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

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

2 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.

3 Ramazzini (1713) Various and manifold is the harvest of diseases reaped by certain workers from the crafts and trades that they pursue. All the profit that they get is fatal injury to their health, mostly from two causes. The first and most potent is the harmful character of the materials they handle The second, I ascribe to certain violent and irregular motions and unnatural postures of the body, by reason of which, the natural structure of the vital machine is so impaired that serious diseases gradually develop there from. Ramazzini, B.: Treatise on the Diseases of Workers (1713), Translated by W.C. Wright (1940), New York: Hafner Publ. Co., 1964.

4 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.

5 Names of Muskuloskeletal disorders Work Related Musculoskeletal Disorders (WRMSD) Cumulative trauma disorders (CTD) Repetitive trauma disorders Repetitive strain injuries (RSI) Occupational Overuse syndromes Occupational cervicobrachial disorders Musculoskeletal Pain/Symptoms (…)

6 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 process Related 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 episodic Often unreported Multiple work and personal causes

7 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.

8 Risk Factors

9 Personal CTD Factors Gender Age Obesity Pregnancy Rheumatoid arthritis Oral contraceptives Endocrinological disorders, e.g., diabetes Acute trauma, e.g., bruises, burns, lacerations Vitamin B-6 deficiency Gynecological surgery, e.g., oophorectomy, hysterectomy (Wrist size and shape) (Fitness)

10 LBP and Individual Risk Factors Age Female 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)

11 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) ) 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)

12 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: )

13 LBP and Psychosocial Factors Work Organization (production rates, timetables, control and test systems) Relationships with colleagues and superiors

14 LBP and Psychosocial Factors Workload 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 (9): )

15 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 body Flexions and torsions Maintenance of fixed postures for prolonged periods (repetitive manual work)

16 Fattori di rischio professionali (AASS) High-frequency repetitive movements Movements requiring the use of force Awkward postures Localized compressions Vibrations Other factors: low temperatures, absence of adequate recovery times

17 Evidence of Relation between Biomechanical Risk factors and WMSDs - NIOSH (Bernard,1997) Hand/Wrist CTS Strong Evidence (+++) Evidence (++) Insufficient Evidence (+/0) RepetitivenessX ForceX PostureX VibrationsX CombinationX

18 Evidence of Relation between Biomechanical Risk factors and WMSDs - NIOSH (Bernard, 1997) Hand/Wrist Tendonitis Strong Evidence (+++) Evidence (++) Insufficient Evidence (+/0) RepetitivenessX ForceX PostureX CombinationX

19 Evidence of Relation between Biomechanical Risk Factors and WMSDs - NIOSH (Bernard, 1997) Elbow Strong Evidence (+++) Evidence (++) Insufficient Evidence (+/0) RepetitivenessX ForceX PostureX CombinationX

20 Evidence of Relation between Biomechanical Risk Factors and WMSDs - NIOSH (Bernard, 1997) Shoulder Strong Evidence (+++) Evidence (++) Insufficient Evidence (+/0) RepetitivenessX ForceX PostureX VibrationsX

21 Evidence of Relation between Biomechanical Risk Factors and WMSDs - NIOSH (Bernard, 1997) Lombalgia Strong Evidence (+++) Evidence (++) Insufficient Evidence (+/0) MHL (Manual Handling of Loads) X Flexion/Torsion of trunk X PostureX Vibrations * X * Vibrations transmitted to the whole body (Whole body vibration)

22 MHL and Awkward Postures

23 Rachis Posture: examples

24 Musculoskeletal Disorders in Europe (European Foundation, Dublin, 2000) Third Survey on Workers' Health: 33 % report backache 28 % report stress disorders 23 % report shoulder and neck pain 13 % report upper limb pain

25 Percentage of workers reporting each individual symptom (European Foundation 2005)

26 Incidence of ODs Recognised by INAIL in the Years within the Industry Sector

27 INAIL DATA, 2000 WRMSDs granted by SMG (incidence rate by type of disorder) WRMSDs sent to SMG (distribution by region)

28 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

29 INAIL - % of MSDs by type of disorder

30 INAIL - % MSDs by age

31 Low back pain, LBP 80% of the population suffer from LBP at least once in their lifetime 50% of cases resolve within 4-8 weeks 85% of relapses The 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: )

32 USA: Top 10 Most Costly Physical Conditions (by component) (Goetzel RZ, et al. JOEM 2003: studio riguardante più di lavoratori americani)

33 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

34 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 …

35 Possible Mechanisms involved in the development of WR- fatigue and pain

36 Shoulder: Anatomical Hints

37 Shoulder: Main Disorders Acute Tendonitis Tendinosis (with/without calcification) Rotator cuff lesions/ruptures Bursitis Conflict Syndromes Arthrosis (Scapulo-humeral Periarthritis ??!!)

