Strategies to tackle musculoskeletal disorders at work: training

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Rik Op De Beeck, PREVENT, Belgium

Introduction

Strategies to tackle Musculoskeletal Disorders (MSDs) at the work place are characterised by an integrated, multidisciplinary and participatory approach. Due to the multiple risk factors and causes of MSDs, prevention strategies focus as well on technical (engineering) measures, as on organizational aspects of the work but also on the attitude and behaviour of the people involved in the work by training and education.

This article brings to focus this last aspect. How important is training in the prevention of work related MSDs?

European legislative background

The OSH Frame Work Directive of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work is also applicable in the prevention of MSD. The general principles of prevention listed in the directive are the following:

  • avoiding risks;
  • evaluating the risks;
  • combating the risks at source;
  • adapting the work to the individual;
  • adapting to technical progress;
  • replacing the dangerous by the non- or the less dangerous;
  • developing a coherent overall prevention policy;
  • prioritizing collective protective measures (over individual protective measures);
  • giving appropriate instructions to the workers.

More specific the Directive 90/269/EEC related to the Manual Handling of Loads describes the obligations of employers in the prevention of MSDs related to manual handling[1]

Employers must take appropriate organisational and technical measures, in order to avoid the need for the manual handling of loads by workers or, if this is not possible, in order to reduce the risk involved in the manual handling.

This Directive clearly refers to the need of training. It is stipulated that workers and/or their representatives must be informed of all measures to be implemented with regard to the protection of safety and health. Employers must ensure that workers and/or their representatives receive general indications and, where possible, precise information on the weight of a load and on the centre of gravity of the heaviest side when a package is eccentrically loaded. Employers must ensure that workers receive in addition proper training and information on how to handle loads correctly and the risks they might be exposed to.

In general employers have to inform workers about the risks related to the work they are doing.

Types of training

Training is widely used in prevention strategies for MSDs. This has to do with the dominating theory that providing people with better knowledge and skills (and better work conditions) will result in a positive change [2]. Traditionally training related to the prevention of MSDs is associated with ‘Back’ or ‘Neck’ schools. Today this concept is enlarged and fits into a global prevention approach. Information and training activities can play an important role in the primary prevention of MSDs, but only when this training is part of a general prevention strategy focused on the reduction of risks in the work place[3].

Behaviour of individuals is strongly determined by their knowledge and attitudes. An important step in reducing health risks is to ensure that the individuals concerned perceive MSD to be a genuine risk. Managers are unlikely to implement changes, or employees to adopt changes to their working practices, unless they are genuinely concerned about the issue.

Two main categories of interventions on behavioural modification can be distinguished: education and exercises[4].

Education and training

Education and training evolved from the classic 'back or neck schools' to more general ergonomic-related guidance and training programmes, with different topics (e.g. manual handling, assembling work, computer work). These training programmes are most effective when organised in a simulated work situation or on the job.

Training methods to prevent MSDs generally fall into two parts:

1. Education in ergonomics and biomechanical principles to recognise and understand work related risks and how to prevent them, but also to increase awareness of MSDs so that safe work methods and healthy lifestyle are adopted. In many cases training programmes are used to introduce the methodology of participatory ergonomics. People learn about ergonomics and look for risks in their (own) work environment and give ideas to improve the working conditions:
  • recognition of hazards for MSDs;
  • problem-solving programs designed to provide workers with the information and skills necessary to participate in hazard control activities.

Education in the prevention of work-related MSDs can also include campaigns and the dissemination of written information, for example through brochures or leaflets on ergonomics-related topics. Film, video and multimedia can be used to make the training more ‘visual’.

Different target groups can be identified: managers, supervisors, operators, engineering departments, human resource officers, and medical staff.

2. Practical training (on the job) in:
  • the correct use of work equipment (lifting devices, chairs, furniture);
  • how to organise work and the work station in an ergonomic way;
  • safe working postures (sitting, standing, reaching);
  • safe manual work techniques: handling, lifting, pulling and pushing of loads;
  • working with a computer in an ergonomic way.

Target groups are managers, supervisors and production operators or office workers.

Physical training or exercises

Physical training or exercises can be encouraged through workplace health promotion programmes. They aim to reduce the discrepancy between the workload and the worker's physical capacity. Physical fitness training and sport are used to increase the individual physical capacity in order to cope with the physical workload.

