Fortnightly review: work factors and upper limb disorders

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Abstract
In 1713, Ramazzini wrote of upper limb problems in professional writers (box).1 His observations of causative factors (prolonged static postures, highly repetitive work, psychological attributes of the work) and difficulties in treatment and management are still debated today. The diseases of persons incident to this craft arise from three causes: first constant sitting, second the perpetual motion of the hand in the same manner, and thirdly the attention and application of the mind …. Constant writing also considerably fatigues the hand and whole arm on account of the continual and almost tense tension of the muscles and tendons. I knew a man who, by perpetual writing, began first to complain of an excessive weariness of his whole right arm, which could be removed by no medicines, and which was at last succeeded by a perfect palsy of the whole arm. Ramazzini (1713)1 Precise identification of the tissue(s) responsible may be difficult in symptom based conditions. The non-specific soft tissue disorders may involve loss of grip and pinch strength, and nerve dysfunction, and are the source of concern, debate, and, often, litigation. Other disorders of the upper limb may allow a definite diagnosis. The diagnostic criteria used may depend on the setting—for example, sensitive criteria (low false negative rate) may be needed in an occupational setting and more highly specific criteria used in secondary or tertiary care to avoid overdiagnosis. Prospective studies support the relation between physical exposures in the work system and upper limb disorders.2 Some studies show a relation between increased exposure and increased response.3 4 There is some conflict between the epidemiological findings and current theory relating to underlying disease and possible mechanisms for the disorders under investigation.5 Current epidemiological evidence is often based on studies with weak designs.6 7 The consistency …