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1.  UPPER AIRWAYS CANCER, MYELOID LEUKAEMIA AND OTHER CANCERS IN A COHORT OF BRITISH CHEMICAL WORKERS EXPOSED TO FORMALDEHYDE 
American journal of epidemiology  2014;179(11):1301-1311.
The International Agency for Research on Cancer controversially has classified formaldehyde as causing nasopharyngeal carcinoma and myeloid leukaemia. To provide further information on this question, we extended follow-up of 14,008 chemical workers at six factories in England and Wales, covering the period 1941-2012. Mortality was compared with national death rates, and associations with incident upper airways cancer and leukaemia were explored in nested case-control analyses. Excess deaths were observed from cancers of the oesophagus (100 v 93.1 expected), stomach (182 v 141.4), rectum (107 v 86.8), liver (35 v 26.9) and lung (813 v 645.8), but none of these tumours exhibited a clear exposure-response relationship. Nested case-control analyses of 115 men with upper airways cancer (including one nasopharyngeal cancer), 92 with leukaemia, and 45 with myeloid leukaemia indicated no elevations of risk in the highest exposure category (high exposure for ≥1 year). When the two highest exposure categories were combined the odds ratio for myeloid leukaemia was 1.26 (95%confidence interval: 0.39, 4.08). Our results provide no support for a hazard of myeloid leukaemia, nasopharyngeal carcinoma or other upper airways tumours from formaldehyde, and indicate that any excess risk of these cancers, even from relatively high exposures, is at most small.
doi:10.1093/aje/kwu049
PMCID: PMC4189094  PMID: 24714728
Cancer; chemical industry; formaldehyde; mortality; myeloid leukaemia; nasopharyngeal cancer
2.  The role of mental health problems and common psychotropic drug treatments in accidental injury at work, a case-control study 
Objectives
Mental illness and psychotropic drugs have been linked with workplace injury, but few studies have measured exposures and outcomes independently or established their relative timings. To address this shortcoming, we conducted a case-control study nested within a database prospectively recording injury consultations, diagnoses and drug prescriptions.
Methods
The Clinical Practice Research Datalink logs primary care data for 6% of the British population, coding all consultations (by the Read system) and drug prescriptions. We identified 1,348 patients aged 16-64 years from this database who had consulted a family doctor or hospital over a 20-year period for workplace injury (cases, 479 diagnostic codes) and 6,652 age, sex, and practice-matched controls with no such consultation. Groups were compared in terms of consultations for mental health problems (1,328 codes) and prescription of psychotropic drugs prior to the case’s injury consultation, using conditional logistic regression.
Results
In total, 1,846 (23%) subjects had at least one psychiatric consultation before the index date and 1,682 (21%) had been prescribed a psychotropic drug. The odds ratio for prior mental health consultation was 1.44 (P<0.001) and that for psychotropic drug treatment was 1.57 (P<0.001). Risks were significantly elevated for several subclasses of mental health diagnosis (e.g. psychosis, neurosis) and for each of the drug classes analysed. Assuming causal relationships, about 9-10% of all workplace injuries leading to medical consultation were attributable to mental illness or psychotropic medication.
Conclusions
Mental health problems and psychotropic treatments may account for an important minority of workplace injuries.
doi:10.1136/oemed-2013-101948
PMCID: PMC3984107  PMID: 24627304
3.  Dupuytren’s contracture and occupational exposure to hand-transmitted vibration 
Aims
The relation between Dupuytren’s contracture and occupational exposure to hand-transmitted vibration (HTV) has frequently been debated. We explored associations in a representative national sample of workers with well-characterised exposure to HTV.
Methods
We mailed a questionnaire to 21,201 subjects aged 16 – 64 years, selected at random from the age-sex registers of 34 general practices in Great Britain and to 993 subjects chosen randomly from military pay records, asking about occupational exposure to 39 sources of HTV and about fixed flexion contracture of the little or ring finger. Analysis was restricted to men at work in the previous week. Estimates were made of average daily vibration dose (A(8) r.m.s.) over that week. Associations with Dupuytren’s contracture were estimated by Poisson regression, both for lifetime exposure to HTV and for exposures in the past week >A(8) of 2.8 ms−2 r.m.s.. Estimates of relative risk (Prevalence Ratio (PR)) were adjusted for age, smoking status, social class and certain manual activities at work.
Results
In all 4,969 eligible male respondents supplied full information on the study variables. These included 72 men with Dupuytren’s contracture, 2,287 with occupational exposure to HTV, and 409 with A(8)>2.8 ms−2 in the past week. PRs for occupational exposure to HTV were elevated 1.5-fold. For men with an A(8)>2.8 ms−2 in the past week, the adjusted PR was 2.85 (95% confidence interval 1.37 to 5.97).
