CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 351, pp 21-31 © 1998 Lippincott-Raven Publishers Muscle Injury in Repetitive Motion Disorders Gisela Sjogaard, PhD, DMSc; and Karen Sgaard, PhD Documentation of causality between repetitive motions and musculoskeletal disorders calls for detailed understanding of the exposure variables and the corresponding physiologic responses in the biologic tissues. Quantifica- tion of the kinetics in some jobs characterized by repetitive motions is summarized with the physiologic responses in the muscles. Muscle activity pattern was studied in different shout- der muscles or muscle parts, and in elbow and wrist flexor muscles. Activity pattern was de- pendent on the kinetics of the work require- ments. This holds true for the compound elec- tromyographic signal and for single motor units, Low threshold motor units have been lentified that are recruited continuously, the so called Cinderella fibers. The physiologic consequences of prolonged muscle fiber activ- ity are reviewed, revealing mechanisms for the development of necrotic changes in the muscle, which support the likelihood of work related- ness for musculoskeletal disorders. ‘The work requirements in numerous occupa tions today impose little challenge on human muscle power, that is, on high work intensity. On the contrary, they are characterized by the small muscles in the finger, hand, arm, and shoulder repetitively performing low forces From the Department of Physiology, National fnstitute of Occupational Health, Copenhagen, Denmark, Reprint requests to Karen Ssigaard, PhD, Department of Physiology, National Institute of Occupational Health, LersoParkalle 105, DK 2100 Copenhagen 9, Denmark, 24 relative to their maximum strength, whereas the larger muscles in the lower body may re- main inactive while in the sitting position or work at low intensity while standing or walk- ing. Muscles are able to maintain such forces for prolonged periods. Therefore, exhaustion in terms of failure to meet the force requirements is rare. This is in contrast to physically heavy work tasks often within primary and secondary occupations, where the worker is forced to take a break or change to less intense tasks because of perceived exertion. The lack of such breaks in low intensity work introduces a de novo risk factor, and musculoskeletal troubles frequently are reported during highly repetitive work tasks, because they often ate seen within ter- tiary occupations.5 Muscle activity sustained or repeated for prolonged periods has been de- scribed as being related causally to the devel- ‘opment of muscle disorders.*4° The most fre- quent sites for repetitive motion disorders are the upper limb and neck and shoulder areas, for which reason the authors have studied the work requirements (exposures) for finger, hand, arm, and shoulder muscles in numerous work places.2410212549 The aim of another series of studies was to describe muscle activity pattern including recruitment of single motor units in various muscles in relation to the kinetics of the work.74748 Finally, some studies have fo- cused on various physiologic responses during such motor activity that may play a role as causal links for the development of muscle22 Sjogaard and Sogaard dysfunction.$7.1922.7.4 This paper summarizes some of the results in a sequence from expo- sure in the workplace to adverse health out- ‘come focusing on the physiologic responses in the muscle tissue (Fig 1). Detailed knowledge of acute physiologic responses, normally oc- curring to meet the work requirements and the more long term effects, is essential for the doc- umentation of work relatedness and also for implementing effective preventive strategies. Because of the high plasticity of the muscle tis- sue, the long term effect may be an adaptation or deterioration of tissue function.¥ The latter condition may play a decisive role in the devel- ‘opment of repetitive motion disorders, whereas optimal job design may elicit a training effect and as such promote health. CHARACTERISTICS OF EXPOSURE VARIABLES IN THE, WORK PLACE Many different occupations are characterized by highly repetitive motions including meat EXPOSURE ACUTE RESPONSE | LONG TERM EFFECT| — Fig 1. An exposure-response-effect model that conceptualizes causality for the development of musculoskeletal disorders. The acute response refers to the physiologic responses in the bio- logic tissues during the performance of the work task, whereas the long term effect refers to physiologic and pathophysiologic changes after the work is performed. F>co—<—oz-|_ @ZOTOPT Clinical Orthopaedics and Related Research cutting, cleaning, operating sewing machines, and