Corresponding Author: Fauziah
Amin
E-mail: fauziahamin30@gmail.com
INTRODUCTION
Carpal Tunnel Syndrome is a syndrome
with pain or tingling (paresthesia) or numbness on the hand due to pressure
conditions by the wrist flexor ligament tendons due to repetitive trauma to the
median nerve in the carpal tunnel (Suma’mur, 2013). The hallmark of classic CTS is pain or paresthesia (numbness and
tingling) in a distribution that includes the median nerve involving the first
three fingers and the lateral half of the fourth finger (Kothari, 2022).
In essence, Carpal Tunnel Syndrome
(CTS) develops due to a combination of compression and pulling mechanisms.
Compression leads to increased pressure cycles, hindering venous outflow and
causing local swelling. This pressure compromises the microcirculation of the
median nerve. Consequently, the nerves are damaged, leading to dysfunctional
myelin sheaths and axons, as well as inflammation in the surrounding tissue,
diminishing their protective functions. Repetitive wrist movements worsen the
condition, causing further nerve damage. Additionally, inflammation in any of
the nine flexor tendons within the carpal tunnel can exert pressure on the
median nerve. Typically, sensory fibers are affected before motor fibers, and
even autonomic nerve fibers within the median nerve can be impacted (Sevy et al., 2022).
There
are several risk factors associated with CTS. In working conditions, work using
tools with great power or pressure, excessively flexed and extended hand
positions and under prolonged conditions, repetitive use of flexor muscles, and
exposure to vibration are some of the factors that have been reported. CTS can
also result from various conditions, including inflammatory or non-inflammatory
arthropathy, trauma or wrist fracture, diabetes mellitus, obesity,
hypothyroidism, pregnancy, and genetic factors. (Franklin
& Friedman, 2015).
As CTS progresses, symptoms may
also be felt while awake, especially during activities that require sustained
arm positioning or repetitive movements. In some cases, there is progression
from intermittent to persistent sensory complaints and from paresthesia to
sensory loss in the hands. Permanent sensory loss is usually a late finding
characterized by a characteristic clinical pattern that can be felt by the pain
of the fingers connected to the median nerve, pain in the hand or arm,
especially at night or when working, weakness and wasting of the thenar
eminence muscles, loss of sensation in hand in the median nerve, which runs from your forearm into the palm,
tingling in the palms that are distributed to the median nerve, this condition
is often bilateral (Ginsberg, 2010; Kothari, 2022;
Salawati & Syahrul, 2014).
Therefore, this systematic review aimed to review the existing
literature to determine the role of occupational risk factors and summarize the
available data on risk factors to know how the risk could contribute to CTS
based on the newest research.
METHOD
The journal
databases used are ScienceDirect, PubMed, ResearchGate, and Scopus. The
keywords used in the search are occupational risk factors and carpal tunnel
syndrome. Reviewers select research based on the title, abstract, and article.
The inclusion criteria in the literature review conducted were: 1) Scientific
articles written in English; 2) Articles published in journals and proceedings;
3) Articles published in 2019-2023; 4) The eligibility of articles will also be
determined if they contain any or all of the variables: awkward posture of the
hand, repetitive hand movements, and vibration from the machine used by the
hand; 4) The research was conducted using cross-sectional, cohort,
case-control, and experimental studies on work-related risk factors that can
cause Carpal Tunnel Syndrome.
Exclusion criteria
include: 1) Not fully accessible; 2) in the form of a literature review; 3) If
the variable of occupational risk factors for CTS is intervened with other
variables besides the risk factors previously mentioned and exposure time while
working. Suppose the keyword occupational risk factors used is not found in the
journal on the portal used. In that case, the keywords will be assisted with
awkward posture, hand-arm vibration, OR repetitive hand movements.
Articles taken
based on the conditions met, among deviation) study period, the year of
publication, the research design and research method, the research area, and
the association between occupational risk factors (repetitive movement,
vibration exposure, hand posture (flexion, extension, radial or ulnar
deviation)), and CTS. The entire review was carried out in accordance with the
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines statements. The relevant PRISMA flowchart, which summarizes the
outcomes of this methodology, is shown in Figure 1.
