neurological occupational diseases
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Neurological Occupational Diseases
Assoc. Prof. Pavel Urban, M.D. Ph.D.
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Proportion of Neurological Occupational Diseases in the Total Number of Occupational Diseases
0
5
10
15
20
25
30
35
1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Peerc
en
t
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Main Categories of Occupational Diseasesin 2004
28%28%28%28%
21%21%21%21%21%21%21%21%
17%17%17%17%
2%2%2%2%
11%11%11%11%
NeurologicalNeurologicalNeurologicalNeurological
Respir ator yRespir ator yRespir ator yRespir ator y
DermatosesDermatosesDermatosesDermatoses
InfectionsInfectionsInfectionsInfections
IntoxicationsIntoxicationsIntoxicationsIntoxications
Other sOther sOther sOther s
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Neurological Occupational Diseases in 2004
84%84%84%84%
10%10%10%10%
1%1%1%1% 4%4%4%4% 1%1%1%1%
Carpal tunnel syCarpal tunnel syCarpal tunnel syCarpal tunnel sy
Cubital tunnel syCubital tunnel syCubital tunnel syCubital tunnel sy
CombinationsCombinationsCombinationsCombinations
Neur oboreliosisNeur oboreliosisNeur oboreliosisNeur oboreliosis
Tick-borne encephalitisTick-borne encephalitisTick-borne encephalitisTick-borne encephalitis
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Prerequisites for a Diagnosis of a Neurological Occupational Disease
• Typical clinical manifestation
• Reasonable exclusion of alternativecauses
• Proof of relevant exposure
• Appropriate temporal association between exposure and disease
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Neurological Occupational Diseases Caused by Chemical Noxae
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(1) Toxic Encephalopathy
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Clinical Manifestationof Toxic Encephalopathy
• Pseudoneurasthenic syndrome
• Psychoorganic syndrome
• Dementia
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Laboratory Testsfor Toxic Encephalopathy
• Psychological examination
• Electroencephalography
• Evoked potentials (P300, VEP, BAEP)
• Neuroimaging methods (CT, NMR, PET, SPECT)
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The Most Frequent Causes of Occupational Toxic Encephalopathy
Parkinsonian syndromeManganese
Parkinsonian syndromeCarbon monoxide
ErethismMercury vapor
Euphoria,
pseudohallucinations
Toluene
Psychiatric disordersCarbon disulphide
Solvent syndromeOrganic solvents mixture
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Differential Diagnosisof Toxic Encephalopathy
• Non-toxic causes of diffuse encephalopathy
– Aging
– Incipient neurodegenerative disorder
• Non-occupational neurotoxicants
– Alcohol
– Drug abuse
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Treatment of Toxic Encephalopathy
• Removal from exposure
• Nootropic drugs
– Piracetam
– Gingko biloba preparations
• Free radicals scavengers
– Vitamin E
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(2) Toxic Neuropathy
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General Characteristicsof Toxic Neuropathy
• Symmetrical
• Sensorimotor
• Distal
• Polyneuropathy
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• Distal axonopathy – “dying back process“
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Clinical Manifestationof Toxic Polyneuropathy
• Sensory disturbances
– Paresthesiae and numbness in a “gloves and stockings” distribution
– Tactivle, thermal, and vibratory sensation diminished
• Deep tendon reflexes diminished or absent
• Motor disturbances
– Usually mild
– Initial sign: dorsiflexion of the big toe weakened
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Laboratory Testsfor Toxic Polyneuropathies
• Nerve conduction studies (the sural and tibial nerves)
• Electromyography
• Quantitative sensory testing
• Somatosensory evoked potentials (detection of toxic myelopathy)
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• Central-peripheral distal axonopathy
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Most Frequent Causes of Occupational Toxic Neuropathies
Acrylamide, TCDD, Organophosphates
Others
Carbon disulphide, Trichlorethylene, n-Hexane
Organic solvents
Lead, Thalium, Mercury
Toxic metals
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Differential Diagnosisof Toxic Neuropathy
• Alcoholic polyneuropathy
