Professional Documents
Culture Documents
Introduction
This guide was written by the National Board of Industrial Injuries (Arbejdsskadestyrelsen) in Den-
mark in order to describe the conditions for decisions on occupational diseases claims reported on or
after 1st January 2005.
Thus this guide only applies to diseases reported on or after 1st January 2005. Such diseases are
assessed on the basis of the Workers Compensation Act, cf. Consolidated Act No. 278 of March 14,
2013, with subsequent amendments.
Diseases reported before 1st January 2005 are assessed on the basis of Act No. 943, the Act on Pro-
tection against the Consequences of Industrial Injuries of October 16, 2000, with subsequent
amendments. Such diseases are not covered by this guide.
This guide was written for anybody who needs to know more about the management of occupational
diseases claims, including the decision makers of the National Board of Industrial Injuries as well as
trade unions, attorneys, and insurance companies. The guide will be useful in the processing of claims
and will give an understanding of the requirements to the correlation between a disease and a specific
exposure.
The guide is not exhaustive for all diseases. It does, however, deal with the general conditions for
recognition of all diseases reported on or after 1st January 2005, including diseases on the list of
occupational diseases as well as diseases that are processed, under section 7(1)(ii) of the Act, without
application of the list.
For a number of diseases the guide furthermore describes the specific conditions for recognition of the
disease in question, including the specific requirements to diagnosis and exposure. For these diseases
the guide specifies the overall recognition requirements appearing from the list of occupational
diseases. The guide furthermore replaces any previous guides regarding such diseases.
This guide also includes a special paragraph on diseases that may qualify for recognition, without
application of the list of occupational diseases, after submission to the Occupational Diseases Com-
mittee (Chapter 22). If a disease is not described in this guide, but in a previous one, the previous guide
still applies in principle.
National Board of Industrial Injuries, February 1, 2015
Hanne Rathsach
/Pernille Ramm Kristiansen
1
1.2. List of guides to particular diseases
The special conditions for recognition of a number of diseases are described in detail in the
subparagraphs of this guide. The particular diseases set out in this guide are listed below.
A list of previous guides that still apply to diseases reported on or after 1st January 2005 is stated
below.
Chapter 1 General conditions and unlisted diseases (special nature of the work)
Chapter 2 Hearing disorders
Chapter 3 Back and hip disorders
Chapter 4 Knee diseases
Chapter 5 Vibration diseases
Chapter 6 Other diseases of the musculoskeletal system
Chapter 7 Lung diseases
Chapter 8 Mental diseases
Chapter 9 Cancer diseases
Chapter 10 Skin diseases
2
Posttraumatic stress disorder (Chapter 8)
Cancer diseases (Chapter 9)
Contact eczemas (Chapter 10)
1.2.3 Diseases reported from 1st January 2005 and covered by other valid guides
Hernia (in Danish only)
Tooth injuries (in Danish only)
Solvents poisoning (in Danish only)
3
Chapter 1. General conditions and diseases not on the list (the special nature of the
work)
List of contents
1. General conditions
1.1. Legal basis
1.2. Medical documentation
1.3. Conditions for recognition of diseases reported on or after 1st January 2005
1.3.1. Recognition on the basis of the list of occupational diseases
1.3.2. Pre-existing and competitive diseases/factors
1.4. Diseases reported before 1st January 2005
1.5. Delimitation between accident and occupational disease
1.6. Gathering information
2. Diseases not on the list (the special nature of the work)
2.1. General conditions for recognition without applying the list
2.2. Assessment of the disease
2.2.1. Medical documentation of causalities
2.2.2. Diagnosis and pathological picture
2.2.3. Disease information
2.3. Assessment of the exposure
2.3.1. Gathering information and documentation
2.3.2. Relationship with the Working Environment Act and the Medico-Legal Council
2.4. Pre-existing and competitive conditions
2.5. Claims management by the National Board of Industrial Injuries (Arbejdsskadestyrelsen)
2.5.1. Assessment to turn down or submit the claim to the Occupational Diseases Committee
2.5.2. Submitting the claim to the Committee
2.6. Examples of decisions not based on the list
2.6.1. Hearing disorders
2.6.2. Diseases of neck, neck/shoulder, back and hip
2.6.3. Diseases of hand, arm and shoulder
2.6.4. Diseases of foot, knee and leg
2.6.5. Diseases of lungs, respiratory passages and mucous membranes
2.6.6. Diseases of other organs
2.6.7. Cancer diseases
2.6.8. Mental illness
2.6.9. Other diseases
2.7. The Occupational Diseases Committee
4
1. General conditions
The provisions for recognition of occupational diseases reported on or after 1st January 2005 are set out
in sections 5, 7 and 8 of the Consolidated Workers Compensation Act.
The new occupational diseases concept (section 7 of the Act) applies only to diseases reported on or
after 1st January 2005.
Diseases reported before 1st January 2005 will still be assessed in pursuance of section 10 of the Act on
Protection against the Consequences of Industrial Injuries.
Workers Compensation Act, cf. Consolidated Act No. 278 of March 14, 2013
5.
An industrial injury within the meaning of this Act shall be an accident, cf. section 6, or an occupational disease, cf. section
7, which is a consequence of the work or the working conditions, subject, however, to section 10 A.
6. (1)
An accident within the meaning of this Act shall be a personal injury caused by an incident or exposure that occurs suddenly
or within five days.
(2)
For accidents the legal effects of this Act shall be applicable from the date of the accident or the date of cessation of the
exposure causing the accident, except where the Act stipulates otherwise.
7. (1)
Occupational diseases within the meaning of this Act shall be
(i) diseases which according to medical documentation are brought about by specific influence to which
certain groups of people, through their work or working conditions, are more exposed than persons not
having such work. Furthermore occupational diseases shall comprise such diseases as are contracted by a
live-born child prior to its delivery as a consequence of its mother's work during pregnancy. The Director
General of the National Board of Industrial Injuries, after negotiations with the Occupational Diseases
Committee, cf. section 9, shall compile a list of such diseases as are deemed to be of the said nature;
(ii) other diseases, including diseases in a live-born child contracted prior to its delivery, where it is established
either that, on the basis of the most recent medical documentation, the disease meets the requirements set out
in the first sentence of paragraph (i) of this section, or that it must be deemed to have been caused, solely or
mainly, by the special nature of the work.
(2)
This Act shall be applicable to diseases caused by influence on parents prior to the conception or after the delivery of a child
where changes are made in the list referred to in subsection (1)(i) above, or in accordance with subsection (1)(ii), where it is
established that such influence had an injurious effect on foetus or child.
(3)
Diseases comprised by subsection (1)(ii) and subsection (2) above may be recognised only after submission to the Occu-
pational Diseases Committee, cf. section 9. Such diseases shall be submitted to the Occupational Diseases Committee where
the National Board of Industrial Injuries deems it possible that the disease will qualify for recognition.
8. (1)
Any person having contracted a disease included in the list of occupational diseases, cf. section 7(1), shall be entitled to
benefits under this Act, except where it is deemed to be likely beyond reasonable doubt that the disease was brought about
by non-occupational circumstances.
(2)
For occupational diseases the legal effects of this Act shall be applicable as per the date of notification of the disease, except
where the provisions of this Act stipulate otherwise.
5
1.2. Medical documentation
With the introduction of a new occupational diseases concept on 1st January 2005, the requirement for
including new diseases on the list of occupational diseases was changed to the sufficient medical
documentation.
This means that there has to be documentation of a correlation between exposure and disease. The
documentation must be substantiated by surveys, made by recognised medical experts, of a number of
cases that provide the basis for a correlation between exposure and disease.
For "medical documentation" the following requirements must be met
In principle all of the above conditions have to be met. However, in the concrete assessment of whether
to include a disease on the list of occupational diseases the specific conditions can be differently
weighted.
For further information on medical documentation, including documentation of the particular diseases
in this guide, see Appendix 1.
1.3. Conditions for recognition of diseases reported on or after 1st January 2005
Under the Act a disease reported on or after 1st January 2005 qualifies for recognition as an
occupational disease if
The disease meets the conditions for recognition in pursuance of the current Administrative Order on
the List of Occupational Diseases Reported on or after January 1, 2005, or
The disease qualifies for recognition after submission to the Occupational Diseases Committee
(section 7, subsection 1(ii) of the Act)
In order for a disease to qualify for recognition on the basis of the list of occupational diseases reported
on or after 1st January 2005, the following applies.
1. The claim must meet the overall requirements for recognition of occupational diseases set out in the
Consolidated Workers Compensation Act.
6
2. The disease must in addition meet the following general conditions, cf. section 1 of the
Administrative Order on the List of Occupational Diseases, and in pursuance of section 7(1)(i) of the
Act:
(i) The harmful exposure shall have such severity and duration as, according to
medical documentation, is able to cause the disease.
(ii) According to medical documentation, the pathological picture shall correspond to
the harmful exposure and the disease.
(iii) There shall be no factors making it likely beyond reasonable doubt that the disease
was brought about by non-occupational circumstances, cf. section 8(1) of the Act.
Furthermore the special conditions set out under the individual items of the list of occupational diseases
must be met. And furthermore, additional requirements to disease and exposure may be described in a
valid guide. Such requirements similarly have to be met.
With regard to recognition of diseases not on the list we refer to Chapter 1, paragraph 2, of this guide,
which describes the general and specific conditions for recognition of diseases and exposures not
covered by the list.
The diseases mentioned on the list can be caused by factors other than work. For instance the
symptoms may be age-related or result from other illness, or they may have been caused by exposures
in a persons leisure time, including previous injuries. In that case it is either a pre-existing disease that
came about before the work-related exposure or a competitive disease, i.e. a disease which is different
from the reported disease but shows the same symptoms, or a pathological condition that was caused
by non-occupational exposures.
If the general and special conditions for recognition are met and the disease is not fully or mainly
competitive or pre-existing and the exposure is not competitive, then the disease will qualify for
recognition as a work-related disease if it meets the recognition requirements besides.
If there are competitive or pre-existing diseases or competitive causes or exposures that do not rule out
recognition as an occupational disease, but contribute to the development of the disease and the
symptoms, such circumstances will affect the amount of the compensation. This means that we may
make a deduction from the compensation for permanent injury and/or the compensation for loss of
earning capacity. (Section 12 of the Act)
Diseases reported before 1st January 2005 are assessed on the basis of the current list of occupational
diseases reported before 1st January 2005 and any appurtenant guides.
Under the Act claims that were previously turned down on the basis of the conditions that applied prior
to 1st January 2005 cannot in principle be resumed with a view to an assessment on the basis of the
7
new list. Usually this also applies in cases where a disease or an exposure that has been turned down is
later included on the list of occupational diseases reported on or after 1st January 2005.
However, a claim that was turned down on the basis of the previous list may be resumed if the disease
or exposure turned down is later included on the previous list of occupational diseases reported before
1st January 2005.
Injuries occurring as a result of short-term exposures for up to 5 days are in principle assessed as
accidents. For further information see the Boards guide to recognition of accidents.
Injuries occurring after exposure for longer periods will usually be assessed on the basis of the rules for
occupational diseases.
The National Board of Industrial Injuries is under an obligation to gather the information necessary to
ensure that decisions are made on a justifiable basis. This follows from the so-called official maxim.
Injured persons contribute to the information of the case, for instance by answering questions or by
having themselves examined by a doctor.
If there is a need for further information on the disease or the exposure or other matters, we examine
the case in more detail. For example we may ask the injured person to elaborate on the description of
the development of the disease or the exposure. We may also ask the employer for more detailed
information or gather supplementary medical information.
In the processing of the claim we may request and obtain a medical certificate from a specialist of
occupational medicine. We i.a. ask the medical specialist to describe in detail and make an assessment
of the concrete working conditions and the concrete exposures. The medical specialist will furthermore
make an individual assessment of the impact of the exposures on the development of the disease in the
examined person in question. The medical specialist will describe the onset and course of the disease
and state any previous or simultaneous diseases/symptoms and any impact they may have on the
current complaints.
We may also obtain other types of medical specialists certificates in order to get information on the
development of the disease and any competitive or pre-existing diseases.
The guide furthermore includes a collection of examples to illustrate the many different possibilities of
recognising a disease without basing the decision on the list. However, the collection of examples is far
from exhaustive.
In each case we make an assessment of whether the case should be submitted to the Committee. If,
against the background of our knowledge of the practice of the Committee and the medical knowledge
in the field, we find that submission of the case to the Committee would be futile, either due to the
nature of the disease, the exposure or the causality, the claim will be turned down without submission
to the Committee. (Section 7(3) of the Act)
The principles for when we usually submit a claim to the Committee are set out in Chapter 1, paragraph
2.5.1.
The Occupational Diseases Committee recommends recognition of a claim if one of the following
conditions is met
This usually applies to diseases that may soon be expected to be included on the list of
occupational diseases. It very rarely occurs, however, that diseases are recognised on the basis
of this provision.
In the majority of cases the disease will be recognised instead on the basis of the provisions of
the Act on the special nature of the work, see below. This is done if it is found that the work
has mainly or solely caused the reported disease. The available medical knowledge will also
be included in this assessment.
2. General conditions for recognition of a disease caused by the special nature of the work
The condition for recognition under this provision is that the disease must be deemed to have
been caused, solely or mainly, by the special nature of the work (section 7(1)(ii) of the Act).
This calls for a very concrete assessment where both of the following two conditions need to
be met:
9
The work, including the working conditions, must have involved loads and exposures
which, according to an overall, concrete assessment, must be deemed to lead to a
special risk of developing the disease in question.
The particularly risky work must, according to a concrete assessment, be likely,
beyond reasonable doubt, to have caused the injured persons disease.
If a claim is submitted to the Occupational Diseases Committee, the Committee will recommend
recognition of the claim as an industrial injury or turning down the claim. If the Committee
recommends turning down a claim, this is done against the background of an assessment of both of the
above.
The primary reason for turning down a claim is that the disease was not mainly or solely caused by the
given exposures in the workplace (the special nature of the work). In other words, the Committee has
reached the conclusion that it is more likely that the disease was caused by factors other than the stated
work-related exposures.
Usually, however, the Committee will not point to other factors that may have contributed to the
development of the disease as this is often not possible. The cause of many diseases may be unknown
or complex or many-facetted.
We make a decision on the claim on the basis of the Committees recommendation. (Section 7(3) of the
Act)
How special, extraordinary or atypical the work has been in relation to other types of work carries less
weight. What matters is whether the work can be deemed to be the predominant cause of the disease.
This is based on a very concrete assessment where the available medical knowledge and experience in
the field are factors which carry considerable weight in the overall estimate of the causality of the case
in question.
In practice there will be a number of diseases where there is good medical documentation that the
diseases are not caused, mainly or solely, by special work-related exposures.
10
Such diseases are for instance diseases that are very prevalent in the population as a whole. It is not
possible to point to any particular risk factor for the development of the disease that can be referred to
special work functions or exposures. In other words, the disease may have been caused by different
factors such as age, family disposition, lifestyle, other diseases, or private injuries and exposures.
The same applies to a number of exposures where there is firm knowledge that they cannot, in
themselves or as a predominant factor, cause an occupational disease. Therefore, in connection with
such exposures, the claim will usually be turned down without submission to the Committee because
such submission must be seen as futile.
One example is work involving repeated, slight movements of fingers/hands without simultaneous
strenuousness, awkward working postures or other special loads on fingers/hands. Therefore, a disease
of the hand or fingers will not in principle be deemed to have developed as a consequence of very
slight, repeated loads.
It could also be relatively stressful work functions or exposures which, however, were carried out so
few times per day or for such a short time that they could not in themselves, or as the predominant
factor, be regarded as sufficiently risky for the development of a given disease against the background
of the present medical knowledge.
We are following the medical developments very closely and are including new research results in
general discussions of disease correlations and discussions of specific claims submitted to the
Committee. This is done in close co-operation with our medical consultants, who represent the various
medical specialties.
This means that the practice of the Committee in various fields of diseases is not static. The assessment
of the causality in the various disease areas may change over time in step with the appearance of new
medical knowledge.
In order to recognise a disease without application of the list it is necessary to have a medical diagnosis
which is as clear as possible.
The diagnosis constitutes a substantial decision basis for the Committees assessment of the case, and if
the diagnosis is not clear, this will make it considerably harder to assess the correlation between the
disease and the exposure.
This means that we often gather some medical information before making a decision on the claim, also
after submission of the claim to the Committee. We will typically obtain a medical specialists
certificate and medical records from a hospital, medical specialist or GP (including any functions
health certificate), which may ensure a clear overview of the diagnosis, the general pathological picture
and any competitive/pre-existing diseases or injuries.
For the same reason the handling of a claim to be submitted to the Committee will take longer than
claims that can be decided on the basis of the list and without submission to the Committee. However,
we do aim at speedy management of claims regarding particularly critical diseases, where a quick
assessment is of great significance for the injured person.
11
When a claim is submitted to the Committee, one of our medical consultants has assessed it
beforehand. The medical consultant will go through the medical information of the case and make an
assessment of the medical diagnosis and other medical matters that are relevant for the Committees
subsequent assessment of the claim.
The Occupational Diseases Committee does not always agree with the diagnosis made in a medical
specialists certificate or with the medical specialists assessment of the causality between disease and
exposure. In the last instance it is the Committees assessment that forms the basis for the decision and
in such cases this will appear from the recommendation made in the specific case.
In the processing of the claim we typically obtain a medical certificate from a specialist of occupational
medicine, except where there already exists a good and complete medical record of occupational
medicine or another adequate work description.
The certificate or report of occupational medicine must include information of the concrete work
conditions and exposures in the workplace as well as a thorough description of the disease.
The diagnosis
The onset of the disease
The development of the disease
The treatment of the disease
Competitive or existing diseases/injuries
Current symptoms (symptoms/complaints stated by the injured person)
Present objective/clinical signs (the medical specialists findings in the examination)
Results of any other examinations such as x-rays, scans, or ultrasound
A detailed work anamnesis (work description)
To the extent it is deemed necessary in order to get a better overview of the disease, we will
furthermore obtain a medical specialists certificate from a doctor who is specialised in the concrete
type of disease.
For a number of lung diseases, for instance, this could be a lung specialist or perhaps a specialist of
radiology. In connection with musculoskeletal disorders of the knees, arms, shoulders, etc., it is
sometimes necessary to get a report from an orthopaedic surgeon which can supplement and elaborate,
from a medical point of view, the information on occupational medicine.
In a few cases, in connection with complex cancer diseases, we will obtain an assessment from an
expert working for the Danish Cancer Society. This assessment will give an overview of the medical
knowledge in the field and an assessment of the probability of any correlation between the disease and
the stated exposures at work in the specific case.
12
In addition, in some cases, we will obtain supplementary medical information from a GP or hospital or
medical specialists examinations or x-ray and scan descriptions. In a few cases we also gather
information from a physiotherapist, a chiropractor, etc.
All gathered information will be included in the Committees assessment of the claim.
Formally, under the Act, the burden of proof with regard to the employment and the exposures in the
workplace lies with the injured person, but under the so-called official maxim we have a general
obligation to provide information in the processing of claims. In their judgement of 1993 (U
1993.220B), the Supreme Court (Hjesteret) also took a position on this question, stating that it is not
expedient or legally or economically possible to make it the concern of employees to currently gather
evidence of their working conditions.
Therefore the National Board of Industrial Injuries is under an obligation to obtain adequate
documentation of the relevant working conditions.
In specific cases it may be vital that injured persons should be able to remember relevant exposures
themselves as such information may be the only available information for the elucidation of the claim.
If the injured person cannot remember, the claim will typically be turned down as there is no
documentation of any relevant exposures that the work mainly or solely has caused the reported
disease.
Whether the injured persons information can be regarded as sufficient and the stated exposures can be
regarded as realistic and likely will always depend on a concrete assessment. This assessment will take
into account the knowledge of general exposures in the trade in question.
Before submitting the claim to the Committee we try to get the best possible description and
documentation of the exposures that the injured person has suffered. First we gather information from
the injured person to get an initial overview of any relevant exposures and relevant working conditions.
We furthermore gather ATP information stating where the injured person has been employed and for
how long (based on number of paid-in ATP months per year in each employment). However, the ATP
(labour market supplementary pensions) scheme only started in 1964, and therefore the information in
some of the cases does not cover all relevant employments.
Furthermore, statements of payments from employers up to around 1970 have been inadequate in a
number of cases.
13
Finally, on the basis of the information from the injured person, the work description etc. from the
specialist of occupational medicine, and the ATP information, we will try to obtain comments from
relevant employers regarding each exposure.
Normally we try to obtain employer comments from the relevant main employment(s) (typically 1-3
employers), i.e. the employments of the longest duration with the most substantial relevant exposure.
If the most substantial employments date far back, we often try to get information from one or more
recent employers if there were relevant exposures in such employments, even if the employments in
question do not constitute the main exposure.
In a number of cases it can be a problem to get information of the exposures the injured person has
suffered through the employer. In particular this would apply to employments dating far back, where
the employer may have stopped work long ago and may even have died. Many employers do not reply
to our letters or cannot remember employments or exposures dating far back in time.
Therefore, in some cases, we gather supplementary witness statements from previous colleagues, trade
union representatives in the workplace or others, as a supplement to information from the injured
person and perhaps the employer. This may happen in cases where the employer has stopped work or
does not reply and in cases where there is a lot of disagreement between the injured person and the
employer with regard to the exposure.
Besides we have the option of examining the working conditions and the exposures in detail by way of
other methods which, however, are only used in special cases.
Thus we can send our travelling inspector to the workplace for a closer examination of the working
conditions together with the workplace representatives and the injured person himself. The travelling
inspector is typically used in cases where there is serious disagreement between the employer and the
injured person on the exposures and where the outcome of the case depends on clarification of the
working conditions and the concrete exposures and where it has not been possible to get proper
clarification or documentation of the conditions in any other way.
In addition we can ask the Working Environment Authority to make a closer examination of the
workplace and the concrete working conditions. And finally we may arrange for an examination under
oath of the employer with regard to the working conditions. This hardly ever happens, however.
2.3.2. Relationship with the Working Environment Act and the Medico-Legal Council
Occasionally we receive copies of judgements under the Working Environment Act and judgements
regarding general Acts and principles in connection with compensation law. The judgements are
typically about employers being held liable for compensation as a consequence of negligence in
connection with the employment. Injured persons or their legal representatives want us to include these
judgements in the assessment of their claim. In such cases, of course, we will include the information
of the judgement in our assessment of the case.
14
Usually, however, the Workers Compensation Act does not take into consideration the legal aspects of
compensation and the inherent question of guilt, but is solely based on whether the disease was caused,
mainly or solely, by the special nature of the work.
This often means that the Committee adopts a different view of the employment and the causality than
the view reflected in judgements under the Working Environment Act and general Acts and principles
pertaining to compensation law.
The Committee is not bound in their assessment by a judgement made according to general
compensation principles. Therefore the Committees assessment does not take into consideration any
guilt on the part of the employer, but solely whether the work is likely, beyond reasonable doubt, to
have been the cause of the disease in question.
In some cases, however, a judgement may contribute to clarifying special exposure conditions in the
workplace which, together with other information of the case, contribute to documenting a particularly
risky exposure which mainly or solely must be regarded as the cause of the reported disease.
In a few cases we also receive assessments from the Medico-Legal Council, who, in connection with
e.g. court proceedings, have been asked to make a statement on the disease and any correlation with
exposures in the workplace. We furthermore have the possibility of obtaining statements from the
Medico-Legal Council in special cases in connection with concrete claims. We include the Councils
statement in our overall assessment of the claim, but are not bound by the statement.
If there are any pre-existing diseases or competitive exposures which may fully or partly have caused
the onset of the disease, an assessment has to be made, in the concrete case, as to whether the pre-
existing or competitive disease or the competitive exposures contribute to the general pathological
condition to such an extent that the disease cannot solely or mainly have been caused by the special
nature of the work. If this is the case, the disease cannot be recognised as an occupational disease.
If the disease can be deemed to have been caused mainly by the special nature of the work, even though
there are pre-existing or competitive factors that contribute to the general pathological condition, the
aggravation of the disease may be recognised as a consequence of the special nature of the work if it
meets the Committees recognition requirements besides due to causality.
If there are competitive or pre-existing diseases or competitive causes or exposures which do not
preclude recognition as a consequence of the special nature of the work, but contribute to the
development of the disease and the overall condition, such factors will have an impact on the
calculation of the compensation. This means that we may make deductions in the compensation for
permanent injury and perhaps also in any compensation for loss of earning capacity. (Section 12 of the
Act)
15
2.5. Claims management by the National Board of Industrial Injuries (Arbejdsskadestyrelsen)
2.5.1. Assessment to turn down or submit the claim to the Occupational Diseases Committee
When the National Board of Industrial Injuries finds that the claim qualifies for recognition,
it is always submitted to the Committee
When the National Board of Industrial Injuries finds that the claim is very close to
qualifying for recognition, it is usually submitted to the Committee
When the Committee has not previously taken a position on the issue in question (causality)
When there is doubt as to whether the exposures set out are adequate to meet the
requirements of section 7(1)(ii) and section 7(2)
When the claim is within focus areas where submission to the Committee has been agreed
with the Committee
When the National Social Appeals Board (Ankestyrelsen) has decided that the claim should
be submitted to the Committee
Before submitting the claim, we will have clarified the possibilities of recognising the injury as an
accident or occupational disease covered by the list.
That a claim is submitted does not necessarily mean that the claim will be recommended for
recognition in the end. Whether or not the disease in question was caused, mainly or solely, by the
special nature of the work, depends on a detailed and quite concrete assessment.
We write a draft for the Committees recommendation to either turn down or recognise a claim.
However, it is ultimately the Committees assessment that forms the basis for the final recommendation
and our subsequent decision. This may in certain cases have the effect that the Committee changes our
draft for recommendation from turning down to recognising the claim or vice versa.
The National Social Appeals Board may also refer the case back to us and actually instruct us to submit
the claim to the Committee as recognition cannot beforehand be deemed to be futile.
If the National Social Appeals Board has referred the case back to us with a view to any submission to
the Committee, we will handle the case like all other cases, making a thorough assessment of the
chances of the case on the Committee as described above. The case will be turned down as futile or
submitted to the Committee with a draft recommendation to recognise or turn it down.
16
If the National Social Appeals Board has decided that the case will be submitted, the case is submitted
to the Committee with a draft recommendation for turning down or recognising it, depending on the
information and nature of the case.
In a few cases the National Social Appeals Board, when referring the case back to us, will have taken a
final position, in the assessment of the claim, on one or more matters.
This means that the National Social Appeals Board has made a decision on one or more part questions
of the case. In such cases we usually include the part decisions made by the National Social Appeals
Board as finally decided questions in our draft recommendation, which the Committee therefore in
principle does not have to decide on when assessing the claim.
This is because the National Social Appeals Board is a supreme instance in relation to the National
Board of Industrial Injuries and thus also in relation to any recommendations from the Occupational
Diseases Committee, on which our decisions are based. Thus we cannot change decisions, including
part decisions, which have already been made by the National Social Appeals Board.
Then we hear the relevant parties to the case, typically the injured person or his/her legal representative
and the insurance company. In connection with the hearing we are sending copies of all the information
which will be included in the Committees assessment of the claim, as well as a copy of the temporary
recommendation of the case. Then there is a time limit of usually 14 days for the parties heard to come
forward with any comments on the recommendation and the forwarded information.
If we receive comments within the time limit, the comments will be assessed with a view to any
postponement of the case for further processing, a changed recommendation based on new information,
or an unchanged recommendation to the Committee taking into consideration the new information,
which in that case will be included in the Committees further processing of the claim.
If we only receive the comments after expiry of the time limit and the case has already been submitted
to the Committee, the new information will usually be treated as a complaint, depending, however, on
the nature of the information.
The Committees discussion may have four different outcomes for the final recommendation on the
case:
The recommendation is unchanged in relation to the forwarded draft on which the parties
have been heard.
The recommendation is unchanged with regard to result, but is based on a Committee
majority decision. This means that a minority on the Committee wished a different outcome
and disagrees with the majority decision. The dissent of the minority will then appear from
the Committees final recommendation and our subsequent decision.
The recommendation is changed in relation to the forwarded draft on which the parties have
been heard. This means that a recommendation to turn down the claim has been changed to
17
recognition (or vice versa) between our first draft and the final recommendation by the
Committee. In such cases, before making a decision on the case, we have to hear the
involved parties on the new and final recommendation from the Committee.
The case is postponed, after gathering new information, with a view to a new submission of
the claim. The case will then be processed further in line with the Committees wishes and
resubmitted to the Committee with a new draft recommendation including the new
information on the case. Before the claim is submitted again, the parties will be heard on the
information of the case and the new recommendation.
Once the case has been submitted to the Committee, we make a decision on the case on the basis of the
Committees discussions and the final recommendation. If the case has been postponed, we process it
further with a view to resubmitting it later.
Example 2: Claim turned down tinnitus without loss of hearing (noise from turbines)
A man worked for 10 years as a turbine engineer on a drilling rig. The work was typically performed in
severe noise from the turbines. He subsequently developed an uncomfortable, ringing tinnitus.
Audiological examinations showed the hearing to be normal.
The Committee found that the tinnitus symptoms had not been caused, mainly or solely, by noise
exposures in the workplace. The Committee took into consideration that, on the basis of the medical
knowledge in the field, it can only be deemed to be likely beyond reasonable doubt that there is a
correlation between tinnitus and working in noise if, at the same time, it is possible to establish loss of
hearing as a consequence of the work. In this case, however, the hearing was normal.
Example 1: Recognition of degenerative arthritis and prolapsed cervical disc (heavy lifts on neck and
shoulder girdle)
A man worked as a beer delivery man for more than 10 years. The daily lifting load was about 16
tonnes in the form of beer cases and soda cases weighing 11-23 kilos and beer barrels weighing 17-42
kilos. The work was characterised by frequent lifts of two boxes at a time on the neck and shoulder
girdle, and furthermore there were difficult access and lifting conditions on the customers premises.
He was subsequently diagnosed with degenerative arthritis and a prolapsed cervical disk.
18
The Committee found that the degenerative arthritis and the prolapsed cervical disc had come about
mainly as a consequence of the heavy work as a beer delivery man for more than 10 years. The work
was characterised by heavy lifting work with many heavy single lifts on the neck and shoulder girdle
that constituted a particular risk of developing the reported diseases.
Example 2: Recognition of chronic neck and shoulder pain (fishing industry worker for 6.5 years)
A 36-year-old woman had worked as a production worker in a fishing factory for a total of 6.5 years.
She worked in the packing department, two thirds of the time de-skinning and one third of the time
vacuum packing the fish. Her work involved numerous movements of her upper arms every day when
handling several thousands of fishes, equivalent to at least 30 movements per minute. It also appeared,
however, that she worked for a total of 1.5 years in the packing department and then had a one-year
break from work. After this she worked for 5 years in the same function, and then her disease set on, in
the form of chronic neck and shoulder pain with moderate to considerable tenderness of several
muscles of the neck and shoulder region. It was not possible to recognise the claim on the basis of the
list of occupational diseases since there had not been a continued work load for at least 6 years up to
the onset of the symptoms. The reason was that she had been without any work load for one year
between the two work periods of 1.5 and 5 years respectively.
The Committee found that the fishing industry workers chronic neck and shoulder pain had developed
mainly as a consequence of her work. On the basis of a concrete assessment, the very quickly repeated
movements of her upper arms for an uninterrupted 5-year period up to the onset of the symptoms, with
a previous load period of 1.5 years, must be deemed to constitute a substantial risk of developing neck
and shoulder pain.
Example 3: Recognition of chronic neck and shoulder pain (bookbinders assistant for more than 30
years)
A 54-year-old woman developed chronic neck and shoulder pain with considerable tenderness of the
neck and shoulder attachment. The disease set on after more than 30 years work as a bookbinders
assistant with various employers. The work involved many high-repetitive functions and furthermore a
static load on the neck and shoulder girdle. It included 12 years with Post Danmark, where she had to
sort stamps or assemble and bundle sheets of stamps. Both functions involved considerable precision
work with numerous movements of fingers and wrists and static locking of the neck and shoulder
girdle. In other employments she i.a. had strenuous and high-repetitive work for her arms with sorting,
assembling and pushing together sheets of paper, magazines etc. The claim had previously been turned
down several times by the National Board of Industrial Injuries and the National Social Appeals Board,
who did not find sufficient documentation that she met the load requirements set out in the list of
occupational diseases reported before 2005. They had taken into consideration that the work had been
of a dynamic nature and that she therefore had not had sufficiently monotonous precision work with
fixation of the neck and shoulder musculature. The Medico-Legal Council made a statement and found
that she had chronic neck and shoulder pain. The Medico-Legal Council furthermore found that the
work in bookbinders, which had involved relatively heavy, dynamic work, and the work with Post
Danmark, which had been high-repetitive work with a static load, must be deemed to have been a
substantial factor for the development of chronic neck and shoulder pain.
The Committee agreed with the Medico-Legal Council in their assessment. The Committee found that
the bookbinders work for a considerable number of years mainly had caused the chronic neck and
shoulder pain. The work had involved relatively heavy, dynamic work as well as high-repetitive work
19
with a static load on the neck and shoulder musculature, which increases the risk of developing the
disease in question. The assessment also took into account that a new review on chronic neck and
shoulder pain in 2007 had established moderate documentation of a correlation between quickly
repeated movements of the upper arms and the disease.
Example 4: Claim turned down prolapsed cervical disc (moderate lifting work without lifts on
neck/shoulder)
A man worked in the music industry for 20 years. First he was a driver for 10 years. This involved
lifting work when loading and unloading stage equipment, technical equipment and instruments from a
lorry and when building a stage, lifting about 3.5 tonnes per day. In between there were heavy lifts, for
which he used a harness system. The last 10 years he worked as a stage assistant, building stages and
transporting light and sound equipment as well as instruments. Here the daily lifting load was also 3.5
tonnes. There were no regular, heavy lifts on the neck and shoulder girdle. After 20 years he had
problems with the back of his neck and was diagnosed with a prolapsed cervical disc.
The Committee found that the prolapsed cervical disc had not been caused, mainly or solely, by the
work as a driver and stage assistant for many years. The Committee took into consideration that the
lifting work had not generally been stressful for the neck, and the lifts were not regular heavy lifts on
the neck and shoulder girdle.
Example 5: Claim turned down prolapsed cervical disc (heavy healthcare work, no time correlation)
A woman worked for 28 years as a healthcare assistant in various healthcare institutions, hospital
departments and homecare. The first 22 years the work was characterised by many heavy healthcare
tasks with more than 30 patient handlings per day. In this period she occasionally performed transfers
of patients. This was stressful for her neck because the patients held onto her neck while being
transferred. This only happened, however, when she did not have a colleague to help her. The last 6
years she had less stressful work in homecare and in this period she had no transfers with direct loads
on the neck. After 28 years she developed neck pain and was diagnosed with a prolapsed cervical disc.
The Committee found that the prolapsed cervical disc had not, mainly or solely, come about as a result
of the healthcare work as she had had no direct loads on the neck for 6 years up to the onset of the
disease, and the previous transfers of patients had not been frequent besides.
Example 6: Claim turned down degenerative arthritis and muscular tension of neck (truck driver)
A man drove forklift trucks for 26 years. The first 8 years the truck was without a drivers cab, and
therefore he suffered a lot of exposure to cold. Throughout the whole period he drove backwards about
half of the working time and therefore often turned his neck backwards. After 6 years work he
developed pain of the neck and subsequently both shoulders. A medical specialist later diagnosed him
with degenerative arthritis of the neck and chronic muscular tension of the neck and shoulder region.
The Committee did not find that the degenerative arthritis of the neck and the chronic muscular tension
of the neck and shoulder girdle had been caused, mainly or solely, by the described work as a truck
driver for a number of years. The Committee took into consideration that there was no medical
documentation of any causality between the described exposures in the form of cold and frequent
turning of the neck and the reported diseases, and that the work had not led to any direct impact on the
neck and shoulder that constituted a special risk of developing degenerative arthritis of the neck or
chronic muscular tension of the neck and shoulder region.
20
Back
Example 1: Recognition of prolapsed lumbar disc (lifts in combination with knocking with a rod)
A man worked for 13 years as a semi-skilled worker in a sugar factory. For 8 months a year, the work
consisted in knocking off sugar from inside a silo. For this he used a 6-metre rod, which weighed about
10 kilos. He stood on the floor or on a ladder and pushed the rod hard, up into the silo. The daily lifting
load of this work was at least 3 tonnes. In addition, 4 months a year, he performed heavy lifting work,
cleaning the silos. This work involved single lifts of about 70-80 kilos and a total daily lifting load of
more than 10 tonnes. After about 8 years work he was diagnosed with a prolapsed lumbar disc.
The Committee found that the prolapsed lumbar disc had mainly developed as a consequence of the
work in the sugar factory for 13 years. They took into consideration that the combination of high lifts
of the rod and the continual upward knocking in postures that were awkward for the back, for two
thirds of the year, had been very stressful for the back. At the same time, for one third of the year, he
had performed heavy lifting work with extremely heavy and back-loading single lifts.
Example 2: Recognition of chronic low-back pain (awkward lifts and many downward jumps from
trains)
A man worked as a train station worker for a considerable number of years. The last 12-13 years he
only did shunting work. He i.a. did coupling and decoupling of trains and engines and shunting of
trains with hand-operated switches. He prepared trains for service, performing brake tests and
mounting lamps. The work involved a daily lifting load of typically 3-4 tonnes. Occasionally he also
had very heavy single lifts of 60-80 kilos. The lifting work was mainly done in very awkward, stooping
working postures. In addition there were many daily upward and downward jumps from trains. The
downward jumps sent shocks through his back. Towards the end of the period he developed daily low-
back pain radiating into the right buttock.
The Committee found that the chronic low-back pain had been caused mainly by shunting work for
more than 10 years. The Committee took into consideration the combination of a daily and often
awkward load of about 3-4 tonnes, recurring and very heavy single lifts, and many back-loading
downward jumps from trains.
Example 3: Recognition of prolapsed lumbar disc (very heavy lifting work 4 months/year for 25 years)
A man worked as a harbour worker (casual labourer) for a bit less than 4 months a year for 25 years.
The remaining months he did not have work that was stressful for the back. The work consisted in
loading and unloading ships with manual lifts of sack goods, boxes and ox carcasses. The first 10-15
years the work was extremely stressful with a daily lifting load of about 50 tonnes and single lifts
between 40 and 110 kilos. In later years the work was more varied, but also very hard on the back. To
this should be added that the lifts typically were made in awkward postures. Towards the end of the
period he developed low-back pain and was diagnosed with a prolapsed lumbar disc.
The Committee found that the prolapsed lumbar disc had been caused mainly by the extremely heavy
and awkward, back-loading lifting work for 25 years, in particular the stressful lifting in the first half of
the period, the daily lifting load having been 50 tonnes with many, extremely heavy, single lifts. The
Committee furthermore took into consideration that the load period, converted to an employment rate
of 8 months per year, was equivalent to a total of 11-12 years.
21
A mechanic worked for 15 years in various garages. The first 5 years the work consisted in repairing
and replacing engines and gear boxes, changing wheels and brakes, and sheet metal work. More than
half of the working day was spent in the pit, where he had to work with his back stooping or bent
sideways. The daily lifting load was 3-5 tonnes and involved generally occurring, heavy single lifts of
up to about 70 kilos. Subsequently he worked for 10 years in a number of different employments, as a
sheet metal smith two thirds of the time and as a general mechanic one third of the time. The tasks were
cutting, welding, and fitting and unfitting of car parts. He nearly always performed the work lying
under the cars, in a stooping posture, lying with his knees bent and a flexed back or huddled up.
However, the amount of heavy lifting work was limited in this period. Towards the end of the period he
developed daily and chronic low-back pain.
The Committee found that the chronic pain had been caused mainly by the work as a mechanic for 15
years. The Committee took into consideration that the work had mainly been done in back-loading,
huddled-up or stooping working postures under cramped conditions, and that this exposure in itself
constituted a special risk of developing a chronic low-back disease. In addition there had also been
extremely heavy lifting work for about 5 years out of the total exposure period.
Example 6: Claim turned down chronic low-back pain (heavy lifting work for 4 years and periodic
lifting work)
A man worked as a beer delivery man for 4 years. The first 1.5 years the work involved a daily lifting
quantity of approximately 20 tonnes. The last 2.5 years the daily lifting quantity was approximately 8
tonnes. The single lifts were usually 40-50 kilos. Before the employment in question, he had worked
for 3-4 years as a fire guard, which did not involve any work that was stressful for the back. Previously,
for various periods of time over 3 years, when working as a welder in a shipyard, he had back-loading
work. He worked in bottom tanks in lying, huddled-up and back-loading working postures. As a young
man he had worked as an errand boy in the vegetable market, where he had moderate to heavy lifting
work. In between, for long periods of time, he did not have back-loading work. He had tended to have
periodic back pain since his youth, but while working as a beer delivery man, towards the end of the
work period, his condition was significantly aggravated and he had daily, chronic low-back pain.
The Committee found that the chronic low-back pain had not been caused, mainly or solely, by the
work as a beer delivery man or by one of his previous periodic employments with back-loading work.
22
The Committee took into consideration that in connection with the significant aggravation of his low-
back pain he had been working for 4 years as a beer delivery man with a daily load of 8-20 tonnes and
single lifts of less than 50 kilos. This exposure alone could not be deemed to constitute any special risk
of developing a chronic low-back disease. Before this, in his long employment as a fire guard, he had
not had back-loading work. Therefore there was no time correlation with the previous periods of back-
loading work as a welder, errand boy and worker in the vegetable market.
Hip
Example 1: Claim turned down degenerative arthritis of left hip (moderate lifting work and jumping
down from a refuse lorry)
A man worked for 16-17 years as a refuse collector. At the beginning of the period the work consisted
in collecting refuse sacks. This involved many manual lifts of typically 20-25 kilos. Later on, sack
trucks and refuse containers were introduced. The first 3-4 years the daily lifting load was about 6
tonnes, later somewhat less (about 4 tonnes). The work furthermore involved downward jumps from
the refuse lorry, about a hundred times a day, at the various collection points. Towards the end of the
period he developed pain in his left hip and was diagnosed with severe degenerative arthritis of the left
hip. He later had replacement hip surgery. X-rays of his right hip showed normal conditions.
The Committee found that the degenerative arthritis of the left hip had not been caused, mainly or
solely, by the work as a refuse collector. The Committee took into consideration that there is not at
present any medical documentation of a correlation between moderate lifting work of typically 4 tonnes
per day and/or many jumps from a lorry and the development of degenerative hip arthritis. Nor can the
described loads in connection with moderate lifting work for 16-17 years and frequent downward
jumps from a refuse lorry, based on a concrete assessment, be deemed to be particularly risky for the
development of left-side degenerative hip arthritis.
More information:
Chronic pain with physical findings in the neck-shoulder girdle and exposures in the workplace
(www.ask.dk)
A critical review of evidence for a causal relationship between computer work and musculoskeletal
disorders with physical findings of the neck and upper extremity (www.ask.dk)
23
The Committee found that the exposure to heavily vibrating hand tools, with continuous impact on the
tendon plate of the hollow of the hand for a long period of time, mainly had caused the right-side hand
disease.
Example 2: Recognition of effects of fracture and cyst formation at carpal bones (marking pistol)
For 19 years, 30-40 times a day, a steel technician marked metal plates with a marking pistol. The
metal plates passed through his left hand during the marking, a very severe recoiling force exposing his
left hand to very forceful pressure. He developed considerable hand problems, and a medical
examination showed cyst formation and fractures to several carpal bones.
The Committee found that the severe recoiling force on his left hand mainly had caused the cyst
formation in several of the small, left-hand hand carpal bones and several carpal bone fractures.
Example 3: Recognition of impact on the radial nerve (quickly repeated, strenuous work)
A man worked for 1.5 years in a chicken slaughterhouse. For 3 hours a day, his work consisted in
suspending chickens, weighing a bit more than 2 kilos, from a hook hanging above a conveyor belt. He
had to place the chicken with its leg in the hook a bit above shoulder height, and the work involved
some exertion. He lifted about 1,000 chickens per hour, equivalent to a total lifting load of 5.5 to 6.5
tonnes. He subsequently developed pain and restricted motion of his right arm. A neurological
examination documented an effect on the radial nerve of his forearm.
The Committee found that the impact on the radial nerve of the right forearm had been caused mainly
by the work in the chicken slaughterhouse. The suspension of chickens had been high-repetitive,
monotonous and strenuous and had furthermore led to a severe impact on the right arm, due to the long
reaching distances and high working postures.
The Committee found that there was a blocked artery at the left wrist (left arteria ulnaris), which had
been caused mainly by the work as a machine operator. The Committee took into consideration that the
operator many times a day, using pressure from her left wrist, had pressed down a button for 10-12
seconds, and that the exposure constituted a special risk of blocking an artery in the left wrist.
Example 5: Recognition of irritation of the pronator teres muscle of the forearm (cutting work)
A 43-year-old slaughterhouse worker for well over 20 years worked with cutting and deboning of beef
and veal and front ends etc. He took the 30- to 120-kilo meat units from a sliding bar in the ceiling. Part
of the meat had been cut off. Then he deboned and cut the meat with swift, strenuous, pressing and
twisting movements. For this he used a knife with his right hand, while with his left hand fixating,
24
lifting and throwing the meat into trays in front of the cutting table. Most of the meat was cold, tough
and stiff to cut. He deboned and cut 1,200 kilos of meat per day, equivalent to 16-20 hind quarters.
Towards the end of the period he developed pain in his right elbow, radiating down into the hand and
right thumb. He subsequently had surgery to loosen the median nerve of the right elbow. A medical
specialist diagnosed him with the effects of median nerve compression in the right forearm.
The Committee found there was irritation of the big pronator teres muscle of the right forearm.
The Committee furthermore found that the disease had been caused mainly by many years of work as a
slaughterer. He had been performing swift and very strenuous deboning and cutting work with twisting
of the right forearm. The arm was furthermore put under stress by pressing, pulling and twisting
movements during the work.
Example 6: Recognition of synovitis of the flexion tendons of the little finger and the ring finger
(welder)
A 55-year-old man worked for 9 years as a welder. He welded for the major part of the working day,
but also worked to a lesser extent with an angle grinder. The welding work was performed with various
types of welding handles, all of which he operated with his right hand. The large welding handle was
about 30 centimetres long and had a diameter of approximately 5 centimetres and weighed 1 kilo. The
smallest welding handle was also about 30 centimetres long, was 2.5 centimetres in diameter and
weighed 300-400 grams. During the welding he had to constantly activate the welding handle. When
using the large welding handle, he used the four uttermost fingers of his right hand. When activating
the small welding handle he used the 2nd finger of his right hand. The handle was being held with a
powerful grip, and he was only able to close the hand around the small handle. After some years he
started getting a numb sensation in several fingers of his right hand. He developed problems with
closing his hand and completely flexing his fingers, and a medical specialist made the diagnosis of
right-side synovitis (inflammatory condition) of the flexor tendons, with resulting trigger finger
phenomenon.
The Committee found that the welder had developed an inflammatory condition of the flexor tendons
of the little finger and the ring finger of his right hand (synovitis of the flexor tendons of the 4th and 5th
fingers) mainly as an effect of the exposure as a welder for a number of years. The Committee took into
consideration that for many years there had been static and strenuous stress on the right hand and
forearm in connection with operating welding handles.
25
the bow straight forwards and backwards in order to get the best sound. This required precise
movements of his right hand with the fingers statically fixated in the same posture.
The Committee found that the tendovaginitis of the right hand mainly had been caused by many years
of intensive violin play. The work of leading the bow had led to stressful, high-repetitive and awkward
movements of his right wrist.
Example 8: Recognition of supinator syndrome (pressure on the radial nerve of the forearm) (machine
engineer)
A 48-year-old man worked for almost 10 years with the manufacture of engines in a large factory. His
working tasks primarily consisted in decoupling and fitting spools for truck motors. As part of the work
he cut cables with an air-pressure machine with a foot pedal. After cutting he insulated the cable with a
pair of pliers, twisting each cable end 2-3 times. He made several hundred twisting movements per day.
In addition he cut off copper pieces with a large pair of scissors and fitted the cables on spools.
Towards the end of the working period he developed pain in his left forearm, and in connection with an
operation a medical specialist diagnosed him with pressure on the deep branch of the radial nerve in the
place where it passes below the supinator muscle.
The Committee found that he suffered from a left-side supinator syndrome (pressure on the radial nerve
of the forearm). The Committee found that the supinator syndrome had been caused mainly by the
manufacture of motors for a considerable number of years. The Committee took into consideration that
in particular the function of insulating a large number of cables every day had been done manually with
a pair of pliers and involved many powerful twisting and turning movements of the left forearm as well
as squeezing of the left hand.
Example 9: Recognition of inflammatory condition and lesion of the meniscus discs between the carpal
bones (metal worker working with drilling machine etc.)
A 31-year-old man worked for 3 years as a metal worker in a machine factory. The work was varied
metal work with repairs and manufacture of equipment for the slaughter industry. The work involved
the use of many different tools, including a drilling machine for drilling of holes in rustproof steel
plates which would suddenly get stuck with a severe recoiling force against his right hand in particular.
The metal worker also had to fixate pipes with a steel block while a colleague was hammering hard on
the steel in order to adjust the pipe. This work would go on for long periods of time. In connection with
a period of much adjusting of pipes the metal worker developed deep pain in his right wrist region. An
MR scan showed a lesion of the meniscus discs between the carpal bones (discus triangularis) and an
operation established a degenerate lesion of the discs with inflammation.
The Committee found that the meniscus disc lesions between the carpal bones and the inflammatory
condition had developed mainly as a consequence of working as a metal worker. He had been exposed
to numerous micro traumas to his hand root (carpus) during the work of adjusting the pipes and to
substantial stresses when working with the drilling machine which had a severe recoiling effect when it
got stuck.
Example 10: Recognition of bilateral inflammatory condition of the thumbs (tendinitis) (social worker
working with tube feeding)
A 52-year-old female social worker worked for 5 years in a specialised home for very
26
care-demanding, brain-damaged and multi-handicapped children. She herself cared for two children
who needed to be fed liquids and food through a tube 3 times per shift. It took her about one hour to
give a child a main meal, and she effectively administered tube feeding approximately 5 hours a day.
She tube fed by pressing down a piston with her right thumb held in an awkward position. The piston
was subsequently pressed quite down completely. In the course of one hour she pressed down the
piston about 40 times. As she began to develop complaints in her right hand, she switched over to her
left hand, which developed the same symptoms and pain after a while. A medical specialist diagnosed
her with bilateral thumb tendinitis (tendinitis digiti man. bilat.). The employer confirmed the job
description, but believed there were many breaks in the course of the 5 hours of tube feeding and that
the work was not as strenuous as described by her.
The Committee found, from a general perspective, that the bilateral inflammatory condition of the
thumbs (tendinitis) had been caused mainly by the tube feeding work. The reason is that the work
involved very strenuous pressure with her thumbs over a long period of time at short intervals as well
as awkward working positions for her thumbs, which substantially increases the risk of developing
tendinitis of the thumbs.
Example 11: Recognition of lunatum malacia of the right hand root (smith for 29 years)
A 52-year-old man had worked as a smith for 29 years. He was employed in the production of
machines for meat and bone meal production and worked stainless steel as well as black iron. He
produced containers and performed grinding, welding, torch cutting, forging with a sledge hammer,
fitting, and knocking off slag with an air chisel. He also performed heat-bending of edges on big drums
with a diameter up to 2 metres. During the performance of the work he was holding a powerful burner
in his left hand and a sledge hammer in his right hand. He heated up the edges and then hit hard on
these with the hammer.
He did this work for 20 per cent of his working day and furthermore worked with a cutting torch for 25
per cent of the working time. For a week up to a summer holiday, with 2-3 hours of overtime per day,
the smith had a major task involving the use of an angle grinder. He had to grind difficult units in a
container, and it was necessary to twist and turn his hands. Very soon after this he developed pain in
his right wrist and was referred by his own doctor to an x-ray examination, which showed lunatum
malacia as well as cyst formation in the trapezius of his right wrist. According to the information of the
case the sledge hammer weighed 4 kilos and the angle grinder weighed 7 kilos.
The Committee found that the smith mainly had developed a bone disease of his right wrist, in the form
of lunatum malacia (disease of a moon-shaped carpal bone) as a consequence of the exposures at work.
The Committee took into consideration that for 30 years the smith had had a job that involved forging
of and knocking on large steel units and this job was very strenuous for his right hand and wrist.
Example 12: Claim turned down degenerative arthritis of the wrist and the carpometacarpal joint of
the thumb (fitting worker)
A 59-year-old woman for 35 years worked as a fitter in three different electronics companies producing
hearing aids or measuring instruments. In all three employments her work consisted in fitting small
elements to e.g. print plates. It was precision work with many repeated movements of the wrist and
fingers without use of much force. In the last 13-year employment, however, she also had to cut a great
deal of metal parts, which involved minor exertion of hand and fingers. Towards the end of the period
she developed pain in her right hand and was diagnosed, after an x-ray examination, with degenerative
arthritis of the right wrist and the carpometacarpal joint of the thumb.
27
The Committee found that the degenerative arthritis of the right wrist and the carpometacarpal joint of
the thumb had not been caused, mainly or solely, by the work as a fitter for many years. The
Committee took into consideration that there is no general medical documentation of any correlation
between the development of degenerative arthritis of the wrist or the carpometacarpal joint of the
thumb and various exposures in the workplace, except in very special cases after very severe exposure
to heavily vibrating tools. Nor did the work involve any extraordinary loads on the wrist or thumb
which, based on a concrete assessment, might be deemed to be particularly risky with regard to the
development of degenerative arthritis.
Elbow
Example 1: Recognition of tennis elbow (non-varied work with twisting, precision milling)
A woman worked for 2 years as an ear plug technician in a hospital. The work consisted in producing
ear plugs by taking impressions for the plugs and moulding the plugs and grinding them. For a 5-month
period there was an understaffing problem and therefore she almost only did precision milling. She
held the ear plug with her left hand, operating with her right hand a 25-centimetre hand drill machine
weighing 200 grams. With a precision grip she held the front end of the hand drill and used a fixed grip
to operate it. The drill operated at between 5,000 and 20,000 revolutions per minute. Towards the end
of the 5-month period she developed pain in her fingers and the right-side elbow joint and was
diagnosed with tennis elbow. The disease did not qualify for recognition on the basis of the list, the
work not being strenuous within the meaning of the list.
The Committee found that the tennis elbow had come about mainly as a result of working with
precision milling for 5 months. The elbow had been exposed to non-varied, elbow-loading work with
continuous twisting movements.
Example 2: Recognition of tennis elbow (quickly repeated movements with tense musculature)
A woman worked as a porcelain painter for 22 years. Throughout the working day, she made precision
painting, painting 30-40 units a day with 500 painting movements for each. In one day she made about
20,000 small movements with her paint brush in her right hand. The work at the same time involved
constant tension of the musculature of her right forearm. She developed pain in her right arm and was
diagnosed with a right-side tennis elbow.
The Committee found that the quickly repeated precision work as a porcelain painter, with numerous
movements of her right upper arm and elbow and simultaneous constant tension of the muscles of the
right forearm, mainly had caused the right-side tennis elbow.
Example 3: Recognition of right-side tennis elbow, left-side tennis elbow turned down (very intensive
PC-mouse work as a technical drawer/CAD operator)
A 56-year-old, female technical drawer for 14 years was employed doing sea surveying. In the sailing
season she had very long workdays, working up to 16 hours a day up to 5 days a week. In this period
she drew with the PC mouse in her right hand for about half of the working time or up to 40 hours a
week. Then she changed to another business where she did very intensive, computer-based CAD work
for 90-95 per cent of her working day. She operated a ball mouse with her right hand and the keyboard
with her left hand. After well over 1 year in the new job she developed pain of both arms and was
diagnosed by a medical specialist with bilateral tennis elbows.
The Committee found that the right-side tennis elbow had been caused mainly by her work. The
Committee took into consideration that she had had intensive work with a PC mouse for many years,
28
many hours a day. To this should be added a very intensive period of more than 1 year up to the onset
of the disease, when she had been working with CAD drawing, using a ball mouse many hours a day.
The CAD work required many mouse clicks each minute and also much precision. The described work
involved constant, substantial stress on the musculature of the right forearm, which constituted an
increased risk of developing a right-side tennis elbow.
However, the Committee found that the left-side tennis elbow had not been caused, mainly or solely,
by work. They took into consideration that the substantial stress of intensive work with a PC mouse had
been on the right side, whereas the left side was only exposed to stresses from normal keyboard work,
which do not increase considerably the risk of developing a tennis elbow.
The work did not meet the list requirements for recognition of a tennis elbow under C.4.1. The injured
persons work occasionally involved strenuousness in connection with handling of persons, but the
elbow was not under stress several times per minute for at least 3-4 hours a day. Nor were there any
awkward work movements or strenuous static work for at least half of the working day.
The Occupational Diseases Committee found that the injured persons left-side tennis elbow had been
caused mainly by the work as a radiation nurse, which involved about 80-125 lifting movements per
work day in connection with positioning of patients for x-rays. The Committee took into consideration
that these lifting movements involved a special load on the extension musculature of the forearm.
Example 5: Claim turned down tennis elbow (lithographer with varied work without exertion)
For 2 months a lithographer worked all day cutting print samples (leaflets) on a cutting table. The
sheets were typically cut into 16 A4 pages, which were taped together and placed on the table. Then
each A4 page was cut with a hobby knife along a ruler. She held the ruler fixated with her left hand and
led the hobby knife with her right hand, occasionally with her arms fully stretched. The hobby knife
was led in the hollow of her hand and with her index finger stretched. Once the leaflet was cut, she
folded the pages, placed them together and stapled them. She subsequently developed a right-side
tennis elbow.
The Committee found that the tennis elbow had not, mainly or solely, developed because of the
described lithography work. The work had not involved any actual exertion in connection with the
work of pressing down the knife, or unvaried, elbow-loading work movements with for example
twisting of the elbow joint, even though leading of the knife had led to a certain static tension of the
musculature of the forearm.
Example 6: Claim turned down nerve squeezing of wrist and elbow (strenuous work without
pressure)
A man worked in a fish shop for 10 years. Every other week he drove a truck, handling up to 30-40,000
5-kilo boxes a day, but without substantial lifting load. Every other week he worked as a washer, lifting
about 5,000 5-kilo boxes every day, equivalent to 25 tonnes. This work was very strenuous, however,
29
and quickly repetitive. He developed pain in his right arm and was diagnosed with squeezing of a nerve
of the elbow and wrist/forearm (ulnar nerve).
The Committee found that the nerve squeezing of the wrist/forearm and elbow (ulnar nerve) was not
caused, mainly or solely, by work. This is because this disease, according to the present medical
knowledge, comes about after direct pressure impact on the nerves of the wrist/forearm. The work in
question had not involved such pressure.
Example 9: Claim turned down bilateral tennis and golfers elbow (social and healthcare helper)
The injured person developed complaints in both elbows after 12 years work as a social and healthcare
helper in home care. She was diagnosed with bilateral tennis and golfers elbow. The injured persons
work mainly consisted in personal care, cleaning, and shopping on behalf of the citizens. There were
varied tasks in connection with visiting the citizens. The injured person i.a. had to help with visits to
the bathroom, taking off support stockings, getting the citizens dressed, giving them medicine, serving
food, and transferring citizens to and from bed, toilet and wheelchair. It is estimated that for the major
part of the employment 30-40 handlings of persons were carried out per shift.
30
The work did not meet the list requirements for recognition of a tennis and golfers elbow under C.4.1
and C.4.2. The injured persons work involved occasional exertion in connection with handling of
persons, but the elbow was not under stress several times per minute for at least 3-4 hours a day. Nor
were there any awkward work movements or strenuous static work for at least half of the working day.
The Occupational Diseases Committee found that there was no medical documentation that a bilateral
tennis and golfers elbow might in general be caused by work as a social and healthcare helper. The
Committee also found that the injured persons bilateral tennis and golfers elbow had not been caused,
mainly or solely, by stresses in the workplace with 30 to 40 handlings of persons per day. The
Committee took into consideration that the injured persons work functions with care and cleaning
tasks had not involved sufficient elbow-stressing movements to cause the diseases.
Example 1: Recognition of rotator cuff injury (high-repetitive filleting work without force)
A woman worked as a filleting worker in a fish factory. The work consisted in filleting about 1 tonne of
fish per day with more than 30,000 cutting movements. She held the fish with her left hand while
leading the knife with her right hand with continuous, small movements of the right shoulder joint and
a fixated elbow and forearm, but without actual strenuousness of the shoulder. After well over 4 years
she developed pain in her right shoulder and a shoulder operation established degeneration of the
rotator cuff of the shoulder.
The Committee found that, even though there was no actual exertion of the shoulder, the numerous
small movements of the right shoulder joint, in connection with several years of filleting work, mainly
had caused the right-side rotator cuff injury because of the constant impact on the shoulder joint.
Example 2: Recognition of biceps and shoulder tendinitis (factory worker for 20 years)
A 52-year-old woman developed pain in her right shoulder and an orthopaedic examination established
tendinitis (inflammatory degeneration) of the biceps and supraspinatus tendon of her right shoulder. For
well over 20 years she had been employed as a factory worker in a factory producing hand saws. The
first 13 years she performed manual welding and worked at a screw table without any major stress on
her shoulder. For 7 years up to the onset of the disease, every second week, she performed the same
function as before. Every second week she fed a machine with saw blades and handles. This involved
many daily lifts of bundles and boxes weighing 11-12 kilos. The lifts were awkward for her shoulders
and the majority of the lifts were made at 60 degrees or higher, and here she had to turn and tip the
boxes. It was not possible to recognise the claim on the basis of the list. The stresses on the shoulder
had not occurred on a daily basis, but only every two weeks.
The Occupational Diseases Committee found that the biceps and shoulder tendinitis had developed
mainly as a consequence of the factory work. Every second week for 7 years she had been doing
shoulder-loading work, including heavy and high lifts when feeding handles and saw blades into the
machine, which increased the risk of developing a disease of the shoulder and upper arm.
Example 3: Recognition of bilateral degeneration of the rotator tendons of the shoulder (auxiliary
nurse)
After 20 years work as an auxiliary nurse the injured person developed increasing complaints from her
right shoulder joint and after another 9 years work the complaints were followed by left-side shoulder
complaints. She was diagnosed with degeneration of the rotator tendons of both shoulders (bilateral
rotator cuff syndrome). The injured person worked for a total of 30 years as an auxiliary nurse with
31
healthcare work involving many daily handlings and transfers of severely care-demanding and
immobile patients in nursing homes and hospitals respectively. Among other things, there were
handlings of patients with unsupported lifts between bed and chair; patients who were lifted to a
bedpan chair and then bathed in bathrooms with subsequent lifts to beds, as well as nappy change or
linen change for bedridden patients. There were about 80 patient handlings per shift.
