ISSN 1612-3352

Editors in Chief

Prof. Dr. Claus F. Claussen, Neurootological Research Institute of the Research Society for Smell, Taste, Hearing and Equilibrium Disorders at Bad Kissingen (4-G-F). Bad Kissingen, Germany.
Dr. med. Julia M. Bergmann,
Dr. med. Guillermo O. Bertora,
Otoneuroophthalmological Neurophysiology,
Buenos Aires, Argentina.

Production Managers

Dr. med. Julia M. Bergmann,
Dr. med. Guillermo O. Bertora,
Otoneuroophthalmological Neurophysiology,
Buenos Aires, Argentina.

Associated Editors

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Objectively and quantitatively testing workmen under the danger of falling hazards for disequilibrium by means of standing and s


More than 20 years back in occupational medicine we were confronted, that only 2% of the officially accepted occupational hazards are falling accidents. However, 20% of all the fatal occupational hazards, recorded in the Federal Republic of Germany, were occupational falling accidents. The severity of the trauma in the falling accidents has forced the West German Labour Control Authorities (Berufsgenossenschaften) to working out a special preventive decrete (Unfallverhütungsvorschrift G-41 “Arbeiten mit Absturzgefahr”) for selecting special risks by a preventive measure. There cranio-corpo-graphy was introduced as an objective and quantitative equilibrium test with an instant test recording of the vestibular spinal performance, delivering a radar image like chart. This test chart objectively and quantitatively could be used for formulating objections against employments of labourers suffering from dysbalance.

The concept of cranio-corpo-graphy takes into consideration that vestibular spinal equilibrium control is aiming at the stabilisation of the erect body position and the stabile head and gaze position on top of the body.

In 1968 cranio-corpo-graphy was designed as a none electronic, simple office procedure for vestibular spinal tests recording head and body movements. The light tracing of the head and shoulder movements were transformed through an instant camera into photographs, which looked like images of the head and shoulders, floating through the space. This set of tests especially was developed for the West German Berufsgenossenschaften (Labour Security Surveillance Boards) as a field test for occupational medical purposes, combining a stepping test (Unterberger,1938, Fukuda, 1959) with a standing test (Romberg, 1848). In 1983 it was officially introduced into occupational medicine in West Germany through the decrete G-41 of the West German Labour Security Surveillance Boards (Berufsgenossenschaften).

Recently we have further developed a system for marking the shoulders and the head instead of with light marks now with ultrasound markers together with a computer system, creating a local positioning system. This new system is called “Ultrasound computer cranio-corpo-graphy (US-CCG)”:

US-CCG has a great advantage in that it is working digitally. In a computer based databank, which can simultaneously be read out, it is possible to construct the single traces of both the shoulder markers and both the head markers separately and interrelate the movements between the head and shoulder recordings. It also allows us virtually to reconstruct trajectories of head and neck movements in a spatio-temporal, as well as in 3-dimensional mode, by our most recent special software development of “HUMAN SPACE TRAIL CLAUSSEN (HUSPATRAC®)”.

In Germany much research related to occupational illnesses is performed since the 2nd half of the 19th century. Nowadays it is conducted under the auspices of the German Berufsgenossenschaften (Labour security Surveillance Boards). Guidelines and decretes have been passed from these institutions together with the West German Ministry for Occupation with respect to the prevention of various types of labour risks, accidents and hazards. The act G-41 “Arbeiten mit Absturzgefahr” (Hazards due to falling accidents) is regulating the preventive screening investigation for disequilibrium amongst German workers. Due to the decrete G-41 the expertise of specialists in the field of occupational health is also needed with respect to equilibriometry.

Being member of the council for formulating Act G-41, we could contribute our ideas about our neurootological history scheme NODEC and about the specially built up objective and quantitative photo-optical cranio-corpo-graphy (CCG). The latter was invented especially for the purposes of occupational medicine by Claussen in 1968.

Act G-41 follows the administrative structure of all similar decretes for preventing occupational hazards. Firstly the limited field of application and access from spedific professionals is defined. It generally mentions all the professions, where a professional may be in danger of falling due to his work.