RESULTS AND DISCUSSION
The research included in this study included nine articles from
The United States, Sweden, France, Denmark, Botswana, Pakistan, and Finland
with different types of work. Initially, we reviewed the titles and abstracts
of articles featured in each database used for this review; duplicate papers in
the database were identified, and selection criteria were established with the
following criteria: 1) Throughout the review of titles and abstracts, we
retained papers regarding CTS and risk factors of interest, such as repetitive
hand movements, exposure to hand-arm vibrations, and awkward hand postures. 2)
Articles written in languages other than English will be rejected. After we
selected works that met the predetermined criteria, we carried out a full
review of each work. We classified them based on risk factors based on the work
on CTS and then included them in this study. Figure 1 shows the flowchart of
this literature review screening steps.
Figure 1. Systematic Review Flowchart
Based on a bibliographical search using the ScienceDirect, PubMed,
ResearchGate, and Scopus databases, 632, 494, 190, and 668 articles were found
for a total of 1984 research papers. Furthermore, 15 articles were identified
as duplicates, bringing the total to 1969 articles after duplicates were
removed. We thoroughly reviewed the remaining 58 articles following the
previously described criteria. According to the criteria, we rejected 14
articles because they were related to CTS factors other than those examined in
this study, for example, the Body Mass Index, hypertension, smoking,
socio-demographic, and psychosocial. Furthermore, there are four articles with
full text in a foreign language, 26 cannot be accessed for the full text, and
five are systematic reviews. Lastly, nine articles were eligible for the
literature review.
Table 1. List of selected Studies
|
Author
(Years)
|
Study
Design
|
Population
|
Method
|
Result
|
|
(Harris Adamson et al., 2022)
|
Prospective cohort study
|
372 workers
with a prevalence or incidence of CTS were followed for up to 6.4 years
|
Exposure
was assessed by observation and measurement of force using Borg CR-10,
repetition using Hand Activity Level scale, hand posture using % time =30° wrist flexion and extension, and 2018
ACGIH TLV for hand activity. Hazard Ratios were estimated
using Cox models.
|
In the upper tertile of the Hand Activity Level Scale,
there was a nearly doubling of the risk for job change (HR 2.17; 95% CI
1.17-4.01), a total hand repetition rate of 1.75 (95% CI 1.02-3.02), a
percentage of time spent in all hand exertions of 2.20 (95% CI 1.21-4.01),
and a sixfold increase for high job strain.
|
|
(Vihlborg et al., 2022)
|
Case-control
study
|
Four thousand three hundred ninety-six cases of
CTS were obtained from the National Outpatient Register of Sweden.
|
For each employment, the daily 8-hour equivalent
vibration level (A(8)) for hand-arm vibration exposure was determined.
Logistic regression was used to examine the data.
|
HAV exposure raised the likelihood of CTS by 1.61
OR (95% CI: 1.46-1.77). With a mean year exposure above 2.5 m/s2, the risk
increased to OR 1.84 (95% CI 1.38- 2.46).
|
|
(Roquelaure, Jégo, et al., 2020)
|
Prospective
Study
|
1367 workers as participants (804 men and 563
women)
|
With Borg's rating of perceived exertion, wrist
bending, pinching, and hand-transmitted vibrations, biomechanical risk
factors are evaluated. To investigate the connections between incident CTS
cases, use structural equation modeling (SEM).
|
Symptomatic CTS risk was directly increased by
biomechanical factors (exertion, wrist bending, pinching, and
hand-transmitted vibration) (standardized coefficient = 0.19; P=0.011).
|
|
(Maghsoudipour et al., 2021)
|
cross-sectional study
|
106 dentists from dental schools in Tehran
|
The amount of vibration exposure (hour/day) was
measured. To confirm the diagnosis of CTS, a nerve conduction velocity (NCV)
test was performed. Using an independent T-test and logistic regressions, the
analysis was carried out.
|
Vibration exposure greater than two hours per day
(OR: 2.5) was a significant risk factor for CTS among dentists.
|
|
(Ijaz et al., 2023)
|
cross-sectional study
|
150 workers a subject
|
The
self-designed questionnaire was used to know the subject's demographic,
working hours and experience, and type of work (e.g., drilling, cutting,
vibration, and carrying loads).
|
Types of work (p-value = 0.04) and type of
activity (p-value = < 0.01) showed a significant association with CTS
prevalence in workers.
