ORIGINAL ARTICLE
Symptoms of Nervous System Related Disorders Among Workers
Exposed to Occupational Noise and Vibration in Korea
Seunghyun Lee, MPH, Wanhyung Lee, MD, Jaehoon Roh, MD, PhD, Jong-Uk Won, MD, PhD,
and Jin-Ha Yoon, MD, PhD
Objective: The aim of this study was to determine the relationship between
vibration and noise exposure in the workplace and certain nervous system
related symptoms (NSRS) among Korean workers. Methods: Using data
from the fourth Korean Working Conditions Survey, we investigated the
influence of vibration and noise with three categories; none, mild, and
severe, on sleep disturbance, overall fatigue, and headache/eye strain using
logistic regression analysis with stratification by personal protective equip-
ment (PPE) wearing status. Results: Severe noise/vibration exposure was
associated in a dose–response fashion with NSRS; the odds ratios (ORs) for
sleep disturbance, headache/eyestrain, and overall fatigue were 1.48/1.06,
1.46/1.26, and 1.56/1.28 for severe and mild noise/vibration exposure,
respectively, compared with no exposure. Workers who did not wear PPEs
were the most affected. Conclusions: Occupational exposures to vibration
and noise are associated with NSRS. Additional longitudinal studies and
tightened education and safety measures are warranted.
O ccupational and personal injuries, as well as disease or death
resulting from occupational accidents, have become a
serious concern for workers in most industrialized countries.
Occupational injuries and accidents cause considerable psycho-
logical, social, and physical harm to workers. Such events can have
negative effects on a worker’s livelihood, as well as that of his/her
company and society as a whole.1 The International Labour Organ-
ization estimates that occupational accidents or diseases are
responsible for over 2 million deaths worldwide, or approximately
6000 people every day.2 Moreover, almost $3.0 trillion is spent
annually covering the costs of occupational accidents and disease
directly and indirectly.3
Occupational accidents and injuries occur because of hazard-
ous workplace environments; many such sites often harbor situ-
ations that exceed workers’ physiological and psychiatric
tolerance.1,4,5 Although the focus on the causes of occupational
accidents and injuries has changed over time, workers’ physical and
mental status (including health and general condition) have always
been included in assessments.6 A number of physiological and
psychiatric conditions have been reported to be associated with
the risk of injury and accidents in the workplace.1,7 –9
Disturbance of body and mental status have led to the poor
conditions of working populations, declined attention and
From the First Department of Internal Medicine, School of Medicine, University
of Occupational and Environmental Health, Kitakyushu, Japan (Lee); The
Institute for Occupational Health (Drs Lee, Roh, Won, Yoon); Graduate
School of Public Health, Yonsei University College of Medicine, Seoul (Drs
Roh, Won, Yoon); Incheon Worker’s Health Center, Namdong-gu (Drs Lee,
Roh, Won, Yoon); and Department of Preventive Medicine, Yonsei University
College of Medicine, Seoul, Republic of Korea (Drs Roh, Won, Yoon).
Both Seunghyun Lee and Wanhyung Lee contributed equally.
All aspects of study design, data analysis, and manuscript writing were inde-
pendent of funders.
The authors declare that they have no conflicts of interest.
Address correspondence to: Jin-Ha Yoon, MD, PhD, The Institute for Occu-
pational Health, Department of Preventive Medicine, Yonsei University
College of Medicine, 50, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
(flyinyou@gmail.com).
Copyright ß 2017 American College of Occupational and Environmental
Medicine
DOI: 10.1097/JOM.0000000000000935
JOEM  Volume 59, Number 2, February 2017
Copyright © 2017 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
motivation for working, languid habits in the workplace, and
difficultly judging hazardous situations that can lead to accidents
and injuries.10,11 Workers may also exhibit psychological or phys-
iological dysfunction related to the nervous system.12,13 Interest-
ingly, fatigue, eye strain/headache, and sleep disturbance/insomnia
have shared mechanisms and are related nervous system disorders
that are related to reduced health status in workers.14– 16 Further-
more, such symptoms may be directly or indirectly responsible for
human errors that lead to industrial accidents or injuries.
There are several occupational factors and working con-
ditions linked to nervous system disruption.17–19 According to
previous research, occupational exposure to the environmental
hazards of noise and vibration can play an important role in
addressing the issue of fatigue, eye strain/headache, sleep disturb-
ance, and insomnia of workers.20,21 Some studies have reported that
chronic exposure to noise or vibration can continuously stimulate
the autonomic nervous system, causing sustained central autonomic
arousal and stimulation of sympathetic nervous activity. Peripheral
nervous system induction might be an important risk factor for
nervous system related symptoms (NSRS).20,22,23
A considerable amount of literature concerning occupational
exposures has been published. A few studies have suggested that
noise and vibration exposure are associated with NSRS, including
sleep disturbances, eyestrain and headache, and overall fatigue.
However, these studies have traditionally concentrated on the
relationship between a single occupational exposure factor and
multiple symptoms, or the association between two exposure factors
and a single symptom.17,24 –26 However, workers are often exposed
to both noise and vibration simultaneously in their work environ-
ments, for example, when handling large machines and equipment.
Large vehicles can also generate both vibration and noise. Thus,
attention should be paid to the association between occupational
exposure to both noise and vibration together and any NSRS. In
addition, the World Health Organization recommends that appro-
priate personal protective equipment (PPE) should be used to
minimize exposure to hazardous sources; however, PPE usage
remains very low27,28 and no studies to date have investigated
the relationship between NSRS induced by exposure to noise or
vibration in terms of compliance with PPE requirements.
Therefore, we conducted this study to investigate whether an
association exists between the hazardous occupational risk factors
of vibration and noise and the NSRS of sleep disturbance or
insomnia, overall fatigue, and headache and eyestrain in Korean
workers, using data from a national representative survey in Korea.
In addition, we evaluated whether PPE usage had any effect on these
symptoms in terms of workers’ safety.
METHODS
Study Population
This study was based on data acquired from the 4th Korean
Working Conditions Survey (KWCS) conducted by the Occu-
pational Safety and Health Research Institute (OSHRI) in 2014.
Study participants included employed individuals over 15 years of
age selected from across the country using multistage systematic
cluster sampling methods. The survey was conducted through
191
 Lee et al
face-to-face interviews during house visits by trained interviewers.
All participants provided written informed consent. The quality of
the KWCS has been assured and the survey has been deemed valid
and reliable.29 A total of 50,007 individuals participated in the 4th
KWCS; our study included the adult population over 20 years old
and having complete data on education, household income, symp-
toms, working duration, and other relevant variables (27,436 partici-
pants; 23,688 men and 3748 women).
Main Variables
