Forebyggelse af arbejdsrelateret muskelskeletbesvær i et historisk perspektiv. Korsør 4. maj 2015

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1 Forebyggelse af arbejdsrelateret muskelskeletbesvær i et historisk perspektiv Johan Hviid Andersen Professor, overlæge, ph.d. Dansk Ramazzini Center, Arbejdsmedicinsk klinik Universitetklinik, Hospitalsenheden Vest, Herning Korsør 4. maj 2015 Historien om smerter i nakke-skuldre og arme illustreret med egne undersøgelser Historien om ondt i ryggen Udfordringer When a doctor visits a workingclass home, he should be content to sit on a three-legged stool, if there isn t a gilded chair, and he should take time for his examination; and to the questions recommended by Hippocrates, he should add one more What is your occupation? 1

2 The Report on the Sanitary Condition of the Working-Class contains information which attests the same fact. In Liverpool, in 1840, the average longevity of the upper classes, gentry, professional men, etc., was thirty-five years; that of the business men and betterplaced handicraftsmen, twenty-two years; and that of the operatives; daylabourers, and serviceable class in general, but fifteen years. The Parliamentary reports contain a mass of similar facts Engels, Frederick. Condition of the Working Class in England. London,, GBR: ElecBook, p 182. Historien om arbejdsrelaterede smerter i nakke, skuldre og arme 1713 De Morbis Artificum - B. Ramazzini 2

3 Historisk udvikling af arbejdsrelaterede armsmerter 1713 De Morbis Artificum - B. Ramazzini 1820 Writers cramp TELEGRAPHISTS CRAMP Historisk udvikling af arbejdsrelaterede armsmerter 1713 De Morbis Artificum - B. Ramazzini 1820 Writers cramp 1875 Telegraphists cramp 1888 Occupation neuroses- neurasteni Kvinder og jøder 3

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5 Historisk udvikling af arbejdsrelaterede armsmerter 1713 De Morbis Artificum - B. Ramazzini 1820 Writers cramp 1875 Telegraphists cramp 1888 Occupation neuroses- neurasteni Kvinder og jøder Tenosynovitis/peritendinitis/tendovaginitis 5

6 Historisk udvikling af arbejdsrelaterede armsmerter 1713 De Morbis Artificum - B. Ramazzini 1820 Writers cramp 1875 Telegraphists cramp 1888 Occupation neuroses- neurasteni Kvinder og jøder Tenosynovitis Occupational cervicobrachial disorder (OCD) Cumulative trauma disorder (CTD) Repetitive strain injury (RSI) Symaskinesygdommen LO-medlemmer kontaktet maj besvarelser 6

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8 Andersen JH, Gaardboe O. Prevalence of persistent neck and upper limb pain in a historical cohort of sewing machine operators. Am J Ind Med 1993;24: Andersen JH, Gaardboe O. Musculoskeletal disorders of the neck and upper limb among sewing machine operators: A clinical investigation. Am J Ind Med 1993:24:

9 index 1980=100 Antal anmeldelser til AT Produktivitet pr. arbejdskraftenhed og muskel-skelet sygdomme Ny lov År Produktivitet syersker Anden fremstillingsvirksomhed Anmeldelser i P Frost and JH Andersen Shoulder impingement syndrome in relation to shoulder intensive work Occup. Environ. Med. 1999;56;

10 PRIM ÅRHUS Danapak/Neopak Esselte Post Jylland Tulip HERNING Femilet/Pagh/Damgaard Danish Crown Vinderup fjerkræ LEGO GLOSTRUP Ambu Bilka/OBS Kelsen NKT GIRO PLM Post Sjælland Kartonnage, ilægning, fratagning Kontorartikler, pakning, montage Post-og pakkesortering Pakning, skinker, pålæg 3 Systuer Svineslagteri, opskræring, udbening, pakning Ophængning, slagtning, udbening, pakning Montage, pakkearbejde Mekanisk montage af livredningsudstyr Kassearbejde i Supermarked Pakning af kager, båndarbejde Elektronisk og mekanisk montage Indtastning af bilag, alm. kontorarbejde Pakning, overvågning, kvalitetskontrol Post-og pakkesortering 10

11 Ergonomiske risikofaktorer KRAFT Nakke > 20 o (% tid) Rep. skulder (bev. pr minut) Statisk skulder (% tid) Svinesl. (196) Fjerkræ (226) Tulip (53) Kelsen (77) Syersker (227) LEGO (167) Esselte (99) PLM (62) NKT (39) Neo-og danapak (191) Postsort. (272) Bilka/OBS (74) GIROBANK (326) AMBU (51) Alle ( 2060) Andersen JH, Kaergaard A, Frost P, Thomsen JF, Bonde JB, Fallentin N, Borg V, Mikkelsen S. Physical, psychosocial and individual risk factors for neck/shoulder pain with pressure tenderness among workers performing monotonous, repetitive work. Spine 2002;27: Andersen JH, Kaergaard A, Mikkelsen S, Jensen UF, Frost P, Bonde JP, Fallentin N, Thomsen JF. Risk factors in the onset of neck/shoulder pain in a prospective study of workers in industrial and service companies. Occup Environ Med 2003; 60: Symptom cases Clinical cases (n = 636) (n = 82) Physical risk factor N OR adj 95% CI OR adj 95% CI Repetition - ref Low (1-15 mov./min.) to to 2.6 High (16-40 mov./min.) to to 5.8 Force - ref < 10% of MVC to to 3.6 > 10% of MVC to to 4.2 Neck flexion - ref < 2/3 of time to to 2.9 > 2/3 of time to to 5.1 Lack of recovery - ref < 80 % of time to to 2.9 > 80% of time to to 3.9 Odds ratios adjusted for psychosocial and individual factors 11