Point 2 covers various dates about investigation. In workers, who fit into this category of G-41, investigations are performed prior to the employment in an endangered profession. Regularly during performing his profession after defined time intervals, investigations are compulsory. After retirement or after changing his profession into a non hazardous occupation, there need not to be any more follow-ups.

During the first investigation a broad history scheme is applied with questions for background diseases of the cardio vascular, the metabolic, the neurological, the psychiatric and other types of disorders. A special questionnaire, related to our system NODEC, investigates for vertigo, nausea and other neurootological complaints.

Special physical investigations deal with equilibriometry, mainly based on head and body instability. For testing for dysbalances, the Romberg standing test and the Unterberger/Fukuda stepping test are introduced into the scheme and should be recorded objectively and quantitatively by means of the cranio-corpo-graphy (CCG) until now on a voluntary level.

Besides vision and hearing are controlled. Also the cardio-vascular function is investigated by electrocardiography at rest and under strain, for instance by means of an ergometer with an impact up to 120 Watt during 5 minutes.

Furthermore metabolic investigations, like glucose tests, blood analysis, including gamma-GT are applied. Besides also psychiatric tests may be added.

Occupational medical criteria for evaluating the neurootological investigation with respect to Act G41:

The investigation is evaluated with respect to the classification health risk versus no health risk.

The grouping is: where a health risk is stated as such and then a subdivision is performed: other groups are introduced, namely permanent health risks, or limited health risks.

As the CCG comes with a yardstick of normal ranges, they can be used for formulating abilities:
Persons exhibiting a lateral sway from 20cm or a lateral deviation of 80° towards the right or 70° towards the left in the stepping test cranio-corpo-graphy (step test CCG) must be excluded from professions with a risk of falling accidents. The same holds for standing CCG sways above 12cm longitudinally or lateral sways above 10cm. Also patients suffering from chronic vertigo with severe objective findings in electronystagmography in the vestibular ocular or in the retino ocular tests are to be excluded.

However, the tests can be repeated for measuring whether or not habituation, adaptation or restitution has occurred after an imbalance.

Besides the criteria of imbalance or disequilibrium, other persons are excluded with the decretes of mobility or loss of strength in the arms or the legs.

Patients with severe cardio-vascular disorders, with a tendency to seizures of epileptic or other types, with severe diabetes mellitus, with thyroid toxicosis are also excluded.

Cases of severe loss of visual acuity, or major scotomas, as well as a disabling decrease in the hearing function is also excluding from hazardous occupations with a danger of falling.

Psychiatric diseases and mental debility, as well as alcohol abuse or other addictions also permanently exclude from these professions.

A time limited health risk is disequilibrium or other of the above mentioned diseases, which shows the tendency towards recovery and restitution.

For ending the phase of an objection of the type of a limited health risk, it must be warranted, that the worker is no more danger for himself or for others.

Included into the regular investigations according to the decrete G-41 are construction workers on high rising buildings, workers on antennas, high tension cables, bridges, towers, masts, chimneys, flood-lights etc. In these groups regular follow-ups are compulsory.
Labourers up to the age of 25 years are monitored every 36 months, between 25 and 50 years every 24 to 36 months and above the age of 50, every 12 to 15 months.

However, if the labourer has been ill for several weeks or if the occupational medical service of that special company has doubt about the health risk, earlier reinvestigations are possible. Also if the labourer himself wishes a reinvestigation, this has to be performed.