Health problems were assessed from self-reported question-
naires that inquired about symptoms. Sleep disturbance or insomnia,
headaches/eyestrain, and overall fatigue events were measured from
responses to the question: ‘‘Over the last 12 months, did you have
any of the following health problems?’’ which is identical to the
question used in the European Working Conditions Survey. At the
same time, work-related injury was investigated using the question:
‘‘Were you injured at work during the previous 12 months?’’
Participants who answered ‘‘yes’’ were considered to have experi-
enced any symptom and injury. In addition, subjects were asked the
following questions regarding occupational exposure: ‘‘In your
workplace, are you exposed to noise so loud that you have to raise
your voice to keep a conversation during work?’’ and ‘‘In your
workplace, are you exposed to vibrations from hand tools and
machinery?’’ A previous study estimated the accuracy of the
responses regarding perceived noise to have a sensitivity of
68.4% and a specificity of 74.6% with respect to a noise exposure
of 85 dB (as measured by a noise dosimeter).30 Another study
investigated the vibration perception thresholds in exposed workers,
and found the optimal limit to be 138 dB (sensitivity 63%; speci-
ficity 86%) at 500 Hz.31 Our participants answered each question
subjectively according to a seven-point scale (all of the time, almost
all of the time, approximately three-fourth of the time, approxi-
mately half of the time, approximately one-fourth of the time,
almost never, never). According to previous study, responses were
divided into three categories: none, mild, and severe. Workers who
were never exposed to vibration and noise are categorized as
‘‘none,’’ workers who exposed for one-fourth or less of the working
hours were categorized as ‘‘mild,’’ and workers who exposed for
half or more of the working hours were categorized as ‘‘severe.’’32
Covariates
Potential confounding variables included sex, age (grouped as
20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 years), educational level,
and household income. Occupational characteristics included occu-
pational classification, shift work (yes or no), working hours, and
whether PPE was used. Occupational classifications were regrouped
into four of the 10 major categories of the International Standard
Classifications of Occupations, according to skills and duties: white-
collar workers (managers, professionals, technicians, and associate
professionals), pink-collar workers (clerical support, service, and
sales workers), green-collar workers (skilled agricultural, forestry,
and fishery workers), and blue-collar workers (crafts and related
trades, plant and machine operators and assemblers, and elementary
occupations). Mean number of working hours per week was calcu-
lated, and usage of PPE was categorized as those who did not require it
(No need), those who required it and always used it (Need/wear), and
those who required it but did not use it (Need/no wear).
Statistical Analysis
Statistical analyses were performed using SAS statistical
software (version 9.4; SAS Institute Inc., Cary, NC). x2 tests were
used to assess differences between general characteristics of
the study population by noise and vibration exposure levels. Before
deriving the final regression model, multicollinearity tests that were
assessed by calculation of variance inflation factors were carried out
192
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JOEM  Volume 59, Number 2, February 2017
using regression model diagnostics. Variance inflation factors val-
ues more than 2.5 were considered indicative of multicollinearity.33
There was no multicollinearity between independent variables, and
therefore, all models were adjusted for age, sex, working hours,
household income, PPE status, occupational characteristics, level of
education, and shift work in the final logistic regression after
stratification by PPE status. Odds ratios (ORs) and 95% confidence
intervals (95% CIs) for each symptom were estimated using a
logistic regression model stratified by PPE status and adjusted
for age, sex, educational level, household income, work hours,
and whether participants worked in shifts. We then conducted linear
regression analysis for total number of NSRS and exposure level of
noise and vibration with stratification by PPE use. ORs were
computed according to exposure level (none ¼ 0, mild ¼ 1, and
severe ¼ 2) for each NSRS. Finally, we also measured the associ-
ations between occupational injury prevalence and NSRS, stratified
by PPE status. A two-tailed P value less than 0.05 was considered
statistically significant.
RESULTS
The study population comprised 27,436 respondents,
including 23,688 (86.4%) male and 3748 (13.6%) female workers
(Table 1). Levels of exposure to occupational vibration and noise
source during more than half of their working time (severe
exposure) were 15.3% and 11.0%, respectively. The prevalence
of sleep disturbance, headaches/eyestrain, and overall fatigue dif-
fered significantly by noise exposure; headaches/eyestrain and
overall fatigue (but not sleep disturbance) differed significantly
according to vibration exposure.
Tables 2 and 3 show the relationships between noise and
vibration exposure levels and each of the investigated symptoms
using logistic regression. Associations stratified by PPE usage are
also shown. Compared with the no-noise exposure group, high noise
exposure was associated with sleep disturbance, headache/eye-
strain, and overall fatigue after adjusting for age, sex, educational
status, household income, occupation, work hours, shift work, and
PPE status. For workers who did not require PPE, a high level of
noise exposure was significantly associated with all symptoms.
Associations for headaches/eyestrain and overall fatigue remained
significant in adjusted analyses. In addition, there were significant
associations between high noise levels and headache/eyestrain and
overall fatigue in workers who required PPE and always wore it at
work. However, there was no significant association with sleep
disturbance. Finally, the strongest associations between high noise
exposure and NSRS were observed in workers who were required to
use PPE but neglected to do so (sleep disturbance OR: 4.17, 95% CI:
1.21 to 14.34; headache and eyestrain OR: 3.01, 95% CI: 1.73 to
5.24; overall fatigue OR: 2.93, 95% CI: 1.78 to 4.84).
Table 4 summarizes results of linear regression models for
total number of nervous system related symptoms and total
exposure level of noise and vibration. There were significantly
increased total numbers of NSRS according to increasing exposure
level. The largest association between exposure level and nervous
system related symptoms was found for workers who required but
did not wear PPE at the workplace.
Figure 1 shows the prevalence of occupational injury accord-
ing to the severity of noise and vibration exposures, stratified by the
number of NSRS. For workers with one or two symptoms, the rates
of occupational injury were 1.0%, 2.6%, and 3.6% in the no-
exposure, mild, and severe noise exposure groups, respectively.
The prevalence of occupational injury significantly increased
according to the severity of noise exposure among workers with
all three sets of symptoms (4.3%, 5.2%, and 13.2% in the none,
mild, and severe exposure groups, respectively) (Fig. 1A). For both
noise and vibration exposure, there was a statistically significant
trend (P < 0.005) according to the total number of NSRS. In the
ß 2017 American College of Occupational and Environmental Medicine
 JOEM  Volume 59, Number 2, February 2017 Occupational Noise and Nervous System Disorders