12 Headlines from the 1990s Mediernes kogebog for at sprede rædsel og bekymring Flow chart NUDATA Linkage to national register on sickness abcense for more than 2 weeks 2146 followed For 52 weeks WorkPaceRecorder 12

13 Clinical disorders Baseline One-year follow-up Diagnoses Right Left Right Left Rotator cuff tendonitis % % % % Lateral epicondylitis % % % De Quervain % % % 0 Tension neck % % Neck/shoulder myalgia % % % % Forearm myalgia % % % 0 Pronator syndrome % % 0 0 Supinator syndrome % % Korrelation coef. =0.61 Mikkelsen S,Vilstrup I, Lassen CF, Kryger A,Thomsen JF, Andersen JH. Validity of questionnaire self-reports on computer, mouse and keyboard usage during a 4 week period. Occup Environ Med 2007;64: Outcome measures: The NUDATA- 13

14 Time with mouse (black) and right elbow pain (red) Week number neck Right shoulder Right elbow Right forearm Right hand/wrist 14

15 Er der en sammenhæng mellem computerarbejde og længerevarende smerter / kroniske smerter? Længerevarende smerter -incidens Nakke* Skulder* Albue** Underarm** Håndled/hænder** Kroniske smerter incidens Længerevarende defineret som: Mindre end gns. 2,5 i 4 uger efterfulgt af 3 uger med mere end 4 i gns. Smerteskala fra 0-7. Kronisk defineret som: Ingen eller få smerter ved baseline og betydelige smerter og ubehag efter 1 års follow-up Andersen JH, Vilstrup I, Lassen CF, Kryger A, Brandt L, Overgaard E, Mikkelsen S. Computer mouse use predicts acute pain but not prolonged or chronic pain in the neck and shoulder. Occup Environ Med 2008;65(2): Mikkelsen S, Lassen CF, Vilstrup I, Kryger AI, Brandt LP, Thomsen JF, Gerster M, Grimstrup S, Andersen JH. Does computer use affect the incidence of distal arm pain? A one-year prospective study using objective measures of computer use. Int Arch Occup Environ Health ;85(2): Andersen JH, Fallentin N, Thomsen JF, Mikkelsen S. Risk Factors for Neck and Upper Extremity Disorders among Computers Users and the Effect of Interventions: An Overview of Systematic Reviews. PLoS One May 12;6(5):e Results n NUDATA-blev påbegyndt Forskere afliver museskader Scientific papers published 2003 to

16 Arbejdet og ryggen - Rygsmerternes historie RYGSMERTERNES HISTORIE HEKSESKUD 16

17 År ,5 Passagerer i millioner , , , ; Passagerer: 1200 døde og alvorlige skader The Campbell Act vedtaget i 1864: Erstatning til passagerer. Blandt ansatte døde og 3500 alv. ulykker pr. år The spinal concussion model Railway Spine the whole train of nervous phenomena arising from shakes or jars or blows on the body, and desribed as characteristic of so-called Concussion of the Spine, are in reality due to chronic inflammation of the spinal membranes and cord 1875 On concussion of the Spine, Nervous Shock, and other Obscure injuries of the Nervous System in their Clinical and Medico-Legal Aspects The primary effects of these concussions or commotions of the spinal cord are probably due to molecular changes in its structure OPDAGELSEN AF DISCUS PROLAPSEN i 1934 Mixter og Barr 17

18 Et historisk perspektiv Mennesker har altid haft ondt i ryggen, og det er ikke mere almindeligt eller alvorligt end det altid har været Hvad der har ændret sig er hvordan vi opfatter og tackler ondt i ryggen. Tre hoved ideer fra det 19nde århundrede lagde fundamentet til vores tankegang: Rygsmerter kommer fra rygsøjlen og involverer nervesystemet Rygsmerter skyldes en skade Ryggen er irriteret og skal hvile Opdagelsen af discus førte disse ideer sammen og siden har den medicinske tankegang været domineret af ortopædkirurgien Clinical red flags Clinical yellow flags Occupational blue flags Socio-occupational black flag Organic pathology Concurrent medical problems Iatrogenic factors Beliefs Coping strategies Distress Ilness behaviour Willingness to change Family reinforcement Work status Health benefits and insurance Litigation Work satisfaction Working conditions Work characteristics Social policy Biomedical factors Psychological or behavioural factors Social and economic factors Occupational factors Low back pain Physical risk factors Physical factors Heavy manual work Twisting and bending Vibrations (whole body) Standing walking Sitting Evidence Moderate Moderate - Strong Strong small associations No evidence No evidence Hoogendoorn WE et al. Scand J Work Environ Health 1999;25: Nachemson AL, Jonsson E (eds). Neck and Back Pain. Lippincott Williams & Wilkins, Hansson T, Westerholm P. Arbete och besvär i rörelsesorganen. Arbete och hälsa nr 2001:12. 18

