Cost-utility of maintained physical activity and physiotherapy in the management of distal arm pain: an economic evaluation of data from a randomized controlled trial.

BACKGROUND: Arm pain is common, costly to health services and society. Physiotherapy referral is standard management, and while awaiting treatment, advice is often given to rest, but the evidence base is weak. OBJECTIVE: To assess the cost-effectiveness of advice to remain active (AA) versus advice to rest (AR); and immediate physiotherapy (IP) versus usual care (waiting list) physiotherapy (UCP). METHODS: Twenty-six-week within-trial economic evaluation (538 participants aged ≥18 years randomized to usual care, i.e. AA (n = 178), AR (n = 182) or IP (n = 178). Regression analysis estimated differences in mean costs and Quality-Adjusted Life Years (QALYs). Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves were generated. Primary analysis comprised the 193 patients with complete resource use (UK NHS perspective) and EQ-5D data. Sensitivity analysis investigated uncertainty. RESULTS: Baseline-adjusted cost differences were £88 [95% confidence interval (CI): -14, 201) AA versus AR; -£14 (95% CI: -87, 66) IP versus UCP. Baseline-adjusted QALY differences were 0.0095 (95% CI: -0.0140, 0.0344) AA versus AR; 0.0143 (95% CI: -0.0077, 0.0354) IP versus UCP. There was a 71 and 89% probability that AA (versus AR) and IP (versus UCP) were the most cost-effective option using a threshold of £20,000 per additional QALY.  The results were robust in the sensitivity analysis. CONCLUSION: The difference in mean costs and mean QALYs between the competing strategies was small and not statistically significant. However, decision-makers may judge that IP was not shown to be any more effective than delayed treatment, and was no more costly than delayed physiotherapy. AA is preferable to one that encourages AR, as it is more effective and more likely to be cost-effective than AR.

Frailty, prefrailty and employment outcomes in Health and Employment After Fifty (HEAF) Study.

OBJECTIVES: Demographic changes are requiring people to work longer. No previous studies, however, have focused on whether the 'frailty' phenotype (which predicts adverse events in the elderly) is associated with employment difficulties. To provide information, we assessed associations in the Health and Employment After Fifty Study, a population-based cohort of 50-65-year olds. METHODS: Subjects, who were recruited from 24 English general practices, completed a baseline questionnaire on 'prefrailty' and 'frailty' (adapted Fried criteria) and several work outcomes, including health-related job loss (HRJL), prolonged sickness absence (>20 days vs less, past 12 months), having to cut down substantially at work and difficulty coping with work's demands. Associations were assessed using logistic regression and population attributable fractions (PAFs) were calculated. RESULTS: In all, 3.9% of 8095 respondents were classed as 'frail' and 31.6% as 'prefrail'. Three-quarters of the former were not in work, while 60% had left their last job on health grounds (OR for HRJL vs non-frail subjects, 30.0 (95% CI 23.0 to 39.2)). Among those in work, ORs for prolonged sickness absence, cutting down substantially at work and struggling with work's physical demands ranged from 10.7 to 17.2. The PAF for HRJL when any frailty marker was present was 51.8% and that for prolonged sickness absence was 32.5%. Associations were strongest with slow reported walking speed. Several associations were stronger in manual workers than in managers. CONCLUSIONS: Fried frailty symptoms are not uncommon in mid-life and are strongly linked with economically important adverse employment outcomes. Frailty could represent an important target for prevention.

Mortality from multiple sclerosis in British military personnel.

