Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair

Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
Musculoskeletal Health of Hairdressers –
Protection of Occupational Health and Safety
                               at Workplace
                           Medical Reference Document
Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
Imprint                                                                                       Contents

                                                                                              Abstract Scoping Review........................................................................................................4

                                                                                               The hairdressing sector in Europe..................................................................................6
                                                                                               1.1. European efforts to strengthen occupational health and safety
Authors:                                                                                      		protection............................................................................................................8
Agnessa Kozak1                                                                                 1.2. Social dialogue efforts within the hairdressing sector....................................8
Claudia Wohlert1
Tanja Wirth1                                                                                  2.The musculoskeletal system.......................................................................................10
Olaf Kleinmüller1                                                                               2.1. Structure and function.....................................................................................10
Miet Verhamme2                                                                                  2.2. Musculoskeletal disorders (MSD)....................................................................11
Rainer Röhr 3                                                                                 		2.2.1. Work-related MSD.................................................................................11
Albert Nienhaus1,4                                                                            		     2.2.2. Risk factors for MSD..............................................................................13
                                                                                              		2.2.3. Economic relevance..............................................................................19
 University Medical Centre Hamburg-Eppendorf, Competence Centre for Epidemiology              		     2.2.4. The economic benefit of MSD prevention within companies...........21
and Health Services Research for Healthcare Professionals (CVcare), Hamburg, Germany
                                                                                              3.Scoping review on musculoskeletal health of hairdressers....................................22
    Unie van Belgische Kappers vzw, Gent, Belgium                                               3.1. Background......................................................................................................22
                                                                                                3.2. Methods............................................................................................................24
 The German Confederation of Skilled Crafts, Germany (former CEO (2004-2014) and                3.3. Results..............................................................................................................25
former secretary of Coiffure EU)                                                              		      3.3.1. Prevalence of musculoskeletal disorders...........................................26
                                                                                              		      3.3.2. Reasons for leaving the trade...............................................................26
 Department of Occupational Medicine, Hazardous Substances and Public Health, Ins-            		3.3.3. Comparative findings............................................................................27
titution for Statutory Accident Insurance and Prevention in the Health and Welfare Servi-     		      3.3.4. Work-related risk factors......................................................................27
ces (BGW), Hamburg, Germany                                                                   		      3.3.5. Preventive and rehabilitative approaches to prevent or reduce
Design and implementation:                                                                    		      3.3.6. Strategies and barriers to reduce or prevent MSD.............................31
in.signo GmbH, Hamburg, Germany                                                                 3.4. Discussion........................................................................................................32
                                                                                                3.5. Conclusions......................................................................................................33
Picture credits:
Fotolia/LIGHTFIELD STUDIOS (Cover), iStock/Nastasic (p. 5), (p. 6-7),             4.        Outcomes of the workshops in Hamburg and Paris – ergoHair project................34
Fotolia/Leonid (p. 9), Fotolia/ (p. 14), iStock/robertprzybysz (p. 17),
Fotolia/Jacob Lund (p. 20), iStock/dimid_86 (p. 22-23), Fotolia/JackF (p. 30, 39), Fotolia/   5.Ergonomic and organizational approaches to prevention......................................40
Maksim Shebeko (p. 34-35), Fotolia/phpetrunina14 (p. 40-41), Fotolia/pololia (p. 49),           5.1. Outcomes of the ergoHair project workshops..............................................42
iStock/DjelicS (p. 78-79)                                                                     		     5.1.1. Prevention in training and continuing professional
Funding:                                                                                      		     5.1.2. Ergonomic design and equipment......................................................43
This project was funded by the European Union (Reference VS/2017/0077)                        		5.1.3. Ergonomic working...............................................................................45
                                                                                              		     5.1.4. General organizational conditions in the workplace..........................46
Publication date:                                                                             		5.1.5. Risk assessment...................................................................................47
4. April 2019                                                                                   5.2. Musculoskeletal complaints during pregnancy.............................................49

                                                                                              6.        Annex............................................................................................................................50

                                                                                              7.        References....................................................................................................................66

Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
Abstract Scoping Review                                                                          ween European committees for social dia-        Section 2 is dedicated to the anatomical
                                                                                                     logue within the sector. By doing so, it con-   structure and functions of the musculoske-
                                                                                                     tributes to the harmonization of occu-          letal system and work-related MSD. The
                                                                                                     pational health and safety with a particular    prevalence of work-related MSD, multifac-
    Objective Hairdressers are exposed to           regions or exhibited a greater risk of leaving   focus on ergonomic workplace design and         torial risk factors and the cost of this health
    conditions that can cause or exacerbate         the profession for health reasons. Common        equipment. Furthermore, it aims to help         problem are presented in detail. Further-
    musculoskeletal disorders (MSD). The pur-       risk factors include working with arms           promote effective, ergonomic work proces-       more, there is a discussion of the economic
    pose of this scoping review is to gain          above shoulder level, repetitive movements,      ses. The overarching goal is to raise awa-      benefits of preventive measures to counter
    insight into the current state of research on   forceful exertion of upper extremities, awk-     reness of the stresses and strains faced by     MSD at work.
    MSD in hairdressing.                            ward back postures and movements, high           hairdressers and consequently reduce the
                                                    mechanical workload and standing. The            number of work-related musculoskeletal          Section 3 presents the systematic litera-
    Methods Studies published up to May             effect of these risk factors can be enhanced     disorders (MSD) and conditions (MSC) in         ture appraisal (scoping review) completed
    2017 (Update Nov, 2018) were identified by      by the lack of adequate breaks, high wor-        this sector throughout Europe by develo-        as part of the ergoHair project. In line with
    a systematic search using electronic data-      kload, and general distress. Six rehabilita-     ping and disseminating preventative ergo-       the aims of the project, the collated studies
    bases (MEDLINE, PUBMED, CINAHL, Web             tive and preventive intervention studies         nomic measures and standards in a target        provided the scientific basis for the initia-
    of Science, LIVIVO), Google Scholar and         were found. Only the rehabilitative studies      group-specific fashion.                         tive. The epidemiological insights delivered
    reference lists of articles. Studies were       showed positive effects on the manage-                                                           by these studies allow conclusions to be
    screened by two researchers and synthe-         ment of physical and mental strain and           The project builds on the European frame-       drawn about the occupational and health-
    sized in a narrative and quantitative man-      resulted in significant pain reduction, incre-   work agreement on the protection of occu-       related stresses and strains encountered
    ner. Pooled effect estimates for 12-month       ased physical capacity and knowledge of          pational health and safety in the hairdres-     by hairdressers and clearly indicate that
    and point prevalence of MSD were calcu-         potential risk factors for MSD.                  sing sector, signed in 2016. The objectives     there should be a stronger focus on steps
    lated, using random effects models.                                                              identified in this agreement are to contri-     to protect occupational health and safety
                                                    Conclusion These data provide some evi-          bute to the development of a collective,        both at work and in educational settings.
    Results Overall 44 studies were included.       dence for work-related risk factors for MSD      research-based European standard for
    Nineteen studies reported MSD prevalence:       in hairdressers and indicate that there          protecting health and safety in the work-       Section 4 compiles further research results
    the highest 12-month prevalence was found       should be an intense focus on preventive         place. One of the five focal issues is the      that were presented in the workshops in
    for the lower back 48% (95% CI 35.5-59.5),      technical, organizational and individual         prevention of MSD. The parties who make         Hamburg and Paris.
    neck 43% (95% CI 31.0-55.1), shoulders          measures for health and safety at work.          up the signatories to the agreement are
    42% (95% CI 30.1-53.2) and hand/wrists          High quality and long-term intervention          particularly concerned with communica-          Section 5 then collates suggestions and
    32% (95% CI 22.2-40.8). In comparison to        studies are needed to clarify the effective-     ting at the earliest possible opportunity the   recommendations for promoting healthy
    other occupational groups, hairdressers         ness of complex preventive concepts in           need for preventative and health-promo-         and safe working conditions for hairdres-
    reported more frequent MSD in all body          hairdressing.                                    ting behaviour in the workplace. This           sers by designing ergonomic workplaces
                                                                                                     encompasses issues such as product              and work processes.
                                                                                                     acquisition, workflow organization and the
                                                                                                     treatment of employees. The aim of this
                                                                                                     medical reference document is to provide
                                                                                                     professionals in the hairdressing sector
    Introduction                                                                                     with a guideline listing the criteria which
                                                                                                     should be taken into account when deve-
                                                                                                     loping a healthy work environment.