The disease, bilateral rotator cuff syndrome, did not qualify for recognition on the basis of Group C,
item 5.1, the load requirements not having been met. The healthcare work set out led to strenuous
movements of the shoulder in connection with the many patient handlings, but there were no frequently
repeated shoulder-stressing movements. Nor was there any static lifting of the upper arm to about 60
degrees or more.
The Occupational Diseases Committee found that the injured persons bilateral rotator cuff syndrome
was mainly a consequence of the stressors while working as an auxiliary nurse with many daily
handlings and transfers of very care-demanding patients.
Example 4: Claim turned down rotator cuff lesion (low-repetitive work without exertion)
An operations engineer in a pharmaceutical factory worked for 3 years looking after a washing
machine for capped vials for insulin. In three daily shifts of 1.5 hours, or in total a little more than half
of the working day, he placed box trays with capped vials or pencil glasses on a tilting tray at shoulder
height. Then, with a spatula, he scraped the glasses down onto a tilting tray. He did the scraping down
of glasses with a quick movement, pulling his right arm downwards with the spatula, at the same time
pulling the box upwards with his left hand. This movement was made once per minute, equivalent to
270 movements distributed on the whole day. The remaining part of the day he checked capped vials in
light panels and placed them in boxes without any substantial stress on the shoulder. After 2.5 years he
developed pain in his right shoulder and was operated for a rotator cuff lesion.
The Committee found that the right-side rotator cuff lesion had not been caused, mainly or solely, by
the work as an operations engineer in connection with the washing function described above. The
Committee took into consideration that there had been a total of 270 high lifts of the right arm as well
as downwards, slanting, light pulling of glasses every day. The work had not been high-repetitive or led
to any exertion of the right shoulder joint. Therefore the work had not, mainly or solely, involved a
shoulder load that was so intense or strong that it constituted a particular risk of developing the
reported disease.
Example 5: Claim turned down nerve injury in shoulder and cervical degenerative arthritis (light to
moderate lifting work)
A man worked as a warehouse manager for about 30 years. The work was generally varied, but
involved moderate lifts amounting to about 2-4 tonnes per day. The typical single lifts were about 15
kilos, but heavier lifts of up to 50 kilos did occur. The lifts were not usually heavy lifts on the neck and
shoulder girdle. After 24 years work he developed pain in his neck and left shoulder. Examinations
showed signs of a nerve injury to his left shoulder, probably as a consequence of a sudden load pulling
at his shoulder (a traction lesion). In addition he was diagnosed with moderate degenerative arthritis of
the cervical neck.
The Committee found that the left-side traction lesion of the shoulder or the degenerative arthritis of
the cervical neck had not been caused, mainly or solely, by the many years of light to moderate lifting
work. The Committee took into consideration that there was no medical documentation that a nerve
injury in the shoulder or degenerative arthritis of the cervical neck might develop as a consequence of
32
the described exposures. Nor did a concrete assessment prove that the described exposures, in the form
of light to moderate lifting work without any particular direct loads on the shoulder and neck region,
constituted any particular risk of developing the reported diseases.
Example 6: Claim turned down rotator cuff lesion (no time correlation with stressful work)
A woman worked as a bookbinder for well over 20 years. The work involved many daily lifts of
encyclopaedias weighing up to 10-20 kilos and a total daily lifting load of 10-13 tonnes. In addition she
pushed paper together and handled large quantities of paper at a folding machine, often with her arms
above shoulder height and with twisting movements of the shoulder joint. She stopped work in 1987
and 8 years later she developed a bilateral rotator cuff syndrome. It was not possible to document
shoulder symptoms between the cessation of work and the onset of the disease 8 years later.
The Committee found that the bilateral rotator cuff syndrome had not been caused, mainly or solely, by
the shoulder-loading work as a bookbinder for 20 years. The Committee took into consideration that
there was no documentation of any time correlation between the stressful work and the development of
the disease 8 years after cessation of the exposure.
Example 7: Claim turned down bursitis and calcification of the shoulder (factory worker in a cooler
factory)
A 30-year-old woman worked for 4 years in a cooler factory, assembling auto coolers. She stood at a
table assembling the various elements for the cooler. A cooler weighed 1-6 kilos, and it appeared that
the work occasionally required lifts of the upper arms to shoulder level, one minute at a time. The work
also involved long reaching distances and a number of light lifts. She believed she had assembled 130-
140 coolers a day. After well over 3 years she developed pain in her right shoulder, and examinations
in hospital showed signs of beginning calcification of her right shoulder and furthermore a bursitis
(inflammation of a shoulder bursa). There were not, however, any signs of disease of the rotator
tendons of the shoulder.
The Committee found that the right-side bursitis and beginning calcification of the shoulder had not
been caused, mainly or solely, by the work. The Committee took into consideration that the described
loads did not increase the risk of developing the reported diseases. And there had not been any direct
and persistent pressure on the shoulder that might increase the risk of developing bursitis.
Example 8: Claim turned down shoulder pain (textile designer using CAD)
A 40-year-old female textile designer developed pain and stiffness/tenderness of her right shoulder.
Several medical examinations showed normal shoulder conditions, except for pain and tenderness. She
had worked for 5 years for a textile company where she had two different tasks which both took up half
of her time. One task was CAD drawing and setting up graphic colour cards for salesmen, for which
she used a CAD pen about half the time. The other task was to produce CAD drawings for textile
prints, and here she used a CAD pen for about 75 per cent of the time. Overall she used a CAD pen
approx. 20 hours a week. While drawing she had to lift her forearm from the table so it was not
supported.
The Committee found that the right-side shoulder pain had not been caused, mainly or solely, by
working as a textile designer. The reason was that diseases above elbow level after work with CAD pen
and PC mouse cannot be deemed to be work-related. This is because the upper arm, shoulder and neck
in connection with this type of work are not stressed in a way that substantially increases the risk of
developing a disease. To this should be added that she only used a CAD pen about 20 hours a week.
33
Example 9: Claim turned down bilateral degeneration of the rotator tendons of the shoulders (social
and healthcare assistant)
In 2005 the injured person began to develop pain in his right shoulder and immediately after pain in his
left shoulder as well. He was diagnosed with degeneration of the rotator tendons of both shoulders
(bilateral rotator cuff syndrome). Since 1981 the injured person had worked as an auxiliary nurse and
then as a social and healthcare assistant in a nursing home and hospital departments respectively. The
total employment period included work functions on a daily basis with 30 to 40 transfers of severely
care-demanding patients in connection with personal hygiene and bed baths, linen change and dress.
Furthermore the work included help at meals, writing of reports and operating the bells.
The disease, bilateral rotator cuff syndrome, did not qualify for recognition on the basis of Group C,
item 5.1 of the list, the requirements not being met. The described care work involved strenuous
movements of the shoulder in connection with handling of patients, but there were no frequently
repeated, shoulder-loading movements. Nor was there any static lifting of the upper arm to about 60
degrees or more.
The Occupational Diseases Committee found that there was no medical documentation that the injured
persons bilateral rotator cuff syndrome might in general have been caused by the work as a social and
healthcare worker. The Committee also found that the injured persons symptoms were not, mainly or
solely, caused by the work stress of 30 to 40 patient transfers on a daily basis. The Committee stressed
that the transfers and the assistance in connection with personal hygiene had not led to shoulder-
loading movements to an extent that would have been sufficient to cause the disease.
More information:
Associations between work-related exposure and the occurrence of rotator cuff disease and/or biceps
tendinitis (www.ask.dk)
Computer work and musculoskeletal disorders with physical findings of the neck and upper extremity
(www.ask.dk)
Carpal tunnel syndrome and the use of computer mouse and keyboard. A review (www.ask.dk)
Example 1: Recognition of tendon degeneration of knee (kneeling work for many years)
A floor fitter worked for 30 years in various firms. He typically had a working week of 60-70 hours,
and the work consisted in laying linoleum, wooden floors, floors in wet rooms and carpets in private
homes and in businesses. The total daily lifting of the various materials amounted to 2.5-3.5 tonnes.
The work was often done in stooping and awkward working postures. 60 per cent of the working time
was spent in kneeling work postures. After about 15 years he developed tenderness in both knees,
which was aggravated over time. He was subsequently diagnosed with calcification or cartilage
formation in the tendons of both kneecaps.
The Committee found that the tendon degeneration, in the form of calcification or cartilage formation
in the tendons of both kneecaps, had been caused mainly by many years of working as a floor fitter.
34
The Committee in particular took into consideration that there had been kneeling work for 60 per cent
of the working day for 30 years.
The Committee found that the hamstring syndrome had been caused mainly by playing intensive
football for a considerable length of time. The Committee took into consideration that there was some
medical documentation of a correlation between this disease and professional football, and that the
work led to considerable stress on the legs, which must be regarded as a special risk of developing a
muscular disease of this nature.
The Committee found that she suffered from an overuse syndrome in the flexion tendons of her left
ankle and foot, which had been caused mainly by many years of work as a ballet dancer which was
extremely stressful for the foot and ankle.
Example 4: Recognition of degenerative arthritis of the big toe (ballet dancer for 45 years)
A man worked as a ballet dancer with the Royal Theatre for about 45 years. The work involved
extreme physical foot pressures, including powerful jumps and half toe turns. He developed pain etc. in
his left big toe, and a medical specialist diagnosed him with degenerative arthritis of the metatarso-
phalangeal joint of his left big toe and severe deformation as a consequence of calcification around the
joint.
The Committee found that the degenerative arthritis and the deformation of his left big toe had been
caused mainly by many years work as a ballet dancer, which had been extremely stressful for foot and
toes.
Example 5: Claim turned down cartilage lesion of knee (twisting of knee joint)
A man worked for 5 years with packing and driving a truck in a slaughterhouse. Part of the time he
placed cartons on a pallet with a vacuum lifter, which he placed on top of the carton on a conveyor belt.
He then lifted up the carton, turned round with a twisting movement in his left knee and placed it on a
pallet. He did this work 4 days a week. He furthermore operated a stapler (an unsprung electric pallet
lifter) one day a week, driving over a bump 500 times a day. After 4 years he had pain in his left knee.
He had an arthroscopic operation which showed frayed cartilage at the back of his left knee.
The Committee found that the work in the slaughterhouse had not, mainly or solely, caused the
cartilage injury in his left knee. The Committee took into consideration that he had done pallet work 4
35
days a week and operated a stapler one day a week. The twisting of his knee in connection with pallet
work and driving over a bump many times a day with the stapler had not led to any pressure on the left
knee that was so significant that it could be deemed to constitute a special risk with regard to
developing a cartilage lesion.
More information:
Osteoarthritis in the hip and knee (www.ask.dk)
Is a jumpers knee work-related? A systematic review to find evidence for a possible case definition
(www.ask.dk)
36
The Committee found that the asthma mainly had been caused by exposures to substances in the
workplace. The Committee in particular took into consideration that the operator had been working
with glue with acrylate compounds, which is known as a potential cause of asthma.
Example 4: Recognition of irritated mucous membranes of nose and throat (coolants and oil)
A machine engineer worked for many years in a shipyard. He worked at a grinding machine,
manufacturing ship parts. The machine used coolants and lubricants for cooling stones and unit for
transporting away the dust. Normally the system was closed, but towards the end of the working period
a defect occurred in the machine so that the suction system blew the coolant and vaporised oil into his
face. The defect was corrected after 2 months. He developed complaints from skin, eyes and mucous
membranes, and a medical specialist diagnosed him with dry mucous membranes of nose and throat.
The Committee found that working with the defective grinding machine mainly had caused irritated
mucous membranes in nose and throat. The Committee took into consideration that the machine
engineer for 2 months had been exposed to direct contact with coolant and vaporised oil on his face.
Example 5: Recognition of chronically irritated mucous membranes of nose and sinuses and
perforation of the nasal septum (process operator exposed to dust from minerals and vitamins)
A 55-year-old man worked for well over 12 years as a process operator in a business manufacturing
mixtures of vitamins and minerals as additives to food. For the longest period of time, his work
consisted in weighing out raw materials and producing and weighing out mixtures. Despite having an
exhaust system and mechanical ventilation he was unable to avoid dust from i.a. lemon acid, foline
acid, carbonate, potassium iodine, etc. After some time he developed dryness and irritation in his nose,
which typically became evident during the weighing-out work. A medical specialist found that he had
developed a hole in the nasal septum as well as chronically irritated mucous membranes of nose and
sinuses.
The Committee found that the process operator mainly had developed chronically irritated mucous
membranes in his nose and sinuses with subsequent perforation of the nasal septum due to his work,
where he had been exposed to dust from various minerals and vitamins.
The Committee found that due to exposure to welding smoke the welder mainly had developed
considerable aggravation of a private, pre-existing asthma. It was included in the assessment that heavy
welding smoke can trigger asthma in a person who is sensitive beforehand and has a private disposition
for developing asthma. When calculating the compensation for permanent injury and loss of earning
capacity, the National Board of Industrial Injuries may make a deduction in the compensation to the
37
extent that the private disposition for asthma can be deemed to be a contributory cause of part of the
asthma disease.
Example 7: Claim turned down lung fibrosis (grinding dust from metal and grinding agents)
A man worked for many years as a metal grinder. For 10 years he worked with hand grinding of fittings
for kitchen sinks and bathrooms. Here he was exposed to grinding dust from brass and stainless steel
and various grinding agents. He developed reduced lung function and a medical specialist diagnosed
him with lung fibrosis.
The Committee found that the lung fibrosis had not, mainly or solely, been caused by the described
exposure to grinding dust and grinding agents. The Committee took into consideration that the cause of
the lung fibrosis in the concrete case was unknown, and that the rather sudden onset and quick
progression of the disease made it unlikely that there should be any correlation with the many years of
exposure to metal dust. The lung disease you would typically see after many years of exposure to metal
dust is pneumoconiosis, and x-rays and tissue microscopy showed no signs of that disease.
Example 8: Claim turned down indoor air quality symptoms (poor ventilation and micro fungi in
school
A woman worked as a school teacher for more than 20 years. Already a short while after she was
employed she began to develop symptoms of dryness of throat, eyes and nose, dizziness, headaches,
eczema, concentration problems, etc. She furthermore experienced immunodeficiency and had an
increasing number of sickness periods. There was no general improvement after the school moved to
other premises 15 years after she started work there. A medical specialist diagnosed her with indoor air
quality symptoms.
The Committee found that the work as a teacher in the buildings in question had not, mainly or solely,
caused a disease related to indoor air quality. The Committee found that it was not a specific disease
caused by indoor air quality exposures, including micro fungi exposure. The Committee found that she
suffered from indoor air quality symptoms, which is a diffuse system complex with symptoms such as
dryness and irritation of mucous membranes of eyes, nose and throat, dry skin and unspecified general
symptoms, such as headaches, fatigue, or reduced concentration ability. Scientific surveys have shown
an increased frequency of these symptoms in relation to certain indoor air quality conditions, i.a.
maintenance level and building materials. There is uncertainty as to the significance of micro fungi, but
a few reports raise the suspicion that massive growth of micro fungi may be a contributing factor. The
documentation in the field is uncertain, however. In the teachers case there was no evidence of any
physical, pathological changes that might form the basis for the diagnosis of indoor air quality
symptoms, and it was not possible to document any allergic or equivalent reaction to fungi or other
exposures.
Example 9: Claim turned down chronic obstructive lung disease/bronchitis (waiter exposed to passive
smoking)
For 23 years a 42-year-old man had worked as a waiter and occasionally as a cook in several hotels.
About half of the 23-year-period he was exposed to extensive passive smoking in restaurants and bars
with poor ventilation. It appeared that the waiter was a never smoker and that the spouse was a no
smoker as well. In childhood he was exposed to passive smoking through his father, who smoked 15
cigarettes per day. Towards the end of the period he developed coughing and shortness of breath and in
a lung function examination was diagnosed with chronic obstructive lung disease (bronchitis) with a
certain asthma element.
38
The Committee found that the work and the exposure to passive smoking for a number of years had
not, mainly or solely, caused the chronic obstructive lung disease (bronchitis). The Committee took
into consideration that there is no known medical correlation between exposure to passive smoking and
the development of chronic, obstructive lung disease (bronchitis), and that there was no description of
any concrete circumstances in the workplace that might be regarded as significantly increasing the risk
of developing the disease in question.
Read more about the practice of the Occupational Diseases Committee with regard to chronic
bronchitis after exposure to passive smoking. (www.ask.dk)
Example 2: Recognition of pharynx cancer (welding fumes, asbestos dust and other substances in a
shipyard)
A man worked for 18 years as a shipbuilder in a steel shipyard. The first 5 years he worked with
handling of steel plates. Half of the time was spent torch cutting or welding. Much of the work was
done in ships tanks with limited ventilation. The next 13 years he worked with repairs in a floating
dock. He i.a. removed insulation material (polyuretan foam), and then he removed with a cutting torch
a black, pitch-like material from the underside of the plates. Then he welded on new plates. Several
times a day the polyuretan foam caught fire. In addition he occasionally worked with stainless steel.
There was sometimes asbestos dust in the room in connection with piping work. He seldom took part in
39
this, however. 5 years after cessation of work he developed swelling and hypersensitivity (tickling
cough). He was then diagnosed with cancer on the left side of the pharynx/left tonsil (tonsil cancer).
The Committee found that the pharynx cancer had been caused mainly by working for 18 years in a
steel shipyard. The Committee took into consideration that the ship builder had not been a smoker or
had any substantial alcohol consumption, factors which are known causes of this rather rare type of
cancer. He had suffered a number of risky exposures in the workplace for some time, even though the
research into causalities, and thus the medical documentation in the field, was limited.
Example 4: Recognition of breast cancer after night-shift work (nurse for 21 years)
A 57-year-old woman was diagnosed with cancer in her left breast and underwent an operation to have
her breast removed. She subsequently received radiotherapy and chemotherapy. When the disease set
on, she had worked in a hospital for 21 years as a nurse. She had had 24-hour shifts and combined
evening/night shifts stretching from 13:00 till 07:30. Almost over the whole period she had 3 night-
shifts per week. Previously, in other employments as a nurse, she had had night-shifts once or twice a
week for about 10 years. In connection with this case the National Board of Industrial Injuries obtained
an assessment from an expert from the Danish Cancer Society, from which the following appeared.
There are many types of shift work, but those including recurring night work seem to cause the most
significant upsets in the natural, biological circadian rhythm.
The claim was recognised after submission to the Occupational Diseases Committee.
Against the background of the current research on breast cancer and night shift work, including in
particular a survey report from 2013, the Committee has set up a practice for recommending
recognition. According to practice, the Committee will in principle recommend recognition of a claim
if the person in question has worked many hours during the night (between 23:00 and 06:00) for at least
25-30 years and at least once a week on average. Thus this is seen as a substantially increased risk of
developing breast cancer. There may possibly be an increased risk of developing breast cancer in
connection with several night shifts per week in relation to one night shift per week. A majority on the
Committee therefore found that several night shifts per week will also in future be included in the
assessment of the concrete claim and may be in favour of recognition despite less than 25 years of night
shift work. There must not be any clear competitive causes of the disease. On the basis of this practice
the Committee decided that the nurses left-sided breast cancer was caused mainly by the recurrent
night-shift work (section 7(1)(ii)). The Committee took into account that the nurse had had night work
more than once a week for more than 20 years and that there was no information of other substantial
risk factors that might explain the development of the disease.
Example 6: Recognition of cancer of the bladder (plumber exposed to soot and PAHs from ships
boilers)
For a period of approximately 23 years, a 63-year-old plumber had suffered daily and occasionally
substantial exposures to soot from oil-fired plants in connection with supervising and repairing boilers,
primarily ships boilers. In the course of the first 15 years, he did not wear respiratory protection when
working on the boilers. But the safety measures when working abroad after the said period were also
described as insufficient. At the beginning of 2008 the plumber was diagnosed with cancer of the
bladder, which was treated by removing his bladder and inserting an artificial bladder. An expert
assessment made by the Cancer Society showed that soot from burning of organic substances,
including coal and oils, had a high content of polycyclic aromatic hydrocarbons (PAHs), which would
increase the risk of skin as well as lung cancer. A more recent examination of the scientific literature in
this field furthermore showed that many years of substantial exposure to soot also increases the risk of
cancer of the bladder by as much as 2-2 times the normal risk. The plumber had never been a smoker,
and there was no information of any other exposures that might be suspected of increasing the risk of
cancer of the bladder.
The Committee found that the plumbers cancer of the bladder had developed mainly as the
consequence of many years of close contact with PAHs (polycyclic aromatic carbon hydrides), which
are under strong suspicion for being able to cause cancer of the bladder, and that there was no
information about competitive risk factors in the case.
Example 7: Claim turned down breast cancer (hairdresser exposed to chemical substances and
vapours)
A 46-year-old woman had worked as a hairdresser for a little less than 30 years. For about 50 per cent
of the time her work consisted in hair cutting. For another 50 per cent of the time she had tasks such as
washing of hair, colouring, highlights, and perms, using a broad variety of hairdressers chemicals. She
only wore gloves towards the end of the 30-year period, when she was diagnosed with cancer of her
right breast with spreading to the lymph nodes. She had an operation where the cancer tumour and the
lymph nodes were removed and subsequently received radiotherapy and chemotherapy as well as anti
estrogen treatment. She has not had a relapse for 3 years but still goes to check-ups. In connection with
the processing of the claim the National Board of Industrial Injuries obtained an expert assessment
from a consultant and head of research with the Cancer Society on general documentation of causalities
in the field and a concrete assessment of the case in question. The expert assessment concluded that
there is not at present any knowledge of substances or products in the hairdresser business that may be
scientifically linked with breast cancer. The disease may furthermore have a number of other causes
unconnected with work including hormonal factors, hereditary disposition, lifestyle, and environ-
ment. The latest research results in the field indicate that there may be a slightly to moderately
increased risk of developing breast cancer after hairdresser work, in particular after more than 10 years
work within the trade. The results are not clear, however, and it is not yet possible to point to concrete
causalities for specific substances etc. in the trade. Against this background the expert assessment
found it to be likely beyond reasonable doubt that the disease had been caused by other factors than
work.
The Committee found that the breast cancer had not been caused, mainly or solely, by the many years
of work. The reason was that the disease may have many different causes unrelated to the working
42
environment and that it cannot be presumed at present that the hairdresser has suffered exposures in her
work as a hairdresser which would substantially increase the risk of developing breast cancer.
More information:
Review of nightshift work and risk of breast cancer, 2013 (www.ask.dk)
Example 2: Recognition of stress response (home help exposed to media coverage of neglect of a
client)
A 54-year-old woman affiliated with a municipal nursing facility had worked as a home help for a
number of years. Over the years she had been exposed to a number of very unpleasant deaths among
various clients. These did not, however, cause any mental discomfort. Towards the end of the
employment period she looked after an elderly man in his flat. The man, who was mentally ill, had
developed a very aggressive behaviour after a brain haemorrhage and hit and spat at the helpers. He
was locked up in his flat upon the demand of the local authority and was in general very loud and
noisy. The neighbours therefore contacted the media, and national television covered the story for
several days. The TV station filmed the staircase where he lived and described the local authoritys
handling of the mentally ill citizen as neglect and power abuse. The home help appeared several times,
involuntarily, in the coverage. Even though her face was partly blurred, she was subsequently contacted
by relatives and friends who were wondering about her working for the local authority and the
described way of handling a mentally ill citizen. Following these events she developed an unspecified
stress response with depressive elements.
The Committee found that the home help had developed an unspecified stress response mainly as a
consequence of her work. The Committee took into consideration that as an employee of the local
authority and carer of the person in question she was exposed to very unpleasant and mentally stressful
television coverage. The local authority and the home help were accused of power abuse and neglect,
and she was recognised by the surroundings and confronted with her part in the events.
Example 3: Recognition of stress response (verbal/physical threats and attacks by a big boy)
A woman worked for 4 years in an after-school day-care facility with severely disabled children. The
last 3 years she looked after an 11-year-old boy who was severely affected by DAMP disorder. The boy
was big and stocky. He was violent and threatening, verbally and physically, and there were
43
descriptions of several actual attacks. A medical specialist diagnosed her with a severe degree of
periodic depression.
The Committee found that the mental symptoms were consistent with a stress response. The Committee
furthermore found that the mental illness had been caused mainly by working as a day carer. She had
been exposed for a long time to verbal and physical threats as well as direct physical attacks from a big
boy suffering from DAMP disorder.
Example 4: Recognition of stress response (direct and indirect violence from mentally disabled
persons)
A 46-year-old woman worked for 2-3 years as a qualified day carer in an institution for mentally and
physically disabled adults. The residents were often extrovert reacting, and it appeared from internal
injury reports that she had been hit on the body by several residents. The blows were often of a sudden
and unexpected nature, but she had never felt in mortal danger. A lot of times the residents had hit out
at her and missed, and they had for example pulled at her hair. She gradually developed mental
symptoms with depressive elements and had anxieties about going to work. A specialised psychiatrist
diagnosed her with unspecified stress response.
The Committee found that the qualified day carer had developed an unspecified stress response mainly
because of her work with extrovert reacting mentally and physically disabled adults. The Committee
took into consideration that there was documentation of a number of mentally stressful events,
involving direct and indirect (threats of) violence, which significantly increased the risk of developing
the disease in question.
44
The Committee found that the female prison guard had developed a depression mainly as a
consequence of the ongoing sexual advances and offences for a prolonged period of time. The
Committee took into consideration that the employer was able to confirm the incidents and that three
colleagues had experienced similar incidents.
Example 7: Recognition of stress response (parking guard exposed to violence and threats)
A 36-year-old woman worked for 6 years as a parking guard in Copenhagen. The work led to a number
of violent incidents with verbal and physical attacks. She was exposed to threats that she would be
trashed, persecuted, kicked in the face, killed with a club and run down by a car. Furthermore she
experienced being spat on, in the eye and on her clothes. People threw eggs at her, and she did
experience being persecuted and that someone attempted to run her down in a car. After some years she
developed sleep problems and became increasingly irritable. After someone tried to run her down her
symptoms increased, and she had increasing problems with lack of energy, concentration problems,
irritability, sleep problems and a tendency to isolate herself. A specialised psychiatrist made the
diagnosis of personality change caused by catastrophic experiences.
The Committee did not agree with the specialised psychiatrists diagnosis. The experiences described
were not of such an extremely stressful nature as to give grounds for the diagnosis of personality
change caused by catastrophic experiences. They did, however, find that the described mental
symptoms were consistent with a stress response.
The Committee furthermore found that the stress response had been caused mainly by the mental
stresses in her work as a parking guard. The Committee took into consideration that she had been
exposed to violence as well as threats of violence, including threats on her life and attempts at running
her down in a car.
Example 8: Recognition of depressive single episode (teacher exposed to severe harassment and
bullying, including sexual harassment, from students)
A woman worked for a few years as a teacher in a municipal school. In the course of the last year she
was repeatedly exposed to verbal and physical abuse from the students. One instance was when half of
the students did not turn up for class and the remaining students mocked her and used deprecating
terms, pushed her, and were very unruly. She also experienced an episode where a student touched her
on the breasts and another where a student drew with a felt pen in her crotch area. Furthermore she
experienced an incident where a student was sexually harassed by three boys in a school toilet without
any intervention on the part of the school management. Finally she experienced how the parents did not
back her up, called her all sorts of names and did not show up at for meetings planned to solve the
problems. In one instance a student had threatened, in an email to another student, to kill her. The
school was only able to verify a few of the incidents described, one being a student expelled from class
because of unruly behaviour. However, colleagues were able to testify that there was a bad work
environment with a lot of unrest and poor backing from management. She eventually developed mental
symptoms in the form of anxiety, invasive thoughts, concentration problems, hyper sensitivity to noise,
sleeping difficulties and isolation problems.
The Committee found that, mainly as a consequence of her work, the teacher had developed a mental
disorder in the form of a depressive single episode, having been exposed to deprecating remarks, an
unpleasant mail, and sexually loaded comments and actions on the part of some pupils.
Example 9: Recognition of unspecified stress reaction (nurse exposed to severe harassment and
bullying from her medical superior and colleagues)
45
A nurse worked for 5 years in a medical department in a hospital. Towards the end of the period she was
asked by a consultant to commit active euthanasia by giving a very sick patient a painkiller overdose. She
could not carry out the order and some days later she anonymously reported the incident to the Danish
Patient Safety Database. She could not, however, bring herself to report the consultant to the police, even
though she was encouraged to do so. A short while later the consultant summoned a crisis meeting in which
he called her a liar. He produced a copy of the anonymous report to the Danish Patient Safety Database and
at the same time indicated that she had reported him to the police. The consultant subsequently criticised her
way of co-operating and several colleagues took his side and became abusive towards her. The nurse
experienced that co-operation deteriorated and that she was ostracized by the consultant and several others in
the department. Other doctors furthermore signed a letter to management in which they stated that they were
unable to co-operate with her. Several crisis meetings were held without any result, and in a meeting where
the consultant was supposed to withdraw his accusations things got completely out of hand. The nurse was
severely abused and taunted. A short while after the meeting she had to take sick leave because of a mental
breakdown. In this period she also learned that other people outside the hospital, including a doctor whose
children were in the same day-care facility as her own, had heard about the conflict from the opposing party.
A psychiatric specialist made the diagnosis of adjustment reaction.
The Committee did not agree with the medical specialist that the symptoms were consistent with an
adjustment reaction. The Committee found, however, that the nurse had an unspecified stress response and
that this disease had mainly developed due to her work as a nurse. In the workplace she had been exposed to
frequent, severe bullying and harassment for a long period of time from a medical superior and colleagues.
Example 10: Recognition of aggravation of pre-existing posttraumatic stress response (prison officer
accused of leaking confidential information to inmates)
After well over 1 years work in a prison, a 41-year-old female prison officer was summoned to an official
interview where she was accused of having leaked information to an inmate. Colleagues had informed
management that they had seen an inmate standing behind her, reading on her PC monitor. She was
furthermore accused of having shown some papers to an inmate. A colleague had also heard an inmate say
about another inmate that he would know more, once the female prison officer came to work the next day.
She was furthermore accused, after a violent incident, of having visited an inmate in a section where she did
not work, and of having stayed there for 10 minutes. She was later sought out by two police officers who
questioned her about accusations that she had passed confidential information to inmates, including
information on when there would be searches in the prison, thus giving them the time to hide forbidden
things. However, the head of police decided to suspend the case as there was no reasonable assumption that
any criminal offence had been committed. The woman had previously developed a post-traumatic stress
response as a consequence of an incident of serious threats from an inmate. This incident had already been
recognised as an accident at work. In connection with the accusations in the workplace her symptoms
reappeared, including anxiety attacks, nightmares and flashbacks, avoidance symptoms, lack of energy,
vigilance, isolation tendency and sleep problems as well as concentration problems.
The Committee found that the prison officer had suffered a substantial aggravation of her previous post-
traumatic stress response mainly as a consequence of her work. The Committee took into consideration that
she had been exposed to events of a mentally stressful nature, having been accused of passing confidential
information to prison inmates, and having undergone a stressful process with an official interview and
interrogation by the police, with the final result that the investigation was given up as groundless.
Example 11: Recognition of depression after threats (train inspector for 8 years)
46
A 34-year-old woman had worked as a train inspector for well over 8 years when she developed a
severe depression. Before this, in the course of the 8 years, she had been exposed to repeated, serious
threats from passengers who had not bought a ticket and who reacted aggressively when faced with the
prospect of having to pay a fine, and from drunk or otherwise aggressive passengers. In connection
with the onset of the disease she experienced threats from a passenger who had not bought a ticket and
would have to pay a fine. The passenger became very aggressive, made verbal threats, and hit out at
her.
The Committee found that the train inspectors depression had come about mainly as the result of
several episodes of serious threats from passengers in the course of an 8-year period.
Example 12: Recognition of anxiety attacks (mine sweeper in Bosnia and Eritrea)
A 33-year-old man was diagnosed with anxiety attacks after he had been stationed several times from
1995 to 2000 as a mine sweeper, first in Bosnia and then in Eritrea. In 1996, in Bosnia, he experienced
several severe deaths when a patrol vehicle hit a mine, and he furthermore worked with mine sweeping
and experienced the danger involved in this kind of work. In 2000, in Eritrea, he experienced a severe
death when a boy was run down by a tank truck. He tried to help the boy, but to no avail. At the same
time he was being surrounded by screaming women and feared that he might be blamed for the
accident. His disease developed over time, but he did not see a psychologist until 2003, when several of
his mates had been killed in an accident in Kabul in Afghanistan while he himself was back in
Denmark. He was there to receive the killed and the wounded and went to see the parents of the
deceased, together with army representatives. By that time there was a very severe outbreak of his
disease. The Danish Defence verified the described accidents in Bosnia, Eritrea and Afghanistan.
The Committee found that the mine sweeper had developed anxiety attacks mainly as a consequence of
the severe and mentally stressful incidents he had been part of, in particular in Bosnia and Eritrea
where he was directly involved and felt under threat.
Example 13: Recognition of unspecified stress response after sexual harassment (office worker)
A 54-year-old female office worker developed an unspecified stress response with effects such as
anxiety, sadness, lack of energy, sleeping problems and isolation tendency after experiencing sexual
harassment from a middle manager at work. The middle manager had on several occasions made sexual
comments towards her and the other female employees and had on several festive occasions fondled
her and others. During a lunch meeting in the city with the rest of the staff the middle manager touched
her under her dress and she had to push him away. Two colleagues confirmed the incident and later a
settlement was reached in the workplace.
The Committee found that the office worker had developed an unspecified stress response mainly as a
consequence of sexual advances made over some time, culminating with offensive fondling during a
lunch meeting.
Example 14: Recognition of depressive single episode (manager exposed to severe harassment and
threats)
After severe harassment from an employee, in her capacity as manager of a job centre, a 45-year-old
woman developed depression with sadness, irritability, memory problems, reduced concentration and
low self-esteem as well as sleep problems. She experienced thefts in the workplace, also of some of her
things, which were found with the relatives of the employee in question. Subsequently she and her
daughter received severe threats on the phone from the employee in question, and later the employee
received a judgement because of this.
47
The Committee found that the depressive single episode had been caused mainly by repeated instances
of severe harassment and threats from an employee in the job centre.
Example 16: Claim turned down mental illness (work environment and child pornography
accusations)
A man worked for about a year as a skilled day-carer in an after-school day-care facility. He described
a mentally unfavourable working environment and co-operation difficulties. He was furthermore
accused of having downloaded child pornography on one of the institutions computers. He was
questioned by the police and the case was mentioned a lot in the press. Later the police dropped the
charges made against him. He felt mentally unwell and was diagnosed with post-traumatic stress
response.
The Committee found that the mental illness was not, solely or mainly, a consequence of the described
stresses in the workplace. The Committee took into consideration that the described co-operation
difficulties and the mentally unfavourable working environment could not be deemed to have been
stressful to such a degree that it involved a special risk of developing mental illness, including a post-
traumatic stress response. Any mental disorders caused by the charges of downloading child
pornography could not, according to the Committees assessment, be regarded as a consequence of the
work.
Example 17: Claim turned down unspecified stress response (office worker exposed to sexual
harassment)
An office worker was for a long time exposed to mental and sexual harassment from a superior and
eventually developed an unspecified stress response. She i.a. told how the manager hinted at sexual
subjects and fondled her very intimately on several occasions. Once when they were out driving, the
manager allegedly stopped the car, pulled her towards him and fondled her. Over a 5-year period,
according to the office worker, there were at least 20 episodes of sexual harassment. Furthermore she
felt that she was being socially excluded from the office, bullied and prevented from doing her job.
As the information from the office worker and the employer did not coincide and it was not possible to
verify the incidents in any other way, the National Board of Industrial Injuries requested that the Legal
Advisor to the Danish Government (Kammeradvokaten) should interview the parties to the case.
This did not, however, lead to any additional information that might document the events in question.
48
A majority on the Committee found that the office worker had developed an unspecified stress
response mainly as a consequence of protracted sexual harassment from a manager in the workplace.
The majority on the Committee took into consideration that the office worker had described many
instances of offensive and excessive sexual harassment over time and that there was good correlation
between this information and the development of a mental disorder. There was no emphasis on any
factors that were directly contrary to the information from the office worker, even though it was not
possible to provide specific documentation of the incidents described. A minority on the Committee
found that there was insufficient documentation of the incidents. The claim was recognised by the
National Board of Industrial Injuries as a majority on the Committee had recommended recognition of
the claim.
The National Social Appeals Board turned down the claim and thus changed the decision made by the
National Board of Industrial Injuries. The Appeals Board took into consideration that the incidents of
sexual harassment described were not sufficiently documented, nobody in the workplace being able to
verify them. Therefore the National Social Appeals Board found that circumstances in the workplace
had not, mainly or solely, led to the unspecified stress response.
More information:
Review report on stress and mental disorders (www.ask.dk)
Example 2: Recognition of ischaemic heart disease/blood clots in the heart (bus driver for 15 years)
A 57-year-old bus driver suffered two blood clots in the heart within a very short period of time and
subsequent examinations established poor blood supply to the heart musculature (rest ischaemia). He
had a balloon angioplasty and was diagnosed with coronary artery heart disease. He was a non-smoker
and there was no information of other substantial private factors that might increase the risk of
developing ischaemic heart disease. For 7 years prior to symptom onset he had worked as a bus driver
with a company where the working conditions were very stressful. There were poor working conditions
with long driving times and few breaks and no sticking to timetables. This led to anger among the
passengers, and the anger was directed at him. Furthermore the maintenance of the buses was very
49
poor, and they frequently broke down during the workday. There were sudden changes in the timetable,
poor planning of shifts, and sudden driver replacements during shifts. Finally his notice period was
suddenly reduced from 6 months to 14 days. For some time he furthermore had to pee behind the bus
because there were no toilet facilities and not enough time in the timetable to use a toilet anyway.
The Committee found that the ischaemic heart disease had developed mainly as a consequence of his
work. The Committee took into consideration that for more than 5 years the bus driver had experienced
long-term and persistent high demands in combination with lack of support in the workplace, i.a. with
buses frequently breaking down due to poor maintenance, and no sticking to timetables so that the
passengers got upset. Furthermore there were many changes in the timetables, which led to poor work
planning with inexpedient driver replacements in the middle of the route and increasingly longer shifts
where he had to sit in the bus without a break.
Example 3: Recognition of inflammation of the eyes (washing of wheels with chemical substances)
A 59-year-old woman worked in a wheel factory, where for some months she had to manually degrease
the wheels. For this she used Klensol 112, a cleaning product containing glycol, alcohol, and methyl-2-
pyrrolidone. In connection with this work she had a severe reaction from her eyes, and a specialist of
occupational medicine made the diagnosis of passing eye irritation (conjunctivitis purulenta tox.prof.)
The Committee found that the eye disease had been caused mainly by work. However, the Committee
took into account that, prior to the onset of her eye disease, she had to wash and degrease a number of
rims and wheels, and that she used a brush, dipping it in a bucket containing Klensol 112 K mixed with
water. The Committee in particular took into consideration that Klensol 112 K contains methyl-2-
pyrrolidone and that this substance is a local irritant.
Example 6: Claim turned down itching skin (stationing in Kuwait/Iraq, using malaria medicine)
A 38-year-old, male employee of the Danish Defence Force was for two periods of approximately 6
months stationed in Kuwait and Iraq. During the stays he developed itching and a reddish rash on his
chest, which got worse when exposed to the sun. It appeared that he took malaria-preventive medicine
in the form of chlorokin phosphate, but that he stopped doing this as the skin disorder got worse. Some
years after the stationing a specialist of skin diseases found that the skin was slightly thickened on his
chest (hyper keratosis) and that he had skin irritation (dermal inflammation), but the degeneration could
not be diagnosed more specifically, and after some years the skin was normal again.
The Committee found that the itching skin problems had been caused, mainly or solely, by being
stationed twice in Kuwait and Iraq. The reason was that it was not possible to point to a likely
correlation between the itching skin and particular exposures during the stationing. Nor was it likely,
from a medical point of view, that there was any correlation between the use of chlorokin phosphate
and the described skin problems.
The Occupational Diseases Committee is appointed by the Minister for Employment, who appoints the
Chairman of the Committee and eight members (appointed for 3 years at a time). In addition there are
deputy members.
The Chairman is appointed after a recommendation made by the National Board of Industrial Injures.
The eight members and deputy members are appointed by the following parties, the number of
members stated in a parenthesis: The National Board of Health (1), the Working Environment
Authority (1), the public employers (1), the Salaried Employees' and Civil Servants' Confederation (1),
the Danish Employers Confederation (2), the Danish Confederation of Trade Unions (2).
The Occupational Diseases Committee makes advisory statements to the National Board of Industrial
Injuries regarding
The National Board of Industrial Injuries can furthermore obtain from the Committee advisory
statements on questions pertaining to occupational diseases. The Committee can furthermore call in
special experts to participate in the meetings as advisors.
51
The Occupational Diseases Committee forms a quorum when the Chairman and at least one member
appointed by each of the employer/wage earner organisations and one of the other members are
present. Furthermore there are rules regarding legal incapacity which have the effect that a member of
the Committee cannot participate in the processing of claims in which the member has a special
interest.
In practice the Committee meets at least once a month to take a position on concrete claims regarding
occupational diseases, and sometimes they meet more often than that. Besides there are regular
meetings about principal discussions of various fields of occupational diseases and about the revision
of the list, which must take place at least once every two years.
Minutes are made of the meetings of the Committee and of meetings regarding concrete cases. The
National Board of Industrial Injuries acts as secretariat to the Committee. This involves writing drafts
for the Committees recommendations in concrete cases which are subsequently discussed on the
Committee.
52
Chapter 2. Hearing disorders
List of contents
53
1. Noise-induced loss of hearing (A.1)
The following hearing disease is included, according to the stated exposure, on the list of occupational
diseases (Group A, item 1):
Disease Exposure
A.1. Noise-induced loss of hearing Severe noise for several years
(DLA professionalis)
The diagnosis must have been made on the basis of a characteristic audiogram and information on
exposure to severe noise in the workplace for at least 5 years.
An audiogram shows measurements of the hearing threshold at different frequencies. The hearing curve
is found by connecting the points. An audiogram states in decibel hearing level (dB HL, called dB
below) the lowest audible level for each stated frequency. Normal hearing thresholds are less than or
equal to 20 dB across the entire frequency area.
Sound arises when air molecules are made to vibrate in time. When the molecules move, the air in front
of them is compressed (pressure increase), and the air behind them is made thinner decreased
pressure. It is only the vibration energy that spreads. The number of sound waves per second is called
the frequency and is measured in Hertz (Hz). 1,000 Hz is equivalent to 1,000 sound waves per second.
The bass region is the region up to and including 500 Hz, the middle region goes up to and includes
2,000 Hz, and the treble region goes up to and includes 8,000 Hz.
Symptoms
The person in question experiences a decreased perception of sound, but not necessarily a decreased
perception of speech or an actual hearing and communication impairment. A hearing and commu-
54
nication impairment is a loss of hearing that affects the ability to communicate in active daily life. An
assessment of the hearing and communication ability is used for determining compensation for
permanent injury, but not in connection with the question of recognition.
The difference between hearing loss and hearing impairment exists because it is the frequencies 4,000-
6,000 Hz that are first damaged by exposure to noise. The prevailing part of the spoken sound
information in the frequency area is under 4,000 Hz. Damage in the frequency area 4,000-6,000 Hz
therefore leads to limited problems with regard to the perception of speech.
Objective signs
Continual exposure to noise typically leads to a dip most pronounced at 4,000 Hz. Impulsive noise
leads to a dip most pronounced at 6,000 Hz. After several years of exposure to severe noise quite a
considerable group will have developed a minor hearing loss at 4,000 Hz. After exposure for some time
this damage is aggravated and other frequencies are affected. The poorest hearing threshold must be
lower than 20 dB as it would otherwise be a hearing threshold within the normal range.
For a noise-related dip the hearing threshold at 4,000 Hz is lower than at 3,000 Hz. At 2,000 Hz there is
only an effect after up to 20 years exposure to noise, and therefore the hearing threshold should always
be better than at 3,000 and 4,000 Hz. For persons younger than 65 years the hearing thresholds for
higher frequencies should likewise be better than at 4,000 or 6,000 Hz. Graphically the hearing curve
will usually be normal up to and including 2,000 Hz and have a characteristic V-shape, with an apex at
4,000-6,000 Hz. After noise exposure for a very long time, high-frequency measurements like 2,000-
3,000 Hz are affected, and partly due to age degeneration (see the paragraph on competitive diseases
below) the curve will tend to move unilaterally towards treble.
A steep fall from 1,000 Hz or a dip at 3,000 Hz is due to other hearing diseases than noise-related
hearing loss.
As a very important main rule there must be a symmetric hearing loss as long-term exposure to noise is
usually consistently bilateral. If there is only a hearing loss on one ear, therefore, this would normally
not be in favour of recognition.
For much severer noise the time limit for the daily noise exposure can be reduced. The requirement for
at least 5 years noise exposure cannot be reduced.
Hearing loss can for instance be hereditary or caused by other illness or by other environmental
exposures, for instance noise in a persons leisure time. Hearing loss is often age-related. In a number
of cases the cause of the hearing loss is unknown. In the event of hearing loss that is not noise-related it
is either a pre-existing disease that existed prior to the work exposure, or a competitive disease, i.e.
another disease than noise-induced hearing loss showing the same audiogram fluctuations, or a hearing
loss that is a consequence of other causes or exposures not related with the work.
If there is a pre-existing or competitive disease or there are competitive causes of the development of
the disease, it has to be assessed, in each specific case, whether the pre-existing or competitive disease
or the competitive exposure is the only or the main cause of the disease. If this is the case, the disease
does not qualify for recognition as a work-related disease.
If the general and special conditions for recognition are met and there are no competitive or pre-
existing diseases or competitive exposures that are the full or the main cause of the disease, the disease
will qualify for recognition as a work-related disease if it otherwise meets the requirements for
recognition.
If there are competitive or pre-existing diseases or competitive causes or exposures that do not exclude
recognition of the disease as an occupational disease, but contribute to the development of the disease
and the complaints, such factors may have an effect on the amount of the compensation. (Section 12 of
the Act).
If there is a complete hearing loss, we usually do not recognise the claim, even if the exposure to noise
meets the requirements. Thus exposure to noise cannot lead to a complete loss of hearing. The hearing
loss therefore must be deemed to be a consequence of a competitive cause.
Tinnitus
Tinnitus (ICD 10, H93.1) occurs without hearing loss, but in persons suffering from a hearing loss
tinnitus appears more frequently than in the population as a whole.
Therefore, under the Workers Compensation Act, if there is tinnitus and a noise-induced hearing loss
at the same time, tinnitus is deemed to be a consequence of the noise-induced hearing loss. This means
that a hearing loss which is not in itself sufficient for a permanent injury rating of 5 per cent may be
rated, in combination with severely uncomfortable tinnitus, at 5 per cent or more.
56
Competitive hearing diseases are deemed to be relative causes of tinnitus. For a small hearing loss with
a substantial competitive hearing disease the competitive disease must be deemed to be the cause of
tinnitus.
In order for tinnitus to be regarded as a consequence of a noise-related hearing loss, tinnitus must be
established not later than the date when the exposure to noise ceased. In special cases, such as serious
illness or substantially changed life conditions, tinnitus can be deemed to be a consequence of noise
damage for up to one year after the exposure. This is because it takes some time, under such
circumstances, to notice any tinnitus.
Frequency
57
Age graphs for unscreened female population
For women age alone gives an even, symmetrical, falling hearing threshold. For example, at the age of
60, 1,000 Hz 8 dB, 2,000 Hz 12 dB, 4,000 Hz 20 dB.
Frequency
Mnires disease
A complex of symptoms, initially consisting of attacks of unilateral hearing loss, ringing in ears and
vertigo. Gradually a permanent, unilateral or asymmetric, hearing loss develops, which will often be
the most pronounced in the bass region. Fluctuating hearing curves are characteristic. An abnormal
adjustment of the pressure in the lymph liquid of the inner ear is of significance for the disease, but the
actual cause is unknown.
DLA typus incertus (hearing loss of unknown origin, but definitely not a consequence of noise)
A difference between the hearing on the right and left ear (asymmetry) often speaks in favour of DLA
typus incertus. Similarly, atypical reflex thresholds often speak in favour of DLA typus incertus.
58
Diseases of the middle ear
Hearing loss as a consequence of diseases of the middle ear cannot have been caused by noise. For a
purely middle-ear-related hearing loss the hearing thresholds will definitely, for bone conduction, be
normal or close to normal.
Sequelae otitis media are consequences of inflammation of the middle ear and can be accompanied by
hearing loss.
Hearing loss as a consequence of several years of exposure to severe noise in the workplace is on the
list of occupational diseases, item A.1.
There are no other hearing disorders which, according to the present knowledge, give grounds for
submission of a claim to the Occupational Diseases Committee. Therefore, submission of other hearing
diseases to the Occupational Diseases Committee will usually be futile.
Example 1: Recognition of noise-induced loss of hearing (smith for more than 25 years)
A 48-year-old man had been exposed to noise since 1977, working for several different employers. The
sources of the noise were sheet metal work, machines, power saws, turning lathes and similar
equipment. The noise exposure had fluctuated in the whole period, from severe (85-90 dB) to
extremely severe (>95 dB) and had been present for about half of the working day. An audiologist had
performed an audiometric examination and made the diagnosis of noise-induced loss of hearing (DLA
professionalis).
Tone audiometry:
59
The claim qualifies for recognition on the basis of the list. For a period of more than 25 years, the
injured person was exposed to severe noise for half of the working day. There is good correlation
between the hearing loss and the exposure to noise in the workplace.
An audiologist had performed an audiometric examination and diagnosed DLA professionalis, DLA
typus incertus and tinnitus. The diseases were described as troublesome and permanently present in
both ears.
Tone audiometry:
The claim qualifies for recognition on the basis of the list. The injured person has for 8 years been
exposed to extremely severe noise for most of the working day. There is good correlation between the
hearing loss and the exposure to noise in the workplace. Tinnitus can be compensated as a consequence
of the work-related part of the hearing loss.
The hearing loss already around 2,000 Hz shows that, besides the noise-induced hearing loss, there is
also a hearing loss of unknown origin (DLA typus incertus) which is definitely not due to noise
exposure, and the hearing threshold at 4,000 Hz is very high in relation to the duration of the noise
exposure. In the event of any compensation, the amount of the compensation will be reduced
accordingly. (Section 12 of the Act)
An audiologist had made an audiogram and made the diagnosis of DLA professionalis.
60
Tone audiometry:
The claim qualifies for recognition on the basis of the list. The injured person was exposed, for several
years, to severe noise in the workplace and thus sustained a hearing loss that was work-related.
Example 4: Recognition of moderate, noise-induced loss of hearing with severely troublesome tinnitus
(sheet metal smith for 20 years)
A 52-year-old man had worked as a car mechanic/sheet metal smith for different employers from 1982
to 2002. Through all the years, for about half of the working day, he had been exposed to severe noise
(85-90 dB) from grinding machines, angle grinders, car engines, etc. In addition to hearing loss, the
injured person also complained of severely troublesome tinnitus, beginning in 1999, which caused
irritability and insomnia.
An audiologist had made an audiometric examination and diagnosed DLA professionalis and tinnitus.
Tone audiometry:
The claim qualifies for recognition on the basis of the list. The injured person was exposed to severe
noise for 20 years and sustained a hearing loss as a consequence of the work (DLA professionalis). The
measured loss of hearing according to the audiogram is consistent with exposure to noise, there being
good correlation between the measured hearing loss and the noise exposure in the workplace. There is
no information of competitive causes of tinnitus, and as it came about before the exposure as a sheet
61
metal smith ceased, the hearing loss is recognised as a work-related hearing loss and tinnitus as a
consequence of the same. This means that even if the hearing loss is not in itself given a 5 per cent
permanent-injury rating, the combination of the hearing loss and the severely troublesome tinnitus
means that it will be possible to rate the permanent injury at 5 per cent or more.
It should be noted that when the compensation is determined, tinnitus will be regarded as being a
consequence of the work-related part of the hearing loss as it is not very likely that tinnitus was caused
by other factors than work. Thus there are no competitive causes of the onset of tinnitus, and the
tinnitus disorder came about before the sheet metal smith stopped being exposed to noise. (Section 12
of the Act)
Example 5: Recognition of moderate hearing loss with severely troublesome tinnitus (printer for 23
years competitive hearing disease)
For 23 years a 54-year-old labels printer was exposed, for largely the whole day, to severe to very
severe noise (85-95 dB) from printing machines, rotary press and compressors. In the course of the last
2 years he developed an increasing tinnitus disorder in both ears. At the beginning it was more
pronounced when he came home from work, but later it was present largely all the time. The tinnitus
was described as being severely troublesome, partly disturbing his sleep at night and partly preventing
him from having conversations in the workplace. An audiologist had made an audiogram and
diagnosed DLA professionalis, tinnitus and DLA hereditaria.
Tone audiometry:
The claim qualifies for recognition on the basis of the list as there was sufficient exposure to noise and
an audiogram that i.a. showed a pronounced impact on hearing at 4,000 Hz (DLA professionalis).
Besides there are competitive causes of the hearing loss, the audiogram being asymmetric and with a
tendency to dip already at 3,000 Hz (DLA hereditaria), and the steepest fall in the hearing thresholds is
from 2,000 Hz to 3,000 Hz.
Tinnitus must be deemed to be a relative consequence of the noise-induced hearing loss as well as the
hereditary hearing disease, and this will be taken into account when determining the compensation.
(Section 12 of the Act)
62
Example 6: Claim turned down noise-induced loss of hearing (metal worker for 20 years mainly
other causes)
A 50-year-old metal worker was employed in a shipyard from 1973 to 1989 and again from 1991 to
1994. He was exposed in the workplace to very severe noise (90-95 dB) for about half of the working
day. From about 1993 he noticed a hearing loss and had furthermore occasional ringing in his ears.
An audiologist made an audiogram and also diagnosed DLA typus incertus, tinnitus and DLA
professionalis.
Tone audiometry:
The claim does not qualify for recognition on the basis of the list. The curve of the audiogram shows
that, even though the injured person was exposed to sufficient noise for several years, the hearing loss
had not been caused mainly by noise. There is asymmetry with a continued dip in hearing thresholds
against the treble. The dip at 4,000 Hz appears in the ear with the poorest hearing. The hearing loss
therefore must be deemed to have other causes than exposure to noise.
Example 7: Claim turned down tinnitus without work-related hearing loss (in-the-home day carer for
26 years)
A 52-year-old woman who, since 1978, had worked within the municipal day-care system, reported
tinnitus and reduced hearing and stated that every day, over the years, she had been exposed to noise in
the form of constant commotion and noise from shouting and screaming children.
An audiologist performed an audiometric examination and stated that she had tinnitus as well as DLA
incertus dxt. et sin. (bilateral, noise-related hearing loss).
63
Tone audiometry:
The claim does not qualify for recognition on the basis of the list. The course of the hearing curves is
inconsistent with a noise-related hearing loss, the curves being very asymmetric and per definition
normal in both ears at 4,000 Hz. Thus tinnitus cannot be recognised as a work-related disease, either.
Nor is the noise exposure commotion and shouting/screaming from the children in her care in itself
sufficient to be regarded as severe noise. Therefore the conditions for recognition on the basis of the list
of occupational diseases are not met in this respect, either.
Example 8: Claim turned down hearing loss (operations engineer for 26 years no correlation with
noise)
In the period from 1964 to 1990, a 56-year-old operations engineer had worked, for about half of the
working day, in very severe noise from old relays (90 to 95 dB). From 1990 till work cessation in 2004
he was no longer exposed to noise as he transferred to work with computer maintenance. He only no-
ticed around 1998 that his hearing had been reduced. An audiologist performed an audiometry test.
Tone audiometry:
64
The claim does not qualify for recognition on the basis of the list. Regardless that the exposure to noise
was sufficient to develop a hearing loss, the injured person only noticed a hearing loss more than 8
years after he was no longer exposed to noise in the workplace.
Thus there is no time correlation between the symptoms and the exposure. Therefore the hearing loss
must be deemed to have had other causes than work.
Example 9: Claim turned down hearing loss (slaughterhouse worker for 2.5 years noise exposure
too brief)
A 27-year-old woman had reported a hearing loss after working for 2.5 years in a big slaughterhouse
and using severely noisy machines (85-90 dB) for cutting up meat. She had not previously been
exposed to severe noise in the workplace. An audiogram had been made.
Tone audiometry:
The claim does not qualify for recognition on the basis of the list. The duration of the noise exposure
was not sufficient for the loss of hearing to have been caused by exposure to noise. And the measured
hearing lies within the normal range.
Example 10: Claim turned down hearing loss in employee in day-care centre (not severe noise)
A 52-year-old day carer reported loss of hearing as a consequence of working for more than 30 years as
a day-carer in day-care centres for children aged 0 to 6. The childrens shouting and commotion in
connection with activities inside and outside the centre were, she felt, the reason for her loss of hearing.
An audiogram had been made, and DLA professionalis and DLA typus incertus had been reported.
65
Tone audiometry:
The claim does not qualify for recognition on the basis of the list. Childrens commotion and shouting
cannot be characterised as severe noise (at least 85 dB), and therefore the exposure is not sufficient to
cause a noise-related hearing loss.
Decibel (dB) Measuring unit for the intensity and pressure of sound
Dip A dip is a V-shaped downward bend as opposed to a peak, which is an
upward bend. Exposure to impulse noise results in a dip which is most
pronounced at 4,000 Hz.
DL Discrimination loss
DLA (Degeneratio Labyrinthi Reduction in the functionality of the cochlea in the inner ear
Acustici)
DLA hereditaria Hereditary hearing loss
66
DLA professionalis Hearing loss as a consequence of exposure to noise for several years.
Appears as a dip at about 4,000 Hz in an audiogram
DLA typus incertus Hearing loss of unknown cause, but definitely not as a consequence of
exposure to noise
Hertz (Hz) Measuring unit for the number of sound waves per second
MCL Most comfortable loudness
67
Chapter 3. Back and hip diseases
List of contents
68
1. Chronic low-back disease (B.1)
The following disease of the low back is included on the list of occupational diseases (group B, item 1):
Disease Exposure
B.1. Chronic low-back disease
with pain Back-loading lifting work involving lifting/upward
(lumbago/sciatica, lumbar pulling of heavy objects and many tonnes of lifting per
prolapsed disc, degenerative low- day for a considerable number of years
back disease) Back-loading lifting work with generally occurring,
extremely heavy and awkward single lifts and several
tonnes of lifting per day for a considerable number of
years
Back-loading care work with many daily handlings of
adults or older handicapped children for a considerable
number of years
Back-loading, daily exposure to whole-body vibrations
from heavily vibrating vehicles for a considerable number
of years
A medical doctor must have made one of the following ICD-10 diagnoses: M47 (degenerative arthritis
of the spine), M48 (other diseases of the spine), M51 (diseases of discs of other vertebrae than of the
neck), or M54 (back pain).
69
The diagnosis is made against a medical background, combining the following information
X-ray examinations, MR scans and CT scans of the lumbar spine can contribute to diagnosing
degeneration, but not to confirming the pathological pain. Myelography (examination with contrast
material) of the spinal canal can contribute to diagnosing spinal stenosis.
Symptoms
Chronic (daily or frequent) pain in the low-back region, perhaps with radiating pain to buttock, back of
thigh and lower leg (sciatica). For prolapsed disc: Radicular pain and perhaps paralyses of foot and toes
and sensory disturbances. Typically there is aggravated pain in connection with any load.
Objective signs
Spinal curvature (sciatica scoliosis)
Motion. There is often restricted motion, but this is not a requirement for the diagnosis
Painful reaction to movements
Localised tenderness of bones and muscles
The above objective signs can in certain cases be relevant for the permanent-injury rating, but not for
the question of recognition, the only requirement being chronic (daily or frequent) pain.
Main conditions
In order for work to be characterised as back-loading lifting work with lifting/upward pulling of heavy
objects and many tonnes of lifting per day for a considerable number of years, the following
requirements must in principle be met
Stressful lifting work must have been performed for a fairly consecutive period of 8-10 years and
The lifting work amounted to 8-10 tonnes per day and
The lifted objects weighed at least 50 kilos each (for men) or 35 kilos each (for women)
The requirements with regard to duration, total daily lifting quantity and the weight of objects can be
reduced, see below.
70
Only actual lifting and upward pulling are included in the assessment of the work carried out. Thus the
assessment does not include pushing and horizontal pulling of objects.
The 8-10-year requirement can be reduced if the lifting quantities were very large, i.e. more than 15
tonnes a day however, the requirement cannot be reduced to less than 3-4 years.
Driving a wheel barrow can to some extent be included when assessing the lifting-work requirements.
The requirement of a daily lifting quantity of 8-10 tonnes means that the starting point is about 10
tonnes. This lifting quantity can be reduced to 8 tonnes when
the exposure lasted more than 8-10 years, or
it is a woman or a particularly slight man or a young person, or
the burdens were carried over a long distance, or
there were at least 3-4 load factors and each burden weighed 15-18 kilos or more
The requirement of the total daily lifting quantity of 8-10 tonnes can furthermore be reduced in the
event of
an unusually long exposure period substantially in excess of 10 years (15 years or more), or
special exposure circumstances, for example lifting work under cramped conditions or work in the
fishing industry (see fishing below), or
lifting work in connection with iron binding in a stooping position (see iron binding below)
The total daily lifting quantity cannot, however, be reduced to less than 4-6 tonnes depending on the
type of exposure.
If several persons perform the lift together, it is not possible to make a mathematical reduction of the
weight of the burden, the load being different for the particular persons partaking in the lift. In such
cases it is necessary to make a concrete assessment of the load.
The requirements to the weight of the particular burden can be reduced in cases where the lifting
postures are particularly awkward.
The weight requirement for each lift can, depending on the circumstances, be reduced to 8 kilos for
men and 5 kilos for women.
The weight of the particular lift is not mathematically reduced for each of the above factors, but
depends on a total assessment of the work performance.
The requirement to the lifting quantity can be further reduced if there are special exposures in addition
to those set out above, for example a particularly long exposure period. If there are such special
exposures, the requirement to the daily lifting quantity can be reduced to 4 tonnes.
Fishermens lifting work may also qualify for recognition on the basis of item B.1.(b) if there are
generally occurring, very heavy single lifts, but there are no grounds for reducing the requirement to
the daily lifting quantity to under 3-3.5 tonnes.
There must have been 8-10 years of more or less continuous fishing with the number of days at sea that
are normal for fishing (in principle approximately 8 full months of labour market supplementary
pension payments ATP-months or about 150 days at sea per year).