19 Lifting and LBP Exposure Lifting Exposure-response Punnett, 1991 Case-control Macfarlane, 1997 Cohort - 1 year Hoogendoorn, 2000, 2002 Cohort 3 year Jansen, 2005 Cohort - 1 year Observed 10 pounds Self-reports 25 pounds Observed 25 kg Observed > 10kg/time 2.2( ) No Males 2.0( ) Females 1.5( ) No 1.6 ( ) No 1.0( ) No Conclusions Limited scope for preventing first time onset of LBP Certain evidence for prevention of consequences of LBP Certain evidence for succes of involvement of all stakeholders at the workplace More research on sociocultural and societal aspects of LBP and other musculoskeletal pain in a life-course perspective is strongly needed Distribution of all musculoskeletal pain among women and men in the working population From the ASUSI-study, N=14,241 19

20 Sickness absence in a follow-up of 1½ years in the ASUSI-study N=14,241 Virker interventioner mod ondt i ryggen? Palmer K, Coggon D et al., Rheumatology

21 STATUS ON MSDs- challenges? A lot of risk factors have been established, mostly with minor to moderat importance Problems with exposure measurements Several large cohort studies have been performed Some pointing at physical risk factors others at psychosocial risk factors Robust exposure-response relationships are sparse Incidence of MSDs is hard to know where to begin Biology is for the most part unknown Intervention studies have mainly been disappointing Multidimensional classification of MSDs 1. Somatic symptoms Number of symptoms (regional, widespread) Type (e.g. sensoric, motoric) 2. Pathofysiological changes e.g. inflammation, other organic disease 3. Mental health Depression, anxiety, other. 4. Beliefs and behavior Fear-avoidance Catastrophizing Health behavior 5. Work ability and functioning Prognosis Return to work (RTW) Kultural influences Attribution Medicalization of the Worried well Compensation schemes Media influence Pharmaceutical power Interest groups 21

22 CUPID STUDY Questionnaire data on 12,426 participants from 47 occupational groups in 18 countries Nurses (17 groups), office workers (16) and other workers (14 groups) Includes one-month prevalence of pain at different anatomical sites and possible risk factors Scand J Work Environ Health. 2014;40(1): doi: /sjweh.3381 CR IT PK LK PK JP JP-2 JP PK NZ EE SP CO GR UKLB LB LK-1 LK-2 JP-1 BR NZ AUNI IR NZ UK SP LK EC NI CR UK LB SA SA EC EE EC BR IT GR BR IR GR Prevalence (%) of disabling low back pain Office workers Nurses Other workers CR NI Coggon et al. Pain 2013 Jun;154(6): Ændring af sygdomsbegreb Disease Illness Skjult sygdom/risikofaktorer "de indbildte raske" Nedsat tolerance "de indbildte syge" 22

23 Almindelige myter Ondt i ryggen: Skyldes sædvanligvis arbejdet Betyder underliggende skade eller sygdom Kan blive helbredt med medicinsk behandling Hvis det går helt galt hjælper en operation Forværres af arbejdet Behøver sygemelding Ingen mulighed for at vende tilbage til arbejdet før man er 100 % klar Den videnskabelige evidens Det er multifaktorielt - Arbejde er kun én og ofte ikke den vigtigste faktor. Der er sjældent tegn på underliggende sygdom eller skade. Og selv om det er det, er skaden ikke uafvendelig Behandling kan mindske symptomerne, men helbreder ikke Nej, det er farligt at blive opereret i ryggen Arbejdet kan være svært et stykke tid, men giver kun sjældent en blivende skade De fleste klarer at blive i arbejdet eller genoptage arbejdet selvom der er symptomer Langtidssygemelding er sjældent nødvendig eller gavnlig Arbejde er terapeutisk og er nødvendig for at komme sig Patienter skal opfordres og støttes til at genoptage arbejdet så hurtigt som muligt, også selvom der er symptomer Den professionelles ord kan være en betydningsfuld intervention. De forkerte ord om et helbredsproblem eller dets relation til arbejdet kan skabe eller vedligeholde myter. Den professionelles ord skal afspejle evidens giv positive budskaber og man myter i jorden. 23

24 Hierarki af undersøgelses design systematisk review af RCTs validitet RCT kohorte case kontrol tværsnit cases intervention observationel 24