Finnish Institute of Occupational Health

Danish National Research Centre for the Working Environment

Norwegian National Institute of Occupational Health
A conceptual model for work-related neck and upper-limb musculoskeletal disorders
Author(s): Thomas J Armstrong, Peter Buckle, Lawrence J Fine, Mats Hagberg, Bengt Jonsson,
Asa Kilbom, Ilkka AA Kuorinka, Barbara A Silverstein, Gisela Sjogaard and Eira RA
Viikari-Juntura
Source: Scandinavian Journal of Work, Environment & Health, Vol. 19, No. 2 (April 1993), pp.
73-84
Published by: the Scandinavian Journal of Work, Environment & Health , the Finnish Institute
of Occupational Health , the Danish National Research Centre for the Working Environment ,
and the Norwegian National Institute of Occupational Health
Stable URL: http://www.jstor.org/stable/40966116
Accessed: 02-03-2015 14:44 UTC

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REVIEWS
Health1993;19:73- 84
ScandJ WorkEnviron

A conceptual model forwork-relatedneck and upper-limb

musculoskeletal disorders
PhD,1Peter Buckle,PhD,2LawrenceJ Fine, MD,3Mats Hagberg,MD,4
byThomas J Armstrong,
BengtJonsson,MD,4Asa Kilbom,MD,4IlkkaAA Kuorinka,DrMedSc,5Barbara A Silverstein,
DrMedSc5
PhD,6Gisela Sjogaard, DrMedSc,7Eira RA Viikari-Juntura,
ARMSTRONGTJ,BUCKLE P, FINE LJ,HAGBERGM, JONSSONB, KILBOM A, KUORINKA
ERA. A conceptual
modelforworkIAA,SILVERSTEINBA, SJOGAARDG, VIIKARI-JUNTURA
relatedneckandupper-limb
musculoskeletal
disorders
ScandJ WorkEnvironHealth1993;19:7384. Thispaperpresents
a conceptual
modelforthepathogenesis
ofwork-related
musculoskeletal
disorders.The modelcontainssetsof cascadingexposure,dose,capacity,andresponsevariables,such
thatresponseat one levelcan actas dose at thenext.Responseto one ormoredosescan diminish
or
increasethecapacityforresponding
to successivedoses.The modelis usedas a framework
fordisof work-related
andnervedisorders.
It is intended
as a bemuscle,tendon,
cussingthedevelopment
to be modified
to explainnewfindings
as theybecomeavailable.In research,
itcan helpto
ginning,
areasneedingadditional
dataforthedevelopment
andexpression
ofwork-related
musculoskelidentify
etal disorders.
Researchers
can use it to designlaboratory
and fieldstudies.In practice,it demonstrates
therelationship
betweencommonexposurefactorsand different
responses.This information
canbe usedtoevaluateanddesignjobs fortheprevention
ofwork-related
musculoskeletal
disorders.
cumulative
traumadisorders,
nervepathoKeyterms:carpaltunnelsyndrome,
dose-response,
fatigue,
straininjuries,
tendonandmuscledisorder,
work-related
disorders.
tendinitis,
genesis,repetitive

This paper concernsa model forthedevelopmentof

work-related
neckand upper-limbdisorders.It brings
togetherthe collective experience of researchers,
frommanycountries,who have each recognizedthe
need fora model thataddresses both scientificand
practicalaspects and theirinteractions.
The scientificliterature
showsthatthehealthproblems consideredin the model are foundworldwide,
in bothindustrialand nonindustrialgroups.Historical recordsand otherdocumentation
show thatmany
of thedisordersin questionhave been recognizedfor
centuries,and theirassociationwithoccupationswas
recordedlong beforesickness benefitschemes and

compensationclaims were in existence.It is perhaps

inevitablethatany studyor discussionof theexpression of the disordersquickly leads to a consideration of the preexistingsocial conditions,and the effectson individualsand organizations.The balance
between such factorsis complex and is further
justificationfordevelopinga model such as theone presentedin thiscommunication.
Regardless of nationaland culturaldifferencesin
social thoughtsor attitudestowardsstatesof health,
musculoskeletalproblemsare found.The extentof
theproblemsis difficultto establishbecause definitions, diagnostic criteria,and official statisticsare
rarelycomparablefromcountryto country.
Limitationsin establishingcausalityare evidentin
currentmethodologieswhenthesemethodologiesare
1 Centerfor
of Michigan,Ann applied to mostworkplacestudies.These limitations
Ergonomics,
University
should not be seen as a barrierto the interpretation
UnitedStates.
Arbor,
Michigan,
2 The RobensInstitute
of Industrial
and Environmental of data fromthe many epidemiologie studies that
Healthand Safety,University
of Surrey,
Surrey,
Eng- identifyassociations, but ratheras limitationsthat
land.
exist in
areas of health-relatedresearch. A
3 NationalInstitute
forOccupational
and
Safety Health model ofmany
the
interaction
betweenphysiological,meCincinnati,
Ohio,UnitedStates.
4 National
Institute
ofOccupational
Health,Solna,Swe- chanical, individual,and psychosocial factorsproden.
vides a frameworkfor integratingepidemiologie
5 Institute
ofOccupational
Finland.
Health,Helsinki,
withlaboratorystudies.
6
and ResearchProgram findings
Safetyand HealthAssessment
This model was developed to highlightthe multiStateDepartment
ofLaborand
(SHARP),Washington
factorialnatureof work-related
neck and upper-limb
UnitedStates.
Olympia,
Washington,
7 Industries,
National
Institute
ofOccupational
Health,Copenhagen, disordersand to assist in the understandingof the
Denmark.
betweenexposure,
complexnatureof theinteractions
and
The
model can also be
dose,
capacity,
response.
to:Dr TJArmstrong,
Center
forErgonomReprint
requests
ofMichigan,
1205Beal-IOEBuilding,
Ann considereda tool forresearchplanningand studyinics,University
MI 48109-2117,
USA.
Arbor,
terpretation.
73

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ScandJWork
Environ
Health1993,vol 19,no 2

in proThereis an important
roleforresearchers
andrehabilforprevention
vidingthoseresponsible
itationwiththeinformation
requiredto developeffectivestrategies.
The modeloutlinedreflectsthis
need.It is hopedand expectedthatthemodelwill
be developedfurther.

