Int Arch Occup Environ Health (2003) 76: 3949 DOI 10.

1007/s00420-002-0375-8

O R I GI N A L A R T IC L E

Pascal Madeleine Birthe Lundager Michael Voigt Lars Arendt-Nielsen

The effects of neckshoulder pain development on sensorymotor interactions among female workers in the poultry and sh industries. A prospective study
Received: 7 November 2001 / Accepted: 28 June 2002 / Published online: 1 October 2002 Springer-Verlag 2002

Abstract Objectives: The purpose of this prospective laboratory study was to follow newly employed workers in the sh or poultry industry for 6 months and investigate possible changes in sensory manifestations and motor performance during low load, repetitive work simulation. It was investigated whether the changes were an eect of employment duration and of development of neckshoulder complaints. Methods: Twelve newly employed female lleting employees without any sign of neckshoulder tenderness/pain at the time of employment of 0 months took part in two laboratory recording sessions planned within 1 month of employment and after 6 months of employment at the plant. After 6 months, six workers out of 12 had developed pain and/ or tenderness in the neckshoulder region. The recording sessions evaluated sensory-motor aspects by measuring pressure pain threshold, work-task timing, cutting forces, surface electromyographic activity of four shoulder muscles, displacement of the centre of pressure, and 3D movements of the arm and trunk during simulation of low load, repetitive lleting. Results: Eects due to the duration of employment were observed in both groups, i.e. decreased sensibility to pressure, decrease in the duration of the work cycle, increased arm starting position with respect to the upright position, and decreased range of motion of the arm and trunk (P<0.05) after 6 months. Among the workers with neckshoulder complaints, increased sensibility to

pressure, lower force level, higher electromyographic activity, decreased amplitude of arm movement, and increased trunk posture and movement amplitude (P<0.05) were observed, compared with workers without complaints. Conclusions: Dierences in terms of sensory manifestations and motor control strategy were seen after 6 months of employment with or without neckshoulder complaints. In general, changes in sensory manifestations and motor control strategy after 6 months work were most likely of importance, as they underlined a learning process as employment duration increased. Moreover, the present sensorymotor changes observed among workers with neckshoulder complaints highlighted the potential physical risk factors associated with low load, repetitive work. Keywords Movement co-ordination Muscle synergy Work-related musculoskeletal disorders Neckshoulder region

Introduction
Discomfort and pain originating from the neckshoulder region, leading to the development of work-related musculoskeletal disorders (WMSDs), are complaints frequently observed in workers performing low load, static or repetitive work (Hagberg and Wegman 1987; Bernard 1997; Akesson et al. 1999). Indeed, prevalence rates as high as 60% have been reported for secretaries performing low load, repetitive work (Kamwendo et al. 1991). Physical risk factors have been dened for the development of WMSDs. Those risk factors are primary: level of work load, repetitiveness, duration of the work, insucient rest, handarm vibration, and static posture (Sommerich et al. 1993). However, psychosocial factors such as mental stress, time pressure, and job satisfaction, together with the workers individual characteristics, are most likely as important (Kilbom and Persson 1987; Elert et al. 1991; Armstrong et al. 1993; Sjgaard et al. 1995).

P. Madeleine (&) M. Voigt L. Arendt-Nielsen Center for Sensory-Motor Interaction (SMI), Aalborg University, Fredrik Bajers Vej 7, Building 3, 9220 Aalborg, Denmark E-mail: pm@smi.auc.dk Tel.: +45-96-358833 Fax: +45-98-154008 B. Lundager Department of Occupational Medicine, Aalborg University Hospital, Aalborg, Denmark

