Title:
Running Head:
Authors:
Institutions:
The George Institute for Global Health, Sydney Medical School, The
Daniel Steffens
The George Institute for Global Health, Sydney Medical School, The
University of Sydney, P.O. Box M201 Missenden Rd, Sydney,2050,
New South Wales, Australia.
Phone: +61 2 8238 24 34
Email: dsteffens@georgeinstitute.org.au
Word count:
249 (Abstract);
Funding:
None.
2795(Text).
Conflict of interest: The authors declare that they have no conflict of interest.
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as an
Accepted Article, doi: 10.1002/acr.22378
2014 American College of Rheumatology
Received: Mar 19, 2014; Revised: May 01, 2014; Accepted: May 27, 2014
Abstract
Objective: To investigate the influence of various weather conditions on risk of low back
pain.
Methods: We conducted a case-crossover study in primary care clinics in Sydney, Australia.
993 consecutive patients with a sudden, acute episode of back pain were recruited from
October 2011 to November 2012. Following the pain onset, demographic and clinical data
about the back pain episode were obtained for each participant during an interview. Weather
parameters (temperature, relative humidity, air pressure, wind speed, wind gust, wind
direction and precipitation) were obtained from the Australian Bureau of Meteorology for the
entire study period. Weather exposures in the case window (time when participants first
noticed their back pain) were compared to exposures in two control time-windows (same
time duration, one week and one month before the case window).
Results: Temperature, relative humidity, air pressure, wind direction and precipitation
showed no association with onset of back pain. Higher wind speed (OR 1.17, 95% CI 1.04 to
1.32; p=0.01; for an increase of 11 km/h) and wind gust (OR 1.14, 95% CI 1.02 to 1.28;
p=0.02; for an increase of 14 km/h) increased the odds of pain onset.
Conclusions: Weather parameters that have been linked to musculoskeletal pain such as
temperature, relative humidity, air pressure, and precipitation do not increase the risk of a low
back pain episode. Higher wind speed and wind gust speed provided a small increase in risk
of back pain and while this reached statistical significance, the magnitude of the increase was
not clinically important.
Keywords: Low back pain; weather; epidemiology; case-crossover study.
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Patients with musculoskeletal pain commonly report that their symptoms are
influenced by the weather, but this issue has not been evaluated in robust research or
for the most common musculoskeletal condition, back pain.
There was no association between temperature, relative humidity, air pressure, wind
direction and precipitation and risk of back pain.
Higher wind speeds slightly increased the odds of back pain onset but the effect is not
important.
Patients with musculoskeletal pain commonly report that certain weather conditions influence
their symptoms, the pain from rheumatoid arthritis being a clear example of this (1-3).
Previous studies have reported that cold or humid weather conditions (4,5) and changes in
weather conditions (6) negatively influence symptoms in patients suffering chronic pain.
Despite the high frequency with which this belief is reported, there are few robust studies that
have investigated this potential association. The key problems are that study participants are
not blinded to the study hypotheses, the studies have no control period and data are mainly
based upon subjective recall of both weather and symptoms.
It is a methodological challenge to assess the effect of the weather on pain onset using
traditional study designs. To our knowledge, only two studies has assessed whether aspects of
the weather influence musculoskeletal pain using a case-crossover methodology (3,7). The
case-crossover approach was specifically designed to study exposures, like the weather, that
have a short induction time and transient effect. With this design it would be possible to
evaluate the increased risk associated with aspects of the weather by comparing exposure to
meteorologic variables at the time of the pain onset or exacerbation (defined as case window)
and in earlier periods when the person was pain-free (defined as control windows) (8).
Subsequent to completing a case-crossover study evaluating physical and psychosocial
triggers for an episode of low back pain (LBP) we became aware of the limited data on
weather and musculoskeletal pain. We took the opportunity to link back pain data from the
original data set and historical weather data obtained from meteorological records. The aim of
this study was to quantify the transient increase in risk of a sudden onset of acute LBP
associated with the following weather parameters: temperature (C), relative humidity (%),
air pressure (hPa), wind speed (km/h), wind gust (km/h), wind direction (degrees true) and
precipitation (mm).