acerbated
andtheycanimbyworkplace
exposures,
to remember
that
pairworkcapacity.It is important
and environmental
and sopersonalcharacteristics
ciocultural
factors
usuallyplaya roleas riskfactors
forthesediseases.Someofthehealthproblems
presentedin the model have characteristics
of both
work-related
andoccupational
diseases,especiallyif
levelsarehigh.
exposure
Workrelatedness
The"workrelatedness"
ofmusculoskeletal
disorstudas dersis supported
Musculoskeletal
disorders
shouldbe characterized
bynumerous
epidemiologie
thanas "occupation- ies (2- 21). (See table1.) It can be seenthatthese
"work-related
diseases"rather
al diseases"(1). An occupational
diseaseis defined disordersare not uniqueto any one occupational
as a diseaseforwhichthereis a directcause-effect group.Reportedoccupationsincludemeatprocesandmanufacturofficeworkers,
betweenhazardanddisease(eg, asbes- sors,letter
carriers,
relationship
diseasesaredefined
as ers of manyproducts.The commontraitof these
Work-related
tos-asbestosis).
orintensive
use ofthehands.
and the groupsis repetitive
whentheworkenvironment
multifactorial
The incidenceandprevalenceofmusculoskeletal
butas
ofworkcontribute
significantly,
performance
inreference
withreducedhand
of factors,
to thecausationof dis- disorders
one of a number
populations
diseases can be partially workarelow,butnotzero.(See table1.) Thismorease (1). Work-related
is evidenceofother,
nonwork-related
causedbyadverseworkconditions.
probably
Theycanbe ex- bidity

Table 1. Epidemiologiestudies of the relationshipbetweenworkexposureand musculoskeletalresponsevariablesprovide

evidenceof a dose-responserelationship.
EMG= electromyography)
(95% CI = 95% confidenceinterval,
Study population

Exposure

Study^

Exposed
prevalence

Referents'
prevalence Rjsk

incidence

incidence
5 exposed
referents

Male industrialworkers belonging to an occupational

health center: 20 cases of
degenerative shoulder tendinitis(3 cases of tendinitis
due to general inflammatory disorder excluded),
contrasted to 34 referents
matched forage and workshop (2 referentsfor each
case)
Shipyardwelders(131males)
with more than five years
of welding experience, contrastedto office workers(57
males) age 40 years or older

Work with hands at or Caseabove shoulder level; ex- referent

posure assessed by interview and observation of
physician

11 exposed
cases

Localized shoulder muscle Crossfatigue; workwithelevated sectional

arms withhands at or above
shoulder level; exposure
measured for welders by
observation and EMG in another study

18%

Meat cutters (90 males)

contrasted to construction
foremen (77 males)

"Overstrain of the extensors and flexorsof the wrist

and fingers";exposure data
from previous published
literature and plant walk
throughs
Work tasks strenuous to
the muscle-tendon structures of the upper limb; exposure data fromprevious
published literature and
plant walk throughs
Work tasks strenuous to
the muscle tendon structures of the upper limb; exposure data fromplantwalk
throughs

Packers (118 females) contrasted to employees in

nonstrenuous jobs (197 female office workers and
supervisors)
Meat processing workers
(377 meatcutters, sausage
makers, packers) contrasted to workers in nonstrenuous jobs (332 office
workers,maintenance men,
supervisors)

2%

95% C|

Referenee
Response and comment
ber

11

2.7-42

Shoulder tendinitis;adjustment for potential confounders (age) not performed in the analysis

13

1.7-95

Shoulder tendinitis;adjustment for potential confounders (age) not performed in the analysis; the
number of welding years
not associated with outcome

Crosssectional

8.9%

1.3%

7.4

0.91-61

Tennis elbow (lateral epicondylitis)

Cohort

7.0%

1.1%

6.4

Epicondylitis (lateral and

medial) causing a visit to
the doctor; adjustment for
potential confounders (age)
not performedin the analysis

Crosssectional

0.8%

0.8%

Epicondylitis (lateral and

medial)

Scissors makers (90 fe- Number of pieces handled; Crossmales, 3 males) contrasted grasping with the fingers sectional
to shop assistants (females) wide open
in a big department store

18%

14%

1.4

0.7-2.9

Hand-wrist tendinitis (DeQuervain);tendinitisrelated

to number of pieces handied

Repetitivearm work,repeti- Crosstive motions up to 25 000 sectional

cycles per workday; exposure assessed fromobservation analysis of video
and froman interview

56%

14%

8.1

4.5-14.6

Muscle-tendon syndrome;
adjustment for potential
confounders (age) not performed in the analysis

Assembly-linepackers (152
females) in food production
industrycontrasted to shop
assistants (133 females) in
a department store (cashiers excluded)

(continued)

74

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Environ
Health1993,vol 19,no 2
ScandJWork
Table 1. Continued.

Study population
Industrialworkers(N = 652)

Exposure

Crosssectional

Work tasks strenuous to Cohort

the muscle-tendon structures of the upper limb; exposure data frompreviously published literatureand
plant walk throughs

incidence

incidence

Rjsk

g5% Q|

0.6%

29.4

3.3%

0.9%

3.9

16.3%

0.7%

24

Referenee
Response and comment
ber
9

Hand and wrist tendinitis;

control for age, gender,
plant years on the job

10

Hand-wrist tendinitis (DeQuervain); adjustment for

potential confounders (gender, age) not performed in
the analysis

Tenosynovitis or peritendinitis(including DeQuervain)

causing a visit to the doctor

1.1-14

61%

28%

4.1

2.3-7.2

Tension neck syndrome;

adjustment for potential
confounders (gender, age)
not performedin the analysis

Crosssectional

38%

11%

4.9

1.8-13

11

Tension neck syndrome;

adjustment for potential
confounders (gender, age)
not performedin the analysis

Observations fromfilmsof Crossthe work tasks; each as- sectional

sembly-lineworkerhandled
3400 shoes per day; repetitive arm movements

14%

1%

7.3

1.6-33

12

Tension neck syndrome,

adjustment for potential
confounders (age) not performed in the analysis

Scissors makers (90 fe- Number of pieces handled, Crossmales, 3 males) contrasted grasping with the fingers sectional
to shop assistants (133 fe- wide open
males) in a big department
store
Data entryoperators (50 fe- Constrained head and arm
males, 3 males) contrasted posture
to office workers (55 females and males)