operating computers. Work tasks charae- terized by a high demand of precision but rel- atively low external force demands, as tasks performed by computer operators, show a general movement pattern, with shoulder, hand, and fingers being increasingly repeti- tive.2826 This means an increasing shortening, velocity for the more distal muscles, while the shoulder and neck muscle groups are con- tracting in a prolonged static manner. How- ever, when a relatively large external force is exerted as during meat cutting and cleaning work, the mean and peak velocity during the work cycles may be similar for the shoulder and wrist. Table 1 shows the kinematic data obtained from three-dimensional analysis of video recordings of two meat cutters perform- ing two different deboning work cycles. Deboning belly pork lasted approximately 1 minute and deboning shoulder pork lasted ap- proximately 3 minutes. Data shown are aver- ages of all the movement cycles for each joint performed during the entire work cycle. The importance of the kinematic parame- ters was shown in a study of cleaners using two different techniques, scrubbing and mopping.#64” After the work period, classic electromyographic signs of fatigue were found in the trapezius muscle for the mop- ping group but not for the scrubbing group. During work the results for the two groups were similar regarding electromyographic amplitude, average arm abduction, range of movement, and mean velocity. Table 2 shows the videobased kinematic data from motion analysis study of floor cleaning. In the field study six cleaners performed mop- ping and another six cleaners performed scrubbing, whereas in the laboratory study the six cleaners performed both working techniques. One typical movement cycle was analyzed for each worker; during mopping this corresponded to approximately 1.5 sec- onds and during scrubbing to approximately 1 second. The only significant difference was that during a work cycle the scrubbing group reached a maximum velocity nearlyNumber 351 June, 1998 TABLE 1. Recordings of Two Meat Cutters Muscle Injury in Repetitive Motion Disorders 23 Kinematic Data Obtained From Three-Dimensional Analysis of Video Work Range of Mean Velocity Peak Velocity Joint Process Movement Movement (*) —_(‘/second) (*Isecond) Wrist Deboning of Flexion 35 49 298 belly pork Extension "a 51 256 Ulnar deviation 55 48 308 Radial deviation 30 48 207 Deboning of Flexion 45 4a 210 shoulder pork Exlension 56 43 232 Ulnar deviation 7 4a 393 Radial deviation 15 a2 298 Shoulder Deboning of Flexion 73 63 249 belly pork Extension 26 8s 315 ‘Abduction 7 38 194 ‘Adduction 5 38 174 Deboning of Flexion 73 46 229 shoulder pork Extension 24 48 222 ‘Abduction 7 37 199 ‘Adduetion 5 34 ait twice as high as the mopping group which worked at a more constant speed. Therefore, this study indicates that for the stabilizing shoulder muscles, variation in velocity may prevent muscle fatigue probably because of more varied recruitment patterns. Well known occupational risk factors for hand and wrist disorders are extreme wrist an- gles, high repetitiveness, and high grip force level. Lately, dynamic parameters such as ve- locity and acceleration have been shown to be important factors." Marras and Schoen- marklin* studied 40 subjects performing high or low risk tasks, all performed without use of hand tools. In high risk tasks mean and peak acceleration in wrist flexion and extension were 824° and 4471° per second? compared with 494° and 2588° per second? in the low risk tasks. Correspondingly, in the high risk task mean and peak acceleration in radial and ulnar deviation were 494° and 3077° per sec- ond?, compared with 301° and 1759° per sec- ond? in the low risk group. For work with hand tools, acceleration may be an even more important variable because in addition to the ‘mass of the hand, the mass of the tool must be accelerated. Therefore, frequent wrist acceler- ation and deceleration will induce large and repetitive force demands on the wrist muscles during such work. Meat cutting is an example of a work task with the knife as a small hand tool, which is held in the hand during the en- tire working day. In a study of meat cutters,®9 mean and peak acceleration in ulnar deviation was 428° and 3755° per second, which is in the same range as Marras and Schoen- ‘marklin*! found for the high risk tasks. During wrist flexion mean and peak acceleration was 461° and 3039° per second? and during exten- sion, 421° and 2946° per second. This was lower than found for the high risk work tasks without hand tools but, considering the weight of the tool, still of a magnitude likely to impose high force demands. Therefore, during work