- Observatory: EurWORK
- Published on: 08 October 2007
Disclaimer: This information is made available as a service to the public but has not been edited or approved by the European Foundation for the Improvement of Living and Working Conditions. The content is the responsibility of the authors.
This study examines the impact of work changes on the resurgence of work-related musculoskeletal diseases in Ireland, as of 2006.
The Community strategy on health and safety at work (2002 – 06) calls for working towards a healthier occupational environment. It sets three prerequisites for a high quality working environment:
a global approach to wellbeing at work taking into account of changes in the nature of work and the emergence of new risks;
consolidating a culture of risk prevention by combining a variety of political instruments and building partnership;
better application of existing laws, pointing out the costs of non-policy.
There are many definitions of Musculoskeletal disorders (MSDs). The most common are:
Repetitive strain injuries (RSIs)
Musculoskeletal disorders, or Musculoskeletal diseases (MSDs)
Work related Upper Limb Disorders (WRULD)
Work related musculoskeletal diseases
Cumulative trauma disorders (CTDs)
Over Use Disorders (OUD)
Some of them restrict the domain of observation to some part of the body (for instance WRULD) or to the causes of such diseases (RSI, CTD). Both “disorders” and “diseases” are used. This depends on the historical insurgence of such diseases: some of them stress “repetition” (RSI), others (CTD, OUD) the fact that “work demands habitually exceed a worker’s capacity to respond to these demands” (Putz-Anderson, 1988).
The 2002 Scoreboard on implementing the Social Policy Agenda draws the attention to new types of risks emerging giving rise to new health problems involving musculoskeletal disorders.
The 2002 Council resolution includes in its goals the prevention of work-related diseases, especially those most widespread amongst European workers, such as those related to exposure to toxic substances, the hearing loss and MSDs, taking into account changes in working population according to gender, aging, demographic dynamics, disabled worker conditions, ethnic and cultural diversities, and transformations in labour regimes, working times and work organization
Figures available show that Musculoskeletal disorders (MSDs) are the main occupational disease suffered by European workers. The LFS 1999 additional module by Eurostat shows that MDSs are more than 50% of serious work-related diseases, with a prevalence rate over 2,5%, i.e. more than 4 millions of employees. Some industries show higher prevalence rates: Health and social work (over 4%), construction, transport and communication (over 3%).
According to the 3rd EWCS, one worker over 3 (32,2%) alleges backache, 22.8% of workers allege muscular shoulders and neck pain, 12.9% muscular upper limb pain, 11.5% muscular lower limb pain. Gender differences are not very significant, although job characteristics differ significantly. They show an increase over the 90s. However, a number of epidemiological studies have found that women are at higher risk for WR-ULDs, although workplace risk factors are generally found stronger than gender effects.
Such upwards trends show that MSDs are no more “traditional” ones, linked mainly to some manual tasks (repetitive movements, carrying heavy loads, vibrations) but are increasingly widespread in services sectors (care, hotels and restaurants) and amogst working with PCs and ICT devices.
Cost of MSDs have been estimated by some countries. There are direct costs (absence days, rehabilitation) and indirect costs (production losses, quality losses, mistakes and errors, gap in productivity of the substitute, ecc.). Netherlands estimates are 1.7% of GNP, both direct and indirect, while UK estimates of direct costs are around .8% of GNP in 1995-1996. in Finland, socio-economic costs of MSDs were estimated as 1% of GNP and in Germany as .61% of GNP (European Agency for Safety and Health at Work, 2000, first-phase consultation paper ).
MSDs and working conditions
Work-related MSDs were usually associated to repetitive tasks or to those implying carrying of heavy loads, vibrations, inadequate postures such as in construction, transport, agriculture sectors and, more recently, by caregivers. According to ergonomists, they are “multifactorial in nature. In work environment, these are problems attributable to repetitive work under strict spatio-temporal constraints” (Bourgeois, 2000). The expert forecast on emerging physical risks related to occupational health and safety strongly agree on the lack of physical activity and on the combined effect of exposure to MSDs risk factors and psychosocial risk factors (such as job insecurity and fear of the future), thus enlarging the target of such diseases.
MSDs affect all parts of the body allowing the individual to move and work, with strong interrelations between nervous and muscular systems: back, neck, shoulders, upper and lower limbs. They result from an accumulation of mechanic constraints, repetitive movements, short production cycle, heavy lifting, poorly designed work stations..., PC...