Assembly-lineworkers in a
shoe manufacturing line
(102 females) contrasted to
nonassembly workers (102
females) (Rhomboid muscle tenderness)

Referents'
prevalence

12%

High-force high-repetitive Crossjobs compared with low- sectional

force low-repetitive jobs;
EMG and video analysis of
jobs

Packaging and folding Exposure according to job

workers (41 males, 328 fe- categories; no exposure
males) contrasted to knit- measurements
ting workers (203 males,
149 females)
Sausage makers (107 females) contrasted to employees in nonstrenuous
jobs (197 female office
workers and supervisors)

^udy^

Exposed
prevalence

Workers for a jet engine Use of vibratinghandtools

manufacturer (27 females
and 3 males withcarpal tunnel syndrome) and 90 randomly gender-matched

Casereferent

All butchersfromtwo small

slaughterhouses (17 males)
with 3-32 years of experience

Lifting, tearing, and han- Crossdling of carcasses withleft sectional

hand versus using tools
with right hand; exposure
determined by observation

Industrialworkers(N = 652)

High-force high-repetitive Crossjobs compared with low- sectional

force low-repetitive jobs;
EMG and video analysis of
jobs

Assembly workers(N = 479) Various occupations

contrasted to administrative and clerical workers

13.8

13

Carpal tunnel syndrome

identified from workers'
compensation reports and
plant medical personnel

53%

24%

14

Carpal tunnel syndrome diagnosed from subjective

symptoms and electrodiagnosis

1.7-142

15

Carpal tunnel syndrome,

control for age, gender,
plant years on the job

2.3

1.4-3.7

16

Carpal tunnel syndrome according to nerve conduction velocity; no symptoms

9.4

2.4 - 37

17

Carpal tunnel syndrome;

control forage and gender

4.8

1.5-16

18

Carpal tunnel syndrome;

control forage and gender

14.8

19

Workers' compensation for

carpal tunnel syndrome; female : male ratio 1.2 : 1 and
mean age 37.4 years

5.6%

Crosssectional

47%

Frozen food factory work- Frozen food factory work- Crossers (N = 207)
ers exposed to cold
sectional

37%

Carpal tunnel syndrome re- Vibration > 20 years

lease patients (38 males)
contrasted to hospital and
community referents (N =
143)
Washington state workers Industrial codes - oyster
and crab industryworkers
(in United States)

Casereferent

0.2%

Register
incidence

0.6%

28%

4.3%

16

_
Employees from government vehicle maintenance
workshops using hand as
hammer (79 males) contrasted to employees from
government vehicle maintenance workshops who
did not use hand as hammer (48 males)

Habitual hand hammering Crossdefined as using the hand sectional

to hammer more than once
a day according to interview

14%

0%

16.3

2.7-100

20

Hypothenar hammer syndrome; adjustment for

potential confounders (age)
not performedin the analysis

Platers in a plant producing

paper and pulp machinery
(89 males) contrasted to office workers at the same
plant (N =61)

Exposure assessed
by Crossquestionnaire, observation sectional
and vibration level and
duration measurements;
platersexposed to vibration
mainly during grindingbut
also duringuse of hands as
hammers

37%

20%

2.8

1.3-6.2

21

Hypothenar hammer syndrome; right ulnar artery;

adjustment for age in the
analysis

75

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Scand J WorkEnvironHealth 1993, vol 19, no 2

causes.Thesebackground
cases areconsistent
with however,
thestudieswithsuchfindings
haveeither
the conceptof theWorldHealthOrganization
of been based on nonoccupational
populationsor the
"workrelatedness"
Studiesin
(1).
occupational
exposurewas notquantified.
in theresponsesreported
in table1 whichoccupational
The variation
andthe
exposurewas quantified
is possiblyduetodifferences
in thecriteria
usedfor levelofexposurewas highhaveshownthattherisk
case definitions
and the methodsof examination. associatedwithpersonalfactorswas small when
Mostresearchers
definecases by clinicalexamina- compared
withthatassociatedwithoccupational
extion(symptoms
andclinicalfindings),
butsomeuse posures(9, 13, 15, 25). Similarcases have been
clinicalfindings
without
andvisaversa. foundforotherpersonalfactorsof musculoskeletal
symptoms
Becausemusculoskeletal
disorders
area problem disorders.
commonto manydifferent
musculoskeletal
disorders
can resultin
occupationsand work
Although
tissues painandimpairedworkperformance,
groupsandbecausetheycaninvolvedifferent
theycan also
areoftenreferred go unreported.
A worker'sdecisiontoreport
andbodylocations,
thesedisorders
a probtocollectively
as cumulative
trauma
disorders,
social,
repeti- lemcanbe influenced
byhisorherpersonal,
straininjuries,or andeconomiccircumstances.
tivetraumadisorders,
Studiesofjob satisfacrepetitive
of tionandstresshave,as yet,beeninconclusive
overusesyndromes.
Whilea literalinterpretation
(26as a practical 29). Peerpressurecan also contribute
eachtermsuggestssubtledifferences,
to a
directly
related worker'sdecisionto reporta problem.It can also
matter
theyreferto thesamediagnostically
muscu- contribute
to theproduction
ofa disorder
The term"work-related
indirectly
groupofproblems.
a workerto workfasteror slower
is usedinthispaper.
loskeletaldisorder"
by encouraging
Whilean exactdiagnosisis desirableforaffected (30).
in the
Workers'willingnessto reportmusculoskeletal
itis notalwayspossible,particularly
workers,
tocultural
differences
which
ofa musculoskel- problems
earlieststagesofthedevelopment
maybe related
theirperception
and willingness
to tolerIn mostcases it is desirableto inter- influence
etaldisorder.
mixed
of symptoms
venebeforeexplicitpatterns
develop. atepain.Studiesoftheseissueshaveproduced
that findings
fromdisorder
to
touse case criteria
itmaybe desirable
Therefore
(31, 32). The progression
influenced
at theexpenseof disability
is probably
havea highdegreeof sensitivity
strongly
bypsychoandeconomicfactors
In otherwords,at theearlieststagesof social,cultural,
(33).
specificity.
whethera
it may not be important
development,
disturis due to a biochemical
worker'sdiscomfort
of thetenbancein themuscleor to a deformation
inwork The model
donbecausebothcanrespondtoa reduction
modelis to account
The goal of ourdose-response
intensity.
factors
suchas age, forthefactorsandprocessesthatresultin work-reManystudieshaveconsidered
andcongen- latedneckand upper-limb
chronic
disorders.
The ultimate
diseases,fitness,
weight,
gender,
italdifferences.
Age andgenderhavebeenlinkedto objectiveof sucha modelis to specifyacceptable
In its
ofcarpaltunnelsyndrome
(16, 22- 24); limitson workdesignfora givenindividual.
symptoms
dose-response
simplestform,a lumped-parameter
foursets
as thefollowing
modelcanbe characterized
and
variables:
ofinteracting
dose,capacity,
exposure,
Becausethesevariablesare
1.)
(See
figure
response.
Exposure
measuresof thesystemstateat anytime,theyare
(WorkRequirements)
to as statevariables.
referred
EXTERNAL