In the secondary prevention (to halt the further development of MSDs) and in the tertiary prevention (reducing disability) training and exercise therapy[5] can also play a role in:

  • the reduction of pain related to MSDs;
  • the increase of the functional status of the patient.

These positive effects can increase the quality of life and facilitate the return to work.

Effectiveness and limits of training

Education and training

The cost of training depends on the wage of the trainer, the price it costs to allow employees to participate and the possible loss of production time.

The effectiveness of training depends on the type of training and also on how this training is part of a global prevention strategy. Several studies[6][4] [7] show that educational programmes and training as a sole preventive measure, have little effect on the prevention of MSDs, particularly when the realities of the work environment prevent the adoption of safe work postures or hinder the use of ideal lifting techniques.

For example a short training in lifting techniques is not enough to prevent work related low back pain. If the job requirements are physically stressful, the behaviour modification will not eliminate the inherent risk. Therefore designing ergonomic workplaces (for example an ergonomic manual handling or computer work station) and working in a safe work organisation are fundamentally better than training people to behave safely.

For training to be successful, it must be part of a comprehensive ergonomic intervention. Evidence suggests that such interventions involving participation of workers and managers, the tailoring of training to suit the person and specific task requirements, along with equipment or task design/redesign, are effective in reducing MSDs. The emphasis in training should be on changing attitudes and behaviour and promoting risk awareness among workers and managers [8].

Physical training

There is clear evidence from research that (intensive) physical exercise programmes on the reduction of low back pain and other MSDs are effective. In particular exercises in muscle strengthening appear to have a positive effect[4][9].

In the return to work process of persons with chronic low back pain, physical conditioning programmes involving the workplace, or physical conditioning being part of integrated care management may have had a positive effect on reducing sick leave, but the evidence is not conclusive [10].

Training as part of a holistic approach is also important for the retention, rehabilitation and reintegration of workers who already suffer from MSDs.

Training principles and points of attention

Integrated in a global prevention approach

Referring to the European regulations on manual handling and to general accepted good practice, four basic steps can be formulated to tackle MSDs. These steps are applicable as well for manual handling activities as for repetitive work or office work.

Step 1 – Avoid hazardous postures, movements or manual handling as far as possible Attention should be given to the ergonomic design or redesign of the workplace, tools, technical equipment, furniture, chairs, etc. All operations involving repetitive movements, static muscular load, lifting, carrying, transferring, pushing or pulling loads have to be evaluated and one should consider whether the work/task can be performed in another way. The work has to be organised in a way that repetitive or monotonous tasks are avoided and that workers don’t have to adopt awkward work postures. Can things be done differently? By reorganising the way things are done, it is possible to eliminate hazardous manual operations or hazardous work postures (office, assembling task, …).

Step 2 – Assess the risks for injuries related to manual work, manual handling or hazardous working postures that cannot be avoided and reduce the risk as far as possible Observe each manual handling operation and the corresponding work posture that takes place. For office workers this can mean to analyse the work posture of the office workers during their computer work.

Consider how these operations or work postures could be made easier and less risky. Changes in the work organisation can reduce the time exposed to the risks. Ask the workers and involve them in the process of thinking about improvements. Then draw up and implement an action plan. First, tackle those operations or situations that cause the highest risk. Try out changes on a small scale initially, to make sure that they are feasible. Involve the workers in the evaluation of the changes.

Step 3 – Train the management, employees and other target groups in ergonomics and more specific in safe handling techniques and in ergonomic working methods Good training is very important but will never be a solution on its own. The training has to fit into the global approach. Because training is focused on changing values, attitudes, habits and behaviour, it has to be adapted to the company culture and the specific industry or work environment. The training method, the content and the timing of the training have to be suitable for the specific target group.

Step 4 – Physical exercise There is clear evidence that physical exercise is important in the prevention of MSDs. This training has to be well balanced and adapted to the capacity and the preferences of the individual. Full body training, endurance, muscular strengthening and flexibility exercises must be part of the training.

