When Work is Related to Disease, What Establishes Evidence for a Causal Relation?

Learning from the Experience of the COVID-19 Pandemic: A New Paradigm for Occupational Biohazard Assessment and Management

The COVID-19 pandemic has affected workplaces in many different aspects. In this scenario, Occupational Physicians played a crucial role in assessing and managing the risk of SARS-CoV-2 infection and associated diseases to guarantee workers' health and the safety of workplaces. However, the pandemic experience has drawn attention to several critical issues in overall biohazard prevention and management strategies, originating from important knowledge gaps in our scientific understanding. An extensive analysis of the relevant hurdles that have emerged in our medical field can bring valuable lessons for the post pandemic future, not only in preparation for possible new pathogens with pandemic potential but also with principles and concepts applicable to managing all biological agents. In particular, a paradigm shift is needed to properly approach occupational diseases caused by infective agents, accurately define the "case", assess exposure and possible causal relationship with work appropriately, and effectively manage the specific risk through implementing appropriate preventive and protective measures. In this framework, the Occupational Physician should expand his contribution based on his unique expertise and specific competencies, confirming his role as the go-to consultant in all occupational health matters, but also in a multidisciplinary approach, considering different scientific expertise and evidence.

Prevalence of low back pain among Irish radiographers

BACKGROUND

According to the literature, low back pain (LBP) is one of the top ten diseases and injuries contributing to disability-adjusted life years worldwide. To the best of the authors' knowledge there are no studies investigating the prevalence of LBP among radiographers working in Ireland or have compared prevalence rates with the national population or other cohorts of radiographers or healthcare professionals. This study aimed to determine the prevalence of LBP among radiographers working or who have previously worked in Ireland and to identify any causative factors.

METHODS

A cross-sectional study in the form of an online questionnaire was developed. Participation was advertised online via social media platforms. Inclusion criteria included qualified radiographers working in Ireland or who had recently worked in Ireland. Section A of the questionnaire focussed on acquiring demographic data. Section B comprised eight questions relating to LBP, including current and previous experiences, causative factors and consequences. Further details on any episodes of LBP in the previous year, whether work and leisure activities had been affected, whether any extracurricular activities caused LBP, and whether a participant sought professional advice. Section C (six questions) used a 5-point ordinal scale to collect information on the frequency of specific tasks performed by radiographers in their daily roles. Section D involved exploratory questions, including whether LBP has forced a career change if they knew anyone who has changed their career as a result of LBP, reaction to the amount of manual handling required for radiographers, whether they thought manual handling training was sufficient, thoughts on the availability of assistive transfer devices, reasons for not following correct patient transfer guidelines, and finally whether they were concerned about LBP affecting their future.

RESULTS

151 radiographers participated in this study, and the point prevalence rate of LBP was 50%, with 12 months prevalence rate of 75%. Regarding activity levels, 25% (n=37) reported reduced work activity, and a further 43%(n=65) reduced leisure activities due to LBP. 37% (n=56) have sought medical advice from a doctor, physiotherapist, or other HCP concerning their LBP in the last year. 68% (n=104) of respondents who have LBP confirmed it was not a result of any extracurricular activities.

CONCLUSION

The prevalence of LBP among radiographers in Ireland was high and 4.7 times higher than the period prevalence rate recorded in the general population. LBP rates were similar to radiographers working in other jurisdictions. Data from this study may help manage LBP and monitor any interventions' effectiveness.

Towards harmonisation of case definitions for eight work-related musculoskeletal disorders - an international multi-disciplinary Delphi study

Background

International consensus is needed on case definitions of work-related musculoskeletal disorders and diseases (MSDs) for use in epidemiological research. We aim to: 1) study what information is needed for the case definition of work-related low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral and medial elbow tendinopathy, and knee and hip osteoarthritis, and to 2) seek consensus among occupational health professionals/researchers regarding the case definitions of these work-related MSDs.

