Occupational exposures and complaints of neck, shoulder, arm, or hand

A systematic review

Reading time approx. 17 minutes Published: Publication type:

SBU Assessment

Presents a comprehensive, systematic assessment of available scientific evidence for effects on health, social welfare or disability. Full assessments include economic, social and ethical impact analyses. Assessment teams include professional practitioners and academics. Before publication the report is reviewed by external experts, and scientific conclusions approved by the SBU Board of Directors.

Published: Report no: 349 Registration no: SBU 2018/747 ISBN: 978-91-88437-93-8 https://www.sbu.se/349e

Introduction

This systematic review is a sequel to the report “Occupational exposures and neck and upper extremity disorder” published by SBU in 2012. The term complaint is used as a general description of all symptoms in a region and comprises pain, discomfort, and specific diseases.

Conclusions

This systematic literature review has uncovered a substantial body of evidence that supports an increased risk of complaints of neck, shoulder, arm, or hand are associated with a variety of occupational exposures. Conclusions are not formulated for the results evaluated as having a very low certainty of evidence. No results were evaluated as having a high certainty of evidence. The review evaluates longitudinal studies on the association between exposures in the workplace and complaints but cannot give a definite answer to whether occupational exposure is the only contributing factor to these complaints.

People with the following occupational exposures more often develop complaints of neck or neck/shoulders than people who are not subjected to the specified exposure to the same degree:

  • working with the neck bent forwards or backwards (moderate certainty)
  • working with arms elevated (low certainty)
  • working with repetitive arm movements (low certainty)
  • experiencing high quantitative demands (low certainty)
  • experiencing an imbalance between efforts and rewards (low certainty)

People with the following occupational exposures more often develop complaints of shoulders or impingement than people who are not subjected to the specified exposure to the same degree:

  • doing heavy lifting and forceful work with neck and/or shoulders (moderate certainty)
  • working with arms elevated (moderate certainty)
  • working with repetitive arm movements (moderate certainty for shoulder complaints and low certainty for impingement)

People with the following occupational exposures more often develop complaints of arms and/or forearms than people who are not subjected to the specified exposure to the same degree:

  • doing heavy lifting and forceful work with neck and/or shoulders (moderate certainty)
  • doing forceful work with wrist and/or hand (low certainty)
  • working with repetitive arm movements (low certainty)

People exposed to forceful work with neck and/or shoulders more often develop ulnar nerve entrapment than people who are not subjected to the specified exposure to the same degree.

People with the following occupational exposures more often develop complaints of wrists and/or hands than people who are not subjected to the specified exposure to the same degree:

  • doing forceful work with wrists and/or hands (moderate certainty)
  • doing forceful work combined with repetitive movements with hands (moderate certainty)
  • working with wrists in a bent or twisted position (low certainty)
  • working with repetitive wrist and/or hand movements (low certainty)
  • experiencing high job strain, that is a situation where one experiences high job demands combined with low control or decision latitude at work (low certainty)

People with the following occupational exposures more often develop carpal tunnel syndrome than people who are not subjected to the specified exposure to the same degree:

  • doing forceful work with wrist and/or hand (moderate certainty)
  • doing forceful work combined with repetitive movements with hands (moderate certainty)

Results regarding differences between men and women were inconclusive, so this report cannot conclude if women and men with similar occupational exposures develop complaints of neck, shoulders, arms, or hands to a different extent.

Background and Aim

The objective of this systematic review is to assess the scientific evidence describing the influence of occupational exposures on the development of complaints in the neck, shoulders, arms, or hands. A wide range of occupational exposures were investigated, for example, physical workload, and psychosocial and organisational factors.

Review questions

  1. Is there an association between exposures in the workplace and complaints of neck, shoulders, arms, or hands?
  2. To what extent do these associations differ between women and men?

Inclusion criteria

The inclusion criteria were structured according to PEOS (Population, Exposure, Outcome, and Study design).

PEO

Population: Workers in various occupations.

Exposure: Exposures in the workplace. Exposures only assessed by job title, and vibration exposures were excluded.

Outcome: Complaints of neck, shoulders, arms, or hands. Indirect assessments of complaints, such as sick leave, were excluded.

Study design: Prospective and retrospective cohort studies and case-control studies.

Language: English, Swedish, Norwegian, or Danish.