– CDT – Carbohydrate Deficient Transferin
• Diabetic polyneuropathy
• Paraneoplastic polyneuropathy
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Treatment of Toxic Polyneuropathy
• Removal from exposure
• Vasoactive drugs
• Vitamins (B1, B6, B12, E)
• Antiepileptic drugs
– carbamazepin
– gabapentin
– pregabalin
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Neurological Occupational Diseases Caused by Physical Factors
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(1) Long-term overload of extremities by physical work
(2) Working with vibrating tools
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(1) Long-term overload of extremities by physical work
(1) Heavy physical work
(2) Highly repetitive movements
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Occupation-Related Compressive Neuropathies
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• Upper extremities
– Median nerve
• Pronator teres syndrome
• Carpal tunnel syndrome
– Ulnar nerve
• Cubital tunnel syndrome
• Canalis Guyoni syndrome
– Radial nerve
• Supinator syndrome
• Lower extremities
– Fibular nerve
– Tibial nerve
• Tarsal tunnel syndrome
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Carpal Tunnel Syndrome
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Etiology of Carpal Tunel Syndrome
• Endogenous factors
– Inflammation• Tendinitis
• Dermatomyositis
– Endocrinological changes• Pregnancy
• Birth control pills
• Ovarial hypofunction
• Hypothyroidism
– Metabolic changes• Diabetes mellitus
• Gout
• Exogenous factors
– Post-traumatic changes
– Manual work
ahok
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Types of Occupational ActivitiesRelated to CTS
• Static overload due to forceful and repetitive contraction of flexor muscles in the forearm
– Examples: working with a hammer or grinder, manipulating heavy loads
• Stereotyped repetitive flexion-extension of fingers
– Examples: manual cow-milking, typing, playing musical instruments
• Activities involving pinching, screwing etc.
– Examples: clockmakers, minute work
• Direct pressure on the wrist
– Examples: dentists, bikers, working with scissors
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Subjective Symptoms of CTS
• Numbness upon awaking
• Nocturnal paresthesiae (“Brachialgiaparesthetica nocturna”)
• Daily paresthesiae
• Clumsy hand movements
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Objective Signs of CTS
• Hypesthesia in the distal median area
• Weakness of the abductor pollicis brevis muscle
• Muscle and skin trophic changes
• Local findings
– Punctum dolorosum
– Pseudoneuroma
• Provocative tests
– Tinel’s sign
– Phalen’s sign (Flexion test)
– Extension test
– Elevation test
– Digital compression test
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Laboratory Diagnostic Tests for CTS
• X-ray examination
• CT, NMR
• Quantitative sensory testing
• Nerve conduction studies
• Needle electromyography
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Differential Diagnosis of CTS
• Proximal median neuropathy (pronator teressyndrome)
• Brachial plexopathy (upper trunk)
• Thoracic outlet syndrome
• Cervical radiculopathy (especially C6)
• Polyneuropathy
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Treatment of CTS
• Removal from exposure
• Splinting of the wrist
• Vasoactive drugs
• Nonsteroidal anti-inflammatory drugs
• Local application of corticosteroids
• Surgery
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Occupational Compressive Neuropathiesin the Lower Extremities
• Compression of the Fibular nerve
– Examples: potato-lifters, miners, pavers, carpetlayers
• Tarsal tunnel syndrome (Tibial nerve)
– Examples: ballet dancers, jockeys, long-distance runners
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PNS Damage Caused by Working with Vibrating Tools
• Mononeural lesion
– Pathophysiological mechanism: compressiveneuropathy
– Most frequently - CTS
• Bineural lesion
– Pathophysiological mechanism: ischemicneuropathy
– Both the median and ulnar nerves damaged
– Frequent association with vibration white fingers
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Occupational Cramps
• Synonyms– Occupational spasms– Occupational neuroses
• Examples– Graphospasm – Telegraphist’s cramp – Trumpeter’s mouth– Horn player’s torticollis
• Pathopysiology– Focal dystonia?– Psychogenic origin?
• Treatment– Behavioral techniques– Botulinum toxin injections