Arbejdsskadestyrelsen

Vejledning om erhvervssygdomme anmeldt fra 1. januar 2005

Februar 2015, 10. udgave

National Board of Industrial Injuries

February 2015, 10th edition

Guide to Occupational Diseases

Reported on or after 1st January 2005

1.1. General conditions

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
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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.

Diseases not included in this guide may be covered by a previous guide.

A list of previous guides that still apply to diseases reported on or after 1st January 2005 is stated
below.

1.2.1. List of contents of the guide

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

Appendix 1 Medical documentation

1.2.2. Diseases covered by this guide

Diseases not on the list (Chapter 1)
Noise-induced loss of hearing (Chapter 2)
Chronic low-back disease (Chapter 3)
Degenerative arthritis of both hip joints (Chapter 3)
Degenerative arthritis of the knee joint (Chapter 4)
Bursitis (Chapter 4)
Meniscus disease of the knee joint (Chapter 4)
Jumpers knee (Chapter 4)
Hand-arm vibration disorders (Chapter 5)
Chronic neck and shoulder pain (Chapter 6)
Diseases of hand and forearm (Chapter 6)
Carpal tunnel syndrome (Chapter 6)
Tennis and golfers elbow (Chapter 6)
Shoulder diseases (Chapter 6)
Pleural plaques (Chapter 7)
Chronic bronchitis COLD (Chapter 7)
Asthma (Chapter 7)
Lung disease with restricted lung function of the obstructive type (Chapter 7)
Pneumonia (Chapter 7)

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Posttraumatic stress disorder (Chapter 8)
Cancer diseases (Chapter 9)
Contact eczemas (Chapter 10)

See the end of this guide for appendices on medical documentation.

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)

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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

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1. General conditions

1.1. Legal basis

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.

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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

1. A biologically natural and logical explanation to the disease

2. An exposure whose nature and scope make the disease likely
3. A correlation between exposure and disease, e.g. increased exposure leading to increased disease
severity
4. Surveys of prevalences in the population that confirm a correlation
5. Convincing reporting of cases established in medical examinations
6. A considerable overfrequency of the disease in persons who suffer this exposure compared to
persons who are not exposed

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)

1.3.1. Recognition on the basis of the list of occupational diseases

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.

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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.

1.3.2. Pre-existing and competitive diseases/factors

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 it is a pre-existing or competitive disease or a competitive exposure that is the cause of the

development of the disease, then it has to be assessed, in each concrete case, whether it is the pre-
existing or competitive disease or the competitive exposure that is the most likely or the main cause of
the disease. (Section 5 of the Act, cf. section 7 and section 8(1))

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)

1.4. Diseases reported before 1st January 2005

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.

1.5. Delimitation between accident and occupational disease

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.

1.6. Gathering information

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.

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
2.3. Assessment of the exposure
2.4. Pre-existing and competitive conditions
2.5. Claims management by the National Board of Industrial Injuries (Arbejdsskadestyrelsen)
2.6. Examples of decisions not based on the list
2.7. The Occupational Diseases Committee
8
Introduction
This guide describes the handling of diseases that are not included on the list of occupational diseases,
but may possibly qualify for recognition, without application of the list, after submission of the claim to
the Occupational Diseases Committee.

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.

2.1. General conditions for recognition without applying the list

Recognition of diseases and exposures not included on the list of occupational diseases can only be
obtained after submission to the Occupational Diseases Committee. The Committee makes an
assessment of whether the disease, according to the most recent medical documentation, meets the
requirements for inclusion on the list, or whether it seems likely that it was caused solely or mainly by
the special nature of the work. (Section 7(1)(ii) of the Act)

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

1. General medical documentation

If there is general medical documentation of a correlation between the work-related exposure
and the development of the reported disease, the Committee may recommend recognition of a
specific claim. (Section 7(1)(ii) of the Act)

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:
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 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)

Our decisions usually follow the recommendation made by the Committee.

2.2. Assessment of the disease

2.2.1. Medical documentation of causalities

Just like the exposures leading to their development, diseases that are recognised without application of
the list, following a recommendation made by the Occupational Diseases Committee, can be very
different.
In principle, all forms of diseases and in several cases also syndromes (symptom complexes) can be
recognised as occupational diseases as a consequence of the special nature of the work. And a large
number of exposures can be regarded as particularly risky for the development of a given disease.

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.

2.2.2. Diagnosis and pathological picture

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.
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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.

2.2.3. Disease information

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 medical certificate must include the following:

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.

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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.

2.3. Assessment of the exposure

2.3.1. Gathering information and documentation

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.

We furthermore obtain a medical certificate from a specialist of occupational medicine or a similar

certificate. Such a document typically gives us a rather detailed work description (anamnesis), stating
all relevant work exposures in the course of the whole life of the injured person. Usually the
occupational medicine certificate also includes a list of the previous employers of the injured person
and the periods when the injured person worked for them.

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.

2.4. Pre-existing and competitive conditions

Some diseases may have other causes than work.

The symptoms may for instance have been caused by age or other illness, or they can be due to
exposures in the persons leisure time, including previous injuries. Then it is either a pre-existing
disease which was present before the occupational exposure or a competitive disease, which means
another disease than the reported disease which gives the same symptoms or has an effect on the
general disease condition.

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

The assessment made by the National Board of Industrial Injuries

The principles for submitting a claim to the Occupational Diseases Committee are as follows

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 assessment made by the National Social Appeals Board

Occasionally the National Social Appeals Board refers cases back to us with the request that we make a
new assessment of whether the case should be submitted to the Committee.

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.

2.5.2. Submitting the claim to the Committee

Before submission of a case to the Committee we gather the necessary medical information and make
an assessment of the same, including a medical assessment.

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.

2.6. Examples of decisions not based on the list

2.6.1. Hearing disorders

Example 1: Ear canal eczema and infection (diving work)

A man worked for more than 10 years as a diver in a harbour. When he was diving in a warm water
wetsuit, warm water entered the hood, which had a drying-out effect on his ear ducts. He subsequently
developed ear canal eczema and ear canal infection.
The Committee found that the ear canal eczema and infection had mainly been caused by working as a
diver, due to continued exposure to warm water in the ear canals.

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.

2.6.2. Diseases of neck, neck/shoulder, back and hip

Neck and neck/shoulder

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.

Example 4: Recognition of chronic low-back pain (awkward working postures)

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 5: Recognition of chronic low-back pain (slaughterer handling livestock)

A 49-year-old man had worked as a slaughterhouse worker for 24 years. The first couple of years the
work consisted in packing meat. The daily lifting load was 8-10 tonnes, and there were single lifts of 30
kilos. The next 22 years he worked with killing livestock. He led livestock about 30-35 metres from a
stable to the killing place. Many of them were hard to handle, and the work of taking them to the killing
place led to knocking about, hard pulls, falls and actual flying through the air. Once the animal had
arrived at the killing place, the slaughterhouse worker tied it to a hook and shot it. Then he had to
position a chain on the animals legs, in order for it to be lifted by a crane. However, many of the
animals fell down in such a way that he had to drag/pull them up to 1 metre to get to the chains. He
managed to kill up to 150 livestock per day, and each animal weighed 300-400 kilos. When pulling
about half of the animals to the chains at the killing place, he handled a total of about 20 tonnes per
day. Towards the end of the period he developed chronic low-back pain, and x-rays showed
degeneration of the lumbar spine (commencing degenerative arthritis).
The Committee found that the chronic low-back disease had been caused mainly by the work. They
took into consideration that the work had involved special loads on the back when he struggled with
livestock outside the stable and furthermore very heavy handling of dead animals at the killing place.

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)

Osteoarthritis in the hip and knee (www.ask.dk)

2.6.3. Diseases of hand, arm and shoulder

Hand and forearm

Example 1: Recognition of Dupuytrens contracture (vibrating hand tools)

A semi-skilled worker for 24 years worked with different types of heavily vibrating hand tools for
about one third of the working day. Towards the end of the employment he developed, in his right
hand, Dupuytrens disease (contracture of the fingers caused by damage to the tendon plate of the
hollow of the hand).

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.

Example 4: Recognition of blocked artery at wrist (direct pressure impact)

For several periods of time, the last time for 6 months, a machine operator worked at a machine
plotting texts in foil for advertising signs etc. The work consisted in taking rolls of foil and mounting
them on a spool. Then the foil was pulled out and fixed to a machine roll. Once the machine had plotted
the text, the foil was rolled back up on the roll again. This was done by activating a button by means of
the left wrist for 10-12 seconds at a time. According to the examination made by the Occupational
Health Service, the button had to be activated 100-150 times per day in connection with changing the
rolls. She developed symptoms of carpal tunnel syndrome in her left hand/forearm. It was not possible,
however, to establish this disease in neurophysiological examinations. But there were medical signs of
blocking of an artery in her wrist.

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.

Example 7: Recognition of tendovaginitis of the wrist (violinist)

A 49-year-old man developed tendovaginitis of his right hand with pain and swelling. He had worked
as a professional violinist for 34 years, including 22 years as an employee of the Royal Theatre. He had
up to 210 services/concerts a year and furthermore had to be available when other musicians were ill or
absent. During the seasons, which typically were autumn, winter and spring, he had rehearsals in the
morning and concerts at night. He had one weekly day off. The effective playing time was not allowed
to exceed 6.5 hours a day, and he had to rest for 4.5 hours between rehearsals and concerts. During the
concerts there were fewer and shorter breaks. He played first violin, and there was a violin in most
performances. He typically played 50 minutes an hour and not less than 30 minutes. While playing, he
led the bow with this right hand and handled the strings with his left. The bow was fixated with his
right thumb and long finger, whereas the right index and little fingers were used to balance the bow.
The pressure on the strings was the same, no matter where on the bow the string was activated. He led

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.

Example 4: Recognition of left-side tennis elbow (radiation nurse)

The injured person developed left-side elbow complaints in 2006. He was diagnosed with a left-side
tennis elbow. The injured person worked in hospital wards from 1999 till 2006, first as an operation
nurse and from 2005 as a radiation nurse. The injured person had to support patients when they were
about to lie down on the radiation bed and had to adjust the position of the patient, which required
some exertion. Furthermore the injured person had to handle and adjust various types of apparatus.

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 7: Claim turned down golfers elbow (slicer in a slaughterhouse)

A 44-year-old woman worked in a slaughterhouse for 9 years. For one third of the working day, her
work consisting in placing various kinds of meat units in a slicing machine. In the course of 5 minutes
she sliced three whole pieces of meat weighing between 5 and 15 kilos. The ham was the heaviest, and
half of the production was sliced ham. She lifted the goods with both hands, arms stretched, from a
holder into the slicing machine, which was positioned at chest height. Once the slicing machine had
been filled up, it was started, and the meat was cut. For the remaining two thirds of the working day she
put the sliced meat into a plastic wrapping. The slices were moved onto a sub film and were positioned
away from the edges and made to look nice and presentable. The sliced meat weighed about 150 grams,
and a plastic tray was filled up about 20 times per minute. Towards the end of the period she developed
pain in her left arm and was diagnosed with a left-side golfers elbow.
The Committee found that the described work in the slaughterhouse had not, mainly or solely, caused
the left-side golfers elbow. The Committee took into consideration that the work for the major part
(two thirds) of the working day was characterised by movements that were not stressful for the elbow,
without strenuousness or other exposures that substantially increase the risk of developing a golfers
elbow. Furthermore, the exposures for one third of the working day were not so stressful for the left
arm that they might be seen as the cause of the disease.

Example 8: Claim turned down tennis elbow (piano player/repetitor)

A 48-year-old woman worked for well over 12 years as a piano player and repetitor at the Royal
Theatre. She played in the orchestra as well as the Ballet School. She rehearsed during the day and
played in connection with performances at night, and the average playing time per day was typically 4-
6 hours. There were great variations, however. Some days she played for up to 10-11 hours, but never
for less than 4 hours a day. Towards the end of the period she developed pain in her right arm, and a
medical specialist diagnosed her with right-side tennis elbow.
The Committee found that the right-side tennis elbow had not been caused, mainly or solely, by the
work as a professional piano player. The Committee took into consideration that the work of playing
the piano was repetitive for the hands, but could not be seen as strenuous or awkward for the right
elbow or in other ways particularly risky for the development of a right-side tennis elbow.

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.

Upper arm and shoulder

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)

2.6.4. Diseases of foot, knee and leg

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.

Example 2: Recognition of hamstring syndrome (professional/intensive football)

A young man worked as a professional footballer for 6 years. The work involved a lot of hard physical
training, many times a week. After well over 5 years he suddenly, without any external cause, had pain
high up at the back of his right thigh. He was subsequently operated for a hamstring syndrome in his
right leg.

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.

Example 3: Recognition of overuse syndrome of ankle/foot (ballet dancer for 14 years)

A woman worked for 14 years as a professional ballet dancer with the Royal Ballet. The work involved
considerable pressure on feet, ankles and legs due to frequent training and many performances. She
developed pain and swelling around her left ankle, and a medical specialist diagnosed her with
tendovaginitis at the flexion tendons of the left foot as well as overuse of tendons between the talus and
calcaneus of her left foot.

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)

2.6.5. Diseases of lungs, respiratory passages and mucous membranes

Example 1: Recognition of lacking sense of smell (chemical smell samples)

A man worked as a chemical engineer for 30 years. He carried out smell analyses by using his sense of
smell. Through the years he had sniffed at a large number of various substances, such as propionic acid,
sulphur dioxide, butanol and organic solvents, trimethyl and dimethylamine, and acids and nitrous
gases. For a period of 25 years he handled these smell samples 2-3 times a week on average, with a
total duration of about 1 hour. After 22 years he experienced the symptoms of an onsetting reduced
sense of smell. A medical specialist diagnosed him with lack of sense of smell (anosmia).
The Committee found that the loss of sense of smell had been caused mainly by many years of
exposure to various substances in connection with smell tests. The Committee took into consideration
that for 25 years, several times a week, he had sniffed at samples containing various substances,
including organic solvents, acids and nitrous gases. The medical literature furthermore indicates that in
special cases there may be a correlation between strong-smelling substances and anosmia (loss of sense
of smell).

Example 2: Recognition of chronic rhinitis (print dye and particle pollution)

A man worked for about 20 years for a daily newspaper. He worked at a printing machine which did
not have any exhaust system. He developed symptoms in the form of reduced sense of smell and taste
as well as swollen mucous membranes in the nose. A medical specialist diagnosed him with chronic
rhinitis (allergic inflammation of the mucous membranes of the nose/hay fever), but not actual allergy.
The Committee found that the chronic rhinitis mainly was a consequence of the considerable particle
pollution/print dye dust to which the printer had been exposed in the workplace for many years.

Example 3: Recognition of asthma (acrylate compounds)

A woman worked for 3 years as an operator in a medical product company. She worked in the latex
department with the production of uridoms. She dipped uridoms in a silicon fluid and placed them on
replicas and took them off again. The last year she worked with uridoms made of plastic granulate.
Here she used a new type of adhesive containing acrylate compounds. She took part in stirring the
glues in a container. The glues were then squirted into the uridoms, which were run through ovens and
rolled by hand. When doing this type of work she was exposed to glue vapours. In one particular
incident acrylate adhesive was squirted all over her face, and afterwards she developed increasing
sneezing fits and coughing. Later she developed a productive cough and breathing problems, and a
medical specialist diagnosed her with asthma.

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.

Example 6: Recognition of asthma welder with exposure to welding smoke)

A 33-year-old man worked for 2 years in a steel factory. His work consisted in welding steel
constructions for the building sector and he worked in a big hall together with about 12 welders. There
was no exhaust system and only one ventilator, which did not work. The welding was CO2 welding in
black steel, and there was severe heat generation and smoke the smoke was often so dense that they
could not see from one end of the hall to another. The Working Environment Authority had inspected
the factory and found problems with the exhaust system. There was respiratory protection equipment
available, but filtrating respiratory protection was not sufficiently effective in connection with welding.
It also appeared, however, that on the day of the inspection there were only four welders present in the
hall and not 12. After one year the welder began to develop an increasingly dry, irritated cough and
wheezing. He had some allergy tests made, and these showed hypersensitivity to birch pollen, grass
pollen and dust mites. He was later diagnosed with asthma bronchiale professionalis.

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)

2.6.6. Diseases of other organs

Example 1: Recognition of benign bladder polyp/bladder papilloma (dyes, printing work)

A man worked for well over 30 years as a printer for a newspaper. His primary task was to look after
the printing works that produced coloured prints. He i.a. filled up print dyes and cleaned the machine
with paraffin oil. The work also involved contact with solvents. For well over 20 years the work was
done at a high pressure machine which gave off a lot of dye dust to the surroundings. He was diagnosed
with a growth at the left side of his bladder, and a detailed cystoscopic examination showed that there
was a bladder tumour without ingrowth, a benign bladder polyp (bladder papilloma).
The Committee found that the benign bladder polyp had developed mainly as a result of the work as a
printer for many years. The Committee took into consideration that surveys show an increased risk of
developing a bladder polyp in connection with printing work, due to contact with dyes.

2.6.7. Cancer diseases

Example 1: Recognition of lymphatic cancer (non-Hodgkin lymphoma) (herbicides etc.)

A man worked for well over 20 years as an agricultural technician in connection with research and
experimental work. 95 per cent of the time he worked with weed-killers and 5 per cent of the time he
worked with growth regulation agents. For 3 months every spring he tested new agents every day. For
3-4 months every autumn he made tests about 2-3 times a week. In this connection he mixed 2-30
substances with water every day and occasionally was in direct contact with the substances. After 20
years he noticed that he had swollen lymph nodes. He was later diagnosed with lymphatic cancer (non-
Hodgkin lymphoma). The Committee found that the lymphatic cancer, in the form of non-Hodgkin
lymphoma, had been caused mainly by the work with herbicides. The Committee took into
consideration that there is a medico-scientific suspicion of a correlation between non-Hodgkin
lymphoma and herbicides, that the exposure was substantial and had stretched over many years, and
that the onset of the disease occurred when he was relatively young.

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 3: Recognition of oral cavity cancer (glasshouse)

A man worked for 20 years as a glassblower in a large glasshouse. The work involved exposure to
excessive heat in connection with blowing of glass (hot glass steam), contact with glass dust and
iron/metal dust as well as contact, for much of the period, with asbestos and manganese. He developed
a cancer tumour in the oral cavity, starting from the tongue, and was given radiation therapy with a
positive result. It appeared that he was a never smoker.
The Committee found that the oral cavity cancer had been caused mainly by the work as a glassblower
for many years. Medical knowledge points to a correlation between the exposures from glassblowing
and the development of the disease in question, and furthermore he was a non-smoker.

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.

About breast cancer in general

With about 4,000 new cases each year, breast cancer in women is the most rapidly increasing cancer
disease in Denmark. Among women the disease constitutes almost 25 per cent of all cancer cases, not
including general skin cancer. The risk of cancer in women has been on a steady increase since the
Cancer Registry was established in 1943, the age-adjusted prevalence today being twice as high as in
the 1940s. Part of the prevalence seems to be the result of a carcinogenic effect of the female hormone
estrogen, which a woman generates in her body. Accordingly, the risk of breast cancer is significantly
reduced when the strength or duration of estrogen in a womans body is reduced, for instance in case of
a late first menstrual bleeding or an early menopause. The risk is also reduced as a consequence of one
or more pregnancies, in particular if the first pregnancy occurred at an early age. The use of sex
hormones (contraceptive pills and medication for menopausal symptoms) implies an increased risk of
breast cancer, as is also the case for natural estrogen. However, the negative effect of estrogen
medication ceases already a few years after cessation of the treatment. Furthermore a daily, moderate to
large consumption of alcohol has been linked with an increased risk of breast cancer, and a small
number of cases in the population were caused by exposure to ionising radiation (x-rays and gamma
rays). However, only a minor part of the increase in breast cancer since the 1940s can be explained by
changes in the known risk factors over time. The major part of the increase was caused by factors
which have been inadequately mapped or are unknown. One of these factors is regular and long-lasting
night work, which now is suspected of being able to increase the risk of breast cancer. Finally there is
evidence that about 5 per cent of the breast cancer cases in the Danish population are caused by
40
hereditary factors, in particular certain congenital mutations of two genes known as BRCA1 and
BRCA2. Tobacco smoking does not seem to increase the risk of breast cancer.

Night-shift work with interruptions in the circadian rhythm

In the course of the past 10 years surveys have indicated that work during the dark hours can be a risk
factor for breast cancer in women. Researchers have found that the increased risk might have been
caused by the sleep hormone melatonin, which possibly offers protection against the development of
cancer. Melatonin is generated during the night, when you are asleep, in a gland in the brain. The
secretion of this hormone is restricted or interrupted if you are awake and are somewhere with artificial
lighting.

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 5: Recognition of skin cancer (auxiliary nurse exposed to x-rays)

A 65-year-old auxiliary nurse had worked with x-rays for more than 30 years in a hospital. More than
half the time she was in the examination room and nearly every day she helped fixate patients on the
plinth during the x-ray process. She wore a lead apron, but her hands were always unprotected during
x-raying. A couple of years after she had ceased doing this work she developed skin cancer of the
squamous cell carcinoma type on the 3rd and 4th finger of her right hand. She later had both of her
fingers amputated. Subsequently there was localised spreading of the tumour to other fingers and one
heel as well as to her cervix and possibly her lungs. An expert assessment made by a consultant and
head of research with the Danish Cancer Society found it to be likely beyond reasonable doubt that the
skin cancer had been caused by the many years of exposure to a large dose of x-rays.
The Committee found that the skin cancer on her right-hand fingers had developed mainly as a
consequence of the work. This was because there was substantial daily exposure for many years to x-
rays, which considerably increases the risk of developing skin cancer. The Committee also took into
account that the disease primarily developed on her hands, which were unprotected during the x-raying.
According to practice in this field, the other cancers will be able to be regarded as a consequence of the
recognised skin cancer (the primary cancer) to the extent that there is documentation that the other
41
cancers were caused by the recognised skin cancer (i.e. were secondary cancer forms via spreading of
cells). Therefore they may be included in the Boards calculation of compensation.

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)

2.6.8. Mental illness

Example 1: Recognition of stress response (social and healthcare helper)

A woman worked for a number of years as a social and healthcare helper in a nursing-home facility.
She was accused of stealing from one of the residents, and the case was reported to the police. After
about a week the objects were found in the residents possession and the theft charges were dropped.
She felt mentally unwell in connection with the accusations and a medical specialist diagnosed her with
an acute stress response.
The Committee found that the acute stress response had been caused mainly by the accusation and
suspicion to which she had been exposed in the workplace. The Committee took into consideration that
it must be regarded as mentally stressful to be accused of theft and suspected by colleagues, residents
and relatives. The Committee in particular took into consideration that the matter had been reported to
the police and that the charges were later dropped.

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.

Example 5: Recognition of depression (accusations of theft, reported to police, dismissal)

A nurse worked in the care of the elderly and was accused several times of stealing from various
clients. In two instances she was reported to the police, but the police subsequently dropped the
charges. In a later instance she was called in for an official interview and was suspended and
subsequently dismissed. No formal charges had been made. She developed symptoms of a mental stress
response and a medical specialist subsequently diagnosed her with depression (depressive single
episode of a moderate degree).
The Committee found that the nurse had developed a depression mainly as a consequence of her work.
The Committee took into consideration that she had been accused of stealing several times, and that the
police in the reported cases had dropped the charges made against her. The last time she had been
dismissed without any formal charges being made. The Committee found that the accusations had been
of a mentally very stressful nature, which constituted a special risk of developing a depression.

Example 6: Recognition of depression (prison guard exposed to sexual harassment)

In connection with her work as a prison guard in a large state prison, a woman was continuously, for 2
years, exposed to sexual harassment from a colleague. At the beginning the harassment consisted of
remarks of a sexual nature, and later the colleague began to touch the woman in various places on her
body. It developed into sexual advances and physical offences once or twice a week. The female prison
guard was increasingly affected by the incidents. She became miserable and nervous, tended to cry
more, experienced concentration problems, and became slightly stressed and found it difficult to sleep.
A specialised psychiatrist made the diagnosis of depression. The employer confirmed that the colleague
in question had been reported, and three other colleagues had also reported the person in question for
sexual offences.

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)
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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 15: Claim turned down periodic depression (vicar)

In the course of a number of years, a 50-year-old vicar developed increasing symptoms of depression
of a periodic (recurrent) nature. The vicar had worked in a small town for more than 10 years, and there
had been several disagreements between residents and the local church council. In addition the vicar
had some stressful tasks like helping in connection with funerals after severe deaths, etc. Among other
things there had been disagreement as to how to conduct the service, and protesters ran for the church
council election due to changes in the physical surroundings of the vicarage. This led to serious
cooperation problems with the church council. All complaints were turned down by the bishop,
however, who also had several talks with the vicar in connection with the current of complaints from
the local church council.
The Committee found that the periodic depression had not developed, mainly or solely, as a
consequence of the mental stresses as a vicar. The reason was that the exposures described, such as the
work of supporting relatives in connection with severe deaths and the poor cooperation with the church
council and others, including repeated complaints and criticism, could not be deemed to be sufficiently
mentally stressful to substantially increase the risk of developing a depression.