Search period: From 2010 to 2021. Final search august, 2021.

Databases searched: Embase via Elsevier, Ovid MEDLINE, PsycInfo via EBSCO, and Scopus via Elsevier.

Client/patient involvement: No

Method

A systematic review was undertaken following the PRISMA statement and standard methods used by SBU adapted to the context of occupational exposures. Studies that fulfilled the inclusion criteria were assessed for risk of bias by two experts independently, using pre-set protocols. After conducting independent assessments, the two experts had to agree on a mutual relevance and risk of bias classification. Only studies with low or moderate risk of bias were included in the assessment. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results

A total of 19 451 abstracts were identified by the literature search (see Flow chart), 908 were read in full-text and 133 studies were eligible. Sixtyfive longitudinal or case-control studies were considered to have a low or moderate risk of bias and were included in the analyses.

Tables below. Summary of findings for the association between occupational exposure and complaints of neck, shoulders, arms, or hands. The results are based on longitudinal and case-controls studies.

Table 1 Neck or neck/shoulders.
⊕◯◯◯ = Insufficient scientific evidence; ⊕⊕◯◯ = Limited scientific evidence
Occupational exposureNumber of studies
Number of participants total (n)
Location of complaintsGRADEInterpretation
Force (push, pull, lift, or exert a force)
with neck and/or shoulders 7 studies
n=4677
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
with wrist and/or hand 1 study
n=1324
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
Posture
Neck posture 5 studies
n=47 918
Neck or neck/shoulders ⊕◯◯◯ A positive association exists
Trunk posture 3 studies
n=40 557
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
Upper arm posture 8 studies
n=13 347
Neck or neck/shoulders ⊕⊕◯◯ A positive associa­tion exists
Sitting 2 studies
n=2135
Neck or neck/
shoulders
⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Movements
Repetitive arm move­ments 4 studies
n=47 225
Neck or neck/
shoulders
⊕⊕◯◯ A positive associa­tion exists
Repetitive wrist and/or hand move­ments 2 studies
n=1642
Neck or neck/
shoulders
⊕◯◯◯ Cannot determine if an associa­tion exists
Combination of physical exposures
Force and trunk posture 1 study
n=317
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
Akward lifting 1 study
n=6745
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
Force and neck/shoulder posture 1 study
n=91
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
Psychosocial work demands
Quantitative demands 10 studies
n=17 788
Neck or neck/shoulders ⊕⊕◯◯ A positive association exists
Qualitative demands 3 studies
n=3990
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
Job strain 3 studies
n=759
Neck or neck/shoulders ⊕◯◯◯ Cannot determine if an associa­tion exists
Effort-reward imbalance 3 studies
n=3754
Neck or neck/shoulders ⊕⊕◯◯ A positive associa­tion exists
Effort level 2 studies
n=1489
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job insecurity 1 study
n=245
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job stress 1 study
n=25 806
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Working with temporary workers 1 study
n=1510
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Role conflict 2 studies
n=9161
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Work pace 1 study
n=1510
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Psycho­social work resources
Job control 12 studies
n=39 101
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Social support 8 studies
n=5455
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Predictability 1 study
n=2416
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Rewards 2 studies
n=1489
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Advance­ment oppor­tunities 4 studies
n=5500
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Organisa­tional factors
Shift work 3 studies
n=4512
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Overtime work 1 study
n=1324
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Scope of work 2 studies
n=1532
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Temporary employ­ment 1 study
n=1510
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Accord system 1 study
n=245
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Destruc­tive leader ­1 study
n=951
Neck or neck/shouldersy ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Fair leadership 3 studies
n=10 076
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Social factors
Bullying 1 study
n=5277
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Other exposures
Visual environ­ment 1 study
n=208
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Sensory demands 1 study
n=208
Neck or neck/shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists

 