BACKGROUND: While analysing trends in occupational mortality in England and Wales, we noticed an unexpectedly elevated proportion of deaths from multiple sclerosis (MS) among men in the armed forces. AIMS: To document and explore possible explanations for the observed excess. METHODS: We analysed data on underlying cause of death and last full-time occupation for 3,688,916 deaths among men aged 20-74 years in England and Wales during 1979-2010, calculating proportional mortality ratios (PMRs) standardised for age. We compared PMRs for MS in the armed forces with those for each main social class, and in selected other occupations. We also compared PMRs for MS with those for motor neurone disease (MND). RESULTS: The overall PMR for MS in the armed forces during 1979-2010 was 243 (95%CI 203-288). The excess was apparent in each of three separate decades of study (PMRs, ranging from 220 to 259), and across the entire age range. PMRs for MS were not elevated to the same extent in comparator occupations, nor in any of the main social classes. There was no parallel increase in PMRs for MND. CONCLUSIONS: These findings suggest that the high proportional mortality from MS in British military personnel is unlikely to have occurred by chance, or as an artefact of the method of investigation. However, the only military cohort study with published results on MS does not support an increased risk. It would be useful to analyse data on MS from other established military cohorts, to check for evidence of a hazard.

Exposure to welding fumes and lower airway infection with Streptococcus pneumoniae.

BACKGROUND: Welders are at increased risk of pneumococcal pneumonia. The mechanism for this association is not known. The capacity of pneumococci to adhere to and infect lower airway cells is mediated by host-expressed platelet-activating factor receptor (PAFR). OBJECTIVE: We sought to assess the effect of mild steel welding fumes (MS-WF) on PAFR-dependent pneumococcal adhesion and infection to human airway cells in vitro and on pneumococcal airway infection in a mouse model. METHODS: The oxidative potential of MS-WF was assessed by their capacity to reduce antioxidants in vitro. Pneumococcal adhesion and infection of A549, BEAS-2B, and primary human bronchial airway cells were assessed by means of quantitative bacterial culture and expressed as colony-forming units (CFU). After intranasal instillation of MS-WF, mice were infected with Streptococcus pneumoniae, and bronchoalveolar lavage fluid (BALF) and lung CFU values were determined. PAFR protein levels were assessed by using immunofluorescence and immunohistochemistry, and PAFR mRNA expression was assessed by using quantitative PCR. PAFR was blocked by CV-3988, and oxidative stress was attenuated by N-acetylcysteine. RESULTS: MS-WF exhibited high oxidative potential. In A549 and BEAS-2B cells MS-WF increased pneumococcal adhesion and infection and PAFR protein expression. Both CV-3988 and N-acetylcysteine reduced MS-WF-stimulated pneumococcal adhesion and infection of airway cells. MS-WF increased mouse lung PAFR mRNA expression and increased BALF and lung pneumococcal CFU values. In MS-WF-exposed mice CV-3988 reduced BALF CFU values. CONCLUSIONS: Hypersusceptibility of welders to pneumococcal pneumonia is in part mediated by the capacity of welding fumes to increase PAFR-dependent pneumococcal adhesion and infection of lower airway cells.

Trends in mortality from occupational hazards among men in England and Wales during 1979-2010.

OBJECTIVES: To monitor the impact of health and safety provisions and inform future preventive strategies, we investigated trends in mortality from established occupational hazards in England and Wales. METHODS: We analysed data from death certificates on underlying cause of death and last full-time occupation for 3 688 916 deaths among men aged 20-74 years in England and Wales during 1979-2010 (excluding 1981 when records were incomplete). Proportional mortality ratios (PMRs), standardised for age and social class, were calculated for occupations at risk of specified hazards. Observed and expected numbers of deaths for each hazard were summed across occupations, and the differences summarised as average annual excesses. RESULTS: Excess mortality declined substantially for most hazards. For example, the annual excess of deaths from chronic bronchitis and emphysema fell from 170.7 during 1979-1990 to 36.0 in 2001-2010, and that for deaths from injury and poisoning from 237.0 to 87.5. In many cases, the improvements were associated with falling PMRs (suggesting safer working practices), but they also reflected reductions in the numbers of men employed in more hazardous jobs, and declining mortality from some diseases across the whole population. Notable exceptions to the general improvement were diseases caused by asbestos, especially in some construction trades and sinonasal cancer in woodworkers. CONCLUSIONS: The highest priority for future prevention of work-related fatalities is the minority of occupational disorders for which excess mortality remains static or is increasing, in particular asbestos-related disease among certain occupations in the construction industry and sinonasal cancer in woodworkers.

