‘Sitting disease’

 

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I wrote the following in 2003 and some is dated.  The main thrust remains largely unaltered.

The new workplace

In the last 20 years the ethos of business management has resulted in ‘downsizing’ of the workforce, and this trend continues apace   Office staff has been reduced by cutting middle management and even contracting out jobs to the third world.

 New workers

The remaining staff are expected to work harder in a Service Industry type environment.  John Monks, General Secretary of the TUC, referred at the Congress in September 2000 that the £23 billion of unpaid overtime was leading to ‘burnout Britain’.   Work contracts are relatively short and do not give the lifetime security of the past.   The culture of ‘presenteeism’, due to fear of redundancy, results in workers remaining at work for long periods.   The work is liable to be more exacting, with high demands but low job decision latitude.  Work has become result orientated, extends across all time zones and never finishes.

 Stress

The new office conditions which give rise to anxiety and fatigue, added to long hours spent in a physiologically unfriendly environment,  leads to high levels of morbidity and breakdown.    The simple explanations for this  state of affairs  is psychological ‘stress’.  An extreme expression of stress is described in America. Dotcom employees with excessive workloads in collapsing companies are found to be sabotaging equipment and systems and attacking fellow staff. This occured when Michael McDemott shot seven people at Edgwater technology.   Security and executive protection companies, such as Pinkertons and Interpahase International have found a recent business increase of 25%.

High skill workers

Paradoxically the power position of employer and employee may be reversing.  Employees of high skill and competence are likely to regard firms as a mere commodity.  Already highly rewarded financially they will look for and expect a pleasant, healthy and stress free environment.  Firms will have to  provide this if they are to attract and keep the high quality workers required for a first world economy.  Some US firms have preempted this on the grounds that they have the best staff in the world and in order to optimise their, expense being of little relevance.   In the UK, as a consultant orthopaedic physician I am never ceased to be surprised when my highly paid patients tell me of the physiologically inadequate dealing room environment which is reponsible for their breakdown.

Decrease productivity and costs

The expected increase in productivity that was expected from computerisation has not materialised and on the contrary productivity has actually decreased.   This decrease is less apparent in offices where  productivity assessment has not been rigorous and computerisation has been gradual and  almost certainly occurs to the same extent.   These firms  have cost problems at several levels including decreased productivity, increased staff ’churn rate’ and litigation.   The loss of a worker carries costs to a firm.

Extent of Morbidity in the office

In the UK, HSE figures reveal that 1 in 11 of the \vork force suffer occupational health problems,   involving 750,000 people, and 1.3 million  lost days of production.   Dependent  upon the environmental conditions occuring in a  particular office this  reduction in overall   performance ranges  from 18% to 52%.    These figures represent only the tip of an iceberg when considering the vast number of people suffering from minor symptoms which are ignored, being regarded as a part of normal working life.   Although  not reported, minor morbidity undermines the efficiency and productivity of the individual.   As a large percentage of employees are affected, a lower performance throughout an office can often go undetected if \vork task efficiency is not  measured systematically.

 Litigation .

There were 164,000 claims for stress related conditions in1999-2000, an increase of a third on the previous year.   270, 000 people daily take a day of work . The cost to the UK is £7 billion a year (Sunday Times  25/3/01).   In addition to costs,  media coverage of  litigation results in damage to a firms reputation.

Hysterical Epidemic spirals

 Repetitive Strain Injury (RSI)  is an example.  RSI was described as an epidemic of office workers in Australia and prompted widespread litigation with damages awarded.   The medical reaction concluded that most, if not all,, was psychogenically determined and perpetuated by financial rewards.  In the UK a judge ruled, that the plaintiffs case should be rejected, on medical evidence, on the grounds that RSI was not a medical condition.   Subsequent medical investigation demonstrated specific local lesions in some cases and a less certain generalised pain condition in others.  The condition is now renamed Work Related Upper Limb Disorder (WRULD) and providing a local anatomical lesion can be identified is now accepted as a respectable condition by doctors and lawyers.   A similar affair occured earlier in Sweden when the government became concerned by an expensive epidemic of LBP among workers.  Following an investigation by Professor Alf Nachemson  a reduction in the over generous benefit system was recommended and this resulted in the epidemic subsiding rapidly to the normal incidence.

