Cleaners and musculoskeletal disorders

Transcription

1 39 Cleaners and Cleaners wrk in all industry sectrs and wrkplaces, frm htels t hspitals and factries t farms. They wrk inside and utdrs, including in public areas. Often wrking at night r in the early mrning, smetimes alne, cleaners are fund in every setting and the wrk they d is essential. 1 Cleaners may either be emplyed directly, wrking in their emplyer s premises, r they may wrk in a lcatin run by a third party. They may be emplyed by public services, private enterprises, r they may be selfemplyed. Cleaners may als be emplyed by a cntractr, wrking at several lcatins ver the curse f a week. Cntract, r industrial, cleaning is a multi-millin Eur industry emplying millins f wrkers acrss Eurpe. Mst cleaners are wmen and wrk part time. A significant prprtin f wrkers cme frm ethnic minrities 2. Staff turnver is generally high, caused by a high level f temprary wrk and shrt fixed-term cntracts 3. Althugh these emplyment patterns can cause difficulties, harm t cleaning wrkers can and must be prevented. Abut this E-Fact Cleaners are best defined by task rather than as a sectr r grup. Cmmn tasks are surface cleaning mpping, dusting, vacuuming, plishing flrs and wrk surfaces and rutine husekeeping. While cleaning wrk can include tasks such as windw and street cleaning, the fcus f this E-Fact is n the preventin f harm t paid wrkers carrying ut general cleaning. The aim f this E-Fact is t infrm wrkers, their supervisrs and emplyers, and ccupatinal safety and health (OSH) prfessinals in the prfessinal cleaning sectr, abut wrk-related (MSDs). It identifies the risk factrs that cleaners can face in the curse f their wrk and prvides advice n the practical steps that can be taken t prevent r reduce the risks that cleaners face. What are wrk-related? Cleaning activities can be physically demanding and shuld be dne withut expsing wrkers t the risks f accidental injury r wrk-related ill health. Numerus investigatins have shwn, hwever, that cleaners are at risk f develping MSDs f the back, neck, shulders, elbws, hands and lwer limbs as a result f their wrk. MSDs are impairments f bdily structures such as muscles, jints, tendns, ligaments, nerves, bnes and the lcalised bld circulatin system, that are -1-

2 caused r aggravated primarily by wrk and by the effects f the immediate envirnment in which wrk is carried ut. They can affect any part f the bdy. Lw back pain is a majr wrkrelated disrder in almst all physically demanding jbs. It can be defined as chrnic r acute pain in the lumbar r buttck area (smetimes called lumbag), r in the upper leg regin (smetimes called sciatica). Lw back pain may arise frm muscular r ligamentus strain, deteriratin f the jints r discs f the spine, r frm pressure n the nerve rts within the spine. Muscle strain is prbably the mst cmmn cause f back pain 4. Lifting and carrying heavy lads is a majr cause, but pushing and pulling r the need t adpt awkward flexed r twisted bdy pstures fr lng perids are als risk factrs. Other parts f the bdy and limbs can be affected. Neck and upper limb disrders result frm impairments f bdily structures such as a tendn, nerve, muscle, jint, bursa r the lcalised bld circulatin system, that arise principally frm the perfrmance f wrk and the effects f the immediate envirnment where the wrk is carried ut. They include a wide range f inflammatry and degenerative cnditins such as shulder injuries caused by prlnged wrk with hands abve head height r wrist injuries caused by repetitive wrk. Symptms include pain and/r reduced ability t functin nrmally. This can affect any regin f the neck, shulders, upper arms, elbws, frearms, wrists, and hand. Disrders f the lwer limbs are als fund. Husemaid s knee was ne f the first ccupatinal diseases t be identified and was assciated with tasks perfrmed while kneeling by husehld cleaners. Even tday, sme cleaning tasks require lng perids spent standing still, which can cause varicse veins in legs. Sme MSDs exhibit well-defined signs and symptms: tendnitis an inflammatin and sreness f a tendn resulting frm repeated mvement f a jint; carpal tunnel syndrme damage t a nerve running thrugh the wrist and int the hand frm repeated bending f the wrist while hlding tls tightly r by cnstantly pressing the wrist against a hard bject; vibratin white finger numbness and tingling f the fingers, especially in cld weather, resulting frm changes t the nerves and bld vessels f the hand caused by use f vibrating hand tls; thracic utlet syndrme reduced bld flw in the shulder and arm caused by wrking abve head height r by carrying heavy lads in the hands with the arms hanging straight dwn. -2-

