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Whole-Body Vibration related Health Disorders in Occupational Medicine

A Systematic Review and International Comparison

Eckardt Johanning

Columbia University, Center for Family and Community Medicine, New York, NY, and

Occupational and Environmental Life Science, Albany, NY, U.S.A.

Corresponding Author. Email:

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic

Workers with whole-body vibration (WBV) exposure likely report non-specific health

complaints. Health and safety providers may not recognize such occupational injuries and

be unfamiliar with appropriate exposure assessment and prevention. This is an up-dated

systematic review of clinical studies, medical evidence, differential diagnostic evaluation

protocols, surveillance programs, national and international standards, and intervention

recommendations utilizing PubMed and other online resources. In summary, several

studies show a clear trend: with increasing duration and intensity of occupational WBV

exposure primarily musculoskeletal or neurological disorders of the spine occur. Other

organ damage has also been reported. In some European Union countries, spinal injury

caused by WBV is recognized as an occupational disease and may be compensable. The

WBV-related injury diagnosis includes a review of the work-history, exposure

assessment and differential diagnostic evaluation. WBV health surveillance should assess

health status of WBV-exposed workers and address preventive measures.

Keywords: whole-body vibration, occupational health, musculoskeletal

disorders, spine, causation, prevention

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
Practitioner Summary:

Workers with whole-body vibration (WBV) exposure report a variety of health

complaints or debilitating physical disorders. Health and safety providers frequently do

not recognize such injuries (mainly disorders of the spine), or may be unfamiliar with

exposure assessment and prevention. This review addresses health issues, exposure

assessment and preventive measures.

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
1) Introduction

It is estimated that more than four million workers in the United States of

America (or 2.7% of the US workforce) are exposed to whole-body vibration (WBV)

every day at work. This include vehicle operators, workers in construction, agriculture,

railroad and fishing industry, forestry, service workers, mechanics and heavy machine

operators. Of these more than half a million are operating engineers in the United States

(U.S.) with exposure to WBV while operating bulldozers, motor graders, backhoes,

cranes and other construction vehicles. Among professional drivers, the rate of

musculoskeletal disorders (MSD) is recognized to be very high. In the U.S. the Bureau of

Labor Statistics (BLS) reported that the rate of MSD cases among industry workers was

33% of all reported injuries and illnesses for 2011. Drivers of road or off-road vehicles

belonged to a group of occupations that had twice the rate of days-away-from-work

compared to other occupations that sustained MSDs. Although, specific numbers for

WBV caused injuries are not collected in the U.S., the problem of WBV among operators

of construction equipment, mining, transportation and the railroad industry has been

described in the literature. In 2011, the highest proportion accounted for back injuries

with 36% of reported sprain, strain and tear cases followed by body parts such as

shoulder (12%), knee (12%), ankle (9%) and others. (Kittusamy and Buchholz 2004,

Waters et al. 2008) (Mayton 2008) (Tak and Calvert 2011) (Bureau of Labor Statistics

2012) . Although machine operators and professional drivers are likely exposed to

multiple occupational hazards including noise, awkward or static postures, heavy lifting,

temperature extremes, chemical and fumes exposures, shift-work, psycho-social stressor,

etc., WBV exposure represents a constant factor that cumulatively may add up to

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
several Millions of road/track miles or several hundred-thousands of hours during a life-

time of work.

The study of the WBV, exposure and the association of adverse performance,

comfort and health effects and ways to reduce harmful levels of WBV goes back now

more than 60-70 years, but there appears to be a lack of recognition by health care

providers due to the technical complexity and seemingly non-specific adverse medical

outcomes. Some key medical findings and review papers have been published over the

years summarizing the past research history, clinical and epidemiological findings

(Coermann 1938, Coermann, Magid, and Lange 1962), (Von Gierke and Coermann

1961) (Christ and Dupuis 1966) (Seidel and Heide 1986, Heide and Seidel 1978) (von

Gierke 1984, Christ and Dupuis 1966, Dupuis and Zerlett 1987) (Rosegger 1970) (Griffin

1978, Lewis and Griffin 1978, Griffin 1990, Wasserman and Badger 1973, Hulshof and

van Zanten 1987) (Bovenzi and Hulshof 1999, Teschke et al. 1999, Seidel et al. 2008,

Bernard et al. 1997) (Pope et al. 2002). These published studies and reviews in the past

have addressed particular exposure assessments and clinical outcomes related to WBV,

but the majority are now more than a decade old and newer technology and medical tools

have become available to warrant an up-dated review. In particular, these studies often

lack clinical information important for the occupational health provider and a differential

diagnostic approach. The goal of this study is to provide an updated systematic review

from an occupational medicine and practitioner perspective of recent and important

scientific clinical studies, address diagnostic medical criteria and differential diagnostic

methods currently in use to establish specific adverse occupational health outcomes and

injuries, as well as examine a medical causation link. This paper will review the

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
recognized harmful effects of acute or long-term WBV exposure in occupational

medicine leading to injury and disability based on expert review. A further goal is to

review international compensation practices, available injury and occupational disease

claim statistics and examine recent trends.