Management strategies

There is  general assumption that the increase of morbidity is due to emotional stress.   Companies have therefore turned to a bewildering variety of stress management strategies. This has given scope to gurus of many hues, starting with stress counselling and release.   Any procedure that alters the environment or shows concern for staff leads to an improvement .  This improvement has been shown to be temporary and is equivalent to the ‘placebo effect’ in medical practice.  This confuses any assessment of effectiveness unless this is measured over a longer time span, at least six months, so that results can show long term significance.

Government response.

Government, recognising the effect on the economy, has attempted to reduce stress by  increaseing workplace legislation.      Much of this legislation merely confirms good practice that brings economic benefits that should have been already apparent to efficient management.  These benefits should be stressed, so that they will be implemented without resentment, rather than relying on  legislation, and worse, European legislation, which tends to produce the counterproductive unionisation which was so largely responsible for damaging the UK economy in the Wilson & Callaghan years.   Government and industry also instituted a meta-analysis of the effects of  treatment and management of LBP.  Unsurprisingly , in addition to confirming views expressed by orthopaedic physicians for several decades, it concluded that a return to work , in the absence of obvious contraindication, constituted the best management.

Physiological stress.

There is not yet a general appreciation that environmental factors, air quality, light , noise, are stressors and operate on a more basic physio-pathogenic level.   These are probably more aetiologically significant, but less easily  identified by the individual, than psychological stress.

As many as one in five new consultations in medical primary care fail to identify a recognised organic  medical condition.    Some prove to be transient, about 10-15% are shown to have an organic cause, some have an unrecognised organic cause but most have symptoms that persist and are never explained in spite of apropriate investigation.   A consideration of the symptoms of stress, medically unexplained conditions and symptoms scored in the OptEnCo environmental assessment (above) are similar.   This overlap suggests that common  psychological and environmental aetiological factors are present.

A number of hypotheses have been expressed to account for these symptoms.  Some psychological studies suggest that childhood illness, mismanagement or abuse are predisposing factors.  Others may have overt psychiatric disorders such as anxiety, depression or a phobic personality.   Most have a complex mix of aetiological factors , biological, psychological, social and cultural.  Adverse or threatening environmental conditions  which result in a’fright, flight, fight’ response is due to neurohumeral mechanisms mediated through the hypothalamic-pituitry-adrenal axis and result in widesrpead physiological changes (see below).  These include vascular changes, hyperventilation and muscle tension which may be interpreted as symptoms or if prolonged give rise to medical organic disorders including those associated with immunological difficiency.  If threats are prolonged and an  emotional factor is recognised they are popularly termed ‘stress’.  The environmental physiological component, which may be the more important stressor, is usually ignored.

 Morbidity, productivity and the environment

 Although psychogenic factors may play a part in the office environment  of minor everyday symptoms, these may not be of prime importance.  This unexpected finding was made by John Jukes, an engineer and productivity consultant, who was asked to investigate why a Design and Construction Unit (DCU) with a staff of 235 was failing to meet an expected target of 25% increase of productivity when a CAD system, costing £1.5 million,  was installed.  They were urged to work harder and  productivity actually fell further.  A number of indoor environmental factors were identified.   The ergonomics of the chairs and workstations were improved. Productivity rose.   Full spectrum polarised lighting was installed. Productivity rose further.  The indoor air quality (IAQ) was improved with HEPA filters and negative ionisation. The plants recommended by NASA were installed. Productivity rose further.  Electrostatic and electromagnetic fields were addressed. Production rose further.   The final cost was about £3500 per workstation, the 25% target was easily passed and the DCU was able to reduce its workforce  by 40%.