3 Many ther disrders, hwever, are less well defined and invlve pain, discmfrt, numbness and tingling sensatins thrughut the areas affected such as the neck shulders, upper limbs, lw back r legs. These types are smetimes called nn-specific MSDs. Often they cannt be diagnsed easily, but they can lead t physical impairment and even disability. Hw d MSDs ccur? Acute episdes f pain and/r impairment may arise frm ne single excessive verlad r assault; fr example, the direct impact f heavy mechanical lads can rupture sft tissues r break bnes. Mre ften, hwever, MSDs result frm the effects f many repeated, apparently mderate lads that are endured ver an extended perid. These lads may nt appear t cause (immediate) injury but, if they are impsed regularly ver many mnths r years, they can cause deteriratin f muscles and ther bdily structures that lead t micrscpic injuries in the tissues. When ding physical wrk, prviding sufficient time t rest is allwed between successive expsures, the bdy will grw strnger. (This is the gal f physical training r rehabilitatin.) If, hwever, insufficient time is allwed t recver frm the cnsequences f fatigue, r if the lading is sustained fr t lng, MSDs can result. Therefre, there are tw primary risk factrs at wrk: the magnitude f the lading: the amunt f physical effrt applied including the weights that are handled r the frces t be ppsed the expsure perid: the length and frequency f the physical activity leading t the fatigue and need fr recvery. MSDs and the rganisatin f cleaning wrk Organisatins ften demand cleaning wrk t be dne utside regular wrking hurs t minimise the disruptin caused. As a result, prfessinal cleaning is ften a part-time jb. One study fund that while three-quarters f cleaners wrked fur r five days a week, nearly seven ut f 10 wrked fewer than six hurs a day. Hwever, 20% f cleaners d extra paid wrk in additin t their cleaning wrk 5. These variable wrking times f cleaners make it difficult t apply the generally accepted limits fr physical wrk lads that are based n a wrking week f five days, each f 7½ t 8 hurs. Tasks carried ut by cleaners A Dutch reprt 6 lked at the wrk carried ut by cleaners and their expsure t MSD risk factrs. It fund that mre than 20% f cleaners reprt having t lift, pull, push r carry heavy lads f mre than 25kg in their wrk. They have t d their jbs in a range f wrking pstures, with ne study revealing that 14% f cleaners suffer frm expsure t many high-risk -3-

4 factrs fr MSDs. These include: walking; standing; wrking when stped, squatted, r kneeling; and wrking with the arms abve shulder r belw knee level. The fllwing risk factrs fr particular sub-sectrs have been identified: interirs (cleaning inside buildings): lng perids walking, wrking with a flexed r twisted bdy. Static wrk lads hardly ever ccur; public transprt: wrking face dwn and with a flexed upper bdy; twisted bdy, neck r head; static wrk lads; industrial (cleaning in a prcessing envirnment): wrkers suffer frm uncmfrtable wrking pstures in general; sitting fr lng perids f time; walking fr relatively little time each day 7. Between 54 and 79% f all cleaners reprt having t make frequent r cntinuus repetitive mvements, and mre than half reprted always having t be physically active with the whle bdy. Male wrkers reprted having t use high frces in their wrk frequently, and are mre likely t wrk with vibrating hand tls than wmen. Hw widespread are MSDs in cleaning? In a survey f interirs cleaners, 74% reprted experiencing muscular aches, pains and discmfrt in the last year. Medical advice fr these aches and pains had been sught by 52% f thse affected 8. The main bdy areas f cncern were lw back (46%), neck (33%), knees (24%), right shulder (23%) and right wrist/hand (22%). French researchers fund certain jbs were linked t a greatly increased risk f stearthritis in the knees, hips and hands; the wrkers fund t be mst at risk were female cleaners, wmen in the clthing industry, male masns and ther cnstructin wrkers, and male and female agriculture wrkers 9. Why shuld actin be taken? Preventing MSDs benefits all: The wrker remains in wrk and s maintains his incme and health. Absence f back r ther pain and less fatigue frm easier wrk-lads increases the general well-being f the wrker The emplyer benefits a fit and healthy wrker wrks better, and is less likely t be absent. Investing in new ergnmic tls carries a cst, but can equally deliver benefits t ffset these csts. Fr example, applying membrane cleaning reduces r remves the need t purchase chemical cleaners, and cleaning prcesses requiring less strain tend t deliver prductivity gains The state benefits as it des nt have t pay health care r benefits t cleaners wh are n lnger able t wrk -4-