TABLE 1. Demographic Characteristics of Study Population

Occupational Noise Occupational Vibration
Exposure Level, n (%) Exposure Level, n (%)

None Mild Severe P None Mild Severe P

Total 12,729 (46.4) 11,698 (42.6) 3,009 (11.0) 12,564 (45.8) 10,684 (38.9) 4,188 (15.3)
Gender <0.0001 <0.0001
Men 10,871 (45.9) 10,092 (42.6) 2,725 (11.5) 10,710 (45.2) 9,150 (38.6) 3,828 (16.2)
Women 1,858 (49.6) 1,606 (42.8) 284 (7.6) 1,854 (49.5) 1,534 (40.9) 360 (9.6)
Age, years <0.0001 <0.0001
<30 1,607 (52.9) 1,146 (37.8) 282 (9.3) 1,608 (53.0) 1,094 (36.0) 333 (11.0)
30–39 2,992 (49.0) 2,520 (41.3) 589 (9.7) 3,031 (49.7) 2,268 (37.2) 802 (13.1)
40–49 3,859 (45.1) 3,750 (43.8) 946 (11.1) 3,893 (45.5) 3,327 (38.9) 1,335 (15.6)
50–59 3,263 (43.6) 3,298 (44.1) 925 (12.3) 3,130 (41.8) 3,023 (40.4) 1,333 (17.8)
60 1,008 (44.6) 984 (43.6) 267 (11.8) 902 (39.9) 972 (43.0) 385 (17.0)
Education level <0.0001 <0.0001
Elementary school 354 (41.4) 389 (45.4) 113 (13.2) 305 (35.6) 402 (47.0) 149 (17.4)
Middle school 794 (39.1) 927 (45.7) 309 (15.2) 715 (35.2) 887 (43.7) 428 (21.1)
High school 5,223 (42.9) 5,215 (42.8) 1,740 (14.3) 5,044 (41.4) 4,681 (38.5) 2,453 (20.1)
University or higher 6,358 (51.4) 5,167 (41.8) 847 (6.8) 6,500 (52.5) 4,714 (38.1) 1,158 (9.4)
Household income 0.0011 <0.0001
First quartile 2,962 (46.1) 2,815 (43.8) 651 (10.1) 2,957 (46.0) 2,628 (40.9) 843 (13.1)
Second quartile 2,553 (47.8) 2,253 (42.2) 534 (10.0) 2,529 (47.4) 2,084 (39.0) 727 (13.6)
Third quartile 3,714 (46.4) 3,347 (41.8) 940 (11.8) 3,587 (44.8) 3,029 (37.9) 1,385 (17.3)
Fourth quartile 3,500 (45.7) 3,283 (42.8) 884 (11.5) 3,491 (45.5) 2,943 (38.4) 1,233 (16.1)
Occupational classification <0.0001 <0.0001
White-collar workers 1,833 (49.2) 1,569 (42.1) 327 (8.7) 1,955 (52.4) 1,387 (37.2) 387 (10.4)
Pink-collar workers 8,620 (54.2) 6,461 (40.7) 818 (5.1) 8,805 (55.4) 6,164 (38.8) 930 (5.8)
Green-collar workers 356 (37.9) 477 (50.7) 107 (11.4) 210 (22.3) 530 (56.4) 200 (21.3)
Blue-collar workers 1,920 (28.0) 3,191 (46.5) 1,757 (25.5) 1,594 (23.2) 2,603 (37.9) 2,671 (38.9)
Working time (hours/week) <0.0001 <0.0001
<48 6,854 (49.1) 5,773 (41.4) 1,330 (9.5) 6,921 (49.6) 5,234 (37.5) 1,802 (12.9)
48 5,875 (43.6) 5,925 (44.0) 1,679 (12.4) 5,643 (41.9) 5,450 (40.4) 2,386 (17.7)
Shift work <0.0001 <0.0001
Yes 775 (38.8) 928 (46.4) 296 (14.8) 771 (38.6) 804 (40.2) 424 (21.2)
No 11,954 (47.0) 10,770 (42.3) 2,713 (10.7) 11,793 (46.4) 9,880 (38.8) 3,764 (14.8)
Personal protective equipment <0.0001 <0.0001
No need 11,168 (53.0) 8,551 (40.6) 1,348 (6.4) 11,295 (53.6) 7,924 (37.6) 1,848 (8.8)
Need/wear 1,373 (24.3) 2,757 (48.9) 1,511 (26.8) 1,130 (20.0) 2,395 (42.5) 2,116 (37.5)
Need/no wear 188 (25.8) 390 (53.6) 150 (20.6) 139 (19.1) 365 (50.1) 24 (30.8)
Symptoms of nervous system related disorders
Sleep disturbance 0.0036 0.7688
Yes 12,393 (46.5) 11,346 (42.6) 2,896 (10.9) 12,206 (45.8) 10,369 (38.9) 4,060 (15.2)
No 336 (41.9) 352 (44.0) 113 (14.1) 358 (44.7) 315 (39.3) 128 (16.0)
Headache/Eye strain <0.0001 <0.0001
Yes 10,407 (47.6) 9,162 (41.9) 2,275 (10.4) 10,136 (46.4) 8,489 (38.9) 3,219 (14.7)
No 2,322 (41.5) 2,536 (45.4) 734 (13.1) 2,428 (43.4) 2,195 (39.3) 969 (17.3)
Overall fatigue <0.0001 <0.0001
Yes 10,145 (48.9) 8,574 (42.3) 2,050 (9.9) 9,933 (47.8) 7,882 (38.0) 2,954 (14.2)
No 2,584 (38.8) 3,124 (46.9) 959 (14.3) 2,631 (39.5) 2,802 (42.0) 1,234 (18.5)
Occupational injure since last year <0.0001 <0.0001
Yes 12,627 (46.8) 11,432 (42.4) 2,913 (10.8) 12,489 (46.3) 10,481 (38.9) 4,002 (14.8)
No 102 (22.0) 266 (57.3) 96 (20.7) 75 (16.1) 203 (43.8) 186 (40.1)