Preparation

As stated before, training must be part of a global prevention programme to tackle MSDs, in which work-related risk factors are avoided or if not possible, are reduced by technical and organisational measures. Before embarking on a training that requires particular working methods, it is important to make sure that:

  • there is no work pressure or demands that would make this acquired work behaviour impossible;
  • the work environment, the workplace and technical equipment support the desired behaviour and work method.

Therefore it is necessary, before starting a training programme in a company, to ensure the commitment of the management to apply this global approach to prevent MSDs. In this perspective it can be interesting to start with a short training for the management to raise knowledge and awareness for the prevention of MSDs.
In this stage a decision can be taken for which target groups training has to be organised. To have a significant influence on the company culture, it is necessary to focus on different target groups. For example when workers are given appropriate training, it is important to ensure that managers and supervisors are also aware of the good practices that have been recommended, and that they regularly encourage the workforce to adopt appropriate techniques and ensure they continue to be used.
The objectives of the training have to be determined and have to be communicated to the trainees.
A good planning is important. The number of participants should be limited (maximum 10-12) to make interaction and active participation possible. Enough time is necessary to increase awareness and knowledge, to change attitudes and to learn new skills or work techniques. Repeated training sessions of 2-3 hours seem to be more effective than training sessions of a full day. The time interval between the different sessions should be limited (less than two weeks).
The infrastructure and the technical equipment available in the training room can have an important impact on the effectiveness of the training (PowerPoint computer presentations, video, pictures, …). Didactic material such as anatomical spine models, which are designed for hands-on demonstrations, can help to explain the functioning of the spinal column and to understand the risks. Sufficient place is needed to make the training practical and to be able to organise practical exercises. So the location or training room has to be adapted to this kind of training.

Realistic and Tailor-made

Training to improve work techniques for operators or office workers has to be organised ‘on the job’ or in simulated conditions, with real tools and products and in a realistic environment. To change the behaviour it is important that participants experience the benefit of the new ‘safe’ work techniques. If they are convinced that the principles and the work methods they have learnt really help them, they will be more motivated to change habits and to apply the new principles. Workers must know the risk factors, be receptive and ready to make changes in behaviour and practice these behaviours until they become part of their personal habits [11]. This is most likely to be achieved through industry and task specific training that is tailored to recipients’ level of knowledge and understanding of the risks [8].

Keep the training alive

It is also important to keep in mind that each (new) employee must be trained and retrained periodically to reinforce safe and ergonomic practices. Keep records of who has received training, when the training was organised and what the content of the training was.

Trainer

The person who gives the training has to be expert in MSDs but also in educating and training people. This means that he or she has the necessary pedagogic and communicative skills. The trainer has to visit the workplaces of the trainees, determine the best practices and make sure that the content of the training reflects the working conditions.

Content

Training for industrial activities

This training can consist of different topics and can be organised for different target groups:

Table 1: Selection of ergonomic topics for different target groups






































Source: [12]

Picture 1: Starting body position manual lifting

Ergonomic work techniques that can prevent MSDs generally involves training aimed at reducing the number and types of awkward neck, back, wrist and shoulder postures, minimising the levels of mechanical forces applied and reducing the number of repetitive motion patterns. This can be accomplished by analysing the tasks that have to be carried out. Video analysis can be used to make a detailed analysis to look for the best practice. During the training it can also be useful to work with video, in order to give feedback to the trainees about their performance. Some principles to reduce risks for MSDs by improving postures and movements:

  • keep joints in neutral (natural) position during work (no bending, twisting or overstretching);
  • avoid unnecessary movements or force exertion;
  • keep arms and hands close to the body while lifting or manipulating;
  • before lifting, put your feet in such a way that the load is as close as possible to the body (see picture 1). When lifting, keep your back in the natural curve, use the muscles of your legs and abdomen to lift the weight. In this position there will be less strain on the low back ligaments, it minimises disc compression and the overall strength requirements and there is a clear mechanical advantage (small lever of the load). This way of lifting requires a good physical condition (strength leg muscles);
  • slow lift movement cause less (peak) compressive force on the intervertebral discs;
  • during carrying it is also important to keep the load close to the body;
  • to push or pull loads, it is important to start the movement slowly: this requires less initial force. The force has to be delivered by the muscles of the legs and to use the body weight to move the load.