with hand tools, acceleration may be an important parameter for identifica- tion of high risk groups considering the weight of the tool. MUSCLE ACTIVATION PATTERNS. DURING REPETITIVE MOTION Based on the assessment of the kinetics in the work place, standardized experiments were24 Sjagaard and Sogaard Clinical Orthopaedics and Related Research TABLE 2. Videobased Kinematic Data of Shoulder From Field and Laboratory Study of Floor Cleaning* Work. Range of Mean Velocity Peak Velocity Process Movement Movement (°) (/second) (/second) Field study Mopping ‘Abduction/adduction 4ot sat wat (26-76) (34-100) (70-139) Sorubbing Abduction/adduction 46 84 182 (21-84) (60-130) (144-216) Lab study Mopping ‘Abductionfadduction 36 43 (18-45) (21-58) Scrubbing ‘Abduction/adduction 54 91 (37-74) (61-163) * Values in parentheses indicate range. 1 = mean. conducted in the laboratory simulating essen- tial exposure variables. During the perfor- mance of such standardized tasks, several physiologic variables were monitored simul- taneously in detail, The methods and proce- dures were as follows: Muscle activity pattern was studied in six women during various ac- tivities requiring as much as 20% maximum voluntary isometric contraction force based on electromyographic recordings from three parts of the deltoideus, three parts of the trapezius, the biceps brachii, the triceps brachii, the latissimus dorsi, the pectoralis major, the supraspinatus, the infraspinatus, and the subscapularis. Additionally, motor unit activity pattern was recorded in three muscles (the supraspinatus, the biceps brachii, and the flexor carpi radialis). The supraspinatus muscle was studied during 30° arm abduction (approximately 10% maxi- mum voluntary isometric contraction force) sustained for 30 minutes, which was close to exhaustion. The biceps brachii muscle was studied during static (10% maximum volun- tary isometric contraction force) and dynamic contractions with the same relative load and mean angular velocities ranging from 10° to 40° per second performed by six women. Fi- nally, the flexor carpi radialis muscle was studied during dynamic concentric wrist flex- ion (repeated every sixth second at a mean ve~ locity of 10° per second at an intensity of 30% of maximal aerobic capacity or approximately 10%-20% maximum voluntary isometric contraction force), in five men with muscle fiber compositions ranging from 15% to 65% slow twitch fibers in that muscle. Muscle ac- tivity pattern was studied by surface or wire electromyography (compound electromyo- graphic signal). Data are presented as root mean squared values in microvolts and rela- tive to maximum electromyographic activity recorded during maximum voluntary isomet- ric contraction force. Mean power frequency was calculated for fatigue evaluation. For identification of single motor unit activity, needle electromyography was used. The latter was analyzed by decomposition of the signal recorded by a quadripolar needle for firing pattern and mean firing rate. The results from these series of experi- ments may be summarized as follows: Peak activation for each of the 13 shoulder mus- cles occurred, when performing static forces with the hands in the three-dimensional space, in those force directions for which the muscles generally are considered to be prime movers. More importantly, however, all mi cles were active in a wide range of force di- rections, covering approximately 100° on each side of the direction for peak activation, and they only were silent for a limited rangeNumber 351 June, 1998 of directions Although interindividual dif- ferences were shown, the data were suffi- ciently consistent to allow for gen force sharing between the various muscles or muscle parts regarding external work require- ments. This implies that the work task pre- dicts the muscle activation pattern. In line with this, it was shown that changes in the de- mands of precision and speed of the work task significantly affected muscle activity pattern during dynamic work performed with the hands. Electromyographic activity increased in all muscles with speed and the electromyo- graphic activity more than doubled from low to maximum speed.#? At preset, high speed electromyographic activity in all muscles in- creased with increased precision demand. At low speed, precision demand did not affect electromyographic activity significantly. Muscle activity pattern studied during prolonged arm abduction showed fatigue de- velopment in abductor muscles such as the deltoideus based on the increase in root mean square value (51 V — 83 HV) and de- crease in mean power frequency (77 Hz.