It is possible to deviate from the principle of a minimum of 10 years, just as for ordinary lifting work, if
there are special circumstances. This applies, for instance, if the daily lifting load substantially exceeds
6 tonnes or the lifting conditions are very awkward. However, the minimum is 3-4 years.
Main conditions
In order for work to be characterised as back-loading lifting work involving generally occurring,
extremely heavy and awkward single lifts and several tonnes of lifting per day for a considerable
number of years, the following conditions must be met
Daily, stressful lifting work for a fairly consecutive period of at least 8 years and
A total daily lifting load of not less than 3 tonnes and
Generally occurring, extremely heavy and awkward single lifts and
The remaining lifts must, in terms of weight, be consistent with the requirements under item
B.1.(a) regarding normal lifting work
72
The duration of the lifting work
There must have been regular lifting work for at least 8 years, with generally occurring, extremely
heavy, single lifts carried out under particularly awkward circumstances every day. The duration
requirement cannot be reduced to less than 8 years.
75-100 kilos for men and 50-75 kilos for women in connection with one of the special load factors
mentioned under item (a) or
50-75 kilos for men and 35-50 kilos for women in connection with two of the special load factors
mentioned under item (a) or
50 kilos for men and 35 kilos for women in connection with three of the special load factors
mentioned under item (a)
Main conditions
In order for work to be characterised as back-loading care work with many daily handlings of adults or
older handicapped children, the following conditions must in principle be met
The requirement of at least 8-10 years of stressful care work cannot be reduced to less than 8 years.
73
The daily exposure in healthcare
In principle there must have been back-loading care work in connection with for example bed-ridden
patients/residents, dependent wheelchair users or other dependent patient/resident groups and back-
loading care work equivalent to at least 20 daily patient-handling tasks (including lifts and transfers).
The care work must constitute a substantial part of the working day. If the work for most of the day
pertains to other functions than care work, such as cleaning, shopping and different service tasks, it will
not be characterised as stressful care work.
A general characteristic of work in the healthcare sector is that it does not really compare with other
lifting work. There often is a combination of lifting and pulling and support in potentially bad working
postures. To this should be added that this type of work involves living and unhandy burdens making
sudden and unpredictable movements that may increase the load.
The assessment of back-loading care work takes into account the amount of care as well as the
description of the patient/resident composition, including the number of wheelchair users and the
number of bedridden patients and other, severely dependent, patients/residents; the design of the
workplace, and the number of daily patient-handling tasks. In addition the amount of other working
tasks such as cleaning, shopping and nursing can be included in the overall assessment.
Lifting or handling or transferring a person counts a hundred per cent, even if two persons have been
lifting together or appliances have been used, for instance a lift, a turning sheet or a turning swivel.
This is because, even when employees use appliances or lift together, there will be a load on the low back
in the form of a partial lift.
But the access to appliances and the number of lifts performed by two persons, as well as space, can be
decisive in situations where the load is not quite substantial enough. This is because it is the combination
of the weight of the burden and the work in a stooping posture or with a twisted back that must be
regarded as stressful for the low back. Lack of appliances, cramped space conditions and many patient-
handling tasks without help from others may thus contribute to qualifying the load for recognition.
The requirement to the daily number of patient-handling tasks can be reduced if the back-loading work
lasted considerably longer than 8-10 years or the circumstances of the care work were unusually
stressful. Considerably longer than 8-10 years usually means 15 years or more.
Circumstances that contribute to making work in healthcare particularly stressful are unpractical and
restricted space conditions and lay-out of rooms, lack of appliances, the patients or residents inability
to co-operate, or many unsupported lifts of persons.
74
The requirement with regard to the number of daily patient-handling tasks cannot be reduced to less
than 10, however.
Main conditions
In order for work to be characterised as back-loading, daily exposure to whole-body vibrations from
heavily vibrating vehicles for a considerable number of years, there must in principle have been
Daily exposure to heavily vibrating vehicles for a fairly consecutive period of 8-10 years and
Driving on an uneven surface and
A daily vibration exposure of 0.70-0.80 m/s2 for a substantial part of the working day i.e. in
principle of a normal working day. This is equivalent to a daily vibration exposure for 8 hours of
0.60 m/s2
Exposure to vibrations usually through a seat (in a sitting posture)
The requirement to the number of years can be reduced if the exposure was particularly severe. This
means that the daily vibration exposure was more than 1 m/s2 for a minimum of three quarters of a
normal working day, equivalent to a daily vibration exposure for 8 hours of 0.80m/s2.
Inadequate suspension or shock absorption of the vehicle or seat will also be able to reduce the duration
requirements.
The guiding norm requires a daily vibration load of 0.70-0.80 m/s2 for a substantial part of the working
day i.e. in principle three quarters of a normal working day. This is equivalent to a daily vibration
exposure (8 hours) of 0.60 m/s2. With a vibration intensity above this level the requirement to the daily
exposure time is reduced, and with a daily exposure time of more than three quarters of a normal
working day the requirement to the vibration intensity is reduced. The requirement cannot, however, be
reduced to less than 0.60 m/s2.
The requirement to the daily exposure time can furthermore be reduced if there has been particularly
long-term exposure, i.e. 15 years or more. The requirement cannot, however, be reduced to less than
half of a normal working day.
The intensity of whole-body vibrations is measured in m/s2 in three directions at right angles to each
other. See figure 1, which describes the measurement of vibrations and the correlation between
75
vibration intensity and daily exposure time. The highest measured value in any one of the three main
directions is used to assess the injury risk.
Whole-body vibrations can be measured by way of a flat rubber plate with embedded vibration sensors
placed on the seat under the operator. The acceleration of the vibrations is measured in m/s2 in three
directions at right angles to each other. In the diagram shown in the figure the vibration intensity is
indicated on the vertical axis and the exposure time on the horizontal axis.
Horizontal vibration intensity must be multiplied by 1.4 before a comparison is made with vertical and
the figure is applied. The diagram includes two parallel curves. With exposures below the lower curve
there are no clearly documented, harmful health effects. Between the curves there may be a health risk.
Above the upper curve there is a health risk.
2
Example: The measured vibration intensity in the dominating direction is 1 m/s . This implies that the
risk of injury is small if the exposure time is shorter than a little less than 2 hours a day. If, on the other
hand, the exposure time is longer than about 5 hours a day, the risk of injury is great.
76
most caterpillar vehicles
certain trucks
certain contractors machines
many forestry machines
2
0.70-1 m/s :
many contractors machines
a number of tractors and farming tools
some old lorries without modern suspension
certain trucks
particular cranes
2
Under 0.70 m/s :
certain trucks
most cranes
most semi-trailers and lorries
vans
buses
cars
trains
ships
As the above list shows, driving with tracked vehicles, contractors machines including bulldozers,
excavators, dumpers, loaders, and cable diggers; tractors and other agricultural machines, as well as
forestry machines, could in principle imply vibrations of a sufficient intensity.
Furthermore, driving some types of trucks (understood as vehicles for lifting a load) could imply
sufficient vibration exposure. Such trucks must, however, have massive rubber wheels and have been
used on an uneven surface.
In a few, quite special cases, work with cranes will also imply sufficient vibration exposure.
However, driving with trains, buses, semi-trailers, lorries, vans, passenger cars including taxis and
sailing with ships will usually not imply vibrations of a sufficient intensity.
Further information on the vibration intensity of the various vehicles can be downloaded from the
German database http://www.las-bb.de/karla/index.htm
In each case there must be documentation that there were whole-body vibrations of an intensity and
duration as stated above. The documentation requirement means that an estimated statement of the
vibration exposure is not sufficient. If at all possible, there must be a description of the work
machines/vehicles used. This includes the type of machines/vehicles, production year,
suspension/shock absorption of vehicle or seat, the duration of the exposure (per day and in years),
vibration intensity, and a description of the circumstances under which the machine/vehicle was used.
77
If it is not possible to get specific information on these matters, an estimate is made on the basis of the
information available. A prerequisite for recognition is that it can be established, against this
background, that there was an exposure of the required severity and duration.
The concept of "daily" allows for disregarding short-term interruptions. This applies regardless of
whether the interruption occurs because the person in question for a short while performs other types of
work in the workplace or because there have been short periods of unemployment.
However, this also means that loads on the low back occurring only briefly and in employments spread
over a long period of time or in the performance of short-term seasonal work usually do not count if the
periods are added together. This may lead to the claim being turned down.
The same person has often been employed in several places, and the intensity of the lifting work often
varies.
If each separate employment meets the requirements but the duration of the particular employment is
not sufficient, all employments are included in the overall assessment. This also applies if the
exposures in the various employments were of a different nature. In that case it is a prerequisite
that the loads belong to one or more of the groupings of lifting and other loads listed below:
The decision will, however, depend on an overall assessment of all factors constituting the load,
according to the description of the factors back in time. The assessment naturally takes into account
that it can be hard to describe factors far back in time and that the documentation requirement therefore
must be deemed to have been met, even if the description is not quite specific.
If different work functions were performed in the course of the working day, an assessment will be
made of the total daily load on the back. This assessment will be based on an estimate of the load of
each work function on the low back as well as the total duration of the various exposures.
78
For example there may be an alternation between heavy lifting work for one third of the working day
and driving with heavily vibrating vehicles (exposure to whole-body vibrations) for one third of the
working day. In the last third of the working day no back-loading work is performed. In such cases
there is an alternation between different work functions in the course of the working day. Two of the
functions meet the requirements to relevant exposure, and these exposures at the same time stretch over
more than half of the working day. The claim therefore qualifies for recognition on the basis of the list.
For back diseases the relevant time correlation is that the first symptoms of the disease or in certain
cases the aggravation of a pre-existing disease turn up some time after the commencement of the
back-loading work.
Some time is usually understood as several years, depending on the scope of the exposure. The assess-
ment takes into account, for instance, whether there have been large daily lifting quantities, very heavy
single lifts, or a massive exposure to whole-body vibrations, or whether it was a young person.
In such cases, from a medical point of view, there will be a time correlation between the work and the
development of the low-back disease, even if the first symptoms appear shortly after the
commencement of the back-loading work.
This also means that the disease must not have manifested itself as a chronic disease before
commencement of the stressful work. On the other hand, a single previous case of acute low-back pain
with complete recovery does not in itself lead to the claim being turned down.
A characteristic course of events is that low-back pain develops gradually in the course of some years
after commencement of the back-loading lifting work and that the disease is gradually aggravated and
becomes more painful in connection with continued exposure.
It is often part of the pathological picture that the disease at some point in time is acutely aggravated. In
such cases it is not of any particular importance whether such acute aggravation occurs in connection
with the work or in a different situation, as long as the aggravation actually occurs in a period when
there is back-loading work. If the acute aggravation for instance occurs outside working hours, without
it being an accident, it will still be possible to refer the disease to back-loading work. Similarly this
applies in cases where there is a pre-existing low-back disease and a clear aggravation occurs in the
same way as set out above.
A decisive argument against recognition would be if there is a period without symptoms between
cessation of the back-loading work and the onset of the disease. This applies, for example, if a low-
back disease occurs after several years without employment or after several years employment in jobs
that do not involve any load on the back. This applies whether or not previous work met the load
requirements. If for a period of time there has been back-loading work, the disease can be recognised if
it occurs in a later period of more moderate, but still relatively back-loading work.
79
Documentation
In each case there needs to be documentation that the work has involved lifting work, with a
quantification of daily lifting as well as the size of each particular lift. The requirement for quanti-
fication of lifting work means that an estimated statement of the daily lifting quantity, care burden or
exposure to whole-body vibrations is not sufficient.
Nor is it therefore sufficient that the work was within a trade where, according to trade descriptions,
work generally is physically hard and involves a load on the back. Such more general descriptions can,
however, support any information that can be procured besides as part of the processing of the claim in
question.
In the processing of the claim we may ask for a medical certificate from a specialist of occupational
medicine. We will i.a. ask the medical specialist to describe and assess the nature and scope of the
work functions, including the types of lifting work, care work or driving with heavily vibrating vehicles
that have actually been performed. The medical specialist will also assess in detail the load of the work
functions on the low back in relation to the work functions in question.
The medical specialist will make an individual assessment of the significance of the load factors for the
development of the disease in the examined person. The examination will also include other objective
factors of relevance for the assessment of the disease and a description of the anamnesis, including the
onset of the disease and its course, as well as examinations and treatments, including x-rays and scans,
and information of any treatment provided by a chiropractor or physiotherapist.
Congenital anomalies:
Block vertebrae
Transition vertebrae:
Lumbosacral transition vertebrae (symmetric, asymmetric)
80
Disc degeneration and prolapsed disc: Prolapsed disc can occur without provocation in patients
with disc degeneration or in connection with back traumas
Only chronic low-back diseases with pain are covered by item B.1 of the list. Furthermore there must
have been exposures that meet the requirements for recognition.
Other diseases or exposures not on the list will be recognised in special cases after submission to the
Occupational Diseases Committee.
The Occupational Diseases Committee has for a number of years recommended recognition of other
harmful exposures, for example:
Iron binding in a stooping posture without simultaneous lifting work
Work in a fixed working posture without simultaneous lifting work
Heavy lifting work
Besides, if the symptoms of a chronic low-back disease appear in connection with the back-loading
work, there may i.a. be a basis for submitting the claim to the Committee in cases where the injured
person, at a very young age, performed very heavy lifting work or other extraordinarily back-loading
work for a few years. The practice of the Occupational Diseases Committee in the assessment of claims
81
not covered by the list will frequently be updated on the website of the National Board of Industrial
Injuries.
Example 2: Recognition of back pain after lifting of objects (bookbinders assistant for 17 years)
The injured person worked for 17 years as a bookbinders assistant in a large plastics production
business. Her work mainly consisted in operating a machine that stuck foil to sheets of cardboard. She
filled cases with stacks of cardboard at one end of the machine and removed ready laminated ring
binders in stacks of 25 pieces at the other end. Each lift weighed approximately 10 kilos on average,
and many of the lifts were made with her arms fully extended, in a stooping position, or with her low
back twisted. Furthermore there was more than one lift per minute. The total daily lifting load was 9-10
tonnes. After well over 12 years work she developed low-back pain and a medical specialist
subsequently diagnosed her with chronic low-back pain.
The claim qualifies for recognition on the basis of the list. The bookbinders assistant had been doing
heavy lifting work for 17 years, amounting to 9-10 tonnes per day. The work involved lifting of
objects, weighing around 10 kilos, to and from a plastic laminating machine. The lifting work involved
several special load factors, including lifting of objects with arms fully extended, lifting in a stooping
position and/or with twisting of the low back, as well as more than one lift per minute. Therefore there
are grounds for reducing the requirement to the weight of each single lift to about 10 kilos. She
developed low-back pain after well over 12 years work, and there is good causality and time
correlation between the work and the disease.
Example 3: Recognition of back pain after lifting of objects (cardboard worker for 20 years)
The injured person worked, for well over 20 years, as a cardboard worker in a large industrial business.
The work involved frequent lifts of cardboard units in bundles weighing from a few kilos to about 35
kilos, the average weight being 15-20 kilos. She took the bundles from a pallet and lifted them to a
table. Here they were punched together and subsequently lifted into a machine. She furthermore lifted
units from machine to pallets. There was more than one lift per minute, and there were lifts at more
than half arms length from the body, lifts in a stooping posture, and lifts with arms above shoulder
height. The total daily lifting load was 13-15 tonnes. After well over 15 years work she developed
82
daily low-back pain, and a medical specialists examination as well as x-rays showed considerable
degenerative arthritis of the low back.
The claim qualifies for recognition on the basis of the list. The injured person had been doing heavy
lifting work for 20 years, with a daily lifting load of 13-15 tonnes. Each object weighed 15-20 kilos on
average, and she made more than one lift per minute, lifted at more than half arms length from the
body and lifted in a stooping posture or with her arms lifted above shoulder height in connection with
lifts to and from a pallet. Therefore there are grounds for reducing the 35-kilo weight requirement for
each lift for women to a 15-20-kilo requirement. In addition, the total daily lifting load and the
exposure period were substantial and significantly higher than the 8-10-year requirement set out in the
list of occupational diseases. Furthermore there is good time correlation between the load and the onset
of the disease.
Example 4: Recognition of back pain after lifting of objects (postal worker for 18 years)
The injured person worked as a postal worker for 15 years. The first 5 years the work included
reloading of railway wagons with frequent lifts of parcels and sacks weighing 1-100 kilos (average
weight 30-35 kilos). The following years he worked in the central sorting at the post office, emptying
postbags, sorting mail for shelving units and packing mail in bags for distribution. This work involved
lifts of 100-200 heavy mail bags weighing 30-60 kilos on average; sorting of letters (approximately
2,000 letters per hour), and packing of mail in bags weighing 30-60 kilos on average. These bags were
lifted onto a packing line. The daily lifting load from objects weighing between 30 and 60 kilos was 6-
8 tonnes. The work was furthermore characterised by frequent lifts in unfavourable working postures at
a low or high working height, i.e. below knee level or above shoulder height; long and twisted reaching
distances, stooping lifting postures, and lifts with the arms held far away from the body. After well over
15 years work he developed increasing low-back pain. A medical specialist and examinations in a
hospital established a prolapsed disc as well as low-back degeneration.
The claim qualifies for recognition on the basis of the list. The postal worker for more than 15 years
had heavy lifting work with a daily load between 6 and 8 tonnes. The lifted objects typically weighed
between 30 and 60 kilos, and the lifting conditions were very awkward and stressful. The nature and
scope of the lifting work, measured in tonnes and years, give grounds for reducing the requirements to
the weight of each lift and to the daily load respectively. The postal worker has developed a chronic
low-back disease with pain, and there is relevant and good correlation between the course of the
disease and the lifting work.
Example 5: Recognition of back pain after lifting of objects (airport porter for 10 years)
The injured person worked for well over 10 years as a porter in Copenhagen Airport. The work
consisted in loading and unloading about 10 planes per day in a four-man team. The weight of the
baggage per plane varied from a few hundred kilos to 4 tonnes per plane, an average of 1.2 tonnes per
plane. The total daily lifting load was equivalent to 4-5 tonnes per person, and the individual lifts
typically weighed 15-25 kilos. A great deal of the lifting work occurred in unfavourable working
postures, characterised i.a. by squatting or kneeling lifts in the cargo room of the plane, and with
frequent twisting of the low back. After 8 years work he had increasing low-back trouble with daily
pain, which was aggravated under stress. A medical specialist made the diagnosis of chronic low-back
pain. The claim qualifies for recognition on the basis of the list. The injured person developed a
chronic low-back disease with pain after working for 10 years as an airport porter, loading and
unloading airplanes. He had a daily lifting load of 4 to 5 tonnes with typical single lifts of 15-25 kilos.
The work was characterised by very awkward and back-loading lifting conditions, i.a. many lifts in a
83
squatting or kneeling posture in cramped airplane cargo rooms, long reaching distances and frequent
twisting of the low back. Therefore there are grounds for reducing the requirement to the daily lifting
load to 4-5 tonnes and the requirements to the weight of the units to 15-25 kilos. Furthermore there is
good correlation between the work and the onset of the disease.
Example 6: Claim turned down lifting of objects (warehouse assistant for 17 years)
The injured person worked for 17 years as a warehouse assistant in a large green-grocery production
plant. The work included different types of warehouse work and daily lifts of pallets, fruit boxes etc.
Each lift typically weighed between 3 and 25 kilos, and the total daily lifting load was between 0.5 and
1 tonne. In addition, he did a great deal of horizontal pulling of heavy pallet trolleys etc. After more
than 30 years work he developed daily low-back pain with restricted motion of the low back. A
medical specialist made the diagnosis of lumbago (low-back pain). The claim does not qualify for
recognition on the basis of the list. The injured person had a chronic low-back disease after working for
many years as a warehouse assistant. The daily lifting load was less than 1 tonne, however, and thus
substantially less than 8-10 tonnes per day. Horizontal pulling of trolleys cannot be included under
back-loading work as it was not back-loading upward pulling. Therefore it is not back-loading work to
an extent that is covered by the list.
Example 7: Claim turned down upper thoracic back pain after work as a cleaner (for 10 years)
The injured person worked with cleaning of a companys premises and bathrooms, 5 hours a day for 5
years and then full time for 5 years. The work consisted in wiping of surfaces, emptying wastepaper
baskets, vacuuming and washing of floors. She had a cleaning trolley in some of the places with a
hand-operated wringing machine and a dry/wet mop. In other places she kept a bucket and some floor
scrubs. She carried the bucket around with her and washed with bucket and cloth. In a few places she
had dry/wet mops, which were manually wrung. There were three vacuum cleaners at her disposal,
which she carried around with her through the production premises to the various rooms. Floors were
washed when needed. In the last couple of years she had increasing problems in the form of thoracic
back pain and was diagnosed by a medical specialist with thoracic facet syndrome (upper thoracic back
pain). There was no pain of the low back.
The claim does not qualify for recognition on the basis of the list. The reported disease, thoracic facet
syndrome (upper thoracic back pain), is not on the list of occupational diseases as the medical docu-
mentation in the field shows no correlation between exposures at work and this disease. Nor are there
any grounds for submitting the claim to the Occupational Diseases Committee on the assumption that
the claim may be recognised without application of the list, the disease being a consequence of the
special nature of the work. This is because the exposure, in the form of cleaning work, cannot be
deemed to be a special risk with regard to the development of thoracic back pain.
Example 8: Recognition of back pain after extremely heavy lifts (bricklayer for 8 years)
The injured person worked for 8 years as a landscape gardener for a large local authority. For the
greater part of the working day, the work mainly consisted in different types of paving. He was i.a.
employed to lay cobbles and setts in driveways and to lay pavements. The work involved a total daily
lifting load of 3-5 tonnes. Furthermore, there were generally occurring lifts of heavy kerbstones and
slabs that weighed 75 to 150 kilos and were lifted by 1-2 persons. Other units weighed 8-50 kilos. The
work typically occurred under lifting conditions that were very hard on the back, such as lifts at a low
height, at awkward angles, at a long reaching distance, and with much twisting of the low back. After 8
84
years work he had severe and acute low-back pain without any external cause, and an examination at
the hospital diagnosed a prolapsed disc of the low back. After conservative treatment he still suffered
from daily back pain and restricted motion of the low back.
The claim qualifies for recognition on the basis of the list. The injured person had a chronic low-back
disease with pain after 8 years of heavy lifting work as a bricklayer. His daily lifting load was 3 to 5
tonnes, and the work was characterised by frequent, extremely heavy single lifts of 75 to 150 kilos
under very awkward and back-loading lifting conditions. As a consequence of the awkward lifting
conditions, there are grounds for reducing the requirement to the weight of each, extremely heavy, lift.
Therefore the claim meets the requirements of the list.
Example 9: Recognition of back pain after extremely heavy lifts (machine fitter for 8.5 years)
The injured person worked for well over 8.5 years as a fitter of machine parts in a large machine
manufacturing business. His work mainly consisted in mounting electro motors to large machine parts.
The motors typically weighed between 50 and 95 kilos. Mounting included lifting or partial lifting of
motors from van to machine, frequently at a long reaching distance, with a twisted low back, and lifts
in a stooping position when the motor part was lifted from van to machine, juggled into place and
positioned correctly before the final fitting. Each motor typically required several handlings, and the
daily lifting load was 3 to 4 tonnes. After about 7 years work he developed a low-lying back pain that
gradually became chronic with daily pain and restricted motion of the low back. A medical specialist
made the diagnosis of low-back disc degeneration, and this diagnosis was confirmed by an x-ray
examination.
The claim qualifies for recognition on the basis of the list. The machine fitter had heavy lifting work
for 8.5 years that involved lifts, under very awkward and back-loading lifting conditions, of objects
weighing between 50 and 95 kilos. Therefore there are grounds for reducing the requirement to the
weight of each single lift to between 50 and 95 kilos. As there was a daily lifting load of at least 3
tonnes and the injured person had a chronic low-back disease in good time correlation with the heavy
lifting work, the claim meets the requirement for recognition on the basis of the item of the list of
occupational diseases pertaining to lifting of extremely heavy objects.
Example 10: Claim turned down back pain after extremely heavy lifts (slaughterer for 15 years)
The injured person worked for well over 15 years as a livestock slaughterer in a large provincial
slaughterhouse. The work involved frequent lifts of parts from cut-up livestock, including half parts,
hindquarters and forequarters, and generally occurring single lifts of 75 to 100 kilos. The daily lifting
load amounted to between 4 and 6 tonnes. The work was generally characterised by unfavourable
lifting conditions, lifts over long distances, a long reaching distance, lifts above shoulder height, and
many lifts on the neck and shoulder girdle. After 15 years he transferred to work as a gut cleaner in a
pork slaughterhouse. This work was not characterised by loads on the back. After well over 5 years of
working in the pork slaughterhouse he developed daily low-back pain radiating into the right leg, and a
medical specialist made a diagnosis of lumbago with sciatica.
The claim does not qualify for recognition on the basis of the list. The livestock slaughterer had a
chronic low-back disease after many years of heavy lifting work with frequent, extremely heavy, single
lifts and a daily lifting load of 4 to 6 tonnes. However, he only developed the symptoms of the disease
after 5 years of subsequent work as a gut cleaner, which did not involve any substantial load on the
back. Therefore there is no time correlation between the previously stressful lifting work as a livestock
slaughterer and the development of the disease.
85
1.6.3. Back-loading care work (B.1.(c))
Example 11: Recognition of back pain after care work (nurse for 19 years)
A 50-year-old nurse worked for well over 19 years in a hospital emergency ward. The work i.a.
involved transfer of patients from gurney to x-ray elevating table and then to the bed. The transfers
were made about six times a day in co-operation with paramedics or hospital porters. The transfers
were particularly hard on the back because it was usually difficult for the patients to co-operate. There
were 10 to 20 back-loading patient handlings per day. Towards the end of the period she developed
low-back pain of a chronic nature. This pain was present almost every day and was aggravated in
connection with various loads on the back.
The claim qualifies for recognition on the basis of the list. For a very long period of time, more than 15
years, the nurse had 10 to 20 back-loading patient handlings per day. There are grounds for reducing
the minimum requirement of 20 daily patient handlings to 10 as the load period was longer than 15
years. Furthermore, the work was particularly stressful as the patients injuries made it hard to transfer
them. There is good correlation between the work and the onset of the back disease and there is back
pain almost every day.
Example 12: Recognition of back pain after care work (home help for 8.5 years)
A home help worked for 8.5 years on evening shifts for a local authority. As an element of compre-
hensive care, the work involved visits with citizens in their homes and visits with citizens in nursing
homes. Each shift was comprised of approximately 25 visits, 12 of these with dependent citizens. The
care tasks with the dependent citizens involved personal transfers in connection with change of clothes
and diapers in bed, transfers from chair to bed and vice versa, and assistance in connection with visits
to the bathroom. She typically performed 2-3 transfers in the home of each of the dependent citizens,
which was equivalent to approximately 25-35 back-loading patient handlings for each shift. After about
7.5 to 8 years work, she developed increasing low-back problems. Towards the end of the employ-
ment, her problems became more chronic with daily pain. A medical specialist made the diagnosis of
degeneration of the low-back spine.
The claim qualifies for recognition on the basis of the list. The home help performed back-loading care
work for more than 8 years, characterised by about 25 to 35 handlings per day of citizens in need of
care. Thus the requirement of a minimum of 8 to 10 years of stressful care work, with at least 20 daily
patient handlings, is met. There is good correlation between the onset of the back disease and the back-
loading care work.
Example 13: Recognition of back pain after care work with older handicapped children (social worker
for 13 years)
A social worker worked for about 13 years in a 24-hour institution for children and young people with
severe physical and mental disabilities. The average age in the house was 13-14 years. The social
worker was affiliated with a house where there were five wheelchair users who were very much in need
of care, and three residents who were mobile, but required care. Persons lifts were used in connection
with baths and other visits to the bathroom. To use the lift, the person in question had to be placed in
the connecting sail, which happened by rolling or pushing the person onto the sail. The employer stated
that the children were lifted and transferred in connection with many of the activities they took part in,
and that there were many heavy patient-handling tasks every day. After 12-13 years the social worker
developed chronic low-back pain, and hospital examinations showed two minor disc prolapses of the
low back.
86
The claim qualifies for recognition on the basis of the list. The injured person worked as a social
worker for more than 8-10 years with older handicapped children. The work was characterised by many
daily handlings of heavy persons in need of care. The number of lifts and handlings of persons has not
been explicitly stated, but according to the description there probably was a care intensity that must be
deemed to have required at least 20 daily back-loading patient-handling tasks. Furthermore there is
good correlation between the onset of the disease and the care work.
Example 14: Recognition of back pain after care work (healthcare assistant for 23 years)
The injured person worked for 23 years as a healthcare assistant in a nursing home. The first 8 years
she had less than eight patient-handling tasks per day. Subsequently she had 15 patient-handling tasks
per day, except for a 7-year period when she had 25 to 30 patient-handling tasks per day. The clients
were extremely dependent, and there were many wheelchair users and very few independent residents.
After more than 20 years work she developed daily pain in the low back, and a medical specialist
diagnosed her with chronic low-back pain.
The claim qualifies for recognition on the basis of the list. The injured person worked as a healthcare
assistant for 23 years with residents in a nursing home who were in need of extensive care. The first 8
years cannot count as back-loading care work as there were less than 10 patient-handling tasks per day.
However, she had between 25 and 30 patient-handling tasks per day for 7 years and, in addition to that,
well over 8 years with 15 patient-handling tasks per day. She had care-intensive work that easily met
the more-than-7-year requirement of the list, and in addition she had moderately heavy healthcare work
for 8 years. There are grounds for reducing the requirement to the number of patient-handling tasks to
15 per day for part of the period as there was overall a very long exposure period with relevant care
work for 15 years and the work furthermore constituted a heavy load on the back. There is furthermore
good time correlation with the onset of the disease in immediate connection with the period with the
heaviest type of care work.
Example 15: Recognition of back pain after care work (nurse for 9 years)
The injured person worked as a nurse in a medical hospital ward with many elderly patients. The work
consisted in conventional nursing tasks such as administration of medication, dressing of wounds, and
paperwork, as well as various types of patient-handling tasks in connection with caring for patients who
were bed-ridden, walking-impaired and dependent. According to information from herself and her
employer, she performed 20 to 25 rather heavy patient-handling tasks per day. At the age of 45, after
well over 9 years of care work, she developed daily low-back pain as well as restricted motion. A
medical specialist made the diagnosis of degenerative arthritis of the lumbar spine.
The claim qualifies for recognition on the basis of the list. The injured person worked as a nurse for 9
years, and her work involved at least 20 stressful patient-handling tasks per day. She developed a
chronic low-back disease in the form of degenerative arthritis of the low back, and the onset of the
disease is in good time correlation with the back-loading care work.
Example 16: Claim turned down back pain after care work (social and healthcare helper for 4 years)
A 56-year-old social and healthcare helper worked for a total period of 4 years in a private homecare
business. The work consisted in various care and in-the-home tasks with clients in their private homes.
A female patient was getting out of bed on her own to make room for the healthcare helper so that she
could make the bed and elevate the headboard. While making the bed she suddenly felt acute low-back
pain, which subsequently became more chronic. There was no information of the specific number of
daily patient-handling tasks in the course of the 4-year work period, but it appeared that the work
87
consisted in rather easy care functions and other kinds of assistance. Before the employment in
question, the social and healthcare helper had been a housewife without any earned income for a 10-
year period. Before that, she worked for a number of years as a home help employed by the local
authority. In that period she had no back problems, however. The claim does not qualify for recognition
on the basis of the list. The social and healthcare helper only performed care work for a consecutive 4-
year period up to the onset of the back problems, thereby not meeting the requirements of the list for at
least 8-10 years of care work for a fairly consecutive period of time. Furthermore, the care work was
not very heavy and probably did not involve more than 10 patient-handling tasks per day. This is
somewhat less than the 20 daily patient-handling tasks that are usually required in order for care work
to count as sufficiently stressful. Even though the healthcare helper previously had potentially stressful
care work for a number of years, this period does not count due to the subsequent 10-year interruption
of the exposure. Furthermore, in the same previous exposure period there were no low-back symptoms.
Example 17: Claim turned down back pain after work with small children (in-the-home day carer for
14 years)
A 50-year-old, in-the-home day carer looked after 0-to-3-year-olds in her own home for 14 years. The
work involved frequent lifting of the children to chair, pram, bed, and the other way round, equivalent
to approximately 120 lifts per day. The children weighed from 6 to about 15 kilos. At the end of the
period she developed low-back pain, and a medical specialist diagnosed her with degenerative arthritis
of the low back.
The claim does not qualify for recognition on the basis of the list. For 14 years, the day carer handled
small children aged 0 to 3 years, but the exposure in question is not covered by the list of occupational
diseases as there was no back-loading care of adults or older handicapped children. Nor are there any
grounds for submitting the claim to the Occupational Diseases Committee with a view to any
recognition not based on the list. This is because the handling of small children cannot, against the
background of the current medical documentation in the low-back field, be the only or predominant
cause of a low-back disease.
Example 18: Claim turned down back pain after care work (home help for 12 years)
A home help worked for 12 years, paying two to three visits to elderly clients each day. The clients
needed help to get out of bed, go to the bathroom, and dress. In addition, she paid one to two visits
where she performed cleaning tasks. The remaining visits in the course of the day involved easier care
tasks, such as medication and helping clients get their support stockings on and off. Altogether there
were between 5 and 8 back-loading patient-handling tasks per day. After 12 years she developed
chronic low-back pain, and x-rays showed degeneration of the lumbar spine.
The claim does not qualify for recognition on the basis of the list. In the 12 years of care work, the
home help only had five to eight patient-handling tasks per day. Therefore she did not have back-
loading care work to the extent required by the list; i.e. at least 20 patient-handling tasks per day for at
least 8-10 years. Furthermore the injured person, for the major part of the working day, performed
other tasks apart from care, and therefore the work was not characterised by back-loading care work for
the greater part of the working day.
Example 19: Claim turned down back pain after care work (healthcare assistant for 10-12 years)
The injured person worked for 10-12 years as a healthcare assistant in different hospital departments
and was employed in more than 10 places in the period in question. For about 3 years she had well over
20 stressful patient-handling tasks per day, whereas there were 10-15 or less the rest of the time. There
is no description available of particularly stressful care conditions, including difficult space and access
88
conditions. After about 8 years work she developed daily low-back pain radiating into both legs, and a
medical specialist made the diagnosis of lumbago with sciatica.
The claim does not qualify for recognition on the basis of the list as the injured person did not have
stressful care work meeting the requirements of the list; i.e. at least 20 patient-handling tasks per day
for at least 8-10 years. She only had at least 20 daily patient-handling tasks for 3 years. Besides there
are no grounds for reducing the requirement to the daily number of patient-handling tasks to 10-12 for
the remaining 7-9 years as the total exposure period was not at least 15 years and the care work was not
described as unusually stressful.
Example 20: Claim turned down back pain after care work (healthcare assistant for several periods)
The injured person worked as a healthcare assistant in a medical department in a hospital in the periods
1973-87, 1991-93 and 1994-98. From 1998 and onwards she only had administrative work functions.
The low-back disease, in the form of a prolapsed lumbar disc, had its onset in 1993. She had substan-
tially care-intensive work from 1973 to 1987, but in this period there was no back trouble. From 1987
to 1991 she did not do care work. From 1991 to 1993 and from 1994 to 1998 she had care work again,
but the type of work was not quite adequate (10-12 patient-handling tasks per day).
The claim does not qualify for recognition on the basis of the list. The healthcare assistant had stressful
care work for a prolonged period of 14 years, followed by a period of 4 years without care work. After
that she had easy to moderate care work for 7-8 years, and her low-back disease had its onset in this
last period. There were no symptoms of a chronic low-back disease in the first period from 1973 to
1987, when the stress involved in the care work was relevant. Then she had a work period of 4 years
without stressful care work. From 1991 and onwards she had easy to moderate care work for 7-8 years
with somewhat less than 20 patient-handling tasks per day. The last exposure period was only 7-8
years, and this in itself is not adequate for recognition on the basis of the list. The stressful period from
1973 to 1987 does not count as she had a rather long period of 4 years without any relevant exposure
between the two periods with back-loading work. Therefore there was not a fairly consecutive period of
8-10 years with relevant, stressful care work, performed in good time correlation with the onset of the
disease.
The claim qualifies for recognition on the basis of the list. The injured person developed a chronic low-
back disease with pain after operating heavily vibrating entrepreneurial machines, with an acceleration
level of about 1 m/s2, for three fourths of the working day for well over 13 years. There has been
exposure to whole-body vibrations to an extent that comfortably meets the requirements of the list, and
there is good correlation between the disease and the exposure.
89
Example 22: Recognition of back pain after whole-body vibrations/lifts (warehouse work for 10 years)
The injured person worked for well over 10 years as a warehouse worker and truck driver in a large
production firm. More than half of the working day, the work consisted in operating trucks with hard
rubber wheels in outdoor terrain and on an uneven surface. The average acceleration level when driving
was about 0.8 m/s2. For the remaining part of the working day he was employed in placing and
procuring various goods in the warehouse.
This work involved a great deal of manual lifting to and from warehouse shelves at high and low
working heights. The goods typically weighed between 30
and 60 kilos, the lifts involving stooping, lifting below knee height or above shoulder height, much
twisting of the low back and long reaching distances. The daily lifting load was calculated at 4-5
tonnes. After well over 10 years work he developed daily low-back pain and severely restricted motion
of the low back, and a medical specialist made the diagnosis of chronic low-back pain.
The work qualifies for recognition on the basis of the list. The injured person had relevant back-loading
exposure to whole-body vibrations from driving trucks for 3-4 hours a day and heavy lifting of 4-5
tonnes for 3-4 hours per day. Each burden weighed between 30 and 60 kilos and the lifting conditions
were awkward and very stressful for the back. Overall, therefore, the requirements according to items
(a) and (d) on the list were met in combination. There was furthermore good correlation between the
onset of the back disease and the exposure in the workplace.
Example 23: Recognition of back pain after whole-body vibrations (waste worker for 10 years)
A 37-year-old man worked at a waste station for 10 years. His work consisted in operating waste
handling machines, including a wheeled loader and a compactor, on internal and uneven roads and
areas with holes. The wheeled loader was for overturning and loading waste into e.g. containers, and
the machine shook heavily. The compactor was used for compressing and driving on top of waste and
also shook heavily. He drove these machines all day throughout the years. According to a report from
the Occupational Health Service, the whole-body vibrations in connection with operating these
machines were between 1.1 and 1.4 m/s2. Towards the end of the period he developed chronic low-
back problems with daily pain.
The claim qualifies for recognition on the basis of the list. For 10 years the waste worker had back-
loading work with exposure to whole-body vibrations of more than 1 m/s2 when driving heavily
vibrating vehicles on an uneven surface, 7-8 hours a day. There is good correlation between the work
and the development of chronic low-back pain.
Example 24: Claim turned down back pain after whole-body vibrations (bus driver for 14 years)
The injured person worked as a bus driver for well over 14 years. The work involved continuous, slight
twisting of the low back when selling tickets as well as an impact through the low back when crossing
bumps on the road and driving on uneven surfaces. Driving took place in a normally suspended bus and
led to a vibration exposure of somewhat under 0.5 m/s2. After well over 14 years work she developed
daily back pain, and a medical specialist made the diagnosis of moderate degenerative arthritis of the
low back.
The claim does not qualify for recognition on the basis of the list. The bus driver was not exposed to
heavy lifting work or whole-body vibrations from heavily vibrating machines. Driving a bus for 14
years involved slight vibration exposures of less than 0.5 m/s2. This does not, however, meet the
90
requirements for an exposure of at least 2.5 m/s2. Besides, there were no extraordinary exposures that
might give grounds for recognition of the claim.
Example 25: Claim turned down prolapsed disc after whole-body vibrations in a standing posture
(truck operator for 20 years)
A 53-year-old man worked in a delicatessen factory for well over 20 years. The work consisted in
operating an electric pallet-lifter with massive rubber wheels, primarily indoors in a warehouse. It
appeared that the floors were uneven at the beginning, due to level differences. While driving he was
standing, and therefore there were no whole-body vibrations into his back through a seat. The work in
question did not involve any lifting.
After well over 15 years he developed low-back pain, which later became chronic and radiated into his
right leg. He was subsequently diagnosed with a prolapsed lumbar disc and had an operation. After the
operation he still suffered from daily pain and restricted low-back motion.
The claim does not qualify for recognition on the basis of the list as the truck operator was not exposed
to whole-body vibrations through a seat into the low-back (sitting posture). The exposure to whole-
body vibrations occurred in a standing posture, and this type of exposure is not covered by item B.1.(d)
of the list. This is because the vibrations in a standing posture are considerably absorbed by the legs,
which reduces the impact on the low back. In this case there was no extraordinarily severe vibration
impact that might significantly increase the risk of developing a low-back disease and thus might give
grounds for submitting the claim to the Occupational Diseases Committee with a view to any
recognition not based on the list.
Sciatica Disease of the hip, radiating pain at the back of the lower extremity
Scoliosis Sideward curve of the spine
91
Spondylarthrosis, spondylosis, Degenerative arthritis of the spine
osteochondrosis vertebralis
Vertebra lumbalis Lumbar vertebra
Disease Exposure
B.3. Degenerative arthritis of both hip Hip-loading lifting work involving many heavy single lifts and
joints (arthrosis coxae primaria a total daily lifting quantity of several tonnes for a considerable
bilateralis) number of years
Main conditions
A medical doctor must have made the diagnosis of degenerative arthritis of both hip joints (arthrosis
coxae primaria bilateralis M16.0).
In order to make the diagnosis of degenerative arthritis of both hip joints, the following requirements
must be met
The disease cannot be recognised on the basis of the list if there is only evidence of degenerative
arthritis of one hip. This is because the load from a lift will be transmitted biomechanically via the
pelvis to both hips, and therefore both hips will usually be affected by the lifting work. Unilateral
degenerative arthritis of the hip joint is furthermore very often caused by other factors than exposures
in the workplace.
92
Claims regarding unilateral degenerative arthritis of the hip joint may qualify for recognition after
submission to the Occupational Diseases Committee in cases where there has been substantial exposure
relevant for the development of degenerative arthritis of one hip joint. (See also 2.5)
In order for bilateral degenerative arthritis of the hips to be recognised on the basis of the list, it does
not necessarily have to be symmetrical (the same degree of degenerative arthritis of both hips). The
disease may very well be severe in one hip and more moderate in the other.
If we receive notification of a case of unilateral degenerative arthritis of the hip and it appears that the
injured person has only had an x-ray examination of the one hip and there are also symptoms from the
other, we may gather information on the possibility of arthritis of the other hip. This may mean a
supplementary x-ray examination, if necessary. This will in particular be relevant in cases where the
exposure may be sufficient for recognition based on the list and where it is therefore all-important to
examine if the disease is bilateral, even though it may only have been medically explained on one side.
Symptoms
Pain of the hip joints
The pain triad:
o starting pain
o stress pain
o resting pain
Feeling of weakness/instability
Reduced walking distance
Perhaps creaking of the hip joints
Reduced motion of the hip joints
Objective signs
Reduced motion (particularly at the beginning in connection with inward rotation, later also in
connection with abduction and extension)
Limping gait
Wasting of buttock muscle
Reduced walking function
Reduced walking distance
There always have to be available results of an x-ray examination of both hip joints at two levels,
establishing degenerative arthritis of both hip joints.
In order to establish any degenerative arthritis of the hip joints the x-rays must show a narrowed joint
gap in the hip joints.
At the same time there may also be other classic radiological signs of degenerative arthritis, such as
bone and joint deformities, osteophytes, subchondral cysts, and changes in bone density.
As a supplement, the degenerative arthritis may have been established by MR or CT scans. Such
examinations cannot, however, replace an x-ray examination at two levels.
93
Time correlation
A prerequisite for recognition as an occupational disease is a relevant time correlation between the
development of degenerative arthritis of both hip joints and the hip-loading lifting work.
The relevant time correlation usually exists when the first symptoms of the disease appear, or a final
diagnosis is made, a considerable amount of time after the commencement of the stressful lifting work.
Besides it will be characteristic that the disease is gradually aggravated with increasing complaints in
correlation with a continued exposure.
Furthermore, there must not be any diagnosed degenerative arthritis of the hip joint prior to the
commencement of the stressful lifting work. This is because such a diagnosis would be an essential
indication that the disease is likely to have been caused by other factors than work.
One decisive argument against recognition would be if, from the cessation of the hip-loading work until
the onset of the disease, there was a prolonged period of time without any symptoms. This applies, for
instance, if the degenerative arthritis of the hips only becomes symptomatic after 5 years without
employment or 5 years employment in a job that is not stressful for the hips. This applies regardless of
whether the person in question previously had a job that met the exposure requirements.
If there previously was a period of sufficiently hip-loading work, within the meaning of the list of
occupational diseases, which was followed by a period of more moderate, but still somewhat hip-
loading lifting work, then the disease may qualify for recognition, even if it only came about in the later
exposure period. Then the later, slighter exposure will be deemed to have had a maintaining effect,
even if the stresses in this period would not in themselves lead to recognition.
Main conditions
In order for degenerative arthritis of both hip joints to be recognised on the basis of the list, there need
to have been the following hip exposures:
In certain cases the requirements to duration and total daily lifting quantity may be reduced, see below.
It is not possible to disregard or reduce the requirement for heavy single lifts of at least 20 kilos,
equivalent to an average, weekly exposure of at least 1 tonne.
Hip-loading lifts
94
In order for lifting work to be characterised as hip-loading, it must have involved hip-joint stresses
caused by lifts able to cause degenerative arthritis. Usually this means lifts involving a certain shift of
weight in the hips while the objects increasing the load on the hip joints are being handled.
Usually, easy lifts of a few kilos will not be regarded as a relevant load on the hips, provided they are
made close to the body, at about the height of the hips, and take place without any special load on the
hips that would cause a shift of weight in the hip joints due to, for instance, stooping, forward bending,
walking, etc.
In connection with heavy lifts of relatively many kilos, the weight in itself may lead to a substantial
weight load on the hip joint, leading to an increased risk of development of a disease. Therefore, heavy
lifts of many kilos in a standing or walking posture are usually always hip-loading, regardless of any
other lifting conditions.
The assessment of the load includes only full lifts and partial lifts, including lifts by several persons,
and handling that is not a free lift, but involves an element of lifting.
Degenerative arthritis caused by lifting work in a sitting posture is not included on the list of
occupational diseases.
Pushing or upward, horizontal or downward pulling of objects etc., or a load in connection with picking
up a wheelbarrow etc., is not in itself hip-loading and therefore is not included on the list.
However, work involving many partial lifts of a wheelbarrow with heavy material will be able to be
included as a special load factor in combination with hip-loading lifting work.
Hip-loading and handling of persons, including lifting of persons (care etc.) are not covered by the list.
In principle there must have been at least 15 years of hip-loading lifting work for a fairly consecutive
period of time, at the employment rate normal for the occupation in question.
The requirement for at least 15 years exposure may be reduced if there were very large lifting
quantities (more than 12 tonnes a day) and/or other quite particular load conditions.
The requirement with regard to the duration of the exposure cannot be reduced to less than 10 years.
95
The daily lifting quantity
In principle there must have been a daily lifting quantity of at least 8 tonnes.
This requirement is understood as a requirement for an average lifting quantity seen over a prolonged
period of time (weeks). Thus there is no requirement that at least 8 tonnes should be lifted every single
day.
The requirement for a lifted quantity of 8 tonnes may be reduced if one or more of the following factors
are present
the exposure lasted substantially longer than 15 years (20 years or more), or
the injured person is a very slight or very young person, or
the work involved many, very heavy, single lifts per day of at least 40 kilos for men and 30
kilos for women, or
the work involved special load conditions, such as lifting work in cramped conditions, many
heavy lifts in connection with walking on stairs, ladders, etc., or many partial lifts of
wheelbarrows with heavy material, or
physically stressful agricultural work
The requirement to the total daily lifting quantity cannot be reduced to less than 5 tonnes.
The work must have involved generally occurring, heavy single lifts of at least 20 kilos, equivalent to
an average weekly load of at least 1 tonne.
This could for instance be 50 single lifts of 20 kilos or at least 25 single lifts of 40 kilos per week.
The heavy lifts are included as part of the total daily lifting load of at least 8 tonnes.
There is no requirement for a sufficient number of single lifts of at least 20 tonnes every single working
day. The requirement should be seen as a measure of a number of average lifts seen over a prolonged
period of time (weeks).
It is not possible to disregard or reduce the requirement for heavy single lifts of at least 20 kilos,
equivalent to at least 1 tonne per week.
If several persons are lifting together, it is not possible to distribute mathematically the weight of the
lifted object, the load being different for each person taking part. In such situations it is necessary to
make a concrete assessment of the load.
Only degenerative arthritis of both hip joints is covered by item B.3 of the list. Furthermore there must
have been exposures meeting the recognition requirements.
Degenerative hip arthritis not covered by the list may in special cases be recognised after submission to
the Occupational Diseases Committee.
One example may be degenerative hip arthritis developed after many years of heavy lifting work
distributed on separate, unconnected periods of time.
Another example may be unilateral degenerative hip arthritis in a forest worker who for many years
had many daily lifts of extremely heavy logs or similar objects, which caused a load on one hip.
A third example may be a farmer who had a total daily lifting load of less than 5 tonnes per day, but
whose work involved, for instance, a considerable number of extremely heavy lifts in awkward lifting
postures, other quite particular hip loads and/or heavy lifting work at a very young age, when his body
and bone growth were not fully completed.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
97
in very awkward and hip-loading postures involving stooping and/or twisting of the hip joints. The
work involved an average daily lifting load of approximately 5-5.5 tonnes with typical and often
awkward single lifts of 10-20 kilos, causing a stressful shift of weight in the hip joints, as well as a
considerable number of heavy single lifts of at least 20 kilos, which was equivalent to 1-2 tonnes per
week out of the total load.
The claim qualifies for recognition on the basis of the list. The 42-year-old agricultural worker had
heavy and physically stressful agricultural work for 22 years (more than 15 years) and was diagnosed,
towards the end of the period, with degenerative arthritis of both hips. Her work involved a typical
daily lifting load of at least 5 tonnes with relevant, hip-loading single lifts of typically 10-20 kilos,
including a considerable number of very heavy single lifts of at least 20 kilos, equivalent to at least 1
tonne per week. There was a very long exposure period of more than 20 years as well as physically
stressful agricultural work, and therefore the requirement to the daily exposure can be reduced from 8
to 5 tonnes. There is also good time correlation between the exposures and the onset of the disease.
98
typical single lifts of 20-25 kilos. This work he did for 11 years, until the medical specialist made the
diagnosis. By then he had had moderate symptoms for about 10 years.
The claim qualifies for recognition on the basis of the list. From his early youth and for 8 years, the
drivers assistant had heavy, hip-loading lifting work amounting to more than 20 tonnes per day, and
after that, for 2 years, he had relevant, hip-loading lifting work, amounting to 10-12 tonnes, with many,
very heavy single lifts. Besides, the other lifts in the total period were relevant with regard to load on
the hips. As the drivers assistant was very young at the time of the exposure and had a daily lifting
load in excess of 20 tonnes for most of the period, the requirement to the duration of the load can be
reduced from 15 to 10 years. The more moderate lifting work of about 3-4 tonnes in the last 11 years
will be included as maintaining, hip-loading lifting work, even though this exposure period would
not in itself qualify for recognition. Therefore there is also good time correlation between the onset of
the disease around the age of 30 and the load.
Example 7: Claim turned down unilateral degenerative hip arthritis after moderate lifting work (river
supervisor)
A 56-year-old man worked for 23 years as a river supervisor for a regional authority. The work mainly
consisted in dredging of rivers and looking after the river banks, including grass mowing and nature
conservation. The daily lifting load was about 5-6 tonnes, with typical single lifts of 10-12 kilos, in the
form of wet river material on a fork. The lifting conditions were usually difficult he stood in the river,
shovelling the river material upwards onto the river bank. However, there were hardly ever any heavy
single lifts of 20 kilos or more. Towards the end of the period the river supervisor was diagnosed with
moderate to severe degenerative arthritis of the right hip, whereas x-rays of the left hip showed normal
conditions. The claim does not qualify for recognition on the basis of the list. The river supervisor did
not suffer from bilateral degenerative hip arthritis, which is a requirement for recognition on the basis
of the list. And even if the degenerative arthritis had been bilateral, it still would not qualify for
recognition on the basis of the list as the work did not involve sufficient hip-loading lifting work. The
daily lifting load was 5-6 tonnes, i.e. less than 8 tonnes. Besides, there were no heavy single lifts of at
least 20 kilos, amounting to a total of at least 1 tonne per week. Nor did the river supervisor have many
100
daily, very heavy single lifts of at least 40 kilos or other special stress conditions that might give
grounds for reducing to 5-6 tonnes the daily requirement for a lifting load of 8 tonnes. In this case there
are no grounds for submitting the claim to the Occupational Diseases Committee as the river supervisor
did not perform heavy, hip-loading work, which is a special risk factor in connection with the
development of unilateral degenerative hip arthritis.
Example 8: Claim turned down bilateral degenerative hip arthritis after lifting work in good lifting
postures (fitting worker/controller)
A 57-year-old woman was diagnosed by a medical specialist and after x-ray examinations with
moderate, degenerative arthritis of both hips. She had worked for about 16 years in a business that
manufactured components for the machine industry. Her work consisted in controlling fittings of
components lying on a conveyor belt in front of her, and in occasionally checking with a screwdriver
the correct fitting of individual components. The work was performed in a standing posture in front of
the belt, and each object typically weighed between 5 and 8 kilos. When performing the control, the
fitting worker lifted each single object in order to assure its quality and then put it back on the belt in
front of her. The daily lifting load amounted to approximately 8 tonnes in the form of approximately
1,000-1,500 lifted components per day. To this should be added a number of daily lifts of boxes with
discarded metal objects and pallets weighing 20-30 kilos each and constituting an aggregate weekly
load of about 1 tonne. It appeared from the information of the case that the work at the belt was
performed in working postures that were beneficial for the hips, the lifts being performed close to the
body without any load on the hip joints such as twisting and turning, stooping, lifts away from the
body, high lifts, etc. The heavy single lifts amounting to about 1 tonne per week were made in hip-
loading lifting postures. The claim does not qualify for recognition on the basis of the list. The fitting
worker for 16 years performed lifting work equivalent to about 8 tonnes, with typical single lifts of 5-8
kilos. From a general point of view, the total daily lifting load of 8 tonnes and the duration of the load
for more than 15 years meet the requirements of the list. By far the most lifts were performed in good
lifting postures, however, which were not particularly stressful for the hip joints. Furthermore, the
single lifts typically weighed 5-8 kilos, which cannot in itself be deemed to be sufficiently heavy to
cause a relevant, stressful shift of weight in the hips, the lifting postures not being stressful. Even
though the injured person met the general requirements to the daily load and the duration of the load as
well as the requirement for heavy single lifts amounting to at least 1 tonne per week, the work cannot,
since the lifting conditions in connection with the other lifted objects were not stressful for the hip
joints, be deemed to be sufficiently stressful for the development of bilateral degenerative hip arthritis.
More information:
Osteoarthritis in the hip and knee. Influence of work with heavy lifting, climbing stairs or ladders, or
combining kneeling/squatting with heavy lifting. Review (www.ask.dk)
101
disease
Arthron (Greek) Joint
Arthrosis, osteoarthrosis,
A chronic joint disease with degeneration and atrophy of the joint
osteoarthritis, degenerative
cartilage
arthritis
Bilateralis Bilateral
BMD Bone Mineral Density (calcium content of bones), for instance in
connection with hormonally reduced calcium content (BMD) of the
femoral head
BMI Body Mass Index; BMI over 30 = severe obesity
BMI is calculated as kilos/(metres)2
Bursa Fluid-filled cavity
Bursitis Inflammatory degeneration of a bursa
Calv-Legg-Perthes disease The three names refer to the three medical researchers who described
the disease. The disease is also called osteochondritis deformans
juvenilis. It is an aseptic bone necrosis (aseptic = infectious condition
without bacteria, necrosis = tissue death) of the epiphysus of the caput
femoris (caput = head, femur = thigh bone, epiphysiolysis = slipped
growth area). It is a disease that in particular hits boys, especially
overweight boys aged 5-15. In the femoral head there is a growth area.
A slip in this area causes a dislocation of the two bone parts bordering
on the growth area. This causes a secondary deformation of the
femoral head
Caput Joint head, for instance caput femoris (the joint head of the thigh
bone)
Coxa, coxae Coxa = hip, coxae = hips
Coxalgia Pain of the hip joint (coxa = hip, algos = pain)
CT scan CT is short for computer tomography. Tomography means that the x-
ray tube that emits the rays evolves around the scanned
(photographed) object. When a CT scan is performed, an x-ray is sent
through the tissue.
102
The easiest to see is hard tissue with low transparency (such as bones,
which therefore are white), and the hardest to see is tissue with high
transparency (soft tissue), but many muscles and other soft
tissue/organs, prolapsed discs, some tumours, some degeneration of
the brain as well as blood vessels and bleeding can be seen. Cranial
bones and vertebrae are better seen in a CT scan than in an MR scan.
103
tissue, tissue fluids, blood vessels, muscles, tendons, ligaments, organs, soft
tissue, prolapsed discs, and the brain, as well as tumours and bleeding.
Furthermore it is possible to cut thin cross-sections at intervals of few
millimetres transversely, axially and diagonally to the area in question.
Therefore it is also possible for the physician to look into anatomy and
diseased degeneration in various selected areas, in the axial and transverse
planes of patients.
The images are digitalised and can be stored and reformatted later on, so that
other requests regarding the images can be met.
The National Board of Industrial Injuries is not allowed to request this type
of paraclinical examination (MR scan).
104
consistent with the joint surface (bone loss). Often the reactive bone
degeneration, particularly in the form of sclerosing and osteophytes,
becomes more pronounced in this period.
Osteoporosis Atrophy of the bone mass; os = bone, porosis = porosity
A condition where a reduced calcium content of the bone makes bone tissue
prone to fracture
Pistol grip deformity A congenital deformity of the hip, causing the femoral neck and the
condyles to look like the shaft of a revolver
Primaria Primary stage
Subchondral cyst Sub = under, chondros = cartilage, cyst = cavity.
A cavity of the bone under the cartilage of a joint
105
Chapter 4. Diseases of the knee
List of contents
106
1.Degenerative arthritis of the knee joint (D.1)
The following knee disease is included on the list of occupational diseases (group D, item 1):
Disease Exposure
D.1. Degenerative arthritis of the knee joint Kneeling and/or squatting work for many years
(arthrosis genus)
A medical doctor must have made the diagnosis of degenerative arthritis of one or both knee joints
(arthrosis genus, ICD-10 M17).
The diagnosis of degenerative arthritis of the knee joint requires the presence of
relevant subjective complaints and
clinical manifestations and
clinical, objective degeneration and
established arthrotic degeneration in x-rays, assessed on the basis of standing exposures of the
knee joint and sitting exposures of the knee cap
Subjective complaints
Pain of the knee joint
Swelling of the knee joint
The load triad:
- Start pain
- Stress pain
- A weak and unstable sensation
Ease when resting
Reduced walking distance
Creaking in connection with moving the knee joint
107
Restricted motion of the knee joint (flexion and extension deficiency)
Objective signs
Swelling of the knee joint with effusion below the knee cap
Creaking in connection with moving the knee joint
Restricted knee joint motion (frequent extension deficiency)
Atrophy of the thigh muscle (quadriceps)
Deformation and malalignment
Instability (in progressed cases)
Swelling at the back of the knee joint (Baker cyst)
Reduced gait function
Kneeling work is work that is performed while lying on one or both knees. Squatting work is work with
one or both knees maximally flexed. Examples of work functions where kneeling or squatting work or
a combination of both is performed would be bricklayers work, such as fitting bathroom; roofer work,
or floor-layer work.
The requirement for kneeling and/or squatting work for many years means that in principle kneeling
and/or squatting work must have been performed for more or less uninterrupted period of 20 to 25
years.
It must have been a work function where at least half of the working day (at lest 3-4 hours) was spent
doing kneeling and/or squatting work. Furthermore there is a requirement regarding time correlation
between the exposure and the onset of the symptoms.
One decisive argument against recognition would be if there was a period without symptoms between
the cessation of the knee-loading work and the onset of the symptoms. This applies, for instance, if the
symptoms of degenerative arthritis of the knees develop after several years without employment or
after several years of employment without any load on the knees. This applies regardless of whether
there previously was work that met the exposure requirements.
If there has been knee-loading work for a period of time meeting the exposure requirements, the
degenerative arthritis may be recognised, even if the symptoms arise in a later period of more
moderate, but still relatively knee-loading work.
108
Rheumatoid arthritis
Systemic diseases with secondary joint symptoms
Previous infection of the knee joint
Secondary joint symptoms to infectious diseases
Age
Gender
Examples of other exposures that might be recognised after submission to the Committee would be
work involving lifts of heavy burdens in twisting and awkward, knee-loading postures, for example
much climbing of ladders and scaffolding with heavy burdens. Entrepreneurial work, work as a
bricklayers assistant and work as a farmhand are examples of work that can be particularly stressful
for the knee.
Also ballet dancers and professional athletes, whose work causes special loads on the knee joints in the
form of frequent downward jumps and/or much twisting and turning of the knees, are examples of
particularly knee-loading types of work that it may be relevant to submit to the Committee.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
Example 1: Recognition of degenerative arthritis of both knees after kneeling work (bricklayer for 30
years)
A 59-year-old man had worked as a bricklayer for more than 30 years. The first 15 years he did
brickwork, foundation work, smoothing of concrete layers on floors and in bathrooms in new building
projects, as well as tile-fitting. The masonry work and tiling work had been partly kneeling work,
whereas smoothing of concrete layers was kneeling work only. Altogether he had worked in a kneeling
position for 75 per cent of the day. He had increasing pain in his knees and was diagnosed by a medical
specialist with degenerative arthritis of both knees joints. The diagnosis was confirmed by x-rays.
The claim qualifies for recognition on the basis of the list. The bricklayer performed kneeling work for
the major part of the working day, for a period of more than 30 years. He was diagnosed with
degenerative arthritis of both knees, and there is good time correlation between the disease and the work.
Example 2: Recognition of degenerative arthritis of the left knee after kneeling and squatting work
(welder for 30 years)
A 54-year-old man had worked as a welder for 30 years. The first 22 years the work was mainly done
in a squatting or crawling posture under cramped conditions, mainly with pressure on the left knee. The
remaining years the work was performed in a standing posture for two thirds of the working day,
whereas one third of the working day was spent in a kneeling posture. He developed symptoms in his
left knee, and the diagnosis of degenerative arthritis of the left knee was made by a medical specialist.
