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Occupational Medicine Advance Access originally published online on December 6, 2006
Occupational Medicine 2007 57(2):104-111; doi:10.1093/occmed/kql141
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© The Author 2006. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Comparison of sensorineural symptoms between UK orthopaedic surgeons and gynaecologists

SC Roberts1, K Harrild2, J Mollison2, E Murphy3 and GP Ashcroft1

1 Department of Orthopaedics, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZB, UK
2 Department of Public Health, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZB, UK
3 Department of Environmental & Occupational Medicine, University of Aberdeen, Liberty Safe Work Research Centre, Foresterhill Road, Aberdeen AB25 2ZB, UK

Correspondence to: S. C. Roberts, Department of Orthopaedics, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZB, UK. Tel: +44 1224 553004; fax: +44 1224 555199; e-mail: sam.roberts{at}doctors.org.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background We have previously described significant differences in self-reported neurological symptoms of orthopaedic surgeons when compared to a group of gynaecologists. We suggested that this may be secondary to occupational sources of hand-transmitted vibration. The original study was intentionally brief and failed to address potential confounders.

Aims To compare the prevalence of sensorineural symptoms between UK orthopaedic surgeons and gynaecologists and adjust for potential confounding factors.

Methods Postal questionnaires were sent to 2040 members of the British Orthopaedic Association and 1797 members of the Royal College of Gynaecologists requesting information about demographics and self-reported neurological symptoms. Demographics of the orthopaedic surgeons and gynaecologists were compared using chi-squared tests and independent t-tests. Multiple logistic regressions were carried out to compare the prevalence of symptoms while adjusting for potential confounding factors.

Results Differences in the demographic profile of the orthopaedic surgeons and gynaecologists were identified: orthopaedic surgeons were predominantly male, were more junior in grade, were younger, used double gloving more often, had larger glove size, were more likely to be ambidextrous, to use vibrating tools outside of work and to consume greater amounts of alcohol. Orthopaedic surgeons reported a higher prevalence of tingling and numbness of fingers while at work and at other times. These differences were significant even after adjusting for potential confounding factors.

Conclusion Observed differences could be related to exposure to hand-transmitted vibration at work. Further assessment of risk to orthopaedic surgeons from hand-held power tools used in the course of their work is recommended.

Keywords      Hand-transmitted vibration; occupational health; orthopaedic surgeons; power tools; sensorineural symptoms; upper limb


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Orthopaedic surgeons are a unique group within the medical profession using hand-held air and electric powered tools in the course of their work, thus exposing them to vibration. We previously described differences in self-reported neurological, but not vascular symptoms, of orthopaedic surgeons when compared to gynaecologists [1]. Gynaecologists were chosen as a comparison group since they are not usually exposed to orthopaedic practice during their training. General surgeons were considered for use as a comparison group, as we thought they would be more similar to orthopaedic surgeons. However, during the current training system that exists in the UK, general surgeons usually spend at least 6 months as an orthopaedic senior house officer. It was believed to be of greater importance that the group was more likely to have no exposure to vibration at work than have potential differences in demographic characteristics. Air-powered saws used in routine orthopaedic practice were tested in a laboratory setting. The testing showed that with limited tool use, orthopaedic surgeons could be exposed to vibration levels known to result in symptoms of hand–arm vibration syndrome (HAVS) in other industries [1].

A new European Directive [2] governing exposure to physical agents, including vibration, came into force in the UK on the 6 July 2005. This directive forced an update to health and safety law in the UK, with the Health & Safety Executive (HSE) instituting the Control of Vibration at Work Regulations 2005 [3] replacing the previous regulation HSG88—Hand–Arm Vibration [4]. The new regulations have resulted in a reduction of the daily action level of vibration exposure to 2.5 ms–2. Based on this new limit, and using the HSE Hand–Arm Vibration Exposure Calculator [5], we have calculated that orthopaedic surgeons could breach the daily vibration action limit after only 26 min of tool usage in 1 day. This calculation is based on a typical vibration acceleration of 9.97 ms–2 produced by orthopaedic saws which has been reported [1]. This figure was measured using the now superseded British Standards Institute (BSI) standard BS 6842:1987 [6]. In calculating the figure of 26 min tool usage, the BSI measurement was converted to the International Organization for Standardization (ISO) standard, ISO 5349-1 [7] (the standard to which the new HSE regulations relate). The ISO 5349-1 measure of the vibration accelerations produced by orthopaedic saws was calculated as 10.7 ms–2.