Unexpectedly, it was also found that not only the symptoms that were likely to be due to environmental deficiencies improved but also the seemingly psychogenic stress related symptoms.  This suggests that if environmental stressors are removed then people can deal more easily with their psychological stresses.  This observation by Jukes that it is environmental factors that are the main aetiological agents in producing stress belies the conventional wisdom that the main cause is psychological.  This has arisen because these symptoms are typically of the sort that are regarded as of psychological or psychosomatic origin.    In many cases the evidence of breakdown is by a common psychosomatic pathway which exhibits itself to the clinician, therapist or management and is taken at face value.  If  physical environmental stressors, over prolonged periods, can potentiate the effects of psychological stress leading to overt symptomatology then it is to be expected that treatment aimed at the psychological stress will be ineffective or benefits will be temporary. This, in practice, is what is found.   On the other hand once the physical stressors are removed or reduced the individual can respond effectively to psychological stress and symptoms are reduced.   The findings, following environmental optimisation of 300 buildings throughout the world involving  30,000 workers has confirmed this.

The practical implications are encouraging.   Physical environmental stressors can be assessed and measured so that effective measures can be introduced to correct them.   These measures are simple, precise and produce a pleasant and stimulating workplace, with increased productivity, at no great cost.   The cost of a full optimisation is about £5000 for each workstation and less if incorporated in a new development.   This cost is recuperated in about 3 years by increased productivity.   A standardised assessment  has developed for symptoms, environmental satisfaction and the physical environment.    A  baseline normal has been established and it has found that 80% of these workers experience excessive symptoms due the various physical stressors in the office environment.   When the physical office environment is optimised there was found to be an 80% decrease of symptoms and up to  a 32% increase of productivity.

The Ideal Environment

It has been realised that the solutions to the various indoor factors that result in physiological stress tended to aproximate the indoor environment to that of the outdoor environment of a temperate overcast summer day.

• Full spectrum polarised lighting is set to be equivalent to the light outdoors on an overcast day (in Washington DC at midday, to be precise). (PRODUCTIVITY AND WORKPLACE STRESSORS→ for fuller account)
• Air that has been HEPA filtered and negatively ionised is equivalent to mountain top air near a waterfall or the air quality that occurs following the electrical discharge of a thunderstorm.  Most offices have the positive ionisation  due to electrical and electromagnetic (EMF) emissions from the multiplicity of machines in the modern office that occurs before a thunderstorm or during prolonged desert winds.  PRODUCTIVITY AND WORKPLACE STRESSORS→
• There are background  EM fields found in nature but these are small compared to those found in offices and to a lesser extent in homes.  PRODUCTIVITY AND WORKPLACE STRESSORS→
• A high and prolonged level of noise is rare in nature but poor acoustics in an office leads to raised voices, distraction and increased measurable levels of stress hormones.  Office equipment generate saw-tooth sounds which in nature are used by animals as aggressive warning signals and square-wave sounds which are used for identification.   Both cause alarm and are likely to be stressors in humans.  PRODUCTIVITY AND WORKPLACE STRESSORS→
• Chemical and particulate pollutants are in low concentration in nature and easily dispersed by air currents or denatured by ultra violet light.   The high levels found in industrial society are even higher in an enclosed office space where some are being produced. (See  PRODUCTIVITY AND WORKPLACE STRESSORS→ for fuller account)
• Toxic Volatile Organic Compounds  (See  PRODUCTIVITY AND WORKPLACE STRESSORS→ for fuller account including VOCs, )

Early, and even late, hominids were active and alert to changing circumstances.   Sitting in chairs came very late in human development.  The present epidemic of Low Back Pain (LBP) is associated largely to a sedentary lifestyle and poor chair design.

Solutions

Ergonomics.  60% of adults suffer back problems annually.   1.6 million attended out-patients clinics, a five fold increase in the last decade. Of these 85% receive no definite diagnosis.  The incidence of backache (Low Back Pain, LBP) has increased enormously in recent years and LBP is rising while overall accident  totals are falling.  This suggests, in the context of offices, that the increasingly sedentary habits of mankind are a major , probably fundamental, aetiological factor.   There are 500,000 work related cases of LBP compared to 33,000 work related back accidents.  The reduction of accidents to the back may be due to the efforts of the HSE to make management more aware of the dangers and to take proactive measures.      Although ergonomic advice on sitting is freely given this is relatively ineffective as biomechanically suitable work chairs simply do not exist at present (2006).   Efforts to address this are under way and solutions should soon be on the market.  This is not only of importance to the individual but nationally as the cost to UK industry in lost production is at least £5.1 billion and the cost to NHS £480 million.  LBP constitutes the largest illness group in people of working age resulting in 14 million G.P consultations per year.