5 What are the risk factrs fr MSDs in cleaning? Cleaning is demanding and labur intensive. The tasks that cleaners undertake invlve expsure t many f the main risk factrs fr musculskeletal disrders: awkward pstures such as reaching r stping high applicatin f frces such as wringing actins r cntrlling equipment repetitive mvements and insufficient rest perids (all sub-sectrs) lifting and carrying lads (industrial cleaning) static wrk lads (high-pressure spraying r verhead cleaning) wrking in cnstricting space (public transprt) pr ergnmics design f the shape, size, adjustment and angle f equipment handles. Pr wrk rganisatin cmbined with strenuus wrk can cntribute t the develpment f MSDs in cleaners. Risk factrs include: high wrk speed and intensity lack f cntrl ver wrk and breaks high wrklad and time pressure pr wrk schedules pr r n training little appreciatin f cleaning wrk fear f making mistakes high jb turnver in cleaning limited career develpment. In unhygienic situatins, r when the dirt is hazardus, cleaners wear glves. Glves, hwever, can make the hands ht and uncmfrtable. They can als reduce the wearer s effective grip strength and hasten the nset f fatigue. Vibratin frm prly designed r maintained equipment can cntribute t hand-arm vibratin syndrme, tingling, numbness r white fingers frm reduced bld flw. When using wrk equipment, such as vacuum cleaners and flr buffers, which are ften used by cleaners n a daily basis, the main issues f cncern fr users were fund t be: lifting, pushing, pulling and carrying machines vibratin frm machines unsuitable handle shape, size and angle inadequate machine maintenance difficulty with handle adjustment. -5-

6 Using mps with shrt handles, wringing ut mps and emptying buckets int high level sinks are just sme f the inapprpriate wrking practices that lead t backache and strains. Preventin f MSDs in cleaning wrk Musculskeletal disrders can be prevented in cleaning wrkers thrugh effective safety and health management. A Eurpean apprach t tackling MSDs has been set ut as fllws 10 : Avid MSD risks Evaluate the risks that cannt be avided Tackle the risks at surce Adapt the wrk t the individual Adapt t changing technlgy Replace what is dangerus with what is safe r less dangerus Develp a cherent verall preventin plicy, addressing the whle lad n the bdy Give cllective prtective measures pririty ver individual prtective measures Give apprpriate instructins t wrkers. And, t keep wrkers with MSDs in wrk: Prvide rehabilitatin Reintegrate wrkers that suffer r have suffered frm MSDs back int wrk When evaluating the risks that cannt be avided, the risks frm all tasks shuld be assessed. The assessment shuld take int cnsideratin the lads lifted and carried, pstures adpted, the speed at which wrk is cmpleted, the cnditin and suitability f the wrk equipment, the wrk envirnment and individual capacity such as gender r age t ensure the safety and wellbeing f cleaners. Whether the risks f MSDs arise frm the manual handling f cleaning equipment, the vibratins f buffing machines, pr pstures assciated with equipment design, regular use f persnal prtective equipment r invlve yung persns r new r expectant mthers, the need fr risk assessment and the avidance f risk remain central t preventin. Selectin f wrk equipment fr cleaners Investigatins int the demands f cleaning tasks have highlighted inadequacies in the design f cmmnly used cleaning equipment that result in the wrker adpting extreme, static r cnstrained pstures, repetitive mvements and using high frce levels 11. Prblems with mpping systems, buffing machines and vacuum machines were identified and an equipment purchasing checklist was develped. -6-