Capacity ~*

Dose

J
!- I

'

Response 1
- Response2
- ^

Responsen

INTERNAL

Figure 1. The proposed model containssets of cascading

exposure,dose, capacity,and response variables,such that
the response at one level can act as a dose at the nextlevel. In addition,the response to one or more doses can dior increase (adaptation)thecapacityfor
minish(impairment)
respondingto successive doses.

Exposure
factors
to theexternal
(eg, workreExposurerefers
dose (eg, tisthatproducetheinternal
quirements)
sue loads and metabolicdemandsand factors).For
of the workplaceand the
example,the geometry
ofwork
determinants
shapeofthetoolsareimportant
The size,shape,andweightofworkobjects
posture.
of tissueloads. Work
determinants
are important
ofthefrequendeterminants
areimportant
standards
Italso is posof
muscle
contractions.
and
velocity
cy
siblefortheresponseofonetissuetoresultin a dose
tissue.(See figure1.) Forexamthataffects
another
ple, connectivetissuecan thickenas its adaptsto
can lead to pressureon
stress,and thisthickening
nervecapacity.
adjacentnervesandimpaired

76

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Scand J WorkEnvironHealth 1993, vol 19, no 2

Not all important

workrequirements
and other Capacity
workenvironment
factorsare physicalcharacterisrefers
Capacity,whether
physicalor psychological
tics.Conflicting
job demands,suchas theneed to to theabilityof theindividualto resistdestabilizaincreaseboththequalityand quantity
of theprod- tionduetovariousdoses.
ExamplesincludetheabilEven characteristics
of the
uct,can be important.
of tissuesto resistdeformation,
the abilityto
ity
workenvironment,
suchas thethreat
ofa plantclos- maintain
concentrations
ofmetabolites
whenexposed
andthesecharacteristicsto forcesof exertionor movement
ing,can also be important,
or nonphysical
canbestbe considered
as workenvironment
factors factors
suchas a strong
senseofself-esteem
ora high
rather
thanas workrequirements.
capacityto resistmentalstress.Accordingto the
modelcapacitycan be reducedor enhancedbypreDose
vious doses and responses.For example,previous
canreducesubstrate
levelsorincreasemeDose refersto thosefactorsthatin someway dis- exertions
are tolerated
turbtheinternal
stateoftheindividual.
Disturbances tabolitelevelsso thatfewerexertions
before
and
discomfort
occur.
be
or
fatigue
Similarly,
prior
may mechanical,
physiological, psychological.
can resultin residualdeformation
of conare tissue exertions
Examplesof mechanicaldisturbances
orlowerforce
forcesand deformations
thatare producedas a re- nectivetissuesso thatfewerexertions
Most indisultofexertion
ormovement
ofthebody.Examples is requiredto producemicrofailures.
of physiological
disturbances
are consumption
of vidualsareable to adaptto certaintypesandlevels
Musclescan developincreasedaerobic
metabolic
ofmetabolites,
ion of activity.
substrates,
production
or
anaerobic
metaboliccapacity.Connective
tissues
and
tissue
of
displacement,
damage.Examples psynotall tisare anxietyaboutthework canadaptbybecoming
however,
stronger;
chologicaldisturbances
suesadaptatthesamerate.A musclecanadaptfaster
loadandthelackofsocialsupport
fromfamily.
thana tendonandresultinreducedtendoncapacity.
Response
Responseincludesthechangesthatoccurinthestate
variablesof theindividual.
Examplesare a change Muscle disorders
insubstrate,
ion
by-product, concentrations,
temperand individualfactors
ature,or theshapeof tissues.One responsecan in Physicalworkrequirements
turnbe a newdose,whichthenproducesanother
re- determine
muscleforceandlengthcharacteristics
as
oftime,whichin turndetermines
muscle
sponse.For example,an exertionof thehandcan a function
cause changesin tissueshapeand in substrate
and energy
Muscleenergy
in
requirements.
requirements
metabolite
whichthencan leadtomuslevels,whichinturnresultindiscomfort.turncan leadto fatigue,
Theresponses
thatareproducedas a resultofan- cle disorders.
Muscleresponses
canbe characterized
otherresponsearereferred
to as secondary,
tertiary, as a seriesofcascadingmechanicalandphysiologiandthelike,depending
on thenumber
ofpreceding cal events.MechanicalresponsesincludedeformaIn thepreviousexample,tissuedeforma- tionandtheyielding
ofconnective
tissueswithin
the
responses.
tionandsubstrate
andmetabolite
levelsareprimary muscle,as well as increasesin intramuscular
tissue
anddiscomfort
is a secondary
responses,
response. pressure,whichcan affectthemuscleblood flow
The relationship
betweendose and statevariable mechanically
(34, 35). PhysiologicalresponsesinFor cludeelectrochemical
and metabolicchanges(36).
responsecan be alteredby previousexertions.
an exertion
drawson highenergy Initialresponsesincludeelectricalexcitation,
shiftexample,initially
storeswithin
themuscle.Later,itcandraw ingions,activation
ofcontractile
andmephosphate
proteins,
on themuscleglycogenand fattyacid stores.The chanicaldeformation
of muscletissues.These reeffect
of a dose can occurimmediately
or itcan re- sponsesare followedby shifting
concentrations
of
offorcewillpro- substrates
andmetabolites.
Theselocal changesare
quirelongperiodsoftime.Exertion
duceimmediate
elasticdeformation
oftendons.Re- conveyedto thecentralnervoussystemby sensory
exertions
overthecourseof a afferent
nervesand cause corresponding
sensations
peatedor prolonged
workshiftcan resultin viscousdeformation
of tis- of effort
anddiscomfort,
or whatis referred
to colsues. Repeatedand prolongedexertions,
day after lectivelyas "perceivedfatigue."Of noteis thefact
oftis- thatthesesensory
affrents
affect
the
day,canresultinchangesinthecomposition
simultaneously
sue.Thesechangescan resultin increaseddose tol- cardiorespiratory
responsesto matchtheincreased
erance.Such changesare referred
to as adaptation needformusclebloodflowto supplysubstrates,
inand are a desirableeffectof training.
The changes cludingoxygen,andto prevent
theaccumulation
of
can also resultin reducedcapacity,whichis an un- metabolites.
However,if intramuscular
pressureis
desirableeffect.
maintained
at a highlevelforprolonged
periodsof
A quantitative
ofall ofthehumancom- time,as duringsustainedstaticcontractions,
the
description
and thechangesin
ponentsand of all of thestatevariablesis notyet blood flowcan be insufficient,
thediscussionwillfocuson ex- intramuscular
homeostasis
is vitalforforcedeveloppossible.Therefore
tomuscles,tendons,
andnerves. ment(37).
amplespertaining
77