Methods

A two-round Delphi study was conducted with occupational health professionals/researchers from 24 countries. Definition of work-related MSDs were composed of a case definition with work exposures. Round 1 included 32 case definitions and round 2, 60 case definitions. After two rounds, consensus required 75% of the panellists to rate a case definition including work exposures ≥7 points on a 9-point rating scale (completely disagree/completely agree).

Results

Fifty-eight panellists completed both rounds (response rate 90%). Forty-five (70%) panellists thought that for LBP a case definition can be based on symptoms only. Consensus was only reached for work-related medial elbow tendinopathy, while the lowest agreement was found for knee osteoarthritis. Where consensus was not reached, this was – except for LBP - related to physical examination and imaging rather than disagreement on key symptoms.

Conclusion

Consensus on case definitions was reached only for work-related medial elbow tendinopathy. Epidemiological research would benefit from harmonized case definitions for all MSDs including imaging and physical examination for LRS, SAPS, CTS, lateral elbow tendinopathy and hip and knee osteoarthritis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04871-9.

Diagnostic criteria for musculoskeletal disorders for use in occupational healthcare or research: a scoping review of consensus- and synthesised-based case definitions

Background

The aim of this study was to identify case definitions of diagnostic criteria for specific musculoskeletal disorders (MSDs) for use in occupational healthcare, surveillance or research.

Methods

A scoping review was performed in Medline and Web of Science from 2000 to 2020 by an international team of researchers and clinicians, using the Arksey and O’Malley framework to identify case definitions based on expert consensus or a synthesis of the literature. Seven MSDs were considered: non-specific low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral or medial elbow tendinopathy, and knee and hip osteoarthritis (OA). Case definitions for occupational healthcare or research were charted according to symptoms, signs and instrumental assessment of signs, and if reported, on work-related exposure criteria.

Results

In total, 2404 studies were identified of which 39 were included. Fifteen studies (38%) reported on non-specific LBP, followed by knee OA (n = 8;21%) and CTS (n = 8;21%). For non-specific LBP, studies agreed in general on which symptoms (i.e., pain in lower back) and signs (i.e., absence of red flags) constituted a case definition while for the other MSDs considerable heterogeneity was found. Only two studies (5%), describing case definitions for LBP, CTS, and SAPS and lateral and medial elbow tendinopathy respectively, included work-related exposure criteria in their clinical assessment.

Conclusion

We found that studies on non-specific LBP agreed in general on which symptoms and signs constitute a case definition, while considerable heterogeneity was found for the other MSDs. For prevention of work-related MSDs, these MSD case definitions should preferably include work-related exposure criteria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04031-z.

Gasoline-station workers in Brazil: Benzene exposure; Genotoxic and immunotoxic effects

Chronic exposure to benzene is a risk factor for hematological malignancies. Gasoline-station workers are exposed to benzene in gasoline, via both inhalation and dermal contact (attendants and managers) or inhalation (workers in the on-site convenience stores and offices). We have studied the exposure of these workers to benzene and the resulting genotoxic and immunotoxic effects. Levels of urinary trans, trans-muconic acid were higher among gasoline-station workers than among office workers with no known exposure to benzene (comparison group). Among the exposed workers, we observed statistically significant biological effects, including elevated DNA damage (comet assay); higher frequencies of micronuclei and nuclear buds (CBMN assay); lower levels of T-helper lymphocytes and naive Th lymphocytes; lower CD4 / CD8 ratio; and higher levels of NK cells and memory Th lymphocytes. Both groups of exposed workers (inhalation and inhalation + dermal routes) showed similar genotoxic and immunotoxic effects.

Elbow tendinopathy and occupational biomechanical overload: A systematic review with best-evidence synthesis

OBJECTIVES

To evaluate the evidence of an association between occupational and non-occupational exposure to biomechanical risk factors and lateral elbow tendinopathy, medial elbow tendinopathy, and olecranon bursitis.

