K T Palmer

Occupation and epicondylitis: a population-based study

OBJECTIVEnTo explore the relationship between occupational exposures and lateral and medial epicondylitis, and the effect of epicondylitis on sickness absence in a population sample of working-aged adults.nnnMETHODSnThis was a cross-sectional study of 9696 randomly selected adults aged 25-64 years involving a screening questionnaire and standardized physical examination. Age- and sex-specific prevalence rates of epicondylitis were estimated and associations with occupational risk factors explored.nnnRESULTSnAmong 6038 respondents, 636 (11%) reported elbow pain in the last week. Of those surveyed, 0.7% were diagnosed with lateral epicondylitis and 0.6% with medial epicondylitis. Lateral epicondylitis was associated with manual work [odds ratio (OR) 4.0, 95% CI 1.9, 8.4]. In multivariate analyses, repetitive bending/straightening elbow >1u2009h day was independently associated with lateral (OR 2.5, 95% CI 1.2, 5.5) and medial epicondylitis (OR 5.1, 95% CI 1.8, 14.3). Five per cent of adults with epicondylitis took sickness absence because of their elbow symptoms in the past 12 months (median 29 days).nnnCONCLUSIONnRepetitive exposure to bending/straightening the elbow was a significant risk factor for medial and lateral epicondylitis. Epicondylitis is associated with prolonged sickness absence in 5% of affected working-aged adults.

Optimising case definitions of upper limb disorder for aetiological research and prevention: a review

Experts disagree about the optimal classification of upper limb disorders (ULDs). To explore whether differences in associations with occupational risk factors offer a basis for choosing between case definitions in aetiological research and surveillance, we analysed previously published research. Eligible reports (those with estimates of relative risk (RR) for >1 case definition relative to identical exposures were identified from systematic reviews of ULD and occupation and by hand-searching five peer-review journals published between January 1990 and June 2010. We abstracted details by anatomical site of the case and exposure definitions employed and paired estimates of RR, for alternative case definitions with identical occupational exposures. Pairs of case definitions were typically nested, a stricter definition being a subset of a simpler version. Differences in RR between paired definitions were expressed as the ratio of RRs, using that for the simpler definition as the denominator. We found 21 reports, yielding 320 pairs of RRs (82, 75 and 163 respectively at the shoulder, elbow, and distal arm). Ratios of RRs were frequently ≤1 (46%), the median ratio overall and by anatomical site being close to unity. In only 2% of comparisons did ratios reach ≥4. We conclude that complex ULD case definitions (e.g. involving physical signs, more specific symptom patterns, and investigations) yield similar associations with occupational risk factors to those using simpler definitions. Thus, in population-based aetiological research and surveillance, simple case definitions should normally suffice. Data on risk factors can justifiably be pooled in meta-analyses, despite differences in case definition.

Mortality of workers exposed to ethylene oxide: extended follow up of a British cohort

Aims: To obtain further information about the risks of cancer associated with occupational exposure to ethylene oxide Methods: Follow up was extended by 13 years for a cohort of 2876 men and women with definite or potential exposure to ethylene oxide in the chemical industry or in hospital sterilising units. Subjects were traced through National Health Service and social security records, and their mortality was compared with that expected from rates in the national population by the person-years method. Results: Analysis was based on 565 deaths, of which 339 had occurred during the additional period of follow up. Mortality was close to or below expectation for all causes (565 deaths v 607.6 expected), all cancers (188 v 184.2), and for all specific categories of malignancy including stomach cancer (10 v 11.6), breast cancer (11 v 13.2), non-Hodgkin’s lymphoma (7 v 4.8), and leukaemia (5 v 4.6). All five deaths from leukaemia occurred in the subset of subjects with greatest potential for exposure to ethylene oxide, but even in this group the excess of deaths was small (2.6 expected). Conclusions: The balance of evidence from this and other epidemiological investigations indicates that any risk of human cancer from ethylene oxide is low, particularly at the levels of occupational exposure that have occurred in Britain over recent decades. This may reflect the capacity of human cells to repair DNA damage caused by the chemical, which is a potent genotoxin and animal carcinogen.

Raynaud's phenomenon in workers exposed to vibration

Chronic exposure of hands to vibration is now a well described cause of Raynauds phenomenon. According to Palmer et al , it is estimated that 220u2009000 cases of Raynauds phenomenon are attributable to exposure to vibration in Great Britain.1 These epidemiological data, based on a questionnaire, are considered to be reasonably accurate.2About 4.2 million workers are exposed to hand transmitted vibration but the real impact on health and the economy is unknown.3More precise clinical data are therefore necessary before implementing a large preventive programme.nnThe hand-arm vibration syndrome encompasses a wide range of disorders as it is responsible for digital blanching and paraesthesias.4 Different vascular problems—such as a pure vasospastic phenomenon, a digital organic microangiopathy, or an occlusive arterial thrombosis—can be found. A diffuse vibration neuropathy with involvement of mechanical skin receptors or carpal tunnel syndrome are also often associated.5 The relation between these neurovascular disorders is not clear but autonomic dysfunction in carpal tunnel syndrome can induce a Raynauds phenomenon which is curable with surgery.6 The prognosis of these neurovascular troubles depends on the underlying problem and cannot be evaluated with a simple questionnaire. As … nnDr K T Palmer