38 Elbow: Anatomical Hints Elbow and Forearm Pain Diagram

39 Epicondylitis Medial Epicondylitis Olecranon Bursitis Compression of the ulnar nerve at the elbow Elbow: Main Disorders Estensori Flessori

40 Hand: Anatomical Hints

41

42 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

43 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

44 Tendon nodule at the metacarpal- phalangeal level associated with deficit in digit extension due to purely mechanical factors Trigger Digit

45 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

46 Musculotendinous Disorders of the Upper Limb: diagnosis Clinical: Symptoms: pain, difficulty sleeping on the affected side Signs: 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

47 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

48 US: Longitudinal Section of the Wrist

49 US: Cross Section of the Wrist

50 Cross-sectional MR of the Wrist

51 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

52 Rachis: Most Frequent Disorders Changes in the curvature of the spine (scoliosis, kyphosis, lordosis) Osteoporosis Spondilolisis, spondilolistesis SCOLIOSI LORDOSI CIFOSI

53 Rachis Disorders: Diagnosis Clinical: Signs and Symptoms Provocative Tests Diagnostic Imaging (XR, CT, MR) Electrophysiological Tests

54 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

55 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)

56 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

57 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

58 Quebec Task Force Classification for Spinal Disorders Categories 1-3 are based only on anamnesis Category 4 is based on clinical tests Categories 5-7 are based on instrumental test results Categories 8-10 are based on the response to therapy Classification is mainly based on the clinical picture

59 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)

60 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

61 Forces on L5/S1 BW Body weight L H load weight b distance CM body -L 5 /S 1 h distance CM object -L 5 /S 1 (MC: mass centre) Low back muscle force F M Disc Compression Force F C LHLH h b BW L5-S1 Disc Moment W

62 Biomechanics of the Rachis

63 Biomechanics of Rachis Load on L3 in different positions (subject weighing about 70 Kg)

64 Is there a Limit? Experimental data obtained from corpses Critical force value above which the risk for lumbar damage increases: 3400 N

65 Factors Influencing the load exerted on the rachis during Lifting Operations Load magnitude Frequency of lifting Duration of lifting Load distance from the body Position of load at the beginning and end of lifting (Lifting speed)

66 Risk Assessment of MHL NIOSH Washinghton's Standard Method Method proposed by ACGIH Snook & Ciriello tables on pushing, pulling and carrying EN …

67 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

68

69 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).

70 Biomechanical Risk Assessment for the Upper Limbs General 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 (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) (…)

71 TLV - ACGIH _____ TLV Action Limit

72 Biomechnical VR for the Upper Limbs: further Methods reported by the Literature Check-list proposed by Keyserling Job Strain Index OCRA Index (and OCRA check-list) OREGE Method RULA Method (Rapid Upper Limb Assessment)

73 Occupational Medicine Prof. Francesco S. Violante Relational Factors, Work and Health

74 Health stato di benessere psico-fisico e sociale che consente allindividuo di fruire di tutte le sue risorse fisiche, emotive e mentali (WHO 1988)

75 Classification Person/Environment Relationships Interpersonal Relationships

76 Person/Environment Relationships Temporal aspects of the work day and work itself Content of work Work organization

77 Interpersonal Relationships Interpersonal relationships in the work group Interpersonal relationships with supervisors

78 Stress risposta aspecifica dellorganismo per ogni richiesta effettuata su di esso dallambiente esterno (Hans Selye, Nuture 1936)

79 Work-related Stress reazione emotiva, cognitiva, comportamentale e fisiologica ad aspetti avversi e nocivi del contenuto, dellambiente e dellorganizzazione del lavoro (Agenzia Europea per la Sicurezza e la Salute sul Lavoro, 2000)

80 Work-related Stress linsieme 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)

81 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)

82 Stressor or Stressing Agent fattore che spinge lorganismo alladattamento (Hans Selye, Nuture 1936)

83 Stressors Classification p Physical p Chemical p Biological p Biomechanical p Psychosocial (International Labour Organization, ILO 1986)

84 Stressors

85 Physical Causes Noise Vibrations Ionizing radiations High and low temperatures High humidity, etc. Stressors

86 Chemical Causes Toxic substances Harmful substances Stressors

87 Biological Causes Seasonal Changes Infections Low-calories diets Diseases Organic traumas Jet-lag ( caused by fast travel across different time zones ), etc. Stressors