METHODS

We carried out a systematic review of the literature. We searched MEDLINE (up to November 2019) and checked the reference lists of relevant articles/reviews. We aimed to include studies where (a) the diagnosis was based on physical examination (symptoms plus clinical signs) and imaging data (if any); and (b) the exposure was evaluated with video analysis and/or direct measurements. A quality assessment of the included studies was performed along with an evaluation of the level of evidence of a causal relationship.

RESULTS

We included four studies in the qualitative synthesis: two prospective cohorts and two cross-sectional studies. All the included studies investigated "lateral/medial epicondylitis", albeit the diagnosis was not supported by imaging techniques. Two cohort studies suggested that a combination of biomechanical risk factors for wrist/forearm is associated with increased risk of "lateral epicondylitis". This association was not observed in the two included cross-sectional studies. The cohort studies suggested that a Strain Index score higher than 5 or 6.1 could double the risk of "lateral epicondylitis". No association with increased risk of "medial epicondylitis" was observed.

CONCLUSIONS

There is limited evidence of a causal relationship between occupational exposure to biomechanical risk factors and lateral elbow tendinopathy. For medial elbow tendinopathy, the evidence is insufficient to support this causal relationship. No studies on olecranon bursitis and biomechanical overload were identified.

Work Disabling Nerve Injury at Both Elbows Due to Laptop Use at Flexible Workplaces inside an Office: Case-Report of a Bilateral Ulnar Neuropathy

Background: This case report describes whether a female civil servant who developed bilateral ulnar neuropathy can be classified as having an occupational disease. Methods: The Dutch six-step protocol for the assessment and prevention of occupational diseases is used. Results: Based on the six-step protocol, we propose that pressure on the ulnar nerve in the elbow region precipitated the neuropathy for this employee while working prolonged periods in elbow flexion with a laptop. Conclusion: Despite the low incidence laptop use might be a risk factor for the occurrence of ulnar neuropathy due to prolonged pressure on the elbow. Employers and workers need to be educated about this disabling occupational injury due to laptop use and about protective work practices such as support for the upper arm and elbow. This seems especially relevant given the trend of more flexible workspaces inside and outside offices, and given the seemingly safe appearance of laptop use.

Criteria for diagnosis and attribution of an occupational musculoskeletal disease

BACKGROUND

Criteria for diagnosis and compensation of occupational musculoskeletal diseases varies widely between countries as demonstrated by the large differences between countries with comparable economics and social systems (for example, within the European Union). Several countries have a list of occupational diseases and sometimes these lists include diagnostic and attribution criteria, but these criteria are usually not very specific, and they may also be very different.

OBJECTIVES

The aim of this paper is to explicitly define what are the information needed for an evidence-based diagnosis and attribution of an occupational musculoskeletal disease.

METHODS

Based on the general framework of evidence-based medicine, a review is presented of the information required to define: - when a musculoskeletal disease is present, according to the best available techniques; - how to define a relevant exposure to biomechanical risk factors, according to the best available techniques.

RESULTS

Criteria are presented to combine information regarding the diagnosis of a musculoskeletal disease and exposure to biomechanical risk factors for an evidence-based attribution of the disease to the occupational exposure. The criteria use a probabilistic model that combine epidemiologic and medical findings, workplace exposure assessment, and non-occupational factors evaluation.

DISCUSSION

The use of the proposed criteria may improve the process of diagnosis and attribution of an occupational musculoskeletal disease. In addition, it makes possible to associate a probability rank to the attribution and, ultimately, it may improve the overall quality of the decisional process of the occupational physician.

Work-relatedness of inguinal hernia: a systematic review including meta-analysis and GRADE

Purpose

Clinicians need to know whether inguinal hernia (IH) can be attributed to work to answer questions regarding prevention and medical causation. This review describes whether work-related risk factors are associated with IH.

Methods

A systematic review was performed in Medline via PubMed until February 3rd, 2020. Inclusion criteria were that IH was diagnosed by a clinician, and workers exposed to work-related risk factors were compared to workers less exposed or not at all. A quality assessment and a meta-analysis using Cochrane’s RevMan 5.3 were performed, including GRADE for quality of evidence.

