Edited by

ALLAN TOOMINGAS • SVEND ERIK MATHIASSEN

EWA WIGAEUS TORNQVIST

Published in
cooperation with
the University of
Gävle, Sweden
 Edited by
ALLAN TOOMINGAS • SVEND ERIK MATHIASSEN
EWA WIGAEUS TORNQVIST

Published in
cooperation with
Boca Raton London New York
the University of
CRC Press is an imprint of the
Taylor & Francis Group, an informa business Gävle, Sweden
This book was previously published in Sweden as Arbetslivsfysiologi, by Studentlitteratur.

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Contents
Preface���������������������������������������������������������������������������������������������������������������������vii
Editors����������������������������������������������������������������������������������������������������������������������� ix
Authors���������������������������������������������������������������������������������������������������������������������� xi

Chapter 1 Work, Working Life, Occupational Physiology�����������������������������������1

Allan Toomingas, Svend Erik Mathiassen, and
Ewa Wigaeus Tornqvist

Chapter 2 Work Demanding High Energy Metabolism������������������������������������� 19

Ewa Wigaeus Tornqvist

Chapter 3 Work Requiring Considerable Muscle Force������������������������������������� 59

Katarina Kjellberg

Chapter 4 Work in Awkward Postures���������������������������������������������������������������� 99

Karin Harms-Ringdahl

Chapter 5 Work with Highly Repetitive Movements���������������������������������������� 117

Fredrik Hellström

Chapter 6 Prolonged, Low-Intensity, Sedentary Work������������������������������������� 141

Allan Toomingas

Chapter 7 Work with High Levels of Mental Strain����������������������������������������� 183

Bo Melin

Chapter 8 Work That Disrupts the Diurnal Rhythm���������������������������������������� 215

Torbjörn Åkerstedt

Chapter 9 Work in Heat and Cold��������������������������������������������������������������������� 237

Désirée Gavhed

v
vi Contents

Chapter 10 A Good Working Life for Everyone������������������������������������������������� 271

Allan Toomingas, Margareta Bratt Carlström,
and Svend Erik Mathiassen
Preface
A well-functioning society is dependent on a productive working life, which not only
provides the working population with an income but also promotes health and well-
being. This book, Occupational Physiology, is about the working human’s physical
and mental capacities and needs, and how these correspond to prevailing conditions
in current working life. Solid knowledge of these issues is an essential basis for cre-
ating a working life that is, at the same time, effective and pursues the vision of “a
health-promoting working life for everybody.”
This book meets a need for a clear and easy-to-grasp textbook focusing on impor-
tant issues in occupational physiology. It addresses some of the major public health
problems of the present time—musculoskeletal disorders and stress—and describes
how these problems are related to conditions in working life. The book explains asso-
ciations among work, well-being, and health according to recent theories and knowl-
edge within the field. It also presents methods for risk assessment and provides
information about relevant health and safety directives. Finally, emphasizing the
health-promoting potential of work, advice and guidelines are given on how to arrange
for a good working life from the perspective of the working individual, the company,
and society as a whole. Thus, the book has its objective in being of practical use.
Occupational Physiology is a textbook for educational programmes devoted to
“man at work,” for instance, professionals in occupational health services, in occu-
pational and environmental medicine, and in other professions devoted to health
promotion in occupational life. It also addresses safety officers, trade union repre-
sentatives, company management, and other stakeholders having influence on the
organization and contents of work.
The book focuses on a number of common, yet stressful, working conditions,
such as work requiring considerable physical or mental effort, sedentary or repetitive
work, work at inconvenient hours or work in a hot or cold climate. The chapters are
written by experts within each area. By referring to situations in working life, the
book differs from other textbooks in work physiology, which adhere to a traditional
medical−anatomical structure, separating the physiology of the cardio-respiratory
system, the nervous system, and so on. The present new approach makes the book
easier to grasp, closer to applications in working life, and thus more attractive to the
target groups.
The book is intended to be easily accessible to anyone with a secondary educa-
tion, and does not require any prior specialist knowledge of medicine or physiology.
“Fact boxes” in the chapters explain and further deepen the text. References and sug-
gestions for “Further Reading” are at the end of each chapter for the purpose of
additional knowledge.
The book is an updated and internationalized translation of a Swedish textbook,
Arbetslivsfysiologi, published in late 2008 by Studentlitteratur in Lund. The former
National Institute for Working Life in Sweden supported the original publication,
whereas the translation into English was funded by the University of Gävle.

vii
viii Preface

The original Chapters 2 through 9 were reviewed for their physiological content
by Professor Gisela Sjøgaard, currently associated with the Institute of Sports
Science and Clinical Biomechanics at the University of Southern Denmark, and we
wish to express our sincere appreciation for her contribution. Margareta Bratt
Carlström, ergonomist at Avonova Occupational Health Services in Stockholm, has
provided us with excellent comments on the different chapters.

Allan Toomingas
Svend Erik Mathiassen
Ewa Wigaeus Tornqvist
Editors
Allan Toomingas, PhD, MD, is a registered psychologist, an associate professor in
occupational and environmental medicine, and a senior researcher at Karolinska
Institutet, Institute of Environmental Medicine and the Centre for Musculoskeletal
Research, University of Gävle, Sweden. He is also a physician at the clinic for
­occupational and environmental medicine at the Karolinska University Hospital in
Stockholm. His major research areas include work-related musculoskeletal disor-
ders, healthy ICT work, and methods of occupational health services. He teaches and
organizes educational programmes at the Karolinska Institutet mainly for medical
students and specialists in occupational health services.

Svend Erik Mathiassen, PhD, is a professor and research director at the Centre for
Musculoskeletal Research, University of Gävle, Sweden. His main research interest
lies in physical variation in working life: how to measure “variation,” effects on per-
formance, fatigue, and disorders of different types of variation, and interventions in
working life promoting or counteracting variation. His interest in exposure variabil-
ity has also led to extensive research on cost-efficient strategies for collecting and
analysing data on physical load. Thus, he has been involved in studies of variation
among, for instance, hairdressers, industrial assembly workers, cleaners, flight bag-
gage handlers, office workers, and house painters. He is also currently engaged in a
scientific advisory committee formed by the Swedish government to aid in matters
related to its work environment policy.

Ewa Wigaeus Tornqvist, PhD, was a professor in ergonomics at KTH, Royal

Institute of Technology, School of Technology and Health, and the University of
Gävle, Centre for Musculoskeletal Research at the time this book was written. Her
major research area is work-related musculoskeletal health. She teaches work physi-
ology, ergonomics, and epidemiology for engineering and technology students and
for specialists in occupational health services. From March 2011 she has been a pro-
fessor in occupational health and dean of the School of Health Sciences, Jönköping
University, Sweden.

ix
Authors
Torbjörn Åkerstedt, PhD, is a professor of behavioural physiology and director of
the Stress Research Institute, Stockholm University. He is also affiliated with the
Department of Clinical Neuroscience at the Karolinska Institutet. His major research
focus is on sleep, alertness, stress, and work hours. He has published more than 230
papers in peer-reviewed scientific journals.

Margareta Bratt Carlström, BSc in physical therapy, is a physiotherapist/ergonomist.

She was a former senior administrative officer at the Swedish Work Environment
Authority, Department of Ergonomics and Workplace Design. She is now a consult-
ant in a private company, Avonova Occupational Health Service Ltd. (Stockholm),
where she specializes in tasks regarding the legal framework and provisions for work
environment conditions.

Désirée Gavhed, PhD, is a researcher at the Karolinska Institutet, Stockholm,

Sweden. She has performed laboratory and field studies in thermal and work physiol-
ogy for many years at the National Institute for Working Life, Stockholm, Sweden.
She teaches thermal and work physiology in occupational safety and health educa-
tion programs, worked as consultant for the Swedish Work Environment Authority,
and was involved in international standardization work in the area.

Karin Harms-Ringdahl, PhD, registered physiotherapist, is a professor in physio­

therapy at Karolinska Institutet, Stockholm. She has a combined position at the
clinic of physical therapy at the Karolinska University Hospital in Stockholm. Her
major research areas are work-related musculoskeletal disorders and movement
science. She conducts research and teaches and arranges educational courses at the
Karolinska Institutet for physiotherapy students.

Fredrik Hellström, PhD, is a researcher at the Centre for Musculoskeletal Research

and the Department of Occupational and Public Health Sciences, University of
Gävle, Sweden. His major research areas are physiological responses to repetitive
and static work as well as basic mechanisms behind work-related muscle pain. He
teaches muscle physiology, motor control, and ergonomics to physiotherapists and
students within health education.

Katarina Kjellberg, PhD, is a researcher and lecturer at Karolinska Institutet,

Department of Public Health Sciences. Her main research interests concern work-
related musculoskeletal health, work ability, sickness absence, ergonomics in the
health care sector and cash-register work, and methods and practices for the occupa-
tional health services, such as methods for assessment of work technique, work abil-
ity, and early occupational rehabilitation. She teaches and arranges educational
programs at the Karolinska Institutet for specialists in occupational health services.

xi
xii Authors

Bo Melin, PhD, is a professor in work psychology and the head of the psychology
division at Karolinska Institutet. His field of research is within psychobiological
stress reactions and health. More recently, he is involved in studies regarding cogni-
tive and emotional capacities in relation to health and achievement in life within a
work-related frame. This relatively new field is often addressed as cognitive epidemi-
ology. He is a member of several scientific committees and teaches at a new five-year
psychology program at the Karolinska Institutet.
 1 Work, Working Life,
Occupational Physiology
Allan Toomingas, Svend Erik Mathiassen,
and Ewa Wigaeus Tornqvist

Photo: Illar Toomingas

CONTENTS
1.1  Work: A Major Part of Life................................................................................ 2
1.2  Work, Exposure, and Physiological Responses................................................. 3
1.3  Exertion and Fatigue.......................................................................................... 6
1.4  Work Ability....................................................................................................... 7
1.5  Adaptation for Good and for Bad....................................................................... 9
1.6  Preconditions for Human Work....................................................................... 10

1
2 Occupational Physiology

1.7  Work-Related Musculoskeletal Disorders........................................................ 11

1.8 Occupational Physiology from a Historical Perspective.................................. 14
1.9  Occupational Physiology: This Book.............................................................. 16
References................................................................................................................. 18

1.1  WORK: A MAJOR PART OF LIFE

Working has always been an integral part of human life. Work has been a precondi-
tion for the survival of the individual, the success of companies and business, and the
existence of society. In their early environments as hunter–gatherers, people contrib-
uted, according to their ability, to the tasks that arose. Most of them probably engaged
in a broad range of tasks, but presumably with a marked difference between the
genders. There were no specific workplaces, but the tasks were carried out within
families as a part of daily life. Gradually, a differentiation arose between “work” and
“leisure,” which has become permanent in most cultures right up to the present day.
Different individuals and groups eventually developed different competences and
specializations—professions were created which varied and vary with regard to both
physical and mental demands. The most important “work tool” has, in most cases,
been the human body itself. Heavy, yet varying, manual work which dominated in
earlier days has presumably had a training effect on fitness and strength as well as
endurance. Tools and machines have been developed to increase efficiency and to
carry out more sophisticated work that would not have been possible without these
aids, and thus the burdens—at least the physical ones—have gradually decreased in
most occupations. This industrial development also meant that work in most cases
had to be located at specific workplaces where equipment was available.
In today’s post-industrial society, one can discern a blurring of the differences
between work and leisure, particularly in the knowledge production sector of work-
ing life. Many tasks can, with the help of electronic information and communication
technology (ICT), be carried out almost anywhere and at any time. Work and leisure
therefore merge together once again without boundaries in either time or space, as
before industrialization. What cannot be discerned, however, is any retreat from pro-
fessional specialization to a situation where most individuals help carry out most
working tasks. On the contrary, modern working life demands increased specializa-
tion, even within different professions. Companies and organizations focus their
activities on “core areas” in which they develop their specialized competitiveness.
Working life in post-industrial society is therefore characterized in many ­professions
by a protracted strain, if at a low intensity, on the body that does not provide any
obvious variation. At the same time, the mental strain is often high. The computer is
nowadays the most common piece of equipment used. At the same time, many pro-
fessions with heavy, uncomfortable, or monotonous loads—in health care and con-
struction, for example—still exist.
Work fills a large part of people’s lives. In our society, work, and travel to and
from work, takes up more than half of our waking lives during the working week.
How work is designed and carried out has considerable significance both for indi-
vidual performance, health and well-being, as well as for the success of companies
and business and the existence of communities.
Work, Working Life, Occupational Physiology 3

1.2  WORK, EXPOSURE, AND PHYSIOLOGICAL RESPONSES

Every time someone is faced with a task, they decide—consciously or uncon-
sciously—how the body and mind need to be involved in order to carry out that task.
This processing of information about the task gives rise to a strategy with both con-
scious and unconscious components as to which movements, muscular efforts, and
mental processes are to be invested. The task itself—for example, delivering the mail
in an urban area, moving the residents in a care home from bed to dining table, or
needing to decide on a vital treatment of a patient—exists independently of the per-
son who subsequently carries out the work. The way in which the task is realized and
therefore the loads that occur in the body are on the other hand unique to the indi-
vidual person. Each individual has their own way, their “working technique,” which
depends on both physical and mental factors such as body length, muscle capacity,
experience, and attitude. A good working technique is an important precondition for
coping with high productivity, while, at the same time, the physical and mental load
remains favourable to the body.
The physical and mental load then gives rise to a physiological response, which in
a preliminary phase is the immediate, short-term attempt of the body to adapt. For
example, sweat is produced when working in a hot environment in order to keep
body temperature from rising too much. If the load continues for a longer time, it
may be that the adaptation is not sufficient to maintain a physiological balance. Then
various more or less adverse effects may arise, for example, an increase in body
temperature when heat cannot be completely transferred to the surroundings, or a
marked muscle fatigue after repeated physically demanding work cycles. These
effects can, in their turn, lead to further physiological responses in a cascading
sequence; for example, prolonged heat stress can cause a deterioration of the physical
and mental capacity as body temperature gradually rises.
If the original load then drops or is discontinued, the body usually manages to
recover to its basic functioning, so that it is ready for new loads. Different bodily
functions take different durations for recovery. For example, maximal voluntary
muscle strength drops fairly rapidly during heavy muscular work, while it usually
recovers within seconds or minutes when the muscle relaxes. On the other hand, it
can take hours or days to restore a bodily fluid deficit or nutrition deficiency. The
body is constantly switching between being in a stress phase, where it is “being
­broken down” in what is known as a catabolic process, and being in a recovery phase,
where it is once again being “built up” in what is called an anabolic process (see also
Chapter 6, Section 6.11). The balance over time between catabolic and anabolic
phases is decisive for the well-being of the body and mind. A situation with con-
stantly inadequate recovery after periods of physical or mental stress can lead to
long-lasting impaired health, performance, and work ability, in the sense that it will
take a very long time to return to full capacity, even if that may be possible. Section 1.4
takes up this phenomenon in relation to the concept of work ability.
Figure 1.1 shows a model of these sequences of events, using the terminology that
is often employed within occupational research. The concept of exposure means
“something the individual encounters.” “External exposure” in the model therefore
covers both the task that is to be carried out and also the working conditions that
4 Occupational Physiology

External exposure
Independent of the individual

Dependent on the individual

Internal exposure
Modification

Feedback
Acute response

Long-term effect

FIGURE 1.1  Model describing the association between the work task (external exposure),
the load on the person carrying out the work (internal exposure), and the physiological adap-
tation of the body to the work in the short term (acute response) and long term (chronic effect).
The model also illustrates the fact that the associations are influenced (modified) by who is
performing the work, and that both external and internal exposure can be changed through
feedback.

affect how that task may be realized, such as technical equipment, working environ-
ment, work organization, and psychosocial conditions. The task of “delivering post
in postal delivery district Number 14” is therefore an external exposure, just like the
number of letterboxes and their positioning, and the time allowances the employer
has established for the work. The common denominator for all external exposure is
that it is independent of the individual undertaking the work.
The “internal exposure” denotes the loads arising on and in the body when the
individual carries out the work. The postal delivery worker will, for example, walk a
number of steps, bend down towards the letterboxes, stretch out an arm, and insert
the letters. As the development of force is the basic precondition for movement, both
of our own bodies and of objects in the world around us, force may be regarded as
the primary expression of the internal exposure of the musculoskeletal system. Work
postures and work movements are often used as more easily observable expressions
of internal exposure. As far as mental loads are concerned, there is no clear counter-
part to force as the primary internal exposure.
Both external and internal exposure changes over time. For example, the angle of
the upper arm in relation to the vertical changes constantly over a day as the ­individual
moves, and also changes from day to day. To gain an overall picture of exposure, we
must understand its amplitude (level), frequency, and duration (Figure 1.2). Amplitude
and frequency can be combined in the concept “variation,” which represents the
change in exposure over time. The variation is thus characterized by how much the
exposure changes, how quickly it changes, and whether there is a recurrent pattern of
similar exposure elements, such as in repetitive, cyclic assembly work.
Work, Working Life, Occupational Physiology 5

Force development (% max)

20

Amplitude

10

Frequency

Duration
0
0 1
Time (min)

FIGURE 1.2  The three basic dimensions of exposure during 1 min of force development in
a muscle: amplitude, that is to say, the level of the force, here illustrated by the average force;
frequency, that is to say how quickly the exposure changes over time, illustrated by the
(changes in) force every 3 s of registration; duration, that is to say how long the exposure
continues, illustrated by the fact that exposure in this case goes on for 1 min.

As described above, internal exposure then gives rise to a cascade of physiologi-

cal reactions, or “acute responses” (Figure 1.1). These responses are acute in the
sense that they return relatively quickly to their initial state if the exposure ceases.
Responses that have a longer recovery period or do not recover at all may then be
regarded as “long-term effects.” Long-term effects can be positive, as an increased
physical capacity, following from a training programme, and negative, as muscle
pain resulting from prolonged exposure to awkward working postures.
Individual factors influence, or “modify,” each of the stages between external
exposure and long-term effects. The same task leads to different internal exposures
in different individuals, for example, because they choose different working tech-
niques. The same internal exposure produces different physiological responses, pri-
marily due to the fact that individuals differ in their performance capacity. For
example, the muscle force required to carry a heavy bag with letters corresponds to
50% of the maximum strength for one individual, but only 20% for another. In the
first case, the individual is loaded more and will become tired considerably more
quickly than in the second case. There will also be substantial differences between
individuals with regard to reaction patterns, even when internal exposures are simi-
lar. This applies to both acute responses, for example, drowsiness during night work,
and long-term effects, for example, back pain caused by heavy lifting. The model in
Figure 1.1 also illustrates the fact that the individual may react to a load by trying to
change it, in a so-called “feedback loop.” The loop can be involuntary or an act of
conscious will. One example of the former is that muscle coordination (i.e., internal
exposure) changes with fatigue. An example of voluntary feedback is the attempt to
6 Occupational Physiology

restructure one’s work if one has shoulder pain, that is, changing the working tech-
nique or reorganizing the time-line of work.
Exposure and response are terms used consistently within physiology and
­medicine. At the same time as the exposure−response model forms the basis for
­understanding physiological events, it is applicable as a starting point for the discus-
sion of many issues in working life. If, for example, one wishes to understand the
reason why more women than men have neck and shoulder pain, the model helps the
user to structure her thinking. Could this be explained by the fact that the external
exposure of women and men differ because women have tasks different from those
of men? Or is it because women “translate” an external exposure to an internal one
in a way different from that of men—for example, because women generally speak-
ing are shorter than men? Or can the same internal exposure give rise to different
physiological short- and long-term responses in women and men, for example,
because women, generally speaking, have lower muscle strength and oxygen uptake
capacity than men? Maybe the differences result from the fact that women experi-
ence and report pain and other disorders in a different way than men?

1.3  EXERTION AND FATIGUE

The varying demands of work are thus managed by the individual through varying
physical and mental initiatives, leading to varying internal physical and mental loads
and physiological responses. Situations that stress the individual significantly in rela-
tion to his/her current capacity (ability), and which result in strong physiological
reactions, are regarded as strenuous.
The degree of exertion can therefore be different in different individuals carrying
out the same work. Someone who has a low capacity frequently experiences more
exertion when carrying out the same work than someone who has a higher capacity.
The working technique is also decisive of what proportion of an ­individual’s capacity
he or she uses, and therefore how strenuous the work will be. An ­individual who only
needs to exert half his/her muscle strength or just becomes a little hot and sweaty
feels less physically stressed than someone who has to exert maximum strength or
becomes very hot and sweaty. On the other hand, when working at one’s maximum
capacity one is always just as stressed, namely to the maximum, irrespective of
capacity. Correspondingly, all healthy people are assumed to be just as (minimally)
stressed when completely at rest. A good working technique limits physical and
mental exertion and fatigue while maintaining productivity.
Exertion is basically an individual experience. If we wish to acquire a measure of
individual exertion, we can therefore in a systematic way ask the individuals to
assess the exertion they feel on a scale, for example, the Borg Scale (see Chapter 6,
Section 6.12). We can also estimate the degree of exertion from the behaviour of the
individual. Breathing heavily, for example, or puffing and blowing and groaning
when working, may be a sign of great exertion.
If a job continues for a long time without opportunities for rest, recuperation, and
recovery, there is eventually a reduction in the individual’s ability to perform, for
example, to provide muscle power or to keep mentally alert. This reduction in capacity
is physiologically defined as fatigue. Physiological fatigue is often accompanied by the
Work, Working Life, Occupational Physiology 7

individual also feeling tired. Fatigue may, however, be experienced without any visible
physiological changes, just as physiological fatigue can exist without any apparent sub-
jective experiences. It is possible to measure physiological fatigue, for example, by the
decline in muscle strength, or by certain changes in the electrical muscle activity
(EMG—see Chapter 6, Section 6.12). It is also possible to ask the individual to describe
and quantify his/her perception of fatigue in a questionnaire, or to carry out tests of
vigilance or reaction times. If for physiological or psychological reasons the capacity
has declined to such a level that it is no longer sufficient to meet the work demands, the
work performance declines both quantitatively and qualitatively. Performance can,
therefore, be used as an indicator of fatigue, for example, the number of assemblies
made per hour or the extent of errors made during a working day.
The fatigue and sleepiness that result from the diurnal rhythm are not directly
related to physical or mental load and have special characteristics (see Chapter 8).

1.4  WORK ABILITY

According to the definition above, fatigue is a transient deficiency in the capacity to
carry out work. In normal cases the ability to work is restored relatively quickly
to the initial state if one is given the opportunity of recovery. Sometimes the ability
to work is, however, limited for a longer time, despite a reasonable recovery period.
The concept of work ability has come to be used increasingly in daily working life
[Nordenfelt 2008]. The concept has usually been used with the approximate mean-
ing of ability to successfully perform occupational work. Work ability can be
reduced in the longer or shorter term (for hours, days, months, years, or perma-
nently), depending on what has caused the reduction and what remedial measures
have been taken. For the individual, the employer, and society, the long-term work
ability is often of vital importance.
Work ability depends on the type and level of the physical, mental, and social
work demands (see Figure 1.3). Examples of demands of this kind may be: transfer
of heavy patients, a long period sitting at a computer, precision work which is visu-
ally demanding, high sound levels, shift work, outdoor work at all seasons, high

Work demands

Work ability

Functional ability

Individual capacity Individual working technique

FIGURE 1.3  Factors affecting an individual’s work ability.

8 Occupational Physiology

work pace, rapid decision-making where errors can mean placing other people’s lives
at risk, reorganizations in which one’s job is threatened, solitary work, or dealing
with customers’ complaints and threats. High demands and demands that are poorly
adapted to the individual may lead to inadequate work ability.
The work ability is also dependent on the individual’s ability to respond to the
various physical, psychological, and social demands of the work, which is to say the
individual’s functional ability (see Figure 1.3). WHO uses the concepts “functioning
and disability” [WHO 2003]. Functioning is, in turn, dependent on individual capac-
ity. The relevant and necessary physical, psychological, and social capacity varies
among different professions and situations. Regarding physical capacity, the demands
at work normally concern capacity and endurance in developing (muscle-) force,
achieving coordinated and precise movements, possessing agility, and sufficient bal-
ance, vision, and hearing. In certain cases, therefore, poor training, for example, in
strength and endurance, may limit the work ability. There are also a number of psy-
chological and social capacities that may be necessary at work, for example, a good
memory, problem-solving skills, verbal ability, stress tolerance, and empathy. If a
function of this kind is decisive at work, then a lack of capacity may again lead to
insufficient work ability. Several factors can reduce the individual’s capacity and
functional ability, for example, pain and other physical or psychological problems,
disease, complications after accidents, addiction, lack of work motivation, or prob-
lematic social conditions. Another cause may be age-related impairment of muscle
power, vision, or hearing. The causes of capacity reduction may have arisen in the
present job or previous jobs or may be completely unrelated to work. There does not
need to be a single cause; it may often be a combination of several, for example, age-
related changes in combination with complications after an accident at work.
A further factor which is decisive for work ability is the individual’s working tech-
nique (see Figure 1.3). The working technique is the individual’s way of “translating”
work demands (external exposure) into internal exposure (see Figure 1.1). A less suit-
able working technique may lead to high internal exposures, which may result in loads
that are too high relative to the individual’s capacity. The work ability may then suffer.
An example of this is a care worker who gets back pain because she moves a patient
from his/her bed to a wheelchair by lifting the entire weight of the patient instead of
making use of transfer techniques resulting in a smaller load. Another example is a
computer user who gets a “mouse arm” by working only with the mouse instead of
alternatively using keyboard shortcuts. A further example is stress-related disorders
caused by completing the day’s tasks as fast as possible without taking breaks.
A lack of work ability is, therefore, an expression of an imbalance between the
demands of work and the individual functional ability, capacity, and working tech-
nique. The same person may have excellent work ability for a specific job, but a
worse ability for a different job that makes different demands. For example, an older
car assembly worker may find it difficult to keep up with a high work pace on a pro-
duction line, even if he is used to it; that is to say, his work ability is reduced. If the
pace was reduced, the worker would keep up and therefore have adequate work abil-
ity. In a corresponding way, the reduction in capacity may have a considerable sig-
nificance in a particular profession, but little significance in a different profession.
For example, a professional singer is presumably not influenced in his/her work
Work, Working Life, Occupational Physiology 9

a­ bility by injuring a hand. A concert pianist, on the other hand, will suffer a serious
reduction in his/her work ability from the same injury.
If an individual’s capacity is impaired, the range of jobs suited to their adequate
capacity becomes limited. This book contains a large number of examples of the
probability of working life, in the longer term, leading to a reduction in physical
capacity, caused by, for example, monotonous repeated movements, sustained mus-
cle activity, mental stress, anxiety, or night work.
A common misconception is that the working ability of the individual is equiva-
lent to his/her capacity or functional ability. The two other factors determining work
ability are then forgotten—working technique and work demands. The result of such
a misconception may be that we try to solve a deficiency in work ability by focusing
only on the individual’s capacity and miss the two other basic options, which is to say
changing the work demands and improving working technique. Chapter 10 presents
ideas on how the work ability can be maintained and increased on physiological
grounds.

1.5  ADAPTATION FOR GOOD AND FOR BAD

Man—Homo sapiens—was at one time shaped by and adapted for life on the African
savannah. Life there is something that we can only have vague notions about.
Presumably, humans were subjected to a variety of both physical and mental loads.
Being able to cope with these loads therefore became vital to survival. This presum-
ably meant being able to see opportunities and risks in different situations, and then
if necessary, being able rapidly to react and act. Being able to mobilize all available
physical and mental resources was important, for example, to run quickly, develop
considerable muscle force, or not be paralysed by a threat. A special asset was man’s
ability to use tools as a supplement to the very flexible and nimble upper ­extremities—
arms and hands. The sensory organs, the brain, and the musculoskeletal system
became optimized on coping with continually changing conditions. Communication,
cooperation, and group support were important. The physical and mental adaptabil-
ity of Homo sapiens has been a decisive factor for the success of man in conquer-
ing the rest of the globe and for mankind now being on the edge of transcending
its limits.
Demands at work are met, as has been described above, by mobilizing physical
and mental resources, resulting in various physiological (adaptation) processes. This
mobilization of resources can be more or less demanding and protracted. Situations
that place great demands on the ability to adapt physically or mentally are sometimes
called “stressors.” Stressors can be of various kinds. They may, for example, be
physical or mental challenges or threats, monotonous repetitive work, work in heat
or cold, and work at night. It is, therefore, not merely a question of stress caused by
insufficient time or high pace to which people often refer. The more or less conscious
experiences of the physical and mental adaptation and the associated physiological
reactions are usually called “stress” or “stress reactions.” It may be a question of both
physical reactions, for example, raised heart rate and blood pressure, and mental
reactions, for example, sleep disturbance, anxiety or feelings of insecurity about not
being able to cope.
10 Occupational Physiology

In the short term, human beings are good at managing stressors of this kind,
that is to say, exposures requiring adaptation. Adaptability does, however, have its
limits. If the stressors last too long, the price of adaptation may be functional dis-
orders and ill-health, for example, cardiovascular disease such as high blood
­pressure or deficient immune defences, aches and pains, and problems with con-
centration and memory. Chapter 7 explains further about these so-called allostatic
concepts.
Correspondingly, the body adapts to low loads. If the bones and joints are not
loaded, they weaken. If the muscles are not used, their strength and endurance
decrease. If the cardiovascular system is not taxed by occasional hard work, fitness
is impaired. Adaptation to low physical load therefore leads to a loss of capacity. If
the inactivity continues for a long period, then the risk of ill health from, for exam-
ple, cardiovascular disease or diabetes increases.

1.6  PRECONDITIONS FOR HUMAN WORK

As explained above, people performing a job have different physical and mental
capacities for living up to the demands of the job as regards, for example, muscle
strength, precise movements, and memory. People of different ages, for example,
vary in maximum muscle strength, endurance and mobility, how quickly and pre-
cisely they can select small parts, and how many figures they can keep in their
head. In order to achieve a productive and healthy working life, it is important to
take into account people’s abilities and limitations when designing tasks, work-
places, and tools.
People also have different physical and mental needs for their well-being and
development. One important need of this kind is to be able to use (activate) and
develop their physical and mental functions, that is to say that muscles and joints are
allowed to move, and that mental abilities are put to use. Researchers suggest that
variation in physical and mental load is a precondition for good functioning and
health. Monotonous activity for prolonged periods of time is prejudicial. As a protec-
tion against overload and wear and as a stimulus to the development of capacity and
functional ability, loads need to vary both as regards level (high−low), complexity
(difficult−easy), and type. For example, the joints of the body are dependent on varia-
tion in position and force for the joint cartilage to receive an optimum supply of
oxygen and nutrients. A fixed joint position over a long period may be directly harm-
ful, as it disturbs this supply. In order to protect against overload and to provide
scope for healing and regenerative processes, recurrent periods of physical and men-
tal recovery are necessary. Leisure time and sleep at night are important. Breaks
during work are necessary, more frequently so with more demanding physical or
mental loads. It is possible to recover exhausted body parts and functions by varying
the work so that other body parts and functions bear or share the load. For example,
arms and legs are allowed to rest if a task is carried out that mostly involves mental
work. Thus, recuperation and recovery can occur even in the absence of a break,
pause, or sleep.
A sensible work organization therefore builds variation of this kind into jobs,
making variation a natural part of the daily work. An optimal working environment,
Work, Working Life, Occupational Physiology 11

suitable tools, and equipments make variation possible. Good working techniques
utilize these opportunities for variation.
In the long term, it is positive for the individual, business, and society if work
takes into account people’s physical and mental preconditions and needs and is not
merely regarded as a source of income for the individual and a production factor for
the company. An exhausted individual, or someone who is in pain or frustrated, can-
not be expected to be optimally productive. Work performance in terms of both
quantity and quality, may suffer.
Occupational physiology and occupational medicine have a tradition of primarily
addressing exposures at work that may result in fatigue, disorders, and other prob-
lems. But, as is clear from earlier discussion, it is not harmful to be subjected to load.
On the contrary, both physical and mental structures and functions require to be
activated so as not to degrade. But inadequate load or overloads of various kinds may
also be harmful to health. The challenge in working life is to find those patterns of
activity and recovery which in the short term as well as long term promote health and
well-being as well as productivity and quality of performance. Sports science and
physical education have engaged in similar issues for decades. Today these fields
have an advanced knowledge of the effects of different training methods on oxygen
uptake, muscle capacity, health, and performance. In comparison with this, the
knowledge of the effects of different load patterns in working life is insufficient and
vague. We have qualitative knowledge that, for example, “repetitive assembly move-
ments over a long period provide an increased risk of disorders in the lower arm,” or
that “frequent heavy lifts may result in back pain.” However, we lack quantitative
knowledge about “how much,” “how often,” and “how long.” One explanation of this
lack of knowledge is, among other things, that the patterns of load in working life are
far more complicated in time and space than a well-planned training programme for
athletes. As is evident in this book, it is therefore only possible to provide general
principles for what good work should look like, for example, that it should allow for,
and even support, physical and mental variation, or that awkward work postures
should only occur to a very limited extent.

1.7  WORK-RELATED MUSCULOSKELETAL DISORDERS

Large parts of this book deal with the musculoskeletal system, that is to say, the
skeleton with its joints and ligaments, the muscles with their tendons and bone
attachments, and those parts of the nervous system controlling muscle activity. The
central role of the musculoskeletal system in the book is justified by the fact that
musculoskeletal disorders and injuries have been one of the most widespread health
problems in large parts of the industrialized and post-industrial world for several
decades now. Several population studies of the prevalence of work-related ill health
show that disorders of the musculoskeletal system dominate together with mental
conditions [Eurofound 2007; OSHA/EU 2007; SWEA 2008]. The most prevalent
musculoskeletal disorders, in turn, are backache and pain in the neck/shoulders or
upper extremities, while fatigue and stress lead to the mental outcomes (Table 1.1).
About 35% of European workers (male 38%, female 32%) consider their work to
have negative effects on their health [Eurofound 2007]. Major differences are,
12 Occupational Physiology

TABLE 1.1
Percentage of Workers in 27 European Countries Reporting
Different Symptoms Due to Work in 2005
Percentage
Backache 24.7
Pain in neck, shoulders, or upper extremities 22.8
Fatigue 22.6
Stress 22.3
Headaches 15.5
Irritability 10.5
Injuries   9.7
Sleeping problems   8.7
Anxiety   7.8
Eyesight problems   7.8
Hearing problems   7.2
Skin problems   6.6
Stomach ache   5.8
Breathing difficulties   4.8
Allergies   4.0
Heart disease   2.4
Other   1.6

Source: Eurofound. 2007. Fourth European Working Conditions Survey. European

Foundation for the Improvement of Living and Working Conditions.
http://www.eurofound.europa.eu/pubdocs/​­2006/98/en/2/ef0698en.pdf
Note: More than one symptom may be reported.

h­ owever, found between different EU-countries, from 20% to 70%. Major differ-
ences are also noted among different work life sectors, with more than 60% of work-
ers in agriculture reporting health problems caused by work, followed by workers in
the construction, manufacturing, and health care sectors, where about 40% report
­problems. Least affected are workers in the financial sector, with about 20% report-
ing negative health effects of their work. Agricultural workers mostly report physical
health problems, whereas workers from the education sector report more mental
health problems. The most commonly reported risk factor is repetitive hand and arm
movements, reported by more than 60% of all workers, and painful and tiring posi-
tions, reported by 45% (Table 1.2).
Musculoskeletal disorder is the most frequently reported cause of work-related
disease in many countries (approximately 50% of all cases reported in Sweden) and
second after mental problems the most common cause for long-term disability ben-
efits (30% of all cases in Sweden) [Swedish Social Insurance Agency 2008; SWEA
2010]. A rough estimate is that musculoskeletal disorders caused by work cost the
Swedish society about 1% of GNP merely in sickness and disability benefits. In addi-
tion, disorders cause disruption to the production of companies and organizations
and personal suffering. Work has been estimated that approximately 30–40% of all
Work, Working Life, Occupational Physiology 13

TABLE 1.2
Percentage of Workers in 27 European Countries Reporting Different
Risk Factors during at Least One-Quarter of the Time at Work in 2005
Percentage
Repetitive hand and arm movements 62
Painful and tiring positions 45
Noise 30
Vibrations 24
Low temperatures 22
Smoke, fumes, dust 18
Chemical substances 14
Infectious material  9
Radiation  4

Source: Eurofound. 2007. Fourth European Working Conditions Survey. European Foundation
for the Improvement of Living and Working Conditions. http://www.eurofound.europa.
eu/pubdocs/​2006/98/en/2/ef0698en.pdf
Note: More than one factor may be reported.

ill health in the musculoskeletal system is work related and therefore potentially
should be preventable through changes in working life.
Many reported disorders of and injuries to the musculoskeletal system have been
regarded by those affected and by health care as work related, even if it has not
always been possible to “prove” this by using accepted research methods. When
using the term “work-related,” it is important to bear in mind that disorders can,
indeed, be directly caused by the work. Work can also trigger or accelerate disor-
ders that perhaps have a background in the individual’s constitution or degeneration
due to age. Without the exposures presented at work, these disorders may well have
appeared later in life or may not have manifested themselves at all. Work can also
prevent or delay healing and rehabilitation of an injury, which in itself need not be
caused or triggered by work. Finally, work may lead to complications or in other
ways exacerbate an injury. In these various ways work may influence the emergence
of new cases (incidences) and the occurrence of existing cases (prevalence) of disor-
ders and ill health.
One may ask why work-related disorders of the musculoskeletal system are so
common in today’s working life, despite the fact that major efforts have been made
to prevent and treat them. One important cause among many is that there are a mul-
titude of various risk factors at work for disorders and ill health in the musculoskel-
etal system: work that is too heavy or too inactive, repetitive operations, badly
designed workplaces or tools, vibrations, great precision requirements, a lack of con-
trol of one’s own work or a lack of support from fellow workers and leaders. The
likelihood is great that an individual is faced with one or more such risk factors in
today’s working life. Synergy between different risk factors increases the risk, for
example, if a higher work tempo for a prolonged period is combined with an unsuit-
able working technique and lack of support from colleagues. It is therefore seldom
14 Occupational Physiology

enough to eliminate single risk factors or improve work using a single measure, for
example, ergonomically improved tools. We can compare this with the risk of occur-
rence of other work-related diseases, for example, poisoning, pneumoconiosis, or
hearing damage. In these cases it is often possible to eliminate the risk of ill health
by removing a single risk factor, that is to say, the dangerous chemical, the silica
dust, or the noise.
Another reason that the efforts, in recent decades, to reduce work-related ill
health in the musculoskeletal system have not provided the desired results may be
that the expected positive effects have been counteracted by increased rationaliza-
tion and specialization within working life. This development may, for example,
have resulted in less variation in tasks and fewer natural breaks. A classic example
is the ergonomic interventions directed at dentists in Sweden during the 1960s. By
introducing adjustable chairs in the dentists’ clinics, their uncomfortable postures,
standing forward-leaning and often twisted, were replaced by a somewhat more
comfortable sitting work posture with the equipment within comfortable reach. At
the same time, however, the work was rationalized by transferring some of the den-
tist’s former tasks to other professional groups, for example, the receptionist, the
dental nurse and the dental hygienist. The work of the dentists became less varied
and natural breaks fewer. The reduction in the load level (less leaning forward and
fewer twisted postures) was replaced by a much greater duration of sedentary work
with small movements in constrained work postures. What is more, a piece rate
system was introduced in public dental care, which may have resulted in increased
mental stress, and hence increased muscle tension in shoulders and neck. It is not so
strange, therefore, that researchers have found that dentists even today have a very
high incidence of disorders of the musculoskeletal system, primarily in the neck
and shoulders.
Knowledge of occupational physiology is paramount to understanding why disor-
ders and ill health in the musculoskeletal system have become so common, what one
could and should do to prevent the problems, and possibly even how work could be
designed with the aim of promoting health. The various chapters in this book address
the most important requirements in working life from an occupational physiology
­perspective, explaining in what ways they affect health, well-being, and capacity,
and discussing how a healthy working life can be designed by taking these factors
into account.

1.8  O
 CCUPATIONAL PHYSIOLOGY FROM
A HISTORICAL PERSPECTIVE
People’s physical and mental preconditions and requirements when performing work
change only slowly from a historical perspective. Working life today, however, is
characterized by constant and rapid technical and organisational change, which can
quickly lead to major changes in the work life demands. Some professions disappear
through technical developments and because businesses relocate to other countries.
New professions appear. The majority of professions in working life remain, how-
ever, with more or less radical changes in their contents and technology, and thus in
the external exposures presented to the worker.
Work, Working Life, Occupational Physiology 15

One example of a profession that has undergone major change since the 1940s is
that of forestry work [Attebrant 1995]. In the 1940s and 1950s, work was still car-
ried out manually within many professions, including forestry. Trees were felled,
cut into lengths, and trimmed with a handsaw and an axe. The logs were handled
manually. This implied heavy physical loads, but it also imposed a limit on produc-
tivity. In ­addition, forestry work was markedly seasonal, as it was primarily carried
out during the winter. On the other hand, the work was flexible, and the worker
determined to a considerable extent when he wished to work, for how long, and on
what tasks. During the 1940s, a shortage of lumberjacks arose, which is why some
forestry companies initiated time and motion studies to examine how a more stan-
dardized time scheme might contribute to a more efficient use of labour. In connec-
tion with these time and motion studies, the trade also initiated studies in work
physiology to determine how the work should best be planned to achieve an optimal
time-line of exertion and recovery so as to achieve maximally efficient daily work.
The study showed that forestry work entailed high-energy metabolism correspond-
ing to an oxygen consumption of approximately 2.5 L/min on average during the
working day. This corresponds to approximately 10 times the energy metabolism
during rest (see Sections 2.4 and 2.6 in Chapter 2). The total energy metabolism was
approximately 21,000 kJ/day (for comparison, the turnover of a female office worker
is approximately 9700 kJ/day). The forestry worker’s heavy labour may thus have
led to a training effect. Measurements during the 1940s and 1950s showed that the
­forestry workers of those days were very fit. On the other hand, one problem told to
be significant among the forestry workers, if not supported by quantitative data, was
back pain.
During the 1950s, mechanical aids were introduced in forestry in the form of
power saws and barking machines. Productivity increased, but the total energy
metabolism of someone working in the trade was the same as in earlier days.
Mechanization within forestry continued, and during the 1960s forestry machines
were introduced. Many lumberjacks then became machine operators instead.
Productivity increased markedly. The poor ergonomic design of the driver’s seat,
badly placed and stiff control levers, and poor visibility resulted in awkward work
postures and high local load on the neck and shoulders. Forestry machine drivers
were also extensively exposed to vibrations and shaking. A considerable occurrence
of heavy tasks still remained, which provided physical variation from the otherwise
sedentary work in the driver’s seat. Even if the general workload, measured as energy
metabolism, decreased, the average heart rate over a working day was still approxi-
mately as high as in completely manual forestry work. The reason was probably that
the machine operators were less fit than those lumberjacks carrying out their work
entirely manually. The circulatory load in relation to the capacity was therefore still
high, as was the load on the back. In addition, local loads increased on the neck and
shoulders.
Continued mechanization during the 1970s resulted in a further reduction in gen-
eral metabolic load. The ergonomic design improved in the new forestry machines.
The older, poorly designed forestry machines, however, were still in use, and the
incidence of back pain and disorders of the neck and shoulder was still high or even
increasing. Within occupational physiology research, the focus shifted from studies
16 Occupational Physiology

of whole-body metabolism to investigations into local muscle loads. The load level
(amplitude, cf. Figure 1.1) was of primary interest.
During the 1980s and later, mechanization continued and marked ergonomic
improvements were made in order to reduce the local muscle load on the arms,
shoulders, and neck. Computers were introduced in forestry machines, which further
increased the opportunities of improving both quality and quantity in production.
The sophisticated machines and the high demands on productivity resulted in con-
siderable perceptual and cognitive requirements on the operator. The previously
heavy and dynamic manual forestry work had now been replaced by sedentary work
inside complicated machines, with small repetitive hand/arm movements to control
the small multifunctional levers and buttons, as well as exposure to high levels of
whole-body vibrations and great mental demands. At the beginning of the 1990s, the
sedentary and constrained work in forestry machines comprised 80% of a normal
working day in forestry, of which 90% of the time was occupied by repetitive control
movements.
A development similar to that in the forestry industry can be seen in many other
industries. Technical mechanization has successively reduced the general metabolic
load and, in many cases, also the level of the local muscle load on, for example, back
and neck/shoulder. This has, however, rarely resulted in the anticipated reduction in
the incidence of back, neck, and shoulder disorders. A likely cause is that the occur-
rence of prolonged sedentary work has increased, sometimes including repetitive
arm/hand movements and/or vibrations. As was the case with dentists in the descrip-
tion above, this has led to less variation in work postures and movements and fewer
natural breaks. Research from the 1980s and later indicates that there is no accept-
able minimal level for prolonged muscle load; even very low levels of load can be a
risk if they are sustained without variation or breaks for long periods of time (see
Chapter 6).
Thus, the development of occupational physiology can be explained primarily by
the need to solve the most obvious problems during different historical periods where
there has been an obvious conflict between the demands of work and the physical
and mental capacity and needs of people. Consequently, the focus during the period
from the 1940s to the 1970s was in general, whole-body physical load, emphasizing
energy metabolism, respiration, overall blood circulation, and temperature regula-
tion. During the 1970s and 1980s, the focus moved to the level of local loads on the
muscles. From the 1980s onwards, repetitive operations and low-level but prolonged
load, attracted more attention, including an increased focus on the time pattern of
work and recovery. The effects of mental and psychosocial factors at work on mus-
culoskeletal disorders, particularly in the neck/shoulder region, also received
increased attention from the 1980s onwards.

1.9  OCCUPATIONAL PHYSIOLOGY: THIS BOOK

In order to understand the ability of people to carry out their work and the effects
that this work may have in the short and long term, we need to understand how the
individual functions normally, both physically and mentally, and what bodily reac-
tions occur at different exposures. This is the kind of information offered by the
Work, Working Life, Occupational Physiology 17

great field of knowledge that is physiology, which in its turn can be divided into
subcategories, for example, work physiology, muscle physiology, and climate physi-
ology. In this book we bring together the different physiological areas that are rele-
vant to the study of people doing their jobs under the heading occupational
physiology.
The book concentrates on physiology of the healthy individual and how a lack of
balance between demands, capacity, and needs can lead to problems in physiologi-
cal adaptation. Physiological reactions in extreme work situations, for example,
among divers, firemen, or military aircraft pilots are only touched upon by way of
exception. The book does neither deals with sports physiology, nor with explicit
clinical physiology such as diagnosis, treatment, and rehabilitation of those with ill
health.
With these limitations, the book takes on eight commonly occurring types of
work which produce physical and/or mental loads, and therefore has an effect on
people’s well-being, performance, work ability, and health. The book deals with jobs
that entail

• Work demanding high-energy metabolism (Chapter 2)

• Work requiring considerable muscle force (Chapter 3)
• Work in awkward postures (Chapter 4)
• Work with highly repetitive movements (Chapter 5)
• Prolonged, low-intensity, sedentary work (Chapter 6)
• Work with high levels of mental load (Chapter 7)
• Work that disrupts the diurnal rhythm (Chapter 8)
• Work in heat and cold (Chapter 9)

Most professions entail several of these types of exposure at the same time; for
example, construction includes elements requiring a high-energy metabolism, a
large muscle force, work in extreme postures, repetitive movements, and perhaps
also work in heat and cold. Health care may require large muscle forces to be exerted
in uncomfortable postures, while the mental loads are also high, and the work is
performed in the middle of the night.
The model describing exposure and response (Figure 1.1) forms the basis for the
structure in each individual chapter. The chapters begin with a short story of a per-
son with a job typical for the exposures focused by the chapter. Next, some topical
questions are posed, which the chapter will answer. The occurrence in working life
of the exposures considered is described using statistical data from various coun-
tries, for example, the European Agency for Safety and Health at Work and the
European Foundation for the Improvement of Living and Working Conditions. The
chapters then discuss in greater detail the specific exposure and the normal physio-
logical responses to this. Fact boxes explain and provide greater detail on important
points. The chapters also discuss individual factors influencing how the external
exposure, the work—is translated into internal exposure—loads on the body—and
how the body responds to this internal exposure. The potential health effects of the
exposure and the probable mechanisms leading to pain and other problems are dealt
with. Each chapter then describes methods for assessing relevant exposures. Suitable
18 Occupational Physiology

interventions are also proposed against problematic working conditions of this kind.
The relevant laws and regulations are referred to, and the chapters conclude with a
short summary. A selection of key references and “Further reading” tips are to be
found after each chapter.
Even if the chapters focus on the physiology of the individual, they also provide
information and views on factors at the organizational and societal level determining
the working conditions for the individual. For example, several chapters deal with
the fact that the allocation of work tasks between individuals in an organization
determines the extent of variation in the work of that individual. Also, the laws and
regulations presented illustrate the framework that society has established for work.
The chapters may well be read in the order in which they occur, as certain basic
sections on energy metabolism, the structure and function of the musculoskeletal
system, and certain basic terminology are described in the first chapter in which they
are relevant and then referred to in the subsequent chapters. Otherwise, individual
chapters can be read separately.

REFERENCES
Attebrant, M. 1995. Ergonomic Studies of Lever Operations in Forestry Machines. Master’s
thesis. Lund: University of Lund.
Eurofound. 2007. Fourth European Working Conditions Survey. European Foundation for
the Improvement of Living and Working Conditions. http://www.eurofound.europa.eu/
pubdocs/2006/98/en/2/ef0698en.pdf
Nordenfelt, L. 2008. The Concept of Work Ability. Brussels: P.I.E. Peter Lang.
OSHA/EU. 2007. European Agency for Safety and Health at Work. http://osha.europa.eu/­
topics/msds/facts_html
Swedish Social Insurance Agency. 2008. Social Insurance in Figures 2008. http://www.for​
sakringskassan.se/irj/go/km/docs/fk_publishing/Dokument/Statistik/ohalsostatistik/
sfis08_e.pdf
SWEA. 2008. Work-Related Disorders 2008. Swedish Work Environment Authority. http://
www.av.se/dokument/statistik/officiell_stat/ARBORS2008.pdf
SWEA. 2010. Occupational Accidents and Work-Related Diseases 2009. Swedish Work
Environment Authority. Report 2010:1. http://www.av.se/dokument/statistik/officiell_
stat/STAT2010_01.pdf
WHO. 2003. International Classification of Functioning, Disability and Health—ICF. http://
www.who.int/classifications/icf/en
 2 Work Demanding High
Energy Metabolism
Ewa Wigaeus Tornqvist

Photo:  Rolf NystrÖm

CONTENTS
2.1 Focus of the Chapter and Delimitations vis-à-vis Other Chapters.................. 21
2.2 Prevalence of Demands for High Energy Metabolism in Working Life......... 21
2.3 Energy Metabolism and Physiological Adaptation with Increased
Energy Demand............................................................................................... 22
2.4 Energy Metabolism..........................................................................................24
2.4.1 Type of Work.......................................................................................26
2.4.2 State of Fitness.....................................................................................26
2.4.3 Diet...................................................................................................... 27
2.5 Mechanical Efficiency..................................................................................... 27
2.6 Oxygen Uptake................................................................................................ 29
2.7 Pulmonary Ventilation..................................................................................... 31
2.8 Blood Circulation............................................................................................. 33
2.9 Factors Affecting Individual Load at a Particular External Exposure............ 36
2.9.1 Factors at Work.................................................................................... 36
2.9.1.1 Dynamic and Static Muscle Work........................................ 36
2.9.1.2 Work by Small Muscle Groups............................................. 37
2.9.1.3 Breaks................................................................................... 37
2.9.1.4 Equipment.............................................................................40

19
20 Occupational Physiology

2.9.2 Environmental Factors.........................................................................40

2.9.2.1 Ambient Temperature...........................................................40
2.9.2.2 Humidity............................................................................... 41
2.9.2.3 Height Above Sea Level........................................................ 41
2.9.3 Individual Factors................................................................................ 42
2.9.3.1 Gender................................................................................... 42
2.9.3.2 Age........................................................................................ 43
2.9.4 Lifestyle Factors..................................................................................44
2.9.4.1 Physical Activity and Exercise..............................................44
2.9.4.2 Use of Tobacco...................................................................... 45
2.10 Measuring Occupational Energy Demands..................................................... 45
2.10.1 Technical Measurements.....................................................................46
2.10.1.1 Oxygen Consumption...........................................................46
2.10.1.2 Pulmonary Ventilation.......................................................... 47
2.10.1.3 Heart Rate............................................................................. 47
2.10.2 Observation or Self-Reporting............................................................. 49
2.11 Demands of Work in Relation to Physical Work Capacity.............................. 49
2.11.1 Relative Oxygen Uptake...................................................................... 50
2.11.1.1 Maximal Test........................................................................ 50
2.11.1.2 Submaximal Test.................................................................. 51
2.11.2 Relative Heart Rate Increase............................................................... 53
2.12 Effects of High-Energetic Load....................................................................... 54
2.12.1 Short-Term Effects............................................................................... 54
2.12.2 Long-Term Effects............................................................................... 54
2.13 Recommended Exposure Limits..................................................................... 55
2.14 Measures in Work Requiring High Energy Metabolism................................. 56
2.15 What Does the Law Say About Working with a High Energy
Metabolism?..................................................................................................... 56
2.16 Summary......................................................................................................... 57
References................................................................................................................. 57
Further Reading........................................................................................................ 58

John is 26 years old and has been working for about a year as a bicycle messenger in
Stockholm. John chose the job to earn money for a planned trip around the world and
to develop his physical capacity before setting out. His work includes delivering vari-
ous items of mail to different addresses. His tasks during the working day are con-
veyed to him continuously by two-way radio. John is employed on an hourly basis,
but works full time (40 h a week) and he works at piece rate. A typical working day
involves cycling between 70 and 100 km and usually delivering 20–40 items. John
cycles for ~80% of his working day, that is to say over 6 h a day, while the rest of his
working time involves collecting/delivering items of mail and waiting for new
assignments. In order to earn as much as possible, John cycles as quickly as he can.
He thinks it is hardest to cycle in the centre of the town as he then feels stressed from
all the traffic; additionally, he thinks all the exhaust gases and other air pollution he
breathes in are annoying. On very hot summer days, the work feels particularly
strenuous, and his performance on days like that is lower than normal. When it is
Work Demanding High Energy Metabolism 21

very cold and windy in winter, John finds it difficult to dress correctly so that he does
not freeze, but will not feel too hot when he is cycling quickly. It is particularly
­difficult when it is icy and the roads are slippery. John has studded tyres on his bike
in the winter, but he has nevertheless fallen down once. Admittedly, that time he got
away with just a few scratches, but he thinks it is unpleasant to cycle in traffic when
it is icy. Although John has good physical work ability, he is often so tired after work
that he does not feel up to any social activities.

2.1  F OCUS OF THE CHAPTER AND DELIMITATIONS

VIS-À-VIS OTHER CHAPTERS
Working as a bicycle messenger is heavy physical work characterized by high energy
metabolism, and which puts great demands on the body’s ability to take up oxygen
[Bernmark et al. 2006]. The muscle work is dynamic; that is, the muscles alternate
between contracting and relaxing, as in cycling and walking, for example. Heavy
dynamic work by large muscle groups makes demands on high energy metabolism
and increases the load on the respiratory and circulatory system, which is the focus of
this chapter. The load on the circulatory system increases more if the work is carried
out under heat exposure, for example, on hot summer days, which is described in
Chapter 9. Heavy dynamic work also imposes great demands on muscle force, but the
local load on individual regions of the body is usually not as great as in heavy lifting.
Work demanding great muscle force is dealt with in Chapter 3. Work demanding great
energy metabolism differs appreciably from sedentary work, for example, computer
work, both as regards the load on the respiratory and circulatory system and the load
on the muscles. Prolonged low-intensity and sedentary work is treated in Chapter 6.
This chapter will take up the following issues:

• What happens in the body during heavy physical work?

• What factors influence the internal load on the body at a certain energy
metabolism?
• How can we measure the demands of work on energy metabolism?
• How can we assess the demands of work on energy metabolism in relation
to the individual’s physical capacity?
• What are the effects of heavy physical work on performance, well-being,
and health?
• What exposure limits have been proposed?
• What measures can we take to deal with inappropriately high energy
metabolism?
• What do laws, regulations, and ordinances have to say?

2.2  P
 REVALENCE OF DEMANDS FOR HIGH ENERGY
METABOLISM IN WORKING LIFE
Rapid industrial mechanization has reduced the energetic load in many classically
heavy industries and sectors such as forestry and agriculture, and the iron and steel
industry. The structural transformation of the 1990s also brought with it a reduction
22 Occupational Physiology

in the number of many physically heavy, particularly unqualified, working-class jobs.

Despite this, the proportion of all working men in Sweden reporting heavy physical
labour, so that breathing becomes more rapid at least a quarter of the time, has
remained constant at around 20% since the end of the 1980s (own adaptation of
Statistics Sweden’s Work Environment Surveys 1989–2001) and even increased
somewhat to ~24% during the latter half of the 2000s [SWEA 2009]. No correspond-
ing international statistics are available, but the prevalence is probably about the
same in other industrial countries. One explanation may be increased rate of work
reported both in the statistics and by research. Those occupational groups reporting
heavy physical work, according to the above, are to be found primarily within agri-
culture, forestry, horticulture, and fishing, craft work within the building industry
and manufacturing, as well as postal delivery workers (bicycle messengers cannot be
distinguished in the statistics). Approximately 13% of all women employed in Sweden
report heavy physical work according to the above. The proportion has increased
continuously, from ~9% at the end of the 1980s to ~13% during the latter half of the
2000s [SWEA 2009]. The women are primarily to be found within agricultural and
horticultural work, nursing and care work, hotel and office cleaning, warehousing,
and as postal delivery workers. The increased work rate reported ­generally in work-
ing life is presumably especially obvious within certain female-­dominated occupa-
tional groups in the public sector, such as nursing and care work, for example, where
major staff cuts were made during the 1990s at the same time as the need for care
increased rather than decreased. These changes presumably help explain the fact that
the proportion of women reporting heavy work has increased since the end of the
1980s. Heavy work within many female-dominated service occupations may be
expected to continue to increase, as the need for nursing and care of the elderly is
increasing because of demographic change. The problem of heavy physical work is
also exacerbated by the fact that employees are becoming older, as their physical
capacity declines with increasing age. The proportion who are 55 years of age and
older has increased by 5% points since 1990, and now comprises one-fifth of working
people in Sweden. The proportion of older employees is expected to increase for
some years until the large population groups born in the 1940s retire.
The results of the work environment surveys mentioned above agree reasonably
well with the results in a Swedish sample of the general population, where ~24% of
the men and 11% of the women were assessed as having high energetic load [Wigaeus
Tornqvist et al. 2001].

2.3  E NERGY METABOLISM AND PHYSIOLOGICAL ADAPTATION

WITH INCREASED ENERGY DEMAND
The energy requirement varies greatly between different occupations (Figure 2.1). In
light physical work, for example, sedentary computer work, the energy metabolism
increases during the work to approximately twice the basal metabolic rate, while in
very physically demanding jobs, for example, a bicycle messenger, the energy metabo-
lism may increase to six times the basal metabolic rate. For a man weighing 75 kg, the
basal metabolic rate (seated at rest) is ~7560 kJ/day (see also Section 2.4).
Work Demanding High Energy Metabolism 23

8 METs

6 METs
(about 18 km/h)

4 METs
2 METs

1.5 MET

1 MET

FIGURE 2.1  Energy metabolism at rest and for different tasks, expressed as multiples of
basal metabolic rate, METs. One MET corresponds to the energy metabolism seated at rest
(4.2 kJ/kg of body weight and hour). (Adapted from Ainsworth BE. et  al. 1993. Med. Sci.
Sports Exerc. 25(1):71–80.) Illustration: Niklas Hofvander.

The basal metabolic rate per kilogram of body weight is somewhat lower in
women compared with men, because women have a greater proportion of fatty ­tissue,
whose metabolic activity is low. Basal metabolism also varies between individuals of
the same gender and a basal metabolic rate of 10% above or below the mean value is
not unusual. These individual differences may explain why certain people can
remain slim, while others increase in weight, even if they both eat the same amount
and are equally physically active.
Human beings are adapted to movement and physical activity. Physical activity
demands energy, and the skeletal muscles are unique compared with all the other
tissues of the body in their ability to increase energy metabolism. In extremely physi-
cally demanding activities, the energy metabolism normally increases to 10–20
times the basal metabolic rate; for elite athletes with extremely high physical capac-
ity, it can be up to 30 times the basal metabolic rate. The difference between different
individuals’ energy metabolism, therefore, results mainly from the degree of muscle
work (Figure 2.1).
The ability to perform physical work is dependent on the ability of the muscles
to convert chemically bound energy in the food into mechanical energy in the form
of muscle work. In heavy dynamic muscle work in which large muscle groups are
involved, oxygen uptake ability is of great significance for the release of enough
energy for muscle work. Work of this kind results in a load on respiratory and circu-
latory systems. The internal load on the individual depends on how great a propor-
tion of the individual’s maximum capacity is used in the work. In healthy individuals,
it is primarily the size of the heart’s stroke volume that determines the individual’s
maximal oxygen uptake capacity (VO2 max L/min, where V stands for the volume
and O2 is the chemical symbol for oxygen). VO2 max by definition corresponds to
24 Occupational Physiology

the maximum volume of oxygen uptake per unit of time that can be measured in an
individual. This ability varies considerably between different individuals, depend-
ing on individual factors such as heredity, age, gender, and state of health, as well as
lifestyle factors such as physical training. In maximum work a fit 30-year-old man
with “good” genes (as regards physical capacity) can increase his energy metabolism
~20 times compared with basal metabolic rate, while the corresponding increase for
an unfit 50-year-old woman with less “good” genes is 5–10 times.

2.4  ENERGY METABOLISM

The nutrients that the body needs consist of carbohydrates, fats, proteins, minerals,
vitamins, and water. These substances have to be supplied to (1) cover the body’s
energy needs, (2) cover the need for substances to build various tissues, (3) cover the
need for substances to build up enzymes, hormones, and other important substances,
and (4) replace the body’s losses of important substances. Of these nutrients, it is
only carbohydrates, fats, and proteins whose energy content can be converted from
chemically bound energy into mechanical energy for muscle work. Carbohydrates
exist in the form of glucose in the blood and are stored in the form of glycogen in the
liver and muscles. Proteins are used primarily for construction and renovation work
in the body. The chemically bound energy that is converted, but not used for mechan-
ical energy for muscle work, is converted into heat (see Section 2.5).
The energy metabolism increases linearly with increased work load. Under nor-
mal circumstances, presupposing adequate energy supply, carbohydrates, and fats
are (mainly) oxidized with the help of oxygen into carbon dioxide and water, the so-
called aerobic oxidation. The chemically bound energy in the nutrients is converted
and used partly to form adenosine triphosphate (ATP). ATP is an energy-rich sub-
stance which, when it breaks down, can directly transfer its energy to mechanical
work in a muscle contraction. Under circumstances when the oxygen supply is not
sufficient for an aerobic oxidation, the conversion of energy occurs anaerobically,
and then the carbohydrates are converted without the presence of oxygen, whereby
lactic acid is formed (Figure 2.2).
Anaerobic metabolism can only contribute energy for a very short period, which
is why the body is dependent on aerobic metabolism to maintain the necessary ATP
level. The supply of energy for muscle work lasting for more than a minute or so is
therefore dependent on oxygen supply and the supply of fat and carbohydrates, as
well as necessary enzymes (a substance needed for a certain chemical reaction to
take place).
In anaerobic metabolism, energy is released very quickly, but the stock is very
limited. The speed with which energy is released in aerobic oxidation of carbohy-
drates, and particularly fats, is considerably slower, but the depots are considerably
greater, particularly those of fat. There is an inverse proportionality between the size
of the energy stock and the speed whereby the energy is released (Table 2.1).
The energy metabolism per day at rest is ~6000 kJ for a woman weighing 60 kg and
7600 kJ for a man weighing 75 kg (see also Fact Box 2.1). In physically light occupa-
tions the energy metabolism is ~9200 kJ for a woman and 12,400 kJ for a man, while
a moderately heavy job requires ~10,500 and 15,300 kJ/day, respectively.
Work Demanding High Energy Metabolism 25

ATP ADP + P + energy

CrP + ADP Cr + ATP

Fatty acids Protein Carbohydrate

(glycogen, glucose) Anaerobical
+ NH2 –NH2
+ Energy – Energy

Pyruvate Lactic acid

Acetyl-CoA

O2
Kreb’s citric acid cycle Aerobical
Respiratory chain

CO2 + H2O + energy for building up ATP

FIGURE 2.2  Build-up of ATP in a cell. In the fission of ATP, energy is released, which is
transferred directly, for example, to mechanical work in a muscle cell. The energy released in
other types of metabolism is used to build up ATP. The metabolism of ATP and creatine
phosphate (CrP) and of carbohydrate to lactic acid, via pyruvate, occurs without oxygen, that
is, to say anaerobically. Fatty acids and pyruvate (from carbohydrate and protein) are metabo-
lized with the help of oxygen—that is, aerobically—in Krebs’ citric acid cycle. (Adapted
from Åstrand I. 1990. Arbetsfysiologi. 4th ed. Stockholm: Norstedts förlag (in Swedish),
p. 16. With permission.)

TABLE 2.1
Energy Sources for Muscular Work
Energy Source Body’s Store (kJ) Time (min) Relative Speed
ATP, CrPa in muscles and anaerobic 80 1 1.0
metabolism of carbohydrates
Oxidation of blood glucose 320 4 0.5
Oxidation of liver glycogen 1500 18 0.5
Oxidation of muscle glycogen 6000 70 0.5
Oxidation of fat 33,700 4018 0.25

Source: Data from Jones DA., Round JM. 1990. Skeletal Muscle in Health and Disease. Manchester and
New York, NY: Manchester University Press.
Note: The values for the total size of energy storage (the body’s store) in kJ, the time the energy source
last would last as a sole energy source in work corresponding to 80% of maximum aerobic capacity
and the relative speed for the release of energy.
a Creatine phosphate, which is used for building up ATP from adenosine diphosphate, see Figure 2.2.
26 Occupational Physiology

FACT BOX 2.1

Basal metabolic rate

• Energy metabolism is often expressed in multiples of the basal meta-

bolic rate, so-called metabolic units or METs.
• One MET corresponds to the energy metabolism seated at rest.
• Seated at rest ~4.2 kJ (1 kcal) per kg of body weight is expended per
hour (4.2 kJ × kg−1 × h−1).

The relative proportion of carbohydrate and fat metabolism, respectively, depends

primarily on the following factors:

1. Type of work: intensity and duration

2. State of fitness: fit or unfit individuals
3. Diet: carbohydrate-rich or carbohydrate-poor diet

2.4.1  Type of Work

At rest, or during shorter periods of light-to-moderately heavy physical work, carbohy-
drates and fat contribute approximately equally to the energy supply (presupposing that
the individual eats a normal varied diet) (Figure 2.3). When the work load increases, a
gradual increase occurs in the proportion of carbohydrates metabolized, which is effec-
tive from an energy viewpoint, as the amount of energy released in the metabolism of 1 L
of oxygen is higher in carbohydrate metabolism than in fat metabolism. In very heavy,
almost maximal, work it is carbohydrates that represent 100% of the energy supply
(Figure 2.3). At such a high level of workload the oxygen supply is insufficient, and the
carbohydrates are partly metabolized anaerobically, whereby there is an accumulation of
lactic acid, which means that the functional capacity of the muscle cells deteriorates.
The longer the work continues, the higher the proportion of fat metabolized. In
moderately heavy work, which can go on for 4–6 h (including rest breaks, but with-
out the supply of nutrients), fat can contribute up to 60–70% of energy metabolism.
Although carbohydrate metabolism declines in prolonged moderately heavy work,
the supply of carbohydrates may limit endurance as a result of limited stocks. In
work corresponding to 75% of the individual’s maximal aerobic capacity, the glyco-
gen level in the muscles drops successively and reaches zero after one-and-a-half
hours of work. The more glycogen is available from the beginning, the longer the
work can continue. The glycogen levels can be increased by consuming carbohy-
drate-rich food. By initially emptying the glycogen stores through eating carbohy-
drate-poor food, the depots are stimulated to restock with extra glycogen.

2.4.2  State of Fitness

The ability to make use of fat as a fuel depends on the capacity for oxygen transport.
The proportion of fat metabolism at a particular work load depends on the proportion
Work Demanding High Energy Metabolism 27

Fat Carbohydrate

0% 100%

50% 50%

100% 0%

20 40 60 80 100
Percentage of maximal oxygen uptake

FIGURE 2.3  The proportion of fat and carbohydrate metabolism at different work loads
expressed as a percentage of the subject’s maximal oxygen uptake. The proportion of carbo-
hydrate metabolism increases with increasing work load after ~50% of maximal oxygen
uptake. (Adapted from Åstrand PO. et al. 2003. Textbook of Work Physiology. Physiological
Bases of Exercise. 4th ed. Champaign, IL: Human Kinetics, p. 373. With permission.)

of the maximal aerobic capacity used (Figure 2.3). As physical exercise can increase
the individual’s maximal aerobic capacity (VO2 max/min), the ability to make use of
fat as an energy source at a particular oxygen uptake also increases. In prolonged
work, it is a great advantage to be able to use more fat for oxidation, as the fat stores
are definitely greater than the carbohydrate stores (Table 2.1). Furthermore, as fit
individuals use a smaller proportion of their maximal aerobic capacity in work at a
particular work load, the production of lactic acid is lower in fit people compared
with that in unfit people.

2.4.3  Diet
Adaptation to a fat-rich and carbohydrate-poor diet results in lower glycogen levels
in the muscles and liver, and this results in an increased fat metabolism during work
to save glycogen.

2.5  MECHANICAL EFFICIENCY

Some of the chemically bound energy converted in metabolizing various sub-
stances is turned into heat. This heat production means that the human body tem-
perature can be kept relatively constant at 37°C, even though the ambient
temperature is often lower. In muscle work, relatively large amounts of heat are
produced, and during dynamic work by large muscle groups 70–75% of the energy
28 Occupational Physiology

TABLE 2.2
​Maximal Efficiency in Different Physical Operations
Activity Efficiency (%)
Walking uphill on a 5° slope, without load 30
Walking on a level surface, without load 27
Cycling 25
Going up and down the stairs, without load 23
Using a heavy hammer 15
Lifting weights  9
Shovelling in an upright posture  6
Using a screwdriver  5
Shovelling in stooped posture  3

Source: Data from Kroemer KHE., Grandjean E. 1997. Fitting the Task to the Human. A Textbook of
Occupational Ergonomics. 5th ed. London: Taylor & Francis.

metabolism is ­converted into heat. The mechanical efficiency of the human

being—that is, the proportion of the total energy metabolism used to carry out
external work—therefore reaches a maximum of 30%. Usually, however, the
mechanical efficiency is lower. In work by small muscle groups, primarily work
with the arms, and elements of static working operations, for example, in work
with non-neutral work postures, the mechanical efficiency is considerably lower
(Table 2.2).
The heavier the work, the more heat formed, which must be emitted so that the
body does not overheat. Blood circulation to the skin increases in order to increase
heat transport from the working muscles out to the surface of the body. The secre-
tion of sweat increases in order to increase heat transfer (see also Sections 2.8 and
2.9.2 as well as Chapter 9). Every litre of sweat that evaporates from  the skin
means a heat transfer corresponding to 2450 kJ. Although heat transfer increases
with physical work, the core body temperature also increases. Normally, core
body temperature is dependent on the relative work load, that is, the proportion of
the individual’s VO2 max that is used. The increase in body temperature is con-
sidered to be an active regulator for creating a gradient for heat flow from the core
of the body to the skin and to stimulate sweating. In work at a particular work
load, the body temperature increases continuously for ~40–50 min, and then lev-
els off at a level dependent on the relative workload. The correlation between
body temperature (T) and relative load (VO2/VO2 max) can be described using the
formula

T = 36.5 + (3.0 × VO2 /VO2 max)

In John’s job as a bicycle messenger, he uses on average 30% of VO2 max (see Section
2.11.1) and reaches a body temperature of ~37.4°C.
Work Demanding High Energy Metabolism 29

2.6  OXYGEN UPTAKE

For practical use it is difficult to measure energy metabolism directly, as this
requires measuring the amounts of carbohydrate, fat, and protein supplied and used
respectively, how great the body’s energy stores are, and how they have changed.
Oxygen uptake, like energy metabolism, increases linearly with increasing work
load (Figure 2.4). Energy metabolism can therefore be measured indirectly on the
basis of what is known as the energy coefficient by measuring oxygen uptake. The
energy coefficient is the amount of energy metabolized when 1 L of oxygen is used.
In practical use we use an energy coefficient of 20 kJ (20.2 kJ at rest and 20.6 kJ
at work).
The volume of oxygen (VO2) used in an average adult while seated at rest corre-
sponds to ~3.5 mL/kg of body weight per minute (3.5 mL O2 × kg−1 × min−1). A per-
son weighing 75 kg therefore uses ~0.26 L of oxygen per minute at rest, which equals
an energy metabolism of ~5.25 kJ/min or 7560 kJ/day. While oxygen uptake  for
maximal work (VO2 max/min) in a young, fit man can increase to perhaps 5 L/min,
that is to say ~20 times the basal metabolic rate, the corresponding value for an older
unfit woman can be 1.5 L/min. For a woman weighing 75 kg, this means barely a
sixfold increase on basal metabolic rate, but if she weighs, for example, 52 kg this
means that she can increase her basal metabolic rate of ~0.18 L/min by a good
eight times.

4.0 4.0
Watt

Lactic acid concentration, mmol/L

300
250
8
Oxygen uptake, L/min

3.0 3.0
200
6
150
2.0 2.0

100 4

1.0 50 1.0
2

0 1 2 3 4 5 min 100 200 300 Watt

FIGURE 2.4  Oxygen uptake at submaximal and maximal levels in an individual. On the
left oxygen uptake is illustrated at varying work loads in relation to time; on the right, oxygen
uptake measured every 4–5 min and the corresponding lactic acid concentrations in the blood
are shown. Solid line = oxygen uptake; broken line = lactic acid concentration. Oxygen
uptake at 50 W is ~0.9 L/min, and at 100 W is ~1.5 L/min. This individual’s maximal oxygen
uptake is reached at an intensity of 250 W. Note that the lactic acid concentration in the blood
begins to increase markedly after 50% of the aerobic capacity has been reached. Lactic acid
formation derives primarily from the beginning of the work. (Adapted from Åstrand PO.,
Rodahl K. 1986. Textbook of Work Physiology. 3rd ed. New York, NY: McGraw-Hill Book
Co., p. 300. With permission.)
30 Occupational Physiology

VO2
L/min
End of work
3.0

2.0
Oxygen debt
Oxygen deficit
1.0

1 2 3 4 5 6 7 8 9
Minutes

FIGURE 2.5  Oxygen uptake (VO2 L/min) increases at the beginning of moderately heavy
work until a level is reached where the uptake corresponds to the tissues’ need for oxygen,
what is called steady state. During the first minutes therefore an oxygen deficit arises. After
the end of the work oxygen uptake drops slowly, the oxygen debt is repaid. Basal metabolism
is ~0.25 L/min. (Adapted from Åstrand I. 1990. Arbetsfysiologi. 4th ed. Stockholm: Norstedts
förlag (in Swedish), p. 38. With permission.)

At the beginning of dynamic physical work the oxygen uptake increases until
what is called a steady state is possibly reached, when the uptake of oxygen corre-
sponds to the demands of the muscles (Figure 2.5). It takes several minutes to adapt
breathing and circulation from the basal metabolic rate to the increased demands
of physical work. During this so-called oxygen deficit the demands of the muscles
for oxygen are not being met by the oxygen supplied through circulation. In light
physical work, the amount of oxygen that is stored in the myoglobin is sufficient
for energy metabolism to occur aerobically, despite the fact that the oxygen supply
through the circulation has not had time to adapt to the increased demands. With
somewhat heavier work, the oxygen in the myoglobin is insufficient, and the energy
is provided partly anaerobically, whereupon lactic acid is produced. The heavier
the work, the more lactic acid is produced at the beginning of the work (Figure 2.5).
If we want to find out how much oxygen a particular job demands, the work has
to continue for at least 3–4 min so that we can be sure that we have reached this
steady state.
At a higher work load the oxygen uptake increases, and it levels out at a higher
steady-state level (Figure 2.4). When the work load becomes very high, the
amount of oxygen taken up is insufficient for the work to be performed with aero-
bic energy supply, and precisely as at the beginning of the work the energy supply
is partially anaerobic. The higher the load, the more anaerobic the energy supply
and the higher the lactic acid concentration in the working muscles and in the
blood (Figures 2.4 and 2.6). The lactic acid concentration in the blood begins to
increase appreciably after ~40–50% of maximal aerobic capacity has been reached
(Figure 2.6). If the work continues at this higher load, lactic acid accumulates in
the muscles and blood, and the stiffness, fatigue, or aches then felt in the working
muscles probably result from the lower pH value. The slow decline in oxygen
uptake after the end of work results from the fact that the so-called oxygen debt
Work Demanding High Energy Metabolism 31

15
Skating

Lactic acid concentration, mmol/L

Cycling

10

25 50 75 100
Percentage of maximal aerobic capacity

FIGURE 2.6  Lactic acid concentration in the blood at different loads expressed as a per-
centage of maximal oxygen uptake during cycling and speed skating. Note the higher lactic
acid concentration in skating compared with cycling. The static load on the thigh muscles
resulting from the “sitting work posture” in speed skating results in poorer efficiency com-
pared with dynamic cycling. (Adapted from Ekblom B., Hermansen L., Saltin B. 1967.
Hastighetsåkning på skridsko. Idrottsfysiologi, Rapport no 5. Stockholm: Framtiden. With
permission.)

from the beginning of the work, and possibly during the work, has to be paid back
(Figure 2.5).
Compared with dynamic work—that is, alternation between contraction and
relaxation—the blood circulation in static muscle contractions (see Chapter 6,
Section 6.6) is often impaired and oxygen supply can therefore be insufficient,
whereupon the anaerobic supply of energy increases and lactic acid is formed.
Impaired blood circulation also results in impaired removal of metabolites, which
further influences the accumulation of lactic acid, for example (cf. the lactic acid
concentration in the blood in cycling and in skating, respectively, in Figure 2.6).

2.7  PULMONARY VENTILATION

In the transition from rest to physical work, pulmonary ventilation (litres of air
per minute) increases to accommodate the increased oxygen requirement in the
blood and to vent the excess of carbon dioxide. In light-to-moderately heavy phys-
ical work, pulmonary ventilation increases linearly with an increase in oxygen
uptake (Figure 2.7). After this, pulmonary ventilation increases more per litre of
oxygen taken up as we get closer to the individual’s maximal aerobic capacity.
This so-called hyperventilation is caused by acidic products, for example, lactic
acid, from energy metabolism. The degree of acidity in the blood stimulates the
respiratory centre to increase pulmonary ventilation to vent the excess carbon
dioxide.
32 Occupational Physiology

200

180

Pulmonary ventilation, L/min 160

140

120

100

80

60

40

20

1 2 3 4 5 6
Oxygen uptake, L/min

FIGURE 2.7  Pulmonary ventilation increases with an increase in oxygen uptake. The lines
correspond to the values for four different people in dynamic work with large muscle groups
(cycling or running). The stars (*) represent individual values from elite sportsmen in connec-
tion with the determination of maximal aerobic capacity. Most individuals with a maximal
oxygen uptake higher than 3.0 L/min lie within the shaded area. (Adapted from Åstrand P-O.
et al. 2003. Textbook of Work Physiology. Physiological Bases of Exercise. 4th ed. Champaign,
IL: Human Kinetics, p. 190. With permission.)

When John is exposed to air pollution on streets with dense traffic, the uptake of
pollutants into his body increases (internal exposure) when he cycles fast, because
pulmonary ventilation and blood circulation to the lungs increase (see also Section
2.8 and Fact Box 2.2).

FACT BOX 2.2

The body’s physiological adaptation to higher energy demands can increase
the risk of negative effects of exposure to different kinds of air pollution.
If someone works in an environment with air pollutants, their body is
subjected to a greater internal exposure to pollutants during physical work
compared with being at rest. The greater pulmonary ventilation increases the
amount of pollutants inhaled, and if the substance dissolves in the blood it is
distributed through the vascular system to various organs in a greater quantity
Work Demanding High Energy Metabolism 33

per unit of time during work, compared with at rest. It is important to bear this
in mind in connection with a discussion of the effects of exposure to air pollut-
ants that exist at workplaces or generally in the surrounding environment. For
substances easily absorbed into the blood and fatty tissues, such as the brain,
for example, the risks of central nervous system effects, (e.g., slower reaction
times in exposure to solvents) are greater during physical work than at rest.
Another organ that is sensitive to pollutants is the liver, which functions as the
body’s treatment plant by breaking down pollutants into metabolites which can
be excreted from the body. The impaired liver perfusion that occurs in heavy
physical work, as compared to rest, can result in an impairment of the metabo-
lism and excretion of various pollutants.

