Whole-Body Vibration Related Disorders in Occupational Clinical Setting – An International Comparison.. Dr med. Eckardt Johanning, M.D., MSc Occupational and Environmental Life Science – Albany, New York 2 The medical “outcome” is the patient  The occupational medicine perspective:  The  patient and the occupations with exposure The injured worker: “doc I have back aches- and I can’t do it”  Professional Drivers        Truck and bus drivers, earthmoving engineers Mining vehicles Railroad workers, subway operators Construction Agriculture, fishing industry, Forestry Service workers Johanning - 5th International Conference on Whole Body Vibration Injuries 3 Whole Body Vibration: the good and the bad on medline The good :          “Training & exercise” Geriatric patients Wound care Fractures-bone growths Osteoporosis Menopause reflex muscle activation Back pain COPD – lung disease The bad:  Orthopedic and neurological system:  Lumbar spine and nervous system    low back pain, sciatic pain, degenerative changes Neck & shoulder Gastro-intestinal system Female reproductive organs  Prostate  Peripheral veins  Cochlea-vestibular Johanning - 5th International Conference on system  Whole Body Vibration Injuries 4 Occupational medicine causation analysis  Can it, did it ?  Medical-legal Standard: “more likely than not” (> 50%) FELA “in whole or in part” exposure Link ? Injury / illness Johanning - 5th International Conference on Whole Body Vibration Injuries 5 Occupational - Medicine diagnosis – “real life” often by doctors with No/little occupational medicine training  Patient history, symptoms, prior medical care  Physical examination  Laboratory test  Imaging studies: x-ray, CT, MRI, myelogram etc.  Neurological studies: EMG/NCS  Differential diagnoses  Other medical conditions Johanning - 5th International Conference on Whole Body Vibration Injuries  Both occupational and non -occupational factors 6 CLINICAL EXAMINATION OF a WORKERS WITH LOW BACK COMPLAINTS Diagnoses depends on individual characteristics:  Age? – Latency  Co-morbidity (Osteoporosis, diabetes, arthritis)?  Anthropometric data ?  Smoking ?  Susceptibility?  Genetics/family history  Psycho-social factors? Johanning - 5th International Conference on Whole Body Vibration Injuries  Prior history of back injuries/problems? Differential Diagnosis of Low Back Pain in General medical Practice 7 Mechanical       low back pain (97%) Lumbar strain or sprain (≥ 70%) Degenerative disk or facet process (10%) Herniated disk (4%) Osteoporotic compression fracture (4%) Spinal stenosis (3%) Spondylolisthesis (2%) Non-mechanical   Neoplasia (0.7%) Inflammatory arthritis (0.3%) spinal conditions (1%) Nonspinal/visceral      disease (2%) Pelvic organs—prostatitis, pelvic inflammatory disease, endometriosis Renal organs—nephrolithiasis, pyelonephritis Aortic aneurysm Gastrointestinal system—pancreatitis, cholecystitis, peptic ulcer Shingles Unilateral Johanning - 5th International Conference on Whole Body Vibration Injuries 8 Anatomy of the human spine Johanning - 5th International Conference on Whole Body Vibration Injuries 10 Herniated disc and nerve root compression Johanning - 5th International Conference on Whole Body Vibration Injuries 11 Disc herniation & Lumbar stenosis Johanning - 5th International Conference on Whole Body Vibration Injuries 12 Lumbar herniated disc. Videman, Battie et al “Twin studies” argument: Asymptomatic subjects: n=31 Disc bulge DJD HNP 65% 45% 33% “Defense “ Argument: • Key: Hereditary (genetics) vs. leisure time or work • Smoking • BMI • Muscle strength • No! Whole-body vibration Johanning - 5th International Conference on Whole Body Vibration Injuries 13 Vertebra Facet joints Lordotic curve Intervertebral foramen Degenerative Spinal changes  Decreased disc space height  Osteophytes  Misalignments Johanning - 5th International Conference on Whole Body Vibration Injuries Spondylolisthesis 14 Anterior slippage () of the fifth lumbar vertebra on the sacral base can be identified in lateral views Johanning - 5th International Conference on Whole Body Vibration Injuries 15 Aging and degeneration Johanning - 5th International Conference on Whole Body Vibration Injuries Anatomical model MR image 16 Visco-elastic Disc and Degeneration J Wendlová: Wien Med Wochenschr (2010) 160/17–18: 464–469 Johanning - 5th International Conference on Whole Body Vibration Injuries 17 Endplate changes over time Johanning - 5th International Conference on SJ Furgosen, T Steffen: Eur Spine J (2003) 12 (Suppl. 2) : S97–S103 Whole Body Vibration Injuries 18 Vertebral Endplate & Degeneration J Wendlová: Med Wochenschr (2010) 160/17–18: 464– Johanning Wien - 5th International Conference on 469 Whole Body Vibration Injuries SJ Furgosen, T Steffen: Eur Spine J (2003) 12 (Suppl. 