- 61 Hz) of the surface electromyogram. On the motor unit level, a continuous firing was seen in the supraspinatus for 95% of the ac- tive motor units.2” The average mean firing rate remained unchanged at approximately 1 Hz, whereas the standard deviation of the mean firing rate increased showing an in- creased instability in the firing of the motor units, An increasing number of motor units with large action potential amplitudes were recruited at the end of the contraction period where fatigue had occurred.2° Motor unit activity pattern comparing sta- tie and dynamic contractions showed that in the biceps brachii during the static contrac- tion, 66% of the motor units were firing con- tinuously and this was true for approximately 40% during the dynamic contractions.4748 Ap- proximately 60% of the motor units were ac- tive in the concentric phase and the eccentric phase, showing frequency modulation; that is, each motor unit had higher firing rate in the concentric than in the eccentric phase. Muscle Injury in Repetitive Motion Disorders 25 During dynamic wrist flexion, surface electromyographic recordings had root mean square values of 180 jLV to 290 LV and mean power frequency values of 90 Hz to 120 Hz independent of muscle fiber composition in the flexor carpi radialis. However, in the subject with the highest percent slow twitch fibers, only motor units with action poten- tials smaller than 1000 UV were found and these showed the most continuous firing pat- tern5 Mean firing rate was not different be- tween subjects, but double discharges were found only in the subject with the lowest per- cent slow twitch fibers (Fig, 2). Such double discharges may indicate that the correspond- ing muscle fibers in this motor unit develop much higher tension than deduced from the mean firing rate.‘ Thus, the relative load on single muscle fibers may be underestimated if only based on mean firing rate. Another aspect of importance during low force development is that although the muscle as a whole may not be metabolically ex- hausted, this may be the case for single muscle fibers. The muscles are composed of different muscle fiber types, and, correspondingly, mo- tor units have different recruitment thresholds. A stereotype recruitment order has been docu- mented, which means that with increasing force the low threshold motor units always are being recruited first.!3 These findings support the notion that during muscle activity fre- quently occurring in occupations with repeti- tive motions, some motor units may become exhausted metabolically, the Cinderella fibers, PHYSIOLOGIC RESPONSES TO REPETITIVE MOTOR UNIT RECRUITMENT The electrical muscle activity described above elicits two mechanical responses: muscle ten- sion and muscle tissue pressure. Muscle ten- sion is synonymous with muscle force and is transmitted to tendons and bones and thus is es- sential for performing mechanical work. Intra- muscular tissue pressure (hydrostatic pressure) in the muscle increases in proportion to the26 _ Sjogaard and Sogaard mure Mutt Mu 10 we we ee Muy wus Mus mus wus mu2 mut 108 TS we Clinical Orthopaedics and Related Research 7 ‘seconds Fig 2. In the upper part is shown force (solid line) and motor unit (MU) recruitment pattern in the flexor carpi radi- alis muscle during a part of a wrist contraction. Each line shows the interfiring interval bar plot of one motor unit. The arrow points to a double dis- charge of the motor unit Num- ber 9 at the time 2.232 seconds in the recording. Be- low is presented the double discharge, showing an interfr- Line T T T T 1206 1.292 1295 Seconds Seconds seconds muscle force development. The absolute level of muscle tissue pressure in millimeters of mercury varies widely between and within muscles and depends among others on the anatomy of the muscle itself and its surround- ings. A bulky muscle attains higher intramus cular pressures than a thin muscle, and a mus- cle with bony surroundings or tight facia shows relatively large increases because of the low compliance of these surroundings. At high con- traction forces the intramuscular pressure may attain values far above blood pressure and ob- ing interval of only 3 msec, based on single fiber record- ings from three different spatial electrode positions. viously cause muscle blood flow to be oc- cluded in areas where intramuscular pressure exceeds blood pressure, the highest pressures normally occurring deep in the muscles. How- ever, even at low level contractions, the com- plex microcirculatory regulation may become impeded. First, at low blood flow velocities it is not the mean blood pressure but the diastolic pressure that is decisive for maintenance of blood flow With prolonged contractions, the muscle water content will