These draft guidelines cut through the unfounded professional attitudes to back pain including: bogus diagnoses, illegitimate statements about causation, alarmist prognoses, prognoses based on bio mechanical models and so on. Application of the guidelines should see greater accuracy of medical care and reductions in liability exposure, but only if they are used. Evidence from: N Bogduk. Draft- Evidence-Based Clinical Guidelines For The Management Of Acute Low Back Pain Table 6.1  of the draft guidelines is reproduced in the Radar report. It details which factors really do influence prognosis. The Radar report is available to subscribers: 1#12 1

In principle, the NHS+ service will broaden reasonably practicable access to health screening, pre placement medicals , rehabilitative expertise and guidance on prevention. There will be less acceptance of SME’s not doing the right thing. A small change in liability insurance exposure is foreseeable. NHS+ Launch 19th November 2001 NHS+ is an Occupational Health service now being offered by NHS Trusts to their local communities in exchange for money. Any profits should be reinvested in the local service, there is no central organisation taking money out of the local schemes. When the NHS was established, occupational health services were not included in the core requirements, even though the health/work link was a strong feature of the debate at the time. For many years, NHS staff had limited occupational health support for their own needs, but staff shortages, under performance, sickness absence and ill health retirement costs have led to the creation of comprehensive services wh

The HSE consultation document CD 173 outlines how the Chemical Agents Directive (98/24/EC) modifies the duties under COSHH and the Control of Lead at Work Regulations. HSC propose to retain the UK conditional “So far as is reasonably practicable”  despite objections from the EC and there are potential confusions concerning material contribution and addition to risk. The Radar report is available to subscribers: 1#11 15

The new duties extend the explicit  responsibility of property owners and occupiers. There are also changes to health surveillance regimes. Surveillance could result in insurers being put on notice of the risk of serious disease in 20 to 40 years time. This would create a data management problem. Evidence from: HSE Con Doc CD 176. The Radar report is available to subscribers: 1#11 13 Evidence from: Managing asbestos in premises. rev. ed., HSE, 2001. (INDG223 (rev2)) ISBN 07176209214 Aimed at people who own, occupy, manage or have responsibilities for premises which may contain asbestos and explains a new duty to manage these premises under the revised Control of Asbestos at Work Regulations (due to come into force in 2002). It advises how to identify, assess and manage any asbestos-containing materials in premises to protect the health of workers or others who may use the premises. A checklist is included. Comment Health surveillance organised in this way should be effective in setting

Human exposure to SV 40 was not widespread but did occur by means of contaminated polio vaccine in the early 1960’s. For the present, links between SV40 and mesothelioma would appear to remain speculative. Evidence from: C Carroll-Pankhurst et al. British Journal of Cancer. November (2001) Vol.85 #9 p 1295. The Radar report is available to subscribers: 1#11 12

IARC classified crystalline silica as a probable carcinogen in 1987, however, significant doubts remain. This study suggests that silicosis is not a cause of lung cancer. By chance the study also finds that silica is associated with death from diseases of the urinary system (kidney disease). Evidence from: P Carta et al. Occupational and Environmental Medicine. December (2001) Vol.58 # 12 p 786. The Radar report is available to subscribers: 1#11 11  

Specialists often assume that osteoarthritis is caused by heavy labouring work. But is it? If it is then defences should be explored as should potential case load. Evidence from: A Lievense et al. Journal of Rheumatology. November (2001) Vol. 28 #11 p 2520. Systematic review of research findings linking work with osteo arthritis of the Hip. 16 articles were selected in out of 2,921 on the grounds of study quality. All retained studies found hip OA associated with heavy vs. light workload. 12 of these were statistically significant but none were high quality cohort studies. That is they were snaphots. So the authors suspect recall bias as a possible explanation for the association. 10 of the 16 studies showed a dose response relationship. Comment This review is of an acceptable quality. The association and dose-response relationships could both be explained by the availability and seeking of medical assistance: Hip OA cases are more likely to seek treatment because pain hinders work hen

Elective surgery is not usually within the scope of this database. However, the current debate about implants illustrates a more general problem of medicalising a sense of low well-being and finding an identifiable event to blame. Any defect in the implant or defective surgery could heighten such concerns, but wouldn’t necessarily make them any more valid. Besides medical liability, product liability could be in the frame. Evidence from: P Tugwell et al. Arthritis and Rheumatism. November (2001) Vol. 44 # 11. p 2477. Links between silicone implants and rheumatological disease have been promoted for many years. This research paper is a review of all the evidence for such an association. 1773 relevant articles using any sort of connective tissue disease (CTD) (including rheumatoid arthritis etc.) outcome as the variable of interest. NO association was found between a new syndrome or established diagnoses. Full report available: http://www.fjc.gov/breimlit/science/report.htm Comment