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)

2.6.9. Other diseases

Example 1: Recognition of toxic brain injury (manganese and solvents)

A man worked for over 20 years at a steel rolling mill (Stlvalsevrket). The work consisted in
painting production numbers with a diluted paint. He was bending over the warm plates while painting
and inhaled vapours from the process. Furthermore he removed numbers with a lacquer remover and
torch-cut plates. In this connection he was exposed to dust containing manganese. The first 10 years he
worked without a mask. The last 4-5 years his work consisted in adding manganese to steel. Even
though he used a mask, he was massively exposed to dust which penetrated his mask. Towards the end
of the period he developed headaches, fatigue, forgetfulness and concentration problems, and a
neuropsychological examination showed a moderate to severe reduction in intellectual function,
probably because of a toxic brain injury.
The Committee found that the toxic brain injury had been caused mainly by working with solvents and
manganese for a number of years. Studies point to an increased risk of developing toxic brain injury
after exposure to such substances. Furthermore, there was no aggravation of the condition after
cessation of work, which might have indicated other causes of the disease.

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 4: Recognition of acute blindness (consultant on development projects)

A 38-year-old man worked for a year for an engineering company in Ethiopia as a consultant on
development projects. He was employed to evaluate and supervise a development project in a province
where he was exposed to bad sanitation and primitive food production with lack of hygiene, and he
frequently visited local health clinics where infections occurred. Furthermore the area was known for
an increased risk of developing eye diseases, including cases of acute blindness. He had several
instances of worms and amoebic infections and towards the end of his stay developed increasing vision
complaints, which in very quickly developed into blindness in both eyes.
The Committee found that the consultant had become blind mainly as a consequence of working on the
development project in Ethiopia, where he had been exposed to bad sanitation and poor food hygiene
and had been in close contact with persons with infections and viruses that increased the risk of eye
diseases and blindness.

Example 5: Recognition of chronic hepatitis C (auxiliary nurse exposed to patients blood)

A 56-year-old female auxiliary nurse experienced increasing problems with diffuse joint and muscle
pain and was tested positive for hepatitis C antibody. It appeared from the examinations that she had
never been a drug addict, been a blood donor or received blood transfusions, and she had not been
tattooed or pierced. She had worked for many years as an auxiliary nurse in a maternity ward in a
hospital and for 6-12 months before the onset of the disease she had worked in a midwife centre. In the
maternity ward she had assisted at deliveries and gynaecological examinations. During the deliveries it
was sometimes impossible to avoid contact with blood and amniotic fluid, and she furthermore did
some cleaning and took blood samples from placentas and umbilical cords after the deliveries. She used
syringes and needles, which involved a risk of contact with blood, including stains in her eyes. Her
employer confirmed that she had had several syringe injuries and furthermore that there had been an
50
incident when she was spattered with blood on her face and eyes. It was not possible, however, to
determine when these incidents occurred, and it was not clear if she had been infected with hepatitis C
on one of these occasions. It was not possible to recognise the case on the basis of the list of
occupational diseases, there being no specific source of infection.
The Committee found that the auxiliary nurses hepatitis C had been contracted mainly as a
consequence of her work of assisting at deliveries where she had been in contact, several times, with
blood during the deliveries and furthermore had had syringe injuries.

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.

2.7. The Occupational Diseases Committee

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

Revisions of the list of occupational diseases (section 7(1)(i), 3rd sentence)

Decisions on claims reported to the National Board of Industrial Injuries under section 7(1)(ii)

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.

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Chapter 2. Hearing disorders
List of contents

1. Noise-induced loss of hearing (A.1)

1.1. Item on the list
1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (noise-induced loss of hearing)

53
1. Noise-induced loss of hearing (A.1)

1.1. Item on the list

1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (noise-induced loss of hearing)

1.1. Item on the list

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)

1.2. Diagnosis requirements

There must be a diagnosis of DLA professionalis (noise-induced loss of hearing, ICD-10 H83.3), made
by a medical doctor.

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.

Sound pressure is measured in decibel (dB), which is a logarithmic scale. An increase of 6 dB

constitutes a doubling of the sound pressure and an increase of 10 dB constitutes a tripling of the sound
pressure. Therefore, in order for the sound to be audible, a 10 dB deterioration in the hearing threshold
necessitates a tripling of the sound pressure.

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.

Aggravation after cessation of work

There also has to be a time correlation between the exposure and the disease. Noise-related injuries are
not aggravated after cessation of the exposure. This means that a work-related hearing loss must be
established within a short while after the cessation of the noise exposure. It does happen, however, that
the injured person only notices the hearing loss after cessation of the noise exposure, in connection
with substantially changed life conditions. If, after cessation of the noise exposure, several years pass
before the hearing loss is discovered, this would indicate that the hearing loss did not have any
correlation with the noise exposure in the workplace.

1.3. Exposure requirements

Severe noise is at least 85 dB as a median value for the working day.
The requirement to the duration of the noise exposure, in terms of years, depends on the energy
quantity affecting the inner ear. The energy quantity is measured in dB LAeq, which monitors the
median value of the fluctuating noise level to which a person is exposed for a given period of time. The
assessment of the noise exposure in the workplace applies dB LAeq for 8 hours a day. For a noise
55
exposure of 85 dB LAeq per day, an exposure period of at least 5 years is required in order to establish
that the noise would be able to result in a hearing loss.

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.

1.4. Pre-existing and competitive diseases/factors

Hearing loss can be caused by factors other than work.

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.

Competitive or pre-existing diseases usually appear from the audiogram.

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.

Examples of competitive diseases

Age graphs for unscreened male population

It should be noted that for men age alone gives an even, symmetrical, falling hearing threshold. For
example, at the age of 60, 1,000 Hz 8 dB, 2,000 Hz 15 dB, 4,000 Hz 28 dB.

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

DLA senilis or presbyacusis (age-related hearing loss)

Often it is only at the age of 65 that age-related hearing loss has an impact on the perception of speech.
Age-related hearing loss typically hits the highest treble area 6,000 to 8,000 Hz the most. The area
3,000-4,000 is hit a bit less frequently. As an effect of this, a noise-related dip can disappear with age-
related degeneration. At a higher age an overall assessment is needed as to whether there is a mixture
of age- and noise-related noise damage.

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 hereditaria (hereditary hearing loss)

The hearing loss can be congenital, or it develops later, and is hereditary. Many different audiograms
are seen for DLA hereditaria. U-shaped hearing curves with best hearing for the lowest and highest
frequencies, hearing curves with a steep fall towards the treble in the area 1,000 Hz-2,000 Hz, and
hearing curves with the poorest hearing in the bass region are some of the shapes seen.

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.

Otosclerosis (hearing loss as a consequence of bone disease in the ear)

In connection with otosclerosis a new bone is formed around the foot plate of the stapes. The bone can
spread to the cochlea, and then a bone conduction examination does not show normal audiogram
sequences. Otosclerosis typically leads to varying degrees of hearing loss in one or both ears.

1.5. Managing claims without applying the list

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.

1.6. Examples of decisions based on the list

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.

Example 2: Recognition of noise-induced loss of hearing (machine operator for 8 years)

A 56-year-old man had worked for a contractors business, in the period 1995-2003, as a machine
operator. He was exposed to noise from machines, pneumatic hammers and, in particular, drills. The
noise was extremely severe (>95 dB) for most of the working day.

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)

Example 3: Recognition of noise-induced loss of hearing (machine engineer for 5 years)

A 38-year-old machine engineer who, in the period from February 1995 to April 2000, had worked in a
machine shop, was exposed to severe to very severe noise (85 to 95 dB), throughout the working day,
from angle grinders, drilling machines, pneumatic hammers and similar equipment.

An audiologist had made an audiogram and made the diagnosis of DLA professionalis.

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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)

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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).

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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.

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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.

1.7. Medical glossary (noise-induced loss of hearing)

Latin/medical term English translation

Bone conduction Is used to establish if the hearing loss is located in the middle ear or in
the external ear. If bone conduction and air conduction are the same,
the injury is located in the inner ear. If there is deviation, there is a
different (competitive) cause. The difference indicates that sound is
unable to enter the ear. Is indicated as [ ] or < > in the audiogram
Cochlea Snail-shell inner ear structure
dB LAeq Measuring unit for the energy equivalent, A-weighted sound pressure
level in dB, which can be determined for any period of time

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

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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 senilis/presbyacusis Age-related hearing loss

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

Morbus Mnire Mnires disease. Symptom complex consisting of attacks of

dizziness, ringing in ears and hearing loss. Is caused by disease of the
labyrinth
Otosclerosis Hearing loss as a consequence of a bone disease in the ear
Recruitment Indicates that a person has a strong sense of sound, even if the hearing
threshold has not been exceeded very much. Means that a person will
perceive even a very small increase in sound pressure as a strong
perception of sound
Reflex thresholds Are measured at 500, 1,000, 2,000 and 4,000 Hz. The reflexes of the
middle ear are released , which is a normal reaction in the ear to
sudden, severe noises. High thresholds (i.e. a large number of decibels
are required/the arrows are further down in the audiogram) are
typically seen in connection with hearing loss not caused by noise or
age degeneration, but it is also to some extent the case for younger
persons. There are individual differences
Sequelae otitis media Hearing loss as a consequence of inflammation of the middle ear
Speech audiometry A hearing-loss assessment test, where the person listens to a number
of different words in a quiet as well as a noisy environment
SPL Sound pressure level
SRT Speech reception threshold
Tinnitus Ringing in ears
TTS Temporary threshold shift. Moderate hearing loss which quickly
disappears in the minutes/hours after severe noise exposure
Previously terms such as hearing disability and communicative disability have been used in score
conclusions in medical certificates. Today these terms are being replaced by the terms hearing ability
and communicative ability.

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Chapter 3. Back and hip diseases
List of contents

1. Chronic low-back disease (B.1)

1.1. Item on the list
1.2. Diagnosis requirements
1.3. Exposure requirements
1.3.1. Back-loading lifting work (B.1.(a))
1.3.2. Back-loading lifting work with extremely heavy lifts (B.1.(b))
1.3.3. Back-loading care work (B.1.(c))
1.3.4. Back-loading whole-body vibrations (B.1.(d))
1.3.5. General conditions for all exposures
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.6.1. Back-loading lifting work (B.1.(a))
1.6.2. Back-loading lifting work with extremely heavy lifts (B.1.(b))
1.6.3. Back-loading care work (B.1.(c))
1.6.4. Back-loading whole-body vibrations (B.1.(d))
1.7. Medical glossary (chronic low-back disease)
2. Degenerative arthritis of both hip joints (B.3)
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 (degenerative arthritis of both hip joints)

68
1. Chronic low-back disease (B.1)

1.1. Item on the list

1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (chronic low-back disease)

1.1. Item on the list

The following disease of the low back is included on the list of occupational diseases (group B, item 1):

Disease
B.1. Chronic low-back disease
with pain
(lumbago/sciatica, lumbar
prolapsed disc, degenerative low-
back disease)
Exposure
Back-loading lifting work involving lifting/upward
pulling of heavy objects and many tonnes of lifting per
day for a considerable number of years
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

1.2. Diagnosis requirements

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).

The diagnoses comprise the diseases

1. 1. Lumbago/sciatica
2. Lumbar prolapsed disc
3. Degeneration of the low back (osteochondrosis, spondylosis, spondyloarthrosis, spinal
stenosis)

Furthermore there must be daily or frequent pain.

69
The diagnosis is made against a medical background, combining the following information

The injured persons subjective complaints (symptoms)

A clinical, objective examination
Any supplementary x-ray examination, MR scan or CT scan

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

For a prolapsed disc perhaps radicular symptoms such as

Positive Lasgues test (radicular pain at raising of extended legs)
Muscular atrophy
Reduced strength
Sensory disturbances and neutralisation of reflexes

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.

1.3. Exposure requirements

1.3.1. Back-loading lifting work (B.1.(a))

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.

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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 duration of the lifting work and special load factors

In principle there must have been 8-10 years of more or less continuous work at the normal
employment rate for the trade in question.

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.

The daily lifting quantity and special load factors

In principle there needs to have been a daily lifting quantity of 8-10 tonnes. A daily lifting quantity of
8-10 tonnes every single day is not a requirement, however. The requirement is to be seen as an
indication of an average lifting quantity over a certain period of time (weeks).

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.

The weight of each lift and special load factors

The weight of each burden must in principle have been 50 kilos for men and 35 kilos for women.

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.

Awkward lifting postures are

Lifts above shoulder height
More than one lift per minute
71
 Lifts involving twisting of the low back
Lifts in a stooping posture or
Lifts at more than half arms length from the body

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.

Special conditions for lifting work in the fishing industry

As lifting work in fishing takes place under particularly stressful conditions, such as bad weather, work
on deck, long working hours, rare breaks and other stressful work functions like pulling of nets and
trawls in a stooping working posture, the requirements with regard to the total daily lifting quantity are
reduced. In principle there needs to have been a total daily lifting quantity of about 6 tonnes.

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.

1.3.2. Back-loading lifting work with extremely heavy lifts (B.1.(b))

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

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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.

The daily lifting quantity

It is furthermore a condition that the total daily lifting quantity, including the heavy single lifts and any
other lifting work, amounts to at least 3 tonnes.

The weight of each lift and special load factors

An extremely heavy single lift is in principle a lift of 100 kilos or more. The lift can be performed by
one or several persons. If several persons are performing the lift together, there is no mathematical
reduction of the weight of the burden as the load typically will not be evenly distributed.

The requirement to the weight of each lift can be reduced to:

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)

1.3.3. Back-loading care work (B.1.(c))

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

Daily stressful care work for at least 8-10 years and

Work with personal care of dependent adults or older handicapped children for a substantial
part of the working day and
At least 20 back-loading handlings of persons (lifts, handlings or transfers) every day

The duration of the care work

There must have been a minimum of 8-10 more or less consecutive years of exposure, with an
employment rate of at least 8 months of work per year.
The requirement of 8 months work per year can be met, for example, by working part time (two thirds
of full time) for a whole year, or working full time for 8 months and not working for 4 months. In the
healthcare sector it is normal to have 56 hours employment every two weeks, which is also regarded as
full time.

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.

Handling of persons and special load factors

A common characteristic of the patient-handling tasks that can be taken into consideration is that the
tasks must have implied an element of lifting, the employee lifting the full weight, or part of the
weight, of the patient/resident. There will typically be an element of lifting in connection with
transferring patients/residents between for example bed, chair, bedpan chair and wheelchair, or in
situations where the patient/resident needs to be changed or turned in bed or to be helped higher up in a
bed or chair. Or similarly, when a bedridden patient/resident needs help to get into a sitting position, or
from a sitting to a standing position.

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.

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The requirement with regard to the number of daily patient-handling tasks cannot be reduced to less
than 10, however.

1.3.4. Back-loading whole-body vibrations (B.1.(d))

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)

Exposure duration and special load factors

In principle there need to have been 8-10 years of daily exposure to whole-body vibrations.

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 time requirement cannot be reduced to less than 3-4 years.

The severity of the vibrations and special load factors

There must have been driving on an uneven surface with heavily vibrating vehicles, with the vibrations
coming through a seat (sitting posture). Vibration exposure in a standing posture usually is not
adequate to be covered by the list.

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.

Figure 1: Whole-body vibrations

The International Standardisation Organisation (ISO), against the background of surveys made, has set
out the correlation between exposure intensity for whole-body vibrations and the risk of health injuries
in general. The standard is called ISO 2631 and is shown in the figure below.

Areas of different health risks in connection with whole-body vibrations

Vibration acceleration in m/s2

Exposure time in hours

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.

The vibration intensity of different vehicles

Figure 2: Examples of vibration intensities for some types of moving work tools and means of
transport in operation
2
Over 1 m/s :

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 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

Documentation of whole-body vibrations

The indication of the vibration level is subject to substantial uncertainty as the character of the surface
and the speed of the vehicle in question are of great importance for the total whole-body vibrations in
the specific case.

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.

1.3.5. General conditions for all exposures

Daily load and main function

The above work and load factors included in the assessment need to have been the main function of the
person in question. This function must have constituted a substantial part of the working day, and in
principle there needs to have been a daily load (with the exception of fishing and healthcare work,
where there are special requirements).

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.

Several employments and combinations of loads

Whether to recognise or turn down a reported occupational disease depends on an overall assessment of
the exposures that the person in question has suffered.

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:

Substantial daily total of lifts

Extremely heavy single lifts
Special load conditions
Exposure to whole-body vibrations
Back-loading care work

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.

The time correlation

It is a prerequisite for recognition that there is a relevant time correlation between the disease and the
strain on the low back.

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.

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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.

1.4. Examples of pre-existing and competitive diseases/factors

Congenital anomalies:

Block vertebrae
Transition vertebrae:
Lumbosacral transition vertebrae (symmetric, asymmetric)

Early-developed back deformities:

Morbus Scheuermann (juvenile dorsal kyphosis/curving of the spine): Growth disturbance in the
vertebrae healing up with wedge-shaped vertebrae
- High-lying morbus Scheuermann (at the thoracic part)
- Low-lying morbus Scheuermann (at transition between thoracic back and low back)
Spondylolisthesis (vertebral slippage/subluxation): The most frequent spondylolistheses are
subluxation of the lowest vertebra, which is due to laxity of the arcus (arcolysis) and is
congenital, and degenerative spondylolisthesis, which is not congenital. The olisthesis
(slippage) is established with an increasing frequency from childhood
Scoliosis (sideward curving of the back): The condition is seen in congenital bone malformation
and muscular diseases and can be hereditary

Degenerative back diseases:

Spondylarthrosis, spondylosis, osteochondrosis ((degenerative)arthritis of the spine): Is diagnosed
by way of x-rays, but x-ray degeneration does not have to be symptomatic

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 Disc degeneration and prolapsed disc: Prolapsed disc can occur without provocation in patients
with disc degeneration or in connection with back traumas

Traumatic back injuries:

Fracture: Compression fracture of vertebrae
Distortion

Dystrophic bone joint diseases of the back:

Osteoporosis (diffuse atrophy of the bone mass), which can be due to disturbances of the calcium
metabolism and can be age-related (more frequent in women)
Osteomalacia (reduced calcium content of the bones), which is due to vitamin D deficiency

Inflammatory back diseases:

Morbus Bechterew (spondylarthritis ankylopoietica): Inflammatory back disease (similar to
rheumatoid arthritis), which is a genetic disease

1.5. Managing claims without applying the list

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

Iron binding in a stooping posture

In principle there must have been 8-10 years of work with iron binding in a stooping posture. This type
of work is characterised by being strenuous work in a stooping posture.

Work in a fixed working posture

There needs to have been a work function where, due to external circumstances, it was not possible to
change the working posture. This may be the case for welders working in bottom tanks of ships under
very cramped conditions, where welding occurs in a fixed and at times very awkward working posture.
The duration of this type of work must in principle have been about 8 years or more. In addition the
Committee has recognised a few claims where the injured persons had extremely stressful work
functions. One example was a tunnel digger lying on his stomach in a cramped tunnel and digging his
way forward.

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.

1.6. Examples of decisions based on the list

1.6.1. Back-loading lifting work (B.1.(a))

Example 1: Recognition of back pain after lifting of objects (bricklayers assistant for 10 years)
The injured person worked for 10 years as a bricklayers assistant and partly also as a scaffolding
worker. The work consisted in assisting 2-3 bricklayers. This involved many daily lifts of building
materials, scaffolding elements, etc. The lifts typically weighed 10 kilos or more and were performed in
back-loading working postures due to the working conditions on the various building sites. His total
daily exposure was about 8-9 tonnes. Towards the end of the period he developed severe low-back pain
and later had low-back surgery because of a prolapsed disc. Subsequently he suffered from continuous
daily pain.
The claim qualifies for recognition on the basis of the list. The bricklayers assistant for 10 years had
heavy, back-loading work amounting to 8-9 tonnes, with typical single lifts of 10 kilos or more. The
lifts were made in stooping working postures, with a twisted back and under other stressful circum-
stances. There is good correlation between the development of a prolapsed disc and the back-loading
work.

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.

1.6.2. Back-loading lifting work with extremely heavy lifts (B.1.(b))

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.

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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.

1.6.4. Back-loading whole-body vibrations (B.1.(d))

Example 21: Recognition of back pain after whole-body vibrations (concrete worker for 13 years)
The injured person worked as a concrete worker in a major entrepreneurial business for well over 13
years. For the major part of the working day (about 6 hours), his work mainly consisted in operating
different kinds of entrepreneurial machines in connection with excavation and planning etc. on building
sites. He i.a. operated bulldozers, excavators and large tractors, and the driving frequently happened on
a very uneven surface. According to the information of the case there typically was a load of about 1
m/s2. After 12 years work he developed increasing low-back pain, and a medical specialists
examination, in combination with an x-ray examination, established severe degenerative arthritis of the
lumbar spine.

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.

1.7. Medical glossary (chronic low-back disease)

Latin/medical term English translation

Arcus Vertebral curve
Columna recti Straight back, lack of normal spinal curvatures
Discus Vertebral disk
Discus degeneration Disease of the disk with reduced disk height
Dolores dorsi Back pain
Facet joint syndrome Pain consistent with one of the real joints between two lumbar
vertebrae
Kyphosis A curving of the spine causing a bowing of the back, which leads to a
hunchback or slouching posture
Lumbago Acute low-back pain, perhaps with restricted motion
Prolapsus disci Prolapse of the inner core of the discus through the external ring,
intervertebralis causing pressure on nerve

Radicular pain Radiating pain in a nerve supply area

Sciatica Disease of the hip, radiating pain at the back of the lower extremity
Scoliosis Sideward curve of the spine

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Spondylarthrosis, spondylosis, Degenerative arthritis of the spine
osteochondrosis vertebralis
Vertebra lumbalis Lumbar vertebra

2.Degenerative arthritis of both hip joints (B.3)

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

2.1. Item on the list

The following disease of the hips is included on the list of occupational diseases (group B, item 3):

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

2.2. Diagnosis requirements

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

relevant subjective complaints and

clinical, objective degeneration and
degenerative arthritis established in x-rays (perhaps also MR scans or CT scans)

All three of the above 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.

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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

Paraclinical examinations and findings

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.

2.3. Exposure requirements

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:

Hip-loading lifting work for at least 15 years

A total daily lifting quantity of at least 8 tonnes
Out of this lifting quantity, there need to have been generally occurring, heavy single lifts of at least
20 kilos, equivalent to a total of at least 1 tonne per week
The remaining lifts must also have been relevant with regard to load on the hips

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.

Examples of relevant, hip-loading factors that may be included in the assessment:

The weight of the lifted objects
The lifts are performed in awkward, hip-loading working postures, such as
o Lifts in stooping postures
o High lifts with stretched hips
o Lifts with turning and twisting movements of the hip joints
o Lifts at some distance from the body
o Lifts while walking
o Lifts while walking on stairs etc.

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.

The duration of the lifting work

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.

Number and weight of the heavy single lifts

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.

2.4. Examples of pre-existing and competitive diseases/factors

Congenital deformities of the hip joints:
o hip dysplasia
o Calv-Legg-Perthes disease
o pistol grip deformity
Idiopathic degenerative arthritis (degenerative arthritis with unknown cause)
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 Repeated micro-traumas with lesion of the hip socket, the labrum (cartilage ring), and/or the
lateral joint cartilage of the hip
Femora-acetabular impingement (impingement = squeezing, femur = thigh bone, acetabular =
hip socket) during flexion/inward rotation of the hip joint
2
Severe obesity (BMI above 30. Body Mass Index = kg/(m) )
Previous fractures to and/or into the hip joint
Bone death of the femoral head (caput necrosis)
Severe traumas against the hip joint
Great difference in length of legs (more than 3 cm)
Hormonally reduced calcium content (Bone Mineral Density/BMD) of the femoral head
Real arthritis (rheumatoid arthritis)
Secondary arthritis after infection of the hip joint
Secondary arthritis after infectious diseases and systemic diseases
Secondary arthritis following the ingestion of or treatment with medicine
Advanced age

2.5. Managing claims without applying the list

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.

2.6. Examples of decisions based on the list

Example 1: Recognition of bilateral degenerative hip arthritis (agricultural worker)
A 42-year-old (female) agricultural worker was diagnosed by a medical specialist with moderate
degenerative arthritis of both hip joints. The degenerative arthritis was also established in an x-ray
examination at two levels. No competitive diseases were found. The agricultural worker had worked on
various large farms for well over 22 years. The work had involved different types of heavy agricultural
work, including a lot of stable work in connection with looking after stock (cows and pigs), and heavy
physical work in the fields. 50 per cent of her work was performed in the fields and 50 per cent in the
stables. In connection with her work she lifted a considerable number of heavy sacks weighing 20-30
kilos. And the work in connection with mucking out with fork and wheelbarrow, as well as the
handling of milk cans, constituted heavy, physical work with many lifts. The work was often performed

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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.