Epidemiological studies show that “work densification” due to time pressure and imperative deadlines, following the introduction of just-in-time methodologies, increased the influence of organizational factors over MSDs: “even more than risk factors, work organization “determines” the characteristics of work situations and may potentiate pathogenic effects” (Douillet, Schweitzer, 2002).
Brenner, Fairis and Ruser (2004) show similar findings in USA: cumulative trauma disorders increased impressively along 80s and early 90s. “Despite the importance of this trend in CTDs and the link posited with workplace transformation, surprisingly little research has been undertaken to explore this relationship”.
According to the ACSHH opinion adopted in May 2001, the risk of MSDs are to be taken into account especially when changes are made to the work organisation requires comprehensive information and awareness-raising policies.
Unlike the so-called “traditional” risk, MSDs arise as the result of a “singular combination of multiple personal and collective, material and psychological factors bound up with the practical way work is organised” (Douillet, Schweitzer, 2002). Amongst the latter, there is increasing evidence that stress and MSDs have significant interplays (see for instance HSE report in the oil industry) with causal direction in both senses.
Buckle and Woods (2002) summarise workplace factors affecting MSDs occurrence in 5 areas:
social support received by colleagues, supervisors or management, tends to reduce their occurrence because of their impact on mental and physical health and stress;
access to health information, have a similar impact because of its role in implementing improvement strategies;
job insecurity, temporary and piecework: less skilled manual workers at the lower end of labour market are affected the most, including part-time workers, with poor job-specific experience and/or confinement to worst jobs;
low status work, i.e. low paid, unskilled, paced and repetitive work, where no training is required and poor control on the job, show higher occurrence rates;
income show a negative relation with MSDs occurrence because of its impact on living conditions, esp. housing, education, clothing and fuel.
They can be modified by organizational and ergonomic interventions, while individual factors do not. Amongst the latter, education, age, gender, ethnicity are seen as significant. The Foundation papers discussed below (see section 4.) explore in depth their impact.
From this brief discussion, three structural changes can explain the resurgence of MSDs: a) changes in organizations, increasing time-based competition with lean supervision staff and without an increase in work autonomy, b) changes in work status and labour regimes, with higher weight of non-standard workers, c) changes in the workforce composition according to gender, age, and ethnicity, having different social habits with respect the traditional male breadwinner reference model. a) and b) affect the quality of work by itself, while c) affects the reference workforce on which jobs are designed and therefore the perceived quality of work.
The normative frame: the EU level
The Health and Safety at work Framework Council Directive 89/391 directive, introduces general prevention principles applicable to all occupational risks, aimed to ensure a higher degree of protection of workers at work through the implementation of preventive measures to guard against accidents at work and occupational diseases, and through the information, consultation, balanced participation and training of workers and their representatives. Article 6.2d states that the employer should take measures necessary for “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 method, with the view, in particular, to alleviating monotonous work an work at a predetermined work-rate and to reducing their effect to health”
Other individual health and safety directives address risk factors for MSDs:
the Council Directive 89/665/EEC, as amended by the Council Directive 95/63/EC on minimum safety and health requirements for the use of work equipments by workers at work. Article 5a, under the heading “Ergonomics and occupational health”, states “the working posture and position of workers while using work equipment and ergonomic principles must be taken fully into account by the employer when applying minimum health and safety requirements”
the Council Directive 89/656/EEC on minimum safety and heath requirements for the use of personal protective equipments (PPE) by workers states at article 4 that all personal protective equipment must “correspond to existing conditions at the workplace” and they must “take account of ergonomic requirements and the worker's state of health”
the Council Directive 89/686/EEC on the approximation of implementation of the PPE directive in National States legislation, states that “any impediment caused by PPE to movements to be made, postures to be adopted and sensory perception must be minimized; nor must PPE cause movements which endanger the user or other persons” (Article 184.108.40.206 Annex II)
the Council Directive 90/269/EEC on the minimum safety and health requirements for the manual handling of loads where there is a risk particularly of back injury to workers, states that the “employer should take appropriate organizational measures, or shall use the appropriate means, in particular mechanical equipments, in order to avoid the need for the manual handling of loads by workers”. (article 3.1)
the Council Directive 90/270/EEC on the minimum safety and health requirements for work with display screen equipments states that “employers shall take appropriate measures to remedy the risks found, on the basis of the evaluation (…….) taking account of the additional and/or combined effects of the risks so found” (article 3.2) , with specific references to risks to eyesights, physical problems and problems of mental stress.