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
2) Methods

For this systematic review online searches were performed with search terms

related to the topic of published and peer-reviewed studies, case-series reports, evidence

based diagnostic methods and causation analysis, occupational disease claims and

regulations published in English and German until the end of 2013. The following on-line

available literature search engines were utilized: The US National Library of Medicine

National Institutes of Health (, Cochrane Library


(, and the Katalog der Deutschen

Nationalbibliothek ( and

the software Endnote X7 was used to process citations. The search terms were: Year(s)

2013 or earlier, (whole-body) vibration, occupational disease (etiology/adverse effects,

prevention, control), human(s) case-control design, human(s) prospective design, clinical

outcome, vibration exposure, occupational statistic(s) and numerical data, diagnostic and

practice guideline, risk assessment, back, spine, low back, lumbar, disc, vertebral,

intervertebral, spondylitis, spondylolisthesis, sciatica, injury, compensation, prevention,

control and occupational disease. The retrieved citations and articles were sorted and

selected for relevance in the systematic review based on occupational epidemiological

evidence (considering Hills and Rothmans weight of evidence for causation (Monson

1990) (Rothman 1998)), driver/operator occupation(s), exposure assessment

methodology, occupational clinical outcome(s) and diagnostic criteria information

(musculoskeletal disorders and others), available relevant diagnostic and work history

information, causation definition and statistical information provided (i.e., was the

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
general and specific causation analysis based on well-established principles in

occupational and environmental medicine? (see (Laumbach 2011). The occupational

disease information and statistics were obtained from national registries or institutes in

Germany (Dr. Stefan Gravemeyer and Deutsche Gesetzliche Unfallversicherung

(DGUV), St. Augustin, Germany), The Netherlands (Dr. PPFM (Paul) Kuijer and the

National Dutch Register of Occupational Diseases of the Netherlands, Center for

Occupational Diseases, Coronel Institute of Occupational Health, Academic Medical

Center, Amsterdam), Belgian (Fund for Occupational Disease (O.D.F.)), France (Dr. P.

Donati and INRS) and Italy ( Prof. M. Bovenzi, M.D., (University of Trieste) and Italian

Workers Compensation Authority (INAIL). Limitation of this paper: This is not a meta-

analysis of available epidemiological studies and populations. Furthermore, the review of

non-occupational medicine studies, therapeutic applications, strictly experimental work

or animal studies are not the focus of this paper. A review of the differences and

limitations of particular diagnostic modalities, imaging technology and laboratory tests

are also not the focus of this paper.

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
3) Results

In the online citation services over a thousand medical study citations (i.e.,

PubMed citations for whole-body vibration n= > 1200) can be found that report on

various possible beneficial (i.e., conditioning or orthopedic treatments) as well as

detrimental effects of whole-body vibration exposure, which may be confusing to the

naive reader and requires a critical approach. Studies in occupational health of whole-

body vibration exposures goes back more than 60-70 years and are often found in the

specialty journals. While early research concentrated for a variety of reasons primarily on

vertical vibration in military applications and vehicles, farming and heavy equipment

operators (Spear, Keller, and Milby 1976), newer research has studied tri-axial WBV in

the horizontal and vertical direction on a variety of different operator seats and with

different ergonomic designs in automobiles, bus, taxi, trucks, forklifts, light-rail cars,

subways, railroad locomotives and rail-construction vehicles (maintenance-of-way

vehicles), utility vehicles, ATVs, speed boats, helicopters, etc.. Since much of the earlier

research has concentrated on operators of vehicles with mainly vertical (denoted as the z-

axis) vibration much of the evidence relates to vertical spinal impact on the seated

subject, however with the technological advances in instrumentation and measuring

devices also multi-axis (horizontal= for-after (x-axis) and lateral (y-axis)) vibration and

shocks measurements have gained importance in the exposure and health assessment.

A measurement methodology of WBV is detailed in the International Standards

Organization (ISO) guideline ISO 2631-1 Mechanical vibration and shock - Evaluation

of human exposure to whole-body vibration. The ISO standards are adapted by

consensus of the member countries of the International Standards Organization (ISO). In

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
the USA, the American National Standards Organization (ANSI) has adopted key

portions of ISO 2631 as a consensus standard under S3.18. The ANSI S3.18/ISO 2631

standard is strictly voluntary and should not be considered a health standard such as those

issued by the Occupational Safety and Health Agency (OSHA) regulations. The

American Conference of Governmental Industrial Hygienist (ACGIH), a professional

organization, has proposed the concept of Threshold Limit Values (ACGIH-TLV )

as industry guidelines for the control of WBV at the workplace, which are also voluntary

guidelines and not law in the U.S.(Hygienists and (ACGIH) 2012).