7 Prblems fund with mpping systems included: unsuitable mp heights uncmfrtable grip design high pressures needed t squeeze mps heavy, unstable buckets. Prblems fund with buffing machines included: excessive machine height, weight and vibratin pr grip, trigger and lever design awkward lcatin f cntrls, cmbined with high activatin pressures. Prblems fund with vacuum machines included: pr grip design lack f safety/pwer indicatin displays flex management difficulties. The checklist belw emphasises the need fr the equipment buyer t cnsider the particular requirements f the wrkfrce, the tasks undertaken and the wrk envirnment fr example, the lcatin f taps, strage facilities, access, and flr surface materials befre equipment purchase. Wrkers wh will be using the equipment shuld be invlved in its selectin t ensure that the dimensins suit all members f the wrkfrce, and that it is apprpriate fr the tasks. i i Further help may be available in yur Member State. Fr example, the Dutch scial partners in prfessinal cleaning have develped ergnmic criteria fr use by purchasers. See -7-

8 Questins when purchasing cleaning equipment Is the equipment f an acceptable weight, a suitable height and easy t mve by the full range f thse emplyed? Are all cntrls/levers easy t reach and cmfrtable t perate (fr left and right handed wrkers)? Is it pssible t grip the machine easily acceptable hand span mm and are the frces required t perate triggers, cntrls and levers acceptable - less than10 N? Des the equipment prvide feedback t the user when an actin is cmpleted; fr example, click when a disc is attached crrectly? Is there perceptible vibratin frm the equipment? Are safety lights and displays prvided n the equipment? Is flex management acceptable; fr example, utriggers that hld flex away frm handle? Is the equipment suitable fr the wrk envirnment; fr example, stairs, lifts, ramps, access, size f rms, restricted spaces? Have yu cnsulted yur cleaning wrkfrce and cnsidered prviding a range f equipment that will accmmdate all ptential users? Wrk rganisatin measures t reduce MSDs Wrk schedules: it is imprtant fr the supervisr/manager t identify the varying levels f wrk demand when planning hw and when tasks are cnducted, and t cnsider fluctuatins in wrklad during the day, week, mnth r semester. Infrmatin shuld be prvided t help wrkers understand the value f taking breaks and hw t recgnise fatigue and ther MSD symptms. Teamwrk: grup wrk reduces the amunt f time the cleaner spends wrking alne. In additin, wrking in a team allws individuals t increase their levels f respnsibility at wrk, giving an pprtunity t develp persnal and ccupatinal skills. It als encurages greater cmmunicatin and a better scial supprt netwrk at the wrkplace. Jb extensin: cnsideratin shuld be given t extending the cleaners rle t enrich jb cntent; fr example, the integratin f cleaning and care wrk. It is crucial that cleaning is regarded as essential wrk and that cleaners receive psitive feedback, guidance and help frm their supervisrs and c-wrkers. This is likely t imprve their mtivatin and jb satisfactin. Cmmunicatin/scial supprt: it is imprtant fr supervisrs and managers t talk t their staff and allw them a frum t cntribute and participate in decisins abut their jb; cnsultatin with staff prir t wrkplace/equipment change is vital fr the success f that the change. Initiatives t reduce musculskeletal risks are mre likely t be successful -8-