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Basic demographic and clinical data were collected by telephone interview (9). Only those
patients who were interviewed within 14 days from the onset of their LBP were included. In
total, 993 people with LBP participated. All participants were 18 years or older.
Meteorological data
Sydney is the state capital of New South Wales and the most populous city in Australia. It has
a temperate climate with warm summers and mild winters, and rainfall spread throughout the
year. Meteorological data were obtained from the Australian Bureau of Meteorology for the
entire study period from five Sydney weather monitoring stations (www.bom.gov.au). The
weather stations were located in three main regions: Sydney Central (Sydney Airport066037), Sydney North West (Penrith Lakes-067113 and Badgerys Creek-067108) and
Sydney South West (Mount Annan-068257 and Camden Airport-068192). Two weather
stations (Penrith Lakes and Mount Annan) did not provide data on air pressure; therefore, air
pressure data were used from two neighbouring weather stations (Badgerys Creek and
Camden Airport). For each participant enrolled in the study, we used data from the weather
station closest to the region where they lived. The following hourly weather parameters were
obtained: temperature (C), relative humidity (%), air pressure (hPa), wind speed (sustained
wind speed averaged over 10 minutes leading up to the time of the observation - km/h), wind
gust (short burst of high speed wind averaged over 3 seconds leading up to the time of the
observation - km/h), wind direction (direction where the wind is coming from - degrees true)
and precipitation (mm).
Study design
To determine whether there is an association between weather parameters and LBP onset, we
used a case-crossover design. This design compares exposure to weather parameters at the
time of back pain onset (defined as the case window) with exposure at the same time one
6
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week and one month prior to the pain onset (defined as control windows 1 and 2,
respectively) for each participant. The time periods for exposure were defined as following:
(i) within 1 hour (average value at 1 hour immediately before the pain onset), (ii) at 24 hours
(average value at 24 hours immediately before the pain onset) and (ii) average value within
24 hours (average value from 0 to 24 hours immediately before the pain onset).
To determine whether change in the weather parameters is associated with LBP onset, we
computed a change score using this formula: average value over 0-24 hours immediately
prior to the pain onset minus average value over 25-48 hours immediately prior to the pain
onset for each participant.
Statistical analysis
Firstly, a descriptive analysis was performed. Characteristics of the study subjects and
distribution of weather parameters was reported. Secondly, the analysis followed standard
methods for stratified analyses. In the case-crossover design, the individual subject is the
stratifying variable (8,11). We used the pair-matched analytic approach (conditional logistic
regression) to contrast exposures (meteorological variables) for the case period with
exposures for the control period. For each subject, one case period was matched to two
control periods exactly one week and one month before the date and time of the pain
onset.(11) Odds ratios (OR) and 95% confidence intervals (95% CI) were derived comparing
exposure in the case window with each one of two control windows. All weather parameters
were treated as continuous variables and we calculated the OR associated with a 1 standard
deviation (SD) increase in the weather parameter. The analyses were performed using
STATA version 12 (12).
Results
Primary care clinicians screened 1639 consecutive patients from October 2011 to November
2012, where 993 met the inclusion criteria and consented to enter the study. Table 1 shows
characteristics of the study participants. The mean (SD) age was 45.2 (13.4) years. Most
participants were male (54.2%), professional workers (34.2%) and had a mean (SD) number
of previous episodes of back pain of 5.9 (14.0).
During the study period of 13 months, the mean and range for the weather parameters were:
1.4 mm of precipitation (ranging from 0.0 to 115.4), 16.7 C of temperature (ranging from 0.7 to 37.5 C), 71.6 % of relative humidity (ranging from 6.0 to 100.0 %), 11.2 km/h of
wind speed (ranging from 0.0 to 74.0 km/h), 16.2 km/h of wind gust (ranging from 0.0 to
100.0 km/h), 164.6 degrees true of wind direction (ranging from 360.0 to 0.0) and 1017.3
hPa of air pressure (ranging from 994.7 to 1035.8 hPa) (Table 2).