2.8  BLOOD CIRCULATION

In the transition from rest to heavy physical work, oxygen uptake—as has previously
been mentioned—may increase up to 30 times at the same time as the cardiac out-
put; that is, the total blood circulation (heart rate × stroke volume) increases fivefold.
The greater increase in oxygen uptake compared with the cardiac output is due to a
greater proportion of the oxygen content of the blood being used in heavy work; that
is, the oxygen content in mixed venous blood decreases, and the so-called arterio­
venous oxygen difference increases (Figure 2.8). According to Fick’s principle,

Oxygen uptake (VO2 ) = cardiac output (Q)

× arteriovenous oxygen difference [(a − v )O2 diff ]

The cardiac output increases linearly with an increase in oxygen uptake, from
~5 L/min at rest to ~25 L/min at 70–80% of maximal aerobic capacity (Figure 2.8).
The increase is achieved partly through the heart rate in most cases increasing lin-
early with greater oxygen uptake, and partly through the stroke volume increasing on
a rising curve, reaching its maximum value at 40–50% of the maximum aerobic
capacity. At rest the heart rate is normally ~60 beats/min and the stroke volume is
~80 mL, increasing to ~200 beats/min and 125 mL, respectively, at maximum work.
Individual variations, however, are great, which is described below.
The increase in the arteriovenous oxygen difference results partly from an actual
increase in oxygen use per volume unit of blood in the working muscles, and partly
from a redistribution of the circulating blood volume, so that a much larger propor-
tion of the blood supply goes to the working muscles (Figure 2.9). The higher the
haemoglobin content in the blood, the higher the oxygen content in the arterial blood.
Women have on average a lower haemoglobin content compared with men (on aver-
age 13.9 g and 15.8 g/100 mL of blood, respectively), which results in a lower arterial
oxygen content in women—~16 mL compared with ~19 mL of oxygen/100 mL of
blood, and thus a lower arteriovenous oxygen difference, which presumably explains
the moderately higher cardiac output in women at a particular oxygen uptake. At rest
the oxygen content in mixed venous blood is ~10–12 mL/100 mL of blood dropping
34 Occupational Physiology

Systolic blood pressure

Diastolic blood pressure

a – v O2 diff

Cardiac output

Stroke volume

Heart rate

25 50 75 100
Percentage of maximal aerobic capacity

FIGURE 2.8  Heart rate, cardiac output, arteriovenous oxygen difference, and systolic blood
pressure increase with a rise in oxygen uptake or work load. The stroke volume normally
reaches maximum value at ~40–50% of maximal aerobic capacity. O = arterial oxygen con-
centration (a), ▲ = oxygen concentration in mixed venous blood (v ). (Adapted from Åstrand
I. 1990. Arbetsfysiologi. 4th ed. Stockholm: Norstedts förlag (in Swedish), p. 71.)

to ~2 mL/100 mL of blood in very heavy work, while the oxygen content of venous
blood from a hard-working muscle can be zero.
Out of the cardiac output at rest of ~5 L/min, about 80–85% is distributed to the
internal organs, and 15–20% to the skin and muscles (Figure 2.9). During heavy
work, the figures are reversed: 80–85% of the cardiac output of ~25 L/min is directed
to the skin and muscles, while 15–20% goes to the internal organs. In absolute ­figures,
Work Demanding High Energy Metabolism 35

Organ/tissue Blood flow Blood flow

at rest during heavy physical work

Blood from the heart 5 L/min 25 L/min

(cardiac output) 100% 100%
Coronary vessels 0.2 L/min 1 L/min
4–5% 4–5%
Gastrointestinal tract 1.25 L/min 0.75 L/min
25–30% 3–5%
Kidneys 1 L/min 0.5 L/min
20–25% 2–3%
Central nervous system 0.75 L/min 1.25 L/min
15% 4–6%
Skeleton 0.15 L/min 0.125 L/min
3–5% 0.5–1%
Skin 0.25 L/min
5%
Muscles 0.75 L/min 20 L/min
15–20% 80–85%

Cardiac output Rest Organ/tissue Heavy work Cardiac output

5 L/min L/min L/min 25 L/min

0.2 Coronary vessels 1

1.25 Gastrointestinal tract 0.75
1 Kidneys 0.5
0.75 Central nervous system 1.25
0.15 Skeleton 0.125
0.25 Skin
0.75 20
Muscles

FIGURE 2.9  Cardiac output can increase by a factor of five in the transition from rest to
very heavy physical work, and at the same time the relative distribution of blood flow to vari-
ous organs changes. Notice the marked increase in blood flow to the skin and muscles in
heavy work. The blood flow to the vessels of the heart itself and to the central nervous system
also increases in heavy physical work. (Adapted from Åstrand I. 1990. Arbetsfysiologi. 4th
ed. Stockholm: Norstedts förlag (in Swedish), p. 70.)

this means a 20-fold increase in blood flow to skin and muscles, from ~1 L/min at
rest to 20 L/min during heavy work. The blood flow to various organs is regulated by
changes in the diameter of the smallest arteries (the arterioles). In increased muscle
work, when the need for oxygen to the working muscles increases, the vessels dilate
(vasodilation) while they contract (vasoconstriction) when there is less need for oxy-
gen. Apart from skin and muscles, the lungs also of course receive greatly increased
blood circulation, but in absolute figures the coronary vessels in the heart and the
central nervous system also receive greater blood circulation. The stomach and intes-
tines, liver and kidneys can, on the other hand, receive a decreased blood supply
36 Occupational Physiology

during heavy work. In the transition from rest to physical work one can sometimes
get what is called a “stitch,” which presumably results from the reduced circulation
to the stomach and intestinal system.
The heart muscle pumps blood out into the vascular system at a certain pressure.
When the left ventricle contracts, blood is pumped out through the aorta, and the
pressure in the aorta is usually ~120 mm Hg (16.0 kPa), which is called the systolic
blood pressure. When the aortic valves then close between heartbeats, the blood
pressure in the aorta drops, and the lowest pressure that can be measured in the aorta
is usually ~80 mm Hg (10.6 kPa), which is called the diastolic blood pressure. The
normal pressure in young healthy people at rest is ~120/80 mm Hg.
In connection with physical work, blood flow to the working muscles increases in
order to meet the demand for oxygen supply and to remove carbon dioxide and other
metabolites, for example, lactic acid, and excess heat. For this it is necessary for the
heart muscle’s contractive force, as well as the cardiac output and blood pressure, to
increase. Systolic blood pressure increases more than diastolic pressure in physical
work (Figure 2.8). The blood pressure reaction during work can provide important
information about the individual’s cardiovascular system. The blood pressure
increase during work is, for example, greater in older individuals compared with
younger ones. This is presumably the result of a decreased elasticity in the vessels
with increasing age. In, for example, cycling at a heart rate of ~150 beats/min,
healthy men of 20–30 years of age have a pressure of ~150/80 mm Hg, while blood
pressure in men between 50 and 60 years of age is ~210/95. The individual variation
in blood pressure reaction at an increased work load is, however, relatively large.

2.9  F ACTORS AFFECTING INDIVIDUAL LOAD AT

A PARTICULAR EXTERNAL EXPOSURE
Load on the individual, the internal exposure at a certain external exposure—for
example, cycling 100 km and delivering 30 items of mail during an 8-h working
day—is affected by a number of factors. The internal load results from, among other
things, factors at work, for instance, how certain operations are carried out, how the
work is organized, for example, as regards breaks, and what equipment is used. The
internal load is also affected by factors in the environment, such as how hot it is.
What is more, there are individual characteristics, for instance age, and lifestyle fac-
tors, such as physical exercise, which are of great significance for individual load at
a certain external exposure. Psychological factors are not dealt with in this chapter,
but these aspects are taken up in Chapter 7.

2.9.1  Factors at Work

2.9.1.1  Dynamic and Static Muscle Work
Seen from a functional perspective, two different types of muscle work are distin-
guished, dynamic and static muscle contractions, respectively (see Chapter 6,
Section 6.6).
Most operations contain both dynamic and static work. Work with the arms and
hands lifted—for example, carpentry, painting, and cleaning work—involves static
Work Demanding High Energy Metabolism 37

loads primarily in the neck and shoulder muscles. The efficiency and the maximal
performance (VO2 max/min) declines appreciably with elements of static work oper-
ations (see Table 2.2). In hammering nails at different heights, for example, oxygen
uptake is relatively constant if the nails are being hammered in with lowered or lifted
arms, but the performance, the number of nails/min, is considerably lower when
nailing into a ceiling compared with nailing at bench height (Figure 2.10). The effi-
ciency when nailing with lifted arms is therefore lower. Heart rate, blood pressure,
and lactic acid concentration are higher when nailing into a ceiling compared with
nailing at bench height.

2.9.1.2  Work by Small Muscle Groups

As mentioned earlier, the body’s ability to achieve maximum oxygen uptake is only
reached in dynamic muscle work by large muscle groups. In maximum work with
the arms, approximately only 70% of VO2 max is achieved. If leg work resulting in
maximum oxygen uptake is distributed in both the arm and leg muscles, there is
often no noticeable increase in VO2 max, as the maximal uptake capacity can be
achieved with legwork. On the other hand, the work can be carried out for a longer
period, as the load is distributed over a greater muscle mass.
In submaximal work by small muscle groups, compared with large groups, the
cardiac output at a certain oxygen uptake is largely the same, but the heart rate is
higher and its stroke volume is lower. The blood pressure reaction is significantly
higher at a specific cardiac output. The higher blood pressure and higher heart rate
in work by small muscle groups result in poorer efficiency compared with work by
large muscle groups. The reason for the higher blood pressure is presumably a vas-
cular contraction (vasoconstriction) in the inactive muscles to offset a vascular dila-
tion (vasodilation) in the muscle that is working.

2.9.1.3  Breaks
Extremely heavy operations in which the employee can choose their own work rate
can be made easier, without any decline in production, by inserting short breaks.
Figure 2.11 shows the heart rate of a person carrying pieces of iron weighing 30 kg
from a machine to a palette. When he, for example, carried 14 pieces in a row and
subsequently took a break, continued to carry 14 pieces and took another break, he
reached a heart rate of ~150 beats/min at the end of each work cycle. The length of
the break was always 1.5 times longer than the duration of each work period. When
he reduced the number of pieces of iron before he took a break—still with a break
time 1.5 times longer than the work period—his heart rate dropped. When he took
four pieces of iron each time, and therefore took 14 short breaks, he reached a heart
rate of 110 beats/min. The shorter the period of work, the lower the heart rate, despite
the fact that the production was the same. After ~13 min he had carried 56 pieces of
iron in each case. By further reducing the number of pieces of iron the heart rate
dropped further, but the work seemed disjointed.
Similar results have also been shown in laboratory trials with cycling and running
as types of work. The load, measured both as heart rate and concentration of lactic
acid in the blood, declined further the shorter the working period. In these trials the
effect of the length of the break was also studied. Interestingly enough, there was no
38 Occupational Physiology

Nailing Cycling Standing

arms
Bench Wall Ceiling 50 W 75 W Max Down Up
Number of 3.0
nails/min VO2

15 2.0

10
1.0
5

Heart rate

150

100

50

Blood pressure
mm Hg kP

150 S 20

100 D 13

50 6

Venous lactic acid concentration

mmol/L
4.0
2.0

Bench Wall Ceiling 50 W 75 W Max Standing

arms
Down Up

FIGURE 2.10  The reaction when hammering nails in different body postures, during cycling,
and standing with the arms alongside the body or with arms lifted above the head. Despite a
constant oxygen uptake (VO2 L/min) of ~1 L/min in the different body postures when
Work Demanding High Energy Metabolism 39

Heart rate
beats/min

160

140

120

100

80

0 2 4 6 8 10 12 Minutes
56 bars 4 × 14
8×7
14 × 4

FIGURE 2.11  The heart rate of an individual loading four lots of 14 iron pieces (broken
line), eight lots of seven iron pieces (thick line) and 14 lots of four iron pieces (thin line). The
heart rate was appreciably lower in short work cycles compared with long cycles, despite
constant production. (Adapted from Åstrand I. 1990. Arbetsfysiologi. 4th ed. Stockholm:
Norstedts förlag (in Swedish), p. 84. With permission.)

marked drop in heart rate and lactic acid concentration if the length of the break was
extended beyond a certain minimum, presupposing that the work period was short.
The conclusions are that the work period must be as short as possible, so that the load
is as low as possible, while the length of the break is not as critical to the outcome.
The explanation of the results is presumably that, when an individual works with a
high load for a short period, the oxygen supply is adequate, despite an inadequate
oxygen supply during the activity. One possible explanation for this is that the myo-
globin supplies the muscles with oxygen at the beginning of each work period.
Myoglobin, which is to be found in all muscle cells, is closely related to haemoglobin,

FIGURE 2.10  Continued. hammering nails, production dropped from ~15–5 nails/min in

the transition from nailing into a bench to nailing into the ceiling. Efficiency therefore
dropped. The heart rate when cycling at 50 watts was ~100 beats/min and when nailing the
ceiling ~130 beats/min despite the same oxygen uptake. Systolic blood pressure (S) was ~150
(20.0) and 170 mm Hg (22.6 kPa), respectively, and diastolic pressure (D) was ~80 (10.6), and
110 mm Hg (14.6 kPa), respectively. The venous lactic acid concentration was at its maximum
when hammering nails into the ceiling. Note that diastolic blood pressure was higher when
standing at rest with the arms raised above the head than when cycling at 75 W. At maximum
performance on the cycle, diastolic blood pressure was lower than when nailing into the ceil-
ing. (Adapted from Åstrand I., 1990. Arbetsfysiologi. 4th ed. Stockholm: Norstedts förlag (in
Swedish), p. 78. With permission.)
40 Occupational Physiology

and has the ability to bind oxygen. Over a short work period of at most 30 s, the
oxygen needs are presumably covered by the amount of oxygen bound to the
­myoglobin. During the break the myoglobin is then loaded with new oxygen in just a
few seconds. In principle, the work can continue aerobically for an indefinite time, as
long as the work periods are not so long that the oxygen reserves in the myoglobin
become exhausted, because then anaerobic energy metabolism takes over and lactic
acid is formed.
In many forms of heavy work, where the employees themselves can regulate their
work rate, putting in frequent short breaks to reduce the load works very well. In
machine-controlled occupations it is not always possible for employees to influence
the pattern of work and breaks, but the work can be controlled according to the prin-
ciples mentioned above so as to reduce load.
It is important not to confuse the above-mentioned short breaks with other, longer
breaks for recuperation, which are motivated by other reasons, both from a work
environment viewpoint as well as a social viewpoint. Apart from a proper lunch
break and a break for a snack both in the morning and afternoon to replenish energy
stores, John needs to take breaks fairly often to drink water. He needs to drink at
least half a litre per hour, and more if it is hot outside, so as not to impair his perfor-
mance. If John does not drink enough, dehydration sets in; this results in a lower
stroke volume at a certain work load, which is compensated for by an increased heart
rate. This results in greater exertion and a reduction in performance.

2.9.1.4  Equipment
The design of equipment and tools can be very important both for the load on the
individual and for productivity. In many cases, it is possible with simple means to
improve the equipment so as to improve efficiency (Figure 2.12a and b). Simple mea-
sures for the bicycle messenger John are, for example, to adjust his saddle height
optimally (to reduce static load on thigh muscles and improve efficiency) and to
ensure that his tyres are correctly inflated. A cycle with a large number of gears
means that John can optimize his efficiency, for example, when cycling up and down
hills. For the slaughterhouse worker Janis (see Chapter 5), simple measures, such as
keeping his cutting tools sharp, affect the load considerably.

2.9.2  Environmental Factors

2.9.2.1  Ambient Temperature
Ambient temperature affects physical performance (see also Chapter 9). Work in a
hot climate increases the cardiovascular load on the individual at a specific external
exposure. Heart rate at a submaximal work load increases as a result of the greater
blood circulation to the skin in order to transport heat from the working muscles to
the skin for heat transfer. Prolonged heat exposure may lead to dehydration as a
result of increased sweating, if the water loss is not replaced. Fluid deficit alone
increases heart rate at a certain work rate, and performance is further reduced. Even
with a fluid deficit corresponding to 1% of body weight, the capacity to work declines
measurably. Prolonged heat exposure also impairs mental and neuromuscular func-
tion. This impairment can result in a greater risk of misjudgments and slips, thereby
Work Demanding High Energy Metabolism 41

(a)
100
83 78
Oxygen uptake

21”
16”

8”

(b)
100
85
Oxygen uptake

Tyre pressure 2.2 Kp/cm2 Tyre pressure 4.0 Kp/cm2

(215.8 kPa) (392.4 kPa)

FIGURE 2.12  At a constant-sized load and transport speed oxygen uptake is lower when using
wheelbarrows with large wheels compared with small ones (a) and with a high tire pressure
compared with low (b). Oxygen uptake with small wheels and badly inflated tyres, respectively,
is set at 100, and oxygen uptake using larger wheels and a greater tyre pressure is expressed as
a percentage of the oxygen uptake measured in the worst circumstances. (Adapted from Hansson
J.-E. 1970. Ergonomi vid byggnadsarbete. Research Report no. 8: Byggforskningen, State
Council of the Building Industry (in Swedish).) Illustration: Niklas Hofvander.

increasing the risk of accidents. It is therefore important to assess heat exposure to

ensure optimum conditions for health and productivity.
Heavy work in cold conditions is primarily a problem before there is time to warm
up the muscles. As blood circulation and nerve conduction velocity are lower in cold
tissues, the function in the musculoskeletal system is impaired, which reduces the indi-
vidual’s physical capacity and increases the risk of injury (see also Chapters 3 and 9).

2.9.2.2  Humidity
High humidity impedes physical capacity and increases the cardiovascular load on
the individual at a specific level of external exposure, as it is more difficult to retain
the heat balance when heat transfer through the evaporation of sweat decreases (see
also Chapter 9).

2.9.2.3  Height Above Sea Level

Work at high altitude impedes physical capacity. Oxygen pressure in the air we
inhale, which is normally at ~760 mm Hg at sea level, declines the higher we go. At
3000 m above sea level, for example, the oxygen pressure has decreased to about
500 mm Hg. The lower oxygen pressure in the air at high altitude results in a lower
oxygen concentration in arterial blood, and thereby a lower arteriovenous oxygen
42 Occupational Physiology

difference. In order to compensate for the lower level of oxygen extraction, pulmo-
nary ventilation and heart rates are higher at a certain submaximal work load in
people who are not acclimatized, that is to say before the body has had time to adapt
to the high altitude. Maximal aerobic capacity results from maximum cardiac output
and maximum arteriovenous oxygen difference (according to Fick’s principle, see
Section 2.8). Maximum cardiac output is, however, the same irrespective of altitude,
and as in principle all oxygen is extracted from the blood passing the working mus-
cles at maximum work rate, VO2 max is reduced, and thereby physical capacity,
before the body has had time to acclimatize to the high altitude.
During a long stay at high altitude, that is to say acclimatization, several physio-
logical changes occur in order to compensate for the lower oxygen pressure in the air
inhaled. At a prolonged stay at high altitudes, physiological adaptations to compen-
sate for the reduced oxygen pressure in the inspired air, that is acclimatization, takes
place. Over the first few days, pulmonary ventilation continues to increase. The hae-
moglobin concentration gradually increases after various periods of acclimatization
at high altitude, so that the oxygen content per litre of arterial blood may be the same
in an acclimatized individual at high altitude as at sea level. This means that heart
rate at a specific submaximal work load begins to drop, and gradually reaches the
same or even a lower level compared with the rate at sea level. Other physiological
changes also occur, for example, increased capillary density and increased myoglo-
bin concentration in the muscles as well as altered enzyme activity. The initial reduc-
tion in VO2 max is gradually recovered and is, for example, at 3000 m reduced by
5–10% in acclimatized individuals compared with ~20% for non-acclimatized
individuals.

2.9.3  Individual Factors

The differences in performance capacity between different individuals are quite con-
siderable. As much as 70% of physical capacity is thought to result from genetic
factors. Some of the differences can be explained by differences between the genders
and between different age groups, and also differences in body size. The major dif-
ferences existing between individuals within each group involve, however, consider-
able overlaps between the groups. Various medical conditions, for example, heart
and lung disease may of course appreciably impair capacity, but this is not dealt with
in detail here.

2.9.3.1  Gender
Women’s maximal aerobic capacity, VO2 max in L/min, is after puberty on average
65–75% of that of men (Figure 2.13). The relatively large individual distribution
should, however, be noted. Out of all the individuals of a certain age group, ~2.5%
have 25% lower aerobic capacity and 2.5% have 25% better aerobic capacity than the
average for the group. The distribution also implies that ~2.5% of all men have an
aerobic capacity that is lower than that of the average woman.
The differences between men and women results, in part, from differences in
body size. On average, VO2 max increases with increased body weight raised to 2/3.
When we take into account size, women’s VO2 max/kg of body weight is on average
Work Demanding High Energy Metabolism 43

Max VO2
L/min

Cross sectional data

5.0 Longitudinal data

4.0

3.0

2.0

1.0

10 20 30 40 50 60
Age (years)

FIGURE 2.13  Average values for maximal aerobic capacity (VO2 max L/min) measured in
350 normal people from the ages of 4–65 running on a treadmill or cycling on a cycle ergo­
meter. Filled circles with solid lines represent men and empty circles with broken lines repre-
sent women. The thin solid lines and broken lines represent two standard deviations for men
and women, respectively. Filled and unfilled triangles represent 31 male and 35 female stu-
dents, respectively, training to be physical education teachers, who were measured during
their training and again 20 years later. (Adapted from Åstrand I. et al. 1973. Reduction in
maximal oxygen uptake with age. J. Appl. Physiol. Nov. 1, 35:649–654. Bethesda, MD:
American Physiological Society. With permission.)

75–80% of that of men. This is primarily because of the greater proportion of fatty
tissue, which has a low-energy metabolism, in women (~12 kg compared with 8 kg
in a normal woman or man, respectively). A number of studies show that if VO2 max
is expressed per kilogram of fat-free body weight (what is called lean body mass),
there are no differences between men and women. As oxygen uptake increases with
body weight raised to 2/3, women should have a somewhat higher VO2 max expressed
per kilogram of fat-free body weight. The observed lower VO2 max than expected in
women can be explained by the lower haemoglobin concentration and thereby lower
maximum arteriovenous oxygen difference.
The average lower maximal aerobic capacity in women compared with men usu-
ally means that women use a greater proportion of their maximum capacity at a
specific energy metabolism. This means that a job requiring a specific energy metab-
olism—that is, oxygen uptake—is carried out at a higher heart rate and with greater
exertion by the average woman compared to the average man.

2.9.3.2  Age
The maximal aerobic capacity increases with increased growth during childhood up
until puberty, whereupon there is a gradual decline with increased age (Figure 2.13).
At the age of 65, VO2 max is on average ~70% of the value of that of a 25-year-old.
44 Occupational Physiology

Max heart rate

beats/min

200
+2SD

150
–2SD
10 20 30 40 50 60
Age (years)

FIGURE 2.14  Average values for maximal heart rate (beats/min) measured in 350 normal
people from the ages of 4–65 running on a treadmill or cycling on a cycle ergometer. Filled
circles with solid lines represent men and empty circles with broken lines represent women.
Filled and unfilled triangles represent 31 male and 35 female students, respectively, training
to be physical education teachers, who were measured during their training and again 20
years later. The thinner solid lines represent two standard deviations (one standard deviation
is ~10 beats/min for all age groups). (Adapted from Åstrand I. et al. 1973. J. Appl. Physiol.
35:649–654 Bethesda, Maryland: American Physiological Society. With permission.)

Therefore, VO2 max for an average 65-year-old man is approximately the same as
that for an average 25-year-old woman.
There are many reasons for this decline in aerobic capacity with increasing age.
Changes in lifestyle, for example, a reduction in physical activity, are presumably a
contributing factor, but physiological changes also take place with increasing age.
Pulmonary ventilation becomes less effective, and the gas exchange in the lungs
occurs more slowly. Additionally, maximal heart rate declines appreciably and
thereby also the heart’s maximum minute volume (Figure 2.14).
Apart from the cardio-respiratory changes occurring with increased age, muscle
mass and maximal muscle force are reduced (see Chapter 3).

2.9.4  Lifestyle Factors

Our living habits—for example, diet, physical activity and exercise, and sleep, as
well as the use of tobacco and alcohol—and our entire lifestyle affect our health and
well-being as well as our physical capacity (see also Chapter 6). In this section we
describe the short-term effects on physical capacity of physical exercise and the use
of tobacco. As regards the significance of lifestyle for the more long-term health
consequences, we refer the reader to reference literature in this field (see Further
Reading).

2.9.4.1  Physical Activity and Exercise

Physical capacity is influenced by the degree of physical activity and exercise.
Physical exercise can be defined as all forms of repeated physical activity that
Work Demanding High Energy Metabolism 45

improve or maintain endurance, strength, mobility, and/or coordination. In order for

the exercise to be effective, it needs to have sufficient intensity, frequency, and dura-
tion and that the time for recuperation between exercise sessions is sufficient, as
physiological adaptation to greater demands occurs during the rest period. For more
detailed information and advice regarding physical exercise, the reader is referred to
textbooks on training physiology (e.g., Åstrand et al. 2003).
In order to achieve the best training effect as regards aerobic capacity, it is
important that exercise is dynamic and involves large muscle groups, such as in
walking/jogging, cycling, or swimming. The increase in maximal aerobic capacity
after regular exercise results from both a central adaptation through greater stroke
volume and a peripheral adaptation through greater oxygen extraction in the active
muscles, that is to say the arteriovenous oxygen difference increases. The increase
in stroke volume results in a lower heart rate at a particular work load and cardiac
output as well as a higher maximum cardiac output (cf. Fick’s principle, see Section
2.8). The higher maximal cardiac output results only from an increased maximal
stroke volume, while the maximal heart rate is not affected by exercise. The increase
in the arteriovenous oxygen difference is achieved through changes in the muscles
involved, so that the muscles adapt to the work at a higher load. The adaptation
comprises a number of effects, such as the content of enzymes in the muscle cells,
sensitivity to hormones, increased capillary density in the muscles, and increased
muscle mass.

2.9.4.2  Use of Tobacco

Apart from the serious health risks, smoking also results in marked acute effects on
physical capacity. Smoking leads to an increase in respiratory resistance by two to
three times the normal value even after one or two cigarettes. This is not noticed so
much during rest, as not so much air is needed then; but during physical work, when
pulmonary ventilation increases, the smoker usually feels more breathless during
exertion. Smoking also affects blood circulation. Heart rate at a certain submaximal
oxygen uptake has been shown to be 10–20 beats/min higher after smoking one or
two cigarettes, and the difference in heart rate between smokers and non-smokers is
greater the higher the work load. Both the nicotine and carbon monoxide in tobacco
smoke affect blood circulation. Nicotine use results in reduced peripheral circulation
through the blood vessels contracting (vasoconstriction), increased heart rate and
blood pressure at a certain work load, and effects on hormone secretion. Tobacco
smoke contains up to 4% carbon monoxide, the ability of which to bond with haemo-
globin is ~225 times higher than that of oxygen. Even a low carbon monoxide level
impairs the blood’s ability to transport oxygen (through reducing the arteriovenous
oxygen difference because of a lower oxygen content in arterial blood), which appre-
ciably reduces physical capacity.

2.10  MEASURING OCCUPATIONAL ENERGY DEMANDS

In order to determine whether the energy demands of an occupation are unaccept-
ably high, one must be able to perform a more detailed assessment than is possible
with the normal values reported for various occupational groups (Table 2.3).
46 Occupational Physiology

TABLE 2.3
Classification of Physical Work Load for Various Occupations Based on
Oxygen Consumption and Corresponding Cycle Ergometer Load
Cycle Oxygen
Ergometer Uptake Heart Rates
Classification (W) L/min METs (Beats/min) Occupation
Very heavy >125 >1.75 >6.7 >150 Heavy manual forestry, heavy
labour manual transport labour,
firefighting with breathing
apparatus
Heavy labour 100–125 1.5–1.75 5.7–6.7 130–150 Heavy construction work,
agricultural labour
Moderately 50–100 1.0–1.5 3.8–5.7 100–130 Heavy healthcare work,
heavy labour construction work, service,
and cleaning work (hotel and
restaurant)
Light labour 40–50 0.75–1.0 2.8–3.8 80–100 Household work, light factory
work, light healthcare work,
laboratory work, retail work
Very light 20–40 0.5–0.75 1.9–2.8 70–80 Office work, car driving,
labour <20 <0.5 <1.9 <70 seated work (reading,
writing)

Source: Data from Åstrand I. 1990. Arbetsfysiologi. 4th ed. Stockholm: Norstedts förlag (in Swedish);
Fallentin N. 1995. Arbejdsfysiologi, pp. 118–135. Köpenhamn: Arbetsmiljöinstituttet (in
Danish).
Note: The table also indicates the corresponding METs (for individuals weighing 75 kg), average heart rate
variation and examples of occupations within the respective categories. Note that work load classifi-
cations based on oxygen consumption and corresponding heart rate values refer to an average 20- to
30-year-old, and that the considerable variation among individuals must be taken into account.

2.10.1  Technical Measurements

2.10.1.1  Oxygen Consumption
Measuring oxygen consumption has proved to be a reliable method for assessing
energy metabolism and therefore represents one acceptable way of assessing occupa-
tional demands from an energy perspective. Oxygen consumption can be determined
by calculating the difference between the measured oxygen content in inhaled and
exhaled air.
Portable equipment is available that can perform continuous oxygen consumption
monitoring in the field and which weighs only a few kilograms (see Chapter 6, Figure
6.9). The results can be stored on a portable unit or wirelessly transferred to a com-
puter, allowing for real-time tracking on a display screen. The energy demands of a
number of different physical activities have been measured and documented
[Ainsworth et  al. 1993, 2000]. Johns’ oxygen consumption in his job as a bicycle
Work Demanding High Energy Metabolism 47

messenger was measured over three different working days, and his average oxygen
consumption was found to be 1.54 L/min.
Although the equipment and methods have been simplified in recent years, mea-
suring oxygen consumption in the field is not an easy method for practical uses and
is more suitable for research purposes instead. The equipment is relatively expensive,
and special skills are required to calibrate and operate the equipment to obtain accu-
rate results.

2.10.1.2  Pulmonary Ventilation

For occupations that are physically not very intensive, measuring pulmonary ventila-
tion with a flow meter is a relatively easy way of estimating oxygen consumption.
Pulmonary ventilation increases linearly with increased oxygen consumption from a
rest state up to a pulmonary ventilation of 40–50 L/min (Figure 2.7). This means that
occupational energy demands entailing oxygen consumption below 1.75–2 L/min
can be measured based on pulmonary ventilation. John’s average pulmonary ventila-
tion in his job as a bicycle messenger is ~33 L/min, which corresponds to an oxygen
consumption of 1.5 L/min (Figure 2.7).

2.10.1.3  Heart Rate

Today, one can find user-friendly and relatively inexpensive equipment that can be
used to continuously monitor heart rate over an entire working day with a good
degree of accuracy (see Chapter 6, Figure 6.9). Assessing energy demand based on
monitoring heart rate is possible because there is a linear correlation between work
load and oxygen consumption (i.e., a constant efficiency factor) and between heart
rate (within a certain range) and oxygen consumption. In order to perform this type
of measurement, however, a so-called “biological calibration” is required. This
calibration is usually performed on a cycle ergometer. The individual’s own cor-
relation between work load/oxygen consumption and heart rate is determined at
least two, but preferably three, submaximal loads within the heart rate interval
anticipated for the work in question (Figure 2.15). Based on the individual’s (usu-
ally) linear correlation, oxygen consumption can then be estimated based on heart
rate as measured at a steady state during a work task. John’s average heart rate
­during his work as a bicycle messenger is 96 beats/min, which for him corresponds
to  an oxygen consumption of 1.55 L/min and a work load of just over 100 W
(Figure 2.15).
An important limitation on the use of heart rates as a measure of energetic work
load is, however, that the heart rate, as previously mentioned, is affected by a num-
ber of factors other than oxygen uptake alone. In heat exposure and work including
static load as well as work by small muscle groups, the heart rate increases and
alters the “normally” linear correlation between heart rate and oxygen uptake
(Figure 2.16). At low-to-average physical load, the heart rate also increases as a
result of mental stress. For a reliable assessment of energetic work loads on the
basis of heart rate measurements, one should therefore carry out the biological
calibration under conditions which to the greatest extent possible are similar to
actual working conditions. Heart rate in itself is, however, a good measure of exer-
tion on the individual.
48 Occupational Physiology

Heart rate
beats/min
220
210

200
190
180
170
160
150
140
130
120

110
100
90
80
70

60
50

VO2, L/min
1.0 2.0 3.0 4.0 5.0 6.0
Load,
50 100 150 200 250 300 350 400 Watt

FIGURE 2.15  Biological calibration of the correlation between work load/oxygen con-
sumption and heart rate. John’s heart rate was measured at three work loads (50, 100, and
150 watts) on a cycle ergometer (× connected with a solid line). During his workday as a
bicycle messenger, John’s average heart rate is 96 bpm, which corresponds to an oxygen con-
sumption of ~1.55 L/min (see ----- for the correlation between John’s working heart rate and
oxygen consumption). John’s maximum oxygen uptake (VO2 max) was measured at 5.1 L/
min, meaning that he is using ~30% of his VO2 max (1.55/5.1 × 100) while working as a
bicycle messenger. John’s measured maximum heart rate was 195 beats/min and in the figure
John’s calibration line has been extrapolated linearly to his maximum heart rate (–––––). If
it is not possible to measure a person’s VO2 max L/min, it can be predicted on the basis of the
point of intersection between the person’s extrapolated calibration line and maximum heart
rate (see ...... for the correlation between John’s maximal heart rate and VO2 max L/min). In
certain people the calibration line deviates with very heavy work (.......), that is to say the oxy-
gen uptake increases relatively more than the heart rate, which means that VO2 max L/min of
these people will be underestimated somewhat. For instance, VO2 max for a person whose
increasing heart rate in reality deviates, according to the dotted line in the figure, will be under-
estimated by ~7% (predicted VO2 max 5.1 L/min compared with real VO2 max 5.5 L/min).
Work Demanding High Energy Metabolism 49

Static muscular
work
Dynamic work by
Heart rate Work in hot small muscle groups
environment

Dynamic work by
large muscle groups

Energy metabolism

FIGURE 2.16  With increasing energy metabolism, the heart rate increases more steeply in
simultaneous heat exposure and with elements of static muscular work and work by small
muscle groups compared with dynamic work by large muscle groups. (Adapted from Kroemer
KHE., Grandjean E., 1997. Fitting the Task to the Human. A Textbook of Ocupational
Ergonomics. 5th ed. London: Taylor & Francis, p. 116. With permission.)

2.10.2  Observation or Self-Reporting

As an alternative to technical measurement, energy demands at work can be assessed
on the basis of observation or self-reporting of various tasks/activities. On the basis
of published reference values for energy demands for various activities [Ainsworth
et al. 1993, 2000] and the total time taken for each activity, one can calculate time-
weighted average values over a working day [Edholm 1966; Pernold et  al. 2002].
John has kept a diary of his activities for a working week. He usually cycles for 6.5 h,
at an average speed of ~18 km/h, which corresponds to ~6 METs. For the rest of the
time he collects and delivers various items of mail and awaiting new tasks. Collecting
and delivering items of mail takes about 60 min of each working day, and then John
is often jogging both across a flat surface and a great deal up and down stairs, which
on average corresponds to ~7 METs. For 30 min he is standing waiting for new tasks,
and chatting to his employer and customers, ~1.8 METs [Ainsworth et al. 1993]. His
time-weighted average value on a normal working day is

(6.5 × 6) + (1.0 × 7) + (0.5 × 1.8) h × METs/8 h = 5.9 METs.

For John, who weighs 75 kg 5.9 METs corresponds to an oxygen uptake of 1.55 L/
min (5.9 × 3.5 mL O2 × kg−1 × min−1 × 75 kg = 549 mL/min or 1.55 L/min) (see
Section 2.6).

2.11  D
 EMANDS OF WORK IN RELATION TO
PHYSICAL WORK CAPACITY
The great variation in physical capacity implies that a certain task can be carried out
with low exertion for certain individuals, while the same job can be very strenuous
50 Occupational Physiology

for others. Generally speaking, a specific external exposure is more strenuous for
women compared with men and for older people compared with younger ones, even
if the variations within the respective gender and age group are considerable. In
order to be able to evaluate whether a certain work load is unacceptably high, we
have to take into account the individual’s maximal work capacity. The relative load
expresses the relation between the demands of work and the individual’s maximal
work capacity, and can be expressed as

Relative load (%) = 100 × (Demands of work/individual’s maximal work capacity)

2.11.1  Relative Oxygen Uptake

Methods for measuring work demands, expressed as demands for oxygen uptake, are
described in the previous section. Individual physical capacity, expressed as maxi-
mal aerobic capacity (VO2 max/min), can be measured directly through a so-called
maximal test or indirectly on the basis of a submaximal test.

2.11.1.1  Maximal Test

In a maximal test on a cycle ergometer or treadmill, the work load is gradually
increased and oxygen uptake measured at each stage. Oxygen uptake increases lin-
early with an increase in work load until the level is reached where oxygen uptake
does not increase further despite the fact that the load increases (Figure 2.4). The
highest oxygen uptake that can be measured corresponds by definition to the indi-
vidual’s maximal aerobic capacity, VO2 max. John has undergone a maximal test in a
work physiology laboratory. His maximal aerobic capacity was 5.1 L/min, that is to
say an increase of 19 times the basal metabolic rate (19.4 METs), which is assessed as
being a very high physical capacity. In the previous section, we stated that John’s
oxygen uptake was 1.54 L/min on average during his working day working as a bicy-
cle messenger, which therefore corresponds to ~30% (1.54/5.1 alt. 5.9/19.4) of his
maximal aerobic capacity.
John’s friend Paul, who is also 26 years of age, has also had his maximal aerobic
capacity tested. Paul has a sedentary job as a computer technician and on an average
spends 12 h a day sitting in front of a computer screen. Paul drives to and from work
and takes no physical exercise in his leisure time. His primary interest apart from
computers is in films, and his leisure time is devoted mostly to watching TV and
going to the cinema. His maximal aerobic capacity was 2.5 L/min, that is, half that
of John, which at his age is a very low level of fitness. If Paul were to cycle at the
same speed as John, that is, to say with an oxygen uptake of ~1.5 L/min, he would
have to use 60% (1.5/2.5) of his maximal capacity, which would be very strenuous
for him. It would be impossible for him to maintain that tempo for a whole working
day. If Paul on the other hand were to cycle with the same relative load as John, his
lower tempo would result in a considerably lower performance than John’s.
In most physical activities, body weight in itself involves a load, for example, in
walking and running. Then it is more relevant to express the maximal aerobic capac-
ity related to kilogram of body weight; in millilitres of oxygen per kilogram of body
Work Demanding High Energy Metabolism 51

weight and minute (mL × kg−1 × min−1). John weighs 75 kg and his aerobic capacity
related to kg body-weight is 68 mL × kg−1 × min−1 (5100 mL × 75 kg−1 × min−1). If
John had instead weighed 100 kg, this value would have been 51 mL × kg−1 × min−1.
When John is collecting and delivering items of mail, he often jogs to and from his
bicycle, which corresponds to ~7 METs, that is to say an oxygen consumption of
~24.5 mL × kg−1 × min−1 (7 × 3.5 mL × kg−1 × min−1). This corresponds to 36%
(24.5/68) of his maximal aerobic capacity in millilitres of oxygen per kilogram of
body weight and minute. If John on the other hand weighed 100 kg, the same exter-
nal work (exposure) would have corresponded to 48% (24.5/51).
Tests to determine maximal aerobic capacity presuppose laboratory conditions
with the need for specially trained staff and specialist equipment. If we do not have
the opportunity to measure the maximal aerobic capacity, we can predict it with a
reasonable degree of accuracy on the basis of the individual’s maximal heart rate and
biological calibration line for submaximal loads (Figure 2.15). John’s maximal heart
rate, when his work load was increased in stages until his heart rate did not increase
any further despite a higher load, was 195 beats/min. If we extend John’s biological
calibration line to his measured maximal heart rate, the reading will be a corre-
sponding maximal aerobic capacity of ~5.1 L/min. For some people, however, oxy-
gen uptake increases, relatively speaking, more than heart rate during very heavy
work, which means that the maximal aerobic capacity of these individuals will be
slightly underestimated (Figure 2.15).

2.11.1.2  Submaximal Test

In workplace studies, submaximal tests are usually used to predict maximal aerobic
capacity. These tests are usually carried out on a cycle ergometer and do not require
the maximal performance, which is why they are considerably easier to conduct.
Most submaximal tests are based on the fact that there is a linear correlation between
oxygen uptake and heart rate, which is common. Oxygen uptake in certain individu-
als increases relatively speaking more than heart rate during very heavy work, which
is why the maximal aerobic capacity in such cases will be underestimated.
Submaximal tests also presuppose a constant mechanical efficiency similar to all
individuals. Certain people manage a certain work load with a lower energy metabo-
lism than others, and people who are very much overweight have a higher oxygen
uptake at a certain load. The differences in efficiency in cycling are relatively small
compared with running, where the technique and the body weight have a greater
significance for energy metabolism. Furthermore, it is presupposed that the maximal
heart rate depends only on age, despite the fact that the distribution within a certain
age group is relatively large (Figure 2.14).
In order to calculate an individual’s maximal aerobic capacity, one can measure
their heart rate (after 3–4 min, that is, to say when the steady state has been achieved,
see Figure 2.5) at two or three submaximal rates at least. If a straight line is adjusted
to the results describing the relationship between heart rate and work load, this line
can then be extended to the value for a predicted maximal heart rate based on age.
The individual’s maximal aerobic capacity can then be assessed in a corresponding
way to that shown in Figure 2.15, with the difference that the results in the figure are
based on a measured, and not predicted, maximal heart rate. The decline in maximal
52 Occupational Physiology

heart rate with increasing age is evident from data in Figure 2.14 described with the
formula

Maximal heart rate = 220 – age [ Astrand et al. 2003]

Another study shows a somewhat smaller age-related decrease in the maximal heart
rate, described with the formula

Maximal heart rate = 210 – (0.662 × age) [Bruce et al. 1973]

On the basis of the formulae given above, John’s predicted maximal heart rate is 194
and 193 beats/min, respectively. His predicted maximal aerobic capacity on the basis
of a submaximal test is ~5.0 L/min (compare with the process in Figure 2.15). In
John’s case, the difference between the predicted and measured maximal heart rate
is small (193 or 194 compared with 195 beats/min) and his predicted VO2 max does
not differ very much from the measured value (5.0 compared with 5.1 L/min). The
difference between the predicted and measured maximal aerobic capacity is often
greater than it is in John’s case. On the basis of the submaximal test of VO2 max
above and his predicted oxygen uptake, based on average heart rate during work as a
bicycle messenger (see Section 2.10.1 about heart rate), John’s work as a bicycle mes-
senger is predicted as corresponding to ~31% (1.55/5.0) of his VO2 max.
Another common method for predicting the maximal aerobic capacity on the
basis of the cycle ergometer test is based on the Åstrand and Åstrand nomogram.
Here the heart rate is only registered at one submaximal load (~140 beats/min for
subjects <50 years of age and ~120 for older subjects) and the maximal aerobic
capacity can then be calculated on the basis of heart rate at the chosen work load.
The value obtained then has to be corrected for age [Åstrand et al. 2003]. The nomo-
gram is based on empirical research into a very large number of people, and the
correlation between heart rate at a submaximal work load and maximal aerobic
capacity is therefore fairly good at the group level. When John carried out a cycle
ergometer test at the load of 200 watts, his heart rate at steady state was on average
132 beats/min. After correction for age (reading value × age factor) John’s VO2 max
is estimated at 5.2 L/min.
On the basis of Åstrand’s submaximal test of John’s VO2 max and his predicted
oxygen uptake, based on average heart rate when working as a bicycle messenger
(see Section 2.10.1 about heart rate), John’s work as a cycle messenger is estimated to
correspond to ~30% (1.55/5.2) of his VO2 max.
At the individual level the results of submaximal tests must be evaluated with
care, as the error is relatively great, which results in the predicted value of VO2 max
not always corresponding to the real (measured) value. This error results primarily
from the great distribution in maximal heart rate even within a particular age group
(see Figure 2.14). The error means that 95% of the individuals in a certain age group
have a maximal heart rate which lies within the limits of ±20 beats/min from the
average value. This means, for example, that 2.5% of a group of 26-year-olds have a
maximum heart rate higher than 213 beats/min (193 + 20) and 2.5% have a ­maximum
Work Demanding High Energy Metabolism 53

heart rate lower than 173. Individuals with a higher maximal heart rate than the aver-
age will be underestimated and vice versa (see Figure 2.15 and compare the pre-
dicted VO2 max at different maximal heart rates). This source of error can be
corrected if we know the individual’s real maximal heart rate and use that in the
prediction instead of a group average value. Another source of error is the variation
in efficiency. This error means that 95% of the individuals in a group have an oxygen
uptake that lies within the limits of ±12% of the average value at the respective work
load. This results in 2.5% of the group of people tested at, for example, 150 W, which
on average requires an oxygen uptake of 2.1 L/min, have an oxygen uptake higher
than 2.35 L/min [2.1 + (0.12 × 2.1) L/min] and 2.5% have an oxygen uptake lower
than 1.85 L/min [2.1 – (0.12 × 2.1) L/min]. An individual who has an oxygen uptake
of 1.8 L/min at 150 W has a very high efficiency, and the individual’s predicted VO2
max will be overestimated, while a person with low efficiency will be underesti-
mated. A further source of error is that heart rate in some individuals does not
increase linearly with a rise in oxygen uptake all the way up to the maximal. For
individuals whose heart rate increases relatively speaking less than their oxygen
uptake during heavy work, the predicted VO2 max will be underestimated somewhat
(Figure 2.15).
The sources of error listed above mean that the test result is incorrect for many
people. The size of the error in Åstrand’s submaximal cycle ergometer test means
that 95% of all those individuals tested lie within the limits of ±30% of the actual
value. This means, for example, that for 2.5% of the group of individuals whose VO2
max according to Åstrand’s test is predicted to be 5.2 L/min, the real value lies below
3.6 L/min [5.2 – (0.3 × 5.2) L/min] and for 2.5% the real value lies above 6.8 L/min
[5.2 – (0.3 × 5.2) L/min] (even if such a high maximal aerobic capacity is very
unusual). If the test is carried out according to the standardization requirements, the
results have good reproducibility; that is, the degree of deterioration or improvement,
respectively, of an individual’s VO2 max can be followed with high precision, even if
the absolute value is subject to relatively high uncertainty.

2.11.2  Relative Heart Rate Increase

The relative load can also be described on the basis of heart rate. In order to compen-
sate for the age-related reduction in maximal heart rate, the relative load is best
expressed as a relative heart rate increase, that is, the difference between the heart
rate increase at work divided by the maximal heart rate increase (the heart rate
reserve).

Relative heart rate increase (%) = 100 × (heart rate at work

− heart rate at rest ) / (maximal heart rate
− heart rate at rest )

John’s heart rate was on average 96 beats/min when working as a bicycle messenger;
his maximal heart rate was 195 and rest value 55 beats/min, which means a relative
heart rate increase of 29% [(96–55)/(195–55)]. If we assume that Paul’s heart rate at
54 Occupational Physiology

the same cycling speed was ~140 beats/min, and that he has the same maximal heart
rate as John but a rest pulse of 60 beats/min, then his relative heart rate increase at
the same work load is 56% [(135–60)/(195–60)].
If John were 60 years old instead (a predicted maximal heart rate of 170 beats/
min), a heart rate of 96 beats/min would be more strenuous and correspond to a rela-
tive heart rate increase of ~36%.

2.12  EFFECTS OF HIGH-ENERGETIC LOAD

2.12.1  Short-Term Effects
Both physical and mental fatigue are common short-term effects of working at high
energy metabolism. Fatigue is defined as a state of disturbed equilibrium (homoeo-
stasis) and can result in both subjective and objective symptoms as well as impaired
ability to work. Physical exhaustion can be local and/or central, and sometimes
aches/pains occur in combination with a general feeling of fatigue. Both aches/pains
and fatigue should be interpreted as a warning signal to prevent overload, and work
should be interrupted or the work load reduced to achieve recuperation. Fatigue can
result in impaired sensory and motor control as well as impaired perception and
cognitive functions, which can lead to poor coordination and increase the risk of
overload injuries in, heavy manual work, for example.

2.12.2  Long-Term Effects

High energy metabolism implies a physically active life, which often has many posi-
tive health effects such as a reduced risk of cardiovascular disease, obesity, diabetes,
osteoporosis, and certain forms of cancer, as well as an improved immune defense
system. Physical inactivity is more widespread in today’s society and a greater public
health problem (see Chapter 6). In most occupations with a high energy metabolism,
the occurrence of heavy manual handling is common, for example, within the nurs-
ing and care professions (see Chapter 3), which is why much of what is called heavy
work has an excess risk of such things as overexertion accidents and disorders of the
musculoskeletal system. Many people are unable to work until they are 65 years of
age, and have to take early retirement. Today there is no scientific evidence that
heavy physical work generally has a positive effect on physical capacity. Some stud-
ies indicate that heavy work can even accelerate the age-related decline in physical
capacity. Presumably, in most occupations the load is not optimal as regards level,
duration, frequency, and, perhaps above all, recuperation to provide a central and
peripheral adaptation, and therefore a training effect.
As regards John the bicycle messenger, he has chosen his job among other things
to improve his physical capacity before undertaking an adventurous journey. John
has the advantage that he himself can determine his work load and he has therefore
been able to increase the tempo successively, whereupon his fitness has improved.
When he started out as a bicycle messenger, his maximal aerobic capacity was
~4.3 L/min, and after two months had increased by almost 20% to 5.1 L/min. John
organized his work such that, when road and traffic conditions allowed, he cycled at
Work Demanding High Energy Metabolism 55

an intensity corresponding to 70–80% of its maximum ability for between half an

hour and an hour, and subsequently at a slower pace for the same length of time to
recuperate, and in this way he could gradually improve his maximal capacity. There
are, however, few occupations where the work can provide such good preconditions
for exercise. One negative effect which, however, John experiences as a result of his
work is that he is often so tired after work that he cannot manage a social life. As
John himself can affect his work load, he would be able to reduce the physical strain
by taking it a little easier. Admittedly he would then earn a little less money, but he
would have the energy left after work to cope with a social life. Many people with
heavy physical occupations, for example, within the nursing and care professions,
cannot affect their work load, however, which means that many people have diffi-
culty in coping with their work when they become older and their physical capacity
declines.

2.13  RECOMMENDED EXPOSURE LIMITS

The International Labour Organization (ILO) has suggested 33% of VO2 max as the
highest acceptable average load during an 8-h working day. If this cannot be achieved
through organizational and/or technical measures, the ILO recommends a shorter
working period [Bonjer 1971].
The proposal for an acceptable load for work with high energy metabolism is
based on the fact that it should be possible to maintain the work load over an 8-h shift
without the physiological balance being disturbed (maintaining homoeostasis); that
is, without an accumulation of lactic acid in the blood and without an increased heart
rate (when maintaining the work load) [Jørgensen 1985]. The starting point is that
the work should not cause such fatigue that the individual would not have the strength
for active and meaningful leisure time. The determination of the exposure limit is
based on the demands of the work for oxygen uptake in relation to the individual’s
maximal aerobic capacity, that is, relative load. In practical situations, when there is
no opportunity to measure oxygen demands in the work and the individual’s maxi-
mal aerobic capacity, it is possible to assess the relative load on the basis of measur-
ing heart rate at work, the individual’s biological calibration line, and submaximal
test for calculating the individual’s VO2 max (see Section 2.11.1.2). If the individual’s
maximal heart rate has not been measured but predicted on the basis of age, the
uncertainty in these assessments is so great that the result is best suited for an evalu-
ation at group level, while the results for specific individuals have to be evaluated
with care.
In continuous dynamic work by large muscle groups, the accumulation of lactic
acid does not occur if the work rate does not exceed ~40% of the individual’s maxi-
mal capacity (VO2 max) (Figure 2.6). It has also been shown that in dynamic work
by major muscle groups, the individual makes use of 35–40% of VO2 max if their
work rate can be determined freely. If the work on the other hand includes manual
handling, which most occupations with high energy metabolism do, the elements of
static muscle work and work by minor muscle groups result in a lower efficiency. An
individual’s maximal aerobic capacity may, for example, drop by 20–40% in lifting
work compared with dynamic cycle work. In lifting work, lactic acid accumulates at
56 Occupational Physiology

a lower oxygen uptake compared with dynamic work by large muscle groups. In
order to take into account occupations including manual handling, 30–35% of VO2
max, measured during dynamic muscle work on, for example, a cycle ergometer, has
been proposed as a reasonable exposure limit for an 8-h working day [Jørgensen
1985]. In order to include most employees, the energy demands of work should not
exceed an oxygen uptake for men of <40 years of age: 0.7 L/min, men over 40 years
of age: 0.6 L/min, women under 40 years of age: 0.6 L/min, women over 40 years of
age: 0.5 L/min [Jørgensen 1985]. It should be noted, however, that these values do
not exclude local fatigue as a result of heavy manual handling, which is why any
risks of accidents to and disorders in the musculoskeletal system have to be assessed
separately.
John’s relative load (internal exposure in relation to the individual’s aerobic capac-
ity) when working as a bicycle messenger corresponded to ~30% of his VO2 max. If,
for example, instead of being 26 years of age he had been 60 years of age (predicted
maximal heart rate of ~170 according to Bruce; see Section 2.11.1 on submaximal
tests), his VO2 max would have been ~4.15 L/min, instead of 5.1 L/min (see
Figure 2.15). The same external work (external exposure), corresponding to an oxy-
gen uptake of 1.54 L/min would then have required 37% of his VO2 max, and would
therefore have exceeded the recommended exposure limit.

2.14  M
 EASURES IN WORK REQUIRING HIGH
ENERGY METABOLISM
In jobs with high-energetic load, it is important that the individuals themselves are
able to determine their work pace and control both their work load and breaks. It is
particularly important for older workers in order to be able to continue to work up to
the normal pensionable age. In very heavy work, short breaks can considerably
reduce the exertion while maintaining production. In addition, there should be a
review of the tasks to see whether they can be broadened to include physically less
demanding operations, for example, reading and writing, so that the phases of heavy
work can be alternated with tasks allowing for physical recuperation. In many work
situations, energetic load can be reduced through mechanization, improved equip-
ment and technical aids. In occupations where it is impossible to avoid elements
requiring extremely high physical demands, for example, for fire-fighters in rescue
work and the like, physical training must form part of the work so that a high physi-
cal capacity can be retained.

2.15  W
 HAT DOES THE LAW SAY ABOUT WORKING
WITH A HIGH ENERGY METABOLISM?
Within the EU there are no explicit work environment rules regarding work demand-
ing high energy metabolism. There is, however, a framework directive which in gen-
eral regulates the employer’s responsibility to ensure that employees can carry out
their work without risk to their health [Directive 89/391/EEC]. The practical conse-
quences of this mean that employees with jobs demanding a high energy metabolism
Work Demanding High Energy Metabolism 57

must be given clear freedom of action as regards breaks and pauses, consumption of
food and drink, and so on. Additionally, really heavy work should be alternated with
lighter work, for example, administrative tasks as described in the previous section.
Another piece of European legislation which has a certain bearing on this type of
work is a directive regulating the use of personal protective equipment [Directive
89/656/EEC]. In it, there are demands that protective recruitment should be designed
ergonomically and adapted to the employee. It is important to reduce the physical
load in occupations demanding higher energy metabolism in which personal protec-
tive equipment must be worn at the same time.

2.16  SUMMARY
This chapter deals with heavy physical work characterized by high energy metabo-
lism and which makes great demands on the body’s ability to take up oxygen. Almost
1/5 of the working population of Sweden and probably most other postindustrial
countries are considered to have an occupation with high energy metabolism. Heavy
physical work results in load on the respiratory and circulatory organs, and the rela-
tive load on the individual depends on how great a proportion of the individual’s
maximal capacity is used in the work. With a high relative load on the individual,
lactic acid is accumulated during the working day, and fatigue occurs. The load on
the  individual in a specific amount of work performed depends on factors in the
work—for example, how different operations are carried out, how the work is orga-
nized, and what equipment is used. The load is also affected by factors in the envi-
ronment, for example, how hot and humid it is. Additionally, there are individual
characteristics—for example, age—and lifestyle factors—for example, physical
activity and training—which are of great significance for individual load at a specific
exposure.
To avoid developing such fatigue that the individual has no energy to pursue active
and meaningful leisure time, it is recommended that the average load during an 8-h
working day should not exceed 33% of the individual’s maximal aerobic capacity.

REFERENCES
Ainsworth BE., Haskell WL., Leon AS. et  al. 1993. Compendium of physical activities:
Classification of energy costs of human activities. Med. Sci. Sports Exerc.
25(1):71–80.
Ainsworth BE., Haskell WL., Whitt MC. et al. 2000. Compendium of physical activities: An
update of activity codes and MET intensities. Med. Sci. Sports Exerc. 32(9):498–516.
Åstrand I. 1990. Arbetsfysiologi. 4th ed. Stockholm: Norstedts förlag (in Swedish).
Åstrand I., Åstrand PO., Hallbäck I., Kilbom Å. 1973. Reduction in maximal oxygen uptake
with age. J. Appl. Physiol. 35:649–654.
Åstrand PO., Rodahl K. 1986. Textbook of Work Physiology. 3rd ed. New York, NY: McGraw-
Hill Book Co.
Åstrand PO., Rodahl K., Dahl HA., Stromme SB. 2003. Textbook of Work Physiology.
Physiological Bases of Exercise. 4th ed. Champaign, IL: Human Kinetics.
Bernmark E., Wiktorin C., Svartengren M. et al. 2006. Bicycle messengers: Energy expendi-
ture and exposure to air pollution. Ergonomics. 49(14):1486–1495.
58 Occupational Physiology

Bonjer FH. 1971. Energy expenditure. In L. Parmeggiani (ed), Encyclopedia of Occupational

Health and Safety, pp. 458–460. Geneva: International Labour Organization.
Bruce R., Fisher LD., Cooper MN. et al. 1973. Separation of effects of cardiovascular disease
and age on ventricular function with maximal exercise. Am. J. Cardiol. 34:546–550.
Directive 89/391/EEC—On the introduction of measures to encourage improvements in the
safety and health of workers at work.
Directive 89/656/EEC—On the minimum health and safety requirements for the use by work-
ers of personal protective equipment at the workplace.
Edholm OG. 1966. The assessment of habitual activity. In K. Evang and K. Lange Andersen
(eds), Physical Activity in Health and Disease, pp. 187–197. Oslo: Universitetsforlaget.
Ekblom B., Hermansen L., Saltin B. 1967. Hastighetsåkning på skridsko. Idrottsfysiologi,
Rapport no 5. Stockholm: Framtiden (in Swedish).
Fallentin N. 1995. Tungt fysisk arbejde. In G. Sjögaard (ed), Arbejdsfysiologi, pp. 118–135.
Köpenhamn: Arbetsmiljöinstituttet (in Danish).
Hansson J.-E. 1970. Ergonomi vid byggnadsarbete. Research Report no. 8: Byggforskningen,
State Council of the Building Industry (in Swedish).
Jones DA., Round JM. 1990. Skeletal Muscle in Health and Disease. Manchester and New
York, NY: Manchester University Press.
Jørgensen K. 1985. Permissible loads based on energy expenditure measurements. Ergonomics
28(1):365–369.
Kroemer KHE., Grandjean E. 1997. Fitting the Task to the Human. A Textbook of Occupational
Ergonomics. 5th ed. London: Taylor & Francis.
Pernold G., Wigaeus Tornqvist E., Wiktorin C. et al. 2002. Validity of occupational energy
expenditure by interview. AIHA J. 63:29–33.
SWEA. 2009. The Work Environment 2009. Swedish Work Environment Authority and
Statistics Sweden. Work Environment Statistics, Report 2010:3 (in Swedish with
English summary).
Wigaeus Tornqvist E., Kilbom Å., Vingård E. et  al. 2001. The influence on seeking care
because of neck and shoulder disorders from work-related exposures. Epidemiology
12(5):537–545.

FURTHER READING
Nordic Council of Ministers. 2004. Nordic Nutrition. Recommendations 2004. Integrating
Nutrition and Physical Activity. 4th ed. Copenhagen: Nordic Council of Ministers.
 3 Work Requiring
Considerable
Muscle Force
Katarina Kjellberg

Photo: Joakim Romson

CONTENTS
3.1 Focus of the Chapter and Delimitations vis-à-vis Other Chapters..................60
3.2 What Characterizes Work Requiring Considerable Muscle Force?................ 61
3.3 Prevalence of Heavy Muscle Work in Working Life....................................... 62
3.4 The Structure and Function of the Musculoskeletal System........................... 63
3.5 Load on the Musculoskeletal System in Heavy Muscle Work........................64
3.5.1 The Relationship between Force and Motion......................................64
3.5.2 Factors Affecting the Size of Load...................................................... 69
3.5.3 Working Technique.............................................................................. 71
3.6 Gender Aspects................................................................................................ 72
3.7 Age Aspects..................................................................................................... 73
3.8 Physiological Responses to Work Requiring Great Muscle Force.................. 74
3.8.1 Acute Response.................................................................................... 76
3.8.2 Long-Term Effects............................................................................... 77
3.9 Disorders of the Musculoskeletal System Related to Heavy Muscle Work..... 79

59
60 Occupational Physiology

3.9.1 Mechanism of Injury........................................................................... 79

3.9.2 Pain...................................................................................................... 82
3.10 Risk Factors..................................................................................................... 83
3.11 Methods for Assessing Load on the Musculoskeletal System.........................84
3.11.1 Biomechanical Models........................................................................84
3.11.2 Electromyography................................................................................ 85
3.11.3 Measurements of External Exposure................................................... 86
3.11.4 Models and Checklists......................................................................... 86
3.12 Prevalence of Musculoskeletal Disorders as a Result of Heavy
Muscle Work.................................................................................................... 87
3.13 What the Law Says About Work Requiring Considerable Muscle Force........ 87
3.14 What Can Be Done to Reduce the Risks of Heavy Muscle Work?................. 89
3.14.1 Measures at the Workplace..................................................................90
3.14.1.1 The Work Task......................................................................90
3.14.1.2 Workplace Design.................................................................90
3.14.1.3 Organization of Work........................................................... 91
3.14.2 Measures at the Individual Level......................................................... 91
3.15 Summary......................................................................................................... 93
References.................................................................................................................94
Further Reading........................................................................................................97

Karen is 40 years old and works part-time at an orthopedic clinic in an emergency

hospital. She has been working as an assistant nurse for 20 years, the last three years
in the same ward. In the ward, patients who have fractures and who have undergone
various types of orthopaedic operations are cared for. These patients often need a
great deal of assistance during transfers, as many of them have recently had opera-
tions or are elderly. Karen assists patients during transfers about 10–15 times each
day. Her work otherwise consists primarily of changing dressings, taking samples,
patient bed care, taking round and collecting in meal trays, moving beds with patients
to and from operations, and unpacking material in the stores. Karen enjoys her work
but feels that patient transfers are heavy for her back. The ward is not big enough for
so many patients requiring care. The premises are cramped and access to technical
aids is poor. She also feels that her knowledge of transfer technique and the use of
technical aids are inadequate. She attended an introductory course in transfer tech-
niques when she started care work, and has since gone on short half-day courses on
three occasions, most recently 5 years ago. Karen has pain in her lower back from
time to time, particularly when she is assisting patients during transfers, during
patient care in beds and when she is moving patients’ beds. She has had short periods
of absence due to illness several times a year as a result of these problems.

3.1  F OCUS OF THE CHAPTER AND DELIMITATIONS VIS-À-VIS

OTHER CHAPTERS
This chapter deals with work requiring considerable muscle force—that is, a large
proportion of the muscle’s maximal contractile capacity. Work of this kind occurs
when the employee has to overcome considerable external forces, for example, the
Work Requiring Considerable Muscle Force 61

gravitational force of a load which is being lifted, or resistance from a patient bed
which has to be set in motion. This chapter describes the loads arising on the muscu-
loskeletal system in work requiring considerable muscle force, and physiological
responses to this load. High loads are often limited to the lumbar spine, the shoulder,
the forearm or knee joint, for example, which is why they are called local load.
Prolonged periods of heavy muscle work also involve demands being made on the
body’s ability to metabolize energy, and thereby on oxygen uptake and blood supply.
This energetic load is known as whole-body load. How energy metabolism adjusts to
increased energy demands is not dealt with in this chapter, but is described in
Chapter 2.
This chapter answers questions such as:

• What factors influence the load on muscles and joints in manual handling
of burdens and patient transfers?
• Is working technique of any significance?
• How should heavy muscle work be designed for an adaptation of muscle
strength to occur to meet the demands at work?
• What happens in muscles and other parts of the body during prolonged
heavy muscle work?
• Why does pain occur in the lower back when handling loads?
• What can Karen or her employers do to help her avoid problems in muscles
and joints?
• What can Karen do to keep on with this work right up until she retires?

3.2  W
 HAT CHARACTERIZES WORK REQUIRING
CONSIDERABLE MUSCLE FORCE?
In working life, considerable local loads arise primarily when the employee is per-
forming heavy manual handling. Manual handling is usually defined as transferring
loads where the employee, using muscle force, lifts, lowers, pushes, pulls, carries,
holds, or supports an object or living being [SWEA 1998; EUR-Lex 1990]. Another
common example of work requiring great muscle force is work using hand-held
machines and tools.
These types of work tasks are often dynamic in character, that is, the muscles
change their length and force when they contract. Often each task lasts only for a
relatively short period, for example, during a lift, but recurs on repeated occasions
during the working day. The muscle can then make use of almost 100% of its strength
(100% MVC—see Fact Box 3.1), and relax shortly thereafter. Repeated work opera-
tions requiring somewhat less muscle force over a longer period without time for
recovery are also counted as work requiring considerable muscle force, for example,
lifting goods in a warehouse for a large part of the working day. Carrying loads and
forceful grips when working with hand-held machines and tools may also require a
great deal of muscle force. In this case it is a question of uninterrupted work with few
breaks for rest over a longer period. All three types of work requiring considerable
muscle force—that is, occasional peak loads for short periods, repeated loads for a
longer period, and an uninterrupted load with few breaks for rest over a longer
62 Occupational Physiology

FACT BOX 3.1

MVC, Maximal Voluntary Contraction: MVC is a measure of the individual’s
maximal contractile ability, or maximal strength, in a particular muscle or
muscle group, or in a specific movement of the joint. MVC is measured in
terms of force (N) or torque (Nm).
%MVC, percentage of Maximal Voluntary Contraction: The development
of force in the muscle or muscle group, or in a specific movement of the joint,
relative to the individual’s maximal capacity. % MVC therefore expresses how
much the individuals exert themselves in relation to their muscle strength.

period—may lead to injury as a result of overloading the musculoskeletal system

(see Section 3.9.1).
Karen’s work with patient transfers involves major muscle groups, particularly in
the trunk and legs, and also in the arms and shoulders. Those muscles that effect the
transfer itself are naturally active, but so too are muscles used to ensure both that the
body is stabilized and does not yield to countervailing forces arising during the
transfer, and that the legs are firmly on the ground. Joints, tendons, and ligaments are
also subjected to considerable strain. Patient transfers make special demands on
staff, as patients are living individuals who have to be managed. Here it is not usually
a question of lifting an individual’s entire body weight from the ground, but of sup-
porting a patient who bears some of the weight on the legs, for example, when trans-
ferring between a bed and a wheelchair, or of pulling the patient higher up in the bed.
Patient transfers are often tricky to accomplish from a motor point of view, and make
considerable demands on staff regarding the coordination of movements and force
development, as well as their ability to cooperate with colleagues and patients.
Patients can be recalcitrant, and the staff have to be constantly prepared for unex-
pected events, such as a patient suddenly resisting or fainting. Often, care staff work
in confined spaces, which may impede safe work postures and safe working tech-
nique, therefore increasing the demands on muscle force. Entirely manual lifts are
necessary particularly in acute situations—when a patient unexpectedly collapses,
for example—and among rescue and ambulance personnel.
Forceful grips in work with hand-held tools, for example, among plumbers and
carpenters, put strain especially on the muscles of the hand and forearm.

3.3  PREVALENCE OF HEAVY MUSCLE WORK IN WORKING LIFE

Despite the fact that a great deal of the heavy work in, for example, industry has been
mechanized, automated, and replaced by modern technology, heavy manual han-
dling and other work requiring considerable muscle forces is still common in work-
ing life. These tasks will presumably never be completely replaced by, for example,
mechanical aids. This applies also to work within the nursing and care professions,
where manual transfer of people will never be entirely avoidable.
Heavy manual handling occurs in many commonly occurring occupations and is
more frequent among men than among women. According to the 2010 European
Work Requiring Considerable Muscle Force 63

Working Survey, 42% of working men and 24% of working women in European Union
(EU) countries reported that their work involved carrying or moving heavy loads at least
a quarter of the time [Eurofound 2010]. In contrast, 13% of women, but only 5% of men,
reported that they lifted or moved people at least a quarter of the time in their work.
Manual handling of people is thus more frequent among women than among men.
In Sweden, the proportion of the working population lifting heavy loads daily in
2009 was 10% of women and 18% of men [SWEA 2010a]. Heavy lifting is defined as
lifting at least 15 kg several times a day. It is worth noting that the same load, for
example, 15 kg, requires a greater proportion of the maximal strength for an average
woman than for an average man. It is, therefore, more difficult for a woman to lift
this weight. Heavy lifts are common in several female-dominated occupations, such
as assistant nurses and nurses’ aides within hospitals, among care assistants and
personal assistants in the care sector, and among preschool staff. For both women
and men, heavy lifts are common in warehouse work. Examples of other occupations
where heavy lifting is common for men are agricultural work, construction work,
carpentry, and work in the food industry.
No substantial change is taking place with regard to the prevalence of heavy man-
ual handling. In Sweden, between 1995 and 2009, the proportion of women working
with heavy lifts decreased from 16% to 10%, and the proportion of men from 22% to
18% [Statistics Sweden 2011]. The European figures given above for carrying heavy
loads remained unchanged since 2000 [Eurofound 2010].

3.4  T
 HE STRUCTURE AND FUNCTION OF THE
MUSCULOSKELETAL SYSTEM
The musculoskeletal system forms the basis of a person’s ability to perform move-
ments and develop force. It consists of the skeletal system and the muscular system.
These two systems are linked both structurally and functionally. The skeletal system
consists of bones and joints. The muscular system consists of skeletal muscles and
tendons. A skeletal muscle, consisting of groups of muscle bundles, runs together into
tendons. The tendons penetrate the bone tissue, which is how they provide the muscle
with a steady anchoring point in the skeleton. Functionally, the skeletal muscles
together with the skeletal system produce motion of the body parts and move the body
in space. They also help to support the body, that is, they keep the body in an upright
position and stabilize it during motion or in a particular position without motion.
A muscle acts across one or several joints through being attached to different
parts of the skeleton. A movement occurs in a joint by means of one or more muscles
contracting. The tensile force generated by the muscle is then transmitted to the
skeleton through tendons. Depending on where the muscle attaches in relation to a
joint, it will either produce a bending or extending of the joint. Muscles that have a
bending function, and others that have an extending function, operate across every
joint. Muscles that have the same effect across a joint are called agonists, and those
with an opposing effect are called antagonists. These muscles work together in com-
plicated patterns so that appropriate movements can be carried out. Antagonists may
also contract simultaneously so that no movement occurs in a joint, so-called
­co-contraction. This is a way to stabilize a joint.
64 Occupational Physiology

Apart from the skeleton, muscles and tendons, the musculoskeletal system also
consists of ligaments, joint capsules, cartilage, and nerves that innervate the muscles,
so-called motor neurons.
The musculoskeletal system is, in turn, a tool in a larger system for controlling
movements: the motor system. Also included in the motor system is the central ner-
vous system (CNS). The CNS sends out signals to the muscles based on previous
motor experiences and on information that the CNS acquires from sensory organs in
muscles, joints, and skin, for example.
The structure and function of the muscles are described in Chapter 6, Section 6.4.
The interplay between the nervous system and muscles is described in Chapter 6,
Sections 6.4.4 through 6.4.6 and also in Chapter 5, Section 5.4, where the role of the
CNS is explained. A basic description of the structure and function of the skeleton
and connective tissue may be found in textbooks on anatomy and physiology. An
important difference between muscles and connective tissue is that the former con-
tain contractile components, which means that the muscles can contract and produce
force, so-called active muscle force. The connective tissue also plays an important
role in joint motion by transmitting and resisting tensile forces and in a stretched
condition exerts force so as to return to their original length, so-called passive forces.
There is also connective tissue in the muscle. These passive structures therefore con-
tribute to motion and stabilization of the body parts.

3.5  L OAD ON THE MUSCULOSKELETAL SYSTEM IN

HEAVY MUSCLE WORK
In manual handling work, the muscles develop force to overcome or resist external
forces. In order to carry out a lift, the gravitational force of the object has to be over-
come. The gravitational force of the body parts—that is, the trunk, head, and arms—
also has to be overcome. In order to be able, for example, to push a hospital bed or a
wheeled stretcher when moving patients, the friction force between the wheels and
the floor has to be overcome. These external forces (external exposure in Figure 1.1;
see also Chapter 1, Section 1.2) give rise to forces acting on and within the various
structures of the musculoskeletal system (internal exposure in Figure 1.1; see also
Chapter 1, Section 1.2). Forces acting on and within the musculoskeletal system are
usually called mechanical load.

3.5.1  The Relationship between Force and Motion

Biomechanics may be defined as the application of the principles of mechanics to the
study of biological systems. The laws of mechanics are used to describe human move-
ments and the forces acting on various body parts during movement. They are also
used to describe how external forces give rise to load on the various structures of the
musculoskeletal system. In this section, the basic principles of biomechanics will be
explained very briefly, and are limited to those principles we need to know in order to
understand the relationship between external forces and loads on the ­musculoskeletal
system. In order to acquire a more fundamental understanding of the principles, the
reader is referred to textbooks in biomechanics (see Further Reading).
Work Requiring Considerable Muscle Force 65

According to the laws of motion, a force is required to start, stop, or change the
direction and velocity of the motion. This force is proportional to the magnitude of
the acceleration (i.e., the increase in velocity) or deceleration (i.e., the decrease in
velocity). The greater the accelerations or decelerations of the motion, the greater the
forces will be. This is the reason why measuring acceleration is an important com-
ponent in biomechanical studies in order to calculate forces.
If an object does not move, or is moving with a constant velocity (i.e., to say accel-
eration is 0), then the sum of all forces affecting the object is equal to 0. This also
means that, for the object to be able to be at rest or in dynamic equilibrium—that is,
to be able to move at a constant velocity—any force must be resisted by an equal and
opposite force. As an example, the gravitational force, that is, the force by which the
Earth’s force of attraction subjects all objects on its surface, is resisted by an equally
large reaction force for the force of gravity not to pull the object towards the interior
of the Earth.
In biomechanics we speak of external forces generated outside the human body
and internal forces generated within the body. The external forces are composed of
the gravitational forces acting on the objects we are working with, and the gravita-
tional forces on parts of our own body, as well as forces from, or applied to, external
objects, for example, when a person is pushing an object. The internal forces are
the  active muscle forces as well as passive tensions in, for example, the tendons,
­ligaments, fascia, and joint capsules. These internal forces may in turn cause so-
called compression and shear forces acting on the joints. A compressive force acts
perpendicular to the joint surface, pressing the joint surfaces against each other. One
example is the compressive force on the disc between the fifth lumbar vertebra and
the upper part of the sacrum (the L5/S1 disc), which is often calculated in assess-
ments of load on the lumbar spine. A shear force acts parallel to a joint surface, that
is to say, perpendicular to the compressive force, and tends to cause a joint surface to
slide in relation to the other joint surface.
A lever is an object that can rotate about an axis. According to the lever prin-
ciple, a force that acts on a lever has a pivoting or rotating effect on that lever. This
applies when the force does not act through the axis of rotation of the lever. The
rotating ability of the force is called the force’s moment (or moment of force,
torque). The effect of a force on a lever depends, on the one hand, on the magnitude
of the force and, on the other, on the length of the moment arm and can be calcu-
lated as:

Torque = Force × Moment arm,

where the moment arm is defined as the perpendicular distance from the action line
of the force to the axis of rotation. The rotating ability of the force, the moment, is
applied in a specific direction. In calculations, we consider the moments being
directed clockwise or anticlockwise. One precondition for an object that can rotate
being in balance is that the moments acting clockwise are equal to the moments act-
ing counterclockwise (torque equilibrium).
The ability of the muscle to produce motion thus depends not merely on the con-
tractive force of the muscle, as the moment arm of the muscle has an equal ­significance.
66 Occupational Physiology

10 kg

F×10

d/10 F

FIGURE 3.1  An example of unfavourable leverage in the muscles. When someone is hold-
ing a weight of 10 kg in their hand with a 90° angle at the elbow, the weight will cause an
external torque on the elbow joint which will extend the elbow joint. In order to maintain this
joint position, the elbow flexors have to produce an equally large internal torque. As the
weight’s moment arm (d) is 10 times longer than the moment arm of the elbow flexors (d/10),
the elbow flexors have to develop a force that is 10 times greater than the gravitational force
of the weight. The muscles therefore have to develop a force of ~1000 N (F × 10), which may
be compared with the gravitational force of the weight of ~100 N (F). In the example, the fact
that the weight of the forearm also contributes to the external torque is not taken into account.

When the muscle pulls at a muscle attachment, the bone acts as a lever and a move-
ment occurs in the joint. For the muscle, the moment arm comprises the right-angled
distance from the direction of pull of the muscle to the axis of rotation (Figure 3.1).
In biomechanics, we also talk about external torque, caused by external forces,
and internal torque, caused by internal forces. In order for the position of a joint to
be maintained, or a body posture to be sustained, the external and internal torques
therefore have to be equal—that is, balanced (Figure 3.1). In order to carry out a
movement, the muscles have to achieve an internal torque that exceeds the external
torque caused by gravitational forces and any other external forces. As the muscles
usually have much shorter moment arms than the external forces, the internal forces
may become very great, even with small external loads.
In the two calculation examples (Examples 3.1 and 3.2) that follow, biomechanical
calculations are made for load on the lumbar spine when a man is standing holding a
weight in front of him (Figure 3.2). The gravitational force of the load and his own body
weight cause an external torque which wants to bend his upper body forward. In order
to counteract this, the back muscles have to produce an internal torque in the opposite
direction, which is of equal magnitude to the one that wants to bend his upper body
forward. If the load is to be moved—that is, lifted—the internal torque has to exceed
the external torque. As the moment arms of the muscles are short in comparison with
those of the external forces, great muscle force has to be developed which, in turn,
compresses the discs between the vertebrae of the back. A rule of thumb is that the back
muscles have a moment arm of ~6 cm in relation to the L5/S1 disc [Jorgensen et al. 2001,
Work Requiring Considerable Muscle Force 67

2003]. In Calculation Example 3.1, the muscle force of 2292 N may be compared with
the combined gravitational force of the upper body and the box of 450 N. This means
that the back muscles have to work with a contractive force which is approximately five
times greater than the total gravitational force of the upper body and the box.

Calculation Example 3.1

A man weighing 80 kg and who is 180 cm tall stands bent forward holding a
very light but bulky box in front of him (Figure 3.2a). The system is regarded as
being in equilibrium—that is, no movement is occurring. The calculations are
carried out in relation to the axis of rotation in the disc between the L5 vertebra
and the sacrum (L5/S1 disc). The fact that the weight of the box and the body

(a) (b)

dU
dU X
X dB
dB

FB
FU FB
FU

F B = 10 N d B = 0.55 m F B = 150 N d B = 0.30 m

F U = 440 N d U = 0.30 m F U = 440 N d U = 0.15 m

FIGURE 3.2  A man standing, leaning forward, holding a very light but bulky box in front
of him (a), and standing upright holding a smaller, but heavier box in front of him (b). FB = the
gravitational force of the box in Newtons (N); FU = the gravitational force of the upper body
in Newtons (N); dB = the moment arm of the box in relation to the L5/S1 disc; dU = the moment
arm of the upper body in relation to the L5/S1 disc. For calculations, see calculation
Examples 3.1 and 3.2.
68 Occupational Physiology

segments above the L5/S1 joint also contributes to a direct compression of the
disc has not been taken into account.
Mass of the box: 1 kg.
Moment arm of the box: 0.55 m.
Mass of the upper body: 44 kg.
Moment arm of the upper body: 0.3 m.
The bending-forward torque (= the external torque) on the L5/S1 disc:
Contribution of the box: 10 N × 0.55 m = 5.5 Nm.
Contribution of the upper body: 440 N × 0.3 m = 132 Nm.
Total external torque: 137.5 Nm.
Total internal torque (=extending torque): 137.5 Nm.
Moment arm of the extensor spinae muscles: 6 cm.
Contractive force in the extensor spinae muscles = compressive force
on the L5/S1 disc: 137.5 Nm/0.06 m = 2292 N.

Calculation Example 3.2

The same man, as in Calculation Example 3.1, is standing upright and holding a
smaller but heavier box in front of him (Figure 3.2b). The calculations have been
made in the same way as in the previous calculation example.
Mass of the box: 15 kg.
Moment arm of the box: 0.3 m.
Mass of the upper body: 44 kg.
Moment arm of the upper body: 0.15 m.
The bending-forward torque (=the external torque) on the L5/S1 disc:
Contribution of the box: 150 N × 0.30 m = 45 Nm.
Contribution of the upper body: 440 N × 0.15 m = 66 Nm.
Total external torque: 111 Nm.
Total internal torque (=extending torque): 111 Nm.
Contractive force in the extensor spinae muscles = compressive force
on the L5/S1 disc: 111/0.06 = 1850 N.

The two different work situations in the calculation examples may be compared.
This illustrates the relative importance of the body’s contribution to the load on the
lumbar spine in different work postures, and how much extra great load an external
weight may add. Calculation Example 3.1 shows that the load arising from the body’s
own weight in an awkward work posture may represent a large proportion of the total
load. In Calculation Example 3.2, the man is standing in a more favourable work pos-
ture and holding a smaller but heavier box. Here the weight of the box makes a greater
contribution to the load.
The moment arm of the muscle is not constant, but varies depending on the joint
angle, which means that the moment produced by one and the same muscle force
changes during a movement. Inversely, a constant moment requires that muscle
force varies during movement.
Lifting, in particular, has been the subject of a large number of biomechanical
studies over the years [van Dieën et al. 1999]. For the most part, it is the ­compressive
Work Requiring Considerable Muscle Force 69

force on the L5/S1 disc that is being calculated, as this is regarded as a risk factor for
the development of low back pain. The biomechanical models are based on simpli-
fications and assumptions, which means that the forces calculated may be both
underestimated and overestimated. Biomechanical analysis is described further in
the section on methods for assessing load on the musculoskeletal system (see
Section 3.11.1).