Example 2: Recognition of bilateral degenerative hip arthritis (gardeners help)

A 52-year-old woman worked for 20 years as a gardeners help in a large plant production business.
The work had involved numerous 5-10-kilo single lifts, in the course of the working day, of 1-2 plants
at a time, and the daily lifting load was about 5-6 tonnes. The lifting conditions were typically awkward
and hip-loading with many lifts away from the body, with twisting and turning of the hip joints, and
with many stooping lifts. Besides, many times a day she lifted boxes of flowers/vegetables to and from
lorries. Each of these boxes weighed 30-35 kilos or more. The very heavy single lifts of at least 30
kilos amounted to about 1.5 tonnes per week out of the total load. Towards the end of the work period
she had increasing pain in the hip regions and after medical specialist and x-ray examinations she was
diagnosed with severe, bilateral degenerative arthritis of the hip joints.
The claim qualifies for recognition on the basis of the list. The gardeners help had a daily lifting load
of 5-6 tonnes for 20 years (more than 15 years) with single lifts of 5-10 kilos. The lifts were made in
working postures that were awkward for the hips, and there were many, very heavy single lifts of at
least 30 kilos, amounting to more than 1 tonne per week. Due to the long load period and the many,
very heavy single lifts of at least 30 kilos, there are grounds for reducing the requirement to the daily
lifting load from 8 tonnes to 5-6 tonnes. There is also good time correlation between the onset of the
disease and the work.

Example 3: Recognition of bilateral degenerative hip arthritis (drivers assistant)

In a medical specialist and x-ray examination, a 37-year-old drivers assistant was diagnosed with
slight to moderate, bilateral degenerative hip arthritis (arthrosis coxae primaria bilateralis). It appeared
that for 10 years, from a very young age, 15 to 16, he had heavy lifting work. First he worked for 8
years as a boy and drivers assistant in a feedstuff business. Every day he delivered grain, feedstuffs,
fertilisers, etc. to farmers. The goods were transported in sacks weighing 50-60 kilos, and he did the
loading as well as the unloading of sacks. Every day he delivered about 10 to 15 tonnes, which he lifted
twice. Thus, for 8 years, the daily lifting load was about 20-30 tonnes, with frequent, very heavy single
lifts of more than 40 kilos. After that he worked for 2 years as a driver in another business, delivering
paper and other school materials to educational institutions. The lorry was loaded with boxes of paper
and materials weighing 20-60 kilos. This was done by means of a forklift truck, whereas the unloading
on the customers premises was done manually, resulting in a daily lifting load of 10-12 tonnes. Out of
this load, there were daily, very heavy single lifts of more than 40 kilos. After 10 years he was trans-
ferred to less physically stressful drivers work. Here his daily lifting load amounted to 3-4 tonnes, with

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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 4: Recognition of bilateral degenerative hip arthritis (bricklayers assistant)

A 58-year-old bricklayers assistant had pain in the hip regions and was diagnosed by a medical
specialist with bilateral degenerative arthritis (arthrosis coxae primaria bilateralis). The diagnosis was
confirmed by x-ray and CT scans of the hip joints. The bricklayers assistant had worked for two or
three bricklayers for well over 25 years. His work involved lifting in connection with scaffolding work,
lifting of materials, and lifting of sacks and buckets of mortar and bricks. To this should be added the
daily use of wheelbarrows with heavy material. Each brick only weighed 3 kilos, but they were lifted in
bundles of eight, weighing a total of 24 kilos. The work typically involved single lifts between 15 and
30 kilos. Every day, furthermore, he had quite a few 40-kilo lifts, amounting to 1-2 tonnes per week.
The typical daily lifting quantity for a bricklayers assistant, based on general descriptions in the
bricklayer trade, is 8-9 tonnes, but this particular person lifted 6-9 tonnes, the heaviest loads occurring
in the first 5-10 years.
The claim qualifies for recognition on the basis of the list. The bricklayers assistant had hip-loading
work for much more than 15 years, with a daily load of 6-9 tonnes. The lifts generally were relevant
with regard to the load on the hips, due to the weight of the burdens, at least 15 kilos, and the lifting
postures, which typically were awkward. There were also many heavy single lifts of more than 20
kilos, amounting to more than 1 tonne per week. As the total exposure period was very long (more than
20 years) and the work furthermore involved a number of very heavy single lifts of more than 40 kilos,
the daily load requirement can be reduced, in this case, to a minimum of 6 tonnes. The daily work with
a heavily loaded wheelbarrow, which involved many heavy, partial lifts and starts, is also included as a
special load factor. Also, there is good time correlation between the heavy, hip-loading lifting work and
the onset of the disease after many years exposure.

Example 5: Recognition of bilateral degenerative arthritis (stone paving worker)

A 56-year-old man worked for a local authority for 28 years as a stone paving worker. About half the
working time he laid cobblestone drives, about one third of the time he laid highroad stone drives and
other drives, and the remaining part of the working time he laid pavements. The paving work i.a.
consisted in laying tiles, laying cobblestones, laying plaza areas, and doing repair work. Tiles and
stones weighed from 10-20 kilos up to 60-80 kilos and were typically laid manually. Kerbstones
weighed up to 100-200 kilos and were handled and lifted by two men at a time. The work was
performed in very hip-loading, stooping postures and also involved much twisting of the hip joints. The
total daily lifting load was 6-7 tonnes. There were many, very heavy single lifts of 40 kilos or more,
equivalent to several tonnes a week. About 18 years after commencing the work he had moderate
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symptoms with hip joint pain. However, he only saw a doctor several years later and was diagnosed
with moderate to severe degenerative arthritis of both hip joints. The diagnosis was confirmed by an x-
ray examination. The claim qualifies for recognition on the basis of the list. The paving worker had
heavy, hip-loading work for much more than 15 years and a daily lifting load of 6-7 tonnes. He had
very heavy, single lifts of more than 40 kilos, equivalent to much more than 1 tonne per week, and the
remaining lifts were also relevant with regard to the load on the hips, due to the weight and to awkward
lifting postures. As the load period was in excess of 20 years and there were many, very heavy, single
lifts of more than 40 kilos, there are grounds for reducing the daily lifting requirement from 8 tonnes to,
in this case, 6-7 tonnes. There is also good time correlation between the work and the onset of the
disease after 18 years.

Example 6: Recognition of bilateral degenerative arthritis (dray man/beer delivery man)

In x-ray examinations a 49-year-old man was diagnosed with severe degenerative arthritis of the right
hip joint and slight to moderate degenerative arthritis of the left hip joint. By the time he was
diagnosed, he had worked as a dray man/beer delivery man for 12 years. His work consisted in
delivering cases of beer and soda to shops, restaurants, pubs, etc. The last couple of years the lorry was
loaded with a pallet lifter without any manual lifts, but the dray man practically always had to deliver
manually the cases of beer and soda on the customers premises. The daily lifting load the first years
was in excess of 12 tonnes, and the last couple of years it was 8-10 tonnes. The single lifts weighed
between 17 kilos (one case of soda) and 45 kilos (two cases of beer lifted at the same time). To this
should be added some daily lifts of filled beer barrels of 30-40 kilos. Besides, the lifting conditions
were typically very awkward due to unpractical access on the customers premises, much walking on
stairs, much twisting and turning of the hip joints, and many high or stooping lifts. The claim qualifies
for recognition on the basis of the list. The dray man had relevant, hip-loading lifting work with a daily
lifting load of more than 12 tonnes for about 10 years and subsequently, for 2-3 years, 8-10 tonnes,
with typical single lifts of at least 17 kilos. Besides, he had many heavy single lifts of at least 20 kilos
(one case of beer weighs 22-23 kilos), equivalent to more than 1 tonne per week. Finally he had
several, very heavy, single lifts of at least 40 kilos (two cases of beer together), which were made under
particularly stressful lifting conditions. The many, very heavy, single lifts of more than 40 kilos and the
generally very unfavourable lifting conditions, in combination with a very large, daily lifting load of
(10-)12 tonnes, give grounds for reducing the load requirement from 15 years to, in this case, 12 years.

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
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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)

2.7. Medical glossary (degenerative arthritis of both hip joints)

Latin/medical term English translation
Acetabulum Hip socket
Arthritis Inflammatory degeneration of one or several joints
Arthritis rheumatoides Rheumatoid arthritis or real arthritis; a chronic, progressive joint

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 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.

The CT examination consists of a number of images generated and

stored in a computer. In this way cross-sections of tissue are made
which are much more detailed than ordinary x-rays. As the images are
digitalised, it is possible to create different windows where specific
bones or soft tissue can be viewed. Furthermore it is possible to cut
thin cross-sections of few centimetres across the scanned area.
It is also possible, in the axial and transverse planes of patients, to
look into anatomy and diseased degeneration in various selected areas.

The images can be stored and reformatted later on so that other

requests regarding the images can be met, including three-dimensional
images.

What it is possible to see

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 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.

What it is not possible to see

Small soft tissue and small organs, fine degeneration of tissue,
meniscus injuries

When are CT scans used

For example in connection with degeneration of bones, such as
fractures, joint luxation, arthritis of joints, injuries to the structure of
the brain, prolapsed discs, bleeding, and some tumours.

The National Board of Industrial Injuries is not allowed to directly

request this type of paraclinical examination (CT scan).

What CT scanning requires

CT scanning requires referral by a medical specialist or a hospital
Dysplasia coxae congenita Congenital hip dysplasia (dys = bad, plaxia = growth, coxae = hip joints,
congenita = congenital). Congenital degeneration of the hip joint with a flat
joint socket and forward turning of the femoral neck
Femora-acetabular impingement Impingement = squeezing, femur = thigh bone, acetabular = pertaining to the
hip socket
Femur Thigh bone
Gravis Severe/grave (stage)
Idiopathic Of unknown cause
Labrum Ring of fibrous cartilage around the edge of the articular (joint) surface of a
bone
Lateral On the outer side
Medial On the inner side
MR scan MR is short for Magnetic Resonance. When an MR scan is performed, a
giant magnet is applied, so there are no x-rays.
As it uses magnetism, the examination cannot be used, or is ill suited for,
areas where metal has been inserted (for example joint prostheses made of
metal). This is decided in each case by the x-ray department operating the
MR scanner. An MR scan brings tissue and tissue fluids into fluctuations by
means of magnetism, and the cells polarise.
At the examination patients in many cases need to lie still in an enclosed
small cylinder (torpedo) for at least the 20 to 30 minutes that the scan takes.
The outcome of an MR scan is a number of images which are generated and
stored in a computer. In this way it is possible to create cross-sections of
tissue that are much more detailed than ordinary x-rays and CT scans.

What it is possible to see

As the images are digitalised, it is possible to create different windows and
view a variety of anatomical details/pathological degeneration of bones,

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 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.

When are MR scans used

MR scans are often used as a supplement to clinical/paraclinical
examinations. For neuro diagnostics, however, they can constitute the
primary examination. Cranial bones and vertebrae are harder to see in an MR
scan than in a CT scan.

The National Board of Industrial Injuries is not allowed to request this type
of paraclinical examination (MR scan).

What MR scanning requires

Special referral by a hospital
Examination of the patient by a medical specialist
A precise and well-founded indication
Information of the patient before the examination
That the patient is not restless, upset or afraid
That the patient does not suffer from claustrophobia
That the patient does not have very broad shoulders
That the patient is not obese
That the patient is not a child (children often need sedation)
That the patient does not have metal (for example a pacemaker or splint
and nails in a bone) in the area to be scanned

If it is suggested in a medical specialists certificate that an MR scan should

be performed, the National Board of Industrial Injuries has to make a
decision on the following to questions:
Is it absolutely necessary to have an MR scan before the Board is able to
assess and decide the claim?
Who will refer the patient to MR scanning? It could be the specialist who
wrote the medical certificate, but not all medical specialists are employed in
hospitals and not all medical specialists are able to make such referrals
Who will deal with the further proceedings if the MR scan shows
degeneration that requires treatment?
Narrowed joint gap Reduced gap between the visible bone parts of a joint. This is seen as an
indication of a reduced cartilage height in the joint
Necrosis Bone death
Osteophyte along the edges of Irregular, newly formed bony tissue under the periosteum, as seen in
joints connection with chronic inflammatory conditions and arthritic degeneration
around a joint. Osteophytes are generally occurring, but are not a definite
sign of any arthrosis (arthritis); they can be secondary to other joint diseases
for instance they can have formed after traumas (posttraumatic).
In the later stages of the disease there is often destruction of the bone,

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 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

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Chapter 4. Diseases of the knee
List of contents

1. Degenerative arthritis of the knee joint (D.1)

1.1. Item on the list

1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (degenerative arthritis of the knee joint)
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)
3. Meniscus disease of the knee joint (D.3)
3.1. Item on the list
3.2. Diagnosis requirements
3.3. Exposure requirements
3.4. Examples of pre-existing and competitive diseases/factors
3.5. Managing claims without applying the list
3.6. Examples of decisions based on the list
3.7. Medical glossary (meniscus disease of the knee joint)
4. Jumpers knee (D.4)
4.1. Item on the list
4.2. Diagnosis requirements
4.3. Pre-existing and competitive diseases/factors
4.4. Exposure requirements
4.5. Managing claims without applying the list
4.6. Examples of decisions based on the list
4.7. Medical glossary (jumpers knee)

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1.Degenerative arthritis of the knee joint (D.1)

1.1. Item on the list

1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (degenerative arthritis of the knee joint)

1.1. Item on the list

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)

1.2. Diagnosis requirements

A medical doctor must have made the diagnosis of degenerative arthritis of one or both knee joints
(arthrosis genus, ICD-10 M17).

The diagnosis is made by a medical doctor against the background of a combination of

the injured persons subjective complaints (symptoms)
a clinical, objective examination
paraclinical examinations (x-rays, MR scans, CT scans)

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

This means that all of the above 4 requirements have to be met.

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
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 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

1.3. Exposure requirements

In order for degenerative arthritis of the knee joint to be covered by the item on the list, there must have
been kneeling and/or squatting work for many years.

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.

1.4. Examples of pre-existing and competitive diseases/factors

2
Severe obesity (BMI above 30. Body Mass Index = kg/(m) )
Previous knee trauma
Joint injuries
Cruciate ligament injuries
Meniscus injuries
Malalignment (for example knock knees)

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 Rheumatoid arthritis
Systemic diseases with secondary joint symptoms
Previous infection of the knee joint
Secondary joint symptoms to infectious diseases
Age
Gender

1.5. Managing claims without applying the list

Only degenerative arthritis of the knee joint is covered by this item on the list. Furthermore there must
have been exposures that meet the requirements to recognition.
Other diseases or exposures not on the list may in special cases be recognised after submission to the
Occupational Diseases Committee.

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.

1.6. Examples of decisions based on the list

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.
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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.
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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)

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1.7. Medical glossary (degenerative arthritis of knee joint)

Latin/medical term English translation

Arthritis Inflammatory degeneration of one or several joints
Arthritis rheumatoides Rheumatoid arthritis or real arthritis, a chronic, progressive joint disease

Arthron (Greek) Joint

Arthrosis, osteoarthrosis, A chronic joint disease with degeneration and atrophy of the joint cartilage
osteoarthritis, degenerative
arthritis
Articulatio genus Knee joint, a composite joint formed between three bones, i.e. the thigh bone
(femur), the shin bone (tibia) and the knee cap (patella). It is formed with
three separate joint cavities which already early in the embryo stage fuse into
one; parts of the original separations remain, however (and may form a
mucous fold = a plica). According to its formation with three cavities, the
joint can be divided 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

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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)

2.1. Item on the list

The following disease is included on the list of occupational diseases (group D, item 2 bursitis of
knee, and group J, item 1 bursitis other than in the knee):

Disease Exposure

D.2. Inflammatory degeneration of knee Persistent, external pressure for days or longer
bursa (bursitis)

J.1. Inflammatory degeneration of a bursa

other than in the knee (bursitis)

2.2. Diagnosis requirements

A medical doctor must have made the diagnosis of bursitis, i.e. inflammatory degeneration of a bursa
(ICD-10 M70.1 M70.7).

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.

The diagnosis is made by a medical doctor against the background of a combination of

the injured persons subjective complaints (symptoms)
a clinical, objective examination
paraclinical examinations (blood samples, perhaps also x-rays, MR scans, CT scans)

Symptoms
Reddening
Swelling (increased liquid in the bursa)
Pain
Heat

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 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

Division into categories

Normally inflammatory degeneration of a bursa is categorised as follows.

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.

2.3. Exposure requirements

In order for inflammatory degeneration of a bursa (bursitis) to be covered by the item on the list, there
must have been an impact on the bursa in the form of persistent, external pressure for days or longer.
Inflammatory degeneration of a bursa occurs relatively frequently in the population, regardless of
occupation. In many cases, however, it is not a work-related disease, but for example the effects of an
infectious condition. Work-related exposures in connection with for example kneeling work, where
there is a constant pressure impact, do, however, lead to an increased 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 bursa in question. Whether the work can be
deemed to be relevantly stressful depends on a concrete assessment of the exposures, seen in relation to
the development of the disease.

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).

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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.

2.4. Examples of pre-existing and competitive diseases/factors

Systemic diseases
Secondary swelling of bursa in connection with a general infection of the body

2.5. Managing claims without applying the list

Only inflammatory degeneration of a bursa (bursitis) is covered by the item on the list. There must
furthermore have been exposures that meet the recognition requirements.

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.

2.6. Examples of decisions based on the list

2.6.1. Bursitis of the knee

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.

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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.

2.6.2. Bursitis other than in the knee

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.

2.7. Medical glossary (bursitis of the knee)

Latin/medical term English translation
Arthron (Greek) Joint
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
Bursitis acuta Acute inflammatory degeneration of a bursa
Bursitis chronica Chronic inflammatory degeneration of a bursa
Femur Thigh bone

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Genu Knee
Patella Knee cap
Tibia Shin bone

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3. Meniscus disease of the knee joint (D.3)

3.1. Item on the list

3.2. Diagnosis requirements
3.3. Exposure requirements
3.4. Examples of pre-existing and competitive diseases/factors
3.5. Managing claims without applying the list
3.6. Examples of decisions based on the list

3.1. Item on the list

The following knee disease is included on the list of occupational diseases (Group D, item 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

3.2. Diagnosis requirements

A medical doctor must have made the diagnosis of meniscus disease of the knee joint (ICD-10 M23.2
or S83.2).
The disease can develop relatively acutely, but may develop into a chronic condition.
The medical diagnosis is made against the background of a combination of
the injured persons subjective complaints (symptoms)
a clinical, objective examination
perhaps a supplementary arthroscopy examination and/or MR scan

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.

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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 load can be characterised as relevantly stressful if the work

lasted for days or longer
was performed with the knee bent the major part of the working day
was performed under cramped conditions where it was impossible to fully extend the knee
was performed with turning of the knee joint while the knee was bent

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.

3.4. Examples of pre-existing and competitive diseases/factors

Previous knee traumas

Previous joint injuries
Previous cruciate-ligament injuries
Previous traumatic meniscus injuries
Leisure time and sports injuries of the knee joint
(Age)

3.5. Managing claims without applying the list

Only meniscus diseases of the knee joint are covered by this item of the list. Furthermore there need to
have been exposures that meet the requirements for recognition. Other diseases or exposures not on the
list may in special cases be recognised after submission to the Occupational Diseases Committee. One

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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.

3.6. Examples of decisions based on the list

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
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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.

3.7.Medical glossary (meniscus disease of knee joint)

Latin/medical term
Arthritis
Arthritis rheumatoides
Arthron (Greek)
Arthrosis, osteoarthrosis,
osteoarthritis, degenerative cartilage
arthritis
Articulatio genus
English translation
Inflammatory degeneration of one or several joints
Rheumatoid arthritis or real arthritis, a chronic, progressive joint
disease
Joint
A chronic joint disease with degeneration and atrophy of the joint
Knee joint, a composite joint formed between three bones, i.e. the
thigh bone (femur), the shin bone (tibia) and the knee cap (patella). It
is formed with three separate joint cavities which already early in the
embryo stage fuse into one; parts of the original separations remain,
however (and may form a mucous fold = a plica)
According to its formation with three cavities, the joint can be divided

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 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

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4. Jumpers knee (D.4)

4.1. Item on the list

4.2. Diagnosis requirements
4.3. Pre-existing and competitive diseases/factors
4.4. Exposure requirements
4.5. Managing claims without applying the list
4.6. Examples of decisions based on the list
4.7. Medical glossary (jumpers knee)

4.1. Item on the list

The following knee disease is included on the list of occupational diseases (Group D, item 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

4.2. Diagnosis requirements

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

relevant subjective complaints and

clinical, objective degeneration
perhaps a supplementary ultrasound examination and/or MR scan

It is possible to recognise unilateral as well as bilateral cases of jumpers knee.

About the disease

Stresses on the kneecap tendon (patella ligament), in the form of jumping/running with frequent
acceleration and deceleration while flexing and extending the knee, lead to microscopic ruptures at the
patellar tendon attachment at the lower edge of the kneecap. The first symptom is tenderness, which at
first disappears when the knee gets warm. Gradually, because the load often continues despite the
tenderness, tendon degeneration occurs (tendinitis). If the degeneration is chronic and more severe, it is
called tendinosis.

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

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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.

Fig. 1 the knee seen from the front

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

Paraclinical examinations and findings

The diagnosis is usually made in a general medical examination. Ultrasound scans or MR scans will be
able to establish thickening of the tendon, small nodes, scar tissue formation, partial ruptures and
calcification of the tendon.

4.3. Pre-existing and competitive diseases/factors

The National Board of Industrial Injuries will make a concrete assessment of whether any stated
competitive factors are of a nature and an extent that might give grounds for completely turning down

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the disease or whether there are grounds for making a deduction in the compensation if the claim is
recognised.

Examples of possible competitive factors:

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)

4.4. Exposure requirements

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.

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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.

Duration of the work

The load in the form of jumping/running med frequent starts and stops (acceleration/deceleration)
while flexing and extending the knee must in principle have lasted at least 12 hours per week for a long
time (for months).

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.

4.5. Managing claims without applying the list

Only jumpers knee is covered by group D, item 4, of the list of occupational diseases. Furthermore the
suffered exposures must meet the requirements for recognition.
Jumpers knee not covered by the list may in special cases be recognised after submission of the claim
to the Occupational Diseases Committee.

This may for instance be a jumpers knee developed after

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 (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.

4.6. Examples of decisions based on the list

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

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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)

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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)

4.7. Medical glossary (jumpers knee)

Latin/medical term English translation
Anterior In front of
Arthritis Inflammatory degeneration of one or several joints
Arthrosis Degenerative arthritis
Arthroscopy Scoping or looking into a joint
Bursitis Inflammatory degeneration of a bursa
Chondromalacia patella Softened cartilage behind the knee cap
Femoral Of the femur
Femoro-patellar pain Pain in the joint between kneecap (patella) and thigh bone (femur)
syndrome
Femur Thigh bone
Lateral On the outer side
Ligamentum cruciatum Cruciate ligament
Ligamentum patellae The common tendon, which continues from the patella (knee cap) to the
tibia (shin bone)

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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

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Chapter 5. Vibration disorders
List of contents

1. Hand-arm vibration disorders (white finger, peripheral neuropathy,

degenerative arthritis (C.3))

1.1. Item on the list

1.2. Diagnosis requirements
1.2.1 White finger
1.2.2. Peripheral neuropathy of hand/fingers
1.2.3. Degenerative arthritis of wrist and elbow
1.3. Exposure requirements
1.3.1. Exposure requirements for white finger and peripheral neuropathy
1.3.2. Exposure requirements for recognition of degenerative arthritis (arthrosis) of
wrist and elbow joint
1.3.3. Vibration intensity, tools and measuring units
1.4. Managing claims without applying the list
1.5. Examples of decisions based on the list
1.5.1. Examples of decisions on white finger
1.5.2. Examples of decisions on peripheral neuropathy
1.5.3. Examples of decisions on degenerative arthritis of elbow/wrist

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1. Hand-arm vibration disorders (white finger, peripheral neuropathy,
degenerative arthritis (C.3))

1.1. Item on the list

1.2. Diagnosis requirements
1.2.1 White finger
1.2.2. Peripheral neuropathy of hand/fingers
1.2.3. Degenerative arthritis of wrist and elbow
1.3. Exposure requirements
1.3.1. Exposure requirements for white finger and peripheral neuropathy
1.3.2. Exposure requirements for recognition of degenerative arthritis (arthrosis) of
wrist and elbow joint
1.3.3. Vibration intensity, tools and measuring units
1.4. Managing claims without applying the list
1.5. Examples of decisions based on the list
1.5.1. Examples of decisions on white finger
1.5.2. Examples of decisions on peripheral neuropathy
1.5.3. Examples of decisions on degenerative arthritis of elbow/wrist

1.1. Item on the list

The following vibration-induced diseases of the hand and arm are included on the list of occupational
diseases (group C, item 3):

Disease Exposure
C.3.1. Vibration-induced white finger Work with heavily vibrating hand tools (hand-arm
(Raynauds syndrome, Raynauds disease) vibration)

C.3.2. Peripheral neuropathy of hands/fingers

(morbus alius nervorum periphericorum)

C.3.3. Degenerative arthritis of elbow or wrist

(arthrosis primaria/other specified forms of
arthrosis)

Carpal tunnel syndrome: See item C.2.

