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Objectively and quantitatively testing workmen under te danger of falling hazards for disequilibrium by means of standing and s | ASN
Archives for Sensology and Neurootology in Science and Practice
Prof. Dr. Claus F. Claussen, Neurootological Research Institute of te Research Society for Smell, Taste, Hearing and Equilibrium Disorders at Bad Kissingen (4-G-F). Bad Kissingen, Germany.
Dr. med. Julia M. Bergmann,
Dr. med. Guillermo O. Bertora,
Te editors welcome authors to submit articles for publications in te ASN.
Read te Information for Authors.
Objectively and quantitatively testing workmen under te danger of falling hazards for disequilibrium by means of standing and s
Prof.Dr.med. Claus F. Claussen (Bad Kissingen, Germany)
XXXI Congress of te NES - Bad Kissingen - Germany
More than 20 years back in occupational medicine we were confronted, that only 2% of te officially accepted occupational hazards are falling accidents. However, 20% of all te fatal occupational hazards, recorded in te Federal Republic of Germany, were occupational falling accidents. Te severity of te trauma in te falling accidents has forced te West German Labour Control Authorities (Berufsgenossenschaften) to working out a special preventive decrete (Unfallverhütungsvorschrift G-41 “Arbeiten mit Absturzgefahr”) for selecting special risks by a preventive measure. There cranio-corpo-graphy was introduced as an objective and quantitative equilibrium test with an instant test recording of te vestibular spinal performance, delivering a radar image like chart. This test chart objectively and quantitatively could be used for formulating objections against employments of labourers suffering from dysbalance.
Te concept of cranio-corpo-graphy takes into consideration that vestibular spinal equilibrium control is aiming at te stabilisation of te erect body position and te stabile head and gaze position on top of te body.
In 1968 cranio-corpo-graphy was designed as a none electronic, simple office procedure for vestibular spinal tests recording head and body movements. Te light tracing of te head and shoulder movements were transformed through an instant camera into photographs, which looked like images of te head and shoulders, floating through te space. This set of tests especially was developed for te West German Berufsgenossenschaften (Labour Security Surveillance Boards) as a field test for occupational medical purposes, combining a stepping test (Unterberger,1938, Fukuda, 1959) with a standing test (Romberg, 1848). In 1983 it was officially introduced into occupational medicine in West Germany through te decrete G-41 of te West German Labour Security Surveillance Boards (Berufsgenossenschaften).
Recently we have further developed a system for marking te shoulders and te head instead of with light marks now with ultrasound markers together with a computer system, creating a local positioning system. This new system is called “Ultrasound computer cranio-corpo-graphy (US-CCG)”:
US-CCG has a great advantage in that it is working digitally. In a computer based databank, which can simultaneously be read out, it is possible to construct te single traces of both te shoulder markers and both te head markers separately and interrelate te movements between te head and shoulder recordings. It also allows us virtually to reconstruct trajectories of head and neck movements in a spatio-temporal, as well as in 3-dimensional mode, by our most recent special software development of “HUMAN SPACE TRAIL CLAUSSEN (HUSPATRAC®)”.
In Germany much research related to occupational illnesses is performed since te 2nd half of te 19th century. Nowadays it is conducted under te auspices of te German Berufsgenossenschaften (Labour security Surveillance Boards). Guidelines and decretes have been passed from these institutions together with te West German Ministry for Occupation with respect to te prevention of various types of labour risks, accidents and hazards. Te act G-41 “Arbeiten mit Absturzgefahr” (Hazards due to falling accidents) is regulating te preventive screening investigation for disequilibrium amongst German workers. Due to te decrete G-41 te expertise of specialists in te field of occupational health is also needed with respect to equilibriometry.
Being member of te council for formulating Act G-41, we could contribute our ideas about our neurootological history scheme NODEC and about te specially built up objective and quantitative photo-optical cranio-corpo-graphy (CCG). Te latter was invented especially for te purposes of occupational medicine by Claussen in 1968.
Act G-41 follows te administrative structure of all similar decretes for preventing occupational hazards. Firstly te limited field of application and access from spedific professionals is defined. It generally mentions all te professions, where a professional may be in danger of falling due to his work.