Typical durations of exposure for orthopaedic surgeons are difficult to ascertain because duration varies with the operation being performed and the patient being operated on. In preparing for this study, we observed surgeons performing operations using the tools in question. Usage per operation varied widely from <30 s to in excess of 6 min. The number of operations in a day also varied with up to five being performed. We believe that it is possible for surgeons to frequently approach and exceed 26 min of tool use in 1 day.

The previous study was a pilot designed to ascertain symptom prevalence only. Simple demographics were not requested in order to keep the questionnaire brief and to maximize the response rate. The study that is reported here had two aims: to describe and compare the demographics of UK orthopaedic surgeons with UK gynaecologists and to compare neurological symptoms of the two groups while adjusting for potential confounding factors.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
A postal questionnaire was designed based on the HAVS health surveillance questionnaire published by the Faculty of Occupational Medicine, Royal College of Physicians of England (1993) [8]. A number of questions requesting details of any neurological symptoms experienced by the participants were included. Only one question relating to vascular symptoms was included because the previous survey had shown no difference between the groups. Participant's demographics were requested including previous medical history and details relating to orthopaedic surgical practice. The questionnaire was designed to be completed within 5 min, with minimal writing.

Orthopaedic surgeons and gynaecologists were identified from mailing lists provided by the British Orthopaedic Association (BOA) and the Royal College of Obstetricians and Gynaecologists (RCOG). Permission was obtained to send questionnaires to all consultants and trainees. The use of these mailing lists did not breach the Data Protection Act 1998, as members of both these organizations were advised that their details may be used for this purpose and were given the opportunity to exclude the use of their name. No inducements were offered; however, we provided freepost business reply envelopes. Mailings were carried out over a 2-month period commencing April 2001. Ethics committee approval was not sought because when the research protocol was written in 2000, the guidelines of our local ethics committee, Grampian Research Ethics Committee, stated that ethics approval was not required for surveys of NHS staff. This view was also accepted by the body that awarded the grant for this project, the Chief Scientist Office of the Scottish Executive Health Department.

Questionnaires were read using a standard desktop personal computer running a specialist optical character recognition (OCR) software package (Eyes and Hands, Readsoft AB, Helsingborg, Sweden). A 10% sample of questionnaires was checked for accuracy.

Statistical analysis was performed using SPSS 11.5 for Windows. Demographics of the orthopaedic surgeons and gynaecologists were compared using {chi}2 tests (including Pearson's and tests for trend, with continuity corrections and exact tests as required), except for age, which was compared using an independent t-test. Multiple logistic regression was carried out to compare the prevalence of symptoms while adjusting for the following potential confounding factors: age, gender, smoking status, alcohol consumption and use of powered tools outside of work. The adjusted P-value relates to the Wald statistic for speciality in the multiple logistic regression model.

Assumptions had to be made about hand dominance, due to a large proportion of respondents failing to answer the relevant question. Given that surgical instruments are generally designed to be used in the right hand, it was decided to assume that individuals who claimed to be ambidextrous, or had failed to answer, were right handed. Therefore, sensitivity analyses were carried out by repeating the multiple logistic regression excluding people who replied that they were ambidextrous, and then in addition excluding people who did not answer the question relating to hand dominance. Data are presented as absolute number (percentage) unless otherwise stated.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
Of the names received from BOA and RCOG, those individuals who resided outside the UK or had incomplete mailing addresses were excluded. A total of 137 questionnaires were returned unopened due to inaccuracies of addresses (the majority were no longer known at the supplied address). The number of surveys sent and returned is represented diagrammatically (Figure 1). Response rates of 44 and 39% were achieved for orthopaedic surgeons and gynaecologists, respectively.