3.5.2  Factors Affecting the Size of Load

On the basis of biomechanical principles, a number of fundamental work factors may
be distinguished that are important for the size of load on the local muscles and
joints. These are factors that should be taken into account in risk assessments of dif-
ferent jobs and in efforts to prevent injuries as a result of heavy muscle work. In
manual handling, it is primarily the following factors that are important for the size
of the load on the lumbar spine:

1. The weight of the object

2. The position of the object relative to the body
3. The body weight
4. The body posture
5. The degree of symmetry/asymmetry of trunk movements
6. The velocity and acceleration of the movements

In lifting, the weight of the object (point 1) is obviously important for the size of load
on the lumbar spine. If the other conditions of the lift are the same, there is a proven
linear correlation between the weight of the object and the compressive force on the
lumbar spine.
Points 2 and 4 are significant for the moment arms of the external forces which,
according to the lever principle, are important for the size of the load. If an object
being lifted is held close to the body, the moment on the lumbar spine (point 2) is
reduced. The size and shape of the object affect the length of the moment arm. A
large bulky object means that the moment arm is long (Figure 3.2). The work posture
of the individual (point 4) affects the moment arms of both the object and the gravi-
tational forces of the individual’s own body segments (Figure 3.2). If the individual
performing the lift bends the trunk forward, the moment arms of both the object and
upper body weight are longer than when the individual is standing upright.
The body weight of the individual lifting also contributes to the load on the lum-
bar spine (point 3). In some work postures the load arising as a result of the body’s
own weight may represent a large proportion of the total load (see Calculation
Example 3.1). Even in work situations without manual handling of objects, the load
on the lumbar spine may be great if the employee is standing in an awkward work
posture, that is, the work posture in itself may cause considerable load.
Additionally, the body posture of the individual is decisive for the distribution
between compressive force and shear force, which acts on the back when lifting, for
instance. The more the back is bent forward, the greater the shear force acting
between each pair of vertebrae (Figure 4.5).
70 Occupational Physiology

In asymmetrical movements in the trunk—that is, when the lift is performed

while twisting the back—the load is particularly unfavourable on the spinal col-
umn (point 5). This is because there is tensile stress on the fibrous ring of the
vertebral disc (annulus fibrosus) when the vertebrae above and below rotate in
relation to each other. Tensile stress of this kind in combination with high com-
pressive forces on the disc when lifting may cause injury to the fibrous ring. A lift
may also be asymmetrical without twisting the back. When we lift or carry a load
with one hand, the muscles on the opposite side from the lifting hand are acti-
vated to stabilize the back, so that we do not lean to one side. Holding a load in
one hand may cause more than double the compressive force acting on the L5/S1
disc compared with the distribution of the load equally between both hands.
When lifting with one hand during movement, these effects are, however, not as
clear-cut [Cole and Grimshaw 2003].
The greater the accelerations or decelerations in a movement, the greater the mus-
cle forces required (point 6). Lifting a box rapidly from the ground therefore requires
a greater muscle force than lifting it slowly. It should be pointed out that this applies
to the maximum muscle force required during a lift—that is, the peak load—and not
the overall load across the entire lift, which may very well be greater when the lift is
carried out slowly.
There are, of course, a number of other factors that in different ways may affect
load in manual handling. Examples of factors of this kind are the ease with which the
object may be grasped, requirements for precision, space, the condition of the floor
(e.g., whether it is uneven, slippery, or unstable), unsuitable shoes, work pace, and
staffing (i.e., to say the opportunity of cooperation). Work requiring considerable
muscle force, as well as precision in work with hand-held tools, places great demands
on the stability of the joints. As has been mentioned earlier, this stabilization is often
achieved by muscle contraction on both sides of the joint to be stabilized (see Section
3.4). Cocontraction of this kind adds to the load on the joint. A specific problem
arises when the employee does not know what a particular load weighs, or how the
weight within it is distributed. Both unexpectedly light and unexpectedly heavy
loads may cause problems, on the one hand, because too much effort is used and one
loses balance, and on the other hand, because too little force is applied, which means
that the movement is unexpectedly brought to a halt, possibly leading to overload and
injury to the lumbar spine, for example.
The internal load gives rise to physiological responses in the various structures of
the musculoskeletal system, which in turn, if one is unlucky, may give rise to injury.
This will be described in subsequent sections. Of great significance for how the
physiological responses develop is not only the muscle’s contractive force (ampli-
tude) but also the time aspect; that is, how long the muscle contracts (duration), how
often it contracts (frequency), and how long it is allowed to rest and recover between
each work period (Figure 1.2). Similarly, the time aspect is important when we are
studying loads on other structures in the musculoskeletal system. For instance, in
order to be able to assess the physiological responses to lifting objects of a certain
weight, it is not sufficient to know the load level on the L5/S1 disc; we must also take
into account how often the lift is performed during the working day, and the time
between lifts.
Work Requiring Considerable Muscle Force 71

3.5.3  Working Technique

Some of the factors determining the size of load on the body—during a lift, for
example—are determined by the work task itself, by how the workplace is designed
and how the work is organized. The individual employee can influence other factors
through the choice of working technique [Kjellberg 2003]. Working technique is the
individual’s way of “translating” an external mechanical exposure—that is, a work
task—into an internal exposure (see Chapter 1, Section 1.2, Figure 1.1). Working
technique may, on the one hand, be regarded as (1) the motor performance of a task,
on the other, as (2) how the individual organizes the task and designs the workplace
where that task is to be carried out.
The same movement or motor task may be carried out using a number of different
combinations of joint movements and development of force in different muscles (see
Chapter 5, Section 5.4.4). An example of variations in the motor performance is that
different individuals exert themselves to different extents in performing the same
work task. We can recruit a different number of muscles, use a different amount of
muscle force, and activate counteracting muscles at the same time (cocontraction) to
varying degrees. Another example is that we can work with moment arms of differ-
ent lengths.
In lifting or in transferring a patient, the load or the patient may be held close or
far away from the body. We can work slowly or quickly, smoothly or jerkily. An
apparently simple task such as lifting a box from the floor up onto a table may be
carried out in many different ways. One may, for example, bend one’s back and knee
joints to varying degrees and in different time patterns, activate different muscles
and to different extents. Patient transfer is a more complicated task, and here one
might expect even greater variations between individuals as to how to carry out a
specific transfer. Each individual has a unique way of moving, for example, a unique
gait pattern. The movement patterns of an individual presumably comprise the basis
for their individual working technique.
An example of the second aspect of working technique may be that a load can be
divided up into smaller portions. The working heights can be adjusted, more space
created, and help provided by using a technical aid or help from a colleague. Hospital
beds are often height-adjustable. The space can be adjusted by moving objects
restricting the available space or by choosing to carry out the task in a place where
there is sufficient space—for example, choosing the largest toilet on a hospital ward
when the patient needs help moving between a wheelchair and the toilet. In patient
transfer, patients can be encouraged to help out and in this way the loads to which the
care staff are subjected are reduced.
There is no unanimous evidence that any specific lifting or patient transfer method
is the best one to use in all lift or transfer situations. As an example, we might men-
tion the innumerable studies comparing the stoop lift with the squat lift, where the
results have been rather contradictory [van Dieën et al. 1999]. A stoop lift implies a
lift performed by straight legs and bending the trunk forward, a squat lift is a lift
performed by bending the knees and keeping the back straight. Both methods have
their advantages and disadvantages. As regards compressive force on the lumbar
spine, the squat lift is preferable if the load is lifted from a position between the feet.
72 Occupational Physiology

If that is not possible, for example, if the weight is bulky and has to be lifted in front
of the knees, the load is approximately the same size in the squat lift as in the stoop
lift. The reason for this is that in this situation the squat lift does not result in a
shorter moment arm than the stoop lift. As far as shear forces on the lumbar spine
are concerned, these have proved to be higher in stoop lifts compared with squat
lifts. Lifting using the squat lifts also requires more energy, as the entire upper body,
which is lowered when we bend our knees, also has to be moved vertically. In
repeated lifting, the squat lift may be felt to be more tiring, especially for the thigh
muscles, which extend the knees. When people have not been taught to use a specific
lifting method, they often use a technique which is a cross between the squat lift and
stoop lift [Straker 2003].
The individual’s choice of working technique is governed and restricted by a
number of factors in the work situation, such as the character of the work task
(e.g., a patient’s weight and functional ability), workplace design (e.g., space), and
work organization (e.g., staffing and time pressures). The choice of working tech-
nique is also governed and restricted by individual conditions such as physical
capacity (including muscle strength), coordination skills, body size, experience,
and knowledge [Kjellberg 2003]. The individual therefore adapts their working
technique to the situation in which the task is to be carried out as well as to their
own abilities.
The same individual may also vary their working technique on different occa-
sions in performing a specific task. To what extent an individual can, for example,
repeat their lifting technique in a specific lifting task depends, in part, on their expe-
rience and skill. One precondition for the individual to be able to repeat the same
movement pattern and development of force is that the lifting technique has become
second nature and that a motor program has been created for this skill. This means
that the lift is “automated,” and can be carried out without any conscious control of
movements. We may compare this with techniques in sports, where the ability to
repeat the movement pattern is decisive for good sporting achievements. An inexpe-
rienced beginner finds it difficult to repeat a movement pattern from time to time.
This may be the reason why unnecessarily large loads sometimes occur. At the same
time, a standardized working technique is not always preferable as far as load on the
musculoskeletal system is concerned. If a task has to be carried out frequently, a
varied movement pattern may result in the load being distributed across different
structures, which reduces the risk of injury.
In manual handling work it often happens that employees receive training, for
example, in lifting and transfer techniques. What characterizes a good working tech-
nique and measures to promote good working technique on the part of employees
will be dealt with in Section 3.14.

3.6  GENDER ASPECTS

Different people have different preconditions, or physical capacity (see Chapter 1,
Sections 1.2 through 1.4), to carry out physically heavy work, which also affects their
physiological responses. The same internal exposure (see Chapter 1, Section 1.2 and
Section 3.5) ­produces differing physiological responses in ­different employees
Work Requiring Considerable Muscle Force 73

depending on variations in their physical capacity. There are differences between

women and men in their capacity to cope with work tasks requiring large muscle
force, among others, differences in muscle strength and aerobic capacity (see Chapter
2) and, possibly, differences in coordination skills and motor patterns.
Women’s maximal muscle strength is on average lower than that of men, which
primarily results from men having larger muscle fibres and thus greater muscle mass.
The difference in strength between the genders is greater in the upper extremities
than in the lower. Women’s maximal muscle strength in their legs is on average
~65–75% that of men, in their trunk muscles it is 60–70%, while in their elbow
muscles it is only 50% [Åstrand et al. 2003, Chapter 8]. There is, however, a wide
distribution in muscle strength within the two genders, which means that there are
women who are stronger than men within the same age group. Women’s lower maxi-
mal strength means that a job requiring certain strength, for example, lifting an
object weighing 15 kg, will require a greater proportion of women’s capacity com-
pared with men’s. An average woman therefore becomes more tired than an average
man when lifting something.
Differences in working technique have been observed between men and women,
for example, in the lifting technique [Lindbeck and Kjellberg 2001]. Differences of
this kind presumably result, in part, from the fact that women have to adapt their
technique and compensate for lower muscle strength in heavy manual handling
work. The differences may also originate in gender differences in the flexibility of
joints and muscles, anatomical differences, and possible differences in coordination
skills and motor patterns. In sports, it has been shown that gender differences exist
in, for example, running and throwing techniques. Differences between the genders
have also been shown in the neuromuscular function and the ability of the muscles
to develop force; for example, men have more rapid development of force.
The design of workplaces is sometimes better suited to certain individuals and
less well suited to others. As an example, working heights may be poorly adapted for
both short and tall individuals to be able to work optimally. Often, workplaces are
suited to men’s dimensions (anthropometrics), which results in disadvantages to
women.

3.7  AGE ASPECTS

People’s capacity to cope with work requiring considerable muscle force declines
with increasing age; among other things, muscle strength, aerobic capacity (see
Chapter 2), and certain motor functions (see below) decrease.
Maximal muscle strength is achieved generally at around the age of 20, and
then declines gradually [Åstrand et al. 2003, Chapter 8]. The strength of a 65-year-
old is on average 75–80% that of the strength of a person between 20 and 30 years
of age. After 65 years of age, a more rapid decline in strength occurs. There are,
however, major differences between individuals as to when this accelerating
decline begins, which depends, among other things, on how much physical activity
the individual is engaged in. The extent of the decline with age is greater in the leg
and trunk muscles compared with the arm muscles. The declining muscle strength
74 Occupational Physiology

with age depends largely on the fact that the muscle mass decreases (see Chapter 6,
Section 6.8).
Aging also brings with it changes in the properties of the motor units, that is to
say in the neuromuscular function [Enoka 2008, Chapter 9]. Reaction time increases,
the balance deteriorates, and the ability to control submaximal force (e.g., maintain-
ing a constant grip force) declines. It is unclear as to what extent deterioration in
motor ability with age is a result of aging in itself or that we engage in less physical
activity with increased age.
The fact that physical activity declines with increasing age means that an imbal-
ance may occur between the physical demands of work and the individual’s physical
capacity, which implies that the reserve capacity of the aging employee diminishes
[de Zwart et al. 1995]. This may have the consequence that the older employee is
more often subjected to loads that are too great in relation to their physical capacity,
and more often has poor recovery compared with a younger employee.
One means of coping with the physical demands of work is that the ageing
employee develops compensatory strategies—that is, changes their working tech-
nique [de Zwart et  al. 1995]. This may be a question of using technical aids to a
greater extent, enlisting the help of workmates, and working at a slower pace. How
much the older employee can alter their working technique depends on how much
decision latitude they have in the work situation. The experience one acquires at
work with increasing age means that one becomes more skilful and efficient in car-
rying out the tasks, which presumably often compensates for a diminishing physical
capacity. For older employees, it is particularly important to have the opportunity of
exercising control over their work situation, so that they can adapt the work to their
capacity and ability. Rigid control, a lack of breaks, and a high work pace may result
in older people being excluded from physically heavy work.

3.8  P
 HYSIOLOGICAL RESPONSES TO WORK REQUIRING
GREAT MUSCLE FORCE
The motor system is characterized by great adaptability [Enoka 2008, Chapters 8
and 9]. When the system is subjected to a new load, it adapts to these new demands
by building up its capacity. The cells and tissues in the muscles and connective tis-
sue, circulation system, and energy metabolism, as well as the control of movements,
are all adapted. Changes are specific, that is, only the functions used in a particular
physical activity, such as a particular work task, will undergo adaptation. Adaptations
are also transient. As soon as a physical activity ceases, the system will adapt to the
new, lower load requirements.
The mechanism underlying this adaptability consists of the constantly ongoing
remodelling process (see also Chapter 6, Section 6.11.3, Figure 6.7). Cells and tissues
in the body are continually renewed by degradation and reconstruction. The normal
aging process means that the degradation is somewhat greater than the reconstruc-
tion, that is to say there is a gradual degeneration in the tissues of the body with
increasing age. This ageing process is presumably governed by the genes. The deg-
radation process proceeds at different rates in different individuals depending on
Work Requiring Considerable Muscle Force 75

genetic factors and lifestyle. The degradation is, in part, retarded and counteracted
by physical activity. Subjecting oneself to mechanical load stimulates, and is neces-
sary for, reconstruction and growth. The load must not, however, be so great that the
tissues are damaged. A lack of load produces the opposite effect, that is, it stimulates
a more rapid degradation of cells and tissues. In other words, both too little and too
much load can weaken and damage the musculoskeletal system; the optimal load for
the tissues is something in between.
With a new mechanical load, breakdown of the tissues initially takes place (the
so-called acute response, see Chapter 1, Section 1.2 and Fact Box 3.2) (Figure 3.3).
If there is sufficient time for recovery, not only does reconstruction take place, but
also a reinforcement of the tissues occours (the so-called training effect) [Åstrand
et al. 2003, Chapter 11; Enoka 2008, Chapter 9]. An adaptation of this kind presup-
poses that the load is greater than that to which the individual is commonly sub-
jected, but that it is not so great as to cause damage to the tissues. The load must also
be of sufficient duration, and recur at regular intervals. A training effect is more
prolonged than the acute response, but is still reversible (so-called long-term effect—
see Fact Box 3.2). A lack of recovery or too high a load may, on the other hand, lead
to the opposite effect. The tissues are not reconstructed and micro-injuries accumu-
late in the tissues. If degradation of the tissues of this kind is allowed to continue for
a long period, it may develop into irreversible damage.
The physiological responses (the training effects) of work requiring great muscle
force are, under optimal conditions:

• Greater strength and endurance in the muscles.

• Greater strength in the connective tissues.
• Improved control of movements, that is, improved coordination and balance.
• Increased capacity of the circulation system and a more appropriate energy
metabolism (see Chapter 2).

FACT BOX 3.2

Acute response: The immediate response from the motor system, when it is
subjected to a new load on a single occasion of physical activity. The acute
response to mechanical load often implies a degradation of tissues. The pro-
cesses are short term and reversible, that is, they revert quickly to their original
state when the load ceases.
Long-term effects: The cumulative responses from the motor system when
subjected to load under recurrent physical activity for a longer time period.
Under optimal conditions—that is, at the correct combination of amplitude,
frequency, and duration of load—the long-term effects mean a buildup of the
tissues (training effect). These adaptations are often long term, but reversible
when the load ceases. Long-term effects may also, under non-optimal condi-
tions, mean a continual degradation of tissues and impaired tolerance of new
loads. The tissues become more vulnerable to injury. If this process continues
for a long period, changes of this kind may become irreversible.
76 Occupational Physiology

Reconstruction
Degradation
Capacity

Loading Recovery Time

FIGURE 3.3  Degradation and reconstruction of tissues and capacity as an effect of a new
load exceeding the load to which the system is usually subjected. If there is sufficient time for
recovery, not only reconstruction of what has degenerated takes place, but also a reinforce-
ment of the tissues (training effect).

3.8.1  Acute Response

Heavy muscle work may lead to fatigue in the muscles. Muscle fatigue may be
defined as an exercise-induced impairment of the muscles’ ability to produce force,
and may be caused by a number of different physiological changes in the muscles
[Åstrand et al. 2003, Chapter 15; Enoka 2008, Chapter 8]. Muscle contractions arise
as a result of a long chain of processes, which is described in Chapter 6, Sections
6.4.4 and 6.4.5. Muscle fatigue can arise as an impaired function at each stage in this
chain, both at the central level and peripherally in the muscle cells. This means that
there is no single cause of muscle fatigue that may be applied to all types of work or
all levels of muscle activity. Muscle fatigue is an appropriate adaptation to heavy
work. The perceived fatigue is a clear signal that the muscle needs to rest so that
injury does not occur. In a force development close to the maximum (100% MVC—
see Fact Box 3.1), the muscle becomes fatigued within a few seconds, because
the local energy substrates that power the contraction run out. When the muscle is
working uninterruptedly, in what is called static muscle activity (see Chapter 6,
Section 6.6), at ~50% of its maximal capacity (50% MVC), its endurance time is
approximately 1 min. An example of work of this kind is carrying a heavy load. In
uninterrupted work at 30% MVC, the endurance time is approximately 3 min. If the
muscle rests between contractions—that is, in dynamic muscle activity—the endur-
ance time is longer. Muscle fatigue is normally reversible, and the muscles recover
during rest from work. How long this recovery takes depends on which type of work
has caused the fatigue. When muscle fatigue has arisen as a result of high load over
a short period, the time required for recovery is shorter compared with its having
arisen over a long period of work at low load levels. Many heavy lifts one after the
other lead quickly to fatigue in the muscles, but recovery also occurs relatively
quickly.
After heavy muscle work which the individual is not used to, delayed onset muscle
soreness may arise [Åstrand et al. 2003, Chapter 11; Enoka 2008, Chapter 8]. This is
Work Requiring Considerable Muscle Force 77

also a reversible process, but with a somewhat longer time horizon than for muscle
fatigue. The condition is characterized by tenderness, stiffness, and weakness in the
muscles, appearing approximately 24–48 h after the physical exertion and lasting
approximately 3–5 days. Delayed onset muscle soreness is presumably the result of a
local inflammatory reaction, but there is no generally held view among researchers
as to the mechanisms behind such pains. What we do know is that it is more common
that eccentric work (see Chapter 6, Section 6.6) triggers delayed onset muscle sore-
ness. One cause may be mechanical damage to the connective tissue of the muscle.
Muscle biopsies have also revealed damage to the structure of the muscle fibres.
Delayed onset muscle soreness also constitutes a warning signal that a rest period
from heavy work is necessary, so that injury does not occur in the muscles involved.
If, after delayed onset muscle soreness has subsided, the work that triggered the
pains is repeated a number of times, the symptoms will gradually decline.

3.8.2  Long-Term Effects

When someone starts strength training, their muscle strength during the first weeks
may increase by 20–40% without an increase in muscle size [Åstrand et al. 2003,
Chapter 11]. This is because the initial training effect consists only of adaptations in
the nervous system. The ability to activate the muscles increases, for example,
through a greater synchronization of the motor units in such a way that they dis-
charge action potentials at the same time to a greater extent (see Chapter 6, Sections
6.4.4 through 6.4.6). The synchronization of synergistically acting motor units
increases, while the activity of antagonistic units decreases, that is to say, coactiva-
tion decreases. If the training continues, an adaptation also occurs in the muscles
after 4–8 weeks, primarily through the cross-sectional area of the muscle fibres
increasing (hypertrophy) (see Chapter 6, Section 6.4.3). The effect of strength train-
ing is specific, that is, the increase in strength is most pronounced at exactly the joint
position and in the movement in which the muscle has been trained.
Heavy muscle work can also increase muscle endurance. In the context of train-
ing one distinguishes between strength training and endurance training. In endur-
ance training, the ability of the muscles to make use of energy efficiently is improved.
The capacity for aerobic metabolism (see Chapter 2, Section 2.4) is improved through
increasing the number of mitochondria and capillaries, and thereby the ability of the
muscles to use oxygen and nutrients to form ATP. The ability to make use of fat as
an energy source also increases.
Heavy muscle work does not, however, always provide the training effect in mus-
cle strength that one might expect. On the contrary, prolonged physical load at work
seems to be able to reinforce the age-related degradation of muscles and other tissues
(see Section 3.7). In younger people, greater muscle strength has been found in indi-
viduals with heavy manual work compared with individuals with sedentary work
[Era et al. 1992; Tammelin et al. 2002], but this may result from a selection of young
strong individuals to occupations of that kind. In middle-aged or older individuals,
in contrast, several studies have shown that employees with heavy physical work in
general seem to have lower muscle strength compared with those with a low physical
load at work [Era et  al. 1992; Nygard et  al. 1988; Torgen et  al. 1999]. Muscle
78 Occupational Physiology

e­ ndurance and physical fitness have also been shown to be worse. The absence of the
training effect of heavy work may result from a monotonous, excessive load on indi-
vidual muscles over a long period of time in combination with insufficient time for
recovery and reconstruction. Moreover, the older employee often has a lower reserve
capacity as a result of their declining muscle strength (see Section 3.7), which pre-
sumably causes the load more often to be too high and recovery often to be insuffi-
cient in comparison with a younger employee. For the work to have a constructive
effect, it should presumably involve variations in the load with alternating light and
heavy loads, variation in which muscles are loaded, and sufficient time for recovery
between loads. In many types of work requiring great muscle force, for example,
Karen’s work with patient transfer, the load is presumably also too sporadic to pro-
duce a training effect. Working life seldom provides the correct combination of
amplitude, frequency, and duration. There have also been discussions on whether
one explanation as to why heavy work does not always result in an increased physical
capacity might be that individuals with physically heavy work devote themselves to
a lesser extent to physical training in their leisure time compared with individuals
with sedentary work.
The load on the skeleton during heavy work yields a stronger and more solid
skeleton. Of greatest significance is load in a longitudinal direction, that is, carry-
ing one’s own body weight and possibly other loads. The skeleton adapts to
mechanical load through the load stimulating bone growth and reconstruction in
the constantly ongoing remodelling process (see Chapter 6, Section 6.11.3). From
20 years of age onward, a gradual loss of bone tissue and bone minerals takes place
as a result of the fact that the amount of bone tissue built up is somewhat less than
the tissue that degenerates [Åstrand et  al. 2003, Chapter 7]. The skeleton also
changes in its composition and becomes more brittle (osteoporosis). This loss
increases with advancing age, as the degradation becomes greater in relation to the
new growth. The loss also becomes more rapid if the skeleton is not subjected to
mechanical load.
Heavy manual work that involves the joints regularly being exposed to short-
term load may have positive effects on the joint cartilage. Repeated short-term
loads of a cyclical character stimulate the construction of cartilaginous tissue and
make it harder and thicker [Åstrand et al. 2003, Chapter 7]. An acute effect of cycli-
cal load is that the joint cartilage swells and increases in thickness, which may hap-
pen in just a few minutes. This is caused by fluid seeping into the cartilage from its
surroundings when the cartilage is alternately pressed together and released (like a
sponge). The increased fluid content in the joint cartilage means that the contact
surfaces in a joint increase, and the compressive force per unit of area decreases,
which reduces the risks of injury to the joint. One way of preventing overload of the
joints in heavy work, therefore, is to warm up beforehand. The supply of nutrients
to the cartilage also depends on this mechanism. In inactivity, the supply becomes
insufficient, which means that the cartilage breaks down. Prolonged continuous
loads, or loads that are too great, can also injure the cartilage and may lead to its
degradation. Both too little or too much load thus contributes to the degeneration of
joint cartilage. The changes are, however, conditioned by age and heredity to a
great  extent. With advanced age, the joint cartilage gradually degenerates, for
Work Requiring Considerable Muscle Force 79

example, the discs in the spinal column and the joint cartilage in the hip and knee
joints. The fluid content decreases and the cartilage becomes less elastic. The degree
of degeneration varies strongly between different individuals. These changes may
lead to arthritic changes in the joints. It is unclear as to what extent physical load at
work may affect the development of degeneration of joint cartilage and discs in the
spinal column.
Tendons and ligaments also adapt to a greater mechanical load by becoming
stronger and stiffer. Muscle work that puts strain on tendons and ligaments causes
the cross-sectional area to increase and the properties of the connective tissue to
change so that it becomes stronger per unit of area [Åstrand et al. 2003, Chapter 7].
Increased stiffness in a tendon increases its ability to transfer force from the muscle
to the bone. In both tendons and ligaments, the ability to resist external forces
increases, as well as the ability to develop force from a stretched condition. The
absence of load has the opposite effect, with reduced strength and stiffness. The
tendon, including its attachments to muscle and bone, has a poorer capability of
adapting than the muscle, as muscle has a greater ability for metabolic activity. This
may result in an imbalance in strength between the tendon and muscle, when the
mechanical load increases, and in a risk of overload injuries.
The control of movements also undergoes an adaptation when we are given work
tasks requiring great muscle force. The more number of times the same task is per-
formed, the more automated the force development and motor patterns become (see
Chapter 5, Section 5.4). Automation usually leads to better coordination of muscle
efforts and movements, and greater economy of movement—that is, less energy is
used to carry out a specific task. Automated motor patterns are difficult to change,
and it is important to practise appropriate and sustainable habits from the beginning
(see Section 3.5.3).

3.9  D
 ISORDERS OF THE MUSCULOSKELETAL SYSTEM
RELATED TO HEAVY MUSCLE WORK
Musculoskeletal disorders reported by employees with heavy muscle work are
­primarily localized in the lower back, but also in the neck, shoulders, arms, hands,
hips, and knees. The acute physiological responses to mechanical load described in
the previous section—that is, muscle fatigue and delayed onset muscle soreness (see
Section 3.8.1)—may be seen as signals that the muscle needs rest, thus providing
protection against overload. Problems in the form of discomfort, aches, and pains
may also be the first signal that an injury is occurring and that something in the
individual’s work situation or working technique needs to be altered to avoid this.
One way to prevent chronic, irreversible injury to the musculoskeletal system is,
therefore, to be watchful for early signs of this kind.

3.9.1  Mechanism of Injury

Most researchers agree that too great a mechanical load can give rise to injury to the
various structures of the musculoskeletal system, but the exact mechanisms behind
the injuries have not been clarified. Many tasks involving handling heavy objects or
80 Occupational Physiology

people give rise to loads approaching the tolerance levels of the tissues. In certain
conditions, and for certain individuals, this limit is exceeded and injury occurs.
Different individuals have different degrees of sensitivity to being affected by injury;
their muscles, bone tissue, tendons, ligaments, and cartilage tolerate different amounts
of load. How strong you are is also of great significance, of course. Differences of this
kind in individuals may be genetic, or may be based on gender or age (see Sections 3.6
and 3.7, respectively) or previous exposure to mechanical load (see Section 3.8.2). The
individual’s working technique may, of course, also be important in terms of the risk
of being injured (see Section 3.5.3).
Initially in this chapter, three types of load were described as arising during work
tasks requiring great muscle force: occasional peak loads for short periods, repeated
loads for a longer period, and an uninterrupted load with few breaks for rest over a
longer period. The mechanisms for possible injury differ between these three types
of load [McGill 1997].
An occasional load that exceeds tissue tolerance on one occasion is enough for an
injury to occur (Figure 3.4). One example is the assistant nurse who, by herself, helps
a patient weighing 90 kg to transfer from a wheelchair to a toilet in a narrow toilet
space. The patient cannot help as much as the nurse had expected, but hangs onto her.
At the same time the nurse has to twist her own back so they can turn around to the
toilet seat. A sudden acute pain occurs in her lower back. This is usually known as a
musculoskeletal injury and is a common reason for reporting occupational injuries
(see Section 3.12).

(a) (b) (c)

Force Force Force

Tissue Tissue Tissue

tolerance tolerance tolerance

Safety margin

Loading

Loading Loading

Time Time Time

FIGURE 3.4  Different mechanisms of injury with three types of loads involved in work
requiring great force: occasional high peak loads for short periods (a), repeated loads for a
longer period (b), and an uninterrupted load with few breaks for rest over a long period (c).
One single load on one occasion may reduce the safety margin to zero and cause injury
(shown with a small arrow) if the load exceeds the tolerance level of the tissues (a). A cumula-
tive trauma can arise with repeated loads at relatively low levels (b) or with a relatively low
load continuing without interruption for a long period (c). The loads initially fall short of the
tolerance level of the tissues, but this level gradually decreases. When the safety margin
approaches zero, injury may occur. (Modified and reprinted from Journal of Biomechanics,
30(5) McGill, S.M. The biomechanics of low back injury: Implications on current practice in
industry and the clinic, 465–75, Copyright (1997), with permission from Elsevier.)
Work Requiring Considerable Muscle Force 81

Another injury scenario is a cumulative trauma, resulting from somewhat lower

loads that are either repeated without sufficient time for recovery or that continue
uninterrupted for a longer period (Figure 3.4). The repeated or uninterrupted loads
initially fall below the tolerance level of the tissues, but may lead to the tissue slowly
being broken down and the tolerance levels dropping. When the tolerance level has
dropped so much that there is no longer any safety margin for the load to which the
person is exposed, an injury occurs. One example of repeated low loads would be a
warehouse worker who lifts 5 kg boxes onto pallets for a large part of his working day.
Over and over he strains the tissues of his lumbar spine, which causes a slow deterio-
ration in its tolerance level until an injury in one of the tissues occurs. As an example
of an uninterrupted load with few rest periods, one might mention the postal delivery
worker who carries bundles of mail weighing ~5 kg up and down flights of stairs in
blocks of flats. The declining tolerance levels that appear in a cumulative trauma also
increase the risk of a single overload occurring. This means that it is not always pos-
sible to distinguish these injury mechanisms from each other when an injury occurs.
One example of this may be when the warehouse worker described above lifts a
heavier box towards the end of the workday and feels acute pain in the lower back.
There are also other injury mechanisms concerning the way in which muscles are
recruited and supplied with blood during highly repetitive and/or prolonged work
with a very low force development. These mechanisms for injuries to muscles are
explained in Chapters 5 and 6. It is possible that mechanisms of this kind to a certain
extent might even explain how pain develops in the muscle during work requiring
great muscle force.
Examples of tissue damage that may occur when the mechanical load is too high
might be micro-fractures in the skeleton (e.g., in a vertebra), damage to discs (herni-
ated disc), muscle rupture, tendon inflammation (tendinitis), ruptures in tendons and
ligaments, ruptures or inflammation in joint capsules (e.g., the joint capsules in the
facet joints), and degeneration of joint cartilage and discs. Micro-injuries occurring
at forces below the tissue tolerance level accumulate when there is insufficient recov-
ery, causing inflammations and degenerative processes. In low-back disorders, for
instance, we often do not know exactly which structure has been damaged and what
the injury looks like anatomically. This applies to both acute problems and disorders
arising after a long period of load.
The degrading effects of cumulative loads may develop gradually over a very long
period, causing chronic, irreversible degenerative changes, for example, in the joint
cartilage and discs in the spinal column. It may be difficult to differentiate tissue
changes of this kind from normal changes due to age. In this way, pain and functional
impairments may arise without any specific, time-determined injury having occurred.
Altered or imperfect control of movements may contribute to injuries arising in
the musculoskeletal system. The situation may arise, for instance, when one is tired
or unused to a work task, after prolonged inactivity, or in cases of pain and functional
impairment. Imperfect coordination or balance may entail risks of accidents in man-
ual handling work such as improper grips, stumbling, and losing one’s balance when
lifting. It also happens that acute back pain occurs after a relatively simple and
­common back movement at low load, for example, bending down to pick up a pen
that has dropped on the floor. One possible explanation is muscle control dysfunction
82 Occupational Physiology

[McGill 1997; Panjabi 2006]. Normally, the back is stabilized during movements by
the muscles between the different segments of the spine. One hypothesis that has
been proposed is that injuries may arise as a result of a temporary defective function
of the inter-segmental stabilizing muscles. The vertebrae may then end up in extreme
postures where irritation and injury may arise in some tissue [Cholewicki and McGill
1996]. The sudden need for the body to recover stability may presumably also lead
to muscle spasm and overload of individual tissues.
It is not unusual that sudden and unexpectedly high loads arise during manual
handling work, such as when a patient unexpectedly falls during a transfer, or when
a load that has to be lifted weighs more than expected. Such sudden loads may also
disturb the stability in the spine when the CNS does not have time to resist the load
by increasing the cocontraction of antagonistic trunk muscles. During patient trans-
fers, accidents often occur when the patient behaves in an unexpected manner, such
as when they suddenly resist or faint.

3.9.2  Pain
Discomfort, aches, and pains in the musculoskeletal system do not in themselves
reveal the cause of the problems. Pain in the musculoskeletal system may be caused
by tissue damage or tissue irritation from any structure containing nociceptors—
peripheral nerve endings that send pain signals when damage occurs. As an example,
all the tissue components in the lumbar spine, apart from the central parts of the
discs, are provided with nociceptors. Pain from the lower back may therefore be
caused by an injury to the vertebra, disc, facet joint, joint capsule, ligament, muscle,
blood vessel, or nerve tissue. In order for nociceptive pain to arise, it is necessary for
the nociceptors to be stimulated mechanically, chemically, or thermally. Stimulation
of this kind often leads to a reflex-induced muscle contraction (spasm) across the
painful area, which may persist even after the initial tissue damage has healed.
Another type of pain is neurogenic pain resulting from damage in the peripheral
(e.g., pressure on a nerve root) or CNS.
Which tissues are affected in musculoskeletal disorders is often unclear, as the
perception of pain is often diffusely located. Changes or deviations from the “nor-
mal” appearing on ordinary x-rays of the spine, for example, often have no connec-
tion with the individual’s symptoms. Conversely, it is often difficult to find any
visible changes in the tissues of patients with back pain. In these cases of so-called
non-specific disorders, the doctor often gives a symptomatic diagnosis, for example,
lumbago (i.e., pain located between the lowest rib and the gluteal cleft on the back of
the thighs) and sciatic pain (i.e., pain with a distribution corresponding to the inner-
vation area of the sciatic nerve). Only ~10–20% of all those seeking medical care for
back pain receive a diagnosis based on the known cause. These are called specific
back disorders, for example, disc prolapse, spinal stenosis, compression of the verte-
bra, and inflammatory back diseases.
The pathophysiological mechanisms behind how the majority of pain conditions
in the musculoskeletal system arise are, therefore, insufficiently explained. In all
probability, the physiological and psychological processes underlying the pain are
complex and multi-factorial.
Work Requiring Considerable Muscle Force 83

3.10  RISK FACTORS

From epidemiological studies, associations have been proved between a number of
different exposures in working life and musculoskeletal disorders. Associations have
been shown not only with both physical and psychosocial working conditions, but
also with factors that do not have anything to do with work, such as individual, leisure
time, and lifestyle factors. Moreover, previous musculoskeletal disorders have also
been shown to be a strong risk factor for new disorders. Knowledge of how the various
risk factors interact in the onset of disorders is deficient. The threshold for hazardous
exposure—that is, the amplitude, frequency, and duration at which a load is harm-
ful—is not well known. The lack of knowledge sometimes leads to the associations
between work and musculoskeletal disorders being questioned, even if the situation is
really that we do not know enough to be able to draw any safe conclusions.
A large number of studies have shown that manual handling constitutes a risk fac-
tor for low-back disorders [Burdorf and Sorock 1997]. More specifically, there is
strong evidence that heavy lifting is a risk factor [Bernard 1997; da Costa and Vieira
2010; Hoogendoorn et al. 2000]. How heavy lifting is defined varies somewhat from
study to study. There is a lack of studies investigating specifically how heavy, how
often, and how long one can lift objects before problems arise. Frequent lifting of
objects weighing at least 15 kg is often stated as a risk factor [Lotters et al. 2003].
Frequent lifting is normally defined as more than 15 lifts per day [Hoogendoorn et al.
2000]. There is some evidence for a positive association between carrying out patient
transfers and an increased occurrence of back disorders [Burdorf and Sorock 1997].
Whole-body vibrations have been reported as a risk factor for back disorders
[Bernard 1997; Burdorf and Sorock 1997]. Whole-body vibrations often occur in
occupations where heavy lifting and stooped and twisted work postures are common,
for example, among long-distance lorry drivers who load and unload the goods they
transport. It has not been clarified as to whether whole-body vibrations alone can
cause problems in the lower back, or whether they constitute a risk only in combina-
tion with other ergonomic risk factors [Okunribido et al. 2008; Palmer et al. 2003].
The relationships between work requiring considerable muscle force and prob-
lems in the neck, shoulders, arms, and hands are less evident. The association is
clearest with regard to work with hand-held tools. For problems in the shoulder
region, there is evidence for repetitive work with the arms held above shoulder height
and work for long periods with the arms in this position [Bernard 1997; Svendsen
et al. 2004; van Rijn et al. 2010]. The association becomes stronger if these postures
are combined with working with hand-held tools. An association has also been
shown between lifting, pushing, or pulling heavy objects and neck/shoulder disor-
ders [Grooten et al. 2004; Harkness et al. 2003; van Rijn et al. 2010]. Using consider-
able hand force for a large part of the day, for example, by squeezing with the hand
or pinching with fingers around tools, comprises a risk for disorders in the elbow,
forearm and hand region, particularly for tendinitis in the elbow and wrist [Bernard
1997; Sluiter et al. 2001]. The associations are stronger if the forceful grip is com-
bined with repetitive movements of the elbow and/or wrist [Bernard 1997].
Disorders in the hip and knee joints connected with heavy work consist primarily
of arthritis in these joints. There is consistent evidence for the fact that heavy lifting
84 Occupational Physiology

is a risk factor for hip-joint arthritis [Jensen 2008a]. There is also an established asso-
ciation between farm work and hip-joint arthritis [Jensen 2008a]. For knee-joint
arthritis, there is evidence for heavy lifting and work in a kneeling and squatting posi-
tion [Jensen 2008b; McMillan and Nichols 2005]. It is difficult to separate the effects
of lifts from the effects of work postures loading the knees, as these exposures often
occur in the same occupations, for example, among floor-layers and miners.

3.11  M
 ETHODS FOR ASSESSING LOAD ON THE
MUSCULOSKELETAL SYSTEM
3.11.1  Biomechanical Models
Biomechanical models may be used to calculate the load on the musculoskeletal
system in work tasks requiring great forces. Calculations are based on measurements
of external forces, body postures, and movements over time. Biomechanical models
have varying degrees of complexity. A static analysis is the simplest and most ele-
mentary means of assessing load on the musculoskeletal system. In an analysis of
this kind, the fact that a movement is occurring is not taken into account, but an
object or system is studied as if it is at rest or at movement equilibrium. If we use a
static model to calculate forces on the muscles and joints in lifting, then we “freeze”
the movements and calculate the forces at a specific body posture, for example, in the
starting position when the load is just about to be raised from the ground. We do not
take into account the fact that accelerations take place at the same time. What is
necessary is to measure the angles of the joints. In the simplest analysis, the only
external forces taken into account are the gravitational forces (from the load being
lifted and from one’s own body parts). Calculation Examples 3.1 and 3.2 are exam-
ples of static analyses of this kind.
A truer picture of the loads arising during movements is given by a dynamic
analysis. When analysing rapid movements, it is necessary to use a dynamic analy-
sis. As an example, the peak load on the lumbar spine may become twice as great
when a load is lifted quickly compared with holding it still. If a static analysis is
performed on such a rapid lift the load may be seriously underestimated. In a
dynamic analysis, the system is regarded as being in motion and subjected to forces
that cause accelerations. For these calculations, it is necessary to measure the accel-
erations of the movements. In manual handling work, the hands are often exposed to
forces other than gravitational forces alone, for example, when pushing or pulling an
object, or working with a machine or hand tool. Here it is necessary to measure the
size and direction of the forces from, or applied to, the object, by force transducers
or dynamometers, and how the forces change during the work cycle being analysed.
Alternatively, we may measure the reaction forces from the ground, the ground reac-
tion force, with a so-called force plate.
The models may be either two dimensional or three dimensional. The simplest
and often the most practical applicable analysis is the two-dimensional one. In
Figure 3.2, the work is studied in one plane, that is to say, it is assumed that it is car-
ried out without twisting the trunk. In order to analyse work tasks in which move-
ments occur in several planes, three-dimensional analyses may need to be carried
Work Requiring Considerable Muscle Force 85

out. In patient transfers, the health care provider’s movements and exertion of force
rarely take place solely in one plane. An example is when a patient is to be trans-
ferred from the edge of the bed into a wheelchair. Even if asymmetrical movements
are involved in most work situations, a two-dimensional analysis may often provide
a good idea of the size of the load.
The most sophisticated biomechanical models are the dynamic three-dimensional
models. Technical developments in the computer field have made it possible to carry
out such comprehensive analyses in a short time. Collecting data for these models is,
however, still very time consuming and can mostly only be done in the laboratory.
The biomechanical analyses do not usually take into account the fact that there
are often stabilizing cocontractions, which add to the load. This is one reason why
the forces that exist “in reality” are presumably considerably greater than those cal-
culated using biomechanical models. It is also the case that different people may use
different strategies for recruiting muscles to produce the same force, which biome-
chanical analysis does not take into account. The models also provide deficient infor-
mation about forces acting on individual tissues.
The time aspect is of great significance for how a load affects the physiological
responses in the tissues, and whether the load gives rise to injuries. The biomechani-
cal calculation only gives a snapshot of the load and gives no guidance as to how
tiring a job is, or how great the cumulative load is during a work shift.

3.11.2  Electromyography
Electromyography (EMG) is a method for directly measuring the muscle activity
level, which reflects muscle force development. Electrodes register the electrical sig-
nals generated in the muscle when it contracts, known as action potentials (see
Chapter 6, Sections 6.4.5 and 6.12.6).
EMG can be used to estimate the force development in the muscle. When the
intensity of the muscle contraction increases, EMG activity also increases. This rela-
tionship varies from muscle to muscle, from individual to individual, and from one
measurement occasion to another. In order to be able to compare the activity from
different measurement occasions, the EMG activity is often expressed in relation to
the activity in well-defined test contractions, for example, an MVC (MVC—see Fact
Box 3.1). The EMG amplitude at work may then be expressed as %MVC. Analysing
the amplitude of the EMG signal as a measure of muscle load is an important and
common method in studies of load on the musculoskeletal system at work. Analyses
of this kind are simplest to interpret in work carried out with slow movements with
limited ranges of motion. In rapid movements with considerable ranges of motion it
is more difficult to know what the EMG signal represents. The analyses may be used
to compare different methods of carrying out manual handling work, for example, in
using different technical aids, or in evaluating changes in workplace design. EMG
registration can be carried out throughout the entire working day, which means that
we also obtain a measure of the cumulative load of an occupation.
EMG can also be used to study the coordination between muscles in movement
(e.g., a work task) by registering which muscles are involved and when these muscles
are active.
86 Occupational Physiology

3.11.3  Measurements of External Exposure

The load on the musculoskeletal system may also be estimated from measurements
of external exposure (see Section 3.5). The size and direction of external forces may
be measured with spring dynamometers and electronic force transducers. Information
about the weight of an object being lifted may also be used to assess the internal
load. Body postures (joint angles) may be recorded with measuring devices, for
example, inclinometers, accelerometers, and video based measurement systems
[David 2005]. With these instruments, measurements can be made throughout entire
working days. It can also be observed how often and how long the employee adopts
specific work postures, how often and how long he or she lifts or carries out some
other activity, and the weight of the load lifted. A large number of observational
methods are available [Takala et al. 2010]. Trained observers can carry out observa-
tions of this kind with a stopwatch, paper, and pen. The observations can also be
registered directly on small hand-held computers with the help of specially devel-
oped software. The observations may be made directly at the workplace or indirectly
by first videotaping the work to be observed. The advantage of video observations is
that the recorded sequences may be observed several times, and in this way more
variables may be registered than in direct observations. Moreover, employees can
themselves report which activities are being carried out, how long they last and how
often. Self-reporting of joint angles, for example, has proved to have low reliability,
however. With the aid of diaries, repeated registrations may be carried out for a long
period.

3.11.4  Models and Checklists

There are more or less simple models and checklists for directly identifying and
assessing work situations with hazardous loads on the musculoskeletal system. In
the provisions of the Swedish National Board of Occupational Safety and Health
on Ergonomics for the prevention of musculoskeletal disorders [SWEA 1998],
there are simple so-called three-zone models (red–yellow–green) for assessments
of lifting (see Section 3.13) and pushing and pulling work [SWEA 1998, Appendix
A]. In 1981, the US National Institute for Occupational Safety and Health (NIOSH)
presented its Work Practices Guide for Manual Lifting, recommendations for lifts
based on psychophysical, energetic, biomechanical, and epidemiological criteria
[NIOSH 1981]. These NIOSH guidelines were subsequently revised in 1991
[Waters et al. 1994]. The lifting recommendations are ­formulated as a relatively
simple function in which the weight limits for symmetrical two-handed lifts may
be calculated. The calculations are based on a maximal weight of 23 kg that can be
lifted without risk on a few occasions under optimal conditions. This “permissi-
ble” weight is reduced by six multiplication factors: horizontal distance, vertical
height, vertical lift distance, number of lifts per minute, degree of asymmetry, and
ease of grip. The recommended weight limit represents a weight which almost
all healthy workers can manage to lift without involving a risk of developing low-
back pain.
Work Requiring Considerable Muscle Force 87

3.12  P
 REVALENCE OF MUSCULOSKELETAL DISORDERS
AS A RESULT OF HEAVY MUSCLE WORK
Work-related disorders in the musculoskeletal system are more common in occupa-
tions characterized by heavy manual handling than the average among women and
men in employment. European statistics show that 25% of the workers in Europe
report back problems [Eurofound 2007]. In Sweden, between 2005 and 2010, just
over a fifth of the women working as cooks and postal delivery workers reported that
they had problems as a result of heavy manual handling, compared with 6% of all
women in employment [SWEA 2010b]. Among men, 22% of concrete workers, 19%
of bricklayers, and 16% of plumbers stated that they had problems caused by heavy
manual handling, compared with 5% of all men in employment. In many of these
occupations back disorders are the most frequent kind of problem, while in other
occupations in which considerable muscle force is required, problems are also com-
mon in the neck, shoulders, and arms.
In the United Kingdom, more than one-third of all musculoskeletal workplace
injuries reported each year are caused by manual handling [HSE 2009]. In Sweden,
the Swedish Work Environment Authority annually publishes statistics on occupa-
tional injuries based on the accidents at work and work-related disorders reported
to the Swedish Social Insurance Administration. Of those accidents at work that
resulted in absence in 2005, physical overload was given as the cause of the
­accident (called musculoskeletal injury) in just over one in four of the accidents
reported among women and just over one in six of those reported among men
[SWEA 2007]. Among women, half of these musculoskeletal injuries had occurred
in contact with people, for example, lifting and transferring people. Assistant
nurses, nurse’s aids, care assistants, and personal assistants are the female occupa-
tional groups reporting the most musculoskeletal injuries. Six out of every 1000
employees reported a musculoskeletal injury between 2004 and 2006. For men, the
most vulnerable occupational group is fire fighters, of which 11 out of every 1000
employees reported a musculoskeletal injury during this time period. For the entire
working population, the average was 1.6 cases per 1000 employees. Of the work-
related disorders reported, six out of 10 were caused by load factors (called muscu-
loskeletal disorders) for both genders [SWEA 2007]. An injury is assessed as being
a musculoskeletal disorder if it has arisen through the effect over a long period of
heavy lifting, or monotonous and awkward work postures and work movements. In
just over half of all musculoskeletal disorders reported by both men and women,
lifting and transferring heavy loads was stated to have contributed to the onset of
the injury.

3.13  W
 HAT THE LAW SAYS ABOUT WORK REQUIRING
CONSIDERABLE MUSCLE FORCE
Within the EU there is a general framework directive concerning measures to
promote improvements in employee safety and health at work [EUR-Lex 1989].
This directive regulates employers’ responsibilities for ensuring that employees
88 Occupational Physiology

are able to carry out their work without risk to their health. The employer is
obliged to:

• Adapt the work to the individual, especially as regards the design of the
workplace, the choice of work equipment, and the choice of working and
production methods.
• Develop a coherent overall prevention policy that covers technology, orga-
nization of work, working conditions, and the influence of factors related to
the working environment.
• Give appropriate instructions to the workers [EUR-Lex 1989, article 6].

The directive also states that the employer shall ensure that each worker receives
adequate health and safety training, in particular in the form of information and
instructions specific to his workplace or job [EUR-Lex 1989, article 12]. The training
shall be carried out on recruitment, in the event of a transfer or a change of job, in the
event of the introduction of new work equipment or a change in equipment, and in
the event of the introduction of any new technology. The training shall be adapted to
take account of new or changed risks, and repeated periodically if necessary.
The obligations of the worker are also regulated in the directive [EUR-Lex 1989,
article 13]. The worker is responsible for following the instructions given by the
employer, taking care of their own health and safety and that of coworkers in accor-
dance with the instructions and their training, and making correct use of necessary
equipment.
Within the EU there is also a specific minimum directive for manual handling
[EUR-Lex 1990]. Manual handling of loads is defined in this directive as “any trans-
porting or supporting of a load, by one or more workers, including lifting, putting
down, pushing, pulling, carrying or moving of a load, which, by reason of its charac-
teristics or of unfavourable ergonomic conditions, involves a risk particularly of back
injury to workers” [EUR-Lex 1990, article 12].
The directive takes as its starting point the fact that employers are instructed to
attempt to avoid manual handling of loads in all circumstances [EUR-Lex 1990,
article 3]. To avoid the need for manual handling, the employer shall take appropriate
organizational measures, or shall use the appropriate means, in particular mechani-
cal equipment. If this cannot be avoided, the employer shall take other measures to
minimize the risks of this work. In an appendix to the directive, there are a large
number of factors and aspects that have to be taken into account—for example, the
characteristics of the load, the characteristics of the work environment, whether the
lift is carried out with the trunk twisted, how long and how often lifts have to be
performed, and individual risk factors [EUR-Lex 1990, Appendix 1]. The employer
shall organize the workplace in such a way as to make such handling as safe and
healthy as possible [EUR-Lex 1990, article 4].
Moreover, the employers must ensure that workers receive proper training in
working technique and information about the possible risks that exist, and how they
can be avoided [EUR-Lex 1990, article 6]. The employer must also make sure that
the worker receives precise information on the weight of the load and the centre of
gravity of the heaviest side when a package is eccentrically loaded.
Work Requiring Considerable Muscle Force 89

Another important requirement in the directive concerns participation of

e­ mployees and their representatives, for example, those representatives with specific
responsibility for the safety and health of workers, in questions relating to safety and
health in manual handling work [EUR-Lex 1990, article 7].
Many countries have more detailed national rules—provisions, for instance—
governing this area. There exist national guidelines and general advice as a support
for measures to prevent risks at work. As an example, in the provisions of the
Swedish National Board of Occupational Safety and Health on Ergonomics for the
prevention of musculoskeletal disorders [SWEA 1998], manual handling, and other
exertions of force are dealt with in a specific section (Section 3). It states that the
employer shall ensure that manual handling and other work requiring exertion of
force shall as far as is practicable be organized and designed in such a way that the
employee can work without being exposed to physical loads that are injurious to
health or unnecessarily fatiguing. In the comments to this paragraph, one further
step is taken, where it is stated that employers shall in the first place investigate
whether manual handling can be avoided completely. If this is not possible, risk
analysis of the work should be carried out, and measures taken subsequently, for
example, regarding the design of loads, provision of technical aids, and work orga-
nization measures. It is also stated that normally, manual lifting of people should
not need to be carried out within the health and social care. It is possible to transfer
people without lifting them.
No absolute threshold is given for the weight of a load to be lifted, but it is said
that many factors affect the risk of injury in a lifting situation. In a model for assess-
ing lifts, two factors are taken into account: the weight of the load to be lifted and the
distance between the load and the body [SWEA 1998, Appendix A]. The model
applies to symmetrical lifts with two hands under ideal conditions.
What is recommended here is:

• Maximum 25 kg when the load is within forearm distance (~30 cm) of the
body.
• Maximum 15 kg when the load is within three-quarter arm distance
(~45 cm) of the body.

The model has a list of influencing factors that should be taken into account, for
example, how long and how often lifts have to be carried out, whether the lift is car-
ried out with a stooped or twisted body, whether the object is difficult to grasp, and
whether the person lifting is strong or weak. The more the number of “aggravating”
factors, the more one should reduce the maximum weight given in the model.

3.14  W
 HAT CAN BE DONE TO REDUCE THE RISKS OF HEAVY
MUSCLE WORK?
To reduce the risks of heavy muscle work, a number of measures have to be taken in
many different areas. Many of these measures are touched upon in the European
legislation relating to this area (see Section 3.13).
90 Occupational Physiology

3.14.1  Measures at the Workplace

3.14.1.1  The Work Task
Manual handling of heavy loads should as far as possible be avoided entirely. When
heavy lifting is necessary, technical aids should be used. Technical aids mean every-
thing from machinery to trucks, hoists, and carts. Employees can push or pull loads
instead of lifting them. In pushing and pulling work, it is important to have low fric-
tion between the load and the ground, but high friction between the shoes of the
employees and the ground. Employees should roll their loads instead of carrying
them. When running trolleys and patients’ beds, for example, it should be possible to
run these with reasonable strength. The wheels should be easy to steer and provide
low friction against the ground. The trolley should be provided with handles at a
suitable height.
Loads can be divided into smaller, lighter units. It is important to acquire infor-
mation about the weight of the load, and how the mass is distributed within it, in
order to be able to adapt one’s effort and working technique.
Within nursing care, a common policy is that patients should not be lifted manu-
ally; that is, that one should not lift the entire body weight of the patient from the
ground. If the patient cannot participate in the transfer, a mechanical hoist or other
transfer aids should be used. Most patient transfers can be carried out using technical
aids. When transferring a patient in the bed, the patient can be pulled instead of
lifted, for example, with the aid of a draw-sheet. The participation of the patient will
facilitate a transfer. This presupposes that the patient is informed about how the
transfer is to be carried out. A common cause of musculoskeletal injuries among care
staff is the patient suddenly resisting or behaving in an unexpected manner. Another
assumption is that the transfer technique is adapted to the patient’s preconditions and
ability. For technical aids to be useful they have to be easily available, functional,
and suited to the purpose. Staff must have adequate knowledge of how they are used.
In work with hand-held machines, tools, and controls, these should be designed so
that they allow a grip that is adjusted to the requirements for both power and preci-
sion, that the gripping force is evenly distributed across the hand, and that the grip
allows for a neutral position of the hand and wrist. They should suit the hand sizes of
different users. Moreover, they should not require too great a trigger force, be as light
as possible and well balanced.

3.14.1.2  Workplace Design

The workplace should be designed so that there is sufficient space for work in suit-
able work postures, space to use technical aids and sufficient for two coworkers to
cooperate. Within nursing care, both in an institution and in private accommodation,
it is unsuitable for beds to be placed against a wall if the patient needs assistance
during transfers. There should be sufficient space around the bed for two care staff
to collaborate. The bed should also be height-adjustable to allow safe work postures
for the care staff. There should be sufficient space around the toilets. If it is not pos-
sible to arrange sufficient space in a toilet, one should consider whether the transfer
could take place somewhere else. This may be arranged so that the transfer takes
place outside the toilet onto a mobile toilet seat which is then rolled into the toilet.
Work Requiring Considerable Muscle Force 91

Some thought should be given to where objects that have to be transferred are
located, both as regards their starting point and their final position. The distance of
the transfer should be as short as possible. If it can be avoided, the objects to be lifted
should not be placed at floor level and should not be lifted to positions above shoul-
der height.
Stairs should be avoided as a transport route for heavy or cumbersome loads.
Consideration should be given to managing obstacles in the form of differences in
level, such as doorsteps, or slippery, uneven, sloping, or unstable ground.

3.14.1.3  Organization of Work

Work involving elements of heavy manual handling should also contain lighter work
tasks, so that there is an opportunity for recovery. The heavier the load to be handled,
the more time should elapse between lifts.
In heavy manual handling, for example, in patient transfers, there should always
be an opportunity of working together with coworkers. This presupposes good staff
planning and adequate staffing levels. How the work is organized has great signifi-
cance, such as whether the organization of the nursing care on a hospital ward allows
cooperation, or whether workers in the home care service work alone or in pairs.
How much time is allocated for a work task affects how it is carried out. If a
worker feels under time pressure, they may perhaps not take the time to fetch an aid,
or to go and ask a colleague for help. This may also result in “carelessness” in how
the worker performs the task, and in working with rapid and jerky movements.
One way of increasing the prerequisites for employees to use safe working tech-
niques and make use of aids is to introduce a policy at the workplace on how various
work tasks should be carried out. On a ward, as an example, a policy of this kind would
cover how many people should assist, as well as which transfer methods and transfer
aids should be used in patient transfers. It may be a good idea to document how each
individual patient should be transferred, so that all the staff use the same method. There
should also be training routines for working technique (see Section 3.14.2).
One overarching aspect of the organization of work is how great an influence the
employees have over their own work. This applies, for example, to what should be
done, when and where tasks should be carried out, and working methods for these.
Increasing the employees’ decision latitude is one way of making it possible for the
individual to be able to adapt their work to their own capacity, and in this way
reduces the risk of overload. The fact that the work must be adapted to the individ-
ual is regulated in the EU’s general framework directive, which concerns measures
to promote improvements in employee safety and health at work [EUR-Lex 1989]
(see Section 3.13). In Sweden, the employer has a duty prescribed by law to give the
employee an opportunity of influencing the planning and execution of their own
work [SWEA 1998].

3.14.2  Measures at the Individual Level

One precondition for employees to be able to carry out their work in a suitable way
and to avoid hazardous loads is that they have good skills in working technique. The
employer is responsible for ensuring that the employee has the training necessary to
92 Occupational Physiology

be able to prevent musculoskeletal disorders (see Section 3.13). It is important to prac-

tise safe working technique from the beginning. It may be difficult later to alter
ingrained motor patterns. A good starting point is to undergo training in working
technique, such as lifting and transfer technique. The principles of safe working tech-
nique in lifting and in patient transfers may be studied in Fact Boxes 3.3 and 3.4. Most
of these principles can be derived from the biomechanical factors affecting the size of
the load on the musculoskeletal system (see Section 3.5.2). The training should be
focused on encouraging the participants, on the basis of these principles, to adapt
their working technique to the specific work situation and to their own and the
patient’s abilities. Working technique training should be included in any introduction
course for new employees. It is important that the training is long enough and that it
is repeated regularly. It is also important that it is adapted to the conditions at the
employee’s own workplace, and that it is supported by the organization through ensur-
ing that there is space for the employee to actually use safe working technique. Apart
from training courses, there needs to be opportunities for training and instruction at
the workplace. Having good role models among colleagues may also be important.
The principles of lifting technique (Fact Box 3.3) may be applied to most manual
handling tasks, even to patient transfers. Apart from these, there are a number of
more specific principles applying to the special situation represented by a patient
transfer (see Fact Box 3.4).

FACT BOX 3.3

Principles of safe working technique in lifting:

• Reduce the weight of the load.

• Lift the load close to the body.
• Avoid lifting below knee level or above shoulder level.
• Avoid lifting from a starting position where the trunk is extremely
bent forward.
• Avoid lifting while at the same time twisting the back.
• Avoid jerky movements.
• Use technical aids in heavy lifts.
• Cooperate with colleagues in making heavy lifts.

FACT BOX 3.4

Principles of safe working technique during patient transfers:

• Inform the patient.

• Allow the patient to perform as much as possible of the transfer.
• Use transfer aids.
• Adjust the height of the bed.
Work Requiring Considerable Muscle Force 93

• In most cases there should be at least two employees cooperating.

• Never lift the entire weight of the patient from the base—use a
mechanical hoist.
• Pull instead of lifting.

In patient transfer, care should also be taken to make the transfer comfortable and
safe for the patient. Moreover, it is a common dilemma within nursing care that the task
of the staff is to rehabilitate patients, which means that patients must be trained to carry
out, as much as possible, the transfer themselves. This may result in not using transfer
aids, despite the fact there is a risk that the load on the care staff will be too great.
In order to cope with tasks requiring great muscle force, it is necessary for the
employee to have a sufficiently high physical capacity. As mentioned earlier, the
effect on the muscles and other tissues provided by load at work is often insufficient
to build them up and increase the individual’s physical capacity (see Section 3.8.2).
This applies especially to the older employee [Ilmarinen 2001]. Employees carrying
out heavy muscle work need to have a greater physical capacity, including muscle
strength, than is usually required at work to be able to manage occasional peak loads.
An example is Karen’s work with patient transfers, where she is subjected to extra
large loads when a transfer goes wrong, such as when a patient faints during the trans-
fer. It is therefore recommended that employees with this type of work carry out some
physical training. Specific training of muscle strength and endurance are important.
In Karen’s work, what is needed are primarily back, abdominal, shoulder, and leg
muscles that are strong and have sufficient endurance to manage the heavy patient
transfers. This applies to most types of manual handling work. It is also important to
receive all-round training of muscle strength, muscle endurance, fitness, mobility, bal-
ance, and coordination. Good physical fitness is important to increase endurance and
thereby reduce fatigue at work. Often this type of work also makes great demands on
energy metabolism. Fatigue can lead to impaired control over movements and care-
lessness, which may result in accidents at work, such as tripping or grasping a load in
an incorrect way. Good mobility, balance, and coordination are also significant for
adequate control of movements and for the ability to have good working technique.
Studies have shown that physical training can alleviate and speed up recovery
from back problems [Professional Associations for Physical Activity (Sweden)
2010]. Training strength, endurance, mobility, as well as physical fitness, has a posi-
tive effect. Studies on the preventive effect from physical activity on back pain do
not, however, show consistent results.
Providing employees with physical training in working hours may be one way for
the employer to help ensure that they have sufficient physical capacity to cope with
their tasks and maintain their work ability right up to retirement.

3.15  SUMMARY
Work requiring considerable muscle force often involves heavy tasks that last only a
short period of time, but are repeated a number of times during the working day. The
94 Occupational Physiology

muscles are activated close to their maximal capacity for a short period, and then
later relaxed. This type of work is common in heavy manual handling; that is, lifting
and moving loads such as in the nursing and care professions and in construction and
warehouse work. In occupations involving manual handling, uninterrupted work
requiring somewhat lower muscle force for a longer period is also common—holding
and carrying loads, for example. Manual handling involves muscles in the trunk,
legs, shoulders, and arms. Another common example of work requiring great force
is work with hand-held tools, for example, among plumbers and carpenters, which in
particular puts strain on the muscles of the hand and forearm. The force the muscles
need to produce to move a load depends primarily on the weight of the load, how far
from the body the load is held, the work posture of the individual, and how quickly
the load is lifted. In an optimal work situation, the individual can influence these
factors through their choice of working technique. Using a careful working tech-
nique may be a method of avoiding harmful loads on the muscles, tendons, and
joints. The size of the load arising on these structures may be calculated by using
biomechanical methods. Different individuals have different physical preconditions
for carrying out physically heavy work. The lower maximal muscle strength of older
individuals and women compared with younger individuals and men means that a
specific job will require a greater proportion of their capacity. Under optimal work-
ing conditions—that is, at the correct combination of amplitude, frequency, and
duration of mechanical load during work—an adaptation of, among other things,
muscle strength and tissue strength to the requirements of the work takes place. On
the other hand, a lack of recovery or too high a load may cause injuries. Musculoskeletal
disorders are more common in occupations characterized by heavy manual handling
than the average among working women and men. Manual handling of heavy loads
should as far as possible be avoided entirely. For example, patient transfers in the
nursing and care professions should be carried out using methods other than lifting.
In European legislation, the employer is instructed to avoid heavy manual handling
as far as possible. Where the need for the manual handling of loads by workers can-
not be avoided, the employer shall take the appropriate measures to reduce the risks
of manual handling, for example, by providing technical aids and ensuring that the
staff regularly receives training in working technique. Heavy work should be supple-
mented by physical training, as the load provided by the work is rarely constituted in
such a way that muscles and tissues are built up to a sufficient extent.

REFERENCES
Åstrand, P.-O., K. Rodahl, H. Dahl, and S. Strömme. 2003. Textbook of Work Physiology.
Physiological Bases of Exercise. 4th ed. Champaign: Human Kinetics.
Bernard, B.P., ed. 1997. Musculoskeletal Disorders and Workplace Factors. A Critical Review
of Epidemiological Evidence for Work-Related Musculuskeletal Disorders of the Neck,
Upper Extremity and Low Back. Cincinnati: CDC-NIOSH.
Burdorf, A. and G. Sorock. 1997. Positive and negative evidence of risk factors for back disor-
ders. Scand J Work Environ Health 23:243–256.
Cholewicki, J. and S.M. McGill. 1996. Mechanical stability of the in vivo lumbar spine:
Implications for injury and chronic low back pain. Clin Biomech 11(1):1–15.
Work Requiring Considerable Muscle Force 95

da Costa, B.R. and E.R. Vieira. 2010. Risk factors for work-related musculoskeletal disorders:
A systematic review of recent longitudinal studies. Am J Ind Med 53(3):285–323.
Cole, M.H. and P.N. Grimshaw. 2003. Low back pain and lifting: A review of epidemiology
and aetiology. Work 21(2):173–84.
David, G.C. 2005. Ergonomic methods for assessing exposure to risk factors for work-related
musculoskeletal disorders. Occup Med (Lond) 55(3):190–9.
van Dieën, J.H., M.J.M. Hoozemans, and H.M. Toussaint. 1999. Stoop or squat: A review of
biomechanical studies on lifting technique. Clin Biomech 14(10):685–96.
Enoka, R.M. 2008. Neuromechanics of Human Movement. 4th ed. Champaign: Human
Kinetics.
Era, P., A.L. Lyyra, J.T. Viitasalo, and E. Heikkinen. 1992. Determinants of isometric muscle
strength in men of different ages. Eur J Appl Physiol Occup Physiol 64(1):84–91.
EUR-Lex. 1989. Council Directive 89/391/EEC of 12 June 1989 on the introduction of mea-
sures to encourage improvements in the safety and health of workers at work. http://
eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31989L0391:EN:HTML
EUR-Lex. 1990. Council Directive 90/269/EEC of 29 May 1990 on the minimum health and
safety requirements for the manual handling of loads where there is a risk particularly
of  back injury to workers. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=​
CELEX:31990L0269:EN:HTML
Eurofound. 2007. Fourth European Working Conditions Survey. European foundation for the
improvement of the living and working conditions. http://www.eurofound.europa.eu/
pubdocs/2006/98/en/2/ef0698en.pdf
Eurofound. 2010. Fifth European Working Conditions survey—2010. European foundation
for the improvement of the living and working conditions. http://www.eurofound.
europa.eu/surveys/ewcs/2010/index.htm
Grooten, W.J., C. Wiktorin, L. Norrman et al. 2004. Seeking care for neck/shoulder pain: A
prospective study of work-related risk factors in a healthy population. J Occup Environ
Med 46(2):138–46.
Harkness, E.F., G.J. Macfarlane, E.S. Nahit, A.J. Silman, and J. McBeth. 2003. Mechanical
and psychosocial factors predict new onset shoulder pain: A prospective cohort study of
newly employed workers. Occup Environ Med 60(11):850–7.
Hoogendoorn, W.E., P.M. Bongers, H.C. de Vet et al. 2000. Flexion and rotation of the trunk
and lifting at work are risk factors for low back pain: Results of a prospective cohort
study. Spine 25(23):3087–92.
HSE. 2009. Getting to Grips with Manual Handling. A Short Guide. London: Health and
Safety Executive.
Ilmarinen, J.E. 2001. Aging workers. Occup Environ Med 58(8):546–52.
Jensen, L.K. 2008a. Hip osteoarthritis: Influence of work with heavy lifting, climbing stairs or
ladders, or combining kneeling/squatting with heavy lifting. Occup Environ Med
65(1):6–19.  
Jensen, L.K. 2008b. Knee osteoarthritis: Influence of work involving heavy lifting, kneeling,
climbing stairs or ladders, or kneeling/squatting combined with heavy lifting. Occup
Environ Med 65(2):72–89.
Jorgensen, M.J., W.S. Marras, K.P. Granata, and J.W. Wiand. 2001. MRI-derived moment-
arms of the female and male spine loading muscles. Clin Biomech 16(3):182–93.
Jorgensen, M.J., W.S. Marras, P. Gupta, and T.R. Waters. 2003. Effect of torso flexion on the
lumbar torso extensor muscle sagittal plane moment arms. Spine J 3(5):363–9.
Kjellberg, K. 2003. Work technique in lifting and patient transfer tasks. Doctoral thesis, Arbete
och Hälsa, 2003:12, Institute of Internal Medicine, Department of Occupational
Medicine, The Sahlgrenska Academy at Göteborg University, National Institute for
Working Life, Göteborg.
96 Occupational Physiology

Lindbeck, L. and K. Kjellberg. 2001. Gender differences in lifting technique. Ergonomics

44(2):202–214.
Lotters, F., A. Burdorf, J. Kuiper, and H. Miedema. 2003. Model for the work-relatedness of
low-back pain. Scand J Work Environ Health 29(6):431–40.
McGill, S.M. 1997. The biomechanics of low back injury: Implications on current practice in
industry and the clinic. J Biomech 30(5):465–75.
McMillan, G. and L. Nichols. 2005. Osteoarthritis and meniscus disorders of the knee as occu-
pational diseases of miners. Occup Environ Med 62(8):567–75.
NIOSH. 1981. Work Practices Guide for Manual Lifting. Cincinnati, Ohio: National Institute
for Occupational Safety and Health.
Nygard, C.H., T. Luopajarvi, T. Suurnakki, and J. Ilmarinen. 1988. Muscle strength and mus-
cle endurance of middle-aged women and men associated to type, duration and intensity
of muscular load at work. Int Arch Occup Environ Health 60(4):291–7.
Okunribido, O.O., M. Magnusson, and M.H. Pope. 2008. The role of whole body vibration,
posture and manual materials handling as risk factors for low back pain in occupational
drivers. Ergonomics 51(3):308–29.
Palmer, K.T., M.J. Griffin, H.E. Syddall et al. 2003. The relative importance of whole body
vibration and occupational lifting as risk factors for low-back pain. Occup Environ Med
60(10):715–21.
Panjabi, M.M. 2006. A hypothesis of chronic back pain: Ligament subfailure injuries lead to
muscle control dysfunction. Eur Spine J 15(5):668–76.
Professional Associations for Physical Activity (Sweden). 2010. Physical Activity in the
Prevention and Treatment of Disease. Stockholm: Swedish National Institute of Public
Health.
van Rijn, R.M., B.M. Huisstede, B.W. Koes, and A. Burdorf. 2010. Associations between
work-related factors and specific disorders of the shoulder—A systematic review of the
literature. Scand J Work Environ Health 36(3):189–201.
Sluiter, J.K., K.M. Rest, and M.H. Frings-Dresen. 2001. Criteria document for evaluating the
work-relatedness of upper-extremity musculoskeletal disorders. Scand J Work Environ
Health 27(Suppl 1):1–102.
Statistics Sweden. Statistical database, The Work Environment. http://www.ssd.scb.se/­
databaser/makro/start.asp (accessed 110103).
Straker, L. 2003. Evidence to support using squat, semi-squat and stoop techniques to lift
­low-lying objects. Int J Ind Erg 31(3):149–60.
Svendsen, S.W., J.P. Bonde, S.E. Mathiassen, K. Stengaard-Pedersen, and L.H. Frich. 2004.
Work related shoulder disorders: Quantitative exposure-response relations with reference
to arm posture. Occup Environ Med 61(10):844–53.
SWEA. 1998. Ergonomics for the Prevention of Musculoskeletal Disorders, AFS 1998:1.
Stockholm: Swedish National Board of Occupational Safety and Health.
SWEA. 2007. Occupational accidents and work-related diseases 2005 (Arbetsskador 2005)
(In Swedish). In Arbetsmiljöstatistik. Stockholm: Swedish Work Environment Authority.
SWEA. 2010a. The Work Environment 2009. Stockholm: Swedish Work Environment
Authority. http://www.av.se/dokument/statistik/officiell_stat/ARBMIL2009.pdf
SWEA. 2010b. Work-Related Disorders 2010. Stockholm: Swedish Work Environment
Authority. http://www.av.se/dokument/statistik/officiell_stat/ARBORS2010.pdf
Takala, E.P., I. Pehkonen, M. Forsman et  al. 2010. Systematic evaluation of observational
methods assessing biomechanical exposures at work. Scand J Work Environ Health
36(1):3–24.
Tammelin, T., S. Nayha, H. Rintamaki, and P. Zitting. 2002. Occupational physical activity is
related to physical fitness in young workers. Med Sci Sports Exerc 34(1):158–65.
Work Requiring Considerable Muscle Force 97

Torgen, M., L. Punnett, L. Alfredsson, and A. Kilbom. 1999. Physical capacity in relation to
present and past physical load at work: A study of 484 men and women aged 41 to 58
years. Am J Ind Med 36(3):388–400.
Waters, T.R., V. Putz-Anderson, and A. Garg. 1994. Applications Manual for the Revised
NIOSH Lifting Equation. Cincinnati: National Institute for Occupational Safety and
Health.
de Zwart, B.C.H., M.H.W. Frings-Dresen, and F.J.H. van Dijk. 1995. Physical workload and
the ageing worker: A review of the literature. Int Arch Occup Environ Health
68(1):1–12.

FURTHER READING
Åstrand P.-O., K. Rodahl, H.A. Dahl, and S.B. Stromme. 2003. Textbook of Work Physiology.
Physiological Bases of Exercise. Windsor, Canada: Human Kinetics.
Hall S.J. 2006. Basic Biomechanics. 5th ed. Boston, MA: McGraw-Hill Higher Education.
Nordin M. and V.H. Frankel. 2001. Basic Biomechanics of the Musculoskeletal System. 3rd ed.
Baltimore, MD: Lippincott Williams & Wilkins.
Wilmore, J.H., D.L. Costill, and W.L. Kenney. 2008. Physiology of Sport and Exercise.
Champaign, IL: Human Kinetics.
 4 Work in Awkward
Postures
Karin Harms-Ringdahl

Photo: Karin Harms-Ringdahl

CONTENTS
4.1 Focus and Delimitation.................................................................................. 101
4.2 Prevalence in Working Life........................................................................... 102
4.3 Description of the Exposure.......................................................................... 103
4.4 Normal Physiological Responses and Mechanisms...................................... 105
4.5 Potential Negative Results of Exposure......................................................... 110
4.5.1 Does it Hurt?...................................................................................... 110
4.6 Incidence of Disorders................................................................................... 110
4.7 Risk Assessment............................................................................................ 111
4.8 Measures in Critical Conditions.................................................................... 112
4.9 What Does the Law Say About Work in Awkward Work Postures?............. 114
4.10 Summary....................................................................................................... 114
References............................................................................................................... 115
Further Reading...................................................................................................... 116

99
100 Occupational Physiology

Andrej, who is 32 years old, is 1.81 m tall and weighs 78 kg, has a live-in partner,
and works as a painter. He works for a large company which is often commissioned
to undertake new constructions. For Andrej it is mostly a matter of painting ceilings
in flats. Some ceilings are spray-painted; others painted using a large roller on a
long pole (Figure 4.1a). The ceilings are completed using a smaller roller or brush.
This involves working with heavy equipment, which requires considerable effort
from Andrej’s arm and shoulder muscles, with his hands held at shoulder height or
higher. In addition, he has to look up at the ceiling so as not to splash ceiling paint
over the entire apartment (Figure 4.1b). The relatively heavy effort from his shoul-
der muscles, with his hands lifted up high at the same time as his neck is bent back,
means that Andrej gets pains in his neck and shoulder muscles as well as headaches.
This is exacerbated by time pressures in noisy new constructions, which makes it
difficult to take regular breaks or to vary his work posture.
Andrej is touching up the paintwork in a kitchen, when the plumber arrives with
a dishwasher on a trolley. This machine has to be connected up in a narrow space
beneath a sink unit (Figure 4.2), as soon as the carpet fitter (Figure 4.3) has laid a
protective floor covering. And then the electrician has to get in and connect the
power, but first he has to access the ceiling light. The dishwasher has to wait. The
narrow space under the sink unit means that they have to get down on their knees and
twist their backs. At the same time, they carry out work with their hands, which
makes demands on being able to see clearly what they are doing. The electrician,
who is 47 years old, wears varifocal glasses, which means that he has to bend and
twist his neck in order to focus at the correct distance, as varifocals have different
focal lengths in the upper and lower part of the lens, and moreover have only a lim-
ited lateral field of view. If he tries to hold his neck in a more comfortable posture,
his field of vision becomes blurred. Despite wearing knee-pads, his knees ache and
the muscles in his back are sore.

(a) (b)

FIGURE 4.1  As (a) and (b) painting involving one hand held high above the head. The
neck is bent back so that the painter can see the results of his work. The paint roller, which
has to be rolled evenly, requires great activation of the neck and shoulder muscles, com-
pressing the joints of the neck in a position that is bent back. Photo: Christer Spångberg.
Work in Awkward Postures 101

FIGURE 4.2  Installation of a dishwasher where the plumber is on his knees with one shoul-
der stretched forward in an extreme posture, attempting to push the machine into place.
Photo: Karin Harms-Ringdahl.

4.1  FOCUS AND DELIMITATION

This chapter deals with what happens when workers need to carry out tasks in
uncomfortable or awkward work postures, in which the joints come under strain
close to the limit of their range of motion, something that happens when someone
has to twist and bend in order to carry out their work. It is reasonable to assume that
this is what we, in daily life, call awkward work postures, a concept that occurs in
questionnaire-based surveys from the Swedish Work Environment Authority and in
European statistics on work-related disorders. Along with keeping the back and joints
in awkward work postures, sometimes workers are required to hold that position for

FIGURE 4.3  In carpet laying work and when welding carpet joins, the carpet fitter stands
and crawls on hands and knees with his back bent and somewhat twisted and his neck slightly
bent backward. Photo: Karin Harms-Ringdahl.
102 Occupational Physiology

a fairly long time while carrying out work with their hands, often using a tool and
with a demand for visual accuracy. Apart from uncomfortable work postures, this
also means that the muscles are often working monotonously and repetitively for
long periods (see also Chapter 5). At building sites, moreover, the work is sometimes
carried out under hot or cold conditions (see also Chapter 9) and under conditions
that imply that workers are dependent on one another’s tasks, and therefore may
experience stress resulting from waiting for someone else to finish (see also Chapter
7). This chapter, however, mostly deals with the strain put on the joints and back
while working in twisted or stooped awkward work postures.
In this chapter you will find answers to questions such as:

• How are muscle activity and joint load affected, and thereby the risk of
pain, when the back and neck are held in an uncomfortable, stooped posture
while working?
• Why do people get knee joint disorders from squatting down for a long
time?
• Why can someone experience the symptoms of a slipped disc if they put
strain on their back while twisting or bending it at the same time?
• Why is it more strenuous to twist one’s body into an extreme, rotated pos-
ture, so that it is possible to look backwards, despite which the biomechani-
cally stressful moment does not increase in comparison with a more
comfortable, neutral position?
• Why do the neck and shoulders ache when painting a ceiling for a long
time?
• Why does the back ache when straightening up again after standing or sit-
ting stooped forward?
• Why are people not particularly strong when working in positions close to
the limit of their joints’ range of motion?
• Can Andrej do anything at work to be able to perform his job tasks without
all these problems?