At present efforts are being made  by the Ministry of Health, HSE and some major industries to reduce the incidence and length of time off work by popularising the results of a number of studies in an occupational environment that show that workers with LBP benefit by remaining at work.  Although helpful to some extent these trials are criticised  because of a lack of accurate diagnosis. Many backache patients are suffering from an ‘illness syndrome’ and these are best managed by an immediate return to work.  Many more are simply looking for a day or two off work.  Others have genuine mechanical causes for their LBP and benefit from ergonomically designed furniture.   Only a limited number of doctors have the degree of training and experience which are required for the the diagnosis of these various groups.  It is likely  in each of these conditions that stress, and in particular physiological stress, plays a part.  Studies have yet to be done to sort out the extent and relevance of these factors.

IAQ

In addition to temperature and humidity control recirculated  air requires HEPA  filtration and negative ionisation to remove micro particles,  organisms and, to some extent, VOCs.

Quite apart from the general benefits to  staff, the Indoor Air Quality improvement has a marked effect on airborn  pathogens, as NI is microbiocidal.

The NHS has recently commissioned a year-long study in conjunction with Leeds University to (finally) quantify the microbiocidal effects of NI, and will be utilising the units recommended by OptEnCo.  OptEnCo has also agreed an provisional experimental protocol in the United States with the National Institute of Occupational Safety & Health  and the U.S. EPA. It is intended to conclude a study in conjuction with the Neonate and Geriatric Units of the Veterans’ Hospital in Cincinnati to show the benefits of NI to those with compromised immune systems.

EMR

The effects of elecromagnetic radiation of varying wavelengths on biological systems is still controversial, although the evidence is going towards the likelihood of them having an effect.  Recent work suggests an explanation of the physiology involved.   It is impossible to fully abolish these effects in the EMR rich modern office, but they can be reduced by the use of computer flat screen technology, grounded shielding of CRTs and simply increasing the distance of the operator from the screen.

VOCs

A  bewilderingly large array of Volatile Organic Compounds, such as formaldehyde, are given off by new furniture and carpets and are cumulative toxins which can give rise to a number of both mild and serious conditions.

Noise

Sound is a far  more common physiological stressor than most people realise. Artificial noises generated by lifts, office equipment and so on tend to cause the body to continuously tense and relax. Poor sound design often means straining to hear your telephone call whilst being over-aware of what’s being said on the other side of the office. A series of hard flat surfaces ( office walls and ceilings ) bounces sound waves into a series of chaotic reflections that are hard to interpret.

Lighting

Indoor lighting is, unlike outdoor lighting, unpolarised. Fluorescent tubes emit only a limited band of the full light spectrum enabling only 8% of the receptor cells in the retina to be stimulated.  The increase in lighting level that is required and the multidiractional light transmission results in glare which distracts from visual acuity.   Worse, tubes also flicker at the mains frequency of 52 cycles/sec which is not apparent  at a conscious level but is a physiological stressor.   In addition, the flicker may further clash with the refresh rate of a CRT computer screen.  Halogen lights  generate even more glare.

Stress from lighting can be easily and cheaply corrected by the use of full spectrum polarised lighting which aproximates to overcast outdoor conditions.  As less power is required, running and environmental costs are reduced.

Attitudes to Morbidity

Most office managers are unaware of environmental deficit and minor morbidity is ignored and regarded as normal.   The relationship between the physical office environment, minor morbidity and productivity is not understood.   Most symptoms abate on quitting the office and others settle with a day or two off work.   It is only when a worker is forced to leave the job as a result of a possible work related illness that senior management become aware that a problem exists.   The danger of litigation can seriously concentrate the mind.

 Litigation .