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Health expenses due to WMSDs in the western countries have increased to such an extent that prevention of WMSDs has become a high priority. However, in the literature related to this topic, little is known about the exposure/response relationships and the pathophysiology behind the development of WMSDs. Recordings of the combination of force, movement, and surface electromyography (EMG) are frequently made to investigate work-related risk factors and to suggest modications of work processes (Westgaard and Winkel 1997). Surface EMG is usually preferred to other methods when the impact of neckshoulder pain on motor activity is being assessed. Increased static EMG is frequently reported in patients with trapezius myalgia (Veiersted et al. 1990; Elert et al. 1991; Veiersted et al. 1993; Sandsjo et al. 2000). Occupational studies com bining sensory, physiological and biomechanical recordings are rare. Recently, Madeleine et al. (1999) presented evidence that experimental (intramuscular saline injection) and chronic neckshoulder pain modulates motor performance in occupational settings, i.e. changes in working rhythm, muscle activation pattern, postural activity, and movement amplitude of subjects or patients performing the same controlled work process. Furthermore, the evidence of work-related risk factors in the development of WMSDs is mostly based on epidemiological studies (Hagberg and Wegman 1987; Kamwendo et al. 1991; Bernard 1997; Akesson et al. 1999), and the major part of the studies investigating the interaction between neckshoulder complaints and muscular eort has been cross-sectional (Westgaard and Winkel 1997). In the physiological part of their prospective eld study, Veiersted et al. (1993) suggest the use of surface EMG as a predictor of trapezius myalgia. Lower rates of gaps, i.e. unconscious interruptions in the EMG activity, have been identied as a predictor for future patient status. However, other studies do not report any dierences in gap frequency between workers with or without neckshoulder pain (Takala and Viikari-Juntura 1991; Jensen et al. 1993), questioning the validity of using gap as a predictor for WMSD development. There is still a clear lack of biomechanical and physiological studies aimed at assessing the employment duration eects on the development of WMSDs. Dierent muscle synergies in response to a rather well-standardised work task have been previously reported (Kadefors et al. 1976; Kilbom and Persson 1987; Westgaard et al. 1993; Nieminen et al. 1995; Mathiassen and Winkel 1996). These dierent physiological and biomechanical responses can be of importance, as they substantiate that dierent motor control strategies to well-dened motor tasks can occur. Investigating the eects of employment duration and the development of neckshoulder complaints on the sensory and motor responses to a repetitive task can be a way to increase our knowledge of why some workers develop WMSDs whereas others with the same work situations do not develop such disorders.

The present prospective laboratory study was performed with the aim of following newly employed workers in the sh and poultry industries for 6 months and assessing possible variations in sensorymotor interactions during simulation of low load, repetitive work. These possible variations were investigated in relation to employment duration, i.e. 0/6 months and the development of neckshoulder pain, i.e. non-pain/pain.

Subjects and methods

Subjects Eighteen right-handed women newly hired by a sh or poultry company took part in the rst recording session. Unfortunately, six of them had left the company (for conjunctural reasons) by the time of the second recording session. Twelve women participated in both recording sessions (mean age 27.8 (SD 8.7) years; body mass 68.4 (SD 13.1) kg; height 168.8 (SD 4.6) cm). The study inclusion criteria for the rst session within 1 month of employment at the plant were: (1) newly employed (less than 1 month) lleting worker without any experience in the sh and poultry industries, (2) older than 18 years, (3) Danish speaking, (4) no low load, repetitive work within the last 3 years and, at the maximum, 1 year of low load, repetitive work within the past 5 years, (5) no neckshoulder pain or history of injuries in the neckshoulder region or systemic illness, and (6) not pregnant at time of employment at 0 months. The local ethics committee approved the study, and informed consents were obtained from all participants. The studies were conducted in conformity with the Declaration of Helsinki.

Protocol An experienced physician examined the workers for tender areas or trigger points (Travell and Simons 1982) of shoulder girdle muscles (blind assessment). Prior to the beginning of the recording session, information on the pain intensity and location in the upper extremities was collected while the subject was at rest. The pain intensity was measured on a visual analogue scale, 0 corresponding to no pain and 15 to intense pain. No worker reported pain at the rst recording session. After 6 months of sh/poultry work, six subjects had tender or sore neckshoulder muscles and mentioned pain in the right shoulder [six subjects out of six, mean pain intensity: 6 (SE 1)], left shoulder [two subjects out of six, mean pain intensity: 6 (SE 1.5)] and right wrist (one subject out of six, mean pain intensity: 2). Based on the tenderness and complaints information, the subjects were divided into two groups of workers, with (n=6) and without (n=6) neckshoulder complaints. The recording sessions were composed of (1) sensory assessment consisting of pressure algometry measurements (assessment of the subjects muscle sensitivity to pressure) and (2) motor recordings where the subjects simulated low load, repetitive work. The workers acted as their own controls. Before any motor recordings were begun, the subjects were made familiar with the work task. The subjects practised in order to be able to perform the task without error (time events and rhythm). After this practice period, motor recordings (work task timing, surface EMG, postural activity, and arm and trunk movements in 3D) were performed three times for 3 min. Figure 1 presents the experimental set-up.