Job dissatisfaction and the older worker: baseline findings from the Health and Employment After Fifty study.

OBJECTIVES: Demographic changes are requiring people to work longer. Labour force participation might be promoted by tackling sources of job dissatisfaction. We aimed to describe the epidemiology of job dissatisfaction in older British workers, to explore which perceptions of work contribute most importantly, and to assess possible impacts on health. METHODS: Participants aged 50-64 years were recruited from 24 English general practices. At baseline, those currently in work (N=5437) reported on their demographic and employment circumstances, overall job satisfaction, perceptions of their work that might contribute to dissatisfaction, and their general health, mood and well-being. Associations of job dissatisfaction with risk factors and potential health outcomes were assessed cross-sectionally by logistic regression, and the potential contributions of different negative perceptions to overall dissatisfaction were summarised by population attributable fractions (PAFs). RESULTS: Job dissatisfaction was more common among men, below age 60 years, those living in London and the South East, in the more educated and in those working for larger employers. The main contributors to job dissatisfaction among employees were feeling unappreciated and/or lacking a sense of achievement (PAF 55-56%), while in the self-employed, job insecurity was the leading contributor (PAF 79%). Job dissatisfaction was associated with all of the adverse health outcomes examined (ORs of 3-5), as were most of the negative perceptions of work that contributed to overall dissatisfaction. CONCLUSIONS: Employment policies aimed at improving job satisfaction in older workers may benefit from focussing particularly on relationships in the workplace, fairness, job security and instilling a sense of achievement.

Risk of cancer in workers exposed to styrene at eight British companies making glass-reinforced plastics.

OBJECTIVES: To provide further information on the risks of lymphohaematopoietic (LH) and other cancers associated with styrene. METHODS: We extended follow-up to December 2012 for 7970 workers at eight companies in England which used styrene in the manufacture of glass-reinforced plastics. Mortality was compared with that for England and Wales by the person-years method, and summarised by SMRs with 95% CIs. A supplementary nested case-control analysis compared styrene exposures, lagged by 5 years, in 122 incident or fatal cases of LH cancer and 1138 matched controls. RESULTS: A total of 3121 cohort members had died (2022 since the last follow-up). No elevation of mortality was observed for LH cancer, either in the full cohort (62 deaths, SMR 0.90, 95% CI 0.69 to 1.15), or in those with more than background exposure to styrene (38 deaths, SMR 0.82, 95% CI 0.58 to 1.14). Nor did the case-control analysis suggest any association with LH cancer. In comparison with background exposure, the OR for non-Hodgkin's lymphoma/chronic lymphocytic leukaemia in workers with high exposure (estimated 8-h time-weighted average of 40-100 ppm) for ≥1 year was 0.54 (95% CI 0.23 to 1.27). Mortality from lung cancer was significantly elevated, and risk increased progressively across exposure categories, with an SMR of 1.44 (95% CI 1.10 to 1.86) in workers highly exposed for ≥1 year. CONCLUSIONS: We found no evidence that styrene causes LH cancer. An association with lung cancer is not consistently supported by other studies. It may have been confounded by smoking, but would be worth checking further.

Sensory impairments, problems of balance and accidental injury at work: a case-control study.