    The objective of the project “Development       proposals contained in the social partners’      Section 1 contains a description of the
    and promotion of a healthy and safe wor-        agreement regarding the development of a         hairdressing sector in Europe and the gene-
    king environment through the design of          healthy and safe work environment in the         ral approaches taken by both the European
    ergonomic workplaces and work proces-           hairdressing sector [1, 2]. To accomplish        Union and the social partners from within
    ses in the hairdressing sector” (ergoHair)      this, it aims to strengthen synergies and        the industry to strengthen the protection of
    is the uniform implementation of the core       promote the exchange of information bet-         occupational health and safety.

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Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
1                                                                                                  1

        The hairdressing sector in Europe

        The hairdressing sector in Europe consists primarily of small and micro busines-
        ses. There are an estimated 400,000 hair salons with approximately one million
        hairdressers. That is equivalent to around 0.4–0.8% of a country’s employees [3,
        4]. Self-employment is widespread in the hairdressing sector. According to a study
        of eight EU Member States1, around 50–60% of all hair salons are run by self-
        employed stylists without any employees. The growth rate for hairdressing busi-
        nesses is between 12% and 149% in EU countries. Italy, Germany and France have
        the largest number of businesses. Alongside one-person salons, the number of
        companies that run hairdressing chains or offer franchises is also on the rise [4].
        In Germany, these are believed to account for a 15% share of all hairdressing busi-
        nesses [5]. The majority of employees are women: in most countries, 9 out of 10
        hairdressers are female. Compared with other sectors, young people are over-
        represented in hairdressing; more than half of employees are below the age of 34
        [4]. This industry is also hallmarked by a large proportion of part-time workers
        (approximately 40%) [3]. However, there are considerable differences between
        countries in this respect. In the Netherlands, for instance, 70% of hairdressers are
        part-time, compared with just 9% in Hungary. The sector is also characterized by
        high staff turnover. In the Netherlands and the United Kingdom, around 16% and
        14% of employees respectively leave their job within a year [4]. In Denmark, hair-
        dressers spend an average of 8.4 years in the profession (including time spent in
        training) [6].

        Denmark, France, Germany, Hungary, Italy, the Netherlands, Slovenia, United Kingdom

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Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
1.1. European efforts to
1       strengthen occupational health
                                                         Health protection became a key issue for
                                                         the hairdressing industry back in the 90s.
                                                                                                        various target groups – such as instructors,
                                                                                                        teachers, workers and salon managers –
                                                                                                                                                       ped protection measures and require a
                                                                                                                                                       knowledge of them as part of hairdressing
        and safety protection                            This was triggered by a rise in work-related   could implement the social partners’           training and in professional tests and final
                                                         skin conditions since the late 80s (e.g. in    agreements at national level. In response      examinations [10]. According to the social
        Preventing or minimizing physical hazards        Germany), which forced many hairdressers       to this call, Osnabrück University comple-     dialogue participants, the number of skin
        in the workplace is a fixed part of the EU       to leave the profession. As long ago as        ted the projects Safehair 1.0 and 2.0 bet-     disorders reported in the hairdressing
        Member States’ occupational health and           2001, CIC Europa – the predecessor of          ween 2009 and 2012 on behalf of the social     industry has fallen sharply as a conse-
        safety policy. Article 153 of the Treaty on      Coiffure EU – and UNI Europa Hair &            partners and the European Commission.          quence of the joint efforts. Furthermore, in
        the Functioning of the European Union (EU)       Beauty agreed on a set of guidelines for       The key outcome of the projects was a          2014, EU-OSHA and the social partners
        authorizes the European Council to impose        working conditions. The corresponding list     voluntary commitment on the part of the        developed an online risk assessment tool,
        minimum requirements by means of direc-          of demands included key elements of the        social partners – agreed in the Declaration    OiRA, for the hairdressing sector [11].
        tives to ensure that steps are taken to better   European agreement on the protection of        of Dresden – to uphold the jointly develo-
        protect workers’ health and safety. The          health in the hairdressing sector which was
        legal requirements differ between EU Mem-        subsequently signed in 2012. In 2011, the
        ber States. Each state has leeway and can        social partners began discussing a more
        establish stricter regulations for the protec-   concrete health protection agreement
        tion of workers and their interests when it      covering a wider range of issues. This
        incorporates directives into national legis-     agreement was signed in April 2012 in the
        lation [7]. Directive 89/391/EEC explicitly      presence of the then Commissioner for
        makes employers responsible for individu-        Employment, Social Af-fairs and Inclusion,
        ally adapting the working environment with       László Andor. It covers the following areas:
        regard to workplace design, the choice of        • Use of substances, products and tools
        equipment/materials and the choice of pro-       • Protection of the skin and respiratory
        duction methods [8]. In its priorities for         tracts
        occupational safety and health research for      • Prevention of musculoskeletal disorders
        the period 2013–2020, the European               • Working environment and work organi-
        Agency for Safety and Health at Work (EU-          zation
        OSHA) recommends developing and imple-           • Maternity protection
        menting multidimensional ergonomic mea-          • Mental health
        sures which take individual, technical and
        organizational aspects into account [9].         The European Commission was asked to
                                                         transpose this agreement into a European
                                                         directive, making it mandatory for all hair-
        1.2. Social dialogue efforts                     dressing businesses. This request has not
        within the hairdressing sector                   yet been fulfilled because a number of
                                                         Member States objected to parts of the
        Social dialogue is a fundamental part of the     agreement. Following renewed negotia-
        European social model whose legal basis          tions, a revised framework agreement on
        is set down in Articles 151–156 of the Treaty    the protection of occupational health and
        on the Functioning of the European Union         safety was signed in June 2016 [1, 2]. This
        [7]. Various European hairdressing organi-       focuses primarily on protecting the skin
        zations participated in this dialogue. These     and respiratory tracts and preventing MSD.
        were Coiffure EU on the employer side and        With regard to work-related skin disorders,
        UNI Europa Hair & Beauty on the employee         the social dialogue originally called for a
        side. The social dialogue centred above all      European research project to be initiated.
        on two issues: harmonizing vocational trai-      Based on scientific findings, this research
        ning and protecting workers’ health.             project was to issue statements on how the

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Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
The musculoskeletal system                                                                       2.2. Musculoskeletal disorders                        cal and psychomental effects of working in
                                                                                                          (MSD)                                                 a particular profession and the associated