Point 2 covers various dates about investigation. In workers, who fit into this category of G-41, investigations are performed prior to te employment in an endangered profession. Regularly during performing his profession after defined time intervals, investigations are compulsory. After retirement or after changing his profession into a non hazardous occupation, there need not to be any more follow-ups.
During te first investigation a broad history scheme is applied with questions for background diseases of te cardio vascular, te metabolic, te neurological, te psychiatric and other types of disorders. A special questionnaire, related to our system NODEC, investigates for vertigo, nausea and other neurootological complaints.
Special physical investigations deal with equilibriometry, mainly based on head and body instability. For testing for dysbalances, te Romberg standing test and te Unterberger/Fukuda stepping test are introduced into te scheme and should be recorded objectively and quantitatively by means of te cranio-corpo-graphy (CCG) until now on a voluntary level.
Besides vision and hearing are controlled. Also te cardio-vascular function is investigated by electrocardiography at rest and under strain, for instance by means of an ergometer with an impact up to 120 Watt during 5 minutes.
Furthermore metabolic investigations, like glucose tests, blood analysis, including gamma-GT are applied. Besides also psychiatric tests may be added.
Occupational medical criteria for evaluating te neurootological investigation with respect to Act G41:
Te investigation is evaluated with respect to te classification health risk versus no health risk.
Te grouping is: where a health risk is stated as such and then a subdivision is performed: other groups are introduced, namely permanent health risks, or limited health risks.
As te CCG comes with a yardstick of normal ranges, they can be used for formulating abilities:
Persons exhibiting a lateral sway from 20cm or a lateral deviation of 80° towards te right or 70° towards te left in te stepping test cranio-corpo-graphy (step test CCG) must be excluded from professions with a risk of falling accidents. Te same holds for standing CCG sways above 12cm longitudinally or lateral sways above 10cm. Also patients suffering from chronic vertigo with severe objective findings in electronystagmography in te vestibular ocular or in te retino ocular tests are to be excluded.
However, te tests can be repeated for measuring whether or not habituation, adaptation or restitution has occurred after an imbalance.
Besides te criteria of imbalance or disequilibrium, other persons are excluded with te decretes of mobility or loss of strength in te arms or te legs.
Patients with severe cardio-vascular disorders, with a tendency to seizures of epileptic or other types, with severe diabetes mellitus, with thyroid toxicosis are also excluded.
Cases of severe loss of visual acuity, or major scotomas, as well as a disabling decrease in te hearing function is also excluding from hazardous occupations with a danger of falling.
Psychiatric diseases and mental debility, as well as alcohol abuse or other addictions also permanently exclude from these professions.
A time limited health risk is disequilibrium or other of te above mentioned diseases, which shows te tendency towards recovery and restitution.
For ending te phase of an objection of te type of a limited health risk, it must be warranted, that te worker is no more danger for himself or for others.
Included into te regular investigations according to te decrete G-41 are construction workers on high rising buildings, workers on antennas, high tension cables, bridges, towers, masts, chimneys, flood-lights etc. In these groups regular follow-ups are compulsory.
Labourers up to te age of 25 years are monitored every 36 months, between 25 and 50 years every 24 to 36 months and above te age of 50, every 12 to 15 months.
However, if te labourer has been ill for several weeks or if te occupational medical service of that special company has doubt about te health risk, earlier reinvestigations are possible. Also if te labourer himself wishes a reinvestigation, this has to be performed.
In te special Act G-41, dealing with workers with a danger of falling hazards, te preventive aspect of occupational medicine demands that te neurosensorial aspect especially has to be considered. Any severe imbalance or attack of disorientation due to vertigo of te peripheral vestibular type or due to vertigo of te central, or optokinetic or cervical mechanisms or due to an inborn vertigo of te height should be excluded. Te screening procedure, being described above, can be added by special neurootological investigations in centers with facilities for electronystagmography, electroencephalography, electrocardiography etc. Te screening scheme of Act G-41, being described above, is thought to be executed by any medical doctor, serving in occupational medicine. In Germany this mostly goes for employees of occupational medical centers.