Specific provisions are provided by the Council Directive 92/57/EEC on the minimum safety and health requirements for work in temporary and mobile construction sites, which constitute an area of activity that exposes workers to particularly high levels of risk, with specific reference to the conditions under which various materials are handled (article 8.c);
The Council Directive 98/37/EC on the approximation of the laws of the Member States relating to machinery, states that “Under the intended conditions of use, the discomfort, fatigue and psychological stress faced by the operator must be reduced to the minimum possible taking ergonomic principles into account” (article 220.127.116.11, Annex II)
The annex of the Council Directive 2001/45/EU concerning the use of work equipment provided for temporary work at a height on work at height, states that “if (it) cannot be carried out safely and under appropriate ergonomic conditions from a suitable surface, the work equipment most suitable to ensure and maintain safe working conditions must be selected” (article 4.1.1, Annex)
The Council Directive 2002/44/EC on the minimum safety and health requirements regarding the exposure of workers to the risks arising from physical agents, such as vibrations, states “it is considered necessary to introduce measures protecting workers from the risks arising from vibrations owing to their effects on the health and safety of workers, in particular muscular/bone structure, neurological and vascular disorders” (point 3).
The Council Directive 93/104/EC concerning certain aspects of the organization on working time, in stating the minimum standards for weekly working time, rests, breaks and annual leaves, relies on “the general principle of adapting work to the worker, with a view, in particular, to alleviating monotonous work and work at a predetermined work-rate, depending on the type of activity, and of safety and health requirements”, (article 15) including therefore MSDs.
Impact of the MSD reports by the EU-OSHA on work-related neck and upper limb disorders and on work-related low back disorders concluded that the existing knowledge could be used in the development of practical, preventive strategies and that there is limited but convincing evidence of the effectiveness of work system interventions that have incorporated ergonomics. However, after the 2000 European Week for the Safety and Health at Work devoted to MSDs, only the reports based on the 3rd EWCS provided further comparative evidence.
A first-phase consultation process of the social partners on musculoskeletal disorders at work is acting to come eventually to an agreement A preliminary step in this direction is the agreement in agriculture signed by GEOPA-COPA (Committee of Professional Agricultural Organisations in the European Union, the employers’ association in agriculture) and EFFAT (European Federation of Food, Agriculture Tourism trade unions), the 21th November 2005.
Some secondary analyses of the 3.rd European Working Conditions Survey
The report “Work organisation and health at work in the European Union” show that the share of employed women affected by occupational diseases sharply fall after 30 years of service, while men do so only for stress. This means that women more likely drop out the labour market. Authors draw up four typologies of worker: “autonomous”, mainly associated with clerical tasks, “flexible” especially for work schedules, mainly associated with hotel&catering and health services, “constrained”, mainly associated with services and hotel& catering again, and “automated” workers, associated with repetitiveness and lack of autonomy, mainly concentrated in manufacturing industries. MSDs are concentrated amongst workers performing heavy tasks, typically in construction, agriculture, and those performing repetitive tasks, typically manufacturing. They are significant also between “autonomous” workers, with figures not so far from more physically demanding jobs: more than one woman over four report suffering backache, more than 20% MSDs at neck and shoulders. Similar figures are shown by men, although their tasks in physically demanding jobs require are more heavy tasks, while women perform more repetitive jobs.
According to the report Time and work: work intensity, work intensity is on the increase in Europe: from 1995 to 2000, employees experienced an intensification of their jobs and that increase time pressures at work affect workers’ state of health. In the majority of cases, “there is a positive link between the physical problems recorded and the work intensity factors”. This link is significant for most or all MSDs listed in the case of automatic constraints, dependence on collegues activities, direct supervision by the boss and presence of customer for at least ¾ of working time, while commercial constraints do not show such relations.
The report Employment status and working conditions shows that non-permanent and self employed workers are significantly more exposed to unfavourable ergonomic conditions, which can give rise to “classical” MSDs, while part-time workers do not display significant differences. Their impact over health is discussed by the report Type of employment and health in the European Union: backache are more likely among self employed, while muscular pains are more likely among self-employed and full-time fix term employee with respect to full-time permanent workers. Extreme temperatures, repetitive movements and vapours are the unfavourable working conditions which increase the most the occurrence of both backache and muscular pain. Absence of social support is weakly significant for the former and not significant fot the latter, while both job control and job demand have a strong impact on both diseases above mentioned.