2                                                                                                         The term “musculoskeletal disorders” co-
                                                                                                                                                                overloading or incorrect loading of the loco-
                                                                                                                                                                motor system [23-26]. There are many
         2.1. Structure and function                       of exercise can prompt degenerative chan-      vers a variety of degenerative and inflamm-           forms of work-related MSD (figure 1). The
                                                           ges – also known as osteo-arthritis – espe-    atory injuries and conditions affecting the           World Health Organization (WHO) defines
         Together, the skeletal elements, joints and       cially in older people [13].                   locomotor system. They affect both passive            these as the interplay of various factors
         skeletal muscles make up the locomotor                                                           and active structures. These disorders range          from the work environment which contri-
         system. The body’s supportive framework           The active locomotor system consists of        from mild short-term symptoms (e.g. tight             bute significantly to causing and/or exacer-
         consists of bony and cartilaginous skeletal       muscles, tendons and ligaments. They are       muscles resulting from overloading or incor-          bating MSD to different extents [15]. Kro-
         elements which are held together by con-          primarily responsible for active movement      rect loading) to irreversible, chronic condi-         emer (1989) defines three stages of
         nective tissue. Skeletal muscles move             and maintaining an upright posture via         tions (e.g. osteo-arthritis). Damage to the           work-related MSD: Stage 1: symptoms are
         parts of the skeleton or hold them in a cer-      voluntary and involuntary contraction and      musculoskeletal system occurs when exter-             experienced at work but go away; Stage 2:
         tain position. The locomotor system is divi-      relaxation of the muscles.                     nal mechanical loads exceed the maximum               symptoms last overnight after a day at work;
         ded into active and passive structures. The                                                      load-bearing capacity of the individual struc-        Stage 3: symptoms continue at rest, disturb
         bones, joints and cartilage of the skeletal       Muscle: There are more than 400 muscles        tures within the body [15]. Pain is the primary       sleep and last for months or years [27].
         system are classed as passive structures          in the human body; they make up approxi-       symptom of MSD. There are two types of
         [13]. They fulfil the following main functions:   mately 45% of the body mass. There are         pain: acute and chronic. Acute pain acts as           The proportion of work-related MSD can only
         • Supporting and acting as levers for             three basic types of muscle: skeletal          a biological warning to prevent further               be estimated roughly due to their predomi-
           muscles                                         muscle, smooth muscle (e.g. walls of the       damage to the locomotor system. Chronic               nantly multicausal genesis and high preva-
         • Protecting other organs (e.g. ribcage           gastrointestinal tract) and cardiac muscle.    pain has moved beyond this point and impe-            lence among the general population [28]. In
           protects the heart and lungs)                   Unlike the other types, skeletal muscle is     des the patient’s use of their locomotor sys-         industrialized nations, around a third of all
         • Storing the minerals calcium and phos-          controlled by a voluntary nerve impulse. At    tem [16]. This results in high, intangible costs      sickness-related absences are attributable to
           phate                                           rest, skeletal muscle accounts for 20–25%      for the patient, such as restricted physical          MSD. Conditions or injuries affecting the back
         • Producing blood cells in the bone mar-          of energy expenditure [12, 13]. There are      function or a lower quality of life [17, 18]. Pati-   account for approximately 60% of these.
           row [12]                                        gender-specific differences too: men have      ents are also less able to work and less pro-         They are followed by conditions affecting the
                                                           a higher muscle mass than women (30 kg         ductive as a consequence [19]. The condi-             upper extremities, which are also referred to
         Bones: An adult’s skeleton is made up of          versus 24 kg on average). This means that      tions and symptoms are heterogeneous;                 collectively as repetitive strain injuries or
         approximately 200 bones. Its shape is             women only have 65% as much physical           they vary considerably depending on their             cumulative trauma disorders [15]. In the
         determined genetically, while the inner           strength as men [12, 14].                      location2 and the tissue structure affected           Labour Force Survey (EU-27), 8.6% of wor-        2
                                                                                                                                                                                                                     (1) Upper extremities,

                                                                                                          [20]. Musculoskeletal disorders are among                                                                  (2) cervical vertebrae
         structure is influenced by external factors                                                                                                            kers (20 million people) reported work-related
         (e.g. a healthy diet, a supply of calcium and     Tendons and additional structures :            the most widespread conditions within the             health problems in the previous 12 months;           (3) thoracic vertebrae
         vitamin D, and balanced weight bearing)           When muscles contract, tendons joining         population. Population surveys conducted              most of these were complaints affecting the          (Th1–Th12),

                                                                                                          worldwide (n = 23) show that between 13.5%                                                                 (4) lumbar vertebrae (L1–L5)
         [12].                                             the bone to the muscles transmit the force                                                           locomotor system [29]. According to the
                                                           to the skeleton. They consist of tough, fib-   and 47% of the general population is affec-           European Occupational Disease Statistics
                                                                                                                                                                                                                     (5) lower extremities[20]
         Joints and cartilage: Joints connect car-         rous collagen tissue. Depending on the         ted by chronic musculoskeletal pain [21]. A           (2005), work-related MSD accounted for the
         tilaginous and/or bony skeletal structures        location, shape and architecture of the        recent Europe-wide survey found that back             largest share – 38% – of all occupational
         and allow the individual parts of the trunk       muscle, tendons are classed as tensile ten-    pain (43%) and muscular pain in the arms              diseases in 12 EU Member States. The inclu-
         and the extremities to move. They also            dons, compressive tendons or aponeuro-         (41%) were by far the most common comp-               sion of carpal tunnel syndrome (CTS) takes
         serve to transfer energy. Most articulating       ses [13]. When muscles work, friction is       laints. Women reported MSD significantly              this percentage up to 59% [30]. The ten most
         surfaces are covered with hyaline cartilage       generated. Additional structures such as       more frequently than men [22].                        common occupational diseases for the
         and surrounded by a cavity which is filled        muscle fascia, tendon sheaths, bursae and                                                            reporting years 2001–2007 include CTS and
         with synovial fluid and encased in a joint        sesamoid bones are very important in mini-                                                           conditions affecting the muscular and tendi-
         capsule. The cartilage receives an optimum        mizing the energy, which is expended as a      2.2.1. Work-related MSD                               nous insertions, the tendon sheaths (e.g. ten-
         supply of nutrients when it is regularly          result [12, 13].                                                                                     dosynovitis, epicondylitis) and the angioneu-
         worked and relaxed by means of move-                                                             Epidemiological studies provide sufficient            roses, which are caused by mechanical
         ment. High unilateral load carrying or a lack                                                    evidence that MSD is caused by the physi-             stresses (e.g. Raynaud’s syndrome) [31].

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Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
2.2.2. Risk factors for MSD                         models. Along with occupational demands,
                                                                                                                                                                                                       these include genetic predispositions,

2                                                                                                                                                  Epidemiological studies have sufficiently
                                                                                                                                                   documented that there is an above-ave-
                                                                                                                                                                                                       social factors, levels of training and pro-
                                                                                                                                                                                                       ductivity, and stress perception and resis-
                                                                                                                                                   rage occurrence of degenerative MSD in              tance [16] (figure 2). However, not all of
                                                                                                                                                   occupations where workers are exposed to            these are risk factors as such, i.e. factors
                                                                                                                                                   considerable physical strains [23, 25, 26,          which contribute towards causing MSD.
                                                                                                                                                   35, 36]. However, the ways in which MSD             Reference is increasingly made to risk indi-
                                                                                                                                                   is explained and viewed have evolved sub-           cators which are frequently observed in
                                                                                                                                                   stantially in recent years: instead of focu-        association with the symptoms, such as
                                                                                                                                                   sing solely on biomechanically based cau-           work dissatisfaction or lack of gratification
                                                                                                                                                   sality theories, there has been a shift to-         [12].
                                                                                                                                                   wards complex biopsychosocial disease

         Neck                                        Back                                             Shoulder
                                                                                                                                                          Socio-economic factors                              Behavioral factors
         • Cervical spondylosis                      • Interverterbral disc disorders                 • Rotator cuff syndrome
         • Thoracic outlet syndrome                  • Back pain                                      • Bicipital tendinitis                              •   Social class                                    • Physical inactivity
         • Tension neck syndrome                                                                      • Shoulder capsulitis                               •   Age                                             • Malnutrition and malnourish-
                                                                                                                                                          •   Education                                          ment
                                                                                                                                                          •   Labour status/unemployment                      • Tobacco use