300 Diabetes and risk of accidental injury at work

Objectives To assess the effect of diabetes on risk of occupational injury, we undertook a case-control analysis nested within the UK General Practice Research Database (GPRD). Methods The GPRD logs all primary care data for participating general practices (6% of the population). Medical consultations are classified by the Read system and drug prescriptions according to the British National Formulary (BNF). We identified 1,348 patients aged 16–64 years consulting over a 10-year period with workplace injury (cases) and 6,652 age, sex, and practice-matched controls with no such consultation. Groups were compared in terms of their diabetic status (defined by 320 Read codes and 355 BNF drug codes); and for those with diabetes, according to risks from diabetic eye disease, other complications, blood sugar-lowering treatment (insulin or oral hypoglycaemics), and indices of sub-optimal control. Associations were explored using conditional logistic regression. Results In all, 199 (2.5%) subjects were classed as diabetic before the index date, including 77 with eye involvement, 86 on insulin and 52 with poor diabetic control. Odds of occupational injury consultation were seldom elevated relative to non-diabetics (e.g. OR 1.01 overall, 1.02 in diabetics on insulin) and for some measures were lower (e.g. OR for eye involvement 0.72). Only suboptimal chemical control (HbA1C >7%) in the 12 months before the index date was associated with a slightly elevated risk (OR 1.35); no differences were statistically significant. Conclusions These findings are reassuring. Lower risks in some comparisons may reflect chance or a degree of health selection out of hazardous work. In any event, current employment practices are not placing diabetic workers at particular risk of workplace injury.

Differences in prevalence of wrist/hand pain by country and occupation: findings from the CUPID study

Objectives Musculoskeletal disorders of the wrist and hand have been linked with various occupational activities, including use of computer keyboards and other repetitive manual tasks. They are also influenced by psychological risk factors. To explore a hypothesised role of culturally determined health beliefs and expectations, we compared rates of wrist/hand pain in workers carrying out similar occupational tasks in culturally diverse settings. Methods As part of the CUPID study, a standardised questionnaire was used to collect baseline data on musculoskeletal symptoms and their risk factors from samples of nurses (12 countries), office workers (10 countries) and manual workers carrying out repetitive tasks with their hands (nine countries). Analysis focused on 9347 workers aged 20–59 years. Simple descriptive statistics were used to compare the prevalence of wrist/hand pain by occupational group and country. Results Among the office workers, almost all of whom used a computer keyboard for ≥4 h/day, the 1-month prevalence of wrist/hand pain varied from 3% in Pakistan and 6% in Japan to 37% in Brazil and 38% in Nicaragua. Within countries, prevalence rates in nurses were generally similar to those in office workers. Pakistani and Japanese manual workers also had low rates of wrist/hand pain, but the lowest prevalence was in Brazilian cane cutters (2%), and the highest in Italian workers at a toy factory (43%). Conclusions Country of residence appears to be a much more important determinant of wrist/hand pain than workplace physical activity. Possible reasons for the major differences in prevalence between countries will be discussed.

Improving the classification of upper limb disorders

Objectives Experts disagree about the optimal classification of upper limb disorders (ULDs). To explore whether differences in associations with risk factors can offer a framework for choosing between case definitions in aetiological research and surveillance, we conducted a systematic review. Methods Reports with estimates of relative risk (RR) for >1 case definition relative to identical occupational exposures were identified from (i) systematic reviews of ULD and occupation and (ii) by hand searching five peer-review journals published over the past two decades. We abstracted details of case and exposure definitions and paired estimates of RR, for alternative case definitions with identical occupational exposures. Differences in RR between paired definitions were expressed as the ratio of RRs, typically using that for the more elaborate of the two definitions as the numerator. Results The 21 eligible reports yielded 320 pairs of RRs (82, 75 and 163 respectively at shoulder, elbow, and distal arm). Ratios of RRs were often <1 (46%), the median ratio overall and by anatomical site being close to unity. In only 2% of comparisons did ratios reach >4. Conclusion: More elaborate case definitions of ULD (eg, those involving physical signs, more specific symptom patterns, and additional investigations) yield similar associations with occupational risk factors to those using simpler definitions. Thus, for purposes of aetiological research and surveillance, simple case definitions will often suffice. Our findings also provide a justification for pooling data on risk factors in meta-analyses, despite differences in case definition.

The Diagnosis of Soft Tissue Disorders of the Upper Limb

Abstract Background: Pain in the upper limbs is a common symptom and a cause of significant morbidity. Pain may arise as a result of specific disorders such as rotator cuff tendinitis or lateral epicondylitis, or may occur in the absence of diagnostic physical signs. Until recently, research in this field has been hampered by the lack of an agreed system of classification of soft tissue upper limb disorders but in 1997, new diagnostic criteria were proposed by a UK multidisciplinary workshop. Working from these consensus criteria, we developed and tested a new examination algorithm. Methods: We conducted a comprehensive computerised literature review in order to derive a workable examination schedule. In two separate studies in a hospital clinic and a general population sample, we tested its feasibility for use by trained research nurses and its reproducibility and face validity in two different populations. Results: The between-observer reproducibility of physical signs in the hospital clinic was good to excellent (kappa coefficients 0.66-1.0 for most categorical variables). In the general population, between-observer reliability of physical signs was generally less good, but the rehability of agreement of specific diagnoses remained acceptable, with a median kappa coefficient of 0.66 (range 0.21-0.93). When compared against the standard of physicians’ diagnoses, the schedule was sensitive (58-87%) and highly specific (84-100%). Conclusion: The Southampton examination schedule represents a feasible, and reproducible tool with face validity; suitable for use in future research into upper limb disorders, and has the backing of UK consensus criteria.