According to the report “Gender, jobs and working conditions in the European Union” gender differences in ergonomic working conditions “are largely a result of men’s greater involvement blue-collars (manual) jobs” and these differences are negligible in professional jobs: men report more frequently “carrying heavy loads” and hazardous ergonomic conditions, while women report more frequently “monotonous work”. However women report slightly higher muscle-related problems.
The Foundation report “Quality of work and employment in Europe. Issues and challenges” summarizes these results ad follows : “organizational change do not always meet expectation” and “the development of “new” forms of work organization … is not necessarily resulting in improved working conditions….. lean organizations are often associated with more intensive working. This in turn leads to higher stress and MSDs, and accident rates”(p. 16). Finally, gender differences could be explained by the double workload and other psychosocial factors attaining working conditions and job status.
The various terms listed above in describing MSDs all put the accent on repetitive and cumulative motions.
The Eurostat description of EODS methodology provides some useful comparative insight about disease statistics and the general functioning of national work-insurance systems, e.g. who compensate occupational diseases, in particular MSDs included and at what degree of seriousness are listed: only some of the MSDs are recognized as such by National Insurance Agencies (NIAs) and other agencies entitled by government and/or social partners in playing such a role. There are two main obstacles to their recognition: certain activities outside work expose people to similar risks, especially women (see question 3 below); and the nature of the contract does not help to point to the occupational origin of the disease.
Please, report the official definition of WR-MSDs, if any, or the most widespread one. Please specify whether it includes backaches.
The Department of Social and Family Affairs administers the Irish Government’s scheme to ensure workers suffering occupational injuries or illnesses receive financial support while out of work because of an occupational injury or illness. The scheme, the Occupational Injury Benefits scheme (OIB) does not define musculoskeletal disorders, but a number of conditions that are considered to fall under the heading are listed in the scheme and those suffering injury/illness as a result of one of these conditions is entitled to benefit. The conditions are: tendonitis and carpal tunnel syndrome.
lease check whether criteria illustrated in the above EODS paper have been updated in the meantime. Are recognition criteria by NIAs taking into account gender differences? Have there been any changes in last years both in general and wrt to gender issues in particular?
Not under the scheme.
Reporting is another key preliminary issue. Two orders of problems can be identified.
Clinical reporting, statistical sources (mainly based on self-reporting), working conditions surveys and administrative sources from NIAs and Health Systems tend to differ. The latter heavily depend on the institutional definitions (both legal and administrative settings) both about their causes and their nature. Figures are often collected and classified according non-homogeneous criteria, and at different analytical level in terms of part of the body affected and causes. For instance, the LFS 1999 additional module reported MSDs in an aggregated way (Q217), while the 2007 LFS ad hoc module questionnaire distinguish (Q215/216) MSDs according three regions affected: neck, shoulder, arms and hands (WR-ULD); hips, legs, feet; back.
According to Eurostat, this make difficulties to collect comprehensive European level data on recognized MSDs. Also in the EU-15, it is not granted that the European standards (EODS in our case) are employed. This causes a further problem of comparability.
Working conditions survey are probably the least dependent on institutional (legal) framework, but cultural/social habits could can affect reporting work related MSDs. However, an UK study shows significant consistencies amongst self-reported and clinical results (see the Foundation report “Quality of work and employment in Europe. Issues and challenges”.)
This very short overview, far from being complete, outlines some of the main questions related to reporting
1.1 Please list the main sources of information about WR-MSDs (NIAs and other insurance agencies empowered by government and/or social partners, WCS, public health, statistical bureaux). Please describe the way WR-MSDs are categorized by public authorities and NIAs according to the part of the body affected (upper/lower limb, bone, joint or muscle problem, hips, legs, feet, knees, back, neck, shoulders, arms, etc. ..), causes (repetitive work, vibrations, heavy loads, postures, PCs, etc…..) and occupational and demographic characteristics (labour contracts, occupation, age, gender).
1.1 The figures published by the Department do not go into the detail required. The Department published the Renaissance Project Report on Preventing Chronic Disability from Low Back Pain (2004). The report found that 27% of the increase in expenditure on social welfare scheme was due to musculoskeletal disorders, the majority of which were lower back pain.
1.2 Please describe the number, type and variety of questions advanced in MSDs. Please report the exact formulation of questions advanced in working conditions surveys. What is the evolution over time of question formulation?