109
The diagnosis was confirmed by an x-ray examination. The claim qualifies for recognition on the basis
of the list as he did kneeling and squatting work as a welder for 30 years. For 22 of those years, there
was relevant knee-loading work for more than half of the working day.
Example 3: Recognition of degenerative arthritis of both knees after kneeling and squatting work
(machine engineer for 28 years)
A 53-year-old man worked as a machine engineer for 28 years, doing kneeling and squatting work for 3
to 5 hours a day. After 25 years he had symptoms from both knees. A medical specialist established
degenerative arthritis of both knees.
The claim qualifies for recognition on the basis of the list. The engineer was diagnosed with
degenerative arthritis of both knees after having had kneeling and squatting work for 28 years. The
knee-loading work was performed for the major part of the working day, and there is good time
correlation between the onset of the disease and the work.
Example 4: Recognition of degenerative arthritis of both knees after kneeling work (pipe smith for 24
years)
A pipe smith had worked in a shipyard for 24 years. He had been welding half of the time and fitting
pipes the other half of the working day. The work was performed under cramped conditions and often
in awkward postures. 90 per cent of the time the work was performed in a kneeling posture. The pipe
smith had been using knee protection for the whole of the employment period. There was a pre-existing
trauma of the right knee which had not given any symptoms. He developed pain in both knees, and a
medical specialist diagnosed him with degenerative arthritis of both knees, more pronounced in the
right knee.
The claim qualifies for recognition on the basis of the list. The pipe smith was diagnosed with
degenerative arthritis of both knees, after 24 years of kneeling work under cramped conditions in
awkward positions for approximately 90 per cent of the working day. The pre-existing trauma had no
significance for the assessment of the claim.
Example 5: Claim turned down degenerative arthritis of left knee after kneeling work (ship builder
for 25 years)
A 49-year-old man had worked as a ship builder for 25 years when he started getting symptoms from
his left knee. The work as a ship builder involved welding in the bottom of ships. The work was
performed in a kneeling posture for one third of the working day.
The claim does not qualify for recognition on the basis of the list. The ship builder performed kneeling
work for one third of the working day for 25 years and developed degenerative arthritis of his left knee.
Thus he meets the requirement for kneeling work for at least 20-25 years. However, the claim does not
meet the requirement that the kneeling work must have been performed for at least half of the working
day.
Example 6: Claim turned down degenerative arthritis of both knees after kneeling and squatting work
(metal worker for 29 years)
A 63-year-old man had been employed as a plumber and metal worker for 29 years. The first 8 years
the work consisted in repairs under train wagons and in replacing sanitary equipment and seats in the
wagons. Approximately 2 hours of the working day he worked in a kneeling posture.
110
The next 21 years he was employed as a boiler man, where every day, for approximately 2 hours in
connection with repairs, he was crawling in channels 70 centimetres high. The remaining work did not
involve any special load on the knees. He subsequently developed degenerative arthritis of both knees.
The claim does not qualify for recognition on the basis of the list. The metal worker developed
degenerative arthritis of both knees after having performed kneeling and squatting work for about one
fourth of the working day for 29 years. Therefore he does not meet the conditions that there must be
kneeling and/or squatting work for at least half of the working day for 20-25 years.
Example 7: Claim turned down degenerative arthritis of left knee after kneeling work (insulation
worker for 30 years)
A 49-year-old man had worked as an insulation worker for 30 years. The work was performed from
floor, ladder and scaffolding. There had not been any lifting of heavy burdens. According to the
information of the case he had performed kneeling work for 60 per cent of the working day. At the age
of 19, after a twisting trauma to his left knee and later recurring pain, the insulation worker had the
external meniscus of his left knee removed.
An arthroscopy examination a few years later established onsetting degenerative arthritis of the
external joint chamber of his left knee. Already in connection with the previous operation a medical
specialist made the diagnosis of degenerative arthritis consistent with the external joint chamber, where
the meniscus had been removed. The diagnosis was confirmed by x-rays of the knee.
The claim does not qualify for recognition on the basis of the list. It must be deemed to be very likely
that degenerative arthritis of the external joint chamber of the left knee can be attributable to the
removal of the external meniscus, degenerative arthritis of the external joint chamber of the left knee
already having been established a few years after the injury. The meniscus injury has no correlation
with the work.
Example 8: Claim turned down degenerative arthritis of both knees after kneeling and squatting work
(carpet fitter for 15 years)
A 52-year-old floor-layer had worked for 15 years with laying and fitting of carpets. Over half of the
working day was spent in a kneeling or squatting posture. At the age of 50 he started getting symptoms
from both knees. He was diagnosed with degenerative arthritis of both knee joints. He was 1.80 metres
tall and had for many years been obese, weighing about 130 kilos (BMI=130/ (1.8)2= 40).
The claim does not qualify for recognition on the basis of the list. The injured person only performed
kneeling and squatting work for a period of 15 years. Therefore there has not been kneeling and/or
squatting work for at least 20-25 years. There is furthermore considerable obesity.
More information:
Osteoarthritis in the hip and knee. Influence of work with heavy lifting, climbing stairs or ladders, or
combining kneeling/squatting with heavy lifting. Review (www.ask.dk)
111
1.7. Medical glossary (degenerative arthritis of knee joint)
112
2. Bursitis (inflammatory degeneration of bursa, D.2 and J.1)
2.1. Item on the list
2.2. Diagnosis requirements
2.3. Exposure requirements
2.4. Examples of pre-existing and competitive diseases/factors
2.5. Managing claims without applying the list
2.6. Examples of decisions based on the list
2.7. Medical glossary (bursitis of the knee)
Disease Exposure
D.2. Inflammatory degeneration of knee Persistent, external pressure for days or longer
bursa (bursitis)
The disease can develop relatively acutely, but may develop into a chronic condition. Both conditions
are covered by the item of the list.
Bursitis caused by infection (bacteria) is only covered if there are indications of a localised infection of
the knee or a bursa, in other parts of the body, not caused by a general body infection. A localised
infection leading to bursitis may have been caused by the kneeling work and contamination of the knee
caused by such work. Similarly, bursitis other than in the knee may have been caused by a localised
contamination where the bacteria are absorbed through the skin in connection with work.
Symptoms
Reddening
Swelling (increased liquid in the bursa)
Pain
Heat
113
Perhaps restricted motion due to pain
Objective signs
Swelling of the bursa
Thickening of the capsule of the bursa
Perhaps pain-related restriction of motion in the joint
In the acute phase there may be heat, swelling, reddening and pain in connection with palpation of
the bursa
Callosity over the bursa
Acute bursitis
Acute bursitis may be conditioned by an infection (for example with bacteria) or
a condition similar to an infection (without bacteria), as a consequence of irritation (for example in that
the knee cap is constantly being pressed against the floor while the person is kneeling).
The condition is characterised by reddening, swelling, pain, heat, and restricted motion due to pain.
Chronic bursitis
Chronic bursitis can be conditioned by a previous infection (for example with bacteria) or
a previous condition similar to an infection (without bacteria), as a consequence of chronic irritation
(for example in that the knee cap is constantly being pressed against the floor while the person is
kneeling).
The condition is characterised by a thickening of the capsule around the bursa and increased liquid in
the bursa. Often there will be thickened skin over the bursa due to the persistent external pressure.
Inflammatory degeneration of a bursa, caused by infectious conditions with or without bacteria,
without preceding work involving exposure to external pressure, is not covered by the item.
In order for the load to be characterised as relevantly stressful for a bursa there must have been
work that involves constant external pressure, for example against the knee cap
work with a relevant pressure impact for days or longer
The stressful work must have been performed for at least half of the working day (3-4 hours).
114
It is a prerequisite for recognition that there is good time correlation between the disease and the
stressful work.
The exposure must be assessed in relation to the persons size and physique, and there must besides be
good time correlation between the exposure and the onset of the disease.
In the processing of the claim we may obtain a medical certificate from a specialist of occupational
medicine. We may i.a. ask the medical specialist to describe and assess the concrete working conditions
and the concrete exposures of the bursa in question. The medical specialist will furthermore make an
individual assessment of the impact of the exposures on the development of the disease in the examined
person in question.
The medical specialist will also give a description of the onset and development of the disease and state
any previous or simultaneous diseases or symptoms and any impact they may have on the current
complaints.
In special cases, other diseases or exposures not on the list may be recognised after submission to the
Occupational Diseases Committee.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
Example 1: Recognition of bursitis at the front of the right knee cap (floor-layer for 1.5 weeks)
A 37-year-old floor-layer was laying floors in a big sports hall. The work took about 1.5 weeks, and he
laid floors for about three fourths of the working day. On the last day he had acute irritation of the
bursa in front of his right knee cap with swelling, tenderness, reddening and pain, and a medical
specialist made the diagnosis of bursitis of the bursa in front of the right knee cap. The diagnosis was
confirmed by a blood sample.
The claim qualifies for recognition on the basis of the list. The floor-layer was diagnosed with
inflammatory degeneration of the bursa at the front of the right knee cap after many days of kneeling
work, which led to persistent pressure on his right knee cap for more than half of the working day.
There is furthermore good time correlation between the work and the disease.
115
Example 2: Recognition of bursitis at the front of the left knee cap (floor cleaning for 8 days)
A 45-year-old cleaner worked in a large industrial cleaning business. For a period of 8 days she worked
with intensive cleaning of delicate wooden floors in a big, private company. This work involved
polishing, in a kneeling posture, of floor and staircase areas for well over two thirds of the working
day. On the last day she felt pain, tenderness and swelling at the front of her left knee cap. A medical
specialist diagnosed her with left-side inflammatory degeneration of the bursa at the front of the knee
cap.
The claim qualifies for recognition on the basis of the list. For the major part of the working day, for 8
days, the cleaner performed kneeling work, leading to persistent pressure on her left knee cap, in
connection with polishing of wooden floors and stairs. Her disease, inflammatory degeneration of a
bursa at the front of the left knee cap (bursitis), furthermore developed in good time correlation with
the knee-loading work.
Example 3: Recognition of bursitis at the front of the right knee cap (ladder work for 12 days)
A 52-year-old painter was painting from a ladder for the major part of the working day for 2 weeks.
During the work his right knee cap was being pressed against a step of the ladder. Towards the end of
the period he had pain and swelling at the front of his right knee cap, and his doctor diagnosed him
with right-sided bursitis. The diagnosis was confirmed by a blood sample.
The claim qualifies for recognition on the basis of the list. The painter performed work on a ladder for
days, which led to persistent, external pressure on his right knee cap for more than half of the working
day. He subsequently developed bursitis at the front of the knee cap, and there is good correlation
between the onset of the disease and the work.
Example 4: Claim turned down bursitis at the front of the right knee cap (floor-layer for 8 months)
A 23-year-old floor-layer worked for a period of well over 8 months. The work consisted in kneeling
work for the major part of the working day. Towards the end of the work period he had increasing pain,
tenderness, swelling and irritation at the front of his right knee cap. Furthermore he had other problems
in the form of feeling unwell and a slight fever. A blood sample showed a general infection in his body
caused by bacteria. A medical specialist made the diagnosis of bursitis at the front of the right knee cap
as a consequence of a general bacterial infection condition.
The claim does not qualify for recognition on the basis of the list. The floor-layer performed work, for
a long period of time and for the major part of the working day, that was relevant with regard to knee
exposure. His disease, inflammatory degeneration of the bursa at the front of the right knee cap, is,
however, very likely to have been caused by the general bacterial infection condition of his body,
which is unconnected with his work.
Example 5: Claim turned down bursitis at the front of the right knee cap (electrician for 19 years)
A 43-year-old electrician worked in a small business for a considerable number of years. His work
typically consisted in minor electric repairs in private homes, and there was a maximum of one hour of
kneeling work per day. After well over 19 years work he developed an acute pain condition, with
reddening and swelling, at the front of his right knee. A medical specialist made the diagnosis of right-
sided, inflammatory degeneration of the bursa at the front of the knee cap. A blood sample confirmed
the diagnosis.
The claim does not qualify for recognition on the basis of the list. The electrician was diagnosed with
inflammatory degeneration of the bursa at the front of the right knee cap after many years work as an
116
electrician. However, his work only for one hour a day consisted in work that involved persistent
pressure against the knee cap. Therefore he does not meet the requirement with regard to having per-
formed work leading to persistent, external pressure against a bursa for at least half of the working day.
Example 6: Recognition of bursitis of the elbow (cleaning of glass test tubes for 6 years)
A 54-year-old woman developed inflammatory degeneration of a bursa of her right elbow (bursitis)
with reddening, swelling, and pain. The disease developed in connection with her work for several
years as a cleaner in a laboratory where she cleaned glass test tubes 4 out of 7 hours a day. This was
done at a counter which was 95 cm tall and had an integral sink and a raised edge. As the sink was 22
cm deep, she was unable to position her legs under the counter, and therefore she had to lean over the
countertop, supported by her right elbow on the edge of the countertop. She first rubbed the test tubes
clean of Indian ink markings and then rinsed them with both hands.
In order to clean a test tube on the inside she held it in her left hand while inserting a swab with her
right hand. She washed about 400 tubes a day, and as she handled each of them four times, she handled
approximately 1,600 tubes per day.
The claim qualifies for recognition on the basis of the list. For 4 hours a day, and for several years, the
cleaner had the task of cleaning glass test tubes. She had to support her right elbow on the edge of a
sink, which resulted in direct pressure on a bursa of her elbow. There is good causality and time
correlation between the work and her disease.
Example 7: Recognition of bursitis of the heel bone (wearing stiff safety boots for 6 years)
A semi-skilled worker in a concrete manufacturing factory developed pain, tenderness and swelling,
consistent with the heel bone of his right foot, after wearing new, stiff safety books for 2 months. The
safety boots were very tight and very stiff around the heel bone, thereby putting pressure on the heel
bone. A specialist of occupational health made the diagnosis of inflammatory degeneration of a heel
bone bursa. After the worker stopped wearing the new safety boots, the complaints receded.
The claim qualifies for recognition on the basis of the list. After wearing new, stiff safety boots for a
couple of months, which caused persistent pressure on his heel bone, the worker developed bursitis
consistent with his right heel bone.
117
Genu Knee
Patella Knee cap
Tibia Shin bone
118
3. Meniscus disease of the knee joint (D.3)
Disease Exposure
D.3. Meniscus disease of knee joint (laesio Work in a squatting position under cramped conditions
meniscus genus) for days or longer
The diagnosis of meniscus disease of the knee joint is made in principle in a clinical, objective
examination. The certainty of the diagnosis may be optimised by way of a supplementary arthroscopy
examination and/or MR scan.
Symptoms
Pain of the knee joint (on the inside or outside, depending on whether it is the outer or inner
meniscus that has been injured)
Swelling of the knee joint
Locking
Lacking extension of the knee joint
Objective signs
Swelling of the knee joint with effusion under the knee cap
Restricted motion of the knee joint (extension deficiency)
Thigh muscle (quadriceps) atrophy
Tender joint line
There are a number of meniscus tests, but they are not very reliable
The results of the clinical examination may be optimised by way of a supplementary arthroscopy
examination and/or MR scans. We cannot, however, request such examinations ourselves.
119
3.3. Exposure requirements
In order for a meniscus disease of the knee joint to be covered by this item of the list, there must have
been exposure in the form of work in a squatting posture under cramped conditions for days or longer.
Meniscus diseases/lesions of the knee joint are frequent in the population, regardless of occupation. In
many cases, however, it is not a work-related disease. Stress factors at work as described above do,
however, lead to a certain increase in the risk of developing the disease.
The load must be mechanically and physiologically relevant for the disease. This means i.a. that the
performed work must have involved a relevant load on the knee joint. Whether the work can be deemed
to have been stressful to a relevant extent depends on a concrete assessment of the loads on the knee
joint in relation to the development of the disease.
The stressful work must have been performed for at least half of the working day.
It is a prerequisite for recognition that there is good time correlation between the disease and the knee-
loading work. The load must be assessed in relation to the persons size and physique, and there must
besides be good time correlation between the exposure and the onset of the disease.
In the processing of the claim we may obtain a medical certificate from a specialist of occupational
medicine. We will i.a. ask the medical specialist to describe and assess the concrete working conditions
and the concrete loads on the knee joint. The medical specialist will furthermore make an individual
assessment of the impact of the loads on the development of the disease in the examined person in
question. In this connection the medical specialist will give a description of the onset and development
of the disease and state any previous or simultaneous knee diseases or knee problems and any impact
they may have on the current complaints.
If an arthroscopy examination and/or MR scan has been made, such examinations can form part of the
assessment and act as a supplement to the clinical examination.
120
example of an exposure that may be recognised after submission to the Committee as being the cause
of a meniscus disease of the knee joint is work as a carpenter with a lot of ladder climbing, which
involves frequent rotation of the knee joints.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
Example 1: Recognition of meniscus disease of left knee joint (ships welder for 2 weeks)
A 41-year-old welder worked in a shipyard. For the major part of the working day, the work consisted
in repairing bottom tanks in a container ship. The tanks were 140 cm tall, which meant that for much of
the working day he had to work in an awkward, squatting working posture with knees bent and knee
joints rotated. He worked i.a. with welding and hammering the plates into place. After 2 weeks work
in the bottom tanks he developed symptoms from the meniscus of his left knee with locking of the knee
joint, swelling, tenderness and pain. A medical specialist made the diagnosis of meniscus lesion of the
left knee, and the diagnosis was confirmed by an MR scan.
The claim qualifies for recognition on the basis of the list. The ships welder was diagnosed with a
meniscus lesion of his left knee after having performed knee-loading work as a ships welder for 2
weeks. For much more than half of the working day, the work was characterised by awkward, squatting
working postures, and at the same time, in particular in connection with work with the hammer, he had
to bend and rotate his knees. There is furthermore good time correlation between the exposure in the
workplace and the onset of the disease.
Example 2: Recognition of meniscus disease of right knee after work (plumber for 6 days)
A 27-year-old plumber worked for 6 days with pipe replacements in a large institution. In the period in
question, about 4-5 hours a day, the work consisted in taking down old pipes and putting up new ones
in the basement system of the institution. It was a very low cellar, the working height being about
120 centimetres. The work therefore had to be performed in an awkward, squatting posture. When
taking down the old pipes and putting up new ones he frequently bent his knees and at the same time
rotated his knee joints in a stooping working posture. After 6 days work he had pain, tenderness and
swelling in his right knee, and a medical specialist made the diagnosis of right-sided meniscus lesion,
based on an arthroscopy examination. He had not previously had problems with his right knee.
The claim qualifies for recognition on the basis of the list. The plumber performed knee-loading work
for days, his work for more than half of the day being characterised by squatting and awkward working
postures, causing frequent rotation and flexion of his knees. He was diagnosed with meniscus lesion of
the right knee, and there is good correlation between the onset of the disease and the knee-joint loading
work.
Example 3: Claim turned down meniscus disease of both knee joints (plumber for 2 years)
A 31-year-old plumber worked in a small business for well over 2 years. His work mainly consisted in
different types of replacement of pipes and sanitary equipment in private homes, including special
piping work and replacement of sanitary equipment in kitchens and bathrooms. The work involved
some kneeling as well as squatting work, but typically there were relatively good space conditions,
allowing him to extend his knees and change working postures during the performance of the work.
After well over 2 years work he had pain and tenderness as well as locking, first in his right knee and
121
after a short while also in the left knee. A medical specialist and an MR scan in a hospital established
minor meniscus injuries to the inner meniscus of both knees. In addition there were indications of
chondromalacia (softened cartilage) of both knees as well as beginning degenerative arthritis of the
right knee.
The claim does not qualify for recognition on the basis of the list. After working for well over 2 years
the plumber was diagnosed with a meniscus lesion in both knees. However, his work was not
characterised by squatting work under cramped conditions where he would have to bend his knees and
at the same time rotate his knee joints for at least half of the working day. Therefore it was not knee-
loading work to an extent covered by the list. Furthermore competitive knee diseases were found.
These must be deemed to have been significant for the overall knee condition.
Example 4: Claim turned down meniscus disease of right knee (ships painter for 5 years)
A 42-year-old painter worked in a shipyard for a period of well over 5 years. More than half of the
working day his work consisted in spray-painting bottom tanks of the ships and in other hardly
accessible ships areas. The space conditions were typically very cramped and the working height was
low. During this part of the working day, the work was usually performed in a squatting posture with
knees bent and knee joints rotated. He had no knee problems, however, in this employment. After well
over 5 years work he found a new job and was employed in a normal painters firm, where the major
part of the work was performed in a standing posture and under good space conditions. After well over
2 years employment in the new job he had sudden pain, tenderness and swelling of his right knee, and
a medical specialist made the diagnosis of right-sided meniscus injury. An MR scan showed a medium
to severe meniscus lesion of the knee.
The claim does not qualify for recognition on the basis of the list. The ships painter had relevant knee-
loading work with squatting under cramped conditions during his 5-year employment.
However, he only developed symptoms of a right-sided meniscus disease 2 years after changing to
work as an ordinary painter, which did not put stress on his knee. Therefore there is no good time
correlation between the disease and the previous, knee-joint loading work.
122
into three parts
Pars femoropatellaris (the joint between the thigh bone and the back
of the patella (knee cap))
Pars femorotibialis lateralis (the joint between the external femoral
condyle and the external tibial (shin bone) plateau)
Pars femorotibialis medialis (the joint between the internal femoral
condyle and the internal tibial (shin bone) plateau)
Bursa Fluid-filled cavity
Bursa praepatellaris Fluid-filled cavity at the front of the knee joint, sitting in front of the
knee cap between the skin and the fascia lata (a band of fibrous
connective tissue) above the knee cap
Bursitis Inflammatory degeneration of a bursa
Chondromalacia patella Softened cartilage behind the knee cap
Chondros (Greek) Cartilage
CT scan See 22.4. above
Femur Thigh bone
Genu Knee
Lateral On the outer side
Malacia Soft
Medial On the inner side
Meniscus lateralis External meniscus, half-moon-shaped cartilage disc between thigh
bone and shin bone
Meniscus medialis Internal meniscus, half-moon-shaped cartilage disc between thigh
bone and shin bone
MR scan See 22.4. above
Patella Knee cap
Syndrome Disease complex, a group of associated symptoms
Tibia Shin bone
X-ray See 22.4. above
123
4. Jumpers knee (D.4)
Disease Exposure
D.4. Jumpers knee Jumping/running with frequent starts and stops
(tendinitis/tendinosis patellaris) (acceleration/deceleration) while flexing and extending the knee
Main conditions
A medical doctor must have made the diagnosis of jumpers knee (tendinitis/tendinosis patellaris) ICD-
10 M76.5).
In order to be able to make the diagnosis of jumpers knee, the following requirements must be met
In some cases the symptoms occur at the tendon attachment from the frontal part of the thigh extensors
(musculus quadriceps femoris) at the upper edge of the kneecap.
Tendinitis/tendinosis at the tendon attachment at the lower and upper part of the kneecap as well as at
the tendon attachment at the lower leg (tuberositas tibiae) are on the list.
The large anterior thigh muscle is composed of four muscles. The muscles are all attached to the upper
edge of the kneecap. The kneecap tendon connects the lower edge of the kneecap with the upper and
124
front part of the shinbone (tuberositas tibia) The function of the kneecap tendon therefore is to transfer
the performance of the large anterior thigh muscle when the knee is flexed and extended.
The kneecap tendon, which connects the lower part of the kneecap with the shinbone, is subject to a
loss of stress when it has to transfer the power released by the powerful thigh musculature to the lower
leg. This frequently repeated load can lead to a rupture at the tendon attachment at the lower edge of
the kneecap.
Symptoms
Tenderness
Pain
Aggravation of pain when knee is flexed/extended under load
Swelling
Warmth
Objective signs
Perhaps pain-related restricted motion of the knee
Tenderness at the tendon attachment above or below the kneecap
125
the disease or whether there are grounds for making a deduction in the compensation if the claim is
recognised.
Meniscus lesion
Rupture of the anterior cruciate ligament
Rupture of the posterior cruciate ligament
Cartilage damage (osteochondral lesions)
Periosteal ruptures (periosteal avulsion)
Tendon inflammation
Accumulation of fluid in the joint
Bursitis
Inflammation of a plica (plica synovialis)
Rupture of the kneecap tendon
Degenerative arthritis (arthrosis)
Soft cartilage at the back of the kneecap (chondromalacia patellae)
Main conditions
In order for jumpers knee to be recognised on the basis of the list, there must have been the following
exposure:
Jumping/running with frequent acceleration and deceleration while flexing and extending the knee
This disease is caused by high pressure on the kneecap in connection with jumping/running, where
there is continued acceleration and deceleration with simultaneous flexing and extending of the knee.
Jumpers knee is the most frequent in sports involving a lot of jumping, for example volleyball and
basketball, which are characterised by jumping and landing where high pressure on the kneecap is
created through acceleration and deceleration during flexing and extending of the knee, which may
overload the tendon above or below.
This is a load pattern which is also seen in certain other types of professional athletes such as football
players, badminton players, tennis players, runners etc., the running movement consisting of bursts of
starting and landing performed many times during the activity.
Intensive weight-training
Intensive weight-training for a long period of time can contribute to the development of the disease.
This is because weight-training with a heavy weight-load increases considerably the pressure on the
kneecap in connection with continued flexing and extending of the kneecap.
This type of load may increase the risk of developing jumpers knee and may give grounds for reducing
the requirement to the duration of the load per week and the total duration in relation to the paragraph
below.
126
However, weight-training alone without a load involving jumping/running cannot in itself lead to
recognition of jumpers knee on the basis of the list.
Hard surface
Jumping and running on a hard surface (indoor courses or outdoor courses with a hard surface or
similar conditions) may increase relatively the pressure on the kneecap and thus also the load on the
knee tendon (patellar tendon) in connection with jumping/running on a soft surface (grass, gravel, etc.).
This type of load may increase the risk of developing jumpers knee and may give grounds for reducing
the requirement to the duration of the load per week and the total duration in relation to
jumping/running on a soft surface, see the paragraph below.
The requirement that the weekly load must have been at least 12 hours and that the total duration of
jumping/running must have been months can, however, be reduced if the load has occurred in
combination with at least 5 hours of intensive weight-training per week and/or jumping/running on a
hard surface.
If there has been a substantial weekly load for 20 hours or more, it is also possible to reduce the
requirement to the duration.
The requirement to the weekly load in the form of jumping/running cannot be reduced to less than 8
hours per week.
The requirement to the total duration of the load cannot be reduced to less than one month.
Time correlation
A prerequisite for recognition is a relevant time correlation between the development of jumpers knee
and the knee-loading work with continued jumping/running.
The relevant time correlation will usually be that the first symptoms of the disease develop some time
after commencement of the stressful work (weeks/months depending on the severity and nature of the
load).
If the onset of the symptoms does not occur in close connection with a relevant load (immediately or
within a few days after the exposure), this will indicate that there are other causes of the disease.
Furthermore, jumpers knee must not have been diagnosed prior to relevant exposure at work.
127
(a) Many hours of hard weight-training per week, where the person in question has not, or only to a
very limited extent, been exposed to loads in connection with jumping/running
(b) Extraordinarily severe weekly loads for less than one month (for weeks)
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
Example 1: Recognition of right-sided jumpers knee (professional football player for 8 years)
A 32-year-old male football player was diagnosed by a medical specialist with right-sided jumpers
knee (tendinosis patellaris), consistent with the tendon attachment under the kneecap. The disorder was
established in a clinical examination and by an MR scan, and there were no other competitive diseases.
For the past 8 years he had been a professional player in one of the big clubs in Denmark, and he had
practised at least once every day. For certain periods of time, for instance up to the start of the season,
practice was more intensive and included training in the morning, training in the evening, and games.
The training was varied and consisted in general football playing, interval training, running, and
weight-training with heavy weights. The football player practised indoors on parquet floors and outside
on grass and man-made grass. A common feature of all training was high pace and intensity. In
addition to training he also played games. He was a regular on the team and therefore started on the
pitch in most of the games, which meant that in the course of one season he played a game
approximately once a week. His total load from jumping and running was estimated at about 20-25
hours per week. To this should be added about 5 hours of intensive weight-training.
The claim qualifies for recognition on the basis of the list. For a number of years, the football player
played ball and practised for more than 12 hours per week on average and was diagnosed with right-
sided jumpers knee (tendinosis patellaris dxt.). Practice as well as games were characterised by
jumping/running with many starts and stops (acceleration/deceleration) while flexing and extending the
knee and with a continual load on the patellar tendon. He also trained with weights, which contributed
to the load. There is also good time correlation between the load and the onset of the disease.
Example 2: Recognition of left-sided jumpers knee (professional handball1 player for 3 years)
A 27-year-old woman was employed on a contract with one of the leading Danish handball clubs for 3
years and played professional handball on top level. In the course of the last year she gradually
developed complaints in her left knee, right above the kneecap, with pain and tenderness as well as
stiffness. Her complaints were particularly evident when she was standing on her left leg and shooting
and running. She had never before had any symptoms from her left knee, and there was no known
trauma to her left knee. A medical specialist in a clinical examination diagnosed her with left-sided
jumpers knee (patellaris tendinitis), consistent with the tendon attachment to the upper part of the
kneecap, which was confirmed by an ultrasound examination. In the course of her 3 years as a
professional player she practised on an average 4-5 times a week and from 3 to 5 hours at a time. The
training alternated between handball training and various handball exercises, stamina training by means
of running, and various strength and weight-lifting exercises. To this should be added games about
once a week, which, like most of the training apart from running, took place indoors in a sports centre
1
The European version of handball
128
on a hard surface. Practice as well as games were characterised by quick changes in pace and many
quick starts and stops as well as jumping up and down, which led to stresses on the left kneecap tendon.
The claim qualifies for recognition on the basis of the list. For more than 3 years the handball player
played handball and practised more than 12 hours per week on average and after 3 years she was
diagnosed with left-sided jumpers knee consistent with the tendon attachment at the upper part of the
kneecap. Training as well as games were characterised by high pressure on the kneecap in connection
with jumping/running with frequent starts and stops (acceleration/deceleration) while flexing and
extending of the knee. In addition, by far the major part of the load occurred indoors on a hard surface.
There is also good time correlation between the load and the onset of the disease.
Example 3: Recognition of right-sided jumpers knee (professional badminton player for 4 years)
A 28-year-old woman had for 4 years worked as a professional badminton player in a big Danish club
when she developed a right-sided jumpers knee with pain, tenderness, swelling and slightly restricted
motion of the knee. A medical specialist diagnosed her with right-sided jumpers knee (tendinosis
patellaris), consistent with the tendon attachment at the lower part of the kneecap, and the condition
was also diagnosed by an MR scan. Her career as a professional badminton player had involved hard
training for several days a week and matches more or less every weekend. The matches involved
jumping/running with continued starts/stops while flexing and extending her knee. The weekly load
was 25-30 hours.
The claim qualifies for recognition on the basis of the list. The badminton player suffered an exposure
relevant for the development of jumpers knee, in the form of jumping/running 25-30 hours a week for
several years and with frequent starts and stops while flexing and extending the knee.
Example 4: Claim turned down left-sided jumpers knee (professional football player working part
time)
A 25-year-old man in a clinical examination was diagnosed with left-sided jumpers knee (tendinitis
patellaris) consistent with the tendon attachment to the lower part of the kneecap. He was a part time
employee in a bank and worked 25 hours a week as a bank adviser. Furthermore he was employed the
last 2 years on a part time contract in a Jutland League football club. Here he practised for about 2
hours, about 4 times a week. During the season, which lasted approx. 8 months, there was only practice
3 times a week, however. He was a replacement player and played about 10 games in the course of a
season. The training mostly consisted in football playing and exercises on a grass course. One of the 3-
4 weekly training sessions consisted in intensive weight-training and strength training.
The claim does not qualify for recognition on the basis of the list. Even if there is a diagnosis of left-
sided jumpers knee, the load as a semi-professional football player was not sufficient. The football
player on an average practised and played games 8 hours a week, including 2 hours of weight-training.
Therefore he does not meet the requirements for exposure in the form of jumping/running with quick
and frequent starts and stops while flexing and extending the knee at least 12 hours a week, perhaps in
combination with intensive weight-training at least 5 hours a week or playing on a hard surface, which
might give grounds for reducing to 8 hours the requirement to the total weekly load. Nor has his work
as a bank adviser led to any relevant loads on his left knee. Nor are there grounds for submitting the
claim to the Occupational Diseases Committee, the football player not having experienced any
extraordinary knee loads constituting any particular risk of developing left-sided jumpers knee.
Example 5: Claim turned down right-sided jumpers knee (professional football player for 6 months)
129
A 25-year-old female football player was diagnosed by a medical specialist with right-sided jumpers
knee with severe and chronic degeneration (tendinosis patellaris), consistent with the tendon
attachment to the lower part of the kneecap. By then she had been a professional football player for 6
months and practised several hours a day, including approx. 4 hours of weight-training per week. In
addition she had played 20 whole football games as a professional in the course of 6 months. Her total
weekly load was about 25 hours. Games as well as training were characterised by jumping/running
with frequent starts and stops while bending and extending the knee, and there was pressure on the
kneecap. It appeared that a year previously she had jumpers knee in the same place, which developed
in connection with football playing in her leisure time as member of an ordinary football club. After
sustaining this injury she had been treated with non-steroidal anti-inflammatory drugs (NSAID), and
the condition had calmed down for a couple of months up to her employment as a professional football
player. But there had been a continued tendency to pain in the knee after severe loads during training.
The claim does not qualify for recognition on the basis of the list. Even though the stresses as a
professional football player for 6 months were sufficient to develop jumpers knee, the football player
previously, and without correlation with work, suffered from jumpers knee. This substantially
increases her disposition to develop the disease again due to chronic degeneration of the tendon
attachment. Therefore the new disorder in the same place is not covered by the list. Nor are there any
grounds for submitting the claim to the Occupational Diseases Committee. This is because it was not
possible to recognise the disease, it not being likely beyond reasonable doubt that the disorder was
caused, solely or mainly, by working as a football player.
More information:
Is a jumpers knee work-related? A systematic review to find evidence for a possible case definition
(www.ask.dk)
130
Meniscus lateralis External meniscus, half-moon-shaped cartilage disc between thigh bone
and shin bone
Meniscus medialis Internal meniscus, half-moon-shaped cartilage disc between thigh bone
and shin bone
M. quadriceps Quadriceps muscle, the large muscle at the front of the thigh
MR scan See 22.4. above
NSAID Nonsteroidal anti-inflammatory drugs
Osteochondral Bone and cartilage
Patella Knee cap
Peritendinitis Inflammatory degeneration of the tissue enveloping a tendon
Plica synovialis Synovial fold
Pronation Slight inward rolling motion the foot makes during a normal walking or
running stride
Supination Turning or rotating (the foot) by adduction and inversion so that the
outer edge of the sole bears the body's weight
Tendinitis/tendinosis Inflammatory degeneration of a tendon (tendinitis)
Tendovaginitis/tenosynovitis Inflammatory degeneration of a tendon sheath (there are no tendon
sheaths in the knee, and therefore there occurs no tendovaginitis/
tenosynovitis consistent with the knee)
Tibia Shin bone
131
Chapter 5. Vibration disorders
List of contents
132
1. Hand-arm vibration disorders (white finger, peripheral neuropathy,
degenerative arthritis (C.3))
Disease Exposure
C.3.1. Vibration-induced white finger Work with heavily vibrating hand tools (hand-arm
(Raynauds syndrome, Raynauds disease) vibration)
133
For medical requirements for each disease we refer to the subparagraphs below.
The clinical diagnosis of white finger is in principle made in a clinical objective examination.
If the clinical objective examination cannot immediately confirm the diagnosis of white fingers, an
attempt can be made at documenting the disease in the ways stated below. If the attempt at provoking
an attack of white fingers is not successful, the disease cannot be deemed to have been documented and
the claim cannot be recognised on the basis of the list.
Description of symptoms
Regardless of the documentation method used, there always has to be a clear symptom description
which sets out in detail which fingers and how much of the fingers may react with colour changes and a
dead feeling. Furthermore there needs to be a detailed description of the delimitation and of the course
of the attacks (prevalence, frequency, and duration).
Work-related vibration disorders are usually reviewed by specialists of occupational health, but the
documentation of attacks can also take place in other ways, see above.
134
Symptoms
Vibration-induced white fingers are triggered by the cold and are seen as paleness (lividness) of the
fingers from the tips, with a sharp delimitation towards the proximal joint of the finger. During the
attack all affected fingers feel dead. The attack may include one or more fingers, but seldom affects the
thumb. When the attack is subsiding, the lividness is replaced by a blue/red discolouration
accompanied by a tickling sensation.
Objective signs
The diagnosis of white fingers is basically made in a clinical examination. Findings in a clinical
examination while the person in question is having a white finger attack will be sharply delimited white
fingers, involving one or more fingers on one or both hands.
In a large number of cases there will be a need for the person in question to have supplementary
medical examinations made:
If there is a clear discrepancy between exposure to vibrating tools and the severity of the disease, it
needs to be examined in detail what the explanation may be.
135
1.2.2. Peripheral neuropathy of hand/fingers
A medical doctor needs to have made the diagnosis of peripheral neuropathy of hands/fingers (morbus
alius nervorum periphericorum) ICD-10 G64.9.
The diagnosis is made against the background of a combination of
The injured persons subjective complaints (symptoms)
A clinical objective examination
The result of a neurophysiological examination (EMG/ENG), provided such an
examination has been made. We cannot demand invasive examinations, but this
type of examination can also be made non-invasively with surface electrodes
Furthermore it may be beneficial to take a blood sample in order to rule out that
substantially competitive conditions such as alcoholism, diabetes, B12 vitamin
deficiency or folic acid deficiency may be the primary cause of the disease
Peripheral neuropathy means injury to the distal nerves (impact on nerve ends or degeneration of nerve
roots) and may occur in hands as well as feet.
Peripheral means that there is damage to the ends/roots of one or more nerves with diffuse neuropathic
complaints as a consequence of an impact on several big main nerves (nervus medianus, nervus ulnaris
and nervus radialis) of the forearm. See also figure 1 below.
Figure 1: The three main nerves of the forearm/hand (n. radialis, n. ulnaris and n. medianus,
white in the drawing)
n radialis
n ulnaris
n medianus
Peripheral neuropathy is caused by an impact on the wrist, where the three said nerves run under a
ligament on the under side of the wrist, and therefore the symptoms need to radiate from the wrist itself
into the hand, not higher up in the arm.
The disease needs to involve at least one of the three said main nerves of the forearm with consistent
symptoms. Usually the disease will affect several of the mentioned three nerves (polyperipheral
136
neuropathy), but the disease can also be limited to a single nerve (monoperipheral neuropathy). Both
types are covered by the list.
The peripheral nerves are divided into sensor and motor nerves. The sensory nerve impulses have the
effect that you for instance feel touch, pain, temperature, and pressure. The motor nerve impulses go to
musculature and tendons. This means that peripheral neuropathy may become manifest as fine motor
and sensory complaints, but not necessarily both at the same time.
Peripheral neuropathy can also be an accompanying disease to white fingers (Raynauds disease) and
will in that case accompany the white finger attacks as opposed to an independent peripheral
neuropathy, where the symptoms typically will be of a more permanent nature. The peripheral
neuropathy will then in principle be regarded as a consequence of white fingers, which may qualify for
recognition on the basis of the list, and therefore will not be processed as an individual disease.
Cases of neuropathy in other regions than hands and fingers are not covered by this item of the list of
occupational diseases. If there is peripheral neuropathy of hands as well as feet, this will furthermore be
indicative of the disease having other causes than hand-arm vibrations in the workplace.
Nor are other nerve diseases of the arm, such as impingement/impact on the nervus medianus (carpal
tunnel syndrome), nervus ulnaris or nervus radialis with symptoms consistent with other diagnoses than
peripheral neuropathy, including symptoms higher up in the arm than the wrist and fingers, covered by
this item on the list.
For carpal tunnel syndrome, as opposed to peripheral neuropathy radiating from the medianus nerve,
there will be a well-delimited pressure neuropathy at the wrist. An EMG/ENG examination will
likewise contribute to clarifying if it is a case of carpal tunnel syndrome or peripheral neuropathy.
If impingement/impact on the nervus medianus (carpal tunnel syndrome), nervus ulnaris or nervus
radialis has been established, with accompanying peripheral neuropathy, it is not possible to recognise
the peripheral neuropathy as a separate disease under item C.3 of the list, but perhaps as an
accompanying disease to the primary disease provided this disease is recognised as an occupational
disease.
For impingement/impact on nervus ulnaris, reference is made to item J.2 of the list. For carpal tunnel
syndrome (nervus medianus), reference is made to item C.2 of the list.
Symptoms:
Pain
Paresthesias (tingling or pricking in fingers)
Reduced sensitivity in hand/fingers (reduced sense of vibration and temperature)
Reduced force
Reduced fine motor function of fingers
Objective findings:
Findings in a clinical examination can be
Reduced sensitivity of fingers, palm and back of hand
Changed sense of pain, temperature and vibration
137
Changed sense of distinction between blunt and pointed
Reduced force and motion/motor function
The reliability of the diagnosis can be optimised by a supplementary examination for measuring of the
nerve conduction velocity (neurophysiological examination by means of electroneurography = ENG
examination or electromyelography = EMG examination), which may be able to establish
dysfunctioning of the nerve function consistent with the peripheral nerves of the hand/fingers.
We cannot demand invasive examinations, but this type of examination can nowadays also be made
non-invasively with surface electrodes.
Competitive diseases/factors:
Like most other diseases, peripheral neuropathy can develop or become aggravated as a consequence of
other diseases or factors not connected with work. Therefore the National Board of Industrial Injuries
will make a concrete assessment of whether the nature and extent of any disclosed competitive factors
may give grounds for turning down the disease entirely or whether, if the claim is recognised, there are
grounds for making a deduction in the compensation.
Examples of possible competitive factors which may affect the onset or the course of the disease:
Diabetes 1 and 2
Raynauds disease (white finger)
Toxic factors (alcohol, medicine, metals, solvents, radiotherapy/chemotherapy etc.)
Infections (HIV, borreliosis, etc.)
Connective tissue diseases (real arthritis/rheumatoid arthritis and other autoimmune diseases)
Traumas/fractures with nerve damage
Carpal tunnel syndrome
Impingement of nervus ulnaris and nervus radialis
Certain types of degenerative arthritis or prolapsed disc of the cervical spine with root
involvement
Plexus brachialis impact/lesion
Neuropathy in other regions than the hands/fingers
Vitamin and folic acid deficiency
In order to make the diagnosis of degenerative arthritis of wrist or elbow joint, the following are
required:
Relevant subjective complaints and
138
Clinical manifestations and
Clinical objective changes and
Arthritic degeneration of elbow or wrist established by x-rays or scans
Degenerative arthritis of the fingers, including the carpometacarpal joint of the thumb, is not
covered by the list.
Competitive diseases/factors
Like most other diseases, degenerative arthritis of the elbow or wrist can develop or become aggravated
as a consequence of other diseases or factors not connected with work. Therefore the National Board of
Industrial Injuries will make a concrete assessment of whether the nature and extent of any disclosed
competitive factors may give grounds for turning down the disease entirely or whether, if the claim is
recognised, there are grounds for making a deduction in the compensation.
Examples of possible competitive factors which may affect the onset or the course of the disease:
A condition for recognising white fingers and peripheral neuropathy of hands/fingers is that there must
have been vibration through hands and arms from hand-held tools, hand-held machines or stationary
machines, the exposure happening through some kind of object.
Exposure to whole-body vibrations from vehicles etc. is not covered by this item.
Requirements are made to vibration intensity as well as duration. The intensity is measured by
vibration acceleration, the so-called frequency-weighted acceleration, which is indicated by a
measuring unit in metres per second2 (m/s2) or decibel (dB). Vibration levels less than 2.5 m/s2 or 128
dB are not covered by the list.
Against the background of surveys made, the International Organization for Standardization (ISO) has
set up the correlation between exposure intensity and duration and stated the intensity/duration where
10 per cent of those exposed to vibrating tools will develop white fingers.
This standard (ISO 5349 from 1986) is the starting point for the Boards assessment of the vibration
exposure and can be seen in form 1 under paragraph 8.3.3.
More specific requirements to the vibration exposure will depend on the severity of the exposure as
well as the extent of the use of heavily vibrating hand tools per day and over time with reference to the
form.
139
Therefore, in order to be able to assess the vibration exposure, it is necessary to know the types of tools
that have been used, for how many hours per day and for how many years.
For the purposes of making an assessment, if it is not possible to get information on the concrete
acceleration level of the tool, there is a form with an indicated average level, see form 2 in paragraph
8.3.3.
It should be noted that old tools usually have a higher vibration level than new tools, which are often
vibration dampened.
It is furthermore a prerequisite for recognition that there should be a good time correlation between the
disease and the work with vibrating tools. For white fingers and peripheral neuropathy the relevant time
correlation is that the first symptoms of the disease are seen some time after commencement of the
stressful work of hand and arm. Depending on the extent and severity of the load, some time usually
means about one year and up to several years.
However, the assessment must stress whether for instance there have been extraordinarily severe, daily
stresses. In such cases, from a medical point of view, there will be a time correlation between the work
and the development of the disease, even if the onset of the first symptoms is a short while after
commencement of the wrist-loading work. However, the disease must not have been manifest as a
chronic disease before commencement of the stressful work.
The load needs to be assessed in relation to the persons size and physique, and furthermore there needs
to be a good time correlation between the exposure and the onset of the disease.
When processing the claim, the National Board of Industrial Injuries may obtain a medical certificate
from a specialist of occupational medicine. The medical specialist will i.a. be asked to describe in detail
the applied vibrating tools and their degree of vibration in relation to the individual work function, as
well as the daily time spent and the total duration of using the tools in question.
The medical specialist will furthermore make an individual assessment of the importance of stress
factors for the development of the disease in the examined person in question.
1.3.2. Exposure requirements for recognition of degenerative arthritis (arthrosis) of wrist and
elbow joint
Degenerative arthritis (arthrosis) of wrist and elbow joint only qualifies for recognition under item C.3
of the list after particularly severe and long-term exposure to vibrating tools.
In principle there needs to have been at least 20 years exposure with a daily load of up to several
hours, using extremely heavily vibrating tools with a vibration severity of at least 10 m/s2 in the form
of for instance pneumatic percussion tools (for instance road breakers) or similar tools.
Furthermore there must not be other substantial competitive factors such as the effects of fractures of
the wrist or elbow.
140
1.3.3. Vibration intensity, tools and measuring units
The relationship between Hertz and m/s2 and dB (vibration frequency in relation to vibration
acceleration)
2.5 m/s2, which is the minimum limit for vibration intensity in order to recognise a claim on the basis
of the list, is equivalent to 128 dB.
In a few cases the concept of Hertz (Hz) is used as the unit stated for the vibration load rather than the
units m/s2 or dB. However, these are two entirely different units which are not immediately
comparable.
The measuring units dB and m/s can be mutually converted and are a measure of the vibration
acceleration (= intensity or severity), whereas Hertz expresses the vibration frequency as such, meaning
only fluctuations per minute.
Frequencies in the area 6-20 Hertz are the most harmful, and frequencies over 1,000 Hertz are less
harmful. Therefore, a tool that primarily has a high vibration frequency (a high Hertz number) will
typically lead to a relatively low acceleration level (vibration intensity) measured in m/s or dB.
However, determining the vibration intensity will require an actual measurement of the tool based on
acceleration rather than vibration frequency (in m/s2 or dB).
Typical high-frequency hand-held tools with a high Hertz number, but relatively low vibration
acceleration and therefore low vibration intensity, are dentists drilling and grinding tools and
corresponding high-frequency instruments/tools with a high number of revolutions. The vibration
intensity for this type of tool will typically be significantly lower than the list requirement of at least
2.5 m/s2 (128 dB).
Table 1 on the correlation between exposure to vibrations and vibration-induced diseases of hand
and fingers
The table shows the correlation between daily exposure in hours per day, number of years and the
degree of vibration intensity. The form states how much it takes for white fingers/neuropathy to
develop.
141
Table 2 with examples of acceleration levels for some types of vibrating hand-held tools in the
period 1970-1984
Re acceleration group:
I: Less than 3 m/s2 II: 3-10 m/s2 III: More than 10 m/s2
(under 130 dB) (130-140 dB) (over 140 dB)
Type of machine/work Acceleration group Comment
I II III
Angle grinders X X The grinding disc substantially
affects the level.
X New grinders.
142
Other diseases or exposures not on the list will in special cases qualify for recognition after submission
of the claim to the Occupational Diseases Committee.
Examples of special exposures which may be recognised as causes of diseases not on the list:
White fingers (Raynauds disease) or peripheral neuropathy after vibration exposures between 2
and 2.5 ms2 for a very considerable number of years
White fingers (Raynauds disease) or peripheral neuropathy after vibration exposures with
severe vibration intensity for less than one year
White fingers after significant frost exposure for a considerable period of time, including as a
consequence of actual frostbite
Dupuytrens disease (contracture of the fingers caused by damage to the tendon plate of the
hollow of the hand) as a consequence of work with severely vibrating hand-held tools
Hypothenar hammer syndrome (acute thrombosis and/or pseudo aneurysm of the ulnar artery in
the hypothenar region) as a consequence of repetitive blunt traumas (blows) against the hand or
work with severely vibrating hand-held tools
For specific examples we refer to the guide to the special nature of the work, chapter 22.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
143
few days later he experienced how his fingers became livid when exposed to cold. An examination by
his GP, which included a simple cold provocation test, established white finger of the 2nd, 3rd and 4th
fingers of his right hand (Raynauds phenomenon, dxt.).
The claim qualifies for recognition on the basis of the list. The metal worker was exposed to severely
vibrating hand-held tools with a vibration intensity of between 4 and 22 m/s2 for 1-2 hours a day for 15
years, up to the onset of symptoms, and has furthermore been diagnosed with white fingers in a cold
provocation test. Thus he meets the list requirements for recognition of white fingers.
The claim qualifies for recognition on the basis of the list. For 30 years the warehouse manager had
worked with hand-held vibrating tools with an acceleration level of more than 5 m/s2. The white finger
disease has been confirmed in an EMG examination and includes several fingers on his right and left
hand, both of which have been exposed to the stresses from the hand-held vibrating tools.
The claim does not qualify for recognition on the basis of the list, there being no documentation of
white fingers. To this should be added that the exposure is below the requirements of the list, the
gardener only having been exposed to vibration stresses of between 3 and 8 m/s2 for 2 hours a day one
day a week, which is equivalent to an average of less than 0.5 hours per day, distributed on a 5-day
work week, for 6 years. Nor are there any grounds for submitting the claim to the Occupational
Diseases Committee.
The claim qualifies for recognition on the basis of the list. The machine operator has been exposed to
powerful vibrating tools with an intensity of 10 m/s2 or more for half of the working day for 5 years,
including 4 years up to symptom onset. He therefore meets the requirements for recognition, on the
basis of the list, of peripheral neuropathy of four fingers on each hand, which has been documented in
blood pressure measurements, and no other cause of the disease has been found.
145
Example 7: Recognition of right-sided peripheral neuropathy (unskilled worker in a quarry for 22
years)
A 58-year-old man worked for 22 years as an unskilled worker in a granite quarry on the Danish island
of Bornholm, where his job was to bore holes for positioning of explosives. He was exposed to
severely vibrating hand/arm tools for about half of the working day, such as pneumatic drills, hand-
operated excavators and pneumatic chisels. The typical vibration intensity was 8-10 m/s2. After 5-6
years he developed signs of white finger (Raynauds disease), which was recognised as an industrial
injury. In the last couple of years of his employment he developed reduced sensibility and motor
capacity of his right hand and he experienced reduced strength. A nerve conduction examination
showed slightly reduced nerve conduction velocity of the ulnar nerve and the median nerve
respectively, but without any sign of carpal tunnel syndrome or any actual effect on or paralysis of the
ulnar nerve. The neurophysiological medical specialist made the diagnosis of digital neuropathy of the
fingers of the right hand (injury to the nerve fibres of the fingers in connection with using vibrating
tools).
The claim qualifies for recognition on the basis of the list. The unskilled worker for 22 years was
exposed to very severely vibrating hand-held tools for half of the working day and has been diagnosed
with polyperipheral neuropathy of the fingers of his right hand. To the extent that he has previously
received compensation for these effects, the calculation of the compensation may deduct any overlap
between the consequences of neuropathy and the recognised white finger disease.
Example 9: Claim turned down diffuse right-sided neuropathy symptoms (machine worker for 18
years)
A 62-year-old man worked as a machine worker/fitter for several different undertakings for many
years. The last 18 years he was exposed, for 3-5 hours a day, to severe hand-arm vibrations from tools
that he used for assembling machines. These were for instance shuffle sanders, powerful drilling
machines and grinding machines. His work besides was very strenuous work with much heavy
handling and many strenuous movements of his right hand and arm. Towards the end of the period he
146
developed burning, itching, and painful sensory disturbances in his right forearm and hand and all
fingers, in particular the 3rd, 4th and 5th fingers. However, extensive hospital examinations, including
measurements of nerve conduction velocity, showed no clear signs of diseases of his arm, including
effects on or impingement of one or more nerves of the arm (median, ulnar or radial nerves), or
peripheral neuropathy.
The claim does not qualify for recognition on the basis of the list. Though the machine worker has
performed work with severely vibrating hand-held tools several hours a day for a considerable number
of years and thus has suffered relevant exposure with regard to developing peripheral neuropathy, he
has not been diagnosed with this disease. Nor have any other, possibly work-related diseases of the arm
been established that might qualify for recognition, on the basis of the list or after submission to the
Occupational Diseases Committee, as a consequence of the very strenuous work.
Example 10: Claim turned down peripheral neuropathy and impingement of the ulnar nerve
(bricklayer for 19 years)
A 57-year-old man worked as a skilled bricklayer for 19 years up to 1986, when he left the trade and
found other work that was not so hard on his arms. As a bricklayer he mainly worked with repairs and
new buildings in the agricultural sector. He i.a. used pneumatic chisels up to several hours a day. From
1986 he was employed as a machine operator with no or only very sporadic vibrations from hand-held
tools. Around 1992-1993 he began to develop complaints in both forearms, and examinations
established impingement of the ulnar nerve on his right side and peripheral neuropathy on his left side.
The peripheral neuropathy on his left side does not qualify for recognition on the basis of the list. The
disease only developed several years after the relevant stresses and cannot, with regard to time and
cause, be referred to the exposure to vibrating hand-held tools up to 1986. The impingement of the
ulnar nerve on the right side is not covered by item C.3 of the list, but may be recognised on the basis
of item J.2 of the list if there has been external direct pressure on the ulnar nerve for a considerable
period of time. This is not the case here, however. Nor are there any grounds for submitting the
diseases to the Occupational Diseases Committee.
Example 11: Claim turned down peripheral neuropathy (dentist for 21 years)
A 50-year-old man worked as a dentist for 21 years. Towards the end of the period he developed
mononeuropathy of the 2nd finger of his right hand with i.a. a tingling sensation, which was established
by measuring the nerve conduction velocity (ENG examination). He worked up to about 50 hours a
week as a dentist. An estimated 36 hours he worked with patients sitting in the dentists chair. For
about 1.5-2 hours a day he worked with a hand-held tooth drill, which he handled between the 1st, 2nd
and 3rd fingers of his right hand. A high proportion of his work was precision work with relatively
long-term, fixated working positions. The occupational health specialist involved in the case stated that
dentists are exposed to vibrations at a typical frequency between 6,000 and 40,000 Hertz. In the
specific case it was found that the vibration intensity had been at a level from under 1m/s2 to a
maximum of a little more than 1m/s2, the severest exposure having been early in the period.
The claim does not quality for recognition on the basis of the list. The dentist has been diagnosed with
peripheral neuropathy in the form of mononeuropathy (neuropathy from one nerve). The work with
high-frequency vibrating hand-held tools, in the form of primarily tooth drills, for up to 1.5-2 hours a
day has, however, led to a vibration intensity somewhat below the level of at least 2.5 m/s2 which is the
minimum requirement for recognition of vibration-induced hand-arm diseases on the basis of the list.
Nor have there been any extraordinary vibration stresses that might give grounds for submission of the
claim to the Occupational Diseases Committee.
147
1.5.3. Examples of decisions on degenerative arthritis of elbow/wrist
Example 12: Recognition of degenerative arthritis of the elbow (metal grinder for 30 years)
A 52-year-old man had worked for 30 years as a metal grinder, grinding metal about 5 hours a day. For
grinding he used hand-held and very severely vibrating grinding machines with an acceleration power
between 18 and 20 m/s2. After 30 years exposure he began to have problems with his left elbow,
which he was unable to fully extend, and he had tingling in all fingers of his left hand. x-rays of his left
elbow showed initial degenerative arthritis. The metal grinder had not had fractures to elbow, wrist or
other parts of his left arm.
The claim qualifies for recognition on the basis of the list. For 30 years and many hours a day he was
exposed to very severely vibrating hand-held tools with a vibration intensity of more than 10 m/s2, and
there is no information of competitive factors of any significance for the onset of the disease.
Example 13: Claim turned down degenerative arthritis of the wrist (floor layer for 45 years)
Since completing his apprenticeship at the age of 20, a 65-year-old floor layer had been laying floors
many hours a day. When working he used his left hand in particular, this being his primary hand. He
lifted heavy carpets and flooring material, pushed floors, sawed, puttied, and added adhesive with his
left hand. He also occasionally sanded the floors, using a big sanding machine, but the extent of this
work was only a few days a month. An examination by his GP towards the end of the period led to
suspicion of degenerative arthritis of his left wrist, which was established in a later x-ray examination.
The claim does not qualify for recognition on the basis of the list. The floor layer was not exposed to
hand-arm vibrations from very severely vibrating hand-held tools for several hours a day for a large
number of years. Nor have there been any other extraordinary stresses which might give grounds for
submission of the claim to the Occupational Diseases Committee.
148
Chapter 6. Other diseases of the musculoskeletal system
List of contents
149
5.4. Examples of pre-existing and competitive diseases/factors
5.5. Managing claims without applying the list
5.6. Examples of decisions based on the list
5.7. Medical glossary (chronic neck and shoulder pain)
150
1. Diseases of hand and forearm (C.1)
De Quervains disease, which is tenosynovitis of the tendons that move the thumb, is included under
this item (tenosynovitis styloideae radii M65.4).
Diseases of the hand/wrist and a finger may be included under the item.
Generalised or diffuse pain of hand or forearm, tendon lumps (ganglion M67.4), trigger finger
(stenosing tendovaginitis/digitus saltans M65.3) and diseases of tendons and tendon tissue in other
parts of the body cannot be recognised under item C.1.
Symptoms
For tendovaginitis, tendinitis and peritendinitis there is pain, tenderness and, in the acute condition,
maybe swelling, heat and reddening of the attacked area.
The symptoms of infection and inflammation are the following:
Pain (dolor), reddening (rumor), heat (calor), swelling (tumor), and restricted motion (functio laesia).
Objective signs
151
Direct tenderness and pain in connection with palpation of the area. In the acute phase there
may be swelling and grating, the same as when trying to squeeze a bag of potato flour
Indirect tenderness and aggravation of pain in connection with resistance movements and
extension of the tendon
Tenderness along the tendons or the transition between tendons and muscles of the forearm (at
the elbow joint or the wrist), without actual muscular tenderness
In terms of intensity, the load needs to be mechanically and physiologically relevant in relation to the
disease in question. Ordinary lifting work, for instance, regardless of weight, does not in itself make the
work strenuous and stressful for hand or forearm, whereas repeated lifting in combination with a
functional posture which is awkward for the wrist can be relevantly stressful. Therefore, whether or not
the work is stressful for the hand or the forearm depends on a concrete assessment of the general work
load in relation to the disease.
Strenuous work
Relevant elements in the assessment of whether the work is strenuous can be
the degree of use of muscular force of hand/wrist in connection with the work
whether the work involves application of gripping force
whether the unit gives resistance
whether there are simultaneous twisting or turning movements
awkward working postures for hand/wrist besides
Repetitive work
In order for it to be characterised as repetitive, the work must involve repeated movements of the
fingers or the hand, at a certain frequency/intensity, for a substantial part of the working day. In
principle there need to have been several repeated movements per minute.
The frequency of stressful movements cannot be determined in detail, but depends on a concrete
assessment of the repetition frequency, seen in relation to the work strenuousness and the posture of the
hand or wrists.
152
Movements in awkward postures are not optimal and thus increase the load on for example muscles,
tendons and connective tissue.
For example there may be alternation between very strenuous work with slight to moderate repetition
for one third of the working day, and highly repetitive, but only moderately strenuous work with the
wrist held in awkward positions for one third of the day. In the last third of the working day, no work is
performed that is stressful for the hand or wrist. In such cases there is alternation between different
work functions in the course of the working day, where two of the work functions meet the
requirements to relevant exposure and where, at the same time, the exposures stretch over more than
half of the working day. The claim therefore qualifies for recognition on the basis of the list.
The load will be assessed in relation to a persons size and physiognomy, and there needs to be good
time correlation between the exposure and the onset of the disease.
In our processing of the claim, we may obtain a medical certificate from a specialist of occupational
medicine. We will i.a. ask the medical specialist to describe and assess in detail the strenuousness, the
repetition, and the load of the working posture on hand or wrist, in relation to the work functions in
question. The medical specialist will furthermore make an individual assessment of the impact of
exposure factors on the development of the disease in question in the particular examined person.
153
Nerve diseases of hand or forearm can, however, be covered by the list under other items (e.g. item C.2
or C.3).
Other diseases or exposures not on the list may in special cases be recognised after submission to the
Occupational Diseases Committee. Examples of diseases that may be recognised after submission to
the Committee are arthritic diseases of the hand and radial tunnel syndrome.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
The right-thumb tendovaginitis qualifies for recognition on the basis of the list. The work for one week
involved intensive de-pipetting work for 5-6 hours a day with manual pipettes, which required
frequently repeated movements with moderate strenuousness and awkward postures for the right
thumb. The thumb was also previously exposed in the same way, but to a lesser extent.
The bilateral tendovaginitis qualifies for recognition on the basis of the list. For several years and about
4 hours a day, the cleaner suffered a relevant load on both wrists in connection with high-pressure hose
cleaning and, to a lesser extent, by wet mopping of rough floor surfaces. Both of these functions were
performed with repeated, strenuous and awkward movements of both wrists.
The tendovaginitis of the right wrist qualifies for recognition on the basis of the list. The packer
performed lifting work and folding of cartons, which led to repeated, awkward and slightly strenuous
movements of the right wrist for more than half of the working day and for several months.
The right-wrist tendovaginitis qualifies for recognition on the basis of the list. For 1.5 years, for at least
half of the working day, his work involved repeated, strenuous and awkward movements of the right
wrist in connection with grinding. Spray-lacquering work also involved a strain on the wrist, though to
a lesser extent.