Conclusions
Our findings suggest that risk of Dupuytren’s contracture is more than doubled in men with high levels of weekly exposure to HTV.
doi:10.1136/oemed-2013-101981
PMCID: PMC3963601  PMID: 24449599
4.  Maintained physical activity and physiotherapy in the management of distal upper limb pain – a protocol for a randomised controlled trial (the arm pain trial) 
Background
Distal upper limb pain (pain affecting the elbow, forearm, wrist, or hand) can be non-specific, or can arise from specific musculoskeletal disorders. It is clinically important and costly, the best approach to clinical management is unclear. Physiotherapy is the standard treatment and, while awaiting treatment, advice is often given to rest and avoid strenuous activities, but there is no evidence base to support these strategies. This paper describes the protocol of a randomised controlled trial to determine, among patients awaiting physiotherapy for distal arm pain, (a) whether advice to remain active and maintain usual activities results in a long-term reduction in arm pain and disability, compared with advice to rest; and (b) whether immediate physiotherapy results in a long-term reduction in arm pain and disability, compared with physiotherapy delivered after a seven week waiting list period.
Methods/Design
Between January 2012 and January 2014, new referrals to 14 out-patient physiotherapy departments were screened for potential eligibility. Eligible and consenting patients were randomly allocated to one of the following three groups in equal numbers: 1) advice to remain active, 2) advice to rest, 3) immediate physiotherapy. Patients were and followed up at 6, 13, and 26 weeks post-randomisation by self-complete postal questionnaire and, at six weeks, patients who had not received physiotherapy were offered it at this time. The primary outcome is the proportion of patients free of disability at 26 weeks, as determined by the modified DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire.
We hypothesise (a) that advice to maintain usual activities while awaiting physiotherapy will be superior than advice to rest the arm; and (b) that fast-track physiotherapy will be superior to normal (waiting list) physiotherapy. These hypotheses will be examined using an intention-to-treat analysis.
Discussion
Results from this trial will contribute to the evidence base underpinning the clinical management of patients with distal upper limb pain, and in particular, will provide guidance on whether they should be advised to rest the arm or remain active within the limits imposed by their symptoms.
Trial registration
Registered on http://www.controlled-trials.com (reference number: ISRCTN79085082).
doi:10.1186/1471-2474-15-71
PMCID: PMC3975277  PMID: 24612447
Randomised controlled trial; Arm pain; Physiotherapy; Advice; Rest; Active; Pain management
5.  INTERNATIONAL VARIATION IN MUSCULOSKELETAL SICKNESS ABSENCE: FINDINGS FROM THE CUPID STUDY 
Objectives
To quantify the variation in rates of absence for musculoskeletal pain across 47 occupational groups (mostly nurses and office workers) from 18 countries, and to explore personal and group-level risk factors that might explain observed differences.
Methods
A standardised questionnaire was used to obtain information about musculoskeletal pain, sickness absence and possible risk factors in a cross-sectional survey of 12,416 workers (92 to 1017 per occupational group). In addition, group-level data on socioeconomic variables such as sick pay and unemployment rates were assembled by members of the study team in each country. Associations of sickness absence with risk factors were examined by Poisson regression.
Results
Overall, there were more than 30-fold differences between occupational groups in the 12-month prevalence of prolonged musculoskeletal sickness absence, and even among office workers carrying out similar occupational tasks, the variation was more than ten-fold. Personal risk factors included older age, lower educational level, tendency to somatise, physical loading at work and prolonged absence for non-musculoskeletal illness. However, these explained little of the variation between occupational groups. After adjustment for individual characteristics, prolonged musculoskeletal sickness absence was more frequent in groups with greater time pressure at work, lower job control, and more adverse beliefs about the work-relatedness of musculoskeletal disorders.
Conclusions
Musculoskeletal sickness absence might be reduced by eliminating excessive time pressures in work, maximising employees’ responsibility and control, and providing flexibility of duties for those with disabling symptoms. Care should be taken not to overstate work as a cause of musculoskeletal injury.
doi:10.1136/oemed-2012-101316
PMCID: PMC3710073  PMID: 23695413
Sickness absence; musculoskeletal; international; risk factors; time pressure; job control
6.  Risk of miscarriage and occupational activity: a systematic review and meta-analysis regarding shift work, working hours, lifting, standing and physical workload 
Objective
Previous studies have indicated that shift work, long working hours and prevalent workplace exposures such as lifting, standing and physical workload increase the risk of miscarriage, but the evidence is conflicting. We conducted a systematic review of original research reports.
Methods
A search in Medline and EMBASE 1966 - 2012 identified 30 primary papers reporting the relative risk (RR) of miscarriage according to one or more of the five occupational activities of interest. Following an assessment of completeness of reporting, confounding and bias, each risk estimate was characterised as more or less likely to be biased. Studies with equivalent measures of exposure were pooled to obtain a weighted common risk estimate. Sensitivity analyses excluded studies most likely to be biased.