                                                                                                                                                                                                                             Structural factors

                                                                                                                                           Work-related factors                                                              • Potential tripping hazards

                                                                                                                                           •   Trade sector
                                                                                                                                           •   Overload/incorrect loading
                                                                                                                                           •   Psychosocial stress
                                                                                                                                           •   Lack of gratification                                                                 Physical constraints/
                                                                                                                                           •   Work dissatisfaction                                                                  pre-existing conditions
                                                                                                                                           •   Lack of social support
                                                                                                                                                                                                                                     •   Overweight/obesity
                                                                                                                                                                                                                                     •   Sport injuries
                                                                                                                                                                                                                                     •   Accidents
         Elbow                                       Hand                                             Hip/Knee                                                                                                                       •   Impairment of senses
         • Lateral epicondylitis                     • Carpal Tunnel Syndrome                         •   Hip osteoarthritis
         • Medial epicondylitis                      • DeQuervain‘s disease                           •   Knee osteoarthritis
         • Cubital/Radial                            • Wrist Tenosynovitis                            •   Meniscus injury                                 Psychological factors
           Tunnel Syndrome                           • Hand-Arm-Vibration                             •   Bursitis
                                                                                                                                                          • Depressive disorders                              Health competence
         • Non-specific forearm pain                   Syndrome
                                                                                                                                                          • Fear or anxiety
                                                     • Trigger finger
                                                                                                                                                          • Stress, family pressures                          • Low health awareness

          Figure 1: MSD which can be caused by biomechanical factors (modified from the ILO [32]; Mani & Gerr [33]; Sluiter et al. [34])           Figure 2: Potential influential factors for musculoskeletal impairment and conditions, modified from Walter & Plaumann [12]

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Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
Table 1: Reasonable evidence risk factors for MSD

                                                                                                                                                                                 Work-related risk factors with reasonable evidence
                                                                                                                                                                                              of a causal relationship
2                                                                                                                                                                                                                                                                                  2
                                                                                                                                           Body region                     biomechanical               psychosocial                   individual
                                                                                                                                           Neck                     • awkward posture            • low level of work          • female gender
                                                                                                                                                                                                   satisfaction and           • co-morbidity
                                                                                                                                                                                                                              • smoking
                                                                                                                                                                                                 • high level of distress

                                                                                                                                           Lower back               • awkward posture            • negative affectivity       • younger age
                                                                                                                                                                    • heavy physical work        • low level of job control   • high BMI
                                                                                                                                                                    • lifting                    • high psychological
                                                                                                                                                                                                 • high work dissatis-

                                                                                                                                           Shoulder                 • heavy physical work        • high levels of distress
                                                                                                                                                                                                 • performing monotonous
                                                                                                                                                                                                 • low level of job control

                                                                                                                                           Elbow                    • prolonged computer                                      • co-morbidities
                                                                                                                                                                       work                                                   • older age
                                                                                                                                                                    • heavy physical work
                                                                                                                                                                    • awkward posture
                                                                                                                                                                    • repetitive work

                                                                                                                                           Wrist/hand               • prolonged computer                                      • high BMI
                                                                                                                                                                       work                                                   • older age
                                                                                                                                                                    • heavy physical work                                     • female gender
                                                                                                                                                                    • awkward posture
                                                                                                                                                                    • repetitive work
                                         A systematic review of longitudinal studies     Biomechanical risk factors
                                                                                                                                           Hip                      • lifting
                                         in various professional groups examined         Exposure to biomechanical risk factors at
                                         the influence of work-related and individual    work – such as awkward forced postures,                                    • heavy physical work
                                         risk factors for MSD. This determined levels    heavy lifting and carrying, frequent bending      Knee                     • awkward posture                                         • co- morbidities
                                         of evidence for the individual risk factors     and twisting of the upper body, manually                                   • lifting
      Reasonable evidence risk
                                         and parts of the body. The evidence ex-         handling loads, repetitive work, physicale-                                • repetitive work
    factors—satisfied at least one
    of the criteria for causality, but   presses the extent to which the statistical     xertion or whole-body vibrations – con-
                                                                                                                                          Source: da Costa & Vieira [24]
    bias or confounding factors
    could not be completely ruled
                                         associations observed in studies can be         tributes towards causing and/or exacerba-
    out (most of the studies pre-        trusted and therefore viewed as a causal        ting symptoms. The combination, duration,        The European Foundation for Improvement             ting or carrying heavy loads, and vibration
    sented 1–3 potentially mislea-
    ding factors). Strong evidence       relationship. Table 1 shows “reasonable         frequency and intensity of these factors         of Living and Working Conditions (Euro-             are the most common physical risk factors
    risk factors—satisfied at least       evidence” biomechanical, psychosocial           can cause considerable damage to anato-          found) conducts regular surveys on wor-             in Europe (figure 3) [22, 38]. The individual
    four of the five criteria for cau-
    sality and bias and confoun-         and individual risk factors3 for the respec-    mical structures such as muscles, tendons,       king conditions in Europe every five years.         dimensions of the so-called physical envi-
    ding factors were controlled         tive body regions [24]. It is noticeable that   joints and nerves. If adaptability is reduced    The sixth survey reaches the conclusion             ronment index4 reveal substantial differen-      4
                                                                                                                                                                                                                                                 The physical environment
    for or were not present (most                                                                                                                                                                                                              index (one dimension of job
    of the studies presented no          there is a very high probability of exposure    and there is a lack of compensation mecha-       that the physical work environment has              ces between professions. For example,            quality) comprises 13 indica-
    misleading factors). Strong
                                         to biomechanical factors having a dama-         nisms, this can give rise to excessive strain,   barely improved over recent years. Expo-            workers in the skilled trades have the high-     tors related to specific physical
    evidence was not assigned to                                                                                                                                                                                                               hazards (e.g. vibration from
    any of the risk factors [24].        ging effect on all regions of the body. The     which in turn results in pain and decreased      sure to posture-related risk factors remains        est and therefore worst score for postural       hand tools, tiring positions,
                                         next section takes a closer look at the indi-   productivity. Accordingly, the consequen-        very frequent. Exposure via repetitive              risks at 37 points; the average for the EU-28    temperature or lifting/moving
                                                                                                                                                                                                                                               people, etc.) [22].
                                         vidual risk dimensions.                         ces vary from person to person [37].             movements, static and forced postures, lif-         is 24 points [22].

    14                                                                                                                                                                                                                                                                       15
Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
Exposed to physical risks over time (% exposed quarter of time or more)                                       among women than men [31, 41, 42]. Gen-           Lifestyle:
                                                                                                                                                der-specific difference could also be exp-      Weight/diet: Overweight and obese wor-

2                                                                                                                                               lained by different exposures to occupati-
                                                                                                                                                onal risk factors. A review indicates that
                                                                                                                                                                                                kers have a higher risk of suffering from
                                                                                                                                                                                                MSD and take longer to recover than those
                    Vibrations                                                                                                                  men are at greater risk of back pain due to     whose weight is normal [47]. Furthermore,
                                                                                                                   1991 EC12                    heavy lifting and carrying and for neck/        the Western lifestyle 6 contributes towards
                                                                                                                                                shoulder complaints caused by hand or           a negative calcium balance and bone demi-
                        Noise                                                                                      1995 EU15                    arm vibrations. Meanwhile, women have a         neralization [48].
                                                                                                                                                higher risk of neck/shoulder complaints
                                                                                                                   2000 EU27                    resulting from awkward static arm postures      Smoking: Bone atrophy and fractures
           High temperatures
                                                                                                                                                [43].                                           have been observed more frequently
                                                                                                                   2005 EU27                                                                    among heavy smokers (including passive
           Low temperatures
                                                                                                                                                   Socio-economic status: A low SES (low        smokers). Smoking also delays healing and
                                                                                                                   2010 EU27                    level of education5, low income or qualifi-     increases complications in connection with      5
                                                                                                                                                                                                                                                  The assumption is that edu-
          Breathing in smoke/                                                                                                                                                                                                                   cation – along with access to
          dust and/or vapours
                                                                                                                                                cations) correlates strongly with the preva-    fractures and trauma [49]. In addition, smo-    good employment opportuni-
                                                                                                                                                lence and incidence of MSD (figure 4) [31,      king has been linked to local inflammatory      ties – also enables healthier
                                                                                                                                                                                                                                                lifestyles and choices, which
                                                                                                                                                44, 45]. Absences from work due to back         reactions by the musculoskeletal system         can protect individuals from
         Chemical substances
                                                                                                                                                pain are more frequent among workers in         (e.g. epicondylitis) and greater sensitivity    disadvantages later in life.