OBJECTIVES: Sensory impairments are becoming increasingly common in the workforces of Western countries. To assess their role in occupational injury, and that of disorders of balance, we undertook a case-control study. METHODS: Using the Clinical Practice Research Datalink, which documents all medical consultations, referrals and diagnoses in primary care for 6% of the British population, we identified 1348 working-aged patients who had consulted medical services over a 22-year period for workplace injury (cases) and 6652 age-matched, sex-matched and practice-matched controls. Risks were assessed by conditional logistic regression, for earlier recorded diagnoses of visual impairment, common eye diseases, hearing loss, perforated ear drum, non-acute otitis media and disorders of balance. RESULTS: In all, 173 (2.2%) participants had an earlier eye problem, 792 (9.9%) an ear problem (including 336 with impaired hearing and 482 with non-acute otitis media) and 266 (3.3%) a disorder of balance. No associations were found with glaucoma, cataract, retinal disorders or perforation of the ear drum specifically, but adjusted ORs were moderately elevated for eye and ear problems more generally, and higher where there was a record of blindness or partial sight (OR 1.90, 95% CI 1.05 to 3.44) or non-acute otitis media (OR 2.04, 95% CI 1.64 to 2.54). Risks for non-acute otitis media and for disorders of balance were particularly elevated for consultations in the 12 months preceding injury consultation (OR 2.70, 95% CI 1.58 to 4.62 and 1.77, 95% CI 1.01 to 3.11, respectively). CONCLUSIONS: Problems of vision, impairments of hearing and disorders of balance all may carry moderately increased risks of occupational injury.

Soft tissue sarcoma, non-Hodgkin's lymphoma and chronic lymphocytic leukaemia in workers exposed to phenoxy herbicides: extended follow-up of a UK cohort.

OBJECTIVES: To provide further information on the possible carcinogenicity of phenoxy herbicides, and in particular their relationship to soft tissue sarcoma (STS), non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukaemia (CLL). METHODS: We extended follow-up to December 2012 for 8036 men employed at five factories in the UK which had manufactured phenoxy herbicides, or in a contract spraying business. Mortality was compared with that for England and Wales by the person-years method. Nested case-control analyses compared men with incident or fatal STS (n=15) or NHL/CLL (n=74) and matched controls (up to 10 per case). RESULTS: 4093 men had died, including 2303 since the last follow-up. Mortality from all causes and all cancers was close to expectation, but an excess of deaths from NHL was observed among men who had worked for ≥1 year in jobs with more than background exposure to phenoxy herbicides (19 deaths, SMR 1.85, 95% CI 1.12 to 2.89). Four deaths from STS occurred among men potentially exposed above background (3.3 expected). In the nested case-control analyses, there were no significantly elevated risks or consistent trends across categories of potential exposure for either STS or NHL/CLL. Among men who had worked for ≥1 year in potentially exposed jobs, the highest OR (for STS) was only 1.30 (95% CI 0.30 to 5.62). CONCLUSIONS: Our findings are consistent with the current balance of epidemiological evidence. If phenoxy herbicides pose a hazard of either STS or NHL, then any absolute increase in risk is likely to be small.

Health and Employment after Fifty (HEAF): a new prospective cohort study.

BACKGROUND: Demographic trends in developed countries have prompted governmental policies aimed at extending working lives. However, working beyond the traditional retirement age may not be feasible for those with major health problems of ageing, and depending on occupational and personal circumstances, might be either good or bad for health. To address these uncertainties, we have initiated a new longitudinal study. METHODS/DESIGN: We recruited some 8000 adults aged 50-64 years from 24 British general practices contributing to the Clinical Practice Research Datalink (CPRD). Participants have completed questionnaires about their work and home circumstances at baseline, and will do so regularly over follow-up, initially for a 5-year period. With their permission, we will access their primary care health records via the CPRD. The inter-relation of changes in employment (with reasons) and changes in health (e.g., major new illnesses, new treatments, mortality) will be examined. DISCUSSION: CPRD linkage allows cost-effective frequent capture of detailed objective health data with which to examine the impact of health on work at older ages and of work on health. Findings will inform government policy and also the design of work for older people and the measures needed to support employment in later life, especially for those with health limitations.

Upper airway cancer, myeloid leukemia, and other cancers in a cohort of British chemical workers exposed to formaldehyde.