Results
Working fixed nights was associated with a moderately increased risk of miscarriage [pooled RR 1.51 (95% CI 1.27-1.78, n=5], while working in 3-shift schedules, working for >40 hours weekly, lifting>100 kg/day, standing > 6 hours/day and physical workload were associated with small risk increments, with the pooled RRs ranging from 1.12 (three shift schedule, n=7) to 1.36 (working hours, n=10). RRs for working hours and standing became smaller when analyses were restricted to higher quality studies.
Conclusion
These largely reassuring findings do not provide a strong case for mandatory restrictions in relation to shift work, long working hours, occupational lifting, standing and physical workload. Considering the limited evidence base, however, it may be prudent to advise women against work entailing high levels of these exposures and women with at-risk pregnancies should receive tailored individual counselling
doi:10.5271/sjweh.3337
PMCID: PMC3699369  PMID: 23235838
counselling; embryonal loss; fetal death; guidelines; pregnancy; occupation; workplace
7.  Work activities and risk of prematurity, low birthweight and pre-eclampsia: an updated review with meta-analysis 
Objectives
We assessed the evidence relating pre-term delivery (PTD), low birthweight, small for gestational age (SGA), pre-eclampsia and gestational hypertension to five occupational exposures (working hours, shift work, lifting, standing and physical workload). We conducted a systematic search in MEDLINE and EMBASE (1966–2011), updating a previous search with a further six years of observations.
Methods
As before, combinations of keywords and MeSH terms were used. Each relevant paper was assessed for completeness of reporting and potential for important bias or confounding, and its effect estimates abstracted. Where similar definitions of exposure and outcome existed we calculated pooled estimates of relative risk in meta-analysis.
Results
Analysis was based on 86 reports (32 cohort investigations, 57 with usable data on PTD, 54 on birthweight and 11 on pre-eclampsia/gestational hypertension); 33 reports were new to this review. For PTD, findings across a substantial evidence base were generally consistent, effectively ruling out large effects (e.g. RR>1.2). Larger and higher quality studies were less positive, while meta-estimates of risk were smaller than previously and best estimates pointed to modest or null effects (RR 1.04 to 1.18). For SGA, the position was similar but meta-estimates were even closer to the null (eight of nine RRs ≤ 1.07). For pre-eclampsia/gestational hypertension the evidence base remains insufficient.
Conclusions
The balance of evidence is against large effects for the associations investigated. As the evidence base has grown, estimates of risk in relation to these outcomes have become smaller.
doi:10.1136/oemed-2012-101032
PMCID: PMC3653070  PMID: 23343859
pregnancy; occupation; review; meta-analysis
8.  PATTERNS OF MULTI-SITE PAIN AND ASSOCIATIONS WITH RISK FACTORS 
Pain  2013;154(9):1769-1777.
To explore definitions for multi-site pain, and compare associations with risk factors for different patterns of musculoskeletal pain, we analysed cross-sectional data from the Cultural and Psychosocial Influences on Disability (CUPID) study. The study sample comprised 12,410 adults aged 20-59 years from 47 occupational groups in 18 countries. A standardised questionnaire was used to collect information about pain in the past month at each of 10 anatomical sites, and about potential risk factors. Associations with pain outcomes were assessed by Poisson regression, and characterised by prevalence rate ratios (PRRs). Extensive pain, affecting 6-10 anatomical sites, was reported much more frequently than would be expected if the occurrence of pain at each site were independent (674 participants v 41.9 expected). In comparison with pain involving only 1-3 sites, it showed much stronger associations (relative to no pain) with risk factors such as female sex (PRR 1.6 v 1.1), older age (PRR 2.6 v 1.1), somatising tendency (PRR 4.6 v 1.3) and exposure to multiple physically stressing occupational activities (PRR 5.0 v 1.4). After adjustment for number of sites with pain, these risk factors showed no additional association with a distribution of pain that was widespread according to the frequently used American College of Rheumatology (ACR) criteria. Our analysis supports the classification of pain at multiple anatomical sites simply by the number of sites affected, and suggests that extensive pain differs importantly in its associations with risk factors from pain that is limited to only a small number of anatomical sites.
doi:10.1016/j.pain.2013.05.039
PMCID: PMC3747979  PMID: 23727463
9.  Patterns of multisite pain and associations with risk factors 
Pain  2013;154(9):1769-1777.
Summary
In a large cross-sectional survey, pain affecting 6–10 anatomical sites showed substantially different associations with risk factors from pain limited to 1–3 sites.