In the European Union (EU) legal requirements obligate the employer and others

to investigate and protect workers from harmful and preventable vibration (Directive

2002/44/EC) and certain action limits and exposure limits are recommended to EU

member countries for implementation (Christ 1996). Countries within the EU have

adopted different national exposure limits, worker protection measures and legal

requirements (Griffin 2004, Hulshof et al. 2002). In some European countries injuries and

disability caused by occupational whole-body vibration exposure are recognized as a

compensable occupational disease (i.e., Germany, Belgium, The Netherlands, Italy and

France) and specific work-place monitoring, technical-ergonomic interventions and

education about prevention efforts are in place. The particular criteria for work-place

injuries and occupational disease compensation differ in these countries. The clinical

aspects and the differential diagnostic process will be reviewed in detail below. Several

scientific reviews of the available data and studies have concluded that there is strong and

sufficient evidence to link long-term or intense WBV exposure to back disorders,

primarily of the lower spine (the lumbar segment) ( (Bovenzi and Hulshof 1999),

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
(Bernard et al. 1997), (Teschke et al. 1999) (Panel on Musculoskeletal Disorders and the

Workplace 2001) (Notbohm, Schwarze, and Albers 2009). WBV can lead to work-related

disability. In a prospective disability retirement study of Danish workers (n= 4215), self-

reported exposure to WBV was identified as a predictive risk factor for disability pension

retirement after adjustment for various other factors (Tuchsen et al. 2010). In a 3-year

follow-up study of psycho-social and mechanical risk factors in the general working

population of Norway (n=12 550, age 18-66y), WBV was identified as an important risk

factor for work-related disability with an odds ratio of 4.15 (95% CI 1.77 9.71) and

twice higher than other commonly recognized risk factors. Increasing WBV exposure

duration during the work day increased the statistical risk for disability (Sterud 2013).

There are no similar studies for the US or Canada, where WBV related injuries or

disabilities are not specifically recorded.

Workers exposed to occupational whole-body vibration (WBV) may report non-

specific health complaints or debilitating physical disorders, primarily related to the

musculoskeletal system (especially the lower and cervical spine). Typical health

complaints and concerns reported by patients with WBV exposure are listed in table 1.

Many of the reported symptoms are non-specific and health care providers and safety

professionals may not recognize such WBV related health complaints and occupational

injuries or be unfamiliar with appropriate exposure assessment. In the clinical evaluation

of workers with WBV individual characteristics are important for the physician, such as

age, anthropometric data (body-mass index), smoking habits, other medical conditions

(i.e., rheumatologic diseases, psoriatic arthritis, scoliosis, kyphosis, infections,

osteoporosis and fibromyalgia) and history of prior injury, psycho-social factors, and

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
most importantly prior history of back disorders or complaints. In the general medical

practice the prevalence of a prolapsed intervertebral disk among persons with low back

pain in primary care is low and estimated to be 1 to 3 percent. About 4 percent of patients

with low back pain in primary care settings have a compression fracture, and about 1

percent have a tumor or other red flag conditions (Chou 2011).

Vibration exposure and posture assessment

Spinal disorders among WBV-exposed workers are increasingly more common

the longer and more intensive the exposure is, but definitive threshold limits or a linear

dose-response relationship have not been established for various reasons. It is recognized

that certain ergonomic working conditions are important co-factors in a vibration and

shock exposure risk assessment (Burdorf and Sorock 1997) (Pope, Wilder, and

Magnusson 1999, Pope, Goh, and Magnusson 2002) (Kittusamy and Buchholz 2004).

Furthermore awkward body posture and WBV are likely to have modifying or synergistic

effects in the pathological development of accelerated degenerative joint disease and

muscular-skeletal stress (Seidel and Heide 1986) (Toren 2001, Skrzypiec et al. 2013,

Huber et al. 2010, Brinckmann, Biggemann, and Hilweg 1989). Nevertheless, there is a

paucity of papers that have studied at simultaneously exposure to whole-body vibration

and awkward posture among operators of mobile equipment. Pilot studies have shown

that some vehicle operations may lead to the combined stressors of WBV and awkward

postures (see Figure 1) (Johanning 2011, Schfer and Ellegast 2006, Johanning, Fischer,

and Ellegast 2006, Tiemessen, Hulshof, and Frings-Dresen 2007). Different seating

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
posture and backrest inclination tend to influence the experienced vibration discomfort

(Basri and Griffin 2013, Paddan et al. 2012).

Additionally, it may be beneficial to study the suspension characteristics of the

operators seats because appropriate seating contributes to primary prevention. Results of

the floor-to-seat vibration transfer measurements (SEAT) in the field may indicate that

the seat can magnify the vibration exposure due to defects and insufficient dampening

technology. Other factors that may influence the exposure effects of WBV are climate

conditions, cold temperature, exposure of body parts to draft, noise, air pollutants,

solvents, etc.