Occupational classification are regrouped to four groups from 10 major groups of International Standard Classifications of occupations by skills and duties level; white-collar
workers (managers, professionals, and technicians and associate professionals), pink-collar workers (clerical support workers and service and sales workers), green-collar workers
(skilled agricultural, forestry, and fishery workers), and blue-collar workers (craft and related trades workers, plant and machine operators, and assemblers, and elementary
occupations).

group of workers exposed to occupational vibration, the prevalence
of occupational injury also significantly associated with the total
number of NSRS (P for trend for having one or two symptoms
<0.05, P for trend for having all symptoms <0.05) (Fig. 1B). The
prevalence of occupational injury also increased according to the
severity of noise and vibration exposures when workers were
stratified according to PPE usage status (Fig. 2A). In the Need/
wear group, the rates of occupational injuries were 1.9%, 3.1%, and
3.9% in the none, mild, and severe exposure groups, respectively. In
the Need/no wear group, occupational injury rates were 2.1%, 2.7%,
and 3.1% in the three groups. Furthermore, the prevalence of
occupational injury significantly increased according to vibration
exposure severity in all PPE usage categories (P for trend <0.05 for
all PPE status groups).
DISCUSSION
This is the first study undertaken to investigate the relation-
ship between workers’ nervous system related health and exposure

ß 2017 American College of Occupational and Environmental Medicine 193

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 Lee et al JOEM  Volume 59, Number 2, February 2017

TABLE 2. Odds Ratios and 95% Confidence Intervals for Nervous System Related Symptoms According to Noise Exposure
From Logistic Regression Analyses
Odds Ratio (95% Confidence Interval)

Noise Exposure Sleep Disturbance Headache/Eye Strain Overall Fatigue

Total population (n ¼ 27,436)

None (n ¼ 12,729) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 116,998) 1.13 (0.97–1.31) 1.23b (1.15–1.31) 1.33b (1.25–1.41)
Severe (n ¼ 3,009) 1.48a (1.17–1.87) 1.46b (1.32–1.62) 1.56b (1.42–1.72)
Protective equipment: No need
Population (n ¼ 21,067)
None (n ¼ 11,168) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 8,551) 1.11 (0.93–1.31) 1.23b (1.14–1.32) 1.36b (1.27–1.46)
Severe (n ¼ 1,348) 1.50a (1.11–2.32) 1.46b (1.27–1.68) 1.64b (1.44–1.87)
Protective equipment: Need/wear
Population (n ¼ 5,641)
None (n ¼ 1,373) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 2,757) 1.26 (0.83–1.89) 1.24a (1.05–1.46) 1.13 (0.98–1.31)
Severe (n ¼ 1,511) 1.47 (0.92–2.35) 1.39a (1.16–1.68) 1.30a (1.10–1.54)
Protective equipment: Need/no wear
Population (n ¼ 728)
None (n ¼ 188) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 390) 1.61 (0.50–5.17) 1.55 (0.98–2.46) 1.94a (1.29–2.90)
Severe (n ¼ 150) 4.17a (1.21–14.34) 3.01a (1.73–5.24) 2.93a (1.78–4.84)