Work task The simulated time-paced work task was new for all subjects and was dened after eld observations in the sh and poultry industries (Madeleine et al. 1999). A work cycle was constituted of the following time events: (1) left-hand movement one: Take a llet

41 Motor recordings and analysis The work-task timings of the left hand (Tlhon and Tlho) were measured for each cycle with a force-sensing resistor device (Toptronic, Echternach, Luxembourg) to evaluate the work rhythm. A full bridge strain gauge knife (Figs. 1 and 2) was built and calibrated to measure the onset/oset (Tcuton and Tcuto) and the force applied during the cutting phases of each work cycle (Madeleine et al. 1999; Juul-Kristensen et al. 2002). A multimeter (Fluke 37, Tilburg, The Netherlands) was used by the experimenter to visualise the actual cutting force. The maximum force was detected for each cutting event. The task time events were sampled at 0.5 kHz. Bipolar EMG surface electrodes (Medicotest N-10-E, lstykke, Denmark) were aligned (inter-electrode distance 2 cm) on abraded ethanol-cleaned skin along the direction of the muscle bres of the right deltoideus anterior (halfway between the lateral 1/3 of the clavicula and the insertion of the deltoideus), deltoideus medius (halfway between the acromion and the insertion of the deltoideus medius), infraspinatus (infraspinous fossa, two nger breadths below the medial portion of the spine of the scapula), and trapezius (2 cm laterally from the mid-distance between vertebra C7 and the acromion) (Fig. 1). Pre-ampliers with a gain of 100 were attached to the electrodes. In total, the EMG signals were amplied 1,000 times, band-pass ltered 10400 Hz, and sampled at 1 kHz. They were analysed in the time domain, the root mean square (RMS) values were computed for each muscle and for each work cycle during an active phase, i.e. during cutting events and during a nonactive part, i.e. no right arm-movement. The RMSactive values of the EMG for each cutting event of each work cycle were computed and normalised to a reference voluntary electrical activation corresponding to a 20-N cutting force in the same arm position. The RMSnon-active corresponding to the background RMS EMG value were calculated for each work cycle in a 300-ms window (before the rst cutting event) and normalised to a reference value measured during a non-active part, i.e. the right arm rested on the workbench (Fig. 2). The non-normalised RMSactive/RMSnon-active ratio was also computed for each work cycle. The ground reaction forces (in the lateralmedial, anterior posterior, and inferiorsuperior directions) and reaction moments (around the sagittal and frontal axes of the force platform) applied by the standing subject on a force platform (AMTI model OR652000, Watertown, USA) were measured (Figs. 1 and 2). The force platform signals were amplied 2,000 times, low-pass ltered at 10.5 Hz (second order), and sampled at 0.5 kHz. The maximum amplitudes of the centre-of-pressure (CoP) displacement in the frontal and sagittal planes were calculated as the dierence between the maximum and minimum of the CoP displacement to measure the postural activity during work simulation (Madeleine et al. 1999) for each cycle. A 3D motion analysis system (McReex, Qualysis A/S, Partille, Sweden) was used to record upper right arm and trunk movements (Fig. 1). The measurements were carried out at a sampling frequency of 30 Hz. Three cameras were used, and they acted as infrared illuminator and detector of passive and reective markers. Two triplets, complexes of three passive markers, were attached with Velcro on the upper back (thorax) and around the upper right arm and tracked in 3D by direct linear transformation. Reference recordings where the subjects were placed in an upright position in the laboratory co-ordinate system for the right arm and the trunk were performed. These recordings were used to determine the subjects initial position during work simulation. Then, work simulation recordings were made. After the tracking procedure, the 3D coordinates of each marker were low-pass ltered with a Butterworth lter (order 4, cut-o frequency 3 Hz). Relative motion between the right arm and the back could therefore be determined. The movements of the upper arm were expressed as anatomical exion extension, abductionadduction, and inwardoutward rotation in relation to the trunk. The movements of the trunk were expressed in terms of exionextension, rightleft lateral exion, and rotation in relation to the laboratory. The subjects right arm and the trunk starting position were extracted in 3D to measure the subjects