|
|
(Erick et al.,
2021)
|
cross-sectional study
|
184 hairstylists randomly selected hair salons in
Gaborone, Botswana
|
The participant's psychosocial and physical work
demands on hairstylists and awkward postures, such as prolonged and
repetitive wrist flexion, extension, radial and ulnar deviation, abnormal
patterns of wrist movements, firm grasping, repetitive use of the hand, use
of handheld tools that vibrate, or positions that put pressure on the wrist,
were assessed using an anonymous self-administered questionnaire. Then,
Chi-Square and logistic regression models were used to analyze the data.
|
Awkward CTS symptoms were associated with posture
(OR 2.52, 95% CI: 1.03–6.19) and great muscular effort when performing a task
(OR 2.39, 95% CI: 1.01–5.72).
|
|
Lund et al.,(2019)
|
Cohort study
|
Employees who experienced hand vibrations (with a
hazard ratio of 2.29 and a 95% confidence interval of 1.48–3.54) and
individuals engaged in physically demanding occupations (with a hazard ratio
of 1.71 and a confidence interval of 1.06–2.76) faced a higher likelihood of
being hospitalized due to Carpal Tunnel Syndrome (CTS).
|
Thirty different jobs, including office work,
childcare, laundry work, and slaughterhouse work, had their wrist movements
measured electrogoniometrically. We calculated the mean power frequency
(MPF), range of motion (ROM), and wrist angular velocity. The risk of CTS by
quintiles of preceding exposure levels was assessed by adjusted incidence
rate ratios (IRRadj) using Poisson regression models.
|
Exposure–response association between wrist angular
velocity and CTS with an IRRadj of 2.31 (95% CI 2.09 to 2.56) when
exposed to the highest level compared with the lowest. MPF also showed an
exposure–response pattern, although less clear, with an IRRadj of
1.83 (1.68 to 1.98) for the highest compared with the lowest exposure level.
|
|
(Hulkkonen et al., 2020)
|
Cohort study
|
6326 workers as respondents from the Northern
Finland Birth Cohort of 1966 who
attended the 31-year follow-up in 1997
|
The study evaluated the relationship between
background characteristics, occupational and physical factors, and
hospitalization for Carpal Tunnel Syndrome (CTS) using the univariable Cox
proportional hazards regression model. Subsequently, variables that remained
significant in sex-specific analyses or analyses combining both sexes and
were adjusted for sex were incorporated into the multivariable Cox
proportional hazards regression models.
|
Employees who experienced hand vibrations (with a
hazard ratio of 2.29 and a 95% confidence interval of 1.48–3.54) and
individuals engaged in physically demanding occupations (with a hazard ratio
of 1.71 and a confidence interval of 1.06–2.76) faced a higher likelihood of
being hospitalized due to Carpal Tunnel Syndrome (CTS).
|
|
(Roquelaure, Jégo, et al., 2020)
|
Cross-sectional
|
Seven hundred eleven men aged 30-65 years old and
working as either farmers or agricultural workers in 2009-2010 within a
cohort covered by the French Agricultural Workers' and Farmers' Mutual
Benefit Fund.
|
Using a self-administered questionnaire, CTS and
exposure to chemical and physical wrist stressors were evaluated. Using
multivariate logistic regression models, associations between CTS and
personal/medical factors, exposure to physical wrist stressors, exposure to
chemicals, and co-exposure to physical wrist stressors and chemicals were
investigated.
|
CTS was associated with exposure to physical
wrist stressors [OR = 2.6 (1.1-5.9)].
|
Finally, nine articles were grouped
according to the factors stipulated for this review, i.e., hand repetitive
movement, hand-arm vibration, and awkward hand posture. Several articles
address occupational risk factors together (i.e., biomechanical factors and
wrist angular velocity) and have results related to CTS
also included. Based on the study reviewed, Table 1 shows two kinds
of literature have significant results for hand repetitive movement association
with CTS; five kinds of literature have found an association between hand tools
vibration and CTS, and four kinds of literature found an association between
awkward hand posture when working with CTS.
Hand Repetitive Movement
In the studies that have been
reviewed, repetitive hand movements are associated with the appearance of CTS
complaints in workers (Harris Adamson et al.,
2022). Repetitive or repetitive movements are a series of
movements that have little variation and are performed every few seconds, which
can result in muscle fatigue and tension (Sekarsari et al.,
2017). Jobs that include highly repetitive motions are
hairdressers, which were discussed in the research conducted by Erick et al. One
of the occupational groups that may be more susceptible to CTS is hairdressers.