Descriptive data for the meteorological parameters in the case and control windows are
presented in Table 3. Estimates of fixed parameters from conditional logistic regression
models for each weather parameter are also presented in Table 3. Only two of the 28 analyses
were significant: wind speed 24hours prior to onset (odds ratio 1.17, 95% CI 1.04 to 1.32;
p=0.01; for an increase of 11 km/h) and wind gust 24hours prior to onset (odds ratio 1.14,
95% CI 1.02 to 1.28; p=0.02; for an increase of 14 km/h) increased the risk of back pain.
None of the other weather parameters investigated were associated with back pain onset.
Discussion
Statement of principal findings
This study provides the first evaluation of the influence of the weather on the most common
musculoskeletal condition, back pain. Contrary to popular belief, weather parameters, such as
temperature, precipitation, air pressure, wind direction and humidity, were not associated
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with the onset of back pain. Unexpectedly, heavier wind speed 24hours prior to an episode
increased the risk of back pain but the magnitude of the effect was very small and unlikely to
be clinically important. Additionally we did not adjust the critical p value for multiple
comparisons and if this was done the obtained p values of 0.01 and 0.02 for wind parameters
would no longer be statistically significant.
Strengths and weaknesses of the study
The use of a case-crossover design is a strength of this study. In case-crossover studies, cases
act as their own controls, consequently, case-crossover studies are not confounded by timeinvariant risk factors, since exposure information is collected from the same individual (11).
The timing and nature of our study means that we avoided some of the potential problems
associated with the case-crossover design. We avoided the problems associated with recall as
exposure data were objectively measured and obtained independently of the back pain data.
As both participants and assessors were blinded to the study hypotheses we avoided bias
associated with peoples beliefs about weather and pain. Lastly we enrolled a large and well
defined cohort of consecutive patients from primary care clinics.
This study has some limitations that should be taken into account. First, our data did not
include potentially important individual data, such as time spent outdoors, characteristics of
housing or work and air conditioning, which could modify participants vulnerability to
weather conditions. Second, we used meteorological data obtained from three main regions in
Sydney and assumed that the LBP onset occurred to the individual while in a region close to
their home. This may have introduced misclassification for some patients exposure. The
effect of this non-differential bias would be to change the present findings towards the null
(13). Using data from three distinct weather regions however, helped minimise the spatial
variations in the weather parameters that exist within regions (14). Third, participants time
of back pain onset was based on their recall, which is a potential limitation of retrospective
studies. Therefore, participants were asked to use their diary, calendar or smartphone to help
recall the onset time. Also, to avoid time recall bias, interviews were performed as soon as
possible after the onset of back pain, with the mean time between pain onset and presentation
to primary care of 3.0 2.1 days and from presentation to interview of 1.9 1.9 days.
Strengths and weaknesses in relation to other studies, discussing important differences
in results
There is little published research investigating the effect of the weather on musculoskeletal
pain. Of the two previous case-crossover studies one found no effect of relative humidity,
pressure, rain, hours of sun and cloud cover on symptoms of rheumatoid arthritis (3) while
the other found that higher wind speed slightly increased the risk of hip fracture (7) but only
in a sub-group of participants. Typically the research cited to support a relationship between
weather and LBP uses very weak designs. For example many studies simply survey patients
about their opinion on the effect of weather on their symptoms (4-6). Sometimes the belief
that weather affects musculoskeletal pain is supported by reviews of studies which report
higher prevalence of musculoskeletal pain in studies conducted in cooler settings, however
there are other between study factors that could also have contributed to this finding (15). At
present there is no evidence, derived from robust research that supports the widespread belief
that the weather affects musculoskeletal pain. There is however some evidence for other
health conditions. Previous case-crossover studies have shown that exposure to lower
temperatures increases the risk of myocardial infarction (16), while higher temperatures and
lower pressures lead to an increase in risk of headaches (17).
