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high. The study, however, did show a significant risk for carpal tunnel syndrome for blue-collar work, use of excessive force of the hands, working with excessively flexed or extended wrist, or the use of hand-held vibratory tools; these findings are not mentioned by Dr. Szabo.

Dr. Szabo cites the paper of Greenland and Robins (1988) to suggest that without knowledge of cofactors that contribute to carpal tunnel syndrome, “estimates offered by Hagberg as well as the ones used in the NAS report must be interpreted with caution.” In fact, the thrust of the Greenland and Robins argument is that such attributable risk calculations may severely underestimate (not overestimate, as implied by Dr. Szabo) the proportion of cases in which the etiologic factor is important because of possible interactions between that factor and the cofactors. Greenland and Robins cite numerous examples in which a small excess risk masks a much larger effect of a primary study factor.

Several articles cited by Dr. Szabo in his discussion of the epidemiology literature on carpal tunnel syndrome did not meet the quality criteria (insufficient participation and inadequate exposure measures were common problems) used by the panel in selecting articles for the epidemiology review and so are not included in the report.

In his dissent, Dr. Szabo states, “More importantly, reliance on ergonomics to the exclusion of medical and health risk factors can have adverse consequences for the patient.” Nowhere in its report does the panel suggest the exclusive use of ergonomic interventions.

It is important to reemphasize the fact that we made a major effort to base our conclusions on literature that met accepted scientific criteria and that the report represents consensus of all of the panel members except for Dr. Szabo. At the same time, the report makes plain the panel's view that the literature about musculoskeletal disorders is incomplete, as all clinical and scientific literatures are, and also emphasizes the importance of continuing research on a variety of fronts. There is, however, sufficient basis in the research to date to support our conclusions and recommendations.

Jeremiah A. Barondess, Chair

Mark R. Cullen

Barbara de Lateur

Richard A. Deyo

Sue K. Donaldson

Colin G. Drury

Michael Feuerstein

Baruch Fischhoff

John W. Frymoyer

Jeffrey N. Katz

Kurt Kroenke

Jeffrey C. Lotz

Susan E. Mackinnon

William S. Marras

Robert G. Radwin

David Rempel

David Vlahov

David H. Wegman

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