A hairdresser's duties may also occasionally include planting, twisting, and
styling dreadlocks. Other duties include braiding, washing, and drying the
client's hair. These tasks entail jerky or repetitive hand motions (Erick et al., 2021).
Repeated wrist movements will
cause friction on the tissues in the wrist, which can cause injury. This wound
can become scar tissue (scar tissue) as part of the tissue healing process on
the wrist. The volume of scar tissue increases at the wrist and can compress
the median nerve (Daniels, 2014). Thick scar tissue will form around the median nerve, which can
result in nerve pulling (Aboonq, 2015). Inflammatory thickening of the synovial tissue increases tissue
volume, increasing fluid pressure within the carpal tunnel. The increased
carpal tunnel pressure will, in turn, put pressure on the median nerve, leading
to poor blood circulation. Over time, ischemia eventually leads to long-term
effects such as irreversible damage to flexor synovial cells and median nerve
synovial thickening, with further severity of median nerve fibrosis and
demyelination and can lead to CTS (Riccò & Signorelli, 2017).
Hand-Arm Vibration
Exposure to hand vibration is a
risk factor for CTS. Direct vibration of the hand or the use of a vibrating
handheld device will impact increasing muscle contractions. Vibration can also
cause mechanical abrasion of the tendon sheaths neurological and circulatory
disorders. Vibration can directly injure peripheral nerves, nerve endings, and
mechanical receptors and cause symptoms of numbness, tingling, pain, and loss
of sensitivity. The vibrations can immediately affect the digital arteries (Mallapiang & Wahyudi, 2015). Research on dentists conducted by Maghsoudipour et al. (Maghsoudipour et al., 2021) shows that the risk of CTS increases the longer a person is
exposed to the vibration of the machine used or what is commonly called Hand
Arm Vibration. According to previous studies, carpal tunnel syndrome is the
most common self-reported musculoskeletal disorder among dentists (de Jesus Júnior et al., 2018).
The review also found other
articles that stated that hand-arm vibration also increased the prevalence of
CTS among workers in Sweden (Vihlborg et al., 2022). This cohort study found that Exposure to HAV increased the risk
of CTS with an OR of 1.61 (95% CI 1.46–1.77). The risk increased with a mean
year exposure above 2.5 m/s2 to OR 1.84 (95% CI 1.38– 2.46).
Vibration above 2.5 m/s2 based on regulations includes Exposure
action value, which means the level of daily vibration exposure to HAV for a
worker above which steps should be taken to minimize exposure (The Control of Vibration at Work
Regulations, 2005). Workers exposed to vibration in Northern Finland also had
complaints of CTS (HR 2.29, 95% CI 1.48–3.54). Furthermore, research conducted
by (Ijaz et al., 2023) found that workers in marble factories who use drilling cutting tools
and other vibrating hand tools and carry out high-force activities
significantly correlate with the incidence of CTS. These types of work can
cause compression of the median nerve and can cause complaints of CTS. Exposure
to HAV is also associated with concomitant exposure to various ergonomic
factors, such as static load and high force grip on tools, which themselves
increase the risk of CTS (Aroori & Spence, 2008)(van Rijn et al., 2009). Van Rijn et al. discovered similar research,
claiming that repetitive work (cycle time 50% of cycle time performing the same
movements) and hand-arm vibration daily 8-hour energy-equivalent
frequency-weighted acceleration of 3.9 m/s2 compared to the action value of 2.5
m/s2 described in the ACGIH on hand-arm vibration are all associated with CTS (ACGIH, 2021).
Awkward Hand Posture
Farmers and
agricultural workers who are respondents to research conducted by Roquelaure et al. (Roquelaure, Jégo, et al., 2020) are subjected to a variety
of physical wrist stressors at work, such as awkward wrist postures, repetitive
motions, and manual handling of loads, which increases the pressure in the
carpal tunnel. The position of the wrist and the pressure experienced when
doing work or using equipment are co-factors contributing to CTS's emergence.
The longer the wrist position is awkward, the higher the risk of developing CTS
(Sekarsari et al.,
2017). Research on other subjects also conducted by
Roquelaure et al. (Roquelaure, Garlantézec, et al.,
2020) showed that exposure to biomechanical risk factors,
such as high perceived workload, hand-transmitted vibration, and
repetitive/sustained wrist bending and pinching directly increased the risk of
CTS.