Meaning of the study: possible explanations and implications for clinicians and
policymakers
10
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Our study provides clear evidence that weather does not have an important effect on LBP
onset. Only a trivial increase in the risk was observed with higher wind speed 24hours prior
to the onset of pain in this population of Australian adults. One possible explanation for the
lack of effect in our results may be the temperate climate of the Sydney region where the
study was conducted. Regions with more extreme weather conditions may present a different
result, but further research is needed. Interestingly, the popular belief about temperature,
precipitation, air pressure, wind direction, humidity and its association with back pain seems
to be stronger than the data would support. It should be noted however, that there may be
musculoskeletal conditions other than low back pain that may be affected by weather
parameters and this is an important area for further research.
Unanswered questions and future research
Further studies are needed to confirm our findings in wider populations and also to determine
whether there is a subgroup of people in which weather is more strongly associated with back
pain onset. Case-crossover designs could be conducted in other musculoskeletal pain
conditions. The importance of indoor temperatures, characteristics of housing or work and air
conditioning use should be taken into account, since, if a majority of the events occur within
the home, the results obtained in relation to meteorological variables may be biased towards
the null value. The small association found with higher wind speed may be better explained
in regions where summer and winter are generally relatively extreme, rather than the
moderate hot and cold of temperate regions.
In addition, co-exposure to multiple triggers (e.g. physical and meteorological factors) may
increase risk of back pain more than simple exposure to one meteorological trigger. We are
unaware of any study that has investigated this for musculoskeletal conditions. Additionally,
using the case-crossover design to investigate whether exposure to weather parameters is
11
associated with pain exacerbation or flare ups, in a sample of people with chronic back pain,
may provide useful explanations for disease aetiology and how to improve quality of life.
Conclusion
In conclusion, the study shows that common weather parameters previously believed to
influence musculoskeletal pain do not increase the risk of an episode of LBP. This study did
however, find a weak association between exposure to higher wind speed, wind gust and back
pain onset but the magnitude of this effect was small and therefore not clinically important.
12
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Study approval: Ethical approval for the study was granted by the University of Sydney
Human Research Ethics Committee (protocol number 05-2011/13742).
Acknowledgements: We would like to thank all clinicians who participated in the
TRIGGERS study.
Contributor statement: All authors were involved in the design of the study. DS prepared