Results

The search resulted in 540 references. Fourteen studies fulfilled the inclusion criteria, of which three were included in a meta-analysis, all three being of high quality, including 621 workers diagnosed with IH. The meta-analysis revealed significant associations with physically demanding work (OR 2.30, 95% CI 1.56–3.40). Two prospective studies, including 382 and 22,926 cases revealed associations that this was true for male workers with a lateral IH that reported standing or walking for more than six hours per workday (OR 1.45, 95% CI 1.12–1.88) or lifting cumulative loads of more than 4000 kg per workday (OR 1.32, 95% CI 1.27–1.38). The level of certainty for the latter two work-related risk factors was moderate and high according to GRADE.

Conclusion

Lateral IH among males is associated with work-related risk factors depending on the level of exposure to the time standing/walking per workday, or the amount of load lifted per workday.

Electronic supplementary material

The online version of this article (10.1007/s10029-020-02236-0) contains supplementary material, which is available to authorized users.

Cancer risk among career male and female Florida firefighters: Evidence from the Florida Firefighter Cancer Registry (1981-2014)

BACKGROUND

Firefighters are at increased risk for select cancers. However, many studies are limited by relatively small samples, with virtually no data on the cancer experience of female firefighters. This study examines cancer risk in over 100,000 career Florida firefighters including 5000 + females assessed over a 34-year period.

METHODS

Florida firefighter employment records (n = 109 009) were linked with Florida Cancer Data System registry data (1981-2014; ~3.3 million records), identifying 3760 male and 168 female-linked primary cancers. Gender-specific age and calendar year-adjusted odds ratios (aOR) and 95% confidence intervals for firefighters vs non-firefighters were calculated.

RESULTS

Male firefighters were at increased risk of melanoma (aOR = 1.56; 1.39-1.76), prostate (1.36; 1.27-1.46), testicular (1.66; 1.34-2.06), thyroid (2.17; 1.78-2.66) and late-stage colon cancer (1.19;1.00-1.41). Female firefighters showed significantly elevated risk of brain (2.54; 1.19-5.42) and thyroid (2.42; 1.56-3.74) cancers and an elevated risk of melanoma that approached statistical significance (1.68; 0.97-2.90). Among male firefighters there was additional evidence of increased cancer risk younger than the age of 50 vs 50 years and older for thyroid (2.55; 1.96-3.31 vs 1.69; 1.22-2.34), prostate (1.88; 1.49-2.36 vs 1.36; 1.26-1.47), testicular (1.60; 1.28-2.01 vs 1.47; 0.73-2.94), and melanoma (1.87; 1.55-2.26 vs 1.42; 1.22-1.66) cancers.

CONCLUSION

Male career firefighters in Florida are at increased risk for five cancers with typically stronger associations in those diagnosed younger than the age of 50, while there was evidence for increased thyroid and brain cancer, and possibly melanoma risk in female firefighters. Larger cohorts with adequate female representation, along with the collection of well-characterized exposure histories, are needed to more precisely examine cancer risk in this occupational group.

Work-relatedness of lumbosacral radiculopathy syndrome: Review and dose-response meta-analysis

OBJECTIVE

Clinicians need to know whether lumbosacral radiculopathy syndrome (LRS) can be attributed to work. This review describes what work-related risk factors are associated with LRS.

METHODS

A systematic review was performed in PubMed and Embase. Inclusion criteria were that LRS was diagnosed by a clinician and workers exposed to work-related risk factors were compared to workers less or not exposed. A quality assessment and a meta-analysis were performed, including a dose-response analysis.