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Health1993,vol 19,no 2
ScandJ WorkEnviron

canactivate
thepain
stimuli
Musculardamagecan be a resultof hightension meansthatlowthreshold
can occur
contrac- systemor thatevenspontaneous
as seenespeciallyineccentric
activity
development,
nerves(51).
tions,whichcan lead to musclefiberZ-linerupture innociceptive
muscleplaysa cruinMotor
control
oftheworking
work
also
causes
Such
muscle
(38).
largedelayed
Therecruitofdisorders.
creasesin serumcreatinekinase(39), andthesein- cialroleinthedevelopment
can occuraccordof themotoneurons
creaseslikewisecan be seen in relationto occu- mentpattern
(ie, thesmallunitsareactipationalwork(40, 41). Such changesare common ingto thesize principle
thesame
in musclesoreness,andtheyarereversible vatedatlowforces)(52,53). Consequently,
findings
ifthemuscleis allowedto restandrecover.Repair unitcan be recruited
duringa given
continuously
loadon the
eveniftherelative
of con- worktask.Therefore,
of muscleinjuryincludestheregeneration
tissue muscleas a wholeis low,theactivemotorunitcan
tractilefibers,as well as thatof connective
(42). Oftenrepairis greaterthantheoriginaldam- workclose to its maximalcapacity.These lowmotorunitsmayhavea highriskofbeing
age,andin suchcases themuscleadaptsto tolerate threshold
theseunitshavebeenidenthestressthatcausedthedamage.Repairof a sin- damaged(54). Actually,
changes,
gle case of damageshouldbe completeaftera few tifiedas showingmarkedmorphological
mechweeksor months.
However,ifdamageoccursdaily describedas redraggedfibers(55). Another
is
recruitment
thecapacityof themuscle anismto inducea stereotype
due to a workactivity,
pattern
due to
to repairthedamageas fastas the activationof gamma motoneurons
maybe insufficient
of metabolites
can develop. ischemiaor theaccumulation
itoccurs,andlong-lasting
(56).
impairment
duetomenofmuscletension
thegeneration
suf- Finally,
without
Whena muscleis fatigued
repeatedly
ficient
recovery
beingallowedfor,muscledisorders talloadcancausean overloadon somespecificmusare likelyto occur,as has alreadybeen discussed. cle fibers(57). In addition,Edwards(58) has pubandCentralMechofPeripheral
levelis not lished"Hypothesis
on a subcellular
Theprecisemechanism
anisms
mechanito
the
be
due
not
known
and
Underlying
OccupationalMuscle Pain and
only
may
yet
disor- Injury."
cal eventsinthemuscle,but,in occupational
Fromthisdiscussionitcan be seenhowan exerevents
tometabolic
ders,itmoreoften
maybe related
in themuscle.Depletionofenergycan resultin ac- tionof thebodyleadsto a seriesofresponses.The
of eachresponsedependson thecapacimagnitude
pain(43).
tivity-related
has beendrawnto theaccumu- ty of the tissueand its exposureto previousreLately,attention
in talationofcalcium(Ca) ionsintheintracellular
space sponses.Some ofthesestepsare summarized
offatigueandpaindere- ble 2. Theultimate
reporting
(44). Calciumis releasedfromthesarcoplasmic
andcan enterthemuscle pendson theireffecton workcapacityrelativeto
contraction
ticulum
during
factors.
clearanceofCa++fromthecytosolic workdemandsandon socioeconomic
cell.Insufficient
to increase,and
spacecausestheCa++concentration
in thatCa++
has seriousimplications
theincrement
Tendon disorders
which
can break
increasesphospholipase
activity,
downthemembrane
lipidsandcause increasedcell Tendondose is relatedto tensileforcesfrommusand to contactand shearingforces
oftoxic cle contractions
andan accumulation
membrane
permeability
In additionCa++increasesthesuscepti- fromadjacentanatomicsurfaces(eg,bonesandligmetabolites.
lipidsto freeradicals,which aments).Tendonresponsescan be mechanicalor
bilityofthemembrane
Mechanicalresponsesincludeelastic
of hypoxictissue. physiological.
areformed
duringreoxygenation
andyielding.
func- andviscousdeformation
Physiological
Finally,Ca++overloadcan altermitochondrial
of nervereceptors,
tion(45).
responsesincludethetriggering
Larssonet al (46) andLindmanet al (47) report- healing,andadaptation.
disorders
sitesoftendon
Themostcommon
thatsuggest
in musclemorphology
ed differences
among
arethewrist,
workers
elbow,and
forearm,
thatsubjectswithchronicmyofascialpain have a industrial
fortendon
thannor- shoulder
levelsoffatigue
lowercapacityandhigher
(6, 40, 59, 60). Theterminology
is notwelldefined.
with disorders
areconsistent
malsubjects.Thesemechanisms
Kurppaetal (61) used
ofthetendonsheath
forinflammation
the pathologically
highratesof fatigueand low tenosynovitis
of theparatenforinflammation
(48) for and peritendinitis
byHagberg& Kvarnstrm
reported
strength
shoulder
withmyofascial
pain.Reducedlo- don.
patients
is fairly
of shouldertendinitis
musclewas correlat- The pathogenesis
cal bloodflowin thetrapezius
factorforshoulThe predisposing
ed withmyalgiaandraggedredfibersin 17 patients wellunderstood.
of
is oftendegeneration.
withchronicmyalgiaandwas relatedto staticload dertendinitis
Degeneration
and
of
is
caused
tendon
the
In
work
perfusion
impairment
by
(49).
particular
assembly
duringrepetitive
stress.Cell death
inaddition
tomechanical
canbe insufficiently
theactivemusclefibers
perfused nutrition,
in
whichchalkcan
debris
thetendon,
due to increasedpressurein theseareas (50). Dis- within
forming
The tencanleadtothe deposit,is theinitialformofdegeneration.
inmuscular
microcirculation
turbance
thebicepsbrachii(long
in the dons to the supraspinata,
of pain receptors
sensitization
(nociceptors)
mussensitization head),and theupperpartsof theinfraspinata
muscleandpainat rest.Pain receptor
78