155
The claim qualifies for recognition on the basis of the list as the work was performed at a highly
repetitive pace and required considerable exertion, including much lifting and pulling with
simultaneous twisting and turning movements of the wrist and application of gripping force.
The claim qualifies for recognition on the basis of the list. The seamstress performed work that was
strenuous and repetitive and stressful for the forearm. The work involved repeated movements with
exertion and gripping force as well as twisting of the wrist. A simultaneous trigger finger is not covered
by the recognition as it cannot be deemed to have been work-related.
The claim qualifies for recognition on the basis of the list. The work was repetitive and required
considerable exertion in connection with repeated heavy lifts and simultaneous turning movements of
the wrist throughout the working day.
Example 9: Recognition of wrist tendinitis (carpenter with strenuous work for 3 weeks)
A 24-year-old man worked as a carpenter. After a storm he worked intensively for a period of 3 weeks,
making emergency cover-ups for destroyed roofs. The work involved many lifts of heavy roof plates,
which he subsequently tightened with a 2-3-kilo, battery-run drilling machine. He fastened about 1,000
screws per day, and each screw involved exertion of his right hand, with simultaneous twisting of the
wrist. Immediately after performing this work he developed wrist tendinitis of his right wrist.
The right-wrist tendinitis qualifies for recognition on the basis of the list. For a three-week period the
carpenter had intensive roof work, and the fixing of roof plates involved continued, strenuous and
awkward movements of his right wrist several times per minute and, to a certain extent, heavy and
awkward lifts of roof plates.
Example 10: Recognition of De Quervains disease (fitting worker with tenosynovitis of the thumb)
A fitting worker worked in a large electronics business that manufactured various metal components.
She had three different work functions in the course of the working day. In one function she operated a
riveting machine, performing high-pace work movements with pressing and twisting of the thumb and
applying moderate muscular strength. In the other function she fitted different part components. This
work likewise involved some strenuousness with a direct load on the right thumb and occurred at a
156
moderate to high pace in working postures that were slightly awkward for the thumb. In the last
function she forwarded components/products to other departments and did general casual work such as
clearing away and supplying new part components. The last function did not involve any special load
on the thumb. The three work functions were rather evenly distributed over the working day. After
about 2 years work she developed pain and motion problems consistent with the thumb side of the
wrist, and a medical specialist found that it was a case of De Quervains disease. No signs of
degenerative arthritis were found in the examinations.
The claim qualifies for recognition on the basis of the list. The fitting worker performed repetitive to
highly repetitive work, at the same time applying muscular force with her right thumb, in connection
with handling of components. For well over 2 years she performed work functions straining the thumbs
for more than half of the working day in different work functions and was subsequently diagnosed with
tenosynovitis of a tendon at the right-hand thumb (De Quervains disease). There is good correlation
between the exposures and the pathological picture.
Example 11: Recognition of tendinitis of the hand after heavy kitchen work
A kitchen helper worked in an old central kitchen in a hospital. For more than half of the working day
her work consisted in performing rather hard kitchen helper functions, such as heavy stirring work,
cleaning of vegetables etc. with a brush, cleaning of many pots, pans and dishes with a sponge and a
brush, and thorough cleaning of the surfaces of the kitchen with a sponge, brush, and cloth in the
course of and at the end of the working day. Besides she performed a great deal of heavy and awkward
lifting of goods, kitchen utensils, etc. After well over 8 years employment she developed pain in her
right hand radiating into the forearm. The medical specialist made the diagnosis of tendinitis of the
right hand.
The claim qualifies for recognition on the basis of the list. The kitchen helper performed different types
of heavy kitchen work, including heavy stirring, heavy cleaning of vegetables and kitchen utensils, as
well as cleaning of kitchen areas, for several years and for more than half of the working day. The work
involved frequent, repeated turning, twisting and flexion/extension movements of her right hand and
wrist with application of a great deal of muscular force, and there is furthermore good time correlation
between the onset of the disease and the work.
Example 12: Recognition of tendovaginitis of the left thumb (cleaning for 10 years)
A 52-year-old woman worked as a full-time cleaner, for more than 10 years, for several employers. Her
last job was in a hotel, where she worked 4.5 years prior to the onset of the disease. She developed pain
in her left thumb and wrist as well as swelling and reddening, and a specialist of occupational medicine
diagnosed her with left-sided tendovaginitis of the tendons of the thumb (De Quervain sin.).
In her last job leading up to the onset of the disease she had stressed her left wrist, mopping floors 50-
60 per cent of the time or about 4 hours a day, and wringing a cloth for about 1.5 hours a day, about
twice per minute. The remaining work functions consisted in vacuum cleaning, wiping of surfaces
without wringing cloths, emptying wastepaper baskets, etc. The functions of wet mopping and
wringing cloths implied repeated, awkward and strenuous movements of her left hand and thumb up to
many times per minute, for a total of 5.5 hours a day, whereas the remaining functions were not
stressful for her left hand.
The claim qualifies for recognition on the basis of the list. The cleaner performed cleaning work with
floor mopping and wringing of cloths for several years, about 5.5 hours a day. Both functions implied
157
repeated, awkward and strenuous movements of the left hand. She furthermore has clear signs of
tendovaginitis of the left thumb (De Quervains disease) and there is good time correlation between
disease and work.
Example 13: Claim turned down tendovaginitis of fingers in laboratory technician (blood sampling
etc.)
A laboratory worker worked in a hospital for 4 years, every day using a blood sampling system
requiring her to create a partial vacuum in the container by pulling back a piston. This movement was
made with both hands, with a powerful thumb and index finger grip, 60 to 100 times a day. In addition
she performed varied types of laboratory tasks, including screwing off small container caps. She
typically did the blood sampling for a couple of hours a day. She developed pain of both hands and was
diagnosed with tendovaginitis of the 1st, 2nd and 3rd fingers of both hands.
The claim does not qualify for recognition on the basis of the list. The work involved easy, strenuous
movements of the fingers of both hands up to 60-100 times a day, but apart from that there was no
relevant strain on the fingers. The work movements involved in operating the blood sampling system
were not stressful to an extent covered by the list. It was taken into consideration that the laboratory
work did not involve repeated, strenuous or perhaps awkward work movements for the fingers within
the meaning of the list. In particular, the requirement for repeated strenuous movements cannot be
deemed to have been met.
Example 14: Claim turned down tendovaginitis in postal worker (sorting and easy lifts)
For a couple of years a woman was employed as a postal worker, sorting letters, newspapers and
magazines and coding them using a keyboard. The work involved a great deal of very easy lifts and
some turning movements of the wrist in the course of the working day. She developed pain in her right
wrist and was diagnosed with tendovaginitis.
The claim does not qualify for recognition on the basis of the list. Even though the sorting work was of
a repetitive nature, it was not strenuous work. Nor were there any special and risky loads besides that
might give grounds for submission of the claim to the Occupational Diseases Committee.
Example 15: Claim turned down tendovaginitis in social and healthcare helper (care work)
A social and healthcare helper worked in home healthcare for well over 7 years. The work involved
heavy morning care of an elderly, walking-restricted client with about 5-7 patient-handling tasks a day.
In addition, she had easier care and support functions with two other clients with about 2-4 patient-
handling tasks a day. And besides she had tasks in connection with cleaning and shopping etc. She
developed pain of her right wrist after 6 years, and her doctor diagnosed her with tendovaginitis of the
right wrist.
The claim does not qualify for recognition on the basis of the list. The injured person was employed for
several years doing a combination of healthcare work and practical tasks (cleaning, shopping, etc.) with
different clients in home healthcare. The work, including the care work described, was not charac-
terised by strenuous, repetitive movements, and the disease therefore is not covered by the list. Nor are
there any grounds for submitting the claim to the Occupational Diseases Committee.
Example 16: Claim turned down tendovaginitis of the thumb tendon of the right hand (De Quervains
disease) in home help
158
The injured person had complaints from the thumb of her right hand after having worked as a home
help for about 9 years. She worked 30 hours a week in home care doing varied tasks, including
cleaning up to a couple of hours a day. The cleaning tasks included vacuum cleaning, dusting and floor
wash and cleaning of kitchens, baths, and toilets. The care work consisted in helping four clients get
out of bed every morning. This included washing them in bed, getting them dressed in bed and helping
them sit in a chair. The injured person had up to 20 handlings of each client. Once a week she helped
them take a bath, and the injured person also put on support stockings 6 or 7 times a day.
The claim does not qualify for recognition on the basis of the list. The injured person for several years
had a combination of home care work in the homes of various clients. The work, including the care
work described above, was not characterised by strenuous, repetitive movements of the thumb for at
least 3-4 hours a day, and therefore the disease is not covered by the list of occupational diseases. Nor
are there any grounds for submitting the claim to the Occupational Diseases Committee.
Example 17: Claim turned down tendon irritation of hand in assistant technician (PC and mouse/pen)
An assistant technician worked for over 10 years doing PC work and using professional design
programmes as well as Microsoft programmes. She worked with a PC mouse and, towards the end of
the period, a pen for 5-7.5 hours a day, 4 days a week. She developed pain in her right arm and hand,
and her doctor diagnosed her with tendon irritation (peritendinitis) of her right hand.
The claim does not qualify for recognition on the basis of the list, the work using PC mouse and pen
not involving relevant exertion of the right hand. This is a list requirement.
Nor are there grounds for submitting the claim to the Occupational Diseases Committee in order to
obtain recognition of the claim without application of the list.
The reason is that there is no adequate medical documentation that working with PC mouse and pen
generally increases the risk of diseases of the hand or wrist, even after several years of intensive PC
work. Nor is the only or predominant cause of the tendon irritation of the right hand the persons work.
This is because the exposure set out above, 20-30 hours work per week for 10 years with a PC mouse
and pen, cannot be deemed to be a particular exposure that substantially increases the risk of
developing the reported disease.
More information:
A critical review of evidence for a causal relationship between computer work and musculoskeletal
disorders with physical finds of the neck and upper extremity (www.ask.dk)
159
Tendovaginitis Inflammatory degeneration of a sheath of a tendon
The suffix it is Inflammation caused by micro organisms or inflammatory degene-
ration without micro organisms. With regard to work-related diseases
the inflammatory degeneration is always without micro organisms.
Disease Exposure
C.2. Carpal tunnel (a) Work with heavily vibrating hand tools for a considerable amount of time
syndrome
(b) A combination of quickly repeated, strenuous and/or awkward, wrist-loading
work movements for a considerable amount of time
(c) Work with objects leading to direct and persistent pressure on the median
nerve of the carpal tunnel for a considerable amount of time
A medical doctor must have made the diagnosis of carpal tunnel syndrome (ICD-10 M56.0).
Carpal tunnel syndrome is caused by a squeezing of the median nerve of the hand (nervus medianus) in
the so-called carpal tunnel of the flexion side of the wrist. Apart from the median nerve, nine tendons
pass through this tunnel. If there is lack of space there may be pressure on the nerve, and the symptoms
of this pressure are called carpal tunnel syndrome.
160
the result of a neurophysiological examination (EMG/ENG), if available we are not allowed
to request any invasive examinations
The clinical diagnosis in connection with carpal tunnel syndrome is made by way of a clinical,
objective examination. The certainty of the diagnosis can be optimised with a supplementary nerve
conduction examination (neurophysiological examination by means of electro neurography or electro
myelography).
If a nerve conduction examination does not confirm the diagnosis of carpal tunnel syndrome, there is
not adequate documentation of the disease, and the claim cannot be recognised on the basis of this item
on the list.
If the injured person has been operated for carpal tunnel syndrome, operative intervention will in itself
be sufficient documentation of the disease, even if a nerve conduction examination performed after the
operative intervention may not be able to support the diagnosis.
Symptoms
Sensory disturbances in the medianus region
Painful dead sensations (paraesthesia)
Aggravation of pain and symptoms under stress
Night-time aggravation of pain and other symptoms (perhaps wormlike sensations at the wrist)
Objective signs
The diagnosis of carpal tunnel syndrome is usually made in a clinical examination. Findings in a
clinical examination can be
reduced sensation of fingers, palm, and back of hand
change in sense of pain and temperature
change in sense of distinction between blunt and pointed
muscular atrophy
The results of the clinical examination can be optimised by a supplementary nerve conduction
examination. If it is carpal tunnel syndrome, the neurophysiological examination will show dysfunction
of the nerve function consistent with the carpal tunnel.
The disease carpal tunnel syndrome is frequent in the population regardless of occupation, in particular
in women. In many cases it is not a work-related disease. However, work exposures, as outlined above,
do lead to a considerably increased risk of developing the disease.
161
The load needs to be mechanically and physiologically relevant for the disease. This means i.a. that the
performed work must have constituted a relevant load on the wrist. Whether the work was relevantly
stressful depends on a concrete assessment of the total load on the wrist seen in relation to the
development of the disease.
Requirements are made to vibration intensity as well as duration. The intensity is measured by the
acceleration of the vibration, the so-called frequency-weighted acceleration, which is indicated as
metres per second2 (m/s2) or decibels (dB). In principle the load will correspond to at least a vibration
level of 2.5 m/s2.
Tools with a vibration level of less than 2.5 m/s2 usually will not be regarded as heavily vibrating hand-
held tools, and exposure to such tools will not be covered by the list.
For the requirements with regard to the exposure period, refer to the form below regarding vibration
exposure in hours/years, depending on the vibration severity of the applied tools. As appears from the
form, there usually must have been a relevant exposure for at least 1-2 years (acceleration level 10-20).
The duration and intensity need to be equivalent to the standards stated in the form. This means that the
requirements to the duration per day or year will be less strict if the vibration level is higher than stated
in the standard. Therefore, in order to be able to assess the vibration exposure, it is necessary to know
what type of vibrating tool has been used as well as its vibration rate. Furthermore information is
needed on the number of hours per day and number of years the tool was used. If it is not possible to
get information on the concrete acceleration level of the tool, the form states for the assessment the
average levels.
It should be noted that old tools usually have a higher vibration level than new ones, which are often
vibration-dampened.
Form on the correlation between exposure to vibrations and carpal tunnel syndrome
The form shows the correlation between daily exposure in hours and years and the degree of vibration
intensity. The form states how much it takes for carpal tunnel syndrome to develop.
162
20 6 years 4.2 years 3 years 2.1 1.5 1.1
years years years
The calculations in the form were made on the basis of ISO-standard No. 5349.
Examples of acceleration levels for some types of vibrating hand-held tools in the period 1970-
1984. Frequency-weighted acceleration at the grip during paid work:
Re acceleration group:
I: Less than 3 m/s2 II: 3-10 m/s2 III: More than 10 m/s2
(under 130 dB) (130-140 dB) (over 140 dB)
Type of machine/work Acceleration group Comment
I II III
Angle grinders X X The grinding disc substantially
affects the level.
X New grinders.
X Most.
X With vibration dampening.
Circular saws for plate
cutting X Auto repair.
Poker vibrators X Most.
X Certain new models.
163
2.3.2. Quickly repeated, strenuous and/or awkward work movements (C.2.(b))
If a claim is to be recognised on the basis of item C.2 of the list, carpal tunnel syndrome, there needs to
have been a combination of quickly repeated, strenuous and/or awkward wrist-loading work move-
ments for a considerable amount of time. A combination means that the work needs to include at least
two of the stated load factors; i.e. quickly repeated, strenuous and/or awkward work movements.
The frequency of the stressful movements cannot be finally determined, but depends on a concrete
assessment of the repetition frequency in relation to the performance of the work and the remaining
stressful conditions involved in the work, such as simultaneous, awkward working postures for the
wrist and/or exertion.
In order that the work can be seen as being characterised by awkward work movements, there need to
be movements that cause a special load on the wrist. Such movements are made with the wrist held in
an awkward posture deviating from the normal functional posture or involve continuous twisting,
turning, extension or flexion movements of the wrist. In principle there needs to be considerable
deviation from the optimal functional posture.
Combined assessment
If there is a very high degree of strenuousness and the working postures at the same time are very
awkward for the wrist, the repetition frequency requirement will be relatively less strict. However,
there always has to be a certain repetivity of the work movements. Similarly, in connection with
moderately strenuous work and good working postures for the wrist, the requirement to the repetition
frequency will be stricter.
If the work involves quickly repeated work movements with simultaneous, very awkward working
postures, there will not be a requirement for strenuousness in excess of what is normal in order to move
the hand (normal functional power). However, a simultaneous exertion somewhat in excess of the use
164
of normal functional power does contribute to the risk of developing a disease and therefore this would
speak in favour of a reduction in the requirement to the repetition frequency and the awkwardness of
the working posture.
If the work is characterised by quickly repeated and strenuous work movements, the working postures
do not necessarily have to be awkward at the same time.
2.3.3. Work with objects leading to direct and persistent pressure (C.2.(c))
Work with objects leading to pressure on the median nerve of the carpal tunnel means work processes
using objects (tools or other units) that cause persistent and external, direct pressure on the nerve in the
course of the working day.
The specific requirements to the duration of the exposure will depend on a concrete assessment of the
nature and scope of the load (severity). If there has been a very extensive exposure, this would speak in
favour of a relatively brief exposure period (1-2 years). A relatively moderate exposure, on the other
hand, would require a longer exposure period. Similarly, if there has been a very long exposure period,
this would speak in favour of a reduction of the requirement with regard to the intensity of the
exposure.
For work with heavily vibrating tools, however, special rules for the duration apply, depending on the
vibration intensity of the tools and the daily exposure in terms of hours. See the above paragraph on
work with heavily vibrating hand-held tools, including the form on vibration intensity in relation to the
duration.
A prerequisite for recognition is a good time correlation between the disease and the wrist-loading
work. For carpal tunnel syndrome the relevant time correlation exists if the first symptoms of the
disease occur some time after the commencement of the wrist-loading work. Depending on the
exposure, some time is usually understood as at least 1-2 years.
However, the assessment does take into account if, for example, there have been extraordinarily big,
daily loads. In such cases, from a medical point of view, there will be a time correlation between the
work and the development of the disease, even if the first symptoms show within a shorter period after
the commencement of the wrist-loading work. However, the disease must not have manifested itself as
a chronic disease before the stressful work was commenced.
The stressful work needs to have been performed for at least half of the working day.
If different work functions were performed in the course of the working day, an assessment of the total
daily load on the wrist will be made. This assessment will include the load caused by each work
function and the total duration of the different loads.
For example there may have been alternating, quickly repeated and strenuous wrist-loading work
movements for one third of the working day and quickly repeated and very awkward work movements
for one third of the working day. In the last third of the working day no wrist-loading work was
performed. In this case there is a shift between different work functions over the working day, two of
165
the work functions meeting the requirements for a relevant exposure, and the exposures at the same
time stretching over more than half of the working day. The claim therefore qualifies for recognition on
the basis of the list.
The load will be assessed in relation to the persons size and physiognomy, and besides there must be
good time correlation between the exposure and the onset of the disease.
In our claims management we may obtain a medical certificate from a specialist of occupational
medicine. We will i.a. ask the medical specialist to describe and assess, in concrete detail and in
relation to the particular work functions, the frequency and nature of the work movements. The assess-
ment will include the application of force and the working postures of the wrist, and perhaps the
vibrating tools used and their degree of vibration intensity, as well as any direct pressure exposures.
The medical specialist will furthermore make an individual assessment of the impact of load factors on
the development of the disease in the specific examined person. A nerve conduction examination may
form part of the assessment as a supplement to the clinical examination.
Example 3: Claim turned down carpal tunnel syndrome (forklift truck driver for 7 years)
The injured person had worked as a warehouse worker in a large company for well over 7 years. For
almost the whole working day, his work consisted in driving a forklift truck. According to the
information of the case he drove older trucks, where vibrations from the vehicle were transmitted to the
driver via the steering wheel. According to the information of the case the vibration level was very
moderate, however, and under 1 m/s2. After well over 7 years work a medical specialist diagnosed the
injured person with carpal tunnel syndrome of the left hand.
The claim does not qualify for recognition on the basis of the list. The injured person suffered a left-
hand carpal tunnel syndrome, after working for several years as a forklift truck driver with moderate
vibration exposures to the wrist from the vehicle. However, the vibration exposure does not meet the
requirements of the list, the vibration level being substantially below 2.5 m/s2.
167
The injured person worked as a fish trimmer in a fish factory for 3 years. She sat at a conveyor belt,
trimming fish with a short, sharp fillet knife. The trimming included the removal of neck bone, fillet
bone, fin root bone, tail bone and middle bone, using small cutting movements. In connection with the
trimming, her hand and forearm were locked in each cut with simultaneous turning of the wrist.
However, the work did require the application of a bit of hand force. She trimmed on average 7-10
fishes per minute, equivalent to well over 60 slight movements per minute with the knife hand (right
hand). After well over 3 years work she developed pain and sensory disturbances as well as a dead
sensation of her right hand and forearm. A medical specialist made the diagnosis of right-hand carpal
tunnel syndrome, which was confirmed in a neurophysiological examination.
The claim qualifies for recognition on the basis of the list. The injured person worked as a fish trimmer
for 3 years before developing a right-hand carpal tunnel syndrome. The work was characterised by
extremely quickly repeated, small cutting movements with moderate exertion of the right knife hand,
performed in a slightly awkward wrist posture, which was stressful for the right wrist. There is
furthermore good time correlation between the work with the extremely quickly repeated, moderately
strenuous and awkward work movements for 3 years and the onset of the disease.
Example 5: Recognition of bilateral carpal tunnel syndrome (book binder for 10 years)
The injured person worked full time in a book binding firm for about 10 years. Her work mainly
consisted in operating a book machine and feeding it with paper sheets. She picked up a stack of paper
and placed it in a vertical position in front of her. Then she adjusted the sheets of paper. She placed
with both hands the papers at the feeding entrance of the machine, which was positioned at chest
height. She fed the machine well over 14,000 sheets an hour, equivalent to a frequency of 30-40
feedings per minute. After well over 10 years work she developed chronic pain of both forearms,
especially the right arm. A medical specialist made the diagnosis of bilateral carpal tunnel syndrome
and she was subsequently operated in both arms.
The claim qualifies for recognition on the basis of the list. The injured person worked as a book binder
and performed quickly repeated work movements with both hands about 30-40 times per minute,
feeding a book machine with paper. The work consisted in very quickly repeated and awkward, wrist-
loading work movements. The work furthermore involved some strenuous work in a few work
processes. The injured person has a bilateral carpal tunnel syndrome after many years exposure, and
there is good correlation between the work that was stressful for both wrists and the development of the
disease.
168
The claim qualifies for recognition on the basis of the list. The injured person worked as a slice man in
a slaughterhouse for several years, his work consisting in slicing and peeling of sausages. The work
was characterised by quickly repeated and strenuous work movements in awkward, wrist-loading
working postures many times per minute. After 4 years work he developed right-hand carpal tunnel
syndrome and there is good correlation between the wrist-loading work and the development of the
disease.
Example 7: Recognition of carpal tunnel syndrome (roof coater for 2.5 years)
The injured person worked as a roof coater doing roof repairs for 2.5 years. He worked under a
piecework agreement for well over 8 hours a day. The work consisted in coating roofs with coating kit,
which was applied by means of a special pump. The pump was equipped with a spray pistol via a hose.
The pump, which had to be handled and moved many times a day, weighed 75 kilos. The hose pressure
was 220 bar. The kit pump was hard to operate, and the work was hard on the wrist. The use of the
spray pistol required frequent activation with simultaneous exertion of the right hand, and the right
wrist was exposed to very awkward working postures in the coating of the roof surfaces. After well
over 2.5 years work the injured person developed pain in his right wrist and forearm, and a medical
specialist made the diagnosis of right-hand carpal tunnel syndrome.
The claim qualifies for recognition on the basis of the list. The injured person developed a right-hand
carpal tunnel syndrome after work as a roof coater for 2.5 years. The work was very stressful for the
right wrist, with repeated work movements many times per minute, which required a great deal of
exertion of his right hand. The work was furthermore performed in working postures that were very
awkward for the wrist.
After 3 years work she developed symptoms in her right forearm, and a medical specialist made the
diagnosis of right-hand carpal tunnel syndrome.
The claim qualifies for recognition on the basis of the list. The injured person had wrist-loading fitting
work for 3 years and then developed a right-hand carpal tunnel syndrome. The work was characterised
by many repeated work movements with the right hand and simultaneous exertion in awkward, wrist-
loading working postures.
169
The injured person worked as a cleaner in the morning in a big super market, 30 hours a week. The
work mainly consisted in cleaning a big, 3,000 m2 linoleum floor, using a wash pump machine run by
batteries. The machine was 0.5 metres wide, weighed 500-600 kilos and reached up to her chest. The
machine was operated by way of two horizontal handles at chest height. When moving forward the
machine she had to push the handles down, and when moving it backwards she had to push them up.
The machine was turned by pulling and pushing the handles. Floor washing in narrow corridors
involved repeated turns of the machine and twisting of the wrists. The operation of machine
furthermore required the application of a great deal of hand force. After well over 6 years work she
developed severe pain and sensory disturbances of her right hand and wrist as well as moderate pain of
her left wrist. A neurophysiological examination established a right-hand carpal tunnel syndrome.
There was no sign, however, of a carpal tunnel syndrome on the left side.
The claim qualifies for recognition on the basis of the list as far the right-sided carpal tunnel syndrome
is concerned. The pain of the left wrist is not covered by the recognition as there is no documentation
of the disease carpal tunnel syndrome in the left wrist. The injured person had wrist-loading work as a
cleaner for 6 years, operating a big and heavy floor washer. The work involved many repeated work
movements with some exertion, performed in awkward, wrist-loading working postures, including
frequent turning movements, and there is good correlation between the work and the onset of the
disease.
Example 10: Recognition of carpal tunnel syndrome (cleaner for 8.5 years)
A 39-year-old man worked as an office cleaner for 8 years and then for 6 months as a cleaner in a
slaughterhouse. In connection with cleaning offices he had to clean office premises of more than 1,000
m2 every day, mopping floors 70 per cent of the time or about 5-6 hours per day. He did wet mopping
for 2-3 hours and subsequent wiping of wet floors with dry mops. Both types of mopping included
slightly to moderately strenuous, monotonous and very quickly repeated movements with mopping in
8-patterns up to about 60 times per minute, in combination with turning and bending movements of the
wrists. The work of wiping and vacuum cleaning for less than 30 per cent of the working time was not
described a particularly strenuous or repetitive. In the slaughterhouse he had to clean as well as tidy up.
The cleaning mainly consisted in using a high-pressure hose up to 4-5 hours a days, including quickly
repeated movements of the wrists in combination with powerful and awkward movements of the wrists.
To this should be added many heavy lifts and much pushing when handling garbage and machines in
connection with tidying up. Towards the end of his employment in the slaughterhouse he developed
symptoms of carpal tunnel syndrome and was operated in both wrists.
The claim qualifies for recognition on the basis of the list. The cleaner was diagnosed with bilateral
carpal tunnel syndrome, for which he has had an operation. He had been a cleaner for many years,
more than 3-4 hours per day performing quickly repeated and awkward movements of the wrists by
mopping. The wet as well as the dry mopping (wiping off the wet floor) involved much application of
wrist force. Towards the end of the period he had cleaning work in a slaughterhouse, which likewise
involved quickly repeated, strenuous and awkward movements for both wrists in connection with high-
pressure hosing and heavy tidying up for many hours a day. There is good time correlation between the
disease and the workloads.
170
studio. When playing she held the violin in her left hand, whereas the right hand was taking the violin
bow back and forth at a quick pace in awkward postures, with constant twisting and turning movements
of the right wrist. After well over 4 years work she developed pain and sensory disturbances of her
right wrist. A medical specialist diagnosed her with right-arm carpal tunnel syndrome.
The claim qualifies for recognition on the basis of the list. The injured person developed a right-sided
carpal tunnel syndrome after very wrist-loading work as a violinist for several years. Her work had the
effect that her right wrist was exposed to very quickly repeated movements in awkward wrist-loading
working postures for a great part of the working day. There is furthermore good time correlation
between the work and the development of the disease.
The claim qualifies for recognition on the basis of the list. For several years the fisherman had
repetitive and strenuous, wrist-loading work with typically awkward posture for both wrists in
connection with setting nets and pulling them in, and handling fishes and cleaning them. There is good
correlation between the work and the development of bilateral carpal tunnel syndrome.
The left-side carpal tunnel syndrome qualifies for recognition on the basis of the list. The carpenter for
many years performed work that was stressful for his left wrist/forearm in connection with holding
onto laths and roof tiles with strenuous gripping movements which were awkward for the wrist. To this
should be added that using the nail gun also led to continuous, powerful blows to the left hand.
Example 14: Recognition of bilateral carpal tunnel syndrome (baker for 9 years)
A 27-year-old man worked as a baker for 9 years. For about half the time he had very long work weeks,
up to 80-90 hours. The work consisted in preparing dough (45 per cent of the time), scraping dough (10
per cent), flattening dough (40 per cent) and various other tasks (5 per cent). A large number of the
tasks were manual, including the cutting up and stretching of the dough, with exertion and twisting and
turning of the wrists, as well as flattening the dough with the palms and the root of the hand with
171
powerful, quick movements and many lifts in the course of the working day. After about 5 years he was
beginning to develop pain of both wrists and a tendency to tingling in his fingers after long working
days. The complaints increased in the course of some years, and eventually, i.a. in a neurophysiological
examination, he was diagnosed with bilateral carpal tunnel syndrome.
The bilateral carpal tunnel syndrome qualifies for recognition on the basis of the list. The baker for a
great part of the working day and for many years performed quick, powerful and awkward movements
of both wrists when handling large quantities of dough, in particular in connection with kneading,
flattening and scraping.
Example 15: Claim turned down carpal tunnel syndrome (packer for years)
The injured person worked in a large meat manufacturing business, packing frozen burgers for 8-9
months. She stacked the burgers, seven at a time, and put them in a cylindrical bag at chest height.
Each bag contained 25 burgers. The packed burger bag was then lifted onto a packing belt at the same
height and closed by a colleague. The work was quick, and she packed up to 1,500 bags per day with
frequent handlings each minute. After well over years work she developed a right-hand carpal
tunnel syndrome and had a successful operation.
The claim does not qualify for recognition on the basis of the list. The injured person developed a right-
hand carpal tunnel syndrome after 8-9 months work as a packer, the work being quick and
characterised by frequent handlings of burgers every minute. Even though she performed wrist-loading,
very quickly repeated work in moderately awkward working postures, the claim does not meet the list
requirements with regard to the duration of the exposure. To recognise the claim there must have been
an exposure for at least 2 years, but the packer only performed wrist-loading work for about 9 months.
Example 16: Claim turned down carpal tunnel syndrome (packer for 7 years)
The injured person worked in a nappy factory for well over 7 years. Her work consisted in packing
nappies. She took about 20 nappies from a belt, turned them 90 degrees and put them down in a
packing machine and pushed a button. She had about 4-5 handlings of nappy stacks to the packing
machine per minute. The work was performed at a good working height and with very limited turning
of the wrists. Nor was the work characterised by strenuousness. After 6-7 years work she developed
symptoms of a right-hand carpal tunnel syndrome, diagnosed by a medical specialist.
The claim does not qualify for recognition on the basis of the list. The injured person developed a right-
hand carpal tunnel syndrome after well over 7 years work packing nappies. The work involved a
limited number of repeated work movements per minute (4-5 movements) and was not characterised by
considerable strenuousness and/or awkward working postures. Therefore, the requirement that at least
two of the load factors of quickly repeated work movements, strenuousness and awkward working
postures should be present was not met.
Example 17: Claim turned down carpal tunnel syndrome (social and healthcare helper for 4 years)
The injured person worked as a social and healthcare helper in a nursing home for well over 4 years.
The work consisted in offering help in connection with personal care, getting dressed, and visits to the
bathroom, as well as serving food and administering medicine for typically four residents. The work
was varied, but led to about 20 patient-handling tasks per day. After 4 years work she had pain in her
left wrist and a medical specialist made the diagnosis of left-hand carpal tunnel syndrome.
172
The claim does not qualify for recognition on the basis of the list. The injured persons work with
personal care in a nursing home for well over 4 years did not involve quickly repeated, strenuous
and/or awkward work movements that strained the left wrist several times per minute. Therefore the
claim does not meet the requirements for recognition set out in the list of occupational diseases.
Example 18: Claim turned down carpal tunnel syndrome (cleaning for 1 year)
A 47-year-old woman was diagnosed with bilateral carpal tunnel syndrome in an EMG examination
(measuring of the nerve conduction rate). It furthermore appeared from the medical information that
she suffered from a metabolic disease, in the form of myxedema, for which she was receiving
treatment. The competitive disease, causing accumulation of fluid, constituted a considerable risk of
developing carpal tunnel syndrome. Her symptoms set on a little less than 1 year after she began as a
cleaner in the town hall. In connection with this work she washed the floor with a wet mop approx. 4
hours per day and besides had functions like vacuum cleaning, sweeping, wiping off surfaces, etc. She
had previously had easier casual work without stress on the wrists.
The claim does not qualify for recognition on the basis of the list. The cleaner was diagnosed with
bilateral carpal tunnel syndrome after a little less than 1 years cleaning work. The basic principle for
recognising carpal tunnel syndrome is 2 years of preceding relevant stress. This requirement may be
reduced to 1 year if there have been substantial exposures. This is not the case here. To this should be
added that there is a substantially competitive disease in the form of myxedema, which causes some
disposition for developing carpal tunnel syndrome due to accumulation of fluid in the wrists.
The case has furthermore been submitted to the Occupational Diseases Committee for an assessment
not based on the list. The Committee did not find, however, that the disease was only or predominantly
work-related. The Committee took into consideration that there was no description of any extraordinary
stresses that might increase the risk of developing carpal tunnel syndrome and that besides there was a
competitive disease which in itself was able to cause carpal tunnel syndrome.
The right-hand carpal tunnel syndrome qualifies for recognition as a complication to tendovaginitis as
this disease can be recognised on the basis of item C.1, quickly repeated and moderately strenuous and
awkward movements, which have constituted a load on the right wrist relevant for the development of
this disease. She developed carpal tunnel syndrome in immediate connection with the tendovaginitis,
and therefore there is good correlation between the two diseases and the exposure in the workplace.
More information:
Carpal tunnel syndrome and the use of computer mouse and keyboard. A Review (www.ask.dk)
174
2.7. Medical glossary (carpal tunnel syndrome)
Latin/medical term English translation
Carpal tunnel Tunnel found at the flexion side of the wrist. Through this tunnel run
the median nerve and nine tendons. The base of this tunnel is an
indentation at the root of the hand. The ceiling of this tunnel forms a
thick, transverse, sinuous ligament (ligamentum carpi transversum).
Carpal tunnel syndrome A carpal tunnel syndrome is caused by compression of the median
nerve of the carpal tunnel.
An impact on the nervous threads of the muscles can cause atrophy of
the muscles of the palm of the hand (thenar).
An impact on the nervous threads of the sensory nerves can cause
sensory disturbances and/or painful numbness (paraesthesies).
Carpos (Greek) Wrist
Carpus The root of the hand, which is between the forearm and the
metacarpus and consists of eight small carpal bones
ENG Electroneurography and electromyelography are neurophysiological
EMG examinations of nerves and muscles that can show
changes in the action potential and/or conduction rate of the nerve
changes in nerves and/or their conduction rate and whether there is
pressure on the nerve
Even if the patient has clinical symptoms similar to those seen in
connection with carpal tunnel syndrome, the patients does not have
the disease if the neurophysiological examination is normal
Ligamentum carpi Thick, transverse, sinuous ligament found at the flexion side of the
transversum wrist and forming the ceiling of the carpal tunnel
Nervus medianus The median nerve, which i.a. runs through the carpal tunnel at the
flexion side of the wrist. The median nerve is both a motor and
sensory nerve.
The nerve is a motor nerve to four different muscles
(a) Musculus abductor pollicis brevis (short abductor muscle of
thumb)
(b) Musculus opponens pollicis (opposing muscle of thumb)
(c) Musculus flexor pollicis brevis (short flexor muscle of thumb)
(d) Musculi lumbricalis I + II (small lumbrical (worm-like) muscles of
the middle hand)
The nerve is a sensory nerve to
1. The flexion side of the thumb, the flexion side of the 2nd
finger, the flexion side of the 3rd finger, and the flexion side of
that half of the 4th finger that is turned towards the 3rd finger,
as well as that part of the palm which belongs to these fingers
2. That part of the thumb which is turned towards the 2nd finger,
at the extension side of the distal parts of the 2nd and
3rdfingers, as well as that half of the distal part of the 4th finger
which is turned towards the 3rd finger
175
Phalens test Examination where the person presses the backs of the hands against
(positive hyper flexion test) each other at 90 degrees downward flexion of the wrists.
If the test is positive there are signs of carpal tunnel syndrome, or the
existing symptoms are aggravated. The test is not very reliable as a
basis for the diagnosis.
Prayer sign test Examination where a person presses the palms of the hands against
(positive hyperextension test) each other at 90 degrees upward flexion of the wrists (as in prayer).
If the test is positive there are signs of carpal tunnel syndrome, or the
existing symptoms are aggravated. The test is not very reliable as a
basis for the diagnosis.
Tinels signs A symptom of reaction from oversensitive nervous threads in the form
of tingling sensations or radiating pain when the nerve is tapped.
Disease Exposure
C.4.1. Tennis elbow (a) Strenuous and repetitive work movements
(epicondylitis lateralis) (b) Strenuous work movements in awkward positions
C.4.2. Golfers elbow (c) Strenuous static work
(epicondylitis medialis)
Epicondylitis is an inflammatory degeneration of the tissue and the origin of the tendons at the
epicondylus (bony projection on the sides of the elbow), probably as a consequence of small ruptures.
176
Generalised or diffuse pain cannot be recognised on the basis of the list.
Symptoms
Pain and pronounced tenderness, consistent with the lateral epicondylus (tennis elbow), and the medial
epicondylus (golfers elbow) respectively. The pain is aggravated when the arm is used, in particular
for golfers elbow when the wrist is bent downwards against resistance and for tennis elbow when the
wrist is flexed upwards against resistance. The pain can radiate downwards or upwards in the arm.
Objective signs
Direct tenderness and pain in connection with palpation of the region, and perhaps swelling. There can
be restricted motion of the elbow, hand and finger joints, either solely due to pain or combined with
tissue degeneration.
Work involving a strenuous load on the muscles attached to the elbow joint causes a risk of
epicondylitis. With regard to strenuousness, the load needs to be mechanically and physiologically
relevant for the disease. Ordinary lifting work, for instance, regardless of weight, does not in itself
make the work strenuous with regard to the elbow.
Whether or not the work is strenuous and elbow straining depends on a concrete assessment of the
general loads involved in the work.
The following would be in favour of regarding the work as relevantly strenuous for the elbow:
Repeated strenuous twisting or turning movements
Repeated strenuous movements against resistance
Static fixation of an object with the use of force
Strenuous work movements in combination with awkward, elbow straining working postures
177
Strenuous work
The concept of strenuous work movements/application of muscular force implies that there must be a
certain application of force in excess of the functional power normally used to apply, turn, bend, or
stretch the wrist/elbow. This can for instance be the use of pressure, which causes a certain load and
strain on the relevant muscles.
Factors contributing to the risk of developing disease in connection with strenuous work are
work with the elbow joint in end position, a load on the extensor muscles (for tennis elbow) or flexor
muscles (for golfers elbow), work in awkward postures, repetitive work movements or a static load on
a muscle group when fixing an object while applying muscular force in a certain cycle.
Repetitive work
In order for the work to be regarded as repetitive, it must involve continuous movements, of a certain
frequency/intensity, of the elbow joint for a substantial part of the working day. In principle there must
have been several repeated movements per minute.
The frequency of stressful movements cannot be determined in detail, but depends on a concrete
assessment of repetition frequency, seen in relation to the strenuousness of the work and the other loads
on the elbow joint.
Awkward postures
The assessment of whether the working posture is awkward for the elbow takes into account if, and to
what degree, the elbow is exposed to awkward flexion, extension or turning movements. All joints have
a normal functional posture. This is the joint posture that gives an optimal function of the extremity
(arm or leg). Movements occurring in other postures than the normal posture are characterised as
awkward. The greater the deviation from the normal posture, the more awkward it is. Movements in
awkward postures are not optimal and thus increase the load on for example muscles, tendons, and
connective tissue.
If there has been a very high degree of strenuousness and/or very awkward working postures for the
elbow joint, the requirements to the repetition frequency will be relatively less strict. In the event of
slight to moderate strenuousness and/or good to optimal working postures the requirement to the
repetition frequency will be similarly stricter.
The load must be assessed in relation to the persons size and physiognomy, and there must be good
time correlation between the exposure and the onset of the disease. In principle there must have been a
relevant load for at least half of the working day (3-4 hours).
If different work functions were performed in the course of the working day, an assessment will be
made of the total load on the elbow. There will be an assessment of the load from each work function,
as well as the total duration of each. Thus alternating work functions and a certain variation in the work
may well lead to a relevant and sufficient load.
178
For example there may be alternation between very strenuous work with slight to moderate repetition
for one third of the working day and for one third of the working day high-repetitive work with the
elbow held in awkward postures with slight to moderate strenuousness. In the last third of the working
day no work is performed that strains the elbow. In such cases there is alternation between different
work functions in the course of the working day. Two of the work functions meet the requirements to
relevant exposure, the exposures at the same time stretching over more than half of the working day.
The claim can therefore be recognised on the basis of the list.
In the processing of the claim we may request a medical certificate from a specialist of occupational
medicine. We will i.a. ask the medical specialist to describe and assess the application of force, the
repetition and the load of the working posture on the elbow, specifically and in detail, in relation to the
work functions in question. The medical specialist must furthermore make an individual assessment of
the impact of load factors on the development of the disease in question in the specific examined
person.
Only tennis elbow (epicondylitis lateralis) and golfers elbow (epicondylitis medialis) are covered by
the list item on elbow diseases, C.4. Furthermore there need to have been exposures meeting the
recognition requirements.
Other diseases or exposures not on the list will in special cases qualify for recognition after submission
to the Occupational Diseases Committee.
An example of a disease that may be recognised after submission to the Committee is a disease of the
biceps muscle at the elbow joint.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
179
both hands against a big wheel. Both elbow joints and shoulders were thrown a bit forward while the
unit was being pushed against the wheel. He polished 30-50 units per hour, weighing between 300
grams and 2 kilos. After 9 years employment he had pain in both elbows and a medical specialist
diagnosed him with bilateral tennis elbows.
The claim qualifies for recognition on the basis of the list. The work involved repeated, strenuous, even
awkward, stressful working postures and movements for both elbows all day for a considerable period
of time, and there is good correlation between the exposure and the onset of the disease.
Example 2: Recognition of tennis elbow (equipment worker with bolt work for 6 months)
A man worked for many years as an equipment worker in the technical department of a hospital. His
work consisted in the repair of beds, wheelchairs, office chairs and other equipment and generally did
not constitute a strain on the elbow. However, for 6 months he mainly did repairs on new electric beds
that had broken down. He had to fit reinforcement units under the beds by screwing them on. He turned
the beds over onto the side and unscrewed the broken parts. This work required a lot of exertion as the
bolts had been glued together with the nuts. There were 6-8 bolts on each bed and it was not possible to
use electric tools in connection with the work. After removing the old bolts he had to screw the
reinforcement unit back on, and the beds had to be fitted with bolts again. He managed to repair 6-7
beds a day. After a few months doing this type of work he had pain in his right elbow and a medical
specialist diagnosed him with right-sided tennis elbow.
The claim qualifies for recognition on the basis of the list. Working with bolts for several months
involved repeated, strenuous movements of the right elbow in connection with loosening and screwing
bolts onto electric beds. The work was furthermore awkward for the right elbow, involving much
twisting and turning of the elbow joint, and there is good correlation between the load and the disease.
The claim qualifies for recognition on the basis of the list. The fishing worker for several weeks carried
out work involving cutting and removing of salmon roe. The work involved quickly repeated and
slightly to moderately strenuous movements of the elbow joints. The work also involved awkward
twisting and turning of the elbow joints. There is good correlation between the load on both elbow
regions and the development of bilateral tennis elbow.
Example 4: Recognition of tennis elbow (seine and trawl binding for 5 years)
A man worked with seine binding for 4 years in a trawl business. His work consisted in cutting out
different pieces of nets with an ordinary knife, which he held in his right hand while holding and lifting
180
the net with his left hand. The various nets were sewn together with a mending needle. The smallest
mending needles weighed 100-200 grams whereas the largest weighed up to 10 kilos. He was always
holding the mending needle in his right hand. He made knots with his right hand while holding the
thread with his left hand. For each knot he made a strenuous thumb and index finger grip with his left
forearm turned inwards. When making the knot, i.e. pulling it together, he did this with a very powerful
jerk of his right hand while holding back with his left hand, which at the same time was turned
outwards. In order for the knot to be made stable, he made a very quick and strenuous movement,
which gave him a feeling of getting a blow up through the left arm. He made at least 500 knots per
hour. The work of sewing the various net pieces together took about half of the working day. The other
half of the working day he spent cutting, lifting and dragging whole trawls, pieces of nets, ropes and
chains. He developed severe pain of the left elbow and a medical specialist diagnosed him with a left-
side tennis elbow.
The claim qualifies for recognition on the basis of the list. For 4 years and half of the working day, the
seine binding work involved quickly repeated and slightly to moderately strenuous loads on the left
elbow in outward turned and inward turned postures. There is good correlation between the disease and
the elbow straining work.
Example 11: Recognition of tennis elbow and golfers elbow (housepainter for 2 months)
After having worked for 2 months on large wall surfaces as well as door frames with spot puttying,
hole puttying, grinding, coating and basic painting, a housepainter had symptoms of a right-sided tennis
elbow and golfers elbow. While puttying the walls, which she did most of the time in the period in
182
question, she used a big stopping knife. One floor with six flats was finished each week. A medical
specialist made the diagnosis of right-sided tennis and golfers elbow.
The claim qualifies for recognition on the basis of the list. The work of puttying, grinding and coating,
including the puttying of large wall surfaces with the big knife, included repeated flexion and extension
movements against resistance with application of muscular force. The injured person was diagnosed
with right-sided tennis elbow and golfers elbow, after having performed continuous, strenuous and
repeated movements that were stressful for the relevant muscle groups of the elbow region.
Example 13: Recognition of tennis elbow (industrial lacquerer spray painting for 1.5 years)
The injured person worked as an industrial lacquerer in the painting hall of a major industrial
manufacturing company. The work mainly consisted in spray painting various large units with a spray
pistol. The hose of the spray pistol was about 10 metres long, and the weight of the pistol alone was
about 7-8 kilos. He held the spray pistol fixated in his right hand with a strenuous static grip, while at
the same time pressing his thumb against the tap, spraying the units. After 1.5 years work he
developed pain in his right arm, and a medical specialist made the diagnosis of right-sided tennis
elbow.
The claim qualifies for recognition on the basis of the list. The industrial lacquerer performed spray
painting with a spray pistol, and the work involved static fixation of pistol and hose in a fixated
working posture under simultaneous, stressful application of muscular force. There is good correlation
between the described work exposures, in the form of a continuous, static and strenuous load on
relevant muscle groups, and the development of an elbow disorder.
Example 15: Recognition of tennis elbow (employed in a cheese dairy for 3 years)
A woman worked in a dairy, picking out and cutting cheeses. The first 3 years the work consisted in
cutting three-kilo cheeses with a string, and then the cheeses were placed in a machine that cut them in
triangles. After that the production was restructured. The cheeses were now taken from the shelves in
183
packets of 3 cheeses weighing 3 kilos each. The cheeses were wrapped in plastic, which had to be cut
up and ripped apart with the application of great force. Then, in order to separate them, the cheeses
were banged against the table top with some exertion. The cheeses were then placed in a machine,
which cut them up. The cutting rate was 500-600 cheeses per hour. The cut-up cheeses were then
picked up and packed. After working for a short while in the new function she developed elbow
trouble. A medical specialist diagnosed her with right-sided tennis elbow.
The claim qualifies for recognition on the basis of the list. The work of unpacking the cheeses, of
separating them by banging them against the table and, before that, cutting them with a string, was
repetitive and strenuous, elbow-loading work, whereas the packing in itself cannot be characterised as
strenuous work. Altogether, she performed relevant elbow-loading work movements for more than half
of the working day for a bit more than 3 years.
184
Example 18: Claim turned down tennis elbow (cleaning part time, 19 hours a week for 5 years)
A 46-year-old woman worked as a cleaner in a military barracks, 19 hours a week. According to the
information given by herself, 2/3 of the working day, or about 2 hours a day, were spent washing floors
with a dry or wet mop, fairly evenly distributed. The work with the wet mop in particular was relatively
heavy and strenuous for her right arm. Furthermore, for a limited period of a couple of months, she was
hired to mop, for about one hour a day, using a new system which was heavier to use than the mop
system used so far. It did also appear, however, that in addition to the mop work she did a number of
diversified cleaning tasks such as cleaning of several toilets, sweeping, washing of tables and window
sills, emptying of dustbins, etc. Towards the end of the period she developed a right-sided tennis elbow.
The claim does not qualify for recognition on the basis of the list. The cleaner had relatively diversified
work. Only the work with the wet mop can be characterised as relevantly strenuous for the right elbow,
whereas the other work functions, including the work with the dry mop, involved very moderate
exertion of the elbow. Altogether the use of the wet mop was estimated at one hour per day and, for a
brief period of time, about one more hour or a total of 2 hours per day. Therefore she does not meet the
requirement for a relevant exposure of the right elbow for at least half of a normal, full working day (3-
4 hours) for a considerable period of time.
Example 19: Claim turned down right-sided tennis elbow (butcher and bodybuilder)
A 29-year-old butcher worked for a few weeks on a slaughter chain in a big slaughterhouse. His work
consisted in cutting out back pieces with his right hand (the knife hand). It was piecework and the work
was fast, awkward and strenuous for his right arm. After a short while he developed pain in his right
elbow region and was diagnosed with right-sided tennis elbow. It also appeared from the information of
the case that for about 2 months up to the onset of the complaints he had been in intensive hormonal
treatment, being a bodybuilder in his spare time.
The right-sided tennis elbow does not qualify for recognition on the basis of the list. For a short period
of a couple of weeks, the work as a butcher was relevantly strenuous, repetitive and awkward for his
right elbow, but in this case it is likely beyond reasonable doubt that the right-sided tennis elbow was
caused by the intensive hormonal treatment. This is because the hormonal treatment in question is
known to cause a massive build-up of the muscles, which very frequently has consequences, such as a
tennis elbow. Therefore the disease must very likely have been caused by other than occupational
circumstances, cf. section 1(3) of the Administrative Order and section 8(1) of the Act.
Example 20: Claim turned down tennis elbow (postal worker for 2 years)
A postal worker had worked for 2 years sorting letters, newspapers, magazines and small packages.
Then she developed right-sided elbow pain. Her GP diagnosed her with a tennis elbow.
The claim does not qualify for recognition on the basis of the list. The work as a mail sorter has not
involved any twisting or turning movements in the elbow joint, movements against resistance or static
fixation of objects with simultaneous use of muscular force, and the working postures cannot besides
be regarded as awkward. The injured person therefore does not meet the requirements with regard to
strenuous, elbow-straining work.
Example 21: Claim turned down bilateral tennis and golfers elbow (healthcare assistant)
The injured person developed complaints in both elbows after having worked in healthcare for
approximately 25 years. In the period 1975 till 2004/2005, the injured person worked as a healthcare
185
assistant. The first years the injured person worked full time, later she worked 32 hours a week, and the
last 15 years up to 2004/2005 she worked 26 hours a week. In all the years the injured person worked
with difficult, care-demanding patients, each of whom required 20-40 handlings per shift. The tasks
varied. The injured person had to help patients with meals and bed baths and had to change linen and
turn patients and change them etc.
The claim does not qualify for recognition on the basis of the list. The healthcare assistant had
relatively varied healthcare work. The work involved occasional exertion in connection with handling
of persons, but the elbows were not under stress several times a minute for at least 3-4 hours per day.
Nor were there, for the major part of the working day, any awkward work movements or strenuous
static work. Furthermore, for 7 years, until the onset of the elbow disorder, the injured person had part-
time work amounting to 26 hours per week. There are no grounds for submitting the claim to the
Occupational Diseases Committee.
More information:
A critical review of evidence for a causal relationship between computer work and musculoskeletal
disorders with physical findings of the neck and upper extremity (www.ask.dk)
186
4. Shoulder diseases (C.5)
4.1. Item on the list
4.2. Diagnosis requirements
4.3. Exposure requirements
4.4. Examples of pre-existing and competitive diseases/factors
4.5. Managing claims without applying the list
4.6. Examples of decisions based on the list
4.7. Medical glossary (shoulder diseases)
Disease Exposure
C.5.1. Rotator cuff-syndrome/impingement syndrome (a) Repetitive and strenuous shoulder
movements, in combination with an
C.5.2. Symptoms from or degeneration in the long assessment of the position of the arm in
biceps tendon (biceps tendinitis, tendinitis caput connection with the load
longum musculus bicipitis brachii) or
(b) Static lifting of upper arm to about 60
degrees or more
Together they coordinate and stabilise the shoulder joint and movements together with other muscles
around the shoulder joint.
Impingement occurs when the rotator-cuff tendons and the bursa of the shoulder are squeezed due to
swelling of the tendons or the soft tissue around the tendons.
Rotator-cuff syndrome/impingement syndrome are clinical diagnoses that can be made on the basis
of a correctly performed, general medical examination of the shoulder.
187
Shoulder tendinitis means an inflammatory condition of the tendons of the shoulder joint. The
diagnosis is used as a less specific designation of diseases of the rotator-cuff tendons when it is not
possible to state precisely where the degeneration of the rotator-cuff tendons is located.
The short biceps tendon is not a functional part of the rotator cuff. The short biceps tendon therefore is
not covered by item C.5 of the list of occupational diseases.
Diagnoses
The diagnoses of rotator cuff syndrome/impingement syndrome as well as symptoms from or
degeneration in the long biceps tendon cover complaints from the rotator cuff around the shoulder
joint and/or the long biceps tendon.
The medical diagnoses are made on the basis of a combination of
Objective signs
A prerequisite for the clinical diagnosis in connection with rotator-cuff syndrome/impingement
syndrome is tenderness in connection with palpation of the shoulder joint. Furthermore at least one of
the following findings must be present
Muscular atrophy
Reduced motion
Pain provocation when arm is moved against resistance (indirect shoulder pain for at least one
out of the 4 tendons)
Positive impingement test (for instance Neers test and Hawkins test )
Positive pain curve
Deficient function of at least one of the 4 rotator cuff tendons (for instance drop-arm test for
musculus supraspinatus, infraspinatus drop test, external rotation lag sign and internal rotation
lag sign)
Rotator-cuff syndrome can be perceived as an overall diagnosis whereas the diagnosis of impingement
syndrome is a subgroup where there is a clinically positive impingement test.
The clinical diagnosis of symptoms from or degeneration in the long biceps tendon is made when
the following are found
Degeneration or lesion of the rotator-cuff tendons and other structures of the shoulder can be
diagnosed by way of
188
Ultrasound scan
X-ray examinations
CT scan
MR scan
Arthroscopy
The paraclinical (image etc. ) examinations can be used to confirm a clinical diagnosis that has already
been made, but cannot be used to repudiate the clinical diagnosis.
Abnormal findings in such paraclinical examinations may be significant in the assessment of any
differential diagnosis (see item 10.4).
Repetitive movements
Repetitive movements of the shoulder joint are a special risk factor for the development of the stated
shoulder diseases.
In order for the work to be called repetitive in a relevant manner for the shoulder or the upper arm, it
must be characterised by monotonously repeated movements, of a certain frequency, of the shoulder
joint. Usually there will have been monotonously repeated movements of the shoulder joint up to
several times per minute (movements forward-upward, backward-upward, outward-upward and/or
rotation).
The frequency of the stressful movements cannot be determined in more detail, but depends on a
concrete assessment of the repetitive frequency, seen in relation to the strenuousness of the work, and
any awkward movements or positions of the shoulder/upper arm (for instance long reaching distance,
work with arm lifted or repeated lifts of the upper arm or many twisting and turning movements of the
shoulder joint).
If there are very strenuous movements and perhaps also awkward and shoulder-loading working
positions, the requirement to repetitive frequency will be relatively small. On the other hand, the
requirement to the repetitive frequency will be bigger if the work is performed with moderate
strenuousness and in working positions that are favourable for the shoulder/upper arm.
Repetitive work, including highly repetitive work, which occurs without any strenuousness at all is not
covered by the list of occupational diseases.
189
When the work is very repetitive (quickly repeated), there need only be few other risk factors present.
That is, the work may for instance consist in monotonously repeated movements of the shoulder joint
without any particularly high lifts of the upper arm or the units weighing very much.
Strenuousness
Work that involves shoulder-loading strenuousness constitutes a special risk factor with regard to
development of the stated shoulder diseases.
In order for the work to be characterised as shoulder-loading, strenuous work, there needs to have been
strenuousness somewhat in excess of what would normally be required to lift and turn the arm. This
applies in particular in cases where the work is characterised by repeated movements of the shoulder
joint, without any simultaneous working postures that are stressful for the shoulder/upper arm.
Shoulder-loading, strenuous work is for instance work that involves a lot of pushing, pulling or lifting
with the application of a great deal of muscular force in the shoulder/upper arm, perhaps with
simultaneous twisting and turning movements of the shoulder joint (for instance in connection with
deboning in a slaughterhouse).
The assessment of whether the work can be regarded as strenuous in a relevant way for the shoulder
and shoulder musculature includes
Awkward working postures or movements of the shoulder/upper arm are a special risk factor for the
development of shoulder diseases when the awkward positions or movements occur in combination
with repetition and strenuousness.
Working postures or movements that are particularly stressful for the shoulder/upper arm might be
work in the exterior position of the arm with long reaching distance
work with lifted arm or repeated lifts of the upper arm
work with twisting and turning movements of the shoulder joint, perhaps against resistance
work with lifts with brief cycle time (little restitution)
The maximum load on shoulder/upper arm occurs when the shoulder or upper arm is strained
repeatedly by many upward- and inward-going movements against the shoulder and against resistance
190
with simultaneous application of force, while at the same time the arm is being held in the exterior
position or lifted high.
Lifting of arm
Work with repeated high lifts of the arm to about 60 degrees or more constitutes a substantial risk
factor for the development of shoulder diseases when the repeated lifts at the same time involve only
moderate strenuousness.
However, work with moderate lifting of the arm to, for instance, 30 degrees can only be characterised
as a substantial risk factor if, in addition to repeated work movements, there is a certain degree of
strenuousness.
On the other hand, work involving very quick and monotonously repeated movements of the shoulder
joint in moderately stressful working postures (for instance low lifts of the arm to 30-40 degrees)
cannot be deemed to be sufficiently shoulder-loading, unless the work at the same time involves a
certain (slight to moderate) strenuousness.
191
Different work functions (varied work)
If different work functions have been performed in the course of the working day, an assessment will
be made of the total daily load, seen in relation to the load from each work function on the
shoulder/upper arm.
For example there can be alternation between very strenuous work with moderate repetition for one
third of the working day and high-repetitive work with simultaneous, repeated lifts of the arm to 30-40
degrees and slightly strenuous work for two thirds of the working day. The last third of the working
day no shoulder-straining work is performed. In this case there are alternating work functions in the
course of the working day, two of the work functions meeting the requirements to a relevant load. The
relevant load furthermore extends over more than half of the working day. The claim therefore qualifies
for recognition on the basis of the list.
Other matters
The load will be assessed in relation to the persons size and physique, and there needs to be good time
correlation between the exposure and the onset of the disease.
In the assessment of the claim we may obtain a medical certificate from a specialist of occupational
medicine. We will i.a. ask the medical specialist to describe and assess in detail the concrete working
conditions and the concrete loads. The medical specialist will furthermore make an individual
assessment of the significance of the load for the development of the disease in the specific examined
person. The medical specialist will also make a description of the onset of the disease and the
development of the disease and state any previous or simultaneous diseases or symptoms and their
possible impact on the current complaints.
We may also obtain other forms of medical specialists certificates in order to get information on the
course of the disease and the connection with any competitive or pre-existing diseases.
192
Joint pain and rheumatoid arthritis as an element of a localised connective tissue or joint disease
(arthralgia and arthritis)
Degeneration of the spine radiating into to the shoulder joint
Diseases of the cervical neck (degenerative diseases, root pressure, etc.)
Pain triggered by other organ systems (heart, lungs, abdomen, liver, diaphragm)
Degenerative arthritis of the shoulder joint (arthrosis humero scapularis)
Degenerative arthritis of the acromioclavicular joint with considerable osteophytes, affecting
the underlying soft-tissue structures (arthrosis articuli acromio clavicularis)
Deficient coordination of the musculature between the shoulder and the upper arm (secondary
impingement)
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
193
A 28-year-old man worked for 3 weeks with concrete breaking with a pneumatic hammer and a
concrete hammer, about 8 hours a day. He only had one 5-minute break per hour. Both machines had to
be pressed hard against the concrete floor under application of muscular force of arm and shoulder and
had to be lifted approximately every 15 seconds, which was equivalent to about 2,000 lifts per day.
After 3 weeks he developed increasing pain in his right shoulder and a medical specialist diagnosed
him with right-sided rotator cuff lesion.
The claim qualifies for recognition on the basis of the list. The work of breaking concrete with a
pneumatic hammer and concrete hammer was high-repetitive and extremely strenuous for the right
upper arm and shoulder. It furthermore involved awkward shoulder-straining movements. There is
good correlation between the exposure and the onset of the disease.
Example 3: Recognition of rotator cuff syndrome (machine engineer for 2.5 years)
A woman worked for 2.5 years as a CNC punch machine operator in a manufacturing business. The
work involved repeated lifting of units, weighing from 1.5 to 12 kilos, onto a machine. The heavy units
weighing 8 to 12 kilos had to be lifted up and fixed at above eye level. She held the units in place with
her left arm while fastening them with her right. For fastening of the units she used an air key. She
developed pain in her left shoulder and a medical specialist diagnosed her with left-sided rotator cuff
syndrome.
The claim qualifies for recognition on the basis of the list as a combination of C.5.1.(a) and C.5.1.(b).
The machine engineer for 2.5 years operated a CNC punch machine, performing repeated lifts and
fastening of units weighing up to 12 kilos. The work was relatively low-repetitive, but did on the other
hand involve a certain amount of strenuousness as well as awkward working postures for her left
shoulder in connection with holding large units, including long, high lifts, which had a static element
and allowed little restitution of the shoulder. There is furthermore good correlation between the disease
and the load.