88 Biomechanical Causes Manual handling of heavy loads Uncomfortable or tiring postures, etc. Stressors

89 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

90 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

91 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

92 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

93 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

94 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

95 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

96 Society and Stress CHANGES IN PATTERNS OF WORK SOCIAL DISINTEGRATION INCREASE IN METRIAL BENEFITS BREAKDOWN OF FAMILY FAST & QUICK SOCIETY VALUES BREAKDOWN OF NEIGHBOURHOOD ENVIRONMENTAL DAMAGE INCREASED UNEMPLOYMENT SHIFT TOWARDS SKILLED LABOUR

97 Causes of Stress: Organizational Influence Intrinsic to the job Relationship at work Factors Intrinsic To the individual Role in the organization Organizational structure and climate Career development Home-work interface

98 Demand-control Demand-control-support Person-environment Fit Effort-reward Effort-distress Work-related Stress Models

99 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

100 Working Conditions High strain high demand and low decision latitude Examples: assembly-line jobs, supermarket cashiers, security forces Passive low demand and low decision latitude Examples: data entry employees, room cleaners, refuse collectors The Demand-Control Model

101 Working Conditions Active high demand and high decision latitude Examples: physicians, teachers, researchers, lawyers, journalists Relaxed (or Low strain) low demand and high decision latitude Examples: sales representatives, pharmaceutical representatives The Demand-Control Model

102 The Demand-Control Model of Stress (Karasek) High control Low control LowHigh Decision Latitude Job Demands Low strain JobActive Job Passive Job High Strain Job

103 Job demand Decision latitude Workplace social support The Demand-Control-Support Model

104 Low CONTROL High Low SUPPORT High Low DEMAND High Relaxed Active Passive High Strain The Demand-Control-Support Model (Johnson and Hall, 1988)

105 The Different Aspects of Stress Stress response: Physiological processes Cognitive reactions Emotional reactions Behavioural reactions

106 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

107 The Nervous Pathways Activation of the nervous sympathetic system and medullary portion of the suprarenal glands (liberation of catecholamines)

108 The Endocrine Pathway Activation of the cortical portion (liberation of corticosteroids) of the suprarenal glands

109 Hypothala mus Anterior Hypophysis Suprarena l Cortex Immune System Lymphocytes Macrophages/monocytes Neutrophils Immune System Lymphocytes Macrophages/monocytes Neutrophils IL – 1 IL – 2 IL – 6 TNF - a Cortisol The Endocrine Pathway

110 Hypophysis Hypophysis Hormones Hormonal Receptors Immune System Autonomous Nervous System Cytokines TemperatureAnorexiaDrowsiness Reduced Libido STRESS Hypothalamus The Endocrine Pathway

111

112 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

113 Types of Ergotrope Responses Positive Stress or eustress Negative Stress or distress

114 Distress Eustress Distress Best Worst

115 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

116 Human Performance and Stress OPTIMUM PERFORMANCE BURNOUT BOREDOM FRUSTATION INCREASING STIMULATION STRESS EFFECTIVE, ALERT Increasing Level of performance

117 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)

118 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)

119 Why does an Event become Stressful? Distress does not only depend on the building up of events, but also on the perception that individuals have of them, i.e, the emotional weight that they carry

120 Evaluation of the Stressful Event processo mentale mediante il quale diamo allevento 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)

121 Coping Process linsieme 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)

122 03/06/08Medicina del Lavoro – Prof. Francesco S. Violante 122 The Coping Balance PRESSURE CANT COPE EXCESS PRESSURE COPING EQUILIBRIUM

123 Dynamics of the Stress-Disease Process

124 Who is most exposed to Stress? Workers with a A-type behaviour pattern Young workers Old workers Immigrant workers Single working mothers Disabled workers

125 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.

126 A-type Behaviour Characteristics Extremely afraid of losing time Low self-confidence High aggressiveness Hostility in any situation Drive to self-destruction

127 Distress due to a Lack of Stressors Distress can stem from an excess, but also from a lack of stimuli

128 Lack of Stimuli: Examples Undernutrition Silence Social Isolation Unemployment Retirement Want of affection

129 Warning Signs of Distress Emotional manifestations Cognitive manifestations Behavioural manifestations Physiological manifestations

130 PHISICALPSYCHOLOGICAL STRESS EMOTIONAL BEHAVIOURAL The effects of Stress on the Individual

131 Anxiety or depression Irritability or apathy Sleep disorders Panic attacks Emotional Manifestations

132 Difficulty concentrating Difficulty learning new things Difficulty memorizing Difficulty maintaining attention Difficulty being creative Cognitive Manifestations

133 Seeking comfort in: Cigarettes Alcohol Food Psychotropic drugs Drugs Behavioural Manifestations

134 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

135 Why does Stress cause Disease? Theory of specificity Theory of general susceptibility

136 The Effects of Stress Inefficient functioning of the organization High costs STRESS Pressure spiral Behavioural effects on the individual Individual ill-healt

137 Theory of Specificity Specific types of behaviour would lead to specific diseases example: type-A person coronaropathies

138 Theory of general susceptibility When prolonged, the response to stress reduces immune defenses, thus increasing susceptibility to any disease (not to specific ones)

139 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

140 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

141 Stress Diseases Cardio- and cerebrovascular diseases Neoplastic diseases Osteomuscular diseases Gastrointestinal diseases Sleep disorders Cephaleas Anxiety and depression disorders, etc.