and cleaned the data. QL performed the statistical analysis. DS and CGM wrote the first draft.
All authors contributed to further drafts. CGM had full access to all of the data in the study
and takes responsibility for the integrity of the data and the accuracy of the data analysis. All
authors have read and approved the final manuscript.
13
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15
Page 16 of 20
Central
(n=666)
Sydney North
West (n=256)
Sydney
South West
(n=71)
Overall
(n=993)
Gender (Male)
356 (53.5%)
138 (53.9%)
44 (61.9)
538 (54.2%)
Age (years)
45.0 14.2
45.3 11.8
47.2 11.6
45.2 13.4
Height (cm)
172.9 10.3
170.6 9.9
173.9 12.2
172.4 10.4
Weight (Kg)
78.8 17.7a
78.7 19.4
80.2 17.7
78.8 18.1b
BMI (kg/m2)
26.2 5.0a
26.9 5.9
26.4 4.4
26.4 5.2b
5.1 2.7
4.5 2.8
4.9 2.9
4.9 2.7
6.3 15.9
4.7 7.7
6.2 12.6
5.9 14.0
3.0 2.1
2.7 2.1
2.9 2.0
3.0 2.1
2.4 2.2
1.9 1.9
3.0 2.3
2.3 2.2
Depression status
2.7 2.6
2.7 2.8
2.9 2.8
2.7 2.7
Pain
5.1 2.1
5.7 2.1
5.4 2.1
5.3 2.1
GPES
1.8 1.8
1.7 1.7
1.7 1.9
1.8 1.8
Tense/ anxious
4.0 2.5
4.1 2.7
4.1 2.6
4.0 2.5
64 (9.6%)
27 (10.5%)
10 (14.1%)
101 (10.2%)
Compensation
47 (7.1%)
26 (10.2%)
15 (21.1%)
88 (8.9%)
320 (48.1%)
98 (38.3%)
32 (45.1%)
450 (45.3%)
Not employed
124 (18.6%)
29 (11.3%)
9 (12.7%)
162 (16.3%)
69 (10.4%)
30 (11.7%)
4 (5.6%)
103 (10.4%)
31 (4.7%)
15 (5.9%)
1 (1.4%)
47 4.7%)
Labourer
13 (2.0%)
10 (3.9%)
7 (9.9%)
30 3.0%)
14 (2.1%)
10 (3.9%)
3 (4.2%)
27 (2.7%)
Manager
106 (15.9%)
39 (15.2%)
11 (15.5%)
156 (15.7%)
Professional
234 (35.1%)
83 (32.4%)
23 (32.4%)
340 (34.2%)
Sales Worker
33 (5.0%)
17 (6.6%)
2 (2.8%)
52 (5.2%)
42 (6.3%)
23 (9.0%)
11 (15.5%)
76 (7.7%)
Upper back
39 (5.9%)
18 (7.0%)
2 (2.8%)
59 (5.9%)
Lower back
666 (100.0%)
256 (100.0%)
71 (100.0%)
993 (100%)
65 (9.8%)
19 (7.4%)
11 (75.5%)
95 (9.6%)
22 (3.3%)
15 (5.9%)
5 (7.0%)
42 (4.2%)
Medication
What do you do for a living
Pain locationc
16
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72 (10.8%)
23 (9.0%)
12 (16.9%)
107 (10.8%)
31 (4.7%)
12 (4.7%)
5 (7.0%)
48 (4.8%)
20 (3.0%)
8 (3.1%)
1 (1.4%)
29 (2.9%)
8 (1.2%)
3 (1.2%)
0 (0.0%)
11 (1.1%)
20 (3.0%)
3 (1.2%)
3 (4.2%)
26 (2.6%)
5 (0.8%)
2 (0.8%)
0 (0.0%)
7 (0.7%)
Moderate
251 (37.7%)
98 (38.3%)
22 (31.0%)
371 (37.4%)
Severe
328 (49.3%)
127 (49.6%)
36 (50.7%)
491 (49.5%)
Very severe
87 (13.1%)
31 (12.1%)
13 (18.3%)
131 (13.2%)
Not at all
16 (2.4%)
5 (2.0%)
0 (0.0%)
21 (2.1%)
A little bit
75 (11.3%)
24 (9.4%)
2 (2.8%)
101 (10.2%)
Moderately
161 (24.2%)
72 (28.1%)
15 (21.1%)
248 (25.0%)
Quite a bit
259 (38.9%)
97 (37.9%)
30 (42.3%)
386 (38.9%)
Extremely
155 (23.3%)
58 (22.7%)
24 (33.8%)
237 (23.9%)
Sedentary
346 (51.9%)
149 (58.2%)
43 (60.5%)
538 (54.2%)
Insufficient activity
114 (17.1%)
34 (13.2%)
15 (21.1%)
163 (16.4%)
Sufficient activity
206 (30.9%)
73 (28.5%)
13 (18.3%)
292 (29.4%)
Sedentary
212 (31.8%)
112 (43.7%)
33 (46.5%)
357 (35.9%)
Insufficient activity
122 (18.3%)
41 (16.0%)
11 (15.5%)
174 (17.5%)
Sufficient activity
332 (49.8%)
103 (40.2%)
27 (38.0%)
462 (45.5%)
Pain severity
n=665.
b
c
n=992.
Pain location was assessed using a pain mannequin provided to participant by the referring clinician.
