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• W2022208954 abstract "The Authors Reply: We are grateful for the opportunity to respond to Dr Nathan's letter about carpal tunnel syndrome (CTS), although we again stress that he and Dr Hadler devote disproportionate attention to this disorder compared with other, more prevalent work-related musculoskeletal problems. We readily agree with Dr Nathan that prospective studies, using validated methods of exposure assessment and health outcome, will help answer substantial questions regarding the natural history, diagnosis, and management of carpal tunnel syndrome and other upper-extremity cumulative trauma disorders. Clarifying the relationships between visual display terminal use and CTS and other disorders is particularly challenging because these disorders are multifactorial, case definitions have not been well established, and exposures are difficult to measure precisely. On several other matters, we disagree with Dr Nathan. Dr Nathan, for example, relies heavily on his own studies to support his belief that cumulative occupational keyboard use is not associated with CTS. We do not share Dr Nathan's confidence in this work. All of Dr Nathan's studies, save one,1 use the Kimura inching technique with a 0.4-millisecond (ms) cut point for abnormality wherein the maximum latency difference for median-nerve sensory fibers is determined in 1-cm increments.2 Using this cut point, Dr Nathan's original cross-sectional study of 471 industrial workers identified 39% as abnormal even after excluding those who had prior CTS surgery.3 This extraordinarily high and implausible prevalence was addressed by the American Association of Electrodiagnostic Medicine which, in an evidence-based analysis of the utility of various nerve-conduction tests compared with clinical case definitions, concluded that Dr Nathan's 0.4-ms cut point was overly sensitive and insufficiently specific (nearly 20% false positives) to classify individuals correctly.4 Indeed, in another analysis of the same subjects, using the more specific 0.5-ms cut point, Dr Nathan reported that only 17% of these workers had the abnormality.5 By continuing to use the 0.4-ms criterion, Dr Nathan's studies are so full of false positives that any associations between work factors and disease are likely to be obscured. His longitudinal studies, which use hands, rather than individuals, as the dependent variable in multiple regression analyses, exaggerate this effect. Despite these limitations, Dr Nathan was still able to detect an association between work and CTS in individuals. Table 4, from his original article, demonstrates a significant association between high force/high repetition and a doubling of nerve conduction velocity abnormality. The estimated risk (odds ratio = 2.1; 95% confidence interval, 1.4 to 3.2; P < 0.01) is similar to that reported by others.6-8 Dr Nathan urges government officials to give more attention to the impact of personal factors such as obesity, wrist dimensions, and heredity on musculoskeletal problems. This puzzles us because Dr Nathan's strongest model for non-work factors explains only 16% of the variance.9 Baseline body mass index, the most substantial contribution to total explained variance, had a correlation of only 0.153 with longitudinal nerve conduction change. In a more recent study, Dr Nathan reports that current smoking, caffeine use, and coffee consumption explain only 5% of the risk for CTS in women and that prior alcohol abuse and current beer consumption explain only 3% of the risk for CTS in men.10 Dr Nathan references several review articles and a statement by the Council for the American Society for Surgery of the Hand in support of his belief that an occupational cause of musculoskeletal disorders remains only a possibility. Our reading of these references is different. For example, although Stock did report that previous reviews reached widely varying conclusions about occupational risks for musculoskeletal disorders, her own review convinced her that there is strong evidence of a causal relationship between repetitive, forceful work and the development of musculoskeletal disorders....11 Dr Nathan is unduly impressed with Vender's review, which considered 2054 published articles and found all to be flawed.12 Of these articles, 97% (n = 2002) were rejected simply because they were not written by authors who are very active in the area of upper extremity chronic disorders/CTD or who are cited frequently. Most of the others were rejected because they studied symptoms and physical findings rather than clinical diagnoses or because they relied upon history and physical examination rather than electrodiagnostic studies. After these exclusions, Vender concluded that sufficient evidence does not exist in the medical literature to conclude that work is the sole cause of so-called cumulative trauma, hardly a surprising finding given that virtually every clinician and researcher in the field already agrees that musculoskeletal disorders are multifactorial. As Dr Nathan points out, Gerr finds that epidemiologic studies of video display terminals and musculoskeletal disorders have typically been limited by insufficient exposure and health outcome information and that well-designed prospective studies are needed.13 We note that Gerr also explained that these problems with study design frequently have the effect of underestimating associations. Dr Nathan's reliance on an epidemiologic conclusion by the American Society for Surgery of the Hand, a highly respected organization of hand surgeons, is curious. In a nationwide survey of its members, more than one third of the Society's members only occasionally, or never, obtain NCV studies preoperatively.14 In Washington State, we insist on preoperative documentation of nerve conduction abnormalities to avoid potentially inappropriate surgery in workers with CTS. Dr Nathan describes Dr Silverstein's inability to detect efficacy from ergonomic changes in a 3-year follow up study. He fails to note that the reason the study was unable to demonstrate the effectiveness of ergonomic changes is that there were no changes in either the forcefulness or repetitiveness of the jobs in this study between baseline and follow-up. We close with another area of agreement with Drs Nathan and Hadler-a shared concern that many workers needlessly become victims of medical care and compensation systems that encourage long-term disability. Part of the problem is that inappropriate surgery (thoracic outlet surgery, carpal tunnel release) or prolonged and ineffective conservative management often prolongs disability while opportunities for primary and secondary prevention (eg, through job modification and accommodation, tool design, job retraining, and early return-to-work programs) are neglected. We the opportunity to find common ground with Drs Nathan and Hadler on such constructive, health-affirming strategies. Gary Franklin, MD, MPH; Michael Silverstein, MD, MPH; Barbara Silverstein, MD, MPH Washington State Department of Labor and Industries; Olympia, WA; Department of Environmental Health; University of Washington; School of Public Health Seattle, WA" @default.
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• W2022208954 title "Evidence for Work-Related Musculoskeletal Disorders" @default.
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