All models adjusted for age, sex, education, income, occupational classification, work time, shift work.
a
P < 0.05.
b
P < 0.0001.

to noise and vibration at workplace with PPE status. We found that
exposure to noise and vibration was associated with all three NSRS
investigated (sleep disturbance, headache/eye strain, and overall
fatigue), and this association was not attenuated by possible
confounding factors.
The observed associations between occupational noise and
vibration exposure and NSRS are consistent with results from
previous studies.17,24 –26,34 There are several possible explanations
for these findings. Some researchers have postulated possible
mechanisms to explain the relationship between occupational

TABLE 3. Odds Ratios and 95% Confidence Intervals for Nervous System Related Symptoms According to Vibration Exposure
From Logistic Regression Analyses
Odds Ratio (95% Confidence Interval)
Vibration Exposure Sleep Disturbance Headache/Eye Strain Overall Fatigue

Total population (n ¼ 27,436)

None (n ¼ 12,564) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 10,684) 1.00 (0.86–1.17) 1.07a (1.00–1.14) 1.21b (1.14–1.29)
Severe (n ¼ 4,188) 1.06 (0.84–1.34) 1.26b (1.14–1.39) 1.28b (1.17–1.40)
Protective equipment: No need
Population (n ¼ 21,067)
None (n ¼ 11,295) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 7,924) 1.07 (0.90–1.27) 1.11a (1.03–1.20) 1.28b (1.19–1.37)
Severe (n ¼ 1,848) 0.94 (0.68–1.29) 1.16a (1.02–1.32) 1.19a (1.05–1.34)
Protective equipment: Need/wear
Population (n ¼ 5,641)
None (n ¼ 1,130) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 2,395) 0.72 (0.48–1.09) 0.94 (0.79–1.12) 0.95 (0.81–1.11)
Severe (n ¼ 2,116) 0.95 (0.62–1.46) 1.23a (1.02–1.48) 1.16 (0.98–1.38)
Protective equipment: Need/no wear
Population (n ¼ 728)
None (n ¼ 139) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Mild (n ¼ 365) 2.56 (0.54–11.97) 0.92 (0.56–1.51) 1.40 (0.90–2.18)
Severe (n ¼ 224) 5.83a (1.22–27.75) 2.04a (1.20–3.48) 2.17a (1.33–3.55)

All models adjusted for age, sex, education, income, occupational classification, work time, shift work.
a
P < 0.05.
b
P < 0.0001.

194 ß 2017 American College of Occupational and Environmental Medicine

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 JOEM  Volume 59, Number 2, February 2017 Occupational Noise and Nervous System Disorders

TABLE 4. Linear Regression Analyses for Number of the Nervous System Related Symptoms According to Total Vibration and
Noise Exposure Level
Number of Nervous System Related
Symptoms

Variable Participants ß (Standard Error) P

Total exposure level of vibration and noise Total participants (n ¼ 27, 436) 0.0399 (0.0034) <0.0001
PPE-wearing status
No need (n ¼ 21,067) 0.0340 (0.0042) <0.0001
Need/wear (n ¼ 5,641) 0.0284 (0.0077) 0.0002
Need/no wear (n ¼ 728) 0.0971 (0.0233) <0.0001

All model adjusted for age, sex, education, income, occupational classification, work time, shift work.
PPE, personal protective equipment.

exposure to vibration or noise and NSRS. The extent of NSRS due to
vibration exposure depends on magnitude, frequency, and direction.
As vibration exposure levels increase, visual interference, sleep
disturbance, headaches, and fatigue can occur. Workers who operate
vehicles or industrial machinery and those who work inside of a
building during its construction are exposed to vibration that causes
nervous system excitation and can produce imbalance in the auto-
nomic nervous system.35 Furthermore, it has been reported that
long-term exposure to vibration might lead to hyperactivity in the
sympathetic nervous system.25 Such nervous system disruptions
could easily lead to fatigue and sleep disturbance. Motion sickness
related discomfort, especially in the eye, can occur even in healthy
persons.36 Also, vibration can induce visual vestibular mismatch
that can also lead to eyestrain.37,38 At present, it is generally
accepted that workers exposed to vibrations can subsequently
experience problems in the autonomous parts of the brain, leading
to symptoms, including persistent fatigue, headaches, eye irritation,
and sleep disruption.39
Noise that is pervasive can lead to both auditory and nonauditory
health effects among workers. Sleep disturbance is the most prevalent
symptom in populations exposed to occupational noise. Even daytime
noise exposure induces autonomic, motor, and cortical nervous
systemic hyperarousal40 and interferes with sleep quality as exempli-
fied by delayed sleep onset, early awakening, and an increase in the time
spent awake and/or in superficial sleep stages.41 Furthermore, occu-
pational noise exposure can exacerbate physical exertion because of the
overstimulation of the motor nervous system, causing fatigue.42 Symp-
toms in migraine and tension headache patients are aggravated by
exposure to noise and physical activity,43 both of which are common in
the workplace. A previous study reported that noise-induced headaches
were associated with an elevated temporal pulse amplitude.44 Workers
inside buildings experienced unexplained eye symptoms that became
more severe when they were exposed to daytime noise.45 As noise
exposure is associated with tolerance for nervous systemic overload,
excessive nervous systemic noise stimulation can increase environ-
mental hypersensitivity to chemicals or odors.46 This hypersensitivity
can lead to eyestrain by sensory nervous system irritation.47
Interestingly, NSRS were linked to combined exposure to
noise and vibration in the workplace. There was a statistically
significant statistical interaction effect between noise and vibration
exposure and NSRS (P value for interaction <0.0001, data not
shown). Furthermore, according to results from the linear regression
model in Table 4, we can infer a dose–response relationship
between noise and/or vibration exposure and NSRS. Previously
published studies have similarly reported a combined effect of noise
and vibration. For example, a summation of the effects on annoy-
ance was found from exposure to both noise and vibration.48 In
workplace, workers exposed to vibration could be exposed to noise
as well. Thus, workers who had vibration white finger frequently
presented severe hearing loss together.49 Findings from our study
have important implications for understanding of combined
exposure to multiple occupational hazardous that could harm
workers’ health. Future studies on the different NSRS linked to
complex occupational exposures are therefore recommended.
The elevated risk of NSRS among workers who did not use PPE
is a novel finding. To our knowledge, our study represents the first

