stress-Disease Process
INTERAZIONEtra lavoratori e situazioni di stress
EFFETTIlegati allo stress
DANNIalla salutedovuti astress
VALUTAZIONE
COPING EFFICACE
Attivazione di meccanismineurologici.
Risposta neurovegetativae neuroendocrinaPREDISPOSIZIONE
SUSCETTIBILITA’COPING
INEFFICACE
Effetti patologici legati allaattivazione del sistema
neurovegetativo eneuroendocrino.
ESAURIMENTODEL PROCESSO
Who is most exposed to Stress?
Workers with a A-type behaviour pattern
Young workers
Old workers
Immigrant workers
Single working mothers
Disabled workers
“A-type Behaviour” Extremely afraid of losing time the individual does more things at the same time, and takes on more commitments than he can handle. Low self-confidence the individual is unconsciously unsecure and has little faith in his abilities; in order to gain self-esteem, he keeps talking about himself in an egocentric manner. Another index of insecurity is the extreme perfectionism in any activity, associated with an intolerance of even light criticism and the need to feel approved. High aggressiveness the individual wants to dominate over others, without worrying about their feelings or rights. Hostility in any situation the individual is in constant competition with others, he is always suspicious and mistrustfuland and is always finding fault with everything. Drive to self-destruction Carl Gustav Jung said that “the conditions that can lead to success are the same that can lead to death”: these words are particularly suitable to describe the A-type personality, who never takes a rest and never relaxes. This subject must prove to be constantly active and feels guilty if he is not busy doing something.“B-type Behaviour” The B-type ways of feeling and acting lack the characteristics typical of the A-type behaviour.
A-type Behaviour
Characteristics
Extremely afraid of losing time
Low self-confidence
High aggressiveness
Hostility in any situation
Drive to self-destruction
Distress due to a Lack of Stressors
Distress can stem from an excess, but also from a lack of stimuli
Lack of Stimuli: Examples
Undernutrition Silence Social Isolation Unemployment Retirement Want of affection
Warning Signs of Distress
Emotional manifestations
Cognitive manifestations
Behavioural manifestations
Physiological manifestations
PHISICAL PSYCHOLOGICAL
STRESS
EMOTIONAL BEHAVIOURAL
The effects of Stress on the Individual
Anxiety or depression
Irritability or apathy
Sleep disorders
Panic attacks
Emotional Manifestations
Difficulty concentrating
Difficulty learning new things
Difficulty memorizing
Difficulty maintaining attention
Difficulty being creative
Cognitive Manifestations
Seeking comfort in:
Cigarettes
Alcohol
Food
Psychotropic drugs
Drugs
Behavioural Manifestations
Palpitations
Xerostomia and copious perspiration
Polachiuria
Nausea and vomiting
Inappetence or bulimia
Cephalea and sleep disorders
Cervicalgia and lumbalgia
Digestive disorders and/or irregular alvus, etc.
Physiological Manifestations
Why does Stress cause Disease?
Theory of specificity Theory of general susceptibility
The Effects of Stress
Inefficientfunctioning
of the organization
High costs
STRESS
Pressure spiral
Behaviouraleffects on the
individual
Individualill-healt
Theory of Specificity
Specific types of behaviour would lead to specific diseases
example: type-A person coronaropathies
Theory of general susceptibility
When prolonged, the response to stress reduces immune defenses, thus increasing susceptibility to any disease (not to specific ones)
Why are specific organs affected?
Concept of Locus minoris resistentiae:
Distress weakens the individual's defenses, increasing the probability for the most vulnerable organs or functions (i.e., those less able to withstand morbid processes) to be affected
Why are some People affected and others not?
It is us who cause events to turn into stressors, as a result of our evaluation and coping
Stress Diseases Cardio- and cerebrovascular diseases
Neoplastic diseases
Osteomuscular diseases
Gastrointestinal diseases
Sleep disorders
Cephaleas
Anxiety and depression disorders, etc.