4.2  PREVALENCE IN WORKING LIFE

Awkward work postures can be encountered, for example, in a number of industrial,
agricultural, building, and patient care jobs. In the European Union (EU), ~45%
(ranging between 24% and 66% among countries) of the working population report
being subjected to tiring or painful postures at least a quarter or more of the time,
including 15% who report being exposed all or almost all the time [Eurofound 2006].
In the building industry, tasks often result in work being carried out with the body
in very awkward postures, as the building itself establishes the framework for the
environment—which is not so easy to alter in relation to the task. While the building
industry is dominated by male employees, the opposite is the case in the care sector.
The demands of the job and the opportunity for influence are considered to be a fac-
tor that mediates work-related disorders [Karasek et al. 1981]. Table 4.1 shows that
building workers nevertheless feel that they have more physically awkward work
Work in Awkward Postures 103

TABLE 4.1
Proportion (%) of Workers between 1999–2003 Who Assessed Awkward
Work Postures of Various Kinds and Opportunities of Influencing their
Working Environment
Number of Employees 1999/2003 Percent
Work Environment Issues: Men and Women All Men All Men Construction
Experience at work
  – Has strenuous work postures 36 33 58
  – Has strenuous heavy work 27 27 57
  – Has strenuous, monotonous work 29 27 40
movements
  – The work is strenuous and inflexible 18 15 7

Several times every day compelled

  – To lift at least 15 kg each time 17 21 39
  – To bend and twist in the same way 26 24 31
several times an hour
Demands and influence
  – Cannot determine when different 43 37 34
tasks are to be done

Source: Lundholm L. and Swartz H. 2006. Musculoskeletal Ergonomics Statistics. Report 2006:2E
Swedish Work Environment Authority. http://www.av.se/dokument/statistik/­english/Musculo­
skeletal_ergonomics_statistics.pdf.
Note: The number of men employed in the Swedish Construction Industry each year during the period
was ~212,000.

postures, although they actually report that they have a less restrictive and a freer job
than other men and women, respectively [Lundholm and Swartz 2006].
But computer work may also involve uncomfortable work postures, if the shoul-
der joints are kept in a (moderately) outward-rotated position for a long period, such
as when using a mouse that is placed a little too far to the side of the keyboard
[Karlqvist et al. 1998]. Computer work can also mean that the wrists are kept at a
sharp angle for long periods of time, with entrapment disorders (the so-called entrap-
ment of the median nerve in the carpal tunnel) as a result.

4.3  DESCRIPTION OF THE EXPOSURE

The design of the environment and those activities we carry out at work and in our
leisure time, together with our body dimensions and movement habits, determine what
positions put strain on our joints and how much of our relative muscle strength the task
demands. Normally we try to work with our back, neck, and joints in relatively neutral
positions (see Fact Box 4.1). Then the muscles help above all to stabilize the body and
to ensure that the work can be done with the use of optimal force and movement. If the
task allows, we alter our body posture so that the work can be carried out in the most
104 Occupational Physiology

FACT BOX 4.1

The neutral zone in a joint—the area where it is relatively equidistant from the
limit of the range of motion in all directions. The ligaments that stabilize the
joint are relatively similar and equally lightly loaded. When the joint is kept in
a neutral posture, load occurs in the neutral zone of the joint. When the joint is
at the limit of its range of motion, this is termed as an extreme posture [Harms-
Ringdahl 1986; Harms-Ringdahl and Ekholm 1986].

comfortable way possible, which also means that we ­spontaneously vary our work
posture. When the task demands that manual work must be performed, and the worker
needs to control hand-held tools, workplace design, and the opportunities for its adap-
tation relative to the body dimensions of the employee have a decisive significance on
which work postures they adopt. Sometimes a conflict may also arise, which has to do
with the time factor. From a short-term perspective, it may take a longer time to opti-
mize a work posture than to carry out the task in a more awkward body posture, which
may not hurt at the time. The use of glasses may sometimes also be a factor, which
means that a worker has to bend and twist the cervical spine to be able to see properly.
A common problem for people who have acquired glasses as a result of age-related
changes in their eyesight (difficulties of focusing at short distances) is the difficulty of
gaining visual acuity for different distances. Varifocal glasses mean that the size of
the optimal field of vision and visual acuity can be adjusted by changing the head posi-
tion and thereby the angle of the neck. Someone without glasses can see out of the
corner of their eye or in the upper or lower part of their field of vision, and in this way
one is able to keep the cervical spine in a more comfortable, neutral position.
In Andrej’s case, there is a given height to the ceiling, and the ceiling has a given
area that has to be painted. This means that he needs to bend his neck back to be able
to see upto the ceiling while he is working. A brush or roller is certainly light, but
once dipped in paint, its weight increases considerably. In addition, he needs to press
the roller or brush against the surface and lift his arms so that his hand is raised
above the head height in order to be able to reach. If Andrej uses a roller on a long
pole (Figure 4.1a), he can hold his hands lower than when he is painting the ceiling
with a shorter roller. As a roller on a long pole can be held in front of his body, he
does not need to bend his neck as far back in order to see as and when he is using a
roller with a short pole (Figure 4.1b). At the same time, a long pole means that con-
siderable force is required for the muscles of the neck and shoulders to manoeuvre
the tool in an efficient way against the surface of the ceiling.
Dishwashers have to be connected with pipes and electrical installations, located
far inside cupboards under sink units, which means that the installer has to twist in
order to reach (Figure 4.2). Often he has to work on his knees to get into this kind of
narrow space.
Electrical work means drawing cables across the ceiling using great precision and
sometimes a heavy hand-held tool, and while standing on a ladder. Using a more
uncomfortable work posture is easy to choose over taking the time to move the
­ladder again and again so as to reach more comfortably. The requirements for precision
Work in Awkward Postures 105

FIGURE 4.4  Illustration of how muscles that pass two joints (hip and knee, respectively,
knee and wrist) act together to provide a stooped position in the lumbar spine and cervical
spine. The Achilles tendon attaches to the back of the heel and forms a lever vis-à-vis the
rotation centre of the foot joint. Illustration: Christer Spångberg.

work and the importance of the hand-held tool, as well as the hand and arm strength
needed to carry out the task, add to the strain caused by the body posture itself.
The strain at a joint’s extreme posture (see Fact Box 4.1) may cause a temporarily
limited range of motion in another adjacent joint. This is the result of some muscles,
for example, those at the back of the thigh, passing through two joints. An example of
an effect of this kind is when driving a car with the driving seat in a low, pushed-back
position (Figure 4.4). The position of the accelerator pedal means that the ­driver’s
right leg is stretched forward so that the foot can reach the pedal, which means that
the knee joint is almost straight. The narrower the angle between the thigh and the
trunk, the more the muscles at the back of the thigh tighten when the knee joint is held
outstretched. It is then difficult to sit and at the same time retain curvature in the lum-
bar spine. The driver has to sink with a rounded lumbar spine into a completely bent
position, which at the same time means that the cervical spine is bent back further and
the chin is pointed so as to be able to keep one’s eyes on the road. At the same time,
the opportunity of twisting the cervical spine is limited, and it becomes more difficult
to turn to look back over one’s shoulder into the “dead angle.”

4.4  NORMAL PHYSIOLOGICAL RESPONSES AND MECHANISMS

The joints in the body are a precondition for mobility. The joint is a functional unit
consisting of joint surfaces, ligaments, and joint capsule, which are covered on the
inside by the synovial membrane, which produces synovial fluid, which in turn
increases the capacity for gliding. The joint surfaces, which have various anatomical
designs, are constructed so as to create good contact between the surfaces, and are
usually more or less arched. The joint surfaces are covered in cartilage, which makes
it possible for them to glide against each other with very little friction. In movement,
a translatory sliding movement in the plane of the joint surfaces and an angular,
106 Occupational Physiology

Fs
Fs

Fc Fg
Fg Fc

FIGURE 4.5  Work in a position that is markedly stooped puts strain on ligaments and con-
nective tissue around the vertebrae. The illustration shows the bodies of the vertebrae in the
lower lumbar spine with the intervening discs seen from the side (on the left in a neutral,
upright position; on the right in a position leaning forward). Fg—gravitational force, Fc—
compressive force, and Fs—translational force (i.e., shear force). Illustration: Niklas
Hofvander. Modified after Christer Spångberg.

biased rotation movement take place. Strain on the joint creates both compressive
forces perpendicular to the joint surface and translatory forces, depending on the
directional force of the load (Figure 4.5).
Sometimes there are cartilage discs, the so-called meniscuses as in the knee
joints (Figure 4.6), and vertebral discs as in the back (Figure 4.5) and neck, which
help distribute the compressive force over a larger area, ensuring that the load per
unit area is reduced.
Joint cartilage has no blood vessels and receives its nutriment through osmosis—
that is, an equalization of concentration through a membrane; it benefits from var-

Femur with joint surface

to patella and tibia

Collateral Collateral
ligament ligament

Cruciate ligament
Meniscus

Insertion of the
patellar ligament
Fibula to tibia

FIGURE 4.6  Knee joint (without the kneecap) seen from the front with the most important
stabilizing ligaments—cruciate ligaments and collateral ligaments. Illustration: Niklas
Hofvander. Modified after Christer Spångberg.
Work in Awkward Postures 107

ied load, for example, as happens in the cartilage of the hip when walking. In varied
load, the cartilage is compressed and the load then released, which provides an
effect as though squeezing out a bath sponge. This increases the supply of nutriment
to the joint cartilage (see also Chapter 3, Section 3.8.2). As most of our movements
in daily life occur at the neutral position of the joints, the joint cartilage is, relatively
speaking, thicker in the central areas of the joint surfaces—the neutral zone of the
joint—while it is thinner in the more peripheral, outer parts, and is in those parts
more sensitive to load.
The joints are stabilized by ligaments and joint capsules, which centre on the load
and prevent the joint from luxating (“dislocating”). The ligaments perform an impor-
tant function in ensuring that the joint is stable at rest and in movement (Figure 4.6).
When the joint is under strain at the limit of its range of motion, some of the liga-
ments are greatly tensed and the joint surfaces are pressed together in the extreme
position of the joint, which impairs the exchange of nutriment to the cartilage and
accelerates wear. This happens, for example, in the knee joints when squatting or
kneeling. Prolonged uneven strain can lead to wear, in that the nutriment exchange
to the cartilage becomes impaired.
Sudden overloads can also damage the various structures of the joint. This might,
for example, be a question of a healthcare worker who catches a falling patient,
which may lead to powerful compressive force in the worker’s spinal column, which
among other things compresses the vertebral discs of the lumbar spine. A compres-
sion of this kind can affect the vertebral disc so that its viscous content is pressed out,
leading to what is known as a slipped disc. If a slipped disc presses on the nerves
emanating from the spinal column, painful symptoms appear. As these nerves in the
lumbar spine reach down primarily to the legs, the pain or numbness that then occurs
will be perceived as coming from the affected leg. Pain of this kind has been called
after the nerve which goes down into the legs—sciatic pains. Putting great strain on
the spine through heavy lifting, for example, particularly with a twisted or flexed
back, also results in an uneven strain on the vertebral discs, which further increases
the risk of a slipped disc.
Connective tissue around muscles and in tendons and ligaments has viscoelastic
properties, which means that it has a length adapted to the physiological range of
motion and which, with varied everyday loads, returns to its original length. The
physiological range of motion normally varies somewhat between individuals; how-
ever, some people regard themselves as “stiff” while others see themselves as “very
supple.” If connective tissue is stretched for a long period with a particular force, the
tissue lengthens and its tension declines—known as “creeping phenomenon”—and
the range of motion increases even after the stretching force is removed. If, instead,
one avoids making use of the normal, physiological range of motion in a joint, for
example, when an arm or leg is in plaster or when it is painful, the connective tissue
is shortened and the range of motion is reduced. Varied moderate load in the various
positions of the joint on the other hand instead helps build up the cartilage, and the
joint becomes more resistant to load. Wear on the connective tissue may mean that
the original length is altered, and thereby the biomechanical conditions in the joint.
If the ligaments are damaged and held in an extended position, the stability of the
joint is affected and there is a risk of wear on the cartilage of the joint surfaces,
108 Occupational Physiology

known as arthritis, which in turn makes the joint more sensitive to load than normal
(see also Chapter 3, Section 3.8.2).
The joints are surrounded by muscles, both shorter muscles which only serve one
joint and longer ones serving two or more joints. The muscles attach to the bone with
a structure of tendons. The surrounding muscles are important both for the stability
of the joint and its ability to cope with loads, as well as counteracting external loads
and achieving movement.
When joints are under strain near the limit of their range of motion, the ligaments
are stretched as well as other connective tissue structures surrounding the muscles
and serving the relevant joint. Stretching the muscles and tendons in extreme pos-
tures activates the Golgi tendon organ, which signals that the tendon is being
stretched. After a while, depending on load and time, the pain receptors are stimu-
lated and we feel pain, a pain, the intensity of which instantaneously increases at the
moment when returning to the starting point, and which can persist for a long time
even though we have started to move again.
The muscles’ ability to develop force is also dependent on the relative muscle
length at a certain angle, and, moreover, co-varies with the tendon’s moment arm
(lever) to the joint’s axis of rotation (Figure 4.7). The strength (force × moment arm)
one can develop at a certain joint angle varies at different angles of the joint. Given
the same moment arm length a somewhat extended muscle can produce more force
than a shortened, but the overall strength of the muscle anyhow declines the nearer
one comes to the extreme joint position, due to shorter lever arms. When the joint is
kept in its extreme posture, those muscle groups that counteract the load—that is,
those that can bring the joint back to a more neutral position—are very extended and
their moment arm shortened. The strength the individual can develop in this situa-
tion is therefore more limited. As working life often demands that a certain opera-
tion is carried out with a certain force, a relatively greater proportion of the strength
capacity is used to carry out that operation compared with carrying it out with the
joints and muscles in a more comfortable work posture (see also Chapter 3).

Fm

M M

FIGURE 4.7  Strength in the elbow flexors (Fm × M) depends on muscle force Fm in the
biceps muscle and the tendon’s moment arm (the perpendicular distance M) to the elbow
joint’s axis of rotation. On the left a schematic image showing examples of two different
elbow angles with varying muscle length and moment arm. Illustration: Christer Spångberg.
Adapted by Niklas Hofvander.
Work in Awkward Postures 109

FIGURE 4.8  Work in a markedly stooped posture puts strain on ligaments and connective
tissue around the vertebrae. Photo: Christer Spångberg.

On the other hand, help can be received from the stretched connective tissue
structures to counteract the strain in an extreme posture. An individual with,
­relatively speaking, less muscle strength can then exploit the connective tissue struc-
tures to counteract the strain, and does not then need to develop any muscle activity.
Gardening, which means that one needs to flex the lumbar spine to the limit of its
range of motion, is one example of an awkward work posture in which the level of
activity in the back muscles is low while the mechanical load on the structures of the
back is high (Figure 4.8). The load comprised by body weight is carried completely
by the ligaments around the vertebrae and the fasciae of the connective tissue around
the muscles. The muscles in the back of the leg are also extended considerably, but
there the activity levels in the muscles help keep the body in balance.
The increased strain on the joints in extreme posture contributes to an increase in
both the compressive forces and translatory forces in the back (Figure 4.5). The con-
struction of the back is optimized so as to take up compressive forces, while its toler-
ance to translatory forces, which increase the strain on the joint capsules and
ligaments, is less sound.
While the muscle activity subsides, despite the fact that the load moment increases
when bending one’s back and putting load on the joints in their extreme posture with
the aid of gravity (see Figure 4.8), the reverse is the case when twisting one’s body
around its own longitudinal axis. In twisted body postures, the muscle activity
increases logarithmically with the angle of rotation, without the load moment itself
increasing, the closer to the limit of the range of motion one comes, as the ligaments
and joint capsules are tightened. In that situation, a mechanical load in an awkward
posture is combined with a high muscular static load to keep the joint in its extreme
posture [Torén and Öberg 1999].
110 Occupational Physiology

A loading moment can therefore be counteracted both by muscle activity and/or

connective tissue structures and trigger pain depending on intensity and duration
[Harms-Ringdahl 1986; Harms-Ringdahl and Ekholm 1986].

4.5  POTENTIAL NEGATIVE RESULTS OF EXPOSURE

4.5.1  Does it Hurt?
We have all walked bent over for a long time picking berries, weeding the garden or
slumped down in a sofa, and have then wondered why it is so painful in the lower
back when we get up. The pain lasts for a while, but can also reappear as a kind of
delayed onset muscle soreness, like the day after physical exercise, depending on
how long the extreme posture load has lasted. The slow and dull ache points to the
fact that the slower, inward-reaching pain nerve fibres modulate the pain.
Why a prolonged, but, relatively speaking, light stretching at the extreme posture
of the joint should lead to tenderness and pain when moving in otherwise entirely
pain-free individuals is not completely known, but there are several theories.
There are many nociceptive receptors (pain-sensitive nerve fibres) in the connec-
tive tissue structures, as well as ligaments, joint capsules, connective tissue fasciae,
and tendons, which can be stimulated mechanically. The cartilage structures them-
selves, on the other hand, have no pain receptors. But if the cartilage in a joint is
damaged, this can give rise to a painful reaction in the joint. A change in the chemi-
cal environment of the nociceptive receptors can also stimulate the pain receptors in
the ligaments and periosteum [Wenngren et al. 1998]. There is even speculation that
the raised pressure occurring inside the joint and in the bone tissue itself, when it is
under strain near the limit of its range of motion, might produce pain.
Pain as a result of extreme posture can also generate a continuous muscle reflex
activity which can contribute to activating muscle spindles and substances that trig-
ger pain in the tissues [Johansson et al. 1999].
Within veterinary medicine, provocation load in extreme postures is used to chart
lameness in horses as a result of joint disorders; the joints in one leg at a time are
flexed at the same time as some of the weight of the horse rests on the flexed joint for
a standard number of seconds. Then the load is released and the horse is allowed to
jog for a few paces to see whether lameness is present. A corresponding argument
can be adduced for human beings. If, for any reason, someone has pain in a joint, the
pain-free range of motion is restricted. The extreme posture approaches the neutral
zone and it is painful when they use their own muscle force or when a clinician flexes
the joints to the limit of the now restricted range of motion.

4.6  INCIDENCE OF DISORDERS

Based on EU27 statistics from 2005, in which 235 million people from 31 countries
participated, 45% of EU workers in the construction sector and 39% in the health
sector reported that their health had been affected by their work; backache and mus-
cular pain were the most frequently reported physical symptoms [Eurostat 2009].
Work in Awkward Postures 111

The risk of developing a disorder as a result of awkward work postures depends,

to a great degree, on the size of the workload in the extreme posture and the time the
exposure lasts. This means that it is difficult to assess the actual incidence of hazard-
ous exposure to awkward work postures in working life. According to EU statistics
from 2005, 25–66% of the workers (a mean of 45%) in 31 countries report exposure
to tiring or painful positions at least a quarter of the time, of whom 18% report such
exposure all or almost all the time. The figures have remained relatively similar over
the last 10 years [Eurofound 2006].
Awkward work postures are the most frequent cause of disorders among men and
the second most frequent cause among women. One in five male painters, chimney
sweeps (23.2%), and building and construction workers (21.0%), one in six motor
vehicle mechanics and motor vehicle repairers (18.3%) and electrical installers
(18.1%) in Sweden report disorders as a result of awkward work postures [Weiner
and Bastin 2005].
The equivalent applies to one in four female hairdressers and skin therapists
(27.0%) and one in five cooks (23.3%), assistant nurses (20.3%), employees in institu-
tional households and restaurants (19.2%), and hotel cleaners (19.1%).
Why a somewhat higher proportion of women than men report disorders as a
result of awkward work postures is unclear, but there may be many reasons, such as
women are more likely to report disorders or that tools and work heights often are
better adapted to men’s hand and body sizes, which makes the work postures more
stressful for a smaller person. Direct measurements show, however, that women
have more awkward work postures than men. This applies primarily to those who
have little influence over their work situation and who work in professions where
women are predominant [Leijon et al. 2005].
Among women-dominated professions under county council, municipal and pri-
vate direction, there is a 60% greater incidence of reported work-related disorders
among dental nurses (after adjusting for the difference in age distribution) (period
prevalence = 1.6) [Weiner 2006]. The tasks of dental nurses involve both awkward
work postures and prolonged static muscle work in combination (see Chapter 6).

4.7  RISK ASSESSMENT

There are different methods of quantifying the incidence of awkward work move-
ments. Observations over a working day or several days are time consuming, whether
these observations are carried out by an on-site observer who then enters all the values
manually into a computerized system, or are done using video-recorded data. Problems
occur, however, when the work is mobile and cannot be reproduced using two-­
dimensional observations. A more objective method is the use of an angular gauge that
can be applied to the joints in question and which provides angular values around three
axes and computerized signals. Here the work movements can be related to percentage
proportions of the range of motion of the relevant joint around the corresponding axes.
In an experimental study, subjects have been asked to assess how comfortable/
uncomfortable it is to keep their shoulder joint and neck in a given position in differ-
ent parts of its range of motion [Kee and Karwowski 2001]. Even though this was
done for a very short time and with individuals who had no disorders, for example, it
112 Occupational Physiology

was felt to be uncomfortable even after 60 s to hold one’s arm rotated outward 25°
from the shoulder. It is common for the computer mouse to be placed next to the
keyboard, which causes this precise outward-rotated shoulder position [Karlqvist
et  al. 1998]. As regards the neck, all directions of movement were regarded as
increasingly uncomfortable the further one deviated from holding one’s head in a
neutral posture [Kee and Karowski 2001].
Assessments of the degree of exertion, and discomfort or pain are also frequently
carried out with the aid of various types of scale. The more specific the question
asked, the more specific was the response received. In statistical studies of the work-
ing environment in the EU (e.g., the Fourth European Working Conditions Survey),
questions are asked, for example, about whether one experiences work postures as
painful or tiring and awkward. One problem with questions of this kind is that it is
not possible to distinguish whether it is the tasks in awkward positions or the work of
muscles in various work postures which mean that the posture is experienced as
strenuous or awkward. People are, however, as a rule, good at making various types
of assessments of experiences with a high degree of reproducibility, assuming that
they are asked a precise question [Leijon et al. 2002]. On the other hand, it is more
uncertain as to how possible disorders influence the assessment of exposure and its
duration. It is more probable that a person with a disorder in a particular work pos-
ture will report it as awkward and of longer duration compared with a person without
any disorder in the same work posture. It is also very possible for someone to change
their work postures and try to avoid awkward positions as far as possible if they have
disorders triggered by strain.
Another possibility in risk assessment is that people who are sick and off work for
a long period or who have changed jobs or ended their employment as a result of any
disorders are not picked up in the study. Studies in which a group of individuals are
followed over time are therefore to be recommended.

4.8  MEASURES IN CRITICAL CONDITIONS

The most important measure is to revise work postures and tasks so that load on the
body and work movements varies naturally during the working day. Moderate load
in varied work postures reduces the risk of disorders, while inflexible work postures
increases the risk, irrespective of the external load and position of joints.
While seated work sites can often be altered to make it easier for the employee,
there are many examples of environmental factors that cannot easily be adjusted,
and where instead it is necessary to consider whether there are any work aids to
reduce the strain on the body and in this way facilitate variation and the carrying
out of tasks (Figure 4.9). In the left-hand-side picture, one can work with one’s
back and joints in comfortable work postures. In the right-hand portion of the pic-
ture the work is not altogether made easier by using a step. As the task is so close
to ground level, both back and neck are kept in awkward work postures. In this
case, the entire vehicle should instead have been raised with the help of a lift to
facilitate the work. Presumably, it would also have been better to carry out the
work standing up.
Work in Awkward Postures 113

(a) (b)

FIGURE 4.9  A simple moveable step (a) allows work to be carried out without needing to
twist or stoop in order to gain access. On the other hand, working on a step—depending on
the work height—may also mean that it is more difficult to gain access (b). Photo (a): Christer
Spångberg; (b): Karin Harms-Ringdahl.

Preventive measures can be divided into two groups—Technical devices and

Organization of work. While different types of aid can adjust the work height for
the employee, so that the work postures become comfortable and inflexible body
postures are avoided, work organization measures can build in natural variation.
Different measures by which the employee is reminded at regular intervals to take
breaks without these occurring naturally have most often not resulted in the
intended effect.
Those aids available on the market often provide opportunities for changing the
work height−employee relationship. Different types of simple steps are an example
of this (Figure 4.9). Other examples may be lengthening the pole on a paint roller, or
adapting the tool so that it is easier to reach, and creating good lighting at the work-
place. In work in restricted spaces, it is often easier to see what should be done in a
strong light. For our spectacle-wearing electrician, the work area which he can see
close up is much larger in a good light. There is also the possibility of using bifocal
glasses with the lenses reversed, showing the immediate surroundings at the top of
the lens, which reduces the need to bend the neck back in carrying out precision
work at above head height.
From a work organization point of view, there is an attempt to create the precondi-
tions for body movements being variable both as regards range of motion and mus-
cles. Changing ingrained movement habits, however, takes time and requires
practice. On Andrej’s part, one might imagine that his work could be reorganized so
that he does not have the same task all day, or perhaps even for several days in a row.
Vertical work could be alternated with tasks in the lower area of movement.
Training forms part of the work organization measures, even if the results of pro-
viding information about ergonomics are not unequivocal. This might be because it
is merely information, and because a worker is seldom given the opportunity of
training the performance of work movements in the same systematic way that a
sportsman, for example, a golfer, trains the different movements needed to pursue
his sport in a way that is optimal for his body.
114 Occupational Physiology

4.9  W
 HAT DOES THE LAW SAY ABOUT WORK IN AWKWARD
WORK POSTURES?
For the EU member states, there are a number of minimum directives applying to the
work environment and health [Directive 89/391/EEC, Directive 89/654/EEC,
Directive 89/655/EEC]. There are no detailed rules in these directives applying to
awkward body postures, but it is clearly evident that employers have a responsibility
to perform a risk assessment on all jobs as regards ergonomics and to take measures
above all to remove risks, and secondly to minimize them.
Another piece of European legislation that has a bearing on work postures is the
directive regulating the use of personal protective equipment [Directive 89/656/
EEC]. In this directive there are demands that personal protective equipment should
be designed ergonomically and adapted to the employee. It is important to reduce the
physical strain in jobs involving awkward body postures at the same time as personal
protective equipment is being used.
The member states have national legislation to implement and concretize the
directives. There are often national guidelines and general advice as a support for
measures to prevent risks at work.
Regulations about work postures that should be avoided are given in very general
terms and as a rule issue from the muscle load and body postures which may be thought
to cause disorders, how heavy a weight one should lift, push or pull, and how still one
should sit. For awkward work postures, in principle the corresponding regulations for
sitting apply (see further in Chapter 6) as for standing and walking tasks. Work using
the back and neck in stooped and/or twisted work postures, like work with the hands
above shoulder height or below knee height, is regarded as a risk factor for disorders
triggered by strain, if this occurs periodically or over a large part of the working period.
There are checklists [Kemmlert 1995] and models for identifying and assessing
awkward work postures, where risk factors for disorders triggered by strain are eval-
uated in three risk factors: red, yellow, and green. Organizational measures for
achieving variation of work movements should be aimed at, while awkward work
postures, such as prolonged stooped or twisted positions with high demands on
vision, maintained periodically or for long periods, should be avoided.

4.10  SUMMARY
Work with a high demand for work postures in which the extremity joints and the back
and neck are under strain close to the limit of range of motion is normally quite fre-
quent, perhaps particularly in the building trade but also in other types of work.
Approximately 8–10% of the population state that they have disorders of the muscu-
loskeletal system as a result of awkward work postures. Loads close to the limit of the
range of motion are counteracted by connective tissue structures, and may be associ-
ated with little or a great deal of muscle activity, depending on whether the position
can be maintained with the help of gravity or whether it is necessary to twist around a
longitudinal axis. The cartilage is thinner at the limit of the range of motion and more
sensitive to major compressive forces than if the corresponding force impacts on the
cartilage in the central portions of the joint. We are also less strong in the angles of the
Work in Awkward Postures 115

joint near the limit of the joint’s range of motion. Forces parallel to the surface of the
joint (translatory forces) that stretch the ligament and joint capsules can arise. Pain
occurs after a period of strain in an extreme posture, and more rapidly if the individual
already has a disorder in the joint concerned. There are pain-sensitive nerve fibres in
the connective tissue structures that help generate pain. Countermeasures consist of
ergonomic changes, and changes to the organization of  work, that promote varied
body movements and load in more neutral joint positions.

REFERENCES
Eurofound. 2006. Fourth European working conditions survey. European Foundation for the
Improvement of Living and Working Conditions. http://www.eurofound.europa.eu/pub-
docs/2006/98/en/2/ef0698en.pdf
Eurostat. 2009. Statistics in focus. 63/2009. http://epp.eurostat.ec.europa.eu/cache/ITY_
OFFPUB/KS-SF-09-063/EN/KS-SF-09-063-EN.PDF
Directive 89/391/EEC—On the introduction of measures to encourage improvements in the
safety and health of workers at work. European Agency for Safety and Health at Work.
http://osha.europa.eu/en/legislation/directives/the-osh-framework-directive/1
Directive 89/654/EEC—Concerning the minimum safety and health requirements for the
workplace. European Agency for Safety and Health at Work. http://osha.europa.eu/sv/
legislation/directives/workplaces-equipment-signs-personal-protective-equipment/
osh-directives/2
Directive 89/655/EEC—Concerning the minimum safety and health requirements for the use
of work equipment by workers at work. European Agency for Safety and Health at Work.
http://osha.europa.eu/en/legislation/directives/workplaces-equipment-signs-personal-
protective-equipment/osh-directives/3
Directive 89/656/EEC—On the minimum health and safety requirements for the use by work-
ers of personal protective equipment at the workplace. European Agency for Safety and
Health at Work. http://osha.europa.eu/en/legislation/directives/workplaces-equipment-
signs-personal-protective-equipment/osh-directives/4
Harms-Ringdahl K. 1986. On assessment of shoulder exercise and load-elicited pain in the
cervical spine. Biomechanical analysis of load-EMG-methodological studies of pain
provoked by extreme position. Scand J Rehab Med Suppl 14:1–40.
Harms-Ringdahl K. and Ekholm J. 1986. Intensity and character of pain and muscular activity
levels elicited by maintained extreme flexion position of the lower cervical-upper tho-
racic spine. Scand J Rehab Med 18:117–126.
Johansson H., Sjölander P., Djupsjöbacka M., Bergenheim M., Pedersen J. 1999.
Pathophysiological mechanisms behind work-related muscle pain syndromes. Am J Ind
Med Suppl 1:104–106.
Karasek R., Baker D., Marxer F., Ahlbom A., Theorell T. 1981. Job decision latitude, job
demands, and cardiovascular disease: A prospective study of Swedish men. Am J Public
Health 71:694–705.
Karlqvist L., Bernmark E., Ekenvall L., Hagberg M., Isaksson A., Rosto T. 1998. Computer
mouse position as a determinant of posture, muscular load and perceived exertion.
Scand J Work, Environ & Health 24:62–73.
Kee D. and Karwowski W. 2001. The boundaries for joint angles of discomfort for sitting and
standing males based on perceived discomfort of static joint postures. Ergonomics
44:614–648.
Kemmlert K. A method assigned for the identification of ergonomics hazards—Plibel. 1995.
Appl Ergon 26:199–211.
116 Occupational Physiology

Leijon O., Wiktorin C., Härenstam A., Karlqvist L., MOA Research Group. 2002. Validity of
a self-administered questionnaire for assessing physical workloads in a general popula-
tion. J Occup Environ Med 44:724–735.
Leijon O., Bernmark E., Karlqvist L., Härenstam A. 2005. Awkward work postures: Association
with occupational gender segregation. Am J Ind Med 47:381–393.
Lundholm L. and Swartz H. 2006. Musculoskeletal Ergonomics Statistics. Report 2006:2E
Swedish Work Environment Authority. http://www.av.se/dokument/statistik/english/
Musculoskeletal_ergonomics_statistics.pdf
Torén A. and Öberg K. 1999. Maximum isometric trunk muscle strength and activity at trunk
axial rotation during sitting. Appl Ergon 30:515–525.
Weiner J. 2006. Arbetsorsakade besvär i landsting och privat sektor—en jämförelse.
Stockholm: Swedish Work Environment Authority (In Swedish). http://www.av.se/
dokument/statistik/sf/sf2006_02.pdf
Weiner J. and Bastin M. 2005. Work-Related Disorders 2005. Stokholm: Swedish Work
Environment Authority and Statistics Sweden. http://www.av.se/dokument/statistik/offi-
ciell_stat/ARBORS2005.pdf
Wenngren B. I., Pedersen J., Sjölander P., Bergenheim M., Johansson H. 1998. Bradykinin and
muscle stretch alter contralateral cat neck muscle spindle output. Neurosci Res
32:119–129.

FURTHER READING
Rom W. N. and Markowitz S. B. 2007. Environmental and Occupational Medicine.
Philadelphia: Lippincott Williams and Wilkins.
 5 Work with
Highly Repetitive
Movements
Fredrik Hellström

Photo: Johan Karltun

CONTENTS
5.1 Focus and Delimitation.................................................................................. 118
5.2 Prevalence of Highly Repetitive Work in Working Life............................... 119
5.3 Repetitiveness and Exposure......................................................................... 120
5.3.1 The Work Cycle and Its Elements..................................................... 120
5.3.2 What Does Exposure Look Like?...................................................... 120
5.3.3 Variability of Exposure...................................................................... 122
5.3.4 Repetitiveness and Similarity............................................................ 122
5.4 Physiology of Repetitive Movements............................................................. 122
5.4.1 How Do We Choose to Move?........................................................... 122
5.4.2 Internal Models and Movements....................................................... 123
5.4.3 Motor Patterns................................................................................... 124

117
118 Occupational Physiology

5.4.4 Degrees of Freedom and Redundancy in Motor Systems................. 124

5.4.5 Restrictions on the Utilization of the Number of Degrees
of Freedom......................................................................................... 125
5.4.6 Muscle Synergies............................................................................... 126
5.4.7 Sensory Motor Function in Repetitive Movements........................... 127
5.4.8 Direct Responses in Exposure to Highly
Repetitive Movements....................................................................... 128
5.5 Pathophysiological Mechanisms in Exposure to Highly
Repetitive Movements................................................................................... 131
5.5.1 Changes in Work Allocation in the Muscle....................................... 131
5.5.2 Tendons and Nerves........................................................................... 134
5.6 Consequences of Repetitive Loads among the Population............................ 134
5.7 Risk Assessment............................................................................................ 135
5.8 What Measures Can be Taken to Minimize the Risks
of Repetitive Work?....................................................................................... 136
5.9 What do Laws, Regulations, and Provisions Have to Say?........................... 137
5.10 Summary....................................................................................................... 138
References............................................................................................................... 138
Further Reading...................................................................................................... 139

Janis, 27, has worked for 5 years as a meat-dresser in a large slaughterhouse. As a meat-
dresser, Janis dresses the carcasses of pigs that have been rough-butchered by a butcher.
The carcasses are divided into halves or quarters that are either lying flat or hanging on
a hook. The work involves separating the meat from the bone; portions are cut out and
the fat is removed. The cuts of meat that are divided are placed on a conveyor belt,
which takes them to sorting and packaging. Janis carries out most of the operations
manually and works together with fellow workers in a team. The incidence of rotation
between different tasks is limited. The different operations that Janis carries out make
varying demands on strength and precision and take between 40 and 60 s to complete.
Janis often works on one operation for a whole day, for example, cutting shoulder joints
from pigs. In his work, Janis lifts weights of up to 15 kg; occasionally these peak as
high as 25 kg. During his work, the force he needs to use to cut varies between 11% and
30% of his maximum force, with peaks at over 50%. The pace of work is high, and the
time allocated for breaks is short. Janis begins at 6:00 in the morning and finishes work
at 2:30 in the afternoon. He takes a total of 30 min break, divided into two periods
during the day. His wages are in part performance-related, and so Janis wants to do as
much work as possible during the working day. It is cold in the premises where Janis
works. To protect himself against cuts, he has to wear protective gloves and a protec-
tive apron. Janis is often physically exhausted at the end of the working day.

5.1  FOCUS AND DELIMITATION

This chapter deals with work in which movements are repeated over and over again,
at the same time as requirements are imposed for precision in movement and the
muscles are used with considerable force. Janis’ job as a meat-dresser in a slaughter-
house is a good example of this type of work. The chapter also illustrates how
Work with Highly Repetitive Movements 119

repeated movements, and the requirements for precision and force, are combined
during the entire day or parts of the working day.
The focus in the chapter is on short repeated movements, and the chapter there-
fore deals only with movements of a maximum duration of five min. It is common,
however, that movements are much shorter (between 5 s and 2 min). There are also
jobs that entail large elements of repeated movements and precision demands, but
which do not require the muscles to be used forcefully, for example, computer work.
Computer work will be discussed in Chapter 6. Jobs that do not have a very repetitive
element, but where considerable force is needed—called heavy manual trades—
have been discussed in Chapter 3.
This chapter focuses on the physiology behind the performance of highly repeti-
tive movements, and how highly repetitive movements with demands for force and
precision may lead to disorders. The chapter will, among the things, answer ques-
tions such as:

• What preconditions does the body have for carrying out repetitive work?
• Why is a prolonged exposure to the combination of repetitive movements,
force, and precision particularly taxing?
• Is working technique in repetitive movements of any significance?
• What happens to the muscles in repetitive work?

5.2  P
 REVALENCE OF HIGHLY REPETITIVE WORK
IN WORKING LIFE
Janis is not alone in being subjected to highly repetitive movements, and force and
precision demands, in his work. Various professions where highly repetitive work is
common are to be found primarily within difference sectors of the food industry, for
example, in the slaughterhouse sector, including the preparation of meat products, or
the fish processing sector, and within the manufacturing industry, focusing on assem-
bly work, particularly the assembly of motor vehicles. In Europe ~1 million people
worked as butchers, meat-dressers, head butchers, or pork butchers in 2006, with
most of these workers in countries such as Germany (202,000), France (157,000),
and Poland (125,000). Approximately 130,000 people worked in the fish processing
industry, in Europe, with predominance in countries such as Spain, the United
Kingdom, and France. During 2006, ~2.2 million people worked on motor vehicle
assembly in Europe, with predominance in Germany (980,000), France (416,000),
and the United Kingdom (326,000). During the financial crisis of 2008–2009 the
motor vehicle industry was hard hit, which means that the figures may have changed.
A large proportion of these people worked in systems with line production, the so-
called assembly lines, with either a continuous movement of the line or with a system
where the line stops for a limited time while the task is performed. The system of
assembly line production means that the work is more constrained and has a greater
element of repetitive operations than in systems with greater autonomy as regards
movements and tempo.
In total, in Europe, 62% of the working population state that they have been
exposed to repetitive hand or arm movements for at least a quarter of their working
120 Occupational Physiology

day [Eurofond 2007]. The statistics collated from different member states in the
European Union (EU) on exposure to repetitive work are not entirely uniform, but
may also include exposure to considerable demands for muscle force and precision,
or less strenuous jobs with repetitive elements. The statistics are therefore not com-
pletely transferable to those professions mentioned above, but nevertheless give a
picture of the situation.

5.3  REPETITIVENESS AND EXPOSURE

5.3.1  The Work Cycle and Its Elements
To perform an operation and return to the initial position again is called the work
cycle, and the time it takes is called cycle time. Usually, the work cycle contains one
or more operations that are repeated with high frequency. In Janis’ case, it takes
about a minute to cut out a whole joint of meat, which may be regarded as one work
cycle, but during that minute Janis carries out a number of cutting movements with
his arm and hand. The cutting movements consist in their turn of very short repeated
movements (1–2 s of cycle time). A single repeated movement that forms part of a
work cycle might be called a cycle of movements. The cycle of movements also has
a cycle time. A work cycle may therefore consist of differing levels, where shorter
operations with similar movements—cycles of movements—build up into the more
comprehensive work cycle.

5.3.2  What Does Exposure Look Like?

When Janis is working, it takes a minute to cut out a shoulder. During that minute he
executes ~30 cutting movements with his knife. If Janis works cutting out shoulders
from 6.00 in the morning to 2.30 in the afternoon, he makes at least 12,000 cutting
movements with his arm and hand during his working day. In order to be able to cut,
Janis needs to use ~20% of the maximum strength (maximum voluntary contraction
(MVC)) in his arm, at the same time as it is important that he cuts accurately, as the
product has to maintain a high quality. On a few occasions Janis may need to use
more than 50% of his MVC in his work. The maximum force that Janis can generate
in a particular movement is, however, dependent on the speed with which the move-
ment is made. The quicker the movement, the lower the maximum force the muscle
can generate. When Janis cuts out shoulders during the work cycle, he has a maxi-
mum speed in his shoulder movements of up to 315°/s and an average speed of ~65°/s.
This means that it is probable that Janis is close to the maximum of what can be
achieved in this specific movement.
He also needs to hold a knife, and for this he needs to use ~30% of his maximum
grip force on average. It is common that the force required varies a great deal over
the work cycle. The variation is illustrated in Figure 5.1 where the percentage of time
of different grip force levels vary during different time periods of a work cycle when
a butcher is preparing a piece of prime rib of beef. A grip force of 50–60 N corre-
sponds to 20–40% of the maximum grip force, which is relatively powerful.
Work with Highly Repetitive Movements 121

15

Force <1 N

Force 1–20 N
Percent of total time

10
Force 21–40 N

Force >40 N

0
0–6 s 7–12 s 13–18 s 19–24 s 25–30 s
Time periods of 30 s work cycle

FIGURE 5.1  ​Different grip forces during different time periods in one individual cutting a
piece of prime rib of beef. The percent of total time at different force levels are shown in each
time period of the 30 s work cycle. N = Newton. (Modified from McGorry, RW., Dowd, PC.,
Dempsey, PG. 2003. Appl Ergon 34:375–82.)

In order to access the right places, Janis needs to position his body appropriately.
This sometimes means stooped and twisted body postures along with keeping his
arms above shoulder height. More about working in extreme body postures can be
found in Chapter 4. At the same time, as the body posture is important, the position
of the head must be carefully monitored, as eyesight is important when all the cuts
must be made in the right places during dressing. This means that the muscles of the
neck need to be tense all the time to keep the head still. The requirements on cutting
in a particular way restrict the opportunities for otherwise carrying out the work in
different ways; the work posture becomes fixed.
The neck muscles also help to stabilize the shoulders. As precision is higher in the
hand than in the shoulder, the shoulder is used to roughly adjust the position and
subsequently stabilize the arm. This puts continuous strain on the neck muscles.
The material that Janis is working with is also of importance to the exposure; if
the meat is, for example, too cold, it becomes more laborious to cut into it, because
cold meat is stiffer and harder. The exposure therefore consists of a combination of
continuous and dynamic loads with considerable force development, carried out in a
relatively fixed work posture (see Chapter 6 about dynamic muscle work). The same
combination is also well documented in the fish processing industry and the assem-
bly industry. When boning fish, activity of up to 56% of maximum electromyography
activity has been measured in the muscles of the forearm, and a grip force of 31–34%
of maximum hand grip force. Cycle times for different operations in the fishing
industry vary between 5 s and 60 s, where operations of 5 s cycle time involve han-
dling objects with weights of up to 2 kg. Operations with cycle times of 60 s involve
122 Occupational Physiology

handling objects of up to 21 kg [Nordander et al. 1999]. The work described above is
also combined with a fixed work posture, primarily for the neck.

5.3.3  Variability of Exposure

Even if the task is the same, the relative load which muscles and joints are exposed
to varies between individuals, as all individuals do not, for example, use the same
proportion of their maximum force. For example, the hand grip force varies in a
particular operation in the butchering of a pig between 11% and 35% of MVC, when
different butchers are compared. The same difference in force between individuals
has also been shown in assembly work using laminate sheets (installation, gluing,
and final polish). This distribution of the force employed between individuals may
depend on several different factors. Maximum strength (MVC) may vary among
individuals, and/or individuals solve the problem in different ways. In order to be
able to solve the task in different ways, it is necessary that the task allows this. By
measuring the difference in how different individuals carry out the task, we can
acquire some understanding of how inflexible the task is. The more flexible the task
is, the greater the opportunity for differences between individuals. It is, however, not
certain that everyone exploits or is even able to exploit the opportunity that exists to
vary their work within those parameters that the task allows. Variability within the
individual’s performance of a task compared with that of other individuals may pro-
vide information about how similar the exposure is between work cycles, and thereby
the flexibility in that individual’s working technique.

5.3.4  Repetitiveness and Similarity

Repetitive movements are movements carried out in the same or similar ways over
and over again. Despite the fact that great pains have been taken to define repetitive-
ness in movements, there is really no definitive answer as to what is the best method.
This is primarily because there are two different expressions relating to repetitive-
ness: (1) frequency of movements and muscle activity, and (2)  ­similarity between
repeated events. These two are sometimes confused. The first relates to the degree of
change in loading per unit of time. Similarity describes how similarly a repeated
movement is performed over time. The performance can be measured in parameters
such as time taken, force required, and the range of the movement in space.

5.4  PHYSIOLOGY OF REPETITIVE MOVEMENTS

5.4.1  How Do We Choose to Move?
Movements of various parts of the body can arise in many different ways. We can
choose to perform movements ourselves, movements may occur through reflexes,
or be governed by more automated systems such as when we walk, for example. We
can also be subject to external forces that set our body parts in motion. When a move-
ment occurs, it is often a combination of different ways of moving a body part. Reflexes
and automated movements can be affected by external forces, and by our own will to
Work with Highly Repetitive Movements 123

move a part of our body; for example, we can counter changes in the ground we are
walking on or change our walking style. We can also compensate by increasing the
force we generate, for example, when it is difficult to cut through something hard.
The repetitive movements that Janis carries out when he is working are move-
ments that he himself initiates and over which he has conscious control. To carry out
these movements his nervous system needs to know and analyse a number of differ-
ent factors affecting his performance, for example, what Janis’ body looks like and
how it works, what the surroundings are like, what emotional condition Janis is in,
his motivation in performing the movements and previous experiences of doing so.
In Janis’ case, the environment provides important limits to how movements can be
performed. Those cuts he makes must be correct and must be made within a specific
predetermined time, so that Janis manages to do as much as possible during his
working day. This therefore governs what opportunities Janis himself has to choose
regarding how he moves. Janis is also limited by the fact that he is holding a sharp
object (the knife) and in certain cases has to make very specific movements to avoid
injuring himself.

5.4.2  Internal Models and Movements

In order to be able to perform the movements that are required and at the same time
stay within the limitations imposed by the environment, information is necessary
about what the environment looks like and its properties, and what the body looks like
and how it functions. The dominant theory for how the central nervous system (CNS)
can deal with all this information is based on the creation of internal models with
regard to how the movement should be performed [Wolpert et al. 1995]. The internal
models describe the properties of the environment and the body, for example, how our
arms work or the properties of the knife and its function. On the basis of these models,
the nervous system can predict what is going to happen if, for example, the muscles of
the forearm are activated when the hand is holding a knife. In order to create accurate
models of the body, the objects we hold, and the environment, information from the
eye and different receptors in muscles, joints, and the skin are very important. The
creation of internal models is the one of the first steps in performing a movement.
In order to build up internal models, different reference systems are created.
These may either be centred on ourselves or on an object outside our body. A refer-
ence system also helps determine how various things relate to one another. For
example, one reference system describes where the knife in my hand is located with
reference to the eye that is, looking at the knife. The body then creates a number of
different reference systems that are linked together. As we know how the eyes are
located in relation to the head, a reference system between the head and the eyes can
be created. This is developed further, as we know how our arms are placed in rela-
tion to our head and our arms to our hands and so forth. Finally, an entire reference
system including the head, the arm, the hand, and the knife is built up. The knife can
now be related to our own body and the environment around us. As these various
reference systems are based on each other, they are also dependent on each other, and
if one reference system changes, the others must be updated. Previous experiences of
handling a knife help us to create and update the reference systems dealing with
124 Occupational Physiology

objects like the knife more quickly and thereby also updating the internal models.
The CNS works constantly with a set of different reference systems and makes
changes to these. With the aid of the internal models that have been built up of our-
selves and our environment, a specific internal model is created for a limited move-
ment we intend to perform. The internal model forms a basis for determining how
and in what order muscles should be used, a “motor pattern,” which is explained in
the next section.

5.4.3  Motor Patterns

Signals that activate muscles are called motor commands and are generated in dif-
ferent areas of the brain. Several motor commands build up a motor pattern, which
in turn is dependent on what the internal model of the movement looks like. A motor
pattern can be seen as the solution the internal model uses in order to achieve its aim
with a movement. The choice of motor pattern is limited in this way not merely by
properties in the environment but also by the object that has to be handled and by the
properties of the musculoskeletal system. Lifting something heavy with a particular
movement does not produce the same motor patterns as lifting something light in the
same trajectory. Previous experience of making similar movements is of importance
for which motor pattern will be used and therefore for the performance of the move-
ment. When an internal model is established, it becomes easier to find motor patterns
when similar movements are to be repeated.
When Janis makes his repeated cutting movements, he does not need to create a
new motor pattern each time, but can use the same pattern time and time again, pos-
sibly with some minor adaptation, as there is an internal model for the movement.
However, neither the internal model nor the motor pattern used are constant, but may
change with the help of information generated by receptors in muscles, joints, and the
skin. This results in a tendency for repetitive movements to imitate the last movement
carried out, and not the first in a series of repeats. Janis’ cutting movements do not,
therefore, need to be as similar in each repetition as they may appear at first glance.
The nervous system can also generalize between two similar movements where
internal models support each other. In this way, no new motor patterns need to be cre-
ated all the time just because a minor modification occurs, for example, in the envi-
ronment. For any internal model to become permanent, a certain amount of time is
needed for confirming the motor memory [Cohen and Robertsson 2007]. It is impor-
tant during the period of confirmation not to create internal models that are similar, as
this makes confirmation more difficult. Gradual changes in the task lead to the inter-
nal model being gradually changed, and somewhere there is a limit where the modi-
fied model differs from the original to such an extent that it is stored as a new model.

5.4.4  Degrees of Freedom and Redundancy in Motor Systems

Every joint in the body can move in a number of directions. The shoulder joint can,
for example, be angled upward, downward to either side, and can rotate. These move-
ments are independent of each other and can occur without affecting each other. The
number of possible independent movements that can be made in a joint is called the
Work with Highly Repetitive Movements 125

number of degrees of freedom of the joint. The arm consists of hand, elbow, and
shoulder joints, and these joints together have a number of degrees of freedom. Put
simply, the wrist may be said to have two degrees of freedom—movements upward,
and downward, and to the right and the left. The bones of the forearm, which are
linked to the wrist and elbow, can rotate and in this way produce rotation of the wrist
and hand. This rotation adds one degree of freedom. The elbow joint adds a further
degree of freedom, and the shoulder joint adds three degrees of freedom. In total, the
whole arm in this simplified model has seven degrees of freedom. In order to deter-
mine the position of the hand, only three degrees of freedom are required, corre-
sponding to the three dimensions in space. There is, therefore, a surplus of degrees
of freedom for positioning the hand in space using the arm, and this surplus is called
redundancy. Redundancy means that there are several different possibilities for com-
bining angles of the shoulder, elbow, and wrist joints and still produce the same
position for the hand.
In order to achieve these different angles of the joint, different motor patterns are
needed. When Janis cuts his shoulders of pork, the redundancy with regard to
degrees of freedom means that he will be able to do this in many different ways and
still make all the joints of meat the same. What causes Janis to use one particular
motor pattern rather than another is not clear. Nor is it certain that Janis makes use
of different motor patterns during the working day. He may perhaps be using the
same one the whole time. It is not just the performance of the movement that can be
varied; the activation of individual muscles can also be varied. In trials where people
have had to hold their arms stretched straight out from their body and are therefore
loading the neck muscles, different people have differing abilities to change their
motor patterns and at the same time reach the desired goal as regards muscle activa-
tion. It is not clear as to what significance this has for any potential development of
disorders. In an experimental study, experienced, healthy butchers and a control
group of healthy “nonbutchers” carried out a simulated cutting task consisting of a
series of cutting movements [Madeleine et al. 2003]. The two groups demonstrated
different activation patterns of the muscles involved, where the experienced group
was characterized by a more varied pattern and lower activation levels. This illus-
trates that they may have different ways of activating groups of muscles, but never-
theless achieves the same result. Even within a muscle there are degrees of freedom.
A large number of different combinations of motor units can lead to the same final
effect of muscle activation. When Janis carries out a repetitive task, his body there-
fore provides the preconditions for varying both motor pattern and muscle activation
in different ways, despite the fact that the aim of the movement is the same.

5.4.5  Restrictions on the Utilization of the Number of

Degrees of Freedom
How the number of degrees of freedom is used may be restricted by factors from the
environment. For example, movements with considerable demands for precision can
result in a smaller number of degrees of freedom being available, as the entire move-
ment has to be carried out in a very exact way in each work cycle. Some of the
­combinations of joint angles which theoretically lead to the same hand position are
126 Occupational Physiology

not “allowed” in practice. In this way, there is less possibility of variation of muscle
activity between different cycles. This is particularly important in jobs where there
is repetition of a movement and at the same time a requirement for precision. We also
have a built-in restriction on how different degrees of freedom can be used: how the
joint surfaces and ligaments are designed in different joints. These structures only
allow certain movements and thereby restrict how the degrees of freedom can be
used. The utilization of the degrees of freedom is therefore also affected if any struc-
ture, for example, a joint, is damaged. Adaptations in motor function may then lead
to certain muscle activities being impossible to perform without resulting in pain.
Pain in itself is also a factor that influences the internal model and thereby the choice
of motor pattern.

5.4.6  Muscle Synergies

An important property of the body which contributes to motor patterns being vari-
able is that there are more muscles around most joint than are theoretically required
to carry out all of those movements permitted by the anatomy of the joint. The CNS
in this way has to choose suitable patterns of muscle activations that reduce the
redundancy in the degrees of freedom to carry out the specific movement desired. A
suitable pattern of this kind is called a muscle synergy. Different muscles therefore
work together in synergies in order to achieve a certain desired mechanical effect.
For example, to simplify somewhat, the head has three degrees of freedom in rela-
tion to the body, but there are 23 muscles on each side of the spine that participate in
moving the head. Depending on the desired movement, the CNS chooses the synergy
that best suits the task. For example, moving your gaze from one place to another is
carried out in three different ways:

• Eye movements
• Head movements
• A combination of eye and head movements

How synergies are organized precisely and governed is relatively unknown.

Presumably, some aspects are innate and others are acquired through learning. As
learning is important, different people may have learnt different methods to coordi-
nate their muscles in synergies when they perform a particular movement. The dif-
ferent ways of working are also revealed through different cycle times, force levels,
and a different number of cuts, for example, on the part of butchers carrying out the
same task. The butchers whose muscle activity was measured may have changed
their motor patterns to better adapt to the job. In a comparison between experienced
meat dressers and beginners, the experienced butchers’ muscle activation patterns
resulted overall in a shorter period for the work cycle, something that may be of
financial advantage, as butchers often work on individual piece rates.
Coordination of the muscles in the synergy is well defined to specific movements.
Many muscles that act across several joints may be agonists (working in the same
direction) in one case and antagonists (working in the opposite direction) in another,
depending entirely on what types of movements are being carried out. In movements
Work with Highly Repetitive Movements 127

that comprise several joints and muscles acting across both one and two joints, a
movement becomes a pattern of muscle activations in which muscles can work
together with each other in certain components of the movement and against each
other in other components. In complicated movements, the coordination of activa-
tion and deactivation of agonists and antagonists is of major significance. If syner-
gies are not adapted to a movement, there is a risk that the aim of the movement is
not achieved, and that strain during the movement increases as muscles counteract
each other. There can, however, be conflicts where one and the same muscle is
needed for different tasks. One muscle that is activated in many different tasks is the
trapezius muscle. This muscle generally helps in stabilization, and in movements of
the shoulder joint or the head. The trapezius muscle is divided up into different func-
tional units, which makes it easy for the muscle to take part in different tasks at the
same time. When Janis cuts out shoulders of pork, he is dependent on muscle syner-
gies functioning optimally. A disturbance of, for example, the trapezius muscle
might lead to a failure of the work apportionment within the muscle and certain por-
tions of the muscle becoming overloaded.
An important tool enabling the body to evaluate and monitor a synergy is sensory
information. Sensory information affects all the stages in the chain from planning to
choice of motor pattern and performance of a movement. Moreover, the sensory
information is important for optimization and adaptation of muscle activity.

5.4.7  Sensory Motor Function in Repetitive Movements

There is a constant interaction between sensory and motor signals in the nervous
system. The performance of movements generates sensory signals that affect how
future movements will be carried out. Sensory signals into our CNS come from
receptors placed in our muscles, joints, and skin. Visual impressions and those sig-
nals sent by the organs of balance in the ears are added to sensory signals. Common
to all signals is that they are continually monitored and analysed by the CNS. All
sensory signals do not reach our consciousness, but sometimes remain at a deeper
and more unconscious level. Sensory information from the periphery, that is, from
muscles, joints, and skin, is sent through the spinal cord via different switching sta-
tions, and ends up in the somatosensory areas of the cerebral cortex. On the way up
to and in the somatosensory areas, sensory information is collated from various
sources into an overall picture. Much points to the fact that the CNS can weight
sensory information—that is, to ascribe varying significance to sensory informa-
tion from different parts or sources. There are strong links between somatosensory
and motor areas in the cerebral cortex. There are also other places where sensory
and motor functions cooperate, for example, in the cerebellum and at different lev-
els in the spinal cord. Sensory information is in this way particularly important in
the learning of new movements, that is, the creation of new internal models and
motor patterns. The principal sources of sensory information for movements are
vision and the muscle spindles. Muscle spindles are 1–2 mm contractile receptors
that lie in parallel to ordinary muscle cells in most of the muscles of the body. The
number varies between different muscles. Some muscles have no muscle spindles,
while ­others have thousands. Muscle spindles send continuous information about
128 Occupational Physiology

how tense various muscles are and whether they are being lengthened or
shortened.
Muscle spindles are therefore a great help in the CNS’s understanding of move-
ment and positions in the musculoskeletal system (see also Chapter 6). The impor-
tance of sensory information from muscle spindles depends on the context in which
the movement is performed and how the information is weighted. When Janis makes
an automated rhythmical movement, for example, such as walking, information from
the muscle spindles plays a minor role. There are already clear internal models used
by the nervous system to predict what is going to happen in precisely these move-
ments. This sensory information is used more for controlling starting points and
ending points, and for being part of how the interplay between different muscles
works in motor patterns at the spinal cord level. Sensory information can then be
used as signals to change to between different motor patterns. In carrying out an
automated rhythmical movement, it is only in cases of unforeseen deviations from
the anticipated movement when the sensory information is used as a basis for direct
correction of muscle activity. How substantial this correction is depends on the
weighting that the nervous system places on the signals. The significance of certain
signals may, however, be altered by the nervous system, if the signals are assessed as
containing important information.
Sensory information from muscle spindles and other receptors responding to
movement, for example, in joints and skin, affects motor functions through reflexes
at the spinal cord level. The most classic reflex which a muscle spindle is involved in
is the stretching reflex, where stretching a muscle spindle through direct connections
to the α-motor neuron leads to a contraction of the same muscle. This means that
activity in the muscle spindle can make it easier for the α-motor neuron to send sig-
nals out to the muscle. Just as the muscle spindles in themselves are not identical, nor
is their influence on the α-motor neuron completely uniform. The muscle spindles
have been shown to help in controlling which motor units are to be activated and
deactivated [Grande and Cafarelli 2003]. In muscle fatigue, the sensory information
from the muscle spindles changes [Pedersen et al. 1998]. This has consequences for
all motor functions dependent on sensory information. Above all, the internal models
that use sensory information to predict how the body and the environment will react
are affected. If the sensory information is disturbed, it will affect the internal models
and, by extension, which muscle synergies are used to perform a movement.

5.4.8  Direct Responses in Exposure to Highly Repetitive Movements

Exposure to highly repetitive movements leads to a number of direct responses in the
body. These responses consist of reactions in muscles, joints, tendons, and the ner-
vous system to the load to which the body is subjected, including the muscle work
that is being carried out. As highly repetitive work implies recurrent activation of
muscles in arms, shoulders and neck, with momentary activations above 50% of the
MVC, muscle fatigue is a natural and anticipated response. Acute muscle fatigue
means that the muscle loses some of its ability to develop force. This, in turn, means
that a greater mobilization is required on the part of the CNS for that muscle to cope
with the same task. It is very rare in working life that development of muscle fatigue
Work with Highly Repetitive Movements 129

in individual muscles continues until the work can no longer be carried out. Instead,
the aim of the movement is realized using different muscle synergies. Either a modi-
fication occurs in the motor pattern, or a new internal model and a completely new
motor pattern are created. Muscle fatigue is often accompanied by aches and a warm
sensation in the muscles which comes from muscle work, as well as a general feeling
of fatigue. At the end of the work a feeling of stiffness can also appear, and pain
when moving the muscles are not uncommon. As acute muscle fatigue also affects
force development in a negative way, muscle weakness can be experienced several
days after the end of the work. In muscles whose primary task is to stabilize the body
so that the arms are able to carry out comprehensive repetitive movements, acute
muscle fatigue is not as pronounced, presumably because the activation level is
lower. In different types of repetitive force load, force levels and cycle times for
variations of force have different effects on muscles in the forearm and muscles in
the neck.
The pattern for muscle fatigue in the trapezius muscle during continuous work
differs a great deal between different individuals, while the pattern for muscle fatigue
in the surrounding muscles are more similar for different individuals. This differ-
ence in the development of fatigue in the trapezius muscle in particular presumably
has to do with the role of the muscle both as a stabilizer for the head and in moving
the shoulder joints. The development of fatigue is also sensitive to variations in load.
Experiments show that the experience of fatigue occurs significantly later if the load
is varied than if the load is constant, even if the total load intensity does not change
[Mathiassen 1993]. The experience of fatigue is counteracted by variation in load,
and in this way the work may be carried out for a long period. When Janis is work-
ing, he is exposed to a mixture of constant and dynamic load, which means that the
development of fatigue becomes complicated.
In repetitive movements, biochemical changes in the muscle cells occur. These
changes are the consequences of the way in which the muscle works. An important
precondition for the occurrence of a muscle contraction is liberation of calcium ions
in the individual muscle cell. In the prolonged repetitive activation of a motor unit,
there is a risk of the structures in the muscle cell responsible for calcium release
becoming damaged. If damage occurs, it becomes more difficult for muscle cells to
contract. This makes for very prolonged muscle fatigue with a reduction in force
development lasting up to 72 h after the end of the work. As the effect of muscle
fatigue is prolonged, there is an impending risk that the period for rest and recupera-
tion will be insufficient. Recuperation is important for the muscle to be able to repair
itself. If the repair cannot be carried out, there is a risk that motor units that have to
work hard will become damaged.
In repetitive muscle work and with loads without any change in force and muscle
length (so-called static load, see Chapter 6), lactic acid (lactate) is formed as a con-
sequence of a reduction in oxygen supply to the muscle. Only 20–60 min of repeti-
tive arm work at 10–15% of MVC produces an increase in lactic acid in the trapezius
muscle. There is more about the production of lactic acid and its effects in Chapter 2.
Another substance that is produced in muscle contractions when muscles are tense
without any change in force and position is bradykinine (BK). Production also occurs
as a consequence of changes in muscle pH which in turn may arise if a great deal of
130 Occupational Physiology

lactic acid is formed. BK affects nerve receptors in the muscle so that they become
activated and acquire increased sensitivity. The greater sensitivity applies not merely
to lactic acid and BK, but also to other substances which may be produced, and to
mechanical and thermal stimulation. Other substances that may be formed are ara-
chidonic acid and various interleukins. Arachidonic acid forms the basis for the pro-
duction of prostaglandins. Preventing the production of prostaglandins is the aim of
certain painkillers belonging to the group known as NSAIDs (see Fact Box 5.1).
Interleukin 6 (IL-6) is important for repairs and building up muscle, at the same time
as it is also involved in inflammation and pain.

FACT BOX 5.1

NSAIDS (NON-STEROID ANTIINFLAMMATORY DRUGS)
Analgesic drugs containing, for example, acetylsalicylic acid, ibuprofen, or
naproxen. Drugs containing paracetamol do not belong to this group.

Common to all direct responses in work is that they contribute to rebuilding

muscles and other tissues. Direct responses therefore need not only be regarded as
unpleasant or troublesome, but are a precondition for the slow adaptation of the body
to various loads, for example, greater muscle capacity as a result of high muscle
activity (see also Chapter 6). For the body able to rebuild itself rest is needed and
thus recuperation after work becomes important.
Repetitive muscle activation also leads to tendons and joints being affected, and
in the same way as muscles, these need a period of recuperation after work in order
to be repaired and reinforced. Tendons and joints have fewer blood vessels to help
to carry away the waste products formed and to provide them with new energy and
new building blocks for repair. If only a small part of a muscle has to work hard, then
a small part of the tendon also receives greater load. Generally speaking, it takes an
even longer time for a tendon to build up its strength than it does for a muscle. This
means that the tendon for certain periods may be disproportionately weaker than the
muscle. Often in the transition between tendon and muscle there is a sensitive point,
as the tissue is weaker there. Nerves can be damaged, for example, by repetitive
movements of the wrist. What is most common is that an inflammation forms in and
around the nerves, and as a consequence the nerves become compressed. This leads,
in the longer term, to pain, deterioration in motor function, and loss of sensation in
the area served by the nerves. An example of a condition of this kind is carpal tunnel
syndrome.
Studies of direct responses to repetitive work also show that our movement and
position sense are affected, presumably because the ability of the muscle spindles
to provide good information deteriorates (see Fact Box 5.2). Deterioration in move-
ment and position sense produces less well-controlled movements, as planning and
performance of movements are dependent on good sensory information. This may
be linked to a feeling of clumsiness and heavy-handedness.
Work with Highly Repetitive Movements 131

FACT BOX 5.2

MOVEMENT AND POSITION SENSE
This means that we can keep track of where our arms and legs are without
needing to use our eyesight. Movement and position sense is very dependent
on sensory information from the muscle spindles, but information from recep-
tors in tendons, joints, and skin is also significant.

5.5  P
 ATHOPHYSIOLOGICAL MECHANISMS IN EXPOSURE
TO HIGHLY REPETITIVE MOVEMENTS
Highly repetitive work is a combination of dynamic work requiring force, using the
arms and part of the shoulder, and a prolonged activation of the muscles in the neck
and shoulder at a lower level of force. For a detailed review of the explanatory mech-
anisms for pain from prolonged low-intensity load, see Chapter 6.
Fatigue has long been considered to be a preliminary stage to injury. The current
recommendation that breaks at work are good for preventing disorders is based
partly on the fact that subjective fatigue is lower if a job is divided up into smaller
parts with breaks between than if the same job is carried out without a break. It is,
however, important to take into account the fact that physiological changes in the
muscle do not always go hand-in-hand with the subjective fatigue experience. For
example, the levels of potassium outside the muscle cells do not always decrease in
parallel with subjective fatigue during a break. Potassium remains high during the
break even though the subjective fatigue diminishes. If the work continues after the
break, the muscles will not have rested sufficiently, even though it feels as if it has.
The potassium level is linked to the level of calcium, which is very important for the
muscle to function in an efficient way. As the breaks do not provide a sufficient
reduction in the potassium level, there is therefore a risk that the muscle might
become damaged as a result of changes in calcium levels.
The exact mechanisms for how disorders arise in an exposure to repetitive move-
ments with a requirement for force and precision are not known. There is, however,
a great deal of data to support the fact that control and allocation of muscle activity
are very important.

5.5.1  Changes in Work Allocation in the Muscle

When a muscle is activated, the motor units start up in a particular order. Exactly
which motor units are used is governed not merely by what force is required and
how rapidly the force needs to be developed, but also how the movement is to be
performed in space. Normally, an assemblage of motor units and muscle synergies
is used in a movement. In order to be able to use different muscle synergies and
vary the motor units, a surplus of degrees of freedom is required. If the possibility
of making use of the number of degrees of freedom is restricted, the opportunities
for variation are reduced, and the risk that the same motor units or muscles have to
perform a large share of the task increases.
132 Occupational Physiology

When Janis is working, he is exposed to constant strain on his neck muscles at

the same time as the more forceful repetitive work with his arms. The strain on his
neck muscles is produced partly by the need to stabilize his head, and also by reac-
tion forces to the work in his forearm. With prolonged low-intensity loads, there is a
risk that the motor units activated first are also those that are deactivated last. There
is then a risk that the muscle cells in these motor units will not recover sufficiently.
These motor units are called Cinderella units, as they are the first to start work and
the last to finish. When registering electrical activity from individual motor units in
individuals both at work and in an experimental environment, continuously active
motor units have been registered for ~1  h. There is, however, still some uncertainty
as to what significance these Cinderella units have in the development of disorders
[Hägg 2000]. More about the possible significance of the Cinderella units in pro-
longed low-intensity loads can be found in Chapter 6. The risk of Cinderella units
forming in Janis’ arm muscles may be assumed to be lower than in his neck muscles,
as dynamic movements with more powerful muscle contractions seem to make it
easy for any Cinderella units to be replaced by other motor units. Janis’ work should
then give him an advantage in his arm muscles, as the allocation of work in those
muscles should be better. There are, however, other factors in the work which act
in the opposite direction. The precision needed in the work restricts the number of
degrees of freedom in Janis’ movements. For Janis, there is only a small opportunity
of varying muscle activations if he is going to cut out perfect joints of meat, which
his performance-related pay is partly based on. This can lead to the same motor units
having to work in Janis too, as there are a limited number which can perform a spe-
cific task that Janis carries out. The need to see clearly also reduces the opportunity
of exploiting the degrees of freedom, as a consequence of holding his head still is an
activation of neck muscles that reduce the opportunities of changing the position of
his neck and shoulders. This happens independently of whether Janis has otherwise
perfect vision. The neck muscles find themselves in a complicated situation, where
the requirement of stability of the head has to be combined with the need for move-
ment in the shoulder. Sensory information here plays an important role in creating
suitable activation patterns to meet both demands.
Janis employs considerable force in his movements, which may lead to extensive
muscle fatigue in the motor units which take the greatest share of the load. When
muscle fibres in a motor unit begin to tire, the activation frequency of the motor unit
increases. The greater activation frequency and the local changes in the muscle cells
contribute to the feeling of fatigue in the muscle. However, it is not certain that the
feeling of fatigue is relative to the load to which individual muscle cells are sub-
jected, rather than fatigue reflecting the condition of the entire muscle. When certain
motor units cannot generate the desired force, other motor units have to be activated
to be able to carry out the task. These other motor units do not need to be optimal for
this specific task, but there is a risk that this leads to greater loads. The greater loads
derive from a greater element of simultaneous activations of counteracting muscles
(antagonists) in order to stabilize and maintain the precision in the development of
force. An increase in the agonist–antagonist contraction in muscle fatigue can lead to
a decrease in the time of individual muscles for rest and to an increase in the produc-
tion of various chemical substances in the muscles.
Work with Highly Repetitive Movements 133

Simultaneous activation of antagonistic muscles (agonists and antagonists) around

joints is also a way for the CNS to increase control over a movement. Weaker con-
trol of movements can result from repetitive movements affecting the movement
and position sense. The sensory information that builds up the movement and posi-
tion sense is important in creating suitable internal models. If the models are not
adapted to what is actually happening in the tissue, there is a risk that the wrong
motor patterns are activated. For Janis these incorrect motor patterns can mean that
the performance of repetitive movements in combination with force and precision
requirements leads to a greater load on his muscles, tendons, and joints.
The reduced opportunity of relieving tired motor units and/or muscles generates
a potential starting point for disorders. It has, however, been shown that different
people differ in how well they make use of the opportunities that exist to carry out
the same work with different movement and muscle activation patterns. To what
extent this predicts who is going to develop disorders or not has currently not been
demonstrated, but it is a reasonable hypothesis. Muscle pain in itself affects motor
function by changing muscle synergies with the main aim of reducing the load on
the painful muscle. If the aim of the movement is maintained, despite the fact that
the main muscle for this movement is signalling pain, it will be necessary for other
muscles to compensate for any loss of force. Preexisting pain can therefore further
increase the load on other muscles. This can also be seen as a pure defense mecha-
nism to protect a potentially damaged muscle from further damage.
A prolonged activation of individual motor units or the entire muscle gener-
ates production of various metabolites and inflammatory substances. The produc-
tion of metabolites is primarily an effect of the need for energy in the muscle cells.
Inflammatory substances are produced as a response to the muscle cells being dam-
aged and needing to be repaired. Repair, however, requires rest. A constant state of
insufficient recuperation and overconcentration of metabolites and various inflam-
matory substances leads to an increased and altered sensitivity on the part of sensory
nerves in and around the muscle. As these nerves are not only sensitive to various
substances, but also to mechanical influence, the threshold will be lowered for when
mechanical influence results in pain. If a prolonged activation of sensory nerves
continues, physical changes in the connections in the spinal cord may occur. These
changes in the connections may lead to changes in the CNS interpretation of signals
from the periphery. For example, sensory nerves, which do not normally transmit
signals about nociceptive pain, now are interpreted by the CNS to do so. Generally
speaking, an increase has occurred in how sensitive the nervous system is to activa-
tion. This increased and altered sensitivity is called central sensitization. Central
sensitization may be an important mechanism, alongside physiological, psychologi-
cal, and social risk factors, that develop transitory episodes of pain and discom-
fort into prolonged chronic pain. Central sensitization may also be an important
source for why pain in the muscle continues when the original causes of the pain are
removed. As regards the origin of chronic pain, see also Chapter 6.
Experimental studies on prolonged exposure to repetitive loads in human beings
are rare. However, there are data from animal studies. In a series of experiments on
repetitive work, rats were trained to receive food at a particular rate [Barbe and Barr
2006]. The rats performed a special movement four times a minute for 2 h/day and
134 Occupational Physiology

3 days/week for a total of 8 weeks. After only 3 weeks the rats showed marked
increases in inflammatory substances and changes to their motor function. The pro-
duction of inflammatory substances increased over the first 6 weeks of load, to sub-
sequently decrease somewhat up to the eighth and final week, but not back to their
original value. The experiment shows also that cells from the immune defense sys-
tem had been activated and had migrated into muscle and tendon tissue.

5.5.2  Tendons and Nerves

Repetitive movements not only affect muscles, but also tendons and nerves. How
tendons are loaded depends on which muscle activation is occurring. There is no
opportunity for variation of load within the tendon; rather the tendon is exposed to
the variation produced by the muscle. The actual variations in load within the tendon
are, however, less than in the muscles, and the risk of overload of the tendon is
greater. In this way, the tendon is in greater need of rest to recuperate after a load. It
is therefore probable that disorders often appear first in tendons and subsequently in
muscles. Damage to tendons may probably arise because of a number of different
mechanisms, for example, mechanical wear with resulting inflammation and changes
to the structure of the tendon, or a reduction in the blood flow to the tendon. Both
cases lead to structural changes in the tendon which mean that the susceptibility of
the tendon to strain is increased. Reduction of blood flow is due to compression of
the blood vessels serving the tendon. Tendons have from the outset relatively poor
blood flow, which contributes to the increased sensitivity.
Nerves, too, can be affected by repetitive movements insofar as nerves slide
against the surrounding tissue when they change position. A constant repetition of
the same movement leads to an inflammation process starting in the epineurium with
consequent swelling. Swelling causes increased pressure on the nerve with pricking
sensations, numbness and pain as a result. In the healing process there is a risk that
the nerve’s ability to slide in the epineurium is reduced, which makes for increased
sensitivity to strain in the area.

5.6  C
 ONSEQUENCES OF REPETITIVE LOADS AMONG
THE POPULATION
In Europe, 49% of workers in the groups of machine operators and assemblers stated
that work affects their health, and 34% report muscle disorders [Eurofond 2007]. A
study from Sweden shows that during the period 1996–2005 the proportion of all
employed women stating that work has caused disorders as a result of short repeated
operations has been around 4%, with a peak in 2003 at 4.9% [SWEA 2008]. For men
during the same period an increase from 2.6% in 1996 to 3.4% in 2005 can be seen
in disorders relating to short repeated operations [SWEA 2008]. Between 2000 and
2005 almost 5% of men and a good 9% of women within manufacturing industry
stated that they had disorders as a result of short repeated operations; no details of
the disorders were, however, given [SWEA 2008]. Among butchers, meat-dressers
and vehicle assemblers the frequency of reported work-related diseases because of
physical strain was more than 15 cases/1000 individuals in 2004 [SWEA 2005].
Work with Highly Repetitive Movements 135

In Denmark during the period 1993–2003 the average number of reported cases
per year of physical symptoms related to repeated monotonous work was a good
11  cases/1000 employees, among pig and cattle slaughterers [DWEA 2003]. The
specific diagnosis of supraspinatus tendinitis, that is to say, inflammation in one of
the tendons of the shoulder, occurred in almost 9% of slaughterhouse workers in
Denmark in the same period [Frost et al. 2002]. Previously, it has been reported that
up to 14.5% of workers in fish processing have epicondylitis [Chiang et al. 1993], and
up to 12% of workers in other jobs with high demands for repetitiveness [Kurppa
et al. 1991]. The effect on the median nerve, known as carpal tunnel syndrome, is a
well-known result of repetitive work (cycle times of <10 s), particularly in combina-
tion with forces of 4 kg or more [van Rijn et al. 2009]. There is considerable support
for the fact that repetitive movements under strain are a strong risk factor for the
development of muscle pain and inflammation in tendons and tendon attachments in
the thumb, wrist, elbow, and shoulder.
For muscles in the neck/shoulder, repetitive work, along with a prolonged, stooped
head position, has been identified as risk factors for developing pain. Repetitive work
in combination with prolonged so-called static load (loaded with no changes in force
or muscle length) in the neck generally produces a greater risk of disorders.

5.7  RISK ASSESSMENT

In order to identify risks in connection with repetitive work, it is important to study
carefully the work being done. Initially typical tasks are identified at work, particu-
larly those tasks where repetitive operations occur over a long work task period. In
Janis’ case, he lifts down a large part of a pig and subsequently works on it. He does
this several times during the workday. Several different work cycles can be identified
in this task. Janis begins by cutting out a bone and subsequently cutting the meat into
a specific joint. On this basis, a description on the classification of risk factors for
each work cycle will be made, for example, how repetitive the work is, what force is
required, what the work posture is like, demands on precision, and other factors such
as cold. The different work cycles are brought together and the order in which they
are carried out, how long each work cycle lasts, and time allocated for recuperation
or rest is taken into account. Generally speaking, in a risk assessment of repetitive
work it is important to study the combination of repeated movements, force develop-
ment, duration, and the need for precision. It is important to take into account how
long the exposure occurs, for the individual risk factors on the one hand and for
combinations of risk factors on the other. There are three main groups of methods to
assess exposure and by extension risks:

• Self-reporting
• Observations
• Direct measurements

Self-reporting includes methods such as interviews, questionnaires, and diaries.

Employers may assess the incidence of, for example, a particular work posture, fre-
quency of movements, force development, duration of certain work tasks, or fatigue.
136 Occupational Physiology

The advantage is that the methods are often simple to use and relatively inexpensive.
Usually, a large number of participants are needed for the data collected to be repre-
sentative of the group being investigated. In using observational methods, various
parameters are annotated by an observer on preprinted forms or entered directly into
a computer. What is annotated or entered varies between different systematic meth-
ods; for example, some only take into account individual parts of the body and others
take into account whole work postures. The advantage of simple observation methods
is that they are relatively practical and inexpensive, and highly suited to investigating
work postures and simple repetitive tasks. The disadvantages are that the methods can
be influenced by the fact that the same observer assesses different people at different
time points during the working day, and different observers do not assess in the same
way. Video recording and subsequent analysis of the film are more time consuming,
and are used more for jobs with a more varied pattern of movements. Video-based
systems involve high costs and require technical support and user training.
Below, a selection of observation methods is summarized, as well as their main
areas of use and function. For additional methods and a short description of these,
the reader is referred to the publication by David GC (see Further Reading).
Rapid upper-limb assessment provides a quick impression of primarily work pos-
tures and external load. The method not only makes use of classifications of work
postures, but also provides information about repetition and the use of force and is
usable as initial screening of all jobs where there is exposure to repetitive operations.
The strain index is a semiquantitative method in which six different variables
relating to the task are measured or assessed. All the variables are divided into five
criteria, where each criterion corresponds to a figure. All the assessments are multi-
plied, and this produces an index. Studies have shown that this index measures the
risk of disorder.
The occupational repetitive actions (OCRA) Risk Index is used to assess work
postures, force, and cyclicity in repetitive work. The method takes into account many
different variables, which are weighted together in a risk value.
Direct measurement methods are based on the fact that different measuring
instruments are attached to the individual who performs a task. This may be equip-
ment to measure joint angles, range of motion, muscle activity, or forces. This method
is suitable for studies of simulated work tasks in controlled environments such as
laboratories. It is, however, quite possible to take measurements at workplaces, but
this requires experience and great knowledge. When attaching measuring equipment
to individuals, one also risks affecting their method of work.

5.8  W
 HAT MEASURES CAN BE TAKEN TO MINIMIZE THE
RISKS OF REPETITIVE WORK?
An increased variation is prescribed as one of the most important measures to counter
risk in critical conditions involving repetitive work. Variation of work tasks and varia-
tion within the work task are two types of variation that are conceivable. Also the use
of breaks for recuperation is part of a good intervention: on the one hand, the breaks
give greater variation; on the other, they provide a direct opportunity for recuperation.
It is also important for there to be sufficient time for recuperation between shifts, so
Work with Highly Repetitive Movements 137

that the body is as rested as possible at the start of work. Interventions in the work that
lead to additional degrees of freedom being available for the motor system are pre-
sumably also valuable. This can be done through workers being allowed to rotate
between many different work tasks, what is known as job rotation (see Chapter 6,
Section 6.14). It is important that the various tasks in a job rotation are not too similar
to each other, because then there would be no variation in the exposure. A good tool
is to build up an organization where disorders are caught early through systematic risk
assessment, and where there is follow-up of the work situations as well as close col-
laboration between occupational health care and the companies.