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Health1993,vol 19,no 2
ScandJWorkEnviron

ele havezonesofavascularity
of thewrist,and thisfriction
leads
(62, 63). Signsofde- ingmovements
suchas cell death,chalkdeposits,and to inflammation
andswellingofthetendons.Tendgeneration
inthisarea initishasbeeninducedintheAchillestendonofrabarelocatedpredominantly
microruptures
of avascularity.
of thecirculation
and bitsbyelectricalstimulus
conImpairment
leadingto repetitive
thusaccelerated
tractions
is
caused
(70).
degeneration
bycompressionandstatictensionoftheshoulder
tendons.The
Extensiveworkcan also be performed
in sports,
ofthetendonsoccurswhenthearmis andthusthereis a strong
compression
analogybetweenwork-reelevated.
ofthearm,therotator
cuff latedandsport-related
tendinitis.
swimDuringelevation
Competitive
tendonsandtheinsertions
on thegreater
overheadarmmovements
areat
tuberosity merswithrepetitive
arecompressed
underthecoracoacromial
arch.It is riskforimpingement
(71). Lateralepisyndrome
believedthatthiscompression
orimpingement
is suf- condylitis
is knownas tenniselbow sincetheconficient
to impairperfusion
ofthetendon.
ditionhasbeenattributed
totennisplaying.(See, eg,
Tendoncirculation
is also dependent
on muscle reference
72.)
in thetendonis inversely
tension.Circulation
As inmuscleresponses,
itcanbe seenhowan exprotothetension
andceasesatgreater
tensions. ertionof thebodyleads to a seriesof tendonreportional
Recentstudieshave shownthattheintramuscularsponses,whicharesummarized
intable2.
in thesupraspinata
muscleexceeds30 mm
pressure
flexionor Table2. Characterization
Hg (-3.99 kPa) at 30 degreesof forward
ofwork-related
musculoskeletal
disin theshoulder
abduction
joint(3, 64). An impair- ordersingeneraland muscle,tendon,and nervedisordersin
accordingto sets of cascading exposure and rementofbloodcirculation
occursatthispressure
lev- particular
sponse variablesas conceptualizedin the model.
el. Since themajorblood vessel supplying
thesuIndividual'scapacity Response
tendon
runsthrough
thesupraspinata
mus- Exposure-dose
praspinata
ofthetendonmay Musculoskeletalsystem
cle,itis likelythatthecirculation
be disturbed
flex- Workload
alreadyat 30 degreesof forward
Bodysize and shape Jointposition
Worklocation
Muscle force
Physiologicalstate
ionorabduction
intheshoulder
joint.
Workfrequency
Psychologicalstate Muscle length
Thesedeformations
can increasewithsuccessive Workduration
Muscle velocity
Frequency
exertions
due to theviscoelasticproperties
of tenMuscle disorders
dons.Goldsteinet al (65) demonstrated
that,when Muscle force
Muscle mass
Membranepermeability
flexordigitorum
tendonsweresubjected Musclevelocity
profundus
Muscle anatomy
Ion flow
Fibertype
Membraneaction
Frequency
to 500 repetitions
of an 8-s axial load followedby Duration
composition
potentials
2 s ofrest,theviscousstrainwas equal to theelasEnzymeconcenEnergyturnover
tration
muscle
(metabolism)
tic strain.Whena 2-s load was followedby 8 s of
Energystores
enzymes,and energy
stores
Capillary
density
the
viscous
strain
was
or
rest,
negligible.
Repeated
Intramuscular
pressure
exertions
withinsufficient
time
Ion imbalances
prolonged
recovery
Reduced
substrates
canleadtoa deformation
oftendons
andreduced
perIncreasedmetabolites
and water
fusionthatpersists
wellbeyondtheperiodofwork.
Increasein blood
In thedegenerated
tendon,it is possiblethatexpressure,heartrate,
cardiac
output,
ertiontriggers
an inflammatory
"foreign
body"remuscle blood flow
Muscle
to
the
debris
of
dead
cells
and
in
results
acfatigue
sponse
Pain
tivetendinitis.
In addition,
infection
(viral,urogeniFree radicals
Membranedamage
or
inflammation
a subtal) systemic
maypredispose
Z-discruptures
in theshoulder.One hyAfferent
activation
ject to reactivetendinitis
thatmakestheimmune Tendon disorders
pothesisis thatan infection
Stress
activeincreasesthepossibility
ofa "foreign Muscleforce
Anthropometry
system
Muscle length
Tendonanatomy
Strain(elastic& viscous)
in the Musclevelocity
structures
body"responseto thedegenerative
Vascularity
Microruptures
Necrosis
Frequency
Synovialtissue
tendon.
Jointposition
Inflammation
Thepathogenesis
oflateralepicondylitis
Fibrosis
is notyet Compartment
pressure
Adhesions
wellunderstood.
Thepredominant
is thatmitheory
Swelling
Pain
occurat theattachment
ofthemuscleto
croruptures
thebone,morespecifically
between
theinsertion
and Nerve disorders
force
Stress
Anthropometry
theperiosteum
of thebone,causinginflammationMuscle
Muscle length
Nerveanatomy
Strain
Muscle
status
This
could
be
due
to
velocity
Electrolyte
Rupturesin perineural
(66 68).
phenomenon
repeti- Frequency
Basal compartment tissues
tivehighforceexceedingthestrength
of thecolla- Joint
Proteinleakage
pressure
position
Rupturesin perineural
usu- Compartment
genfibersofthetendonorigin.The microtear,
tissue
pressure
Proteinleakageinnerve
allyintheoriginoftheextensor
carpiradialisbrevis,
trunks
resultsin theformation
of fibrons
andgranular
tisEdema
Increasedpressure
suesas a consequence
ofrepetitive
trauma(69).
Impairedblood flow
TendonsarekeptinplaceatthewristbyligamenNumbness,tingling,
conductionblock
touscompartments.
The firstdorsalwristcompartNerveaction
mentcanbe narrow
andcauseexcessivefriction
potentials
dur79