17
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Table 2: Features of weather parameters in three Sydney conurbations from October 2011 to November 2012
Parameters
Precipitation (mm)
Temperature (C)
Relative humidity
(%)
Wind speed (km/h)
Wind gust (km/h)
Wind direction
(degrees true)
Air pressure (hPa)
Sydney Central
Mean SD
Min
Max
Mean SD
Min
Max
Mean SD
Min
Max
1.4 4.9
0.0
75.4
1.5 5.9
0.0
115.4
1.3 5.0
0.0
80.0
17.9 4.6
6.0
37.5
16.8 6.0
1.1
37.1
15.5 6.1
-0.7
37.4
65.8 18.0
6.0
100.0
75.2 23.1
11.0
100.0
73.8 21
10.0
99.0
19.9 9.9
0.0
74.0
6.9 5.9
0.0
50.0
7.0 5.3
0.0
33.0
25.6 12.9
0.0
100.0
11.0 9.2
0.0
74.0
12.0 9.0
0.0
61.0
190.9 106.0
0.0
360.0
163.1 111.3
0.0
360.0
139.6 108.1
0.0
360.0
1017.2 6.4
994.7
1035.3
1017.3 6.5
995.6
1035.7
1017.3 6.6
995.0
1035.8
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Table 3: Exposure and estimates of fixed parameters for included weather conditions (n=993)
Case window
Control window 1
Control window 2
Weather parameters
a
a
(onset day)
(1 week ago)
(1 month ago)a
Precipitation (mm)
Within 1 hourc
1.12 4.36
1.24 5.45
1.21 4.75
d
At 24 hours
1.14 5.02
1.20 4.56
1.25 4.89
e
Average value over 24 hours
1.20 3.42
1.36 4.15
1.35 3.77
f
Change from 0-24 to 25-48 hours
0.15 4.05
-0.23 4.58
0.03 4.90
Temperature (C)
Within 1 hourc
17.72 5.36
17.64 5.44
17.26 5.72
d
At 24 hours
17.65 5.46
17.61 5.52
17.21 5.56
e
Average value over 24 hours
16.91 4.28
16.95 4.33
16.55 4.60
Change from 0-24 to 25-48 hoursf
-0.03 2.32
-0.13 2.17
-0.17 2.12
Relative humidity (%)
Within 1 hourc
62.92 20.74
63.94 20.36
64.84 20.53
At 24 hoursd
63.29 21.05
64.16 20.99
64.32 20.72
e
Average value over 24 hours
66.36 14.37
67.27 13.90
67.78 13.96
f
Change from 0-24 to 25-48 hours
0.67 12.19
0.72 11.88
0.38 11.55
Wind speed (km/h)
Within 1 hourc
16.56 10.37
16.55 10.78
16.32 10.67
d
At 24 hours
17.26 10.90
16.30 10.60
16.45 11.04
e
Average value over 24 hours
16.11 8.38
15.77 8.44
15.74 8.82
f
Change from 0-24 to 25-48 hours
-0.15 6.14
-0.10 5.89
-0.68 6.19
Wind gust (km/h)
Within 1 hourc
22.41 13.16
22.53 13.92
22.05 13.53
d
At 24 hours
23.22 13.88
22.08 13.43
22.38 14.20
e
Average value over 24 hours
21.54 10.24
21.16 10.39
21.14 11.00
Change from 0-24 to 25-48 hoursf
-0.16 8.43
-0.16 8.08
-0.96 8.49
19
Odds Ratio
(95% CI)b
P value
1 SDb
0.59
0.76
0.32
0.05
5
5
4
4
0.52
0.75
0.63
0.30
5
5
4
2
0.14
0.20
0.09
0.93
21
21
14
12
0.99
0.01
0.19
0.85
11
11
8
6
0.81
0.02
0.26
1.00
14
14
10
8
Page 20 of 20
186.01 107.96
191.75 102.40
186.67 59.92
-0.06 53.94
182.36 107.00
194.45 106.80
184.78 59.87
0.25 54.38
194.28 104.60
189.42 108.09
187.39 59.66
0.79 55.69
0.39
0.51
0.36
0.9
107
107
60
54
1017.65 6.49
1017.26 6.53
1017.34 6.40
0.16
1017.62 6.39
1017.23 6.31
1017.29 6.49
0.14
1017.61 6.03
1017.12 6.08
1017.23 6.04
0.06
-0.13 4.85
0.09 4.91
0.08 4.63
0.28
20