1.2. Diagnosis requirements

A medical doctor must have made one of the following diagnoses:

White finger (Raynauds syndrome/Raynauds disease) ICD-10 I73.0

Peripheral neuropathy of hand/fingers (morbus alius nervorum periophericorum)
ICD-10 G64.9
Degenerative arthritis of elbow/wrist (arthrosis primaria/other specified forms of arthrosis of
elbow or wrist) ICD-10 M19.0 or M19.8)

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For medical requirements for each disease we refer to the subparagraphs below.

1.2.1. White finger

A medical doctor must have made the diagnosis of white finger (Raynauds syndrome/Raynauds
disease) ICD-10 I73.0.

The diagnosis is made against the background of a combination of

the injured persons subjective complaints (symptoms)
a clinical objective examination

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.

Simple, standardised cold provocation test performed by a doctor. As the

attacks are triggered after exposure to cold, part of the examination can also be
made by way of a simple cold provocation test where the person in question keeps
his/her fingers under cold running water or inserts the finger in ice water for 5
minutes in order to provoke a white-finger attack
Photo documentation. When an attack occurs, a witness confirms the white
fingers by way of a photo of the person reporting the white fingers. The photo
needs to show the face and hands of the person in question
Certification by a doctor. An examining doctor (for example a specialist of
occupational medicine) certifies that, in the examination, he or she has seen white
finger attacks in the person in question with a detailed symptom description as set
out below
Perhaps a vascular-physiological examination. The examination is performed
in a special laboratory with registration of finger blood pressure before and after
finger cooling. The results of the examination can be dubious, however, as there
may, in particular in the summer, occur falsely negative results. However, if a
vascular-physiological examination shows a positive white finger result, the
disease is regarded as having been documented.

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.

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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:

A. Measuring of blood pressure of the arms

B. Assessment of wrist pulses when lifting arms and turning head sideways at the same
time
C. Stethoscopy of neck arteries and heart
D. Description of the trophic structure (i.e. the nutritional condition of the tissues:
reduced blood supply during the attacks may have led to reduced nutrition of skin and
sub skin, which can lead to formation of sores) and colours of the hands

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.

Examples of pre-existing and competitive diseases/factors

Like most other diseases, white fingers 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:
Familiar disposition (white fingers can be hereditary)
Information of Raynauds disease of the toes
Previous arm fractures
Other vascular diseases of the arms
Connective tissue diseases (real arthritis/rheumatoid arthritis and other autoimmune diseases)
Polycytemy (a condition with abnormal increase in the number of red blood cells)
Symptoms or information of any arteriosclerotic diseases, i.e. diseases caused by arterial blocks
Tobacco consumption
Medicine consumption (for instance ergotamine alkaloids, a type of medication used for
migraine, or beta blocs, which are used in connection with heart diseases and hypertension

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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

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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

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 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

1.2.3. Degenerative arthritis of wrist and elbow

A medical doctor needs to have made the diagnosis of degenerative arthritis of the wrist or
degenerative arthritis of the elbow (arthrosis primaria/other specified forms of arthrosis of the elbow
or wrist), ICD-10 M19.0 or M19.8.

The medical diagnosis is made against the background of a combination of

The injured persons subjective complaints (symptoms)
A clinical objective examination
Paraclinical examinations (x-rays, MR scans, CT scans)

In order to make the diagnosis of degenerative arthritis of wrist or elbow joint, the following are
required:
Relevant subjective complaints and

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 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:

Previous fractures of the wrist or elbow

Connective tissue diseases (real arthritis/rheumatoid arthritis and other autoimmune diseases)

1.3. Exposure requirements

1.3.1. Exposure requirements for white finger and peripheral neuropathy

For the diseases white fingers (Raynauds syndrome/Raynauds disease) and peripheral neuropathy of
hands/fingers there must in principle have been relevant stressful work for a consecutive period of time
consistent with the stresses compared with time in table 1 under item 8.3.3.

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.

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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.

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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.

Frequency-weighted acceleration Hours: Hours: Hours: Hours: Hours: Hours:

2
(m/s ) 0.25 0.5 1 2 4 8

2.5 More More 24 years 17 years 12 years 8.4

than than years
25 years 25 years
5 24 years 17 years 12 years 8.5 6 years 4.2
years years
10 12 years 8.5 years 6 years 4.2 3 years 2.1
years years
20 6 years 4.2 years 3 years 2.1 1.5 1.1
years years years
The calculations in the table were made on the basis of ISO-standard No. 5349

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 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.

Surface grinders X E.g. auto repair.

Fixed grinding machines X X Exposure to vibration in the

unit.
Electrical, non-percussion E.g. drilling in wood, plastics
drilling machines X and metal.

Pneumatic, non-percussion X Workshop industry.

drilling machines
X New drilling machines.
Percussion drills and hammer
drills X E.g. electricians, wiring.
X E.g. drilling in wall.
Chisel hammers X Most large and old machines,
workshop industry, auto repair
shops, breaking of concrete and
asphalt.
X New machines.

Riveting hammers X Old, aeroplane and shipyard

work.
X X New, aircraft work.

Holder-on in connection X Conventional iron work.

with riveting
X X New constructions, small rivets.

Bolt tools (compressed air) X Most, auto industry. Larger

machines, give higher vibration
levels.

X Slow hauling tools.

X Old (before 1968).
Power chain saws X New.

Clearing saws X Most.

X With vibration dampening.

Circular saws for plate X Auto repair.

cutting
Poker vibrators X Most.
X Certain new models.

Handlebar grips and pedals X Higher levels for certain

agricultural machines.

1.4. Managing claims without applying the list

This item of the list covers only the diseases white fingers (Raynauds syndrome/Raynauds disease),
peripheral neuropathy of hands/fingers and degenerative arthritis (arthrosis) of wrist or elbow joint
after the above-mentioned hand-arm vibration exposures.

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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

Lunatum malacia (Kienbcks disease) as a consequence of repetitive blunt traumas (blows)

against the hand or work with severely vibrating tools

Peripheral neuropathy of fingers/hands as well as toes/feet due to long-term exposure to

extreme cold with permanent injuries to the peripheral nerves of fingers or toes

Peripheral neuropathy of fingers/hands as well as toes/feet as a consequence of exposure to

organic solvents such as n-hexane and methylbutylketone

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.

1.5. Examples of decisions based on the list

1.5.1. Examples of decisions on white finger

Example 1: Recognition of white fingers (metal worker for 15 years)

A 44-year-old man worked as a metal worker for 15 years, being in charge of maintenance of various
machines used by the company in the building trade and at the same time doing actual metal work. He
used hand-held vibrating tools in the form of angle grinders, hammer drills, chisel hammers, and
percussion drills. The vibration intensity of the tools was between 4 and 11 m/s2, and he worked with
these tools on an average of 1-2 hours a day. Towards the end of the period he experienced a tingling
and numb sensory disturbance radiating into the three middle fingers of his right hand, and already a

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.

Example 2: Recognition of white fingers (warehouse manager for 30 years)

A 62-year-old man worked for 30 years for a major company as a warehouse manager. As part of his
work he had to test the hand-held tools used by the companys plumbers. He used angle grinders and
hammer drills as well as concrete hammers for breaking up floors. When testing them, he used both
hands to operate the tools. This work was done for about one hour every day. The hammer drill as well
as the concrete hammer had an acceleration velocity of more than 10m/s2, whereas the angle grinders
typically accelerated about 5 to 8 m/s2. Towards the end of the period he first experienced attacks of
white finger when exposed to cold or when grabbing cold metal. A subsequent EMG examination
established white fingers on his left hand (2nd and 3rd finger) and white fingers on his right hand (2nd,
3rd and 4th 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.

Example 3: Claim turned down white fingers (gardener for 7 years)

A 33-year-old female gardener developed white fingers after having used, for 6 years, about one day a
week for 2 hours, an electric as well as an engine-operated hedge cutter. According to the information
given, the electric hedge cutter was acceleration dampened, vibrating at about 3 m/s2, whereas the
engine-operated hedge cutter accelerated at about 8 m/s. She used these tools more or less to the same
extent. Towards the end of the period she developed increasing pain of the fingers of the right hand in
particular, but it was not possible to establish white fingers, either in a cold provocation test or an EMG
examination.

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.

Example 4: Claim turned down white fingers (electrician for 25 years)

For about 25 years, in connection with electrician work in new building and renovation projects, a 55-
year-old male electrician had been using a percussion drill with a vibration intensity of about 5-10 m/s2
about 2-3 hours a day. In the course of a few years, the injured person, according to his own
information, developed white fingers, localised to the 2nd and 3rd finger of the right hand. There was
furthermore information that since his youth the electrician had had insulin-requiring diabetes.
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An examination in the hospital failed to establish Raynauds syndrome (white fingers) by way of a cold
provocation test. A photo of the hand during an attack, which was obtained later, showed that the whole
hand, including the back of the hand, was livid. The hospital had made the diagnosis of diabetes-related
neuropathy.
The claim does not qualify for recognition as the forwarded photos documented that it was not a case of
white fingers, white fingers affecting only the fingers, which become livid from the tips of the fingers
down towards the carpometacarpal joint of the finger with a sharply delimited transitional line between
the white finger and the part of the finger not affected by the disease.
It is furthermore futile to submit the claim to the Occupational Diseases Committee since the disease
was caused by the insulin-requiring diabetes and therefore was not, only or predominantly, caused by
the special nature of the work of operating hand-held vibrating tools for 2-3 hours a day for 25 years.

1.5.2. Examples of decisions on peripheral neuropathy

Example 5: Recognition of bilateral peripheral neuropathy (machine operator for 5 years)

A 36-year-old man worked for a total of 5 years for a major contracting business as a machine operator.
For about half of the working day he used heavily vibrating hand-held tools such as hydraulic hammer,
pneumatic hammer, plate vibrator and a ground lopper. The tools had a typical vibration intensity of
approximately 10 m/s2 or more. In the course of the last year he developed increasingly tingling
sensations in all fingers of both hands except the thumbs. A hospital examination ruled out i.a.
sclerosis, carpal tunnel syndrome and diabetes as possible causes of the complaints. A blood pressure
measurement showed that there was an immeasurable pressure on all examined fingers on both hands.
No white finger was triggered in this measurement or in other tests, and he was diagnosed with a nerve
disease (peripheral neuropathy) of arms/hands as a consequence of vibrating work (neuropathia
extremitas).

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.

Example 6: Recognition of right-sided peripheral neuropathy (carpenter for 32 years)

A 50-year-old man worked as a carpenter for 32 years, every day for approx. a half to one hour using
heavy hand and arm vibrating tools, such as a drill hammer with a powerful percussion hammer, screw
machines, heavy accumulator machines, nail pistols, angle grinders and concrete hammers. The
vibration intensity for the tools used was 3-10 m/s2. The last couple of years he developed complaints
in the form of a cold feeling and tingling in the 3rd finger of his right hand, in particular when exposed
to cold. Suspicion of carpal tunnel syndrome or white finger was ruled out in neurophysiological
examinations, and no other causes of the disease were found. The neurophysiological measurement did,
however, establish degeneration consistent with vibration neuropathy.
The claim qualifies for recognition on the basis of the list. The carpenter was exposed to severely
vibrating, hand-held tools with a vibration intensity of 3-10m/s2 for more than 30 years and in a
neurophysiological measurement was diagnosed with monoperipheral neuropathy of the 3rd finger of
his right hand without any other known causes.

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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 8: Recognition of bilateral peripheral neuropathy (ships engineer for 24 years)

A 48-year-old man worked for 24 years in the smithy of a ship, using heavy, hand-arm vibrating tools
1-4 hours a day, typically 2 hours a day. He i.a. used angle grinders, heavy drilling machines and
various grinding devices, which typically had a vibration intensity of 5-10 m/s2. In later years he
increasingly developed sensory disturbances localised to both hands, in the form of tingling sensations
in both hands and all fingers of both hands. There was gradual aggravation of the paresthesies and
sensory disturbances in both hands, which occasionally spread to about the middle of both upper arms.
Some years previously he had been diagnosed with degeneration of the cervical neck, where a small
prolapse was found. There were no grounds, however, for an operation, and there was no indication of
root pressure that might lead to symptoms in the peripheral nerves. A neurophysiological specialist,
after measuring the nerve conductivity of the fingers of both hands, made the diagnosis of mixed
sensory/motor peripheral neuropathy of both hands.
The claim qualifies for recognition on the basis of the list. The engineer has been exposed to heavily
vibrating, hand-held tools for typically 2 hours a day for over 20 years and there is documentation of
peripheral neuropathy of both hands. Though he has been diagnosed with degeneration (degenerative
arthritis) and a prolapsed disc of the cervical neck, it is not possible to establish any correlation
between these diseases and the complaints regarding his hands, and therefore there are no grounds for
turning down the neuropathy claim due to competitive causes or making any deduction for complaints
overlapping with the diseases of the cervical neck.

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.

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Chapter 6. Other diseases of the musculoskeletal system
List of contents

1. Diseases of hand and forearm (C.1)

1.1. Item on the list
1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (hand and forearm)
2. Carpal tunnel syndrome (C.2)
2.1. Item on the list
2.2. Diagnosis requirements
2.3. Exposure requirements
2.3.1. Work with heavily vibrating tools (C.2.(a))
2.3.2. Quickly repeated, strenuous and/or awkward work movements (C.2.(b))
2.3.3. Work with objects leading to direct and persistent pressure (C.2.(c))
2.3.4. General conditions for the exposures (a) to (c)
2.3.5. As a complication to tendovaginitis (C.2.(d))
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
2.6.1. Work with heavily vibrating hand tools (C.2.(a))
2.6.2. Quickly repeated, strenuous and/or awkward work movements (C.2.(b))
2.6.3. Work with objects causing direct pressure (C.2.(c))
2.6.4. As a complication to tendovaginitis (C.2.(d))
2.7. Medical glossary (carpal tunnel syndrome)
3. Tennis elbow and golfers elbow (C.4)
3.1. Item on the list
3.2. Diagnosis requirements
3.3. Exposure requirements
3.4. Examples of pre-existing and competitive diseases/factors
3.5. Managing claims without applying the list
3.6. Examples of decisions based on the list
3.7. Medical glossary (tennis elbow and golfers elbow)
4. Shoulder diseases (C.5)
4.1. Item on the list
4.2. Diagnosis requirements
4.3. Exposure requirements
4.3.1. Repetitive and strenuous shoulder movements (exposure (a))
4.3.2. Static lifting of upper arm (exposure (b))
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
4.6.1. Repetitive and strenuous shoulder movements (exposure (a))
4.6.2. Static lifting of upper arm (exposure (b))
4.7. Medical glossary (shoulder diseases)
5. Chronic neck and shoulder pain (B.2)
5.1. Item on the list
5.2. Diagnosis requirements
5.3. Exposure requirements
5.3.1. The time requirements
5.3.2. Other load requirements

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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)

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1. Diseases of hand and forearm (C.1)

1.1. Item on the list

1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (hand and forearm)

1.1. Item on the list

The following diseases of hand and forearm are included on the list of occupational diseases (group C,
item 1):
Disease Exposure
C.1. Tendovaginitis (inflammation of the synovial Strenuous and repetitive work movements, in
sheath) and inflammatory degeneration of tendon or combination with an assessment of the working
tissue surrounding the tendon (tendinitis and periten- posture of the hand in connection with the load
dinitis)

1.2. Diagnosis requirements

A medical doctor must have made one of the following diagnoses:
Tendovaginitis (inflammatory degeneration of a synovial sheath), tendinitis (inflammatory
degeneration of a tendon), or peritendinitis (inflammatory degeneration of the tissue surrounding a
tendon). (ICD-10 M65.4, M.65.8, M65.9, M67.9, M72.0)

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.

The medical diagnosis is made against the background of a combination of

the injured persons subjective complaints (symptoms)

a clinical, objective examination

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

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 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

1.3. Exposure requirements

As for the diseases of hand and forearm covered by the item on the list, there must have been strenuous
and repetitive work movements. The load must be seen in combination with an assessment of the
awkwardness of the working posture, i.e. in combination with an assessment of the posture of the
hand/wrist in connection with the load. In principle there must have been a relevant load for at least
half of the working day (3-4 hours).

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.

Awkward working postures

The assessment of whether the working posture is awkward for the hand/wrist takes into account if and
to what extent the hand/wrist is exposed to awkward flexion, pulling or turning movements. All joints
have a normal functional posture. This is the posture of the joint that gives the optimal function of the
extremity (extremity = arm or leg). Movements that occur in other positions than the normal posture
are characterised as awkward. The larger the deviation from the normal posture, the more awkward the
posture.

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Movements in awkward postures are not optimal and thus increase the load on for example muscles,
tendons and connective tissue.

Combined load assessment

If there is a very high degree of strenuous work and/or very awkward working postures for the
hand/wrist, the requirement to the repetition frequency will be relatively smaller. Similarly, in
connection with slightly to moderately strenuous work and/or good to optimal working postures, the
requirement to the repetition frequency will be larger.
Diseases after highly repetitive work without a certain degree of strenuousness will not, however,
qualify for recognition on the basis of the item of the list, just as strenuous work without repetition is
not included.
If different work functions have been performed in the course of the working day, the assessment will
include the overall load on the hand/wrist, as well as the load of each work function and the total
duration of the load. Thus, alternating work functions, and therefore a certain variation in the work,
may well result in a relevant and sufficient hand or wrist load.

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.

1.4. Examples of pre-existing and competitive diseases/factors

Degenerative arthritis of fingers and/or wrists
Rheumatoid arthritis of fingers and/or wrists
Symptoms from tendons and muscles as a consequence of age (age-related degeneration)
Effects of a fractured wrist
Systemic diseases (for example diabetes)

1.5. Managing claims without applying the list

Only tendovaginitis and inflammatory degeneration of a tendon or tissue surrounding a tendon
(tendinitis and peritendinitis) of the hand or forearm are covered by item C.1 of the list. Furthermore
there need to have been exposures meeting the recognition requirements.

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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.

1.6. Examples of decisions based on the list

Example 1: Recognition of tendovaginitis of right thumb in laboratory technician (pipetting)

A young woman worked for several years as a bio-analyst in a hospital. Half of the working time her
work consisted in de-pipetting with various pipettes. Most of them were operated manually. She held
the pipette in a full hand grip with the 2nd, 3rd, 4th and 5th fingers of her right hand, while activating the
pipette with her thumb. When using the manual pipettes, she virtually had to overstretch her thumb and
then abduct it 2-3 centimetres. Furthermore, when activated, the manual pipettes required some
exertion of her right thumb. She performed about 225 de-pipettings per hour, equivalent to a cycle time
of about 20 seconds per manoeuvre. She would typically do sequences of pipetting work part of the
day, sometimes more than one sequence a day. The rest of the day she worked on a PC or did other
laboratory tasks. For a one-week period she made de-pipettings for 5-6 hours a day with manual
pipettes. She subsequently developed tenderness and swelling of her right thumb and a medical
specialist diagnosed her with tendovaginitis of the right thumb.

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.

Example 2: Recognition of bilateral tendovaginitis (cleaner in a swimming theme park)

A 32-year-old woman worked for 5 years as a cleaner in a large swimming theme park. The work
consisted in cleaning large areas with a high-pressure hose for more than 3 hours a day. The operation
of the hose required constant pressure on the dead-man switch with her left hand and controlling the
100-bar-pressure hose, using a powerful grip, and switching from right to left hand and vice versa. She
turned the pressure up and down with her right hand, which resulted in repeated twisting of the wrist
and a strenuous grip. In addition, for about one hour a day, she washed floors with a rough surface,
using wet mops with both hands. The remaining working tasks were more varied and easier. Towards
the end of the period she developed pain, tenderness and swelling of both wrists, and a medical doctor
diagnosed her with bilateral tendovaginitis.

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.

Example 3: Recognition of tendovaginitis of wrist (packer)

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A 58-year-old woman developed tendovaginitis of her right wrist after having worked for about 6
months as a packer in a candy factory. Her job consisted in pouring candy into a packing machine,
lifting 7-8-kilo trays of candy about 750 times a day. At the same time she had to fold 500 cartons, and
the candy bags had to be checked and stamped. Then she had to place a lid on the cartons, close them
with tape and label them. The cartons weighed 8-10 kilos when full and were stacked on pallets, 64 on
each. 10-11 pallets were filled every night. It appeared that in particular the work with awkward lifts of
7-8-kilo trays many times a day and the numerous cartons to be folded involved twisting and turning
movements of the right wrist.

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.

Example 4: Recognition of tendovaginitis of wrist (spray lacquering and grinding)

The injured person worked for 1.5 years with spray lacquering in a company that built platform trucks
etc. The work consisted in grinding, preparing and spray painting. He performed the grinding work
manually with very coarse grinding paper, while holding an excenter grinder very hard. The work
involved several repeated, strenuous movements of the right wrist and also twisting of the wrist. This
work he did for at least half of the working day. In connection with auto spray painting his movements
were mainly horizontal, and he let go of the trigger for a moment in each extreme position. He typically
operated the trigger with his 2nd and 3rd fingers. Thus the auto spray painting involved repeated flexion
movements of the right wrist. In connection with industrial lacquering there were all sorts of move-
ments with repeated flexing and turning of wrist and forearm as well as frequent activation of the
trigger. The work with round nozzles involved a rotation movement of the wrist. He had to hold the
spray trigger in a strenuous grip. Furthermore he often did spray lacquering lying on his back and with
his arm stretched upwards. He developed pain and swelling of his right wrist and was diagnosed with
tendovaginitis of the right wrist.

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.

Example 5: Recognition of tendon disease of the forearm in a slaughterhouse worker (lifts)

A slaughterhouse worker had to transport trolleys of hams from cooling room to conveyor belt. He then
placed the hams on the conveyor belt at approximately 1 metres height. Placing the ham on the belt, he
lifted with simultaneous turning of his right forearm. The hams weighed approximately 8-12 kilos. He
was diagnosed with a tendon disease of his right forearm after well over 2.5 years work.
The claim qualifies for recognition on the basis of the list. The work involved strenuous and frequently
repeated movements for the major part of the working day with simultaneous turning of the forearm.

Example 6: Recognition of tendon disease of the forearm in a slaughterhouse worker (cutting)

A slaughterhouse worker had worked with cutting up meat for many years. He was right-handed and
while cutting held the meat with his left hand in a steel glove. It was his left hand that twisted, pulled
and lifted the meat numerous times every day. He developed complaints consistent with his left
forearm and was diagnosed with tendon disease of the forearm.

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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.

Example 7: Recognition of tendon disease of the forearms (industrial seamstress)

A seamstress worked with sewing of tents. She had to sew the ready made tent walls together with the
roof made of vinyl and then sew on grass edges. With her 1st and 2nd fingers (mainly of the right hand)
she had to pull 15-20 metres of vinyl through the sewing machine and at the same time control the
sewing itself. After a couple of weeks doing this work she developed pain and a functional impairment.
The doctor found that she had pain in both hands and wrists. The diagnosis was a tendon disease of the
forearms.

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.

Example 8: Recognition of tendovaginitis of the forearm (sawmill worker lifts)

A sawmill worker had a work function where he had to handle tree trunks. The tree trunks were 2
metres long and had a diameter of 10 centimetres. The tree trunks were often wet. The trunks were
lifted from a horizontal to a vertical position and were placed in a tube, and a machine cut blocks off
the trunk. In connection with this work function he made simultaneous turning movements of the
forearms. After 4 months of work in this function the sawmill worker was diagnosed with tendo-
vaginitis of the forearm.

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
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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)

1.7. Medical glossary (hand and forearm)

Latin/medical term English translation
Infection Infectious degeneration caused by micro organisms
Inflammation Inflammatory degeneration with or without micro organisms
Peritendinitis Inflammatory degeneration of the tissue enveloping a tendon
Tendinitis Inflammatory degeneration of a tendon

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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.

2. Carpal tunnel syndrome (C.2)

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 (carpal tunnel syndrome)

2.1. Item on the list

The following nerve disorders of hand and forearm are included, according to the stated exposure, on
the list of occupational diseases (group C, item 2):

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

(d) As a complication to tendovaginitis on the flexion side of the wrist qualifying

for recognition on the basis of the list

2.2. Diagnosis requirements

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.

The medical diagnosis is made against the background of a combination of

the injured persons subjective complaints (symptoms)

a clinical, objective examination

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 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.

2.3. Exposure requirements

In order for the disease carpal tunnel syndrome to be covered by the list, there need to have been
exposures in the form of work for a long time with heavily vibrating hand-held tools, a combination of
quickly repeated, strenuous and/or awkward wrist-loading work movements, or work with objects
causing pressure on the median nerve of the carpal tunnel. The disease can in addition be recognised as
a complication to tendovaginitis of the flexion tendon of the wrist if the latter disease qualifies for
recognition on the basis of the list.

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.

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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.

2.3.1. Work with heavily vibrating tools (C.2.(a))

A condition for recognising carpal tunnel syndrome after exposure to vibrating hand-held tools is that
there must have been vibration through hands and arms from hand-held tools, hand-held machines or
stationary machines, the vibration occurring through some kind of object.