Litigation is regarded as an American disease and it is hoped that it will not spread to here or if it does so it will be in a less virulent form.   However it is arriving and the legal and medical climate of litigation is changing.  To take Repetitive Strain Injury (RSI)  as an example.  RSI was described as an epidemic of office workers in Australia and prompted widespread litigation with damages awarded.   The medical reaction concluded that most if not all was psychogenically determined and perpetuated by financial rewards.  In the UK a judge ruled, that the plaintiffs case should be rejected , on medical evidence, on the grounds that RSI was not a medical condition.   Subsequent medical investigation demonstrated specific local lesions in some cases and a less certain generalised pain condition in others.  The condition is now renamed Work Related Upper Limb Disorder (WRULD) and providing a local anatomical lesion can be identified is now accepted as a respectable condition by doctors and lawyers.   A similar affair occured earlier in Sweden when the government became concerned by an expensive epidemic of LBP among workers.  Following an investigation by Professor Alf Nachemson  a reduction in the over generous benefit system was recommended and this resulted in the epidemic subsiding rapidly to the normal incidence.

 Legislation

Litigation becomes a real possibility when a patient actually has to stop work because of ill health due to working conditions.   Hitherto there has been a reluctance to institute proceedings as it has been difficult to prove the relationship between the condition and the workplace.   This is changing as research progresses with more awareness of the factors involved.   On the other hand most doctors are inclined to discourage litigation as this perpetuates symptoms and can lead to depressive illness.

Firms have to obey legislative standards administered by the Health & Safety Executive.  These are minimal requirements and do not neccesarily meet the requirements that  have been shown to be needed to reduce morbidity.    The European Union is introducing more stringent standards which are likely to add to the cost of industry.  For example, Dutch regulations specify height adjustable desking for workstations that are used for more than 2 hours/day.    As desk height is a factor in preventing LBP and WRULD at a price of about £2000 it provides a degree of cost effectiveness.

The political and legal perception of litigation is moving towards the American model.  Just as the Prime Ministers wife, Cherie Blair,  has started chambers to deal with the litigation expected by the influx of EU and Social Chapter generated regulations, so legal firms are being set up to identify, capture and proceed with workplace health related  litigation.  This will certainly be very tough on management.   In addition to damages,  punitive measures, including prison, are envisaged.  The EU regulations are more stringent than the HSE regulations which presently apply in the UK and are likely to be strictly monitored by a resurgent Trades Union movement.  The beneficial effects of optimising the office environment to both health and productivity could be more than counterbalanced by EU inspired unionism if this should turn militant.

Management Perceptions.

It is a view at the best end of the management spectrum, in the USA,   that highly paid, expert workers should have optimum working conditions to provide maximum productivity.  Anything less would be economic foolishness.  This is not the view held by many UK firms which employ a highly paid workforce in an environment which reduces their productivity by a  measurable and high percentage.  This is accentuated in the control room environment which operate on a full time basis and where mistakes can lead to a catastrophe.   This has been honourably recognised by such firms as Transco, BT, C&W and some police forces which have been careful to optimise the environment in such premises.

As a doctor working in the field of musculo-skeletal disorders I see a number of individuals as patients who are highly paid and work in poor environments. The poor ergonomic facilities result in a musculo-skeletal breakdown and in addition they usually have symptoms of stress.   As they are well paid they are not prepared to litigate and often do not wish to confront the management with their problems, and may even try to keep them secret.   Some smaller firms have a macho philosophy which extends to their expert workforce who are proud to grit their teeth and carry on  in an adverse environment.   The breakdown, when it comes, is complete.

The  view in some low tech firms, and  in 3rd world work practice, is that optimisation is uneconomic as the rate of worker turn over (churn rate)is too great.   It is not recognised that a better environment would reduce the churn rate and increase the productivity of the individual worker, even in a society with low wages and high unemployment.  Firms employing third world practices exist in the UK especially in areas where there are illegal immigrants.   When condemning this situation it must be remembered that sixpence a day is better than no bread.

The majority of firms fall between these extremes.  They are aware that there are problems which can prove to be expensive.  Doctors are employed as consultants.  There is a considerable body of expertise available in the field of industrial medicine which has helped to reduce accidents and prevelance of industrial disease.   However,  background environmental factors have only been considered piecemeal and their overall importance is  yet to be fully appreciated.

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