194
Example 5: Recognition of impingement syndrome (slaughterhouse worker for 9 months)
A 41-year-old man for 9 months did slaughterhouse work with various functions. His work consisted in
deboning and cutting front ends. When cutting front ends, he had to take down and hang up the front
ends on Christmas tree hooks. Both deboning, cutting and taking down and hanging up on Christmas
tree hooks involved frequent movements of the right shoulder joint, the upper arm often being either
taken forward or outward, as well as repeated lifts of the right arm to 60 degrees or more. There were
also movements of the shoulder joint that involved strenuousness. He developed complaints consistent
with his right shoulder and a medical specialist made the diagnosis of right-sided impingement
syndrome.
The claim qualifies for recognition on the basis of the list. The slaughterhouse worker developed a
right-sided impingement syndrome after having for several months performed repetitive movements of
the shoulder joint with simultaneous strenuous work and repeated lifts of his right upper arm to at least
60 degrees. There furthermore were awkward working postures, including work with the arm in
exterior positions, and short cycle times with little restitution of the right arm. The work was very
stressful for the right shoulder, and there is furthermore good time correlation between the exposure
and the onset of the symptoms.
The claim qualifies for recognition on the basis of the list. The industrial operators first work function
was relevantly shoulder-straining as the work involved repetitive movements of the shoulder joint with
strenuousness, with the arm extended in exterior positions and with repeated lifts of the right upper arm
to more than 60 degrees. The other work function (servicing of colleagues) cannot be characterised as
shoulder-straining work as they did not involve repeated movements of the shoulder joint with
strenuous exposure of the shoulder or stressful lifts of the upper arm. The first function, however, did
take more than half of the working day and was relevantly stressful for the development of rotator cuff
syndrome of the right shoulder.
195
Example 7: Recognition of impingement syndrome (machine engineer for 2.5 years)
A 34-year-old man worked for well over 2.5 years as a machine engineer. The work consisted in
driving part units for pumps through a machine. The units weighed from a few kilos up to 30 kilos and
had to be lifted manually into the machine and fastened between four claws. Heavy units were lifted in
by way of a crane. He lifted the units up to the correct position, and then the unit was fastened by
means of a T-key. Once the unit was fastened, he made it extra tight with the T-key by pulling with his
right hand and pushing with his left hand. Each unit required up to several fastening movements, which
were performed with strenuousness. The key was positioned in such a way that it was not necessary to
reach upward, but there was a long reaching distance forward. In the course of a working day he
fastened up to 100 units with several fastening movements for each unit. The injured person developed
pain in his right shoulder and a medical specialist diagnosed him with right-sided impingement
syndrome.
The claim qualifies for recognition on the basis of the list. The injured person performed work that
involved repeated movements of the shoulder joint in combination with great exertion, his right arm
being held in exterior positions. He performed the stressful work for more than half of the working day
for 2.5 years. There is furthermore good time correlation between the load and the onset of the
symptoms.
The claim qualifies for recognition on the basis of the list. The slaughterhouse worker performed
relevant, shoulder-joint straining work for 4 years and developed a right-sided impingement syndrome.
The first work function involved repetitive movements of the shoulder joint with strenuous work and
repeated lifts of the upper arm of up to more than 60 degrees, the arm at the same time being held in
exterior positions, and the movements were performed with a short cycle time. The other work function
consisted in pushing and pulling and did not involve a relevant load on the right shoulder. The first
work function was, however, very shoulder-straining for more than half of the working day and for
several years, and there is good time correlation between the load and the onset of the disease.
196
Example 9: Recognition of degeneration of the long biceps tendon (municipal gardener for 17 years)
A 57-year-old man worked for 17 years as a gardener for a local authority. His work consisted in
maintaining the rivers and streams of the municipality. Apart from the periods when the rivers and
streams were frozen, he kept streams and rivers free from earth, leaves, roots, garbage and mud. He
stood on the bottom of the stream, shovelling up the mud. He spent two thirds of the working day doing
shovelling work in the period from April to, and including, November (8 months) and well over one
third of the working day the rest of the year (4 months). The remaining part of the working day he
maintained the banks of rivers and streams, i.e. he cut grass driving a lawn mower. Occasionally,
however, he also cut edge crops with a scythe. After 17 years work he developed pain in his right
upper arm. In the examination made by a medical specialist it was not possible to establish a rotator
cuff syndrome, but the medical specialist made the diagnosis of degeneration of the right biceps
tendons (biceps tendinitis).
The claim qualifies for recognition on the basis of the list. When shovelling bottom crops from streams,
the gardener performed work with repetitive movements of his right shoulder joint and upper arm with
strenuousness and repeated lifts up to or above 60 degrees. This type of work was very hard on his right
biceps tendon. He furthermore had relevantly stressful work in connection with periodical cutting of
edge crops with a scythe. The work function of cutting grass with a motorised grass cutting machine
cannot be characterised as a strain on the right upper arm. The overall, relevantly stressful work
functions did, however, constitute more than half of the working day for the major part of the year and
for a considerable number of years. Furthermore there is good time correlation between the work and
the onset of the symptoms.
Example 10: Recognition of bilateral rotator cuff syndrome (packer for 8 years)
A 36-year-old woman worked for 8 years as a packer in a business manufacturing disposable plastic
service. Her tasks consisted in picking up and packing plastic mugs. Via a belt, the mugs came from the
machine and landed on the packing table, where they were packed in plastic bags. The plastic bags
were lying on a shelf at head height. The plastic bag was packed around the mugs, and as the bag was
narrow, the work required precision and slight to moderate strenuousness, with movements from head
height to table height. Once the plastic bag was on, the package was pressed against a tape machine at
table height with little exertion. Then it was put in a cardboard box containing 25 pieces. Once they had
been filled, the cardboard boxes were stapled to eye height. The packer was able to complete a couple
of thousand packages a day, and each package required several movements in the shoulder joints. After
eight 8 years she developed symptoms from both shoulders, and a medical specialist made the
diagnosis of bilateral rotator cuff syndrome.
The claim qualifies for recognition on the basis of the list. The woman developed bilateral rotator cuff
syndrome after packaging the whole working day for 8 years. The work involved frequently repeated
movements in both shoulder joints, with repeated lifts of the upper arms to 60 degrees or more, and in
addition slight strenuousness, the arms occasionally being held in exterior positions. The work was
furthermore characterised by a short cycle time with little restitution of the arms. There is furthermore
good time correlation between work and the onset of the symptoms.
Example 11: Recognition of degeneration in the long biceps tendon (carpenter for 6 months)
A 28-year-old man worked for 6 months as a carpenter for a large contractor. For the major part of the
day the work consisted in fitting ceilings of gypsum board or other materials, typically in big, newly-
built office buildings. When fitting the ceilings he grabbed a gypsum board, with his left hand or both
hands, from a tall trolley next to the ladder on which he was standing. He lifted the board, which could
be big and relatively heavy, up to the ceiling with both hands. Then he fitted the board, using an
197
electric screwdriver. He was left-handed, and the work, which involved some strenuousness with the
arm lifted, was performed with his left hand. After well over 6 months employment he developed pain
in his left upper arm and a medical specialist made the diagnosis of left-sided biceps tendinitis.
The claim qualifies for recognition on the basis of the list. The carpenter for 6 months performed
repeated, stressful movements of the left upper arm and shoulder joint with simultaneous, repeated,
high lifts of his left arm and exertion when fitting ceiling boards. There is furthermore good time
correlation between the work and the development of a left-sided biceps tendinitis.
Example 13: Recognition of rotator cuff syndrome (window cleaner for 12 years)
A 52-year-old man had worked with window cleaning, full time for 12 years, for two different
employers. The last 8 years he mainly cleaned windows in business buildings. His work consisted in
soaping and wiping off with a squeezer weighing 0.5 kilos. He moved his tool from side to side across
the window surfaces and only occasionally up and down. He held the tool in his right hand, and when
soaping he made large movements across the windows with rotation in his shoulder joint, often in
maximally extreme shoulder postures. He repeated these movements when squeezing the soap and
water off the window again and at the same time maintained a constant pressure on the window. He
usually began as high up as he was able to reach and then, once he had reached shoulder height, bent
his knees or moved further down on the ladder. Only the lowest section of the window was cleaned
with the arm below shoulder height. About half the time he worked with the arm lifted to or above
shoulder height. He carried out movements in the shoulder joint approx. once every second. After about
9-10 years he developed pain in his right shoulder, which was aggravated towards the end of the
period, and eventually he was diagnosed with right-sided rotator cuff syndrome with pain, tenderness,
reduced motion, and a positive pain curve in the shoulder.
The claim qualifies for recognition on the basis of the list. The window cleaner has right-sided rotator
cuff syndrome, and the disease developed after many years of work where, more or less the whole day,
he had very quickly repeated and awkward movements in his right shoulder and simultaneous
strenuousness (exposure (a)). In addition, the shoulder was for much of the working day lifted to 60
degrees or more (exposure (b)).
198
Example 14: Recognition of bilateral rotator cuff syndrome (cleaning work for 5 years)
A 37-year-old woman worked as a cleaner in a botanical garden for 5 years. Her work was
characterised by strenuous and repeated movements of her upper arms/shoulders for approx. 4 hours a
day in connection with wet mopping of floors. She made about 64 movements in her shoulder every
minute in connection with mopping in a figure-8 pattern, holding the shaft with her left hand at chest
level and her right hand at naval level. Her left upper arm was held lifted at about 60-70 degrees as the
controlling arm, whereas the right moved the mop around in extreme positions. The mopping work was
strenuous, in particular for her right side, the surface of the floor being extremely dirty. The rest of the
time she emptied bins and cleaned toilets and staff rooms. After approximately 4 years she developed
pain and restricted motion of both shoulders and subsequently was diagnosed with bilateral rotator cuff
syndrome.
The claim qualifies for recognition on the basis of the list. The cleaner for mange years before the onset
of the disease in both shoulders worked with quickly repeated, awkward and strenuous movements of
her right shoulder (exposure (a)), while her left upper arm/shoulder was held lifted to 60-70 degrees
(exposure (b)). These loads occurred about 4 hours a day. The rest of the day there were no other
substantial shoulder loads.
Example 15: Claim turned down rotator cuff syndrome (sausage maker for 12 years)
A 39-year-old woman was employed for 12 years in sausage production. The work involved two
different work functions. When filling a sausage, a casing was placed on a horn, and then a device was
started which forced sausage meat out through the horn and into the fitted casing. During this process
she had to ensure that the casing was pushed along while sausage meat was being filled into it. The
work involved frequently repeated, small movements of the right shoulder, without any considerable
strenuousness and without repeated high lifts of the arm. The other work function was when the long
sausages had to be placed on a pin, hanging in pairs from the pin. The pin was fastened to a device at
chest level. She hung up the sausages with her right hand, her right upper arm lifted to 60 degrees or
more, and with outward rotation of the arm, but no strenuousness. Once the sausages had been hung up
on the pin, the pin was lifted off the device and placed on a rack. The pin then weighed 3 kilos, and the
lifts involved moderate exertion with simultaneous, high lifts of the right upper arm. The injured person
spent well over two thirds of the working day on the first function and about one third of the working
day on the other function. After about 12 years work she developed pain and motion problems in her
right upper arm and a medical specialist subsequently diagnosed her with right-hand rotator cuff
syndrome.
The claim does not qualify for recognition on the basis of the list. In connection with the first work
function, which constituted two thirds of the working day, there were monotonously repeated, small
movements of the right shoulder joint, but without strenuousness and without repeated, stressful lifts of
the upper arm. In connection with the other work function, which constituted one third of the working
day, the work was characterised by repeated movements of the right shoulder joint in combination with
repeated lifts of the right upper arm to at least 60 degrees as well as moderate strenuousness. However,
relevant shoulder-joint straining work was only performed for one third of the working day (in the
other work function). Therefore the claim does not meet the requirement for shoulder-joint straining
work for at least half of the working day.
Example 16: Claim turned down rotator cuff syndrome (slaughterhouse worker for 8 years)
A 38-year-old man worked in an industrial slaughterhouse for well over 8 years. The work mainly
consisted in cutting hams and small roasts. For a small part of the working day he was organising,
cleaning and performing casual tasks. The cutting work was done at a table with good working height.
199
The work involved many repeated movements of the right shoulder joint (the cutting hand) with some
simultaneous exertion of the right arm, but without substantial lifting work. His left hand held the meat
pieces during the cutting, but was not exposed to risky loads. Nor did the organising or cleaning or
casual tasks involve harmful loads on his left shoulder. After about 8 years employment he developed
increasing pain in his left shoulder and a medical specialist diagnosed him with left-sided rotator cuff
syndrome.
The claim does not qualify for recognition on the basis of the list. The slaughterhouse worker
performed cutting work for the major part of the working day for 8 years, and the work was relevantly
stressful for his right shoulder. The work did not, however, involve relevant, risky loads on his left
shoulder in the form of repeated and strenuous movements of the left shoulder joint, in combination
with any awkward working postures or movements. Therefore there is no correlation between the left-
side rotator cuff syndrome and the work.
Example 17: Claim turned down rotator cuff syndrome (painter for 6 years)
A 32-year-old man worked for well over 6 years as a painter in a large painters business. In the last 6
months leading up to the onset of the disease, his work mainly consisted in painting radiators with a
small roll and small paintbrushes. According to the information in the claim form, including a medical
certificate from a specialist of occupational medicine, the work involved many repeated movements of
his right arm and partly his right shoulder. The work did not, however, involve strenuousness, and the
work was performed in good working postures for right arm and shoulder. He was developing pain in
his right shoulder, and a specialist of occupational medicine made the diagnosis of right-sided rotator
cuff syndrome. The clinical diagnosis of rotator cuff syndrome was confirmed by an MR scan that
showed rotator tendon degeneration.
The claim does not qualify for recognition on the basis of the list. The painter performed fine paint
work for about half a year, up to the development of symptoms of a right-sided rotator cuff syndrome.
The work was characterised by many repeated movements of his right arm and partly his right
shoulder. However, it did not involve strenuousness or awkward working postures or movements of
arm and shoulder. Therefore there is no correlation between the work and the shoulder disease.
Example 18: Claim turned down right-sided shoulder disease (mechanic for 24 years)
A 58-year-old man worked as a lorry mechanic for 24 years. He made all types of repairs on lorries,
including brakes, wheels, engines and gear boxes. He worked about 70 per cent of the time in a pit,
where most of his tasks of repairing gear boxes, air ducts, steering, rear axles, springs, etc. were carried
out with his arms at shoulder height or above shoulder level. He used big spanners and air keys to
screw on and off a lot of nuts. 30 per cent of the time he worked outside the pit, for instance changing
big wheels. Here he often had to use a hammer to loosen drums, which might weigh 25-30 kilos. It
appeared that 30 years previously he had fractured his right collar bone in connection with motor racing
in his leisure time. Subsequently there were signs of degenerative arthritis of the acromioclavicular
joint. He had experienced periodical pain in the shoulder after the previous injury, but the pain
gradually became more constant. X-rays showed signs of degenerative arthritis of the acromio-
clavicular joint and effects of fractures.
The right-sided shoulder disease does not qualify for recognition on the basis of the list. The work as a
lorry mechanic was relevantly stressful for the right shoulder for many years, with a combination of
repeated, strenuous and awkward shoulder movements and work for a long time with static lifts of the
right upper arm to shoulder level. However, in this case there is no sign of a shoulder disease included
on the list, and the complaints may very likely be referred to the previous fracture to the collar bone
and the degenerative arthritis of the acromioclavicular joint, which were not caused by work.
200
Example 19: Claim turned down left-sided rotator cuff syndrome in home help
The injured person developed left-shoulder complaints in 2002. The injured person worked in the
period 1986-1990 as a home help, which involved cleaning. There were no health problems in that
period. From 1990 and onwards, the injured person was employed as a home help performing
healthcare work. Every day there were 6 to 7 visits to citizens in their own homes. Here the injured
person performed care-related tasks in connection with bed baths, changing, and person transfers.
There were up to 40 person transfers per day with turning and lifting of persons in their beds. There
were transfers from sail to lift, including cooperation with a colleague when lifting heavy persons.
The claim does not qualify for recognition on the basis of the list. The work as a home help cannot be
characterised as repetitive or strenuous, shoulder-loading work, perhaps in combination with awkward
work movements or positions. Nor has there been a continued load on the left upper arm in connection
with static lifting of the arm to 60 degrees or more for several hours a day for a relatively long period
of time. Therefore there has been no load that was relevant for the development of the disease rotator
cuff syndrome. There are no grounds for submitting the claim to the Occupational Diseases Committee.
Example 20: Recognition of rotator cuff syndrome (factory worker for 5 years)
A 58-year-old woman worked for 5 years as a factory worker in a crisp factory. She had two functions.
Half the time she put labels on boxes of crisps. This work was not stressful for her right shoulder. The
other half of the working day she sorted crisps at a conveyor belt where the fried crisps came out. She
had to remove all the crisps that had been overcooked and were too dark. The woman was 1.55 metres
tall, and as a consequence of the belts position, in order to reach up to the belt, she had to hold up both
upper arms to about 60 degrees. As the belt was moving, she did not get a chance to rest her arms
during the half of the working day when she was doing the sorting. After 5 years work she developed
pain and motion problems in her right arm, and a medical specialist subsequently made the diagnosis of
right-sided rotator cuff syndrome.
The claim qualifies for recognition on the basis of the list. The function of putting labels on boxes was
not stressful for the shoulder as putting labels on boxes was done with repeated work movements
without strenuousness and without considerable lifting of the right upper arm. However, the function of
sorting crisps, due to the womans low height compared with the height of the sorting table, meant that
she worked with the upper arm statically held at about 60 degrees for half of the working day for
several years. There is furthermore good correlation between the onset of the disease and the
performance of the work.
Example 21: Recognition of bilateral impingement syndrome (slaughterhouse worker for 2-3 years)
A 32-year-old woman worked as a slaughterhouse worker in a poultry slaughterhouse for well over 3
years. The womans work function consisted in hanging chickens on hooks. The chickens came in on a
running belt, and the woman took the chickens from the belt and hung them up on a number of hooks
dangling above the belt. Due to the womans low height (1.60 metres) she had to hold her arms up
above shoulder height in order to reach the hooks. Even though she made lifting and lowering
movements of her arms, this did not involve lifting and lowering of the upper arms and the shoulders,
but only movements in forearms and elbows. The upper arms and shoulders were held static above 60
degrees during the performance of the work. After 2-3 years she developed pain in both upper arms and
shoulders and a medical specialist diagnosed her with bilateral impingement syndrome.
201
The claim qualifies for recognition on the basis of the list. Even though the slaughterhouse worker
made lifting and lowering movements of her forearms by hanging up chickens, the upper arms and
shoulders were being held statically lifted to about 60 degrees for the whole of the working day for 2-3
years. After 2-3 years she developed bilateral rotator cuff syndrome. There is furthermore good time
correlation between the load and the onset of the symptoms.
Example 23: Recognition of rotator cuff syndrome (insulation worker for 1 year)
A 27-year-old woman worked as an insulation worker for well over 1 year. Her work mainly consisted
in fitting insulation in ceilings. She held her upper arms lifted towards the ceiling for the major part of
the working day. Occasionally she lowered her arms to pick up some new insulation material. The
medical specialist made the diagnosis of right-hand rotator cuff syndrome.
The claim qualifies for recognition on the basis of the list of occupational diseases. The injured person
performed work that was characterised by static fixation of the upper arms above 60 degrees, for the
major part of the working day, for well over 1 year. Even though she occasionally lowered her arms,
this happened for such a short time that the shoulder did not get the time to rest before the arm was
raised again to above 60 degrees. Furthermore the arm was lowered only a few times, in relative terms.
There is furthermore good time correlation between the work and the development of a right-sided
rotator cuff syndrome.
Example 24: Claim turned down degeneration in the long biceps tendon (plumber for more than 20
years)
A 52-year-old man worked for more than 20 years as a plumber in a small business. The work i.a.
involved fitting of sinks and toilets and repairs and replacements of different pipes and installations in
bathrooms, kitchens, and heating systems in private homes and businesses. The work is described, in
the occupational medical report, as varied, but there might on particular days have been a lot of work
where the arms were held lifted to 60 degrees or more, i.a. in connection with pipe installations and
work on heating systems. He developed pain in his right upper arm, and a medical specialist made the
diagnosis of right-sided degeneration of the long biceps tendon (biceps tendinitis).
The claim does not qualify for recognition on the basis of the list. The injured person mainly performed
varied work as a plumber, the arms only a few times being held statically lifted. Apart from that, there
is no information of other work functions that were stressful for the upper arms. The work cannot be
characterised as repetitive and strenuous, shoulder-loading work, in any combination with awkward
work movements or postures. Nor has there been a continued load on the right upper arm in connection
with static lifts of the arm to 60 degrees or more for several hours a day for a long period of time.
Therefore the exposure has not been relevant for the development of the disease biceps tendinitis.
202
More information:
Associations between work-related exposure and the occurrence of rotator cuff disease and / or biceps
tendinitis. A reference document (www.ask.dk)
A critical review of evidence for a causal relationship between computer work and musculoskeletal
disorders with physical findings of the neck and upper extremity (www.ask.dk)
Frozen shoulder A clinical syndrome characterised by painful restriction of the active and
passive motion of the shoulder joint without any specific cause being
established
Humerus Upper arm bone
Impingement syndrome Squeezing phenomenon
Infection Infectious degeneration caused by micro organisms
Movements of the shoulder joint Flexion: forward-upward
Extension: backward-upward
Abduction: outward-upward
Rotation: turning
Pain arch, pain curve Pain in the shoulder joint during movement of the arm from a lifted posture
to a higher lifted posture (typically the pain occurs between 60 and 120
degrees)
Painful arch syndrome A clinical syndrome characterised by pain in the shoulder and upper arm
during abduction of the arm, with freedom from pain at the extremes of the
range of movements
Peritendinitis Inflammatory degeneration in the tissue enveloping a tendon
Rotator cuff The cuff about the front of the shoulder joint composed of the supraspinatus
tendon, the infraspinatus tendon, the subscapularis tendon and the tendon
from teres minor. These tendons co-ordinate and stabilise the joint and the
movements together with other muscles around the shoulder joint
203
Rotator cuff lesion Fissure or other injury in the rotator cuff
Tendinitis Inflammatory degeneration of a tendon
The suffix it is Inflammation caused by micro organisms or inflammatory degeneration
without micro organisms. With regard to work-related diseases the
inflammatory degeneration is always without micro organisms.
Disease Exposure
B.2. Chronic neck and Quickly repeated movements of shoulder/upper arm, perhaps in
shoulder pain combination with bending of the neck and/or static load on the neck and
(cervicobrachial syndrome) shoulder girdle, for a considerable number of years
Symptoms
Chronic (daily) pain of the neck and shoulder region
Muscle tenderness of the neck and shoulder girdle (see figure below)
Any aggravation of pain in connection with load on the region
Any restricted motion
In order for the disease to be covered by the list, there needs to be chronic (daily) pain.
204
The 12 areas of the neck and shoulder region (6 on each side):
Objective signs
The clinical diagnosis of cervicobrachial syndrome (chronic neck and shoulder pain) is made by way of
a combination of
1. Indication of palpation tenderness in 12 areas of the neck and shoulder girdle (6 on each side),
stating in a form, on a scale from 1 to 4, the pain in connection with palpation:
1 = no tenderness
2 = slight tenderness
3 = moderate tenderness
4 = considerable tenderness
Before the diagnosis of cervicobrachial syndrome (chronic neck and shoulder pain) can be made, there
must be
moderate to considerable tenderness of several of the 12 muscle areas of the neck and shoulder
girdle as well as
moderate to considerable distribution of tenderness to several of the 12 muscle areas
205
The tenderness may be unevenly distributed on the two sides if there is good correlation between the
uneven distribution and the load.
It is the combination of the severity of the pain and the distribution of pain/tenderness which, together
with the relevant exposures at work and the duration of the exposure, makes it possible to make the
diagnosis of work-related, chronic neck and shoulder pain.
In addition to palpation tenderness there may be restricted motion of neck and shoulder and/or
increased muscular consistency. Restricted motion or increased muscular consistency is not a
diagnostic requirement, however.
Quickly repeated movements of the shoulder/upper arm, perhaps in combination with bending of the
neck and/or a static load on the neck and shoulder region, for a considerable number of years, increase
the risk of developing chronic neck and shoulder pain, which is characterised by moderate to
considerable tenderness of several muscle areas of the neck and shoulder region.
The load needs to be mechanical and physiologically relevant for the disease.
The work may have involved different work functions, and thus a certain job variety, in the course of
the working day. If different functions were carried out in the course of the working day, an assessment
will be made, for each function, of the concrete load on the neck and shoulder region. The duration of
the various types of loads usually needs to be equivalent to at least half of the working day (3-4 hours).
For instance, in the course of the working day, there may be alternation between two different
functions, each involving relevant, quickly repeated movements of shoulders/upper arms and lasting in
total a little more than half of the working day. To this could be added two other functions without
quickly repeated movements of shoulders/upper arms, lasting in total a little less than half of the
working day and not meeting the exposure requirements. In this case there is alternation between four
different work functions in the course of the working day, two of these functions meeting the relevant
exposure requirements. As these two functions at the same time stretch over more than half of the
working day, the claim will qualify for recognition on the basis of the list.
206
5.3.1. The time requirements
There must have been a load on the neck and shoulder for a considerable period of time.
This usually means that neck and shoulder loading work must have been performed
If there has been a particular load on the neck and shoulder, it will be possible to reduce the
requirement to the duration of the exposure (number of hours/months/years).
The total duration requirement in terms of years cannot be reduced to less than 6 years.
Particular neck and shoulder exposures that may contribute to a reduction in the time
requirement:
Extremely quick movements of the shoulder/upper arm usually means at least 25-30 movements of the
shoulder/upper arm per minute, or more.
Long-lasting and considerable bending of the neck for large parts of the working day, without any
chances of restitution (rest) and straightening of the muscles of the neck, may reduce the requirements
to the total duration of the exposure, but not to less than 6 years.
Long-lasting, static load on the neck and shoulder girdle, where the musculature of the neck and
shoulder girdle is fixated in the same posture for very long periods of time and for the major part of the
working day, may be able to reduce the requirement to the total duration of the exposure, but not to less
than 6 years.
Besides, a reduction in the time requirement to not less than 6 years will depend on a concrete
assessment of the extent and scope of the special neck and shoulder exposures.
Movements of the shoulder/upper arm are movements of the shoulder joint and/or the upper arm.
207
In principle there need to have been more than 15 movements of the shoulder/upper arm per minute if
the work is to be described as quickly repeated work within the meaning of the list. This number may
be reduced, but not to less than 10 movements per minute, if the work was characterised by special load
factors.
The following special load factors may contribute to reducing the requirement to the number of
repeated movements per minute, but not to less than 10 movements per minute:
There is no requirement that the quickly repeated movements were made with both shoulders/upper
arms. If the load was one-sided, however, it should always be consistent with clear symptoms with
regard to the diagnostic criteria for chronic neck and shoulder pain on the side that suffered the relevant
exposure.
On the other hand, clear symptoms on both sides would not speak against recognition, even if the load
was relatively one-sided.
The list does not cover monotonous precision work performed close to the body and involving repeated
movements of the hand, forearm and/or elbow, or any static load on the neck and shoulder girdle and/or
bending of the neck without simultaneous, quickly repeated movements of shoulder/upper arm.
If the work was generally characterised by bending of the neck, it is possible to reduce the requirement
to the number of repeated movements of the shoulder/upper arm per minute, but not to less than 10
movements per minute.
Short-term or very slight bending of the neck in the course of the working day will not be characterised
as relevant bending of the neck within the meaning of the list.
Bending of the neck without simultaneous, quickly repeated movements of the shoulder/upper arm is
not covered by the list.
208
The requirement for a static load on the neck and shoulder girdle does not mean that there must not
have been any short-lasting movements of the neck and shoulder girdle in the course of the working
day. But the work needs to have involved a certain amount of continued fixation of the neck-and-
shoulder girdle musculature, in largely the same posture, for long intervals at a time.
If the work generally was characterised by a static load on the neck and shoulder girdle, it is possible to
reduce the requirement to the number of repeated movements of the shoulder/upper arm per minute, but
not to less than 10 movements per minute.
A static load on the neck and shoulder musculature without simultaneous, quickly repeated movements
of the shoulder/upper arm is not covered by the list.
In order for the work to be characterised as relevantly strenuous with regard to the neck and shoulder
musculature, there must always have been strenuous movements of the shoulder/upper arm, but not
necessarily exertion of the muscles of the neck. If the work did involve exertion of the neck
musculature, however, this will also be included in the overall assessment of the load.
In order for the work to be seen as characterised by strenuous movements of the shoulder/upper arm,
there needs to have been exertion somewhat in excess of what would normally be required to lift and
turn the arm without the influence of particular loads. This applies in particular in cases where the work
is characterised by repeated movements without any simultaneous, stressful working postures for the
shoulder/upper arm.
Relevantly strenuous movements of the shoulder/upper arm may for instance be work that involves a
lot of pushing, pulling or lifting with the application of a great deal of muscular force in the shoulder,
perhaps with simultaneous twisting and turning movements of the shoulder joint (for instance in
connection with deboning in a slaughterhouse).
The assessment of whether the work can be regarded as strenuous in a relevant way for the neck and
shoulder musculature includes
the degree of using muscular force of the shoulder/upper arm and perhaps neck
whether the unit offers resistance
whether there are simultaneous twisting or turning movements of the shoulder joint and perhaps
the neck
whether the work is performed in awkward postures of shoulder/upper arm and perhaps the
neck, for instance in extreme postures
If the work was in general characterised by strenuous movements of the shoulder/upper arm, it will be
possible to reduce the requirement to the total duration of the load, but not to less than 6 years.
209
Very strenuous movements of the shoulder/upper arm will be able to reduce the requirement to the
number of repeated movements per minute, but not to less than 10 movements per minute.
Strenuous movements of the shoulder/upper arm without simultaneous, quickly repeated movements of
the shoulder/upper arm are not covered by the list. Strenuousness of elbow, forearm or hand is not
covered by the list.
The assessment of the load must take into account the persons size and physiology.
Furthermore there must be good time correlation between the onset of the disease and the neck and
shoulder loading work. The first symptoms of the disease need to appear some time after the
commencement of the neck and shoulder loading work. Depending on the scope of the load, some
time is usually understood as several years.
However, the assessment does take into account whether there have been, for instance, extraordinarily
heavy, daily loads. In such cases, from a medical point of view, there will be a time correlation between
the work and the development of the disease, even if the first symptoms occur soon after the
commencement of the neck and shoulder loading work.
This also means that the disease must not have manifested itself as a chronic disease before the
stressful work was commenced. On the other hand, a single, previous case of acute neck and shoulder
pain with complete recovery does not in itself lead to the claim being turned down.
It will be characteristic for chronic neck and shoulder pain to develop gradually in the course of a few
years after the commencement of the stressful work and for the disease to be gradually aggravated with
increasing pain in connection with continued exposure.
It occasionally belongs to the pathological picture that the disease at some point in time is acutely
aggravated. In such cases it is of no special significance whether such an acute aggravation occurs in
connection with the work or in a different situation, as long as the aggravation actually occurs in a
period of neck and shoulder loading work. If the acute aggravation for example occurs outside working
hours, without it being an accident, the aggravation may still be referred to the neck and shoulder
loading work.
In cases where the injured person has ceased doing the neck and shoulder loading work, there must not
have been any considerable aggravation after cessation of the exposure. Any substantial aggravation
after cessation of the exposure would be in favour of finding that the neck and shoulder disease was not
work-related.
In the processing of the claim we may request a medical certificate from a specialist of occupational
medicine. The medical specialist will among other things be asked to describe and assess the different
work functions and the frequency and nature of the work movements. This description would include a
detailed account of the concrete types of loads and their severity and duration in the course of the
working day and seen over time. The medical specialist will also make an individual assessment of the
impact of stress factors on the development of the disease in the specific examined person.
210
The medical specialist will furthermore make a clinical examination, including an examination of the
palpation tenderness in the 12 areas of the neck and shoulder region, and state the outcome of the
examination in a special form (tenderness intensity as well as distribution of tenderness in the 12
areas). The examination will furthermore include other objective matters of relevance for the
assessment of the disease as well as a description of the anamnesis, including a description of the onset
of the disease, its progress, examinations and treatments, i.a. x-rays and scans and the result of these, as
well as any treatment by a chiropractor or physiotherapist.
Arthritic degeneration
Arthritic degeneration shown in an x-ray of the cervical spine, the acromio-clavicular joint or the
shoulder joint does not in itself lead to the claim being turned down. What matters is the degree to
which this arthritic degeneration gives or will give symptoms of significance for the assessment of the
reported disease.
Chronic neck and shoulder pain and degeneration of the rotator cuff tendons of the shoulder
joint
If it is merely a case of degeneration of the rotator tendons of the shoulder joint, this disease cannot be
recognised on the basis of the item on the list regarding chronic neck and shoulder pain.
By way of example, an exposure that may qualify for recognition after submission to the Committee is
a very strenuous load on the neck and shoulder musculature without simultaneous, quickly repeated
work movements within the meaning of the list.
Another example might be extremely quickly repeated movements of shoulders/upper arms, perhaps in
combination with other particular loads on the neck and shoulder musculature, for a period of less than
6 years.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
211
Example 1: Recognition of chronic neck and shoulder pain (industrial seamstress for 7 years)
The injured person worked full time for well over 7 years as an industrial seamstress, sewing work
clothes at an overlock sewing machine. The work involved quickly repeated movements of
shoulders/upper arms, about 20 times per minute. During her work, in step with the sewing process, she
led her arms and shoulders forward. The neck and shoulder girdle was fixated in largely the same
position most of the time, only briefly interrupted when she had to pick up a new unit. In the last year
she developed chronic pain of the neck and shoulder region and a medical specialist diagnosed her with
chronic neck and shoulder pain with considerable tenderness (severity 3-4) in five of the areas of the
neck and shoulder musculature. The claim qualifies for recognition on the basis of the list. The
seamstress was diagnosed with chronic neck and shoulder pain, after having performed quickly
repeated movements of shoulders/upper arms with a simultaneous, long-lasting static load on the neck
and shoulder girdle, after sewing full time and for a number of years. As there were quickly repeated
movements of the shoulders/upper arms more than 15 times a minute in combination with a long-
lasting, static load on neck and shoulder girdle, it is possible to reduce the requirement to the duration
of the load from the normal 8-10 years to 7 years in this case. Furthermore there is good time
correlation between the neck and shoulder loading work and the onset of the disease.
Example 2: Recognition of chronic neck and shoulder pain (slaughterhouse worker for 6 years)
A 48-year-old man worked full time as a slaughterhouse worker for 6 years. His work mainly consisted
in deboning and cutting up large meat units with a saw or knife. Part of the cutting work he performed
in a standing posture, cutting suspended meat units with his arms lifted, whereas he performed other
cutting and deboning tasks in a standing posture at a conveyor belt. The work was generally charac-
terised by movements of the right shoulder/upper arm, 10-15 times per minute, and simultaneous,
substantial exertion of the right shoulder. Furthermore, half of the working time the work was
characterised by prolonged bending of the neck when he was cutting and deboning, standing at a
conveyor belt. Towards the end of the period he developed chronic neck and shoulder pain, both on the
right and the left side of the neck and shoulder girdle, with tenderness (degrees 3-4) in most of the 12
muscle areas of the neck and shoulder region.
The claim qualifies for recognition on the basis of the list. The slaughterhouse worker performed full-
time work for 6 years. Most of the time his work was characterised by repeated movements of mainly
his right shoulder/upper arm, 10-15 times per minute, with simultaneous, heavy exertion of his right
shoulder and prolonged bending of the neck. As the work involved repeated shoulder movements in
combination with heavy exertion of the shoulder and long-lasting bending of the neck, the requirement
to the duration of the load can be reduced from the normal 8-10 years. The requirement to the number
of shoulder movements per minute can likewise be reduced from more than 15 movements per minute
to, in this instance, 10-15 movements per minute. This is because the work involved heavy exertion of
the right shoulder and bending of the neck. He developed chronic neck and shoulder pain which meets
the requirements to the diagnosis for the right and left side and therefore meets the requirements for
recognition of the disease as a whole, even though the load was mainly on the right side.
Example 3: Recognition of chronic neck and shoulder pain (wood industry worker for 8.5 years)
A 32-year-old woman worked full time in the wood industry for well over 8.5 years. For the major part
of the working day she stood at a cut-off saw, feeding it with boards 4-5 metres long. After they had
been cut off, the boards slid onto a belt for further processing. In the performance of the work she
grabbed from a pallet lifter on her right side, with both hands, the long boards in bundles of four. She
then lifted them onto the feed table of the cut-off saw and pushed them in. Each bundle required three
handlings and she had a daily production of 10,000 boards. This is equivalent to about 7,500 handlings
212
per day (7 hours) or 15-20 handlings per minute. Each handling task constituted movements of the
shoulder joints. In the course of the last year she developed increasingly severe, bilateral neck and
shoulder pain and was diagnosed by a medical specialist with chronic neck and shoulder pain with
considerable tenderness (rated at 3-4) in 10 out of the 12 muscle areas of the neck and shoulder region.
The claim qualifies for recognition on the basis of the list. The wood industry worker for 8.5 years
performed quickly repeated work movements, 15-20 times per minute, when handling boards fed into a
cut-off saw. The disease also meets the diagnostic requirements of the list and the onset of the disease
was in good time correlation with the neck and shoulder loading work.
Example 4: Recognition of chronic neck and shoulder pain (electronics fitter for 6.5 years)
The injured person worked as an electronics fitter for 11-12 months a year, for a total of 6.5 years, in a
company manufacturing control electronics and electrical boards for the windmill industry. The work
consisted in print fitting and soldering, sitting at a worktable. She picked up components on her left,
placed them in the print lying in front of her, and soldered the components onto both sides of the print
with a soldering iron in her right hand and soldering tin in her left hand. The soldering was done with
quick movements of hands, arms and shoulders, the neck and shoulder girdle being fixated in largely
the same position during the work process, and at the same time the neck was mainly flexed. The work
was performed at a high pace with more than 15 movements of the shoulders/upper arms per minute.
Towards the end of the period she developed increasing and gradually considerable, chronic pain in
neck and shoulder girdle. A medical specialist diagnosed her with severe chronic neck and shoulder
pain (cervicobrachial syndrome) with tenderness rated 3-4 in eight areas of the neck and shoulder
region. The claim qualifies for recognition on the basis of the list. The electronics fitter developed
severe chronic neck and shoulder pain with considerable tenderness in most of the 12 areas of the neck
and shoulder region after fitting and soldering work which for a number of years was characterised by
quickly repeated movements of shoulders/upper arms, more than 15 times per minute. As the work was
also characterised by a prolonged, static load on the neck and shoulder girdle and bending of the neck
for most of the working day, there are grounds, in this case, for reducing the requirement to the
duration of the load from the usual 8-10 years to 6.5 years.
Example 5: Recognition of chronic neck and shoulder pain (industrial laboratory technician for 9 years)
The injured person worked full time for a little more than 9 years (108 months) as an industrial
laboratory technician in a pharmaceutical company. About 4 hours a day, the work mainly consisted in
control tasks involving testing for toxins of the companys products for cell cultivation. Most of the
work was performed in a sitting posture with a pipette in sterile benches, behind a glass plate. The work
was done with frequent movements, about 20 times per minute, of the right upper arm/shoulder, which
was halfway lifted away from the body. She developed severe neck and shoulder region pain and a
medical specialist diagnosed her with chronic neck and shoulder pain with considerable tenderness
(rated 4) in five of the areas of the right neck and shoulder region, and with slight to moderate
tenderness (rated 2-3) in the remaining areas.
The claim qualifies for recognition on the basis of the list. The injured person was employed as an
industrial laboratory technician for 9 years, doing pipetting work, which the major part of the working
time involved quickly repeated movements of the right upper arm/shoulder, more than 15 times per
minute. She subsequently developed chronic neck and shoulder pain with considerable tenderness in a
large part of the neck and shoulder region, and there is good correlation between the load on the neck
and shoulder region musculature and the onset of the disease. Even though the work was mainly
performed with the right upper arm/shoulder, this does not speak against her having developed neck
and shoulder pain on both her right and left side. The main thing is that she suffered relevant exposure
213
on her right side, where the diagnostic requirements to the spreading and severity of the tenderness are
fully met.
Example 6: Recognition of chronic neck and shoulder pain (sail maker for 7.5 years)
For a total of 7.5 years, 10-12 months a year, a woman worked as a sail maker, sewing sails for big
sailing boats. The whole working day, the work involved sewing of different canvas materials,
typically rather coarse and relatively heavy fabric. She typically made 15-18 movements per minute of
both shoulders/upper arms, using a great deal of muscular force when handling the big canvas pieces to
and from the machine and during the sewing itself, and she often had to turn over and reposition the
pieces. Towards the end of the period she developed constant pain and tenderness of the neck and
shoulder region, and a medical specialist made the diagnosis of chronic neck and shoulder pain with
considerable tenderness (rated 3-4) in nine of the areas of the neck and shoulder region.
The claim qualifies for recognition on the basis of the list. Throughout the working day, the sail maker
performed repeated movements of the shoulders/upper arms, 15-18 times a minute, with some exertion
of the shoulders. As the work involved exertion of the shoulders, it is possible to reduce the
requirement to the total duration of the exposure from the usual 8-10 years to, in this case, 7.5 years.
Example 7: Recognition of chronic neck and shoulder pain (industrial butcher for 6 years)
An industrial butcher worked full time for a little over 6 years in a large turkey slaughterhouse. His
work partly consisted in suspending 8 to18-kilo turkey hens and cocks on moving hooks. The lifting
height was from knee height to above shoulder height and the suspension required some exertion of
both shoulders/upper arms. Suspending the turkeys, he made about 20 movements of both upper
arms/shoulders per minute. This he did for one third of the working day. For another third of the
working day he cut out turkey stomachs and gizzards. The cutting was made at shoulder height, and he
was able to handle 5-8 turkeys per minute. As each cutting required several movements of primarily his
right shoulder, the work typically involved 16-20 movements of the right upper arm/shoulder per
minute and some exertion of the shoulder. The last third of the working day he pulled out guts from
suspended turkeys, 10-16 sets of guts per minute. He pulled with both arms, with his hands at shoulder
height and the upper arms almost extended. Each pull typically required 1-2 very powerful movements
of both shoulders/upper arms, or a total of 10-32 movements per minute. Towards the end of the period
he developed pain of the neck and shoulder girdle, mainly on his right side. A medical specialist found
considerable muscular tenderness (rated 3-4) in seven muscle areas of the neck and shoulder region, six
of them being on the right side, as well as restricted motion of the neck and right shoulder.
The claim qualifies for recognition on the basis of the list. The industrial butcher developed chronic
neck and shoulder pain with considerable tenderness in seven out of 12 muscle areas of the neck and
shoulder region, mainly on the right side. The disease developed after he worked for 6 years as a turkey
butcher. He performed quickly repeated movements, typically 16-20 times a minute, of the upper
arms/shoulders for the major part of the working day, the heaviest load being on the right shoulder.
Furthermore, the work was characterised by a great deal of exertion of the upper arms/shoulders, which
allows a reduction in the time requirement from 8-10 years to, in this case, 6 years.
Example 8: Recognition of chronic neck and shoulder pain (fishing industry worker for 6.5 years)
For a total of 6.5 years, 8-10 months a year, a woman worked full time in a company in the fishing
industry. Her work partly consisted in cutting out frozen fish blocks and partly in lifting and handling
boxes of fish. She lifted boxes containing four frozen fish blocks of 7.5 kilos, or a total of 30 kilos,
from a pallet to a worktable. The lifts were made from below knee height to above shoulder height.
Then she separated the frozen fish blocks and with a knife cut them into smaller, 2.5-kilo pieces. The
214
separation of the frozen blocks and cutting them into smaller blocks involved strenuous and quickly
repeated, twisting movements of mainly the right shoulder, about 30 times per minute. She then with a
circular saw cut the smaller blocks into filets, which also required very quickly repeated movements of
the shoulder. Finally the filets were put into boxes able to contain 20-25 kilos of fish and were lifted
onto pallets. The lifts were made from below knee height to above shoulder height. This work involved
quickly repeated movements of both shoulders/upper arms, about 25 times per minute. In the end she
developed pain of the neck and shoulder region, and a medical specialist found moderate to con-
siderable tenderness (rated 3-4) on the right side, in five of the 12 muscle areas of the neck and
shoulder girdle. The medical specialist made the diagnosis of chronic, right-sided neck and shoulder
pain with severe myogenous degeneration and impingement syndrome of the right shoulder.
The claim qualifies for recognition on the basis of the list. The fishing industry worker performed
extremely quickly repeated movements of the right shoulder, between 25 and 30 times per minute for
the entire working day. As the work involved extremely quickly repeated shoulder movements 25-30
times per minute, there are grounds for reducing the requirement to the total duration of the exposure
from 8-10 years to, in this case, 6.5 years. There is also good correlation between the various work
functions, which primarily constituted a load on the right upper arm/shoulder, and the chronic neck and
shoulder pain rated at 3-4 in 5 muscle areas on the right side of the neck and shoulder girdle. The right-
sided impingement syndrome is part of the neck and shoulder disorder and will therefore be included
when the amount of the compensation is determined.
Example 9: Recognition of chronic neck and shoulder pain (punching work in the metal industry for 9
years)
A man worked full time for well over 9 years in an industrial company that produced various metal
units. He worked at a machine punching metal sheets for smaller units. The work consisted in placing
metal sheets in the punching machine and activating the latter by means of two handles. The metal
sheets measured up to 1.0 x 1.2 metres and weighed between 5 and 15-18 kilos. The sheets were taken
from a carriage at the side of the machine and lifted to the punching machine from below hip height to
above hip height. This required some exertion in connection with the lift itself and when placing the
sheet in the machine. The activation of the two handles also required some force. He punched about
2,000 units per day, each unit typically requiring four movements of both shoulders/upper arms. This is
equivalent to nearly 20 movements per minute. After 8 years he started getting pain in the neck and
shoulder musculature. A medical specialist later made the diagnosis of chronic neck and shoulder pain
with findings of considerable tenderness of eight areas of the neck and shoulder musculature as well as
restricted motion of the neck. An x-ray examination also showed signs of moderate degenerative
arthritis of the cervical neck without nerve involvement.
The claim qualifies for recognition on the basis of the list. For 9 years the metal industry worker
performed quickly repeated movements of both shoulders/upper arms, more than 15 times per minute
and for the entire working day, and he developed chronic neck and shoulder pain with a tenderness
rated 3-4 in eight out of 12 muscle areas. When determining the compensation there are no grounds for
making a deduction for the degenerative cervical arthritis, the arthritis so far being moderate and
asymptomatic.
215
Example 10: Recognition of chronic neck and shoulder pain (bookbinder for 7 years)
The injured person worked full time for 7 years as a bookbinder. Two thirds of the time her work
consisted in lifting stacks of printed forms from machines and packing them into cartons. Each pile and
the ready-packed cartons weighed up to 20 kilos. She packed about 125 cartons per hour with typically
eight handlings and shoulder movements per carton. This is equivalent to about 16 movements of both
upper arms/shoulders per minute. First she lifted stacks of paper into smaller piles, which she subse-
quently assembled with a powerful grip with both arms and banged against the table. Subsequently the
assembled piles had to be lifted up onto the edge of the carton with lifts above shoulder height and with
extended arms. Eventually the cartons were lifted onto a euro pallet next to the machine. Most tasks of
packing forms also involved exertion in both upper arms/shoulders. The last third of the working day
she separated sheets of paper with a knife. This work also involved a large number of repeated move-
ments of upper arms/shoulders, typically 20 times per minute. She developed pain of the neck and
shoulder girdle towards the end of the period. A medical specialist diagnosed her with chronic neck and
shoulder pain with moderate to considerable tenderness in five out of 12 muscle areas of the neck and
shoulder region.
The claim qualifies for recognition on the basis of the list. The bookbinder developed chronic neck and
shoulder pain with moderate to considerable tenderness in five out of 12 muscle areas. The disease
came about after 7 years of work involving, during the whole day, quickly repeated movements of both
upper arms/shoulders, between 16 and 20 times per minute. Furthermore, half of the time the work was
characterised by exertion of upper arms/shoulders, which gives grounds for reducing the requirement to
the total duration of the exposure from 8-10 years to, in this case, 7 years.
Example 11: Recognition of chronic neck and shoulder pain (seamstress for 24 years)
A 57-year-old woman worked from home as a seamstress for 24 years. Some of the years she only
worked a few months, i.a. due to maternity leave, and for a few scattered years she was without
employment. Altogether she had an employment rate of 6-7 months per year in the 24-year-period. Her
work as a seamstress in the home mainly consisted in sewing work clothes, primarily work jeans for
men, and the work was characterised by quickly repeated movements of the shoulders/upper arms,
more than 15 times per minute, and a simultaneous, static load on the neck and shoulder girdle for a
large part of the working day. After well over 20 years work she developed increasing headaches from
the neck, and a medical specialist subsequently made the diagnosis of severe, chronic neck and
shoulder pain. It appeared from the specialists certificate that there was moderate to considerable
tenderness (rated 3-4) in eight out of the 12 muscle areas of the neck and shoulder girdle.
The claim qualifies for recognition on the basis of the list. The seamstress had relevant neck and
shoulder loading work for a total period of 24 years. The work was interrupted for a few periods, or she
worked part time due to maternity leave etc., and therefore her employment rate was only about 6-7
months per year. As there was a particularly long load period of more than 15 years with employment
equivalent to full employment most of the years, and as the general requirements to a relevant load,
duration of load and pathological picture are met, the claim is covered by the list.
Example 12: Recognition of chronic neck and shoulder pain (seamstress in the home for 6-6.5 years)
A 49-year-old woman worked from home as a seamstress for 6-6.5 years. She was paid by the hour.
The work consisted in sewing trousers for men and women on an overlock machine. The work in-
volved quickly repeated movements of the shoulders/upper arms, more than 15 times per minute, and
also a long-lasting, static load on the neck and shoulder girdle. She worked about 10 hours a day by far
the major part of the period, which was documented by her employers pay accounts. After well over 6
years work she developed increasing neck headaches and neck and shoulder tenderness. A medical
216
specialist subsequently diagnosed her with severe cervicobrachial syndrome with considerable
tenderness (rated 3-4) in seven out of the 12 muscle areas. Besides she suffered from slight tenderness
(rated 1-2) of the last five muscle areas, and she was diagnosed with a slight, right-sided rotator cuff
syndrome.
The claim qualifies for recognition on the basis of the list. The seamstress was diagnosed with severe,
chronic neck and shoulder pain after working from home for 6-6.5 years. As she had very long, 10-hour
workdays and the work also involved a prolonged, static load on the neck and shoulder girdle, as well
as quickly repeated movements of the shoulders/upper arms, there are grounds for reducing the require-
ment to the duration of the load from normally 8-10 years to, in this case, 6-6.5 years. The degeneration
of the rotator tendons of the right shoulder joint (rotator cuff syndrome) is seen as part of the general
neck and shoulder syndrome and will therefore be included in the assessment of the claim with regard
to permanent injury.
Example 13: Recognition of chronic neck and shoulder pain (cleaning for 30 years)
A 58-year-old woman worked for about 30 years as a cleaner in various hospitals, the last 15 years full
time. She particularly cleaned laboratories, x-ray department, hall, and a couple of small cafes. She
began by wiping off furniture etc. for about 1-2 hours, and then she cleaned toilets for about 1 hour.
Floor mopping took up about half of the total working hours or 3.5-4 hours per day. The first years she
used an old-fashioned floor scrub and a cloth, but later she switched over to wet mops and, partly, dry
mops. At the beginning there was a drip-dry stem for the mops, but later she worked with wet mops,
which had to be replaced. When mopping she made 40-60 movements of her upper arms per minute
with some simultaneous application of force in case of wet mopping. For most of the period she
developed tension of the neck and shoulder region with pain occurring when at rest as well as when she
was working. A medical specialist diagnosed her with chronic neck and shoulder pain, and the medical
specialist found moderate to considerable tenderness of 7 out of 12 muscular areas in the neck and
shoulder region.
The claim qualifies for recognition on the basis of the list. The cleaner had very quick, repetitive
movements far more than 16 times per minute when mopping for half of the working day and for more
than 8-10 years. She has furthermore developed chronic neck and shoulder pain with moderate to
considerable tenderness in more than 3-4 of the 12 muscle areas of the neck and shoulder region.
Example 14: Claim turned down chronic neck and shoulder pain (industrial seamstress for 10 years)
A 47-year-old woman worked as an industrial seamstress for 10 years. The work consisted in sewing
different units, mainly trousers, on an overlock machine. She was paid by the piece. The work was
characterised by quick and repeated, monotonous shoulder movements with fixation of the neck and a
static load on the shoulders. Already after well over one years work she developed chronic neck and
shoulder pain with daily complaints. A medical specialist made the diagnosis of chronic neck and
shoulder pain with considerable tenderness of the neck region (two areas rated 3) and slight tenderness
of the right shoulder girdle (three areas rated 1-2).
The claim does not qualify for recognition on the basis of the list. The seamstress had neck and
shoulder loading work with quickly repeated movements of the shoulders/upper arms for 10 years.
However, she developed chronic neck and shoulder pain already after one years work. The exposure
period of one year before the disease became chronic was too brief for the disease to be recognised on
the basis of the list. Besides, there was no moderate to considerable tenderness with moderate to
considerable distribution to the 12 muscular areas of the neck and shoulder region, but only moderate
217
to considerable tenderness in a very moderate part (two areas) of the 12 muscle areas. Therefore, within
the meaning of the list, the pain was not chronic neck and shoulder pain.
Example 15: Claim turned down chronic neck and shoulder pain (industrial seamstress for 12 years)
The injured person worked for 12 years as an industrial seamstress, paid by the piece, in a large clothes
manufacturing business. The work was performed at an overlock machine, where she partly sewed
trouser parts together and partly sewed zips into trousers. The work was monotonous and characterised
by quick work movements of shoulders and arms, neck and shoulder being exposed to a static load for
the major part of the working day. Towards the end of the period she developed a condition of general
muscular pain, including pain of the neck and shoulder region, of arms, hands, thoracic back and low
back. A medical specialist made the diagnosis of fibromyalgia with muscular tenderness of several
parts of the body, including general and slight to moderate muscular tenderness of the neck and
shoulder region.
The claim does not qualify for recognition on the basis of the list. The seamstress for 12 years
performed stressful work that was relevant for the development of chronic neck and shoulder pain. She
was not, however, diagnosed with chronic neck and shoulder pain, including moderate to considerable
tenderness of an essential part of the neck and shoulder region, but with the disease fibromyalgia.
Therefore it was not chronic neck and shoulder pain within the meaning of the list.
More information:
A critical review of evidence for a causal relationship between computer work and musculoskeletal
disorders with physical findings of the neck and upper extremity (www.ask.dk)
Chronic pain with physical findings in the neck-shoulder girdle and exposures in the workplace: A
systematic review (ww.ask.dk)
218
Flexion Bending
Musculus infraspinatus The infraspinous muscle, which originates below the shoulder blade
and attaches to the greater tubercle (tuberculum majus) of the arm
bone. The muscle is so called because it originates below (infra) a
bony projection on the posterior surface of the shoulder blade, the
spine of the scapula (spina scapulae)
Musculus levator scapulae The levator muscle of the scapula, which originates from the
transverse processes of the four upper cervical vertebrae and attaches
to the shoulder blade. The muscle is so called because it elevates the
shoulder blade
Musculus pectoralis major The greater pectoral muscle, which originates like a fan from the
collar bone (clavicle), the sternum and ribs and attaches to the greater
tubercle (tuberculum majus) of the arm bone. The muscle is called the
greater pectoral muscle (pectus = chest and major = great) due to its
size and extension at the front of the chest
Musculus supraspinatus The supraspinous muscle, which originates from above the shoulder
blade and attaches to the great tubercle (tuberculum majus) of the arm
bone. The muscle is so called because it originates above (supra) a
bony projection on the posterior surface of the shoulder blade, the
spine of the shoulder blade (spina scapulae)
Musculus trapezius The trapezius muscle, which originates from cervical and thoracic
vertebrae and attaches to the clavicle, the acromion and the shoulder
blade. The muscle is so called because if seen from behind, the right
and the left muscles combined form a trapezius shaped muscle plate
Pain arch, pain curve Pain in the shoulder joint during movement of the arm from a lifted
posture to a higher lifted posture (typically the pain occurs between 60
and 120 degrees)
Palpation Examination through touching/feeling through a muscle
Regio nuchae The posterior cervical region, a trapezius shaped region at the back of
the neck. Anatomically regio nuchae is delimited as follows:
- Upwards by a curving line on the cranium (linea nuchae superior)
- Sideward by the exterior (lateral) edge of the trapezius muscle
- Downwards by a transverse, horizontal line from the processus
spinosus of the 7th cervical vertebra (vertebra prominens) to the
acromion
219
Chapter 7. Lung diseases
List of contents
220
1. Pleural plaques (E.3.3)
Disease Exposure
E.3.3. Pleural plaques after known asbestos Asbestos
exposure
Pleural plaques are thickenings of the pleura, caused by asbestos. They are not found in the actual lung
tissue, but are formed on the pleura on the inside of the chest. Pleural plaques are white, callous
growths. They are formed after relatively insignificant exposure to asbestos, but it often takes 15-25
years for them to become visible in x-rays of the lungs.
Typical pleural plaques are usually (if not always) bilateral, but often asymmetrical with regard to size
or position. They are often, but not necessarily, calcified.
Biological mechanism
Thin asbestos fibres with a diameter of less than 3 micrometres (my) can reach the alveoli peripherally
in the lungs and penetrate to the pleura. The cleaning cells (microphages) of the organism are trying to
ingest and remove these fibres. This leads to the release of enzymes and connective tissue-forming
substances, which are found to be the cause of the formation of pleural plaques through a slowly
progressing process. They become visible in x-rays after 10-15 years and calcify after 20-25 years.
Symptoms
There are usually no symptoms, but chest pain complaints may occur in very rare cases.
Objective signs
Thickenings of the pleura, perhaps calcified, which are seen as spots in x-rays or lung scans.
The diagnosis of pleural plaques is made by a medical doctor on the basis of
221
X-ray examination or scan of the lungs
Clinical, objective examination (in order to rule out any other lung disease)
In rare cases, in connection with rather substantial asbestos exposure, pleural plaques may lead to a
measurable decrease in the breathing capacity (restrictive lung function). That a person has pleural
plaques is sign of previous asbestos exposure, but it does not in itself constitute any increased risk of
shorter longevity, asbestosis or pleural or pulmonary cancer.
In the majority of cases where the disease qualifies for recognition as an occupational disease, there
will be no permanent effects of the disease. In such cases the claim will be recognised without any
compensation being paid for permanent injury or loss of earning capacity. In a few cases there will be
permanent consequences in the form of pain conditions and/or restricted lung function. In such cases a
permanent injury will be estimated and based on the permanent-injury rating list of the National Board
of Industrial Injuries.
In addition the following, more specific requirements with regard to exposure and the course of the
disease will have to be met.
Exposure requirements
There needs to have been exposure for some time, in the form of direct handling of, or equivalent, very
close and hazardous contact with, asbestos or asbestos-containing material.
In principle there must have been a daily exposure for some months or a more sporadic exposure
(recurrent, but not necessarily daily) for some years. Daily exposure is understood as exposure for part
of the working day and not just briefly. In the event of massive daily exposure, however, the limit with
regard to exposure duration can be reduced to a few days.
The relevant hazardous exposure may i.a. have occurred in connection with direct handling of asbestos
in for instance the factory Eternitfabrikken or in connection with work with asbestos-containing
insulation materials, asbestos plates, asbestos-containing brake linings, etc.
More moderate types of exposure, such as work in offices with defective, and perhaps leaking,
asbestos-containing ceilings, will not qualify for recognition on the basis of the list.
Finds of pleural plaques without simultaneous and certain (documented) and relevant occupational
exposure cannot lead to recognition, even though the disease, based on the current knowledge, can only
be caused by asbestos. If there has not been a relevant and established occupational exposure, the
222
disease must most likely be attributed to private types of asbestos exposure not covered by the
legislation.
Latency time
The formation of pleural plaques occurs through a slow process, which means that the pleural plaques
usually only become visible in x-rays 10-15 years after the exposure and only calcify 20-25 years after
the exposure.
For the disease to be recognised on the basis of the list, therefore, there is in principle a requirement for
a latency time of 10 years or more. In connection with massive exposure, however, the latency time can
be reduced to about 5 years. The latency time is the time that passes from a person was exposed to
asbestos or asbestos-containing materials until the onset of the disease.
In principle the pleural plaques must be bilateral as the occurrence of unilateral plaques after relevant
exposure is very rare. If there has been a relevant and documented exposure, however, and the
remaining recognition requirements are met, finds of unilateral plaques are also be covered by the list.
The disease will furthermore be established in lung x-rays or scans.
In the processing of the claim, we may obtain a medical certificate from a specialist of occupational
medicine. We will i.a. ask the medical specialist to describe and assess in detail the concrete working
conditions and the concrete exposures. The medical specialist will furthermore make an individual
assessment of the impact of the exposures on the development of the disease in the examined person in
question. The medical specialist will in this connection give a description of the onset and development
of the disease and state any previous or simultaneous diseases or symptoms and any impact they may
have on the current complaints.
We can also obtain other types of medical specialists certificates in order to get information on the
development of the disease and any competitive or pre-existing diseases.
Competitive causes
Competitive causes of pleural plaques are not known, and smoking in particular is not a known cause.
Thus there is no certain knowledge that other types of exposure than exposure to asbestos or asbestos-
containing material might lead to pleural plaques. Other degeneration of the pulmonary pleura than
might be mistaken for pleural plaques are the effects of tuberculosis, inflammatory conditions or
traumas.
Subpleural fat
The most frequent competitive diagnosis is subpleural fat. 10-20 per cent of suspected plaques found in
x-rays were due to this. Subpleural fat can be distinguished from pleural plaques in HRCT scans, but
this examination involves a minor exposure to radiation and is therefore not required by the National
Board of Industrial Injuries. As is the case for pleural plaques, subpleural fat is entirely without
symptoms.
223
In cases where there is a definite diagnosis stating that it is subpleural fat and not pleural plaques, it
will not be possible to recognise the claim under the Act. This is because subpleural fat is not included
on the list and because there is no known medical documentation that the disease may be work-related.
In cases where there is doubt as to whether it is subpleural fat or pleural plaques and a closer
examination of the diagnosis cannot be requested, it will be possible to recognise the claim on the basis
of the list. This applies in cases where the other requirements for recognition, including relevant
exposure and the development of the disease, are also met.
All of the above-mentioned diseases are caused by asbestos exposures. They are separate and different
diseases of varying severity.