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.

Frequency-weighted acceleration Hours: Hours: Hours: Hours: Hours: Hours:

2
(m/s ) 0.25 0.5 1 2 4 8

2.5 More More 24 17 years 12 years 8.4

than than years years
25 years 25 years
5 24 years 17 years 12 8.5 6 years 4.2
years years years
10 12 years 8.5 years 6 years 4.2 3 years 2.1
years years

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 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.

Surface grinders X E.g. auto repair.

Fixed grinding machines X X Exposure to vibration in the

unit.
Electrical, non-percussion E.g. drilling in wood, plastics
drilling machines X and metal.

Pneumatic, non-percussion X Workshop industry.

drilling machines
X New drilling machines.
Percussion drills and hammer
drills X E.g. electricians, wiring.
X E.g. drilling in wall.
Chisel hammers X Most large and old machines,
workshop industry, auto repair
shops, breaking of concrete and
asphalt.
X New machines.

Riveting hammers X Old, aeroplane and shipyard

work.
X X New, aircraft work.

Holder-on in connection X Conventional iron work.

with riveting
X X New constructions, small rivets.

Bolt tools (compressed air) X Most, auto industry. Larger

machines, give higher vibration
levels.

X Slow hauling tools.

Power chain saws X Old (before 1968).
Clearing saws X New.

X Most.
X With vibration dampening.
Circular saws for plate
cutting X Auto repair.
Poker vibrators X Most.
X Certain new models.

Handlebar grips and pedals X Higher levels for certain

agricultural machines.

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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.

Quickly repeated work movements

In order that the work can be seen as being characterised by quickly repeated work movements that
constitute a load on the wrist in a relevant way, the work must involve quickly repeated movements of
the wrist for a substantial part of the working day. This usually means monotonously repeated and
stressful work movements performed many times per minute.

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.

Strenuous work movements

Relevant elements in the assessment of whether the work movements are strenuous can be
the use of muscular power in connection with the work
whether the unit resists
whether there are simultaneous twisting, turning, flexion or extension movements of the wrist

Awkward work movements

A factor contributing to the risk of disease development is work in working postures that are awkward
for the wrist. All joints have a normal functional posture. This is the joint posture that gives the optimal
function of the extremity (extremity = arm or leg). Movements that occur in other positions than the
normal posture are regarded as awkward. The greater the deviation from the normal posture, the more
stressful it would be. Movements in awkward positions are not optimal and thus increase the load on
for example muscles, tendons and connective tissue.

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
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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.

2.3.4. General conditions for the exposures (a) to (c)

In principle, relevantly stressful work needs to have been performed for a continuous period of 2 years
or more.

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.

2.3.5. As a complication to tendovaginitis (C.2.(d))

Carpal tunnel syndrome can in some cases develop as a natural consequence of and complication to
tendovaginitis at the flexion side of the wrist. If the tendovaginitis can be recognised on the basis of the
requirements of the list with regard to this disease (item C.1), the carpal tunnel syndrome will be
recognised as a complication to tendovaginitis, based on the list requirements applying to
tendovaginitis.

2.4. Examples of pre-existing and competitive diseases/factors

Arthritis of the wrist and/or the root of the hand
Effects of a fractured wrist
Tendon lump (ganglion)
Certain types of osteoarthritis of the cervical spine with root exposure
Prolapsed disc of the cervical spine
Neuropathy
Idiopathic (unknown) causes
Age-related degeneration of the wrist
Diabetes
Pregnancy
Obesity (Body Mass Index larger than 30-31)
Excess growth (acromegaly)
Too low metabolism (myxedema)

2.5. Managing claims without applying the list

It is only the disease carpal tunnel syndrome that is covered by this item on the list. There furthermore
need to have been exposures that meet the recognition requirements.
Other diseases or exposures not on the list will in special cases be recognised after submission to the
Occupational Diseases Committee.
One example of an exposure that may be recognised, as a cause of carpal tunnel syndrome, after
submission to the Committee is extremely high-repetitive and strenuous work where the disease
developed within the first year.
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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.

2.6. Examples of decisions based on the list

2.6.1. Work with heavily vibrating hand tools (C.2.(a))

Example 1: Recognition of carpal tunnel syndrome (metal worker for 8 years)

The injured person was employed as a metal worker in a shipyard for well over 8 years. In connection
with sheet metal work he used an air chisel, a plan grinder, an axis grinder, a drill and a pneumatic
hammer. On an average, he used the hand-held vibrating tools for 4-5 hours a day, and the tools had a
vibration intensity of between 3 and 8 m/s2. He started getting pain and sensory disturbances in his right
hand and wrists after 7-8 years. 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 was exposed to heavily
vibrating tools for half of the working day while working as a metal worker for 8 years, and the tools
he used had a substantially wrist-loading vibration level of 5-6 m/s2 on average. There is good corre-
lation between the development of a right-hand carpal tunnel syndrome and the load and its duration.

Example 2: Recognition of carpal tunnel syndrome (electrician for 40 years)

The injured person worked as an electrician for various employers for 40 years. For more than 20 years
he was employed as a wage-earner in his own firm. The work consisted of various electricians tasks
and involved daily use of a milling drill and a hammer drill for 1-2 hours. After 40 years he developed
complaints of his right hand with pain and a dead sensation and tingling in the fingers. A medical
specialist diagnosed him with right-hand carpal tunnel syndrome, and he had a successful operation.
The claim qualifies for recognition on the basis of the list. The electrician was exposed to severe
vibrations from milling drill and hammer drill for 1-2 hours a day for 40 years. The tools had a
vibration level between 3 m/s2 and more than 10 m/s2, and there is good time correlation between the
exposure and the onset of the disease.

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.

2.6.2. Quickly repeated, strenuous and/or awkward work movements (C.2.(b))

Example 4: Recognition of carpal tunnel syndrome (fish trimmer for 3 years)

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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.

Example 6: Recognition of carpal tunnel syndrome (slaughterhouse worker for 4 years)

The injured person worked as a slice man in a slaughterhouse for well over 4 years. His work consisted
in peeling salami sausages weighing 5 kilos each. He cut down with his right hand the sausages from a
rack and put them on a table. Then he cut off the end of the sausage, lifted it with his left hand and
pulled the sausage skin halfway off with his right hand. He placed the sausage in a vertical position and
tore off the rest of the sausage skin. His production was between 1,200 and 2,000 sausages per day and
each sausage was handled several times, corresponding to about 10-15 handlings per minute. After 4
years work he developed pain and sensory disturbances of his right forearm and hand. A medical
specialist diagnosed him with carpal tunnel syndrome of the right hand. A neurophysiological
examination confirmed the diagnosis.

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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.

Example 8: Recognition of carpal tunnel syndrome (fitter for 3 years)

The injured person worked for well over 3 years as a fitter in a business manufacturing lamps and
ceiling fittings. For about three fourths of the working day she was shaping fittings at a bending
machine. One fourth of the working day she was hand-assembling reflectors for ceiling fittings,
assembling the units with a rivet pistol. She was able to assemble 100-300 fittings per day, leading to
many repeated work movements per minute. The work with the rivet pistol required some exertion of
her right hand and involved frequent twisting, turning and flexion movements of the wrist. In
connection with the bending work she took a pile of aluminium plates of varying sizes to a work table,
where she held each of the units into a bending machine activated with a foot pedal. Then she removed
the units and placed them in a pile. This meant that she had to reach out and lift at a maximum reaching
distance with twisting of the wrist, but with limited exertion. Her production amounted to 300 units per
hour, and each unit was handled several times.

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.

Example 9: Recognition of carpal tunnel syndrome (cleaner for 6 years)

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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.

Example 11: Recognition of carpal tunnel syndrome (violinist for 4 years)

A woman worked full time as a professional violinist in a large symphony orchestra. The work
involved many hours of daily practice as well as frequent concert performances and recordings in a

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.

Example 12: Recognition of carpal tunnel syndrome (fisherman for 7 years)

A man worked as a fisherman for well over 7 years. He mainly worked in net fishing. One third of the
time he set out the nets, and two thirds of the time he pulled in nets and emptied them. When emptying
the nets, he pulled out the fishes with both hands with strenuous gripping movements, holding the net
as well as the fishes. Furthermore, he crushed crabs for a few days. He handled about 250 cods, 2,400
flat fishes, or 2,000 crabs in one day. The rest of the time he did Danish seine fishing, sorting and
cleaning fishes. He was holding the fish with his right hand and at the same time, with a strenuous
gripping and cutting movement of his left hand, cut into the fish and removed its intestinal system. The
work involved in setting nets and pulling them up again also led to strenuous gripping loads for both
wrists. Towards the end of the period he developed pain of both wrists and forearms and a neuro-
physiological examination established bilateral carpal tunnel syndrome.

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.

Example 13: Recognition of carpal tunnel syndrome (carpenter/roofer for 12 years)

A 44-year-old carpenter for a 12-year period installed Decra roofs. For the major part of the day, the
work consisted in holding tight laths or roof tiles with a powerful, left-hand grip while shooting nails
from a nail gun with his right hand. It appeared that the work involved continuous blows to the palm of
the left hand when he was using the nail gun. After a number of years he developed a tingling sensation
in the fingers of his left hand and was diagnosed in the end with carpal tunnel syndrome. He subse-
quently had a successful operation.

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
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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.

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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.

2.6.3. Work with objects causing direct pressure (C.2.(c))

Example 19: Recognition of carpal tunnel syndrome (fitter for 2 years)

The injured person worked as a fitter in a large business manufacturing different large metal units. His
work mainly consisted in fitting heavy metal bands on big metal plates with metal nuts. During the
fitting he used a big monkey wrench, which involved a nearly constant pressure against the median
nerve for a great part of the working day. After almost 2 years work he developed pain in his forearm
and hand, 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 has a right-hand carpal
tunnel syndrome as a consequence of his work as a fitter. For almost 2 years he was exposed to a nearly
constant pressure from a big wrench against the median nerve in the carpal tunnel.

2.6.4. As a complication to tendovaginitis (C.2.(d))

Example 20: Recognition of carpal tunnel syndrome as a complication to tendovaginitis (metal worker
for 6 months)
The injured person worked for well over 6 months as a metal worker in a large steel-manufacturing
business. The work consisted in the manufacture of elements for grid constructions and, to a lesser
extent, fitting/welding. In the manufacturing process he cut out pipes weighing between 1 and 15 kilos.
The pipes were placed in a rack, and then he lifted one pipe at a time and milled both ends. Finally the
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pipes were lifted to a press, a thread was positioned, and he activated the press. He had well over 8
handlings per pipe, equivalent to up to 2,000 handlings per day. The work with the many lifts of pipes
was done with extended wrists and involved some strenuousness. In addition, there were many repeated
work movements which led to twisting, turning and flexion movements of the wrist. After a few
months employment he developed pain in his right wrist and his forearm. A medical specialist made
the diagnosis of right-hand tendovaginitis as well as right-hand carpal tunnel syndrome.

The claim qualifies for recognition as a complication to tendovaginitis as tendovaginitis can be

recognised on the basis of the requirements of the list and there is good correlation between the two
diseases. The injured person had wrist-loading work for 6 months. The work was characterised by
strenuous and repeated work movements and simultaneous, awkward working postures for the right
wrist. The exposure therefore meets the requirements to recognition as stated under tendovaginitis of
the hand and forearm (item C.1).

Example 21: Recognition of carpal tunnel syndrome as a complication to tendovaginitis (packing

operator for 15 years)
A woman worked as a packing operator for 15 years, packing meat in a slaughterhouse. Per hour she
packed about 600 hams or cuts, taken from the middle of the pigs back, into boxes weighing 25 kilos
each. When packing the back pieces she had to fold them straight and hold them firmly squeezed and
adjusted so that they slid into the packing machine. When packing tenderloins she packed 1,200 items
per hour into 5-kilo boxes. The packing work involved many gripping movements with the right hand
and twisting movements of the right wrist in connection with the numerous lifts. When packing 25-kilo
boxes she had to operate a vacuum lifter, which was stressful for the arms as she had to take hold of it
from above head height. This involved pulling and stretching of her right arm. She had to press down
the button on the vacuum lifter with a powerful bending movement of all fingers in order to manage to
pull it down and it order to get it to let go of the box again after the lift. The work generally involved
many lifts at arms length and above the head, due to her moderate height. Towards the end of the
period the packing operator developed tendovaginitis of her right wrist and was later diagnosed with
carpal tunnel syndrome on the same side.

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)

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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

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Phalens test
(positive hyper flexion test)
Examination where the person presses the backs of the hands against
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
(positive hyperextension test)
Examination where a person presses the palms of the hands against
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.

Syndrome Disease complex, a group of associated symptoms

Tinels signs A symptom of reaction from oversensitive nervous threads in the form
of tingling sensations or radiating pain when the nerve is tapped.

3. Tennis elbow and golfers elbow (C.4)

3.1. Item on the list

3.2. Diagnosis requirements
3.3. Exposure requirements
3.4. Examples of pre-existing and competitive diseases/factors
3.5. Managing claims without applying the list
3.6. Examples of decisions based on the list
3.7. Medical glossary (tennis elbow and golfers elbow)

3.1. Item on the list

The following elbow diseases are included, according to exposures, on the list of occupational diseases
(group C, items 4.1 and 4.2):

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)

3.2. Diagnosis requirements

There must be a medical diagnosis of epicondylitis lateralis (tennis elbow, ICD-10 M77.1) or
epicondylitis medialis (golfers elbow, ICD-10 M77.0).

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.

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Generalised or diffuse pain cannot be recognised on the basis of the list.

The medical diagnosis is made against the background of a combination of

the injured persons subjective complaints (symptoms)
a clinical, objective examination

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.

Objective signs for golfers elbow

Indirect tenderness and pain aggravation in connection with active downward flexion of the wrist
against resistance. The pain is aggravated when the elbow joint is extended. Pain is also released in
connection with passive upward flexion and simultaneous outward turning of the forearm with an
extended elbow joint.

Objective signs for tennis elbow

Indirect tenderness and pain aggravation in connection with active upward flexion of the wrist against
resistance. The pain is aggravated when the elbow joint is extended. Pain is also released in connection
with passive downward flexion and simultaneous inward turning of the forearm with an extended
elbow joint.

3.3. Exposure requirements

Complaints of elbow-joint pain are frequent, regardless of occupation (1 to 5 per cent of the population
suffer from epicondylitis). Specific exposures, however, lead to an increased disease risk.

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

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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.

Combined assessment of the load

Diseases occurring without strenuousness will not qualify for recognition on the basis of this item of
the list. Nor will diseases occurring without repetition, awkward working postures or static loads, while
fixating an object and applying muscular force, qualify for recognition, even if the work besides
involved some strenuousness.

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.
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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.

3.4. Examples of pre-existing and competitive diseases/factors

Degenerative arthritis (arthrosis) of the elbow joint
Real arthritis (rheumatoid arthritis) of the elbow joint
Symptoms from tendons and muscles as a consequence of age (age consistent degeneration)
Effects of elbow joint fracture
Systemic diseases (connective tissue diseases)
Degenerative arthritis of the cervical spine with radiation
Prolapsed disc of the cervical spine with radiation
Cartilage degeneration on the elbow joint (osteochondritis dissicans)
Squeezing of radial nerve in its course through a tunnel of the forearm (radial tunnel syndrome)

3.5. Managing claims without applying the list

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.

3.6. Examples of decisions based on the list

Example 1: Recognition of tennis elbows (polisher for 9 years)

A man worked full time as a polisher for 9 years, grinding and polishing water taps. When polishing he
pressed the units hard against the polishing or grinding machine. The grinding did not require as much
strength as the polishing. In both cases he worked in a sitting, stooping posture, pressing the unit with

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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.

Example 3: Recognition of tennis elbows (fishing worker for 4 weeks)

A woman worked for well over 4 weeks as a seasonal worker on a salmon farm. The salmon came in
on a belt, and she was holding tight the fish in an upper hand grip with the left hand while cutting it
open with a knife held in her right hand. Then the roe, weighing 300-500 grams , was partly or
completely cut free and completely removed with the left hand in an upper grip, and thrown forward on
the belt. Sometimes the fish had not been cut quite open and then she had to do this as well. It was
monotonous and high-repetitive work with inward and outward twisting of both wrists and twisting and
turning of the elbow joints. The work with the knife, as well as holding tight the fish and ripping out
the roe, involved a certain application of force. She cut 4-5 fishes per minute, equivalent to 7-9 tonnes
of fish per day, each weighing 3-5 kilos. After a couple of weeks work she developed initial pain in
both elbow joints and a medical specialist subsequently diagnosed her with bilateral tennis elbow.

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
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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 5: Recognition of tennis elbow (fence builder for 17 years)

A man worked as a fence builder for 17 years, fitting security fences. He started out by drilling post
holes, using mainly a bobcat with a ground drill. In some places, however, he had to dig out the post
holes manually. Then the posts were put into the holes, and the holes were filled with hand-mixed
cement, which was hard to prepare. Subsequently 6 mm iron wires were fastened along the top and the
bottom of the whole fence. At each corner he made a loop which was twisted around itself with a pair
of flat-nosed pliers and cut with a pair of cutting nippers. Finally the wire fencing was fitted with a 2
mm iron wire seam along the 6 mm upper wire. The work in particular involved strain on the elbow in
connection with the repeated use of pincers for cutting iron wire as well as the use of flat-nosed pliers
for twisting of loops. On an average he used the cutting nippers 600 times a day. Each loop had to be
twisted 4-6 rounds. This was equivalent to repeating the twisting movement of his right elbow 6-700
times a day. Cutting as well as twisting of the various wires required a considerable exertion of the
hand, thus straining the extensor muscle of the forearm. Also stitching the wire fencing to the upper 6
mm iron wire involved repeated twisting movements of the right hand, even though this was not as
strenuous as when he used the pliers. On an average he spent 2-3 hours a day doing strenuous, elbow
straining tasks. Towards the end of the work period he developed 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. The work as a fence builder involved
repeated, strenuous and elbow loading movements, in particular in connection with using pliers 2-3
hours per day for 17 years. The work was relevantly stressful for the development of right-sided tennis
elbow. As the total load period was very long, the requirement for a relevant load for at least half of the
working day may furthermore be reduced to 2-3 hours a day.

Example 6: Recognition of tennis elbow (forest worker for 14 days)

A forest worker worked exclusively with a power saw for a 14-day period. During the work with the
power saw the musculature of his right forearm was strained when the power saw was pressed against
the tree, and the power saw was at the same time held in a fixated posture away from the body.
Towards the end of the period he developed pain in his right elbow. He was diagnosed with tennis
elbow of his right arm.
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The claim qualifies for recognition on the basis of the list. The work meets the requirement for
strenuous work in an awkward posture, with static fixation of an object and simultaneous application of
muscular force, and there is good correlation between the load and the pathological picture.

Example 7: Recognition of golfers elbow (carpenter for 2-3 months)

A carpenter worked from October, exclusively straightening arming iron. In January came the onset of
symptoms of a right-sided golfers elbow. In the performance of the work, the tip of a hammer was
placed through the eye of the iron and the arming iron was straightened by pulling up or down.
The claim qualifies for recognition on the basis of the list. The work involved turning against resistance
and repeated movement against resistance and can be characterised as strenuous since muscular force
was applied at the same time. There was a major load on the relevant muscle groups in connection with
the development of the golfers elbow.

Example 8: Recognition of tennis elbow (slaughterhouse worker for 4 months)

A slaughterhouse worker repeatedly during the day used 30-40 cuts to loosen the flesh from half pigs
heads conveyed on belts. His left hand was used to hold the head tight, and the right hand was used to
apply the knife. After 4 months the slaughterhouse worker had pain in his right elbow and was
diagnosed with right-sided tennis elbow.
The claim qualifies for recognition on the basis of the list. The work involved repeated movement
against resistance with the knife arm while using muscular force and can be characterised as strenuous.
The slaughterhouse worker had a right-sided tennis elbow in close correlation with the work load.

Example 9: Recognition of tennis elbow (slaughterhouse worker for 1 year)

A slaughterhouse worker boned hams and front parts with his right hand. The knife was taken to a
horizontal position and at the same time pressure was exerted on the knife at the right thumb. Other
cuts required ingoing as well as outgoing half-circle movements while at the same time pressure was
exerted on the knife. After well over 1 year, the injured person had pain in his right elbow and was
diagnosed by a medical specialist with right-sided tennis elbow.
The claim qualifies for recognition on the basis of the list. The work required pressure on the knife
while turning the forearm, and the movements can therefore be characterised as strenuous and
relevantly stressful for the development of right-sided tennis elbow.

Example 10: Recognition of tennis elbow (housekeeper for 1.5 months)

A housekeeper in an institutional kitchen developed pain in her right elbow after she had been stirring
food for a month and a half, 4 hours a day. The remaining part of the working day she performed other
functions, such as making sandwiches and washing up. She was diagnosed with right-sided tennis
elbow.
The claim qualifies for recognition on the basis of the list. The hard work of stirring food involved
repeated movements against resistance while at the same time requiring muscular force for a substantial
part of the working day, and the housekeeper had a right-sided tennis elbow in immediate connection
with this 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

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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 12: Recognition of golfers elbow (machine engineer for 3 months)

The injured person worked as a machine engineer in a foundry manufacturing metal bars. He worked
on a machine, making 15 units per hour. He had to tighten and loosen hand wheels positioned at
shoulder height. After 3 months exposure he was diagnosed with right-sided golfers elbow.
The claim qualifies for recognition on the basis of the list. The work of tightening and loosening the
hand wheels of the machine was strenuous and straining on the elbow since a great deal of muscular
strength was needed for the twisting movements. The injured person developed a golfers elbow in
good time correlation with the strenuous exposure.

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 14: Recognition of golfers elbow (fish cutter for 2 years)

The injured person worked in the fish industry cutting different fish. The fishes were crudely cut on a
machine, and she then made filleting, and cut off fins and tail etc. with a knife. According to the
specialist of occupational medicine, the work was done at a relatively high pace with simultaneous
twisting and flexion/extension movements of the right wrist, and partly of the elbow joint, and required
some muscular force against resistance. She developed pain in her right arm after well over 2 years
work, and the medical specialist made the diagnosis of right-sided golfers elbow.
The claim qualifies for recognition on the basis of the list. It was relatively high-repetitive cutting
work, with simultaneous strenuousness against resistance and twisting movements as well as
flexion/extension movements of wrist and elbow. This type of work is relevantly stressful for the
development of a right-sided golfers elbow.

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
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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.

Example 16: Recognition of tennis elbow (cleaning work for 3 years)

A 55-year-old cleaner worked full-time in a printing shop for 3 years. She cleaned offices, corridors,
toilets, and the canteen. Her work consisted in vacuum cleaning, washing of floors, washing of tables,
washing of toilets, etc. She washed floors for approximately 3 hours a day and stairs for approximately
30 minutes; vacuum cleaned for about 1 hour, wiped off tables for about 1 hour and washed toilets for
about 2 hours. When washing tables and toilets she wrung a cloth several times per minute, using
strenuous wringing and turning movements of elbows and wrists. For washing of floors she used a wet
mop and a wringing machine. The toilets were often very dirty, and she had to use a lot of force to
scrub them clean. Towards the end of the period she developed pain in her right elbow and a medical
specialist diagnosed her with a right-sided tennis elbow (epicondylitis lateralis humeri dxt.) with direct
tenderness on palpation as well as indirect tenderness (tenderness when moving against resistance).
The claim qualifies for recognition on the basis of the list. The cleaner has had strenuous, repetitive and
awkward work movements in her right elbow in connection with wet mopping and washing of stairs for
a total of approx. 3.5 hours per day. In addition she also had powerful stresses on her elbow in
connection with numerous wringing movements every day. These stresses are equivalent to 3-4 hours
per day and existed for 3 years up to the onset of the disease.

Example 17: Recognition of golfers elbow operator in aluminium business

A 53-year-old woman worked for 4 years as a machine operator for a large manufacturer of aluminium
profiles. All day her work consisted in operating a cut-off saw. She grabbed profiles that were 6 metres
long and weighed between 3 and 30 kilos (typically 6-10 kilos) from a pallet and pulled them over to
the saw, where she positioned them. Then she activated two buttons, tightening the unit and sawing it
in two. The units were typically cut into 4 pieces, which she then picked up and packed into bundles, 3-
4 together. Then she lifted them onto a table and blew them clean with an air pressure pistol. Then they
were lifted onto a pallet and packed. She typically produced 70-80 units an hour with typically a total
of approximately 300 lifts at 3/4 arms length. The work involved constant twisting of the right wrist.
She developed pain in her right forearm and was diagnosed with right-sided golfers elbow.
The right-sided golfers elbow qualifies for recognition on the basis of the list. This is because the work
as an operator of a cut-off saw for several years constituted slightly to moderately strenuous and
repetitive work for the right elbow with several hundred lifts per hour of objects weighing typically 6-
10 kilos. The work furthermore involved awkward movements of the right elbow with twisting and
turning.