Training for office workers

Topics of training for office workers include:

  • Principles of ergonomic work design and work organisation;
  • The health risks of office work and more particularly of working with visual display units;
  • MSDs and the risk factors of MSDs;
  • Prevention measures related to:
    • computer equipment and furniture
    • sitting and working posture
    • arrangement of the workspace and lay-out
    • work environment
    • work organisation;
  • Physical exercise.

Psychosocial factors

Most interventions aimed at reducing MSDs focus on the physical aspects. Such an approach overlooks important psychosocial influences, which have been found to be associated with MSDs. This aspect has to be considered in the strategy to prevent MSDs. Organisational measures can reduce stress. This should also be integrated in the training of the employees: how to cope with work related stress?

Physical exercises

There are several types of physical training programmes: spinal flexion exercise, extension exercise, isometric strengthening exercise for abdominal and lumbar muscles and aerobic exercise. The possible exercises used as a prevention method include strengthening of weak muscles and of tight muscles and ligaments, stabilisation of hypermobile segments, correcting poor posture, etc.

The general purpose is to increase the physical capacity to cope with the workload. All kinds of sport activities (e.g. football, basketball, jogging, swimming) can have positive effects and are often more appreciated and motivating (having fun). These activities also offer a possibility to strengthen muscles and tendons and have a positive effect on the cardiovascular system. It is known that sports activities also reduce the negative effects of stress on the human body. Therefore physical training and sports can be recommended, not only for industrial workers involved in manual handling or assembly work, but also for office workers who have often a lack of movement.

Companies try to motivate their employees to participate in physical exercise by:

  • paying a part of or the total participation fee;
  • organising physical exercises in group or sports activities;
  • providing accommodation and material;
  • allowing participation to activities during working hours or during breaks;
  • sponsoring participation in activities such as ‘start to run’, organised joggings, tournaments etc.

Young people

Very often people only understand MSDs problems when they have experienced them themselves. Nevertheless it is worthwhile trying to ensure a correct understanding of MSDs risks and prevention at an early age. The fact that many young people use computers, or computer games intensively and carry heavy school bags makes that many people entering the workforce may have already been exposed to some degree of MSDs risk. Targeting information, education and training at these young people could help prevent this predisposition and improve the accuracy of their risk perception.

Conclusion

Training, education and physical exercise can be effective if it is embedded in a global prevention approach of MSDs. The aim is to change the ergonomic culture of a group and the attitude and behaviour of individuals related to the prevention of MSDs. Also healthy lifestyle has to be promoted.

Training in the prevention of MSDs can be useful for an industrial environment but also for office workers. Training in companies should only be started when there is a clear commitment of the management to apply this global prevention approach. Training must be well planned (timing, location, small groups…), well prepared and adapted to the target group. The objectives must be clear. After the training the participants of the different target groups must realise what their specific role is in the prevention of MSDs. The new and safe work techniques that are educated to workers should be realistic and applicable in the real work. The technical equipment and the workplace have to support the desired behaviour. Training can also be an occasion to start with participatory ergonomics.

Physical exercises and training can also help persons who already suffer from MSDs and have a positive effect on the return to work. Because of the impact of MSDs on the working population, this topic should be part of the education of young people. They should be made aware of the risks related to and the prevention of MSDs.