If rehabilitation interventions are to be provided accurately it seems that adopting same approach for back and neck pain may be inappropriate. Evidence from: SZ George. Spine. October (2001) Vol. 26 #19 p 2139 A refinement of the role of fear avoidance in the course of chronic pain conditions is suggested by this research. The hypothesis being tested is that fear avoidance beliefs (FAB) would have different effects on the course of two very similar injuries located in different parts of the body, the lower back and, neck. FAB believed to be determined by stressful life events, personality, previous history of pain, and pain coping strategy? However it is not clear that the effect of each of these can be independently measured. The study made assessments of cases that had been referred to a chronic pain clinic. FAB were the same for both neck pain and back pain cases, however the associated disability was worse for back cases. Pain and disability were related for back cases but not nec

The work reported here describes a randomised control trial of a locally developed book on the self-management of back pain. Reductions in pain and disability were found during week one in the booklet group and in the advice to exercise group but not in the “both” group. There was no detectable difference between groups in pain/function scores at week three. Evidence from: P Little et al. Spine. October (2001) Vol. 26 #19 p 2065 The Radar report is available to subscribers: 1#11 7

It may be valid to apply a premium weighting on drivers who have recovered from TBI. Evidence from: BE Masel et al. Archives of Physical Medicine and Rehabilitation. November (2001) Vol. 82 #11. p 1526. A study of daytime sleepiness among TBI cases after apparently full recovery. Case series n = 71, 38 months after injury. Measured objectively in a live-in sleep laboratory. 47% hypersomnolance rate did not show up on self-report. That is, the hypersomnolant were unaware of their tendency to sleep during daytime. Comment It is generally held that motorists who fall asleep at the wheel would be aware that there was a risk in advance. This work suggests that former TBI cases (after 38 months) were unaware of their risk of daytime sleeping.

The bio mechanical model of whiplash promotes the orthodoxy that relative motions of head and torso, if eliminated, would eliminate whiplash neck injury. The novel device reported here would reduce relative motion, but its effect on claims would need to be validated. Evidence from: AF Tencer et al. Spine. November (2001) Vol. 26 #22 p 2432. A study of the relative motions of head and torso during rear end collision and the effectiveness of a head restraint air bag. New head restraint air bag was closer to the head, and absorbed some of the shock. Test speeds were below 10 kph. Relative motion was reduced. Comment If relative acceleration is important in causing injury at these speeds the new device would seem to offer some protection. Other studies have shown that even when torso and head are strapped firmly to the same rigid board, a rear end impact results in some deformation of neck alignment.

Whiplash cases were compared with asymptomatic persons. For common law purposes this is the wrong control group unless, on the balance of probabilities, the claimant can show they had above average health prior to the index event. This choice of asymptomatic control group is of some interest to medics but even here the choice has limited application. It would be useful if a specific lesion can be identified in whiplash cases and ruled out in all other neck pain cases. Evidence from: PT Dall’Alba. Spine. October (2001) Vol. 26 #19 p 2090. A report of a study of Range of Movement (ROM) for whiplash neck injury victims who are symptomatic after 3 months but before two years from the date of injury. Reduced range of motion was detected vs. control group. Comment Although a computerised measurement system was deployed, the technique could be criticised for failing to ensure there could be no contribution from torso rotation. A more complete study would have measured fear of movement and, at

If the standard biomechanical model of causation doesn’t have any practical utility, why is it so popular? It may be that no credible alternative has been proposed, but that doesn’t mean a defectice model should be adhered to. Defective models lead to defective assumptions and defective claims handling. Evidence from: R Ferrari. Spine. October (2001) Vol. 26 #19 p 2063. An editorial on the subject of research into whiplash neck injury. There is consensus that direction of vehicle impact is not prognostic of acute or chronic problems or litigation status. So if direction doesn’t matter, protection in vehicle is irrelevant. So why continue to focus research into protection from just one direction? The best treatments take no account of detailed pathology, so why study it any more? Good treatments such as nonspecific exercise regimens and general advice do not require deep understanding of pathology. Identification of an acute lesion would not explain why some develop ch

This Radar report collates a number of relevant findings in response to the Stewart report. Topics addressed include: Planning-related liability. Causation. Exposure control guidelines – duty of care. Childhood leukaemia – incidence. Risks to fire fighters. The Radar report is available to subscribers: 1#11 2  

Evidence from: A Conference held on the 29th November 2001 Notes on a presentation by: Julie McLean Speech and Language therapist Voice Care Network UK Voice and speech are controlled by a complex arrangement of muscles. These muscles are subject to the same aches and pains that can affect any other muscle. Habitual tension in the voice muscles can be the result of body posture, head posture and facial tension. Tension may have its origins in lack of general well being, poor seating and poor equipment arrangement. As a result, some people develop a syndrome called dysphonia (voice loss) which has features in common with diffuse RSI. In her opinion, emotions, ergonomics and habits conspire to produce a chronic pain/tension syndrome which results in voice loss. Good practice