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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
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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)

3.7. Medical glossary (tennis elbow and golfers elbow)

Latin/medical term English translation
Condyle Round bump on a bone where it forms a joint with another bone
Epi Above
Infection Infectious degeneration caused by micro organisms
Inflammation Inflammatory degeneration with or without micro organisms
Lateral On the outer side
Peritendinitis Inflammatory degeneration of the tissue enveloping a tendon
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

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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)

4.1. Item on the list

The following diseases of the shoulder are included, according to the stated exposures, on the list of
occupational diseases (group C, item 5):

Disease
C.5.1. Rotator cuff-syndrome/impingement syndrome
C.5.2. Symptoms from or degeneration in the long
biceps tendon (biceps tendinitis, tendinitis caput
longum musculus bicipitis brachii)
Exposure
(a) Repetitive and strenuous shoulder
movements, in combination with an
assessment of the position of the arm in
connection with the load
or
(b) Static lifting of upper arm to about 60
degrees or more

4.2. Diagnosis requirements

One or more of the following diagnoses must have been made by a medical doctor
Rotator-cuff syndrome/impingement syndrome (M75.1 and M75.4)
Tendinitis caput longum musculus bicipitis brachii (symptoms from or degeneration in the long
biceps tendon) (M75.2)
Tendinitis musculi articulatio humeri (shoulder tendinitis) (M75.1)

Rotator-cuff syndrome/impingement syndrome

Rotator cuff is a term covering the mutual cuff formed around the front of the shoulder joint by 4
tendons from 4 muscles:
The supraspinatus tendon
The infraspinatus tendon
The subscapularis tendon
The teres minor tendon

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.

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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.

Symptoms from or degeneration in the long biceps tendon

The long biceps tendon is functionally part of the stabilisation of the shoulder joint and is subject to the
same exposures as the 4 rotator-cuff tendons.

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

The injured persons subjective complaints (pain, reduced motion, etc.)

A clinical objective examination

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

Tenderness of the biceps tendon on the anterior surface of the shoulder

Indirect tenderness (for instance Speeds test or Yergasons test)

Degeneration or lesion of the rotator-cuff tendons and other structures of the shoulder can be
diagnosed by way of

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 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).

4.3. Exposure requirements

4.3.1. Repetitive and strenuous shoulder movements (exposure (a))

Diseases of the shoulder and the biceps tendon with the stated diagnoses can be recognised on the basis
of the list when work has been performed that leads to repetitive and strenuous shoulder movements.
The assessment will furthermore include an assessment of the posture of the arm in connection with the
load.
With regard to strenuousness, the load must be mechanically and physiologically relevant in relation to
the disease in question. This means that the work movements must constitute a relevant strain on the
shoulder joint or the biceps tendon in a relevant way. Whether the work is relevantly stressful for the
shoulder joint/upper arm depends on a concrete assessment of the various risk factors involved in the
work (the repetition, the exertion, and any stressful working postures for shoulder/upper arm).

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.

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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

the degree of application of muscular force of the shoulder/upper arm

whether the unit offers resistance
whether there are simultaneous twisting or turning movements of the shoulder joint
whether the work is performed in awkward postures of shoulder/upper arm, for instance in
extreme postures or when the upper arm is lifted high up

Awkward working postures or movements

All joints have a normal functional posture. This is the joint posture that gives the optimal function of
the extremity (extremity = arm or leg). Movements occurring in other positions than the normal
position are regarded as awkward. The greater the deviation from the normal posture, the more stressful
it will be. Movements in awkward positions are not optimal and thus increase the load on for example
muscles, tendons and connective tissue.

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

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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.

Lifting and cycle time

When the arm is lifted, the blood flow through the tendons of the rotator cuff is reduced. When the arm
is subsequently lowered, the blood flow will be improved, and the tissue gets a chance to restitute. The
relationship between how long the arm can be held lifted in relation to how long it is lowered is called
the cycle time.
The briefer the cycle time, the more the tendons of the rotator cuff are affected because the restitution
phase becomes brief. This means that work where the arms are held lifted for relatively long and
lowered for a relatively short while (brief restitution) is more stressful for the shoulder than work that
involves brief lifts and lowering of the arm for some time (long restitution).
Therefore the cycle time will also be included in an assessment of the load on the shoulder joint in
cases where repeated lifting of the arm has taken place.

Combined assessment of the load

If the work is characterised by very quickly and monotonously repeated movements of the shoulder
joint, with simultaneous, very stressful working postures for the shoulder/upper arm (for instance a
long reaching distance, work with the arm lifted high up, or repeated lifts of the upper arm or many
twisting and turning movements of the shoulder joint), there will only be a requirement for moderate
strenuousness in excess of the normal functional power used to move the arm in connection with the
performance of the work.

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.

The duration of the exposure

In principle there must have been relevant shoulder-loading work every day for at least half of the
working day (3-4 hours) and for a long time (for months).
However, the duration requirement also depends on a concrete assessment of the various risk factors of
the work (the repetition, strenuousness and any awkward working postures or movements of the
shoulder/upper arm).
Thus, if the work has been very stressful for the shoulder, this would speak in favour of requiring a
relatively brief exposure period of relatively few months. If the work has been more moderately, yet
relevantly, stressful for the shoulder joint, this would require that the work took place for a relatively
long exposure period of several months.

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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.

4.3.2. Static lifting of upper arm (exposure (b))

Diseases of the shoulder and the long biceps tendon with the stated diagnoses are furthermore covered
by the list when work is performed that leads to static lifting (fixation) of the upper arm to about 60
degrees or more.
In order that the disease can be recognised on the basis of the list, the upper arm must have been fixated
at about 60 degrees or more in largely the same posture for a great part of the working day (for hours)
and for a considerable amount of time (for months).
In order for the work to be characterised as static, it is decisive that the joints affected by the muscles
are kept in largely the same posture during the work. This implies that work which is characterised by
repeated lifting/lowering movements of the arm cannot be characterised as a static load. However, in
cases where the shoulder and upper arm are held statically lifted to 60 degrees or more during the work,
while forearm and hand are working with repeated lifting/lowering movements, there will be a relevant
load on the shoulder and upper arm.

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.

4.4. Examples of pre-existing and competitive diseases/factors

Deposits of calcium hydroxyapatite in the rotator-cuff tendons with any secondary degenerative
changes in connection with such calcium deposits (tendinitis calcaria)
Frozen shoulder
Painful laxity of the shoulder joint (subluxation and generally loose joints)

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 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)

4.5. Managing claims without applying the list

Only rotator-cuff syndrome/impingement syndrome and symptoms from or degeneration in the long
biceps tendon are covered by the list item on shoulder diseases. 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
of the case to the Occupational Diseases Committee.
Examples of diseases of the shoulder or upper arm that might be recognised after submission of the
case to the Committee are diseases of the short biceps tendon or the tendon attachment of the biceps
muscle at the elbow. There is no sufficient medical documentation that would lead to inclusion on the
list of occupational diseases of degeneration of the biceps tendons 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.

4.6. Examples of decisions based on the list

4.6.1. Repetitive and strenuous shoulder movements (exposure (a))

Example 1: Recognition of degeneration of the rotator-cuff tendons in the form of shoulder tendinitis
(packing worker for 6 years)
A 41-year-old man worked for 6 years with transfer to pallets of cardboard boxes containing small
ventilation pumps. Each box measured 15 x 15 x 15 centimetres and weighed 3-4 kilos. When
transferring the boxes to the pallets he grabbed a horizontal row of 3-4 boxes weighing a total of 11-15
kilos, which he firmly, with both hands, held pressed together and transferred to a pallet. The distance
between the two boxes at each end was 60-70 centimetres, and the fixation was performed with his
shoulder joint slightly lifted, part of the exertion thus occurring via the shoulder cuff muscles. He
usually made this manoeuvre 1,000-1,200 times each day. For a period of 6 weeks he worked overtime
every two weeks, which meant that he handled about 5,000 boxes a day, equivalent to 1,500 lifts to
pallets per day. In this connection he developed bilateral shoulder pain and a medical specialist
diagnosed him with bilateral shoulder tendinitis (inflammatory degeneration of rotator-cuff tendons).
The claim qualifies for recognition on the basis of the list. The packing worker for 6 years carried out
shoulder-loading work with repeated movements of the upper arms in combination with slight to
moderate gripping/fixation exertion of the upper arms, long reaching distances and lifted shoulder
joints, and there is good correlation between the disease and the load.

Example 2: Recognition of rotator-cuff lesion (concrete breaking for 3 weeks)

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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.

Example 4: Recognition of biceps tendinitis (newspaper packer for 10 years)

A woman worked as a packer at a newspaper for well over 10 years. She packed newspapers, maga-
zines and brochures and furthermore worked at an inserting machine. Packing of newspapers and
magazines was done at a conveyor belt, where she lifted 5- to 25-kilo stacks of newspapers and
magazines from a conveyor belt onto a pallet lifter. She first lifted up the stack with one hand, left or
right depending on the conveyor belt she was standing at, and then grabbed hold of it with the other
hand. The work at the inserting machine consisted in lifting stacks of newspapers from a pallet to the
inserting machine. She took one stack of 35 newspapers at a time. First she lifted up the stack and
separated it with her left hand, and then she lifted it onto the inserting machine with both hands. Here
the stack was slightly bent from each side and adjusted before it was lifted into the machine. The pallet,
sitting on a pallet lifter, was packed up to head height. Due to a high edge on the inserting machine
each stack had to be lifted up to shoulder height. When she packed brochures, stacks were lifted from a
pallet onto a work table. Here the brochures were first counted and then tied up with cross strings, and
finally they were lifted onto another pallet. The hardest part of the work was lifting stacks of brochures
from the pallet onto the table with right or left hand, depending on where she was standing. Generally
the work was performed at a very high pace, often with very long work days. She developed pain in her
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 packing worker for 10 years had high-
repetitive work with many high and strenuous, rather heavy lifts, which were awkward and stressful for
the left upper arm. There is good correlation between the disease and the exposure.

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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.

Example 6: Recognition of rotator cuff syndrome (industrial operator for 3 years)

A 38-year-old woman had worked for 3 years as an industrial operator. For two thirds of the working
day her work consisted in removing ready-made plates from a plant. The plates weighed approximately
10 kilos and measured 60 x 150 centimetres. The plates had to be distributed on three different pallets.
She first grabbed hold of the remotest edge with her right hand while holding the lower edge with her
left hand. Then she lifted the plate to a vertical position with her right arm. Then the plate was lifted
onto one of the three pallets and stapled from hip height to shoulder height. The last third of the
working day she serviced other employees by picking up empty pallets and driving away the full
pallets. The pallets ran on rails in the floor, and this work did not involve repeated movements of the
shoulder joint, strenuousness or repeated lifts of the arm. She developed complaints in her right
shoulder, and a medical specialist made the diagnosis of right-sided rotator cuff syndrome.

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.

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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.

Example 8: Recognition of impingement syndrome (slaughterhouse worker for 4 years)

A 44-year-old man worked as a slaughterhouse worker for well over 4 years. For approximately 60 per
cent of the working day he was cutting front ends weighing 10-12 kilos. The front ends were hanging
on hooks, from where they had to be lifted manually at varying lifting height, from knee level to head
height, onto the cutting table. During the cutting work he performed movements with his right arm that
led to inward and outward turning of the shoulder joint. Furthermore the shoulder blade of the front
ends had to be removed manually. This happened by lifting the shoulder blade with a knife, gripping
hold of it and pulling it out with a strenuous pulling movement. The last approximately 40 per cent of
he working day the injured person was a service man. As a service man he i.a. had to empty lorries.
This happened by pulling Christmas tree hooks out of the lorry with his right hand. In addition he
pushed racks with meat hooks from cooler room to cutting rooms. The work as a service man did not
involve any particular loads on the shoulder joint, only moderate movements of the shoulder joint and
moderate strenuousness. After 4 years work he developed pain and restricted motion of his right
shoulder, and a medical specialist made the diagnosis of right-sided impingement syndrome. A
subsequent MR scan of the shoulder showed normal findings.

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.

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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
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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 12: Recognition of shoulder tendinitis (packer for 3 years)

A 42-year-old woman worked for 3 years as a packer in a large bakery. Her work consisted in
packaging flatbread. She worked at a conveyor belt, which was positioned at elbow-height on her right
side. By reaching her right hand forward or a bit sideward, she grabbed a stack of six small flatbreads
from the conveyor belt. Then she placed the stack in a small carton on another conveyor belt on her left
side. The work was performed at a very high pace, with a relatively long reaching distance for the right
shoulder and occasionally with slight twisting and turning movements in the shoulder joint. A stack of
flatbread weighed about 0.4 kilos, and the lifting and handling of a stack required only moderate
exertion. The daily piecework rate was several thousand pieces. After about 3 years work she de-
veloped pain and tenderness in her right upper arm and shoulder and a medical specialist made the
diagnosis of right-sided shoulder tendinitis. The claim qualifies for recognition on the basis of the list.
The packer for 3 years performed high-repetitive work in combination with slight strenuousness in
connection with minor lifting. The work movements were furthermore performed with arms lifted to
elbow height, with some reaching distance and with slight twisting and turning movements in the right
shoulder joint. The work was therefore relevantly stressful for the development of a right-sided
shoulder 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)).

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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.

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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.
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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.

4.6.2. Static lifting of upper arm (exposure (b))

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.
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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 22: Recognition of shoulder tendinitis (auto mechanic for 9 months)

A 25-year-old man worked as an auto mechanic for 9 months. He was specialised in changing
silencers. For two thirds of the working day, on an average, he worked in a pit, removing and putting in
silencers on the underside of cars with his arms stretched upward. The remaining part of the working
day he performed other mechanics work that did not involve static lifts of the upper arms or other
loads on the shoulder. He developed pain and restricted motion of his right shoulder and a medical
specialist diagnosed him with right-sided shoulder tendinitis.
The claim qualifies for recognition on the basis of the list. The injured person worked as a mechanic for
9 months, which involved static fixation of the upper arms above 60 degrees for the major part of the
working day. He developed a right-sided shoulder tendinitis, and there is good correlation between the
onset of the disease and the performance of the work.

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.

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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)

4.7. Medical glossary (shoulder diseases)

Latin/medical term English translation
Acromion The projection of the shoulder blade
Articulatio acromion clavicularis The acromioclavicular joint (joint between the collarbone and the acromion,
which is a wide, flat projection on the external corner on the posterior
surface of the spine of the shoulder blade)
Articulatio humero scapularis The shoulder joint
Biceps muscle The two-headed flexor muscle of the upper arm
Bursa Fluid-filled cavity
Bursa subacromialis Fluid-filled cavity between the ceiling of the shoulder joint and the joint
capsule of the head of the arm bone
Bursitis Inflammatory degeneration of a bursa (fluid-filled cavity) often causes
symptoms in the form of impingement (squeezing) syndrome
Degeneration Reduction in functionality as a consequence of breaking down of tissue

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

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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.

5. Chronic neck and shoulder pain (B.2)

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
5.7. Medical glossary (chronic neck and shoulder pain)

5.1. Item on the list

The following disease of the neck and shoulder region is included, according to the stated exposure, on
the list of occupational diseases (group B, item 2):

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

5.2. Diagnosis requirements

A medical doctor must have made the diagnosis of cervicobrachial syndrome (chronic neck and
shoulder pain, ICD-10 M.53.1).

The medical diagnosis is made against the background of a combination of

The injured persons subjective complaints (symptoms)
A clinical, objective examination

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.

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 The 12 areas of the neck and shoulder region (6 on each side):

SEEN FROM THE FRONT SEEN FROM THE BACK

The 12 muscle areas (6 x 2) appear in the illustration in grey colour:

Musculus trapezius
Musculus levator scapulae
Musculus infraspinatus
Musculus supraspinatus
Musculus pectoralis major
Regio nuchae

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

2. Indication of the number of tender areas (out of the 12 areas)

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

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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.

Neck and shoulder pain with

no or slight tenderness (rated 1 or 2)
limited distribution of moderate to considerable tenderness (rated 3 or 4) to a few muscular
areas
does not meet the diagnostic requirements to the disease cervicobrachial syndrome (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.

5.3. Exposure requirements

In order for the disease cervicobrachial syndrome (chronic neck and shoulder pain) to be covered by
the list, there must have been exposure, for a considerable number of years, in the form of 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 girdle.

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.

No distinction is made between work in a standing and a sitting posture.

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.

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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

a. for at least 8-10 years

b. for at least 8 months per year
c. for at least half of the working day (3-4 hours per day)

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 quickly repeated movements of shoulders/upper arms

Long-lasting bending of the neck
Long-lasting, static load on the neck and shoulder girdle
Strenuous movements of the shoulder/upper arm
A very prolonged, daily exposure (more than 8 hours per day)

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.

5.3.2. Other load requirements

Quickly repeated movements of the shoulder/upper arm

In order for the work to be characterised as relevant neck and shoulder loading work within the
meaning of the list, there need to have always been quickly repeated movements of the shoulder/upper
arm, of a certain frequency/intensity, for at least half of a normal working day (3-4 hours per day).

Movements of the shoulder/upper arm are movements of the shoulder joint and/or the upper arm.

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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:

Bending of the neck

A static load on the neck and shoulder girdle
Very strenuous movements of the shoulder/upper arm
A very prolonged, daily load (more than 8 hours per day)
A very prolonged load period (15 years or more)

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.

Bending of the neck

Work with bending of the neck is work that is characterised by being performed in postures where the
neck is fixated in a flexed position for some time while quickly repeated movements are being made
with the shoulder/upper arm. There is no requirement, however, that the neck should be bent all the
time.

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.

Static load on the neck and shoulder girdle

Static load on the neck and shoulder girdle means that the work is characterised by working postures
where the neck and shoulder girdle is fixated in the same posture for some time while quickly repeated
work movements are being made with the shoulders/upper arms.

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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.

Strenuous movements of the shoulder/upper arm

If the work involved quickly repeated movements of the shoulder/upper arm in combination with a
certain exertion of the shoulders/upper arms and perhaps also the neck, this might be able to reduce he
requirement to the number of repeated movements per minute or the requirement to the duration of the
load over time.

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.

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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 pathological picture and the time correlation

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.
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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.

5.4. Examples of pre-existing and competitive diseases/factors

Muscular pain with causes other than work (for example fibromyalgia)
Certain kinds of arthritis of the cervical spine and/or shoulder joint
Prolapsed cervical disc
Disease/symptoms caused by degeneration of tissue and bones
Effects of whiplash injury
Previous neck and shoulder pain (onset before commencement of the stressful work)

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.

5.5. Managing claims without applying the list

Only chronic neck and shoulder pain (cervicobrachial syndrome) is covered by item B.2. regarding
neck and shoulder diseases. There furthermore need to have been exposures meeting the recognition
requirements of the list. Other unlisted diseases or exposures will in special cases qualify for
recognition after submission to the Occupational Diseases Committee.

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.

5.6. Examples of decisions based on the list

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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
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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
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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
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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.

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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
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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)

5.7. Medical glossary (chronic neck and shoulder pain)

Latin/medical term English translation

Arthrosis cervicalis Degenerative arthritis of the cervical spine
Brachium Arm (in anatomy in particular the upper arm)
Cervix Neck
Cervicobrachial Pertaining to neck and shoulder girdle

Degeneration Decline or breakdown of normal function, for instance degeneration of

the lumbar spine, which may cause a prolapsed disc. There are many
causes of degeneration of tissue, including hormonal causes, age-
related change, reduced blood supply and the effects of traumas, as
well as systemic diseases such as real arthritis and rheumatoid arthritis
Extension Stretching

Fibromyalgia Muscular arthritis

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Flexion Bending

Impingement syndrome Syndrome where a structure, for example a tendon, is caught/squeezed

in the shoulder joint
Muscle infiltration Pain and tenderness of the muscles

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

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Chapter 7. Lung diseases
List of contents

1. Pleural plaques (E.3.3)

1.1. Item on the list
1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (pleural plaques)
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 smoking or other private causalities
2.7. Managing claims without applying the list
2.8. Examples of decisions based on the list
3. Asthma (E.8)
3.1. Item on the list
3.2. Diagnosis requirements
3.3. Exposure requirements
3.4. Examples of pre-existing and competitive diseases/factors
3.5. Managing claims without applying the list
3.6. Examples of decisions based on the list
4. Lung disease with restricted lung function of the obstructive type (E.9)
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
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

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1. Pleural plaques (E.3.3)

1.1. Item on the list

1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Medical glossary (pleural plaques)

1.1. Item on the list

The following lung disease and exposure are included on the list of occupational diseases (Group E,
item 3.3):

Disease Exposure
E.3.3. Pleural plaques after known asbestos Asbestos
exposure

1.2. Diagnosis requirements

The diagnosis of pleural plaques after known asbestos exposure (J.92.0) must have been made by a
medical doctor.
Pleural plaques should not be mistaken for the diseases lung asbestosis or widespread formation of
connective tissue in the pulmonary pleura (fibrosis pleurae) with affected lung function, which also are
included on the list under the group of asbestos-related diseases (Group E, item 3.1 and 3.2).

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

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 X-ray examination or scan of the lungs
Clinical, objective examination (in order to rule out any other lung disease)

The course and consequences of the disease

Frequently there are no symptoms, and the condition is discovered by coincidence in an x-ray
examination of the lungs made for other reasons. In rare cases there may have been pain from the chest
or the patient may have found it hard to breathe.

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.

1.3. Exposure requirements

When there has been relevant exposure in the form of asbestos, pleural plaques can be recognised on
the basis of the list.

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

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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.

1.4. Examples of pre-existing and competitive diseases/factors

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.

Pre-existing or competitive diseases

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.

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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.

Other asbestos-related pulmonary and pleural diseases

In some cases, in addition to finds of pleural plaques, there will be finds of cancer of the pleura or the
peritoneum (malignant mesothelioma), cancer of lungs or respiratory passages (bronchogenic
carcinoma or larynx cancer), lung asbestosis and/or widespread formation of connective tissue in the
lungs with affected (restricted) lung function. For many claims it will be typical for pleural plaques to
be discovered by coincidence in connection with examinations of the other and typically more serious
disease cases.

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.

Other disease conditions

Other degeneration of the pleurae that might be mistaken for pleural plaques are the consequences of
tuberculosis, inflammatory conditions or traumas. Usually, however, such degeneration is only
unilateral. The above-mentioned competitive diseases and conditions may in some cases have affected
the pleurae, thus affecting the general condition and function of the lungs, but they cannot in
themselves lead to the development of pleural plaques.
Therefore, if there are definite signs of pleural plaques and the claim meets the recognition
requirements, any pre-existing or competitive lung diseases or conditions will not have any influence
on recognition of the claim.

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)

Obstructive lung disease with impaired lung function

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Obstructive lung disease with impaired lung function has no correlation with asbestos diseases and can
therefore not be attributed to exposure to asbestos or asbestos-containing material. However,
obstructive lung disease with impaired lung function may be caused by other types of disease
conditions in the lungs and by smoking.

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.

1.5. Managing claims without applying the list

Only pleural plaques after asbestos exposure, i.e. handling of or other prolonged, close contact with
asbestos or asbestos-containing materials are covered by the list.
Other diseases or exposures not on the list will in special cases be recognised after submission of the
claim to the Occupational Diseases Committee.
One example of another asbestos-related disease of the pleura that might be recognised after
submission of the claim to the Committee is asbestos-related pleuritis with pleural effusion.

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.

1.6. Examples of decisions based on the list

Example 1: Recognition of pleural plaques (mechanic for 30 years)
A 51-year-old mechanic worked in different employments for well over 30 years. For a number of
years in the 1970s, the work involved contact with asbestos when asbestos-containing brake linings
were changed, one to several times a week. He had to blow the brakes clean with pressurized air, which
caused the asbestos to whirl up into the breathing zone. The asbestos exposure for several years of the
period in question was documented by the employer. In a routine x-ray examination towards the end of
2004, the mechanic was diagnosed with bilateral and calcified pleural plaques.

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.

Example 2: Recognition of pleural plaques (insulation worker for 2-3 months)

A 53-year-old insulation worker worked in 1976 for a period of about 2-3 months in a small business.
The work consisted in changing old insulation material in piping systems and lining with new
insulation material. Both the old and the new insulation material contained a lot of asbestos. The work
occurred indoors without any kind of safety protection and with massive exposure to asbestos dust for
the whole of the working day. He subsequently changed to other work and was not later exposed to
contact with asbestos. The asbestos exposure was confirmed by a previous colleague as it was no
longer possible to obtain documentation from the previous employer. In mid-2004 he started getting
slight breathing problems, and an x-ray examination established widespread, calcified pleural plaques
with moderately reduced (restrictive) lung function. However, the medical examination also showed

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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.

Example 3: Recognition of pleural plaques (carpenter for 5 years)

A 62-year-old man worked as a carpenter for many years. For a 5-year period in the latter half of the
1970s the work sporadically (several days a month, but not every day) consisted in cutting asbestos
plates in connection with roof-laying. He i.a. cut corners off the plates and cut them in half, and the
handling of plates occurred without any kind of asbestos protection. In 2004 he had increasing
breathing problems, and subsequent medical examinations established the disease mesothelioma
(malignant cancer of the pleura) as well as moderate pleural plaques in the pleurae. Furthermore the
examination established a severely restricted lung function.