To explore definitions for multisite pain, and compare associations with risk factors for different patterns of musculoskeletal pain, we analysed cross-sectional data from the Cultural and Psychosocial Influences on Disability (CUPID) study. The study sample comprised 12,410 adults aged 20–59 years from 47 occupational groups in 18 countries. A standardised questionnaire was used to collect information about pain in the past month at each of 10 anatomical sites, and about potential risk factors. Associations with pain outcomes were assessed by Poisson regression, and characterised by prevalence rate ratios (PRRs). Extensive pain, affecting 6–10 anatomical sites, was reported much more frequently than would be expected if the occurrence of pain at each site were independent (674 participants vs 41.9 expected). In comparison with pain involving only 1–3 sites, it showed much stronger associations (relative to no pain) with risk factors such as female sex (PRR 1.6 vs 1.1), older age (PRR 2.6 vs 1.1), somatising tendency (PRR 4.6 vs 1.3), and exposure to multiple physically stressing occupational activities (PRR 5.0 vs 1.4). After adjustment for number of sites with pain, these risk factors showed no additional association with a distribution of pain that was widespread according to the frequently used American College of Rheumatology criteria. Our analysis supports the classification of pain at multiple anatomical sites simply by the number of sites affected, and suggests that extensive pain differs importantly in its associations with risk factors from pain that is limited to only a small number of anatomical sites.
doi:10.1016/j.pain.2013.05.039
PMCID: PMC3747979  PMID: 23727463
Pain; Multisite; Widespread; Definition; Risk factors
10.  Differences in risk factors for neurophysiologically confirmed carpal tunnel syndrome and illness with similar symptoms but normal median nerve function: a case–control study 
Background
To explore whether risk factors for neurophysiologically confirmed carpal tunnel syndrome (CTS) differ from those for sensory symptoms with normal median nerve conduction, and to test the validity and practical utility of a proposed definition for impaired median nerve conduction, we carried out a case–control study of patients referred for investigation of suspected CTS.
Methods
We compared 475 patients with neurophysiological abnormality (NP+ve) according to the definition, 409 patients investigated for CTS but classed as negative on neurophysiological testing (NP-ve), and 799 controls. Exposures to risk factors were ascertained by self-administered questionnaire. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated by logistic regression.
Results
NP+ve disease was associated with obesity, use of vibratory tools, repetitive movement of the wrist or fingers, poor mental health and workplace psychosocial stressors. NP-ve illness was also related to poor mental health and occupational psychosocial stressors, but differed from NP+ve disease in showing associations also with prolonged use of computer keyboards and tendency to somatise, and no relation to obesity. In direct comparison of NP+ve and NP-ve patients (the latter being taken as the reference category), the most notable differences were for obesity (OR 2.7, 95 % CI 1.9-3.9), somatising tendency (OR 0.6, 95% CI 0.4-0.9), diabetes (OR 1.6, 95% CI 0.9-3.1) and work with vibratory tools (OR 1.4, 95% CI 0.9-2.2).
Conclusions
When viewed in the context of earlier research, our findings suggest that obesity, diabetes, use of hand-held vibratory tools, and repeated forceful movements of the wrist and hand are causes of impaired median nerve function. In addition, sensory symptoms in the hand, whether from identifiable pathology or non-specific in origin, may be rendered more prominent and distressing by hand activity, low mood, tendency to somatise, and psychosocial stressors at work. These differences in associations with risk factors support the validity of our definition of impaired median nerve conduction.
doi:10.1186/1471-2474-14-240
PMCID: PMC3765327  PMID: 23947720
Carpal tunnel syndrome; Nerve conduction; Case–control; Obesity; Vibration; Occupation; Psychosocial; Somatising tendency; Upper limb disorders
11.  Impact of carpal tunnel surgery according to pre-operative abnormality of sensory conduction in median nerve: a longitudinal study 
Background
We have previously proposed that sensory nerve conduction (SNC) in the median nerve should be classed as abnormal when the difference between conduction velocities in the little and index fingers is > 8 m/s. In a prospective longitudinal study, we investigated whether this case definition distinguished patients who were more likely to benefit from surgical treatment.
Methods
We followed up 394 patients (response rate 56%), who were investigated by a neurophysiology service for suspected carpal tunnel syndrome. Information about symptoms, treatment and other possible determinants of outcome was obtained through questionnaires at baseline and after follow-up for a mean of 19.2 months. Analysis focused on 656 hands with numbness, tingling or pain at baseline. Associations of surgical treatment with resolution of symptoms were assessed by Poisson regression, and summarised by prevalence rate ratios (PRRs) and associated 95% confidence intervals (95% CIs).
Results
During follow-up, 154 hands (23%) were treated surgically, and sensory symptoms resolved in 241 hands (37%). In hands with abnormal median SNC, surgery was associated with resolution of numbness, tingling and pain (PRR 1.5, 95% CI 1.0-2.2), and of numbness and tingling specifically (PRR 1.8, 95% CI 1.3-2.6). In contrast, no association was apparent for either outcome when median SNC was classed as normal.