9 if they invlve wrkers and their representatives wrking tgether with managers and supervisrs. Reprting system fr musculskeletal ill health: a system shuld be in place fr the early reprting and mnitring f musculskeletal ill heath s that remedial actin can be taken. Training: ccupatinal prgrammes t imprve skills and knwledge thrugh training and qualificatins shuld be available. Almst all cleaners claim they have n pprtunity t develp their career. General health and safety training will increase the awareness f risks and gd practice. Further, training n all machines and equipment used is essential t imprve pstures adpted and the degree f exertin required fr effective cntrl; scheduling skills are necessary if team wrking is intrduced. Equipment maintenance: a maintenance prgramme shuld be in place that instigates regular scheduled inspectins t ensure that all equipment is in gd wrking cnditin, brken r ld equipment is recnditined, repaired r replaced prmptly, and that vibratin characteristics f prly maintained machines are rectified. Measures t cntrl the risk f develping MSDs Since changes in the wrking envirnment are ften unfeasible, the fllwing pint-by-pint ptins fr cntrlling risk fcuses n administrative measures such as educatin and ther infrmatin, gd husekeeping, reductin f use f hazardus chemicals, avidance f expsure and persnal prtectin. They are drawn frm a guide prduced fr the Eurpean cleaners by the scial partners in the cleaning sectr 12 Administrative measures include rtating cleaning jbs t reduce the effects f mntnus wrk and adjusting unfavrable wrking hurs and activities with a high physical wrklad r significant envirnmental expsures. Tasks culd be distributed between wrkers. The respnsibilities fr prtecting the health and safety f cleaning wrkers shuld be agreed n by the cntract cleaners emplyer, prperty wners, and facility managers, and implemented 13. A training prgramme including written infrmatin and educatin (persn-t-persn training r vides within curses r wrkshps) can be used t imprve wrkers awareness f hazards and knwledge f simple ways t reduce risks. In certain situatins adjustable tls can be used t avid bending. Carts may be used t mve cleaning tls and prducts frm ne place t anther t reduce the musculskeletal lad. Secure ladders shuld always be used t reach higher bjects rather than chairs r ther furniture. Membrane cleaning instead f water-based cleaning will lead t lwer physical wrk lads (see belw). -9-

10 Imprved ergnmically designed tls and equipment shuld be intrduced. High-pressure spraying and blasting tls: using these tls results in a cmbined static and dynamic wrk lad, vibratin and nise. Wrking times shuld be limited. Gd ergnmic design f equipment will reduce sprains and strains. Cleaning with water-fed extensin ples: these are mainly used fr cleaning windws but can als be used fr surface cleaning. Wrkers d nt have t carry and place ladders and d nt need t climb them. At the end f the ples a brush is fed with demineralised water. This easily disslves dirt frm plished surfaces such as glass, ceramic tiles, r painted metal r wd. The demineralised water dries withut leaving smears n the surface, s shammying is unnecessary. The ples are sld in lengths f up t 13 metres. Therefre wrking at heights when using the ples can lead t the bimechanical lad n the neck increasing. This can greatly increase the risk f MSDs. Limiting the number f wrking hurs cleaners carry ut this task during the day is an effective way f cntrlling the risk. Membrane cleaning Membrane cleaning is based n micrfibre technlgy. It was intrduced s cleaning culd be dne with less physical effrt and withut chemicals. After being successfully used as dishclths, the system is nw als in use fr flr cleaning. Psitive effects have been reprted, such as the need t use less physical effrt and a reduced risk f accidents caused by slipping. The suppliers f cleaning devices claim that a better standard f cleaning results frm the use f micrfibres. With traditinal mps the dirt tends t get spread, whereas the dirt readily adheres t the micrfibres and s is remved. Implementatin f membrane cleaning is nt as easy as it may initially appear. A well rganised and maintained prfessinal cleaning regime is imprtant, including washing ut the micrfibre clths and patches. When using mps this is als imprtant, but it can easily be neglected. The fact that n chemicals are used may give the wrng impressin that the resulting cleaning is pr: ne des nt smell chemicals and fr many peple the smell f sap is a traditinal reassuring indicatin f cleanliness. A UK survey f cleaning wrk 14 als identified simple actins that can be taken. Prlnged flexed pstures were adpted when making beds. The bed clthing cmprised blankets and sheets. Therefre, duvets were used -10-