RESULTS

The search resulted in 7,350 references and 24 studies that fulfilled the inclusion criteria: 19 studies were rated as having a high risk of bias and 5 as having a low risk of bias. The median number of LRS patients per study were 209 (interquartile range 124-504) and the total number of participants was 10,142. The meta-analysis revealed significant associations with heavy physically demanding work (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.48-2.79), bending or twisting of the trunk (OR 2.43, 95% CI 1.67-3.55), and lifting and carrying in combination with bending or twisting of the trunk (OR 2.84, 95% CI 2.18-3.69). No significant associations were found for professional driving (OR 1.46, 95% CI 0.90-2.35) or sitting (OR 1.08, 95% CI 0.49-2.38). A dose-response relation was present per 5 years of exposure for bending (OR 1.12, 95% CI 1.04-1.20), lifting (OR 1.08, 95% CI 1.02-1.14) and the combination of bending and lifting (OR 1.14, 95% CI 1.01-1.29).

CONCLUSIONS

Moderate to high-quality evidence is available that LRS can be classified as a work-related disease depending on the level of exposure to bending of the trunk or lifting and carrying. Professional driving and sitting were not significantly associated with LRS.

Work-related risk factors for specific shoulder disorders: a systematic review and meta-analysis

The objective of this systematic review and meta-analysis is to examine which work-related risk factors are associated with specific soft tissue shoulder disorders. We searched the electronic databases of Medline and Embase for articles published between 2009 and 24 March 2016 and included the references of a systematic review performed for the period before 2009. Primary cross-sectional and longitudinal studies were included when outcome data were described in terms of clinically assessed soft tissue shoulder disorders and at least two levels of work-related exposure were mentioned (exposed vs less or non-exposed). Two authors independently selected studies, extracted data and assessed study quality. For longitudinal studies, we performed meta-analyses and used GRADE (Grades of Recommendations, Assessment, Development and Evaluation) to assess the evidence for the associations between risk factors and the onset of shoulder disorders. Twenty-seven studies met the inclusion criteria. In total, 16 300 patients with specific soft tissue shoulder disorders from a population of 2 413 722 workers from Denmark, Finland, France, Germany and Poland were included in the meta-analysis of one case-control and six prospective cohort studies. This meta-analysis revealed moderate evidence for associations between shoulder disorders and arm-hand elevation (OR=1.9, 95% CI 1.47 to 2.47) and shoulder load (OR=2.0, 95% CI 1.90 to 2.10) and low to very low evidence for hand force exertion (OR=1.5, 95% CI 1.25 to 1.87), hand-arm vibration (OR=1.3, 95% CI 1.01 to 1.77), psychosocial job demands (OR=1.1, 95% CI 1.01 to 1.25) and working together with temporary workers (OR=2.2, 95% CI 1.2 to 4.2). Low-quality evidence for no associations was found for arm repetition, social support, decision latitude, job control and job security. Moderate evidence was found that arm-hand elevation and shoulder load double the risk of specific shoulder disorders. Low to very-low-quality evidence was found for an association between hand force exertion, hand-arm vibration, psychosocial job demands and working together with temporary workers and the incidence of specific shoulder disorders.

Occupational Exposure to Knee Loading and the Risk of Osteoarthritis of the Knee: A Systematic Review and a Dose-Response Meta-Analysis

BACKGROUND

Osteoarthritis of the knee is considered to be related to knee straining activities at work. The objective of this review is to assess the exposure dose-response relation between kneeling or squatting, lifting, and climbing stairs at work, and knee osteoarthritis.

METHODS

We included cohort and case-control studies. For each study that reported enough data, we calculated the odds ratio (OR) per 5,000 hours of cumulative kneeling and per 100,000 kg of cumulative lifting. We pooled these incremental ORs in a random effects meta-analysis.

RESULTS

We included 15 studies (2 cohort and 13 case-control studies) of which nine assessed risks in more than two exposure categories. We considered all but one study at high risk of bias. The incremental OR per 5,000 hours of kneeling was 1.26 (95% confidence interval 1.17-1.35, 5 studies, moderate quality evidence) for a log-linear exposure dose-response model. For lifting, there was no exposure dose-response per 100,000 kg of lifetime lifting (OR 1.00, 95% confidence interval 1.00-1.01). For climbing, an exposure dose-response could not be calculated.

