Occupational Medicine
Prof. 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 disorders
 Repetitive strain injuries (RSI)
 Occupational Overuse syndromes
 Occupational cervicobrachial disorders
 Musculoskeletal 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 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
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 nonoccupational) such as certain cancers and lung
disorders, both of which have multiple causality.
Risk Factors
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)
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)
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 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 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 body
Flexions and torsions
Maintenance of fixed postures for prolonged
periods (repetitive manual work)
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
Evidence of Relation between Biomechanical
Risk factors and WMSDs - NIOSH (Bernard,1997)
Hand/Wrist
CTS
Strong
Evidence
(+++)
Evidence
(++)
Repetitiveness
X
Force
X
Posture
X
Vibrations
Combination
Insufficient
Evidence
(+/0)
X
X
Evidence of Relation between Biomechanical
Risk factors and WMSDs - NIOSH (Bernard, 1997)
Hand/Wrist
Tendonitis
Strong Evidence
Evidence
(+++)
(++)
Repetitiveness
X
Force
X
Posture
X
Combination
X
Insufficient
Evidence
(+/0)
Evidence of Relation between Biomechanical
Risk Factors and WMSDs - NIOSH (Bernard, 1997)
Elbow
Evidence
Strong
Evidence
(+++)
(++)
Repetitiveness
X
Force
X
Posture
Combination
Insufficient
Evidence
(+/0)
X
X
Evidence of Relation between Biomechanical
Risk Factors and WMSDs - NIOSH (Bernard, 1997)
Shoulder
Repetitiveness
Strong
Evidence
(+++)
Evidence
(++)
X
Force
Posture
Vibrations
Insufficient
Evidence
(+/0)
X
X
X
Evidence of Relation between Biomechanical
Risk Factors and WMSDs - NIOSH (Bernard, 1997)
Lombalgia
Strong Evidence
Evidence
(+++)
(++)
MHL
(Manual Handling
of Loads)
X
Flexion/Torsion of
trunk
X
Posture
Vibrations*
Insufficient
Evidence
(+/0)
X
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 backache
 28 % report stress disorders
 23 % report shoulder and neck pain
 13 % 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, 2000
WRMSDs 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
Mounting, Assembly
43,4
Clothing Industry
7,3
Meat Processing
5,8
Sorting/ Selection
5,2
Confection/ Packaging
4,7
Wood Smoothing
4,4
Driving of Mechanical Vehicles
4,4
Footwear and Leather Industry
4,1
Other
20,7
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 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: 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)
Workers at risk of Low Back Pain
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

Musculoskeletal Disorders due to
Overload: Physiopathogenesis
EXPOSURE
TO BIOMECHANICAL RISK FACTORS
ADAPTATION
(TRAINING EFFECT)
•Reaction
•Reaction
•Reaction
•Reaction
•…
1
2
3
4
DAMAGE
(MUSCULOSKELETAL DISORDER)
Possible Mechanisms involved in the
development of WR- fatigue and pain
Shoulder: Anatomical Hints
Shoulder:
Main Disorders
Acute Tendonitis
 Tendinosis
(with/without
calcification)
 Rotator cuff
lesions/ruptures
 Bursitis
 Conflict Syndromes
 Arthrosis
 (Scapulo-humeral
Periarthritis ??!!)

Elbow: Anatomical Hints
Elbow and Forearm Pain Diagram
Elbow: Main Disorders
Epicondylitis
 Medial
Epicondylitis
 Olecranon
Bursitis
 Compression of
the ulnar nerve
at the elbow

Flessori
Estensori
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
De Quervain's Syndrome
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

Trigger Digit

Tendon nodule at the metacarpalphalangeal level associated with deficit in
digit extension due to purely mechanical
factors
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 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

Diagnosis of CTS and other Peripheral
Neuropathies
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

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
ARTROSI

Arthrosis (radiculopathy)

Herniated Disc
(radiculopathy)
degenerative disease of the bone leading to
the formation of osteophytes
COMPRESSIONE
NERVOSA
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
ERNIA
Rachis: Most Frequent Disorders

Changes in the curvature
of the spine (scoliosis,
CIFOSI
kyphosis, lordosis)

Osteoporosis

Spondilolisis,
spondilolistesis
LORDOSI
SCOLIOSI
Rachis Disorders: Diagnosis
Clinical: Signs and Symptoms
 Provocative Tests
 Diagnostic 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)
2)
3)
4)
5)
Pain without radiation
Pain with proximal radiation
Pain with distal radiation
Pain with radiation to the extremities and
neurological signs
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)
2)
3)
4)
5)
6)
Confirmed compression of a spinal nerve
root (CT or MR)
Stenosis of the vertebral canal
Post-surgical status (1-6 months after
intervention)
Post-surgical status (more than 6 months
after intervention)
asymptomatic\symptomatic
Chronic painful syndrome
Other diagnoses
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

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
Low back
muscle force
FM
Disc
Compression
Force
FC
BW Body weight
LH load weight
L5-S1
Disc
Moment
b distance CMbody-L5/S1
BW
h distance CMobject-L5/S1
W
b
(MC: mass centre)
h
LH
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 magnitude
 Frequency of lifting
 Duration of lifting
 Load distance from the body
 Position of load at the beginning and end of
lifting
 (Lifting speed)