5.9  W
 HAT DO LAWS, REGULATIONS, AND PROVISIONS
HAVE TO SAY?
Specific legislation on highly repetitive work does not exist either at the EU level or
at the federal level in the United States. Within the EU there are a number of differ-
ent directives regarding exposure to risk factors in working life, but none that directly
address highly repetitive movements. On the other hand, in the EU there is an over-
arching framework directive which applies to measures for promoting improvements
in employees’ safety and health at work (Directive 89/391/EEC). In this directive
there is an explicit reference in Article 6 which in part is applicable to highly repeti-
tive work. This is based on the fact that the employer is bound to adapt the work to
the individual, in particular as regards the design of workplaces, choice of work
equipment, and choice of work and production methods, with the intention of pri-
marily reducing monotonous work and work with fixed piecework rates, and reduc-
ing their effects on health. In the United States there is also comprehensive legislation
about worker safety and health which includes the fact that the employer is respon-
sible for removing risks at work which may cause serious injury to the worker.
In many European countries there are, however, more detailed national rules and
advice as well as regulations and support concerning highly repetitive movements. In
Sweden, the texts of the provisions are detailed as regards highly repetitive work
[SWEA 1998]. For example, the paragraph dealing with monotonous, repeated,
strictly controlled, or fixed work runs: “the employer must ensure that work that is
repeated monotonously, strictly controlled or fixed does not normally occur.” It fur-
ther states that if special circumstances demand that such work nevertheless must be
performed, the employer should take measures to minimize the risk; for example,
“job rotation, job enlargement, breaks, or other measures to increase variation at
work.” In the general advice clarifying the provisions in Sweden, the point that car-
rying out repeated movements often requires static work in the surrounding muscles
is stressed. There is, therefore, a link between different forms of physical load. The
general advice also describes favourable load. It is characterized by repeated varia-
tion, balance between activities and recuperation as well as time limits. It is also
pointed out here that tiring physical strain is not necessarily injurious to health, but
that exposure times and recuperation period are important factors to assess. There
are also standards applying to a highly repetitive work published by the International
organization for standardization (ISO 11228-3 2007) and European Standard
(CEN prEN1005-5 2007) which provides guidance in the identification and ­evaluation
138 Occupational Physiology

of risk factors associated with highly repetitive work. Standards are, however, only
recommendations and not legislation.

5.10  SUMMARY
Highly repetitive jobs often comprise a combination of repetitive movements, force
requirements, and precision. A difficult job is that of a butcher, but employees in other
professions, for example, in the food production and the assembly industries, also
carry out highly repetitive work. In order to perform a movement, our brain needs to
collect information before the movement is performed, plan the movement, carry it
out, and finally evaluate the movement. In order to do this, the brain creates an inter-
nal model of various conditions for the movement. Then a suitable motor pattern is
generated, moving, for example, our arm to the desired location. There are often a
number of ways of performing a movement and still achieving the end result.
Restrictions on the ability to vary a movement can result from demands for precision
or force, or that the repetitive movement has to be carried out in a particular way. The
restriction may lead to overuse of particular muscles and/or muscle fibres if muscle
synergies and motor units cannot be alternated. The lack of variation becomes most
prominent when the repetitive movements, demands for forced, and demands for pre-
cision are combined. Exactly how this subsequently leads to pain has not been clari-
fied, but presumably a long-term accumulation of various substances produced in the
muscle resulting in a central sensitization are important. Pain in itself also result in the
body changing its method of moving. This may, in turn, lead to overload on other
muscles or muscle fibres. An activation of muscles in a very similar way also provides
a potential effect on tendons, as the repeated load on the muscle is transferred to the
tendon. In order to counteract disorders, an increase in variation both between work
tasks and within work tasks as well as sufficient time for recuperation is suggested.

REFERENCES
Barbe, MF., Barr, AE. 2006. Inflammation and the pathophysiology of work-related musculo-
skeletal disorders. Brain, Behavior, and Immunity 20:423–29.
CEN prEN1005-5. 2007. European Committee for Standardization.
Chiang, HC., Ko, YC., Chen, SS., Yu, HS., Wu, TN., Chang, PY. 1993. Prevalence of shoulder
and upper-limb disorders among workers in the fish-processing industry. Scand J Work
Environ Health 19:126–31.
Cohen, D., Robertson, E. 2007. Motor sequence consolidation: Constrained by critical time
windows or competing components. Exp Brain Res 177:440–46.
DWEA. 2003. Overvågningsrapport 2003. The Danish Working Environment Authority.
http://www.at.dk/Tal/sw13757.asp.
Eurofond. 2007. Fourth European Working Conditions Survey. European Foundation for the
Improvement of the Living and Working Conditions. http://www.eurofound.europa.eu/
pubdocs/2006/98/en/2/ef0698en.pdf
Frost, P., Bonde, JPE., Mikkelsen, S. et  al. 2002. Risk of shoulder tendinitis in relation to
shoulder loads in monotonous repetitive work. Am J Ind Med 41:11–8.
Grande, G., Cafarelli, E. 2003. Ia Afferent input alters the recruitment thresholds and firing
rates of single human motor units. Exp Brain Res 150:449–57.
Work with Highly Repetitive Movements 139

Hägg, G. 2000. Human muscle fibre abnormalities related to occupational load. Euro J Appl
Physiol 83:159–65.
ISO 11228-3. 2007. Ergonomics—Manual handling—Part 3: Handling of low loads at high
frequency. Geneva: International Organization for Standardization.
Kurppa, K., Viikari-Juntura, E., Kuosma, E., Huuskonen, M., Kivi, P. 1991. Incidence of teno-
synovitis and epicondylitis in a meat processing factory. Scand J Work Environ Health
17:32–7.
Madeleine, P., Lundager, B., Voigt, M., Arendt-Nielsen, L. 2003. Standardized low-load repet-
itive work: Evidence of different motor control strategies between experienced workers
and a reference group. Appl Ergon 34:533–42.
Mathiassen, SE. 1993. The influence of exercise/rest schedule on the physiological and psy-
chophysical response to isometric shoulder–neck exercise. Euro J Appl Physiol Occup
Physiol 67:528–39.
McGorry, RW., Dowd, PC., Dempsey, PG. 2003. Cutting moments and grip forces in meat
cutting operations and the effect of knife sharpness. Appl Ergon 34:375–82.
Nordander, C., Ohlsson, K., Balogh, I. et al. 1999. Fish processing work: The impact of two sex
dependent exposure profiles on musculoskeletal health. Occup Environ Med 56:256–64.  
Pedersen, J., Ljubisavljevic, M., Bergenheim, M., Johansson, H. 1998. Alterations in informa-
tion transmission in ensembles of primary muscle spindle afferents after muscle fatigue
in heteronymous muscle. Neuroscience 84:953–59.
van Rijn, RM., Huisstede, B., Koes, BW., Burdorf, A. 2009. Associations between work-
related factors and the carpal tunnel syndrome—A systematic review. Scand J Work
Environ Health 35:19–36.
SWEA. 1998. Ergonomics for the Prevention of Musculoskeletal Disorders. Statute Book
(AFS) 1998:1 Swedish Work Environment Authority. http://www.av.se/dokument/
inenglish/legislations/eng9801.pdf
SWEA. 2005. Occupational Accidents and Work-Related Diseases. Swedish Work Environment
Authority. http://www.av.se/dokument/statistik/officiell_stat/ARBMIL2005.pdf
SWEA. 2008. Work-Related Disorders 2008. Swedish Work Environment Authority. http://
www.av.se/dokument/statistik/officiell_stat/ARBORS2008.pdf
Wolpert, DM., Ghahramani, Z., Jordan, MI. 1995. An internal model for sensorimotor integra-
tion. Science 269:1880–82.

FURTHER READING
Buckle, P., Devereux, J. 1999. Work-Related Neck and Upper Limb Musculoskeletal Disorders.
Bilbao: European Agency for Safety and Health at Work.
David, GC. 2005. Ergonomic methods for assessing exposure to risk factors for work-related
musculoskeletal disorders. Occup Med 55:190–99.
Johansson, H., Windhorst, U., Djupsjöbacka, M., Passatore, M. 2003. Chronic Work-Related
Myalgia. Neuromuscular Mechanisms Behind Work-Related Chronic Muscle Pain
Syndrome. Gävle: Gävle University Press.
van Rijn, RM., Huisstede, B., Koes, BW., Burdorf, A. 2010. Associations between work-
related factors and specific disorders of the shoulder—A systematic review. Scand J
Work Environ Health 36:189–201.
Schmidt, AA., Lee, T. 2005. Motor Control and Learning. A Behavioral Emphasis. 4th revised
edition. Leeds: Human Kinetics Publishers.
Sluka, AA. 2009. Mechanisms and Management of Pain for the Physical Therapist. Seattle.
IASP Press.
Visser, B., van Dieen, JH. 2006. Pathophysiology of upper extremity muscle disorder. J
Electromyogr Kinesiol 16:1–16.
 6 Prolonged, Low-Intensity,
Sedentary Work
Allan Toomingas

Photo: Lars Erik Byström

CONTENTS
6.1 Focus and Delimitation.................................................................................. 143
6.2 Prevalence of Prolonged, Low-Intensity, Sedentary Work............................ 143
6.3 What Characterizes Prolonged, Low-Intensity, Sedentary Work?................ 144
6.4 Muscles At Work........................................................................................... 144
6.4.1 Muscles Perform Work...................................................................... 144
6.4.2 The Structure of Muscles................................................................... 146
6.4.3 Types of Muscle Cell......................................................................... 148
6.4.4 The Innervation of Muscles............................................................... 149
6.4.5 How Muscles Work............................................................................ 149
6.4.6 Regulating Muscle Force................................................................... 150
6.4.7 Blood Supply to the Muscles............................................................. 151
6.5 Arms and Hands are Flexible but Require Stabilization............................... 152
6.6 Static Load on the Musculoskeletal System.................................................. 153
6.7 Problems with Work Involving Prolonged, Low‑Intensity Static Load......... 155

141
142 Occupational Physiology

6.7.1 Symptoms.......................................................................................... 155

6.7.2 Damaged Structures.......................................................................... 156
6.8 Gender- and Age-Related Differences........................................................... 157
6.9 Explanatory Models....................................................................................... 158
6.9.1 Different Models................................................................................ 158
6.9.2 The Cinderella Model for Muscle Activation.................................... 160
6.9.3 Impaired Blood Flow as a Cause of Pain.......................................... 161
6.9.4 Altered Biochemistry as a Cause of Pain.......................................... 162
6.9.5 Motor Control in Prolonged, Low-Intensity Sedentary Work........... 163
6.9.6 Sensitization and Propagation of Pain............................................... 163
6.9.7 Other Explanatory Models................................................................ 164
6.10 Scientific Evaluations..................................................................................... 164
6.11 Sitting Still: A Health Risk in Itself.............................................................. 164
6.11.1 Sedentary Work is Physically Low-Intensity Work........................... 164
6.11.2 Sedentary Work Could Be a Health Risk.......................................... 165
6.11.3 The Continuous Remodeling of the Body......................................... 166
6.11.3.1 A Model.............................................................................. 166
6.11.3.2 Muscles............................................................................... 167
6.11.3.3 Joints................................................................................... 167
6.11.3.4 Skeleton............................................................................... 168
6.11.3.5 Coordination and Balance.................................................. 168
6.11.3.6 Body Fat.............................................................................. 168
6.11.4 Health Risks from Physical Inactivity............................................... 169
6.12 Is the Job Low Intensity, Sedentary, or with Static Load?............................ 170
6.12.1 Occupational Designation.................................................................. 170
6.12.2 Self-Reported Physical Activity and Level of Exertion..................... 170
6.12.3 Observations of Work........................................................................ 171
6.12.4 Measuring Physical Activity.............................................................. 172
6.12.5 Measuring Energy Metabolism......................................................... 172
6.12.6 Measuring Muscle Activity............................................................... 173
6.13 What the Law Says about Prolonged Low-Intensity, Sedentary, and
Static Work.................................................................................................... 174
6.14 Suggestions for Improvements....................................................................... 176
6.14.1 Organization of Work........................................................................ 176
6.14.2 The Level of Activity at Work and in Connection with Work........... 178
6.14.3 Work Equipment................................................................................ 178
6.14.4 The Individual................................................................................... 178
6.14.5 Society............................................................................................... 179
6.15 Summary....................................................................................................... 180
References............................................................................................................... 180
Further Reading...................................................................................................... 182

Suzanne is 47 and has worked full time for some years in the customer service sec-
tion of an insurance company. She has contact with the company’s clients by tele-
phone, e-mail, and sometimes by text message. All the details of the company’s
products and their clients are on computers. She therefore uses her computer to
Prolonged, Low-Intensity, Sedentary Work 143

retrieve information and enter new details into client accounts. A new task ­introduced
a year ago is that, if there are gaps between incoming client calls, she has to ring up
potential new clients to offer them the company’s services. Altogether, she normally
finds time for between 75 and 100 customer calls on each working day. Employees
have a fixed monthly salary with a bonus for the number of new clients they recruit.
She gets on well with her colleagues and likes providing a service to clients, but
is no “sales type” and feels uneasy at the sales calls she is forced to make.
For many years, Suzanne has felt stiffness in her neck and shoulders. For 6 months
she has been troubled almost daily by headaches and a constant ache between her
shoulder blades. Sometimes it is difficult to see the screen clearly, and it is a strain to
look for different lines in the menu and small text boxes in the various programmes
that she has to have open on the screen at the same time.

6.1  FOCUS AND DELIMITATION

This chapter deals with jobs where the physical load is low as regards energy metab-
olism and muscle force. This is in contrast to Chapters 2 and 3 where it is high. The
work is instead marked by being sedentary, with prolonged, low-intensity physical
load. The mental load may be high. This chapter does not, however, go into greater
detail about the origins of mental load. On this, see Chapter 7.
This chapter, among other things, takes up the following issues:

1. What happens in the muscles after working for a long time in the same
work posture?
2. Why can pain result from low-intensity work, for example, when using a
computer mouse?
3. Why is there pain in the neck and shoulders when working with one’s
hands?
4. How does the body react to a low level of activity for long periods?
5. How do we design healthy work if that work is prolonged, low intensity
and sedentary, for example, where computers are used for a large part of
the day?

6.2  P
 REVALENCE OF PROLONGED, LOW-INTENSITY,
SEDENTARY WORK
There is a great deal that indicates that prolonged, low-intensity, sedentary work has
become much more common in working life over recent decades. This is in part a
result of the transformation of the economy from the production of goods to the pro-
duction of knowledge and services. A great deal of these and other jobs is carried out
while sitting still, for example, at a checkout, in the driver’s seat, or at a computer.
Approximately 1/4 of the people working in Sweden state that they work sitting still
for more than 2 h at a stretch everyday [SWEA 2010]. Approximately 44% of those
people working in Stockholm County in 2006 stated that they had sedentary work.
An Australian study from 2005 reported from a community sample that the average
self-rated occupational seated time was 4.2 h/day among professionals, 3.5 among
white-collar workers, and 2.3 h among blue-collar workers [Mummery et al. 2005].
144 Occupational Physiology

Studies of objectively measured physical activity in population samples from

Australia and the United States report that adults of working age spend 7.3–8.4 h/day
at a sedentary activity level, that is, about 50% of their waking time [Healy et al.
2007; Matthews et al. 2008]. One such sedentary occupational setting is computer
work. According to the European Working Survey in 2010 among the European
Union (EU) countries, 52% of the total questioned used computers for 25% of their
working hours or more [Eurofound 2010]. About 29% use them all, or almost all, of
the time. The use is somewhat higher among women, but more or less equal among
different age groups. The trend towards an increasing use of computers at work can
be traced back over the last 25 years in Sweden (Figure 6.1). It can be estimated that
roughly a third of all working hours in Sweden in 2009 were spent in front of a com-
puter. Industries in which computers are used a great deal are, for example, customer
service work (call centres), offices, education, communication and media work, and
the world of banking and finance.
In the production of goods, the work is also often prolonged, low-intensity manual
work, for example, in assembly work involving light electrical components. Many
processes within the production of goods are automated and computer controlled.
The human task is now that of monitoring processes sitting at a control panel or in
front of a monitor.
Childhood and school years are also spent sitting still for long periods. Leisure
time, too, among young people and adults is often devoted to sedentary activities, for
example, TV, computer games, or surfing the internet. Travel to and from work or
school often involves sitting still in a private car or on public transport.

6.3  W
 HAT CHARACTERIZES PROLONGED, LOW-INTENSITY,
SEDENTARY WORK?
Sedentary work is often characterized by workers sitting for the greater part of the
working day and being active with their hands. Their hands are holding or are active
with materials or equipment, for example, a keyboard and computer mouse. Force
development in the active muscles is low, in typical cases just a few percent of maxi-
mum voluntary strength (MVC), but is exerted almost without a break for long peri-
ods. The variation in force development is small, as is the variation in work postures
and work movements. This prolonged, low-intensity muscle work is often described
as “static” in the literature on ergonomics, even if this is not correct from a strictly
physiological viewpoint (see Section 6.6).

6.4  MUSCLES AT WORK

6.4.1  Muscles Perform Work
The muscles are one of the few structures in the body that can exert physical force
and in this way bring about movement. Muscles can be found in many places in
the body and can vary in size, form, and properties. Usually, we think about some
of the ~600 muscles producing movement of the neck, arms, trunk, and legs
Prolonged, Low-Intensity, Sedentary Work 145

(a)

% Men Women

70

60

50

40

30

20

10

0
1984 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

(b)
%
40

30

20

10

0
1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

(c)

%
20

10

0
1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

FIGURE 6.1  The proportion of men and women aged 16–64 working with computers:
(a) for some part of the working day; (b) at least half of the working day, and; (c) almost all
the time. Development during the period 1984–2009. (Modified from SWEA. 2010. The
Work Environment 2009. Stockholm: Swedish Work Environment Authority, pp. 58–69.
http://www.av.se/dokument/statistik/officiell_stat/ARBMIL2009.pdf).
146 Occupational Physiology

FIGURE 6.2  Superficial muscles of the musculoskeletal system of the upper body. (Arrows:
trapezius muscles.) (Photo and copyright: Primal Pictures Ltd. http://www.primalpictures.
com. With permission.)

(Figure 6.2). There are, however, muscles also in the heart, in the airways, and in
the walls of the intestines and of blood vessels.
Muscles in the body work by exerting force for a certain period. The muscle work
in the musculoskeletal system may involve, for example, supporting the body’s own
weight or moving the body. The work can also involve lifting heavy loads, manipu-
lating various tools, operating controls, or manoeuvring a computer mouse. In this
last case, the force required is extremely small, but it is often prolonged.

6.4.2  The Structure of Muscles

The muscles of the musculoskeletal system are constructed from densely packed
long muscle cells. The cells are “wrapped up” in a surrounding membrane, and the
ends of the long cells morph into a strong connective tissue which anchors both ends
of the muscle to some part of the skeleton, for example, the bones of the forearm. In
certain muscles, this connective tissue forms a long tendon running up to a point of
attachment on the skeleton, for example, one of the finger bones. The muscle attach-
ments may also be spread across a large area of several parts of the skeleton, such as
the source of the trapezius muscle, which runs down the whole way from the back of
the skull along the entire length of the cervical and thoracic spine (Figure 6.2). The
force that the muscles exert is transferred via the attachment points to the skeleton,
which can then move in relation to each other. Different movements are made
depending on which muscles are active.
A single muscle cell can be several centimeters long, but is only 0.03–0.1 mm in
diameter (Figure 6.3 and Fact Box 6.1). Muscle cells cannot usually divide after
Prolonged, Low-Intensity, Sedentary Work 147

Striated muscle

a
b c
d
Muscle cell
Myofibril

Sarcomere
2 mm
H-band
Z-disc Z-disc

A-band I-band

Myosin Actin
filament filament

Z-disc M-line Z-disc

g h i
Myosin head

Myosin filament

Actin filament

G-actin molecules Tropomyosin Troponin complex

FIGURE 6.3  Building up the muscles of the musculoskeletal system, (a) muscle of the upper arm
with magnification of some individual muscle cells (b); (c) individual muscle cell; (d) myofibril
where the striation is visible and where the various visible bands I, A, H, and Z are indicated; (e)
schematic picture of some sarcomeres (the contractile unit between the Z disks); (f–i) cross section
through various parts of the sarcomeres. (Below) Detailed picture of actin and myosin filaments
with myosin and troponin protuberances assisting in the sliding of the two filaments against each
other. (Modified from Åstrand, PO. et al. 2003. Textbook of Work Physiology. Physiological Bases
of Exercise. 4th ed. Champaign: Human Kinetics. Illustration: Lena Lyons.)
148 Occupational Physiology

FACT BOX 6.1

The muscle cell is covered by a cell membrane. There is an electrical poten-
tial difference between the outside and inside of the cell membrane, which
is called the membrane potential. Just as in the nerve cell, this membrane
potential comes about through potassium ions “being pumped” into, and
sodium ions out of, the cell membrane. The surface of the muscle cell has
indentations in the cell membrane at regular intervals which branch out as
a network inside the cell, known as T-tubuli. Inside the cell and in close
association with the cell membrane around the T-tubuli, there is the sarco-
plasmatic reticulum (reticulum = net) which in turn forms a dense network
around the myofibrils.

birth, other than in special cases after injury. The number of muscle cells is, there-
fore, largely constant, and during old age diminishes (see Section 6.8). With exercise,
the number of muscle cells does not increase, but the individual cells increase in
diameter, so that the entire muscle increases in thickness.
Every muscle cell consists of a bundle of myofibrils that are each ~0.001–
0.003 mm in diameter (“myo” is the Latin word for muscle) and in their turn consist
of long chains of proteins arranged according to a characteristic striated pattern vis-
ible through a microscope (Figure 6.3). Two of these oblong proteins, actin and myo-
sin, partially overlap with each other. The actin and myosin molecules can slip
against each other. This movement demands energy. The energy exists in the form of
ATP molecules produced in the muscle cell’s numerous mitochondria (see Chapter 2,
Section 2.4).

6.4.3  Types of Muscle Cell

The individual muscle cells in a muscle vary with regard to how quickly they
increase their force development and how quickly they tire in continuous activity.
One type of muscle cell, known as Type I, provides slow but constant force devel-
opment with prolonged stimulation. This type works primarily with aerobic
metabolism (see Chapter 2, Section 2.4). Type I cells are found to a great extent in
the muscles of the trunk and legs which hold up the body, the so-called postural
muscles. Another type, known as Type IIX, provides rapid force development
which, however, rapidly fades away. These cells work primarily with anaerobic
metabolism (see Chapter 2, Section 2.4). Type IIX can be found to a great extent,
for example, in the arm muscles. An intermediate Type IIA has also been described.
Different muscles have different proportions of these cell types. Different indi-
viduals differ in their proportions, partly because of genetic differences and partly
on the basis of how the muscles are used. The proportion of Type I and Type II,
respectively, can, for example, be changed through training. Endurance training
increases the proportion of Type I, and strength training or sprint training increases
the proportion of Type II.
Prolonged, Low-Intensity, Sedentary Work 149

6.4.4  The Innervation of Muscles

Muscle activity is regulated by nerve signals. From the spinal cord a nerve runs
together with a blood vessel to the middle of the muscle belly. The nerve consists of
many different nerve fibres (neurons). These convey signals from the spinal column
and brain out to the muscles activating the muscle for contraction (called α-motor
neurons). Other neurons convey signals from the muscles to the spinal cord and
brain, such as pain signals. Special neurons run to and from the muscle spindles (see
Fact Box 6.2).

FACT BOX 6.2

In the muscles there are receptors that are sensitive to how stretched or con-
tracted the muscle is, known as muscle spindles. In the muscle attachment or
tendon from the muscle there are other receptors that are sensitive to the mus-
cle’s traction force, called the Golgi tendon organs. In addition, there are recep-
tors in the skin, in the joints and in the joint capsules that signal the position
of the joints. Receptors that report pain are numerous in the connective tissue
between the muscle cells, around the muscle and in the muscle attachments.
Together, the different receptors and the neurons cooperate in producing
functional and coordinated movements and force development, for example,
when we are working.

Groups of muscle cells are functionally joined to what are called motor units. A
motor unit is linked to one and the same α-motor neuron. This means that all muscle
cells in the motor unit receive the same signal for muscle activity, and will therefore
be activated simultaneously and with the same force. The cells in a motor unit can
be dispersed between other motor units, but are usually to be found in an area which
is about 5 mm in cross section. Motor units may consist of anywhere from a few up
to 1000 muscle cells. In muscles where motor ability and precision are important,
for example, in the muscles of the eye and face, the number of cells involved is low.
In muscles that primarily exert great force, for example, in the torso and legs, the
number is high.

6.4.5  How Muscles Work

A nerve signal from the α-motor neuron triggers depolarization of the membrane
potential along the entire surface of all muscle cells in the motor unit. The depolar-
ization spreads into the muscle cells through the T-tubuli (see Fact Box 6.1).
Depolarization occurs when so-called ion canals open up for potassium and sodium
ions that then stream out of and into the cell. After about a millisecond, the ion canals
close and the membrane potential is restored, in that potassium and sodium ions are
pumped in respectively out again through an active energy-intensive process. This
momentary change in the membrane potential is called the action potential.
150 Occupational Physiology

T-tubuli and the sarcoplasmatic reticulum are a way of rapidly disseminating the
simultaneous activation of the myofibrils throughout the muscle cell. In the contact
between T-tubuli and the sarcoplasmatic reticulum, the action potential triggers the
liberation of calcium ions to the cell fluid around the myofibrils. The increase in
calcium content leads to the actin and myosin molecules sliding together a little.
The calcium in the cell fluid quickly reverts to its state of rest again; however, in that
the calcium ions are reabsorbed into the sarcoplasmatic reticulum through an energy-
intensive pumping mechanism. The odd nerve impulse in this way leads to a short,
invisible or imperceptible twitch in the muscle. With repeated dense impulses from
the α-motor neuron, the myofibrils do not have time to return to their state of rest,
but the slippage between actin and myosin molecules continues, so that the overall
result is a noticeable shortening and force development in all the muscle cells of the
motor unit.

6.4.6  Regulating Muscle Force

The force that can be exerted at a particular movement or operation can be regulated
in several different ways. The force in a particular motor unit can be amplified by
increasing the frequency of action potentials in the α-motor neuron. The strength
can be further increased by recruiting more motor units. By recruiting strong motor
units, that is to say, those with many cells, the force can be further increased. When
a muscle activity begins, motor units with a low number of cells are usually recruited,
that is to say, with low maximum force. These are often of Type I. Units recruited for
considerable forces usually have numerous cells and therefore contribute greater
force. These are frequently of Type II. It is difficult to carry out work demanding
precision with simultaneous high force development, as the motor units recruited for
high force do not allow precise adjustment of the force. A further way of increasing
the force is to connect up several interacting muscles (agonists) and disconnect the
counteracting muscles (antagonists).
Force development is at its maximum when the actin and myosin units overlap
maximally beside each other, which happens when a muscle is approximately half-
contracted. The more the muscle is drawn out or contracted beyond the middle posi-
tion, the more the actin and myosin units have slipped apart from each other, and the
less force the muscle can then produce. The position of the joint is also important, as
the muscles are often attached to the skeleton some way from the particular axis,
which allows the muscle to use the lever effect that then arises (see also Chapter 3,
Section 3.5 and Chapter 4, Section 4.4). Maximum leverage is achieved in the joint
position where the lever is at maximum length, for example, angling the elbow joint
at ~90° for the biceps muscle in the upper arm. The orientation of the muscle cells
inside the muscle is also important. Maximum force can be developed in the muscles
where all the cells run parallel to the direction of force development. The more the
cells are angled away from this direction, the more force is lost.
The rapidity of the muscle contraction is also significant for force development.
The higher the contraction speed, lesser is the force that can be developed. Maximum
force can be achieved when the muscle contracts during stretching, known as eccen-
tric contraction (see Section 6.6). The maximum power generation of the muscle,
Prolonged, Low-Intensity, Sedentary Work 151

that is to say, the energy development per unit of time—the product of force and
velocity—is, however, normally at about one-third of the maximum speed of
contraction.
In the long term, it is possible to increase the maximum muscle force by training
muscle capacity. Initially, exercise improves the coordination between the different
motor units and agonists–antagonists, so that they work more effectively on the pre-
cise activity that is being trained. In the longer term, training also increases the
number of myofibrils in the muscle cell, so that the individual cells become larger
(but not more in number). The cross-sectional area of muscle increases, which is pos-
sible to see in, for example, bodybuilders.

6.4.7  Blood Supply to the Muscles

A muscle that is working hard is the tissue which, together with the central nervous
system, has the highest energy metabolism per unit of weight in the body. If the
muscle works hard for several minutes, the energy metabolism may increase more
than 50 times compared with the state of rest. This requires a corresponding flexi-
bility in blood supply, so that the supply of oxygen and energy substrate as well as
the removal, for example, of carbon dioxide, corresponds to the need. The blood
flow through the muscles can increase from 3–5 mL/s per 100 mL of muscle mass
up to 100 mL/s or more. The total energy metabolism of the body muscles may
increase from 20 up to 2000 W. In hard physical work, the muscles can take up to
~80% of all blood flow from the heart, compared with 15–20% at rest (see Chapter
2, Figure 2.9).
Muscles are, in consequence, well provided with blood vessels with dense
branches (capillaries) between the muscle cells. Cells of Type I have a greater capil-
lary density than Type II. Regulation of the blood flow to the muscle is carried out
primarily by the muscles in the walls of the blood vessel contracting so that they cut
off the blood flow, or relaxing and thereby increasing the blood flow. Regulation is
governed by the sympathetic nervous system. A somewhat constricted flow occurs
when at rest. During muscle work, a general increase in the activity of the sympa-
thetic nervous system takes place, which initially provides further general vascular
contraction in the body’s muscles. Blood flow in the working muscle increases, how-
ever, through the local influence of heat development in the muscle, oxygen con-
sumption in the blood, and various metabolites excreted locally in the muscle when
it is working, for example, lactic acid, low pH, carbon dioxide, and potassium. In this
way, the blood is directed primarily to those muscles that are active.
When the muscle is activated, the pressure inside it increases (intramuscular
pressure). This increase in pressure occurring inside the muscle can easily be so
great that it prevents blood flow to the muscle. In dynamic muscle work (see Section
6.6) muscle contractions alternate with muscle relaxation. In the relaxation phase,
the intramuscular pressure drops and the blood flow returns. Initially, a compensa-
tory increase in the blood flow through the muscle occurs, so that the balance is
restored as regards, for example, oxygen, carbon dioxide, and pH value. In static
muscle work, however, (see Section 6.6), the diminished muscle blood flow can lead
to a rapid development of fatigue.
152 Occupational Physiology

The blood vessels transporting the blood away from the muscle, the veins, are
provided with valves inside the muscle so that when the muscle is activated and con-
tracts, the blood is pushed in the right direction towards the heart. Dynamic muscle
activity can therefore help blood circulation.

6.5  A
 RMS AND HANDS ARE FLEXIBLE BUT
REQUIRE STABILIZATION
One of the subtleties of the human body is that it is so flexible and agile. This applies
particularly to the arms, which through the shoulder blades, shoulder, elbow, and
wrist joints are able to provide the hands with almost unlimited opportunities of
adopting different positions. This can be used in tasks requiring the hands to work in
special positions and with special movements, for example, handicraft, care work,
writing with a pen or a keyboard, or manoeuvring a computer mouse. Mobility
comes at a price however, namely the price of stability. The hand has to be able to
exert force on what it is handling or wishes to affect. In its working position, the hand
then has to be stable, and not give way to the counteraction of the object being han-
dled. In order for the hand to be stable in its working position, it is necessary for the
whole arm and its attachment to the thorax and spinal column to be stable. If consid-
erable forces are required at work, then the whole body has to be stabilized, and also
stand firmly against the floor so as not be moved by the exertion of force.
Those counterforces that arise, for example, when we move a computer mouse,
have to be counterbalanced by corresponding muscle activity in the entire system
from the neck and out to the hand. In rapid movements, for example, keyboard work,
the system does not have time to counterbalance the counterforces in detail. Stability
then has to be achieved by generally making the joints extra stiff through activity in
the agonists and antagonists (see Section 6.4.6) [Johansson et al. 2003, pp. 83–94].
Stabilization and counterbalancing occur unconsciously and continue as long as the
arm and hand are being used, and presumably as long as there is an intention, con-
scious or unconscious, to use them. Stabilization must exist before the arm and hand
begin to be used. This arm−hand stabilizing muscle activity involves muscles all the
way from the neck out to the hand. In order to keep the spinal column in the desired
position, stabilization also needs to occur on the left-hand side of the neck and shoul-
der, even if only the right arm and hand are being used. In a corresponding way, there
has to be stabilization and coordination between the focusing of the eye and move-
ments in the neck, shoulders, and arms when work requiring hand−eye coordination
is being done (see Fact Box 6.3). Generally speaking, we can assume that work
requiring precision makes greater demands on the stability of joints than work with
lower demands.
In the stabilization of joints and the coordination of movements, muscles are
activated that entirely or in part assist or counteract each other’s forces and move-
ments, agonists and antagonists, respectively. A typical example is the wrist, sta-
bilized by agonists and antagonists on each side of the forearm which attempt to
bend and stretch the wrist, respectively. Work demanding great precision probably
makes great demands on coordination between all the muscles involved. A good
Prolonged, Low-Intensity, Sedentary Work 153

FACT BOX 6.3

HAND–EYE COORDINATION
In the majority of tasks at work and in other contexts where the hands are used,
we are dependent on being able to see what we are doing, where objects and
tools are located, what they look like and how they should be grasped, moved,
and positioned. A typical example of this is manoeuvring a computer mouse,
so that the cursor ends up in the right place on the screen. This collabora-
tion requires advanced coordination between the control of the muscles and
different sensory organs, such as, eyesight, balance, joint senses, and muscle
spindles. The eye has to cooperate with the musculoskeletal system, both with
regard to the eye’s own muscles which govern its movements, and the muscles
of the neck and shoulders, which adjust the position of the head and shoulders,
as well as the muscles of the arms and hands, which govern the position of
the hand and movements. If coordination between the hand and the eye is
impaired, problems may arise—not merely in the form of a poor work out-
come, but also in the form of discomfort, dizziness, headaches, and tense and
aching muscles of the neck and shoulders.

working technique means that one has a good balance between the activity of ago-
nists and antagonists at an optimal level so that the muscles do not become fatigued
too quickly. Fatigued muscles act with poor precision. Factors such as pain and stress
may further impair the coordination between agonists and antagonists, which leads
to increased activity on their part to achieve the stability and coordination that the
work requires.
Stabilization and coordination in intensive manual work therefore requires mus-
cle activity in the neck, shoulders and arms which goes on for as long as the hands
need to be used, but which in itself does not lead to any movement. This stabiliz-
ing muscle activity is added to the activity needed to carry out the task itself, for
example, to manoeuvre the computer mouse.
Knowledge of stabilizing and coordinating muscle activity is, however, as yet
deficient.

6.6  STATIC LOAD ON THE MUSCULOSKELETAL SYSTEM

Muscle activity can be carried out dynamically or statically. In dynamic activity, the
muscle is shortened or lengthened. We can see that the arm, leg, or body part moves,
and we understand that the muscle is working. Leg muscles carry out dynamic
­activity when we walk, the trunk muscles when we bend over and turn around, and
the arm muscles when we are hammering or typing on a keyboard. Dynamic muscle
activity leading to a shortening of the muscle is called concentric activity. For exam-
ple, the muscles in the back work concentrically when we stretch upwards from hav-
ing been bending forward. If the muscle exerts force at the same time as it is being
154 Occupational Physiology

extended, this is called eccentric activity, for example, when the muscles in the back
resist when we bend forward.
In static activity, the muscle develops force without changing its length, that is,
without achieving any movement. It works isometrically. The lack of movement
means that it is difficult to see that the muscle is actually active, for example, when
the head is held leaning forward, or the arm is held out. In most physiological studies
of isometric activity the muscle force development is kept constant in a so-called
isotonic contraction. Static activity is therefore for a physiologist often both isomet-
ric and isotonic. Muscle work of this kind quickly leads to exhaustion. In ~50% of
maximum voluntary muscle contraction (MVC), endurance is ~1 min. A lack of
blood supply because of intramuscular pressure is a probable explanation for the fact
that the force terminates. Lower load levels increase endurance, but even at 5–10%
of MVC, there are clear signs of fatigue within 1 h. In that case, it occurs presumably
as a result of a shift in the chemical environment in the muscle cells. Old ergonomic
recommendations about 15% of maximum voluntary contraction as an upper limit
for the load level in prolonged work therefore conflict with today’s knowledge.
Within working life and ergonomics the concept of static muscle activity has
become fuzzier. “Static” muscle activity is there used to describe circumstances in
which the muscle is active for a long period without any major change in either force
or position, and with few or no rest periods. Slow and/or minor changes in force and
position can occur, which are incompatible with the strict physiological definition
above. Such low-intensity activity can continue for a long time (minutes or hours)
and initially gives no signals of fatigue or discomfort. The ergonomic significance of
“static” muscle work has been given wide circulation, as the lack of muscle rest and
inadequate recovery are regarded as the probable cause of many of the disorders that
can arise in prolonged low-intensity muscle work (see Section 6.7). “Static” muscle
work of this kind in the neck and shoulders can often be found as the basic compo-
nent in jobs where the hands are busy with tools or materials. It may, for example, be
a question of assembly work in the manufacturing industry, sewing machine work at
a garment manufacturer, work at the checkout in a supermarket, or at a computer.
During computer work, it has been seen that the trapezius muscle works correspond-
ing to 1–10% of MVC for large parts of the work period. Similar levels have been
measured from the muscles of the forearm.
Prolonged “static” muscle work without interruption may lead to an adverse strain
on the muscles, but also on the muscle attachments, tendons, connective tissue, and
joints, if they remain in the same position for a long period.
Prolonged “static” load on the neck, shoulders, and arms can arise for different
reasons in a job in which the hands are used [Johansson et al. 2003, pp. 5–46]. One
reason may be the need to stabilize the neck, arms, and shoulders in manual work as
explained above. If the arms and hands are lifted against gravity, neck and shoulder
muscles have to be activated for purely biomechanical reasons. The load on the neck
and shoulders could be decreased by leaning the arms and hands, for example, against
a tabletop. Load can also occur from maintaining an awkward work posture, for
example, by twisting the neck. Precision demands seem to increase the load further.
Finally, “static” load can arise for reasons that are not directly motivated by how the
work task is to be carried out. It may, for example, be a question of ­unconsciously
Prolonged, Low-Intensity, Sedentary Work 155

shrugging the shoulders in tense or stressful situations. The stress may be linked to
time pressures at work, difficulties or conflicts, or other psychological or social rea-
sons. Factors that do not have to do with work at all, for example, worry about one’s
own or one’s family’s health, financial worries, or family conflicts, may possibly lead
to similar muscle tensions (see Chapter 7, Section 7.11). Pain or other discomfort is in
itself stressful, and may lead to increased muscle activity, and therefore in the longer
term to even more pain in a vicious circle. Noise disturbance, for example, from ven-
tilation equipment, or colds and draughts can also lead to tense musculature.
Prolonged “static” loads thus arise as a result of factors both within and outside
work. There are presumably major differences between people concerning the incli-
nation to use their muscles uninterruptedly and invariably “statically,” even when it
is a question of carrying out the same task. These differences result both from the
choice of working technique, which can be influenced by instruction, and uncon-
scious patterns of motor control (see Chapter 5, Section 5.4).
Prolonged “static” muscle work occurs presumably more rarely during leisure
time than at work. Leisure time activities are usually more physically varied, and
contain more dynamic muscle work. There are of course exceptions, for example, in
computer and television games and the like. During our leisure hours, we are also
more at liberty to take breaks and discontinue jobs that may produce strain on the
muscles. Nor is there perhaps the same state of stress which is often the case in work-
ing life.

6.7  P
 ROBLEMS WITH WORK INVOLVING PROLONGED,
LOW‑INTENSITY STATIC LOAD
6.7.1  Symptoms
Neck pain is common in the general working population in most countries for which
there is reliable information. Typically 30–50% of the workforce are affected on an
annual basis, and 10–15% report that it interferes with their daily activities [Côte et al.
2008]. Office and computer workers are found to have the highest incidence of neck
disorders. Other high-risk professionals are dentists and other medical staff. Disorders
usually include a continuous ache or pain arising in certain body positions or move-
ments. The disorders can be localized, for example, in the neck or between the shoul-
der blades. In many other cases they are, however, diffuse and difficult to locate. Not
unusually, pain is located to other, often more peripheral, parts of the body (so-called
referred pain), for example, in the shoulders and arms, or as headaches. Disorders
may start as a diffuse feeling of fatigue, stiffness, or tension. In typical cases, the
disorders become increasingly intensive, more widespread, and more prolonged. The
transition to aches and pains is insidious. Many people also feel pain or tenderness
when the doctor palpates the neck and shoulder area, for example, the trapezius mus-
cle. The disorders often affect the neck and shoulder in both halves of the body, even
if we use our right hands the most. The reason for this is presumably that muscles in
both halves of the body have to be active in order to stabilize the neck and shoulder
area (see Section 6.5). Characteristic of the disorders is that they may vary in localiza-
tion and intensity. Periods of disorder can be triggered by loads at work or life in
156 Occupational Physiology

general. In extreme cases, the disorders lead to prolonged periods of sickness off work
and disability pension. Alternative jobs without loads that trigger problems in the
neck and upper extremities may be difficult to find.

6.7.2  Damaged Structures

Precisely which structures and tissues are affected in such disorders is in many cases
unclear. Medical examinations rarely find any damage, and do not result in a specific
diagnosis. We call cases of this kind non-specific and we make a symptomatic diag-
nosis, for example, cervicalgia (= neck pain). In many cases the disorders can be
localized to muscles, for example, the trapezius, and are then diagnosed as “neck
myalgia” (myalgia = muscle pain). The localization of non-specific disorders is very
similar to what we see in those disorders triggered by muscles, which is why it may
be asked whether the two types are not closely related to each other (Figure 6.4).
Deeper-lying muscles and other structures are more difficult to investigate, which
means that their contribution to the disease panorama is less well known.
Microscopic studies of painful muscles have shown various types of damage in
Type I cells in the trapezius and forearm [Hägg 2000; Johansson et  al. 2003, pp.
95–109]. It has also been found that the muscle cells have increased in thickness.
There has, however, been no corresponding increase in the size or number of blood
vessels. That might cause a local oxygen deficiency in these muscles. It has also been
possible to observe impairments in the function of the mitochondria in Type I cells,
which may lead to impairments in the energy supply to the muscle with ATP. It has,
however, not been possible to prove conclusively that the damage has arisen directly

FIGURE 6.4  Distribution across the body of commonly occurring non-specific disorders
(left) and muscle disorders (right). Note that these disorders rarely occur at the front of the
body or the legs. Illustration: Niklas Hofvander.
Prolonged, Low-Intensity, Sedentary Work 157

from prolonged, low intensity load, or that it is the damaged muscle cells that give
rise to the pain.
The muscle attachments and tendons may sometimes be the cause of aches and
pains in the neck and upper extremities in individuals with jobs involving “static”
load. Usually, tendons and muscle attachments around the shoulder joint are affected,
which is called rotator cuff tendinitis. Corresponding problems may arise in the
elbow joint, for example tennis elbow, where the muscle attachments of the forearm
are affected. Similar disorders can also occur in various tendons around the wrist.
Peripheral nerves that control the muscles or that convey sensory stimulation pass
through many narrow passages on their way from the spinal column and to their final
destination in the body, for example, in the hand. A prolonged pressure on a tissue—
for example, a nerve—impairs its blood supply. Tissues then swell up, which in turn
further increases the pressure in a narrow space. When a nerve becomes trapped or
exposed to pressure, discomfort arises in the form of numbness, pricking sensations,
or pain. This discomfort is often localized to the part of the body which the nerve
serves, for example, the hand. Disorders may, however, spread or be diffuse, and dif-
ficult to localize in the body. The most common places for nerves in the upper extrem-
ities to be trapped is—from the inside and out—the exit of the nerves through the
cervical spine; the exit from the neck region out to the arm between the muscles and
below the collar bone; and the narrow passages around the elbow joint and in the
wrist. One cause of prolonged pressure or the trapping of peripheral nerves may be
twisted or bent work postures. A trapped nerve in the wrist, known as carpal tunnel
syndrome, is common, which may be caused by prolonged deviated postures or repet-
itive movements of the wrist, particularly in connection with high grip force. Different
individuals vary in sensitivity, presumably depending on different anatomical cir-
cumstances in narrow passages, and also depending on hormonal factors that may
result in swelling, for example, pregnancy or medical conditions such as diabetes.
Loading of the musculoskeletal system in the lower body seems to be associated
with fewer and different problems than those affecting the upper extremities, which
may seem to be paradoxical, as, for example, the muscles in the legs constantly help
maintain balance when standing up. The difference may be because muscles in the
legs are developmentally adapted to constant work. When we are standing, we are
also unconsciously varying our centre of gravity, for example, shifting from leg to
leg, so that different muscles are active alternately (so-called postural sway).
Prolonged standing may, however, result in swelling in the legs and varicose veins
(enlarged venous blood vessels). Unsuitable footwear and hard floors can result in
disorders of the ligaments and connective tissue of the feet. Prolonged work in a
kneeling or squatting position, for example, among floor-layers, may lead to arthritis
of the knee joints, presumably because of adverse pressure distribution across the
joint cartilage of the knee joint (see Chapter 4, Section 4.4).

6.8  GENDER- AND AGE-RELATED DIFFERENCES

A greater proportion of women than men report disorders of the neck and upper
extremities. The reason for this is contentious and presumably multifaceted. One of
the explanations given is that women are overrepresented in “static” loaded
158 Occupational Physiology

p­ rofessions, for example, within administrative work with a great deal of computer
use, work at checkouts, or assembly work in industry. But even within the same pro-
fession, women can be exposed to greater load than men. This may be because tools
are designed for men, and women are forced to adopt more awkward work postures
when they use them. One example is the computer keyboard, which in its standard
designs is rather wide. Right-handed people like to place the mouse on the right-hand
side of the keyboard. For women, this means that their right upper arm is angled
outwards more than among men, because generally women’s shoulders are narrower.
This increases the load on women’s muscles, among others the trapezius. Other
causes that are frequently mentioned are that women are often burdened with more
stress factors, both at work and in the family. It should be added that several studies
have found that women are more pain sensitive and more affected by pain. This may
also explain part of the difference in reporting disorders between the genders as
regards the neck and upper extremities.
Older people lose muscle cells in the motor units, which then become weaker
[Åstrand et al. 2003, Chapter 4]. This applies particularly to muscle cells of Type II.
The entire muscle becomes thinner (sarcopenia). The number of α-motor neurons
also declines. The α-motor neuron from other motor units may then grow out and
take over control, which, however, makes for a reduction in precision in the move-
ments. It is well known that speed, coordination, and balance decline, particularly
with advanced age. With increasing age, the elastic components of the musculoskel-
etal system degenerate, for example, in muscles, tendons, connective tissue, and joint
capsules. Over the years you get stiffer! Stimulation in the form of well-judged
dynamic physical load can compensate for the loss of force and coordination in such
age-related changes. It should therefore be particularly important to maintain these
functions through compensatory training and avoid monotonous, prolonged periods
of sitting still.

6.9  EXPLANATORY MODELS

6.9.1  Different Models
There is no clear-cut explanation of why prolonged, low-intensity, “static” work leads
to disorders and illness in the musculoskeletal system. Various explanatory models
describe different pathogenetical mechanisms [Huang et al. 2002; Johansson et al.
2003, pp. 5–46; Visser and van Dieën 2006]. Some describe factors leading to unin-
terrupted “static” activation of the muscles; others explain how the muscle reacts to
such activation. Further theories describe how pain can arise, be sustained, and be
experienced. The models do not contradict each other, but need to be combined for
us to be able to understand the entire sequence of events between workload and
experience of pain. It is probable that there are different mechanisms, the signifi-
cance of which varies at different stages of the development of the disorder, as well
as in different situations and for different people.
Figure 6.5 provides a general model of how some of the most common explana-
tory factors may be thought to act together in the genesis of disorders involving
prolonged, low-intensity, static muscle activity. As described above, work tasks,
Prolonged, Low-Intensity, Sedentary Work 159

Work demands Psychosocial

Bodily constitution (biomechanical/mental) conditions
Working conditions/
equipments
Working technique
Demands on
Stressors
stabilization of joints

Static muscular activity

Motor
control

Cinderella Impaired
phenomenon blood flow

Biochemical changes
(Ca 2+ , K +, free radicals neuropeptides, etc.)
Inflammation

Discomfort/pain

Peripheral/central sensitization
Chronic/widespread pain

Disease/handicap

FIGURE 6.5  Model of factors involved in the emergence of disorders and ill health in the
muscles with prolonged, low-intensity, static muscle activity. Note the two-way arrows
between stressors and pain/illness where stress can influence the emergence of pain and ill-
ness, which in turn can give rise to stress. Note also several other possible vicious circles,
where the result of static muscle activity by means of the Cinderella phenomenon or impaired
blood flow and biochemical changes and pain may increase static muscle activity. Several of
these factors impair motor control of muscle activity or give rise to stress. Both of these can
in their turn further increase static muscle activity. See the text for more detailed
explanations.

equipment, or tools in many cases are such that they give rise to “static” muscle
activity. In other cases, also described above, it may be a question of unsuitable
working technique without rest and support for the arms and hands. In addition,
adverse psychosocial conditions and various stressors may increase muscle tension.
The need for stabilization, described at the beginning of this chapter, is a further
factor that may contribute to the “static” muscle activity. The significance of motor
control and the interaction with psychological stressors in the genesis of, for ­example,
160 Occupational Physiology

the Cinderella phenomenon and impaired blood circulation, changes in the biochem-
ical environment, inflammation, and pain are discussed below. It should be borne in
mind throughout that individual differences exist at many different levels which
modify the effects, among others as regards physical constitution/anatomy, motor
muscle control, coping with stress and pain, and illness. This may explain why not
everyone reacts the same way to similar occupational contexts.
Some of the commonly occurring explanatory models are described below.

6.9.2  The Cinderella Model for Muscle Activation

The explanatory model that has perhaps attracted the greatest attention is what is
known as the Cinderella model [Johansson et  al. 2003, pp. 127–132]. The back-
ground is that there seems to be a system for how motor units are connected
(recruited) when a muscle increases its contractive force from zero upward. First
Type I cells are recruited, initially weak ones. If the force needs to be increased
further, gradually more and more powerful motor units are recruited and more of
Type II (Figure 6.6). When the muscle then reduces the contractive force, the motor
units are disconnected in the reverse order from that in which they were connected.
This means that those motor units connected last will be the first to be disconnected.
Those that were connected first will be active for the longest time and will be the last
to be disconnected. Just as in the case of Cinderella in the fairytale, these “Cinderella
units” will be the first to be woken up to go to work and the last to go to their rest.
Unlike heavy muscle work, which provides clear feelings of fatigue and discomfort,
prolonged low load does not give any necessary signals that it might be a good idea
to take a break or change working technique. The Cinderella units can therefore
remain active for a long period. The model thus describes why certain muscle
cells might be active for a long period, but provides no explanation as to why this is
disadvantageous. This is explained by other models (see Sections 6.5 and 6.9.3
through 6.9.6).

Force

MU 6

MU 5

MU 4
MU 3
MU 2
MU 1
Time

FIGURE 6.6  Illustration of the Cinderella model showing how motor units (MUs) are
recruited in a particular order, MU1–MU6, when force development increases in a muscle.
When the force then decreases, the motor units are phased out in reverse order so that the
units first recruited are phased out last and therefore are active longest. Note that the units
recruited last contribute greater force than those recruited first.
Prolonged, Low-Intensity, Sedentary Work 161

The Cinderella model has been verified in several studies where electromyogra-
phy (EMG) signals have been recorded (see Section 6.12.6) from individual motor
units in the trapezius or forearm muscles. The Cinderella units have been found to be
active for long periods of isometric and isotonic muscle contraction, just as in com-
puter mouse work. The same units have also been active in slow movements in dif-
ferent work postures. Experiments have also shown that the same motor units as
those activated in physical work can also be active during mental stress, when no
physical work is taking place.
Studies have shown that the Cinderella pattern does not always occur, however,
and that it can be varied in different situations. Motor units seem also to be able to
work according to a substitution or stand-in principle, where an active unit can be
replaced by another with the same function during an ongoing contraction. Some
individual studies have found indications that such an exchange between active
motor units can be stimulated by the muscle making a powerful contraction, or the
opposite, that there is a brief pause.
The Cinderella model emphasizes that it is not enough to reduce the load level. If
the level does not decrease to zero, there will be active Cinderella units that in the
longer term may be damaged. Healthy work must therefore be based on a variation
between activity in different muscles and/or muscle rest (recovery). The substitution
principle also opens the door to motor units within the same muscle relaxing alter-
nately, and perhaps finding the necessary recovery, even when the muscle in its
entirety continues to work.
One example of the importance of muscle rest may be found in a study of female
food production workers who filled chocolate creams in chocolate boxes on a con-
tinuous belt [Veiersted et al. 1993]. The ability to relax and rest the shoulder muscles
(trapezius) differed between individuals when there was an involuntary break in the
flow of chocolate creams on the belt. Measurements showed that some of the women
relaxed and allowed their shoulder muscles to rest on such occasions. Others kept
their muscles tensed. The study showed that within a few months considerably more
of the women who did not relax developed pains in the neck and shoulders. Other
studies of computer workers, medical secretaries, and checkout staff in supermar-
kets have shown that people with muscle pain have fewer episodes of muscle rest of
the trapezius than those who are pain free, even if it is impossible to determine
whether the lack of muscle rest gives rise to, or is a result of, the pain.

6.9.3  Impaired Blood Flow as a Cause of Pain

Another explanatory model that is often put forward as to why constant activation of
a muscle might lead to damage and pain is based on the fact that the blood circulation
then becomes impaired. When a muscle contracts, the intramuscular pressure
increases as described above. In this way, the blood circulation through the muscle
worsens. In static muscle work, as opposed to dynamic, no muscle relaxation occurs,
which may lead to the intramuscular pressure remaining at a level that prevents
blood flow. This may, for example, be the case for the supraspinatus muscle located
at the upper edge of the shoulder blade just under the trapezius muscle [Järvholm
et al. 1988]. The supraspinatus muscle lifts the upper arm outwards or forward in the
162 Occupational Physiology

shoulder joint. Pressure measurements have shown that, even in a lift of 30° in the
shoulder joint, the pressure increase has affected the blood flow. A greater lift
increases the pressure. Insufficient flow can lead to oxygen deficiency in the muscle,
and in this way to a number of biochemical processes that can produce pain. A well-
known process in oxygen deficiency is the formation of lactic acid which results in a
lower pH value. In a corresponding way, it has not been possible as clearly to prove
reduced blood circulation in the trapezius muscle during low-intensity contractions.
Impaired blood circulation has, however, been measured in the trapezius muscles of
people with muscle pain [Johansson et al. 2003, pp. 111–115]. Whether this is the
cause or effect of the pain is unclear, however. It has not been established whether
similar phenomena occur in other muscles. Muscles lying close together and sur-
rounded by bone or taut fascia (connective tissue) do not have much space to expand
into. The pressure increase there may become significant even at low levels of con-
traction. Presumably, there are also individual differences in sensitivity to static load
that from this viewpoint are dependent on differences in anatomical circumstances.
Stressors can, by their vasoconstrictive activity in the sympathetic nervous sys-
tem, also impair blood flow (Figure 6.5).
Another problem is that blood supply to the supraspinatus tendon which com-
prises a continuation of the supraspinatus muscle out to the upper part of the humerus
mainly goes via blood vessels through the muscle. Impairment of the blood circula-
tion may therefore also affect its tendon. This tendon is located in a confined space
in a bone channel in the shoulder blade where, moreover, there might be parts with
meager blood supply. The tendon therefore has a poor blood supply, even under nor-
mal conditions. Tissues affected by oxygen deficiency swell up. The swelling in turn
contributes to a further pressure increase, and it is possible then to end up in a vicious
circle of impaired blood circulation—oxygen deficiency—swelling—pressure
increase as a result. The result can be inflammation of the tendon (rotator cuff tendi-
nitis) with subsequent scar formation and weakening. The confined space in the bone
channel can vary between individuals, which may explain why different people have
varying sensitivities to static work from this aspect.
The model therefore stresses that impairments in circulation are one explanation
for musculoskeletal disorders. There are, however, research findings that contradict
the idea that impair blood circulation is the only cause of such disorders.

6.9.4  Altered Biochemistry as a Cause of Pain

Some researchers have emphasized the possibility that the calcium ions released in
the muscle cell when it is activated stimulate the release of destructive enzymes
which cause intracellular and extracellular tissue damage (Figure 6.5). This, together
with possibly increased extracellular potassium levels, may lead to pain stimulation
of the nerve endings and release of neuropeptides, for example, bradykinin and pros-
taglandins, which in turn stimulate the pain receptors. Another explanatory model is
based on the fact that the so-called free radicals are formed in connection with the
blood flow suddenly increasing in the muscle after having been shut off during mus-
cle contraction. Such free radicals are very reactive, and it is feared that they damage
the membranes of the muscle cells, enzymes, and the ion pump. Whether this is a
Prolonged, Low-Intensity, Sedentary Work 163

problem at low levels of local static load is controversial. Impairments in the biome-
chanical environment lead to different inflammatory processes being put into action
(Figure 6.5).

6.9.5  Motor Control in Prolonged, Low-Intensity Sedentary Work

The chemical substances formed in a local inflammation may presumably intensify
the tendency on the part of the central nervous system to recruit the motor units
according to the “Cinderella principle.” If that is the case, then a vicious circle devel-
ops, in which constant muscle activation leads to chemical changes, which lead to an
even greater risk of constant activation (Figure 6.5). The muscle spindles play a cen-
tral role in this circle. Release of pain-stimulating substances in the muscle stimu-
lates the pain-sensitive neuron, which leads to the spinal column and there affects
outgoing nerves to the same and other muscles. A special effect occurs in the so-
called γ-motor neuron that regulates the sensitivity of the muscle spindles [Johansson
et al. 2003, pp. 291–300]. Other pain stimuli, for example, from joints, also have the
same effects. According to the model, the chemical changes reduce the sensitivity of
the spindles, and the motor activity becomes “coarser.”
These impairments can spread not only to nearby muscles, but also to muscles in
the other half of the body. The result is a spread of the impairments in proprioception
and coordination of the muscle movements. Impairments in coordination lead to
greater activity in the agonists–antagonists, which puts further load on the muscles.
A greater need also arises to stabilize the joints, particularly centrally in the body,
which also leads to greater muscle activity.
The sensory neurons in the muscles which react to inflammatory substances also
affect the activity in the sympathetic nervous system, and in this way the blood
­circulation, which becomes impaired. Activity in the sympathetic nervous system
can also further impair the muscle spindle function [Johansson et  al. 2003,
pp. 243–273].

6.9.6  Sensitization and Propagation of Pain

Stimulation of free nerve endings (pain receptors), for example, between muscle
fibres, causes them to secrete neuropeptides (such as substance P) which stimulate
nearby mast cells to secrete, for example, histamine, prostaglandins, and leukotri-
enes, or other substances leading to pain and inflammation through dilation of the
blood vessels, swelling and an accumulation of white blood cells [Johansson et al.
2003, pp. 207–224]. These substances increase the sensitivity of the pain nerves, so
that heat, cold, or touch triggers pain (peripheral sensitization) (Figure 6.5). In addi-
tion, the area sensitive to pain increases in extent as a result of altered activity in the
central nervous system (central sensitization). These phenomena may explain how
pain can become more extensive than what is justified by the original injury. The
altered activity in the central nervous system may continue even after the original
source of the pain has healed. The disorders have then gone from having a local
source, which is perhaps quite easy to remedy, to becoming central (in the nervous
system) and then being much more difficult to deal with.
164 Occupational Physiology

Pain is experienced by the individual affected. How it is experienced, its intensity,

character, and, above all, its emotional significance—irritating, threatening, or anx-
iety-inducing—varies between individuals and different situations (Figure 6.5).
Circumstances in the individual’s environment, particularly those with a positive or
negative influence on their emotional state, may affect their experience of pain.
Pain and illness are often stressors in themselves, and can therefore be added to
the other stressors affecting activity and blood flow through the muscle (Figure 6.5).
Here, too, a vicious circle can develop, where stress leads to static muscle activity
and an impairment of muscle coordination and blood circulation with the resulting
development of pain and more stress.

6.9.7  Other Explanatory Models

There are further models that attempt to explain the muscle pain, either as a result of
friction between muscle cells [Johansson et  al. 2003, pp. 117–126], as a result of
hyperventilation, or as a condition similar to migraine with dilated blood vessels.
None of these models are today generally accepted.

6.10  SCIENTIFIC EVALUATIONS

The overall picture from research shows that there is evidence for a link between
prolonged, low-intensity, static work and disorders of the musculoskeletal system.
Reviews that have been published during the last 10–15 years have looked at varying
aspects of strain and disorders with diverging criteria, and therefore arrive at rather
different conclusions. A major review from the United States does not specifically
take up “static” load as a risk factor [Bernard 1997]. It does, however, conclude that
there is strong evidence for a link between awkward work postures and disorders of
the neck and upper extremities. A Dutch review considers that sedentary work for a
large part of the day with a static work posture for the neck and upper extremities
without breaks constitutes a risk for neck disorders [Sluiter et al. 2001]. Keeping the
arm outstretched without support for several minutes repeatedly for most of the day
constitutes a risk for disorders in the shoulder and upper arm. A review from the
United Kingdom concludes that there is evidence that static loading of the neck and
shoulder muscles in combination with repetition and neck flexion increases the risk
of neck pain and pathological findings in a medical examination of the neck [Palmer
and Smedley 2007]. A recent joint international review from 2008 found evidence
that sedentary work is a risk factor for neck pain [Côte et al. 2008].

6.11  SITTING STILL: A HEALTH RISK IN ITSELF

6.11.1  Sedentary Work is Physically Low-Intensity Work
Prolonged low-intensity work is often of generally of low intensity as regards the
demand for energy metabolism (see Chapter 2, Section 2.3). Work is often carried
out when sitting still, for example, at a computer. Classic office work required a cer-
tain amount of handling of, for example, papers, files, post, and copying. In computer
Prolonged, Low-Intensity, Sedentary Work 165

work, many of these functions can be dealt with while seated at a computer.
Communication with colleagues at work and others is carried on via the intranet,
e-mail, and the internet. Office workers in a typical case walk between 3000 and
4000 steps everyday, compared with 9000–10,000 steps for manual workers.
Older people usually have a more immobile lifestyle and move less than younger
people. The number of steps that older people take is usually between 20% and 40%
fewer than among young people. Age in itself reduces the body’s maximal aerobic
capacity and muscle strength. This age effect is added to the negative effect of less
physical activity, so that many older people among the workforce do not have suffi-
cient fitness and strength to manage physically more taxing work tasks (see Chapter
2, Section 2.9 and Chapter 3, Section 3.7).

6.11.2  Sedentary Work Could Be a Health Risk

There are few studies that have proved negative consequences for health from pro-
longed sedentary work. Most manifestations of ill health from such work may be
expected to arise only after many decades, often after the age of 50–60. Carrying out
studies in which one follows the working conditions and state of health of groups for
decades is very expensive and difficult to do. The effects of activity in working life
must also be held separate from the effects during leisure time and other factors, for
example, smoking, diet, and social group. For this reason, only a few studies of this
kind have been carried out worldwide.
One such study from London was able to show as early as the 1950s that seden-
tary bus drivers had a higher incidence of cardiovascular disease than the bus con-
ductors who ran up and down the stairs of double-decker buses [Morris et al. 1953].
Postmen ran less risk than staff who worked at the post office. Recent studies have
shown that prolonged sitting still in itself, for example, at work, may comprise a risk
of serious and potentially life-threatening illnesses, including diabetes, cardiovas-
cular disease, and cancer (see also Section 6.11.4) [Mummery et al. 2005; Moradi
et al. 2008; Ekblom-Bak et al. 2010; van Uffelen et al. 2010; Lynch 2010]. This risk
seems to arise irrespective of whether one is otherwise physically active, for exam-
ple, keeping fit during the leisure time. The causal mechanisms are as yet unclear.
An adverse influence of sitting still for prolonged periods has been found on lipid
metabolism [Katzmarzyk et al. 2009]. Information about how much physical activ-
ity is needed to avoid these risks is, however, limited. The conclusion we can draw
from these new findings is that sitting still for prolonged periods should be avoided
both at work and in leisure time. Proposals for measures remedying this can
be  found in Section 6.14. Lack of physical activity was rated as one of the most
important emerging physical risks related to occupational safety and health by 66
experts invited by the European Agency for Safety and Health at Work [European
Agency 2005].
Studies have shown a divided picture of the link between the demands of work on
physical activity on the one hand and physical capacity and ill health on the other
[Savinainen et al. 2004]. This is paradoxical, as there is clear proof of a positive link
between physical capacity, health, and physical activity during leisure time. Possible
explanations of this paradox are that physical activity at work is not sufficient to
166 Occupational Physiology

achieve a noticeable training effect, that the time for recovery is insufficient, or that
other factors at work, for example, stressors, influence the training effect. It is known
that psychosocial stressors, for example, a lack of control at work, increase the risk
of cardiovascular disease.

6.11.3  The Continuous Remodeling of the Body

6.11.3.1  A Model
The cells and tissues of the body, for example, muscles, connective tissue, and
tendons, do not remain in a steady state after development during puberty. They
are constantly replaced by being broken down (catabolic processes) and rebuilt
(anabolic processes) in a remodeling process [Åstrand et al. 2003, Chapters 3, 7,
11]. Figure 6.7 shows a possible model of how physical activity at work or during
leisure time (e.g., exercise) provides stimulation to a reinforcement of structures
under strain in the musculoskeletal system and cardiovascular system. The lack of
load results in a weaker structure. However, sufficient nutrients are necessary for
reconstruction, that is to say, energy-rich substrate and building blocks (e.g., amino
acids). The must also be time for recovery after activity. It can be assumed that the

Physical activity
Training Work

Internal exposure
Neuromuscular Time
cardio-respiratory Recovery
A C
n systems a
a t
b a
o b Neuroendocrino-
Neuroendocrino- Constantly ongoing
l o logical system
logical system i remodeling process l
c i
Stressors
c

Neuromuscular
cardio-respiratory
capacity + function Nutrients, etc.
Improved Deteriorated

Decreased pain Increased pain

Increased Decreased
- health - health
- functional ability - functional ability
- work ability - work ability

FIGURE 6.7  Illustration of factors contributing to the constant catabolic–anabolic remod-

eling process in the body. The outcome can be better health, function, and a better ability to
work. Or vice versa. See the text for more detailed explanations.
Prolonged, Low-Intensity, Sedentary Work 167

lack of recovery time leads to the opposite effect in the form of accumulating
(micro-) injuries. The lack of time for recovery can also be one of the reasons as
to why people with high physical load at work (heavy work) often have poor fit-
ness, strength, and endurance in their musculoskeletal systems (see Chapter 3,
Section  3.8.2). Anabolic hormones—growth hormone, for example—can stimu-
late reconstruction. Growth hormone is secreted primarily during sleep. Major
sleep disturbances may impair this process. Stress hormones are catabolic, which
is why chronic stress may impair reconstruction. The result of an optimally stimu-
lated reconstruction may, according to the model, be better health and an increased
capacity to work and function. The result of a lack of stimulation or too high a load
may be the opposite—poorer health, and a decreased capacity to work and func-
tion. All things in moderation!
Of the body’s proteins, about 0.3–0.4% is replaced everyday [Åstrand et al. 2003,
Chapter 11]. Roughly speaking, we can say that all the proteins in the body will have
been replaced within a year. The rate of this turnover varies a great deal, however,
between different tissues. Cells in the gastrointestinal tract, for example, in mucous
membranes and body fluids are quickly replaced. Cells in the nervous system, for
example, are replaced very slowly, if at all.

6.11.3.2  Muscles
Of the muscle proteins, ~0.1% is replaced everyday [Åstrand et al. 2003, Chapter 11].
Of the contractile muscle proteins, about half are estimated to be replaced over a
1-to-2-week period. Physical activity reduces breakdown (particularly in Type I
cells) and stimulates new synthesis (particularly in Type II). This also applies to the
heart muscle cells. The strength and quality in the musculoskeletal system, for exam-
ple, muscles, ligaments, and tendons, decreases with inactivity. After a month’s
immobilization in a plaster cast, for example, they have fallen by half. It then takes a
long period to recover strength.
Physical activity also increases mitochondrial activity in the muscles, and thus
the ability of the muscles to use oxygen and nutrients to form energy-rich ATP mol-
ecules that are necessary for muscle function. In physical inactivity, the maximal
aerobic capacity (fitness) decreases [Åstrand et  al. 2003, Chapter 11]. Half of the
body’s oxidizing enzymes are replaced within a week, and the glycolytic enzymes
are replaced within a few days. Aerobic capacity falls by ~25% after 3 weeks of bed
rest. See also Chapter 2, Section 2.12 and Chapter 3, Section 3.8.2.

6.11.3.3  Joints
Joint cartilage is not provided with blood vessels, but is dependent on, for example,
oxygen and nutrients being supplied from the environment, just as it is on metabolic
products being removed. This transport occurs with limited capacity during rest,
through so-called passive diffusion and osmosis. A more efficient method of boost-
ing the transport is to dynamically load the joint cartilage. We then achieve a sponge
effect in which the joint cartilage alternately absorbs fluid which is then pressed out
[Åstrand et al. 2003, Chapter 7]. Inactivity therefore makes for a poorer exchange of
nutrients for the joint cartilage. A static compression of the cartilage, for example,
because the joint is being held for a long time in a particular position without
168 Occupational Physiology

­ ovement, may be particularly damaging, as it hampers even this weak transport

m
through diffusion. See also Chapter 3, Section 3.8.

6.11.3.4  Skeleton
The skeleton is a living tissue. Cells found in all bone tissue, for example, in the
femur, are constantly breaking down the bone structure and others are rebuilding it
again. We can provide a rough estimate that after approximately 10 years this
replacement corresponds to the weight of the entire skeleton [Åstrand et al. 2003,
Chapter 7]. Unfortunately, from the age of about 20 a small amount of bone mineral
and bone tissue is being lost, so that the skeleton in time becomes less robust (osteo-
porosis). This loss increases if the skeleton is not loaded. We should, therefore, load
the skeleton for the equivalent of 3 h/day by standing or walking to reduce this loss
[Åstrand et al. 2003, Chapter 7]. It is known that in postmenopausal women osteopo-
rosis increases particularly rapidly. It is, therefore, particularly important that in this
group harmful inactivity is avoided and favourable loading stimulated.

6.11.3.5  Coordination and Balance

Inactivity also impairs the coordination of muscle movements and balance in the
body. The risk increases of faulty manipulation, stumbling, dizziness, and accidents.
This, in combination with age-related weaker musculature and skeleton, substan-
tially increases the risk of falls and fractures among older people. The risks of pro-
longed sitting still are therefore particularly high for older people.

6.11.3.6  Body Fat

Low physical activity leads to low energy metabolism in the body. It is not possible
to increase it through mental activity, because the total energy metabolism of the
nervous system is relatively unaffected by mental activity. Energy metabolism at rest
is ~0.9 MET (For MET see Chapter 2, Section 2.3) [Ainsworth et  al. 2000]. The
energy metabolism in sedentary computer work is ~1.5 MET, ~2 MET in traditional
office work, and 2–3 MET in, for example, sedentary assembly or monitoring work.
A 60 kg individual in sedentary work of this kind therefore metabolizes between
720–1440 kcal (3.0–6.0 MJ) over an 8-h shift. In more active professions, the energy
metabolism is 4–5 MET, which corresponds to ~1920–2400 kcal (8.0–10.0 MJ) over
the same period. A difference of 1000 kcal (4.2 MJ) per working day corresponds to
the energy we take on board when we eat ~100 g of pure fat or 250 g of sugar or other
carbohydrates. An individual weighing 60 kg working full time, who transfers from
an active and moderately strenuous job, for example, as a nurse (4 MET) to low-
intensity, sedentary work, for example, providing medical information over the
phone (2 MET), may count on a weight rise of up to ~13 kg over one working year if
they continue to consume as much food (energy) as in their previous job. In this cal-
culation, we have taken into account the fact that, the heavier one becomes, the more
energy is metabolized at a certain level of activity.
There is therefore a risk, particularly in low-activity jobs, that the energy intake
through food exceeds what is metabolized during the day, if there is no increase in
metabolism during leisure hours. The risk of becoming overweight and obese is
clear.
Prolonged, Low-Intensity, Sedentary Work 169

6.11.4  Health Risks from Physical Inactivity

Low physical activity and being overweight/obese may make for a risk of developing
Type II diabetes and an increase in harmful blood lipids [SNIPH 2010]. It has also
been found that there is a link between a lack of physical exercise and a greater risk
of high blood pressure. Each of these comprises a risk factor in the development of
cardiovascular diseases such as angina, heart attack, and stroke. Prolonged physical
inactivity may therefore have serious complications. Facts indicate that the risk of
such health problems is more closely linked to the lack of physical activity than to
being overweight. It may therefore be more dangerous to be of normal weight but
inactive than overweight but physically active.
In recent decades the indications have been growing of a link between lack of
physical activity in the form of exercise and the development of cancer [Dept. of
Health 2004; Lynch 2010]. This is primarily a question of breast cancer in women
and prostate cancer in men. In addition, there is a link to cancer of the gastrointesti-
nal tract. Low physical activity has also been linked to motor impairments in the gut
with an increased risk of constipation, haemorrhoids, and diverticulosis.
Many of the health consequences that have been mentioned can also be influ-
enced by different stressors, such as adverse psychosocial conditions, primarily high
mental demands, a lack of control over one’s own work, and lack of social support
from management and colleagues [Palmer and Smedley 2007; Côte et  al. 2008].
Sedentary work with poor psychosocial conditions and other stressors may therefore
be assumed to be particularly unhealthy.
Apart from the link between physical activity and physical health, in recent times
information has also come to light about the link with mental well-being [SNIPH
2010]. Physical exercise seems to reduce sensitivity to stress. It may also provide a
more positive self-image, and satisfaction with oneself as an individual. The general
sense of well-being increases. Exercise has also been proved to have a positive effect
on depression. Sleep disturbances are another problem area in which physical activ-
ity may have beneficial effects. The incidence of psychological disorders of this kind
is higher among women and among older people.
All in all, it has been shown that physical activity in the form of physical exercise
has a positive effect on a large number of both physical and psychological functions.
Positive effects can in most cases be seen against an existing state of ill health, both
as directly healing and as enhancing the quality of life in chronic illness. In many
cases a preventive effect against the emergence of such ill health can also be seen.
Inversely, WHO reports that physical inactivity is among one of the 10 most common
causes of death in the developed countries. It also causes a large proportion of the
losses of health (Disability Adjusted Life Years—DALY = the number of years lost
with full health where account has been taken of how serious the health loss is)—
23% of them linked to cardiovascular disease, 16% to colon cancer, 15% to Type II
diabetes, 12% of strokes, and 11% linked to breast cancer.
The link between these widespread diseases and physical activity at work is in
most cases unclear, but information about these links is growing (see Section 6.11.2).
It is unclear as to what proportion of the cases of these illnesses can be ascribed to
periods of low-intensity, sedentary work. Most of the illnesses have a multifaceted
170 Occupational Physiology

background, but with a probable influence both from working life and from life in
general. A working life becoming more sedentary will scarcely contribute to a posi-
tive development of public health, however.

6.12  I S THE JOB LOW INTENSITY, SEDENTARY, OR WITH

STATIC LOAD?
There are different methods of assessing general physical activity and specific mus-
cle activity in connection with work: (a) occupational designation; (b) self-reported
activity; (c) observation of work; (d) using measuring devices.

6.12.1  Occupational Designation

A rough way of assessing physical activity and energy needs at work is to use occu-
pational designations, trade designations, or the like. There are tables of energy use
for different professions and activities [Ainsworth et al. 2000]. The advantage of this
method is that it is very simple and inexpensive. The disadvantage, however, is that
it provides a very rough picture, as it does not take into account the specific circum-
stances of the workplaces and individuals involved. The information can also become
outdated and give a distorted picture of the current situation. Information about mus-
cle load also rarely occurs in registers of this kind.

6.12.2  Self-Reported Physical Activity and Level of Exertion

Perhaps the most common method of getting some measure of the activity is that the
individuals themselves assess the degree of activity or exertion at work. Usually, a
questionnaire with scales is used, where it is possible to choose the level of work
among specific alternatives, for example, how “heavy” the job has been, how long
the activity has continued, and how often. The advantage of this type of assessment
is that the individual is being instructed to think about a particular time period, for
example, “the past year” or “a typical day.” It is also possible to use a questionnaire
to obtain information from many individuals at relatively low cost. The disadvantage
is that the reliability and validity of the responses may be questioned. The quality of
the responses is dependent on the individual remembering correctly and not allow-
ing irrelevant factors to influence their response.
Factors often affecting assessments of activity in intensity levels are the individual’s
frame of reference and working capacity. If two people have the same job, one who is
seldom physically active will presumably assess the incidence of certain physical activ-
ity as occurring more often, for example, how often you do “heavy work,” than another
person who is more used to physical activity. An individual who, for example, is out of
shape or lacks muscle strength will also be more laboured in a given physical job and
therefore presumably describe the intensity as higher than someone who has good fit-
ness or strength. It is, therefore, often more reliable to ask directly how strenuous the
individual experiences a particular job as being, and present the response according to
a scale, for example, Borg’s Scale (Figure 6.8) [Borg 1998]. Exertion is the internal
exposure that occurs when an individual with a ­certain capacity is subject to certain
Prolonged, Low-Intensity, Sedentary Work 171

6 No exertion at all
7
Extremely light
8
9 Very light
10
11 Light
12
13 Somewhat hard
14
15 Hard (heavy)
16
17 Very hard
18
19 Extremely hard
20 Maximal exertion

FIGURE 6.8  Borg’s rated perceived exertion (RPE) scale 6–20. The scale values 6–20
are set so that, when multiplied by 10, they correspond to the pulse in short-term dynamic
work by major muscle groups, for example, on a bicycle ergometer, in a healthy 20–25-year-
old person of average fitness.

external exposure, for example, cycling at 100 W or lifting 25 kg. The Borg Scale is
constructed in such a way that the endpoints comprise “no exertion” and “maximum
experienced or imaginable exertion” respectively, that is to say, a range that is reason-
ably similar for all individuals. An assessment, for example, in the middle of the scale,
therefore means an approximately equivalent experience of exertion for everyone.

6.12.3  Observations of Work

Another method that is frequently used to measure physical activity is to observe the
individual’s activity at work. Trained observers can, with the aid of a stop watch,
record the incidence and timing of some predetermined activities. They can, for
example, observe the time taken for sedentary and standing work, the time with the
hands above shoulder height or the neck twisted. In order to facilitate observations of
this kind there are special computer programmes for small palm computers on which
one records one’s observations and which can also calculate results, for example, the
proportion of time in sedentary work. As an alternative to observations on site, one
can, using a web camera or video recorder, record sequences of work so as to later
register the activity from the recording in peace and quiet. By inspecting the record-
ings several times, one can register considerably more than one has time for in real
time on site. The advantage of observations is that it is possible to avoid the influence
of such irrelevant factors as might affect self-assessment (see Section 6.12.2). There
is also a broad spectrum of activity parameters to choose from. The disadvantage of
observations is that they take a long time and are therefore expensive, and with rea-
sonable resources it is possible to observe for only a limited period of time. The reli-
ability and validity of measurement results depends on the observer having captured
sufficiently long and realistic “time windows.” Quality is also dependent on having
172 Occupational Physiology

(a) (b)

(c) (d)

FIGURE 6.9  Personal monitoring equipment: (a) Heart rate monitor (“pulse meter”); (b)
heart rate monitor with accelerometer; (c) pedometer; (d) oxygen consumption logger—
MetaMax 3B. Photo: (a–c) Martin Toomingas; Photo: (d) CORTEX.

chosen the relevant aspects of physical activity and that these have been observed
with high reliability and validity.

6.12.4  Measuring Physical Activity

There is, nowadays, a selection of measurement instruments for recording physical
activity which can be carried on the person during a working day or over several
days. The basic principle for most of them is that the body’s position and movements
vis-à-vis gravity are recorded. Pedometers are commercially available which can be
attached to a belt or the like (Figure 6.9c). Other instruments that measure whether
the subject is sitting or standing/walking include inclinometers and accelerometers.
A more or less sophisticated computerized programme software is connected to the
various instruments to calculate activity during the recording period. The advan-
tages of instrumental monitoring of body movements is that many irrelevant factors
that may affect the assessments are avoided. It is also possible to record over a long
period, from days to weeks, and in this way to gain quite a good understanding of the
activity. The cost of these instruments varies, but for example, pedometers are fairly
cheap. The quality is dependent both on acquiring relevant aspects of physical activ-
ity and that the measurements are technically reliable.

6.12.5  Measuring Energy Metabolism

All muscle and physical activity increases energy metabolism in the body compared
with a state of rest. The increase in energy metabolism requires a greater uptake of
Prolonged, Low-Intensity, Sedentary Work 173

oxygen and blood circulation. A relatively simple method of assessing energy metab-
olism is to measure heart rate (see Chapter 2, Section 2.10). There are commercially
available and inexpensive personal monitoring instruments for recording heart rate
which can store data for a complete working day or longer (Figure 6.9a–b). The
advantage of this type of monitoring is that long-term monitoring can be carried out
without disrupting the natural activity. The disadvantage is that the heart rate is also
influenced by factors other than physical activity, for example, stress. This influence
of mental processes may lead to substantial false estimates of the physical activity
level at low levels, for example, in sedentary work. To acquire more reliable mea-
surements of energy metabolism, one can measure oxygen consumption from the air
inhaled (see Chapter 2, Sections 2.6 and 2.10, and Figure 6.9d). Sophisticated moni-
toring methods such as these are more suited to expert users.