2) : S97–S103 19 Fusion Surgery in locomotive engineer 59y Johanning - 5th International Conference on Whole Body Vibration Injuries 20 “Much Ado About Nothing” ? by Shakespeare Commercial Industry and Public Service claimed /recognized occupational disease (BK 2110) for 2006-2011 and Comparison with Netherland Source: DGUV Coronel Institute , Amsterdam All claims & recognized WBV-BK 2110 1200 1000 800 Claims 600 WBV BRD 400 200 0 25 20 1995 2000 2005 2006 2007 2008 2009 2010 2011 recognized claims: 15 WBV BRD 10 WBV Dutch 5 0 Johanning - 5th International Conference on Whole Body Vibration Injuries 1995 2000 2005 2006 2007 2008 2009 2010 2011 2012 21 Spinal disorders ICD 10(BK 2110 ) 2006-11 4% 1% 1% 1% M42 Osteochondrose M47 Spondylose, M50 Zervikale Bandscheibenschäd en 93% M51 Sonstige Bandscheibenschäd Johanning - 5th en International Conference on Source: DGUV Whole Body Vibration Injuries M42 Osteo-chondrose M47 Spondylosis, M50 Cervical disc disorder M51 Lumbar disc disorder M54 Lumbar Pain Total = n year 7 11 13 1089 51 1171 200611 0 0 0 48 0 48 200611 0 7 1 25 26 64 200612 0 0 72 59 5 73 Surgery Rail n=103 Dutch recognized BRDrecognized ICD - 10 Diagnoses Claims BRD =n WBV Exposure related Diagnoses Raillocomotive n=103 22 10 36 200613 Johanning - 5th International Conference on Whole Body Vibration Injuries Sources: DGUV, Coronel Institute (Amsterdam), Johanning MD PC 23 Railroad Train worker diseases grouped by age and number of major diagnoses (MSD, CDV, Metabolic, GI, Psychiatric, other) 100% 12 90% 80% 31 15 70% 60% 50% 31 35 40% 30% 20% 20 38 10% 0% 18 30y to 49y 50y to 64y US Railroad Train Operator 5 Diagnoses 4 Diagnoses 3 Diagnoses 2 Diagnoses 1 Diagnosis Johanning - 5th International Conference on Whole Body Vibration Injuries German population (Fuchs et. al. Bundesgesundheitsblatt 4/ 2012) 24 “Shock & Jolts” ISO 2631-1 – Vibration measurement standard  Crest Factor   +   (ISO 2631-1: >9 ACGIH-TLV (2012): >6) VDV > 1.5 > 1.75 MTVV aw VDV aw ⋅ T 1/ 4 Additional methods suggested for risk assessment Johanning - 5th International Conference on Whole Body Vibration Injuries 25 ISO 2631-5 Background:  Military research and application:  Blood in Urine of Tactical Ground Vehicle Operators  “hematuria observed in 50% of the company” (Alem 2005)  Health Hazard assessment (HHA) –US Army-Aeromedical Research Laboratory (USAARL), Fort Rucker, Al. conducts experimental research: 54 healthy, 19-40 y US Army Soldier Volunteers  Up to 7 h/d or 4 h/d for 5 d TGV ride signature exposure - 5th International Conference on  some tolerated VDV(8)Johanning of 66 over a 7 h period  Whole Body Vibration Injuries 26 Spine compression fracture risk according with calculation of R –values according to ISO 2631-5 (2004) from locomotives and other vehicle data * 2.5 2 1.5 1 0.5 0 R - ISO 2631-5 Johanning - 5th International Conference on Whole Body Vibration Injuries * In cooperation with Herrn J. Hofmann (Woelfel AG) 27 3 “Instationaritaets factor” (IF) according to DIN SPEC 45697:2012-06 – if present calculate according to DIN SPEC 2.5 2 1.5 IF ax 1 IF ay IF az 0.5 UP 6886 (1h 37min) UP 6886 (1h 34min) UP 6886 (3h 18min) CSX F350 off-road (12min) Johanning - 5th International Conference on Whole Body Vibration Injuries CSX F350 road (11 min) BNSF 7355 (2h 30min) BNSF 7355 (1h 42min) BNSF 1942 (2h 20min) Audi A3 (11 min) 0 28 Spine compression fracture risk according the to alternative DIN SPEC 45697:2012-06 method* (by spinal level T12 to L4/S1) 1.6 Audi A3 (11 min) 1.4 1.2 BNSF 1942 (2h 20min) 1 BNSF 7355 (1h 42min) 0.8 0.6 BNSF 7355 (2h 30min) 0.4 0.2 0 R T12-L1 L1-L2 L2-L3 L3-L4 L4-L5 L5-S1 CSX F350 road (11 min) Johanning - 5th International Conference on * In cooperation with Herrn J. Hofmann (Woelfel AG) Whole Body Vibration Injuries CUELA posture & VIBRATION measurement & analysis 29 Johanning - 5th International Conference on Whole Body Vibration Injuries WBV-CUELA posture analysis detail: - 5th International RED: Head forward angle YELLOW:Johanning Back forward angle BLUE:30vibration/shock Conference on Whole Body signal Vibration Injuries Yard switching extreme postures % of time Comments Cervical rotation right 9.4 Looking into mirror Cervical flexion 10.4 Control panel / communication radio Lumbar rotation right 3.5 Looking out of window Lumbar forward flexion 47.1 Control levers operation Vibration: 0.5 to 1 m/sec2 15.9 1 to 1.5 m/sec2 3 > 1.5 m/sec2 17.2 Johanning - 5th International Conference on Whole Body Vibration Injuries 31 32 Outlook  Is it the bone  Is it the muscle  Is it the soft-tissue (collagen fibers?)  Is it the posture  Is it the genetics/ hereditary  Is it the compensation system  What ever - Go for it:  Prevention opportunities Johanning - 5th International Conference on Whole Body Vibration Injuries