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Chang Gung Med J. 2005 Apr;28(4):237-46.

Cumulative trauma disorders in betel pepper leaf-cullers visiting a rehabilitation clinic: experience in Taitung.

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Department of Rehabilitation, Chang Gung Memorial Hospital. 123, Dabi Road, Niaosung Shiang, Kaohsiung, Taiwan 833, ROC.



Betel pepper (Piper betle L.) cultivation is an important agricultural industry in Taitung, Taiwan, and culling leaves is very labor-intensive. This case study compares the proportion of cumulative trauma disorders (CTDs) between cullers and those with other occupations.


Patients with musculoskeletal disorders in the rehabilitation clinic of a local hospital in Taitung were enrolled. This all female cohort was divided into a culler group (betel pepper cullers, n = 20), and a non-culler group (other occupations, n = 47). Three cullers were interviewed, and were also recorded to elucidate the related ergonomics. Patients were diagnosed using plain radiography and ultrasonography.


The act of culling involves an overhead internal rotation of both shoulders with extended elbows while standing, followed by wrist flexion and forearm pronation. Flexing of the fingers is also required by the tools, 'iron nails' fitted onto both thumbs. The proportions of patients with shoulder impingement syndrome (SIS) and carpal tunnel syndrome (CTS) were significantly higher among cullers than non-cullers (0.45 vs. 0.15, p = 0.011 and 0.40 vs. 0.06, p = 0.002, respectively). Furthermore, the total frequency of CTDs displayed a positive linear correlation with employment duration (r = 0.618, p = 0.004).


Proportions of occupational SIS and CTS were higher among betel pepper cullers than those with other occupations. These CTDs may have resulted from a prolonged static posture and repetitive motions during culling.

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