6.12.6  Measuring Muscle Activity

Muscle activity can be monitored with the aid of electrodes recording electrical activ-
ity from the action potentials, so-called electromyography (EMG). Today there is com-
mercially accessible monitoring equipment for recording surface EMG (Figure 6.10).
Portable equipment is also available that can store recorded activity for many hours. A
simplified version of equipment of this kind usually forms part of so-called biofeed-
back equipment used to train individuals to relax their muscles, usually the trapezius.
Normally the total activity from the action potentials of many motor units is recorded
with electrodes fixed to the skin outside the muscle, so-called surface EMG (Figure
6.11). This method is most suitable for surface muscles, for example, the trapezius or the
flexors and extensors of the wrist on the forearm. The graphs that are shown are complex
and should be compared with EMG registrations under special controlled conditions, for
example, in a maximal voluntary contraction (MVC). EMG activity during work can
then be compared with activity in the MVC ­measurement and expressed as a percentage
of this (MVC%). Performing maximum muscle contractions may involve a certain risk

FIGURE 6.10  EMG recording of activity in the trapezius muscles. Photo: Allan Toomingas.
174 Occupational Physiology

EMG, µV
100

–100
52 53 54 55 56
Seconds

FIGURE 6.11  Surface EMG from the trapezius muscle including 2 s muscle rest (micro-
pause). Photo: Göran Hägg.

of damage, which is why people often instead often use what is called a reference con-
traction, for example, holding a kilo weight with outstretched arm if the measurement
applies to the trapezius muscle. The EMG activity during the work is then compared
with the activity during the reference contraction (REF%). We are often interested in
recording muscle rest, that is to say, that the EMG activity is zero, or near to zero.
The advantage of EMG registration is that it is a technically well-developed method
of measuring muscle activity. Measurement records activity from a limited area (a few
cm2), which is an advantage as it is possible in that way to know which muscle is being
measured. One disadvantage, however, is that only a small part of the body’s muscle
activity is visible. Most movements and all work, however, demand coordinated activity
from many different muscles. Another disadvantage is that with surface EMG it is only
possible to measure activity in muscles near the surface. Moreover, the registrations
may easily be subject to disturbance from, electrical devices, for example. In order to
achieve high quality in the measurements, the registration should be quality checked,
which can be time consuming if it is a question of a large number of measurements.
With the aid of thin needle electrodes pushed into the muscle, it is possible to
record EMG activity from individual muscle cells. Activity patterns can be studied
in individual motor units, for example, breaks with muscle rest. Such a zero activity
can be very short (seconds), so-called EMG gaps. Measurements with needle EMG
are very demanding and best suited to laboratory studies.

6.13  W
 HAT THE LAW SAYS ABOUT PROLONGED LOW-
INTENSITY, SEDENTARY, AND STATIC WORK
Prolonged sedentary and low-intensity static work is not explicitly mentioned or
­covered by EU directives. Nor do the different national work environment laws take
such work into consideration. There are, however, some EU Directives at a more
Prolonged, Low-Intensity, Sedentary Work 175

general level that are applicable to such work. From the EU Council Directive 89/391/
EEC the following general directives regarding the organization of work can be
emphasized [EUR-Lex 1989] (italics mine).
1. “The employer shall take the measures necessary for the safety and
health protection of workers, including prevention of occupational risks
and provision of information and training, as well as provision of the
necessary organization and means. The employer shall be alert to the
need to adjust these measures to take account of changing circumstances
and aim to improve existing situations” (Section II, Article 12).
2. “The employer shall implement the measures on the basis of the follow-
ing general principles of prevention: A) adapting the work to the indi-
vidual, especially as regards the design of work places, the choice of
work equipment and the choice of working and production methods...;
B) developing a coherent overall prevention policy which covers tech-
nology, organization of work, working conditions ...; C) giving appro-
priate instructions to the workers” (Section II, Article 6).
3. “The employer shall ensure that each worker receives adequate safety
and health training, in particular in the form of information and instruc-
tions specific to his workstation or job” (Section II, Article 12).
4. “It shall be the responsibility of each worker to take care as far as pos-
sible of his own safety and health ...” (Section III, Article 13).
These articles stress the responsibility of the employer to organize the work and
choose production methods that protect the health of the workers. Logically, this
must also cover health risks from prolonged, sedentary, and static work. Employers
should therefore organize work and design production methods bearing this in mind
and informing and training their workers in how to avoid the risks. The workers have
a responsibility to work in a way that is healthy.
Computer work has become very common in today’s working life, as is described
in Section 6.2. Computer work is, therefore, probably the most common setting for
sedentary work. From the EU Council Directive 90/270/EEC regarding work at
computers, the following relevant directives can be highlighted from Section II
[EUR-Lex 1990] (italics mine).

1. “Employers shall be obliged to perform an analysis of workstations in

order to evaluate the safety and health conditions to which they give rise
for their workers, particularly as regards possible risks to eyesight, phys-
ical problems and problems of mental stress. Employers shall take
appropriate measures to remedy the risks found ..., taking account of
the additional and/or combined effects of the risks so found” (Article 3).
2. “The employer must plan the workers’ activities in such a way that daily
work on a display screen is periodically interrupted by breaks or changes
of activity reducing the workload at the display screen” (Article 7).
3. “Workers shall receive information on all aspects of safety and health
relating to their workstation, in particular information on such measures
applicable to workstations as are implemented under Articles 3, 7 and 9.
176 Occupational Physiology

Every worker shall also receive training in use of the workstation before
commencing this type of work and whenever the organization of the
workstation is substantially modified” (Article 6).

The risks of prolonged sedentary work were not generally recognized when this
Directive was formulated in the 1980s. But the “physical problems” stressed in
Article 3 may be applicable to risks from prolonged sedentary work. Organizing
computer work with regular interruptions by way of breaks or other activities, as
stated in Article 7, is one way of reducing such risks. It could also be argued that the
Directive gives support to the suggestion that workstations should be equipped with
height-adjustable desks, allowing the worker to alternate between seated and stand-
ing computer work in order to decrease sedentary work. Similar to Directive 89/361
above, information to computer workers about health risks and training in good
working techniques is stressed here too.
The Directive also stresses aspects that influence the risk of prolonged static load
on the musculoskeletal system, mainly in the neck and upper extremities. In the
Annex, the Directive specifies requirements on the software, the environment and
equipment at the workstation, including the furniture. These measures could reduce
the risk of static load on the neck and upper extremities of the computer user.
Adjustability and flexibility are stressed regarding the chair: “The chair shall be
stable and allow the operator easy freedom of movement and a comfortable position”
(Annex). The Directive also specifies the need for an eye test, and corrective glasses
if necessary, before commencing computer work and at regular intervals thereafter
(Article 9). These actions can also reduce the risk of static load on the neck and
shoulders.
The International Standards Organization (ISO) has formulated a large number of
quite detailed standards regarding different aspects of computer work stations [ISO
2010]. Standards have the state of “recommendations,” not of law.

6.14  SUGGESTIONS FOR IMPROVEMENTS

6.14.1  Organization of Work
Basically, work should be organized so that both physical and mental variation and
recovery are built in. Uniform and monotonous loads should be avoided. Special
care should be taken to ensure that such jobs are not done under time pressure or
other stressful conditions. The combination with the high demands for precision
should also be avoided, for example, as regards hand–eye coordination. If the work
by its nature involves adverse loads of this kind, it should be alternated with other
work tasks which are more favourable from these aspects and/or have breaks at
regular intervals. The more adverse loads found in the work, the more important it
is to limit the time workers are exposed to it, and it is even more important that the
work is interrupted for variation and recovery. A ground rule is that it is better to
have many short breaks than few long ones. In, for example, intensive computer
work, breaks of 1–5 min several times an hour have proved to be advantageous also
for productivity.
Prolonged, Low-Intensity, Sedentary Work 177

Both the knowledge base of physiology and studies from working life support the
idea that loading that is “optimal” is best. “Optimal” applies then to both the physical
and mental intensity of the load, its frequency and variation, and its duration (see
Chapter 2, Section 2.12; Chapter 3, Section 3.14; Chapter 5, Section 5.8; Chapter 6,
Section 6.11; Chapter 7, Sections 7.8 through 7.10, Chapters 9 and 10). Often the most
effective means of achieving physical and mental variation and recovery is to alter-
nate between different work tasks during the working day. Recovery does not need
only to mean that the worker “rests” and is inactive. Carrying out other tasks or
working in a different way may be recuperative for the muscles of the shoulders, for
example. To do something more routine or more manual may be recuperative after
work that has required great mental concentration. One could perhaps sort the post,
make the afternoon coffee for the department, tidy one’s desk, or tidy up around the
workplace. One can alternate between routine tasks and meetings or personal in-
service training or instructing new colleagues.
The work organization solutions for achieving variation are various. The degree
of variation can be more or less extensive. One common method is the so-called job
rotation. This implies that on a regular basis, usually several times a day, one alter-
nates between different tasks of a similar nature. It might, for example, be a question
of changing between stations on an assembly line where various parts are being fit-
ted to a car. This may provide some variation in loads as regards, for example, work
posture, force development in muscles, precision demands for hand − eye coordina-
tion, compared with what would be the case if one were to install the same part all
day long. Another example is to alternate between sitting at a checkout in a super-
market where the customers’ purchases come from the right or from the left respec-
tively. Such variation is often rather limited, however. Often the musculature of the
neck/shoulders is loaded in a similar way, as the different jobs between which the
worker is alternating all require intensive work involving hands and arms.
A higher degree of variation is often desirable, and may be achieved using the
so-called job enlargement or job enrichment. This is where alternation between
tasks or new tasks of a completely different character is introduced. In the example
with the assembly line, it might be a question of fetching parts from the stores, con-
ducting quality control on the finished work, or planning next week’s staffing of the
line. In the example with the cashier in the supermarket, it may be a question of
stacking shelves, price-marking goods, decorating and organizing signs or planning
and ordering goods from the wholesaler. The examples describe the addition of tasks
with an ever-increasing degree of mental complexity. More comprehensive variation
often requires a broader competence than if a worker is carrying out one task. What
the “optimal” variation is between the uniformly monotonous and the complex and
demanding is different for different individuals and during different phases of their
professional life. Further training and skills development are therefore important
factors in making variation in work possible. Good organization of work provides
scope and development opportunities for everyone to find the variation that is “opti-
mal.” There is no sharp dividing line between job rotation—job enlargement—job
enrichment, but it is a question of differing degrees and characters of variation.
A different example is job exchange in which on a regular basis, usually with
some days or weeks in between, the worker changes between different jobs,
178 Occupational Physiology

­ orkplaces, and/or employers, for example, in an employers’ circle. There are exam-
w
ples from health care, where nurses alternate between providing medical advice over
the telephone and traditional nursing in a hospital. It may also be a matter of chang-
ing between completely different professions, for example, a (part-time) farmer who
supplements his income with work as a salesperson at a local supermarket.

6.14.2  The Level of Activity at Work and in Connection with Work

If the work is low intensity and sedentary by nature, all opportunities should be
taken to add operations with favourable loading moments and an increase in energy
metabolism. Arranging meetings on the move or having standing coffee breaks is a
minor contribution. Sharing the responsibility for cleaning the workplace is another.
The workplace is the place, apart from the family, to which most people regularly
return and where they have a social network. Make use of the work group to motivate
and stimulate good physical activity, for example, by distributing pedometers and
establishing targets for the number of steps walked per week. The workplace may
also join some kind of health-promoting activity through occupational health ser-
vices or acquire fitness certification for their group. A physical fitness hour with a
selection of activities during paid working hours is another well-justified solution.
The workplace can also facilitate physical activity in connection with commuting,
for example, by organizing places to leave bicycles which are secure and protected
from the weather.

6.14.3  Work Equipment

Work equipment, for example, desks and chairs, should be designed so that they
allow for physical variation and recovery. An example of this is a desk, for example,
for computer work, which can easily be raised or lowered for variation between
seated and standing work.
It is vital that the working environment in general does not cause further adverse
loads, for example, glare from windows or light fittings, or stressful noise from a
ventilation unit. Particular problems can arise in so-called open office landscapes
where a large number of potentially stressful elements may exist.
Employees should know how equipment is used and be aware of suitable working
technique. It is also necessary for them to understand why it is important and what
health risks there are at work. One should be aware that such knowledge does not
last, and needs to be refreshed from time to time.
There is essential, concrete ergonomic advice about workplaces and choice of
equipment in connection with computer work published in literature and on various
web sites [Toomingas 2007].

6.14.4  The Individual

The keywords for the individual are to use a working technique that makes use of the
opportunities for variation and recovery. Variation and recovery apply to both physi-
cal and mental work. In order to avoid work involving prolonged static load, workers
Prolonged, Low-Intensity, Sedentary Work 179

should vary their work posture and movements frequently. It is also important to
relieve the load on the arms and hands and the weight of any tools and materials. In
computer work, it is a good idea if the forearms can rest on armrests or the desk top
when working at a keyboard and with the mouse. One should also avoid prolonged
work postures that deviate from the neutral position of the joints, for example, look-
ing up for a long time or turning one’s neck to the side. It is therefore important to
adjust equipment in the correct manner so that adverse loading on the body is
minimized.
Several concrete pieces of advice about working technique in connection with
computer work can be found on various web sites [Toomingas 2007].
One way of achieving physical variation in computer work is to alternate between
sitting and standing. Computer workers who stand for 4 h a day instead of the “nor-
mal” 2 h increase their energy metabolism by the equivalent of a weight loss of
~2.5 kg/year. As the work is of such low intensity that the body does not get the nec-
essary stimulation for reconstruction, all other opportunities for increasing energy
metabolism and dynamic load should be utilized. One might, for example, walk up
the stairs instead of taking the lift or escalator. Cleaning or carrying out other practi-
cal tasks at the workplace not only provides a necessary addition to the load, it also
increases variation both physically and mentally.
In most low-intensity and sedentary work, however, there is a practical limit to
how much the work tasks can be varied or the energy metabolism increased. More
physically demanding and energy-intensive activities outside work must then supple-
ment this. Taking a lunchtime walk, maybe together with a group of friends, is one
example. Commuting is another important opportunity that should be used, as they
occur frequently. Walking or cycling instead of taking the car is also good for the
environment.
A common recommendation is that every adult should be physically active for a
total of at least 30 min everyday (possibly divided into 10 min sessions) at a level that
corresponds to a brisk walk (~50% of maximal aerobic capacity) [SNIPH 2010].
Lunchtime walks and walking to and from work fit in here very well. What is more,
two or three times a week for about 45–60 min one should exert oneself so as to get
really out of breath and sweaty (~75% of maximal aerobic capacity). Activities which
are pleasurable and which suit personal tastes and interests should be chosen. The
choice may be between traditional gymnastics, aerobics, jogging, dance, hard work
in the garden, and the like.

6.14.5  Society
Society should, through its various organizations, authorities, and functions, strive to
provide a working life that promotes physical and mental variation and recovery,
together with optimum physical load and energy metabolism. An example of this is
training and information in such issues of public health for both individuals and also,
for example, social decision-makers, CEOs, and representatives of business. Schools
should take up these questions early in childhood and emphasize in their timetabling
the importance of regular physical activity and good working technique as well as
the avoidance of sitting still for prolonged periods. Through different financial
180 Occupational Physiology

i­ ncentives it is possible to stimulate individuals and companies to promote physical

activity. Society’s various organizations should also stimulate ways of promoting
physically active leisure time.
The local community can stimulate and facilitate active commuting by, for exam-
ple, designing footpaths and cycle tracks that are safe from traffic, particularly on
roads that connect to major workplaces.

6.15  SUMMARY
Sedentary, prolonged low-intensity work is common, for example, in computer jobs.
Despite their low load, jobs of this kind may cause disorders, particularly in the neck
and upper extremities. Comprehensive documentation exists providing various
hypotheses about causal mechanisms behind the origins of such disorders.
Impairments may occur in blood flow to the muscles, tendons, and nerves. An uneven
distribution of load between different parts of the muscle may lead to overload in
particularly vulnerable parts. Working with one’s hands also activates muscles in the
neck and shoulders, which can then be subjected to long-term load, particularly if
muscle tensions induced by stress appear. Relaxing breaks and a variation in work
posture and movements, or, even better, variation involving other activities entirely,
may reduce the risk of problems. Too low of a load over a prolonged period may lead
to damaging metabolic processes and a lack of buildup of capacity in the tissues and
organs of the body, which in the long term may lead to various more or less serious
health conditions, for example, in the cardiovascular system. Prolonged, sedentary
low-intensity work should be alternated with other more mobile activities and be
supplemented by regular physical exercise.

REFERENCES
Ainsworth, BE. et al. 2000. Compendium of physical activities: An update of activity codes
and MET intensities. Med Sci Sports Exerc 32(Suppl 9):498–504.
Åstrand, PO., Rodahl, K., Dahl, H., Strömme, S. 2003. Textbook of Work Physiology.
Physiological Bases of Exercise. 4th ed. Champaign: Human Kinetics.
Bernard, B. 1997. Musculoskeletal Disorders and Workplace Factors: A Critical Review of
Epidemiological Evidence for Work-Related Musculoskeletal Disorders of the Neck,
Upper Extremity and Low Back. Washington: CDC-NIOSH.
Borg, G. 1998. Borg’s Perceived Exertion and Pain Scales. Champaign: Human Kinetics.
Côte, P. et al. 2008. The burden and determinants of neck pain in workers. Spine 33:S60– S 74.
Dept. of Health. 2004. At Least Five a Week: Evidence on the Impact of Physical Activity and
its Relationship to Health. A Report from the Chief Medical Officer. London: Department
of Health.
Ekblom-Bak, E., Hellenius, ML., Ekblom, B. 2010. Are we facing a new paradigm of inactiv-
ity physiology? Br J Sports Med 44:834–835.
EUR-Lex. 1989. Council Directive of 12 June 1989 on the Introduction of Measures to
Encourage Improvements in the Safety and Health of Workers at Work (89/391/EEC).
http://eur-lex.europa.eu/en/index.htm
EUR-Lex. 1990. Council Directive of 29 May 1990 on the Minimum Safety and Health
Requirements for Work with Display Screen Equipment (90/270/EEC). http://eur-lex.
europa.eu/en/index.htm
Prolonged, Low-Intensity, Sedentary Work 181

Eurofound. 2010. Fifth European Working Conditions Survey—2010. European foundation for
the improvement of the living and working conditions. http://www.eurofound.europa.
eu/surveys/ewcs/2010/index.htm
European Agency. 2005. Expert Forecast on Emerging Physical Risks Related to Occupational
Safety and Health. Luxembourg: European Agency for Safety and Health at Work.
Healy, G. et al. 2007. Objectively measured light-intensity physical activity is independently
associated with 2-h plasma glucose. Diabetes Care 30:1384–1389.
Huang, GD., Feuerstein, M., Sauter, SL. 2002. Occupational stress and work-related upper
extremity disorders: Concepts and models. Am J Ind Med 41:298–314.
Hägg, G. 2000. Human muscle fibre abnormalities related to occupational load. Eur J Appl
Physiol 83:159–165.
ISO. 2010. Ergonomic Requirements for Office Work with Visual Display Terminals (VDTs)
ISO 9241. International Organization for Standardization. http://www.iso.org/iso/home.
html
Johansson, H., Windhorst, U., Djupsjöbacka, M., Passatore, M. 2003. Chronic Work-Related
Myalgia. Neuromuscular Mechanisms Behind Work-Related Chronic Muscle Pain
Syndromes. Gävle: Gävle University Press.
Järvholm, U., Styf, J., Suurkula, M., Herberts, P. 1988. Intramuscular pressure and blood flow
in supraspinatus. Eur J Appl Physiol 58:219–224.
Katzmarzyk, P., Church, T., Craig, C., Bouchard, C. 2009. Sitting time and mortality from all
causes, cardiovascular disease, and cancer. Med Sci Sports Exerc 41:998–1005.
Lynch, L. 2010. Sedentary behavior and cancer: A systematic review of the literature and pro-
posed biological mechanisms. Cancer Epidemiol Biomarkers Prev 19:2691–2709.
Matthews, C. et al. 2008. Amount of time spent in sedentary behaviours in the United States
2003–2004. Am J Epidemiol 167:875–881.
Moradi, T., G. Gridley, Björk, J., Dosemeci, M., Berkel, HL., Lemeshow, S. 2008. Occupational
physical activity and risk factor for cancer of the colon and rectum in Sweden among
men and women by anatomic subsite. Eur J Cancer Prev 17:201–208
Morris, JN., Heady, JA., Raffle, PAB., Roberts, CG., Parks, JW. 1953. Coronary heart disease
and physical activity of work. The Lancet 1053–1057 + 1111–1120.
Mummery, K., Schofield, G., Steele, R., Eakin, E., Brown, W. 2005. Occupational sitting time
and overweight and obesity in Australian workers. Am J Prev Med 29:91–97.
Palmer, K. and Smedley, J. 2007. Work relatedness of chronic pain with physical findings—A
systematic review. Scand J Work Environ Health 33:165–191.
Savinainen, M., Nygard, CH., Ilmarinen, J. 2004. A 16-year follow-up study of physical
capacity in relation to perceived workload among ageing employees. Ergonomics
15:1087–1102.
Sluiter, J., Rest, K., Frings-Dresden, M. 2001. Criteria document for evaluating the work-
relatedness of upper-extremity musculoskeletal disorders. Scand J Work Environ Health
27 (Suppl 1).
SWEA. 2010. The Work Environment 2009. Stockholm: Swedish Work Environment Authority,
pp. 58–69. http://www.av.se/dokument/statistik/officiell_stat/ARBMIL2009.pdf
SNIPH. 2010. Physical activity in the prevention and treatment of disease. The Swedish
National Institute of Public Health. Report R 2010:14.
Toomingas, A. 2007. Computer Work. Stockholm: Swedish Work Environment Authority.
http://www.av.se/dokument/inenglish/themes/computer_work.pdf
van Uffelen, J. et al. 2010. Occupational sitting and health risks. Am J Prev Med 39:379–388.
Veiersted, B., Weestgaard, RH., Andersen, P. 1993. Electromyographic evaluation of muscular
work pattern as a predictor of trapezius myalgia. Scand J Work Environ Health
19:284–290.
Visser, B. and van Dieën, JH. 2006. Pathophysiology of upper extremity muscle disorders. J
Electromyogr Kinesiol 16:1–16.
182 Occupational Physiology

FURTHER READING
Arnetz, B. and Ekman, R. 2006. Stress in Health and Disease. Weinheim: Wiley-WCH.
Delleman, N., Chaffin, D., Haslegrave, C. 2004. Working Postures and Movements—Tools for
Evaluation and Engineering. Boca Raton, FL: Taylor & Francis.
Kuorinka, I. and Forcier, L. (eds). 1995. Work-Related Musculoskeletal Disorders (WMSDs):
A Reference Book for Prevention. London: Taylor & Francis.
Wilmore, JH., Costill, DL., Kenney, WL. 2008. Physiology of Sport and Exercise. Champaign:
Human Kinetics.
 7 Work with High Levels
of Mental Strain
Bo Melin

Photo: Joakim Romson

CONTENTS
7.1 Focus and Delimitation.................................................................................. 185
7.2 Incidence of Work with High Mental Load................................................... 186
7.3 Stressors and Stress Reactions....................................................................... 186
7.3.1 Are There Any Differences between Mental and
Physical Stressors?............................................................................. 187
7.3.2 Absence of Recuperation................................................................... 189
7.4 Stress Reaction: A Physical Response to Mental Exposures......................... 189
7.4.1 Neural Adaptation.............................................................................. 191
7.4.2 Endocrine Adaptation........................................................................ 191

183
184 Occupational Physiology

7.5 Stress Reaction in Two Different Systems: The Sympathetic

Adrenomedullary System and the HPA Axis................................................ 191
7.6 Autonomous Nervous System and SAM System........................................... 192
7.6.1 Sympathetic and Parasympathetic Nervous System.......................... 192
7.7 Hypothalamus–Pituitary–Adrenal Axis........................................................ 192
7.7.1 The Question is a Very Complex One............................................... 194
7.7.2 Interplay between the SAM System and HPA Axis, and
Saliva Cortisol Relations to Health.................................................... 194
7.7.3 Connection between Stress and Cognition........................................ 195
7.7.4 Stress and Cognitive Performance..................................................... 196
7.8 Work Organization Conditions Impacting on Mental Load.......................... 196
7.8.1 Common Psychosocial Models.......................................................... 197
7.8.2 Psychosocial Environment is Perceived in Different Ways............... 199
7.9 Cognitive Load.............................................................................................. 199
7.10 Routine Work Is Carried out at the Level of Procedural Memory................200
7.10.1 Organization of Work from a Cognitive Perspective......................... 201
7.10.2 Link between Behaviour and Cognitive Load................................... 203
7.10.3 Link between Cognition and Emotion...............................................204
7.11 Mental Load: Effects on the Musculoskeletal System..................................204
7.11.1 Mental Load and Muscle Activity.....................................................205
7.12 Physiological Measures of Mental Load.......................................................206
7.12.1 Brain Imaging Technologies..............................................................206
7.12.2 Brain Activity....................................................................................206
7.13 More Indirect Methods..................................................................................207
7.13.1 Heart Rate..........................................................................................207
7.13.2 Heart Rate Variability.......................................................................207
7.13.3 Sweat Gland Activity.........................................................................208
7.13.4 Blink Rate..........................................................................................208
7.13.5 Pupil Dilation.....................................................................................208
7.13.6 Random Eye Movements (Entropy)...................................................208
7.13.7 Breathing...........................................................................................208
7.13.8 Electromyography..............................................................................208
7.13.9 Hormones...........................................................................................209
7.14 Subjective Measures of Mental Load............................................................209
7.14.1 Cooper–Harper Rating Scale.............................................................209
7.14.2 Modified Cooper—Harper Rating Scale and
Bedford Workload Scale....................................................................209
7.14.3 Overall Workload Scale..................................................................... 210
7.14.4 NASA TLX........................................................................................ 210
7.14.5 SWAT................................................................................................. 210
7.14.6 Broader Subjective Instruments......................................................... 210
7.15 What Does the Law Say About Mental Load?.............................................. 210
7.16 Summary....................................................................................................... 211
References............................................................................................................... 211
Further Reading...................................................................................................... 212
Work with High Levels of Mental Strain 185

Victoria is a doctor, aged 30. Her work in a care profession means that she must be
responsive and take a large responsibility for patients’ lives and safety. She often has
to make quick and rational decisions both on her own initiative and together with
other people. The demands from patients and the fear of making a mistake often
result in a feeling of concern that will not go away even after the end of a day’s work.
Her experience of stress, felt in both body and mind, is very tangible.
Working with people, and not least working with people in distress, often involves
considerable mental strain. Staff in not only the care professions, but also in schools,
and those working at call and contact centres, in a reception, in shops, and restau-
rants, are occupational groups burdened with considerable social and mental
demands. Within these occupations, staff have to devote energy to, for example,
restraining spontaneous feelings and maintaining detachment in their relationship
with patients, students, clients, or customers.
Being subject to heavy psychological demands in our working environment does
not in itself need to imply anything negative for our own health, but may on the con-
trary provide a stimulus, provided the stresses feel manageable and are of relatively
short duration, and provided there is an opportunity for recuperation. But when the
demands become too great, or when we experience prolonged frustration for other
reasons, a number of negative mental and physical reactions may occur.
Sometimes Victoria has to operate. In surgery, experience, precision and “high tech-
nology” are often characteristically used in conjunction. Even when she is operating, the
mental strain is pronounced; but it is of a rather different character, involving less emo-
tion than when out in the ward. This is where the strain has more to do with concentra-
tion, a mental or cognitive involvement which must not be disturbed. If, nevertheless, a
disturbance does occur, there is an increased risk of making a mistake, which would be
very serious in the case of an operation. Many occupations involve great demands on
precision and concentration—for example, the work of welders, precision tool makers,
dentists, and slaughterhouse workers. A high level of cognitive involvement that cannot
be disturbed is required, for example, of interpreters, call centre operators, and actors.

7.1  FOCUS AND DELIMITATION

This chapter has a biopsychosocial framework; it describes psychological exposures
and reactions to them. The chapter differs from other chapters insofar as here the focus
is on exposures that only individuals themselves can describe and express. Here there
are no objective exposure limits for the relevant exposures. Mental exposures are in a
sense invisible, and are made visible and recordable with the aid of various methods
such as scales, questionnaires, brain scanning techniques, psychophysiological tech-
niques, and different types of experiments. It is the reactions to the exposures that are
recordable and can be measured both subjectively and physiologically. By way of intro-
duction, we describe not only what a stressor is and the differences between physical
and mental stressors, but also their similarities in the stress reaction itself. Allostatic
load is important in this context. Thereafter, we give an account of the biology of the
stress reaction to subsequently deal with mental strain in two partially different senses.
On the one hand, we deal with the mental strain resulting from how the psychosocial
work environment is configured in general, that is, how work is organized, how time
186 Occupational Physiology

pressures and feelings in interpersonal relationships impact on the person as an organ-

ism (e.g., Victoria as a doctor in the accident and emergency ­department and out in the
ward). On the other, we deal with the mental strain caused by more specific cognitive
demands in the work. In other words, how people and their brains interpret and process
specific information and how they react to and manage this information (e.g., Victoria
during surgery). In our technological age, the configuration of the working environ-
ment is largely a question of how we use and function together with technology. Finally,
the relationship between mental load and muscle activity is illustrated, as well as what
the Work Environment Act has to say about mental load.
In this chapter, the following questions will be addressed:

• What is the difference between physical and mental load in working life?
• How does mental load and stress in working life originate?
• What happens in the body under mental strain and stress?
• Can mental load and stress at work be harmful?
• Can we measure the degree of mental strain and stress?
• Has mental load in working life changed over the years?
• What does the Work Environment Act have to say about mental load in
working life?

7.2  INCIDENCE OF WORK WITH HIGH MENTAL LOAD

The mental load on doctors is often described as high, and in a population of Swedish
doctors almost three quarters stated that the work is mentally demanding [Ohlin
2001]. The mental load derives partly from the work itself with patients, but also in
large part from comprehensive organizational changes and new IT-related adminis-
trative operating systems that have to be run by the doctors themselves. The doctor’s
situation in this way has similarities to the working situation of others who work with
people in vulnerable situations, and who are experiencing similar organizational
changes. In the Western world it is work within the nursing, school, and care sectors
that provides the most jobs. In 2006, it was estimated that 68.6% of those employed
in Europe were working in these sectors, and only 25% in industry [Eurostat 2008].
The trend in Europe is to a continued percentage rise within nursing, schools, and
care, and a continued percentage decrease in industry. In Sweden in the 1990s, and
at the beginning of the millennium, it was within these sectors that absence due to
illness, as well as the length of absence, was most pronounced, and where mental
symptoms and injuries due to strain comprised a very high proportion of long-term
absence due to illness. The European Union has identified that “work-related stress
is, after back pain, Europe’s biggest work-related health problem.” It is estimated that
these work-related health problems cause more than half of all sick leave in Europe
[European Agency for Safety and Health at Work 2004].

7.3  STRESSORS AND STRESS REACTIONS

Time pressures and high psychological demands are examples of stressors, or
­conditions that exist in many occupations (read more about the psychosocial working
Work with High Levels of Mental Strain 187

environment later in this chapter). If Victoria experiences these factors emotionally

or cognitively as time pressures or as demands that are too great, they constitute
stressors. These are usually called mental stressors. Stressful heat, cold, and noise
are also common stressors, but these are usually assigned to the category physical
stressors.
Victoria lives in a changing work environment, with both time pressures and con-
siderable demands, which in their turn make great demands on the adaptability of
her body or organism and imply that in every “new” situation she has to react in a
way that is functional for her. The stress reaction is an example of our ability to
adapt. The stress reaction is produced in stressful situations and these are a normal
physiological reaction resulting from a stressor.
A mental or cognitive stressor is as a rule qualitative in kind (stress that has to be
interpreted by the individual) so that it puts strain on the memory or demands continu-
ous attention, rapid reactions, or contact with other people. If the work is closely con-
trolled and inflexible, or involves too much responsibility or competition, it may lead to
high mental strain. The situation can be exacerbated if unclear or contradictory expec-
tations are imposed on the employee. The same applies to too great a quantity of work
and a lack of access to information, as well as changes occurring in the work itself.

7.3.1  Are There Any Differences between Mental and Physical Stressors?
As regards exposure, it may seem self-evident to distinguish between physical and
mental stressors. Stress reactions caused by physical stressors such as noise, vibra-
tion, heat, and cold can disturb the internal balance of the body so that a stress reac-
tion results. Physical stressors disturb the internal balance of the body, regardless of
how we experience them mentally. It can be said that physical stressors have an
impact on the internal environment of the body without higher cognitive functions
needing to be employed (read more about cognitive functions later in this chapter).
As regards the stress reaction itself, it is interesting that the division into physical and
mental stress reactions is not as obvious. The allostatic model (see Fact Box 7.1)
describes a harmful course of events on the basis of the concepts of allostasis and
allostatic load (Figure 7.1) [McEwen 2000a,b]. Allostasis means the process that
ensures that the body’s physiological systems are in balance, and that homeostasis is
thereby maintained during varying external conditions. These external conditions
may be of different kinds—physical as well as mental/psychosocial. Allostasis has a
primarily protective function for the body, but allostatic processes can also act to the

FACT BOX 7.1

During the 1990s, Bruce McEwen, Professor of Neuroendocrinology at Rockefeller
University, introduced the concepts of “allostasis” and “allostatic load” in relation
to homeostasis. In the scientific literature, allostatic load has, in part, replaced the
concept of stress, and allostasis is seen as a complement to homeostasis. The con-
cept of allostasis is drawn more widely than homeostasis and emphasizes, among
other things, the importance of understanding the mechanisms for recuperation.
188 Occupational Physiology

(a) 1
Biological response
Stress
Restitution

0
0 1 2 3 4
Time

(b) 1 (c) 1
Biological response

Biological response
Hatched line
illustrates normal
adaptation
0 0
0 2 4 6 8 10 0 2 4 6 8 10
Time Time
(d) 1
(e) 1
Biological response

Biological response

0 0
0 1 2 3 4 5 6 0 1 2 3 4
Time Time

FIGURE 7.1  According to McEwen’s model, a normal or sound reaction is to be found, and four
types of situations which can lead to allostatic load, resulting in less sound reactions over time
Modified from McEwen [2000a] by Melin [2003]. (a) Normal stress reaction, with mobilization
and easing off/recuperation when the stressor has ceased. (b) Repeated reactions as a result of
challenges precipitated by repeated stressors. (c) Failure to adapt to repeated challenges.
Adaptation here (the circled line) can save the body from excessive stress hormones or load, for
example. One example of this is appearing in public, which initially can trigger anxiety and stress
symptoms, but when repeated can become a habit which does not feel at all disagreeable or bur-
densome. In the case of phobias, for example, a phobia of spiders, each time when a spider appears
a strong physiological and mental reaction is triggered. In phobia treatment tools are provided to
manage the stressor (the spider), whereby more adequate mental and physical reactions occur on
sighting a spider. A certain habituation can also occur as a result of exposure to physical stressors
(e.g., noise), but it is seldom suitable to accustom oneself or adapt oneself to. The physical stressors
that have a considerable impact on homeostasis should preferably be avoided completely. (d)
Inability to “shut off” allostatic response. This is the largest category of allostatic load as regards
the existing examples. Not everyone’s blood pressure recovers after acute stress. Failure to reduce
HPA activity (read more about the HPA axis later in this chapter) in the evening is a kind of allo-
static load. A perhaps unexpected consequence is that women may have a reduced bone-mineral
density as a result of depression. This may be due to allostatic load with raised hormone levels,
which is linked to depression, also causing chronically reduced calcium levels. (e) Inadequate
allostatic response may occur, which triggers a compensatory increase in other allostatic systems.
If, for example, adrenalin is not secreted as a response to stress, then the sensitivity to autoim-
mune and inflammatory disturbances will increase (Fact Boxes 7.2 and 7.3).
Work with High Levels of Mental Strain 189

detriment of the body and produce harmful effects if they do not disappear within a
reasonable period. In other words, they give rise to allostatic load.
The normal allostatic reaction, for example, the stress reaction, is triggered by
a stimulus and is subsequently maintained over an appropriate time interval so as
finally to cease (illustrated in Figure 7.1a). Four situations (illustrated) are thought
to promote negative allostatic load (Figure 7.1b−e); (b) repeated and frequent stress;
(c) inability to adapt to stress and adequately reduce the stress response; (d) inability
to shut off the stress response after a stressor has ceased; (e) in an interrupted stress
response when, for example, the stress hormone level is not raised in a stress situa-
tion and instead other compensatory physiological responses ensure that allostasis is
maintained [Melin 2003, pp. 237–238].
The prolonged load to which these situations give rise is exhausting for the body.
The result of maintaining allostasis under such circumstances is increased vulner-
ability in those organs and systems which act to restore homeostasis, and as a result
physical and mental symptoms may arise.
According to the reasoning about allostatic load that has been given, there is no
difference whether, in her work as a doctor, Victoria is subjected to mental or physi-
cal stressors. From an allostatic perspective, there is therefore no difference between
a physical and mental stressor. However, [McEwen 2000b] considers that a stress
reaction is absolutely necessary in situations requiring physical activity, but that it
is scarcely functional when we are subjected to psychosocial stress, with no element
of physical activity. Many jobs today contain few or no elements of physical activity.

7.3.2  Absence of Recuperation

McEwen’s model, like previous stress models, emphasizes that energy mobilization
is something healthy, sound, and normal in situations requiring energy. At the same
time, the model focuses on the fact that problems only arise when energy is mobi-
lized constantly without any periods of recovery. Perhaps the individual has been
giving all they have for months and years without sufficient recuperation. In pro-
longed stress and allostatic load, the balance has shifted between the body’s cata-
bolic (“breaking down”) and anabolic (“building up”) conditions towards the
catabolic end, which has an impact on the constantly ongoing remodeling process
described in Chapter 6, Section 6.13. The result may be weakened structures and
impaired healing processes. The situation can be exacerbated by a lack of recupera-
tion, particularly in cases of prolonged sleep disturbance (Fact Boxes 7.2 and 7.3).

7.4  S TRESS REACTION: A PHYSICAL RESPONSE

TO MENTAL EXPOSURES
A stressor, mental or physical, gives rise to a stimulus causing the body’s
homeostasis—its constant internal environment—to be disturbed. The stress
reaction is the adaptation that is made, neurally and endocrinally, in order to
restore the homeostatic condition in the body when a stressor has thrown it out
of balance.
190 Occupational Physiology

FACT BOX 7.2

In prolonged energy mobilization, the so-called hypothalamic–pituitary–adre-
nal (HPA) system facilitates the body’s preparedness to cope with situations
that demand energy. This system is activated by stress, and initially provides
an increase of cortisol in the blood (the body’s own cortisone) and enhances
the capacity of the immune defense system. If the system grows tired, no mobi-
lization/activation takes place. The cortisol level in the blood is then low and
does not increase (is not mobilized) to match external stress. In normal cases,
the cortisol level in the blood is high in the morning—but with fatigue it is low
in the morning instead—and remains unchanged throughout the day instead
of dropping towards the evening [Kristensen et al. 2011].

FACT BOX 7.3

In animal studies [De Kloet et al. 1998], it has been observed that raised cor-
tisol levels lead to impaired cell function or cell death, respectively, in certain
areas of the hippocampus (e.g., a deep-seated structure in the limbic system
that is important for our short-term memory). Corresponding finds have been
made using a magnetic resonance imaging (MRI) scanner on people with post-
traumatic stress disorder (PTSD) and in adults who have suffered known seri-
ous abuse as children. This in its turn correlates with impaired verbal memory
found in neuropsychological tests. The two types of receptors for cortico-
steroids are: mineralocorticoid receptors (MR) and glucocorticoid receptors
(GR). MR are to be found to a great extent in the hippocampus and in other
areas of the limbic system. They are activated by basal HPA activity, which
follows a diurnal rhythm and has a bonding capacity, that is, 6–10 times stron-
ger in relation to corticosteroids than GR. GR are in their turn also localized in
different areas of the brain, primarily in the hippocampus, the hypothalamus,
the amygdala, and the prefrontal cortex [Nordling 2003, pp. 18–19].
When HPA activation increases, for example, in cases of acute stress, GR
are involved to a greater extent, and then a suppression of the HPA axis usu-
ally follows [McEwen 2006]. If the system is subjected to prolonged stress,
however, the effect is quite different. The hippocampus is the structure that
has primarily been studied, and seems to be affected by prolonged high levels
of stress hormone. This should be seen against the basis of the large propor-
tion of both MR and GR receptors (described above) that can be found within
the structure. In chronically raised levels of cortisol, signal transmission in the
hippocampus becomes damaged, and outgoing communications are reduced.
The consequence is that the inhibition of corticotropin-releasing hormone
(CRH)-producing neurons in the hypothalamus is disturbed, and in this way
the release of cortisol is not reduced. One hypothesis is that this may be a pos-
sible explanation for the cognitive disturbance observed in many patients with
Work with High Levels of Mental Strain 191

poor concentration, memory, and over-sensitivity to many impressions. Even if

the patients themselves feel better, this cognitive disturbance seems to last for
a long period, causing problems and a long drawn-out rehabilitation [Nordling
2003]. You can read more about stress and the involvement of the brain in Fact
Box 7.4.

7.4.1  Neural Adaptation

On the neural level, the stress reaction leads to a greater activation of the sympa-
thetic nervous system, and an inhibition, generally speaking, of the parasympathetic
nervous system. The effects of an increased sympathetic activation is that the heart
rate (HR), blood pressure, and blood sugar levels are raised, the pupils dilate, sweat
is secreted, and the external blood vessels contract. Researchers usually describe this
response or reaction as a necessary adaptation for action, either through attack (fight)
or flight. The reaction is intended to defend the body against an acute danger.

7.4.2  Endocrine Adaptation

Endocrine adaptation occurs through an increased internal secretion of certain hor-
mones, for example, adrenalin, norepinephrine, glucocorticoid, glucagon, prolactin,
and vasopressin. At the same time, the internal secretion of other hormones decreases,
for example, testosterone and, in the long term, also growth hormones.
The neural and endocrinal changes together result in the body adapting to the
acute stress situation through increasing the availability of stored energy increases
and intensifying cardiovascular activity. The adaptation also means that the body’s
­development—that is, anabolic functions such as growth, reproduction, and
­digestion—decline at the same time as the immune defenses are affected and cogni-
tive acuity is raised.

7.5  S TRESS REACTION IN TWO DIFFERENT SYSTEMS:

THE SYMPATHETIC ADRENOMEDULLARY SYSTEM
AND THE HPA AXIS
It is important to be aware that the dominating effects of the stress reaction result
from activity in two separate but not independent systems: the sympathetic adre­
nomedullary (SAM) system and the HPA axis (in somewhat older literature the
abbreviation PAC may be found). The central substances acting in the systems are
the classic stress hormones adrenaline and norepinephrine, which are collectively
called catecholamines (SAM) or glucocorticoids, primarily in the form of cortisol
(HPA). The best-known health problems associated with these systems affect the
cardiovascular system, such as, for instance, high blood pressure, heart attacks, and
cerebral infarctions. But prolonged activation or strain on these systems is also
assumed to be of significance for the development of diabetes (reduced insulin
­sensitivity), infections (disturbed immune function), and cognitive impairment
192 Occupational Physiology

(­hippocampus degeneration, see Fact Box 7.4). The hormones adrenalin and norepi-
nephrine dominate in situations requiring active exertion. High or markedly low cor-
tisol levels (HPA) seem, on the other hand, to be related to a greater extent to situations
when the individual is passive and helpless and where they are subjected to stress for
a long period. Both systems are described in greater detail below [McEwen 2006].

7.6  AUTONOMOUS NERVOUS SYSTEM AND SAM SYSTEM

7.6.1  Sympathetic and Parasympathetic Nervous System
The autonomous nervous system spontaneously controls activity in organs such as
the heart, the adrenal medulla, the glands and the stomachic-intestinal canal, and
activity in the smooth muscles, for example, around the blood vessels. The overrid-
ing function of the autonomous nervous system is to maintain a constant internal
environment—homeostasis—and this is traditionally divided into the sympathetic
and parasympathetic nervous systems. These are usually activated antagonistically.
In the case of the heart and the intestines, for example, one system acts as a stimulus
and the other as a retardant.
The activity in the parasympathetic nervous system helps, among other things, to
reduce HR and increase activity in the stomach and intestines at the same time as
producing contractions in the pupils as well as in the bladder and intestine. In the
sympathetic nervous system there is a certain constant activity to maintain blood
pressure and heart activity. Increased activity occurs in the system when the body is
subject to stress and the internal homeostasis is disturbed. This may happen, for
example, with considerable mental and emotional strain, but also with hypothermia,
oxygen deficiency, muscular strain, or severe pain. The effects of increased sympa-
thetic activation are raised blood pressure, HR, and blood sugar levels; dilated pupils;
sweating; and contraction of surface blood vessels. Researchers usually describe this
reaction as a necessary adaptation for action, either through attack (fight) or flight,
and its purpose is to protect the body against urgent danger.

7.7  HYPOTHALAMUS–PITUITARY–ADRENAL AXIS

As a reaction to a mental stressor, the body also reacts—apart from the activity in the
autonomous nervous system described above—with an increased production of cor-
ticosteroids secreted from the adrenal cortex. Corticosteroids are divided into min-
eralcorticoids which regulate the salt balance of the body, and glucocorticoids which,
among other things, increase the amount of glucose (sugar) in the blood.
Glucocorticoids—the stress hormone cortisol is one—are internally secreted
from the adrenal cortex as a result of physical or mental stressors. The internal secre-
tion is preceded by activity in the HPA axis and its purpose is to maintain a physio-
logical reaction primarily associated with acute stress.
Apart from the fact that the glucose level is raised, greater glucocorticoid secre-
tion helps mobilize energy through activating a breakdown of carbohydrates, pro-
teins, and lipids (blood fats). When the glucocorticoid level is raised, cardiovascular
activity also increases at the same time as the anabolic processes associated with
Work with High Levels of Mental Strain 193

reproduction, growth, and immune defense slow down. Glucocorticoids also act as
an anti-inflammatory. The glucocorticoid cortisol enters the blood stream within a
few minutes after a stress stimulus, and bonds primarily (95%) to protein; the remain-
der circulates freely and bonds with different structures in the brain. In recent years,
cortisol has been the subject of intensive study in relation to the brain. Important
areas of the brain that have receptors for cortisol are the hippocampus, the amygdala,
the pituitary gland, the hypothalamus, and the prefrontal cortex. The hippocampus
is the structure that has attracted the greatest interest in research into the effects of
stress on our brain structures. This is because it has a large number of receptors for
cortisol, and is also involved in important cognitive processes (see Fact Box 7.4).

FACT BOX 7.4

STRESS AND THE INVOLVEMENT OF THE BRAIN
Several brain structures are involved in the HPA axis, and the internal secre-
tion of glucocorticoids from the adrenal cortex is thus controlled by the brain.
Information comes into the brain about homeostasis, and signals are integrated
into the brain structure called the hypothalamus. Various structures of the
brain which project to the hypothalamus include the amygdala and hippocam-
pus in the limbic system within the cerebrum. Under stress, these areas receive
information about somatosensory and visceral change, chemical levels in the
blood and, moreover, information of a more psychological nature, such as the
presence of threat, aggression, other emotions, and motivation. The base level
of glucocorticoids that the body always needs is governed partly by the area
in the hypothalamus called the suprachiasmatic nucleus. Information comes in
here about circadian rhythms in the form of light changes during the day (see
Chapter 8 on Diurnal Rhythm). The concentration of glucocorticoids follows
this rhythmicity, and changes during the day so that the level is lowest when
falling asleep and highest directly after waking up. It is therefore very impor-
tant to monitor this rhythmicity in connection with measuring the hormone
cortisol [McEwen 2006].

DO CHANGES IN THE HIPPOCAMPUS RESULT

FROM PROLONGED STRESS?
Interesting pieces on structural changes in the hippocampus are reviewed
[Alderson and Novack 2002], as well as [Sapolsky 2003; McEwen 2000b]. The
research situation is such that no certain correlation has been proved in humans
between high cortisol levels as a result of stress and neuron death (atrophy) in
the hippocampus. There is some support from, among other sources, an MRI
study of traumatized war veterans who were found to have smaller hippo-
campus volumes than corresponding healthy individuals [Gurvits et al. 1996;
Gilbertson et al. 2002]. In animal studies, atrophy—that is, the withering away
of the neuron—has been discovered in the hippocampus, which is an example
of the harmful effect of prolonged, repeated, and chronically high levels of
194 Occupational Physiology

glucocorticoids. Studies also show that raised concentrations of cortisol can

lead to harmful effects in the hippocampus in the form of increased vulner-
ability on the part of the neurons, a decline in neurogenesis—that is, a regen-
eration of neurons—and a smaller contact surface with other neurons through
the filaments of the neurons, the dendrites, being affected [Nordling 2003].

7.7.1  The Question is a Very Complex One

Researchers always emphasize the complexity in the process contributing to struc-
tural changes in the hippocampus (and also the prefrontal cortex) as a result of stress
and the fact that, for example, cortisol is only one among many other processes affect-
ing the harmful course of events. Moreover, there are divided opinions on why struc-
tural changes would arise in the hippocampus as a result of overexposure to cortisol.
Even low levels of cortisol have been shown to disturb the HPA axis and to pro-
duce negative effects on the hippocampus. This has been proved in certain cases of
PTSD. The mechanism has, however, not been explained. Recently, research has
drawn attention to the relationship between PTSD and the structural changes in the
hippocampus associated with the symptoms. A twin study indicates that a smaller
hippocampus volume may be the cause of greater sensitivity to PTSD. In this way,
the size of the hippocampus may have a significant role even in the development of
mental trauma and may thus be linked to an individual’s vulnerability to stress. This
can be compared with other theories that the structure undergoes morphological
changes after a trauma and, therefore as a consequence of stress acts as a kind of
“trauma memory.” A great deal of research remains to be done before we can gain
clarity into how the brain is affected by stress, and as the heading indicates, the ques-
tion is a very complex one.

7.7.2  Interplay between the SAM System and HPA Axis, and Saliva
Cortisol Relations to Health
How the interplay between the two systems occurs is not entirely understood, but it is
probable that it is not a question of two independent systems. Research has shown, for
example, that norepinephrine from the SAM system can also stimulate activity in the
HPA axis. What is more, it has come to light that the same hormones regulating activ-
ity in the HPA axis (CRH) also affect the release of adrenaline and norepinephrine
from the SAM system. The time it takes for cortisol to be secreted in a stress reaction
is several minutes. This can be compared with the rapid catecholamines adrenalin
and norepinephrine, which are released within seconds of exposure to a stressor. As a
result of, among other things, this delay in releasing cortisol, several researchers have
asked themselves what function cortisol really performs. Is the hormone part of the
stress reaction in itself, or does cortisol have a longer term, protective effect on those
processes arising in a stress reaction? Both explanations are usually put forward as
probable, and possibly cortisol fulfills both functions (see Fact Box 7.5).
Work with High Levels of Mental Strain 195

FACT BOX 7.5

(A) Cortisol mobilizes energy and inhibits anabolic processes that are not
immediately needed (in acute stress) to handle the stressor, which may be
regarded as a strategic adaptation at the precise moment of stress. (B) The
immune defense is inhibited so as to protect the individual against the harm-
ful effects of the stress reaction in a longer-term perspective (with protracted
stress) [Nordling 2003, pp. 16–18].

In work-related studies, saliva cortisol is an often-used measure. Recently,

[Kristenson et  al. 2011] have reviewed this literature. They conclude that it is
apparent that single measures of absolute concentrations of salivary cortisol, for
most health-related variables, seldom give significant findings; deviation mea-
sures, in terms of diurnal deviations and/or laboratory stress tests seem to be more
strongly and consistently associated with a number of factors, such as socioeco-
nomic status, psychological characteristics, biological variables in terms of over-
weight and abdominal fat accumulation, and mental and somatic disease. Across
disorders, the pattern related to ill-health/stress is generally characterized by a
flatter diurnal cortisol curve, which in most cases is due to attenuated morning
and/or increased evening levels, or a reduced response to a laboratory stress test.
For some specific questions, single mean values seem to provide valuable informa-
tion, but in all cases a careful design in terms of power and standardization is
important. However, the authors conclude: “thus, salivary cortisol can be a useful
biomarker in many settings, if caution is taken in the choice of methods used.”

7.7.3  Connection between Stress and Cognition

Stress research has long attempted to study the connections between various psy-
chosocial loads and stress reactions. At the same time, it has been observed that
different individuals react with widely varying physiological responses, for exam-
ple, to such exposure. Consequently, not everyone reacts in the same way, even if
the exposure appears superficially to be the same for everyone. We have a brain
that, in a psychological sense, has encoded various experiences during our lives,
and which from a biological perspective has neurons that are connected in differ-
ent ways. These psychological and biological differences between individuals
mean that people at work identify and deal with challenges in the most varied
ways. The brain has been something of a “black box” within stress research for a
long period, but where contributions from the cognitive and neurocognitive sci-
ences have greatly contributed to a growth in knowledge in recent years. Research
shows that cortisol secreted in the stress response affects certain cognitive func-
tions (see Fact Boxes 7.3 and 7.4). The results are, however, not entirely clear cut as
regards which functions are affected and what period of time that changes follow.
There is, however, a great deal of evidence to suggest that the cognitive effect as a
result of stress is selective, and in this way certain functions may be affected in a
situation at the same time as others remain intact. In order to investigate the effects
196 Occupational Physiology

of cortisol on cognitive functions, research subjects have either been exposed to

experimentally induced stress, had a pharmacologically induced rise in their cor-
tisol levels, or already showed changes in their cortisol levels as a result of illness.
Cognitive functions that have been proved to deteriorate are the declarative mem-
ory (see more on different types of memory later in this chapter) and the working
memory, divided and selective attention, concentration and learning, and verbal
representation. The outcomes of the various studies are not clearcut, and among
the functions mentioned is also an altered cognitive capacity as a result of high
cortisol levels.

7.7.4  Stress and Cognitive Performance

The general pattern for how cognitive performance is affected by increasing expo-
sure to corticosteroids is an inverted U-shaped function. A deficiency in stress
hormones makes for poorer cognitive performance which is also produced by
exaggeratedly high levels. At moderate levels of stress hormone, cognitive perfor-
mance may on the other hand be improved. This inverted U was described using
simpler methods (e.g., measuring the pulse) as far back as the early 1900s, and
came to be called Yerkes−Dodson’s Law of Motivation, which says that there is an
inverted U correlation between the level of exertion and the level of performance.

7.8  W
 ORK ORGANIZATION CONDITIONS IMPACTING
ON MENTAL LOAD
If the work organization circumstances at a workplace are not good, they constitute
stressors, which may lead to stress reactions of a kind described earlier in this chapter.
When the concept of psychosocial work environment is used in the context of
working life, attention is drawn to the need for a holistic view of people at work. First
and foremost, people are studied in relation to factors that specifically affect their
work, even if the balance between work and leisure time has been studied more
intensively in recent years [Nylen et  al. 2007]. Below we attempt to exemplify
Victoria’s work, which was described in the introduction, within areas relating to the
circumstances of a psychosocial nature in the organization of the work.
Organizational characteristics. This is where the organization is often described
from the perspective of a matrix (project-oriented) or line organization, for instance—
hierarchical or flat organizational structures, respectively. What does the hospital’s
organization look like; is it hierarchical or flat or does it have some other form? What
position does a newly qualified doctor like Victoria have in this hierarchy?
Work content. The content is reflected in descriptions of workload, repetitive
tasks, influence and control, cognitive or mental load. How is Victoria able to influ-
ence her work situation? Can she change her tasks, and in that case does she need
to have this confirmed by a superior? Can she stop operating if she feels tired?
Interpersonal relationships. This relates to the degree of support from work col-
leagues, subordinates, and superiors at the workplace. What does Victoria’s support
from management and work colleagues look like? Is this support stronger for exam-
ple from the nurses than from the management?
Work with High Levels of Mental Strain 197

The temporal design of work tasks. This relates to the organization’s planned
working hours, work cycles, and shift work. Does Victoria work at night? What is the
planned length of time she is allowed for each patient?
Overtime. Treated in the same way as working hours, but here in the sense of
overtime work. In Victoria’s case we can define overtime work as working hours not
planned by the organization; that is, Victoria has to work longer to look after acutely
ill patients who quite simply cannot be handed over to a replacement.
Economy. Are, for example, the replacement levels, salary systems and contract
systems satisfactory? Does Victoria earn a reasonable salary in relation to the vari-
ous demands of her job?
Work status. Does the work have status and value for the individual seen from the
perspective of those around them, that is, how is Victoria’s work valued by other
people?

7.8.1  Common Psychosocial Models

One of the best-known models used in research into the role of psychosocial factors
in health in larger populations is the so-called Demand and Control model. Its origi-
nators [Karasek and Theorell 1990], have constructed this model as a four-field
­diagram (Figure 7.2), in which various types of work are placed with psychological
demands on the vertical scale and control (decision latitude, powers) on the ­horizontal
High

Active Tense
Different demands

Low

Relaxed Passive

High Low

Control/authority over decisions

FIGURE 7.2  The Demand and Control model describes the psychosocial load at work.
Reducing the demands of work is not always the best solution to avoid stress. Greater control
over the work situation may be the solution. A further dimension which is sometimes to be
found in the model has to do with social support, which is assumed to play an important role
for how one experiences stress. (Modified from Karasek RA. and Theorell, T. 1990. Healthy
Work—Stress Productivity and the Construction of Working Life. New York: Basic Press.)
198 Occupational Physiology

What is the price? What do l gain in return?

FIGURE 7.3  The Effort−Reward model describes the notion that, if the individual works
under great time pressure, or if the work is very demanding, for example, overtime work
(effort), this must be balanced by their being treated with respect by superiors and co-work-
ers, and receiving support in difficult situations (reward). Otherwise considerable stress is
caused as a result of the lack of a reward. Illustration: Niklas Hofvander.

scale. Examples of occupations making considerable psychological demands are

those with a very high work rate on assembly lines, other industrial work with a high
work rate, and those involving uncertainty about continued employment and service
occupations. These occupations are characterized by heavy demands in combination
with low control, not only as regards the job but also as regards social and informal
contacts at the workplace.
In conditions such as these, a great deal of tension is assumed to arise and to be
maintained during a period when nothing at work gives any scope for activity to
reduce the tension. It is assumed to continue as a “psychological or mental tension,”
which has consequences both for physical and mental health. A commonly occurring
model which is easier to describe from an individual perspective—from the perspec-
tive of our friend Victoria, for example—is the so-called Effort–Reward model
[Siegrist 1996]. Its originator, Johannes Siegrist, considers that there must be a bal-
ance between the effort demanded by the task and the reward the individual receives
for carrying out that task (Figure 7.3).
The model has its origins in part in the aforementioned Demand and Control
model, but focuses on reward rather than on control. It also has similarities with
other previous individually oriented stress models, for example, Lazarus’ contribu-
tion (see Figure 7.4). Sigesrist’s model may be said to take into account Victoria’s
interplay between external factors in the environment (the demands and duties facing

External demands Individual capacity/resources

FIGURE 7.4  The Demand–Resource Model is often illustrated in the form of an old-fash-
ioned pair of scales. If the individual’s ability weighs light in comparison with the weight
from the demands of their surroundings, or if these demands are regarded as light in relation
to the individual’s ability, stress results. It is best if the demands and the ability are matched,
in balance. Illustration: Niklas Hofvander.
Work with High Levels of Mental Strain 199

Victoria, namely demands made by the hospital and the chief consultant and the
patient’s needs) and internal factors in the form of the individual’s ability to cope
with these on the one hand (e.g., Victoria’s need for control and ability to cope with
stress) and, on the other, those factors comprising compensation or reward for her
efforts (does Victoria know, e.g., that she receives financial rewards, recognition, or
status commensurate with the demands made on her?)
A more individualistic and cognitive model that partly originates from a pioneer
of stress research is Richard Lazarus’ model [Lazarus 1966]. This cognitively ori-
ented model focuses on the fact that, when the individual is faced with demands from
their surroundings, the brain makes an assessment: Is this important for me? Can I
cope with it? Can I use my abilities? A Swedish pioneer, Marianne Frankenhaeuser,
used to express the consequences of the model in the following way: “If there is a
balance between demands and one’s own ability, the challenges feel stimulating and
one may experience positive stress. But if the demands are too high or too low, the
stress can become a torment” [Nylen et al. 2007].

7.8.2  Psychosocial Environment is Perceived in Different Ways

In order for a psychosocial demand to be perceived by the individual, it has to have
some significance; that is, it must have cognitive content. For Victoria, different psy-
chosocial demands are in many ways a more “invisible” or intangible load, and for
this reason are difficult to provide with intelligible content, unlike more physical
loads. When researchers measure the effects of the impact of different psychosocial
factors on different individuals at the same time, we always find individual reaction
patterns. One reason may be that what Victoria experiences as time pressure is not
experienced in the same way by her colleagues, which is why they of course have
different reaction patterns. But even if Victoria and her colleagues were to experi-
ence time pressure in exactly the same way, they react in very different ways physi-
cally and mentally, which we described in a physiological sense earlier in this
chapter. For the time being, we may note that, as Victoria has learnt from previous
experiences and as these experiences differ from those of her colleagues, she remem-
bers, behaves, and reacts differently to psychosocial challenges. The psychosocial
challenges have, quite simply, different cognitive content for Victoria and for her col-
leagues. Nor are we equal in a biological science (e.g., the neurons in our brains are
not connected in the same way). The physically delimited workplace is therefore
experienced differently by different people. For example, not all individuals at a
physically delimited workplace find the work interesting or experience stress. This
means that a workplace in the singular does not exist in any sense if we ask more
than one individual about their workplace.

7.9  COGNITIVE LOAD

Biologically different cognitive loads (see the previous section on the SAM system
and HPA axis, for example) may imply stresses that alter or threaten to alter the
“internal environment” of the body, for example, in the form of a hormonal or endo-
crinal change or as a physiological load on the processes within the central nervous
200 Occupational Physiology

system (CNS). Psychologically one can see a load within the cognitive systems,
which can be measured in the form of a measurement of performance, concentration,
involvement, and different kinds of memory capacities.
It is on the whole difficult to imagine any job which does not involve both physical
and cognitive/mental loads and challenges. The slaughterhouse worker (Chapter 5)
has a job characterized by manual handling involving major muscle groups such as
the muscles of the torso and legs. Physical load may result in considerable strains on
his musculoskeletal system; for example, on his muscles, joints, tendons, and liga-
ments. But working in a slaughterhouse also implies a cognitive load, as the demands
for precision and perhaps also the feeling of being under time pressure may be pro-
nounced. Tasks demanding both precision and speed are jobs that imply that mis-
takes may occur. In the case of the butcher, this would perhaps be in the form of cuts
if his knife slips. Just as the physical load varies, the cognitive load in all probability
changes, for example, depending on what part of the animal is being butchered. The
greater the precision required, the more cognitive resources have to be allocated, and
the more refined the motor feedback required for the task. From a cognitive perspec-
tive, the brain works in different ways depending on whether what the butcher is
working on is connected with learning something new or whether the action is auto-
mated (routine tasks). If the action is strongly automated, the work as a rule is carried
out at what memory research calls a procedural memory level (read more about pro-
cedural memory level in the next section). Something that, on the other hand, is quite
new or unexpected requires greater mental effort and closer attention to be able to
carry out the work. In order to be able to do two things simultaneously, it is neces-
sary that these are automated, so that neither of them requires one’s total attention.
This is not least important in occupations where the risk of injury is high. As the
working memory, which could be said to be a measure of the processing capacity of
our thinking, is limited, there is not a great deal over for anything else when the
butcher devotes himself to what is not automated. A high allocation of cognitive
resources is, for example, found in a job constantly requiring the individual to have
a very limited opportunity of thinking of anything other than what must be carried
out at that precise moment.

7.10  R
 OUTINE WORK IS CARRIED OUT AT THE LEVEL
OF PROCEDURAL MEMORY
All work, now as in earlier times, involves forms of mental or cognitive load. Care
professions (Chapter 3), the work of the electrician (Chapter 4), and the building
worker (Chapter 9), working on computers (Chapter 6), the work of the long-distance
lorry driver and bicycle messenger (Chapters 2 and 8), all challenge cognitive sys-
tems in different ways and different tasks at different moments, for example, one
work cycle. If there is no danger (e.g., icy roads) present, it could be said that an
experienced bicycle messenger or driver is working on an automated level, or proce-
dural memory level (read more about procedural memory in the next section).
Characteristic of this level is that the work can be carried out at the same time as it
is possible to think about something else. That is to say, an experienced bicycle mes-
senger at work, when the weather is good and there is little traffic, can be thinking
Work with High Levels of Mental Strain 201

TABLE 7.1
Examples of Sources of Information to which a Bus Driver Needs Access in
Order to Control his Vehicle
Sources of bodily information—that is, sources Cognitive sources of cognitive information—
of the kind that do not require conscious that is, sources of the kind requiring more
assessment, or require very little conscious advanced assessment.
assessment. After it is memorized, this information is retained
Sensory skin input at a procedural level, but rapidly climbs to
Motor feedback higher levels and processing, for example, in
Balance sensations related to movement of the bus case of danger.
Fatigue/wakefulness Status of various instruments
Situation of the passengers
Noise/vibrations
Light conditions
Position of the bus
GPS
Relative speed
Fuel
Surroundings
Geography
Weather/road conditions
Traffic density
Time

about things completely different from his work. But even at this level it is necessary
for a driver, for example, to use many different sources of information to be able to
drive his vehicle safely. In Table 7.1, examples are provided of various sources of
information of this kind.
As soon as a cognitive information source indicates a deviation from the normal
(e.g., the road surface suddenly becomes icy), the automated level is abandoned, and
cognitive structures dealing with more complex information take over; the cognitive
load increases. It may be similar for the doctor, Victoria. An operation which is
almost routine suddenly becomes dramatic as a result of unexpected internal bleed-
ing in the patient. This increase in cognitive load also launches our stress systems in
the way described previously.

7.10.1  Organization of Work from a Cognitive Perspective

Changes in production processes can be described from a cognitive perspective.
New forms of production imply that anyone who has worked and thought in a par-
ticular way will have to think in a different way in a new form of production. The
“Ford” assembly line used in the car industry (sometimes a little inaccurately called
the Taylor line), with its relatively simple and short physically executed work cycles,
was considered by many people to be belittling, as the individual was regarded like
a robot who could be replaced when worn out. The operations were considered to be
so easy to carry out that no mental activity seemed to be needed, that is to say,
202 Occupational Physiology

thought and action could be separated. The work was carried out at the procedural
memory level. During the 1970s, many of these traditional assembly lines were
replaced by autonomous work teams with job enlargement in the form of larger units,
greater responsibility for quality, and longer work cycles. This method of working
made quite different cognitive demands and resulted in different mental loads from
the more traditional assembly line. Individual people had to plan their work in a dif-
ferent way from previously; planning needs the ability to think ahead—that is, to
make use of what within memory cognition research is called prospective memory.
Prospective memory has to do with the fact that that what has to be remembered
occurs in the future, for example, remembering to submit the stores report before a
specific date. Prospective memory can help us to reduce stress, as with the aid of
planning for the future we can prevent what is worrying us from becoming as serious
as it would have been without any planning. On the other hand, in situations in which
we feel more helpless, for example, the threat of losing our jobs, prospective memory
helps create anxiety. Other cognitive abilities or memories also need to be used in an
increasingly complex process and these affect, for example, the declarative memory,
which helps us to verbalize, for instance, complex processes so that all learning does
not need to be done completely from scratch, and shortcuts for how the work is to be
carried out can be transferred between experienced and inexperienced co-workers.
In the increasingly complex environment greater demands are also made on seman-
tic and episodic memories, which both, roughly speaking, have to do with learning
and remembering specific and more general factual information about the work pro-
cess [Melin 2003].
Traditional assembly line work in this way became more cognitively complex and
thought and action became more intertwined. The more intertwined the higher cog-
nitive levels were with the action itself, the higher the cognitive involvement and less
scope to think about anything other than a single consequence. It is a good thing if
the work content leading to the cognitive involvement is felt to be interesting, mean-
ingful, and contributes to development. It is not as good if the work content lead to
cognitive involvement perceived as uninteresting or monotonously repetitive. Then
we can talk of a mental or cognitive strain rather than work which is cognitively
stimulating. An information flow leading to a constant cognitive involvement results
in the individual having a very limited opportunity for thinking of anything other
than what has to be carried out at that moment. If this information flow is felt to be
monotonously uninteresting, we have a work situation that is difficult to manage and
which in the long term becomes a cognitive strain. One question is whether jobs
today contain “more” cognitive strains of the kind that is described above. From this
perspective the increased establishment of call centres, for instance, is interesting
(Chapter 6).
The ability of using one’s senses to absorb and manage technically transmitted
information mentally or cognitively has become an increasingly important part of
most occupations today. This is the case not least within nursing care, with the intro-
duction of electronic records and referral management, appointment systems, and
computerized financial accounting systems. At the same time as technical systems
are becoming ever more common within occupations involving people contact,
another trend in industry may be noted, where one sees increasing elements of social
Work with High Levels of Mental Strain 203

demands. One study [Melin et al. 1999] shows that, at industrial workplaces where
earlier research has been taken on board, and among other things modern job rota-
tion has been introduced with longer and more varied work cycles, this leads to
greater demands for social interaction and cooperation. By rearranging the work at a
car assembly plant according to new research recommendations, the workers became
less tired during their shift and had lower pulse rates and fewer stress hormones in
their blood. In addition, the car fitters could relax better after work and recover more
quickly. There was only one thing that the workers thought needed extra effort, and
that was on the social plane. They were forced to interact more with their workmates
in order to coordinate the work, which could sometimes lead to minor conflicts.
These observations agree well with the trends that many people can see, namely
that the mental strain is increased but in a different way, within the care professions
and in industrial occupations. This applies, among others, to mental demands as a
result of new technical systems in nursing, for example, and—within industry—
greater mental demands as a result of the demands for social competence. These
greater demands for social ability apply not merely to “workers of the future,” who
move between short project jobs and are dependent on well-developed networks, but
may therefore also come to affect employees in traditional manual work.
The psychosocial environment, and thereby the cognitive strains, have undergone
major change over time, while the stress reactions remain the same. This applies
both to assembly lines and nursing. The doctor, Victoria, is presumably cognitively
challenged and has mental strains in a different way from those of her colleagues just
a few years ago. The mental load originates, on the one hand, from the work with
patients itself, and on the other, to a large extent from comprehensive organizational
changes and new IT-related administrative operating systems that have to be used by
the doctors themselves.

7.10.2  Link between Behaviour and Cognitive Load

Within research there is no conceptual agreement as to what is considered to be
mental or cognitive load. Concepts such as mental variation occur frequently in con-
nection with repetitive work in an industrial environment. Many industrial occupa-
tions involving assembly and packaging may be characterized as repetitive and
monotonous, which are factors increasing the risk of developing musculoskeletal
problems, in particular in the upper extremities. For this reason, an increase in varia-
tion in the work, both physical and mental, is often suggested in connection with the
process of change within the industry.
Job enlargement, for example, job rotation, a different pattern of breaks, and an
incentive to interrupt repetitive movements, are frequent proposals within this type
of industrial occupation so as in this way to achieve greater variation. In other work-
ing environments, for example, those that are strongly computerized such as work in
control rooms, but also many service occupations that are not primarily regarded as
physically demanding, the concept of cognitive load is used without direct reference
to variation. What might be meant by cognitive load is, for example, that the com-
puter users have to exert themselves mentally, for example, in order to retain the
instructions in their memory. A high cognitive load arises, for instance, if the system
204 Occupational Physiology

does not provide support to the user, and the users themselves have to remember the
elements. In order to avoid this, it is usual to suggest, for example, having drop-down
menus where the user’s various alternatives are visible. Here the point of reference is
the encounter between the different mental models of the system designer and the
user. In other words, the user has a mental model of the system that has been created
according to the user’s own tasks, previous experience, documentation, education,
what the system looks like and how it behaves. On the other hand, the system designer
also has a mental model, but this is created on the basis of how the system is con-
structed, for example, with different procedures, functions, access routes or database
structures, and also on the basis of what the system looks like graphically. The
designer’s model and the user’s model do not correspond, and a discrepancy arises,
which is why many cognitive resources have to be allocated on the part of the user to
adapt to the system.

7.10.3  Link between Cognition and Emotion

Distinguishing cognition from emotion is a classic problem, for which there is no
space for discussion within the framework of this chapter. The finely calibrated
facial expressions of the human face are unique to us. In many species, as in human
beings, a common emotional expression is, for example, to shrug the shoulders in
cases of threat. Birds raise their wings and fur-bearing animals bristle. It should be
emphasized that cognitive stress is rarely disconnected from the emotional features
of our everyday lives. Often cognitive stress (e.g., the feeling of being under time
pressure) is used as if the phenomenon was free of emotional charge. The experience
of time pressure, for example, is unique to a being that has the cognitive ability to
comprehend time. Human beings have the ability to understand clock time, and
therefore a purely cognitive ability. For Victoria, time pressure is something more
than experiencing the difficulty of finding time for something vital, maybe a patient
who needs care—and it thereby becomes an emotionally loaded stressor. Time pres-
sure of work can therefore not merely be regarded as a clearly cognitive stress, but
also as a strongly emotionally charged stressor, which is why there are reasons to
assume that as soon as we talk about cognitive or mental load, it is also a question of
emotional stress and not merely cognitive stress.

7.11  M
 ENTAL LOAD: EFFECTS ON THE
MUSCULOSKELETAL SYSTEM
The American physiologist and pioneer in the field of stress research, Walter B.
Cannon, wrote at the beginning of the last century that muscle tension in the body is
an appropriate reaction when we are subject to stress and threats. This muscle reac-
tion makes possible a greater readiness to cope with impending danger. As early as
the 1930s, some experimental studies were made on human beings that, with the
methodology of that time, studied muscle activity in relation to mental stress. Among
others, so-called focus attention studies were carried out, which for instance mean
that individuals at rest had to imagine themselves lifting various objects. Greater
muscle activity could be registered in the muscles relating to the lifts the individual
Work with High Levels of Mental Strain 205

was imagining. In a study of this kind a kind of dose–response correlation was

found; the heavier the object the individual imagined that they were lifting, the
greater the muscle activity. Based on a hypothesis that deaf people, who used sign
language to a greater extent than those who could hear, would show greater activity
in the muscles of the hand also during “non-verbal” problem-solving tasks, it was
discovered that this was indeed the case, using the most modern methods of the time.

7.11.1  Mental Load and Muscle Activity

As work generally always involves a certain measure of physically induced muscle
activity, it is interesting to ask whether mental stress contributes to greater activity in
the trapezius apart from the pre-existing physical load [Melin and Lundberg 1997;
Lundberg 2002]. Several studies have been carried out to investigate this. An example
of studies of this kind is a relatively early one in which an attempt was made to keep
the physical load constant during two different experimental situations while a stress-
ful mental arithmetic task was imposed in one of the situations. The constant physical
load consisted of the subjects having to move not particularly heavy balls between
two containers. Muscle activity monitored using EMG (see Chapter 6, Section 6.12.6)
showed a very strong increase in activity in the trapezius (75% increase) in the com-
bination of moving the balls and doing mental arithmetic compared with merely mov-
ing the balls. A similar increase in activity, though not as strong, has been measured
in other studies. Among other things, training sessions and competitive sessions have
been compared for pistol-shooters. Here the weight of the pistol comprises the con-
stant physical load and the element of competition the mental load, while the training
session involves less mental stress. The training session generated greater activity in
the trapezius both just before the competition session and during the training session.
Similar patterns have been found in female checkout staff, which showed that mental
stress combined with physical stress resulted in greater muscle activity than the pres-
ence of physical stress or mental stress alone. In some studies varying degrees of
difficulty at work have been studied in work at computer terminals, where it is possi-
ble to see a pattern characterized as follows: the higher the degree of difficulty, the
higher the muscle activity. A common way of studying the degree of cognitive com-
plexity is to use what is called the Stroop test. This test provides conflicting informa-
tion that generates stress in the test subjects. In several studies the test has been shown
to lead to increased EMG activity beyond what has already been produced by rela-
tively low physical load. In a Danish study, among others, the Stroop test was used in
conjunction with work on a computer. The researchers found greater muscle activity
in the trapezius both when using the mouse and the keyboard.
In other studies the degree of cognitive/mental complexity has been varied. In one
experiment the complexity was varied between two levels (low and high complexity)
in conjunction with a reaction time test on a computer monitor. Here it was found
that, generally speaking, all the test subjects reacted with a somewhat raised EMG
activity under both sets of conditions. When the degrees of complexity were com-
pared, it was found that eight out of the 18 test subjects in repeated provocations
consistently generated a higher EMG activity in the trapezius at a high degree of
complexity compared with activity at a low degree of complexity, while other
206 Occupational Physiology

s­ ubjects showed a more varied pattern. An experimental study of female checkout

staff in a department store showed that cognitive load combined with physical stress
resulted in greater EMG activity than the presence of physical stress or mental stress
alone.
Emotion has been studied in the form of anxiety when faced with an unpre-
pared oral presentation on the part of 42 male university students. The study was
intended to investigate physiological reactions during and after preparations and
to compare extroverted with introverted individuals. One of the physiological
measurements was surface EMG activity in the trapezius. Introverts increased
their muscle activity more during preparations than extroverts. Introverts also
found it more difficult to reduce their muscle activity during the stipulated rest that
followed the preparations.
There are also studies showing no effects of a cognitive load above the level to
which the physical load alone contributed. Presumably, the cognitive load does not
contribute to any further measurable muscle tension if the physical load is high. How
mental load and light physical loads may contribute to disturbance and pain in the
muscles is shown in Chapter 6.

7.12  PHYSIOLOGICAL MEASURES OF MENTAL LOAD

Today there are different brain imaging technologies that provide a great deal of
information about how various brain structures are involved in the stress process.

7.12.1  Brain Imaging Technologies

Magnetic resonance tomography (MRT) works in such a way that the resonance
imaging camera causes the hydrogen nuclei in the body to change their magnetiza-
tion with the help of a combination of magnetic fields and radio waves (RF pulses).
After each RF pulse the atomic nuclei revert to their original magnetization, emitting
radio waves at the same time. The radio waves are picked up by an antenna, and a
computer converts the information into a series of cross-sectional pictures. An
example is studies of the differences in oxygen content arising in the brain during a
certain challenge/function. For example, the MR signal in the motor centre of the
brain changes when a finger is moved. This is called functional magnetic resonance
imaging.
Positron emission tomography (PET) studies are used primarily to discover and
locate tumors. The technology has also been used in stress research. This technology
measures, among other things, blood flow and the use of glucose in various organs,
primarily in the brain and heart.

7.12.2  Brain Activity

Brain activity is a good measure for studying cognitive demands at work in certain
restricted situations. The electroencephalogram (EEG)—that is, a representation of
the electrical activity of the brain—is often used as a measure of brain work in cog-
nitive tasks. The EEG spectrum is analysed to determine how high the activity is
Work with High Levels of Mental Strain 207

when performing various cognitive tasks. By recording activity at the same time
using electrodes at several points on the crown of the head, one can produce a topo-
graphical map showing the distribution of electrical activity across the crown.
Examining these topographical maps shows which parts of the brain are active dur-
ing different periods of a complex work process under high mental work load. What
is primarily studied is how the effect changes in the so-called alpha and delta bands.
The others are the theta and beta bands. Mental work loads reduce the effect in the
alpha band and increase the effect in the delta band. EEG as a method is very sensi-
tive to blinking and head movements. These movements therefore have to be mea-
sured and, by using computer programmes, the effects to which they give rise have
to be filtered out.

7.13  MORE INDIRECT METHODS

Cognitive load can, as has previously been described, be seen as a strain on the pro-
cesses in the CNS. For this reason, there are possibilities that the load on the CNS
also affects physical processes other than those directly linked to information pro-
cessing in the system. This gives us opportunities to measure indirectly the cognitive
work load with the aid of physiological indicators. Some examples are given below.

7.13.1  Heart Rate

HR or pulse is a commonly used indicator of mental workload. When the mental
load increases, the pulse also increases. The two most common methods of mea-
suring pulse are HR, which is quite simply the number of heart beats per minute,
and Interbeat Interval (IBI), where the time between beats is measured. The moni-
toring equipment required is relatively simple, but one has to be aware that the
very simplest equipment sometimes measures the pulse as an average over too long
a period, which can lead to the loss of important information. One method of
acquiring good data is to measure IBI continually with EKG and subsequently
convert to HR. Then we get both a high degree of accuracy and a measure which
is easy to relate to HR. As the main task of the heart is to provide the body with
blood, there is a risk that results become misleading if major changes occur in the
physical load during or between tests. One can therefore advantageously supple-
ment HR with methods that measure movement, for example, with actigraphic
monitoring (see also Chapter 6, Section 6.12). If there is a high correlation between,
for example, body movement measured using actigraphy and pulse, it is probable
that an increase in pulse will result from the movements in themselves and not
from the mental load. A simple method for monitoring HR is to use the so-called
pulse clocks (Chapter 6, Section 6.12).

7.13.2  Heart Rate Variability

Heart rate variability, HRV, has been used as a measure of mental work load. What
we mean by HRV is the periodicity by which the HR varies. Normally, this is five to
ten times a minute. High cognitive activity is assumed to reduce HRV.
208 Occupational Physiology

Some researchers are doubtful about using HRV in complex cognitive tasks. They
consider that such tasks reduce HRV so much that it reaches a level where it cannot
decrease any more, and thereby no longer functions as a measure of load. Other
researchers consider that the use of the technique for monitoring cognitive load
should be avoided, as research indicates that it measures emotional rather than cog-
nitive work load.

7.13.3  Sweat Gland Activity

The sweat glands are found in large numbers in the palms of the hands and on the
bottom of the feet. Galvanic skin response is used to measure sweat gland reaction
activity in the skin. The skin’s conductivity changes when people react—consciously
or unconsciously—to mental load and emotions. The emotion that arises, even before
it reaches the conscious stage, creates a reaction in the skin. The method therefore
registers changes very quickly. In the conscious phase we often notice ourselves
sweating.

7.13.4  Blink Rate

Blink rate is a common measure in research into mental load. Blink rate tends to
decline when visual demands increase. This is a result of being practically blind dur-
ing the period that the eyelid is closed, which leads to the possibility of discovering
important visual events increasing as blink rate decreases.

7.13.5  Pupil Dilation

Research has shown that the pupil increases in diameter when mental load increases.

7.13.6  Random Eye Movements (Entropy)

When mental workload increases, random eye movements tend to decrease. This is
measured by equipment that registers where one is looking and the fact that one then
analyzes the pattern one sees.