11 instead t reduce the amunt f time cleaners spent wrking in a pr psture. High levels f exertin when mpping, caused by the use f ineffective detergents in a hard water area, were reprted by cleaners at a hspital trust. Therefre it was decided that cleaners wuld use nly simple detergents fr mpping. This reduced the amunt f effrt the cleaner had t exert t clean the flr and als resulted in cleaner flrs. Cleaners cmplained f pain, discmfrt and fatigue after wrking n the night cleaning shift. It was fund that peak wrklads at night meant the cleaners n this shift had mre wrk t d. Wrk schedules were evened ut t ensure sme cleaners were nt under pressure t perfrm mre wrk. When peple have t wrk t fast, gd wrk practices tend t be set aside, putting the cleaner at risk. Cleaners reprted difficulty when mving and lifting buckets f water, and back pain and fatigue after mpping. The buckets might have been t large r verfilled, while metal buckets were heavy t lift and carry. Buckets shuld be nly partly filled with water t reduce the lad and they shuld be made easier t mve by prviding plastic buckets with wheels fr mpping flrs. Excessive stretching and reaching was required t clean high areas. The crrect equipment fr high cleaning was prvided such as a stepladder t hang curtains and a lng-handled tl t dust. This reduced the amunt f time the cleaner spent reaching verhead. Cleaners experienced difficulty in mving heavy buffing and vacuuming machines at the wrkplace. Lighter machines were tested, staff were cnsulted and this lead t suitable equipment being bught. The Eurpean legal framewrk and MSDs Eurpean directives transpsed int all Member States makes emplyers respnsible fr minimising risks t wrkers safety and health. This includes prtecting wrkers frm MSDs and prtecting wrkers such as cleaners wh may be part-time wrkers r in temprary cntracts. The fllwing directives are f particular relevance ii : 89/391/EEC - the framewrk directive - defines prvisins and general guidelines t encurage the imprvement f gd wrking cnditins and this directive is the legal basis fr natinal law in all EU Member States. This general directive des nt relate directly t MSDs, hwever, it des blige emplyers t take the necessary measures t safeguard wrkers safety and health in every aspect f their wrk; 89/655/EEC and 89/656/EEC. These directives cver the suitability f wrk equipment and persnal prtective equipment, which affects the ii Access t all EU legislatin, including the directives referred t here in all fficial languages can be fund at:

12 risk f MSDs. All persnal prtective equipment must take accunt f ergnmic requirements and the wrker s state f health, and it must fit the wearer crrectly after any necessary adjustment. 90/269/EEC describes emplyers bligatins cncerning the manual handling f lads when there is a risk f back injury and within which gender issues and the prtectin f yung peple in the wrkplace can be addressed. 93/104/EC cncerns the rganisatin f wrking time. Factrs such as repetitive wrk, mntnus wrk and fatigue can increase the risk f MSDs. Requirements are set ut in this directive relating t breaks, weekly rest, annual leave, night wrk, shift wrk and wrk patterns. 98/37/EC deals with machinery, whse design must take int accunt ergnmic principles s that the discmfrt, fatigue and psychlgical stress f the peratr are reduced t a minimum. Ergnmic principles must als be applied t cntrl devices, persnal prtective equipment and driving seats. Machinery must be s designed that risks resulting frm vibratin are reduced t a minimum. The directive als includes imprtant infrmatin n prtectin against mechanical hazards such as the risk f break-up during peratin. 2002/44/EC sets ut expsure limits and values fr hand-arm and whle-bdy vibratin. Emplyers must assess the risks, avid r reduce expsure, and infrm and train their wrkers in minimising vibratin risks. The directive als sets ut requirements cncerning the mnitring f wrkers health. 2006/42/EC deals with machinery, interchangeable equipment, safety cmpnents, lifting accessries, chains, rpes and webbing, remvable mechanical transmissin devices and partly cmpleted machinery. It als cvers essential health and safety requirements relating t the design and cnstructin f machinery. Further infrmatin Eurpean Agency fr Safety and Health at Wrk, Accident preventin in practice ISBN , 2001, E-fact 11 - Eurpean legal requirements relating t wrk-related (MSDs), 2007, E-fact 14 - Hazards and risks assciated with manual handling in the wrkplace, 2007, E-fact 15 - Wrk related (MSDs) and the pace f wrk, 2007,