In the special Act G-41, dealing with workers with a danger of falling hazards, the preventive aspect of occupational medicine demands that the neurosensorial aspect especially has to be considered. Any severe imbalance or attack of disorientation due to vertigo of the peripheral vestibular type or due to vertigo of the central, or optokinetic or cervical mechanisms or due to an inborn vertigo of the height should be excluded. The screening procedure, being described above, can be added by special neurootological investigations in centers with facilities for electronystagmography, electroencephalography, electrocardiography etc. The screening scheme of Act G-41, being described above, is thought to be executed by any medical doctor, serving in occupational medicine. In Germany this mostly goes for employees of occupational medical centers.
Such centers, have been involved into this study revising the efficacy of Act G-41 after 20 years. The centers which have performed our joint study are the BAD Hannover and the Construction Labour Surveillance Board (Bauberufsgenossenschaft) at Braunschweig, Germany. Now after 20 years of action with Act G-41 we also want to study if cranio-corpo-graphy has to be applied not on a voluntary but on a compulsory level within Act G-41.
The stepping test of Unterberger and Fukuda is much more sensitive for imbalance and disequilibrium than the standing test of Romberg. This could also be proved, when looking into the files at two occupational medical centers at Hanover and at Braunschweig. Only in Hannover regularly cranio-corpo-graphy was applied. But there the decision was made, that the standing test CCG was left out and only the stepping test cranio-corpo-graphy was used for undermining the decisions of certifying ability or of objection to further employment. With the inspectory test evaluation of the standing test and of the stepping test in Braunschweig also much more importance was given to the stepping test than to the standing test, even though the two tests were only subjectively inspected by the physicians and then, according to their subjective judgement reported in the files and weighed for the judgement of objectionor non objection.

When applying cranio-corpo-graphy, cases with pathological results can be objectively classified and permanently excluded, whereas cases with a milder symptomatology then can also be classified and put into a scheme where they are controlled through a follow-up for differentiating whether or not they are at long lasting health risk, or whether they can be classified finally as no health risk.

As neurootologists we know, that we have seen many cases after minor or major falling accidents with head traumas. From this we can conclude, that there is an important demand for the prevention of these professional falling hazards.

On the other side labourers who feel that they are instabile at working positions in the height and who are personally not willing due to some sort of anxiety, vertigo of the height or psychogenic vertigo cannot be forced to work at high positions under the danger of falling hazards. They are directly excluded from the ability scheme.

As on the other hand labourers working at positions on elevated places are frequently receiving bonuses on their salaries. Then in Germany we have observed cases of dissimulation from workers for instance with labour in high positions, on antennas, high tension cablings etc. These labourers, even though being incapacitated for the work in high positions, were afraid of loosing their bonuses. Then they tried to override or dissimulate their vertigo. This vertigo then only first was objectively proved through the investigation of Act G-41 with the application of the stepping test cranio-corpo-graphy. Thereafter a second history frequently has clarified that the subjective complaints and background diseases were hidden by the employee.

In our own studies, which formally had been executed by some other members of our team, we have observed that correlations exist between cardio vascular disorders and metabolic disorders of severe diabetes mellitus on one hand and with pathological cranio-corpo-graphy patterns on the other hand.

Finally it must be mentioned, that patients suffering from a subjective and objective disequilibrium nowadays can undergo a systematic neurootological therapy which again is monitored by means of cranio-corpo-graphy. This first stage of equilibriometry can be added then by a differentiated set of electronystagmography with various vestibular ocular, retino ocular and complex equilibrium tests.

As we follow the project of cranio-corpo-graphy being introduced into occupational medicine in Act G-41 since 1968, which now is a time span of 36 years, we can now state, that cranio-corpo-graphy within the procedure described in Act G-41 is simple to be applied and to be performed. It can very practically be applied. It can be performed by any staff personnel at any occupational medical investigation unit. The results, which are looking like radar images can be as well become interpreted by the medical doctor, as well as by the patient. It is an objective document about a functional ability, which can be copied and then being kept on the one hand in the files of the institution and on the other hand handed over to the patient for his own papers and probably also for showing it to his personal physicians.

During the last years we have developed a new technology for even easier quantitative and numerical read outs of the cranio-corpo-graphy by means of an ultrasound cranio-corpo-graphy with a charting system, where the 4 main parameters of the stepping test or the 2 main parameters of the standing test are directly and electronically measured. They appear on the printout of the chart by the end of the test already.
All in all we now see it to be necessary, that an objective and quantitative recording of the equilibriometric stepping test should become compulsory instead of voluntary for being executed within the Act G-41.



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