The same result was
found in research conducted by Erick et al. (2021), which claims that hairstylists adopt awkward
postures while performing these tasks, particularly when using a lot of
movement. When performing a task, awkward posture and fluid movements were
positively linked to a higher risk of developing CTS. However, most patients
reported mild symptoms of CTS and its mild interference with daily activities.
Other factors that were discovered to contribute to the development of CTS
symptoms included hair washing, an awkward posture, a great deal of muscular
effort when performing a task, and stressful work.
The results of these
studies can be supported by the research conducted by Keir et al. (1997, 1998), who reported that extreme wrist extension or flexion
can put a lot of pressure on the carpal tunnel, damaging the median nerve. This
physiological evidence backs up the theory that persistent awkward wrist
postures in workers can cause CTS. High repetition of a hand doing flexion or extension increased the
occurrence of CTS (van Rijn et al., 2009).
CONCLUSION
Various professions in this world come with
risk factors associated with their tasks. Especially those arising from
exposure to work activities that can lead to occupational diseases, one of
which is Carpal Tunnel Syndrome. Research indicates that Carpal Tunnel Syndrome
is linked to repetitive hand movements, hand-arm vibrations, and awkward hand
postures during work. The exposure in this context involves repetitive hand
motions, prolonged awkward body postures, and the use of vibrating tools, all
of which are associated with an increased risk of CTS in workers. Monitoring
the handheld vibrating tools used by workers and evaluating hand postures and
the intensity of repetitive movements during working hours is necessary to
reduce pain complaints and maintain workers' productivity.
REFERENCES
Aboonq, M. S. (2015). Pathophysiology of carpal tunnel
syndrome. Neurosciences (Riyadh, Saudi Arabia), 20(1), 4–9.
ACGIH. (2021). The Threshold Limit Values (TLVs) and
Biological Exposure Indices (BEIs).
Aroori, S., & Spence, R. A. J. (2008). Carpal tunnel
syndrome. The Ulster Medical Journal, 77(1), 6–17.
Daniels, N. (2014). Carpal Tunnel Syndrome - Causes,
Prevention and Treatment. BookRix GmbH & Co. KG.
de Jesus Júnior, L. C., Tedesco, T. K., Macedo, M. C., Agra,
C. M., Mello-Moura, A. C., & Morimoto, S. (2018). A self-report joint
damage and musculoskeletal disorders data among dentists: a cross-sectional study. Minerva
Stomatologica, 67(2), 62–67.
https://doi.org/10.23736/S0026-4970.17.04033-X
Erick, P., Benjamin, K., Raditloko, S., Tapera, R., &
Mbongwe, B. (2021). Risk factors for self-reported carpal tunnel syndrome among
hairstylists in Gaborone, Botswana. International
Journal of Occupational Medicine and Environmental Health, 34(3),
437–450. https://doi.org/10.13075/ijomeh.1896.01659
Franklin, G. M., & Friedman, A. S. (2015). Work-Related
Carpal Tunnel Syndrome: Diagnosis and Treatment Guideline. Physical Medicine
and Rehabilitation Clinics of North America, 26(3), 523–537.
https://doi.org/10.1016/j.pmr.2015.04.003
Ginsberg, L. (2010). Lecture Notes: Neurology (9th
ed.). Wiley-Blackwell.
Harris Adamson, C., Eisen, E., Kapellusch, J., Hegmann, K.,
Thiese, M., Dale, A.-M., Meyers, A., Bao, S., Gerr, F., Krause, N., &
Rempel, D. (2022). Occupational risk factors for work disability following
carpal tunnel syndrome: a pooled prospective study. Occupational and
Environmental Medicine, 79, oemed-2021.
https://doi.org/10.1136/oemed-2021-107771
Hulkkonen, S., Shiri, R., Auvinen, J., Miettunen, J.,
Karppinen, J., & Ryhänen, J. (2020). Risk factors of hospitalization for
carpal tunnel syndrome among the general working population. Scandinavian
Journal of Work, Environment & Health, 46(1), 43–49.