increase” and corre- spondingly the thickness of the muscle hasNumber 351 June, 1988 been shown to increase,” Such state of edema- tous tissue with increased volume will increase tissue pressure in a deliminated closed muscle compartment with low compliance. At contrac- tion levels approximately 5% to 10% maxi- mum voluntary isometric contraction force, in- tramuscular pressures of 40 to 60 mm Hg or ‘more have been reported in muscles such as the supraspinatus in the shoulder. '618 Adequate muscle blood flow is essential for muscle function because force develop- ment relies on the conversion of chemically bound energy to mechanical energy, a process also called energy turnover or me- tabolism, Some chemically bound energy or substrate is located in the muscle tissue (es- pecially glycogen) but may become depleted during prolonged activities. Therefore, the supply of substrates (including oxygen) to the muscle is crucial for such activities. The ultimate substrate in the conversion of chem- ical energy to mechanical energy is adeno- e triphosphate, which is broken down in the myofibrils during the crossbridge cy- cling. Adenosine triphosphate is of signifi- cance for the detachment of actin and myosin and insufficiency of this process may cause rigor or contracture with massive pain. In normal muscle contractions, the actin and myosin coupling is initiated by the release of Ca* from the sarcoplasmic reticulum into the cytosol, and has been the focus in some studies on muscle fatigue.!5! PATHOPHYSIOLOGIC MECHANISMS IN MUSCLE PAIN AND DISORDERS A relationship between prolonged moder- ately increased tissue pressure and patho- genic changes have been identified in rela- tion to compartment syndromes. Pressures more than 30 mm Hg maintained for 8 hours have been shown to induce necrotic changes in the muscle even if no active contraction was performed and energy demand therefore was minimal." One possible mechanism is that although initially blood flow is suffi- Muscle Injury in Repetitive Motion Disorders 27 cient during low level contractions, this may not be the case when the contraction is main- tained for prolonged periods. Conditions with low flow and low perfusion pressure may provoke granulocyte plugging in the capillaries which effects microcirculation, but also may facilitate formation of free radi- cals, which have a highly toxic effect.2236 To relieve the increased muscle tissue pressure, it has been suggested to perform a fas- ciotomy, for example, for the supraspinatus muscle. However, based on biomechanical estimates, force vectors perpendicular to the fiber orientation may play a role in distend- ing the extracellular matrix and thereby in- duce mechanical distortion of the interstitial space, where the sensory afferents including receptors are located.” ‘As described above, insufficient flow im- pairs metabolism and effects electrolyte bal- ance including Ca’* homeostasis. During the past decade, attention has been drawn to the pathogenesis of Ca induced damage of muscle cells.'8 The reuptake of Ca?* into the sarcoplasmic reticulum is a process depend- ing on adenosine triphosphate, which may be insufficient during prolonged activity be- cause it accounts for as much as 30% of the energy turnover during muscle activity. En- ergy crisis may result in an influx of Ca from the extracellular space. Consequently, the cytosolic free Ca is likely to be in- creased above normal for a prolonged time. This has serious implications on the phos- pholipids including those in the muscle membrane. Ca has a direct effect on phos- pholipase activity and in addition, increases the susceptibility of the membrane lipids to free radicals, which have a highly toxic ef- fect as mentioned above. These processes promote breakdown of the muscle mem- brane.8 Finally, prolonged increased cytoso- lie Ca®* concentration induces a Ca? load on the mitochondria and eventually may impair adenosine triphosphate formation, a suffi cient concentration of which is a prerequisite for active force production, For more details see a recent review chapter.