The International Agency for Research on Cancer controversially has classified formaldehyde as causing nasopharyngeal carcinoma and myeloid leukemia. To provide further information on this question, we extended follow-up of a cohort of 14,008 chemical workers at 6 factories in England and Wales, covering the period 1941-2012. Mortality was compared with national death rates for England and Wales, and associations with incident upper airway cancer and leukemia were explored in nested case-control analyses. We observed excess deaths from cancers of the esophagus (100 observed vs. 93.1 expected), stomach (182 vs. 141.4), rectum (107 vs. 86.8), liver (35 vs. 26.9), and lung (813 vs. 645.8), but none of these tumors exhibited a clear exposure-response relationship. Nested case-control analyses of 115 men with upper airway cancer (including 1 nasopharyngeal cancer), 92 men with leukemia, and 45 men with myeloid leukemia indicated no elevations of risk in the highest exposure category (high exposure for ≥1 year). When the 2 highest exposure categories were combined, the odds ratio for myeloid leukemia was 1.26 (95% confidence interval: 0.39, 4.08). Our results provide no support for an increased hazard of myeloid leukemia, nasopharyngeal carcinoma, or other upper airway tumors from formaldehyde exposure. These results indicate that any excess risk of these cancers, even from relatively high exposures, is at most small.

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 1348 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 6652 age, sex and practice-matched controls with no such consultation. Groups were compared in terms of consultations for mental health problems (1328 codes) and prescription of psychotropic drugs prior to the case's injury consultation using conditional logistic regression. RESULTS: In total, 1846 (23%) subjects had at least one psychiatric consultation before the index date and 1682 (21%) had been prescribed a psychotropic drug. The OR 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 (eg, 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.

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) root mean squared velocity (rms)) over that week. Associations with Dupuytren's contracture were estimated by Poisson regression, for lifetime exposure to HTV and for exposures in the past week >A(8) of 2.8 ms(-2) rms. Estimates of relative risk (prevalence ratio (PR)) were adjusted for age, smoking status, social class and certain manual activities at work. RESULTS: In all 4969 eligible male respondents supplied full information on the study variables. These included 72 men with Dupuytren's contracture, 2287 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% CI 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.

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).

Work activities and risk of prematurity, low birth weight and pre-eclampsia: an updated review with meta-analysis.

OBJECTIVES: We assessed the evidence relating preterm delivery (PTD), low birth weight, 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 to 2011), updating a previous search with a further 6 years of observations. METHODS: As before, combinations of keywords and medical subject headings 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 (RR) in meta-analysis. RESULTS: Analysis was based on 86 reports (32 cohort investigations, 57 with usable data on PTD, 54 on birth weight 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 (eg, RR>1.2). Larger and higher quality studies were less positive, while meta-estimates of risk were smaller than in previous analyses 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.

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 OR (95% CI) for the highest relative to the lowest exposure categories of 2.3 (1.0 to 5.6), 2.6 (1.5 to 4.6) and 1.9 (1.1 to 3.3) respectively. Development of new multi-site pain was most strongly associated with working for ≥40 h per week (OR 5.0, 95% CI 1.1 to 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.

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 low back pain (LBP) incidence and persistence in Spanish workers. METHODS: As part of the international Cultural and Psychosocial Influences in Disability (CUPID) study, 1105 Spanish nurses and office workers 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 12-month follow-up, they were asked about LBP and associated disability in the past month. Associations with LBP incidence and persistence were assessed by log binomial regression, and characterised by prevalence rate ratios (PRRs) with associated 95% 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, new LBP was predicted by poor mental health (PRR 1.5, 95% CI 1.0 to 2.2), somatising tendency (PRR 1.8, 95% CI 1.2 to 2.7) and presence of LBP for >1 month in the year before baseline (PRR 4.7, 95% CI 3.1 to 6.9). Among 392 subjects who had LBP at baseline, 59.4% reported persistence at follow-up, which was associated with presence of symptoms for >1 month in the 12 months before baseline (PRR 1.4, 95% CI 1.2 to 1.7) and more weakly with somatising tendency, and with adverse beliefs about LBP work-relatedness and prognosis. CONCLUSIONS: In Spain, as in northern European countries, psychological and culturally-influenced factors have an important role in LBP development and persistence.

International variation in absence from work attributed to musculoskeletal illness: findings from the CUPID study.

OBJECTIVES: To quantify the variation in rates of absence due to 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 (92-1017 per occupational group). Additionally, 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 tenfold. 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.

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.

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.