CONCLUSION

There is moderate quality evidence that longer cumulative exposure to kneeling or squatting at work leads to a higher risk of osteoarthritis of the knee. For other exposure, there was no exposure dose-response or there were insufficient data to establish this. More reliable exposure measurements would increase the quality of the evidence.

Myoclonic seizure prior to diagnosis of chronic toxic encephalopathy: a case report

Background

“Thinner” is a widely used industrial mixture of organic solvents. Exposure to organic solvents is usually not considered to be a possible cause of epilepsy, despite descriptions of toxic effects on the central nervous system. There are only a few reports about a possible epileptogenic effect of organic solvents exposure. We report a case of myoclonic seizure at the workplace that shows a remarkable coincidence between exposure to a thinner mixture and the occurrence of an epileptic seizure.

Case presentation

We present the case of a 50-year-old Belgian woman exposed to organic solvents for more than 20 years in a paintbrush manufactory. In 2009, her biological monitoring of hippuric acid (primary urinary metabolite of toluene) exceeded the threshold limit value of the American Conference of Governmental Industrial Hygienists.

In 2012, after a period of high organic solvents exposure without the use of proper collective or personal airway protection, she had a seizure with myoclonic movements of her four limbs and loss of consciousness at her workplace. An electroencephalogram, computed tomography and magnetic resonance imaging of her head were within limits. Non-toxicological and toxicological causes were investigated. Her seizures did not reappear after workplace removal.

Two years after her epileptic insult she was diagnosed with chronic toxic encephalopathy type 2b.

In 2015, volatile organic compounds were measured at her workplace. Multiple (3/18) air samples exceeded the Belgian time-weighted average over 8 hours (77 mg/m³) for toluene.

Conclusions

Knowledge about the impact of solvent exposure on the occurrence of epileptic insults is lacking. Long-term exposure to organic solvents is usually not considered to be a possible cause of epileptic seizure. But epileptic discharges have been described on electroencephalogram recordings for patients with chronic toxic encephalopathy. Myoclonic encephalopathy has been reported in toxic conditions.

This case emphasizes a possible unusual neurological presentation of occupational exposure to organic solvents. It may be explained by lowering of the threshold for seizures due to high solvents exposure, most probably by toluene. This case suggests a chronological connection between a high occupational exposure to solvents and an epileptic insult. We found no other plausible cause.

Reducing the underreporting of lung cancer attributable to occupation: outcomes from a hospital-based systematic search in Northern Italy

PURPOSE

Occupational exposure to lung carcinogens is and was common in workplaces. 5-25 % of lung cancers (LCs) could be causally attributable to occupation; however, LC underreporting and undercompensation are widespread, with remarkable tolls paid by individuals and society. This work aims to: describe an ongoing hospital-based systematic search (SS) of occupational LC; improve aetiological diagnosis; increase number and quality of LC notifications.

METHODS

Through a short form, physicians at a public hospital referred incident LC to the Occupational Health Unit (OHU). Only patients selected through the form were interviewed; a personal, occupational and clinical history was collected; reports were sent to the ward and Local Health Authority, with aetiological diagnosis criteria and probability of causation.

RESULTS

From 1998 to 2013, 3274 cases of LC were notified to the OHU; prior to the system, just couple of dozens were assessed. A total of 1522 patients were fully interviewed; in 395 cases, causation was attributed to occupation (26 % of interviewed patients); all were notified to authorities, as compared to the handful reported before the system was adopted. Main aetiological agents were silica, asbestos, polycyclic aromatic hydrocarbons, truck driving, painting, multiple exposures. Compensation rate was remarkable (39 %).

CONCLUSIONS

Through SS, many occupational LCs were found that otherwise would have been lost. Aetiological diagnosis proved to be rich of scientific advantages and practical implications, with attention to equity and social aspects. SS was easy, accountable and fostered multidisciplinary collaboration among medical specialties, significantly reducing underreporting and undercompensation of occupational LC.

Exposure Reconstruction and Risk Analysis for Six Semiconductor Workers With Lymphohematopoietic Cancers

OBJECTIVE

To investigate whether workplace exposures to recognized lymphohematopoietic carcinogens were possibly related to cancers in six semiconductor-manufacturing workers.