‘28 _Sjogaard and Sogaard An aspect accentuating the occurrence of a Ca load in single muscle fibers is the in- trinsic motor unit recruitment patterns dis- cussed above, Performing highly skilled movements and accurate manipulations, it is likely that the same motor units are being recruited continuously. This holds true for pure static and slowly force varying and low velocity dynamic contractions (Fig. 3).48 Additionally, contractions may be elicited because of reflexes causing an even more stereotypic recruitment pattern than during voluntary contractions. Mental load has been shown to generate nonpostural muscle tension in shoulder muscles and the same holds true for visual demands and neck muscles.273032.54 Also, reflexes orig nating in the muscle itself from chemore- ceptors and mechanoreceptors may play a role, and recently the gamma loop has been Dynamic 10°/s 0.8 ee/8 180 wW/ 8.8 03/0 wn Fig 3. Three recordings from various contraction modes of the biceps brachii muscl Static anisotonic Clinical Orthopaedics and Related Research proposed to play a role in developing a po- tentially vicious cycle? The muscle fibers being activated continuously have been termed Cinderella fibers, because they are working from early to late.'? A high en- ergy turnover occurs in these fibers and most likely the fibers receive the least blood flow, because tissue pressure increases in their vicinity because of the mechanical contraction impeding blood flow.! The pathogenic mechanisms described above re- garding accumulation of Ca and free radi- cals may be a concern, especially on the single muscle fiber level. Prolonged activ- ity of specific motor units throughout an 8- hour work-day may cause insufficient time for full recovery of these motor units be- cause of a long lasting element of fatigue? that has been shown to occur in simulated occupational settings.’ ‘This may cause Static 8,8 asf 189 wa in the upper part is shown the shape of the motor unit action potential in the concentric signal. In the middle a short section of the raw recording of each contraction shows the shape used for identification of the motor unit. In the bottom is the firing pattern of all identified motor units and the arrow indicates the activity pattems of the identical motor unit during the three different types of contraction. The s% line show time history of the force. (Reprinted with permission from Sogaard K: Motor unit recruit- ment pattern during low-level static and dynamic contractions. Muscle Nerve 18:292~300, 1995.)Number 351 June, 1998 necrosis and finally cell destruction of these fibers. In line with this, fibers with marked degenerative characteristics have been found more frequently in biopsies of the trapezius from patients with work related chronic myalgia than in healthy subjects. ‘The degenerative fibers identified are slow twitch fibers that connect with low thresh- old motor nerves.! MUSCLE FATIGUE PERCEPTION AND DEVELOPMENT OF MUSCLE DISORDERS Muscle fatigue has been proposed as a pre- cursor to muscle disorders, and prevention of fatigue development often is considered as a preventive strategy. Consequently, the gen- eral trend has been to decrease muscle force requirements. At low level muscle loads the development of fatigue perception is post- poned but not abolished; that is, low loads may be maintained for much longer periods than high loads. One important feedback mechanism for fatigue is the release of K from the intracellular to interstitial space where the sensory afferents are located. At high contraction intensities the K flux causes a significant increase in interstitial or extra- cellular K concentration. This concentration is the main determinant for the concomitant reduction in the muscle membrane potential, which may be blocking the transmission of action potentials. This fatigue mechanism protects the individual muscle fibers from en- ergy depletion and consequently adenosine triphosphate concentrations remain suffi- ciently high to prevent rigor and cell death, This is in contrast to the condition during low contraction forces, where the membrane po- tential largely is maintained at resting level in all fibers, including the active ones, because the interstitial or extracellular K concentra- tion is maintained close to resting level.®8 Consequently, interstitial K concentration no longer plays a role as a feedback variable for the perception of fatigue. The fatigue mecha- nism thus seems to be different during high Muscle Injury in Repetitive Motion Disorders 29 and low contraction intensities. In the latter case, action potential transmission is not af- fected and therefore all the contraction in- duced metabolic processes proceed, includ- ing the high increases in cytosolic Ca% concentrations. If such a condition is main- tained in individual muscle fibers for pro- longed and/or repeated periods because of a stereotype recruitment pattern, necrotic changes in the muscles may be the ultimate consequence. References 1. Allen DG, Westerblad H, Lee JA, Linnergren Role of excitation-contraction coupling in muse fatigue. Sports Med 13:116-126, 1992 2. Armstrong T, Bir C, Foulke J, et al: Muscle re- sponses to simulated torque revctions of hand held power tools. Ergonomics (In press). 