Conclusions
Our definition of abnormal median SNC distinguished a subset of patients who appeared to benefit from surgical treatment. This predictive capacity gives further support to its validity as a diagnostic criterion in epidemiological research.
doi:10.1186/1471-2474-14-241
PMCID: PMC3765505  PMID: 23947746
Carpal tunnel syndrome; Neurophysiology; Case definition; Validity; Surgery; Outcome
12.  Symptoms, signs and nerve conduction velocities in patients with suspected carpal tunnel syndrome 
Background
To inform the clinical management of patients with suspected carpal tunnel syndrome (CTS) and case definition for CTS in epidemiological research, we explored the relation of symptoms and signs to sensory nerve conduction (SNC) measurements.
Methods
Patients aged 20–64 years who were referred to a neurophysiology service for investigation of suspected CTS, completed a symptom questionnaire (including hand diagrams) and physical examination (including Tinel’s and Phalen’s tests). Differences in SNC velocity between the little and index finger were compared according to the anatomical distribution of symptoms in the hand and findings on physical examination.
Results
Analysis was based on 1806 hands in 908 patients (response rate 73%). In hands with numbness or tingling but negative on both Tinel’s and Phalen’s tests, the mean difference in SNC velocities was no higher than in hands with no numbness or tingling. The largest differences in SNC velocities occurred in hands with extensive numbness or tingling in the median nerve sensory distribution and both Tinel’s and Phalen’s tests positive (mean 13.8, 95% confidence interval (CI) 12.6-15.0 m/s). Hand pain and thumb weakness were unrelated to SNC velocity.
Conclusions
Our findings suggest that in the absence of other objective evidence of median nerve dysfunction, there is little value in referring patients of working age with suspected CTS for nerve conduction studies if they are negative on both Tinel’s and Phalen’s tests. Alternative case definitions for CTS in epidemiological research are proposed according to the extent of diagnostic information available and the relative importance of sensitivity and specificity.
doi:10.1186/1471-2474-14-242
PMCID: PMC3765787  PMID: 23947775
Epidemiology; Evidence-based medicine; Hand; Nerve compression syndromes; Wrist
13.  Concise guidance: Pregnancy - occupational aspects of management 
Summary
Most pregnant women are exposed to some physical activity at work. This guidance is aimed at doctors advising healthy women with uncomplicated singleton pregnancies about the risks arising from five common workplace exposures (prolonged working hours, shift work, lifting, standing and heavy physical workload). The adverse outcomes considered are: miscarriage, preterm delivery, small-for-gestational age, low birthweight, pre-eclampsia and gestational hypertension. Systematic review of the literature indicates that these exposures are unlikely to carry much of an increased risk for any of the outcomes, since small apparent effects may be explicable in terms of chance, bias, or confounding, while larger and better studies yield lower estimated risks than smaller and weaker studies.
In general, patients may be reassured that such work is associated with little, if any, adverse effect on pregnancy. Moreover, moderate physical exercise is thought to be healthy in pregnancy and most pregnant women undertake some physical work at home. The guidelines provide risk estimates and advice on counselling.
PMCID: PMC3653071  PMID: 23472500
14.  RISK FACTORS FOR NEW ONSET AND PERSISTENCE OF MULTI-SITE MUSCULOSKELETAL PAIN IN A LONGITUDINAL STUDY OF WORKERS IN CRETE 
Objectives
To explore occupational and psychological risk factors for the incidence and persistence of multi-site musculoskeletal pain.
Methods
We conducted a longitudinal investigation of three occupational groups in Crete, Greece. Baseline information was obtained at interview about pain in the past year at each of six anatomical sites, and about possible risk factors for subsequent symptoms. Twelve months later, subjects were re-interviewed about pain at the same anatomical sites in the past month. Pain at two or more sites was classed as multi-site. Associations with new development and persistence of multi-site pain at follow-up were assessed by logistic regression.
Results
Analysis was based on 518 subjects (87% of those originally selected for study). At follow-up, multi-site pain persisted in 217 (62%) of those who had experienced it in the year before baseline, and was newly developed in 27 (17%) of those who had not. Persistence of multi-site pain was significantly related to physical loading at work, somatising tendency and beliefs about work as a cause of musculoskeletal pain, with ORs (95%CIs) for the highest relative to the lowest exposure categories of 2.3 (1.0-5.6), 2.6 (1.5-4.6) and 1.9 (1.1-3.3) respectively. Development of new multi-site pain was most strongly associated with working for ≥ 40 hours per week (OR 5.0, 95%CI 1.1-24.0).
Conclusions
Our findings confirm the importance of both physical loading at work and somatising tendency as risk factors for multi-site pain, and suggest that persistence of pain is also influenced by adverse beliefs about work-causation.
doi:10.1136/oemed-2012-100689
PMCID: PMC3526653  PMID: 22864252
15.  Psychological and culturally-influenced risk factors for the incidence and persistence of low back pain and associated disability in Spanish workers: findings from the CUPID study 
Objective
To assess the importance of psychological and culturally-influenced factors as predictors of incidence and persistence of LBP in a Spanish working population.