METHODS

A job-exposure matrix was developed for chemical and physical process agents and anticipated by-products. Potential cumulative occupational exposures of the six cases were reconstructed. The role of workplace exposures in cancer was evaluated through quantitative risk assessment and by comparison with epidemiological literature.

RESULTS

Two workers were potentially exposed to agents capable of causing their diagnosed cancers. Reconstructed exposures were similar to levels in outdoor environments and lower than exposures associated with increased risks in epidemiological studies. Cancer risks were estimated to be less than 1 in 10,000 persons.

CONCLUSIONS

The development of cancer among the six workers was unlikely to be explained by occupational exposures to recognized lymphohematopoietic carcinogens.

Caracterização do nexo técnico epidemiológico pela perícia médica previdenciária nos benefícios auxílio-doença

Introdução o Nexo Técnico Epidemiológico Previdenciário (NTEP) modificou a caracterização da etiologia ocupacional de agravo que justifica benefício previdenciário auxílio-doença no Brasil. Objetivo descrever o perfil de requerimentos em que houve indicação de NTEP pelo sistema previdenciário e analisar fatores associados à caracterização/descaracterização do nexo pela perícia médica. Métodos estudo retrospectivo analítico, com amostra de 822 laudos médicos periciais emitidos em São Paulo, entre 2008 e 2011. Realizada regressão logística para avaliar a associação entre a caracterização do NTEP e sexo, idade e diagnóstico incapacitante. Resultados o perfil dos segurados foi de homens (60,6%), na faixa etária de 30-39 anos (31,8%), com lesão por causa externa (35,0%). Foi descaracterizado o NTEP em 59% das situações, a maioria devido ao relato dos trabalhadores de que a lesão não tinha ocorrido no trabalho (70,9%). Houve associação entre a caracterização do NTEP e o diagnóstico da doença incapacitante, principalmente em relação aos distúrbios osteomusculares (OR 7,45; IC 95% 4,88-11,38). Conclusão o diagnóstico é um fator fortemente associado à aplicação do NTEP pela perícia médica. Há uma descaracterização frequente da espécie acidentária nos requerimentos, o que pode minimizar a justiça social ao trabalhador lesionado em decorrência do exercício do seu trabalho.

Work-relatedness of low back pain in nursing personnel: a systematic review

BACKGROUND

Although non-specific low back pain (LBP) is known to be multifactorial, studies from across the globe have documented their higher prevalence in nurses. This systematic review was conducted to ascertain whether this much-documented association constitutes a causal relationship, and whether there is a discernible threshold of exposures associated with this elevated risk.

METHODS

PRISMA guidelines were followed and standard critical appraisal tools were applied. The outcome of interest was non-specific LBP or back injury; exposure was "performing nursing duties." Applicable studies, published in English during 1980-2012, were identified through database searches, screened against preset inclusion/exclusion criteria. Ergonomic assessments of nursing tasks were included along with epidemiological studies. Bradford Hill considerations for causation were utilized as a framework for discussing findings.

FINDINGS

Of 987 studies identified, 89 qualified for inclusion, comprising 21 longitudinal, 36 cross-sectional analytic, 23 descriptive biomechanical/ergonomic, and 9 review studies. Overall studies showed that nursing activities conferred increased risk for, and were associated with back disorders regardless of nursing technique, personal characteristics, and non-work-related factors. Patient handling appears to confer the highest risk, but other nursing duties are also associated with elevated risk, and confound dose-response assessments related to patient handling alone. Associations were strong, consistent, temporally possible, plausible, coherent, and analogous to other exposure-outcomes, with risk estimates ranging from 1·2 to 5·5 depending on definitions. A threshold of nursing activities below which the risk of back disorders is not elevated has not been established.

INTERPRETATION

Notwithstanding the bio-psycho-social nature of LBP, and complexities of studying this area, sufficient evidence exists of a causal relationship between nursing tasks and back disorders to warrant new policies.