References

  1. 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 (fourth individual Directive within the meaning of Article 16 (1) of Directive 89/391/EEC). Available at: [1]
  2. Wijk, K. Mathiassen, S., 'Explicit and implicit theories of change when designing and implementing preventive ergonomics interventions - a systematic literature review', Scandinavian Journal of Work, Environment & Health, 2011, vol. 37(5), pp. 363-375
  3. Op De Beeck, R., Hermans, V., Research on work-related low back disorders, European Agency for Safety and Health at Work, Luxembourg, 2000, pp. 39–40. Available at: [2]
  4. 4.0 4.1 4.2 Michaelis, M., IPP-aMSE – Identification and prioritisation of relevant prevention issues for work-related musculoskeletal disorders (MSDs) - Work package 4 - Prevention approaches: evidence-based effects and prioritised national strategies in other countries, Bergische Universität Wuppertal, 2009, pp. 72. Available at: www.dguv.de/content/prevention/campaigns/msd/review/ap_4_e.pdf.
  5. Van Tulder, M.W.,Ostelo,R., Vlaeyen,J.W.S., Linton,S.J.,Morley, S.J., Assendelft, W.J.J., 'Behavioural treatment for chronic low back pain', Spine, 26(3), 2000, pp. 270-81.
  6. Martimo, K.P., Verbeek, J., Karppinen, J., Furlan, A.D., Takala, E.-P., Kuijer, P., Jauhiainen, M., Viikari-Juntura, E., 'Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review', BMJ, Volume 336, 2008, pp. 429-31.
  7. Hoe, V., Urquhart, D., Kelsall, H., Sim, M., 'Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults (Review)', Cochrane review, Cochrane Library 2013, Issue 6, Available at [3]
  8. 8.0 8.1 HSE – Health and Safety Executive, Manual handling training - Investigation of current practices and development of guidelines, Research Report, RR 583, 2007. Available at: [4]
  9. Rasotto, C, Bergamin, M., Simonetti, A., Maso, S., Bartolucci, G., Ermolao, A., Zaccaria, M., 'Tailored exercise program reduces symptoms of upper limb work-related musculoskeletal disorders in a group of metalworkers: A randomized controlled trial', Manual Therapy, 2014, Available at: [5]
  10. Schaafsma, F., Whelan, K., van der Beek, A., van der Es-Lambeek, L., Ojajärvi, A., Verbeek, J., 'Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain (Review)', Cochrane Library, 2013, Issue 8.
  11. Stevenson, J., 'Looking forward by looking back: helping to reduce work-related musculoskeletal disorders', Work, 2014, vol. 47, pp. 137-141.
  12. Op De Beeck, R., 'Opleiding preventie van MSA', PreventActua, 2010, nr. 14.


Links for future reading

EU-OSHA - European Agency for Safety and Health and Work, Musculoskeletal Disorders (no publishing date available). Retrieved on 17 June 2015, from: [6]

EU-OSHA - European Agency for Safety and Health and Work, OSH in figures: Work-related musculoskeletal disorders in the EU - Facts and figures, Publications Office of the European Union, Luxembourg, 2010, pp. 179. Available at: [7]

EU-OSHA - European Agency for Safety and Health and Work, Work-related musculoskeletal disorders: prevention report, Publications Office of the European Union, Luxembourg, 2008, pp. 106 Available at: [8]

EU-OSHA - European Agency for Safety and Health at Work, Work-related musculoskeletal disorders: Back to work report, Publications Office of the European Union, Luxembourg, 2007, pp. 100. Available at: [9]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 39 - Cleaners and musculoskeletal disorders, 2008. Available at: [10]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 28 - Patient handling techniques to prevent MSDs in health care, 2008. Available at: [11]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 24 - Musculoskeletal disorders (MSDs) in HORECA, 2008. Available at: [12]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 19 - Prevention of vibration risks in the construction sector, 2007. Available at: [13]

EU-OSHA - European Agency for Safety and Health and Work, E-fact 17 - The prevention of work-related neck and upper limb disorders (WRULDs) in construction, 2007. Available at: [14]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 13 - Office ergonomics, 2007. Available at: [15]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 12 - Work related musculoskeletal disorders in the service and retail sectors, 2007. Available at: [16]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 1 - Musculoskeletal disorders in construction, 2004. Available at: [17]

EU-OSHA - European Agency for Safety and Health at Work, The human-machine interface as an emerging risk, Available at: [18]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 45 - Checklist for preventing bad working postures, Available at: [19]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 44 - Checklist for the prevention of manual handling risks, Available at: [20]

EU-OSHA - European Agency for Safety and Health at Work, E-fact 43 - Checklist for preventing WRULDs, Available at: [21]