13 E-fact 16 - Hazards and risks leading t wrk-related neck and upper limb disrders (WRULDs), E-fact 9 - Wrk-related (MSDs): an intrductin, 2007, Factsheet 71 - Intrductin t wrk-related musculskeletal disrders, 2007, Factsheet 72 - Wrk-related neck and upper limb disrders, 2007, Factsheet 73 - Hazards and risks assciated with manual handling f lads in the wrkplace, 2007, Healthy Wrkplace Initiative checklist n cleaning ecklist_cleaning Health & Safety Executive Manual handling slutins yu can handle, HSG115 ISBN Caring fr Cleaners: Guidance and case studies n hw t prevent 2003 HSG234 ISBN HSE bks, Sudbury Sufflk. Internatinal Labur Organizatin, Internatinal hazard datasheets n ccupatin cleaner (industrial premises), /htm/cleaner.htm Kelly, V. & Devereux, J.J. (2005). Legal issues in wrk-related : A Eurpean perspective frm the UK. In Ny I & Karwwaski W, (Eds.): Handbk f human factrs in litigatin, Chapter 10. Bca Ratn: CRC Press.) Zck, J.P. Wrld at wrk: Cleaners., Respiratry and Envirnmental Health Research Unit, Municipal Institute f Medical Research (IMIM), Dr Aiguader 80, E Barcelna, Spain, =10&hits=10&RESULTFORMAT=&authr1=J.+P.+Zck&andrexactfullt ext=and&searchid= _480&firstindex=0&srtspec=r elevance&resurcetype=1&jurnalcde=emed References 1 Eurpean Federatin f Cleaning Industries, The Cleaning Industry in Eurpe, An EFCI Survey Editin 2006 (Data 2003) 2 Eurpean Federatin f Cleaning Industries, The Cleaning Industry in Eurpe, An EFCI Survey Editin 2006 (Data 2003)

14 3 Mrmnt, M., Institutinal representativeness f trade unins and emplyers rganisatins in the industrial cleaning sectr, Université Cathlique de Luvain, Institut des Sciences du Travail, Prject number VC/2003/0451, 146 pp. 4 Bernard, B.P., editr, Musculskeletal disrders and wrkplace factrs. A critical review f epidemilgic evidence fr wrk-related f the neck, upper extremity, and lw back (1997), Natinal Institute fr Occupatinal Safety and Health (NIOSH), Cincinnati (OH). 5 ORBIS, Zer assessment wrklads in the prfessinal cleaning and windw cleaning sectr (in Dutch: Nulmeting arbeidsbelasting Schnmaak en glazenwassersbranche), Amsterdam, the Netherlands, ORBIS, Zer assessment wrklads in the prfessinal cleaning and windw cleaning sectr (in Dutch: Nulmeting arbeidsbelasting Schnmaak en glazenwassersbranche), Amsterdam, the Netherlands, ORBIS, Zer assessment wrklads in the prfessinal cleaning and windw cleaning sectr (in Dutch: Nulmeting arbeidsbelasting Schnmaak en glazenwassersbranche), Amsterdam, the Netherlands, Wds, V., Buckle, P., Musculskeletal ill health amngst cleaners and recmmendatins fr wrk rganisatinal change, Internatinal Jurnal f Industrial Ergnmics 36, 61-72, Rssignl, M. et al., Primary stearthritis f hip, knee, and hand in relatin t ccupatinal expsure, Occupatinal and Envirnmental Medicine, 62: , Eurpean Agency fr Safety and Health at Wrk, FACTS 71 Intrductin t wrkrelated, Wds, V., Buckle, P., An investigatin int the design and use f wrkplace cleaning equipment. Internatinal Jurnal f Industrial Ergnmics 35, , Health and safety in the ffice cleaning sectr, cpies can be dwnladed in English, French, Dutch and Spanish at Health and Safety fr Cleaning Cntractrs in NSW, Guidelines.htm 14 Wds, V., Buckle, P., and Haisman, M., 1999 Musculskeletal Health f Cleaners. HSE. Cntract research reprt