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 4: Recognition of pleural plaques (plumber for 8 years)

A 64-year-old plumber worked for a large company for well over 8 years, down through the 1970s and
early 1980s. For the major part of the working day, his work mainly consisted in exchanging pipes and
making repairs and installing new piping systems. His employer at the time later confirmed that there
had been daily exposure to asbestos, a substantial part of the piping at that time being insulated with
asbestos-containing materials. Towards the end of 2004, after a period of moderate chest pain and
breathing problems, he was diagnosed with rather pronounced pleural plaques. According to the
medical specialist had he dyspnoea (instances of breathing problems) and a slightly restricted lung
function as a consequence of the disease. There were no signs of asbestosis or other disease of lungs or
pleurae.
The claim qualifies for recognition on the basis of the list. The plumber was exposed to frequent
contact with asbestos-containing insulation material for several years and developed pleural plaques
many years later. There is good time correlation between the disease and the asbestos exposure, and his
complaints, in the form of dyspnoea and reduced lung function, are all attributable to the work-related
disease.

Example 5: Claim turned down pleural plaques (office employee for 2 months)
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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.

1.7. Medical glossary (pleural plaques)

Latin/medical term English translation
HRCT scan High Resolution Computer Tomography scan
Lung asbestosis Pneumoconiosis, i.e. a disease of the lungs caused by the inhalation of
inorganic dust which is deposited in the lungs and provokes inflammatory
degeneration and fibrosis. Lung asbestosis is a consequence of the inhalation
of asbestos dust (J.61.9). The disease is included on the list of occupational
diseases.
Other types of pneumoconiosis are silicosis, anthracosis, siderosis,
berylliosis etc. Lung asbestosis is furthermore a type of silicosis, asbestos
consisting of calcium and magnesium silicate.
Mesothelioma Tumour originating from the mesothel, which is a layer of cells lining a
mucous membrane. Is found in benign and malignant forms.

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

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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.

What can be seen

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
(such as soft tissue, which therefore is dark or cannot be seen at all)

What cannot be seen

Most soft tissue, organs, ligaments, cartilage, muscles

When are x-rays used

For example in connection with degeneration of bones: fractures, joint
luxation, arthritis of joints; control of inserted joint prostheses or metal
(splints and nails, marrow nails).
The National Board of Industrial Injuries is not allowed to directly request
this type of paraclinical examination (x-rays).

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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

2.1. Item on the list

The disease chronic bronchitis/chronic obstructive lung disease is included on the list of occupational
diseases (Group E, item 7):

Disease Exposure

E.7. Chronic bronchitis/COLD (a) Vapours/gases/dust and/or smoke for many

years

2.2. Diagnosis requirements

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

Relevant subjective complaints and

Clinical, objective degeneration

Symptoms
Cough
Sputum expectoration in some cases
Reduced lung function (shortness of breath, in particular in connection with exertion)

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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.

2.3. Exposure requirements

In order for chronic bronchitis/chronic obstructive lung disease to be covered by the item on the list of
occupational diseases, there must have been one or more exposures over several years, as set out
below.

2.3.1. Vapours/gases/dust and/or smoke

Chronic bronchitis and chronic obstructive lung disease may develop after exposure to various types of
vapours/gases/dust and/or smoke for some time.
This may involve largely all dusty or smoky work processes, and the exposures may be unspecific as
well as specific. An unspecific exposure means that the exposure can be composed of several different
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substances and that the specific course cannot be identified with certainty. A specific exposure can for
instance be vapours/gases/dust and/or smoke from aluminium or hard metal.

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.

2.5. Working conditions

In the assessment of whether the exposure at work is sufficient for the disease to be recognised it is
relevant to consider if the work was performed indoors or outdoors. The exposure will be higher in
small rooms without adequate ventilation and lower where the work is performed out of doors.

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.

2.6. Competitive factors smoking or other private causalities

Like most other diseases, chronic bronchitis/chronic obstructive lung disease may develop or get worse
as a consequence of other factors unrelated to work. Therefore, in each specific case, the National
Board of Industrial Injuries will make an assessment of whether any stated competitive factors are of a
nature and a scope that may give grounds for making a deduction in the compensation.

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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).

2.7. Handling claims without applying the list

Only chronic bronchitis/chronic obstructive lung disease is covered by group E, item 7 of the list.
Furthermore there need to have been exposures on the list which meet the requirements for recognition.

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:

At least 20 years exposure to passive smoking,

on a daily basis for at least half of the working day, and
intense smoke exposure in small rooms

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).

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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.

2.8. Examples of decisions based on the list

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)

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3. Asthma (E.8)

3.1. Item on the list

3.2. Diagnosis requirements
3.3. Exposure requirements
3.4. Examples of pre-existing and competitive diseases/factors
3.5. Managing claims without applying the list
3.6. Examples of decisions based on the list

3.1. Item on the list

The disease asthma is included on the list of occupational diseases (Group E, item 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

3.2. Diagnosis requirements

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

Relevant subjective complaints (symptoms) and

Clinical, objective degeneration

Asthma is a very prevalent disease in the population, and only a minor proportion is caused by
exposure to harmful substances in the workplace.

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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

Clinical examinations and findings

The medical examinations must describe a symptom picture that makes likely an asthma diagnosis.
The asthma diagnosis is made by documenting variations in the respiratory passage resistance of 20 per
cent or more (peak flow measurements) and 15 per cent or more (FEV1 measurements).

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:

Provocation with histamine, metakolin, mannitol or similar substances

Exertion test
Measuring of the lung function at home with a hand-held peak flow meter, from morning till
night or from day to day, or a spirometer measurement by a doctor (morning/evening)
Bronchia-extending spray
Prednisone treatment

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.

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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.

Objective signs of asthma

Establishing allergic asthma (allergy)

Allergic asthma can be established in one of the following tests:

a. Skin prick test

b. Positive RAST test, i.e. measuring of allergy antibodies in the IgE blood type
c. Positive histamine release test, i.a. histamines are released from the while blood cells in a
blood test after contact with the specific allergen from the workplace

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.

Establishing non-allergic asthma

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.

3.3. Exposure requirements

In order for asthma to be recognised under item E.8 of the list of occupational diseases, there must have
been one or more of the exposures set out below.

(a) Plants or plant products

Typical occupational groups: Bakers, sawmill workers and people working with feedstuffs.

(b) Animals or animal products

Typical occupational groups: Agricultural workers, slaughterhouse workers, laboratory workers in
contact with test animals, and workers in the fishing industry.

(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.

(d) Isocyanates and certain anhydrides in epoxy resins

Typical occupational groups: Painters, car lacquering workers; employees in the paint industry, metal
industry and pharmaceutical industry, or person working in rooms with incomplete combustion besides.

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.

(e) Chromium and some chromium compounds

Typical occupational groups: Steel mill workers, workers in the metal, chromium and dye industries,
and in connection with cement work and use of chrome-tanned products. Steel contains chromium, and
therefore welding and similar work on steel materials will be included.

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(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.

(h) Hard metal

Typical occupational groups: Workers in the metal industry and welders working with hard metal. Hard
metal is a special mixture of powder metals resulting in extreme hardness. The core of the material is
the element wolfram tungsten, which through a special process gets chemically tied with coal.

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.

Exposure to welding smoke

Exposure to welding smoke is not necessarily covered by the list item regarding asthma. What is
decisive is whether the weld is done in materials containing chromium, cobalt or nickel, which is the
case for some types of iron. Therefore it will be very important in these types of cases to obtain more
detailed information of the type of iron the work has involved as well as the more detailed composition
of the material.

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.

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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.

3.5. Managing claims without applying the list

Only asthma is covered by group E, item 8 of the list. Furthermore, as stated in the list of occupational
diseases, there must have been exposures meeting the recognition requirements.

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)

Work with platinum-containing products

We refer to chapter 1 of this guide, which describes cases where the decisions are not based on the list
of occupational diseases.

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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.

3.6. Examples of decisions based on the list

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.

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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.

Example 4: Recognition of asthma under E.8.(c) (cleaner exposed to enzymes)

A 51-year-old woman was employed for 7 years as a cleaner in a laboratory where various enzymes
were used. The work i.a. consisted in emptying dustbins containing tablet residues, and there was a
certain generation of dust when the bags were emptied and closed. Furthermore she had to close and
move bags full of work clothes from the production. The bags were often overfilled and when the
clothes were transferred to another bag, it generated dust. Already after a couple of years work she
developed symptoms in the form of shortness of breath and was later diagnosed with allergy to various
enzymes. A specialist of occupational medicine diagnosed her with asthma.

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.

Example 5: Recognition of asthma under E.8.(d) (goldsmith exposed to isocyanates)

A 45-year-old man worked for 26 years as a goldsmith and only to a very limited extent used
respiratory protection. In connection with gold and silver work the materials were warmed up, which
released isocyanates from the materials. After 15 years the goldsmith experienced episodes of breathing
problems, coughing and wheezing. There was a considerable improvement in his lung function during
long holidays. Eventually he was diagnosed with asthma and then ceased work. After cessation of work
the symptoms disappeared from the respiratory passages.

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.

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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.

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4. Lung disease with restricted lung function of the obstructive type (E.9)

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

4.1. Item on the list

Lung disease with restricted lung function of the obstructive type is included on the list of occupational
diseases (Group E, item 9):

Disease Exposure

Lung disease with restricted lung function of Isocyanates

the obstructive type

4.2. Diagnosis requirements

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:

Relevant subjective complaints (symptoms) and

Clinical, objective changes

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

Establishing a lung disease with restricted lung function

A lung function test made in a hospital or by a GP

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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 are used in different trades. It is used for instance in:

The building and construction industry
The plastics industry
The iron and metal industry
The wood industry
The car industry
The electrics and electronics industry

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.

4.4. Examples of pre-existing and competitive diseases/factors

Examples of possible competitive factors that may affect the development or course of the disease:
Tobacco smoking
Alpha-1 antitrypsin deficiency, which is a hereditary gene disorder

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.

4.5. Managing claims without applying the list

Only lung disease with restricted lung function of the obstructive type is covered by Group E, item 9 of
the list. There must furthermore have been exposures meeting the recognition requirements, as stated
on the list. A lung disease with restricted lung function of the obstructive type which is 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.

4.6. Examples of decisions based on the list

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.

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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

5.1. Item on the list

The disease pneumonia is included on the list of occupational diseases (Group E, item 10):

Disease Exposure

Pneumonia Vanadium and vanadium compounds

5.2. Diagnosis requirements

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:

Relevant subjective complaints (symptoms) and

Clinical, objective changes

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.

5.3. Exposure requirements

In order for pneumonia to be covered by the item on the list, there must have been a relevant exposure,
as described in detail below.

Exposure to vanadium and vanadium compounds

Vanadium is an element which is primarily used for the manufacture of hard steel. Vanadium is i.a.
found in armour for tanks and other military vehicles, airplane engines, ball bearings, and springs in
cars and surgical equipment.

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.

5.4. Examples of pre-existing and competitive diseases/factors

If, in connection with diagnosing pneumonia, other specific causes of pneumonia have been diagnosed,
such as legionella disease, it may in some cases have the effect that we make a reduction in the
compensation amount or turn down the claim.

5.5. Managing claims without applying the list

Only pneumonia is covered by Group E, item 10 of the list. There must furthermore have been
exposures meeting the recognition requirements, as stated on the list.

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.

5.6. Examples of decisions based on the list

Example 1: Recognition of pneumonia (E.10) (exposure to vanadium)

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.

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Chapter 8. Mental disorders
List of contents

1. Posttraumatic stress disorder (F.1)

1.1. Item on the list
1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Delimitation between accident and occupational disease

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1. Posttraumatic stress disorder (F.1)

1.1. Item on the list

1.2. Diagnosis requirements
1.3. Exposure requirements
1.4. Examples of pre-existing and competitive diseases/factors
1.5. Managing claims without applying the list
1.6. Examples of decisions based on the list
1.7. Delimitation between accident and occupational disease

1.1. Item on the list

The following mental disease is included on the list of occupational diseases (Group F, item 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)

1.2. Diagnosis requirements

The disease posttraumatic stress disorder (PTSD2) must meet the below diagnosis criteria according to
the WHOs international classification of diseases ICD-10: F43.1.

A: Exposure to stressful events or situations (either short- or long-lasting) of an exceptionally

threatening or catastrophic nature

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

C: Avoidance of all activities 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.

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 e. An enhanced startle reaction

E: The disorder is present within 6 months from the traumatic experiences

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.

Recognition will be based on an assessment of the diagnosis made by a specialist of psychiatry.

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.

1.3. Exposure requirements

The disease is deemed to be caused mainly by external stresses and may perhaps have permanent
mental consequences. The diagnosis itself includes an assessment of the nature of the exposure.

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.

Examples of relevant exposure may be

severe threats causing a sense of mortal danger, for instance war action, being under fire, or
dangerous driving in mined areas
rescue work in catastrophe areas with severe stresses
mortal danger when exposed to violence or threats of violence

1.4. Examples of pre-existing and competitive diseases/factors

In some cases there may be pre-existing or competitive mental illness which is without any correlation
with the particularly stressful exposures in the workplace, but relevant for the overall pathological
picture. Similarly, other circumstances than circumstances related to work may be significant for a
persons mental condition.

Examples of pre-existing or competitive diseases may be depression, anxiety, psychoses, or similar

disorders.

1.5. Managing claims without applying the list

Only the disease posttraumatic stress disorder, including delayed-onset PTSD with PTSD symptoms
within 6 months, is covered by item F.1 on the list. There must furthermore have been exposures
meeting the stress requirements.

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

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 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.

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1.6. Examples of decisions based on the list

Posting (military stationing and relief work)

Example 1: Recognition after stationing to the peace-keeping forces

An officer who was stationed more than once, to regions at war, in the peace-keeping forces saw how a
local soldier was executed by being shot through the mouth. He was furthermore exposed to a number
of violent incidents, both direct war action and assaults on civilians. He developed posttraumatic stress
disorder.

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.

Example 2: Recognition after relief work

A driver drove relief supplies to regions at war. He saw how whole towns were wiped out and he had to
drive in regions with direct war action. The convoy was stopped every day by armed soldiers or
civilians who threatened him with arms to get money etc. The driver developed posttraumatic stress
syndrome.

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.

Example 3: Recognition after work for relief organisation in Kosovo

A male employee in a Danish relief organisation worked for nearly 6 months as a warehouse manager
in a major city in a region at war, where he was exposed to violence and murder threats. According to
the medical specialists report the diagnosis was posttraumatic stress disorder.
The claim qualifies for recognition on the basis of the list. The warehouse manager was exposed to
threats of violence and murder and had reason to take the threats seriously. There is furthermore good
correlation between the work-related exposures and the disease.

Example 4: Recognition after being sent to war zones

A driver had been sent to a war zone for 6 months. He worked as a driver and several times a week
took part in transportation of military equipment from one camp to another. Typically there were
several vehicles driving in line through unmarked mined areas. During transportation the vehicles
occasionally came under fire by local militias, in particular when the transport occurred in the evening
and during the night. The transports became very stressful for the driver, being in high alert because of
the concrete dangers involved in the transports. Immediately after coming home he developed
symptoms of mental illness with nightmares, pronounced fatigue and bursts of anger, but only about a
year and a half after he had been sent out did a medical specialist diagnose him with PTSD.

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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.

Example 5: Claim turned down sent out to military camp

A soldier had been sent out to work as a cook in a military camp in a war zone. He was part of the
permanent staff in the camp and had no errands outside the camp area. In the area, in particular during
the night, there were a number of shooting incidents, but they were not directed at the camp. The
soldier heard about shootings at other soldiers when they were out on patrol, but he was only in the
camp. After coming home, according to the medical specialists certificate, he developed symptoms
consistent with PTSD within a few months.

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 prison service and the police

Example 6: Recognition after work as a prison officer

A prison officer was for several years employed in a prison where the work became more and more
stressful, i.a. due to several so-called strong prisoners. He had worked for 20 years as a prison officer
and had, in particular in later years, been exposed to increasing stressful exposures in the form of biker
attacks from outside, threats, shouting and suicide attempts. It appeared from the medical specialists
certificate that the diagnosis was posttraumatic stress disorder.

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.

Example 7: Recognition after work as a prison officer

The injured person had for many years worked as a prison officer, i.a. in a prison where the work was
very stressful and where there were threats, violent incidents, etc. Subsequently he was employed in a
prison where he was exposed to violence, hand grenade attacks and shooting with automatic weapons.
Furthermore he was first on the spot when a prisoner attempted to commit suicide. It appeared from the
medical specialists certificate that the diagnosis was posttraumatic stress disorder.
The claim qualifies for recognition on the basis of the list. The injured person was exposed to threats of
violence and actual violence as well as exceptionally severe mental stresses. He subsequently
developed symptoms consistent with posttraumatic stress disorder, and there is good correlation
between the mental disease and the exposures in the workplace.

Example 8: Recognition after work as a police officer

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A police officer was called out, in connection with his work, to several fatal road accidents, an accident
where a small child was drowned, murder incidents and a fatal shooting incident, where the injured
person himself was in serious danger. It appeared from the medical specialists certificate that the
diagnosis was posttraumatic stress disorder.
The claim qualifies for recognition on the basis of the list. The police officer, as part of his work in the
police force, was called out to a number of incidents involving violent deaths as well as a fatal shooting
incident. In two of the situations his life was at risk. He subsequently developed symptoms of
posttraumatic stress disorder.

Example 9: Claim turned down work as a prison officer

A 50-year-old man had worked for 20 years as a prison officer. In this employment he was exposed to
daily conflicts with the inmates, was threatened with broken glass and knives, and was kicked in the
face in connection with an arrest. Well over 4 years after leaving the job he had symptoms of a mental
disease with nightmares and emotional complaints. The medical specialist established symptoms of a
moderate traumatic stress condition.

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

Example 10: Recognition after work as a home help

A home help had for some years worked with a female patient who was paralysed on one side. The
patients spouse behaved very aggressively and threateningly in the home helps presence, hit and
kicked at objects and knocked a fist into the wall, right above the head of the home help. The medical
specialists certificate stated the diagnosis of posttraumatic stress disorder.

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 12: Claim turned down exposure to complaints (nurse)

A nurse who was employed in municipal home care received complaints from relatives in connection
with supervision of an elderly man. In that connection she was called in to a meeting with management
and received a reproof. She felt unjustly treated. No actual psychiatric diagnosis was made.
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The claim does not qualify for recognition on the basis of the list, the nurse not having been diagnosed
with posttraumatic stress disorder. Nor was it any exceptionally threatening or catastrophic exposure
that might have led to a posttraumatic stress disorder. Therefore the claim does not meet the
requirements to diagnosis or relevant exposure. At the same time it must be deemed to be futile to
submit the claim to the Occupational Diseases Committee.

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.

Serious sexual accusations or offences

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

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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.

Other exceptional exposures

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.

Example 17: Recognition after exposure to several robberies (bank employee)

A bank clerk had worked in different banks for many years. Down through the years she had witnessed
several armed robberies against the bank. In two robberies in 1998 she was in close contact with the
robber and was threatened with a gun. After the two robberies in question she developed symptoms of a
mental disease in the form of flashbacks, vigilance, and lack of energy and concentration problems. A
specialist of psychiatry made the diagnosis of posttraumatic stress disorder.
The claim qualifies for recognition on the basis of the list. The bank clerk witnessed a number of armed
bank robberies and was threatened herself a couple of times. Following the threats against herself she
developed symptoms of a posttraumatic stress disorder, and there is good correlation between the
pathological picture and the exposure to the exceptionally threatening situations.

Exposure to complaints, co-operation problems, etc.

Example 18: Claim turned down exposure to complaints (physician)

The injured person was a physician and was stationed for a period of time in a war zone. After coming
home he found himself being exposed to various accusations and complaints from colleagues and a
superior regarding the way he had conducted his office. According to the medical specialists report, he
developed a posttraumatic stress disorder. On the whole, however, the complaints were passing.
The claim does not qualify for recognition on the basis of the list. The stationed physician was exposed
to co-operation problems, including various accusations. However, he was not exposed to mentally
stressful cases of accusations and complaints that were so exceptional that this might be deemed to
have been sufficient for the development of a posttraumatic stress disorder. There is furthermore very
inadequate documentation of any posttraumatic stress disorder according to the diagnosis criteria, even
though the medical specialist made this diagnosis. Depending on the nature of the co-operation
problems and the accusations, the claim might be submitted to the Occupational Diseases Committee

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for the purposes of assessing whether the disease was solely or mainly caused by exposures in the
workplace, see Chapter 1.

Example 19: Claim turned down exposure to co-operation problems

A warning operator employed in the Air Force experienced a poor work environment and co-operation
problems. Besides she had problems in connection with the introduction of new technology. She
developed symptoms that were consistent with the diagnosis of posttraumatic stress disorder.
The claim does not qualify for recognition on the basis of the list as there was not any extraordinary
exposure that might in itself be sufficient to cause a posttraumatic stress disorder.
Depending on the nature of the co-operation problems and the accusations, the claim might be
submitted to the Occupational Diseases Committee for the purposes of assessing whether the disease
was solely or mainly caused by exposures in the workplace, see Chapter 1.

1.7. Delimitation between accident and occupational disease

There are cases where, over a period of time, there are a number of accidents, for example in the form
of violence, threats of violence or similar incidents, which may be recognised separately as accidents.
For recognition of mental diseases as a consequence of accidents we refer to the guide to accidents.

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.

Examples of delimitation between accident and occupational disease

Example 20: Recognition after work as a train driver

A train driver employed with the Danish Rail Service for well over 30 years had through the years been
exposed to several stressful incidents. He had run down a suicidal person and had run down other
persons several times. These cases had been recognised as accidents. Apart from that, he had been
threatened with a knife. After nearly having run down a group of persons who were drunk he went on
sick leave. He had developed a posttraumatic stress disorder.
The claim qualifies for recognition on the basis of the list. The train driver was exposed to several
severe incidents that were mentally stressful, and he developed posttraumatic stress disorder with
anxiety symptoms, flashbacks (nightmares) and avoidance behaviour. In this case the particular
incidents were not handled as separate accidents, and no previous compensation had been paid for
them. The different incidents can therefore be seen as one occupational disease following exposure to
several exceptionally stressful incidents over a number of years, and the compensation is determined in
connection with the one and same claim.

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,
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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)

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Chapter 9. Cancer diseases
List of contents

1. Cancer diseases (Group K)

1.1. Items on the list
1.2. The disease/diagnosis
1.2.1. What is cancer
1.2.2. Medical information
1.2.3. Competitive diseases/factors
1.2.4. Tobacco consumption
1.3. The exposure
1.4. Urgency procedure for particularly serious cancer diseases
1.5. Recent cancer research reflected in the list of occupational diseases
1.6. Individual cancer diseases
1.6.1. Lung cancer (K.4.1.)
1.6.2. Cancer of the pulmonary pleura (K.4.2.) and the peritoneum (K.2.1.) mesothelioma
1.6.3. Nasal and sinus cancer (K.4.3.)
1.6.4. Cancer of the urinary bladder (K.5.2.)
1.6.5. Skin cancer (K.3.)

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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.

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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.

1.1. Items on the list

The following cancer diseases are included on the list of occupational diseases (Group K):

Item Cancer disease organ/region

K.1.1. Leukaemia
K.1.2. Myeloid leukaemia

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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

Cancer diseases on the list

Cancer diseases qualify for recognition on the basis of the list if there is medical documentation of a
type of cancer included on the list (see the above table).
Furthermore there needs to be documentation of relevant exposure. This exposure also has to be on
the list in connection with the type of cancer in question.
Exposures that may lead to recognition of a cancer disease on the list are stated next to each type of
cancer on the list under group K.

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.

Cancer diseases not on the list

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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.

1.2. The disease/diagnosis

1.2.1. What is cancer

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.

Malign tumours = cancer

In a malign tumour the cells are not normal. As a consequence of genetic degeneration
mutation the cells have divided too much and formed a tumour, a hyperplasia in Latin. In addition
there is a more serious defect in the genes of the cell another mutation that changes its shape and
the way it looks. This is called displasy (dyes = bad, plays = formation) or precursors of cancer.

Spreading of cancer (metastases)

Normal cells are destroyed if they are diseased, but cancer cells go on living and generating new cells.
If cancer cells are not treated, they may in time grow into the organs nearby. Once the cancer tumour
penetrates the surrounding tissue and spreads, it is a case of invasive cancer. If the cancer tumour has
not grown through the surrounding tissue, it is called cancer in situ (on the spot).

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.

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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.

Main groups of types of cancer

Cancer may arise in almost all cells of the body, but in some places more often than others. Often a
type of cancer is named after the organ in which it is situated, for instance breast cancer or lung cancer.
But a cancer type also has a Latin name after the cells in which it starts

- 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

(Danish Cancer Society, www.cancer.dk)

1.2.2. Medical information

In order for a cancer disease to be recognised on the basis of the list, a medical doctor must have made
a diagnosis consistent with one of the cancer diseases on the list (Group K).

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.

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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.