Methods
As part of the international CUPID study, 1105 Spanish nurses and office workers, aged 20-59 years, answered questions at baseline about LBP in the past month and past year, associated disability, occupational lifting, smoking habits, health beliefs, mental health, and distress from common somatic symptoms. At follow-up 12 months later, they were asked again about LBP and associated disability in the past month. Associations with the incidence and persistence of LBP were assessed by log binomial regression, and characterised by prevalence rate ratios (PRRs) with associated 95% confidence intervals (CIs).
Results
971 participants (87.9%) completed follow-up. Among 579 with no LBP at baseline, 22.8% reported LBP at follow-up. After adjustment for sex, age and occupation, development of new LBP was predicted by poor mental health (PRR 1.5, 95%CI 1.0-2.2), somatising tendency (PRR 1.8, 95%CI 1.2-2.7), and presence of LBP for >1 month in the year before baseline (PRR 4.7, 95%CI 3.1-6.9). Among 392 subjects who had LBP at baseline, 59.4% reported persistence at follow-up. Persistence of LBP was associated with presence of symptoms for >1 month in the 12 months before baseline (PRR 1.4, 95%CI 1.2-1.7), and more weakly with somatising tendency, and with adverse beliefs about the work-relatedness and prognosis of LBP
Conclusion
In Spain, as in northern European countries, psychological and culturally-influenced factors have an important role in the development and persistence of LBP.
doi:10.1136/oemed-2011-100637
PMCID: PMC3526654  PMID: 22864247
low back pain; health beliefs; mental health; somatising tendency
16.  HOW COMMON IS RSI? 
Objective
Statistics from Labour Force Surveys are widely quoted as evidence for the scale of occupational illness in Europe. However, occupational attribution depends on whether participants believe their health problem is caused or aggravated by work, and personal beliefs may be unreliable. We assessed the potential for error for work-associated arm pain.
Methods
We mailed a questionnaire to working-aged adults, randomly chosen from five British general practices. We asked about: occupational activities; mental health; self-rated health; arm pain; and beliefs about its causation. Those in work (n = 1769) were asked about activities likely to cause arm pain, from which we derived a variable for exposure to any ‘arm-straining’ occupational activity. We estimated the relative risk (RR) from arm-straining activity, using a modified Cox model, and derived the population attributable fraction (PAF). We compared the proportion of arm pain cases reporting their symptom as caused or made worse by work with the calculated PAF, overall and for subsets defined by demographic and other characteristics.
Results
Arm pain in the past year was more common in the 1,143 subjects who reported exposure to arm-straining occupational activity (RR 1.2, 95% confidence interval 1.1 to 1.5). In the study sample as a whole, 53.9% of 817 cases reported their arm pain as work-associated, whereas the PAF for arm-straining occupational activity was only 13.9%. The ratio of cases reported as work-related to the calculated attributable number was substantially higher below 50 years (5.4) than at older ages (3.0) and higher in those with worse self-rated and mental health.
Conclusions
Counting people with arm pain which they believe to be work-related can overestimate the number of cases attributable to work substantially. This casts doubt on the validity of a major source of information used by European Governments to evaluate their occupational health strategies.
doi:10.1136/oem.2007.035378
PMCID: PMC3689197  PMID: 18056747
17.  Disabling musculoskeletal pain in working populations: Is it the job, the person, or the culture? 
Pain  2013;154(6):856-863.
Summary
Large international variation in the prevalence of disabling forearm and low back pain was only partially explained by established personal and socioeconomic risk factors.
To compare the prevalence of disabling low back pain (DLBP) and disabling wrist/hand pain (DWHP) among groups of workers carrying out similar physical activities in different cultural environments, and to explore explanations for observed differences, we conducted a cross-sectional survey in 18 countries. Standardised questionnaires were used to ascertain pain that interfered with everyday activities and exposure to possible risk factors in 12,426 participants from 47 occupational groups (mostly nurses and office workers). Associations with risk factors were assessed by Poisson regression. The 1-month prevalence of DLBP in nurses varied from 9.6% to 42.6%, and that of DWHP in office workers from 2.2% to 31.6%. Rates of disabling pain at the 2 anatomical sites covaried (r = 0.76), but DLBP tended to be relatively more common in nurses and DWHP in office workers. Established risk factors such as occupational physical activities, psychosocial aspects of work, and tendency to somatise were confirmed, and associations were found also with adverse health beliefs and group awareness of people outside work with musculoskeletal pain. However, after allowance for these risk factors, an up-to 8-fold difference in prevalence remained. Systems of compensation for work-related illness and financial support for health-related incapacity for work appeared to have little influence on the occurrence of symptoms. Our findings indicate large international variation in the prevalence of disabling forearm and back pain among occupational groups carrying out similar tasks, which is only partially explained by the personal and socioeconomic risk factors that were analysed.