Fig. 1 Low load, repetitive work simulation. The subject is holding a knife in the right hand for cutting event and force recording (N); a voltmeter indicates the cutting force. Sensors 1 and 2 are used for the recording of the left-hand movement time event (V). The subject is standing on a force platform (postural activity recording, i.e. displacement of the CoP); arm and trunk triplets are attached with Velcro (3D recordings of the arm and trunk movement); bipolar EMG surface electrodes are aligned (recording from upper trapezius, infraspinatus and deltoideus medialis muscles) from conveyor-belt 1 (simulated by pressing on a sensor); (2) lefthand movement: Put it on the workbench (micro-pause); (3) right-hand movement one: Cut it the rst time while applying an approximately 20-N force in the diagonal direction; (4) right-hand movement two: Cut it again while applying an approximately 20N force parallel to frontal plane; (5) left-hand movement two: Put the llet on conveyor-belt 2 (simulated by pressing on a sensor). Arm rest on the workbench was possible during non-active parts of the work cycle. Cutting force (see below) feedback was given to the experimenter to ensure that the force was kept at approximately 20 N. A tone generator was triggered every second to control the subjects working rhythm. This led theoretically to 12 work cycles/ min. The timing and the load level of the task were standardised to enable averaging and comparison. Pressure pain recording and analysis An algometer (Somedic Algometer type 2, Sollentuna, Sweden) was used to apply pressure via a 1-cm2 cylinder. The pressure pain thresholds (PPTs) were determined for the left and right semispinalis capitis (under the muscle tendon, 2 cm from the midline), trapezius (pars descendens, 2 cm laterally from the mid-distance between vertebra C7 and the acromion), levator scapulae (medial to insertion located to angulus superior scapulae), supraspinatus (supraspinous fossa, 2 cm beside the medial portion of the spine of the scapulae), infraspinatus (infraspinous fossa, two nger breadths below the medial portion of the spine of the scapula), pectoralis major (pars sternocostalis) and vastus medialis (mid-distance between canalis inguinalis and the knee, anteromedial) muscles twice. The pressure was increased with a 30-kPa/s slope until the subject detected the PPT. The two measured PPTs were averaged for each muscle.

42 Fig. 2 Example of one work task cycle for subject no. 8. From the top, left-hand movement (V) time events one (dashed line) and two (dash-dot line) with their onset and oset (Tlhon and Tlho), cutting force (N) or right-hand movement with their onset and oset (Tcuton and Tcuto); rectied EMG activity (mV) of the right trapezius, infraspinatus, deltoideus anterior (Deltoideus Ant.) and deltoideus medius (Deltoideus Med.) with the onset and oset used to compute RMSnon-active and RMSactive values; CoP displacement (cm) in the frontal (CoPx: solid line) and sagittal (CoPy: dotted line) planes

posture prior to work simulation. The range of motion (ROM, measured as the maximum dierence in amplitude) and the area under the curve, i.e. angletime area of the cutting events (providing a measure of the amplitude and duration of movement) expressed in degrees (and s) were computed in 3D for both right arm and trunk movement for each work cycle (Madeleine et al. 1999). The parameters extracted from each work cycle (3-min recording) regarding work task timing, cutting force, EMG, posture and movement analysis were averaged prior to statistical analysis.

levator scapulae, supraspinatus, infraspinatus, pectoralis major, and vastus medialis for PPT measurements)/motor task event (left hand movements one and two, cutting events one and two for timing measurements)/muscles (right deltoideus anterior, deltoideus medius, infraspinatus, and trapezius for EMG measurements)/movement directions (exion/abduction/rotation for arm and trunk movement measurements)] with the Student-Newman-Keuls (SNK) method for multiple comparisons. P 0.05 was considered signicant.

Results
Statistics We applied two-way repeated measures [eects of employment duration (0/6 months) and complaint status (pain/non-pain)] and three-way ANOVA [eects of employment duration, complaint status and muscles (left and right semispinalis capitis, trapezius,

Pressure algometry The three-way ANOVA showed a signicant dierence in the mean PPT for employment duration (F=10.88,

