Occupational Medicine Prof. Francesco S. Violante Musculoskeletal Disorders due to Biomechanical Overload

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

(++)


(+/0)

Repetitiveness X

Force X

Posture X

Combination X

Evidence of Relation between Biomechanical Risk Factors and WMSDs - NIOSH (Bernard, 1997)

ElbowStrong

Evidence

(+++)

Evidence

(++)


(+/0)

Repetitiveness X

Force X

Posture X

Combination X


ShoulderStrong

Evidence

(+++)

Evidence

(++)


(+/0)

Repetitiveness X

Force X

Posture X

Vibrations X


LombalgiaStrong

Evidence

(+++)

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


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


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


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 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


Hypophysis

Hypophysis Hormones

Hormonal Receptors

Immune System

Autonomous Nervous SystemCytokines

Temperature Anorexia Drowsiness

Reduced LibidoSTRESS

Hypothalamus



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”


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”


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”


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”


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


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)


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)


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


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


Consequences of Health

“Reactions and Events”

Adaptation Disorder (AD) Post-traumatic Stress Disorder (PTSD)


The symptoms described can organize into the two main syndromic pictures, which represent the psychiatric responses to stressing conditioning or situations

Documents

Occupational Medicine Prof. Francesco S. Violante Musculoskeletal Disorders due to Biomechanical Overload