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Health1993,vol 19,no 2
ScandJWork
Environ

Nerve disorders

eludedthatthesestressesand tissuechangeswere
ofactivity,
relatedcarAs withtendons,
theconceptofdose,whenapplied involvedinthepathogenesis
tunnel
Similar
observations
andconpal
syndrome.
to nerves,impliesmusclecontractions,
jointposi- clusionshavebeenmade other
(23).
by
investigators
and
movements
which
tions, joint
producepressure The effectof a
givendose dependson theindianddeformation
ofthenerves.Someindividuals
exvidual'scapacity.Whether
an increaseincarpaltunperienceresponsesthatcontinuewell beyondthe nel
of bloodflowin
pressurecausesan impairment
normalcontraction.
In addition,
nervepressureand
the
nerve
is
blood
Individdependent
upon
pressure.
deformation
canpersist
after
thecontraction
as a secuals
with
blood
intrahigh
pressure
require
higher
effect
oftheswelling
ofadjacenttendons
and
ondary
inturnleadto carpaltunnelpressureelevationto decreaseblood
tendonsheaths.
Mechanicalresponses
flowand
nervefunction
(78). Whether
large
a seriesof physiological
responsesthatultimately orsmall impair
tunnel
areas
increase
the
risk
for
carpal
carpal
Nervescan also be
includeimpaired
nervefunction.
is a disputedissue(79, 80). It may
affected
andlow tempera- tunnelsyndrome
byexposureto vibration
be
that
the
residual
volumeplaysan important
role
tures.
Hormonalstatusmayinfluence
in
thepressure
(81).
canal the
etal (73) showedthatintracarpal
Lundborg
in
canal.
levels
of
carpal
High
estrogen pregnancy
and senpressurecan lead to impairedconduction
ofwaterinthebody.Met(82) increasetheretention
in
1
of
the
median
nerve
less
than
h.
function
sory
abolicdisorders
maymakethenervemoresusceptiAn increaseincarpaltunnelpressure
ofthreeto six ble to
inthecarpaltunnel.
increases
Exampressure
valuewas foundduringisometric
timestheresting
ofmetabolic
disorders
arediabetesmellitus
and
ples
ofwristandfinger
orisotonicmaximalcontractions
ofthemediannerveproxamyloidosis.
Compression
muscles(74). Thesechangeswererelatedtomechan- imalto thewrist thethoracic
outlet)maymake
(eg,
ofthemediannerve.
ical pressure
andperfusion
ofblood
thenervemoresusceptible
toan impairment
A responseis an effectofthedose causedbyex- flowinthewrist(doublecrush
(75).
syndrome)
inthemediannerverecirculation
posure.Impaired
have shownthatperipheral
Otherinvestigators
sultsin tingling,
numbness,
pain,anda loss ofmo- nervedisorders
of
can resultfromthetransmission
in
in thehand.The impairedfunction
torfunction
the
pressurefroman externalworkobjectthrough
ve- skinto an
thenervecan be measured
bynerveconduction
nerve(83- 86). A localized
underlying
threshold
shifts
(73). Ithas pressure
locitychangesorsensory
mm
above50
Hg (-6.65 kPa) in thecarpal
also beenclaimedthatpain in theshouldercan be tunnelor pressureabove thesystoliclevel froma
paintriggered
bycompression tourniquet
entrapment
proximal
aroundtheupperarmcauses a conducofthemediannerveatthewrist(75).
tionblockin themediannerveat thewrist(73, 78).
ofthemediannervein certainpos- Extremeflexionor extension
ofthewristcausesan
Compression
turesis thebasisof'Thalen's"orthe"wristflexion" increaseofpressure
in thecarpaltunnelthatcan afand otherprovoca- fectthebloodperfusion
testforcarpaltunnelsyndrome
ofthemediannerve(74, 87,
tivetestsofnervefunction
(23). The acuteresponse 88).
hasbeendescribed, In thecase ofmaterials
modified
toexposure
itis evidentthat
bycapacity
handling,
butthemodelcan also be appliedto chronic(long- thepoorergonomie
designof toolswithrespectto
effects.
Wristextension
(theexposure)
may weight,shape,and size can imposeextremewrist
standing)
ofthenerve"(thedose) leadingto positionsand theuse of highforceson theworker
cause"stretching
a powergripand
(theresponse).In turn,thesemicro- (89,90). Holdingan objectrequires
microruptures
there- hightensionin thefingerflexortendonsthatcause
a dosegenerating
maybe considered
ruptures
is thencon- increasedpressurein thecarpaltunnel.The heavier
Inflammation
sponseof inflammation.
Tis- theobject,thegreater
oftissuescarring.
sidereda dosewitha response
toholdthe
thepowerrequired
altersthecapacityofthenerveandmay object.
suescarring
also be a dose of pressureincrease.A permanent Handandarmvibration
incausesan involuntary
due creaseinpowergripthrough
increase
a reflexofthestrength
mayleadtonervedegeneration
pressure
A pressure
increasehas receptors
bloodperfusion.
toimpaired
cancauseprovibration
(91). Furthermore,
andinward teinleakagefromthe blood vessels in the nerve
alreadybeenshowntoblocktheoutward
in
andresultinedemaandincreased
trunks
axoplasmicflowsinthenerve(75, 76).
pressure
also resultin edema
andtherefore
Microscopicstudiesof tissuesin thecarpaltun- thenervetrunks
inthenerve(92).
nel in wristspecimenshave revealedchanges(eg, andincreased
pressure
andfibrousconexertion
of fibrocytes
increasedthickening
As is thecase withmusclesandtendons,
nectivetissue)in theradialandulnarbursaandthe of thebodyresultsin a seriesof mechanicaland
ofthesechangescor- physiologicaldoses and responsesof the nerves.
mediannerve(77). Thepattern
of stressesproducedbe- Doses andresponses
ofa certain
respondswiththepattern
typeandmagnitude
tweenthetendons,
butotherdosfora nerveto function,
nerves,andadjacentflexorreti- arenecessary
thatre- es and responsescan impairits function.
naculumandcarpalbones.It was suggested
In time,
wristare nervesadaptin waysthatincreasetheirtolerance
witha flexedorextended
to
peatedexertions
factorsin theetiology.The authorscon- increasingdoses. Thereappearsto be a seriesof
important
80