7.13.7  Breathing
Breathing involves several parameters that can be used to monitor mental workload.
Airflow, air volume, temperature, and variation in inhaling and exhaling can be
monitored. As the monitoring is disturbed by speech, its use is limited in many con-
texts. The method is used in such things as studying cognitive load in connection
with computer work. The gas exchange between the lungs and the blood is also
studied.

7.13.8  Electromyography
See Chapter 6, Section 6.12.6.
Work with High Levels of Mental Strain 209

7.13.9  Hormones
As described earlier in the chapter, the monitoring of stress hormones is frequently
carried out in connection with research-related stress studies (see the descriptions of
SAM and the HPA axis earlier in the chapter).

7.14  SUBJECTIVE MEASURES OF MENTAL LOAD

Subjective methods have proved to be particularly relevant for monitoring mental
workload, but there is no method that works by itself in all situations [Gawron
2000]. Some methods are very similar to each other, others are very different. Some
use broader questionnaires, whereas others use more specific scales for monitoring
specific work situations. Examples of the latter are: The Cooper-Harper Rating
Scale, the Bedford Workload Scale, the Overall Workload Scale, the NASA TLX,
and the SWAT [Hancock and Meshkati 1988].

7.14.1  Cooper–Harper Rating Scale

The Cooper−Harper scale has the form of a tree diagram. It was created in 1969 by
George Cooper and Bob Harper, two test pilots from the United States. The intention
was to create a method for evaluating new or modified (primarily military) aircraft as
regards how easy the plane was to handle in different situations. It also provides a
measure of how great a mental load the pilot is experiencing. The Cooper−Harper
scale is divided into 10 steps, where one represents excellent properties (very low
mental workload) and 10 represents major deficiencies (overload). The Cooper−
Harper scale is something of a standard scale for evaluating the handling characteris-
tics of an aircraft in different situations. It measures both performance and mental
workload and is relatively simple to use.

7.14.2  Modified Cooper—Harper Rating Scale and

Bedford Workload Scale
The Modified Cooper−Harper Scale (MCH) was developed to be used in those
cases where the task was not primarily motor or psychomotor. A scale was needed
that better captured cognitive functions such as, for example, perception, observa-
tion, evaluation, communication, and problem-solving. In brief, the following
changes were introduced: the terminology was modified in the tree diagram; the
endpoints of the scale were changed to “very easy” and “impossible,” and the pilots
were asked to assess the mental workload rather than the effort required to control
the aircraft. The Bedford Workload Scale is a modification of the original Cooper−
Harper scale. The structure is similar to the Cooper−Harper scale with a tree struc-
ture, but the terminology has been changed. The individual has to decide whether
the task could be completed, whether the mental workload was acceptable, or
whether it was satisfactory without a reduction of the load. The scale uses an
assessed reserve capacity on the part of the pilot during different situations to assess
their mental workload.
210 Occupational Physiology

7.14.3  Overall Workload Scale

The Overall Workload (OW) Scale is a bipolar scale (ranging between “very low”
and “very high” from left to right), on which test subjects estimate their mental load
over 20 steps.

7.14.4  NASA TLX

In the NASA Task Load Index (TLX) six dimensions are used to measure workload:
mental demand, physical demand, time pressure, how well the task was carried out
(performance), exertion, and frustration. The concept of workload is used here
instead of mental workload. This is because NASA-TLX is a so-called multidimen-
sional method, which attempts to capture more aspects of the concept of workload—
physical demands, for example.

7.14.5  SWAT
SWAT (Subjective Workload Assessment Technique) is, like NASA-TLX, a multidi-
mensional scale. In trials with SWAT, three scales were used with three steps in
each. The scales are: (1) time pressure, which reflects the time available for planning,
carrying out and supervising a project; (2) mental load, which assesses how much
conscious mental effort is required to carry out a task; and (3) psychological stress
load, which estimates how much confusion, frustration, risk, and anxiety is associ-
ated with the trial.

7.14.6  Broader Subjective Instruments

Then there are a number of instruments to monitor stress in a wider perspective.
Earlier in the chapter mention was made of Karasek’s and Theorell’s model, and
Siegrist’s and Frankenhaeuser’s models. There are variants of the questionnaires and
scales for these models. One might add Spielberg’s and Vagg’s “Job Stress Survey,”
which is also to be found in several languages, and which aims to identify the sources
of work-related stress at the workplace [Spielberg and Vagg 1999]. The instrument is
answered first as regards how seriously various stressors are felt to be, and subse-
quently a decision is made on how often they occur. In this way, information is
acquired about the degree of seriousness and frequency of the stressors.

7.15  WHAT DOES THE LAW SAY ABOUT MENTAL LOAD?

All the member states in the EU are covered by a general directive which applies to
safety and health at work [i] (Directive 89/391/EEC). This also includes mental
health at work. When this applies to working conditions in computer work, there is
also a minimum directive with official communications affecting mental load [ii]
(Directive 90/270/EEC).
As regards legislation in the United States, see Chapter 10.
Work with High Levels of Mental Strain 211

7.16  SUMMARY
Allostasis means the process that ensures that the body’s physiological systems are
in balance, and that homeostasis is thereby maintained during varying external con-
ditions. Allostasis has a primarily protective function for the body, but allostatic
processes can also act to the detriment of the body and produce harmful effects if
they do not disappear within a reasonable period. That is, they can give rise to allo-
static load. It is therefore important to be able to recuperate, irrespective of which
load one is subject to. In this chapter we have said that, as regards exposure, it may
seem self-evident to distinguish between physical and mental stressors. The physical
stressors have an impact on the internal environment of the body without higher
cognitive functions needing to be employed. As regards the stress reaction itself, it is
interesting that the division into physical and mental stress reactions is not as obvi-
ous. We have also said that cognitive functions may be disturbed as a result of pro-
longed mental stress, and cortisol (the HPA axis) is suspected of playing an important
role in this context. In this chapter we have described how different memories such
as, for example, the work memory and procedural memory, are made used in differ-
ent operations. Routine work is often done at the procedural memory level, while
newer tasks and those requiring more problem-solving skills require a different kind
of memory use. In this chapter we have also mentioned different methods of moni-
toring mental load, for example, direct brain imaging methods to more indirect phys-
iological measurements and self-reported feedback. The introduction of new
technology has brought with it new cognitive demands in almost all areas of working
life. New technology in many cases implies radically new working methods, and
challenges that are not always entirely easy to discover, as mental exposure is more
inaccessible (more invisible) than physical exposure. All member states in the EU are
covered by a general framework directive applying to safety and health at work
including mental health at work.

REFERENCES
Alderson, AL. and Novack, TA. 2002. Neurophysiological and clinical aspects of glucocorti-
coids and memory: A review. J Clin Experim Neuropsychol. 24(3):335–355.
Directive 89/391/EEC—On the introduction of measures to encourage improvements in the
safety and health of workers at work. European Agency for Safety and Health at Work.
http://osha.europa.eu/en/legislation/directives/the-osh-framework-directive/
Directive 90/270/EEC—On the minimum safety and health requirements for work with display
screen equipment. European Agency for Safety and Health at Work. http://osha.europa.
eu/en/legislation/directives/the-osh-framework-directive/
De Kloet, ER., Vreugdenhil, E., Oitzl, MS., Joels, M. 1998. Brain corticosteroid receptor bal-
ance in health and disease. Endocr Rev. 19(3):269–301.
Eurostat. 2008. National Accounts, annual average. http://ec.europa.eu/publications/booklets/
eu_glance/66/index_en.htm
European Agency for Safety and Health at Work, Bilbao. 2004. http://europa.eu/legislation_
summaries/employment_and_social_policy/health_hygiene_safety_at_work/​c11110_en.htm
Gawron, VJ. 2000. Handbook of Human Performance Measures. Mahwah, NJ: Lawrence
Erlbaum Associates.
212 Occupational Physiology

Gilbertson, MW., Shenton, ME., et.al. 2002. Smaller hippocampal volume predicts pathologic
vulnerability to psychological trauma. Nature Neuroscience 5:1242–1247.
Gurvits, TV., Shenton, ME., et al. 1996. Magnetic resonance imaging study of hippocampal
volume in chronic, combat-related posttraumatic stress disorder. Biological Psychiatry
40:1091–1099.
Hancock, PA. and Meshkati N. (eds.) 1988. Human Mental Workload. Netherlands: Elsevier
Science Publishers B.V.
Karasek RA. and Theorell, T. 1990. Healthy Work—Stress Productivity and the Construction
of Working Life. New York, NY: Basic Press.
Kristenson, M., Garvin, P., Lundberg, U. (eds.) 2011. The Role of Saliva Cortisol Measurement
in Health and Disease. Bussum, Holland: Bentham Science Publishers. Open Access.
Lazarus, RS. 1966. Psychological Stress and the Coping Process. New York, NY:
McGraw-Hill.
Lundberg, U. 2002. Psychophysiology of work: Stress, gender, endocrine response, and work-
related upper extremity disorders. Am J Ind Med 41(5):383–392.
McEwen, BS. 2000a. The neurobiology of stress: From serendipity to clinical relevance. Brain
Res 15:172–189.
McEwen, BS. 2000b. Allostasis, allostatic load, and the ageing nervous system: Role of excit-
atory amino acids and excitotoxicity. Neurochem Res 25(9–10):1219–1231.
McEwen, BS. 2006. Protective and damaging effects of stress mediators: Central role of the
brain. Dialogues Clin Neurosci 8(4):367–381.
Melin, B. 2003. “Mental assembly lines” risks for cognitive overload. In C. Otter von (ed.) In
and Out in the Swedish Working Life (page 235–251). Stockholm: NIWL (In Swedish).
Melin, B., Lundberg, U., Söderlund, J., Granqvist, M. 1999. Psychological and physiological
stress reactions of male and female assembly workers: a comparison between two differ-
ent forms of work organization. J Organiz Behavior 20:47–61.
Melin, B. and Lundberg, U. 1997. A biopsychosocial approach to work-stress and musculosk-
eletal disorders. J Psychophysiol 11:238–247.
Nordling, S. 2003. Stress and Exhaution within a Neuropsychological Perspective, An
Overview. Inst for Cognitive Science, Umeå University. (In Swedish).
Nylén, L., Melin, B., Laflamme, L. 2007. Interference between work and outside work
demands relative to health, unwinding possibilities among full-time and part-time
employees. Int J Beh Med 14:229–236.
Ohlin, E. 2001. Studies of physicians’ work-situation. Physicians Magazine 38(101):2865–
2866. (In Swedish).
Sapolsky, RM. 2003. Why Zebras Don’t get Ulcers. New York, NY: Henry Holt and Company.
Siegrist, J. 1996. Adverse health effects of high effort/low reward conditions. J Occup Health
Psychol 1(1):27–41.
Spielberg, CD. and Vagg, PH. 1999. Job Stress Survey JSS. Odessa: Psychological Assessment
Resources Inx.

FURTHER READING
European Journal of Applied Physiology (EJAP) 2006 (2) has a special edition on mental and
physical load and can be found as a PDF at the following link: http://www.springerlink.
com/content/1439–6327/ The same journal also has a previous and important special
edition in this field with an editorial signed by Gisela Sörgaard, Ulf Lundberg, and
Roland Kadefors.
Linton, S. (ed). 2000. New Avenues for the Prevention of Chronic Musculoskeletal Pain and
Disability. Amsterdam, New York, NY: Elsevier Science.
Work with High Levels of Mental Strain 213

Nilsson, LG., Adolfsson, R., Bäckman, L., de Frias, CM, Molander, B., Nyberg, L. 2004.
Betula: A prospective cohort study on memory, health and ageing. Ageing Memory and
Cognition 11:132–148.
Sapolsky, RM. 2003. Why Zebras Don’t Get Ulcers. New York, NY: Henry Holt and Company.

Below are some references to get advice on how to design one’s own questionnaire for specific
purposes, for example, in working life.

McColl, E., Jacoby, A., Thomas, L., et al. 2001. Design and use of questionnaires: A review of
best practice applicable to surveys of health service staff and patients. Health Technol
Assess 5:1–256. Comprehensive systematic overview of questionnaire methodology.
Deals with, for example, layout, phrasing of questions, response format, administrative
methods and drop-out. Freely accessible on—www.ncchta.org or through ELIN.
Scientific Advisory Committee of the Medical Outcomes Trust. 2002. Assessing health status
and quality-of-life instruments: Attributes and review criteria. Quality of Life Research
11:193–205. Detailed criteria for assessing the quality of monitoring instruments,
including a discussion of explanations. Freely available via ELIN.
 8 Work That Disrupts
the Diurnal Rhythm
Torbjörn Åkerstedt

Photo: Joakim Romson

CONTENTS
8.1 Focus and Delimitation.................................................................................. 216
8.2 Definitions and Scope.................................................................................... 217
8.3 Prevalence of Unsocial Working Hours........................................................ 218
8.4 What the Law Has to Say About Working Hours......................................... 218
8.5 Diurnal Rhythm and Sleep: The Main Components..................................... 219
8.5.1 Diurnal Rhythm................................................................................. 219
8.6 Measuring the Diurnal Rhythm.................................................................... 222
8.7 Sleep.............................................................................................................. 223
8.8 Shift Work and Sleep..................................................................................... 225
8.9 Causes of Sleep Disturbance......................................................................... 226
8.10 Effects of Wakefulness, Performance, and Safety........................................ 227
8.10.1 Effects of Wakefulness and How to Measure Them......................... 227
8.10.2 Effects on Performance and Safety................................................... 229
8.11 Other Health Effects...................................................................................... 231
8.11.1 Mortality............................................................................................ 231
8.11.2 Disorders of the Stomach and Intestines........................................... 231
8.11.3 Cardiovascular Disease..................................................................... 231
8.11.4 Other Illnesses................................................................................... 232
8.12 Individual Differences................................................................................... 232

215
216 Occupational Physiology

8.13 Special Factors Concerning Working Hours................................................. 233

8.14 Risk-Reducing Measures............................................................................... 233
8.15 Summary....................................................................................................... 235
References............................................................................................................... 235
Further Reading...................................................................................................... 236

The time is around 7 am; George, 57, is getting out of bed and thinking about the day
ahead—and the evening’s night drive. In the morning he makes sure that the chil-
dren get to school, does the shopping, and cuts the lawn. In the afternoon he tries to
take a nap. He gets just half-an-hour’s sleep before it is time to drive to the haulage
contractors at 5 pm. He collects his brand-new 25 m-long truck with its 620 hp V8
diesel engine, which conforms to the EU’s new exhaust gas directive, and drives to
the freight terminal. Then he begins a couple of hours work, loading the truck and
doing paperwork. At 8.15 pm he sets off. There is only moderate traffic and driving
is easy. Towards midnight, darkness and mild fatigue creep over him and it is time
for a break. He has a late dinner at a roadhouse, drinks coffee, buys a couple of
bottles of Coca Cola, and continues on his way. For a while he thinks about his eating
habits, his weight problem, and the company doctor’s warning about the risk of dia-
betes—his blood values are not ideal. What to do?
The road is now relatively empty and soporific, and the effects of the coffee only
last for about an hour. The fatigue becomes obvious, and his stomach makes itself
felt. George turns up the volume on the CD player, winds down the window, drinks
a Coca-Cola, and tries to get into touch with his fellow drivers on the CB. This helps
a little against the fatigue. At 4 in the morning, the fatigue is almost overpowering,
but now he is approaching his destination and he is not tempted to take a further
break, even if his eyelids are heavy. He wonders whether he nodded off briefly just
now. But there is not much else to do other than continue on—there are no stopping
places for heavy vehicles in the area. Luckily he succeeded in taking a nap before he
set off, and so it should be possible to drive on for another hour. He arrives at his
destination as the sun is rising at 5 am.
There he hands over his truck to a colleague who will be taking it further on.
Slightly groggy from fatigue, he goes into the overnight room above the garage and
lies down on the bed exhausted. He sleeps for about 51/2 h and is woken at around
11 am by a combination of his own biological clock and noise from the terminal. He
feels that he has slept too little, but it is not possible to get any more sleep just now. He
will have to try to take a nap later, before he takes a new trailer back the next night.

8.1  FOCUS AND DELIMITATION

It is not only George’s occupational group that has experiences of this kind. They
also apply to pilots, locomotive drivers, boat crews, workers in the process industry,
doctors, nurses, and even economists and technicians in global companies that never
close. Most of these people experience fatigue and sleep disturbances. Some of them
also experience stomach reactions. Many of them find themselves in hazardous work
situations. Drivers are, however, the group in which impaired performance resulting
Work That Disrupts the Diurnal Rhythm 217

from sleepiness or fatigue has the most obvious consequences. Below, we have tried
to summarize what working hours that disturb the diurnal rhythm look like, what the
law has to say, what the health effects are, what the physiological reactions look like,
what the effects are of different types of working hours, and what countermeasures
could possibly be introduced.
In this chapter, the following issues will be dealt with:

• Is George’s sleepiness a safety risk?

• Can people drive a heavy vehicle at any time and for any length of time?
• How much sleep do they have to have?
• For how long can they be awake?
• Why do we sleep?
• How do we prevent dangerous fatigue?
• How effective is a nap?
• Is health affected by shift work?

8.2  DEFINITIONS AND SCOPE

What diurnal rhythm-disrupting work time systems are we dealing with? If day work
involves the hours between 7 am and 6 pm, most other working times may disrupt
the diurnal rhythm, particularly if night work is involved. A combination of morn-
ing, afternoon, and night shifts (three-shift work) is often used (see Figure 8.1), espe-
cially in traditional industrial work. In Europe, the employee often alternates between
these shifts, whereas in the United States permanent shifts are more common. If
night work is not required, the resulting schedule is often some variety of two-shift

Team Mon Tue Wed Thu Fri Sat Sun

Slow rotation
1 M M M M M M M
2 – A A A A A A
3 A – – N N N N
4 N N N – – – –
5 – – – – – – –

Rapid rotation
1 M M A A – – N
2 N N – – M M A
3 A A – – N N –
4 – – M M A A –
5 – – N N – – M

FIGURE 8.1  Examples of shift schemes. Figures indicate week and shift team. A = after-
noon shift, M = morning shift, N = night shift, – = day off.
218 Occupational Physiology

work (morning and evening shifts). The term “shift work” is here used in a generic
sense. There are a number of other work schedules that do not divide the 24 h period
into equal portions, but are more irregular. This is characteristic of health care and
transport work, for example.
A new form of working hours is the 12 h shift, which often means that the work
alternates between a day shift and night shift. As a worker then clocks up a 36 h
week in 3 days, this provides more days off—4 days every week. This has become
particularly popular in Europe by shift workers who make good use of the free
time—workers who: moonlight, study, like the outdoors, do sports, and other
groups.
On-call work means that the employee is available for a largely immediate work
input over a certain time period. The amount of work is expected to be considerably
less than what is usual during a normal shift. The proportion of work is, however,
unspecified.

8.3  PREVALENCE OF UNSOCIAL WORKING HOURS

According to Eurofound (www.eurofound.eu), ~20% of those employed in the EU
work “shift work.” About one-third of these people at least occasionally work night
shifts. The definition of “shift work” is unspecified, but probably refers to employees
who do not have regular working hours each day.

8.4  WHAT THE LAW HAS TO SAY ABOUT WORKING HOURS

European working hours are regulated through the Working Time Directive (Directive
2003/88/EEC). This does not include a ban on night work, but on the other hand it does
have rules about a maximum 8 h shift (on average) for night work, a ban on overtime
in connection with night shifts, a ban on shifts longer than 8 h in connection with par-
ticularly sensitive work, and directed medical examinations of night-shift workers
(permanent night work—not shift work). Furthermore, the shortest daily rest period is
set at 11 h, the maximum working week at 48 h on average (including overtime) and
the shortest weekly rest period at 35 h (including a preceding 11 h daily rest period).
There can be a deviation from the directive if compensation is provided in the form of
time off later. Recently, the law has been modified so that previously “exempt” groups,
such as doctors, for example, also have to be limited to a 48 h working week and 11 h
daily rest period.
The EU driving time rules (for heavy traffic) restrict the total driving time to 9 h
each day (on 2 days each week 1 h of extra driving time is allowed) (Directive
2002/654/EEC). A break (of at least 15 min) must be taken after not more than 4.5 h
of driving. During the working shift a total of at least 45 min of break must be taken.
Note that, apart from driving time, in practice it is possible to work a further 4 h on
things like paperwork or loading, for example, without encroaching on the 11 h daily
rest period. The weekly rest period has to be taken after not more than 6 days’ driv-
ing and must last for at least 45 h. A reduction to 36 h can be made at the driver’s
domicile or to 24 h elsewhere—provided that compensation in time is given within
3 weeks. The total working time over a 2-week period is restricted to 90 h. The daily
Work That Disrupts the Diurnal Rhythm 219

rest period has to be at least 11 h, but may be reduced to 9 h three times a week if
compensation in time is given no later than the week following.
The United States does not have any general regulation on working hours—other
than that 40 h/week is considered full-time work. Instead, some particularly sensi-
tive areas have a specific Hours of Work regulation. One such area is road transport
with heavy vehicles. Thus, the Federal Motor Carrier Safety Administration has
hours of service regulations for commercial motor vehicle drivers carrying goods
(slightly different for passenger drivers). This includes a maximum driving time of
11 h (after 10 h off duty). A driver may not drive beyond the 14th consecutive hour
after coming on duty, following 10 consecutive hours off duty. The weekly limit is
60–70 h on duty, and a driver may restart a period of 7 or 8 consecutive days after
taking 34 h off duty. Drivers using a sleeper berth must spend at least 8 consecutive
h in the sleeper berth, plus a separate 2 consecutive h in berth, off duty.
It should be stressed that very little emphasis is laid on work during the night
hours (the “diurnal low”), which may be the most important factor to regulate from
a safety point of view.

8.5  D
 IURNAL RHYTHM AND SLEEP: THE MAIN
COMPONENTS
The health effects of working hours that disrupt the rhythm deal with such things as
sleep, wakefulness, accident risk, cardiovascular disease, and stomach and intestinal
disorders. They have a close link to diurnal rhythm and sleep. In this section, we
therefore introduce these concepts.

8.5.1  Diurnal Rhythm

Almost all physiological and psychological functions demonstrate a rhythmical
behaviour over a 24-h period, that is, the level fluctuates between low and high val-
ues with a periodicity of 24 h [Czeisler and Dijk 2001]. The parameters employed to
describe the rhythm are the same as those for a sine function; that is, the amplitude
(the difference between the highest and lowest value), phase (the point in time of
maximum value), and length of the period (the time between two peaks, that is, 24 h
under normal circumstances).
Despite the fact that the basic diurnal pattern is approximately the same for most
functions, there are major differences in timing. The hormone cortisol (see Fact Box
8.1), for example, reaches its highest level early in the morning; body temperature
peaks in late afternoon and the pineal gland hormone melatonin peaks during the
night (Figure 8.2). Generally speaking, however, most rhythms reach their maximum
values during the day. It might be of interest to know that the bladder fills up four
times as fast during the day as it does at night—which can easily disturb morning
sleep. In addition, the stomach’s ability to digest food is at its lowest late at night and
at its highest in the afternoon. Late in the night is therefore the wrong time for food,
that is, difficult to digest (fat, proteins). Susceptibility to medicines varies with the
time of day, and late at night is, moreover, the point in time when most people die or
are born (spontaneously).
220 Occupational Physiology

FACT BOX 8.1

Cortisol is a hormone produced in the adrenal cortex on a signal from the pitu-
itary gland in the brain. The aim is, among other things, to release more energy
in detrimental situations, and cortisol is therefore often used as an indicator of
stress. The hormone has a very marked diurnal rhythm with a peak at around
5 am. Melatonin is another hormone produced in the pineal gland. It has a
marked diurnal rhythm that reaches its maximum between 4 am and 5 am.
The hormone conveys signals from the biological clock out into the body and
lowers the metabolism. This last helps melatonin to facilitate sleep. Melatonin
also affects the setting of the biological clock, and is sometimes used to treat
individuals who have maladjusted biological clocks.
The adaptation of the diurnal rhythm to night or morning work is a difficult
one. Not even constant night workers can completely adapt their physiology to
night work. What they need, of course, is help from daylight, and that occurs at
the “wrong” time (i.e., during the day) in relation to night work. When people
come out into the light from a night shift (around 6–7 am), their biological clock
will stop the delay in the rhythm which light exposure during the night shift
would have produced. The result is that melatonin, cortisol, body temperature,
and other diurnal rhythm-regulating physiological variables are retained in their
settings for day work. Often, however, we find a slight permanent delay in the
diurnal rhythm of shift workers. An exception is night workers on oil rigs in the
North Sea, where workers are not exposed to light to any great extent (they work
indoors). There is actually an adaptation in that case, as the diurnal rhythm is
adjusted for the indoor lighting, which of course follows the work-rest cycle.
If, on the other hand, we travel to another time zone, we are helped by the day-
light of the new time zone, and the changeover then occurs relatively quickly. Over
4–5 days we will have adapted, for example, to New York time (westwards 6 h
later than in the central part of Europe). It takes considerably longer to adjust to a
flight eastwards, that is to time zones that lie ahead of us. This means that we have
to shorten our day; that is, we have to go to bed earlier. This is less ­physiological—
we are better constructed for flying west; that is, delaying the cycle.
A particular problem is that clock structures are also to be found in other
organs—for example, in the liver, kidney, lungs, and heart. People need signals
from the SCN, but the peripheral clocks are nevertheless relatively automatic.
If we reset our diurnal rhythm, the biological clocks of the various organs
will adapt themselves and “their” target organs at speeds that differ from
each other. The long-term effect of this desynchronization is unclear, but it is
assumed to be negative.
Being a morning person means you have an early maximum in your diurnal
rhythm—both for body temperature and wakefulness. This means that sleep
during the daytime is more difficult for the morning person. There is also, of
course, an early trough—sleepiness comes earlier during the night shift. The
circumstances for the evening person are the opposite. Above all, early morn-
ings are difficult.
Work That Disrupts the Diurnal Rhythm 221

120 37.2
Mel (pg) Temp
37.1
100

Body temperature (°C)

37.0
80
Melatonin (pg)

36.9
60
36.8
40
36.7

20 36.6

0 36.5
0 12 24 12 24 12
Time of day

FIGURE 8.2  Diurnal rhythm for body temperature (temp) and melatonin (mel) over a
period of 60 h of wakefulness; pg = picogram.

The anatomical structure that regulates the diurnal rhythm is to be found in the
front lower part of the hypothalamus—just above the optic chiasma, and is called the
“suprachiasmatic nucleus” (SCN). This biological clock consists of ~10,000 cells,
each of which are controlled by their own genes. Some of these are called Per, Tim,
and Clock. The genes are active (“express” themselves) during the daytime. This
results in the production of proteins in the periphery of the cells. The proteins are
carried back to the cell core and there inhibit any further “expression” by the genes.
This cycle of activation and inhibition is what comprises the clock mechanism—the
time is approximately a 24-h period. When the activity has reached zero, the next
cycle begins. The whole group of cells together help each other to maintain a stable
rhythm.
The cells of the biological clock also receive direct light information from the
retina, which is used to “adjust” the setting. Without light information, the clock
starts to “run slow”—it gets slower and out of time with the alternation of day/night.
Light has its greatest effect on an individual who is awake immediately before or
after the trough in the diurnal rhythm (of body temperature), around 5 am. Light
before this point (and some hours beforehand) leads to a good hour’s delay in the
rhythm. The clock interprets light at this time as an extension of the day—which is
why it delays its setting. Light after this time (and 6 h beyond that) leads to a cor-
responding advancement—light is regarded as an early sunrise. In this way, we
adapt to different time zones and to winter- and summer time. The strength of the
light also has significance. Usually, indoor lighting is rarely sufficient—if one does
not spend a large part of the day in darkness and only has light during the critical
hours. The clock can also be affected by activity (via serotonin and neuropeptide Y)
or by food intake (via the appetite hormones leptin and ghrelin). But it is light that
is the most important timer. The literature often uses the term “Zeitgeber” or
“Synchronizer.”
222 Occupational Physiology

8.6  MEASURING THE DIURNAL RHYTHM

Measuring the diurnal rhythm for various bodily functions really involves simply
deciding which function one is interested in, and then measuring that one a sufficient
number of times to be able to form a view about the appearance of the rhythm.
Among the favourite variables for measurement is body temperature, which is mea-
sured using a temperature sensor inserted up to 10 cm into the rectum and connected
to a portable physiological monitor. The reason that body temperature is interesting
is that it reflects the body’s metabolism, and that physiological and psychological
capacity are improved by high metabolism and impaired by low metabolism. Sleep
has the opposite relationship—it is improved by low metabolism and impaired by
high metabolism.
Favourite variable number two is probably melatonin (see Fact Box 8.1). This is
governed directly from the SCN, supplies maximum levels at around 4 am, and is
very low in the daytime. This lowers the metabolism and is affected (suppressed) by
exposure to light. It is often used as a measure of the setting of the biological clock.
By measuring the melatonin in saliva once an hour under constantly faint light con-
ditions between 7 pm and 12 pm, one can estimate the setting of the SCN. Some time
after 7 pm a steep rise occurs in melatonin secretion—“dim light melatonin onset”
which is used to estimate the point in time at which the peak of the rhythm occurs.
The techniques for analysing melatonin in urine and blood have existed for a long
time. Today methods of analysing melatonin in saliva have become very popular
among researchers into diurnal rhythms, because of the ease of acquiring samples.
Favourite variable number three is cortisol (see Fact Box 8.1). The function of
cortisol has been discussed in Chapter 7 and its relation to stress is well known. It has
a very stable diurnal rhythm, which also reflects the setting of the SCN. The level is
lowest before, and, in particular, during the first hours of sleep, when active inhibi-
tion prevents secretion. Then the level rises towards point in time around awakening.
For a long time there have been methods for analysing cortisol in blood and urine; in
recent years, analysis of cortisol in saliva has become very popular among research-
ers in stress and diurnal rhythms.
Measurements of diurnal rhythms in the work environment are often imprecise,
as, for example, melatonin is affected by light at the work place, and body tempera-
ture is affected by physical activity. One solution that is sometimes successful is to
measure light and activity simultaneously. This can be used to adjust the values
acquired. Anyone interested in this can acquire an activity meter (actigraph—see
Section 6.12.4 in Chapter 6) which measures activity levels and which can be com-
plemented with a light meter (and other monitoring instruments). Today activity
meters are used a great deal in the field research into diurnal rhythms, stress, and
sleep.
In certain exclusive laboratory trials, temperature is measured continuously in the
rectum, and blood samples are taken every 20 min via a catheter. This last requires
almost heroic efforts with regard to timing in order to ensure that the flow is not
blocked and to provide follow-up treatment (e.g., centrifuging) of the blood and
freezing it. Studies of this kind take many days and therefore make great demands
on the logistics of monitoring. Often the subject is isolated from all timers so that the
Work That Disrupts the Diurnal Rhythm 223

dynamics of the diurnal rhythm can be studied. This means that the experimenters
must not give signals about the time of day—not even subtle signals such as appear-
ing unshaven at 5 am.

8.7  SLEEP
Sleep is an altered state of consciousness during which the perception of external
stimuli is strongly reduced, and a conscious act is impossible. Physiologically it is a
state of reduced metabolism and increased anabolism (physiological construction).
Characteristic changes are lower body temperature, heart rate, and blood pressure, at
the same time as the secretion of growth hormone and testosterone increases, as well
as the activity of the immune system.
The physiological signs of sleep are registered using an electroencephalogram
(EEG), electrooculogram (EOG), and electromyogram (EMG). The EEG depicts
brain activity via electrodes attached to the scalp; the EOG describes eye activity via
electrodes attached near the outer corners of the eyes; and the EMG describes activ-
ity in, for example, the muscles of the chin by means of electrodes attached to the
skin.
During sleep the EEG shows slow, but large, wave movements, increasing in size
with increased depth of sleep. The EOG shows no activity before falling asleep (with
closed eyes) but shows slowly billowing waves (slow eye movements (SEM)) on fall-
ing asleep. It also shows rapid, jerky movements when the subject is dreaming (rapid
eye movement (REM) sleep). EMG activity is high when the subject is awake and
declines slowly the deeper the subject sleeps. REM sleep is characterized by very
rapidly falling EMG activity.
Sleep is divided into five different stages (Figure 8.3). Stage 1 is a transitional
phase from wakefulness to sleep and has no value for recuperation. Stage 2 is “base

2
Sleep stage

0 120 240 360 480

Time since going to bed (min)

FIGURE 8.3  Sleep progresses during the night in a wave movement, from awake (stage 0),
shallow sleep (stages 1 + 2), to deeper sleep (stages 3 + 4), to dream sleep (REM = blackened,
to shallow sleep, etc.). A total of 4–6 cycles of this kind are gone through each night.
224 Occupational Physiology

sleep” which takes up half of the sleep period. During this stage we recuperate but
not to the maximum. Stages 3 and 4 are deep sleep with maximum recuperation.
This is when we are also most difficult to wake up and are confused if we are woken.
During REM sleep, which deviates considerably from other sleep, the brain and the
rest of the body show raised activity, but strangely enough the postural muscles are
relaxed (we cannot stand up or sit up). It is at this sleep stage that dreams are pro-
duced, even if dream images sometimes can occur in, for example, stage 2. We
dream between four and six times every night. Deep sleep is always prioritized and
is able to dominate the first half of sleep (see Figure 8.3). REM sleep is then withheld
and is not released in earnest before the second half of sleep.
Disturbed sleep (insomnia) is characterized by a long period of falling asleep
(more than 30 min), an increased number of awakenings (more than four), and/or
relatively long periods of wakefulness during sleep (a total of at least 30 min). Often
stages 3 and 4 are also reduced. The former often comprise the main criteria for
sleep disturbance in clinical contexts. The diagnosis manuals for sleep disturbance
also require that the problem should exist for at least a month so as not to be regarded
as temporary. It is also necessary that the sleep disturbance should have conse-
quences in the form of fatigue, irritability, or reduced functional capacity.
The function of sleep has not been fully explained. Sleep is a necessary precondi-
tion for activities while awake in the short term and for life itself in the long term.
The minimum requirement of sleep seems to be around 7 h—in the long term. In the
short term—from day to day—a sleep reduction from 8 to 6 h only has a marginal
impact. After a reduction by 3 h one does, however, notice certain effects on the level
of wakefulness and behaviour, and after the loss of a complete night’s sleep the per-
son affected shows a noticeably reduced capacity, comparable with the effects of
sleeping pills. Three nights without sleep results in an almost total inability to carry
out normal tasks requiring attentiveness, mental activity, or decision-making. As
regards mortality, in the very long term this is somewhat higher among individuals
who regularly sleep <4 h or more than 11 h a day.
Lack of sleep is compensated for primarily by more intensive (deep) sleep. For
every hour we are awake we have to pay back ~3 min of deep sleep (stage 4). If, for
example, we lose a night’s sleep, we retrieve what we have missed largely by
increasing the depth of our sleep—the length of sleep plays a minor role. A lost
night’s sleep can be regained the next night without our sleep being any longer!
Increased depth is enough. Dream sleep seems to be considerably less important in
the short term, and the lack of dream sleep does not seem to be made up. Long
periods of suppressed dream sleep do, however, increase the pressure on recupera-
tion, and there are signs indicating that dream sleep is important for the memory in
the longer term. Research findings into the different stages of sleep are still not
complete, but it seems as if deep sleep (stages 3 + 4—often called “slow wave
sleep,”) is necessary for the ability to keep oneself awake and for the immune
defense system. REM sleep, on the other hand, seems to be associated with metab-
olism and temperature regulation. Both kinds of sleep seem to be important for
memory consolidation.
Recently, results have been presented from different quarters showing that experi-
mentally curtailed sleep leads to raised levels of the stress hormone cortisol and of
Work That Disrupts the Diurnal Rhythm 225

blood fats (triglycerides) and to an impaired ability on the part of insulin to carry
blood sugar to the cells. One working week with sleep cut by half leads to blood
sugar levels above those necessary for diagnosing type 2 diabetes. The same obser-
vations have been made in patients suffering from insomnia or sleep apnoea (suspen-
sion of breathing during sleep).

8.8  SHIFT WORK AND SLEEP

One might discuss which physiological and health effects are most important in shift
work. The clearest and most obvious effects are, however, those which affect sleep
and wakefulness [Åkerstedt 2003]. It also seems to be those factors that determine
whether one can cope with unusual working hours or not. The latter try to leave
shiftwork. This process of elimination indicates that individuals with considerable
experience of night work have fewer problems with sleep and wakefulness than
would a non-selected group. Disturbed sleep and wakefulness in connection with
shift work are included in a diagnosis group called “Shift Work Sleep Disorder” in
the international diagnosis manual for sleep disturbances [AASM 2005]. This identi-
fies a large group of people who suffer from problems in sleeping or from “non-
restorative sleep” on most days when working night shift—but otherwise sleep
normally. This group has an increased probability of not coping with shift work, and
has a greater risk of, for example, accidents, absence due to illness and cardiovascu-
lar disease.
The effects of shift work on sleep have been fairly well researched. Field surveys
of three-shift workers and similar groups have shown that sleep disturbances are
very common. At least three-quarters of the shift workers were affected by sleep
disturbance. EEG studies of sleep among workers with rotating shifts show relatively
consistent results, irrespective of whether these are carried out in the laboratory or in
the home. Sleep during the daytime and sleep before an early-morning shift is 1–4 h
shorter than night sleep in connection with daytime work. The reduction primarily
affects stage 2 and REM (dream sleep). Stages 3 and 4 (deep sleep) seem not to be
affected. In addition, sleep onset latency is abbreviated in day sleep after a morning
shift, and REM sleep often sets in earlier, though not always.
Often the sleep pattern before the morning shift does not vary between individu-
als, that is, most people go to bed and get up largely at the same time. In relation to
evening or night work, the variation between individuals is considerable. Morning
shifts are also characterized by the sleep quality being disturbed by something that
is very similar to stress. The more one is worried about the difficulty of waking up,
the less deep sleep (stages 3 + 4) is produced. The subjective effects that mark morn-
ing shift sleep have to do with non-spontaneous waking (almost everyone uses an
alarm clock or some other method) and a feeling of not being thoroughly rested.
Approximately one-third of night workers supplement their main sleep with a nap,
which is often a direct function of the abbreviation of their main sleep.
One would imagine that working for several nights in a row would mean that
sleep improves day by day. This is not normally the case, however. Sleep curtailment
remains—even for individuals with permanent night work. There are sometimes
tendencies to adaptation, particularly in relation to permanent night work, but the
226 Occupational Physiology

effect is very limited. The reason is, as discussed earlier, that the adjustment of the
biological clock to night work is counteracted by exposure to daylight on the morn-
ing after the night shift.

8.9  CAUSES OF SLEEP DISTURBANCE

Several earlier studies have pointed to the fact that noise levels are higher during the
day to explain why daytime sleep is shorter after a night shift. On the other hand,
sleep after a night shift is shorter even in the quietest laboratory environment. So,
noise does not seem to be the main cause of disturbed daytime sleep.
As has been mentioned previously, a stronger influence is exercised by the bio-
logical diurnal rhythm. If we postpone going to bed to a time other than the optimal
(about 11 pm–7 am), our sleep will be negatively impacted (Figure 8.4). The later one
goes to bed (12 pm, 2 am, 4 am, etc.), the shorter the sleep will be—until bedtime
the next day around 4–6 pm, when the length of sleep will begin to increase. The
reason is that the switching point of the biological clock (around 5 am) is followed by
increasing metabolism. In this way, the sleep process is disrupted and one wakes up
early. If one stays awake until the next evening, the diurnal rhythm will have turned
(round about 5 pm) and the disrupting effect begins to subside.
It has also been shown that it is not merely the time of waking that is regulated by
the diurnal rhythm, but also the time of going to bed (if social influences are lim-
ited). The maximum readiness for sleep coincides approximately with the diurnal
trough in body temperature, but usually the first signs of approaching sleep appear a
couple of hours earlier. It is interesting to note that the “going to bed signal” is pre-
ceded by a short phase of great wakefulness, when it is very difficult to sleep.

12

11

10
Length of sleep (h)

4
23 7 15 23
Time of day

FIGURE 8.4  Length of sleep after going to bed at different times of the day. Note that at 11 pm
on the left one has been awake for 16 h and at 11 pm on the right one has been awake for 40 h.
Work That Disrupts the Diurnal Rhythm 227

8.10  EFFECTS OF WAKEFULNESS, PERFORMANCE, AND SAFETY

8.10.1  Effects of Wakefulness and How to Measure Them
Most surveys show that three-shift workers and similar groups experience fatigue
more often than day workers [Åkerstedt 2003]. Normally, fatigue is general during
the night shift, scarcely noticeable during the afternoon shift and of short duration
during the morning shift. Certain studies report cases where sleepiness has been so
great that it has led to people falling asleep during the night shift.
The methods of measurement for sleepiness/wakefulness are largely a matter of
subjective assessments. One of these is the so-called visual analog scale for sleepi-
ness, which is usually presented as a 10-cm long line with “very alert” and “very
drowsy” at its endpoints. Likert scales are also popular. They have a number of steps,
usually 7 to 9, where each step is based on the description of the phenomenon of
sleepiness. An example is the “Karolinska Sleepiness Scale” which has the following
basis: 1 = extremely alert, 2 = very alert, 3 = alert, 4 = quite alert, 5 = neither alert
nor drowsy, 6 = first signs of sleepiness, 7 = drowsy but no effort to stay awake, 8
drowsy some effort to stay awake, and 9 = very drowsy + major effort to stay
awake + fighting sleep (see also Figure 8.5 in which this scale is used).

N
5
Sleepiness

2
6 18 6
Time of day

FIGURE 8.5  Self-assessed sleepiness during the morning (M), afternoon (E), and night (N)
shift—with time between shifts eliminated so as to illustrate the diurnal pattern. Sleepiness
assessed on the Karolinska Sleepiness Scale of 1–9, where higher values indicate great
sleepiness.
228 Occupational Physiology

Another popular model is the so-called multiple sleep latency test which mea-
sures readiness for sleep at several times during the daytime (after a normal night’s
sleep). The subject is provided with electrodes for the EEG and EOG (in the same
way as for sleep), placed in a dark room and asked to lie down, close their eyes, and
not fight sleep. The time from going to bed up to the first 20-second interval with
sleep comprises the measure (in minutes). The trial is interrupted after the first sleep,
or after 20 min if sleep has not occurred (the maximum value is then 20). Normal
values lie between 10 and 20 min. The criterion for suspecting unhealthy fatigue is a
time to falling asleep of <5 min. At the end of a night shift, values of around 2–3 min
are often measured.
Other variants quite simply comprise the number of sleep events in EEG and
EOG during work or under controlled situations during a break from work. Sleep
events chiefly mean all activity within the frequency range of the EEG signal that
one knows is related to sleepiness or sleep. This means, above all, the interval
between 4 and 12 Hz (α and θ activity). The EOG then generally shows slow undu-
lating eye movements or at least very slow blinks. The latter means that the eyelid
stays closed for more than 0.15 s. Active wakefulness produces EEG frequencies of
more than 12 Hz (β activity). A number of studies show that increases in SEM and α
and θ activity in EEG are directly related to sleep and behavioural interruptions in
the interaction with the surroundings (often called “lapses” in the literature) just as
they are to the experience of sleepiness.
Figure 8.5 shows what self-assessed sleepiness looks like during a morning, after-
noon, and night shift. The graphs have been produced for different days but collated
to illustrate the clear pattern of the diurnal rhythm. Sleepiness is lowest during the
afternoon shift, average during the morning shift, and very high towards the end of
the night shift.
There are few physiological studies of sleepiness in connection with night-shift
work. In a study carried out by Torsvall et al. [1989], however, EEG and EOG were
registered at work. This was done with the help of a small recorder carried by the
subject during a 24-h period including the morning, afternoon, or night shift. During
working hours, a quarter of the participants showed sleep patterns in the EEG. This
occurred in most cases during the second half of the night shift, and never in connec-
tion with any other shift. It is important to emphasize that the company did not sanc-
tion sleeping on the job; nor were they aware that this was taking place. Similar
studies have been carried out on locomotive drivers, truck drivers, and pilots. All
these groups show clear signs of sleeping at work (α and θ activity, SEM). In the
introductory section, George showed a greater activity primarily in the α band, and,
furthermore, slow blinks at about 3–4 am when he had been driving for 7–8 h.
Data on how many people suffer from sleepiness vary somewhat, depending on
exactly what is meant by the concept. Most night workers do, however, report greater
sleepiness during night work and morning work. More than half report at least one
occasion of falling asleep at work, and 10–20% experience this in connection with
every night shift.
The underlying causes of these effects on wakefulness are primarily the length of
time awake, the length of the previous sleep, and the phase (point in time) in the
diurnal rhythm. The shorter the previous sleep has been, the longer one has been
Work That Disrupts the Diurnal Rhythm 229

awake and of course the closer to the trough (4 am–6 am) in the diurnal rhythm one
finds oneself, the more severe the sleepiness becomes. The combination of these
effects has been modeled mathematically, and today there are several such models to
predict future sleepiness levels. These models generally also predict performance
and safety, which are discussed below.

8.10.2  Effects on Performance and Safety

If sleepiness at the workplace is as extensive and as dramatic as has been suggested
above, one might expect an impact on performance and consequently on productiv-
ity and safety. A classic in this field is a study carried out by Bjerner et al. [1955]
showing that the incorrect readings taken at a gasworks over 20 years had a clearly
marked peak during the night shift (Figure 8.6). A less prominent peak also occurred
during the afternoon. Similar results have been demonstrated for performance
among locomotive drivers and the response time for telephone operators. But gener-
ally speaking, few effects can be found on performance. The reason is presumably
that a great deal of work is machine controlled, and that rather little of the production
depends on individual performance.
A large number of studies have also been carried out using different types of
performance testing. Most show clear effects of night work on, for example, reac-
tion times and different types of what are called tracking test (following a move-
ment with some kind of joystick or steering wheel). Laboratory studies also very
consistently indicate clear negative effects on performance in a number of psycho-
logical tests. One method for summarizing the effects is to compare them with the
effects of ­alcohol. Several studies have been carried out, and work late at night

Night
6000 Morning
Afternoon

5000

4000
Errors

3000

2000

1000

0
0 6 12 18 24
Time of day

FIGURE 8.6  Effect of time-of-day/shift on incorrect readings at a Swedish gasworks.

230 Occupational Physiology

seems to entail a drop in performance to the same extent as having a blood alcohol
level of 0.8 per thousand.
One serious effect of fatigue is a reduction in safety. With a serious lack of
sleep, the interplay between the individual and their surroundings is interrupted. If
this coincides with a situation that requires action, an accident may occur. The
transport sector is the area where the connection between shift work and accidents
appears most clearly. The US National Transportation Safety Board has drawn the
conclusion that fatigue is one of the most important causes of accidents within the
transport area (15–30% of all accidents), and that fatigue is the most important
individual factor in accidents involving heavy traffic on the roads. It is primarily
single-vehicle accidents that multiply in night driving [Philip and Åkerstedt 2006].
But all kinds of road accidents, apart from accidents while passing, increase late
at night.
An interesting analysis has been presented by the Association of Professional
Sleep Societies’ Committee on Catastrophes, Sleep, and Public Policy. The report
draws attention to the fact that the core meltdown of the nuclear power station at
Chernobyl in the then Soviet Union occurred at 1:35 am, and was caused by a fault
resulting from human error (clearly related to the scheduling of work shifts). In the
same way, the accident at the nuclear power station at Three Mile Island in the United
States occurred between 4 am and 6 am, and was caused not merely by the fault in
the valve which meant that there was a leakage of cooling water, but primarily by the
fact that no one had noticed this occurring. Similar incidents which, however, were
prevented at the last minute, occurred in 1985 at the David Beese reactor in Ohio and
at the Rancho Seco reactor in California. Finally, the committee also observes that
the catastrophe involving the NASA space shuttle Challenger originated in errors of
judgment made early in the morning by people who had not had sufficient sleep (as
a result of part-time night work) in the days leading up to the launch. It should be
stressed that almost the entire official attention in connection with these accidents
has been focused on their technical aspects.
Despite convincing research results, knowledge about fatigue as a cause of acci-
dents has is seldom considered in the work on safety at workplaces, or in traffic
safety work. The reason is, presumably, partially a question of tradition within the
responsible organizations and partially the difficulty of measuring fatigue in real
situations and to take appropriate action. The sleep latency test, by the way, is not
suitable for field use by the side of the road since being stopped by police is likely to
enhance alertness.
As regards monitoring methods for mental performance, at least, then presum-
ably the simple serial reaction time test is the one most often used and also the most
sensitive to a fatigue-related drop in performance. This means that anyone who is to
be studied is given a series of signals (a lamp lights up) at intervals of 2–9 s. The task
is immediately to press a corresponding button. The tracking test in various forms is
also sensitive. This means that, using a joystick or the like, the subject has to follow
a dot on a screen which moves unpredictably. Both these types of tests have been
used in field studies. But, just as in the case of physiological tests, “masking” occurs,
that is to say conditions such as the work situation, lighting, or noise may easily
impact on the performance.
Work That Disrupts the Diurnal Rhythm 231

8.11  OTHER HEALTH EFFECTS

The longer-term effects on health primarily concern mortality, cardiovascular dis-
ease, disease of the stomach and intestines, cancer, depression, and disruptions in
pregnancy.

8.11.1  Mortality
Mortality among shift workers has been investigated very little. In one of the few
(careful) studies, Taylor and Pocock [1972] compared mortality in a group consisting
of 8603 day and shift workers over a period of 13 years. The only difference that
could be proved was that former shift workers have a higher mortality than the then
current day or shift workers. The reason for the lack of studies is presumably the
turnover among shift workers. It is difficult to gain a clear picture of the amount of
shift work that has taken place, not least among day workers, as most studies of mor-
tality are conducted afterwards, and registers in general lack sufficient information
about previous working hours. Later studies have shown similar results.

8.11.2  Disorders of the Stomach and Intestines

Studies show that irregular working hours, and night-shift work in particular, are
associated with disorders of the stomach and intestines, for example, loss of appetite,
constipation, “gas,” and heartburn. One of the most systematic studies (34,047 indi-
viduals) showed that stomach ulcers were 10 times as common in two-shift workers
than day workers, and 12 times more common in three-shift workers [Angersbach
et al. 1980]. Among former shift workers, stomach ulcers were ~20 times more com-
mon. The differences between shift workers and others began to appear ~5 years
after hire.
The mechanism underlying the problems is presumably that the diurnal pattern
for stomach enzymes and for the stomach’s motor patterns does not correspond to the
sleep/wakefulness pattern. The pattern of food intake is, furthermore, irregular. A
high nocturnal intake of food seems to be linked to increased blood lipid levels.
Eating at around the time of the trough in the diurnal rhythm seems to cause an
altered metabolic reaction, among other things, a reduction in the ability of insulin
to store blood sugar in the cells (more blood sugar remains in the blood). The energy
metabolism is also different at different times of the day. On the other hand, there
are  today no data linking the stomach ulcer bacterium Helicobacter pylori with
shift work.

8.11.3  Cardiovascular Disease

Cardiovascular disease is one of the more important areas for the study of the effects
of working hours. The effects appear clear and many outline studies have been pub-
lished. In a study of a paper manufacturer, the incidence of heart attacks between
1968 and 1983 was reported for a group consisting of 504 shift and day workers, and
this was related to how great the exposure (number of years) had been for shift
232 Occupational Physiology

­ orkers [Knutsson et al. 1986]. A few of the original participants were not traceable.
w
The age-standardized relative risk for shift workers compared with day workers was
1.4 (i.e., 40% excess risk). It was not possible to determine the risk for workers with
<2 years exposure (no one in that group had a heart attack). In the group of workers
with 2–5 years, exposure of the risk was 1.5; for 6–10 years’ exposure, it was 2.0; and
for 16–28 years’ exposure, it was 2.2 and 2.8, respectively. In the group with more
than 21 years of shift work, the risk dropped to 0.4. This last is assumed to result
from a selection effect—the most sensitive workers had left shift work.
The reason behind the excess risk among shift workers is not known, but may
have to do with the raised blood lipid levels which are often to be found among shift
workers. This may be the result, for example, of too great a food intake at night, poor
diet, or sleep disturbance, and so on.

8.11.4  Other Illnesses

Several studies have shown a certain excess risk of low birth weight among the chil-
dren of shift-working mothers, and there are signs of a higher proportion of sponta-
neous abortions. Shift work also seems to increase the risk of cancer, particularly
breast cancer in women and prostate cancer in men. The reason is unclear, but it has
been proposed that exposure to light at night leads to a suppression of melatonin
secretion during the night shift, and that the anticarcinogenic effects of the melato-
nin are therefore reduced. Diabetes also appears to have a link to shift work, even if
the scientific support is still as yet limited.

8.12  INDIVIDUAL DIFFERENCES

There are quite clearly major individual differences in one’s ability to tolerate night
shift work. Often one finds that the majority of workers have very few problems,
while the group with major problems scarcely exceeds 10%. There is also a group
that is at least as big that has no negative reactions at all from shift work. Many
attempts have been made to identify special risk groups who might potentially suffer
from unusual working hours. No clear conclusions can be drawn, however. There are
scarcely any gender differences. Increased age may possibly mean greater difficul-
ties, primarily with daytime sleep (the sleep mechanism is somewhat weaker in older
individuals, and the diurnal rhythm’s waking effects take over). Night sleep is, of
course, also disturbed by increased age, but relatively modestly—waking more often
and waking up earlier, again resulting from a weaker sleep mechanism. This leads to
a greater difficulty in coping with shift work with increased age; 45 years of age
seems to be a turning point. One interesting observation that has been made in sev-
eral studies is that older people are less sensitive than younger ones to sleepiness
when taking the odd night shift.
Morning people have problems in relation to night shifts, but on the other hand
have advantages on morning shifts. In all likelihood, it is also true that individuals
with a tendency to sleep disturbance have greater problems with night work, as the
sleep that follows encounters resistance from their biological clock. This has, how-
ever, not been studied.
Work That Disrupts the Diurnal Rhythm 233

One observation which may be relevant is that those individuals who are most
physiologically adapted to night work (high melatonin levels during the day and low
during the night) have fewer problems. This presumably reflects the greater focusing
on night work on the part of the individual and possibly a more successful approach
to dealing with daytime sleep. This last may mean that they black out the bedroom
more efficiently, that they avoid exposure to light on the way home from their night
shift (with the help of dark glasses) and that they also have an evening orientation
in their lives on their days off. These are speculations, however, which still have to
be tested.
One study recently investigated what characterizes shift workers with a very neg-
ative, or respectively very positive, attitude to their working hours. A number of
factors were tested, and in brief the strongest factor was much greater fatigue in rela-
tion to night work in combination with a lack of recuperation during sleep [Axelsson
et al. 2004]. The sleep was, however, not curtailed. Ongoing research is being pur-
sued in order to determine what factors may be involved in fatigue.

8.13  SPECIAL FACTORS CONCERNING WORKING HOURS

There are a number of aspects of disruption in the diurnal rhythm that have to be
taken into account when we talk about the effects of unusual working hours. One of
these is the time between shifts. Evidently, extremely rapidly rotating shifts (with 8 h
between shifts) do not provide sufficient time for recuperation. A somewhat slower
rotation—2–3 similar shifts in a row—seems to be a good compromise. Longer
sequences of night work increase fatigue (physiological adaptation does not occur).
Another factor is the direction of the rotation. As postponement seems to be an
inbuilt tendency in the circadian rhythm when synchronizers are not in evidence, it
is natural to allow the work shifts to alternate from morning to afternoon and then
night. Going from an afternoon shift to a morning shift on the other hand means that
the time off between shifts is shortened to 8 h, which results in greater fatigue.
Backward rotation is, however, often the wish of the employee to achieve a longer
continuous time off.
Long shifts are often physiologically unproblematic if they do not exceed 12 h, as
long as there are breaks and the workload is not too high. This also applies to the
transport field—a long period of wakefulness, reduced sleep, or night work is con-
siderably more important causes of fatigue. As mentioned earlier, extended work
shifts are a marked trend in Europe—to provide long continuous periods of time off.
The number of days in a row which can be worked without physiological effects
is unknown, but there are studies indicating that the risk of errors rises markedly
among locomotive drivers after 7 successive days of work. Some studies have shown
similar effects for industrial work.

8.14  RISK-REDUCING MEASURES

Working at night is in itself not physiological. It can logically never be equivalent to
day work as regards strain, but as has been discussed above, there are factors that can
improve the situation.
234 Occupational Physiology

Presumably the most important countermeasure is reduced work hours. Fatigue

needs to be counteracted with sleep and a normalization of the diurnal rhythm. Then
an extra day is needed to adjust from night work.
It may also be that a shift longer than 8 h may help (paradoxically enough), as
fewer days are in this way allocated to night work; the worker has more days with
natural (night) sleep and avoids early morning shifts which also constitute a problem
of difficult and non-physiological waking times. But the work load also has to be
adapted so that the worker can cope with long shifts, and there has to be the oppor-
tunity for breaks when the nature of the work requires it.
The days off work which form part of the shift compensation, or which are
acquired through taking longer shifts, should of course be used for recuperation
immediately once the load has ceased. That is where they are needed most. To moon-
light during leisure time is inappropriate because it often prevents rest and
recuperation.
One could discuss whether permanent night work might be an alternative to that
system of alternation between shifts which now dominates. It is somewhat easier to
deal with night work if it is made permanent. The disadvantage of permanent night
work is, however, that one risks ending up being excluded from in-service training
and other things that happen during the daytime. Employers should therefore ensure
that day work is also undertaken.
In night shift work it is otherwise a good idea to have an early end to the shift.
This makes for longer sleep. Ending the night shift at 5 am provides an almost nor-
mal length of sleep, in that one has time to get in around 6 h of sleep before the
diurnal rhythm’s wake-up effect sets in during the early afternoon (see Figure 8.4).
The disadvantage is that the morning shift is affected by a reduction in sleep because
of having to get up so early.
Individuals must themselves ensure that they optimize their sleep environment.
This means a total blackout of the bedroom, low temperature (14–16°—air condi-
tioning in summer) and a silent environment (earplugs are recommended). One
should also ensure that incomplete daytime sleep is complemented by taking naps
and restricting any moonlighting. A short (20 min) nap can easily replace 2 h of lost
main sleep. The reason is that main sleep is very ineffective towards the end, while
the nap is more effective. Shift workers should also be aware of their diet so as to
counteract raised blood lipid levels.
The greater difficulty of daytime sleep with advancing age (as mentioned earlier)
may often make it impossible to continue with night work. For this group and for
others with recuperation problems in daytime sleep, there is today no alternative
other than transferring to some form of day work (or stopping work completely). It is,
moreover, wise to try to find an opportunity for alternation between timetables with
and without night work, so as to allow employees who want to work at night to do so
when they feel they are able and need to.
We should also be aware that treatment with pharmaceuticals to reduce fatigue
has begun to be used in the United States. It is, however, unclear as to whether this
is suitable in the long term. Nothing is known about the consequences, and it is
­doubtful as to whether fatigue, as a natural reaction to too little sleep, should be
treated at all.
Work That Disrupts the Diurnal Rhythm 235

8.15  SUMMARY
George’s sleepiness is, as we have seen, a safety risk when he is driving his truck.
Night work and morning work cause a conflict with the normal day-oriented physiol-
ogy. The result is problems in sleeping during the daytime and being awake at night
time. In the long term this has consequences for safety and health. If someone is
awake for more than 16 h or asleep for <6 h, there is a clearly increased safety risk.
Shift work also has certain negative effects on long-term health. The function of
sleep is to restore the brain’s functional level after the reduction occurring during the
waking hours of the day. Sleep is also a precondition for the rest of the body’s physi-
ology to be able to recuperate and function normally. There is really no way of elimi-
nating these problems. On the other hand, we can alleviate the effects by sleeping
strategically (a nap is extremely efficient), optimizing our sleep environment, and
ensuring that we have regular recuperation. It is also important to be aware of the
greater risk of accidents in connection with night work, and of the need for a healthy
diet. Legislation has taken note of some of the problems by limiting the length of
driving time, but on the other hand in practice it ignores (strangely enough) the
effects of working at night.

REFERENCES
AASM ICSD. 2005. International Classification of Sleep Disorders, Revised: Diagnostic and
Coding Manual. Chicago, IL: American Academy of Sleep Medicine.
Angersbach, D., P. Knauth, H. Loskant, MJ. Karvonen, K. Undeutsch, and J. Rutenfranz.
1980. A retrospective cohort study comparing complaints and disease in day and shift
workers. Int Arch Occup Environ Health 45:127–140.
Åkerstedt, T. 2003. Shift work and disturbed sleep/wakefulness. Occup Med 53:89–94.
Axelsson, J., T. Åkerstedt, G. Kecklund, and A. Lowden. 2004. Tolerance to shift work—How
does it relate to sleep and wakefulness? Int Arch Occup Environ Health 77:121–129.
Bjerner, B., Å. Holm, and Å. Swensson. 1955. Diurnal variation of mental performance.
A study of three-shift workers. Br J Ind Med 12:103–110.
Czeisler, CA. and D-J. Dijk. 2001. Human circadian physiology and sleep–wake regulation.
In: Takahashi, FW. and RY. Moore. (Eds), Handbook of Behavioral Neurobiology. New
York: Kluwer Academic/Plenum Publishers, pp. 531–569.
Directive 2002/15/EC of the European Parliament and of the Council of 11 March 2002 on the
organisation of the working time of persons performing mobile road transport activities.
http://eur-lex.europa.eu//en/index.htm
Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003
concerning certain aspects of the organisation of working time. http://eur-lex.europa.
eu//en/index.htm
Knutsson, A., T. Åkerstedt, B. G. Jonsson, and K. Orth-Gomér. 1986. Increased risk of isch-
emic heart disease in shift workers. The Lancet 12;2:89–92.
Philip, P. and T. Åkerstedt. 2006. Transport and industrial safety, how are they affected by
sleepiness and sleep restriction? Sleep Med Rev 10:347–356.
Taylor, PJ. and SJ. Pocock. 1972. Mortality of shift and day workers 1956–68. Br J Ind Med
29:201–207.
Torsvall, L., T. Åkerstedt, K. Gillander, and A. Knutsson. 1989. Sleep on the night shift:
24-Hour EEG monitoring of spontaneous sleep/wake behavior. Psychophysiology
26:352–358.
236 Occupational Physiology

FURTHER READING
Boggild, H. 2009. Settling the question—The next review on shift work and heart disease in
2019. Scand J Work Environ Health 35:157–161.
Sallinen, M. and G. Kecklund. 2010. Shift work, sleep and sleepiness—Differences between
shift schedules and systems. Scand J Work Environ Health 36:121–133.
 9 Work in Heat and Cold
Désirée Gavhed

Photo: Allan Toomingas

CONTENTS
9.1 Focus and Delimitation.................................................................................. 239
9.2 Prevalence of Work and Disorders in Heat and Cold.................................... 239
9.3 What Characterizes Work in Heat and Cold?................................................240
9.4 Heat Production, Heat Loss, and Temperature Regulation...........................240
9.5 Cold................................................................................................................ 243
9.5.1 Physiological Responses to Cold and the Effects on Work
Ability and Health............................................................................. 243
9.5.1.1 Rest..................................................................................... 243
9.5.1.2 Work....................................................................................244
9.5.2 Risks in Cold..................................................................................... 247

237
238 Occupational Physiology

9.6 Heat................................................................................................................ 249

9.6.1 Physiological Responses to Heat and the Effect on Work Ability
and Health.......................................................................................... 249
9.6.1.1 Rest..................................................................................... 249
9.6.1.2 Work.................................................................................... 250
9.6.2 Acclimatization to Heat and Performance in the Heat...................... 251
9.6.3 Risks with Heat.................................................................................. 253
9.7 Indoor Climate............................................................................................... 255
9.8 Gender Aspects of Work in an Extreme Climate.......................................... 255
9.9 Age Aspects of Work in an Extreme Climate............................................... 256
9.10 Measurement and Rating of Thermal Climate.............................................. 257
9.10.1 Scales for Rating Climate Experience............................................... 257
9.10.2 Measuring Physical Factors............................................................... 258
9.10.3 Physiological Measurements............................................................. 259
9.10.4 Methods for Assessing the Risk of Hypothermia.............................. 259
9.10.4.1 Insulation Required Index, Insulation Needs..................... 259
9.10.4.2 Wind Chill Index................................................................260
9.10.5 Methods for Assessing the Risk of Heat Strain................................. 261
9.10.5.1 Wet Bulb Globe Temperature............................................. 261
9.10.5.2 Predicted Heat Strain.......................................................... 262
9.10.6 Methods for Assessing Discomfort from Heat and Cold in
Indoor Climate................................................................................... 262
9.10.6.1 Predicted Mean Vote.......................................................... 262
9.11 Remedial Measures for Climate Problems.................................................... 262
9.11.1 Measures in the Cold.........................................................................264
9.11.1.1 Clothes against the Cold.....................................................264
9.11.2 Measures in the Heat......................................................................... 265
9.12 What the Law Says About Work in Heat and Cold.......................................266
9.13 Summary....................................................................................................... 267
References............................................................................................................... 267
Further Reading...................................................................................................... 268

Bert, who is 57, has worked full time for many years for a building firm in Canada.
He works all year round, mainly outdoors. The firm primarily constructs office
buildings and private houses. Bert’s tasks vary. Sometimes the work is very heavy
when there are building materials to be carried. At other times, it is fairly seden-
tary, when he supervises machine work, for example, when a hoist is moving
materials.
Bert generally enjoys his work, but is starting to think that it is hard going with
the heavy operations in very hot or very cold weather. He is not as physically active
in his leisure time as he was 20 years ago, when he often went skiing during the cold
season and went swimming a lot in summer. In winter, Bert feels a little stiff, and
has pain in his knees and in two fingers which got frostbitten one particularly cold
winter. During the days of summer he gets very tired after work and can even feel
a little unwell when he is at his worst. In recent health checks, he was found to have
Work in Heat and Cold 239

high blood pressure, and he now has to take antihypertensive drugs on a regular
basis.

9.1  FOCUS AND DELIMITATION

This chapter deals with how working in the heat and cold affects the body and pro-
ductive capacity. The demands made on the body’s physiological adaptability
increase when it is subjected to external stress. In extreme conditions, such as doing
heavy work in the heat, the body does not always manage to compensate for the
considerable heat load, and the risk of injury and ill health is considerable. This
chapter answers questions such as:

• Can Bert’s bad knee have anything to do with the climate at his workplace?
• Why is Bert’s pulse rate so high when he works in the sun?
• How can Bert protect himself against heat and cold?
• Are there any opportunities for anticipating what conditions people can
work under in different climates, and for how long?
• Does Bert’s age have any significance for his work ability in heat and cold?

9.2  P
 REVALENCE OF WORK AND DISORDERS IN
HEAT AND COLD
Many people have problems with the climate at their workplaces. The problems are
varied in nature and depend on whether it is a question of outdoor work, an office
workplace, or work in industry. Problems with the climate at workplaces seem not to
have been dealt with to any extent over the last 20 years, and there is little to indicate
that exposure to climate will change to a great extent in the coming decade. The
concept of thermal climate has to do with heat and cold, unlike the psychosocial
climate. Exposure to climate is the dose of heat or cold, humidity, and wind speed to
which people are subjected.
A large number of workers are exposed to cold and/or heat at their workplaces,
and many of them experience cold and/or heat strain [Eurofound 2007]. The greatest
proportion of disorders is reported from work that is mostly performed outdoors,
manufacturing work, and transport work. About a quarter of the workers in Europe
are exposed to low or high temperatures for a quarter or more of their workday. In
all, 25% of the workers are exposed to “high temperatures which make them perspire
even when not working,” while 22% are exposed to “low temperatures whether
indoors or outdoors.” Male workers are more exposed to challenging thermal envi-
ronments than female workers are, according to EU Working Conditions statistics
(heat: 31% for males vs. 18% for females, low temperature: 29% for males vs. 13%
for females). This is because a large proportion of men work in businesses involving
either high or low temperatures such as building and installation, forestry and agri-
culture, and manufacturing industry. In the European Union (EU) member states,
the reported percentage of workers experiencing thermal strain ranges from 14% to
45% [Eurofound 2007]. In order to reduce the number of disorders, thorough knowl-
edge and practical measures are required.
240 Occupational Physiology

9.3  WHAT CHARACTERIZES WORK IN HEAT AND COLD?

Exposure to extreme climates varies in both time and intensity in different businesses.
In work in a large-scale kitchen, staff only go into the refrigeration and freezer rooms
on a few occasions each day to fetch or leave food and stay there for a very short span.
Building workers, as in our first example, can be exposed to extreme cold or sunshine
and heat throughout their working day. Frequently, climate problems are related
directly to the business and/or the outdoor climate. Examples are workplaces with
heat-generating processes, for example, manufacturing pulp or casting metals.
The most common causes of climate problems in outdoor work are solar radiation
in hot environments in combination with heavy work as well as wind and cold in cold
climatic zones. In parts of the world where the climate varies a great deal between
different regions and seasons, work has to be adapted to the specific situation. Even
in a normal indoor climate (e.g., an office) climate-related problems often occur.
It is important that assessments of the risks of disorders are based on the real
exposure to climate, that is to say how long and with what intensity the employee is
exposed to heat or cold, and not merely on measurements of the climate at the
workplace.
The following environmental and individual factors are of significance for the
individual’s well-being.

Climate Individual
• Air temperature • Heat production (which is dependent on work load)
• Radiant temperature • Thermal properties of clothing
• Wind speed
• Humidity

9.4  H
 EAT PRODUCTION, HEAT LOSS, AND TEMPERATURE
REGULATION
In the digestion of food, carbohydrates, fats, and proteins are metabolized to form
energy-containing substances used for life-sustaining processes, work, growth, and
recuperation (among others, ATP—see Chapter 2, Section 2.4). At rest, this energy
metabolism is called basal metabolism or Basal Metabolic Rate, BMR (see Fact
Box 9.1).

FACT BOX 9.1

OXYGEN CONSUMPTION, ENERGY METABOLISM
At rest, ~3.5 mL of oxygen is used per minute and kilogram of body weight,
which for a person weighing 80 kg amount to 0.28 L of oxygen/min. The
energy metabolism is ~6 kJ/min, which means that the heat output developing
in the body is ~100 W/m2 or ~55 W/m2 of body surface at rest. The body sur-
face of a “standard” person is ~1.7 m2 (man 1.8 m2 and woman 1.6 m2).
Work in Heat and Cold 241

At work, the stored chemical energy is converted into mechanical work and heat.
The proportion of the energy not directly used for work (the efficiency) in dynamic
muscle work with major muscle groups is at most 30%, but is negligibly small when
small muscle groups are recruited (e.g., arm work). For example, when Bert is ham-
mering nails, his efficiency is 15%, and 85% of the energy is therefore converted into
heat. For many work operations, all the converted energy becomes heat (see Section
9.10.2).
The temperature in the body core (the central parts of the body containing the
internal organs) is at rest normally around 37°C and usually varies ~0.5°C during the
day. This is important because all biochemical processes in the internal organs and
the brain function optimally at around 37°C. Other organs are also dependent on
temperature; for example, the muscles function best when they are warm.
Body temperature, like many other physiological functions, has a diurnal vari-
ation, which can influence the experience of the thermal climate and its effects
(see also Chapter 8, Section 8.5.1). The body heat content (and thereby tempera-
ture) is determined by the balance between heat production from the basal meta-
bolic rate, heat production in the muscles during physical work, and the heat
emitted by the skin surface. In a normal room climate there is a temperature gra-
dient (a gradually changing temperature difference) from the body core to the
body surface and from the body core to legs and arms, which are normally some
degrees lower (Figure 9.1). The skin temperature therefore varies across the whole
body, but is usually 33°C in the trunk at, for example, room temperature and
wearing indoor clothes.
In muscle work, the core body temperature and the muscle temperature rise with
increasing physical load (which should not be confused with a fever).

Hot Cold

37° 37°
36° 36°

32°

28°

34°

31°

FIGURE 9.1  Temperature distribution in the body in hot and cold environments. Illustration:
Niklas Hofvander.
242 Occupational Physiology

Radiation
Evaporation

Convection
Convection

Conduction

FIGURE 9.2  Heat exchange between the body and its surroundings. Illustration: Niklas
Hofvander.

The heat from the body surface is emitted through convection, radiation, conduc-
tion, and evaporation and by respiration through convection and evaporation (see
also Figure 9.2).

• Convection (movements in air or fluid): the surrounding air or water is

heated by contact with the skin. Warm air is lighter than cold and therefore
flows upwards along the body and away from the body. Wind or movements
of the body leads to increased convection; that is, more heat is emitted from
the body surface.
• Radiation: heat is emitted through electromagnetic waves directly from the
skin to colder surfaces in the surroundings (or vice versa through solar radi-
ation for other heat radiation, e.g., from a furnace).
• Conduction: heat is transferred directly in the contact surface between the
skin and the material.
• Evaporation: heat is emitted from the body when it accompanies the fluid
evaporating on the surface of the skin and mucous membranes and away from
the body. With high humidity in the surroundings or if tight clothes are worn,
sweat and moisture evaporates poorly, and the cooling effect is reduced.

In water, which has heat conductivity 25 times higher than air, large quantities of
heat are quickly transferred through conduction, for example, when diving. Heat
transfer can also occur in the opposite direction, from the surroundings to the body
surface, when the body is exposed to heat radiation or warm air. The temperature of
the body surface may then approach, or in extreme cases exceed, that of the core.
The body strives for a balance (homoeostasis) between heat production and heat
transfer (heat balance) to maintain an optimum environment for all the biochemical
Work in Heat and Cold 243

processes necessary to life. Temperature regulation involves thermoreceptors that

are constantly measuring the temperature and which send a signal to the control
centre in the hypothalamus in the central nervous system (CNS) (Fact Box 9.2).
Certain receptors are stimulated by cold, others by heat. Deviations from normal
body temperature activate regulators with the aid of hormones and the nervous sys-
tem. Nerve signals are transmitted from the hypothalamus to those organs involved
in temperature regulation (blood vessels, heart, sweat glands, adrenal glands, thy-
mus, and skeletal muscles).

FACT BOX 9.2

The heat and cold receptors in the skin are neurons, which in their receptor
portions have ion channels which open under temperature stimulation. It is
perhaps noteworthy that the ion canals of the cold receptors can also be opened
by chemical substances, for example, menthol, which explains why menthol
produces a feeling of cold.

The most important physiological mechanisms of temperature regulation are:

• Blood vessel constriction/dilation

• Sweating
• Shivering
• Changes in metabolism

For more detailed studies of temperature regulation, see textbooks in physiology

(listed in Further Reading).
What is generally meant by cold load or heat load is a situation where the body’s
temperature regulation is activated; see the subsequent sections on heat and cold.
This is a result of the physical work load (which makes for increased body tempera-
ture) and how warm one’s clothes are (which prevent heat from being emitted from
the body) when the ambient climate puts strain on the body. As previously men-
tioned, other climatic factors also affect climate load on the individual. In this way,
“heat” and “cold” are not precise temperatures. In the context of measurements and
ratings, ambient temperatures below +10°C are termed as “cold,” 10–30°C are called
“indoor climate,” and above 30°C are called “heat” (see Section 9.10).

9.5  COLD
9.5.1  Physiological Responses to Cold and the Effects on
Work Ability and Health
9.5.1.1  Rest
When Bert is supervising a building project in the cold, his body is protected by the
circulation being redistributed from the peripheral body parts (hands, feet, ears, and
nose) to the central parts of the body and the brain (see also Figure 9.1). The hands
244 Occupational Physiology

Skin temperature °C
35 Finger temperature walking in –10°C wearing winter clothes

30

25 Intermediate load

20

15

Low load
10

5
0 10 20 30 40 50 60
Time (min)

FIGURE 9.3  Skin temperature largely follows skin blood flow. More heat is formed with
moderately heavy work (thick line), which stimulates opening of the contracted vessels in the
finger and warms it up. Light work (thin line), which means lower heat production, cannot
stimulate opening of the vessels.

and feet therefore easily get cold in cold conditions (Figure 9.3). If the cooling con-
tinues, the body’s other defense is to increase heat production by causing Bert to
shiver (see Fact Box 9.3). Shivering is stimulated by a reduction in skin temperature
and the resultant reduction in core temperature (core temperature represents 67–80%
of the driving force behind shivering). Shivering therefore occurs in principle only
when one is generally motionless.

9.5.1.2  Work
9.5.1.2.1  Energy Metabolism and Work Ability
The energy metabolism is not noticeably higher in the cold at a certain level of
muscle work under other similar conditions, unless body temperature is reduced a
great deal and/or shivering begins. Under circumstances like these, energy metabo-
lism increases (see Fact Box 9.3). On the other hand, somewhat more energy may be
metabolized in cold than at room temperature when Bert moves a great deal. One of
the reasons for this is that he wears more clothes in the cold, which weigh more and
in part restrict his body movements, so that more energy is needed to move (see Fact
Box 9.3). In other cases, it might be because he wants to move more in the cold to
keep warm.
The physical work ability can be limited in the cold, partly resulting from the fact
that his joints and muscles are chilled. There will also be narrower margins up to
Bert’s maximum possible work output, as heavy winter clothes make for extra
weight.
Work in Heat and Cold 245

FACT BOX 9.3

• At work, energy metabolism increases by ~3% per extra kilogram of
clothing.
• Shivering may increase energy consumption and heat production by
up to approximately five times the rest value. When shivering, the
skeletal muscles contract intermittently, thereby creating heat, which
can warm up the body. The greater energy requirements in shivering
are provided for by an increase in the glucose release from the store
of glycogen in the liver.

9.5.1.2.2  Circulation and Work Ability

In the cold, the sympathetic nerves are activated, releasing the transmitter sub-
stance norepinephrine. This stimulates a contraction of vessels in the skin (see
Figure 9.4) via adrenergic receptors (muscle tone in the vessel walls). Particularly
significant for temperature regulation (both in heat and cold) are vessel structures
called arteriovenous anastomoses, AVAs. AVAs form a direct link between arteri-
oles and venules and can constrict or open, thereby substantially altering the blood
flow in the intermediate capillaries. In fingers and toes, the ears and the nose,
where the blood flow varies most, there are a great number of AVAs. As the blood
flow can be cut off particularly effectively there, these parts of the body are also
particularly vulnerable to cold. In warming up, the blood flow increases quickly
again.

20
Blood flow, mL/100mL tissue/min

15

10

0 10 20 30 40 50
Ambient temperature (°C)

FIGURE 9.4  The dependence of blood flow on ambient temperature measured in the hand.
(Data from Brown, GM. and J. Page. 1952. J Appl Physiol. 5:221–227.)
246 Occupational Physiology

At skin temperature <31°C, the vessels of the skin are at maximum contraction.
Blood flow in the skin is therefore low when sitting down or standing up. In the
extremities the blood flow is redirected to deep veins and arteries, which function as
a heat exchanger, so that heat is conserved.
A reduction in surface circulation of warm blood leads to a reduction in heat
transfer from the skin. There are two reasons for less heat to be transferred. On the
one hand, the temperature difference between the body surface and the surroundings
is lower when the skin becomes cooler; on the contrary, the heat conduction capacity
of skin with minimal circulation is lower than in tissue that is perfused with blood.
Insulation of the tissue which is not perfused increases two to three times. Note that
the blood flow to the head is not noticeably affected by the cold, as the blood vessels
there have very few sympathetic nerve fibres. This results in a large proportion of the
heat leaving the body being emitted from the head, if it is not protected.
The increase in central blood volume means that blood pressure increases. The
body attempts to compensate for the increase in blood pressure. This is done by low-
ering the heart rate and reducing the heart’s stroke volume, and through an increase
in kidney filtration (more urine is produced). This is presumably the reason why we
often need to urinate in cold weather. More fluid also “leaks” to the space between
the cells (interstitial compartment). The proportion of blood volume excluding blood
cells (plasma volume) may decrease by up to 15%. The blood therefore becomes
more viscous and sluggish, which increases the risk of local frostbite and strain on
the heart (see also Section 9.5.2).

9.5.1.2.3  The Musculoskeletal System

Cooling affects endurance, strength, power generation, speed, and coordination of
movements. The speed of conductivity falls in nerves (by 1–2 m/s per degree) mak-
ing reflexes and movements slower and less precise. The resistance of tissues can
also deteriorate, with a greater risk of damage in muscle work in cold or with sudden
overload.
Dynamic work ability decreases in the cold. Power generation falls ~3–8% for
each degree of reduction in muscle temperature in short-term dynamic work.
Moreover, isometric force development (in maximum voluntary contraction) is lower
when the muscle is cold. Endurance in static work, however, has an optimum at
around 27°C muscle temperature and falls both above and below this. In the cold,
more motor units have to be recruited to achieve the same force as at room tempera-
ture, or else the active units have to increase their force (see Chapter 6, Section 6.6).
Muscle fatigue therefore occurs earlier.
In most jobs, a good ability to work with the hands is required. Feeling in the
fingers, which is very important in precision work, starts to drop off even at a skin
temperature of 32°C (which is normal temperature) and falls further when cooled
down to 7–8°C, when the nerve conductivity ceases. Mobility in the fingers begins
to diminish at around 21°C (skin temperature) and becomes severely limited at about
16°C.
Apart from the physical work ability, mental functions are also affected by cool-
ing, which produces uneasiness and may distract the individual at work.
Work in Heat and Cold 247

9.5.1.2.4  Breathing
Breathing in cold air and exposing the face to cold air may impair physical work
ability and produce disorders. A running nose is a common reaction to cold, which
can be annoying and distracting.
Cold air is dry, containing only small amounts of water—just a few grams per
kilogram of air. Warm air can contain considerably more water. The mucous mem-
branes in the nose and airways humidify the dry air so that it becomes saturated with
water vapor. In physically heavy work, when large volumes of cold air are exhaled
through the mouth, there is a risk that the mucous membranes in the airways dry out
and become irritated. See Section 9.5.2.

9.5.1.2.5  What Happens in the Cells?

The effect of exposure to cold on human cells has not been well researched. It has
been observed that the lipid composition in the cell membrane changes, so that its
function can be maintained, and that RNA synthesis, protein synthesis, and cell
growth decrease. The protective so-called cold-shock proteins are formed when the
cells are exposed to cold, and so they can better withstand the strain.

