I'm writing this column from my hotel room in Chicago. My plane back to Los Angeles leaves in a couple of hours and I know that I have a column due (if not overdue), so this provides me with a good chance to write. I came to Chicago to speak at a conference titled "Advanced Topics in Medical Disability Management." The program was attended by a variety of MDs, RNs and claims managers from across the U.S. and Canada. Most are employed by large companies and/or workers' compensation carriers. My role was to speak about the chiropractic profession and, I must admit, I have had a great time. Some of the questions directed at me were very pointed and serve to highlight the perceptions, and sometimes the misperceptions, of many in the health care fields (more of that in another column).
One of the presentations on the agenda was Dr. Nortin Hadler, a rheumatologist from the University of North Carolina, Chapel Hill. This was the second time that I have had the pleasure of meeting and listening to Dr. Hadler. I was fortunate enough to have lectured on a similar program in Aspen in February of this year. The title of his talk was "Arm Pain in the Workplace: An Iatrogenic Concept." If you have not heard Dr. Hadler or read any of his writings, he is a most interesting and thought provoking individual.
Dr. Hadler presented a convincing argument for his position that there is no evidence to support the idea that cumulative trauma disorders, particularly carpal tunnel syndrome, are work-related. In stating his case, he cited the problems with telephone directory assistance operators that made so much news in the middle of the 1980s. Similar to the repetitive strain epidemic in Australia, it appears that the extremely high incidence of CTS in specific locations had little, if anything, to do with the nature of the keyboard used in the course of the job. To support his position, Hadler demonstrated that only certain locations had a high incidence of problems, while other locations had no change in the frequency of disorders.
Interestingly, the keyboards used at those locations having a high incidence of CTS and those with a low incidence were identical. This fact is important because the keyboard was blamed for the problems. In fact, a class action lawsuit was filed against the manufacturer of the keyboard claiming that its faulty design was a direct cause of CTS. It would appear reasonable that if the keyboard was the culprit, all locations using such devices would have experienced a similarly high incidence of problems.
After the discussion of the development of CTS in telephone operators, Dr. Hadler continued his talk by dissecting some of the more well-known articles regarding work-related upper extremity disorders. One by one, he disassembled them, pointing out weaknesses in the methodology, design flaws, and problems in the statistical analysis used. He is quite an effective speaker and makes cogent arguments. His conclusion from this morning's lecture was that we have created a problem where none really exists. Arm pain, he states, is a natural phenomenon, much like back pain, and it has very little to do with the work that we do.
Dr. Hadler takes an unusual stand. He claims that disorders such as carpal tunnel syndrome are actually rare. According to Dr. Hadler, if you don't have electrodiagnostic confirmation of median nerve changes, you don't have carpal tunnel syndrome. You simply have arm pain. He states that it is not ergonomic problems, but psychosocial factors that take arm pain and transform it into carpal tunnel syndrome. He is very clear in expressing his opinion that the indemnity system that we call workers' compensation, and everyone who has anything to do with it, creates claimants where none should exist.
I must admit, I agree with a good deal of what he says. I am also of the opinion that psychosocial factors produce a major impact on injured workers. On a number of occasions I have presented a talk titled "Factors that Influence Disability," where I make an argument that is somewhat similar to Hadler's, i.e., disability is a result of psychosocial issues rather than injury severity. Much of the literature on workers with disabilities, whether they suffer from carpal tunnel syndrome, back pain, or myocardial infarction, demonstrates that the most important prognostic factors are indeed psychosocial and attitudinal rather than physical. Disability has much more to do with who we are than how badly we are injured.
Unfortunately, as I looked around the room at the individuals Dr. Hadler was addressing, I became concerned. His message was clear. "There is no relationship between work and CTS." My concern is that some of the people in the audience, people who are responsible for managing claims at companies across the country, may actually believe him. As a result, some individual working in an assembly plant in Michigan, who develops early signs of CTS when symptoms are present before any evidence of disruption of nerve conduction velocity, may not be listened to. After all, the evidence clearly shows that "there is no CTS unless it is confirmed by electrodiagnosis."
Somewhere between the convincing argument of Dr. Hadler and the experience of a large group of seemingly hysterical telephone operators is a realistic middle ground. In my opinion, it is clear from the evidence that carpal tunnel syndrome is a work-related condition, at least partially work-related. Ergonomic and epidemiologic literature demonstrate a significant increase in the incidence of CTS in a number of occupations that have in common such things as hand-intensive activities. While Dr. Hadler may not agree, there appears to be a relationship between force, repetition, vibration, awkward hand position and the development of the symptoms of CTS. Coupled with this, it has also been demonstrated that there are a number of individual factors that contribute significantly to the development of CTS. These include obesity, pregnancy, wrist fractures, even the dimensions of the wrist.
It is also clear that individuals who do not like their jobs, their co-workers, or their supervisors have a higher reported incidence of hand and wrist pain, some of which may be labeled CTS. Likewise, individuals who feel stressed or feel they have little control over their jobs also report higher rates of problems ranging from CTS to back pain to neck pain, etc. Perhaps many people who like their jobs, like their co-workers and supervisors, and feel like they have some choices in life and some control, actually put up with the inconvenience of a little arm pain. So do they have carpal tunnel syndrome or not?
Dr. Hadler is really asking: "Should the system pay for all of the aches and pains that accompany life?" Should we make the work place responsible for every ailment that has any association to the activities that we must perform on a daily basis? Apparently, I'm not the only person who quivers a bit when I see a checker in a grocery store wearing a wrist brace.
As clinicians, we have an obligation to our patients to do everything within reason to facilitate their recovery and to prevent recurrence of their problems. Too often, however, we assist them in becoming disabled. We create a picture of a sick person by an overindulgence in diagnostic tests and unnecessary procedures. We blame work for their problems when it is not necessary. We keep them off work for long periods when it is not necessary. We encourage them to seek the advice of attorneys when it is not necessary. All these things we do to the detriment of those individuals who really need help.
Perhaps we can learn something from Dr. Hadler, and perhaps he could learn something from us. It makes sense to me to accept the work-relatedness of many musculoskeletal conditions. If we accept the premise that the social environment of work is a major contributor, then we must accept the fact that there is a work-relatedness to CTS and a variety of other musculoskeletal disorders. After all, work is not just a series of physical stresses that are piled one on top of the other, day after day. It is, instead, where we spend much of our lives. The fact that work is often times unpleasant, monotonous and stressful should not be ignored.
However, it also makes sense to not overdo our reaction. It is not necessary for every person with early symptoms of CTS to wear a brace, quit their jobs, or sue their employer. It is also not necessary for individuals with typical aches and pains that accompany working, aging, and life to rush to the doctor for comfort. Nor is it necessary for doctors to spend large sums of money in a wasted effort to solve each and every ailment that afflicts humankind. It is necessary for each individual to accept responsibility for their own conditions and to take steps to minimize the impact of apparent stresses and strains.
Thank you to Dr. Hadler. Your thoughts and ideas provide an opportunity to reflect on the sad state of workers' compensation and the role of disability. I invite your comments.
Paul D. Hooper, DC
2562 Castle Rock Rd.
Diamond Bar, CA 91765