Detailed examination of research findings showed that WBV can (at very high levels) aggravate organic conditions but its action as an initiator of injury remained uncertain.The clearest finding was that high levels of exposure to WBV made work uncomfortable / too difficult for a significant proportion of people who have back pain. They then report back pain as the reason for work absence. The Radar report is available to subscribers: 1#10 22

HSE has been vigorously promoting interventions where workplace causation is in doubt. This choice may cause HSE some difficulty meetings its agreed targets. One solution would be to accept that causation was rather too easily being assigned. Evidence from: D Coggon. Occupational and Environmental Medicine. November (2001) Vol.58 # 11 p 691. HSE activity on occupational health has been challenged by the setting of targets to be met within 5 and 10 years (from 2000). However, the actual targets and baselines have caused considerable debate. This paper brings some of the more scientific arguments into the open, they illustrate the difficulties HSE have in deciding what an occupational disease is. Revitalising H&S set targets: “a 20% reduction in the incidence of work related ill health to be achieved by the year 2010”. Considerable doubt remains about the definition and measurement of current levels and what proportion of these really can be eliminated by better practice. [Andrew Aut

There are currently 600,000 with Chronic Obstructive Pulmonary Disease (COPD) in the UK. Vocational rehabilitation would be more successful if the suggested options were employed.  Evidence from: A statement made by the British Thoracic Society. Thorax. November (2001) Vol.56 #11 p 827 The Radar report is available to subscribers: 1#10 20

IARC have produced a monograph on the subject of lung cancer and man-made vitreous fibres. IARC monographs programme: Carcinogenic risks from airborne man-made vitreous fibres [glass wool, rock wool, and slag wool] Man-made vitreous fibres in the form of wools are widely used in thermal and acoustic insulation and in other manufactured products in Europe and North America. These products, including glass wool, rock (stone) wool, and slag wool, have been in use for decades and have been extensively studied to establish whether fibres that are released during manufacture, use, or removal of these products present a risk of cancer when inhaled. Andrew Auty prepared a report for ABI in 1999 and concluded that the case for carcinogenicity had not been made, but that these wools should be classed as irritants. [A small proportion of people in physical contact with these wools have a strong, short-term inflammatory reaction]. An earlier IARC review (1988) provide no evidence of increased risk

Short term effects of exposure are well-known and usually reversible. This study sought an association between cumulative exposure and signs of peripheral nerve symptoms (PNS). Evidence from: A Pilkington et al. Occupational and Environmental Medicine. November (2001) Vol.58 # 11 p 702. Short term effects were observed as expected. The Radar report is available to subscribers: 1#10 17

If shift work increased the intensity of heart disease risk factors by some non-volitional mechanism then there would be a good case for controlling shift work in a way which counteracts that mechanism. But first, is there a significant effect on risk factors? Evidence from: B Karlsson et al. Occupational and Environmental Medicine. November (2001) Vol.58 # 11 p 747. A study of known risk factors for heart disease and their association with shift work. 27,485 Swedish workers took part. Blood and build were analysed. Obesity was found to be more prevalent among all ages of women shift workers, but only two age groups of men. Increased triglycerides (>1.7 mmol/l) were found for two groups of shift working women but not men. Impaired glucose tolerance was found among 60-year old women shift workers. Comment The authors conclude that shift work presents an increased risk of heart disease. However, risk factors for disease are not indicators that disease will necessarily occur. Strengths

If BMI is a risk factor for asthma then it should also be a risk factor for atopy. But it isn’t, according to this study. The suggestion is that either atopy or asthma may be being misdiagnosed. Atopy is diagnosed by objective tests. Evidence from: E von Mutius et al. Thorax. November (2001) Vol.56 #11 p 835. Does body mass index (BMI) correlate with diagnosis of childhood asthma? 7505 children aged between 4 – 17 took part in the study. Extensive background details and medical exam for status. Physician diagnosis or treatment for asthma was used to identify asthmatics. Relative to lowest quartile, BMI, top quartile OR = 1.77 (95% CI = 1.44 to 2.19) BMI was not correlated with atopy. Comment Possible explanations include a high rate of false diagnosis (activity intolerance is used by many physicians as a clear sign of asthma or direct effect of being overweight on breathing or sensitisation of an inflammatory mechanisms?

The research report referenced here examines the feasibility of providing written instruction informing about signs and personalised care for each child with a known predisposition. It finds that such personalised programmes can be obtained and managed successfully. Evidence from: DA Moneret-Vautrin et al. Allergy. November (2001) Vol. 56 # 11 p 1071 Allergy prevention and response would seem to be reasonably practicable in schools. The Radar report is available to subscribers: 1#10 14