Ijaz, S., Ali, M., Saeed, S., Ali, M., Sultan, S., &
Shah, R. U. (2023). Prevalence of Carpal Tunnel Syndrome and its Associated
Risk Factors among Workers of Marble Industries of Abbottabad. Journal of
Women Medical and Dental College, 1(4 SE-Articles).
https://doi.org/10.56600/jwmdc.v1i4.53
Keir, P. J., Bach, J. M., & Rempel, D. M. (1998). Effects
of finger posture on carpal tunnel pressure during wrist motion. The Journal
of Hand Surgery, 23(6), 1004–1009.
https://doi.org/10.1016/S0363-5023(98)80007-5
Keir, P. J., Wells, R. P., Ranney, D. A., & Lavery, W.
(1997). The effects of tendon load and posture on carpal tunnel pressure. The
Journal of Hand Surgery, 22(4), 628–634.
https://doi.org/10.1016/S0363-5023(97)80119-0
Kothari, M. J. (2022). Carpal tunnel syndrome: Clinical
manifestations and diagnosis. UpToDate by Wolters Kluwer.
Maghsoudipour, M., Hosseini, F., Coh, P., & Garib, S.
(2021). Evaluation of occupational and non-occupational risk factors associated
with carpal tunnel syndrome in dentists.
Work (Reading, Mass.), 69(1), 181–186.
https://doi.org/10.3233/WOR-213467
Mallapiang, F., & Wahyudi, A. A. (2015). Gambaran Faktor
Pekerjaan dengan Kejadian Carpal Tunnel Syndrome (CTS) pada Pengrajin Batu
Tatakan di Desa Lempang Kec. Tanete Riaja Kabupaten Barru Tahun 2015. Al-Sihah:
The Public Health Science Journal, 7(1 SE-Volume 6-8, Nomor 1-2,
Tahun 2014-16). https://doi.org/10.24252/as.v7i1.1974
Riccò, M., & Signorelli, C. (2017). Personal and
occupational risk factors for carpal tunnel syndrome in meat processing industry workers in Northern
Italy. Medycyna Pracy, 68(2), 199–209.
https://doi.org/10.13075/mp.5893.00605
Roquelaure, Y., Garlantézec, R., Evanoff, B. A., Descatha,
A., Fassier, J.-B., & Bodin, J. (2020). Personal, biomechanical,
psychosocial, and organizational risk factors for carpal tunnel syndrome: a structural equation
modeling approach. Pain, 161(4), 749–757.
https://doi.org/10.1097/j.pain.0000000000001766
Roquelaure, Y., Jégo, S., Geoffroy-Perez, B., Chazelle, E.,
Descatha, A., Evanoff, B., Garlantézec, R., & Bodin, J. (2020). Carpal
Tunnel Syndrome Among Male French Farmers and Agricultural Workers: Is It Only Associated With Physical Exposure? Safety
and Health at Work, 11(1), 33–40.
https://doi.org/10.1016/j.shaw.2019.12.003
Salawati, L., & Syahrul, S. (2014). Carpal Tunel
Syndrome. Jurnal Kedokteran Syiah Kuala, 14(1).
Sekarsari, D., Pratiwi,
arum dian, & Farzan, A. (2017). Hubungan Lama Kerja, Gerakan
Repetitif dan Postur Janggal Pada Tangan Dengan Keluhan Carpal Tunnel Syndrome
(CTS) Pada Pekerja Pemecah Batu Di Kecamatan Moramo Utara Kabupaten Konawe
Selatan Tahun 2016. Jurnal Ilmiah Mahasiswa Kesehatan Masyarakat Unsyiah,
2(6).
Sevy, J. O., Varacallo, M., & Kabir, R. (2022). Carpal
Tunnel Syndrome. StatPearls Publishing.
Suma’mur. (2013). Higene Perusahaan dan Kesehatan Kerja
(HIPERKES) (2nd ed.). Sagung Seto.
The Control of Vibration at Work Regulations, (2005).
van Rijn, R. M., Huisstede, B. M. A., Koes, B. W., &
Burdorf, A. (2009). Associations between work-related factors and the carpal
tunnel syndrome—a systematic review. Scandinavian Journal of Work,
Environment & Health, 1, 19–36.
https://doi.org/10.5271/sjweh.1306
Vihlborg, P., Pettersson, H., Makdoumi, K., Wikström, S.,
Bryngelsson, I.-L., Selander, J., & Graff, P. (2022). Carpal Tunnel
Syndrome and Hand-Arm Vibration: A Swedish National Registry Case-Control Study. Journal of
Occupational and Environmental Medicine, 64(3), 197–201.
https://doi.org/10.1097/JOM.0000000000002451