⊕◯◯◯ = Insufficient scientific evidence; ⊕⊕◯◯ = Limited scientific evidence; ⊕⊕⊕◯ = Moderately strong scientific evidence
Occupa­tional exposureNumber of studies
Number of partici­pants total (n)
Location of com­plaintsGRADEInter­pretation
Force (push, pull, lift, or exert a force)
with neck and/or shoulders 7 studies
n=83 203
Shoulders ⊕⊕⊕◯ A positive associa­tion exists
with neck and/or shoulders 5 studies
n=44 233
Impinge­ment ⊕⊕⊕◯ A positive associa­tion exists
with wrist and/or hand 1 study
n=167
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Posture
Trunk posture 1 study
n=317
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Upper arm posture 12 studies
n=87 676
Shoulders ⊕⊕⊕◯ A positive associa­tion exists
Upper arm posture 6 studies
n=45 689
Impingement ⊕⊕⊕◯ A positive associa­tion exists
Elbow and/or wrist posture 1 study
n=38 897
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Movements
Repetitive arm move­ments 7 studies
n=84 075
Shoulders ⊕⊕⊕◯ A positive associa­tion exists
Repetitive arm move­ments 5 studies
n=44 739
Impingement ⊕⊕◯◯ A positive associa­tion exists
Precise move­ments with arms 1 study
n=240
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Combina­tion of physical expo­sures
Force and posture 2 studies
n=2103
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Force, posture, and repetitive move­ments 2 studies
n=42 798
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Psychosocial work demands
Quantita­tive demands 6 studies
n=40 279
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Quantitative demands 3 studies
n=38 134
Impingement ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Qualitative demands 2 studies
n=735
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job strain 3 studies
n=4533
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Effort-reward imbalance 1 study
n=106
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Effort level 1 study
n=1801
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Obstacles and interrup­tions 1 study
n=1801
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job insecurity 1 study
n=1801
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Working with tempo­rary workers 1 study
n=1655
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Work pace 1 study
n=1655
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Psychosocial work resources
Job control 8 studies
n=42 713
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job control 3 studies
n=38 134
Impingement ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Social support 7 studies
n=47 306
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Social support 3 studies
n=43 283
Impingement ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Predicta­bility 1 study
n=1655
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Advance­ment oppor­tunities 2 studies
n=6880
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Organisational factors
Shift work 2 studies
n=3111
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Overtime work 2 studies
n=3111
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Security climate 1 study
n=247
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Tempo­rary employ­ment 2 studies
n=3111
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Other exposures
Heat 1 study
n=1655
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Visually demanding work 1 study
n=1655
Shoulders ⊕◯◯◯ Cannot deter­mine if an associa­tion exists

 

Table 3 Arms.
HAL TLV = Hand Activity Level – Threshold Limit Value
⊕◯◯◯ = Insufficient scientific evidence; ⊕⊕◯◯ = Limited scientific evidence; ⊕⊕⊕◯ = Moderately strong scientific evidence
Occupational exposureNumber of studies
Number of participants total (n)
Location of complaintsGRADEInterpre­tation
Force (push, pull, lift, or exert a force)
with neck and/or shoulders 5 studies
n=273 806
Arms ⊕⊕⊕◯ A positive associa­tion exists
with neck and/or shoulders 3 studies
n=233 744
Ulnar nerve entrapment ⊕⊕⊕◯ A positive associa­tion exists
with wrist and/or hand 4 studies
n=231 494
Arms ⊕⊕◯◯ A positive associa­tion exists
with wrist and/or hand 3 studies
n=1805
Epicondylalgia ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Posture
Trunk posture 1 study
n=699
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Upper arm posture 1 study
n=3833
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Elbow and wrist posture 5 studies
n=270 388
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Movements
Arm movements 1 study
n=229 689
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Repetitive arm movements 3 studie
n=272 252
Arms ⊕⊕◯◯ A positive associa­tion exists
Wrist and/or hand movements 4 studies
n=231 414
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Wrist and/or hand movements 3 studies
n=1725
Epicondylalgia ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Repetitive wrist and/or hand movements 4 studies
n=231 127
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Combination of physical exposures
Force and posture 1 study
n=611
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Strain Index 2 studies
n=1026
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Grip score 1 study
n=229 689
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
HAL TLV 1 study
n=495
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Psychosocial work demands
Quantitative demands 1 study
n=531
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job insecurity 1 study
n=531
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job stress 1 study
n=531
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Work pace 1 study
n=531
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Psychosocial work resources
Job control 1 study
n=531
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Social support 3 studies
n=1725
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Social support 3 studies
n=1725
Epicondylalgia ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Other exposures
Heat 1 study
n=3833
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Cold 1 study
n=3833
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Temperature changes 1 study
n=3833
Arms ⊕◯◯◯ Cannot deter­mine if an associa­tion exists