The medical certificate will include the following disease-related information

1. The diagnosis
2. The onset of the disease
3. The aetiology of the disease
4. The treatment of the disease
5. Competitive or pre-existing diseases
6. Current symptoms (the complaints stated by the injured person)
7. Current objective/clinical signs (medical findings in a medical examination)
8. Results of any other examinations, such as x-rays, scans or ultra sound
9. A detailed occupational history (work description)

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.

Primary or secondary cancer

In each case we decide if the reported disease is a primary or secondary cancer disease.

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

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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.

1.2.3. Competitive diseases/factors

There is rarely just one single cause of cancer. Whereas some factors increase the risk, other factors
slow down the development of cancer. There is a complex interplay between many factors that have an
influence on whether a person gets cancer and how the disease is going to develop.

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.

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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.

1.2.4. Tobacco consumption

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.

1.3. The exposure

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.
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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)

Occupational-health records or medical specialists certificates usually give an overview of working

conditions and any exposures over time, as well as a list of employers where the exposure most likely
took place.

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.

1.4. Urgency procedure for particularly serious cancer diseases

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

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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.

1.5. Recent cancer research reflected in the list of occupational diseases

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.

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We furthermore refer to the IARC list and monographs on various carcinogenic exposures
(www.iarc.fr).

1.6. Individual cancer diseases

1.6.1. Lung cancer (K.4.1)

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.

Causes of lung cancer

With around 3,500 new cases each year, lung cancer is a relatively frequent type of cancer in Denmark.
Out of this number 2,000 cases are men and 1,500 cases are women, but the trend is a decrease for men
and an increase for women.

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.
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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

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 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.

Lung cancer caused by asbestos (K.4.1.(d))

In order for lung cancer caused by asbestos to be recognised on the basis of the list, the basic
requirement is a considerable exposure to asbestos, equivalent to

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.

Tobacco consumption in connection with asbestos-related lung cancer

Exposure to asbestos increases the risk of lung cancer by 2-5 times, depending on the extent of the
exposure, but if a person is a smoker and is also exposed to asbestos, the risk is increased 20-50 times,

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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.

Lung cancer caused by passive smoking (K.4.1.(m))

Lung cancer caused by passive smoking in principle qualifies for recognition on the basis of the list if
the following conditions are met

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.

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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.

Lung cancer caused by nickel or chromium (welding fumes etc.)

Lung cancer caused by the exposures nickel and chromium are included on the list.
In principle, in order for the disease to be recognised, there must have been substantial exposure for a
number of years to nickel and/or chromium with inhalation of dust or smoke containing particles from
the substances in question. The assessment of the claim will furthermore include whether the work was
performed indoors (larger exposures) or outdoors (smaller exposure) as well as the use of aids such as
respiratory protection equipment.

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.

Lung cancer caused by soot, coal tar or coal-tar pitch

Lung cancer caused by exposure to soot, coal tar or coal-tar pitch is on the list of occupational diseases.

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.

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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.

Examples of decisions on lung cancer

Example 1: Recognition of lung cancer after asbestos (carpenter)

A 62-year-old carpenter worked for 40 years for different employers. Through the years he performed
versatile carpenter work, but often he laid and repaired roofs. The first 15 years he mainly worked on
standard houses with asbestos-cement roofs, making many roof constructions and laying asbestos-
cement roofs at least one day a week. He furthermore cut and mounted asbestos-cement containing wall
plates below fascia boards on horizontal roofs. The work i.a. involved cutting of asbestos-cement plates
with a circular saw with a fibre blade, which produced a lot of dust. He did not use respiratory
protection equipment or other protection. Towards the end of the period he was diagnosed with lung
cancer of the left lung (neoplasma malignum pulmonis sin). It appeared from the information of the
case that the carpenter had had a daily tobacco consumption of 5-10 cigarettes for 8-10 years.

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

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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 4: Recognition of lung cancer after passive smoking (waitress)

A 70-year-old woman worked for a little over 20 years as a waitress, first in an inn (7 years) and then
on a ferry (13-14 years). Through all the years she worked in very smoke-filled rooms where
colleagues as well as customers smoked a lot and where there was only very little ventilation. Well
over 10 years after retiring she was diagnosed with lung cancer of the right lung (neoplasma malignum
pulmonis dxt.). It appeared from the information of the case that the waitress had never smoked herself
and that her spouse had only smoked very little in the home.
The claim qualifies for recognition on the basis of the list. The waitress developed lung cancer of the
right lung after well over 20 years of considerable exposure to passive smoking in the workplace.
When recognising the claim we took into account the good correlation between the massive exposure
to passive smoking in the workplace for 20 years, the development of lung cancer and furthermore the
latency period of more than 10 years from the exposure till the onset of the disease. Furthermore it was
taken into account that the waitress was a never smoker and only suffered moderate passive smoking in
her private life. Therefore there are no grounds for making a deduction in the subsequent compensation
payment.

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
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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

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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.

Examples of decisions on pulmonary cancer and peritoneal cancer (mesothelioma)

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Example 1: Recognition of pulmonary cancer (mesothelioma) after asbestos (smith)
A 59-year-old man worked for 4-5 years in his youth as an apprentice and later as a skilled smith in an
engine factory. The work involved periods of severe exposure to asbestos fibres in connection with
preparation, including drilling, cutting and grinding, of asbestos coupling plates, and being in an
unventilated workshop with asbestos fibres in the air. There was no information of any asbestos
exposure in later employments. At the age of 59 the smith had increasing difficulty breathing and was
subsequently diagnosed with cancer of the left pulmonary pleura (malignant mesothelioma). Besides he
had a moderate to large tobacco consumption for many years.
The claim qualifies for recognition on the basis of the list. The smith suffered a relevant and sometimes
rather severe exposure to asbestos for several years in an engine factory. There is good correlation
between the established mesothelioma, the exposure and the long latency period of 30-40 years from
the exposure till the onset of the disease. In this case and other cases regarding cancer of the pulmonary
pleura or peritoneum (mesothelioma) any tobacco consumption is disregarded, tobacco smoke not
having any impact on the development of mesothelioma.

Example 2: Recognition of pulmonary cancer (mesothelioma) after asbestos (glove seamstress)

A 79-year-old woman was diagnosed with cancer of the left pulmonary pleura (malignant pleural
mesothelioma). She had 40 years previously, for a 5-year period, been employed in a small firm, where
she sewed work gloves. Part of the material used was asbestos. A cutter cut the material for the gloves,
including asbestos plates. The injured person then sewed the asbestos pieces onto the palms of the
gloves and across the back of the hand. During the cutting there was a lot of asbestos dust in the room.
There was no ventilation whatsoever, either at the needling machine or in the basement in general.
They produced about 100 gloves a day and used approximately one big asbestos plate per day.
The claim qualifies for recognition on the basis of the list. The glove seamstress had worked with
asbestos every day for a 5-year period, manufacturing work gloves, and had furthermore suffered a
daily exposure to asbestos-containing dust when cutting asbestos plates in the basement. There is good
correlation between the development of cancer of the left pulmonary pleura, the work as a glove
seamstress with daily asbestos exposure for 5 years and, furthermore, the long latency period of 35-40
years from the exposure till the onset of the disease.

Example 3: Recognition of peritoneal cancer (mesothelioma) after asbestos (teacher)

A 75-year-old man had for 30 years worked as a teacher at a technical university. The first 15 years,
when teaching chemistry, he used asbestos-coated wire nets for experiments. The wire nets were often
defective, with white powder falling off and left lying on the table. Ten years after cessation of work he
had severe dyspnoea with severe fatigue and was subsequently diagnosed with cancer of the
peritoneum (malignant mesothelioma).
The claim qualifies for recognition on the basis of the list. In connection with teaching chemistry, the
teacher for periods of time, and sometimes several times a week for a number of years, was in contact
with asbestos-containing dust from wire nets. There is good correlation between the development of
peritoneal cancer, the many years of moderate exposure to asbestos-containing dust, and the long
latency period of 25-40 years from the exposure till the onset of the disease.

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
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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.

1.6.3. Cancer of the nasal cavity and sinuses (K.4.3)

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.
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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.

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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.

Examples of decisions on cancer of the nasal cavity and sinuses

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.

1.6.4. Cancer of the urinary bladder (K.5.2)

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

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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

Workers in the leather industry

Painters (there are known and suspected carcinogens in paint and solvents)
Drivers and garage mechanics (exhaust fumes containing polycyclic aromatic compounds and
nitro-polycyclic aromatic compounds)
Workers in the aluminium industry (aromatic amines such as 2-Napthylamine, 4-
Aminobiphenyl and benzidine)
Printers (aromatic amines in print dyes)
Workers in the rubber industry
Employees in the hairdressing trade

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.

Examples of decisions on cancer of the bladder

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 2: Recognition of cancer of the bladder after work as a painter

A 58-year-old man had worked as a painter for more than 40 years. He had primarily worked as a
house painter, but for 5 years he painted train carriages and for 2 years he lacquered cars. For a great
deal of the period he had been working with turpentine-based products, but had also been exposed to
organic solvents. For a total of 15 years the injured person had smoked 10-13 cigarettes a day or a little
less than 10 package years. Towards the end of the work period he developed cancer of the bladder.
The claim qualifies for recognition on the basis of the list. The painter suffered relevant exposure to
turpentine-based products and organic solvents in the workplace, which leads to an increased risk of
developing cancer of the bladder. There is good correlation between the exposures from working as a
painter and the disease. As the total tobacco consumption was less than 10 package years, no deduction
will be made in the subsequent compensation for permanent injury or loss of earning capacity.

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.

1.6.5. Skin cancer (K.3.)

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

1. Basal cell carcinoma

2. Squamous cell carcinoma
3. Melanoma cancer
4. Precursors of skin cancer

Basal cell carcinoma

Basal cell carcinoma (carcinoma basocellulare, neoplasma malignum cutis aliud, ICD-10, C44) is
the most prevalent form of skin cancer. It is the total amount of exposure to sunlight over time which is
significant for the development of basal cell carcinoma. Intermittent solar radiation also has an impact
on the development of basal cell carcinoma. Basal cell carcinoma becomes more prevalent with age.
Basal cell carcinoma grows in the skin and spreads locally like a slow-growing sore, but does not
spread to other parts of the body.
The diagnosis is made by way of a microscopic examination of a tissue sample. This type of cancer can
usually be cured.

Squamous cell carcinoma

Squamous cell carcinoma (carcinoma spinocellulare, ICD-10, C44) is the second most prevalent form
of skin cancer. Squamous cell carcinoma occurs in areas of the skin that have been exposed to the sun,
such as face, back of neck and hands. It is the total amount of sunlight a person has been exposed to
over time that is significant for the development of squamous cell carcinoma.
As opposed to basal cell carcinoma, squamous cell carcinoma can, in rare cases, spread to the lymph
nodes and further into the body. Therefore, in rare cases, the disease may be a very serious disease,
even fatal.
The diagnosis of squamous cell carcinoma is made by way of a microscopic examination of a tissue
sample.

Melanoma cancer (malignant melanoma)

Melanoma cancer can develop from benign moles or originate on the normal skin.
The disease melanoma cancer (malignant melanoma, melanoma malignum cutis, ICD-10 C43)
originates in the pigment cells of the skin. The disease most frequently occurs in places where a person
has had a sun burn, but can also develop in other places on the body.

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.

Precursors of skin cancer (actinic keratoses)

Actinic keratoses are not skin cancer, but a precursor of squamous cell carcinoma, which in rare cases
can develop into actual skin cancer. Actinic keratoses are a sign that the skin has been damaged by the
ultraviolet rays of the sun. They usually occur on the scalp, in particular in bald men. They also occur
on the parts of the skin that are exposed to sun light, including ears, face and hands. Actinic keratoses
are very prevalent in the population, in particular among the elderly. The diagnosis is made by way of a
microscopic examination of a tissue sample. (Danish Cancer Society, www.cancer.dk)

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.

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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.

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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.

Examples of decisions on 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.
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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.

Example 3: Recognition of skin cancer after solar radiation (gardener)

A gardener worked out of doors for 15 years, all year round, from the age of 17. In particular in the
summer he was exposed to a lot of sun and towards the end of the period he developed skin cancer
(basal cell carcinoma) at the upper part of the back of the neck.

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)

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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

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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.1. Allergic eczema Allergens

(for instance preservatives, rubber additives, latex, foods,
etc.)

G.2. Other irritative skin diseases One or more irritants or physical factors
(for instance toxic eczema)

Group I, item 9

Disease Exposure

I.9. Allergic eczema Nickel

Group I, item 5.1

Disease Exposure

I.5.1. Allergic eczema Chromium and some chromium compounds (for instance in
the metal and dye industries)

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Furthermore skin cancer is included under Group K, item 3, of the list. See Chapter 9.

1.2. General information

The above items pertain to various forms of contact eczema as well as contact urticarial (nettle rash):

Allergic contact eczema

Toxic (irritative) contact eczema
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).

1.2. Diagnosis requirements

1.2.1. Allergic or irritative eczema

Contact eczema may have been caused by allergy or irritation. Even though the two mechanisms give
rise to the same clinical degeneration, they basically are two quite different reactions.

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.

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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.

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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.

1.2.2. Contact eczema

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

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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

Patch tests, also known as epicutaneous testing

Patch tests are an examination for contact allergy (type-4 allergy). Usually, in workers compensation
cases, epicutaneous testing will always be performed. A standard test series of allergenic substances
(approx. 28, see glossary) is used for this purpose. These substances include metals, perfumes,
preservatives, and rubber additives. In addition to this standard test supplementary samples can be
tested, e.g. substances to which the persons are exposed in their work. Small extracts of the allergens
are placed on the skin. The test is read after 2 and 3 days, and perhaps later as well.

Type-4 allergy
Reactivity time: 2-3 days

Mediation: Cells (t-lymphocytes)

Disease: Contact eczema

Diagnosis: Patch tests

(=epicutaneous testing)

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.

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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.

Prick testing and specific IgE

A prick test is an examination for acute allergy ("type-1 allergy"), which is found in connection with
contact urticaria (nettle rash), hay fever, asthma and anaphylactic shock. In this examination a small
allergen extract is introduced into the top layer of the skin, using a small sharp instrument. The reaction
is read after 15 minutes and shows a raised, red welt.
By means of a blood test it is possible to detect the antibodies in the blood which provoke the allergic
nettle rash (specific IgE).

Type-1 allergy
Reactivity time: minutes

Mediation: IgE antibody

Disease: nettle rash (urticaria) hay fever

asthma
shock
Diagnosis: prick test
IgE measurement (blood sample)

Allergic contact eczema

Allergic contact eczema is present when there are clinical symptoms of contact eczema (established by
a doctor) simultaneously with exposure to a substance to which the person is allergic. The allergy must
have been established by means of a patch test (epicutaneous testing).

Frequent causes of work-related allergic contact eczema are:

rubber additives (e.g. thiuram, mercapto, carbamate)

preservatives (e.g. formaldehyde, isothiazolinones, parabens)
epoxy and acrylate
nickel
chromium

The list is not exhaustive and it is important to be aware of other causes of allergic contact eczema.

Toxic (irritative) contact eczema

Toxic contact eczema, also known as irritative contact eczema, is present when there are clinical
symptoms of contact eczema (established by a doctor), simultaneously with exposure to one or more
substances which are known to cause skin irritation. There is no available test for establishing irritative
contact eczema, but a negative reaction to epicutaneous testing indicates irritative contact eczema.

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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.

Contact urticaria (nettle rash)

Contact urticaria of the allergic type exists when there are clinical symptoms of contact urticaria
(established by a doctor), simultaneously with exposure to a substance to which the person in question
is allergic (type-1 allergy). Contact urticaria of the non-allergic type appears when there are clinical
symptoms of contact urticaria (established by a doctor) simultaneously with exposure to one or more
substances which are known to trigger this reaction.

Frequent causes of contact urticaria are

latex (natural rubber)
foods
plants

The list is not exhaustive so it is important to be aware of other causes of contact urticaria.

1.3. Exposure requirements

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.

1.3.1. Allergic eczema (G.1)

Exposures in connection with allergic contact eczema

For reported allergic contact eczemas to be recognized, there must be proof of occupational exposure to
the allergen(s) in question. The exposure must seem likely, e.g. due to direct detection of the allergen in

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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.

Allergy to rubber additives (G.1)

Manufactured rubber products contain additive substances such as thiuram, mercapto and carbamate.
Contact eczema caused by allergy to one or more of these additive substances is quite normal.

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.

Glove eczemas (G.1)

Contact eczemas caused by wearing gloves require special mention as these eczemas become
increasingly frequent and because glove eczemas can be caused by allergic or irritative contact eczema
or contact urticaria. Glove eczemas cause symptoms such as slight or severe eczema changes on hands
and wrists.

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.

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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

1.3.2. Other irritative skin diseases (G.2)

Exposure in connection with toxic (irritative) contact eczema

For reported irritative contact eczemas to be recognized, there must be proof of occupational exposure
to irritants. There must be an account of the irritants provoking the pathogenic effect, and there must be
proof of the causality between exposure and disease, including the intensity of the exposure. This for
instance means that the number of hand washes per work day and/or the number of hours with wet
hands must be stated in the medical certificate. Likewise, if relevant, it is important to know the
number of hours that rubber gloves were worn per work day. Also in these cases the exposure must be
estimated to exceed the exposure in the persons private life.

Exposure in connection with contact urticaria

The same applies to contact urticaria as to allergic and toxic (irritative) contact eczema.

1.3.3. Special forms of work-related contact eczemas or contact urticaria

Nickel allergy and eczema (I.9)

Nickel allergy often appears in workers compensation cases, nickel allergy being frequent in general.

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.

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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.

Aggravation of non-occupation nickel allergy (G.2)

Persons with non-occupational nickel allergy may later become occupationally exposed to nickel and
this may cause an aggravation of the eczema disease. In such cases it is a work-related aggravation of a
pre-existing condition. If the general and special conditions for recognition of the disease are met
besides, the reported disease qualifies for recognition, perhaps with a reduction in the compensation
due to pre-existing nickel allergy. If the nickel allergy is pre-existing, the eczema will be seen in the
course of days to weeks, provided the exposure is sufficient.

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.

Chromium allergy and eczema (I.5.1)

Contact eczema caused by chromium allergy in persons who are occupationally exposed to chromium
and some chromium compounds, and where the occupational exposure is estimated as being in excess
of the private exposure, qualifies for recognition as an occupational disease. The allergy is established
by a patch test. In this case the chromium sensitization itself leads to an increased compensation.

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.

Combined contact eczemas

The above paragraph deals with the theoretical issues in connection with allergic and irritative contact
eczema and contact urticaria. In practice several of these types of eczema will often appear at the same
time. A pre-existing irritative eczema destroys the barrier function of the skin and makes allergen
access to the skin easier. Conversely, a skin with persistent allergic eczema is more vulnerable to
irritants such as detergents. Thus the types of eczema are able to occur at the same time. Recognition of
both diseases in the same person requires independent documentation for each disease. Thus eczema
after wearing gloves, where allergy to the gloves has been established, will only qualify for recognition
of allergic eczema, except where there is documentation that irritation has also played a part in addition
to using gloves, for instance the course of the illness.

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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.

1.4. Employer liable to take out insurance

General information about the employer liable to take out insurance

It appears from section 6(4) of the Workers Compensation Act which employer in principle has to take
out insurance when it is an occupational disease, including a work-related skin disease.

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.

With regard to toxic (irritative) contact eczema

The toxic contact eczemas are in principle recognised with the current or most recent employer as 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.

With regard to allergic contact eczemas

Allergic contact eczemas are recognised with the employer where the allergy developed as the
employer liable to take out protection.

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.

With regard to mixed toxic and allergic contact eczema

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If the person in question has obtained recognition of a toxic or an allergic contact eczema, and if,
several years later, there are complications to the previously recognised skin disease, it is still the
employer previously pointed out who is the employer liable to take out protection.
However, if it is a completely new skin disease which, according to a medical assessment, is not a
complication to the previously recognized skin disease, the question of determining an employer liable
for protection will depend on the type of contact eczema which the person in question has developed,
see the above.

1.5. Examples of pre-existing and competitive diseases/factors

Contact eczema can be caused by other factors than work. It may be a pre-existing disease which is or
previously has been present prior to the work-related exposure. It may also be a competitive disease,
that is, a disease other than the reported disease, which results in the same symptoms. Contact eczema
can also be caused by exposures in a persons free time.

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.

1.5.1. Pre-existing and competitive disorders

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

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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.

Other skin diseases

A few other skin diseases can be pre-existing or competitive disorders in relation to contact eczema.

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.

1.5.2. Competitive disorders

Contact eczemas may have been caused by competitive exposures/disorders. A person who is exposed
to an allergenic or irritative factor in his work and thereby develops eczema may at the same time be
exposed to similar factors in his free time, thus developing competitive exposures and disorders.

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.

1.6. Processing claims not on the list

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.

1.7. Examples of decisions on the basis of the list

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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 (G.1)

A 53-year-old man was employed with grinding of epoxy units. He periodically wore gloves, but his
face was not protected. After approximately one year he developed facial eczema and after another year
hand eczema. He had previously had healthy skin. Allergy tests (patch tests) showed allergy to epoxy
compounds, but was negative with regard to the gloves he wore. The eczema degeneration was severe
and required sick leave. The claim was recognized on the basis of item G.1 (epoxy) of the list.

Example of irritative contact eczema (G.2)

A 55-year-old woman who had worked with cleaning for about 25 years developed hand eczema. She
had not primarily used gloves and had wet hands for at least 4 hours a day. She previously had healthy
skin. Allergy tests (patch tests) were negative. The eczema persistently recurred and she had several
sick leaves. Eventually she had to leave her employment, and therefore her eczema got better. The
claim was recognized on the basis of item G.2 (wet work) of the list.

Example of irritative contact eczema (G.2)

A 30-year-old woman who had for 2 years worked as a kitchen help developed hand eczema. She
handled foods on a daily basis and performed casual cleaning in the kitchen. She had wet hands most of
her work day. Allergy tests were negative, including testing for foods. She previously had healthy skin.
The claim was recognized on the basis of item G.2 of the list (foods/wet work).

Example of irritative contact eczema (G.2)

A 25-year-old woman, who was an apprentice hairdresser, had hand eczema onset during her
apprenticeship. Her work had primarily consisted in washing, colouring and toning of hair. She had not
worn gloves. She washed the customers hair between 10 and 20 times a day. Allergy tests (patch tests)
including hairdresser tests were negative. The claim was recognized on the basis of item G.2 (wet
work) of the list.

Example of nickel eczema (I.9) and irritative contact eczema (G.2)

A 33-year-old woman, who previously had healthy skin, had hand eczema onset after 6 months
employment in a cleaning job. She mostly wore gloves at work, but was also exposed to water and
cleaning agents during the whole workday. She had had eczema under the bright buttons of the uniform
provided by the employer. Allergy tests (patch tests) showed allergy towards nickel. She had not
previously had any skin reaction to bright objects, trinkets, buckles, etc. The employer confirmed that
the uniform buttons released nickel. The claim was recognized on the basis of list item G.2 (wet
work/gloves) as well as item I.9 (nickel).
Example of allergic eczema rubber additives (G.1)
A 50-year-old woman working as a nurse had hand eczema onset. She frequently wore rubber gloves
and washed her hands many times a day. She had previously had healthy skin. Allergy tests (patch
tests) showed allergy to rubber chemicals (thiuram-mix) and own gloves. The specific IgE-latex blood
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sample (test for allergy towards natural rubber) was negative. The eczema receded after she changed to
plastic gloves. The claim was recognized on the basis of list item G.1 (rubber chemicals).

Example of allergic eczema rubber additives and latex (G.1)

A 45-year-old qualified surgical nurse developed hand eczema. She performed surgical hand wash and
wore gloves for several consecutive hours, several times a day. There were no previous skin diseases.
Allergy tests (patch tests) showed allergy to rubber additives (thiuram), and in addition a prick test was
positive with regard to latex. The claim was recognized on the basis of item G.1 of the list (rubber
additives and latex).

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).

1.8. Medical glossary

Latin/medical term English translation

Atopia Tendency to allergic asthma, hay fever and atopic eczema
Allergens Units able to sensibilise and trigger contact allergic reactions
Allergic contact eczema Contact eczema triggered by allergens
Widely used test series with 28 patch test with generally occurring
Standard test series
allergens
Epicutaneous test Patch test (type IV allergy)
Irritants Units able to trigger irritative eczema
Irritative contact eczema Contact eczema triggered by irritants. Also known as toxic eczema
A nettle rash triggered by contact with substances in the
Contact urticaria environment. This may be caused by a type-1 allergic reaction or a
non-allergic reaction
Patch tests Epicutaneous test. Test for contact allergy (type-4 allergy)
Latex Natural rubber
Prick test Test for acute allergy (type-1 allergy)
IgE-analysis Blood test for the same as the prick test
Sensibilisation Application and/or development of allergy
Allergic reaction triggered by antibodies in the blood. May cause
Type-1 allergy
nettle rash, asthma and general symptoms with anaphylactic shock
Allergic reaction triggered by cell reaction in the skin. May cause
Type-4 allergy
eczema

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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.

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