If pleural plaques have been established in combination with one or more of the more serious, asbestos-
related pulmonary and pleural diseases such as lung asbestosis, cancer of the pleura, lung cancer or
widespread formation of connective tissue with affected (restricted) lung function, the disease pleural
plaques is treated as an accompanying disease to the more serious disease that typically has conse-
quences, and thus pleural plaques can be recognised as an element of the overall, serious disease
condition.
This means that, if the more serious claim qualifies for recognition on the basis of the list, we do not
register a separate claim regarding pleural plaques in cases where the disease is established in
combination with the more serious asbestos-related diseases of the lung or pleurae. In such cases the
overall consequences of the diseases will be referred to the claim regarding the serious disease.
If there are pre-existing or competitive diseases/exposures of the lungs that contribute to the overall
lung symptoms, such factors may, however, have an impact on the amount of the compensation. This
means that we may make a deduction in the compensation for permanent injury and/or loss of earning
capacity. (The Workers Compensation Act, section 12)
Therefore, if an examination has established pleural plaques with obstructive (not restrictive) lung
disease with impaired lung function after relevant exposure, the disease in itself will be covered by
recognition. It will not be possible, however, to pay compensation for permanent injury or compen-
sation for loss of earning capacity as the symptoms must be attributed to other factors than work.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
The claim qualifies for recognition on the basis of the list. The mechanic was diagnosed with bilateral
pleural plaques more than 10 years after exposure, for a number of years in the 1970s, to recurrent,
direct contact with asbestos-containing materials. There is good correlation between the exposure to
asbestos and the find of calcified pleural plaques 25-30 years later.
225
obstructive lung disease with impaired lung function, and it appeared from the information of the case
that he had been a heavy smoker for a number of years.
The claim qualifies for recognition on the basis of the list. The insulation worker had, for a brief period
of a few months, suffered direct and massive exposure to the inhalation of asbestos dust while working
with asbestos-containing insulation materials. He has been diagnosed with widespread bilateral pleural
plaques, and there is good correlation between the asbestos exposure and the onset of the disease many
years later. It is only possible to grant compensation for permanent injury and any compensation for
loss of earning capacity for that part of the reduction in lung function that is of a restrictive nature and
is therefore with certainty due to the asbestos exposure. The obstructive lung disease with impaired lung
function cannot have been caused by asbestos and must most likely be deemed to have been caused by
many years of smoking.
In this case pleural plaques will be handled and recognised as an element of the aggregate asbestos-
related disease complex of the mesothelioma case. Both diseases are without doubt due to the sporadic,
but established asbestos contact in the workplace for a number of years. As there is a serious, asbestos-
related lung disease apart from pleural plaques, we will not register a separate claim for pleural
plaques. The disease pleural plaques is included in the recognition of the disease mesothelioma, and the
symptoms are fully attributed to the mesothelioma claim, this disease undoubtedly being the cause of
the severely restricted lung function.
Example 5: Claim turned down pleural plaques (office employee for 2 months)
226
A 49-year-old woman worked, for a couple of months at the end of the 1970s, as an office employee in
a business. Later on it was discovered that there were asbestos-containing ceiling plates in the office
where she had been working all day. A corner ceiling plate was slightly defective, and there had
possibly, but not definitely, been a very moderate leak from the corner ceiling plate. However, the plate
was not close to the area in the office where the office employee had been sitting. Thus she had not
been in any direct contact with the asbestos-containing ceiling plates (handling or similar contact), but
x-ray examinations well over 25 years later established moderate pleural plaques in both pleurae.
The claim does not qualify for recognition on the basis of the list. For a couple of months the office
employee worked in an office with an asbestos-containing corner ceiling plate that possible had a
moderate leak as a consequence of a defect. However, the claim does not meet the requirement that
there needs to have been direct contact with asbestos or asbestos-containing material for some time
through direct handling or similar contact. The disease pleural plaques cannot in this case be attributed
to the indirect, brief and very moderate, potential exposure from an asbestos ceiling plate in the
workplace.
Example 6: Claim turned down pleural plaques (bank employee for 26 years)
A 52-year-old bank employee worked for 26 years in the same bank, in later years as a customer
adviser. The work did not involve any known asbestos exposure, but in a routine lung examination at
the end of 2004 he was diagnosed with moderate, bilateral pleural plaques. The medical records stated
that in the 1970s he had been making repairs on this own house, including the replacement of roof
plates that probably contained asbestos.
The claim does not qualify for recognition on the basis of the list. The customer adviser was not
exposed to relevant contact with asbestos in the bank, and finds of pleural plaques must therefore most
likely be attributable to private asbestos exposure.
Mesothelioma pleurae Cancer of the pulmonary pleura after exposure to asbestos (J45.1).
The disease is included on the list of occupational diseases
Obstructive lung Reduced lung function as a consequence of an obstruction of the airflow
disease through the lungs
227
Plaques Spots or calcifications
Pleuritis Inflammatory condition of the pulmonary pleura. The suffix -itis means
inflammation caused by micro organisms or inflammatory degeneration
without micro organisms. With regard to work-related diseases the
inflammatory degeneration is always without micro organisms.
Pulmonary pleura Membrane lining the lungs
Restrictive lung disease Reduced lung function as a consequence of a decline in lung volume
Widespread connective- Fibrosis pleurae, increased quantity of connective tissue in the pulmonary
tissue formation in the pleura more prevalent than pleural plaques (only dispersed spots on the
pulmonary pleura pulmonary pleura), but besides the same type of disease. Is found with and
without symptoms.
The disease is included on the list (with symptoms).
The disease should not be mistaken for pulmonary fibrosis/lung fibrosis
(increased quantity of connective tissue in the lung itself). This is a disease
that can be caused by different exposures as well as other diseases, such as
tuberculosis, pneumonia and infarct, and unknown causes. Lung fibrosis is
also called chronic interstitial pneumonia or diffuse lung fibrosis (J84.1).
X-ray X-rays pass through tissue onto a photo plate and a negative type picture is
made (the more solid a structure, the whiter it appears on the film). The
examination consists of one image, a three-dimensional structure being
shown flatly on the film. Therefore there is no depth in the image and
degeneration is shown as overlying.
228
2. Chronic bronchitis/chronic obstructive lung disease (COLD) (E.7)
2.1. Item on the list
2.2. Diagnosis requirements
2.3. Exposure requirements
2.3.1. Vapours/gases/dust and/or smoke
2.4. Duration
2.5. Working conditions
2.6. Competitive factors tobacco consumption
2.7. Managing claims without applying the list
2.8. Examples of decisions based on the list
Disease Exposure
Main conditions
The diagnosis of chronic bronchitis/chronic obstructive lung disease (J.41 and J.44.9) must have been
made by a medical doctor.
The diagnosis of asthmatic bronchitis is not, in principle, included under the above item. This diagnosis
is used by some doctors to describe a condition of diffuse respiratory symptoms, in particular in young
children, but usually has nothing to do with actual asthma or bronchitis. Therefore the condition is not
covered by item 7 of the list, except where there is medical documentation that it is a case of
bronchitis/chronic obstructive lung disease.
In order make the diagnosis of chronic bronchitis/chronic obstructive lung disease, the following
requirements must be met
Symptoms
Cough
Sputum expectoration in some cases
Reduced lung function (shortness of breath, in particular in connection with exertion)
229
Objective signs
There is a significant diagnostic overlap between the two diseases chronic bronchitis and chronic
obstructive lung disease, and both diseases can occur at the same time.
Whether there is a medical diagnosis of chronic bronchitis or chronic obstructive lung disease will not
affect the question of recognition of the claim. Both diseases are on the list and the criteria for
recognition are the same. The calculation of the compensation will be based on the actual symptoms
and objective finds and not on the diagnosis.
Chronic bronchitis results in daily coughing and sputum expectoration from the respiratory passages,
but not in restricted lung function. Chronic bronchitis is defined as coughing and sputum expectoration
from the respiratory passages for at least 3 months of at least 2 consecutive years, where there are no
other causes of the chronic sputum.
Chronic obstructive lung disease is characterised by restricted lung function, perhaps with coughing
and sputum expectoration, due to increased obstruction of the respiratory passage, and the disease is
defined as persistent respiratory passage obstruction with reduced bronchial volume, which means that
the bronchias allow less air to pass. Most healthy persons exhale more than 80 per cent in less than a
second, but the percentage typically decreases with age.
Chronic obstructive lung disease is measured by registering a reduction in the Forced Expiratory
Volume in 1 second (FEV1), but an almost normal Forced Vital Capacity (FVC). The FEV1/FVC
ratio, the so-called Tiffeneau value, will also be reduced, and the Tiffeneau value will be less than 70
per cent (FEV1/FVC under 70 per cent).
Reduced lung function can be registered either by way of an exertion test, for instance on a test bicycle,
or by measuring the lung function at home with a hand-held peak flow meter from morning till night or
from day to day, or by a spirometer measurement performed by a GP (morning/night).
The major difference between chronic obstructive lung disease and asthma (item E.8 on the list) is that
the lung function in connection with asthma will vary with shifts from reduced to normal function,
depending on whether or not there is a relevant exposure. For chronic obstructive lung disease the
reduction in lung function will be lasting.
Time correlation
A prerequisite for recognition is that there is good time correlation between the development of chronic
obstructive lung disease and the exposure in the workplace. In principle the first symptoms must have
developed during the relevant exposure.
The typical work functions with exposures to specific or unspecific forms of vapours/gases/dust and/or
smoke are:
Welding
Torch cutting
Chimney sweeping
Agricultural work
Insulation
Drilling
Moulding
Wood working
Paper and textile industry
The list merely includes examples of typical work functions with exposure to dust/smoke and is not
exhaustive.
This means that exposure to other types of vapours/gases/dust and/or smoke for several years can also
lead to recognition on the basis of item E.7.(a) of the list.
2.4. Duration
In principle there must have been 8-10 years of massive exposure to vapours/gases/dust and/or smoke.
Particularly massive exposure may have the effect that the time requirement for exposure can be
reduced after a concrete assessment.
All exposures must in principle have occurred more or less every day.
If the work was performed inside, it is relevant to look at any ventilation and breathing protection. If
there has been ventilation and breathing protection has been used, the exposure will be lower.
Thus, if protection has been good, a longer exposure time is required in order to recognise the disease
than if ventilation and other protection have been defective.
231
Examples of possible competitive factors that may affect the development or course of the disease:
Tobacco smoking
Alpha1-antirypsin deficiency (AATD, a hereditary gene disorder)
Air pollution
Private causes
Smoking is a very significant cause of chronic bronchitis/chronic obstructive lung disease, and
therefore smoking may in some cases lead us to make a deduction in the compensation.
A tobacco consumption of less than 7 grams of tobacco per day or less than a total of 10 package years,
will not, as a main rule, lead to any reduction in any compensation amount, provided the exposure
besides has been fully adequate to cause the disease.
A tobacco consumption of 30-40 package years or more will in principle have the effect that there are
grounds for making a deduction in the calculation of the compensation if the claim is recognised, this
very high consumption being a very likely cause of the disease.
1 gram of tobacco is equivalent to 1 cigarette. Other types of tobacco, for instance pipe tobacco, cigars
and small cigars, are also converted into grams.
One package year is equivalent to 20 cigarettes a day for one year (20 x 365 = 7,300 cigarettes).
A person who has been smoking 10 cigarettes per day for 15 years has smoked, in terms of package
years, a total of 7.5 package years (10 x 365 x 15: 7,300).
Chronic bronchitis/chronic obstructive lung disease not covered by the list of occupational diseases will
in special cases qualify for recognition after submission of the case to the Occupational Diseases
Committee.
A number of scientific articles determine a correlation between exposure to passive smoking and the
development of COLD/chronic bronchitis. Therefore, cases where the injured person has experienced
the following exposures will be submitted to the Occupational Diseases Committee for their
assessment:
The injured person must not have been a smoker themselves, nor must the person in question have been
exposed to passive smoking at home or in their private lives. Finally the symptoms of COLD must
occur in connection with exposure to tobacco smoke (within months or few years).
232
Concrete cases of COLD after exposure to passive smoking will be submitted to the Occupational
Diseases Committee for a concrete assessment of whether the disease was mainly or solely caused by
the special nature of the work. In the concrete discussions the Occupational Diseases Committee will
include the above issues.
With regard to cases decided without applying the list we refer to chapter 1 of this guide.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
Example 1: Recognition of chronic obstructive lung disease under E.7 (chimney sweep exposed to soot,
dust, etc.)
A 57-year-old man worked for 20 years as a chimney sweep and towards the end of the period
developed respiratory passage problems in the form of shortness of breath when climbing ladders.
Subsequently he also developed mucus in his respiratory passages and a cough, in particular when in
contact with insulation material, soot, smoke, and dust. He was massively exposed to dust during
chimney sweeping, and he did not use respiratory protection to begin with. A lung function
examination established reduced lung function and he was diagnosed with chronic obstructive lung
disease. He had smoked no more than 1 package year all his life. The claim qualifies for recognition on
the basis of the list. In the performance of his work the chimney sweep was massively exposed to dust
for many years, and he was diagnosed with chronic obstructive lung disease. The tobacco consumption
of no more than 1 package year was very moderate and did not contribute to the disease.
Example 2: Recognition of chronic obstructive lung disease under E.7 (welder exposed to welding
smoke)
A 62-year-old man worked for 35 years as a welder in a shipyard. The work was performed in small
rooms inside the ships and generated a great deal of smoke. In particular at the beginning of the period
there was no sufficient respiratory protection, and the ventilation was poor throughout. The generation
of smoke during the welding process resulted in frequent coughing attacks so that he had to go outside
to get some fresh air. He had never been a smoker. Over a number of years he developed signs of
chronic bronchitis med frequent coughing and sputum expectoration and towards the end of the period
developed respiratory passage problems in the form of breathing problems. He was diagnosed with
chronic obstructive lung disease in a lung examination performed in a clinic of occupational medicine.
The claim qualifies for recognition on the basis of the list. In the performance of his work the welder
was massively exposed to unspecific welding smoke in a room with poor ventilation and insufficient
respiratory protection for a significant number of years, and there is good time correlation between the
exposure to welding smoke and the disease.
More information:
Occupational COPD Correlations between Chronic Obstructive Pulmonary Disease and various types
of physical and chemical exposures at work. A scientific reference document on behalf of The Danish
Working Environment Research Fund (www.ask.dk)
233
3. Asthma (E.8)
Disease Exposure
E.8. Asthma Dust or vapours from
(allergic and non-allergic) (a) Plants or plant products
(b) Animals or animal products
(c) Enzymes, dyes, persulphate salts, synthetic resin or
medicaments and precursors thereof
(d) Isocyanates and certain anhydrides in epoxy resins
(e) Chromium and some chromium compounds
(f) Cobalt
(g) Aluminium
(h) Hard metal
(i) Nickel
Main conditions
The diagnosis of asthma (ICD-10 J.45) must have been made by a medical doctor.
The diagnosis of asthma bronchiale, which is equivalent to asthma, is also covered by the list.
Both allergic and non-allergic forms of asthma can be covered by the list.
The diagnosis of asthmatic bronchitis is not, in principle, covered by the item. This diagnosis is used by
some doctors to describe a condition of diffuse respiratory symptoms, in particular in young children,
but usually has nothing to do with actual asthma. Therefore the condition is not covered by the list,
except where there is medical documentation that it is a case of asthma.
In order make the diagnosis of asthma, the following requirements must be met
Asthma is a very prevalent disease in the population, and only a minor proportion is caused by
exposure to harmful substances in the workplace.
234
Asthma is used as a generic term for a condition characterised by episodes of breathing problems.
These breathing problems are caused by a periodic obstruction of the respiratory passages (the small
bronchias). There are many factors that contribute to the development of asthma and many that can
provoke attacks.
In practice the diagnosis of asthma bronchiale is used as well. This diagnosis is equivalent to asthma.
Asthma is a condition where the small bronchias are inflamed/irritated, either as a consequence of a
previous infection (for instance with bacteria) or a previous inflammatory condition (without bacteria).
Inflammation/irritation of the small bronchias makes the respiratory passages more sensitive to specific
external irritants (trigger factors), which cause the respiratory passages to contract and thereby reduce
the airflow and cause breathing problems in the person in question. The medical term for this is
hyperactivity of the respiratory tract.
Asthma is furthermore characterised by the lung function being normal or almost normal between the
attacks or normal as a result of bronchia-extending medical treatment. As opposed to chronic bronchitis
the increased resistance in the respiratory passages can be affected by bronchia-extending medicine
such as Beta2 agonist spray, Bricanyl or Ventoline, or treatment with adrenal cortex hormones.
In many cases the attacks will be triggered by irritants in the air, such as tobacco smoke, fog, or dust
from work processes or other exposures from the environment.
Symptoms
Breathing problems (hard to empty the lungs of air)
Shortness of breath or a wheezing sound in the chest
Perhaps coughing, a pressing sensation on the chest, and hoarseness
The asthma diagnosis can be made by way of relevant symptoms and at the same time a positive
outcome of one or more of the following tests:
In an asthma patient there will be signs of less space in the bronchias, which means that the bronchias
allow less air to pass. Most healthy persons exhale more than 80 per cent in less than a second, but the
percentage typically decreases with age.
235
Asthma is measured by registering periodical changes of more than 15 per cent of the Forced
Expiratory Volume in 1 second (FEV1), but an almost normal Forced Vital Capacity (FVC).
The FEV1/FVC ratio, the so-called Tiffeneau value, will also be reduced, and the Tiffeneau value will
be less than 80 per cent of the expected value (FEV1/FVC under 80 per cent).
The main difference between asthma and chronic obstructive lung disease (item E.7 on the list) is that
the lung function for asthma will vary, alternating between reduced and normal function, depending on
any relevant exposure. For chronic obstructive lung disease the lung function reduction is permanent.
For allergic asthma there has to be documentation of hypersensitivity (allergy) to an exposure in the
workplace which is mentioned on the list of occupational diseases.
Specific bronchial provocation tests with relevant allergens, performed by specialised departments of
occupational or lung medicine can also be used for the assessment of the question of recognition. The
National Board of Industrial Injuries would not directly recommend this type of tests as they rarely lead
to any aggravation of the disease.
If there is documentation of asthma attacks in connection with the work as well as allergy to an
exposure in the workplace included on the list of occupational diseases, asthma qualifies for
recognition on the basis of the list.
For non-allergic asthma it is harder to establish any causation with exposure to substances in the
working environment.
Therefore there are stricter requirements to the medical documentation of any correlation between the
asthma attacks and the exposure at work.
In this connection it is vital to know if the injured person had asthma before the beginning of the work-
related exposure and to obtain information on the preceding development of the disease.
In cases of severe and long-lasting cases of preceding asthma or asthma with substantial, competitive
private allergens or established irritants this may have the effect that the claim is turned down
completely or that deductions are made from the compensation.
236
However, if the injured person only had asthma as a child or the disease has become aggravated in
connection with relevant exposures at work, it is possible to recognise the disease, perhaps with a
deduction.
Repeated measurements with a peak flow meter will often show if the injured persons lung function
becomes reduced in connection with work and improves during the weekends, for instance, or in
holidays, or the other way round.
(c) Enzymes, dyes, persulphate salts, synthetic resin or medicaments or precursors thereof
Typical occupational groups: Hairdressers, dye workers, employees in the pharmaceutical industry and
soldering workers.
Isocyanates are a generic term for a group of chemical substances which are much used in industry
today, for instance in the production of lacquers. The substances are used in the production itself and in
the finished products.
Isocyanates are released in great quantities when materials coated with isocyanates are heated to 150-
200 degrees centigrade. This is the case, for instance, with lacquered car parts repaired/welded in
garages or electronic parts that are repaired.
Isocyanates are also released by oxidation of chlorine-containing degreasing agents in the metal
industry; by galvanization and steel hardening and by gold and silver work. Also, isocyanates are often
used in products composed of two components which, when mixed, react with each other during the
production of plastic. Isocyanate is the hardener. The other component contains polyol and is called the
resin. Sometimes polyol and isocyanate are delivered premixed. The hardened product is also called
PUR (plastic) or polyurethane.
237
(f) Cobalt
Typical occupational groups: Workers in the electronics industries or in the manufacture of special
steel, coins, and trinkets. Cobalt has for centuries been used to give glass, glazing and ceramics an
intense blue colour. Iron may include cobalt, and therefore iron welding etc. may be included on the
list.
(g) Aluminium
Typical occupational groups: Workers in the metal industry and welders.
The above list of typical occupational groups is merely a guiding list and it is not exhaustive with
regard to persons who may suffer relevant exposure to the substances in question. Other occupations
will also be covered by the list to the extent that it is the same exposure as set out above.
(i) Nickel
For instance grinding or welding of nickel-containing materials, including nickel-containing iron.
Welding/grinding in stainless steel releases chromium, and therefore work with steel will in principle
be included.
Time correlation
A prerequisite for recognition is that the symptoms of the disease set on in close time correlation with
the work-related exposure to asthma-provoking substances. In principle asthma attacks will occur in
immediate connection with the work.
In special cases late asthma qualifies for recognition if there are attacks up to 16 hours after the
exposure in the workplace. However, in such cases it has to be documented that similar attacks do not
occur at the same hour of the day during weekends or holidays (i.e. periods without any work
exposure) and that a suspected exposure primarily occurs in the workplace.
On the other hand, there is no requirement for the exposure to have a certain duration or severity. This
is because asthma is in some cases triggered after a short while and in connection with even limited
exposures.
238
3.4. Examples of pre-existing and competitive diseases/factors
Like most other diseases, asthma can develop or become aggravated as a consequence of other diseases
or factors not connected with work. Therefore the National Board of Industrial Injuries will make a
concrete assessment of whether any disclosed competitive factors are of a nature and scope that may
give grounds for turning down the disease entirely or whether, if the claim is recognised, there are
grounds for making a deduction in the compensation.
Examples of possible competitive factors which may affect the onset or the course of the disease:
Tobacco smoking
Private allergy (for instance to house-dust mites or pollen)
Genetic disposition to allergy
Medicine consumption
Tobacco smoking cannot be deemed to be the primary cause of asthma. But there may be consistence
in the symptomatic picture for asthma and diseases that are primarily caused by tobacco smoking.
Therefore, in some cases smoking may have the effect that a reduction is made in the compensation
payment.
Asthma not covered by the list will in special cases qualify for recognition after submission of the
claim to the Occupational Diseases Committee.
Examples of cases that may qualify for recognition not based on the list:
Asthma caused by working for a long time with low-molecular irritants (factory worker who
operated a wall paper printing machine producing using acrylic foam)
Asthma bronchiale caused by several years of cleaning of smoke ovens, using alkaline foam
detergents and chlorinated substances etc.
Asthma caused by several years of exposure to ethanolamines in cooling and lubricating oils
(machine engineer)
Asthma bronchiale caused by exposure for a long time to strong basic aerosols, calcium
hydroxide, and dust from hydrate calcium (looking after plant for cleaning of smoke gases)
We refer to chapter 1 of this guide, which describes cases where the decisions are not based on the list
of occupational diseases.
239
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
Example 1: Recognition of asthma under E.8.(a) (day-care worker exposed to mould fungus)
A 35-year-old woman was employed for 4 years as a helper in a crche. Shortly after she started work
she would catch a cold very often and had sinusitis and problems when staying indoors. Her symptoms
were headaches, fatigue and eye irritation. In the course of her employment she developed a persistent
cough and tended to have breathing problems and eventually a specialist of pulmonary diseases
diagnosed her with asthma. A building report described rather substantial deficiencies in the indoor air
quality in her workplace, in the form of humidity damage, and according to the report there was visible
mould formation.
The claim qualifies for recognition on the basis of the list. The day-care worker developed asthma after
working in humidity damaged rooms with visible mould attack. There is a good time and causal
relationship between the development of asthma and exposure to harmful plants (mould fungus) in the
workplace.
Example 2: Recognition of asthma under E.8.(b) (worker in fishing industry exposed to fish vapour)
A 47-year-old man was employed for 15 years in the fishing industry in a filleting department. After 10
years he became responsible for the production and the machines, the administrative work being
performed in an office in affiliation with the packing department. However, when a machine broke
down, which would occur up to 10 times a day, he was occupied with the production machines, trying
to get them running again. In the course of the last year he developed increasing respiratory passage
problems with coughing, periodic attacks of wheezing, and breathing problems. In connection with
being transferred to a different department he experienced a considerable improvement in his
symptoms. He was diagnosed with asthma and tests showed that he was allergic to certain types of fish.
The allergies were relevant in relation to the exposures to fish vapour in the workplace, and peak flow
measurements showed aggravation when we was there.
The claim qualifies for recognition on the basis of the list. The fishing industry worker developed
asthma as a consequence of work on premises where there was fish vapour. He was furthermore
diagnosed with allergy towards certain types of fish which were also part of the production in the
workplace. There is a good causal relationship between the development of asthma and the exposures
in the workplace to vapour from animals/animal products.
Example 3: Recognition of asthma under E.8.(a) and E.8.(b) (service technician exposed to dust from
plants and animals)
A 58-year-old man worked for 10 years as a service worker with cleaning of animal boxes. In the
performance of his work he was exposed to dust, urine and faeces from mice, rats, hamsters, rabbits,
dogs, and cats, as well as straw and sawdust. Towards the end of the period he developed symptoms of
asthma in the form of red and irrigated eyes as well as breathing problems which developed when he
was in the workplace. The symptoms disappeared after a long presence from work and completely
disappeared after cessation of work.
240
The claim qualifies for recognition on the basis of the list. The service worker has developed asthma as
a consequence of his work. For a considerable number of years he suffered significant exposure to dust
or vapour from animals, animal products and plant products. There is good correlation between the
exposure from dust and vapours in connection with cleaning work and the symptoms, which
disappeared temporarily after a long absence from work and completely when he stopped doing the
work in question.
The claim qualifies for recognition on the basis of the list. The cleaner developed asthma as a
consequence of exposure to dust from enzymes in the workplace. She tested allergic to enzymes and
the symptoms of the disease developed in close time correlation with her work.
The claim qualifies for recognition on the basis of the list. For a considerable number of years the
goldsmith suffered considerable exposure to isocyanates when working gold and silver into jewellery.
There is good correlation between the exposure from isocyanates and the symptoms, which disappeared
during holidays and completely disappeared in connection with cessation of work.
Example 6: Recognition of asthma under E.8.(e) (auto spray painter exposed to isocyanates)
A 42-year-old man worked for 10 years as an auto spray painter in the car industry. After 4 years he
began to work in the spray paint department and subsequently developed coughing and wheezing in
connection with physical exertion. He stopped smoking, but the symptoms continued and also
interfered with his sleep during the night. During holidays he experienced a clear improvement. After
his GP had diagnosed him with asthma, his employers gave him a better hood for protection against the
paint vapours, and then his symptoms disappeared and he was able to continue in his job.
The claim qualifies for recognition on the basis of the list. For a considerable period of time the auto
spray painter suffered substantial exposure to isocyanates in connection with spray painting of cars.
There is a good time and causal relationship between the exposures in the workplace, where he was in
contact with isocyanates in connection with painting of cars, and the asthma symptoms, which likewise
receded after he began to use better respiratory protection.
241
Example 7: Claim turned down asthma under E.8.(b) (agricultural worker exposed to pigs)
A 24-year-old agricultural worker on a big pig farm reported an asthma claim after a few months of
work with pigs. He was inside the pig stables for most of the work day and was in close contact with
the animals in connection with mucking out, piglet births, etc. Furthermore there was a constant reek of
pigs in the stable, and the exhaust equipment was inadequate. It appeared from the medical information
that he had been suffering from asthma since childhood and that he had experienced continuous and
periodic, very severe attacks of asthma, right up to the beginning of his work in the pig stable. Several
years before he had furthermore tested allergic to cats, dogs, pigs, and several other animals as well as
a number of plants and pollen, but he had nevertheless for a significant number of years helped out, in
his free time and on a daily basis, in his fathers pig production and was still doing this. Furthermore he
had a dog himself. There was no record of any change in the attack patterns, and he had just as frequent
and just as severe attacks during weekends and holidays as in connection with work.
The claim does not qualify for recognition on the basis of the list. The agricultural worker was
diagnosed with asthma and is allergic to pigs. He furthermore suffered relevant exposure to pigs while
working in a pig stable for 6 months. However, before starting in this job he had asthma attacks for a
significant number of years and previously tested allergic to many different sources, including pigs and
dogs. He is in contact with pigs in his free time and also has a dog himself, even though he is allergic to
such animals. Furthermore there is no evidence of any substantial aggravation in his condition in clear
connection with his work. Overall it is likely beyond reasonable doubt that his asthma was primarily
caused by his previous asthma and the continued private exposure, including in particular the daily
contact with pigs and his dog.
242
4. Lung disease with restricted lung function of the obstructive type (E.9)
Disease Exposure
Main conditions
A medical doctor needs to have diagnosed a lung disease with restricted function of the obstructive
type (RADS) (J.44.8). There must be increased respiratory passage resistance. Lung disease with
restricted lung function of the obstructive type is not the same disease as chronic bronchitis/COLD.
In order to make a diagnosis of lung disease with restricted function of the obstructive type, the
following requirements must be met:
Symptoms
Reduced lung function in the form of shortness of breath, in particular in connection with
exertion
Objective signs
A lung function test establishes a reduction in the Forced Expiratory Volume in 1 second
(FEV1) of less than 80 per cent of the normal, expected expiratory volume
243
4.3. Exposure requirements
In order for a lung disease with restricted lung function of the obstructive type to be covered by the
item on the list, there must have been one or more relevant exposures for many years, as described in
detail below.
Exposure to isocyanates
Isocyanates are a generic term for a group of chemical substances which are much used in industry
today, for instance in the production of lacquers. The substances are used in the production itself and in
the finished products.
Isocyanates belong to the group of components that make various materials harden. They are found i.a.
in lacquer, paint, glue, foam, sealing, plastic products, laminates, print plates, cable insulation, plaster
material, and jointing material.
Isocyanates are released in great quantities when materials coated with isocyanates are heated to 150-
200 degrees centigrade. This is the case, for instance, with lacquered car parts which are
repaired/welded in garages or electronic parts that are repaired. Heating may occur in connection with
fires, but also in connection with normal work processes such a welding, soldering, cutting, grinding,
founding and heating by hot air.
Isocyanates are also released by oxidation of chlorine-containing degreasing agents in the metal
industry; by galvanization and steel hardening and by gold and silver work. Also, isocyanates are often
used in products composed of two components which, when mixed, react with each other during the
production of plastic. Isocyanate is the hardener. The other component contains polyol and is called the
resin. Sometimes polyol and isocyanate are delivered premixed. The hardened product is also called
PUR (plastic) or polyurethane.
Time correlation
In principle there need to have been 4-5 years of daily or almost daily exposure to isocyanates. In the
event of particularly massive exposure the time requirement may be reduced after a concrete
assessment.
Working conditions
In the assessment of whether the exposure in the workplace is sufficient for recognition of the disease,
it is relevant to look at the conditions under which the work was performed. The exposure will be
244
greatest in small rooms without proper ventilation, whereas the exposure will be smallest when the
work was performed out of doors.
If the work was performed indoors, it is essential to look at whether there has been ventilation and
whether respiratory protection equipment has been used.
If the protection measures have been efficient, it requires a longer-lasting exposure in order to
recognise an occupational disease than if exhaustion and other protection measures were deficient.
Smoking is a substantial cause of lung disease with restricted lung function of the obstructive type.
Therefore, in some cases, smoking may lead to a reduction in the compensation amount.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
Example 1: Recognition of lung disease with restricted lung function of the obstructive type (E.9) (auto
mechanic exposed to isocyanates)
A 32-year-old man worked for 6 years as an auto mechanic in the car industry with various car repairs,
including welding and grinding of body parts. He had never smoked, but towards the end of the 6-year-
period he developed coughing and sputum and had shortness of breath in connection with physical
exertion. A medical examination established reduced lung function and the Tiffeneau value
(FEV1/FVC) was measured at 60 per cent. He was diagnosed with restricted lung function of the
obstructive type.
The claim qualifies for recognition on the basis of the list. For 6 years the auto mechanic was
significantly exposed to isocyanates, which are released in connection with welding and grinding when
the car lacquer is warmed up. There is good time correlation and causality between the exposure in the
workplace and the disease.
245
5. Pneumonia (E.10)
5.1. Item on the list
5.2. Diagnosis requirements
5.3. Exposure requirements
5.4. Examples of pre-existing and competitive diseases/factors
5.5. Managing claims without applying the list
5.6. Examples of decisions based on the list
Disease Exposure
Main conditions
A medical doctor needs to have diagnosed pneumonia (pneumonia/pleuropneumonia non specificata
J.18.9).
In order to make a diagnosis of lung disease with restricted function, the following requirements must
be met:
Symptoms
Eye and nose irritation as well as coughing followed by the development of pneumonia with a fever in
the course of a few days.
Objective signs
A fever higher than 38C and pneumonia diagnosed by way of stethoscopy of the lungs, or degeneration
typical for pneumonia established by way of x-rays of the lungs.
246
It is also used in the production of glass, adding blue and green colours, and in the manufacture of dyes
and lacquers. It is also found in connection with exposure to large quantities of tarry soot in chimney
sweeps.
It is only when using vanadium for the production and manufacture of steel and glass that exposure
takes place. Later use of the materials does not cause exposure to vanadium.
Time correlation
A prerequisite for recognition is that the symptoms of the disease have developed in close time
correlation with work-related exposure to vanadium.
There is no requirement, however, that the exposure should be of a certain duration or intensity. This is
because pneumonia in some cases develops after a short while and even after limited exposure.
Working conditions
In the assessment of whether the exposure in the workplace is sufficient for recognition of the disease,
it is relevant to look at the conditions under which the work was performed.
The exposure will be greatest in small rooms without proper ventilation, whereas the exposure will be
smallest when the work was performed out of doors.
If the work was performed indoors, it is essential to look at whether there has been ventilation and
whether respiratory protection equipment has been used.
If the protection measures have been efficient, it requires a longer-lasting exposure in order to
recognise an occupational disease than if exhaustion and other protection measures were deficient.
Pneumonia not covered by the list of occupational diseases may in special cases be recognised after
submission of the claim to the Occupational Diseases Committee.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
247
A 55-year-old man worked for 30 years as a steel worker in a steel rolling factory. Part of the work
consisted in the production and founding of armour plates. In 2009 the factory received a large order
for armour plates, which meant that for a long period of time he only worked with steel with added
vanadium. Subsequently he developed irritation of eyes and nose, and a few days later he was
diagnosed with pneumonia.
The claim qualifies for recognition on the basis of the list. The injured person was exposed to
vanadium, which is released in connection with the production of steel/armour plates. There is good
time correlation between the exposure in the workplace and the disease.
248
Chapter 8. Mental disorders
List of contents
249
1. Posttraumatic stress disorder (F.1)
Disease Exposure
F.1. Posttraumatic stress Traumatic events or situations of short or longer duration that are of an
disorder (where symptom exceptionally ominous or catastrophic nature
onset of the disease is
within six months and the
disease is fully present
within a few years)
B:
1. Repeated reliving of the trauma in intrusive memories ("flashbacks") or nightmares, or
2. Severe discomfort at exposure to circumstances reminiscent of the trauma
D:
1. Partial or total loss of memory (amnesia) regarding the traumatic experiences or
2. Persistent symptoms of autonomic hyper arousal with hyper vigilance, including at least two of the
following
a. Insomnia
b. Irritability or bursts of anger
c. Concentration problems
d. Hyper vigilance
2
In Denmark the abbreviation PTSD usually refers to the ICD-10 diagnosis of posttraumatic stress disorder. This is also
what is meant in this guide. It should be noted that there is no reference to the American diagnosis criteria. This is because
there are different disease criteria as well as exposure requirements to Post Traumatic Stress Disorder (PTSD) according to
the American diagnosis classification DSM-IV compared to posttraumatic stress disorder according to ICD-10.
250
e. An enhanced startle reaction
The last diagnostic criterion for PTSD (criterion E) is set out as follows in the English version of WHO
ICD-10: Criteria B, C and D all occurred within six months of the stressful event, or the end of a
period of stress. (For some purposes, onset delayed more than six months may be included but this
should be clearly specified separately). The diagnostic criterion is expanded in the clinical
descriptions and diagnostic guidelines3: The onset follows the trauma with a latency period which may
range from a few weeks to months (but rarely exceeds 6 months).
Against the background of the interpretation in the English-language version of the diagnosis
requirement, the disease PTSD must in principle have been diagnosed within 6 months from cessation
of the exposure. However, the English version also shows that it is possible to specifically disregard the
requirement.
In summary this means that the diagnosis of PTSD can be made when the injured person meets the
diagnostic requirements mentioned under A to E. In some persons, however, the full onset of the
disease is not until after the 6 months, but the persons in question get some of the symptoms set out
under B, C and/or D within the first months. This is also called delayed-onset PTSD.
Delayed-onset PTSD is covered by the item on the list when the person in question, within 6 months,
has had some of the symptoms mentioned under B, C and/or D and the diagnosis of PTSD can be made
within a few years from exposure cessation. A few years is in principle understood as 1-2 years.
If the disease shows absolutely no symptoms the first 6 months, then the list requirements to the
diagnosis have not been met and a PTSD diagnosis that may be made later will not be covered by the
list. These diseases may, after a concrete assessment, be submitted to the Occupational Diseases
Committee, see Chapter 1.
In some cases the medical specialist will state the diagnosis of posttraumatic stress disorder or PTSD,
even though the disease may not meet the diagnostic requirements for quite extraordinary stresses
and/or the symptom picture. There may for instance be a symptom picture that is consistent with the
PTSD pathological picture, without any occurrence of traumatic incidents or situations, short- or long-
lasting, of an exceptionally threatening or catastrophic nature.
It is the National Board of Industrial Injuries that assesses whether the diagnosis requirements are met,
including the requirements for extraordinarily stressful mental exposures and the time correlation.
Other diagnoses such as stress response (including acute or unspecified stress response), adjustment
reaction and depression are not covered by item F.1 on the list, except where the National Board of
3
Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines.
251
Industrial Injuries finds that the pathological picture corresponds with and meets the requirements to
the disease posttraumatic stress disorder.
A number of the other conditions/diseases may, however, in case of extraordinary mental stresses, be
recognised without the list after submission of the case to the Occupational Diseases Committee. This
also applies to PTSD if there have not been any symptoms within the first 6 months or if PTSD is only
present later than 2 years from exposure cessation.
In principle it is not possible to make this diagnosis unless there has been exposure to traumatic events
or situations, short- or long-lasting, of an exceptionally threatening or catastrophic nature.
All other PTSD claims, including delayed-onset PTSD that is only fully present several years after
cessation of the exposures, may be submitted to the Occupational Diseases Committee with a view to
making a decision on recognition. This also applies to claims where some of the PTSD symptoms
occurred within the first 6 months but the disease only was fully established after several years.
The following elements may be included in the assessment of whether PTSD claims should be
submitted to the Occupational Diseases Committee for the purposes of a concrete decision on whether
the disease was only or mainly caused by work:
Is there a fair time correlation between exposure and disease onset (some years)
The nature and scope of the exposure, including whether there have been repeated exposures
within a number of years
252
Exposures as part of the work in professional groups
If the exposure meets the stress requirement for PTSD, but the injured person has only insufficient
PTSD symptoms, the Occupational Diseases Committee will be able to decide if the disease qualifies
for recognition as an unspecified stress response. If the injured person later on is diagnosed with PTSD
due to exposures at work, this will in principle be regarded as a consequence of the original recognition
and the effects will thus entitle the injured person to compensation.
Other symptoms or exposures not on the list will in special cases qualify for recognition after
submission to the Occupational Diseases Committee.
The following mental diseases may, after a concrete assessment, be deemed to have been caused by
external stresses and may be recognised after submission of the claim to the Committee:
Stress response (including acute stress response, other stress disorders and unspecified forms of
stress response (F43))
Depression (including depressive single episode F32). Most depressions are passing, and
usually it is not possible to distinguish these from the more persistent types of depression, other
than by following the course of the disorder. There is no requirement for the disease to be
permanent
Generalised anxiety disorder (other anxiety disorders F41)
Phobias (including phobic anxiety disorders F40)
Obsessive compulsory disorder (OCD, obsessive actions)
Somatoform conditions F45 (complaints of bodily symptoms without the presence of any
physical cause)
Certain psychoses. Enduring psychoses are not, however, deemed generally to have external
stress factors as dominant causes
Enduring personality change after catastrophic experience F62 (when the disease is not covered
by the diagnosis of posttraumatic stress disorder)
Whether these mental diseases will be deemed to have been caused by a work-related exposure will
depend on a concrete assessment including symptom onset, the course of the disease and the nature and
extent of mental exposures.
Mental illness with the diagnosis of adjustment reaction will not normally qualify for recognition as an
occupational disease. This diagnosis covers very moderate, unspecified and passing mental complaints
which are not usually regarded as actual occupational diseases within the meaning of the Act and may
besides develop after even very moderate exposures.
See Chapter 1 for examples of decisions on mental diseases not covered by the list.
The practice of the Occupational Diseases Committee in the assessment of claims not covered by the
list will frequently be updated on the website of the National Board of Industrial Injuries.
253
1.6. Examples of decisions based on the list
The claim qualifies for recognition on the basis of the list. As part of the service in the peace-keeping
forces, the officer had been exposed to a number of stressful situations. The medical examinations
established a mental disease in the form of posttraumatic stress disorder, and there was good correlation
between the work-related exposures of an exceptionally threatening and stressful nature and the
disease.
The claim qualifies for recognition on the basis of the list. The driver developed posttraumatic stress
syndrome after having been exposed to a number of violent incidents as a driver delivering relief
supplies in regions with direct war action and threats in connection with robberies and similar
incidents. There is furthermore good correlation between the work-related exposures and the disease.
254
The claim qualifies for recognition on the basis of the list. The soldier was exposed to exceptionally
threatening situations in connection with transports through mined areas and had furthermore been
involved in war action, having been shot at. Immediately after coming home, he developed PTSD
symptoms, and the disease was established within a few years from exposure cessation.
The claim was turned down as the exposures did not meet the requirements of the list to PTSD, despite
his PTSD symptoms immediately after coming home. Even though he stayed in a military camp in a
war zone, he did not experience dangerous situations, neither having had any errands outside the camp
nor having been shot at in the camp or in any other way having been exposed to danger. Furthermore
there is no possibility that the Occupational Diseases Committee will recommend recognition of the
claim. This is because the solider has not experienced any exposures that solely or mainly caused his
mental illness.
The claim qualifies for recognition on the basis of the list. The prison officer was for quite some time
exposed to severe threats and other violent, mentally stressful incidents in his work as a prison officer,
being in contact with psychologically very stressful prisoners. Furthermore he had developed
symptoms consistent with posttraumatic stress disorder.
The claim does not qualify for recognition on the basis of the list, and there are no grounds for
submission of the claim to the Committee. The prison officer had psychologically very stressful
experiences from his work, but only developed mental symptoms 4 years after cessation of work.
Therefore there is no good time correlation between the exposure and the development of the disease.
Healthcare work
The claim qualifies for recognition on the basis of the list. In her work, the home help experienced
instances of a very threatening and aggressive behaviour on the part of a clients husband. Against the
background of the description of the incidents it must seem likely that she had reason to feel sincerely
and personally threatened. Furthermore she had developed symptoms of posttraumatic stress disorder
in relevant time correlation with the exposure.
Example 11: Recognition after work in an institution for the mentally handicapped
A young woman was for some years employed in a 24-hour institution for the mentally handicapped
and had for one year been exposed to four violent assaults where she was kicked and beaten. The
medical specialists certificate stated the diagnosis of posttraumatic stress disorder.
The claim qualifies for recognition on the basis of the list. The woman was exposed to several violent
assaults in the workplace, being kicked and beaten. She subsequently developed symptoms of
posttraumatic stress disorder.
Example 13: Claim turned down work in a psychiatric hospital and nursing home (healthcare
assistant)
A healthcare assistant working permanent night shifts in a psychiatric hospital and a psychiatric nursing
home developed, according to the medical specialists assessment, symptoms of a posttraumatic stress
disorder. The exposure was depicted in general terms, and neither the healthcare assistant nor others
were able to give an account of concrete and specific, mentally stressful episodes or courses of events
where she had been directly involved or exposed.
The claim does not qualify for recognition on the basis of the list as, according to the assessment made
by the National Board of Industrial Injuries, it was not a posttraumatic stress disorder. There is no
description of any concrete and relevant, exceptionally threatening or catastrophic exposures that might
lead to the disease. Nor are there any grounds for submitting the claim to the Occupational Diseases
Committee.
Education
Example 14: Recognition after work as a teacher to children with development problems
A teacher was employed in a school where the children had development problems and learning
disabilities. He was a personal teacher to a big autistic boy with recurrent extroverted and aggressive
behaviour. The boy had repeatedly hit the teacher, who furthermore was exposed to various accusations
from the parents. The case was mentioned in the media and the name of the teacher was publicised. It
appeared from the medical specialists report that he had developed symptoms of mental illness.
The claim qualifies for recognition on the basis of the list. In connection with the work the teacher had
been exposed to repeated incidents of violence from a big, extroverted, autistic boy as well as
accusations from the parents. The case furthermore became the object of media coverage, and the
injured persons name was publicised. In correlation with this he developed clear symptoms of
posttraumatic stress disorder.
Example 15: Recognition after judgement and later acquittal of paedophilia charges (unqualified
pedagogue)
A young man worked, for two separate periods, as an unqualified pedagogue in a kindergarten.
Towards the end of the employment he was accused of sexually abusing some of the children and the
matter was reported to the police. He was charged with sexually offending several children in the
kindergarten as well as a child in another institution. In the course of events he was exposed to a mob
rule attitude and received several anonymous threats. His mother received similar anonymous threats.
The local City Court found him guilty of some of the charges and sentenced him to one year in prison.
Later the High Court acquitted him of all charges. Following the accusations and the court proceedings
257
he developed a posttraumatic stress disorder with symptoms such as anxiety, nightmares, evasive
behaviour, insomnia, irritability, restlessness, hyper vigilance and concentration problems.
The claim qualifies for recognition on the basis of the list. The unqualified pedagogue was exposed to
accusations of sexually offending children and was later charged and sentenced by the local City court.
In the course of the events he was exposed to mob rule attitudes, and he and his mother received
anonymous threats. He was later acquitted of all charges in the High Court, but had by then developed
a posttraumatic stress disorder. There is good time correlation and causality between the development
of the disease and the exceptional exposure in the form of accusations and judgement for sexually
offending children, and besides the exposure to mob rule and threats.
Example 16: Recognition after exposure to threats and violent death in the workplace
A clerk selling tickets in a train station experienced suicides, other deaths and threats while working in
the station. Therefore she developed a posttraumatic stress disorder.
The claim qualifies for recognition on the basis of the list. The incidents in the form of threats and
violent deaths in the workplace are much in excess of what she might be prepared for in a job as a
clerk. The incidents are of an exceptionally stressful nature, and there is furthermore good correlation
between the onset of the disease and the incidents.
258
for the purposes of assessing whether the disease was solely or mainly caused by exposures in the
workplace, see Chapter 1.
If, in addition to incidents that are treated like accidents, there are stressful incidents that are not
recognised, it will be possible to assess the whole course of events and recognise the disease as an
occupational disease if the criteria for recognition of a posttraumatic stress disorder are met besides.
When determining the compensation payment, however, we may make a deduction if compensation
has previously been granted as a consequence of recognised accidents.
Example 21: Claim turned down occupational disease after work with the mentally handicapped
(social worker)
A social worker had since 1963 worked with mentally disabled clients, primarily mentally disabled
men. He had obtained recognition as accidents of three violent incidents. In 1992 a mental trauma was
recognised as an accident, and he was granted compensation for permanent injury. He had not since
been exposed to experiences in the workplace that were very mentally stressful. The claim does not
qualify for recognition as an occupational disease. The social worker has not since the incident in 1992,
259
which had already been recognised as and accident, been exposed to violent incidents to an extent that
might lead to a permanent mental disorder. There is no description of any mental consequences in
excess of what has already been compensated as a consequence of the recognised accidents.
Example 22: Claim turned down occupational disease after work as a psychiatric healthcare assistant
A healthcare assistant had been employed in a psychiatric nursing home since 1978 on regular night
duty. In later years he had he been alone on night duty. Two incidents had been reported and
recognised as accidents. In March 1992 he was kicked by a threatening and scolding patient. The
incident was recognised as an accident without any compensation being granted. After this incident he
had violent anxiety attacks and became weepy and afraid of the dark. He resumed work in June 1992.
In 1994 there were violent incidents where his colleagues were involved, and he felt unwell again and
started drinking.
The claim does not qualify for recognition as an occupational disease on the basis of the list. The event
in 1992 was recognised as an accident, and in 1991 he developed symptoms of posttraumatic stress
disorder, which was complicated by excessive alcohol consumption. The condition was passing, but he
had a relapse in 1994 in connection with violence/threat incidents in relation to colleagues. There is no
documentation of any relevant mental trauma in connection with the relapse, and the relevant previous
incidents were recognised as accidents. It should be assessed, however, whether the relapse might be
attributable to the recognised accident in 1992, and if this previous case therefore should be reassessed.
More information:
The relationship between work-related stressors and the development of mental disorders other than
post-traumatic stress disorder (www.ask.dk)
A scientific review addressing delayed onset posttraumatic stress disorder and posttraumatic depression
(www.ask.dk)
260
Chapter 9. Cancer diseases
List of contents
261
1. Cancer diseases (Group K)
Introduction
In the following paragraphs we describe the possibilities of and conditions for recognition of work-
related cancer diseases included on the list of occupational diseases reported on or after 1st January
2005.
This guide is first and foremost intended as a help to decision makers employed in the National Board
of Industrial Injuries and others who need to learn more about cancer diseases. It includes general
information on our management of cancer disease claims, a detailed description of selected cancer
areas, and a number of guiding examples of decisions based on the list. The list of examples is by no
means exhaustive, however.
This guide is furthermore meant to be a tool for doctors who need to keep themselves informed of
cancer diseases as potential occupational diseases.
Doctors and dentists who, in their work, discover or suspect that a person has developed an established
or presumed work-related disease, or in any other way has developed health problems due to harmful
exposures in the workplace, must report such cases to the Working Environment Authority and the
National Board of Industrial Injuries.
The obligation to report such cases lies with any doctor or dentist, regardless of whether he or she is a
practitioner or employed in a hospital, clinic, or any other institution, or in the occupational health
system. However, in hospitals, clinics, etc. the duty to report lies solely with the head physician or
dentist in each department. Claims must be reported not later than 9 days after the doctor or dentist
becomes aware of the disease/injury and the presumed correlation with work.
(Administrative Order No. 950 of November 26, 2003 on doctors and dentists duty to report work-
related diseases to the Working Environment Authority and the National Board of Industrial Injuries
in Danish only)
A doctor or dentist who fails to meet their obligation to report an occupational disease will be punished
by fine in pursuance of the Danish Working Environment Act.
A 2004 report from the Danish Cancer Society points out, however, that far from all work-related
cancer diseases are reported. Well over 200 potentially work-related cancer claims are reported each
year, even though new surveys indicate that 2 to 4 per cent of all new cancer cases reported every year
may fully or partly have been caused by work. This is equivalent to up to 1,300 cases per year.
(Reporting of selected work-related cancer cases (1994-2002) to the National Board of Industrial
Injuries, Danish Cancer Society, March 2005 in Danish only)
The recognition percentage for the well over 200 cancer claims reported each year was a bit over 50 per
cent in the period 2003-2005. Cancer is often a very serious disease with significant consequences for
the injured persons, and notification of the claim can in many cases lead to compensation for
permanent injury and loss of earning capacity.
262
As a consequence of the problem of underreporting of cancer diseases, the National Board of Industrial
Injuries has launched a campaign to ensure that more doctors in future report presumed cases of work-
related diseases to us. We have taken the following concrete initiatives:
We target information to doctors in hospital departments who treat cancer patients, telling them
of their duty to report claims and the problem of underreporting
We focus in medical journals on doctors duty to report claims and the problem of
underreporting
We have written this guide to cancer diseases on the list of occupational diseases, which
describes in detail the requirements for and possibilities of recognising work-related cancer
Since 2007 we have therefore introduced an automatic claims reporting scheme via a special cancer
register. The scheme ensures that all new cases of mesothelioma (asbestos) and cancer of the sinuses
(wood dust) are reported by the Danish Cancer Register to the National Board of Industrial Injuries. It
is also very important that the disease should be reported within the time limit by the doctor or dentist
who has a duty to report it.
Doctors and dentists must report presumed or established occupational diseases. The 9-day time limit is
from the day when the doctor or dentist becomes aware that it is probably the work that is the cause of
the disease (Workers Compensation Act, section 31(3) and section 34). A doctor or dentist who fails to
meet his or her obligation to report an occupational disease will be punished by fine (Working
Environment Act).
The injured person may also send a compensation claim directly to us. This has to happen within one
year from the date when the injured person was told by a doctor that the disease might have been
caused by work. Usually we cannot disregard the 1-year time limit by referring to the fact that the
doctor or dentist has not met their obligation to report the disease.
This guide was written with a view to providing information on cancer diseases from a workers
compensation perspective. We have emphasized such matters as are particularly important for our
claims management and our assessment of reported cancer diseases, based on the list of occupational
diseases reported on or after 1st January 2005. The guide is not a medical guide to treatment of cancer
diseases. Nor does it offer exhaustive information on cancer for cancer patients or others who wish to
obtain detailed medical information on types of cancer, examinations, treatment, etc.
For a more detailed source of medical information on cancer diseases we refer to the website of the
Danish Cancer Society, www.cancer.dk
See chapter 1 for more information on work-related cancer diseases not on the list.
Whenever possible, the National Board of Industrial Injuries offers speedy claims management for
particularly serious cancer cases.
The following cancer diseases are included on the list of occupational diseases (Group K):
263
K.1.3. Lymph and blood producing organs
K.1.4. Non-Hodgkin lymphoma
K.2.1. Peritoneum (mesothelioma)
K.2.2. Liver and biliary ducts
K.2.3. Liver
K.2.4. Liver (angiosarcoma)
K.2.5. Stomach
K.2.6. Nasal pharynx
K.3. Skin
K.4.1. Lung
K.4.2. Pulmonary pleura (mesothelioma)
K.4.3. Nasal cavity and sinuses
K.4.4. Mucous membranes of sinuses and processus mastoideus (epitelial tumours)
K.4.5. Larynx
K.5.1. Kidney
K.5.2. Urinary bladder
K.6.1. Connective tissue
K.6.2. Breast
K.6.3. Bone (sarcoma)
K.6.4. Cancer without specification (all types of cancer not included under other items)
K.6.5. Thyroid gland
For an overall list of the many specific exposures that may lead to the cancer types on the list, we refer
to the List of Occupational Diseases reported on or after 1st January 2005. You can also see all of group
K in Appendix 1.
Some cancer diseases can only be recognised on the basis of the list if they were caused by one or few
relevant exposure(s). One example is cancer of the kidney (K.5.1), which is only recognised on the
basis of the list if it was caused by work in coke manufacture.
Other cancer diseases can be recognised on the basis of the list if they were caused by many different
exposures. One example is skin cancer (K.3), which can be recognised as an effect of exposure to
arsenic, anthracene, creosote, mineral oil, crude paraffin, shale oil, solar radiation, soot, coal tar as well
as work in coke manufacture, coal gasification and oil refinery.
264
Cancer diseases not included on the list may, after submission of the claim to the Occupational
Diseases Committee, be recognised as a consequence of the special nature of the work. See more in
chapter 1.
For cancer diseases reported before 1st January 2005, we refer to the List of Occupational Diseases
reported before 2005.
Cancer is a disorder of the cells, the cells of a given region of the body beginning to grow
uncontrollably and for no purpose. All cells contain genetic material that controls the activity of the
cell. Cancer cells may develop if the genetic material is damaged (mutation).
The body is composed of billions of cells, new ones being formed all the time, thus replacing destroyed
or worked-out cells. In this way the organism can be maintained and grow. The whole process is
strictly controlled by the genetic material of the cells, i.e. the genes. Therefore cell division is part of
the bodys natural maintenance and a prerequisite for life.
Benign tumours
Normal cells usually divide without problems, but sometimes they divide too much. This is quite
normal and is seen as a small benign tumour somewhere in the body. If you take a tissue sample of the
tumour and look at the cells in a microscope, they still look normal only there are too many of them.
Benign tumours do not spread to other parts of the body and should not be confused with cancer. They
may disappear by themselves or stay where they are. This type of tumour is not included among the
cancer diseases on the list.
If the cancer cells reach the blood or lymph ducts, the disease may move further around in the body and
settle and grow in organs completely separate from the organs in the proximity of the place of origin of
the cancer. Cancer cells that become disconnected and settle somewhere else in the body are called
metastases (Greek for removal). If breast cancer, for instance, spreads to bones and liver, this is due to
metastasising.
265
You could also say that the original form of cancer is the primary cancer and that new cancer
formations in other parts, as a consequence of general spreading, are called secondary forms of cancer.
- Carcinomas are cancers of glands and skin and mucous membrane cells for instance in the
breast, bronchias, uterus and digestive tract
- Sarcomas are cancers of muscular cells, bone cells and connective tissue cells
- Leukaemia is cancer of the white blood cells
- Lymphomas are cancers of the cells of the lymph system
It is up to the National Board of Industrial Injuries to decide if the disease/diagnosis is consistent with a
disease on the list or if there may be grounds for submitting the claim to the Occupational Diseases
Committee with a view to recognition not based on the list.
The cancer diagnosis must, as far as possible, be made in a microscopy test where there is a positive
find of malign cell degeneration (malign tumour). In some cases, however, it is not possible to get a
microscopic test. In such cases a clinical image and a description of the aetiology in the hospital
records may contribute to making the diagnosis seem likely. The National Board of Industrial Injuries
cannot demand microscopic examinations or other examinations requiring invasive intervention.
In the event of death we furthermore obtain a death certificate as well as any autopsy report if such a
report is available. The National Board of Industrial Injuries may request an autopsy report in cases of
doubt if we become aware, immediately after the death of the injured person, that the death may be
work-related. In that case a post-mortem examination requires the consent of the surviving relatives.
By far the most reported cancer claims come from a clinic of occupational medicine, but the claim may
also come from the treating hospital department (for instance an oncology department or a lung
department), a medical specialist, the injured persons GP, the injured person or the injured persons
trade union, etc.
After receiving the claim we gather the necessary additional information for the further processing of
the claim. If the medical records are not already enclosed with the claim form, we will i.a. obtain
medical records from the treating hospital, which will give an overview of diagnosis, pathological
picture, condition and treatment.
266
We will also gather medical records from the clinic of occupational medicine if it appears from the
claim form that the injured person has had an occupational examination and the records are not already
enclosed with the claim form.
If the injured person has not yet been examined in a clinic of occupational medicine, we will in most
cases ask a clinic near the injured person to issue a medical specialists certificate. The medical
certificate will include information of the concrete working conditions and exposures in the workplace
as well as a thorough description of the disease.
To the extent we find it necessary in order to get a better overview of the disease, we may also get a
medical specialists certificate from a doctor who is specialised in the concrete disease area. This may
for instance be a certificate from a pulmonary specialist, or perhaps a specialist of radiology, if the
claim pertains to the lung or the pulmonary pleura.
Besides we will in some cases gather supplementary medical information from GP, hospital, medical
specialists examinations or x-ray or scan descriptions.
In the event of very complex cancer diseases we will in a few cases get a special assessment from a
particularly specialised doctor that may give an overview of the medical knowledge in the field and a
medical assessment of the likelihood of a correlation between the disease and the exposures described
in the concrete case.
In a few cases the first reported cancer disease turns out to be a secondary form of cancer that has come
about as a consequence of spreading of the original cancer (metastases). In our assessment of whether
the claim qualifies for recognition we only decide on the primary cancer disease as it is only this
disease that may be work-related.
Secondary cancer forms are a result of the general spreading of the cancer in the body (metastasising)
and do not in themselves have any relation to specific exposures at work. However, if we recognise the
primary cancer disease as an occupational disease, the effects of the recognised disease, including
secondary cancer forms and the effects of these, will in principle be included in any compensation.
Latency time
267
The development of cancer occurs through a slow process, which means that the disease often only
breaks out many years after the carcinogenic exposures, depending on the type and extent of the
exposure and the specific form of cancer.
The time that passes from the exposure till the onset of the disease is called the latency time.
The typically long latency time for cancer diseases means that, before it can be said that there is a
medical correlation between disease and exposure, a number of years must have passed from the
exposure till the onset of the disease. In other words, there usually must have been a long latency time.
If the cancer disease breaks out within a short period of time (months or a few years) after the exposure
to otherwise relevant carcinogens, this would be an argument against the disease having come about
due to such exposures at work.
The assessment of the latency time will also include an assessment of the scope of the exposure. If the
exposure to harmful substances was massive, this would often speak in favour of a relatively short
latency time. If the exposure was more moderate, this would be in favour of a longer latency time
before the onset of the disease.
The working environment and the exposures there may increase the risk of developing cancer, and
employees in certain trades therefore have a significantly higher risk of getting cancer than others.
However, surveys also indicate that it is the total exposure from the working environment and the
behaviour of a person outside the workplace, in their leisure time, that overall may increase or decrease
the cancer risk.
Under the Workers Compensation Act, the cancer forms and exposures included on the list of
occupational diseases are forms of cancer where scientists have found good medical documentation of
causality between a specific type of cancer and specific types of exposures in the workplace. (Section
7(1) of the Act)
In many areas we have no or only limited knowledge of the development of cancer and its causes. This
means that several cancer forms or exposures are not included on the list and cannot be recognised
without applying the list after submission of the claim to the Occupational Diseases Committee. This is
because we lack adequate medical documentation of the causality in the field, even though it can only
rarely be completely ruled out that the disease may have been caused by exposures in the workplace.
See more about documentation in the field of cancer in Appendix 1.2.
If, during the processing of a claim, we receive information of factors apart from work that may very
likely have contributed significantly to the onset of the disease, such information will, however, be
included in the overall assessment of the claim.
268
If factors without any relation to work contribute to the aetiology of the disease, without thereby being
seen as the main causes of the onset of the disease, the claim may qualify for recognition. This requires,
however, that it is a listed disease and that the diagnosis and exposure requirements are met. In such
cases we may sometimes make a deduction from the compensation if there have been substantial
competitive factors without any relation to work. This means that we may make a deduction in the
compensation for permanent injury and perhaps from the compensation for loss of earning capacity.
(Section 12 of the Act)
So a health situation may qualify for recognition as an occupational disease, even if it was not solely a
consequence of an industrial injury, but is a combination of the effects of an occupational exposure
which in itself is sufficient for meeting the list requirements and competitive factors. In such cases we
are able to make a deduction from the compensation so that the injured person only obtains
compensation for the consequences of the industrial injury.
