Psychosocial risk factors for musculoskeletal disorders (MSDs)

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Swenneke van den Heuvel, Netherlands Organisation for Applied Scientific Research

Introduction

It has been known for some time that risk factors in the workplace can have a negative effect on health. Ramazzini was one of the first scientists to identify occupational health hazards[1]. He wrote about diseases of the musculoskeletal system caused by sudden and irregular movements and the adoption of awkward postures.

It is now widely recognised that physical demands on the body, such as those associated with manual handling activities, repetitive movements and prolonged sitting, can lead to an increased risk of either causing or exacerbating musculoskeletal disorders (MSDs). Risk factors for musculoskeletal disorders in manual handling of loads; Risk factors for musculoskeletal disorders — working postures.

However, despite extensive efforts to reduce these risks in the workplace, the level of MSDs amongst workers has remained largely unchanged. For example, the percentage of workers reporting one or more MSD declined from 60% to 58% between 2010 & 2015[2]. It appears that there are many factors contributing to this continuing problem[3]. However, one factor appears to be that, until recently, there has been relatively little attention paid to the potential role of psychosocial risks in relation to MSDs.

Psychosocial work characteristics include aspects such as work demands, job control and social support at work. In earlier studies, these factors were considered as potential confounders when exploring the relationship between physical exposure and symptoms[4]. More recently however, psychosocial factors have become considered to be independent risk factors for causing or exacerbating MSDs.

What are psychosocial factors?

There are no globally accepted definitions of work-related psychosocial factors. In general, such factors refer to individual subjective perceptions of the organisation of work, such as hours worked, work-rest cycles, workplace culture, and management style. They often carry emotional value and have the potential for causing physical or psychological damage to health[5]. A similar description is provided by the European Agency for Safety and Health at Work: “Psychosocial risks arise from poor work design, organisation and management, as well as a poor social context of work, and they may result in negative psychological, physical and social outcomes such as work-related stress, burnout or depression.”[6]

According to EU-OSHA, some examples of working conditions leading to psychosocial risks are:

  • Excessive workloads
  • Conflicting demands and lack of role clarity
  • Lack of involvement in making decisions that affect the worker and lack of influence over the way the job is done
  • Poorly managed organisational change, job insecurity
  • Ineffective communication, lack of support from management or colleagues
  • Psychological and sexual harassment, third party violence

In the scientific literature, the adverse health effects of psychosocial factors at work are often attributed to a combination of these different factors. The most widely known is Karasek’s demand-control-support model. According to this model, the risk of adverse health effects (in particular stress), will increase if high job demands are combined with low control. A low level of support will increase the adverse effects of the combination of high demand and low control[7].

Another well-known model combining the effect of different work-related psychosocial factors is Siegrist’s Effort-Reward Imbalance (ERI) model. The assumption of the ERI model is that an imbalance between efforts and rewards leads to adverse health effects[8] (including MSDs).

These are important concepts as they both illustrate the fact that some psychosocial factors can have positive effects. Thus, in the demand-control-support model, the negative effects of high job demands can be offset by the positive influences of a high degree of perceived personal control and/or strong support from co-workers or supervisors/managers. Similarly, the ERI model reflects the recognition that the potentially adverse effects of high levels of (mental) effort can be offset by high perceived rewards.

There is evidence that these two concepts reflect different aspects of the psychosocial environment and have effects separate from each other[9].

Prevalence of work-related psychosocial factors

According to the 6th wave of the European Working Conditions Survey (EWCS) carried out in 2015, almost a quarter of respondents (23%) reported that they almost always had to work at very high speed with a further third (37%) stating that this occurred between 25-75% of the time. Similar proportions (27% & 37%) reported having to work to very tight deadlines. Having to work at very high speeds for at least 25% of the time was most often reported in the Public Administration (including education and health) (52%) and Financial and other services (56%) sectors. Those working in Public Administration were most likely to have to hide their feelings at least some of the time (69%) and workers in this same sector were most likely to experience having to deal with angry clients at least 25% of the time (51%) or find themselves in emotionally disturbing situations (49%).

An analysis of similar survey results over the years showed that the percentage of workers who reported that their job involved working to tight deadlines for at least a quarter of the time had slightly increased from 59% in 2000; 61.9% in 2005; 62.1% in 2010 and to 64% in 2015 (with variations between individual countries)[10].