9.5.1.2.6  Cold Acclimatization

Acclimatization to cold in the long term can occur locally through vascular con-
striction in peripheral parts of the body not being activated in the cold. This means
that the nerve–muscle function in hand/feet can be maintained, but at the same
time means a greater heat transfer, which may cool down the body if exposure is
long term. After a month of working outdoors, Bert’s hands keep warm for much
longer than at the beginning of the winter, but not all of his colleagues are affected
in this way. It is very individual. It is still uncertain whether acclimatization of the
whole body occurs in the cold. Psychological adaptation probably occurs, which
means that the experience and the unpleasantness of cold declines after regular
exposure.

9.5.2  Risks in Cold

By constricting AVAs in the skin, the body can maintain the heat balance if exposure
is short term or mild, but at the cost of comfort. When the skin temperature falls, it
first feels unpleasant, then a feeling of cold and pain follows. If the hands get cold,
the risk of accidents in manual work increases, as muscle capacity falls off and coor-
dination of movements is considerably impaired.
If the cold load is considerable, then vascular contraction is not enough to main-
tain the inner body temperature. Hypothermia, which implies that the body tem-
perature falls below 35°C, is however unusual at work. Most cases of hypothermia
have been among people who are intoxicated, have a psychological illness or
dementia, or people who have had accidents or gotten lost. It is, however, important
to be aware that certain pharmaceuticals, alcohol, and nicotine affect temperature
regulation. The most important risk factors for hypothermia and injuries are shown
in Fact Box 9.4.
248 Occupational Physiology

FACT BOX 9.4

RISK FACTORS FOR HYPOTHERMIA AND INJURIES

• Wind
• Handling cold metal objects and fluids • Increases chilling and the risk of frostbite
• Inadequate or wet clothing
• Low physical activity • Low heat production, easy to become chilled
• Illness • Increases sensitivity
• Particularly susceptible individuals
• Ice and snow, darkness • Makes work more difficult, risk of slipping

Frostbite occurs when the temperature of the tissues falls below 0°C. Ice crystals,
which shred the cell membrane, are formed in the fluid between the cells, and the
cells dry out (through osmosis). Frostbite can be severe, and in the worst cases results
in tissue death, which requires amputation or may lead to increased sensitivity to
cold and impaired sensitivity long after the injury has healed.
When the face is exposed to cold wind (or cold water), as when Bert is work-
ing outdoors in winter, a reflexogenic reduction in heart rate (via parasympaticus)
occurs at the same time as an increase in blood pressure activated by the sympa-
thetic system. This can cause problems for Bert, who has high blood pressure, and
for people with other cardiovascular diseases, as it means greater strain on the
heart.
Respiratory disorders can also be triggered by cold on the face and body. The
bronchial tubes in the airways contract owing to stimulation of nerves under sympa-
thetic control (β-adrenergic receptors). In extreme cold, heavy work with high lung
ventilation may imply a risk of damage to the airways. In strenuous work in cold
conditions, 4–20% of healthy individuals experience asthma-like symptoms. There
are indications that heavy breathing of cold air can lead to inflammation of the lower
airways. The risks increase at air temperatures below –20°C. Disorders of the mus-
culoskeletal system are more common at cold workplaces than at those at room tem-
perature, and seem to increase with exposure time. Bert’s problems with his knees
are presumably linked to his exposure to cold. Table 9.1 lists medical disorders that
may arise from or be exacerbated by cold, and illnesses that may involve problems
when working in the cold.
There are considerable individual differences in tolerance to cold, which have
to be taken into account when making a risk assessment. Particular risk groups in
working life are individuals:

• Who have previously been susceptible to cold or who have had frostbite.
• Who are inexperienced in working in the cold.
• With certain chronic illnesses (see above) and/or who are taking medicine
which affects temperature regulation.
• With an ongoing infection and fever.
Work in Heat and Cold 249

TABLE 9.1
Health Problems and Disorders with Cold Strain
Cardiovascular diseases Ischemic heart disease (coronary disease, resulting in
oxygen deficiency in the heart), high blood pressure
(hypertension).
Cold—allergy Allergic reaction with swelling and rash on the skin
after reheating cold skin. Also general symptoms,
such as headache, breathing difficulties (dyspnea),
tachycardia (palpitations), and allergic shock occur.
Diabetes In diabetes, nerve function and blood circulation are
often impaired peripherally. This exacerbates the
hypothermia.
Respiratory diseases A large proportion of people with asthma and chronic
obstructive lung disease experience disorders in the
cold. The symptoms often arise in connection with
exertion. People with chronic bronchitis also
sometimes have asthma-like symptoms in the cold.
Raynaud’s syndrome/white fingers Impaired circulation in the fingers. The fingers go
pale because the circulation is cut off. The syndrome
is often the result of a vibration injury, but can also
be an innate overreactivity on the part of the vessels.
Skin diseases Psoriasis and various forms of skin complaints, which
involve damage to dermal layers, may increase heat
transfer from skin and thereby the risk of frostbite.
Some types of dermatitis can these be exacerbated
by cold, for example, atopic dermatitis.
Endocrine diseases Deficient pituitary function and hypothyroidism (lack
of the hormone thyroxine). The hormones are
necessary for normal heat production and
metabolism.
Diseases of the musculoskeletal system Tendinitis, lumbar spine conditions, pain in shoulders
and knees. Repetitive wrist movements in the cold
increase the risk of carpal tunnel syndrome

9.6  HEAT
9.6.1  Physiological Responses to Heat and the Effect on Work
Ability and Health
9.6.1.1  Rest
When Bert is exposed to heat at rest, his body protects itself against overheating
through a major proportion of the blood flow being diverted from central parts of
the body to the skin, mucous membranes, and peripheral parts of the body (Figure
9.4), which get warmer. In physical labour, large parts of the blood, as usual, go to
the working muscles. If the heating continues, Bert begins to sweat to give off more
heat.
250 Occupational Physiology

9.6.1.2  Work
9.6.1.2.1  Energy Metabolism
Energy metabolism is in certain cases somewhat higher during work in the heat than
at lower temperatures. When Bert is doing carpentry, his energy metabolism
increases, and thereby the temperature in his muscles and the rest of his body. When
he is doing heavy work, heat production is compensated for by heat transfer, which
involves stress on the body even at normal temperatures. Hot working days also fur-
ther limit how heavy his work can be, and how long he can work without risk to his
health. The increase in muscle temperature also increases the degradation of glyco-
gen in the muscle, reduces fat oxidation, and increases the accumulation of lactic
acid (lactate). In heavy physical work, the release of adrenaline is increased (in the
heat, around twice as much), which also increases the degradation of muscle
glycogen.
9.6.1.2.2  Circulation
Rerouting of some of the blood volume that the heart pumps out every minute (car-
diac output) from the internal organs to the muscles, skin, and peripheral parts of the
body is carried out through stimulating the autonomous nervous system. In the heat
this leads to the dilation of the vessels in the skin (relaxation of the musculature/
reduction in muscle tension in the walls of the vessels) and an opening of arterio-
venous anastomoses (see Section 9.5.1 on blood flow in the cold). In order to com-
pensate for the greater volume of the vessels, the cardiac output increases through
increasing the heart’s contractive force and rate. The heart rate is thus a relatively
simple measure of circulation load and heat load, which can be used in assessing
physiological strain in the heat. Physical training to improve the heart’s ability to
work therefore provides much better preconditions for working in the heat. Bert, who
is no longer so fit, therefore becomes more tired than before when doing heavy work
in the heat.
9.6.1.2.3  Sweating and Fluid Balance
At rest, the body emits ~30 g (0.3 dL) of fluid per hour through the skin, the mucous
membranes, and the lungs in the form of water vapor (also called perspiratio insensi-
bilis) even when not sweating. The ability to sweat is the most important human attri-
bute for tolerating heat. The body has between 2 million and 5 million sweat glands.
We normally sweat 0.5–1.5 L/h in the heat, but in extreme conditions sweating may
be as high as 3 L/h. When sweat evaporates (vaporizes), energy as heat is lost from the
skin and this makes possible the removal of the heat carried there via the blood (Fact
Box 9.5). There is a considerable individual variation in the sweating function, which
depends on things such as hereditary factors, the level of physical training, and heat
acclimatization. Both training and habituation (see Acclimatization, Section 9.6.2)
increase the production of sweat and thereby cooling the body.
An increase in central and peripheral temperature (central temperature is more
important than skin temperature) activates the sweat glands. The signals go out from
the CNS to sympathetic postganglionic nerves (nerves that have one end in the mass
of nerve cell bodies, the ganglia, outside the spinal cord) which stimulate the produc-
tion of sweat. Peripheral thermoreceptors can modify the response.
Work in Heat and Cold 251

FACT BOX 9.5

About 2430 kJ of thermal energy is used to evaporate 1 L of sweat.

9.6.1.2.4  The Musculoskeletal System

At higher muscle temperature the speed of the contraction increases. Maximum
force development in the muscle seems to be little affected, however, by muscle tem-
peratures between 25°C and 40°C. Heat load leads to more rapid fatigue and lower
endurance both in dynamic and static work. One of the causes may be that central
stimulation of the motor units decreases with heat load. The aerobic energy delivery
declines with physical work in the heat, and lactate is more easily formed.

9.6.1.2.5  How is the Work Ability Affected?

The first noticeable effects of heat load, apart from the feeling of overheating, are
psychologically conditioned disorders, such as discomfort and irritation. Both dis-
comfort and heating can affect mental functions, such as attention, and the ability to
carry out complex tasks. The effect is a gradual one, and eventually performance
capacity becomes impaired. The risk of missing important information, for example,
traffic signals when Bert is driving his car home from work on a hot day, increases
with heat load. The extent to which different individuals are affected varies, and
depends on how quickly heat is stored in the body, the type of task, and work skills.
If Bert does not have sufficient fluid intake during the working day, sweating
leads to dehydration. The fluid deficit impairs his physical work ability, all the more
so the greater the deficit. A fluid deficit of, for example, 1.6 L in an individual weigh-
ing 80 kg (i.e., to say 2% of body weight) suffers impairment in endurance of 10–20%.
As sweat contains salt, fluid loss means that salt is lost at the same time. With major
fluid loss, the salt has to be compensated for with things like energy drinks or extra
salt. It should be noted that a normal diet often contains an excess of salt.

9.6.1.2.6  What Happens in the Cells?

When the temperature exceeds ~40°C in the muscle cells, permeability of the mito-
chondrial membrane and a number of metabolic changes affecting the function of
the muscle presumably occur. For example, oxidative phosphorylation in the mito-
chondria, which provides energy-rich molecules for things like muscle work,
decreases. The so-called heat-shock proteins (HSP) are formed with heat stress.
They protect the DNA of the cell and other proteins from being destroyed. HSP is
also formed as a result of other types of stress, such as oxygen deficiency and glucose
deficiency in the cells. Knowledge of this subject area is still very limited.

9.6.2  Acclimatization to Heat and Performance in the Heat

By frequently being or working in the heat, adaptation of the entire system occurs,
which means that the sweating capacity and regulation of blood flow are improved.
This process is called heat acclimatization. The full effect is achieved after 7–10
days of regular exposure to heat. The majority of the positive effect is achieved as
252 Occupational Physiology

39.5
180

1.4
39.0
160
Rectal temperature (°C)

Heart rate beats/min

Sweat loss (kg/h)

38.5

140 1.3

38.0

120
1.2

37.5
0 1 3 5 7 9
Days

FIGURE 9.5  Physiological effects of 9 days’ heat acclimatization on core (rectal) tempera-
ture, sweating, and heart rate. Triangles = sweat loss in kg per hour; hollow circles = rectal
temperature in°C; solid circles = heart rate in beats per minute. (Modified from Lind, AR.
and DE. Bass. 1963. Fed. Proc. 22:704–708. With permission.)

soon as 3–4 days. Physical exercise also results in similar physiological adaptations
as in heat training. Heat training is, by analogy with physical exercise, more efficient
the longer and hotter the daily dose. The effect of the training is a very marked
decrease in the feeling of exertion and physiological strain at work.
After heat acclimatization at any given level of physical work, the heart rate is
lower, the stroke volume and skin blood flow are greater, and heart activity and
sweating more efficient (quicker activation of sweat glands and activation of more
sweat glands, greater production of sweat), all of which leads to lower body tem-
perature (Figure 9.5). As mentioned earlier, the distribution of blood pumped from
the heart away from internal organs to the muscles and skin alters during work.
After acclimatization, blood flow to the skin increases while maintaining circula-
tion in the inner organs. The plasma volume increases as a result of the increase in
the amount of protein in the plasma through synthesis, recycling, and fluid leaking
in from the space outside the vessel. Total loss of heat acclimatization takes
3–4 weeks.
Work in Heat and Cold 253

9.6.3  Risks with Heat

Heat balance can be maintained normally through the vessels in the skin dilating and
as a result of sweating. If the ambient temperature (and humidity) is too high in mod-
erately heavy work, for example, at an air temperature exceeding 25°C, these protec-
tive reactions are not enough, and body temperature increases. The greatest medical
risks of working in the heat are overheating of the body, dehydration/fluid deficit, and
burns. The effect on mental functions can have serious consequences with mistakes
leading to accidents; for example, drivers missing traffic lights and causing a traffic
accident. Several factors in the environment produce risks of heat strain or injuries:

• High air temperature (or water temperature when diving)

• High humidity
• Solar radiation or heat radiation
• Hot surfaces and fluids
• Tight clothes
• High work rate, heavy physical work

Combinations of several of these factors increase the risk. High humidity in combi-
nation with high air temperature, for example, mean that not less sweat evaporates
from the skin over a given period of time, which increases the rate at which the body
heats up. In fire fighting with breathing apparatus, to take an extreme example, fire
fighters are exposed to all of the above-mentioned risk factors.
The high demands for blood supply to both the working muscles and skin at the
same time can lead to overload, exhaustion, and collapse (see more below).
Intensive sweating and drinking too little can lead to dehydration and salt defi-
ciency (see Fact Box 9.6). In dehydration, the plasma volume, and the stroke volume
and minute volume of the heart decrease (this is also the result of overheating).
Fainting may occur as a result of fluid deficit (circulation to the brain decreases), and
muscle cramps as a result of major losses of salt and minerals and muscle fatigue. If
heat syncope or other heat problems occur, the correct acute treatment should be
given, and possible hospital treatment should follow.

FACT BOX 9.6

Sweat contains 0.5–1.0% minerals and organic substances, primarily NaCl
(salt), urea, lactate, and potassium ions.

Another risk in heat strain is too excessive a sugar concentration in the blood
(hyperglycemia), as the glucose uptake does not increase in the cells, despite the fact
that glycogen degradation increases in heat (see p. 250).
Burns, which can occur in contact with hot surfaces and fluids, require rapid cool-
ing and often medical attention.
Most people cope with reasonable heat load and may, as mentioned above, train
their tolerance. The physiological capacity in work in the heat, however, varies a
254 Occupational Physiology

great deal between individuals. A very small group of people are heat intolerant, and
suffer severely in hot environments. A large number of illnesses, obesity, or a gener-
ally fragile state of health makes for greater sensitivity to heat load. Alcohol, caf-
feine, nicotine, and other drugs as well as certain pharmaceuticals impair heat
tolerance by affecting the CNS or peripheral functions, for example, vascular con-
traction and relaxation. For instance, antihistamines (for allergies) impair heat trans-
fer, both through their influence on the hypothalamus and on the sweat glands.
Apart from climate exposure, there are several individual factors that increase the
risk of heat strain:

• Pregnancy (higher heat production)

• Small body mass (heats up quickly)
• Obesity (circulation already loaded)
• Age (less tolerance with increased age)
• Cardiovascular disease (circulation functions less well)
• Diabetes (poor peripheral circulation)
• Skin complaints, for example, scleroderma (impaired peripheral circulation)

Overheating of the body can be dangerous (Table 9.2). It is therefore important that
both the person working in the heat and the supervisor are aware of early signs (con-
siderable discomfort and a feeling of being hot, a paradoxical experience of cold, in
combination with thirst, headache, a feeling of being sick, and impaired concentra-
tion). Work should be stopped immediately and cooling measures started straight
away. In cases of heat stroke, body temperature continues to rise uncontrollably if
nothing is done. Together with burns these are the most serious conditions in the
heat, and they require immediate medical intervention.

TABLE 9.2
Medical Consequences of Excessive Heat Load
Dehydration Leads to impaired sweating function in
circulation, and may lead to headache, dizziness,
and fainting.
Edema Swelling of hands, feet, and ankles as a result of
salt and fluid deficit.
Heat rash Characterized by increased histamine response
leading to eczema and respiratory disorders.
Heat cramp Muscle cramp as a result of salt deficit, fluid
deficit, and muscle fatigue.
Heat exhaustion (resulting from a fall in blood Sometimes in combination with raised body
pressure) and muscle cramp temperature, often resulting from fluid deficit
leading to weakness, a feeling of sickness,
dizziness, disorientation, and sometimes fainting.
Heat syncope, heat stroke (resulting from high Sweating ceases, serious CNS impact with
body temperature) symptoms as for heat exhaustion as well as
initially high heart rate and later weak pulse and
renal failure
Work in Heat and Cold 255

9.7  INDOOR CLIMATE

Indoor climate normally implies no great strains on the body in the way that a more
extreme climate does. Despite this, complaints are often made about the climate
particularly in offices. Common concerns are that it is draughty and too cold. One
explanation for this is that office work normally involves a great deal of sitting/stand-
ing, where the individual has low heat production, and is therefore sensitive to small
variations in the climate of the surroundings. Another contributory factor is that
people wear light clothes, which do not protect all parts of the body equally, for
example, the neck or the legs. Movements of the air are felt as draughts when they
exceed around 0.15 m/s (0.3 miles/h) (depending to a certain extent on the air tem-
perature and degree of turbulence). Cooling that only affects certain parts of the
body contributes to the total climate experience, even if central body temperature is
not particularly affected. Low temperature outdoors means that poorly insulated
walls and windows lead to cold and radiation draught indoors. Radiation draught
means an experience of draught which is not caused by high air velocity, but rather
by heat being lost through radiation from part of the body to a cold surface.
Particularly cold indoor climates, for example, cold stores in the food industry, are
dealt with in the section on cold above.
In summer, solar radiation means that it becomes too hot indoors, for example, in
buildings with large glass windows. At the beginning of a heat wave, it is usual for
many people working in offices to complain about the heat. Unfamiliarity with heat,
both psychological and physiological, means that many people experience the first days
as trying. Gradually, familiarization occurs, and the discomfort and strain decline. It is
frequently possible to find the causes of the complaints in the physical work environ-
ment. Perhaps the ventilation plant is not dimensioned correctly for cold air. Staff that
have external contacts at work usually have some kind of formal dress or uniform and
cannot therefore always adapt their clothing to the heat. There may be an opportunity
to wear a lighter variant of the formal uniform which is acceptable, which is a negotiat-
ing issue between the employees and employer. For these reasons, it is a good idea to
distinguish between the thermal climate and other environmental factors when pre-
senting or discussing factors in the indoor environment, as sometimes the concept of
indoor climate also comprises air quality, electrical and magnetic factors, as well as
light and sound factors. Only thermal factors are dealt with in detail in this book.
High air temperature does, however, contribute to the fact that air quality is expe-
rienced as poor, and that the air feels stale. Sometimes discontent at other conditions
of the working environment, for example, poor psychosocial environment, are pro-
jected onto the thermal climate and air quality.

9.8  GENDER ASPECTS OF WORK IN AN EXTREME CLIMATE

Some factors that are relevant to discussions relating to the significance of gender for
climate impact are:

• Body mass
• Surface/volume ratio
256 Occupational Physiology

• Subcutaneous fat
• Physical capacity (which influences heat production)
• Perspiration (which influences heat transfer)

The first three aspects of climate mentioned above are connected with body dimen-
sions and build, and are not therefore gender factors in themselves. Cooling and
heating of a body with less mass occur more rapidly than one with more mass. They
also occur more rapidly if the surface is greater in relation to the volume is greater,
as heat is emitted from the body surface. As a group, women have both less absolute
body mass and a lighter build (smaller diameter of the skeleton and muscles).
Individuals with a small body mass and slimmer build cannot normally stay as long
in a hot or cold climate as a bigger and more powerfully built person. In physically
heavier work, one’s own heat production also influences how great heating or cooling
is. A high physical capacity being exploited means a high heat production, which
counteracts cooling in cold locations and increases the heat load in hot locations.
Women generally have more subcutaneous fat than men. In cold, when the vessels
are contracted peripherally, the amount of subcutaneous fat has a certain signifi-
cance for cooling the body, as fat is a good insulator (has a low heat conduction
capacity). It is, however, primarily in water that the effects of the greater insulation
become noticeable, for example, in diving work.
Sweating, which is necessary to cool the body in great heat, differs somewhat
between the genders, even if one takes body size into account. Women sweat less
than men with exertion and/or heat exposure. There are differences in both the
amount of sweat and how quickly sweating begins. In situations where the opportu-
nities for evaporation are limited, as where humidity is very high, or tight protective
clothing is being worn, the difference has little significance. Then body size is deci-
sive for how much heat can be stored before body temperature gets too high. All in
all, the theoretical differences between the genders from a climate point of view do
not have a great practical significance in normal working conditions. Variations
within the entire group of men and women as regards body dimensions, experience,
and physiological reactions presumably contribute to greater differences in climatic
effects than the differences between the genders.

9.9  AGE ASPECTS OF WORK IN AN EXTREME CLIMATE

Increasing age is often associated with deteriorating physiological functions, includ-
ing temperature regulation and aerobic capacity (see Chapter 2). It is, however, dif-
ficult to distinguish between what directly results from chronological age and what
derives from the change in lifestyle that often accompanies age (e.g., poorer physical
work capacity and increased sitting still). With age, the sensitivity in the tempera-
ture-regulating structures and organs (e.g., sweat glands and blood vessels) decreases
and structural changes occur in the skin. This means that “protective” reactions to
heat and cold, such as constriction or dilation of the vessels in the skin, begin later in
older people than in younger ones, and sweat production is lower in older people than
in younger ones. Tolerance of heat and cold may therefore decline with age. One
should be aware that a great deal of the knowledge about age and climate is based on
Work in Heat and Cold 257

studies of individuals who have progressed beyond the age of active working life.
Apart from the normal physiological changes already mentioned, the relatively com-
mon illness-induced impairments in aerobic capacity occur, for example, in ischemic
heart disease.
To sum up, the observed differences directly related to age are relatively minor,
but if we take into account the physiological consequences, and lifestyle changes in
advancing years, the tolerance of climate effects are somewhat lower in older indi-
viduals than in younger ones.

9.10  MEASUREMENT AND RATING OF THERMAL CLIMATE

In order to assess the effect of the thermal climate, the following are used, listed by
increasing degree of difficulty:

• Subjective ratings
• Measurements of physical factors
• Physiological measurements

and combinations of these.

9.10.1  Scales for Rating Climate Experience

By asking employers to assess their experiences by using standardized rating scales
[ISO 10551 1995], we gain an understanding of how difficult the climate problem is
regarded as being. It is simple from the viewpoint of measurement technology but
only provides a rough measure of assessment. One example of a commonly used rat-
ing scale for heat and cold can be seen in Figure 9.6. To discover causes and to make
an overall assessment based on detailed information, we need to measure the physi-
cal environment and evaluate and measure workload and the properties of clothing.

How do you rate the thermal

sensation of your body?

+3 Hot
+2 Warm
+1 Slightly warm
0 Neutral
–1 Slighty cool
–2 Cool
–3 Cold

FIGURE 9.6  Rating scale for thermal sensation. This can also be used for individual parts
of the body, for example, hands and feet. (From ISO 10551. 1995. Ergonomics of the Thermal
Environment—Assessment of the Influence of the Thermal Environment Using Subjective
Judgement Scales. International Organization of Standardization, Geneva.)
258 Occupational Physiology

9.10.2  Measuring Physical Factors

To be able to assess the effect of climate on the body, physical measurements need to
be carried out. The measurements should properly comprise the following:

• Air temperature
• Radiant temperature
• Mean radiant temperature
• Air velocity
• Air humidity
• Work rate (work load, heat production)
• Clothing insulation and water vapor resistance.

Air temperature can be measured quite simply with a screened thermometer. Radiant
temperature requires special sensors and is measured in six directions in the room
(ceiling, floor, and all the walls). Air velocity can be measured mechanically with a
turbine wheel, but indoors electronic instruments are preferable, as they are more
sensitive. Humidity can be measured using a modified thermometer or with sophis-
ticated air humidity sensors. For certain assessments, special types of temperature
have to be measured. The sensors are specially designed and are used in particular
situations, for example, globe temperature and natural wet bulb temperature for Wet
Bulb Globe Temperatures, an index for assessing heat load. Detailed descriptions of
measuring instruments for climatic factors are to be found in the standard ISO 7726
[1998].
To measure oxygen consumption/workload/heat production and the thermal
properties of clothing is more complicated than the other factors, as these require
particular methods and measuring instruments which are not normally readily avail-
able. They are therefore assessed most readily with the help of indirect methods and
estimates.
Assessment of metabolic rate and calculation of heat production can be carried out
with the help of formulae and tables in the standard ISO 8996 [2004]. Measurement of
work rate is described in Chapter 2. From oxygen consumption during the job in ques-
tion, heat production can be calculated or approximated. Heat production (H) = meta-
bolic rate (M)—the mechanical work rate (W) performed (see Section 9.4).
For many jobs involving static muscle work mechanical efficiency is so low (see
Chapter 2) that heat production can be equated with the total metabolic rate, that is
to say, H ~ M.
The calculation of metabolic rate M (W/m2) is:

M = EE × VO2 L/h (W ) (9.1)

in which EE = energetic equivalent in Watt-hours per liter of oxygen and VO2 is the
oxygen consumption in liters of oxygen per hour. The conversion coefficient for cal-
culating metabolic rate is assumed to be 20.6 kJ/L of oxygen [ISO 8996 2004].
The thermal properties of clothing (insulation and water vapor resistance) are
measured on what is called a thermal manikin. Insulation and water vapor resistance
Work in Heat and Cold 259

can also be estimated with the help of tables to be found in the standard ISO 9920
[2007].

CALCULATIONS 9.1
When Bert is hammering nails, he uses 0.8 L of oxygen per minute. Metabolism
yields 20.6 kJ/L of oxygen, which gives 0.8 × 20 600 J/60 s = 275 W.
The efficiency is ~15% for hammering nails and the rest, that is to say
275 W × 0.85 = 233 W, is therefore converted into heat.

9.10.3  Physiological Measurements

It is also possible to measure the effect of the climate on the individual by carrying
out physiological measurements, that is to say by measuring heart rate (see also
Chapter 2), fluid loss, body temperature, and skin temperature. It is important that
the measurements are carried out in a standardized manner. The methods are
described in international standard ISO 9886 [2004]. Physiological measurements
may also need to be carried out in medical monitoring and checks on individuals
who are assessed as being at great risk in hot and cold environments ISO 12894
[2001]. This can help to discover early signs of ill health, to protect particularly
sensitive individuals, and to prevent accidents conditioned by certain medical
complaints, for example, impaired judgement or ability to react on the part of
drivers.

9.10.4  Methods for Assessing the Risk of Hypothermia

It is not acceptable for the body’s core temperature to drop during the working day.
Thermal comfort implies that the climate is felt to be pleasant. Comfort should be
the aim, of course, but it is not always possible to achieve this in an extremely cold
climate. There are tried and tested methods that can be used for assessing how cold
affects the individual. Those methods described here are the ones most frequently
used for assessing cold strain, and stress.

9.10.4.1  Insulation REQuired Index, Insulation Needs

The Insulation REQuired Index (IREQ) is a method used for assessing the risk of
cooling of the whole body. This is based on a calculation of the heat balance and
environmental factors affecting the heat balance. The result of the calculation com-
prises a value for the insulation on the part of the clothing system needed to maintain
the heat balance. Good insulation properties, for example, in the material Styrofoam,
mean that little heat escapes from the material, in this case clothes. IREQ is expressed
by the unit m2 ×°C/W or clo (1 clo = 0.155 m2 ×°C/W and corresponds to the insula-
tion in normal clothing indoors in winter).
For work at a given level of physical activity in a given thermal environment,
certain clothing insulation is required to counteract hypothermia of the body core
and to provide comfort. The connection between these factors is illustrated by the
260 Occupational Physiology

10
W/m2
9
70
8

7 Air speed = 0.2 m/s

90
Insulation (clo)

6 Relative humidity = 50 %

5 115

4 145
175 Maximum insulation of winter clothes
3
200
230
2 260

0
–50 –40 –30 –20 –10 0 10 20
Operative temperature (°C)

FIGURE 9.7  Requirement for clothing insulation to avoid hypothermia in various combina-
tions of work rate (lines marked W/m 2) and operative temperature (x-axis). Moderately heavy
work (175 W/m2 body area) requires an insulation of ~2 clo at −20°C. 1 clo corresponds to
normal indoor clothing. The practical upper limit for insulation with current clothing systems
is 3–4 clo (shaded in the figure). Above this limit, working time has to be restricted to avoid
hypothermia (see Section 9.10.4). Operative temperature is an overall appraisal of air and
radiant temperature. Air temperature = operative temperature in a room where the ceiling,
walls, and floor are at the same temperature as the air. (Modified from Gavhed, D. and I.
Holmér. 2006. The Thermal Climate at the Workplace. Arbetslivsrapport 2006:2, National
Institute for Working Life, Stockholm. (In Swedish).)

diagrams in Figure 9.7. The diagram can be used to predict clothing needs, to choose
suitable working clothes, and to assess the risk of hypothermia in the body core dur-
ing a working day.
Despite the fact that Bert has adequate clothes to protect him from the cold, he
cannot work an entire day in certain climatic conditions. In work while standing in
an air temperature below approximately –10°C, there are no work clothes that can
protect sufficiently against hypothermia of the body. Working hours then have to be
limited. The longest suitable shift (DLE, Duration Limited Exposure) can be calcu-
lated. There are diagrams, tables, and computer programmes for calculating IREQ
and DLE in the standard ISO 11079 [2007].

9.10.4.2  Wind Chill Index

Even when Bert has established a heat balance, he risks frostbite in severe cold. Bare,
unprotected skin is most vulnerable. Often the face and ears are not protected, and
sometimes work has to be carried out with bare hands even in the cold. Chill increases
noticeably with wind. The Wind Chill Index, WCI, is used for assessing the risk of
Work in Heat and Cold 261

TABLE 9.3
Wind Chill Index
Air Velocity
(m/s) Air Temperature (°C)
    0   −5  −10  −15  −20  −25  −30  −35  −40
 2   −1   −6  −11  −16  −21  −27  −32  −37  −42
 5   −9  −15  −21  −28  −34  −40  −47  −53  −59
 8  −13  −20  −27  −34  −41  −48  −55  −62  −69
16  −18  −26  −34  −42  −49  −57  −65  −73  −80
25  −20  −28  −36  −44  −52  −60  −69  −77  −85

Note: The figures show the temperature in °C which with no wind provides the same chilling effect (heat
loss) in combination with a cold wind at a certain air temperature when bare skin is exposed to the
cold wind. Can be used for assessing the risk of discomfort and frostbite. Shaded squares mean
high risk of frostbite. Care should also be taken at a wind chill temperature of −21°C, as pain can
occur and the risk of frostbite exists with longer exposures.

frostbite on bare skin. It cannot therefore be applied to parts of the body covered by
clothing. The method is based on a calculation of the local heat transfer from the skin
to the surroundings at a given air temperature and wind speed. As a help in the
assessment, there is a table in which the risk levels are indicated (Table 9.3). Both
IREQ and WCI are described in detail in the international standard ISO 11079
[2007].
Assessment of the risk of frostbite in contact with cold surfaces: Methods for
assessing frostbite arising in contact with cold surfaces are described in the stan-
dard ISO 13732-3 [2005]. The risk is dependent on the surface temperature, dura-
tion of contact, the material, and its heat conduction capacity (e.g., wood has a low
and metal high heat conduction capacity) and the pressure against the contact
surface.

9.10.5  Methods for Assessing the Risk of Heat Strain

9.10.5.1  Wet Bulb Globe Temperature
Wet bulb globe temperature (WBGT) is a heat index for heat load, requiring rela-
tively simple and straightforward measurements. It is calculated on the basis of mea-
suring air humidity and globe temperature (a kind of average of air and radiant
temperature, measured with a thermometer in a metal globe painted black). In addi-
tion, a rough classification of physical activity is required. WBGT is used to assess
the effects of continuous or varying work in heat, and is particularly suitable for
assessing environments where there is heat radiation.
The measured WBGT value is compared with reference values, which must not
be exceeded. The reference values indicate a level of heat load that is acceptable and
safe for almost all healthy individuals. This does not therefore apply to people who,
for various reasons, have an impaired heat tolerance (see Section 9.6.3).
262 Occupational Physiology

For most of the existing heat problems in working life, WBGT is a simple, practi-
cable and sufficiently accurate assessment method. More about WBGT can be found
in the standard ISO 7243 [1989].
On occasions when a more detailed and analytical assessment of the climate situ-
ation is required, or if the WBGT is exceeded, one might on occasion need to use
PHS (see below).

9.10.5.2  Predicted Heat Strain

The predicted heat strain (PHS) method is based on a calculation of the heat balance
so as not to exceed an acceptable limit for heat storage and fluid loss in a normal
individual [ISO 7933 2004]. PHS requires more complicated measurements, calcula-
tions, and assessments than WBGT, and should only be carried out by specially
trained staff.
Assessment for risk of burns from contact with hot objects: There are methods for
assessing the risk of burns in contact with hot surfaces [ISO 13732-1 2006]. In the
same way as in the case of contact with cold surfaces, the risk depends on more fac-
tors than merely temperature (see Section 9.6.3).

9.10.6  Methods for Assessing Discomfort from Heat and Cold in

Indoor Climate
9.10.6.1  Predicted Mean Vote
Predicted mean vote (PMV) is a comfort index used for assessing thermal indoor
climate (10–30°C) [ISO 7730 2005]. It is based on an empirical correlation between
thermal sensation, the ambient climate, physical activity, and clothing (Figure 9.8).
PMV is a value on the rating scale presented in Figure 9.6. The value 0 indicates that
a group of individuals with the same combination of workload, clothing insulation
and climate—in an office landscape, for example—would consider that it was nei-
ther hot nor cold. For each PMV value there is a predicted percentage dissatisfied
(PPD) value, which can be used to predict the levels of demand placed on the work-
place climate. It has been ascertained that, however good the climate, there will
nevertheless always be around 5% of people who are dissatisfied because of the indi-
vidual variations in experience.

9.11  REMEDIAL MEASURES FOR CLIMATE PROBLEMS

Climate problems, like other work environment problems, should be prevented.
First, the causes of the problem should be eliminated if possible; second, the sources
of the problem should be reduced, and finally, the individual should be protected
with protective equipment and measures tailored to the individual. In outdoor work,
it is of course a question of reducing exposure and protecting the individual from the
wind and weather.
At the social level, laws and regulations provide guidelines for the consideration
that should be shown. In the field of climate, the rules are in many cases quite general
and do not go into detail. As definitive exposure limits for climate do not exist, a good
knowledge of the effects of climate on working people is necessary for ­preventive
Work in Heat and Cold 263

0 0.1 0.2 m2 oC/W

met W/m2
Optimal operative temperature
3.0 175

150
10
12
125
Activity

14
2.0 16
18
20 100
22
24
75
26
1.0 28
50

0 0.5 1.0 1.5 clo

Clothing insulation

FIGURE 9.8  Recommended operative temperature when working at a certain work rate
(Activity, met) with certain clothing insulation (Clothing insulation, clo). Operative tempera-
ture: see the caption of Figure 9.7. 1 met = 58 W/m2, 1.0 clo = 0.155 m2°C/W. The broken line
shows that at 1.2 met and 0.75 clo, 22°C is optimal. (Modified from Gavhed, D. and I. Holmér.
2006. The Thermal Climate at the Workplace. Arbetslivsrapport 2006:2, National Institute
for Working Life, Stockholm. (In Swedish).)

work. The aim of the rules is to create a safe working environment for the promotion
of good health, and thermal comfort is also the aim to the greatest possible extent. The
employer has some leeway in achieving this and the way it is done may vary.
At the management level, risk assessment has to be carried out, and action plans
for dealing with climate risks have to be produced as part of the systematic work on
the working environment. In certain businesses, risks associated with climate occur
only sporadically and for short periods or periodically (e.g., repairing the ovens in
steel works).
Risk management should comprise:

• Introduction and training in risks in hot and cold work.

• Medical checks with special regard to risk groups.
• Good organization of tasks across the working day and the season, so that
to the greatest extent the work is allocated to the time involving the least
load from a climate viewpoint.
• Climate protection around building sites against wind in cold weather and
solar radiation in warm weather.
• Supervision by workmates or management in high-risk work.

If the risks remain when the employer has carried out measures in the physical envi-
ronment and organization of work, then measures will be required at an individual
264 Occupational Physiology

level, such as the improvement of clothes and breaks. Individuals can themselves, as
far as possible, adapt their work rates (workload, apportionment of work/breaks) to
climatic circumstances.

9.11.1  Measures in the Cold

At cold workplaces it is important, apart from the measures already mentioned, to
arrange good opportunities for heating; warm facilities for taking breaks, infrared
heat for warming hands, heated cabinets for drying clothes and regular breaks for
warming up.

9.11.1.1  Clothes against the Cold

Clothes provide one of the most important opportunities for protecting the individual
against hypothermia, and may often be the only factor in the environment which it is
possible to vary to adapt to different climatic conditions at work. Insulation in clothes is
important. The best insulator in clothes is stationary air. Apart from exploiting this fact,
clothes systems against the cold should be based on the multi-layer principle, which
means that people wear several layers of clothes one on top of the other. On the one hand,
the different layers may have different functions, on the other, air that the body has
warmed up can be enveloped between the layers and the insulation can thus be improved.
An efficiently functioning clothing system is built up according to the following
principles:

• The clothes nearest to the body should fit closely around the body, so that
the heated air next to the skin remains there. The material must not absorb
moisture, because body moisture and sweat must not remain close to the
skin. If sweating is not expected, it is possible to use absorbent materials.
• The next layer of clothing should insulate well, be flexible and keep its form
well. In a very cold climate the intermediate layer may need to consist of
two insulating layers. Common materials in the intermediate layer are wool
and wool mixes as well as purely synthetic and insulating materials, such as
fleece and fur fibre.
• The outer layer should be a shell garment which lets through water vapor
yet is windproof and durable. Windproofing is particularly important if the
garment is to be used outdoors or in cold stores or freezers, where fans
cause considerable air movement, and headwinds cause cooling where
industrial trucks are being used. In jobs where workers are exposed to the
cold for a short time, extra clothing, such as a heat vest or jacket, is used on
top of the ordinary working clothes.

Apart from the trunk, the arms and legs, the head, the feet, and the hands need to be
well protected in the cold. A relatively large amount of heat is lost from the head, as
the blood vessels in the crown and back of the head do not contract in the same way
as in other peripheral parts of the body. Hands and feet need a great deal of insula-
tion in relation to other parts of the body, as they have a large area compared with
their mass and easily lose heat. It is also important of course to keep the body warm,
because you have to be able to use your hands and feet in almost all work.
Work in Heat and Cold 265

Clothing systems for the cold result in certain negative ergonomic consequences.
Clothing systems comprise many garments that together add up to a relatively heavy
weight. In this way, the range of motion and freedom of movement are limited, and
the energy demand increases because of the weight. For this reason, it is best to
choose light garments, which also have a well-thought-out functional design. Hoods,
and to a certain extent head gear, limit the field of vision and the ability to hear so
that communication with the surroundings is impaired, which is a considerable risk
factor in many workplaces. All garments and possible protective equipment should
also work together with each other, for example, gloves and cuffs or helmets and
collars.

9.11.2  Measures in the Heat

Heat storage in the body can be prevented largely in three different ways:

• Reducing the heat built up in physical work.

Examples of measures: reduce the total working time per hour with breaks or reduce
the workload.

• Prevent heat input from the surroundings via direct radiation or hot air.

Examples of measures: screen off sources of radiant heat and use fans if the air tem-
perature is lower than ~35°C (at higher temperatures the body receives heat and heat
cannot be transfer through convection).

• Increase in heat transfer from the body, primarily through sweat

evaporation.

Examples of measures: make evaporation easier by reducing the air humidity, using
suitable clothing and drinks, conduct heat training.
It is important that clothes do not prevent heat transfer. They should therefore be
permeable to air and water vapor and allow a large amount of air exchange through
the clothes. In situations where extreme heat exposure cannot be avoided, protective
clothing, and other protective equipment are required. Then the system that provides
the best heat transfer should be chosen.
It is very important to have drinks on hand at the workplace. Prompt and regular
consumption of water, corresponding to the fluid loss, counteracts the detrimental
effects of dehydration to a great extent (Fact Box 9.7).

FACT BOX 9.7

Water is normally the best drink to replace fluid losses through sweating.
Note that the experience of thirst is not a sufficient signal to cover the need.
Maintaining body weight during the day is a measure of sufficient fluid
266 Occupational Physiology

compensation. A mug of water at 10–15°C every 20 min during physical

work is a benchmark. This should, however, be adapted to the existing cir-
cumstances. In long-term and heavy sweating (more than an hour and more
than 21/2 L), extra salt is needed, with normal salt intake otherwise. The
salt content should not be <0.7 mg/mL in drinks for fluid compensation for
sweating.
Coffee and other drinks containing caffeine and beer should be avoided, as
they increase the excretion of urine. Drinks with a great deal of sugar should
also be avoided.

9.12  W
 HAT THE LAW SAYS ABOUT WORK IN HEAT
AND COLD
The laws are in general not detailed as regards climate exposure and climate load,
but are merely frameworks for the physical work environment. The EU working
environment directive states that the thermal climate should be suitable and adapted
to the activity (Directive 89/654/EEC). Nor is there legislation in the United States
that addresses the temperature of a workplace, unless one considers the General
Duty Clause of the Occupational Safety and Health Act. According to Canadian
regulations, the resulting thermal strain of the physical exposure is considered, for
example, a worker’s core body temperature should not exceed 38°C or fall below
36°C. For certain establishments, such as care facilities, special temperature limits
apply. The laws usually prescribe that work hygiene conditions, as regards air, for
example, should be satisfactory and that personal protective equipment should be
used when adequate protection against ill health and accidents cannot be provided
by other means.
There are therefore few exposure limits for the lowest temperature at which work
can be carried out. Sometimes such exposure limits are written into local agree-
ments. However, recommendations for prevention of thermal strain on workers exist
in international guidelines and standards. For example, threshold-limited values
(TLV) for heat exposure are provided in standard ISO 13732-1 [2006]. As they are
based on how hard one is working and whether one is heat acclimatized, there are
several exposure limits. In light work, for example, the WBGT should not exceed
30°C, while in heavy work it should not exceed 26°C.
PMV [ISO 7730 2005] provides benchmarks for the operative temperature
indoors, 22°C ± 2°C for sedentary work in normal clothing, but provides no limit
values. It is also pointed out in the standard that the workplace should be designed
keeping in mind what suits different individuals.
The reason for the lack of exposure limits in laws on the working environment is
that climate load (the “inner” exposure) varies depending on several environmental
factors (air temperature, radiant temperature, air humidity, and air velocity), on
workload and on the properties of the work clothes. As detailed exposure limits are
Work in Heat and Cold 267

not available, assessments of the risk discomfort and ill health have to be made in
each individual case.

9.13  SUMMARY
Heat and cold increase the strain on most of the body’s physiological systems. Body
temperature is regulated by the nervous system to counteract overheating and
­hypothermia with the aid of changes in blood flow to the peripheral parts of the body.
In the heat, sweating helps considerably in the cooling process. The effects of cli-
mate exposure can vary as to degree of severity, from discomfort to health problems.
The individual’s innate ability to adapt and physical training can affect the extent to
which the climate impacts on human beings. It is important that the risks of climate
exposure are assessed so that relevant preventive measures can be taken to amelio-
rate load and to maintain the individual’s work ability. Assessment and measures can
be supported by laws, regulations, and standards.

REFERENCES
Brown, GM. and J. Page. 1952. The effect of chronic exposure to cold on temperature and
blood flow of the hand. J Appl Physiol. 5:221–227.
Directive 89/654/EEC—Concerning the minimum safety and health requirements for the
workplace. European Agency for Safety and Health at Work. http://osha.europa.eu/sv/
legislation/directives/workplaces-equipment-signs-personal-protective-equipment/
osh-directives
Eurofound. 2007. Fourth European Working Conditions Survey. European Foundation for the
Improvement of Living and Working Conditions. Office for Official Publications of the
European Communities, Luxembourg.
Gavhed, D. and I. Holmér. 2006. The Thermal Climate at the Workplace. Arbetslivsrapport
2006:2, National Institute for Working Life, Stockholm (in Swedish).
ISO 7243. 1989. Hot Environments—Estimation of the Heat stress on Working Man, Based on
the WBGT-Index (Wet Bulb Globe Temperature). International Organization of
Standardization, Geneva.
ISO 7726. 1998. Ergonomics of the Thermal Environment—Instruments for Measuring
Physical Quantities. International Organization of Standardization, Geneva.
ISO 7730. 2005. Ergonomics of the Thermal Environment—Analytical Determination and
Interpretation of Thermal Comfort Using Calculation of the PMV and PPD Indices and
Local Thermal Comfort Criteria. International Organization of Standardization, Geneva.
ISO 7933. 2004. Ergonomics of the Thermal Environment—Analytical Determination and
Interpretation of Heat Stress Using Calculation of the Predicted Heat Strain.
International Organization of Standardization, Geneva.
ISO 8996. 2004. Ergonomics of the Thermal Environment—Determination of Metabolic Rate.
International Organization of Standardization, Geneva.
ISO 9886. 2004. Ergonomics—Evaluation of Thermal Strain by Physiological Measurements.
International Organization of Standardization, Geneva.
ISO 9920. 2007. Ergonomics of the Thermal Environment—Estimation of Thermal Insulation
and Water Vapour Resistance of a Clothing Ensemble. International Organization of
Standardization, Geneva.
268 Occupational Physiology

ISO 10551. 1995. Ergonomics of the Thermal Environment—Assessment of the Influence of

the Thermal Environment Using Subjective Judgement Scales. International Organization
of Standardization, Geneva.
ISO 11079. 2007. Ergonomics of the Thermal Environment—Determination and Interpretation
of Cold Stress When Using Required Clothing Insulation (IREQ) and Local Cooling
Effects. International Organization of Standardization, Geneva.
ISO 12894. 2001. Ergonomics of the Thermal Environment—Medical Supervision of Individuals
Exposed to Extreme Hot or Cold Environments. International Organization of
Standardization, Geneva.
ISO 13732-1. 2006. Ergonomics of the Thermal Environment—Methods for the Assessment of
Human Responses to Contact with Surfaces—Part 1: Hot Surfaces. International
Organization of Standardization, Geneva.
ISO 13732-3. 2005. Ergonomics of the Thermal Environment—Methods for the Assessment of
Human Responses to Contact with Surfaces—Part 3: Cold Surfaces. International
Organization of Standardization, Geneva.
Lind, AR. and DE. Bass. 1963. Optimal exposure time for development of acclimatization to
heat. Fed. Proc. 22:704–708.

FURTHER READING
Åstrand, PO., K. Rodahl, HA. Dahl, and S. Stromme. 2003. Textbook of Work Physiology-
Physiological Bases of Exercise, Chapter 13, Temperature regulation. Human Kinetics
Canada, Windsor, Ontario.
Fregly, MJ. and CM. Blatteis (eds.). 1996. Handbook of Physiology, Section 4: Environmental
Physiology. Vol. 1. Oxford University Press, New York, NY.
International Organization of Standardization, Geneva. International Ergonomics/thermal
standards and standards for man-machine-interaction; http://www.iso.org
ISO 11399. 1995. Ergonomics of the thermal environment—Principles and application of rel-
evant International Standards.
ISO 13731. 2001. Ergonomics of the thermal environment—Vocabulary and symbols.
ISO 14505-2. 2006. Ergonomics of the thermal environment—Evaluation of thermal environ-
ments in vehicles—Part 2: Determination of equivalent temperature.
ISO 14505-3. 2006. Ergonomics of the thermal environment—Evaluation of thermal environ-
ments in vehicles—Part 3: Evaluation of thermal comfort using human subjects.
ISO 15265. 2004. Ergonomics of the thermal environment—Risk assessment strategy for the
prevention of stress or discomfort in thermal working conditions.
ISO 15743. 2008. Ergonomics of the thermal environment—Cold workplaces—Risk assess-
ment and management.
ISO/TS 13732-2. 2001. Ergonomics of the thermal environment—Methods for the assessment
of human responses to contact with surfaces—Part 2: Human contact with surfaces at
moderate temperature.
ISO/TS 14415. 2005. Ergonomics of the thermal environment—Application of International
Standards to people with special requirements.
ISO/TS 14505-1. 2007. Ergonomics of the thermal environment—Evaluation of thermal envi-
ronments in vehicles—Part 1: Principles and methods for assessment of thermal stress.
Kroemer, KHE. and E. Grandjean. 1997. Fitting the Task to the Human: A Textbook of
Occupational Ergonomics, Chapter 20, Indoor climate. Taylor & Francis, London.
Oksa, J., and H. Rintamäki. 1995. Dynamic work in cold. Arctic Med Res. 54(Suppl
2):29–31.
Parsons, KC. 2003. Human Thermal Environments: The Effects of Hot, Moderate, and Cold
Environments on Human Health, Comfort, and Performance. Taylor & Francis, London.
Work in Heat and Cold 269

Stellman, JM. (ed.). 1998. ILO Encyclopaedia of Occupational Health and Safety. Vol. 2,
Chapter 42, Heat and cold. International Labour Office, International Labour
Organization, Geneva. ISBN 92-2-109203-8 (CD and online) http://www.ilo.org
Wilmore, JH., and DL. Costill. 2004. Physiology of Sport and Exercise, Part IV, Chapter 10,
Exercise in hot and cold environments: Thermoregulation. Human Kinetics Europe,
Leeds, UK.
10 A Good Working Life
for Everyone
Allan Toomingas, Margareta Bratt Carlström,
and Svend Erik Mathiassen

Photo: Allan Toomingas

271
272 Occupational Physiology

CONTENTS
10.1 Work is Important.......................................................................................... 273
10.2 What is Good Work—Some Principles......................................................... 273
10.2.1 Just Right, Not Too Little, and Not Too Much.................................. 273
10.2.2 Variation and Recovery..................................................................... 273
10.2.3 Health-Promoting Work.................................................................... 274
10.3 Maintaining and Increasing Work Ability.................................................... 275
10.3.1 Adapt the Demands of the Work....................................................... 276
10.3.2 Good Working Technique.................................................................. 277
10.3.3 Increasing the Individual’s Capacity................................................. 277
10.4 What the Law Says........................................................................................ 277
10.4.1 General Aspects................................................................................. 277
10.4.2 Specific Aspects................................................................................. 278
10.5 Trends in Today’s Working Life....................................................................280
10.6 Work–Life Balance........................................................................................ 283
References............................................................................................................... 283

George is a caretaker. After having tried various kinds of work, he has finally found
a job he enjoys. He started work 25 years ago in a slaughterhouse, but had to leave
his job as a meat-dresser when his arms ached so much that he could not pursue his
favourite hobby—darts. Since then he has worked under the pressure of piece work
on building sites, where the work always seems to be behind schedule, as a truck
driver spending long nights on the road, and sitting the whole days in front of a com-
puter at a call centre selling mobile phone contracts.
It was then that the job as a caretaker came up. Quite the perfect mix of main-
taining district heating units, weeding flowerbeds, helping tenants with various
repairs and installations, sitting at the computer and ordering goods, and a lot more
besides outdoors or indoors according to the season and the weather—a job rich in
variation, rarely boring, or doing the same thing twice. Of course, sometimes there
may be emergency calls and a lot to do, for example, when there has been a water
leak, lifts have got stuck, or parties have become too noisy. Sometimes the job can
be heavy, stressful, or uncomfortable, for example, when George has to scrabble
around in attics to change the filters on ventilation units or unblock stoppages in
the pipes down in the culvert. But those stresses are temporary, and he rarely needs
to go to bed worrying about the next day. He is in control of his job and can by and
large plan his own working day. The boss has great confidence in George. George
has gone down to his standard weight and feels better than he has for many years.
He and his colleagues who look after the neighboring residential areas go to the
gym in the centre of town twice a week. And last, but not least: he is popular
among the tenants, particularly since he started organizing a darts tournament in
the club room twice a week. George likes to tell you about what a good life he
has—that his job is the best he has ever had. George’s job is just right for him—the
perfect match.
A Good Working Life for Everyone 273

10.1  WORK IS IMPORTANT

Work is a precondition for the maintenance of society and the great majority of indi-
viduals. Society is based on people’s work. Chapter 1 described how work has
­consistently been a dominant part of human existence, and that the location of that
work and its role in life have been different during different periods of history.
Apart from providing a salary and support, work also gives the individual a role
and a possible sense of coherence in society. It also gives life a structure and a pulse.
For the majority of people, the workplace also provides an opportunity for regular
social contacts. Work can provide opportunities for using the individual’s talents and
for professional development. For most people being involuntarily excluded from
working life as a result of unemployment or illness is a great hardship.
To feel that you can do a good job and be satisfied with your achievements is
characteristic of a good quality of life. To feel needed, but not exploited, is some-
thing everyone should experience.

10.2  WHAT IS GOOD WORK—SOME PRINCIPLES

The various chapters of this book have presented proposals for how working life might
be designed in order to promote real achievements, good health, and well-being. These
proposals follow some basic principles for good work, which are summarized here.

10.2.1  Just Right, Not Too Little, and Not Too Much
Rarely is the “untranslatable” Swedish word lagom* quite as apt as when we are try-
ing to describe what good work looks like from the viewpoint of occupational physi-
ology. In most of the chapters of this book the preconditions for productive and
health-promoting work could be summarized using this word lagom. Exposures
have to be “just right”. This applies to a working day that contains just the right tasks,
a work pace that is optimal, demands for muscle exertion that are optimal, move-
ments, hot or cold or dry or moist air, psychological demands, and control over one’s
own work, as well as variation—both physical and mental—that are all optimal.
What is optimal may vary between different individuals and at different stages of life.
Good work also provides scope for the individual to adapt and develop. It is a chal-
lenge in a world of work characterized by specializations, rapid work, slimmed-down
organizations, and short lead times to find physical and mental demands that are just
right when adjusted to individual needs and capacity.

10.2.2  Variation and Recovery

Other key words that have recurred throughout this book are variation and recovery.
People are good at putting up with physical loads and mental stress if these expo-
sures are of short duration and do not recur too frequently. Minor injuries that occur
as a result of work will be repaired when exposures cease. But this process of repair

* The Swedish word lagom comes from an ancient Swedish word meaning “according to the law” and
“what we agreed,” “suitable,” “befitting.” Here we translate it as “just right” or “optimal.”
274 Occupational Physiology

presupposes that there is sufficient time and opportunity for recovery (see Chapter 6,
Section 6.11). Any imbalance between breaking down (catabolism) and reconstruc-
tion (anabolism) leads to chronic problems. Sleep is an important period for repair
and reconstruction. A long period of sleep disturbance may therefore be regarded as
a serious alarm bell that the body’s opportunities for recovery are in the danger zone.
Recuperation and recovery can also occur during waking hours. Breaks can pro-
vide an opportunity for recovery. Work can also allow for recovery if the load is
varied by, for example, alternating work postures and movements. Structures that
previously have been under load can now rest and recover, while other structures are
exposed. George’s job as a caretaker is an example of a job that can provide good
opportunities for recovery because it contains a variety of tasks with different expo-
sure profiles.
Variation in one’s work tasks can therefore be seen as a particular attractive oppor-
tunity for recovery, since it can be carried out during ongoing work. Un­­fortunately, we
know surprisingly little about what type of variation is the most effective from a
physiological and psychological standpoint, how much variation is good in different
occupations and for different individuals, and what tasks should optimally be com-
bined, if we wish to achieve an optimal pattern of exertions and recovery.

10.2.3  Health-Promoting Work

It is self-evident to most of us that work should not cause injury or ill health. Great
efforts have therefore been made to prevent accidents and work-related disorders of
different kinds. The risk of suffering serious injury at work is low in most postindus-
trial countries. Unfortunately, still many employees are affected by other kinds of
disorders that are associated with their work. Examples have been described in the
previous chapters.
In addition to preventing ill health, there has been an increasing interest in achiev-
ing the more ambitious target of promoting and consolidating good health at work
and through work. The focus so far has primarily been physical training and differ-
ent kinds of dietary advice. Also, the prevention of addiction, for example, to tobacco
and alcohol, is often included in health promotion at work. Avoiding harmful sub-
stances is not a way of promoting health, however, but rather a way of preventing ill
health. A non-smoker does not improve his health by not taking up smoking. A
smoker, on the other hand, curbs his ill health by giving up smoking.
Other important health-promoting factors are access to clean air and pure water,
good living conditions, good sleep, natural and cultural experiences, opportunities
for personal development, and a good social status. Most of these factors lie outside
work and affect what is happening directly at the workplace only to a limited extent,
even if there are examples of companies that show concern for their employees’ well-
being and development in a broader perspective. More rarely has the question been
asked whether, and in that case, how the work itself might be able to promote good
health, that is to say, in a narrow sense, boost the individual’s capacity and functional
ability. Another related aspect is whether work might be able to increase our resis-
tance to injuries and ill health. Those functions and organs where we can most obvi-
ously improve health and resilience are those which are exposed at work and which
A Good Working Life for Everyone 275

may adapt to different loads through the constant remodeling process described in
Chapter 6, Section 6.11, that is, primarily the circulatory and the musculoskeletal
systems and mental/psychological functions.
Physical activity is necessary in order to preserve or improve the capacity of the
circulatory and the musculoskeletal systems, something that is taken up in Chapters
2 and 6. Physical activity has also been shown to have both a preventive and some-
times therapeutic effect as regards many illnesses, of which a number are both com-
mon and serious, for example, high blood pressure, heart disease, diabetes, cancer,
and depression (see Chapter 6, Section 6.11).
In the ideal case, the demands of work should be of such a kind and at such a level
that they contribute to improving the individual’s capacity and in this way increasing
their work ability. One might imagine that bicycle messengers increase their physical
capacity as a result of their work (Chapter 2), or that mentally intensive work for a
period leaves the individual better prepared to meet similar demands in the future
(Chapter 7). The demands in most occupations in today’s working life are, however,
such that they do not provide the training effect which should be able to increase
capacity or protect against illness. Tasks are seldom designed so that they alternate
between periods of high demand for oxygen uptake or muscle force and periods of
recovery, which are necessary to build up a good capacity. In order to achieve an
adequate training effect, one therefore has to supplement this with physical training
outside productive work. Most jobs could, however, be designed so that they contrib-
ute to maintaining basic fitness and strength, for example, by avoiding prolonged
sitting (see Chapter 6, Section 6.14).
Favourable psychological and social conditions at work also have great significance
for both physical and psychological health and productivity. Factors that are particu-
larly important include the opportunity of being able to influence working conditions
and achieving stimulation and personal development. It is also important for us to gain
support and recognition from people important to us in the social groups within which
we move. A good “status” in working life, just as in society, has been shown to be an
important factor for good health. The opposite, for example, being bullied or in some
other way being made a social outcast, is a serious threat to health. The same applies
to being subjected to other people’s arbitrary behaviour, threats of impending changes
for the worse, or not being able to shake off worries about the future.
The potentials of work in helping promote good health do not apply to all of our
biological systems, however. As far as we know, it is not possible, for example, to
improve our hearing or the resistance of our auditory system to future hearing
impairment from high noise levels. Nor is it possible through work to make a healthy
skin more resistant to future eczema or other skin diseases. Nor is it known how it
would be possible to improve a healthy person’s resistance to chemical poisoning,
dust or gases, or to the influence of vibrations or ionizing radiation. The only way is
to avoid such harmful exposures.

10.3  MAINTAINING AND INCREASING WORK ABILITY

In Chapter 1, Section 1.4 we described how the concept of work ability has taken the
centre stage in working life. Shortcomings in work ability have been noticed among
276 Occupational Physiology

large parts of the population of working age. Shortcomings in work ability are, as
described in Chapter 1, Section 1.4, the result of an imbalance between the demands
of work and the individual’s functional ability, capacity, and working technique.
From occupational physiology (and from ergonomics) we can obtain guidelines for
how to achieve a better balance.

10.3.1  Adapt the Demands of the Work

An important basic principle, if we wish to maintain or increase work ability is to
adapt the demands of the job to the capacity and ability of the individual. This does
not always need to mean that we lower demands for quantity or quality in the indi-
vidual’s production, even if this may be the answer in situations where there is no
other solution. One such example is an understaffed hospital ward, where increasing
the number of staff is sometimes the only sensible solution for maintaining the qual-
ity of care and the long-term health of staff. Another example is to adapt the work
pace, which is a relatively unexploited but powerful measure that has been shown to
increase work ability, particularly among older workers.
The demands of work can be reduced, without necessarily lowering production
results through suitable technical solutions, equipment, and tools. For example, on a
hospital ward one can lower the demands for exerting large muscle forces on the part
of the staff by acquiring ergonomically well-designed lifting equipment for patient
transfers.
Another important method for adapting the demands of work is to organize it in
a way that increases variation in the individual’s job. Working methods, equipment,
and tools should in themselves allow for variation, but organizational initiatives such
as job rotation, job enlargement, and job exchange are presumably more effective
sources of variation (see Chapter 6, Section 6.14). The initiatives can be more or less
radical and should prioritize those physical and mental functions primarily at risk for
overexertion, fatigue, disorders, or injury. The physiological aim of job rotation, for
example, is to vary the demands of the job and in this way alternate exposures
between several different physical and mental functions, so as, in this way, to favour
recovery (see Section 10.2).
If sufficient variation cannot be achieved in the productive work itself, then suit-
able breaks and pauses should be introduced. In many cases it is possible, particu-
larly in the case of heavy work or work demanding close attention, to reduce exertion
without lowering productivity by using short and regular pauses.
Sometimes it is not possible to adapt the demands of work to the individual’s
capacity by taking reasonable steps, for example, if a truck driver has suffered seri-
ous visual impairment. Then the most reasonable solution must then be a change of
duties to work where the driver’s capacity and ability are adequate. The solution
does, however, have its limitations, as some of the commonest causes of reduced
capacity, for example, neck and shoulder pain, may imply a reduction in work ability
in most occupations where people work a great deal with their hands, including com-
puter work. The same applies to stress-related physical or mental disorders, which
may be limiting at most of today’s highly effective and goal-oriented workplaces.
A Good Working Life for Everyone 277

There are today unfortunately few ordinary jobs that provide opportunities for an
individually adjusted pace of work.

10.3.2  Good Working Technique

Work ability can be maintained and even increased through good working tech-
nique. Good working technique optimizes the load, makes for less exertion and less
fatigue and reduces the risk of developing disorders and ill health (see Chapter 1,
Section 1.4). With good working technique, the individual can utilize opportunities
for variation and recovery offered by the task, the work organization and the equip-
ment. Additionally, a good working technique is characterized by people working in
a relaxed way, in comfortable work postures, without unnecessary muscle activity or
stress. This is facilitated by the worker being fairly familiar with and confident about
the task. An individual with reduced capacity as regards certain functions can often
regain their work ability by training in a different working technique that makes use
of other intact functions. Well-known examples are people with visual impairments
who learn to read Braille with their fingers. Persons with “mouse arm” on their right-
hand side can train to use their left hand too, and above all learn the short-cut keys
on their keyboard so that use of the mouse can be minimized. Older employees can
develop a working technique in which the work is organized with more short breaks,
which reduces the requirements on fitness and endurance.

10.3.3  Increasing the Individual’s Capacity

The balance between the demands of work and the functional ability of the individ-
ual can also be achieved by increasing the individual’s capacity. Many professionals,
for example, doctors, actors, and researchers, presuppose a mental and/or social
capacity and ability at a level which perhaps only a small section of the population
can match. Professions that necessarily presuppose a considerable physical capacity
are less common, particularly in industrialized and postindustrial countries.
Examples are firefighters, divers, pylon workers, and military and police officers.
Here it may be necessary to improve work ability by increasing the individual’s
capacity in the specific physical functions required. In this way, the short- and long-
term physiological effects of the exposure are alleviated. For example, a paramedic
or firefighter should be able to carry an unconscious person with only a modest
increase in pulse rate and without developing a serious muscle fatigue. This ensures
both the safety and health of the paramedic or firefighter and that of the person who
is being helped. It is usual that professional groups of this kind are given physical
training during paid working hours.

10.4  WHAT THE LAW SAYS

10.4.1  General Aspects
For member states in the European Union (EU), there are a number of directives
bearing on working environment and health [EU 1989a, EU 1989b, EU 1989c, EU
278 Occupational Physiology

1990]. The overarching framework directive describes how the working environ-
ment project is to be pursued systematically and in collaboration between employers,
safety representatives, and other employees [EU 1989a]. Employers should ensure,
for example, that risk assessments are carried out regarding all relevant aspects of
the work: physical, mental, and social. If risks are identified, then remedial measures
should be taken and followed up. As directives are not particularly detailed, the EU
member states have national legislation, often in the form of provisions, which put
into concrete form the demands in the directives.
In the United States there are comprehensive working environment regulations in
the Occupational Safety and Health (OSH) Act [OSHA 2010a]. They contain no
explicit legal demands for ergonomics and physical load at work. In Chapter 5,
“Duties,” there is a general paragraph that states the employer’s responsibility for
eliminating risks at work which may lead to an employee dying or being seriously
physically injured. There are a large number of mandatory standards in the field of
work environment linked to the OSH Act, though none that directly apply to ergo-
nomics and physical load. The federal body that issues these standards, the
Occupational Safety and Health Administration (OSHA), has published guidelines on
ergonomics for some industries [OSHA 2010b]. These are not mandatory, but refer to
the paragraph mentioned above in the fifth chapter of the law. Another important
American body, whose activities are regulated in the OSH Act, is the National Institute
for Occupational Safety and Health (NIOSH). This is a federal institution, which
pursues research, development, and training in the field of the working environment.
NIOSH have large-scale programmes that relate, for example, to ergonomics, muscu-
loskeletal disorders, working in cold or heat, and stress at work.
In Asia, Japan, for example, has an “Industrial Safety and Health Act” (Act No 57
of 1972, revised 2006). Article 3(1) applies to the employer’s responsibility not
merely to prevent accidents, but also in general to create a comfortable industrial
working environment in which constantly improved measures are promoted to
secure the health and safety of the employees [ILO 2006].
One tool for companies and businesses to live up to the requirements of direc-
tive and national laws in practice is to introduce a system for managing the work-
ing environment, for example, OHSAS 18001 [BSI 2007]. Other tools are the
global (ISO) and European (CEN) standards that often derive from legal require-
ments. While some CEN standards supporting the EU Machinery Directive (EN
614, EN 1005) give mandatory directions to machinery designers in how to control
musculoskeletal health risks, ISO standards are not compulsory, though they do
comprise a practical way of fulfilling requirements in laws and national regula-
tions. There are a large number of ISO standards that have a bearing on different
types of load at work.

10.4.2  Specific Aspects

The chapters in this book have specified some important EU directives, national
Work Environment Acts, and provisions that are relevant to the working conditions
dealt with in detail in that specific chapter. These are, generally speaking, focused on
A Good Working Life for Everyone 279

protecting the employees against harm and illness. This can be read from the formu-
lations of the general aims of the directives and acts, for example:

“... the employer shall take the measures necessary for the safety and health protection
of workers, including prevention of occupational risks ...” [EU 1989a, Article 6.1].

“The purpose of this Act is to prevent ill-health and accidents at work and generally to
achieve a good working environment” [SWEA 1978, Chapter 1, Section 1].

The directives and acts do not usually have anything to say about work promoting
health. In Norway, as an exception, the expectations regarding work are on a higher
level. It is stated in the Norwegian Work Environment Act, (Chapter 1, Section 1.1)
that: “The purpose of the Act is to secure a working environment that provides a
basis for a health promoting and meaningful working situation .... ”
There is, on the other hand, some support in the EU directives and the national Work
Environment Acts for the need for physical and mental variation at work, for example:

“…adapting the work to the individual, especially as regards… working and production
methods, with a view, in particular, to alleviating monotonous work and work at a pre-
determined work-rate and to reducing their effect on health” [EU 1989a, Article 6.2d].

“The employer shall ensure that work which is physically monotonous, repetitive,
closely controlled or restricted does not normally occur. If special circumstances
require an employee to do such work, the risks of ill-health or accidents resulting
from physical loads which are dangerous to health or unnecessarily fatiguing shall be
averted by job rotation, job diversification, breaks or other measures which can aug-
ment the variation at work.” [SWEA 1998, Section 4].

Neither EU directives nor the national Work Environment Acts have anything to
say on the subject of work ability. There is, however, clear support for the adaptation
of the job to the capacities and preconditions of the individual worker, for example:

“... adapting the work to the individual, especially as regards the design of work places,
the choice of work equipment and the choice of working and production methods”
[EU 1989a, Article 6.2d].

“Working conditions shall be adapted to people’s differing physical and mental apti-
tudes.” [SWEA 1978, Chapter 2, Section 1].

Regarding working technique, the employer has the obligation to ensure that the
employees have sufficient knowledge of healthy and safe work:

“The employer shall take appropriate measures so that workers and/or their representa-
tives ... receive ... all the necessary information concerning:

– the safety and health risks and protective and preventive measures and activities
in respect of both the undertaking and/or establishment in general and each type
of workstation and/or job” [EU 1989a, Article 10.1a].
280 Occupational Physiology

“The employer shall ensure that the employee has sufficient knowledge regarding:

1. Suitable work postures and working movements.

2. The proper use of technical equipment and aids.
3. The risks entailed by unsuitable work postures, working movements, and unsuit-
able manual handling.
4. Early indications of the overloading of joints and muscles.

The employer shall further ensure that the employee is given the opportunity of train-
ing in a suitable working technique for the task involved. The employer shall also
ensure compliance with the instructions given” [SWEA 1998, Section 6].

There are no general demands on the minimal capacity of employees in the direc-
tives or acts. But the employer has to take this into consideration nevertheless:

“Where he (the employer) entrusts tasks to a worker, he must take into consideration
the worker’s capabilities as regards health and safety” [EU 1989a, Article 6.3b].

The Swedish Work Environment Authority has promulgated provisions on occu-

pational medical supervision concerning occupations that make heavy demands on
the physical capacity of the worker: divers, fire fighters using breathing apparatus,
and pylon workers [SWEA 2005]. These professionals need a specific certificate
based on a thorough medical examination stating that they are fit for the job.

10.5  TRENDS IN TODAY’S WORKING LIFE

Working life has always undergone change, as mentioned in Chapter 1. New lines of
business and new occupations appear and others disappear. Changes are usually
slow and occur over many decades. In certain cases they can be dramatic, such as the
growth of call centres, which in the past 10 years have become the most rapidly
growing sector of the labour market. Another trend in today’s working life is the
expanding “entertainment sector” which generates new professional groups, from
designers of computer and adventure games to wilderness guides and retreat leaders.
Other businesses will essentially endure, for example, schools and education, health
care, care of the elderly and needy, and other occupations in the service sector,
including retail, handicrafts, hotels and restaurants, and office cleaning. The service
sector is constantly expanding, and today employs almost 70% of all workers in the
EU member states; at the same time the number of workers employed in the produc-
tion of goods, in agriculture and forestry, and in manufacturing industry is gradually
decreasing. Changes are also occurring as regards working methods and equipment.
For example, information and communication technology (ICT) is used for an
increasing number of tasks at work.
All the changes in the labour market and in working methods naturally have
effects on working conditions. Today, >60% of all workers within the EU are white-
collar workers with varying levels of skill. Major changes are also occurring in the
structure of the working population. People are entering employment later in life in
step with the longer period of education among young people. The proportion of
A Good Working Life for Everyone 281

older workers is increasing as a result of demographic changes in the population. The

pension age is in the process of being raised in many countries. The health of older
people has generally improved in each generation, which boosts the opportunities for
prolonging working life. Many older people are, fortunately enough, also interested
in continuing to work, provided that the job can be adapted to their needs and condi-
tions, for example, as regards working hours. This means that the average age of the
working population will increase, and that an increasing number will therefore have
age-related reductions in physical capacity and various more or less serious health
problems. This presents working life with challenging demands for adjustments.
In many countries there are major groups of inhabitants who were born abroad.
They presumably bring with them a great variety of different experiences of working
life from their home countries, which should enrich business and working life in their
new country. Possible problems for the individual need to be addressed with mutual
understanding and adaptation. Linguistic and cultural differences may sometimes
make understanding things like safety instructions, for example, more difficult.
Current difficulties for individuals of differing ethnic origin in finding suitable jobs,
particularly those on a level with their personal competence, should successively
diminish as the demand for labour is expected to increase (see below). This should
also involve a decline in employment in the gray sector, where the working environ-
ment and safety is often deficient and is beyond the supervision of the authorities.
The feared labour shortage, assumed to be a result of demographic changes in the
population, should result in everyone being welcome on the labour market—even
those people who, for different reasons, have reduced capacity and ability, for exam-
ple, on the grounds of age, ill health, or limitations in mental or physical abilities.
Adapting work requirements to the needs and capacities of different individuals then
becomes increasingly necessary to retain work ability among the working popula-
tion in general.
Working life is becoming increasingly knowledge intensive. “Simple” jobs are
disappearing at a rapid rate. Knowledge acquired in compulsory school does not go
very far. Requirements for physical capacity and skills are being replaced to an ever-
increasing extent by requirements for mental, emotional, and social competence. In
each generation, more individuals are expected to gain university or college degrees
to fulfill the demands for skills in business. The opportunities of further education
and the gradual shift in the demands for skills may, of course, be stimulating for the
majority of people. For those who, for various reasons, find it difficult to fulfill the
demands, it is important for the actors in working life to find alternative careers.
Another current trend in today’s working life, which will presumably continue in
the future is the increasing emphasis on individual responsibility. Individuals should
take responsibility for being “serviceable” by keeping competent, healthy, and
strong. They should exercise and eat sensibly. They should update their CVs and
their qualifications. They should cultivate their networks and acquire a per-
sonal  trainer and coach. On the one hand, this trend provides the individual with
­opportunities for stimulation and development, and greater opportunities for control
and management of one’s own work. But if the stress on the individual is combined
with the trend towards demands for greater confidence and efficiency, as described
above, then this development can become a stressor and a source of insecurity for the
282 Occupational Physiology

individual who is not stimulated by a drive to “invest in yourself” or is lacking in

self-confidence. An individual who does not succeed easily gets left behind. Warning
signals can be seen, for example, among many school students with stress and pains
who view a future working life with concern. It is, therefore, an important challenge
for the community to design new welfare and social security systems that suit the
new conditions on the labour market.
Within the manufacturing industry one can see a development in the Western
world towards most large companies outsourcing parts of their production or their
support functions to specialized subcontractors—preferably in other countries—and
rationalizing the production that remains towards greater elements of automation
and computerization. Among both subcontractors and parent companies, the choice
of different tasks in this way becomes more limited. Those tasks that are on offer are
very similar as regards physical demands and therefore provide only limited oppor-
tunities for varying work postures, movements, and force development. A further
trend in both industry and the service sector is to introduce neo-Tayloristic produc-
tion systems with a strong focus on avoiding non-value-added time, which is consid-
ered waste. This probably leads to less scope for variation and recovery in that
spontaneous stoppages at work have disappeared, as well as to more short cycle,
repeated operations.
More and more work is done with the help of ICT. Approximately 70% of the
working population in many countries today use the computer in their work, and the
proportion that have a computer as their main equipment is increasing (see Chapter
6). At a rough estimate, 25–35% of all hours worked in many countries are now spent
on a computer, and the proportion will presumably increase.
The computer has thus become our commonest tool. It is a valuable aid that facili-
tates and streamlines work and which has meant a radical development in most
enterprises in society. The opportunities for communication and contact have also
been developed considerably, for example, through mobile phones, text messaging,
and e-mail. One example of modern communication technology in combination with
computers is the huge growth in customer service centres (call centres) which started
to expand in the 1990s. Increasingly advanced and complex services that require
higher education will be provided via this form of customer communication.
Examples are information on health and pharmaceutical preparations, legal and
financial advice, and various forms of technical support. Even public authorities are
increasingly transferring their customer contacts to call centres, for example, the tax
authorities, the social insurance office, and police service. This expansion of call
centre activity, like the expansion in many other lines of business, will bring a fur-
ther increase in the number of workers with prolonged, low–intensity, and con-
strained sedentary work. Physical inactivity may in the future become one of the
greatest problems in the working environment [European Agency 2005].
The development within ICT also results in work becoming “unbounded,” or flex-
ible, in time and space when it is no longer tied to a particular workplace, as one can
work on the computer even at home or when traveling. This boundlessness may
increase the individual’s freedom to decide when and where they do their work,
which may make it easy for work to be combined with other tasks in life, for exam-
ple, looking after ailing parents. Other people can continue to work from home when
A Good Working Life for Everyone 283

their workplace has moved to another town or when they themselves have chosen to
move away. It is, however, a question of avoiding working hours becoming infinitely
long when, for example, one takes work back to the home computer. Also, this devel-
opment means that mental and physical exposures at work and leisure become more
similar; life as a whole offers less variation.
Even the boundaries within workplaces have been eradicated, as open office land-
scapes have become more common in many sectors of the labour market. Sometimes
workers do not even have their own desks, but arrive at work and sit in anywhere that
which is temporarily vacant. This makes demands on adaptability both as regards
equipment and the individual.
Another trend is the move towards a 24-h society. People expect services to be
provided round the clock, every day of the year. This form of boundlessness in time
has consequences for staff working hours. A similar boundlessness also affects other
large groups in working life who are expected to be online and available via e-mail
and mobile phone in their leisure time, including holidays. The opportunities for
mental recovery then have to be emphasized, so that availability is not so compre-
hensive and intrudes on private life and leisure time.

10.6  WORK–LIFE BALANCE

A good job provides an optimal combination of stimulations, challenges, develop-
ment, and safety that is just right, and is characterized by a balance between the
demands of work and the individual’s working technique and capacity. In a working
life that one-sidedly stresses the responsibility of the individual, there will only be
room for those individuals who have great self-confidence, good capacity, and a
well-developed working technique. This may provide problems at times when the
capacity is utilized to the full and may even be found wanting, for example, during
parenting, just as during periods of ill health or when one grows older.
Good work should stimulate everyone according to their preconditions towards a
positive development of their skills and work ability. Good working life should also
be “permissive” in its demands, so that even those people with limited capacity and
less than optimum working technique are able to do a valuable job with good work
ability right up to retirement age, while maintaining good health and quality of life
for the duration of their life.
That would be a good working life for everyone!

REFERENCES
BSI. 2007. OHSAS 18001:2007. British Standards Institution. www.bisgroup.com
EU. 1989a. Directive 89/391/EEC—On the Introduction of Measures to Encourage
Improvements in the Safety and Health of Workers at Work. http://eur-lex.europa.eu/
EU. 1989b. Directive 89/654/EEC—Concerning the Minimum Safety and Health Requirements
for the Workplace. http://eur-lex.europa.eu/
EU. 1989c. Directive 89/655/EEC—Concerning the Minimum Safety and Health Requirements
for the Use of Work Equipment by Workers at Work. http://eur-lex.europa.eu/
EU. 1990. Directive 90/270/EEC—On the Minimum Safety and Health Requirements for Work
with Display Screen Equipment. http://eur-lex.europa.eu/
284 Occupational Physiology

European Agency. 2005. Expert Forecast on Emerging Physical Risks Related to Occupational
Safety and Health. Luxembourg: European Agency for Safety and Health at Work.
ILO. 2006. Industrial Safety and Health Act (Act No. 57 of 1972). Unofficial translation from
Japanese to English by The International Labour Organization. http://www.ilo.org
OSHA. 2010a. OSH Act of 1970. Occupational Safety & Health Administration. www.osha.
gov/pls/oshaweb/owadisp.show_document?p_table = OSHACT&p_id = 2743
OSHA. 2010b. Regulation (Standards—29 CFR) http://www.osha.gov/index.html
SWEA. 1978. Swedish Work Environment Act (last revised in May 2011). The Swedish Work
Environment Authority. http://www.av.se/inenglish/
SWEA. 1998. The Swedish Work Environment Authority’s Provisions on Ergonomics for the
Prevention of Musculoskeletal Disorders. AFS 1998:1. http://www.av.se/inenglish/
SWEA. 2005. The Swedish Work Environment Authority’s Provisions on Occupational
Medical Supervision AFS 2005:6. http://www.av.se/inenglish/
Ergonomics & Human Factors

In a clear and accessible presentation, Occupational Physiology focuses on important

issues in modern working life. Exploring major public health problems such as musculosk-
eletal disorders and stress, this book explains connections between work, well-being, and
health based on up-to-date research in the field. It provides useful methods for risk
assessments and guidelines on arranging a good working life from the perspective of
the working individual, the company, and society as a whole.

The book focuses on common, stressful situations in the work life of different professions.
Reviewing bodily demands and reactions in eight selected common but contrasting job
types, the book explains relevant physiology in a novel way. Rather than being structured
according to organs in the body, the book accepts the complex physiology of typical jobs
and uses this as an entry. In addition to physiological facts, the book discusses risk factors
for disorders and gives ideas on how to organize and design work and tasks so as to
optimize health, work ability, and productivity.

Although many books cover physiology, they are based on a traditional anatomical
structure (e.g., addressing the physiology of the cardiovascular system, the gastrointestinal
system, and so forth) and require readers to synthesize this knowledge into real-life
complex applications. Occupational Physiology is, instead, structured around a
number of typical jobs and explains their physiology, as complex as they may be. This
approach, while still presenting the physiology needed to understand occupational life,
demonstrates how to use this information in situations encountered in practice.

Published in
cooperation with
the University of
Gävle, Sweden

K13002
ISBN: 978-1-4398-6696-2
90000

9 781439 866962