Distinguishing sinusoidal vibration and exposure containing shocks and irregular


In an occupational study of agricultural workers the daily exposure to combined

whole-body vibration and mechanical shock were significantly associated with the

prevalence of low back pain (LBP) and neck pain in operators of quad bikes

(Milosavljevic et al. 2012). Spinal response to repeated shocks and loading are complex

and should be distinguished from a simplistic prediction of forces in the risk analysis

(Seidel and Griffin 2001). The ISO 2631-1standard for measuring mechanical vibration

and shock evaluation of human exposure to whole-body vibration recognizes that for

vibrations containing shocks the so-called basic rms-evaluation method may

underestimate the true exposure risk (International Organization for Standardization

(ISO) 1997). A method has been proposed in ISO 2631-5:2004 to quantify vibration

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
containing multiple shocks in relation to lumbar vertebral endplates. The underlying

concept and algorithm was originally based on military applications and research ((ISO)

2004) (Cameron et al. 1996) (Alem 2005). However, its validity and lack of supportive

epidemiological data have been questioned for occupational health and safety risk

assessments (Seidel et al. 2006) (Waters et al. 2007) (Hinz et al. 2008) (Seidel et al.

2008) (Seidel et al. 1999). An alternative method (VibRisk model) that estimates

structural failure risk of the lumbar spine from vibration containing repeated shocks and

jolts has been proposed. It incorporates different typical driving body postures and

physical factors of vehicle operators ( (2009)). For

example, comparing field data using the ISO 2631-5 algorithm and with the VibRisk

model, apparent dissimilarities for spinal injury (endplate failure) predictions were found.

While the ISO 2631-5 risk calculation model suggested for all disk level (T12 to S1), the

same level of failure prediction for the vertebrae endplates, the VibRisk model

showed different risk prediction depending on the different typical driver postures (i.e.,

vehicle group comparison) and the lumbar disk level (L1 to S1), which would be more

consistent with the clinical experience of more frequent defects at lower spine levels.

(Johanning 2011). Further studies are needed to validate the different approaches in an

occupational health risk assessment.

The patient evaluation in occupational medicine.

There is agreement in the literature that medical evaluation of a patients with

spine disorders, in particular occupational WBV-exposed patients shall include a

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
complete occupational and medical history, a focused occupational exposure risk

assessment followed by a physical and neurological examination to identify a set of so-

called red flag conditions for underlying serious conditions (i.e., fracture of the

vertebra or disc herniation), and the functional impact regarding physical

abilities/disabilities (Johanning 2000) (Pope et al. 2002), (Pillastrini et al. 2012),

(Williams et al. 2013),(van der Windt et al. 2010), although some specific testing

procedures may have only limited value in predicting specific imaging findings such as

radiculopathy, disk herniations or vertebral fractures (Al Nezari, Schneiders, and

Hendrick 2013). The examiner should recognize key important clinical health outcomes

presenting as pain and sensory or motor abnormalities of the lower extremities that are

related to disc protrusion, disc prolapse, and progressive degenerative changes of the

spine (i.e., endplates of the vertebral body and facet joints) characterized by chondrosis,

osteochondrosis, spondylosis, and spondylarthrosis.

The evaluation generally includes:

Physical examination complete & focused, including observation, palpation,

functional, strength and range-of-motion tests, neurological motor and sensory

evaluation, including a forward flexion, hyper-extension test, and slump test and

Straight Leg Raising (SLR) test;

Laboratory test blood or urine (i.e., Urinalysis, ESR, ANA, Rheumatoid Factors,


Imaging studies: x-ray, computed tomography (CT), magnetic resonance imaging

(MRI), myelogram etc.

Neurological functional studies: EMG/NCS

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
Differential diagnoses considerations

A process of evaluating co-existing medical conditions: hormonal,

metabolic, cancer, infections, psychiatric and psychosocial conditions.

What are causes or aggravating factors?

Besides ruling out non-specific or episodic low back pain, one needs to be aware of so-

called red flag conditions that require further evaluations and are part of the differential

diagnostic work-up, i.e., traumatic fractures, infections, osteoporosis, cancer, abdominal

aneurysm, or psychological disorders with somatic complaints and non-organic physical

signs. Imaging should be performed for staging purposes or evaluation of neurological

abnormalities during the examination. MRI is usually the preferred method for imaging

especially of soft-tissue disorders, but CT are also acceptable to document skeletal

findings; plain film x-rays are suitable for evaluation of spinal malformation, scoliosis,

osteoporosis, recent acute trauma, or in some cases of non-specific back pain. Some MRI

studies of asymptomatic patients have shown that degenerative findings may be present

without particular identified risk factors and for other reasons. As always, clinical

correlation of imaging studies with the patient history, occupational risk factors,

physiological tests and objective neurological findings are important in the proper


Comparison of national laws and regulations recognizing occupational WBV

exposure and disease.