As noted above, exposure to physical risk factors differs between occupations and the type of industry. Since, as the figures suggest, psychosocial factors are also different among those groups, it is possible that the relationship between psychosocial factors and MSDs is also different. However, with most of the more powerful prospective studies (as opposed to cross-sectional studies) being drawn from population-based samples there is very little firm evidence on which to base firm conclusions regarding variations between different employment sectors, sizes of company, or specific occupations. One relatively homogeneous group of workers that has been studied separately is office workers.

Psychosocial factors in office workers

Work with computers is becoming increasingly prevalent in Europe; according to the EWCS the percentage of people working with computers for most all of their working day has increased from 17.6% in 2000 to 28.8% in 2010; with a further slight increase to 30.3% in 2015 (proportion working all or almost all of the time with computers, laptops, smartphones, etc.)[11]. Since computer-related office work has intensified, attention to the health status of office workers and the possible risk factors of computer work has increased. The attention has focused on arm-wrist-hand and neck-shoulder symptoms. Originally, mainly physical risk factors, such as computer use and static postures, were seen as significant contributing factors to the problem[12][13].

In recent years there has been an increase in the number of high quality studies published that have investigated the impact of psychosocial factors on MSDs. The interaction between psychosocial and physical factors has been studied, but psychosocial factors were also identified as independent risk factors. Most studies conclude that risk factors for neck-shoulder pain and arm-wrist-hand pain in computer workers consist of a mixture of physical and psychosocial work characteristics[14][15][16][17][18]. However, the evidence from a relatively recent series of review papers suggests a mixed picture. A review of three prospective studies on office workers, concluded that there was only limited evidence regarding any association between work demands (divided into cognitive, sensory and 'job' demands) and the onset of low back pain, with what evidence there was appearing to indicate no effect[19]. In contrast, a second review of computer users concluded that there was significant evidence for a relationship between neck pain and two measures of job demand: time pressure and task difficulty. However, almost all of the papers included in their review were cross-sectional, making it difficult to draw any causal inferences[20]. The one prospective study in their review explored a variety of types of MSD (neck, shoulder, forearm/hands) with neck pain the only one to attain clear statistical significance[14].

A further complication in recent years, particularly relevant to those involved in computer-based work, has been the increase in remote working, including home working. This trend has been further boosted by the increase in working from home in many countries, associated with the worldwide COVID-19 pandemic. This has resulted in a potential increase in both physical risks, as many such workers do not necessarily have access to a well-designed workstation, but also psychosocial risks. Thus, such scenarios can create challenges in maintaining a suitable work-life balance, as well as potentially reducing the support structure often available in conventional office environments. To possibly balance this, some workers find the greater personal control possible when working remotely to be beneficial.

Psychosocial factors in other types of work

Many studies investigating psychosocial risk factors and MSDs include mixed populations, with workers from various industries and with different jobs making it difficult to identify any specific patterns. For example, a study of over 1500 French workers found that a lack of recognition of completed work increased the risk of chronic low back pain but the sample was drawn from the general working population making it impossible to establish any sector or occupation-specific relationships[21].

Despite this general difficulty, a relationship has be found between psychosocial factors and MSDs in occupational groups other than office workers. In workers with monotonous work, an unfavourable effect was found on neck and shoulder pain[22]. A study investigating workers from industrial and service companies found that low job satisfaction predicted neck/shoulder pain and lower limb pain[23].

In a study investigating workers at automobile repair garages, low decision authority or job control (control over work speed, breaks, decisions etc.) predicted neck pain, low back pain, and total musculoskeletal pain[24].

In a study among health care workers it was found that an increased risk for compensated musculoskeletal injuries of the lower back and lower limb was related to low job control[25][26]. A more recent systematic review and meta-analysis of longitudinal studies of nurses and nursing aides identified a statistically significant positive effect of high demand-low control on low back pain in the preceding 12 months.

Although limited in the occupations covered, these studies illustrate that the effect of psychosocial factors are not limited to office workers.