1.2 See answer above
1.3 Is there any research of analyse of causes available?
Trends of MSDs and their social impact
MSDs complaints show a growth across the editions of the EWCS, supporting the argument of “work densification” and that actual prevention instruments are not fully adequate in order to cope with them. As discussed above, organizational changes, which reflect both changes in competition and HRM practices (see for all Oesterman, 2000), play a key role in such a trend. Such trends can differ significantly across sectors, occupations, firm size and gender.
The increasing participation of women to labour market make the need of engendered prevention policies for the following reasons:
a. According to Pèze (2002), “women are massively hit by MSD not only because of their morphology and hormonal factors, but because work organisation keep them out massively from conception and decision-making”: therefore, workplace design is based on the prevailing occupational group, i.e. men;
b. horizontal and vertical segregation literature show that some industries are significantly engendered (for all Hakim, 1992)
c. women still cope with more domestic tasks than men, facing thus larger risk exposure outside work.
The report “Work organisation and health at work in the European Union” investigates the relationship between health according three broad classes of organizational factors, an engendered approach from the 3rd EWCS:
temporal framework, according to the two sub-dimensions of internal flexibility (shifts, long hours, night work, sundays working, no fixed times) and industrial type of the pace of work (depending on the automatic speed of the machine, depending on quantitative standards)
scope of manoevre, according to the two sub-dimensions of autonomy (no possibility to choose or modify the pace of work; no possibility to choose or modify the methods of work, no possibility to choose or modify the sequence of tasks, not allowed to take a break) and of control (respect of precise quality standards, personal evaluation of the quality of their work);
social relationships, according to the three sub-dimensions of the commercial constraints (the pace depends on the current demands from customers etc.) discussions (no possibility of discussing work organization when changes occur, no possibility of discussing your working conditions in general) and continuing training.
1.4 Please report figures on absence days caused by MSDs (from NIAs and other Agencies, or WCS where the former are not available) according to parts of the body affected and causal agent, and their trends over last 10 years, disaggregated by labour contracts, occupation, age, if it were possible in a engendered way, accordingly to the sources available described in Q2. Please report these trends for the following sectors (with the same caveat): manufacturing and mining, health and education, transport and communication.
The figures from the Department are not analysed in the manner envisaged. The Health & Safety Authority (the Irish Governmental Agency charged with responsibility for occupational health and safety) published a report on Best Manual handling practices at Dublin Airport (2005). In a statement accompanying the report the Authority estimated that one-third of all workplaces injuries were related to manual handling practices.
1.5 Please report figures from WCSs on MSDs suffered according to parts of the body affected and causal agent, and their trends over last 10 years, disaggregated by labour contracts, occupation, and age in an engendered way by gender, accordingly to the sources available described in Q2. Please report these trends for the following sectors (with the same caveat): manufacturing and mining, health and education, transport and communication.
For the reasons stated above this is not possible
1.6 Please provide some crosstables of MSDs according to part of the body affected and, if possible, causal agent, with the following organizational factors in an engendered way, showing trends from the 90s and taking into account the questions included in WCS for each country:
pace of work (speed or repetitiveness, tight deadlines)
autonomy (in general and wher possible breaks opportunities , scope on pace of work, scope on methods);
use of PCs and other ICTs devices;
scope of discussion over work organization and/or organizational changes;
1.6 Not available
Trends of MSDs and their economic impact
MSD has consequences both on health and work efficiency. This latter can be accounted in lower productivity of both the affected worker and his/her substitute.
Lower work efficiency is just part of the costs. They are both direct (compensation, treatment, medical care) and indirect (production lost, loss of quality in production, errors/mistakes in production, absenteism, replacement). As we have seen in the introduction, estimates produced by some countries differ in included costs.
Just from these few cases, their amount is undoubtedly huge and calls for prevention policies and a careful evaluation of their impact in terms of costs and benefits.
1.7 Are there estimates of MSDs costs? If any, which direct and indirect costs are included? Who carry them? If not, what indicators are monitored by policy makers and Agencies in order to propose/draw new policies, esp. in prevention?
There are a number of estimates, but their reliability is an issue. Could we please discuss?
1.8 Are there “return to work policies” (by whom/ on what level/ whose initiative/ involvement of the actors) developed and implemented (in general and specifically for MSDs)?