Figure 1
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  		Figure 1. Diagram of questionnaire return.

 
A difference in the demographic profile was found between the two professional groups (Table 1). The orthopaedic group had a significantly greater proportion of males than females, were more junior in grade, were younger, used double gloving more often, had larger glove size, were more likely to use vibrating tools outside of work and consumed greater amounts of alcohol. Differences between the groups also existed in ethnicity, scrubbing technique and surgical scrub solution used. With regard to handedness, more orthopaedic surgeons claimed to be ambidextrous.


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  		Table 1. Demographics/characteristics of respondents

 
Table 2 presents the prevalence of neurological symptoms with unadjusted and adjusted odds ratios and their 95% confidence intervals in the dominant and non-dominant hands of the study and control groups. Symptoms which were statistically more prevalent in orthopaedic surgeons were tingling of fingers while working, and at other times, and numbness in fingers while working, and at other times. Symptoms were more prevalent in the dominant hand. Interestingly cold neither increased symptoms in orthopaedic surgeons nor caused blanching, indeed gynaecologists had greater prevalence of numbness in response to cold. Orthopaedic surgeons were also more likely to have difficulty with fine movements of fingers, but in their dominant hand only. This could be an important finding as this symptom is often seen in cases of HAVS [9,10]. However, this finding must be interpreted cautiously due to the low numbers of respondents reporting this symptom.


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  		Table 2. Neurological symptoms of respondents

 
Twenty-one per cent of respondents missed out the question with respect to hand dominance. Along with individuals claiming to be ambidextrous, these people were assumed to be right handed. Sensitivity analysis showed that these assumptions did not materially affect the estimates of odds ratios for the prevalence of symptoms (data not shown, but available upon request).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
This paper has shown a greater prevalence of neurological symptoms in the hands of orthopaedic surgeons, a group of health care workers regularly exposed to hand-transmitted vibration, in comparison to gynaecologists a group of health care workers not routinely exposed to hand-transmitted vibration. Specifically, orthopaedic surgeons reported greater tingling and numbness of fingers while working, which was more prevalent in the dominant hand. These symptoms were also more prevalent at other times, indicating that this is not just a transient phenomenon for some. These results are similar to a survey previously presented [1]. Cold does not appear to be a trigger for these symptoms as cold-induced symptoms (both neurological and vascular) were more prevalent in gynaecologists.

There were numerous differences in the demographics of the two groups; however, after adjusting for confounding factors, and after performing sensitivity analyses, the prevalence of symptoms in orthopaedic surgeons remains statistically different. The most significant difference between the groups is the male preponderance with >95% of orthopaedic respondents male versus only 68% in the gynaecology group. This was not unexpected, as anecdotally orthopaedic surgery tends to be a male-dominated speciality. The study could have been restricted to men but this would have generalized results to male orthopaedic surgeons.

The group of orthopaedic surgeons had significantly more middle graders (registrars and others) than the gynaecologists. If both groups had a shared occupational cause for their symptoms then one would expect that the group with more experience, i.e. the group with a greater number of consultants, would have a greater prevalence of symptoms. However, this was not the case in this survey.

Looking at differences in surgical practice, there were some significant differences anticipated. Orthopaedic surgeons were more likely to double glove and tended to wear larger gloves. These factors could not have been excluded in study design, but both these differences could potentially be a cause for the increased prevalence of symptoms.

With regard to previous medical history, the only significant difference was upper limb peripheral nerve entrapment though it is not known which nerve was affected. The most likely would be the median nerve causing carpal tunnel syndrome. Considering this condition is more common in females [11], the group with more females would be expected to have a higher prevalence. However, it is in fact the group with the fewest females, i.e. orthopaedic surgeons, which has the highest prevalence. It may be that orthopaedic surgeons have misdiagnosed their neurological symptoms as a peripheral nerve entrapment syndrome or alternatively the peripheral nerve entrapment may be a consequence of vibration exposure. Carpal tunnel syndrome may be caused by hand-transmitted vibration [8,12].