E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
In the USA and Canada, injuries or occupational diseases caused by WBV are not

uniquely recognized. No special OSHA vibration standard has been promulgated under

the United States Occupational Safety and Health Act (OSHA). Vibration like many

other work place hazards is considered to fall under the General Duty Clause of OSHA

mandating that the employer shall provide a workplace free from recognized hazards that

are causing or are likely to cause death or serious physical harm to his employees (29

U.S.C. 654, 5(a)1).l.. In the U.S., the workers compensation system run by the States

for industrial workers (i.e., construction, transportation), will recognize occupational

injuries if the injury or condition is either caused or aggravated by a job over a period of

time. No special requirements for a work-place measurement of WBV or specific

exposure threshold limits exist. The causation of an occupational disease is legally

recognized under the compensation system by a more likely than not (or more than

50% likelihood) statement by the physician. Railroad workers in the U.S. are covered

under the Federal Employee Liability Act (FELA). This law provides compensation to

injured workers for work-related injuries. The injured worker has to show that the

railroad was negligent in some way in not providing a safe place to work, or that it

violated a safety regulation or rule. The worker has to also show that this negligence

played some part in causing the injury to the worker. These questions will be decided by

a jury trial in court.

European Union

In the European Union several member countries have made great strides to

recognize and prevent WBV-occupational injuries and diseases of professional drivers in

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
road and off-road vehicles. It is recognized that WBV exposure often occurs in

combination with other ergonomic stressors such as heavy lifting, prolonged seating,

awkward postures and other work place hazards. As such the Commission of the

European Communities included in the 2003 list of likely occupational diseases: disc-

related diseases of the lumbar vertebral column caused by the repeated vertical effects of

whole-body vibration (2003/670/EC recommendation; Annex II, item 2.502). It appears

that the EU member countries have quite different rules and regulations regarding WBV

caused injuries and compensation requirements (Hulshof et al. 2002) (Griffin 2004).

Injured workers in these countries may or may not qualify for disability or financial

compensation depending on where they work, what vehicles they operated and what type

of injuries they report. Nevertheless, there is great emphasis on prevention and hazard

evaluation in these EU countries particularly after the introduction of the so-called

Machine Directive 2002/44/EC of the European Parliament and of the Council of 25

June 2002 on the minimum health and safety requirements regarding the exposure of

workers to the risks arising from physical agents (vibration) (2002/44/EC 2006) .


After the unification of Germany, the introduction of new occupational disease

classifications regarding spinal injuries and degenerative effects became law in 1993,

although in the East and West Germany occupational injuries caused by WBV were

recognized well before that. In Germany, compensable spinal injury caused by WBV is

now regulated under the occupational disease regulation No. 2110 (BeK 2110) and

specific medical findings, an occupational history and exposure documentation are

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
required. Diseases of the cervical or lumbar spine with disk involvement caused by

excessive and accelerated wear and tear are required for the consideration of a claim. The

clinical findings have to include: disc protrusion, disc prolapse, progressed degenerative

changes of the spine (i.e., endplates of the vertebral body and facet joints) characterized

by chondrosis, osteochondrosis, spondylosis, and spondylarthrosis. In Germany, in order

to qualify for an occupational disease claim, the condition has to result in a total inability

to perform any employment and furthermore an exposure duration of typically more than

10 years on the job has to be documented. Three specific clinical conditions are

recognized according to the legal instructions (Merkblatt 2005) for an occupational


a) The lumbar syndrome (ICD-10: H54.5) which is characterized by recurring and

chronic discomfort in the lumbar region due to irritation of the posterior ligament,

ligamenta flava or periosteum.

B) Mono- or poly-radiculopathy (ICD-10: H54.1 to H54.4) with radiation to the leg(s),

often in combination with a lumbar syndrome; caused by nerve root irritation due to

degenerative morphological changes of the spine primarily at level L3 to S1, and less

common at level L1 and L2. Typical are sensory or motor deficits, reflex abnormalities

and signs of sciatica.

C) Cauda equina syndrome (CES) (ICD-10: G83.4). A special case of poly-radiculopathy

involving the lumbar plexus with functional abnormities of internal organs (bladder,

colon, erectile dysfunction) and characteristic saddle distribution in the lower pelvis area

and legs. It is caused by a massive median disk prolapse at the L3/L4 or L4/L5 level and

generally a red flag emergency condition requiring immediate medical intervention.