                                                                                                                                                low-qualified, manual jobs. This observa-       to pain [48].                                   6
                                                                                                                                                                                                                                                  Sedentary living, caffeine and
              Tiring or painful                                                                                                                 tion is virtually constant regardless of gen-                                                   alcohol consumption, smoking
                     positions                                                                                                                                                                                                                  and possibly high animal pro-
                                                                                                                                                der and age [46].                               Exercise: Inactivity is an independent risk     tein consumption [48]

                                                                                                                                                                                                factor for back problems [50]. Decreased
                 Heavy loads                                                                                                                                                                    production of joint fluid (synovia), which
                                                                                                                                                                                                serves to protect the surface of joints, can
              Repetetive hand                                                                                                                                                                   also exacerbate wear and tear to joints [51].
           or arm movements

                                  0%           10%            20%             30%             40%            50%             60%          70%

                                  Figure 3: Percentage of physical risk factors for workers in Europe – results of earlier Eurofound
                                  surveys [38]

                                  Eurofound (2012), Fith European Working Conditions Survey, Publications Office of the European Union,

                                  Individual, lifestyle-related influential                 Age: Aerobic and muscular performance
                                  factors                                                 decrease with age, which impairs the phy-
                                  Like most chronic conditions, MSD are trig-             sical ability to work [39]. Older employees
                                  gered by multiple risk factors. In addition to          are more prone to work-related MSD than
                                  stress at work, aspects such as sport, lack             younger ones due to their reduced functio-
                                  of exercise, diet and substance use play a              nal capacity [40]. However, the increase is
                                  significant role in their development. Fur-             less marked among 55 to 64-year-olds.
                                  thermore, systemic diseases such as diabe-              This phenomenon is also known as the
                                  tes and rheumatoid arthritis can have a                 “healthy worker effect”, i.e. employees who
                                  negative impact on the pathogenesis. The                are unwell retire early [31].
                                  risks vary with age, gender and ethnicity or
                                  socio-economic status (SES) [37]. A number                Gender: According to several studies,
                                  of factors are listed here by way of example:           there is a higher overall prevalence of MSD

    16                                                                                                                                                                                                                                                                       17
Musculoskeletal Health of Hairdressers - Protection of Occupational Health and Safety at Workplace - ErgoHair
2.2.3. Economic relevance                         France, 2007: Work-related MSD caused
                              100 %
                                                                                                                                                                                                      the loss of 7.5 million working days, which

2                             90 %                                                                                                                  MSD are responsible for 40% of all global
                                                                                                                                                    payments in kind and compensation for
                                                                                                                                                                                                      went hand in hand with financial damage
                                                                                                                                                                                                      of € 736 million [62].
                              80 %
                                                                                                                                                    occupational diseases and work accidents
                              70 %                                                                                                                  (figure 5) [59]. Work-related back comp-          Germany, 2016: All MSD (ICD8 M00–M99)             8
                                                                                                                                                                                                                                                         ICD – International Classifica-
                                                                                                                                                                                                                                                        tion of Disease.
                                                                                                                                                    laints in connection with all occupational        were responsible for the loss of 154 million
                              60 %
                                                                                                                                                    health problems are estimated to cost the         working days, associated with production
                              50 %                                                                                                                  Member States’ economies between 2.6%             downtime costs of € 17.2 billion and € 30.4
                                                                                                                                                    and 3.8% of the gross social product [60].        billion in lost gross value added [63].
                              40 %
                                                                                                                                                    Estimates put the cost of work-related
                              30 %                                                                                                                  MSD in the upper extremities at between           Finland, 2004: Work-related MSD caused
                                                                                                                                                    0.5% and 2% of the gross social product           direct costs of € 222 million.
                              20 %
                                                                                                                                                    [61]. A comparison of the cost of work-rela-
                              10 %                                                                                                                  ted MSD is made more difficult by differen-       Austria, 2004: MSD were responsible for
                                                                                                                                                    ces in the individual countries’ insurance        the loss of 7.7 million working days.
                                            Low educational level          Intermediate educational level          High educational level           systems, a lack of standardized recording
                                                                                                                                                    criteria and the way in which costs are           Slovenia, 2006: MSD were responsible for
                                      Figure 4: Percentage of work-related health problems (MSD; stress, depression or anxiety; other)              logged. As a result, the following list only      the loss of 2.47 million working days [62].
     “Low educated wor-               in the EU-27 population by educational level7 [31]                                                            sets out to present a number of examples
    kers reported work-
    related problems                                                                                                                                from specific countries:
    more often and were                  Musculoskeletal health problems           Stress, depression or anxiety            Other health problems
    more likely to report
    MSDs as the most
    serious work-related
    problem. In 68% of
    those with low edu-
    cational level with a
    work-related health
                                                                                                                                                                                                              14 % Accidents
    problem MSD was
    the main problem.
    For those in the high
    level of education
    cla s sif ic ation this                                                                                                                                                                                                 3 % Tumors
    was true for 44%”                 Psychosocial and work-organizational                  Lengthy sickness-related absences caused
    (Eurostat, 2010).                 influential factors                                   by MSD have been observed more fre-                                                                                                3 % Skin Diseases
                                      Systematic reviews show links between psy-            quently in employees who face intense time
                                      chosocial factors and MSD [24, 52-54].                pressure at work and have little job control                     40 %
                                      These can have a negative effect on the               [55]. The following additional factors stem-            Musculoskeletal                                                                9 % Respiratory Diseases
                                      condition’s progression with regard to beha-          ming from the work environment and orga-
                                      viour and dealing with pain. Psychological            nization can also have a negative impact on
                                      tension resulting from conflicts at work or           workers’ health [56-58]:
                                                                                                                                                                                                                               8 % Central Nervous System Impairments
                                      within the family can manifest itself physi-          • fast-paced work,
                                      cally and impair the autonomic nervous sys-           • monotonous workflows,
                                      tem. The body reacts with increased muscle            • insufficient breaks,
                                      tone, which in turn can trigger muscle tight-         • precarious employment,
                                      ness. Mobility is severely limited by the pain,       • unfavourable remuneration systems and                                                                               16 % Heart & Circulatory Diseases
                                      resulting in inactivity and compensatory                working time models.                                                           7 % Mental Health Disorders
                                      postural adjustments. Possible long-term
                                      physical effects are muscle loss and joint
                                      misalignment [12].                                                                                            Figure 5: Worldwide compensation costs for work-related diseases and accidents (ILO[59])

    18                                                                                                                                                                                                                                                                               19
2.2.4. The economic benefit of MSD                 In studies with negative or inconsistent out-
         prevention within companies                        comes, there was a lack of support from

2        Sultan-Taïeb et al. (2017) produced a cost-
                                                            managers, the intervention did not meet
                                                            employees’ needs and the “intervention
         benefit assessment of ergonomic work-              dose” was too low [64].
         place-related interventions for the preven-
         tion of occupational MSD. They also                As part of a further study, 300 companies
         examined factors which had a favourable            from 15 countries were asked for their sub-
         or obstructive effect on the implementation        jective assessment of the overall economic
         process. The cumulative savings after the          effects of prevention and health protection
         intervention were higher overall than the          in the workplace (return on prevention).
         total investment (with a payback period of         According to this, the direct effects of pre-
         3 to 5 years for employers and 0.82 to 9           vention measures were a reduction in
         years for accident insurance companies).           hazards, greater awareness of occupatio-
         All of the studies showed that ergonomic           nal risks, and a decrease in dangerous
         equipment and an overall strategy signifi-         behaviour and work accidents. The most
         cantly reduced accidents and claims for            significant indirect effects were improved
         compensation. In studies with positive eco-        image and improved workplace culture
         nomic outcomes, there was substantial              (figure 6) [65]. However, it must be added
         support from upper and middle manage-              as a caveat that these results are based on
         ment and staff participation was also high.        self-assessments by companies.