How psychosocial factors could lead to MSDs

Psychosocial factors are often associated with stress. Nevertheless, numerous studies have demonstrated that they also have an association with MSDs and there is now widespread recognition that this effect is causal[27]. The possible associations between psychosocial factors and MSDs are illustrated in Figure 1[22]. In this simple model, psychosocial factors are shown as having an effect in two ways. Firstly, they have an effect on physical factors and, through this to MSDs. Secondly, they have a direct pathway to MSDs, shown in this model as being mediated through stress symptoms. It should be noted that other potential pathways are believe to exist, for example there are suggestions that some of the risk factors such as those listed above can have a direct influence on MSDs.

Figure 1: Possible associations between psychosocial factors at work and MSDs

Figure 1: Possible associations between psychosocial factors at work and MSDs

There are thus several possible pathways by which psychosocial factors could lead to MSDs as illustrated by this model. Other, more complex models have been prepared by a number of different authors that serve to demonstrate growing awareness of the complex interactions involved[27].

As noted above, one possible pathway by which psychosocial factors at work may influence MSDs, is by increasing the exposure of workers to unfavourable physical factors. For example, high job demands may lead to more rapid (rushed) movements, with an increased level of repetitive activity. Conversely, in sedentary occupations, high work demands might lead to longer periods of physical inactivity with fewer breaks and extended working hours[4].

In a second suggested pathway, the relationship between psychosocial factors and MSDs could be mediated by stress symptoms. Stress creates physiological responses which have been the subject of a large body of research for many years. Initially, authors described a ‘fight or flight’ reaction in animals during situations where they either had to flee or prepare to fight in order to defend themselves from danger[28]. Similar fight or flight reactions have also been found to occur in humans during times of stress or danger. These are not confined to a behavioural response, but refer explicitly to physiological responses, such as dilation of the pupils, increased heart rate, and the release of adrenaline and cortisol into the bloodstream.

Translated to the reality of the workplace, work-related psychosocial factors can lead to stress and, like a perceived threat to our survival, this stress will evoke physiological responses and may cause musculoskeletal symptoms. For example, this stress response may increase the tone in muscles, with this higher level of tension increasing the strain associated with physical activities or causing the muscles to become more easily fatigued. Additionally, it may increase the duration of muscle activity and reduce the scope for recovery. Stress may also intensify the perception of pain, or undermine the mechanisms used to cope with pain. Also, stress may modify the physical and behavioural responses to pain[29]. Seen from a more pathophysiological perspective, apart from increasing muscle activity, stress may also impair circulation and the supply of oxygen to tissues as a result of hyperventilation. In this way, prolonged stress may degrade tissue quality and impair tissue repair processes[30]. One important consequence of this delayed recovery is to increase the risk of an MSD becoming chronic.

Evidence for the relationship between psychosocial factors and MSDs

Many scientific studies have demonstrated an independent effect of psychosocial risk factors for MSDs and a recent EU-OSHA review summarises the published evidence[27]. Although isolated studies have suggested relationships between particular psychosocial factors and specific MSDs the current evidence (2021) suggests that there is no consistent pattern to this relationship. The associations between psychosocial risk factors and MSDs identified in the research literature are many and varied and it is not possible to identify more consistent patterns or to relate particular risk factors to specific MSDs. However, this is not unexpected and should not be regarded as undermining the strength of the general relationships that have been identified. With physical risk factors such as the weight of objects; the frequency with which objects are handled; and the postures adopted in handling some objects, not all factors apply all the time. A study of physical factors in, for example, the electronics assembly industry, would not be expected to identify the weight of the items being assembled as a significant risk factor for causing upper limb disorders. Logically therefore, if "control" does not emerge as a contributory psychosocial risk factor in a given workplace, this does not invalidate control as a potential risk in any workplace.

The failure to identify relationships between particular risk factors and types of MSD is not unexpected as many, if not all, of the suggested explanatory mechanisms do not suggest differential pathways to different muscles in different parts of the body. One exception might be that those MSDs largely associated with muscle strains (overload), such as much low back pain, might be affected differently to some upper limb disorders attributed to tendon inflammation (such as tenosynovitis). However, as at present all of the explanatory mechanisms are largely speculative with no clear mechanistic pathway being identified, it is not possible to develop this further.

Although most of the published evidence relates to MSDs affecting the back, neck and upper limbs, there have been a few studies into lower limb MSDs. The situation here appears to be much the same – although the comparatively limited number of studies make any definitive statement uncertain.