Such centers, have been involved into this study revising te efficacy of Act G-41 after 20 years. Te centers which have performed our joint study are te BAD Hannover and te Construction Labour Surveillance Board (Bauberufsgenossenschaft) at Braunschweig, Germany. Now after 20 years of action with Act G-41 we also want to study if cranio-corpo-graphy has to be applied not on a voluntary but on a compulsory level within Act G-41.
Te stepping test of Unterberger and Fukuda is much more sensitive for imbalance and disequilibrium than te standing test of Romberg. This could also be proved, when looking into te files at two occupational medical centers at Hanover and at Braunschweig. Only in Hannover regularly cranio-corpo-graphy was applied. But there te decision was made, that te standing test CCG was left out and only te stepping test cranio-corpo-graphy was used for undermining te decisions of certifying ability or of objection to further employment. With te inspectory test evaluation of te standing test and of te stepping test in Braunschweig also much more importance was given to te stepping test than to te standing test, even though te two tests were only subjectively inspected by te physicians and then, according to their subjective judgement reported in te files and weighed for te judgement of objectionor non objection.
When applying cranio-corpo-graphy, cases with pathological results can be objectively classified and permanently excluded, whereas cases with a milder symptomatology then can also be classified and put into a scheme where they are controlled through a follow-up for differentiating whether or not they are at long lasting health risk, or whether they can be classified finally as no health risk.
As neurootologists we know, that we have seen many cases after minor or major falling accidents with head traumas. From this we can conclude, that there is an important demand for te prevention of these professional falling hazards.
On te other side labourers who feel that they are instabile at working positions in te height and who are personally not willing due to some sort of anxiety, vertigo of te height or psychogenic vertigo cannot be forced to work at high positions under te danger of falling hazards. They are directly excluded from te ability scheme.
As on te other hand labourers working at positions on elevated places are frequently receiving bonuses on their salaries. Then in Germany we have observed cases of dissimulation from workers for instance with labour in high positions, on antennas, high tension cablings etc. These labourers, even though being incapacitated for te work in high positions, were afraid of loosing their bonuses. Then they tried to override or dissimulate their vertigo. This vertigo then only first was objectively proved through te investigation of Act G-41 with te application of te stepping test cranio-corpo-graphy. Thereafter a second history frequently has clarified that te subjective complaints and background diseases were hidden by te employee.
In our own studies, which formally had been executed by some other members of our team, we have observed that correlations exist between cardio vascular disorders and metabolic disorders of severe diabetes mellitus on one hand and with pathological cranio-corpo-graphy patterns on te other hand.
Finally it must be mentioned, that patients suffering from a subjective and objective disequilibrium nowadays can undergo a systematic neurootological therapy which again is monitored by means of cranio-corpo-graphy. This first stage of equilibriometry can be added then by a differentiated set of electronystagmography with various vestibular ocular, retino ocular and complex equilibrium tests.
As we follow te project of cranio-corpo-graphy being introduced into occupational medicine in Act G-41 since 1968, which now is a time span of 36 years, we can now state, that cranio-corpo-graphy within te procedure described in Act G-41 is simple to be applied and to be performed. It can very practically be applied. It can be performed by any staff personnel at any occupational medical investigation unit. Te results, which are looking like radar images can be as well become interpreted by te medical doctor, as well as by te patient. It is an objective document about a functional ability, which can be copied and then being kept on te one hand in te files of te institution and on te other hand handed over to te patient for his own papers and probably also for showing it to his personal physicians.
During te last years we have developed a new technology for even easier quantitative and numerical read outs of te cranio-corpo-graphy by means of an ultrasound cranio-corpo-graphy with a charting system, where te 4 main parameters of te stepping test or te 2 main parameters of te standing test are directly and electronically measured. They appear on te printout of te chart by te end of te test already.
All in all we now see it to be necessary, that an objective and quantitative recording of te equilibriometric stepping test should become compulsory instead of voluntary for being executed within te Act G-41.
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