FIGURE 1. (A) Occupational noise exposure and prevalence of occupational injury with stratification of total number of nervous
system related symptoms. (B) Occupational vibration exposure and prevalence of occupational injury with stratification of total
number of nervous system related symptoms. P for trend <0.05.

ß 2017 American College of Occupational and Environmental Medicine 195

Copyright © 2017 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
 Lee et al
FIGURE 2. (A) Occupational noise exposure and prevalence of occupational injury with stratification of personal protective
equipment status. (B) Occupational vibration exposure and prevalence of occupational injury with stratification of personal
protective equipment status. P for trend <0.05.
attempt to investigate the effect of occupational exposure on symp-
toms stratified according to PPE usage. We observed that workers who
did not use PPE had a significantly higher risk for NSRS owing to
noise exposure than those using PPE. We also observed that workers
who did not use PPE had a higher risk of sleep disturbance and overall
fatigue due to noise or vibration exposure than those using PPE. Also,
in dose–response relationship analysis, there was a significantly
higher risk for NSRS among workers in the Need/no wear PPE group
than others. These findings suggest that use of PPE in the workplace
may help prevent occupationally induced NSRS.
Furthermore, our data showed that the occupational injury
rose as levels of exposure to occupational noise and vibration
increased, as did the number of NSRS. The highest prevalence
of occupational injury was found among workers required to wear
PPE but who did not wear it. PPE is intended to be used by workers
as protection against hazardous work environments; therefore, it is
necessary to increase safety education and management programs
that emphasize the importance of using PPE and describe the
negative health effects of occupational noise exposure.
According to Heinrich’s domino theory, multiple errors
caused by unsafe conditions, including unsafe mechanical or
physical environments and erratic behaviors or activities that
deviate from normally accepted safe practices, might result in
occupational injuries.50–52 NSRS are known for their diverse effects
on humans; a previous study revealed that vibration exposure might
exacerbate sensory-motor problems such as the failure of force
control caused by increased overall muscle tension and fatigue.
Vibration can also be a precursor to injury.53 In addition, noise may
impair attention by direct distraction, which hinders recognition of
warning signals and receipt of communications. Effects of noise on
performance have been attributed to increased arousal, wherein
diminished concentration exacerbates fatigue and stress. These
unsafe environments generally result from a lack of awareness
and/or mismanagement.54,55 Also, some studies reported that
workers who suffer from sleep problem and headaches have diffi-
culties with concentration, memory, decision-making, and morale.
Work productivity is impaired due to higher rates of absenteeism,
decreased mental concentration, and difficulty performing work
duties. Workers with NSRS are responsible for several times more
industrial accidents than healthy workers.11,56,57 Fatigue is also
responsible for the occurrence of occupational accidents, as it
decreases a worker’s ability to process clues regarding a potentially
hazardous situation.10 Thus, it is possible to hypothesize that
workers with NSRS are more likely to incur injury at the workplace,
with a higher risk for injury among workers required to wear PPE
196 ß 2017 American College of Occupational and Environmental Medicine
Copyright © 2017 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
JOEM  Volume 59, Number 2, February 2017
but not wearing it. The findings can make an important contribution
to protecting vulnerable workers from occupational injury.
Several limitations to our study must be acknowledged. First,
data were not available for alcohol or smoking habits, which are also
related to sleep disturbance, overall fatigue, and headache/eye strain.
Second, information on symptoms and exposures was obtained using
self-administered questionnaires; this method may be subject to recall
bias and insufficiently detailed information regarding exposures or
symptoms. For example, human exposure to vibration includes
whole-body vibration, motion sickness, and hand-transmitted
vibration.36 Workers in an occupational environment may be exposed
to all these types of vibration, and we could not differentiate between
them in our study. Finally, NSRS could be exacerbated by depression
or other stressful life factors for which data were not collected.
However, this study considered many potential confounders, includ-
ing age, sex, education, income, occupational classification, work
time, shift work, and PPE use. In addition, the quality of the KWCS
was deemed to be valid and reliable to investigate working popu-
lations and occupational hazards.29 Our study has several important
strengths that must be considered alongside the above-mentioned
limitations. First, the study had a large sample size that is represen-