Implications for intervention strategies

The research literature and evidence from the workplace[31] indicates that most interventions aimed at addressing work-related MSDs have just addressed physical risk factors. Similarly, interventions focussing on psychosocial risks have primarily sought to address psychosocial outcomes such as work-related stress. However, as summarised above, findings in the scientific literature emphasise that work-related MSDs arise from multiple risk factors, with bio-behavioural, psychosocial and organisational factors playing an important part, as well as biomechanical risk factors (although it should be noted that these physical factors appear to play the bigger role). Given this multifactorial background to causation, it seems logical that an integrated, multifactorial approach to prevention seems the most promising strategy. In an extension of the scope of any holistic approach, some authors have advocated the inclusion of modifiable personal factors[32], such as obesity and general physical activity, again with an established relationship to MSD risk.

Research has shown that interventions based on single measures appear to be less likely to prevent MSDs than a multifactorial strategy. As advocated by EU-OSHA, a holistic approach is needed, covering physical and psychological demands, and therefore addressing both physical and organisational aspects of work. This approach promises to be most successful if it is embedded in a participatory environment and in a strong prevention-oriented corporate culture[33].

A recent study of the reasons behind the apparent persistence of MSDs in the workplace[34] identified a number of potential factors at play, including a tendency for many employers to adopt a too narrow approach. Amongst its recommendations was the need to encourage a broader perspective on risk assessments and prevention – that is to further encourage and endorse this holistic approach. It recognised the importance of not just covering the physical risks associated with workplace tasks (such as repetitive actions or working in awkward postures), but also psychosocial risks. The study also recognised that the need for a comprehensive (holistic) approach applied, not just to the assessment and prevention of risks but also to those involved in that investigative process. Involvement in a process helps to obtain commitment to that process and the inclusion of workers and management acting as a team serves to maximise the prospect of a successful outcome.

Such an integrated approach has been recommended by many other players, including the European Trade Union Confederation (ETUC). The ETUC emphasises the need for a comprehensive and integrated approach in relation to a new directive, aimed at the primary prevention of MSDs. They state that a strategic approach towards MSDs should be comprehensive, multidisciplinary and participative; in particular, it should consider all parts of the human body, and biomechanical and specific work organisation factors – especially the issue of time pressure[35][36]. Nevertheless, such a strategy has not yet been adopted. This approach has been endorsed by a more recent ETUC (ETUI) publication[37] and by a further recent extensive EU-OSHA evidence review[27].

Although the integrated approach has been recommended by researchers and policy makers, little is known of the effect on MSDs of interventions that include the improvement of psychosocial factors. Very few studies have reported on the preventive effect of such interventions for work-related MSDs and studies with proper evaluations of such interventions are lacking. However, there is some evidence that, to be successful, a physical ergonomics programme should have an organisational dimension and entail the involvement of the workforce[38].

Not only primary prevention of MSDs but also rehabilitation of those with MSDs will profit from an integrated approach (multidisciplinary rehabilitation). A systematic review[36]found that, as well as contributing to the development of MSDs, psychosocial factors can create barriers to returning to work for those with chronic MSDs. It suggested that the complexity of interacting factors in respect of rehabilitation and the prevention of recurrence (where individual psychological barriers to returning have also to be taken into account) can make such a multifactorial approach even more necessary in rehabilitating workers compared to initial prevention of MSDs. As well as clinically-based treatment and rehabilitation (that can entail a psychological element to address issues such as a fear of further pain), a comprehensive approach should extend into the workplace. Here, adapting tasks to accommodate any residual physical limitations (including perhaps restricting the range of activities required or reducing the duration of working time) should be accompanied by addressing any psychological barriers within all levels of the workforce and management. The review found that, in general, the quality of evidence relating to interventions was limited and did not allow any specific content to be formulated. However, the best evidence suggested that a multifactorial approach offered the most promising outcome. This should include interventions aimed at:

  • treating residual symptoms;
  • enhancing the work capabilities of the individual (through, for example, tailored exercise);
  • making adaptations to the workplace.

Effective treatment/rehabilitation programmes appear to contain multiple components, such as knowledge conditioning (e.g. education or information about pain and the human anatomy), psychological conditioning, physical and work conditioning and relaxation exercises. Patients with negative recovery expectations take longer to return to work. There is also evidence that, as well as various psychosocial aspects of work (including in particular the absence of support from managers and co-workers; and excessive demands), individual factors such as low mood, somatising tendency, health beliefs (e.g. fear avoidance beliefs) all adversely affect the occurrence and persistence of musculoskeletal pain symptoms[39]and are therefore likely to impact on rehabilitation.