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
The diagnosis and assessment focuses on the patients degree of pain, motor-and sensory

deficits, range-of-motion and functional impairment, loss of strength and control of the

lower extremity, and also the psychological status. In addition, radiological imaging are

important in the overall assessment, specifically the findings of narrowing of the

intervertebral disk spaces, osteochondrosis, spondylarthrosis and spondylosis. Any non-

mechanical changes of the spine caused by inflammatory and genetic conditions, tumors,

traumata or other factors are excluded (osteoporosis, Morbus Paget, ankylosing

spondylitis (M. Bechterews disease), non-degenerative spondylolisthesis and disorders

of internal organs). The examiner in Germany is advised to also consider typical postural

stress (awkward posture of driver), individual factors (age at exposure onset, gender and

constitutional stamina) and spine resilience (Merkblatt 2005, Seidel 2005). A typical

WBV occupational daily exposure of 0.63 m/s2 (aw(8)), primarily in the vertical z-axis

direction, are required and typically more than 10 years of job seniority. In some cases

lower exposure levels should be considered as health risks according to the 2110 BeK

regulation instructions. The examiner should also consider other factors such as vehicle

type and loading, road and off-road driving conditions, speed and driver experience,

frequency of shocks and jolts, age above 40 years at start of WBV exposure, periods of

short but high exposure to WBV and shocks, strong horizontal vibration and long

duration exposures even at low levels.

Trends and Statistics

The numbers of WBV occupational disease claims and recognized cases under

BeK 2110 in Germany reported by the DGUV (German Social Accident Insurance)

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
have continuously dropped. The initial high number of claims with 1000 has now fallen

to about two hundred annually for the time period from 1995 to 2012. A very low number

of cases actually met all the legal requirements in order to be accepted as an

occupational disease so that the injured workers receive a special disability pension (See

Figure 3).

The Netherlands:

In the Netherlands WBV caused injury was established in 1997 as occupational

disease, but principally for preventive purposes without any special financial

compensation (Hulshof et al. 2002). Compensation for work-related injuries falls under

general social disability claims. Reporting of such conditions by Dutch physicians was

noted to be notoriously inadequate, although it is required to report a disease or disorder

caused by a load exposure, or burden which predominantly took place in the work or

working condition to the Netherlands Centre for Occupational Diseases. Diagnostic

criteria appear to be less stringent than for example in Germany. Painful conditions

resulting in significant disability are required, but findings of imaging abnormalities (i.e.,

degenerative spinal changes) are not necessary. In the Netherlands vibration in all three

directions (horizontal x- and y-axis, and the vertical z-axis) or the vector sum are taken

into account for the exposure assessment (Hulshof et al. 2002). In any case, comparing

the trends in Germany to the Dutch system it shows that that the absolute number of cases

was similar to Germany, although it appears that proportionately more cases are listed in

the Netherlands (See Figure 4). Comparing the specific medical diagnoses of reported

and recognized WBV injuries and occupational diseases following the ICD-10 Coding

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
classification system, we note that most of these claims were related to lumbar disk

disorders (with myelopathy or radiculopathy) coded as M51.- under the ICD-10 coding

(See table 2).


In France WBV-related occupational diseases are recognized since 1999 under

Tableaux n0 97 for workers with regular occupational exposures on listed vehicles

including farm tractors. The clinical examination criteria focuses on radicular symptoms

(sciatic pain) due to disc herniation at L4 -L5 or L5-S1, or radicular pain following

dermatomes from herniation at L2-L3, L3-L4, or L4-L5. In France radiological findings

consistent with lumbar herniated disc and the documentation of vehicles that have been

listed and recognized to have high vibration levels are required (INRS 1999). Between

400 to almost 500 cases are reported yearly in the general industry and about 280 in the

agricultural industry based on available data from 1999 to 2012 [personal

communication] (see Figure 4).


In Belgium, the Fund for Occupational Disease (O.D.F.) handles all occupational

disease claims from the general industry including back disorders due to WBV exposure.

In 1974 Belgium was one of the first countries to recognize the osteo-articular diseases

caused by mechanical vibration"(code 160501). This was revised and updated in 2002

with the premature osteoarthritis caused by mechanical vibration transmitted to the body

through the seat definition (code 160512) (Hutsebaut 2013). Accordingly, all claims for

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
a WBV disability and financial compensation must fulfill three steps, an administrative

review, exposure field assessment and professional opinion by an orthopedic consultant.

Current interpretation of the scientific evidence by the O.D.F. (Royal Decree of 2004:

code 160503 regarding mechanical vibration or heavy lifting) favors a physical exam

finding and the diagnoses of radicular symptoms combined with herniated discopathy or

osteoarthritis (spondylosis) to establish a necessary causal relationship. Specifically the

medical diagnosis of mono or poly-radiculopathy (sciatic) (confirmed by neurological

exam or EMG/NCS study), cauda equina or spinal stenosis syndrome, a degenerative

herniated disc, and premature osteoarthritis of L4-L5 or L5-S1 as confirmed by

radiological imaging (X-ray, CT or MRI) are now recognized. Five years of WBV

exposure duration are required as the minimum with an average weighted vibration level

of 0.8 m/s2. The number of reported claims reached a high in 2007 with n=3020 and since

then a continuous reduction with n=838 in 2012 for the code 160503 diagnoses. Of

these claims only 14% meet all the criteria and are accepted for compensation by

O.D.F., with almost 2/3 showing premature spondylosis and one third disc lesions

(Hutsebaut 2013). [For further details see also [manuscript Hutsebaut ].