tative of Korean workers. Second, we evaluated three NSRS based on
exposure to two occupational hazards, in contrast to previous studies
that have investigated only single symptoms or occupational hazard
types. Finally, we measured the effect of exposure to occupational
hazards stratified according to PPE usage.
CONCLUSION
This study showed meaningful associations between
exposure to noise and vibration and three different NSRS. These
findings enhance our understanding of the effects of occupational
exposure to noise and/or vibration on individual or total of NSRS.
Global awareness programs and continuing education for protecting
workers against exposure to occupational hazards are warranted.
Further clinical and longitudinal studies are needed to overcome
some limitations of the present study.
ACKNOWLEDGMENT
We would like to thank participants of KWCS for the oppor-
tunity to this research.
REFERENCES
1. Garcrencent di S, Mariscal M, GarcGa-Rodrarc M, GaRitzel DO. Working
conditions, psychological/physical symptoms and occupational accidents.
Bayesian network models. Saf Sci. 2012;50:1760–1774.
 JOEM  Volume 59, Number 2, February 2017
2. International Labour Organization. Safety and health at work: a vision for
sustainable prevention: XX World Congress on Safety and Health at Work
2014: Global Forum for Prevention, 24–27 August 2014, Frankfurt,
Germany. Geneva, International Labour Office, 2014.
3. International Labour Organization. Safety and Health in the Use of Chemi-
cals at Work. Geneva, International Labour office; 2013:6–7.
4. Khanzode VV, Maiti J, Ray P. Occupational injury and accident research: a
comprehensive review. Saf Sci. 2012;50:1355–1367.
5. Suzuki K, Ohida T, Kaneita Y, et al. Mental health status, shift work, and
occupational accidents among hospital nurses in Japan. J Occup Health.
2004;46:448–454.
6. Hamalainen P. Global Estimates of Occupational Accidents and Fatal Work-
Related Diseases. Tampere, Finland: Tampere University of Technology; 2010
7. Melamed S, Yekutieli D, Froom P, Kristal-Boneh E, Ribak J. Adverse work
and environmental conditions predict occupational injuries. The Israeli
Cardiovascular Occupational Risk Factors Determination in Israel (COR-
DIS) Study. Am J Epidemiol. 1999;150:18–26.
8. Uehli K, Mehta AJ, Miedinger D, et al. Sleep problems and work injuries: a
systematic review and meta-analysis. Sleep Med Rev. 2014;18:61–73.
9. Williamson A, Lombardi DA, Folkard S, Stutts J, Courtney TK, Connor JL.
The link between fatigue and safety. Accid Anal Prev. 2011;43:498–515.
10. Swaen G, Van Amelsvoort LBL, Bvoo U, Kant I. Fatigue as a risk factor for
being injured in an occupational accident: results from the Maastricht Cohort
Study. Occup Environ Med. 2003;60:i88–i92.
11. Léger D, Guilleminault C, Bader G, Levy E, Paillard M. Medical and socio-
professional impact of insomnia. Sleep 2002; 25:625–629.
12. Fontes R, Ribeiro J, Gupta DS, et al. Time perception mechanisms at central
nervous system. Neurol Int. 2016;8:5939.
13. Mennemeier M. Arousal, attention, and perception. In: Chatterjee A, Coslett
HB, editors. The Roots of Cognitive Neuroscience: Behavioral Neurology and
Neuropsychology. New York: Oxford University Press; 2013. pp. 131–170.
14. Stepanski E, Zorick F, Roehrs T, Young D. Daytime alertness in patients with chronic
insomnia compared with asymptomatic control subjects. Sleep. 1988;11:54–60.
15. Torres-Harding S, Jason LA. What is fatigue? History and epidemiology. In:
DeLuca J, editor. Fatigue as a Window to the Brain. Cambridge, MA: MIT
Press; 2005. pp. 3–17.
16. Murata K, Araki S, Kawakami N, Saito Y, Hino E. Central nervous system
effects and visual fatigue in VDT workers. Int Arch Occup Environ Health.
1991;63:109–113.
17. Chazelle E, Chastang J-F, Niedhammer I. Psychosocial work factors and
sleep problems: findings from the French national SIP survey. Int Arch Occup
Environ Health. 2016;89:485–495.
18. Park JB, Nakata A, Swanson NG, Chun H. Organizational factors associated
with work-related sleep problems in a nationally representative sample of
Korean workers. Int Arch Occup Environ Health. 2013;86:211–222.
19. Nieuwenhuijsen K, Bruinvels D, Frings-Dresen M. Psychosocial work
environment and stress-related disorders, a systematic review. Occup Med
(Lond). 2010;60:277–286.
20. Yoon J-H, Won J-U, Lee W, Jung PK, Roh J. Occupational noise annoyance
linked to depressive symptoms and suicidal ideation: a result from nation-
wide survey of Korea. PLoS One. 2014;9:e105321.
21. Gitanjali B, Dhamotharan R. Effect of occupational noise on the nocturnal
sleep architecture on healthy subjects. Indian J Physiol Pharmacol.
2003;47:415–422.
22. Hardoy MC, Carta MG, Marci AR, et al. Exposure to aircraft noise and risk of
psychiatric disorders: the Elmas survey–aircraft noise and psychiatric dis-
orders. Soc Psychiatry Psychiatr Epidemiol. 2005;40:24–26.
23. Murata K, Araki S, Maeda K. Autonomic and peripheral nervous system
dysfunction in workers exposed to hand-arm vibration: a study of RR interval
variability and distribution of nerve conduction velocities. Int Arch Occup
Environ Health. 1991;63:205–211.
24. Ribet C, Derriennic F. Age, working conditions, and sleep disorders: a
longitudinal analysis in the French cohort E.S.T.E.V. Sleep. 1999;22:491–504.