142 Stress Diseases Disease malattia, ossia lalterazione strutturale e/o funzionale dellorganismo umano oggettivamente documentabile (Agenzia Europea per la Sicurezza e la Salute sul Lavoro. Ricerca sullo stress correlato al lavoro,2000)

143 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)

144 Stress Diseases Sickness Behaviour comportamento di malattia, ossia le reazioni della persona ai sintomi, nonché allinsieme 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)

145 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

146 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

147 Burnout Syndrome The term burnout means burnt,exhausted (Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev Psychol 2001; 52: )

148 Definition risposta prolungata a fattori stressanti cronici legati allattività 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: ) Burnout Syndrome

149 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: ) Burnout Syndrome

150 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: ) Burnout Syndrome

151 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: ) Burnout Syndrome

152 Causes Inadequate social support Role ambiguity Extreme conflict with colleagues and/or superiors Burnout Syndrome

153 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

154 Symptoms Psychic (cognitive and emotional) Behavioural Psychosomatic Burnout Syndrome

155 Psychic Symptoms Loss of psychic energy Loss of motivation Loss of self-esteem Loss of control Burnout Syndrome

156 Behavioural Syndrome Strong lack of commitment at work Self-destructive behaviours Hetero-destructive behaviours Burnout Syndrome

157 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

158 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)

159 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)

160 Mobbing Definition una condizione di violenza psicologica, intenzionale e sistematica, perpetrata in ambiente di lavoro per almeno sei mesi, con lobiettivo di espellere il lavoratore dal processo lavorativo (Gilioli R et al. Documento di Consenso. Un nuovo rischio allattenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)

161 Percentage of workers Incidence of Mobbing in the UE countries (European Parliament. Committee on employment and social affairs. Report on harassment at the workplace. July, 16, /2339-INI)

162 03/06/08Occupational Medicine – Prof. Francesco S. Violante 162 Prevalence of Mobbing by Sector (Monaco E, et al. Patologie emergenti in Medicina del Lavoro: il mobbing. G Ital Med Lav Erg 2004; 26: 1, 28-32)

163 03/06/08Occupational Medicine – Prof. Francesco S. Violante 163 Prevalence of Mobbing by Sex (Monaco E, et al. Patologie emergenti in Medicina del Lavoro: il mobbing. G Ital Med Lav Erg 2004; 26: 1, 28-32)

164 03/06/08Medicina del Lavoro – Prof. Francesco S. Violante 164 Prevalence of Mobbing in the Public and Private Sectors (Monaco E, et al. Patologie emergenti in Medicina del Lavoro: il mobbing. G Ital Med Lav Erg 2004; 26: 1, 28-32)

165 03/06/08Occupational Medicine – Prof. Francesco S. Violante 165 Prevalence of Mobbing among Employees and Managers (Monaco E, et al. Patologie emergenti in Medicina del Lavoro: il mobbing. G Ital Med Lav Erg 2004; 26: 1, 28-32)

166 03/06/08Medicina del Lavoro – Prof. Francesco S. Violante 166 Prevalence of Mobbing by Class of Age (Monaco E, et al. Patologie emergenti in Medicina del Lavoro: il mobbing. G Ital Med Lav Erg 2004; 26: 1, 28-32)

167 Types of mobbing Strategic mobbing Emotional or relational mobbing Non-intentional mobbing (Gilioli R et al. Documento di Consenso. Un nuovo rischio allattenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)

168 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 allattenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69) It is more frequent in private companies Vertical Mobbing

169 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 allattenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69) Prevalent in the civil service

170 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 allattenzione 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

171 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

172 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)

173 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)

174 Consequences of Health Early Warning Signs Psychosomatic disorders Emotional disorders Behavioural disorders (Gilioli R et al. Documento di Consenso. Un nuovo rischio allattenzione della medicina del lavoro: le molestie morali (mobbing). Med Lav 2001; 92: 61-69)

175 Consequences of Health Reactions and Events Adaptation Disorder (AD) Post-traumatic Stress Disorder (PTSD) (Gilioli R et al. Documento di Consenso. Un nuovo rischio allattenzione 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


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