doi:10.1016/j.pain.2013.02.008
PMCID: PMC3675684  PMID: 23688828
Low back; Forearm; Pain; International; Socioeconomic; Psychosocial
18.  Professional driving and prolapsed lumbar intervertebral disc diagnosed by magnetic resonance imaging – a case–control study 
Objectives
The aim of this study was to investigate whether whole-body vibration (WBV) is associated with prolapsed lumbar intervertebral disc (PID) and nerve root entrapment among patients with low-back pain (LBP) undergoing magnetic resonance imaging (MRI).
Methods
A consecutive series of patients referred for lumbar MRI because of LBP were compared with controls X-rayed for other reasons. Subjects were questioned about occupational activities loading the spine, psychosocial factors, driving, personal characteristics, mental health, and certain beliefs about LBP. Exposure to WBV was assessed by six measures, including weekly duration of professional driving, hours driven at a spell, and current 8-hour daily equivalent root-mean-square acceleration A(8). Cases were sub-classified according to whether or not PID/nerve root entrapment was present. Associations with WBV were examined separately for cases with and without these MRI findings, with adjustment for age, sex, and other potential confounders.
Results
Altogether, 237 cases and 820 controls were studied, including 183 professional drivers and 176 cases with PID and/or nerve root entrapment. Risks associated with WBV tended to be lower for LBP with PID/nerve root entrapment but somewhat higher for risks of LBP without these abnormalities. However, associations with the six metrics of exposure were all weak and not statistically significant. Neither exposure–response relationships nor increased risk of PID/nerve root entrapment from professional driving or exposure at an A(8) above the European Union daily exposure action level were found.
Conclusions
WBV may be a cause of LBP but it was not associated with PID or nerve root entrapment in this study.
doi:10.5271/sjweh.3273
PMCID: PMC3436743  PMID: 22249859
back pain; disc pathology; whole-body vibration
19.  Occupational activities and osteoarthritis of the knee 
British medical bulletin  2012;102:147-170.
Background
The prevalence of knee osteoarthritis (OA) is rising and the search for interventions to mitigate risk is intensifying. This review considers the contribution of occupational activities to disease occurrence and the lessons for prevention.
Sources
Systematic search in Embase and Medline covering the period 1996 to November 2011.
Areas of agreement
Reasonably good evidence exists that physical work activities (especially kneeling, squatting, lifting, and climbing) can cause and/or aggravate knee OA. These exposures should be reduced where possible. Obese workers with such exposures are at additional risk of knee OA and should therefore particularly be encouraged to lose weight.
Areas of uncertainty/research need
Workplace interventions and policies to prevent knee OA have seldom been evaluated. Moreover, their implementation can be problematic. However, the need for research to optimise the design of work in relation to knee OA is pressing, given population trends towards extended working life.
doi:10.1093/bmb/lds012
PMCID: PMC3428837  PMID: 22544778
Gonarthrosis; employment; occupational; aetiology
20.  The older worker with osteoarthritis of the knee 
British medical bulletin  2012;102:79-88.
Background
Changing demographics mean that many patients with large joint arthritis will work beyond traditional retirement age. This review considers the impact of knee osteoarthritis (OA) on work participation and the relation between work and knee replacement (TKR).
Sources
Two systematic searches in Embase and Medline, supplemented by three systematic reviews.
Areas of agreement
Probably, although evidence is limited, knee OA considerably impairs participation in work (labour force participation, work attendance and work productivity).
Areas of uncertainty/research need
Little is known about effective interventions (treatments, work changes and policies) to improve vocational participation in patients with knee OA; or how type of work affects long-term clinical outcomes (e.g. pain, function, the need for revision surgery) in patients with TKRs. The need for such research is pressing and opportune, as increasing numbers of patients with knee OA or TKR expect to work on.
doi:10.1093/bmb/lds011
PMCID: PMC3428873  PMID: 22544779
Gonarthrosis; employment; occupational; management; work participation
21.  Correction: The CUPID (Cultural and Psychosocial Influences on Disability) Study: Methods of Data Collection and Characteristics of Study Sample 
PLoS ONE  2012;7(10):10.1371/annotation/3faf76e5-f73e-427f-9d60-8f94939b0f7e.
doi:10.1371/annotation/3faf76e5-f73e-427f-9d60-8f94939b0f7e
PMCID: PMC3491867
22.  Optimal case definitions of upper extremity disorder for use in the clinical treatment and referral of patients 
Arthritis care & research  2012;64(4):573-580.
Objective
Experts disagree about the optimal classification of upper limb disorders (ULDs). To explore whether differential response to treatments offers a basis for choosing between case definitions, we analysed previously published research.