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OSH: Ergonomics, Design, Equipment design, Workplace design and layout, Ergonomic factors, Risk assessment, Back care, Exercise and physical activity, Health monitoring and screening, Health surveillance, Primary prevention, Return to work, Musculoskeletal disorders
NACE: Growing of non-perennial crops, Growing of perennial crops, Animal production, Mixed farming, Support activities to agriculture and post-harvest crop activities, Logging, Support services to forestry, Fishing, Aquaculture, Mining of hard coal, Mining of lignite, Extraction of crude petroleum and natural gas, Mining of metal ores, Quarrying of stone, Mining support service activities, Processing and preserving of meat and production of meat products, Processing and preserving of fish, Processing and preserving of fruit and vegetables, Manufacture of vegetable and animal oils and fats, Manufacture of dairy products, Manufacture of grain mill products, Manufacture of starches and starch products, Manufacture of bakery and farinaceous products, Manufacture of other food products, Manufacture of prepared animal feeds, Manufacture of beverages, Preparation and spinning of textile fibres, Weaving of textiles, Finishing of textiles, Manufacture of other textiles, Manufacture of wearing apparel, Tanning and dressing of leather; dressing and dyeing of fur, [[Property:NACE 15 12|]], Manufacture of footwear, Sawmilling and planing of wood, [[Property:NACE 16 2|]], Manufacture of paper and paper products, Printing of newspapers, Other printing, Binding and related services, Manufacture of coke oven products, Manufacture of basic chemicals, Manufacture of pesticides and other agrochemical products, Manufacture of paints, Manufacture of soap and detergents, Manufacture of perfumes and toilet preparations, Manufacture of explosives, Manufacture of glues, Manufacture of basic pharmaceutical products, Manufacture of pharmaceutical preparations, Manufacture of rubber and plastic products, Manufacture of glass and glass products, Manufacture of refractory products, Manufacture of clay building materials, Manufacture of other porcelain and ceramic products, Manufacture of cement, Manufacture of articles of concrete, Cutting, Manufacture of abrasive products and non-metallic mineral products n.e.c., Manufacture of basic metals, Manufacture of structural metal products, Manufacture of tanks, [[Property:NACE 25 3|]], Manufacture of weapons and ammunition, Forging, Treatment and coating of metals, Machining, Manufacture of cutlery, Manufacture of other fabricated metal products, Manufacture of electronic components and boards, Manufacture of computers and peripheral equipment, Manufacture of communication equipment, Manufacture of consumer electronics, Manufacture of instruments and appliances for measuring, Manufacture of optical instruments and photographic equipment, Manufacture of electric motors, Manufacture of batteries and accumulators, Manufacture of wiring and wiring devices, Manufacture of electric lighting equipment, Manufacture of domestic appliances, Manufacture of general-purpose machinery, Manufacture of other general-purpose machinery, Manufacture of agricultural and forestry machinery, Manufacture of metal forming machinery, Manufacture of other special-purpose machinery, Manufacture of bodies (coachwork, Manufacture of bodies (coachwork, Building of ships and boats, Manufacture of air and spacecraft and related machinery, Manufacture of military fighting vehicles, Manufacture of motorcycles, Manufacture of furniture, Manufacture of jewellery, Manufacture of musical instruments, Manufacture of sports goods, Manufacture of games and toys, Repair of fabricated metal products, Installation of industrial machinery and equipment, Electric power generation, Manufacture of gas; distribution of gaseous fuels through mains, Sewerage, Waste collection, Waste treatment and disposal, Materials recovery, Remediation activities and other waste management services, OFFICE CLERKS, Civil engineering, Demolition and site preparation, Electrical, Building completion and finishing, Roofing activities, Maintenance and repair of motor vehicles, Sale, Retail sale in non-specialised stores, [[Property:NACE 47 2|]], Retail sale of automotive fuel in specialised stores, Retail sale of information and communication equipment in specialised stores, Retail sale of other household equipment in specialised stores, [[Property:NACE 47 6|]], Retail sale of other goods in specialised stores, Retail sale via stalls and markets, Passenger rail transport, Freight rail transport, Urban and suburban passenger land transport, Freight transport by road, Sea and coastal passenger water transport, Sea and coastal freight water transport, Inland passenger water transport, Inland freight water transport, Passenger air transport, Freight air transport and space transport, Postal activities under universal service obligation, Hotels and similar accommodation, Holiday and other short-stay accommodation, Camping grounds, Publishing of books, Software publishing, Television programming and broadcasting activities, Wired telecommunications activities, Wireless telecommunications activities, Computer programming, Information service activities, Accounting, Research and experimental development on natural sciences and engineering, Combined facilities support activities, Office administrative and support activities, Activities of call centres, Organisation of conventions and trade shows, Hospital activities, Medical and dental practice activities, Residential care activities, Washing and (dry-, Hairdressing and other beauty treatment