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P=0.001), complaint status (F=39.2, P<0.001) and investigated muscles (F=11.29, P<0.001). The mean PPT was greater (P<0.05, SNK) for the non-pain subjects than for the pain ones, i.e.337.7 vs. 240.8 kPa (SE of least-square mean 1.5 kPa). The mean PPT increased from 263.7at 0 months work to 314.8k Pa (SE of leastsquare mean 1.5 kPa) after 6 months work. There was a tendency towards signicant interaction between employment duration and complaint status (F=3.8, P=0.052). Table 1 presents the mean PPT ( SE) at duration of employment 0/6 months and for complaint status pain/non-pain. Work task timing and force The three-way ANOVA showed a signicant dierence in the mean duration for the motor tasks (F=64.42, P<0.001). The mean motor-task durations were all signicantly dierent from each other (P<0.05, SNK), i.e. 0.403 s for left-hand movement one, 0.648 s for cutting event one, 0.606 s for cutting event two and 0.455 s for left-hand movement two (SE of least-square mean 0.004 s). The two-way ANOVA showed a signicant dierence in the mean work cycle duration for employment duration (F=5, P=0.049). It was longer (P<0.05, SNK) after 6 months work, i.e. 4.99 s, compared with 0 months, i.e. 4.85 s (SE of least-square mean 0.04 s). For the applied cutting force, the two-way ANOVA showed a signicant dierence in the mean cutting force
Table 1 Mean ( SE) PPT (kPa) values at employment duration 0 and 6 months for pain (n=6) and non-pain (n=6) subjects. At time 0 months, no workers had pain (fullment of the inclusion criteria). The dichotomy used here is based on the measurement made after 6 months of employment where six workers out of 12 had developed tenderness and/or pain in the neck shoulder region

for complaint status (F=8.34, P=0.016). It was greater (P<0.05, SNK) for the non-pain subjects, i.e. 22.82 N, than for the pain subjects, i.e. 18.74 N (SE of leastsquare mean 0.99 N). EMG The three-way ANOVA tended to show a signicant dierence in the mean normalised RMSactive values (Fig. 3a) for complaint status (F=3.36, P=0.07). For the background EMG activity, the three-way ANOVA showed a signicant dierence in the mean normalised RMSnon-active values (Fig. 3b) for complaint status (F=7.77, P=0.007). The mean normalised RMSnon-active values were greater for the pain subjects, i.e. 1.36, than for the non-pain ones, i.e. 1.03 (SE of least-square mean 0.021). The three-way ANOVA showed a signicant dierence in the mean RMSactive/RMSnon-active ratio (Fig. 3c) for complaint status (F=6.02, P=0.016) and investigated muscles (F=45.09, P<0.001). The mean RMSactive/RMSnon-active ratio was greater for the nonpain subjects, i.e. 6.44 than for the pain ones, i.e. 5.87 (SE of least-square mean 0.1). Posture and movement No eects of employment duration and complaint status were seen in terms of postural activity in the frontal and sagittal planes.

PPT (kPa)

0 Months Pain Non-pain 24338.3 246.433.8 328.343.6* 330.849.5 331.441.5* 244.844.2 575.7109* 229.827.6 235.325 324.851.2 324.434 345.749.1* 224.542.7 597.8105* 327.349.6

6 Months Pain 236.927.4 225.064.0 276.342.9 314.078.6 270.244.0 156.826.3 514.048.7 207.729.3 210.044.5 267.345.6 283.655.3 259.451.4 189.337.3 530.446.7 281.545.8 Non-pain 272.761.2 253.488.5 374.791.4 324.784.6 315.670.6 295.786.7 603.590.1 249.054.6 272.581.3 342.278.4 319.982.8 382.495.2 270.476.5 597.2100.3 348.181.6

*Signicant value between pain and non-pain (P <0.05, SNK)

Right semispinalis capitis muscle Right trapezius muscle Right levator scapulae muscle Right supraspinatus muscle Right infraspinatus muscle Right pectoralis major muscle Right vastus medialis muscle Left semispinalis capitis muscle Left trapezius muscle Left levator scapulae muscle Left supraspinatus muscle Left infraspinatus muscle Left pectoralis major muscle Left vastus medialis muscle Mean values

202.727.5 154.533.6 198.541.1 22243.3 185.224.5 143.724.3 295.836.3 161.416.1 181.352.8 201.144.9 218.840.3 173.826.1 146.323.5 317.341.8 200.234