In Italy, an occupational disease caused by WBV is not separately recognized as

an entity or separately listed, but are part of a surveillance system for occupational

musculoskeletal disorder. The criteria for vibration-induced lower back disorders are

defined by the Italian Society of Occupational Medicine and Industrial Hygiene (Bovenzi

2007). It is recognized that there is not a specific vibration induced injury and many

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
clinical features may also be found in other conditions, requiring a differential diagnostic

process by the occupational health physician that includes an occupational history,

physical examination and various clinical and laboratory tests. Since 2006 employers

have to implement the EU directive as per Italian legislative degree 81/08, perform WBV

measurements, provide preventive services and monitor adverse health reactions

(Nataletti et al. 2008). In 2008, WBV-caused injuries became legally recognized in Italy

(Legislative Decree 81/2008) (81/2008) 2008), but no specific reporting data is available

as of today. An Italian data base for vibration measurements has been established for

exposure references at the National Institute of Occupational Prevention and Safety

(ISPESL) in Rome, Italy ( ).

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
3) Discussion

A key findings of this systematic review is that occupational medicine is about

recognizing injuries and diseases that are essentially preventable. This requires detailed

medical knowledge, sufficient education and training and vigilance of the health care

provider and in the case of WBV, often cooperation with technical experts and a

differential diagnostic approach to rule-out or rule-in medical abnormalities. In this

review different national approaches in WBV exposure surveillance and defining

occupational disease as well as establishing medical causation are evident. In many

industrialized countries WBV is principally recognized as a physical hazard in the work

place, however, but only in few countries with a long history of WBV-related research

and a tradition of institutionalized workplace health and safety, WBV-injury is

specifically recognized in the national labor laws. In some of these countries it is defined

as a compensable occupational disease limited to non-inflammatory and mechanical

spinal injuries with painful neurological complications (i.e., disc herniation and nerve

root disorders), primarily of the lumbar spine. Over the years the number of claims and

compensated conditions look as if they have dropped in many European countries with

occupational disease registrations. This appears to be in part due to national differences in

the legal definitions, institutional and financial compensation practices. An earlier review

of the national recognition practices had shown similar differences and the establishment

of an uniform internationally accepted criteria was suggested (Hulshof et al. 2002). More

than a decade later it appears that this is still not the case. It may also be explained by

several decades of exposure protection and prevention efforts in these countries, i.e.,

administrative controls, special vehicle dampening design and utilizing improved

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
ergonomic suspension seats (Viikari-Juntura 1997, Christ and Dupuis 1966, Burdorf and

Swuste 1993) (Pope et al. 2002, EU The Directorate-General for Employment 2008,

Hulshof et al. 2002). The considerably higher number of recognized and accepted

occupational WBV-cases in France and Belgium compared to Germany and the

Netherlands reflects more likely socio-economic differences than strictly medical or

epidemiological findings (see Figure 4). In summary, a proper WBV-related injury

diagnosis and causation analysis includes a critical review of the work history, exposure

data assessment and a clinical differential diagnostic evaluation. The medical diagnosis,

treatment and prevention of occupational low back disorders has been reviewed in

clinical consensus protocols, but typically requires multi-disciplinary involvement

(Johanning 2000) (van Tulder et al. 2006). Several well-designed studies have

consistently shown, that WBV is strongly associated with acute or chronic low back pain,

peripheral neuropathy and progressive degenerative changes of the spine and inter-

vertebral disc disorders. This became the basis for the legal definitions of WBV-related

occupational disease in some European countries. WBV exposure may also lead to

complaints by vehicle operators of the neck, shoulder, digestive disorders, circulatory

disorders, auditory effects, and reproductive problems, which is likely caused or

aggravated by other co-existing factors. In occupational medicine a causal diagnosis is

based on objective medical findings, a differential diagnostic methodology (ruling out of

other diagnoses and conditions) and supportive work exposure history and if available

specific measurement data indicating long-term and intense exposures to WBV. A

definite dose-response relationship or specific threshold limits have not been firmly

established and different health standard levels for action or health limits exist in

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
different countries. Nevertheless, it is recommended to maintain exposure levels in the

workplace as low as technically and feasibly possible (Griffin 2004). ISO 2631 part 5

(2004) with its restriction to vertebral endplate fractures and particular seating

requirements appears in its current version not to relate to common diagnoses among

disabled professional drivers in occupational medicine. It remains uncertain whether

relying on solely numerical risk calculations as suggested by the can realistically and

safely predict deleterious spinal outcomes in occupational settings with a widespread

spectrum of biological variability and different working conditions. Further research and

studies of precise seating posture and WBV are needed to better understand the complex

interactions of spinal movements, posture and vibration or shock and jolts (Halpern 1992)