1998, 3. Armstrong 7), Buckle P, Fine LJ eta: A conceptual model for work-related neck and upper-limb muscu- loskeletal disorders. Seand J Work Environ Health 19:73-84, 1993, 4, Bystrdm S: Physiological response and acceptability of isometric intermittent handgrip contractions. Ar bete och Halsa 38:1—108, 1991, 5. Bystrim S, Sjpgaard G: Potassium homeostasis dur- ing and following exhaustive submaximal static hand- trip contractions. Acta Physiol Scand 142:59-66, 1991, 6. Christensen H, Pedersen MB, Sjegaard G: A national ‘ross sectional study in the Danish wood and furni- ture industry on working postures and manual mate- rial handling, Ergonomics 38:793-805, 1995. 7. Christensen H, Sogaard K, Jensen BR, Finsen L, Sjagaard G: Intramuscular and surface EMG power spectrum from dynamic and static contractions. J Electromyogr Kinesiol 5:27-36, 1995, 8, Das DK, Essman WB: Oxygen Radicals: Systemic Events and Disease Processes. Basel, S Karger 1-196, 1990. 9, Edwards RHT, Hill DK, Jones DA, Merton PA: tigue of long duration in human skeletal muscle exercise. J Physiol 272:769-778, 1977. 10, Finsen L: Biomechanical aspects of ‘occupational neck postures during dental work. Int J Ind Erg (in Press) 1998. 1, Hargens AR, Schmidt DA, Evans KL, et als Quar tion of skeletal-muscle necrosis in a model Compat- ment syndrome, J Bone Joint Sung 63A:631-636, 1981. 12, Hig GM: Static Work Loads and Occupational ‘Myalgia—A New Explanation Model. In Anderson PA, Hobart DJ, Danoff JV (eds). Electromyogruphi- cal Kinesiology, Amsterdam, Elsevier Science Pub- ishers BV 141-144, 1991, 13, Henneman E, Olson CB: Relations between struc- ture and funetion in the design of skeletal muscles. J Neurophysiol 28:581~598, 1965.30 14 15, 19. 20. ai. 2. 23 24, 25. 26. 27. Sjogaard and Sogaard Henrikson KG: Muscle pain in neuromuscul orders and primary fibromyalgia, EurJ Appl Physiol, 57:348-352, 1988. Jackson MJ, Jones DA, Edwards RHT: Experimen- tal skeletal muscle damage: The nature of the cal- cium-activated degenerative processes. Eur J Clin Invest 14:369-374, 1984, 3. Firvholm U, Palmerud G, Herberts P, Higfors C, Kadefors R: Intramuscular pressure and electromyo- raphy in the supraspinatus muscle at shoulder ab- duction. Clin Orthop 245:102-109, 1989. Jensen BR, Fallentin N, Bysirim S, Sjogaard G: Plasma potassium concentration and Doppler blood fNow during and following submaximal handgrip con- tractions. Acta Physiol Scand 147:203-21 1, 1993. Jensen BR, Jorgensen K, Huijing PA, Siagaard G: Soft tissue’ architecture and intramuscular pressure in the shoulder region, Eur J Morphol 33:205-220, 1995, Jensen BR, Jorgensen K, Sjgaard G: The effect of prolonged ‘isometric contractions on muscle fluid balance. Eur J Appl Physiol 69:439-444, 1994, Jensen BR, Pilegaard M, Sigaard G: Motor unit re~ cruitment pattern in m. supraspinatus during pro- onged low-level static contractions. Acta Physiol Scand 151:16A, 1994, Abstract. Jensen BR, Schibye B, Spgaard K, Simonsen EB, Sjagaard G: Shoulder imuscle load and muscle tigue among industrial sewing-machine operators. Eur J Appl Physiol 67:467—475, 1993. Jensen BR, Sjgaard G, Boramyr S, Arborelius M, Jorgensen K: Intramuscular laser-Doppler flowme- try in the supraspinatus muscle during isometric contractions. Eur J Appl Physiol 71:373-378, 1995. Jensen C, Finsen L, Olsen HB, et al: CAD-Work: Physical Exposure and Musculoskeletal Troubles. In ‘Seppili P, Luopajirvi T, Nygird C-H. et al (eds). From Experience to Innovation. IEA ‘97. Proceed- ings of the 13th Triennial Congress of the Interna- tional Ergonomics Association, Tampere, Finland 1997. Vol 7. Helsinki, Finnish Institute of Occupa- tional Health 413-415, 1997. Johansson H, Sojka P: Pathophysiological mecha- nisms involved in genesis and spread of muscular tension in occupational muscle pain and in chronic ‘musculoskeletal pain syndromes: A hypothesis. Med Hypotheses 35:196-203, 1991, Juul-Kristensen B, Christensen H: Chasing of chick fens—Energy Expenditure and Musculoskeletal ‘Work Load. In Nielsen R, Jorgensen K (eds). Ad- vances in Industrial Ergonomics and Safety. Lon- don, Taylor & Francis 285-292, 1993. Juul-Kristensen B, Jensen C, Finsen L, et al: Wrist Load in Computer Work. In Seppil P, LuopajirviT, Nyglrd C-H, etal (eds). From Experience to Inno vation. IEA ‘97. Proceedings of the 13th Triennial Congress of the International Ergonomics Associa- tion, Tampere, Finland 1997. Vol 4, Helsinki, Finnish Institute of Occupational Health 168-170, 1997. Kunita K, Fujiwara K: Relationship between reac- tion time of eye movement and activity of the neck extensors. Eur J Appl Physiol 74:553-557, 1996, 28, 29, 30. 31. 22, 33, 34, 35, 36. 37. 