Stress Diseases
Disease
“malattia, ossia l’alterazione strutturale e/o funzionale dell’organismo umano oggettivamente documentabile”
(Agenzia Europea per la Sicurezza e la Salute sul Lavoro. Ricerca sullo stress correlato al lavoro,2000)
Stress Diseases
Illness
“infermità, ossia lo stato di malessere soggettivamente percepito dalla persona”
(Agenzia Europea per la Sicurezza e la Salute sul Lavoro. Ricerca sullo stress correlato al lavoro,2000)
Stress Diseases
Sickness Behaviour
“comportamento di malattia, ossia le reazioni della persona ai sintomi, nonché all’insieme di percezioni, valutazioni, atteggiamenti e interpretazioni che li condizionano”
(Agenzia Europea per la Sicurezza e la Salute sul Lavoro. Ricerca sullo stress correlato al lavoro,2000)
Cardio- and cerebrovascular diseases Myocardial infarction Essential arterial hypertension Stroke Sudden death
Neoplastic diseases Smoking pulmonary carcinoma Alcohol liver carcinoma Food colon carcinoma
Osteomuscular diseases Cervical rachis Lumbar rachis Upper limbs
Stress Diseases
Gastrointestinal diseases Gastric or duodenal peptic ulcers Irritable colon syndrome Ulcerous rectocolitis
Sleep disorders Disorders of initiation and maintenance of sleep Disorders related to excessive daytime drowsiness
Cephaleas Migraine Musculotensive cephalea
Anxiety and depression disorders Acute stress disorder Post-traumatic anxiety disorder Depressive disorders
Stress Diseases
Burnout Syndrome
The term “burnout” means “burnt”, “exhausted”
(Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev Psychol 2001; 52: 397-422)
Definition
“risposta prolungata a fattori stressanti cronici legati all’attività lavorativa di tipo emozionale ed interpersonale, definita da tre dimensioni: esaurimento emotivo, spersonalizzazione ed inefficacia”
(Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev
Psychol 2001; 52: 397-422)
Burnout Syndrome
Emotional Exhaustion
“la persona prova un progressivo disinteresse per il proprio lavoro”
(Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev Psychol 2001; 52: 397-422)
Burnout Syndrome
Depersonalization
“la persona diventa sempre più fredda” e prova un sempre maggior senso di distacco nei confronti degli altri (collaboratori, utenti, pazienti, ecc.)“(Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev Psychol 2001; 52: 397-422)
Burnout Syndrome
Ineffectiveness
“la persona prova un profondo senso di fallimento ed un sentimento di delusione nei confronti del proprio lavoro”
(Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev Psychol 2001; 52: 397-422)
Burnout Syndrome
Causes
Inadequate social support Role ambiguity Extreme conflict with colleagues and/or superiors
Burnout Syndrome
At-risk Subjects
Subjects with no clear boundary between themselves and others Subjects with no clear boundary between professional and personal life More ambitious and motivated subjects Subjects driven by an exaggerated need to help others
Burnout Syndrome
Symptoms
Psychic (cognitive and emotional) Behavioural Psychosomatic
Burnout Syndrome
Psychic Symptoms
Loss of psychic energy Loss of motivation Loss of self-esteem Loss of control
Burnout Syndrome
Behavioural Syndrome
Strong lack of commitment at work Self-destructive behaviours Hetero-destructive behaviours
Burnout Syndrome
Psychosomatic Symptoms Palpitations Xerostomia and copious perspiration Acne, eczema, aphtae Nausea, vomiting, epigastralgia, pyrosis Inappetence or bulimia Cephalea and sleep disorders Frigidity, impotence, loss of desire Irregular alvus (constipation or diarrhoea), etc
Burnout Syndrome
Mobbing
The term mobbing derives from the verb “to mob”, meaning “to attack”, “to surround”
(Lorenz K. Das sogenante Boese. Zur Naturgeschichte der Aggression. Wien, 1963)
Mobbing
Definition
“un comportamento ripetuto, immotivato, rivolto contro un dipendente o un gruppo di dipendenti, tale da creare un rischio per la sicurezza e la salute”
(Leymann H. The content and development of mobbing at work. European Journal of Work and Organizational Psychology 1996; 5: 2)
Mobbing
Definition
“una condizione di violenza psicologica, intenzionale e sistematica, perpetrata in ambiente di lavoro per almeno sei mesi, con l’obiettivo di espellere il lavoratore dal processo lavorativo”
(Gilioli R et al. Documento di Consenso. Un nuovo rischio all’attenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)
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Incidence of Mobbing in the UE countriesIncidence of Mobbing in the UE countries(European Parliament. Committee on employment and social affairs. Report on
harassment at the workplace. July, 16, 2001. 2001/2339-INI)
Types of mobbing
Strategic mobbing Emotional or relational mobbing Non-intentional mobbing
(Gilioli R et al. Documento di Consenso. Un nuovo rischio all’attenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)
Strategic Mobbing
Precise strategy intentionally adopted by the company and/or company management towards one worker (individual mobbing) or a group of workers (collective mobbing)
(Gilioli R et al. Documento di Consenso. Un nuovo rischio all’attenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)
It is more frequent in private companies Vertical Mobbing
Emotional Mobbing
It stems from a dramatic change in the interpersonal relations between employer and employee (vertical mobbing or bossing) or, more often, among colleagues (horizontal mobbing)
(Gilioli R et al. Documento di Consenso. Un nuovo rischio all’attenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)
Prevalent in the civil service
Non-intentional Mobbing
The company management has no precise strategic intention to eliminate or to adversely affect a worker through acts of psychological violence
(Gilioli R et al. Documento di Consenso. Un nuovo rischio all’attenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)
Although there is no malice, the company management is guilty of nonfeasance
Affected Subjects (targets)
Workers highly involved in their job or creative and innovative workers
Subjects with disabilities or subjects with reduced working capacity compulsorily placed in a job, but thwarted by employers, superiors or co-workers
Subjects considered “different” for various reasons (e.g., geographical provenance, religion, lifestyle, sexual orientation, etc.)
Workers deliberately taking no part in their colleagues'/superiors' illicit practices
Mobber's Behaviours
Harassment directed at the individual continuous humiliations continuous offences (also concerning private and familial life)
Harassment directed at the activity continuous contempt for the activity performed continuous criticism of the activity performed acts of sabotage (tampering and falsification of documents)
Mobber's Behaviours
Harassment concerning the worker's role strong reduction in the worker's role downgrading of duties unjustified transfers to distant sites
Harassment concerning the worker's status Empty desk syndrome (the subject is deprived of the tools needed to carry out his activity and is completely shut out with no explanations and no assignments) Stacked desk syndrome (quantitative and/or qualitative overload)
Consequences of Health
Early Warning Signs
Psychosomatic disorders Emotional disorders Behavioural disorders
(Gilioli R et al. Documento di Consenso. Un nuovo rischio all’attenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)
Consequences of Health
“Reactions and Events”
Adaptation Disorder (AD) Post-traumatic Stress Disorder (PTSD)
(Gilioli R et al. Documento di Consenso. Un nuovo rischio all’attenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)
The symptoms described can organize into the two main syndromic pictures, which represent the psychiatric responses to stressing conditioning or situations