Risk Assessment of MHL
NIOSH
 Washinghton's Standard Method
 Method proposed by ACGIH
 Snook & Ciriello tables on pushing, pulling
and carrying
 EN 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 workrelated 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 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 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 Keyserling
 Job Strain Index
 OCRA Index (and OCRA check-list)
 OREGE Method
 RULA Method (Rapid Upper Limb
Assessment)

Occupational Medicine
Prof. 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
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)
Work-related Stress Factors
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)
Kasl's List
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
Society and Stress
CHANGES IN PATTERNS OF WORK
INCREASED UNEMPLOYMENT
SHIFT TOWARDS
SKILLED LABOUR
BREAKDOWN
OF FAMILY
SOCIAL
DISINTEGRATION
FAST & QUICK’
SOCIETY VALUES
INCREASE IN
METRIAL BENEFITS
BREAKDOWN
OF NEIGHBOURHOOD
ENVIRONMENTAL DAMAGE
Causes of Stress:
Organizational Influence
Intrinsic to
the job
Relationship
at work
Factors
Role in the
organization
Organizational
structure
and climate
Intrinsic
To the
individual
Career
development
Home-work
interface
Work-related Stress Models

Demand-control

Demand-control-support

Person-environment Fit

Effort-reward

Effort-distress
The Demand-Control Model

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 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
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
Decision Latitude
The Demand-Control Model of
Stress (Karasek)
High control
Low strain Job
Low control
Passive Job
Active Job
High Strain Job
Low
High
Job Demands
The Demand-Control-Support Model

Job demand

Decision latitude

Workplace social support
Low SUPPORT High
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
The Endocrine Pathway
Hypothala
mus
Anterior
Hypophysis
Suprarena
l Cortex
Cortisol
IL – 1
IL – 2
IL – 6
TNF - a
Immune System
Lymphocytes
Macrophages/monocytes
Neutrophils
The Endocrine Pathway
Temperature
Anorexia
Drowsiness
Reduced Libido
STRESS
Hypothalamus
Hypophysis
Autonomous Nervous System
Cytokines
Hypophysis Hormones
Hormonal Receptors
Immune System
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
Distress
Eustress
Distress
Best
Worst
0
1
2
3
4
5
6
7
8
9
10
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
60
50
40
Increasing
30
Level of
performance
20
10
0
OPTIMUM
PERFORMANCE
EFFECTIVE,
ALERT
BOREDOM
FRUSTATION
STRESS
INCREASING STIMULATION
BURNOUT
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 the
building up of events, but also on the
perception 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)
The Coping Balance
PRESSURE
CAN’T COPE
EQUILIBRIUM
EXCESS
PRESSURE
03/06/08
COPING
Medicina del Lavoro – Prof. Francesco S.
Violante
122
Dynamics of the Stress-Disease
Process
VA
L
U
TA
ZIO
N
E
IN
TE
R
A
ZIO
N
E
tralavoratori esituazioni di stress
S
U
S
C
E
TTIB
IL
ITA
’
C
O
P
IN
G
IN
E
FFIC
A
C
E
E
F
F
E
TTI
legati allostress
P
R
E
D
IS
P
O
S
IZIO
N
E
D
A
N
N
I
allasalute
dovuti a
stress
C
O
P
IN
GE
FFIC
AC
E
E
SA
U
R
IM
E
N
TO
D
E
LP
R
O
C
E
SSO
 A
ttivazionedi m
eccanism
i
neurologici.
 R
ispostaneurovegetativa
eneuroendocrina
E
ffetti patologici legati alla
attivazionedel sistem
a
neurovegetativoe
neuroendocrino.
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
The effects of Stress on the
Individual
PHISICAL
PSYCHOLOGICAL
STRESS
EMOTIONAL
BEHAVIOURAL
Emotional Manifestations

Anxiety or depression

Irritability or apathy

Sleep disorders

Panic attacks
Cognitive Manifestations

Difficulty concentrating

Difficulty learning new things

Difficulty memorizing

Difficulty maintaining attention

Difficulty being creative
Behavioural Manifestations
Seeking comfort in:

Cigarettes

Alcohol

Food

Psychotropic drugs

Drugs
Physiological 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.
Why does Stress cause Disease?


Theory of specificity
Theory of general susceptibility
The Effects of Stress
Inefficient
functioning
of the
organization
High
costs
STRESS
Behavioural
effects on the
individual
Pressure spiral
Individual
ill-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)
Stress Diseases
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
Burnout Syndrome
The term “burnout” means “burnt”,
“exhausted”
(Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev
Psychol 2001; 52: 397-422)
Burnout Syndrome
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
Loss
Loss
Loss
of
of
of
of
psychic energy
motivation
self-esteem
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
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)
Incidence of Mobbing in the UE countries
16,3
9,9
9,4
8
4,8
4,7
Grecia
5,5
Spagna
Italia
Germania
Irlanda
Francia
6
Belgio
7,3
UE
10,2
Svezia
18
16
14
12
10
8
6
4
2
0
Regno Unito
Percentage of workers
(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
colleagues'/superiors' illicit practices

part
in
their
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
 strong reduction in the worker's role
 downgrading of duties
 unjustified transfers to distant sites
worker's role
 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