25. Jiao K, Li Z, Chen M, Wang C, Qi S. Effect of different vibration frequencies
on heart rate variability and driving fatigue in healthy drivers. Int Arch Occup
Environ Health. 2004;77:205–212.
26. Prashanth KM, Sridhar V. The relationship between noise frequency com-
ponents and physical, physiological and psychological effects of industrial
workers. Noise Health. 2008;10:90–98.
27. Goelzer B, Hansen CH, Sehrndt G. Occupational Exposure to Noise: Evalu-
ation, Prevention and Control. Geneva: World Health Organization; 2001.
28. Carpenter WS, Lee BC, Gunderson PD, Stueland DT. Assessment of personal
protective equipment use among Midwestern farmers. Am J Ind Med.
2002;42:236–247.
ß 2017 American College of Occupational and Environmental Medicine
Copyright © 2017 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
Occupational Noise and Nervous System Disorders
29. Kim YS, Rhee KY, Oh MJ, Park J. The validity and reliability of the
second Korean working conditions survey. Saf Health Work. 2013;4:
111–116.
30. Ahmed HO, Dennis JH, Ballal SG. The accuracy of self-reported high noise
exposure level and hearing loss in a working population in Eastern Saudi
Arabia. Int J Hyg Environ Health. 2004;207:227–234.
31. Virokannas H. Vibration perception thresholds in workers exposed to
vibration. Int Arch Occup Environ Health. 1992;64:377–382.
32. Kim KS, Kwon OJ. Prevalence and risk factors of hearing loss using the
Korean working conditions survey. Korean J Audiol. 2012;16:54–64.
33. Raum E, Küpper-Nybelen J, Lamerz A, Hebebrand J, Herpertz-Dahlmann B,
Brenner H. Tobacco smoke exposure before, during, and after pregnancy and
. risk of overweight at age 6. Obesity. 2011;19:2411–2417.
34. Heo Y-S, Chang S-J, Park S-G, et al. Association between workplace risk
factor exposure and sleep disturbance: analysis of the 2nd Korean Working
Conditions Survey. Ann Occup Environ Med. 2013;25:41.
35. Harada N. Autonomic nervous function of hand-arm vibration syndrome
patients. Nagoya J Med Sci. 1994;57(Suppl):77–85.
36. Crocker MJ. Handbook of Noise and Vibration Control. Hoboken, NJ: John
Wiley & Sons; 2007.
37. Wertheim A. Working in a moving environment. Ergonomics. 1998;41:
1845–1858.
38. Longridge N, Mallinson A. Visual vestibular mismatch in work-related
vestibular injury. Otol Neurotol. 2005;26:691–694.
39. Griffin M. Minimum health and safety requirements for workers exposed to
hand-transmitted vibration and whole-body vibration in the European Union;
a review. Occup Environ Med. 2004;61:387–397.
40. Muzet A. Environmental noise, sleep and health. Sleep Med Rev. 2007;11:
135–142.
41. Basner M, Babisch W, Davis A, et al. Auditory and non-auditory effects of
noise on health. Lancet. 2014;383:1325–1332.
42. Vyas H, Das S, Mehta S. Occupational injuries in automobile repair workers.
Ind Health. 2011;49:642–651.
43. Wöber C, Holzhammer J, Zeitlhofer J, Wessely PWP, Wly PWC. Trigger
factors of migraine and tension-type headache: experience and knowledge of
the patients. J Headache Pain. 2006;7:188–195.
44. Martin PR, Todd J, Reece J. Effects of noise and a stressor on head pain.
Headache. 2005;45:1353–1364.
45. Witterseh T, Wyon DP, Clausen G. The effects of moderate heat stress and
open-plan office noise distraction on SBS symptoms and on the performance
of office work. Indoor Air. 2004;14:30–40.
46. Nordin S, Millqvist ELE, Lvis O, Bende M. The chemical sensitivity scale:
psychometric properties and comparison with the noise sensitivity scale. J
Environ Psychol. 2003;23:359–367.
47. Millqvist E. Mechanisms of increased airway sensitivity to occupational
chemicals and odors. Curr Opin Allergy Clin Immunol. 2008;8:135–139.
48. Howart H, Griffin M. Subjective response to combined noise and
vibration: summation and interaction effects. J Sound Vib. 1990;143:
443–454.
49. Zhu S-k, Sakakibara H, Yamada Sy. Combined effects of hand-arm vibration
and noise on temporary threshold shifts of hearing in healthy subjects. Int
Arch Occup Environ Health. 1997;69:433–436.
50. Heinrich HW, Petersen D, Roos NR, Brown J, Hazlett S. Industrial Accident
Prevention: a Safety Management Approach. New York: McGraw-Hill;
1980 .
51. Caputo AC, Pelagagge PM, Salini P. AHP-based methodology for selecting
safety devices of industrial machinery. Saf Sci. 2013;53:202–218.
52. Nahrgang JD, Morgeson FP, Hofmann DA. Safety at work: a meta-analytic
investigation of the link between job demands, job resources, burnout,
engagement, and safety outcomes. J Appl Psychol. 2011;96:71–94.
53. Adamo DE, Martin BJ, Johnson PW. Vibration-induced muscle fatigue, a
possible contribution to musculoskeletal injury. Eur J Appl Physiol.
2002;88:134–140.
54. Yoon J-H, Hong J-S, Roh J, Kim C-N, Won J-U. Dose-response relationship
between noise exposure and the risk of occupational injury. Noise Health.
2015;17:43–47.
55. Witterseh T, Wyon DP, Clausen G. The effects of moderate heat stress and
open-plan office noise distraction on SBS symptoms and on the performance
of office work. Indoor Air. 2004;14(Suppl 8):30–40.
56. Linton SJ, Bryngelsson L. Insomnia and its relationship to work and health in
a working-age population. J Occup Rehabil. 2000;10:169–183.
57. Seifert TD, Evans RW. Posttraumatic headache: a review. Curr Pain Head-
ache Rep. 2010;14:292–298.
197