In conclusion, both prevention and rehabilitation strategies concerning work-related MSDs will profit from a multidisciplinary approach.

Resources

Rydstedt, L., W., & Weston, J., P. The relation between psychosocial working conditions and work-related musculoskeletal complaints. In: Graveling R (ed). Ergonomics and musculoskeletal disorders (MSDs) in the workplace. Boca Raton: CRC Press..2019.

References

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Links for future readings

EU-OSHA –European Agency for Safety and Health at Work. Expert forecast on emerging psychosocial risks related to occupational safety and health (OSH), 2007. Available at: http://osha.europa.eu/en/publications/factsheets/74

EU-OSHA – European Agency for Safety and Health at Work. Work-related musculoskeletal disorders: prevention report, 2008. Available at: http://osha.europa.eu/en/publications/reports/en_TE8107132ENC.pdf

EU-OSHA – European Agency for Safety and Health at Work. Work-related musculoskeletal disorders: prevention report, 2008. A summary. Available at: http://osha.europa.eu/en/publications/factsheets/78

EU-OSHA – European Agency for Safety and Health at Work. Work-related musculoskeletal disorders: Back to work report, 2008. Available at: http://osha.europa.eu/en/publications/reports/7807300

EU-OSHA – European Agency for Safety and Health at Work. Work-related musculoskeletal disorders: Back to work report, 2008. Fact sheet. Available at: http://osha.europa.eu/en/publications/factsheets/75

EU-OSHA – European Agency for Safety and Health at Work. OSH in figures: Stress at work – facts and figures. 2009. Available at: http://osha.europa.eu/en/publications/reports/TE-81-08-478-EN-C_OSH_in_figures_stress_at_work

EU-OSHA – European Agency for Safety and Health at Work. OSH in figures: Work related musculoskeletal disorders in the EU – facts and figures. 2010. Available at: http://osha.europa.eu/en/publications/reports/TERO09009ENC

EU-OSHA – European Agency for Safety and Health at Work. Introduction to work-related musculoskeletal disorders, 2007. Fact sheet. Available at: http://osha.europa.eu/en/publications/factsheets/71

EU-OSHA – European Agency for Safety and Health at Work. Work-related musculoskeletal disorders (MSDs): an introduction, 2007. E-Fact. Available at: http://osha.europa.eu/en/publications/e-facts/efact09

EU-OSHA – European Agency for Safety and Health at Work. Prevention of psychosocial risks and stress at work in practice, 2002. Available at: http://osha.europa.eu/en/publications/reports/104

EU-OSHA – European Agency for Safety and Health at Work. How to tackle psychosocial issues and reduce work-related stress, 2002. Available at: http://osha.europa.eu/en/publications/reports/309

EU-OSHA – European Agency for Safety and Health at Work. How to tackle psychosocial issues and reduce work-related stress, 2002. Fact sheet. Available at: http://osha.europa.eu/en/publications/factsheets/32

EU-OSHA – European Agency for Safety and Health at Work. Practical advice for workers on tackling work-related stress and its causes, 2002. Fact sheet. Available at: http://osha.europa.eu/en/publications/factsheets/31

EU-OSHA – European Agency for Safety and Health at Work. Work related stress, 2002. Fact sheet. Available at: http://osha.europa.eu/en/publications/factsheets/22

EU-OSHA – European Agency for Safety and Health at Work. Stress at work: Summary of an Agency report, 2002. Fact sheet. Available at: http://osha.europa.eu/en/publications/factsheets/8

EU-OSHA – European Agency for Safety and Health at Work. Hazards and risks leading to work-related neck and upper limb disorders, 2007. E-fact. Available at: http://osha.europa.eu/en/publications/e-facts/efact16

EU-OSHA – European Agency for Safety and Health at Work, Musculoskeletal disorders (website, no publishing date available). Retrieved on June 2011, from: http://osha.europa.eu/en/topics/msds/index_html

EU-OSHA – European Agency for Safety and Health at Work, Work on Stress. (website, no publishing date available). Retrieved on June 2011, from: http://osha.europa.eu/en/topics/stress

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OSH: Psychological and organisational hazards, Psychosocial work environment, 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