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The three-way ANOVA showed a signicant dierence in the mean arm starting position for employment duration (F=12.99, P<0.001) and movement direction (F=31.81, P<0.001). The arm starting position with respect to an upright position was greater (P<0.05, SNK) after 6 months work, i.e. 4.3 than after 0 months, i.e. 4.9 (SE of least-square mean 0.5). Signicant dierence in the mean arm ROM for employment duration (F=5.79, P=0.019) and a tendency, for movement directions (F=2.89, P=0.064), were observed. The arm ROM was greater (P<0.05, SNK) at 0 months, i.e. 31.4 than after 6 months work, i.e. 26.2 (SE of least-square mean 0.4). For the arm, the three-way ANOVA showed a signicant dierence in the mean angletime area under cutting one and cutting two events for complaint status (F=4.79, P=0.032 and F=8.99, P=0.004, respectively) and movement direction (F=4.34, P=0.017 and F=9.51, P<0.001, respectively). The mean angletime areas under cutting one and cutting two were greater (P<0.05, SNK) for the non-pain subjects, i.e. 9.9s and 13.4s than for the pain ones, i.e. 7.5s and 9.5s (SE of least-square mean 0.2s and 0.3s). A tendency towards signicant interaction between complaint status and movement direction was observed (F=2.86, P=0.065). Figure 4 presents the oset corrected (the initial position was subtracted), averaged, arm and trunk movement in 3D at duration of employment 0/6 months and for complaint status pain/non-pain. For trunk movement, the three-way ANOVA showed a signicant dierence in the mean trunk starting position for complaint status (F=4.82, P=0.032) and movement direction (F=20.5, P<0.001). The trunk starting position with respect to the reference position was greater (P<0.05, SNK) for the pain subjects, i.e. 10.1 than for non-pain subjects, i.e. 5.9 (SE of leastsquare mean 0.4). Signicant interaction between employment duration and movement direction was observed (F=6.1, P=0.004). Signicant dierence in the mean trunk ROM for employment duration (F=8.01, P=0.006) and for movement direction (F=26.29, P<0.001), were observed. The trunk ROM was greater (P<0.05, SNK) at 0 months, i.e. 21.3 than after 6 months work, i.e. 16.4 (SE of least-square mean 0.4). For the trunk, the three-way ANOVA showed a signicant dierence in the mean angletime area under cutting one for complaint status (F=5.18, P=0.026) and movement direction (F=5.14, P=0.009). The mean angletime area under cutting one was greater (P<0.05, SNK) for the pain subjects, i.e. 7.3s than for the nonpain ones, i.e. 4.8s (SE of least-square mean 0.2s). A signicant interaction between complaint status and movement direction was observed (F=5.52, P=0.006).
Fig. 3 Normalised RMSactive (a) and RMSnon-active (b) values, and absolute RMSactive/RMSnon-active ratio (c), of the right trapezius, infraspinatus, deltoideus anterior (Deltoideus Ant.) and deltoideus medius (Deltoideus Med.) EMG activity (mean + SE) at the employment durations 0 and 6 months for pain (shaded columns, n=6) and non-pain (non-shaded columns, n=6) subjects

Discussion
The results of this prospective laboratory study showed a high incidence of development of neckshoulder

45 Fig. 4 Oset corrected (initial position) averaged arm (a) and trunk (b) movement angles () in 3D at employment duration 0 months for pain (n=6) and non-pain (n=6) subjects and 6 months for pain (n=6) and non-pain (n=6) subjects

complaints for workers performing low load, repetitive work. After 6 months of such work compared with 0 months of employment, increased sensibility to pressure, increase in the work cycle duration, increased arm starting position and decreased arm and trunk ROM were observed for the workers with and without neckshoulder complaints (Table 2). Increased

sensibility to pressure, lower force level, higher EMG activity, decreased arm movement amplitude and increased trunk posture and movement amplitude were observed for workers with neckshoulder complaints compared with workers without complaints for both 0 and 6 months of employment recordings (Table 3).

46 Table 2 Overview of the ndings regarding sensory and motor control recordings dierences in terms of employment duration Employment duration: 6 months compared with 0 month Sensory recordings PPT Superior Superior Superior Inferior Inferior