(Lyons 2002). Limitations of this review and study are the risk of observer and reporting

bias (health care provider, focus on practical approaches), incomplete retrieval of studies

(i.e., reports not listed in the citation search libraries and unknown to the author) and

limiting the review to German and English publications for the most part. Furthermore,

this review was prompted by a recent multi-disciplinary international conference on

WBV to provide an overview from a clinical perspective and no meta-data computation

or risk ratios were calculated. Nevertheless, administrative and technical approaches have

been suggested to monitor workers with WBV for early signs of adverse health reactions

and introduce prevention steps to control hazardous exposures (Johanning, Hulshof, and

Christ 1997, Hulshof et al. 2006, Tiemessen, Hulshof, and Frings-Dresen 2009, Pope et

al. 2002). The aims of improved WBV health surveillance are to assess health status and

improve the diagnosis of vibration-induced disorders at an early stage, to inform the

workers on the potential risk associated with vibration exposure, and to provide guidance

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
to employers and employees. The seemingly declining number of reported WBV-claims

and occupational disease cases in some European countries may be a sign that WBV-

exposure reduction and prevention efforts are having positive effects, but it also requires

early clinical recognition and intervention in occupational medicine.

E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic

Tables and Figures:

Table 1: Health complaints and symptoms of vibration exposure by Organ System

Orthopedic and neurological system:

Localized or radiating pain, discomfort, numbness, tingling, loss of feeling and muscle control in spine or

Gastro-intestinal system:
Nausea, vomiting, indigestions
Flank pain (renal)
Hemorrhoids related seating discomfort.

Female reproductive organs:

Localized pain, discomfort, irregular periods, concern for pregnancy

Burning sensation, urgency,
Concern for cancer symptoms: hematuria or prostate enlargement / PSA marker elevation

Peripheral veins

Cochlea-vestibular system- vertigo

Table 2: Comparison of WBV injuries/occupational disease claims by physician findings and diagnostic

classification (ICD 10, 2013) in Germany and the Netherlands (General Industry) for the time period of

2006 to 2012. (Source DGUV, Dr. S. Gravemeyer; Coronel Institute, Dr. PPFM (Paul) Kuijer, Dr. HF

(Henk) van der Molen)

Claims BRD = Dutch recognized
n (BK 2110) cases
ICD - 10 Diagnoses (BK 2110)

M42.- Osteochondrose 7 0 0

M47.- Spondylose, 11 0 7

M50.- Cervical disc disorder 13 0 1

M51.- Lumbar disc disorder 1089 50 25

M54.- Lumbar Pain 51 0 26

Total = n 1172 50 64

Years 2006-12 2006-12 2006-12

Back Flexion Lateral
20.4 25.0
-10< <10 15.0
|10< <20| 10.0
-20>>20 5.0 -10<<10
<vib.> 1.5=
0.5 R <vib.
. ..


Figure 1) Locomotive operator during switching of rail cars. Hands operating controls located

to the left of the seat during WBV exposure. Below: Result of measurements of lateral back

flexion with the CUELA system during coupling maneuver and in comparison with three vector-

sum vibration exposure levels category (low (0), medium (2) and high (3).
WBV occupational disease claims
(BeK 2110) and recognized cases



600 Claims



1995 2000 2005 2006 2007 2008 2009 2010 2011 2012

Figure 2: Numbers of WBV occupational disease claims and recognized cases under BeK 2110

in Germany from 1995 to 2012 (General Industry) (Source: DGUV, Dr. S. Gravemeyer)

500 488

422 411
392 381
400 377 379




21 12 12 106 1012 1315

68 67 710 410
1995 2000 2005 2006 2007 2008 2009 2010 2011 2012
WBV Germany BeK2110 21 12 12 6 10 10 13 6 7 4
WBV Dutch 8 6 12 15 7 10 10
French T97 110 422 411 392 377 363 381 379 488

Figure 3: Comparison of yearly number of WBV related occupational disease cases in Germany

(BeK 2110), The Netherlands, and France (Tableaux No. 97) (General Industry). (Source

DGUV, Dr. S. Gravemeyer; Coronel Institute, Dr. PPFM (Paul) Kuijer, Dr. HF (Henk) van der

Molen; P.M. Donati. INRS, France)

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E. Johanning Medical Diagnosis of Whole-body Vibration Disorders-A systematic
Funding: No special outside funding was received for this systematic review and paper


Acknowledgement: I wish to acknowledge the support by Dr. Stefan Gravemeyer

(Deutsche Gesetzliche Unfallversicherung (DGUV), St. Augustin, Germany), Dr. PPFM

(Paul) Kuijer (Coronel Institute of Occupational Health, Academic Medical Center,

Amsterdam, The Netherlands), Dr. P. Donati (INRS, France) and Prof. M. Bovenzi, M.D.

(University of Trieste, Italy).