Methods
We screened 183 randomised controlled trials (RCTs) of treatments for ULDs, identified from the bibliographies of 10 Cochrane reviews, four other systematic reviews, and a search in Medline, Embase, and Google Scholar to June 2010. From these, we selected RCTs which allowed estimates of benefit (expressed as relative risks (RRs)) for >1 case definition to be compared when other variables (treatment, comparison group, follow-up time, outcome measure) were effectively held constant. Comparisons of RRs for paired case definitions were summarised by their ratios, with the RR for the simpler and broader definition as the denominator.
Result
Two RCT reports allowed within-trial comparison of RRs and thirteen others allowed between-trial comparisons. Together these provided 17 ratios of RRs (five for shoulder treatments, 12 for elbow treatments, none for wrist/hand treatments). The median ratio of RRs was 1.0 (range 0.3 to 1.7; interquartile range 0.6 to 1.3).
Conclusion
Although the evidence base is limited, our findings suggest that for musculoskeletal disorders of the shoulder and elbow, clinicians in primary care will often do best to apply simpler and broader case definitions. Researchers should routinely publish secondary analyses for subgroups of patients by different diagnostic features at trial entry, to expand the evidence base on optimal case definitions for patient management.
doi:10.1002/acr.21588
PMCID: PMC3428871  PMID: 22213545
23.  Mortality from infectious pneumonia in metal workers: a comparison with deaths from asthma in occupations exposed to respiratory sensitizers 
Thorax  2009;64(11):983-986.
Introduction
National analyses of mortality in England and Wales have repeatedly shown excess deaths from pneumonia in welders. During 1979-1990 the excess was attributable largely to deaths from lobar pneumonia and pneumonias other than bronchopneumonia, limited to working-aged men, and apparent in other metal fume-exposed occupations. We assessed findings for 1991-2000 and compared the mortality pattern with that from asthma in occupations exposed to known respiratory sensitizers.
Methods
The Office of National Statistics supplied data on deaths by underlying cause among men aged 16-74 years in England and Wales during 1991-2000, including age and last held occupation. We abstracted data on pneumonia for occupations with exposure to metal fume and on asthma for occupations commonly reported to surveillance schemes as at risk of occupational asthma. We estimated expected numbers of deaths by applying age-specific proportions of deaths by cause in the population to the total deaths by age in each occupational group. Observed and expected numbers were compared for each cause of death.
Results
Among working-aged men in metal fume-exposed occupations we found excesses of mortality from pneumococcal and lobar pneumonia (54 deaths vs. 27.3 expected) and from pneumonias other than bronchopneumonia (71 vs. 52.4), but no excess from these causes at older ages, or from bronchopneumonia at any age. The attributable mortality from metal fume (45.3 excess deaths) compared with an estimated 62.6 deaths from occupational asthma.
Conclusion
Exposure to metal fume is a material cause of occupational mortality. The hazard deserves far more attention than it presently receives.
doi:10.1136/thx.2009.114280
PMCID: PMC3442248  PMID: 19703831
24.  MUSCULOSKELETAL PAIN IN ELITE PROFESSIONAL MUSICIANS FROM BRITISH SYMPHONY ORCHESTRAS 
Background
Professional musicians may have high rates of musculoskeletal pain, but few studies have analysed risks by work activities or the psychosocial work environment.
Aims
To assess the prevalence and impact of musculoskeletal pain, and its relation to playing conditions, mental health and performance anxiety, in musicians from leading British symphony orchestras.
Methods
Musicians from six professional orchestras completed a questionnaire concerning their orchestral duties and physical activities at work; mental health (somatising tendency, mood, demand, support and control at work, performance anxiety); and regional pain in the past four weeks and past 12 months. Prevalence rates were estimated by anatomical site, and associations with risk factors assessed by logistic regression.
Results
Responses were received from 243 musicians (51% of those approached), among whom 210 (86%) reported regional pain in the past 12 months, mainly affecting the neck, low-back, and shoulders. Risks tended to be higher in women, in those with low mood, and especially in those with high somatising scores. Only weak associations were found with psychosocial work stressors and performance anxiety. However, risks differed markedly by instrument category. Relative to string players, the odds of wrist/hand pain were raised 2.9-fold in wind players, but 60% lower in brass players, while the odds of elbow pain were 50% lower among wind and brass players.
Conclusions
Musculoskeletal pain is common in elite professional musicians. A major personal risk factor is somatising tendency, but performance anxiety has less impact. Risks differ substantially by instrument played, offering pointers towards prevention.
doi:10.1093/occmed/kqr129
PMCID: PMC3428866  PMID: 22003061
25.  Optimising case definitions of upper limb disorder for aetiological research and prevention – a review 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1136/oemed-2011-100086
PMCID: PMC3427012  PMID: 22006938

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