38, 39, 4 a2, 43, Clinical Orthopaedics and Related Research Larsson S, Bengisson A, Bodegird L, Henriksson KG, Larsson J: Muscle’ changes in ‘work-related chronic myalgia. Acta Orthop Scand 59:552-556, 1988, Laursen B, Jensen BR, Németh G, Sjogaard G: An EMG-driven shoulder mode! in three dimensions. Book of Abstracts. XVth Congress of the Interna- tional Society of Biomechanics. Jyviiskyli, Fin- and, University of Jyviskyli 532-533, 1995. Lie I, Watten RG: culomotor factors in the actiology (of occupational cervicobrachial diseases (OCD). J Appl Physiol 56:151~156, 1987. Marras WS, Schoenmarklin RW: Wrist motions in industry. Ergonomics 36:341~351, 1993, Mense S: Considerations concerning the neurobio- logical basis of muscle pain. Can J Physiol Pharma- col 69:610-616, 1991 Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 18:35-40, 1990. Petic D: Plasticity of Muscle. Berli ter & Co 1980. Schibye B, Skov T, Ekner D, Christiansen JU, Sjagaard G: Musculoskeletal ‘symptoms among sewing machine operators. Scand J Work Environ Health 21:426-433, 1995 Schmid-Schinbein’ GW: Capillary plugging by ‘granulocytes and the no-reflow phenomenon in the microcirculation, Fed Proc 46:2397—2401, 1987. Sjagaard G: Muscle energy metabolism and elec- trolyte shifts during low-level prolonged static con- (raction in man, Acta Physiol Scand 134:181-187, 1988, Sjogaard G: Potassium and fatigue: ‘The pros and ccons. Acta Physiol Scand 156:257-264, 1996. Sipgaard G: Intramuscular Pressure May Prevent Delayed Onset Muscular Soreness. Theoretical Con siderations Based on De Novo Biomechanical Mod- elling. In Capodagtio P, Bazzini G (eds). Advances in Occupational Medicine & Reh: 1 Activi- ties of the Upper Limbs: Aspects of Occupational and Rehabilitation Medicine. Vol 3. Pavia, Italy, Le Collane della Fondazione Salvatore Maugeri 3744, 1997 Walter de Gry- |. Sjagaard G, Jensen BR: Muscle Pathology With Overuse. In Ranney D (ed). Chronic Musculoskele- tal Injuries in the Workplace. Philadelphia, WB Saunders Company 17-40, 1997, Sjogoard G, Kiens B, Jagensen K, Saltin B: Intra- muscular pressure, EMG and blood flow during low-level prolonged static contraction in man. Acta Physiol Scand 128:475-484, 1986. Sjagaard G, Laursen B, Németh G, Jensen B: High Speed Precision Tasks Increase Muscle Activity. Book of Abstracts XVth Congress of the Interna- tional Society of Biomechanics, JYviiskyli, Finland 858-859, 1995. Abstract. Sjogaard G, McComas AJ: Role of interstitial potas- In Gandevia S, Enoka R, McComas AS, Stuart D, Thomas CK (eds). Fatigue: Neural and muscular mechanisms. Tucson, Motor Control Press 69-80, 1995,Number 351 dune, 1998 44, Sjogaard G, Savard G, Juel C: Muscle blood flow uring isometric activity and its relation 10 muscle fatigue. Eur] Appl Physiol 57:327-335, 1988. 43, Sjogaard G, Sogaard K, Christensen H, et al: Mus- cle fibre composition and! motor unit’ recruitment pattem during dynamie contractions in humans. ‘Acta Physiol Scand 151:16A, 1994, Abstract. 46. Sogaard K: Biomechanics and Motor Control Dut ing Repetitive Work. A Biomechanical and Elec- tromyographical Study of Floor Cleaning. PhD Thesis. Copenhagen, National Institute of Occupa- tional Health, University of Copenhagen 1-90, 1994. 47. Spgaard K: Motor unit recruitment pattern during Tow-level static and dynamic contractions. Muscle Nerve 18:292-300, 1995. 48, Spgoard K, Christensen H, Jensen BR, Finsen L, Sjogaard G: Motor control ‘and kineties during low level concentric and eccentric contractions in. man, Blectroenceph Clin Neurophysiol 101:453~460, 1996. 49. Sagaard K, Fallentin N, Nielsen J: Work load dur- ing floor cieaning. The effect of cleaning methods and work technique. Eur J Appl Physiol 73:73-81, 1996. Muscle Injury in Repetitive Motion Disorders 34 $0, Spgaard K, JuulKristensen B, Birch L, Chri tensen H: Biomechanical Evaluation of Wri Movement During Meatcutting. Book of Abstracts. XVIth Congress of the International Society of Biomechanics. Tokyo, Japan, The University of Tokyo 224, 1997. 51, Westerblad H, Lee JA, Linnergren J, Allen DG: Cel- sms of fatigue in skeletal muscle, Am J Physiol 261:C195-C209, 1991 52, Westgaard RH, Bjprklund R: Generation of muscle tension additional to postural muscle load. Er- ‘gonomics 30:911-923, 1987. 53, Wersted M, Eken T, Westgaard RH: Activity of sin- ‘gle motor unit in attention-demanding tasks: Firing pattern in the human trapezius muscle. Eur J Appl Physiol 7 54, Wasted M, Westgaard RH: Attention-related mus ty in different body regions during VDU ity. Exgonomi 55. Zajue FE: Recruitment and Rate Modulation of Mo- {or Units During Locomotion. in Desmedt JE (ed) Motor Unit Types, Recruitment and Plasticity in Health and Disease. Vol 9. Basel, S Karger 149-160, 198.