Motor control strategy: work task timing and cutting force The measurement of dierent time events in the work cycle enables a precise description of the work task and the work pace. The simulated work process was highly standardised, consisting of left and right hand timepaced movement. All in all, 24 movements (12 cycles times two cutting events) were performed with the right arm every minute. The duration of exertion (proportion of work in the cycle) was 4 s, and a 1-s micro-pause was included in the cycle in between the rst movement of the left hand and the cutting event. The work pattern was of major importance as it imposed a muscular eort, i.e. applied forces, muscle synergies, posture and movement of the upper body. When the same work task was simulated, the time event duration was increased during experimental or chronic neckshoulder pain, highlighting a decreased working rhythm (Madeleine et al. 1999). Even though a highly repetitive work cycle, a longer work cycle duration was observed after 6 months of employment (Table 2). The eects of such a marginal tendency can be of importance when repetition of the work cycle over days, weeks and years is considered. The level of the applied cutting force used in the present study corresponded well to the level determined during real work measured in a eld study (JuulKristensen et al. 2002). Decreased force performance is generally reported for patients suering from either work-related myalgia or bromyalgia (Veiersted et al. 1990; Elert et al. 1991). Despite the fact that a voltmeter for real-time assessment of the force was used, the cutting force was lower for the subjects with neckshoulder complaints, underlining the eect of the pain on the applied cutting force. Indeed, the force decrease can certainly be seen as a protective response (Lund et al. 1991; Madeleine et al. 1999). Motor control strategy: EMG Surface EMG has been widely used to assess shoulderregion activity (Mathiassen et al. 1995). It is worthy to note that the shoulder muscle synergy developed during work simulation can hardly be described thoroughly by four muscles of the right upper extremity, underlining the complexity of the shoulder girdle (Mathiassen and Winkel 1996; Madeleine et al. 1999). The normalised EMG activities were analysed during non-active, i.e. no right-arm movement and active, i.e. right-arm movement (cutting event) parts of the work cycle. The computed normalised RMSnon-active values corresponded to the static background EMG activity of the work cycle, while the RMSactive values corresponded to EMG activity during the two cutting events. The normalised RMSactive and RMSnon-active values were greater for the neckshoulder complaints group than for the group without complaints (Table 3). The absolute ratio,

Motor control recordings Work task Work cycle duration Arm movement Position prior to work simulation ROM Trunk movement ROM

Table 3 Overview of the ndings regarding dierences in sensory and motor control recordings in terms of complaint status Workers complaint status: pain compared with non-pain Sensory recordings PPT Inferior Inferior Superior Superior Inferior Inferior Superior Superior

Motor control recordings Work task Cutting force Surface EMG Normalised RMSactive Normalised RMSnon-active Ratio RMSactive/ RMSnon-active Arm movement Angletime area under cutting events Trunk movement Position prior to work simulation Angletime area under cutting events

Sensory aspects Pressure algometry has been widely used to assess deep tissue sensitivity to pressure in occupational settings (Onishi et al. 1982; Mathiassen and Winkel 1996; Hagg and Astrom 1997; Madeleine et al. 1998). In the present study, we observed that the employment duration and the complaint status had an eect on the PPTs. The PPTs increased with increasing employment duration, highlighting a general decreased sensitivity with time for both groups of workers. The workers with neckshoulder complaints had lower PPTs than the workers without complaints also at time of employment 0 months. Similar results are reported in patients with WMSDs, i.e. increased muscle sensibility to pressure (Onishi et al. 1982; Hagg and Astrom 1997; Madeleine et al. 1998). Moreover, this increased sensitivity was bilateral and expanding to some more distal areas. Similar observations of referred pain have been made previously in butchers with chronic neckshoulder pain (Madeleine et al. 1998). Low load, repetitive work can lead to generalised muscle tenderness or muscle hyperalgesia expanding to both sides of the upper body. Our results, i.e. increased muscle tenderness or hyperalgesia, tended to give credit to theories of the vicious circle and the hyperactivity theory (Travell et al. 1942; Schmidt et al. 1981; Johansson and Sojka 1991), explaining the propagation of pain from one muscle to others.

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dened as the division between RMSactive and RMSnon-active values, was greater for the group without complaints than for the group with complaints. Dierence in the absolute ratio highlights a general lack of relative changes in EMG amplitude among the group with complaints. A similar observation has previously been reported in employees with neckshoulder pain (Sandsjo et al. 2000). It is most likely that those dier ences were also potent at the time when the workers were without complaints, as has been suggested by Veiersted at al. (1990). Previous studies have also reported similar results, e.g. increased EMG activity between contractions in bromyalgia patients (Elert et al. 1991) and higher static EMG level for workers with previous neckshoulder pain episodes, compared with workers without complaints (Veiersted et al. 1990; Veiersted et al. 1993). Interestingly, a tendency towards a greater level of activity during active and non-active parts of the work cycle for the workers with complaints, compared with those without complaints, was observed at 0 months for the infraspinatus muscle (Fig. 3a and b). The infraspinatus actions include external rotation of the arm and stabilisation of the head of the humerus. In general, a higher EMG level may have some prognostic relevance for further development of WMSDs in the neckshoulder region. This inability to relax is even more marked when it is taken into account that the cutting force was lower for the group with neckshoulder complaints. On the contrary, decreased static and dynamic EMG activity of the painful muscle are seen in the presence of acute experimental neckshoulder pain (Madeleine et al. 1999). The present results seem better to support hyperactivity theories associated with chronic stages (Travell et al. 1942; Schmidt et al. 1981; Johansson and Sojka 1991) than the pain adaptation model which predicts sensorymotor interaction in terms of active protection of the painful muscle (Lund et al. 1991). Motor control strategy: posture and movement Static posture and repetitive movement are well-known risk factors associated with WMSDs (Sommerich et al. 1993; Sjgaard et al. 1995). Workers suering from chronic neckshoulder pain have an increased postural activity(Madeleine et al. 1999); however, we did not observe any eects of employment duration or complaint status on the postural activity computed as the amplitude of the CoP. When looking at the arm and trunk position prior to work simulation, we observed more awkward positions, i.e. greater dierences from the starting position and the reference upright position, for the arm after 6 months work and for the trunk for the group with neckshoulder complaints. This might not be seen as a favourable trait. In terms of ROM, decreases were observed for the arm and the trunk after 6 months (Table 2). This can probably be interpreted as an improvement in the