For a great number of cancer forms, tobacco consumption will have an impact on our assessment of the
claim, smoking being known as a substantial contributing factor for the development of many cancer
diseases. Therefore, in some cases, tobacco smoking may lead to us making a deduction in the
compensation.
In each specific case we will make a concrete assessment of the extent of the tobacco consumption and
the size of the risk, seen in relation to the type of disease in question and the character and scope of the
work-related exposures.
A tobacco consumption of less than 7 grams of tobacco per day or less than a total of 10 package years,
will not, as a main rule, lead to any reduction in a compensation amount, provided the exposure besides
has been fully adequate to cause the disease.
1 gram of tobacco is equivalent to 1 cigarette. Other types of tobacco, for instance pipe tobacco, cigars
and small cigars, are also converted into grams.
One package year is equivalent to 20 cigarettes a day for one year (20 x 365 = 7,300 cigarettes).
A person who has been smoking 10 cigarettes per day for 15 years has smoked, in terms of package
years, a total of 7.5 package years (10 x 365 x 15: 7,300).
Special conditions apply for cases regarding lung cancer caused by passive smoking at work. Here it is
a condition for recognition of the claim that the injured person should be a never-smoker. See also
1.6.1.
In order for the claim to be recognised on the basis of the list, there must have been one or more
exposures that are included on the list in relation to the cancer form in question. The exposure must
furthermore have been of a nature and extent (intensity and duration) relevant for the development of
the cancer disease in question.
269
In the processing of the claim we will gather information on and, if possible, documentation of the
carcinogenic, work-related exposures in the specific case.
The process of gathering information regarding harmful exposures in the workplace is sometimes
difficult in cancer cases, i.a. because the relevant information typically dates far back in time
and may be hard to remember for injured persons, employers, and others. There may also be a mixed
exposure picture with many different types of potentially carcinogenic exposures in the course of a
long life of work. It may also be difficult to get a full picture of the extent to which each exposure has
taken place and with what employers.
As a starting point we will gather information on the possible exposures in the workplace on the basis
of the following sources
The injured person/the trade union (questionnaires etc.)
Clinic of occupational medicine (records or medial specialists certificate)
Employer(s)
Labour Market Supplementary Pensions Fund (ATP; information on employments/employers
over the years)
In order to ensure documentation of the exposure, we will also try to ask the relevant employers for any
comments on the information on the employment and the potentially carcinogenic exposures. In
connection with serious cancer diseases we ask the employers to deal urgently with our letter. If the
case is extremely urgent, we may also phone the employer and ask about the working conditions.
If the employer does not reply or cannot largely confirm that the gathered information is consistent
with the actual circumstances, we will try to gather from other sources supplementary information of
the exposures in the workplace.
Such information may be supplementary information from the Working Environment Authority and the
Occupational Health Service about the concrete workplace; general descriptions of the trade including
information on exposures in the trade in question, or perhaps information from previous trade-union
representatives or colleagues in the workplace.
We subsequently make an assessment of whether the stated exposures can de deemed to be well-
documented and whether they were sufficient to cause the cancer disease in question.
In very serious cancer disease cases we endeavour to express handle the claim to the extent this is
possible within the framework of the Act. We i.a. ask for express handling of the claim by the clinic of
occupational medicine, in the hospital departments involved, with the employer and, in a few cases,
also with the insurance company (the Labour Market Occupational Diseases Fund), who, according to
270
the Act, must be heard with regard to the information of the case before any recognition letter can be
written.
We are in close co-operation with our medical consultants in the field of cancer and if it is a serious
cancer disease, we usually also involve the medical consultant in the processing of the claim as soon as
we receive the claim. In this way we can get a quick medical assessment of the pathological picture, of
the severity of the disease and of any causality in the case in question. Often the medical consultant
will also be able to advise us on any supplementary information we may need in order to be able to
make a quick decision.
The National Board of Industrial Injuries and the Occupational Diseases Committee, at a meeting in
August 2005, made a thorough revision of the field of cancer by updating the list of occupational
diseases in relation to the most recent and internationally recognised cancer research results.
The inclusion on the list of diseases and exposures in the field of cancer is based on the results from the
international cancer research, which are gathered and assessed by the WHO cancer centre in Lyon,
France, the International Agency for Research on Cancer (IARC). (www.iarc.fr)
The results of this research appear from the IARC monographs on cancer, which give an account of and
assess the potential causalities in various fields of cancer.
The criterion for including a cancer disease and its appurtenant exposure on the Danish list of
occupational diseases usually is that the causality between a given disease and exposure (the evidence)
has been categorised by the IARC as certain or likely. This means that the exposure, in relation to a
given cancer disease, must be categorised by the IARC in group 1 or 2A.
In addition the specific Danish requirements to the medical documentation in the field also have to be
met in accordance with the occupational diseases concept on which the list is based.
In the revision, lung cancer caused by passive smoking at work was i.a. included on the list. Read more
in paragraph 1.6.
Besides, the revision led to the inclusion on the list of occupational diseases reported on or after 1st
January 2005 of 25 other, new diseases or exposures in the field of cancer.
The National Board of Industrial Injuries and the Occupational Diseases Committee follow closely the
medical developments. New research findings are part of the general discussions of the cancer field and
discussions of concrete claims, also in close co-operation with our medical specialists, who represent
the various medical specialties. This means that our practice in the cancer field is not static, the
assessment of cancer causalities changing over time in step with the addition of new medical
knowledge. Since 2005 that Committee has examined the field of cancer several times. See Appendix
1.
A thorough examination of the IARC assessment of the documentation basis for various diseases and
exposures in the field of cancer, as well as a list of particularly exposed trades/occupations in
connection with each exposure, can be seen in Appendix 1.
271
We furthermore refer to the IARC list and monographs on various carcinogenic exposures
(www.iarc.fr).
Diagnosis requirements
In order for the disease lung cancer to be recognised on the basis of item K.4.1 of the list, a medical
doctor must have made the diagnosis of lung cancer/bronchial cancer (Aden carcinoma spumonis or
neoplasm maligned bronchi save spumonis; ICD-10 C34).
The lungs consist of a main airway (trachea), which, like a tree, branches out into many, smaller and
smaller, bronchial tubes (bronchi). It is not possible, disease wise, to distinguish between different parts
of the lung system. This means that, disease wise and with regard to the item of the list on lung cancer,
the lung system comprises cancer of the lungs, the respiratory tracts and the bronchi.
Larynx cancer is not covered by this list item, but by item K.4.5. Nor is cancer of the pulmonary pleura
(mesothelioma) covered by this item, but by item K.4.2.
It is estimated that around 85 per cent of all cases of lung cancer are caused by active tobacco smoking.
The risk of developing lung cancer increases proportionately with the size and duration of the
consumption of tobacco.
Also passive smoking is a documented cause of lung cancer, but this factor plays a much smaller role
than active smoking.
A large survey made in 2002 by the International Agency for Research on Cancer (IARC) of the WHO
concluded, against the background of a very large number of surveys of the cancer risk from passive
smoking, that the excess risk of developing lung cancer in a passive smoker in the home is in the range
of 20 per cent for women and 30 per cent for men, as compared to the risk in a person who is not
exposed to passive smoking or an active smoker himself.
The excess risk of developing lung cancer as a consequence of passive smoking in the workplace was
assessed in the same survey at 12-19 per cent for both sexes.
Furthermore the IARC survey of passive smoking shows that the exposure to carcinogenic substances
in connection with passive smoking is 50-100 times less than the exposure in connection with active
smoking. This means, for instance, that the risk from exposure to passive smoking from the
surroundings amounting to a total of 20 package years is comparable to the risk from a persons own
smoking (active smoking) of 0.2-0.4 package years. One package year = 20 cigarettes per day for one
year.
272
The surveys furthermore indicate that a very moderate tobacco consumption for an active smoker of a
total of less than about 300 cigarettes (= 300 grams of tobacco) in the course of a persons whole life
does not constitute any increased risk of developing lung cancer.
With a tobacco consumption of more than 300 cigarettes, the risk of developing lung cancer begins to
increase proportionately with the consumption and the duration.
Other known causes of lung cancer in Denmark are in particular related to exposures in the working
environment. Particularly exposed occupational groups in Denmark, with regard to the development of
lung cancer, are groups that have worked with asbestos (asbestos-cement workers, carpenters/roof
fitters, mechanics, insulation workers, plumbers), painters, welders (nickel and
chromium),occupational drivers (diesel fumes), and workers in iron and metal production, as well as
persons who have been exposed to arsenic. (Danish Cancer Society, www.cancer.dk)
Exposure requirements
The following work-related exposures that can cause lung cancer are included on the list (K.4.1):
Substances:
(2,3,7,8-Tetraklorodibenzo-para-dioxin (dioxin)
Alfa-chlorinated toluenes and benzoylchlorid (combined)
Arsenic and arsenic compounds
Asbestos
Beryllium and beryllium compounds
Bis(chloromethyl)ether and cloromethyl methyl ether (technical grade) (oat cell)
Cadmium and cadmium compounds
Insecticides (non-arsenical)
Chromium compounds
Crystalline quartz
Nickel compounds, including combinations of nickel oxides and nickel sulphides in the nickel
refinery industry
Particles of metallic cobalt containing wolfram carbide (tungsten)
Passive smoking
Radon and radon daughters
Mustard gas (sulphuric mustard)
Soot
Coal-tar and coal-tar pitch
Strong inorganic acid mists containing sulphuric acid
Talc containing asbestiform fibres
Diesel exhaust fumes
Bitumen in connection with asphalt roof work
Processes:
Aluminium production
Iron and metal founding
273
Coke production
Coal gasification
Painter (occupational exposure as a)
Mining of iron core (hematite/jernglans) with radon exposure
Production of art glass, glass containers, and pressed ware
A number of the stated exposures are very rare as causes of lung cancer in Denmark, working in
Denmark nowadays usually not leading to such exposures. This applies for instance to mining with
exposure to iron core containing radon as well as exposure to metallic cobalt with wolfram carbide.
Other exposures occur more frequently and therefore will more often cause cases of work-related lung
cancer. This applies in particular to asbestos, which is the cause of almost all recognised, work-related
cases of lung cancer processed by the National Board of Industrial Injuries.
Lung cancer qualifies for recognition on the basis of the list if there has been relevant and sufficient
exposure to one or more of the mentioned influences in the workplace.
Furthermore, all exposures must have had a certain intensity as well as duration.
The requirement to the extent of each exposure depends on the type of exposure in question and the
carcinogenicity of the substance in question. The time requirement to exposure from asbestos, for
instance, is much less strict than the requirement to exposure in the form of passive smoking. You do
not have to be exposed to asbestos for very long before the risk of developing lung cancer increases
considerably.
Below follows a description of some of the frequent work-related exposures in Denmark that may lead
to lung cancer, including detailed information on factors regarding disease and exposure that may have
an impact on our decision on the claim.
At least one year of massive exposure (for instance employment in the factory
Eternitfabrikken, demolition work with established asbestos exposure or other direct
asbestos handling (for instance insulators), or
5-10 years of moderate asbestos exposure (for instance ship-yard work in closed spaces,
special work with asbestos roofs (for instance roof fitters and carpenters); plumbing or
insulation work with regular asbestos exposure, lorry mechanics with many replacements of
brake linings with asbestos). Indoor work carries more weight than outdoor work, and direct
exposure (contact) carries more weight than indirect exposure, or
an exposure calculated at not less than 25 (fibres/cm3) per year. This means an exposure
equivalent to 1 fibre/cm3 for 25 years or 2 fibres/cm3 for 12.5 years etc.
274
depending on the exposure to asbestos and the total tobacco consumption. In other words, it is much
more dangerous to be exposed to two carcinogenic substances at the same time.
Massive daily exposure to passive smoking in the workplace for a number of years (about 20
years or more)
The injured person must be a never smoker (see below)
The injured person must only have been moderately exposed to private passive smoking
A latency period of 10 years or more (the time that passes from the exposure till the onset of the
disease)
Any poor ventilation in the workplace
Lung cancer among Danish women who have never smoked themselves is estimated at 10 new cases
per year per 100,000 persons (year 2000). So lung cancer in non-smoking women is a very rare disease.
The same applies to men. By way of comparison, approximately 85 per cent of all 3,500 new cases of
lung cancer per year are due to smoking.
A number of studies have shown an increasing risk of developing lung cancer in step with increasing
exposure to tobacco smoke in the environment. In the past few years a number of studies have been
made of persons who never smoked but have spouses who smoke in the home.
These studies showed that passive smokers have a certain excess risk of lung cancer and that the risk in
general is higher (20-30 per cent increased risk) for passive smokers in the home than at work (12-19
per cent increased risk).
For passive smokers, however, the risk from exposure to carcinogenic substances through smoke from
the surroundings is generally about 50-100 times smaller than the risk to active smokers from active
consumption on the same scale.
This means that the risk of developing lung cancer in a person who has smoked for instance 20
cigarettes per day for 10 years is 50-100 times bigger than the risk in persons who have been exposed
to passive smoking from 20 cigarettes for 10 years.
Passive smokers are exposed to the same carcinogenic substances as smokers but in lower
concentrations. Passive smoking is exposure to second-hand tobacco smoke, which is a mixture of
the smoke exhaled by active smokers, and the side stream smoke emitted from the burning tobacco
made thinner by mixing with the surrounding air. Therefore passive smokers are exposed to the same
potentially carcinogenic substances as active smokers. Such carcinogens include benzene, 1,3-
butadiene, benz(a) pyren and many others, only in smaller concentrations.
Passive smoking has been included under category 1 in the IARC cancer list
i.e. under exposures that are definitely carcinogenic in humans. The National Board of Industrial
Injuries has subsequently included passive smoking on the list of occupational diseases, in accordance
with recent research in this field. See the IARC cancer list here: (www.iarc.fr).
Our specific requirements to the exposure in connection with the recognition of a claim regarding
passive smoking match the medical knowledge of causation in this field.
275
Particularly exposed groups in the labour market with regard to the development of lung cancer after
passive smoking are employees in the hospitality trade who have worked in very smoke-filled
environments for a number of years. Exposure to passive smoking in other businesses, however, will
qualify for recognition in the same way as work in the hospitality trade if the disease and the exposure
meet the specific requirements for recognition.
Never smoker
The concept of never smoker means that the injured person must never have been a smoker.
In practice this means that injured persons must not, in the course of their whole lives, have had a total
tobacco consumption from active smoking amounting to more than 300 cigarettes (= 300 grams of
tobacco).
If the consumption was more than 300 cigarettes over time, the risk of developing lung cancer
increases substantially and proportionately with the size of the consumption and the duration, and such
cases will not qualify for recognition on the basis of the list.
Particularly exposed groups in the labour market are welders who have worked with stainless steel with
inhalation of welding/grinding dust or welding fumes with particles of the substances in question. In
principle there needs to have been a rather considerable exposure for a considerable period of time
(several years).
As for other types of work-related lung cancer, substantial tobacco consumption would be included in
the assessment of the claim as a competitive cause.
As for coal tar and coal-tar pitch, these substances are included because polycyclic aromatic
compounds, which are part of coal tar based products (including tar-containing recycled asphalt), are
known causes of i.a. lung cancer. This applies in cases where there has been substantial exposure for a
number of years with close contact with the substances in question.
Lung cancer can be recognised, for instance, if there has been exposure in connection with production
or use of asphalt products/coal products containing coal tar, which would involve inhalation of particles
and vapours.
276
In Denmark asphalt products used today are mainly bitumen products without any content of coal tar.
Bitumen products are not known as having any carcinogenic effect. Recycled asphalt, however, may in
certain cases contain coal tar.
As for exposure to soot, the substance is on the list because exposure to soot, in particular from
chimneysweep work, is a known cause of lung cancer. A lung cancer disease may for instance qualify
for recognition if the injured person has been a chimneysweeper for a considerable number of years
with daily exposure to soot from chimneys and fireplaces.
Also other types of soot exposure, such as exposure to soot from coal and from oil refinery plants, may
be covered if the exposure has been considerable.
The prevalence of cases of lung cancer after exposure to soot or coal tar is very small in Denmark, but
may, as stated above, occur in particular among chimneysweepers (soot) and asphalt or road workers
(coal tar). Also other job groups will be covered by the list, however, if the exposure to the substances
in question has been relevant and considerable.
As is the case for other types of work-related lung cancer, substantial tobacco consumption would be
included as a competitive cause in the assessment of the claim.
The claim qualifies for recognition on the basis of the list. The carpenter suffered massive exposure to
asbestos, breathing in asbestos-containing dust, at least one day a week for many years. There is
furthermore good correlation between the asbestos exposure, the development of cancer of the left lung
and the long latency time of 35-40 years from the first exposure till the onset of the disease. As he had
a rather moderate tobacco consumption of well under 10 package years, there are no grounds for
making a deduction in the compensation for permanent injury and loss of earning capacity.
Example 2: Recognition of lung cancer after asbestos with deduction for tobacco consumption (smith)
A 55-year-old man developed lung cancer of his right lung (neoplasma malignum pulmonis dxt.). It
appeared from the information of the case that 15 years previously he had worked as a repair smith in a
large power plant for a total of 17 years. The work involved control, inspection, repair and maintenance
of kettles, pumps and pipes, and he was frequently in contact with insulation materials containing
asbestos. The work generated a considerable amount of smoke from the materials in question. It
277
furthermore appeared that for many years he had had a considerable cigarette consumption of 15-20
cigarettes a day.
The claim qualifies for recognition on the basis of the list. The repair smith suffered relevant exposure
to asbestos-containing materials largely every day for a long period of time and developed lung cancer
of his right lung more than 10 years after that. There is good correlation between the disease, the
exposure and the latency period of more than 15 years from the exposure till the onset of the disease. In
determining the compensation for permanent injury and loss of earning capacity we will make a
deduction for the considerable tobacco consumption of more than 10 package years, which is regarded
as contributing to the development of the disease and its consequences by 50 per cent.
Example 3: Recognition of lung cancer after asbestos and diesel fumes (shipyard worker)
A 70-year-old man had worked in a big shipyard for well over 40 years. The first decade he was
employed as an unskilled shipyard worker in the repair department and later in the rigger department.
The work involved recurring contact with asbestos-containing materials and also considerable exposure
to diesel fumes in connection with gasification from diesel engines, particularly in the rigger hall. He
had only smoked for 4-5 years in his early youth. After 40 years he developed lung cancer of his right
lung (neoplasma malignum pulmonis dxt.).
The claim qualifies for recognition on the basis of the list. The shipyard worker was for 40 years
exposed to frequent contact with asbestos-containing materials and suffered substantial exposure to
exhaust fumes from diesel engines in a great hall with many diesel-run engines. There is good
correlation between the disease, the exposure to asbestos and diesel fumes and the long latency time of
up to 40 years from the first exposure till the onset of the disease.
Example 5: Claim turned down lung cancer (passive smoking for many years, but also a smoker)
A 63-year-old man had worked in an office for 30 years when he was diagnosed with lung cancer of
the right lung (adenocarcinoma). He had shared an office with two ladies for slightly longer than 20
years. Each of them had a daily tobacco consumption of 20 and 40 cigarettes respectively. Of their
consumption half was smoked in the office, equivalent to approximately 30 cigarettes a day or a total of
30 package years over time. The injured person was a non smoker, but had smoked for a brief period of
time, 3-4 years, in his youth. His daily consumption was 3-4 cigarettes, or a total of approximately 0.6
278
package years (approximately 4,500 cigarettes). His wife was and always had been a non smoker, and
he had only been very moderately exposed to passive smoking on other private occasions.
The claim does not qualify for recognition on the basis of the list. The injured person developed lung
cancer after having been exposed to passive smoking in the workplace, but also smoked in his youth
with a total tobacco consumption of approximately 4,500 cigarettes (0.6 package years), which was
substantially in excess of 300 cigarettes in the course of a whole life. Therefore the disease is not
covered by the list of occupational diseases.
The claim was submitted to the Occupational Diseases Committee with a view to any recognition
without application of the list. The Committee recommended to turn down the claim as the office
workers risk from active smoking in the concrete case was in excess of the risk from passive smoking
in the workplace, and in this case active smoking must be deemed to constitute the greatest risk of
developing lung cancer. Therefore it is not very likely that the disease was caused by passive smoking
in the workplace. The Committee in their assessment took into account that exposure to smoke from
the surroundings constitutes a risk 50-100 times smaller than exposure to a persons own smoking of
the same number of cigarettes. The office worker was exposed to smoke from the surroundings
amounting to approximately 30 package years (30 cigarettes per day for 20 years). The risk from this
passive exposure is equivalent to the risk from active smoking in the interval 0.3-0.6 package years.
Altogether the risk of developing lung cancer caused by passive smoking is increased by 10 per cent.
He furthermore had an active consumption of cigarettes amounting to about 0.6 package years. This
tobacco consumption in itself increases the risk of developing lung cancer by about 15-20 per cent.
The risk from active smoking in this case is in excess of the risk of being exposed to passive smoking
in the workplace. Therefore it cannot be deemed to have been established that the disease
predominantly or mainly was caused by passive smoking in the workplace.
The processing of the claim included an expert assessment form the Danish Cancer Society of the
concrete risk in the case in question.
1.6.2. Cancer of the pulmonary pleura (K.4.2) and the peritoneum (K.2.1) mesothelioma
Diagnosis requirements
In order for the diseases pulmonary cancer and peritoneal cancer to be recognised on the basis of items
K.4.2 or K.2.1 of the list, a medical doctor must have made the diagnosis of pulmonary cancer or
peritoneal cancer of the type malignant mesothelioma (mesothelioma pleurae (pulmonary pleura), ICD-
10 C45.0, or mesothelioma peritonei (peritoneum), ICD-10 C45.1).
Exposure requirements
Cancer of the pulmonary pleura or the peritoneum may qualify for recognition on the basis of the list if
one of the following exposures has been present
(a) Asbestos
(b) Erionite
(c) Talc containing asbestiform fibres
Furthermore, the following requirements must be met in order to recognise the claim
Documented or likely exposure to asbestos or asbestos-containing materials in the workplace
If the exposure was massive, there need only have been weeks of exposure
279
Typical work-related sources of asbestos exposures are work in the now closed Eternitfabrikken in
Aalborg, Denmark; demolition work, shipyard work, roof work and plumbing with handling of
asbestos-containing materials, as well as mechanic work involving contact with asbestos-containing
brake linings or couplings. However, other types of relevant exposure to asbestos in the workplace may
also be covered by the list. See also Appendix 1 on trades/occupations with possible asbestos exposure.
In Denmark we mainly see exposure to asbestos (a). However, exposure to erionite, which is a rare,
asbestiform mineral (b), and talc containing asbestiform fibres (c) can similarly cause mesothelioma
and is therefore also covered by the item, even though such exposures seldom occur in Denmark.
In 2000 63 Danish men and 13 Danish women developed pulmonary cancer. Cancer of the pulmonary
pleura constitutes 0.5 per cent of cancer in men and 0.1 per cent of cancer in women. 3 men out of
100,000 are diagnosed with pulmonary cancer in one year, and 1 out of 100,000 women get the same
diagnosis.
Asbestos-related pulmonary cancer occurs 10 times more frequently than asbestos-related peritoneum
cancer.
Most of those who get pulmonary cancer or peritoneal cancer are over 60 years of age because it takes
many years for the exposure to asbestos to lead to the disease (long latency period). Younger people
can, however, get pulmonary cancer or peritoneal cancer as well if they were exposed to asbestos at a
young age.
That mainly men get the disease has to do with the fact that mainly men have been exposed to asbestos
to a great extent in relation to different types of work and in some cases also in their spare time (for
example in connection with roof slating etc.).
Around 90 per cent of the reported cases of mesothelioma are recognised as industrial injuries.
According to a survey from the Danish Cancer Society from 2004, however, far from all, actually
work-related cases of pulmonary cancer are reported as possible industrial injuries.
Therefore, from 2007, a new reporting scheme via a special cancer register has been introduced. The
scheme ensures that all new cases of mesothelioma are reported by the Danish Cancer Register to the
National Board of Industrial Injuries. Work with asbestos and asbestos-containing materials was quite
normal up to the beginning of the 1980s, but seldom occurs today due to a number of restrictions
against asbestos. However, as mesothelioma as a consequence of asbestos has a long latency period of
10-40 years, there are still many cases of this form of cancer. There may also today be a few cases of
contact with asbestos, for example in connection with work with old roof materials, insulation and
similar materials.
Tobacco smoking
We never make a deduction in the compensation (for permanent injury and loss of earning capacity)
after recognising an asbestos-related case of pulmonary cancer or peritoneal cancer.
This is because tobacco smoking is of no relevance for the development of pulmonary cancer or
peritoneal cancer.
Example 4: Claim turned down pulmonary cancer (mesothelioma) after asbestos (self-employed
smith)
An 80-year-old, retired smith was diagnosed with cancer of the right pulmonary pleura (malignant
mesothelioma). It appeared from the information of the case that previously, for a 10-year period, he
281
had run his own business, where he was exposed to asbestos in connection with the preparation of
asbestos plates for various machines. Han had not previously or later been exposed to asbestos or
asbestos-containing materials in various employments as a smith and machine worker. The injured
person was not employed as a wage-earner in his own business, nor had he taken out insurance against
occupational diseases for self-employed persons with the Labour Market Occupational Diseases Fund,
this scheme only taking effect as of 1st January 2004.
The claim does not qualify for recognition under the Act. The disease has come about as a consequence
of exposures as a self-employed person in the workplace. The disease is not covered by the Act with
regard to insurance, the injured person not having been employed as a wage-earner in his own business
and having failed to take out insurance against occupational diseases valid for the period in which the
exposure occurred.
Diagnosis requirements
There are two types of cancers of the nasal cavity and sinuses: adenocarcinoma (a cancer of gland
cells), which originates from the gland tissue of the nasal mucous membrane and is the more prevalent
form, and squamous cell carcinoma, which originates from skin cells at the nostrils.
The most typical diagnoses of cancer of the nasal cavity and sinuses are nasal cavity cancer (neoplasma
malignum cavi nasi ICD-10, C30.0) and cancer of the sinuses (neoplasma malignum sinuum nasi ICD-
10, C31). All the above types are included on the list of occupational diseases.
Cancer of the nasal pharynx is seen as cancer of a part of the digestive system and is therefore assessed
under item K.2.6 of the list.
Exposure requirements
The following work-related exposures that can cause cancer of the nasal cavity and sinuses are
included on the list (K.4.3):
Substances:
(a) Formaldehyde
(b) Chromium compounds
(c) Nickel compounds, including combinations of nickel oxides and sulphides in
the nickel refinery industry
(d) Wood dust
Processes:
(e) Manufacture of isopropanol in strong acid process
(f) Furniture and cabinet making
(g) Boot and shoe manufacture and repair
For all exposures there usually must have been a substantial and long-term exposure, in principle for
several years.
For example, with regard to wood dust or formaldehyde, the exposure must have lasted more than 10
years. For particularly heavy exposures it is possible to reduce the exposure limit to about 5 years.
282
A particularly severe exposure to wood dust will be an exposure above the limit value of 2 mg/m3. For
formaldehyde a particularly severe exposure will be an exposure above the limit value of 0.4 mg/m3.
In Denmark, the vast majority of reported cases of cancer of the nasal cavity and sinuses are believed to
have been caused by exposure to wood dust in connection with various types of wood processing.
As formaldehyde also occurs in the wood and furniture industry it can sometimes be difficult to decide
whether the exposure to wood dust or formaldehyde is the more substantial factor. Therefore it may
well be a combination of the two exposures, both included on the list, that causes the cancer disease. If
the injured person has suffered relevant exposure to wood dust in connection with work in the wood or
furniture industry, we usually base our recognition of the claim on this exposure.
There are also a few cases of exposure to formaldehyde, chrome and nickel only, whereas the other
types are more unusual. Smoke from welding and cutting of stainless steel contains nickel as well as
chromium, and both can cause the development of cancer of the nasal cavity and sinuses.
Adenocarcinoma of the nasal cavity and sinuses is a relatively rare type of cancer with only about 12
new, known cases per year. On the other hand it is nearly only seen in persons who have been exposed
to wood dust and/or formaldehyde.
Between 90 and 100 per cent of the reported claims are recognised as work-related cancer. Thus the
recognition percentage is very high for this specific type of cancer. That the disease is not reported may
be of great significance for the injured person, who may in this way miss out on compensation.
Therefore, from 2007, a new reporting scheme via a special cancer register has been introduced. The
scheme ensures that all new cases of mesothelioma are reported by the Danish Cancer Register to the
National Board of Industrial Injuries.
The number of cases of squamous cell carcinoma of the nasal cavity and sinuses is lower than the
number for adenocarcinoma.
An update within this field in 2013 and early 2014 resulted in a changed practice regarding
adenocarcinoma.
For adenocarcinoma, the risk is increased after some years of exposure to wood dust, even at rather
low exposure levels. This type of cancer qualifies for recognition after some years (in principle 4 years)
of exposure in undertakings where there is a documented exposure to wood dust of 1 mg/m3 or
equivalent exposure.
For squamous cell carcinoma (cancer of the skin cells) there is a limited risk after many years of
exposure to wood dust, and the recognition requirement is therefore long-term and severe exposure.
There needs to have been exposure to wood dust amounting to 1 mg/m3 over 10 years. For particularly
severe exposures the exposure limit may be reduced to about 5 years. Particularly severe exposure to
wood dust will be 2 mg/m3.
283
The latency period the time from exposure till the disease is diagnosed is often several decades
(probably up to more than 40 years). However, some things indicate that there is an increased risk of
developing adenocarcinoma already after 10 years.
Tobacco consumption
Tobacco smoking does not have any particular impact on the development of adenocarcinoma of the
nasal cavity and sinuses. Tobacco consumption, therefore, is of no relevance for our assessment of
these types of claims.
Tobacco smoking can, however, cause or contribute to the development of squamous cell carcinoma
of the nasal cavity and sinuses. Therefore, as is also the case for other types of work-related cancer,
substantial tobacco consumption may be included in the assessment of a claim regarding squamous cell
carcinoma of the nasal cavity and sinuses. Read more under 1.2.4.
Example 1: Recognition of adenocarcinoma of the nasal cavity and sinuses after wood dust (furniture
joiner)
A 57-year-old man worked for 15 years as a furniture joiner in a joiner business where he was exposed
every day to a considerable amount of wood dust from various exotic woods. The ventilation
conditions were furthermore poor. He subsequently developed adenocarcinoma of the nasal cavity
(neoplasma malignum cavi nasi). The claim qualifies for recognition on the basis of the list. The joiner
suffered daily exposure to wood dust for more than 10 years, and there is good time correlation and
causality between the development of adenocarcinoma of the nasal cavity and the work.
Example 2: Recognition of squamous cell carcinoma of the nose after wood dust (warehouse worker)
A 55-year-old man worked for 10 years as a warehouse worker in a wholesale business which traded in
various kinds of wood products. He was in charge of his own storage hall, handling different types of
wood such as teak, oak, cherry, ash, maple, walnut and elm. His work consisted in receiving and
sorting wood as well as storage and sales. The work involved a certain daily exposure to wood dust in
the storage hall, i.a. in connection with handling of materials and sweeping, and there was no
ventilation. Towards the end of the period he developed tenderness and bleeding from the nose. A
hospital examination established tumours on the right and left side of the nasal septum. A microscopic
examination established squamous cell carcinoma of the nose. It furthermore appeared that the
warehouse worker had been a heavy smoker for a number of years with a consumption equivalent to
more than 10 package years.
The claim qualifies for recognition on the basis of the list. The warehouse worker suffered daily
exposure to wood dust for 10 years and developed squamous cell carcinoma in good causal and time
correlation with the exposure. In the subsequent calculation of the compensation we will make a
deduction for the substantial tobacco consumption of more than 10 package years, this being significant
for the development of squamous cell carcinoma of the nasal cavity and sinuses.
Example 3: Recognition of sinus cancer after nickel and chromium (welding instructor)
A 60-year-old man worked for 15 years as a welding instructor in a business selling welding
equipment. In the recurring demonstrations of the welding equipment he was exposed to welding fumes
and cutting fumes from stainless steel for 5-10 hours a week. The fumes from welding and cutting of
stainless steel contained chromium as well as nickel. Both are carcinogenic in respect of nasal cavities
284
and sinuses. Nearly 10 years after this work he developed cancer of the sinuses (neoplasma malignum
sinuum nasi).
The claim qualifies for recognition on the basis of the list. For a number of years, 5-10 hours a week,
the welding instructor was exposed to welding and cutting fumes containing nickel as well as
chromium, both of which can cause cancer of the sinuses. There is good correlation between the
disease and the exposure and the latency period of 10-25 years from the exposure till the onset of the
disease.
In order for the disease cancer of the urinary bladder to be recognised on the basis of item K.5.2 of the
list, a medical doctor must have made the diagnosis of cancer of the urinary bladder (neoplasma
malignum vesicae urinariae ICD-10, C67). The concept of cancer of the bladder comprises a broad
spectrum of bladder tumours, ranging from benign polyps (which are not really a cancer) to malignant
cancer tumours.
The cells of the mucous membrane may begin to grow uncontrollably and form a polyp. If the cells
grow into the connective tissue layer under the mucous membrane and further into the bladder muscle,
then it is an actual cancer tumour.
In order for cancer of the bladder to be recognised on the basis of the list, a medical doctor must have
made the diagnosis of a malignant form of cancer of the urinary bladder (malignant tumour) or a
precursor of a malignant form of cancer of the bladder.
Exposure requirements
In order for cancer of the bladder to be recognised on the basis of item K.5.2 of the list, there must have
been one or more of the following exposures
Substances:
(a) 2-Napthylamine
(b) 4-Aminobiphenyl
(c) 4-Chloro-ortho-toluidine and its strong (hydrochloride) salts
(d) 4-4'-Methylene bus chloroaniline (MOCA)
(e) Arsenic and arsenic compounds
(f) Benzidine and benzidine-based dyes
(g) Ortho-toluidine
(h) Coal-tar and coal-tar pitch
(i) Diesel exhaust fumes
Processes:
(j) Aluminium production
(k) Auramine production
(l) Hairdresser work in men
(m) Coal gasification
(n) Rubber industry
(o) Painter (occupational exposure as a)
(p) Magenta manufacture (fuchsine)
(q) Boot and shoe manufacture and repair
285
The exposures must in principle have been substantial for a number of years. This applies to all
exposures.
In Denmark work-related cancer of the urinary bladder is seen in particular within the following
occupational groups
Cancer of the bladder is 10 times as prevalent in the Western world as in Eastern Europe and Asia and
is the most prevalent in white males. In 2000 1,206 Danish men and 410 Danish women were
diagnosed with cancer of the bladder. Cancer of the bladder constitutes 7.9 per cent of all cancer cases
in men and 2.4 per cent in women. 52 men out of 100,000 are diagnosed with cancer of the bladder in
the course of one year. 14 out of 100,000 women get the same diagnosis.
With approximately 1,200 new cases per year among Danish males, cancer of the urinary bladder and
bladder papillomas (benign as well as malignant) are a relatively prevalent form of cancer. The various
forms are internationally combined in one group, cancer of the bladder, because there is progression
between benign bladder papillomas, which may in time become malignant, and malignant cancer
forms, and because all forms have the same causes. (Danish Cancer Society, www.cancer.dk)
Tobacco consumption
Smoking is very relevant for the development of cancer of the bladder and is known as one of the most
significant causes of the disease, even if the significance of tobacco consumption is relatively smaller
than for the development of lung cancer.
Compared with non-smokers, tobacco smoking increases 2-3 times the risk of developing cancer of the
bladder, and the risk increases with increasing consumption. A heavy smoker has a 5 times increased
risk compared to a non smoker. The amount of tobacco per day as well as the number of years the
person has been a smoker increase the risk.
As is the case for other forms of work-related cancer, substantial tobacco consumption will therefore be
included in the assessment of a claim regarding cancer of the bladder. Read more under 1.2.4.
Example 1: Recognition of cancer of the bladder after diesel exhaust fumes (mechanic)
A 60-year-old man had worked for more than 30 years as a mechanic in a garage. It was a relatively
large garage where they repaired 40-45 cars a day, and there were a lot of exhaust fumes from i.a.
diesel engines in the course of the day. Ventilation in the garage was poor. Immediately after cessation
of work the mechanic had blood in his urine and a hospital examination established cancer of the
286
bladder. The injured person had been a moderate smoker for a short while in his early youth, but had
not smoked later on.
The claim qualifies for recognition on the basis of the list. For a very large number of years, the
mechanic suffered a virtually daily exposure to diesel exhaust fumes in a garage. He was only a very
moderate smoker and only when he was quite young, and therefore there are no grounds for turning
down the claim on the basis of tobacco consumption or for making deductions in the compensation
because of tobacco smoking. There is good correlation between the disease and the exposure to diesel
exhaust fumes for many years.
Example 3: Recognition of cancer of the bladder after print dyes (aromatic amines, printing worker)
A 60-year-old man had worked as a repairman at a printers for more than 30 years. The major part of
the working day was spent repairing rotating machines, and every day he was covered in the print dyes
used in the business over the years. He was furthermore in close contact with organic solvents. The
print dyes contained aromatic amines in the form of 4-Aminobiphenyl, benzidine and 2-Naphthy-
lamine. Immediately after cessation of work he developed cancer of the bladder. It appeared from the
documents of the case that the repairman had had a daily tobacco consumption of 10 cigarettes for
more than 50 years. Thus the tobacco consumption was about 25 package years.
The claim qualifies for recognition on the basis of the list. The repairman for a number of years had
suffered considerable exposure to print dyes containing aromatic amines in the form of 2-Napthy-
lamine, 4-Aminobifenyl and benzidine, which are all on the list as relevant exposures for the
development of cancer of the bladder. There is good correlation between the disease and the exposures.
However, the decision on the compensation will make a deduction for the large tobacco consumption
amounting to substantially more than 10 package years.
Example 4: Claim turned down cancer of the bladder after pesticides (gardener)
A 60-year-old man had worked as a gardener for about 40 years. In this connection he had suffered
massive exposure to pesticides, having been in charge of spraying crops on more than 90 square
kilometres of land. Han i.a. sprayed for lice, mildew and vermin and i.a. used Lindan, DDT, Round Up,
Reglone, Gramazone and Maladon. Han sprayed from a tank truck and with a container mounted on his
back. He usually sprayed from May till September and approximately one day a month. He did not use
a mask or protective clothing until towards the end of the period. Several of the pesticides that the
injured person had used were known as possible carcinogens, but not in relation to cancer of the
bladder. At the age of 60 he was diagnosed with cancer of the bladder (transitio cellular carcinoma
grade 3 with muscular invasion).
287
The claim does not qualify for recognition on the basis of the list. The gardener did not suffer
exposures included on the list connected with the disease cancer of the bladder. Furthermore there are
no grounds for submitting the claim to the Occupational Diseases Committee with a view to any
recognition not based on the list, the mentioned pesticides, based on the current medical knowledge in
the field, not leading to any significantly increased risk of developing cancer of the bladder.
The concept of skin cancer on the list (item K.3) comprises all malignant forms of cancer related to the
skin, including also precursors of skin cancer.
Medically a distinction is made between several forms of skin cancer, the most frequent being
A known cause of melanoma cancer is ultraviolet radiation from the sun and sun beds. Excessive
periodic sunbathing and sun burns, in particular in childhood, increase the risk of developing the
288
disease, whereas constant exposure to solar radiation probably provides protection from melanoma
cancer. This is because the skin does not get the same degree of damage from the UV radiation. In
particular fair-skinned people and people with red hair are at risk. This is because they have less of the
pigment melanin, which is the natural protection of the skin against the harmful rays of the sun.
Exposure requirements
In order for skin cancer to be recognised on the basis of item K.3 of the list, one or more of the
following exposures must have been present
Substances:
(a) Arsenic and arsenic compounds
(b) Anthracene
(c) Creosote compounds
(d) Mineral oil, untreated and mildly treated
(e) Crude paraffin
(f) Shale-oil or lubricants extracted from shale
(g) Solar radiation
(h) Soot
(i) Coal-tar and coal-tar pitch
Processes:
(j) Coke production
(k) Coke gasification
(l) Petroleum refining
Usually there must have been substantial exposure to one or more of the above for a considerable
period of time.
The assessment of these claims takes into consideration whether there have been any private exposures
that are able to cause skin cancer. For the exposure to solar radiation in particular, it is the cumulative
exposure, in the event of basal cell carcinoma, squamous cell carcinoma and actinic keratosis, i.e. the
total amount of light throughout a whole life, which counts as the cause of the development of the
disease. In such cases it must seem likely that the exposure to sun (light) in the course of the working
day was in excess of the private exposure over time.
Therefore there must have been outdoor work which has resulted in a substantial, occupational
exposure to the sun. An additional occupational UV radiation dose of about 40 per cent (in relation to
indoor work) is sufficient to cause cancer. The duration of the outdoor work (the exposure to
occupational solar radiation) usually must amount to 40 per cent more than what a person would
usually experience in the course of a whole life.
289
The following factors, among others, are included in the assessment of the claims:
- The injured persons age
- The number of years with occupational exposure to the sun
- The proportion of occupational solar exposure during a day at work
In Denmark the exposure must have occurred during the summer period (6 months) as there is no
substantial solar radiation in Denmark during the 6 months of winter. Window glass protects from solar
radiation to such an extent that indoor work, including work in hothouses etc., is not connected with the
development of skin cancer.
The assessment of the occupational exposure to solar radiation may begin with the table below.
However, to the information in the table should be added concrete information about special
circumstances of the solar exposure, such as exposure with reflection from water or in thin air, such
factors being significant for the assessment of the dose.
Exposure to UV radiation (dose) is stated in SED units (a measure of the redness of the skin with a
given dose). Average Danes outside the labour market receive 168 SED units per year. When working
indoors, the dose is reduced to 132 SED units per year, whereas for outdoor work it is increased to 264
SED units per year.4
(Number of exposure years x 132 SED5) / (age x 132 SED6) x 100 = extra UV radiation from
outdoor work as a percentage
Years Age
of 30 35 40 45 50 55 60 65 70 75 80
outdoor
work
5 17 14 13 11 10 9 8 8 7 7 6
10 33 29 25 22 20 18 17 15 14 13 13
15 50 43 38 33 30 27 25 23 21 20 19
20 57 50 44 40 36 33 31 28 27 25
25 63 56 50 45 42 38 36 33 31
30 67 60 55 50 46 43 40 38
35 70 64 58 54 50 47 44
40 73 67 62 57 54 50
The orange entries show a sufficiently increased prevalence of occupational exposure to UV radiation
in relation to private exposure in order for the stresses to be covered by the list requirements.
There are special requirements with regard to melanoma cancer. This is because long-term exposure to
solar radiation, seen in isolation, does not constitute any special risk of developing melanoma cancer.
4
In fig. 6 of the review A Scientific Review Addressing Occupational Skin Cancer, the SED in connection with outdoor
work is described as 224 SED. According to the note on fig. 6, this figure is too low, as it should rather be doubled or
tripled. Therefore, the assessment of the exposure to sun light is based on the doubled figure, consistent with 264 SED.
5
132 SED is the increased number of SED units per year to which a person is exposed when working outdoors in Denmark,
in relation to indoor work.
6
132 SED is the average exposure for a Dane working indoors.
290
The risk of melanoma increases if the exposure to UV radiation is intermittent (periodic) or results in
sun burns.
Exposure to intermittent UV radiation or sun burns will usually occur as a private exposure throughout
a persons life. Private exposure to UV radiation therefore needs to be clarified in such cases.
Similarly, special jobs with a risk of intermittent solar radiation and sun burns can be related to the
development of melanoma cancer. However, in order for the disease melanoma cancer to be recognised
on the basis of the list of occupational diseases, there need to have been repeated occupational
exposures to solar radiation, accompanied by sun burns. There must have been sun burns with red,
painful skin, perhaps with symptoms which are similar to a first degree burn. The number of sun burns
depends on a concrete assessment of the claims. Furthermore the assessment of the claims will take
into consideration whether there has been constant occupational exposure to the sun as this probably
has a protective effect with regard to sun burns, whereas intermittent solar radiation increases the risk
of burns and melanoma cancer.
Some of the exposures on the list may cause all of the mentioned forms of skin cancer. This applies, for
instance, to ultraviolet light (solar radiation). Other exposures are in some cases specifically related to
one of the above forms of skin cancer, but not to the other forms.
The latency period for the various exposures also varies. The latency period is the time that passes,
from the exposure occurs, until the onset of the disease. The risk of developing skin cancer increases
with the total exposure to UV radiation from birth up to the current age.
The Boards medical consultant specialised in dermatology will participate in the processing of the
case, making a medical assessment, based on the medical documentation in the field, of the stated
diagnosis and the possible causalities between the specific form of cancer and the stated exposures.
Claims regarding skin cancer not included on the list will in some cases, after submission to the
Occupational Diseases Committee, qualify for recognition without application of the list.
Concrete cases of for instance occupational exposure to artificial radiation, such as welding and glass
blowing, may be submitted to the Occupational Diseases Committee with a view to an assessment of
whether the disease was caused, solely or mainly, by the special nature of the work.
Tobacco consumption
Generally there is no good documentation that tobacco smoking is a significant risk factor for the
development of skin cancer.
Example 1: Recognition of skin cancer (basal cell carcinoma) after arsenic (chemical production)
A 60-year-old man had for 32 years worked as a repairman in a large chemical manufacturing
company. For a 10-year period, halfway through the employment, he suffered substantial exposure to
peroral contact with dust containing arsenic. About 10 years after the arsenic exposure he developed
recurring outbreaks of skin cancer on large parts of his body. These were regularly removed by a skin
specialist. The skin cancer was of the basal cell carcinoma type.
291
The claim qualifies for recognition on the basis of the list. The repairman, during the performance of
his work, suffered substantial contact with arsenic-containing dust for a prolonged period of time and
subsequently developed skin cancer of the basal cell carcinoma type. The disease as well as the
exposure are covered by the list, and there is good causal correlation and a relevant latency time of 10-
20 years from the exposure till the onset of the disease.
Example 2: Recognition of skin cancer on penis after work on drilling rig (engineer)
A 50-year-old man worked for 15 years as a repairman and turbine engineer on drilling rigs. In the
workplace he was exposed to moderate to large quantities of crude oil from the extraction, refined oils
from the machinery and soot from turbines and burners. The work involved a great deal of soiling of
skin and clothes all over the body, including contact with chemical compounds in the form of
polycyclic aromatic hydrocarbons (PAHs), which are known to be very carcinogenic. The work
furthermore was associated with poor hygiene. Towards the end of the period the engineer developed
skin cancer in the form of a squamous cell carcinoma under the foreskin of his penis.
The claim qualifies for recognition on the basis of the list. The engineer had been in close contact with
various types of oil and chemical compounds while working on a drilling rig, taking part in oil
production and processing consistent with the exposure process of petroleum refining on the list. There
is good correlation between the development of skin cancer on the penis and the continued soiling of
clothes and skin with various oil products. It is also likely hat his penis was exposed to soot and oil
residues with PAH compounds when urinating. There is furthermore a latency period of up to 15 years
from the beginning of the exposure till the onset of the disease.
The claim qualifies for recognition on the basis of the list. The gardener developed skin cancer in the
form of basal cell carcinoma at the back of his neck after many years of considerable exposure to solar
(ultra violet) radiation in the affected region. There is good correlation between the disease, the
exposure, and a latency period of up to 15 years from the beginning of the exposure till the onset of the
disease.
More information:
A Scientific Review Addressing Occupational Skin Cancer (www.ask.dk)
292
Chapter 10. Skin diseases
List of contents
1. Skin diseases
1.1. Items on the list (Group G and Group I, items 9 and 5.1)
1.2. General information
1.2. Diagnosis requirements
1.2.1. Allergic irritative eczema
1.2.2. Contact eczema
1.3. Exposure requirements
1.4. Employer liable to take out insurance
1.5. Examples of pre-existing and competitive diseases/factors
1.5.1. Pre-existing and competitive diseases
1.5.2. Competitive diseases
1.6. Processing claims not on the list
1.7. Examples of decisions based on the list
1.8. Medical glossary (skin diseases)
1.9. Literature
293
1. Skin diseases
Introduction
1.1. Items on the list (Group G and Group I, items 9 and 5.1)
The following skin diseases are included on the list of occupational diseases:
Group G, items 1 and 2
Disease Exposure
G.2. Other irritative skin diseases One or more irritants or physical factors
(for instance toxic eczema)
Group I, item 9
Disease Exposure
Disease Exposure
I.5.1. Allergic eczema Chromium and some chromium compounds (for instance in
the metal and dye industries)
294
Furthermore skin cancer is included under Group K, item 3, of the list. See Chapter 9.
The above items pertain to various forms of contact eczema as well as contact urticarial (nettle rash):
These diseases qualify for recognition as work-related diseases when both the general and the special
requirements under each item are met.
For allergic contact eczemas, the diagnostic criteria for allergic contact eczema have to be met, the
occupational exposure to the allergen in question must be documented/seem likely, and the
occupational exposure must be estimated as exceeding the private exposure.
Similarly, for irritative contact eczemas the diagnostic criteria for irritative contact eczema must be
met, the occupational exposure to irritants must be documented/seem likely, and the occupational
exposure must be estimated to be in excess of the private exposure.
The same applies to contact urticaria as applies to allergic and irritative contact eczema. These diseases
are recognized under Group G, item 1 (allergic contact urticaria) and item 2 (non-allergic contact
urticaria).
Allergy
Contact allergy is caused by skin contact to chemical substances which are able to penetrate the skin
and affect the immune system of the epidermis.
This process activates some special cells (T-lymphocytes), which become capable of recognising the
substance in question, and these cells are spread in the immune system of the whole body. In the event
of renewed exposure to the same allergen (provocation), the activated cells wander up into the skin and
trigger an eczema reaction. This type of allergy is called type-4 allergy.
295
Thus allergic contact eczema can break out only if the person in question has previously been exposed
to the allergen. How long it takes from the first exposure to the onset of the allergy depends on a
number of factors, i.a. how potent is the allergen and how intensive the exposure. It is not unusual to
have been exposed to an allergen for months or years before the allergy breaks out and becomes
symptomatic.
Allergic contact urticaria (contact nettle rash) appears when, in connection with previous exposure,
specific antibodies to the substance in question have been formed. These antibodies are present in the
blood stream, and the allergic reaction releases histamines. The allergy in connection with allergic
contact urticaria is called type-1 allergy, and the allergic reaction releases symptoms such as nettle
rash, asthma, diarrhoea and shock.
296
For both types of allergy the condition is chronic. This does not mean, however, that you have
symptoms. The symptoms are only released when you get in touch with the allergen in question. Thus
there is a difference between having a contact allergy and having contact eczema. Having a contact
allergy means that, when you are exposed to the allergen in question, you may develop eczema. Having
a contact eczema means that you currently have symptoms.
Irritation
Irritative contact eczema is triggered when skin-irritant substances break down the surface of the skin.
This breakdown leads to a complex series of cell reactions provoking eczema. Irritative contact eczema
is triggered by repeated exposure to one or several skin irritants. The reaction usually develops
gradually and does not, as is the case for allergy, imply any specific recognition in the immune system
of the substance. The symptom of irritative contact eczema is an eczema which cannot be clinically
distinguished from allergic contact eczema.
For non-allergic contact urticaria the reaction is triggered by a local, direct impact of the substance in
question on the skin, which releases histamines. The symptom is nettle rash.
Background
Contact eczema is a frequent disorder which sets in as a consequence of contact to allergens or skin
irritants in the environment. Irritative contact eczema is more frequent than allergic eczema, whereas
297
contact urticaria is considerably rarer. Hand eczema appears in one year in approx. 10 per cent of the
population and is in most cases due to contact eczema. Skin disease is the second most frequently
reported, and the most frequently recognised, work-related disorder in Denmark (2012), and contact
eczemas constitute approx. 95 per cent. Contact eczema often affects young persons, and for more than
half the onset of the disease is between 18 and 35 years of age. The disease affects women more
frequently than men.
Diagnostic criteria
The clinical findings in connection with allergic and irritative contact eczema cannot with certainty be
distinguished from each other and will therefore be described under one heading.
Contact eczema is an intensely itching skin disorder. In the acute phase redness, swelling, papules
(small wheals) and vesicles (small blisters) are seen, and the skin changes may weep. In the chronic
phase a thickening of the skin (lichenisation) is seen, together with peeling and cracks.
For contact urticaria, itching, redness and swelling develop within few minutes after the exposure.
Work-related contact eczemas are frequently localised to the hands, but also to the feet, arms, legs, and
face. The eczema can spread, and in rare cases other skin areas may be involved in the disease. Work-
related contact eczemas and work-related contact urticaria exist when the diagnostic criteria are met,
the occupational exposure is documented, and the exposure requirements are met.
Allergy testing
Type-4 allergy
Reactivity time: 2-3 days
If one or more tests trigger an eczema reaction, it is called a positive reaction. This means that the
tested person is allergic to the substance in question. Then it is up to the medical specialist to decide if
the positive reaction is relevant in relation to the reported eczema disorder.
298
If an irritant reaction to a substance has been found in the test, this does not mean that the tested person
has an irritative eczema, but only that the test has caused skin irritation. This is because, for instance,
the concentration of the substance has been too high in the test and has no correlation with irritative
(toxic) eczema.
Type-1 allergy
Reactivity time: minutes
The list is not exhaustive and it is important to be aware of other causes of allergic contact eczema.
299
Frequent causes of work-related irritative contact eczema are
soaps
organic solvents
oils and cooling lubricants
foods
gloves
The list is not exhaustive so it is important to be aware of other causes of irritative contact eczema.
The list is not exhaustive so it is important to be aware of other causes of contact urticaria.
Allergic eczema qualifies for recognition under Group I, item 5.1, after occupational exposure to
chromium and certain chromium compounds.
Furthermore allergic eczema qualifies for recognition under Group I, item 9, after occupational
exposure to nickel and certain nickel compounds.
Finally allergic eczema qualifies for recognition under Group G, item 1, when the skin disease was
caused by substances in the workplace which are not mentioned elsewhere and the hypersensitivity to
the substance has been established.
The toxic (irritative) eczemas qualify for recognition under Group G, item 2, when the skin disorder
was caused by substances or exposures not mentioned elsewhere and there is an established correlation
between the onset and continued existence of the disease and the presence of one or more irritative
substances or physical factors in the working environment.
300
the workplace (e.g. nickel in a tool), or through information on product composition. The occupational
exposure must be deemed to be in excess of the exposure the person gets in his private life.
Contact eczema caused by rubber additives in persons who have not previously had symptoms of this
and are occupationally exposed to rubber products (e.g. gloves), and whose occupational exposure is
estimated to be in excess of the private exposure, can be recognised as work-related.
The frequent use of gloves may have an irritant impact on the skin, which then causes the development
of irritative contact eczema, but use of rubber gloves may also lead to the development of allergic
contact eczema towards rubber additives, see above.
Furthermore, use of rubber gloves may lead to the development of allergic contact urticaria towards
latex.
301
Thus diagnosing of glove allergy comprises epicutaneous testing (patch tests) as well as a prick test
and/or blood test for specific IgE for latex.
Glove eczema Patch test with rubber Prick test with latex IgE over for latex
additives* RAST test for latex
Irritative
Allergic +
Urticarial** + +
* thiuram, mercapto, carbamate
** One positive test is sufficient
Contact eczema caused by nickel allergy in persons who have not previously had symptoms of nickel
allergy and are occupationally exposed to nickel, and whose occupational exposure is estimated to be in
excess of the private exposure, can be recognised as work-related under item I.9. In this case the nickel
sensitisation as such leads to an increase in the compensation. The nickel content of metal objects can
be examined by means of a nickel analysis kit (the dimethylglyoxim test).
Approximately 10 per cent of women and 1 per cent of men in Denmark have nickel allergy, and the
most common cause of nickel allergy is due to perforation of the ears (piercing) in connection with
wearing earrings. In cases where the acquired nickel allergy was caused by perforation of the earlobes,
for example, the allergy towards nickel is not work-related. Persons with a private nickel allergy are
usually aware of the allergy, either because of eczema of the earlobes due to nickel-containing earrings
or because of eczema after contact with other bright metal objects. They may also have been diagnosed
in connection with previous allergy tests by a dermatologist.
302
Nickel allergy will be able to develop in the workplace, either due to persistent or short-term, but
repeated contact with nickel salts or metal objects releasing nickel. The exposure to nickel must usually
have lasted for months to years in order for nickel allergy to develop, but a briefer, extensive exposure
may also qualify for recognition after a concrete assessment.
Exposure to nickel may for instance be found in the electronics industry, in metal work, and in
handling of tools, keys, and coins. The exposure must be documented or likely.
As it is not the onset of a new occupational allergy, an aggravation of a private nickel allergy does not
qualify for recognition under I.9 or G.1. Instead the aggravation needs to be recognized under G.2 if the
exposure has been relevant. The reason is that an aggravation of a privately induced nickel allergy is
regarded as an irritative eczema, the allergy already being present, and the aggravated eczema is caused
by work-related contact with nickel.
It will typically be exposure for months or years to chromium and some chromium compounds. For
instance in the metal and dye industry, in connection with concrete work or when using chrome-tanned
products, including leather goods, gloves and shoes, as well as metal. The exposure needs to be
documented or seem very likely.
303
If it is a question of toxic as well as allergic eczema, two claims have to be registered. This is because
there are two different diagnoses and two different items on the list. The same applies where for
instance it is a newly developed work-related nickel allergy and a work-related toxic eczema.
Thus the employer liable to take out insurance is the undertaking where the injured person last suffered
harmful exposures which are deemed to have caused the disease in question. This does not apply,
however, if there is documentation that the disease was caused by work in another undertaking.
If it is not possible to point out a liable employer with some certainty, the case is referred to special
category.
In certain situations, in connection with recognition of work-related contact eczema, it can be difficult
to determine who is the employer liable to take out insurance.
However, if there are several employers, it is the employer where the person was employed in
connection with the onset of the disease who is the employer liable to take out insurance. It is a
condition, however, that the person in question had an outbreak of eczema since the onset and that it is
not possible to provide documentation that the eczema was caused by work in another undertaking.
However, if the person in question was eczema free for 6 months or more, it is the employer where the
person was employed when the eczema broke out again who in principle is the employer liable to take
out protection, provided, however, that there we no long-lasting, eczema-free periods later on.
As a main rule, the allergy is deemed to have developed with the employer where the person was
employed when the allergy was established, provided, however, that the person in question was
exposed to the allergenic substance(s) used by the employer in question.
However, if the person in question has been subject to intense exposure to the same substance(s) with a
previous employer, the previous employer can be pointed out as the employer liable to take out
protection.
Therefore, in each concrete case, the National Board of Industrial Injuries will assess if any stated
competitive/pre-existing factors are of a nature and extent which may give grounds for making a
deduction in the compensation in case the claim is recognized.
Atopia
Atopia is a common name for the diseases atopic eczema, hay fever, and allergic asthma. These three
diseases are closely related since there is a common mode of inheritance and since the presence of one
disease makes a person disposed for the development of one of the two others. In relation to contact
eczema, only atopic eczema is seen as a pre-existing disorder, and a genetic predisposition for atopic
disorders cannot be regarded as a pre-existing disorder.
Atopic eczema
Atopic eczema is also called infantile eczema or asthma eczema. The symptoms are eczema localised at
the flexor skin folds (elbows, knees, ankles, and wrists) and appear in particular in children, the
frequency of the disease today being about 15 per cent. About 70 per cent, however, outgrow the
disease before reaching adult age.
All who have or have had atopic eczema are at an increased risk of developing toxic contact eczema of
their hands, irrespective of occupation, and major surveys show that about 25-50 per cent of persons
with previous or current atopic eczema will develop hand eczema.
If the general and special conditions are met, but there is at the same time a pre-existing, current or
previous atopic eczema which contributes to the reported disorder, this may give grounds for making a
deduction in the compensation if the claim is recognized.
If the general and special conditions are met and only short-term, passing and slight atopic eczema
changes in childhood are described, there are in principle no grounds for making a deduction.
Psoriasis
305
Psoriasis is a skin disease appearing in 2 per cent of the population. In persons suffering from psoriasis,
an influence on the hand, for example friction, may trigger psoriasis elements on exposed skin,
typically on the hands. Besides, hand psoriasis may be difficult to distinguish from chronic eczema
change. Psoriasis cannot be recognised as an occupational disease on the basis of the list.
If, due to documented occupational exposure, there has been an aggravation of pre-existing psoriasis,
there will be an assessment, in each specific case, of whether the reported skin disease qualifies for
recognition or a deduction from the compensation has to be made. It will then be recognized as under
G.2.
Allergies
Pre-existing allergies may have an effect on the current eczema, but not necessarily so. The situation is
handled as in cases of nickel allergy.
The weighting of the reservation takes into account the localisation of the eczema before and after the
industrial injury. The weighting is always based on a concrete assessment.
The diseases under Group I, items 5 and 9, and Group G, items 1 and 2, are mentioned in the guiding
permanent-injury rating list of the National Board of Industrial Injuries (Arbejdsskadestyrelsen). It is a
normal table, which means that the Board in principle makes a decision consistent with the rating stated
in the list for the injury in question.
If the disease is recognized and there are competitive/pre-existing diseases, this will in certain cases
affect the permanent injury rating. This means that the pre-existing or competitive disease in certain
cases gives rise to a reduction in the overall permanent-injury rating.
It should be noted that a separate permanent injury rating is given for work-related allergy to frequently
occurring allergens.
Contact eczema claims are rarely submitted to the Occupational Diseases Committee as these diseases
often qualify for recognition on the basis of the items of the list of occupational diseases.
306
Example of allergic eczema chromium (I.5.1)
A 50-year-old man with previously healthy skin was employed in a tannery where he primarily worked
with chromium tanning of wet hide. He wore protective gloves, but had not been able to stop tanning
liquid from running into the gloves. After 6 years employment he developed eczema on hands and
forearms. The eczema got better at the beginning of holidays, but gradually increased and resulted in
sick leave and cessation of work later on because of the eczema. Allergy tests (patch tests) showed
allergy to chromate. The claim was recognized on the basis of item I.5.1 (chromium) of the list.
Example of allergic eczema and irritative contact eczema (G.1 and G.2)
A 36-year-old woman, a qualified cook, developed hand eczema. At first the hand eczema was only
periodically present, but gradually became persistent. The eczema got better in work-free period, but
did not recede. After some years with hand eczema, it became worse when she handled prawns. She
had previously had healthy skin. Allergy tests (patch tests) were negative, but the prick test for shellfish
was positive. The claim was recognized on the basis of item G.2. of the list (foods) as well as item G.1.
(shellfish).
308
1.9. Literature
Kanervas occupational dermatology. eds.: Rustemeyer, Th., Elsner, P., John, S.M., Maibach, H.I.
(Eds.) 2. ed. 2012. Springer
Information about allergy and eczema can be found here: www.videncenterforallergi.dk.
309