                          Reduced hazards                                                              5.08

                         Reduced breaches                                                              5.04

                        Reduced accidents                                                              4.98

                      Reduced fluctuations                                           3.80

                       Reduced disruptions                                                  4.30

                        Reduced downtime                                                    4.35

                         Reduced wastage                                             3.80

              Reduced time for catching up                                           3.83

               Improved quality of products                                              3.99

           Improved adherance to schedules                                               4.01

            Increased number of innovations                                                4.19

             Improved customer satisfaction                                               4.15

                 Improved corporate image                                                          4.80

                Improved workplace culture                                                         4.75

                Increased hazard awareness                                                             5.05

                              Total average                                                  4.41

                                                                                                                  1 = no impact
                                              0        1         2         3         4             5          6   6 = very strong impact

            Figure 6: Effects of occupational health and safety within the company (ISSA [65])

    20                                                                                                                                     21
3                                                                                                      3
         Scoping review on musculoskeletal health
         of hairdressers

         3.1. Background

         Musculoskeletal disorders (MSD) are common in the working age population and
         are conditions that affect passive (bones, joints) and/or active structures of the
         body (muscles, tendons, ligaments, peripheral nerves) [37]. Since MSD account
         for a high proportion of compensable occupational diseases worldwide many
         efforts have been undertaken to ascertain the potential risk factors in the develop-
         ment of MSD and its prevention in the workplace setting [23]. MSDs are highly
         prevalent in manual-intensive occupations such as manufacturing, construction or
         services [26, 35, 36]. Hairdressers are a group of workers whose working ability
         and health condition may be affected by specific occupational activities. A daily
         task analysis showed that experienced hairdressers spend on average 29% of their
         time cutting, 17% dying, 10% blow-drying and 8% washing hair. These activities
         required frequent sagittal or lateral bending and twisting of the back (e.g. washing
         hair at the sink), static postures and long-standing periods. Repetitive tasks have
         been observed during all client-related activities [66]. Results from kinematic pos-
         ture analysis revealed that hairdressers spend 9-13% of their total working time
         with arms elevated over 60° [67, 68]. Working with elevated arms above shoulder
         level is considered a major risk factor for clinically verified shoulder disorders or
         persistent severe pain [69, 70]. The relatively high force exertion and wrist velocity
         – combined with prolonged exposure – may account for the higher rate of hand/
         wrist pain, especially in female hairdressers [71]. In a study on the working condi-
         tions of Finnish hairdressers, the most hazardous factors for health were repetitive
         movements, awkward working postures, standing, draft, uncomfortable tempera-
         tures and chemicals [72]. To understand the impact of MSDs on hairdressers requi-
         res quantification of the MSD prevalence, disability or injury, the identification of
         potential risk factors for these health consequences as well as effective preventive
         or rehabilitative measures. This is the first attempt to systematically map the cur-
         rent state of research on these aspects by synthesizing empirical, measurement-
         based or interventional studies in hairdressing.

    22                                                                                            23
3.2. Methods                                   Stage 3: Study selection                         Stage 5: Collating, summarizing and                        3.3. Results
                                                                                   Studies on musculoskeletal health were           reporting the results
                                    Due to a variety of study designs and a lack   considered for the analysis if they reported     To collate and aggregate the data on                       Our search strategy identified 186 articles,
                                    of summary of evidence, we decided to          separate results for hairdressers, assessed      disease frequency in a comprehensible                      of which 44 met the eligibility criteria for the

3                                   conduct a scoping review. The general pur-
                                    pose of a scoping review is to examine the
                                                                                   MSD frequency, work-related risk factors
                                                                                   and preventive or rehabilitative measures
                                                                                                                                    way, we chose a pooled testing strategy
                                                                                                                                    [74]. However, as we did not appraise the
                                                                                                                                                                                               qualitative data synthesis (see Fig 7). The
                                                                                                                                                                                               characteristics of the included studies are
                                    extent and nature of research activity, sum-   against MSD. The following inclusion crite-      study quality, the estimates may be biased                 provided in the Annex 1. Of the eligible stu-
                                    marize the relevant findings and to identify   ria were applied:                                and should serve as approximate values                     dies 29 were conducted in European coun-
                                    research gaps [73]. For methodological         (i) Population : includes hairdressers           which require further exploration. Where                   tries. The majority of the included studies
                                    purposes, we implemented the six-stage               who continue to work in their job and      indicated, 12-month and/or point-preva-                    (84%) were published after the year 2000,
                                    framework for a scoping review as adopted            those who have changed or left their       lence data were extracted and pooled11                     which indicates that research in this occu-           11
                                                                                                                                                                                                                                                       As substantial heterogeneity
                                                                                                                                                                                                                                                     — variability in the population
                                    by Arksey and O’Malley [73]. The six stages          profession for health reasons. Also        using the Excel spreadsheet developed by                   pational setting has recently increased. Of           of effects between studies —
                                    have been implemented as follows:                    other related professions such as cos-     Neyeloff et al. [74]. All potential work-rela-             these, one study applied a qualitative                was suspected, we used ran-
                                                                                                                                                                                                                                                     dom effects models to calcu-
                                                                                         metologists were considered.               ted risk factors examined in the studies                   design with interviews [75] and three were            late the pooled effect estimate
                                    Stage 1: Identification of the research        (ii) Exposure: includes ergonomic, bio-          were extracted and grouped into superor-                   national surveys of occupation-specific               for pain/disorder prevalence in
                                                                                                                                                                                                                                                     different body sites. Hetero-
                                    question                                             mechanical, organizational and psy-        dinate risk categories.                                    data which included hairdressers [76-78].             geneity was quantified using
                                    The following question should be answered:           chosocial factors which occur in the                                                                  One study examined trends in compensa-                the Chi-square (χ2) and I stati-
                                                                                                                                                                                                                                                     stics. The latter is expressed
                                    What is known from the existing literature           occupational context of hairdressers.      Stage 6: Consultation exercise                             tion claims for WRMSDs [79]. Furthermore,             as percentage of the total vari-
                                                                                                                                                                                                                                                     ability between studies: the
                                    about the frequency of MSD, work-related       (iii) Intervention: includes all interventions   The methodology and findings of the sco-                   seven studies were related to evaluation
                                                                                                                                                                                                                                                     higher the percentage, the
                                    risk factors and measures to prevent or              that aim to prevent or reduce MSDs.        ping review were presented at a European                   research [80-86], three studies solely mea-           higher is the degree of hetero-
                                    reduce MSD in hairdressers? We were see-       (iv) Outcome: includes health disorders          workshop within the project ‘ergoHair’.                    sured working postures while performing
                                    king to present an overview of all themati-          related to musculoskeletal system          Workshop participants provided further                     regular hairdressing tasks [68, 71, 87] and
                                    cally relevant material in a clear and com-          such as (recurrent) pain, discomfort,      ideas and suggestions for interpretation of                three studies were from the same cohort of
                                    prehensible manner. Therefore, the study             tingling, numbness, stiff joints, swel-    study findings and recommendations for                     students entering working life [88-90]. All
                                    results were summarized and analyzed by              ling or dull aches.                        preventive measures.                                       but one study predominantly included
                                    applying a thematic approach based on the      (v) Study design: includes peer review                                                                      females [91]. In one study, only cosmetolo-
                                    three subsections of the study question:             and non-peer-review publications of                                                                   gist were queried [92].
                                    (1) What is the prevalence and/or incidence          all study designs except editorials,
                                        of MSD in the different body sites?              commentaries, conference papers
                                    (2) Which work-related risk factors are                                                                          MEDLINE                  PUBMED                    CINAHL            Web of Science                   LIVIVO