 

Table 4 Wrists and hands.
HAL TLV = Hand Activity Level – Threshold Limit Value
⊕◯◯◯ = Insufficient scientific evidence; ⊕⊕◯◯ = Limited scientific evidence; ⊕⊕⊕◯ = Moderately strong scientific evidence
Occupa­tional exposureNumber of studies
Number of participants total (n)
Location of com­plaintsGRADEInterpre­tation
Force (push, pull, lift, or exert a force)
with neck and/or shoulders 5 studies
n=46 994
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Heavy lifting 3 studies
n=44 947
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
with wrist and/or hands 8 studies
n=49 565
Wrist and hand ⊕⊕⊕◯ A positive associa­tion exists
with wrist and/or hands 5 studies
n=9055
Carpal tunnel syndrome ⊕⊕⊕◯ A positive associa­tion exists
Posture
Upper arm posture 1 study
n=3824
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Elbow and/or wrist posture 8 studies
n=1 066 050
Wrist and hand ⊕⊕◯◯ A positive associa­tion exists
Movements
Wrist and/or hand movements 2 studies
n=1 019 616
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Repetitive wrist and/or hand move­ments 8 studies
n=52 671
Wrist and hand ⊕⊕◯◯ A positive associa­tion exists
Repetitive wrist and/or hand movements 5 studies
n=12 169
Carpal tunnel syndrome ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Combination of physical exposures
HAL TLV 4 studies
n=6469
Wrist and hand ⊕⊕⊕◯ A positive associa­tion exists
HAL TLV 3 studies
n=6229
Carpal tunnel syndrome ⊕⊕⊕◯ A positive associa­tion exists
Strain index 2 studies
n=2991
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Psychosocial work demands
Quantitative demands 3 studies
n=9775
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Job strain 3 studies
n=2288
Wrist and hand ⊕⊕◯◯ A positive associa­tion exists
Job insecurity 1 study
n=6407
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Working with temporary workers 1 study
n=415
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Work pace 1 study
n=366
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Psycho­social work resources
Job control 3 studies
n=4828
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Social support 3 studies
n=7387
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Predictability 1 study
n=1532
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Advancement opportunities 1 study
n=1532
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Organisational factors
Shift work 2 studies
n=1937
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Overtime work 2 studies
n=3584
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Other exposures
Heat 1 study
n=3824
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Cold 2 studies
n=4239
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists
Temperature changes 1 study
n=3824
Wrist and hand ⊕◯◯◯ Cannot deter­mine if an associa­tion exists

Conflicts of interest

According to SBU’s requirements, the experts and scientific reviewers participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.

The full report in Swedish

Arbetsmiljöns betydelse för besvär och sjukdom i nacke, axlar, armar och händer

Flow chart

Out of 19523 articles screened in full text, 133 were eligible. 45 had high risk of bias,  88 low or moderate risk of bias.

Project group

Experts

  • Svend Erik Mathiassen, Senior Professor at the Department of Occupational Health Science and Psychology, University of Gävle
  • Helena Sandén, MD and PhD at the Department of Public Health and Community Medicine, University of Gothenburg
  • Magnus Sverke, Professor of Work and Organisational Psychology at the Department of Psychology, Stockholm University
  • Jens Wahlström, Associate Professor at Department of Public Health and Clinical Medicine, University of Umeå

SBU

  • Margareta Hedner, PhD and Project Manager
  • Sara Fundell, Project Administrator
  • Jan Adolfsson, Assistant Project Manager(until December 2021)
  • Martin Norman, Assistant Project Manager (from January 2022)
  • Agneta Brolund, Information Specialist (until March 2020)
  • Hanna Olofsson, Information Specialist (from January 2021)
  • Jenny Odeberg, Head of Department

 External reviewers

  • Lars Adolfsson, Adjunct Professor at the Division of Surgery, Orthopedics and Oncology, University of Linköping
  • Jane Frølund Thomsen, MD at the Department of occupational and environmental medicine, Bispebjerg and Frederiksberg Hospital
  • Ulf Lundberg, Senior Professor, Professor at Centre for Health Equity Studies (CHESS), Stockholm University and Karolinska institutet
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