NEWS
& COMMENTARY |
Important
Occupational Medicine News Developments William L. Newkirk |
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Journal of
the American Medical Association (JAMA) Occupational
Health and Safety Administration (OSHA) American
College of Occupational and Environmental Medicine (ACOEM) Environmental |
Full-Time Splinting may be Superior to Night-Time Splinting in CTS A new study published in the April 2000 issue of the Archives of Physical Medicine and Rehabilitation finds scientific evidence to support the efficacy of neutral wrist splints in Carpal Tunnel Syndrome (CTS) and suggests that physiologic improvement is best with full-time splint wear. The study, performed by William C. Walker, MD and colleagues from the Department of Physical Medicine and Rehabilitation, Medical College of Virginia at Virginia Commonwealth University, evaluated 21 patients, of whom 17 completed the study. Patients were provided with thermoplastic, custom-molded, neutral wrist splints and instructed to wear them either full-time or night-only. The combined sample improved in three of four outcome measures: sensory distal latency, symptom severity, and functional deficits. Subjects receiving full-time wear instructions showed superior distal latency improvement, both motor and sensory, when compared with subjects receiving night-only wear instructions. Comment: This study, although small, provides some direction in instructing patients on the use of wrist splints in CTS. In the past few years, several other groups have looked at aspects of wrist splinting in CTS. Finsen and colleagues evaluated splints after surgery and stated: "We conclude that four weeks of postoperative immobilization confers no detectable benefit." (Acta Orthop Scand 1999 Jun;70(3):288-92). Luchetti and colleagues evaluated intra-carpal pressures in 15 CTS patients and reported: "Slightly lower pressures were found when the wrist was splinted, but the difference was not significant, nor were critical pressure levels prevented by splinting."(J Hand Surg [Br] 1994 Feb;19(1):35-7). Rempel and colleagues concluded in their study of 15 normal individuals: "Our data indicate that the median nerve is subjected to increased pressure within the carpal tunnel during repetitive hand activity. Wearing a flexible wrist splint during activity limits the range of wrist motion but has no significant effect on carpal tunnel pressure." (J Hand Surg [Am] 1994 Jan;19(1):106-10). Current information, then, would: 1) not support the use of splints post-operatively; 2) indicate that splinting does not significantly lower intra-carpal pressures in CTS or normal patients; and 3) indicate that splints can assist in improving nerve functions, particularly if worn constantly. If increased intra-carpal pressures are the cause of CTS, then findings 2 and 3 are somewhat contradictory. – William L. Newkirk, MD, FACPM (wln) House of Representatives Votes to Block Ergonomic Standard, Again On June 7, 2000 in what is becoming a ritual of battle on OSHA’s proposed ergonomic standard, the House of Representatives voted 220-203, in a mostly party-line vote, to block the regulations. The vote probably has more symbolic than real significance, however, because President Clinton is virtually sure to veto legislation blocking OSHA, and the provision must also survive a House-Senate conference committee. As expected, some business groups praised the House action. Harold B. Wells, Chairman of the National Auto Dealers Association stated: "This vote is another important step towards protecting America’s auto and truck dealerships and other small businesses from these unreasonable and overly burdensome regulations." Labor opposed it. "It appears to be an effort on the part of some to provide cover and encourage members to support legislation that is blatantly anti-family,’’ AFL-CIO lobbyist Peggy Taylor said. Comment: This is a not unexpected step on the rocky road to an ergonomic standard. What is more important than this vote is how OSHA will revise the proposed standard in light of public comments they received. In any event, the proposed standard will be challenged in court as soon as its final version is announced. The process is far from over. - wln Five New Self-Audit Protocols Released by EPA On May 25, 2000 the Environmental Protection Agency (EPA) released five additional self-audit protocols for conducting environmental compliance audits. The EPA is continuing to encourage the development of self-assessment programs to help facilities meet their obligations to comply with environmental laws. For greater flexibility, users can custom-tailor the protocols to more specific environmental aspects associated with their facility. The EPA has already issued four self-audit protocols, and plans to issue four more by December 2000. The nine protocols that are currently available can be obtained at www.epa.gov/oeca/ccsmd/profile.html. Third COX-2 Inhibitor is Released On April 13, 2000 the U.S. Food and Drug Administration approved meloxicam (Mobic®) tablets for marketing as a treatment for osteoarthritis. Meloxicam will be marketed in the United States jointly by Boehringer Ingelheim Pharmaceuticals, Inc. and Abbott Laboratories. Meloxicam is a once-daily medication for relief of the signs and symptoms of osteoarthritis. It is the third new non-steroidal anti-inflammatory drug (NSAID) introduced into the market in the past two years. COX-2 Inhibitor s have Fewer Long-Term Side Effects than Older NSAIDsOn April 17, 2000 the results of the Celecoxib Long-term Arthritis Safety Study, a 13-month, multi-center, randomized, double-blind outcomes trial of about 8,000 arthritis patients were reported at the American College of Physicians’ annual meeting. The study found that arthritis patients taking four times the recommended osteoarthritis dose of the celecoxib (Celebrex) experienced fewer symptomatic gastrointestinal ulcers and ulcer complications than did patients taking ibuprofen and diclofenac. Ibuprofen and diclofenac were associated with a significantly greater GI blood loss over the course of the study. Comment: Searle and Pfizer, Inc., the drug’s promoters in the United States, funded the Celecoxib study. For this reason, the conclusions should be accepted carefully. Nonetheless, the study does demonstrate that the advantages of COX-2 inhibitors over older NSAIDS are probably real. Cost is the major concern with COX-2 inhibitors, and therefore the introduction of meloxicam (Mobic®) may provide a lower cost alternative. Mobic® is reported to be priced 20 percent lower than Celebrex® and Vioxx® for the starting and maintenance daily dose. - wln |
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