This was a large UK national survey with a response rate of only 44 and 39%. This introduces the problem of response bias for individuals who had symptoms. However, as gynaecologists had a greater prevalence of symptoms in response to cold, this may equilibrate the effect of response bias. The survey requested information about use of specific tools at work; therefore orthopaedic surgeons would have known that they were the study group, again raising the possibility of response bias. However, despite this potential for bias the prevalence rate of neurological symptoms in the vibration-exposed group (16–29%) versus the vibration-non-exposed group (6–14%) compares favourably with a national survey of all occupations [13], which reports prevalence rates of 22 and 13%, respectively. This may suggest the effect of response bias was negligible. However, since there was no information about the non-responders in this survey, caution must be taken when generalizing our results, as their characteristics may differ from those that responded.

This was a survey of self-reported symptoms with no objective measurement of disease. The diagnosis of HAVS requires a thorough clinical assessment including exposure history and examination. Furthermore, the study design cannot show a causal relationship between vibration and symptoms. Therefore, the work that has been presented in this paper alone does not prove or disprove a link between hand-transmitted vibration and the prevalence of neurological symptoms in orthopaedic surgeons. However, taking into account the data on vibration produced by hand-held orthopaedic saws [1] there is a strong argument that there may be a link.

It could be argued that as the highest odds ratios for symptoms occurred while at work, the problems experienced are mainly transient. As such, the symptoms could be related to tool use and other ergonomic issues such as force used, posture and repetitive activity. If the symptoms are connected to ergonomics, then altering the tool design may resolve the issue. Further investigations and risk assessments would likely reveal whether symptoms are related to these ergonomic issues.

We know of only one previous study looking at the effect of hand-transmitted vibration on orthopaedic surgeons [14], which concluded there was no risk. However, this study made this conclusion based on measured vibration accelerations of equipment falling within the safe limit for the average time that the equipment was used. The average time was based on only 54 individuals and did not look at any symptoms that may be attributed to vibration. Furthermore, the tools which were tested were not the same as the tools that we have previously reported on [1].

HAVS is an occupational disease that normally affects manual workers exposed to vibration. The understanding of this disease is constantly changing but it is accepted that sufferers can be affected by three types of symptoms: vascular, neurological and musculoskeletal [8,15,16]. Until relatively recently, it was believed that all these symptoms occurred concomitantly and no one symptom could exist exclusively. Moreover, the symptoms which were thought to be most disabling were the vascular symptoms; as such in the UK only the vascular symptoms of HAVS is a prescribed disease [12,17,18].

There is now evidence to support that the different components of HAVS may exist individually [8,16,19,20]. In a change to previous practice, the process to compensate ex-coal workers in the UK, now compensates for sensorineural symptoms [17,21]. The Industrial Injuries Advisory Council has also recommended for a second time that the sensorineural symptoms become a prescribed disease [19]. It is also becoming evident that the neurological symptoms are possibly more disabling than the vascular symptoms [22,23]. A number of studies have looked at vibration-exposed workers who work in tropical climates [24–26]. These workers appear to suffer mainly from neurological symptoms, with no increase in prevalence of vascular symptoms compared to controls. These findings may suggest why the orthopaedic surgeons in this study experienced a higher prevalence of neurological symptoms without the presence of finger blanching.

The Control of Vibration at Work Regulations 2005 requires that employers perform a risk assessment for all workers exposed to vibration [2,3], ensuring no individual exceeds the daily exposure action limit [2,3,5]. If this condition is breeched then detailed records of vibration exposure must be kept for each employee and a more detailed risk assessment must be performed. A health surveillance programme must also be initiated if an employee has symptoms that, it is thought, have probably been caused by exposure to vibration in the workplace.