                                                                                         and policy statements.
                                                                                                                                                      (n = 44)                (n = 110)                 (n = 47)             (n = 46)                     (n = 62)
                                        associated with MSD?
                                    (3) Which work-related measures are            Reports published in English, German,
                                        applied to prevent or reduce MSD in        Dutch, French, Italian, Portuguese and
                                        hairdressers?                              Spanish were included. Two reviewers                                   Records after duplicates removed
                                                                                                                                                                      (n = 169)
                                                                                   independently assessed the title, abstract

                                    Stage 2: Identifying Relevant Studies          and full text of the articles. In the event of                                                                                                      Records identified through
                                                                                                                                                                                                                                            other sources
                                    A systematic literature search was conduc-     disagreement consensus was achieved by                                                                                                                       (n = 17)
                                                                                                                                                              Title and abstract screening
                                    ted in the electronic databases MEDLINE,       discussion.                                                                          (n = 186)
     Population: hairdress* OR
                                    PUBMED, CINAHL, Web of Science and                                                                                                                                                                      Records excluded
    barbering OR cosmetologist*     LIVIVO. The key words for population9 were     Stage 4: Charting the data                                                                                                                                   (n = 109)

    OR beautician* OR coiffeur*OR
                                    combined with key words for outcome10.         General information on author(s), year of                            Full-text articles assessed for eligibility
    beauty culture*.
                                                                                                                                                                          (n = 77)
                                    We also searched the reference lists of        publication, study location, publication                                                                                            Records excluded, with reasons (n = 33)
      Outcome: musculoskeletal                                                                                                                                                                                         (1) Outcome (n = 7)
    symptoms OR musculoskeletal     identified articles and Google Scholar. The    type, aim, design, participant characteris-
                                                                                                                                                                                                                       (2) No separate description of results (n = 7)
    pain OR musculoskeletal dis-    search included peer-reviewed and non-         tics, methodology and outcome measures                                                                                              (3) Out of focus (n =10)
    orders OR musculoskeletal                                                                                                                        Records included in the qualitative synthesis
                                    peer reviewed literature published from the    were recorded. The data was extracted by                                                                                            (4) Population (n = 4)
    diseases OR upper limb* OR                                                                                                                                         (n = 44)                                        (5) Language (n = 5)

    upper extremity* OR neck pain
                                    inception of the database up to Aug. 17,       one person (AK) and verified by another
    OR back pain OR shoulder
                                                                                                                                                              Information on prevalence
    pain.                           2017 (Update Nov. 5, 2018).                    reviewer (TW).                                                                      (n = 19)
                                                                                                                                                                                                                     Figure 7: Flowchart of the study selection

    24                                                                                                                                                                                                                                                                            25
3.3.1. Prevalence of musculoskeletal               3.3.2. Reasons for leaving the trade              3.3.3. Comparative findings                     musculoskeletal injuries was significantly
                                 disorders                                                                                                                                            higher among the self-employed (66.8%
                                                                                    A Finnish study assessed the risk of leaving      A National German Health Survey provided        vs. 29.7%) [99].
                                 In total, 19 studies provided data on MSD          the profession for health and other reasons       a representative analysis of back pain pre-

3                                prevalence in at least one body site and were
                                 pooled depending on the given time frame,
                                                                                    among female hairdressers as compared
                                                                                    to workers engaged in commercial work.
                                                                                                                                      valence by occupation category. Hairsty-
                                                                                                                                      lists/beauticians belong to the top 4 high-     3.3.4. Work-related risk factorss
                                 e.g. 12-month or point MSD prevalence [78,         The relative risk of leaving the profession       risk occupations for back pain (e.g. the
                                 86, 92-108]. In a subgroup analysis, studies       among hairdressers was increased by 2.7           12-month was 70% and 7-day prevalence           Fifteen studies examined potential risk fac-
                                 from European countries were pooled [78,           (95% CI 1.1-6.3) for a repetitive strain injury   was 47%) [78]. According to the U.S. Natio-     tors for work-related MSD (WRMSD) in
                                 86, 92, 94, 96-100, 105]. The greatest             of the wrist and elbow and by 1.7 (95% CI         nal Health Interview Survey on back pain,       hairdressers – either by means of self-
                                 12-month MSD prevalence was reported for           1.2-2.5) for diseases of the neck or shoul-       female hairdressers belong to the top 6 high-   rating or statistical estimation (Annex 4).
                                 the lower back 48%, neck 43%, shoulder             ders [109]. Two studies from Denmark exa-         risk occupations for back pain [76]. Epide-     They varied greatly in types of risk factors,
                                 42% and hand/wrist 32%. The point MSD              mined the health reasons for leaving the          miologic surveillance data on carpal tunnel     the applied methods and the reporting of
                                 prevalence was on average lower: 34%,              hairdressing trade: one with retrospective        syndrome (CTS) from Maine and Loire regi-       the findings [72, 88-92, 95, 97, 98, 100-102,
                                 31%, 37% and 31%, respectively. The ove-           and one with prospective study design.            ons in France showed that a substantial pro-    104, 108, 112]. The reported risk factors
                                 rall MSD with no specification of body site        Among all former hairdressers the primary         portion of new CTS cases (between 2002-         were synthesized into the following six
                                 and time frame was 55%. If only studies            health complaint causing them to leave            2004) among female hairdressers were            main categories:
                                 from European countries were considered,           their job was musculoskeletal pain (42%)          attributable to work (attributable risk frac-
                                 the 12-month MSD prevalence remained               followed by hand eczema (23%), other              tions 86.6%). Thus, they belong to the top      1. Strenuous hand or arm postures and
                                 similar for the respective body sites: 45%,        diseases (21%) and allergy (18%) [6]. The         10 high-risk occupations for CTS [77].             movements (e.g. arms above shoulder,
                                 47%, 41% and 35% (figure 8). A study from          prospective study showed that during the                                                             repetition)
    Figure 8: Pooled             France examined trends in hairdressers‘            3-year follow-up, 21.8% of the hairdressing       In a case-control study, which was con-         2. Awkward postures and movements of
    12-month and point MSD
                                 compensation claims for the years 2010-            apprentices had left the trade; of them           ducted with 147 hairdressers and 67 non-           the spine (e.g. bending and twisting the
    prevalence of the spine,
    upper and lower extremi-     2016. The overall claim rate for work-related      70.4% due to health complaints. The most          hairdressing controls, hairdressers repor-         back)
    ties. Subgroup results:      MSD increased by 12.8% (n.s.). Permanent           frequently reported reasons were muscu-           ted significantly higher levels of MSD,         3. Workload and biomechanical strain
    Prevalence from Euro-        disability (incidence rate 2/1000) and num-        loskeletal pain (47.4%), followed by skin         including shoulder (OR 11.6, 95% CI 2.4-           (e.g. mechanical workload, overtime,
    pean studies are indica-
                                 ber of lost work days significantly increased      diseases (42.1%) and respiratory symp-            55.4) wrist/hand (OR 2.8, 95% CI 1.1-7.6),         no breaks)
    ted by the abbreviation
    EU (for detailed results,    by 16% respectively. In total 666,461 days         toms (23.7%) [110].                               upper back (OR 3.8, 95% CI 1.0-14.9) or         4. Prolonged standing and sitting
    see annex 2 and 3).          were lost due to work-related MSD [79].                                                              lower back pain (OR 4.9, 95% CI 1.5-15.9)       5. Other factors (e.g. work experience,
                                                                                                                                      [96]. In a further comparative study with          mental stress and burnout, gender or
                                                                                                                                      office workers female hairdressers repor-          low support)
                                                                                                                                      ted pain in all body regions significantly      6. Specific hairdressing tasks (e.g. cut-
                                                                                                                                      more often (neck 36% vs. 8%, shoulders             ting, dying or styling hair)
                                                                                                                                      39% vs. 10% or hand/wrists 41% vs. 4%)
                                                                                                                                      [101]. In a case-control study from Turkey      Mastrominico et al. [112] showed that all
                                                                                                                                      the frequency of CTS in female hairdres-        principle hairdressing activities performed
                                                                                                                                      sers was slightly higher compared to unem-      for at least 50% of the working day, exhibi-
                                                                                                                                      ployed female control group (RR 1.35,           ted intermediate to high risk for upper limb
                                                                                                                                      95%CI 0.98-1.84). In addition, they showed      disorders (ULD). Similarly, Mahdavi et al.
                                                                                                                                      significantly higher pain intensity and func-   [102] found that 61% of studied postures
     Lower Back            Neck                 Shoulder            Hand/Wrist              Elbow                 Knee                tional loss levels. Hairdresser who were        could be classified as high risk postures for
     • 12-mos: 47.5 %      • 12-mos: 43.1 %     • 12-mos: 41.6 %    • 12-mos: 31.5 %        • 12-mos: 11.4 %      • 12-mos: 26.3 %    diagnosed with CTS worked significantly         MSD.
     • Point: 34 %         • Point: 30.8 %      • Point: 36.6 %     • Point: 30.6 %         • Point: /            • Point: /          longer in their profession than those hair-
     • EU 12-mos:          • EU 12-mos:         • EU 12-mos:        • EU 12-mos:            Finger                Feet                dressers without CTS [111]. A study from        The following studies examined hairdres-
    		 45 %               		 47.4 %           		 40.6 %            		 34.7 %                                                          France analyzed data from occupational          sing activities and/or the corresponding
                                                                                            • 12-mos:            • 12-mos:
     • EU point:           • EU point: /       • EU point: /        • EU point: /                                                     health examination of self-employed and         body postures and movements of the mus-
                                                                                           		 24.6 %            		 26.8 %
    		 38.7 %
                                                                                                                                      wage-earning hairdressers. The risk of          culoskeletal system.