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Health1993,vol 19,no 2
ScandJWorkEnviron

thresholds
between
thedoselevelsnecessary
fornor- theloss ofprecisionandaccuracyoftheless expenmalfunction
func- sivechecklist
andthosewhichleadtoimpaired
orquestionnaire
methods.
tion.Thethresholds
Muscleforceandjointpositionare probablythe
appeartovaryamongpeopleand
within
mostcommonly
usedmethodsto estimatedose. To
peopleovertime.
measurecapacity,anthropometry,
musclestrength,
and psychologicalcharacteristics
have been used.
Muscle biopsiescan also be used,buttendonand
Psychosocial interaction
nervebiopsiesarenotethnically
acceptable.
In theprevious
theinteractions
sections
between
dosThe responsesrangefrompain,fatigue,discomes andresponses
indifferent
tissuessuchas muscle,
orothersubjective
tomoreobjective
symptoms
andnervehavebeenindicated.
The interac- fort,
tendon,
factorssuchas nerveactionpotentials,
muscleactionsbetweenpsychosocial
exposures,
psychologi- tionpotentials,
andedema,manyofwhich
ruptures,
cal factors,
andtissueresponsesareless wellestab- can
be quantified
conditions
onlyunderlaboratory
lished,butpossiblepathwayshave been described
Someoftheobjectiveresponsesmentioned
(98,
99).
by,forexample,Theorellet al (93). The quantita- canbe measured
attheworkplace,
butitis moreusutiverelationships,
needto be describedin al to
however,
on subjectiveassessment,
oftencombined
rely
future
research.
witha clinicalexamination.
Severalcomponents
of
clinicaltestshavebeennotadequately
validatedand
needfurther
evaluation.
Use of the model
The measurement
andquantification
ofexposure,
The proposedmodelshouldbe usefulin thedesign dose,capacity,andresponseis encouraged
whenevof studieson theetiologyandpathomechanisms
of er possible.By applying
themodel,theopen-mindwork-related
musculoskeletal
as wellas in ed researcher
disorders,
maydiscovernew exposures,doses,
theplanning
andevaluation
ofpreventive
which,aftertheirdiscovprograms. capacities,andresponses,
studiesamongworking
Epidemiologie
populations ery,canbe quantified.
commonin
usuallyfocuson associationsbetweenthetop and
Modelingis becomingincreasingly
bottomof thecascade (see figure1) withphysical bothsocialandnatural
science.Thestrength
ofmodworkload,psychological
andenvironmen-eling,givena highvalidityofthemodel,is thatthe
demands,
talriskfactors
ofworkat one endandthemanifes- outcomeofa seriesofeventscanbe predicted
withtationsof symptoms,
at the outextensiveexperimentation.
In thecase of musdiseases,or disabilities
other.
Unbalanced
andworkhistories
are culoskeletaldisorders,a validationof the entire
age,gender,
forepidemiologie
studies.These modelthrough
or epidemiologie
studies
frequent
problems
laboratory
factorscan be controlled
in laboratory
duetothelong-lasting
disease
studies,but is hardly
conceivable,
it is unethical
to exposehumansubjectsto a situa- process.
tionthatis believeda prioriwillmakethemsick.The
The hypotheses
to prevent
underlying
attempts
modelcan be usedto identify
intermediate
musculoskeletal
disordersare seldom
respons- work-related
canalpressure,
toevaluatese- formally
es, suchas intracarpal
stated;in manycases theprevention
prolectedexposurefactorswithminimum
riskto the gramscan be describedas "trialanderror"exercishumansubject.
es. Mostattempts
areneverevaluated,andtherefore
Animportant
research
is how thevalidity
oftheoriginalhypothesis
cannotbe testquestionconcerning
wellexposure,dose,response,and capacitycan be ed. The proposedmodelcan be used to identify
inmeasuredand quantified.
Variousstudieshave as- termediate
dosesandresponses.
sessedexposureusingjob titleorjob classification,
onpossibleriskfactors,
questionnaires
job checklists
filledoutby theresearchers,
and diobservations,
rectmeasurements
andcost Concluding remarks
(94), withquantifiability
ofassessment
as onemovesfromthebe- The proposedmodeladdressesthecomplex,multiincreasing
to theend of thelist.The use of quantifi- factorial
natureofwork-related
neckandupper-limb
ginning
ablemethods
hasbeenstrongly
andsev- disorders.
It hasbeendevelopedthrough
theexperiencouraged,
eralmethods
areavailable.(See, eg,references
95ence and resultsof researchin manydisciplines.It
time(ie, providesa clear framework
forunderstanding
97.) If one wantsto extendthemeasuring
the
assesslong-term
cumulative
therearefew complexnature
oftheinteractions
between
exposure),
exposure,
methods
ofdirect
measurement
and dose,capacity,andresponse.
(eg,goniometers)
thecostofsuchstudiesis ofmajorconcern.
It is hopedthatone use of themodelwill be to
Repeated
use ofvalidatedchecklists
is less costly,andthede- aid researchers
inidentifying
doseandresponsevarof a job-exposure
matrix(ie, individual iables in theirstudies.In particular,
theuse of the
velopment
is moreeconomicalforan assess- modelshouldgeneratemoreefficient
exposure
profiles)
planningand
mentofcumulative
theetiology
exposure.However,ithas been evaluationof bothresearchaddressing
difficult
tofindthebestcompromise
between
thepre- and pathomechanisms
of thesedisordersand intercisionandcostofdirectmeasurement
studies.
exposurewith ventionandprevention
81

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ScandJWork
Environ
Health1993,vol 19,no 2

References

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