The results of this study have significant implications for the occupational health of orthopaedic surgeons. In addition, if surgeons are experiencing symptoms while operating it also raises questions about patient safety. Based on the recommendations of the European Directive 2002/44/EC, the results of this survey and previous work [1], we believe that an extensive risk assessment of orthopaedic power tools needs to be performed including in vivo testing of orthopaedic tools. Evaluation of impact has not been made but clearly there may be a requirement to implement health surveillance where exposure assessments indicate high levels of daily exposure. The rationale for this is (i) in vitro testing has shown that orthopaedic surgeons may be at risk from hand-transmitted vibration [1], (ii) manufacturers of orthopaedic power tools do not supply information about the vibration accelerations produced by these tools, (iii) we have presented evidence demonstrating that the prevalence rate of neurological symptoms experienced by orthopaedic surgeons is greater than the rate experienced by a group of professionals working in a similar environment but not exposed to vibration. We believe that it is probable that this is as a result of exposure to vibration in the workplace.

A full risk assessment and redesign of any potential ergonomic factors is a long-term solution to the problem and will not protect orthopaedic surgeons immediately. A possible preventative strategy would be for symptomatic surgeons to delegate more tasks to trainees so that vibration exposure could be spread more equally between individuals. If this failed to reduce symptoms then other changes to working practices could be considered such as changing the case mix balance of patients seen by surgeons to favour operations that would not require the use of vibrating tools.


Key points
  • Orthopaedic surgeons are a group of workers who are exposed to hand-transmitted vibration and report a higher prevalence of sensorineural symptoms compared with a group working in a similar environment but not exposed to occupational vibration.
  • The survey suggests that the symptoms reported by orthopaedic surgeons are probably related to exposure to occupational sources of hand-transmitted vibration.
  • The European Directive 2002/44/EC requires that if a worker complains of symptoms and it is probable that this is related to an occupational hazard then a risk assessment should be performed. A full risk assessment of exposure to hand-transmitted vibration from the use of hand-held powered orthopaedic tools is recommended.

 


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. Roberts SC, Koti M, Ashcroft GP, Gorman DG. (2001) Assessment of risk to orthopaedic surgeons from hand-transmitted vibration. J Bone Joint Surg Br 83-B:(Suppl. III), 343–344.

  2. European The. (2002) Parliament and The Council. Directive 2002 /44/EC. Off J Eur Commun 45:L 17713–19.

  3. Health and Safety Executive. (2005) Statutory Instruments 2005 No. 1093: The Control of Vibration at Work Regulations 2005(The Stationery Office Books, London).

  4. Health and Safety Executive. (1994) Hand-Arm Vibration HSG88(HSE Books, Sudbury).

  5. Health and Safety Executive. Hand-Arm Vibration Calculator, Version 3. 2005 http://www.hse.gov.uk/vibration/hav/hav.xls (17 August, 2005 date last accessed).

  6. Standards British. (1987) Institution. Guide to Measurement and Evaluation of Human Exposure to Vibration Transmitted to the Hand: BS 6842:1987 1st edn (BSI, London).

  7. International Organization for Standardization. (2001) Mechanical Vibration: Measurement and Evaluation of Human Exposure to Hand-Transmitted Vibration: Part 1: General RequirementsInternational standard ISO 5349-1, Geneva pp. 1–24.

  8. Faculty of Occupational Medicine of the Royal College of Physicians. (1993) Hand-Transmitted Vibration: Clinical Effects and Pathophysiology 1st edn (The Royal College of Physicians of London, Great Britain).

  9. Toibana N, Ishikawa N, Sakakibara H. (2002) Measurement of manipulative dexterity in patients with hand-arm vibration syndrome. Int Arch Occup Environ Health 75:106–110.[Web of Science][Medline]

  10. Palmer KT, Griffin MJ, Syddall H, Cooper C, Coggon D. (2002) The clinical grading of Raynaud's phenomenon and vibration-induced white finger: relationship between finger blanching and difficulties in using the upper limb. Int Arch Occup Environ Health 75:29–36.[Web of Science][Medline]

  11. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hubbard R. (2004) Risk factors in carpal tunnel syndrome. J Hand Surg [Br] 29:315–320.[CrossRef][Medline]

  12. Department for Work and Pensions. (2004) A Guide to Industrial Injuries Disablement Benefits DB1 edn (DWP Communications, Leeds).