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In a study by Chen et al. [71], the mechani-    that the daily workload of hairdressers is     the spine during cutting hair. All four hair-   hands. The mean value for palmar wrist fle-
         cal exposure of hairdresser’s and barber’s      high and aggravated by the lack of regular     dressing tasks led to highly repetitive         xion, expressed as the 90th percentile, was
         wrists were assessed by using electromyo-       breaks. Similar results were found in a        actions of the upper extremities. The Kil-      greater for hairdressers than the overall
         graphy (EMG). Female hairdressers exhibi-       Dutch study. More than six hours of repea-     bom [115] reference values for high repeti-     mean for other occupations (21° vs. 10°).

3        ted significantly greater EMG activity
         (p2.5 rep/     Moreover, hairdressers exhibited a slightly
                                                                                                        min), and for the elbow and hand (>10 rep/      higher mean angular velocity (20°/s vs.
         xion speed (velocity) in their non-dominant     atest strain on the musculoskeletal system.    min) were both significantly exceeded, par-     17°/s). With respect to static and peak load
         hand (p4         of 52% of the total working day in contrast     tive and three rehabilitative measures. One
         working day with arms elevated at >60°          seconds). Moreover, they often had to          to other students (< 33%). The relative time    study evaluated a new Ergonomic Tool
         (right arm 6.8% and left arm 5.5%). Expo-       stretch their arms over the shoulder level     of sustained muscle activity showed a sig-      Design (ETD) scissors.
         sure to elevated arm postures was more          and perform tasks with horizontal adduc-       nificant correlation with pain (r= 0.21,
         strenuous during customer tasks (which          tion of the arms. While washing at the sink,   p30°        exercise program targeted to the cervical and
         ted et al. [86].                                static postures. During washing and cut-       (45% vs. 35%), >60° (11% vs. 1%) and            lumbar spine in combination with an ergono-
                                                         ting hair, forward flexion of the neck was     >90° (2% vs. 0.4%). For every additional        mic brochure. The control group received
         In a pilot study from Portugal, 77% of the      frequently observed. This poor posture         unit increase in arm elevation of more than     only the brochure. After six weeks of inter-
         hairdressers reported that they performed       was often combined with hunched back.          60°, an estimated 28% increase in shoulder      vention, no significant differences were found
         their activities in a standing position, 17%    Those who used the rolling stool often         pain was found among female students            in pain intensity or level of disability between
         in a sitting position with rotation of the      exhibited a steeply inclined lumbar spine      [90]. Moreover, the authors observed a sig-     the exercise and control groups.
         spine and 7% in a sitting position with ele-    and had to raise their hands more often        nificant increase in the prevalence of
         vated arms above shoulder level. In regards     above shoulder level [66]. The same            moderate/severe pain for female students        Similarly, Veiersted et al. [86] examined the
         to upper limb activities during work, 30%       authors report that during cutting, dying      over the course of 6.5 years (RR 1.5, 95%       effect of a short-term intervention, inclu-
         performed repetitive and dynamic move-          and blow-drying, more than 25% of time         CI 1.24-1.81). Mechanical workload and          ding five recommendations on working
         ments and 60% elevated objects above            was spent in flexion (angles >20° and >60°)    perceived muscle tension were identified        techniques to reduce neck and shoulder
         shoulder level (>60°) [97].                     and abduction (>-20° and >-60°) for both       as risk factors for neck and shoulder pain      workload, such as working with less eleva-
                                                         shoulders. Pronation (>20 and >40°) of         in women [89]. According to a study by          ted arms and relaxing the upper body and
         Figueiredo da Rocha and Simonelli [113]         both elbows was observed during all tasks.     Mussi and Gouveia [104], uncomfortable          follow-up instructions. The control group
         found that hair straightening with a round      Extension (>-25° and >-50°) of the left        neck and shoulder postures were likewise        received a brochure with corresponding
         brush requires high mechanical overload of      hand was observed for cutting and washing      associated with MSD in hairdressers (OR         illustrations. Time spent with highly eleva-
         the cervical and spinal columns (e.g.           hair. A high proportion of time with forward   2.8, 95% CI 1.4-5.5).                           ted upper arm postures above 90° was
         straightening curly hair takes up to one        curvature of the spine was recorded during                                                     reduced from 4% to 2.5%. No intervention
         hour). Moreover, the upper limbs are strai-     cutting (66%), washing (62%) and dying         Nordander et al. [105] explored the expo-       effect was detected on muscular load,
         ned from repetitive movements in protrac-       (36%). The greatest proportion of time in      sure-response relationship between work-        velocity of arm movements or neck and
         ted extended positions. They concluded          static awkward postures was observed on        related risk factors and MSD in elbows and      shoulder complaints.

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