subjects motor control strategy. However, when the angletime area under the cutting events was compared, the complaint status played a role. The angletime area of movement was smaller for the arm and greater for the trunk for the group with complaints (Table 3). A more dynamic pattern of movements is associated with low risk in terms of WMSD development (Kilbom and Persson 1987). On the other hand, in the presence of experimental or chronic neckshoulder pain, increases in arm and trunk movements are seen (Madeleine et al. 1999). Our results partly supported the hyperactivity theories (increased postural activity for the trunk and arm and increased trunk movement amplitude) and pain adaptation model (decreased arm movement amplitude). Moreover, they emphasised functional dierences, the trunk had a postural function while the right arm was involved in the cutting events and that employment duration as well as neckshoulder complaints aected control of movement. Limitations Prospective laboratory studies in occupational health are rare. In the present study, the number of subjects enrolled was 20 but was reduced to 18 by the time the study started. Unfortunately, 6 months later six workers had left the company, not because of neckshoulder pain but due to restructuring. Because of such problems, the number of subjects included in occupational studies are often low (Mathiassen and Winkel 1996). This is probably one of the reasons why we were not able to nd WMSD predictors at an employment time of 0 months, despite the fact that sensorymotor changes were observed due to employment duration and complaint status. Future prospective studies should also integrate and assess information regarding the workers psychophysical state. The classication of the workers (with/without complaints) was on the basis of manual palpation and/or subjective pain intensity and/or pain location. The basis for this classication was due to the fact that neck shoulder pain per se has an inuence on workers motor performance (Madeleine et al. 1999). For this reason, complaint status and employment duration were used to assess their eects on the outcome parameters. Our results conrmed that many cases of neckshoulder complaints can occur during the rst 6 months of employment (Veiersted and Westgaard 1993). Work task simulation in laboratory studies is by denition a simplication of real work. Attributes such as work organisation, incentive systems and work place physical factors are lost. On the other hand, other undesirable eects such as electrical and visual noise may be introduced, worsening the quality of the measurements. Apart from the fact that the all-biomechanical laboratory has to be moved to the work place, the work task is much more dicult to control. In practice, this means that the exposure is not the same for all subjects

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and, therefore, limits the validity of averaging technique and comparison. Unequal exposure, together with the known large surface EMG inter-subject variability and poor reproducibility (Veiersted et al. 1990; Jensen et al. 1993), results in poor reliability. Well-standardised work simulation in laboratory studies can partly counteract these eects and be complementary to eld studies. Moreover, the changes observed here might seem marginal, but due to the highly standardised work task, they highlighted even more the eects of employment duration and neckshoulder complaints. In conclusion, dierent sensory manifestations and motor control strategy were seen after 6 months work with or without neckshoulder complaints. Such changes in sensorymotor interactions are most likely of importance, as they underlined a learning process as employment duration increased, i.e. a more ecient motor strategy, as a longer work cycle and decreased amplitude of arm and trunk movement were observed. Moreover, the dierences in deep tissue sensitivity and motor performance observed among workers with and without neck-complaints highlighted the potential physical risk factors, i.e. cutting force level, EMG activity amplitude, arm and trunk posture and movement amplitude, associated with low load, repetitive work. All in all, the observed sensorymotor interactions underline the value of study assessing sensory manifestations and motor control.
Acknowledgements The authors are grateful to Dr. Gert Thomsen for his help in selecting the subjects. This work was nancially supported by Arbejdsmiljfondet, Sygekassernes Helsefond, N and FS Jacobsens Fond, and the Danish National Research Foundation.

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