  13. Palmer KT, Griffin MJ, Bendall H, Pannett B, Cooper C, Coggon D. (2000) The prevalence of sensorineural symptoms attributable to hand-transmitted vibration in Great Britain: a national postal survey. Am J Ind Med 38:99–107.[CrossRef][Web of Science][Medline]

  14. Mirbod SM, Yoshida H, Inaba R, Iwata H. (1993) Exposure to segmental vibration and noise in orthopaedists. Ind Health 31:155–164.[Web of Science][Medline]

  15. Gemne G, Pyykko I, Taylor W, Pelmear PL. (1987) The Stockholm Workshop scale for the classification of cold-induced Raynaud's phenomenon in the hand-arm vibration syndrome (revision of the Taylor-Pelmear scale). Scand J Work Environ Health 13:275–278.[Web of Science][Medline]

  16. Brammer AJ, Taylor W, Lundborg G. (1987) Sensorineural stages of the hand-arm vibration syndrome. Scand J Work Environ Health 13:279–283.[Web of Science][Medline]

  17. McGeoch KL, Lawson IJ, Burke F, Proud G, Miles J. (2005) Diagnostic criteria and staging of hand-arm vibration syndrome in the United Kingdom. Ind Health 43:527–534.[CrossRef][Web of Science][Medline]

  18. Taylor W. (1985) Vibration white finger: a newly prescribed disease. Br Med J (Clin Res Ed) 291:921–922.

  19. Industrial Injuries Advisory Council. (2004) Hand-Arm Vibration Syndrome: Report by the Industrial Injuries Advisory Council in Accordance with Section 171 of the Social Security Administration Act 1992 Reviewing the Prescription of the Vascular and Sensorineural Components of Hand-Arm Vibration Syndrome Cm 6098 edn (The Stationary Ofiice, Norwich).

  20. Tyler LE, Lawson IJ, McGaig RH. Faculty of Occupational Medicine of the Royal College of Physicians. (1993) Classification and staging of vascular and neurological symptoms of hand-arm vibration syndrome. . Hand-Transmitted Vibration: Clinical Effects and Pathophysiology. Part 2: Background Papers to the Working Party Report 1st edn (The Royal College of Physicians of London, Great Britain) pp. 55–60.

  21. Lawson IJ and McGeoch KL. (2003) A medical assessment process for a large volume of medico-legal compensation claims for hand-arm vibration syndrome. Occup Med (Lond) 53:302–308.

  22. Mason HJ, Poole K, Elms J. (2005) Upper limb disability in HAVS cases—how does it relate to the neurosensory or vascular elements of HAVS? Occup Med (Lond) 55:389–392.

  23. Poole K and Mason H. (2005) Disability in the upper extremity and quality of life in hand-arm vibration syndrome. Disabil Rehabil 27:1373–1380.[CrossRef][Web of Science][Medline]

  24. Yamamoto H, Zheng KC, Ariizumi M. (2002) A study of the hand-arm vibration syndrome in Okinawa, a subtropical area of Japan. Ind Health 40:59–62.[Web of Science][Medline]

  25. Futatsuka M, Inaoka T, Ohtsuka R, Sakurai T, Moji K, Igarashi T. (1995) Hand-arm vibration in tropical rain forestry workers. Cent Eur J Public Health 3:(Suppl.), 90–92.

  26. Futatsuka M, Shono M, Sakakibara H, Quoc Quan P. (2005) Hand arm vibration syndrome among quarry workers in Vietnam. J Occup Health 47:165–170.[CrossRef][Web of Science][Medline]


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