Yes. Firstly see Renaissance project mentioned above. Also see Workplace Safety Code a joint employer, employee and Governmental project designed to encourage undertakings to adopt return to work policies for those suffering occupational injuries or illnesses.
Such information are collected just in order to have a flavour of the shared awareness of their social and economic impact, and as such we deal with them. Please do not devote more than 300 words.
Prevention policies and room to manoeuvre
The figures/data so far available seem to suggest that we are not sure the EU is already the downward part of the slope of the reported graph form Brenner et al. (2002). The 2002 Scoreboard on implementing the Social Policy Agenda statement about the “insufficiency of current occupational health and safety practices and hence the cost of non-social policy to businesses and workers” could be applied to MSDs. As the Community strategy on health and safety at work (2002 – 06) points out, “the preventive approach set out in Community directives has not yet been fully understood”.
According to various studies, such as those summarized in Bourgeois et al. (2000) both MSDs and stress-related disorders arises out of work situations which limit workers’ discretion. Along these lines Coutarel (2003) suggests preventive strategies based on the notion of room to manoeuvre (“marge de manoeuvre”). i.e. the means and opportunities of action an employee has in a given production situation to influence and correct the work process. This gives the possibility for the individual to have control over the work situation and to use personal capacities.
According to Douillet, Schweitzer, 2002, “expanding workers’ discretion (…) becomes a key prevention priority: not just to reduce the physical and psychological stressors, but also as a way of recognizing the individual’s creativity at work”. The organizational changes in order to prevent MSDs must therefore include all the concerned stakeholders (Daniellou, 2005).
Therefore, the room to manoeuvre approach calls for prevention strategies based on interventions at an early stage at the design of the workplace according a participative method, which can be different labelled and stylized across countries. This calls for the opportunity in developing some quality indictors in order to set benchmarking policies, such as:
Good quality working conditions;
Possibilities of cooperation;
Organisation of work which allows to make maximum of benefit out of the workforce
Stability in the workforce/low staff turnover
Limits of such a prevention approach are economic constraints (productivity/overall performance maintainance, further investments) and social constraints (population characteristics, level of experience, training, levels of exposure).
1.9 In general, plant-level prevention policies are “risk elimination oriented” or centered around “risk information”? What the role of social partners?
It is too early yet to examine plant level policies. When the Workplace Safety Code has been embedded in workplaces the information required will become available.
1.10 Please illustrate some plant-level good practices (at least one in manufacturing and one in services) following (or showing significant similarities with) the “room to manoeuvre” approach above skecthed, showing in particular the adopted approaches and the impact both in working conditions and firm performance. Is there any specific strategy of the kind towards small and medium enterprises?
1.10 See answer above
1.11 Have been developed any quality indicators measuring “room to manoeuvre” preventive strategies?
1.11 See answer above (1.10)
Brenner, Fairis and Ruser, 2004, “”Flexible” work practices and occupational safety and health: exploring the relationship between cumulative trauma disorders and workplace transformations”, Industrial relations 43.
Bourgeois F. (ed.), 2000, TMS et travail: quand la santé interroge l’organisation. ANACT.
Clot Y., 2005, “Les TMS: hypersollicitation ou hyposollicitation”, communication presented at the “1.er congrés francophone sur les TMS du membre supèrieur”, Nancy, 30-21 may 2005.
Coutarel F., 2004, La prevention des troubles musculo-squelettiques en conception: quelles marges de manoeuvre pour le dèploiment de l’activitè?, Coll. Thèses et Mèmoires, Universitè Victor Segalen Bordeaux 2 – ISPED, Laboratoire d’Ergonomie des Systèmes Complexes.
Daniellou F., 2005, “TMS et modèles d’organisation du travail et de la produciont”, communication presented at the “1.er congrés francophone sur les TMS du membre supèrieur”, Nancy, 30-21 may 2005.
Hakim C. (1993), “Segregated and Integrated Occupations: A New Approach to Analysing Social Change”, European Sociological Review 4.
Oesterman P., 2002, “Organizing the US Labor Market: National Problems, Community Strategies”, in Trubek D., Zeitlin J. (eds.) Reconfiguring work and welfare in the New Economy, Oxford, Oxford University Press, 2002
Pèze M. (2002), Approche psychosomatique et psychodynamiques des TMS. Mimeo.
Putz-Anderson V. (2002), Cumulative trauma disorders – A manual for musculoskeletal diseases of the upper limbs. Taylor&Francis, London.